OBJECTIVE • To define fertility and infertility • To identify the types of infertility • To know the general statistic in the world • To revise an overview of infertility cases in HUSM • The explain the etiologies and pathophysiology of infertility • To list the diagnostic investigation towards infertility • To identify the implication of infertility to individual, family and society • To understand nurses role in taking care of client with infertility problem • To state effective prevention and treatment for infertility INTRODUCTION World Health Organization statistics imply that infertility and sterility will be the third most serious diseases in the 21st century after cancer and cardiovascular diseases. Fertility can be defined as the ability to conceive and have children, the ability to become pregnant through normal sexual activity result of sperm and egg meeting each other almost immediately after ovulation. (Acupuncture Herbal, Treatment & Cure, 2006). Infertility can be defined as the failure to conceive baby after a year of regular intercourse without contraception. This is the term health care providers’ use for women who are unable to get pregnant, and for men who are unable to impregnate a woman, after at least 1 year if trying. Infertility can be divided into two categories which is primary infertility and secondary infertility. Primary infertility is the lack of conception despite cohabitation and exposure to pregnancy (WHO, 1991) or inability to conceive after regular intercourse for at least one year without contraception. While secondary infertility is the failure to conceive following a previous pregnancy despite cohabitation and exposure to pregnancy (in the absence of contraception, breastfeeding, or postpartum amenorrhea) (WHO, 1991) and usually occurs in mothers who have previously been pregnant at least once, but are unable to achieve another pregnancy. Infertility is a terribly frustrating problem that affects thousands of couples every year. But it is not a life sentence, and often there is much that can be done to treat this condition and achieve pregnancy. Without any treatment of infertility, only about 15-20% of couples will conceive naturally. The prognosis varies from individual to individual. However, statistically, a cause can be determined for 80-85% of infertility cases. Once a cause is known, infertility can usually be successfully treated. STATISTIC In most countries about 1 in 10 couples have some form of fertility problems. Recent estimation put the figures as about 350,000 couples in Malaysia who suffer infertility. Only 30%- 40% of cases are reported due to male infertility compared to female infertility because female chances of having baby drop rapidly every year after age 30.Research have show that risk for infertility increase with age. Age (years) Risk for infertility (%) 15 - 24 4.1 25 - 34 13.1 35 - 44 21.4 In Connecticut, A study regarding relationship between coffee drinking and risk of not conceiving had been perform with 1,909 women as a sample cases. This study shows a significant relationship between these two factors. Amount of coffee drink (cup) per day Risk of not conceiving (%) 1 55% 1.5 - 3 100% >3 176% If a woman keeps having miscarriages, it is also called infertility. (NICHD, 2006). People with prolonged exposure to dry cleaning or paint related chemicals (thinners, strippers, paints in general) are anywhere from 2 to 5 times more likely to have a miscarriage. But, studies show that 20% to 25% of miscarriages are due to immune system problems. Factors causing infertility Percentage of infertility Tubal factors 36% Ovulatory Disorders 33% Endometriosis 6% Unknown 40% ETIOLOGY OF FEMALE INFERTILITY The most common etiology of female infertility is ovulation disorders. Second is the tubal factor followed with endometriosis, other factors and uterine/cervica; factors. Ovulation disorders are the major causes of infertility in female. These can be caused whether by the flaws of regulation of reproductive hormones by hypothalamus and pituitary gland or ovary problem. There are a few problems that are categorized in ovulation disorders such as abnormal follicle stimulating hormone (FSH) and luteinizing hormone (LH) secretion, polycystic ovary syndrome (PCOS), luteal defect and premature ovarian failure. PATHOPHYSIOLOGY OF FEMALE INFERTILITY FSH and LH play an important role in stimulating the follicle. Therefore, if abnormality occurs in the secretion of these two essential hormones, ovulation process might be affected. Polycystic ovary syndrome (PCOS) is the problem at which some of the eggs develop into cyst (little sacs filled with fluid). This cyst is build up inside the ovary and may enlarge. This formation of cyst could be due to the high production of androgen (male hormone) inside female body. Therefore, women with this kind of problem would have irregular menstrual cycle. Luteal defect occur because of the production of progesterone that is essential to prepare uterine lining for fertilization and implantation of zigot is not enough. Therefore, fertilization cannot occur when this happen. Premature ovarian failure also one of the ovulation disorders. This problem is cause by autoimmune response at which the immune system wrongly attacks the ovarian tissues. It results in loss of ovum and decrease of estrogen production. Tubal factor occur when there is a block the ovum transport from the ovary through fallopian tube. Therefore, fertilization cannot occur. Third contributor of female infertility is endometriosis. Endometriosis is the growth of endometrial tissues (tissues that lines inside the uterus) that suppose to growth in the uterus but it growth outside the uterus and attached to other organs such as ovaries and fallopian tubes. There are also some causes which is unexplained because all the investigation done give negative results. So, the causes of infertility cannot be defined. A couple who had this unexplained infertility has higher risk to get spontaneous miscarriage. Others factor that contribute to female infertility are age, stress level, poor diet intake, sexually transmitted disease, drugs, smoking and genetic. ETIOLOGY IN MALE INFERTILITY Infertility in male also can be cause by many factors such as impaired sperm production, impaired sperm delivery, lifestyle and environmental exposure. The first cause of male infertility is an impaired of sperm production at which the production of sperm is affected by many causes such as varicocele, undescended testis, testosterone deficiency, chromosome defect, infections and hormonal disorders. Second cause of male infertility is impaired sperm delivery. Examples of a problem that can interfere in sperm delivery are sexual issues, blockage of epididymis or vas deferens, retrograde ejaculation, no semen, misplaced urinary opening, anti-sperm antibodies and cystic fibrosis. Lifestyle also can contribute into male infertility such as alcohol, drug, tobacco smoking, emotional stress, age, malnutrition and obesity. Environmental also effect male infertility. Examples of environmental exposure that can lead to male infertility are pesticides and other chemical agents, overheating the testicles, exposure to radiation or X-ray and cancer and its treatment. PATHOPHYSIOLOGY OF MALE INFERTILITY Sperm production can be impaired by many conditions. First condition is varicocele. Varicocele is a swollen vein the scrotum that may reduce normal cooling of testicles. This results in reduction of sperm count and motility. Second condition is undescended testis. It is a condition at which the one or both of the testes did not descend from the abdomen to the scrotum during fetal development. Sperm production might be impaired by this condition because the testicles are exposed to higher internal body temperature compared with temperature inside the scrotum. Testosterone deficiency also can contribute to impaired sperm production. Infertility can result from disorders of the testicles themselves, or an abnormality affecting the glands in the brain that produce hormones that control the testicles (the hypothalamus or pituitary glands). Sperm delivery can be impaired by blockage of epididymis or vas deferens. This blockage might be congenital. Therefore, sperms cannot be transport from testis out to penis. Absent of semen also can affect sperm delivery. The sperm cannot be transport from penis to vagina because semen brings along the sperm to the vagina. IMPLICATION OF INFERTILITY The psychological and emotional impact of infertility on a couple can be considerable. A couple suffered the feeling such as guilt, anger, depression, anxiety, inadequacy, grief, loss of control and low self-esteem. Men and women react differently to this issue. Women are more suffer psychosocial distress and higher level of depression, whereas men less distress and are able to adapt to childlessness. Only when male factors are diagnosed as the source of the fertility problem does the response become more negative with increased feelings of depression, social isolation and failure. Ambivalence may be a problem when one partner already has a biological child. The couple may have poor communication skills so that they are unable to express themselves and disclose their true feeling to each other. With the myriad of feelings surrounding infertility, good coping skills are essential. The couple must acknowledge their feelings, allow ourselves time to feel the sadness, anger, and frustration. Seek support whether through friends, professional counseling, groups, or online forums, finding somewhere to talk which can understand and help. get the more information about infertility, including alternatives like adoption or living child-free. Infertility is not conclusion in our life, fill with other relationship and set a specified time each day for the topic, and use the rest of the day to talk about other things. A couple also can get advice from the professional individual. It can help in coping with the emotional stress of infertility and seeking counseling before and during treatment. ROLE OF THE NURSE IN INFERTILITY The role of the fertility nurse is to provide a holistic approach to fertility investigation, treatment, and early pregnancy through compassionate, informed and evidence-based practice. Fertility nurses work as part of multi-professional teams whose focus is on delivering a high standard of care. We must give emotional, mental and physical support to the couples. As a educator, nurses should educate the lifestyle issues that can impact on fertility, like smoking and weight, as well as helping couples work out the best times of the month to have sex. Organize the pre-conception clinic to provide preconception health advice to couples who are worried about their fertility. Focuses on menstrual cycle awareness and helps a couple to work out when they are most fertile so that they can plan sexual intercourse. Advocate the second visit focuses on menstrual cycle awareness and helps a couple to work out when they are most fertile so that they can plan sexual intercourse. Advocate patient about the test and treatment. There are many way to cope with this problem, such as medication, IVF (in vitro fertilization), IUI (intrauterine insemination), egg donor, and GIFT (gamete intra fallopian transfer). Give the knowledge and the confidence to help patient in making decision. Create a community, discuss about fertility treatments, ask the questions, give answers, understand the patient needs, and make decisions with confidence. INFERTILITY PREVENTION Unfortunately, most cases of infertility are beyond any basic method of infertility prevention. This fact should not, however, preclude anyone trying to conceive from taking some basic preventative measures to ensure they are functioning at a reasonably high level of physical and emotional health during this process. Lifestyle Precautions Avoid excessive exercise (which can lead to a variety of menstrual disorders) Cease any recreational drug use Quit smoking. Smoking has been linked to miscarriages. You can use Nicotine Replacement or Smoking Medication. Minimize caffeine and alcohol intake (alcohol can disturb hormonal balances and lead to miscarriages) Apply methods of stress relief that don’t involve alcohol (such as meditation and other relaxation techniques) Practice safe sex to avoid contracting sexually transmitted diseases (STDs) Maintain a reasonably ideal body weight (to prevent hormonal imbalance) Avoid exposure to environmental hazards, including pesticides and heavy metals (such as lead and mercury) ) and are properly protected from radiation (during X-rays, etc) Keep a chart to follow your monthly cycle, as one’s cycle is an important indicator of overall health. Health Precautions In the event an STD is contracted, seek early medical help Maintain a diet featuring fresh fruits and vegetables (specifically, foods high in folic acid) Weight should be kept under control; Have regular physical examinations (including pap smears) Take the appropriate steps to control health issues such as diabetes and hypothyroidism Look into your family history of fertility, specifically with your biological mother (genetics play an important role in fertility) Ask your physician or pharmacist about whether any medications you’re taking, including prescriptions, over-the-counter medications and any herbal remedies you take, have been shown to cause fertility. SUGGESTIONS For couples struggling with infertility, "just relax" may be the most aggravating two-word phrase in the English language. "Those are fighting words," says infertility expert Sandra Berga, MD, chair of the Department of Gynecology and Obstetrics at Emory University in Atlanta. Couples don't need or appreciate any suggestion that infertility is "all in their head," she says. They also don't need to hear another story about a couple who finally conceived on a cruise ship or had three babies after they "stopped trying." Such advice may be maddening, but it also contains a seed of truth, Berga says. Studies conducted over the years strongly suggest that emotional stress can actually impair fertility in men and women. For many couples suffering from infertility of unknown origin, this apparent obstacle is also an opportunity. Berga and other researchers have found that some couples can dramatically increase their chances of conceiving simply by learning how to cope with stress. Instead of intrusive advice from well-meaning friends, infertile couples need professional help, Berga says. An infertility specialist can check each partner for underlying illnesses or anatomical problems that can make it hard to conceive. Learning how to cope with stress will not help all infertile couples, of course, particularly if the infertility is caused by a biological problem such as a lack of viable eggs. In such cases, those seeking a pregnancy would probably be advised to consider advanced reproductive technologies, such as using donor eggs. But if there's no other obvious explanation, psychological stress just might be the culprit. In such cases, Berga says, a professional counselor or therapist may be able to help couples handle stress and put them on the path to parenthood. CONCLUSION Traditionally, women have sought fertility service when unable to become pregnant, and the focus of medical evaluation has been directed toward ‘female factors’. This has cause frustration and depression among women and making coping with infertility really hard. Research has shown that the psychological stress experienced by women with infertility is similar to that of women coping with illnesses like cancer, HIV, and chronic pain. The truth is infertility does not have a single cause because successful pregnancy is a multi-step chain of events. The cause of infertility can rest in the woman or the man, or can be from unknown factors or a combination of factors. Implications can occur within individual, family as well as society. It is nurses’ job to play their role in order to manage client with infertility problem.