please write  5 pages paper from this chapterInfertilityIncidenceInfertility is a serious concern that affects 1 in 4 couples of reproductive age, with increasing incidence correlated with increased age (Crawford & Steiner, 2015; Lobo, 2017). Commonly infertility is considered to be a diagnosis for couples who have not achieved pregnancy after 1 year of regular, unprotected intercourse when the woman is less than 35 years of age or after 6 months when the woman is older than 35 years of age. Fecundity is the term used to describe the chance of achieving pregnancy and subsequent live birth within one menstrual cycle. Fecundity averages 20% in couples who are not experiencing reproductive problems (American Society of Reproductive Medicine [ASRM], 2012).Probable causes of infertility include the trend toward delaying pregnancy until later in life, a time when fertility decreases naturally and the prevalence of diseases such as endometriosis and ovulatory dysfunction increases. Questions exist regarding whether there has been an increase in male infertility or whether male infertility is more readily identified because of improvements in diagnosis.For the couple experiencing infertility, diagnosis and treatment strategies require considerable physical, emotional, and financial investment over an extended period of time. Feelings connected with infertility are many and complex, often interfering with quality of life. It is common for infertile couples to experience anxiety from the need to undergo many tests and examinations and from a perception of feeling “different” from their fertile friends and relatives. The following four goals provide a framework for nurses who care for infertile persons:• Provide the couple with accurate information about human reproduction, infertility treatments, and prognosis for pregnancy. Dispel any myths or inaccuracies from friends or the mass media that the couple may believe to be true.• Help the couple and the health care team accurately identify and treat possible causes of infertility.• Provide emotional support. The couple may benefit from anticipatory guidance, counseling, and support group meetings, either face-to-face or online. The organization RESOLVE ( provides online support, advocacy, and education about infertility for both the infertility community and health care providers.• Guide and educate those who fail to conceive biologically about other forms of treatment such as in vitro fertilization (IVF), donor eggs or semen, surrogate motherhood, and adoption. Support the couple in their decisions regarding their future family.It is important for nurses to encourage all healthy women and men to maintain a normal body mass index (BMI) and avoid sexually transmitted infections (STIs) and exposures to substances or habits (such as smoking) that impair reproductive ability. While these health-promoting activities will not ensure fertility, they will enhance overall health as the individual or couple is coping with the stresses of infertility.Factors Associated With InfertilityAlthough exact percentages vary somewhat with populations, approximately 85% to 90% of couples seeking infertility care are treated with medication or surgery, with 3% being treated with in vitro fertilization or other assisted reproductive methods (ASRM, 2016). About 40% of infertility is related to a male factor or a combined male and female factor (ASRM, 2016). About 20% of infertility is unexplained (Lobo, 2017). For those couples and individuals for whom a specific cause of infertility is not detected, the focus of infertility treatment has shifted from attempting to correct a specific pathology to recommending and initiating the treatment that is most effective in achieving pregnancy for this unique couple at this time in their reproductive life span. Assisted reproductive technologies (ARTs) have proven to be effective, even in couples who experience unexplained infertility.Unassisted human conception requires a normally developed reproductive tract in both the male and female partners. For simplification, each live birth necessitates synchronization of the following:• The male must deposit semen with sperm that has the capacity to fertilize an egg close to the cervix at the time of ovulation. The sperm must be able to ascend through the uterus and uterine tubes (male factor). The cervix must be sufficiently open to allow semen to enter the uterus and provide a nurturing environment for sperm (cervical factor).• The uterine tubes must be able to capture the ovum, transport semen to the ovum, and transport the fertilized embryo to the uterus (tubal factor).• Ovulation of a healthy oocyte must occur, ideally within the parameters of a regular, predictable menstrual cycle (ovarian factor).• The uterus must be receptive to implantation of the embryo and capable of nourishing the growth and development of the fetus throughout the normal duration of pregnancy (uterine factor).An alteration in one or more of these structures, functions, or processes results in some degree of impaired fertility. Boxes 5.1 and 5.2 list factors affecting female and male infertility.Box 5.1Factors Affecting Female FertilityOvarian Factors• Developmental anomalies• Anovulation—primary• Pituitary or hypothalamic hormone disorders• Adrenal gland disorders (rare)• Congenital adrenal hyperplasia (rare)• Anovulation—secondary• Disruption of hypothalamic-pituitary-ovarian axis• Anorexia• Insufficient body fat in athletic women• Increased prolactin levels• Thyroid disorders• Premature ovarian failure• Polycystic ovary syndrome• Medications• Oral contraceptives• Progestins• Antidepressant and antipsychotic drugs• Corticosteroids• ChemotherapyTubal/Peritoneal Factors• Developmental anomalies of the tubes (see Fig. 5.1)FIG 5.1 Abnormal uterus. A, Complete bicornuate uterus with vagina divided by a septum. B, Complete bicornuate uterus with normal vagina. C, Partial bicornuate uterus with normal vagina. D, Unicornuate uterus.• Reduced tubal motility• Inflammation within the tube• Tubal adhesions• Disruption caused by tubal pregnancy• EndometriosisUterine Factors• Developmental anomalies of the uterus (see Fig. 5.1)• Endometrial and myometrial fibroid tumors• Asherman’s syndrome (uterine adhesions or scar tissue)Vaginal-Cervical Factors• Vaginal-cervical infections• Cervical mucus inadequate• Isoimmunization (development of sperm antibodies)Other Factors• Nutritional deficiencies• Obesity• Thyroid dysfunction (hyperthyroidism and hypothyroidism)• Idiopathic conditionsBox 5.2Factors Affecting Male FertilityHormonal Disorders• Congenital disorders• Tumors of the pituitary gland or hypothalamus• Trauma to the pituitary gland or hypothalamus• Hyperprolactinemia• Excess of androgens, estrogen, or cortisol• Drugs and substance abuse (recreational and prescribed drugs)• Chronic illnesses• Nutritional deficiencies• Obesity• Endocrine disorders (e.g., diabetes)Testicular Factors• Congenital disorders• Undescended testes• Hypospadias• Varicocele• Viral infections (e.g., mumps)• Sexually transmitted infections (e.g. gonorrhea, chlamydial infection)• Obstructive lesions of the epididymis and vas deferens• Environmental toxins• Trauma• Torsion• Castration• Systemic illnesses• Antisperm antibodies• Changes in sperm from cigarette smoking or use of heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, or methaqualone• Decrease in libido from use of heroin, methadone, selective serotonin reuptake inhibitors, or barbiturates• Impotence from use of alcohol or antihypertensive medicationsFactors Associated With Sperm Transport• Drugs• Sexually transmitted infections of the epididymis• Ejaculatory dysfunction• Premature ejaculationIdiopathic Male InfertilityFor conception to occur, both partners must have normal, intact hypothalamic-pituitary-gonadal hormonal axes that support the formation of sperm in the male and ova in the female. Sperm can remain viable within a woman’s reproductive tract for at least 3 days and for as long as 5 days. The oocyte can only be successfully fertilized for 12 to 24 hours after ovulation. The couple seeking pregnancy should be taught about the menstrual cycle and ways to detect ovulation (see Chapter 3). They should be counseled to have intercourse 2 to 3 times a week; or, if timed intercourse does not increase anxiety, they should be encouraged to engage in intercourse the day before and the day of ovulation. Fertility decreases markedly 24 hours after ovulation.Care ManagementInfertility care management includes a team of health care providers, including an obstetric care provider, fertility specialist, embryologist, genetic counselor, and mental health provider or counselor. The nurse is a key member of the care management team and assists in the assessment and education of the infertile couple. As part of the assessment process, he or she obtains information from the couple through interview and physical examination, including if this couple’s situation is one of primary (never experienced pregnancy) or secondary (previous pregnancy) infertility. Religious, cultural, and ethnic data may place restrictions on use of available treatments.In addition, the nurse obtains and monitors results of diagnostic testing. Some of the information and data needed to investigate impaired fertility are of a sensitive, personal nature. The couple may experience feelings of invasion of privacy, and the nurse must exercise tact and express concern for their well-being throughout the interview. The tests and examinations associated with infertility diagnosis and treatment are occasionally painful and often intrusive. The couple’s intimacy and feelings of romantic attachment are often impaired as they engage in this process. A high level of motivation is needed to endure the investigation and subsequent treatment. Because multiple factors involving both partners are common, the investigation of impaired fertility is conducted systematically and simultaneously for both male and female partners. Both partners must be interested in the solution to the problem. The medical investigation requires time (3 to 4 months) and considerable financial expense. Box 5.3 describes the status of insurance coverage for infertility treatment.Box 5.3Insurance Coverage for InfertilityAs of October 2016, only 15 states had mandated some form of insurance coverage for infertility. These mandates included in vitro fertilization in some states, whereas others only covered some diagnostic tests. Some states require health maintenance organizations (HMOs) to cover some costs, whereas in others HMOs are exempt. Patients need information about what they can expect from their insurers. The state Insurance Commissioner’s office can provide information about an individual state. The website for the American Society for Reproductive Medicine ( has more complete information.Assessment of Female InfertilityEvaluation for infertility should be offered to couples who have failed to become pregnant after 1 year of regular intercourse or after 6 months if the woman is older than 35 years of age. Investigation of impaired fertility begins for the woman with a complete history and physical examination. A complete general physical examination should include height and weight and estimation of BMI. Both obesity and being underweight are associated with anovulation disorders. Signs and symptoms of androgen excess such as excess body hair or pigmentation changes should be noted. The general physical examination is followed by a specific assessment of the reproductive tract. A history of infections of the genitourinary tract and any signs of infections, especially STIs that could impair tubal patency, should be assessed. Bimanual examination of internal organs may reveal lack of mobility of the uterus or abnormal contours of the uterus and tubes. A woman may have an abnormal uterus and tubes as a result of congenital abnormalities during fetal development). These uterine abnormalities increase risk for early pregnancy loss.Laboratory data, including routine urine and blood tests, are collected. The initial clinic visit serves as a preconceptional visit and as initial assessment of possible causes of infertility. The woman should be taking folic acid supplements, and all immunizations should be current to prepare for possible pregnancy.Diagnostic TestingThe basic infertility survey of the female involves evaluation of the cervix, uterus, tubes, and peritoneum; detection of ovulation; and hormone analysis. Timing and descriptions of common tests are presented in Table 5.1.TABLE 5.1General Tests for Impaired FertilityTest or ExaminationTiming (Menstrual Cycle Days)RationaleHysterosalpingogram (HSG) (uterine abnormalities, tubal   patency)7–10Late follicular, early proliferative phase; will not   disrupt a fertilized ovum; may open uterine tubes before time of ovulationChlamydia immunoglobulin G antibodies (tubal patency)VariableNegative antibody test may indicate tubal patency   assessment (HSG); not needed in low-risk womenHysterosalpingo-contrast sonography (uterine   abnormalities, tubal patency)7–10Late follicular, early proliferative phase; will not   disrupt a fertilized ovum; evaluates tubal patency, uterine cavity, and   myometriumSerum progesterone (ovulation)7 days before expected mensesMidluteal-phase progesterone levels; check adequacy of corpus   luteum progesterone productionAssessment of cervical mucus (ovulation)Variable, ovulationCervical mucus should have low viscosity, spinnbarkeit   (ability to stretch) during ovulationBasal body temperature (ovulation)Chart entire cycleElevation occurs in response to progesterone; documents   ovulationUrinary ovulation predictor kit (ovulation)Variable, ovulationDetects timing of lutein hormone surge before ovulationSemen analysis (male factor)2–7 days after abstinenceDetects ability of sperm to fertilize eggSperm penetration assay (male factor)After 2 days but ≤1 week of abstinenceEvaluates ability of sperm to penetrate eggFollicle-stimulating hormone (FSH) level (ovarian reserve)Day 3High FSH levels (>20) indicate that pregnancy will not   occur with woman’s own eggs; value <10 indicates adequate ovarian reserveClomiphene citrate challenge test (CCCT) (ovarian reserve)Administer clomiphene 100 mg days 5 through 9Assess FSH on days 3 and 10 in presence of clomiphene   stimulation; high FSH levels (>20) indicate that pregnancy will not occur   with woman’s own eggs; FSH <15 suggestive of adequate ovarian reserveFrom Genetics & IVF Institute. (2013). Fertility: Clomiphene citrate test. Retrieved from status regarding ovulation can be evaluated through menstrual history, serum hormone studies, and use of an ovulation predictor kit. If the woman is older than 35 years of age, the clinician may choose to assess “ovarian reserve” or how many potential ova remain within the ovaries. A common evaluation of ovarian reserve is measurement of follicle-stimulating hormone (FSH) levels on the third day of the menstrual cycle. The uterus and fallopian/uterine tubes can be visualized for abnormalities and tubal patency through hysterosalpingogram (x-ray film examination of the uterine cavity and tubes after instillation of radiopaque contrast material through the cervix). If the woman is at risk for endometriosis (implants of endometrial tissue outside of the uterus) or adhesions, diagnostic laparoscopy may be indicated. Test findings favorable for fertility are summarized in Box 5.4.Box 5.4Summary of Findings Favorable to Fertility1. Follicular development, ovulation, and luteal development are supportive of pregnancy:a. Basal body temperature (presumptive evidence of ovulatory cycles) is biphasic, with temperature elevation that persists for 12 to 14 days before menstruation.b. Cervical mucus characteristics change appropriately during phases of the menstrual cycle.c. Days 3 to 10 follicle-stimulating hormone (FSH) levels are low enough to verify the presence of adequate ovarian follicles.d. Day 3 estradiol levels are low enough to verify the presence of adequate ovarian follicles.e. Woman reports a history of regular, predictable menses with consistent premenstrual and menstrual symptoms.2. The luteal phase is supportive of pregnancy:a. Levels of plasma progesterone are adequate to indicate ovulation.b. Luteal phase of menstrual cycle is of sufficient duration to support pregnancy.3. Cervical factors are receptive to sperm during expected time of ovulation:a. Cervical os is open.b. Cervical mucus is clear, watery, abundant, and slippery and demonstrates good spinnbarkeit and arborization (fern pattern) at time of ovulation.c. Cervical examination reveals no lesions or infections.4. The uterus and uterine tubes support pregnancy:a. Uterine and tubal patency are documented by (1) spillage of dye into the peritoneal cavity, and (2) outlines of uterine and tubal cavities of adequate size and shape with no abnormalities.b. Laparoscopic examination verifies normal development of internal genitals and absence of adhesions, infections, endometriosis, and other lesions.5. The male partner's reproductive structures are normal:a. There is no evidence of developmental anomalies of penis, testicular atrophy, or varicocele (varicose veins on the spermatic vein in the groin).b. There is no evidence of infection in prostate, seminal vesicles, and urethra.c. Testes are more than 4 cm in largest diameter.6. Semen is supportive of pregnancy:a. Sperm (number per milliliter) are adequate in ejaculate.b. Most sperm show normal morphology.c. Most sperm are motile, forward moving.d. No autoimmunity exists.e. Seminal fluid is normal.Assessment of Male InfertilityThe systematic investigation of infertility in the male patient begins with a thorough history and physical examination. Assessment of the male patient proceeds in a manner similar to that of the female patient, starting with noninvasive tests.Diagnostic Testing and Semen AnalysisThe basic test for male infertility is semen analysis. A complete semen analysis, study of the effects of cervical mucus on sperm forward motility and survival, and evaluation of the ability of the sperm to penetrate an ovum provide basic information. Sperm counts vary from day to day and depend on emotional and physical status and sexual activity. Therefore, a single analysis may be inconclusive. A minimum of two analyses must be performed several weeks apart to assess male fertility.Semen is collected by ejaculation into a clean container or a plastic sheath that does not contain a spermicidal agent. The specimen is usually collected by masturbation following 2 to 7 days of abstinence from ejaculation. The semen is examined at the collection site or taken to the laboratory in a sealed container within 2 hours of ejaculation. Exposure to excessive heat or cold is avoided. Commonly accepted values for semen characteristics are given in Box 5.5. If results are in the fertile range, no further sperm evaluation is necessary. If results are not within this range, the test is repeated. If subsequent results are still in the subfertile range, further evaluation is needed to identify the problem.Box 5.5Semen Analysis: Normal Values• Semen volume at least 1.5 mL• Semen pH 7.2 or higher• Sperm density greater than 15 million/mL• Total sperm count greater than 39 million per ejaculate• Normal morphologic features greater than 4% (normal oval)• Motility (important consideration in sperm evaluation)—percentage of forward-moving sperm estimated with respect to abnormally motile and nonmotile sperm, 40%• Liquification—usually within 15 minutes but no longer than 60 minutesNOTE: These values are not absolute but are only relative to final evaluation of the couple as a single reproductive unit. Values also differ according to source used as a reference.Data from World Health Organization. (2010). Laboratory manual for the examination of human semen (5th ed.). Geneva, Switzerland: Author.Hormone analyses are done for testosterone, gonadotropin, FSH, and luteinizing hormone (LH). The sperm penetration assay and other alternative tests may be used to evaluate the ability of sperm to penetrate an egg. Testicular biopsy may be warranted. Scrotal ultrasound may be used to examine the testes for presence of varicoceles and identify abnormalities in the scrotum and spermatic cord. Transrectal ultrasound is used to evaluate the ejaculatory ducts, seminal vesicles, and vas deferens.Psychosocial ConsiderationsInfertility is recognized as a major life stressor that can affect self-esteem; relations with the spouse or partner, family, and friends; and careers. Psychologic responses to the diagnosis of infertility may tax a couple's capacity for giving and receiving physical and sexual closeness. The prescriptions and taboos for achieving conception may add tension to a couple's sexual functioning. They may report decreased desire for intercourse, orgasmic dysfunction, or midcycle erectile disorders.To be able to deal comfortably with a couple's sexuality, nurses must be comfortable with their own sexuality so they can better help couples understand why aspects of sexual intimacy need to be shared with health care professionals. Nurses need current factual knowledge about human sexual practices and must be accepting of the preferences and activities of others without being judgmental. They must be skilled in interviewing and therapeutic use of self, sensitive to the nonverbal cues of others, and knowledgeable regarding each couple's sociocultural and religious beliefs (see Clinical Reasoning Case Study).Clinical Reasoning Case StudyInfertilityDiane is a 39-year-old accountant who has recently married for the first time. Charles is 41 years of age and has two children from a previous marriage. Diane has a history of amenorrhea dating back to when she was in college and a member of the track team. Currently her menstrual periods are irregular. She wants to have a baby “before it's too late,” and she and Charles have been having unprotected sex for almost 1 year. They have come to the fertility clinic today for an evaluation. Diane tells the nurse that she has heard about the success of in vitro fertilization (IVF) and wants to know if she will be able to have it performed. How should the nurse respond to Diane's comments and questions?1. Evidence—Is evidence sufficient to draw conclusions about what response the nurse should give?2. Assumptions—Describe underlying assumptions about the following issues:a. Age and fertility: Is Diane's age a factor in her concern regarding infertility?b. Infertility as a major life stressor: To what extent can infertility or the fear of being infertile cause stress?c. Success rates for IVF pregnancy and birth: Is IVF a reasonable treatment to consider (after having a thorough workup)?d. Causes of female infertility: What are some of the reasons that Diane may be infertile?3. What implications and priorities for nursing care can be drawn at this time?4. Describe the roles and responsibilities of members of the interprofessional health care team who may be caring for Diana and Charles.The couple facing infertility exhibits behaviors of the grieving process such as those associated with other types of loss. The loss of one's genetic continuity with the generations to come can provoke decreased self-esteem, a sense of inadequacy as a woman or a man, and feelings of loss of control over personal destiny. Infertile individuals can perceive dissatisfaction with their marriages or partner relationships. Not all people have all the reactions described, nor can it be predicted how long any reaction will last for an individual. Often a mental health counselor with experience and expertise dealing with infertility can be very helpful to an individual or couple.If the couple does not conceive, they should be assessed regarding their desire to be referred for help with adoption, donor eggs or semen, surrogacy, or other reproductive alternatives. The couple may choose to continue in a child-free state. Both health care providers and patients should have a list of agencies, support groups, and other resources within their community such as the ASRM ( and RESOLVE ( TreatmentsBoth men and women can benefit from healthy lifestyle changes that result in a BMI within the normal range; moderate daily exercise; and abstinence from alcohol, nicotine, and recreational drugs. For the woman with a BMI >27 and polycystic ovary syndrome, losing just 5% to 10% of body weight can restore ovulation within 6 months. Anovulatory women with a BMI <17 who have eating disorders or intense exercise regimens benefit from weight gain. Nevertheless, this population sometimes is reluctant to alter their behaviors, and counseling should be advised.Simple changes in lifestyle may be effective in the treatment of subfertile men. Only water-soluble lubricants should be used during intercourse because many commonly used lubricants contain spermicides or have spermicidal properties. Instead of wearing briefs, the male should wear boxer shorts and loose pants because these tend to decrease scrotal temperature and may prevent a decrease in sperm count. High scrotal temperatures can be caused by daily hot tub baths or saunas that keep the testes at temperatures too high for efficient spermatogenesis. These conditions lead to only lessened fertility and should not be used as a means of contraception.Most herbal remedies have not been proven clinically to promote fertility or to be safe in early pregnancy and should be taken by the woman only as prescribed by a physician or nurse-midwife who has expertise in herbology. Relaxation, osteopathy, stress management (e.g., aromatherapy, yoga), and nutritional and exercise counseling have been reported to increase pregnancy rates in some women. Herbs to avoid while trying to conceive include licorice root, yarrow, wormwood, ephedra, fennel, goldenseal, lavender, juniper, flaxseed, pennyroyal, passionflower, wild cherry, cascara, sage, thyme, and periwinkle. All supplements or herbs should be purchased from trusted sources to ensure that they do not contain contaminants.Medical TherapyOne goal of infertility assessment and treatment is to determine which couples are likely to respond to conventional therapies in a timely manner. Another goal is early referral of couples who will need ARTs to concieve. In general, any fertility treatment is more likely to result in a live birth in women who are younger than 35 years of age, with successful outcomes decreasing for women older than 40 years of age.Pharmacologic therapy for female infertility is often directed at treating ovulatory dysfunction by either stimulating or enhancing ovulation so more oocytes mature. These medications include (1) clomiphene citrate as initial therapy for many women with intermittent anovulation; (2) a combination of clomiphene and metformin for women with anovulation and insulin resistance; (3) human menopausal gonadotropin (HMG), FSH, and recombinant FSH (rFSH) to stimulate follicle formation in women who do not respond to clomiphene therapies; (4) human chorionic gonadotropin to induce ovulation when follicles are ripe; (5) gonadotropin-releasing hormone (GnRH) agonists at the beginning of a cycle to sequence HMG therapies; (6) progesterone to support the luteal phase of the cycle; and (7) bromocriptine (Parlodel) for women who have excess prolactin (Lobo, 2017).Treatment of certain medical conditions may result in improved fertility. The woman who is hypothyroid benefits from thyroid hormone supplementation. Treatment of endometriosis could include trials of danazol, progesterone, continuous combined oral contraceptives, or GnRH agonists to suppress menstruation and shrink endometrial implants. This regimen would be followed by ovulation induction. Adrenal hyperplasia is treated with prednisone. Any infections present in the infertile couple should be treated with appropriate antimicrobial therapy.Clomiphene citrate (with the possible addition of metformin) is often the initial pharmacologic treatment of the infertile woman because it is inexpensive and the side-effect profile is less than other medications that induce ovulation. There is an increased risk for giving birth to twins or higher order multiples with clomiphene therapy.The more powerful medications used to induce ovulation include GnRH agonists followed by gonadotropin therapy. These medications are extremely potent and require daily ovarian ultrasonography and monitoring of estradiol levels to prevent hyperstimulation of the ovaries. Combinations of these medications are used with ART to stimulate ovulation before harvesting eggs.Drug therapy may be indicated for male infertility. As with women, problems with the thyroid or adrenal glands are corrected with appropriate medications. Infections are identified and treated with antimicrobials. FSH, HMG, and clomiphene may be used to stimulate spermatogenesis in men with hypogonadism. Men who do not respond to these therapies are candidates for intracytoplasmic sperm injection (ICSI), which is a procedure that injects sperm directly into the egg as part of IVF. ICSI has enabled men with very low sperm counts to achieve biologic reproduction.The infertility specialist is responsible for fully informing patients about the prescribed medications. The nurse must be ready to answer patients' questions and confirm their understanding of the drug, its administration, potential side effects, and expected outcomes. Because information varies with each drug, the nurse must consult the medication package inserts, pharmacology references, health care provider, and pharmacist as necessary. The nurse should also provide anticipatory guidance regarding the time given for a medication trial before referral to a specialist in ART would be indicated if the couple wants to continue to attempt to become pregnant.Table 5.2 includes information on selected medications for infertility treatment.TABLE 5.2Medication Guide to Selected Infertility MedicationsDrugIndicationMechanism of ActionDosageCommon Side EffectsClomiphene citrateOvulation induction, treatment of luteal-phase inadequacyThought to bind to estrogen receptors in the pituitary   gland, blocking them from detecting estrogenTablets, starting with 50 mg/day by mouth for 5 days   beginning on fifth day of menses; if ovulation does not occur, may increase   dose next cycle; variable dosageVasomotor flushes, abdominal discomfort, nausea and   vomiting, breast tenderness, ovarian enlargementMenotropins (human menopausal gonadotropins)Ovarian follicular growth and maturationLH and FSH in 1 : 1 ratio, direct stimulation of ovarian   follicle; given sequentially with hCG to induce ovulationIM injections; dosage regimen   variable based on ovarian responseInitial dose is 75 International   Units of FSH and 75 International Units of LH (1 ampule) daily for 7–12 days   (not to exceed 12 days) followed by 5000 to 10,000 International Units hCG   (if serum estradiol <2000 pg/mLOvarian enlargement, ovarian hyperstimulation, local   irritation at injection site, multifetal gestationsFollitropins (purified FSH)Treatment of polycystic ovary syndrome; follicle   stimulation for assisted reproductive techniquesDirect action on ovarian follicleSubcutaneous or IM injections; dosage regimen variableOvarian enlargement, ovarian hyperstimulation, local irritation   at injection site, multifetal gestationsHuman chorionic gonadotropin (hCG)Ovulation inductionDirect action on ovarian follicle to stimulate meiosis and   rupture of the follicle5000–10,000 International Units IM 1 day after last dose   of menotropins; dosage regimen variableLocal irritation at injection site; headaches,   irritability, edema, depression, fatigueGnRH agonists (nafarelin acetate, leuprolide acetate)Treatment of endometriosis, uterine fibroidsDesensitization and downward regulation of GnRH receptors   of pituitary gland, resulting in suppression of LH, FSH, and ovarian functionNafarelin, 200 mcg (1 spray) intranasally twice daily for   6 months; leuprolide acetate 3.75 mg IM every month for 3–6 monthsNafarelin—irritation, nosebleedsBoth nafarelin and leuprolide—hot   f

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