Infertility fertile ground for psychological issues

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

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)

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

Whether to seek treatment
 Duration of infertility
 Time remaining for conception

Prevalence of Infertility
 10-15% of couples
 Approximately 1 in 6 couples
 7.3 million infertile people in the U.S.

Prevalence by Age
 Under 35: 1 in 10
 35 – 40 1 in 7
 Over 40 1 in 4

Causes
 24% male factor
 21% ovarian dysfunction
 14% tubal factors
 13% other known factors
 About 25% unexplained
 20 – 25% more than one cause

Absolute Infertility – 40%
 Azoospermia
 Anovulation
 Female genital tract occlusion

Relative Infertility – 60%
 Ovulation disorders
 Oligospermia
 Peritubal adhesions (PID)
 Sperm antibodies
 Disorders of the uterus and cervix
 Several problems together

Trends in Recent Years
 37% increase (‘82 – ’87)
 Causes:
 STD’s
 Environmental Toxins
 Delayed Childbearing
 Overweight

Chance of Pregnancy by Age
 Up to age 34: 90%
 Ages 35 - 40: 67%
 Ages 41 – 45: 15%

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

Costs of Treatment
 Most procedures are not covered by insurance
 IVF - $12,000 - $15,000 per cycle
 Emotional costs
 Health costs

Health Costs
 28% risk of multiple gestation
 27% preterm birth rate
 36% low birth weight

Success Rates of IVF
 19% in 1993
 28% in 1997
 40% in 2002

ASRM’s average success rate report
for IVF, 2008
 31.6%

USF’s REI Program, Dr. Shayne
Plosker, 2008
 Age 35 and under +50%
 Age 35 - 40 25 - 30%
 Age 40 and over 17%

Most Common Forms of ART
 IVF
 Blastocyst Transfer
 Intracytoplasmic Sperm Injection (ICSI)

Range of Common Reactions
 Disbelief
 Sense of time pressure
 Envy and resentment
 Guilt and self-recrimination
 Sense of loss of control

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

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)

Fertility
Study of women undergoing insemination gave them a
measure of general anxiety before the procedure.
Those with higher anxiety took longer to conceive

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%

Stress Reduction Improves
Conception
IVF patients offered relaxation training, cognitive
restructuring and self-instructional management more
likely to conceive on first cycle.

Conception
Women who took a mild anxiolytic on days 8-18 of
menstrual cycle were twice as likely to conceive as a
control group.

Conception
Alice Domar’s multifactorial treatment model has
consistently shown a decrease in depression and
anxiety, and a modest increase in pregnancy in
participants.

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

NEVER TELL AN INFERTILE
WOMAN TO “JUST RELAX”

Changing Reactions to Infertility
over Time

Couple Issues
A. Different cultural pressure to procreate on women
and men

Couple Issues
B. Gender Differences
1. In coping
2. In decision making
3. In communicating

Couple Issues
C. Treatment of Couples
1. Impersonal framing
2. Understanding inner world of parner
3. Brainstorming
4. Compromise
5. Case example

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

Losses Related to Long-Term
Infertility
 Relationship
 Health
 Status
 Self-esteem
 Self-confidence
 Security
 Fantasy
 Symbolic value

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

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

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

Domar’s Behavioral Medicine
Program
C. Focus on nutrition and exercise

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

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

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

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 .

Infertility fertile ground for psychological issues

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Infertility fertile ground for psychological issues