Way forward





Fertility awareness


In our society, fertility awareness (FA) is deficient, since cultural and religious factors increase the prevalence of misconceptions and myths. Core factors encompass low education, persistent health-related issues, scarcity of resources for well-being, nonexistence of a developed public health system, and inadequate coverage by insurance policies. Contributing factors include poor access to fertility options, scarce knowledge about risk factors for infertility, and health warnings of postponing childbirth ( Fig. 13.1 ).




Fig. 13.1


Factors effecting fertility awareness.


According to a study conducted in Pakistan, the reported prevalence of infertility is approximately 22% with 4% primary and 18% secondary infertility. The cultural and religious perspective about assisted reproductive technologies is also unclear, resulting in reduced acceptability.


Sufficient knowledge about infertility can urge young couples to seek timely medical care. We, therefore, recommend that infertile couples should be guided to approach the right person at the right time. Theinfertility clinics must have a list of relevant books and articles in local languages, audiovisuals, brochures, as well as the services of counselors who deals with fertility-related matters of individuals of different educational status. Additionally mass communication should play a very effective role to address misconceptions, myths, and religious taboos through health shows and discussion forums with popular celebrities/health ambassadors. Support of religious authorities should also be obtained through sensitization meetings, so as to research and clarify any misconceptions at different forums portraying the correct Islamic views on treatment options such as IVF, for better acceptability.


Role of healthcare professionals: First line of contact


In United Kingdom, Germany, and other developed countries, counseling of infertile couples and diagnostic evaluation come under the domain of primary care physicians. Counseling is offered at the time of first consultation and during the procedure by a person/specialist/psychologist who has a limited role in the management of the couple. According to the American Society for Reproductive Medicine (ASRM), these counseling techniques offered on case-to-case basis will enable the couples to face physical and emotional challenges of infertility and its treatment. Measures to improve general health through lifestyle modifications should also be included in this process. Comprehensive knowledge of the counselor and counseling skills can therefore decrease the perceived stress of subfertile couples and, therefore, improve treatment consequences. Once counseled and diagnosed properly, the couple can be offered the first line of treatment, failing which immediate referral is planned.


Unfortunately, a majority of subfertility patients belong to developing countries, where negative consequences of childlessness are more as compared to developed countries. Fertility awareness is minimal; cultural limitations, treatable recurrent infections, poor access to health facilities, and lack of appropriate counseling pose a serious threat to fertility. Access to newer technologies is rare, being costly and limited to big cities, making it unaffordable for a majority. Insignificant resources and low commitment of the government darken the scenario further. We postulate that the healthcare providers in primary care settings, being the first line of contact with the couple, can play a pivotal role to prevent infertility. Awareness and counseling sessions in the initial stages educate the patients about risk factors, which facilitate screening for and treating preventable causes, thus promoting patient compliance since “Beauty has no age; Fertility does.”


Counseling may be supported through print media (brochures) and where facilities exist, online modules and awareness workshops. If the couple does not conceive in a year’s time, the healthcare professional should proceed with prompt referral to infertility specialist.


Fertility in primary healthcare settings: Challenges and solutions


Infertility treatment in low socioeconomic countries is a stand-alone. Knowing the status of education and prevention in developing countries, efforts are required at national level to develop administrative guidelines, to incorporate infertility into primary-level reproductive healthcare programs. For the successful inclusion of infertility diagnosis in these circumstances, it is necessary that the knowledge and skills of healthcare workers should be updated through ongoing, regular training programs. Sufficient facilities should also be made available for routine investigations, since early identification of cause and prompt treatment can minimize complications of procedures. While the diagnosis and treatment of infertility are comparatively expensive, it is recommended that more advanced, operational, secure, and cost-effective ART strategies should be proposed by public and private sectors. A possible solution can be government’s initiatives to pledge low-cost IVF programs, supplemented with funding from international agencies and other resources. Agencies from the private sectors should also be invited to join hands to address awareness issues and mass communication to improve the quality of care for subfertility.


WHO recommendations and fertility counseling


To address fertility issues in the broader concept of medical, social, cultural, and religious dictums, it is a prerequisite that all activities are integrated at three levels, namely personal, interpersonal, and social. World Health Organization (WHO) and Human Fertilization and Embryology Authority (HFEA) recommend that instead of individuals, couples seeking fertility treatment should be counseled. Both partners should be approached together and counseled so that they accept one another’s feelings and face challenges collectively. Where cultural constraints prevail, individual counseling may additionally be done to reduce stress in infertile women. Counseling services and materials should be available, depending upon the educational status of couples/individuals and local circumstances/languages. Keeping in mind the diverse counseling needs of infertile couples, options of a number of suitable psychosocial provisions and counseling intermediations come up. At personal level, steps to improve preventative behavior through awareness programs will help prevent the treatable. According to the recommendations of WHO, “ Public awareness of infertility and its causes should be increased to improve preventative behavior and to diminish the stigmatization and social exclusion of infertile men and women .” Research has found that being open about infertility and seeking support from outside can help both men and women cope better with emotional distress. Social support comes from friends, family, and support groups, since they allow one to be better understood; to share feelings and emotions that could not have been shared anywhere else. A time and cost-efficient method of group counseling can be organized in the form of small groups to reduce social isolation, educate couples, discuss their problems, share experiences, convey information, teach and practice relaxation skills, and then identify couples for further psychological support. Access to helpline maintains confidentiality in a two-way communication process and helps to remove misconceptions contributing to behavior change.


Advanced counseling


Reproductive health and the field of subfertility can additionally benefit from the specialized services of a health coach, an individual who fills the gap between patient and doctor, to impart knowledge to the patient for improved attitude and practices of self-care. Once the diagnosis of infertility is established, couples should be counseled in detail on treatment choices available. For those who opt for IVF/ICSI, a detailed discussion is required on the nature of problem, chances, possibilities, and assistances of IVF in agreement with the current Human Fertilization and Embryology Authority (HFEA) code of practice. To improve compliance, they should be informed about the length of intervention, that a complete cycle of IVF comprises of downregulation, ovarian stimulation, ovulation induction, embryo transfer, and cryopreservation of frozen embryo(s). Relaxation techniques including yoga meditation have been proved to reduce the perceived stress supporting success after IVF or ICSI.


Infertility clinic: First visit protocols


The first visit calls for a realistic, evidence-based protocol for the management of infertile couples rather than bombarding them with information overload. A multidisciplinary approach is therefore required for a good clinical practice, following principles of care that the couple anticipates throughout treatment. This understanding may help infertility specialists to recognize and support couples who have a greater possibility of emotional distress, during various phases of interventions. It includes the following.


History taking, examination, and routine investigations


History taking and examination of both partners individually and then collectively with focus on duration of infertility, number of previous ART treatment cycles, treatment protocols, results of fertilization and psychological adjustment throughout the cycle, followed by routine investigations ( Tables 13.1–13.6 ).



Table 13.1

Infertility management protocol: history of female partner.

Adopted from Kamel R: Management of the infertile couple: an evidence-based protocol, Reprod Biol Endocrinol 8(1):21, 2010. doi-org.easyaccess1.lib.cuhk.edu.hk/10.1186/1477-7827-8-21.
















































S. no. History Inclusions
1 Present history


  • Elements of current problem, length of infertility in years, age, occupation




  • Associated conditions of vaginal/cervical discharge, hair growth, acne, breast change, hot flushes, change in dietary habits, symptoms of diabetes, hypertension, history of drugs, smoking, consumption of alcohol, and intake of caffeine

2 Menstrual history


  • Onset of menarche, duration, and frequency of the cycle, relevant complaints

3 Obstetric history


  • Previous conceptions (gravidity), parity, miscarriages




  • Induced abortion and its complications

4 Contraceptive history


  • Type of contraceptives, duration of use

5 Sexual history


  • Living together




  • Enough time for relation




  • Knowledge about timing of relation




  • Relevant complaints associated:




    • Difficult coitus



    • Pain during coitus


6 Past history


  • Medical: rubella status, pelvic inflammatory diseases, tuberculosis




  • Surgical: removal of ovarian cysts, appendicectomy, open/laparoscopic laparotomy, previous cesarean section, cervical conization

7 Family history


  • Especially important in cases of subfertility:




    • PCOS and endometriosis, cousin marriages



    • Diabetes mellitus, hypertension, twin’s birth, breast cancer


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Jan 4, 2021 | Posted by in GYNECOLOGY | Comments Off on Way forward
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