Fertility counselling

What impact does fertility counselling have on the quality of life, mental health and decision-making processes of people with cancer?

Infertility or impaired fertility brought about by cancer treatment is associated with an increased risk for heightened psychological distress and reproductive concerns from the time of cancer diagnosis through to survivorship.^[1] Therefore, the opportunity to preserve fertility at the time of cancer diagnosis or later may assist in lowering levels of distress.

One component of fertility preservation management is fertility counselling, where patients are provided with information regarding the likely impact of gonadotoxic cancer treatment on their future fertility as well as information on suitable fertility preservation options. Fertility counselling aims both to assist in decision-making for fertility preservation treatment and also to provide psychological support at a difficult time for patients. Given its multipurpose role, fertility counselling may form part of an oncological or reproductive consult, and/or as a session with a mental health professional to further explore the implications of fertility preservation options as well as the emotional impact of threatened infertility.^[2]

Quality of life and mental health

When considered as a separate psycho-social counselling session, fertility counselling may assist with decision-making and lower anxiety.^[3] However, research is mixed, with another study demonstrating that although the presence of a psychologist in collaboration with a reproductive clinician is deemed to be helpful and appreciated by patients, an individual counselling session at the time of fertility preservation may elevate already heightened anxiety in the short term.^[4] This is most likely due to the increase in psychological pressure inherent in confronting treatment choices and actively engaging with decision-making.

Fertility counselling at the time of cancer diagnosis may assist in lowering decisional conflict and decisional regret, while improving access to fertility preservation treatment.^[5][6] Patients feel fertility counselling is most favourable when adequate time is taken to explore fertility preservation options and when they feel supported in their decision-making processes.^[7] It is also likely to be advantageous if clinicians possess greater reproductive knowledge, with preference for counselling by a reproductive specialist when integrated into a medical consult and not an oncology clinician alone.^[5]

Given that heightened emotional distress may be the primary reason why fertility preservation is not undertaken,^[8] it is important that patients are adequately supported in exploring fertility treatment options by a suitably trained mental health clinician. Women who receive fertility counselling are also more likely to undergo pre-treatment fertility preservation^.[8] Positive experiences of fertility counselling are associated with having enough time for counselling, the opportunity to ask questions, fertility preservation options clearly explained and discussed, being involved in decision-making and the presence of a psychologist in collaboration with reproductive specialist.^[7][4]

Research suggests that short term fertility, psychosexual or educational interventions provided throughout cancer treatment or survivorship, tailored to either adolescent or young adult patients, or adult patients of reproductive age, may be beneficial. These fertility interventions were shown to increase fertility and sexual health knowledge, lower emotional distress and depression associated with infertility or poor reproductive outcomes, and increase quality of life by improving social interactions or symptom management.^{[9][10][11][12]} As such, there appears to be merit in the provision of subsequent fertility counselling support throughout the cancer journey; in both managing ongoing fertility and family planning needs and reproductive complications and to assist in improving patient quality of life and mental health.

There is currently limited research evaluating the psychological impact of fertility counselling at the time of cancer diagnosis to assist in fertility preservation decision-making and support. Further research is needed to validate the best format for counselling or most suitable clinician to implement fertility counselling when fertility care is delivered as part of a multi-disciplinary team. The suitability of fertility counselling provision will depend on both the model of care implemented within local contexts and available resources within any health setting. Further implementation research is needed to best elucidate the most appropriate model of care for ongoing fertility support, throughout cancer treatment and survivorship.

Evidence-based recommendation	Grade
Fertility counselling should be offered to everyone with potentially curable cancer, ideally by a reproductive specialist and/or trained counsellor. Counselling should include education about fertility preservation options and support for patient decision-making.	B