Therapy during fertility treatment: what it can offer and what it cannot

“I don’t need therapy. I just need it to work this time.”

The sentence is said calmly, almost politely. Whoever says it is often in the middle of a third or fourth attempt, with injection reminders on their phone, scan dates in the calendar and, in their head, an exact count of how many days are left until the test. They are right: what they want is not a conversation. They want a child. And no hour in a therapy room can guarantee that.

But there is something else in the same sentence. “Just need it to work this time” means that everything else — the exhaustion, the anger at every pregnancy announcement, the silence between partners, the shame in front of colleagues — has been put to one side until the test is positive. And treatment can go on far longer than anyone expects at the start. In this post I want to answer honestly a question people in treatment often ask themselves: what can therapy actually give me, if it cannot give me the one thing I want?

What treatment does to a person

How emotionally demanding medically assisted reproduction is gets a closer look in the post Assisted reproduction and its emotional cost, so here only briefly. Treatment is not one event but a rhythm: hope at the start of a cycle, tension during monitoring, relief or disappointment at every result, then two weeks of waiting that people often describe as the hardest part, and finally the outcome. When it is negative, the circle starts again — sometimes already with thoughts of the next attempt, before there has been any room for sadness about this one.

On top of that, treatment reaches into every layer of life at once: the body, sex, work, money, relationships with family and friends. Jacky Boivin, one of the leading researchers in this field, has long pointed out that distress around infertility is not “oversensitivity” but an understandable response to prolonged uncertainty that a person cannot control. You can find a short explanation of this in the knowledge base under infertility and distress.

Stress is not the reason it doesn’t work

Before I get to therapy, I need to take apart one of the most stubborn beliefs. People in treatment hear it from relatives, colleagues and sometimes from themselves: “Just relax and it will happen.” A quiet logic follows from it — if it doesn’t work, I wasn’t relaxed enough. And if I go to therapy, it is so that I will be calmer and therefore get pregnant.

In 2011, Boivin, Griffiths and Venetis published a meta-analysis in the BMJ of 14 prospective studies involving 3,583 women in treatment. They looked at whether emotional distress before treatment began predicted a less successful outcome. The answer was no: distress was not associated with the result. The authors stated explicitly that this finding can be used to reassure women — their worry will not spoil their chances.

This matters for two reasons. First, it takes away guilt that people in treatment already carry far too much of. Second, it changes the purpose of therapy. You don’t come to therapy to become a “better patient” and so improve the statistics. You come because you are a person going through something hard — and that is a good enough reason.

What therapy can offer

The first thing people describe is simple: a place where you don’t have to be optimistic. At the clinic, the talk is of numbers, hormones and protocols. At home, the talk is often of the next step. Friends say “it’ll happen”. Very few places allow you to say out loud: “I don’t believe it will any more.” Or: “I hate my sister because she’s pregnant, and I hate myself for hating her.” The therapy room is one of the rare places where a sentence like that can stay, without anyone rushing to correct it.

The second is grief. Every failed cycle is a loss — not always the loss of a pregnancy, but always the loss of a possibility that was real for a few weeks. Those around you usually don’t see it, so there is no room for sadness. As with other losses I have written about in The grief nobody acknowledges, this sadness doesn’t disappear if you skip it. It piles up.

The third is decisions. Treatment demands many decisions in a short time: whether to continue, when to take a break, how much longer, whether to consider donor cells, when to tell your parents. Therapy doesn’t decide for you, but it can help you separate what you yourself think from what others expect of you and from what fear is dictating. One of the hardest moments — when to say enough — is the subject of When is enough enough? Deciding to end fertility treatment.

The fourth is something characteristic of relational family therapy, the approach I am training in. The wish for a child did not arise in a vacuum. Your mother and father are in it, their story of how they came to have children, messages about what a woman or a man without a child is, perhaps losses in earlier generations that were never spoken about. When treatment goes on for a long time, these layers start to make themselves heard. Sometimes only then does it become clear why a particular remark from your mother-in-law hurt so much.

What therapy cannot do

Since I promised honesty, this part matters just as much.

Therapy does not increase the chance of pregnancy — at least, that is not something I can claim. Some studies pointed to a link between psychological support and treatment success; Alice Domar and colleagues reported in 2000 a higher pregnancy rate among women who took part in group programmes. But later reviews were more cautious. A meta-analysis published by Frederiksen and colleagues in 2015 showed that psychosocial interventions reduce distress, while the evidence on pregnancy is less solid. So I don’t promise it. If someone promises otherwise, be careful.

Therapy does not answer medical questions. What a particular result means, whether it makes sense to change protocol, what your options are at your age, what a test result means — these are questions for your gynaecologist or the team looking after you. A therapist can help you put those questions into words and find the courage to ask them. But they must not answer them.

Therapy does not take away the pain that is part of loss. It is not about learning how not to be sad when the test shows one line again. It is about sadness not becoming all that you are, and about not being alone with it.

Therapy does not replace psychiatric help when that is needed. When that is the case, I describe in When you need a psychiatrist first.

A couple in treatment: two rhythms

Treatment mostly happens in the woman’s body, but both partners live through it. And almost never in the same way. She has the hormones, the scans and the procedures in her body. He often feels he can only watch, and in that there is a helplessness he has no words for. She wants to talk about what is happening. He might rather not, because it feels as if talking only adds to the pain. She reads that as indifference. He reads her need to talk as proof that he cannot help her.

This pattern is not a sign that the couple don’t love each other. It is a sign that each grieves and copes in their own way — more on that in Grieving as a couple: why you grieve differently. But if it stays unspoken, it can spread to everything else: to sex that becomes a task, to arguments about who told whom what, to the quiet loneliness of two people who want the same thing.

Couples therapy during treatment is not about “fixing” the couple. It is about both of you hearing how the other is living through the same journey. Often that alone is enough for you to stop fighting each other and turn once more towards the same difficult, shared goal.

When in treatment therapy helps

There is no right moment. But some moments are the ones at which people often decide they will no longer go it alone. I have shown them in the picture below.

Before the first attempt, therapy can be short and practical: a conversation about what each of you expects, whom you will tell, how you will make decisions together and what you will do if the first attempt fails. It is no coincidence that the European Society of Human Reproduction and Embryology (ESHRE), in its 2015 guideline, recommends that information about the emotional side of treatment be part of routine care — even before treatment starts.

While waiting for a result, people most often describe thoughts that go round in circles: every sensation in the body becomes a sign, every day is too long. In psychology this is called rumination. Therapy doesn’t switch it off, but it can help it stop being the only thing happening.

After a negative result or a pregnancy loss, the need for support is often greatest, yet that is also when it is hardest to go anywhere — because it feels as if you have to move on as fast as possible. And finally there is the decision about whether and how to continue. A review by Gameiro and colleagues in 2012, which looked at why people discontinue treatment, found psychological burden among the main reasons — not only medical or financial ones.

How it sounds in the room

This is how part of a conversation with a couple who have just received a third negative result might sound (a composite, not a real person):

“He started talking about the next cycle in the car. As if nothing had happened.”
“Because if I don’t talk about the next one, I don’t know what to say. I can’t help you.”
“I don’t need you to help me. I need you to be sad with me for five minutes.”
“… I thought that if I was sad, it would break you even more.”

This short excerpt holds the whole story of many couples in treatment. One copes by looking ahead, the other by stopping. Both are looking after the other — he by being strong, she by wanting to be heard. And both end up alone. The therapist’s task here is not to judge who is right. It is to help what they have just told each other stay long enough for them to hear it.

How to choose the support that suits you

Not every therapy is for everyone, and not every therapist is right for every period of life. A few questions you can ask yourself:

• Do I need a space of my own or a shared one? Individual therapy and couples therapy are not rivals. Sometimes it makes sense to start with one and add the other later.
• Does the therapist have experience with this subject, or at least openness to it? They don’t need to have been through treatment themselves. But it matters that they don’t answer with platitudes and don’t try to be a doctor.
• Do I feel safe with them, even when I am angry or in despair? This is probably the most important question of all.

You can read more about recognising a therapist who suits you in How to choose the right therapist for you. And if you are wondering what actually happens in sessions over time, What you can expect from individual therapy may help.

I see people in person in Ljubljana, and I work in English as well as Slovenian — so if English is the language you are most at home in, you are very welcome. If coming to Ljubljana isn’t possible for you, it is better to find someone closer than to keep putting it off — during treatment, having someone matters more than exactly who it is.

Exercise: an agreement for the two-week wait

The two weeks between the procedure and the test are the hardest part for many people. This exercise doesn’t remove the uncertainty, but it helps put boundaries around it. Do it together, before your next procedure, or do it on your own.

1. Each of you write down what weighs on you most during these days. It might be your mother’s questions, searching for symptoms online, the silence at home. Don’t explain, just write.
2. Agree on a “worry window”. Fifteen minutes a day at the same time, when talk of the test, symptoms and fears is allowed. Outside that window, when the thought comes up, you say to each other: “That belongs in the window.”
3. Choose one thing a day that has nothing to do with treatment. A walk, a film, cooking. Not so that you “relax”, but so that life doesn’t become nothing but a waiting room.
4. Agree who will know what, and when. Whom will you tell about the result, and who will only find out later? Agreeing in advance saves you from questions you won’t have the strength to answer in a hard moment.
5. Write down in advance what you will do on the day the test is negative. Not a plan for the next attempt — a plan for that day. Who will call work, what you will eat, whether you will go out or stay in.

The last step seems bleak, but people often say it was the one that brought the most relief. When the day you dread is at least a little prepared for, fear doesn’t have to stand guard all the time. You can also lean on self-compassion here — speaking to yourself the way you would speak to a friend in the same place.

Where this post doesn’t apply

It wouldn’t be fair not to say this too: therapy during treatment is not essential. The ESHRE guideline says that most people in treatment cope with their distress using the support they already have — a partner, friends, the information they receive from healthcare staff. Only a minority need specialised psychological help. If you have people around you who hear you, and if you still recognise yourself despite everything, that can be enough.

Equally, therapy is not the right path when the main problem is a lack of information. If you don’t know what your result means or what your options are, the first step is a conversation with your doctor, not a therapist. And when the belief that you “have to go to therapy” only weighs on you further, as one more task on the list, it makes sense to wait.

Finally: if your distress grows to the point of thinking you can no longer go on living, this is not something to wait for the next appointment with. In Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline in Slovenia on 116 123 (24 hours a day). In immediate danger, call 112. More on the difference between crisis help and therapy in First aid is not therapy.

What to remember

• Distress is not why treatment fails — a meta-analysis of 14 studies found no link between emotional distress before treatment and the outcome.
• Therapy does not guarantee a pregnancy and does not answer medical questions; those belong with your gynaecologist or the team looking after you.
• Therapy can offer room for grief after every failed cycle, for conversation as a couple and for the decisions that have to be made.
• Partners often cope with treatment differently; that is not a sign they don’t love each other, but that they need words for the difference.
• Therapy isn’t compulsory. For most people the support they already have is enough — what matters is that you are not alone.