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Infertility fertile ground for psychological issues

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Review of the latest research in the field on grief therapy and practice tips for practitioners. Topics include:

• Overview: Definition, prevalence, trends, costs, success rates,
• Reaction to the diagnosis of infertility: Stress, anxiety, depression
• Couple issues
• Psychological treatment of infertility
• When to refer to a psychologist
• Conclusions
 Infertility would be stressful for anyone
 With intervention, as failure persists, the stress level increases
 Infertility frequently causes stress on the couple relationship which requires attention and management
 While stress may be a causative factor for infertility, its management may be a therapeutic intervention

Presented by Susan Stuber, Ph.D. at Tampa General Hospital, Department of Obstetrics & Gynecoloy, Grand Rounds, April 28, 2010. A copy of the full presentation notes accompanying these slides may be obtained by contacting Dr. Stuber at sstuber@susanstuberphd.com.

Published in: Health & Medicine

Infertility fertile ground for psychological issues

  1. 1. FERTILE GROUND FOR PSYCHOLOGICAL ISSUES Susan C. Stuber, Ph.D. [Presented at Tampa General Hospital, Department of Obstetrics & Gynecoloy, Grand Rounds, April 28, 2010] Copyright 2010 Susan Stuber, PhD 1
  2. 2. Definition of Infertility  Inability to conceive after one year of unprotected intercourse (if under 35)  Inability to conceive after six months of unprotected intercourse (if over 35) Copyright 2010 Susan Stuber, PhD 2
  3. 3. Facts Challenging the Defintion  Only 16-21% of couples meeting the “one year” definition remain infertile throughout their lives  30% of couples take more than one year to conceive Copyright 2010 Susan Stuber, PhD 3
  4. 4. Whether to seek treatment  Duration of infertility  Time remaining for conception Copyright 2010 Susan Stuber, PhD 4
  5. 5. Prevalence of Infertility  10-15% of couples  Approximately 1 in 6 couples  7.3 million infertile people in the U.S. Copyright 2010 Susan Stuber, PhD 5
  6. 6. Prevalence by Age  Under 35: 1 in 10  35 – 40 1 in 7  Over 40 1 in 4 Copyright 2010 Susan Stuber, PhD 6
  7. 7. Causes  24% male factor  21% ovarian dysfunction  14% tubal factors  13% other known factors  About 25% unexplained  20 – 25% more than one cause Copyright 2010 Susan Stuber, PhD 7
  8. 8. Absolute Infertility – 40%  Azoospermia  Anovulation  Female genital tract occlusion Copyright 2010 Susan Stuber, PhD 8
  9. 9. Relative Infertility – 60%  Ovulation disorders  Oligospermia  Peritubal adhesions (PID)  Sperm antibodies  Disorders of the uterus and cervix  Several problems together Copyright 2010 Susan Stuber, PhD 9
  10. 10. Trends in Recent Years  37% increase (‘82 – ’87)  Causes:  STD’s  Environmental Toxins  Delayed Childbearing  Overweight Copyright 2010 Susan Stuber, PhD 10
  11. 11. Chance of Pregnancy by Age  Up to age 34: 90%  Ages 35 - 40: 67%  Ages 41 – 45: 15% Copyright 2010 Susan Stuber, PhD 11
  12. 12. Creating a Life: Professional Women and the Quest for Children, Sylvia Ann Hulett  33% of women over 41 earning over $55,000 are childless  49% who make over $100,000 are childless  Only 14% said they didn’t want children  90% of women interviewed believed they could conceive after 40 Copyright 2010 Susan Stuber, PhD 12
  13. 13. Costs of Treatment  Most procedures are not covered by insurance  IVF - $12,000 - $15,000 per cycle  Emotional costs  Health costs Copyright 2010 Susan Stuber, PhD 13
  14. 14. Health Costs  28% risk of multiple gestation  27% preterm birth rate  36% low birth weight Copyright 2010 Susan Stuber, PhD 14
  15. 15. Success Rates of IVF  19% in 1993  28% in 1997  40% in 2002 Copyright 2010 Susan Stuber, PhD 15
  16. 16. ASRM’s average success rate report for IVF, 2008  31.6% Copyright 2010 Susan Stuber, PhD 16
  17. 17. USF’s REI Program, Dr. Shayne Plosker, 2008  Age 35 and under +50%  Age 35 - 40 25 - 30%  Age 40 and over 17% Copyright 2010 Susan Stuber, PhD 17
  18. 18. Most Common Forms of ART  IVF  Blastocyst Transfer  Intracytoplasmic Sperm Injection (ICSI) Copyright 2010 Susan Stuber, PhD 18
  19. 19. Copyright 2010 Susan Stuber, PhD 19
  20. 20. Range of Common Reactions  Disbelief  Sense of time pressure  Envy and resentment  Guilt and self-recrimination  Sense of loss of control Copyright 2010 Susan Stuber, PhD 20
  21. 21. Sources of Stress  Not getting pregnant  Lack of support  Failure to identify a cause  Difficulties of treatment  High cost of treatment  Relationship strain  Life on hold Copyright 2010 Susan Stuber, PhD 21
  22. 22. Anxiety and Depression Affect Fertility 1995 study on women undergoing one IFV cycle had them complete daily stress ratings. Women who did not become pregnant reported more stress than those who did (Morrow, Thoreson, Penny, 1995) Copyright 2010 Susan Stuber, PhD 22
  23. 23. Anxiety and Depression Affect Fertility Study of women undergoing insemination gave them a measure of general anxiety before the procedure. Those with higher anxiety took longer to conceive Copyright 2010 Susan Stuber, PhD 23
  24. 24. Anxiety and Depression Affect Fertility 330 women completed psych. Questionnaires prior to starting an IVF cycle. Conception rate for non-depressed women: 29% Conception rate for depressed women: 12% Copyright 2010 Susan Stuber, PhD 24
  25. 25. Stress Reduction Improves Conception IVF patients offered relaxation training, cognitive restructuring and self-instructional management more likely to conceive on first cycle. Copyright 2010 Susan Stuber, PhD 25
  26. 26. Stress Reduction Improves Conception Women who took a mild anxiolytic on days 8-18 of menstrual cycle were twice as likely to conceive as a control group. Copyright 2010 Susan Stuber, PhD 26
  27. 27. Stress Reduction Improves Conception Alice Domar’s multifactorial treatment model has consistently shown a decrease in depression and anxiety, and a modest increase in pregnancy in participants. Copyright 2010 Susan Stuber, PhD 27
  28. 28. Is Infertility Associated with Psychiatric Disorder  Historically, the pendulum has swung  Data exists to support a “yes” and a “no” answer  It goes both ways: psychiatric factors contribute to infertility, and infertility causes anxiety and depression  Pragmatic focus on decreasing stress is a good one Copyright 2010 Susan Stuber, PhD 28
  29. 29. NEVER TELL AN INFERTILE WOMAN TO “JUST RELAX” Copyright 2010 Susan Stuber, PhD 29
  30. 30. Changing Reactions to Infertility over Time Copyright 2010 Susan Stuber, PhD 30
  31. 31. Copyright 2010 Susan Stuber, PhD 31
  32. 32. Couple Issues A. Different cultural pressure to procreate on women and men Copyright 2010 Susan Stuber, PhD 32
  33. 33. Couple Issues B. Gender Differences 1. In coping 2. In decision making 3. In communicating Copyright 2010 Susan Stuber, PhD 33
  34. 34. Couple Issues C. Treatment of Couples 1. Impersonal framing 2. Understanding inner world of parner 3. Brainstorming 4. Compromise 5. Case example Copyright 2010 Susan Stuber, PhD 34
  35. 35. Copyright 2010 Susan Stuber, PhD 35
  36. 36. Issues at Time of Diagnosis  Normalize feelings  Coping with anxiety  Planning for upcoming medical treatment  Anticipating impact on marital relationship  Avoiding self-blame and regret  Assisting with decision making Copyright 2010 Susan Stuber, PhD 36
  37. 37. Losses Related to Long-Term Infertility  Relationship  Health  Status  Self-esteem  Self-confidence  Security  Fantasy  Symbolic value Copyright 2010 Susan Stuber, PhD 37
  38. 38. Rosenberg and Epstein’s Nine Pointers  Educate yourself about infertility  Identify your feelings  Challenge unrealistic thoughts  Work together as a couple  Organize your social life  Be active consumers  Be organized  Have a plan  Know when to give up Copyright 2010 Susan Stuber, PhD 38
  39. 39. Domar’s Behavioral Medicine Program at Cambridge, MA A. Relaxation Techniques 1. Progressive muscle relaxation 2. Meditation 3. Imagery 4. Yoga 5. Body scan 6. Diaphragmatic breathing Copyright 2010 Susan Stuber, PhD 39
  40. 40. Domar’s Behavioral medicine Program at Cambridge, MA B. Stress Management 1. Challenging negative thought patterns 2. Cognitive restructuring 3. Learning how to be good to oneself 4. Journaling 5. Assertiveness training 6. Humor to reduce stress Copyright 2010 Susan Stuber, PhD 40
  41. 41. Domar’s Behavioral Medicine Program C. Focus on nutrition and exercise Copyright 2010 Susan Stuber, PhD 41
  42. 42. Copyright 2010 Susan Stuber, PhD 42
  43. 43. When to Refer Infertility Patients for Psychological Screening  Consider your role and ethical responsibility  Psychologist can screen for mental illness, substance abuse, criminal involvement  Must decide own ethical parameters Copyright 2010 Susan Stuber, PhD 43
  44. 44. When to Refer Infertility Patients for Psychological Treatment  Offer to every patient  Time of diagnosis  After prolonged treatment  After miscarriage or other trauma  Whenever distress is evident  When they won’t end treatment Copyright 2010 Susan Stuber, PhD 44
  45. 45. Conclusions  Infertility would be stressful for anyone  With intervention, as failure persists, the stress level increases  Infertility frequently causes stress on the couple relationship which requires attention and management  While stress may be a causative factor for infertility, its management may be a therapeutic intervention Copyright 2010 Susan Stuber, PhD 45
  46. 46. FERTILE GROUND FOR PSYCHOLOGICAL ISSUES Susan C. Stuber, Ph.D. A copy of the full presentation notes accompanying these slides may be obtained by contacting Dr. Stuber at sstuber@susanstuberphd.com . Copyright 2010 Susan Stuber, PhD 46

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