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Infertility and Mental Health

P. Tracy Crudup-Arata

Department of Counseling, Freed-Hardeman University

DBH 710: Basis of Human Behavior

Mark Crowell, D.S.W.

November 9, 2020
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Infertility and Mental Health

The journey that an individual embarks upon when suffering from infertility can greatly

impact their life medically, financially, and personally. The struggle to conceive a child and the

impact it imparts on women is multi-faceted. Infertility affects females of child-bearing age and

current statistics illustrates that 48 million couples suffer from infertility whether it is primary or

secondary infertility (World Health Organization, 2020). Primary infertility is diagnosed when

no other biological children have resulted and secondary infertility is a minimum of one

biological child that has been conceived.

Patients undergoing infertility treatment have a higher risk of being diagnosed with post-

traumatic stress disorder, depression, and anxiety (Rooney & Domar, 2018). The level of stress

will vary from woman to woman, based upon the mental and physical health of the individual.

There are many steps to the infertility process that women must navigate. This includes multiple

medical procedures, possible time away from their profession in order to recover, managing the

physiological and psychological changes, including disappointment and grief. Each experience is

personal and each must learn to effectively manage their expectations and their reality. As

clinicians become increasingly knowledgeable about the mental health effects of the infertility

journey, they are better able to evaluate, plan, and implement the most appropriate treatment and

care.

In-vitro fertilization is one of the prominent procedures in assisted reproductive

technology (ART) that women utilize to conceive. The procedure is costly, usually takes

multiple attempts, usually not covered by insurance, and offers no guarantees. According to the

Center for Disease Control and Prevention, approximately 1.7% of United States births are the
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result of utilizing ART (Center for Disease Control and Prevention [CDC], 2019). The mental

health status of a woman choosing in-vitro fertilization is vital. The individual needs to be

assessed in a variety of areas in order to determine the psychological stability that is needed to

undergo the fertility treatment (Lawson, Klock, Pavone, Hirshfeld-Cytron, Smith & Kazer,

2015). The Center for Disease Control and Prevention 2017 Fertility Clinic Success Rates Report

illustrated that 284,385 ART procedures were performed in United States in 2017. There are 448

fertility clinics that report their statistics to the CDC each year. Of the 284,385 ART procedures,

there were 68,908 live births in 2017 (Center for Disease and Prevention, 2020).

Trends

Infertility patients are in crisis (Peterson et al., 2012). The risk factors for stress during

infertility treatment can escalate due to several factors including accepting the state of being

childless, managing the depression, coping, and understanding the possible relationship

sacrifices that may present during the process (Wischmann et al., 2009). Based on CDC’s 2018

Fertility Clinic Success Rates Report, there were 306,197 ART procedures 456 reporting clinics.

This is eight additional clinics that have opened in one year to meet the demand for infertility

treatment. This demand increased the resulting births in 2018 to 73,831 (Center for Disease and

Prevention, 2020). This is an increase of 4,923 births which increases the number of women that

will possibly suffer from mental health effects from the stress of infertility.

Demographics and Epidemiological

The Center for Disease Control reports that women aged 15-49 with impaired fecundity

is 13.1%, with subgroups of married women aged 15-49 with impaired fecundity being 16.2%.

Married women in the same age range that are infertile are reported as 8.8% while only 12.7%
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utilize fertility treatments (Center for Disease Control and Prevention [CDC], 2020). One study

suggested that 56.5% of women in their research scored in the clinical significant range for

depression on multiple assessments and 75.9% of women scored in the clinically significant

range for anxiety. Symptoms for each were higher for women who remained infertile without

ever conceiving than those achieving a live birth (Pasch et al., 2016). It is reported that

approximately 1 in 8 couples have trouble conceiving or sustaining a successful pregnancy

(Rooney & Domar, 2018).

Importance

The importance of studying this area of mental health is vital due to the enormous gaps in

literature, previous findings, current studies and the rising number of infertility cases each year.

Some studies point to increased stress and mental health effects but some studies are completed

early in pregnancy and may not take into account the journey to conceive or the stress or rate of

miscarriage. One study conducted in the United States, illustrated that infertility patients utilizing

in-vitro fertilization procedures had lower level of depressive symptoms than the general

population undergoing pregnancy-related procedures (Lewis, Liu, Stuart & Ryan, 2013).

A different study suggests infertile women were less likely to suffer from post-partum

depression after achieved live birth than other women (Raguz, McDonald, Metcalfe, O’Quinn, &

Tough, 2014). One association between stress and infertility has been linked to the personal view

of motherhood and how infertility patients view giving birth as being representative of defining

themselves as a woman (Neter & Goren, 2017).

With the rising number of ART procedures annually, there are other factors to consider

such as deciding what to do with existing embryos that may not be utilized. Some opt to have
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these embryos adopted by other infertile couples and they agree to terminate their rights to the

embryo (Frith & Blyth, 2013). This can cause further distress for the patient. Understanding how

stress impacts the fertility is of vital importance. A study of salivary α-amylase levels which is a

biomarker for stress was conducted on 501 participating women in the United States. The results

indicated that females in the top 25% for clinically significant level were twice as likely to suffer

from infertility (Rooney & Domar, 2018). Being able to manage the level of stress before during

and after pregnancy plays an importance key role in the success of conception and pregnancy.

In my private practice, one of my specialty areas is infertility counseling. I have seen

many patients over the years ranging from initial infertility diagnosis to termination of their

infertility treatment. Initial diagnosis usually presents as disbelief and self-doubt and termination

of infertility journey can range from lack of success with their journey to eventually delivering a

healthy baby. The range of mental health stress is varied and may affect several vital areas of

their life. Some struggle to afford the repeated treatments that may be necessary and some

struggle to maintain their relationships during the repeated stress.

The range of distress must be diagnostically assessed, a plan of treatment established, and

then implemented. Every woman undergoing infertility treatment has different goals, different

resources, and different perspectives about family. Every patient undergoing infertility treatment

has to be able to explore the risks associated with the medical procedures, the emotional stress,

social and moral dilemmas as well as the personal risks to self and family. Providers must be

able to implement their expertise by having a thorough understanding of the mental health

impact of infertility.
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Resource Sheet

1. Research Highlights: key points/research findings

 Infertility impacts 48 million couples which is 24 million females.

 The rate of infertility procedures is increasing.

 The cost of the procedures is escalating.

 The stress associated with infertility is related to personal of motherhood, the

financial impact, psychological and physiological trauma including PTSD and grief

and relationship issues.

 Females experience greater mental health issues as a result of infertility than men.

 Knowledge of clinician is vitally important to understand the multiple effects of

infertility.

2. Academic Resources:

a. Infertility Counseling: A Comprehensive Handbook for Clinicians by Sharon N.

Covington & Linda Hammer Burns

ISBN-13: 978-0521619493

b. The Boston IVF Handbook of Infertility: A Practical Guide for Practitioners Who

Care for Infertile Couples, 4th Edition (Reproductive Medicine and Assisted

Reproductive Techniques) by Steven Bayer

ISBN-13: 978-1138633025

c. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by

Bessel van der Kolk M.D.

ISBN-13: 978-0143127741
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d. Walking through Infertility: Biblical, Theological, and Moral Counsel for Those Who

Are Struggling by Matthew Arbo & Karen Swallow Prior

ISBN-13: 978-1433559310

e. Frozen Dreams: Psychodynamic Dimensions of Infertility and Assisted Reproduction

1st Ed. by Allison Rosen & Jay Rosen

f. Mothers in Waiting by Crystal Bowman ISBN-13 : 978-0736975360

g. Infertility and PTSD by Joanna Flemons ISBN-13 : 978-1542615549

h. The Hormone Factor in Mental Health by Linda Rio ISBN-13 : 978-1849059299

i. Conquering Infertility: Dr. Alice Domar's Mind/Body Guide to Enhancing Fertility

and Coping with Infertility by Alice Domar ISBN-13 : 978-0142002018

j. https://www.healthline.com/health/best-books-infertility#Unsung-Lullabies

3. Internet, Popular Press, and Media Resources:

a. The Fertility Podcast –thefertilitypodcast.com/podc.+ Follow

b. Fertility Friday Radio Podcast –fertilityfriday.libsyn.com+ Follow

c. Fertility Wellness with The Wholesome Fertility Podcast –

thewholesomelotusfertility.com.+ Follow

d. Mastering Your Fertility –anchor.fm/mastering-your-fertility+ Follow

e. Your Fertility Hub--yourfertilityhub.com/podcast+ Follow

f. The Egg Whisperer--theeggwhisperer.libsyn.com+ Follow

g. The Fertility Warriors--robynbirkin.com/category/pod.+ Follow

h. https://www.healthline.com/health/best-infertility-blogs#4

i. https://www.mysurrogatemom.com/top-ten-infertility-blogs/

4. Community-based and Professional Practice Resources:

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a. https://www.asrm.org/resources/patient-resources/

b. https://www.reproductivefacts.org/resources/educational-

videos/?_ga=2.112068876.928399747.1604276703-62133600.1604276703

c. https://www.reproductivefacts.org/resources/state-infertility-insurance-laws/

d. https://resolve.org/

e. https://www.reproductivefacts.org/faqs/faqs-about-the-psychological-component-of-

infertility/

f. https://www.fertilitymemphis.com/

g. https://psychologytoday.com

h. https://www.ihr.com/infertility/

i. https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=2000

j. https://agcscholarships.org/about-agc/
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References

Center for Disease Control and Prevention (2019). Assisted reproductive technologies.

https://www.cdc.gov/art/artdata/index.html

Center for Disease and Prevention (2020). ART success rates.

https://www.cdc.gov/art/artdata/index.html

Center for Disease Control and Prevention (2020). Infertility.

https://www.cdc.gov/nchs/fastats/infertility.htm

Frith, L., & Blyth, E. (2013). They can’t have my embryo: the ethics of conditional embryo

donation. Bioethics 27(6), 317-324. http://dx.doi.org/10.1111/bioe.12034

Lawson, A., Klock, S., Pavone, M., Hirshfeld-Cytron, J., Smith, K., & Kazer, R. (2015).

Psychological counseling of female fertility preservation patients. Journal of

Psychosocial Oncology, 33(4), 333-353.

http://dx.doi.org/10.1080/07347332.2015.1045677

Lewis, A., Liu, D., Stuart, S., & Ryan, G. (2013). Less depressed or less forthcoming? Self-

report of depression symptoms in women preparing for in vitro fertilization. Archives of

Women’s Mental Health 16(2), 87-92. http://doi: 10.1007/s00737-012-0317-8

Neter, E., & Goren, S. (2017). Infertility centrality in the woman’s identity and goal adjustment

predict psychological adjustment among women in ongoing fertility treatments.

International Journal of Behavioral Medicine 24(6), 880-892.

http://dx.doi.org/10.1007/s12529-017-9693-9
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Pasch, L., Holley, S., Bleil, M., Shehab, D., Katz, P. & Alder, N. (2016). Addressing the needs of

fertility treatment patients and their partners: are they informed of and do they receive

mental health services? Fertility & Sterility 106(1), 209-215.

https://doi.org/10.1016/j.fertnstert.2016.03.006

Peterson, B., Boivin, J., Norré, J., Smith, C., Thorn, P., & Wischmann, T. (2012). An

introduction to infertility counseling: a guide for mental health and medical professionals.

Journal of Assisted Reproduction and Genetics, 29(3), 243–248.

https://doi.org/10.1007/s10815-011-9701-y

Raguz, N., McDonald, S., Metcalfe, A., O’Quinn, C., & Tough, S. (2014). Mental health

outcomes of mothers who conceived using fertility treatment. Reproductive Health 11(1).

http://doi:10.1186/1742-4755-11-19

Rooney, K., & Domar, A. (2018). The relationship between stress and infertility. Dialogues in

Clinical Neuroscience, 20(1), 41–47.

https://doi.org/10.31887/DCNS.2018.20.1/klrooney

Wischmann, T., Scherg, H., Strowitzki, T., & Verres, R. (2009). Psychosocial characteristics of

women and men attending infertility counselling. Human Reproduction, 24(2), 378–385.

https://doi.org/10.1093/humrep/den401

World Health Organization (2020). Infertility. https://www.who.int/news-room/fact-

sheets/detail/infertility