reviewed by Tatiana A. ROMANOVA

Why infertility has a psychological effect on the couple?

Infertility may be one of the most difficult experiences a woman can have in her lifetime. The emotional consequences of an infertility diagnosis can be devastating, which may be little known to patients and medical personnel. From a psychological standpoint, infertility has similarities to other chronic illnesses. (Pamela Fawcett Pressman, www.pressmanandassociates.com)

Parenthood is one of the major transitions in adult life for both men and women. The stress of the non-fulfillment of a wish for a child has been associated with emotional squeal such as anger, depression, anxiety, marital problems and feelings of worthlessness. Partners may become more anxious to conceive, ironically increasing sexual dysfunction and social isolation. Couples experience stigma, sense of loss, and diminished self-esteem in the setting of their infertility (Prasanta Kumar Deka, Swarnali Sarma, 2010).

The infertile couple may experience shame and embarrassment at their inability to conceive naturally. When the couple presents with their suspicions that one or both have infertility problems, it is imperative that no blame be placed or reinforced. Infertility is a problem for the couple and should be addressed as a couple issues (Reed, Susan A., 2001).

Behavior of the couple as a result of infertility

Stress, depression and anxiety are described as common consequences of infertility. A number of studies have found that the incidence of depression in infertile couples presenting for infertility treatment is significantly higher than in fertile controls, with prevalence estimates of major depression in the range of 15%-54%. Anxiety has also been shown to be significantly higher in infertile couples when compared to the general population, with 8%-28% of infertile couples reporting clinically significant anxiety. The causal role of psychological disturbances in the development of infertility is still a matter of debate (Prasanta Kumar Deka, Swarnali Sarma, 2010).

Proposed mechanisms through which depression could directly affect infertility involve the physiology of the depressed state such as elevated prolactin levels, disruption of the hypothalamic-pituitary-adrenal axis, and thyroid dysfunction. One study suggests that depression is associated with abnormal regulation of luteinizing hormone, a hormone that regulates ovulation.. Since stress is also associated with similar physiological changes, this raises the possibility that a history of high levels of cumulative stress associated with recurrent depression or anxiety may also be a causative factor (Prasanta Kumar Deka, Swarnali Sarma, 2010).

Infertility comes as a severe shock to couples who have probably taken their fertility for granted. It presents them with one of their first major crises together. This life crisis can lead to many reactions, often following a pattern, but varying in degree from person to person.

Surprise. Their infertility obviously comes as a surprise to couples who have taken normal fertility for granted, have used birth control, and even planned their families. Ignorance of normal fertility and unrealistic expectations may well aggravate their surprise.

Denial. Although it may seem illogical, this mechanism does occur, and it seems necessary to allow the mind and body to adjust to the newly discovered infertility problem. Comments such as "1 don't really want a child anyway" are frequently made, even though the person really desperately desires to become pregnant.

Anger. Once a couple acknowledges infertility and goes for investigation and treatment, to a varying extent control of the couple emotional and physical wellbeing is surrendered to medical personnel. This may result in anger. Such anger can be real and directed towards family members who continually ask about the absence of children or offer inappropriate advice such as "Go away on holiday" or "Stop working". The anger may not appear rational and directed towards their partner, doctor or social groups. It may be important to ventilate this anger with professional assistance. If this does not occur, frustration, mistrust and embarrassment will ensue, which can further aggravate the next reaction, viz. isolation.

Isolation. Infertile couples often feel alone. This is partly explained by the fact that sexuality is often equated with fertility. Thus the couple or one of the partners may feel too embarrassed to discuss the fertility problem. Isolation is thus further increased. Isolation may also lead to the indirect acceptance of advice, often inappropriate, or the use of alternative scientifically unproven non- medical options. Unfortunately this also makes them fair game for unscrupulous "non-medical practitioners". The isolation reaction also prevents the seeking of support so badly needed by the couple. To overcome this, fertility education and contact with infertility support groups may be helpful.

Guilt. A guilt reaction is common, and yet is often difficult to explain. It can follow the realization that one partner is the cause of a couple's infertility problem, and thus is denying the other partner a child. Sometimes an infertile person will look for a guilty act to put his or her infertility into a cause and effect relationship, eg failure of religious observance, premarital sex, abortion, unkind wishes and so on. Guilt is difficult to discuss and share. Furthermore, guilt can add to the already poor ego strength of an infertile person and increases the feeling of being bad. The guilt feeling may lead a person to try and "atone for his or her sins" and he or she may often seek some form of religious assistance. Guilt can also lead to self-destruction attempts through alcohol, drugs, apathy, weight loss or gain. Obviously, in reality there is no relationship between an individual's worthiness and fertility! 

Grief. If a couple fails to have a child or gives up trying, grief is an inevitable result. For the non-grieving person, whether the other half of the couple, a close friend or a relative, it is exceedingly difficult to understand how one can grieve over a child who never existed. However, the grief is just as real and painful, possibly more so, than if a real loss had occurred. Real losses have various related rites that help overcome grief, whereas with infertility no such rites exist. It should be recognized that the grief expressed is real, and no attempt should be made to prevent the person from expressing it. Sometimes counseling may be needed to help work through the grief. (www.fertilityeast.com.au)

Can this grief be described by “five grief stages” (by Elizabeth Kulber-Ross) again as represented above: denial, anger, bargain, depression and acceptance?

Feelings of sadness, depression, anxiety, and preoccupation with infertility are common. In the literature this is referred to, in part, as anticipatory grief: “We are mothers in our hearts before our babies find us.” This phenomenon occurs even with otherwise happy, well-adjusted women. (Pamela Fawcett Pressman, www.pressmanandassociates.com). Recently in social network communities, this phenomena has been named as “EAS: Empty Arms Syndrome”, what correctly describe emotional and psychological feeling following gradual loss of hope to be parents.

Infertility can be classified on as an ambiguous loss.
Ambiguous loss occurs when a loved one is physically present, but psychologically absent. With no official verification of death, no possibility of closure, and no rituals for support, there is no resolution of grief (Boss 1999). In case of infertility, the “baby” is very much psychologically present, but physically not a tangible presence (D. Harris, 2011).

It is important to remember that:

The reactions may affect each member of the couple to a different degree, in different combinations and this may lead to serious effects on a couple's inter-personal communications.

These reactions, often linked with poor communications, can easily affect the couple's sex life, which in turn can further aggravate their relationship, and so a vicious cycle is set in motion (www.fertilityeast.com.au)

Male and female partner respond differently

In general, in infertile couples women show higher levels of distress than their male partners; however, men’s responses to infertility closely approximate the intensity of women’s responses when infertility is attributed to a male factor³. Both men and women experience a sense of loss of identity and have pronounced feelings of defectiveness and incompetence. Emotional stress and marital difficulties are greater in couples where the infertility lies with the man. Therefore the psychological impact of infertility can be devastating to the infertile person and to their partner. (Prasanta Kumar Deka, Swarnali Sarma, 2010).

The three factors, in order of importance for the women were,
1. "Having Children is a Major Focus of Life"
2. "The Female Role and Social Pressure"
3. "Effect on Sexual Life"
The men in the study reversed the order of importance of factors 1 and 2. The third factor was equally significant to both the men and women. Women experienced their infertility more strongly than the men. Women also showed a more intense desire to have a baby than men (Prasanta Kumar Deka, Swarnali Sarma, 2010).

Women (rather than men) almost always experience a greater degree of emotional distress with infertility. A man’s distress, however, tends to be more focused on how to support his distraught female partner and infuse her with his optimism for a successful outcome. The intensity of emotional distress a woman may experience is often surprising, even to her. She may feel distraught each month that she has a failed attempt at pregnancy. Once a woman has made the emotional shift to motherhood, each month without a child may feel empty. Women describe it as “an aching in my heart.” For many women, each month without a baby is a painful loss, similar to grieving a deceased loved one.

Women may also experience shame, guilt, or a feeling of inadequacy. Pregnancy has long been associated with womanhood, and failing at something so fundamental to a woman’s identity can be a terrible blow. A woman may search her mind for what she “did” to cause the infertility and unfairly blame herself. Often, women and couples “hide” their infertility struggles as they continue to fulfill daily obligations, carrying the secret burden of a life crisis. (Pamela Fawcett Pressman, www.pressmanandassociates.com)

Depression or a history of depression has been found to be associated with a decline in ovarian function and therefore may also contribute to female causes of infertility (Harlow et al. 2003).

Psychosomatic causes of infertility

Infertility in women may be caused by ovulatory dysfunction caused by endocrine dysfunction, polycystic disease, nutrition or stress, uterine abnormalities such as fibroids, Asherman's syndrome, or congenital abnormalities, alterations in fallopian tubal integrity attributable to infection or endometriosis, cervical mucoid inadequacy, and/or exposure to diethylstilbestrol in utero (Reed, Susan A., 2001).

Male infertility factors include ductal obstruction as a result of sexually transmitted diseases or prostatitis, hypogonadism caused by androgen receptor deficiency, ejaculatory dysfunction, varicoceles altering spermatogenesis, and gonadotoxin exposure, including radiation, chemicals (herbicides, organic solvents, etc.), drugs, alcohol, chemotherapeutic agents, and anabolic steroids.1,9,10 Often, causes of infertility in both males and females can be identified and treated by the primary care practitioner (Reed, Susan A., 2001).

For female, psychological factors may decrease the libido and so reduce the frequency of intercourse. They may also lead to painful spasm of the "vaginal" muscles, so preventing intercourse from taking place. These factors may also exert their influence on the woman's pituitary gland and interfere with ovulation. This in turn may lead to changes in her menstrual cycle such as absence of periods or irregular bleeding (www.fertilityeast.com.au).

For male, psychological factors may work in one of two ways. Firstly, they can affect his performance of the sexual act, causing failure of erection (impotence) or reduction of sexual drive, thus decreasing the number of times intercourse occurs over the fertile period, if it occurs at all. Secondly, psychological factors may affect the pituitary gland and interfere with hormonal control of sperm production. This not only reduces sperm numbers but also may lead to adverse changes in sperm quality (www.fertilityeast.com.au)

Usual coping strategies, such as hard work and perseverance, are inadequate to manage the crisis of infertility, which leaves many women and couples unsure of how to cope and feeling a loss of control. This loss of control is what many women find most difficult to handle. It is also the reason why patients can be irritable or angry at treatment staff. (Pamela Fawcett Pressman, www.pressmanandassociates.com)
NEXT Chapter
BACK