Mind Matters

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I have just returned from the European Society for Reproductive Health and Embryology (ESHRE) annual conference which took place in Prague. Now, as you might expect, this old-world city was fabulous, but my favorite part of attending conferences is renewing old friendships and sharing new thoughts and experiences with colleagues in the field of fertility counseling. It amazes me how many more similarities than differences we share when it comes to servicing the needs of our patients. The globe feels like a village when a bunch of counselors get together. There we are, talking and sharing (usually over drinks), members of a small community. No matter that our mother tongues are different, no matter that we hail from such diverse countries as Saudi Arabia, Israel, Greece, Germany, Belgium or Japan. Our working themes are the same.

How do we persuade our governments that in the long run it is cost-effective to cover the costs of ART, and that every citizen should have access to care? How do we convince clinics that counseling is an integral part of the overall treatment process? Did you know that the small country of Japan has more than 600 IVF centers and only five to seven infertility counselors in the entire country? Canada has about 25 clinics and as many counselors.

How do we develop global professional standards and practice guidelines for the provision of psychosocial care that would be pertinent to all cultures and countries? This lofty task is doable since, as counselors, we address the same emotionally-based issues when helping infertility patients. In a nutshell, we facilitate coping with overwhelming feelings of sadness, anger and blame. We try to reduce the level of stress that results from treatment and infertility so that it won’t compound problems within the relationship, social network, workplace, and so on. We try to modify maladaptive lifestyle choices like smoking, poor nutrition, or anxiety, to improve pregnancy chances and personal well-being. We address the short- and long-term implications of having children with assisted intervention either with one’s own genetic gametes or through alternatives like donation and adoption. We provide information about risks, and help patients set realistic goals, establish deadlines, explore options and confront ethical and religious dilemmas. And we have to do all this while being culturally sensitive.

Within many countries there is a diversity of races, ethnicities and cultures - a microcosm of the world, really. The Canadian government, being aware of this multiplicity, dictates in its new legislation that we cannot withhold the provision of fertility treatments based on race, ethnicity, marital status or sexual preference. That means that single men or women, gay or lesbian couples and mixed-race couples all have the right to be treated for their inability to have a child whether the obstacles are medical or social.

Different cultures differ in their needs, however, and we must be sensitive to those needs. One size does not fit all! For example, lesbian couples will have different parenting needs than heterosexual couples. Children of lesbian parents have to deal with potential discrimination, the absence of a father, and the obvious origins of their conception. Furthermore, cross-cultural issues in the treatment of infertility are becoming even more important as patients migrate and cross borders to obtain treatments unavailable in their own countries. The influence of family traditions, heritage and gender role expectations have implications for reproductive choices. For example, it may not be in the best interest of the child to be told his origins if he were conceived through donor insemination with parents of Greek or Armenian descent versus those from a less patriarchal society. Thus, we as counselors must be aware of these cultural differences and not impose our own biases.

In some societies, like Mexico, a woman might do anything for the possibility of becoming pregnant. Motherhood is the sole function that determines the identity of the majority of women in Mexican society. In Canada, women are under less social pressure to conform to traditional gender roles. And what about the Canadian couple in which the wife has blocked tubes but who are observant Roman Catholics and essentially forbidden from using ARTs, as conception is considered a divine power that man cannot interfere with? In this case, because IVF is viewed as a mortal sin, we must let go of our own beliefs and direct the couple toward adoption.

It is for these reasons and many more that the International Infertility Counseling Organization (IICO) was formed at the ESHRE meeting in Madrid in 2003. It is a group made up of counselors and counseling societies representing the four corners of the Earth and we met in Prague for our bi-annual meeting. I have great faith in the power of this group and the dedication of each member and it is my belief that together we will be able to effect progressive change for infertility patients both on global and individual levels. 

Finally, allow me to briefly review three studies which were presented at this conference that I think this readership will find interesting and encouraging. One Israeli study found that artificial insemination (IUI) success rates were improved by using a bit of comic relief. One hundred eighty-three women were randomly assigned to either be entertained by a clown during an IUI procedure or not. The results showed that thirty-three women in the humour group conceived, compared to only 18 in the control group – a significant difference of 35%.

In another study, one hundred twenty-three women undergoing IVF were randomly assigned to one of three groups. In the experimental group, women were trained to do a progressive muscular relaxation (PMR) technique for 20 minutes before the embryo transfer (ET) and daily thereafter. Two comparison groups were asked to listen to atmospheric music or short stories before the ET and after. The findings were that anxiety levels decreased for both the PMR and music groups in the days leading up to the pregnancy test, but for the 80% who had to do a second IVF cycle, those who did PMR showed improved well-being, reduced anxiety and most importantly, better embryo quality from the previous cycle. 

Along the same lines, an American study looked at young, otherwise healthy women who were infertile because they had stopped ovulating. Although the convention has been to attribute this anovulation to being underweight, this study hypothesized that it was actually due to underlying stress. To prove this, the authors looked at women of normal weight and found that cortisol levels, a stress-sensitive hormone, were elevated. The women were then randomly assigned to one of two groups. Half received cognitive behaviour therapy (CBT) for 20 weeks aimed at reducing stress, the other half were simply observed. The results – an astounding 80% of the women who received CBT started to ovulate again, as opposed to only 25% of those in the control group and 30% of the CBT women became pregnant within two months.

Although these three studies have their individual, methodological limitations, combined they suggest a powerful conclusion. To put it simply, stress reduction techniques are an effective therapy for reducing the distress associated with infertility and for some will improve pregnancy rates. Furthermore, in comparison to medical and surgical treatments they are inexpensive, non-invasive, easily accessible and self-managed with no short- or long-term negative consequences. And that is why in the medical world of infertility treatment it is important to remember that mind does matter!

22^nd Annual Meeting of the European Society for Human Reproduction and Embryology, June 18-21, 2006, Prague, C.R. In Hum Rep 21, Supplement 1, 2006: Abstract Book.