Structured teaching programme on the knowledge regarding infertility among infertile couple




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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

KARNATAKA, BANGALORE

Annexure-II


PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION




1.


NAME OF THE

CANDIDATE AND ADDRESS




ADITI AGARWAL

Ist YEAR M.SC NURSING,

DHANWANTARI NURSING COLLEGE ,

NO 41/3,VINAYAKA NAGAR , CHIKKABANAVAR,

BANGALORE-560090




2.


NAME OF THE INSTITUTION




DHANWANTARI NURSING COLLEGE ,

NO 41/3,VINAYAKA NAGAR , CHIKKABANAVAR,

BANGALORE-560090



3.


^ COURSE OF STUDY AND

SUBJECT



MASTER IN NURSING,

OBSTETRICS AND GYNECOLOGICAL NURSING

4.

DATE OF ADMISSION

30/11/2009


5.


^ TITLE OF THE TOPIC




STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE REGARDING INFERTILITY AMONG INFERTILE COUPLE




5.1


STATEMENT OF THE PROBLEM


^ A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON THE KNOWLEDGE REGARDING INFERTILITY AMONG INFERTILE COUPLE IN SELECTED HOSPITAL AT BANGALORE.




6. BRIEF RESUME OF THE INTENDED STUDY:


6.1. INTRODUCTION:


Infertility and sterility are terms used to describe the inability of a couple to produce a child. In addition, many beliefs, superstitions, and rituals have focused on the female responsibility to reproduce and until recently there has been little recognition that the male factors contribute to about a third of the causes of infertility. Medical science has developed many new ways to diagnose and treat infertility. However, some of the procedures are highly sophisticated and not readily available to those who need them. It is also known that there is a psychological component to infertility which produces stress in the individual and in the couple. Wise counseling by physicians, nurses and midwives should help to release this tension and in some cases where there are no medical or mechanical barriers, conception may occur1.

Infertility is a major life crisis 2. Infertility can cause depression, anxiety, social isolation and sexual dysfunction ^ 3, 4. Due to this frustrating experience many infertile couples would seek medical help and finally will receive assisted reproductive treatment 5. According to patients' conditions most patients receive in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Most couples that plan to have treatment experience extensive and emotionally challenging methods of diagnosis and treatment 6.


Incidence of Infertility:


The World Health Organization (WHO) reveals that between 2–10% of couples worldwide are unable to conceive primarily, about 60–80 million couples in the world are infertile, and it is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years7. Further 10–25% couples experience secondary infertility 8. About 15% couples of childbearing age seek medical help for infertility, usually after about two years of failing to conceive. Among these couples, causative factors are found in about 30-40% of females and in 10–30% of males. In 15-30% of cases, both partners have detectable abnormalities. In France, 18% of couples of childbearing age said that they had difficulties in conceiving.


Today, 1 out of every 6 young couples suffers from an infertility related problem. The etiology of infertility is related to a female factor in 40% of the cases and to a male factor in another 40%. In 10-20% of the cases, both male and female factors are involved. Unexplained infertility is observed in up to 10% of the cases 9-11.


In a study conducted in 1997 on 1,992 20 to 30 year old women living in Tehran, 78.1% had successful conception in the first year of their marriage and the gross infertility rate was 21.9 %. In another study in 1996, in the city of Isfahan, the primary infertility rate was 15.1% 12. World Health Organization (WHO) has described infertility as one of the important health problems worldwide 13.


Causes, Sign & Symptoms, Risk Factors, Tests and Diagnosis and Treatment Options of Infertility 14:


Causes of Infertility:


A. Causes of Male Infertility: Impaired production or function of sperm, impaired delivery of sperm, General health and lifestyle, Environmental exposure, etc.


B. Causes of female infertility:

Fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin (hyperprolactinemia), polycystic ovary syndrome (PCOS), early menopause (premature ovarian failure), benign uterine fibroids and pelvic adhesions. Other cause in women is medications, thyroid problems, cancer and its treatment, other medical conditions, caffeine intake.


^ Sign & Symptoms of Infertility:

The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms. In some cases, an infertile woman may have abnormal menstrual periods, an older than 30 or haven't menstruated in six months, pelvic pain, endometriosis, pelvic inflammatory disease (PID) or repeated miscarriages. An infertile man may have some signs of hormonal problems, such as changes in hair growth or sexual function, low sperm count or a history of testicular, prostate or sexual problems.


^ Risk Factors of Infertility:

Many of the risk factors for both male and female infertility are the same. They include: Age, tobacco smoking, alcohol use, being overweight, being underweight, too much exercise, caffeine intake.


Tests and Diagnosis of Infertility:


A. Tests for men: General physical examination, Semen analysis, Hormone testing, Transrectal and scrotal ultrasound.

B. Tests for women: Ovulation testing, Hysterosalpingography, Laparoscopy, Hormone testing, Ovarian reserve testing, Genetic testing, Pelvic ultrasound.


Treatment Options for Infertility: Several options are offered to couples depending on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as clomiphene citrate, cabergoline, metformin or gonadotropins. Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Treatment options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies (ART), such as intracytoplasmic sperm injection (ICSI). Assisted reproductive technologies refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years.


^ 6.2. NEED FOR THE STUDY:


Expecting a child is the most joyous moment of every woman. Pregnancy comes with a lot of responsibility that are associated with the individual and child.

Infertility may have many emotional and psychological implications, Depression, hopelessness, fatigue, feelings of loneliness, isolation and anxiety lie among the adverse effects of infertility in young couples 15 which necessitate provision of counseling and psycho-social support in this field. Indicating emotional problems among infertile women and giving them psychological care is as important as the medical treatment needed for them. The support of the spouse is an emotional factor influencing life satisfaction in infertile women. On the other hand, while men are not exempt from the psychological impacts of infertility, they are usually neglected from support services provided by many infertility clinics. Therefore, the provision of psycho-social services to infertile couples; not only women, but also the rest of the family and especially the spouses, should be considered 16, 17. So far, different methods such as provision of training regarding infertility treatment strategies, cognitive behavioral therapy and pharmacotherapy have been evaluated. A significant number of couples complain that they are not told about the treatment path and a lot of their questions remain unanswered. This information gap might lead to anxiety. The goal of this study is to evaluate the impact of provision of training regarding infertility treatment strategies on the anxiety level of infertile couples.

Women with polycystic ovarian syndrome (PCOS) often are infertile because they don't ovulate. 40% to 80% of women with PCOS have a problem with fertility. The reason for this wide variation is that polycystic ovary syndrome is a complex metabolic syndrome, with multiple factors that can interfere with fertility 18, 19.

Fertility is a transient biological state that depends on the fertility potential of the couple. During a women’s lifetime, the ovary will go through different states of hormonal secretion and ovulation. The concept of the ovarian cycle as a continuum considers that all types of ovarian activity encountered during the reproductive life are normal responses to different environmental conditions in order to ensure the health of the mother and child. During the first two years after menarche, occasional anovulatory cycles may occur. However, subsequently, a healthy ovary will exhibit regular monthly ovulations, characterized by a 25 to 36 day cycle (32, 33, and 35). The ovulatory cycles are normally only interrupted by pregnancies and breastfeeding. Normal ovulatory activity and fertility are restored following pregnancy and breast feeding, however, stress or excessive exercise may result in a chronic ovulatory dysfunction that requires therapy. Anovulatory cycles frequently occur as menopause approaches. This is an expected part of woman’s reproductive life cycle 20.


^ 6.3. STATEMENT OF THE PROBLEM:

“A study to assess the effectiveness of structured teaching programme on the knowledge regarding infertility among infertile couple in selected hospital at Bangalore.”


6.4. OBJECTIVES:

  1. To assess the pre-test and post-test knowledge of experimental group.

  2. To assess the pre-test and post-test knowledge of control group.

  3. To compare the pre-test and post-test knowledge of experimental group.

  4. To compare the pre-test and post-test knowledge of control group.

  5. To correlate the pre-test and post-test knowledge score between experimental and control group.

  6. To associate the demographic variable with level of knowledge in experimental and control group.

6.5. HYPOTHESES:

H1: There will be a significant difference in the knowledge level in experimental group than

control group.

H2: Significance association of demographic variables with knowledge level regarding

infertility.


6.6. ASSUMPTION:


1. Reinforcement concepts of infertility enrich learning and leads to modification of one’s behaviors.

2. Participatory care will improve self-esteem towards the promotion of health.


^ 6.7. OPERATIONAL DEFINITION:


A. Assess: It refers to evaluation or estimation of knowledge level.


B. Effectiveness: In this study it refers to the extent to which the structured teaching programme has achieved the desired effect as measured by gain in knowledge level of infertile couple through questionnaire


^ C. Knowledge: The ability of infertile couple to respond towards the questionnaire on the selected aspect of infertility.


D. Structured Teaching Programme: It is a systematically prepared teaching programme which will be taken for 45 minutes to educate the infertile couple regarding infertility.


^ E. Infertility: The inability of a couple to produce a child.

a. Primary-no pregnancy has occurred.

b.Secondary-pregnancy has occurred at one time, but-currently no pregnancy or repeated spontaneous abortion.


F. Infertile couple: Any given couple who is infertile may be related to the female partner, the male partner or the combination of both.


^ 6.8. CRITERIA FOR SAMPLE SELECTION:


Inclusion criteria: All the infertile couple who:

a. Attend the infertility clinics.

b. Are willing to participate in the study

c. Can understand Hindi/English/Kannada


Exclusion Criteria: All the infertile couple who;

  1. Are associated with other obstetric complications.

  2. Have other chronic illness

  3. Cannot understand Hindi/English/Kannada.


6.9. DELIMITATION:

a. infertile couple who are unmarried/illiterate

b. sample size limited to 32 infertile couple

c. prescribed data collection is 4-6 weeks


^ 6.10. SIGNIFICANCE OF THE STUDY:

The purpose of the study is to improve the knowledge of infertility among infertile couple who are attending selected infertility clinics at Bangalore.


6.11. CONCEPTUAL FRAMEWORK:

This study is based on ‘GENERAL SYSTEM THEORY’


^ 6.12. REVIEW OF LITERATURE: Review of literature is key in research process. It is an Exclusive, Exhaustive and systematic examination of earlier/contemporary. This chapter attempts to present on overview of the literature reviewed under following heading:


A. Studies related to prevalence/incidence of infertility

B. Studies related to causes of male and female infertility

C. Studies related to risk factor of infertility

D. Studies related to effect of treatment in infertility

E. Studies related to use of flavor enhancer on fertility

F. Studies related to sexual history of the couple


^ A. Studies related to prevalence/incidence of infertility:


In a follow-up study of 1297 couples registered at a Nova Scotia infertility clinic with a complaint of infertility of at least 12 months' duration, the cumulative pregnancy rate at 36 months, with 95% confidence limits, was found to be 49. 4%. The predictors of pregnancy by univariate analysis were a favourable primary clinical diagnosis (p < 0.001), a duration of infertility of less than 3 years (p < 0.001), a single diagnosis for the infertility (p < 0.001), a previous pregnancy in the partnership (p = 0.001) and a length of marriage of less than 4 years (p = 0.002). Proportional hazards analysis confirmed these variables as predictors of pregnancy. The highest cumulative pregnancy rates after 12 and 36 months of follow-up were observed in cases of ovulation deficiency, and the lowest were seen in cases of tubal defects. However, before the process of diagnosing infertility begins, useful prognostic information can be determined from the length of marriage, the duration of infertility and the partnership's history of previous pregnancy 21.


The prevalence of infertile couples differs according to the definition of couple infertility. If we accept the most commonly used definition, i.e. the lack of pregnancy after 1 yr of unprotected regular intercourse, infertile couples represent about 10–15% of all couples. According to the definition of the European Society for Human Reproduction and Embryology, i.e. the lack of pregnancy within 2 yr by regular coital exposure, the prevalence of infertile couples in Europe and North America is approximately 5–6% 22.


^ B. Studies related to causes of male and female infertility:


One-half of 1% of men was functionally sterile in 1938. Today it has reached between 8-12% (an over 15-fold increase). "Functionally sterile" is defined as sperm counts below 20 million per milliliter of semen 23


A high number of abnormal sperm heads is associated with decreased fertilization. Some drugs such as sulphasalazine, used to treat inflammatory bowel disease can drastically reduce semen quality 24


Ovulatory dysfunction can be suggested by late menarch, presence of premenstrual syndrome, abnormal cycle length, amount of menstrual loss, premenstrual spotting, hot flushes (hypoestrogenism), and excessive physical exercise and/or weight changes (due to eating disorders) greater than 10% in the past year. Systemic diseases such as diabetes mellitus and thyroid dysfunction that are not adequately treated may also have adverse effects on fertility. Medical treatments may cause temporary (sex steroids) or permanent (cytotoxic agents, abdominal irradiation) damage to the ovulatory function 25.


^ C. Studies related to risk factor of infertility:


8.4% of women 15-44 years had impaired ability to have children and about half of these couples eventually conceive. These are overall average infertility figures pertaining only to women-statistics will vary greatly depending on the age of the woman. Couple infertility rates are nearly double this percentage since it then takes into account male infertility 26.


38% of female non-smokers conceived in their 1st cycle of attempting pregnancy compared to 28% of smokers. Smokers were also 3-4 times more likely than non-smokers to have taken greater than a year to conceive 27


A study of 1,909 women in Connecticut found the risk of not conceiving for 12 months (the usual definition of infertility), was 55% higher for women drinking 1 cup of coffee per day - 100% higher for women drinking 1 and one-half to 3 cups and 176% higher for women drinking more than 3 cups of coffee per day 28.


Risk of infertility increased in females who reported exposures to textile dyes, dry cleaning chemicals, noise, lead, mercury and cadmium. There was a significant risk of increased time to conception among women exposed to anti-rust agents, welding, plastic manufacturing, lead, mercury, cadmium, or anesthetic agents 29


^ D. Studies related to effect of treatment in infertility:


Expensive fertility treatments resulted in only a 6 percentage point improvement in achieving pregnancy over "infertile" couples who just "kept trying. In a study of 1,145 couples who had been diagnosed as infertile, only half of them were treated to help attain pregnancy. After a two to seven-year follow-up, pregnancies occurred in 41% of the treated couples and 35% of the untreated couples 30.


Infertility by itself does not threaten physical health but has a strong impact on the psychological and social well-being of couples. In the last two decades, progress in caring for the infertile couple, in particular progress in the field of assisted reproduction and micromanipulation, has provided significant hope for many couples for whom hope could not have been offered in the past. This is especially true for bilateral tubal disease and for male factor infertility, as nearly all couples with male factor infertility can now undergo either one (or more) IVF or ICSI attempt(s). For couples with other causes of infertility, however, the differences in pregnancy rates often do not reach statistical significance 31.


A study was conducted in 32 couples in the age group of 21-43 years, who had primary infertility ranging from 1-12 years. The female partner was given Evecare syrup at a dose of 2 teaspoonfuls for 6 months. The male partner was given Speman tablet at a dose of 2 tablets, twice daily for the same period. The females were advised urine test to detect human chorionic gonadotropin (HCG), if they had a missed period for duration of more than 15 days. After 3 months of treatment, 6 females tested positive, 4 tested positive after 4 months and 4 tested positive after 6 months of treatment. The pregnancies were later confirmed with pelvic ultrasonography, which showed live fetus without any abnormalities. Among the males, there was a marked improvement in the sperm count especially in those males who had abnormal or low sperm count. A complete analysis was done at the end of 6 months and the final report showed that the fertility rate after Evecare and Speman therapy was 43.75%. This combined therapy could bring out a good outcome in infertile couples if they used Evecare and Speman for at least 6 months 32.


^ E. Studies related to use of flavor enhancer on fertility:


MSG (Monosodium Glutamate), a common flavor enhancer added in foods, was found to cause infertility problems in test animals. Male rats fed MSG before mating had less than a 50% success rate (5 of 13 animals), whereas male rats not fed MSG had over a 92% success rate (12 of 13 animals). Also the offspring of the MSG treated males showed shorter body length, reduced testes weights and evidence of overweight at 25 days. MSG is found in accent, flavored potato chips, Doritos, Cheetos, meat seasonings and many packaged soups 33


^ F. Studies related to sexual history of the couple:




The sexual history of the couple is very important. The frequency and timing of intercourse and the use of lubricants should be assessed. It happens frequently that an infertile couple abstains from intercourse and has only ‘timed’ exposures in the middle of the cycle, but there is no evidence that prolonged abstinence increases the chances of pregnancy: abstinence (7–8 days) should be reasonably recommended only if oligozoospermia is present. Use of lubricants should be discouraged because of their detrimental effect on semen quality 34.


^ 7. MATERIAL AND METHODS OF STUDY:


7.1. Sources of Data: From the infertile couples. The couples who had not conceived for more than one year after stopping contraception, and females, who had failed assisted conception were included in this study. Infertile couples, who were married for 1-12 years participated in the study. The minimum age of the male partner was 26 years and maximum was 50 years. The female partners ranged between 21–40 years. In addition, demographic and clinical characteristics of patients including age, gender, education, duration of infertility, previous treatment for infertility and infertility causes were also collected. The information provided included etiology of infertility, treatment methods, individualized treatment plans for couples, initial assessment before treatment, the number of times they had to visit the specialist, financial expenditure and success rates in the method suggested.


^ 7.2. Research Design:

A Quasi-experimental design which includes Manipulation, control and no randomization.

Two group pretest-posttest design

Group

Pre-assessment

Intervention

Post-assessment

Experimental

01

X

02

Control

01

--

02


Key:

01-Pre assessment of knowledge level regarding infertility

02- Post assessment of knowledge level regarding infertility

X-Structured teaching programme regarding infertility.


^ 7.3. Method of Data Collection: Data will be collected by direct interview after obtaining consent from subjects and authority. The background information will be collected through demographic schedule prepared by the investigator and level of knowledge will be assessed by semi structured questionnaire for demographic variables regarding infertility.


^ 7.4. Sampling Procedure:


Population: All the infertile couple who were attending hospital

Samples: Infertile couples who fulfill the inclusive and exclusive criteria are the samples.

Sample size: According to the avaibility of infertile couple at that time. The couples receiving the training (experimental group) and the couples of the control group were selected randomly and equally divided into two groups as experimental group and control group.

^ Sampling technique: Non-probability convenient sampling

Setting: In selected hospital at Bangalore.

Pilot study: Pilot study is planned with 10% of population.


8. VARIABLE:

a. Independent variable: Structured teaching programme.

b. Dependent variable: Knowledge level regarding infertility.


^ 9. PLAN FOR DATA ANALYSIS:

The plan for data analysis includes descriptive and inferential statistics.


Descriptive statistics: To describe the knowledge and demographic variables, number, frequency, percentage, mean standard deviation.


Inferential statistics: To compare the knowledge between the groups independent ‘t’ test within the group paired ‘t’ test and to associated the demographic variable with knowledge Chi square or ANOVA.


^ 10. Ethical consideration:


Does study require any investigation or intervention to be conducted on?

Yes. Informed consent will be taken from the respondents.


Has ethical clearance been obtained from Hospital authorities in case study requires investigation?

Yes. Permission obtained from the medical officers of selected hospitals at Bangalore and copy of the same letter will be sent to Nursing Superindent and ward incharge sister.


^ 11. LIST OF REFERENCES (Vancouver Style):



  1. Elizabeth M. E., Associate Professor, University of North Carolina at Chapel Hill, N.C., U.S.A.




  1. Leiblum S.R., Greenfield D.A., Infertility: psychological issues and counseling strategies, New York, 1997:83-102.




  1. Fassino S., Piero A., Boggio S, Piccioni V, Garzaro L: Anxiety, depression and anger suppression in infertile couples, Hum Reprod, 2002, 17:2986-2994.




  1. Chen TH, Chang SP, Tsai C.F., Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic, Hum Reprod 2004, 19:2313-2318.




  1. Van B.F., Verdurmen J, Ketting E., Choices and motivations of infertile couples, Patient Educ Counsl 1997, 31:19-27.




  1. Greil A.L., Infertility and psychological distress: a critical review of the literature. Soc Sci Med 1997, 45:1679-1704




  1. Winston R., The complete guide to fertility & infertility, revised edition, Pan Books, London, 1993.




  1. WHO technical report series 820, Recent advances in medically assisted conception, World Health Organization, Geneva, 1992.




  1. Cooper S.L, Glazer E.S., Beyond Infertility, The new paths to parenthood. 2nd ed., New York, Lexington Books, 1994: 78-79.




  1. Marrs R., Fertility Book, 3rd Ed. New York: Delacorte press, 1994: 115.




  1. Sadok B.J., Sadok VA. Kaplan & Sadok, Synopsis of Psychiatry and Behavioral Sciences/Clinical Psychiatry, 10th ed., 2007: 857-869.




  1. Allameh Z, Ghanei M, Adibi P, Salami F, Prevalence of primary infertility. Thesis for Medical Doctrate Degree, Isfahan University of Medical Sciences, 1995.




  1. Barouti E, Ramezani F, Heidari M, Khaljabadi F., Primary infertility based on the age at the first- time marriage in Tehran. Hakim J Research. 1999, 2(2): 88-93.




  1. www. Mayo Clinic.com




  1. Sadok BJ, Sadok VA. Kaplan & Sadok Synopsis of Psychiatry and Behavioral Sciences/Clinical Psychiatry. 10th ed., 2007; 857-869.




  1. Boivin J, Andersson L, Psychological reactions during in vitro fertilization: similar response pattern in husbands and wives. J Human Reprod.1998, 13: 3262-3267.




  1. Seif D., Alborzi S, Alborzi S. The effect of emotional and demographic factors on life- satisfaction of infertile women. Infertility and Reproductive J. 2001, 66: 71-74.




  1. Infertility: Frequently asked questions. National Women's Health Information Center. http://www.womenshealth.gov/FAQ/infertility.cfm. Accessed April 30, 2009.




  1. Brassard M., et al., Basic infertility including polycystic ovary syndrome. Medical Clinics of North America. 2008, 92:1163.




  1. Pilar V. P., Fertility Disorders and the Billings Ovulation Method, 2005: 1-8.




  1. John A.C., Ying S., Wilson E.H., Can Med Assoc. J., Vol. 130, February 1, 1984: 269.




  1. Crosignani P.G., Rubin B., Guidelines to the prevalence, diagnosis, treatment and management of infertility, Hum Reprod. 1996, 11:1775–1807.




  1. Jacobson C., Reproductive Genetics Center Vienna, Virginia.




  1. Skakkebaek N. E., Lancet, June 11, 1994: 1474




  1. World Health Organization, Manual for the standardized investigation and diagnosis of the infertile couple, Cambridge University Press, UK, 1993.




  1. Howard Jones, New England Journal of Medicine December 2, 1993: 1710.




  1. Baird D., Journal of American Medical Association, 1985, 253:2979-83.




  1. Rivard C. I., Journal of the American Medical Association, December 22, 1993.




  1. Boguslaw, Environmental Health Perspectives 1993, 101(suppl 2): 85.




  1. Collins J. A., New England Journal of Medicine November 17, 1983.


  1. Shushan A., Eisenberg V.H., Schenker JG. Subfertility in the era of assisted reproduction: changes and consequences, Fertil Steril, 1995, 64:459–469.





  1. Nalini B., Shenoy S.K., The Role of Herbal Drugs in Infertile Couples, Obs. & Gynae., Today, 2003, 8 (5): 281-287.




  1. William J. P., Barnhart J.E., et. al., Neurobehavioral Toxicology, 1979, 2:1-4.




  1. Cooper T.G., Keck C, Oberdieck U, Nieschlag E. Effects of multiple ejaculations after extended periods of sexual abstinence on total, motile and normal sperm numbers, as well as accessory gland secretions, from healthy normal and oligozoospermic men. Hum Reprod, 1993, 8:1251–1258.





12.


Signature of the Candidate





13.


Remarks of the Guide






14.


Name and Designation of Guide






15.1


Signature





15.2


Head of the Department






15.3


Signature





15.4


Remarks of the Principal





15.5


Signature




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