Health: Body and soul

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 pregnancy.

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 example.

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 mind-body.

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 surrogacy.

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 problem.

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.

The 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.”

A loving 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 treatment.

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 authors state.

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 years.

After each implantation and pregnancy, she had to rest in a hospital bed for long periods, but even so, the fetuses failed to develop.

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 difficult.

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 fertility.

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.

One 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 hospital.

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 social phobia.

Israeli researchers studying healthy male students found that their sperm quality was reduced during stressful exam time.

European 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.

“Liana,” a 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 tradition.

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.

The medical 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.