Alisa Hafkin, LCSW

Sex in a relationship plays a significant role in whether one can have a baby or not. Although reproduction can take place without sex, most couples wanting to have a baby begin so by engaging in sex that includes intercourse. The beginning phase is sex on a regular basis and if a pregnancy does not occur, the next step is assisted reproductive technology. Repeated unsuccessful attempts at pregnancy is followed by deciding whether to stop infertility treatment and then choosing to remain childless or adopt.

During infertility treatment, which can take place over a number of months and up to several years, couples go through many changes in their relationship and a particular area of concern is within the sexual relationship. There is a recognizable shift from sex for the sake of pleasure, intimacy and spontaneity to calculated, routinized and analyzed intercourse for the sake of pregnancy. Reproduction is intimately connected to sexuality and therefore it effects one’s self-image and self-esteem, especially when sex does not produce a child.

When couples go through a year of unprotected sexual intercourse without becoming pregnant, they may begin to feel an increasing pressure on their sexual relationship to make something happen and then experience tremendous disappointment when nothing does. This seesaw of emotions each month increases the likelihood that emotional baggage will enter the bedroom. As infertility treatments begin and continue, more people enter the bedroom including doctors, nurses, family and friends, making sex a group act that does not resemble the sexual relationship that once was.

If infertility treatments do not result in a pregnancy, couples then face the concept of childlessness. To many this is inconceivable and can result in delaying the end of fertility treatments. When couples decide they will no longer continue treatment, they must take the time to understand the loss. They have already experienced an initial sense of loss by the discovery of an infertility issue and the inability to conceive naturally. This can seem like a betrayal of one’s body and a loss of self, femininity and masculinity. Ending treatment is an expression of the permanence of not having a biological child and feeling the death of that wished for dream.

The phase that follows is taking the time to process that loss. Seeing a future self without children is extremely painful and couples need the opportunity to grieve and slowly develop a new concept of themselves and their future. Childlessness represents a different world view than originally anticipated; from an internal perspective about one’s place in the world to an external perspective of how one is seen in the world. The emotions that accompany involuntary childlessness need to be validated, heard and held within the couple framework and hopefully, by a therapist who can provide a safe place for grief to be expressed. Saying goodbye to the dreamed for child is painful and can occur as couples begin to envision a future that has meaning and a renewed sense of hope.

Couples who decide that having a child, whatever the method, is their desired outcome face adoption as the next option after infertility treatment has ended. The key point here is that couples do have to commit to stopping treatment to allow for time to grieve the loss of a biological child. If that does not take place, couples may find themselves stuck in past grief that prevents them from making positive a attachment to their adopted child. It is important to let go, as much as possible, the idea of a biological child because an adopted child is not a replacement but a unique child entitled to love that is not based in loss. It is also important for both partners to agree to the idea of adoption so that the foundation is set up to accept an adopted child as a result of a joined commitment.

There are many challenges couples deal with when going through infertility treatment including pressure and changes to the sexual relationship, coming to terms with not having a biological child, a future without children and adoption. Each of these issues has deep and lasting ramifications and they require energy, trust, insight, time, support and education to get through each of these stages.

Modern science has made it is possible for a child to be genetically and non-genetically related to five parents at the same time: the intended parents, the egg donor, the sperm donor and the gestational carrier. The many combinations of how to conceive and carry a child are daunting in their complexity and they have deep implications for the the individual, couple, unborn and future child, children already existing and extended family members. A diagnosis of infertility is the first step in the process of alternative family building and each of the options available to prospective parents needs careful and thorough consideration.

The extent to which an individual and couple are ready to move on to alternative ways of bringing a child in to the world is dependent on their ability to grieve the loss of reproduction in the traditional manner. The implications of being unable to typically conceive a child are vast and may include shock, fear, depression, shame, anxiety, and a loss of a sense of self. A genetically linked child is the optimal outcome for most people who desire to have a family and coping with loss due to infertility is an important step before moving on to options that include egg, sperm and embryo donation and surrogacy.

Sperm donation has been done for approximately 100 years and only in the past 30 years has egg donation been an option. Embryo donation is also relatively a new option but the number of embryos is limited due to most parents choosing not to donate. Sperm donation is considered easier than egg donation in that sperm production does not involve invasive medical procedures. Egg donation involves medical intervention to stimulate egg production after which, the eggs are extracted for fertilization. There are differences in how men and women react to an infertility diagnosis and it is important to take those differences in to consideration when presented with the idea of sperm, egg and embryo donations and surrogacy.

There are many factors to consider when contemplating the use of donor sperm, eggs, embryos and a surrogate. Each individual is seen at some point in the process as the patient and is therefore, the focus of attention. With that in mind, there is a constant shift of focus from a hope for a normally conceived child to an infertility diagnosis, to a sense of loss, to alternative options, to making the best/most informed choice, to understanding the legal, cultural, financial, religious issues, to a loss of control, to trust and ultimately to having a baby. The importance of having guidance through this process cannot be stressed enough. Individuals and couples facing the use of donors and surrogates cannot possibly contemplate all the issues that can arise, therefore psychoeducation and emotional support are essential components for making the experience as positive an empowering as possible.

How do you know when it’s time to get help? How can you tell what you’re feeling is really a problem? How many days, weeks, months of depression and anxiety do you have to go through before you realize it’s time for help? Once you do accept that it’s time for help, how do you go about finding someone to help you? Who do you ask? Who do you trust?

We live in a world of Facebook, twitter, instagram, etc where everyone seems to be having a great time. Life is beautiful…..for others! Look at all the incredible places people are going to, look at all the beautiful things people are buying, look at all the wonderful relationships people are having. The list goes on and on, leaving us feeling embarrassed that we are not living a fantastic life, prompting us to ask the question, “what is wrong with me”?

There is nothing wrong with you – you just need some help getting back on track. Depression and anxiety are insidious in that they creep up without your realizing there is a problem, until there is a problem. We rationalize away our sadness and wave away our nervousness and inability to sleep, eat or enjoy life. We tell ourselves “I can handle this” or “I’m under a lot of stress”.

You don’t have to live a life of sadness and fear. You don’t have to suffer or feel ashamed of needing guidance and support. It is ok to seek out help when you feel depressed and anxious and it is much better to do so sooner rather than later as delaying help sets up unhealthy patterns that can eventually seem normal. If you feel you have gotten to the point where a smile doesn’t come easily to your face, the light is no longer in your eyes and life is heavy and tiresome, it is time to get help. Call me. We will talk and you are the one to decide if we proceed. As trust builds, we can begin to uncover the root of the problem and find ways to help you cope and regain your vitality.

In an effort to get pregnant after repeated unsuccessful attempts and/or miscarriages, individuals and couples face the prospect of undergoing tests to find out the reason for their infertility. A referral is made to an infertility specialist who determines, if possible, the cause of infertility and in doing so, may uncover a genetic anomaly. There are a variety of reasons why a pregnancy may not occur including lack of ovulation, blockages, sperm deficiencies and parental age. The contribution of a genetic factor to infertility is a component that needs to be taken in to account. It has been found that some of the causes of infertility have been associated with specific genetic anomalies including chromosomal abnormalities, gene disorders and mutations and inheritance factors.

The significance of these findings is twofold in that an individual or couple must deal with the shock of an infertility diagnoses and the subsequent shock of discovering there is a genetic disorder.  This opens up a myriad of complex physical and emotional issues that place prospective parents in a position of vulnerability as they decide not only how to proceed with their genetic family goals but whether they should proceed with trying to have a genetically related child.

Genetic issues that arise during testing for pregnancy failure may result in the discovery of a disorder that not only causes infertility buy may also cause health related risks for the parent. Individuals and couples who identify as coming from specific areas of the world or are of a particular race or ethnic background may choose to have genetic testing done before attempting pregnancy only to find out they either have a genetic disorder or may be carriers. Test results from an amniocentesis during pregnancy may show genetic anomalies in the fetus that will impact whether the pregnancy is terminated or not. Genetic anomalies discovered in embryos during IVF present the dilemma of deciding what to do with the embryos. An identified genetic disorder, when first discovered, creates more questions than answers.

Genetic counseling and individual/couples therapy can help answer some of the questions that prospective parents grapple with as they decide their next steps. A diagnosis of infertility triggers a host of feelings including shame, guilt, shock, anger, hopelessness and fear and when combined with the discovery of disease and/or the potential of having an unhealthy baby, the sense of isolation, confusion and sadness is compounded. Genetic counseling provides information on the nature of the disorder and the risks associated with passing along that disorder. In addition, genetic counselors provide information on what types of procedures are available for detecting genetic issues, before, during and after a pregnancy. A therapist can help individuals and couples cope with all the information that has to be processed, while providing a safe space to explore the intense feelings that a diagnosis of infertility and a genetic disorder causes.

The fourth session focused on the issue of infertility as it relates to step families, lesbian and gay couples and single women. As one might imagine, these three areas are rife with complicating areas of concern and it is of prime importance that an infertility counselor be sensitive to the distinct ways each group deals with an infertility diagnosis. As we progress in society to increasing our acceptance of alternative ways of building a family, each group requires a therapeutic approach that is tailored to meet the particular needs of that group.

Step families dealing with infertility have to navigate many players as they proceed with infertility treatments. Children, ex-spouses and extended family members all have distinct responses to the idea of another child and when faced with infertility, special consideration must be given to the health of the family community. There are emotional concerns for the already existing children such as, will they continue to hold a special place in the family if the parents are taken up with infertility treatments. For older children, there may be concern over how much money is spent on infertility treatments; money that might be used for education or help with other economic concerns.

It is not uncommon for there to be a higher incidence of infertility in step families as one or both partners may be older. Studies show that advanced age is a major factor in the inability to naturally conceive. If a partner without children is diagnosed with infertility, the other partner may not be able to provide the necessary support needing during the stress of assisted reproduction interventions.

With gay and lesbian couples, there are a host of issues related to the use of gestational carriers, donated sperm and eggs. With this population, there is the opportunity for each partner to potentially have a genetically related child and the complexities of contracting with potential donors as well as gestational carries involves investigation and legal issues that are different in each state. Society has progressed to the place where more and more gay and lesbian couples are exploring parenthood and when hit with an infertility diagnosis, the sense of loss may trigger a deep sadness about not being able to realize a now more accepted status of parenting within this population.

Single women, either by choice or by circumstance face the pain of infertility without the much needed support. Many women today are choosing to become single mothers and society no longer looks on this as a negative. In years past women were only able to have children within the confines of marriage as they were economically dependent on men. In today’s society, women have greater potential to achieve economic independence and therefore are able to consider parenting on their own. When faced with a diagnosis of infertility, single women suffer this trauma alone. There are many reasons why a woman may choose to parent alone, some of which may stem from not being able to find a partner. When also faced with infertility, a single woman has to deal with not fulfilling two of society’s still present expectations – connecting with a life partner and becoming a mother.

A diagnosis of infertility is a devastating occurrence in anyone’s life who wishes to be a parent. First married or partnered couples suffer a great deal of pain, anger, shame, guilt, loss and fear when faced with infertility and the invasive treatments associated with trying to conceive a child. Special populations such as step families, gay and lesbian couples and single women deal with a host of additional issues that bear great weight on an already stressful situation such as infertility. The pressure to deal with the infertility from a supportive family and economic platform is increased profoundly in these alternative populations. The approach toward helping these couples and individuals requires sensitivity and the ability to look at one’s own belief systems without prejudice.

Yesterday was the third infertility counseling session and a host of topics were covered including how to best assess and then assist individuals and couples, using modalities that have been shown to have the most efficacy. These modalities can include psychodynamic psychotherapy, cognitive behavioral therapy, group therapy and alternative medical and healing techniques including acupuncture, mind-body work, prayer, homeopathy among many others.

Assessment is one of the most key elements in the beginning stage of infertility counseling. Often times, one session may be all a therapist has to learn about and then help guide a patient(s) who has been diagnosed with infertility. It is therefore essential that any and all tools be used to best uncover some of the personal challenges a patient(s) may face as they move forward with trying to have a baby.

An individual or couple coming for infertility counseling may not be seeking help with trying to make major changes in their lives. Their focus of attention is trying to find ways to deal with the satellite issues surrounding infertility such as stress reduction, education about infertility and learning how to negotiate and communicate with a partner. The responsibility of the therapist is to help the individual or couple identify goals and then facilitate their ability to achieve those goals. There may be things that arise along the way such as relationship and financial problems, family pressure, mental health issues and unexpected medical findings. If the individual or couple is willing to explore those issues as well, the therapeutic process can continue along that vein while simultaneously incorporating them in to the current infertility discourse.

An infertility counselor has to be sensitive to gender differences when dealing with clients who have been diagnosed with infertility. Historically, women were thought to be primarily responsible for infertility but with advanced diagnostic techniques, it has been discovered that male factor infertility occurs in a significant number of cases. Women and men deal with this diagnosis differently and it is of extreme importance to understand those differences. Women tend more to seek out help, whereas men tend to hold back from sharing. The injury to one’s sense of self is perceived differently by men and women and therapy can help a couple understand one another’s coping styles and work to help achieve mutuality.

Feeling stress, anxiety or depression is to be expected when undergoing infertility treatment as long as it remains within manageable boundaries. Techniques and psychological practices used to help an individual or couple deal with these issues is of prime importance, as it promotes a sense of empowerment and an improved sense of self.

Claire Cain Miller wrote an important article in the November 9, 2014 business section of The New York Times entitled “The leave Seldom Taken”, which focuses attention on the advantages and challenges of fathers taking paternity leave. The article states that men who go on paternity leave have more potential to form healthier bonds with their children and they are likely to be more involved in the years ahead. The article also states that paternity leave helps promote increased earnings for mothers returning to work and it can decrease the potential for depression after child birth.

The darker side of this equation is the reality that many fathers face similar road blocks to work advancement that many new mothers face. In other words, men confront negative consequences for taking paternity leave by getting passed over for promotions and raises.

This translates to a conflict of priorities for both men and women with men being disproportionately less inclined to take advantage of any provided leave time. Ms. Miller writes, “when men…become active-enough parents and begin looking like what we think of as mothers – they can be penalized”. She goes on to site a study that found men received “worse job evaluations” and another study found that men “were at greater risk of being demoted or laid off because they were perceived to have negative traits that are used to stigmatize women, like weakness and uncertainty, not masculine ones like competitiveness and ambition”.

A significant aspect of this article is the finding that when men participate more in child care early on, there is an increase in participation in the future. This is an important distinction in that setting the tone for sharing the burden of earning income and care taking fosters a more equitable environment that benefits both parents and child. The challenging aspect for many men in taking paternity leave will be dealing with some of the negative responses from the work place. It takes courage to be a trend setter and pursue what is important personally and professionally and it requires work environments and relationships that do not foster a negative culture or promote sanctions against a father who takes paternity leave.

“Depression is the most common health problem women face. As many as one in four will experience it during their lifetime, and about one in seven will experience postpartum depression”; David Bornstein, New York Times, October 20, 2014.

Postpartum depression is gaining more and more attention in today’s media but it still remains an under diagnosed and under treated problem for many women. If left untreated, postpartum depression can become a deeper and more problematic issue not only for the mother but also for her child and other relationships at large. It is important to note that struggling with the stressors of having a new baby is normal but only to a degree that one feels emotionally stable enough to face those challenges. Once depression goes past approximately four weeks or longer, it is extremely important that help is provided as quickly as possible.

The New York Times article goes on to state that there are effective treatments for depression including psychotherapy and cognitive behavior therapy but without proper screening by primary care physicians and ob/gyns, many women endure their depression symptoms alone and caregivers are at a loss as to how to help.

Mr. Bornstein writes about two programs, DAWN and Moving Beyond Depression, that are proving to be successful in identifying and treating women with postpartum depression. Both programs involve screening for depression by ob/gyns and once identified, women are guided to take advantage of care managers, education, therapy and home visits. Another program uses a telephone based model in which women, who have been identified as having a high risk for depression, receive supportive phone calls from mothers who experienced postpartum depression and recovered with appropriate treatment.

Relief from postpartum depression is very possible with proper diagnosis and treatment. It is important for women and men to be educated about the risks of postpartum depression and that a prior history of depression increases the risk of depression after birth. The sooner a woman receives a diagnosis and help, the better the outcome, not only for herself but also for her child and partner.

In September I began a training in infertility counseling with Sharon Covington, MSW and Nancy Hafkin, PhD and together with seven other practitioners in the field, we began the journey to learn more about assisting individuals and couples who are facing challenging reproductive issues. Our second session’s focus of attention was on identifying some of the mental health issues that can arise as a result of getting a diagnosis of infertility and its subsequent treatment.

When clients go through a period of approximately one year of regular, unprotected intercourse without a resulting pregnancy, reproductive assistance is usually the next step in aiding conception. Clients are referred to a reproductive specialist and an in-depth assessment is done to determine the cause of infertility. When clients first find out the reason they have been unable to conceive they may experience a range of emotions including shock, disbelief, anxiety, depression, shame and anger .

Assisted reproductive specialists and their support staff are trained in guiding clients through the medical steps of promoting fertility but when clients confront emotional challenges that can arise during this process, counseling may be a helpful component of treatment. A diagnosis of infertility can affect one’s sense of self; a deep realization of an altered perception of body, mind and soul. It can affect close personal relationships with partners, family and friends and navigating through this phase while undergoing rigorous medical interventions may be aided by talking with a therapist trained in assisted reproductive issues.

The range of emotions experienced by men and women upon receiving an infertility diagnosis is vast and those who have a strong relationship and support network appear to have an increased ability to manage the future challenges of trying to have a baby. Sometimes an infertility diagnosis opens up older issues including relationship problems, family expectations, societal pressures, history of abuse among others. The diagnosis itself is not the only trigger for powerful emotions as the options presented for conception including hormone treatment, donor eggs, donor sperm, IVF, surrogacy, etc. all require a thoughtful approach requiring self awareness, honesty and the ability to collaborate with one’s partner and medical staff while remaining in the community as a family member, worker and friend.

A person who is diagnosed with infertility confronts an unexpected reality; a future self and plan that goes against what had been thought of as a given – I/we will become pregnant and have a baby. Infertility creates a paradigm shift that requires the strength to negotiate a variety of medical interventions and unexpected emotional states.

The recent articles in The New York Times, “Thinking of Way to Harm Her (June 15, 2014) and “After Baby, an Unraveling” (June 16, 2014)  highlight postpartum depression and they have brought much needed attention to this underserved community of struggling parents.

I believe that postpartum depression has for too long been diagnosed primarily as a hormonal issue which often times it is not. It is a composite illness that affects both women and men with many identifiable markers. Postpartum depression is different from baby blues and new parents need to be educated about these differences. Baby blues occurs in women after birth and can last approximately three to four weeks. It is characterized by a fluctuation in mood, including sadness, irritability, anger, etc. This occurs because of a rebalancing of hormones to pre-pregnancy levels. Some of the indicators of postpartum depression include more of the same feelings that occur during the first four weeks but they don’t abate and often times increase.

Identifying who is at risk is of prime importance and depression screenings should be part of the ongoing care for women during and after pregnancy. Women with a history of depression should be closely monitored by their ob/gyn during and after delivery. Women should be encouraged to share their history of depression with their child’s pediatrician so that appropriate care can be provided to the new mother as early as possible in her child’s life.

The recent articles served to raise and support a new level of consciousness about this condition that has far reaching implications beyond the mental and physical health of new parents. As we know, the long term emotional health of a newborn is dependent on the emotional wellbeing of its parents.