Canadian Medical Association Journal 1996; 154: 1559-1561
© 1996 Evelyne Michaels
Jeri Hepworth, an associate professor of family medicine at the University of Connecticut School of Medicine, and Susan McDaniel, who teaches classes in psychiatry and family medicine at the University of Rochester School of Medicine, recently came to Toronto to speak to physicians, health care professionals and about 50 infertile couples during workshops sponsored by a private infertility clinic.
"Doctors are accustomed to helping their patients cope with physical illness," says Hepworth. "They must understand that their infertile patients, who aren't technically ill, often face a cycle of disappointment and anxiety that places them under tremendous strain."
As medical family therapists, Hepworth and McDaniel represent a new breed of American counsellor who specializes in helping patients and families cope with medical illness or disability, including infertility. They also educate medical students and physicians about ways to recognize and resolve common problems arising from infertility treatment.
According to a report from the American College of Obstetricians and Gynecologists, a medical diagnosis can now be established for about 90% of infertile couples. Reproductive technology can help about half of those who seek treatment to conceive.
But patients often find the experience of assessment and treatment emotionally daunting (see McCall M: Pursuing conception: a physician's experience with in-vitro fertilization [in brief / en bref]. CMAJ 1996; 154: 1075-1079). Besides coping with the initial diagnosis and the possibility of being childless, they endure a chronic hope-loss cycle. In many cases, they must accommodate diagnostic and treatment procedures that can be invasive and embarrassing: men having to masturbate into a bottle to produce semen for a sperm count, or women having to visit their doctor's office for a postcoital exam.
New technologies that help many infertile couples conceive often involve exhaustive cycle monitoring and hormone regimens, the use of donor eggs and sperm, and repeated inseminations. They place such complex psychosocial and physical demands on patients that some American infertility specialists insist that couples undergoing treatment make ongoing visits to therapists.
Hepworth and McDaniel say that the experience of infertility is similar to coping with the death of a loved one or being diagnosed with a chronic illness. After the diagnosis is known, patients may go through stages of mourning: denial, shock, anger, bargaining, depression and, finally, acceptance.
"Regardless of who carries the medical diagnosis," says McDaniel, "women tend to assume the emotional responsibility and express the couple's pain." She adds that men are socially conditioned to be more silent in their distress, either denying or avoiding their feelings, or else becoming brooding or withdrawn.
Doctors should also be aware that infertile couples are often on a different wavelength about the entire experience -- the women want to talk about feelings and options, while the men want simply to try and forget the problem.
Infertility often causes one or both partners to withdraw from their friends and family to avoid being exposed to small children or pregnant women, reminders of what they see as their own failure. This withdrawal makes the couple feel even more isolated and helpless.
Hepworth and McDaniel say the following strategies, currently employed by medical family therapists and other counsellors, can be adapted for use by family physicians and specialists who treat infertile patients.
Both Cadesky, who specializes in reproductive gynecology and surgery, and Laskin, who is a specialist in reproductive endocrinology, are assistant professors in the Department of Obstetrics and Gynaecology at the University of Toronto. They also work at a private fertility clinic in Toronto.
They admit that when it comes to dealing with the emotional aspects of infertility, most Canadian clinics are not as advanced as their American counterparts.
Some American clinics have medical social workers or other counsellors on staff, or at least available, to help clients who are also experiencing psychosocial problems. However, this aspect of care is not covered by Canada's medicare system, which means that it is usually the doctor's responsibility to make time to deal with these issues. "Unfortunately," says Cadesky, "it doesn't always happen."
Although some patients have physiologic problems that are complex and require referral to specialists, Cadesky says family physicians are quite capable of diagnosing and successfully treating many types of infertility. "Family doctors are in an ideal position to provide support to infertile patients," he adds. "They are probably more familiar with the patient's health and personal history than the specialist, and [likely] have already established a trusting relationship." Even if a family doctors or gynecologists aren't directly involved in diagnosis and treatment of the problem, they can still provide information and counselling if patients need it.
According to American medical family therapists Jeri Hepworth and Susan McDaniel, the role of the doctor in treating infertility is complex. "You become the object of lifelong gratitude if the treatment is successful, or the object of anger if the treatment fails," Hepworth says. Researchers who study infertility treatment say that frustration with the physician sometimes serves as a unifying force for a disappointed couple, but this "cycle of idealization and embittered anger" can be very stressful for the physician.
Physicians who treat infertility face problems that other doctors might never encounter. For example, should they schedule appointments for infertile patients alongside those of mothers who are coming for prenatal checkups or well-baby visits? Some specialists make an effort to schedule infertility patients separately, but others believe it is better for patients to realize that they can expect to encounter pregnant women and babies everywhere -- in their families, at work, on the street, in the doctor's waiting room.
Besides discussing treatment options, infertility specialists may also find themselves refereeing a couple's discussions about money. Certain treatments, such as in-vitro fertilization, are expensive and may not be covered by health insurance, and couples may disagree about making such a major financial commitment. One partner may be willing to spend thousands of dollars on the possibility of parenthood, but the other may have different priorities.
Infertile patients often hesitate to complain or discuss psychological problems. Laskin says he is often the last one on the team to hear that a patient is upset with some aspect of the infertility diagnosis and/or treatment. Patients are far more likely to make a comment to a nurse, lab technician or receptionist than to a physician.
"These patients often worry that they'll be labelled as difficult or hysterical, which will compromise their treatment," he says. "We do our best to reassure them about this and encourage them to bring any problems forward during assessment or treatment."
Some couples are reassured by continuing advances in reproductive technology, feeling that this will bring them closer to a solution. But Hepworth says developments such as egg donation and the use of surrogate wombs also raise new and troubling ethical and emotional dilemmas for patients and physicians. "There's no doubt that as reproductive medicine continues to advance, the emotional and psychological aspects of infertility can only become more complicated," she concludes.