Part One: Supporting Women with Medically Unexplained Infertility
This article outlines an approach to supporting women with medically unexplained infertility.
The use of holistic interventions alongside Western Assisted Conception Treatments (ACT) is well known. Most fertility clinics offer fertility counselling to support women and couples to navigate their choices.
Overview
In our model[i], women are invited to join a weekly psychotherapy group. Women continue to access acupuncture and naturopathic nutrition in parallel to their group therapy.
A focused therapy group offers women with medically unexplained infertility a ready-made supportive community that understands the difficulties. The therapy work deals with the ‘here and now’ of everyone’s situation, and also extends to the impact on individual women of their childhood.
This sort of group offers women a safe and confidential opportunity to explore feelings that can rarely be talked about with partners/family or fertility doctors as they often relate to the impact of adverse events/trauma in childhood.
Therapy aims include:
reducing anxiety
improving self-care
increasing self-awareness
improving self-compassion
improving overall health
These are particularly important considerations and outcomes for this cohort of women who often seek ACT in their late 30s to mid-40s. These are women who have often avoided feelings of early anxiety through high achievement, individualism and perfectionism. These women, we find, have often ‘burnt out’ in their fast-paced careers, or are living with a constant fear of breaking down.
Key concepts in this article
Medically unexplained infertility.
Balance and regulation through holistic interventions.
Adverse events in childhood and childhood trauma.
HPA axis and fertility systems development.
Infertility as a symptom of deep distress and ambivalence.
The clinical impact of group psychodynamic/ analytic psychotherapy.
Definition
In Western medicine, medically unexplained infertility is defined broadly as when fertility testing hasn’t found a medical explanation for why a woman can’t conceive, usually after a year of trying.
Holistic interventions
Nutritional support, hormone testing and TCM[ii] are the holy grail of holistic interventions for women with non-medical infertility. From a holistic perspective, for this cohort of women, there is no such thing as ‘unexplained infertility,’ only ‘unexplored imbalances.’ Naturopathic nutritionists offer much more in-depth hormone testing than most fertility clinics, and acupuncture therapists will focus on hormonal balance together with kidney health.
Psychological coping strategies
In our psychotherapy work with women struggling with a diagnosis of medically unexplained infertility, we have found a prevalent type of coping strategy: women seem to need to believe that they are the strongest person in the room.
Perhaps unsurprisingly, these are often women with a history of unresolved childhood trauma, which appears to manifest as particular coping mechanisms, which, if unacknowledged, can affect partner choice and health/self-care behaviours.
Furthermore, a deeper exploration of the feelings hidden from consciousness often reveals that many of these high-coping women actually feel ambivalent and even frightened about becoming a mother, which often links back to these early experiences of being (inadequately) mothered.
Qualitative research and case study findings
We will focus here on four interrelated areas: trauma and physical illness; adverse events in childhood and fertility issues; psychology of women seeking treatment for infertility; and psychoanalytic casework about issues that emerge in psychotherapy.
Trauma and physical illness
Clinical authors such as Gabor Mate (When the Body Says No, 2003) describe the many ways in which our emotions affect our health – in particular our unprocessed emotions.
The mechanisms by which this happens are beyond the scope of this article (not to mention authors!), but it seems that unmanageable stress can manifest as under-development in various brain systems (the hypothalamic-pituitary-adrenal axis or HPA-Axis).
A look at PubMed revealed research into the actual mechanisms behind this problem, and Joseph (2017) reported that stress activation of the HPA-Axis can result in underdevelopment of the systems that drive normal fertility:
Events that challenge the environment of an organism activate the central stress response system, which is primarily mediated by the hypothalamic–pituitary–adrenal (HPA) axis. The regulatory functions of the HPA axis govern the cardiovascular and metabolic system, immune functions, behaviour, and reproduction. Activation of the HPA axis by various stressors primarily inhibits reproductive function… (Joseph, 2017).
Adverse events in childhood
Research into links between adverse events in childhood, menstruation problems and difficulties conceiving makes for fascinating reading. Published in 2015, researchers found that the more ACEs there were, the more chance there was of a woman experiencing fertility difficulties.
29% of women experienced 4+ ACEs and 48% experienced 1-3 ACEs. The most prevalent ACE’s were:
parents separated or divorced (45%)
parent threatened child (29%)
family verbally abusive, including name-calling (27%)
parent hit child (23%)
father violent towards mother (22%)
emotional abuse (18%)
mental illness in family (18%)
It is worth noticing that the prevalence of ACEs such as sexual abuse and substance abuse in the family was lower (10% and 7% respectively), which shows us how much damage is done by day-to-day (chronic) neglect and insecurity.
Psychological issues:
Psychotherapists tend to be interested in three things:
What sort of stress the patient has suffered?
At what stage of development did the injury occur (in particular was the child pre-verbal)?
Has the experience been processed and integrated into the patient’s sense of being them (identity)?
To explore this, we think together about how our client relates in the here and now; and what might be manifesting as a communication about unresolved emotional experiences in the past.
This is always very individual work, but psychology studies provide useful questionnaire-driven summaries. For example, a psychology study in 2014 into personality differences between fertile women and women with fertility difficulties suggested that infertile women tended to be more wounded - often expressed through narcissism, defences and attachment style.
All childhood trauma is a deep attachment wound. If this breach of trust is not worked through, it ‘maps’ us to repeat unhelpful/defensive ways of relating, in order to continue to protect ourselves (and too often, keep up the fight). Put another way, unresolved childhood trauma influences what we believe, how we feel and how we behave.
Many women with medically unexplained infertility may not be medically ‘diagnosed’ until their late 30s. Understandably, they go into fertility services with their well-developed defence systems on overdrive and with deep anxieties about running out of time.
Part Two
See the second part to this blog to find out more about the sorts of issues that emerge in a therapy group for women with medically unexplained infertility.