It is a widely
held expectation that if and when we choose to, we will be able to have a
family. We do not challenge this assumption until difficulties in conceiving
are encountered and for some this presents a major life crisis. The pain and
loss can be immense. And, not surprisingly, infertility can have a significant
negative impact on marital and sexual relationships. It is a multilayered and
complex phenomenon and a number of issues are involved for the individual and
couple going through it, as it spans the biological, emotional, physical,
relational, social, financial and psychological domains.
The Impact and
effects of infertility
This differs
between males and females, regardless of the cause. It is the nature of these
different experiences, in addition to the actual infertility issue, that can
exert a significant strain on the couple relationship. The extent to which
infertility exerts a negative psychological impact can differ between
individuals and couples and is likely to be due to a number of factors,
including: their desire for a child/family; past experience; family history;
relationships past and present; diagnosis; cultural beliefs; and treatment
outcome. These factors are also likely to contribute to whether infertility
becomes an experience that prompts individuals and/or couples to seek
counseling, at what stage and for how long.
The impact of
infertility in females and males outlined below describes the key characteristics
that are experienced by each member of the couple regardless of the cause of
infertility; like male factor, female factor or unexplained. The experience is
doubtless more complex than the descriptions suggest and each individual and
couple will have their own unique experiences – not to mention diagnosis or
lack of one – that feed into their responses to infertility, and which ideally
need to be established and explored in the course of counseling.
Impact and
effects on females
The female
experience can be both complex and painful. It is generally characterized by
periods of intense feelings of isolation – from her partner, her social circle
and society. As more than one female client has reflected, it can feel as if
they are ‘on the outside looking in on the rest of the world’. Females can feel
unsupported and misunderstood throughout the experience, which adds to their
despair and isolation. Pregnancy and motherhood is inextricably wrapped up in
perceptions of femininity, and infertility can evoke a pervasive sense of
failure as a woman, a person, and, in cases of unexplained and female factor
infertility, she can feel that her body has failed her.
All of which can have a
devastating effect on self esteem. For those females who desire a child, this
desire can increase as the possibility of having one reduces and for some it
can become overwhelming, which creates a sense of urgency about finding a
‘solution’ to the problem. The result of this can be that treatment is pursued
without pausing to consider the impact of this route on them, their body, their
partner and their relationship. Treatment can be an unpredictable, long
drawn-out rollercoaster of hoping, waiting and disappointment, which may or may
not result in the birth of a child, and which can take a serious toll on
females in a number of ways. Ultimately the experience for females can be one
of grief.
Impact and
effects on males
Whilst many
males have a strong desire for a child and a family, unlike many females they
tend to have a ‘pragmatic ambivalence’ towards fatherhood and children. That
is, they will be happy if it happens; yet can come to accept if it does not. A
symptom of their pragmatic ambivalence is that they consciously adopt a
compliant position in relation to treatment. One consequence of this and their
inability to ‘fix the problem’ – as perhaps they can in other situations – is
that they tend not to express their negative feelings about the treatment
process or how they feel about having/not having children, to their partner.
This can be mistaken by their partner as ‘not caring’, but, on the contrary, it
is often because they care about their partner so much that they adopt this
position. This, in combination with the medical focus on the female, can leave
males feeling marginalized and inadequate throughout the experience, and this
is further compounded in cases of male-factor infertility. It can also lead to
a build-up of resentment, which is mirrored by their partner.
The experience
for males can be an anxiety-filled one that poses a major threat to their
masculinity. However, it is not necessarily an experience they either want or
feel able to share with their partner, or anyone else. And unfortunately, this
can lead people around them to make the assumption that they are ‘OK’ and
‘coping fine’. This is often not the case and, moreover, it can add to their
anxiety and sense of inadequacy. Another feature of the experience for males is
that they worry about the pressure on their partner, and their partner’s
increasing desire for a child, and the prospect of what might happen in the
future if they do not achieve their goal. So it can be a time of great
insecurity for males.
Impact and
effects on the couple
A combination
of factors, including female sense of isolation, male pragmatic ambivalence,
growing resentments, the medical, emotional and financial pressures of
treatment and uncertainty about what the future holds, can exert extreme stress
on the couple relationship. This normally manifests in a distance between them.
The result of this distance is at best a lack of communication and at worst a
breakdown of communication, which for many couples can result in separation.
Throughout the experience, couples tend to oscillate between periods of
distance and closeness, and the nature and frequency of these distances is
likely to be a key factor in whether couples stay together during and beyond
the experience.
How can
counseling helpful for infertile couples?
Given that
infertility impacts on males and females in distinct ways and that they tend to
deal with it in their own way, it follows that they each have distinct
counseling needs. The couple unit also has its own distinct counseling needs.
So there is a role for both individual and couple counseling, and, where there
are older children involved, there is a case for family therapy.
How counseling
helpful for females partner
The sense of
extreme isolation in females can be a distressing time, during which they
experience high levels of negative emotion and often feel unsupported and not understood.
Here, counseling can be of great benefit, and a long-term counseling
relationship may be of benefit throughout their journey, as and when they feel
they need support. In addition, there are points which can be particularly
difficult for females, where counseling can help. These include: the time
around treatment eg immediately prior to, during and following, regardless of
outcome; at critical points such as a miscarriage, anniversaries of due dates
of lost pregnancies; when friends/family fall pregnant; and on being told
treatment is not a viable option with their own eggs.
Following
treatment, and regardless of whether they become mothers or not, females can
experience a ‘delayed’ reaction in which they may be confronted with a host of
issues that have been unresolved due to being on the ‘treatment treadmill’.
Counseling can play an important role in terms of minimizing or preventing this
reaction, which may also have a negative effect on the bonding process with a
child or children.
How counseling
helpful for males partner
As mentioned
above, many males do not necessarily have a desire or need to discuss their
feelings with anyone, let alone a ‘counselor’, and may run in the opposite
direction if it is suggested, particularly in cases of male-factor infertility.
However, this reaction is not as straightforward as it appears. Many males who
do access counseling will reflect that if they had known ‘what counseling was’
they would probably have gone for it sooner, particularly in cases of male factor
infertility. They also expressed their concerns about confidentiality – which
their partner might ‘find out’ how they really felt. This can act as a
deterrent. Yet many males say they do feel the need to talk, in private, to
someone outside of their relationship about the trauma of the experience but
that they did not necessarily know how to find a counselor or what to expect
when they got there.
Males who do
access counseling, in addition to talking about their feelings, tend to want to
gain some kind of understanding about infertility and its impact. This includes
a desire to understand the medical diagnosis and procedures and what the female
experiences emotionally and physically, so that they know how to help their
partner. Males also have a desire for their partner to understand what they may
be experiencing emotionally and psychologically so that they are not perceived
as ‘not caring’ and ‘being fine’, when often they are not, despite outward
appearances.
How counseling
helpful for couples
Couples can
benefit from counseling at each stage of the infertility journey, chiefly
through the facilitation of communication and understanding between them. In
addition, couples can use counseling to help them deal with a number of
specific issues as they arise – such as decision-making around treatment
options, miscarriages, failed cycles and when they achieve a pregnancy, for
instance.
What are the
limitations of counseling?
Given the
distressing nature of infertility, it is not surprising that many individuals
and couples express a desire to receive psychological support. Yet what is
perhaps surprising is that less than 25 per cent tend to access it. There are
the feelings of failure (females) and inadequacy (males) which contribute to
the low uptake. But part of the explanation is that, unlike medical
intervention, counseling cannot provide a ‘solution’ to the problem of
infertility and so it is often not considered or offered.
Furthermore,
counseling often tends to focus on realistic goals and objectives, which
clients do not always find useful, and some can find this counterproductive. At
the time of treatment, couples feel a need to be optimistic and strong to cope
with the rigorous demands of it. They are also likely to be full of hope for
the outcome of the treatment cycle and their future. They may not wish to
discuss the more bleak and painful options at this stage. Counselors working
with this client group need to be aware of this and be able to work with
clients in a way they find beneficial.
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