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Section 25
Three Distinct Types of Counseling

Question 25 | Test | Table of Contents

Infertility counseling
Infertility counseling has been developing as a specialist field of practice since the late 1980s, following the Warnock Committee recommendations in 1984 that 'counseling should be available to all infertile couples and third parties at any stage of treatment, both as an integral part of NHS provision and in the private sector'. These recommendations were later translated into a statutory requirement through the Human Fertilization and Embryology Act (1990) for licensed clinics, which is upheld by Human Fertilization and Embryology Authority (HFEA) regulations that expect 'individuals … to be able to seek counseling at any stage of their investigation or treatment, i.e. before, during and after treatment'.

Counselors working in the field are expected to hold a qualification and membership of a professional body that meets with specified criteria, and to fulfill a role that is clearly distinguished from information or advice-giving, other patient-clinical staff relationships, and the process of assessment for treatment provision or acceptance as a donor. Counselors may work with clients within a centre, or facilitate their referral to external counseling or other specialist services. The HFEA identifies three distinct types of counseling. The counselor’s skill is in maintaining a primary focus on one whilst incorporating elements of the others:

  1. Implications counseling (donor assisted conception, surrogacy, treatment options) enables clients to reflect upon and understand the implications for themselves and others of the procedures they propose to undertake, exploring the personal meaning as well as the legal, ethical, social and psychological issues.
  2. Support counseling provides emotional support at particular times of stress. Because the process is long, many clients find that their own coping resources become depleted and that other available resources also dwindle over time.
  3. Therapeutic counseling assists people in developing successful coping strategies for dealing with both the short- and long-term consequences of infertility and its treatment.

Prior to the HFE Act there were few practicing infertility counselors and no specialist training or even any requirement for a counseling qualification. It was against this backdrop that the British Infertility Counseling Association (BICA) was founded in 1988, with a primary remit to promote the highest standards of counseling in infertility. This small professional body has made huge strides in promoting the status of counseling in the field of reproductive medicine and health, and in developing professional standards and training. BICA acts in a consultative capacity for the HFEA, other government bodies, related fertility societies and media and public interest groups, and it provides a counselor self-referral service for clients via its website.

Moreover, it was one of the first counseling associations to develop a university-rated, postgraduate level specialist accreditation, which has been followed by a growth in BICA-run training events, including an introductory course for counselors new to practice in licensed treatment centers.

Counseling clients in assisted conception requires a way of working that accommodates clients around and alongside their treatments. It is not unusual for clients to dip in and out of counseling, with its timing, frequency and focus being something over which they can have some sense of control in circumstances that. may otherwise feel uncontrollable and devoid of choice. Versatility, flexibility and the resourcefulness of the counselor are key components in his or her choice of approaches to a wide range of presenting issues (see boxes). Complementary therapies such as hypnotherapy, acupuncture and reflexology feature too -- used by clients for self-support and in some instances to enhance their chances of pregnancy.

Infertility counselors require specialist knowledge (legal, medical, scientific, psychological, sociological) not only for the direct benefit of their clients, but also to enable them to work effectively within a multidisciplinary team, typically made up of clinicians, nurses, embryologists, andrologists (specialists in the treatment of male reproductive disorders), counselors, and laboratory and administrative staff. The counselor’s role may include consultation, supervision, education and support to team members, along with the provision of a professional counseling service for patients. Most specialist infertility counselors are based within licensed centers; some have an external practice base. Some centers make an additional charge for counseling; some include a limited and others an unlimited number of sessions within the overall cost of treatment.

Challenges for clients
Assisted conception is exacting of physical, financial and personal coping resources, often accentuating the pressures of culture, religion or gender difference. Despite the introduction of NICE Guidelines, NHS funding for infertility treatment is minimal and remains a 'postcode lottery'. Treatment cycles are intrusive, invasive, and difficult to integrate with other life and work commitments. An intense and conflicting array of feelings weaves its way through each cycle, creating the proverbial rollercoaster ride. There may be an increasing sense of isolation from the usual support networks of family and friends, and communication between partners may become difficult as they struggle to negotiate a way through the demands of repeated attempts to achieve a pregnancy. Partners may hold back feelings out of concern for the other or fear of making matters worse, leading to increased polarizations and important thoughts and feelings going underground.

'My wife is more upset about different parts of … infertility than I am. She feels like a failure… losing contact with pregnant family and friends and crying so much of the time. I am upset over what it is doing to her both physically and emotionally. As a result, when I do feel like crying … I don't, because I'm afraid my crying would make her worse. I'm playing a game and we are both losing.'

Sexual tensions may also occur due to emotional distancing, pressure to perform sexual intercourse, doubts about its point or purpose, and loss of confidence in oneself as a fully sexual man or woman or complete human being. For many men there is still a sense of confusion between fertility and virility that reinforces feelings of shame and inadequacy. This is reflected in the use of pejorative language such as 'shooting blanks' or being a 'jaffa' (ie seedless). Others, like Benjamin Zephaniah, may have a clear sense of their masculinity and physical prowess, but still struggle to reconcile their loss: 'I reject the idea that my wanting is about machismo… I want to be a daddy; it's the greatest ambition I've ever had and it haunts me every day.' For women this loss may be felt as a lack of fecundity -- fruitfulness and creativity:

'Wasn't it the greatest shame a woman could know, to be found barren? A field that yields no crop, a tundra that supports no life; a glacier, a stone, a vacuum. When your calling is to fill that space, you dream always of rivers -- or seeds -- endlessly.'

In counseling many clients express a sense of being overwhelmed by their infertility and a fear of becoming obsessed by their desire to have a child. The loss of control of events and of a 'normal', familiar self or way of being features prominently. For some, the act of seeking counseling provides an initial sense of containment and relief (see case studies).

There can be a tremendous range of reactions, with people experiencing their infertility, failed treatment and lost pregnancies in profoundly divergent -- not always traumatic -- ways. As with other crises, partners may blame themselves for 'bad choices', such as delaying childbearing or having had an earlier termination of pregnancy. They may also blame others, including doctors, for not warning them about the risks of infertility. Their loss may not be verbalized -- many are too tender and vulnerable to share their feelings. Childlessness can take on an almost taboo-like quality, with neither those who experience it nor those who care about them feeling comfortable to broach the subject.

No matter what the outcome in regard to children, the ordeal of infertility reverberates long after the couple leaves the medical arena. It remains an issue during the years of hoping for a child and through later life-stages -- menopause, grandparenthood, widowhood, old age.

'But of course the pain never wholly goes, and although our marriage remains strong and happy, the grief sometimes catches us by surprise. And corny as it may sound, I would have loved to teach a boy cricket. I would show him what, because of the war, my own dear father, now 98, never had the chance to show me. The other evening I was watching an old movie, The Sea of Grass, when Spencer Tracy said, "Every man should have a son." Suddenly, from out of the blue, I wept.' (Ronald Higgins, 20 years after unsuccessful treatment.)
- Pike, Sheila, Grieve, Kate; Counseling Perspectives on the Landscape of Infertility; Therapy Today; Oct 2006; Vol.17; Issue 8

Personal Reflection Exercise #11
The preceding section contained information about infertility in women.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The effect of infertility counseling interventions on marital and sexual satisfaction of infertile couples: A systematic review and meta-analysis

Alirezaei, S., Taghipour, A., & Latifnejad Roudsari, R. (2022). The effect of infertility counseling interventions on marital and sexual satisfaction of infertile couples: A systematic review and meta-analysis. International journal of reproductive biomedicine, 20(10), 795–806. https://doi.org/10.18502/ijrm.v20i10.12264


Peer-Reviewed Journal Article References:
Casu, G., Zaia, V., Fernandes Martins, M. d. C., Parente Barbosa, C., & Gremigni, P. (2019). A dyadic mediation study on social support, coping, and stress among couples starting fertility treatment. Journal of Family Psychology, 33(3), 315–326. 

Galst, J. P. (2018). The elusive connection between stress and infertility: A research review with clinical implications. Journal of Psychotherapy Integration, 28(1), 1–13.

Hudson, J., Nahata, L., Dietz, E., & Quinn, G. P. (2018). Fertility counseling for transgender AYAs. Clinical Practice in Pediatric Psychology, 6(1), 84–92.

QUESTION 25
Many clients express feeling overwhelmed by their infertility.  What do they fear? To select and enter your answer go to Test.

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