The desire to have children is age-old, but for the one in five. South African couples struggling with infertility there’s a double-edged sword – while infertility has a negative impact on mental well being, its root causes can also lie in mental health disorders such as depression and anxiety.
Women with a history of depression are at greater risk for infertility, while depression and some anti-depressant medications can negatively affect male fertility. At the same time, a struggle with infertility is deeply stressful and can cause feelings of grief and isolation through to full-blown anxiety disorders and depression, as well as conflict in relationships and families.
This makes psychological support a vital part of the “infertility journey”, both before starting and during infertility treatment, because good mental health can have a positive impact on the success of fertility treatment, says Prof Renata Schoeman, psychiatrist and member of the South African Society of Psychiatrists (SASOP).
“Infertility as a reproductive disease affects men and women almost equally, but women are especially vulnerable to severe negative social consequences of being stigmatised, ostracised, even abused or having financial support withdrawn.
“With the focus of Women’s Month on achieving gender equality, it is important too to highlight the impact of women’s health on their social and economic status,” she said.
Infertility is defined by the World Health Organisation (WHO) as “failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected intercourse” and it affects 8 to 14 % of couples, or 48-million couples worldwide.[iv]
The average fertility rate in South Africa is declining in line with global trends and up to 20% of couples face a battle with infertility,1 while infertility is a major reproductive health problem in Africa with a prevalence of 30-40%, due to various factors including poor healthcare, infection control and lack of access to fertility treatments.
“The impact of a struggle with infertility can range from negative thoughts and feelings such as denial, guilt, anger, grief and isolation, which can lead to actual withdrawal from usually enjoyable activities, especially those involving families and children – through to formal diagnosis of mental health disorders,” Prof Schoeman said.
She said infertility was a complex phenomenon with a range of biological causes, while a worldwide rise in infertility due to causes that can’t be medically explained points to there being underlying psychological causes of the problem.
Risk factors contributing to infertility include an existing diagnosis of depression or anxiety disorder, lower levels of happiness and poor overall health, while strong mental health – self-acceptance, independence, positive relationships and social skills, personal growth and a sense of meaning in life – contributes to better outcomes of fertility treatment, she said.
“This supports the importance of diagnosis and treatment of infertility being approached holistically, taking into account both biological and psychological factors. Psychological assessment before commencing with infertility treatments is crucial to understand each patient’s individual risk factors, strengths and psychological resilience or vulnerability, and a collaborative approach to treatment that includes ongoing psychological support or psychotherapy,” Prof Schoeman said.
This approach would assist with the negative impact on mental well-being of infertility and the stresses of the treatment journey, she said, as infertility patients are more likely to suffer from depression, anxiety and social withdrawal, with rates of comorbid psychiatric disorders higher in women with infertility than in male patients.
“It is possible, however, that mental illness symptoms in men are reported less or not investigated. Male infertility is often associated with deep shame and this can be a barrier to men seeking treatment, especially those rooted in African cultural traditions, and men also tend to suppress anxiety which then manifests as psychosomatic illness,” Prof Schoeman said.
She said that in managing mental health as part of infertility treatment, education was vital – “the more information a patient has and the better they understand the basic principles of human reproduction and infertility, the less uncertainty (which contributes to anxiety) will be present.”
“Knowledge helps to manage expectations, and helps patients to remain realistically hopeful.”
The healthcare team should also look out for the psychiatric side-effects of some medications used for infertility treatment, which could lead to symptoms of depression, anxiety, mood swings, decreased libido, irritability, concentration and memory problems, sleeping problems, fatigue, changes in appetite, and even psychosis.
Similarly, anti-depressant medication can influence fertility treatment, and this emphasises the need for a collaborative approach to infertility treatment that focuses as much on mental health as physical health, Prof Schoeman said.