RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1

NAME OF THE

CANDIDATE AND

ADDRESS

Ms. ARJITHA

NOOR COLLEGE OF NURSING,

BHOOPSANDRA MAIN ROAD,

BANGALORE –560 094

2NAME OF THE

INSTITUTION

NOOR COLLEGE OF NURSING,

NO.5, BHOOPASANDRA

MAIN ROAD, RMV II STAGE,

BANGALORE-94.

3 COURSE OF THE STUDY

AND SUBJECT

M.SC. NURSING, 1ST YEAR,

OBSTETRICS AND GYNECOLOGICAL

NURSING

4 DATE OF ADMISSION 01.06.2010

5 TITLE OF THE TOPIC

A STUDY TO ASSESS THE KNOWLEDGE

REGARDING MANAGEMENT OF

INFERTILITY AMONG INFERTILE

WOMEN IN INFERTILITY CLINIC AT

BANGALORE” WITH A VIEW TO

DEVELOP INFORMATION BOOKLET.

1

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

General understanding of the equal contribution of male and female reproductive

cells or role of sexual intercourse in fertilization, reproduction was though to be a

singularly female phenomenon and the role of the male was considered unnecessary

and/or ceremonial. Conception depends on the fertility potential of both male and female

partner. The male is directly responsible in about 30-40 percent & the female is about

40-50 percent and both are responsible in about 10 % cases. Infertility is a failure to

conceive within one (or) more years of regular unprotected coitus1.

The WHO has defined Infertility as a inability to achieve a pregnancy after one

year of unprotected intercourse, when a women has never conceived, despite sexual

relation for a period of one year it is primary infertility, when a women has previously

conceived and is subsequently unable to conceive despite sexual relationship for a period

of one year it is secondary infertility. The couple has not conceived after 12 months of

contraceptive-free intercourse if the female is under the age of 34. The couple has not

conceived after 6 months of contraceptive-free intercourse if the female is over the age of

35 (declining egg quality of females over the age of 35 account for the age-based

discrepancy as when to seek medical intervention). The female is incapable of carrying a

pregnancy to term2.

This ignorance probably contributed to valuing women for their reproductive

abilities but also to blaming women when conception and pregnancy failed. Throughout

history and across cultures, there countless examples of social, religious and cultural

glorification, even idealization of motherhood, and the vilification and mal treatment of

infertile or ‘barren’ women. Infertile women were (and still may be) accused of

witchcraft, socially isolated and ostracized, physical abused, divorced, abandoned, are

forced to accept their husband’s additional wives, or murdered (often by their husband or

their husband’s family). As a result, astrology and numerology were considered

important fertility treatment by providing correct numbers and/or days of the month for

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maximizing fertility and achieving pregnancy. It is generally accepted that ancient

peoples had little understanding of human reproduction and as sterility3.

The experience of infertility is an unwelcome interruption to those who expect

parenthood to be a key identity and adult activity. Most people assume they can become

parents when they are ready, and found that “the vast majority of both husbands and

wives were taken by total surprise when they became aware of their infertility”. A couple

who is having difficulty in conceiving may feel isolated and difficult from others who are

able to conceive. They may separate themselves from others in an attempt to avoid

emotional pain. They may experience a ‘’roller coaster” of emotions, ranging from hope

to despair with each ovulatory cycle. Infertility places stress on the couple’s relationship

one or both may develop poor self- esteem and feel unworthy or unlovable. Intimacy,

love and support are essential components of a couple’s sexual relationship, may be lost

because intercourse takes on a “clinical” and mechanical tone4.

Infertility effects between 80 million and 168 million people in the world today

approximately 1 in 10 couples experience primary and or secondary infertility. The

majority of men and women live in developing world, are infertile due to sexually

transmitted diseases or underlying, untreated health conditions (eg.mal nutrition) while in

the developing world increasing age in women is a major casual factor of infertility. By

the early twentieth century, the pieces of the reproductive puzzle were beginning to fall

into place still. Incidence of 80% of the couples achieve conception if they so desire, with

in one year of having regular inter course with adequate frequency (4-5temes a week)

another 10% will achieve the objective by the end of second year. As such 10% remain

infertile by the end of second year5.

Generally, worldwide it is estimated that 1 in 7 couples have problems

conceiving, with the incidence similar in most countries independent of the level of the

country's development. The remaining 10% is an explained inspire of through

investigations with modern technical know how. It is also strange that 4 out of 10

patients of unexplained category become pregnant with in 3 years without having any

specific treatment. An explained infertility is defined when no obvious cause for

infertility has been detected from all standard investigations and over all incidence is 10-

15 percent. Fertility problems affect 1 in 7 couples in the UK. Most couples (about 84 out

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of every 100) who have regular sexual intercourse (that is, every 2 to 3 days) and who do

not use contraception will get pregnant within a year. About 92 out of 100 couples who

are trying to get pregnant do so within 2 years6.

In some cases, both the men and woman may be infertile or sub-fertile, and the

couple's infertility arises from the combination of these conditions. In other cases, the

cause is suspected to be immunological or genetic; it may be that each partner is

independently fertile but the couple cannot conceive together without assistance. For a

woman to conceive, certain things have to happen: intercourse must take place around the

time when an egg is released from her ovary; the systems that produce eggs and sperm

have to be working at optimum levels; and her hormones must be balanced7.

The factors responsible for infertility are many and varied, with an incidence in

men up to 30% and in women up to 40% and one third of couples the causes of infertility

remain an explained. The most common causes are ovulation failure and sperm disorders.

Due to an ovulation infertility is the rule prior to puberty and after menopause. But it

should be remembered that the girl may be pregnant even before menarche and

pregnancy is possible with in few months of menopause. Conception is not possible

during pregnancy as the pituitary gonadal action is suppressed by high and hence co

ovulation. The common causes of infertility are ovulation problems, Tubal blockage,

Male associated infertility, Age-related factors, uterine problems, Previous tubal ligation,

Previous vasectomy, Unexplained infertility8.

In about 15% of cases the infertility investigation will show no abnormalities. In

these cases abnormalities are likely to be present but not detected by current methods.

Possible problems could be that the egg is not released at the optimum time for

fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the

egg, fertilization may fail to occur, transport of the zygote may be disturbed, or

implantation fails. It is increasingly recognized that egg quality is of critical importance

and women of advanced maternal age have eggs of reduced capacity for normal and

successful fertilization9.

Health disease and condition content is reviewed by the medical review board on

infertility treatment plan will depend on the cause or causes behind in the fertility.

Infertility treatment also depend on whether the problem is from the women side or the

4

man side, both sides remains unexplained. The good news is that of couples dealing with

infertility are treated with low-tech treatments, like medication or surgery, with less than

being treated by assisted reproductive technologies, like IVF. Of those treated for

infertility, 2-3 will go on to have a baby. The women or couple facing infertility exhibits

behaviors of the grieving process and have impaired self concept. Intrauterine

insemination technique has been providing hope infertile couple and when in-vitro

fertilization is either not possible or has repeatedly failed, surrogacy may be viewed as an

alternative10.

Most infertility is really some degree of sub fertility 1 in 7 couple’s needs

specialist help to conceive, including some couples who have conceived before. With

expectant management about 60% of couples with an explained infertility will conceive

within a period of 3 years. IVF and ET may be an option for those who fail to respond.

Fertility drugs, forms of hormone therapy, are designed to trick the ovaries into

producing eggs, sometimes many eggs in a single cycle, by stimulating the woman's

hormones to do their assigned jobs more efficiently or by replacing them with "outside"

hormones. Clomiphene, marketed under the brand names of Clamed and Serophene and

used for the treatment of infertility problems for more than twenty-five years, is an agent

that increases the hormone production. Taken by tablet, clomiphene works by making the

pituitary gland produce large quantities of FSH (follicle-stimulating hormone)11.

A study was carried out on the surrogate motherhood and the legislative responses

to surrogacy in the states New York and California; and explores how discourses about

gender, family, race, genetics, rights, and choice have shaped policies aimed at this issue.

She examines the views of key players, including legislators, women’s organizations,

religious group, the media, and other. The study finds that a common assumption about

our responses to reproductive technologies offers a fascinating picture of how

reproductive policy shape social policy12.

As women postpone childbearing until later in life, a growing proportion of

American women experience infertility. Estimates from a large national sample suggest

that 10%–15% no surgically sterile American women ages 15–44 experience current

fertility impairment. For some women, this impairment extends the period of time

necessary for spontaneous conception, but others can conceive only with medical

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intervention or not at all10. Couples now have fewer than two children an average in most

European countries and they tend to postpone these births until a late age when there is a

natural reduction in fertility. Under normal circumstances the chance of couple

conceiving within are menstrual cycle in 20-25% given that unprotected intensive occurs

at the optimum time the female partner is ovulating regular by and the male partner is

producing sperm of sufficient quality13.

6.1 NEED FOR THE STUDY

Infertility patients have been called the "most neglected silent minority" because

they have a loss that often goes unnoticed. In addition, they face many other often

unnoticed stresses, such as the difficulties of going to work while undergoing infertility

testing and treatments. Even if successful, they may continue to consider themselves

"infertile", often not buying baby clothes or making preparations during their pregnancy.

And if therapies do not work, they often drop out of treatment without closure or support.

For all of these reasons, the author recommends a psychologist as part of an infertility

team, for individual counseling as well as behavioral advice on relaxation training, stress

management, and nutritional and exercise counseling14.

Despite the inherent difficulties of estimating the prevalence of infertility, it is

generally accepted that one in for women are affected at sometime. Mopreover,20% of

couples consult their general physician because of difficulty conceiving, and half of those

couple require specialist care. Research suggests that at least 855 of infertility problems

are physiologically caused. But there is new evidence that the mind also plays a crucial

role. Samuel warson (1993) carried out reproductive biology study may affect fertility

and it was found that much higher level of stress may caused by hormonal problems than

whose infertility was caused by anatomical problems. The unusual feature of infertility is

that it is composed of a series of choice which bring anxiety and stress. We do know that

infertility causes stress, but life stress also causes infertility15.

Psychological symptoms associated with infertility were similar to those of

patients with cancer. "Recent research indicates that chronic stressors are more strongly

related to depressive symptoms than acute stressors”. Infertile Belgian women had more

6

depressed mood, memory/concentration problems and anxiety than a control population.

Both the infertile group and control group agreed that infertility was a severe life event.

Women of infertile couples rated higher on "depress coping" than their partners.

Women with infertility rated lower on "religiousness and search for meaning" than

women with other chronic medical problems. Both male and female infertility patients

were significantly more distressed than the average population, but women showed more

anxiety, depression, hostility, cognitive disturbances, stress levels and decreased self-

esteem than their partners16.

A study is conducted on infertility and health related quality of life . The clinical

effort and technology improved outcomes in infertile couples. However concerns about

quality of life in this group of people because of nature of the disease and its treatment

remind us to realize that although the treatment of infertility is important but the quality

of life of our patient also are equally important and surrogacy17.

A study to explore the attitudes towards different aspects of assisted reproductive

technologies was conducted among 200 pararous women and 200 medical student of

Kuopio university hospital, Finland. Survey was performed among 200 pararous women

and student allow the use of a surrogate mother for lesbian and homosexual couple

whereas the number was below 20% in the group of pararous women18.

An article stated the accurate detection of underlying reproductive abnormalities

helps to guide individual management decisions and maximize ART treatment outcomes.

Clinical evaluation of the infertile couple may be grouped into five categories: semen

analysis. The post coital test (PCT), assessment of ovulation, uterine and tubal evaluation

and laparoscopy of these semen analysis, mid-luteal serum progesterone level and tubal

patency evaluation comprise the initial basic patient work up. However, the use of several

fundamental element of infertility testing is still continuous and evidence suggests that

the current world health organization recommendations for the standard investigational

of the infertile couple are poorly followed19.

The optimal management of endometrial and ovarian cysts in infertile patients is

less well defined, recent evidence of reduced responsiveness to gonadotrophins following

laparoscopy ovarian cystectomy has challenged the traditional surgical approach to

treatment indeed, it has been subjected that surgery should be undertaken only for the

7

treatment of large endometrioses or pain that is refractory to medical treatment or to

exclude malignancy unexpected hysteroscopy abnormalities have reported in up to 40%

of patients during ART workup but there is no compelling evidence that either routine

use of hydroscope before IVF or correction of identified pathology leads to better

treatment outcomes, compared20.

The central paradigm of all ovarian stimulation protocols is to maximize the

beneficial effects of treatment while minimizing the potential risks associated which

OHSS and multiple pregnancy, the amount of exogenous FSH required to induce follicle

development is related to the so called FSH threshold various widely among women,

conventional daily dose of FSH in ART treatment protocols range from 150 -225 IU but

close monitoring and dosage is required because of the considerable inter- individual

variability in ovarian response. The rapid advance such as human embryo cloning, trans-

genetic manipulation, in-vitro fertilization, and surrogate motherhood have been able to

cure infertility to a large extent in Visakhapatnam, India. Scientists and sociologists are

concerned about moral and the achievements in bio-engineering offered hope to those

couples in fulfilling their for children21.

For both men and women, stress was directly correlated with treatment costs and

number of tests and treatments received, and did not relate to age, number of years

married, or number of years of infertility. For women attitude towards infertility

treatments, importance of children, and level of social support significantly affected

stress levels. Authors recommend increasing patients' sense of control, realistic optimism

and social support to reduce stress. Infertile women in a support group that included

yoga, relaxation and imagery had significantly higher pregnancy rates and higher rates of

spontaneous pregnancy. Article discusses the impact of unresolved grief on infertility.

Two case histories, involving previous stillbirth and death of a parent, demonstrate

successful conception after these losses were resolved22.

For women under age 35, the live birth rate for each IVF cycle. For women ages

35-37, the rate is 25% .for women ages 38-40, the rate is 15% to 20%, and for women

over age 40, the success rate is 6% to 10%. This is a situation that has become even more

prominent with the advent of assisted reparative technologies in which the female partner

under goes disproportionately more treatment, regardless of the etiology of the infertility

8

diagnosis. Patrick Steptoe and Robert advised which begin the modern era of human

reproduction in which reproduction did not require sexual intercourse, used any array of

assisted reproductive technologies, and could be facilitated by various forms of donated

gametes, embryos23.

Infertility patients after ask if they are contributing to their own infertility by the

stress they are experiencing. They worry that their stressful lifestyle, job (or) working

schedules may be deter mention to their success in achieving pregnancy. After having

attempted conception without success, care having experienced miscarriage, most

patients experience shock, denial, fantasizing, guilt, bargaining, become, sadness,

anxiety, depressive feelings, hopelessness and sometimes a sense that their lives are out-

of-control and isolation24.

Infertility is a threatening condition and both husband & wife inevitable display

anxiety. For some women, acknowledge the loss of fertility and undergoing donor

ooctye treatment was worse than experience a death in the family. The role of the nurse

in such situation is to understand the purpose of the various diagnostic procedures for

infertility and to provide information, so that both partners can cope with the problem.

Knowledge by nurses may serve primarily in an emotionally supportive role by providing

and may be involved in physical intervention associated infertility for diagnosis and

treatment purposes25.

Nurse should encourage and participate in the development of clinical framework

that would allow for the transfer of evolving genetic information. So, nurse and other

healthcare providers can use the finding presented to enhance clinical practice and

stimulate future research. Hence the investigator felt the need to determine the knowledge

regarding management of infertility among infertile married women.

6.2 REVIEW OF LITERATURE

The review of literature enabled the investigator to gain insight into the area of

research and to develop conceptual framework, formulate questionnaire and make

decision regarding methodology.

The review of various studies was organized and presented.

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A study was conducted on psycho physiological infertility. Many infertile women

with physical defects have significant emotional disorders, and many infertile women

with no demonstrable physical defect have no significant emotional disorders. The

treatment of psycho physiological infertility should include identifying specific areas of

conflict and then attempting to modify responses, attitudes, and affects that cause or

intensify the conflicts. Through a learning experience, anxious and insecure patients can

be helped to tolerate the anticipation of pregnancy and parenthood. Even those who do

not achieve pregnancy can be helped to maintain their feelings of self-worth and self-

esteem26.

A study was conducted to assess quality of life, sexual health, and depression in the

female partner of infertile couples. Female partners completed the Female Sexual

Function Index (FSFI) and a modified Self-Esteem and Relationship (SEAR)

Questionnaire. Male partners completed the SEAR and the International Index of Erectile

Function (IIEF). Both partners completed the Center for Epidemiological Studies

Depression Scale (CES-D) for depression and the Short Form-36 (SF-36) for general

quality of life. Demographic, fertility, and co morbidity information was recorded. One

hundred and twenty-one couples constitute the study population. Mean female and male

age, respectively. Most (92%) couples were married. Mean duration of relationship and

marriage were, respectively. Mean duration of attempted conception, 19% of women had

moderate and 13% had severe depression. Women reported significantly worse SF-36

Mental Health subscale scores compared with normative values. The mean total FSFI

score was , with 26% of the women scoring below 26.55, an established cut-off for high

risk of female sexual dysfunction. FSFI scores had a modest positive correlation with

male IIEF scores , and there was a trend toward a negative correlation with female CES-

D scores . These relationships were maintained on multivariate analysis .Depression and

sexual dysfunction are prevalent in female partners of infertile couples. Female sexual

function is positively correlated with male partner sexual function in this population27.

A study was conducted to find out the relationship between infertility and

psychosocial distress: (1) psychosocial problems trigger infertility; (2) infertility triggers

psychosocial distress; and (3) there is an interactive causal relationship between infertility

and psychosocial distress. The controlled research on these three hypotheses was

10

reviewed. The 30 publications that met inclusion criteria provide convincing evidence

that, taken as a whole, patients diagnosed and treated in infertility clinics show

significantly higher levels of psychosocial distress than do control groups. As well, in

general, female patients score higher on psychosocial distress measures than males.

However, the authors conclude that research designs to date have failed to control crucial

variables that permit conclusive empirical tests of the three hypotheses. The paper closes

with recommendations for future research that would accelerate the evaluation of

scientific data available on the subject28.

A study conducted to investigates the association of coping style and the degree of

satisfaction regarding social support from primary support groups with distress symptoms

of involuntarily childless individuals. Women especially experienced more health

complaints, more anxiety and depression symptoms and more complicated grief than the

general population. Regression analysis shows that when controlled for sex and the

duration of involuntary childlessness, the concepts passive coping style and

dissatisfaction with social support were positively associated with health complaints,

depression, anxiety and complicated grief. The concept active coping style was

negatively associated with depression, anxiety and complicated grief. Explained variance

of the different distress symptoms varied from 30 to 65%. A moderating association of

perceived social support is only found between a passive coping style and health

complaints. Psychosocial interventions should be continued after the childlessness has

become definite. By teaching couples how to cope actively with their childlessness and

how to ask for support, the negative consequences of their childlessness may be

decreased29.

A study was conducted to draw the psychosocial profile of couples who consult

fertility clinics. More specifically, it consists of a) comparing the psychosocial status of

subjects who seek fertility consultation with that of normal subjects or individuals at

grips with psychological problems; b) determining whether there are profile differences

between men and women who seek fertility consultation; and c) assessing whether it is

possible to predict the nature of the psychosocial profile of the subjects from various

sociodemographic and medical characteristics. The sampling includes 30 couples who are

consulting a specialist in a fertility clinic belonging to a Montréal-area hospital. Analysis

11

of results shows that the psychosocial profile of subjects consulting a fertility clinic is

midway between that or normal subjects and that of individuals suffering of

psychological problems. The psychological status of men and women consulting a

fertility clinic is different according to three variables: depression, self-esteem and stress.

Finally, multiple regression analysis has allowed the author to identify several medical

characteristics linked to the extent of the psychosocial difficulties experienced by the

infertile subjects30.

A study was conducted to investigate the survey involving 281 patients awaiting

assisted reproduction treatment at five Centers in three countries, and 289 population

controls, investigated whether the patients had experienced more negative emotional

feelings and negative emotional impact during periods when they were attempting to

conceive as compared with the controls, and whether there was any difference in their

well-being at the time of consultation31.

The study was performed in the context of currently divergent views as to the burden

of fertility problems. The survey was carried out using questionnaires of the self-

administration type. Women with fertility problems did in fact consistently report a

higher prevalence of negative emotions than the controls with reference to the periods

during which they had been trying to conceive. Patients reported more changes in

interpreter relationships (either negative or positive). Sexuality was negatively affected

among the patients. At the time of consultation, the patients had less favorable scores

than the controls on scales for depressed mood, memory/concentration, anxiety and fears,

as well as for self-perceived attractiveness. 1in 4 (24.9%) of the patients had scores

indicating depressive disorders as compared with only 6.8% of the controls. Current well-

being was even more markedly affected in patients with previous unsuccessful in-vitro

fertilization (IVF) experience. The 'infertility' life event was perceived as severe by both

patients and controls. Both prior to consultation and during diagnosis and treatment,

women with fertility problems had a higher prevalence of reported negative psycho-

emotional experiences than women without fertility problems32.

A study was conducted to evaluate the effects of a crisis intervention program on

improving psychosocial responses and enhancing coping strategies for infertile women

attending different stages of an In-Vitro Fertilization V Embryo Transfer (IVF-ET)

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treatment program. In the experimental group, infertile women completed and answered a

questionnaire and received nursing crisis intervention at the initial stage of treatment (day

3). This included (1). Viewing a video explaining the therapeutic process of IVF-ET, (2).

self-hypnosis and muscle relaxation training, and (3). Provision of cognitive-behavioral

counseling. The same questionnaire was used again for subjects at the stage of embryo

transfer and before taking a pregnancy test. The women in the control group were only

interviewed using the same questionnaire and at the same times as the experimental

group. There was a reduction in psychosocial response in terms of interpersonal

relationships, and there was an interaction between intervention effects and stage of

treatment.. However, in terms of state of anxiety, confrontational problems, and isolated

mind/body relaxation, there were significant differences between the two groups of

infertile women at some stages of IVF-ET treatment. The women in the experimental

group perceived a positive effect of the nursing intervention in relieving their

psychosocial responses. The results of this nursing crisis intervention could be helpful in

nursing practice when dealing with infertile women attending IVF treatment programs37.

A study was Conducted to develop and test the effectiveness of a brief online

education and support program for female infertility patients. The psychological

outcomes assessed included infertility distress, infertility self-efficacy, decisional

conflict, marital cohesion and coping style. Program dosage and satisfaction were also

assessed at four weeks follow-up. Women exposed to the online program significantly

improved in the area of social concerns related to infertility distress, and felt more

informed about a medical decision with which they were contending . Trends were

observed for decreased global stress , sexual concerns , distress related to child-free

living, increased infertility self-efficacy and decision making clarity . A dosage response

was observed in the experimental groups for women who spent >60 min online for

decreased global stress (P = 0.028) and increased self efficacy . This evidence-based

Health program for women experiencing infertility suggests that a web-based patient

education intervention can have beneficial effects in several psychological domains and

may be a cost effective resource for fertility practices33.

A study was Conducted to describes couples attending infertility counseling. More

couples with stressful life events were found in the counseling group. For women taking

13

up counseling, psychological distress, in the form of suffering from childlessness and

depression as well as subjective excessive demand (as a potential cause for infertility),

was higher in comparison to women not counseled. The higher distress for men in the

counseling group was indicated by relative dissatisfaction with partnership and sexuality

and by accentuating the women's depression. Infertile couples seeking psychological

help are characterized by high levels of psychological distress, primarily in women. The

women's distress seems to be more important for attending infertility counseling than that

of the men34.

A study was done to assess new alternative to infertility treatment for women without

ovarian stimulation at Canada, natural cycle IVF produced the world first successful live

birth, but slowly this treatment has been replaced by ovarian stimulated cycle IVF will

increase the number of available embryos for transfer, it directly increases the chance of

pregnancy from the treatment cycle. However, ovarian stimulation is always associated

with side effects. The recovery of immature oocytes followed by in-vitro maturation

(IVM) and IVF is on attractive alternative to stimulated cycle IVF, IVM treatment

provides a successful option to infertile women with polycystic ovaries or polycystic

ovary syndrome. the study concluded that it is now possible to combine natural cycle IVF

with IVM as on alternative for a selected group of women with various causes of

infertility without resource to ovarian stimulation35.

A qualitative study was conducted to assess the experience of Treatment for Infertility

among women who successfully became pregnant at Oxford. In a study in which 18,503

women who had recently given birth were interviewed, 460 women who had received

treatment for infertility (2.6%) were asked to participate in a postal study. it concluded

that women wished to be treated with respect and dignity and given appropriate

information and support. They wanted their distress recognized, to feel cared for and to

have confidence in health professionals I situations where outcomes are uncertain women

acknowledged receiving care from motivated and skilled health professionals and value

the children they have enormously. For many there is now a sense of being complete,

though for some this has been at great emotional and financial cost36.

A study was conducted to assess the experience of women in unsuccessful infertility

treatment at USA. approximately half of the women who seek medical treatment for

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infertility never give birth to a child, extended infertility extracts a particularly

devastation on female patients. Infertility treatment tends to be delivered in an impersonal

needs of patients social workers can play a key role in preventive and clinical

intervention, and can educate medical professionals about the needs of their patients

interview data from a recent study in order to illustrate these needs, offering guidelines

for social workers and medical professionals37.

A study was conducted to assess a pharmocotherapeutic review of treatment options

for Infertility in women. The growing trend for women to wait later in life before having

their first child has placed many women at a higher risk for difficult conception. There

are numerous classes of medications available to assist women to who have been

diagnosed with their infertility. Agents that are used in the treatment of infertility include

clomiphene citrate, aromatize inhibitors, Ganado tropins, chronic gonadotropins,

gonadotrophin releasing hormone antagonists, follitrophin and other miscellaneous

agents, medications chosen for a patient will vary depending on the identified cause of

the infertility, additionally, economic factors will play a role. It is concluded to give

awareness of treatment options and have a basic understanding of the role of these

medications play in the treatment of infertility38.

An article described previously proposed criteria to evaluate successfully ART

treatment outcomes include live birth rates per ovarian stimulation started, healthy live

birth rate per treatment cycle, singleton and multiple live birth rate started treatment cycle

or term live birth per started treatment strategy, which may include multiple cycles.

Because of the lack of a consistent definition of ART success, national criteria for

evaluation of treatment outcomes tend to reflect the local economic and legal

frameworks.

The third EVAR Workshop Group concurred with the ESHRE recommendations

and believes that that birth of a single healthy child should be the aim of ART. Therefore,

the group advocate the use of singleton delivery rate as the goal standard expression of

ART treatment outcome. nonetheless, cumulative delivery rates per retrieved oocyte

cohort using fresh and frozen embryos, or per treatment strategy, must also be

considered. The group also believed that all comparisons of treatment modalities must

incorporate efficacy and safety data, in edition to health-economic evaluations.

15

The future of ART as described, the third EVAR Workshop Group believes the

optimization of singleton delivery rate should be the common aim of all ART clinicians.

Reproductive medicines specialists have responsibility to educate policymakers and the

wider society on the risk of multiple pregnancies and births. Further more, the group calls

on national and international professional bodies to issue guideline promoting a

responsible attitude to eSET, and to help raise awareness of the greater cost-efficacy of

SET compared with DET among health care providers and policymaker.

New techniques in assessing oocyte and embryo quality could also improve

pregnancy and delivery rates per embryo transfer, thus encouraging greater uptake of

SET. This may be achieved by studying oocyte zona birefringence, gene expression

profiling of oocyte cumulus cells, evaluation of spent culture fluid by proteomic analysis

or metabolic profiling using near- infrared spectroscopy. Good quality studies of this

techniques will help evaluate their potential clinical application and contribute to our-

understanding of basic oocyte and embryo biology, and the effect of iatrogenic ovarian

stimulation. In conclusion, members of the third EVAR Workshop Group agreed that

SET should be the primary and of many ART treatment cycles and supported use of

singleton life birth rate as the reported outcome measure from clinical trails and routine

practice. However, the group acknowledged that improved cryopreservation techniques

are required to further increased the global uptake of SET. Within this standard ART

frame work, adaptation and personalization of therapy may help to optimized efficacy

and safety outcomes for individual’s patients39.

An article explored management decisions, including expectant therapy versus IUI,

IVF or ICSI reflect a rudimentary individualization of therapy but are currently based on

limited available evidence. Greater quality control and standardization of clinical and

laboratory evaluations are needed to optimize ART practices and improve individual

patients outcomes. Furthermore, additional well design, good-quality studies are require

to drive improvements in the diagnosis and management of ART processes in future

years.

An article stated the complex nature of infertility has opened new doors for various

treatment modalities as couples search for the answer of their dilemma. Infertility can be

consider as an enigma, a can be a puzzle for both health care providers and couple alike.

16

This is because in many instances even with the determination of the cause and

prescription of appropriate treatment for the problem, successful impregnation still

remains bleak. Thus, more and more couples tern to alternate methods such as

homeopathic infertility treatment40.

A study was conducted other large infertility practice in the country, is participating

in a phase III clinical research study of an investigational drug used for ovarian

stimulation to see if it will ultimately eliminate the need for daily injection for women

undergoing Ovulation Induction and In-vitro Fertilization41.

A study conducted by Fertility Centers of Illinois, SC can provide study medications

and an IVF Cycle for up to 40 subjects, at no cost to subject. Subject may be seen in our

Chicago River North IVF facility for all study monitoring and procedures. All subjects

will take daily IVF study drugs injections. Half of the study subject will be into a group

that is currently available, along with a placebo injection. Egg Retrieval and Embryo

transfer will be done for qualified subjects. Following embryo transfer, additional non

transfer embryo can be electively frozen at an additional cost. As will all drugs studies,

there are strict enrollment criteria for both inclusion into, and exclusive from the study42.

A study was conducted that quality of life score for control group was higher than the

scores reported by the couples with repeated failure treatment and the couples who never

attempted any medical treatment. In addition the study result showed that there were no

significant differences in quality of life score reported between the couples with

repeated failure treatment and the couples who never attempted any medical treatment or

between male and female partners42.

The study found that some dependent variables could predict quality of life in

infertile women. The analysis showed that some independent variables such as age,

previous reproductive tract surgery worse general health but higher environment scores,

advanced education, mental, environment but worse sexual life were predicting factor of

quality of life in Brazilian women experiencing infertility43.

A study was conducted to investigate public opinion regarding different aspects of

oocyte donation among 1000 men is Sweden. A study- specific questionnaire regarding

attitudes towards aspects of oocyte donation was sent to the randomized sample. The

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result showed that a majority of the respondents supported treatment with oocyte

donation. Women were more positive towards disclosure to the offspring than men44.

A study was conducted to determine the option determine the opinion of infertile

Turkish women on gamete donation and gestational surrogacy among 368 women is

assisted reproductive treatment center at gulhane military medical academy. Survey was

done and questionnaire was given. The study showed that 26.7% approve of gamete

donation and gestational surrogacy45.

The international and government organization attitude was determined at Palacky

University, Olomouc .The developments in the field of assisted reproduction during the

last twenty years attracted unexpected public interest in some of its ethical and more

aspects. It is very difficult to find a uniform attitude to ethical concerns of assisted

conception in plural society. The result showed that the public opinion has shifted to a

position where surrogacy is recognize as an appropriate response to infertility in some

circumstances and it is to be expected that this approach will be further strengthened with

stress on positive aspects of familiar life.

A descriptive study was conducted to reveal the general attitudes of Turkish people

towards various aspect of oocyte donation among 400 participation by cluster sampling

methods. The questioning was administered and the result showed that 58% women and

45% men, 65% were married, 5% were diviced, 64% had children,4%had interfertility

problems. Only 15% respondents showed complete objection to oocyte donation and

more men were in favor than women46.

A descriptive study was to determine the attitudes towards gestational surrogacy and

egg donation amongst 250 Turkish married infertile females who had applied for

infertility treatment. The result showed that 24% had positive attitude for surrogate

motherhood and 26% for donation. Among this, 50% females states that identity of the

surrogate mother was not important47.

The opinions and attitudes of the germen general population towards the treatment

methods of reproductive medicine: egg donation, surrogate mothering and reproductive

cloning among 2110 persons, aged 18- 50 years was assessed by face-to-face interviews

with representative survey design. The result showed that legislation of egg donation was

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approved by a slight majority, surrogate mothering found lower overall rates of approval

and reproductive cloning was rejected by the vast majority48.

6.3 STATEMENT OF THE PROBLEM “A Study To Assess The Knowledge Regarding Management Of Infertility Among

Infertile Women In Infertility Clinic At Bangalore” With A View To Develop

Information Booklet.

6.4 OBJECTIVES OF THE STUDY1. To assess the level of knowledge regarding management of infertility.

2. To find out the association between the level of knowledge and demographic

variables among infertile women.

3. To Prepare an information booklet regarding management of infertility

6.5 OPERATIONAL DEFINITIONSAssess

It refers to gather the subjective and objective data. It includes gathering,

classifying and analyzing the information about the knowledge regarding management of

infertility .

Knowledge

It refers to the awareness about the management of infertility and ability of

infertile women to answers the question.

Management of infertility

In this study it refers to the use of a substance or process to preserve or give

particular properties to something related to overcome the situation and able to conceive.

Infertile women

In this study it refers to a condition in which the legally married women is

unable to conceive after at least one year of unprotected, regular intercourse and

confirmed as infertile by an obstetrician and attending infertility clinic for seeking

treatment.

Infertility clinic

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In this study it refers to place where the infertile women seeking counseling and

treatment of their problem.

Information Booklet

A self learning material which consist of meaning/definition, causes, risk factor,

diagnosis and management of infertility.

6.6 ASSUMPTIONS1. Infertile women may have inadequate knowledge regarding management of

infertility.

2. Information booklet will give awareness about treatment of infertility among

infertile women and to take better decision to solve the problem.

6.7 DELIMITATIONSAssessment of knowledge related to management of infertility among infertile

women is limited to know about availability of services to solve the problem.

7.0 RESEARCH METHODOLOGY 7.1 SOURCES OF DATA

In this study primary infertile women who are attending in infertility clinic at Bangalore.

RESEARCH APPROACH

In this study research approach is an descriptive survey approach

RESEARCH DESIGN

The descriptive design will be used in this study

SETTING OF THE STUDY

Setting is the general location and condition in which data collection takes place

in the study. The study will be conducted in Bangalore assisted reproduction technology

clinic at Bangalore.

7.2 DESCRIPTION OF VARIABLES

20

The study variable is knowledge of infertile women regarding management of infertility.

Associated Variable

It refers to those variable which are highly influence the dependant variable such

as age, educational status, residing area, type of family, employment, income, etc. among

primary infertile women.

POPULATION

The target population of the present study includes the infertile women who are

attending infertility clinic at Bangalore.

SAMPLE

In the study the sample consists of primary infertile women who are attending in

infertility clinic at Bangalore

Sampling technique

Non probability Purposive sampling technique will be used to select the subjects for

this study.

Sample size

The sample size in this study is 50 primary infertile women who are attending in

infertility clinic at Bangalore.

SAMPLING CRITERIA

Inclusion criteria - The Infertile Women

1. Only

2. Who all are falls the age between of 18 – 45 years

3. Who are primary infertile married women attending to infertility clinic at

Bangalore.

4. Who are willing to participate.

5. Who can follow to read and write English or Kannada.

6. Who are available during the period of data collection.

Exclusion criteria

1. The infertile women who all are below the age of 18 years and above 45 years.

2. The infertile men

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3. The infertile women, who are not willing to Participate.

4. The infertile women , who does not follow to read and write English or Kannada

5. The infertile women, who are not available during the period of data collection.

DESCRIPTION OF THE TOOL

A structure questionnaire will be prepared and it consists

1. To assess the socio demographic variable of the infertile women

2. To assess the level of knowledge regarding management of infertility among the

infertile women.

7.4 METHOD OF DATA COLLECTIONA prior formal permission will be obtained from the concerned authority. The

purpose of the study will be explained and consent will be obtained from the infertile

women. The investigator will select the sample by purposive sampling method, then

will assess the socio demographic variables. With help of a structured questionnaire to

assess the level of knowledge among group. Following that information booklet about

management of infertility will be given. The total duration of the study is 6 weeks.

STATISTICAL ANALYSIS

The data obtained will be analyzed in terms of objectives of the study by using

descriptive and inferential statistics. Frequency and percentage will be used for analysis

of demographic data of group. Mean, Median and Standard Deviation will be used to

assess level of knowledge. A chi- square will be used to determine the association

between level of knowledge score of infertile women with their selected demographic

variables.

7.5 DOES THE STUDY REQUIRE ANY INVESTIONATION OR

INTERVENTION ON PATIENT OR OTHER HUMANS/ANIMALS?

IF SO PLEASE DESCRIBE BRIEFLY.

Yes, Information booklet will be given and level of knowledge regarding

management will be assessed. No other investigation or intervention will be

conducted on subject.

7.6 ETHICAL CONSIDERATION TOWARDS SAMPLE RELTED TO

STUDY

22

Permission will be obtained from the concerned authority in the hospital to

conduct study. A written consent will be obtained from the participants for their

willingness to participate in the study.

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