Infertility can be experienced as multiple losses -- which not infrequently lead to clinical depression
Although growing numbers of people are choosing not to have children, still for the vast majority it is seen as the inevitable next step as they mature and become established in careers and relationships. Those who reach the position of wanting children, only to find that they are unable to do so, often express great distress and may even show signs of clinical anxiety or depression. In this article I intend to focus particularly on this experience of depression.
About one in six couples experiences infertility in the accepted sense of failure to conceive after at least 24 months of unprotected intercourse. The reasons for this vary:
* Environmental pollution, especially by estrogens, is implicated in reducing sperm quality.
* Sexually transmitted diseases, particularly Chlamydia, often asymptomatic in infertility patients, may impair both male and female fertility; these infections are becoming very much more common in the population.
* Obesity is a rapidly growing problem that increases fertility difficulties due to various complications, including hormonal imbalance and diabetes.
* The age at which women are trying for children is increasing significantly, and there is a strong association (for women especially) of infertility with age, certainly from the age of 38 onwards.
Many of those affected will seek medical advice, and some will go on to tertiary reproductive medicine services for specialist investigation and perhaps assisted reproductive treatment (ART).
It has been suggested that our society, in common with others, is pronatalist in the broad sense that many of our social constructions, norms and institutions are built around the assumption that couples -- or at least women in socially prescribed heterosexual relationships -- should have children. The corollary of this is that those who do not, or cannot, will find themselves - or feel themselves to be -- devalued as full members of society. They may feel excluded and stigmatized by the 'freemasonry of the fertile'. Literature, popular culture, daily discourse, legislation and education are just some of the arenas in which those with fertility issues will complain that they have been bombarded with attitudes and images that value parenthood and devalue non-parenthood. Infertile people describe how friends avoid them, family members pity them, employers refuse them time off for ART appointments, and the NHS and medical insurers refuse to cover more than the minimum of treatment. Seligman has described vividly how feeling devalued by one's social group is the key step towards feeling helpless, which easily leads to depression.
A large body of research now testifies to the significant level of psychological distress amongst those presenting to specialist services with infertility, and reviews of the evidence support this. One recent survey found that 40 per cent of new ART patients exhibited psychiatric disorders. This may consist of clinically significant mental health disturbance, especially after treatment failure, and includes depression, and anxiety. Domar et al studied a range of patient groups with long-standing medical conditions, and found that the rate of depression amongst long-term infertility patients was the second highest after cancer, with one in four experiencing severe depression. Some studies have suggested that long-term disturbance is especially correlated with continued failure to conceive, and that rates of disturbance otherwise return to individual baselines. However, other studies have found long-lasting effects of infertility, including postnatal problems. A recent study found that 15 to 20 per cent of men and women attending infertility clinics were in need of psychiatric help; 68 per cent of these women and 62 per cent of the men accepted or intended to take up counseling, this sub-group having higher levels of distress. The women were said to be more depressed, while the men exhibited more relationship or sexual dissatisfaction. There are also studies that have not found raised levels of distress, but the balance of evidence -- and more recent evidence -- favors the position outlined.
The extent to which psychological distress is a result of infertility or a cause of it is still unclear, though it is likely that both occur. The consensus is that unresolved infertility is the cause of significant levels of distress -- demonstrated in a variety of ways. If a child is not conceived, this distress may continue long term. A review by Eugster and Vingerhoets concluded that infertility per se and not the treatment of it leads to depression. They found that depression peaked in the third year of 'diagnosed' infertility and slowly declined after the sixth year to normal levels. They point out that there are no long-term studies to support conclusions about the very long-term impact. Many issues remain to be entirely resolved, but suffice to note that those undergoing infertility treatment are carrying a significant load of personal distress, especially depression, which merits psychological support.
Loss and depression
In line with many psychotherapeutic models, we might consider the depression associated with infertility as a response to loss. Infertility can involve various kinds of loss:
* Loss of the relationship with a child -- i.e. of the imagined and anticipated role of being a parent of a 'real', related child. Many people approach parenthood with a formed notion of the sort of relationship they would like to have with a child and how they will feel and behave towards that child and relate.
* Loss of the status and prestige of being a parent -- i.e. of the position or standing in society and with one's family and peers that is still associated with being a parent, rather than a non-parent. The sexist assumption is still that an essential aspect of feminine identity is being a mother. Pressure may be less focused on women now, but it can still lead to women feeling inhibited in their careers or to losing employment and other opportunities, to safeguard their fertility or to avoid accusations amongst reproductive specialists and relatives of putting career before family.
Pressure from the in-laws is getting quite intense," my brother and his wife have had two in the time we've been trying. [Mr. M]
* Loss of self-confidence -- i.e. of feeling fully adult, having attained a goal often long-anticipated. Erikson referred to this stage of life involving 'generativity' (in his view meaning demonstrable fertility), failure to achieve which may lead to a self-absorption that involves personal stagnation and impoverishment. A rather damning indictment of the childless state!
Felt shocked, hurt, why us? Very hurt deep down -- and alone; everyone else can have them. I'm really sensitive to so many people getting pregnant; makes it doubly worse. [Ms B]
* Loss of one's stake in the future, or of genetic immortality -- i.e. feeling the family name will not live on, and there will be nothing of the individual to survive death. Although the legal importance of genetic relationship in inheritance has diminished in the last century, for many the sense of connectedness to the future remains of great importance. The acceptance of sperm donation and the debates surrounding ending the anonymity of donation are major aspects of this concern for genetic survival.
* Loss of the vicarious fulfillments afforded by parenthood -- which might include giving a child what you wanted as a child; repairing past harms or deprivations and recreating good experiences; providing opportunities not available to oneself, or giving the opportunity to achieve what you were unable to achieve.
* Loss of one's healthy self-image -- in that infertility may spoil the perception you have of yourself as a healthy, fit, 'normal' individual. If one cannot become pregnant or father a child, what might that say about one's general health? Before the menopause, women naturally experience the 'normality' of the monthly cycle; a reassurance (albeit sometimes illusory) that they are 'gynaecologically' healthy. This may be compromised if the expected pregnancy does not result as desired, and the arrival of the monthly period (especially after unsuccessful treatment) may be a painful reminder of continued infertility.
I used to get so desperate, every month, it was a dreadful time. [Mrs. Q]
* Loss of self-esteem -- i.e. of a sense of self-worth that may be associated with meeting important life goals and ambitions and fully performing valued social roles. Paradoxically perhaps, the ever growing range of assisted conception treatments may exacerbate this position: there are so many different approaches to resolving the problems of fertility that 'failure to benefit' might further diminish the individual's sense of self-esteem as a 'successful patient'.
I felt a bit of a failure. The name 'infertility clinic' felt awful; like being called barren. What have I done wrong? [Ms B]
* Loss of one's security in sickness or old age -- though possibly less important in societies with a well-established welfare state, the strains anticipated by a relatively declining workforce and increasingly elderly dependent population (as reflected in the current pensions crisis) will make the role of children possibly more vital in the future.
* Loss of the symbolic value of parenthood -- of being able to say to the world 'I am a full member of society', 'I am normal'. It is a common currency of discussion in groups of the involuntarily childless that only when facing their situation do people realize how frequently conversations, at work and socially, revolve around 'family' -- which is usually a synonym for people's children once they have reached their late 20s and are in a 'steady' heterosexual relationship.
I was very jealous of other women who were pregnant. Made me very resentful. [Mrs. Q]
* Loss of fertility and potency -- being physiologically fertile seems to be associated with a sense of power in other social roles. In particular, many childless couples report major damage to their sexual relationships when a fertility problem is discovered or suspected. Because of the importance of timing intercourse for conception to take place, especially if fertility is already compromised in some way, couples will often report the attendant anxiety of 'performing to order'. Attitudes to infertility conflate sexual potency and fertility; many male patients report their unwillingness to discuss their fertility issues with other men because of the painful things that they hear being said which suggest that a normal sexual relationship cannot continue in the face of infertility (and despite the time so often spent on contraception).
The he-man, macho image takes a bit of a knock…it got to me, changed me; made me less brash. [Mr. J]
I do see him as less of a man sometimes; I've got to admit it. [Mrs. T]
* Loss of the experience of pregnancy and childbirth -- every childless person will report comments from those with children about the personal significance for them of these experiences; the fundamental, almost atavistic, sense of fulfillment, magic and wonder. To face possibly permanent exclusion from these experiences is to face exclusion of a very painful kind for many.
* Loss of security in the pair relationship -- many studies and personal accounts have reported the importance of a strong relationship in supporting couples through infertility treatment and the pressures exerted by continued infertility. With its attendant threats to both masculinity and femininity, and the potential for blame (since two-thirds of couples find that the primary cause for their infertility is located in only one partner), the relationship is very vulnerable. It is certainly the case that while many couples report that the long-term effect of infertility is to cement the relationship, in others the difficulty precipitates an end to the relationship. One couple answering the question 'how has being childless affected you?' vividly expressed not just the strains imposed by infertility but also the added stress of partners reacting very differently to the same situation.
Just wish that we could [conceive] because of the effect that it is having on my wife. Doesn't really affect me, but she's worried and keyed up all the time. Frustrated, but I don't feel desperate. [Mr. C]
I'm depressed and anxious. It's a severe emotional trauma. It's upset our relationship; I'm crabby; sex isn't always enjoyable, very stressful. [Mrs. C]
Although the very long-term effects of infertility are unknown, there does not appear to be significant evidence that infertility per se is a factor in suicide or attempted suicide. However studies of the subject have often pointed out the higher incidence of the childless amongst suicides. Whether this phenomenon relates to the classic Durkheimian anomie that follows a dislocation from supportive social networks or to the personal despair of childlessness is a matter of dispute.
Among the childless couples in my study, all of the women and two-thirds of the men felt themselves to have become more depressed during their infertility and its treatment.
I couldn't sleep at night, I couldn't eat. It really depresses you. I just felt like going away. I asked myself 'what am I living for?’ [Mrs. H]
The only individuals to report that their feelings of depression had subsided after three years were those who had subsequently had children, although over one-third of those who did go on to become pregnant and give birth subsequently reported postnatal depression.
Only a minority of the people I studied consulted their doctor formally about feeling depressed or anxious, including the one woman who was experiencing severe family illness at the time.
A couple of years ago I got panic attacks and daren't go out. I got really depressed then… The doctor gave me tranquillizers, but I went back no different, and he referred me to a psychiatrist. He knew everything I was going through, complete insecurity; no confidence in myself. I can't relax. The GP just said 'Do your hands shake? Then take these tranx'. I just needed someone to say 'No, you're not going mad" [Mrs. L]
Given the range of actual and potential losses experienced by those with fertility problems, it is not surprising perhaps that depression has so often been observed as a significant issue for the involuntarily childless.
Those who work with people with fertility issues must expect to address the potential importance of such losses and the impact of depression on their clients' feelings and relationships.
-Monach, Jim; Stresses and Distresses: Therapy Today; Oct 2006; Vol. 17; Issue 8.
Reflection Exercise #9
The preceding section contained information
about the role of stress in infertility. Write three
case study examples regarding how you might use the content of this section in
Online Continuing Education QUESTION 23
What percentages of women and men attending clinics were found to be in need of psychiatric help? Record the letter of the correct answer the .