Most men and women approach adulthood with the assumption that they can have their own children someday. However, of those who attempt to become biological parents approximately 10% to 15% experience problems with their fertility. While approximately 50% to 60% of all infertility problems can be successfully treated if a couple has access to expert medical care,1 the infertility experience may create a significant emotional burden on the couple and their relationship.1·2 When the choice of fertility is removed, the couple may experience a crisis that threatens all aspects of their emotional well-being.3
The available literature contributing to an understanding of the psychological and social impact of infertility is scarce when compared to the effort and understanding available on the organic aspects.2 Sound and controlled research is lacking regarding the emotional aspects of infertility.2 For those working with infertile couples, familiarity with the available literature is necessary if the health care personnel is to begin meeting the needs of this group of patients.
MEDICAL ASSESSMENT OF THE INFERTILE COUPLE
In the simplest terms, the event of conception implies that: 1) male and female gametogenesis is occurring; 2) the transport system for the male gametes (spermatozoa) through the male ejaculatory system to the site of fertilization in the fallopian tube is adequate; 3) the female gamete (oocyte) is able to move from the ovary to the site of fertilization; 4) the fertilized ovum can be transported to and implanted successfully in the endometrium.
Infertility or subfertility can be defined as the failure to successfully conceive after 12 consecutive months of unprotected intercourse. A thorough evaluation includes the determination that one or more of these physiological steps is altered significantly and the exact nature of the alteration.
Both partners should be seen together at the initial visit. This allows the physician to assess the physiological problems and emotional needs of the couple.
A woman who is menstruating regularly every 26 to 32 days with premenstrual breast tenderness and bloating is probably ovulating. If further confirmation is necessary more sophisticated tests may be undertaken such as a day 2 1 serum progesterone done monthly for three months or serial pelvic ultrasounds for ovarian follicular development.
Obstruction or scarring of the female reproductive tract may be suspected in the ovulatory woman with a past medical history of an abortion (spontaneous or therapeutic), pelvic inflammatory disease, a previous intrauterine contraceptive device, previous abdominal or pelvic surgery (including dilatation/curettage), or inflammatory bowel disease. In these women a thorough general and pelvic examination should be undertaken. A complete pelvic assessment should include cervical cultures for routine bacteriology, chlamydia trachomatis and Ureaplasma urealyticum. Both gonorrhea and the mycoplasma infections have been suggested as causative agents of cervical, endometrial and tubal inflammation and scarring.4
Bacteria have been shown to be adsorbed onto sperm.5 Bacteria of urethral, vaginal or cervical origin may be spread during normal sperm transport through the female reproductive tract and lead to inflammation and scarring.
If a tuboperitoneal cause is suspected then laparoscopy combined with hysteroscopy are the most accurate methods available for assessing the reproductive tract.
No infertility assessment is complete without a thorough history and physical examination of the male partner at the initial visit, and a careful assessment of two and perhaps three semen samples. If a male cause is identified or suspected, further investigation of the woman should be delayed until a course of treatment or where appropriate donor insemination has been attempted. Some patients will choose to adopt at this stage and they should be supported in this decision. Following these investigations, it will be possible to determine if a clear cause of infertility exists (azoospermia, anovulation or tubal occlusion) or if less clear causes are present (oligoovulation, oligoasthenozoospermia, non-occlusive tubal disease or endometriosis). Some couples will have no explainable causes for their infertility.
TREATMENT OF THE INFERTILE COUPLE
The treatment of infertility is as varied as the cause. Female gamete production failure (anovulation) due to hypothalamic suppression or pituitary failure may be treated medically with bromocryptine, clomiphene citrate, exogenous gonadotropins, or episodic GnRH, depending on the underlying problem. Acquired tubal disease is surgically treatable but the results are most discouraging. Microsurgical or less rigorous techniques may be used to perform salpingostomy or salpingoneostomy for terminal tubal occlusion or salpingolysis in non-occlusive disease. The term pregnancy rate in occlusive disease is approximately 30% and varies in non-occlusive disease depending on the degree of scarring.6 Moderate endometriosis may be treated medically with danazol and/or conservative surgery. It is not clearly understood how minimal endometriosis influences fertility.
Unexplained infertility is said to exist when after a complete investigation no apparent cause has been detected. With no further treatment, 64% of those with primary and 79% of those with secondary infertility will become pregnant during a nineyear span from the onset of involuntary infertility.7 For these patients our knowledge is lacking and our best intentions and efforts to help the infertile couple may be based on uncertain scientific foundations.
New therapies often attract wide interest, especially from the infertile. The episodic (pulsatile) self-administration of synthetic GnRH has replaced risky exogenous gonadotropin regimens for ovulation induction. In vitro fertilization and embryo transfer offer alternatives to both the woman with inoperable tubal disease or absent fallopian tubes and the man with significant oligozoospermia. The high technology "magic" associated with the use of the laser has yet to be shown to be superior and safer than cautery with microelectrodes. In new areas of treatment scientific and clinical evidence of efficacy must be demonstrated beyond doubt before they are offered to the infertile couple.
INFLUENCE OF PSYCHOLOGICAL FACTORS ON INFERTILITY
Investigations to date have provided little evidence to substantiate the claims that psychological and emotional difficulties are a cause of, rather than a result of, infertility.2 As such, there is a need for well-controlled studies with significantly large numbers of patients at various stages of fertility assessment if any relationship between psychopathology and infertility is to be identified and dealt with by helping professionals.
Couples with infertility in which no cause has been found, constitute approximately 20% of all couples seen at the University of Calgary. It is one of the most frustrating conditions for both patient and physician. It is in these situations that possible psychological factors are usually implicated. Pregnancy following adoption of a child is often cited by patients and physicians to support the role of stress or psychological factors in otherwise unexplained infertility. There is no scientific evidence that such a causal connection exists.8 Disturbances in neuroendocrine balance as a result of altered emotional states have been suggested as a source of infertility. Several psychoactive drugs and significant weight loss have been shown to alter the normal activities of the hypothalamic-pituitary-ovarian (or -testicular) axis. But the extent to which this relationship contributes to infertility in cases where there are no measurable physiological abnormalities has not been determined. Most studies of psychological contributing factors have focused on an examination of the abnormal personality characteristics of the female member of the couple, despite the fact that 35% to 40% of all infertility can be attributable to the male. The studies are not prospective and provide no conclusive evidence that specific psychological factors alter female fertility.9
Psychosexual maladjustments in the male in the form of impotence, incomplete erection, ejaculatory incompetence and oligospermia have been cited as psychologically linked causal factors of male infertility. These may represent up to 10% of the causes of couple infertility that are revealed following a detailed assessment of the couple.2 They may be expressed also as impotence or the avoidance of intercourse during the woman's fertile period.10 A good history from the couple with direct questioning relating to their sexual relationship will help to reveal an underlying pattern of sexual dysfunction, which may be contributing to their reproductive difficulties. It is important neither to blame psychological disturbances in the absence of a thorough organic assessment nor to refer to possible emotional disturbances in the absence of organic causes at the conclusion of a complete assessment.
EMOTIONAL IMPACT OF INFERTILITY
While a great deal of research has been undertaken into the organic causes of infertility, the emotional impact of infertility has largely been ignored and the studies which have been conducted have been largely uncontrolled and mainly descriptive.1 ' Yet infertility may exact a heavy toll on the quality of life and the emotional well-being of those affected.12 The problem threatens the attainment of a major life goal and may overtax a couple's existing physical, financial and emotional resources.2 It may give rise to a period of emotional disequilibrium and individual vulnerability, and the couple may find themselves lacking those resources needed to provide support for themselves and their partners. The existence of what appears to be an insoluble immediate problem may result in a full-blown crisis situation for the couple.
An important aspect of the "crisis of infertility" may be the overwhelming sense of helplessness and desperation experienced by the couple with the loss of a sense of personal control over such an important life event. There may be a re-awakening of unsolved past problems which compound the depth of the crisis and the degree of difficulty in coping with infertility. The outward signs of this crisis may involve increased anxiety and tension, feelings of frustration, guilt and isolation, and a disruption of the individual's ability to function effectively.3
The individual's and the couple's reaction to infertility depends on the way in which they characteristically deal with loss and disappointment and on the couple's available support system.13 The infertile individual's self-image, self-esteem and sexual identity may come under extreme challenges at this time.1 There may be a resulting tendency in one or both partners toward self-blame, with intense guilt and shame over past perceived transgressions (abortion, extra-marital affairs, venereal disease, etc.). Serious conflicts, anxiety and emotional turmoil may result in the development of a schism between the infertile individual's external and internal self-image.12 Hie woman may feel incomplete, without a sexual identity and/or failure as a woman, leading to a sense of hopelessness, despair, and sometimes intense depression.14 For the man, there may also be a resultant emotional crisis in which his sexual self-esteem, masculinity and virility may be questioned.12 Feelings of depression, isolation, anger, shame, inadequacy and personal failure often accompany the occurrence of infertility, in response to the loss and sense of damage that most couples experience.12'15 Unfortunately, as a defense against their personal inability to produce a child, many couples may cut themselves off from necessary outside support at the time when such support and understanding is most critical.
The investigation and treatment of infertility requires intrusive medical procedures which may be seen as humiliating, embarrassing, painful, threatening and sometimes expensive.2 The intrusive nature of medical assessment and/or treatment may compound the sense of helplessness and loss of personal control experienced by the couple and may add to the couple's already intense level of stress.12
Overextended assessment and treatment may cause the couple to postpone confrontation with their potential childlessness, and may lead them to avoid making important life decisions. While the discovery of a cause of infertility may be devastating, it allows the couple to begin to resolve their feelings and to come to terms with their infertility. It is the responsibility of the physician to design a series of investigations that will rapidly, inexpensively, accurately and in the least invasive way possible, uncover the physical causes of the couple's infertility. Essentially, this means that the medical investigation should determine whether there is regular and adequate ovulation, female reproductive tract integrity and normal male gametogenesis and male sperm transport.6
Because the nature, assessment and treatment of infertility so closely involves the couple's sexual relationship, it is not surprising that this is one of the areas most commonly affected by the problem of infertility. Many couples are asked to perform sexually on specific occasions so that a third party can medically inspect and evaluate the results of their efforts. In the absence of well-controlled clinical studies and in the light of newer tests, one must question the value of some of the methods of fertility assessment and treatment when measured against patient discomfort. In view of the significant emotional impact of some investigations and treatments, scientific validity must be carefully considered and questionable practices should be abandoned. Couples must be counseled during treatment to understand the normal sexual reactions to infertility and must be given permission to return to more spontaneous and intimate lovemaking.
To understand the infertile couple, one must appreciate the feeling of loss that is central to their experience: the loss of a life goal; the loss of a pregnancy experience; the loss of fertility and the loss of the potential to bear children.12 These losses are real for the infertile couple and as such, they must be provided with support and assistance in grieving for their losses.
SUPPORT FOR THE INFERTILE COUPLE
Assistance at all stages of the infertility experience may help the couple to resolve their crisis. Until recently, this support has been limited. Selfhelp books, articles, television programs and support groups have begun to address the needs of the infertile couple, helping to reduce feelings of isolation and to deal with grief. Health professionals are also becoming more aware of the needs of infertile couples.
Various approaches have been used to counsel infertile couples.13,1619 Services which complement the efforts of the medical profession, and which emphasize management of the social and emotional components of infertility may facilitate the emotional healing and resolution process of affected couples.12 If appropriately and skillfully directed by a counseling professional, the increased energy generated by a couple's emotional turmoil may be used to resolve the crisis and rebuild the couple's lives. While very little systematic research has been devoted to determining the specific psychological needs of the infertile, or the effectiveness of current assistance in alleviating the emotional difficulties experienced by them, the available research does support the need for an interdisciplinary approach to the management of infertile individuals. Both medical and psychological assistance may need to be provided within a supportive, non-judgmental, empathetic and caring milieu, which helps the man and woman to come to terms with their infertility.12 The professional should aid the couple in reaching eventual acceptance of their infertility and in examining available alternatives and life decisions.15 If a pregnancy does occur, new strains may be placed on the couple and on their relationship at a time of great emotional vulnerability and paradoxically may place greater stresses on the couple, that may require even more intensive support.14
Assistance may take the form of individual, group, or couple counseling, with treatment ranging from short-term (five sessions) to long-term more than five sessions) intervention. Counseling an infertile couple during and after medical evaluation and treatment may help to alleviate emotional distress and to minimize the psychological trauma of unsuccessful medical treatment.20 Initially, the counselor can help the couple to establish a more realistic time framework for investigation, treatment and outcome, and to create a greater awareness of both the extent and effect of the procedures involved. During investigation and treatment the counselor should acknowledge the stress and anxiety experienced by the individuals and provide information and emotional support during times of crisis.20 Counseling and support may also be necessary at the termination of medical treatment, to assist a couple to come to terms with their infertility and to aid in their decision-making and life planning. This may also be required if the outcome of treatment is positive. Pregnancy and the birth of a "miracle" baby may overtax the couple's already diminished emotional resources as they often feel they have no right to complain about normal difficulties after finally achieving their long sought-after goal.12 The couple may need help to realize that while pregnancy is the end of their infertility, it is not the end of their need to adjust to their changing life circumstances, and that further efforts may be required to integrate and to accept a child into a previously barren marriage.
In conclusion, the available and limited research appears to support the value and the need for a collaborative effort in the management of the medical, social and emotional aspects of infertility if individuals are to successfully resolve their infertility crisis and if their personal growth is to be enhanced and their relationship strengthened as a result of this experience. Such efforts may be necessary at one or at all stages of the infertility experience. Further research on the psychological impact of infertility and the most appropriate way of treating problems that arise from infertility are necessary. The increasing complexity of infertility assessment techniques and treatments makes this need urgent.
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