The nursing care of infertility in general practice

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Reference: Sept-Oct 2024 | Issue 5 | Volume 17 | Page 19

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The 2023 National Clinical Practice Guideline in Ireland states that women/couples seeking a fertility consultation should initially be reviewed in a primary care setting,¹ and the research strongly suggests that nurses are an instrumental part of managing these patients within the primary care model.² Initial conversations about conception and infertility are frequently initiated during routine women’s health investigations, which general practice nurses (GPNs) largely perform, and early work-up tends to begin naturally in primary care while patients are being referred to a fertility specialist or awaiting an appointment with one.

Therefore, GPNs play a pivotal role overall. High-quality care and positive attitudes among nursing staff have also been shown to significantly enhance the compliance of individuals undergoing infertility treatment, improve overall quality-of-care and satisfaction among infertility patients to a significant extent.^2,3,4

Infertility

Infertility (sometimes called subfertility) is a growing issue across Ireland and Europe. It is defined by the World Health Organisation (WHO) and most institutions as the failure to conceive after 12 or more months of regular, unprotected, vaginal sexual intercourse.⁵ Approximately 25 million people in Europe experience infertility issues,⁶ and one-in-six heterosexual couples in Ireland are believed to have difficulty getting pregnant.⁷

The 2023 National Clinical Practice Guideline in Ireland and the American Society of Reproductive Medicine advocate that investigations should be offered to couples of reproductive age who have been trying to conceive for 12 months or longer with no underlying medical condition, or six months for women that are struggling to conceive and are older than 35.^1,8

About 20-to-30 per cent of women in Ireland now have their first child after the age of 35, and it is estimated that one-third of couples in which the woman is over 35 have fertility problems.⁶ The societal shift towards a later age of first pregnancy has therefore led to an increased need for assisted reproductive techniques (ARTs), which generally consist of in-vitro fertilisation (IVF) and other types of medically-assisted reproduction.^1,5

As part of general preconception care, women should be advised that ageing decreases the ovaries’ ability to release healthy eggs for fertilisation and also increases the risk of having a miscarriage.⁹

Causes of infertility

Primary infertility refers to those who have never been pregnant before, while secondary infertility occurs when the woman has had one or more pregnancies in the past, but struggles to conceive again. Issues may occur due to problems relating to either the male or female (or both), and in some cases are unexplained.

Several causative and contributing factors are preventable, while others are challenging to overcome. Hormonal disorders, physical problems, psychological issues, sexual problems, chromosomal abnormalities, and genetic defects are among the diverse range of factors associated with both male and female infertility.

Lifestyle factors such as smoking, excessive alcohol intake, and obesity can also affect both sexes,^5,10 as can exposure to environmental pollutants and toxins such as insecticides, fungicides, pesticides, and others.^10,11

Female infertility
Alongside being over 35 years old, several physical factors commonly contribute to female infertility including; ovulatory disorders; pelvic adhesions; tubal blockages; other tubal/uterine abnormalities; hyperprolactinaemia; recurrent pregnancy loss; and vaginal problems.^4,11

Polycystic ovary syndrome is the most common cause of ovulatory-related female infertility, whereby the ovary produces excess testosterone, but inadequate follicle stimulating hormone (FSH) and luteinising hormone (LH). Genetic abnormalities such as hypogonadism or Turner’s syndrome are also causative factors, while hormonal imbalances like hypothyroidism interrupt hypothalamic-pituitary-ovarian interaction and can also play a role. Pelvic inflammatory disease and previous abdominal or pelvic surgery are common contributors to tubal infertility, as are endometriosis and gynaecological cancers.¹¹

The nutritional and lifestyle status of the woman is also an important factor, as diet, weight, and exercise all affect ovulation due to an increased blood glucose level that can disturb FSH and LH production. Stress also interferes with the production and secretion of LH and FSH; therefore, a holistic approach is vital.¹¹

Male infertility
In males, causative factors include acquired and congenital urogenital abnormalities (such as bilateral orchiectomy, epididymitis, transurethral resection of the prostrate, varicoceles, and retrograde ejaculation); endocrinological causes (usually due to hypogonadism); sperm transport disorders (such as vasectomy); genetic and immunological causes; Prader-Willi syndrome, Laurence-Moon-Biedl syndrome; iron overload syndrome; familial cerebellar ataxia; head trauma; intracranial radiation; testosterone supplementation; hyperthyroidism; malignancies and surgical and/or radiation treatment (such as sellar masses, pituitary macroadenomas, craniopharyngiomas, testicular, and adrenal tumours); drugs and medications; urogenital tract infections; and sexual dysfunction (premature ejaculation, erectile dysfunction).¹⁰ Idiopathic causes – whereby semen parameters are all normal, but the male remains infertile – are responsible for a significant number of cases.¹⁰

Male-related problems account for 27 per cent of infertility cases in Ireland, while female-related factors such as uterine or peritoneal issue (9 per cent); ovulatory disorders (23 per cent); tubal damage (18 per cent); and unexplained causes (23 per cent) account for the rest.¹

Initial investigations/referrals in general practice

Several initial investigations are either carried out or arranged in general practice for patients that are struggling to conceive. It is important that GPNs have knowledge about local and national referral pathways for expert fertility services in order to support couples through their infertility trajectory.

The National Clinical Practice Guideline recommends that all men should have an initial semen analysis performed and compared with WHO reference values.¹ As outlined by the WHO in 2021, the most recently updated normal reference range for semen analysis is outlined in Table 1.¹²

The specimen should be collected after a period of abstinence (two-to-seven days), kept warm, and appropriately transported to a nearby testing facility within 60 minutes of ejaculation to ensure the most accurate results. If abnormal, a repeat analysis should be performed within three months.⁴ Any abnormal results should prompt immediate referral to a urologist and a fertility specialist.

For women, the national guideline in Ireland recommends the following initial investigations:¹

• In women with a regular menstrual cycle, tests to confirm ovulation are not routinely recommended;
• If confirmation of ovulation is required in women with regular menstrual cycle, this can be done with mid-luteal progesterone, urinary LH kits, or a transvaginal ultrasound;
• If ovulation cannot be confirmed, hormonal profile on day two-to-four should be performed to include FSH, LH, and oestradiol;
• Ovarian reserve should be quantified using either antral follicle count and/or anti-Müllerian hormone;
• Baseline transvaginal pelvic ultrasound with a high frequency transducer should be ideally performed in the first 10 days of the cycle;
• Tubal patency should be performed with hysterosalpingogram or hysterosalpingo-contrast sonography where no pelvic pathology is suspected;
• It is reasonable to test thyroid stimulating hormone in women presenting with infertility.

Nursing care of infertility in general practice

Nursing care of infertility in general practice extends from preventive care and initial assessments to addressing the causes of infertility; providing educational material on fertility treatments and planned investigations/procedures; offering lifestyle advice, nutritional guidance, and emotional support; and advocating that couples receive the appropriate management and referrals throughout the entire process. Discussions about fertility should ideally occur as part of a larger conversation about reproductive health, including contraception and sexual health practices, prior to pregnancy planning.⁴

In March 2024, the Irish College of GPs launched a Quick Reference Guide on Fertility Assessment in General Practice that provides comprehensive information on the assessment and management of infertility in general practice. It includes evidence-based pre-conceptual advice for couples and outlines appropriate investigations and onward referral if indicated. GPNs can access this guide through the GP.

Nursing assessment: This should include both partners together, when possible. As well as a thorough family, medical, and surgical history, diet, exercise, and lifestyle status should be discussed with both males and females,^1,4 with a particular focus on alcohol, drug, and tobacco use; body mass index (BMI); and perceived levels of stress. Couples should also be asked about confirmed or possible exposure to pollutants, toxins, or radiation. Drug and medication history is important. Some of the commonly used drugs that increase the risk of infertility include:⁴

• Non-steroidal anti-inflammatory drugs (NSAIDs);
• Chemotherapy;
• Some anti-psychotic and anti-depressant medicines;
• Some anti-seizure medications;
• Some anti-hypertensive drugs;
• Opioids;
• Spironolactone;
• Steroids;
• Thyroid medications;
• Topical agents with hormones;
• Illegal drugs, such as marijuana and cocaine;
• Tobacco;
• Alcohol.

It is important to assess the couple’s sexual practices, including frequency, erectile dysfunction, premature ejaculation, and episodes of failed ejaculations.^4,14 GPNs should also determine the use of past and present contraceptive measures, if there are other children (including from previous relationships), and if either partner has a history of sexually transmitted infection that could lead to pelvic inflammatory disease, such as chlamydia or gonorrhoea.⁴

For females, a thorough menstrual history is essential and should include details of the patient’s normal menstrual cycle, such as length between cycles, duration, amount of bleeding, and age of menarche onset.⁴ All women planning to conceive and/or engage with fertility services should have their varicella status assessed and those who are non-immune should be offered varicella vaccination where possible.¹ Women should also be advised to get flu and whooping cough vaccinations, and GPNs should establish if two doses of the MMR vaccine have been administered.

If patients have not had both doses, GPNs can give the vaccinations and advise these women to avoid getting pregnant for one month after having the MMR vaccination. The National Immunisation Office is available to clarify any queries regarding vaccination status and administration.

Nursing interventions: As well as carrying out practical investigations such as phlebotomy, physical examinations, vaccinations, and others, GPNs play a large role in managing the emotional and psychological stressors many couples face while trying to conceive, which in themselves represent a significant barrier to achieving pregnancy.

Rates of sexual dissatisfaction, depression, anxiety, marital discord, and stigma are significantly high among couples struggling to conceive. Research suggests that couples’ emotional health is often overlooked in primary care settings and needs to be included in fertility assessments.⁴

Studies also indicate that psychological interventions play a substantial role in improving outcomes, with one investigation finding that psychological care doubled the pregnancy rate in infertile women who participated as compared with the control group.^4,13

GPNs can listen to concerns and advise women and their partners to join local support groups, therefore, knowledge of local groups/resources is essential. Some women with a complex medical or psychiatric history may require referral for pre-pregnancy counselling where appropriate.¹

All couples should be advised to abstain from tobacco use and limit or avoid alcohol consumption and the use of recreational drugs to help improve their chances of natural or ART conception.^9,14

The HSE provides and promotes a wide range of smoking cessation services for patients, ranging from online and social media supports to in-person clinics. GPNs can direct patients to these resources on www.quit.ie and www.facebook.com/HSEquit; the National Smokers’ QUITline on 1800 201 203; and HSE quit clinics.

GPNs should advise women to aim for a BMI less than 30kg per m² and explain that overweight and obesity not only reduces fertility, but also raises the risk of several pregnancy problems, such as high blood pressure, blood clots, miscarriage, and gestational diabetes.⁹ It is also recommended that both men and women reduce their caffeine intake to 200mg or with a safe limit of two cups of coffee or four cups of tea per day prior to conception.⁹

Couples should also be advised regarding the optimal frequency of sexual intercourse. The HSE recommends advising couples to have sex every two-to-three days.⁷

Male partners should be advised to keep their testicles cool by wearing loose underwear, moving around regularly, and spending time outside.^9,14 The ideal temperature for sperm production is around 34.5°C.

All women who are planning to become pregnant should be advised to take a 400mcg supplement of folic acid every day before conception (ideally for three months), and continue 400mcg of folic acid for the duration of pregnancy if they do conceive to prevent neural tube defects such as spina bifida. Some women may require a higher dose supplement of 5mg daily if they have a BMI >30; diabetes; take anti-epileptic drugs; or if there is a history of neural tube defects in the family (of either partner).⁹ These cases should be discussed with the GP.

Fertility services and treatment

As well as surgery to correct underlying issues, medications are also a frontline approach in fertility care. Ovulation induction can be achieved for many women through the use of medications such as clomid, tamoxifen, and letrozole, or injections of FSH or LH.¹⁵

Ireland was the only European Union state that did not offer any state-funded access to ART until the approval of state-funded fertility services in September 2023. GPs can now refer patients who meet access criteria to one of the six HSE Regional Fertility Hubs of their choice, which are located in Cork, Dublin, Galway, and Kildare, as well as several satellite clinics in other locations. Private fertility clinics in Ireland then provide care on behalf of the HSE to those recommended for further treatment by a fertility hub.

Eligible patients are entitled to one full cycle of IVF or intracytoplasmic sperm injection (ICSI) treatment. The Minister for Health has also set out details of eligibility criteria for treatment, which sets parameters in respect of the ages of the intending parents, the female patient’s BMI, the number of existing children, and the number of previous IVF cycles accessed. Female patients who meet the criteria will be eligible for treatment if they have been referred by their GP to a regional fertility hub before their 41st birthday.

The Rotunda Hospital recommends that the following tests are carried out in general practice before referral to a specialist.

Female:

• Hormonal profile (day three, four, or five of cycle; FSH, LH, oestradiol, TFT’s, prolactin);
• Mid-luteal phase progesterone level (if regular periods);
• Rubella immunity (within the last two years);
• Smear test (within the last three years);
• Hysterosalpingography, if access for test is possible.

Male:

• Semen analysis in an IVF unit laboratory close to the male partner’s home.

IVF involves the removal of eggs from the ovaries and fertilisation with sperm in a laboratory to create an embryo(s). The most viable embryo(s) is then implanted into the woman’s uterus. ICSI is similar to IVF, except that sperm is injected directly into a healthy ovum. Intrauterine insemination involves inserting sperm into the uterus around the time of ovulation.⁷

If patients require donor eggs or sperm, treatment is not currently available through the HSE. There are no egg or sperm banks in Ireland, and patients will usually get donor eggs or sperm from another country. There are no laws currently in place around surrogacy in Ireland and it is not available through the HSE.

Conclusion

Assessments and treatments within the primary care setting should not negate a referral to a fertility specialist, who can offer more comprehensive consultation and treatment options. For GPNs, the nursing care of infertility encompasses the physical, psychological, and emotional aspects of managing these patients in general practice. GPNs are in an ideal position to identify clients at risk, to collaborate with the GP, to educate, support, and recommend, and to ensure early investigations and treatments are initiated to optimise fertility outcomes and quality of life for couples.