The decision to start a family is an important milestone in the lives of many adults. Often the anticipation of creating a new generation represents the final shift away from one’s own childhood. While this decision is almost always made with a mix of excitement and some ambivalence, when something gets in the way of the expected trajectory, such as infertility or pregnancy loss, a person’s sense of self and identity can suffer a real injury.
A diagnosis of infertility can be the result of many factors, including age-related fertility decline, previous medical treatments such as radiation or chemotherapy, or specific fertility-related medical issues such as low sperm count/mobility or hormonal/structural issues. Discovering that one’s fertility is not intact can have an impact on a person’s emotional wellbeing, sense of agency, and relationships with family and friends.
By the time the decision has been made to pursue fertility treatment, there are likely to have been numerous psychological impacts. In order to begin treatment for infertility, a couple must have been trying to conceive unsuccessfully for a year, or for six months in women over the age of 35. During the period of time preceding fertility treatment, couples often experience excitement and hopeful anticipation, followed by disappointment when pregnancy does not occur. Feelings of shame, loss of trust in one’s body, and grief are just a few of the difficulties patients may be struggling with before fertility treatment has even begun.
Some common themes emerge for couples dealing with infertility, including a wish to be “normal,” and shame regarding not living up to traditional gender expectations. There can be interference with intimacy, where sexual activity becomes perfunctory or scientifically timed rather than arising from a desire for pleasure and intimacy. Couples may have different reactions or coping styles, which can create or intensify emotional distance. Feelings of failure can arise, which can lead to a loss of self-esteem. The feelings of failure can be as profound for men as they are for women when pregnancy is unattainable.
Couples who decided to delay having a child for professional reasons may feel guilty for waiting and may blame themselves for their difficulty conceiving. When fertility patients are high achievers, the inability to become pregnant or maintain pregnancy can have a profound impact on their sense of themselves as capable and competent, which may have been central to their identity.
While undergoing fertility treatment, many patients and couples experience isolation from friends who are pregnant or from those who already have young children. It can be very painful to watch friends who are immersed in their own new families. Baby showers can feel like salt in a deep wound. It can be difficult to hear well-meaning friends and family make statements that are meant to be encouraging but are actually insensitive and hurtful: “Why don’t you just adopt?” “Stop stressing and you will get pregnant.” “Are you eating the right foods?” “Are you sure you aren’t over-exercising?” While social media can provide individuals and couples undergoing fertility treatment with a sense of community with others who share their situation, it can also become a source of significant pain; often the couple perceives that the ability to have children comes easily to others, making them feel more isolated.
Psychological difficulties that may arise include intense feelings of anger, depression, and anxiety about interventions and treatment outcomes. Additionally, the medications used in fertility treatment can have side effects that impact emotional functioning and intensify these feelings, particularly in patients with a history of hormonal sensitivity or psychiatric diagnoses, including anxiety and/or mood disorders. The psychological impact is often overlooked by medical teams as patients are subjected to numerous tests, monitoring and physical interventions.
Even as they may welcome the possibility of having a child that is genetically related to one partner, LBGTQ patients face their own unique stressors. If the couple decides to pursue fertility treatment, they must make a multitude of decisions, including which partner’s gametes are used, who will carry the child (one of the partners or a surrogate), and using a known versus unknown donor. Infertility treatment has historically been targeted primarily at heterosexual couples, and LGBTQ couples may still face judgement and discrimination within their social circles, and even in medical communities. There may also be legal questions to consider, including access to treatment and insurance coverage, custody, etc. Single parents by choice may face similar challenges, including judgment and barriers to treatment.
Fertility treatment includes a broad spectrum of interventions, from drug therapies to more advanced technologies, including IVF (In Vitro Fertilization). Treatment success is not guaranteed, and even when treatment is successful, anxieties and a compromised sense of self may continue. When initial attempts at treatment are not successful, deciding when to stop treatment can be a source of conflict for a couple. When fertility treatment is successful, it is common for a woman to feel that she has somehow forfeited the right to complain in any way about the very real stresses of pregnancy and early motherhood. After all, she went to great lengths to start this family.
Overall, fertility patients are often a high functioning group in a highly stressful situation. Psychotherapy can be very helpful as patients navigate difficult medical and emotional terrain. Planning for the future and having conversations with children regarding disclosure of donor conception can be particularly important when using third party reproduction/donor gametes. Thoughts and feelings that arise during the process and beyond can be explored in treatment, support and education can be provided, and coping skills/styles can be addressed to help manage the stress on the individual and couple. Seeing a therapist who is knowledgeable regarding the issues facing patients undergoing fertility treatment can help make a stressful period much less difficult.