The Infertility Evaluation:  What ANPs Can Do Before a Referral to a Specialist

The below was written by Jordan Moore Vaughan. MSN, APRN, WHNP-BC

Infertility doesn’t discriminate. It affects all races, religions, and all socioeconomic backgrounds. This complex diagnosis can affect physical, mental, and financial well-being. It is often overlooked or misunderstood. During this Infertility Awareness Week, I hope to shed some light on this condition as well as some tools we have as providers prior to referring a patient to a specialist.

Infertility 101

The definition of infertility is the inability conceive after one year of regular, unprotected intercourse, or six months if a woman is over the age of 35.  According to the CDC, as many as 10% of women struggle to become pregnant or continue a pregnancy in the United States.

As an advanced practice nurse (APN), you may be the first point of contact for patients in the fertility journey. Before referring them to an infertility specialist, you can provide them with education and guidance on how to maximize fertility.

Guidance for Women

All women of childbearing age should be on a prenatal vitamin with folic acid. They should not be smoking, and should limit their alcohol and caffeine consumption. Women should also maintain a healthy body weight to promote efficient ovulation and optimal health for continuing pregnancy.

Guidance for Men

The guidance for men is similar. They should also be taking a multivitamin. They should not be smoking, and should limit alcohol consumption. Men also need to maintain a healthy body weight.

In addition, men should not be taking any anabolic steroids, as it affects the hormonal balance between the brain and testes, which impacts sperm production.

Guidance for Couples

Education on the timing of intercourse is very important. To increase the chances of pregnancy, couples should have intercourse during the “ fertile window” which is the  5 days leading up to and the day of ovulation.  You should educate your patients on how to monitor ovulation, whether by menstrual calendar, ovulation predictor kits, or evaluation of cervical mucus.

What APNs Can Do

In order for a woman to conceive three components are necessary: Ovulation, a suitable uterine environment, and motile sperm capable of fertilization. Here are three things you can do before initiating a referral:

Ovarian Reserve Testing

Determine if a woman is ovulating either by a detailed history or by testing. Although there is no perfect test, and generally a combination of testing is used to predict chances of pregnancy, AMH (Antimullerian Hormone) is a promising screening tool to predict ovarian reserve. This may be obtained by blood sample at any day of a women’s cycle, whereas a basal FSH (Follicle stimulating hormone) is only reliable on menstrual days 2-4.  In the literature, a level of > 1 ng/ml is generally considered to be normal.

HSG

Tubal disease is a common cause of infertility. You can rule this out prior to referral.  Screening for a history of Chlamydia is particularly important as it is the primary modifiable cause of tubal factor infertility.  Doing an HSG (hysterosalpingogram) is an inexpensive way to determine tubal status. This is done after a woman stops bleeding and prior to ovulation. This can document tubal patency, uterine anomalies, such as a fibroid or polyp, and uterine malformations, such as a septum.

Semen Analysis 

For the male partner, a semen analysis should be considered early in the evaluation. This analysis is the most accurate evaluation of male fertility and can be used as a cost-effective way to quickly exclude male factors as the cause of a couple’s infertility. Collections should be made with 2-5 days of abstinence for optimal results.  Contact your local fertility practice or lab for specific instructions as all centers are different.

The diagnosis of infertility is life altering for many couples, with lasting psychological impact as well.  As an APN you are in a unique position to guide your patients through the fertility journey providing holistic care and addressing both the physical and emotional well-being aspects.  Because of the length and intimacy of the evaluation, patients may feel more comfortable working with you because of the already established a trusting relationship you have before referral to a specialist.  These are some components of the evaluation that you can do in your practice prior that are helpful in the referral process.

April is Sexual Assault Awareness Month

The below was written by Heidi Fantasia PhD, RN, WHNP-BC. Dr. Fantasia is an Associate Professor at the Solomont School of Nursing, University of Massachusetts – Lowell, and a member of the NPWH Board of Directors

April is Sexual Assault Awareness Month. While this is the 18th year we have recognized this public health issue, there is still work to be done to overcome the shame and stigma that plagues victims of sexual assault. This annual recognition serves two purposes, to raise public awareness about sexual assault, sexual harassment, and abuse, and to provide education, resources, and potential solutions for prevention.

A Common Experience

It is estimated that between 25% and 50% of women will experience an attempted or completed sexual assault during their lifetime. Those rates could even be higher when you consider that many sexual assaults are never disclosed or reported, often times because it was perpetrated by someone who is known to the victim. Sexual assault can be defined in many different ways, but broadly it refers to sexual activity in which consent wasn’t obtained or wasn’t freely given. This includes sexual activity or contact that was unwanted, coerced or occurred after intimidation or threats of harm. Although both women and men can be victims of sexual assault, women have the highest rates.

The Role of a Provider

It is always an individual’s decision whether to disclose an assault. But health care providers play an important role in creating a safe space where people feel supported when talking about uncomfortable topics that they may have never discussed anyone else.

Ask the Questions

Asking simple questions such as “Have you ever been forced to have sex when you didn’t want to”, “Have you ever experienced physical or sexual violence from a partner” and “Are you currently afraid of someone” helps start a conversation. These questions can be modified for any practice setting and asked in person or incorporated as part of the patient history. Letting individuals know that these are routine questions asked of everyone will help reduce stigma and reduce the chance that women feel singled out due to factors such as age, race, ethnicity, sexual behaviors, sexual orientation, and gender identification.

Believe Women and Assure Nonjudgement

Individuals who have experienced assault, whether it was attempted or completed, can experience a range of emotions, including fear of not being believed, shame, embarrassment, and self-blame. They may be worried that others will judge their behavior or relationships. Discussing sexual assault allows for open and honest conversations about consent, coercion, and healthy relationships. The most important way health care providers can help those who have experienced sexual assault is believing their account and listening to their most immediate concern.

Offer Timely Resources

If the assault occurred recently (typically within the past 5-7 days), individuals can be directed to a hospital or center with a sexual assault program that provides forensic evidence collection. This evidence will be used if they decide to move forward with legal proceedings. It is important to make sure those who have experienced sexual assault understand the decision to press charges is completely theirs, and having evidence collected does not mean they have to go down this road now.

If the assault occurred outside of this time frame or if the individual doesn’t want to have this done, the office visit should focus on what they identify as most important. This may include concerns about pregnancy, sexually transmitted infections, or emotional issues such as fear, anxiety, and depression. Providers can offer outside resources for additional support such as individual and group counseling, liaisons with law enforcement, and legal assistance.

Providers Create Change

Increasing awareness of sexual assault as a prevalent public health issue will help decrease victim blaming and normalize conversations about best strategies for prevention. Whether a woman is coming in for an annual checkup or seeking help after a sexual assault, our work as clinicians can help lift the veil of secrecy so that more women can get the care they need.

Black Maternal Health Week: Voice and Visibility for Black Maternal Health

The below was written by  Shawana S. Moore, DNP, MSN, CRNP, WHNP-BC. Dr. Moore is Assistant Professor and WHNP Program Director at Jefferson University. She is also on the NPWH Board of Directors. 

The Black Maternal Health Crisis

We are in the midst of a black maternal health crisis. According to the U.S. Centers for Disease Control and Prevention (CDC):

  • Black women have 3 to 4 times higher rates of death from pregnancy or childbirth-related causes compared to white women.1
  • Black women are more likely than white women to experience complications from maternal morbidities during pregnancy.1
    • Morbidities may include infections, mental health issues, obesity, diabetes, pre-eclampsia, and cardiovascular conditions.2
    • Morbidities may not result in death. However, they do have the ability to affect one’s quality of life.3

These alarming statistics urge us to take action and increase awareness about black maternal health.

As health care providers, more specifically women’s health nurse practitioners, we will likely cross paths with black mothers at some point in our careers. NPs, more than other providers, serve urban areas and rural communities where needs are greatest. It is essential that we see, hear, validate and advocate for this population of women.

Taking Action

A resolution recognizing “Black Maternal Health Week” was introduced in the Senate in 2018 by Senator Kamala Harris (D-CA) as an effort to bring national attention to maternal health care crisis in the black community and the importance of reducing the rate of maternal mortality and morbidity among black women.4 The nation now observes Black Maternal Health Week each year from April 11th -April 17th.

During this awareness week across the United States, campaigns and activities are led by the Black Mamas Matter Alliance to amplify the voices of black mothers and center the values and traditions of the reproductive and birth justice movements.5

Resources for Providers

There are many resources available to assist with the care and advocacy for this population. In 2018, Black Mamas Matter Alliance published a Black Paper entitled Setting the Standard for Holistic Care of and for Black Women.6

Critical Components of Setting the Standard for Holistic Care of and for Black Women include: 6

  • Addressing gaps and ensuring continuity of care
  • Affordable and accessible health care
  • Confidentiality
  • Safe and trauma-informed care
  • Care that centers black women and their families
  • Care that is patient-centered and patient-led
  • Culturally congruent and competent care

An additional resource available is Black Mamas Matter Toolkit. This toolkit was released by the Center for Reproductive Rights in partnership with members of Black Mamas Matter Alliance in 2016.7 It serves as a valuable resource for advocates who have an interest in the health and the well-being of black women and girls.7

Critical Components of Black Mamas Matter Toolkit include:7

  • Human rights-based approach to maternal health
  • Identifying the rights of pregnant and birthing parents
  • Information on the corresponding role of government to ensure safe and respectful maternal health care for all

How Providers Can Help

Black Maternal Health Week provides a forum to create awareness and solutions for health disparities affecting the black maternal population. During the week of Black Maternal Health and throughout your career as a health care provider, please challenge yourself to engage and deepen the national conversation about black maternal health in the United States.8 Consider contributing in areas of community-driven policy, research, and care solutions for this population.8 Black women deserve safe and healthy pregnancies and maternal health care.9  Together, we have the power to ensure they receive it.

References

  1. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. Pregnancy-Related Deaths. Available at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-relatedmortality.htm. Accessed April 8, 2019
  2. CDC Foundation. Report from Maternal Mortality Review Committees. A View Into Their Critical Role. Available at https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf Accessed April 8, 2019
  3. Koblinsky M, Chowdhury M, Moran A, Ronsmans C. Maternal Morbidity and Disability and Their Consequences: Neglected Agenda in Maternal Health. Journal of Health, Population and Nutrition. 2012;30(2). doi:10.3329/jhpn.v30i2.11294
  4. Related Bills – S.Res.459 – 115th Congress (2017-2018): A resolution recognizing “Black Maternal Health Week” to bring national attention to the maternal health care crisis in the Black community and the importance of reducing the rate of maternal mortality and morbidity among Black women. Congress.gov. https://www.congress.gov/bill/115th-congress/senate-resolution/459/related-bills. Published 2019. Accessed April 9, 2019.
  5. Black Maternal Health Week. Apha.org. https://www.apha.org/events-and-meetings/apha-calendar/2019/black-maternal-health-week. Published 2019. Accessed April 9, 2019.
  6. Muse S. Setting the Standard for Holistic Care of and for Black Women. Blackmamasmatter.org. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf. Published 2019. Accessed April 9, 2019.
  7. Toolkits – Black Mamas Matter Alliance. Black Mamas Matter Alliance. https://blackmamasmatter.org/resources/toolkits/. Published 2019. Accessed April 9, 2019.
  8. Black Maternal Health Week – Black Mamas Matter Alliance. Black Mamas Matter Alliance. https://blackmamasmatter.org/bmhw/. Published 2019. Accessed April 9, 2019.
  9. Black Women’s Maternal Health:. Nationalpartnership.org. http://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html. Published 2019. Accessed April 9, 2019.