Maternity - Preconception, part 3: Permanent Sterilization and Infertility

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In this article, we'll finish our coverage on contraception and explain what permanent sterilization is. Then we'll cover infertility, which is the inability to conceive for 6-12 months (depending on patient age). This is the last video and article in the preconception

This series follows along with our Maternity Nursing Flashcards which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

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Contraception: Permanent Sterilization

Sterilization is any form of procedure that renders a patient unable to conceive—to become pregnant or to get others pregnant. The main procedures available for this are a vasectomy to remove sperm from semen and a tubal ligation to prevent eggs from being available to fertilize.

Tubal ligation

A tubal ligation is the ligation (tying) of the fallopian tubes in order to prevent sperm from reaching and then fertilizing an egg resulting in pregnancy.

Usually, the fallopian tubes are cut and cauterized which means they are medically burned with heat or caustic substance to be sealed off.

A tubal ligation is permanent and cannot be reversed. In order for a patient who has had a tubal ligation to have the possibility of becoming pregnant, they would likely need to undergo in vitro fertilization, where the egg and sperm are combined in a lab and then transferred directly to the uterus, skipping the fallopian tube step entirely. So, a tubal ligation does not prevent pregnancy from ever occurring again, but it prevents fertilization via sexual intercourse.

Essure procedure

An Essure procedure was a procedure in which coils were inserted into the fallopian tubes, allowing scar tissue to grow around them and essentially blocking the fallopian tubes, in order to prevent sperm from reaching and then fertilizing an egg resulting in pregnancy. This procedure is not covered in our Maternity Nursing Flashcards, and you are unlikely to be tested on it, because it has been discontinued in the United States since 2019. But you may encounter patients who had this procedure in the past.

Vasectomy

A vasectomy is the cutting and sealing of the vas deferens, which is the tube that carries sperm from the testicles, in order to remove the sperm from semen and prevent sperm reaching and fertilizing an egg resulting in pregnancy. The sperm are still produced, but they are not present in the semen.

After the vasectomy is done, a follow-up sperm count should be done to ensure there are no sperm in the semen, otherwise, it could lead to pregnancy.

Some vasectomies may be reversible, but this is considered a permanent procedure.

Infertility

In this section, we'll talk about infertility. If this is a sensitive subject for you, we invite you to skip this section. As Meris shares in the video, she herself went through infertility and received treatments for it, and it can be disruptive and distressing to a patient's life.

Infertility is defined as the inability to conceive for one year for patients under the age of 35, and for patients over the age of 35, it's the inability to conceive for 6 months. Inherent in the "inability to conceive" is that the patient is trying to conceive. The timeline is shorter for patients over the age of 35 because the risks and difficulty factors of a pregnancy increase with patients over the age of 35, so the timeline is considered shorter.

Infertility risk factors

Some infertility risk factors include: age (egg counts decrease with age), endometriosis because of the presence of scar tissue/inflammation, ovulation disorders like PCOS, tubal occlusions, hormonal disorders (which can include PCOS), low sperm count, or a history of mumps (which can cause inflammation of the testicles).

Infertility diagnostics

There are several diagnostic tests available for diagnosing the causes of infertility, including a semen analysis, hysterosalpingogram, or a hysteroscopy

Semen analysis

Semen analysis is often the first test performed to diagnose infertility, because it's very easy, not invasive, and much more affordable. This allows the provider to rule out (or "rule in") low sperm count. If low sperm count is identified as the cause, then it can be addressed. But if not, then further steps can be taken.

Hysterosalpingogram

Hysterosalpingogram is a long word that's easy to understand if you break it down!

  • Hyster- means uterus (fun fact: this is where the word hysteria comes from; ancient doctors thought hysteria was a "woman's disorder" caused by the uterus moving around the body!),
  • salping- means fallopian tube (like a salpingectomy which is removal of all or part of the fallopian tube in some cases of ovarian cancer)
  • -ogram is a picture or drawing.

So, if you put uterus, fallopian tube, and picture together, you'll know that hysterosalpingogram is imaging of the uterus and fallopian tubes. Sometimes it's called HSG for short.

Usually, a hysterosalpingogram is done while the patient is awake or on twilight sedation. A camera is placed into the uterus and a contrast dye is infused into the uterus, and using fluoroscopy (video x-rays), the provider can see if the dye is able to travel through the fallopian tubes or if they are blocked.

Before a hysterosalpingogram, patients should be assessed for allergies to shellfish and iodine, since the contrast dye contains iodine and similar proteins that may trigger an allergic reaction.

Hysteroscopy

A hysteroscopy is a visual exam of the uterus, using a camera on a scope to assess the uterus for scar tissue or other abnormalities. A hysteroscopy is used as a diagnostic for infertility because abnormalities in the uterus could prevent implantation of a fertilized egg, resulting in infertility. This procedure often happens at the same time as a hysterosalpingogram.

Infertility treatment options

There are a variety of treatment options for infertility, including intrauterine insemination, in vitro fertilization, embryo transfer, donor eggs/embryo/sperm, or a gestational carrier (surrogate). These procedures come at great cost and time to patients and can be extremely stressful, so some patients may choose to say that these procedures are not for them, and go on to adopt.

Intrauterine insemination

Intrauterine insemination (IUI), sometimes referred to as artificial insemination, is when pre-collected and concentrated sperm is inserted directly into the uterus. Patients who use donor sperm may choose intrauterine insemination.

In vitro fertilization

In vitro fertilization, as we mentioned earlier, is a series of complicated procedures that includes when a sperm and an egg are combined in a lab and the resulting embryo or embryos are transferred to the uterus.

Embryo transfer/adoption

Embryo transfer or adoption is when a patient has an embryo transferred to their uterus that was not made from their own egg, but from someone else's egg. A patient may opt to use an embryo from someone that they know, or one that was donated.

How can an embryo be donated? When patients go through in vitro fertilization, there are sometimes extra embryos left over at the lab after the patient has successfully been able to get pregnant. These patients may choose to donate their embryos to another patient.

Donor eggs or sperm

Patients may opt to use donor sperm or donor eggs for a variety of reasons: if there is a problem with their own sperm or eggs, if they are in a same-sex couple, or if they are single and want to have a baby.

Gestational carrier (surrogacy)

Parents or a parent may work with a third person to be their gestational carrier or surrogate. Surrogacy can be "traditional" or gestational, depending on the origin of the egg. In "traditional" surrogacy, the surrogate's own egg is used—it's called traditional because it's older, and it was the only kind of surrogacy done before the technology evolved for gestational surrogacy.

In a gestational surrogacy, the egg of the parent is fertilized in vitro and transferred to the surrogate, so the surrogate is genetically unrelated to the baby.

Gestational surrogacy is a combination of in vitro fertilization and embryo transfer!

Full Transcript: Maternity - Preconception, part 3: Permanent Sterilization and Infertility

Hi. I'm Meris. And in this video, I'm going to be talking about permanent sterilization methods. And just as a trigger warning, I am also going to be discussing infertility. There are chapters here, so if you would like to skip infertility, or if you want to know when it's coming up, you will be able to see that. I'm going to be following along using our maternity nursing flashcards. These are available on our website, leveluprn.com. And if you already have a set of your own, I would definitely invite you to follow along with me. Okay, let's get started.

All right. So first of all, we are going to be talking about sterilization. So sterilization is any sort of procedure that is going to render a patient sterile. Meaning, unable to conceive.

So female sterilization or sterilization of anybody with a uterus is going to be something that is typically called a tubal ligation. So it is where they ligate. Meaning, tie the fallopian tubes. So tubal ligation. Not only do they tie, but in most instances they cut and cauterize. When I had my tubal ligation, my OB-GYN said, "I need you to understand, when I do your surgery, part of your fallopian tubes will be gone forever. If you ever wish to conceive again, you will have to do in vitro fertilization." And I said, "Totally understood. Totally on board."

But the reason I'm saying this is because it is not reversible, okay? This is a permanent thing that cannot ever be reversed.

This is invasive. This does require a laparoscopic procedure in most cases.

It can also be done at the time of a C-section. If a patient is pregnant and knows that they want this to be their last baby, and they are already having a C-section.

Now, sterilization of somebody with a penis is going to be called a vasectomy. So the reason it's called a vasectomy is because it is cutting the vas deferens. So that is the tube that transports semen out through-- well, it actually combines with the seminal fluid. But anyway, point being, it actually severs the connection where the semen can be transported. So the sperm are still produced, but they just don't get to the semen.

So this is very important to understand, that it's not just we do the procedure and okay, goodbye, you're good. You have to do follow up testing. So after the vasectomy is done, a follow-up sperm count should be done to ensure that there are no sperm in that semen. Otherwise, it could lead to pregnancy.

So this one though, reversal may be possible. Not always, but it may be.

But again, you don't want to use this as a form of contraception if you are intending to conceive again in the future. There are other options available to prevent pregnancy. Educate your patients that for all intents and purposes, they should be treating these as permanent procedures.

Now, there's something that's not on this card that I do want to mention briefly, that is the Essure procedure, or it is the fallopian tube coils. So these are coils that are inserted through hysteroscopic imaging. Meaning, with a camera in the uterus. So it's not invasive in terms of you're not cutting into the body. And small coils are placed into the fallopian tube. The body recognizes it as foreign, and scar tissue grows around it. This is kind of becoming falling out of favor. And you can look into the reasons for that. But I just want to bring that up in case you've never seen that, or heard about it, and you have a patient who mentions it.

Okay. So moving on. This is where we're going to be talking about infertility. And if this is a sensitive subject for you, I genuinely, truly, completely understand, and would invite you to skip this because I do not want to do anything that would be upsetting to you or your mental health. Just as a disclaimer, I am someone who had infertility. And so I have been through the infertility treatments myself, and I know how disruptive and distressing it can be to a patient's life.

So let's talk about infertility a little bit. So infertility is defined as the inability to conceive for one year, 12 full months for anybody under the age of 35. For patients over the age of 35, it's six months. So just very important to know. Just because I decided I'm trying to get pregnant, and I don't get pregnant after four months, it doesn't mean that I have infertility.

So there's a lot of different risk factors on here I would invite you to take a look at.

But then what I really want to call your attention to are the diagnostics that can be done to investigate infertility.

The one that most doctors will start with is going to be a semen analysis, because it's very easy, it's not invasive, it's more affordable. And then it essentially allows the provider to rule out or to rule in the male partner. So this is very much often where infertility exploration begins. Now, if we identify the cause, cool, maybe we can stop there and start addressing it. But if not, then we are going to move on.

A hysterosalpingography. Hysterosalpingogram is a very fancy word. Hystero means of the uterus. Salpingo means of the fallopian tube. And gram means a picture of, like on Instagram. So a hysterosalpingogram is a picture of the uterus and fallopian tubes. Now, this is done usually while the patient is awake, or perhaps twilight sedation. A camera is placed into the uterus and take a visual look around. And then a contrast dye is actually infused into the uterus. And using fluoroscopy, the medical provider can look and see, is the dye going through the fallopian tubes or not? Are they open or are they shut?

And then we also have a hysteroscopy. A hysteroscopy is just looking at the uterus using a camera. So the reason that I said it happens [with an] HSG is because they're very often combined. We do one and then the other, but they are separate procedures and can be done separately. So a hysteroscopy can often be done in the office as well.

So very important to understand that there are treatments available for these patients. There are lots of different treatments.

There's intrauterine insemination, IUI.

There is IVF, which is in vitro fertilization.

There is surrogacy.

There is embryo adoption, where you actually transfer an embryo that was not yours to begin with.

And then donor eggs and donor sperm. And then, of course, for some patients, they choose to say this is too expensive or too distressing or too upsetting, and go on to adopt.

So that is a little bit about sterilization and infertility. I hope that review was helpful for you. If it was, please go ahead and like this video so that I know. If you have anything great to add, any really good ways to remember things, I would love to hear it. Leave me a comment below, and I will absolutely read it. And you definitely want to be sure to subscribe to our channel. This is actually it for the preconception playlist for maternity. So you want to be the first to know when the pregnancy playlist starts getting posted. Thanks so much, and happy studying. I did just want to say that my infertility treatments did work. These are my two kiddos. I don't know if you can see that very well. But both of them were infertility success stories, and very, very thankful to have them. So yes, there was definitely - there were a few rainbows on the other side of our thunderstorm.

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