Introduction

Many young adults expect that they will one day become parents; it is a social expectation in many cultures. However, one in six couples will have difficulty in achieving this goal (Burnett & Panchal, 2008; Dayus, Rajacich, & Carty, 2001).

According to the American Society for Reproductive Medicine (ASRM), infertility is a disease of the reproductive system that impairs the body’s ability to conceive a child; infertility is typically diagnosed when couples have been unsuccessful in becoming pregnant after 1 year of unprotected intercourse. The prevalence of infertility varies throughout the world from less than 5% to over 30% in certain regions, while its incidence is increasing in general (WHO, 2003).

The high incidence of this condition has increased the development and use of innovative technologies in IVF, such as ICSI, improved cryopreservation strategies and preimplantation genetic diagnosis/screening methods. However, the growing attention for the medical, biological and genetic aspects of the infertile patients has  not been followed by a parallel attention to  the emotional problems that affect those couples. The risk is to neglect the difficulties of psychological nature that often characterize childless couples. In this area, the role of psychology is not to determinate the factors that may cause infertility, such as some psychological theories sustained (Leiblum SR et al.1988), but to locate and operate on the psychological problems that come from the difficulty of conceiving and from the emotive stress often associated with ART. Indeed, the view on psychosocial factors in infertility has changed. At first, the "psychogenic infertility model" (infertility caused by psychological factors) dominated the research in this field. Nowadays, there are no studies providing evidences of distress as the cause of infertility, rather it is the psychological effects of infertility and of the reproductive treatment that are the focus of research ("psychological consequences model").

The double infertility psychological impact on couples: what does it mean “I’m  infertile”

It is well known that the experience of infertility can be devastating for the couple desiring a child. For women, pregnancy and motherhood are developmental milestones that are highly emphasized by our culture and the society and family pressure is often very hard to deal with. The experience of being unable to achieve a pregnancy may be described as a source of anxiety, fear, sadness, frustration and anger for couples who desire children ( Serafini P et al. 2000; Farinati DM et al. 2006; Cousineau TM et al. 2007; Cwikel J et al. 2004 ), causing feelings of worthlessness and important distress symptoms ( Farinati DM et al. 2006; Wichman CL et al. 2011; Moreira SNT et al. 2006). Infertility may be felt as a stigmatizing condition (Trindade ZA et al. 2002), being described by those who experience it as the most distressful event in their lives (Freeman EW et al. 1985).

Although both men and women are emotionally impacted by their infertility, they typically experience and cope with this loss in different ways. Whereas women are distressed by the infertility itself, men are more likely to be impacted by the relationship fallout and the sadness of their wives (Shapiro, 2009).

In women, the mood response to the diagnosis of infertility has been linked to models of bereavement or grief (Christie, 1997;), depression (Syme, 1997), and anxiety or stress (Mori, 1997). Infertile women are significantly more depressed than their fertile counterparts, with depression and anxiety levels equivalent to women with heart disease, cancer, or HIV-positive status.

Questions such as the lack of spontaneity in sexual life, lack of control of one’s own life and social pressure to have children are some of the difficulties reported by infertile women( Benyamini Y et al. 2005), who may feel infertility as an insult to their self-esteem and femininity (Cwikel J et al. 2004).

The words from a woman experiencing infertility seem to summarize all of these findings:

I cannot conceive or bear children; I am infertile.

My infertility is a blow to my self-esteem, a

violation of my privacy; an assault on my sexuality,

a final exam on my ability to cope, an affront to

my sense of justice, a painful reminder that nothing

can be taken for granted. My infertility is a break

in the continuity of life. It is, above all, a

wound—to my body, to my psyche, to my soul.

The pain is intense” (Jorgensen, 1982)

While women may feel more able to express feelings and display sadness and anger directly, men may struggle with their own feelings and feel quite helpless in trying to comfort their spouse and be frustrated at not being able to solve their infertility (Monach, 1993; Zolbrod, 1993). For men, problems in fertility can be experienced as a “failure as a man” and therefore an assault on one’s masculinity. Men’s masculinity may be challenged and cause feelings of loss of power and potency, which may cause either occasional episodes of impotence or, conversely, promiscuity (Syme, 1997).

For couples, isolation is another aspect of coping with infertility (Salzer, 1991). Contact with the world, where signs of fertility are everywhere, is painful. Difficulties of attending social functions such as baby showers or family birthdays for children may prove to be impossible to bear, and even everyday activities of daily living such as seeing babies at the local market or office picnic can precipitate a strong emotional response. The social stigma of childlessness results in feelings of imperfections and a “spoiled identity” (Maill, 1986). There is a societal assumption that all couples have children. The topic is common in initial conversation when meeting someone for the first time. Some of the effects of dealing with the stigmatization of infertility include attempts toconceal the situation by denying the want of children, developing other interests, and avoiding social situations.

Stress on the couple is in part due to the insidious issue of guilt and blame (Menning, 1980; Zolbrod, 1993). Couples begin to experience tension and distance in their relationship. In two-thirds of the cases of infertility the problem will reside in one partner or the other; thus, guilt, blame, and shame enter in, particularly if either partner has a history of promiscuity, abortion, venereal disease, or drug or alcohol abuse. The partner who “owns” the causality may fear rejection by the fertile spouse. This is, of course, intensified if the specific answer for the infertility is unknown. Even if a medical condition is discovered the couple will feel punished. Couples have to cope with sexual problems that may arise after a prolonged period of unsuccessful attempts at pregnancy. Sex performed on demand is very different from recreational sex. Moreover, sexual urgency around ovulation may also interfere with the wife’s attainment of orgasm.

The psychological impact of starting an infertility treatment

Adding to the difficulties that come from the clinical condition of infertility are problems about the entrance of the couple in a specialized center for the assisted fertilization, in which the couple will have to satisfy the diagnosis program and treatment that often mean an ulterior source of stress.

Syme (1997) noted that in her clinical practice couples went through various phases when involved in infertility treatments. The first was Numbness, when the person described feeling “zombie like,” a reaction that was validated by Jones (1995). During this time of dissociation the dominant thought is that it cannot be true, and actual physical signs such as loss of appetite, difficulty concentrating, and problems with memory may occur. The second phase is that of Yearning, a phase that is accompanied by feelings that they are alone in their infertility. During Yearning it is particularly painful to see babies, so the couple will avoid social situations where children are present. Also, feelings of jealousy and anger are common during this phase. Anger is directed at both the self and others. It may be difficult not to be angry if the cause of the infertility rests with the other partner. This anger may be accompanied by feelings of regret about marrying his or her spouse. The third phase is that of Disorganization and Despair, the longest phase, lasting a minimum of six months. Anger and guilt from the prior phase continue and outbursts of rage will increase. There is concern about being out of control, as the person experiences nightmares, and the fear of being alone as his or her social activities continue to be limited in order to avoid the sight of babies and pregnant women. This phase may be accompanied by feelings of the helplessness and hopelessness most often associated with depression. The final phase of Reorganization is hallmarked by acceptance and reordering of one’s life. It can take couples anywhere from 2–5 years (Syme, 1997) to reach such a state of equilibrium.

Evidences of a couple’s emotional distress can be found looking at the high discontinuation rate of infertile couples before achieving a pregnancy. Brandes and colleagues (2009) found that about half of the infertile couples discontinued fertility care before any treatment was started and nearly two-thirds discontinued before IVF or ICSI was started. Overall, the main reasons for withdrawal from fertility treatment are emotional distress and poor prognosis. So awareness of the motives for discontinuation could optimize fertility care and make it more patients centered, for instance by improving psychological care, or focusing on prevention of emotional distress.

Psychological interventions for infertile couples

Over the last few years, psychological research has demonstrated that, contrary to previous assumption, childless couples cannot be assigned to any psychopathologically defined class (Hammer Burns & Covington, 1999). However the attention to the emotional distress as a consequence of infertility and its treatment has led worldwide to the recommendation to provide psychosocial interventions for infertile couples. Indeed about 15% to 20% of all couples experience reproductive medicine as so stressful that they require psychological counselling (Boivin & Kentenich 2002).

Various types of psychological interventions already exist for infertile patients. Individually, these interventions focus on specific therapeutic approaches.

They vary from the provision of information (Daniluk, 1988; Takefman, 1990) to emotion- and problem-focused interventions (McQueeney et al., 1977) or supportive group interventions (Ferber, 1995), to psychological and sexual counselling (Sarrel and DeCherney, 1985), couple therapy (Diamond et al.,1999; Stammer et al., 2002), cognitive–behavioural therapy (Tuschen-Caffier et al., 1999), and mind–body therapy (Domar et al., 1992b).

Generally, the psychological interventions for childless couples can be divided into two types, individual therapy or group therapy, and three basic categories can be selected from several studies: (1) counselling interventions; (2) focused educational interventions, and (3) comprehensive educational programmes ( J. Boivin 2003). The feature that distinguished educational programmes (focused or comprehensive) from counselling is the therapeutic objective. If the main aim of the intervention is to impart knowledge or provide skills training, then the intervention classes is educational. If, in contrast, the main aim of the intervention is emotional expression and support, and/or discussion of thoughts and feelings related to infertility (as cause or consequence), then the intervention classes is counselling. The difference between focused and comprehensive interventions is in the range of information or skills training provided to participants with focused interventions providing one main skill (e.g., coping or relaxation training) and comprehensive programmes providing a range (e.g., coping and relaxation training).

Another category is educational but it consists of comprehensive and structured educational psychosocial interventions. For example, the Behavioural Medicine Program for Infertility (BMPI, also known as the mind/body program) (Domar, Seibel, & Benson, 1990) is a 10-week group program that includes, for example, cognitive-restructuring, methods for emotional expression, relaxation training, nutrition and exercise.

It has been demonstrated that psychosocial interventions are more effective in reducing negative affect than in changing interpersonal functioning (e.g., marital and social functioning). Pregnancy rates are not affected by psychosocial interventions. Moreover, group interventions which emphasise education and skills training (e.g., relaxation training) are significantly more effective in producing positive change across a range of outcomes than counselling interventions which emphasise emotional expression and support and/or discussion about thoughts and feelings related to infertility. Men and women benefit equally from psychosocial interventions. (J.Bovin, 2003).

Conclusion

Several studies recommending psychosocial interventions for childless couples have been reported in the few last years. However, only a few papers met minimum requirements for good quality studies and they are not empirically supported (Boivin, 2003). One of the few attempts to integrate the different knowledge and scientific evidence on psychological intervention for infertile couples was made in 1991 by experts from seven countries. Discussions in this and subsequent meetings produced a document entitled "Guidelines for Counselling in Infertility" aiming to describe key issues for the counselling of individuals using assisted reproduction (J.Bovin et al., 2001). They are based on the current best practice and are a valid proposal for a counselling framework to improve the care of infertile patients.

However, the theoretical framework of the counselling models described in the literature to date varies, including psychodynamic psychotherapy, cognitive-behavioural techniques, solution-focused psychotherapy, crisis intervention and process-experiential grief counselling (Applegarth, 1999). This issue can lead counsellors to adopt a variety of perspectives to guide their work with infertile couples. Difficulties can arise when the counselling approach adopted by the counsellor is incompatible with the needs or personality of the patient. Indeed, it has never been demonstrated which is the best psychological intervention for infertile patients. Furthermore, this heterogeneity does not assure with certainty the use of a standard and shared approach. Thus, in the IVF field, a gold standard for childless couples' psychological intervention has not yet been identified. Therefore, a future objective might be to attempt to spot among the different existing approaches the one that is mostly efficient for the infertile couples undergoing IVF, strictly evaluating some outcomes that are determinant for the psychological wellness of the single persons (man or woman) and of the couples with the ultimate aim of  improving the quality of their life. Only in a second step, the role of psychology in IVF might be dedicated to the analysis of different psychological factors that may influence the pregnancy rate or that can beset the causes of the infertility.

What we really need at present in IVF is an integrated and pragmatic psychological approach that may efficiently act to reduce the embarrassment and enrich the life of the individual, by increasing his or her list of possibilities to a more complete personal and couple realization.

Bibliografia

Applegarth L: Individual counseling and psychotherpay. In Burns LH and Covington SN (ed): Infertility Counseling: A Handbook for Clinicians. New York: Parthenon     Press, 1999

Benyamini Y, Gozlan M, Kokia E. Variability in the difficulties experienced by women undergoing infertility treatments. Fertility and Sterility. 2005;83:275–283.

Boivin J.et al., Guidelines for counselling in infertility: outline version. Human Reproduction Vol.16, No.6 pp. 1301–1304, 2001

Boivin, J. (2003). A review of psychosocial interventions in infertility. Social Science and Medicine, 57, 2325_2341.

Bongartz, W., & Bongartz, B. (2000). Hypnosetherapie (2. Aufl.) [Hypnosis therapy (2nd ed.)]. Go¨ ttingen: Hogrefe.

Brandes M., J.O.M. van der Steen, S.B. Bokdam, C.J.C.M. Hamilton, J.P. de Bruin, W.L.D.M. Nelen, and J.A.M. Kremer. When and why do subfertile couples discontinue their fertility care? A longitudinal cohort study in a secondary care subfertility population Human Reproduction, Vol.24, No.12 pp. 3127–3135, 2009

Burnett, J. A., & Panchal, K. (2008). Incorporating ideological context in counseling couples experiencing infertility. Journal of Humanistic Counseling, Education and Development, 47, 187-199

Burns, L.H., & Covington, S.H. (2006). Infertility counseling. A comprehensive handbook for clinicians (2nd ed). Cambridge: Cambridge University Press. 

Chan, C.H.Y., Ng, E.H.Y., Chan, C.L.W., Ho, P.C., & Chan, T.H.Y. (2006). Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study. Fertility and Sterility, 85, 339_346.

Christie, G. (1997). Grief management in infertile couples. Journal of Assisted Reproduction and Genetics, 14, 189–191.

Cousineau TM, Domar AD. Psychological impact of infertility. Best Pract & Res Clin Obstet Gynaecology. 2007;21:293–308.

Cwikel J, Gidron Y, Sheiner E. Psychological interactions with infertility among women. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2004;117:126–131.

Daniluk JC (1988) Infertility: intrapersonal and interpersonal impact. Fertil Steril 49,982–990.

Dayus, D., Rajacich, D., & Carty, L. (2001). Promoting health among infertile couples through support groups. Guidance & Counseling, 16, 110-114.

Diamond R, Kezur D, Meyers M, Scharf CN and Weinschel M (1999) Couple therapy for infertility. Guilford Press, New York.

Domar, A.D., Clapp, D., Slawsby, E.A., Dusek, J., Kessel, B., & Freizinger, M. (2000). Impact of group psychological interventions on pregnancy rates in infertile women. Fertility and Sterility, 73, 805_811.

Domar, A. D., Seibel, M., & Benson, H. (1990). The mind/body program for infertility: A new behavioral treatment approach for women with infertility. Fertility and Sterility, 53, 246–249.

Domar A, Zuttermeister PC, Seibel M and Benson H (1992b) Psychological improvement in infertile women after behavioural treatment: a replication. Fertil Steril 58,144–147.

Eunpu, D.L. (1995). The impact of infertility and treatment guidelines for couples therapy. The American Journal of Family Therapy, 23, 115_128.

Farinati DM, Rigoni MS, M¨uller MC. Infertilidade: um novo campo da Psicologia da sa´ude. Estudos de Psicologia. 2006;23:433–439. 

Ferber GM (1995) An empathy-supporting approach to the treatment of infertile women. Psychotherapy 32,437–442.

Fiedler, P. (2005). Verhaltenstherapie in Gruppen (2. Aufl.) [Behavioural therapy in groups (2nd ed.)]. Weinheim: Beltz.

Flu¨ ckiger, C., Regli, D., & Grawe, K. (2005). Allgemeine Psychotherapie im Gruppensetting: Das Zusammenspiel von gruppen- und interventionsspezifischen Wirkfaktoren. [General psychotherapy in group setting: the interaction of group and intervention specific curative factors]. Gruppenpsychotherapie und Gruppendynamik, 41, 306_322.

Freeman EW, Boxer AS, Rickels K, Tureck R, Mastroianni L. Psychological evaluation and support in a program of in vitro fertilizationand embryo transfer. Fertility and Sterility. 1985;43:48–53.

Grawe, K. (1980). Einleitung [Introduction]. In K. Grawe (Ed.), Verhaltenstherapie in Gruppen (pp. 9_26). Mu¨ nchen: Urban & Schwarzenberg.

Hammer Burns & Covington, 1999. Infertility Counseling: A Comprehensive Handbook for Clinicians. Parthenon, London and New York.

Jacobson, E. (1938). Progressive relaxation: a physiological and clinical investigation of muscular states and their significance in psychology and medical practice. Chicago: The University of Chicago Press

Jones, C. (1995). The emotional side of infertility. Shef. eld, U.K.: Next Step Publishing.

Jorgensen, M. (1982). On healing. Newsletter, NYC Resolve, 3.

Lazarus, A.A. (1984). In the mind’s eye: the power of imagery for personal enrichment. New York: Guildford Press.

Leiblum SR. Infertility. In: Blechman EA, Brownell KD, eds. Handbook of Behavioral Medicine for Women. New York: Pergamon Press; 988:116–125.

Lentner, E., & Glazer, G. (1991). Infertile couples’ perceptions of infertility support-group participation. Health Care for Women  International, 12, 317_330.

Levitas, E., Parmet, A., Lunenfeld, E., Bentov, Y., Burstein, E., Friger, M., et al. (2006). Impact of hypnosis during embryo transfer on the outcome of in vitro fertilization_embryo transfer: a casecontrol study. Fertility and Sterility, 85, 1404_1408.

Maill, C. (1986). The stigma of involuntary childnessness. Social Problems, 33, 268–282.

McQueeney DA, Stanton AL and Sigmon S (1977) Efficacy of emotion focused and problem-focused group therapies for women with fertility problems. J Behav Med 20,313–331.

Menning, B. (1980). The emotional needs of infertile couples. Fertility and Sterility, 34, 313–319.

Monach, J. (1993). Childless, no choice. New York: Routeledge.

Moreira SNT, Melo COM, Tomaz G, Azevedo GD. Estresse e ansiedade em mulheres inf´erteis. Revista Brasileira de Ginecologia e Obstetr´ıcia. 2006;28:358–364.

Mori, E. (1997). Anxiety of infertile women undergoing ivf-et: Relation to the grief process. Gynecological and Obstetric Investigation, 44, 157–162.

Peterson, B.D., Pirritano, M., Christensen, U., & Schmidt, L. (2008). The impact of partner coping in couples experiencing infertility. Human Reproducation, 23, 1128_1137.

Reading, A. (1991). Psychological intervention and infertility. In A. Stanton & C. Dunkel-Schetter (Eds.), Infertility: perspectives from stress and coping research (pp. 183_196). New York: Plenum.

Salzer, L. (1991). Surviving infertility. New York: Harper Collins

Sarrel PM and DeCherney AH (1985) Psychotherapeutic intervention for treatment of couples with secondary infertility. Fertil Steril 43,897–900.

Schmidt, L., Tjørnhøj-Thomsen, T., Boivin, J., & Nyboe Andersen, A. (2005). Evaluation of a communication and stress management training programme for infertile couples. Patient Education and Counseling, 59, 252_262.

Serafini P, White J, Petracco A, et al. O bˆe a b´a da Infertilidade. 2^nd ed. S˜ao Paulo, SP: Serono; 2000.

Shapiro, C. H. (2009). Therapy with infertile heterosexual couples: It’s not about gender—Or is it? Clinical Social Work Journal, 37, 140-149. doi:10.1007/s10615-008-0149-1

Stammer H, Wischmann T and Verres R (2002) Counselling and couple therapy for infertile couples. Fam Process 41,111–122.

Syme, G. (1997). Facing the unacceptable: The emotional response to infertility. Human Reproduction, 12, 183–187.

Takefman J (1990) Behavioral treatment for infertile women. Fertil Steril 54,1183–1184.

Trindade ZA, Enumo SRF. Triste e incompleta: uma vis˜ao feminine da mulher inf´ertil. Psicologia USP. 2002;13:151–182.

Tuschen-Caffier B, Florin I, Krause W and Pook M (1999) Cognitive- behavioural therapy for idiopathic infertile couples. Psychother Psychosom 86,15–21.

Zolbrod, A. (1993). Men, women and infertility. New York: Lexington.

Wichman CL, Ehlers SL, Wichman SE, Weaver AL, Coddington C. Comparison of multiple psychological distress measures between men and women preparing for in vitro fertilization. Fertility and Sterility. 2011;95:717–721.

World Health Organization . (2003). Progress report in reproductive health research, No. 23.