The vigorous media coverage of "Octomom" Nadya Suleman in early 2009 touched off a spirited public debate about infertility treatments. Suleman had given birth to octuplets through an advanced technique called in vitro fertilization or IVF. (IVF combines eggs and sperm in the laboratory; the embryos are then inserted into a woman's uterus.) To capitalize on the curiosity, a television special aired with images that advertising claimed were "incredible."
But Octomom is what researchers might call an "outlier" — a person whose experience is not typical. And the coverage of unusual case like this may hide the far more common, and usually private, psychological challenges of infertility.
The Pain of Infertility
While the causes of infertility are overwhelmingly physiological, the resulting heartache may exact a huge psychological toll. The physical and emotional ordeal of infertility treatment often make matters worse.
Many women who have been through it and some of their male partners have said that infertility was the most upsetting experience of their lives.
Other research has suggested that women with infertility feel as anxious or depressed as those diagnosed with cancer or hypertension, or who are recovering from a heart attack.
|Infertility by the Numbers
- About 5% of couples living in the developed world have never been able to become pregnant (called primary infertility). Or they have been pregnant at least once but have not been able to become pregnant again (called secondary infertility).
- About 1.3 million patients receive infertility advice or treatment each year in the United States. Most cases of infertility are due to a physiological problem in the man or woman. Experts used to think that only about a half of all infertility problems were physical in nature; the rest were unexplained or the result of psychological problems in women.
- About one-third of the time a physiological problem is identified in the woman, one-third of the time in the man, and about one-tenth of the time in both partners. In another 10% to 20% of cases (estimates vary), the cause cannot be found.
Men tend to report less distress than women. However, one study found that men's reactions may depend on who is diagnosed with infertility. When their wives or partners are infertile, 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.
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Common Reactions to Infertility
People who learn they are infertile often experience the normal but nevertheless distressing emotions common to those who are grieving any significant loss — in this case the ability to procreate. 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.
Relationships between spouses or partners may suffer. Well-meaning friends and family members may offer misguided advice and opinions that are hurtful. Couples dealing with infertility may avoid friends who are pregnant and have children. They may struggle with anxiety-related sexual dysfunction and other marital conflicts.
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The Stress of Treatment
There are about 40 ways to treat infertility. About 85% to 90% of patients are treated with more straightforward methods, such as advice about timing of intercourse, drug therapy to promote ovulation or prevent miscarriages, and surgery to repair reproductive organs. Only about 3% of patients use more advanced assisted reproductive technology like in vitro fertilization (IVF). While medical interventions offer much-needed help and hope, studies suggest that they may also add to the stress, anxiety and grief that patients are already experiencing from infertility itself.
Medication side effects – The synthetic estrogen clomiphene citrate (Clomid, Serophene) improves ovulation and increases sperm production, but it also can cause anxiety, sleep interruptions, mood swings and irritability (in women). Other infertility medications may cause depression, mania, irritability and thinking problems.
Money worries – Infertility treatment is expensive. The average cost for an IVF cycle using fresh embryos, for example, is over $8,000. Fertility drugs can add another $3,000 to $5,000 per cycle. A minority of states require insurance coverage for infertility treatment, and the extent of coverage varies. Patients who do not have coverage — or who can't pay for treatment — may feel helpless and hopeless. Even patients with insurance coverage may find that copayments or limitations on coverage mean they must pay more than they can afford.
Choices and outcomes – Over all, infertility treatments help about half of patients to become parents. But the chances of success decrease with age. The joy of becoming a parent may be tempered by the need to adjust to new roles and pressures. Couples who have had a previous miscarriage are likely to worry about losing the pregnancy. Older couples may debate whether to have prenatal testing like amniocentesis.
When treatment fails, on the other hand, a new cycle of grieving and distress can be triggered. The distress may be especially severe for patients living in nations like the United States, where the cultural assumption is that as long as you work hard and are persistent, you will succeed in achieving your goal.
It's also difficult to know when to stop seeking treatment. Frequently, one partner wants to end treatment before the other, which can strain a relationship. Most patients need time to make the difficult transition from wanting biological children to accepting that they will have to consider other options like adoption, or remain childless.
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Additional Mental Health Challenges
According to research, infertile patients feel more distressed than other people but, for the most part, they are no more likely to have anxiety, depression and other mental health disorders than people in general. Patients may experience serious mental health problems temporarily 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
Counseling – Short-term counseling can help couples reduce conflict and increase coping and decision-making skills. Patients who have prolonged changes in mood or sleep patterns should see a mental health professional, as these may be signs of anxiety or depression.
Ideally, couples should begin counseling before they start infertility treatment. Some studies suggest that addressing depression, anxiety, and stress, for example, may help increase the chances of giving birth to a child. Clinicians working with infertile patients can provide information on how to manage fatigue, reduce stress and anxiety, and improve communication with others.
Psychotherapy – Studies have shown that two types of therapy can relieve the mild to moderate depression infertile patients experience. The first is interpersonal therapy, which focuses on improving relationships or resolving conflicts with others. The other is cognitive behavioral therapy. It works by helping people identify and change unhealthy patterns of thought or behavior. Research has shown that individual, couples or group psychotherapy can be helpful for treating anxiety or depression.
Relaxation techniques – Experts recommend various relaxation techniques to reduce the considerable stress that infertility and its treatment often cause. These include mindfulness meditation, deep breathing, guided imagery and yoga.
Medications – Antidepressants and anti-anxiety medications are useful for moderate to severe symptoms of depression and anxiety. However, women who take psychiatric medication need to consider the risks to a developing fetus.
Also, some infertility medications can interact with psychiatric drugs. For example, birth control pills prescribed to regulate ovulation may decrease or increase blood levels of drugs given to treat anxiety or depression.
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Although the psychological 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.