CHAPTER 1 INTRODUCTION The writers was a qualified staff nurse for the past ten years.

She had an experience working with government hospital, locally. After qualified from the school of nursing, the writers had been posted at operating theatre department. She works there for almost eight years before she had to transferred out to another department. She gains a lot of experience and useful knowledge while working as a nurse in the operating theatre. The writers change a lot while working at operating theatre, she was more systematically and always thinks in advance and always be prepared for any danger situation. As everybody knows, we cannot predict any emergency cases that will be coming in operating theatre. All the experiences that the writers get from operating theatre, makes she more confidence and competence in her practicing skills and more useful when she make a move to another department, that required more advancement in nursing practice, professional accountability, teamwork, knowledgeable and most important things is patient safety. The writers had been transferred out to Gynecology Department as a field of a new practice. The writers had almost been working for about two years till today. Currently the writers had practicing at one of the brand new government hospital at Alor Setar. She is one of the pioneer at the hospital and she is also had been given responsibility to setting up the IVF Center. The writers had a very though and challenging moment in setting up the IVF Center. She applies all her knowledge and experiences, until the department had successfully been launched after went through all the processes and also co-operation from the staff that showed their dedication to the Gynaecology Department. The writers had been given opportunity and trust by the Director of Nursing, because at that time, only the writers had a special course for the Gynecology. Prior to become a Gynaecology Nurse, the writers took a six month course, which is including theory and practical in specialized area. As a Gynaecology Nurse, the writers needs to focus on patient assessment, supportive care, health teaching and the most important thing is need to access patients physical and emotional status. Due to high infertility rate in Malaysia, makes the writers to put all her effort to take care and give moral and emotional support for the patient. The IVF Fertility Nurse provides constant support and day-to-day advice throughout the highs and lows of your fertility treatment. Often, a special relationship develops, and they will

enjoy nothing more than giving you the good news of your pregnancy. At this department, youll get to know your primary nurse very well. Theyll be the first person you see after meeting your specialists for the first time, theyre always available to answer your questions, and theyll take your blood tests and perform your ultrasounds. The small nursing team at your clinic will:

Provide you with information about your treatment Take your blood for hormone tests Perform your ultrasounds Liaise with your specialist to confirm the next steps in your treatment Refer you to a counselor if you need more support Follow up on your egg collection and embryo transfer Perform insemination procedures, if required Take your pregnancy test If your Fertility Specialist is also your obstetrician, your IVF nurse can continue to care

for you throughout your pregnancy, sometimes even during delivery. IVF Center has a team of 14 nurses in the clinic. They are all experienced midwives or have an extensive womens health background, and when they join Malaysian they undergo rigorous training in venepuncture, ultrasound and insemination. As IVF Center Director of Nursing, the writer brings a wealth of experience owing to her extensive background in gynaecology and infertility nursing. Prior to working with IVF Center, the writer practised fertility nursing at one of the largest teaching hospitals in the Kuala Lumpur. Since moving to Hospital Alor Setar in 2011, the writer has worked as the Unit Nurse Leader at IVF Center. The writer works very closely with IVF s Medical Director, Dr. Murizah, to consolidate protocols across all of the clinics and integrate nursing procedures into clinical practice. In this IVF Center, the nurses are here to answer your questions, discuss concerns and liaise with your doctor. They will perform tests, scans and injections, and teach you how to administer your own injections at home. Your fertility nurse can also provide specific care throughout the early stages of pregnancy. The nurses also guide you through the donor program if you are undergoing treatment using donor sperm, eggs, and embryos or utilizing our surrogacy program. A specialist Early Pregnancy Care Nurse will monitor your early stages of pregnancy, especially if you have experienced a pregnancy loss, or are at risk of this occurring. This includes

all necessary tests and monitoring, as well as liaising with your fertility specialist and providing advice. All the nurses will be responsible for ensuring individualized care for each and every patient to support them through the IVF journey. As an IVF nurse, her job is to help to arrange all the procedures needed for the couples who intend to do the procedures. In vitro fertilization and embryo transfer (IVF-ET) was first successfully used in humans over 25 years ago; since then, more than one million children have been conceived using this technology. IVF is a procedure designed to enhance the likelihood of conception in couples for whom other fertility therapies have been unsuccessful or are not possible. It is a complex process and involves multiple steps resulting in the insemination and fertilization of oocytes (eggs) in our laboratory. The embryos created in this process are then placed into the uterus for potential implantation. Each stage of the procedure is associated with specific risks, as outlined below. Benefit of Therapy IVF is an elective medical treatment. IVF may provide a couple who has been otherwise unable to conceive with a chance to establish a pregnancy. Risks of Therapy Superovulation Stimulates Egg Development The controlled "superovulation" techniques used in IVF are designed to stimulate the ovaries to produce several eggs (oocytes) rather than the usual single egg as in a natural cycle. Multiple eggs increase the potential availability of multiple embryos (fertilized eggs) for transfer and ultimately increase the probability of conception. The medications required to boost egg production may include, but are not limited to the following: Lupron (gonadotropin releasing hormone-agonist), Antagon or Cetrotide (gonadotropin releasing hormone-antagonist), Follistim, Bravelle or Gonal-F (FSH, follicle stimulating hormone), Repronex (combination of FSH and LH, luteinizing hormone), and Pregnyl or Novarel (hCG, human chorionic gonadotropin). Each is administered by injection only. Most medications are given subcutaneously (beneath the skin), though some are intramuscular injections (into the muscle). Risks associated with injectable fertility medications may include but are not limited to, tenderness, infection, hematoma, and swelling or bruising at the injection site. Risks associated with the medications may include, but are not limited to, allergic reactions, hyperstimulation of the ovaries (mild, moderate or severe), failure of the ovaries to respond and cancellation of the treatment cycle.

There are situations that can occur during a stimulation that may necessitate canceling your IVF cycle and stopping treatment for a period of time. This occurs because the ovaries produce either too many or too few eggs in response to drug stimulation protocol. Although we realize that this can be a big disappointment, at times it is necessary to discontinue the use of the medications to avoid the possibility of complications and to afford you the best chance of future success. If canceling the cycle becomes necessary, you will be told to stop your injections. No hCG injection will be given and no egg retrieval will occur. You will be asked to schedule an appointment with your physician to make decisions regarding future treatment cycles. When ovulation induction medications are used in fertility therapy, the ovaries are coaxed to produce more than one egg to the point of maturity. Consequently, hormone levels of estrogen and progesterone reach much higher than normal values. When the estrogen level becomes mildly to moderately elevated, side effects that may be experienced include, but are not limited to, fluid retention with slight transient weight gain, nausea, diarrhea, pelvic discomfort due to enlarged cystic ovaries, breast tenderness, mood swings, headache and fatigue. Ovarian Hyperstimulation Syndrome (OHSS) If the estrogen level rises excessively and hCG is administered to trigger final maturation of the eggs, the following more serious complications may result: 1. Excessive fluid retention with fluid in the abdomen and/or chest cavity; 2. Thrombosis of arteries and/or veins (formation of blood clots) which may lead to stroke, embolus, or potentially fatal complications; 3. Abnormally enlarged ovaries, which have the possibility of rupturing or twisting (a surgical emergency) Any of the three problems listed above may require prolonged hospitalization. Given the potential for such severe complications, it is important that we carefully monitor your response to these medications. This monitoring also allows your physician to determine when the eggs are ready for the next stage, oocyte (egg) retrieval. Monitoring includes frequent blood drawing for estradiol (estrogen) and possibly progesterone, LH and FSH levels. These blood tests will take place over approximately a twelve-day period. Risks associated with blood drawing may include, but are not limited to: 1. Pain at the site of needle stick 2. Tenderness or infection of the skin

3. Bruising or scarring of the site of blood draw 4. Development of a blood clot in the vein (thrombosis, thrombophlebitis) The second portion of the monitoring phase in IVF involves the use of intravaginal ultrasound to track follicular growth. The eggs develop inside fluid-filled cysts of the ovaries called follicles, which enlarge as the eggs mature. Ultrasound studies usually begin after an estrogen response has been measured and continue on a frequent basis until oocyte (egg) retrieval. The ultrasound studies are performed using a vaginal probe. Vaginal sonograms carry no appreciable risk but may cause slight discomfort, particularly as you near the point of ovulation. Ovarian stimulation with the fertility medications causes multiple follicles to develop. This is desirable in IVF because as the number of eggs increases, the chance for success increases. Multiple embryos can also increase the risk of multiple pregnancy. Approximately 2025% of pregnancies with IVF will be multiple. Most of these will be twins, but triplets, quadruplets or even greater multiple pregnancies can occur. A procedure called "selective reduction of pregnancy" has been performed in several medical centers across the country in selected cases of triplets or more. Selective reduction is not offered on site or by GRS staff. More information on this procedure and recommended centers is available on request. Retrieving the Oocytes (egg retrieval) For IVF, collection of eggs is usually performed under transvaginal ultrasound guidance. To accomplish this, a needle is inserted (under IV sedation) through the vaginal wall into the ovaries using ultrasound to locate each follicle. The follicular fluid is drawn up into a test tube to obtain the eggs. Although patients are given pain medications intravenously and are carefully monitored by an anesthesiology staff, some women may experience some discomfort during the procedure. Generally, the oocyte (egg) retrieval takes 20-30 minutes. Patients are usually discharged home within hours after the retrieval. Risks of oocyte (egg) retrieval may include, but are not limited to, the following: 1. Potential reactions from the drugs and procedures used in the administration of anesthesia. 2. Risks associated with the passage of the needle through the vagina into the ovaries (including infection, bleeding, inadvertent damage to adjacent structures including, but not limited to, the bowel, bladder, blood vessels, ureter, uterus or ovary(ies), and adhesion formation (internal scarring) following the procedure. Although uncommon,

significant bleeding or damage to the bowel may occur, and surgery may be required to repair such damage; this is a very uncommon event. Rarely, infection may become severe enough to require hysterectomy and/or removal of one or both ovaries. Collecting and Preparing the Sperm A semen sample will be obtained from the partner by masturbation on the day of the oocyte (egg) retrieval. This is usually obtained while the retrieval is being performed. Abstinence from ejaculation for two to five days prior to providing this semen specimen is recommended. After the specimen is produced, the sperm will be prepared for inseminating the collected eggs in our laboratory. Because this can be a stressful time period for men, the man/partner may be unable to produce a specimen when needed. Men who feel that they may have difficulty producing a semen specimen have the opportunity to have their specimens frozen by our laboratory ahead of time for use in this situation. Testicular biopsy can also be performed as a method to extract sperm for IVF. Insemination of Eggs and Embryo Culture Following egg retrieval, the follicular fluid is immediately transferred to the adjacent laboratory for identification of eggs, evaluation, and preparation for insemination. In the process of collecting the follicular fluid, it is possible that a large number of eggs may be retrieved. It is strongly recommended that all of these eggs be inseminated to maximize the number of embryos available for subsequent transfer. Any objection(s) to this policy should be stated in writing and attached to the IVF-ET consent form with the understanding that pregnancy success may be reduced. Otherwise, the prepared sperm will be added to each egg and they will be allowed to incubate overnight under controlled laboratory conditions. The next day, each egg is evaluated for evidence of fertilization. However, it is possible that no eggs are fertilized. If this happens, the laboratory staff will re-inseminate the eggs or perform intracytoplasmic sperm injection (ICSI) in hopes of obtaining embryos for transfer. If fertilization still does not occur, the eggs will be discarded and the remainder of the procedure will be cancelled. In the case of severe male factor, the couple may be asked to consider the option of using anonymous donor sperm (obtained through a licensed sperm bank for use as a "backup" or secondary sperm source) if it is not possible to obtain sufficient sperm from the partner at the time of fertilization. The eggs that have fertilized will be allowed to develop for two or more additional days under controlled

laboratory conditions before they are placed inside the woman's uterus. Depending upon the couple's wishes, some fertilized eggs/ embryos may be frozen and stored for future use. After the embryos are transferred to the womb, the woman will continue progesterone supplementation that begins on the evening of your egg retrieval procedure. Progesterone can be taken as a combination of oral troches and rectal/vaginal suppositories or by injections. Administration of these medications after egg collection has been shown to create a more favorable uterine environment for the embryos, which therefore increases pregnancy rates. Side effects of progesterone may include, but are not limited to the following: 1. Vaginal dryness; 2. Bloating, breast tenderness; 3. Depression, mood swings; 4. Delay of menses. Synthetic progesterone-like medications have been associated with certain birth defects. By using only natural progesterone, the risk of drug-induced birth defects is significantly reduced. It is important to note, however, that birth defects occur in approximately 3% of spontaneouslyconceived pregnancies in the USA. Therefore, use of natural progesterone does not guarantee a child without a birth defect. Transferring Embryos to the Uterus Embryos are transferred on either day three or day five of development. The embryologists at GRS are highly-skilled in identifying "healthy" embryos and in some cases will recommend that a patient extend embryo development to day five, known as the blastocyst stage. Blastocyst transfer has become quite common in IVF cycles as it can increase chances for success while decreasing the likelihood of multiples. Your physician will work closely with the embryologists to determine if a day three or day five transfer would be ideal for your cycle. Embryos are transferred to the uterus through a small tube (catheter). This procedure is much like a pap smear and does not require any anesthesia and is usually painless. The embryos are placed in a small amount of fluid inside the catheter, which is passed through the cervix at the time of a speculum examination. The embryos are placed in a manner so they reach the top part of the uterus. The number of embryos transferred depends on individual circumstances of the couple, and this decision will be made collectively by you, your physicians and the embryologist. Typically, two to four embryos are be transferred in one treatment cycle. Embryo transfer can

cause mild cramping. Although unlikely, during the embryo transfer the embryo(s) may be displaced through the cervix (causing loss of embryos) or into the fallopian tubes (causing possible tubal pregnancy). There is a small risk of bleeding or infection as a result of the transfer procedure. After transfer, the woman may get dressed and leave after a brief recovery period. A pregnancy test will be done twelve to fourteen days after the transfer, regardless of the occurance of any uterine bleeding. The transfer of several embryos increases the probability of success. A multiple embryo transfer also increases the risk of a multiple pregnancy. Any multiple pregnancy carries an increased risk of miscarriage(s), premature labor and premature birth as well as an increased financial and emotional cost. Pregnancy-induced high blood pressure and diabetes are more common in women pregnant with more than one fetus. Prolonged hospitalization may be necessary for these pregnant women and for the mother and babies after delivery. Tubal (ectopic) pregnancy is also possible, and a combination of normal pregnancy and ectopic pregnancy may occur. A tubal pregnancy is a condition that may require laparoscopy or major surgery for treatment. Like spontaneous (natural) conceptions, pregnancies that arise through IVF may result in miscarriage. In the event of a miscarriage, a dilatation and curettage (D&C) may be necessary. Couples going through therapy must choose and formalize their choice in the appropriate GRS consent form by indicating one of the following options for handling of any remaining embryos: 1. Freezing (cryopreservation) of remaining embryos for use by the couple in future treatment cycles 2. Anonymously donating the embryos for use by another infertile couple(s), if the donating couple and the donated embryos meet the screening criteria (You will not receive any money for this donation, nor will GRS "sell" them. GRS reserves the right to cryopreserve (freeze) any donated embryos as well as the right to discard any donated embryos if a suitable woman cannot be identified to receive the embryos) 3. Allowing the embryos to develop in the laboratory until they perish, at which time they would be disposed of in a manner consistent with professional ethical standards and applicable legal requirements (This usually occurs within six to eight days after egg collection) Theoretical Concerns & Potential for Success: Unfortunately, neither conception nor a successful outcome of pregnancy is guaranteed by the IVF-ET procedure. There are many reasons why pregnancy may not occur with the IVF-

ET procedure. In fact, there are complex and largely unknown factors that limit pregnancy rates following assisted reproductive techniques. Some of the known reasons for failure may include, but are not limited to: 1. There may be a failure to recover an egg because: - follicles that contain mature eggs may not develop in the treatment cycle - ovulation has occurred before time of egg recovery - one or more eggs cannot be recovered - pre-existing pelvic scarring and/or technical difficulties prevent safe egg recovery 2. The eggs that are recovered may not be normal; 3. There may be insufficient semen to attempt fertilization of the recovered eggs because the man is unable to produce a semen specimen, because the specimen contains an insufficient number of sperm to attempt fertilization, because the laboratory is unable to adequately process the specimen provided, or because the option to use a donor sperm as a "backup" was declined; 4. Fertilization of the eggs to form embryos may fail even when the egg(s) and sperm are normal; 5. The embryos may not develop normally or may not develop at all. Embryos that display any abnormal development will not be transferred; 6. Embryo transfer into the uterus may be difficult/impossible, or implantation(s) may not occur after transfer, or the embryo(s) may not grow or develop normally after implantation; 7. Any step in the IVF-ET process may be complicated by unforeseen events, such as hazardous or catastrophic weather, equipment failure, laboratory conditions, infection, human error and the like. In the event the couple should die before embryo transfer, the embryo(s) will be discarded unless other provisions are made in writing. When pregnancy occurs following IVF, it will typically be a normal pregnancy. However, there is always a risk of abnormal pregnancy, miscarriage, blighted ovum, ectopic pregnancy or premature delivery. This is because the process of IVF-ET does not protect against such normal occurrences. Congenital abnormalities, genetic abnormalities, mental retardation or other birth defects which occur in approximately 3% of spontaneously-conceived pregnancies may still occur in children born following assisted

reproductive techniques. A large review of a subset of children born following assisted reproductive procedures found the incidence of developmental anomalies similar to a control group of children spontaneously conceived. Women with multiple pregnancies have a much higher risk of complicated pregnancies, which may include the following: toxemia, preeclampsia, miscarriage, premature labor and delivery, stillbirth, birth defects, and other complications.

AIMS OF DISSERTATION. Through out this paper, the writers will try her best to come out with good recommendation and able to be practice to all healthcare professional, in how to deliver or breaking bad news to the married couple who did not succeed in their IVF procedure and also to be more sensitive at that situation. The main topic to be discuss in this paper is about breaking bad news, a little bit will touch on what is IVF process is all about. It also about to help the married couple who did not succeed in their IVF procedure, to adapt it. Therefore, aim of this paper is to come out with best practice and to be use or as a guidelines to all healthcare professionals, from the period between the initially process of breaking bad news until helping the patient to adapt the reality that they are faul to get a baby. According to Andrews and Row (1991a), adaption leads to optimum health and wellbeing, to the highest quality of life possible and to death with dignity. Breaking bad news is not a small issue that can be left behind. Everyone should give moral and emotional support to married couple who did not succeed in their IVF procedure in helping them to cope with the sad news.

CHAPTER 2 AN OVERVIEW OF INFERTILITY

When a couple is unable to have children, it causes great pain emotionally, intellectually, physically, and spiritually. The feelings of emptiness and loss are overwhelming. The search for reasons and remedies becomes a relentless passion. Doctors, procedures, the time, the cost, the hope, and the hurt are constant companions on the lonely road walked by couples searching for the destination of parenthood. Statistics tell Malaysian that couples do not walk this road alone. According to the Statistics from Gynae Clinic, Hospital Alor Setar, Kedah, one out of every seven couples in Malaysia suffers from infertility problems. This means in the Malaysia, 4.3 million women and their partners, of childbearing years, are infertile. Infertility affects the male or female reproductive system with almost equal frequency. Infertility affects people from every racial, ethnic, religious and socioeconomic level. Infertility is defined as the inability to conceive within one year of trying, or not being able to carry a child to live birth. Infertility may occur in a couples first attempts to bring a child into the world, or as secondary infertility when they have successfully given birth before, but are not able to do so again. Women, who are able to get pregnant, but have miscarriages, are also said to be infertile. Keep in mind that there are as many roads to resolving infertility as there are infertile couples to travel them. The array of options and medical interventions for a couple facing fertility challenges can be confusing and hazardous. Each route brings many ethical, moral, spiritual, emotional, and physical ramifications. It is important to plan carefully to avoid the potholes and ensure a safe trip. Start By Becoming Informed Learning basic infertility information can put you on the road to further discovery. Contact a Natural Family Planning specialist in your area who can help you identify the optimum time for conception. Familiarize yourself with infertility treatment options. Couples who learn about various diagnostic tests, procedures, and medications are better able to make informed decisions. Get In Touch With Your Emotions It is important to realize that infertility is more than just a physical condition. It also involves many emotional issues such as intense feelings of anger, anxiety, frustration, helplessness, loneliness, grief, envy, and even depression. All these emotions can be debilitating if you dont

face them and work to counteract them. You may want to seek support from a professional counselor. Through counseling you can clarify your priorities, improve self concept and your coping skills. Stay Connected To Your Spouse Coping with the uncertainties of infertility, the roller coaster of emotions, the multitude of medical decisions and moral concerns is challenging even for the strongest marriages. Infertility often causes lifestyle changes, reordering of priorities, financial problems, intimacy issues, physical discomfort, career disruption, problems with relatives, and isolation from friends. Since the stress of infertility can place a strain on your relationship, look for ways to nurture your marriage and make your spouse your top priority. Maintain Your Social Life Certain events in everyday life may become difficult. The birth of a friends baby or even seeing a pregnant stranger can bring on a flood of painful feelings. Holidays often seem to focus on children, and Mothers Day or Fathers Day can be difficult. Social functions like baby showers or childrens birthday parties are hard to attend. Many people struggling with infertility problems find it hard to attend religious services. Many infertile couples try to navigate the twists and turns on the journey to parenthood without support. Seek out an infertility support group to avoid isolation. Since the number of people with infertility problems is high, you may be amazed at the support that is available. Prepare a Response to Insensitive Comments Those who struggle with infertility truly suffer greater physical, emotional, marital, and spiritual pain than most people can imagine. Many parents of adult married children do not realize the pain caused by their questions and prods to conceive grandchildren. Insensitive comments by family, friends and strangers can inflict deep wounds. Prepare a well-rehearsed response. You could take the direct approach and say, We want children, but are having trouble. We are seeing a specialist and ask for your prayers. We prefer not to talk about it. Make Important Decisions and Create a Plan Construct an overall plan so you know where you are and where youre headed. Start with the fact that you want to be parents. Then ask what you are willing to do to make it happen. Make decisions that take into consideration your moral principles, family building objectives, money, age and need for control. Find a doctor who agrees with your plan and can help. Be assertive in

stating what you want and do not want to do. You have the right to make your own decisions about treatment. Begin by an honest acknowledgment of your feelings and the medical realities. You and your spouse are different people. You will have different styles, feelings, attitudes and desires. Sharing your perspectives will help you decide which paths to take. Sharing the turmoil of infertility will deepen your commitment to each other, whether you eventually give birth to a child, raise a foster child, adopt a child, or dont raise a child and spend time serving the broader community. Answer these questions to help you make your plan:

What are you both willing to sacrifice to become parents? Do you know the teaching of your faith tradition on this issue? Do you want to respect the dignity of marriage and human life? How much physical and emotional trauma are you willing to endure? What tests do you want to have? How will you do the tests? What treatments will you explore? How many times will you repeat them? How much money will you spend? What doctor or clinic should you select? Will you put your life on hold as you focus on infertility treatments? When will you decide to quit trying? Is your main goal to be a biological parent or is it to have a child join your family? Are you going to focus on conception exclusively, or will you also pursue familybuilding through adoption?

Would you adopt a baby, an older child or a child with special needs? Are you willing to be a family without children?

CHAPTER 3 CAUSES OF WOMEN AND MALE INFERTILITY

A)

Failure to Ovulate Ovulatory disorders are one of the most common reasons why women are unable to

conceive, and account for 30% of women's infertility. Fortunately, approximately 70% of these cases can be successfully treated by the use of drugs such as Clomiphene and Menogan/Repronex. The causes of failed ovulation can be categorized as follows:

(1) Hormonal Problems These are the most common causes of anovulation. The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation. There are three main sources causing this problem:

Failure to produce mature eggs In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature. Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost nonexistent. Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism, anovulation and infertility. This syndrome is characterized by a reduced production of FSH, and normal or increased levels of LH, oestrogen and testosterone. The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan. The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size. The increased level of oestrogen raises the risk of breast cancer.

Malfunction of the hypothalamus The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation. If the hypothalamus fails to trigger and control this process, immature eggs will result. This is the cause of ovarian failure in 20% of cases.

Malfunction of the pituitary gland

The pituitary's responsibility lies in producing and secreting FSH and LH. The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced. This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary. (2) Scarred Ovaries Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur. Infection may also have this impact. (3) Premature Menopause This presents a rare and as of yet unexplainable cause of anovulation. Some women cease menstruation and begin menopause before normal age. It is hypothesized that their natural supply of eggs has been depleted or that the majority of cases occur in extremely athletic women with a long history of low body weight and extensive exercise. There is also a genetic possibility for this condition. (4) Follicle Problems Although currently unexplained, "unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulationdoes not occur.

B)

Poorly Functioning Fallopian Tubes Tubal disease affects approximately 25% of infertile couples and varies widely, ranging

from mild adhesions to complete tubal blockage. Treatment for tubal disease is most commonly surgery and, owing to the advances in microsurgery and lasers, success rates (defined as the number of women who become pregnant within one year of surgery) are as high as 30% overall, with certain procedures having success rates up to 65%. The main causes of tubal damage include:

(1) Infection Caused by both bacteria and viruses and usually transmitted sexually, these infections commonly cause inflammation resulting in scarring and damage. A specific example is Hydrosalpnix, a condition in which the fallopian tube is occluded at both ends and fluid collects in the tube. (2) Abdominal Diseases The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the fallopian tubes and lead to scarring and blockage. (3) Previous Surgeries This is an important cause of tubal disease and damage. Pelvic or abdominal surgery can result in adhesions that alter the tubes in such a way that eggs cannot travel through them. (4) Ectopic Pregnancy This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage and is a potentially life-threatening condition. (5) Congenital Defects In rare cases, women may be born with tubal abnormalities, usually associated with uterus irregularities.

C)

Endometriosis Approximately 10% of infertile couples are affected by endometriosis. Endometriosis

affects five million Malaysian women, 6-7% of all females. In fact, 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population. For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%. This condition is characterized by excessive growth of the lining of the uterus, called the endometrium. Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum. A positive diagnosis can only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes, and pelvic cavity directly. The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting. Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms. The long term cumulative pregnancy rates are normal in patients with minimal endometriosis and

normal anatomy. Current studies demonstrate that pregnancy rates are not improved by treating minimal endometriosis.

D)

Additional Factors

(1) Other variables that may cause infertility in women: At least 10% of all cases of female infertility are caused by an abnormal uterus. Conditions such as fibroid, polyps, and adenomyosis may lead to obstruction of the uterus and Fallopian tubes.

Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive.

Approximately 3% of couples face infertility due to problems with the females cervical mucus. The mucus needs to be of a certain consistency and available in adequate amounts for sperm to swim easily within it. The most common reason for abnormal cervical mucus is a hormone imbalance, namely too little estrogen or too much progesterone.

(2) Behavioral Factors: It is well-known that certain personal habits and lifestyle factors impact health; many of these same factors may limit a couple's ability to conceive. Fortunately, however, many of these variables can be regulated to increase not only the chances of conceiving but also one's overall health.

Diet and Exercise Optimal reproductive functioning requires both proper diet and appropriate levels of exercise. Women who are significantly overweight or underweight may have difficulty becoming pregnant.

Smoking Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth, and low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving with each cycle, either naturally or by IVF, by one-third.

Alcohol Alcohol intake greatly increases the risk of birth defects for women and, if in high

enough levels in the mothers blood, may cause Fetal Alcohol Syndrome. Alcohol also affects sperm counts in men.

Drugs Drugs, such as marijuana and anabolic steroids, may impact sperm counts in men. Cocaine use in pregnant women may cause severe retardations and kidney problems in the baby and is perhaps the worst possible drug to abuse while pregnant. Recreational drug use should be avoided, both when trying to conceive and when pregnant.

(3) Environmental and Occupational Factors: The ability to conceive may be affected by exposure to various toxins or chemicals in the workplace or the surrounding environment. Substances that can cause mutations, birth defects, abortions, infertility or sterility are called reproductive toxins. Disorders of infertility, reproduction, spontaneous abortion, and teratogenesis are among the top ten work-related diseases and injuries in Malaysia today. Despite the fact that considerable controversy exists regarding the impacts of toxins on fertility, four chemicals are now being regulated based on their documented infringements on conception.

Lead Exposure to lead sources has been proven to negatively impact fertility in humans. Lead can produce teratospermias (abnormal sperm) and is thought to be an abortifacient, or substance that causes artificial abortion.

Medical Treatments and Materials Repeated exposure to radiation, ranging from simple x-rays to chemotherapy, has been shown to alter sperm production, as well as contribute to a wide array of ovarian problems.

Ethylene Oxide A chemical used both in the sterilization of surgical instruments and in the manufacturing of certain pesticides, ethylene oxide may cause birth defects in early pregnancy and has the potential to provoke early miscarriage.

Dibromochloropropane (DBCP) Handling the chemicals found in pesticides, such as DBCP, can cause ovarian problems, leading to a variety of health conditions, like early menopause, that may directly impact fertility.

Over their lifetimes, approximately one in every seven couples in Malaysia seeks infertility care. Surprisingly, only half of couples who are trying to become pregnant achieve pregnancy easily and about one in seven Malaysian couples of reproductive age are involuntary infertile; male infertility accounts for half of these cases. Despite the relative importance of infertility due to the male, infertility evaluations have traditionally focused on women, because women tend to seek gynecological care and because men often are reluctant to seek advice. A variety of disorders ranging from hormonal disturbances to physical problems, to psychological problems can cause male infertility. Although many treatment options are now available, in many cases treatment will not work. In many instances, male infertility is caused by testicular damage resulting in an inability of the testicle to produce sperm. Once damaged, the testicle will not usually regain its sperm-making capabilities; this aspect of male infertility is analogous to menopause (though not natural like menopause) for women and cannot usually be treated. Despite medicines limited ability to treat male infertility, many successful treatment options are available for its many causes. Besides testicular damage, the main causes of male infertility are low sperm production and poor sperm quality. Male infertility has many causes--from hormonal imbalances, to physical problems, to psychological and/or behavioral problems. Moreover, fertility reflects a mans overall health. Men who live a healthy lifestyle are more likely to produce healthy sperm. The following list highlights some lifestyle choices that negatively impact male fertility--it is not all-inclusive: Smoking--significantly decreases both sperm count and sperm cell motility. Prolonged use of marijuana and other recreational drugs. Chronic alcohol abuse. Anabolic steroid use--causes testicular shrinkage and infertility. Overly intense exercise--produces high levels of adrenal steroid hormones which cause a testosterone deficiency resulting in infertility. Inadequate vitamin C and Zinc in the diet. Tight underwear--increases scrotal temperature which results in decreased sperm production. Exposure to environmental hazards and toxins such as pesticides, lead, paint, radiation, radioactive substances, mercury, benzene, boron, and heavy metals Malnutrition and anemia. Excessive stress!

Modifying these behaviors can improve a mans fertility and should be considered when a couple is trying to achieve pregnancy. A) Hormonal Problems

A small percentage of male infertility is caused by hormonal problems. The hypothalamuspituitary endocrine system regulates the chain of hormonal events that enables testes to produce and effectively disseminate sperm. Several things can go wrong with the hypothalamus-pituitary endocrine system: The brain can fail to release gonadotrophic-releasing hormone (GnRH) properly. GnRH stimulates the hormonal pathway that causes testosterone synthesis and sperm production. A disruption in GnRH release leads to a lack of testosterone and a cessation in sperm production. The pituitary can fail to produce enough lutenizing hormone (LH) and follicle stimulating hormone (FSH) to stimulate the testes and testosterone/sperm production. LH and FSH are intermediates in the hormonal pathway responsible for testosterone and sperm production. The testes Leydig cells may not produce testosterone in response to LH stimulation. A male may produce other hormones and chemical compounds which interfere with the sex-hormone balance. The following is a list of hormonal disorders which can disrupt male infertility: Hyperprolactinemia: Elevated prolactin--a hormone associated with nursing mothers, is found in 10 to 40 percent of infertile males. Mild elevation of prolactin levels produces no symptoms, but greater elevations of the hormone reduces sperm production, reduces libido and may cause impotence. This condition responds well to the drug Parlodel (bromocriptine). Hypothyroidism: Low thyroid hormone levels--can cause poor semen quality, poor testicular function and may disturb libido. May be caused by a diet high in iodine. Reducing iodine intake or beginning thyroid hormone replacement therapy can elevate sperm count. This condition is found in only 1 percent of infertile men. Congenital Adrenal Hyperplasia: Occurs when the pituitary is suppressed by increased levels of adrenal androgens. Symptoms include low sperm count, an increased number of immature sperm cells, and low sperm cell

motility. Is treated with cortisone replacement therapy. This condition is found in only 1 percent of infertile men. Hypogonadotropic Hypopituitarism: Low pituitary gland output of LH and FSH. This condition arrests sperm development and causes the progressive loss of germ cells from the testes and causes the seminiferous tubules and Leydig (testosterone producing) cells to deteriorate. May be treated with the drug Serophene. However, if all germ cells are destroyed before treatment commences, the male may be permanently infertile. Panhypopituitafism: Complete pituitary gland failure--lowers growth hormone, thyroid-stimulating hormone, and LH and FSH levels. Symptoms include: lethargy, impotence, decreased libido, loss of secondary sex characteristics, and normal or undersized testicles. Supplementing the missing pituitary hormones may restore vigor and a hormone called hCG may stimulate testosterone and sperm production.

B)

Physical Problems

A variety of physical problems can cause male infertility. These problems either interfere with the sperm production process or disrupt the pathway down which sperm travel from the testes to the tip of the penis. These problems are usually characterized by a low sperm count and/or abnormal sperm morphology. The following is a list of the most common physical problems that cause male infertility: Variocoele: A varicocele is an enlargement of the internal spermatic veins that drain blood from the testicle to the abdomen (back to the heart) and are present in 15% of the general male population and 40% of infertile men. A varicocele develops when the one way valves in these spermatic veins are damaged causing an abnormal back flow of blood from the abdomen into the scrotum creating a hostile environment for sperm development. Varicocoeles may cause reduced sperm count and abnormal sperm morphology which cause infertility. Variococles can usually be diagnosed by a physical examination of the scrotum which can be aided by the Doppler stethoscope and scrotal ultrasound. Varicocoele can be treated in many ways (see treatment section), but the most successful treatments involve corrective surgery.

Damaged Sperm Ducts: Seven percent of infertile men cannot transport sperm from their testicles to out of their penis. This pathway may be blocked by a number of conditions: A genetic or developmental mistake may block or cause the absence of one or both tubes (which transport the sperm from the testes to the penis). Scarring from tuberculosis or some STDs may block the epididymis or tubes. An elective or accidental vasectomy may interrupt tube continuity. Torsion: Is a common problem affecting fertility that is caused by a supportive tissue abnormality which allows the testes to twist inside the scrotum which is characterized by extreme swelling. Torsion pinches the blood vessels that feed the testes shut which causes testicular damage. If emergency surgery is not performed to untwist the testes, torsion can seriously impair fertility and cause permanent infertility if both testes twist. Infection and Disease: Mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and syphilis can cause testicular atrophy. A low sperm count and low sperm motility are indicators of this condition. Also, elevated FSH levels and other hormonal problems are indicative of testicular damage. Some STDs like gonorrhea and chlamydia can cause infertility by blocking the epididimis or tubes. These conditions are usually treated by hormonal replacement therapy and surgery in the case of tubular blockage. Klinefelters Syndrome: Is a genetic condition in which each cell in the human body has an additional X chromosome-men with Klinefelters Syndrome have one Y and two X chromosomes. Physical symptoms include peanut-sized testicles and enlarged breasts. A chromosome analysis is used to confirm this analysis. If this condition is treated in its early stages (with the drug hCG), sperm production may commence and/or improve. However, Klinefelters Syndrome eventually causes all active testicular structures to atrophy. Once testicular failure has occurred, improving fertility is impossible. Retrograde Ejaculation: Is a condition in which semen is ejaculated into the bladder rather than out through the urethra because the bladder sphincter does not close during ejaculation. If this disorder is present,

ejaculate volume is small and urine may be cloudy after ejaculation. This condition affects 1.5 percent of infertile men and may be controlled by medications like decongestants which contract the bladder sphincter or surgical reconstruction of the bladder neck can restore normal ejaculation.

C)

Psychological/Physical/Behavioral Problems:

Several sexual problems exist that can affect male fertility. These problems are most often both psychological and physical in nature: it is difficult to separate the physiological and physical components. Erectile Disfunction (ED): Also known as impotence, this condition is common and affects many Malaysian men. ED is the result of a single, or more commonly a combination of multiple factors. In the past, ED was thought to be the result of psychological problems, but new research indicates that 90 percent of cases are organic in nature. However, most men who suffer from ED have a secondary psychological problem that can worsen the situation like performance anxiety, guilt, and low self-esteem. Many of the common causes of impotence include: diabetes, high blood pressure, heart and vascular disease, stress, hormone problems, pelvic surgery, trauma, venous leak, and the side effects of frequently prescribed medications (i.e. Prozac and other SSRIs, Propecia). Luckily, many treatment options exist for ED depending on the cause--these will be discussed in the treatment section. Premature Ejaculation: Is defined as an inability to control the ejaculatory response for at least thirty seconds following penetration. Premature ejaculation becomes a fertility problem when ejaculation occurs before a man is able to fully insert his penis into his partners vagina. Premature ejaculation can be overcome by artificial insemination or by using a behavioral modification technique called the squeeze technique which desensitizes the penis. Ejaculatory Incompetence: This rare psychological condition prevents men from ejaculating during sexual intercourse even though they can ejaculate normally through masturbation. This condition sometimes responds well to behavioral therapy; if this technique does not work, artificial insemination can be employed using an ejaculate from masturbation.

CHAPTER 4 REFLECTION ACCOUNT.

4.1

DESCRIPTION OF EVENTS As mentioned earlier in Chapter 1, the writers working place is at IVF Center,

Gynaecology Department, which provides care to married woman who wants to get babies. After the IVF procedures had been done, the married couple who had done it had to wait for about two weeks to know the results. This is when the breaking of whether good or bad news had to be done. For the good news of course it will all right. Bad news can be mean different things to different people. No one likes to break and heard about bad news. There have been numerous definitions of bad news including, any information, that affects an individuals view of his or her future drastically and negatively. Bad news also defined as information which worsens the individual point of view on their future and may cause long-lasting mental and behavioral problem. As mentioned by Wooley et al (1989) and Finlay and Dallimore (1991), recipients of bad news often remember, where, when and how bad news was communicated. It has been suggested that ineffective or insensitive news disclosure can have a long term adverse impact (Fallowfield, 1993). Moreover, it has been advised that poor news disclosure can be a major factor in provoking litigious complaints. As mentioned earlier in aims of dissertation, the writers are going to focus on breaking bad news to married couple who did not succeed in their IVF procedure. As everybody knows, bad news is a message, which has the potential to shatter hopes and dreams leading to very different styles and futures. Not all healthcare providers especially Doctors, able to break the bad news in a proper manner by using good communication skills. The scope of issue in breaking bad news are wide, such as, how to be honest with patient and not to destroy hope, dealing with the patient emotion, spending the right amount of time and also need to involve with the patients family and close relatives especially in decision making. Breaking bad news is a complex communication task that requires expert verbal and non-verbal skills. As mentioned by Mehrabian (1981), to develop a rapport with patient, healthcare providers needs to be professionally friendly, showing interest and actively using both nonverbal and verbal communication skills. Example for non-verbal communication skills according to Mehrabian (1981) are, eye contact, interested posture and facial gestures. Meanwhile for the

verbal are such as an appropriate language, avoid jargon and technical terms and also rate and intonation of the voice. The writers will describe what was happened, that are being so much concern to the writers. The scenario took place at IVF Center, at one of the consultations room. The writers and her colleague just enter the department to start their duty. At that time, there are couple sitting in front of the registration counter, waiting to be registered by the clerk. According to the clerk, the patient came for her IVF result. It took about twenty minutes for the registration. Upon completion, the clerk call the writers to hand over the patients file. The writers took the file and went to see the couple, to double check the couples identification, by verify it with the couple. This procedure is due to hospital policy in term of patient safety. After satisfied with the couples information, the writers bring along the couple, to the consultation room. Quickly the couple enters the room, and the writers followed from back. In the bright consultation rooms, the Gynae, known as Doctor M was there, together with the couple and the writers. The room is sufficient enough, for all of them to have an important discussion without any interruption. As a nurse, the writers understood her special role to be there with the couples and Doctor M, in the consultation room. As mentioned by Merriam (2006c), nurse is defined as a person who is skilled or trained in caring for the sick or infirm especially under the supervision of a physician. American Nurses Association (2003), define nursing, in part, as provision of a caring relationship that facilitates health and healing and attention to the range of human experiences and responses to health and illness within the physical and social environments. Therefore it is important for the IVF nurse to be in the consultation room through the breaking good/ bad news session. The other reason why the writers maintaining to be in the room is because the writers will be the advocator for the couple. Oxford (2006), define advocate which derived from word advocacy, is a person that pleads a case on someone elses behalf. Nurse advocate as mentioned by Bandman (1987) is most commonly associated with protector of patient rights. Back to the consultation room, everyone seems to be quite. Doctor M is busy looking at the computer screen; she is concentrating to look at the patients laboratory result, until she does not realize the couple, already waiting for her, for almost ten minutes. The couple tries to be patience while waiting. As the hospital is a paperless, meaning most of document related to

patient can be found online. Doctor M is still not getting use with the system and computer hands on. She is still in the process of learning the system. From the writers observation, the couples faces looks bright and was hoping for the good news from the beginning they enter the consultation room. According to their personal information, the wifes was at early age of forty, a housewife, from standard economic background. They had been married for about 15 years. After about ten minutes, sitting face to face, Doctor M still did not entertains the couple and the computer screen still on. At last, Doctor M, wish the couple. He acknowledges himself. After that, straight away Doctor M breaking the bad news, by telling the couple that they did not succeed in their IVF process.

4.2

FEELINGS The writers describe her feeling, with an uncomfortable situation, which she felt

unhappy, guilty, angry and unsatisfied for what had happened to the couple. Doctor M is not professional in doing his job. The writers understood that the patients is under the stage o f shock. The writers can saw from the patients face gesture and body language. This incidence could be avoided to be happening. Furthermore the patients is already quite old and the writers does not know exactly what is the patients perceptions and it is difficult to generalize how old women feel about not able to have babies. The writers also can felt that the patients husband also under the stage of shock and thinking that his wife should not been treated like that. As mentioned by the patients to the writers, Doctor M, does not respect her as a human being. This incidence should not be happen to married couple who did not succeed in their IVF procedure. Doctor M should give an ample time to the couple before breaking the bad news. Doctor M, look in a hurry in delivering the bad news. It could be done in a better way, if Doctor M understands what a good communication skill is. Although it can be said that it is fated not to have any child, the sadness can only be felt by the bearer.

4.3

EVALUATION. The writers facing the situation rationally as positive elements. The writers will shown

her good characteristic such as attitudes, skills and knowledge, engage in person-person relationships, respect the uniqueness of patients; and provide support. It also makes the writers stronger person and never gives up in handling the hard situation. It will make the writers more understand why most married couple with no child needs extra emotional and moral support. From the evaluation, the writers found out; it does not mean that when the Doctor is an expert and senior in certain field, he / she can do well in breaking bad news to the patients. The writers will slowly take the challenge by doing the task. She believes that, she can do it much better than the Doctor. Values of the nursing profession, as well as nurses duties and responsibilities are represented by codes of ethics in nursing. For examples, nurses should respect the rights of patients, responsible for safeguarding human rights. Most important, the writers should assume the major role in determining and implementing acceptable holistic of nursing care and patient-centered mainly to most married couple with no child.

4.4

ANALYSIS

Though the main of communication is to elicit and impart information, the way that is accomplished can have a profound effect on the relationship between the Doctor and the patient, and on a couples approach to their treatments. Due to do not have proper training in breaking bad news or guidelines to follow, the incidence happened. Even though, Doctor M is an experienced in gynae, because she failed to attend any communicating skills courses, make herself not really in how to approach the couple in a good manner. The incidence could be avoid, if Doctor M, apply good communication skills through her discussion in breaking bad news. Healthcare professionals must know what information needs to give and how to convey it. Healthcare professionals should be optimism in the process of honesty in delivering bad news. In addition, the communication of distressing news is demanding for both healthcare professionals and married couple with no child.

4.5

ACTION PLAN The writers will avoid encountering the same situation so she came out with guidelines

that could be followed by all healthcare professionals. Throughout the guidelines, it can be a pathway for professional staffs to deliver bad news to married couple with no child. And also the importance of understanding how delivers bad news affects the couple as they are hoping too much. Couples responses to bad news are highly variable and unpredictable. They may express their distress as extreme anger, and maybe the anger feeling towards the person who convey the bad news. If this occurs, relationship between Doctor-couple is vulnerable and must be

preserved by patience understanding. Healthcare professionals should be prepared for such reaction and be confident in their skill. What always happened was, the healthcare professionals always avoid dealing with the emotional aspects of bad news. The main reason are because lack of training, fear of increasing couples distress, lack of emotional and practical support from colleagues. There are principles that had been recognized in breaking bad news. First, we need to give information to what the couple wishes and is ready to hear, and to give enough time to the process. We need to find out what the couple knows and wants to know, allow enough time and give information in stages, give full information to couples and lastly understand and help couples manage their distress. The married couple with no child also wants healthcare professionals to be honest, compassionate, caring and hopeful. They want to be told in person, in a privacy setting at their pace, with time for discussion and if they wish, with a supportive present, example the gynae nurse. It is important, during breaking bad news; we must make couples feel comfortable, both psychologically and physically. The couples are should be privacy and confidentiality respected. During the discussion, the situation must be free from any distractions and interruptions. Couple also can feel more satisfied if we accompany information-giving with social conversation, show positive verbal and non-verbal behavior and built relationship with them. It will benefit to married couple with no child by practicing this style of communication. In this action plan, the writers would like to highlighted tips that are required in good communicating as mentioned above: Expressing interest in the couple.

Eliciting couples beliefs and concerns. Acknowledging and responding to couples distress. Avoiding jargon and overly complex information. A collaborative and empowering approach. Private and confidentiality. Another important part to remember in breaking bad news is we need to be a good

listener to the married couple with no child. Good communication is a two way process: it requires both effective talking and effective listening. The non verbal behavior such as body language and facial expression of the couple may provide important information about their mood and concerns. To be successful in breaking bad news, meaning to give the couple satisfaction, we need to developed good communication skills in ourselves by practicing how to develop rapport, using open-ended question and keeping good eye contact, summarize and agree a shared view of the problem and how to deal with it and show ability to detect and respond appropriately to couples distress. Through this action plan, the writers hope it can help healthcare professionals in improving themselves in breaking bad news about the unsuccessfulness of their IVF process to the married couple with no child

CHAPTER 5 CONCLUSION

The breaking bad news is a routine but difficult task for many health professionals. It should be taken seriously in delegating the task. It is associated with patients satisfaction, adherence to health advice and improved health outcomes and fewer complains. Gynaecology team especially must be confidence in their ability to disclose unfavorable medical information to married couple with no child. Breaking bad news always been related with communication. How we communicate with the patients? What are we going to communicate? Who are going to communicate? Where are we going to communicate? These are all things that could be a barrier to open communication. According to Penson and Slevin (2002), there are guidelines in communication with the married couple with no child as mention below : Have clear objective, assume nothing and be flexible.

Introduce yourself and establish rapport. Listen and ask open, but directive questions. Question and summarize until you have the whole picture. Acknowledge and address issue. Summarize and screen for other issues. Reinforce realistic hopefulness. A person who breaking the bad news usually is a position of power and this person is the

health professional. Therefore, they need to be prepared themselves before the important day for the couple, in hearing about the bad news. There a few steps for breaking bad news. Initially the healthcare professionals need to do preparation, such as; arrange for some privacy, involve significant others, sit down, make connection with the couple and manage time constraints and interruptions. Step two is assessing the couples perception, by using the open-ended question. Step three is obtaining the couples invitation. Step four is giving knowledge and information to the couple. The fifth step is addressing the couples emotions with empathic responses. The writers hope all information given in this paper, could benefit to others.

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Lobo RA. Infertility: etiology, diagnostic evaluation, management, prognosis. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 41.

Min JK. Guidelines for the number of embryos to transfer following in vitro fertilization. J Obstet Gynaecol Can. Sept 2006; 28(9): 799-813.

The Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of the American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril. 2006 Nov;86 Suppl 5:S51-2.

Jackson RA, Gibson KA, Wu YW, et al. Perinatal Outcomes in Singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol. 2004; 103: 551- 563

Society for Assisted Reproductive Technologists. Clinic Summary Report: All SART Member Clinics. 2005.