READINGS:

Introduction

Unit II examines ethical, legal, and legislative issues affecting leadership and management as well as professional advocacy. This chapter focuses on applied ethical decision making as a critical leadership role for managers. Chapter 5 examines the impact of legislation and the law on leadership and management, and Chapter 6 focuses on advocacy for patients and subordinates and for the nursing profession in general.

Ethics is the systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and the study of what a person’s life and relationships should be, not necessarily what they are. Ethics is a system of moral conduct and principles that guide a person’s actions in regard to right and wrong and in regard to oneself and society at large.

Ethics is concerned with doing the right thing, although it is not always clear what that is.

Applied ethics requires application of normative ethical theory to everyday problems. The normative ethical theory for each profession arises from the purpose of the profession. The values and norms of the nursing profession, therefore, provide the foundation and filter from which ethical decisions are made. The nurse-manager, however, has a different ethical responsibility than the clinical nurse and does not have as clearly defined a foundation to use as a base for ethical reasoning.

In addition, because management is a discipline and not a profession, its purpose is not as clearly defined as medicine or law; therefore, the norms that guide ethical decision making are less clear. Instead, the organization reflects norms and values to the manager, and the personal values of managers are reflected through the organization. The manager’s ethical obligation is tied to the organization’s purpose, and the purpose of the organization is linked to the function that it fills in society and the constraints society places on it. So, the responsibilities of the nurse-manager emerge from a complex set of interactions.

Society helps define the purposes of various institutions, and the purposes, in turn, help ensure that the institution fulfills specific functions. However, the specific values and norms in any institution determine the focus of its resources and shape its organizational life. The values of people within institutions influence actual management practice. In reviewing this set of complex interactions, it becomes evident that arriving at appropriate ethical management decisions can be a difficult task.

In addition, nursing management ethics are distinct from clinical nursing ethics. Although significant research exists regarding ethical dilemmas and moral distress experienced by staff nurses in clinical roles, less research exists regarding the ethical distress experienced by nursing managers.

Nursing management ethics are also distinct from other areas of management. Although there are many similar areas of responsibility between nurse-managers and non–nurse-managers, many leadership roles and management functions are specific to nursing. These differences require the nurse-manager to deal with unique obligations and ethical dilemmas that are not encountered in nonnursing management.

In addition, because personal, organizational, subordinate, and consumer responsibilities differ, there is great potential for nursing managers to experience intrapersonal conflict about the appropriate course of action. Multiple advocacy roles and accountability to the profession further increase the likelihood that all nurse-managers will be faced with ethical dilemmas in their practice. Nurses often find themselves viewed simultaneously as advocates for physicians, patients, and the organization—all of whose needs and goals may be dissimilar.

Nurses are often placed in situations where they are expected to be agents for patients, physicians, and the organization simultaneously, all of which may have conflicting needs, wants, and goals.

To make appropriate ethical decisions then, the manager must have knowledge of ethical principles and frameworks, use a professional approach that eliminates trial and error and focuses on proven decision-making models, and use available organizational processes to assist in making such decisions. Such organizational processes include institutional review boards (IRBs), ethics committees, and professional codes of ethics. Using both a systematic approach and proven ethical tools and technology allows managers to make better decisions and increases the probability that they will feel confident about the decisions they have made. Leadership roles and management functions associated with ethics are shown in Display 4.1.

DISPLAY 4.1 LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOCIATED WITH ETHICS

Leadership Roles

1.  Is self-aware regarding own values and basic beliefs about the rights, duties, and goals of human beings

2.  Accepts that some ambiguity and uncertainty must be a part of all ethical decision making

3.  Accepts that negative outcomes occur in ethical decision making despite high-quality problem solving and decision making

4.  Demonstrates risk taking in ethical decision making

5.  Role models ethical decision making, which is congruent with the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (ANA, 2015), the ANA Nursing Administration: Scope and Standards of Practice (2016), and professional standards

6.  Clearly communicates expected ethical standards of behavior

7.  Role models behavior that eliminates theory–practice–ethics gaps and promotes ethical behavior as the norm

8.  Promotes patients’ self-determination and informed decision making

9.  Collaborates with others to protect human rights and promote social justice

10.  Assures that nurses are represented on interprofessional teams addressing ethical risks, benefits, and outcomes

Management Functions

1.  Uses a systematic approach to problem solving and decision making when faced with management problems with ethical ramifications

2.  Identifies outcomes in ethical decision making that should always be sought or avoided

3.  Uses established ethical frameworks to clarify values and beliefs

4.  Applies principles of ethical reasoning to define what beliefs or values form the basis for decision making

5.  Is aware of legal precedents that may guide ethical decision making and is accountable for possible liabilities should they go against the legal precedent

6.  Continually reevaluates the quality of personal ethical decision making based on the process of decision making or problem solving used

7.  Constantly assesses levels of moral uncertainty, moral distress, and moral outrage in subordinates and intervenes as necessary to protect quality patient care and worker’s well-being

8.  Establishes systems whereby ethical issues impacting stakeholders (health-care consumers, workers, community, etc.) can be addressed and resolved

9.  Recognizes and rewards ethical conduct of subordinates

10.  Takes appropriate action when subordinates demonstrate unethical conduct

Moral Issues Faced by Nurses

Despite 2017 Gallup poll findings that show Americans have ranked nursing as the most honest ethical profession for the 16th consecutive year (Jimenez, 2018), ethical issues are commonplace in nursing. Peter (2018) agrees, noting that “nurses’ moral lives are growing in complexity given rapid changes that are the result of scientific advances, a growing business ethos, and technological processes aimed at standardizing patient care. At times, nurses believe that they cannot respond adequately to the ethical issues that they encounter because of their enormity and nurses’ responsibility to continue to care for patients despite the obstacles” (para. 1).

There are many terms used to describe these moral issues including moral indifference, moral uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas. Moral indifference occurs when an individual questions why morality in practice is even necessary. Moral uncertainty or moral conflict occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is.

On the other hand, moral distress occurs when the individual knows the right thing to do, but organizational constraints make it difficult to take the right course of action. Thus, morally distressed nurses often demonstrate biological, emotional, and moral stress because of this intrapersonal conflict (Edmonson, 2015). Indeed, morally distressed nurses often experience anger, loneliness, depression, guilt, powerlessness, anxiety, and even emotional withdrawal. This then leads to turnover as the nurse leaves the stressful situation for a less stressful environment (Edmonson, 2015). Barlem and Ramos (2015) suggest that moral distress is one of the main ethical problems affecting nurses in all health systems and thus is a threat to nurses’ integrity and to the very essence of quality of patient care.

Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it. Lastly, the most difficult of all moral issues is termed a moral or ethical dilemma, which is being forced to choose between two or more undesirable alternatives. For example, a nurse might experience a moral or ethical dilemma if he or she was required to provide care or treatments that conflicted with his or her own religious beliefs. In this case, the nurse would likely experience an intrapersonal moral conflict about whether his or her values, needs, and wants can or should supersede those of the patient. Because ethical dilemmas are so difficult to resolve, many of the learning exercises in this chapter are devoted to addressing this type of moral issue.

Individual values, beliefs, and personal philosophy play a major role in the moral or ethical decision making that is part of the daily routine of all nurses as well as managers.

How do managers decide what is right and what is wrong? What does the manager do if no right or wrong answer exists? What if all solutions generated seem to be wrong? Remember that the way managers approach and solve ethical issues is influenced by their values and basic beliefs about the rights, duties, and goals of all human beings. Self-awareness, then, is a vital leadership role in ethical decision making, just as it is in so many other aspects of management.

LEARNING EXERCISE  4.10 PART 1:

The Untruthful Employee (Marquis & Huston, 2012)

You are the registered nurse on duty at a skilled nursing facility. Judy, a 35-year-old, full-time nurse’s aide on the day shift, has been with the skilled nursing facility for 10 years. You have worked with Judy on numerous occasions and have found her work to be marginal at best. She tries to be extra friendly with the staff and occasionally brings them small treats that she bakes. She also makes a point of telling everyone how much she needs this job to support her family and how she loves working here. She has a disabled daughter who relies on her hospital-provided health insurance to have her health-care needs met.

Most of the other staff seem willing to put up with Judy’s poor work habits, but lately, you have felt that her work has shown many serious errors. Things are not reported to you that should have been—intake and output volumes that are in error, strange recordings for vital signs, and so on. She has tried to cover up such errors, with what you suspect are outright lies. She claims to have bathed patients when this does not appear to be the case, and has said some patients have refused to eat when you have found that they were willing to eat for you. Although the chief nursing officer acknowledges that Judy is only a marginally adequate employee, she has been unable to observe directly any of the behaviors that would require disciplinary action and has told you that you must have real evidence of her wrongdoing in order to for her to take action.

During morning report, you made a specific request to Judy that a confused patient, Mr. Brown, assigned to her, be assisted to the bathroom, and you told her that someone must remain in the room to assist him when he is up, as he fell last evening. You also told Judy that when in bed, Mr. Brown’s side rails were always to be up. Later in the morning, you take Mr. Brown his medication and notice that his side rails are down and after pulling them up and giving him his medicine, you find Judy and talk with her. She denies leaving the side rails down and insisted someone else must have done it. You caution her again about Mr. Brown’s needs. Thirty minutes later, you go by Mr. Brown’s room and find his bed empty and discover he is in the bathroom unattended. As you are assisting Mr. Brown back to bed, Judy bursts into the room and pales when she sees you with her patient. At first, she denies that she had gotten Mr. Brown up, but when you express your disbelief, she tearfully admits that she left him unattended but stated that this was an isolated incident and asked you to forget it. When you said that it was her lying about the incident that most disturbed you, she promised never to lie about anything again. She begged you not to report her to the chief nursing officer and said she needed her job.

You are torn between wanting to report Judy for her lying because of concerns about patient safety and also not wanting to be responsible for getting her fired. To reduce the emotionalism of the event and to give yourself time to think, you decide to take a break and think over the possible actions you should take.

ASSIGNMENT PART 1: 4.10

Evaluate this problem. Is this just a simple leadership–management problem that requires some problem solving and a decision or does the problem have ethical dimensions? Using one of the problem-solving models in this chapter, solve this problem.

Health Insurance Portability and Accountability Act of 1996

Another area of the law that nurses must understand is the right to confidentiality. Efforts to preserve patient confidentiality increased tremendously with the passage of the HIPAA of 1996 (also known as the Kassebaum–Kennedy Act). Unauthorized release of information or photographs in medical records may make the person who discloses the information civilly liable for invasion of privacy, defamation, or slander. Written authorization by the patient to release information is needed to allow such disclosure.

Many nurses have been caught unaware by the telephone call requesting information about a patient’s condition. It is extremely important that the nurse does not give out unauthorized information, regardless of the urgency of the person making the request. In addition, nurses must be careful not to discuss patient information in venues where it can be inadvertently overheard, read, transmitted, or otherwise unintentionally disclosed. For example, nurses talking in elevators, the hospital gift shop, or in a restaurant for lunch need to be aware of their surroundings and remain alert about not revealing any patient information in a public place.

HIPAA essentially represents two areas for implementation. The first is the Administrative Simplification plan, and the second area includes the Privacy Rule. The Administrative Simplification plan is directed at restructuring the coding of health information to simplify the digital exchange of information among health-care providers and to improve the efficiency of health-care delivery. The privacy rules are directed at ensuring strong privacy protections for patient without threatening access to care.

The Privacy Rule applies to health plans, health-care clearinghouses, and health-care providers. It also covers all patient records and other individually identifiable health information. Although there are many components to HIPAA, key components of the Privacy Rule are that direct treatment providers must make a good faith effort to obtain written acknowledgment of the notice of privacy rights and practices from patients. In addition, health-care providers must disclose protected health information to patients requesting their own information or when oversight agencies request the data. Reasonable efforts must be taken, however, to limit the disclosure of personal health information to the minimum information necessary to complete the transaction. There are situations, however, when limiting the information is not required. For example, a minimum of information is not required for treatment purposes because it is clearly better to have too much information than too little. The HIPAA Privacy Rule and Common Rule also require that individuals participating in research studies should be assured privacy, particularly regarding personal health information.

The Privacy Rule attempts to balance the need for the protection of personal health information with the need to disclose that information for patient care.

Because of the complexity of the HIPAA regulations, it is not expected that a nurse-manager would be responsible for compliance alone. Instead, it is most important that the manager work with the administrative team to develop compliance procedures. For example, managers must ensure that unauthorized people do not have access to patient charts or medical records and that unauthorized people are not allowed to observe procedures.

It is equally important that managers remain cognizant of ongoing changes to the guidelines and are aware of how rules governing these issues may differ in the state in which they are employed. Some provisions of the Privacy Rules mention “reasonable efforts” toward achieving compliance, but being reasonable is provision specific. The American Recovery and Reinvestment Act applies several of HIPAA’s security and privacy requirements to business associates and changes data restrictions, disclosure, and reporting requirements.

Legal Considerations of Managing a Diverse Workforce

Diversity has been defined as the differences among groups or between individuals and comes in many forms, including age, gender, religion, customs, sexual orientation, physical size, physical and mental capabilities, beliefs, culture, ethnicity, and skin color (Huston, 2020b). Demographic data from the United States Census Bureau continue to show increased diversification of the US population, a trend that began almost 40 years ago.

As discussed in later chapters, a primary area of diversity is language, including word meanings, accents, and dialects. Problems arising from this could be misunderstanding or reluctance to ask questions. Staff from cultures in which assertiveness is not promoted may find it difficult to disagree with or question others. How the manager handles these manifestations of cultural diversity is of major importance. If the manager’s response is seen as discriminatory, the employee may file a complaint with one of the state or federal agencies that oversee civil rights or equal opportunity enforcement. Such things as overt or subtle discrimination are prohibited by Title VII (Civil Rights Act of 1964). Managers have a responsibility to be fair and just. Lack of promotions and unfair assignments may occur with minority employees just because they are different and this is illegal.

In addition, English-only rules in the workplace may be viewed as discriminatory under Title VII. Such rules may not violate Title VII if employers require English only during certain periods of time. Even in these circumstances, the employees must be notified of the rules and how they are to be enforced.

Clearly, managers should be taught how to deal sensitively and appropriately with an increasingly diverse workforce. Enhancing self-awareness and staff awareness of personal cultural biases, developing a comprehensive cultural diversity program, and role modeling cultural sensitivity are some of the ways that managers can effectively avoid many legal problems associated with discriminatory issues. However, it is hoped that future goals for the manager would go beyond compliance with Title VII and move toward understanding of and respect for other cultures.

Professional Versus Institutional Licensure

In general, a license is a legal document that permits a person to offer special skills and knowledge to the public in a particular jurisdiction when such practice would otherwise be unlawful. Licensure establishes standards for entry into practice, defines a scope of practice, and allows for disciplinary action. Currently, licensing for nurses is a responsibility of State Boards of Nursing or State Boards of Nurse Examiners, which also provide discipline as necessary. The manager, however, is responsible for monitoring that all licensed subordinates have a valid, appropriate, and current license to practice.

Professional licensure is a privilege and not a right.

All nurses must safeguard the privilege of licensure by knowing the standards of care applicable to their work setting. Deviation from that standard should be undertaken only when nurses are prepared to accept the consequences of their actions, in terms of both liability and loss of licensure.

Nurses who violate specific norms of conduct, such as securing a license by fraud, performing specific actions prohibited by the Nurse Practice Act, exhibiting unprofessional or illegal conduct, performing malpractice, and abusing alcohol or drugs, may have their licenses suspended or revoked by the licensing boards in all states. Frequent causes of license revocation are shown in Display 5.4.

DISPLAY 5.4 COMMON CAUSES OF PROFESSIONAL NURSING LICENSE SUSPENSION OR REVOCATION

  Professional negligence

  Practicing medicine or nursing without a license

  Obtaining a nursing license by fraud or allowing others to use your license

  Felony conviction for any offense substantially related to the function or duties of a registered nurse

  Participating professionally in criminal abortions

  Failing to follow accepted standards of care

  Not reporting substandard medical or nursing care

  Providing patient care while under the influence of drugs or alcohol

  Giving narcotic drugs without an order

  Falsely holding oneself out to the public or to any health-care practitioner as a “nurse practitioner”

  Failing to use equipment safely and responsibly

Typically, suspension and revocation proceedings are administrative. Following a complaint, the Board of Nursing completes an investigation. Most of these investigations reveal no grounds for discipline; however, there are things a nurse should do if he or she becomes aware they are being investigated by the board. These are shown in Display 5.5.

DISPLAY 5.5 ACTIONS A NURSE SHOULD TAKE WHEN BEING INVESTIGATED BY THE BOARD OF NURSING

1.  Do not ignore the Board’s notification. It won’t go away.

2.  Do not unnecessarily share news of the complaint with friends and colleagues as it may undermine your credibility.

3.  Read employee handbooks/contracts/policy and procedures to determine if must report the investigation to your employer.

4.  Consider contacting an attorney.

5.  If a lawyer is needed, hire an experienced one.

6.  Carefully consider anything you put in writing.

7.  Contact your malpractice insurance provider.

8.  If the investigation involves a patient, do not violate HIPAA by copying the patient’s medical record.

9.  Do not alter the patient’s medical record.

10.  Be prepared for a lengthy process of investigation.

Source: Extracted from Mackay, T. R. (2018). What do you mean there’s a complaint?! Texas Nursing, 92(1), 20–22.

If the investigation supports the need for discipline, nurses are notified of the charges and can prepare a defense. At the hearing, which is very similar to a trial, the nurse can present evidence. Based on the evidence, an administrative law judge makes a recommendation to the

LEARNING EXERCISE  5.8: PART 2:

Legal Ramifications for Exceeding One’s Duties

You have been the evening charge nurse in the emergency department at Memorial Hospital for the last 2 years. Besides yourself, you have two licensed vocational nurses (LVNs) and four registered nurses (RNs) working in your department. Your normal staffing is to have two RNs and one LVN on duty Monday to Thursday and one LVN and three RNs on duty during the weekend.

It has become apparent that one of the LVNs, Maggie, resents the recently imposed limitations of LVN duties because she has had 10 years of experience in nursing, including a tour of duty as a medic in the first Gulf War. The emergency department physicians admire her and are always asking her to assist them with any minor wound repair. Occasionally, she has exceeded her job description as an LVN in the hospital, although she has done nothing illegal of which you are aware. You have given her satisfactory performance evaluations in the past, even though everyone is aware that she sometimes pretends to be a “junior physician.” You also suspect that the physicians sometimes allow her to perform duties outside her licensure, but you have not investigated this or seen it yourself.

Tonight, you come back from supper and find Maggie suturing a deep laceration while the physician looks on. They both realize that you are upset, and the physician takes over the suturing. Later, the doctor comes to you and says, “Don’t worry! She does a great job, and I’ll take the responsibility for her actions.” You are not sure what you should do. Maggie is a good employee, and taking any action will result in unit conflict.

ASSIGNMENT PART 2: 5.08

What are the legal ramifications of this case? Discuss what you should do, if anything. What responsibility and liability exist for the physician, Maggie, and yourself? Use appropriate rationale to support your decision.

• please write  5 pages paper from this chapter

  Infertility

  Incidence

  Infertility is a serious concern that affects 1 in 4 couples of reproductive age, with increasing incidence correlated with increased age (Crawford & Steiner, 2015; Lobo, 2017). Commonly infertility is considered to be a diagnosis for couples who have not achieved pregnancy after 1 year of regular, unprotected intercourse when the woman is less than 35 years of age or after 6 months when the woman is older than 35 years of age. Fecundity is the term used to describe the chance of achieving pregnancy and subsequent live birth within one menstrual cycle. Fecundity averages 20% in couples who are not experiencing reproductive problems (American Society of Reproductive Medicine [ASRM], 2012).

  Probable causes of infertility include the trend toward delaying pregnancy until later in life, a time when fertility decreases naturally and the prevalence of diseases such as endometriosis and ovulatory dysfunction increases. Questions exist regarding whether there has been an increase in male infertility or whether male infertility is more readily identified because of improvements in diagnosis.

  For the couple experiencing infertility, diagnosis and treatment strategies require considerable physical, emotional, and financial investment over an extended period of time. Feelings connected with infertility are many and complex, often interfering with quality of life. It is common for infertile couples to experience anxiety from the need to undergo many tests and examinations and from a perception of feeling “different” from their fertile friends and relatives. The following four goals provide a framework for nurses who care for infertile persons:

  • Provide the couple with accurate information about human reproduction, infertility treatments, and prognosis for pregnancy. Dispel any myths or inaccuracies from friends or the mass media that the couple may believe to be true.

  • Help the couple and the health care team accurately identify and treat possible causes of infertility.

  • Provide emotional support. The couple may benefit from anticipatory guidance, counseling, and support group meetings, either face-to-face or online. The organization RESOLVE (www.resolve.org) provides online support, advocacy, and education about infertility for both the infertility community and health care providers.

  • Guide and educate those who fail to conceive biologically about other forms of treatment such as in vitro fertilization (IVF), donor eggs or semen, surrogate motherhood, and adoption. Support the couple in their decisions regarding their future family.

  It is important for nurses to encourage all healthy women and men to maintain a normal body mass index (BMI) and avoid sexually transmitted infections (STIs) and exposures to substances or habits (such as smoking) that impair reproductive ability. While these health-promoting activities will not ensure fertility, they will enhance overall health as the individual or couple is coping with the stresses of infertility.

  Factors Associated With Infertility

  Although exact percentages vary somewhat with populations, approximately 85% to 90% of couples seeking infertility care are treated with medication or surgery, with 3% being treated with in vitro fertilization or other assisted reproductive methods (ASRM, 2016). About 40% of infertility is related to a male factor or a combined male and female factor (ASRM, 2016). About 20% of infertility is unexplained (Lobo, 2017). For those couples and individuals for whom a specific cause of infertility is not detected, the focus of infertility treatment has shifted from attempting to correct a specific pathology to recommending and initiating the treatment that is most effective in achieving pregnancy for this unique couple at this time in their reproductive life span. Assisted reproductive technologies (ARTs) have proven to be effective, even in couples who experience unexplained infertility.

  Unassisted human conception requires a normally developed reproductive tract in both the male and female partners. For simplification, each live birth necessitates synchronization of the following:

  • The male must deposit semen with sperm that has the capacity to fertilize an egg close to the cervix at the time of ovulation. The sperm must be able to ascend through the uterus and uterine tubes (male factor). The cervix must be sufficiently open to allow semen to enter the uterus and provide a nurturing environment for sperm (cervical factor).

  • The uterine tubes must be able to capture the ovum, transport semen to the ovum, and transport the fertilized embryo to the uterus (tubal factor).

  • Ovulation of a healthy oocyte must occur, ideally within the parameters of a regular, predictable menstrual cycle (ovarian factor).

  • The uterus must be receptive to implantation of the embryo and capable of nourishing the growth and development of the fetus throughout the normal duration of pregnancy (uterine factor).

  An alteration in one or more of these structures, functions, or processes results in some degree of impaired fertility. Boxes 5.1 and 5.2 list factors affecting female and male infertility.

  Box 5.1

  Factors Affecting Female Fertility

  Ovarian Factors

  • Developmental anomalies

  • Anovulation—primary

  • Pituitary or hypothalamic hormone disorders

  • Adrenal gland disorders (rare)

  • Congenital adrenal hyperplasia (rare)

  • Anovulation—secondary

  • Disruption of hypothalamic-pituitary-ovarian axis

  • Anorexia

  • Insufficient body fat in athletic women

  • Increased prolactin levels

  • Thyroid disorders

  • Premature ovarian failure

  • Polycystic ovary syndrome

  • Medications

  • Oral contraceptives

  • Progestins

  • Antidepressant and antipsychotic drugs

  • Corticosteroids

  • Chemotherapy

  Tubal/Peritoneal Factors

  • Developmental anomalies of the tubes (see Fig. 5.1)

   

  FIG 5.1 Abnormal uterus. A, Complete bicornuate uterus with vagina divided by a septum. B, Complete bicornuate uterus with normal vagina. C, Partial bicornuate uterus with normal vagina. D, Unicornuate uterus.

  • Reduced tubal motility

  • Inflammation within the tube

  • Tubal adhesions

  • Disruption caused by tubal pregnancy

  • Endometriosis

  Uterine Factors

  • Developmental anomalies of the uterus (see Fig. 5.1)

  • Endometrial and myometrial fibroid tumors

  • Asherman’s syndrome (uterine adhesions or scar tissue)

  Vaginal-Cervical Factors

  • Vaginal-cervical infections

  • Cervical mucus inadequate

  • Isoimmunization (development of sperm antibodies)

  Other Factors

  • Nutritional deficiencies

  • Obesity

  • Thyroid dysfunction (hyperthyroidism and hypothyroidism)

  • Idiopathic conditions

  Box 5.2

  Factors Affecting Male Fertility

  Hormonal Disorders

  • Congenital disorders

  • Tumors of the pituitary gland or hypothalamus

  • Trauma to the pituitary gland or hypothalamus

  • Hyperprolactinemia

  • Excess of androgens, estrogen, or cortisol

  • Drugs and substance abuse (recreational and prescribed drugs)

  • Chronic illnesses

  • Nutritional deficiencies

  • Obesity

  • Endocrine disorders (e.g., diabetes)

  Testicular Factors

  • Congenital disorders

  • Undescended testes

  • Hypospadias

  • Varicocele

  • Viral infections (e.g., mumps)

  • Sexually transmitted infections (e.g. gonorrhea, chlamydial infection)

  • Obstructive lesions of the epididymis and vas deferens

  • Environmental toxins

  • Trauma

  • Torsion

  • Castration

  • Systemic illnesses

  • Antisperm antibodies

  • Changes in sperm from cigarette smoking or use of heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, or methaqualone

  • Decrease in libido from use of heroin, methadone, selective serotonin reuptake inhibitors, or barbiturates

  • Impotence from use of alcohol or antihypertensive medications

  Factors Associated With Sperm Transport

  • Drugs

  • Sexually transmitted infections of the epididymis

  • Ejaculatory dysfunction

  • Premature ejaculation

  Idiopathic Male Infertility

  For conception to occur, both partners must have normal, intact hypothalamic-pituitary-gonadal hormonal axes that support the formation of sperm in the male and ova in the female. Sperm can remain viable within a woman’s reproductive tract for at least 3 days and for as long as 5 days. The oocyte can only be successfully fertilized for 12 to 24 hours after ovulation. The couple seeking pregnancy should be taught about the menstrual cycle and ways to detect ovulation (see Chapter 3). They should be counseled to have intercourse 2 to 3 times a week; or, if timed intercourse does not increase anxiety, they should be encouraged to engage in intercourse the day before and the day of ovulation. Fertility decreases markedly 24 hours after ovulation.

  Care Management

  Infertility care management includes a team of health care providers, including an obstetric care provider, fertility specialist, embryologist, genetic counselor, and mental health provider or counselor. The nurse is a key member of the care management team and assists in the assessment and education of the infertile couple. As part of the assessment process, he or she obtains information from the couple through interview and physical examination, including if this couple’s situation is one of primary (never experienced pregnancy) or secondary (previous pregnancy) infertility. Religious, cultural, and ethnic data may place restrictions on use of available treatments.

  In addition, the nurse obtains and monitors results of diagnostic testing. Some of the information and data needed to investigate impaired fertility are of a sensitive, personal nature. The couple may experience feelings of invasion of privacy, and the nurse must exercise tact and express concern for their well-being throughout the interview. The tests and examinations associated with infertility diagnosis and treatment are occasionally painful and often intrusive. The couple’s intimacy and feelings of romantic attachment are often impaired as they engage in this process. A high level of motivation is needed to endure the investigation and subsequent treatment. Because multiple factors involving both partners are common, the investigation of impaired fertility is conducted systematically and simultaneously for both male and female partners. Both partners must be interested in the solution to the problem. The medical investigation requires time (3 to 4 months) and considerable financial expense. Box 5.3 describes the status of insurance coverage for infertility treatment.

  Box 5.3

  Insurance Coverage for Infertility

  As of October 2016, only 15 states had mandated some form of insurance coverage for infertility. These mandates included in vitro fertilization in some states, whereas others only covered some diagnostic tests. Some states require health maintenance organizations (HMOs) to cover some costs, whereas in others HMOs are exempt. Patients need information about what they can expect from their insurers. The state Insurance Commissioner’s office can provide information about an individual state. The website for the American Society for Reproductive Medicine (www.asrm.org) has more complete information.

  Assessment of Female Infertility

  Evaluation for infertility should be offered to couples who have failed to become pregnant after 1 year of regular intercourse or after 6 months if the woman is older than 35 years of age. Investigation of impaired fertility begins for the woman with a complete history and physical examination. A complete general physical examination should include height and weight and estimation of BMI. Both obesity and being underweight are associated with anovulation disorders. Signs and symptoms of androgen excess such as excess body hair or pigmentation changes should be noted. The general physical examination is followed by a specific assessment of the reproductive tract. A history of infections of the genitourinary tract and any signs of infections, especially STIs that could impair tubal patency, should be assessed. Bimanual examination of internal organs may reveal lack of mobility of the uterus or abnormal contours of the uterus and tubes. A woman may have an abnormal uterus and tubes as a result of congenital abnormalities during fetal development). These uterine abnormalities increase risk for early pregnancy loss.

  Laboratory data, including routine urine and blood tests, are collected. The initial clinic visit serves as a preconceptional visit and as initial assessment of possible causes of infertility. The woman should be taking folic acid supplements, and all immunizations should be current to prepare for possible pregnancy.

  Diagnostic Testing

  The basic infertility survey of the female involves evaluation of the cervix, uterus, tubes, and peritoneum; detection of ovulation; and hormone analysis. Timing and descriptions of common tests are presented in Table 5.1.

  TABLE 5.1

  General Tests for Impaired Fertility

   

  Test or Examination

  Timing (Menstrual Cycle Days)

  Rationale

   

  Hysterosalpingogram (HSG) (uterine abnormalities, tubal   patency)

  7–10

  Late follicular, early proliferative phase; will not   disrupt a fertilized ovum; may open uterine tubes before time of ovulation

   

  Chlamydia immunoglobulin G antibodies (tubal patency)

  Variable

  Negative antibody test may indicate tubal patency   assessment (HSG); not needed in low-risk women

   

  Hysterosalpingo-contrast sonography (uterine   abnormalities, tubal patency)

  7–10

  Late follicular, early proliferative phase; will not   disrupt a fertilized ovum; evaluates tubal patency, uterine cavity, and   myometrium

   

  Serum progesterone (ovulation)

  7 days before expected menses

  Midluteal-phase progesterone levels; check adequacy of corpus   luteum progesterone production

   

  Assessment of cervical mucus (ovulation)

  Variable, ovulation

  Cervical mucus should have low viscosity, spinnbarkeit   (ability to stretch) during ovulation

   

  Basal body temperature (ovulation)

  Chart entire cycle

  Elevation occurs in response to progesterone; documents   ovulation

   

  Urinary ovulation predictor kit (ovulation)

  Variable, ovulation

  Detects timing of lutein hormone surge before ovulation

   

  Semen analysis (male factor)

  2–7 days after abstinence

  Detects ability of sperm to fertilize egg

   

  Sperm penetration assay (male factor)

  After 2 days but ≤1 week of abstinence

  Evaluates ability of sperm to penetrate egg

   

  Follicle-stimulating hormone (FSH) level (ovarian reserve)

  Day 3

  High FSH levels (>20) indicate that pregnancy will not   occur with woman’s own eggs; value <10 indicates adequate ovarian reserve

   

  Clomiphene citrate challenge test (CCCT) (ovarian reserve)

  Administer clomiphene 100 mg days 5 through 9

  Assess FSH on days 3 and 10 in presence of clomiphene   stimulation; high FSH levels (>20) indicate that pregnancy will not occur   with woman’s own eggs; FSH <15 suggestive of adequate ovarian reserve

  From Genetics & IVF Institute. (2013). Fertility: Clomiphene citrate test. Retrieved from http://www.givf.com/fertility/clomidchallengetest.shtml.

  Previous status regarding ovulation can be evaluated through menstrual history, serum hormone studies, and use of an ovulation predictor kit. If the woman is older than 35 years of age, the clinician may choose to assess “ovarian reserve” or how many potential ova remain within the ovaries. A common evaluation of ovarian reserve is measurement of follicle-stimulating hormone (FSH) levels on the third day of the menstrual cycle. The uterus and fallopian/uterine tubes can be visualized for abnormalities and tubal patency through hysterosalpingogram (x-ray film examination of the uterine cavity and tubes after instillation of radiopaque contrast material through the cervix). If the woman is at risk for endometriosis (implants of endometrial tissue outside of the uterus) or adhesions, diagnostic laparoscopy may be indicated. Test findings favorable for fertility are summarized in Box 5.4.

  Box 5.4

  Summary of Findings Favorable to Fertility

  1. Follicular development, ovulation, and luteal development are supportive of pregnancy:

  a. Basal body temperature (presumptive evidence of ovulatory cycles) is biphasic, with temperature elevation that persists for 12 to 14 days before menstruation.

  b. Cervical mucus characteristics change appropriately during phases of the menstrual cycle.

  c. Days 3 to 10 follicle-stimulating hormone (FSH) levels are low enough to verify the presence of adequate ovarian follicles.

  d. Day 3 estradiol levels are low enough to verify the presence of adequate ovarian follicles.

  e. Woman reports a history of regular, predictable menses with consistent premenstrual and menstrual symptoms.

  2. The luteal phase is supportive of pregnancy:

  a. Levels of plasma progesterone are adequate to indicate ovulation.

  b. Luteal phase of menstrual cycle is of sufficient duration to support pregnancy.

  3. Cervical factors are receptive to sperm during expected time of ovulation:

  a. Cervical os is open.

  b. Cervical mucus is clear, watery, abundant, and slippery and demonstrates good spinnbarkeit and arborization (fern pattern) at time of ovulation.

  c. Cervical examination reveals no lesions or infections.

  4. The uterus and uterine tubes support pregnancy:

  a. Uterine and tubal patency are documented by (1) spillage of dye into the peritoneal cavity, and (2) outlines of uterine and tubal cavities of adequate size and shape with no abnormalities.

  b. Laparoscopic examination verifies normal development of internal genitals and absence of adhesions, infections, endometriosis, and other lesions.

  5. The male partner’s reproductive structures are normal:

  a. There is no evidence of developmental anomalies of penis, testicular atrophy, or varicocele (varicose veins on the spermatic vein in the groin).

  b. There is no evidence of infection in prostate, seminal vesicles, and urethra.

  c. Testes are more than 4 cm in largest diameter.

  6. Semen is supportive of pregnancy:

  a. Sperm (number per milliliter) are adequate in ejaculate.

  b. Most sperm show normal morphology.

  c. Most sperm are motile, forward moving.

  d. No autoimmunity exists.

  e. Seminal fluid is normal.

  Assessment of Male Infertility

  The systematic investigation of infertility in the male patient begins with a thorough history and physical examination. Assessment of the male patient proceeds in a manner similar to that of the female patient, starting with noninvasive tests.

  Diagnostic Testing and Semen Analysis

  The basic test for male infertility is semen analysis. A complete semen analysis, study of the effects of cervical mucus on sperm forward motility and survival, and evaluation of the ability of the sperm to penetrate an ovum provide basic information. 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.

  Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a spermicidal agent. The specimen is usually collected by masturbation following 2 to 7 days of abstinence from ejaculation. The semen is examined at the collection site or taken to the laboratory in a sealed container within 2 hours of ejaculation. Exposure to excessive heat or cold is avoided. Commonly accepted values for semen characteristics are given in Box 5.5. If results are in the fertile range, no further sperm evaluation is necessary. If results are not within this range, the test is repeated. If subsequent results are still in the subfertile range, further evaluation is needed to identify the problem.

  Box 5.5

  Semen Analysis: Normal Values

  • Semen volume at least 1.5 mL

  • Semen pH 7.2 or higher

  • Sperm density greater than 15 million/mL

  • Total sperm count greater than 39 million per ejaculate

  • Normal morphologic features greater than 4% (normal oval)

  • Motility (important consideration in sperm evaluation)—percentage of forward-moving sperm estimated with respect to abnormally motile and nonmotile sperm, 40%

  • Liquification—usually within 15 minutes but no longer than 60 minutes

  NOTE: These values are not absolute but are only relative to final evaluation of the couple as a single reproductive unit. Values also differ according to source used as a reference.

  Data from World Health Organization. (2010). Laboratory manual for the examination of human semen (5th ed.). Geneva, Switzerland: Author.

  Hormone analyses are done for testosterone, gonadotropin, FSH, and luteinizing hormone (LH). The sperm penetration assay and other alternative tests may be used to evaluate the ability of sperm to penetrate an egg. Testicular biopsy may be warranted. Scrotal ultrasound may be used to examine the testes for presence of varicoceles and identify abnormalities in the scrotum and spermatic cord. Transrectal ultrasound is used to evaluate the ejaculatory ducts, seminal vesicles, and vas deferens.

  Psychosocial Considerations

  Infertility is recognized as a major life stressor that can affect self-esteem; relations with the spouse or partner, family, and friends; and careers. Psychologic responses to the diagnosis of infertility may tax a couple’s capacity for giving and receiving physical and sexual closeness. The prescriptions and taboos for achieving conception may add tension to a couple’s sexual functioning. They may report decreased desire for intercourse, orgasmic dysfunction, or midcycle erectile disorders.

  To be able to deal comfortably with a couple’s sexuality, nurses must be comfortable with their own sexuality so they can better help couples understand why aspects of sexual intimacy need to be shared with health care professionals. Nurses need current factual knowledge about human sexual practices and must be accepting of the preferences and activities of others without being judgmental. They must be skilled in interviewing and therapeutic use of self, sensitive to the nonverbal cues of others, and knowledgeable regarding each couple’s sociocultural and religious beliefs (see Clinical Reasoning Case Study).

  Clinical Reasoning Case Study

  Infertility

   

  Diane is a 39-year-old accountant who has recently married for the first time. Charles is 41 years of age and has two children from a previous marriage. Diane has a history of amenorrhea dating back to when she was in college and a member of the track team. Currently her menstrual periods are irregular. She wants to have a baby “before it’s too late,” and she and Charles have been having unprotected sex for almost 1 year. They have come to the fertility clinic today for an evaluation. Diane tells the nurse that she has heard about the success of in vitro fertilization (IVF) and wants to know if she will be able to have it performed. How should the nurse respond to Diane’s comments and questions?

  1. Evidence—Is evidence sufficient to draw conclusions about what response the nurse should give?

  2. Assumptions—Describe underlying assumptions about the following issues:

  a. Age and fertility: Is Diane’s age a factor in her concern regarding infertility?

  b. Infertility as a major life stressor: To what extent can infertility or the fear of being infertile cause stress?

  c. Success rates for IVF pregnancy and birth: Is IVF a reasonable treatment to consider (after having a thorough workup)?

  d. Causes of female infertility: What are some of the reasons that Diane may be infertile?

  3. What implications and priorities for nursing care can be drawn at this time?

  4. Describe the roles and responsibilities of members of the interprofessional health care team who may be caring for Diana and Charles.

  The couple facing infertility exhibits behaviors of the grieving process such as those associated with other types of loss. The loss of one’s genetic continuity with the generations to come can provoke decreased self-esteem, a sense of inadequacy as a woman or a man, and feelings of loss of control over personal destiny. Infertile individuals can perceive dissatisfaction with their marriages or partner relationships. Not all people have all the reactions described, nor can it be predicted how long any reaction will last for an individual. Often a mental health counselor with experience and expertise dealing with infertility can be very helpful to an individual or couple.

  If the couple does not conceive, they should be assessed regarding their desire to be referred for help with adoption, donor eggs or semen, surrogacy, or other reproductive alternatives. The couple may choose to continue in a child-free state. Both health care providers and patients should have a list of agencies, support groups, and other resources within their community such as the ASRM (www.asrm.org) and RESOLVE (www.resolve.org).

  Nonmedical Treatments

  Both men and women can benefit from healthy lifestyle changes that result in a BMI within the normal range; moderate daily exercise; and abstinence from alcohol, nicotine, and recreational drugs. For the woman with a BMI >27 and polycystic ovary syndrome, losing just 5% to 10% of body weight can restore ovulation within 6 months. Anovulatory women with a BMI <17 who have eating disorders or intense exercise regimens benefit from weight gain. Nevertheless, this population sometimes is reluctant to alter their behaviors, and counseling should be advised.

  Simple changes in lifestyle may be effective in the treatment of subfertile men. Only water-soluble lubricants should be used during intercourse because many commonly used lubricants contain spermicides or have spermicidal properties. Instead of wearing briefs, the male should wear boxer shorts and loose pants because these tend to decrease scrotal temperature and may prevent a decrease in sperm count. High scrotal temperatures can be caused by daily hot tub baths or saunas that keep the testes at temperatures too high for efficient spermatogenesis. These conditions lead to only lessened fertility and should not be used as a means of contraception.

  Most herbal remedies have not been proven clinically to promote fertility or to be safe in early pregnancy and should be taken by the woman only as prescribed by a physician or nurse-midwife who has expertise in herbology. Relaxation, osteopathy, stress management (e.g., aromatherapy, yoga), and nutritional and exercise counseling have been reported to increase pregnancy rates in some women. Herbs to avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. All supplements or herbs should be purchased from trusted sources to ensure that they do not contain contaminants.

  Medical Therapy

  One goal of infertility assessment and treatment is to determine which couples are likely to respond to conventional therapies in a timely manner. Another goal is early referral of couples who will need ARTs to concieve. In general, any fertility treatment is more likely to result in a live birth in women who are younger than 35 years of age, with successful outcomes decreasing for women older than 40 years of age.

  Pharmacologic therapy for female infertility is often directed at treating ovulatory dysfunction by either stimulating or enhancing ovulation so more oocytes mature. These medications include (1) clomiphene citrate as initial therapy for many women with intermittent anovulation; (2) a combination of clomiphene and metformin for women with anovulation and insulin resistance; (3) human menopausal gonadotropin (HMG), FSH, and recombinant FSH (rFSH) to stimulate follicle formation in women who do not respond to clomiphene therapies; (4) human chorionic gonadotropin to induce ovulation when follicles are ripe; (5) gonadotropin-releasing hormone (GnRH) agonists at the beginning of a cycle to sequence HMG therapies; (6) progesterone to support the luteal phase of the cycle; and (7) bromocriptine (Parlodel) for women who have excess prolactin (Lobo, 2017).

  Treatment of certain medical conditions may result in improved fertility. The woman who is hypothyroid benefits from thyroid hormone supplementation. Treatment of endometriosis could include trials of danazol, progesterone, continuous combined oral contraceptives, or GnRH agonists to suppress menstruation and shrink endometrial implants. This regimen would be followed by ovulation induction. Adrenal hyperplasia is treated with prednisone. Any infections present in the infertile couple should be treated with appropriate antimicrobial therapy.

  Clomiphene citrate (with the possible addition of metformin) is often the initial pharmacologic treatment of the infertile woman because it is inexpensive and the side-effect profile is less than other medications that induce ovulation. There is an increased risk for giving birth to twins or higher order multiples with clomiphene therapy.

  The more powerful medications used to induce ovulation include GnRH agonists followed by gonadotropin therapy. These medications are extremely potent and require daily ovarian ultrasonography and monitoring of estradiol levels to prevent hyperstimulation of the ovaries. Combinations of these medications are used with ART to stimulate ovulation before harvesting eggs.

  Drug therapy may be indicated for male infertility. As with women, problems with the thyroid or adrenal glands are corrected with appropriate medications. Infections are identified and treated with antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in men with hypogonadism. Men who do not respond to these therapies are candidates for intracytoplasmic sperm injection (ICSI), which is a procedure that injects sperm directly into the egg as part of IVF. ICSI has enabled men with very low sperm counts to achieve biologic reproduction.

  The infertility specialist is responsible for fully informing patients about the prescribed medications. The nurse must be ready to answer patients’ questions and confirm their understanding of the drug, its administration, potential side effects, and expected outcomes. Because information varies with each drug, the nurse must consult the medication package inserts, pharmacology references, health care provider, and pharmacist as necessary. The nurse should also provide anticipatory guidance regarding the time given for a medication trial before referral to a specialist in ART would be indicated if the couple wants to continue to attempt to become pregnant.

  Table 5.2 includes information on selected medications for infertility treatment.

  TABLE 5.2

  Medication Guide to Selected Infertility Medications

   

  Drug

  Indication

  Mechanism of Action

  Dosage

  Common Side Effects

   

  Clomiphene citrate

  Ovulation induction, treatment of luteal-phase inadequacy

  Thought to bind to estrogen receptors in the pituitary   gland, blocking them from detecting estrogen

  Tablets, starting with 50 mg/day by mouth for 5 days   beginning on fifth day of menses; if ovulation does not occur, may increase   dose next cycle; variable dosage

  Vasomotor flushes, abdominal discomfort, nausea and   vomiting, breast tenderness, ovarian enlargement

   

  Menotropins (human menopausal gonadotropins)

  Ovarian follicular growth and maturation

  LH and FSH in 1 : 1 ratio, direct stimulation of ovarian   follicle; given sequentially with hCG to induce ovulation

  IM injections; dosage regimen   variable based on ovarian response

  Initial dose is 75 International   Units of FSH and 75 International Units of LH (1 ampule) daily for 7–12 days   (not to exceed 12 days) followed by 5000 to 10,000 International Units hCG   (if serum estradiol <2000 pg/mL

  Ovarian enlargement, ovarian hyperstimulation, local   irritation at injection site, multifetal gestations

   

  Follitropins (purified FSH)

  Treatment of polycystic ovary syndrome; follicle   stimulation for assisted reproductive techniques

  Direct action on ovarian follicle

  Subcutaneous or IM injections; dosage regimen variable

  Ovarian enlargement, ovarian hyperstimulation, local irritation   at injection site, multifetal gestations

   

  Human chorionic gonadotropin (hCG)

  Ovulation induction

  Direct action on ovarian follicle to stimulate meiosis and   rupture of the follicle

  5000–10,000 International Units IM 1 day after last dose   of menotropins; dosage regimen variable

  Local irritation at injection site; headaches,   irritability, edema, depression, fatigue

   

  GnRH agonists (nafarelin acetate, leuprolide acetate)

  Treatment of endometriosis, uterine fibroids

  Desensitization and downward regulation of GnRH receptors   of pituitary gland, resulting in suppression of LH, FSH, and ovarian function

  Nafarelin, 200 mcg (1 spray) intranasally twice daily for   6 months; leuprolide acetate 3.75 mg IM every month for 3–6 months

  Nafarelin—irritation, nosebleeds

  Both nafarelin and leuprolide—hot   flashes, vaginal dryness, myalgia and arthralgia, headaches, mild bone loss   (usually reversible within 12–18 months after treatment)

   

  Progesterone

  Treatment of luteal-phase inadequacy

  Direct stimulation of endometrium

  Vaginal gel 8%, 1 prefilled applicator per day; after   ovulation induction, continue through 10–12 weeks of pregnancy

  Breast tenderness, local irritation, headaches

   

  GnRH antagonists (ganirelix acetate, cetrorelix acetate)

  Controlled ovarian stimulation for infertility treatment

  Suppress gonadotropin secretion, inhibit premature LH   surges in women undergoing ovarian hyperstimulation

  250 mcg daily subcutaneously, usually in the early to   midfollicular phase of the menstrual cycle; usually followed by hCG   administration

  Abdominal pain, headache, vaginal bleeding, irritation at   the injection site

   

  Metformin

  Restores cyclic ovulation and menses in many women with   polycystic ovary syndrome

  Induces ovulation through reducing insulin resistance,   thus affecting gonadotropins and androgens; simulates the ovary

  Initial dose is 500 mg daily and titrated up over several   weeks to 1500 mg/day; administered orally

  Nausea, vomiting, diarrhea, lactic acidosis, liver   dysfunction

   

  Letrozole

  Ovulation induction

  Aromatase inhibitor that inhibits E2 production,   which causes an increase in LH:FHS ratio

  2.5- to 5-mg tablets administered orally for 5 days beginning   on cycle day 3 to 7

  Hot flashes, headaches, breast tenderness; may increase   risk for congenital anomalies

  Data from American Society for Reproductive Medicine. (2013). Medications for inducing ovulation: A patient guide. Retrieved from www.asrm.org/Factsheetsandbooklets; Facts and Comparisons. (2013). A to Z drug facts. Retrieved from www.factsandcomparisons.com; Casper, R.F., & Mitwally, M.F.M. (2016). Ovulation induction with letrozole. UpToDate. Retrieved from https://www.uptodate.com/contents/ovulation-induction-with-letrozole; Medscape. (2017). Menotropins. Retrieved from http://reference.medscape.com/drug/menopur-repronex-menotropins-342877; Lobo R. (2017). Infertility: Etiology, diagnostic evaluation, management, prognosis. In R. A. Lobo, D. M. Gershenson, G. M. Lentz, et al. (Eds.), Comprehensive gynecology (7th ed.). Philadelphia, PA: Elsevier.

  Surgical Therapies

  A number of surgical procedures may be used for problems causing female infertility. Ovarian tumors must be excised. Whenever possible, functional ovarian tissue is left intact. Scar tissue adhesions caused by chronic infections may cover much of the ovary. These adhesions usually necessitate surgery to free and expose the ovary so ovulation can occur.

  Hysterosalpingography is useful for identification of tubal obstruction and also for the release of blockage as demonstrated in Fig. 5.2. During laparoscopy, delicate adhesions may be divided and removed, and endometrial implants may be destroyed by electrocoagulation or laser, as illustrated in Fig. 5.3. Laparotomy and microsurgery may be required for extensive repair of the damaged tube. Prognosis depends on the degree to which tubal patency and function can be restored. In general, laparoscopic surgery for tubal patency is most effective in younger women with distal tubal damage. Older women or those with significant proximal disease should be referred for ARTs that bypass the uterine tube.

   

  FIG 5.2 Hysterosalpingography. Note that the contrast medium flows through the intrauterine cannula and out through the uterine tubes.

   

  FIG 5.3 Laparoscopy.

  In women with uterine abnormalities, reconstructive surgery (e.g., the unification operation for bicornuate uterus) can improve the ability to conceive and carry a fetus to term. Surgical removal of tumors or fibroids involving the endometrium or muscular walls of the uterus may also improve the woman’s chance of conceiving and maintaining a pregnancy to viability, depending on the location and size of the fibroid or tumor. Surgical treatment of uterine tumors or maldevelopment that results in successful pregnancy usually necessitates birth by cesarean surgery near term gestation because the enlarging uterus can rupture as a result of weakness in the area of reconstructive surgery.

  Chronic inflammation and infection can be eliminated by radial chemocautery (destruction of tissue with chemicals) or thermocautery (destruction of tissue with heat, usually electrical) of the cervix, cryosurgery (destruction of tissue by application of extreme cold, usually liquid nitrogen), or conization (excision of a cone-shaped piece of tissue from the endocervix). When the cervix has been deeply cauterized or frozen or when extensive conization has been performed, the cervix may produce less mucus. Therefore, the absence of a mucus bridge from the vagina to the uterus can make sperm migration difficult or impossible. Therapeutic intrauterine insemination may be necessary to carry the sperm directly through the internal os of the cervix.

  Surgical procedures may also be used for problems causing male infertility. Surgical repair of varicocele has been relatively successful in increasing sperm count but not fertility rates. Microsurgery to reanastomose (restore tubal continuity) the sperm ducts after vasectomy may restore fertility.

  Assisted Reproductive Therapies

  The Centers for Disease Control and Prevention (CDC) (2014) defines ART as fertility treatments in which both eggs and sperm are handled. In general, these treatments involve removing the eggs from the woman, fertilizing the eggs in the laboratory, and returning the embryo or embryos to the woman or surrogate carrier. Births that were conceived through ART comprise over 1.5% of all infants born in the United States each year since 2013 (Kaplan, 2015).

  Some of the ARTs for treatment of infertility include in vitro fertilization–embryo transfer (IVF-ET), gamete intrafallopian transfer (GIFT) (Fig. 5.4), zygote intrafallopian transfer (ZIFT), ovum transfer (oocyte donation), embryo adoption, embryo hosting and surrogate motherhood, therapeutic donor insemination (TDI), ICSI, assisted embryo hatching, and preimplantation genetic diagnosis (PGD).

   

  FIG 5.4 Gamete intrafallopian transfer (GIFT). A, Through laparoscopy a ripe follicle is located, and fluid containing the egg is removed. B, The sperm and egg are placed separately in the uterine tube, where fertilization occurs.

  Table 5.3 describes these procedures and the possible indications for ARTs. Donor sperm and donor eggs can be used with ARTs. In addition, surrogates may carry the couple’s biologic child. ARTs are associated with many ethical and legal issues (Box 5.6).

  TABLE 5.3

  Assisted Reproductive Therapies

   

  Procedure

  Definition

  Indications

   

  In vitro fertilization–embryo transfer (IVF-ET)

  A woman’s eggs are collected from her ovaries, fertilized   in the laboratory with sperm, and transferred to her uterus after normal   embryo development has occurred.

  Tubal disease or blockage; severe male infertility;   endometriosis; unexplained infertility; cervical factor; immunologic   infertility

   

  Gamete intrafallopian transfer (GIFT)

  Oocytes are retrieved from the ovary, placed in a catheter   with washed motile sperm, and immediately transferred into the fimbriated end   of the uterine tube. Fertilization occurs in the uterine tube.

  Same as for IVF-ET, except there must be normal tubal   anatomy, patency, and absence of previous tubal disease in at least one   uterine tube

   

  IVF-ET and GIFT with donor sperm

  This process is the same as described previously except in   cases where the male partner’s fertility is severely compromised and donor   sperm can be used; if donor sperm are used, the woman must have indications   for IVF and GIFT.

  Severe male infertility; azoospermia; indications for   IVF-ET or GIFT

   

  Zygote intrafallopian transfer (ZIFT)

  This process is similar to IVF-ET; after IVF the ova are   placed in one uterine tube during the zygote stage.

  Same as for GIFT

   

  Donor oocyte

  Eggs are donated by an IVF procedure, and the donated eggs   are inseminated. The embryos are transferred into the recipient’s uterus,   which is hormonally prepared with estrogen/progesterone therapy.

  Early menopause; surgical removal of ovaries; congenitally   absent ovaries; autosomal or sex-linked disorders; lack of fertilization in   repeated IVF attempts because of subtle oocyte abnormalities or defects in   oocyte-spermatozoa interaction

   

  Donor embryo (embryo adoption)

  A donated embryo is transferred to the uterus of an   infertile woman at the appropriate time (normal or induced) of the menstrual   cycle.

  Infertility not resolved by less aggressive forms of   therapy; absence of ovaries; male partner azoospermic or severely compromised

   

  Gestational carrier (embryo host); surrogate mother

  A couple undertakes an IVF cycle,   and the embryo(s) is/are transferred to another woman’s uterus (the carrier),   who has contracted with the couple to carry the baby to term. The carrier has   no genetic investment in the child.

  Surrogate motherhood is a process   by which a woman is inseminated with semen from the infertile woman’s partner   and then carries the baby to term.

  Congenital absence or surgical removal of uterus;   reproductively impaired uterus, myomas, uterine adhesions, or other   congenital abnormalities; medical condition that might be life-threatening   during pregnancy (e.g., diabetes; immunologic problems; or severe heart,   kidney, or liver disease)

   

  Therapeutic donor insemination (TDI)

  Donor sperm are used to inseminate the female partner.

  Male partner is azoospermic or has very low sperm count;   couple has genetic defect; male partner has antisperm antibodies

   

  Intracytoplasmic sperm injection

  One sperm cell is selected to be injected directly into the   egg to achieve fertilization. It is used with IVF.

  Same as TDI

   

  Assisted hatching

  The zona pellucida is penetrated chemically or manually to   create an opening for the dividing embryo to hatch and implant into the   uterine wall.

  Recurrent miscarriages; to improve implantation rate in   women with previously unsuccessful IVF attempts; advanced age

  Data from American Society for Reproductive Medicine. (2016). Assisted reproductive technologies: A guide for patients. Retrieved from https://www.asrm.org/BOOKLET_Assisted_Reproductive_Technologies/.

  Box 5.6

  Issues to Be Addressed by Infertile Couples Before Treatment

  • Risk for multiple gestation

  • Possible need for multifetal reduction

  • Possible need for donor oocytes, sperm, or embryos or for gestational carrier (surrogate mother)

  • Whether or how to disclose facts of conception to offspring

  • Freezing embryos for later use and what to do with extra embryos

  • Possible risk for long-term effects of medications and treatment on women, children, and families

  • Potential mental health effects (anxiety, depression) related to infertility treatment

  The lack of or misleading information about success rates and the risks and benefits of treatment alternatives prevent couples from making informed decisions. Nurses can provide information so couples have an accurate understanding of their chances for a successful pregnancy and live birth. Nurses also can provide anticipatory guidance about the moral and ethical dilemmas regarding the use of ARTs. If a couple is fortunate enough to have multiple embryos available, they may choose to preserve these for later implantation, which has potential legal implications.

  Legal Tip

  Cryopreservation of Human Embryos 

   

  Couples who have extra embryos frozen for possible transfer must be fully informed before consenting to the procedure. They must make decisions regarding the disposal of embryos in the event of death or divorce. If they no longer want the embryos, they may consider donating them to other couples, contributing them to research, or disposing of them.

  Complications

  Other than the established risks associated with laparoscopy and general anesthesia, few risks are associated with IVF-ET, GIFT, and ZIFT. The more common transvaginal needle aspiration for egg retrieval requires only local or intravenous analgesia. Congenital anomalies occur no more frequently than among naturally conceived embryos. Multiple gestations are more likely and are associated with increased risks for both the mother and fetuses. Nevertheless, ectopic pregnancies do occur more often and pose significant maternal risk (Lobo, 2017).

  Preimplantation Genetic Diagnosis

  PGD is a form of early genetic testing designed to allow identification of embryos with serious genetic abnormalities. Those embryos would not be used in ART. Genetic testing improves the likelihood of successful pregnancy. Micromanipulation allows removal of a single cell from a multicellular embryo for genetic study (i.e., embryo biopsy) (ASRM, 2014). PGD is used clinically in numerous centers around the world. Couples must be counseled about their options and choices and the implications of their choices when genetic analysis is considered.

  Adoption

  Couples may choose to build their family by adopting children who are not their own biologically. With increased availability of birth control and abortion and an increase in single mothers who choose to keep their babies, the availability of healthy newborn infants in the United States is limited (Greenblatt, 2011). Infants with diverse ethnic and racial heritages, infants with special needs, older children, and foreign adoptions are other options (Fig. 5.5).

   

  FIG 5.5 After two miscarriages, this couple chose foreign adoption. (Courtesy of Shannon Perry, Phoenix, AZ.)

  Contraception

  The CDC noted that the capability of Americans to engage in effective family planning as a result of the modern era of contraception was one of the 10 greatest public health achievements of the 20th century (CDC, 2013). Nevertheless, nearly half of all pregnancies in the United States are not planned (Rivlin & Westhoff, 2017). Among adolescent women who were 19 years of age or younger, more than 80% of those who became pregnant did not intend to do so (CDC, 2015). The nurse can play a vital role in preventing unplanned and/or unwanted pregnancy through counseling and education regarding family planning, contraception, and effective birth control. Family planning is the conscious decision about when to conceive or to avoid pregnancy throughout the reproductive years. Contraception is defined as the intentional prevention of pregnancy during sexual intercourse. Birth control is the device and/or practice used to decrease the risk for conceiving or bearing offspring.

  With the wide assortment of birth control options available, it is possible for a woman to use several different contraceptive methods at various stages throughout her fertile years. Nurses provide information about the various methods and help couples compare and contrast available contraceptive options. Providing adequate instruction about how to use a contraceptive method, when to use a backup method, and when to use emergency contraception (EC) can decrease the risk for unintended pregnancy. The Community Focus box presents information about contraceptive education.

  Community Focus

  Education for Contraceptive Use: Student Activity

   

  A suggested activity to learn more about contraceptive use is to observe a nurse doing contraceptive counseling in a family planning clinic. An alternative suggestion is to prepare information on several common contraceptive methods to present to adolescents at a health course in school or at a group meeting, such as for the Girl Scouts, Girls Inc., or a church youth group.

  Care Management

  An interprofessional approach may help a woman choose and correctly use an appropriate contraceptive method. Nurses, nurse-midwives, nurse practitioners, other advanced practice nurses, and physicians have the knowledge and expertise to help a woman make decisions about contraception that will satisfy her personal, social, cultural, and interpersonal needs.

  Assessment for the couple desiring contraception involves assessment of the woman’s medical and reproductive history (menstrual, obstetric, gynecologic, contraceptive), physical examination, and sometimes current laboratory tests. The nurse must determine the woman’s knowledge about reproduction, contraception, and STIs and her sexual partner’s commitment to any particular method. Fig. 5.6 illustrates contraceptive counseling. The nurse obtains information about the frequency of coitus, number of sexual partners (present and past), and any objections that she or her partner might have about specific birth control methods. In addition, the nurse must determine a woman’s willingness to touch her genitals. Religious and cultural factors may influence a couple’s choice regarding a particular contraceptive method. The couple may believe in certain reproductive myths. Unbiased patient teaching is fundamental to initiating and maintaining any form of contraception. The nurse counters myths with facts, clarifies misinformation, and fills in gaps in knowledge. The ideal contraceptive should be safe, effective, easily available, economical, acceptable, simple to use, and promptly reversible. Although no method may ever achieve all of these objectives, significant advances in the development of new contraceptive technologies have occurred over the past 30 years.

   

  FIG 5.6 Nurse counseling a woman about contraceptive methods. (Courtesy of Dee Lowdermilk, Chapel Hill, NC.)

  Contraceptive failure rate refers to the percentage of contraceptive users expected to have an unplanned pregnancy during the first year even when they use a method consistently and correctly. Contraceptive effectiveness varies from couple to couple and depends on both the properties of the method and the characteristics of the user (Box 5.7). Effectiveness of a method can be expressed as theoretic (i.e., how effective the method is with perfect use) and typical (i.e., how effective the method is with typical use). Failure rates decrease over time, either because a user gains experience with and uses a method more appropriately or because the less effective users stop using the method. Safety of a method may be affected by a woman’s medical history (e.g., thromboembolic problems and contraceptive methods containing estrogen). Nevertheless, in most instances pregnancy would be more dangerous to the woman with medical problems than a particular contraceptive method. In addition, many contraceptive methods have health promotion effects. Barrier methods such as the male condom offer some protection from acquiring STIs, and oral contraceptives lower the incidence of ovarian and endometrial cancer.

  Box 5.7

  Factors Affecting Contraceptive Method Effectiveness

  • Frequency of intercourse

  • Motivation to prevent pregnancy

  • Understanding of how to use the method

  • Adherence to the method

  • Provision of short- or long-term protection

  • Likelihood of pregnancy for the individual woman

  • Consistent use of the method

  Following assessment and analysis, the couple determines possible contraceptive methods that are appropriate for their unique situation. Factors to consider when determining a contraceptive method are effectiveness, convenience, affordability, duration of action of method, reversibility of method, time of return to fertility, effects on uterine bleeding patterns, side effects, adverse events, health promotion effects of methods, effect of method on transmission of STIs, and medical contraindications for use.

  The most effective reversible contraceptive methods at preventing pregnancy are the long-acting, reversible contraceptive (LARC) methods (e.g., contraceptive implants, intrauterine contraception). With these methods, theoretic and typical pregnancy rates are the same because the method requires no user intervention after correct insertion. Effective methods include those that prevent pregnancy through exogenous hormones (estrogen and/or progestins) such as contraceptive injections, oral contraceptive pills, contraceptive patches, and vaginal rings. Each of these methods involves user interventions; thus typical-use pregnancy rates are higher than pregnancy rates with perfect use. The least effective contraceptive methods include the barrier methods and natural family planning. Examples include condoms, diaphragms, cervical caps, spermicides, withdrawal, and periodic abstinence during perceived ovulation. Effectiveness rates for these methods vary from user to user, depending on correct application of the method and consistency of use.

  Expected outcomes related to contraceptive counseling are that the couple will verbalize understanding about appropriate contraceptive methods, state they are satisfied with the method chosen, use the method correctly and consistently, experience no adverse sequelae as a result of the chosen contraceptive method, and prevent unplanned pregnancy. The nurse assists with obtaining appropriate informed consent concerning contraception or sterilization, provides appropriate education to the couple, and documents the couple’s understanding of the contraceptive method chosen. Evaluation involves achievement of patient-centered outcomes when the couple engage in effective use of the chosen contraceptive device, experience no adverse sequelae, and achieve pregnancy only when they desire to do so.

  Methods of Contraception

  The following discussion of contraceptive methods provides the nurse with information needed for patient teaching. After implementing the appropriate teaching for contraceptive use, the nurse supervises return demonstrations and practice to assess patient understanding (see Clinical Reasoning Case Study). The couple is given written instructions, telephone numbers, and/or email contact information for questions. If the woman has difficulty understanding written instructions, she and her partner, if available, are offered graphic material, a telephone number to call as necessary, and an opportunity to return for further instruction.