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

Montserrat_casado@pba.edu

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 menopausewww.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 MEDICATIONSDrug 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 self-esteem, 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

Church

Couple

Clinic

?

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. Integration of infertility into the individual’s definition of self

2. Acknowledging that the infertile individual is the expert

3. Promoting acceptance of infertility

4. Acknowledging the losses of infertility

5. Facilitating grief and bereavement

6. Assigning homework

7. Fostering and encouraging individual empowerment

8. Facilitating transcendence of the infertility experience through acceptance (rather than resolution)

9. Promoting responsibility (versus control)

10. 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. Take care of your body2. Make conscious choices

Managing emotions1. Set healthy boundaries

Who is in and who is out?

2. Tell the truthSharing the story

3. Take quiet spaceCentering Self

1. Give yourself permission to grieveRituals

2. See the big pictureRedefine life

(Lombardo & Parker, 2007. I am more than my infertility.)

(Lombardo & Parker, 2007. I am more than my infertility.)

CRISIS WITHIN A CRISIS

Infertility

relationship

Monthly loss

Txts.

$$

Pregnancy loss

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

Couple

MedicalEmotional

Psychological

Physical

SexualSpiritual

Body/Mind

relationship

Grief

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

Domar, A. (). Self-Nurture

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 www.FertilityLifeLines.com

Conceive 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/information-

center.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 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 HarbingerPublications.

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.

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.

Leiblum, Sandra R. (1996). Infertility: Psychological Issues and Counseling Strategies. Lewis, R. (2004). The infertility cure. New York: Little Brown and Co. 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.

Weschler, T. (2006). Taking charge of your fertility. New York: Harper Collins. Williams, C.D. (2006). The fastest way to get pregnant naturally. New York: Hyperion 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/DS00310

http://www.theafa.org/ http://asrm.org/ http://www.resolve.org/ http://www.conceiveonline.com/ http://www.fertilitylines.com/