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Infertility is a prolonged time to conceive, while sterility is the inability to conceive. If a couple does not achieve pregnancy after a year of unprotected intercourse, they are advised to seek fertility evaluation. This evaluation is recommended sooner for those who are unable to conceive after six months of attempting pregnancy, women older than 35, or those who have a known risk factor for infertility. Primary infertility is difficulty conceiving when there has never been a pregnancy. Secondary infertility is difficulty conceiving after having had a pregnancy, regardless of the outcome.
A normally developed reproductive tract in both the male and female partner is essential for fertility. Normal functioning of an intact hypothalamic–pituitary–gonadal axis supports gametogenesis. Sperm remains viable in the female’s reproductive tract for 48 hours or more, but only a few retain fertilization potential for more than 24 hours. Ova remain viable for about 24 hours. Infertility may also be caused by something as simple as poor timing, inadequate frequency of intercourse, or lack of penile penetration.
10% to 20% of couples will have idiopathic (unexplained) infertility.
Infertility assessment: Investigation of impaired fertility begins with a complete history and physical examination. A complete general physical examination is followed by a specific assessment of the reproductive tract and laboratory data.
Female Infertility Causes
Hormonal and ovulatory factors, Tubal and peritoneal factors, Uterine malformations, Endometriosis, Developmental anomalies, Endometritis, Vaginal-cervical factors
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Male infertility causes
Can be caused by structural and hormonal disorders, Undescended testes, Hypospadias, Varicocele (varicose vein of the scrotum), Low testosterone levels, Azoospermia: no sperm cells produced, Oligospermia: few sperm cells produced, Additional Health Issues (similar to women)
Nutritional, genetic & endocrine disorders
STI’s, obesity, environmental hazards
Substance use and abuse; advanced age
Transgender Fertility Issues: Transgender clients have several options for reproduction. Sexually mature individuals may choose cryopreservation of their oocytes or sperm prior to gender confirmation surgery. Individuals with intact reproductive organs may choose to discontinue their hormone replacement therapy and proceed with fertility care based on their biological sex.
Religious Considerations in Fertility: Health care providers must be aware of civil laws and religious proscriptions about sex. Conservative and reform Jewish couples are accepting of most infertility treatment; however, the Orthodox Jewish couple may face problems with infertility investigation and management because of religious laws that govern marital relations. The Roman Catholic Church considers the embryo a human being from the moment of conception; additionally, it regards the following technical procedures as unacceptable: in vitro fertilization (IVF), masturbation to collect semen for the husband/partner, therapeutic donor insemination (TDI), and the freezing of embryos. Other religious groups may have ethical concerns about infertility tests and treatments. Care providers should seek to understand the woman’s spiritual and religious beliefs and how they affect her perception of health care, especially in relation to infertility.
Cultural Considerations in Fertility: In many cultures the responsibility for infertility is usually attributed to the woman. A woman’s inability to conceive may be a result of her sins, evil spirits, or the idea that she is an inadequate person. The virility of a man in some cultures remains in question until he demonstrates his ability to reproduce by having at least one child. Families and faith-based organizations may be disapproving and unsupportive of LGBTQ families.
The nurse begins assessment by obtaining data relevant to fertility through interviewing and assisting in physical examination. The database must include information to identify whether infertility is primary or secondary. Religious, cultural, and ethnic data should be noted.
Options for People Who Have Infertility
Options for People Who Have Infertility
Assisted Reproductive Therapy (ART): manipulation of eggs, sperm, and/or embryo
Ovarian Stimulation: stimulate ovulation using medication
Intrauterine Insemination (IUI): inject sperm into the uterine cavity while ovulation is occurring
In Vitro Fertilization–Embryo Transfer (IVF-ET) retrieve an egg and expose it to sperm, once fertilized implant the embryo into the uterine cavity
Intracytoplasmic sperm injection (ICSI): inject a sperm directly into the egg, implant the embryo into the uterine cavity
Preimplantation genetic diagnosis likely will be done on the embryo to ensure it is genetically healthy
Gamete intrafallopian transfer (GIFT): Similar to IVF, but the mixture of eggs and sperm occurs by laparoscopic injection into the fallopian tube
ZIFT (zygote intrafallopian transfer): Similar to GIFT, but the zygote is inserted into the fallopian tube
Oocyte Donation/ Sperm Donation/ Embryo Donation: used for those who cannot produce healthy eggs or sperm themselves
Surrogate: The embryo is implanted into a woman who will carry the pregnancy
Other Options:
Adoption: The family chooses a child that is already born to raise in their family
Choosing to live without children
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Association of Professors of Gynecology and Obstetrics (2015, September 9). Topic 48: Infertility
Let's Practice!: Infertility
Let's Practice!: Infertility
Answer the following questions about infertility to check your knowledge.
Answer the following questions about infertility to check your knowledge.
Which test used to diagnose the basis of infertility is done during the luteal or secretory phase of the menstrual cycle?
Hysterosalpingogram
Endometrial biopsy
Laparoscopy
Follicle Stimulating Hormone (FSH) level
Answer: 2
Endometrial biopsy is scheduled after ovulation, during the luteal phase of the menstrual cycle.
A hysterosalpingogram is scheduled 2 to 5 days after menstruation to avoid flushing potentially fertilized ovum out through a uterine tube into the peritoneal cavity.
Laparoscopy usually is scheduled early in the menstrual cycle.
Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular.
A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant. The nurse's most appropriate response is:
A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant. The nurse's most appropriate response is:
"Your sperm count seems to be okay in the first semen analysis."
"Only marijuana cigarettes affect sperm count."
"Smoking can give you lung cancer, even though it has no effect on sperm."
"Smoking can reduce the quality of your sperm."
Answer: 4
Use of tobacco, alcohol, and marijuana may affect sperm
"Your sperm count seems to be okay in the first semen analysis" is inaccurate. Sperm counts vary from day to day and depend on emotional and physical status and sexual activity. Therefore a single analysis may be inconclusive.
A minimum of two analyses must be performed several weeks apart to assess male fertility.
Use of tobacco, alcohol, and marijuana may affect sperm counts.
A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional test is needed?
A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional test is needed?
Testicular biopsy
Antisperm antibodies
Follicle Stimulating Hormone (FSH) level
Examination for testicular infection
Answer: 3
The woman has irregular menstrual cycles. The scenario does not indicate that she has had any testing related to this irregularity. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular.
Determination of blood levels of prolactin, FSH, luteinizing hormone (LH), estradiol, progesterone, and thyroid hormones may be necessary to diagnose the cause of irregular menstrual cycles.
A testicular biopsy would be indicated only in cases of azoospermia (no sperm cells) or severe oligospermia (low number of sperm cells).
Antisperm antibodies are produced by a man against his own sperm. This is unlikely to be the case here, because the husband has already produced children.
Examination for testicular infection would be done before semen analysis. Furthermore, infection would affect spermatogenesis.)
In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes or unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their preprocedural interview. The husband asks the nurse to explain what the procedure entails. The nurse's most appropriate response is:
In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes or unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their preprocedural interview. The husband asks the nurse to explain what the procedure entails. The nurse's most appropriate response is:
"IVF is a type of assisted reproductive therapy that involves collecting eggs from your wife's ovaries, fertilizing them in the lab with your sperm, and transferring the embryo to her uterus."
"A donor embryo will be transferred into your wife's uterus."
"Donor sperm will be used to inseminate your wife."
"Don't worry about the technical stuff; that's what we are here for."
Answer: 1
A woman's eggs are collected from her ovaries, fertilized in the laboratory with sperm, and transferred to her uterus after normal embryonic development has occurred.
The statement, "A donor embryo will be transferred into your wife's uterus" describes therapeutic donor insemination.
"Donor sperm will be used to inseminate your wife" describes the procedure for a donor embryo.
"Don't worry about the technical stuff; that's what we are here for" discredits the client's need for teaching and is not the most appropriate response.
Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with a number of legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives so couples can make informed decisions about their choice of treatment. Which issue would not need to be addressed by an infertile couple before treatment?
Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with a number of legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives so couples can make informed decisions about their choice of treatment. Which issue would not need to be addressed by an infertile couple before treatment?
Risks of multiple gestation
Whether or how to disclose the facts of conception to offspring
Freezing embryos for later use
Financial ability to cover the cost of treatment
Answer: 4
Although the method of payment is important, obtaining this information is not the responsibility of the nurse.
It is also of note that 14 states have mandated some form of insurance to assist couples with coverage for infertility.
Risks of multiple gestation is indeed a risk of treatment of which the couple needs to be aware. To minimize the chance of multiple gestation, generally only three or fewer embryos are transferred.
The couple should be informed that there may be a need for multifetal reduction. Nurses can provide anticipatory guidance on this matter.
Depending on the therapy chosen, there may be a need for donor oocytes, sperm, embryos, or a surrogate mother.
Couples who have excess embryos frozen for later transfer must be fully informed before consenting to the procedure.
A decision must be made regarding the disposal of embryos in the event of death or divorce or if the couple no longer wants the embryos at a future time.
A client asks the nurse about the gamete intrafallopian transfer (GIFT) procedure. Which of the following responses would be appropriate for the nurse to make?
A client asks the nurse about the gamete intrafallopian transfer (GIFT) procedure. Which of the following responses would be appropriate for the nurse to make?
Fertilization takes place in the woman's body
Zygotes are placed in the fallopian tubes
Donor sperm are placed in a medium with donor eggs
A surrogate carries the infertile woman's fetus
Answer: 1
Fertilization takes place in the woman's body
The nurse is teaching a class on infertility. The nurse describes infertility as:
The nurse is teaching a class on infertility. The nurse describes infertility as:
Difficulty conceiving because both partners have decreased fecundity.
Women over 35 who are having difficulty conceiving.
The lack of conception despite unprotected sexual intercourse for at least 12 months.
An absolute factor preventing reproduction.
Answer: 3
The lack of conception despite unprotected sexual intercourse for at least 12 months
Infertility is defined as lack of conception despite unprotected sexual intercourse for at least 12 months.
When there is an absolute factor preventing reproduction, it is described as sterility.
A couple having difficulty conceiving because both partners have decreased fertility characterizes subfertility (reduced ability to conceive).
Being a woman over 35 and having difficulty conceiving is a possible risk factor for infertility but does not describe infertility.
The nurse is teaching a couple about fertility during the female reproductive cycle. The couple asks the nurse, "When is the most fertile time for intercourse?" What is the best response by the nurse?
During the luteal phase
3-4 days before and after ovulation.
During the follicular phase.
12-24 hours before and after ovulation.
Answer: 2
3-4 days before and after ovulation.
Based on serial BBT charts, the clinician might recommend sexual intercourse every
other day beginning 3-4 days prior to and continuing until 2-3 days after the expected time of ovulation.
A married woman presents to the infertility clinic. She reports an inability to get pregnant again. She has no children, and a history of two ectopic pregnancies. The nurse can anticipate which test or workup to be ordered for this client?
Endometrial biopsy.
Huhner test.
Hysterosalpingography.
Basal body temperature recording
Answer: 3
Hysterosalpingography.
Ectopic pregnancies can cause scarring in the fallopian tubes, thereby causing an obstruction between the ovaries and the uterus.
Hysterosalpingography is the test to determine tubal patency and uterine structure.
A nurse is working with four clients desiring in vitro fertilization (IVF). Which clients would be good candidates for IVF? Select all that apply.
The client with tubal blockage.
The client whose husband has a very low sperm count.
The client with immunological infertility.
The client with absence of a uterus.
Answers: 1 & 2
The client with tubal blockage.
The client whose husband has a very low sperm count.
The in vitro fertilization (IVF) procedure is selectively used in cases in which
infertility has resulted from tubal factors; mucus abnormalities; male infertility; unexplained
infertility; male and female immunologic infertility; and cervical factors. In IVF, a woman's
eggs are collected from her ovaries, fertilized in the laboratory, and placed into her uterus after
normal embryo development has begun
Worksheets
Worksheets
worksheet Contraception and Infertility.pdfOther Resources
Other Resources
American College of Obstetricians and Gynecologists (2023). Treating Infertility. https://www.acog.org/womens-health/faqs/treating-infertility
Carson, S.A. & Kallen, A.N. (2022, July 21). Diagnosis and Management of Infertility: A Review. Journal of the American Medical Association, 326(1), 65-76. doi: 10.1001/jama.2021.4788
Centers for Disease Control (2023, March 20). Assisted Reproductive Technology (ART) Patient Resources. https://www.cdc.gov/art/patientresources/index.html
Centers for Disease Control (2023, April 26). Infertility FAQs. https://www.cdc.gov/reproductivehealth/infertility/index.htm
Halleran, M., Chernoff, A., & Gordon, J.L. (2022, February 11). Fertility Knowledge Among Women Struggling to Conceive Without Medical Intervention: A Brief Report. Frontiers in Global Women's Health, 3. doi: 10.3389/fgwh.2022.828052
National Institutes of Health (2017, January, 31). Infertility and Fertility Resources. https://www.nichd.nih.gov/health/topics/infertility/more_information/resources
National Institutes of Health (2023). Infertility and Fertility. https://www.nichd.nih.gov/health/topics/infertility
Walker, M.H. & Tobler, K.J. (2022, December 19). Female Infertility. https://www.ncbi.nlm.nih.gov/books/NBK556033/
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