The most significant demographic factors are briefly reviewed here. Other factors have also been investigated but there are few or inconclusive data relating to them.
Age does seem to relate to distress in men with fertility difficulties. A study of 86 men (mean age: 34 years) and 120 women (mean age: 32 years) found that increased age added to the prediction of psychological distress in men but not in women. Although men do not have time constraints on their ability to reproduce, their partners do; as a result, men may still have a feeling that time is running out. Alternatively, it may be that men’s desire for children and family life develops as time goes on and so the inability to have children becomes more distressing with age.
Duration of infertility has also been investigated. The majority of studies report no relationship between length of time trying to conceive and level of distress; however, Berg et al. found that couples where the male partner was more distressed than the female partner (male-distressed group) had been undergoing investigation for a significantly shorter time than other groups. They suggested that men in the male-distressed group might be responding to problems of scheduling sex. Also, most of these studies have focused on couples with primary infertility, although some have included those with secondary problems. Again results are inconclusive, although Morrow et al. found that not having biological children added to the prediction of psychological distress in men but not in women.
Diagnosis and Location of Cause
A factor often overlooked in these studies is the cause of the fertility problem. Edelmann and Connolly suggested that resolution of uncertainty, whether it be by pregnancy or knowledge of azoospermia, is associated with less distress than not knowing. Another study found no difference in scores of distress and marital problems between diagnosed and undiagnosed couples. It may be that even with a diagnosis, uncertainty remains and that knowledge about the cause of the fertility problem may only be useful if it leads to definite statements about outcome. When the cause of infertility was found to be with the man, it was judged by both partners to create more marital difficulties than when the cause was found to be with the woman or with both partners. Infertility in men increased men’s feelings of guilt, isolation, and depression; in the wives of infertile men, it led to increased feelings of guilt and lack of success. McEwan et al. found that women who felt personally more responsible for their infertility were more distressed than those who did not; however, they also found that 44% of women without a diagnosis and 30% of women with a partner with a clear diagnosis still felt responsible for the problem. In a study by Daniluk, participants identified as having an organic fertility problem reported higher levels of depression than their partners did at the time of diagnosis.
Additional support for the presence of greater distress in men with male-factor infertility comes from the longitudinal literature. One study followed-up couples for seven to nine months after an initial visit to an infertility clinic. Using the General Health Questionnaire, they found that infertile men scored lower than men in couples with female factors only, male and female factors, or unexplained infertility. In another study, Slade et al. followed patients three years after consultation; they again found infertile men were the least adjusted. Nachtigall et al. interviewed couples undergoing infertility treatment and found that men with a male-factor problem experienced a more negative emotional response to infertility (in terms of feelings of stigma, loss, and self-esteem) than men without a male factor. Van Balen and Trimbos-Kemper, in a study of 108 couples with long-term infertility (mean 8.6 years), found more feelings of guilt and blame in infertile men than in involuntarily childless men with no identified fertility problem; however, no similar relationship existed between cause and negative feelings in women. Mikulincer et al. found that for both men and women, a diagnosis of male-factor infertility was significantly more distressing and participants reported less well-being than for a diagnosis of female infertility.
Placing emphasis solely on who has the identified problem, however, may be unhelpful, as it does not take into account the fact that feelings of responsibility for infertility are not solely related to the location of the problem. An additional complicating factor is that patients’ views of the source of the problem may differ from the medical diagnosis. Buttler et al. examined the concordance between the perceptions of men attending a subfertility clinic and the medical diagnosis. Interestingly, they found that 17% of men with a male-factor diagnosis disagreed with the medical opinion, while 42.5% of men whose partner was diagnosed as infertile agreed with the diagnosis. Men in couples with a female factor who disagreed with the medical opinion reported a joint or unexplained diagnosis.