Infertility is a reproductive health condition that is often not openly discussed. By not discussing this condition, many stigmas and stereotypes may be ascribed. For example, many think that infertility pertains only to women, although men may also receive an infertility diagnosis. Race and ethnicity can impact how male factor infertility is understood, communicated, and managed. The aim of this chapter is to synthesize available research regarding biopsychosocial variables of male factor infertility with African American men while offering support considerations.

The fertility journey for Black lesbian couples can be both challenging and rewarding. Clinicians must be able to assist their clients therapeutically while they are going through the procedures as well as managing the biological, psychological, social, and emotional aspects of the process. This chapter seeks to help therapists acquire an understanding of the process of conceiving a child within a Black lesbian relationship. It will help clinicians understand how women reconcile being labeled infertile or having issues of infertility when there may be nothing physically wrong. It will explain how gender expression could impact the decision of who should carry the child in Black lesbian relationships. The chapter discusses the process of intrauterine insemination (IUI), in vitro fertilization (IVF), and adoption within the lesbian community and specifically the Black lesbian community. Clinicians will learn how the journey to conceive a child impacts the Black lesbian relationship and what helping professionals need to do in order to effectively help their clients weather the storm.

Trauma occurs when the ability to envisage our future and feel safe in the world is no longer possible. While trauma is often a one-time horrific occurrence, it can also be chronic in nature. Indeed, reproductive trauma can encompass both types of anguish: the frightening and painful loss of a miscarriage, with massive bleeding and the potential need for surgery, or the seemingly endless cycle of hope and despair during fertility treatments. Sadly, for our patients, it is not uncommon to experience both infertility and pregnancy loss, and like a soldier on the battlefield, it can be protracted, leaving deep psychological wounds. This chapter not only explores the trauma that occurs in reproductive patients, but also how we, as fertility counselors, cope with being on the battlefield with them.

This chapter addresses the role, and importance, of individual counseling and psychotherapy in providing psychological assistance and support to patients who are struggling with infertility and loss. Depression and anxiety are the two most frequent emotional sequelae of the infertility experience. The chapter therefore speaks not only to what factors contribute to making fertility counselors effective in their work, but also addresses specific treatment approaches that can yield positive outcomes in working with this unique population. These approaches include psychodynamic psychotherapy, cognitive–behavioral therapy (including dialectical behavior therapy and trauma-focused therapy), and supportive counseling. A brief history and description of each approach is presented in addition to a discussion of ways in which these psychotherapeutic treatments can be effective in working with fertility patients. Each of these approaches can be longer term or time-limited, often depending on the needs and preferences of the patient. The chapter also emphasizes the importance of appropriate professional mental health training as well as an understanding of the unique medical treatments that are an inherent part of the personal experiences of fertility patients. A strong therapeutic alliance is critical to effective individual treatment, and each psychotherapy approach provides strategies for assisting individuals who are emotionally challenged by infertility.

Counseling patients through their journey to conceive can be challenging. When a therapist becomes pregnant, the therapeutic alliance alters. This chapter explores the unique dynamics between the pregnant fertility counselor and reproductive clients. Questions around the “who, what, where, when, why and how” of pregnancy disclosure are used as a tool to help think about the various elements to the therapeutic alliance. Intense feelings can be triggered for a patient who is struggling with infertility or pregnancy loss, but can also trigger emotional reactions for the fertility counselor. The transference and countertransference that arises with the self-disclosure of a pregnancy is likely to unfold complicated dynamics and emotions. The positive and negative implications that a pregnancy disclosure can have from the patient’s point of view, as well as that of the therapist, are addressed. Additionally, the postpartum experience and the return back to work after parental leave are also discussed. While this chapter focuses on the pregnant therapist, the issues raised pertain to all pregnant reproductive medical staff treating infertility patients.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.

This chapter provides an overview of the psychology of infertility as an aspect of reproductive psychology, and the field of fertility counseling. The changing role of reproduction in modern society is reviewed. Major theories related to reproductive psychology, including grief and loss, stress and coping, as well as posttraumatic growth are discussed. Additionally, the history of infertility counseling is described. The US and international guidelines for the provision of psychological services, both assessment and counseling, are provided. The formats for the provision of clinical care are discussed and the clinical research on the impact of psychological services is reviewed. The qualifications for mental health professionals practicing as fertility counselors are also included.

Extraordinary reproductive technologies are continuing to evolve for people needing medical assistance to have a child, which are replete with complex psychosocial issues. Optimal patient care involves the collaboration of numerous healthcare professionals (physicians, nurses, laboratory scientists, administrative staff, as well as counselors) working together to provide reproductive medical services. This chapter provides a biopsychosocial model for the medical and psychosocial assessment and treatment of individuals and couples seeking reproductive medical assistance. Beginning with an overview of infertility and reproductive physiology/pathophysiology, evaluation and treatment are discussed from a collaborative perspective of medical and psychosocial management. All aspects of reproductive medical care are presented from the lifestyle choices to assisted reproductive technologies including IVF, gamete donation and gestational surrogacy. The complex psychological challenges of patients dealing with significant medical conditions and the consequences of invasive medical procedures, coupled with treatment failures and loss are examined. In addition, a collaborative approach to decision-making in treatment and family building alternatives is discussed. The chapter also serves as a springboard to topics in the second edition of Fertility Counseling covering therapeutic approaches, assessment and preparation in assisted reproduction, addressing the needs of diverse of populations, practice issues, and special topics on pregnancy loss, reproductive trauma and resiliency, postpartum adjustment, and the pregnant therapist.

Trauma occurs when the ability to envisage our future and feel safe in the world is no longer possible. While trauma is often a one-time horrific occurrence, it can also be chronic in nature. Indeed, reproductive trauma can encompass both types of anguish: the frightening and painful loss of a miscarriage, with massive bleeding and the potential need for surgery, or the seemingly endless cycle of hope and despair during fertility treatments. Sadly, for our patients, it is not uncommon to experience both infertility and pregnancy loss, and like a soldier on the battlefield, it can be protracted, leaving deep psychological wounds. This chapter not only explores the trauma that occurs in reproductive patients, but also how we, as fertility counselors, cope with being on the battlefield with them.

Fertility counselors see an array of clients who may be diverse in terms of countries of origin, ethnicity, race and/or cultural background. This chapter identifies principles to guide this conversation. These principles include understanding how we consider race, ethnicity and culture, and emphasize the importance of not essentializing race, ethnicity and culture. The chapter continues with a brief overview of the meaning and consequences of infertility in various places worldwide and among migrant and racial minorities in particular, how this can affect access to, use of and experiences with fertility treatments and assisted reproductive technologies (ARTs). Finally, we offer considerations for racially and culturally sensitive clinical approaches in fertility counseling.

Fertility is falling across the developed world. This chapter sets the stage by exploring biological, social, and cultural imperatives and individual psychological motivations to parent, including differences in the longing for a child, (so called ‘baby-lust’), and decisions to remain childfree. The psychological impact of involuntary childlessness (infertility) is a particular focus. Recent demographic changes in developed countries (delayed first birth, fewer children) are considered. The chapter concludes with an overview of the contemporary contexts for becoming a parent to be addressed in different chapters of the book, including illustrative case stories.

While conception, pregnancy and childbirth are ‘natural’ events for most, for some the process is more complicated, medicalised, and marked by unexpected or difficult events. This chapter examines the experience of pregnancy when high investment is juxtaposed with high risk. The impact of a history of infertility, conception involving ART, pregnancy loss is examined in depth as well as evidence regarding the most effective ways to support parents who experience perinatnal loss.

Prolactin (PRL) is a key player in normal physiology and pathophysiology of reproduction. Although not indispensable to achieve gestation in humans (as opposed to rodents), PRL is essential for the development of the mammary gland and for lactation. On the other hand, hyperprolactinemia is a frequent cause of infertility and needs to be corrected in a young woman who actively seeks pregnancy. Dopamine agonists (DA) represent the first-line treatment of prolactinomas, but transsphenoidal surgery may be considered in selected cases. Among DA, preference should be given to cabergoline over bromocriptine, due to its higher efficacy and better tolerance. Both drugs are safe to use during early gestation. In most cases, however, drug withdrawal is advised as soon as the pregnancy is confirmed. Symptomatic tumor growth is a rare event in microprolactinomas (2–3 percent) but more frequent in large macroprolactinomas without previous ablative therapy (15–20 percent). Symptomatic tumor enlargement will usually be successfully treated with resumption of the DA. Breastfeeding is not contra-indicated in women with a prolactinoma. In addition, pregnancy may have a beneficial effect on further endocrine outcome, inducing early remission of hyperprolactinemia in about 40 percent of these women. Data are much less robust in men in whom PRL concentrations are less prone to increase. The male reproductive axis is also less sensitive to the effects of hyperprolactinemia. Nevertheless, significant hyperprolactinemia in men may also cause hypogonadism and infertility and must be treated as in women.

Two main fertility challenges women over 40 face are decreased oocyte quality and quantity. Age is the most significant predictor of oocyte quality. There is no reliable test aimed at evaluating a single oocyte quality in vivo or in vitro following oocyte retrieval or just prior to fertilization. On the other hand, there are good ovarian reserve tests aimed at estimating the residual follicular pool in aging women: AMH, AFC, and cycle day 2-4 FSH. Each have acceptable specificity for detecting diminished ovarian reserve. The majority of clinicians prefer AMH over AFC and FSH due to its technical simplicity, lower intra- and intercycle variability and increased prognostic value in the context of older women 43,44. Once stating a desire to conceive, women who are 40 or older should have an immediate comprehensive infertility evaluation that must include prompt ovarian reserve testing. Lifestyle changes including nutrition, vitamins, exercise, stress reduction and adequate sleep can only assist in the goal. Lastly, preparation, engagement and support of a team of professionals are essential to approach conceiving over the age of 40.

A long-term trend of delayed childbearing in the highly developed countries has resulted in a rising number of women having children at advanced reproductive ages. We draw on vital statistics, register and survey data for European countries to outline the main trends in late reproduction, focusing on fertility plans and actual fertility rates among women past age 40. We pay special attention to education differences in late fertility. We document a rapid increase in late childbearing across Europe, fuelled especially by rising first and second birth rates. The share of women planning their first or second child in their late 30s or early 40s has increased rapidly as well, signalling that many women aim to become mothers at an age when they are likely to face infertility or pregnancy complications. We discuss the role medically assisted reproduction plays in this trend. In conclusion, we argue that trends in late childbearing will become one of the critical factors determining the future of fertility and reproduction.