CC BY
11
Kruvshkova Silvia,
PhD in Psychology, Clinical Psychologist, Forensic Expert,
Center for Mental Health Rousse, University of Rousse "Angel Kunchev", PhD in Psychology, Department of Public Health and health Care E-mail: krovshkova@mail.bg
A TRANSFORMATIVE APPROACH TO TREATING REPRODUCTIVE PROBLEMS IN COUPLES IN FERTILE AGE
Abstract. This article addresses a clinical phenomenon for the 21st century, namely infertility, with the author's idea that this problem has not only a medical aspect, but corresponds to the emotional, behavioral and social well-being of couples with a reproductive problem. In this regard, a complex transformative approach is proposed in the treatment of couples with a reproductive problem, which, using the mechanisms of cognitive functioning, influences and enhances the overall quality of life of couples with a reproductive problem. Finally, the emphasis is on the idea that, at the start of the assisted reproduction process, the couple with reproductive problems should be included in psychological counseling, which will, on the one hand, limit the emotional problems encountered during assisted reproduction and, on the other, increase the likelihood that assisted procedures will produce the desired result.
Keywords: infertility, reproductive problem, transformative approach, psychological counseling.
Infertility is the inability to naturally conceive, parents. In general, clinical studies show that couples
bear or birth of a healthy baby. The definition of with reproductive problems, women manifest higher
WHO based on 24 months of unsuccessful attempts levels of negative experiences than their male counter-
at conception is recommended as a definition used parts, which is explainable given the anthropological
in clinical practice and research across disciplines. In- features of the female gender and the main mission
fertility affects 10-15% of reproductive age couples of women, namely to become a mother. and. On the
worldwide [3; 4]. In recent years, couples seeking other hand, a number of research studies support the
specialized help with reproductive problems have in- hypothesis that distress correlates with a lower preg-
creased dramatically. Although behavioral scientists nancy rate among women undergoing reproductive
are working toward the importance of the emotional treatment. Since psychological factors play an impor-
state of subjects with reproductive problems, there is tant role in the pathogenesis of infertility, research into
still scarce information and research on the effective- this is an important task in influencing and managing
ness of psychological interventions on this popula- this problem, which has cultural and social impact.
tion, of course there is evidence to support the use The success of a complex work related to this
of psychotherapeutic interventions. The emotional phenomenon is not only a set of medical interven-
state in which these subjects fall is associated with tions, but a holistic approach including medical,
emotional disturbances that lead to increased levels psychological and social aspects. The work is about
of anger, depression, anxiety, marital problems, and incorporating a complex model that aims not only to
a sense of worthlessness among couples becoming resolve medical dysfunction, but to radically influ-
ence the behavior of reproductive deficits, changing their lifestyles and enhancing their quality of life.
In recent years, the number of couples seeking assisted reproduction has increased significantly. This is due to the fact that many women of fertile age have delayed conception for a long time due to economic and social reasons, as well as the fact that medicine has advanced rapidly and evolved in this field - developing newer and more successful techniques for treating infertility as well as raising awareness of the services available. It is these possibilities of modern medicine in the field of assisted reproduction that have raised the awareness and, on the other hand, inspired those who have been researching the psychological consequences of infertility. Very often, however, reproductive medicine professionals do not consider the relationship between the reproductive problem and the psychological problems of the couple undergoing assisted reproduction; and the prolonged exposure to infertility treatments for the couple's mood and well-being. However, there is evidence to support the use of psychotherapy interventions in couples with reproductive problems.
The question is why infertility has a psychological effect on the couple. Undoubtedly, parenting is one of the major transitions in adult life, for both men and women [4]. The stress of not being able to fulfill this desire for a child is associated with emotional problems such as anger, depression, anxiety, problems in marriage and feelings of futility. Increasing anxiety in the couple's emotional experiences correlates with heightened sexual dysfunction and social isolation, which in many cases is not accounted for by medical professionals directly involved in assisted reproduction. Relationships within a couple are often broken especially when a pressing decision is needed to resolve a medical problem. In many cases, couples experience stigma, a sense of loss and reduced self-esteem in a situation of infertility. Although proven women experience more emotional suffering associated with the phenomenon of infertility than their male counterparts, both partners experience a sense of loss of
identity (identity) and show marked feelings of defect and incompetence. Women who are trying to conceive often report a clinical degree of depression, similar to women who suffer from cardiovascular disease or cancer. Even couples who have undergone assisted reproduction face considerable stress, often developing into distress. A number of studies support the hypothesis that emotional distress and relationships are greater in couples where the reproductive problem is due to the male partner. Therefore, the psychological impact of infertility can be devastating for the couple.
Factors affecting psychological stress.
A study done in Sweden shows that three separate factors contribute to the psychological stress that women and men experience as a result of reproductive problems:
1. "having a child is a major focus in life"
2. "women's role and social pressure"
3. "effect on social life"
It has been proven that women have a more severe reproductive problem than men [5].
How does infertility affect the couple's behavior?
Stress, depression and anxiety have been described as common consequences of a reproductive problem. A study done at St. John's Medical Center Ivan Rilski " - Tutrakan, Bulgaria in the period 2012-2017. shows that the incidence of depression in couples with reproductive problems who have entered an assisted reproduction program is significantly higher than in fertile controls and ranges from 38-72%. During the same period, it was reported that anxiety was significantly higher in couples with reproductive problems compared to the general population, with 92% of couples with reproductive problems manifesting clinically significant anxiety both at the beginning of assisted reproduction and during the process. Another interesting study on the territory of the medical center is that 15% ofwomen, even before having undergone assisted reproduction, had previously experienced conditions with symptoms of depression, panic disorder or other psychological problem, which in turn supports the
hypothesis that psychological factors can also affect reproductive capacity. Although reproductive deficits affect the couple's psychological well-being, it is important to note that different psychological factors, in turn, affect the reproductive capacity of the two partners. The mechanisms by which depression can directly affect infertility include the physiology of the depressive state, such as elevated prolactin / so-called levels. mood hormone /, disorders of the hypothalamic-pituitary and adrenal axis, as well as thyroid dysfunction. Changes in immune function associated with distress and depression can also adversely affect reproductive function. It is time to point out the need for additional clinical studies to differentiate the direct effects of depression and anxiety from related behaviors, e.g. low libido, tobacco use, alcohol and some surfactants, as well as lifestyle and nutrition, which can also impede the reproductive process. Because stress and distress are associated with a number of physiological changes, this increases the possibility of a history of high levels of cumulative stress correlating with recurrent depression or anxiety, which can also be considered as a cause of reproductive problems.
Over the course of 9 years of psychological work with couples with reproductive problems, I have found that many of the couples with reproductive problems are stuck in the process of assisted reproduction with already increased levels of psychological suffering associated with infertility, but on the other hand, I recognize that the process itself assisted reproduction also in many cases increases the levels of anxiety and symptoms of depression and distress. Since the process of assisted reproduction from a medical point of view is difficult for the couple and is associated with physically less pleasant experiences, each subsequent stage affects the psychological well-being ofthe couple, as well as leads to negative changes related to their behavior and life. especially social exclusion due to low self-esteem based on depressive experiences.
In this regard, the team working with couples with reproductive problems was challenged with
how to respond to adverse psychological conditions, which further complicate the positive outcome of purely medical interventions. At that time, a comprehensive approach was devised that focused entirely on couples with reproductive problems. The idea behind the complex approach was taken from nature, just as a cacophony turns into a beautiful butterfly, and the team performing assisted reproduction as a whole influences the change of the couple. Using psychological techniques for counseling and support, both individual and group, orientation towards the process itself, change in behavior both within and outside the couple, change in eating patterns, physical activity and social activity. Since the idea is in the transformation from a personality with impaired emotional and behavioral functioning to a person with a satisfying sense of self and behavior, as the cacao is transformed into a butterfly through transformation, we called this method transformative. Basically, the approach to the transformation of couples with reproductive problems is based on cognitive concepts that directly influence the motivation and realization of human behavior. The cognitive psychological direction underlies the circular relationship between the body and the psyche. This relationship is a platform for the psychosomatic treatment approach. The cognitive trend is based on the basic theoretical construct, which has been applied for more than three decades, has shown its effectiveness and underlies the modern development of the model of "cognitive vulnerability" of the patient. This vulnerability corresponds to the dominance of dysfunctional beliefs about the world, about themselves and others, which not only disrupts the social functioning of the individual, but also determines the high risk of bodily dysfunction and disorder [1].
It is common for couples with a reproductive problem to experience feelings of loss, anxiety, depression and isolation. The psychological impact of infertility is real and affects both men and women. In women, infertility causes problems with self-esteem, guilt and sadness. Hormone therapies also
have a strong influence on emotions, which makes it difficult to cope with even the small obstacles and challenges in everyday life. Men diagnosed with male infertility factor often consider the diagnosis as a threat to their masculinity or worry that they will not be able to continue their family genetic lineage. Relationships within the couple can be affected if both partners begin to view sexual contact as a mandatory requirement, performed on a timely basis, rather than an intimate and loving act. Financial stress, differing opinions about the extent to which infertility treatment can be continued, and changes in relationship dynamics can also contribute to increased stress and the psychological challenges of the reproductive problem.
As Van den Akker points out, the focus on sexual reproductive health is not a privilege but a necessity [2]. People are sexual beings throughout their lives, and sexual and reproductive health care should focus on improving their lives and personal relationships, not limiting themselves to counseling for a separate assisted reproductive procedure.
According to the WHO, prevention and care for reproductive health are seen as a secondary problem in public health, especially in countries with low social status [3].
It is an indisputable fact that stress has an important effect on reproductive function in a purely physiological aspect [5; 6]. Most studies on stress and assisted reproduction have found a link between higher levels of stress and a lower rate of pregnancy and childbirth [7]. Exposure to stress itself is even
directly related to the inability to conceive and is
considered to be the most common reason for interruption of fertility treatment [8].
The main objective of the emotional counselor in this context is to promote informed reproductive decision-making as well as psychological / emotional / health and well-being throughout all stages and aspects of the reproductive process. The support offered includes reproductive counseling, psychological intervention in infertility, follow-up and care during the various psychological stages of assisted reproduction treatment, couples therapy. In general, reproductive deficits in couples in modern times are not only a medical problem, but also bring emotional, behavioral and social negatives to the couple. For this reason, couples with a reproductive problem need a complex and transformative approach during the implementation of medical assisted reproduction activities, which leads to an increase in the couple's quality of life.
References:
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2. Van den Akker O. B. Reproductive health psychology. - London: John Wiley & Sons. 2012.
3. Mother or nothing. The Agony of Infertility World Health Organization Bulletin 88: 2010; 877-953.
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5. Nakamura K., Sheps S., Arck P. Stress and reproductive failure: past notions, present insights and future directions. J Assist Reprod Genet 25: 2008; 47-62.
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