Manual Clinical Guidelines from Conception to Use

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Guidelines: Adherence to antiretroviral therapy in adolescents and young adults expanded version 01 Aug Two documents have been developed. Guidelines: Adherence to antiretroviral therapy in adolescents and young adults 23 Jul This document provides a quick reference and summary of the main aspects related to supporting antiretroviral therapy adherence for HIV positive adolescents and young adults. Adult antiretroviral therapy guidelines 14 Jul These guidelines are intended as an update to those published in the Southern African Journal of HIV Medicine in and the update on when to initiate antiretroviral therapy in Southern African guidelines on the safe use of pre-exposure prophylaxis in persons at risk of acquiring HIV-1 infection 08 Mar The aim of the this PrEP guideline is to explain what PrEP is, outline current indications for its use, outline steps for appropriate user selection and provide guidance to monitor and maintain PrEP users.

Corrigendum: Society PEP Guidelines 03 Mar This document is a corrigendum to our "Guideline on the management of occupational and non-occupational exposure to the human immunodeficiency virus and recommendations for post-exposure prophylaxis: Update". Guideline on the management of occupational and non-occupational exposure to the human immunodeficiency virus and recommendations for post-exposure prophylaxis: Update 03 Mar This guideline is an update of the post-exposure prophylaxis PEP guideline published by the Southern African HIV Clinicians Society in Guidelines for the Delivery of Antiretroviral Therapy to Migrants and Crisis-Affected Persons in Sub-Saharan Africa 17 Apr Update to guidance to include all types of migrants and crisis-affected populations, including those forcibly displaced.

Guideline on Adult Antiretroviral Therapy 19 Dec update to the Society guideline on adult antiretroviral therapy. A pocket guide to antibiotic prescribing for adults in South Africa 24 Oct This document is provided as an information resource for all health care workers to assist in the appropriate prescribing of antibiotics. Guideline on the management of mental health disorders in HIV positive patients 10 Jan A reference document to assist HIV nurse and doctor clinicians in managing mental health disorders. Guideline for the prevention, diagnosis and management of cryptoccocal meningitis among HIV-infected persons: update 07 Jun Update to guidelines on the prevention, diagnosis and management of cryptoccocal meningitis among HIV-infected persons.

Southern African guidelines for the safe use of pre-exposure prophylaxis in men who have sex with men who are at risk for HIV infection 03 Jul A review of the use of blood and blood products in HIV-infected patients 03 Jun Total motility differs from progressive motility only in the notation of forward movement.

Information from reference Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility. Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease.

Irregular menses; hirsutism; obesity polycystic ovary syndrome ; galactorrhea hyperprolactinemia ; fatigue; hair loss hypothyroidism. Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine fibroids; abnormal palpation and inspection.

Both syndromes result in normal semen volume but low sperm count. Y deletions can be passed to offspring if intracytoplasmic sperm injection is used with in vitro fertilization; genetic counseling is indicated.

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Y deletions. XXY Klinefelter syndrome. Klinefelter syndrome typically results in low testosterone level and an elevated FSH level. Other genetics:.

Clinical guidelines: from conception to use

Because of the inheritance pattern, genetic testing of the partner is warranted, and counseling is indicated if she is a carrier. CFTR gene cystic fibrosis. Low volume semen analysis; transrectal ultrasonography can identify obstruction. Low FSH level; low testosterone level; check prolactin level and, if elevated, perform imaging for pituitary tumor. Infiltrative processes that cause a small number of infertility cases; however, effective treatment is available. Kallmann syndrome. Pituitary tumor.

Subspecialist may consider testicular biopsy to determine obstructive vs. Information from references 6 through 8 , 10 , 19 , and The etiology of female infertility can be broken down into ovulation disorders, uterine abnormalities, tubal obstruction, and peritoneal factors. Cervical factors are also thought to play a minor role, although they are rarely the sole cause. Evaluation of cervical mucus is unreliable; therefore, investigation is not helpful with the management of infertility.

The initial history should cover menstrual history, timing and frequency of intercourse, previous use of contraception, previous pregnancies and outcomes, pelvic infections, medication use, occupational exposures, substance abuse, alcohol intake, tobacco use, and previous surgery on reproductive organs. A review of systems and physical examination of the endocrine and gynecologic systems should be performed. Other considerations include preconception screening and vaccination for preventable diseases such as rubella and varicella, sexually transmitted infections, and cervical cancer, based on appropriate guidelines and risk.

Women in group II include those with polycystic ovary syndrome and hyperprolactinemia. Women in group III can conceive only with oocyte donation and in vitro fertilization. Women with regular menstrual cycles are likely to be ovulating and should be offered serum progesterone testing at day 21 to confirm ovulation. Basal body temperatures are no longer considered a reliable indicator of ovulation, and are not recommended for evaluating ovulation.

A high serum estradiol level greater than 60 to 80 pg per mL [ to pmol per L] in conjunction with a normal FSH level has also been associated with lower pregnancy rates. This combination of laboratory test results may indicate ovarian insufficiency or diminished ovarian reserve. However, these tests have only poor to moderate predictive value despite widespread use. Women with no clear risk of tubal obstruction should be offered hysterosalpingography to screen for tubal occlusion and structural uterine abnormalities. This allows for the diagnosis and treatment of conditions such as endometriosis with one procedure.

Endometrial biopsy should be performed only in women with suspected pathology chronic endometritis or neoplasia. Histologic endometrial dating is not considered reliable nor is it predictive of fertility. When anatomic variance or obstruction is suspected, referral for surgical evaluation and treatment is appropriate.

If an endocrinopathy, such as hyperprolactinemia, is diagnosed, the underlying cause should be treated. In patients with varicocele, there is insufficient evidence to suggest corrective surgery will increase live birth rates, despite improvement in semen analysis results. Women with WHO group I ovulatory disorders should be counseled to achieve a normal body weight.

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  3. Fertility: assessment and treatment for people with fertility problems Clinical Practice Guidelines.

They may benefit from referral to a physician comfortable with prescribing pulsatile administration of gonadotropin-releasing hormone or gonadotropins with luteinizing hormone activity to induce ovulation. Women in WHO group II, including those who are overweight and who have polycystic ovary syndrome, can benefit from weight loss, exercise, and lifestyle modifications to restore ovulatory cycles and achieve pregnancy.

Family physicians may choose to attempt ovulation induction in anovulatory women WHO group II with clomiphene. Ovulation induction agents increase the risk of multiple pregnancy, ovarian hyperstimulation syndrome, and thrombosis, and they may increase the risk of ovarian cancer in women who remain nulliparous. The initial dosage of clomiphene is 50 mg daily for five days starting on day 3 to 5 of the menstrual cycle.

This should be followed by documentation of ovulation via serum progesterone. If this is unsuccessful, the dosage may be increased to mg daily. Patients who do not achieve ovulation after three to six cycles should be referred to an infertility specialist for further treatment.

Overview of Clinical Practice Guidelines

Couples who do not conceive after treatment for six cycles with documented ovulation should also consider referral to an infertility specialist. Couples who have no identified cause of infertility should be counseled on timing of intercourse for the most fertile period i. These may be purchased over the counter and allow couples to predict the most fertile days in the cycle. Additionally, there is concern that the stress of a strict schedule for intercourse may lead to reduced frequency of intercourse.

Figure 1 provides an algorithmic approach to the evaluation of infertility. Algorithm for infertility evaluation. All couples should be counseled to abstain from tobacco use, limit alcohol consumption, and aim for a body mass index less than 30 kg per m 2 to improve their chances of natural conception or using assisted reproductive technology.

Data Sources : A PubMed search was completed using the key terms infertility, subfertility, treatment, etiology, and diagnosis. It was broken down into male and female categories. The search included meta-analyses, randomized controlled trials, clinical trials, and systematic reviews.

Limits were placed on language and human race as well.

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Search dates: January 6, ; January 28, ; February 5, ; and November 18, The views expressed in this material are those of the authors, and do not reflect the official policy or position of the U. Already a member or subscriber? Log in. Address correspondence to Tammy J. Reprints are not available from the authors. Natl Health Stat Rep. Natl Health Stat Report. Estimating the prevalence of infertility in Canada [published correction appears in Hum Reprod. Hum Reprod. Lifetime prevalence of infertility and infertility treatment in the UK: results from a population-based survey of reproduction.

Gutmacher AF. Factors effecting normal expectancy of conception. J Am Med Assoc. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. Incidence and main causes of infertility in a resident population 1,, of three French regions — Fertility: assessment and treatment for people with fertility problems. Clinical guideline no.

All supportive and educative interventions are offered in the context of the helping relationship, which requires competence and compassion. Individuals who present in Stage A typically deny worries or concerns about conception. Their theories express confidence and optimism about conceiving, and they often report correct information about the process of conception. At this time, if the NP has met with only one of the individuals, it is important to schedule a follow-up meeting with the couple in the following few months, or at the time when the couple becomes concerned about lack of conception.

The assessment of each partner's theories reveals couple congruence of conception plans and goals. From the beginning, the NP should promote good communication between the partners. They should be encouraged to ask each other about their thoughts and feelings regarding the problem, as well as about each other. The focus of Stage A intervention is educative. The NP should provide information about conception and ovulation and the factors that affect these.

Attitudes and Perceptions about Clinical Guidelines: A Qualitative Study with Spanish Physicians

The NP will elicit the client's thoughts about conception planning and explore the extent to which the other partner is involved in the plan. The importance of the couple's open communication should be emphasized. Couples who present in Stage B likely voice uncertainty about their future and concerns about their inability to conceive. An assessment of the couple's IWMs may reveal that one partner is more concerned than the other.

The couple might report that they have decreased their conception-related communication, and that there is now tension in the partnership. Statements of personal worth by either partner may reveal decreased self-esteem. Men may report a sense of loss of control, and may feel helpless in trying to comfort their spouses.

Feelings of frustration may occur in either partner, along with feelings of challenged masculinity or femininity. Excessive worry is characterized by reports of thought intrusion. The focus of intervention for Stage B is both educative and supportive. When providing supportive interventions, the NP should be reasonably accessible by appointment and by telephone during office hours as needed by the couple to provide emotional support at particular times of stress.

It is important for the NP to provide realistic hope, to give reliable information, and to dispel myths. By exploring each partner's theory about why conception has not occurred, the NP can then determine if these theories are based on fact or just on fictitious hearsay. The NP can then replace any myths with accurate information. It is the responsibility of the NP to validate each individual's competence as a problem-solver, and to emphasize the importance of open communication about doubts and worries between the couple.

The NP should discuss the effects of stress and anxiety on ovulation, and encourage a sense of control over these factors. By validating the couple's feelings of frustration, the NP provides support and suggests strategies to cope with the frustration and worry.

At this point, it is critical to replace any fear of childlessness with hope for conception. In order to hope, one must minimize fear and its automatic emotional responses. Hope is based on rationality, in which cognitive processes prevail over emotional ones. Maintaining hope involves the ability to tolerate uncertainty. Tolerating uncertainty requires openness and flexibility so that appraisal of the threat is realistic.

Hope is instilled by engaging the couple in reflective thinking by asking nondirective questions. The NP can then help the partners to create ways in which they can deal with social situations and significant others. Supportive interventions should also include providing anticipatory guidance. The NP should discuss what feelings the couple experiences when the female's menstrual cycle occurs, and how they cope with these emotions. Supportive interventions are also useful in dealing with decreased self-esteem. The biological issues in conception, as well as issues that are within the couple's control should be emphasized.

The couple should be counseled on issues such as:. These interventions, along with passage of time, typically ameliorate ordinary worries as described in Stages A and B. Couples in Stage C often present with feelings of powerlessness, depression, guilt, severe anxiety, and shame. The Beck Depression Scale may be used to determine if the patient is suffering from depression.

Women with higher levels of anxiety tend to have a more pessimistic outlook on the possibility of successful pregnancy.

They also experience greater stress-related intrusive ideation with levels similar to psychiatric patients. Additionally, one or both partners may place blame on the other partner for conception difficulties. Blame is a destructive emotional response in the individual and in the couple. The NP should help the couple establish some balance regarding each partner's limits in the process of trying to conceive. If one or both partners present with excessive worry and psychological symptoms, then referral to an appropriate mental health professional is warranted.

The NP will have to help the couple understand this need. Once the referral is made, the couple must be reassured that their relationship with the NP will not end. Collaborative care is encouraged when the couple is in Stage C. In such a collaborative care model, patient education and care are shared by the NP and the mental health professional. One of the most effective strategies for dealing with a client's theory or understanding is Cognitive Behavioral Therapy CBT.

CBT is very effective in treating depression, grief, anxiety, decreased self-esteem and femininity, social isolation, distance in the couple relationship, guilt, blame, anger, feelings of loss of control, and excessive worry. By utilizing CBT, individuals are taught the ability to suppress intrusive thoughts by immediately substituting a positive one.

CBT involves correction of flaws in reasoning and is compatible with the notion of underlying personal theories, as well as understanding and solving problems. By using thought substitution, a positive or hopeful thought is substituted for a negative or pessimistic one.

Clinical guidelines: developing guidelines.

When couples experience fear and panic related to uncertainty of childlessness, CBT may be utilized to encourage hope. The NP should assist the couples with cognitive coping strategies such as goal-setting, rational thinking, and plans about how to achieve those goals. Use of this protocol enables NPs in primary care to provide the support and education that couples experiencing difficulty with conception require.

The effect of psychosocial distress negatively affects fertility. Without this protocol, patients who respond with anxiety and low mood would not ordinarily be treated. The protocol is simple to use with specific assessment parameters and specific interventions. It also serves as a guide for referral. Pike S, Grieve K. Counseling perspectives on the landscape of infertility. Therapy Today. The quest for conception. An over view of the NP's role in fertility care. Adv Nurse Pract. Smith LF. The role of primary care in infertility management. Human Fertil Camb.

A primary care approach to the infertile couple. J Am Bd Fam Pract. Initial management of infertility: an audit of pre-referral investigations and exploration of couples' views at the interface of primary and secondary care. Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface. Support from health care providers and the psychological adjustment of individuals experiencing infertility. J Obstet Gynecol Neonatal Nurs. Fido A, Zahid MA.

Coping with infertility among Kuwaiti women: cultural perspectives. Int J Soc Psychiatry.