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Which issues concerning multiple pregnancies should be addressed during psychosocial counselling?
RBMOnline - Vol 15 Suppl. 3 2007 Reproductive BioMedicine Online; www.rbmonline.com/Article/2754 on web 23 March 2007
Article Which issues concerning multiple pregnancies should be addressed during psychosocial counselling? Marysa Emery FMH Médecin Praticien, Médecine psychosomatique et psychosociale AMPP, Centre de Procréation Médicalement Assistée, Ave Marc Dufour 1, 1007 Lausanne, Switzerland Correspondence: Tel: +41 21 321 15 80; Mobile: +41 79 717 10 78; e-mail: [email protected] Marysa Emery obtained her medical degree and doctorate from the Department of Social and Preventive Medicine, University of Lausanne, Switzerland. Her postgraduate training in psychiatry and psychosomatic medicine brought her to the field of psychosocial counselling for assisted reproduction technologies in 1997, in the team of Professor Marc Germond. Linking psychosocial consultations and clinical research, Dr. Emery engaged in conceptualising and implementing systematic counselling for infertile couples to help avoid multiple births. Her current research interests also encompass the psychosocial implications of open-identity donor insemination for the parents, the offspring and the donors.
Abstract The global rise in multiple pregnancy rates due to assisted reproductive technology has led to the development of various strategies to diminish these rates without jeopardising pregnancy. Policies at treatment centres may include the option of fetal reduction, although each centre is subject to national laws and its own guidelines. However, personal opinions and goals may also influence practice. The development of clinical decisions, therefore, is complex and subject to change. Primary prevention is the best way to reduce multiple births. For preventative psychosocial counselling, some centres employ counsellors, but if not, this becomes the physician’s task. An in-depth assessment is required to define how many embryos to transfer and what risk of multiple birth is acceptable to patients. Counselling should address the following: the relationship between pregnancy rate, multiple pregnancy rate and the number of embryos transferred; benefits and risks of multiple pregnancy; and possibilities for primary and secondary prevention. Patients should voice how they feel facing these issues; which issues are worrisome; how they anticipate these possibilities; and what psychosocial support exists that could be mobilized. In summary, psychosocial counselling reinforces the partnership between couples and the assisted reproductive technology team, allowing for primary prevention and informed consent on multiple pregnancy issues. Keywords: counselling, IVF, multiple pregnancies, prevention
18
Introduction to risk assessment
International dimension
Switzerland is renowned for its beautiful mountain scenery and for its popular winter sports: skiing and snowboarding. Though popular, these sports do raise questions in relation to their inherent risks. Every year, 42,000 Swiss skiers and 25,000 snowboarders require medical treatment for injuries. On average, expenses of more than €5000 per skiing accident and almost €2000 per snowboarding accident are incurred. On average, 40 people die in Switzerland every year as a result of a ski or snowboarding accident (Brügger, 2004). The aim of this observation is not to compare the prevention of multiple pregnancies to accident prevention, but to highlight the growing awareness of risks and of risk assessment within modern culture. The assessment of multiple pregnancy risks will occur within a framework of cultural and individual risk assessment. It is important to note that this applies to patients as well as to professionals.
Around the world, countries have differing legislations relating to assisted reproductive technology as well as differing cultural attitudes towards living with risks. In different treatment centres, there are different skills and procedures, different treatments on offer, different financial possibilities and different ethics inherent to how each team perceives what is best for the patient. Therefore, clinical decisions are not only complex but also subject to change. The International Infertility Counselling Organisation, established in 2003, has been a liaison group of the International Federation of Fertility Societies since 2004. It has 17 members, including the Swiss FertiForum, and serves to promote a comprehensive and ethical approach to the care of people affected by, or involved with, infertility by defining quality standards of communicative and counselling interventions and by supporting international co-operation and education.
© 2008 Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB3 8DB, UK
Article - Psychosocial counselling and multiple pregnancies - M Emery
In order to consider the issues concerning multiple pregnancy that should be addressed in counselling, two studies demonstrating peoples’ reactions from different perspectives to this subject are presented below. The multifaceted aspects, the subjective and the objective, aim to enrich the thought processes developed by clinicians and treatment experts. Subsequently, the concept of systematic preventative counselling used in the centre is described.
mothers who did not respond to the questionnaire were those whose children had the worst outcomes. The overall response rate was 81% and while, undoubtedly, there is a psychological bias in this study, it does offer an interesting view on how assisted reproduction mothers view these questions. Several other studies have observed couples undergoing assisted reproductive technology who preferred a twin outcome (Kalra et al., 2003; Newton et al., 2006).
Safety versus success in single embryo transfer: women’s preferences for outcomes of IVF
Centre de Procréation Médicalement Assistée (CPMA) procedures
In a prospective study by health economists, Scotland et al. (2006) used standard gamble interviews within the context of single embryo transfer (SET) versus double embryo transfer (DET) in a population of 81 women awaiting IVF. The aim was to compare scenarios of adverse birth outcomes of twin pregnancy (cerebral palsy, cognitive impairments, visual impairments, perinatal death) with a treatment failure scenario. The women had to consider one scenario with a certain outcome, for example, ‘your baby will have cerebral palsy’, and compare that with another scenario where there was a possibility of having a healthy baby but where the risks for a worse outcome (perinatal death) were increased.
At the centre in Lausanne, the treatment issues – somatic, psychosocial, technical, ethical, legal – are first discussed with the physician, who talks over the treatment options and their implications with the couple. If the treatment option is IVF or ICSI, the couple is referred to a nurse for an information session, which is a group session with generally four couples. Following the information session, the couple then returns to meet with a counsellor in order to discuss the emotional aspects and treatment implications. The cost of counselling is included within the set price of treatment and is an integral part of the centre’s procedure. In the rare cases where couples do not wish to participate in counselling, it is for the physician to decide if it is necessary before treatment.
When faced with the prospect of treatment failure, i.e. never giving birth, women in the study were willing to accept a significantly greater risk for their child of cerebral palsy or cognitive or visual impairment. These results suggest that women embarking on IVF treatment are influenced more strongly by considerations of treatment success than by future risks to their offspring, however severe those outcomes may be.
Psychosocial counselling is conducted with both partners who attend together. It takes about an hour and the objectives are: to evaluate the couple’s capacity to cope with stress and failure; to assist them on the emotional level; to enhance the partnership with the team at the centre; and to explore possible difficulties of future parenthood (Emery et al., 2003).
In another prospective study, Pinborg and her team took a random sub-population from the Danish Survey on morbidity in 4-year-old IVF/ICSI children to assess attitudes of mothers toward twin pregnancy and SET (Pinborg et al., 2003). A total of 300 questionnaires were sent out, 150 to women with IVF/ ICSI twin delivery and 150 to women with IVF/ICSI singleton delivery. The questionnaire measured preferences for singletons versus twins, and SET versus DET. The results showed that among these women, who had 4-year-old children, 87% of twin mothers and 61% of singleton mothers would prefer to have twins as first-born babies. While not all twin mothers feel this way and while this is a subjective study from which one cannot infer psychological hypotheses, the figures do represent the majority of both twin and singleton mothers. Furthermore, 83% of singleton mothers and 66% of twin mothers disagreed with the idea of SET. Only 13% of singleton mothers and 22% of twin mothers would agree to SET. Among the twin mothers, there was a trend towards more ICSI-treated women.
Issues relating to multiple pregnancies are addressed during this session. The legal and ethical restrictions relate to the Swiss situation, which means a maximum of three embryos transferred, cryopreservation at 2-pronucleate (PN) zygote stage and no embryo selection. Within the CPMA, the ethics are to avoid triple pregnancies, so triple embryo transfer is extremely rare. DET is offered if the risks of having twins are understood and acceptable to couples and no other risk is present. For example, if a woman presents a uterine malformation with a higher risk of miscarriage, the physician will prescribe SET. Similarly, for other medical conditions presenting a risk of decompensation during pregnancy such as various cardiac, pulmonary, neurological or psychiatric conditions, the physician will propose SET. Couples who do not wish to have twins also have the option of SET. However, it may be delicate for a couple to ask for SET if the physician has informed them that DET is possible. Also, in Switzerland, couples turning to assisted reproductive technology are often older (the mean age of women is over 35) and feel that time is running out. Therefore, if a couple has 10 zygotes and the centre suggests SET, they are being asked, potentially, to receive treatment for up to 1 year, trying to get pregnant. Furthermore, in Switzerland, couples must pay for treatment and cryopreservation themselves.
It cannot be deduced from the study to what extent the questioned mothers knew of the risk of adverse outcomes with twin pregnancy and there remains the possibility that the
When counselling couples, the counsellor asks them to consider how they would face the different scenarios. There are couples who welcome the prospect of twins as it enables them to catch
Attitudes of IVF/intracytoplasmic sperm injection (ICSI) mothers towards twin pregnancy and SET
RBMOnline®
19
Article - Psychosocial counselling and multiple pregnancies - M Emery
up on the time lost due to their infertility, to create their family immediately and to reverse their situation of infertility to one of ‘hyperfertility’. But there are also couples who are not enthusiastic about assisted reproduction, who are very prudent and feel that just one child is already a great responsibility. SET may be acceptable to younger couples, where the physician has assessed there is a good chance of pregnancy. The counsellor will discuss single and multiple pregnancy rates of the treatments suggested, specifically for SET and DET. As these rates vary in relation to primary or secondary infertility, fresh or thawed cycle, age of the woman, IVF or ICSI, they will not be detailed here. In this centre, embryos are transferred at the 4-cell stage, about 48 h after oocyte retrieval and, in accordance with Swiss law, cryopreservation is performed at the 2PN stage. This centre has, per oocyte retrieval, a cumulative singleton delivery rate of about 26% and a cumulative twin rate of about 5% (Germond et al., 2004). During counselling, risks inherent to pregnancy are also put forward. All pregnancies present risks for the mother and for the child, but twin pregnancies present higher risks than singleton pregnancies. For the mother, the risks of preeclampsia, postpartum haemorrhage, maternal mortality and possibly postpartum depression are increased (Antoine et al., 2004). For the babies, the risk of prematurity increases nine-fold, with higher risks for cerebral palsy and learning disabilities and the risk of perinatal mortality increases about five-fold (Antoine et al., 2004). The primary prevention of multiple pregnancies is through SET and DET. The centre offers cryopreservation at the 2PN stage, but is unable to offer embryo selection or preimplantation genetic diagnosis as these are prohibited by law. Secondary prevention, should a multiple pregnancy occur, includes fetal reduction from three to two only (and this is now very rare), and close monitoring of pregnancy, which can reduce some of the
20
risks (Cohen, 2006). In order to conclude the counselling session, the couples are asked: (i) how does each partner feel facing these issues and which of them are worrisome; (ii) how does the couple anticipate these possibilities; and (iii) what psychosocial support outside the couple exists and could be mobilized? These questions allow the partners to formulate their actual feelings, which may be positive and energetic or rather negative and fragile. This is useful, for the individuals themselves and for the other partner to hear and take into account. The most worrisome issues for men and women are expressed as ‘how to cope’ with the even higher level of uncertainty linked to a multiple pregnancy. Men are often most worried about their partners, and about how to best support them. Women may be worried about feeling even more responsibility for carrying a pregnancy with more risks, and how to deal with that greater degree of anxiety. Couples anticipate these possibilities in the light of their psychosocial situations. Often they recognize their resources, providing examples of how they managed to cope with other difficult situations, such as a previous illness or the death of a family member. Furthermore, stating their situation as a couple, for example, ‘we handle emotions differently but are attentive to one another’ or ‘we are in on this together’, is generally reassuring and fortifying. Specifying the possibilities for seeking more support if needed (in the family, among friends or professionals) makes this option more real and feasible. A proposition for professional support may also be formulated, if necessary, and the counsellor remains available during and after treatment.
Conclusion When one contemplates twins in an ideal situation, such as the one pictured in Figure 1, it is difficult to confront wouldbe parents with all the implications of having twins. Risk
Figure 1. Healthy sleeping twins (reproduced with parents’ permission). RBMOnline®
Article - Psychosocial counselling and multiple pregnancies - M Emery
assessment is delicate in times where hope and fulfilling ideas regarding motherhood are so strong. In counselling it is, however, possible to increase the awareness of risks. The fundamental questions raised by the studies presented in this paper are what information do couples actually retain and how do they weigh-up the risks described? Further psychological studies on these issues would be helpful for a more precise conceptualisation of the counselling intervention. In accordance with medical deontology, centres agree that it is essential to ensure that each couple has taken part in the risk assessment and decision-making wholeheartedly, as they will then be more apt to accept the outcome of treatment, be it no pregnancy, a singleton pregnancy, or a twin pregnancy. However, only some centres offer specific in-depth counselling. Evidently, a responsible attitude to embryo transfer should be adopted by each centre, but a consensus among centres will not be found easily (Cohen, 2006). Psychosocial counselling represents a useful framework for reflection while continuing to research future safety strategies.
References Antoine J-M, Audebert A, Avril C et al. 2004 Treatments of sterility and multiple pregnancies in France: analysis and recommendations. Gynécologie Obstétrique et Fertilité 32, 7–8. Brügger O 2004 Helmet and wrist protectors in snow sport: effect and specifications. Swiss Council for Accident Prevention BFU Report 54. Cohen J 2006 Embryo transfer: one or two? Reproductive BioMedicine Online 12, 644–645. Emery M, Béran M-D, Darwiche J et al. 2003 Results from a prospective, randomised, controlled study evaluating the acceptability and effects of routine pre-IVF counselling. Human Reproduction 18, 2647–2653. Germond M, Urner F, Chanson A et al. 2004 What is the most relevant standard of success in assisted reproduction? The cumulated singleton/twin delivery rates per oocyte pick-up: the CUSIDERA and CUTWIDERA. Human Reproduction 19, 2442–2444. Kalra SK, Milad MP, Klock SC, Grobman WA 2003 Infertility patients and their partners: differences in the desire for twin gestations. Obstetrics and Gynecology 102, 152–155. Newton CR, McBride J, Feyles V et al. 2007 Factors affecting patients’ attitudes toward single- and multiple-embryo transfer. Fertility and Sterility 87, 269–278. Pinborg A, Loft A, Schmidt L, Andersen AN 2003 Attitudes of IVF/ ICSI-twin mothers towards twins and single embryo transfer. Human Reproduction 18, 621–627. Scotland GS, McNamee P, Peddie V, Bhattacharya S 2006 Safety versus success in SET: women’s preferences for outcomes of IVF. Abstract, European Society for Human Reproduction and Embryology, 22nd Annual Meeting, June 2006 Prague, Czech Republic. Received 19 January accepted 7 March 2007.
2007;
refereed
7
February
2007;
21 RBMOnline®
Article Which issues concerning multiple pregnancies should be addressed during psychosocial counselling? Marysa Emery FMH Médecin Praticien, Médecine psychosomatique et psychosociale AMPP, Centre de Procréation Médicalement Assistée, Ave Marc Dufour 1, 1007 Lausanne, Switzerland Correspondence: Tel: +41 21 321 15 80; Mobile: +41 79 717 10 78; e-mail: [email protected] Marysa Emery obtained her medical degree and doctorate from the Department of Social and Preventive Medicine, University of Lausanne, Switzerland. Her postgraduate training in psychiatry and psychosomatic medicine brought her to the field of psychosocial counselling for assisted reproduction technologies in 1997, in the team of Professor Marc Germond. Linking psychosocial consultations and clinical research, Dr. Emery engaged in conceptualising and implementing systematic counselling for infertile couples to help avoid multiple births. Her current research interests also encompass the psychosocial implications of open-identity donor insemination for the parents, the offspring and the donors.
Abstract The global rise in multiple pregnancy rates due to assisted reproductive technology has led to the development of various strategies to diminish these rates without jeopardising pregnancy. Policies at treatment centres may include the option of fetal reduction, although each centre is subject to national laws and its own guidelines. However, personal opinions and goals may also influence practice. The development of clinical decisions, therefore, is complex and subject to change. Primary prevention is the best way to reduce multiple births. For preventative psychosocial counselling, some centres employ counsellors, but if not, this becomes the physician’s task. An in-depth assessment is required to define how many embryos to transfer and what risk of multiple birth is acceptable to patients. Counselling should address the following: the relationship between pregnancy rate, multiple pregnancy rate and the number of embryos transferred; benefits and risks of multiple pregnancy; and possibilities for primary and secondary prevention. Patients should voice how they feel facing these issues; which issues are worrisome; how they anticipate these possibilities; and what psychosocial support exists that could be mobilized. In summary, psychosocial counselling reinforces the partnership between couples and the assisted reproductive technology team, allowing for primary prevention and informed consent on multiple pregnancy issues. Keywords: counselling, IVF, multiple pregnancies, prevention
18
Introduction to risk assessment
International dimension
Switzerland is renowned for its beautiful mountain scenery and for its popular winter sports: skiing and snowboarding. Though popular, these sports do raise questions in relation to their inherent risks. Every year, 42,000 Swiss skiers and 25,000 snowboarders require medical treatment for injuries. On average, expenses of more than €5000 per skiing accident and almost €2000 per snowboarding accident are incurred. On average, 40 people die in Switzerland every year as a result of a ski or snowboarding accident (Brügger, 2004). The aim of this observation is not to compare the prevention of multiple pregnancies to accident prevention, but to highlight the growing awareness of risks and of risk assessment within modern culture. The assessment of multiple pregnancy risks will occur within a framework of cultural and individual risk assessment. It is important to note that this applies to patients as well as to professionals.
Around the world, countries have differing legislations relating to assisted reproductive technology as well as differing cultural attitudes towards living with risks. In different treatment centres, there are different skills and procedures, different treatments on offer, different financial possibilities and different ethics inherent to how each team perceives what is best for the patient. Therefore, clinical decisions are not only complex but also subject to change. The International Infertility Counselling Organisation, established in 2003, has been a liaison group of the International Federation of Fertility Societies since 2004. It has 17 members, including the Swiss FertiForum, and serves to promote a comprehensive and ethical approach to the care of people affected by, or involved with, infertility by defining quality standards of communicative and counselling interventions and by supporting international co-operation and education.
© 2008 Published by Reproductive Healthcare Ltd, Duck End Farm, Dry Drayton, Cambridge CB3 8DB, UK
Article - Psychosocial counselling and multiple pregnancies - M Emery
In order to consider the issues concerning multiple pregnancy that should be addressed in counselling, two studies demonstrating peoples’ reactions from different perspectives to this subject are presented below. The multifaceted aspects, the subjective and the objective, aim to enrich the thought processes developed by clinicians and treatment experts. Subsequently, the concept of systematic preventative counselling used in the centre is described.
mothers who did not respond to the questionnaire were those whose children had the worst outcomes. The overall response rate was 81% and while, undoubtedly, there is a psychological bias in this study, it does offer an interesting view on how assisted reproduction mothers view these questions. Several other studies have observed couples undergoing assisted reproductive technology who preferred a twin outcome (Kalra et al., 2003; Newton et al., 2006).
Safety versus success in single embryo transfer: women’s preferences for outcomes of IVF
Centre de Procréation Médicalement Assistée (CPMA) procedures
In a prospective study by health economists, Scotland et al. (2006) used standard gamble interviews within the context of single embryo transfer (SET) versus double embryo transfer (DET) in a population of 81 women awaiting IVF. The aim was to compare scenarios of adverse birth outcomes of twin pregnancy (cerebral palsy, cognitive impairments, visual impairments, perinatal death) with a treatment failure scenario. The women had to consider one scenario with a certain outcome, for example, ‘your baby will have cerebral palsy’, and compare that with another scenario where there was a possibility of having a healthy baby but where the risks for a worse outcome (perinatal death) were increased.
At the centre in Lausanne, the treatment issues – somatic, psychosocial, technical, ethical, legal – are first discussed with the physician, who talks over the treatment options and their implications with the couple. If the treatment option is IVF or ICSI, the couple is referred to a nurse for an information session, which is a group session with generally four couples. Following the information session, the couple then returns to meet with a counsellor in order to discuss the emotional aspects and treatment implications. The cost of counselling is included within the set price of treatment and is an integral part of the centre’s procedure. In the rare cases where couples do not wish to participate in counselling, it is for the physician to decide if it is necessary before treatment.
When faced with the prospect of treatment failure, i.e. never giving birth, women in the study were willing to accept a significantly greater risk for their child of cerebral palsy or cognitive or visual impairment. These results suggest that women embarking on IVF treatment are influenced more strongly by considerations of treatment success than by future risks to their offspring, however severe those outcomes may be.
Psychosocial counselling is conducted with both partners who attend together. It takes about an hour and the objectives are: to evaluate the couple’s capacity to cope with stress and failure; to assist them on the emotional level; to enhance the partnership with the team at the centre; and to explore possible difficulties of future parenthood (Emery et al., 2003).
In another prospective study, Pinborg and her team took a random sub-population from the Danish Survey on morbidity in 4-year-old IVF/ICSI children to assess attitudes of mothers toward twin pregnancy and SET (Pinborg et al., 2003). A total of 300 questionnaires were sent out, 150 to women with IVF/ ICSI twin delivery and 150 to women with IVF/ICSI singleton delivery. The questionnaire measured preferences for singletons versus twins, and SET versus DET. The results showed that among these women, who had 4-year-old children, 87% of twin mothers and 61% of singleton mothers would prefer to have twins as first-born babies. While not all twin mothers feel this way and while this is a subjective study from which one cannot infer psychological hypotheses, the figures do represent the majority of both twin and singleton mothers. Furthermore, 83% of singleton mothers and 66% of twin mothers disagreed with the idea of SET. Only 13% of singleton mothers and 22% of twin mothers would agree to SET. Among the twin mothers, there was a trend towards more ICSI-treated women.
Issues relating to multiple pregnancies are addressed during this session. The legal and ethical restrictions relate to the Swiss situation, which means a maximum of three embryos transferred, cryopreservation at 2-pronucleate (PN) zygote stage and no embryo selection. Within the CPMA, the ethics are to avoid triple pregnancies, so triple embryo transfer is extremely rare. DET is offered if the risks of having twins are understood and acceptable to couples and no other risk is present. For example, if a woman presents a uterine malformation with a higher risk of miscarriage, the physician will prescribe SET. Similarly, for other medical conditions presenting a risk of decompensation during pregnancy such as various cardiac, pulmonary, neurological or psychiatric conditions, the physician will propose SET. Couples who do not wish to have twins also have the option of SET. However, it may be delicate for a couple to ask for SET if the physician has informed them that DET is possible. Also, in Switzerland, couples turning to assisted reproductive technology are often older (the mean age of women is over 35) and feel that time is running out. Therefore, if a couple has 10 zygotes and the centre suggests SET, they are being asked, potentially, to receive treatment for up to 1 year, trying to get pregnant. Furthermore, in Switzerland, couples must pay for treatment and cryopreservation themselves.
It cannot be deduced from the study to what extent the questioned mothers knew of the risk of adverse outcomes with twin pregnancy and there remains the possibility that the
When counselling couples, the counsellor asks them to consider how they would face the different scenarios. There are couples who welcome the prospect of twins as it enables them to catch
Attitudes of IVF/intracytoplasmic sperm injection (ICSI) mothers towards twin pregnancy and SET
RBMOnline®
19
Article - Psychosocial counselling and multiple pregnancies - M Emery
up on the time lost due to their infertility, to create their family immediately and to reverse their situation of infertility to one of ‘hyperfertility’. But there are also couples who are not enthusiastic about assisted reproduction, who are very prudent and feel that just one child is already a great responsibility. SET may be acceptable to younger couples, where the physician has assessed there is a good chance of pregnancy. The counsellor will discuss single and multiple pregnancy rates of the treatments suggested, specifically for SET and DET. As these rates vary in relation to primary or secondary infertility, fresh or thawed cycle, age of the woman, IVF or ICSI, they will not be detailed here. In this centre, embryos are transferred at the 4-cell stage, about 48 h after oocyte retrieval and, in accordance with Swiss law, cryopreservation is performed at the 2PN stage. This centre has, per oocyte retrieval, a cumulative singleton delivery rate of about 26% and a cumulative twin rate of about 5% (Germond et al., 2004). During counselling, risks inherent to pregnancy are also put forward. All pregnancies present risks for the mother and for the child, but twin pregnancies present higher risks than singleton pregnancies. For the mother, the risks of preeclampsia, postpartum haemorrhage, maternal mortality and possibly postpartum depression are increased (Antoine et al., 2004). For the babies, the risk of prematurity increases nine-fold, with higher risks for cerebral palsy and learning disabilities and the risk of perinatal mortality increases about five-fold (Antoine et al., 2004). The primary prevention of multiple pregnancies is through SET and DET. The centre offers cryopreservation at the 2PN stage, but is unable to offer embryo selection or preimplantation genetic diagnosis as these are prohibited by law. Secondary prevention, should a multiple pregnancy occur, includes fetal reduction from three to two only (and this is now very rare), and close monitoring of pregnancy, which can reduce some of the
20
risks (Cohen, 2006). In order to conclude the counselling session, the couples are asked: (i) how does each partner feel facing these issues and which of them are worrisome; (ii) how does the couple anticipate these possibilities; and (iii) what psychosocial support outside the couple exists and could be mobilized? These questions allow the partners to formulate their actual feelings, which may be positive and energetic or rather negative and fragile. This is useful, for the individuals themselves and for the other partner to hear and take into account. The most worrisome issues for men and women are expressed as ‘how to cope’ with the even higher level of uncertainty linked to a multiple pregnancy. Men are often most worried about their partners, and about how to best support them. Women may be worried about feeling even more responsibility for carrying a pregnancy with more risks, and how to deal with that greater degree of anxiety. Couples anticipate these possibilities in the light of their psychosocial situations. Often they recognize their resources, providing examples of how they managed to cope with other difficult situations, such as a previous illness or the death of a family member. Furthermore, stating their situation as a couple, for example, ‘we handle emotions differently but are attentive to one another’ or ‘we are in on this together’, is generally reassuring and fortifying. Specifying the possibilities for seeking more support if needed (in the family, among friends or professionals) makes this option more real and feasible. A proposition for professional support may also be formulated, if necessary, and the counsellor remains available during and after treatment.
Conclusion When one contemplates twins in an ideal situation, such as the one pictured in Figure 1, it is difficult to confront wouldbe parents with all the implications of having twins. Risk
Figure 1. Healthy sleeping twins (reproduced with parents’ permission). RBMOnline®
Article - Psychosocial counselling and multiple pregnancies - M Emery
assessment is delicate in times where hope and fulfilling ideas regarding motherhood are so strong. In counselling it is, however, possible to increase the awareness of risks. The fundamental questions raised by the studies presented in this paper are what information do couples actually retain and how do they weigh-up the risks described? Further psychological studies on these issues would be helpful for a more precise conceptualisation of the counselling intervention. In accordance with medical deontology, centres agree that it is essential to ensure that each couple has taken part in the risk assessment and decision-making wholeheartedly, as they will then be more apt to accept the outcome of treatment, be it no pregnancy, a singleton pregnancy, or a twin pregnancy. However, only some centres offer specific in-depth counselling. Evidently, a responsible attitude to embryo transfer should be adopted by each centre, but a consensus among centres will not be found easily (Cohen, 2006). Psychosocial counselling represents a useful framework for reflection while continuing to research future safety strategies.
References Antoine J-M, Audebert A, Avril C et al. 2004 Treatments of sterility and multiple pregnancies in France: analysis and recommendations. Gynécologie Obstétrique et Fertilité 32, 7–8. Brügger O 2004 Helmet and wrist protectors in snow sport: effect and specifications. Swiss Council for Accident Prevention BFU Report 54. Cohen J 2006 Embryo transfer: one or two? Reproductive BioMedicine Online 12, 644–645. Emery M, Béran M-D, Darwiche J et al. 2003 Results from a prospective, randomised, controlled study evaluating the acceptability and effects of routine pre-IVF counselling. Human Reproduction 18, 2647–2653. Germond M, Urner F, Chanson A et al. 2004 What is the most relevant standard of success in assisted reproduction? The cumulated singleton/twin delivery rates per oocyte pick-up: the CUSIDERA and CUTWIDERA. Human Reproduction 19, 2442–2444. Kalra SK, Milad MP, Klock SC, Grobman WA 2003 Infertility patients and their partners: differences in the desire for twin gestations. Obstetrics and Gynecology 102, 152–155. Newton CR, McBride J, Feyles V et al. 2007 Factors affecting patients’ attitudes toward single- and multiple-embryo transfer. Fertility and Sterility 87, 269–278. Pinborg A, Loft A, Schmidt L, Andersen AN 2003 Attitudes of IVF/ ICSI-twin mothers towards twins and single embryo transfer. Human Reproduction 18, 621–627. Scotland GS, McNamee P, Peddie V, Bhattacharya S 2006 Safety versus success in SET: women’s preferences for outcomes of IVF. Abstract, European Society for Human Reproduction and Embryology, 22nd Annual Meeting, June 2006 Prague, Czech Republic. Received 19 January accepted 7 March 2007.
2007;
refereed
7
February
2007;
21 RBMOnline®