Approximately 16% of couples trying to conceive experience some difficulty, but only about 4% of couples trying to conceive remain involuntarily childless.1 During the time period prior to diagnosis of infertility, most of these couples do not receive the same level of care, support, and treatment from their primary care providers that infertile couples receive from specialists.
Couples often approach their primary care providers first with any fertility challenges or concerns.2-4 Current protocols have been established to help primary care nurse practitioners (NPs) address the preconception educational needs, physiologic concerns, and initial workup of couples experiencing difficulty with conception.
The benefits of these protocols are limited because they tend to focus on assessment of the individual partners, rather than on assessment and interventions for the couple as a unit. The couple as a unit presents a number of psychosocial challenges related to sustenance of the relationship during conception efforts. Additionally, these couples have specific psychosocial needs based on the facts that their fertility status is unknown, and that their plans for the future are uncertain.
Scope of the problem
Current research has identified protocols that address the physical needs and initial workup for couples having difficulty conceiving. There are also protocols in place for primary care providers relating to the general population of patients experiencing anxiety and depression.
However, no protocols were identified that specifically addressed the psychosocial interventions for couples experiencing difficulty with conception prior to being diagnosed as infertile or being followed in an infertility clinic.
Further intervention in the primary care setting that focuses on the couple's needs in the relationship can promote the health of the relationship and the ability of each partner to support the other one while trying to conceive. Proper use of clinical guidelines in the primary care setting improves the initial infertility workup as well as reduces the need for referral to a specialist.3,5,6 Since protocols already exist addressing the physiologic needs of these couples, use of such guidelines would allow primary care NPs to address the psychosocial needs as well. Providing the support, education, and other necessary psychosocial interventions can empower couples and help them to navigate this difficult journey.
Background
A great deal of research has described the psychosocial responses of couples and individuals to the diagnosis of infertility. These responses include depression, grief, anxiety, chronic stress, isolation, anger, denial, blame, shame, despair, powerlessness, resentment, failure, decreased self-esteem, insecurity, dejection, hostility, and suicidal ideation.7-12
Couples experiencing difficulty with conception prior to being diagnosed as infertile may also experience these same psychosocial responses. Additionally, they may experience fear of the unknown due to the uncertainty of their fertility status.13-15
Escalating levels of anxiety and stress further perpetuate difficulties with conception in many ways.16,17 These ways include elevated cortisol levels, which in turn suppresses levels of luteinizing hormone, estradiol, progesterone, and testosterone. Suppression of these hormones prevents ovulation from occurring, which leads to impaired fertility.
Psychosocial issues affect both partners
While there is extensive research examining the effects of stress on the female reproductive system, new research indicates that the same stresses that affect female fertility can also affect male fertility. Findings from one of the largest studies ever to examine stress on male infertility indicated that infertility-related stresses compromise sperm quality, as well as other factors associated with male infertility.18
Preconception education is important for both men and women with diminished reproductive health statuses. Primary care providers do not always provide the necessary information.5,6,19,20 In the primary care setting, NPs can offer preconception counseling services that include assessment of the couples' knowledge of the process of conception, teaching how to assess ovulation, and ways to enhance conception during ovulation. Protocols are also available for primary care providers instructing them in the treatment of depression and anxiety in the general population. In addition, there are published recommendations for treating the psychosocial effects of infertility.4,9,10,12,15,21-23 Some of these recommendations may or may not be appropriate for couples who have not yet been diagnosed as infertile.
Difficulty conceiving is a relationship issue. Each partner has constructed individual theories (mental models) about how conception is supposed to happen. Each partner's mental model also includes each partner's perception of the other's thought process, as well as what each partner needs and expects from the other. These assumptions are typically unspoken and not validated, but often guide each partner's behavioral and emotional responses.24 The NP should strongly encourage and promote the couple's communication.
Couple congruence refers to the sense of agreement between a couple in relation to the definition of a stressor and appraisal of its severity. Congruence of thinking about conception is important to marital satisfaction. Men and women in congruent couples typically report lower levels of stress than men and women in noncongruent relationships. This signifies the importance of examining the processes between people in relationships in order to understand the individuals rather than examining the individuals themselves. Further, an individual's adaptation to stress is dependent on the couple's resources, the meaning the couple makes of their situation, and how they cope with the stressor. Couple congruence is best achieved when communication is encouraged.11
A new protocol
The protocol was developed for use with individuals and couples who are experiencing difficulty with conception prior to being diagnosed as infertile. (See Protocol for addressing the psychosocial needs of couples experiencing difficulty with conception.) It emphasizes assessment and intervention with individuals and their partners.
The uncertainty about fertility status, in addition to the monthly disappointment when conception does not occur can create a series of crises and never-ending stress.9 Such crises may lead to excessive worry, deterioration of coping ability, and damage to the couple's relationship. Positive coping can interrupt this negative sequence and protect against the development of serious anxiety and depression. By focusing on promoting the strength of the couple's relationship, the NP can properly assess and intervene within specific parameters that require support and education.
The NP is well prepared to provide emotional and decisional support for couples experiencing anxiety and depression associated with difficulty conceiving. Those couples who do not respond to supportive-educative approaches may go on to develop anxiety and depression that may need treatment by a mental health professional. Revision of mental models is considerably more difficult when the person has serious depression and anxiety.
Nonpharmacologic interventions are encouraged since the couple is attempting conception, and very few medications have been shown to be safe during pregnancy. If depression and anxiety are severe enough to necessitate medication, referral to a mental health professional must be considered. Referral should be initiated especially if the NP does not feel comfortable prescribing medications due to their teratogenic effects.
This protocol is based upon a two-pronged assessment approach-assessment of perspectives, or mental models, and assessment of the degree of concern of the individual partners and of the couple as a unit. Assessment of the partner's and/or the couple's perspectives and levels of concern provide the basis in determining intervention. When couples are engaged in an activity that requires such mutuality, treating the individual may not be as effective as treating the couple.25-27
When an individual partner initially expresses the desire to conceive, the NP places him or her in one of three stages:
* Stage A: Planning/Hoping
* Stage B: Doubting/Wondering
* Stage C: Worrying/Despairing
One stage is distinguished from the other by the severity of concern and psychosocial symptoms exhibited by one or both partners. As a part of a normal reproductive health assessment including plans for conception, the NP assesses the psychosocial responses of either or both partners. Depending on the findings, the NP places the couple in the appropriate stage. The goal of the proposed interventions is to prevent progression to the next level of concern and psychosocial symptoms.
Assessment and intervention using mental models
A helpful way to assess the individual's perspectives concerning conception, as well as the couple's perspectives about each other and their relationship, is through the concept of mental models.25-27 Theories and conceptual frameworks about mental models are now prominent in the thinking of cognitive scientists. These scientists claim that the models (mental representations, theories) constructed by individuals direct the problem-solving and decision-making processes in any situation.
A similar concept of mental models was proposed in the attachment theory known as the Internal Working Model of attachment (IWM). The IWM applies specifically to the mental models that involve relationships, and is most useful in working with couples. The concept of IWMs28,29 is similar to the notion that mental models and mental representations are prominent in an individual's problem-solving and decision-making abilities.
Recent research has focused on the continuity of attachment models across the life span, indicating that early attachment relationships form a sort of template for structuring the interactions and relationship behaviors of emotionally close partners.30 Adult partners develop these ways of thinking (IWMs) about each other, and of thinking about themselves in relationship to one another.
These models include each partner's beliefs, needs, goals, and strategies for having their relationship needs met. These beliefs have been influenced by the individual's culture, religion, and life experiences. IWMs include how each partner thinks the other partner is able and willing to meet needs; as well as the emotions experienced in relation to the expectations, intentions, and evaluations of the self and of the other in the relationship. Among other considerations, these beliefs and emotions inform and direct support-seeking behavior of each of the partners.
One of the most important discernments regarding IWMs is that they operate outside conscious awareness. Before these models can be changed, they must be revealed in order to test the underlying beliefs and expectations.28,29 Once revealed through facilitative communication, partners then have the ability to validate or correct the beliefs. These IWMs can be changed in emotional relationships with partners (or NPs) that correct long-held inaccuracies in the models of the partners.
By accessing an individual's IWM of a problem, the NP can identify the thought process that occurs as the person reasons through the problem. This allows the NP to identify the premises of the client's theory. These premises may contain misinformation and myths about conception that can be corrected once the NP knows the client's perception of the situation.
Interventions are aimed at altering IWMs so that the patient's beliefs and theories consist of accurate information.28,29 Theories about conception are often shaped by myths. The NP can further assess these by asking about what the patients know from the media, stories they have been told by friends and family members, and things they have read.12
These interventions allow individuals, as well as couples, to make well-informed decisions. The corrections also provide support and self-concept validation to the individuals and assist them in meeting each other's relationship needs. The primary care NP is in an excellent position to correct faulty models, which allows the partners to help each other to maintain hope for conception.
Assessment techniques
In order to initiate the protocol, the NP should assess the IWMs of the couple's situation and evaluate their coping resources.1 The NP's assessment of the client's IWM of conception planning provides specific direction for supportive and educative interventions. Assessment begins with explor ation of the individual's IWMs about conception planning and fertility as well as his or her mental models regarding the relationship with the partner and the partnership as a unit.
It is important to obtain the couple's history regardless of the stage in which they initially present. This is necessary because certain past experiences may have shaped the couple's theories of the situation.
During the assessment, the NP should obtain the answers to the following types of questions:
* What are the sources of worry or concern for each partner? Worry about fertility can be mild to excessive.15
* What is the couple's childbirth history and what meaning does each partner make of it?
* Does the couple express concerns about childlessness?
* Is there a history of mental disorders, especially depression and anxiety?
Such preexisting conditions may intensify concerns and worries and distort the way in which the individual thinks about conception planning.
The use of nondirective therapeutic communication techniques can reveal relevant IWMs. These techniques promote exploration of the partners' thought processes. Questions such as:
* What do you think about that?
* What do you think your partner thinks about this?
* To the other partner: What do you think about your chances for conceiving?
* How do you believe you can optimize your conception efforts?
* What is going right and what is going wrong?
These types of conversations can occur in the presence of one or both partners. By utilizing these examples, information can be obtained about what each partner thinks the other partner is thinking and feeling.
The protocol is designed to focus assessment and intervention on the individual's, as well as the couple's, psychosocial responses to conception planning. The stages of psychosocial responses are based upon the intensity of the couples' concerns in addition to the accuracy of their IWMs about the situation.
Stages of conception
Stage A is the Planning and Hoping stage of conception. The IWMs of Stage A couples reveal well-informed beliefs about conception practices and about conception plans. These IWMs are congruent and accurate when validated with each partner.
Stage B is the Doubting and Wondering stage. When a couple has IWMs about why conception has not occurred, resulting in tension in the relationship, they are considered to be in this stage. One or both partners may voice feelings of decreased self-esteem in Stage B, as well as concern about the other partner's perception of the situation. This is a crucial point, when one or both partners project feelings and beliefs on the other without actually validating the accuracy of this information. This is an indication of worsening anxiety and dissatisfaction with the relationship.
Stage C is the Worrying and Despairing stage. In this stage, the signs and symptoms of anxiety and depression are more severe. Blaming of self and/or the partner can result in very low self-esteem to the point that hopelessness and guilt interfere with the couple's ability to relate to one another and also to making upcoming decisions.
It is important to understand that the interventions listed under each stage are inclusive of the previous stage's interventions. For instance, all interventions listed under Stage A will also be followed under Stages B and C. All supportive and educative interventions are offered in the context of the helping relationship, which requires competence and compassion.12
Stage A: Assessment and intervention
Individuals who present in Stage A typically deny worries or concerns about conception. Their theories express confidence and optimism about conceiving, and they often report correct information about the process of conception. At this time, if the NP has met with only one of the individuals, it is important to schedule a follow-up meeting with the couple in the following few months, or at the time when the couple becomes concerned about lack of conception. The assessment of each partner's theories reveals couple congruence of conception plans and goals. From the beginning, the NP should promote good communication between the partners. They should be encouraged to ask each other about their thoughts and feelings regarding the problem, as well as about each other.
The focus of Stage A intervention is educative. The NP should provide information about conception and ovulation and the factors that affect these. The NP will elicit the client's thoughts about conception planning and explore the extent to which the other partner is involved in the plan. The importance of the couple's open communication should be emphasized.
Stage B: Assessment and intervention
Couples who present in Stage B likely voice uncertainty about their future and concerns about their inability to conceive. An assessment of the couple's IWMs may reveal that one partner is more concerned than the other. The couple might report that they have decreased their conception-related communication, and that there is now tension in the partnership.
Statements of personal worth by either partner may reveal decreased self-esteem. Men may report a sense of loss of control, and may feel helpless in trying to comfort their spouses. Feelings of frustration may occur in either partner, along with feelings of challenged masculinity or femininity.9 For example, one woman affected by infertility reported that it was "a blow to her self-esteem, a violation of her privacy, an assault on her sexuality, a final exam on her ability to cope, an affront to her sense of justice, and a painful reminder that nothing can be taken for granted."1
Excessive worry is characterized by reports of thought intrusion.15 Disturbing thoughts such as "I'll never get pregnant," "This is all my fault," or "He blames me for this" appear involuntarily in the mind at any moment, leading to a decreased ability to concentrate or think; and are often accompanied by anxiety.
The focus of intervention for Stage B is both educative and supportive. When providing supportive interventions, the NP should be reasonably accessible by appointment and by telephone during office hours as needed by the couple to provide emotional support at particular times of stress.1 A follow-up visit should be scheduled based upon the amount of support the couple feels they need from the NP. It is important for the NP to provide realistic hope, to give reliable information, and to dispel myths.12 As the couple's theories about the problem are explored, the NP uses supportive interventions to validate their feelings, and also to provide the necessary education to correct misinformation about conception.
By exploring each partner's theory about why conception has not occurred, the NP can then determine if these theories are based on fact or just on fictitious hearsay. The NP can then replace any myths with accurate information. It is the responsibility of the NP to validate each individual's competence as a problem-solver, and to emphasize the importance of open communication about doubts and worries between the couple. The NP should discuss the effects of stress and anxiety on ovulation, and encourage a sense of control over these factors. By validating the couple's feelings of frustration, the NP provides support and suggests strategies to cope with the frustration and worry.
At this point, it is critical to replace any fear of childlessness with hope for conception. In order to hope, one must minimize fear and its automatic emotional responses. Hope is based on rationality, in which cognitive processes prevail over emotional ones. Maintaining hope involves the ability to tolerate uncertainty. Tolerating uncertainty requires openness and flexibility so that appraisal of the threat is realistic. Hope is instilled by engaging the couple in reflective thinking by asking nondirective questions. The NP can then help the partners to create ways in which they can deal with social situations and significant others.
Supportive interventions should also include providing anticipatory guidance. The NP should discuss what feelings the couple experiences when the female's menstrual cycle occurs, and how they cope with these emotions.
Supportive interventions are also useful in dealing with decreased self-esteem.1 The NP should elicit each individual's thoughts about himself/herself as a female or male. The biological issues in conception, as well as issues that are within the couple's control should be emphasized. The couple should be counseled on issues such as:
* Quitting smoking
* Avoiding alcohol
* Effectively communicating with each other
* Managing stress
These interventions, along with passage of time, typically ameliorate ordinary worries as described in Stages A and B.15
Stage C: Assessment and intervention
Couples in Stage C often present with feelings of powerlessness, depression, guilt, severe anxiety, and shame. The Beck Depression Scale may be used to determine if the patient is suffering from depression.31 Severe anxiety may be manifested by preoccupation with conception concerns, thought intrusion, increased heart rate, and/or increased BP. Women with higher levels of anxiety tend to have a more pessimistic outlook on the possibility of successful pregnancy. They also experience greater stress-related intrusive ideation with levels similar to psychiatric patients.9
Additionally, one or both partners may place blame on the other partner for conception difficulties. Blame is a destructive emotional response in the individual and in the couple. The NP should help the couple establish some balance regarding each partner's limits in the process of trying to conceive.12 Couples in Stage C also generally report distance in their relationship, feelings of social isolation, and excessive worry.15
When referral is necessary
If one or both partners present with excessive worry and psychological symptoms, then referral to an appropriate mental health professional is warranted. The NP will have to help the couple understand this need.
Once the referral is made, the couple must be reassured that their relationship with the NP will not end. Collaborative care is encouraged when the couple is in Stage C. In such a collaborative care model, patient education and care are shared by the NP and the mental health professional.20 The NP continues to assess the couple's theories and concerns, and also continues with supportive and educative interventions.
One of the most effective strategies for dealing with a client's theory or understanding is Cognitive Behavioral Therapy (CBT). CBT is very effective in treating depression, grief, anxiety, decreased self-esteem and femininity, social isolation, distance in the couple relationship, guilt, blame, anger, feelings of loss of control, and excessive worry.9
By utilizing CBT, individuals are taught the ability to suppress intrusive thoughts by immediately substituting a positive one.15 The NP can help the individuals practice this technique. While the NP is working to alter and correct IWMs, he or she is actually using some principles of CBT.
CBT involves correction of flaws in reasoning and is compatible with the notion of underlying personal theories, as well as understanding and solving problems. By using thought substitution, a positive or hopeful thought is substituted for a negative or pessimistic one.
When couples experience fear and panic related to uncertainty of childlessness, CBT may be utilized to encourage hope. The NP should assist the couples with cognitive coping strategies such as goal-setting, rational thinking, and plans about how to achieve those goals.13
Summary and implications
Use of this protocol enables NPs in primary care to provide the support and education that couples experiencing difficulty with conception require. The effect of psychosocial distress negatively affects fertility. Without this protocol, patients who respond with anxiety and low mood would not ordinarily be treated. The protocol is simple to use with specific assessment parameters and specific interventions. It also serves as a guide for referral.
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