Kathryn J Watkins, Tracy D Baldo. Journal of Counseling and Development : JCD. Alexandria: Fall 2004. Vol. 82, Iss. 4; pg. 394, 9 pgs
Abstract (Summary)
Infertility affects many individuals and couples. This article begins with a case study of a couple who have experienced infertility yet do not identify infertility as their presenting problem. Clients and counselors alike often overlook infertility. This article offers an overview of the biology of infertility and its psychological and sociological effects. Counseling issues are presented to assist counselors to identify infertility as a concern and provide interventions. [PUBLICATION ABSTRACT]
Infertility affects many individuals and couples. This article begins with a case study of a couple who have experienced infertility yet do not identify infertility as their presenting problem. Clients and counselors alike often overlook infertility. This article offers an overview of the biology of infertility and its psychological and sociological effects. Counseling issues are presented to assist counselors to identify infertility as a concern and provide interventions.Marilyn, 39, and Pedro, 45, have come to you for marital counseling. They report being devout Catholics who are seeking help in determining the cause of their marital discord. Marilyn is Caucasian, and Pedro is Hispanic. They report that they have been married for 14 years, have no children, and for the past 4 years have been "drifting apart." Pedro reports that Marilyn has "changed." She used to be actively involved with their extended families, now he states that "Marilyn has refused to go to my sister's baby shower, and I don't understand her anymore." Marilyn states that she feels depressed and "doesn't feel up to seeing her family." She has also stopped going to many of her typical social functions. Marilyn reports that her mother has been concerned and has stated that Marilyn and Pedro should have a baby. Marilyn shares that her mother continuously questions her about "becoming a Grandma" and puts pressure on her to "be a good Catholic." Pedro observes that Marilyn keeps saying things like, "What's the purpose of living" and "We are failures as adults." Pedro also reports that he is unsatisfied with their sexual relationship. In particular, Marilyn has been anorgasmic, and he has had incidences of impotence. When asked about her sexual relations, Marilyn says that she cannot "stand her menstrual cycle" and all of the "mess it entails," but she does not address the act of intercourse. Pedro reports being confused and that he does not understand the emotional lows Marilyn is experiencing. They are thinking about getting divorced.
Statistics indicate that 3.5 million couples in the United States are infertile (Daniluk, 2001b). In other words, 15% of all couples will experience the frustration of infertility at some point in their relationship (Serono Laboratories, 1996). The high incidence of infertility almost guarantees that the complex emotional roller coaster related to infertility that individuals and couples face will be an issue in some facet of their counseling. To ethically address the issues that clients like Marilyn and Pedro present, counselors must understand the complexities that infertile individuals and couples experience, including the biological, the psychological, and the sociological effects. This article explores the wide array of conditions individuals and couples endure because of infertility and provides specific counseling strategies. For a clearer writing style, the word couple will be used throughout the remainder of this article, although the reader is advised that many "single" people also go through the infertility experience. In addition, the article is written to provide a model for counselors to use. We are not implying that every couple will go through each of these experiences, only that many couples have done so. Coping with infertility is a dynamic, personal process, and couples will experience it through their own lense of understanding.
Infertility is defined as the inability to achieve a viable pregnancy after 12 months of regular, unprotected sexual intercourse (Anderson, 1989; Atwood & Dobkin, 1992; Cooper-Hilbert, 2001; Daniluk, 2001b; Serono Laboratories, 1996). This definition contradicts the 42% of people who have reported that concern about infertility should not begin until after 30 months of unprotected sexual intercourse (Gibbs, 2002). The NationalCenter for Health Statistics (Atwood & Dobkin, 1992) has stated that infertility affects 27.2% of women between the ages of 40 and 44 years who are trying to conceive. This issue of infertility dramatically increases the level of trauma that couples may encounter when they have waited to have children until later adulthood. Anderson reported that 1 in 6 couples in North America are infertile, with that number rising for women who have waited to have children until they are 35 years old and older. Other statistics show that 10% of couples are infertile, with 20% of married couples without children being infertile (Abbey, Andrews, & Halman, 1992). Atwood and Dobkin also suggested that infertility is higher among African American populations and less educated women. Causes for these higher infertility rates might be the lack of resources these populations often face. Otherwise, infertility does not discriminate by gender or ethnicity.
Edelmann and Connolly (1987) conducted a survey questioning infertile couples going through infertility. In particular, they asked, "Would you find it useful to have help/guidance from someone other than a medical specialist?" They found that 39.2% of the respondents answered yes, with 6.7% of that population desirous of weekly help and 83.8% desirous of monthly help. According to these statistics, there are infertile couples who believe they would benefit from services such as counseling. Moreover, infertile couples who participated in an 8-week support group reported less psychological distress and depression than did couples who did not have this type of support (Stewart et al., 1992).
The problem of infertility affects many couples; therefore, it may be helpful for clinicians to understand the history behind some of the feelings and attitudes related to infertility. Atwood and Dobkin (1992) followed the historical implications of infertility from the Bible to tribal and cultural ideologies. It is stated in the Bible, "Be fruitful and multiply," "Give me children or I die," and the implication of these statements is that having children is a blessed event, without which there is no purpose for living. Some primitive, unscientific explanations for infertility have been that it has been brought about by ancestral anger because a particular marriage has taken place, that it is the result of a witch's curse over the person's ovaries or penis, and that it is due to the sexual promiscuity of the woman. Tribal leaders have even blamed infertility on tensions between the two families of origin of a couple. In India, where a high premium is placed on the family, infertility carries a significant stigma, and the blame for it is placed on the woman (Chandra et al., 1991).
Unfortunately, even in more recent times in American culture, infertility has often been blamed on the woman. Klempner (1992) stated that in the 1940s, infertility was linked to the woman's unconscious fear of sexual feelings and to her neuroses. In the 1950s and 1960s, infertility was blamed on the woman's psychological impairment and her ambivalence toward becoming a mother. Faludi (1992) discussed the blame of infertility being placed unjustly on career women or on women who choose to postpone childbearing. The negative media spin surrounding infertility may exacerbate the harmful aspects of the emotional experience for infertile women. In addition to the media's impact, there are inaccurate and uninformed myths such as the following: "This is God's punishment," "This is because I had sex with too many people," "This is happening because I had an abortion," or "I am infertile because I was on birth control for too long." Note that many of these myths still place the blame of infertility upon women and their sexual decisions. As is evident from this brief historical survey, there is a vast misunderstanding in popular culture about the causes of infertility and the emotional trauma that many couples may experience because of it.
BIOLOGY OF INFERTILITY
Because of, and in addition to, the folklore that surrounds infertility, counselors must understand the biological nature of infertility, especially so that counselors may pass this knowledge on to infertile couples. Williams, Bischoff, and Ludes (1992) gave a layman's explanation of infertility. In women, infertility is due to three primary factors. She may not be producing and releasing mature eggs, there may be scarring of the fallopian tubes that may interfere with conception, or the fertilized egg may not be able to implant properly due to structural or hormonal difficulties. For men, the primary reasons for infertility include the number of sperm they produce and the quality of the sperm.
The actual rate of infertility in the United States has not increased over time (Serono Laboratories, 1996). However, as more couples wait to have children, age-related infertility is becoming more common. Serono Laboratories stated that the biological cause of infertility is approximately equally shared between men and women. Of those couples who seek medical assistance for infertility, 35% to 50% still do not achieve a pregnancy (Daniluk, 2001b; Serono Laboratories, 1996). This is a significant portion of couples who undergo all of the medical procedures, as well as the tremendous stress these procedures involve, and still do not achieve a pregnancy. It is important that the counselor understand the basics of what a couple goes through during infertility treatments so that he or she has a deeper understanding of the intrusiveness of the treatments.
MEDICAL PROCEDURES FOR INFERTILITY
Atwood and Dobkin (1992) explained that women are usually assigned the task of taking their basal body temperature (BBT). Serono Laboratories (1996) explained that although this is an inexpensive procedure, it is a daily reminder to the woman of being infertile. The woman takes her body temperature each morning, noting daily changes. She must also note events such as sexual intercourse, sleepless nights, and sickness. Urinary testing may also be done to predict when ovulation is occurring. There are other tests that may be performed such as serum testing, prolactin testing, or thyroid testing. All of this testing is not only time-consuming and expensive, but it is also understandably emotionally draining. The husband is often required to masturbate into cups to test for sperm count. The testing procedures become more and more invasive as time goes on. Testing the cervical mucus during ovulation allows the physician to assess the consistency and elasticity of the mucus, which enables sperm to swim more easily into the uterus. Postcoital testing 4 to 12 hours after sexual intercourse and just before ovulation determines the number of sperm in the mucus. This test often leads to sexual dysfunction because of the demand for the correct timing of collected postcoital mucus. Hysterosalpingograms are performed to look for structural problems, such as blockages and disorders of the uterus. In this procedure, a small tube is placed into the cervix and a dye is released to allow the observation of the flow of the dye. The injection of dye can cause uterine cramping that may last for several hours. In addition to the cramping, a discharge may occur for several hours after the injection. If less intrusive methods do not provide the necessary information, diagnostic laparoscopy is performed to look for scarring and other possible malfunctions of the uterus, fallopian tubes, ovaries, and pelvic cavity. An instrument is passed through the naval cavity, with a second instrument inserted at the pubic hairline. Laparoscopy, which is performed under anesthesia, can leave the woman with a sore throat, shoulder pain, swollen abdomen, and general stiffness. Hysteroscopy may also be done at the same time as the laparoscopy. This is a visual examination of the uterus for abnormalities accomplished by inserting an instrument directly into the uterus. These are just some of the tests that may be performed, and this is only during the exploratory process (Serono Laboratories, 1996).
Once the problem is discovered-although for some couples, there is often no biological explanation-the treatments for infertility begin. Often, hormonal therapies (HT) are used to enhance the hormonal stimulation needed to conceive. HT has grave consequences for the emotional stability of the client, which will be discussed later in this article. There are also medical procedures that may be performed to increase the likelihood of conception. Artificial insemination is usually used for couples when the man is infertile and the woman is fertile. It is relatively painless and performed without an anesthetic. For intrauterine insemination, the doctor inserts sperm directly into the uterus near the time of ovulation. Donor sperm from someone other than the partner may be used for insemination. With in vitro fertilization, mature eggs are removed from the woman, fertilized in a laboratory dish, and after several days, placed back inside the woman's uterus. With gamete intrafallopian transfer, a mixture of sperm and eggs is placed directly into the fallopian tubes. Assisted hatching is the process of putting a hole in the embryo's covering, which increases the chances of embryo development. The current technologies dealing with infertility are far too numerous to be covered effectively and thoroughly in the scope of this article. We recommend that the reader seek out further information from the resources included in the section on counseling issues. This review is meant to be an introduction to familiarize counselors with the terminology and give them an idea of the intrusiveness involved with some of the techniques used to help couples achieve pregnancy. In addition, if the couple have been declared biologically capable of conception but they are still technically infertile, emotional issues may need to be considered. This can be addressed through counseling, which we discuss later in the article.
BIOPSYCHOSOCIAL EFFECTS OF INFERTILITY
Medical Field
Daniluk (2001b) pointed out the tremendous psychological burdens that an infertile couple may experience when working with the medical professionals. Often, clients feel that they are being exploited by persons in the medical field for the purpose of testing out new procedures. The couple may also feel rushed or discouraged from asking questions of their doctors (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Cooper-Hilbert, 2001). Callan and Hennessey (1989) addressed the role overload that the couple may experience related to frequent hospital visits, keeping the necessary appointments, and undergoing surgery. The effort required to cope with infertility may be demanding and stressful: finding the time to complete all of the medical examinations, deciding how much money to invest in the treatments, and determining how long to battle insurance companies for reimbursement for the related medical procedures (Forrest & Gilbert, 1992; Klempner, 1992; Serono Laboratories, 1996). There is the stress of completing the required tests (e.g., BBT, postcoital tests) just as there is fear induced by going through medical treatment and associated physical pain (Connolly & Cooke, 1987). The couple must also decide which treatments to try and when to stop trying (Daniluk, 2001b; Forrest & Gilbert, 1992). There can be a tremendous sense of frustration and anger toward professionals in the medical field for failing to fix the infertility (Forrest & Gilbert, 1992). Serono Laboratories also pointed out the loss of privacy that a couple may feel. All of these medical challenges are often exacerbated by the sense of isolation that the couple may feel.
Lack of Social Support
For many couples, the experience of their infertility is quite isolating and lonely (Atwood & Dobkin, 1992). They feel misunderstood and believe that they lack understanding from most of their friends and family members (Callan & Hennessey, 1989; Daniluk, 2001b). Callan and Hennessey stated that 80% of infertile couples reported being subject to negative comments from others regarding their infertility status. Forrest and Gilbert (1992) added that many couples believe that their friends and family do not know what to say. The couple may not only feel misunderstood, they may also have intense feelings of jealousy and anger toward others who have achieved a successful pregnancy or are celebrating the birth of their biological baby (Butler & Koraleski, 1990). The jealousy and anger can become all-consuming, with the couple unable to attend social events such as children's birthdays or baby blessings. The couple may become enraged at others who are having abortions and couples who achieve a pregnancy without actually trying. These feelings may also result in frustration about child abuse or neglect (Atwood & Dobkin, 1992). Another common experience shared by infertile couples is their own social withdrawal (Butler & Koraleski, 1990). Because of the stress and pain of their own infertility, couples may choose to slowly withdraw from their social contacts, including their family. However, some studies show that women have noted some positive social supports. These have been identified as husbands, family, other infertile women, their doctors, nursing staff, and counselors (Callan & Hennessey, 1989; Gibson & Myers, 2003). Callan and Hennessey also indicated that, in addition to listing counselors as sources of support, they have also been reported as sources of negative encounters. Therapists have been noted as minimizing the grief clients go through and providing erroneous reassurance about clients' infertility situation (e.g., Barton, as cited in Callan & Hennessey, 1989). Such minimization would be, understandably, quite infuriating for any client coping with infertility. Counselors must remember to be genuine in understanding the grave loss that clients feel and must not provide cause for unfounded hopes about achieving pregnancy. As couples become less satisfied with their perceived social support, the level of their depression increases (Fouad & Fahje, 1989). These strong emotions may also be intensified because of the hormonal treatments.