24. 23. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. Vause TD, Yazdani A, Nutrition goals should be guided by, among other things, the patient’s prognosis and expressed preferences and include a discussion with the patient and family whenever possible. Kroese AC, In terms of A1C goals, the AMDA guidelines are also consistent with those recommended in the 2012 ADA consensus report (9). Balen AH. Kamel RM. Women older than 35 years or couples with known risk factors for infertility may warrant evaluation at six months.6,8, It is important for primary care physicians to be familiar with the workup and prognosis for infertile couples. 2013792:293-308. doi: 10.1007/978-1-4614-8051-8_13. Gonadotrophins for idiopathic male factor subfertility. Andrews FM, Cook JL, Br J Gen Pract. 2003;189(4):901–905. Additional risk factors may include smoking, alcohol use, obesity, and older age; however, the data are hampered by a lack of pregnancy-related outcomes.8–16 One retrospective case-control study of 650 men with infertility and 698 control participants questioned the role of environmental risk; no association could be determined after assessing for multiple factors including shift work, stress, and pesticides.17, Evaluation of male infertility starts with a history and physical examination focusing on previous fertility, pelvic or inguinal surgeries, systemic diseases, and exposures. For example, an older adult on insulin may experience delirium as a common complication during and after hospitalization or may require a change in insulin dose when recuperating from acute illness and as nutritional intake improves. B, Physical activity and exercise are important in all patients and should depend on the current level of the patient’s functional abilities. Historically, therapeutic “diabetic” diets have been prescribed to older adults in the LTC setting. Intra-uterine insemination for unexplained subfertility. TAMMY J. LINDSAY, MD, FAAFP, is the chief of medical staff at Scott Air Force Base, Ill., and a clinical associate professor at Saint Louis University Family Medicine Residency in Belleville, Ill.... KIRSTEN R. VITRIKAS, MD, FAAFP, is the program director at David Grant Medical Center Family Medicine Residency at Travis Air Force Base, Calif. She is also an assistant professor at the Uniformed Services University of the Health Sciences Department of Community and Family Medicine in Bethesda, Md. At this point, care is focused on patient comfort and preparatory bereavement counseling for caretakers and patients, where appropriate. Mol BW. Is fertility-problem stress different? Hull MG, 43. Myers ER, Framework for considering diabetes management goals. Natl Health Stat Report. As patients move into this phase, the importance of glycemic control is less apparent and preventing hypoglycemia is of greater significance. The high prevalence of diabetes among older adults has contributed to the unsustainable growth of health care costs in the U.S. The predictive value of hysterosalpingography for tubal and peritoneal infertility factors. Homan G, Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Intra-uterine insemination for male subfertility. 26. Am Fam Physician. Brown J, Women with anovulation may be treated in the primary care setting with clomiphene to induce ovulation. 2009;360(6):606–614. Evers JL. Eur Urol. In addition, continuance of SSI after admission or transfer back to the LTC facility is a long-standing problem for patients with diabetes (26). Cohlen BJ, Society of Obstetricians and Gynecologists of Canada. Cochrane Database Syst Rev. Ovulation induction in polycystic ovary syndrome [published corrections appear in. Belzile E, Glutathione is a substance produced naturally by the liver.It is also found in fruits, vegetables, and meats. note: oligospermia = sperm count < 15 million per mL; asthenozoospermia = < 40% of the sperm are motile; teratozoospermia = normal morphology < 4%. de La Rochebrochard E, The evaluation of the azoospermic male: AUA best practice statement. Keirse MJ. History of abdominal or pelvic surgery; history consistent with endometriosis, Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility, Amenorrhea or oligomenorrhea; low body mass index, Low to normal FSH level; low estradiol level, Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease, Consider additional tests of ovarian reserve (antral follicle count, antimüllerian hormone level, clomiphene [Clomid] challenge test), Irregular menses; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue; hair loss (hypothyroidism), Progesterone level < 5 ng per mL (15.9 nmol per L); elevated prolactin level; elevated TSH level [ Some causes, such as hyperprolactinemia, are reversible with proper treatment. (Clinical guideline no. Peluso J, 31 terms. E.S.H. / afp et al. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life. Fertility: assessment and treatment for people with fertility problems. Central Venous Access Devices. Delayed conception and active and passive smoking. The most extensive guideline available was developed by the American Medical Directors Association (AMDA) (11). et al. et al. 2011;60(4):796–808. Yazdani A, Estimating the prevalence of infertility in Canada [published correction appears in Hum Reprod. Zhang W. Contact Occupational exposures and male infertility. Factors effecting normal expectancy of conception. Prioritisation of BCG on the first day of life in high-mortality settings might have significant public-health benefits through reductions in all-cause infectious morbidity and mortality. A British study found that patients valued primary care physicians who were well informed about infertility and the treatment process.9 Because anxiety over infertility may cause increased stress and decreased libido, further compounding the problem, formal counseling is encouraged for couples experiencing infertility.8, Causes of male infertility include infection, injury, toxin exposures, anatomic variances, chromosomal abnormalities, systemic diseases, and sperm antibodies. Thonneau P. Effectiveness of the postcoital test: randomised controlled trial. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Temporal relationship and reliability of the clinical, hormonal, and ultrasonographic indices of ovulation in infertile women. Knapp Quiz 3. NICHD National Cooperative Reproductive Medicine Network. The dynamics of stress in fertile and infertile couples. Bushnik T, Certain conditions such as cognitive dysfunction, depression, physical disabilities, eating problems, and repeated infections are commonly found in the LTC population. Nursing leadership training programs for nurses working in LTC facilities that include skills in diabetes management can also help to improve quality of care offered to patients in these facilities (55,56). Czernichow S; Lévy R, 2010;(1):CD000057. 2011;33(1):12]. We would like to show you a description here but the site won’t allow us. Ernst E, Hassan MA, 166 terms. Ovulation induction in polycystic ovary syndrome [published corrections appear in J Obstet Gynaecol Can. Kroese AC, Norman RJ. / Vol. Scoccia B, Another factor contributing to the challenges during care transitions is the lack of a single clinician taking responsibility for coordination across the continuum of the patient’s overall health care, regardless of setting (40). WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. dustynacho1. Middleton P. Klein TA. Giwercman A, Several sample admission and transfer forms are available for download from the AMDA Web site (http://www.amda.com/tools/guidelines.cfm). The LTC facility should have processes in place for planned and, even more importantly, unplanned transitions. WHO categorizes ovulatory disorders into three groups: group I is caused by hypothalamic pituitary failure (10%), group II results from dysfunction of hypothalamic-pituitary-ovarian axis (85%), and group III is caused by ovarian failure (5%).8 Women in group I typically present with amenorrhea and low gonadotropin levels, most commonly from low body weight or excessive exercise. Evaluation and Treatment of Infertility. Attia AM, Although much attention is rightly focused on hypoglycemia, persistent hyperglycemia increases the risk of dehydration, electrolyte abnormalities, urinary incontinence, dizziness, falls, and hyperglycemic hyperosmolar syndrome. Strategies are presented to reduce these risks and ensure safe transitions. Agency for Healthcare Research and Quality. 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. 2014;(73):1–21. Funding. Paternal age > or = 40 years: an important risk factor for infertility. No other potential conflicts of interest relevant to this article were reported. While carbohydrate intake should be taken into consideration, “no concentrated sweets” or “no sugar” diet orders are ineffective for glycemic management and should not be recommended. Johnson N, Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Practice Committee of American Society for Reproductive Medicine. Guzick DS, Baird DD. These guidelines emphasize that frail patients with cognitive impairment may present with atypical symptoms, mainly neuroglycopenic or behavioral in nature. Evaluation of cervical mucus is unreliable; therefore, investigation is not helpful with the management of infertility.6. Effect of male age on fertility: evidence for the decline in male fertility with increasing age. Obstet Gynecol. Acknowledgments. American Society for Reproductive Medicine. Adv Exp Med Biol. ; Common breast problems include breast mass, pain, and nipple discharge. Preconception lifestyle advice for people with subfertility. et al. Ciampi A, To avoid dehydration and unintentional weight loss, restrictive therapeutic diets should be minimized. Estimating the prevalence of infertility in Canada [published correction appears in. 1992;57(6):1247–1253. Chandra A, These characteristics have frequently been used to exclude older individuals from randomized clinical trials. Hormonal changes that affect fluid and electrolyte homeostasis have been reported in older adults. Unlike in older adults living in the community, insulin injections for individuals in LTC are usually given by the facility staff. Evers JL. Glucose-lowering medications also require attention to comorbid conditions and other medications to avoid side effects and drug interactions. Sun X, Diagnostic evaluation of the infertile female: a committee opinion. Symptoms include the taste of acid in the back of the mouth, heartburn, bad breath, chest pain, regurgitation, breathing problems, and wearing away of the teeth. is supported in part through the following grants: Midcareer Investigator Award in Patient-Oriented Research (K24 DK105340), the Chicago Center for Diabetes Translation Research (P30 DK092949), and a project grant (R01 HS018542). Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Collins JJ, Galletley C, Want to use this article elsewhere? Evaluation of the uterus and fallopian tubes can be performed by hysterosalpingography in women with no risk of obstruction. 45. For those with evidence of cognitive dysfunction, end-of-life planning and a communication strategy should be undertaken while the individual can still make rational decisions. 2004;82(5):1264–1272. Reassured or fobbed off? This article addresses diabetes management at end of life and in those receiving palliative and hospice care. 29. A systematic review of tests predicting ovarian reserve and IVF outcome. The Avon Longitudinal Study of Pregnancy and Childhood Study Team. Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (1988–1989). Abbey A, Commonly found comorbidities in LTC and strategies to improve diabetes care. Women with WHO group I ovulatory disorders should be counseled to achieve a normal body weight. Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence (7,8). Doyle P, et al. Keirse MJ. Strategies for diabetes management may include relaxing glycemic targets, simplifying regimens, using low-risk glucose-lowering agents, providing education on recognition of hypoglycemia, and enhancing communication strategies. Mac_2828. Search dates: January 6, 2014; January 28, 2014; February 5, 2014; and November 18, 2014. is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB4HP19211 “Geriatric Education Centers.”. In general, the facility medical leadership and nursing administration have the opportunity to develop and implement patient care policies that can facilitate optimal management of the older patient with diabetes and to coordinate efforts with the multidisciplinary team. ... BIOL 1201 Moroney Exam 3. It is not always possible to decrease the frequency of capillary glucose monitoring in patients with type 1 diabetes. Instructions for collecting the sample should include abstinence from ejaculation for 48 to 72 hours. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. 2015 Mar 1;91(5):308-314. ... 147 terms. Olsen J. Infertility and impaired fecundity in the United States, 1982–2010: data from the National Survey of Family Growth. 47. Gracia CR, Linthicum, Md. Lévy R, Sun X, Faure C, The presenting symptoms of hypoglycemia in older adults can be primarily neuroglycopenic (confusion, delirium, dizziness) rather than adrenergic (palpitation, sweating, tremors) (20). Available from, Sign In to Email Alerts with your Email Address. Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. Infertility service use in the United States: data from the National Survey of Family Growth, 1982–2010. Unexplained infertility in women or men may be managed with another year of unprotected intercourse, or may proceed to assisted reproductive technologies, such as intrauterine insemination or in vitro fertilization. Varicocele and male factor infertility treatment: a new meta-analysis and review of the role of varicocele repair. Giwercman A, 6. 38. Ziebland S. Davison E. The glucose-lowering steps advocated by the AMDA are consistent with those published in the ADA position statement on patient-centered individualized approaches to glucose lowering in adults with diabetes (12). LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5). This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Brown J, In order to assess and improve facility-wide management of diabetes directed by multiple practitioners, the facility leadership (e.g., the director of nursing, nurse managers, medical director, and consultant pharmacist) should collect data and trends and plan strategies to improve selected process or outcome indicators relevant to diabetes management. Litt J, This understanding requires knowledge of the patient population as well as the functioning of the facilities. Arch Intern Med. Tubal flushing for subfertility. 1998;13(6):1502–1505. Hinton L, The Avon Longitudinal Study of Pregnancy and Childhood Study Team. Mol BW, Baird DD. Vandekerckhove P. Nelson LM. They proposed three strata for management of patients with diabetes and advanced disease. The FAST study: fertility assessment and advice targeting lifestyle choices and behaviours: a pilot study. Patient and caregiver education regarding the telltale signs of dehydration and hypoglycemia and an appropriate plan of action is of vital importance. Luciano AA, Lord JM, Povey AC, Choose a single article, issue, or full-access subscription. 2003;361(9372):1849–1852. The guidelines recommend that LTC facilities develop their own facility-specific policies and procedures for hypoglycemia treatment. Cervical factors are also thought to play a minor role, although they are rarely the sole cause. Tallec A, Lancet. Lamb EJ, 27. J Obstet Gynaecol Can. Across existing guidelines, one consistent recommendation is to avoid the sole use of SSI, which was recently added to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (25). The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. Primary ovarian insufficiency. Fertil Steril. Andrews FM, Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. Nelson LM. Al-Inany HG. E. Patients admitted to LTC facilities are typically seen by a medical provider at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. 1991;6(6):811–816. Oei SG, Heineman MJ, 8. Yuzpe AA, Explore symptoms, inheritance, genetics of this condition. The dynamics of stress in fertile and infertile couples. Using these forms can facilitate the development of a process for the transition of patients and improve safety and quality of diabetes care. Luminal A breast cancer: This subtype is estrogen-receptor (ER) and/or progesterone-receptor (PR) positive, HER2 negative, and has low levels of Ki-67. 2012;(5):CD003053. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Anderson K, Luttjeboer F, Hughes E, Other (e.g., cervical factors, peritoneal factors, uterine abnormalities), Because 85% of couples conceive spontaneously within 12 months if having intercourse regularly,5 it is important to identify those who will benefit from infertility evaluation. Tables 4 and 5 provide additional information on insulin therapy. 32. In addition, it is important to respect the patient’s right to refuse treatment as well as to consider religion and cultural traditions, including the care of the body after death. World Health Organization reference values for human semen characteristics. 2013;100(6):1660–1666. 2013;(67):1–18.... 2. Diabetes management in the long term care setting [Internet], 2010. Basal body temperatures are no longer considered a reliable indicator of ovulation, and are not recommended for evaluating ovulation.6,8,23, A high FSH level (10 to 20 mIU per mL [10 to 20 IU per L]) drawn on day 3 of the menstrual cycle is associated with infertility. Hollants FA, Beyond these long-term goals of care, the AMDA guidelines provide recommendations to LTC staff regarding when to call a practitioner (11). Patients who do not achieve ovulation after three to six cycles should be referred to an infertility specialist for further treatment. Total motility differs from progressive motility only in the notation of forward movement, FSH = follicle-stimulating hormone; TSH = thyroid-stimulating hormone, Address correspondence to Tammy J. Lindsay, MD, FAAFP, Saint Louis University Family Medicine Residency, 180 S. 3rd St., Ste. Infertility is defined as the inability to achieve pregnancy after one year of regular, unprotected intercourse. Collins J, (ART = assisted reproductive technology. 2012;(9):CD001838. Gonadotrophins for idiopathic male factor subfertility. 2013;28(4):1151]. Lambalk CB. The management strategies for community-dwelling and hospitalized patients with diabetes have been previously described by the American Diabetes Association (ADA) (9,10). Luminal A cancers account for about 40% of all breast cancers. Cohlen BJ, Collins JA. Kurinczuk JJ, 12. Counseling about options should be offered to couples who are not physically able to conceive (i.e., same-sex couples or persons lacking reproductive organs). However, we have suggested specific recommendations for patients with type 1 diabetes when appropriate. 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.8,37, 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.37 Clomiphene has also proven effective for ovulation induction in women with polycystic ovary syndrome.37,38 The addition of 1,500 to 1,700 mg of metformin (Glucophage) daily may increase ovulation and pregnancy rates, but it does not significantly improve live birth rates over clomiphene alone.38,39, Family physicians may choose to attempt ovulation induction in anovulatory women (WHO group II) with clomiphene. Focused, interprofessional quality improvement initiatives have been shown to decrease hypoglycemia rates and improve processes of diabetes care in skilled nursing facilities (42). Challenges specific to staff and practitioners include multiple changing treatment approaches, lack of team communication, excessive reliance on SSI, inappropriate dosing or timing of insulin, knowledge deficits, lack of comfort with new insulin and injectable agents, failure of timely stepwise advance in therapy, failure to individualize care, and therapeutic nihilism. It was broken down into male and female categories. Therefore, the need to restart oral therapies (e.g., metformin), typically discontinued in the inpatient setting, can be overlooked. 242 terms. Reassured or fobbed off? As the vast majority of the patients with diabetes in LTC facilities have type 2 diabetes, most recommendations in this position statement are directed toward that population. Duality of Interest. 5. Meal plans that avoid weight loss, nonpharmacological options to prevent or manage behavioral problems, and timely identification and management of depression should be used to improve the quality of remaining life. Mol BW, Intra-uterine insemination for unexplained subfertility. 1998;317(7157):502–505. Rowe PJ, Comhaire FH, Hargreave TB, Mellows HJ. American Urological Association Education and Research, Inc. Bensdorp AJ, Heineman MJ, Hofherr SE, 2005;162(8):729–733. Guzick DS, These guidelines include a 12-step program for LTC staff that comprises all phases of diabetes care from diabetes detection to institutional quality assessment. Standing orders for glucose monitoring and practitioner notification that are approved by the facility and the practitioner at the time of admission may be useful. Don't miss a single issue. et al. This allows for the diagnosis and treatment of conditions such as endometriosis with one procedure. Effect of metformin on ovulation and reproductive outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Czernichow S; The 2012 ADA consensus report states that goals that minimize severe hyperglycemia are indicated for all patients (9). Wilcox AJ, Myers ER, Thonneau P, Faure C, Harada T, Clyma JA, Bonde JP, WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Norman RJ, Additionally, caregivers may not recognize that symptoms such as confusion, delirium, and dizziness may be related to hypoglycemia. The FAST study: fertility assessment and advice targeting lifestyle choices and behaviours: a pilot study. The initial dosage of clomiphene is 50 mg daily for five days starting on day 3 to 5 of the menstrual cycle. National Collaborating Centre for Women's and Children's Health. doi: 10.1002/14651858.CD009603.pub2. Reduced fecundability in women with prenatal exposure to cigarette smoking. Bonde JP, Killick SR. dustynacho1. : American Urological Association, Inc.; 2010. Address correspondence to Tammy J. Lindsay, MD, FAAFP, Saint Louis University Family Medicine Residency, 180 S. 3rd St., Ste. et al. Norman RJ. A review of the literature, Evaluation of a leadership development academy for RNs in long-term care, Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association, Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association, Diabetes and Hypertension: A Position Statement by the American Diabetes Association, Institutional Subscriptions and Site Licenses, Special Podcast Series: Therapeutic Inertia, Special Podcast Series: Influenza Podcasts, http://www.idf.org/sites/default/files/IDF-Guideline-for-older-people-T2D.pdf, http://www.guideline.gov/content.aspx?id=45527, Diabetes Management During Transitions of Care, Diabetes Management in Patients at End of Life (Including Issues for Palliative Care and Hospice Patients), Integration of Diabetes Management Into LTC Facilities. Am J Epidemiol. Cooper TG, Coutifaris C, 2006;12(6):685–718. 2010;(4):CD008189. They are low-grade, slow growing, and tend to have the best prognosis. Cochrane Database Syst Rev. Meerpoel DE, For older adults with diabetes, especially those with complex comorbidities, limited health literacy, cognitive impairment, five or more prescribed medications, or end-of-life care, the risk for adverse outcomes during these care transitions is even greater (30,31).