Stressful Conditions Related to Pregnancy 525women, further empirical evaluation of the psychosocial and
mental health consequences of miscarriage is necessary using
larger sample sizes, comparison cohorts, and more intensive
monitoring of clinical outcomes.
Infertility
Infertility, de“ned as the inability to conceive a pregnancy
after one year of unprotected coitus or the inability to carry a
pregnancy to a live birth, has been termed a •crisisŽ of our
time (Cooper-Hilbert, 1998). Whether the infertility is pri-
mary (i.e., no pregnancies despite attempts) or secondary
(i.e., at least one past pregnancy, regardless of outcome),
10% to 15% of couples in industrialized nations experience
infertility; approximately half of these couples will eventu-
ally achieve pregnancy (Goldman, Missmer, & Barbier,
2000). Worldwide estimates indicate that approximately 8%
of couples (50 to 80 million people) experienced infertility,
with sub-Saharan countries displaying the highest prevalence
(30% to 50% of women; see review in Goldman et al., 2000).
In the United States, infertility is increasing at a dramatic rate
across all age groups (but particularly among women aged 35
to 44 years), with numbers projected to reach 5.4 to 7.7 mil-
lion by 2025, up from approximately 5 to 6.3 million cur-
rently (Stephen & Chandra, 1997). These increasing rates
have been attributed to a variety of factors, such as delayed
childbearing; undetected pelvic in”ammatory disease due to
increased incidence of sexually transmitted diseases (STDs)
including chlamydia and gonorrhea; use of substances such
as caffeine, nicotine, and alcohol; chronic stress (i.e., neuro-
endocrines such as catecholamines, prolactin, and adrenal
steroids can impact reproduction); and exposure to work and
environmental health hazards (Cooper-Hilbert, 1998; see re-
view in Goldman et al., 2000). Although a single cause of in-
fertility is rarely found, 35% to 40% of infertility cases can be
attributed to male factors (e.g., abnormal sperm count or mo-
bility, adult mumps, hormonal imbalances, injury to repro-
ductive organs, retrograde ejaculation, testicular failure, use
of certain drugs, varicose veins in the scrotum), 35% to 40%
to female factors (e.g., aging or depleted oocyte reserve,
anovulation, body mass index, cervical problems, endocrine
disorders, endometriosis, intrauterine device use, structural
abnormalities of the uterus), and 20% to factors from both
members of the couple (Cooper-Hilbert, 1998; see review in
Goldman et al., 2000).
This •infertility epidemicŽ results in a variety of psy-
chosocial issues relevant to the work of health care and
mental health professionals. When confronted with infertil-
ity, women often experience myriad affective responses,
such as initial shock and denial, disappointment, and anger
(at themselves, their partners, and other women with chil-
dren, for example), helplessness and perceived loss of con-
trol, and guilt or self-blame„particularly those who believe
their infertility problems may be due to past behaviors
such as contraceptive choice, induced abortions, or STDs
(Cooper-Hilbert, 1998; Downey & McKinney, 1992). In a
prospective study, Downey and McKinney found that 11% of
infertile women met criteria for major depression relative to
4% of a fertile population.
There are gender differences associated with reactions
to fertility status (Greil, 1997), with women•s sense of self-
identity more deeply affected than men•s due to socialized
pressures (Whiteford & Gonzalez, 1995). Society places
pressure on women, regardless of socioeconomic status
(SES), ethnic-racial status, and religion, to view motherhood
as her primary adult role. Violating these societal norms and
expectations has both social and personal consequences:
Stigma associated with childlessness that involves social
de“nitions of women as sel“sh, unfeminine, unnatural, and
inadequate„ideas that many women incorporate into their
own self-schema (Lee, 1998; Whiteford & Gonzalez, 1995).
Fertile women who choose motherhood but are in unconven-
tional relationships, such as lesbian women or women with-
out partners, are often subjected to similar social stigma and
may be viewed as deviant (Lee, 1998).
Although visits to all physicians for fertility-related con-
cerns have increased as treatment options become more so-
phisticated and information is more available, the proportion
of couples who seek medical advisement or treatment remain
relatively low (approximately 31% to 48%), with younger
women, European American women, women with higher
SES, and couples with primary infertility more likely to seek
services (see Goldman et al., 2000). Further research ad-
dressing factors associated with access and barriers to treat-
ment is needed.
Infertility intervention options available to women include
hormones, arti“cial insemination, a range of variations on in-
vitro fertilization (IVF), and ovum donation. As both infertil-
ity and its treatments may proceed for an indeterminate
amount of time, impose pressure and stress, and challenge
couple•s coping resources, daily living, interpersonal rela-
tionships, and overall quality of life can be impacted. There
also may be physical pain and other health risks associated
with the often intrusive, reproductive procedures. Each time
a woman does not conceive or cannot carry the fetus to term
following treatment, couples must confront possible distress,
grief, and despair related to multiple losses, and sense of fail-
ure (Greil, 1997). Given the strong stigma associated with
childlessness, many women continue to endure intense treat-
ments despite continued failure to be absolutely certain they