Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority

One in six couples will experience fertility problems at some time in their lives, and only one-half will succeed in becoming pregnant (Seibel, 1997). Infertility rates are projected to increase during the next 20 years as the age distribution of the U.S. population reflects the passing of the baby boom generation through middle age (Chandra & Stephen, 1998). Also, a cohort of couples may have delayed childbearing because of financial and career considerations. If projections prove accurate, many will face fertility problems and complex decisions regarding the use of reproductive technologies, often associated with considerable physical, emotional, and financial cost (Greenfeld, 1997).

Infertility has been associated with substantial levels of stress, generally attributed to its indeterminate and often prolonged time frame and the uncertainty and ambiguity of the diagnosis and treatment process. Infertility is variable in time, and with treatment, can span more than a decade, the average being five years (Domar & Seibel, 1997). For example, by the time a couple initiates an in vitro procedure, they may have been infertile for up to six years and in treatment for four (Boivin, 2003). Infertility treatment has been found to have consequences for subsequent health functioning, quality of life, and psychological well-being during presumed childbearing years (Shapiro, 1982). People may feel depleted, isolated, and vulnerable to the experience of prolonged stress (Valentine, 1986). Research in other populations suggests that psychosocial factors may play a role in mediating or moderating stress appraisal and its consequences.

Stress Associated with Infertility Treatment
The impact of stress on health and the disease process has been established for some time (House, 1987). Although substantial stress has been associated with infertility, systematic research examining the way that stress may affect the reproductive system has not received the level of attention focused on other physiological processes (Kelly, Hertzman, & Daniels, 1997). Stress associated with infertility is increasingly considered both a determinant and a consequence of reduced fertility (Klonoff-Cohen, Chu, Natarajan, & Sieber, 2001). Although no clear pattern has emerged, studies investigating changes in psychoendocrine stress response during in vitro fertilization have found physiological alterations associated with stress (Facchinetti, Matteo, Artini, Volpe, & Genazzani, 1997). 

Factors Associated with Variation in Infertility-Related Stress
Psychosocial factors associated with stress in other populations include social support and self-esteem (Cohen, Kessler, & Gordon, 1995; Thoits, 1995). However, their influence on infertility-related stress is relatively unknown (Stanton & Dunkel-Schetter, 1991). As suggested by Daniels (1993), stress has generally been considered a psychological rather than a psychosocial phenomenon, and attention to social factors that might affect a couple has been neglected. Help has therefore been focused on the couple experiencing the fertility problem, to the exclusion of their social networks and treatment teams (Blyth, 1999). The role of perceived support in stress reduction in infertile couples has been insufficiently addressed, particularly over time (Gibson & Myers, 2002). It may be that the secrecy, withdrawal, and social isolation, often part of the infertility experience, affect perceived and received support (Sandelowski, Holditch-Davis, & Harris, 1990). In addition, support may vary over time (Jirka, Schuett, & Foxall, 1996).

There are gender differences in obtaining support (Daniluk, 1997; Kowalcek, Wihstutz, Buhrow, & Diedrich, 2001). For example, Band and colleagues (1998) found that failure to seek support was among the most significant predictors of distress among infertile men. Stress levels in general are higher for women, as they tend to take greater responsibility for the problem even when the cause is unknown (Greil, 1991). Because more is known about the female reproductive system, women experience more treatment procedures; the complexity of juggling work, family, and treatment responsibilities may increase stress for women (Hurwitz, 1989).

Reduced self-esteem has been found to be both a consequence of infertility and a covariate in adjustment to it (Fleming & Burry, 1988). For example, Bernstein and colleagues (1988) and Greenfeld (1997) concluded that damage to self-esteem was a major component of the infertility experience. Perceived health has been shown to predict future health and mortality (Idler & Angel, 1990). It is possible that the chronic nature of infertility influences perceived health in the years following an infertility diagnosis, and conversely, that perceived health affects the overall stress of the experience. Stage of treatment may also affect perceived stress. Because the probability of treatment failure with repeated in vitro fertilization procedures is high, intervention at almost any time in the process may be useful (Bergart, 2000; Black, Walther, Chute, & Greenfeld, 1992).

Despite long-standing involvement of social workers in adoption and child welfare settings, emotional investment in biological children has infrequently been considered a factor in infertility-related stress (Henning & Strauss, 2002; Holbrook, 1990). It is possible that substantial investment in biological parenting may negatively affect self-esteem when conception does not occur, which may ultimately influence stress appraisal (Matthews & Matthews, 1986). Identification of factors found to be negatively associated with stress may ultimately help both the couples and the individuals who work with them.

Discussion
Psychosocial evaluations can be performed to determine a couple's ability to tolerate the effects of a potentially protracted treatment process and appropriate support recommended when indicated (Covington, 1988). Support from medical staff may be useful at the time of initial diagnosis and with extended treatment failure (Boivin, 2003). In consideration of the important role of the physician--patient relationship, patients and treatment teams should strive to maintain open rapport throughout the course of treatment. With their psychosocial perspective, social workers are in a position to facilitate an open communication process.

Interventions designed to help couples maintain emotional balance while pursuing infertility treatment may be beneficial. At the broader level, education by social workers of physicians and others to promote increased understanding of the infertility experience can be instrumental in facilitating sensitive medical and mental health practice and in contributing to thoughtful and ethical policies regarding the use of reproductive technology.
- Schneider, Myra G., Forthofer, Melinda S.; Associations of Psychosocial Factors with the Stress of Infertility Treatment; Health & Social Work; Aug 2005; Vol. 30; Issue 3.

Lifestyle and Fertility: the Influence of Stress and Quality of Life on Female Fertility

- Palomba, S., Daolio, J., Romeo, S., Battaglia, F. A., Marci, R., & La Sala, G. B. (2018). Lifestyle and fertility: the influence of stress and quality of life on female fertility. Reproductive biology and endocrinology : RB&E, 16(1), 113. doi:10.1186/s12958-018-0434-y

Personal Reflection Exercise #7
The preceding section contained information about stress and infertility treatment.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Casu, G., Zaia, V., Fernandes Martins, M. d. C., Parente Barbosa, C., & Gremigni, P. (2019). A dyadic mediation study on social support, coping, and stress among couples starting fertility treatment. Journal of Family Psychology, 33(3), 315–326.

Galst, J. P. (2018). The elusive connection between stress and infertility: A research review with clinical implications. Journal of Psychotherapy Integration, 28(1), 1–13.

Kang, X., Fang, M., Li, G., Huang, Y., Li, Y., Li, P., & Wang, H. (2021). Family resilience is a protective buffer in the relationship between infertility-related stress and psychological distress among females preparing for their first in vitro fertilization–embryo transfer. Psychology, Health & Medicine.

Online Continuing Education QUESTION 21
What is the effect of stress on infertility? Record the letter of the correct answer the CEU Test.