Reproductive counseling: overview and clinical applications

Reproductive Counseling

Studies have shown that the mean maternal age of motherhood has been increasing since 1980, which although may suit many modern careers and life styles, it puts women at a greater risk of declining fertility. The fundamental manifestation of ovarian aging is not just because of a decrease in the number of oocytes, but also because of a decline in its quality. Moreover, women of advanced maternal age are at a greater risk of developing aneuploidy in embryos. This contributes to their inability to bear a child by increasing both implantation loss and pregnancy failure. (Judy et al., 2012)

In Vitro Fertilization, IVF is one of the forms of assisted reproductive technology that enhances the chances of conception. In IVF, ovaries are stimulated to produce mature oocytes which are retrieved transvaginally under sonographic guidance. Oocyte retrieval is normally an outpatient procedure, performed with adequate analgesia. The sperm and ova are then combined in vitro to prompt fertilization. If viable embryos are made, they are transferred transcervically in to the endometrlal cavity. (Monga, 2008)

Ovarian stimulation for IVF is achieved by daily injections of gonadotrophins. The injections are continued for 11-14 days until the lead follicles are at least 18 mm in diameter on a transvaginal ultrasound. Once the ovaries have been stimulated to produce follicles, hCG is used to cause ovulation. (Monga, 2008)

The main factors which contribute to the outcome of in vitro fertilization are maternal age and ovarian function. The data available in the National summary and fertility clinic reports, from 2009, show that women between 38 to 40 years of age have a 21.1% chance of a live birth from IVF. This is considerably lower than for women who are under 40 years of age, at which time, the percent of live birth from IVF can be as great as 40.5%. Subsequent IVFs may increase the chance of conception. (Bauer, 2011)

Although success rates have made this technology a quick first line resort for clinicians and patients, there are possible risks that are associated with assisted reproductive techniques like IVF. The most significant complications are ovarian hyperstmulation syndrome and multiple pregnancies. Ovarian hyperstmulations syndrome causes ovarian hypertrophy which could result in ascites, pleural and pericardial effusions. The risk of multiple pregnancies increases the risk of pregnancy loss, obstetrical complications and neonatal morbidity. (Monga, 2008)

Current procedure modifications of IVF include in-vitro egg maturation, pre-implantation genetic testing, single embryo transfer and oocyte freezing. This increases the chance of conception and therefore, reduces the cost due to multiple attempts. Oocyte freezing eliminates the need for repeated hyperstimulation. (Goldberg, 2007)

Donor insemination is an option for single women wanting to become a parent, as in this case. This treatment is undertaken in clinics that are licensed by the Human Fertilization and Embryology Authority. Before proceeding with this technique, the woman needs to be fully investigated for patency of Fallopian tubes and her capacity to ovulate, either spontaneously or with stimulation. (Monga, 2008)

There are two types of inseminaton options: intra-cervical or intra-uterine. In both forms, a prepared semen specimen is required from a donor. In intra-cervical insemination, donor semen is deposited in the cervix, while intrauterine insemination is performed using an intrauterine catheter with a 1 or 2 ml syringe. The catheter is then gently passed through the cervical canal and a sperm suspension is expelled into the uterine cavity. (Monga, 2008)

Donor insemination, together with ovarian stimulation, is a simple and inexpensive treatment of subfertilty. The chances of conception per cycle have varied between 8 to 22%. There are certain factors that have an impact on the outcome of this procedure, for example, the maternal age, duration of subfertility and its cause. (Bauer, 2011)

Multiple births are common with in-vitro fertilization and donor insemination. (Judy et al., 2012) The rates of multiple gestations after in vitro fertilization in Europe and the United States are 26.4% and 35.4%, respectively. (Bauer, 2011) This can be reduced by transferring lesser number of embryos. This, however, reduces the odds of conception. (Judy et al., 2012)

Surrogacy may be another option for certain women. In this form of assisted reproduction, a donor egg is used with the commissioning father's sperm or a donor sperm may be used with the commissioning mother. Embryos are then fertilized in-vitro and transferred to the uterus of a surrogate host. (Monga, 2008)

The indications for this treatment include absent uterus, recurrent miscarriage, repeated failure of IVF and certain medical conditions. Clinical pregnancy rates are up to 40% per transfer and series have reported 60% live births. (Bauer, 2011) However, there are certain problems that could arise during this treatment which need to be discussed with couples during counseling. The most common of these issues regards the custody of the child. Most legal laws deny the surrogate parental rights, unless if the surrogate has contributed to the child's genetics. The surrogate may also attempt to seek custody, regardless of any genetic relationship, if the child's security is questionable at the hands of the parents. These laws may differ for different states and couples need to be informed of them, in order to alleviate anxiety. (Echols, 2010)

The commissioning woman may also respond poorly to follicular stimulation. This is usually more common in women who have had a prior hysterectomy. In cases where women cannot ovulate, the surrogate's ovum is used for fertilization. In such scenarios, the surrogate becomes genetically related to the child and legal implications regarding custody can become much more complicated. (Echols, 2010)

Child adoption is usually the last resort for most parents undergoing treatment for infertility. In a study conducted by Adewummi et al., (2012), 42.6% of couples were willing to adopt only if their infertility became intractable. Cultural reasons and family constraints are dominant reasons for unwillingness to adopt amongst most parents. Other issues related to adoption are health related, for example, a child may have an undocumented disease, such as AIDs. However, adoption is a wonderful option for couples who are unable to afford fertility treatment. A background investigation on the child's biological parents and work-up of any health condition can eliminate health related issues.