Infertility, Reproductive Medicine, and the Role of the Psychologist

Infertility, the inability to conceive or have a viable pregnancy after one year of regular unprotected sexual intercourse, is a health-related problem of substantial prevalence which affects approximately one in six couples in their childbearing years. The desire to have a child is such a profound experience that the inability to conceive on one’s own produces a monumental life crisis. Infertility deleteriously affects an individual’s marital, sexual, familial, and social relationships. People are devastated by their losses and frequently are overcome with feelings of depression, anxiety, shame, anger, envy, low-esteem, and grief. In fact, when not quickly resolved, infertility assumes the characteristics of a chronic illness with a constant interplay of physical, cognitive, affective, behavioral, and social factors and the concomitant experience of stress. The psychologist plays a crucial role in the treatment of the emotional components of infertility by using individual, couples, and group therapy to reduce personal distress, resolve relationship and marital problems, and validate and normalize the infertility experience by reducing feelings of shame and isolation.

Over the years infertility treatment has changed dramatically due to advances in medical technology. Once diagnosed, some couples will be able to use the assisted reproduction technologies to achieve a pregnancy with their own genes. However, others will learn that their genes are not viable, and that they require either donor egg or sperm to achieve a pregnancy. Finally, other couples will find that they require the services of another woman to carry their pregnancy for them. The psychologist plays several roles in third party reproduction. She meets with intended parents and conducts psycho-educational consultations to inform them about the major issues as- sociated with family building with donor gametes. Additionally, the psychologist evaluates and screens donors and gestational surrogates for appropriateness and insures they have informed consent regarding the medical procedures they will undergo and the psychological consequences of their participation.

To work with the infertile population it is imperative that the psychologist is nowledgeable about the medical aspects of infertility (including genetic factors), the basic infertility work-up, current treatment options, recurrent pregnancy loss, gender differences, cross-cultural issues, psychopharmacology, and third party reproduction. Additionally, rapidly changing technologies and alternative family building situations involving donor gametes confront professionals with an ever changing array of ethical and legal issues.

Medical Aspects of Infertility

There is general consensus in the medical world that infertility affects men and women equally. Male factor infertility accounts for approximately 40% of re- ported cases, female factor accounts for approximately 40%, and roughly 20% of all infertility remains unexplained. The causes of infertility may be attributed to ovulation disorders (including premature ovarian failure and advanced maternal age), abnormalities in the fallopian tubes, aberrations in sperm quality or numbers, cervical or uterine disorders, immunological problems, endometriosis, cancer treatment, and genetic disorders (for example, Turner Syndrome, Polycystic Ovarian Syndrome, and Klinefelter Syndrome). Additionally, alcohol, tobacco, and marijuana, as well as obesity, negatively impacts both male and female fertility. Excessive exercise, which leads to extremely low body fat, may negatively affect female fertility, and certain types of exercise, such as bicycle riding, may damage male reproduction. The medical evaluation of the infertile couple focuses on detecting ovulation, examining the production and delivery of sperm, and exploring the fallopian tubes and the uterine and pelvic cavity. Reproductive endocrinologists use various medications to induce ovulation, repair fallopian tubes with surgery, improve the uterine lining through life style changes or medication that increase levels of estrogen and progesterone, surgically remove endometriosis, repair uterine problems caused by  fibroids, adhesions, or congenital abnormalities, and use an intrauterine insemination (IUI) to transport sperm directly into the uterus resolving sperm related problems.

Reproductive endocrinologists often use in vitro fertilization (IVF) to treat many forms of infertility. In IVF injectable medications stimulate the ovaries to produce multiple eggs. Once the eggs have reached appropriate maturation, a needle is inserted into the pelvis through the vagina and the eggs are retrieved from the ovaries. An embryologist mixes the retrieved eggs with large numbers of sperm to encourage fertilization. Alternatively, the embryologist may inject a single sperm into the egg by using the intracytoplasmic sperm injection procedure (ICSI) to insure fertilization. Couples may be offered the possibility of preimplantation genetic diagnosis to determine if there are genetic anomalies in the embryo. The fertilized eggs divide for several days, and then the embryos are transferred into the uterus. Extra embryos are frozen. At the time of transfer couples need to decide how many embryos to transfer (possibly leading to multiple pregnancies) and what to do with the cryopreserved embryos. These are complicated decisions, and couples often need help to explore the various options. After a comprehensive infertility evaluation, some women learn they do have viable eggs and some men find they have no sperm. The reproductive endocrinologist offers these couples the possibility of achieving a pregnancy through the use of donor gametes. Advances in technology have allowed reproductive endocrinologists to transfer alternative family building into the medical arena. These developments have created a new frontier for psychologists as we develop and define our roles in assisting doctors, patients, and donor agencies to build healthy families.

Emotional Aspects of Infertility & Infertility Counseling

Most people take fertility for granted and might have spent many years guarding against an unplanned pregnancy. They are shocked to learn about their infertility and often torment themselves for wasting time with birth control and waiting for the opportune time to conceive. Both men and women frequently feel guilty and express the idea that they are being punished for past sexual or behavioral misconduct. Couples experience infertility, from the diagnosis and evaluation through the interventions and treatment, as extraordinarily stressful, and the devastating and painful emotions associated with infertility are well documented in the literature.

The goals of infertility counseling are to enhance the quality of infertile patients’ lives during and after treatment by helping them reduce stress, increase coping, alleviate depression and anxiety, and grieve losses. The psychologist also aids in decision making regarding medical treatment and family building options and assists couples in communication, problem solving, and building a support network. Additionally, she/he prepares patients for different treatment options and raises ethical issues that they may have not previously considered. If treatment is unsuccessful, the couple will need follow up to cope with disappointment, and perhaps, pregnancy loss.

The psychologist needs to work collaboratively with the reproductive endocrinologist to educate the physician about the emotional components of infertility. When a physician acknowledges the patient’s painful experiences as part of the initial diagnosis of infertility, the couple’s ability to cope successfully with infertility is enhanced. Furthermore, it is important for physicians to know whether their patients are depressed or anxious before beginning treatment. When these conditions are left unattended, the patient’s experiences of infertility will become more intolerable, and treatment outcome may be negatively affected. Depression, anxiety, and stress respond to cognitive-behavioral interventions, relaxation techniques,supportive therapy, and psycho-education. If patients are suffering from major depression or severe anxiety, medication may be indicated. It is crucial to be knowledgeable about the effects of medication exposure to the developing fetus.

The Coupleʼs Relationship & Gender Differences

To help the couple the infertility counselor needs to understand gender differences in responses to infertility. Irrespective of the cause of infertility both men and women feel profoundly damaged and their sexual intimacy diminishes. However, men and women tend to have dissimilar reactions. At a time when the need to rely on each other is paramount, different responses interfere with the couple’s ability to understand and support each other.

Women tend to experience significantly more psychological distress than do men as they are more anxious, guilt-ridden, frustrated, and isolated. For men, the feelings associated with infertility are similar to the dynamics of stress reactions associated with other life problems, such as financial or vocational issues. On the other hand, women experience infertility as a unique stressor. They have more injurious effects on sexual self-esteem, sexual satisfaction, and self-efficacy. Women tend to regard childlessness as a personal failure and attribute the cause of infertility to themselves, even when a male factor is diagnosed. When the man is the identified patient, the gap between men and women’s responses to infertility decreases.

Gender related modes of communication make it difficult for a couple to remain connected. Women have a more interpersonal problem-solving approach where they gather information and seek help from others, while men are more oriented toward cognitive problem solving and inclined toward distancing and withdrawal. Couples may become polarized with an escalating sense of despair. The psychologist intervenes to improve couples’ communication, increase intimacy, and work toward joint decision making.

Third Party Reproduction

Third party reproduction is an alternative form of family building in which an individual or a couple uses donor egg, donor sperm, or donor embryo to achieve a pregnancy. Additionally, in cases where there is uterine failure, or when carrying a pregnancy may jeopardize a woman’s well-being, the services of a gestational surrogate may be necessary. A gestational surrogate carries the pregnancy and gives the child to the intended parents at birth. The psychologist has an educative, counseling, and evaluative role in third party reproduction.

Most reproductive endocrinologists require a psycho-educational consultation for their patients who intend to family build with the assistance of donor gametes. The psycho-educational consultation provides patients with information concerning the emotional and psycho- logical issues associated with building a family through donor gametes. The psychologist discusses the transition to alternative family building, the emotional pain associated with losing a genetic tie to one’s child, and the effects on the couple of unequal genetic relatedness to their child. Patients must be made aware of the types of relationships that are available with donors (anonymous or identity-re- lease), considerations in choosing a do- nor, how best to work with donor agencies, and the donor screening process. The consultation also addresses the myriad of psychological and emotional issues associated with disclosing donor origins to children, including crosscultural and developmental considerations for these children. Finally, information is provided concerning genetic counseling, multiple pregnancies, multi-fetal reductions, and cryopreservation of embryos. During the psycho-educational consultation the psychologist assesses whether the patients would benefit from additional support, offers suggestions that may benefit their well-being, and provides resources for further information.

In recent years thousands of births have been achieved through the use of donor gametes. The Center for Disease Control reported that in 2004 alone there were 9283 fresh embryo transfers and 4439 frozen embryo transfers using donor eggs with approximately a 50% success rate for fresh and a 30% success rate for frozen cycles. Psychologists wear their evaluative hat in relationship to gamete donors to determine if the donor can provide informed consent, can physically and psychologically cope and comply with the demands of a treatment cycle, has appropriate motivations and expectations, and is psychologically healthy. Additionally, the psychologist must educate the donor regarding the possible consequences of her donation (present and future) and ensure her psychological well-being. The evaluative process is modified when friends or family members volunteer to be donors or when embryos are being donated. Donor screenings involve a structured clinical interview and the administration of a psychometric test, usually the MMPI-2 or the PAI, and are shared with either the reproductive endocrinologist or the donor agency.

Gestational surrogacy has greatly expanded over the years, and psychologists act as educators, counselors, and evaluators when they work with surrogates and intended parents. Surrogates must be screened for informed consent, appropriateness, and psychological health. If the carrier is in a committed relationship ormarriage, her partner must be involved in the screening process. The psychologist must help the intended parents and the carrier define their expectations and desires for interaction to ensure a healthy working relationship.

Considering the Provision of Treatment

Before commencing with any counseling, screening, or educative process, the psychologist needs to be cognizant of the legal, ethical, and medical issues surrounding infertility counseling, gamete and embryo donation, and gestational surrogacy. The Mental Health Group of The American Society of Reproductive Medicine (ASRM) has published qualification guidelines for mental health professionals working in reproductive medicine. These guidelines establish the minimum qualifications and training necessary to provide infertility counseling. Additionally, they have also published recommended guidelines, constituting the standard of care, for the screening and counseling of oocyte donors, embryo donation, and for the evaluation and counseling of gestational surrogates and intended parents.

Infertility counseling is a developing field that combines mental health, reproductive medicine, genetic counseling, bioethics, and reproductive law. The psychologist is a counselor, educator, advocate,consultant, and evaluator. Individual, couples, and group therapy enhance the quality of the infertile patient’s life before, during, and after treatment, and facilitate the couple’s communication, intimacy, and decision making. Additionally, the psychologist assists in building healthy families through third party reproduction, assesses and protects the well-being of donors and surrogates, collaborates with physicians, donor agencies, and attorneys, and provides interventions to alleviate psychological disorders that occur because of the stresses associated with infertility.

1) American Society for Reproductive Medicine (ASRM.org) and The Mental Health Professional Group

2) Covington, Sharon N., and Burns, Linda Hammer, editors. Infertility Counseling: A Comprehensive Handbook for

Clinicians, 2nd edition. Cambridge University Press, N.Y., 2006

3) Leiblum, Sandra R., editor. Infertility: Psychological Issues and Counseling Strategies, John Wiley and Sons, Inc.,

N.Y., 1997

4) Cooper, Susan and Glazer, Ellen. Choosing Assisted Reproduction: Social, Emotion- al, and Ethical Considerations.

Perspective Press, IN, 1998

5) Domar, Alice D. Conquering Infertility. Viking Penguin, N.Y., 2002

 by Madeline Licker Feingold, Ph.D.

AFA Mental Health Advisory Council

Originally published in: East Bay Psychologist, Fall 2007, the newsletter of the Alameda County Psychological Association