Counselling the infertile couple - a primer for the gynecologist


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Basic counselling skills a gynecologist needs to master when seeing infertile couples

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Counselling the infertile couple - a primer for the gynecologist

  1. 1. Dr Aniruddha Malpani, MD
  2. 2. Common questions Which is the best time to have sex ? Which is the best position ?  Doctor, all the semen leaks out after we have sex !
  3. 3. Medical gobbledygook
  4. 4. Who has the time ?
  5. 5. Encourage questions ! There is no such thing as a stupid question Answering questions improves trust Enhances the doctor-patient relationship Create loyalty
  6. 6. How can I determine my "fertile" period ? Your fertile period is the time during which having sex could lead to a pregnancy. This is the 4 day period prior to ovulation ( release of a mature egg from the ovary). Women normally ovulate 14 days prior to the date of the next menstrual period.
  7. 7. Scheduling sex The “fertile time” is 4 days before ovulation After ovulation, the cervical mucus dries up and the woman becomes infertile Ovulation occurs 14 days before the next period is due ( NMP – 14). Fertile time is NMP – 18, and the next 4 days 
  8. 8.
  9. 9. Scheduling sex Women can estimate their fertile time by tracking their cervical mucus. The “wet days” are the fertile days Over- rigorous scheduling of sex is counterproductive, because it takes the “fun” out of sex. Encourage patients to have sex as often as they like , without scheduling it. No BBTs !
  10. 10. Unconsummated marriages Erectile dysfunction is very common Takes time for patients to open up Patients will not talk about this on their own Please bring it up proactively
  11. 11. Painful sex = Fenton’s Vaginismus These patients need lots of TLC !
  12. 12. My friends say I should have sex exactly on the day I ovulate to get pregnant. How can I do this ? Although having sexual intercourse near the time of ovulation is important, no single day is critical. So, don't be concerned if intercourse is not possible or practical on the day of ovulation
  13. 13. My husband says we should be having intercourse every day to achieve pregnancy. Is this true ? Sperm remain alive and active in woman's cervical mucus for 48-72 hours following sexual intercourse; therefore, it isn't necessary to plan your lovemaking on a rigid schedule.
  14. 14. My sister in law is advising me to keep a pillow under my hips during and after intercourse Sperm are already swimming in cervical mucus as sexual intercourse is completed and will continue to travel up the cervix to the fallopian tube for the next 48 to 72 hours. The position of the hips really doesn't matter.
  15. 15. My gynecologist has said I am normal. Do I still need to get tests done? A routine gynecological examination does not provide information about possible problems which can cause infertility, such as blocked fallopian tubes or ovulatory disorders. Do a systematic infertility workup.
  16. 16. My PCR is positive which means I need anti TB treatment Endometrial PCR for TB is very unreliable Too many false positives
  17. 17. My husband refuses to get his semen tested. He says it is thick and voluminous which means it must be normal. Semen consists mainly of seminal fluid, secreted by the seminal vesicles and the prostate. The volume and consistency of the semen is not related to its fertility potential Sperm count can only be assessed by microscopic examination.
  18. 18. My periods come only once every 6 weeks. Could this be a reason for my infertility ? As long as the periods are regular, this means ovulation is occurring. Some normal women have menstrual cycle lengths of as long as 40 days. Of course, since they have fewer cycles every year, the number of times they are "fertile" in a year is decreased. Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30 day cycle).
  19. 19. My grandmother says that if I just pray and have faith, I will conceive. Believing in god can help you to maintain a positive outlook - but sheer will and blind faith won't overcome a physical problem like blocked tubes or absent sperms.
  20. 20. My husband's blood group is B positive and I am A negative. There is no relation between blood groups and fertility.
  21. 21. Could a psychological barrier be the reason for our infertility ? Unlike many other parts of your lives, infertility may be beyond your control. Don't blame yourself if you are not getting pregnant - it's a medical problem which often needs appropriate medical treatment. Society’s unkind attitudes are often born out of ignorance - and are a kind of "victim- blaming" - ignore them !
  22. 22. My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving ? If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary, and you need a complete evaluation.
  23. 23. My HSG shows my tubes are blocked. I've never had symptoms of PID, so how could my tubes get blocked Many pelvic infections have no symptoms at all, but can cause damage, sometimes irreversibly, to the tubes.
  24. 24. My doctor has advised me to take fertility drugs . I am scared that if I do, then I'll have a multiple births Although fertility drugs do increase the chance of having a multiple pregnancy (because they stimulate the ovaries to produce several eggs), the majority of women taking them have singleton births.
  25. 25. My husband's sperm count varies every time we test it ! How do we determine what the "real" sperm count is ? Even a normal ( fertile ) man's sperm count can vary considerably from week to week. Sperm count and motility can be affected by many factors, including time between ejaculations, illness, and medications.
  26. 26. All my tests are normal and my doctor says my infertility is "unexplained" ! The very fact that I cannot conceive means there must be something wrong ! Is he incompetent ? Yes, you are right. Unexplained infertility is simply a confession of our ignorance, and means that our technology is not good enough to be able to identify the problem.
  27. 27. I have no sperm . Is this because I used to masturbate excessively as a boy ? Masturbation is a normal activity which most boys and men indulge in. It does not affect the sperm count. You cannot "run" out of sperms, because these are constantly being produced in the testes.
  28. 28. My wife is frigid and does not enjoy having sex. Could this be the reason for her infertility? There is no connection between sexual pleasure and fertility. Don't forget that even a woman who gets raped can get pregnant! Maybe you should improve your sexual technique, and spend more time in foreplay and in pleasuring your wife.
  29. 29. My mother feels I am too tense, and that if I just relax, I'll get pregnant If pregnancy has not occurred after a year, chances are there is a medical condition causing infertility. There is no evidence that stress causes infertility. Remember, all infertile patients are under stress - it's not the stress which causes infertility, it's the infertility which causes the stress!
  30. 30. Patients cannot afford IVF IVF is expensive, but babies are priceless ! In fact, IVF is a much more cost- effective use of medical resources than bypass surgery Time is invaluable – and IVF saves time
  31. 31. Not all IVF centers are equally good Give your patients the best chance of success. They trust you – refer them to the best IVF clinic Every IVF success is a feather in your own cap . Work in partnership with IVF clinics, so you can create a fruitful collaboration where everyone wins Insist that the IVF clinic provide documentation and embryo photos !
  32. 32. Who has the time to sit and talk to patients ? Create your own website and refer patients to your website ! Your patients trust you Local language Youtube videos
  33. 33. Free App for Infertile Couples
  34. 34. Internet Positive Patients need Information Therapy !
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