The stressful nature of infertility has long been recognized. In earlier years, the focus was on whether psychological stress or psychopathology prevented conception, particularly for women. With advances in the technological assessment of fertility's organic causes, the number of couples with unexplained infertility has decreased, resulting in less emphasis on mysterious psychological causes of infertility.
Stress could theoretically interfere with pregnancy through direct hormonal effects, or indirectly by impairing a couple's capacity to have effective sexual intercourse or to follow the complex instructions and sexual prescriptions involved in medical treatment. However, the major focus of mental health care for infertile couples is to help them cope with the emotional impact of infertility treatment.
The "normal" stress of infertility treatment
Why is psychological distress a normal state while going through infertility treatment?
A diagnosis of infertility is always stressful. Some men or women might already know or suspect that they are infertile; for example, if they have undergone cancer chemotherapy in the past or have had endometriosis. For others, the failure to conceive a child is very much a surprise. Many couples do not realize that in about 40 percent of infertile couples, a male factor contributes to the problem.
The following factors can emotionally influence couples who have been diagnosed as infertile and/or who might be considering infertility treatment:
- Uncertainty about the success of fertility treatment /li>
- Grief associated with infertility diagnosis
- Feeling of losing control
- Loss of self-esteem
- Financial strain
- Marital stress
- Sexual pressure
- Family pressure
Uncertainty about success of fertility treatment
One of the most difficult issues is the uncertainty about whether treatment for infertility will be successful. Going through diagnostic tests and then trying to conceive for a number of ovulation cycles is an emotional roller coaster of hope and disappointment for many couples.
Spouses sometimes have trouble agreeing on which fertility option to try: adoption, gamete donation, high technology treatments, etc. After many different treatments have been tried unsuccessfully, partners also need to agree on when to give up. However, there is often just one more, possibly more expensive medical treatment that holds some promise of working
Infertility: Source of grieving
Many people do not recognize that infertility is a source of grieving. The loss of a child who was wanted and imagined but never conceived is a legitimate loss, much like suffering a miscarriage or a stillborn baby.
Feeling of losing control
A "typical" couple that participates in an infertility program is in their early to mid-30s, with two white collar or professional careers. Typically, when they've worked hard, they've always achieved their goals. With infertility, however, no matter how hard the couple might work at conceiving and how carefully they follow the physician's instructions, they have limited control over the outcome. It is this loss of control that is so difficult.
Loss of self-esteem
Many men and women feel a loss of self-esteem when they discover they have an infertility problem. They feel less valuable as a spouse and might even doubt whether they are a "real" man or woman. Of course gender and sexuality do not depend on fertility, but feelings do not always respond to logical thinking. Many couples find it painful to be around children, particularly at family gatherings. They also might have to deal with questions from parents about why no grandchildren have yet been conceived.
Because of poor insurance coverage for infertility treatment, choosing to pursue medical options often puts a financial strain on families. Because of the current insurance conditions in the United States, many couples treated for infertility have to pay for part or all the costs out of their pocket. Coverage for mental health services is also often poor, making couples reluctant to seek additional help.
A diagnosis of infertility can affect a marriage relationship. Often the spouse with an infertility factor fears that the other partner will leave and find someone who is able to have children. Sometimes, if only one partner is infertile, he or she will even try to persuade the spouse to get a divorce. Once infertility treatment has begun, one spouse might feel that the other is less motivated to succeed. This creates tremendous anger. Sometimes the stress on the relationship is so great that one spouse will have an affair to prove his or her self-worth or even to demonstrate fertility with someone else.
The demand to have intercourse at the proper times can provoke frustration when one partner has a business trip, is working late, or just cannot get in the mood for sex. Couples who go through cycles of sex on demand often find that lovemaking loses its spontaneity and playfulness. Sex becomes a chore to be performed at mid-cycle only. Sometimes the pressure to perform at mid-cycle is so great that a man has trouble with erection or is unable to ejaculate.
Most couples dread the postcoital test, in which intercourse must be scheduled just before a visit to the infertility clinic. Even providing a semen sample through masturbation can be an unpleasant and anxiety-provoking experience.
For some couples, erection or ejaculation problems are actually causes of infertility and need to be treated with medical or psychological therapies. Women might have trouble getting aroused so that vaginal dryness or muscle tension make intercourse painful. Unfortunately, gel lubricants that could make sex more comfortable interfere with the movement of the sperm through the vagina. It is common to have distracting thoughts about the infertility during sex, further reducing the pleasure that partners feel from lovemaking.
There is no good scientific evidence that having an orgasm during intercourse will increase a woman's chance of conceiving. Some infertility specialists might even tell couples to use special sexual techniques that are not scientifically-proven to enhance fertility, such as telling men to try to ejaculate on a very deep thrust, or telling women to hold their legs up for half an hour after intercourse so that semen will remain deep in the vagina.
Sometimes one or both sides of the family pressures the couple to have children. Spouses might also disagree on disclosing the infertility problem or they might disagree on how much to confide in parents or siblings. This can be an especially difficult issue if the couple chooses to use a sperm or egg donor to conceive.
Some of the common concerns include: Should anyone outside of the couple know? Should the child be told about the gamete donation? There is not one right or wrong answer, but these issues can add stress.
Guidelines to help couples cope
Most couples actually cope quite well with infertility, but some can benefit from professional help. Counseling could take the form of a support group, individual sessions, or couple therapy -- whichever is most appropriate for the problem. Often, the infertility team can offer support and advice, and that might be all that is needed to help a couple cope with infertility.
Some guidelines for coping include:
- Be aware that taking hormones can affect a woman's mood, making her temporarily irritable or depressed. Try to anticipate these times and minimize their impact.
- Change your sex life only as much as you need to. Do have sex at the times your doctor recommends, but try to put a priority on lovemaking the rest of the month, too.
- Make an effort to enjoy sex by varying the setting and the type of foreplay you use. If you have to have sex on demand, try to plan ahead to make the time as relaxed as possible, for example starting sex at a time when you are not totally exhausted or rushed, beginning with a back rub or a bubble bath together to relax, and spending enough time on foreplay to really get aroused.
- If you have distracting thoughts about performing, try to think of a sexual fantasy instead. For example, imagine that you are in an exotic vacation setting, remember a time when lovemaking was especially pleasurable, or think of a love scene in a book or movie that aroused you.
- For women, remember that standing on your head after sex will not help sperm travel through the cervix.
- If a sexual problem is interfering with conception, tell your doctors about it so that they can help you get appropriate medical treatment or sex therapy.
- Talk together about what you value about your relationship. Every relationship serves many purposes besides reproduction: companionship, emotional support, making a home together, sharing leisure activities, and building a financial future. After discussing these things, ask yourselves this question: If you remained childless, would your relationship really be worthless?
- If the extended family is nagging about when you are going to have a child, decide together how to handle this issue as a team. Do not let parents or other family members come between you as a couple.
- Allow yourself and your partner to grieve if a treatment is unsuccessful, or if you give up the idea of having a shared, genetic child. Even if you are very satisfied eventually with a child conceived with an egg or sperm donor, or with an adopted child, you still have experienced a loss and have a right to feel some sadness.
Do you need to see a mental health professional?
Although infertility is rarely a problem caused by stress, mental health professionals can be very helpful in teaching couples techniques to manage stress during infertility treatment, helping them agree on choices that confront them, and helping them grieve and come to an emotional resolution if infertility treatment is not successful.
Although seeing a mental health professional could be viewed by many as a stigma, many infertility programs are requesting that patients routinely go through a psychological counseling session. This is especially helpful for couples before procedures such as in vitro fertilization (IVF) or having a child through gamete donation.
The sessions with a mental health professional allow the infertility program coordinator to identify couples who are having trouble coping or resolving disagreements on how to proceed and to offer appropriate support. Couples also get a chance to discuss their feelings and anxieties.
Some men and women are at high risk for emotional distress related to infertility, especially those who have a shaky marriage relationship, or a history of major depression or anxiety. Other high risk factors include past or current problems with chemical dependency, a history of having been abused as a child, a past event such as an elective abortion or an STD that they fear has contributed to present infertility, or facing difficult choices about using assisted reproductive technology.
© Copyright 1995-2013 The Cleveland Clinic Foundation. All rights reserved.
This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 1/14/2013...#4332