Psychological Components of Infertility

• Date: 01 January 2021
• Author: Amelia Swanson,Andrea Mechanick Braverman
• Published date: 01 January 2021
• DOI: http://doi.org/10.1111/fcre.12552

PSYCHOLOGICAL COMPONENTS OF INFERTILITY

Amelia Swanson and Andrea Mechanick Braverman

Infertility is a medical diagnosis impacting 48.5 million couples globally. Infertility impacts physical and emotional health as

well as social and romantic relationships. People with infertility report feelings of distress, grief, anxiety and depression.

Couples notice changes in their relationships; some report becoming emotionally closer while others report relationship diff‌i-

culties. People may feel more isolated due to lack of social support. People that use third party reproduction, such as donor

egg, sperm, embryo or gestational carriers, have additional emotional impacts during pregnancy and parenting. Continuing

changes to laws complicate international fertility care, particularly given the ongoing COVID-19 pandemic.

Practitioner’sKey Points:

a. Many people with infertility experience psychological distress, grief, anxiety and depression.

b. Infertility may impact men and women differently from an emotional perspective.

c. Active coping can help individuals and couples with infertility.

d. People using donor gametes or gestational carriers often have additional stressors and concerns about parenting.

e. Many people are now seeking infertility treatment internationally which has many logistic and political challenges.

Keywords: Coping; Infertility; International; Psychological Distress;Stress; Third-Party Reproduction.

I. INTRODUCTION

Infertility is a medical diagnosis with wide ranging impacts including on physical and emotional

health as well as social and romantic relationships. Infertility is def‌ined as the inabil ity to conceive

for 12 months for those under 35 years old, and 6 months for those 35 years and older. In the

United States, approximately 62% of couples with infertility do not seek treatment, 11% seek

advice and evaluation, 18% undergo ovulation induction and 9% undergo IVF or other assisted

reproduction (Chandra & Stephen, 2010). The invasive and time intensive nature of evaluation and

treatment can add to the emotional experience of infertility.

Infertility is a common medical issue with over 48.5 million couples globally that are unable to

have a child after 5 years of trying to conceive. Despite advancements in the treatment of infertility,

the prevalence of infertility has changed very little from 1990 to the most recent data from 2017. In

the United States, 13.1% of women experience infertility (National Center for Health Statistics,

2017). Despite infertility being common in the United States, only 12.7% of women have accessed

any infertility services, while only 0.6% have accessed Assisted Reproductive Technology (ART),

such as IVF (National Center for Health Statistics, 2017).

Being a parent has often been seen as an essential developmental task in becoming an adult.

In many cultures, being a parent is an essential part of a person’s standing and value in society.

Additionally, fertility is often seen as a marker of health and tied to fulf‌illing gender roles.

Therefore, those with infertility may be seen as failing to fulf‌ill the expectations of what it means

to be a man or woman in their community. As infertility is a common medical issue in the

United States and globally, it is important to consider the emotional, social and cultural

Corresponding: amelia.swanson@nm.org

We have no known conf‌licts of interest to disclose.

FAMILY COURT REVIEW, Vol. 59 No. 1, January 2021 67–82, doi: 10.1111/fcre.12552

© 2021 Association of Family and Conciliation Courts

implications for people hoping to grow their families. People with infertility who build their fam-

ilies with donor gametes or surrogates have unique emotional experiences during the infertility

process as well as after pregnancy while raising their children. Given the f‌inancial burden of

infertility as well as restrictions due to legal, cultural and religious beliefs, some parents seek

international treatment for infertility and third-party reproduction (donor egg, donor sperm, donor

embryo, and gestational surrogacy) which adds an additional layer of complexity due to ever

changing laws.

II. PSYCHOLOGICAL COMPONENTS OF INFERTILITY

The infertility process is often described as a roller coaster of emotions. People begin each

month hopeful that this will be month that they are able to conceive, anxious for the two-week wait

until they can take a pregnancy test, and then disappointment, and often heartbreak, if they are not

pregnant. This emotional roller coaster is then followed by a few days of sadness and grief, followed

by renewed hope to some extent. Anxiety and stress often become more challenging each month

when conception does not occur. Fertility medical evaluations and treatments often add additional

stressors and hormonal side effects may also increase stress and anxiety.

Through the fertility process, patients often begin to realize that they have limited control over

their fertility and therefore their overall health and life plans. Many infertility patients have no pre-

vious medical history of major illness and assumed that their fertility was good and under their con-

trol. As they are unable to conceive each month, women and men frequently begin to feel “out of

control”and that their “life is on hold.”People often seek ways to gain control over their fertility

by seeking evaluation and treatment and looking to fertility websites, social media, changing eating

habits, exercising and making other lifestyle changes. When they make these changes and are

unable to control their fertility, they continue to feel out of control which often creates or increases

anxiety. People may begin to have intrusive thoughts and worries about infertility, as well as having

anxious behaviors such as excessively seeking information online as a way to feel in control. Anxi-

ety may transition to include a sense of depression and loss with subsequent failed treatment. Peo-

ple may also begin to feel grief and depression due to concerns that they will not be able to have

genetically related children. Due to these complex factors, patients with infertility often experience

grief, psychological distress, and changes to their romantic and platonic relationships (Burns &

Covington, 1999).

A. GRIEFAND PSYCHOLOGICAL DISTRESS DURING INFERTILITY

The experience of grief is related to loss and may include feelings of sadness, anger, jealousy,

disbelief, and acceptance. Grief during infertility has many components including grief about loss

of health, self-esteem, self-conf‌idence and an imagined future child (Mahlstedt, 1985). For many

with infertility, they experience disenfranchised grief which is intense grief that others perceive as a

minor loss. Doka (2002) describes disenfranchised grief as a relationship that is lost that is not

socially recognized (i.e. loss of imagined future child), when the loss itself is not perceived as sig-

nif‌icant to others in their community or culture (i.e. early miscarriage or failed IVF cycle), or the

person grieving is not perceived to have suffered a loss and therefore is viewed as not justif‌ied in

grieving (i.e. loss of having genetically related children). Disenfranchised grief can be particularly

intense and painful because the person grieving often experiences less social support and does not

have a way to openly mourn their loss (Doka, 2002). Treatment and support of grief includes recog-

nizing the loss, rituals or other activities to recognize the importance of the loss, and integrating the

loss into their life moving forward. For those with infertility, these steps are often diff‌icult to engage

in due to lack of support or concern about judgment if they share their experience of infertility with

others. Women undergoing fertility treatment (both ovulation induction and IVF) have been found

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