Approximately one in five Canadian couples experience infertility, defined as being unable to get pregnant after 12 or months of trying (Bushnik et al., 2012). While infertility involves both members of a couple, the process of trying to get pregnant is almost always more burdensome for the intended mother, perhaps explaining why research suggests that infertility takes a greater psychological toll on women (Chiaffarino et al., 2011; Ma et al., 2011; Pasch & Sullivan, 2017; Sexton et al., 2010). In fact, half of infertile women describe infertility as the most upsetting event of their life, whereas only 15% of their male partners do (Freeman et al., 1985). An estimated 30-40% of women with infertility experience clinical levels of depression or anxiety (Chen et al., 2004; Chiaffarino et al., 2011). Experiencing infertility has been associated with psychological difficulties in women, however, there has been little research examining which coping strategies and behaviours may be helpful during these high-distress times of a woman’s cycle.
58 distressed individuals identifying as women who were actively experiencing infertility were recruited via social media, examining the daily coping strategies and fertility monitoring methods (e.g., use of ovulation predictor tests, cervical mucus monitoring), in relation to daily infertility distress among women with infertility. Over the course of one menstrual cycle, daily coping strategies, use of fertility monitoring methods, quality of life, and mood was assessed in the morning and evening of every second day.
During menstruation active coping and behavioural engagement were associated with less depressive mood. Across all phases, social support seeking was associated with greater anxiety and lower emotional quality of life. Use of fertility monitoring techniques was associated with heightened anxiety. The use of avoidance strategies, endorsement of optimism and social support seeking throughout the cycle were significantly predictive of depression ratings following a negative pregnancy test.
The current investigation aimed to improve our understanding of distressed infertile women’s experiences in the context of a natural conception cycle, and to examine coping strategies and fertility monitoring techniques in relation to psychological wellbeing. A number of adaptive and maladaptive coping strategies were identified: adaptive strategies included focusing one’s energy on activities unrelated to conceiving, such as focusing on other life goals, trying to stay optimistic, and actively planning next steps following an unsuccessful cycle. In contrast, avoidance of infertility reminders and seeking emotional support from others were associated with worse psychological outcomes. The use of fertility monitoring techniques was associated with greater anxiety.
Currently available psychotherapies have been found to be only modestly effective in reducing distress among women struggling with infertility (Frederiksen et al., 2015) – in identifying adaptive and maladaptive coping strategies, the current study may provide direction in improving the efficacy of current interventions. For example, the effectiveness of behavioural engagement suggests that approaches such as Acceptance and Commitment Therapy (ACT), which encourages engagement in activities that are in line with one’s values despite psychological or physical ailments, may be effective for infertility-related distress. Behavioural activation, a therapy technique used to reintroduce enjoyable activities in the context of depression, may also be effective for infertility. In light of the identification of avoidance as a maladaptive strategy, graduated exposure as used in Cognitive Behavioural Therapy (CBT) may be a promising intervention in the context of infertility.
Indeed, many women with infertility report avoiding distressing stimuli or situations associated with fertility (i.e., baby showers, children) and women’s avoidance of these stimuli is likely a source of continuing difficulty in their adaptation to infertility and is likely to contribute to social isolation. Exposure could be used to gradually increase women’s ability to tolerate these upsetting stimuli: for example, spending time on a park bench near young children might be at the bottom of an exposure hierarchy, a brief phone call with one’s niece in the middle and attending a friend’s baby shower might be at the top. To our knowledge, current trials of CBT for infertility exclude the use of graduated exposure; however, Acceptance and Commitment Therapy, which explicitly emphasises engaging in emotionally challenging tasks in the pursuit of mental health, has shown promise as an intervention for infertility. Future research developing or adapting interventions for infertility may therefore consider the potential benefit of exposure for this population.
Finally, the observed relationship between social support seeking and worse psychological outcomes highlights the importance of improving women’s interpersonal relationships. Techniques from Interpersonal Psychotherapy, which specifically focuses on improving social relationships to improve wellbeing, may therefore be promising for infertility-related distress. These findings highlight a number of potential areas for clinical targets for future infertility specific interventions. These findings highlight a number of cognitive and behavioural strategies that could be manipulated via psychological interventions to improve distress among women struggling to conceive. The current study points to several coping strategies that may result in improved psychological outcomes if manipulated: decreasing avoidance, increasing focus on alternative goals, and improving the quality of social support received by women experiencing infertility. Future psychological interventions aimed at improving infertility-related distress should aim to manipulate these coping strategies. Abstaining from the use of fertility monitoring techniques may also be considered as a clinical target.
*mother/woman referring to individuals who have the biological capacity to carry a fetus (e.g., have a uterus) although not all may identify with those terms
References
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