The experience of infertility has multiple factors and thus has been examined using a variety of models. The complex and unique nature of infertility, however, makes it difficult to find a single model that adequately takes into account all aspects of this experience. Infertility has been seen to be a process, a life crisis, and a developmental crisis.
Drawing on the work of Lazarus and Folkman, recent infertility research has focused on the stress-coping aspect. At its core is the idea that an event is not stressful per se; rather, for an individual, it is the meaning of the event and the ability to find and use effective coping strategies that determine how the event is experienced. A situation is stressful if the individual perceives that environmental demands exceed his or her resources and endanger his or her well-being. This theory of psychological stress identifies cognitive appraisal and coping as critical mediators of person-environment relationships. This framework has three key processes: (i) primary appraisal (the perception of a potential threat), (ii) secondary appraisal (the perception of the ability to cope with a threat and consideration of a response), and (iii) coping (the process of executing a response to the threat). Situations likely to be appraised as stressful are characterized by unpredictability, negativity, uncontrollability, and ambiguity. Coping comprises two major functions: addressing the problem that is causing the distress (problem focus) and regulating emotion (emotion focus). The framework of Lazarus and Folkman has yielded important results, summarized below.
Cognitive appraisal describes the process by which individuals ascribe causes to and explain events. Stanton et al. assessed cognitive appraisal of infertility in a group of 76 women and 54 men with mixed infertility diagnoses. They developed a measure of appraisal to distinguish between perceptions of infertility as a threat or as a challenge. They found no relationship between cognitive appraisal and distress (infertility specific or general) in men, although men whose wives appraised infertility as more challenging were less distressed than other men.
The inability to conceive may represent a loss of control for infertile individuals. Although Mahlstedt referred to the loss of control observed in couples experiencing fertility problems, there has been relatively little research into how loss of control is perceived. Stanton et al. examined control perceptions in their study of cognitive appraisal and found that couples appraised infertility as relatively uncontrollable but that control perceptions did not relate to general distress or infertility-specific distress in men. In an early study of perceived control in infertility, Platt et al. examined locus of control in 25 couples seeking infertility treatment. They found that infertile men and women had higher scores on the external control scale (indicating that they felt that their situation was determined by forces outside of their control) than a control group of individuals with either no knowledge of their fertility status or with children.
Abbey et al. reported that perceived control was the strongest predictor of fertility-related stress for both sexes. The more control over their infertility individuals perceived, the less distress was reported. Glover investigated perceived control and coping in 83 subferrile men and found that high levels of perceived control were associated with lower anxiety. Infertility distress was lower in those who coped by interpreting their experiences in a positive fashion and by accepting their status and higher in those who focused on their emotions. Additionally, it was found that only infertility control significantly predicted anxiety.
Coping is the process by which individuals attempt to manage stress. Although findings from studies about coping with infertility are mixed, it appears there is a relationship between distress and using avoidance as a coping mechanism. Morrow et al. used the 55-item Ways of Coping — Revised Questionnaire to examine coping strategies in 86 men from infertile couples with mixed location of diagnosis. They derived three factors from the questionnaire scores: self-blame and avoidance, informational and emotional support seeking, and cognitive restructuring. Self-blame and avoidance coping were identified as the best predictors of psychological distress in these men.
Stanton et al. used the Ways of Coping Questionnaire to examine the relationship between coping strategies and general distress in 96 women and 11 men (including 11 couples) with fertility problems. For both men and women, there was a significant correlation between the use of avoidance coping strategies and general distress. Compared with their partners, men were more likely to cope through distancing, self-control, and problem solving, and they were less likely to cope through mobilizing support and avoidance. The partner’s coping style was also an important factor. Wives who used more self-controlling coping had more distressed husbands. Use of this strategy may reflect more limited communication about the infertility problem. Notably, women (but not men) who coped by accepting responsibility for their infertility were found to be more distressed.
Stanton also reported on the way in which infertile individuals compared their coping efforts with those of other infertile individuals. In a sample of 52 couples with mixed diagnosis (13% male factor only), the majority of men thought they coped better than same-sex others. They most often reported being in a better position because of a personal or motivational characteristic, such as their degree of motivation to have a child. Those men who felt they were coping worse than same-sex others attributed it to a personal characteristic such as being too emotional. Men who felt they were coping better than same-sex others were less threatened by infertility. Half of the men saw no difference between their own and their partner’s coping although the tendency was for men to see themselves as coping better than their partner. Overall, the partners did not differ in their appraisals of infertility and, in general, felt relatively little control over their fertility problems. When infertility was perceived as a greater threat, men reported lower well-being, while those men who felt greater control reported a greater sense of well-being. Confrontational coping was the most powerful predictor of distress in men. Participants evidenced more global distress than would be expected in the general population, although general well-being was comparable. There was no difference between the men and women in their general emotional distress.
Edelmann et al. examined coping and mood in their study of 152 couples entering an in vitro fertilization program. Their results indicated that the strategies of acceptance, redefinition of the situation, and direct action were adaptive for the men in their sample.
The results of Morrow et al. revealed that self-blame and avoidance coping were the strongest predictors of psychological distress among infertile men and women. This is consistent with the finding of Stanton et al. that infertile individuals who engage in self-blame and avoidance are at risk for psychological distress. Cook et al. found that infertile individuals who were anxious and / or depressed were more likely to use avoidance-coping strategies than those who did not have emotional problems. The evidence implies that avoidance coping, denying the existence of the problem, and self-blame are risk factors for adverse psychological strain during infertility.
Social support is often viewed as a mediating or buffering factor in the coping process. It has been well documented that seeking social support can have benefits for psychological well-being, particularly for infertile women. Satisfaction with social support has been found to correlate with lower levels of distress in women in infertile couples but not in men. This supports the assertion by Sarason et al. that women receive and value social support to a greater extent than men do. Thus, access to support may be more important for women experiencing stress than for men; however, seeking social support may present infertile men with a particular difficulty since individuals are less likely to pursue social support in situations that threaten self-esteem. These potential sources of support cannot ameliorate anxiety for these men since revealing their fertility problem will further lower their self-esteem. Slade et al. also found that less effective coping reflects increased levels of distress in infertile men compared with fertile men. In their sample of fertile and infertile couples, infertile men used fewer coping strategies, and men with continuing infertility showed the lowest use of social support strategies. Self-blame and detachment were particularly associated with poor marital adjustment.