Disclosure

Nothing to disclose

Counselling in IVF -ART

Poonam Loomba,M.D.

No words can express joys of motherhood

IntroductionNo words can express the grief of an

infertile couple. Apart from being labelled as a social stigma

Infertility should be considered a complex disorder accompanied by mental and emotional stress

Couples seeking fertility treatments

IVF-ART • Labyrinth of corridors

We are their mentors

Infertility counselling

Is gaining recognition all over the world as we have identified the need for expert care and treatment of a unique population

• ThesMany groups have joined together to form organizations reflecting the global perspective of this profession.

Mental health professional group of ASRM IInternational Infertility Counselling Organization Australian and Newzealand infertility Counsellors

Association HEFA British Infertility Counselling Association Germany and Switzerland have patient centered care

which proposes that doctors/nurses can integrate medical and emotional care

Objectives1. Provide a base of knowledge upon which to

ensure optimum care and evidence based therapies.

2. Share genetic health and legal responsibilities.3. Improve couples ’quality of life during and after

treatment4. Minimize long term distress.5. Encourage healthy adjustments of all

participants esp where complex arrangements are involved.

Tools for counselling

Trained staff Updated clinician with evidence based

medicine and recent advances in ART. Module for counselling as per your clinic

protocols and facilities.

1.Psychologist2Psychiatrist3Psychiatric nurses4Family therapist5 Reproductive medicine

professionals6 Genetic specialists

7 Perinatologist8 .Medical team9. Researchers10 .Educators11 Legal and Ethics

advisors12 Support groups

Multidisciplinary approach

ICMR recommends a PG in Social sciences, Medicine ,Psychology /any staff of clinic as a councellor provided he/she is fully aware of infertility related disorders and dilemmas.

Psychology P

Different models of psychological counselling

Deveraux and Hammerman Model:

1.Promote acceptance2.Acknowledge the losses 3.Facilitate grief4.Promote responsibility5.Plan therapeutic sessions

Cooper-Hilbert model:

1.Normalize couple’s infertility experience2 Redifine relationships 3 Assist in goal setting,decision making.4 Stress management5 Separating infertility from self esteem

Medical1. Defining Infertility2. Technology based management options3. Acceptability of tests4. PCOS5. Metabolic disorders6. HIV affected,Hbsag HCV positive7. Cancer patients8. Endometriosis,fibroids9. Male factors

Infertility is defined as inability to conceive during one year of sexual coitus without contraceptives.

Because 25% conceive within 1 month 60% within 6 months 80% within 12 months

Chances of success

• Human fertilisation and Embryology Authority:

• 32.2% for women aged under 35• 27.7% for women aged between 35–37 • 20.8% for women aged between 38–39• 13.6% for women aged between 40–42• 5.0% for women aged between 43–44• 1.9% for women aged 45 and over 

Stages of counselling

1 Pretreatment:2 During Treatment3 Post treatment : Success Failure

DO NOT MAKE

Pre treatment1.Outline an individualized plan for

evaluation, treatment with rationale behind it and provide a decision tree and timeline for the patient.

2.Adapt your plans as per the cultural backgrounds

3 Document everything to be reviewed later4 Share education material/support groups

Information to be shared 1 Basis,limitations and outcomes of treatment

supported with recent data.2 Risks/side effects of drugs/procedure3 Disruption in sexual/domestic life style4 Options of cancellation,change in plan5 Cost with break up.No hidden cost.6 Results conveyed .7 Need to make them aware that child after

attaining 18 yrs has the right to know about identity

Informed consent• All information shared with the patient and

family need to be documented in local language and signed by the couple plus one witness from their family.

• In case the couple is illiterate ask for a family member who can read and write to sign the documentation.

• Discussion should be as per the laws of land.

Evidence based approach

While charting out treatment plans try to include evidence based studies to ensure a quality care .

Share data as per the expectations and mental acceptance of your patients

We must know where to draw a line while dispensing knowledge with our patients

Treatment choices• IUI : Sexual

disorders,Cervical factors,Unexplained,Oligozoospermia.

IVF: Tubal factors,Idiopathic chronic infertlity,Endometriosis,

PCOS,Subnormal male factors.

ICSI: Severe male factors,Fertlization failures after IVF ,

TESA/PESA/MESA: Obstructive/Nonobstructive Azoospermia,

CBAVD, Anejaculation Retrograde ejaculation

ICSI with IVM : PCOS OHSS

Donor eggs Gonadal dysgenesis POF Iatrogenic ovarian failureResistant ovarian syndromePoor responders to inductionCarriers of recessive

autosomal disordersMenopause

Donors should be 21-35 yrs age .

Embryo donation When oocyte donors” partener has Primary

germ cell failure or Inheritable disorder.

CryopreservationSemen freezing: Psychological stress on day

of collection Non availability at the time

of IVF Cycle

Frozen sample needs quarantine for 6 months and person need to be tested for HIV after 6 months of giving sample for freezing.

Embryo freezing

1.Supernumarary embryos 2 OHSS 3 Endometrium issues Counsel regarding the need

to freeze, further process future usage of embryos cost .

Document and get a consent signed.

Oocyte freezing Newer technique Preserve fertility Delayed marriage??

Ovarian tissue cryopreservation:

No pregnancies reported in cases with frozen thawed tissue transplant as of today

Multiple birhs. ...Premature delivery and low birth weight. ...Ovarian hyperstimulation syndrome. ...Miscarriage. ...Egg-retrieval procedure complications. ...Ectopic pregnancy. ...Birth defects. ...Ovarian cancer.Stress

Twins 1:80 in natural births 1:6 after IVF16% of pregnancies after ivf are Multiples compared to 1-2%After natural conception

Spontaneous abortions• Risk is neither higher

nor lower due to ivf as compared to natural conception .

• Aggravating factors are:

Increased age of woman Multiplicity Once heart beat is seen

risk becomes half

Ectopic

(increases with number of retreived oocytes in ivf with non tubal infertility but not in d/r cycles: FS vol104 oct2015)

During treatment

1. Counsel if there is any change in treatment plan,drugs,dosage.

2. Alert about OHSS3. Cancellations due to any reason4. Options of freezing eggs/embryos5. Number of embryos to be transferred6. Day 2 vs day 3 vs blast cyst transfer as

per your clinic protocols

Post treatment

1.Rest and diet2.Sexual relationship3 Drugs and their side effects 4 Psychotherapy 5 Spiritual counselling6 Expected reactions in case of success or

failures or pregnancy losses.

Ultimate skills of counselling

1. Be one in their grief and loss2. Hope against hope after single failed

cycle3. Support groups : share experience with

other patients 4. Alternate options such as surrogacy,egg

bank.sperm bank,embryo bank and adoption.

Counselling at grass root levels

• How should clinics with referral practice manage?

• Fundamentals of treatment options/implications need to be discussed at grass root levels so that there is no confusion created for patients.

Life in womb: Origin of health and disease

A R T: Health of gametes is the origin of adult health

Genetics• The time to prevent mendelian genetic diseases from

donated or own gametes has come.• Every single genetic disease affects 1/1000 or 1/100,000

with a gross prevalence within 0.4%-2.0% range.• 20% of pediatric mortality is due to genetic

disorders .70% ICU admissions are due to genetically determined diseases.

• It is merely a matter of statistics if your ART clinic has not yet received a query

• “ Mrs X child is sick and doctor wants to know donor’s family history and genetic tests conducted”

How genetics works• The goal of achieving parenthood involves having a

healthy newborn at least regarding preventable diseases.• Chromosomal structural ,numerical abnormalities• Monogenic dominant diseases• Monogenic recessive diseases• Single gene disorders• Unpredicted de novo mutations• Weak genetic traits

Classic to Carrier testing• Monogenic dominant disease: Pattern of

inheritance already known• Monogenic recessive diseases:Need to

analyze large number of genes:1,150 genes identified so far.

• Carrier testing focuses on screening diseases present in family

• Globalization has led to spread of genetic traits and altered carrier prevalence

Changing trends • Whole axome or genome sequencing• Next gen sequencing Most powerful tools to to be applied for

carrier testing removing limitations of cost and time

Current cost of 1000 usd is more but in future may come down to 1usd.

ACMG has provided some framework

Future

• We can forecast a widespread implementation of preconception genetic screening for family planners ,to be initiated in IVF Centres.

Miscellaneous1 Complex relationships e. g. single parents,

separated, divorced2 Homosexuals, transgenders, Sexual disorders3 Couples with disabilities4 Counselling of Donors and surrogates for their legal

rights,monetary arrangements and treatment information

5 Special needs e.g.translator ,visa issues 6 Foreign nationals

Benefits

1. Builds up a healthy relationship between provider and recepient.

2. Patients feel they are involved in decision making .

3. Better compliance of treatment.4. Lesser probability of medicolegal issues.