Counseling and couple therapy for infertile couples

Counseling and couple therapy for infertile couples

Heike Stammer

The article describes a two-tier, interdisciplinary design for the psychological counseling and therapy of childless couples. It is solution- and resource-oriented and avoids psychopathological ascriptions. Couples are supported in coming to terms with the crisis of a physical disorder and its emotional consequences; they are also aided in developing prospects and options for a future without a biological child. The procedure is explained in detail and provides a model suitable for application at reproduction medicine centers and gynecological and andrological practices. Sample interventions illustrate the therapeutic attitude advocated.

Fam Proc 41:111-122, 2002


With medical technology constantly coming up with new ways of crossing hitherto insuperable barriers, public interest in what medical science has to offer for infertile couples is keener than ever (Keye, 1999). Old taboos have lost ground (in vitro fertilization has become standard therapeutic practice), new taboos have taken their place (many couples conceal the therapy they are undergoing even from their nearest relatives). At the same time, voluntary childlessness is on the increase, notably among career women up to the age of 30 and older. After that, however, their chances of getting pregnant decline rapidly (Rosenthal & Kingsberg, 1999).

Spectacular reports about fertility treatment approaches successful enough to induce pregnancies after the onset of menopause have cast doubt on the inevitability of what were formerly held to be the natural limits of fertility. Thus, regardless of their actual motives, childless couples are frequently assumed to have made a conscious decision not to have children, and are suspected of doing so for reasons of”selfishness” (Calhoun & Selby, 1980).

Over the last few years, psychological research has demonstrated that, contrary to previous scientific assumptions, childless couples cannot be assigned to any psychopathologically defined class (Hammer Burns & Covington, 1999). This outcome is independent of the presence of organic causes (Dunkel-Schetter & Lobel, 1991; Wischmann, Stammer, Scherg, et al., 2001). At the same time, there is increasing need for qualified psychological support because improved medical treatment possibilities encourage the sometimes unrealistic hope of ultimately having a biological child (Baram, Tourtelot, Muechler, & Huang, 1988). In addition, medical treatment is frequently very time-consuming and may represent an unforeseen source of stress for the majority of couples undergoing it.

Accordingly, psychological research no longer takes much interest in the way fertility disorders might be causally connected with personality features. The main benefit psychology can offer is identifying the stresses involved and indicating possible avenues to explore (Hammer Burns & Covington, 1999). Furthermore, there has been little in the way of controlled studies examining the effectiveness of psychological support for couples who are involuntarily infertile. There are even fewer studies devoted to the evaluation of the role played by couple therapy in this connection (Newton, 1999; Tuschen-Caffier, Florin, Krause, & Pook, 1999).

In this article, the authors outline their theoretical and practical ideas on the issue of couple counseling and therapy in cases of involuntary infertility. In the framework of our study, extending from April 1994 to July 1999, we provided counseling for 377 couples, and 35 couples accepted the offer of a subsequent 10-hour course of couple therapy. A report on the evaluation of our counseling concept has been submitted for publication (Wischmann, Stammer, Scherg, et al., under review).


In line with the aims of “Medical Family Therapy” (McDaniel, Hepworth, & Doherty, 1992), the central concerns of our psychological intervention design are to

* strengthen the ability to cope with the given state of childlessness, independently of the likelihood of somatic measures being successful;

* reduce potential (couple) conflicts about handling infertility treatment;

* improve communication with one another and with the doctors;

* encourage acceptance of the fact that the physical disorder involved may not be susceptible to medical therapy; and

* provide support in managing any changes that may be necessary in life style and plans for the future.

The overall objective is to achieve a general reduction of stress, the secondary effects of which may also have a positive impact on the medical side of therapy. We want to facilitate a more rational approach to decisions about medical treatment and to improve the general prospects of success by enhancing the quality and depth of the information available to the patients. Within this overall objective, major individual concerns are to alleviate any sexual disorders that may be involved and, in the long term, to increase life satisfaction by putting into perspective the unfulfilled desire for a child and giving greater prominence to alternative plans for the future.

Couples are aided in achieving greater awareness of their own autonomy and responsibility in the context of infertility therapy and in attaining/maintaining the communicative bond (“communion”) necessary in their situation: “Communion refers to the need to attend to the communication and the emotional bonds that are often frayed by the challenges of infertility diagnosis, treatment, and interaction with the medical system” (McDaniel et al., 1992, p. 104). This does not mean placing a taboo on separation fantasies and/or desires generated as a potential solution to the present crisis. Further, since all reproduction-medical forms of treatment in Germany are acknowledged by the health insurance institutions and financial considerations are irrelevant for most couples, the emphasis in our work is all the greater on the emotional “costs” and barriers operative in infertility therapy.

At the Department of Medical Psychology of the Psychosomatic Hospital of the University of Heidelberg we have developed a psychotherapeutic approach to physical disorders which we consider to be a viable framework for psychological counseling in cases of involuntary infertility (see Verres, Schweitzer, Seemann, et al., in press). We call this approach “minimal-invasive”; our central concern is to provide psychological counseling that is both ideally low on negative side-effects and at the same time solution- and resource-oriented. It is a framework within which the various subjects addressed in the course of counseling can be integrated into a meaningful context.

Guidelines for Minimal-Invasive Psychotherapy:

1. Job definition: We regard our counseling activity as a job which our clients ask us to do and, as such, requires careful definition. Essentially, we work only on material presented to us by the clients as representing the problem, as they see it, and the ideas for a solution of the kind they desire. We may occasionally question their views and ideas but always with the intention of establishing a new consensus.

2. Low dosage: We keep treatment dosage as low as possible. Either it is long-term and low in frequency or frequent and brief in its overall duration.

3. Normal, not pathological: We aim at a normalization of problems and avoid pathologically oriented ascriptions. The “problems” are regarded from the point of view of hitherto unsatisfactory but still possible solutions.

4. Solution-oriented: We set out to address the imagination about the future of our clients. We provide aid in the search for hitherto undiscovered, individually fitting potential solutions or part-solutions, which may sometimes be unconventional in nature. We do not make any normative suggestions about “good” solutions.

5. Not a training course in correcting deficient skills: We do not train our clients but, rather, place our trust in learning from experience and the ability to appreciate whether a new solution “fits” or not. We suggest avenues our clients might explore in their quest for new ways of acting, thinking, and feeling, which though available to them in theory have yet to be “discovered” with a sufficiently high degree of awareness. It is useful to give the couples access to a broad range of expert knowledge, preferably of an interdisciplinary kind, thus enabling them to find a new approach not only at the emotional but also at the intellectual level.

6. Systems-oriented: We attempt to include the couples’ social environment in looking for solutions to the problem, rather than excluding it as the couples themselves tend to do. Wherever possible, relatives are imagined and drawn upon as potential supporters in the solution-finding process. This means high priority for talking things over with both members of the couple even if it is only the woman who appears to be suffering from the situation.

7. Freedom to complain, lament, grieve, and let off steam: Both in its depressive and aggressive forms, we consider “letting oneself go” to be a potentially beneficial response to physical disorders, in everyday life as well as in psychotherapy. We advise our clients on the degree to which they should “allow themselves” this kind of behavior.

8. Humor: We consider life in general and psychotherapy in particular to be too serious a business to get through without laughter. Accordingly, anecdotes, jokes, cartoons, and general “joshing” play an important role here. The use of humor should be done with caution so that it isn’t experienced by clients as a lack of empathy.

9. Merging counseling and therapy: We do not make a formal distinction between “therapy” and “counseling.” We see both therapy and counseling as an expertly conducted, collaborative exchange aimed at finding solutions.

10. Coming to meaningful terms with infertility and reducing pressures: The ability to integrate a physical disorder into a subjectively meaningful scheme of things facilitates the kind of active adjustment. Focusing attention on the paradigm of “making sense” of the situation will invariably encourage a resource-oriented attitude in therapeutic exchanges. Such an attitude will also improve the likelihood of clients not concentrating too much of their energy on a (possibly hopeless) battle against infertility. Instead they can gradually learn to regard acceptance of the situation not merely with resignation but as an element in an exceptionally mature philosophy of life. This attitude should not be equated with mere fatalism (Verres, 1995).

We have geared our approach to methods developed and used in systemic therapy and psychodynamic therapy and we consider them to be mutually supportive. Systemic questioning techniques facilitate the recognition of patterns of personal and interpersonal reality construction displayed by couples and operative in communication disorders. A consistently resource-oriented approach provides a helpful model for couples to relate to in coming to terms with a situation where physical incapacity is the central focus of infertility treatment. It enables them to develop new alternatives and to re-think their life philosophy. Closing interventions at the end of each session are used to set the couple concrete assignments for the period up to the next session and thus enhance the sustainable effect of the therapeutic encounter, an effective way of revitalizing the feeling of being an agent rather than a patient (von Schlippe & Schweitzer, 1996).

Ideas from the psychodynamic perspective on (sex/gender-specific) transference and countertransference responses are indispensable in establishing and sustaining a constructive therapeutic dialogue (Applegarth, 1999). At the outset of therapy, infertility couples tend toward an excessive and unrealistic idealization of the doctor looking after them. If the treatment proves to be unsuccessful this can then turn into its opposite (extreme devaluation). Identifying and addressing these unconscious defense mechanisms at an early stage can help establish a more open doctor-patient relationship and reduce potential disappointment on both sides.


As of 1994, all couples availing themselves of the Fertility Consultation Service at the University of Heidelberg Women’s Hospital are offered psychological counseling as a matter of routine (see Wischmann, Stammer, Gerhard, & Verres, 2002). The counselors were members of the department of Medical Psychology and not involved in the medical treatment. The aim of these interviews (initially two in number) is to initiate a dialogue with couples on possible kinds of stress associated with the unfulfilled desire for a child and to inform them of the more far-reaching psychological aid available to them should they feel the need. If in the course of these counseling interviews it becomes apparent that there are indeed problematic areas needing to be addressed (e.g., sexual problems, major anxieties about medical treatment, distress about the absence of future perspectives without a child), and the couple displays the motivation to embark on joint psychotherapy, we then offer a subsequent 10-hour course of couple therapy.

For average infertile couples who experience distress, these two interviews are of sufficient help because they can cope this crisis with the given information and their own resources (Boivin, 1997). A two-tier approach of this kind has a number of significant assets. The clearly defined time scheme and the integration into the Fertility Consultation Service substantially reduce inhibitions couples may have about embarking on psychological counseling. Couples have the opportunity of getting to know the psychological counselors in the framework of routine diagnostic processes and to join with them in assessing the necessity for couple therapy. The couples who reject the counseling interviews at the beginning of their medical treatment can ask for them when they need them later.

All couples accepting the offer of counseling are part of our contributions to the regular case conferences taking place at the University of Heidelberg Women’s Hospital, where we also obtain the relevant medical information. This cooperative model involving the psychological counselors and the medical therapists has proved its value since it represents a joint forum at which both sides can familiarize themselves with each other’s approaches and decision-making criteria. It makes the collaboration between the therapists more tangible for the couples themselves and also precludes contradictory recommendations from the two different sources.

Couple relationship patterns militating against coping with the crisis: As in any crisis, involuntary childlessness can either make a couple draw closer together or else cause serious relational problems to escalate, and/or bring latent conflicts to light, which then have to be properly confronted (McDaniel et al., 1992). “The unresolvable conflicts generated by infertility may lead to increased polarization and/or protective silence.” (Meyers, Weinshel, Scharf, et al., 1995, p. 236). In our study we were able to identify two main “couple types,” those giving the impression of being harmoniously enmeshed and their opposite, those appearing to be antagonistically enmeshed. This polarization takes place on the continuum of the regulation of closeness/distance, a continuum that can be thrown off-balance by the stress associated with the unfulfilled desire for a child. When the communication between the couple gravitates too near one of these extremes on the continuum, this can lead to a restriction in the range of responses and decisions available to the couple in question, thus militating against a solution-oriented approach to dealing with the problem of childlessness.

At the harmoniously enmeshed pole, couples experience negative relational aspects as threatening and therefore prefer not to perceive and give expression to them. Here we get the impression of a couple trying to “deserve” a baby by being “good” and doing the “right” things: “All we need to make life just perfect is a baby.” “A child would be the crowning glory.” This may lead to a situation where couples are tempted to avoid engaging with important, potentially conflictual issues because they fear they might jeopardize the harmony between them. Where harmony and traditional images of a “normal” family represent a high ideal for the partnership, infertility may come to be regarded as something “evil” to be eradicated at all costs. Such couples frequently find it difficult to terminate medical treatment either because they cannot accept the finality of their loss or because the partner wishing to terminate the process is reluctant to run the risk of conflict and the feelings of guilt bound up with it. Also, such an ideal may delay the beginning of necessary treatment if couples fear that there might be differences of opinion between them about the number and the extent of the medical treatment measures required.

Though in the short term such conflict-avoidance attitudes may indeed be a source of relief for the couple involved (after all, they can in principle be an effective way of coming to terms with a crisis situation and concentrating on the positive aspects of life), in the long term they can be counterproductive if they prevent couples from deriving benefit from a shared engagement with ambiguous or contradictory feelings as a way of opening up new and meaningful prospects for a life together even without a child.

The other (albeit less common) instance of communicative stagnation between couples with an unfulfilled desire for a child is the situation where the satisfactory aspects of the relationship are progressively lost sight of, leading to acrimony and constant mutual recriminations. At this antagonistically enmeshed pole, couples attempt to gain control over the situation by using the conflicts already existing in their relationship as an explanation for their inability to have children. This prevents them from engaging openly enough with the limits of what is physically possible and attainable for them. In such cases, the child they desire is possibly being regarded too rigidly as a positive perspective for the couple, symbolizing the wish for greater closeness and harmony and representing a way of stabilizing the relationship and taking the stress out of it–in short, as an expedient for “patching things up.” With antagonistically enmeshed couples it frequently appears to be the case that the emphasis they place on present conflicts is a way of avoiding sharing with one another the pain and the mourning triggered by not being able to have biological children of their own. Here, reinterpreting their conflict-centered behavior as a mutual protection against even more unpleasant feelings can have a relieving effect. In the long term, this way of dealing with the situation represents a permanent danger to the communion necessary for a joint attempt to overcome the crisis. Such couples can end up in a state of permanent crisis, making it impossible for them to give each other the necessary mutual emotional support they so urgently need in this situation.


Building a Working Alliance

At the beginning of counseling, the therapist(s) describe the treatment approach and familiarize themselves with the concerns the couple may have. The couple are informed that both of them should feel that his or her individual standpoint is being properly appreciated. Any dissatisfaction with the course the exchanges are taking should be addressed as directly as possible.

Job Definition

At the first counseling session, it is rare for couples with an unfulfilled desire for children to be in a position to say exactly what they expect from the Consultation Service. Thus job definition at the outset of counseling (and particularly of couple therapy) fulfills a number of important functions. One of them is to act as a corrective to unrealistic expectations, such as the assumption that removing “barriers in the mind” will automatically improve pregnancy prospects. Another is to put the ensuing course of therapy on the right “rails” from the outset by establishing a resilient working alliance and defining the roles played by the participants in it. Targets are set and can be used as a gauge of the success of counseling or therapy in both psychic and physical respects. A central concern is to achieve as high a degree of transparency as possible with regard to our therapeutic objectives and procedures.

In the first questions we put to the couple at the outset of counseling, we attach great importance to addressing any possible misgivings they may have about psychological interviews of this kind, thus making it clear to them that critical assessments are not something we would prefer to ignore.

What made you decide to come for couple counseling/therapy? Which one of

you was more in favor? Which one of you was more skeptical? What are your

hopes and misgivings in connection with couple counseling/ therapy? What

would be helpful? What might be harmful for you?

This early job definition phase is a good opportunity for identifying the interaction and coping patterns a couple displays. Has the suffering caused by an unfulfilled desire for a child been delegated exclusively to the woman, who then sees her partner’s apparent indifference as a lack of support for her desire for a child and thus feels left alone with it? Are there any indications of fears that a covert couple conflict might be uncovered? Is going to see a psychologist another effort undertaken by the couple to avoid blaming themselves at a later stage for not having done everything that could reasonably be expected of them? A number of regular sex/gender-specific differences are observable. Men tend to want concrete assistance in coping with stress or “hands-on” advice about how to deal “properly” with the crisis their wives/partners are going through. Women tend to look for emotional support in overcoming their “bouts of depression.”

Intervention Strategies

The intervention strategies were developed mainly for couple therapy. But they can also be used in counseling sessions.

Making hopes and complaints explicit: At the beginning, many couples are understandably reluctant at first to be specific about the more intimate problems they are having and express themselves more generally on the point: “He doesn’t understand me!” “She responds too emotionally!” We then ask the couples to try and be a little more specific, inquiring about how the situation is experienced by the other partner. We then encourage the individual partners to be more precise about what it is exactly that they expect from each other. Frequently this opens up entirely new perspectives for the couple and a more constructive dialogue can then begin.

Circular questioning is frequently a good way of instituting an exchange about reciprocal expectations:

What do you think your partner would like you to do in connection with

further medical treatment? What is your partner’s opinion on further

avenues that need to be explored?

Pinpointing differences between the partners and giving them positive connotations: Couples that highly idealize the harmony existing between them frequently think that equality is important for a happy and fulfilling relationship. This can lead to an attitude of mutual consideration in which existing differences are not supposed to become apparent. The danger here is that the couple may become alienated because of the premium they place on avoiding frankness and potential confrontation. Pointing up this possibly unconscious role behavior may in itself represent a productive querying of ideals that have “congealed” into stereotypes or cliches:

As a couple, you appear to me like a single, harmonious entity. I wonder

just how big the obstacles that prevent you from seriously contradicting

your partner? Do you ever find yourself in that kind of situation? How do

you feel then? What do you do to put a stop to any disputes you have?

Normalizing crises and negative affects: Shame and envy affects directed at other couples with children can occur in various situations (e.g., at family reunions) and are frequently experienced as unpleasant by infertile couples. They may tend to perceive bouts of mourning and pain as exaggerated responses. Frequently they also suffer from a feeling of isolation. We stress that such a subjective reaction is understandable in view of the existential significance that (the prospect of) childlessness is bound to have. A frequent result of this is that at the very next session the couples report a reduction of stress in (say) encounters with pregnant women when they no longer had to expend so much energy on suppressing such feelings.

Envy and resentment are feelings that are unpleasant for you more than

anyone else and do no harm to the people they are directed at. When do you

think it is justified to feel envy and resentment? Do you find it

inappropriate when others grieve over a serious loss? Does sorrow have any

kind of place at all in your life?

Psychotherapy must not be an additional source of moral pressure: Medical treatment accustoms many couples to the necessity of going through a great deal in order to realize their desire for a child. Accordingly, they sometimes consent to psychotherapy as another way of doing everything in their power to fulfill their wish. This applies particularly to couples with idiopathic sterility. The notion of being able to “deserve” a child by doing the “right” things or developing the “right” attitude is one that needs to be systematically dismantled from the outset by providing the couple with information that will put them straight on this point. Therapeutically it is helpful to focus explicit appreciation of the efforts couples have undertaken toward reducing any feelings of guilt that may be present.

I am very impressed by all the efforts you have undertaken to get pregnant.

How do you feel about the fact that those efforts have not yet been

rewarded? How do you come to terms with the injustice of the fact that

other women get pregnant without difficulty, sometimes unintentionally or

even against their wishes? How might psychotherapy help in getting

pregnant? What if psychological interviews turned out not to be a suitable

means to that end?

Externalizing infertility: Subjectively, some couples see the medical diagnosis as a judgment on their identity as woman, man, or couple. They feel infertile in a broader sense, i.e., incapable, deficient, abnormal. In such cases we point out that, though a fertility disorder is a serious problem in the way it affects the couple’s lives, it need by no means be the decisive criterion for their feelings of self-esteem or the quality of their relationship as such.

We never use the term “sterility,” speaking instead of a “fertility disorder,” thus indicating that from our point of view the present crisis can be overcome and should not be equated with the notion that the partnership has conclusively “failed” in this (or any other) respect. The following assignment for the couple is a good way of underlining that a fertility disorder is only one aspect of their lives as individuals and as a couple:

Draw a circle and slice it up like a cake with the individual slices

representing the most important parts of your present life: the fertility

problem, your job(s), leisure and hobbies, friends, your marriage, parents

and siblings, etc. Try to be as concrete as possible in representing your

life as you see it at the moment. Remember that the importance you assign

personally to the various aspects of your life need not necessarily square

with the amount of time spent on them per day/week.

Try noting down your spontaneous ideas on this point, independently of

one another. Censor them as little as possible. Then exchange your

responses and discuss your impressions. Which portions of the “cake” appear

to you to be appropriate and fitting? Which of them would you like to

change? Is there anything new you would like to add?

When you have done this, take the time to draw up a joint plan of the

steps you imagine taking in the immediate future. Be sure to avoid taking

on too much. Decide jointly on the next time you want to get together to

see which of these steps you have taken and which of them you have not. In

the latter case it is worthwhile asking yourselves what good reasons there

may be preventing the realization of your intentions. Think carefully

whether the aims you have set yourselves are still relevant or need to be

corrected. Maybe there are new aims that have developed in the interim.

Talking about the couple’s present sexual relationship: With couples who have been undergoing infertility treatment for a number of years there will almost always be a secondary impairment of their spontaneous sex lives. The couples will frequently feel ashamed about addressing the fact that it has become rare for them to have intercourse and that when they do they are under pressure from the (unspoken) idea/hope that something might/ should “come of it.” It may be helpful to point out that in long-lasting relationships it is quite normal for sexual intercourse to become less frequent in the course of time. Another thing we think is important to underline is that about a third of all pregnancies are “spontaneous,” i.e., come about independently of medical treatment. We then try to understand what reasons there might be for a reduction in the couple’s sex life despite the desire for a child. If couples are inhibiting themselves by expecting themselves to have; a fulfilled, spontaneous sex life while at the same time “going by the clock,” it has proved useful to point out the difference between task-oriented sex during fertile days and pleasure-oriented sex during the rest of the cycle (Galst, 1986; Tuschen-Caffier et al., 1999).

At the outset, the question should be explicitly addressed as to whether the couple is sufficiently cognizant of the facts of reproductive biology and the importance of regular sexual intercourse. The study by Tuschen-Caffier et al. (1999) indicates clearly that some couples were unable to mark the fertile periods of their last menstrual cycle in fertility diaries. Moreover 50% of the couples had not had intercourse during fertile days before the beginning of cognitive-behavioral therapy.

However representative (or otherwise) these findings may turn out to be, they should suffice to point up the importance of inquiring very searchingly into couples’ sexual behavior as a matter of routine and where necessary imparting the necessary information on reproductive biology.

In our experience, most couples are unaware that the probability of

pregnancy following sexual intercourse on fertile days is approximately

thirty percent. How do you estimate your chances? Many couples coming to us

for counseling report impairments to their sex lives since the beginning of

treatment for infertility. Looking back over the last six months how often

would you say you have actually had intercourse on fertile days?

Allowing sorrow: The loss of an unborn child is not a visible loss and its significance is frequently difficult for others to appreciate. It takes some time for a sensitivity to the need for rituals of farewell to develop in connection with this subject. Where couples have a history of earlier miscarriages or babies dead at birth, psychological counseling should give adequate attention to these events and the emotional significance they (may) still have. Bouts of depression are frequently instances of deferred mourning over pregnancies with an unfortunate outcome. These couples are accustomed to receiving little sympathy for their sorrow from their immediate environment and for that reason will tend not to address the subject of their own accord. In therapy it can be of crucial importance for the couple to learn to accept this sorrow as not only an understandable but, in fact, a necessary response. Therapists can develop an individual ritual with the couple to give this kind of leave-taking a specific form:

How long did you mourn the loss of your baby? Did you take your leave of

the baby in a particular form? Some couples plant a tree in the garden to

commemorate the child they lost. Some have a special place where they keep

an ultrasonic picture or a toy they had already bought for the child.

Others place an inscription on the family grave. Could you imagine doing

anything like that?

Making couples aware of the resources they have: Frequently, a couple’s whole outlook on life will be overshadowed by sorrow at their (apparent or actual) inability to have children and impaired by a powerful feeling of helplessness and futility. A good way of helping to restore (intra- and interpersonal) balance is to recall and show explicit appreciation for the successful aspects in the couple’s life so far. The question of how the couple has dealt with difficulties in their lives so far is a way of facilitating renewed access to coping competencies:

What has helped you in dealing with difficult situations in your lives so

far? How have you managed other crises in your lives? Which of you has more

experience with crisis management? Is there anything you might learn from

him or her?

One effective aid in coping with the crisis by strengthening resources is to help couples achieve greater distance from the suffering inflicted on them by not being able to have a child: When you see parents giving as much attention on their children that you actually give on your wish for a child, how would you describe such parents?

Prospects for a future without children: For many couples, envisaging a future without children of their own is tantamount to admitting that they have given up the idea of having a child altogether. Frequently, discussing future childless perspectives that are not entirely bleak and grim is something that often can be done only at the end of couple therapy. Only then can clearly defined decisions be taken on the termination of infertility treatment.

Some couples find it difficult to make plans for a life without a

biological child because they believe this might mean that their desire for

a child is not serious enough after all. But we know from experience that

it can be an assistance in reducing tensions for couples to talk about

prospects for a meaningful future together even without offsprings. Have

you ever talked about that subject?

It also helps some couples to refer to themselves as child-free instead of childless. This distinction can help the couple to achieve greater awareness of the advantages of a life without children and to make use of these advantages with a clear conscience.

Terminating Focal Couple Therapy

Setting and accepting limits may have a disquieting component for many couples wanting a child. Taking leave of hopes for a biological child is a painful process. We feel it to be essential for the therapist to show the couple that he or she believes in their ability to deal with their problems and conflicts on their own from now on. For this to work, it is necessary to keep the prospect of termination of couple therapy from the outset. This begins at the job-definition stage and continues with our principle of inquiring at the fifth session what therapy has achieved so far and what needs to be discussed in the remaining period. In some instances therapy can of course be terminated prematurely or extended for a well-defined period. A session explicitly declared to be the final one is a helpful ritual for taking stock of the whole process and summarizing the perspectives that have developed:

Have your expectations been fulfilled? What has been helpful? What has been

not so helpful? Was there anything missing? What do you think your life

will look like in five years’ time, with or without a child?


In the age we live in, women or couples increasingly defer the decision to have children, thus running the risk of missing out on biologically favorable times for conception. In the Western world, this means that treatment with the resources of reproductive medicine will continue to increase in significance. At the same time the headlong development of technology will face couples and clinicians with new and difficult alternatives in which professional counseling can play an important role in determining one’s own ethical and emotional limits and substantiating one’s position on these points. The approach described here is intended as an incentive to develop further carefully conceived counseling and therapy services for the women and men affected; it is also suitable for inclusion in further education/ training programs for people working in the field of reproductive medicine.

In conclusion, we would like to emphasize that only a minor proportion of the relevant couples (about 20%) actually need a more intensive form of couple counseling (Boivin, Appleton, Baetens, et al., 2001). Also in our study, the standard offering of 2 counseling sessions was adequate for most of the couples with an unfulfilled desire for a child. Like Boivin (1997), however, we do feel it to be beneficial to provide most of the couples not availing themselves of psychological counseling (and probably not needing it) with information brochures and videos on psychosocia] aspects of infertility treatment as a way of supporting them in coming to terms with their personal situation.

One thing that needs to be made clear to couples and the doctors looking after them is that availing oneself of psychological counseling as an aid in coming to terms with and accepting a fertility disorder is not a tacit admission that there is some psychological reason underlying infertility, or that there is some personal incapacity preventing couples from dealing with the situation on their own. What professional counseling can do is assist these couples in discovering new perspectives and hence new scope for action in what may sometimes appear to be a hopeless situation.

* This study was funded by the German Federal Ministry of Education and Science, Research and Technology, as part of the research network “Psychosomatic Diagnosis and Counseling Therapy for Fertility Disorders,” file numbers: 01 KY9305 and 01 KY 9606.


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Manuscript received March 22, 2001; revision submitted July 9, 2001; accepted July 12, 2001.

([dagger]) All authors are affiliated with the Department of Medical Psychology, Psychsomatic Hospital, University of Heidelberg, Germany. Send correspondence and reprint requests to first author: Dipl.-Psych. Heike Stammer, Abteilung fur Medizinische Psychologic, Bergheimer Strasse 20, D-69115 Heidelberg, Germany; e-mail: Heike_Stammer@

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