Adjusting to life when assisted conception fails

Human Reproduction vol.13 no.4 pp.1099–1105, 1998

Adjusting to life when assisted conception fails

Peter Kemeter1 and Jutta Fiegl Institute of Reproductive Medicine and Psychosomatics of Infertility, Hadikgasse 82, A-1140 Vienna, Austria 1To

whom correspondence should be addressed

According to our basic (psychosomatic) tenet, every somatic problem has its emotional side; therefore, medical treatment and counselling are not separate but are interlinked and equally important. First interviews and interviews after failed assisted reproductive technology (ART) are held together in four person settings; the couple with two counsellors. The sessions last for ~1 h. The aim is to help patients escape the agonizing and distressing state in which they are kept by their foci (psychogenic aspects causing distress). Stress and iatrogenic factors are discussed and when patients are able to re-experience their suffering, many possible psychological effects on infertility and/or treatment failure are explored. If the patients consciously perceive these mechanisms of action, they will turn to their basic emotional needs and perspectives; ~30% of them will conceive later while ~20% opt for adoption. However, half of the patients take no positive action, neither giving up nor continuing with activities for a child. Nor do they seek counselling. The analysis of many of their reports argues in favour of an adaptive model for coping with reproductive failure. Key words: ART/counselling/distress/infertility/psychosomatic

Introduction According to our basic tenet, every physical (somatic) problem has an emotional (psychological) side to it. Thus, infertility as such, as well as failed courses of assisted conception are considered in the context of the patients’ social, psychodynamic and biographic background. The primary goal of counselling is, for us together with the patients, to find a focus (psychogenic aspects causing distress; Springer-Kremser et al., 1986) or foci in the couples’ social situation and/or biography and/or psychodynamics which explain the internal conflict underlying their problem. As focusing involves aspects which are not always consciously perceived, it is often hampered by inner defences. Overcoming them is a process which may take a variable amount of time and which may be fraught with many setbacks, i.e. failed courses of assisted conception. Our task is to stand by our patients during these setbacks both physically by offering medical treatment and psychologically by offering counselling. Since 1985, we have counselled couples in four person © European Society for Human Reproduction and Embryology

settings: male and female partner, female psychotherapist and male reproductive endocrinologist (Figure 1; Fiegl and Kemeter, 1989; Fiegl, 1991). The advantages are that somatic and psychosocial aspects are seen as interrelated entities in a setting where a balance of sexes allows more communicative attachments, and where it is possible to learn one from another. After failed assisted conception, we start to discuss the couple’s latest experiences with assisted reproductive technology (ART), including stress and iatrogenic factors, as well as possible somatic and psychic symptoms (of ambivalence). When the patients are able to re-experience their suffering, we turn to possible psychological effects on infertility and/or treatment failure. The following issues are addressed: (i) factors concerning partnership; (ii) psychodynamics of each partner; (iii) biographical factors of each partner; and (iv) psychosocial surroundings and situational factors. In every issue, a variety of foci (psychogenic aspects causing distress) have to be considered. As soon as patients can accept the emotional barriers against pregnancy or a child, counselling turns to the final issue – the labour of mourning and the beginning of rearrangement. This paper describes groups of statements or foci that we frequently find behind failures of assisted conception. Examples of patients who have answered our questionnaire in a previous study (Kemeter, 1992, 1993) are given in some instances as well as comments on the basis of the literature and our experience.

Stress and iatrogenic factors Bad experiences with previous treatments These may be either physical (pain at follicular puncture, overstimulation, etc) and/or emotional (impersonal, embarrassing, no privacy, masturbation under unaccustomed conditions, lack of explanations etc.) In addition, other somatic and psychic symptoms quite frequently crop up during treatment. In our opinion, these are mainly expressions of ambivalence to treatment (Kemeter, 1995). The first and foremost of these bodily symptoms is bad reproductive performance in itself. For the woman, these may include hormonal disorders, low response of follicles to stimulation, low fertilization rate, and low implantation rate. For the man, poor or grossly fluctuating sperm quality. We will come back to these later (see case 3 and comment). Moreover, we also see complaints not obviously connected with treatment, i.e. back pain, rashes, fever (Kemeter et al., 1982), which cannot be distinguished easily from the side-effects of medication or from complications of ovarian stimulation and/or follicle puncture. 1099

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Only with a child is partnership fulfilled This missing child makes the couple feel incomplete and, in their eyes, their partnership is even devaluated. In a way, the missing child prevents them from really loving each other.

Figure 1. Setting at first interview and after failed courses of assisted reproductive technology (ART).

Building up an efficiency drive This happens most commonly by visualization of bodily functions. In an IVF-programme, patients compare their number of follicles in the waiting room in an atmosphere of ‘‘who is the fastest breeder?’’ Generally, the more a pregnancy is seen as the aim of a medical treatment, the more will there be concentration on bodily functions and taking control. No wonder that feelings of tension will also arise. Expectations are too high When compared with the known success rate (Lalos et al., 1985a). Side-by-side with these success-orientated foci we frequently find the above mentioned psychic expressions of ambivalence: acting out (theatrical behaviour, i.e. bringing friends and relatives to puncture or embryo transfer, managing unnecessary stress which complicates treatment, etc). In contrast, some patients are overadapted and stick compulsively to our protocol and advice without daring to ask or to comment. Some, however, idealize the doctor up to the point of flirtation. Taking control of cycle and sex This can be done by the calendar, BBT, ovulation test, restriction alternating with frequent intercourse, etc. Unfortunately, by taking control of their fertility functions, patients suppress their fertility rather than boost it. This was shown in a retrospective study of 665 women conducted by Demyttenaere et al. (1992); the sooner women planning pregnancy stopped using contraception, the later they conceived. By describing these stressful events, patients commonly become aware of the psychosomatic impact of their problem and prepare to tackle more basic problems: Re-evaluation of possible psychic effects on infertility and/ or treatment failure Factors concerning partnership Partners do not seek parenthood with the same intensity One partner is more ambivalent and undergoes treatment only to satisfy the other partner. 1100

Fighting for power Partnership is strained by the fact that one partner persistently reproaches the other with his/her unwillingness to help fulfil their wish for a child (see Case 1). Making the problem taboo In order to indulge the partner, all aspects of infertility and possible future children are put aside. Thereby, a lot of misunderstandings are developing about the real wishes and meanings of the partner. Disturbed sexuality Most couples are experiencing a loss of pleasure with sex when they have sex only for reproductive purposes. This unsatisfying ‘‘hard labour for fertility’’ (Fiegl and Kemeter, 1989) is often taking over in the partnership and causes the couple to avoid or reduce sex generally. Relationship is symbiotic clinging According to Willi (1976) a collusive partnership is based on an unconscious arrangement to take opposite but dependent roles, sometimes in a sado-masochistic way (i.e. strong and controlling man versus weak and dependent woman). The motivation is: By keeping this clinging relationship both need not be afraid of being deserted. Obviously, in such atmosphere of subliminal aggression, there is no room for a child (Stauber, 1979). The following report is, we think, impressive in this regard. Case 1: She had given up after 15 operations and nine courses of in-vitro fertilization (IVF). On the back page of her completed questionnaire (Kemeter, 1992, 1993) she wrote: ‘My marriage ended in divorce last year. In a way I couldn’t stand the pressure any longer, I don’t mean so much the treatments with IVF which I didn’t find so much burdensome. I liked the idea of adopting a child but he refused it consistently. I suffered by the fact that my husband never helped me to accept my infertility, and above all, that he couldn’t accept it as a matter of fact, but instead, unconsciously I am sure, dragged me, literally, again and again to doctors and treatments. One day I was at the end of my wisdom and left my husband; he still cannot understand. For him my reasons are ridiculous. In his opinion he never pressed me in any way and he still would love me in spite of everything. Only for the ‘in spite of everything’ I would have left him. There were, of course, also other difficulties, but we could have managed to patch up the problems and could have stayed married and, compared to the average, could have been ‘happy’, but I got more and more sensitive to this subject and have certainly overreacted to some extent. I simply wanted to have the feeling that he didn’t care that we had no children and that he was just as happy and content with me alone. Today, in the same situation as 10 years ago, I certainly would go for IVF again. I find this to be a stunning possibility to get children of one’s own if otherwise not possible. However, both should know why they want children.’


Personal psychodynamics Endangered masculinity/femininity Patients fear that, without an own child, they aren’t looked at as real men or women (especially in rural areas). Having a child is the only meaning in life Often, the child is badly needed to compensate for missed emotional bonds in the past. Personal fight against one’s body ‘You can attain everything if you really want it’; unfulfilled wish for a child as the first personally experienced border in life. This is especially hard to bear for patients with a performance orientated personality: high expectations in oneself; tendency to compulsive-obsessiveness; low attitude to compromises; low ability to enjoy pleasure; there is no possibility to let things just happen but an increased need to take control. The fact that her body doesn’t function as planned makes a woman with this personality feel extremely helpless. Case 2: Her husband had a daughter from a previous marriage. To date, they had undergone two courses of IVF without success. ‘I don’t want to blame myself for not having tried everything to get a child. I think that no person who isn’t affected by my problem can imagine my hopelessness. There is an everlasting waiting. If you are longing so much for a child you can’t simply stop thinking. There is always this wish. Instead of enjoying our new house I am spending every free minute with thoughts about what our child would look like. It is a vicious cycle! After the second unsuccessful IVF I stopped every medication and we went off on holidays. I hoped so much that I would conceive during that time (silence, relaxation, sun), however, it wasn’t so. At the moment, I’m preparing for the next (last) IVF cycle. I haven’t much time left, I am 37 years old.’ She obviously suffered from her compulsiveness, but couldn’t help it. She was in the middle of an ‘emotional roller coaster’ (Mahlstedt et al., 1987) as patients call the ups and downs of hope and disappointment. We have long made it standard practice to ask couples at their first interview what they had done after they had stopped contraception and before they came to see a doctor because of their childlessness. If they tell us they had systematically planned for pregnancy in the very first unprotected cycle, we take it as a tell-tale indicator of an exaggerated need to take control. The more systematically sexual intercourse is programmed for conception, the greater the risk to turn sexuality, pleasurable as it should be, into ‘hard labour for fertility’ (Fiegl, 1989, 1991). This is well reflected by the scores in the Giessen test (Beckmann and Richter, 1972) which showed that patients with hormonal abnormalities and/or infertility problems were significantly more often overcontrolled (compulsive) than their normal counterparts (Kemeter, 1985, 1988, 1989). The desired child is expected to make personal hopes for change come true Patients hope to become more adult, more acknowledged, more female/male, happier, or just getting rid of an unsatisfying job. If counsellation succeeds, and the patients try to improve

their lives without the ‘help’ of a child, many of them will conceive easily and unexpectedly in due time. Idealism The longer the desire to have a child continues, the more will ideals of motherhood and fatherhood rise. In their imagination, patients see themselves as ideal mothers and fathers who are totally devoted to their children. In reality, however, they have more difficulties in meeting their high expectations, when they later really have children (Fiegl and Kemeter, 1990). Repression of ambivalent feelings towards a child Only positive feelings towards children are presented. However, when counselling addresses the personal experiences as a child or with children, also negative connotations of children (i.e. responsibility, restrictions in personal freedom) will frequently emerge. Even an underlying fear of children can be displayed (rather by nonverbal expression). Biographical factors The desire for a child reactivates one’s own parent–child relationship ‘How welcome a child was I?’ Disadvantaged versus brothers and sisters; fear of being deserted (Springer-Kremser et al., 1986; Springer-Kremser, 1989). Threatening pregnancy image Mother or other close relatives had dramatic pregnancies and/ or deliveries; there are handicapped or stillborn children in the family. Negative outcome of patient’s former pregnancies (interruption, abortion, extrauterine pregnancy, stillbirth, etc.) Not yet detached from the family of origin. Not yet living an adult life of one’s own. The inadequate detachment from the family (see also Sarrel and DeCherney, 1985) is supported by the finding that infertile women identify significantly more often with their mothers than with other women (Kemeter et al., 1985; Kemeter, 1988, 1989, 1996). Projected ideas of the mother ‘Beware of a child, because then you have to give up your own life’. Prophecy It will be difficult for you to get a child (i.e. ‘doctor once said the uterus is small’, or tradition in family: ‘We all have difficulties conceiving’). Difficult integration of puberty and fertility in self-image, difficult acceptance of female role and taboo on sexuality and fertility in the family of origin These women tried to ignore or suppress their femininity during puberty or adolescence as a result of a devaluating attitude towards femininity in their family of origin. All ‘male’ attitudes, like strength, performance-orientation, staying power, are put forward. A classic example is anorexia nervosa, where the girl succeeds in losing her period and her female body shape through starving. A minor expression of anorexia nervosa, anorectic reaction, is frequently found together with oligomenorrhea and amenorrhea. Dramatic separations from children in the past Especially as a result of divorce. Quite often we see men who have children from a former marriage and fail to produce 1101


children in their present marriage because of reduced sperm quality (for changing sperm quality, see also case 3 and comment). Fear of bodily changes during pregnancy The acceptance/non-acceptance of the body may be reflected by bodily well-being/complaints. In fact, there is a strong inverse relationship between functional disturbances (complaints) and self-esteem in women (Eder et al., 1982). Social surroundings, life situation Family, friends and relatives They may exert much pressure on a child (especially in rural areas). A successor is badly needed Problems of migration Differences between cultures and social levels; moving to another place (i.e. by marriage) led to loss of social network (Springer-Kremser, 1986) Professional factors Dissatisfaction (‘child will rescue me from hated job’); high satisfaction (‘child will take me away from my beloved job’); working with inhibited or disabled children. No nest yet for a child Inadequate housing, little space, overcrowded, not feeling at home, no privacy, see case 3. Future perspectives What, if a child will never come? How would a child change our lives? Are there alternatives, i.e. adoption, living without children? Under pressure by age? The following report shows stressful circumstances rooted in the social surroundings and the partnership with obvious influences on reproductive functions, especially sperm production. Case 3: The couple had two unsuccessful courses of IVF with donated spermatozoa. Diagnosis: No spillage of tubes, azoospermia. Eight years later she reported having conceived two children naturally from her husband: ‘At the time of our treatment he was drinking heavily and smoked a lot. We were living in the house of his father, who didn’t allow us to lock any doors. Quite often he used to enter our room without knocking. Thus, we lacked privacy at that time. After we had moved to our own home he soon stopped drinking and I became pregnant and had two children, one after the other. Unfortunately, our second child suffered from atresia of the oesophagus so I had to bring him to the clinic very frequently. Soon I found out that my husband, instead of looking after our elder son, simply locked the boy in and went to the football place. From this time onwards, I couldn’t trust him any longer and this was the beginning of our divorce. At the same time I met my first love again and since he was free and wanted to marry me, I gave in and accepted his proposal.’ In two out of the four cases with azoospermia, where the husband had later fathered children, we had occasion to repeat the sperm counts and found a normal sperm count in one and 1102

oligozoospermia in the other case (73106/ml, 40% motility; Kemeter 1993). One of the women wrote in her questionnaire: ‘....my pregnancy left the urologist speechless!’. It is well-known that spermatogenesis may return after chemotherapy (Marmor et al., 1992) and after radiation (Schlappack et al., 1988). However, the fact that semen quality may change dramatically even in healthy fertile men is not so well-known (World Health Organization, 1992). In IVF the overall results showed a clear drop in semen parameters at the time of egg retrieval (Schoysman et al., 1987) and moreover, most IVF teams are quite familiar with the unpleasant surprise of semen which previously had been normal deteriorates to the point of uselessness right at the time of IVF. As early as 1924, the anatomist Stieve found a complete arrest of spermatogenesis in executed political prisoners but less so in common criminals. His hypothesis was, that ‘sensitive’ political prisoners in ‘death row’ do experience distress more psychosomatically, including effects on their spermatogenesis, than do ‘cold-blooded’ common criminals (Stieve, 1940). He also gave a detailed account of the testicular abnormalities seen in executed prisoners and in a suicide. They included canalicular atrophy with intact Leydig cells, almost complete failure of the spermiogenetic cells to divide and markedly enhanced agglutination of immature intracanalicular cells. Stauber (1979) reported that psychometrically-confirmed high stress levels at the workplace and in the family were correlated with a reduced semen quality. More recently, Greimel et al. (1992), found that males with semen abnormalities unassociated with organ pathology were exposed to significantly higher stress levels at the workplace and had experienced significantly more devastating life events in the past. Bents (1987, 1990) clearly showed in his controlled thesis that psychotherapeutic interventions reduced stress in these men (and their wives) and also improved their sperm parameters and the conception rate. In any case, there are enormous variations in sperm parameters and we should beware of making too precise a prognostic statement based upon them (Hargreave et al., 1986). In most infertile couples we can find one or more of the above foci together with functional disturbances of the reproductive organs. In a way, these functional disturbances of the reproductive organs could also be looked at as ‘normal’ processes of adaptation to ‘abnormal’ circumstances, in other words, they could protect the woman or couple from a pregnancy, which under the present circumstances is (unconsciously) not desired (Eder and Kemeter, 1982; Kemeter and Eder, 1982; Jeker et al., 1988, 1989). A similar adaptive model for the evolution of reproductive failure was put forward by Wasser (1993) in his study on psychosocial stress as a cause of infertility. Although most barriers against pregnancy or children are unconscious, they may surface indirectly by the patients behaviour. There is, i.e., a discrepancy between the uttered intensity of the desire for a child on the one hand and the low mean number of IVF courses on the other (Figure 2). Many patients, similar to the following case, do not have a rational explanation for this. Case 4: In response to stimulation for IVF she produced only


Figure 2. Percentage of IVF courses per patient. Cases without and with successful treatments are shown separately. Success is defined as the birth of at least one living child.

one egg, which did not fertilize: ‘..we didn’t legally apply for adoption. There are too many difficulties and inhuman aspects. Unfortunately, I developed secondary infertility following the non-treatment of adnexitis. Although I went to my gynaecologist (several times!) he couldn’t make the right diagnosis. I cannot express my emotions in words which are coming up every time this matter is raised. I don’t want to speak about this further, because I want to avoid depression’. No matter whether her gynaecologist could have managed to prevent tubal damage, he is certainly a perfect scapegoat for her. Obviously, this defence mechanism, called projection, helps her to ward off feelings of having failed. She did not explain why she tried only one course of IVF, but we can assume that she just wanted to get this hurting matter behind her in order ‘to avoid depression’, as she said. If, however, patients can accept their foci as possible emotional barriers against pregnancy or children, counselling will turn to the next issue, the labour of mourning. Labour of mourning – the beginning of re-arrangement Changing the plan of one’s life Modifying the self-image The body will not realize a principal possibility, namely the one to reproduce. Possibility to stand for one’s infertility in the outside world To become reconciled with the body, which has so long been an enemy ‘The body possibly knows why’, ‘I take it as it is.’ Developing of a new image of parenthood Evaluating alternatives; taking pleasure in life in spite of being childless For the treatment provider, the greatest challenge (which needs all of his skills), is to keep track of both the patient’s somatic condition and their emotional state, especially their fixation on having a child of their own. If there is no major organic defect (i.e. tubes patent and sperm quality about

normal), it will hardly make any difference in the long run, if the patients undergo ART or opt for no treatment (Schoysmann et al., 1991). This does not imply, however, that IVF has no place in patients with patent tubes. It can be done as a procedure which gives the patients support and allows them to make their own experience with assisted conception. But it should not be done as a more technical and more invasive method to continue ‘the hard labour of fertility’. On the contrary, it should be used as a reward for the patients once they succeeded in getting some distance from their problem for a while, i.e. a real break. Some 30% of them will conceive spontaneously during this time (Zeibekis et al., 1976; Kemeter, 1993), unless their tubes are markedly damaged or the sperm quality is consistently very poor. Some patients simply cannot let go and postpone treatment, because they can’t stop their compulsive thinking. These patients need psychotherapeutic help, mainly to reduce their anxiety (Golombok, 1992). Others will conceive after failed assisted conceptions (Steppe, 1970; Schoysman et al., 1991) especially during the time when they are recovering from their disillusion. Most couples overestimated their chances before treatment and are the more disappointed when it fails (Lalos et al., 1985a; Johnston et al., 1987). We can compare their sense of failure with the mourning reaction after the death of a loved one. This may follow characteristic steps: shock, denial, anger and rage, isolation, feelings of guilt and depression, and finally, adaptation and acceptance (Hirsch and Hirsch, 1989). We shouldn’t shy away from talking about their loss. Patients put all their trust in their physician and are greatly relieved to find him stand by them in the bitter moment of failure. This may well mark the beginning of a life counselling effort with the emphasis on the patient’s health and well-being rather than on the medical treatment of infertility, which should be left aside at least for the time being. In addition to the distress, which is worse in women than in men (Wright et al., 1991), there is also an increased risk to 1103


the couple’s marital relationship and their sexual life (Lalos et al., 1985b) if the problem of childlessness prevails. Perhaps this is the time to end it all and feel relieved? Perhaps the idea of adopting a child has finally become acceptable? In institutions where success is measured only by the rate of conceptions and deliveries obtained with assisted conception there will, however, scarcely be time enough for counselling the patients in this way. But our institutions should also be places where patients can learn when enough is enough (Paulson et al., 1991), or where they can discover that the desired child is vicarious for some other personal needs they have (Harrison, 1991). Here, the doctor’s challenge is quite different from his reproductive–technological task. The last report shows how successful adaptation to childlessness can be achieved, for us as gratifying a job as the creation of a child by ART. Case 5: The couple has given up after four unsuccessful courses of AID: ‘One can live more quietly, unstrained and even more satisfied after having drawn the line and after having come to terms. The time during and after treatments is very strenuous and the psychic burden very heavy. Partnership suffers as well. There is always hoping and fearing. Now, we are living more quietly and without concern. There is also more harmony. We both have a profession, can afford more and we are enjoying our freedom. In addition, we are spoiling our nephews! In brief, we simply live a different life. Suggestion for others: take childlessness as a fate. Make the best of it. Try to adapt and enjoy the advantages. Crying and brooding only makes things worse. Acknowledgements The authors thank Katharina Burgholzer and Hannes Kemeter for their excellent assistance in writing the transcripts and preparing the manuscript.

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