Fertility is highly valued in most cultures and the wish for a child is one of the most basic of all human motivations. For women, pregnancy and motherhood are developmental milestones that are highly emphasized by our culture.^1,2 When attempts to have a child fail, it can be an emotionally devastating experience.^3,4 But in the past two decades, advances in reproductive medicine have made the treatment of infertility a highly successful prospect that has given hope and success to thousands of couples. The high-tech reproductive technologies have associated psychological and ethical issues that must be addressed by the infertile couple. Therefore, it is important for the health care professional to understand the psychological issues surrounding infertility.

The purpose of this chapter is to review the psychological issues related to infertility, summarize the relevant research, and describe current provision of psychological consultation to individuals and couples undergoing infertility treatments. This chapter addresses a number of issues regarding the psychological aspects of infertility: (1) a description of infertility as a life crisis; (2) a summary of the losses related to infertility and their impact on self-esteem; (3) the relationship between psychological stress and infertility; and (4) the provision of psychological services to infertility patients.

Infertility is defined as 12 months of appropriately timed intercourse that does not result in conception. Approximately 16% of couples in the United States will have difficulty having a child.⁵ This appears in part because of the trend for some women to delay childbirth until the mid- to late 30s and the associated decrease in fertility after the age of 35. Although there is the perception that infertility is on the rise, it is actually an artifact of the large number of women currently in the childbearing years because of the baby boom of the 1950s and early 1960s. The base rate of infertility among women has remained the same but the absolute number of women in the reproductive years has increased.⁶ Approximately 40% of infertile couples have female factor infertility, 40% male factor, and 20% a combination of both or infertility of unknown etiology.

Before the advances in reproductive technology clinicians believed that infertility, particularly of unknown etiology, was caused by psychological distress.^7,8,9 Investigators tried to identify unconscious or other psychological variables that caused infertility.¹⁰ In the mid-1980s clinicians and researchers began questioning the hypothesis that psychological distress caused infertility.

Instead, they found that psychological distress was a consequence of infertility. With this understanding, mental health professionals have become increasingly involved in the provision of care to infertile patients.^11,12,13

The importance of infertility treatment in the larger field of obstetrics and gynecology is related to the almost universal desire for a child among women. The desire for a child has had different meanings throughout the history of humankind. Before the Industrial Revolution, children were valued for their economic usefulness. After child labor laws were enacted and children were displaced from the workforce, they came to be valued for relational reasons, such as companionship and familial continuity. As Griel¹⁴ suggested, children became economically worthless but emotionally priceless. The shift in the value of children persists today as children are viewed as a source of fulfillment and happiness. Therefore, children have become something that couples work hard to obtain and feel they have a right to. From this vantage point, the seeking of infertility treatment for years and undergoing expensive, psychologically draining treatments can be understood as a result of the 21st century view of the value of the child.¹³

The inability to meet one of their most important life goals is devastating to the infertile individual. The emotional impact of infertility has been described via clinical observation and empirical research. Menning³ used the psychological stages of the grief and loss model (surprise/shock, denial, anger, bargaining, and acceptance) to explain the infertility experience. As she described the reaction to infertility, she also discussed the guilt, anger, depression, and withdrawal that may follow the discovery of impaired fertility. Her descriptions were based largely on her own observations in dealing with couples who were seeking adoption after unsuccessful medical treatment of infertility but have been observed time and time again by other clinicians.

The first stage of the reaction to infertility is surprise. Most couples assume that pregnancy will occur soon after discontinuing contraception because most have spent their sexual lives trying to avoid pregnancy. Couples scrutinize their behaviors, habits, and lifestyle to try to understand why they have not been able to conceive. They also examine the timing, frequency, and technique of intercourse to explain why they have not been able to conceive. If the couple has told others of their attempts to get pregnant, they may be the recipients of well-intentioned advice from friends and family. Chief among these recommendations are “just relax,” and they will get pregnant. Also, others may tell them to get more rest, eat a balanced diet, restrict certain foods and beverages, and cut down on exercise. Couples usually try these things to feel as if they are doing all they can to improve their fertility. Couples try over-the-counter ovulation prediction kits to precisely determine when ovulation is occurring so that intercourse can be properly timed. They may be overly concerned about orgasm or whether leakage of sperm out of the vagina has affected their attempts to conceive. They may have intercourse in uncomfortable positions, more frequently than they desire, and the woman may stay in the supine position after intercourse because she feels it will help aid conception. The common theme among couples who exhibit these behaviors is that they consider themselves inherently fertile but unable to conceive because of circumstances. They believe they can still control their fertility, and the identification of them as infertile has not yet occurred.

When these modifications in lifestyle or intercourse technique are unsuccessful, both the man and woman may examine their past for clues as to the cause of their infertility. Women often assume that they are the cause of the infertility and search their past for a potential cause. Women who have had a sexually transmitted disease or previous abortion may be convinced that the infertility is a result of those events. This may lead them to feel guilty and question their worthiness as a wife and a potential mother. Less often the man may wonder if a past medical condition, medication, or habit may be compromising his fertility. When the couple continues to have difficulty conceiving, most seek medical advice and treatment, including trying to find an explanation for their problem.

As a result, a couple seeking advice regarding fertility comes into their physician's office with a specific need to know why they are infertile to explain or ameliorate the guilt that they feel. They often want to determine the possible role of past behaviors in their infertility. For example, a woman who had an elective abortion and fears it may have caused her infertility may become obsessed with blaming herself for the infertility until she can be reassured by her physician that the two events are unrelated. For some women, obsessive thoughts and ruminations about infertility infiltrate their daily lives and threaten their ability to function at work or at home. The ruminations are an attempt to understand and control the guilt they feel. When a medical basis for infertility has been discovered, the infertile partner usually feels a sense of guilt that they have compromised their spouse's ability to have a child. Carried to the extreme, particularly if the marriage is not strong to begin with, the infertile partner may actively threaten to leave the marriage to free their spouse to procreate with someone else. Alternatively, the fertile partner may engage in actions to influence the dissolution of the marriage.

Another emotional reaction to infertility is depression. The occurrence of depression among infertile women is well documented.¹⁵ The depression may be cyclical and coincide with phases of the treatment cycle, or it may be acute and precipitated by a specific event, such as a family holiday or the announcement of a family member's or friend's pregnancy. Fortunately, for most women the depression is short-lived. Chronic depression caused by infertility may generalize to other areas of a woman's life. She may communicate less or argue more with her spouse, function poorly on the job or at school, or have severe anxiety and agitation. Sometimes, the depression is camouflaged and the couple may consciously or unconsciously sabotage their own attempts to conceive so as to diminish the chance for disappointment. For example, he or she may purposely avoid intercourse at midcycle to avoid the postmenstrual depression that stems from repeated failure.

The feeling of depression is compounded by the loss of control over one's life that many infertile couples experience. For many couples who have been able to achieve almost any goal they have set for themselves, the inability to conceive a child may be the first time when they have lost control of their lives. To compensate, they may wrestle with the infertility team for control over their infertility testing and treatment. For some couples, this attempt to control every aspect of their infertility testing or treatment may be a defense mechanism against their profound sense of helplessness.

At some time during the infertility evaluation and treatment, couples may feel intense anger. They may argue that life has treated them unfairly and that their infertility is unjust. They may become intensely angry when they see individuals, whom they believe undeserving, achieve a pregnancy with little or no effort. They may feel very angry when they hear a pregnant woman display disgust or unhappiness with her pregnancy; when they see women with an unwanted pregnancy seeking an abortion, or when they observe a mother or father abusing their child.

Infertile couples may displace their anger toward others, such as family and friends, who, from the viewpoint of the infertile couple, may not be particularly sensitive to the emotional pain they are feeling. Unfortunately, anger displayed toward family and friends may drive away those who are in the best position of providing emotional support for the infertile couple. One partner may also become very angry with the other if they sense that he or she does not feel the same degree of emotional pain or have the same intense desire to overcome the infertility. The more distressed partner may place unrealistic demands on the other and become very angry if he or she is unable to meet these expectations. The significant differences in how men and women deal with infertility may be particularly noticeable at this time. When infertile couples direct their anger at the medical team, it is often difficult for the team to avoid becoming angry and defensive. Angry couples are often characterized by the treatment team as being difficult. Frequently, it is the office staff, not the physician, who bears the brunt of the patient's anger. Therefore, it is not uncommon for the nursing or office staff to be aware first of a couple who is handling their infertility poorly. It is important for the health care team to realize that the couple's intense feelings of anger really often mask feelings of pain, anxiety, and fear.

In a now-classic article, Mahlstedt⁴ described a series of losses experienced by the infertile couple that helps better understand why the emotional reaction to infertility can be so intense. These losses include loss of self-esteem, relationships, health, and financial security.

The infertile person has a loss of self-esteem by repeatedly attempting to achieve a desired goal (having a baby) but failing to achieve it. When unable to have a child, the failure challenges and may begin to erode their self-esteem. The problem can be significantly worse when the individual has been highly successful in other areas of life and has not developed the coping skills to deal with failure and loss.

A second loss can be the real or feared loss of important relationships. This includes the marital relationship and relationships with family and friends. The marital relationship can be strained or lost because of fears that the fertile partner will leave the infertile partner. Even though a couple is working together toward a common goal, the emotional pain associated with infertility and the stress of the evaluation and treatment may make it difficult for each individual to provide the necessary emotional support for each other. Unfortunately, this occurs at a time when each needs the emotional support and intimacy provided by the other. When they cannot meet each others' needs, each partner may withdraw and isolate themselves.

An additional strain on the relationship may be the changes in the couple's sex life. Several writers have noted that infertile couples have sexual difficulties.^16,17 Sex may become a reminder of the couple's failure to have a child. The increased intrusion into the sexual habits of the couples by the medical team's recommendation for timed intercourse, frequent intercourse, or limited intercourse may make sex feel like a chore. The intimacy and pleasure usually derived from sexual relations may be identified as another loss by the couple.

In addition to marital difficulties, the infertile couple may also experience strain in relationships with family and friends. They may isolate themselves from their family and friends because they consider infertility a private problem that they are uncomfortable sharing. They may also often feel misunderstood when they do share their feelings. They assume and believe that no one else can understand the true intensity of their emotional pain. Unfortunately, they are often right. When they hear over and over that all they need to do is relax and they will conceive, they begin to withdraw. They may stop attending family celebrations, such as baby showers, christenings, Mother's Day, or religious holidays when other family members may bring their children with them. The couple begins to feel left out and stops associating with those who have children. Friends who are pregnant may also be avoided by the infertile couple because they are a reminder that others can get pregnant with ease. The infertile woman's loss of relationships can deprive her of social support, which can compound feelings of isolation and depression.

A third loss related to infertility is the loss of health. The female patient may spend a great deal of time in the infertility clinic for tests and treatments. Although she is not really sick, she may begin to identify with the sick role and begin to feel that her physical health is compromised. In addition, women may also report feeling ill because of the side effects of some of the hormonal medications used to enhance fertility.

A fourth loss is the potential loss of financial security. Infertility treatment, especially in states that do not mandate insurance coverage of infertility treatment, can be extremely expensive, with one cycle of in vitro fertilization (IVF) costing between $10,000 and $15,000.¹⁸ An associated problem is the concern about job security for women. Because women are often the primary focus of the evaluation or treatment, they often have to miss considerable amounts of work. This may place their job in jeopardy. In addition, they often fear telling their employer the reason for their absences, because the employer may assume the treatment will be successful and the woman will be leaving her job. If the employer assumes that the woman will be leaving her job to have a child, the woman may become vulnerable to being laid off or dismissed.

In addition to the descriptive information about the psychological aspects of infertility, since the mid-1980s there has been a growing body of research on the relationship between psychological stress and infertility. These studies began by documenting the psychological stress related to treatment and have continued to examine if there is a causal relationship between psychological stress and infertility.

Psychological Stress and Infertility

Freeman and colleagues¹⁹ found that approximately half of the women in their sample rated infertility as the most stressful experience of their life. In addition they found that 18% of men and 16% of women had significant psychological distress including high levels of depression and somatization. Leiblum and associates²⁰ found that women reported more depression before and after infertility treatment than men and that 34% of the women in her study rated IVF as being very stressful. Baram and associates²¹ surveyed couples after they had completed one cycle of IVF and as an indirect measure of how stressful the procedure was, asked couples if they would undergo IVF again. They found that 38% of the couples reported that they would not undergo IVF again because it was too expensive, the success rate was too low, and they were unwilling to undergo the emotional pain of the procedure. In addition, 18% reported that infertility had a negative impact on their marriage and 66% of women reported that they had become depressed after the procedure, with 13% of the women reporting that they had suicidal ideation after an unsuccessful IVF.

After documenting that infertility and IVF were psychologically stressful, researchers began looking at variables that would predict the development of psychological distress among infertile patients. Newton and colleagues²² investigated pre-IVF psychological factors that were related to post-IVF adjustment. They found that 14% of women had clinically significant levels of anxiety and 24% had clinically significant levels of depression. They found that both post-IVF anxiety and depression were best predicted by pre-IVF trait anxiety, depression, and childlessness. Men did not report clinically significant anxiety or depression.

Two studies have investigated the stressfulness of infertility using a stress and coping model. Based on this model, a situation is stressful if it is perceived as a threat to the person and if the person does not feel they have the coping skills to adapt to it. In this model, infertility is stressful because it threatens the person's plan to have a child, which is highly valued.

The extent to which infertility is stressful is further impacted by the coping skills the person uses. With this model one could identify a priori those individuals for whom infertility would be psychologically stressful. In a study by Litt and colleagues,²³ several variables were assessed to determine their contribution to post-IVF distress. Variables that were assessed included demographic and reproductive history, general appraisal (optimism), situational appraisal (chances for success), and coping skills. After an unsuccessful IVF cycle 20% of the women were clinically depressed. Results indicated that general optimism and perceived responsibility for the cause of the infertility were protective against post-IVF distress. Feelings of loss of control, perceived contribution to the IVF failure, and the use of escape as a coping strategy were related to increased post-IVF distress. In this study, optimism seemed to protect the woman from the threat of infertility. Only one coping strategy, escape coping, was related to post-IVF outcome; women who used escape as a coping strategy experienced greater distress.

In a cross-sectional study of infertile patients, investigators found that for women, the most important factors related to psychological distress were perceived personal control, optimism that they would eventually have a child, and intensity of motivation to have a child.²⁴ High levels of perceived personal control and optimism were related to lower levels of distress and high levels of motivation to have a child were associated with increased distress, that is, the more important it was to the woman to have a child the more distress she reported related to the infertility experience.

Several articles have addressed the relationship between psychological stress (high versus low stress) and outcome (pregnancy versus no pregnancy).^1,25,26 It is frequently believed by patients and even some clinicians that if a couple will just relax they will get pregnant. There is the implicit assumption that psychological stress may prevent a woman from attaining and maintaining a pregnancy. Domar and colleagues²⁷ reported decreases in anxiety and depression among a group of women who underwent a 10-session relaxation program with a subsequent 34% pregnancy rate among the group attendees in a nonrandomized, uncontrolled study. Facchinetti and associates²⁸ reported that women who conceived via IVF had lower cardiovascular vulnerability to psychological stress, as measured by a cognitive stress task on day of egg retrieval, than women who did not conceive. Boivin and Takefman²⁹ concluded that psychological stress was related to IVF outcome in a group of women who kept daily ratings of stress throughout an IVF cycle. Domar and associates³⁰ found higher rates of infertility treatment success in their subjects who were undergoing a mind–body intervention or a professionally led support group compared with women in a control group who received no psychological intervention. While these results supported the assumption that psychological stress influences infertility treatment outcome, methodologic weaknesses, such as small sample size and lack of randomization, make attribution of causality difficult.

Studies that have suggested that there may be a relationship between psychological stress and outcome among IVF women are incomplete because they have not assessed physiological markers of anxiety or hormonal correlates of pregnancy outcome. It has been hypothesized that psychological stress alters levels of cortisol (F), prolactin (PRL), and progesterone (P), which in turn have an adverse affect on pregnancy outcome. There are few studies that have assessed both the physiological and psychological aspects of anxiety during IVF and related it to pregnancy outcome. One study found that levels of self-reported anxiety, PRL, and F increased significantly from baseline to the time of egg retrieval during IVF.³¹ Harlow and colleagues also found that levels of state anxiety and PRL and F all increased during IVF but that there was no relationship between increased anxiety, hormones, and pregnancy outcome.³² Milad and associates found no relationship between pregnancy outcome, psychological stress, and pregnancy hormone levels in a group of IVF patients.³³ Further studies are needed to assess the intricate relationship between psychological anxiety, stress hormones, and pregnancy outcome among infertility patients.

General Considerations

The problem of infertility should be viewed as a couple's problem. Regardless of which member of the couple has the medical problem, the issue of infertility is still shared by the couple. As a result, the couple should be encouraged to participate together in all aspects of the process of evaluation and treatment. In this way, each member of the couple will have a better understanding of the demands made on the other and will be more likely to be a support for his or her partner.

Psychosocial issues should be discussed by the physician with the couple not only at the initial visit but also at follow-up visits, especially when major changes in medical strategy occur. It is easy for the health care team to focus on the mechanical and medical aspects of the process of treatment and evaluation of infertility and to ignore the psychosocial aspects. Therefore, a simple invitation to the couple to discuss their feelings about their infertility and about the evaluation and treatment is important. Also, the physician can inform the couple that psychological services are available at the clinic or through consultants to the practice.

Patient information materials should be available in the clinic, including information about RESOLVE and other support services for couples. Providing information about professionally run support groups or national organizations such as RESOLVE will help acknowledge to the couple that infertility is a life crisis, they are not alone, and that discussing their feelings with others may help. A professionally run infertility support group within the infertility practice may allow patients to self-refer without fearing the label of being emotionally unstable or requiring mental health care. In addition, focused support groups that deal with specific issues such as donor gametes, endometriosis, or adoption may be exceptionally helpful.

Most programs providing assisted reproductive technologies have a mental health care professional, such as a psychologist or social worker, on staff or in consultation to work with their couples. The Mental Health Professional Group (MHPG) of the American Society for Reproductive Medicine (ASRM) has outlined qualifications for mental health professionals providing these services (www.ASRM.org).

Mental health professionals may meet with IVF couples to determine their appropriateness for treatment, provide psychoeducational preparation for treatment, or provide ongoing individual or couples therapy during treatment. It is most common for mental health professionals to provide psychoeducational counseling to prepare the couple for treatment and to discuss the emotional impact of issues specific to IVF, such as the creation and freezing of embryos, embryo disposition, ways of coping with IVF, and processing the loss if treatment is unsuccessful. Finally, the mental health care worker can work with the team to help them understand difficult couples. It is much easier for the IVF team to accept an angry or demanding patient if they have some insight into the personality of the patient from the start. The mental health professional can help the IVF team develop a strategy for dealing with the couple to insure the couple gets high-quality care at the same time the team is not inordinately stressed.

There is no consistent philosophy among IVF programs regarding the psychosocial screening of IVF candidates. Some programs mandate a mental health visit as part of the orientation appointment with IVF. These types of consultations are typically psychoeducational in nature but in rare cases (less than 5%), a psychiatric concern is uncovered that may require postponement or refusal of treatment. Klock and Maier¹² described a set of guidelines for the provision of psychological services for infertile couples. In their guidelines they also set forth conditions under which treatment may be denied or postponed, such as active psychiatric illness, cognitive inability to provide informed consent, active substance abuse, extremely divergent levels of motivation for parenting, severe marital discord, and past legal charges related to competency to parent. In cases in which treatment is postponed or refused it is important that the team and the mental health professional work together to provide consistent feedback and limits to the couple and a clear explanation for their decision.

In addition to routine consultations during infertility treatment, the mental health professional is usually also involved in the screening and counseling of gamete donors and recipients. In these consultations, special issues for the donors and recipients need to be discussed.

It is recommended that gamete donors be seen by a mental health professional before donation to examine their understanding of the donation process, their motivation, to assess their social and reproductive history, substance use, psychiatric history, and to administer psychological testing. There has long been a double standard in the screening of sperm and egg donors, with egg donors undergoing more stringent screening processes. This is typically explained by the relatively greater involvement and risk to the egg donor compared with the sperm donor. As Gorrill and associates³⁴ has demonstrated, there is significant selectivity and attrition in the egg donor screening process.

In general, the studies that have investigated the psychological aspects of egg donors and their postdonation satisfaction have shown that donors are generally free of significant pathology or social dysfunction. Their motives are largely altruistic, such as to provide the opportunity for another woman to have a child. In addition, some donors have had a previously traumatic experience related to reproduction and the opportunity to donate an ovum was an opportunity to compensate for their own personal loss. Studies addressing postdonation satisfaction indicate that a minority of donors have physical side effects from medications or retrieval and most donors are generally satisfied with the donation experience.^{35,36,37,38,39} Klock and associates⁴⁰ found that approximately one third of oocyte donors who completed one donation cycle were willing to donate again and that lack of ambivalence and satisfaction with the procedure are related to willingness to donate again. The role of the mental health professional in working with donors clinically and conducting donor research have been important in adding to the fund of knowledge about this new treatment and also to help insure that the donors will not be harmed psychologically by the donation process.

In addition to working with donors, the mental health professional also provides education and counseling to donor recipients. Clinically, the recipients should have an opportunity to discuss their reaction to the losses of infertility, the use of a gamete donor, the donor selection process, issues in attachment and parenting, and disclosure or privacy related to gamete donation use. The research on sperm and egg donor parents indicate a wide degree of variability in parents' intentions to disclose to the child.^{41,42,43,44,45} There is no consensus among professionals about disclosure or privacy recommendations to make to the couple, but pretreatment counseling is helpful in assisting the couple to come to their own consensus and plan about how to deal with the disclosure issue in their own family and social circle.

A significant need of infertility patients is one that is often overlooked. It is the need for counseling to discuss ending treatment. It is as important to talk about when to end treatment as it is to talk about the treatment itself. The physician can discuss in broad terms the average number of cycles for various types of treatment and continually update the treatment plan. In addition, the mental health professional can encourage the couple to discuss how much time, money, and emotional energy they are willing to devote to infertility treatment and other family building options. Last, couples should be encouraged to take breaks from treatment as time permits, to allow for physical rest and renewal of psychological resilience.

With the explosion of new technologies to treat and deal with impaired fertility, there has also been an increasing need for an understanding of the psychosocial implications of impaired fertility and its treatment. Fortunately, clinical experience and research have provided a great deal of more insight. Health care professionals should remember that infertility is a stressful life event for both women and men. Women are more likely than men to report psychological distress in the form of depression and anxiety related to infertility. Marital and sexual adjustment can be compromised by infertility. Because infertility is a problem that affects the couple, it is recommended that the couple be seen together in the evaluation and treatment and that the emphasis is placed on infertility as the couple's problem. Psychological services for couples undergoing infertility treatment may be beneficial.

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