Biomedical treatments to help infertile couples become parents have advanced
greatly in recent years, but psychological treatment to help them cope has
lagged way behind. And sometimes, the emotional distress from depression and
anxiety alone is a key factor that actually holds back the hoped-for
Fortunately, awareness of this mind-body connection to
infertility is growing and the appearance of a Hebrew volume on the subject will
certainly give it a push. Called Lehavi Yeladim La’olam (To Bear a Child),
released by Aryeh Nir Publishers in Tel Aviv, the book is an important
The 256-page, NIS 89 softcover volume was written by Dr. Zvia
Birman and Prof.
Eliezer Witztum. Birman is a longtime fertility
researcher who was head of the social workers unit in the pediatric, obstetrical
and gynecological departments at Hadassah University Medical Center in
Jerusalem’s Ein Kerem and has provided individual and group therapy to many
infertile couples over the last two decades.
Witztum is a leading
psychiatrist at Beersheba’s Mental Health Center and Ben- Gurion University and
specializes in the complex relationship between culture and society and
The volume is chock-full of very personal stories, using
fictional names of individuals and what they have gone through. It is divided
into five parts: the theoretical background for infertility; the reactions of
the woman and the man to the discovery and the differences between them;
cultural and social aspects of infertility; techniques of intervention and
treatment; and the significance of egg and sperm donation, adoption and
When couples fall in love and marry, life looks rosy and a
couple may take if for granted that they will easily be able to achieve a
pregnancy, unless one or both are already aware of a medical
But, in fact, one out of 10 Israeli couples suffers from an
organic problem that leads to infertility. It is the “fault” of the woman in 35
percent of the cases; of the man in 35%; of both the man and the woman in 20% of
cases; and the cause is undetermined in the remaining 10%. Infertility is
defined as being unable to achieve a pregnancy after a year of regular,
unprotected sexual relations. With help from fertility experts, about two-thirds
of those suffering from infertility will have a pregnancy.
frustration from being denied parenthood can cause a great deal of anger and
lack of understanding between the woman and the man, as the genders naturally
have different experiences, expectations and demands on them while undergoing
fertility treatments, the authors note.
“The woman feels that her life
has been destroyed and behaves in accordance with that feeling, while the man is
frustrated by the feeling that his wife is not the same woman he married. As a
couple, both go through a protracted period of lack of understanding and
loneliness – at a time when each of them needs consideration and support. Most
couples don’t hurl their frustrations at each other in such a brutal way, but
all experience the difficulty of coping with infertility.”
couple, the authors continue, can turn into two hurting individuals – a bitter
and suffering woman and a helpless husband who doesn’t understand how he got
into the situation.
In many cases the infertile wife becomes “addicted”
to fertility treatment, while the husband – whose primary role involves only
supplying semen to impregnate her – is a minor player and can continue his usual
routine, as compared the woman’s long and painful course of
Often, the woman thinks her husband is not filling his role as
supporter, comforter and partner and feels “betrayed,” they write, “because
their couplehood cannot provide what the woman wants more than anything – a
pregnancy. Their own bodies betrayed them because it doesn’t cooperate with the
desire to produce a child.”
Birman and Witztum write that the wife is
usually the first to seek help when she doesn’t get pregnant. The husband tends
to deny the problem and delay the examination and testing for as long as
possible. The natural process of getting pregnant turns into a medical,
technical process without emotion, dealing with sizing the ova sacs, hormone
levels, o v u l a t i o n s c h e d u l e s , amount and quality of sperm and so
on. This inevitably brings conflict and constitutes “blows below the belt” and
can even lead to separation and divorce.
When one couple – Ronit and
Ya’acov – got married, Ronit did not want an immediate pregnancy. She was
studying in university and felt she was too young to be a mother. After a time,
her parents pushed her to have a baby. Her years of taking contraceptives had
hidden her ovulation problems. When she tried to get pregnant and failed, she
found that not only did she have fertility problems but her husband did as well.
Ronit felt some “satisfaction” that he was “to blame” for his low sperm count
and her irregular ovulation was not the only cause. Each member of the couple
might have begun to wonder whether they would have fared better if they had
married somebody else.
But women and men are not “created equal” in
fertility treatment, as she must get hormone injections, have ripe ova removed
surgically to carry out in-vitro fertilization, have an embryo returned to her
reproductive system and wait for a positive test, while the man must only
provide his gametes. This can cause great friction between husband and wife, the
Infertility is on only rare occasions just a physiological
matter, they write. Most often, psychosomatic factors are also involved. Thus,
research on stress and its involvement in fertility have begun to appear. The
story of “Miriam” is provided to illustrate this. She was born with an abnormal
uterus, and at age 25 she underwent surgery to correct the defect. But even
after that, she had difficulty getting pregnant. When she finally did, she
spontaneously miscarried – six times. She underwent IVF over a period of 10
After each implantation and pregnancy, she had to rest in a
hospital bed for long periods, but even so, the fetuses failed to
When Miriam was offered psychological counseling, she turned it
down, saying that “nothing will help me.” Yet, out of desperation, she agreed to
undergo short but frequent therapy sessions with Birman, which gave Miriam some
hope. “She learned to accept her fears, cope with them and realize that they
were a normal part of pregnancy, especially after having miscarried several
times. The patient admitted that losing the fetus was actually ‘easier’ for her
than enduring the constant fear of miscarriage.”
Her body, wrote Birman,
“expressed her conflicts, and getting pregnant became even more
Finally, psychological therapy and fertility treatments were
successful and she gave birth to a healthy boy.” Fourteen months after delivery,
after a spontaneous, unassisted pregnancy, she gave birth without any fertility
treatments to another boy.
Research studies have found that emotional
reactions such as depression, anger, blame, shock, denial and anxiety; loss of
control over the body and emotions; low self-image; and social influences on
couplehood are among the psychological problems affecting
After achieving pregnancy after years of failures, many women
fall into a state of shock, asking again and again if the medical tests
testifying to a growing embryo and fetus are in fact correct. They are more
prepared to get a negative answer than a positive one. Suitable psychological
care can help them overcome the shock.
Treatment for male infertility
includes removing individual sperm from the testicles and injecting them one at
a time into an egg. But even if the sperm are healthy and motile, just giving
sperm in a hospital outpatient room can be difficult for a man.
in the book describes the difficulty he had accomplishing this when “outside the
room, many others waited and knew what I was doing.” Only when the couple was
able to go to a relative’s apartment that was empty during the day was the man
able to relax and produce a sperm sample to bring to the
Infertility can alter a couple’s social and family
relationships. The authors note that many women who can’t get pregnant so avoid
going to brit mila (circumcision) celebrations that the behavior is called
“Circumcision Syndrome.” They thus avoid being queried by relatives and friends
about when they will have a baby and feeling jealous of couples that do. This
often grows into a more serious phenomenon of avoiding social and family events
and completely isolating them. The phenomenon is regarded by professionals as a
Israeli researchers studying healthy male students found
that their sperm quality was reduced during stressful exam time.
studies have shown that after men are told they have a fertility problem, about
60% become impotent for at least several months, or their sperm quality is
likely to decline suddenly. In women, learning they have reproductive problems
causes them to stop ovulating. Thus, physiological problems clearly lead to
psychological problems that, in turn, reduce their fertility.
A woman can
even use her infertility to take revenge on her mother-in-law.
pretty young woman in her 30s, was a university graduate and an occupational
therapist. She met “Avi” at college and they got married. But because Liana’s
lower-class family lived in a development town and Avi came from a well-off
family from a big city, her mother-in-law looked down on her and engaged in a
series of verbal and then even physically violent conflicts with them, throwing
objects out the window into the street.
Liana was able to “take revenge”
on her husband’s family when she found herself unable to get pregnant. While it
was difficult to prove that the emotional difficulties with her in-laws were
responsible, clinical experience shows that this is often a factor. In
psychological therapy, Liana said she “hated” her mother-in-law so much that she
was happy to deny her a grandchild.
The therapist helped her to ease the
anger and understand that the socioeconomic conflicts were behind it. Learning
to avoid the explosions, Liana was even able to go to their home for a Shabbat
dinner without confrontations. As understandings were reached and tempers
cooled, Liana spontaneously got pregnant, to the joy of all – and the couple
decided that to avoid future explosions, they would move to a home more distant
from her in-laws.
Israel is a “world power” in fertility treatments, the
authors write. Not only does every general hospital – there are 26 – in the
country have an IVF unit, but Israel is the only country in the world in which
the cost of producing two healthy babies through fertility treatment for women
up to age 45 is covered by one’s health fund.
There are over 1,800
fertility cycles a year per million residents in Israel, compared to only 240 in
the US and 416 in Britain.
The country’s fertility experts have
contributed much to the world’s know-how in the field.
The influences of
religion and faith on coping with fertility are also discussed in the book.
Being fruitful and multiplying is a biblical commandment (at least for the man),
and having and raising children makes up a major part of Jewish
Fertility in the Beduin sector is also discussed briefly, as
are single mothers and unconventional families. Psychodynamic treatment for
helping the infertile is compared with speedy cognitive behavioral therapy
(CBT), relaxation techniques and stress management.
profession is a “third partner” in the infertile couple’s bearing of a child.
“When the woman and the man contribute their efforts to coping with the medical
treatment, when the woman gets stronger and learns to change her status from a
‘victim’ to an active and optimistic state, when the man takes more
responsibility and agreements are reached on division of labor, a new
partnership is created that is usually fertile. The new form of couplehood that
results significantly improves their quality of life and increases the chances
for successful medical treatment,” the authors conclude.
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