reported sexual problems ranging from lack of desire, pleasure, and spontaneity to erectile dysfunction. Common feelings of infertility such as loss, anger, guilt, despair, depression, shame, and anxiety, began to overshadow intimate feelings of warmth, affection, and emotional connection so that sex became methodical, predictable, and unexciting. This added additional pressure for John who felt the responsibility of performing on demand (e.g., during ovulation, producing semen samples, etc.).

Their differing emotional reactions, communication styles and coping strategies left each of them feeling alone in the struggle, and the stresses resulting from multiple treatment failures put a strain on their personal and emotional well-being. Both felt a sense of profound loss and hopelessness from the unsuccessful IUI and IVF cycles and the miscarriage. They also feared the loss of a genetic tie to potential offspring as they contemplated donor gametes and adoption. They felt a sense of isolation from others and could not agree upon how much information they would share with family and friends and how often they would socialize and attend gatherings that involved children or the potential announcement of pregnancies. Both Julie and John reported feeling isolated, emotionally unsupported, depressed, and rejected by the other.

The case presented above illustrates the typical stressors and psychosocial complications of a couple struggling to conceive. This chapter will address an overview of the psychosocial interplay between infertility and relationship health and will provide a framework to providers about how to address these complex issues.

Discussion

Individuals and couples experience high levels of stress as they attempt to manage the physical, emotional, social, and fnancial concerns related to infertility and treatment. Diffculty conceiving is described as an emotional roller coaster and crisis that chips away at one’s self-esteem, identity, relationships, and ability to cope [1]. Women undergoing fertility treatment characterize infertility as the most stressful experience of their lives [2] and On The Life Events Scale, the failure of IVF is rated equally to breast cancer, death of a family member, and worse than divorce [3].

While trying to conceive, patients no longer feel in control of their bodies or their life plan. Lives are put on hold, attempts to conceive become all consuming, and couples are beholden to treatment [4]. Trying to juggle medical appointments and medicine regimes with job responsibilities can increase pressure and put stress on careers. Not surprisingly, the most common reason why insured patients drop out of treatment is psychological burden resulting from infertility, including treatment [5].

The expectations and communication between a couple are also challenged. In some relationships, partners blame themselves or each other for infertility or medical diagnoses, resulting in anger that interferes with communication and sexual desire and functioning. Often times, one partner will harbor resentment toward the partner that wanted to wait longer to build a family. In another typical scenario, one

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The universal theme of loss for those struggling to conceive is powerful. The grief is complicated because the loss experienced is not just for the longed-for child but also represents loss of self-worth, hope, identity, control, and loss of where they thought they would be at this point in their lives. Guilty feelings are also common and can further fuel a sense of profound loss and responsibility toward family and friends. The infertile couple may experience overwhelming guilt and sorrow about disappointing or denying grandparents-to-be or potential aunts and uncles. The couple may also be consumed with guilt about being unable to fulfll their duties and responsibilities related to “carrying on the family name” or providing an heir.

In circumstances when the couple cannot work through their differences, they may beneft from counseling that can help them improve communication, respect their different coping styles, and ultimately get them back to working out problems as a team. It is encouraging to note that few couples actually separate or divorce as a result of their infertility. Although the diffculties surrounding efforts to get pregnant or carry a child can be extremely stressful for most couples, many ultimately feel that the experience brought them closer together and led to the development of better coping skills.

The feld of fertility counseling comprises an eclectic use of a variety of treatment modalities including but not limited to psychoeducational counseling, therapeutic counseling (e.g., cognitive behavioral), supportive counseling, grief counseling, and counseling that assists couples in decision making about treatment and next steps. The key is to match the right intervention at the right time to serve the emotional needs of the individual and couple. Table 28.1 provides a list of some of the goals and techniques of therapeutic intervention.

The form of counseling provided will be determined by the needs of the couple, the timing of treatment (e.g., initiation, treatment, resolution), the couples’ level of distress, individual personality, and coping factors. The timing of interventions and assessments might be particularly important to their effectiveness since the issues facing the couple at each phase of treatment can differ and require different therapeutic approaches.

Psychoeducational counseling most commonly occurs before treatment begins but can also take place throughout the fertility journey as couples navigate treatment options at different stages. Psychoeducational counseling is aimed at reducing feelings of helplessness and the stress of treatment though preparation. Psychoeducation enhances patient control, addresses decision making and treatment options, and manages expectations.

Less distressed couples may beneft from written psychosocial information provided at key times in treatment or brief counseling that emphasizes education. For example, counselors have developed interventions tailored to specifc challenges, such as coping with the 2-week waiting period before the pregnancy test and preparing couples for treatment [11, 12].

For those whose coping resources are inadequate and/or depleted, such interventions might not be suffcient and ongoing supportive or therapeutic counseling can be used to decrease psychological distress and improve relationship satisfaction for couples experiencing more moderate to severe levels of distress. One form of

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