Art of councelling patients before IVF with evidence based approach

1. Disclosure
Nothing to disclose

2. Counselling in IVF -ART
Poonam Loomba,M.D.

4. No words can express joys of motherhood

5. Introduction
No 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

6. Couples seeking fertility
treatments

7. IVF-ART
• Labyrinth of corridors

8. We are their mentors

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

10. • 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

11. Objectives
1. 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
treatment
4. Minimize long term distress.
5. Encourage healthy adjustments of all
participants esp where complex arrangements
are involved.

12. 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.

13. 1.Psychologist
2Psychiatrist
3Psychiatric nurses
4Family therapist
5 Reproductive medicine
professionals
6 Genetic specialists
7 Perinatologist
8 .Medical team
9. Researchers
10 .Educators
11 Legal and Ethics
advisors
12 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.

16. Psychology P

19. Different models of psychological
counselling
Deveraux and Hammerman Model:
1.Promote acceptance
2.Acknowledge the losses
3.Facilitate grief
4.Promote responsibility
5.Plan therapeutic sessions

20. Cooper-Hilbert model:
1.Normalize couple’s infertility experience
2 Redifine relationships
3 Assist in goal setting,decision making.
4 Stress management
5 Separating infertility from self esteem

21. Medical
1. Defining Infertility
2. Technology based management options
3. Acceptability of tests
4. PCOS
5. Metabolic disorders
6. HIV affected,Hbsag HCV positive
7. Cancer patients
8. Endometriosis,fibroids
9. Male factors

22. 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

23. 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

24. Stages of counselling
1 Pretreatment:
2 During Treatment
3 Post treatment :
Success
Failure

25. DO NOT MAKE

26. Pre treatment
1.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 later
4 Share education material/support groups

31. Information to be shared
1 Basis,limitations and outcomes of
treatment supported with recent data.
2 Risks/side effects of drugs/procedure
3 Disruption in sexual/domestic life style
4 Options of cancellation,change in plan
5 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

33. 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.

34. 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

35. Treatment choices
• IUI : Sexual
disorders,Cervical
factors,Unexplained,Oligoz
oospermia.
IVF: Tubal
factors,Idiopathic chronic
infertlity,Endometriosis,
PCOS,Subnormal male
factors.
ICSI: Severe male
factors,Fertlization failures
after IVF ,

36. TESA/PESA/MESA:
Obstructive/Nonobstructive
Azoospermia,
CBAVD,
Anejaculation
Retrograde ejaculation
ICSI with IVM :
PCOS
OHSS

37. Donor eggs
Gonadal dysgenesis
POF
Iatrogenic ovarian failure
Resistant ovarian syndrome
Poor responders to induction
Carriers of recessive
autosomal disorders
Menopause
Donors should be 21-35 yrs
age .

38. Embryo donation
When oocyte donors” partener has Primary
germ cell failure or Inheritable disorder.

39. Cryopreservation
Semen 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.

40. 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.

41. Oocyte freezing
Newer technique
Preserve fertility
Delayed marriage??
Ovarian tissue
cryopreservation:
No pregnancies reported in
cases with frozen thawed
tissue transplant as of
today

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

45. Twins 1:80 in natural births
1:6 after IVF
16% of pregnancies after ivf are
Multiples compared to 1-2%
After natural conception

47. 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

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

49. During treatment
1. Counsel if there is any change in
treatment plan,drugs,dosage.
2. Alert about OHSS
3. Cancellations due to any reason
4. Options of freezing eggs/embryos
5. Number of embryos to be transferred
6. Day 2 vs day 3 vs blast cyst transfer as
per your clinic protocols

50. Post treatment
1.Rest and diet
2.Sexual relationship
3 Drugs and their side effects
4 Psychotherapy
5 Spiritual counselling
6 Expected reactions in case of success or
failures or pregnancy losses.

53. Ultimate skills of counselling
1. Be one in their grief and loss
2. Hope against hope after single failed
cycle
3. Support groups : share experience with
other patients
4. Alternate options such as surrogacy,egg
bank.sperm bank,embryo bank and
adoption.

54. 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.

55. Life in womb: Origin of health and disease

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

57. 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”

58. 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

60. 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

61. 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

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

63. Miscellaneous
1 Complex relationships e. g. single parents,
separated, divorced
2 Homosexuals, transgenders, Sexual
disorders
3 Couples with disabilities
4 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

65. 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.