- •Series Editor Foreword
- •Preface
- •Contents
- •Contributors
- •Differential Diagnosis
- •Evaluation
- •Treatment
- •Discussion
- •References
- •Background
- •Normal Pubertal Stages
- •Differential Diagnosis of Precocious Puberty
- •Evaluation [1, 3, 4]
- •Treatment [1, 2]
- •Discussion
- •References
- •Background
- •Differential Diagnosis of Delayed Puberty
- •Evaluation
- •History and Physical Examination
- •Laboratory Investigation and Imaging
- •Treatment
- •Discussion
- •Suggested Readings
- •Discussion
- •Differential Diagnosis
- •References
- •Discussion
- •References
- •Differential Diagnosis
- •Evaluation
- •Treatment
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Interpretation of Thyroid Function Tests (TFTs)
- •Iodine Supplementation for Pregnancy and Lactation
- •Screening for Maternal Hypothyroidism
- •Maternal Subclinical Hypothyroidism
- •Thyroid Autoimmunity
- •Maternal Hyperthyroidism: Diagnosis
- •Maternal Hyperthyroidism: Treatment
- •Postpartum Thyroiditis
- •Summary
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Intrauterine Pathology
- •Thin Lining
- •Endometrial Receptivity Analysis (ERA)
- •Chronic Endometritis
- •Conclusion
- •References
- •Discussion
- •References
- •Discussion
- •History
- •Physical Exam
- •Semen Analysis
- •Laboratory Testing
- •Genetic Testing
- •Adjunctive Tests
- •Imaging
- •References
- •Discussion
- •Pathophysiology
- •Evaluation
- •Treatment
- •Lifestyle Changes
- •Medications
- •Phosphodiesterase 5 Inhibitors
- •Vacuum Erection Device
- •Intraurethral Alprostadil
- •Intracavernosal Injections
- •Surgery
- •References
- •Discussion
- •History
- •Semen Analysis
- •Physical Examination
- •Proper Varicocele Examination
- •Laboratory Investigations
- •Additional Investigations for the Pain Include
- •Other Investigations for Infertility in the Context of Varicoceles
- •Treatment
- •Indications for Varicocele Treatment Include the Following
- •Numerous Treatments for Varicocele Exist
- •References
- •Discussion
- •Semen Analysis
- •History and Physical Examination
- •Laboratory Investigations
- •Testicular Biopsy
- •Treatment
- •Surgical Techniques for Sperm Retrieval [13]
- •Fresh Vs. Frozen Sperm
- •Counseling
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Background
- •Epidemiology
- •Evaluation
- •Treatment
- •Non-ART Treatment
- •Accelerated Utilization of ART
- •ART Success Rates
- •Recent Trends in ART
- •Discussion
- •Conclusion
- •Suggested Readings
- •Evaluation
- •Differential Diagnosis
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •References
- •Discussion
- •Suggested Readings
- •Diagnosis
- •Management
- •Discussion
- •References
- •Index
200 |
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reported sexual problems ranging from lack of desire, pleasure, and spontaneity to erectile dysfunction. Common feelings of infertility such as loss, anger, guilt, despair, depression, shame, and anxiety, began to overshadow intimate feelings of warmth, affection, and emotional connection so that sex became methodical, predictable, and unexciting. This added additional pressure for John who felt the responsibility of performing on demand (e.g., during ovulation, producing semen samples, etc.).
Their differing emotional reactions, communication styles and coping strategies left each of them feeling alone in the struggle, and the stresses resulting from multiple treatment failures put a strain on their personal and emotional well-being. Both felt a sense of profound loss and hopelessness from the unsuccessful IUI and IVF cycles and the miscarriage. They also feared the loss of a genetic tie to potential offspring as they contemplated donor gametes and adoption. They felt a sense of isolation from others and could not agree upon how much information they would share with family and friends and how often they would socialize and attend gatherings that involved children or the potential announcement of pregnancies. Both Julie and John reported feeling isolated, emotionally unsupported, depressed, and rejected by the other.
The case presented above illustrates the typical stressors and psychosocial complications of a couple struggling to conceive. This chapter will address an overview of the psychosocial interplay between infertility and relationship health and will provide a framework to providers about how to address these complex issues.
Discussion
Individuals and couples experience high levels of stress as they attempt to manage the physical, emotional, social, and fnancial concerns related to infertility and treatment. Diffculty conceiving is described as an emotional roller coaster and crisis that chips away at one’s self-esteem, identity, relationships, and ability to cope [1]. Women undergoing fertility treatment characterize infertility as the most stressful experience of their lives [2] and On The Life Events Scale, the failure of IVF is rated equally to breast cancer, death of a family member, and worse than divorce [3].
While trying to conceive, patients no longer feel in control of their bodies or their life plan. Lives are put on hold, attempts to conceive become all consuming, and couples are beholden to treatment [4]. Trying to juggle medical appointments and medicine regimes with job responsibilities can increase pressure and put stress on careers. Not surprisingly, the most common reason why insured patients drop out of treatment is psychological burden resulting from infertility, including treatment [5].
The expectations and communication between a couple are also challenged. In some relationships, partners blame themselves or each other for infertility or medical diagnoses, resulting in anger that interferes with communication and sexual desire and functioning. Often times, one partner will harbor resentment toward the partner that wanted to wait longer to build a family. In another typical scenario, one
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28 Psychological Factors and Fertility Counseling |
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partner will blame the other partner’s poor habits such as smoking, unhealthy eating, or lack of exercise for their problems.
Although there appear to be clear differences in the ways that men and women respond to infertility [6], research has shown that overall, both men and women with infertility are signifcantly more distressed than fertile couples [7, 8]. Women also experience greater emotional distress than men because they often assume more personal and social responsibility while managing more of the physical and emotional burden of treatment [4, 9].
Motherhood is seen by many women as a primary role in life and as an integral part of their femininity, gender identity, and sexuality. Women tend to assume that they are the cause of the infertility and begin (often fruitlessly) to search for a cause. They reproach themselves for past “misdeeds” and may even offer to leave their partners so as to free them to have children with another partner. Those who have diffculty getting pregnant or carrying a pregnancy may also feel like a failure as a human being. It is common for some infertile women to describe themselves as “defective” or “damaged goods.” Clearly this self-perception can lead to depression, anxiety, and a loss of self-confdence and competence.
For many men, masculinity and fertility are deeply intertwined. If a male factor is diagnosed, self-esteem and self-image may also be negatively affected resulting in more anxiety, and physical symptoms as well as feelings of shame, loss, and poor self-esteem [7, 8]. An inability to impregnate his partner may strike heavily at a man’s view of himself as “whole” and as virile and masculine. Women often have diffculty having empathy for their partners and may not understand the shame a man who associates potency with manliness may feel when he can’t “make” his partner pregnant, or the anxiety and shame he reports feeling when forced to provide a sperm sample. In a recent study [10], 93% of men stated their well-being had been impacted by infertility and described it as “the most upsetting, dark and emasculating experience of my life.” There is also less social acceptability for men to express these feelings as well as those of disappointment and grief to their partner. Their reluctance to share may also be caused by fear that they will only contribute further to the emotional distress that the couple already experiences.
For many women, thoughts about the infertility as well as the need to discuss it can sometimes feel obsessive. The partner, on the other hand, may feel overwhelmed with his partner’s sadness and her desire to talk about the infertility constantly. He may either respond with calm, reason, and optimism in an effort to comfort his partner and be “the strong one” or he may begin to withdraw because he feels like a failure who can’t fx the problem. If he begins to pull back, she may start to feel that her partner does not care about her distress or does not really want a child. It is typical for the woman to want her partner to be more emotional and for the man to want his partner to be more rational. Women tend to have more diffculty staying optimistic and react to the infertility by expressing themselves emotionally. She may begin to resent her partner’s hopefulness, ability to function effectively at work, and distract himself from the problems. As a result, partners may begin to doubt the stability of the relationship and may withdraw from one another, feeling angry, hurt, and alone.
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The universal theme of loss for those struggling to conceive is powerful. The grief is complicated because the loss experienced is not just for the longed-for child but also represents loss of self-worth, hope, identity, control, and loss of where they thought they would be at this point in their lives. Guilty feelings are also common and can further fuel a sense of profound loss and responsibility toward family and friends. The infertile couple may experience overwhelming guilt and sorrow about disappointing or denying grandparents-to-be or potential aunts and uncles. The couple may also be consumed with guilt about being unable to fulfll their duties and responsibilities related to “carrying on the family name” or providing an heir.
In circumstances when the couple cannot work through their differences, they may beneft from counseling that can help them improve communication, respect their different coping styles, and ultimately get them back to working out problems as a team. It is encouraging to note that few couples actually separate or divorce as a result of their infertility. Although the diffculties surrounding efforts to get pregnant or carry a child can be extremely stressful for most couples, many ultimately feel that the experience brought them closer together and led to the development of better coping skills.
The feld of fertility counseling comprises an eclectic use of a variety of treatment modalities including but not limited to psychoeducational counseling, therapeutic counseling (e.g., cognitive behavioral), supportive counseling, grief counseling, and counseling that assists couples in decision making about treatment and next steps. The key is to match the right intervention at the right time to serve the emotional needs of the individual and couple. Table 28.1 provides a list of some of the goals and techniques of therapeutic intervention.
The form of counseling provided will be determined by the needs of the couple, the timing of treatment (e.g., initiation, treatment, resolution), the couples’ level of distress, individual personality, and coping factors. The timing of interventions and assessments might be particularly important to their effectiveness since the issues facing the couple at each phase of treatment can differ and require different therapeutic approaches.
Psychoeducational counseling most commonly occurs before treatment begins but can also take place throughout the fertility journey as couples navigate treatment options at different stages. Psychoeducational counseling is aimed at reducing feelings of helplessness and the stress of treatment though preparation. Psychoeducation enhances patient control, addresses decision making and treatment options, and manages expectations.
Less distressed couples may beneft from written psychosocial information provided at key times in treatment or brief counseling that emphasizes education. For example, counselors have developed interventions tailored to specifc challenges, such as coping with the 2-week waiting period before the pregnancy test and preparing couples for treatment [11, 12].
For those whose coping resources are inadequate and/or depleted, such interventions might not be suffcient and ongoing supportive or therapeutic counseling can be used to decrease psychological distress and improve relationship satisfaction for couples experiencing more moderate to severe levels of distress. One form of
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Table 28.1 Therapeutic interventions and techniques |
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Therapeutic interventions |
Examples of techniques |
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Psychoeducational counseling |
Provide information about treatment to empower |
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patients and to manage expectations |
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Supportive counseling |
Improve patients’ emotional health and well-being |
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through empathy, validation of feelings, and |
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normalizing distress |
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Improve communication with doctor/ |
Role play typical interactions. Assertiveness training. |
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staff/bosses/friends/family members |
Boundary setting |
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Reduce the stress and demands of |
Relaxation techniques, mindfulness, cognitive |
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fertility treatment |
behavioral strategies |
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Help make informed decisions about |
Enhance problem solving skills |
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family building options or ending |
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treatment |
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Improve couple communication |
Acknowledge different coping styles, learn to fght |
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fairly, teach empathic listening skills |
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Improve intimacy and sexual |
Non procreative sex, dispute male/female myths, date |
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relationship |
night without fertility discussion, devote time to |
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activities and interests that they enjoy together |
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Promote healthy coping strategies |
Replace bad habits with positive coping strategies like |
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exercise, healthy eating habits, relaxation techniques |
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Grief counseling |
Introduce rituals that validate loss and help with |
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acceptance and resolution |
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Encourage patients to make meaning of |
Journaling, resilience training |
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the infertility experience |
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Improve well-being |
Self-care strategies, positive coping, restoring hope |
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Help set boundaries with friends and |
Role play conversations, develop self-protective |
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family members |
strategies |
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Understand social, cultural, and |
Ask questions to become culturally competent and |
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religious factors that contextualize |
respectful, consult with clergy, healers, family |
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infertility and treatment |
members, etc. (with permission) |
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therapeutic counseling is cognitive behavioral therapy (CBT). There is overwhelming evidence that CBT is equivalent to antidepressant medication in the treatment of mild-to-moderate depression and more recent research indicates that it is effective in the treatment of severe depression as well [13]. This short-term form of therapy teaches individuals to recognize and challenge negative self-defeating thoughts and irrational beliefs about themselves, their environment and their future. Table 28.2 illustrates ways to restructure typical negative thoughts couples have about their fertility.
Longer-term therapeutic and grief counseling can be used when psychological stressors are more severe or after an unsuccessful fertility treatment cycle when stress is greatest. Grief counseling can occur at any point throughout the fertility journey. Couples can process frustration about starting later than desired, sadness about the number of eggs/embryos yielded or unsuccessful ART attempts. Couples may need to mourn miscarriages, selective reduction or termination. If couples decide to pursue third party reproduction or adoption, they will need to grieve the