Infertility: Hope and Healing

1. Infertility: Hope and Healing Montse Casado-Kehoe, Ph.D., LMFT, RPT and Nadia Humphreys, M.A., LMHC Smart Marriages : Happy Families Conference July 11, 2009 Montserrat_casado@pba.edu

2. Myths • I am fertile because I have regular cycles • A woman’s fertility gradually declines after age 35 and decreases rapidly after 40 • After 40, a woman has diminished ovarian reserve • Everyone gets pregnant easily • Infertility is a woman’s problem • It’s all stress—relax and you’ll get pregnant • Stress is the result of infertility, not the cause of it • Infertility only has an emotional impact on the woman • The pill postpones menopause www.resolve.org

3. The Meaning of Reproduction • Continuance of the human life cycle • A form of immortality • The “birth right” to experience pregnancy and parenthood • Continuance of the individual’s genetic heritage • “For most women and men the ability to conceive and give birth to a child is paramount to their life long notions of femininity and masculinity, to gender identity, and ultimately, the meaning of life. Bearing children and parenting reflects Eric Erickson’s concept of ‘generativity’ ...” (Linda Applegarth, 2006)

4. Fertility Vocabulary • ART • CASA • CCCT • EEJ • FSH • GIFT • GnRH • HCG • HSG • ICSI • IVF • IUI • LH • MESA • OHSS • PGD • TESE • ZIFT

5. Diagnosis of Infertility • Her • Him • Both • HER • Stigma • Treatment options: • Fertility • Adoption • Childfree

6. Causes of Infertility--Treatment • Reproductive Surgery • Female • Male • Ovulation Induction (IO) and Intrauterine Insemination (IUI) • In Vitro Fertilization (IVF) and Embryo Transfer (ET) • IntraCytoplasmic Sperm Injection (ICSI) • Third Party Reproduction • Egg donor * Embryos • Sperm donor * Uterus • *Social, ethical and legal issues

7. Factors Influencing IVF Success Rates • Age of the woman (and consequently her ovarian reserve) • Normalcy of the uterus and semen quality • Success or failure of fertilization in vitro • Number of embryos transferred • Adequacy of the lutheal phase after transfer

8. Possible Side Effect and Psychological Effect of Medications

9. Infertility-The chicken or the egg • Does infertility cause depression and anxiety? • Do depression and anxiety contribute to infertility? • Do symptoms of stress affect infertility? • Do infertility treatments increase stress? • In one study in England 60% couples dropped treatment because of the psychological burden • Does treatment cost affect stress? • Does a medical model recognize the role of emotions and mental health in fertility txts? • Does the mind affect the body?

10. Possible Psychological Effects of Infertility and Gender Differences • Women report a higher lever of distress than men during infertility, regardless of the locus of impairment (male of female-factor infertility) • Women describe feelings of role-failure, diminished self-esteem, guilt and self-blame • When struggling with male factor infertility, men also may suffer from low self-esteem, loss of self-confidence, and feeling of incompetence, isolation, loneliness, guilt, fear, anger, shame or frustration. • Studies indicate that men appear to be more accepting of being childfree and more willing than women to consider end to treatment, even when infertility is the result of male-factor diagnosis.

11. Seeking Help • Feel empowered • Experience less isolation • Validation of issues • Discuss alternative options • Receive education • Access resources • Reduce anxiety and depression • Decrease preoccupation with fertility • Understand the role of stress • Access coping mechanisms • Find support

12. Counseling Can Help • Infertility distress • Miscarriage • Pregnancy loss • Egg/Sperm donation • Surrogacy reproduction • Adoption • Stress Management • Depression/Anxiety/Irritability • Relationship conflict • Post-partum depression

13. Feelings • Inadequacy • Anger • Sadness • Fear • Anxiety • Frustration • Guilt • Blame • Despair • Worthfulness

14. Emotional Assessment • Anxiety • Depression • Distorted cognitions • Shame • Inadequacy • Self esteem • Blame • Anger • Jealousy

15. Emotional Symptoms • Loss of interest in day-to-day activities • Overwhelming sadness • Depressed mood • Anger outbreaks • Increased anxiety • Increased sexual stress • Loss of appetite • Disrupted sleep patterns • Loss of sense of purpose

16. Physical Symptoms • ↑ Metabolism • ↑ Heart rate • ↑ Blood pressure • ↑ Breathing rate • ↑ Muscle tension • ↓ Sleep • ↑ Anxiety • ↑ Depression

17. Feeling Alone • Tapping into one’s support systems Friends Clinic Family Couple ? Counselor/ Acupunturist/ Nutritionist Church

18. What Counseling Can Offer • Discussion of feelings • Assessment of couple’s relationship • Understanding of grief • Relaxation techniques • Mind-body therapies • Overview of options to become parents • Referrals when appropriate • Validation • Cheerleading • HOPE

19. To Tell or Not Tell • Choose whom to share or whether to share • You don’t have to share • Choose who may support your sharing • Decide how much to share • Fertility issues are personal • Will sharing comfort and empower you? • Set boundaries to protect yourself • Ask for what you need

20. Things Not To Say • “Don’t worry you’ll get pregnant.” • “God has a plan.” • “If it’s meant to be, it will be.” • “If you use sperm donation, it will not be your baby.” • “If you use egg donation, it will not be your baby.” • “If you adopt, it will not be your child.” • “You may be better off without children.” • “If you think positively…”

21. Benefits of Counseling/Psychotherapy Before Fertility Treatments • Facilitate couple communication during the initial and ongoing decision making process • Address psychological factors that might be hindering pregnancy, particularly when infertility is unexplained • Educate the couple about the implication of treatment and the treatment process • Teach coping and stress management skills • Reflect on the emotional aspect of infertility • Address grief related issues related to infertility

22. Counseling Model • Assess the dynamic of the couple: • Pursuer-Distancer • ↑ Conflict • Collaborator-Collaborator • Assess Gender Differences: • Women • Men • Assess Coping Mechanisms • Assess Depression Levels • Assess Stress Management • Assess Sexual Dynamics

23. Phases of Infertility Model • Dawning -first awareness of fertility issues • Mobilization -beginning of diagnostic testing • Immersion -ongoing testing and treatment • Resolution -ending medical treatment; acknowledgement and mourning of loss; refocusing on other possibilities • Legacy -aftermath after infertility: marital, sexual, parenting problems after infertility (Diamond, Meyers, Kezur & Scharf, 1999. Couple Therapy for Infertility.)

24. Deveraux and Hammerman’s Suggested Counseling Model • Integration of infertility into the individual’s definition of self • Acknowledging that the infertile individual is the expert • Promoting acceptance of infertility • Acknowledging the losses of infertility • Facilitating grief and bereavement • Assigning homework • Fostering and encouraging individual empowerment • Facilitating transcendence of the infertility experience through acceptance (rather than resolution) • Promoting responsibility (versus control) • Encouraging self-advocacy

25. Therapeutic Interventions • Cognitive restructuring • Journaling • Development of rituals • Use of metaphors and analogies • Pragmatic problem solving • Creative decision making • Techniques that facilitate bereavement, integration of the infertility experience and problem-solving (Deveraux & Hammerman, 1998)

26. 7 Tools to Survive Infertility • Take care of your body • Make conscious choices Managing emotions • Set healthy boundaries Who is in and who is out? • Tell the truth Sharing the story • Take quiet space Centering Self • Give yourself permission to grieve Rituals • See the big picture Redefine life (Lombardo & Parker, 2007. I am more than my infertility.) (Lombardo & Parker, 2007. I am more than my infertility.)

27. Crisis within a Crisis Pregnancy loss Monthly loss Txts. relationship Infertility Family/Couple $$

28. Silent Grief • Unacknowledged • No recognition of the loss involved monthly • No recognition of failed procedures • Cultural • No recognition of the loss publicly • Rituals • No burial for pregnancy loss • Mourning child lost • Mourning not being pregnant • Financial • Monetary loses

29. Grief Counseling • Encourage the couple to accept their loss • Help the couple experience the pain of grief • Help the couple find an acceptable way to honor and remember the baby’s death • Help couple working through guilt related to miscarriage • Help the couple to eventually withdraw their emotional investment in the loss in order to go forward with life • Work towards grief resolution without baby or with baby (Lombardo & Parker, 2007)

30. Grief, Culture and Systems • Explore how the couple grieves • Ways women grieve • Ways men grieve • Family acknowledgement of the grief • Community acknowledgement • Define grief in counseling • Factors that may affect grief • Emotional • Hormonal • Physical

31. A Counseling Model-Body/Mind/Soul Body/Mind Grief Emotional Medical Couple Psychological relationship Physical Sexual Spiritual

32. Goals in Counseling the Couple • Increase awareness of treatment implications • Address decision conflict • Reduce stress on the relationship • Encourage more active participation in the decision making • Improve communication between the couple and medical staff • Facilitate management of infertility as a couple through identifying: differences in motivation for having children; in reaction to infertility and in coping styles; problems in constructive communication • Assist in dealing with infertility strains on the relationship by providing support for grief work and help the couple identify alternatives and new life perspectives

33. Individual Counseling vs. Couple’s Counseling • Appropriate when one partner experiences a much greater level of distress than the other • When one partner (or both) experiences significant symptoms of depression or anxiety or other mental health problems that require professional intervention • When one partner is unable to move through the grief, while the other partner has moved on

34. Group Therapy • Grief • Loss of Control • Gender Differences • Interpersonal Relationships • Dealing with the Treatment Team • Stress and Coping • Decision Making • Pregnant Group Members

35. Benefits of Group Therapy • Improved social support • Health behavior change • Improved stress management • Possible positive effect on health on fertility • More research needed to determine outcomes on fertility

36. Stress Management Techniques • Moderate Exercise • Acupuncture • Massage • Guided Imagery • Yoga/Fertility Yoga • Sex with no Fertility Agenda (rekindling the couple relationship) • Supportive Friends, family, groups • Being prepared for hurtful comments from friends and family

37. A Strength Model • Client’s strengths • Couple’s strengths • Couple’s resources • Relational • Family • Friends • Spirituality • HOPE • ENCOURAGEMENT • BELIEF

38. People’s Stories • My infertility was the result of a medical condition, one that I could not prevent and no amount of thinking positively about my pain helped. The farther I looked inside of myself to help heal, the sadder I became. Medication to treat the infertility and endometriosis helped (it also put me into early menopause) but it was the anti-depression medicine that really made the difference in my life. For the first time, I reached out for help and the medication took the edge off of the stress and allowed me to work on issues without the constant overwhelming feeling of sadness. …I guess the most important thing a counselor can do is listen to the story from both perspectives. My husband and I had different issues that we were struggling with and just because the infertility affected both of us, it does not mean that we had the same story to tell. –H.

39. Going through the infertility storm was probably one of the most difficult rides of my life! Being unable to get pregnant shook my fragile self esteem, attacked the feeling of security in my marriage and challenged my faith in God.  It was as if someone punched me in the stomach every single month, again and again.  Just as I would feel hopeful, I would meet despair again and again.  Every month - for several years, the same thing over and over.  Hope and then grief would crash over me.  I would try not to be hopeful, but that was impossible.  The pain crept into every area of my life.  Secretly I walked through each day, crying on the inside, but smiling on the outside. Eventually, my focus was able to change from becoming pregnant to becoming a parent.  After four years of struggling with infertility, we decided to direct our finances and emotional investment into becoming parents through adoption.  Although adopting took the sting out of our infertility, there was still pain.  It wasn't until our youngest child (we have two children) was about 4 or 5 years old that the pain was finally small enough that the whispers to God asking for a miracle of pregnancy stopped, and whispers of thanksgiving for what I didn't understand were truly able to be genuine.  Not that I didn't love our children.  We honestly believe God gave these specific children to us; it was more the loss of not experiencing pregnancy that caused the hole in my heart.  When my children were younger, I said to them, "If I could have put YOU in my tummy, I would have done it.  But my tummy is not able to have babies, so God put YOU in someone else's tummy for us."  For us, our experience of infertility is connected to our adoption stories.A counselor who is generally knowledgeable about some of the infertility procedures would be able to understand a little more of what couples face. Processing the death of a dream takes time. Each couple works through it at their own pace, and each individual works through it differently.  A good counselor would help couples cope with how they - the husband and wife - handle the situation differently.  Most of all, a good counselor with a very understanding heart would be patient and encouraging. -T.

40. I don’t know how a counselor would have helped. The most difficult thing was not to have my own child, I mean genetically. I felt "not normal", I was sad and angry. Education would have probably helped. I would have liked to talk to another guy who shared my experience. I wouldn't have felt comfortable attending a support group. I would only go to individual counseling if the counselor shared my experience. Couples counseling may have been helpful but we had so many appointments during that time, I think I would have felt like I was piling on.  I had to take off work constantly for various doctor's appointments. So, I was really stressed out about missing so much work already. –R.

41. The difficulties presented by the fertility issues have been challenging to the relationship as well. Although there are fertility issues associated for both, one major challenge was the perceived importance of the issue. Having a baby is of tremendous importance to me, but I have been switching professional careers, so my focus has been split. And to be honest, at times, I did not give fertility enough priority. Understandably, this was the only issue for my wife. I would have liked for counseling to have provided a vehicle for understanding of these issues from each other’s perspective. Counseling that was familiar and prepared to address these issues would have been very helpful. Additionally, counseling and medical support that could normalize our situation would have also been very helpful because far too often we, and especially my wife, have felt alone in this process. –M.

42. Mind-Body Modalities • Mind-Body Medicine-Any treatment in which the mind is mobilized to treat a physical disorder (Domar, 2002) • Mind-Body Techniques: • Yoga • Breathing • Relaxation • Guided imagery, Self-hypnosis, Visualization • Emotion Freedom Technique • Massage, Therapeutic touch, Reiki • Exercise • Acupunture • Affirmations • Spirituality • Domar, A. (). Self-Nurture

43. Mind-Body Therapy Study, Florida • 10 weeks support group • Meditation, mindfulness, yoga, self-nurture, self-esteem, depression and/or anxiety, coping • Decreased physical and psychological symptoms • 98% improved symptoms • 50% of the people got pregnant within 1 year (Lefebvre, 2009)

44. Money • $$$ involved in treatments • IUI ranges $300 to $700 • IVF ranges $10,000 to $25,000 • Egg Donor $20,000 to $40,000 • Sperm Donor $200 to $600 • Surrogate Mother $60,000-$100,000 • Adoption $25,000-$60,000 • Pregnancy tests and ovulation predictors $10-$250 • Fertility tests $100-$1000 • Hysterosalpingogram HSG $800-$1000 • Laparoscopy surgery $2000-$10,000

45. Costly drugs • Clomiphene Citrate $25-$180 • Femara $25-$50 • Alternative treatments • Acupunture & herbals $75-$150 • Massage $65-$125 • Yoga $25-$50 • Counseling $75-$150

46. Adoption • Grieving the infertility and loss of conceiving a biological child prior to adoption • Explore different types of adoption and resources (domestic, international, infant adoption, adoption from foster care) • Educating couple about the adoption process: • Budget • Right adoption agency • Same race vs. transracial adoption • International adoption • Adopting a special needs child • Adopting from foster care or older child • Closed or semi-open adoptions • Adoption laws

47. If you want to be a parent, then one day you will be a parent but you need to be open to the way in which that will happen. When you are finally holding that child on your arms, it will be your child and you will be its mother no matter how the two of you are brought to each other. --Author unknown

48. Religion and Fertility • Assess client’s religious values • Religions and reproductive technologies • Catholic Church view: • Any technology used to conceive a baby outside intercourse is unacceptable to the Roman Catholic Church (Conceive, April 2009) • Presbyterian, Baptist, Methodist churches are okay with reproductive treatments to conceive a child • Presbyterian Church- Eggs seen as life • Resolve conflict between wanting a child and what religion may see as the appropriate way to conceive a child

49. FAITH Is the substance of things hoped for; the conviction of things not yet seen. --Hebrews 11:1

50. Questions ?