Abstract
Couples (or individuals) present for fertility treatment because they are unable to conceive a viable pregnancy on their own. From a purely medical model perspective, the goal is fairly straightforward: to achieve a pregnancy in patients who would otherwise not have been able to do so, using a menu of reproductive technology options. This medical model approach may not be the best way to comprehensively care for patients, however. The approach tends to ignore social and behavioral factors that may impact outcomes, assumes that patients will remain in care until the anticipated pregnancy is achieved (or is determined to be no longer possible by the physician), and places relatively greater emphasis on achievement of pregnancy than on healthy outcomes for mother and child.
There are no psychosocial problems without biological features, and there are no biomedical problems without psychosocial features.
Couples (or individuals) present for fertility treatment because they are unable to conceive a viable pregnancy on their own. From a purely medical model perspective, the goal is fairly straightforward: to achieve a pregnancy in patients who would otherwise not have been able to do so, using a menu of reproductive technology options. This medical model approach may not be the best way to comprehensively care for patients, however. The approach tends to ignore social and behavioral factors that may impact outcomes, assumes that patients will remain in care until the anticipated pregnancy is achieved (or is determined to be no longer possible by the physician), and places relatively greater emphasis on achievement of pregnancy than on healthy outcomes for mother and child. Some fertility treatment centers have been shifting toward a patient-centered care model that provides an integrated set of services including medical, psychosocial, behavioral, dietary, and alternative interventions. This integrative care approach encourages treatment providers to look more holistically at the patient or couple and deliver care that meets a spectrum of needs.
The goal of this chapter is to examine the delivery of integrative care within a reproductive endocrinology and infertility (REI) clinic setting. The chapter will first examine the nature of integrative care, and why this type of approach may be particularly applicable to fertility treatment patients. It will then review some of the possible components that may be included in an integrative care system, and explore examples of different approaches clinics can take to provide integrated services. We will examine additional considerations related to certain treatment groups, and conclude with a call for providers to consider ways they can use integrative models of care in order to best serve their patients’ family-building goals.
What is Integrative Care and Why is it Useful?
In the United States, the medical system has in many ways taken a reductionist approach that views medical problems as a set of symptoms that must be fixed. Practitioners become specialists who focus on addressing their singular piece of the problem. The health insurance industry reinforces this system – a specific problem within a specific organ system must be identified, then a specific tool applied. Anything outside this limited system falls outside the purview of treatment or insurance coverage. The result is often fragmented, impersonal, and costly care[1].
Calls to address this medical model issue have been around for some time. In 1977, George Engel published a seminal article in Science calling for a new approach. He observed that the “concentration on the biomedical and exclusion of the psychosocial distorts perspectives and even interferes with patient care[2]”. Engel proposed a new biopsychosocial model that would take into account the patient’s thoughts, feelings, and behaviors related to illness and care, as well as the larger social and cultural context in which the care was occurring.
In the decades since, the drumbeat to provide patient care that cuts across disciplines and more effectively addresses the spectrum of patient needs has only increased. The type of biopsychosocial approach that Engel proposed has come to be referred to as integrative care. As applied to medical care, the integrative care model is defined as the delivery of treatment in a way that “reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing[3]”. Integrative care typically has medical, psychological, and a mixture of other services that are collectively incorporated within a patient’s treatment plan[4]. As will be explored below, integrative care is related to, but conceptually different from, collaborative care. Collaborative care is characterized by a “multidisciplinary approach,” where each provider completes their task in an additive way; integrative care moves toward an “interdisciplinary approach” wherein members of the healthcare team work together with a set of shared goals[5].
Infertility in particular warrants such an integrative, biopsychosocial approach to care. For example, take the case of a heterosexual couple presenting for treatment. Both members of the couple are in their early thirties. They have been trying to get pregnant via intercourse for a year now. They started casually, but then attempts were increasingly timed around ovulation. They cannot understand why they are not having success when everyone around them seems to be getting pregnant with little to no effort. The woman consults with her gynecologist, who refers her to an REI clinic. There, they undergo a number of medical tests, including sperm count, follicle count, genetic screening, blood tests, and hormone levels. They both wonder if there is a more natural approach that could help them. The doctor recommends a protocol, and the couple moves forward. They must accept that thousands of dollars will be spent toward a treatment with a limited chance of success. They must tolerate the waiting, the lack of control, and the fear of what it means if treatment does not work. Decisions will need to be made, costs and benefits weighed, priorities identified. The wife, who is overweight, wonders, do I need to lose weight? The husband wonders, are we failing because we are so stressed out? They are sad, they are scared, and they desperately want to know what they can do to improve their odds of success.
There is nothing unique about the case described above – that this is typical highlights the myriad challenges that fertility treatment patients (and their providers) face. Other cases may bring up even more questions for the couple … do donor gametes need to be used? Where do these come from? Do we tell the child? And if so, how? Additional challenges may be layered on top: physical health concerns, mental health concerns, financial concerns, legal concerns, relationship conflict, lack of family or social support, and so on. No single provider can address all these needs. Thus, it is important to remember that fertility treatment does not happen in a medical vacuum – it is a process that occurs within an evolving ecosystem of providers. The integrative care model aims to deliver the kind of ongoing, interdisciplinary support needed to help patients effectively navigate the biological, psychological, and socioemotional challenges inherent in the treatment process.
Components of Integrative Care
Clinics providing REI services will already have the necessary personnel in place related to the medical care of patients (e.g., physicians, nurses, lab technicians, embryologists, genetic screening). This section will look at specific additional services that clinics can implement when providing care from an integrative framework, which would provide psychosocial benefit to patients as they pursue their family-building goals.
Mental Health Services
Although fertility treatment allows couples to achieve pregnancy who otherwise would not have been able to, each cycle of treatment is more likely to fail than to succeed. As such, fertility treatment is very stressful and is associated with extremely high rates of psychological distress for both partners[6,7]. Psychological distress not only has obvious adverse effects on the well-being of the individual and the couple’s relationship, it also reduces the chance of treatment success because it often leads patients to terminate treatment before reaching the ultimate goal of becoming parents[8,9]. Furthermore, working with these highly anxious and depressed patients places significant strain on fertility treatment staff, leading to burnout, lower productivity, and attrition, which are all very costly for clinic functioning[8]. Therefore, integrating mental healthcare providers (MHPs) into fertility treatment serves a number of crucial functions.
The typical role of the MHP includes psychological assessment, psychoeducational support, and counseling of individuals and couples[10]. Counseling goals often include improving ways to cope, making decisions about treatment, or addressing issues between partners. It may also be about dealing with difficult emotions elicited by the diagnosis or treatment, including sadness, guilt, shame, blame, and fear. Other times, treatment may focus on accepting difficult situations and on processing feelings of grief and loss. MHPs can also provide end-of-treatment counseling when treatment is not successful[11]. Cognitive behavioral therapy (CBT)-based interventions in particular have been found to be efficacious in reducing distress[12].
The MHP can also function as an interpreter for the healthcare system. For example, when patients receive difficult or complicated medical information, they often only retain pieces of it or may misperceive what is being said. When care is integrated, the MHP will be in communication with the medical team and will be aware of the patient’s diagnosis and treatment plan. In turn, the MHP is well-positioned to offer psychoeducation to the patient or resolve misunderstandings. They can also help information go to the treatment team from the patient, either through direct communication or by helping patients feel empowered to communicate more effectively with the treatment providers[1].
In addition, some (or even much) of the work the MHP does to benefit patients comes via their interactions with other clinic staff members. This can take several forms. For example, in an integrated care model, all staff with patient contact (e.g., nurses, doctors, receptionists) are seen as involved in the provision of psychosocial care[13]. The MHP can provide the necessary psychoeducation and training to staff members. Further, just as patients experience a roller coaster of stress and emotions, so too can staff. The MHP can help staff members develop the coping skills needed to avoid burnout or compassion fatigue; this can help to improve communication and reduce negative patient–staff interactions so staff can continue to best serve patients’ needs[10]. Finally, more broadly speaking, MHPs are positioned to help clinics assess how they can adjust their service delivery to make treatment less stressful[14]. In this sense, the MHP can move from simply dealing with the stress of treatment to actually making treatment less stressful, thereby improving the experience for patients and staff alike.
Nutritional/Lifestyle Counseling
Maternal diet, weight, and other lifestyle behavioral factors including smoking, substance use, and exposure to toxins undeniably impact the chance of pregnancy as well as maternal and child health outcomes. In fact, obesity has been shown to be so highly associated with IVF success that some providers refuse to treat patients over certain BMI criteria. Recent research argues against this practice based on evidence that lifestyle interventions that delay initiation of IVF are generally ineffective in increasing pregnancy rates. However, it remains clear that weight loss has long-term health benefits for mother and child[15].
The REI doctor working alone is generally ill-equipped to assess and address this multitude of lifestyle and behavioral factors. For example, recent research has shown that fertility physicians acknowledge the importance of screening for eating disorders, but most do not do so and report not feeling confident in their ability to address dietary issues[16]. If lifestyle and dietary issues are not addressed directly by the fertility clinic providers, many patients will go online and discover all sorts of advice about what lifestyle adjustments they should be making in order to conceive. Some people will halt exercise altogether. Others will find tips for the latest fertility-enhancing diet. Unfortunately, certain “interventions” can end up doing more harm than good if they are not based on solid science. For example, a typically active person who ceases all physical activity will notice this takes a major toll on his or her mood and energy level. And some diets can actually do physical harm if a person is losing weight too quickly or not taking in the necessary vitamins and nutrients. Evidence suggests that many patients make behavioral choices that may be detrimental to the goal of healthy pregnancy outcomes[17].
With the goal of promoting healthy pregnancy and optimal maternal and child health outcomes, REI practices should not ignore or refuse patients based on weight or other lifestyle-related behavioral factors, but instead integrate such care into their work. Being able to get detailed, informed answers to their many questions about lifestyle choices can also serve to reduce the stress of fertility patients by providing reassurance, evidence-based guidelines, and supportive interventions as opposed to leaving patients seeking unclear guidance from unreliable sources.
Complementary and Alternative Medicine
Complementary and alternative medicine (CAM) approaches to treating infertility patients have the potential to impact the success of treatment as well as to decrease psychological distress. CAM is broadly defined as “health care approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice[18]”; these interventions are either used together with medical treatment (complement), or in place of them (alternative). CAM is a very large umbrella: it encompasses natural products, such as vitamins, minerals, and herbal therapy. It also includes “mind/body” practices, such as acupuncture, hypnotherapy, meditation, or relaxation techniques.
It has been estimated that between 30% and 60% of infertility patients use CAM approaches concurrently with their treatment (see review by Boivin and Schmidt[19]). Patients use CAM for a number of reasons. They may feel it is safer, less expensive, or more effective than traditional medical interventions. It may be a first resort, used when difficulty conceiving is first noticed, or a last resort, when confronted with failed fertility treatment cycles or miscarriage. The common denominator is that patients are looking for whatever they can find to move them toward “solving” the fertility problem, and they believe that one or more of these approaches may help.
There is substantial evidence of positive outcomes in the use of CAM approaches. Randomized trials generally support acupuncture as an adjunct to fertility treatment, though results appeared contingent on which control group was considered and various treatment-related factors (e.g., timing of treatment, treatment course)[20]. Another highly promising approach is mind/body interventions, which are shown to be efficacious in reducing distress and may positively impact pregnancy rates[12]. As an example, a recent study evaluated the efficacy of a combined cognitive coping and relaxation intervention (CCRI). Results indicated that the intervention led to improved quality of life and reduced anxiety[21], though it did not appear to improve pregnancy success rates or reduce treatment discontinuation.
CAM interventions appear to be rarely discussed by fertility treatment providers with their patients, presumably because the treatments are generally considered to be at best potentially beneficial and at worst benign. A recent study, however, found that patients who elect for CAM use during treatment may actually experience significantly lower pregnancy rates; this could be because those treatments are most likely to be elected by patients with poor prognosis, but the study controlled for some prognostic factors, suggesting other possible negative mechanisms[19]. Also, when CAM treatments are used outside of the REI clinic, the REI provider is often completely unaware of the nature of the treatment, which could include agents or approaches that are contraindicated (e.g., herbal supplements with endocrine effects). Another risk of participation in CAM treatments is that it may give patients the impression that if they only did one more acupuncture treatment or one more relaxation exercise, they would be more likely to be successful. This can breed inappropriate self-blame if treatment fails[22]. Fertility treatment providers can help patients make informed choices and access safe and appropriate services. Thus, a major benefit of delivering CAM within an integrated setting is that the REI clinic can ensure that patients are receiving only the most evidence-based methods of care that will not work against the clinic’s delivery of fertility treatment.
Examples of Different Integrative Approaches
Medical providers can work with other practitioners with varying levels of integration. The level that is right for a given clinic will be determined by a number of factors, including the clinic’s infrastructure and the provider’s commitment to the integrative model. William Doherty proposed a five-level model for conceptualizing the various configurations of integrative care[23]. These levels are illustrated in Table 6.1.
Table 6.1 Levels of integration
Adapted from Doherty[23] and McDaniel, Doherty, and Hepworth[1]. This table presents an example related to integration of mental health services. The same concepts would apply to other services (e.g., nutrition counselors, CAM providers).
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