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Psychological Assessment of the

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					Psychological
Assessment of the
I nf erti e Cou pIe                                DAVID M. BERGER, MD


         SUMMARY
         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
         Toronto.

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.

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