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Counselling forms an important part in the management of infertile couple.

Counselling it is the confidential interaction between a professional and a client aimed at enabling the latter to cope with stressful situations and also take personal decisions related to problem areas.

Hence, the aim of counselling in infertility is to help couples explore, understand, and resolve issues arising from infertility and its treatment, dealing with the varied issues effectively.

Many couples perceive infertility as a loss of hope, dreams, or future plans. There is often impaired marital satisfaction, low self-esteem, sense of loss of control and privacy. The awareness of being childless or its cause can lead to disbelief, shock, sadness, anger, guilt and blaming the partner.

Despite this background, only 20 to 30% of the couple ever avail counselling services and the rest believe they can cope by themselves. Not everyone may require counselling, though it is ideally offered to all couple seeking treatment for infertility. Those seeking assisted reproductive treatment services like patients for IVF, intending couple for surrogacy, donors or surrogates face complex issues that includes biological, psychological, social, legal, spiritual, and ethical concerns. Hence attention to only medical or technical aspects must not overshadow importance of these domains.

Also, those experiencing high distress, social pressures, marital issues, unrealistic expectations, prior failures, newer therapies, delay in therapy, adoption, fetal reduction; those with past history of psychiatric conditions and those needing genetic counselling have to be offered counselling too. People with pre-existing psychiatric conditions need mandatory counselling as do those reporting mood fluctuations.

Assisted reproductive technologies (ART) and stress.

Does stress reduce the success of ART? Studies are not clear about an emphatic yes or no to this question. However, several studies have shown that pre-treatment for depression and anxiety improved the outcomes with ART.

Both the partners must be informed that stress in men or women can affect relationships, reduce libido and also the frequency of intercourse. ART is most stressful of all infertility treatment with women reporting greater infertility-related anxieties than men. Studies have also revealed that unsuccessful treatments increase the women’s level of negative emotions, and this may persist for long.

Types of counselling

1. Implicational counselling
2. Support counselling
3. Therapeutic counselling

Though counselling has been so classified, all the three types are not separate, but they often overlap forming a continuum of patient-centred care.

Implicational counselling

This implies information gathering and assessment. This is done when the individual or the couple seek treatment. They are informed about creating embryos in vitro, storing of the embryos and gametes, their donation and usage for treatment and/or for research. This includes but is distinct from the legal concept of informed consent. This can be done by the medical or the nursing staff of the infertility clinic.

Support counselling

It offers emotional support before, during and after infertility treatment; especially for those experiencing stress, ambivalence, and distress. This can be done by trained clinical psychologist or psychiatric social worker or a professional counsellor. Crisis counselling is counselling during an acute emotional crisis in general or specific to any treatment condition.

Therapeutic counselling

This is counselling directed at development of coping strategies to reduce distress and maximise problem solving. It includes conflict resolution and addressing specific issues like sexual, marital, interpersonal problems. This has to be done by a qualified mental health professional, psychiatrist, or psychologist.

Psychotherapy - This may be required for people going through specific issues arising out of infertility or the pre-treatment or consequences of treatment.

Specific conditions for counselling in infertility

Some of the conditions unique during the treatment of infertility include:

1. Dealing with multiple gestation_ Infertility treatment result in increases incidence of multiple pregnancy. Information sharing and implicational counselling is an opportunity to broach this possibility and encourage reflections on the implications of dealing with multiple pregnancies.
2. Counselling in HIV Sero-discordant couple- The aim is to prevent transfer of infection to the partner or child. The advantage of art in reducing this risk is highlighted. Human sperms lack CD4 and CCR 5 and hence do not carry the HIV virus on their surface. The other components of semen are infective. Therefore, the options include IUI with washed semen can be offered. IVF and art with donor semen can also be offered.
   HIV positive women must receive the prescribed anti-retroviral therapy regularly so that the risk of transmission to the baby is reduced. Mode of delivery has to be discussed and the case merits a multidisciplinary approach.
3. Counselling in donor and surrogacy programs
   The recipient couple have to be extensively counselled about the cost, success and limitation of treatment, multiple births, limitation of donors screening, laws of third-party reproduction and rules of confidentiality both currently and in future.
   The donor is subjected to professional counselling to assess the mental wellbeing . The donor must be counselled to understand the procedure and that there would be no right over the offspring anytime. This has to be done in their local language using an interpreter if necessary. For egg donors the consent of the husband is mandatory.
   All the parties involved in the donor programme must be made to understand current as well as future implications, keeping in mind the emotional legal moral and spiritual issues involved in such programmes.
   The mandatory forms must be signed appropriately after the concerned person/s have been explained appropriately in the language they understand.

Consent before any procedure

The concerned physician should explain the risks, complications, cost, outcomes of all the procedures being performed. The cost of the proposed treatment and the available alternate treatment, evidence for accepting or refusing the treatment must be explained.

The types of consent are- Implied or tacit consent, expressed or verbal consent, and expressed or written consent.

The consent stands valid when, while taking, the patient is of competent capacity to make informed decisions, understands the information that is being given with the ability to retain the information, communicate back and give consent voluntarily without coercion. The patient must be fully informed about the benefits, risks, alternative management including no treatment. The procedure is explained in detail including the medications, anaesthesia, pain, recovery, exposure of intimate area and the impact on daily or personal life as also additional procedures that may be needed; including what would be done and what could not be done.

The risks are categorized as being serious when there is organ trauma, bleeding, OHSS, infection, return to theatre and death. Frequent risks include pain, soreness, bruising, failure to retrieve eggs and failure to fertilise.

Post procedure counselling includes debriefing and Breaking Bad news.

Mistakes are regarded as ‘minor’ when there has been no problem to the patient and correctable action has been taken. A moderate mistake is one where additional suffering exists but is not life threatening. A near-miss episode or death is regarded as a serious error. When something goes wrong, it is appropriate practice to informing the woman, seniors and to apologise for the same.

To conclude, counselling should not be a single step procedure and counsellors should help the couple understand the situation, make sense of the decisions, and fully understand the implications. A good consent is a mandatory addendum in the process of counselling and treatment.