Fig. 14.1
Giessen test profiles of all couples. Typical polarization that can be found in infertile couples’ relationship patterns. Self and partner images (n = 500) (Used with permission of Oxford University Press from Wischmann et al. [21])
On the basic mood scale, the self-assessments of men and women are very close together, whereas the partner images are positioned toward the carefreeness pole of the scale for the men (as seen by the women) and toward the depressive pole for the women (as seen by the men). As Van den Broeck and colleagues [6] point out, it can be helpful to visualize this polarization pattern (or “role allocation”) [19] in couples counseling to normalize its occurrence and to “allow” more flexibility in the allocation of roles. Otherwise the woman may want to talk about her pain and sadness, whereas her partner may feel helpless and withdrawn, resulting in polarization and isolation of both partners at a time where both partners need each other most in their infertility crisis.
14.4.4 What Do You Think Are the Most Helpful Coping Strategies for Infertile Couples?
As Peterson and coworkers could show [22], the coping strategies of both partners in infertile couples are interdependent and do interact. In their study, a partner’s use of active-avoidance coping was related to the increased personal, marital, and social distress for both partners. A woman’s use of active-confronting coping was related to increased male marital distress, and a partner’s use of meaning-based coping was associated with decreased marital distress in men and increased social distress in women. The authors concluded that physicians and mental health providers can use the findings from this study to educate their patients regarding the benefits of meaning-based coping for women and their partners, as well as the gender differences that exist when men engage in meaning-based coping. For the authors it is likely that these differences in the effects of meaning-based coping for men and women are reflective of different gender perspectives on the importance of parenthood.
14.5 Etiology and Pathogenesis
Causes for infertility are nearly equally distributed among women and men: about one-third solely female factor infertility, about one-third solely male factor infertility, about one-third mixed factor infertility, and about 10 % unexplained infertility. In about 9 % of diagnoses, behavior-related infertility causes are prominent (e.g., severe underweight or overweight, drug intake, excessive cigarette smoking, nonorganically caused sexual dysfunctions) [23]. There is no empirical evidence for solely “psychogenic” infertility (emotional stress and intrapsychic blockades acting as the only powerful “conception stoppers”) [24], for increased psychopathology in couples with unexplained infertility or for any infertility-specific couple relationship patterns [21].
14.6 Specific Diagnostic Aspects
As Wischmann et al. point out [19], it is necessary to consider both unconscious areas of the wish for a child (e.g., fantasies and dreams) and the consciously expressed motives and expectations of the couples. After years of infertility treatment, ambivalent feelings linked to the wish for a child or the medical treatment may barely be perceived by the couple as a consequence of their coping attempts. Often these ambivalences are split up in the couple, which means that one partner represents the “pro” side and the other the “con” (e.g., pro/con child, pro/con gamete donation, pro/con adoption, or pro/con termination of treatment). The doctor can see him-/herself as an “advocate of feelings,” including those feelings that the couple has been fending off. This can lead to the couple’s greater critical distance in connection with the child wish or the medical treatment offered. The motivation of the desire for a child should not been questioned, but rather the pressure that the couples feel they are under. The doctor may assist in developing new vistas (including a “plan B” if treatment should finally fail) [4, 6, 7].
Furthermore, processes of transference and countertransference should be kept in mind: In analyzing his/her countertransference, the doctor should keep clear his/her own opinion and ethical attitude toward the desire for a child, reproductive medicine, and treatment boundaries. The doctor’s own experiences with the wish for a child (unfulfilled in general or in the actual partnership) and especially his/her attitude to reproductive medicine techniques that are not legal in the country (but abroad) can negatively influence the doctor-patient relationship. It is also crucial to watch out for partiality in favor of one or the other partner in order to be aware of gender-specific countertransference tendencies: The doctor should be aligned with both couple members, counseling should be neutral, open, and without preposition.
Usually the doctor needs to ask more detailed questions about the couple’s sexuality. This involves inquiring whether coitus is always possible, whether intravaginal ejaculation occurs, and whether the couple experiences any sexual problems. Is the couple well informed about the “fertile window” and about the optimal time of sexual intercourse for enhancing conception chances? Not all couples know that the optimal time for sexual intercourse to conceive a child is 1–2 days before ovulation occurs [25].
14.6.1 How Can You Detect Which Coping Strategies Are Used by the Couple?
To identify patients at risk, questionnaires can be used (e.g., SCREENIVF [26] or the COMPI Coping Strategy Scales) or the doctor must ask the specific questions (based on [7]) about the favored coping style of each partner: “Do you turn to work or substitute activity to take your mind off things?” (active-avoidance coping), “Do you talk to someone about your emotions as childless?” (active-confronting coping), “Do you try to forget everything about your childlessness?” (passive-avoiding coping), or “Do you believe there is a meaning in your difficulties with having children?” (meaning-based coping).
Other specific diagnostic issues can be found in references [3, 6, 19, 27]. Boivin [28] specified the following risk factors for persons who are likely to need intensive counseling: psychopathology (e.g., personality disorder, depression), primary infertility, being a woman, viewing parenting as a central adult life goal, general use of avoidant strategies, poor marital relationship, impoverished social network, situations or people that remind the person of their infertility (e.g., family reunions, pregnant woman), side effects of the medical treatment associated with medication (e.g., mood fluctuation), situations that threaten the goal of pregnancy (e.g., miscarriage, treatment failure) and decision-making times (e.g., start and end of treatment, fetal reduction). In these cases, specific infertility counseling of the couple by a mental health professional or by a psychotherapist might be indispensable [5].
14.7 Specific Therapeutic Aspects
14.7.1 What Kind of Counseling Types Can Be Found in Infertility Counseling?
As shown in the case history, it can be helpful to advise a couple to distinguish between “sex for baby making” and “sex for fun.” This means that on fertile days a more target-oriented approach to sexuality is on the agenda, whereas at other times, desire and/or romantic affection are the determining factors in sexual encounters [8].
Learning of relaxation techniques can be recommended and will facilitate successful coping (but will not improve pregnancy rates in the majority of cases) [29].
As Van den Broeck and coworkers point out, the majority of patients tend to be in a passive position of “wait and see and let the doctor act” during infertility treatment. Therefore it is important to empower them to actively join in the decisions regarding their infertility problems (see Case History). This includes helping to explore possible alternatives to biological parenthood and boundaries of ART treatment [6].
14.8 Critical Reflection and Conclusive Remarks
Because of the sensible and intimate nature of fertility consultation, a stable and empathic-based doctor-patient relationship is very important for successful diagnosis and treatment, especially when discussing the “plan B.” This relationship can only partly be substituted by reading medical guidebooks or Internet use [29]. The experience of infertility is often experienced as a life crisis by these couples. The emotional impact of this experience can be as strong as suffering from severe illness or the loss of a close relative. As health care professionals we can learn from these couples that nearly every life crisis can be conquered with adequate coping strategies and with an open and respectful couple communication behavior. Infertile couples should have the opportunity to easily uptake psychological infertility counseling at any stage of the medical treatment process (and also independent of treatment), but the counseling should not be mandatory. The majority of these couples can cope with this situation without the help of a mental health professional. As there is no guarantee for a live-born child after medical infertility treatment, the discussion of a “plan B” should not become a taboo in the doctor-patient relationship.
Tips and Tricks
In counseling it is important for the health care professional:
To consider both unconscious areas of the wish for a child (e.g., fantasies and dreams) and the consciously expressed motives and expectations of the couples.
To be aware of processes of transference and countertransference: In analyzing his or her countertransference, the health care professional should keep clear his or her own opinion and ethical attitude toward the desire for a child, reproductive medicine, and treatment boundaries.
To watch out for partiality in favor of one or the other partner in order to be aware of gender-specific countertransference tendencies: The doctor should be aligned with both couple members, counseling should be neutral, open, and without preposition.
To ask detailed questions about the couple’s sexuality.
In cases with risk factor (see earlier section on How Can You Detect Which Coping Strategies Are Used by the Couple?), specific infertility counseling of the couple by a mental health professional or by a psychotherapist might be indispensable.
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