Chapter 20 LO

Chapter 20
Family Planning and Infertility
Copyright 2008 by Saunders, an imprint of Elsevier Inc.
Chapter 20
Lesson 20.1
Objectives
1. 2.
3. 4.
5.
6.
Define key terms listed. Identify factors that influence the womans choice of contraceptive method. Discuss five types of contraception. Explain how the male condom should be used to be most effective. Describe a method of contraception that reduces the risk of sexually transmitted infections. List advantages and disadvantages of five types of contraception.
Family Planning
Choice involves

Personal Social Economic Religious Cultural
Reversible Contraception
Decisions on what to use should be

Voluntary With full knowledge of Advantages and disadvantages Effectiveness Side effects Contraindications Long-term effects
Factors in Selecting Contraception

Cost of method Effectiveness Availability Partners support and willingness to cooperate Safety of method Protection against sexually transmitted infections (STIs) Convenience Desirability or personal preference Personal motivation and compliance Religious and moral factors Medical problems
Abstinence
Acts as a contraceptive by eliminating the possibility of sperm entering the womans vagina. Completely effective in preventing pregnancy Is a means of avoiding STIs Rhythm method of contraception includes abstinence during her menstrual cycle when she is most fertile
Fertility Awareness
The understanding that a woman is fertile at ovulation Time of ovulation can be confirmed by

Basal body temperature (BBT) Cervical mucus method (aka Billings method) Symptothermal method Chemical predictor test Rhythm methods (aka calendar method)
Mechanical Barrier Methods

Chemicals or devices Prevent transport of sperm to cervix or implantation of fertilized ovum Spermicides inserted at least 1 hour before coitus
Rarely effective if used alone; use with condom, diaphragm, or cervical cap
Vaginal Spermicides

Immobilize and destroy sperm Neutralize vaginal secretions Viruses and some other pathogens are not susceptible to spermicides Cannot be relied on to protect against STIs Examples: creams, foams, film, suppositories
10
Spermicides
Activate when exposed to body warmth in vagina
Short acting Inactive within an hour after insertion A single application provides protection against 1 ejaculation Can be messy, leak

Low cost and safe Failure rate is 6%
11
Male Condom

Flexible sheath worn over erect penis Inexpensive, accessible, effective means of contraception Reduces spread of STIs Failure rate 3%; if used with spermicides, failure rate 2% or less 4 basic features differ among condoms

Material: latex or polyurethane Shape: reservoir at tip Lubricant: wet jelly or dry powder Spermicides
12
Male Condom (contd)
Latex
Prolonged storage in hot humid climates, or contact with vaginal antifungal creams, suntan oil, or oil-based lubricants, such as petroleum jelly, will cause the latex to break down and the condom will be ineffective for birth control
Polyurethane
Less constricting fit, more resistant to deterioration May enhance sensitivity Compatible with oil-based lubricants Protect against STIs
13
Female Condom
A thick lubricated polyurethane sheath, 7 inches long with flexible ring at each end

Inner ring serves as means of insertion Covers cervix like diaphragm 2nd rings remains outside vagina
Can insert up to 8 hours before intercourse OTC and single use only Do not use with male condom Failure rate is 21%
14
Diaphragm
Latex or rubber cup surrounded by spring or coil that fits snugly over cervix
Can put spermicidal cream or gel in dome and around rim
Prevents passage of sperm into cervix Requires fitting by health care provider
Size should be rechecked after each term birth or if woman gains or loses 4.5 kg (10 lb)
15
Diaphragm (contd)
Holds spermicide in place against cervix for the 6 hours it takes to destroy the sperm Can be inserted up to 4 hours before intercourse Spermicide must be inserted into vagina each time intercourse is repeated Do not leave in place longer than 24 hours Cannot be relied on to protect against STIs Failure rate is 6%
16
Cervical Cap
Cup-shaped device, smaller than diaphragm

Once placed over cervix, remains in placed by suction Not all women can be fitted for this
Can remain in place 24 to 48 hours Fitting should be checked yearly, after childbirth, and after vaginal or uterine surgery
17
Intrauterine Device (IUD)
Small, T-shaped, flexible device inserted by health care provider Provides continuous pregnancy prevention Most often prescribed for women who have had at least 1 term pregnancy Not recommended for women with multiple sexual partners Does not protect against STIs
18
Contraindications for IUD Insertion

Liver disease Copper allergy Breast cancer Immunodeficiency disorders Immunosuppressive therapy Uterine abnormalities Pelvic infection or disorder Undiagnosed vaginal bleeding
19
Hormonal Contraceptives
20
Oral Contraceptives (OCs)
Birth control pill
Prevents pregnancy by suppressing ovulation through combined actions of synthetic estrogen and progestin Thickens cervical mucus Alters decidua of uterus, preventing implantation
Failure rate 1% if taken as directed
21
Minipill

Contains only progestin Works in same way as regular pill but is less effective in suppressing ovulation
22
Side Effects of OCs
Can range from nausea to breakthrough bleeding to thrombus formation
May be either estrogen or progestin related
Adolescents must have at least 3 ovulatory cycles before starting OCs After term delivery, OCs can be started about 4 weeks postpartum OCs can decrease volume of breast milk, so do not start until milk well established
23
Warning Signs for OC Use
Woman should be instructed to notify health care provider if she has
Breast lump Depression Jaundice Abdominal pain Severe leg pain Severe headaches or dizziness Weakness or numbness Vision loss or blurred vision Speech problems Chest pain, cough, or shortness of breath
24
Contraindications to OCs
Vascular pathologic conditions

Thromboembolism or pulmonary embolism Stroke, atherosclerosis, heart disease or failure Hypertension
Breast cancer within 5 years Diabetes with neuropathy Retinopathy, liver disease Smoking Age older than 35 years Pregnancy Migraines with aura
25
Education About OCs

Proper use can increase effectiveness Combination OCs come in packets of 21 or 28 tablets Important to take pill at same time every day
Keeps blood hormone levels stable
Review what she should do if a pill is missed Certain drugs, such as antibiotics, can interfere with effectiveness of OC
26
Follow-up Care for Women Taking OCs

Yearly pelvic examination Pap smear Breast examination Blood pressure measurement
27
Hormonal Skin Patch
Applied to dry skin of buttock, abdomen, upper arm, or torso on 1st day of menstrual period
Wear patch for 1 week and replace each week x 3; week 4 is patch free
Advantages: consistent level of hormone in blood, avoids liver metabolism Not recommended for women weighing 90 kg (198 lb) or more
28
Vaginal Ring
Flexible silicone ring inserted into vagina for 3 weeks, removed for 1 week to allow for menstruation Provides steady low-dose hormone Leukorrhea and vaginal infections common side effects Fertility returns rapidly after ring discontinued
29
Implantable Contraceptives
Implanon, single silicone rod that uses etonogestrel Inserted subdermally Provides contraception for 3 years Does not prevent STIs Can be inserted or removed in outpatient clinic under local anesthesia
30
Injectable Contraceptives
Depo-medroxyprogesterone acetate (DMPA) suspension (Depo-Provera)

Long-acting, injectable progestin Alters cervical mucus so it is hostile to sperm Impairs ovulation and implantation Contraceptive effect could last up to 1 year
Single injection every 3 months
Pregnancy test performed before 1st injection Side effects: menstrual spotting, headache, weight gain; does not protect against STIs
31
Emergency Contraception
Effective if started 24 to 72 hours after unprotected intercourse Take 1 pill, then another 12 hours later Side effects include nausea, vomiting, breast tenderness, and menstrual irregularities Noncompliance with regimen is most common cause of failure
32
Least Effective Methods of Contraception
33
Coitus Interruptus (Withdrawal)
Man withdraws penis from vagina before ejaculation Prevents large quantity of sperm from being deposited into vagina May misjudge timing and withdraw too late Also, fluid that escapes from penis before ejaculation also contains sperm
NOT A RELIABLE METHOD OF BIRTH CONTROL
34
Postcoital Douche
Sperm are known to appear in cervical mucus within a few seconds after ejaculation Sperm can reach site of fallopian tube within a short time Once sperm are in tube, pregnancy can results and douching will not prevent this
35
Breastfeeding
Inhibits ovulation because prolactin alters ovarian response to hormones and return of menses Frequency, intensity, and duration of breastfeeding may maintain anovulatory status for 4 to 6 months; then prolactin decreases and ovulation returns Pregnancy can occur before menses returns
36
Permanent Contraception
Legal aspects
Informed consent Should include risks, benefits, alternatives, and a

statement that procedure is permanent and may be irreversible
No absolute guarantee that the procedure will prevent pregnancy in most procedures Some states require a 30-day waiting period
37
Male Sterilization
Minor surgical procedure
3-cm incision made and vas deferens is severed and occluded
Takes approximately 6 weeks and up to 36 ejaculations to clear remaining sperm On follow-up visits, man may be asked to submit semen samples to assess sperm count Can be reversed in some cases Vasectomy has no effect on sexual performance
38
Female Sterilization

Tubal ligation: surgical procedure Transcervical occlusion: a coil is inserted into each fallopian tube, leading to complete occlusion within 3 months Neither protects against STIs Does not affect menstruation or sexual performance
39
Nursing Responsibilities Related to Sterilization

Listen to patients concerns Verify information regarding benefits, risks, and alternatives Provide emotional support Discuss

Preoperative and postoperative care Signs and symptoms to report
40
Chapter 20
Lesson 20.2
41
Objectives
7. 8. 9.
10.
11. 12.
Describe a therapy to facilitate pregnancy. Review factors that contribute to infertility. Describe four types of treatment protocols in the management of infertility. Explain male sterilization. Explain female sterilization. Discuss the role of the nurse in caring for patients with contraceptive or fertility problems.
42
Infertility and Therapies to Facilitate Pregnancy
43
Definitions of Fertility and Infertility
Fertility: the capacity to conceive or reproduce Infertility: the inability to conceive or reproduce after 1 year of regular, unprotected sexual intercourse; or the inability to conceive at the time desired Sterility: partner has irreversible factor that prevents fertility
44
Infertility

Primary Secondary Unsuccessful pregnancy Single infertility
45
Cultural and Religious Considerations
Fertility (or lack of) is strictly seen as a female problem by some cultures Stigma of infertility can lead to divorce or rejection by family or society Religious norms influence what tests or treatments can be pursued
46
Factors in Fertility

Coital frequency: 3 times per week Age: woman older than 35 years Smoking: increases peristalsis of fallopian tubes Exercise and weight loss
Too much exercisemenstrual irregularity Excessive weightamenorrhea

Diet: B12 deficiency Stress: significant cause of infertility Medical conditions
Pelvic adhesions, pelvic inflammatory disease Endocrine disorders
Use of drugs (prescription or illicit) Exposure to chemicals
47
Infertility Management Program

Contributing factors are discussed Before treatment is initiated, diagnostic tests may be performed Tests may include tubal function, ovulation, hormone levels, BBT, endometrial biopsy Multidisciplinary team includes endocrinologist, urologist, psychologist, gynecologist, nurse, and the couple
48
CAM Medical Therapy for Infertility
Acupuncture thought to increase sperm counts in the male
Ginseng and astragalus
Enhance assisted reproductive technology in the female
49
Male Infertility

Defect in transport system of sperm Defect in sperm production Inability to deposit sperm into woman Use of tobacco, alcohol, illicit drugs can also contribute Some prescription drugs can inhibit sperm production, cause ejaculatory problems, or lead to erectile dysfunction
50
Fertility Tests for Males

Semen and sperm analysis Transrectal ultrasound Hormonal profile Postejaculatory urinalysis to test for retrograde ejaculation Vasograph Genetic testing Postcoital sperm count
51
Treatment of Male Infertility

Surgical intervention for varicocele Antimicrobial therapy for genital infections or trauma to reproductive tract Medications and mechanical aids can be used for erectile dysfunction Instruct male to wear loose-fitting underwear; avoid saunas, smoking, St Johns wort, anabolic steroids; and eat healthy diet
52
Treatment of Female Infertility
Transcervical balloon tuboplasty to unblock fallopian tubes Laparoscopy or laparotomy Laser to remove scar tissue
53
Assisted Reproductive Technology
54
Legal and Ethical Factors in Assisted Reproduction
Can be used in a variety of ways besides helping infertile couples

Couples who want to avoid genetic anomalies Sperm or egg donors Surrogate parent (mother, father, or both) Homosexual couples Single parents
Cloning of a lost child may someday be possible What to do with frozen embryos
55
Assisted Reproductive Techniques (ART)
Examples include

In vitro fertilization (IVF) Gamete intrafallopian transfer (GIFT) In vitro fertilizationembryo transfer (IVF-EF)
Each begins with ovulation induction to permit retrieval of ova Maternal risks include multifetal pregnancy, preterm labor, preeclampsia, cesarean birth, ectopic pregnancy, pelvic organ damage or infection Fetal risks include prematurity, chromosomal anomalies
56
Ovulation Induction
Woman is given medications to induce ovulation
Ovarian hyperstimulation syndrome is not uncommon when ovarian enlargement and follicular cysts are present
One of 3 medications
Selective estrogen receptor modulators Aromatase inhibitors Injectable gonadotropins
57
Therapeutic Insemination

Formerly known as artificial insemination Instillation of ova or sperm into uterus to aid conception Intrauterine insemination can also be used Donor sperm and ova may be frozen and held for 6 months before use to reduce risk of infections that may not have been detectable at initial screening
58
Role of the Nurse in Contraception and Infertility
Assess contraceptive knowledge, attitudes and plans for pregnancy, need for family planning, and preferred methods Nurse is an educator, advocate, and counselor who offers the couple a sense of control and acceptance
59
Question for Review
Why should birth control pills be delayed at least 4 weeks before restarting them after delivery?
60
Review Key Concepts of the Chapter
61

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Chapter 20

Family Planning and Infertility

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Personal Social Economic Religious Cultural

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Decisions on what to use should be

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Factors in Selecting Contraception

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Mechanical Barrier Methods

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Activate when exposed to body warmth in vagina

Low cost and safe Failure rate is 6%

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Male Condom (contd)

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Can put spermicidal cream or gel in dome and around rim

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Cup-shaped device, smaller than diaphragm

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Intrauterine Device (IUD)

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Contraindications for IUD Insertion

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Oral Contraceptives (OCs)

Birth control pill

Failure rate 1% if taken as directed

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Side Effects of OCs

Can range from nausea to breakthrough bleeding to thrombus formation

May be either estrogen or progestin related

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Warning Signs for OC Use

Woman should be instructed to notify health care provider if she has

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Vascular pathologic conditions

Thromboembolism or pulmonary embolism Stroke, atherosclerosis, heart disease or failure Hypertension

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Education About OCs

Keeps blood hormone levels stable

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Follow-up Care for Women Taking OCs

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Hormonal Skin Patch

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Depo-medroxyprogesterone acetate (DMPA) suspension (Depo-Provera)

Single injection every 3 months

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Least Effective Methods of Contraception

Copyright 2008 by Saunders, an imprint of Elsevier Inc.