Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Infertility
N97.9 – Female infertility, unspecified
I. DEFINITION
Inability to conceive after 1 year or more of unprotected intercourse
II. ETIOLOGY
A. Factors in male infertility: faulty sperm production; reproductive tract anomaly; physical and chemical agents (coal tar, radioactive substance, orchitis, other infection, etc.); endocrine disorders; general state of health; blocked vas deferens; testicular infection; injury to reproductive organs/tract; nerve damage; impotence; lifestyle factors (smoking, alcohol, street drugs, etc.); incompatible immunologic factors for sperm—antispermatozoa antibodies
B. Factors in female infertility: blocked fallopian tubes; anovulatory cycles; anatomical anomalies; hormonal imbalance; polycystic ovary syndrome (PCOS); obstruction of vaginal, cervical, and/or uterine cavity; hostile cervical mucus; ovarian cyst or tumor; pituitary tumor; endometriosis; previous sexually transmitted infections (STIs), vaginitis, vaginosis, pelvic inflammatory disease (PID), septic abortion; history of and drug treatment for thyroid disease, depression, asthma; lifestyle factors (alcohol, smoking, street drugs, etc.)
C. Factors in couple infertility: improper technique for intercourse; infrequent intercourse; emotional state; male and female factors contributing to infertility
III. HISTORY
A. What the patient may present with
1. History of failure to conceive for a period with no use of contraception
2. Desire for pregnancy
B. Additional information to be obtained
1. Complete medical and surgical history, including immunizations; family history
2. Complete menstrual history, including menarche, character of menses, frequency, duration, last menstrual period, postmenarche amenorrhea
3. Gynecologic history: anomalies; problems; infections; surgery; abnormal Pap smears, including loop electrosurgical excision procedure (LEEP); diethylstibestrol (DES) exposure; endometriosis; fibroids; previous treatment for menstrual disorders related to PCOS
4. Contraceptive history to the present, including postmethod amenorrhea
5. Obstetric history: any previous conceptions; number of children, abortions, stillbirths; complications
6. Partner’s reproductive history; medical, surgical history
7. Employment history: exposure to radiation, viruses, other substances known to cause sterility, teratogens
8. Sexual history: techniques, frequency, and timing of intercourse in relation to the menstrual cycle; use of lubricants, douches, sex stimulants; trauma
INFERTILITY 153
9. Report of any previous infertility testing, workups; diagnoses; interventions; genetic evaluation
10. Lifestyle history: use of recreational (street) drugs, prescription drugs, alcohol; stress; tobacco, caffeine, eating habits; saunas or hot tubs; exercise (including biking and running)
11. Age of patient/partner may determine timing of intervention
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Pulse
3. Blood pressure
B. Complete physical examination; observation of secondary sex characteristics; signs/symptoms of PCOS
C. External examination (careful observation for signs of infection, lesions, or anomalies)
1. Clitoris
2. Labia
3. Skene’s glands
4. Bartholin’s glands
5. Vulva
6. Perineum
D. Pelvic examination
1. Length of vagina
2. Position and character of cervix
3. Any anomalies
E. Bimanual examination (examine for palpable masses, tenderness, anomalies, signs of trauma)
1. Uterus
2. Ovaries
3. Adnexa
V. DIFFERENTIAL DIAGNOSIS
A. Partner infertility or sterility
B. Sterility
C. Anomaly, absence of reproductive organs
VI. LABORATORY/PRELIMINARY
A. Pap smear; mammogram as appropriate
B. Chlamydia smear; Neisseria gonorrhea culture; rapid plasma reagin (RPR) status (syphilis), tuberculosis status, HIV, hepatitis status, rubella titer, varicella titer
C. Pregnancy test in amenorrhea
D. Complete blood cell count; erythrocyte sedimentation rate
E. Serum progesterone level Days 21 to 23 of cycle
F. Wet mount, vaginal cultures
G. Prolactin level, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), Rh factor, blood type (preferably Days 3–5 of cycle)
H. Hormonal assay (serum) such as FSH, LH, prolactin, estrogen dehydroepiandrosterone sulfate (DHEAS), testosterone, urinary LH 4 to 5 days at midcycle
VII. TREATMENT AND INTERVENTION
A. Infertility workup for the woman
1. Procedures
a. Basal body temperature charts; may use test for LH surge instead
b. Commercially available ovulation tests or devices and fertilitymonitoring devices1
c. Postcoital test—serial if antispermatozoa antibodies
d. Cervical mucus test; sperm antibody level; sperm agglutination test; sperm immobilization test
e. Hysterosalpingogram after menses, before ovulation
f. Endometrial biopsy during luteal phase (2 to 3 days before menstruation)
g. Tuboscopy
h. Ultrasound
i. Laparoscopy with chromotubation, hydrotubation; hysteroscopy; salpingogoscopy
2. Laboratory
a. Workup of partner involving tests done by specialist
b. For complete workup, referral may be in order
VIII. COMPLICATIONS
A. Risks associated with certain tests; costs of testing
B. Persistent infertility, discovery of sterility
C. Effects on couple’s relationship
IX. CONSULTATION/REFERRAL
To gynecologist or infertility specialist; reproductive technology centers; genetic counseling
X. FOLLOW-UP
Long-term process for workup that is staged so patient would be asked to return for next phase of testing if conception not achieved
See PCOS, Chapter 19. See Bibliographies.
NOTE
1. Basal body temperature monitoring; saliva microscopes; ovulation predictor tests, such as Ova-Cue Fertility Monitor.