Assessment of the
I nf erti e Cou pIe DAVID M. BERGER, MD
The psychological assessment of the infertile couple involves ruling out major
psychopathology, and attempting to uncover psychological factors that may be
contributing to the problem of infertility. These factors may be sought out by looking for
subtle and unconscious behavior which works against the wife's becoming pregnant, and
by uncovering fears relating to pregnancy, attempting to connect these fears to events in
the individual's past. Several issues relating to interview technique, particularly those that
run counter to traditional medical training, are discussed.
Dr. Berger is assistant professor of psychiatry at the University of Toronto and
psychiatric- consultant to the Reproductive Biology Unit at Mount Sinai Hospital in
PSYCHOSOMATIC studies of infertility fall into two and here there is the further hope that relief will have some
very general categories. Gross (one might call them beneficial, though unspecified, effect on the problem of
'macroscopic') studies attempt to correlate personality infertility.
traits or levels of mood with infertility. Studies of this kind The majority of patients do not present with gross
have shown, for example, that infertile couples exhibit psychopathology. The doctor then has to work on the
more signs of depression and greater problems on self- assumption that certain psychological factors have an
concept scales than controls.' influence on infertility. The usual assumption, made with-
The second category includes more subtle 'microscopic' out much empirical evidence, is that some complex of ideas
studies which attempt to correlate mood swings or mental is influencing one or both members of a couple to resist
complexes with changes in endocrine status, thereby getting pregnant, to resist having children, or to fear it.
defining the neurophysiological pathways involved. Patients Although this assumption may appear far-fetched, several
in psychoanalysis, for example, have been followed with examples can be given.
daily hormone assays in an attempt to correlate conflicts There are two ways of looking into this question, and
discussed with changes in estrogen levels.2 These studies they complement each other. One is by assessing present
confirm what clinicians have known for years - that shifts behavior; the other is by looking for events and influences
in psychological status coincide with physical changes. The in the patient's past to suggest that such fears may be
most likely pathways are the autonomic nervous system present.
and the adrenal-pituitary axis, both closely connected with
the limbic lobe. The most crucial questions, however, Unconscious Behavior
remain unanswered. It is unclear how these factors interact, A full assessment of the couple's sexual habits is
or whether one group of factors is primary in the etiology. essential, but more than this, one has to keep an ear open
It is against this background that the clinician is asked to for subtle and unconscious behavior that may be working
be of help to the infertile couple. For discussion purposes, against achieving conception. For example, one couple
clinical management of these psychological factors can be presented their sex life as ostensibly problem-free, with one
subdivided into: minor exception: there were brief periods during which
1. Assessment - i.e. attempting to uncover psychological they abstained from sexual intercourse. Further discussion
factors which may be contributing to the infertility revealed that the periods of abstinence coincided with the
problem. wife's peak of fertility. A second couple had misplaced the
2. Helping the couple deal with their emotional response household thermometer during their first attempt at keep-
to the fact of infertility. ing a temperature chart and had never remembered to
The first responsibility of the physician is to decide replace it. Small signs perhaps, but still suggestive of
whether there is gross and obvious psychopathology in unconscious factors at work.
either member of the couple. Is there evidence of psychosis The second approach is essentially one of data gathering.
or severe depression as well as obvious marital conflict? The The aim is to uncover fears and concerns relating to
physician is obligated to treat such a problem in any case, pregnancy and childrearing, as well as events and memories
CANADIAN FAMILY PHYSICIAN/OCTOBER, 1974 89
from the patient's past which might connect to these fears. sense of inadequacy. A husband's smothering concern for
The possibilities are too numerous to list. The doctor an anovulatory wife may be a vehicle for resentment or a
should determine what motives lie behind the wish to have reaction against the fear that he has somehow damaged her.
children. Is the much wanted child an attempted cure for a These are simple examples, but they serve to underline the
failing marriage, one that both partners are ambivalent physician's main task: to uncover false beliefs and un-
about maintaining? How do they feel about children? Is conscious conflicts that may plague the individual or
there anxiety about pregnancy or about their capabilities as undermine the couple's relationship. Relieved of the fic-
parents? Bringing these issues to awareness is a first step tion, husband and wife are then left with the far simpler
towards their resolution. When possible or appropriate, task of mourning the fact - in this instance, the fact of
pointing out the connection of present fears to past events infertility.
can help diminish the impact of the fear. For example, in
one instance, a wife's concerns about pregnancy related to Interview Technique
the fact that her father had died shortly after her mother In medical history-taking, the interviewer begins to have
had become pregnant. a sense of direction at an early stage. He senses the kind of
Because we are all supposed to be wholeheartedly in information he requires and what course he will follow; the
favor of having children - a social myth to which the interview is geared towards 'closure'. In psychiatry the
physician hopefully does not adhere - this material may be opposite is true, at least in one's attempt to understand the
repressed, or at best, talked about with great reluctance. A total personality. Owing to the multiplicity of events and
couple's deciding against having children, it should be influences in the makeup of a human being, the interviewer
noted, may be just as valid a resolution as a decision in the cannot decide early on what events or issues will ultimately
opposite direction. One of the dangers of a reproductive turn out to be crucial. In the case of infertility, for
biology unit is that, in its manner of functioning, it may example, fear of pregnancy or babies, issues around
place an implicit expectation on the client: to become sexuality, and conflicts relating to masculinity vs. feminin-
pregnant. To measure success in terms of number of ity, are only a few of the many areas that may turn out to
pregnancies is onesided. be significant. The interview has to be geared towards
expansion, not closure. The type of question one chooses
Helping the Infertile Couple would be a simple illustration of this. Questions requiring
The second broad area in clinical management is that of yes/no answers are geared towards closure. "Are you
helping the couple deal with the fact of infertility. To some depressed?" is a medical question, whereas "How do you
extent, this entails an about-face. In assessing the infertile feel?" is a better choice from a psychological standpoint. It
couple, one is looking for psychological factors that might allows the patient more room to respond.
be influencing the couple's ability to become pregnant. In In medicine it is important to not miss any relevant
helping the couple deal with the fact of infertility, one is details. Except in cases requiring urgent diagnosis and
looking for guilts, shames, superstitions, etc., which have treatment - and the physician has to become adept at
attached themselves to the fact of infertility, and which do singling these out - this is not so from a psychiatric
not belong there. standpoint. In the long run (this applies specifically to
The problem is essentially one of mourning. The patients with whom one has or expects to have a long term
inability to have children is a real loss, with mourning and relationship) more will ultimately be uncovered by letting
depression as a natural consequence. Empathy is helpful, the patient proceed at his own pace. The patient's own lead
but not sufficient. As in all mourning processes, secret and willingness to talk will direct us to relevant data. There
vices, guilts, shames, and inadequacies may attach them- are few objective signs and no laboratory tests to assist us.
selves to the mourning process, adding to the burden. It is Statements are therefore better than questions. For ex-
not sufficient for the physician simply to accept the fact ample, "This must be upsetting" is better than "How do
that the infertile couple is depressed 'for good reason' and you feel?" The former has a more empathic quality; it is
not to press the matter further - especially where the less demanding and penetrating. The patient has to be
depression seems excessive. He must say "Yes, it is natural considered an ally, not an object.
to be depressed, but let's not stop talking about'it. There may Finally, although medical history-taking stresses ob-
be more". The doctor has to bear with the patient, because jectivity, a psychiatric interview demands a mixture of both
secret vices and shames do not come easily. If he is objectivity and subjectivity. It requires a degree of self-
impatient, he won't discover, for example, that a married awareness in the physician. He must be in touch with his
man attributes his inability to have children to the fact that own feelings and irrational beliefs, acknowledging their
he masturbates - a crazy idea, he knows that, but he just existence or importance without being overwhelmed by
cannot rid himself of it - or that a woman attributes her them. For example: the physician must be able to infer that
infertility to an extra-marital affair. a religious couple might view infertility as a punishment. He
Being told the results of the 'infertility workup' can must be in touch with that side of human nature. Yet, he
trigger a number of responses. In our experience, a high must remain objective enough to be able to communicate -
proportion of husbands, upon being told that they were not iconoclastically, of course - the irrationality of such a
azoospermic, reacted with a period of depression and belief. 4
impotence. The 'guilty' member is invariably depressed. He
or she may handle this with anger towards the spouse who References
initiated the workup. This can be partly alleviated by 1. PLA TT, J. J., FICHER, L., SIL VER, M. J.: Infertile couples:
discussing together the couple's fears and concerns prior to personality traits and self-ideal concept discrepancies. Fertil. and
Steril. 24: 9 72-976, 1973.
the workup. The reaction of the 'exonerated' member of 2. KELLEY, K., DANIELS, G. E., POE, J., EASSER, R., MONROE,
the couple is equally important. A wife may subtly play up R.: Psychological correlations with secondary amenorrhea. Psycho-
her husband's low sperm count to defend against her own som. Med. 16: 129-147, 1954.
90 CANADIAN FAMILY PHYSICIAN/OCTOBER, 1974