Introduction

Midwives will frequently care for couples that have received assistance in achieving their pregnancy. It is important to understand the processes they have to go through to become pregnant, which can contribute to the attitudes and anxieties demonstrated by individuals and create greater challenges for the midwifery team. Most couples will have received their fertility treatment in the private sector and occasionally the transition into normal NHS care may itself be stressful. This chapter provides a background on the issues related to infertility and the factors contributing to the patients’ approach to their pregnancy. It is useful for midwives to establish links with their local fertility services to provide support and information on patients to ease the transition into their care. Improved networking between fertility nurses and midwives would complement care provided in both areas. Awareness of the range of treatment options and the side-effects from treatment provides insight into both the physical and emotional condition of couples requiring midwifery care.

Multiple births are a key issue of concern in both areas of practice and it is essential that couples understand the risks and the care required when pregnant. Singleton pregnancies with the prevention of twin and triplet pregnancies are the ultimate goal of all fertility clinics, requiring appropriate management and monitoring of treatment. Many nurses and midwives have specialized in fertility, providing care and extending their role to perform ultrasound scanning, intrauterine insemination, embryo transfer and implications counselling (Barber 2002). Where possible, it is important for midwives and nurses to normalize pregnancies for couples, enabling them to enjoy their much-desired pregnancy.

Technological advances within the field of reproduction have increased public awareness of infertility and demand for related services. Approximately one in six couples will experience problems conceiving a child (Hull et al 1985, Templeton et al 1990) and will seek assistance to achieve a pregnancy. Since the birth of the world’s first ‘test-tube baby’ over 30 years ago, over one million babies have been born in the UK from in vitro fertilization (IVF). Research has highlighted the stigma, psychological morbidity and long-term implications caused by the experience of infertility on couples (Kerr et al 1999), and these factors impact on successful and unsuccessful couples. Over 95% of service provision exists within the private sector, thus providing a financial hurdle that couples must overcome prior to commencing their treatment.

Human fertilisation and embryology authority (HFEA)

The HFEA was created by the 1990 Act to license and monitor clinics performing various fertility treatments (including IVF, donated egg/sperm/embryo procedures, or research on embryos). All licensed clinics must have a delegated ‘person responsible’ who ensures that the conditions of the licence are carried out. Several forms of treatment are not controlled by the HFEA but may still potentially create similar problems to licensed treatments, including funding, ovarian hyperstimulation and multiple births. The HFEA carries out annual inspections to enable clinics to renew their licences, which include reviewing the welfare of any potential child, clinical and laboratory standards, protocols for practice in all areas and the safety of patients and their families.

As well as a Code of Practice and information to staff and patients, the HFEA maintains a formal register of information regarding specific donors, donor treatments and children born from these treatments (HFEA 2009). (For more information, see the website).

Reflective activity 28.1

How does regulation impact on the delivery and management of care of couples undergoing infertility treatments?

Causes of infertility

See Table 28.1.

Table 28.1 Main causes of infertility

	Incidence
Anovulation	26%
Endometriosis	3%
Tubal damage	13%
Unexplained	30%
Male factor	30%

(Snick et al 1997)

Anovulation

Anovulation may be diagnosed by the GP and may be corrected by drug therapy to initiate ovulation with an anti-oestrogen, such as clomifene – a common treatment for polycystic ovary syndrome (PCOS). Anovulation must be investigated as it may be caused by pathology such as hyperprolactinaemia, which could be corrected and prevent the woman undergoing fertility treatments.

Elevated levels of prolactin inhibit the normal hormonal feedback loop that initiates ovulation. If serum prolactin is elevated to 1000 mU/L, the test should be repeated. This could be caused by stress or from a prolactin-secreting pituitary adenoma or macroadenomas diagnosed with MRI. Treatment includes bromocriptine or cabergoline, which reduce the elevated levels of prolactin and restore normal endocrine activity and facilitate ovulation.

Anovulation can be divided into primary and secondary amenorrhoea – these are primarily caused by pituitary tumours, pituitary ablation, Kallmann syndrome and cancer treatments (see Box 28.1).

Polycystic ovary syndrome (PCOS)

This syndrome is frequently detected in women undergoing investigations for anovulation (Kousta et al 1999). It is characterized by cystic ovaries with more than 10 cysts, 2–8 mm in diameter, distributed around and through an echodense, thickened stroma (Fig. 28.1).

Figure 28.1 Ultrasound scan illustrating a polycystic ovary.

Endocrine features include a raised serum level of luteinizing hormone (LH) and/or testosterone, causing symptoms of acne, hirsutism (hyperandrogenism), oligoamenorrhoea and obesity (Box 28.2). The hypersecretion of LH is associated with menstrual irregularity and infertility. Obesity leads to hypersecretion of insulin, stimulating ovarian secretion of androgens with increased risk of the development of type 2 diabetes (Kousta et al 2000). Anovulation is also associated with endometrial hyperplasia due to increased oestrogen production unopposed by progesterone (Balen & Jacobs 1997). Women with a body mass index (BMI) >28 kg/m² and <20 kg/m² will have decreased fertility. There is an associated deficiency in gonadotrophin production with excessive weight loss, due to diminished production of gonadotrophin-releasing hormone (GnRH).

Ovarian failure

Ovarian failure can happen at any age. If prior to puberty, it is commonly associated with chromosomal abnormality, such as Turner syndrome (45X) (see Ch. 26), or sterility resulting from radiotherapy or chemotherapy for childhood malignancy. Ovarian failure linked with raised gonadotrophins and cessation of periods prior to the age of 40 is associated with autoimmune failure, infection, previous surgery and cancer treatments. There is also a suggested link with familial forms of fragile X (Balen & Jacobs 1997).

Endometriosis

This is caused when endometrial tissue is located outside the uterus, around the pelvis. This may be noted at laparoscopy as blue/black pigmentation (old lesions), red vasculated lesions (active lesions) and white non-pigmented papules (just activating) (Gould 2003). Retrograde menstruation is thought to be the most common cause of endometriosis but altered immune function is also thought to be associated with the condition. It causes pelvic pain, dyspareunia, dysmenorrhea and infertility. Pelvic adhesions, especially around the ovaries and tubes, with cystic lesions on the ovaries, called endometriomas, are common. Symptoms are linked with the menstrual cycle, age and hormonal therapy; treatments include drugs that interfere with the cycle. One group are GnRH agonists, which cause pituitary desensitization, inducing amenorrhoea; another are inhibitors of gonadotrophin secretion, such as danazol, which also have androgenic effects that cause unpleasant side-effects, including hot flushes, acne, oily skin, hirsutism, reduced libido, weight gain, nausea and headaches. Both groups of drug temporarily stop menses and reduce levels of antiendometrial autoantibodies (Balen & Jacobs 1997).