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IVF Counseling

Aboubakr Elnashar

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IVF Counseling

  1. 1. COUNSELING OF IVF PATIENTS Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2. 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. 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. 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. 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. 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. 7.  Infertility and ART  depression,  anxiety,  sexual dysfunction,  damaged self-esteem  difficulties in interpersonal relationships. ABOUBAKR ELNASHAR
  8. 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. 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. 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. 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. 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. 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. 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. 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. 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. 17. 1. Cycle cancellation  discontinuation of ovarian stimulation prematurely without oocyte retrieval.  cancelled before oocyte retrieval ABOUBAKR ELNASHAR
  18. 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. 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. 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. 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. 22.  Such failures may results in feelings  Frustration  Disappointment,  Hopelessness  Depression  Anxiety  Distress  Fear ABOUBAKR ELNASHAR
  23. 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. 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. 25. 4. Successful IVF and successful birth. Counseling  help couples adapt to their new roles as parents.  cope with new challenges. ABOUBAKR ELNASHAR
  26. 26. 5. Pregnancy loss.  Counseling helps them to be prepared ABOUBAKR ELNASHAR
  27. 27. VII. TYPES (PHASES) OF IVF COUNSELING I. Information counseling: Initial II. Implication counseling: Pretreatment III. Supportive counseling: IV. Post Therapeutic ABOUBAKR ELNASHAR
  28. 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. 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. 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. 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. 32.  Steps of the procedure 1.Counseling 2.COS 3.Oocyte retrieval 4.Lab 5.ET 6.LPS ABOUBAKR ELNASHAR
  33. 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. 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. 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. 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. 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. 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. 39. ABOUBAKR ELNASHAR
  40. 40. 2. Myth:  Routine use of hysteroscopy prior to IVF.  Laser hatching.  Thrombophilia screening.  Time lapse.  IMZI.  Role of blastocyst transfer. ABOUBAKR ELNASHAR
  41. 41. 3. The possible problems:  sensitive and nonthreatening way  Obese  PCOS  Poor ovarian reserve  OHSS ABOUBAKR ELNASHAR
  42. 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. 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. 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. 45.  HFEA  support counselling  during the decision-making process and  throughout TT  helping patients to make adjustments to their lives ABOUBAKR ELNASHAR
  46. 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. 47. Post therapeutic 1. If something goes wrong 2. Breaking bad News 3. Detailed report. 4. Future plan. ABOUBAKR ELNASHAR
  48. 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. 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. 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. 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. 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. 53. Thanks ABOUBAKR ELNASHAR
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