This article originally appeared in Psychologica Magazine Winter | Spring 2015 Edition (page 33).

Over the last decade there has been increased attention on the impact a new baby can have on a couple’s relationship. But what about the other side of that coin? What about couples who desperately want to have a baby, but who are struggling to conceive a child?

I work with these couples in my psychotherapy practice, and I hear time and time again how this process of being infertile pulls at the fabric of their relationship, and too often threatens to rip it apart. Understanding what it means to experience infertility, as well as why this experience can pose such a threat to the adult attachment bond, guides my clinical interventions with these couples.

The ‘Perfect Storm’ of Infertility

Infertility is defined by the World Health Organization as “a disease of the reproductive system defined by a failure or inability to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse”. There is obviously a huge range of experiences within this definition of infertility.

A couple who has experienced many years of attempting to conceive, has undergone multiple assisted reproduction procedures, and then suffers a miscarriage, will have a different experience of infertility than a couple who has had a relatively brief period of infertility followed by a successful full-term pregnancy. There are, however, common emotional threads to the experience, which are captured by two words in the WHO definition of infertility; “failure” and “inability”.

For couples experiencing the frustration, heartache and stress of infertility, it is about just that: the failure of the body to do what it is designed to do. Infertility is also about the inability to have control. Women undergoing In Vitro Fertilization (IVF) procedures hand control over their reproductive cycle to their treating physician. In the weeks leading up to an IVF procedure, these women have daily blood tests, daily ultrasounds, and take oral and/or injectable medication to stimulate, suppress, and trigger ovulation.

Male partners are sidelined in this process, helplessly waiting in the wings until they are required to produce their sperm sample. After an egg harvesting procedure — a three- to five-day wait (or more) followed by an implantation procedure — the couple then has an agonizing two-week wait (or more) before receiving test results. If the result is negative, the partners go back to square one if they want to try again.

For couples immersed in this incredibly time-consuming, expensive and invasive process, it can seem almost unfathomable that other couples simply decide they want a child and that it just happens. This can lead to a profound sense of isolation, particularly if the period of infertility treatment is long and filled with disappointments. These couples may start to feel disconnected from friends and family who are excitedly announcing their pregnancies and, perhaps most distressingly, they may also start to feel disconnected from each other — right when they need each other the most.

A Cycle of Disconnection:

Alan*, a man who has watched his wife Lily* undergo numerous unsuccessful infertility procedures, speaks of his frustration and isolation as he sees her struggle with the latest negative pregnancy result. He explains that he tends to avoid going home to be with her when she is upset and angry. He believes she is better off talking to her female friends and individual psychotherapist for support because they seem to know just what to say and do. He deals with his own pain and anger alone at the gym and then avoids making contact with his wife’s red, weary eyes when he finally returns home.

Alan shifts in his chair and wonders aloud if Lily even cares whether he is around anymore. He describes himself as “her punching bag”, and adds that when he recently tried to treat Lily with a day at the spa, she was furious at him for forgetting that she had an appointment at the fertility clinic that day. Alan sits slumped forward in his chair, eyes to the ground and says, “If I do nothing I am accused of not caring. If I do something it is usually wrong and I get pummelld all over again”.

Lily laughs angrily and replies in a voice that quivers with emotion, “That’s because you have no clue what is going on.” She then launches into a long list of all the times he has failed her, counting them off on her fingers as her voice rises in anger: the endless mornings she has spent at the fertility clinic alone; the day he forgot they were getting test results; the way he seems so totally unaffected by everything she is going through. Alan lifts his shoulders, raises his eyebrows and looks at me with a ‘See what I mean?’ look. Under his breath he mumbles something about how the injectable hormones make her totally irrational. Lily snorts with contempt, shakes her head and starts pulling furiously at a loose thread on the sofa cushion.

Infertility and Adult Attachment

As the therapist in the room, this torrent of frustration and disappointment can be confusing. What is happening here? Why are these two people, who love each other, ripping each other apart when what they so desperately need is mutual support and connection? This interaction starts to make perfect sense, however, when it is viewed through the lens of adult attachment theory. This theory highlights the fact that attachment is an innate motivating force across the life span, that attachment relationships offer an essential safe haven of comfort and security in times of distress, and that fear and uncertainty activate attachment needs.

Couples faced with the fear and uncertainty of a prolonged experience with infertility need each other. Having a safe haven in another person is a powerful antidote to the emotional strain of infertility. Some couples can successfully respond to each other’s attachment needs during the infertility process, and may become more closely bonded through the experience of a shared struggle. Couples like Alan and Lily, however, have become stuck in a negative cycle of interaction, which leaves them both feeling alone and vulnerable. The more their emotional needs are not met by the other, the more fearful and uncertain they become.

Attachment-based theories of adult love reveal that while we are hard-wired to need comfort and support from an attachment figure, we are often very bad at actually asking for it. The higher the emotional stakes, the harder it is to ask. Lily desperately wants Alan’s comfort and support, but she is too scared that he will let her down to ask for it. She goes elsewhere (to friends and to her therapist) because there is less on the line. These relationships are safe, while Alan has become risky for her. If she lets herself need him and reach for him, she will be devastated if he is not there, wounded when he turns away from her. She feels vulnerable acknowledging to herself and to Alan how much she needs him, how deeply hurt she is by his lack of attention, and that her biggest fear is that he will drift away and leave her alone to face life without a child by herself. Lily does not reveal this vulnerability to Alan, but rather angrily demands his attention by highlighting his deficiencies, and outlining the ways in which he has failed to meet her needs in the past.

Alan sees this as an attack. He interprets this as a sign that he is not good enough and useless to her as a support system. He tells himself Lily is better off getting support elsewhere and pulls away from her, partly to protect himself from being pummeled by her emotional attacks, and partly to try and protect the relationship. Alan feels helpless and confused. He knows only that he cannot help his wife, so the most he can offer is to give her space and spare her the added burden of his own feelings of sadness and loss. He becomes the emotional rock needing nothing from her and asking for nothing, just pulling further and further away. The more she attacks, the more he retreats. The more he retreats, the more she attacks, and the cycle goes on.

Attachment theory helps us to understand that Lily and Alan are stuck in this vicious cycle because they need each other, and because they care desperately about their emotional connection. Alan would not shrink away if he was unaffected by Lily, and Lily would not plead for his attention if she was not missing him and needing his comfort. It is the cycle of negative interaction that is pulling these two apart, leaving them both lonely and vulnerable.

These cycles are like a dance of emotion, in which the partners are missing each other’s cues and hurting each other in the process. If this cycle continues unchecked, Lily may get to the point where she stops protesting and detaches altogether. Alan may retreat until he becomes unreachable. For both of them, the fear of losing each other is far greater than the fear of infertility with all its inherent disappointment and loss.

Recreating Connection:

Reversing this cycle is about drawing couples back towards each other. If Lily can take the chance in a therapy session of sharing her fears with Alan, he will see the softer, more vulnerable side of her. If he feels safe enough, he may take the tentative step of reaching back towards her, telling her how hopeless he feels, and letting her see his own pain and suffering. If Lily can then reach back to comfort and support him in that moment, the cycle de- escalates, allowing the partners to start moving towards each other in an emotionally connected manner.

This is obviously a highly complex and nuanced process. Also at play is the attachment history of each partner, which may be a powerful but mysterious factor in how a couple interacts. A child who never witnessed a loving bond between his or her parents may not even know what to seek out in a partner. An adult survivor of an abusive or neglectful childhood may be terrified of the vulnerability needed in order to be open and emotionally available to another person.

Emotionally-Focused Couple Therapy is Sue Johnston’s attachment-based and experiential approach, which provides a detailed and comprehensive roadmap of how to do this work. I use EFT as a lens through which to view couple interactions and make use of EFT-based interventions in my work with couples. The EFT therapist guides the couple through the steps of delineating the negative cycle, working towards de-escalating this cycle, and finally creating a new cycle of interaction in which the partners turn towards each other and meet each other’s attachment needs.

The emotional dance between two people will never be perfect. Couples will often miss each other’s emotional cues and step on each other’s toes (so to speak) but when a secure attachment is fostered between them, these missteps become part of a new emotional dance of connection, rather than a trigger for attack or withdrawal. This is important because couples facing the strain and pressure of infertility need the safe haven of a strong relational bond.

Fostering the Relationship as A Safe Haven

There is a tendency for mental health services to focus on the female partner (in heterosexual relationships) while overlooking the impact that infertility has on both partners and the importance of fostering the relational bond.

Women may get referred to a support group, which may specifically exclude men, or simply not speak to their experiences. Women may also be referred to individual psychotherapy to assist them in coping with the infertility process. If a couple is functioning well as a unit, this makes sense and can provide additional support to a woman facing such an emotionally challenging experience. The concern is that when the couple is in distress, a referral to individual therapy for only one member of the unit has the potential to exacerbate the problem.

The individual given the referral may take this as an indication that they are the only one impacted by the infertility experience. The message may be construed as “We see you are suffering and we know your partner cannot support you so we are sending you to someone who can”. The partner who is not referred may feel even more excluded from the infertility experience and perceive the exclusion to mean he does not have the skills needed to support his partner. This may escalate a negative cycle like Alan and Lily’s as she turns more and more to her therapist for support, contrasting her therapist’s warm empathic responses with Alan’s failed attempts to support her. Meanwhile, Alan is left on the sidelines feeling more hopeless and isolated as a result.

Individual psychotherapy can be a wonderful resource for developing coping strategies and processing the complex web of emotions associated with infertility. It is important, however, to consider the relationship as well and recognize the hugely significant role that well-connected partners can play in supporting each other through the emotional minefield of infertility. Even the most brilliant psychotherapist cannot replace the bonds of a secure attachment relationship — the reassurance of one partner’s hand holding the other’s while getting their test results, a loving embrace in a moment of distress.

* The names of clients in this article have been changed to protect client confidentiality, as has the specific discourse/content of the couple therapy sessions.

Polly Sykes is a Registered Psychotherapist who specializes in supporting both individuals and couples who are experiencing infertility. In addition to her Masters Degree in Counselling Psychology, Polly has completed extensive post-graduate training in EFT including an externship in EFT for couples with Dr. Sue Johnston.