Aboubakr Elnashar

1. COUNSELING OF IVF
PATIENTS
Prof. Aboubakr Elnashar
Benha university
Hospital, Egypt
ABOUBAKR ELNASHAR

2. IVF counselling
1. Who should undergo IVF counselling?
2. When IVF counselling is mandatory and when optional?
3. What are the role of IVF counseller?
4. What are the five results of IVF treatment?
5. What are causes of cycle cancellation?
6. What are causes of fertilization failure?
7. What are causes of implantation failure?
8. What are the role of IVF counseller after implantation failure?
9. What are items of IVF information counselling?
10.How can you express success rate of IVF?
11.What are the predictive factors for success of IVF?
12.What are items of implication IVF counselling?
13.What are types of consent?
14.What are items of IVF consent?
15.What should you do if some thing went wrong?
16.How to break bad news?
17.What are items of final report?ABOUBAKR ELNASHAR

3. CONTENTS
i. PSYCHOLOGICAL AND SOCIAL IMPACT OF IVF
ii. DEFINITION OF IVF COUNSELLING
iii.IMPORTANCE OF IVF COUNSELLING
iv.WHO UNDERGO IVF COUNSELLING?
v. HOW IVF COUNSELLING WORK
vi.WHY IVF COUNSELLING WORK
vii.TYPES (PHASES) OF IVF COUNSELLING
ABOUBAKR ELNASHAR

4. I. THE PSYCHOLOGICAL AND SOCIAL IMPACT OF
ART
 Infertility:
 Stress:
 affect the couple's relationship: reduce libido
and frequency of intercourse: contribute to the
fertility problems.
(NICE, 2013)
 Women report significantly greater infertility-related
anxieties than men regarding:
 life satisfaction,
 sexuality,
 self-blame,
 self-esteem and
 avoidance of friends.
(Newton et al, fertil Steril, 1999)
ABOUBAKR ELNASHAR

5.  ART:
 the most stressful of all Infertility treatments
(Connolly et al,Hum Reprod, 1993)
 can be alarming & traumatising.
 provoke many issues of
 emotional,
 cultural
 moral and ethical nature for the patient.
ABOUBAKR ELNASHAR

6. • IVF has the potential to be
 Emotional
 Patients have rated the stress of IVF as other
major life event such as
 death of family member or
 divorce.
 Physical and
 Financial exhausting experience.
 paying high cost of IVF with a somewhat limited
probability of success.
ABOUBAKR ELNASHAR

7.  Infertility and ART
 depression,
 anxiety,
 sexual dysfunction,
 damaged self-esteem
 difficulties in interpersonal relationships.
ABOUBAKR ELNASHAR

8. II. DEFINITION OF IVF COUNSELING
 Counseling
 To provide
 emotional and psychological support for
 a person who is undergoing certain challenges,
difficulties, or experiences in life.
 confidential and reliable environment wherein
they can freely talk about their thoughts and
feelings.
ABOUBAKR ELNASHAR

9.  Provided by
 a counselor
 who has received specialty training
 whose role is to
 listen to the patient
 provide empathy
 assist the patient in dealing with any situation
ABOUBAKR ELNASHAR

10. III. IMPORTANCE OF IVF COUNSELLING
1. Offers a non-judgemental platform for patients to be
clearer about their solutions and seek what they find
best.‫برنامج‬
2. Facilitates decision making regarding the treatment
and whether or not they wish to continue it.
3. Offers them an advanced approach towards their
confusions and questions, giving therapeutic support
to address the problem in a mature manner.
4. The acceptance, loss, grief, future planning and
interpersonal problems are faced and ethics are
taken into rational thinking.
ABOUBAKR ELNASHAR

11. IV. WHO UNDERGO IVF COUNSELLING?
 According to IVF organizations
 all couples should be offered counseling before,
during, and after an IVF procedure
 It is beneficial for couples who have
 undergoing treatment
 unsuccessful treatment
 successful IVF procedure and are now awaiting
the birth of their child
ABOUBAKR ELNASHAR

12. V. HOW IVF COUNSELLING WORK?
 IVF counseling
 Not intended to provide couples with advice
regarding their situation.
 Session should invite both partners to become open
to each other about what they feel.
 Highly recommended step in the process of IVF.
 Offered by
 fertility clinics that offer the procedure
ABOUBAKR ELNASHAR

13.  Fertility clinics offer
 Confidential and reliable environment
 Mandatory IVF pre-treatment counseling
 Optional IVF counseling during and after the
process. This is in accordance with laws
concerning ARTs
 Some clinics offer counseling and consultation over
the phone
ABOUBAKR ELNASHAR

14.  IVF counsellor
 Special training in dealing with the psychological
and emotional implications of ART.
1. Allow couples to
 share their thoughts and feelings while listening
to them
 Without giving
 any advice.
 interfere with the couples’ own decisions
 try to influence them in any way.
 Emotions
 shame, anger, frustration, aggression,
inferiority and rejection
 important to perceive and inspect.
ABOUBAKR ELNASHAR

15. 2. Assist couples
 in any problems they are facing and give them
observation of everything.
 understand the entire process
 cope with the challenges of process
3. Support couples
need especially at the critical points of the process
ABOUBAKR ELNASHAR

16. VI. WHY IVF COUNSELING?
 It is important for couple to understand Implications of
TT.
1. what they are about to do
2. how to cope with effects & implications of TT.
 Results of treatment
1. Cycle cancellation
2. Fertilization failure
3. Implantation failure IVF/ICSI Failure
4. Pregnancy and life birth
5. Pregnancy loss
ABOUBAKR ELNASHAR

17. 1. Cycle cancellation
 discontinuation of ovarian stimulation prematurely
without oocyte retrieval.
 cancelled before oocyte retrieval
ABOUBAKR ELNASHAR

18.  Causes
1. Follicular growth is delayed:
ovarian stimulation over 10 days:
< 3 follicles > 16 mm & E2 < 600 pg/ml.
2. Basal LH is elevated:
LH > 10 IU/l or a premature LH surge occurs
3. Elevated serum P4:
>1.5 ng/ml is detected prior to ovulation induction.
4.OHSS is suspected:
each ovary contains > 10 follicles < 16 mm &
E2 > 3500 pg/ml
ABOUBAKR ELNASHAR

19. 2. Fertilization failure
 The embryos fail to develop in the laboratory
 Failure of transformation of (micro injected) oocytes
into two pronuclei zygote.
 The British Fertility Society has produced a leaflet
(https://www.britishfertilitysociety.org.uk/quickguides/why-did-our-ivf-treatment-
not-work/) on some of the reasons why IVF/ICSI may not work.
ABOUBAKR ELNASHAR

20. 3. Implantation failure
 Patients
 Must accept that TT does not work all the time.
 Around three quarters of IVF is unsuccessful.
 No guarantee for this.
 One of the most important goals of counseling is to
prepare them for any outcome, including
 failed attempt or
 several failed attempts.
ABOUBAKR ELNASHAR

21. I. Endometrial factors
1. Anatomic causes:
Polyp, fibroid, adhesion,
septum
2. Impaired function
Thin endometrium
Altered expression of
adhesive molecules
3. Thrombophilia
4. Immunological factors
ABOUBAKR ELNASHAR
II. Gamete/embryo factors
1. Parental chromosomal
anomalies
2. Poor-quality oocyte
3. Poor-quality spermatozoa
4. Zona hardening
5. Suboptimal culture
conditions
6. Suboptimal embryo quality
7. Suboptimal ET
III. Multifactorial
1. Endometriosis
2. Hydrosalpinges
3. Suboptimal ovarian stimulation
 CAUSES OF RIF

22.  Such failures may results in feelings
 Frustration
 Disappointment,
 Hopelessness
 Depression
 Anxiety
 Distress
 Fear
ABOUBAKR ELNASHAR

23.  Counseling after failure: IVF counselors
1. Help couple sort through these feelings
2. Support.
3. Advise couple to take a few months before
another try. To give them
 enough time to recover from the stress caused
by the failed procedure.
 chance to discuss
 possible reasons of failed TT
 additional effort to improve their chances of
success in case they decide to undergo the
process again.
ABOUBAKR ELNASHAR

24. 4. Make them decide whether they want to try again.
5. Help patients consider other options as well.
 Adoption
 Surrogacy
 Sperm donation.
ABOUBAKR ELNASHAR

25. 4. Successful IVF and successful birth.
Counseling
 help couples adapt to their new roles as
parents.
 cope with new challenges.
ABOUBAKR ELNASHAR

26. 5. Pregnancy loss.
 Counseling
helps them to be prepared
ABOUBAKR ELNASHAR

27. VII. TYPES (PHASES) OF IVF COUNSELING
I. Information counseling: Initial
II. Implication counseling: Pretreatment
III. Supportive counseling:
IV. Post Therapeutic
ABOUBAKR ELNASHAR

28. 1. Information (initial) counseling
1. Indication of the procedure
2. The steps of the procedure
3. PR in general and that for their condition
4. Number and dates of the expected visits.
5. Cost.
ABOUBAKR ELNASHAR

29. Indications of IVF/ICSI
I. Male factor infertility:
1.Severe semen:
NF: ≤2% (4), C: ≤5m (15), M: ≤10% (40)
2.Azoospermia
II. Endometriosis
1. Moderate and Severe
2. Other factors: Poor ORT, abnormal semen,
tubal dis
3. Failure of conception after 6-18 m of surgery
ABOUBAKR ELNASHAR

30. III. PCOS:
1. Other factors: tubal factor, male factor
(Tannys, 2010)
2. Failure to conceive despite at least 6 ovulatory
cycles
IV. Tubal factor infertility:
1. Moderate to severe tubal disease:
tubal block, pelvic adhesions, hydrosalpinx
2. Other factors:
abnormal semen, age >36 yr
ABOUBAKR ELNASHAR

31. V. Unexplained infertility
1. ≤35 y: failure of 6 trials of (HMG, IUI)
2. 35-39: failure of 4
3. ≥39: failure of 2
ABOUBAKR ELNASHAR

32.  Steps of the procedure
1.Counseling
2.COS
3.Oocyte retrieval
4.Lab
5.ET
6.LPS
ABOUBAKR ELNASHAR

33.  ART SUCCESS RATES
Expressed in several ways
• PR
• LBR: more relevant.
PR or LBR can be calculated as a percentage of
 Cycle started
 Retrievals
 Transfers.
ABOUBAKR ELNASHAR

34. ABOUBAKR ELNASHAR
 Prediction of success
(NICE, 2013)
1. Female age
Success falls with rising female age
Success rate.
 25 years: success 45% failure 55%
 42 years: failure 95% success 5%
2. Number of previous tt cycles
Success: falls as the number of unsuccessful cycles increases.
3. Previous pregnancy history
Success: higher

35. ABOUBAKR ELNASHAR
4. BMI
Ideal: 19–30
BMI outside: reduce the success.
5. Lifestyle factors
i. Maternal and paternal smoking
ii. Maternal caffeine consumption can adversely affect
success rate.
6. Advanced Paternal age
(Liu et al, 2011)
 > 40y risks: small. (II-2C)
Spontaneous abortion
Autosomal dominant conditions
Autism spectrum disorders
Schizophrenia.

36. Cost
 Most of patient aggression is issued from
 financial pressure and
 fear of financial inability to continue the program.
 IVF cost is divided into:
1. Center fees.
2. Doctor fees.
3. Drugs fees.
ABOUBAKR ELNASHAR

37. 2. IMPLICATION COUNSELING
 enable the infertile couple to understand the
implications of the proposed treatment.
1. Consent
2. Myth of IVF.
3. The possible problems
4. Sequel of events
ABOUBAKR ELNASHAR

38. 1. Consent
 Written
 Signed by husband and wife
 Includes
 Success rate
 Miscarriage rate: 20%.
 Ectopic pregnancy rate: 1%.
 Severe OHSS: 2%-5%.
 No fertilization: 1%-2%.
 Refund policy in case of no ET.
 General risk of anesthesia and surgical
procedure.
 Cryo embryos fees.
ABOUBAKR ELNASHAR

39. ABOUBAKR ELNASHAR

40. 2. Myth:
 Routine use of hysteroscopy prior to IVF.
 Laser hatching.
 Thrombophilia screening.
 Time lapse.
 IMZI.
 Role of blastocyst transfer.
ABOUBAKR ELNASHAR

41. 3. The possible problems:
 sensitive and nonthreatening way
 Obese
 PCOS
 Poor ovarian reserve
 OHSS
ABOUBAKR ELNASHAR

42. OHSS
 Inevitable complication of IVF.
 To date no available method will predict 100% the
occurrence of OHSS.
 Types of OHSS
1. Early onset:
possibility of freezing of all embryos
2. Late onset:
repeated aspiration+hospital admission.
ABOUBAKR ELNASHAR

43. 4. Sequel of events
 Day of OPU:
 Nu. of retrieved oocytes.
 Evening of OPU:
 Nu. of injected oocytes.
 Following morning:
 Nu. of fertilized oocytes
 day of ET.
 Day of ET:
 Nu. of transferred embryos
 availability of cryo embryos.
ABOUBAKR ELNASHAR

44. 3. SUPPORT COUNSELLING
 essential to overcome the emotional problems of the
couples.
 before, during or after treatment, particularly to those
experiencing stress, ambivalence or distress.
 ESHRE
 provision of emotional support should be
 part of any patient-centred care and TT
 focus specifically on
 the coping resources that patients have
already
 developing new coping strategies that may
help in managing stressful situations.
ABOUBAKR ELNASHAR

45.  HFEA
 support counselling
 during the decision-making process and
 throughout TT
 helping patients to make adjustments to their
lives
ABOUBAKR ELNASHAR

46. 4. POST THERAPEUTIC COUNSELING
 Essential for the couple to cope with the results of TT
1. cycle cancellation
2. Fertilization failure
3. Implantation failure
4. Pregnancy and life birth
5. Pregnancy loss
ABOUBAKR ELNASHAR

47. Post therapeutic
1. If something goes wrong
2. Breaking bad News
3. Detailed report.
4. Future plan.
ABOUBAKR ELNASHAR

48.  Something went wrong
• Minor mistake
did not cause added problem for the woman but
corrective action should have been undertaken.
• Moderate mistake
caused additional suffering to the woman but was
not life threatening.
• Serious error
resulted in the death of the woman or a 'near miss
ABOUBAKR ELNASHAR

49.  When something goes wrong
1. Informing the woman
women prefer to know if they had been subject to
a medical error, even though they had not suffered
any adverse effects.
2. Informing seniors
 it is best to be honest about mistakes
 This will allow reflection on why the error
occurred and how it can be avoided in future.
3. Apologizing
 An apology is often all that the woman wants.
 This does not constitute an admission of guilt.
ABOUBAKR ELNASHAR

50.  Breaking Bad News (BBN)
Kaye's model (1996).
1. Preparation
2. What does he/ she know?
3. Is more information wanted?
4. Give a warning shot
5. Allow denial
6. Explain if requested
7. Listen to concerns
8. Encourage ventilation of feelings
9. Summarize and plan
10. Offer further information.
 Reaction to BBN
• Denial
• Hopeless
• Angry
• Crying
• Blaming herself
• Can’t understand
ABOUBAKR ELNASHAR

51. • Scenarios
– All embryos arrest before transfer
– No embryos to transfer at FET
– No eggs collected/cancelled cycles
– Ectopic pregnancy
– Pregnancy loss
– Low/no gametes, end of genetic journey
ABOUBAKR ELNASHAR

52. Detailed report
 Protocol used.
 Nu. of ampoules and of type used drugs.
 Nu. of retrieved, injected and fertilized oocytes.
 Quality of semen.
 Nu. and quality of transferred embryos.
 Availability of cryo embryos.
ABOUBAKR ELNASHAR

53. Thanks
ABOUBAKR ELNASHAR