Hopelessness set in after the third failed IVF cycle. “We had one embryo to transfer, and it didn’t work,” says Kim Tranell, an editorial director. “My husband and I were both really disappointed, upset and grieving that we had gone through this again. We wondered, ‘What are our chances in the future?’”
Seeing his wife’s despair, Kim’s husband Josh found a therapist in their Brooklyn neighborhood who took their insurance. But the session was “kind of a traumatic 45 minutes,” says Kim, 37. “The therapist said things like, ‘You know what’s bad for trying to have a baby? Stress.’ My problem is way beyond that.” When the therapist had Kim practice deep breathing while visualizing a baby on her chest, she thought to herself, “But I can’t have a baby! That’s why I’m here!”
To Kim, the experience emphasized the need to see a mental health expert who understood reproductive issues, but she didn’t know where to go. One day when she was feeling particularly low, Kim confided in her boss, who mentioned that a colleague had seen a reproductive psychologist while going through postpartum depression. Even better, this psychologist also took Kim’s insurance.
The provider has “been a lifesaver,” Kim says. “Knowing I’ll get to see her and talk through things with her has been my saving grace the last few months.”
While the fields of reproductive psychology and psychiatry have been around for at least two decades, they’ve remained very small until the last seven or eight years, says Lauren M. Osborne, assistant professor of psychiatry and gynecology and obstetrics at Johns Hopkins University School of Medicine. More academic centers have begun offering fellowships in women’s mental health and reproductive psychiatry, though they’re still few and far between.
“We’ve started to think more specifically about how issues related to hormone shifts and the reproductive cycle have an impact on mental health,” explains Marra Ackerman, director of NYU Langone Health’s Reproductive Psychiatry Program. The growing number of professionals who receive this specific training help women work through infertility and postpartum depression, make decisions about taking psychiatric medication during pregnancy, and deal with other challenges where mental health and reproductive health intersect. This way, women can have the healthiest pregnancies and motherhoods possible.
From menstruation through menopause
Reproductive psychologists and psychiatrists work with their patients the same way that most mental healthcare providers do: Women come in for regular sessions, often with their partners in tow, to talk through their emotions. Appointments with reproductive psychiatrists might also involve managing and talking about medication.
“Reproductive psychiatrists have experience and training looking at the impact of hormones on the reproductive life cycle, from puberty through menopause, and how hormonal fluctuation can have an impact on a woman and her psychiatric symptoms,” Ackerman explains. On the other hand, “reproductive psychologists are familiar with the biological factors affecting psychiatric symptoms, but focus more on psychosocial factors and major life transitions, such as becoming parents, as the triggers.”
“Postpartum may be one of the most high-risk times in a woman’s life for a mental health condition to arise.”
Most women who see reproductive psychiatrists are pregnant, trying to get pregnant or postpartum, and trying to weigh the risks and benefits of taking medication and figure out the best way to manage their symptoms. Ackerman cites misconceptions and poor knowledge among obstetricians, primary care physicians and psychiatrists when it comes to managing psychiatric illness during pregnancy. This can lead to women being told they should go off medication or, incorrectly, that their symptoms will abate during pregnancy.
A reproductive psychiatrist can help a woman weigh the risks of continuing to take medication versus leaving her psychiatric symptoms untreated, as well as consider what other options may work for her situation. “There is no recommendation that is 100 percent risk-free,” says Ackerman. “We are trying to help the patient be as successful and symptom-free as possible.”
After the baby is born, “postpartum may be one of the most high-risk times in a woman’s life for a mental health condition to arise,” Ackerman adds, because of the combination of hormonal shifts, the major life transition, sleep deprivation and changes in partner dynamics. Plenty of women who have no history of depression develop postpartum depression, says Osborne. A reproductive psychiatrist can help a woman manage her condition and prescribe medication if necessary.
Lastly, reproductive psychologists and psychiatrists see women who are facing infertility issues or have had miscarriages. For one, treatments such as in vitro fertilization can lead to mood shifts due to the hormones required. Second, these situations can be incredibly stressful for both the woman and her partner, if she has one. Having a third party can help the couple get on the same page and support each other.
“It’s really great having a third party who can say to my husband, ‘She’s the one putting her body through all these medications and getting up really early to have blood drawn every day.”
The Tranells’ reproductive psychologist helped them determine what steps to take after their most recent failed IVF cycle. They’d been trying to have a baby for two years, and Josh wanted to try IVF again immediately, whereas Kim felt she needed more time. With their psychologist, they worked through their options until they agreed on what to do next. “She’s almost a guide through the process — she knows what we’re going through,” Kim says. For example, when it came time to decide if they should try donor eggs, the psychologist helped them think through every consideration and address the multitude of emotions — grief, anxiety, uncertainty — that bubbled up. “You are veering from the path you’ve always seen yourself on,” Kim says. “She’s helped us talk through that and express our feelings in a safe way.”
This allowed Kim and Josh to clearly see each other’s points of view, all in a safe environment. “It’s really great having a third party who can say to my husband, ‘She’s the one putting her body through all these medications and getting up really early to have blood drawn every day,’ so he can better understand my perspective,” Kim explains.
No woman left behind
Despite growth in the field, there still aren’t enough reproductive psych experts to reach every woman. In 2013, Osborne began creating a national curriculum on reproductive psychiatry. “When I went to residency, I knew I’d become a reproductive psychiatrist, so I sought out extra training,” she says. “Within a couple of months afterward, almost all of my classmates called me because they encountered a pregnant patient and weren’t sure what to do. I wondered, ‘Even if people who have some education and a high-quality residency are not sure how to handle this, what’s going on in the rest of psychiatric residency? Are graduates uneducated to treat women?’”
The curriculum provides materials that any psychiatric provider can use to teach residents, self-study materials for trainees and doctors in general practice, and short exams that offer continuing medical education credit. Since 2018, the materials have been used by residency programs in family practice and obstetrics, in addition to psychiatry. Osborne’s group is also creating a certificate for those who complete all modules of the training, and expects to offer it by this summer. “We need to have some kind of accreditation or certification, just like other psychiatry specialists,” says Osborne. “But this is less urgent than making sure all trainees in psychiatry and ob-gyn get at least some training in reproductive psychiatry.”
With this education, any front-line provider could care for women with less severe conditions; for those who need more care, they can make referrals to reproductive psychiatrists. Some psychiatrists already do this for patients who are thinking about having a baby. From one meeting, the reproductive psychiatrist can create a plan for the patient to work on with her regular mental healthcare provider as she goes through pregnancy. This option can be a relief for those who cannot easily access reproductive psychiatrists or prefer to continue seeing their original psychiatrists.
Whatever the case, reproductive psychiatrists can be a resource for women going through a period of hormonal change, whether or not they have a history of mental illness. “Any major life transition can be a time when anxiety and mood changes can present,” Ackerman says. “Pregnancy and planning for pregnancy in particular can be a very vulnerable time, and a time when women first present with symptoms. We urge people to get treatment. Even if you’re not interested in medication, there are alternatives like psychotherapy.”
One of the best resources to find a trained reproductive psychiatrist is Postpartum Support International, which has branches in every state and offers referrals on its helpline. Ackerman also suggests contacting academic medical centers and psychiatry departments near you to ask if they have any reproductive psychiatry specialists. Not all reproductive psychologists and psychiatrists take insurance, so the out-of-pocket costs vary.
But even if it takes time to find an affordable provider near you and get an appointment, “it’s totally worth it, and can make a real difference in how a woman approaches a pregnancy,” Osborne says. “Patients have told me, ‘I wish I had known sooner that reproductive psychiatrists exist, because I would have made other decisions.’”
Kim appreciates how her reproductive psychologist helps with everything from considering donor eggs to little things, like helping Josh grasp why she didn’t want to go to a baby shower. “A few months ago, he would not be able to understand, and now he gets that it’s not about the other person, it’s about what my body can’t do right now,” she says. “That’s really, really wonderful.”