Guidelines for counselling in infertility: outline version

The Guidelines for Counselling in Infertility describe the purpose, objectives, typical issues and communication skills involved in providing psychosocial care to individuals using fertility services. The Guidelines are presented in six sections. The first section describes how infertility consultations differ from other medical consultations in obstetrics and gynaecology, whereas the second section addresses fundamental issues in counselling, such as what is counselling in infertility, who should counsel and who is likely to need counselling. Section 3 focuses on how to integrate patient-centred care and counselling into routine medical treatment and section 4 highlights some of the special situations which can provoke the need for counselling (e.g. facing the end of treatment, sexual problems). Section 5 deals exclusively with third party reproduction and the psychosocial implications of gamete donation, surrogacy and adoption for heterosexual and gay couples and single women without partners. The final section of the Guidelines is concerned with psychosocial services that can be used to supplement counselling services in fertility clinics: written psychosocial information, telephone counselling, self-help groups and professionally facilitated group work. This paper summarizes the different sections of the Guidelines and describes how to obtain the complete text of the Guidelines for Counselling in Infertility.     

Psychological functioning in infertility patients.

This review focuses upon studies of psychological aspects of infertility, as well as on some of the issues and implications which arise from the research. It appears that the major difficulty facing patients during infertility treatment is anxiety, while couples whose treatment was unsuccessful are instead at risk for depression. The long-term consequences for families created as a result of assisted conception are also considered.     

The desire for multiple pregnancy in male and female infertility patients

BACKGROUND: It is apparent that many fertility patients consider multiple birth an ideal treatment outcome. We wished to evaluate the desire for multiple birth among patients, and the effect of patient demographics and recognition of the increased fetal risks of multiple pregnancy on this desire. METHODS: This was a prospective questionnaire study completed by 801 male and female infertility patients attending a tertiary level Canadian university fertility clinic. Two logistic regression analyses were performed with desire for multiple birth with next fertility treatment and recognition of the increased fetal risks of multiple pregnancy as the dependent variables. RESULTS: 41% of patients desired a multiple birth. Increasing duration of infertility or previous assisted reproductive treatment increased, and having previous children or recognition of the increased fetal risks decreased, this desire. Patient age or sex did not affect desire for multiple birth. Previous assisted reproductive treatment was associated with increased recognition of the fetal risks of multiple pregnancy. CONCLUSIONS: A significant proportion of fertility patients considers multiple birth an ideal treatment outcome. Recognition of the increased fetal risks of multiple pregnancy significantly reduced this desire. Patient education may play an important role in assisting physicians in the quest to reduce the contribution of assisted reproductive treatment to multiple births and their attending complications.     

Lifetime prevalence of infertility and infertility treatment in the UK: results from a population-based survey of reproduction

BACKGROUND: The aim of this study was to investigate the prevalence of infertility and the use of infertility treatment among women aged 40-55 years. METHODS: Population-based postal questionnaire survey of UK women. Over 60,000 women randomly sampled from the 2001 electoral roll were sent a questionnaire, and those aged 55 years and under who had ever been pregnant or tried to achieve a pregnancy (n = 6584) were asked to provide a reproductive history. RESULTS: Overall, 2.4% of women aged 40-55 years had unresolved infertility with no pregnancies, and a further 1.9% had been pregnant but not achieved a live birth. The prevalence of unresolved fertility did not differ among birth cohorts. Sixteen percent of women reported ever consulting a doctor because of infertility and 8% reported receiving treatment to conceive. Across the whole sample, 4.2% of women reported that they had achieved at least one pregnancy as a result of treatment. Compared with earlier birth cohorts, women born later were more likely to report consultations (18% versus 13%) and treatment (9% versus 6%) for infertility, and pregnancies as a result of infertility treatment (6.7% versus 2.7%). Among those who reported medical consultations, women born more recently first consulted at a later age compared with those born earlier. CONCLUSIONS: Although both the number of women seeking medical care for infertility and the proportion reporting pregnancies as a result of infertility treatment has increased, there is no evidence to support an overall increase in unresolved infertility over the past 15 years. The vast majority of women aged 40-55 who reported difficulties conceiving did have a child, or children, at some point in their lives.     

The impact of treatment experiences on the course of infertility distress in male patients

BACKGROUND: Previous research on infertile males has delivered equivocal findings on the course of infertility distress in males. The present longitudinal study examines whether there are differentials associated with specific treatment experiences (i.e. duration of treatment, the diagnosis received, and treatment failure of assisted reproductive technologies). METHODS: The sample consisted of 118 patients who twice visited an andrology clinic on their own initiative for fertility work-ups. Baseline and follow-up examinations were > or = 6 months apart. Prior to each fertility work-up, patients completed a questionnaire assessing distress due to infertility. RESULTS: No uniform course of distress could be detected. A significant interaction between treatment experiences indicated that distress rises significantly only in those patients who were in treatment > or = 17 months and experienced treatment failure between the first and the second psychological evaluation. For the diagnosis of male infertility, however, neither a direct nor an indirect impact was identified. CONCLUSION: The present study indicates that the interaction of specific treatment experiences is associated with changes in distress of infertile males.     

Coping with infertility: distress and changes in sperm quality.

Infertility represents a serious stressor for some patients as well as a risk factor for a decrease in sperm quality. The purpose of the present study was to identify coping strategies that went along with both better emotional and physical adjustment to infertility. The sample consisted of 63 patients who contacted an andrological clinic more than one time. Prior to clinical examination, patients filled out a questionnaire referring to the way in which they coped with their wives' previous menstruation. Participants also completed a scale assessing perceived distress due to infertility. Change in sperm concentration since baseline semen analysis and the level of distress were used to evaluate patient's adjustment. The better-adjusted patients showed less prominent overall coping efforts, and a higher proportion of distancing coping strategies. An improvement in sperm quality also was associated with a low cognitive involvement in infertility. Situational uncontrollability of infertility could be a moderator of the effectiveness of coping employed by the better-adjusted patients. In addition, the coping behaviour related to better adjustment could be due to a dispositional stress resistance factor. For clinical implementation of the findings, the attitudes of a patient and the expectations of his wife have to be taken into consideration.     

Male infertility and donor insemination: couples' decisions, reactions and counselling needs

This paper reports findings of a postal survey of 205 couplesbelonging to the National Association for the Childless, whoseinfertility had been attributed to the male partner. Spontaneousresolution was seldom reported, but 36 couples had become parentsby donor insemination (DI) and 28 through adoption. Almost athird of respondents had managed to resolve their childlessness.Although reasons for rejecting DI or preferring other optionswere offered by 60 couples, 125 had taken active steps towardsit. Most of the 80 couples who had been counselled had foundthis helpful. Regardless of counselling, of the 76 couples whohad considered whether or not to tell their children of theirmode of conception, 56 (74%) stated that they had no intentionof doing so. Quantitative indices from two self-report scalesconfirm that male infertility is commonly a source of distress,especially for the female partner. However, the data also suggestthat this is not necessarily associated with chronic maritaldiscord. Couples who had already decided for or against DI reportedless distress than others. The need for mutual support may wellbe enhanced until the couple's quest for a child has been eitherachieved or abandoned.     

Chromosomal factors of infertility in candidate couples for ICSI: an equal risk of constitutional aberrations in women and men

To assess the frequency of chromosomal aberrations in French candidates for intracytoplasmic sperm injection (ICSI), and to explore the existence of a female chromosomal factor in some cases of couple infertility, a collaborative retrospective clinical and cytogenetic study was performed, launched by the Association des Cytogénéticiens de Langue Franciaise (ACLF). The karyotypes of 3208 patients [2196 men (68.4%), 1012 (31.6%) women] included in ICSI programmes over a 3-year period in France were collected. A total of 183 aberrant karyotypes was diagnosed, corresponding to an abnormality frequency of 6.1% (134/2196) for men and 4.84% (49/1012) for women. The following frequencies of abnormalities were observed respectively for men and women: 1.23% (n = 27) and 0.69% (n = 7) for reciprocal translocations, 0.82% (n = 18) and 0.69% (n = 7) for Robertsonian translocations, 0.13% (n = 3) and 0.69% (n = 7) for inversions, 3.32% (n = 73) and 2.77% (n = 28) for numerical sex chromosome aberrations, and 0.59% (n = 13) and 0% for other structural aberrations. Among the male patients of this latter group, 0.40% (n = 9) had a Y chromosome abnormality. Among the male patients with numerical sex chromosome abnormalities, 2.23% (n = 49) were 47,XXY, 0.32% (n = 7) were 47,XYY, and 0.77% (n = 17) had a mosaicism for numerical sex chromosome anomalies. All the female patients with sex chromosome abnormalities (2.77%, n = 28) had mosaicism for numerical sex chromosome anomalies. Even if these cases-the significance of which was sometimes questioned-were disregarded in the analysis, 2.08% (21/1012) of abnormal karyotypes remained in women. An overall increased frequency of chromosomal aberrations was found, and this confirmed that in some cases of poor reproductive outcome there may be a contribution of maternal chromosome aberrations. Indeed, the existence of a chromosome abnormality in the female partner was associated with the group of infertile men in which there was no apparent cause of infertility.     

Ethics and society: Artificial insemination by donor: an alternative for single women

Artificial insemination using donor spermatozoa (AID) has beenknown as a treatment for heterosexual couples where the husbandhas been found to be infertile. The first woman without a malepartner wanting a child by AID was admitted to the fertilitycentre in 1981. In the literature, two categories of alternativerequests, i.e. those from lesbian couples and those from singlewomen, are treated as equivalent family structures since bothlack a father figure. However, single women shoulder the responsibilityfor the child's upbringing alone, whereas in lesbian couplespartners share this responsibility. Some of the objections raisedto alternative types of parenthood therefore refer more to womennot having a partner at all. Since 1981, 94 single women haveasked the Fertility Centre of the Free University of Brusselsto be considered for AID treatment. Data from this group ofalternative requests have been collected. The aim is to drawup a profile of the single women who request AID, and to makea distinction between applicants who were accepted and thosewho were refused.     

A survey of semen donation: phase I--the view of UK licensed centres

It has been suggested that the implementation of the Human Fertilisationand Embryology Act in the UK in 1991 may have had a detrimentaleffect on the supply of semen donors. The aim of this surveywas to obtain data relating to semen donation In the UK during1989–1992. A questionnaire designed to obtain informationabout the recruitment and screening of semen donors, the supplyof semen donors, and use of donated semen for infertility treatmentwas sent to all licensed centres in April 1993 and 93% werereturned for analysis. The results demonstrate that while thenumber of centres recruiting donors and the number of men offeringto be donors have increased in recent years, this has not resultedin an increased supply of donors. Reasons for these findingsare discussed in the light of the Human Fertilisation and EmbryologyAuthority regulations relating to semen donation.     

Evaluation of the relative cost-effectiveness of treatments for infertility in the UK

This paper aims to complement existing clinical guidelines byproviding evidence of the relative cost-effectiveness of treatmentsfor infertility in the UK. A series of decision–analyticalmodels have been developed to reflect current diagnostic andtreatment pathways for the five main causes of infertility.Data to populate the models are derived from a systematic reviewand routine National Health Service activity data, and are augmentedwith expert opinion. Costs are derived from an analysis of extra-contractualreferral tariffs and private sector data. Sensitivity analysishas been carried out to take account of the uncertainty of modelparameters and to allow results to be interpreted in the lightof local circumstances. Results of the modelling exercise suggestin-vitro fertilization is the most cost-effective treatmentoption for severe tubal factors and endometriosis, with surgerythe most cost-effective in the case of mild or moderate disease.Ovulatory factors should be treated medically with the additionof laparoscopic ovarian diathermy in the presence of polycysticovarian syndrome. For other causes, stimulated intrauterineinsemination (unexplained and moderate male factor) and stimulateddonor intrauterine insemination (severe male) are cost-effective.     

The relationship between perceived stigma, disclosure patterns, support and distress in new attendees at an infertility clinic

BACKGROUND: A model suggesting that high perception of stigma is associated with reduced disclosure to others, leading to lower social support and higher distress in new attendees at an infertility clinic is tested. METHODS: Questionnaires measuring stigmatization (Stigma consciousness questionnaire), disclosure of fertility difficulties (Disclosure questionnaire), social support (Duke-UNC Functional Social Support Questionnaire) and fertility-related [Fertility Problem Inventory (FPI)] and generic distress [Hospital Anxiety and Depression Scale (HADS)] were completed by 87 women and 64 men. Data were analysed by gender comparisons, correlations and path analysis. RESULTS: Women reported higher stigma and disclosure than men. For women, stigma and disclosure were unrelated but in men higher stigma was associated with lower disclosure. Perceptions of stigma were related to low social support for both genders. Social support was negatively related to anxiety, depression and overall infertility distress and showed greater predictive capacity than satisfaction with partner relationship. Testing the model showed that, for men, stigma was linked to lower disclosure and support and higher fertility-related and generic distress. Disclosure itself did not link to support. For women, greater disclosure linked only to higher generic distress. Stigma was directly linked to fertility-related distress and to low perceived support which mediated a relationship with generic distress. CONCLUSIONS: Stigma and the wider social context should be considered when supporting people with fertility problems. Greater disclosure may be associated with higher distress in women.     

Cancer incidence following treatment for infertility at a clinic in the UK

BACKGROUND: There is concern about the long-term health impact of ovarian stimulation treatment for infertility, in particular the effect on cancer risk. The aim of this study was to investigate the incidence of cancer in a cohort of women attending a large infertility clinic in the UK. METHODS: Women who were UK residents attending the clinic between January 1, 1975 and December 31, 1989 were identified for the study. The cohort was followed-up and cancer incidence rates calculated. RESULTS: The study cohort was made up of 5556 women of whom 75% had received ovarian stimulation drug treatment at the clinic. A total of 118 cancers (including 55 breast, four corpus uteri and six ovarian) were incident in the cohort from the beginning of 1990 to the end of 1997. The incidence rates of cancer of the breast, corpus uteri and ovary were not significantly different from expectation based on national cancer rates, and were similar for women who had received hormonal treatment to stimulate their ovaries and those who had not. CONCLUSIONS: These data do not support a hypothesis linking infertility treatment involving ovarian stimulation with increased breast, uterine and ovarian cancer over the follow-up period studied.     

The experiences of couples who have had infertility treatment in the United Kingdom: results of a survey performed in 1997

A questionnaire was sent to 2000 members of two of the largest national infertility support organizations as part of the National Infertility Awareness Campaign (NIAC), 1997. A total of 980 questionnaires was completed and returned to the market research company, Ballington Hall. Some 69% of the respondents were aged between 30 and 39 years. One-third of the couples had been trying for a baby for more than 3 years, including one-tenth who had been trying to conceive for more than 10 years. Some 40% of respondents were successful in conceiving, although a significant proportion of these took more than 6 years. About 75% of those surveyed had been forced to pay for some or all of their infertility treatments and investigations, whereas 18% had their treatments funded fully by the National Health Service (NHS). Funding sources for the remaining 7% were unknown. Just over one-third of respondents felt that their GP provided sufficient information about the causes of infertility investigations and treatment, while the majority said that their specialists had been helpful. One in three said that they did not fully understand the medical nature of their own or their partner's infertility. A wide range of negative emotions was experienced by respondents. One in five said they experienced suicidal feelings; one in three said that infertility had strained their relationship; and just over one-quarter found that their relationship improved as a result of the treatment. Some 71% said that they would request counselling if it were offered free, but only 12% had been provided with free counselling on the NHS.     

International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care

INTRODUCTION The purpose of the present study was to review existing population surveys on the prevalence of infertility and proportion of couples seeking medical help for fertility problems. METHODS Population surveys, reporting the prevalence of infertility and proportion of couples seeking help in more and less developed countries, were reviewed. RESULTS Estimates on the prevalence of infertility came from 25 population surveys sampling 172 413 women. The 12-month prevalence rate ranged from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less-developed nations, with an estimated overall median prevalence of 9%. In 17 studies sampling 6410 women, the proportion of couples seeking medial care was, on average, 56.1% (range 42-76.3%) in more developed countries and 51.2% (range 27-74.1%) in less developed countries. The proportion of people actually receiving care was substantially less, 22.4%. Based on these estimates and on the current world population, 72.4 million women are currently infertile; of these, 40.5 million are currently seeking infertility medical care. CONCLUSIONS The current evidence indicates a 9% prevalence of infertility (of 12 months) with 56% of couples seeking medical care. These estimates are lower than those typically cited and are remarkably similar between more and less developed countries.     

Human sperm--egg interactions and their disorders: implications in the management of infertility

The present era of infertility management is characterized byan increasing interest in defects of sperm-egg interactions.When the spermatozoon meets the egg, it must first react withthe enveloping coat which controls sperm access to the cellsurface of the oocyte. Adequate sperm motility is a major conditionfor penetration through the egg investments. The ability ofspermatozoa to respond to physiological stimuli by a timelyacrosome reaction is another necessary prerequisite for thisevent, as well as for sperm fusion with the oocyte. The clinicalsignificance of current laboratory tests evaluating differentaspects of gamete function is discussed and a practical guideis given for their indication and interpretation and for theuse of their results in choosing rational therapy.     

Review of unexplained infertility and obstetric outcome: a 10 year review.

BACKGROUND: Increased maternal and fetal risks have been reported in pregnancies following unexplained infertility. Our aims were to examine the obstetric and perinatal outcome of singleton pregnancies in couples with unexplained infertility and explore the impact of fertility treatment. METHODS: Women with unexplained infertility were identified from the Aberdeen Fertility Clinic Database. Their unit numbers were matched against the Aberdeen Maternity and Neonatal Databank (AMND) in order to extract obstetric records of those women with subsequent pregnancy outcomes. The general obstetric population served as a control group. RESULTS: Women with unexplained infertility were older [30.8 versus 27.9 years, 95% confidence interval (CI) for difference = +2.4 to +3.4] and more likely to be primiparous (59 versus 40%, 95% CI = +1.3 to +1.9). After adjusting for age and parity they had a higher incidence of pre-eclampsia, abruptio placentae, preterm labour, emergency Caesarean section and induction of labour in comparison with the general population (P < 0.05). Perinatal outcome did not differ between women with unexplained infertility and those of the general population. The multiple pregnancy rate was 5.4% higher following fertility treatment than in women who conceived spontaneously (95% CI = +2.8 to +9.7). CONCLUSIONS: Women with unexplained infertility are at higher risk of obstetric complications which persist even after adjusting for age, parity and fertility treatment. The reasons are however unclear and merit further study.     

Infertility, infertility treatment and twinning: the Danish National Birth Cohort

BACKGROUND: We have previously observed that an increasing time to pregnancy (TTP) is associated with a reduced frequency of twin deliveries in couples not receiving infertility treatment. By using updated information, we assessed the frequencies of dizygotic (DZ) and monozygotic (MZ) twin deliveries as a function of infertility (TTP > 12 months), as well as infertility treatment. METHODS: From the Danish National Birth Cohort (1997-2003), we identified 51 730 fertile couples with TTP 12 months and 5163 infertile couples who conceived after treatment. Information on zygosity, available for part of the cohort (1997-2000), was based on standardized questions on the similarities between the twins at the age of 3-5 years. RESULTS: Compared with fertile couples, the frequency of DZ twin deliveries was lower for infertile couples conceiving naturally (odds ratio 0.4, 95% confidence interval 0.2-0.7) and was much higher for infertile couples conceiving after treatment (17.3, 14.4-20.7). The frequency of DZ twin deliveries decreased with TTP in untreated couples, whereas the frequency of MZ twin deliveries remained constant. CONCLUSIONS: The frequency of DZ twin deliveries decreased with TTP and substantially increased with infertility treatment, whereas MZ twin deliveries remained substantially unchanged.     

UK gamete donors' reflections on the removal of anonymity: implications for recruitment

BACKGROUND: In 2005, UK legislation was changed requiring any donor of gametes or embryos used in the treatment of others to agree to the disclosure of their identity to any offspring reaching the age of 18. METHODS AND RESULTS: This paper analyses responses of a survey of existing donors' views on the removal of donor anonymity that was undertaken by the Department of Health (UK) as part of its review that preceded changes to the law on donor anonymity. The survey provides an insight into what it is about the loss of anonymity that some donors find problematic, indicating that although some donors will be reluctant to donate under conditions of non-anonymity, others have concerns about the removal of anonymity that can be addressed. CONCLUSIONS: This paper identifies factors, in particular counselling, support and better information that could maintain gamete donor recruitment in the context of the UK's policy of non-anonymous and non-remunerated donation.     

Infertility: Infertility evaluation in fertile women: a model for assessing the efficacy of infertility testing

A standard infertility evaluation consists of a semen analysis,hysterosalpingogram, post-coital test, endometrial biopsy andlaparoscopy. Although these tests are well grounded in clinicalexperience, information on their ability to discriminate betweenfertile and infertile couples is limited. In this study, weperformed standard infertility tests plus two others-sperm antibodiesand cervical culture for Mycoplasma hominis and Ureaplasma urealyticum–onfertile and infertile couples. Women in the fertile group wereselected from those who had delivered a child within the previous2 years and who were scheduled for a laparoscopic tubal ligation.Women in the infertile group were selected from those presentingfor an infertility evaluation (mean duration of infertility4.2 years), and they were matched by age (±3 years) andrace with fertile subjects. Subjects were recruited from bothprivate and clinic patients. A total of 64 couples (32 matchedpairs) completed the evaluation. At least one ’abnormal‘infertility test was found in 69% of fertile and 84% of infertilecouples. With the exception of tubal damage and endometriosis,which as expected were more common in infertile couples, nosignificant differences between groups for remaining infertilityfactors could be demonstrated. Despite the small size of thecurrent study, these results confirm the feasibility and importanceof comparisons of the prevalence of infertility factors in fertileand infertile couples.