In 2009, the story about a California woman who gave birth to octuplets generated intense media coverage. On the heels of the story came a run of public discussions about infertility treatments. The story did little to shed light on the usually private, psychological challenges faced by women who undergo treatment for infertility. Here's a look at the mental health challenges that about 1.3 million such Americans face each year.
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About 5% of couples in the United States experience infertility. Experts once thought that only about half of the infertility problems they saw were due to physical ailments, with the rest being mistakenly chalked up to emotional problems in the woman.
But most cases of infertility result from a problem in one or both spouses' biology. Here is the approximate breakdown:
- One-third can be attributed to the woman.
- One-third can be attributed to the man.
- One-tenth can be attributed to problems in both partners.
- In 10% to 20% of cases (estimates vary) no cause can be found.
But while the causes are almost always biological, the resulting heartache — often made worse by the demanding nature of infertility treatment — may take a huge emotional toll. For example:
- One study of 200 couples seen at a fertility clinic found that 50% of the women and 15% of the men said that infertility was the most upsetting experience of their lives.
- Another study of 488 American women entering a stress reduction program concluded that women with infertility felt as anxious or depressed as women diagnosed with cancer, suffering from hypertension or recovering from a heart attack.
- Men generally report less distress than women do, although one study found that men's reactions may depend on which partner is infertile. When the problem is diagnosed in their wives or partners, men do not report being as distressed as the women do. But when men learn that they are the ones who are infertile, they experience the same levels of low self-esteem, stigma and depression as infertile women do.
Individuals who learn they are infertile often experience emotions common to grieving any significant loss. In this case it's the inability to have a child. Typical reactions include shock, grief, depression, anger and frustration, as well as loss of self-esteem, self-confidence and a sense of control over one's destiny.
The relationship with a spouse or partner may suffer, too. Friends and family members may unintentionally cause pain with well-meaning but misguided opinions and advice. Couples dealing with infertility may avoid friends who are pregnant and families who have children. They may struggle with an anxiety-related sexual problem or other marital conflicts.
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The Stress of Infertility Treatment
Medical interventions offer much-needed help and hope. Yet studies suggest that they may also add to the stress, anxiety and grief that patients are already experiencing from infertility itself.
There are about 40 ways to treat infertility. About 85% to 90% of patients are treated with straightforward advice about the timing of intercourse, drug therapy to promote ovulation or prevent miscarriages, or surgery to repair reproductive organs. Only about 3% of patients make use of more advanced technologies such as in vitro fertilization (IVF).
Here are common sources of stress during treatment:
Medication side effects
Drugs and hormones used to treat infertility may cause psychological side effects. For example, the man-made estrogen clomiphene citrate (Clomid, Serophene), which improves ovulation and increases sperm production, may cause anxiety, sleep interruptions, mood swings and irritability in women. (These side effects have not been documented in men.) Other infertility medications may cause mood or thinking problems. Patients and doctors may find it difficult to figure out which symptoms are part of a reaction to the situation and which are caused by medications.
Infertility treatments are expensive. Some states require insurance companies to cover the treatment, but most do not. The extent of the coverage varies, too.
The average cost for an IVF cycle using fresh embryos, for example, is more than $8,000. Fertility drugs can cost an additional $3,000 to $5,000 per cycle. Patients who are not covered or cannot afford treatment may feel helpless and hopeless. Even patients with insurance coverage may find they have significant out-of-pocket costs.
Choices and outcomes
Over all, infertility treatments help about half of patients become parents. The chances of success decrease as people age. Patients who get pregnant may be overjoyed, but they also must learn to adjust to the new pressures. Women who have suffered multiple miscarriages, for example, are likely to feel anxious about carrying to term. Older couples may debate testing such as amniocentesis.
Treatment failure, on the other hand, may trigger a renewed cycle of grieving and distress. The distress may be especially severe for patients living in Western developed nations such as the United States, where it's assumed that anyone who works hard and is persistent will achieve a goal.
It's also difficult to know when to stop treatment. Partners may disagree about when to end treatment, thus straining the relationship. Most patients need to gradually, and with great difficulty, make the transition from wanting biological children to accepting that they will have to pursue adoption or come to terms with being childless.
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Additional Mental Health Challenges
Several studies indicate that infertile patients feel more distressed than other people do. More rigorous research, however, has concluded that — for the most part — rates of anxiety, depression and other mental health disorders are no greater than in the general population.
But the research is clear on one point. People dealing with infertility may experience serious mental health problems on a temporary basis, as they deal with the emotional and physical roller coaster typical of infertility treatment.
Infertility treatment can also make existing psychiatric conditions worse. Infertile women with a history of depression, for example, are more likely than other infertile women to become depressed during treatment.
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Therapies That May Help
Many patients find a way to cope on their own. Some find support from friends, family, or one of the many infertility support groups now available in person and online. But other people need additional help.
Short-term counseling is a common option. A counselor can provide support, advice about coping, or help with making important decisions. Some people may experience long-term changes in mood or sleep patterns, or severe relationship problems. They should seek a more comprehensive evaluation, as these may be signs of wider reaching problems.
Ideally, counseling should begin before patients start infertility treatment. Some studies suggest that addressing emotional factors such as depression, anxiety and stress may help increase the chances of giving birth to a child. Clinicians working with patients with infertility can provide information on how to manage fatigue, reduce stress and anxiety, and improve communication with others.
For more persistent problems, psychotherapy is a good idea. Interpersonal therapy, cognitive behavioral therapy or psychodynamic therapy (or some combination) may help individuals deal more effectively with their symptoms, their relationships or their view of themselves. Researchers have shown that individual, group or couples' psychotherapy can be helpful for anxiety or depression.
3. Relaxation techniques
Given that infertility and its treatment often cause considerable stress, experts recommend various relaxation techniques. For example, mindfulness meditation, deep breathing, guided imagery and yoga promote stress management. Visit Harvard's online resource center for stress.
Antidepressants and anti-anxiety medications are useful for treating moderate to severe symptoms. However, women taking these medications will also want to consider the possible effects medications may have on a developing fetus. Some infertility medications can interact with psychiatric drugs, increasing or decreasing the blood levels of some medications used to treat depression and anxiety. When patients and their doctors weigh such factors, they can usually manage medication decisions more comfortably.
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Although the emotional challenges of infertility can be overwhelming, most patients ultimately reach some type of resolution, whether becoming parents to biological children, adopting children or deciding to build a life without children. But this resolution is usually hard won and patients may feel forever changed by the experience of infertility.
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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.