Relationships: why do we bother?’, an inspired topic for BACP’s Private Practice conference, can be anything from an amusing rhetorical question to a profound existential challenge, raising queries about why many of us choose to live our lives in intimate relationships, how we lose and find ourselves in relationships with others, and how we achieve meaning for ourselves, given the inevitable challenges and adverse experiences that can arise by virtue of living within an intimate relationship. Infertility is one such adverse challenge facing an estimated one in seven couples.
Setting the scene
Infertility is generally defined as ‘the failure to conceive after regular unprotected sexual intercourse over one to two years’.1 Fertility problems leading to this failure to conceive can originate from a predominant male factor (30%), female factor (approximately 45%), a combination of both male and female factors (40%), or the infertility cause can be ‘unexplained’ (25%).2 While the origins of the fertility difficulty will be relevant to how individuals and couples negotiate their experience, journeys to treatment often involve significant other life experiences or decisions, which will add complexity to how the diagnosis of infertility is perceived by each individual, and managed by the couple. A couple or one partner may have decided to delay conception in order to develop their career or complete studies, only to find out that their fertility has declined. A couple may meet later in life and one partner might already have children. Treatment for cancer or early menopause may have caused infertility. One partner may have a genetic condition long known about, or more recently discovered, as part of fertility investigations, eg Klinefelter’s or Turner syndrome. The couple may be undergoing fertility treatment because they have lost a child due to genetic conditions or they may have difficulties conceiving a second child (secondary infertility). Past decisions, experiences and losses will inevitably arise in the counselling room because infertility has a broad reach; its effects derive not just from the present, but also from the often-negative reconstruction of past decisions, re-emergence of past losses and anticipated losses of the future.
Emotional impact of infertility
Infertility is generally understood in terms of being a ‘loss’, although a loss with significant elements, differentiating it from traditional concepts of loss. The loss can be tangible due, for example, to miscarriage, ectopic pregnancy, failed treatment, embryos failing to thaw, absence of conception each month. Or it can be intangible: an imagined or hoped for child, the gratification and sense of belonging attached to the experience of pregnancy and delivery, genetic continuity, a child with a chosen partner, with all that represents, an anticipated future, the list could go on. The losses can be repeated, cumulative and enduring, with new aspects of the loss being revealed as time progresses. Assisted reproductive treatment offers the possibility of remedying the situation, resulting in the embracing of two conflicting positions at one time – loss and hope. Infertility can raise a series of existential questions about the core purpose of life: who am I? What am I here for, if not to contribute to the continuation of the human race?
There is a sense of infertility having ‘two complexions’ – it’s a profound loss but without a tangibility to represent that which is lost. Something overwhelmingly painful has occurred but it might yet be remedied. How it feels inside is very different to how most others without the experience perceive it. As Mahlstedt writes: ‘There is much to cry about, and there is nothing to cry about. Everything is lost, and nothing is lost.’3 Exploring and unravelling this dichotomy, the unique experience of individuals and couples, how they negotiate the experience within themselves, their relationships and within society, is the focus of fertility counselling.
As with any loss, the emotional impact of infertility will differ from person to person, and from one loss to another for the same person. One failed treatment or miscarriage may carry more significance than another for an individual; and while one person may view embryos not implanting as the loss of a baby, another may view this as simply a failed treatment. A significant part of any grieving process is considered to be the letting go of a former identity and rebuilding a new one. Identity issues are a significant feature within the fertility counselling room, perhaps made more complex by the fact that there is a protracted period of investigations and treatment when life is on hold, before the basis of the future identity as a parent or childless person/couple can even be glimpsed.
In the counselling room, individuals describe their personalities as having changed, of becoming angry, anxious, depressed and joyless. Jealousy and envy intrude on close relationships. The medical problem is not seen as a physical issue but a personal inadequacy, which can manifest as a sense of shame. Perhaps the fact I cannot get pregnant is because I would not make a good parent, and if I cannot be trusted with children, perhaps I shouldn’t be a teacher? Maybe I have done something wrong and am being punished? If there is anything to attach this guilt and self-blame to, the more certain this thought becomes. Values that have guided one’s life become unreliable: I am used to working hard to achieve what I want, but no amount of hard work will make me pregnant. I am used to controlling and planning my life but I can’t control this. If commitment to becoming a parent included a desire to emulate the good parenting received from a now dead parent, the loss is magnified, as it is if a commitment to being a good parent was a survival strategy for coping with abusive parenting. Life becomes insecure when the principles, beliefs, values and long-held certainties are inexplicably removed.
Life is much disrupted by infertility. Grieving the loss of the life you had expected to live, the parents you had hoped to be, undertaking investigations and treatment, are emotionally burdensome, leaving little energy for other activities. Holidays, career decisions and house moves can be put on hold because you may be called for treatment/might be pregnant/need the money for treatment, or there is simply not the energy. The natural activity of conception becomes medicalised, which can feel invasive. Sexual activity becomes less about pleasure, spontaneity or communication of intimacy and more planned, programmed and about procreation. The greatest disruption is to the lifecycle. Friends move on to become parents, as you are left behind with an increasing sense of feeling isolated and alone. Metaphor is rife in the fertility counselling room: it’s a club that I can’t join; a party I’m not invited to. The language of parenthood and children is like a ‘social currency’, strangers can feel free to enquire about how many children you have. Television advertisements, shopping trips, social gatherings and work refreshment breaks all hold the threat of discomfort or triggering your pain. As Jorgenson writes: ‘My infertility is a blow to my self-esteem, a violation of my privacy, an assault on my sexuality, a final exam on my ability to cope, an affront to my sense of justice, a painful reminder that nothing can be taken for granted. My infertility is a break in the continuity of life. It is above all, a wound – to my body, to my psyche, to my soul.’4
When describing the depth and breadth of the emotional impact of infertility, there is a risk of overstating the universality of response to the detriment of the unique response of each individual/couple. A range of factors will affect any individual’s grief response, for example:
- personal characteristics – coping behaviour, personality, mental health, maturity, stage of development, cultural, ethnic, religious background, belief system, gender, gender role conditioning, concurrent stresses, lifestyle, previous loss history, sense of fulfilment, characteristics of current loss journey
- social factors – family/partner expectations, understanding and support
- physiological factors – physical health, rest, sleep, nutrition, exercise, addictions
All of these and more will influence how any one person will respond to the experience of infertility, and provide rich material for discussion in relation to infertility – culture and faith being two significant issues. So too would a focus on single people or same sex couples who may have fertility problems or choose to undergo fertility treatment as a way of forming their family. I will, however, focus on heterosexual couples and consider some of the dynamics that gender differences can raise when negotiating an infertility journey.
Bearing in mind the ‘health warning’ about overgeneralising it would appear that there are gender differences in responding to infertility experience, which are important to recognise when working with couples and individuals. Infertility is distressing for both partners, but can be more so for women.5 Men can be more confident that treatment will work and can envisage life without being a father more readily than women.6 Women are more likely to cope by talking about their feelings than men and can assume more personal responsibility, feeling a sense of failure. Men can worry more about the impact of infertility on their partner.7 These issues are presented frequently in the counselling room: women attend alone for counselling much more often, men sometimes attend in a supportive capacity, stating that they are coping well but their female partner is struggling. Women may bring a male partner to counselling because he doesn’t talk about their experience or appear to understand/care. There is poignancy in the counselling room when a female hears for the first time her partner exhibit his distress about their infertility, or when he explains that he doesn’t talk at home because he doesn’t want to compound her distress, or he feels helpless to fix the problem. It would be erroneous to confuse the ‘felt sense’ of the experience with differences in presentation, gender role conditioning and coping styles.
Research on gender differences in coping strategies adds further insight relevant to the fertility counsellor. Peterson asserts that couples experiencing infertility can ‘become stuck in a circular pattern where partners seek connection and emotional support, yet communicate in ways that lead to emotional invalidation and interpersonal distance’.9 The nature of an individual’s coping strategy may facilitate one’s own grieving but may conflict with a partner’s coping style, thereby negatively impacting the relationship; for example, the male partner may cope by ‘distancing’ himself from the treatment process or minimising the significance of a treatment failure, while the female partner copes by confronting the emotional impact through discussing her distress.9 The ‘congruence’ or ‘fit’ of couple coping strategies is important but so too is the nature of the coping strategy in the long term; for example, escape/avoidance and accepting personal responsibility/ self-blame for the problem in the long term, can impede accommodating the loss and ‘moving on in life’.
As with any counselling, allowing people to tell their story and have their feelings validated is helpful. The enduring nature of an infertility journey can involve much waiting, lengthy intervals between treatments, and it can become difficult having the same conversations with the same range of people. Some feelings are difficult to discuss within one’s usual support network, such as anger or resentment towards a partner for having a fertility problem, distress with parents who are enjoying relationships with their grandchildren, or jealousy of close friends or relatives who are pregnant. Reframing ‘coping’ in terms of loss and grieving theory can be validating for people who fear they are not coping or are ‘going mad’.
Facilitating conversations between partners, so that each becomes aware of the difference in their partner’s coping or pace of grieving, can be helpful. Peterson suggests ‘using an intervention called “the emotional paradox’’ whereby the problem solving approach of a male partner can be reframed as “protecting behaviour” and thus validated he can be encouraged to be emotionally present for the female partner while she is encouraged to be explicit about her need for emotional validation’.9
Promoting effective communication is desirable in itself, although it may involve looking at a range of options to identify what works best for couples. Identifying ‘fertility talk’ times and ‘fertility free’ times can be helpful, but the shape of these will depend on the needs of both partners. Scarf’s ‘talking and listening tasks’10 can be used to some advantage, and sometimes other support, for example, face-to-face or online support groups, can alleviate the need for all the support to be met within the couple relationship. Other self-care strategies, such as journaling, exercise, meditation, mindfulness etc, can help through distraction and building resilience for coping with the emotional burden.
Discussions about investing in the couple’s relationship, having ‘date nights’ and celebrating other aspects of their lives can be restorative. Sometimes, celebrating or marking whatever positives they can along their journey, if possible, can be uplifting and ‘honour’ what has been lost in a tangible manner; for example, by planting a tree, attending a memorial service or visiting a memorial garden.
The future outlook
There is little doubt that the pain of infertility, similar to any loss, can live on for many people. The loss can be triggered by various scenarios, such as reaching menopause, watching friends going through the grandparent stage, adoptive children becoming pregnant, to name but a few. However, the often-expressed fear of becoming embittered and leading a meaningless, empty life is not borne out in the research. Wischman et al11 suggest that quality of life can be high for definitively childless couples. In Wischman’s study, separation/divorce rates were significantly lower for people with infertility histories than for the general population. The ‘gains’ of a loss experience can also be evident for people who have had infertility experience, in that couples have forged closer relationships, demonstrating improved communication and conflict resolution skills.12
Gerry McCluskey has held a variety of practitioner and management posts in family and childcare and family placement in the statutory and voluntary sectors. Employed by Adoption Routes, a voluntary adoption agency in Northern Ireland, she provides training, statutory adoption services and counselling/intermediary work for adult adoptees and birth families, counselling for birth parents whose children have been placed for adoption and fertility counselling for NHS/private patients. Gerry’s qualifications include BSSc, MSW, Advanced Diploma in Person-Centred Counselling, and Relate Certificate in Couple Counselling. She is a registered member of BACP, accredited with BICA, and a member of the BICA’s Executive and Training Teams and the Irish Fertility Counsellors’ Association. firstname.lastname@example.org
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2. National Institute for Health and Care Excellence. Health and Social Care Directorate, Quality Standards and Indicators, Briefing Paper, March 2014.
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