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Wed 28 Jan 2009 04:00 AM

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The psychology of infertility

Discover what helps couples face an inability to conceive positively.

Discover what helps couples face an inability to conceive positively.

Infertility affects every aspect of a woman's life, from her relationships to her self-esteem to her ability to plan for the future. Women who are involuntarily childless describe an array of difficult emotions, including feelings of grief, anger, frustration, and envy. They can also face social isolation.

Three decades of research have shed light on the psychological and emotional distress caused by infertility.

A recent review suggests that psychotherapy leads to lowered anxiety and depression in infertile women, and may increase conception rates.

In one study, almost 70% of women with infertility had a psychiatric disorder - most commonly adjustment and anxiety disorder.

In another study, Harvard Medical School researchers found that infertile women were as anxious and depressed as women with cancer, high blood pressure, heart disease, and AIDS.

In still other research, infertile women were found to have depression levels twice as high as fertile women, and those who had been trying to get pregnant for two to three years were the most depressed.

Infertility can also exacerbate pre-existing psychiatric conditions. For example, infertile women with a history of depression are more likely to become depressed during treatment, and are also more likely to describe infertility treatment as the most upsetting experience of their lives - even more distressing than divorce or losing a loved one.

But while the agony of infertility is ancient, some aspects of the experience are relatively new, due to the advent of assisted reproductive technologies (ART).

Today, there are more than 40 ways to get pregnant without sexual intercourse. By far, the most commonly used method is in vitro fertilization (IVF), which accounts for more than 99% of ART procedures. IVF clinics can be found throughout the United Arab Emirates and other parts of the Middle East.

Other methods of assisted reproduction include intra-uterine insemination (IUI), intracytoplasmic sperm injection (ICSI), gamete intra-fallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), third-party donation, and surrogate mothering.

These methods give hope to many couples who would otherwise be unable to conceive, but their use can also aggravate existing emotional distress. This possibility is something that mental health professionals should be aware of.

What causes infertility?

For 90% of infertile couples, infertility has a physiological cause. Around one-third of these involve factors that affect the woman, another third involve factors that affect the man, and for 10%-30% of couples there are multiple causes. For 10%, the cause is unknown, or idiopathic.

The most common causes of male infertility are vasectomy, varicocele, and sperm disorders. Temporary causes of male infertility include sexual dysfunction, substance abuse, and testicular overheating from high fevers, saunas, or hot baths. In rare cases, male-factor infertility is caused by genetic factors.

Infertility in women is more complicated. The most common cause is pelvic inflammatory disease. Endometriosis may be responsible for as many as 30% of infertility cases. Another cause of infertility in women is polycystic ovarian syndrome (PCOS).

Fibroids and congenital defects involving the uterus can result in repeated miscarriages. Obesity, nutrition, eating disorders, or substance abuse may also play a role.

About half of all couples that use ART end up with a successful pregnancy. But for the other half, treatment failure can amplify feelings of loss and guilt, and trigger additional painful emotions.Studies suggest that women undergoing ART are at increased risk for psychological distress, such as anxiety and grief, particularly if therapy fails.

The anxiety of facing IVF has been shown to continue throughout treatment. In fact, nearly 50% of couples that start treatment drop out after the first meeting, and in two large studies, two-thirds dropped out before completing treatment, usually due to psychological distress.

For some women, treatment failure can lead to feelings of shame that they have not done enough or tried hard enough to conceive. It can be hard for them to know when it is time to end the process.

And, once they do move on, they may feel frustrated and betrayed because they invested so many years in something that ultimately disappointed them.

Psychological interventions

It's important that infertile women with symptoms of anxiety, depression, or both receive counselling from a trained mental health professional.

Ideally, this counselling should begin before reproductive therapies are started, as studies suggest that addressing factors such as depression, anxiety, and stress is linked to treatment success.

A recent review of studies suggests that psychotherapy leads to lowered anxiety and depression in infertile women, and may increase conception rates. In other research, interpersonal therapy and cognitive behavioural therapy (CBT) have been shown to help infertile patients who have mild to moderate depression.

One form of such therapy is mind-body therapy, developed in 1987 by Alice Domar, PhD, an assistant professor at Harvard Medical School and executive director of the Domar Center for Mind/Body Health in Massachussets.

Studies of mind-body therapy programs have reported that such programs can help patients reduce tension, anxiety, fatigue, and depression, and re-establish their sense of being in control of their lives.

The 10-session workshops, led by mental health professionals or nurses, teach patients relaxation techniques, stress management, and coping skills; introduce revised lifestyle habits; and offer group support.

One study of 184 women who had been trying to conceive for one to two years, suggested that mind-body programmes might even greatly increase the chances of a successful pregnancy.

But recognising a link between stress and infertility is far from telling a woman, "Just relax and you'll get pregnant," says Professor Domar. Even if stress is a proven contributor to infertility, women should not be made to feel responsible.

If there's any silver lining, it is that the stress of infertility is temporary. At some point, most couples reach a resolution, whether it's conception, adoption, or deciding to remain child-free. A few even find the experience transformative.

This article is provided courtesy of Partners Harvard Medical International.

Infertility and stress

It's well known that infertility creates psychological and emotional distress. But does stress cause infertility? There is some evidence to suggest that it may, but the relationship is complex.

Research focusing on depression suggests that it may play a significant role in infertility. In one study, women with a history of depression were twice as likely as women without depression to have infertility.

Another study of women undergoing IVF treatment showed that those who were depressed before treatment had a 13% pregnancy rate, compared to 29% for women who were not depressed before receiving IVF.

Initially, a third study examining the link between job-strain and pregnancy in women did not find a causal relationship. But when the researchers limited the sample to women with unexplained infertility, job strain was found to predict an unsuccessful pregnancy.

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