Counseling People Experiencing Infertility

Definition

• The Practice Committee of the American Society for Reproductive Medicine (2013) defines infertility as a “disease, defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination” (p. 63). This type of infertility is also known as primary infertility.
• Secondary infertility is defined as “the inability to become pregnant or to carry a pregnancy to term, following the birth of one or more biological children. The birth of the first child does not involve any assisted reproductive technologies of fertility medications” (RESOLVE).

Resource:       
RESOLVE-The National Infertility Association
Infertility Diagnosis and Management http://www.resolve.org/diagnosis-management/

Prevalence

• According to the Centers for Disease Control (CDC), approximately 6.7 million women in the United States between 15-44 years of age have an “impaired ability to get pregnant or carry a baby to term” (http://www.cdc. gov/nchs/fastats/fertile.htm).
• For this same age group of women (15-44 years old), 7.4 million have used infertility services.
• Equal percentages of Hispanic, non-Hispanic white, and non-Hispanic black women have an impaired ability to get pregnant or carry a baby to term (10-12%). Asian women are reported to have a lower percentage of fertility impairment (6.7%; CDC, http://www.cdc.gov/nchs/data/nhsr/nhsr067.pdf ).

Resource:       
Centers for Disease Control and Prevention-Infertility http://www.cdc.gov/nchs/fastats/fertile.htm

Identification/Assessment Strategies (Non-Medical)

Fertility Problem Inventory (FPI: Newton, Sherrard, & Glavac, 1999)
The Fertility Problem Inventory (FPI; Newton, Sherrard, & Glavac, 1999) is a 46-item scale which involves individuals rating (on a 0-6 point likert scale) their level of agreement for items related to fertility concerns or beliefs. The results are organized into one global scale and five subscales, including social concern, sexual concern, relationship concern, need for parenthood, and rejection of child-free lifestyle. Social concern reflects the individual’s sensitivity to comments and reminders of infertility and feelings of social isolation. Feelings related to diminished sexual enjoyment and needing to schedule sexual relations are assessed in the sexual concern subscale. The relationship concern area is focused on the relationship with the partner involved in trying to achieve fertility. Items assess the individual’s concerns about the impact of infertility on the relationship and difficulties in discussing infertility with the partner.  Beliefs about future happiness and well-being, being dependent on having a child, and that being child-free is not an option are assessed in the rejection of child-free lifestyle subscale. For clinical purposes, the FPI is designed to be administered by helping professionals who hold a minimum of a master’s degree and have been trained in assessment. The instrument is considered to be an adequate measure of infertility stress for both men and women in different stages of the infertility and assisted reproductive technology experience (Moura-Ramos, Gameiro, Canavarro, & Soares, 2011). Administration time is approximately 15-20 minutes.

Fertility Quality of Life Tool (FertiQoL;  Boivin, Takefman, & Braverman, 2011)
Resource: FertiQoL- http://psych.cf.ac.uk/fertiqol/
The Fertility Quality of Life Tool (FertiQoL) is a 36-item scale that assesses core and treatment-related quality of life, overall life perceptions, and physical health on a 5-point likert response scale (Boivin, Takefman, & Braverman, 2011). The instrument was designed for international use, and is available in 26 languages. The FertiQoL provides six subscale and three total scores with a range of 0 to 100 (higher scores indicate higher quality of life). Four subscales (Emotional-impact of negative emotions on quality of life; Mind-Body-impact of infertility on physical health, cognition, and behavior; Relational-impact of fertility problems on a relationship/partnership; and Social-impact of infertility on social relationships) comprise the Core FertiQoL.  The Core FertiQoL is an indication of the average quality of life that is measured across all domains. The Treatment FertiQoL assesses the average quality of life across treatment domains that include Treatment Environment and Treatment Tolerability. Treatment Environment refers to how the accessibility and quality of treatment has impacted the quality of life. The impact on daily life of any mental and physical symptoms as a result of fertility treatment is measured by the Treatment Tolerability subscale. Mental health and medical health professionals can use the free instrument, and a 10-item treatment mode scale is available for clients who are currently undergoing infertility medical treatments. Administration time is approximately 10-15 minutes for the full scale.

Intervention Strategies

Infertility has been often described as a biopsychosocial crisis for both men and women because it includes multiple physical, financial, social, and psychological stressors (Gibson & Myers, 2000, 2002). Although males and females are both affected by the experience of infertility, researchers have indicated that women are more negatively affected by infertility (Abbey, Andrews, & Halman, 1991; Daniluk, 1997; Raval, Slade, Buck, & Lieberman, 1987; Ulbrich, Coyle, & Llabre, 1990; Peterson et al., 2012; Wright, Allard, Lecours, & Sabourin, 1989). Counseling interventions should be specific to the needs of the individuals and the couple system. Below are three of the most relevant counseling approaches for individuals and couples experiencing infertility.

Resources:     
American Society for Reproductive Medicine: http://www.asrm.org/FACTSHEET_Infertility_Counseling_and_Support/
RESOLVE:  The National Infertility Association

http://www.resolve.org

Gibson, D. M., & Myers, J. E. (2000). Gender and infertility: A relational approach to counseling women. Journal of Counseling and Development, 78, 400-410.

Relational-Cultural Theory
According to the Jean Baker Miller Training Institute (http://www.jbmti.org/Our-Work/relational-cultural- theory), Relational-Cultural Theory (RCT) “posits that people grow through and toward relationships throughout the lifespan, and that culture powerfully impacts relationship.” RCT is a theory that emphasizes the human need for connection through “mutual” relationships within the context of cultural influences. In working with individual and couples experiencing infertility, recognizing how the relationships (i.e., with partner and with others) are being affected within the social construction of parenthood (Gibson & Myers, 2000) is important.  Not only can the theory be used to help the individual and/or couple to reconceptualize their infertility experience, but interventions focused on empathy and mutuality can be implemented.  Specifically, empathy with self can be nurtured in individual and couples counseling with clients who are coping with infertility. Due to the social constructions around being parents, many individuals will blame themselves for not being able to “become” parents and have feelings of guilt or self-blame surrounding those beliefs. Relational cultural theory emphasizes the skill of empathizing with self in order to empathize with others. For a couple, learning a mutual empathy or “mutuality” will energize them as a couple and can provide a new or renewed direction in their lives. Mutuality can also be built into a support group setting for individuals and couples who are coping with infertility.

Grief Counseling
Because there is a cultural expectation that individuals should become parents, those who desire to have children may experience a sense of loss if and when cannot conceive (Watkins & Baldo, 2004). Similar to Kubler- Ross’ (1969) stages of death and dying, individuals and couples may experience feelings of shock, denial, guilt, anger, helplessness, isolation, depression, and loss. These feelings can intensify if there are pregnancy losses added to the experience. If a client interprets infertility from a philosophical point of view (i.e., infertility is part of divine intervention), then the professional counselor could provide counseling that helps the client reconstruct the meaning of infertility (i.e., instead of a loss, this may be a different opportunity; Gibson, 2007; Massey, 2000; Neimeyer, 2000). Hence, the professional counselor helps the client build a new “narrative” about the infertility experience through interventions which involve the client relearning about self, developing an existential grounding, rebuilding inter- and intrapersonal processes, and expanding verbal and nonverbal processing (Briggs & Pehrsson, 2008). Greif processing can be accomplished through the use of books, journaling, art, poetry, or movement. Multicultural considerations should guide the professional counselor in specific interventions that are co-constructed with clients (Payne, Jarrett, Wiles, & Field, 2002). For the couple who is considering the possibility of pursuing either fertility treatments or adoption, the counselor can ask the couple to create two different five- year plans (i.e., one with a child and the other without).  The aforementioned activity can facilitate the couple’s communication, and will help the couple better understand their thoughts and feelings about life without children. This intervention will help the couple gain some sense of control over a situation that has felt very uncontrollable and discouraging (Daniluk, 2001).

Resources:     
Grieving and Growing http://www.resolve.org/support-and-services/Managing-Infertility-Stress/grieving-and-growingcreative- outlets-to-grieving-during-infertility.html
Humphrey, K. M. (2009). Counseling  strategies for loss and grief. Alexandria, VA: American Counseling Association.

Couples Counseling/Sexuality Counseling
Although couples may seek infertility treatment, it is wrong to assume that they are eager to seek counseling for this issue. Professional counselors need to be sensitive to specific cultural groups’ reluctance to seek counseling and discuss issues related to sexuality (Burnett, 2009). Counseling may not be a culturally approved activity (Molock, 1999). If the couple presents for counseling, then a genogram may help the professional counselor understand the couple’s thoughts, beliefs, feelings, and family-of-origin experiences with infertility.  Burnett (2009) proposes “externalizing the problem as a counseling technique that helps couples to think of the problem as separate from themselves” (p. 172). By separating the issue of infertility from the couple, it allows them to process those thoughts and feelings and form goals about the issue to accomplish together. Couples counseling can also help them construct an “alternative dominant cultural discourse” to examine how cultural assumptions related to infertility have impacted their decision-making about their infertility. For example, strong religious beliefs may not allow the couple to think about themselves as not being parents. Finally, the clinical aspects of infertility treatment may impact sexual arousal and interest. These issues and specific interventions related to the sexual relationship can be constructed and implemented in counseling (Long, Burnett, & Thomas, 2006).

Resources:     
Low Sexual Desire and Infertility http://www.resolve.org/support-and-services/you-and-your-partner/low-sexual-desire-andinfertility. html
Living Childfree http://www.resolve.org/family-building-options/living_childfree/