Transcript Slide 1

INFERTILITY:
HOPE AND HEALING
Montse Casado-Kehoe, Ph.D., LMFT, RPT and
Nadia Humphreys, M.A., LMHC
Smart Marriages : Happy Families Conference
July 11, 2009
[email protected]
MYTHS
I am fertile because I have regular cycles
 A woman’s fertility gradually declines after age 35
and decreases rapidly after 40
 After 40, a woman has diminished ovarian reserve
 Everyone gets pregnant easily
 Infertility is a woman’s problem
 It’s all stress—relax and you’ll get pregnant
 Stress is the result of infertility, not the cause of it
 Infertility only has an emotional impact on the
woman
 The pill postpones menopause

www.resolve.org
THE MEANING OF REPRODUCTION
Continuance of the human life cycle
 A form of immortality
 The “birth right” to experience pregnancy and
parenthood
 Continuance of the individual’s genetic heritage
 “For most women and men the ability to conceive
and give birth to a child is paramount to their life
long notions of femininity and masculinity, to
gender identity, and ultimately, the meaning of life.
Bearing children and parenting reflects Eric
Erickson’s concept of ‘generativity’ ...” (Linda
Applegarth, 2006)

FERTILITY VOCABULARY
ART
 CASA
 CCCT
 EEJ
 FSH
 GIFT
 GnRH
 HCG
 HSG

ICSI
 IVF
 IUI
 LH
 MESA
 OHSS
 PGD
 TESE
 ZIFT

DIAGNOSIS OF INFERTILITY
Her
 Him
 Both
 HER
 Stigma
 Treatment options:

Fertility
 Adoption
 Childfree

CAUSES OF INFERTILITY--TREATMENT

Reproductive Surgery
Female
 Male

Ovulation Induction (IO) and Intrauterine
Insemination (IUI)
 In Vitro Fertilization (IVF) and Embryo Transfer
(ET)
 IntraCytoplasmic Sperm Injection (ICSI)
 Third Party Reproduction

Egg donor
* Embryos
 Sperm donor
* Uterus
 *Social, ethical and legal issues

FACTORS INFLUENCING IVF SUCCESS
RATES
Age of the woman (and consequently her ovarian
reserve)
 Normalcy of the uterus and semen quality
 Success or failure of fertilization in vitro
 Number of embryos transferred
 Adequacy of the lutheal phase after transfer

POSSIBLE SIDE EFFECT AND PSYCHOLOGICAL
EFFECT OF MEDICATIONS
Drug
Use
Possible Side Effects
Clomiphene Citrate (=
synthetic estrogen)
Induces ovulation; improves luteal
phase deficiency; increased follicle
number in women
May cause menopausal symptoms
(e.g. hot flashes), mood changes
(e.g. irritability, emotionality and
increased symptoms of
premenstrual syndrome).
Bromocriptine
Treats hyperprolactinemia
(elevated levels of prolactin), which
is associated with ovulatory
dysfunction
Antidepressant effect;
Hypomania;
Psychosis
Progesterone
Endometrial support
Depression;
Decreased libido;
Irritability
Estradiol
Endometrial support
Antidepressant effect;
Introduction of rapid cycling
Gn-RH agonists (e.g.
Lupron and Decapeptil)
Downregulate the pituitary to
prevent premature ovulation during
IVF cycles or used over an
extended period of time (6 months)
to treat endometriosis
Hot flashes; Headaches;
Mood changes (depressive
symptoms especially when used
long-term); Cognitive changes
(poor memory and concentration)
INFERTILITY-THE CHICKEN OR THE EGG
Does infertility cause depression and anxiety?
 Do depression and anxiety contribute to
infertility?
 Do symptoms of stress affect infertility?
 Do infertility treatments increase stress?
 In one study in England 60% couples dropped
treatment because of the psychological burden
 Does treatment cost affect stress?
 Does a medical model recognize the role of
emotions and mental health in fertility txts?
 Does the mind affect the body?

POSSIBLE PSYCHOLOGICAL EFFECTS OF
INFERTILITY AND GENDER DIFFERENCES




Women report a higher lever of distress than men during
infertility, regardless of the locus of impairment (male of
female-factor infertility)
Women describe feelings of role-failure, diminished selfesteem, guilt and self-blame
When struggling with male factor infertility, men also may
suffer from low self-esteem, loss of self-confidence, and
feeling of incompetence, isolation, loneliness, guilt, fear,
anger, shame or frustration.
Studies indicate that men appear to be more accepting of
being childfree and more willing than women to consider
end to treatment, even when infertility is the result of
male-factor diagnosis.
SEEKING HELP
Feel empowered
 Experience less isolation
 Validation of issues
 Discuss alternative options
 Receive education
 Access resources
 Reduce anxiety and depression
 Decrease preoccupation with fertility
 Understand the role of stress
 Access coping mechanisms
 Find support

COUNSELING CAN HELP
Infertility distress
 Miscarriage
 Pregnancy loss
 Egg/Sperm donation
 Surrogacy reproduction
 Adoption
 Stress Management
 Depression/Anxiety/Irritability
 Relationship conflict
 Post-partum depression

FEELINGS
Inadequacy
 Anger
 Sadness
 Fear
 Anxiety
 Frustration
 Guilt
 Blame
 Despair
 Worthfulness

EMOTIONAL ASSESSMENT
Anxiety
 Depression
 Distorted cognitions
 Shame
 Inadequacy
 Self esteem
 Blame
 Anger
 Jealousy

EMOTIONAL SYMPTOMS
Loss of interest in day-to-day activities
 Overwhelming sadness
 Depressed mood
 Anger outbreaks
 Increased anxiety
 Increased sexual stress
 Loss of appetite
 Disrupted sleep patterns
 Loss of sense of purpose

PHYSICAL SYMPTOMS
↑ Metabolism
 ↑ Heart rate
 ↑ Blood pressure
 ↑ Breathing rate
 ↑ Muscle tension
 ↓ Sleep
 ↑ Anxiety
 ↑ Depression

FEELING ALONE

Tapping into one’s support systems
Friends
Family
Clinic
Couple
Church
?
Counselor/
Acupunturist/
Nutritionist
WHAT COUNSELING CAN OFFER
Discussion of feelings
 Assessment of couple’s relationship
 Understanding of grief
 Relaxation techniques
 Mind-body therapies
 Overview of options to become parents
 Referrals when appropriate
 Validation
 Cheerleading
 HOPE

TO TELL OR NOT TELL
Choose whom to share or whether to share
 You don’t have to share
 Choose who may support your sharing
 Decide how much to share
 Fertility issues are personal
 Will sharing comfort and empower you?
 Set boundaries to protect yourself
 Ask for what you need

THINGS NOT TO SAY
“Don’t worry you’ll get pregnant.”
 “God has a plan.”
 “If it’s meant to be, it will be.”
 “If you use sperm donation, it will not be your
baby.”
 “If you use egg donation, it will not be your baby.”
 “If you adopt, it will not be your child.”
 “You may be better off without children.”
 “If you think positively…”

BENEFITS OF COUNSELING/PSYCHOTHERAPY
BEFORE FERTILITY TREATMENTS
Facilitate couple communication during the
initial and ongoing decision making process
 Address psychological factors that might be
hindering pregnancy, particularly when
infertility is unexplained
 Educate the couple about the implication of
treatment and the treatment process
 Teach coping and stress management skills
 Reflect on the emotional aspect of infertility
 Address grief related issues related to infertility

COUNSELING MODEL

Assess the dynamic of the couple:

Pursuer-Distancer



↑ Conflict
Collaborator-Collaborator
Assess Gender Differences:
Women
 Men

Assess Coping Mechanisms
 Assess Depression Levels
 Assess Stress Management
 Assess Sexual Dynamics

PHASES OF INFERTILITY MODEL
I.
Dawning
-first awareness of fertility issues
II.
Mobilization
-beginning of diagnostic testing
III.
Immersion
-ongoing testing and treatment
IV.
Resolution
-ending medical treatment; acknowledgement and
mourning of loss; refocusing on other possibilities
V.
Legacy
-aftermath after infertility: marital, sexual,
parenting problems after infertility
(Diamond, Meyers, Kezur & Scharf, 1999. Couple Therapy for
Infertility.)
DEVERAUX AND HAMMERMAN’S
SUGGESTED COUNSELING MODEL
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Integration of infertility into the individual’s definition
of self
Acknowledging that the infertile individual is the expert
Promoting acceptance of infertility
Acknowledging the losses of infertility
Facilitating grief and bereavement
Assigning homework
Fostering and encouraging individual empowerment
Facilitating transcendence of the infertility experience
through acceptance (rather than resolution)
Promoting responsibility (versus control)
Encouraging self-advocacy
THERAPEUTIC INTERVENTIONS
 Cognitive
restructuring
 Journaling
 Development of rituals
 Use of metaphors and analogies
 Pragmatic problem solving
 Creative decision making
 Techniques that facilitate bereavement,
integration of the infertility experience
and problem-solving
(Deveraux & Hammerman, 1998)
7 TOOLS TO SURVIVE INFERTILITY
1.
2.
1.
Take care of your body
Make conscious choices
Managing emotions
Set healthy boundaries
Who is in and who is out?
2.
Tell the truth
Sharing the story
3.
1.
Take quiet space
Centering Self
Give yourself permission to grieve
Rituals
2.
See the big picture
Redefine life
(Lombardo & Parker, 2007. I am more than my infertility.)
CRISIS WITHIN A CRISIS
Pregnancy
loss
Monthly
loss
Txts.
relationship
Infertility
Family/
Couple
$$
SILENT GRIEF

Unacknowledged
No recognition of the loss involved monthly
 No recognition of failed procedures


Cultural


No recognition of the loss publicly
Rituals
No burial for pregnancy loss
 Mourning child lost
 Mourning not being pregnant


Financial

Monetary loses
GRIEF COUNSELING
 Encourage
the couple to accept their loss
 Help the couple experience the pain of grief
 Help the couple find an acceptable way to
honor and remember the baby’s death
 Help couple working through guilt related
to miscarriage
 Help the couple to eventually withdraw
their emotional investment in the loss in
order to go forward with life
 Work towards grief resolution without baby
or with baby (Lombardo & Parker, 2007)
GRIEF, CULTURE AND SYSTEMS
Explore how the couple grieves
 Ways women grieve
 Ways men grieve
 Family acknowledgement of the grief
 Community acknowledgement
 Define grief in counseling
 Factors that may affect grief

Emotional
 Hormonal
 Physical

A COUNSELING MODEL-BODY/MIND/SOUL
Body/Mind
Grief
Emotional
Medical
Couple
relationship
Psychological
Physical
Sexual
Spiritual
GOALS IN COUNSELING THE COUPLE







Increase awareness of treatment implications
Address decision conflict
Reduce stress on the relationship
Encourage more active participation in the decision making
Improve communication between the couple and medical
staff
Facilitate management of infertility as a couple through
identifying: differences in motivation for having children;
in reaction to infertility and in coping styles; problems in
constructive communication
Assist in dealing with infertility strains on the relationship
by providing support for grief work and help the couple
identify alternatives and new life perspectives
INDIVIDUAL COUNSELING VS. COUPLE’S
COUNSELING
 Appropriate
when one partner
experiences a much greater level of
distress than the other
 When one partner (or both) experiences
significant symptoms of depression or
anxiety or other mental health problems
that require professional intervention
 When one partner is unable to move
through the grief, while the other partner
has moved on
GROUP THERAPY
 Grief
 Loss
of Control
 Gender Differences
 Interpersonal Relationships
 Dealing with the Treatment Team
 Stress and Coping
 Decision Making
 Pregnant Group Members
BENEFITS OF GROUP THERAPY
 Improved
social support
 Health behavior change
 Improved stress management
 Possible positive effect on health on
fertility
 More research needed to determine
outcomes on fertility
STRESS MANAGEMENT TECHNIQUES
 Moderate
Exercise
 Acupuncture
 Massage
 Guided Imagery
 Yoga/Fertility Yoga
 Sex with no Fertility Agenda (rekindling the
couple relationship)
 Supportive Friends, family, groups
 Being prepared for hurtful comments from
friends and family
A STRENGTH MODEL
Client’s strengths
 Couple’s strengths
 Couple’s resources
 Relational




Family
Friends
Spirituality
HOPE
 ENCOURAGEMENT
 BELIEF

PEOPLE’S STORIES

My infertility was the result of a medical condition, one that
I could not prevent and no amount of thinking positively
about my pain helped. The farther I looked inside of myself
to help heal, the sadder I became. Medication to treat the
infertility and endometriosis helped (it also put me into
early menopause) but it was the anti-depression medicine
that really made the difference in my life. For the first time,
I reached out for help and the medication took the edge off
of the stress and allowed me to work on issues without the
constant overwhelming feeling of sadness. …I guess the
most important thing a counselor can do is listen to the
story from both perspectives. My husband and I had
different issues that we were struggling with and just
because the infertility affected both of us, it does not mean
that we had the same story to tell. –H.
Going through the infertility storm was probably one of the most difficult rides of my
life! Being unable to get pregnant shook my fragile self esteem, attacked the feeling of
security in my marriage and challenged my faith in God. It was as if someone punched
me in the stomach every single month, again and again. Just as I would feel hopeful, I
would meet despair again and again. Every month - for several years, the same thing
over and over. Hope and then grief would crash over me. I would try not to be hopeful,
but that was impossible. The pain crept into every area of my life. Secretly I walked
through each day, crying on the inside, but smiling on the outside. Eventually, my focus
was able to change from becoming pregnant to becoming a parent. After four years of
struggling with infertility, we decided to direct our finances and emotional investment
into becoming parents through adoption. Although adopting took the sting out of our
infertility, there was still pain. It wasn't until our youngest child (we have two children)
was about 4 or 5 years old that the pain was finally small enough that the whispers to
God asking for a miracle of pregnancy stopped, and whispers of thanksgiving for what I
didn't understand were truly able to be genuine. Not that I didn't love our children. We
honestly believe God gave these specific children to us; it was more the loss of
not experiencing pregnancy that caused the hole in my heart. When my children were
younger, I said to them, "If I could have put YOU in my tummy, I would have done
it. But my tummy is not able to have babies, so God put YOU in someone else's tummy
for us." For us, our experience of infertility is connected to our adoption stories.
A counselor who is generally knowledgeable about some of the infertility procedures
would be able to understand a little more of what couples face. Processing the death of a
dream takes time. Each couple works through it at their own pace, and each individual
works through it differently. A good counselor would help couples cope with how they the husband and wife - handle the situation differently. Most of all, a good counselor
with a very understanding heart would be patient and encouraging. -T.

I don’t know how a counselor would have helped.
The most difficult thing was not to have my own
child, I mean genetically. I felt "not normal", I was
sad and angry. Education would have probably
helped. I would have liked to talk to another guy
who shared my experience. I wouldn't have felt
comfortable attending a support group. I would only
go to individual counseling if the counselor shared
my experience. Couples counseling may have been
helpful but we had so many appointments during
that time, I think I would have felt like I was piling
on. I had to take off work constantly for various
doctor's appointments. So, I was really stressed out
about missing so much work already. –R.

The difficulties presented by the fertility issues have been
challenging to the relationship as well. Although there are
fertility issues associated for both, one major challenge was the
perceived importance of the issue. Having a baby is of
tremendous importance to me, but I have been switching
professional careers, so my focus has been split. And to be
honest, at times, I did not give fertility enough priority.
Understandably, this was the only issue for my wife.
I would have liked for counseling to have provided a vehicle for
understanding of these issues from each other’s perspective.
Counseling that was familiar and prepared to address these
issues would have been very helpful. Additionally, counseling
and medical support that could normalize our situation would
have also been very helpful because far too often we, and
especially my wife, have felt alone in this process. –M.
MIND-BODY MODALITIES
Mind-Body Medicine-Any treatment in which the
mind is mobilized to treat a physical disorder
(Domar, 2002)
 Mind-Body Techniques:











Yoga
Breathing
Relaxation
Guided imagery, Self-hypnosis, Visualization
Emotion Freedom Technique
Massage, Therapeutic touch, Reiki
Exercise
Acupunture
Affirmations
Spirituality
MIND-BODY THERAPY STUDY, FLORIDA
10 weeks support group
 Meditation, mindfulness, yoga, self-nurture,
self-esteem, depression and/or anxiety, coping
 Decreased physical and psychological symptoms
 98% improved symptoms
 50% of the people got pregnant within 1 year

(Lefebvre, 2009)
MONEY

$$$ involved in treatments






IUI ranges $300 to $700
IVF ranges $10,000 to $25,000
Egg Donor $20,000 to $40,000
Sperm Donor $200 to $600
Surrogate Mother $60,000-$100,000
Adoption $25,000-$60,000
Pregnancy tests and ovulation predictors $10$250
 Fertility tests $100-$1000
 Hysterosalpingogram HSG $800-$1000
 Laparoscopy surgery $2000-$10,000


Costly drugs
Clomiphene Citrate $25-$180
 Femara $25-$50


Alternative treatments
Acupunture & herbals $75-$150
 Massage $65-$125
 Yoga $25-$50
 Counseling $75-$150

ADOPTION
Grieving the infertility and loss of conceiving a
biological child prior to adoption
 Explore different types of adoption and resources
(domestic, international, infant adoption,
adoption from foster care)
 Educating couple about the adoption process:









Budget
Right adoption agency
Same race vs. transracial adoption
International adoption
Adopting a special needs child
Adopting from foster care or older child
Closed or semi-open adoptions
Adoption laws
If you want to be a parent, then one
day you will be a parent but you need
to be open to the way in which that
will happen. When you are finally
holding that child on your arms, it
will be your child and you will be its
mother no matter how the two of you
are brought to each other.
--Author unknown

RELIGION AND FERTILITY
Assess client’s religious values
 Religions and reproductive technologies
 Catholic Church view:

 Any
technology used to conceive a baby outside intercourse is
unacceptable to the Roman Catholic Church (Conceive, April
2009)
Presbyterian, Baptist, Methodist churches are
okay with reproductive treatments to conceive a
child
 Presbyterian Church- Eggs seen as life
 Resolve conflict between wanting a child and
what religion may see as the appropriate way to
conceive a child

FAITH
Is the substance of things hoped for;
the conviction of things not yet seen.
--Hebrews 11:1
QUESTIONS
?
RESOURCES

Fertility LifeLines


Conceive


www.FertilityLifeLines.com
www.conceiveonline.com
Resolve

www.resolve.org
The American Fertility Association
 Fertility Hope



www.fertilityhope.org
American Society for Reproductive Medicine

www.asrm.org
ADOPTION RESOURCES
www.adoptivefamilies.com
 http://www.tapestrybooks.com/
 http://lifeforkids.com/adoption_resources.html
 http://www.dcf.state.fl.us/adoption/faq.shtml
 http://www.fsfapa.org/Home.asp
 http://www.adoptflorida.com/informationcenter.htm
 http://www.beyondconsequences.com/index.html
 http://www.attach.org/2008conf.html
 http://adoption.state.gov/
 http://www.internationaladoption.org/
 http://www.adoption.com/

REFERENCES
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Covington, S. and Burns, L.H. (2006). Infertility Counseling: A Comprehensive Handbook
for Clinicians, 2nd ed. Cambridge, NY: Cambridge University Press.
Chavarro, J.E. & Willet, W.C. (2008). The fertility diet: Groundbreaking research reveals
natural ways to boost ovulation and improve your chances of getting pregnant. New York:
McGraw Hill.
Daniluk, M.F. & Daniluk, J.C. (2001). The infertility survival guide: Everything you need
to know to cope with the challenges while maintaining your sanity, dignity and
relationships. Oakland, CA. New Harbinger
Publications.
Diamond , R., Meyers, M., Kezur, D., & Scharf, C.N. (1999). Couple Therapy for Infertility.
New York: Guildford Press.
Devereux ,L.L. & Hammerman, A.J. (1998). Infertility and Identity: New Strategies for
Treatment. San Francisco: Jossey- Bass Publishers.
Domar, A. (2002). Conquering infertility: Dr. Alice Domar’s Mind/Body guide to
enhancing fertility and coping with infertility. New York: Penguin Books.
Glahn, S. (2004). The infertility companion: Hope and help for couples facing infertility.
Grand Rapids, MI:
Christian Medical Association Resources
Gordon, J., Rydfors, Druzin, M., & Tadir, Y. (2007). Obstetrics, Gynecology and Infertility:
Handbook for
Clinicians, eth ed. Scrub Hill Press, Inc.
Indichova, J. (2001). Inconceivable: A woman’s triumph over despair and statistics. New
York: Broadway Books.
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Jarrett, J.C. (1998). The fertility guide: A couple’s handbook for informed, rational and effective
fertility
treatment. Santa Fe, NM: Health Press.
Kohn, I. and Moffitt, P.L. (1992). A silent sorrow: Pregnancy loss. New York: Delacorte Press.
Lauersen, N.H. &Bouchez, C. (2000). Getting pregnant: What you need to know right now. New
York: Fireside.
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Leiblum, Sandra R. (1996). Infertility: Psychological Issues and Counseling Strategies.
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Lewis, R. (2004). The infertility cure. New York: Little Brown and Co.
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Lombardo, M. & Parker, L.J. (2007). I am more than my infertility: 7 proven tools for turning a
life crisis into a personal breakthrough.
Nadeau, J.C. & Nadeau, M. (2007). The empty picture frame: An inconceivable journey through
infertility. New York: Outskirts Press.
Peoples, D. & Ferguson, H.R. (1998). What to expect when you are experiencing infertility: How
to cope
with the emotional crisis and survive. New York: W.W. Norton & Company, Inc.
Tomlins, J. (2003). The infertility handbook: A guide to making babies. Crows Nest, NSW: Allen
& Unwin.
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Weschler, T. (2006). Taking charge of your fertility. New York: Harper Collins.
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Williams, C.D. (2006). The fastest way to get pregnant naturally. New York: Hyperion
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Winstein, M. (2003). Your fertility signals: Using them to achieve or avoid pregnancy naturally.
St. Louis, MO: Smooth Stone Press.
APA DVD: Counseling Clients Who Have Trouble Conceiving with Susan McDaniel, Ph.D.
Source: www.apa.org
WEBSITES
http://www.mayoclinic.com/health/infertility/DS0
0310
 http://www.theafa.org/
 http://asrm.org/
 http://www.resolve.org/
 http://www.conceiveonline.com/
 http://www.fertilitylines.com/
