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1. 04 INFERTILITY

2. DEFINITION AND CLASSIFICATION
2
 Infertility is defined as failure to conceive after 12 months of regular, unprotected
sexual intercourse.(After 6 months if the woman is >35 years old).
Type Definition Common Causes
Primary
Infertility
Couple has never
conceived.
Ovulatory disorders, tubal blockage,
endometriosis, male factor.
Secondary
Infertility
Couple previously
conceived but unable to
conceive again.
Pelvic infections, postpartum complications,
age-related decline, male factor.

3. 3
CAUSES OF INFERTILITY

4. DIAGNOSTIC MEASURES
4
Aspect Clinical Description / Criteria Notes & Rationale
Definition
• Regular, unprotected sexual intercourse over a 12-month
period without achieving pregnancy.
• This is the standard definition of infertility
for couples under 35 years. For women
35 years, evaluation starts after 6
≥
months.
Frequency • 2–3 times per week throughout the menstrual cycle.
• Ensures exposure during the fertile
window (around ovulation). Daily
intercourse is not necessary and may
slightly reduce sperm count.
Timing (Fertile Window)
• Intercourse during the 5 days before ovulation and on the
day of ovulation.
• Fertilization most likely occurs when
sperm are present in the female genital
tract before ovulation.
No Contraceptive Use
• The couple should not be using any form of contraception
(barrier, hormonal, or withdrawal).
• To ensure maximum opportunity for
conception.
Sexual Function
• Normal libido, erection, ejaculation, and vaginal
penetration are required.
• Any sexual dysfunction (e.g., erectile
dysfunction, dyspareunia, vaginismus)
should be evaluated as a cause of
infertility.
Duration Criterion
• <35 years: attempt conception for 12 months.
≥
• ≥35 years: attempt for 6 months.
≥
• ≥40 years or known risk factors: immediate evaluation.
• Reflects age-related decline in fertility,
especially ovarian reserve.
• Couples should avoid smoking, alcohol abuse, extreme • Supports normal ovulation and sperm

5. 5
FERTILITY TERMINOLOGY
Term Definition Explanation / Notes Measurement
Fecundity The biological capacity of a
woman (or couple) to
conceive and produce a live
birth.
It represents the potential for
reproduction, regardless of
whether conception actually
occurs. It depends on healthy
ovulation, fertilization,
implantation, and maintenance of
pregnancy.
It is a biological concept, not
directly measured, but inferred
from fertility outcomes and
absence of infertility causes.
Fecundability The probability of conceiving
in a single menstrual cycle
among couples exposed to
regular unprotected
intercourse.
It reflects how likely conception
is per cycle — essentially, the
monthly probability of pregnancy.
Usually expressed as a
percentage or probability, e.g.,
fecundability = 20–25% per cycle
in healthy couples
After 6 months ~60% conceive;
→
after 12 months ~85–90%
→
conceive..
Fecundability
Rate
The rate at which conception
occurs per menstrual cycle
among women at risk (not
It’s a quantitative measure of
fecundability.
Example: If 25 out of 100 women
conceive in one cycle, fecundability
rate = 0.25 or 25% per cycle.

6. Female Partner Evaluation
6

7. DIAGNOSTIC MEASURES
7
A. Female Partner Evaluation
Step 1: History & Physical Examination
• Duration and frequency of intercourse
• Menstrual history (cycle regularity, flow)
• Past pelvic infections, surgeries, or obstetric complications
• Signs of hyperandrogenism (hirsutism, acne)
• Weight and BMI (extremes affect ovulation)

8. DIAGNOSTIC MEASURES
8
Step 2: Assessment of Ovulation
Test Normal Range Abnormal Findings Interpretation
Menstrual cycle Regular (21–35 days) Irregular, absent menses Suggests anovulation
Basal Body Temperature
(BBT)
Rise of 0.3–0.5°C after
ovulation
No mid-cycle rise No ovulation
Serum Progesterone (Day 21
of cycle)
≥10 ng/mL indicates
ovulation
<5 ng/mL Anovulatory cycle
LH Surge (Urinary LH test)
Mid-cycle peak (24–36
hrs before ovulation)
No surge detected Ovulatory failure
Transvaginal Ultrasound
(Follicular tracking)
Dominant follicle 18–24
mm ovulation
→
No dominant follicle or no
rupture
Failed ovulation
Endometrial biopsy (rare
now)
Secretory endometrium
7 days post-ovulation
Inactive or proliferative
endometrium
Luteal phase defect

9. DIAGNOSTIC MEASURES
9
Step 3: Tubal Patency and Uterine Assessment
Test Normal Findings Abnormal Findings Remarks
• Hysterosalpingography
(HSG)
Both tubes patent,
free spill of contrast
Blocked tubes,
hydrosalpinx, uterine
anomalies
Done between Day
7–10 of cycle
• Sonohysterography /
HyCoSy
Patent tubes with
free contrast flow
Tubal block
Non-invasive
ultrasound
alternative
• Laparoscopy with
Chromopertubation
Dye seen from
fimbrial ends
Tubal occlusion or
adhesions
Gold standard for
tubal patency
• Hysteroscopy
Normal uterine
cavity
Polyps, septum, adhesions For structural defects

10. DIAGNOSTIC MEASURES
10
Step 4: Hormonal Profile
Hormone Normal Value Abnormal Value Clinical Significance
• FSH (Day 3) <10 IU/L
>10–12 IU/L Diminished ovarian
→
reserve
Reflects ovarian function
• LH (Day 3) 1–1.5 × FSH LH/FSH ratio >2–3 Suggests PCOS
→ Ovulatory dysfunction
• Estradiol (Day 3) <80 pg/mL
>80 pg/mL Early follicular
→
recruitment
Ovarian aging
• AMH (Anti-
Müllerian
Hormone)
1–4 ng/mL
<1 ng/mL Low reserve; >4 ng/mL
→ →
PCOS
Best ovarian reserve
marker
• Prolactin <25 ng/mL >25 ng/mL Hyperprolactinemia
→
Inhibits GnRH and
ovulation
• TSH 0.4–4.5 mIU/L <0.4 or >4.5
Thyroid dysfunction
affects fertility

11. WHAT IS THE DIFFERENCE BETWEEN?
SUPERFETATION ?
 Superfetation is the development of
embryos from multiple ovulation
cycles during a single pregnancy.
 Superfetation involves embryos of
different gestational ages, as one
egg implants and develops before
the second, subsequent ovulation
occurs
SUPERFECUNDATION ?
 Process: A woman releases multiple
eggs during one ovulation period, and
two or more of these eggs are fertilized
by sperm from different acts of
intercourse, potentially from different
partners.
 Outcome: The fertilized eggs implant
and develop, resulting in two or more
embryos that are half-siblings
(different fathers) but are the same
gestational age.
11

12. DIAGNOSTIC MEASURES
12
Step 5: Cervical & Vaginal Factors
Test Normal Finding Abnormal Significance
• Postcoital Test
(within 8–12 hrs)
>5 motile sperm/HPF in
mucus
No motile sperm
Cervical hostility or
antisperm antibodies
• Cervical mucus
Clear, stretchable, fern
pattern
Thick, absent ferning Low estrogen, infection
• Vaginal swabs Normal flora
Infection (BV, Candida,
Trichomonas)
Treatable cause of
infertility

13. DIAGNOSTIC MEASURES
13
Step 6: Uterine and Pelvic Imaging
Test Normal Abnormal Notes
• Pelvic
Ultrasound
Normal uterus, both
ovaries visualized
Fibroids, endometriosis, cysts Baseline imaging
• Doppler USG Normal flow patterns
Ovarian or endometrial vascular
abnormality
Evaluates perfusion
before ART

14. DIAGNOSTIC MEASURES
14
B. Male Partner Evaluation
Step 1: History & Examination
• History: mumps orchitis, trauma, varicocele, smoking, alcohol, heat exposure,
medications
• Examination: testes size (>15 mL normal), varicocele, secondary sexual
characteristics

15. DIAGNOSTIC MEASURES
15
Parameter Normal Range Abnormal Findings Interpretation
• Volume ≥1.5 mL <1.5 mL (hypospermia)
Obstruction, retrograde
ejaculation
• Sperm concentration ≥15 million/mL
<15 million/mL
(oligospermia)
Low spermatogenesis
• Total sperm count ≥39 million/ejaculate <39 million Subfertile
• Motility (progressive)
≥40% total or 32%
≥
progressive
<32% Asthenozoospermia
• Morphology (normal
forms)
≥4% (strict Kruger
criteria)
<4% Teratozoospermia
• Vitality (live sperm) ≥58% live <58% Necrozoospermia
• pH 7.2–8.0
<7.0 obstruction; >8.0
→
infection
→
Assesses seminal tract
• Leukocytes <1 million/mL >1 million infection
→ Seminal infection
Step 2: Semen Analysis
Abnormal semen repeat test after 2–3 weeks
→ before confirming.

16. DIAGNOSTIC MEASURES
16
Test Normal Range Clinical Indication
• FSH 1–8 IU/L High primary testicular failure
→
• LH 1–7 IU/L High with low testosterone hypogonadism
→
• Testosterone 300–1000 ng/dL Low endocrine cause
→
• Prolactin <20 ng/mL High pituitary tumor
→
• Karyotype/Y-chromosome
microdeletion
Normal 46,XY Genetic azoospermia
• Scrotal ultrasound Normal testes Varicocele, obstruction
Step 3: Hormonal & Genetic Tests (if indicated)

17. . COUNSELING, ETHICAL & LEGAL ASPECTS OF ART
17
Domain Description
• Counseling
Emotional support, treatment expectations, stress reduction, and
education on success rates.
• Ethical Aspects
Informed consent, non-commercialization of gametes, confidentiality,
equal rights for donors and recipients.
• Legal Considerations
Regulations on donor anonymity, embryo storage (usually 10 years),
≤
and surrogacy laws as per national acts.

18. Recent Advancements in Fertility Management
18
Technique Description Indications
• Ovulation Induction
Clomiphene citrate, Letrozole,
Gonadotropins
Anovulation (PCOS)
• Intrauterine Insemination (IUI)
Washed motile sperm placed
intrauterine
Mild male factor, cervical factor
• IVF (In Vitro Fertilization)
Oocyte fertilized outside body,
embryo transferred
Tubal block, unexplained infertility
• ICSI (Intracytoplasmic Sperm
Injection)
Single sperm injected into oocyte Severe male factor
• Cryopreservation
Freezing of sperm, oocytes, or
embryos
Fertility preservation
• Preimplantation Genetic Testing
(PGT)
Detects chromosomal/genetic
defects
Recurrent miscarriage, genetic
disease
• Surrogacy Another woman carries pregnancy
Uterine absence or recurrent
pregnancy loss

19. ADOPTION PROCEDURES
19
Steps:
1.Registration at authorized adoption agency
2.Home study and psychosocial evaluation
3.Matching process
4.Pre-adoption foster care (if required)
5.Legal adoption order by court
6.Post-adoption follow-up and counseling
Nurse’s Role:
• Educate parents about legal steps, emotional preparedness
• Support adjustment and bonding with child
• Monitor post-adoption well-being

20. ROLE OF PRACTITIONERS AND NURSES IN INFERTILITY
MANAGEMENT
20
Function Description
• Assessment Collect comprehensive reproductive, medical, and psychosocial history.
• Education Teach about fertility awareness, timing of intercourse, healthy lifestyle.
• Counseling Provide continuous emotional and psychological support during treatment.
• Clinical Support Assist during ART procedures (ovum retrieval, embryo transfer).
• Monitoring Observe response to ovulation induction and early pregnancy outcomes.
• Ethical Practice Maintain confidentiality, informed consent, and patient advocacy.
• Follow-up Care
Manage side effects (OHSS, multiple pregnancy), provide grief counseling if
unsuccessful.

21. SUMMARY
21
 Infertility is a multifactorial condition requiring an integrated approach
involving:
 Comprehensive diagnosis of both partners
 Individualized treatment (medical, surgical, or ART)
 Ethical and psychological counseling
 Nursing involvement throughout the care continuum
 Accurate diagnostic interpretation, patient-centered counseling, and evidence-
based interventions significantly improve conception success rates and
emotional well-being.

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