INFERTILITY COUNSELINGInfertility Counseling: A Comprehensive Handbook for Clinicians, Second Edi-tion, is a comprehensive, multidisciplinary textbook for all health profession-als providing care for individuals facing reproductive health issues. It is themost thorough and extensive book currently available for clinicians in the ﬁeldof infertility counseling, providing an exhaustive and comprehensive reviewof topics. It addresses both the medical and psychological aspects of infertility,reviewing assessment approaches, treatment strategies, medical counselingissues, third-party reproduction, alternative family building, and postinfer-tility counseling issues. Each chapter follows the same format: introduction,historical overview, literature review, theoretical framework, identiﬁcation ofclinical issues, suggestions for therapeutic interventions, and future impli-cation. This edition also includes extensive appendixes of psychological andlegal tools useful to all clinicians, including an Internet database of resourcesand an extensive glossary of terminology.Sharon N. Covington is an Assistant Clinical Professor in the Department ofObstetrics and Gynecology at the Georgetown University School of Medicinein Washington, DC. She is also currently the Director of Psychological SupportServices at Shady Grove Fertility Reproductive Science Center in Rockville,Maryland. A clinical social worker and psychotherapist for more than thirtyyears, she practices individual, couple, and group psychotherapy as well asthe highly specialized area of infertility counseling.Linda Hammer Burns is an Assistant Professor in the Department of Obstet-rics, Gynecology, and Women’s Health at the University of Minnesota MedicalSchool and the Director of Counseling Services at the Reproductive MedicineCenter in Minneapolis, Minnesota. She has been a psychologist for more thantwenty years, providing individual and couple counseling in women’s healthpsychology, with a special focus on reproductive health psychology.
Infertility CounselingA COMPREHENSIVEHANDBOOK FOR CLINICIANSSECOND EDITION Edited by SHARON N. COVINGTON Assistant Clinical Professor Department of Obstetrics and Gynecology Georgetown University School of Medicine Washington, DC LINDA HAMMER BURNS Assistant Professor University of Minnesota Medical School Department of Obstetrics, Gynecology, and Women’s Health Minneapolis, MN
For our husbands,Barry Truitt Covington and Sheldon Robert Burns,and our growing families,Brendan Truitt Covington, Laura Stratford Covington,Michelle Covington Harmon, Scott Newcomer Harmon;and Sean Covington Harmon;Evan Robert Burns, Alicen Burns Spaulding,and Stephen Alan Parlin Spaulding.You will always be the wind beneath our wings.
ContentsList of Contributors page xiForeword by Roger D. Kempers xvPreface xviiPART I. OVERVIEW 1 Psychology of Infertility 1 Linda Hammer Burns and Sharon N. Covington 2 Medical Aspects of Infertility for the Counselor 20 William R. Keye, Jr. 3 The Psychology of Gender-Speciﬁc Infertility Diagnoses 37 William D. Petok 4 Cross-Cultural Issues in Infertility Counseling 61 Michaela Hynie and Linda Hammer BurnsPART II. ASSESSMENT 5 Psychosocial Evaluation of the Infertile Patient 83 Susan Caruso Klock 6 Psychopathology and Psychopharmacology in the Infertile Patient 97 Katherine E. Williams and Laurel N. Zappert 7 Evidenced-Based Approaches to Infertility Counseling 117 Jacky BoivinPART III. TREATMENT MODALITIES 8 Individual Counseling and Psychotherapy 129 Linda D. Applegarth 9 Counseling the Infertile Couple 143 Christopher R. Newton10 Group Approaches to Infertility Counseling 156 Sharon N. Covington11 Behavioral Medicine Approaches to Infertility Counseling 169 Christianne Verhaak and Linda Hammer Burns vii
viii CONTENTS 12 Complementary and Alternative Medicine in Infertility Counseling 196 Jacqueline N. Gutmann and Sharon N. Covington 13 Sexual Counseling and Infertility 212 Linda Hammer Burns PART IV. MEDICAL COUNSELING ISSUES 14 Patients with Medically Complicating Conditions 237 Donald B. Maier, Sharon N. Covington, and Louise U. Maier 15 Genetic Counseling and the Infertile Patient 258 Linda Hammer Burns, Krista Redlinger-Grosse, and Cheri Schoonveld 16 Pregnancy Loss 290 Sharon N. Covington PART V. THIRD-PARTY REPRODUCTION 17 Recipient Counseling for Donor Insemination 305 Petra Thorn 18 Recipient Counseling for Oocyte Donation 319 Patricia L. Sachs and Linda Hammer Burns 19 The Donor as Patient: Assessment and Support 339 Linda D. Applegarth and Sheryl A. Kingsberg 20 Embryo Donation: Counseling Donors and Recipients 356 Linda D. Applegarth 21 Surrogacy and Gestational Carrier Participants 370 Hilary Hanaﬁn PART VI. ALTERNATIVE FAMILY BUILDING 22 Adoption after Infertility 387 Linda P. Salzer 23 Involuntary Childlessness 411 Gretchen Sewall and Linda Hammer Burns PART VII. POSTINFERTILITY COUNSELING ISSUES 24 Ending Treatment 429 Janet E. Takefman 25 Pregnancy after Infertility 440 Sharon N. Covington and Linda Hammer Burns 26 Parenting after Infertility 459 Linda Hammer Burns 27 Assisted Reproductive Technology and the Impact on Children 477 Dorothy A. Greenfeld and Susan Caruso Klock PART VIII. INFERTILITY COUNSELING IN PRACTICE 28 Infertility Counseling in Practice: A Collaborative Reproductive Healthcare Model 493 Sharon N. Covington 29 Ethical Aspects of Infertility Counseling 508 Nancy Stowe Kader and Dorothy A. Greenfeld 30 Legal Issues in Infertility Counseling 521 Margaret E. Swain
CONTENTS ix31 Global Perspectives on Infertility Counseling 544 Jean M. Haase and Eric BlythAPPENDIXES 1 Qualiﬁcation Guidelines for Mental Health Professionals in Reproductive Medicine 559 2 International Comparison of Standards/Guidelines for Infertility Counselors 561 3 Comprehensive Psychosocial History for Infertility (CPHI) 563 4 Psychological Fertility-Related Questionnaires 565 5 Recommended Guidelines for the Screening and Counseling of Oocyte Donors 569 6 Psychological Guidelines for Embryo Donation 572 7 Psychological Guidelines for Evaluation and Counseling of Gestational Carriers and Intended Parents 574 8 Release of Information Example 579 9 Informed Consent: Pre-Psychological Counseling and/or Evaluation Example 58110 Informed Consent: Proceeding with Fertility Treatments: Post-MHP Consultation/Evaluation Example 58311 Embryo Donor Consents: Consent of Couple to Donate Frozen Embryos Example 58512 Embryo Recipients’ Consents: Consent to Receive Thawed Donated Embryos Example 588Resources 593Glossary 597Author Index 615Subject Index 635
List of ContributorsSharon N. Covington, MSW School of PsychologyAssistant Clinical Professor Cardiff, Wales, UKDepartment of Obstetrics and Gynecology Dorothy A. Greenfeld, MSWGeorgetown University School of Medicine Associate Clinical ProfessorWashington, DC USA Department of Obstetrics and GynecologyDirector of Psychological Support Services Yale University School of MedicineShady Grove Fertility Reproductive Science Center New Haven, CT USARockville, MD USA Director of Psychological ServicesLinda Hammer Burns, PhD Yale Fertility CenterAssistant Professor New Haven, CT USAUniversity of Minnesota Medical SchoolDepartment of Obstetrics, Gynecology, and Women’s Jacqueline N. Gutmann, MD Health Clinical Associate ProfessorMinneapolis, MN USA Associate Director, Division of ReproductiveDirector of Counseling Services EndocrinologyReproductive Medicine Center Thomas Jefferson UniversityMinneapolis, MN USA Philadelphia, PA USALinda D. Applegarth, EdD Jean M. Haase, MSWAssociate Professor of Psychology Social WorkerDepartments of Obstetrics & Gynecology, Reproductive Endocrinology and Infertility Reproductive Medicine, and Psychiatry ProgramWeill Medical College of Cornell University University HospitalNew York, NY USA London Health Sciences Centre London, ON CanadaDirector of Psychological ServicesInstitute for Reproductive Medicine Hilary Hanaﬁn, PhDWeill Medical College of Cornell University Director of Counseling ServicesThe New York Presbyterian Hospital Center for Surrogate ParentingNew York, NY USA Beverly Hills, CA USAEric Blyth, PhD Michaela Hynie, PhDProfessor of Social Work Associate ProfessorUniversity of Huddersﬁeld Department of PsychologyHuddersﬁeld, England, UK York University Toronto, ON CanadaJacky Boivin, PhDSenior Lecturer and Associate Professor Nancy Stowe Kader, RN, PhDCardiff University Director, Health Policy and Bioethics xi
xii LIST OF CONTRIBUTORSPal-Tech, Inc. Louise U. Maier, PhDArlington, VA USA Psychologist Private PracticeRoger D. Kempers Avon, CT USAProfessor of Obstetrics and GynecologyEmeritus, Mayo Clinic School of Medicine Christopher R. Newton, PhDRochester, MN USA Assistant Professor Departments of Obstetrics & Gynecology andImmediate Past President IFFS PsychologyPast Medical Director University of Western OntarioAmerican Society for Reproductive Medicine London, ON CanadaEditor EmeritusFertility and Sterility Psychologist University Hospital, London Health SciencesWilliam R. Keye, Jr., MD CentreClinical Associate Professor London, ON CanadaDepartment of Obstetrics and GynecologyUniversity of Michigan William D. Petok, PhDAnn Arbor, MI USA Assistant Clinical ProfessorDirector of the Division of Reproductive Department of Obstetrics and Gynecology Endocrinology and Infertility University of Colorado Health SciencesDepartment of Obstetrics and Gynecology CenterWilliam Beaumont Hospital Denver, CO USARoyal Oak, MI USA Psychologist Private PracticeSheryl A. Kingsberg, PhD Baltimore, MD USAAssociate ProfessorDepartments of Reproductive Biology and Psychiatry Krista Redlinger-Grosse, ScMCase Western Reserve University School of Medicine InstructorCleveland, OH USA Genetic Counseling Graduate ProgramChief, Division of Behavioral Medicine University of MinnesotaDepartment of Obstetrics and Gynecology Minneapolis, MN USAUniversity Hospitals of Cleveland Genetic CounselorCleveland, OH USA Fairview-University Maternal Fetal Medicine CenterSusan Caruso Klock, PhD Minneapolis, MN USAAssociate ProfessorDepartments of Clinical Obstetrics & Gynecology and Patricia L. Sachs, MSW Psychiatry Social WorkerNorthwestern University Medical School Shady Grove Fertility Reproductive ScienceChicago, IL USA CenterPsychologist Rockville, MD USANorthwestern Medical Faculty Foundation Covington & Hafkin and AssociatesReproductive Endocrinology and Infertility Program Rockville, MD USAChicago, IL USA Linda P. Salzer, MSSDonald B. Maier, MD Social WorkerAssociate Professor Private PracticeDivision of Reproductive Endocrinology and Englewood, NJ USA InfertilityDepartment of Obstetrics and Gynecology Gretchen Sewall, RN, LICSWUniversity of Connecticut Health Center Health Promotion and Counseling ServiceFarmington, CT USA Seattle Reproductive MedicineDirector, Division of Reproductive Endocrinology Seattle, WA USA and Infertility PresidentSt. Francis Hospital and Medical Center Donor SecureHartford, CT USA Edmonds, WA USA
LIST OF CONTRIBUTORS xiiiCheri Schoonveld, MS Afﬁliated LecturerAssistant Professor Protestant University of AppliedGenetic Counseling Graduate Program SciencesUniversity of Minnesota Darmstadt, GermanyMinneapolis, MN USA Christianne Verhaak, PhDGenetic Counselor PsychologistFairview-University Maternal Fetal Medicine Center Department of Medical Psychology andMinneapolis, MN USA Obstetrics & GynecologyMargaret E. Swain, RN, JD Radboud University Medical CenterAttorney Nijmegen, The NetherlandsPrivate Practice Katherine E. Williams, MDBaltimore, MD USA Clinical Instructor, Associate DirectorJanet E. Takefman, PhD Department of Psychiatry & BehavioralAssistant Professor SciencesDepartment of Obstetrics & Gynecology Behavioral Neuroendocrinology ProgramMcGill University Women’s Wellness CenterMontreal, QC Canada Stanford University School of MedicineDirector of Psychological Services Stanford, CA USAMcGill Reproductive Centre Laurel N. Zappert, MSMontreal, QC Canada Clinical Research AssociatePetra Thorn, PhD Stanford UniversityPsychologist Department of Psychiatry & BehavioralPrivate Practice SciencesMoerfelden, Germany Stanford, CA USA
ForewordIt is remarkable to see how much the specialty of infer- other major infertility organizations, such as the Amer-tility counselinghas matured and established itself since ican Society for Reproductive Medicine (ASRM) and thethe publication, just six years ago, of the ﬁrst edi- European Society of Human Reproduction and Embry-tion of this important book. I was privileged then, as ology (ESHRE). Within its educational mission, IICOI am again now, to write the Foreword for this text- provides postgraduate courses with national and inter-book, which has become the standard of reference national congresses as well as symposia, workshops,for the profession. As noted by the editors in their and social gatherings. These efforts generate informa-preface, the continuing enthusiasm that has welcomed tive dialogue among both medical and mental healththis text both nationally and internationally has cre- professionals concerning critical legislation and regula-ated the demand to bring all critical chapters up to tions in other countries, practice guidelines, credential-today’s leading edge of knowledge, as well as to add ing of mental health professionals, research on the psy-several relevant and important new ones in this second chosocial aspects of infertility and medical treatmentedition. outcomes, and creating standards of practice in infer- Today, with the continued rapid advances in the tility counseling worldwide.assisted reproductive technologies, there is a much All infertility professionals are indebted to coedi-clearer recognition of the psychosocial issues that may tors Sharon N. Covington, MSW, and Linda Hammerarise over the course of treatment for infertile patients Burns, PhD, as well as their distinguished contribut-as well as the critical role played in their management ing authors for making this textbook as complete andby mental health professionals. Infertility counseling comprehensive as it is, covering the breadth and scopehas become an indispensable adjunct to the practice of the ﬁeld. This new second edition will, ultimately,of reproductive medicine, particularly in those coun- make it possible to provide superior clinical care for alltries at the forefront of new developments in the ﬁeld. patients worldwide. Not only have the editors providedIt is gratifying to see that over recent years, infertility an invaluable service to their discipline by fosteringcounseling has gained appropriate recognition on an this important text, but they both continue to provideeven broader international level, which is addressed in strong leadership in medical organizations at both thedepth in Chapter 31, Global Perspectives on Infertility national and international levels. Linda Hammer BurnsCounseling. Of note has been the collegial networking has played an indispensable role in organizing IICO andinternationally among national counseling organiza- is currently its chair. Sharon Covington has been equallytions and mental health professionals that ultimately active as a founding member of the Mental Health Pro-led to the formation of an international association, fessional Group (MHPG) of ASRM, serving on manythe International Infertility Counseling Organization ASRM committees, including the Society of Asssisted(IICO). IICO continues to grow and evolve, and cur- Reproductive Technologies (SART) Executive commit-rently it is made up of national organizations from tee and as chair, along with Linda Hammer Burns, often countries. IICO has a liaison with the International the MHPG of the ASRM. Both have contributed theirFederation of Fertility Societies (IFFS) and also meets expertise through contributions to other professionalregularly in conjunction with the annual meetings of texts and as reviewers for respected journals in the xv
xvi FOREWORDﬁeld, in addition to their mentoring of mental health advancing their ﬁeld and helping to establish infertilityprofessionals and clinicians new to the ﬁeld of repro- counseling as an indispensable discipline in the inte-ductive health counseling. grated care of infertility patients. I have known and admired them both for many years, This book will beneﬁt all who read it. As I wrote ingoing back to the time when I was editor-in-chief of my previous Foreword, it is designed for serious stu-Fertility and Sterility and it was my pleasure to be able dents and practitioners of infertility counseling. It willto publish a number of Sharon Covington’s important be a valuable resource text for medical libraries and willjuried scientiﬁc contributions, as well as calling on both grace the personal libraries of mental health profession-as reviewers. Through their tireless efforts and devotion als, students of reproductive medicine, clinicians, andto excellence, both have distinguished themselves in educators alike. Roger D. Kempers February, 2006
Preface Writers are really people who write books not because they are poor, but because they are dissatisﬁed with the books which they could buy but do not like. – Walter BenjaminWhen we wrote (edited) the ﬁrst edition of this book, pains, it has been successful in bringing together profes-our motivation was simple and straightforward: to pro- sionals from around the world, providing educationalvide a deﬁnitive textbook on infertility counseling. We opportunities and a mechanism for professional collab-had worked in the ﬁeld for a number of years, nurtured oration, and fostering the development of new infertil-its growth and development as a professional specialty, ity counseling societies. Dr. Roger Kempers, who was soand mentored many entering the ﬁeld, yet there was no very helpful during his tenure at ASRM and supportivesingle, scholarly text for professionals. So, with this sim- of our ﬁrst book, has been equally, if not more, helpful inple idea the original text was born. Little did we realize the development of IICO in his position as chair of thethe impact it would have on the profession of infertility International Federation of Fertility Societies (IFFS).counseling, the ﬁeld of reproductive medicine, or on us, We owe him a special debt of gratitude not only for hisboth professionally and personally. We are still amazed professional and personal support, but for his unyield-when we hear (as we have many times) people around ing validation of the professional development ofthe world refer to it as ‘the purple bible.’ This text is not infertility counseling and a collaborative approach toan updated version of the original book, as is often the treatment of infertile patients in acknowledging thecase, but a new book entirely that offers updated ver- importance of psychosocial aspects of infertility.sions of each chapter as well as several new topics. This It was not particularly surprising, as such, when ouris not to say we did not think all of the topics from the ever loyal editor, Nat Russo, approached us with hisoriginal book were not important or relevant, but only usual enthusiasm and insistence about updating thethat limits of space necessitated a reshufﬂing. As such, original text but with a more international perspective.the original text will remain relevant and the new one Although we willingly embraced the idea, little did weof equal and parallel importance. realize then how this new approach would exponen- Since the ﬁrst edition was published, the profession of tially complicate the project, creating new and uniqueinfertility counseling has evolved and so have our own challenges for us – as well as our contributors.professional perspectives. One of the most signiﬁcant To our contributors who met these challenges withchanges has been the development of an international varying degrees of dread and/or excitement, we owe aperspective on infertility counseling. This has been trig- very special thank you. All are respected (and busy) pro-gered by our own travel instincts (and Linda’s predilec- fessionals in their own right and their efforts here aretion for visiting infertility clinics wherever she travels) exceptional. We appreciate each of them for their pro-but also interest in our textbook that has brought us fessional expertise, effort, and time. A special thankscontacts, questions, and requests for consultations from to those who provided extra doses of personal encour-around the world. Recognizing this, Linda spearheaded agement and kindness – especially when our own spir-the formation of the International Infertility Counsel- its or stamina waned. Many of the contributors haveing Organization (IICO) – with the support and helpful played signiﬁcant roles in the professional develop-guidance of Sharon who was a founding member of ment of infertility counseling worldwide and continuethe Mental Health Professional Group of the American to do so through an array of professional activities.Society of Reproductive Medicine. Although IICO con- While many contributors were authors in the ﬁrst edi-tinues to experience (as all new organizations) growing tion, some are new to this volume and, as such, faced xvii
xviii PREFACEunanticipated hurdles and problems. Despite the dis- Linda has remained at the University of Minnesotatinct trials and travails of this edition, we wish to express Medical School, Department of Obstetrics, Gynecology,our appreciation for each author’s willingness to con- and Women’s Health, and the Reproductive Medicinetribute their expertise and knowledge and for their Center. Although he is retired now, special thankspatience and tolerance of our suggestions, critiques, will always be owed to Dr. George Tagatz, whoand ‘improvements’ of their work. Although we real- decades ago offered me a job and allowed me toize we have become rather notoriously exacting edi- design and implement an infertility counseling pro-tors (applying the same exacting standards to our own gram that became an integral part of patient care andwork), we hope (and think) that despite our often rigor- the model and impetus for this book. Dr. Theodoreous demands, we have kept their friendships and they (Ted) Nagel was there that day when Dr. Tagatz askedare well aware of our very deep appreciation. (on behalf of both of them), “Linda, how would As before, we must also thank our respective prac- you like to work here?” And despite the vicissitudestices and colleagues. Over the years, Sharon has seen of our respective careers, we are both still here –her practice expand at Shady Grove Fertility Repro- in large part due to Dr. Nagel’s determined refusal toductive Science Center from one ofﬁce, one doctor, and allow either of us to retire – even when it seemed likeﬁve staff members, to one of the largest practices in the a good idea. Over the years, I have come to appreci-United States with eight ofﬁces, eighteen physicians, ate not only his professional mentoring but his quickand more than 250 employees . . . and still growing. The wit, extraordinary intelligence, and personal kindness.list of all the important people at Shady Grove who have He has, more than any other colleague, tolerated myhelped and supported me along the way is too extensive big ideas (even when skeptical) and supported my var-to include, yet a few (though not exclusively) stand out: ious other commitments and interests without com-Dr. Robert Stillman, Dr. Michael Levy, Dr. Eric Widra, plaint – and more often than not, offered his own ideasand Dr. Arthur Sagoskin for helping me deﬁne the col- and insights. In addition, there are other professionalslaborative reproductive healthcare model through their including physicians, nurses, and secretarial staff whorespect and belief in psychological services (and me); have, over the decades, provided rewarding and edify-and nurses Karen Moore, Kathy Bugge, and Michele ing professional as well as personal relationships. ThesePurcell for their exceptional skill, compassion, and include, but, of course, are not limited to, Dr. Markencouragement in our work together over the years. Damario; Bonnie Le Roy, MS; Mary Ahrens, MS; SelinaJust as important are the extraordinary group of clini- Blatz, NP; Mary Danich, NP; Rosie Drechnik, NP; Debcal social workers who have joined me in my practice – Pearo, RN; Neda Tasson, RN; Rachel Radman; andPatricia Sachs, Carol Toll, Ellen Eule, Erica Hanson, Kim Hockett. In addition, I owe a very special debtMichelle Hester, and Carol Miller. They have been of gratitude to colleague, mentor, and friend Sue V.patient with me throughout this revision, picked up Petzel, PhD. She has been there from the very begin-extra work without complaint, always kept their good ning as an exceptionally talented mentor and colleaguenature despite my distraction, and continued to remind who I not only appreciate but respect immensely. Now,me of the importance of this project. I would also like after years of astutely avoiding the ﬁeld of infertilityto thank Dr. Larry Nelson at the National Institutes of counseling, she too has become intrigued with the ﬁeldHealth for giving me the opportunity to work on his and the fascinating patients we assist. A simple thankresearch team, and for his commitment to the psycho- you is really inadequate and, as such, it is my hope thatlogical needs of women struggling with premature ovar- she is well aware of how grateful I am for her profes-ian failure. Special appreciation goes to Nancy Hafkin, sional guidance and personal friendship. Finally, I feelPhD, my friend of more than forty years and cotherapist especially privileged and blessed to have had a careerfor more than twenty, for helping (and putting up with) that has been so intellectually stimulating and profes-me throughout this process with patience, humor, and sionally rewarding and has allowed me to work withwhen needed, clinical interpretation. Thanks, also, to colleagues who not only gave me respect and support,Linda Applegarth, EdD, who was a personal friend but an enjoyable camaraderie.before we began to share the journey in our professional As we continue to practice as infertility counselors,careers of infertility counseling and whose understand- we realize that it is our patients who have provided using and support have been so important to me along with the clinical experience and expertise to enable usthe way. I feel so blessed to have had the opportunity to contribute to this ﬁeld through professional devel-to do work that I love with people that I love working opment and writing. As such, we owe a special debtwith. of gratitude to our patients, both past and present. In
PREFACE xixtheir suffering and resilience they taught us, and from we were forced to relinquish, and yet still they alwaystheir pain and transcendence we learned. We feel hon- supplied us with kindness, love, and a sense of humor –ored and privileged to have been included in their jour- particularly when our spirits lagged or our nerves wereneys through infertility, pregnancy loss, childlessness, frayed. Once again, this book is dedicated to our veryand for many, eventual parenthood. We are who we are special husbands and families including our newesttoday and who we have become (personally and pro- members, because it could never have happened with-fessionally) because of these special clients, and this out their blessing, love, and hard work, in addition toproject (as with the previous book) would have been our own.impossible without them. Finally, we must thank each other. It was Sharon who It goes without saying that we are grateful to our noted that twice in her life she had “married some-families to whom we are not simply indebted – we are one I hardly knew” – once personally and once pro-probably overdrawn! Through the journey of this book, fessionally – and both times it has led to exceptional,we have seen the birth of Sharon’s ﬁrst grandchild and long-lasting ‘marriages.’ Our collaboration and collab-the marriage of Linda’s daughter – in the same month! orative abilities continue to mystify even us. AlthoughThroughout the usual family transitions, personal and we often felt at the end of our tethers and overwhelmedfamily crises, professional challenges, and daily hassles, by the work, we never felt that way with each other.our families have helped us keep our equilibrium (some- We have never disagreed or had a different vision oftimes tenuously) with their steadfast love and support. what this book could or should be. Somehow, despiteOnce again, our children offered generous assistance – both positive and negative stressors in our personal andeven though they are now young adults with lives of professional lives, we were able to remain focused andtheir own and live (most of them) at some distance. working – usually due to large doses of humor andAgain, our children were our computer experts (not only Sharon’s ever present reminder to ‘just breathe.’ Thefor us but for our contributors), research assistants, qualities that helped us through the ﬁrst book (com-secretarial staff, and general aides-de-camp. We wrote munication, intelligence, good humor, and work ethic)through wedding plans, baby preparations, babysitting, have also made this book possible. And as before, wecomputer crashes, cross-country relocations, and natu- not only learned to appreciate each other more, but weral disasters with our single-minded determination, cre- also learned a great deal about ourselves. For its ownating only slight (albeit justiﬁed) grumbles. Our hus- unique reasons, this book was more challenging thanbands, despite their own crises and challenges, have the last, yet also more rewarding. In the end, we are notnever wavered in their support of our work and this only appreciative and proud of the work we have pro-project, providing limitless encouragement and com- duced here, but of the friendship and collaboration thatfort. More than anyone else, they have borne the brunt enabled it.of the stressful challenges of this book, tolerating ourself-imposed work schedules, including working during Sharon N. Covingtonvacations, ﬁlling in on a myriad of responsibilities that Linda Hammer Burns
PART I. OVERVIEW1 Psychology of Infertility LINDA HAMMER BURNS AND SHARON N. COVINGTON A child within my mind. I see The eye, the hands. I see you also there. I see you waiting with an honest care, Within my mind, within my body. . . . – Elizabeth JenningsYearning for children and the heartbreak of barren- Divorce, polygamy, and extramarital affairs remain, asness have been a part of life since the beginning of they have long been, social solutions to infertility, as domankind, chronicled throughout history by religious various forms of adoption and fostering. Examples ofaccounts, myths, legends, art, and literature. Whether other social solutions include the continuing practicedriven by biological drive, social necessity, or psycho- in some cultures of multiple wives in response to infer-logical longing, the pursuit of a child or children has tility (or lack of a son) or the custom in some culturescompelled men and women to seek a variety of reme- requiring a sibling (usually an eldest son) to provide onedies, sometimes even extreme measures. In fact, in all of his children to a younger, childless sibling. Commu-cultures involuntary childlessness is recognized as a cri- nity involvement in the realignment of social relation-sis that has the potential to threaten the stability of indi- ships is exempliﬁed by the native peoples of two smallviduals, relationships, and communities. Every society islands off the coast of South America in which infertil-has culturally approved solutions to infertility involv- ity was addressed by raiding the neighboring island toing, either alone or together, alterations of social rela- steal small children for childless women. Demonstrabletionships (e.g., divorce or adoption), spiritual interces- in each of these examples is the social and emotionalsion (e.g., prayer or pilgrimage to spiritually powerful distress and expense of solutions involving the alter-site), or medical interventions (e.g., taking of herbs or ation of social relationships, thus explaining, in part,consultation with ‘medicine man’). While spiritual the reluctance of individuals to pursue these alterna-and medical remedies for infertility are common and tives until other remedies have been exhausted.often used early on by infertile couples, social solu- Since antiquity, the appeal of religious faith and thetions demanding the alteration of relationships have power of belief in spirits and gods as a remedy forbeen shown to be the last alternative individuals or infertility can be found in all cultures. Fertility sym-couples usually consider. Typically, infertile couples bols, special gods, and fertility rites and customs areare reluctant to jeopardize or disturb close relation- apparent from the highly erotic art of India, to theships (perhaps because social changes are usually per- Celtic goddess of fertility carved into stoned walls ofmanent) because they hope or believe infertility will be ancient Irish castles, to specially shaped and painteda temporary problem. By the same token, reluctance to Navajo pottery. In ancient Greece, a common offeringconsider solutions may be due to the hope and promise to the gods was terracotta votives in the shape of theoften attributed to medical and/or spiritual interven- affected organ (e.g., vagina, uterus, or penis). In addi-tions. Nonetheless, infertile couples use all three mea- tion, the special spiritual power of certain places tosures – social, spiritual, and medical – as remedies for enhance fertility can be seen in a phallic-shaped rocktheir involuntary childlessness; numerous examples of on the island of Maui in Hawaii, as well as in the pil-these remedies exist throughout history and across all grimages made by infertile women of the Carib tribe incultures. One of the most renowned social solutions Mexico to Isla de las Mujeres (Island of Women) and byto involuntary childlessness is King Henry VIII of Eng- many infertile Roman Catholic women to Medjugorjeland, who changed the religion and laws of a country to in Bosnia-Herzegovina. Nevertheless, the importanceaccommodate the need for a child (albeit a male child). of faith either as a means of solving infertility or as a 1
2 LINDA HAMMER BURNS AND SHARON N. COVINGTONsource of comfort cannot be minimized, and religious Infertility counseling, as an emergent specialty withinfaith remains a powerful resource (or painful burden) the mental health professions, has gained recognitionfor many infertile individuals around the world, even and respect for its professional contributions throughtoday. patient care, research, and education as well as for the Infertility affects between 80 million and 168 mil- identiﬁcation of the need for expert care and treatmentlion people in the world today. Approximately one of this unique population in conjunction with com-in ten couples experience primary and/or secondary plex medical treatment. In this book the term infertil-infertility.[3,4] The majority of men and women live ity counselor refers to any mental health professionalin the developing world, are infertile due to sexually (e.g., social worker, family therapist, psychiatrist, ortransmitted diseases or underlying, untreated health psychologist) who has special training in reproductiveconditions (e.g., malnuitrition) while in the develop- medicine. In fact, a major goal and purpose of this booking world increasing age in women is a major causal is to deﬁne the standard of care and practice, profes-factor in infertility. Global rates of infertility vary sional competency, and legal responsibilities for infer-dramatically – from prevalence rates of about 5% in tility counselors worldwide by providing a knowledgesome developed countries to as high as more than base on which to provide optimum clinical care with30% in sub-Saharan Africa. Rates of primary infer- evidence-based therapeutic interventions.tility worldwide are generally 1 to 8% with rates of sec- As a clinical textbook, this book provides a compre-ondary infertility reaching as high as 35%. The rates of hensive overview of the array of clinical issues andinfertility are the highest in the world in what has been therapeutic interventions useful for the practicing infer-termed the ‘infertility belt,’ stretching across central and tility counselor as well as for the mental health pro-southern Africa. fessional who encounters a few patients with repro- Although infertility is a global issue impacting ductive issues (current or past) requiring a clinicalindividual and social well-being, the wide variance in understanding of the relevant issues. This textbookincidence rates contributes to signiﬁcant and unique (like its predecessor) has eight sections that reﬂectpsychosocial consequences as a result of where an the breadth of the experience and issues confrontedindividual experiences involuntary childlessness. This by individuals and couples experiencing infertility:‘stratiﬁcation of infertility’ refers to the ways in which assessment; treatment modalities; medical counselingthe infertility experience is affected by economic, social issues; third-party reproduction and other means ofwelfare, and public health issues. These issues include alternative family building; postinfertility issues; andthe preponderance of poverty, malnutrition, obesity, infertility counseling practice issues. Each chapter fol-smoking, sexually transmitted diseases, or other condi- lows the same format regardless of the topic addressedtions that impact general health and/or fertility; igno- in the chapter: an introduction to the topic, historicalrance of reproduction, sexual health, and/or fertility overview, review of the literature, clinical issues, thera-preservation; lack of availability or access to high- peutic interventions, and future implications. This for-quality medical treatments; and/or the inability to mat is designed to provide both students and profes-access medical treatments for cultural, religious, or sionals with a consistent and predictable treatment oflegislative reasons. Any and all of these factors can each topic and a basis for comparison across topics,and do contribute to infertile individuals traveling thereby enabling optimum and professionally compe-across national or international borders in pursuit of tent clinical care using evidence-based practice princi-medical treatments to facilitate reproduction and/or ples. This chapter outlines the scope and depth of issuesparenthood – a phenomenon often termed ‘reproductive involved in infertility counseling including:tourism.’ In short, as a global condition, infertility is not ■ A historical overview of medical approaches to infer-only a medical condition but also a social and emotional tility and the emergence of infertility counseling in col-condition, in which a shift in emphasis has occurred laborative patient care;from coping with childlessness through social means(e.g., participating in rearing the children of others) to ■ A review of advances in the scientiﬁc study of psy-a dependence on medical interventions – even when chological responses to infertility;accessing them can be challenging. This process has ■ A discussion of the importance of theoretical frame-been referred to as the ‘medicalization of infertility’ – works as a basis for developing clinical interven-the phenomenon in which healthy, yet childless, indi- tions, including relevant infertility-speciﬁc psycholog-viduals become patients, undergoing an array of med- ical theories; andical treatments and assuming the passive patient role ■ A summary of clinical issues and therapeutic inter-in patient–physician interactions – all in pursuit of ventions, which will provide a context for the chaptersparenthood. in this text.
PSYCHOLOGY OF INFERTILITY 3HISTORICAL OVERVIEW their reproductive abilities but also to blaming women when conception and pregnancy failed. ThroughoutThe Trobrian Islanders attributed pregnancy to spirits, history and across cultures, there are countless exam-not sexual intercourse. Chukchi female shamans said ples of social, religious, and cultural gloriﬁcation, eventhey made children via their sacred stones, not through idealization of motherhood, and the viliﬁcation andsexual intercourse or any contribution from men. Aus- maltreatment of infertile or ‘barren’ women. Infertiletralian Ingarda peoples thought women became preg- women were (and still may be) accused of witchcraft;nant by eating special foods or by embracing a sacred socially isolated and ostracized; physically abused;tree hung with umbilical cords from previous births. divorced, abandoned, or forced to accept their hus-The Batak peoples believed no woman could become band’s additional wives; or murdered (often by theirpregnant unless umbilical cords and placentas were husband or their husband’s family). In Japanese, theburied under her house. Ancient Hindus believed word for infertile women is umazume, which is liter-that conception was facilitated by the worship of the ally translated as ‘stone woman.’ The characters usedlingam (erect penis) and yoni (female genitalia) and that spell ‘no-life woman’ or ‘nonbirthing woman.’ Umazumea hole in a rock or cloven tree symbolized the female is considered one of the worst words in the entirebirth passage. Therefore, a woman could improve her Japanese language and it is rarely used because, accord-fertility by passing through a hole in trees or rocks – a ing to traditional custom, the presence of a stoneritual that continues to be practiced in some parts of woman could make a whole village wither. In var-the world even today. ious African, Asian, and Paciﬁc cultures men fear(ed) Women in ancient Africa were encouraged to eat the female vaginal blood, which is not only viewed as pol-eye of a hyena with licorice and dill to aid concep- luting but also thought to weaken any man touchedtion that was guaranteed to occur within three days by it.while Siberian women were encouraged to eat spiders Science altered our understanding of reproductionto facilitate conception. According to African cus- and fertility when, in 1677, Dutch scientist Antontom, to ensure pregnancy men applied a special powder Leeuwenhoek became the ﬁrst to identify spermatozoamade from the crushed roots of nine trees to the penis with the newly invented microscope. In 1765, throughto enable sexual intercourse three times a night, while experiments with dogs, Italian priest and physiolo-African women used vaginal pessaries made of wool gist Lazzaro Spallanzani became the ﬁrst to discoverdipped in peanut oil and wrapped in two cloves of gar- that mammalian reproduction required both the malelic. In ancient Arabia, amulets and/or fertility sym- sperm and female oocyte, that is, that the embryobols were commonly worn as pendants to encourage was the “product of male seed, nurtured in the soilconception, particularly by Egyptian women. Addition- of the female.” However, it was not until the nine-ally, many cultures used fertility fetishes and symbols teenth century that human reproduction (and infertil-such as statuettes of pregnant females or of males with ity) became more clearly illuminated. In 1826, Germanlarge phalluses to maximize fertility. Even today, biologist Karl von Baer discovered the mammalianamulets, herbal remedies, and traditional rituals con- oocyte and identiﬁed mammalian embryonic develop-tinue to be used by many infertile men and women, ment of animals. Together with Heinz Christian Pan-often in conjunction with conventional medical treat- der and based on the work by Caspar Friedrich Wolff,ment, in hopes of achieving the longed-for pregnancy he described the germ-layer theory of embryologi-(child). cal development and the principles that became the In antiquity, menstruation and fertility were believed foundation for comparative embryology. The nextto be inﬂuenced by the waxing and waning of the moon. year, Swiss physiologist and histologist Albert von Kol-As a result, astrology and numerology were consid- liker identiﬁed the function of spermatozoa and thatered important fertility treatments by providing cor- sperm originated from the testes. In 1839, Augustusrect numbers and/or days of the month for maximiz- Gendrin suggested that ovulation controlled menstru-ing fertility and achieving pregnancy. It is generally ation, thereby dispelling the long-standing belief thataccepted that ancient peoples had little understanding menstruation was controlled by the moon and lunarof human reproduction and as such sterility. With lit- phases.tle understanding of the equal contributions of male By the early twentieth century, the pieces of the repro-and female reproductive cells or the role of sexual inter- ductive puzzle were beginning to fall into place. Still, itcourse in fertilization, reproduction was thought to be a was only in the middle of the twentieth century and latersingularly female phenomenon and the role of the male that physicians medically addressed infertility as a cou-was considered unnecessary and/or ceremonial. This ples issue in which both partners were medically evalu-ignorance probably contributed to valuing women for ated rather than viewed as a woman’s medical problem
4 LINDA HAMMER BURNS AND SHARON N. COVINGTON(defect). Nevertheless, infertility treatment contin- infertile couples. It may be argued that medical solu-ued to maintain a paradigmatic example of a medical tions to involuntary childlessness became even moresituation in which throughout much of its history physi- powerful and appealing to the infertile by the end ofcians were men, patients were women, and the focus of the twentieth century with the advent of assisted repro-medical treatment was on the sexual organs. Despite ductive technologies and advanced third-party repro-evidence that men were and are infertile as often as duction.women, throughout history and across cultures, womenhave disproportionately borne the medical, social, and REVIEW OF LITERATUREcultural burden of a couple’s failure to conceive. Thisis a situation that has become even more prominent Original investigations into the psychological aspects ofwith the advent of assisted reproductive technologies infertility focused on individual psychopathology (par-in which the female partner undergoes disproportion- ticularly in women), sexual dysfunction, and infertility-ately more treatment, regardless of the etiology of the speciﬁc distress. Furthermore, early research wasinfertility diagnosis. This paradigm did not dramat- largely based on theoretical speculations or anecdotalically shift despite the advent of assisted reproductive information rather than scientiﬁcally rigorous inves-technology (ART), which began with the birth of Louise tigations. Much of the research focused on psycho-Brown in Great Britain in 1978. Her conception via in logical distress, was exploratory, relied on researcher-vitro fertilization (IVF) was the result of the ground- designed instruments rather than standardized mea-breaking work of British physicians Patrick Steptoe and sures, lacked control or comparison groups, and wasRobert Edwards which began the modern era of human plagued by small numbers. While research on the med-reproduction in which reproduction did not require sex- ical aspects of infertility has expanded exponentially,ual intercourse, used an array of assisted reproductive research on the psychosocial aspects of infertility con-technologies, and could be facilitated by various forms tinues to lag behind by comparison. Nevertheless, theof donated gametes, embryos, and surrogacy. overall quality and quantity of studies have dramatically Infertility counseling, as a profession, emerged improved in recent decades with an increasing numberalmost in tandem with the major medical advance- of infertility counselors acting as researchers investigat-ments in the ﬁeld of reproductive medicine, particu- ing a wider array of issues such as the impact of stresslarly assisted and third-party reproduction. Although on infertility; gender differences in response to inferti-the psychological impact of infertility was addressed in lity; cross-cultural issues; and complicating medicalthe literature beginning in the 1930s, infertility counsel- conditions.ing has emerged as a recognized profession and mental Recently, the focus of research on the psychologicalhealth specialty only within the past thirty years. aspects of infertility has shifted from individual psy-Historically, the role of the mental health professional chopathology to more holistic/interactive views of infer-in the treatment of infertility was to cure the infer- tility and to the impact of advancing assisted reproduc-tile patient’s neurosis thereby curing their infertility. tive technologies. Consequently, there has been a shiftThis approach fell into disfavor in the 1970s as men- from a singular focus on the individual to assessmentstal health professionals working in infertility clinics and interventions aimed at groups, such as couples andbegan providing psychological support, crisis interven- families. In addition, while research and clinical expe-tion, and education to ameliorate the stress of infertil- rience continue to indicate that the vast majority ofity and enhance the patient’s quality of life. Today, infertile men and women do not experience signiﬁcantthe role of the infertility counselor has expanded to levels of psychological trauma or psychopathology, themeet the psychosocial challenges of assisted reproduc- use of advanced medical technology and/or third-partytion and includes assessment, support, treatment, edu- reproduction involving a plethora of additional stres-cation, research, and consultation.[18,20,21] sors may increase psychological distress during speciﬁc Throughout history and across cultures, medical periods of the treatment cycle. As such, investigationssolutions to infertility have been diverse and varied such into responses to assisted reproduction have involvedas relics, charms, incantations, eating special foods, the interactive aspects of medical technology and indi-vaginal treatments, treatments to enhance male sexual vidual and couple response, as well as medical outcome.potency, and special potions and/or poultices. Whether In addition, the focus of both medical and psychoso-‘primitive’ medical treatments or the more sophisti- cial research has become more ‘evidence-based’: howcated assisted reproductive technologies of today, med- research ﬁndings can provide direction for the identi-ical treatments for infertility have always been actively ﬁcation of clinical issues and therapeutic interventionspursued and held particular power and inﬂuence for that are most beneﬁcial and effective.
PSYCHOLOGY OF INFERTILITY 5 Van Balen and Inhorn contend that research on the acknowledged the challenges of lack of heterogeneitypsychosocial aspects of infertility has historically been in the developing world particularly regarding assistedhampered because infertility was: (1) considered a med- reproductive technologies, inconsistent access to orical condition rather than a social problem worthy availability of quality infertility services in the devel-of social analysis (particularly in Western societies); oping world, as well as the lack of consistent standards(2) a taboo subject not easily talked about even in ‘neu- regarding the quality of infertility services. By con-tral’ research settings; (3) an issue emerging in West- trast, little attention has focused on the psychosocialern societies at a time of changing social beliefs about needs and/or the provision of mental health services inparenthood, women’s roles, and the importance of chil- the developing world. Similar challenges exist regard-dren in the lives of men and women; and (4) research- ing the wide variation of attitudes regarding counsel-focused on psychosocial responses to assisted reproduc- ing and mental heath services and the lack of consis-tive technologies and less on the experience of invol- tent standards regarding the quality of available infer-untary childlessness or ‘disrupted reproduction’ and its tility counseling services. As such, underserved, cultur-impact on the lives of individuals and couples. ally diverse, infertile couples seeking infertility treat- In recent decades, however, infertility has gained ment either in their home country or across interna-increasing attention from various social and behav- tional borders remain an area that not only receivedioral scientists who have brought a wider variety of minimal research attention, but, as a result, also failedinvestigative approaches and research methods, in con- to beneﬁt from clearly identiﬁed clinical and therapeu-trast to traditional psychologically oriented qualitative tic interventions based on research evidence.and quantitative methods. Examples of new researchmethodologies include the ethnographic model typ- Psychosocial Interventions for Infertilityically used in anthropology, in which data arecollected on the basis of reproductive life histo- For several decades the provision of psychosocial sup-ries and/or narratives in individual studies;[24–27] port and/or counseling services have been requested bygrounded-theory methodology; discourse analysis (e.g., patients, suggested by professionals, legislated, and/orthe analysis of newspaper accounts); and ethno- recommended on the basis of evidence-based research.graphic, qualitative case studies. These are but a few Infertile patients have requested psychological servicesexamples of the different research approaches that pro- in conjunction with or as an adjunct to medical treat-vide different perspectives, exciting insights, and impor- ment for infertility[31–33] or through consumer advo-tant ﬁndings that help provide a greater understanding cacy organizations (e.g., ISSUE, ICSI, CHILD, Resolve).of the psychosocial impact of infertility, thereby facili- Recommendations for infertility counseling have alsotating the work of infertility counselors by identifying been mandated by legislation and/or regulatory bod-signiﬁcant clinical issues and/or beneﬁcial therapeutic ies.[34–39] At the same time, infertility counseling ser-interventions. vices have been recommended and/or mandated by While the scientiﬁc rigor of psychosocial investiga- medical professional organizations, most often in con-tions has dramatically improved, some signiﬁcant gaps junction with speciﬁc medical treatments.[40–43] Men-in the research remain, particularly regarding the psy- tal health professionals have also made recommenda-chosocial needs of the underserved (reproductive strat- tions for the provision of psychological counseling ser-iﬁcation) as well as the counseling needs of culturally vices.[20,21,44–46]diverse patients and reproductive tourists. A continuing In a review of current research, Boivin addressed theand signiﬁcant problem regarding research on the psy- effectiveness of psychosocial interventions for infertil-chosocial issues of involuntary childlessness is that the ity in terms of the following questions: 1) Do psychoso-preponderance of research to date has focused predom- cial interventions improve well-being?, 2) Do psychoso-inantly on white, heterosexual women living in devel- cial interventions increase pregnancy rates?, and 3) Areoped countries and who, generally, are better educated some interventions more effective than others? Theand have higher socioeconomic status. Far less research review involved a systematic search of all published andhas focused on culturally diverse men and women with unpublished papers in any language and any source thatlimited ﬁnancial or education resources, from devel- (1) described a psychosocial intervention and (2) eval-oping countries, and/or who have limited access to uated its effect on at least one outcome measure in antreatment or speciﬁcally assisted reproduction. The infertile population. A total of 380 studies met the cri-World Health Organization (WHO) has recognized the teria but only 7% were independent evaluation stud-importance of sterility as a health issue of global con- ies. Analysis of these studies showed that psychosocialcern, particularly in developing countries. WHO has interventions were more effective in reducing negative
6 LINDA HAMMER BURNS AND SHARON N. COVINGTONaffect than in changing interpersonal functioning (e.g., improving well-being, and/or enhancing the outcome ofmarital and social functioning). Pregnancy rates were treatment.unlikely to be affected by psychosocial interventions. While the focus of the academic approach inIt was also found that group interventions that had medicine and counseling is research, the focus of theemphasized education and skills training (e.g., relax- applied or clinical approach to medicine and counselingation training) were signiﬁcantly more effective in pro- is implementation of knowledge gained from researchducing positive change across a range of outcomes for the immediate and practical beneﬁt of individuals,than counseling interventions that emphasized emo- couples, and families. In fact, clinicians and researcherstional expression and support and/or discussion about do not have mutually exclusive roles and many infer-thoughts and feelings related to infertility. Men and tility counselors are involved in both research andwomen were found to beneﬁt equally from psychoso- clinical work (i.e., application of research ﬁndings) tocial interventions. This review highlighted the lack of some extent over the course of their careers. The basicwell-controlled, scientiﬁcally rigorous studies based on premise of applied psychology is the use of psychologi-classic experimental methods. This review examined cal principles and theories to overcome practical prob-thirty years of research, yet produced only twenty-ﬁve lems (e.g., reproductive medicine or health psychology).independent studies evaluating psychosocial interven- Infertility counseling is a specialty area with speciﬁctions for infertile individuals of which only eight met theoretical frameworks, clinical issues, and therapeuticminimum requirements for good quality studies. By interventions based on the scientiﬁc model of evidence-contrast, during the same period almost 400 papers based medicine or treatment.were published in which psychosocial interventions for Theoretical approaches to infertility and, as such,infertility were strongly recommended. In short, there infertility counseling have historically been based onremains a signiﬁcant, even urgent need for high qual- a speciﬁc theoretical perspective or speciﬁc principlesity studies to unequivocally address the effectiveness of of theories adapted and applied to infertility. Recently,psychosocial interventions. Boivin suggests that future interest in developing infertility-speciﬁc theoreticalresearch should address (1) who beneﬁts from psycho- frameworks, that contribute to a greater understand-logical interventions, (2) which types of interventions ing of the psychosocial impact of infertility, has beenare most beneﬁcial to which patients, and (3) when growing. Infertility-speciﬁc theoretical frameworks aidis the optimum time to provide psychological inter- infertility counselors as both researchers and cliniciansventions. In summary, by not simply recommending, by identifying the psychosocial phenomena of infertil-but by providing evidence-based research through con- ity, relevant issues, treatment modalities, and beneﬁ-trolled investigative methodology, infertility counselors cial interventions to minimize psychosocial distress andcan provide more effective psychological interventions trauma.with greater conﬁdence. Evolution of Infertility-SpeciﬁcTHEORETICAL FRAMEWORK Theoretical FrameworksIn both psychology and medicine, theories or theoreti- Over the years, infertility-speciﬁc theoretical frame-cal frameworks are the basis for the academic scientiﬁc works have evolved from what have been termed psy-method. Theories (as a collection of interrelated ideas chogenic infertility theories or psychosomatic medicineand facts) are developed to describe, explain, predict, approaches, in which demonstrable psychopathologyand/or change (manage) behavior or mental processes. was thought to play an etiological role in infertility.The purpose of theories is to better understand previous The foundation of psychogenic infertility theories wasconditions that led to a thought, behavior, interaction, Freudian psychoanalytic approaches in which psycho-or phenomenon. As such, the scientiﬁc method involves logical (and medical) disorders were thought to be due(1) stating the problem, (2) forming a theory, (3) devel- to an individual’s unresolved conﬂicts and/or an uncon-oping a hypothesis, (4) testing the hypothesis through scious defense mechanisms that caused or contributeda variety of research methods, and (5) replicating the to sterility. The psychogenic infertility model (alsoresults of the tested hypothesis. As such, theories or the- sometimes referred to as the psychosomatic medicineoretical frameworks are a fundamental component of approach) was introduced in the 1930s and reachedthe research process, while at the same time facilitating its height of popularity during the pronatalist periodand enhancing patient care by identifying relevant clini- of the 1950s and 1960s, particularly in the Unitedcal issues and therapeutic interventions most beneﬁcial States. At a time when up to 50% of infertility prob-and effective in curing or ameliorating sympomatology, lems could not be accurately medically diagnosed or
PSYCHOLOGY OF INFERTILITY 7treated, psychological explanations of potential causes psychological consequences approach that included theor treatment modalities were considered helpful and recommendation of psychological support services inreasonable. However, the vast majority of these theories conjunction with or as an adjunct to infertility treat-focused on psychological (and subconscious) distur- ment. This model was initially presented using abances in women, contending that neurotic conﬂicted combination of theoretical frameworks including devel-feelings about motherhood or their own mothers pre- opmental models, crisis theory, bereavement models,vented conception and the assumption of adult roles. and a predictable pattern to develop a stage theoryFischer described two personality styles in women con- of infertility. Accordingly, the inability to procreatetributing to infertility: the weak, emotionally imma- impaired the completion of adult tasks of intimacy andture, overprotected type, and the ambitious, masculine, generativity creating a period of emotional disequilib-aggressive, and dominating career-type. The ‘weak’ rium, with the potential for either maladjustment orwoman was thought to be unable to separate or dif- positive growth facilitating resolution and homeosta-ferentiate from her mother or express her anger in a sis for individuals or couples. Furthermore, infertilitydirect fashion, or she had an abnormal fear of sex, moth- evoked typical feelings and psychological responses toerhood, pregnancy, and labor that inhibited reproduc- infertility that followed a predictable pattern based ontive ability. ‘Ambitious’ women were infertile because the stages of bereavement; involved recognition of the“becoming pregnant meant accepting sexual feelings, loss; gave meaning to the experience and attained effec-being comfortable in competing with a stronger mater- tive resolution through personal growth; and overcamenal ﬁgure, giving up the fantasy of remaining a child, the losses of infertility.and not having to compete with an unborn child.” In general, the psychological sequelae approach pro-Typically, ‘psychogenically infertile’ men were thought vided a broad view of the interrelationships of individ-to have domineering mothers who over controlled their ual, couple, family, society, and reproductive medicine;sons by threatening withdrawal of love, expecting con- integrated different theoretical frameworks; conceptu-formity to their rigid moral codes, or creating anx- alized infertility as a major life crisis involving stressiety within their sons as a result of their own sex- and grief; and provided a framework for the provision ofual inhibitions. Men, too, were thought to have counseling services. As such, the psychological sequelaeconﬂicted feelings about parenthood or masculinity model was valuable in stimulating the development ofcausing infertility. This theory was recycled dur- consumer advocacy and support organizations; increas-ing the sexual revolution of the 1960s in descriptions ing awareness among mental health and medical pro-of the ‘new impotence’ – men experiencing impotence fessionals of the importance of the psychosocial aspectsas a result of performance pressure from ‘liberated’ of infertility; and legitimizing adjustment to infertilitywomen who expected sexual encounters to be mutually as a problem worthy of empirical study. Still, therewarding. psychological sequelae approach was not without ﬂaws Psychogenic infertility theories fell into disfavor partly and criticism in that it continued to apply a medicalas a result of the increased ability of reproductive model to the complex psychosocial experience of infer-medicine to diagnose and treat infertility problems. tility and failed to consider the social and cultural fac-During the past thirty years, infertility of unknown eti- tors inﬂuencing the experience of involuntary childless-ology has been signiﬁcantly reduced in large portions ness and treatment for it.of the world, eliminating the necessity and/or feasibil- Subsequently, several different approaches haveity of psychological causes of reproductive failure. More been suggested including the psychological cyclicalimportantly, several reviewers of the psychogenic infer- model, the psychological outcome approach, andtility literature concluded that the preponderance of the psychosocial context approach. According to thestudies revealed no consistent or striking evidence of psychological cyclical model, involuntary childlessnesspsychological causes of infertility.[55–58] increases stress levels causing physiological changes Subsequently, psychological sequelae or psychological that inﬂuence treatment outcome. As such, the cyclicalconsequences theories emerged during the late 1970s in model suggests that the psychological distress of infertil-the United States and a worldwide consumer movement ity can and does have biological consequences that canemphasizing that experience of infertility and treatment (and may) inﬂuence conception whether or not medi-for it are emotionally difﬁcult and all-encompassing, cal treatment is used. However, the cyclical modelimpacting all aspects of an individual and couple’s historically failed to address stress levels in the malelife. Hence, infertility was the consequence and not the partner and/or identify what levels of stress were signif-cause of involuntary childlessness.[30,59] Menning was icant (and counterproductive) for speciﬁc individualsone of the ﬁrst to suggest a psychological sequelae or under particular circumstances or situations.
8 LINDA HAMMER BURNS AND SHARON N. COVINGTON The psychological outcome approach is, to some ical research, clinical practice, psychotherapeutic inter-extent, an elaboration on the psychological cyclical ventions, and social policy issues acknowledging themodel in that it involves an integrated mind–body, fam- universal and global context in which infertility is expe-ily system, and biopsychosocial perspective to research rienced and in which treatment is provided both medi-and clinical practice and recognizes the inﬂuence of cally and psychologically. As noted throughout thispsychobiological factors (e.g., stress) on conception and book, how theoretical frameworks have been devel-treatment outcome. The focus of the psychological out- oped and/or applied in infertility vary according to thecome approach is the psychosocial response to infertil- issue or topic being addressed. As such, the psychoso-ity treatment of individuals, couples, and subsequent cial context approach to theoretical frameworks in infer-families as well as psychotherapeutic interventions that tility may be more relevant as it acknowledges thatimpact treatment outcomes. An example is the Heidel- the theoretical framework of individual identity mayberg Model, in which solution-focused counseling be highly applicable to individual psychotherapy orwas found to be helpful for infertile couples, particu- psychopathology but less useful within the context oflarly couples who were highly stressed and who experi- cross-cultural counseling, while stress and coping the-enced deterioration of mood and sexual problems over ories or bereavement theories may have more universalthe course of treatment. application. The psychosocial context approach addresses howinfertility is an experience that occurs within a social Infertility-Speciﬁc Theoretical Frameworksstructure (e.g., marriage, family, community, and cul-ture) and context (e.g., culture or religion). Although Grief and Bereavement Approachesinfertility can be a painful psychological trauma and Infertility involves grief and loss whether it is alife-altering phenomenon that is isolating and stigma- profound distinct loss at the onset of treatment or atizing, it is not simply an individual psychological expe- gradual accumulation of losses over time. The lossesrience but a social experience that occurs within the of infertility may involve the loss of individual and/orcontext of the individual’s or couple’s life and social couple’s health, physical and psychological well-being,milieu. As such, infertility is better understood as a life goals, status, prestige, self-conﬁdence, and assump-‘process’ rather than a single event or series of iso- tion of fertility, loss of privacy and control of one’s body,lated events. The psychosocial context approach is also and anticipatory grief at the possibility of being child-a less individualistic model that takes a more holistic, less.[63,64] Grieving may also involve mourning rela-global approach to understanding the psychosocial phe- tionships altered by infertility whether allowed to slipnomena of infertility and the provision of treatment. away or actually lost or forever changed. As with anyIt addresses cultural, religious, and environmental fac- grief response, the level of attachment (the desire fortors (e.g., natural or manmade disasters such as hur- parenthood, child, or baby) is directly proportionate toricanes or terrorist attacks) that can and do inten- the level of grief an individual or couple experiences.sify or somehow inﬂuence the infertility experience for As such, infertility may typically involve grief responsesindividuals and couples. Furthermore, the psychoso- such as shock, disbelief, anger, blame, shame, and guilt,cial context approach addresses the issues of stratiﬁca- while over time, feelings of loss of control, diminishedtion of medical and mental health services for infer- self-esteem, chronic bereavement, anxiety, and depres-tility (e.g., uneven availability of infertility treatment sion may persist.services); reproductive tourism (e.g., culture clashes Building on bereavement approaches to infertility,when patients travel across borders for reproductive Burns and Covington suggested the keening syndrometreatment); and, ﬁnally, the inﬂuence of culture and/or of infertility-speciﬁc grieving. Within this contextreligion on psychosocial response to infertility as well as keening refers to the traditional Irish custom of griev-the acceptability of medical treatments, mental health ing in which women weep and wail while preparingcare, and/or family-building options. the deceased for burial, while men watched in somber Ultimately, both the psychological outcome and psy- silence (often sharing alcoholic beverages which typ-chosocial context approaches provide perspectives by ically lead to the cultural phenomenon known as theincreasing our understanding of individual, couple and ‘Irish Wake’). The keening syndrome of infertility referscultural differences, providing greater knowledge of to the way in which many couples grieve the losses ofclinical issues and effective therapeutic interventions to infertility: Women weep and men watch – with menimprove patient well-being and response to treatment. often emotionally distancing themselves from the cou-Ultimately, theory development in infertility should ple’s shared loss. This phenomenon can result in hus-expand even further to include the integration of empir- bands becoming the ‘forgotten mourners’ because the
PSYCHOLOGY OF INFERTILITY 9husband is less verbal and expressive with his grief or Individual Identity Theoriesunable to express it in the same open manner as his wife. Infertility as an experience that alters an individual’sUltimately, failure to acknowledge and appropriately identity and sense of a self was suggested as integra-grieve the losses of infertility has an impact on a couple’s tion of infertility into sense of self model by Olshansky,long-term adjustment to infertility, as well as prospec- who contended that the internalization of the infertil-tive decisions regarding treatment and family-building ity experience is instrumental in managing the narcis-alternatives. In many ways, this approach highlights not sistic wounds of infertility. According to this theo-only gender differences in grief and mourning but also retical approach, infertility alters an individual’s sensehow women often assume the role of primary mourner, of self by creating or exacerbating feelings of deﬁ-bearing an unequal share of the emotional burden of a ciency, hopelessness, and shame. Both infertile men andcouple’s grief. Some have suggested that this is because women experience altered self-concept and self-imagewomen are proportionately more distressed than men, as a result of infertility, although they may experience itwhile others argue that it represents a common mari- differently. Women often feel inadequate and deﬁcienttal or cultural pattern in which women assume greater for failing to fulﬁll personal and societal roles, whileresponsibility for the couple’s emotional well-being men often feel inferior, ashamed, and angry. In short,and expressiveness. It may also reﬂect how infertility whether infertility involves an actual pregnancy loss ortreatment is disproportionately geared toward women. the loss of the couple’s wished-for child, it is a loss that By contrast, Unruh and McGrath objected to the is experienced as a narcissistic injury as well as a sym-application of traditional grief and loss theory to infer- bolic loss of self. A core concept of this theory istility because it failed to address the ongoing, chronic that individuals experiencing infertility must integratenature of infertility. They identiﬁed infertility as and incorporate infertility into their individual identity,a chronic sorrow for the infertile, typically involving sense of self, or self-deﬁnition. In so doing, the indi-numerous losses over an extended period of time. In vidual is then able to move beyond a personal iden-fact, infertility-speciﬁc grief may never be completely tity of oneself as ‘infertile’ and transcend the experiencemourned, transcended, or fully integrated. According to through overcoming, circumventing, or reconciling thethe chronic infertility-speciﬁc grief model, even after par- identity of self as infertile.enthood has been achieved or childlessness accepted, In considering the impact of infertility on women,infertility can, and often does, periodically reemerge Unruh and McGrath suggest that infertile women haveonly to be remourned from a different perspective or (1) the right to have control over their bodies, particu-vantage point in the couple’s or individual’s life. larly their reproductive capabilities, and to actively par- It has been suggested that infertility is a disenfran- ticipate in their healthcare; (2) been commonly blamedchised grief in that infertility is a loss that can lead for the conditions that have caused them personal dis-to intense grief, although others may not recognize it tress; (3) been socialized to value themselves primar-or perceive it as minor. Disenfranchised grief has ily for their childbearing roles; and (4) more in com-three categories, all of which are to some extent often mon with each other than their differences in fertil-experienced by infertile couples. It is a grief in which ity. Another theoretical approach that addresses(1) the lost relationship loss has no legitimacy, is socially identity issues in infertile women is Kikendall’s appli-unrecognized, or unacknowledged (e.g., yearned-for cation of self-discrepancy theory. According to this theo-child, miscarriage); (2) the loss itself is not recog- retical approach, infertility is a personal identity crisisnized as signiﬁcant to others in the couple’s social net- in which a woman experiences a conﬂict between herwork or culture (e.g., failed treatment cycle or chem- ideal sense of self as mother or woman and her realical pregnancy); and (3) the griever is not recognized sense of self as infertile.as having suffered a loss and justiﬁed in grieving. Dis-enfranchised grief is recognized as a more complicated Stress and Coping Theoriesbereavement because the usual supports that facilitate Taymor and Bresnick were the ﬁrst to refer to infertil-grieving and the healing process are absent. Further- ity as a stressor and crisis involving interaction amongmore, there are some situations around which losses are physical conditions predisposing to infertility, medi-so socially stigmatizing that individuals are reluctant to cal interventions addressing infertility, reactions of oth-acknowledge their loss. Infertility may be so socially ers, and individual psychological characteristics.unacceptable that the shame of the diagnosis, treat- Stanton and Dunkel-Schetter applied stress and cop-ments for it, and/or family-building alternatives may be ing theory to infertility, noting that infertility is char-lead the infertile individual to keep his or her losses acterized by the dimensions of what individuals ﬁndhidden to minimize social stigma. stressful: unpredictability, negativity, uncontrollability,