Cover Story

According to the American Society for Reproductive Medicine (ASRM), about one in 10 Americans in their reproductive years experiences infertility. And infertility is becoming more common, warns ASRM.

With the availability of contraception, the number of working women and the age of newlyweds all increasing, people are waiting longer than ever before to start families. ASRM estimates that already 20 percent of women wait until after they've turned 35, an age when fertility starts declining dramatically and miscarriages increase (see "Private loss visible").

A diagnosis of infertility--the inability to get pregnant after a year or more of trying--can lead to depression, anxiety and other psychological problems, trigger feelings of shame and failure to live up to traditional gender expectations and strain relationships, say psychologists specializing in infertility. Individuals and couples can struggle with complex decisions about how far to take the quest for children. In vitro fertilization (IVF), frequently uninsured, is unaffordable for many, and other routes like adoption or surrogacy can be just as, or more, expensive and pose their own challenges.

More and more, psychologists are helping people navigate difficult fertility-related decisions and teaching them to use relaxation and other techniques to counter the worry and stress that can accompany fertility problems (see "How to handle a stubborn stork"). Helping individuals and couples realize their baby dreams is certainly the payoff, psychologists say, but even parents who bring home babies can have their own set of post-infertility stresses and anxieties (see "'They are so wanted'").

Women's worries

After receiving a diagnosis of infertility, women often feel anxious and sad, says Andrea Mechanick Braverman, PhD, director of psychological and complementary care at Reproductive Medicine Associates in Morristown, N.J. Their self-esteem can suffer. They often feel hopeless about ever forming the families they want.

Using a cognitive-behavioral approach, Braverman helps women identify and dismantle the dysfunctional messages they're hearing both from themselves and others. Patients often convince themselves that they're not real women unless they have biological children, she says. And patients are barraged by messages blaming them for their infertility.

"They're getting very real messages saying, 'You're too uptight' or 'You're too type A,'" says Braverman.

To combat such messages, she combines therapy and education. What often helps is to share the results of research showing that biological factors are to blame for most cases of infertility, she says (see "Does stress hinder conception?").

Women also face anxiety about specific procedures, such as IVF. Techniques such as deep breathing, guided imagery, yoga and massage can help them relax at all stages of treatment, says Braverman.

Helping women make informed decisions is another large part of Braverman's work.

"There are so many choices," she says, noting that the ever-growing number of options makes specialized training critical for psychologists working in this area.

The goal, she says, is making sure patients thoroughly understand what medical procedures entail, even down to such practical considerations as whether their jobs are flexible enough to allow them to visit the doctor at specific times of day.

It also means helping them think about unintended consequences, says Braverman. A woman contemplating IVF, for example, needs to consider the possibility of a multiple pregnancy. In addition to posing risks to the health of both women and their babies, multiple pregnancies can force parents into difficult decisions about reducing the number of fetuses to increase the chances that others will survive. Patients must also decide how far they're willing to go and what price--both financial and emotional--they're willing to pay for biological children.

In addition, women and their partners must prepare themselves for disappointment in case procedures aren't a success.

"Even with in vitro fertilization, the majority of people aren't going to get pregnant after a single attempt," explains Braverman. "You have to help them prepare a strategy for managing that."

Part of that management strategy may be to explore such options as surrogacy or adoption, she adds.

Complex cases

For some women, infertility isn't the only health problem they're confronting. Such conditions as polycystic ovarian syndrome, chronic pelvic pain and eating disorders can threaten fertility and complicate infertility treatment, says Helen L. Coons, PhD, president and clinical director of Women's Mental Health Associates in Philadelphia.

For other women, a diagnosis of cancer can raise questions about mortality as well as fertility, says Coons, also a clinical associate psychiatry professor at the Drexel University College of Medicine: "They're facing the challenge of an overwhelming threat to their lives and the fear that they may not be able to have the families they had hoped for."

In cases of young women with breast cancer, for example, Coons helps patients learn about their fertility options before they begin chemotherapy, which may cause early-onset menopause. The fact that Coons has co-located her private practice in women's primary care, obstetrics/gynecology and reproductive endocrinology settings facilitates the process, she says.

Men's misconceptions

One often-overlooked group is men, says William D. Petok, PhD, a private practitioner in Baltimore who is one of the few male psychologists in the field. Of the approximately 375 members of ASRM's Mental Health Professional Group, he points out, about 90 percent are female.

Men and women are equally likely to contribute to a couple's fertility problem, says Petok. So-called female factor and male factor infertility each account for about 35 to 40 percent of cases, he says, with combined or unknown causes accounting for the remainder. Yet most of the psychological literature on infertility focuses on women, he notes.

"Infertility potentially cuts into a man's feelings of masculinity," says Petok, noting that traditional notions of masculinity revolve around the ability to conceive children. "That can lead to issues of shame and embarrassment."

Some men also worry about their inability to continue their family's genetic line, adds Petok.

Diagnosis and treatment, while much less invasive than the parallel procedures for women, can bring their own concerns. Performance anxiety is a major issue, says Petok, adding that couples must frequently adhere to rigid love-making schedules.

"Sex becomes a performance rather than a loving act," he explains. "Couples frequently talk about it being like having the doctor in the bedroom with them."

The result can be erectile dysfunction, says Petok.

Just letting male patients know such problems are common goes a long way toward helping them, he says. So does talking them through decision-making. For those whose infertility can't be fixed, Petok will help them explore their feelings about using donor sperm.

Couple power

Infertility doesn't just affect individuals' mental health. It can change the dynamics of relationships, says Ann Rosen Spector, PhD, a private practitioner in Philadelphia.

The stress of infertility and fertility treatment can exacerbate existing problems, such as poor communication skills or money issues. It can also lead to new problems, says Spector. Failure to conceive can lead to recriminations. And couples sometimes find they're not on the same page when it comes to how far they'll go to conceive a child.

These new stressors may also occur at a time when infertility drugs are throwing women off kilter.

"A lot of these women are in a hormonally charged state for a very long time," says Spector. "It's not easy for the woman to live with herself, and it's certainly not easy for her partner."

The problems are compounded for low-income couples, says Gail E. Wyatt, PhD, director of the sexual health program at the University of California, Los Angeles Semel Institute and director of the Center for Culture, Trauma and Mental Health Disparities. Infertility services can be extremely expensive. A single IVF cycle costs an average of $12,400, according to ASRM, and only 14 states currently require insurers to cover at least some diagnostic and treatment services.

Even if low-income patients can somehow afford services, says Wyatt, logistics can get in the way.

"Infertility treatment requires many visits and consistency," she explains. Given long distances and high transportation costs, getting there can be difficult for low-income patients.

Further Reading

Rebecca A. Clay is a writer in Washington, D.C.

A DVD on counseling clients dealing with infertility--with Susan McDaniel, PhD--is forthcoming from APA in fall 2007. Check APA Videos.