The psychology of infertility

Written by Mandy Rodrigues

 

About the psychology of fertility

One of the biggest challenges with infertility is the lack of control. Each stage of our fertility journey is met with different crises to overcome. This journey starts even before we book our first appointment with a fertility specialist, and it continues throughout our pregnancy until we are holding our baby in our hands. Our baby may come to us in a way we never imagined, like in vitro fertilisation (IVF), donor eggs or surrogacy. We may have to use egg freezing techniques to preserve our fertility. Insomuch as each journey has a myriad of emotions like loss, grief, anger and depression; there are ways we can minimise our risk for these inhibiting us.

Research has shown that depression and Post Traumatic Stress Disorder are potential consequences of this path of infertility. Some people worry about their marriages, and the ability to sustain their relationship through this time. Many people do not seek psychological support, whereas it should be part of everyone’s journey from the start; as a form of guidance, support and a trusted form of advice. Not everyone wants to share their journey with family or friends; and there are psychologists in the field of infertility who can provide this very necessary support.

Imagine a morning at the reception room of a fertility clinic. People try not to make eye contact. They try to disappear into the chair, working on their computers or playing with their phones. There is almost an unspoken rule that they don’t talk to one another, and respect one another’s boundaries. They sit in the same boat, but isolated because they don’t want to share. They are new patients all waiting to see the fertility specialist, and are still hopeful.

 

 

What if you knew their stories?

There is the young couple holding hands. As a couple, we may have dreams of becoming parents. We go through our lives preparing in all ways possible to make this happen. We settle down, get a job to create financial security, and avoid falling pregnant unexpectedly. We imagine our partners reflected in our children and imagine a future with a family. This couple eagerly started trying, and it’s not happening.

In the other chair, we have a well-dressed corporate woman busy on her laptop. She comes across as driven and in control but feels embarrassed that she doesn’t have a partner. She has pursued her career relentlessly for years, only to realise she has neglected to put her energy into finding a partner. She feels her dreams of becoming a parent are over, unless she seeks assisted reproductive technology (ART), which she must come to terms with doing as a single mother.

Then there is the woman who has known for years she would need fertility assistance due to a chronic illness like endometriosis or an autoimmune disease.  She has decided the time is right to start pursuing her dream of being a parent and knows she will need ART.  There is a young girl with what looks like her mother, and we wonder why she is here. She has been diagnosed with cancer and is coming for egg freezing. And finally, a same-sex couple, who decide they are ready to use medical science to have their family in the form of surrogacy; an opportunity never made available to them before. They eagerly await the next step in their surrogacy journey.

All these scenarios are different, but all of them are about to climb on the same rollercoaster. All on the same ride, but all silently wishing they will make it to the end before the others. It’s like running a Comrades Marathon. You would like everyone to get a medal, but you know there are limited gold medals, and if you don’t fight for it, someone else will take it. If they all spoke, they would realise that despite their different life journeys, they are not alone in their ride going forward. They are all afraid, all excited, all wanting the same goal. There are enough medals. Some won’t get gold the first-time round. It might take more training, or they might need to run a few marathons.

We have all heard about the rollercoaster of infertility once we start treatment, but what about the process we go through to accept that we need to go to a fertility clinic before we even embark on the journey of treatment?

 

The cycle includes these emotions:

When we first realise that we are not falling pregnant naturally, we react with a sense of surprise. We feel confused; yet we still believe we can control our infertility, and that it is due to factors within our control. We then step into action, where we scrutinise our behaviour and habits, trying everything we can to improve our fertility. We might stop smoking, we change our diets, and we engage in this as a team. As time progresses, we might feel somewhat irritated. This is where fertility triggers* start emerging. We might start reacting negatively to anything reminding us of our struggle to conceive, and well-intentioned advice is met with sadness, irritation, avoidance and tearfulness. We feel misunderstood. We then start feeling angry as we think life is being unfair. This might cause feelings of blame, guilt and shame. As time passes, we accept this is not going to happen without assisted medical treatment, and we actively seek a fertility specialist to help us.

*A situation that reminds us of our inability to conceive and creates a negative reaction, like a baby shower or a pregnant woman

Some words of advice during this early stage:

1. Use the action phase to better your chances for pregnancy. There is only good that can come from you              stopping smoking, managing your diet, and managing your stress. These lifestyle changes will help you            with your fertility journey as well as your pregnancy and coping with the challenges ahead. There is a lot          of research that eating healthy can improve your time to pregnancy and managing your chronic stress                levels can reduce the negative impact stress has on your immune system.

    Visit www.tups.co for a free on-line assessment to establish if you fit into the category of those who                might struggle with infertility from a stress perspective. Research done on the 10-session course                      showed that time to pregnancy was quicker in those that managed their stress. Also, those that needed            IVF fared better if they had completed the course, which can be done online. Use this time to manage                your stress.

2. Decide who you are going to share your fears with at this early stage. Remember that people around you          do not know what to say or will offer well-intentioned advice that might not make you feel better.                      https://mandyrodrigues.com/f/guide-for-family-and-friends.

3. Until we know why this is not happening, this is a couple problem. In fact, once we know the                            reasons for not being able to conceive, this is still a couple problem. Shame, guilt and blame do more                harm than good. These emotions inhibit action and create conflict, depression and anger.

 

Ask yourself these three questions whenever you feel guilty:

  1. Was your infertility deliberate?
  2. Did you make a mistake?
  3. Is infertility an inappropriate behaviour on your part?

 

If you cannot answer yes to all three questions, you are experiencing baseless guilt.

Baseless, unjustified guilt robs us of our joy, our enthusiasm, our energy, our health and our happiness.

    Try this exercise at home:

    • Set up two glasses on your desk or dresser.
    • Get a stash of buttons or jellybeans.
    • Every time you catch yourself in blame or guilt, throw a jellybean into the left glass.
    • Every time you tell yourself, “it is what it is”, throw one into the right glass.
    • At the end of the first week add up the jellybeans and empty.
    • Then start again. By the end of the second week, the “baseless guilt” glass usually       has less!
    • Try for zero by week three.

     

    4. A word of advice: If at any stage during the process, you feel you would rather seek fertility treatment              sooner than later – book an appointment. You can dictate your fertility journey. There is nothing wrong              with seeing a fertility specialist sooner than later. Either you are going to realise that you still have time to        try naturally, which will give you some peace of mind, or you will realise that you cannot afford to wait.            Choosing your fertility specialist can be through referral, location, websites like merckfertilityjourney.co.za      or visiting social media platforms like House of Fertility, where many doctors give brief talks on various            topics. You can choose a fertility specialist based on who you feel you connect with. It is a fallacy that you        will simply be pushed into IVF for your fertility specialist to make money. All are guided by the Southern            African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG) guidelines, and practice      in an ethical manner. You do not need a referring doctor to book an appointment with a fertility specialist. 

     

    Disclaimer: Content provided courtesy of clinical psychologist, Mandy Rodrigues, for medical education purposes. The views expressed in the content do not necessarily reflect the views of Merck.

    SEA/NONF/0520/0016a. May 2020.

    Do you need psychological support?

    Would you even hesitate to suggest to a friend to seek psychological support after a hijacking? What about a friend who has lost someone close to them, and is struggling to cope? Would you refer them to just anyone? Would you think it is absurd that they would like support? What about a friend going through marital problems? You would suggest couple counselling. So why is it any different with infertility? It is a life crisis too.

    Infertility can become like a trauma where you ruminate about having a baby all the time. You structure your life around trying to conceive. You may stay in a dead-end job because you want the maternity benefits. You don’t travel, you drink less, and you save money towards your treatment. So, in essence, you put your life on hold. You also deal with feelings of loss, grief, loneliness, and bargaining. It feels like you have lost a part of yourself, and a part of your future. You might experience relationship difficulties, not only with your spouse, but with extended family and friends.

    Many couples have the misconception that ART causes divorce. This is not so. You try to make sense of your life to explain why you cannot conceive. We call this bargaining, and sometimes infertility does not make sense. Most of us have approached life knowing what we want. We have also known what to do to get that. We have worked hard, and attaining our goals has, mostly, been in our control. However, infertility impacts 1 in 6.1 For that person, or couple, it creates a huge sense of helplessness and hopelessness. If this is not managed, it can result in depression.

    Let’s look at the single mother. She possibly needs to deal with her loss of her dream to have a baby in a partnership. She suffers from the loss of this ideal and the impact of this on her fertility. She needs to make decisions about freezing her eggs, donor sperm and/ or donor eggs. She is often the most marginalised in the reception room as she hardly shares this with anyone. For her, a psychologist can be in her corner about these decisions.

    What about the couple who have happily engaged in setting up that appointment? They have been on the same page until now, and suddenly they worry about the process taking over their lives. They don’t want to reach that stage of desperation. They don’t want to lose their relationship in the process of making a family. They need counselling to realise it is not the fertility treatment per se which causes the marriage problem, but the manner in which the couple cope with it. A study looked at the changes in a marriage across a five-year period of struggling to conceive.2 This study revealed that the longer one is engaged in a fertility process, the more impact this can have on the relationship if not managed adequately.2 Couple’s initially embark on this journey as a team. As they become more disillusioned, they appear not to share with one another the emotional challenges they are going through. They do this to either protect the other party, or because they don’t know how to manage the expectations of the other party. We want to keep the team approach which we experience at the beginning, and not allow a phenomenon called Independent Coping creep in; where you are both too tentative to bring up the “baby subject” in case the other gets upset. Counselling can provide the ideal forum to teach men that their wives will not fall apart and that women, as a rule, look at the worst-case scenario, whereas men generally cope in the here-and-now.

     

    Relationship Changes in Infertility 

    © Mandy Rodrigues

    The same-sex couple in the room, or the couple needing surrogacy, also need support. In fact, as you transition from one form of fertility treatment, even if this is making the decision to do Artificial (intra-uterine) Insemination or IUI, you may need support to discuss this next step. Considering third party assistance like surrogacy and egg donation is a big decision, and psychologists are instrumental in helping couples make these decisions.

     

    Some fallacies that can be debunked in therapy:

    1. “Infertility will change my relationship”

    It might change your relationship, but can change it for the better as you navigate this journey together             with the same goals in mind.

    1. “If I hear I need IVF, my chances at having a family diminish”

    IVF, and other forms of infertility treatment, have a success rate similar to that of natural fertility3. IVF can       also be seen as an expensive medical procedure. Even if it isn’t successful, it will give you an indication of         where the problem lies, and how this can be rectified. 

    1. “I won’t love a baby who is not of my DNA”

    Coming to terms with using donor gametes or a third party like a surrogacy, doesn’t mean you won’t love         your baby as much as you’d imagined. The role of epigenetics also come into play in creating a baby, as             does nurture more than nature. 

    1. “I will lose my partner in this process”

    You might have to manage your communication differently, but this can only be of benefit in the long run         when you are both parents in the future. 

    1. “I cannot afford IVF”

    Attending a fertility clinic does not imply you need IVF. There are other routes that might be explored                before the gold standard of IVF. Remember also, that you might be embarking on a month-to-month basis        which ends up costing you more in the long run when only the gold standard would be successful. Your            months of attempting with less expensive procedures might end up costing more, both financially and              emotionally.

     

    References:

    1. Zargar et al. Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India. Fertility and                Sterility. 1997;68(4):637-643.
    2. Peterson et al. The longitudinal impact of partner coping in couples following 5 years of unsuccessful fertility                      treatments. Human Reproduction. 2009;24(7):1656-1664.
    3. Gnoth et al. Final ART success rates: a 10 years survey. Human Reproduction. 2011;26(8):2239-2246.

     

     

    Disclaimer: Content provided courtesy of clinical psychologist, Mandy Rodrigues, for medical education purposes. The views expressed in the content do not necessarily reflect the views of Merck.

    SEA/NONF/0520/0016a. May 2020.

    Seeking psychological support

    Psychologists specialise in this field of infertility. They are trained in the nuances, are familiar with the medical jargon, and many have been through infertility themselves; creating a passion for helping others. But just as you are unique in your personality, so are psychologists. We connect with people who are similar to us, and the gain we get from therapy depends on the relationship you establish with your psychologist.

    1. Get a referral from someone you know
    2. Ask your fertility specialist to refer you to someone
    3. Visit the SASREG website for a referral in your area
    4. If you are reluctant to see a therapist, there are several support groups you can join like IFAASA, House            of Fertility and “Hannah you are not alone”. They provide for a safe, anonymous space to share your                feelings and also have regular seminars and talks that you can attend.

     

      

    Clinical psychologist, Mandy Rodrigues, has worked in the field of infertility for the past 25 years, having been through her own fertility journey. Her passion includes working with individuals, couples, and groups, helping them to cope with their fertility journeys, and assisting them in making critical decisions. A large part of her practice involves stress management, and the need for a multidisciplinary approach in infertility. She shares her knowledge and passion through lecturing, writing numerous articles, and motivational speaking. 

    Furthermore, Mandy has recently been nominated to the Board of SASREG and is part of the BIOLAWGIC Committee creating guidelines for surrogacy, gamete assessments and especially the new laws surrounding known donors.

    If you would like to know more about Mandy Rodrigues, or wish to contact her, you can do so by visiting her website at www.mandyrodrigues.com.

    Disclaimer: Content provided courtesy of clinical psychologist, Mandy Rodrigues, for medical education purposes. The views expressed in the content do not necessarily reflect the views of Merck.

    SEA/NONF/0520/0016a. May 2020.