Group therapy for 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. 

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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. 

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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 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.

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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. 

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Group therapy is clinically time and cost effective

For so many women with unexplored infertility, the clock is ticking and ‘shields are up.’ Therefore it is understandable that the offer of open-ended psychotherapy over several years to explore childhood trauma is unlikely to feel relevant or manageable.

This is why we believe that therapy for women with medically unexplored infertility in a group is most effective. Yalom (2005) writes that controlled studies show, “... the average person who receives psychotherapy is much improved and the outcome from group therapy is virtually identical to individual therapy.”  

Lorentzen (2014) published his research data, collected over 10 years, evidencing that short-term group analysis (e.g. 20 weekly sessions) is as effective (with some clinical exceptions) as long-term work for prescribed problems. 

The British Infertility Counselling Association (BICA) supports therapy in a group for fertility issues and provides a written guide on group work for women with fertility difficulties (Wheeler, 2012). 

That said, focused therapy groups for women with medically unexplained infertility appear to be rare, which is both a pity for access to therapy and also for research. At RSF Therapy, Sarah Hanchet is a group therapist, trained with the Institute of Group Analysis, as well as a UKCP-registered individual psychotherapist. 

In group therapy, we tend to build mixed groups in order to use conflicts that arise in the group to explore individual (and societal) defence systems. Put simply, the exploration and discussion of conflict enables everyone to learn healthier ways of relating. 

However, there is also a strong clinical argument for a homogenous group, such as a group for women with the same diagnosis. These sorts of groups offer unrivalled support, understanding and empathy; and they thereby act as a vehicle for helping women to build ego strength. 

On the surface, women who are “the strongest in the room” may appear not to lack a strong sense of self. However, the ‘true self’ is usually undeveloped and vulnerable, which is why it is so strongly protected.

Let us turn now to some of the psychological issues that can emerge in therapy groups with this focus.

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Issues that emerge in therapy groups for medically unexplained infertility

Therapy groups work on different levels:

• Individuals can explore their own story. 
• The group can be explored as a holder of projected (disowned) emotions, as someone usually ends up feeling them.
• The group culture can, with good facilitation, become the nurturing mother or parent. 
• Existentially/spiritually the group is often exploring how the struggle to create life contains something of the deeper struggle to be a creative self. 

This sort of therapy group will inevitably focus on the process of trying to conceive, and the relationship with the assisted conception process. Raphael-Leff (2014) summarises the following key themes from her own psychoanalytic work with women over many years.

Powerlessness

Women may go into IVF as a ‘treatment consumer’ but very quickly the relationship between an “infertile woman” and her “baby-doctor” creates an unexpected power dynamic. Women often project their sense of agency/self-efficacy onto their doctor, enrolling them as the expert or indeed saviour. 

While this may enable everyone (medics included) to travel hopefully, the process leaves the woman trying to conceive carrying all the unvoiced feelings for everyone - powerlessness, fear, rage, shame and sadness. For a woman with childhood trauma, this can be overwhelming and lead to unhealthy coping mechanisms. 

Not-feeling

A second theme is the use of rationality as a defence against feeling. The IVF process invites us into medical rationality: measuring, counting, timing and planning. One day we haven’t heard of HCG and the next we are obsessed with our daily blood count! 

For women who have experienced trauma, this way of exercising control over feelings and the body is familiar and potentially dis-associative, so the very act of coping with IVF can trigger unhealthy coping strategies, in particular a disconnection from the body.

Unconscious guilt

Another therapy theme is more existential and it relates to a personal (instinctual) sense of being a woman in a long line of women who became mothers. Women with fertility difficulties often tussle with the fundamental question, “Who am I, if I’m not a mother?” Women who choose not to have children do too, but perhaps this tussle is resolvable with less guilt. Women with fertility difficulties, who want children, often struggle with feelings of guilt and shame. They seek a resolution to the (unconscious) guilt of not being able to give their mother the baby whose egg she herself created and carried to term.

Maternal ambivalence

In mother-daughter relationships where there are already deeply ambivalent feelings, the struggle to conceive can bring up repressed and frightening emotions about self-worth and being enough (loveable). This can be regressive and therefore deeply destabilising, especially during the vulnerable period of trying to conceive, and the emotional exposure of miscarrying. 

Loss

A woman with medically unexplained infertility is likely to be physically and emotionally stuck because she is protecting herself from old wounds. Healing means facing her fears (women will often speak of fearing breakdown and madness); and acknowledging what she has lost. In a group, feelings are amplified (emotions can run high); and then contained and normalised both by the conductor and the group itself.

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Practicalities and how to express an interest

At RSF Therapy, in addition to our individual psychotherapy work, we offer a therapy group dedicated to women with medically unexplained infertility. Here are some details:

• The group is for up to eight women with this diagnosis.
• It meets weekly in person at the same time, near to Great Portland Street, London (if there is enough interest we can also offer an online group).
• The group is open-ended, which means it will run and run.
• Women are only required to commit for one term at a time.
• Terms run from mid-Sep to mid-Dec/mid-Jan to end-March /start-May to mid-July.
• Women may leave at the end of a term (with notice) or opt to stay for a further term.
• The fee is much lower than for individual therapy, at time of writing it is £45/session.
• Women may join further to an individual psychotherapy assessment to explore their history, and their ability to take part in a group without becoming overly dis-regulated or de-stabilised. 

We operate a waiting list in order to keep the group full and women may apply at any time to join. For a conversation with Sarah Hanchet about the group, feel free to email us and see our website for more details about our work.

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Resources:

• Jacobs et al (2015) Adverse childhood event experiences, fertility difficulties and menstrual cycle characteristics, PMCArticles.
• Joseph, DN et al (2017), Stress and the HPA Axis: Balancing Homeostasis and Fertility, PubMed.
• Lorentzen, S (2014) Guidelines for Long and Short-Term Group Analytic Psychotherapy, Routledge.
• Mate, G (2003) When the Body Says No, The Cost Of Hidden Stress, Vermillion.
• Raphael-Leff, J (2014) Dark Side of the Womb: Pregnancy, Parenting and Persecutory Anxieties, Anna Freud Centre
• Wheeler, M (2012) A Creative Approach To Groupwork For Women with Fertility Problems, British Infertility Counselling Association, (BICA) Practice Guides Series.
• Yalom, I (2005) Theory and Practice of Group Psychotherapy, Basic Books

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[i] Psychodynamic Psychotherapy Groups for women with medically unexplained (unexplored) infertility are offered by RSFTherapy Limited, a practice near to Harley Street focused on relationships, sex and fertility difficulties, which works with holistic practitioners.

[ii] TCM means traditional Chinese medicine