Infertility, Contraception &

Abortion (Chapter 7)

• Alicia Bennett
• Shernette Parkinson
• Yolande Thomas
• Gail Yarker
• Kesha Pantry
 Learning Objective
Students should be able to:
• List common causes of infertility

• Discuss the physiologic impact of Infertility

• Describe common diagnosis and treatment for Infertility

• State the Advantages and Disadvantages if methods of

contraceptive use.

• Identify Nursing Interventions that are common with contraceptive

use

• Describe the techniques used for medical and surgical interruption

of Pregnancy

• Recognize ethical, legal, cultural and religious considerations of

infertility, contraception and elective abortion.
 Infertility
Incidence:
• Infertility is a problem for approximately 10% of
reproductive-age couples

• Infertility implies subfertility

• Primary and Secondary infertility

• Diagnosis and treatment is considered physical,

emotional, psychologic, and social effects
 Factors Associated with
Infertility
• Many factors, in both male and female, contribute to
normal fertility

• Timing of intercourse is critical

• Implantation of the blastocyst

• The conceptus must develop normally

• Alteration in one or more of these structures, functions,

or processes
 Assessment of Female
Infertility
• A complete history and physical
• A detailed sexual history
• Hazards in the home and workplace
• Assessment of the reproductive tract
• Inadequate development of secondary sex
characteristics
• Diagnosis
– Infertility survey of the female
 Assessment of Male Infertility
• A thorough history and physical examination
• Semen Analysis
• Study of the effects of cervical mucus on sperm
• Sperm counts
• Semen collection
• Hormone analyses
• Sperm penetration
 Assessment of The Couple
• Postcoital Test/Sims-Huhner Test

• Intercourse is synchronized

• A problem may arise with facilities or the

physician
 Nursing Diagnosis: Impaired
Infertility
• Disturbed body image or risk for situational low self-
esteem related to-impaired fertility
• Decisional conflict related to
• - therapies for impaired fertility
• -alternatives to therapy (e.g. childfree living or adoption)
• Sexually dysfunction related to
• -lose of libido secondary to medically imposed
restrictions
• Social isolation related to
• -Impaired fertility, its investigation, and its management
 Expected Outcome
• Verbalize understanding • Resolve guilt feelings and
of the anatomy and not need to focus.
physiology of the
reproductive system. • Conceive or, failing to
conceive, decide on an
• Verbalize understanding alternative acceptable to
of treatment for any both of them.
abnormalities identified
through various tests and
examinations .
 Plan of Care and Implementation
• Psychosocial

• The woman or couple facing infertility may

exhibit grieving behaviors.

• Couple may report decreased sex desire.

• Referral for mental counseling may be

beneficial.
 Plan of Care and Implementation
Cont’d
Non Medical: Medical:
• In male high scrotal • Female stimulating
temperature may be ovulation
caused by hot tubs and
saunas result in • Increase estrogen
decrease
spermatogenesis.

• Woman have
immunologic reaction
to sperm.
 Plan of Care and Implementation
Cont’d
Surgical:
• Ovarian tumors may be removed.

• Hysterosalpingography is useful for identification of

tubal obstruction and release of blockage.

• Laparotomy use to repair damage tube.

• Surgical repair of varicocele to increase sperm

count
 Reproductive Alternatives
• Vitro fertilization
• Embryo transfer
• Ovum transfer
• Embryo adoption
• Surrogate parenting
Complications
• Ectopic pregnancy
 Contraception
• The intentional prevention of
pregnancy during sexual
intercourse.

• Birth control is used to

decrease the risk of
conceiving.

• Family planning is the

conscious decision on when to
conceive or avoid pregnancy.

• Those who use contraception

can still be at risk for
pregnancy.
Methods of Contraception
Fertility Awareness
Coitus Interruptus (withdrawal):
Method (FAMs):
• Involves the male partner • Identifying the beginning and
withdrawing his penis from the
end of the fertile period of the
woman’s vagina before he menstrual cycle.
ejaculates.
• The 3 phases of the menstrual
• Criticized for being an cycle.
ineffective method of
contraception.
• Observing fertility patterns.
• Has advantages &
• Effectiveness is similar to
disadvantages.
barrier methods.

• Does not protect against STIs

or HIV.
 Natural Family Planning
(Periodic Abstinence)
• Avoidance of intercourse during fertile days.

• Only method of contraception acceptable to the Roman

Catholic Church.

• The human ovum can be fertilized no later than 16 to 24hours

after ovulation.

• Pregnancy is unlikely to occur if a couple abstains from

intercourse 4 days before and 3 or 4 days after ovulation (fertile
period).

• Women with irregular periods have the greatest risk of failure

with this form of contraception.
 Calendar Rhythmic Method
• Practice is based on the number of days in each cycle,
counting form the first day of the menses.

• Fertile period is determined after accurately recording

the lengths of menstrual cycle for 6 months.

• The beginning of the fertile period is estimated by

subtracting 18 days from the length of the shortest cycle.

• The end of the fertile period is determined by subtracting

11 days from the length of the longest cycle.
Standard Days Method (SDM)
• The Standard Days Method is a kind of
calendar method. It is a way to keep track of
your cycle.
• You can only use it if you have regular cycles.
• Your cycle is never shorter than 26 days.
• Your cycle is never longer than 32 days.
• You will not have unprotected vaginal intercourse
from day 8 through day 19 of each cycle.
• Most women use special strings of beads for the
Standard Days Method.
Basal Body Temperature Method
(BBT)
• The lowest body temperature of a healthy
person, taken immediately after waking and
before getting out f bed.

• Temperature varies between 36.2 degrees

Celsius to 36.3 degree Celsius.

• At the time of ovulation there will be a slight drop

in temp (appx 0.5 degree Celsius) for some
women.

• Infection, fatigue, less than 3 hours of sleep per

night, awakening late, and anxiety may cause
temperature fluctuations & alter the expected
pattern.
 Cervical Mucus Ovulation-
Detection Method
• Women check the quantity & character of mucus
on the vulva or introitus with fingers or tissue
paper each day for several months to learn the
cycle.

• The cervical mucus should be free from semen,

contraceptive gels or foams and blood or
discharge from vaginal infections for at least one
full cycle.
 Sympothermal Method
• It combines the BBT and cervical mucus
methods.
• The woman gains fertility awareness as she
learns the physiologic & psychologic symptoms
that mark the phases of her cycle.
• The woman is taught to palpate her cervix to
assess for changes indicating ovulation.
• Calendar calculations and cervical mucus
changes are used to estimate the onset of the
fertile period.
 Home Predictor Test Kit for
Ovulation
• A urine predictor test used by women who want
to plan the time of their pregnancies & for those
who are trying to conceive.

• The urine predictor test detects the sudden

surge of LH that occurs appx 12 to 24 hours
before ovulation.

• The test is not affected by illness, emotional

upset or physical activity.
 Breast Feeding: Lactational
Ammenorrhea Method
• When the infant suckles at the mother’s
breast, a surge of prolactin hormone is
released, which inhibits estrogen
production and suppress ovulation & the
return of the menses.
 Barrier Methods
Spermicides Condoms
• Nonoxynol- 9 ( N-9 ) is a • The male condom is a thin,
surfactant that destroys the stretchable sheath that
sperm cell membrane covers the penis before
• The chemicals attack the contact and removed after
sperm flagella and body ejaculation
preventing the sperm from • Made of latex rubber,
reaching the cervix polyurethane, or natural
• OTC aerosol foams, tablets, membranes such as animal
suppositories, creams, films, tissue ( lamb cecum )
and gels
• Provide a physical barrier
• Should be inserted not for sperm as well as STIs
more than one hour prior to
sexual intercourse
• The female condom is a
• Must be reapplied for each
vaginal sheath made of
additional act of intercourse
polyurethane with flexible
• Effectiveness depends on rings at both ends. The
consistent and accurate use closed end is inserted into
the vagina and anchored
around the cervix; the open
ring covers the labia.
 Barrier Methods Cont’s
Diaphragm
• A shallow, dome shaped, latex or silicone device with a
flexible rim that covers the cervix
• A mechanical barrier to the sperm meeting with the cervix
and a chemical barrier to pregnancy when spermicide is
used
• For proper placement, it must rest behind the pubic
symphysis and completely cover the cervix
• Should be replaced every 2 years or refitted if there is a
20% loss or gain in weight, if she has given birth, had a
second trimester miscarriage, and after any abdominal or
pelvic surgery
• Can be inserted up to 6 hours prior to intercours
• Women should be reminded to empty their bladder before
insertion and after intercourse
• Not a good choice for women with poor vaginal muscle
tone or recurrent UTIs
• Contraindicated for women with uterine prolapse or a
large cystocele
• Although rare, toxic shock syndrome can occur if the
diaphragm is left in too long
 Barrier Methods Cont’s
Cervical Cap
• A soft, small rubber or latex-free silicone dome with firm brim
fitting snugly around the base of the cervix

• Recommended that it remain in place no less than 6 hours

and no more than 48 hours

• Differences from the diaphragm are the smaller size, it can

be inserted hours before sexual intercourse without a later
need for additional spermicide. It requires less spermicide
than the diaphragm when initially inserted, and no additional
spermicide is required for repeated acts of intercourse.

• The woman must check the position of the cap before and
after each act of intercourse
Vaginal Barriers
CONTRACEPTIVE SPONGE
•Small, round polyurethane sponge containing N-9
spermicide designed to fit over the cervix
•Must be moistened with water prior to insertion
•Provides protection for up to 24 hours and can be used
for multiple instances of intercourse
•Should be left in place for at least 6 hours after the
last act of intercourse
•Wearing it longer than 24 – 30 hours puts the woman at
risk for TSS

CONTRACEPTION: HORMONAL METHODS

•Formulations include combined estrogen-progestin
steroidal medications or progestational agents
•Administered orally, transdermally, vaginally,
implantational, or by injection
 Hormonal Methods
Combined Estrogen- Progestin Contraceptives
Oral Contraceptives
• Regular ingestion of combined oral contraceptives (COCs) suppress the
action of the hypothalamus and anterior pituitary, leading to insufficient
secretion of FSH and LH; therefore follicles do not mature, and
ovulation is inhibited.
• Should be taken at the same time every day to maintain adequate
hormone levels and to enhance compliance
• Contraindications for use include history of thromboembolic disorders,
cerebrovascular or CAD, breast cancer, estrogen dependent tumors,
pregnancy, impaired liver function, liver tumor, lactation less than 6
weeks postpartum, smoking , headaches with focal neurologic symptoms
, surgery with prolonged immobilization , any leg surgery, hypertension,
and diabetes mellitus ( of more than 20 years) with vascular disease
• Effectiveness of oral contraceptives is decreased when combined with
certain medications. Use a second method of birth control while taking
them.
• Fertility usually returns quickly after discontinuing oral contraceptives
yet fertility rates are slightly lower for the first 3 to 12 months
Transdermal Contraceptive
System
• Delivers continuous levels of progesterone and ethynyl
estradiol
• Can be applied to lower abdomen, upper arm, buttock, or
upper torso
• Application is on the same day once a week for 3
weeks, followed by a week without a patch
• Bleeding occurs during the week without a patch
• Mechanisms, side effects, and contraindications are similar
to those of COCs

Vaginal Contraceptive Ring

• Made of ethylene vinyl acetate copolymer it delivers
continuous levels of progesterone and ethynyl estradiol
• Worn for 3 weeks followed by a week without the vaginal
ring
• Some wearers may experience vaginitis, leucorrhea, and
vaginal discomfort
• Mechanisms, side effects, and contraindications are similar
to that of COCs
 Progesterone- Only
Contraceptive
• Progestin only methods impair fertility by inhibiting ovulation,
thickening and decreasing the amount of cervical mucus, thinning the
endometrium, and altering cilia in the uterine tubes.

• Oral progestins (minipill) are less effective than COCs. They contain
such a low dose of progestin that they must be taken at the same
time every day. Some women complain of irregular vaginal bleeding.

• Injectable progestins such as Depo-Provera is given subcutaneously

or intramuscularly in the deltoid or gluteus maximus muscle. It is
given during the first 5 days of the menstrual cycle and given again
every 11 to 13 weeks.

• Implantable progestins such as Norplant consist of 6 flexible tubes

that were placed subdermally in the inner upper arm. It provided 5
years of continuous contraception. This was withdrawn from the U.S.
market in 2002.
 Emergency Contraception
• Available in over 100 countries; one • An Antiemetic is recom-mended,
third of these countries requires no 1 hour before each dose, to help
prescription with nausea.

• USA- Plan B is the only EC, without •

a prescription (limited locations). *If the woman does not have a
period 21 days after taking the
medication, she should be
• Plan B contains two doses of evaluated for pregnancy.
levonorgestrel (high doses of
estrogen and progestin.
• NURSING ALERT: EC will not
• protect a woman from
Should be taken within 72 hours of pregnancy, if she engages in
unprotected intercourse or birth
control mishap. unprotected intercourse in the
days or weeks that follow
treatment.
• Prevents ovulation by inhibiting
follicular development.
• IUDs Containing Copper
 Intrauterine Devices
• Small T- Shaped device with Disadvantages: Increases the risk of
bendable arms for insertion through Pelvic Inflammatory disease, specially
the cervix into the uterine cavity.
within the first 20 days after insertion.
Bacterial vaginosis and uterine
• Two strings hang from the stem
through the cervix and protrudes Perforation. No protection against
into the vagina. STDs of HIV

• Two FDA approved IUDs: Nursing Consideration

- The Copper T380A (Paragard)- • Thread Check after Cycles
Effective for up to 10 years
• Remove immediately if pregnancy
- Levonorgestrel Intrauterine System occurs (ultrasounds, later in
(Mirena)- Effective for up to 5 years pregnancy should be used to
localize the IUD and to rule out
placenta previa).
Advantages: Constant
contraception w/o having to take
monthly P.C. pills & the procedure • IUDs during pregnancy increases
is reversible. the chance of septic miscarriage
and ectopic pregnancies

• P.A.I.N.S
T380A & Mirena Intrauterine
Device
 Sterilization
Surgical procedure used to render a person infertile.
Female Sterilization Male Sterilization
• aka,- Bilateral Tubule Ligation • Vasectomy (sealing, tying or
• Outpatient Procedure cutting of the man’s vas
• Failure Rate (varies by method deferens, preventing sperm
and woman’s age)= 0.5% cells from the testes to the
• Tubal Occlusion – Laparoscopic penis.
tubule electrocoagulation (band, • Local Anesthesia/Outpatient
clip) or Electracoagulation and basis.
ligation (severed)
•
• Two methods of Scrotal entry:
Tubal Reconstruction-
Restoration of the tubule conventional or no-scapel
continuity (reanastomosis). vasectomy.
(expensive and uncertain) • Has no effect on potency or
volume of ejaculation
• Tubal Reconstruction- Unlike
women- 90% success rate BUT
only apx 50% become infertile.
 Laws and Regulations
• All states have strict regulations on Informed Consent.

• Many states permit voluntary sterilization of a “mature woman.”

• Sterilization of a minor are an individual who maybe mentally

incompetent is prohibited, in most states.

• Board of eugenicists or other court-appointed individuals my decide

otherwise, in certain situations.

• Legal Tip: If federal funding is used for sterilization, the individual

must be 21 years or older. An Informed consent must include the
risks, benefits and alternatives. It must include a statement that
describes sterilization as a permanent, irreversible method of birth
control and a statement that mandates a 30 day waiting period
between giving a consent the sterilization
 Sterilization/ Nursing Consideration
• Ensure all requirements regarding • Preoperative Care: Assessment,
Informed Consent is met. Laboratory Tests, confirmation of
patient understanding.
Ambivalence and extreme
• Provide information about apprehensions should be reported
alternate options (e.g to the Physician.
contraceptives).
• Post Op: Recovery from the
• Educate patient on the potential anesthesia, v/s, I & O, Lab Values,
discomfort and pain, usually felt prevention and/or early treatment
after the procedure. of infections/ hemorrhage. Control
of discomfort and assessment of
• Assure client that their sexual clnt’s emotional response to the
function will not be compromised. procedure and recovery.

• Disharge Planning: Written

Instructions should be provided.
 Abortion
• Purposeful interruption of pregnancy
before the 20th week of gestation.

• Elected abortion vs. therapeutic abortion.

• Before the 1970’s, abortions were not

legal in the United States.
 First- Trimester Abortion
• Performed less than 9 weeks of gestation

• Surgical vs. Medical Method

• Surgical (Aspiration with vacuum or suctional curettage)-

88% of women elect to use this method.

• Medical Abortion (Mifepristone with progestaglandin and

methotrexate with misoprostol). Used to induce early
abortion. Apx 10% of women uses this route.
Aspiration with vacuum or
Suctional curettage
 Second- Trimester Abortion
• Complicated and costly

• Dilation and Evacuation (D&E) accounts for almost all

the procedures performed (in the Unites States).

• Unterine contractions are induced with a hypertonic

solution (eg. Saline, urea) injected directly into the uterus
with an untertonic agent (eg. misoprostol,
dinoprostone)- 0.8% of abortions in the USA
 Dilation and Evacuation
• Can be performed at any point and up to twenty weeks of gestation.

• Cervix requires more dilation as the products of conception are

larger.

• Often laminaria are inserted several hours or several days before

the procedure.

• Misoprostol may also be applied to the cervix.

• Large cannula is used to evacuate all content, including the

placenta.

• Nursing Care Includes: V/s, providing emotional support,

administering
analgesics, and post-operative monitoring.

• Disadvantage: Possible long term damaging effect on the cervix.

 Emotional Considerations
• Calm, mater-of-fact approach • Discussion about feelings after
the abortion.
• Positive Communication
(clarifying, restating, open- • Information about post-
ended questions- etc) abortion counseling should be
provided, if necessary.
• Information about alternatives
to abortion, should be • Secondary Trimester vs First
provided, if the client chooses Trimester abortion/ level of
to keep her baby (i.e adoption anxiety and distress after the
agencies, support services) procedure.

• Client must be assured of • Actively listen, provide non

continued support if she judgmental support.
decides to go through with the
abortion.