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Supporting Clients Facing Infertility

 

Infertility—a word we usually don’t hear until we are actively trying to get pregnant.

Infertility is defined as the inability to get pregnant or remain pregnant after one year of unprotected sex, or six months if the woman is above the age of 35 years (Center for Disease Control and Prevention, 2019). I remember when I was taught about the “birds and the bees” in middle school and it sounded like anyone could get pregnant at any time. Now, as an adult, I realize this is not the case. In fact, 1 in 8 couples in the U.S. has some form of infertility and the rates of infertility are rising (U.S. Department of Health & Human Services, 2019). There are many hypotheses about why this is happening. Couples are waiting to have children later in life, life has become more stressful, and our food isn’t as nutritious as it used to be. Plus, there are things like cancer treatments, accidents, genetic mutations, and other physiological explanations for infertility.


The following will shed some light on infertility and how to support clients who are undergoing fertility treatments.

Step 1 – Get informed

The infertility world is a world of its own, with its own language. Knowing how to speak about infertility is the first thing that any clinician needs to do in order to be a source of support. In the infertility world, we speak about “spontaneous pregnancies” rather than “natural pregnancies.” It is important to be mindful of this terminology because all pregnancies are natural (no fetus has been carried to term in a lab yet). Further, it is important to recognize this differentiation of terminology because it also comes across as judgmental and punitive when you ask “So, this wasn’t a natural pregnancy?”

Another important term is ART. ART stands for “assisted reproductive technology” and refers to any medical intervention for infertility. Medical interventions can vary from medical treatments such as Clomid (the most commonly used oral hormone), to IUI (intrauterine insemination), to IVF (in-vitro fertilization). While most of us have heard of IVF at this point, it only accounts for about three percent of infertility services in the U.S. (The American Society for Reproductive Medicine, 2017). Success rates are defined as the live birth of a baby and vary from couple to couple, but once a woman is diagnosed with infertility, the overall likelihood for a live birth is about 50 percent (Stacey, 2019).

It is important to understand the statistics. Most couples who start the infertility journey believe that infertility is female-based. Afterall, we are the ones who frequently take years of hormonal (or physical) birth control, we are the ones who carry the fetus, and in general, we tend to blame ourselves when things “go wrong.” So, it is common for a couple to believe the infertility issue is only in the female. However, the statistics for infertility offer the following insights (The American Society for Reproductive Medicine, 2017):

  • Infertility affects men and women equally
  • 25% of couples with infertility have more than one factor that contributes to their infertility
  • In approximately 40% of couples with infertility, the primary cause is male-factor

Step 2 – Understand the emotions

Expect that someone dealing with infertility is going to present with an array of emotions, including grief, fear, shame, hope, and a feeling of unfairness.

Grief hits when a couple starts to realize that their ideas of how to make a baby are altered. Many of us dream of making love and forming a baby together. It is an intimate process that is private. So, when that image gets taken away and replaced with doctor visits, invasions of privacy (emotionally and physically), and oftentimes with many strangers in the room involved in the process, it is important to allow for grief to occur. Having an infertility diagnosis is a bit like having something die. The image of what you thought getting pregnant would look like has died. So, it is important to give clients the opportunity to grieve this loss in therapy.

A lot of decisions related to fertility treatments are fear based. Process this fear in sessions with clients and acknowledge that a lot of their fears are based in reality.

Fear is another powerful emotion that hits most couples with infertility. Some of the most common sources of fear include:

  • Fear about fertility treatments not working
  • Fear of not knowing what the treatments will do to your body long term
  • Fear of having to make decisions about your fertility treatments immediately because “your biological clock is ticking”
  • Fear of having to take time off work
  • Fear of the financial strain of fertility treatments
  • Fear of what others will think if they find out what you’re going through
  • Fear of the relationship not being able to withstand the treatments

A lot of decisions related to fertility treatments are fear based. Process this fear in sessions with clients and acknowledge that a lot of their fears are based in reality. Afterall, any one of these could come true.

A feeling of life being unfair usually also surfaces with infertility. Infertility oftentimes feels like a punishment. Clients might say “I don’t deserve this” or “I’m a good person—why is this happening to me?” There is an underlying schema in most of us that bad things happen to bad people. And infertility is a bad thing, so how can it happen to a good person? Additionally, clients can do everything right with their fertility treatments, follow each of the doctor’s recommendations, and it still might not work. Validating and acknowledging these feelings of unfairness are vital for people undergoing fertility treatments.

Oftentimes, there is shame associated with infertility. There is this notion of “my body can’t do something that it’s supposed to be able to do.” Shame is usually stronger in male factor infertility than in female factor infertility. A lot of men are taught that part of “being a man” is being able to conceive children spontaneously. So, low sperm count or sperm with low motility is something that many men view as shameful or as making them “less of a man.” Shame also creates feelings of isolation because people who are ashamed of something are often less likely to talk about it for fear of drawing negative attention to it.

Finally, the last feeling that is the quiet force supporting fertility treatments is hope. Clients who are still in the treatment stage of infertility still have hope. Hope that the treatments will work, and hope that they will have a biological child. The hope is usually strongest right at the beginning of a new treatment attempt and will continue to grow until right after an implantation attempt or timed sex. Emotional self-preservation kicks in and clients are filled with doubt as they await their first pregnancy test because they don’t want to get too excited and then be disappointed by a negative result. Hope is the emotion that therapists need to carry throughout their work with clients with infertility. Clients will have waves of hope and it is vital for us to be the holders of that hope and the reminders of it.

Step 3 – Best clinical interventions

With the foundation of terminology and some of the emotions involved in treating clients with infertility, it’s time to turn to the clinical interventions. What helps clients with infertility cope with their diagnosis and make educated decisions about their fertility treatments?

Validation. Validating, empathizing, and reflecting clients’ thoughts and feelings about infertility is one of the best treatment approaches. People going through infertility treatments are going through them alone. So, therapy needs to be a safe space. A space where they can talk about these negative emotions and feel heard. Validation allows for this to happen. It allows for clients to feel heard, understood, and supported. It is important to avoid giving suggestions while validating. Questions like “Well, have you tried xyz?” or “How are you taking your medication?” are not only inappropriate but can be perceived as judgmental. Your job is to support the client in processing and coping with this journey.

Clients will have waves of hope and it is vital for us to be the holders of that hope and the reminders of it.

Emotional safety. Creating emotional safety is another strong clinical intervention to use. Most couples undergoing fertility treatments will report that they do not feel emotionally heard or safe with their doctors. They trust that their doctors know how to help them with conception (and keep them pregnant) but these doctors don’t really stop to ask “How are you feeling?” Fertility clinics look just like other doctor’s offices and don’t really give off feelings of love and comfort. So, it’s important for you to create emotional safety in your treatment approach. Sessions with you are when clients can speak about how they feel about their decisions and their fertility treatments. In these sessions, couples can speak about their fears of what the fertility treatments will cost them or cost their marriage. They can also process what they can do to make the process more loving and caring, such as giving each other a kiss when the embryo is transferred into the uterus during IVF or holding hands during IUI. Creating emotional safety will also allow you to support your client in creating meaning of what is happening to their bodies and support them in changing the narrative of their infertility journey.

Systemic application of Cognitive-behavioral therapy (CBT). Finally, the staple of all evidence-based therapy is to incorporate some CBT into your treatment approach. Teaching clients relaxation skills such as deep breathing and positive imagery for them to use while undergoing fertility treatments can help with reducing anxiety in the room and increasing physical comfort. A lot of fertility treatments (i.e., IUI, IVF) involve dilating the cervix. This can be painful and made even more painful if the woman is not relaxed. Therefore, practicing relaxation skills in these moments helps reduce pain. Additionally, cognitive strategies such as thought records and positive mantras can help in creating positive meaning throughout a client’s infertility journey, as well as giving clients ways of remaining positive and hopeful.

Infertility is a life altering diagnosis for many couples. As such, it is important to be educated on the diagnosis and provide treatment that will help clients process and cope with it. For more detailed training on this topic, information is available at the American Society for Reproductive Medicine.

Linda Meier Abdelsayed, MA, is a licensed marriage and family therapist in California and Illinois. She is the founder of Smart Talk (www.smarttalktherapy.com), a teletherapy private practice whose focus is to improve the quality of life for clients. She is a Clinical Fellow of AAMFT and operates a small private practice in Newport Beach, CA (www.smarttalkoc.com) where she specializes in supporting couples with infertility, high risk pregnancy, and postpartum depression. She has been married for 10 years and is the proud mother of 4-year-old boy/girl twins conceived via assisted reproductive technology.


REFERENCES

Center for Disease Control and Prevention. (2019). Reproductive health – Infertility. Retrieved from https://www.cdc.gov/reproductivehealth/infertility/index.htm

Stacey, M. (2019, December). Assisted reproductive procedures. How to Overcome Infertility, 38-47.

The American Society for Reproductive Medicine. (2017) Quick facts about infertility. Retrieved from https://www.reproductivefacts.org/faqs/quick-facts-about-infertility

U.S. Department of Health & Human Services. (2019). Female infertility. Retrieved from https://www.hhs.gov/opa/reproductive-health/fact-sheets/female-infertility/index.html

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