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Resolving infertility: An emotional crisis
Resolving infertility: An emotional crisis Martha E Griffin, RN
Martha E Griffin, RN, MSN, CNOR, is staff
nurse in the open heart surgery recovery room of Brigham and Women’s Hospital, Boston. She received her diploma in nursing at Framingham (Mass)Union Hospital School of Nursing, her BSN from Salem (Mass) State College, and her MSN in community mental health nursing at Boston College, Chestnut Hill, Mass. She is a group leader and Massachusetts support group coordinator for Resolve,Inc,the national support organization for people with problems of infertility.
Most people view infertility as not much of a problem. We are, after all, a generation of birth control practicers. Our attitudes toward those who cannot conceive may be reflected in the comments of humorous columnist Erma Bombeck. She writes, “They’re one of the last groups to come out of the closet . . . they get about as much sympathy as a n eighty-pound woman trying to gain weight . . . and have heard as much advice as people with bad backs.”l But for couples or individuals who want to have children but cannot conceive, it is a life crisis with both physical and emotional dimensions. Surgery is sometimes involved in the diagnosis or treatment of infertility, and the perioperative nurse’s understanding of the physical and emotional dimensions of this crisis can help in providing emotional support for the patient. For many patients having infertility surgery, the perioperative nurse may be the only nursing contact, since these procedures are often done on an outpatient basis. Infertility, the inability to achieve a pregnancy after one year of knowledgeable attempts, or the inability to carry a pregnancy to a live birth, can occupy every waking moment in an individual or a couple’s life. Because it poses threats and losses to an individual’s integrity and valued life goals, infertility constitutes one ofthe major forces in the loss of mental and physical well being.2 In the US, one out of six couples of childbearing age are currently infertile.3 The US Census Bureau estimates this number to be ten million Americans or 15% of the total population. Medical research and successful medical and surgical treatment for infertility are progressing rapidly. An estimated 50% to 60% of all infertility can be successfully treated if appropriate care is sought. Despite the advanced medical and surgical care, however, four to five million people will never
AORN Journal, October 1983, Vol38, No 4
597
Case histories Carol and Mike H were married when they were both 23.They used birth control for five years until Mike finished school,and they were able to buy a home. When the time seemed right to start a family, they stopped using birth control. After several unsuccessful months of trying to become pregnant, Carol was consoled by their family physician who told her that it often takes more time. A year and a half passed before they were told a specialist might be helpful. After a thorough investigation including a laparoscopy, Carol was diagnosed as having endometriosis. The endometriosis was treated medically. After four years of infertility, Carol and Mike were able to start their family.
lem. They sought a second opinion. The second physician diagnosed the problem. Bill had Klinefelter’s syndrome, a genetic abnormality in which the sex chromosome constitution of somatic cells is abnormal, leaving him sterile. Candy and Bill were grateful for an answer but angry for having had it take so long. They considered alternatives open to them and decided artificial insemination by donor was acceptable. Candy conceived in her second cycle.
Candy and Bill F were frustratedby their three year unexplained history of infertility and their physician’slack of commitment to their prob-
Rhonda and Jim S had their infertility unravel slowly. First, it was discovered that Rhonda had an ovulation problem, then it was discovered that Jim had a low sperm count and decreased sperm motility. They tried ovulation inducing drugs and artificial insemination using Jim’s sperm without success. Jim underwent a varicocelectomy,a surgical exci-
conceive and have a biological child of their Physical dimension. Infertility has physical causes. Consider what must physically happen for conception to occur. An ovum traveling down a healthy tube with a clear pathway must meet a structurally healthy sperm capable of penetrating and fertilizing it. It must then journey to a receptive uterus and firmly implant itself. Complex endocrinological factors occur to allow implantation and subsequent placental and fetal development. A problem in any one of these areas has the potential to affect fertility. As the case histories indicate, infertility is both a male and female problem. Statistical data show 35% of infertility causes are attributed to males, 35% to women, 20% to a combination, and lWo ~ n k n o w nStructural .~ defects of either the woman’s or man’s reproductive organs, a past infection, genetic abnormalities, endocrine imbalance or def-
icit, immunological aberrations, or exposure to diethylstilbestrol (DES) in utero could be the etiology of a couple’s problem.6 In addition, the male could have a problem with quality, quantity, and motility of sperm, or the woman could have endometriosis or a disturbance in the quality and quantity of ovulation. Each of these factors, alone and in combination, produces infertility. For some unfortunate couples, the cause is unknown. Emotional dimension. For many, the true agony of infertility is emotional. It becomes a crisis that may be solved by achieving a pregnancy spontaneously from a specific treatment or it can persist for all or part of a couple’s reproductive life. Traditional crisis intervention theory describes a crisis as time limited and predictable. The person may emerge from the crisis 0 at the same level of functioning 0 with increased strength, functionability, and insight to the problem
598
AORN Journal, October 1983, Vol38, No 4
sion of dilated spermatic veins, trying to improve his fertility. It has been two years since the surgery, six years of infertility, and still no children. Rebecca and John C had their first child with-
out difficulty in their first year of marriage. Rebecca had an intrauterine device (IUD) inserted at the six-week postpartum exam. She had no apparent problems with the IUD, and had it removed after three years when they wanted another child. After one year of trying to conceive,they sought medical advice for infertility. Rebecca underwent a hysterosalpingography, an x-ray examination of the uterus and oviducts after the injection of radiopaque dye. It showed blockage in both fallopian tubes. Laparoscopy further revealed an apparent occult infection, probably from the IUD, which had left both tubes in poor condition. The
on a less stable level of functioning. Because infertility differs from a onetime crisis, these outcomes may be altered, and it is possible for maladaptive behavior to increase. The stress can also result in personal growth with increased insight. With each crisis of infertility, couples and individuals may experience a wide variety of feelings. Some feelings are rational, based on real threats of the situation, the diagnostic investigation, or treatment. Others may be irrational, based on myth and superstition. Barbara Eck Menning, the founder and former executive director of Resolve, Inc, a national, nonprofit organization for peer support and education of infertile couples, has worked as counselor and advocate of infertile couples since 1973. She has written extensively on this subject for medical and nursing audiences. She has found most couples experience predictable stages of emotional reactions. Menning identifies the predom-
physicians told Rebecca and John that one tube might be made patent with microsurgery. This procedure carried a possibility of allowing an ectopic pregnancy to occur. They took the chance on the surgery. Rebecca did conceive, but in the eighth week of pregnancy she required an emergency laparotomy for an ectopic pregnancy. Rebecca lost the pregnancy and her only patent fallopian tube. Their only hope is in vitro fertilization. Their emotional investment will be surrounded by more time, more surgery, and much more money. Sarah and Brent A are 28 and 32 respectively. They both have been through several infertility investigations. They were told they were normal, however, they don’tfeel normal. They want to have a baby and have not achieved a pregnancy in six years of trying.
inant reactions as surprise, denial, anger, isolation, guilt, and griefa7 It is easy to understand the couple who is surprised when conception just doesn’t spontaneously happen when birth control is stopped. They deny any physical problem. It is hard for them to believe they may have a physical problem and need to seek medical diagnosis. Their denial helps them absorb reality at a pace they can individually tolerate. Denial may be more profound when an investigation uncovers an untreatable condition. If prolonged denial is the only coping mechanism, it is detrimental to emotional well-being. When couples no longer deny their infertility, they may begin to feel angry. Sometimes, in the diagnostic or treatment process, the couple or the individual feels a loss of control over his or her body and future. They may feel embarrassed, helpless, and frustrated over this loss of control. These feelings accentuate the anger.
AORN Journal, October 1983, V o l 3 8 , No 4
599
S
upport networks assist couples through the crisis.
Anger can be directed to the health care system or at family and friends who are unsupportive. Couples fear their loved ones do not understand. They may be embarrassed by opening this part of their life for discussion. Infertility is personal and sexual. This may lead to a self-imposed isolation. Many couples do not speak openly about infertility. They fear any discussion will elicit pity or advice based on myths such as “relax,” “adopt,” and “take a vacation.” They do not want relatives to think their infertility is related to sexual performance. The couple may be extremely sensitive to pregnancy or little children. They may even withdraw from social or work situations that involve new families. The isolation may be carried over into the couple’s private relationship. Women have traditionally been allowed to express their emotions while most men still internalize them. This can become a barrier to communication. The couple may have scheduled sexual relations according to the woman’s predicted period of ovulation. For some, intercourse becomes “sex on demand,” and mechanical and unpleasurable for some time. Guilt is another reason for extreme isolation. Menning, in her work with infertile couples, found many who ponder their past in search of a n event so bad that deserves this kind of punishment. Some common guilt-laden events
600
that couples experience are 0 premarital sex 0 use of birth control 0 abortion 0 a past pregnancy where the child was given up for adoption 0 venereal disease 0 extramarital affairs 0 masturbation 0 homosexual thoughts or acts 0 sexual pleasure itself.* When the wife or husband remembers what they consider a shameful event, they make every attempt t o atone. When atonement does not seem to alleviate their guilt, the individual begins to grieve. Depression and grief become a n everyday occurrence. Once all hope for a pregnancy is shattered, grieving is natural. But for many it is a strange, puzzling kind of grief. It is the result of a potential loss, not an actual life. It represents many losses the couple may feel individually or as a potential family unit. As individuals resolve their grief, they may experience periods of weeping, sobbing, and have physical symptoms of appetite loss, exhaustion, choking, or a tightness in the throat. Grief is painful but a necessary component to crisis resolution. Eventually each couple will establish a new emotional equilibrium. Some people describe this new state as one of renewed zest and well-being. Often the couple comes to terms with their infertility and
AORN Journal, October 1983, V o l 3 8 , No 4
can begin to examine alternatives such as adoption, childfree living, artificial insemination with donor sperm, or in vitro fertilization. Implications for perioperative nursing. Surgical procedures for the diagnosis or treatment of infertility include dilation and curettage (D & C), hysteroscopy, hysterosalpingograms, culdoscopy, laparoscopy, varicocelectomy, fertility laparotomy (microsurgical and nonmicrosurgical). Vasovasostomy and tubal ligation reversals are procedures for secondary infertility (that after the production of a biological child). The most frequent procedure for infertility is the diagnostic laparoscopy to detect peritoneal, tubal, and peritubal infertility causes. Laparoscopy is also used for a “second look to evaluate previous infertility surgery. Many factors that contribute to female infertility such as minor adhesions and minimal endometriosis can be evaluated and sometimes treated through a laparoscope. When you care for a patient undergoing surgery for infertility, assess their feelings. Surgery for them can represent a new hope or another problem. Diagnostic surgery may reveal a permanent condition that cannot be successfully treated. In that case, surgery represents no hope. Infertile couples may harbor fear of harm to their reproductive organs. The fear of castration or mutilation is on patients’ minds, whether or not it is verbally expressed. You can be reassuring by once again briefly explaining the surgery to be done and acknowledging the emotional impact. Reassurance must be realistic and individualized. Failure to validate the actual surgery to be done may lead to a fantasy about what might be done. Many women who have had initial investigatory procedures have expressed fear the physician will do a hysterectomy either by mistake or without their knowledge.
If the patient remains excessively anxious while waiting in the holding area, the appropriate nursing intervention may be to expedite the case. During the procedure, you can offer support to the awake patient by explaining each procedure before it is done and anticipating the patient’s fears. During the postoperative evaluation, the patient may request more information or peer support. Resolve, Inc, is a national organization with local chapters that offers counseling, information, and an opportunity for couples to join others with similar problems and support each other. Encourage your patient to contact his or her local chapter and to become involved. Support groups such as Resolve, Inc, have helped take the problem of infertility out of the closet. 0 Notes 1. Erma Bombeck, Boston Globe, May 1982. 2. Gerald Caplan, “Mastery of stress: Psychosocia1 aspects,” American Journal of Psychiatry 138 (April 1981)419. 3. US Department of Commerce Bureau of the Census, Statistical Abstract of the United States (1979)65. 4. Barbara Eck Menning, “The emotional needs of infertile couples,” Fertility Sterility 34 (October 1980) 313. 5. Resolve, Inc, Common Questions and Myths about lnfertility (pamphlet), PO Box 474,Belmont, Mass 02178. 6. John Stangel, “The causes of infertility” inFertility and Conception, an Essential Guide for Childless Couples (New York: Factson File, 1978)55-63; M Bibbo et al, “Follow-up study of male and female offspring of DES-exposed mothers,” Obstetrics & Gynecology 49 (January 1977) 7; Stangel, “The causes of infertility,” 68-80;Ann B Barnes et al, “Fertility and outcome of pregnancy in women exposed in utero to diethylstilbestrol,” New .England Journal of Medicine 302 (March 13,1980)610. 7. Menning, “The emotional needs of infertile couples,” 314;Barbara Eck Menning, “The psychosocial impact of infertility,” Nursing Clinics of North America 17 (March 1982) 156-159. 8. Menning, “The emotional needs of infertile couples,” 316.
AORN Journal, October 1983, Vol38, No 4
601
Martha E Griffin, RN, MSN, CNOR, is staff
nurse in the open heart surgery recovery room of Brigham and Women’s Hospital, Boston. She received her diploma in nursing at Framingham (Mass)Union Hospital School of Nursing, her BSN from Salem (Mass) State College, and her MSN in community mental health nursing at Boston College, Chestnut Hill, Mass. She is a group leader and Massachusetts support group coordinator for Resolve,Inc,the national support organization for people with problems of infertility.
Most people view infertility as not much of a problem. We are, after all, a generation of birth control practicers. Our attitudes toward those who cannot conceive may be reflected in the comments of humorous columnist Erma Bombeck. She writes, “They’re one of the last groups to come out of the closet . . . they get about as much sympathy as a n eighty-pound woman trying to gain weight . . . and have heard as much advice as people with bad backs.”l But for couples or individuals who want to have children but cannot conceive, it is a life crisis with both physical and emotional dimensions. Surgery is sometimes involved in the diagnosis or treatment of infertility, and the perioperative nurse’s understanding of the physical and emotional dimensions of this crisis can help in providing emotional support for the patient. For many patients having infertility surgery, the perioperative nurse may be the only nursing contact, since these procedures are often done on an outpatient basis. Infertility, the inability to achieve a pregnancy after one year of knowledgeable attempts, or the inability to carry a pregnancy to a live birth, can occupy every waking moment in an individual or a couple’s life. Because it poses threats and losses to an individual’s integrity and valued life goals, infertility constitutes one ofthe major forces in the loss of mental and physical well being.2 In the US, one out of six couples of childbearing age are currently infertile.3 The US Census Bureau estimates this number to be ten million Americans or 15% of the total population. Medical research and successful medical and surgical treatment for infertility are progressing rapidly. An estimated 50% to 60% of all infertility can be successfully treated if appropriate care is sought. Despite the advanced medical and surgical care, however, four to five million people will never
AORN Journal, October 1983, Vol38, No 4
597
Case histories Carol and Mike H were married when they were both 23.They used birth control for five years until Mike finished school,and they were able to buy a home. When the time seemed right to start a family, they stopped using birth control. After several unsuccessful months of trying to become pregnant, Carol was consoled by their family physician who told her that it often takes more time. A year and a half passed before they were told a specialist might be helpful. After a thorough investigation including a laparoscopy, Carol was diagnosed as having endometriosis. The endometriosis was treated medically. After four years of infertility, Carol and Mike were able to start their family.
lem. They sought a second opinion. The second physician diagnosed the problem. Bill had Klinefelter’s syndrome, a genetic abnormality in which the sex chromosome constitution of somatic cells is abnormal, leaving him sterile. Candy and Bill were grateful for an answer but angry for having had it take so long. They considered alternatives open to them and decided artificial insemination by donor was acceptable. Candy conceived in her second cycle.
Candy and Bill F were frustratedby their three year unexplained history of infertility and their physician’slack of commitment to their prob-
Rhonda and Jim S had their infertility unravel slowly. First, it was discovered that Rhonda had an ovulation problem, then it was discovered that Jim had a low sperm count and decreased sperm motility. They tried ovulation inducing drugs and artificial insemination using Jim’s sperm without success. Jim underwent a varicocelectomy,a surgical exci-
conceive and have a biological child of their Physical dimension. Infertility has physical causes. Consider what must physically happen for conception to occur. An ovum traveling down a healthy tube with a clear pathway must meet a structurally healthy sperm capable of penetrating and fertilizing it. It must then journey to a receptive uterus and firmly implant itself. Complex endocrinological factors occur to allow implantation and subsequent placental and fetal development. A problem in any one of these areas has the potential to affect fertility. As the case histories indicate, infertility is both a male and female problem. Statistical data show 35% of infertility causes are attributed to males, 35% to women, 20% to a combination, and lWo ~ n k n o w nStructural .~ defects of either the woman’s or man’s reproductive organs, a past infection, genetic abnormalities, endocrine imbalance or def-
icit, immunological aberrations, or exposure to diethylstilbestrol (DES) in utero could be the etiology of a couple’s problem.6 In addition, the male could have a problem with quality, quantity, and motility of sperm, or the woman could have endometriosis or a disturbance in the quality and quantity of ovulation. Each of these factors, alone and in combination, produces infertility. For some unfortunate couples, the cause is unknown. Emotional dimension. For many, the true agony of infertility is emotional. It becomes a crisis that may be solved by achieving a pregnancy spontaneously from a specific treatment or it can persist for all or part of a couple’s reproductive life. Traditional crisis intervention theory describes a crisis as time limited and predictable. The person may emerge from the crisis 0 at the same level of functioning 0 with increased strength, functionability, and insight to the problem
598
AORN Journal, October 1983, Vol38, No 4
sion of dilated spermatic veins, trying to improve his fertility. It has been two years since the surgery, six years of infertility, and still no children. Rebecca and John C had their first child with-
out difficulty in their first year of marriage. Rebecca had an intrauterine device (IUD) inserted at the six-week postpartum exam. She had no apparent problems with the IUD, and had it removed after three years when they wanted another child. After one year of trying to conceive,they sought medical advice for infertility. Rebecca underwent a hysterosalpingography, an x-ray examination of the uterus and oviducts after the injection of radiopaque dye. It showed blockage in both fallopian tubes. Laparoscopy further revealed an apparent occult infection, probably from the IUD, which had left both tubes in poor condition. The
on a less stable level of functioning. Because infertility differs from a onetime crisis, these outcomes may be altered, and it is possible for maladaptive behavior to increase. The stress can also result in personal growth with increased insight. With each crisis of infertility, couples and individuals may experience a wide variety of feelings. Some feelings are rational, based on real threats of the situation, the diagnostic investigation, or treatment. Others may be irrational, based on myth and superstition. Barbara Eck Menning, the founder and former executive director of Resolve, Inc, a national, nonprofit organization for peer support and education of infertile couples, has worked as counselor and advocate of infertile couples since 1973. She has written extensively on this subject for medical and nursing audiences. She has found most couples experience predictable stages of emotional reactions. Menning identifies the predom-
physicians told Rebecca and John that one tube might be made patent with microsurgery. This procedure carried a possibility of allowing an ectopic pregnancy to occur. They took the chance on the surgery. Rebecca did conceive, but in the eighth week of pregnancy she required an emergency laparotomy for an ectopic pregnancy. Rebecca lost the pregnancy and her only patent fallopian tube. Their only hope is in vitro fertilization. Their emotional investment will be surrounded by more time, more surgery, and much more money. Sarah and Brent A are 28 and 32 respectively. They both have been through several infertility investigations. They were told they were normal, however, they don’tfeel normal. They want to have a baby and have not achieved a pregnancy in six years of trying.
inant reactions as surprise, denial, anger, isolation, guilt, and griefa7 It is easy to understand the couple who is surprised when conception just doesn’t spontaneously happen when birth control is stopped. They deny any physical problem. It is hard for them to believe they may have a physical problem and need to seek medical diagnosis. Their denial helps them absorb reality at a pace they can individually tolerate. Denial may be more profound when an investigation uncovers an untreatable condition. If prolonged denial is the only coping mechanism, it is detrimental to emotional well-being. When couples no longer deny their infertility, they may begin to feel angry. Sometimes, in the diagnostic or treatment process, the couple or the individual feels a loss of control over his or her body and future. They may feel embarrassed, helpless, and frustrated over this loss of control. These feelings accentuate the anger.
AORN Journal, October 1983, V o l 3 8 , No 4
599
S
upport networks assist couples through the crisis.
Anger can be directed to the health care system or at family and friends who are unsupportive. Couples fear their loved ones do not understand. They may be embarrassed by opening this part of their life for discussion. Infertility is personal and sexual. This may lead to a self-imposed isolation. Many couples do not speak openly about infertility. They fear any discussion will elicit pity or advice based on myths such as “relax,” “adopt,” and “take a vacation.” They do not want relatives to think their infertility is related to sexual performance. The couple may be extremely sensitive to pregnancy or little children. They may even withdraw from social or work situations that involve new families. The isolation may be carried over into the couple’s private relationship. Women have traditionally been allowed to express their emotions while most men still internalize them. This can become a barrier to communication. The couple may have scheduled sexual relations according to the woman’s predicted period of ovulation. For some, intercourse becomes “sex on demand,” and mechanical and unpleasurable for some time. Guilt is another reason for extreme isolation. Menning, in her work with infertile couples, found many who ponder their past in search of a n event so bad that deserves this kind of punishment. Some common guilt-laden events
600
that couples experience are 0 premarital sex 0 use of birth control 0 abortion 0 a past pregnancy where the child was given up for adoption 0 venereal disease 0 extramarital affairs 0 masturbation 0 homosexual thoughts or acts 0 sexual pleasure itself.* When the wife or husband remembers what they consider a shameful event, they make every attempt t o atone. When atonement does not seem to alleviate their guilt, the individual begins to grieve. Depression and grief become a n everyday occurrence. Once all hope for a pregnancy is shattered, grieving is natural. But for many it is a strange, puzzling kind of grief. It is the result of a potential loss, not an actual life. It represents many losses the couple may feel individually or as a potential family unit. As individuals resolve their grief, they may experience periods of weeping, sobbing, and have physical symptoms of appetite loss, exhaustion, choking, or a tightness in the throat. Grief is painful but a necessary component to crisis resolution. Eventually each couple will establish a new emotional equilibrium. Some people describe this new state as one of renewed zest and well-being. Often the couple comes to terms with their infertility and
AORN Journal, October 1983, V o l 3 8 , No 4
can begin to examine alternatives such as adoption, childfree living, artificial insemination with donor sperm, or in vitro fertilization. Implications for perioperative nursing. Surgical procedures for the diagnosis or treatment of infertility include dilation and curettage (D & C), hysteroscopy, hysterosalpingograms, culdoscopy, laparoscopy, varicocelectomy, fertility laparotomy (microsurgical and nonmicrosurgical). Vasovasostomy and tubal ligation reversals are procedures for secondary infertility (that after the production of a biological child). The most frequent procedure for infertility is the diagnostic laparoscopy to detect peritoneal, tubal, and peritubal infertility causes. Laparoscopy is also used for a “second look to evaluate previous infertility surgery. Many factors that contribute to female infertility such as minor adhesions and minimal endometriosis can be evaluated and sometimes treated through a laparoscope. When you care for a patient undergoing surgery for infertility, assess their feelings. Surgery for them can represent a new hope or another problem. Diagnostic surgery may reveal a permanent condition that cannot be successfully treated. In that case, surgery represents no hope. Infertile couples may harbor fear of harm to their reproductive organs. The fear of castration or mutilation is on patients’ minds, whether or not it is verbally expressed. You can be reassuring by once again briefly explaining the surgery to be done and acknowledging the emotional impact. Reassurance must be realistic and individualized. Failure to validate the actual surgery to be done may lead to a fantasy about what might be done. Many women who have had initial investigatory procedures have expressed fear the physician will do a hysterectomy either by mistake or without their knowledge.
If the patient remains excessively anxious while waiting in the holding area, the appropriate nursing intervention may be to expedite the case. During the procedure, you can offer support to the awake patient by explaining each procedure before it is done and anticipating the patient’s fears. During the postoperative evaluation, the patient may request more information or peer support. Resolve, Inc, is a national organization with local chapters that offers counseling, information, and an opportunity for couples to join others with similar problems and support each other. Encourage your patient to contact his or her local chapter and to become involved. Support groups such as Resolve, Inc, have helped take the problem of infertility out of the closet. 0 Notes 1. Erma Bombeck, Boston Globe, May 1982. 2. Gerald Caplan, “Mastery of stress: Psychosocia1 aspects,” American Journal of Psychiatry 138 (April 1981)419. 3. US Department of Commerce Bureau of the Census, Statistical Abstract of the United States (1979)65. 4. Barbara Eck Menning, “The emotional needs of infertile couples,” Fertility Sterility 34 (October 1980) 313. 5. Resolve, Inc, Common Questions and Myths about lnfertility (pamphlet), PO Box 474,Belmont, Mass 02178. 6. John Stangel, “The causes of infertility” inFertility and Conception, an Essential Guide for Childless Couples (New York: Factson File, 1978)55-63; M Bibbo et al, “Follow-up study of male and female offspring of DES-exposed mothers,” Obstetrics & Gynecology 49 (January 1977) 7; Stangel, “The causes of infertility,” 68-80;Ann B Barnes et al, “Fertility and outcome of pregnancy in women exposed in utero to diethylstilbestrol,” New .England Journal of Medicine 302 (March 13,1980)610. 7. Menning, “The emotional needs of infertile couples,” 314;Barbara Eck Menning, “The psychosocial impact of infertility,” Nursing Clinics of North America 17 (March 1982) 156-159. 8. Menning, “The emotional needs of infertile couples,” 316.
AORN Journal, October 1983, Vol38, No 4
601