Assisted Reproductive Technologies: the Nurse’s Role in Preconception Counseling

Infertility prevents around 6.1 million people in the United States from having children. As a result, infertile couples and individuals often seek to become parents through assisted reproductive therapies (ART). Each client has a different situation, so there are a number of assisted reproductive techniques available to suit their needs. Because assisted reproductive technology is a successful option for managing infertility, nurses must assess and evaluate factors affecting fertility, screen for genetic problems, and educate clients about the reproductive options available depending on each individual situation.

Involuntary infertility affects 10% of reproductive-age individuals. Basic infertility services may be used to treat the majority (85-90%) of infertile males and females, but the remaining 10-15% require assisted reproductive technologies. ART also provides options for individuals with or at risk for transmitting a genetic disorder and those experiencing infertility due to advanced maternal age. Since 1992, there have been over 850,000 ART cycles in the U.S. resulting in over 210,000 children conceived (Jones, 2004, p.116). The most common adverse outcome from ART treatment is multiple births which may lead to complications during pregnancy; though studies have found that many patients seeking ART treatment prefer to have twins or triplets instead of just a single infant (Grainger, Frazier, & Rowland, 2006, p.162). “Experience with and refinement of these technologies continue to increase the likelihood that an infertile woman, man, or couple is able to conceive and give birth to a child through the various technologies now available” (Jones, 2004, p.115).

Nurses are often the first healthcare providers that women encounter for preconception and prenatal issues. Preconception care involves the “assessment of risk factors for having a child with a genetic disorder, providing information about preconception, prenatal testing, and reproductive options to minimize the chance of having children with genetic problems.” Nurses obtain the family, medical, obstetric, and genetic history, physical examination, and laboratory results which provide vital information for determining risk factors. Once the risk factors have been assessed, appropriate lifestyle modifications (ex. diet, medications, environments) can be made to optimize preconception and prenatal care (Shapira & Dolan, 2006, p.143).
Nurses provide appropriate preconception and prenatal care, education, and medical counseling for those with known genetic problems to decrease the risk of complications or genetic disorders. Genetic screening of both parents is helpful in diagnosing risks for transmitting a genetic disorder. Around 85-90% of repeated pregnancy loss is due to genetic problems. If one or both parents are carriers of a genetic disorder, or have a genetic disorder themselves, preimplantation genetic diagnosis (PGD) is a very effective option. PGD involves determining the sex and chromosomal make up of an embryo produced through in-vitro fertilization. One benefit of this option is knowing the genetic health of the embryo before it is implanted, therefore eliminating the decision of whether to terminate or not if a genetic condition was found later in the pregnancy. It is possible to find out if embryos are affected with disorders such as cystic fibrosis, sickle cell anemia, and Huntington’s disease (Jones, 2004, p.126). Gender selection is helpful when the parents have been screened with either an X-linked recessive, or a Y-linked disorder. Gender selection is also available for non medical reasons and is virtually always accurate (Barad & Gleicher, 2007, p.2).

Comprehensive preconception care requires building a strong nurse/patient relationship and knowledge of the advances in genetics and reproductive health options. It is critical for nurses to use this knowledge to provide anticipatory guidance and encourage clients to think through their options. The most common assisted reproductive options available include the following: in-vitro fertilization (IVF), preimplantation genetic diagnosis (PGD), and intracytoplasmic sperm injection (ICSI) (Barad, 2007, p.3). In-vitro fertilization is a useful option for clients with diagnoses such as: fallopian tube defect, ovulatory disturbance, or idiopathic infertility (Jones, 2004, p.124). Male infertility is a factor in about 40% of couples seeking ART. Intracytoplasmic sperm injection (ICSI) may be used to achieve pregnancy in this situation. Since only one sperm is needed to fertilize the egg, only very small quantities of semen are needed. This method is used for male clients with semen anomalies, congenital or surgical absence of vas deferens, spinal cord injury, impotence, azoospermia, or idiopathic infertility. An established nurse/patient relationship provides psychosocial support and allows the opportunity for nondirective, nonjudgmental reproductive decision making. Care is delivered in a nondiscriminatory manner, protecting and respecting client autonomy, dignity, and rights. Privacy and confidentiality issues are regulated by state, and federal laws and standards of practice by the ANA (Wille, Weitz, Kerper, & Frazier, 2004, p.37). Nurses also provide referrals to other healthcare providers or professional resources such as genetic counselors, support groups, religious groups, or social workers when needed.

There are a number of factors affecting fertility (ex. diet, exercise, medications, work conditions). Nurses identify risk factors, suggest any modifications needed to maximize fertility, and provide appropriate preconception and prenatal care. Since there are a number of options available for clients experiencing infertility, nurses provide information, resources, and support to help clients make the best possible reproductive decisions. Nurses are effective in the assessment of factors affecting fertility, identifying risks for genetic problems, and providing education and support for clients making the reproductive decisions unique to their situation.

References

Barad, D., & Gleicher, N. (n.d.). Treatment options assisted reproductive technology. Retrieved May 6, 2007, from http://www.centerforhumanreprod.com/treatment_assisted.html

Grainger, D. A., Frazier, L. M., & Rowland, C. A. (2006). Preconception care and treatment with assisted reproductive technologies. Maternal and Child Health Journal, 10(7), 161-164. Retrieved May 28, 2007, from PubMed Central database.

Jones, S.L. (2004). The confluence of two clinical specialties: Genetics and assisted reproductive technologies. MedSurg Nursing, 13(2), 114-122. Retrieved April 16, 2007, from Expanded Academic ASAP database.

Shapira, S. K., & Dolan, S. (2006). Genetic risks to the mother and the infant: Assessment, counseling, and management. Maternal and Child Health Journal 10(7), 143-146. Retrieved May 28, 2007, from PubMed Central database.

Wille, M. C., Weitz, B., Kerper, P., & Fraizer, S. (2004). Advances in preconception genetic counseling. Journal of Perinatal and Neonatal Nursing, 18(1), 28-41. Retrieved April 16, 2007, from ProQuest database.

Intervention 1: Nurses must educate clients about the reproductive options available depending on each individual situation.

Disadvantage 1: Options available are changing constantly due to new research and development of new techniques. Clients may have specific clinical questions that are related to what they have seen or heard in the media. “Media coverage of these issues means that members of the public are quickly aware of new developments. Nurses can therefore find themselves confronted with queries on a rapidly changing and highly complex subject (Hitchen, 2008, pg 27).” It is difficult for organizations involved in assisted reproductive technologies to keep up to date with developments in embryonic and reproductive research due to the huge demand for treatments as well as the continual development of new techniques and research (Hitchen, 2008, pg 27).The area of ART is demanding and unique, and requires the development of specialized nursing knowledge and skills in order to provide safe, effective, and appropriate care to women and their partners receiving ART (Payne, 2007, pg 38).

Disadvantage 2: Another barrier to client education may be that the clients are unwilling to make the necessary lifestyle changes to improve fertility (such as smoking cessation, avoiding drugs and alcohol, and hazardous environments) as well as follow the prescribed treatment plan. The treatment cycles are very involved. “Nurses are required to educate women and their partners particularly about the female reproductive cycle and the different treatment options. The latter are regimens that require strict adherence and administration of oral and injectable medications. The dosages vary depending on the results of blood tests taken throughout the treatment cycle (Payne, 2007, pg 38).”

Intervention 2: Nurses must screen for genetic problems.

Disadvantage 1: One disadvantage could be the cost of genetic testing. Heteroduplex analysis costs $260, DGGE tests cost $250-$800, ASO and PTT tests can cost between $190-$450, while sequencing tests can cost $500-$3,000 each. A few reasons for the high cost are that genetic tests are rare, labor intensive, and undergo multiple levels of review. There may be additional costs to you besides the actual cost of the genetic test. These may include any cost for blood draw or specimen collection, Federal Express or other shipping costs, and genetic counseling or physician fees (Toland, 2000, pg 2). Cheaper medical treatment is available abroad, but the quality and safety of such treatments is not monitored (Hitchen, 2008, pg 28).

Disadvantage 2: Clients may not want to make the ethical decision of what to do if they conceive a child with a genetic disorder. Families who learn that they are at significant risk have multiple alternative reproductive options including: donor egg, donor sperm, sperm separation, preimplantation genetic diagnosis, adoption, or avoidance of pregnancy. Prenatal diagnosis is available to allow preparation for having a child with a genetic disorder or termination of the pregnancy. “The psychosocial implications of genetic counseling and testing are often manifold and couples may have difficulty with decisions and options (Wille, Weitz, Kerpner, & Frazier, 2004 pg 29).”

References

Hitchen, L., (2008). Examining issues in assisted reproduction. Practice Nurse 35(1), 27-30. Retrieved May 25, 2008 from ProQuest database.

Payne, D., (2007). The role of nurses working in ART. Australian Nursing Journal 15(3), 38-39. Retrieved May 25, 2008 from ProQuest database.

Toland, A. E., (2000). Genetic testing: Costs of genetic testing. Retrieved May 12, 2008, from http://www.genetichealth.com/GT_Genetic_Testing_Costs_of_Genetic_Testing.shtml

Wille, M. C., Weitz, B., Kerper, P., & Fraizer, S. (2004). Advances in preconception genetic counseling. Journal of Perinatal and Neonatal Nursing, 18(1), 28-41. Retrieved April 16, 2007, from ProQuest database.