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herish your human connections: Your relationships with friends and family.
—Barbara Bush
LEARNING TARGETS
At the completion of this chapter, the student will be able to:
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Discuss the nurse’s role in providing sexual and reproductive health care.
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Identify advantages and disadvantages of barrier and hormonal contraceptive methods, intrauterine devices and permanent sterilization.
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Teach patients how to use various methods of contraception.
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Assess a patient for short-term complications after an induced abortion.
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Analyze the nurse’s role in infertility care.
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Differentiate among the various advanced reproductive technologies.
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Identify potential alternatives to childbearing for the infertile couple.
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Therapy for Unexplained Infertility
Harrison, E.C., & Taylor, J.S. (2006). IVF therapy for unexplained infertility [Electronic version].
American Family Physician, 73
(1), 63–66.
The purpose of this review was to determine whether in vitro fertilization (IVF) improves the probability of live births in the context of unexplained infertility, compared to alternative man-agement approaches. Unexplained infertility was defined as failure to conceive after 1 year in couples in whom no abnor-malities were found during an infertility work-up. IVF is a pro-cess that involves stimulation of the ovaries with gonadotropins, egg retrieval, and fertilization in the laboratory. Pregnancy rates achieved with IVF therapy have been reported to reach 30%.Alternative management approaches to achieve live births included: (1) expectant management, (2) the administration of clomiphene citrate (Clomid), (3) intrauterine insemination (IUI) with or without controlled ovarian stimulation, and (4) gamete intrafallopian transfer (GIFT).Of the ten randomized controlled trials (RCT) reviewed, six met the study criteria and were included in the meta-analysis. Significant variations among study outcomes and therapies were found; the live-birth rate per patient was considered to be the outcome of interest.Data analysis revealed the following: (1) IVF was found to be significantly better than expectant management in two studies; (2) there were no significant differences in live birth rates among patients who received IVF and those who received intra-uterine insemination; and (3) one study reported a greater live birth rate associated with IVF as compared with GIFT. The use of clomiphene citrate (Clomid) was not compared with other infertility therapies in any of the studies.The researchers concluded that there were insufficient data to allow for the comparison of IVF with other methods of infer-tility treatment and recommended larger randomized trials.It was noted that the cost of a single cycle of IVF reportedly exceeds $10,000.00. Insurance coverage for IVF varies from zero to 100% reimbursement.Risks associated with infertility therapies include psychological stress (e.g., anxiety and depression), multiple gestations, opera-tive risks, and ovarian hyperstimulation syndrome. Approximately 25% of IVF pregnancies involve multiple gestations, which are frequently associated with maternal–fetal complications.
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The Process of Human Reproduction
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Operative risks associated with egg retrieval include a potential for bleeding and infection.
1.
Does this study provide sufficient evidence to suggest that IVF therapy is more effective than other forms of infertility management, when compared to the risks associated with this treatment modality?
2.
How is this information useful to clinical nursing practice?See Suggested Responses for Moving Toward Evidence-Based Practice on the Electronic Study Guide or DavisPlus.
Introduction
Sexuality is a multidimensional concept that encompasses one’s sexual nature, activity, and interest. Influenced by ethical, spiritual, cultural, and moral factors, sexuality constitutes an important component of women’s health. A central role for nurses involves helping women to under-stand their sexual health and assist them with reproduc-tive life planning. This chapter explores the nurse’s roles in various aspects of reproductive health care and con-cludes with a brief overview of some of the legal and ethi-cal issues that surround methods of advanced reproduc-tive technology.
Sexuality and Reproductive Health Care
Women’s health care is a broad term that encompasses the provision of holistic care to women within the context of their day-to-day lives. This approach to health recognizes that a woman’s physical, mental, and spiritual states are interdependent and all affect the present level of wellness. In any therapeutic setting, eliciting the woman’s view of her situation, and assessing her needs, values, beliefs, and supports constitute essential components in formulating an appropriate plan of care.Nurses have an opportunity to work with women in a variety of settings. Teaching about health promotion can take place at community centers, schools, clinics, private offices, and senior centers. The majority of women’s health care is delivered outside of the acute care setting. Approaching women’s health from a com-munity-based perspective enables nurses to recognize each person’s autonomy and provide holistic care that is sensitive to physical, emotional, sociocultural, and situ-ational needs.Sexuality and its reproductive implications are woven into the fabric of human behavior. Because it is such an emotion-laden aspect of life, people have many concerns, problems, and questions about sex roles, behaviors, inhi-bitions, education, morality, and related components such as contraception. The reproductive implications of sexual behavior must also be considered. Some people desire pregnancy; others wish to avoid it. Health concerns con-stitute yet another issue that must be addressed. The ris-ing incidence of sexually transmitted infections, especially HIV/AIDS and herpes virus, has prompted many individu-als to modify their sexual practices. Women often ask questions and voice concerns about these issues to the nurse in the ambulatory care setting. Hence, the nurse may need to assume the role of educator, counselor, or care provider when dealing with sexual and reproductive health matters.It is essential that nurses who practice in reproductive care settings develop an awareness and understanding of personal feelings, values, and attitudes about sexuality. These insights allow the nurse to provide sensitive, indi-vidualized care to women who have their own set of val-ues and beliefs. Nurses must have current, evidence-based information about anatomy and physiology and about topics related to sexuality and reproductive health. Nurses must also be sensitive to the relationship dynamics they may observe when women arrive for care accompanied by their partners.
THE HUMAN SEXUAL RESPONSE
In the 1960s, the research work of Masters and Johnson (1966) helped to define sexuality as a natural component of a healthy human personality. Before that time, human sexuality was often viewed as a negative or nonexistent, sometimes shameful, aspect that needed to be shrouded in secrecy. The work of the two sexuality researchers gave new insights into the physical components of human plea-sure during sexual response and orgasm.Masters and Johnson described four human sexual response phases: excitement, plateau, orgasmic, and reso-lution. The
excitement phase
is characterized by physiolog-ical responses to internal and/or external cues. Women experience vaginal lubrication, breast and pelvic engorge-ment, and increased heart rate, respiratory rate, and blood pressure. Clitoral and labial tissues become swollen, the nipples become erect, and the vagina becomes distended and elongated. Men experience penile engorgement with an increase in circumference and length (erection) along with scrotal thickening and elevation.During the
plateau phase
, women experience the most heightened sense of sexual tension. The labia become more congested, the vagina becomes more fully expanded and the uterus rises out of the pelvis in preparation for intercourse. Most women also experience sexual flushing, tachycardia, and hyperventilation. In men, the testicles enlarge and become elevated and the coronal circumfer-ence of the penis increases. Both genders experience a generalized muscular tension.The
orgasmic phase
is characterized by an intense desire for sexual release due to congestion of the blood vessels. Tachycardia, blood pressure, and hyperventilation are intensified. These sensations build until orgasm is reached.
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Muscular contractions occur in the man’s accessory repro-ductive organs (vas deferens, seminal vesicles, and ejacula-tory duct). There is a relaxation of the bladder sphincter muscles along with contractions of the urethra and peri-rectal muscles followed by ejaculation as orgasm occurs.An overall release of muscular tension takes place dur-ing the
resolution phase
. Both genders experience a feeling of warmth and relaxation and women may experience a brief refractory period or “rest time” before they are inter-ested in sexual intercourse again. Women are capable of experiencing multiple orgasms.Masters and Johnson were instrumental in opening the topic of human sexual response for discussion and study in the United States. The media often send the message that sexuality involves only a physical expression such as the act of sexual intercourse. In actuality, human sexual-ity is a multidimensional phenomenon that touches and permeates many aspects of human behavior.
EXPLORING DIMENSIONS OF SEXUALITY
Sexual Orientations
Even though it constitutes an integral and normal dimen-sion of every human being, sexuality evokes controversy when it involves alternative sexual orientation or sexual expression at either end of the age spectrum.
Heterosexual
sexual orientation is the sexual attraction to or sexual activity with a person of the opposite sex or gender. Het-erosexuality is often considered the norm in America, and any other form of sexual expression is viewed as being outside the realm of “normal.”
Homosexuality
is the sexual attraction to or sexual activity of a person with another individual belonging to the same sex or gender. The term “gay” is often used for homosexual males; “lesbian” is used for females. An esti-mated 2.3 million women in the United States presently identify themselves as lesbians (Marrazzo, 2004). Although a genetic factor has been linked with male homosexuality, no such etiology has been identified for lesbians (Ridley, 2000). Thus, the origin of this sexual orientation in women remains basically unknown.Masters and Johnson (1966) refuted the idea that homosexuality is a mental health disorder. Yet lesbians and bisexuals (individuals who are sexually active with others of both sexes) are more likely to report that they experience poor physical and mental health (Mays, Yancey, Cochran, Weber, & Fielding, 2002). Although the exact etiology of diminished health status among this population is not clear, one factor may relate to homosexual/bisexual women’s hesitancy in seeking health care. The mental and physical discomforts associated with seeking medical attention may translate into a failure to obtain timely pro-fessional help for health concerns or illnesses. Some lesbi-ans may be reluctant to disclose their sexual orientation to their health care provider owing to fears related to hostil-ity, inadequate health care, or breach of confidentiality. Also, in many health care settings, patient heterosexuality is assumed and interview questions are structured toward a heterosexual orientation.Lesbians who decide to bear a child often must undergo a number of medical procedures in order to conceive. In general, lesbian women who choose to have children are firmly committed to their decision, for they must work harder at achieving conception than other women. Signifi-cant health issues also exist for this population. Women who are lesbians are more at risk for breast cancer due to their lower rates of breastfeeding. They are also at risk for sexually transmitted infections (including HIV) and cervi-cal cancer. However, woman-to-woman transmission of sexually transmitted infections is much lower than in heterosexual relationships. Since not all gynecological cancers are related to sexual activity, lesbian women who have never had children may be at an increased risk for endometrial and ovarian cancer. Further, their risk for other cancers (e.g., lung and colon) and heart disease is not different from that of heterosexual women. It is essen-tial that health care providers give correct advice and conduct appropriate cancer and other disease screening for these women. The nurse should develop an approach that does not assume that all patients are heterosexual (Martinez, 2007; Stevens & Hall, 2001). As is true with any group, homosexual women deserve to have their healthcare concerns addressed by compassionate, non- judgmental healthcare providers who are knowledgeable about the healthcare needs of women with alternative sexual preferences.
A Nursing Framework for Promoting Women’s Sexual and Reproductive Health
Nurses who work with women in reproductive care set-tings must understand what is meant by healthy sexual function before they can begin to recognize and under-stand how a behavior becomes dysfunctional. A newer vision of sexuality in women (Basson, 2002; Katz, 2007) takes into account relationships for women by including emotional intimacy, sexual stimuli, and relationship satis-faction as a model of sexual response. Thus, women’s sex-ual response is far more complex and complicated than the achievement of an orgasm with intercourse. Sexuality for women encompasses much more than the physical dimension of the sex act.Sexual dysfunction for women is defined as any sexual situation that causes distress for the woman herself. If the woman is comfortable with a situation, there is no dys-function. If she is distressed by any physical, emotional, or relationship aspect of her sexuality, she may be experienc-ing a dysfunction (Hicks, 2004). Dysfunction can be manifested in the form of pain, arousal disorder, orgasmic disorder, or desire disorder (American Psychiatric Associ-ation [APA], 2000).
ASSESSMENT
A first step in the sexual and reproductive health assess-ment involves the establishment of a trusting relation-ship where the patient feels safe asking questions and sharing concerns. Discussion of sexual issues can be embarrassing for women. Nurses need to be aware of their own sexual biases and beliefs and educate them-selves about the many aspects of sexuality. When assess-ing women for sexual concerns, it is important not to make assumptions about partner preferences or sexual
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