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The Infertility Experience: Biopsychosocial Effects and Suggestions for Counselors

Posted on: Thursday, 9 December 2004, 03:00 CST

Infertility affects many individuals and couples. This article begins with a case study of a couple who have experienced infertility yet do not identify infertility as their presenting problem. Clients and counselors alike often overlook infertility. This article offers an overview of the biology of infertility and its psychological and sociological effects. Counseling issues are presented to assist counselors to identify infertility as a concern and provide interventions.

Marilyn, 39, and Pedro, 45, have come to you for marital counseling. They report being devout Catholics who are seeking help in determining the cause of their marital discord. Marilyn is Caucasian, and Pedro is Hispanic. They report that they have been married for 14 years, have no children, and for the past 4 years have been "drifting apart." Pedro reports that Marilyn has "changed." She used to be actively involved with their extended families, now he states that "Marilyn has refused to go to my sister's baby shower, and I don't understand her anymore." Marilyn states that she feels depressed and "doesn't feel up to seeing her family." She has also stopped going to many of her typical social functions. Marilyn reports that her mother has been concerned and has stated that Marilyn and Pedro should have a baby. Marilyn shares that her mother continuously questions her about "becoming a Grandma" and puts pressure on her to "be a good Catholic." Pedro observes that Marilyn keeps saying things like, "What's the purpose of living" and "We are failures as adults." Pedro also reports that he is unsatisfied with their sexual relationship. In particular, Marilyn has been anorgasmic, and he has had incidences of impotence. When asked about her sexual relations, Marilyn says that she cannot "stand her menstrual cycle" and all of the "mess it entails," but she does not address the act of intercourse. Pedro reports being confused and that he does not understand the emotional lows Marilyn is experiencing. They are thinking about getting divorced.

Statistics indicate that 3.5 million couples in the United States are infertile (Daniluk, 2001b). In other words, 15% of all couples will experience the frustration of infertility at some point in their relationship (Serono Laboratories, 1996). The high incidence of infertility almost guarantees that the complex emotional roller coaster related to infertility that individuals and couples face will be an issue in some facet of their counseling. To ethically address the issues that clients like Marilyn and Pedro present, counselors must understand the complexities that infertile individuals and couples experience, including the biological, the psychological, and the sociological effects. This article explores the wide array of conditions individuals and couples endure because of infertility and provides specific counseling strategies. For a clearer writing style, the word couple will be used throughout the remainder of this article, although the reader is advised that many "single" people also go through the infertility experience. In addition, the article is written to provide a model for counselors to use. We are not implying that every couple will go through each of these experiences, only that many couples have done so. Coping with infertility is a dynamic, personal process, and couples will experience it through their own lense of understanding.

Infertility is defined as the inability to achieve a viable pregnancy after 12 months of regular, unprotected sexual intercourse (Anderson, 1989; Atwood & Dobkin, 1992; Cooper-Hilbert, 2001; Daniluk, 2001b; Serono Laboratories, 1996). This definition contradicts the 42% of people who have reported that concern about infertility should not begin until after 30 months of unprotected sexual intercourse (Gibbs, 2002). The National Center for Health Statistics (Atwood & Dobkin, 1992) has stated that infertility affects 27.2% of women between the ages of 40 and 44 years who are trying to conceive. This issue of infertility dramatically increases the level of trauma that couples may encounter when they have waited to have children until later adulthood. Anderson reported that 1 in 6 couples in North America are infertile, with that number rising for women who have waited to have children until they are 35 years old and older. Other statistics show that 10% of couples are infertile, with 20% of married couples without children being infertile (Abbey, Andrews, & Halman, 1992). Atwood and Dobkin also suggested that infertility is higher among African American populations and less educated women. Causes for these higher infertility rates might be the lack of resources these populations often face. Otherwise, infertility does not discriminate by gender or ethnicity.

Edelmann and Connolly (1987) conducted a survey questioning infertile couples going through infertility. In particular, they asked, "Would you find it useful to have help/guidance from someone other than a medical specialist?" They found that 39.2% of the respondents answered yes, with 6.7% of that population desirous of weekly help and 83.8% desirous of monthly help. According to these statistics, there are infertile couples who believe they would benefit from services such as counseling. Moreover, infertile couples who participated in an 8-week support group reported less psychological distress and depression than did couples who did not have this type of support (Stewart et al., 1992).

The problem of infertility affects many couples; therefore, it may be helpful for clinicians to understand the history behind some of the feelings and attitudes related to infertility. Atwood and Dobkin (1992) followed the historical implications of infertility from the Bible to tribal and cultural ideologies. It is stated in the Bible, "Be fruitful and multiply,""Give me children or I die," and the implication of these statements is that having children is a blessed event, without which there is no purpose for living. Some primitive, unscientific explanations for infertility have been that it has been brought about by ancestral anger because a particular marriage has taken place, that it is the result of a witch's curse over the person's ovaries or penis, and that it is due to the sexual promiscuity of the woman. Tribal leaders have even blamed infertility on tensions between the two families of origin of a couple. In India, where a high premium is placed on the family, infertility carries a significant stigma, and the blame for it is placed on the woman (Chandra et al., 1991).

Unfortunately, even in more recent times in American culture, infertility has often been blamed on the woman. Klempner (1992) stated that in the 1940s, infertility was linked to the woman's unconscious fear of sexual feelings and to her neuroses. In the 1950s and 1960s, infertility was blamed on the woman's psychological impairment and her ambivalence toward becoming a mother. Faludi (1992) discussed the blame of infertility being placed unjustly on career women or on women who choose to postpone childbearing. The negative media spin surrounding infertility may exacerbate the harmful aspects of the emotional experience for infertile women. In addition to the media's impact, there are inaccurate and uninformed myths such as the following: "This is God's punishment,""This is because I had sex with too many people,""This is happening because I had an abortion," or "I am infertile because I was on birth control for too long." Note that many of these myths still place the blame of infertility upon women and their sexual decisions. As is evident from this brief historical survey, there is a vast misunderstanding in popular culture about the causes of infertility and the emotional trauma that many couples may experience because of it.

BIOLOGY OF INFERTILITY

Because of, and in addition to, the folklore that surrounds infertility, counselors must understand the biological nature of infertility, especially so that counselors may pass this knowledge on to infertile couples. Williams, Bischoff, and Ludes (1992) gave a layman's explanation of infertility. In women, infertility is due to three primary factors. She may not be producing and releasing mature eggs, there may be scarring of the fallopian tubes that may interfere with conception, or the fertilized egg may not be able to implant properly due to structural or hormonal difficulties. For men, the primary reasons for infertility include the number of sperm they produce and the quality of the sperm.

The actual rate of infertility in the United States has not increased over time (Serono Laboratories, 1996). However, as more couples wait to have children, age-related infertility is becoming more common. Serono Laboratories stated that the biological cause of infertility is approximately equally shared between men and women. Of those couples who seek medical assistance for infertility, 35% to 50% still do not achieve a pregnancy (Daniluk, 2001b; Serono Laboratories, 1996). This is a significant portion of couples who undergo all of the medical procedures, as well as the tremendous stress these procedures involve, and still do not achieve a pregnancy. It is importa\nt that the counselor understand the basics of what a couple goes through during infertility treatments so that he or she has a deeper understanding of the intrusiveness of the treatments.

MEDICAL PROCEDURES FOR INFERTILITY

Atwood and Dobkin (1992) explained that women are usually assigned the task of taking their basal body temperature (BBT). Serono Laboratories (1996) explained that although this is an inexpensive procedure, it is a daily reminder to the woman of being infertile. The woman takes her body temperature each morning, noting daily changes. She must also note events such as sexual intercourse, sleepless nights, and sickness. Urinary testing may also be done to predict when ovulation is occurring. There are other tests that may be performed such as serum testing, prolactin testing, or thyroid testing. All of this testing is not only time-consuming and expensive, but it is also understandably emotionally draining. The husband is often required to masturbate into cups to test for sperm count. The testing procedures become more and more invasive as time goes on. Testing the cervical mucus during ovulation allows the physician to assess the consistency and elasticity of the mucus, which enables sperm to swim more easily into the uterus. Postcoital testing 4 to 12 hours after sexual intercourse and just before ovulation determines the number of sperm in the mucus. This test often leads to sexual dysfunction because of the demand for the correct timing of collected postcoital mucus. Hysterosalpingograms are performed to look for structural problems, such as blockages and disorders of the uterus. In this procedure, a small tube is placed into the cervix and a dye is released to allow the observation of the flow of the dye. The injection of dye can cause uterine cramping that may last for several hours. In addition to the cramping, a discharge may occur for several hours after the injection. If less intrusive methods do not provide the necessary information, diagnostic laparoscopy is performed to look for scarring and other possible malfunctions of the uterus, fallopian tubes, ovaries, and pelvic cavity. An instrument is passed through the naval cavity, with a second instrument inserted at the pubic hairline. Laparoscopy, which is performed under anesthesia, can leave the woman with a sore throat, shoulder pain, swollen abdomen, and general stiffness. Hysteroscopy may also be done at the same time as the laparoscopy. This is a visual examination of the uterus for abnormalities accomplished by inserting an instrument directly into the uterus. These are just some of the tests that may be performed, and this is only during the exploratory process (Serono Laboratories, 1996).

Once the problem is discovered-although for some couples, there is often no biological explanation-the treatments for infertility begin. Often, hormonal therapies (HT) are used to enhance the hormonal stimulation needed to conceive. HT has grave consequences for the emotional stability of the client, which will be discussed later in this article. There are also medical procedures that may be performed to increase the likelihood of conception. Artificial insemination is usually used for couples when the man is infertile and the woman is fertile. It is relatively painless and performed without an anesthetic. For intrauterine insemination, the doctor inserts sperm directly into the uterus near the time of ovulation. Donor sperm from someone other than the partner may be used for insemination. With in vitro fertilization, mature eggs are removed from the woman, fertilized in a laboratory dish, and after several days, placed back inside the woman's uterus. With gamete intrafallopian transfer, a mixture of sperm and eggs is placed directly into the fallopian tubes. Assisted hatching is the process of putting a hole in the embryo's covering, which increases the chances of embryo development. The current technologies dealing with infertility are far too numerous to be covered effectively and thoroughly in the scope of this article. We recommend that the reader seek out further information from the resources included in the section on counseling issues. This review is meant to be an introduction to familiarize counselors with the terminology and give them an idea of the intrusiveness involved with some of the techniques used to help couples achieve pregnancy. In addition, if the couple have been declared biologically capable of conception but they are still technically infertile, emotional issues may need to be considered. This can be addressed through counseling, which we discuss later in the article.

BIOPSYCHOSOCIAL EFFECTS OF INFERTILITY

Medical Field

Daniluk (2001b) pointed out the tremendous psychological burdens that an infertile couple may experience when working with the medical professionals. Often, clients feel that they are being exploited by persons in the medical field for the purpose of testing out new procedures. The couple may also feel rushed or discouraged from asking questions of their doctors (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Cooper-Hilbert, 2001). Callan and Hennessey (1989) addressed the role overload that the couple may experience related to frequent hospital visits, keeping the necessary appointments, and undergoing surgery. The effort required to cope with infertility may be demanding and stressful: finding the time to complete all of the medical examinations, deciding how much money to invest in the treatments, and determining how long to battle insurance companies for reimbursement for the related medical procedures (Forrest & Gilbert, 1992; Klempner, 1992; Serono Laboratories, 1996). There is the stress of completing the required tests (e.g., BBT, postcoital tests) just as there is fear induced by going through medical treatment and associated physical pain (Connolly & Cooke, 1987). The couple must also decide which treatments to try and when to stop trying (Daniluk, 2001b; Forrest & Gilbert, 1992). There can be a tremendous sense of frustration and anger toward professionals in the medical field for failing to fix the infertility (Forrest & Gilbert, 1992). Serono Laboratories also pointed out the loss of privacy that a couple may feel. All of these medical challenges are often exacerbated by the sense of isolation that the couple may feel.

Lack of Social Support

For many couples, the experience of their infertility is quite isolating and lonely (Atwood & Dobkin, 1992). They feel misunderstood and believe that they lack understanding from most of their friends and family members (Callan & Hennessey, 1989; Daniluk, 2001b). Callan and Hennessey stated that 80% of infertile couples reported being subject to negative comments from others regarding their infertility status. Forrest and Gilbert (1992) added that many couples believe that their friends and family do not know what to say. The couple may not only feel misunderstood, they may also have intense feelings of jealousy and anger toward others who have achieved a successful pregnancy or are celebrating the birth of their biological baby (Butler & Koraleski, 1990). The jealousy and anger can become all-consuming, with the couple unable to attend social events such as children's birthdays or baby blessings. The couple may become enraged at others who are having abortions and couples who achieve a pregnancy without actually trying. These feelings may also result in frustration about child abuse or neglect (Atwood & Dobkin, 1992). Another common experience shared by infertile couples is their own social withdrawal (Butler & Koraleski, 1990). Because of the stress and pain of their own infertility, couples may choose to slowly withdraw from their social contacts, including their family. However, some studies show that women have noted some positive social supports. These have been identified as husbands, family, other infertile women, their doctors, nursing staff, and counselors (Callan & Hennessey, 1989; Gibson & Myers, 2003). Callan and Hennessey also indicated that, in addition to listing counselors as sources of support, they have also been reported as sources of negative encounters. Therapists have been noted as minimizing the grief clients go through and providing erroneous reassurance about clients' infertility situation (e.g., Barton, as cited in Callan & Hennessey, 1989). Such minimization would be, understandably, quite infuriating for any client coping with infertility. Counselors must remember to be genuine in understanding the grave loss that clients feel and must not provide cause for unfounded hopes about achieving pregnancy. As couples become less satisfied with their perceived social support, the level of their depression increases (Fouad & Fahje, 1989). These strong emotions may also be intensified because of the hormonal treatments.

Emotional Roller Coaster

Most infertile couples experience extreme shifts of their emotions. While feeling intensely jealous of a woman who is pregnant, the couple may also have to contend with emotions of selfishness and narcissism (Callan & Hennessey, 1989; Daniluk, 2001b). The man or woman may feel betrayed by his or her body or become angry with his or her partner (Cooper-Hilbert, 2001). Intense guilt may surface over past decisions, such as having an abortion or taking birth control pills, thus increasing self-punishment (Atwood & Dobkin, 1992; Klempner, 1992; Serono Laboratories, 1996). The list of intense experiences that the couple might manifest is quite lengthy and may be the source of considerable pain: guilt, shame, inadequacy, stigmatization, anxiety, stress, fear of spousal rejection, devastation, rage, anger, isolation, helplessness, powerlessness, loss of control, doom, despair, mourning, depression, frustration, feeling cheated, fatigue, moodiness, tenseness, disappointment, and loneliness (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Connolly & Coo\ke, 1987; Daniluk, 2001b; Forrest & Gilbert, 1992; Serono Laboratories, 1996; Williams et al., 1992). The preceding itemization of emotions is by no means an attempt to minimize the pain and intensity of each experience for the couple. Instead, the list is used purposefully to help clarify the vast array of emotions that can overcome the couple at any moment. The list is used to help convey the intense, out-of-control, wavelike emotions that can take over without any warning. This inventory of emotions attempts to communicate the loss of control that the couple may be experiencing, perhaps for the first time in their lives (Cooper-Hilbert, 2001). An added dimension of the emotional roller coaster is that each partner may be experiencing quite different emotions at different times, thus exacerbating a potentially explosive situation (Cooper-Hilbert, 2001). Atwood and Dobkin called attention to the confounding condition resulting when an individual experiences a period of calm and acceptance, believing that the worst is over, and then is unexpectedly surprised with a sudden slam of intense negative emotions.

While all of these emotional changes are occurring, there may also be physical changes taking place throughout the body. Klempner (1992) reported that infertile couples often experience somatic complaints. These may include nausea, heart palpitations, and faintness (Atwood & Dobkin, 1992). Butler and Koraleski (1990) noticed a decrease in cognitive functioning, headaches, and stomachaches. The counselor needs to be aware of all of the physical and emotional changes that occur while a couple is coping with infertility. Developmentally, there are also many additive factors that contribute to the stress that the couple may endure.

Developmental Impact of Infertility

The couple may believe that their life goals have been disrupted and that they will not be able to achieve a major milestone (Butler & Koraleski, 1990). Childbearing is a normative transition, and thus being infertile thwarts a step in adulthood development (Gibson & Myers, 2002). The failure to attain a milestone may also have repercussions for other family members. Hopeful members of the extended family, including expectant grandparents (Cooper-Hilbert, 2001; Forrest & Gilbert, 1992), aunts, and uncles, may feel disappointed by the couples' inability to have a child. The couple may feel that they have failed in their role as adults (Atwood & Dobkin, 1992; Ulbrich, Coyle, & Llabre, 1990) and have failed at having a successful marriage. They may also feel as if their lives are "on hold" as they wait to make future plans because of the hoped for pregnancy (Daniluk, 2001b; Forrest & Gilbert, 1992). With each failed treatment, the couple has to go through the cycle and stigma of being "failures" again and decide once more what to do next (Atwood & Dobkin, 1992; Butler & Koraleski, 1990). Studies have repeatedly documented the loss of control that the couple must face and the loss of the dream of having a biological child (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Forrest & Gilbert, 1992). It is understandable that all of these feelings and emotions will have consequences for the couple's marriage.

Marital Effects of Infertility

The infertility may lead couples to question the purpose and meaning behind their marriage (Matthews & Matthews, 1986). A spouse may begin to feel resentment and rage toward his or her partner (Atwood & Dobkin, 1992) or fear that "they're the one" responsible for the infertility (Cooper-Hilbert, 2001). If one partner places the blame of infertility on him- or herself, there is an increase in distress for that partner (McEwan, Costello, & Taylor, 1987). The couple may lose their original view of what it means to be "family" and all of the options available to them to achieve this end (Cooper- Hilbert, 2001), focusing solely on the inability to have a biological child. Slade, Raval, Buck, and Lieberman (1992) performed a 3-year follow-up study of couples who were infertile. For those couples who remained infertile, the high rates of anxiety, depression, and hostility remained if they did not have strong coping skills. Sabatelli, Meth, and Gavazzi (1988) noted that couples tended to cope better with their infertility when they had higher rates of self-esteem, increased marital commitment, increased marital satisfaction, less denial of the reality of their situation, and were able to reframe the problem so that it was more manageable. It is interesting that both the length of time a couple had been trying to conceive and the causes of infertility were unrelated to levels of stress (McEwan et al., 1987). However, Abbey et al. (1992) noted that the husband's level of stress was related to the wife's self-esteem. In summary, it seems that there is a need to reduce the level of stress by using coping skills and that there should not be "blame" placed on one partner for the infertility. From a positive perspective, when the infertility is acknowledged by both partners, the infertility can actually bring the couple closer through their experience of sharing the problem (Connolly, Edelmann, Cooke, & Robson, 1992). Such a positive perspective has the potential of being enhanced if the counselor brings this awareness to the couple. Although it may be encouraging to hear about a positive side effect of going through the infertility experience, there are still trials that the couple will most likely face, especially with their sexual identities.

Sexual Discomforts Related to Infertility

Infertility can cause a tremendous amount of pressure on the couple's sexual intimacy. The increased desire to produce a child has caused several negative side effects for many couples (Sabatelli et al., 1988). Consistently, couples report that their sexual privacy has been violated by doctors' scheduled copulation demands (Forrest & Gilbert, 1992; Sabatelli et al., 1988), and couples feel as if their sexual identity has been lost (Atwood & Dobkin, 1992). Often the joy of sex has been reduced to a goal-oriented act of achieving a pregnancy , with a focus only on the inabilities and inadequacies of the couple (Cooper-Hilbert, 2001). There can be a generalized decrease in each partner's sex drive (Klempner, 1992). As one can imagine, there are bound to be sexual and physical side effects generated by this "time bomb" of pressure to have a child. For example, the couple may lose a positive sense of their sexuality and feel like sexual intercourse has become a chore (Serono Laboratories, 1996). The possible problems could also include a self- hatred of one's own body, which would certainly affect a person's level of comfort with sexual intercourse (Butler & Koraleski, 1990). Men may experience impotence, while women may experience a decrease in lubrication and anorgasmia (Butler & Koraleski, 1990; Connolly & Cooke, 1987). There may be extramarital affairs, which can only compound the negative situation (Butler & Koraleski, 1990). Sabatelli et al. reported that 56% of women experienced a decrease in sexual intercourse after finding out about the infertility, 59% reported being less satisfied with sexual intercourse, and 49% said they were less comfortable with their sexuality. Couples entering into therapy may need to explore their current feelings surrounding their sexuality. In Sabatelli et al.'s aforementioned study, 63% of couples reported a sense of increased spousal emotional support. However, the stress of coping with infertility primarily carries a tremendous burden for both partners. As introduced below, it is noteworthy that this stress has been dealt with differently, depending on the gender of the partner.

Women and Infertility

Women are often seen as the "victim" of infertility and thus carry more stress and potentially more of the burden than men (Forrest & Gilbert, 1992; Gibson & Myers, 2002; McEwan et al., 1987; Serono Laboratories, 1996; Ulbrich et al., 1990). Younger women tend to be at an increased risk for stress. As women age, they seem to have a greater capacity for acceptance, thus decreasing their level of stress. Specifically, women tend to have higher rates of stress if there is not a diagnosis for the infertility, if their religion places a high importance on children, and if they lack a confiding spouse (McEwan et al., 1987). Women who are anticipating sperm donation may also have an increase in negative dreams, including dreams about infidelity (Forrest & Gilbert, 1992). There is also an additional reality that women must cope with each month: their menstrual period. The menstrual period can be a time of extreme emotion for a woman because it is an obvious, visual indicator that she is still not pregnant (Atwood & Dobkin 1992; Klempner, 1992; Serono Laboratories, 1996; Williams et al., 1992). In People (Schneider, 2002), Shelley Jordan, describing her infertility experience, said, "I would cry every month I got my period" (pp. 82- 84).

Women may also go through the pain of miscarriages, loss of the prospect of breast feeding, and the loss of having the experience of the changes to their body during pregnancy (Forrest & Gilbert, 1992). Women may find their infertility to be devastating and therefore seek comfort by talking about their crisis with friends and partners. This coping style seems to decrease the level of stress experienced by women (Butler & Koraleski, 1990; Gibson & Myers, 2002; McDaniel, Hepworth, & Doherty, 1992; Stanton, Tennen, Affleck, & Mendola, 1992; Williams et al., 1992). Because talking to others is an effective way for women to reduce their anxiety, they may be more open to the process of counseling than are men (McDaniel et al., 1992).

Men and Infertility

Men find that a difficult aspect of coping with the infertility experience is witnessing their partner's pain. This is worsened by their uncertainty about what to say to help console their partner. Men tend to discoun\t women's fear of infertility and suggest that if they "stop worrying" they "will get pregnant." Men may feel helpless and thus shut down emotionally, exactly the opposite of women's experiences (Atwood & Dobkin, 1992; McDaniel et al., 1992; Williams et al., 1992). Ironically, the more men talked about their distress, the more distressed they felt (Williams et al., 1992). This could leave the women feeling as if their spouse does not care; when in reality it simply means that the men had a different coping style. It has been observed that the men view infertility as a disappointment or "bad break," but do not consider it to be as devastating as do many women; thus, the transition into childlessness may be smoother for men than for women (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Ulbrich et al., 1990). Ulbrich et al. noted that the men's, rather than the women's, wishes concerning the infertility problem were often fulfilled. If the men did not want children but the women did, infertility meant they would not have children. If the men wanted children and the women did not, they would likely use the infertility as the basis to divorce.

Although men were often able to deal with the infertility in a manner deemed effective, they also reported struggles with infertility. Men grappled with feelings of inadequacy, lower self- esteem, stolen masculinity, and lost virility (Serono Laboratories, 1996). In addition, even though men may appear to have maintained a better sense of self-identity throughout the infertility experience, their global distress levels were higher than those for women. This may be because their chosen coping styles-avoidance and withdrawal- are aversive in effect; therefore, men may not have taken into consideration the full impact that infertility had on their life (Stanton et al., 1992).

Grief

Being infertile has stripped a sense of control from the couple, and they are left trying to recreate a sense of meaning and purpose for their lives. They may withdraw or go to places where they can be with children to grieve the loss of their anticipated lives as parents (Atwood & Dobkin, 1992). The grief that the couple go through is similar to grief experienced with a terminal illness or death (Cooper-Hubert, 2001; McDaniel et al., 1992). The couple go through feelings of shock, denial, guilt, anger, helplessness, isolation, depression, and loss. It is to be hoped that acceptance and resolution can also be achieved (Cooper-Hubert, 2001; Forrest & Gilbert, 1992; Klempner, 1992; Serono Laboratories, 1996). The couple may experience some of these feelings, move on, and then cycle again through the same intense emotions. Atwood and Dobkin provided an informative breakdown of the grief cycle. They identified four general phases that most couples move through: disbelief and denial, anxiety and loss of control, isolation and guilt, and resolution. It is during the isolation and grief stage that most couples will seek counseling. Therefore, it is important to deeply explore with clients the pain associated with the inability to conceive biological children. There is the hope that resolution will come as the couple accept the loss of control over fertility and are able to take new productive directions in life. This resolution may not occur for some couples. Daniluk (2001b) provided an excellent longitudinal study of what happens to couples once they have made the decision not to have biological children. This process includes hitting a wall of emotion about the full implications of the decision approximately 10 months afterward, a reworking of the past experiences, turning toward the future, and, finally, feelings of surviving rather than feeling victimized. Because these issues are outside the scope of this article, they are simply referenced here for further reading. Infertility specialists strongly recommend counseling for couples going through this experience (McDaniel et al., 1992), which is quite understandable given the extreme challenges that the couple will undergo. Thus the question remains, "As a counselor, how can I be of the most benefit?" Suggestions to address this concern are presented in the following section.

COUNSELING ISSUES RELATED TO INFERTILITY

Infertility is a complex problem with many personal variables for the couple involved. This article is not meant to oversimplify the intensity of experiences, but instead is offered to provide counselors with a framework from which to draw. As in the case of Marilyn and Pedro, not all couples will seek out counseling claiming infertility as their ailment. An unprepared counselor may not even consider the impact of infertility on a couple such as Marilyn and Pedro. If a couple is in the developmental stage at which children may be expected, the counselor should inquire as to their plan in this regard. Was it a personal choice not to have children or forced because of infertility? Has there been a pregnancy and, if so, what was the result? The counselor should explore what it means for the couple to be without children. If there are unresolved pains, explore them. What treatments have they tried? How long have they been infertile? What conclusions have they come to? Try to understand the couple's thoughts and feelings related to their infertility experience. Some infertile couples may have children by adoption or blended families, and therefore the infertility experience may be more difficult to identify. Simply asking, as part of an intake process, how many pregnancies a woman has had can provide critical insights.

Normalize the Experience

Primarily, the counselor needs to bear witness to the pain and normalize the experiences of the client (Daniluk, 2001b; Forrest & Gilbert, 1992). Acknowledge the stress (McDaniel et al., 1992) incurred and provide the opportunity for the couple to vent their frustrations (Williams et al., 1992).

In the previously discussed case, Marilyn and Pedro may need time to examine and analyze the meaning of their infertility. Along with normalizing the experiences, educating the couple regarding typical responses and emotions relating to infertility maybe helpful (Callan & Hennessey, 1989; Cooper-Hilbert, 2001). Atwood and Dobkin (1992) suggested acknowledging the crisis through effective communication and empathic counseling skills. They suggested exploring the couple's feelings of being out of control and helping the couple express feelings of anger, sadness, and helplessness. Therapists should provide the couple with the opportunity and time to express frustrations regarding the responses of their friends and family. Marilyn may need to decide how she wants to respond to her mother when her mother pressures her about children.

If either or both partners are taking medication for the infertility, possible side effects include headaches, nausea, moodiness, emotional outbursts, and distractibility (Butler & Koraleski, 1990; Cooper-Hubert, 2001). Butler and Koraleski suggested assessing the couple's risk level for suicide because they are at a higher risk for this. They also suggested helping the client express fears about treatments, relationships, and future choices. Help the couple to find worth and meaning in life. This can be done by exploring what is meaningful to the couple and what perspectives they have gained through their infertility experience. An identity can be developed, providing them with a sense of a role in society with or without children. The couple's ability to cope with the disappointment of infertility may be enhanced by illustrating their strengths. The counselor must also address the couple's sense of isolation. Forrest and Gilbert (1992) proposed that, during the process of normalizing the couple's experiences, it would be helpful to make a connection to another time when they have had similar emotions. This could provide insight regarding the coping skills that helped the couple cope with that experience, and those strengths can then be drawn upon. Forrest and Gilbert and Atwood and Dobkin (1992) proposed that the counselor should seek to confirm or disconfirm client myths such as "It is my fault because I took birth control." This exploration and normalization of client experiences will lead to the second phase of counseling: gaining self-acceptance.

Self-Acceptance

Often the client feels his or her personal failure, and so the counselor's job is to explore feelings related to self-blame. Daniluk (2001b) stated that self-acceptance is a prerequisite for a satisfying future. The infertility needs to be thought of as an external dilemma that has a medical origin (Cooper-Hilbert, 2001; McDaniel et al., 1992). The loyalty to the marriage or spouse needs to be reaffirmed, because there can be so many personal doubts in this area. The infertility needs to be seen as a couple's challenge, not an individual's problem (Cooper-Hilbert, 2001; Daniluk, 1991). The goals of this phase of counseling are to reaffirm clients' self- esteem (Butler & Koraleski, 1990) and allow them to forgive themselves (Williams et al., 1992). Hopefully, self-esteem and forgiveness can be achieved. However, this may not be possible for all couples. Again, this article is provided as a tool to be used by counselors to help couples. Every couple is going to be different, and the counselor needs to remember this throughout the process. At this point in counseling, providing the couple with an education about different coping styles can be useful. Both Marilyn and Pedro would benefit from sharing their perception of what/who is responsible for their infertility. The counselor can then encourage movement from blame to self to partner acceptance.

Coping and Communication Styles

Because men and women cope differently with infertility, counseling can be used as an opportunity to explore these differences (Forrest & Gilbert, 1992). Counselors need to educate couples about the different coping s\tyles used by men and women. Generally, men may be viewed as "distancers" while women are seen as "pursuers" when considering their styles of communication. Pedro, in this case, does not seem to be struggling with the infertility. This may lead Marilyn to struggle more. Men may want and need help to articulate their loss, while women may need reassurance that their partner cares (Williams et al., 1992). As a couple's coping strategies are increased, so is their ability to handle the crisis (Cooper-Hilbert, 2001). A couple may find relief when each partner understands that their coping styles differ and that individual experiences may occur at different times (Serono Laboratories, 1996). More important, in most cases the woman needs to know that she is not grieving alone.

Coping strategies may include talking to others for support and understanding. Assistance with communication skills can improve the couple's understanding of each other's experience. Effective communication can be accomplished through "I statements," listening, reflecting, and role playing of family needs (e.g., saying no to going to a baby shower; Atwood & Dobkin, 1992). The couple may need to address distancing that has occurred between them regarding triangulation related to the hoped for a child (Cooper-Hilbert, 2001). Understanding coping and communication styles can help the couple come together. Communication about the couple's sexuality concerns may be dealt with next. The couple may have been avoiding sexual intercourse because of the link to infertility and feelings of inadequacy. Sexuality can be addressed in therapy, with a focus on sexual intercourse for fun and closeness instead of for "baby making." Both Marilyn and Pedro present with issues regarding sexuality, sexual performance, and sexual pleasure. Daniluk (2001b) encouraged moving the focus of sexuality off of failure and toward sexual pleasure. Williams et al. (1992) explored all of the potential areas that might need to be addressed regarding couples' sexuality. This includes an examination of "demand performance" and normalizing those feelings; "non-sexed" touching and affection, with a focus on enjoyment; and having the couples take a break from trying to conceive, giving them permission to experience making love again. When communication has been restored, the mourning process can be explored. Prior to considering the mourning process, however, a timeline of when to stop trying to achieve a pregnancy should be developed (Callan & Hennessey, 1989; Cooper-Hilbert, 2001; Forrest & Gilbert, 1992; McDaniel et al., 1992).

Mourning the Loss

When the decision has been made to stop trying to conceive a child, the time has come to grieve for the loss of the hoped for child (Butler & Koraleski, 1990; Callan & Hennessey, 1989; Forrest & Gilbert, 1992; McDaniel et al., 1992). The goal is to reach acceptance and acknowledgment that everything reasonable has been done to try to conceive a child (Connolly & Cooke, 1987). For example, Marilyn and Pedro need to make a conscious decision regarding whether or not they think they have "tried everything." If the couple believe they have not tried everything, the grieving process may not begin. For many couples this process may never begin. The sense of loss, or nonevent, needs to be thought of within the framework of a grief model (Anderson, 1989). Atwood and Dobkin (1992) treated the loss as the "death" of the hoped for child. Along with that loss come the losses of related concepts such as "family," genetic continuance, self-images, pregnancy, childbirth, breast- feeding, parenting, and family roles (i.e., grandparenting). At this point, the importance is focused on grieving for the loss of a biological child. The grief cycle may include disbelief, denial, anxiety, anger, loss of control, bargaining, and fear (Atwood & Dobkin, 1992; Butler & Koraleski, 1990). The couple are entitled to grieve and to work through this process. Creating a ritual to let go of the hope of having a biological child (Williams et al., 1992) and acknowledging the "death" by writing a letter (Daniluk, 1991) may be helpful. When the couple have expressed their emotions surrounding the loss of their hoped for child, a new future can be developed. Cooper-Hilbert (2001) proposed that couples create a genogram of their own families. This would enhance the couple's ability to frame infertility concerns within a family context. For example, an examination of planned and unplanned pregnancies, infertility, adoptions, and abortions may help the couple realize that other family members have experienced fertility struggles and disappointments. This exploration may help the couple gain new perspective and understanding (McDaniel et al., 1992).

Future Orientation

After the couple have achieved a sense of closure regarding the inability to have a biological child, establishing a new definition of family can be addressed. A reconstruction of the goals and motivation for their marriage will help the couple determine a new purpose for their life together, and the desire for parenting can be readdressed (Cooper-Hilbert, 2001; Daniluk, 2001b; Sabatelli et al., 1988). Perhaps the couple could move from a focus on pregnancy to a focus on couplehood or parenting by adoption, forming a new construct of what family means for them and clarifying their own values related to the concept of family (Atwood & Dobkin, 1992; Matthews & Matthews, 1986; Williams et al., 1992). This may include consideration of outward influences as well as inward voices. Examples of exploratory statements suggested by Williams et al. (1992) was, "My church says this . . .""My Mom always says this . . ." Determining what the couple feel may be a difficult task with so many external influences to take into account. External influences seem critical for Marilyn-her mother and her religion. A couple's culture and background will contribute additional ideas about what "family" means. In this case, how does Machismos, or cultural expectations of Latino males to be sexually virile, factor into Pedro's identity? Atwood and Dobkin (1992) suggested using a cocreated language for defining "family." They also suggested having a ritual to signify the fresh start for the couple who have made the decision to stop trying to conceive. A new moment within their relationship is defined where fertility is not the focus. A sorting out of options could occur at this point in counseling. Forrest and Gilbert (1992) pointed out that adoption does not end the couple's pain; it is only another choice. There are costs and benefits involved with the decision that is made regarding whether or not to have children. Financial burdens, career choices, and life goals all need to be explored and prioritized; there may be positive gains from not having a child (Atwood & Dobkin, 1992; Callan & Hennessey, 1989; Daniluk, 2001b; McDaniel et al., 1992; Williams et al., 1992). Guided imagery or roleplays to depict the experiences of adoption and childlessness may be beneficial to help the couple to clarify their choices. Daniluk (2001b) recommended having the couple write down two 5-year plans, one with a child and the other without. Once the couple have made a decision about their future, a sense of control may be gained. If the decision to adopt has been made by the couple, the counselor should continue to be supportive through the "on-hold" waiting process (Daniluk, 2001b).

Gaining Control

The literature consistently points out the need for the couple to feel a sense of control in their lives again (Atwood & Dobkin, 1992; Butler & Koraleski, 1990; Callan & Hennessey, 1989; Cooper-Hilbert, 2001; Daniluk, 2001b). The most significant way the couple can regain control is in the "decision-making" process. Daniluk (2001b) pointed out that the couple must relinquish control over their fertility, but gain control over life choices. This includes deciding whom to tell about their decision and when to tell them (Butler & Koraleski, 1990; Callan & Hennessey, 1989; Cooper- Hilbert, 2001; McDaniel et al., 1992). Role-playing may be done in counseling that could include considering who will be supportive and understanding. Working through these techniques, the couple's life can be taken "off hold" and steps toward future decisions can be made. Gaining control will also help to reestablish lost connections with family and friends (Cooper-Hilbert, 2001; McDaniel et al., 1992; Williams et al., 1992). Gibson and Myers's (2002) study with women indicated a direct correlation between higher growth- fostering relationships and lower levels of stress. Strong relationships for women signify the importance of having a strong social support to help in dealing with infertility. Atwood and Dobkin used the more positive language of "a couple with a fertility problem," which typifies the ability to gain control of life and externalize the crisis. They also proposed creating a life story for the couple that did not include the problem of infertility. This new life story can include creating a new worldview with different meaning and focus for the couple (Cooper-Hilbert, 2001). McDaniel et al. provided the couple an opportunity to remember who they were before the infertility problem.

There are many resources that have been helpful for couples coping with infertility. One of the most beneficial assets for couples seems to be networking with other infertile couples (Atwood & Dobkin, 1992; Callan & Hennessey, 1989; Forrest & Gilbert, 1992; McDaniel et al., 1992). Additional sources for relief and control include books, meditation, prayer, RESOLVE (www.resolve.org), family, and friends (Atwood & Dobkin, 1992; Callan & Hennessey, 1992; Forrest & Gilbert, 1992; McDaniel et al., 1992; Williams et al., 1992). Some noteworthy books include What to Expect When You're Experiencing Infertility: How to Cope With the Emotional Crisis and Survive (Peoples \& Ferguson, 1998); The Infertility Survival Guide: Everything You Need to Know to Cope With the Challenges While Maintaining Your Sanity, Dignity, and Relationships (Daniluk, 2001a); and Not Yet Pregnant: Infertile Couples in Contemporary America (Greil, 1991). Some current online resources include www.asrm.org/, www.fertilityworld.org/, and www.serono.com (retrieved June 30, 2003).

SUMMARY

Marilyn and Pedro have survived what millions of couples have been familiar with: infertility. Marilyn and Pedro's lives were affected biologically, psychologically, and sociologically by their infertility. They did not come to counseling because of infertility, and yet it was discovered that their primary difficulties were embedded in their infertility experiences. Through counseling, they gained a greater understanding of their emotional needs; in particular, Marilyn achieved self-acceptance. They were able to improve their communication, which led to the ability to mourn the loss of the possibility of giving birth to their own child. Their sexual relationship improved, and they addressed what their future family goals were going to be. Most important, they were able to gain control of their lives again and have decided to keep their marriage intact.

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Kathryn J. Watkins and Tracy D. Baldo, Division of Professional Psychology, College of Education, University of Northern Colorado. Correspondence concerning this article should be addressed to Kathryn J. Watkins, 2429 15th Avenue Court, Greeley, CO 80631 (e- mail: katjwat@comcast.net).

Copyright American Counseling Association Fall 2004

Source: Journal of Counseling and Development : JCD

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