In the study "development of a concept of psychosomatic counselling for infertile couples - Heidelberg Fertility Consultation Service" carried out from April 1994 to Mai 1997 at the Heidelberg University Hospital two questions were handled:
1. Is there a difference between involuntarily childless couples and especially couples with unexplained infertility and the reference population regarding marital relationship, life satisfaction, psychical and physical complaints as well as regarding personality structure (diagnostic part of the study).
2. Is it possible to change psychological factors related to the motivation for having a child especially stress due to infertility, depression and anxiety by psychological counselling or couple-therapy (interventional part of the study).
Design and Sample:
Diagnostic part of the study: 564 infertile couples including 140 couples with unexplained infertility entering the Heidelberg University Hospital were examined with psychological questionnaires including the following instruments: questions concerning sociodemographical characteristics, stressful life-events, motivation for having a child, anamnesis regarding the wish for a child, subjective reasons of childlessness, life satisfaction, marital relationship, problem-list, symptom check-list 90-R, and a psychodynamic personality inventory ("Giessen- Questionnaire").
Interventional part of the study: At first a differentiated psychosomatic counselling concept for involuntarily childless couples had been developed. 175 couples attended a two hours' psychological counselling, 25 of these couples had an additional 10 hours of couple-therapy. The effects of these interventions were evaluated by answering the psychological questionnaires a second time and comparing the differences with the values of a waiting- group which included 22 couples waiting in the mean three months for counselling or couple- therapy respectively.
One specifity of our sample was that 33.1% of all patients (women and men) were graduated from university. The high participation of graduated people became very clear for couples with unexplained infertility: in this subgroup 50.4% of men were graduated compared to 36% in other diagnostic groups. The high amount of couples with unexplained infertility in the diagnostic group with 25% was striking. The sample of our study is not representative for infertile couples in these two respects. Couples with idiopathic sterility preferrred "soft" methods of medical therapy rather than invasively reproductive medical treatment. Only 22.8% of women with unexplained infertility had a positive attitude towards in-vitro-fertilization compared with 35.3% of women having other diagnoses. Natural medicine treatment to treat infertility had been offered at the women's hospital one year before the start of the study. Women with unexplained infertility were approximately one year older than women with other diagnoses (32.9 vs 31.8 years). The couples were married one year longer, but had the same duration of the wish for a child (4.2 years). This means that the unexplained infertile couples in our sample decided to have a child later than the other couples.
The diagnostic part showed that infertile couples had a higher satisfaction in life than the reference population of this questionnaire. Women suffered from more anxiety, more depression and more somatic complaints in the symptom check-list. In the "Giessen- Questionnaire" involuntarily childless women showed themselves depressive. The differences on the scales "satisfaction with the financial status", "satisfaction with marital relationship" for both partners and "depression" for women only showed medium effect sizes. There was no difference on the questionnaire to marital relationship. Unexplained infertile women reported more stressful life-events in their childhood than the other diagnostic groups. No other differences between the two groups could be found. Specific psychosocial variables as predictors for pregnancy could not be found. This could be due to the specificy of the sample (many graduated patients, high rate of unexplained infertility). However, couples with non-distressed men showed a higher pregnancy rate. By using the Q-type-factoranalysis on the variables of the "Giessen-Questionnaire" six different couple-types were identified. The general picture of a harmonized or rather symbiotic relationship, as often described in literature, was not typical for the group of couples with unexplained infertility.
In the interventional part of the study it turned out that more couples accepted counselling if both partners reported former stressful life-events ("vulnerable" couples). For the women's decision for counselling or couple-therapy respectively the characteristics "stress due to infertility", depression and anxiety were important. The acceptance-rate of counselling was 34.5% of all couples in the diagnostic group and 51.4% of couples with unexplained infertility. With regard to all couples which entered the medical treatment at Heidelberg University Hospital the rate of acceptance was 16.6% (24.7% for couples with unexplained infertility). After the counselling a couple-therapy was offered to 92 couples. 25 couples accepted (therapy-group). The other 67 couples seemed to suffer less from depression and marital dissatisfaction than those in couple-therapy.
Three independent samples were formed for quantitative evaluation of the effects of counselling or couple-therapy: 59 couples of the counselling group (two hours treatment), 18 couples of the therapy-group (10 hours treatment) and a control group of 22 couples waiting for treatment. Statistically significant was the modification of the central variables "intensity of wish for a child" and "stress due to infertility". These values reduced for women after counselling and even more after couple-therapy. For men only tendencies in reduction of these values were shown. In other relevant variables, i.e. satisfaction in job, marital relationship and sexuality for both partners as well as the reduction of depressivity and anxiety for women the effect sizes were small and the changes were statistically not significant. The profit from counselling was less if the couples had little enthusiasm to being counselled, presenting themselves rather reserved and suspicious of it, and men presenting themselves rather stressed and dissatisfied from life. The pregnancy rates of couples having been counselled and couples not having been counselled were similiar: 22.7% vs. 23.9%.
Qualitative evaluation of feedback after counselling made clear that especially a conversation with a neutral third person was helpful, as well as the offer being couple- orientated and the amount of time being available. With regard to couple-therapy it was critically remarked that the limited time of ten sessions was occasionally felt to be too short. However some couples were satisfied with less than ten sessions.
Altogether ten first and ten final sessions of couple-therapy were investigated by the method of content analysis of the Core Conflictual Relationship Theme (Luborsky) "CCRT". In this case it was shown that the couples' responses towards other people were perceived more positive at the end of the couple-therapy, although the responses of others continued to be perceived rather negatively by the couples.
Infertile couples, especially couples with unexplained infertility have no specific psychological characteristics compared with the reference population of standardized questionnaires except for higher depression and anxiety values for the women. The higher depression and anxiety of infertile women must seen as a result and not a reason for infertility. The relieving effect of psychological counselling independent from pregnancy could be shown in this study. Psychological counselling should be facultative. But especially for vulnerable couples with more stressful life-events it appears to be necessary. A subsequent psychotherapeutic offer should be flexible regarding the number of sessions. The reduction of the number of psychopathological cases of involuntarily childless couples from a psychological point of view should be made public. This could lead to higher acceptance of psychological counselling which may relieve involuntarily childless couples.
Copyright ©: ESHRE 1998.
Published in Human Reproduction Vol. 13, Abstract Book 1, Oxford University
Press 1998, ISSN 0268-1161