INTRODUCTION

Mental health professionals play an important role in reproductive medicine due to the complex psychosocial issues faced by fertility patients. As technological advances in fertility treatment and the use of fertility services in diverse populations have increased, there are growing needs for the skills and services of trained fertility counselors to assist patients and staff. Fertility counseling includes psychotherapeutic intervention and psychoeducational support for  individuals and couples experiencing fertility problems, as well as those utilizing assisted reproductive technology to build a family or preserve fertility. Third-party fertility counseling also includes the utilization of psychological assessments to determine candidacy. The current document is an update of the 2015 revision of the 1995 American Society for Reproductive Medicine (ASRM) Qualification Guidelines for Infertility (1) written by members of the ASRM Mental Health Professional Group (MHPG) in partnership with the ASRM Practice Committee.

A qualified fertility counselor should be able to provide, or refer patients appropriately to, the following services:

• Diagnosis and treatment of mental disorders
• Grief counseling
• Supportive counseling
• Crisis intervention
• Education/information counseling
• Decision-making counseling
• Third-party evaluation and implications counseling
• Psychometric test administration and interpretation
• Sexual counseling
• Support group counseling
• Psychotherapy
• Couples and family therapy
• Referral/resource counseling
• Reproductive endocronology and infertility staff education and consultation

RECOMMENDED MINIMUM QUALIFICATIONS AND TRAINING

Mental health professionals working in reproductive medicine should have the following minimum qualifications and training:

Graduate Degree and Training Requirements

A master’s or doctoral degree from an accredited university in the fields of psychology, psychiatry, social work, psychiatric nursing, counseling, or marriage and family therapy. This translates to a specific minimum educational qualification that can be explicitly stated to include one of the following master’s level or higher
degrees: Ph.D., PsyD, M.D., DO, DNP, MSW, MSN, MFT, MA, and MS in clinical psychology, psychology, psychiatry, counseling, marriage and family therapy, or psychiatric nursing. The curriculum and training should include psychopathology, personality theory, life cycle and family development, family systems theory,  bereavement and loss theory, crisis intervention, psychotherapeutic intervention, and individual, marital, and group therapy.

Graduate training should include a clinical practicum or internship in psychotherapy or counseling that was supervised by a licensed mental health professional.

Psychological Testing Proficiency Associated With Third-Party Reproduction

The ASRM (2017) guidance documents recommend that those individuals being considered for third-party reproduction undergo a psychosocial consultation with psychological testing when appropriate.

Competency in psychological assessment requires highly specialized training that includes didactic instruction, supervised experience, and ongoing education to provide ethical practice (2, 3). The Standards for Educational and Psychological Testing (4) are considered the gold standard for guidance on testing and are published jointly by the American Psychological Association, American Education Research Association, and National Council on Measurement in Education. Content areas necessary for competency in test administration and interpretation are documented in the test user qualification guidelines proposed by the American Psychological Association (5), as well as a number of guidance documents set forth by multiple mental health disciplines (2–6). Individuals within any mental health discipline (eg, social work, counseling, marriage and family therapy, and psychiatry) may have received the basic educational, clinical, and supervision training for competent and ethical testing (2, 5).

Publishers and developers of psychological tests also provide statements regarding the basic qualification levels required for the purchase of psychological testing.  Test publishers such as PAR, Inc., and Pearson do not provide statements regarding the basic qualification levels required for the administration and interpretation of psychological tests. Rather, they explicitly state that they rely on the guidance in the standards and documents cited above regarding qualifications for  competent and ethical use of tests (7, 8). Mental health professionals wishing to administer and interpret psychological tests should review the specific psychological test publisher’s and developer’s referenced qualification guidelines to ensure they meet stated requirements.

Mental health professionals who did not receive relevant training in the administration and interpretation of psychological tests, but who would like to utilize such tests in their practices, are encouraged to seek out relevant graduatelevel courses or training from an appropriate licensing or certification agency. Information on  such courses and training can be obtained from published guidance documents and state licensing laws (3, 5, 9). In addition, arrangements can be made with appropriately qualified colleagues to provide test interpretation.

As with other areas of clinical practice, it is paramount that clinicians follow their state licensure requirements, their professional organization recommendations, and guidelines established for competence in testing.

License to Practice

Mental health professionals must have a license (or registration/certification, where applicable) in the respective mental health field in which they hold an  advanced academic degree in accordance with state and federal laws, professional organization recommendations, and liability insurance coverage. Clinicians providing telemental health services must also follow applicable state and federal laws, professional organization recommendations, and liability insurance coverage requirements (10).

Knowledge of the Medical, Legal, and Psychological Aspects of Infertility

It is mandatory that all fertility counselors have and maintain a comprehensive knowledge of contemporary human reproductive technologies, the legislative frameworks within which these technologies are practiced, and the emotional and psychological experiences and needs of fertility patients and other invested parties (11, 12). The ASRM recommends completion of ASRM training modules as a method of demonstrating training beyond general qualifications. It is important that all fertility counselors have fundamental familiarity with the following specific topics:

1. Medical and legal aspects
   1. Basic human reproductive physiology
   2. Etiology of male and female infertility
   3. Testing, diagnosis, and treatment of reproductive problems
   4. Genetics, genetic testing, and embryogenesis
   5. Development and application of assisted reproductive technologies
   6. Basic understanding of the potential harmful effects of chemotherapy and radiation on fertility
   7. Federal and state-specific legislation governing assisted reproductive technologies
2. Psychology of infertility
   1. Marital and familial issues associated with infertility and its impact on sexual functioning
   2. Approaches to the psychology of infertility, including psychological assessment, bereavement/loss, crisis intervention, posttraumatic stress, stress and coping, and typical/atypical responses
   3. Family-building alternatives, including adoption, third-party reproduction, and child-free lifestyles
   4. Individual and couples treatments that are diversity sensitive and culturally competent
   5. Legal, ethical, and religious issues associated with infertility treatments
   6. Issues related to self-esteem, body image, and identity
   7. Research and clinical literature on
      1. Psychosocial aspects of infertility and assisted reproductive technologies in both intended parents and third parties (eg,  donors, gestational carriers, families, social networks) 
      2. Psychosocial and developmental issues of children conceived by assisted reproductive technologies
      3. Psychosocial aspects of fertility treatment for a range of populations, such as single women, single men, LGBTQ  individuals and couples, and patients of advanced parental age
      4. Psychosocial aspects of fertility preservation and treatment for transgender patients, patients with a serious medical illness, and patients using planned embryo, oocyte, or sperm cryopreservation
      5. Pregnancy loss
      6. Parenting after infertility
      7. Issues of privacy, confidentiality, and patient’s rights
      8. Issues related to disclosure of donor conception to offspring
      9. Impact of psychotropic medications
      10. Sexual identity and functioning

Post-licensure Clinical Experience

The licensed mental health professional should have a minimum of one year of clinical experience providing fertility counseling and/or third-party evaluations under the supervision of, or in consultation with, a qualified and experienced fertility counselor. For qualified individuals interested in conducting psychological testing in the context of third-party reproduction, there should be one year of clinical supervised experience with a qualified licensed mental health professional proficient in testing protocol and interpretation, in addition to the requirements listed above (3).

Continuing Education

Mental health professionals working in reproductive medicine should regularly attend continuing education courses offered by the ASRM or other organizations and educational institutions accredited to provide continuing education in both the medical and the psychological aspects of reproductive health care. This is necessary for continued growth in knowledge and skills for providers in the field. Membership in the ASRM MHPG is strongly encouraged to provide additional opportunities for learning, collegial interactions for mental health professionals in this field, and access to Practice and Ethics Committee Documents and other important publications.

Fertility Counseling Practice Within and Outside the United States

Several guidance documents exist for qualifications and training for mental health professionals working in reproductive medicine in other countries, including

• Guidelines for Counselling in Infertility, European Society of Human Reproduction and Embryology (ESHRE) (13)
• Guidelines for professional standards of practice in infertility  counselling, Australian and New Zealand Infertility Counsellors Association (ANZICA) (14)
• Assisted human reproduction counselling practice guidelines, Canadian Fertility and Andrology Society Counselling Special Interest Group (CSIG) (15)
• How to become an infertility counsellor, British Infertility Counseling Association (BICA) (16)
• Qualification guidelines for infertility counselors, ASRM (16)

These documents speak to the global need for qualified mental health professionals to work side by side with medical, nursing, embryology, and andrology personnel to provide care to fertility patients.

Acknowledgments: This report was developed under the direction of the Practice Committee of the ASRM as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice limitations. The Practice Committee and the Board of Directors of the ASRM have approved this report. This document was reviewed by ASRM members, and their input was considered in the preparation of the final document. The following members of the ASRM Practice Committee participated in the development of this document: Alan Penzias, M.D., Ricardo Azziz, M.D., M.P.H., M.B.A., Kristin  Bendikson, M.D., Marcelle Cedars, M.D., Tommaso Falcone, M.D., Karl Hansen, M.D., Ph.D., Micah Hill, D.O., William Hurd, M.D., M.P.H., Sangita Jindal, Ph.D., Suleena Kalra, M.D., M.S.C.E., Jennifer Mersereau, M.D., Catherine Racowsky, Ph.D., Robert Rebar, M.D., Richard Reindollar, M.D., Chevis N. Shannon, Dr.PH., M.P.H., M.B.A., Anne Steiner, M.D., M.P.H., Dale Stovall, M.D., Cigdem Tanrikut, M.D., Hugh Taylor, M.D., and Belinda Yauger, M.D. The Practice Committee acknowledges the special contribution of the MHPG Qualifications Task Force, including Piave Lake, Ph.D., Claudia Pascale, Ph.D., Angela K Lawson, Ph.D., and Mary P Riddle, Ph.D., in the preparation of this document. All Committee members disclosed commercial and financial relationships with manufacturers or  distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest based on the relationships  disclosed did not participate in the discussion or development of this document.

REFERENCES

1. Mental Health Professionals Group of the American Society for  Reproductive Medicine. Qualification guidelines for infertility counselors, 1995. 
2. American Counseling Association. Standards for qualifications of test users, 2003. Available at:  https://www.nbfe.net/resources/Documents/ACA%20Standard%20for%20Qualififications%20of%20Test%20Users.pdf. VOL. 115 NO. 6 / JUNE 2021 1413 Fertility and Sterility®
3. Board of Trustees, SPA. Standards for education and training in psychological assessment: position of the Society for Personality Assessment. J Pers Assess 2006;87:355–7.
4. American Educational Research Association, American Psychological Association, National Council on Measurement in Education, and Joint Committee on Standards for Educational and Psychological Testing (U.S.). Standards for educational and psychological testing. APA, AERA, NCME, USA; 2014.
5. American Psychological Association. APA guidelines for psychological assessment and evaluation, 2020. Available at:  https://www.apa.org/about/policy/guidelines-psychological-assessment-evaluation.pdf.
6. National Board of Forensic Evaluators. Can licensed mental health counselors administer and interpret psychological tests? 2018. Available at: https://www.nbfe.net/resources/Documents/Can%20Counselors%20Test.pdf.
7. PAR. Qualification levels. Available at: https://www.parinc.com/Support/Qualification-Levels. Accessed December 20, 2020.
8. Pearson. Qualifications policy. Available at: https://www.pearsonassessments.com/professional-assessments/ordering/how-to-order/qualifications/qualifications-policy.html. Accessed December 20, 2020.
9. American Psychological Association. Ethical principles of psychologists and code of conduct. Am Psychol 2002;47:1597–611.
10. American Psychological Association. American Psychological Association guidelines for the practice of telepsychology. Available at: https://www.apa.org/practice/guidelines/telepsychology.aspx. Accessed December 20, 2020.
11. American Society for Reproductive Medicine Practice Committee. Recommendations for practices utilizing gestational carriers: a committee opinion. Fertil Steril 2017;107:e3–10.
12. Practice Committee of the American Society for Reproductive Medicine and Practice Committee of the Society for Assisted Reproductive Technology. Recommendations for gamete and embryo donation: a committee opinion. Fertil Steril 2021, In press.
13. European Society of Human Reproduction and Embryology. Guidelines for counselling in infertility. Available at: https://www.eshre.eu/Specialty-groups/Special-Interest-Groups/Psychology-Counselling/Archive/Guidelines. Accessed January 21, 2021.
14. Australian & New Zealand Infertility Counsellors Association. Guidelines for professional standards of practice in fertility counselling. Available at: http://www.fertilitysociety.com.au/wp-content/uploads/Guidelines-for-Professional-Practice.pdf.
15. Canadian Fertility and Andrology Society Counselling Special Interest Group (CSIG). Assisted human reproduction counselling practice guidelines. Available at: https://cfas.ca/_Library/clinical_practice_guidelines/CSIG_Counselling_Practice_Guidelines_August_2009_.pdf.
16. British Infertility Counseling Association. How to become an infertility counsellor. Available at: https://www.bica.net/memtemp/how-to-become-aninfertility-counsellor. Accessed February 4, 2021.