Document Type : Original Article
1 Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Reproduction and Development, Reproductive Biomedicine Research Center, Royan Institute for Animal Biotechnology, ACECR, Isfahan, Iran
3 Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran;Tehran University of Medical Sciences, Tehran, Iran
Preconception counseling can improve maternalfetal health, both during pregnancy and afterwards. Due to limitations of perinatal care and the importance of maternal health before pregnancy, counseling should be offered before conception. Maintaining a healthy environment around the oocyte and the embryo is essential to the health of the child. Preconception counseling helps prepare for pregnancy and secures the health of the oocyte/ fetus. Preconception training and counseling prepares the parents for a healthy pregnancy, creating ideal conditions for the oocyte and ultimately the fetus. Infertile couples may have been exposed to conditions that contributed to their fertility.
The same factors can affect the health and outcome
of pregnancy. Fertility treatment may be
lengthy, and failure is not uncommon. Their presence
at treatment centers prior to conception and
their high motivation to achieve a healthy pregnancy
offer a good opportunity for preconception
training and counseling, possibly leading to an improved outcome of pregnancy. Despite
planning vigorously to overcome infertility, couples
may lose sight of critical preconception care,
which is the key to a successful pregnancy (
This is a quantitative, descriptive, cross-sectional study of 268 individuals who received treatment for infertility for at least the second time at specialist clinics across the city of Isfahan, Iran. The study was conducted between September 2008 and May 2009. Excluded from the study were couples who used donated eggs/fetuses or gestational surrogacy techniques. Simple sampling method was used. Data were collected from questionnaires, interviews and patient medical records after obtaining written informed consent from subjects.
The research tool consisted of a two-part questionnaire: personal details were entered in part one and included ten items (age, education level, occupation, infertility category, infertility cause, infertility duration, treatment duration, treatment done, outcome of previous treatment, and treatment times). Part two obtained information about the couples’ preconception education/counseling as outlined in reference textbooks. It included two sections: a. personal counseling: life style (exercise, rest, genetic counseling, and personal health), diet (diet and weight balance) sexual health (sexual activity and sexual transmitted infections), substance abuse (addiction, smoking, and drug use) and psychosocial factors; b. treatment counseling: failure, follow up, and side effects.
This section was compiled using specialist textbooks in the field of preconception counseling. Data collection was conducted using medical records or by interviews in cases where records were incomplete. The counseling received by couples was described as 'complete', 'incomplete', or 'not given'.
A pilot study was performed on 20 individuals who were similar to the main study subjects with the intent to assess the reliability of our questionnaire. An alpha reliability coefficient of 0.75 was achieved. Pilot study subjects were not included in the main study. After the completion of sampling, we applied descriptive-analytical statistical methods (Pearson’s chi-square and Spearman correlation analysis) to process data. SPSS software (version 16) was used. The Ethics Committee of the Isfahan University of Medical Sciences approved this study.
We studied 268 couples who presented to fertility
clinics. Ten couples were excluded because
their records were incomplete and five others were
excluded for personal reasons. The demographic
characteristics of subjects are shown in
Basic characteristics according to gender
|< 30 years||150 (56)||69(25.7)|
|30-35 years||84 (31.3)||117 (43.7)|
|>35 years||33 (12.3)||82(30.6)|
|Mean ± SD||29.41 ± 4.99||32.68 ± 5.17|
|Less than high school||84 (31.4)||138 (51.5)|
|High school diploma||115 (42.9)||95(35.41)|
|University degree||69 (25.7)||30(11.19)|
|House keeper||212 (79.1)||0|
Descriptive analytical methods were used for analysis. We demonstrated that primary infertility was 88.1%, with maximum prevalence related to male factors. In 72.8% were not pregnancy before and the maximum prevalence for the previous treatment was induction ovulation (27.2%). Most couples were undergoing their second cycle of infertility treatment (44.8%), and 69% failed the previous treatment. The mean infertility duration was 5.06 (years) and the duration of infertility treatment in couples was 3.64 years. We found that 76.9% of couples had no lifestyle counseling, 70.9% had no diet counseling, 90.7% no sexual health counseling, 90.7% no counseling on the psychosocial aspects of infertility. 56.34% received incomplete counseling on substance abuse, 67.9% received complete counseling on treatment failure. 46.6% of couples received no counseling on follow-up procedures, and 46.6% received no counseling on the side effects of treatment.
Most counseling cases were concerned
with treatment failure (67.9%), with the
fewest cases being related to sexual health
The chi square test was used to examine the relationship between counseling and infertility causes. The results revealed a significant relationship between causes of infertility and individual (p=0.02) as well as therapeutic counseling (p=0.01).
Analysis of the correlation of educational
components/preconception counseling with
some individual characteristics seen in couples
is shown in
Frequency distribution of preconception counseling according etiology of infertility
|Counseling items||Treatment (offered)||Basic items (offered)|
Correlation between counseling and basic individual characteristics
|Education||Treatment times||Duration of infertility treatment||Duration of infertility|
|0.06||- 0.02||- 0.03||- 0.03|
* p<0.05, ** p<0.001 and Others: p>0.05.
In this study we have assessed the availability
of preconception education/counseling to infertile
couples. Researchers recommend that training and
counseling related to various medical, psychological,
social, and health-related aspects of infertility
be integrated into routine programs for infertility
Based on our review of the literature, this is
probably the first study of its kind to comprehensively
address the various aspects of preconception
education/counseling offered to infertile couples.
The demographic characteristics of individuals in
this study make them a representative sample of
infertile Iranian couples, because the distribution
of infertility-related variables/indicators in our
study is similar to that in other studies (
This study demonstrates significant flaws in all aspects
of counseling in basic areas such as lifestyle,
diet, sexual health, substance abuse, and psychosocial
aspects of infertility. Other studies have
shown that factors such as obesity, poor diet, and
substance abuse influence fertility, the outcome of
infertility treatment, perinatal complications, and
the outcome of pregnancy (
According to one study, most infertility specialists
recommend cessation of smoking (
We have found that most couples had not received
any sexual counseling. Studies have demonstrated
that sexual disorders are prevalent
among infertile couples, possibly contributing to
their infertility (
The findings of the present study may have been influenced by either Iranian cultural behaviors (which tend to discourage open conversation about sexual matters), the counselors’ tendency to consider the couples’ sex lives as their private matters, or failure in appreciating the significance of a healthy sexual relationship in achieving a successful pregnancy.
Most individuals in our study had not received
any psychosocial counseling. Several studies have
shown that couples treated for infertility experience
a high level of anxiety (
Mental stress can lead to infertility, reduced
Another study has shown a wide range of psychological
disorders to be more prevalent among
infertile couples compared to healthy ones (
A direct significant relationship that was seen between the causes of infertility and the frequency of personal counseling was probably related to the fact that infertility treatment providers were more likely to offer counseling to individuals with idiopathic infertility. This may help tackle the hidden causes of infertility. Personal preference for counseling may also have played a role.
We found that the majority of individuals had received complete counseling about the failure and side effects of treatment, while no counseling had been offered about follow-up. It is crucial to keep the infertile couples informed about the course and implications of treatment.
Awareness of failure rates, possible side effects,
and treatment follow-up influences the outcome
and cost of infertility treatment (
We found a significant direct relationship between the etiology of infertility and amount of treatment-related counseling. More counseling was offered when the cause of infertility was unknown; these may be accounted for by the patients’ greater concern about their condition, which resulted in more frequent visits. A lower amount of counseling when a male etiology was suspected was probably due to men’s lower involvement in the treatment process, lower attention/sensitivity to the problem, and forgetfulness. This may in part be related to the Iranian male’s cultural tendency to consider their partners as the source of infertility early in the treatment. Some men find it hard to accept that the problem may in fact have a male cause; they remain in denial and discontinue, or fail to attend counseling. Counseling offered by a male counselor, educating the clients about fertility, and improved education will probably increase the demand for counseling in this group of patients.
We have observed a direct relationship between education and some individual characteristics of the patients. Higher education apparently made couples more likely to seek counseling; individual attitudes, personal reactions to suggestions, and the quality of encounters with the therapy team possibly played a role. In other instances no relationship was observed. It was possible the infertility treatment team assumed that well educated couples did not require as much counseling as those less educated. Although educated couples may have some health information, this may be inadequate and complete preconception counseling should be provided. Certain elements in counseling which have exhibited a direct relationship with the number of treatments, length of treatment, and length of infertility may have done so by increasing the sensitivity/interest of both the couples and therapists.
The infertility treatment process usually begins with the induction of ovulation. At this stage, this may still be considered a routine treatment without proper counseling and emphasis on infertility. Thus, in this study the amount of counseling increased with repeated visits and increased duration of treatment. Our results were reasonably consistent with the current status of the treatment system.
To improve the outcome of infertility treatment, we propose that any factor which can shorten the duration of treatment and increase success rates (including counseling) be considered from the outset of treatment. Where significant relationships were not seen, other factors may have been involved.
Further studies are warranted to find stronger links and causative factors.
The provision of preconception counseling to infertile couples in Iran is largely flawed. The greater than usual importance of achieving a successful pregnancy in this group of patients warrants special attention to preconception counseling. We propose that providers and recipients of infertility treatment be sensitized about the importance of counseling; this can be accomplished by using standard forms and educational pamphlets/brochures, as well as virtual training.