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Men, Women and Infertility: Intervention and Treatment Strategies


“The treatment of infertility has for many years tended to ignore what should be obvious: infertility is not just a medical condition to be treated with fertility drugs, surgery or in-vitro fertilization, but is often a crisis that profoundly affects nearly every aspect of one’s personality and life. A thwarted desire to have children may challenge one’s sexuality, social roles, and self-image, and may compound feelings of inadequacy, guilt, grief, and loss of control. Paradoxically, we support expensive and invasive infertility treatments by pointing to the devastation that many infertility patients experience, but we rarely articulate or treat these psychosocial symptoms. Even worse, infertility treatment itself can compound psychosocial distress in ways that are rarely recognized or remedied.

In Men, Women and Infertility: Intervention and Treatment Strategies, Aline Zoldbrod provides an extremely important and valuable contribution to the field by bridging this gap: she articulates common experiences of infertile persons, as has been done less rigorously in self-help literature directed toward patients, and also provides innovative therapeutic strategies for relieving the psychosocial distress that infertility often causes. Zoldbrod aims the book at trained therapists who do not specialize in infertility, and it is a valuable resource for counselors working with families, couples, or individuals whose problems may stem from or be complicated by infertility. I would offer a wider recommendation, though: this book should be required reading for all clinicians working with infertile patients and should be consulted frequently to avoid compounding infertility’s psychosocial distress in routine but avoidable clinical behaviors. Patients, too, may find many chapters useful in understanding and resolving aspects of their difficulties and will find the exercises in the appendices especially helpful. The writing style is engaging and well-paced making the book easy to read straight through or by references from the comprehensive index, although laypersons may find the frequent in-text references distracting. A copious amount of psychological research has been summarized and discussed, as has rarely been done in the infertility literature, making this volume indispensable for anyone interested in the biopsychosocial phenomenon of infertility.

Zoldbrod advocates a multimodal therapy (MMT) approach based on the work of Arnold Lazarus. As she notes most previous work (especially in the patient-oriented materials) focuses on relationships and feelings such as anger and grief. The multimodal approach allows a more comprehensive systematic approach to therapy by integrating behavioral, affective, sensory imaginal, cognitive, interpersonal, and biological aspects of the experience. In other words, we often discuss resolving the grief of infertility, but rarely address the beliefs, imagery, and behaviors that accompany and support such emotions; we frequently note the disruption of marital relationships and sexual enjoyment, but rarely acknowledge or reverse a broader shutting down of nonsexual sensory experience. The MMT approach emphasizes the complexity and breadth of the experience of infertility, and more importantly, offers a variety of practical avenues to remedy various aspects of the distress.

Perhaps most valuable is this volume in Zoldbrod’s empathy and sensitivity to infertile persons; she describes her own experience with infertility along with the theoretical, empirical and therapeutic research that she documents. Above all, she cautions that the psychosocial aspects of infertility should not be seen just as symptoms needing intervention and “cure,” but as profound life experiences that deserve serious attention, understanding, and sympathy.

Certain rarely discussed topics receive special attention in this volume and offer another valuable contribution to the literature on infertility. The majority of the book focuses on women, who tend to initiate medical treatment and who are more likely than men to display more severe symptoms of distress regarding infertility, but an early chapter focuses on male experiences with infertility. Again, paradoxically men are often either left out of infertility discussions or are assumed to be just like women, but Zoldbrod shows that neither description is quite right. She considers a range of gender based influences that include social expectations to reproduce, the freedom or inability to express emotions, parent-child relationships (and especially father-son and mother-daughter dynamics), and expectations of strength and control. Another chapter gives special attention to the treatment of anxiety during pregnancy for patients who have a history of miscarriage; this form of infertility is often ignored in discussions that focus on pregnancy initiation through new reproductive technologies.

The final chapter of the book presents a unique and compelling account of infertility treatment as an experience analogous to rape: when a woman has repeatedly lain on her back with her legs apart, exposed her genitals to any number of barely known doctors and nurses, and experienced genital pain during the procedures, the subjective experience of vulnerability and loss of control over her genitalia can be quite like that of being raped. Because the woman herself chose to undergo such procedures, she may develop an image of taking herself or her sex organs in for repeated abuse. This form of “self-rape” plausibly leads to dissociation from sensory experiences, especially those involving genitalia, and feelings of guilt for what she has done to herself; it is no wonder, then, that many patients undergoing infertility treatments develop sexual dysfunctions similar to those experienced by rape victims. The analogy may be very helpful for patients to understand their complicated and conflicting emotions, and for therapists to help patients identify and resolve the feelings of guilt, anger, humiliation, and withdrawal that may accompany voluntary medical treatments. Clinicians should be especially sensitive to the nature of the procedures they are performing and should heed Zoldbrod’s suggestions for reducing the distress of the protocols.

In short, Men, Women and Infertility is a long-overdue, invaluable contribution to the literature on infertility, and it deserves to be widely read, discussed, and used. I hope that it quickly becomes a standard reference for infertility clinicians, therapists working with infertile people, and infertility patients and those who love them, and even health policy makers who can expand mental health coverage for patients who are not mentally ill, but who are suffering a complex and profound life crisis.”

--Laura Shanner, Journal of Psychosomatic Research, 1997:42:103-4

”Readers may or may not have personal experience with infertility or reproductive technology, but they will come away from this book with an enlightened, sensitized awareness of these very difficult experiences. Aline P. Zoldbrod's book is a wonderful treatment guide for psychotherapists and infertility professionals and should be mandatory reading for obstetrical, gynecological, urological, and women's health care providers. Excerpts should be made available to patients undergoing in vitro fertilization, donor insemination, intrauterine insemination, and infertility treatments...”
--Reviewed in Health and Social Work; 11/1/1995; Meglin, Diane E.

“Zoldbrod's insights and sensitivity to the different ways men and women experience the multiple dimensions of infertility is a major strength of this book. The emotional component of infertility is dealt with clearly and comprehensively. This is an invaluable resource for therapists working with infertile couples."
--Book review, Richard Meth, CISW, (National) RESOLVE Newsletter, Winter, l994 edition

“This thorough and helpful book offers sound suggestions or maintaining a positive self-image and high self esteem through the trauma of infertility... Both patients and physicians will find this book useful. It gives an outpatient population the benefit of a licensed psychologist and certified sex therapist. It is indeed highly recommended reading.”
--Book review, Fertility News, newsletter of the Journal of the American Society for Reproductive Medicine

“This book will be a valuable resource for any health-care provider who has thought there must be more to offer the infertile couple. It deals with the in-depth dynamics and clinical techniques for the infertile patient, and it helps providers deal with their own feelings, concerns, frustrations, and limitations.”
--Joyce Vickers RN, MSN, in Journal of Obstetric, Gynecologic and Neonatal Nursing

“...Although this book is written primarily for clinicians, there is plenty of valuable information for consumers... clear and concise... great information on ‘gender differences’ in coping with infertility, a large section on male emotions, and a discussion on infertility and sexuality which you will not find elsewhere...”
--Barbara Kastner, Resolve of Washington State Newsletter

“Dr. Zoldbrod, a psychologist and sex therapist in the Boston area, is an old hand with RESOLVE and is well qualified to address the impact of infertility (different in men and women) on personality and couple relationships. She goes beyond the descriptive to offer behavioral techniques and exercises including imaging methods such as The Crystal Ball and Onion. This book is written primarily for trained therapists who don’t specialize in infertility, but will give new insights to those who do, and to many health and social work professionals whose work touches the infertile. It may also be helpful to patients. The chapter on 'Medical Treatment as Rape' carries an important message for medical professionals: “pay more attention to the symbolism, imagery, tone, and details of invasive medical treatment.” Indeed, it may be the model patient who can have trouble down the road.”
--The Ferre Institute Newsletter, Volume 12, No. 1, Spring, l996


Part One
. Introduction
. Men, Women and Infertility

Part Two: Losses Across the Personality: Taking a Multimodal Look at Infertility
.Using Multimodal Therapy with Infertility Patients Cognitive and Behavioral Interventions
.Use of Imagery in Treating the Emotional Aspects of Infertility
. Feelings
. Social Support and Interpersonal Relationships
. The Realm of the Physical
. Using a Multimodal Approach to work with an Infertility Patient: The Case of Ann
. Treatment of Anxiety during Pregnancy in Patients with a History of Recurrent Miscarriage

Part Three: Sexuality
. Men, Women and Sexuality
. Medical Treatment as Rape: Sexual Problems in Women as an Aftermath of Treatment for Infertility

. Including Infertility Prayers, Worksheets, Unusual Resources

List of Figures
Figure 1--Stages of Grieving: A Three Stage Diagram
Figure 2--The Grieving Process During Infertility
Figure 3--The Onion Exercise (for reconstituting personality)
Figure 4--Pain Diagram
Figure 5--Lifelong Tasks of Adoptive Parenting
Figure 6--Double Onion Exercise
Figure 7--Tracking Order: Overinterpretation of Normal Uterine Changes During Pregnancy
Figure 8--Interactions of Thoughts, Feelings and Sensations in Creating Anxiety in Pregnant Women with a Past History of Miscarriage
Figure 9--Relative Placement of Uterus and Intestines During Early Pregnancy
Figure 10--Important Factors that Influence Sexuality During Infertility