Holiday Tips During Your Fertility Journey

For a couple that has been struggling with infertility, the holidays can be a particularly painful time. Family gatherings that may be filled with babies and children can serve as bittersweet reminders of what didn’t happen for you this year. You may have had one or more failed cycles or even miscarriages over the past several months. While you and your partner tried to avoid getting your hopes up, it is likely that with each embryo transfer you found yourself daydreaming of holding your precious little one at holiday family gatherings. Whether you’ve been private about your fertility journey or an open book, you can depend on the fact that you are bound to be subject to some uncomfortable conversations about your ability to bear children. 

One woman described a horrific episode early in her fertility journey. Her first retrieval had gone very well and the couple had gotten pregnant on the first embryo transfer. The elated couple shared the good news with both sets of parents and several friends only to learn that they had miscarried at eight weeks. To the woman’s mortification, her husband’s parents had shared the news of their pregnancy with friends who were eager to offer their congratulations at the family’s annual holiday party. She was faced with the task of glumly informing virtual strangers about the miscarriage throughout the endless evening. 

Here are some things to keep in mind as you face gatherings and celebrations with friends and family this holiday season.

  1. Discuss who you will share information with and be specific. Prior to discussing your fertility journey with anyone, it is important that you and your spouse clearly designate who is allowed to be in the know well as any particular details either of you would prefer to keep private. Key to avoiding situations such as the one described above is to tell the people that you confide in that you’d prefer to remain private about you efforts to conceive.

  2. How to handle booze. You might find yourself mid-cycle during the holidays and abstaining from alcohol. This can lead to eyebrow raises and even pointed questions about possible pregnancies. It can be helpful to plan how you are going to handle these situations. Some couples prefer to abstain from alcohol together, while some women feel more comfortable nursing a Sprite to blend in. Whatever your approach, it helps to think about what you’ll say and do when asked about your drink preferences so you aren’t caught off guard.

  3. Plan for invasive questions. It seems that almost every family has that person that asks the awkward and intrusive questions. It can be very difficult to graciously field Aunt Sally’s third degree about your sex life with your partner. Thus, it is essential to anticipate some common situations and plan some responses. Remember, you do not OWE anyone information about your private life and, conversely, the people who are prying are likely well-meaning. By thinking of pithy ways to handle questions and comments, you can avoid being caught off guard.

  4. Come up with a cue. Plan as you will to field awkward and intrusive family and friends, it is likely that one or both of you will find that you need to check in and get strength from one another throughout holiday festivities. It’s helpful to come up with a secret cue that can serve as a signal for your partner to come and give you support. A hand on the shoulder or a stolen moment in a hallway could be just what both of you need to get through a difficult moment at a party or function.

  5. Spend some time processing losses alone. Though the holidays are typically crazy, hustle and bustle times, it is important to make space to process the losses and trials you have been through over the past year. Set aside some time, perhaps a quiet evening, to burn a candle and take turns sharing your thoughts and feelings about your fertility journey. Don’t shy away from shedding tears or expressing your hopes and fears to one another.

  6. Give yourself permission to take breaks or go home early. Finally, it is perfectly acceptable to be choosy about where you go and how long your stay. There is no edict that says you must go to every single gathering for the entire time. Feel free to make brief appearances or choose to spend time with friends and family that are the most safe of supportive of you during this time.

Taking time to plan ahead and care for yourself and your partner can make the holidays more enjoyable. This preparation and thoughtfulness can also help you and your partner to feel closer and better supported by one another and by those you have chosen to include in your fertility journey.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

Communicating with Friends and Family During Infertility Treatment

One of the most difficult aspects of the fertility journey is the way that relationships can shift and change. Many people find support and comfort in unusual places while others are surprised at the insensitivity that they see in close friends. At times people report that their struggle with infertility is treated lightly and they are told by well-meaning friends to, “relax”, “go on vacation,” “stop trying so hard.” Other times, couples report encountering negative judgments about pursuing assisted reproductive procedures to have “their own” baby instead of adopting. Couples struggling with infertility are unable to enter the parenting phase of the life cycle and interactions with family and friends who have children are often painful reminders of their “stuckness.” Conflicts can arise when one member of the couple finds solace spending time with family while the other partner has difficulty tolerating family gatherings.

Couples need to work together to develop ways to interact within their support system during their struggle with infertility. It is helpful to explore the boundaries that existed prior to infertility and assess if these are still comfortable. Central to the navigation of social relationships during infertility treatment is the question of openness versus privacy. Because infertility treatment is often invasive and of a personal nature, both members of the couple need to discuss what they are comfortable revealing and whom they feel they can trust. Relatedly, it is important to consider how sharing of information may impact future offspring. Communication within the couple is key to navigating relationships with their support system and compromise will help each member of the couple get their social needs met without compromising the needs of the other partner. 

Below are some pointers for managing social relationships while struggling with infertility:

  • If possible, consider nurturing relationships with trusted others who have encountered their own issues with infertility.

  • Share your feelings with trustworthy friends and family members. Many people do not understand the emotional stress of infertility. Therefore, it can be helpful for you to identify and share your feelings as you move through the process so that people in your life can be there to support you.

  • Be specific about the types of support that would be helpful. For example, many people launch into problem-solving mode or want to make you feel better. However, sometimes what can be most helpful is a shoulder to cry on.

  • Be honest with friends and family about your preferences about attending child related functions. If you are finding yourself resentful when asked to attend, you may need to put some limits on how often you attend child centered events.

  • Make time to do the things you love with friends and family.

  • Participation in stress-reduction techniques can be very helpful during your infertility journey. You may want to ask a friend to join a local yoga or meditation class.

  • Plan how you are going to respond to awkward or invasive questions or comments such as, “When are you going to start a family?” or “I guess we’ll never be grandparents!” or “Are you sure you want kids, you can have one of mine- haha!” Be firm and pleasant in your responses and know that you are entitled to share as much or as little about your family planning as you want.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

The Threesome You Never Wanted

I was talking with a couple about a difficult experience they had recently while visiting a reproductive endocrinologist. Both noticed that the doctor failed to address herself to the female partner, instead directing her comments to the male partner. Both had various explanations for the behavior – the wife noted a somewhat “flirty” vibe from the female doctor while the husband thought the doctor was uncomfortable with his wife’s somewhat emotional presentation. The wife then became sad and self-blaming for her tearfulness and anxiety. When I brought up some of the common dynamics that often emerge when entering the medical arena, both were surprised and relieved to have the opportunity to consider the complexities that may have colored the interaction.

When couples learn that they are struggling with infertility, they are confronted with innumerable stressors. When a couple enters the medical arena, they often feel that their lives are taken over by doctors. Both members of the couple usually have to undergo expensive and invasive testing. What was once spontaneous, private sexy time often becomes a prescribed, tracked and medically supported act. It is no wonder that many couples feel a tremendous lack of control when undergoing treatment for infertility.

Interestingly, this set of stressors can lead to some common doctor-patient dynamics that are worth exploring further. Triagulation sometimes occurs when one member of the couple forms an alliance with the doctor and the other member of the couple feels excluded from the relationship. This can occur in a number of ways. With assisted reproductive technology (ART) the medical procedures are often frequent and of an intimate nature, which can create a sense of closeness between the woman and her doctor that can lead the woman to idolize or develop a strong emotional attachment to the physician. Partners sometimes feeling excluded from this inner circle and like a “sperm donor.”

Conversely, women may feel sidelined as medical terms and procedures are discussed between a male partner and the doctor. While there are likely many reasons this could happen, we must certainly be sensitive to the possibility that patriarchal values may be subconsciously at play. The traditional physician-patient relationship tends to place more power in the hands of the doctor. Additionally the nature of treatments reinforce gender archetypes of forceful men and passive women.

Other potentially problematic relationship dynamics that can occur are trying to be the “good patient” and hiding sadness, anxiety, disappointment, anger or grief. This desire to be a compliant patient often leads couples to avoid questioning the doctor’s recommendations or seeking second opinions resulting in the couple having less input regarding the course, length and extent of medical procedures. Swallowing negative reactions can lead to bitter disappointment and unexpressed feelings of anger.

Below are some practical tips to ensure that you and your partner remain closely aligned throughout your engagement with the medical system:

1.     Attend as many appointments together as possible.
2.     Write a list of questions and each take turns asking them. Write down and review answers together.
3.     Take some time to review some reputable websites to become more informed about infertility treatments. RESOLVE (www.resolve.org) has wonderful information about infertility as well as online support.
4.     Interview several physicians before choosing one. In addition to analyzing potential providers professional credentials, make sure each member of the couple is comfortable working with the physician and medical team.
5.     Talk often and openly about each partner’s feelings about treatment and infertility related topics.
6.     Engage in ongoing conversations about treatment options and the amount of time and resources each member of the couple wants to allocate to infertility treatments.

Seeking treatment for infertility involves a number of profound decisions and it is key that couples are conscious and present for one another as they interact with the medical system. If you find that you and your partner are struggling with communication, it may be helpful to see the assistance of a psychologist or counselor to work with. You may also find that a support group for couples is a useful tool for keeping the lines of communication open during treatment.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

Accepting Support with Grace

I was enjoying dinner with a cherished group of old friends when we began talking about how to help someone who is going through a health crisis. Specifically, we were talking about a friend of a friend who had recently been diagnosed with cancer but had found it difficult to reach out for help. This discussion led to an “aha” moment for me when I realized both how difficult and necessary it is to be able to receive help from others, particularly when crisis strikes in your life. Asking for, and accepting, help from others can be particularly troubling in our Western society which emphasizes individuality and independence as cultural values. Relying on others can often bring up feelings of shame, guilt and inadequacy. However, research has demonstrated that one’s perception of connectedness to their social network is a reliable indicator of well being (Cohen & Willis, 1985; Helgeson, 2002). As my friends and I discussed our experiences with both being the recipient of, and giver of, support, we reflected that it was very helpful as a support person to be able to offer something concrete to our loved ones during times of crisis. This also supports the well known relationship between giving to others and levels of happiness (Diener & Seligman, 2004).

Within our clinical practice we often see people in a state of crisis who have recently encountered extreme stressors such as a diagnosis of cancer or infertility or an accident that has resulted in ongoing disabilities. Central to our work as psychologists at the Rowan Center is helping our patients build and nurture robust support systems. I thought I would highlight some concrete ways to offer and ask for support. These are general ideas but would be applicable to most medical challenges such as surgery, cancer treatment, infertility treatment, or even the birth or adoption of a new child. I’ve been a recipient of many of these types of support and can attest to the power of having your place in the social circle affirmed by these concrete acts. At the opposite end, I also know that being able to offer support in specific ways has been very important to me during times of crisis in the lives of my friends.

Ways to offer support:

– Meal train (www.mealtrain.com)
– Help with transportation
– Offering to babysit
– Accompanying friends to Dr’s appointments
– Grocery shopping
– Walking the dog or caring for pets
– Taking out and bringing in the trash
– Gassing up the car
– Cleaning the house or hiring a cleaning service
– Scheduling a masseuse to come to the home

Ways to ask for support:

– Choose people you trust to ask for help
– Be specific about what would be helpful
 -Be honest about what would not be helpful
– Remember that people in your life want to support you
– Reflect on times when you were able to help others that you love
– Join a support group for education and social support
– Though it can be difficult to accept support, try and say thank you and allow others to help you
– Make sure to connect to people directly rather than relying on Facebook or other social media posts

Though, in our individualist culture one of the most difficult things to do is accept help from others, remember to accept help with grace and be grateful for your friends and family. Receiving and giving help in times need cements the social bonds that help us to thrive in our lives.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives. 


 REFERENCES

Cohen, S., & Willis, T.A. (1985). Stress, social support, and the buffering hypothesis, Psychological Bulletin, 98, 310-357

Diener, E., & Seligman, M. (2004). Beyond Money: Toward an Economy of Well-Being, Psychological Science in the Public Interest, 5 (1), 1-31.

Helgeson, V. S. (2002). Social support and quality of life.  Quality of Life Research, 12 (1), 25-31

Coping Styles and Infertility

Receiving a diagnosis of infertility can be incredibly stressful for couples. Often couples report changes in the quality of their emotional and sexual relationships (Schmidt, 2005a; Peterson et al., 2007). Other stressors include alterations in relationships with family, friends and coworkers and interactions with a complex medical system. Infertility may call into question your life expectations and deeply impact the way you see yourself, your relationship, the future and the world around you. Because the diagnosis of infertility often comes out of the blue, couples may find themselves unprepared to cope with the multiple stressors that accompany it.

How one copes with the unanticipated stressor of infertility can significantly impact the level of distress one experiences. Researchers studying the effects of infertility have identified four basic coping styles and analyses have revealed the impact that these styles have on stress levels. It can be helpful to reflect on your own coping style and assess whether there are changes you might make to help you get through this difficult time with appropriate levels of support.

One coping method commonly used is active avoidance. This may include avoiding pregnant women and children, keeping feelings related to infertility to themselves and engaging in outside activities to avoid thoughts of infertility. People who are high utilizers of this form of coping report higher levels of personal, marital and social distress (Schmidt et al., 2005a; Peterson et al., 2006a; Peterson et al., 2008). One reason for this may be that avoiding infertility related thoughts and activities may lead to social isolation and lack of support.

The passive avoidance coping style is characterized by hoping for a miracle and feeling that all one can do is wait. This coping style is also found to be linked with greater psychological distress and infertility stress (Terry and Hynes, 1998). A recent study found that when both members of a couple are high utilizers of this coping style they report higher levels of distress (Peterson et al., 2008).

A coping style that has been linked with more positive outcomes is active confronting. Active confronting is characterized by sharing feelings about infertility and actively trying to find solutions to the problem. This coping style has been linked with improved short and long-term adaptation (Vershaak and Hammer Burns, 2006). People using this coping style avail themselves of greater sources of support and feel an increased sense of control over their situation.

Meaning-based coping is a style that has been linked with more positive outcomes (Vershaak and Hammer Burns, 2006). People engaging in this coping style redefine the meaning and implications of infertility. They often report that the experience of infertility has helped them grow as a person. Many apply themselves to other life goals after they have accepted the reality of infertility.

Though you may be reeling from a recent diagnosis of infertility, it is important to be mindful about the coping strategies you use. While avoidance may bring temporary relief from the tempest of feelings that infertility elicits, it has been linked with greater distress in the long-term. Openly communicating to your partner and trusted others about your thoughts and feelings related to infertility can go a long way in establishing a robust support system. Also, working collaboratively with your partner to address problems related to infertility will help you regain a sense of control over the aspects of the situation that you can impact. If you are feeling overwhelmed and unable to cope with your situation it may be helpful to seek out additional support. RESOLVE(www.resolve.org) is a national resource community that provides information about infertility as well as online support groups.

Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention, which she uses in the treatment of patients who are struggling with infertility. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

 REFERENCES

Peterson, B. D., Pirratano, M., Christensen, U., & Schmidt, L. (2008). The impact of partner coping in couples experiencing infertility. Human Reproduction, 23(5), 1128-1137.

Peterson, B. D., Newton, C. R., & Feingold, T. (2007). Anxiety and sexual stress in men and women undergoing infertility treatment. Fertility and Sterility, 88, 911–914.

Peterson, B. D., Newton, C. R., Rosen, K. H., & Skaggs, G. E. (2006a) Gender differences in how men and women referred with in vitro fertilization cope with infertility stress. Human Reproduction, 21, 2443–2449.

Schmidt L., Holstein B. E., Christensen, U., & Boivin, J. (2005a). Communication and coping as predictors of fertility problem stress: Cohort study of 816 participants who did not achieve a delivery after 12 months of fertility treatment. Human Reproduction, 20, 3248–3256.

Terry, D. J. & Hynes, G. J. (1998). Adjustment to a low-control situation: Reexaming the role of coping responses. Journal of Personality and Social Psychology, 74,1078–1092.

Verhaak, C. & Hammer Burns, L. (2006). Behavioral medicine approaches to infertility counseling. In: Covington SN, Hammer Burns L (eds). Infertility Counseling: A Comprehensive Handbook for Clinicians, 2nd ed. New York: Cambridge University Press,169–195.

Shots, Shots, Shots! Coping with Injections During Infertility Treatment

One of the most anxiety provoking aspects of infertility treatment is the self-administration of medications. Many people quake at the site of a needle and the prospect of self-injections may seem overwhelming. Prior to beginning any infertility regimen, you are likely to receive instructions from the nursing staff at your fertility clinic. They will give you tips to minimize the pain and discomfort of injections. Despite this, you are now facing the needle(s) in front of you and are terrified. Below are some tips to help minimize the stress and anxiety associated with self-administering shots.

Prior to your first injection, it is important to organize your medications, supplies and instructions. This can help reduce anxiety by minimizing the preparation prior to your shots. It is helpful to complete your injections at the same time each day. Both partners can set an alarm for the chosen time in order to join together for the injection.

One of the most helpful techniques to reduce anxiety is to enlist the support of others. I recommend that couples create an “injection ritual.” By including your partner in the procedures you reduce your own stress and create an opportunity for bonding throughout the process. This is particularly important as it is usually the woman who bears most of the burden of infertility treatment and partners often report feeling marginalized in the process.

To begin creating an injection ritual, set aside a space in your home in which to administer your medications. Some couples find it helpful to decorate this space with candles, incense or even baby-related items. The space should be could be calming and soothing and relatively free from distractions.

Collaborate with your partner about elements to include in your injection ritual. Many couples find it meaningful to incorporate elements from their religious or spiritual traditions. To begin the ritual, take some time to connect with your partner. Check in with each other about your day and any thoughts or feelings that are coming up about infertility. Practice active listening, giving space for each partner to express individual thoughts and feelings. This provides an opportunity for couples to support one another and strengthen their bond.

Following the check-in, practice a brief relaxation, visualization or meditation exercise. Research has demonstrated the effectiveness of all of these methods in reducing anxiety, but experiment and find what works for you. The three-minute breathing space is relatively brief and effective. Please see the link below that provides access to several free guided meditations. Complete this portion of the ritual by setting an intention for your baby and family.

Now that you are hopefully feeling relaxed and connected to your partner, it is time to administer the medications. Decide who will be administering the shots. Some prefer to self-administer the shots while other prefer their partners to do it. There is no right answer and it may take some time to find the best methods for you. A practical suggestion for minimizing discomfort is using ice to numb the area prior to the injection. Warming the medication prior to injections is sometimes helpful. When injecting into a large muscle, massage following the injection is often relieving. Please consult your medical team prior to trying any injection variations.

The most important aspect of working together to create an injection ritual is to communicate with one another about what works and what doesn’t. By creating an injection ritual you are carving out space to discover together how to support one another through this journey towards parenthood.

Click the link below to access free mindfulness exercises:

http://marc.ucla.edu/body.cfm?id=22

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Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

The Grief and Loss of a Chemical Pregnancy

Few things are as devastating as a chemical pregnancy. A pregnancy is termed a “chemical pregnancy” when a woman has a positive pregnancy test but miscarries before anything can be seen in the uterus. For couples in the midst of the physically and emotionally demanding process of infertility treatment, a chemical pregnancy can trigger intense feelings of loss, hopelessness and sometimes depression. After rejoicing in the news of a positive pregnancy test, a couple is told mere days later that they are no longer expecting. Unfortunately, there is often little space given for grieving as couples are asked to make more complex medical decisions. Sadly, even the term “chemical pregnancy” seems reductionistic for what is often a profound loss.      

Depression and anxiety are quite common in both men and women facing infertility (Fassino, Piero, Boggio, Piccioni, & Garzaro, 2002). Many couples report that infertility is one of the most stressful events in their lives, equivalent to the death of child or spouse (Kedem et al., 1990). It is quite common for people who are undergoing treatment for infertility to feel as though they are on a roller coaster of hope and despair and a “chemical pregnancy” typifies this experience. The psychological stress of a failed cycle is one of the main reasons that couples drop out of infertility treatment (Domar, 2004).

When a couple experiences a “chemical pregnancy” it is common to suffer intense grief as a result. Often couples have developed strong feelings and vivid fantasies while waiting to hear the results of the pregnancy test which only increase with a positive test result. Intensifying the grief of the pregnancy loss is the knowledge that getting pregnant again is likely to be difficult. Unfortunately, the grief associated with a “chemical pregnancy” can be overlooked. In many instances of infertility, particularly with older couples, time is of the essence and there is little room for a lengthy mourning process.

In addition to feelings of grief, it is not uncommon for emotional reactions such as anger, blame and shame to emerge. Some couples may report anger for their unlucky fate. Other potential targets of anger are healthcare providers, particularly in instances when their is no identifiable explanation for the couple’s infertility, which occurs in approximately 10-20% of cases. It is also quite common for couples to place blame on one another, especially if one member carries the infertility factor. Feelings of shame and defectiveness are often reported by women following a “chemical pregnancy” or treatment failure.

Rituals can be very helpful for allowing couples to grieve after experiencing a “chemical pregnancy”. Rituals bring formality and solemnity to the passages of life. They play a critical role in the process of grief and mourning and can provide the opportunity for a couple to empathize and support one another. Both partners should take an active role in planning the ritual and agree on the various elements that will be included. It is sometimes helpful to include special items such as baby clothes or a memorial object. Some couples planted trees or gardens to represent their lost child. Questions to consider when creating a meaningful situation include:

  • What do you need to say to your child?

  • What preparation is needed?

  • Who would you like to include in the ritual?

  • Is there a location where you can hold the ritual that has meaning for both of you?

 In some cases, the cumulative losses and stressors associated with infertility become too much to bear and many women and couples find the support of a couple or individual therapist or infertility group very beneficial. Signs that you may have depression and need to seek professional support include:        

  • Daily tearfulness

  • Not enjoying things as much as you used to

  • Difficulty sleeping and/or eating

  • Feeling guilty, hopeless or irritable

  • Having difficulty concentrating or making decisions

  • Worry or feelings of anxiety that are interfering with daily life

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Dr. Angela Williams is a licensed clinical psychologist, specializing in cognitive-behavioral and humanistic/existential approaches to therapy. She has extensive training in Brief Crisis Intervention as well as mindfulness based therapeutic approaches. Her therapeutic style blends strength-based acceptance with practical skill development. Incorporating mindfulness-based interventions, she helps her clients move through difficult experiences and be more present in their lives.

REFERENCES

Fassino, S., Pierò, A., Boggio , S., Piccioni, V.,  & Garzaro, L. (2002). Anxiety, depression and anger suppression in infertile couples: A controlled study. Human Reproduction 17(11), 2986-2994.

 Kedem, P., Mikulincer, M., Nathanson, Y. E., & Bartov, B. (1990). Psychological aspects of male infertility. British Journal of Medical Psychology 63, 73-80.

 Domar, A., Seibel, M., & Benson, H. (1990). The mind/body program for infertility: A new behavioral treatment approach for women with infertility. Fertility and Sterility, 49, 246-249.

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