Approximately 20% of cases of infertility are due solely to male factor problems and 20% to a female factor; 30% involve both male and female factors, and 30% have no identifiable cause. Although it is widely recognized that infertility can present psychological as well as medical challenges and difficulties, literature dealing with the psychological aspects has tended to focus on women’s reactions to the situation. Men have either been neglected, or it has been assumed that their reactions will be similar to those of their partner. There is a growing body of research that suggests that infertility has a specific impact on men, especially in the case of male-factor problems. The purpose of this post is to review this research and to provide some guidelines for applying this information in clinical practice.

Social Perspectives On Reproduction And Infertility

Psychological Sequelae Of Infertility

Investigation And Treatment

Factors Affecting Responses To Infertility

Appraisal, Coping, And Location Of Cause

In the light of the evidence suggesting that men with male-factor infertility experience greater distress than those with a joint, unexplained, or female-factor diagnosis, some studies have sought to examine differences in appraisal and coping between these groups. Hurst et al. looked specifically at stress and coping mechanisms employed by fertile and subferrile men. They found similar levels of perceived stress in 24 fertile and 25 subferrile men as categorized by their semen samples. Subferrile men, however, had to use more coping resources to maintain the same emotional level as the men in the fertile group.

In order to evaluate the effects of a gender-specific diagnosis of infertility on men, Gannon et al. conducted a study that included men with a male-factor fertility problem (MMF) and men whose partner had a fertility problem (MFF). They focused on the way these men appraised their infertility (for example, whether they saw it as a threat or as a challenge) and the way they coped with it (for example, whether they sought support from others or tried to ignore it). There was no overall difference between the groups in their appraisals of infertility or in their level of adjustment. In both groups, those who appraised infertility in terms of threat and loss showed higher levels of distress, and those who saw themselves as having some control showed greater well-being. The MMF group was significantly more likely to cope through seeking instrumental social support and through mental disengagement than the MFF group. Appraising infertility as a threat and focusing on and venting of emotions were associated with more distress for MMF. For men in the MFF group, a wider range of appraisals and coping styles were associated with distress.

Donor Insemination

Although much of the literature on the impact of infertility and individual responses applies to all those experiencing fertility difficulties, some specific issues arise for couples who use donor insemination. For many years, donor insemination was the only treatment strategy for couples with male-factor infertility. It was first used in the late 1930s and has become common since the 1950s. Initially, donor insemination was received with outrage, although views have changed over the years due to a changing social and moral climate. It challenges societal ideas about paternity and biological versus social fatherhood. In the 1940s, men who donated sperm and men who allowed their wife to have another man’s biological child were regarded with great suspicion. At one time, registering a donor insemination child as that of the social father was in fact a crime.

Although donor insemination is less researched than male infertility in general, there have been some important findings. It has been suggested that donor insemination still carries a stigma and is often shrouded in secrecy. Donors are anonymous and remain untraceable by their offspring. Parents of donor insemination children frequently decide not to tell the child about his or her origins and thus create a secret that may be known only by the parents, but which, in many cases, is known also by other family members and friends. Research suggests that the majority of couples undergoing donor insemination treatment do not intend to tell their child about his or her origins. Parents who do not intend to tell their child have higher distress levels than those who do. Although achieving a pregnancy was the main concern of couples undergoing donor insemination treatment, they also expressed concern about the donor, telling the child (and the impact that might have on the child’s well-being), and the father’s relationship with the child.

Counseling

The process of infertility is often conceptualized in terms of a bereavement process, with couples needing to mourn the losses associated with childlessness (e.g., control of fertility, hopes of parenting, and self-esteem). Menning suggested that bereavement provides a useful model for counseling infertile couples and argued that the need to grieve is often unmet because of the lack of a concrete object. Grieving may be more difficult if there is no finality in the situation; that is, a hope of conceiving continues. In contrast, couples for whom conception is impossible may more easily accept their infertility, process their emotions, and plan for the future. Viewing the knowledge of infertility as a process has implications for applying a bereavement model. Rather than thinking of infertility as a single bereavement, it may be more useful to see it as consisting of multiple monthly losses, with each monthly occurrence reawakening the wide range of emotions associated with being unable to have a child. Such ongoing losses may have a compounding effect, and rather than becoming immune to the experience, each monthly disappointment may draw on decreasing reserves and make coping more difficult.

Although the bereavement model is widely used in counseling infertile couples, it is derived largely from clinical observation and there is little empirical support for it. Certainly, there is evidence that couples describe feelings of loss. Nachtigall et al. found that approximately half their sample of subfertile men reported the discovery of their infertility as a loss, of which two kinds were identified: the loss of potency and the loss of biological children. A much higher proportion of women, however, identified loss and the authors concluded that this reflected the different expectations of parenthood held by men and women. Furthermore, while there are undoubtedly losses associated with infertility, individuals may not necessarily respond to these in ways similar to other losses.

Although many women may find the bereavement model of infertility useful, such a model may be less appropriate for men where feelings of threat and anxiety appear to be more salient and should be considered in counseling. In addition, cultural issues related to models of masculinity should be borne in mind as they form an important context for the male experience. Lee acknowledges that the changing role of men in society is an important contributor to male distress in relation to fertility problems (although he fails to integrate this insight into his approach to therapy in a systematic way). An additional challenge in counseling for infertility is that men and women are usually seen as a couple; thus, counseling must simultaneously address the different issues confronting both partners. One potentially useful approach would be to assist the couple to explore and acknowledge their different reactions to the situation and to draw on these insights to improve communication and understanding as well as to assist in making decisions concerning their course of action.

Summary

Reactions to Infertility

There can be little doubt that men are distressed by infertility. This tends to be greater when a male factor is implicated, and for a sizeable proportion of men, the distress will reach clinically significant levels. The presentation of distress appears to differ for men and women, with anxiety being a more prominent feature in men. This suggests that clinical interventions to address anxiety rather than depression are likely to be useful in male-factor infertility. Levels of distress are mediated by a number of variables: greater age, the absence of children, and male-factor problems are all associated with greater distress in men. A successful pregnancy will generally result in improvements in self-esteem and life satisfaction for men but will inevitably bring its own stresses and challenges, many of which may have been unanticipated. It may be helpful to encourage couples to look beyond the immediate context of diagnosis and treatment to consider these unanticipated events.

The Consultation — Investigation and Treatment

The whole process of investigation and treatment is stressful, with peaks at particular stages, such as egg and sperm collection. The consultation is perceived as being valuable, even when it is not possible to give a firm diagnosis or to offer specific treatment options. The main benefits appear to be derived from the opportunity to discuss concerns and to receive information. Nevertheless, recall of this information may be poor, and the beliefs of patients concerning their diagnosis may differ from those of the clinician. The consultation should, therefore, be viewed as an important opportunity to provide accurate information, to address concerns, and to be therapeutic in its own right. Care should be taken to assess patient understanding and to address any misapprehensions. This could be done, for example, by asking the patient to summarize the information provided.

Dealing with Infertility

Individuals vary widely in the way in which they attempt to manage their reactions to their infertile status. Those who view matters as being beyond their control are likely to be more distressed than those who see themselves as being able to exert some control over the situation. How individuals cope with these stresses is also important. There are some gender differences in coping responses. In general, however, coping through self-blame and avoidance of the issues is associated with heightened distress. Conversely, responses such as redefining the situation (e.g., seeing a challenge rather than a threat), taking positive action, and acceptance can be beneficial. Social support can also be valuable, although men generally find it more difficult than women to access this type of support.

Even men who appear to be coping effectively may be doing so at the expense of deploying a great many coping responses. As coping imposes its own costs, this may have implications for longer-term psychological well-being. It is probably useful to enhance the individual’s sense of control, for example, by involving them as much as possible in decision-making. Coping responses that involve taking positive action, redefining the situation in more positive ways, and moving toward acceptance should be identified and promoted. Men in particular should be encouraged to seek support and to identify other individuals with whom they can discuss their feelings. Having said this, it is important to note that the overriding issue to remember when working with infertile couples is that they are all different. Listening to and understanding individual responses are of paramount importance in providing useful and appropriate support.

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