Infertility Smart Marriages

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					    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
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
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)
FERTILITY VOCABULARY
 ART              ICSI
 CASA             IVF

 CCCT             IUI

 EEJ              LH

 FSH              MESA

 GIFT             OHSS

 GnRH             PGD

 HCG              TESE

 HSG              ZIFT
DIAGNOSIS OF INFERTILITY
 Her
 Him

 Both

 HER

 Stigma

 Treatment options:
     Fertility
     Adoption
     Childfree
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
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
POSSIBLE SIDE EFFECT AND PSYCHOLOGICAL
EFFECT OF MEDICATIONS
Drug                     Use                                     Possible Side Effects
Clomiphene Citrate (=    Induces ovulation; improves luteal      May cause menopausal symptoms
                         phase deficiency; increased follicle    (e.g. hot flashes), mood changes
synthetic estrogen)      number in women                         (e.g. irritability, emotionality and
                                                                 increased symptoms of
                                                                 premenstrual syndrome).

Bromocriptine            Treats hyperprolactinemia               Antidepressant effect;
                         (elevated levels of prolactin), which   Hypomania;
                         is associated with ovulatory            Psychosis
                         dysfunction

Progesterone             Endometrial support                     Depression;
                                                                 Decreased libido;
                                                                 Irritability

Estradiol                Endometrial support                     Antidepressant effect;
                                                                 Introduction of rapid cycling


Gn-RH agonists (e.g.     Downregulate the pituitary to           Hot flashes; Headaches;
                         prevent premature ovulation during      Mood changes (depressive
Lupron and Decapeptil)   IVF cycles or used over an              symptoms especially when used
                         extended period of time (6 months)      long-term); Cognitive changes
                         to treat endometriosis                  (poor memory and concentration)
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?
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.
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
COUNSELING CAN HELP
 Infertility distress
 Miscarriage

 Pregnancy loss

 Egg/Sperm donation

 Surrogacy reproduction

 Adoption

 Stress Management

 Depression/Anxiety/Irritability

 Relationship conflict

 Post-partum depression
FEELINGS
 Inadequacy
 Anger

 Sadness

 Fear

 Anxiety

 Frustration

 Guilt

 Blame

 Despair

 Worthfulness
EMOTIONAL ASSESSMENT
 Anxiety
 Depression

 Distorted cognitions

 Shame

 Inadequacy

 Self esteem

 Blame

 Anger

 Jealousy
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
PHYSICAL SYMPTOMS
 ↑ Metabolism
 ↑ Heart rate

 ↑ Blood pressure

 ↑ Breathing rate

 ↑ Muscle tension

 ↓ Sleep

 ↑ Anxiety

 ↑ Depression
FEELING ALONE
    Tapping into one’s support systems



                  Friends            Clinic




         Family             Couple            ?



                                         Counselor/
                  Church                 Acupunturist/
                                         Nutritionist
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
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
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…”
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
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
PHASES OF INFERTILITY MODEL
I.     Dawning
         -first awareness of fertility issues
II.    Mobilization
         -beginning of diagnostic testing
III.   Immersion
         -ongoing testing and treatment
IV.    Resolution
         -ending medical treatment; acknowledgement and
         mourning of loss; refocusing on other possibilities
V.     Legacy
       -aftermath after infertility: marital, sexual,
       parenting problems after infertility
(Diamond, Meyers, Kezur & Scharf, 1999. Couple Therapy for
    Infertility.)
DEVERAUX AND HAMMERMAN’S
SUGGESTED COUNSELING MODEL
1.    Integration of infertility into the individual’s definition
      of self
2.    Acknowledging that the infertile individual is the expert
3.    Promoting acceptance of infertility
4.    Acknowledging the losses of infertility
5.    Facilitating grief and bereavement
6.    Assigning homework
7.    Fostering and encouraging individual empowerment
8.    Facilitating transcendence of the infertility experience
      through acceptance (rather than resolution)
9.    Promoting responsibility (versus control)
10.   Encouraging self-advocacy
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)
7 TOOLS TO SURVIVE INFERTILITY
1.   Take care of your body
2.   Make conscious choices
        Managing emotions
1.   Set healthy boundaries
       Who is in and who is out?
2.   Tell the truth
       Sharing the story
3.   Take quiet space
        Centering Self
1.   Give yourself permission to grieve
       Rituals
2.   See the big picture
       Redefine life
(Lombardo & Parker, 2007. I am more than my infertility.)
CRISIS WITHIN A CRISIS
                                  Pregnancy
                                  loss

                    Monthly
                    loss

                                          Txts.
     relationship


                    Infertility
                                              Family/
                                              Couple



                                        $$
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
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)
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
A COUNSELING MODEL-BODY/MIND/SOUL


                         Body/Mind         Grief
                                      Emotional
            Medical

                         Couple

                       relationship     Psychological
     Physical



                      Sexual
                                       Spiritual
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
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
GROUP THERAPY
 Grief

 Loss of Control
 Gender Differences

 Interpersonal Relationships

 Dealing with the Treatment Team

 Stress and Coping

 Decision Making

 Pregnant Group Members
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
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
A STRENGTH MODEL
 Client’s strengths
 Couple’s strengths

 Couple’s resources

 Relational
     Family
     Friends
     Spirituality

 HOPE
 ENCOURAGEMENT

 BELIEF
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.
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.
   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.
   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.
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
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)
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
   Costly drugs
     Clomiphene Citrate $25-$180
     Femara $25-$50

   Alternative treatments
     Acupunture & herbals $75-$150
     Massage $65-$125
     Yoga $25-$50
     Counseling $75-$150
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
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
RELIGION AND FERTILITY
 Assess client’s religious values
 Religions and reproductive technologies

 Catholic Church view:
     Anytechnology 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
FAITH




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




            ?
RESOURCES
   Fertility LifeLines
       www.FertilityLifeLines.com
   Conceive
       www.conceiveonline.com
   Resolve
       www.resolve.org
 The American Fertility Association
 Fertility Hope
       www.fertilityhope.org
   American Society for Reproductive Medicine
       www.asrm.org
ADOPTION RESOURCES
 www.adoptivefamilies.com
 http://www.tapestrybooks.com/

 http://lifeforkids.com/adoption_resources.html

 http://www.dcf.state.fl.us/adoption/faq.shtml

 http://www.fsfapa.org/Home.asp

 http://www.adoptflorida.com/information-
  center.htm
 http://www.beyondconsequences.com/index.html

 http://www.attach.org/2008conf.html

 http://adoption.state.gov/

 http://www.internationaladoption.org/

 http://www.adoption.com/
REFERENCES
   Covington, S. and Burns, L.H. (2006). Infertility Counseling: A Comprehensive Handbook
    for Clinicians, 2nd ed. Cambridge, NY: Cambridge University Press.
   Chavarro, J.E. & Willet, W.C. (2008). The fertility diet: Groundbreaking research reveals
    natural ways to boost ovulation and improve your chances of getting pregnant. New York:
    McGraw Hill.
   Daniluk, M.F. & Daniluk, J.C. (2001). The infertility survival guide: Everything you need
    to know to cope with the challenges while maintaining your sanity, dignity and
    relationships. Oakland, CA. New Harbinger
     Publications.
   Diamond , R., Meyers, M., Kezur, D., & Scharf, C.N. (1999). Couple Therapy for Infertility.
    New York: Guildford Press.
   Devereux ,L.L. & Hammerman, A.J. (1998). Infertility and Identity: New Strategies for
    Treatment. San Francisco: Jossey- Bass Publishers.
   Domar, A. (2002). Conquering infertility: Dr. Alice Domar’s Mind/Body guide to
    enhancing fertility and coping with infertility. New York: Penguin Books.
   Glahn, S. (2004). The infertility companion: Hope and help for couples facing infertility.
    Grand Rapids, MI:
     Christian Medical Association Resources
   Gordon, J., Rydfors, Druzin, M., & Tadir, Y. (2007). Obstetrics, Gynecology and Infertility:
    Handbook for
     Clinicians, eth ed. Scrub Hill Press, Inc.
   Indichova, J. (2001). Inconceivable: A woman’s triumph over despair and statistics. New
    York: Broadway Books.
   Jarrett, J.C. (1998). The fertility guide: A couple’s handbook for informed, rational and effective
    fertility
     treatment. Santa Fe, NM: Health Press.
   Kohn, I. and Moffitt, P.L. (1992). A silent sorrow: Pregnancy loss. New York: Delacorte Press.
   Lauersen, N.H. &Bouchez, C. (2000). Getting pregnant: What you need to know right now. New
    York: Fireside.
   Leiblum, Sandra R. (1996). Infertility: Psychological Issues and Counseling Strategies.
   Lewis, R. (2004). The infertility cure. New York: Little Brown and Co.
   Lombardo, M. & Parker, L.J. (2007). I am more than my infertility: 7 proven tools for turning a
    life crisis into a personal breakthrough.
   Nadeau, J.C. & Nadeau, M. (2007). The empty picture frame: An inconceivable journey through
    infertility. New York: Outskirts Press.
   Peoples, D. & Ferguson, H.R. (1998). What to expect when you are experiencing infertility: How
    to cope
     with the emotional crisis and survive. New York: W.W. Norton & Company, Inc.
   Tomlins, J. (2003). The infertility handbook: A guide to making babies. Crows Nest, NSW: Allen
    & Unwin.
   Weschler, T. (2006). Taking charge of your fertility. New York: Harper Collins.
   Williams, C.D. (2006). The fastest way to get pregnant naturally. New York: Hyperion
   Winstein, M. (2003). Your fertility signals: Using them to achieve or avoid pregnancy naturally.
    St. Louis, MO: Smooth Stone Press.
   APA DVD: Counseling Clients Who Have Trouble Conceiving with Susan McDaniel, Ph.D.
    Source: www.apa.org
WEBSITES
 http://www.mayoclinic.com/health/infertility/DS0
  0310
 http://www.theafa.org/

 http://asrm.org/

 http://www.resolve.org/

 http://www.conceiveonline.com/

 http://www.fertilitylines.com/

				
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