The understanding of men’s psychological experience of infertility and its investigation has been made difficult by limited data. In addition, treatment procedures have changed rapidly over the past few years. The introduction of intracytoplasmic sperm injection (ICSI) in the early 1990s opened up the possibility that many men who had previously had little or no hope of enabling their partners to conceive could now do so. Such advances in treatment have influenced men’s experiences of infertility and make it more difficult to have a clear, up-to-date picture of how men respond psychologically to being infertile. The studies reviewed in this section document the individual experience, but because so few have focused on men alone, it will be necessary to include studies that describe the experiences and reactions of both men and women. This approach also allows men’s responses to be compared with those of women.
Impact of Infertility
Studies of Men
Although very few studies have focused on men alone, those that did identified a range of negative effects of infertility on psychological well-being. Higher levels of generalized distress have been identified in men with fertility problems than in men from the general population. For example, Kedem et al. compared 107 men attending a specialist infertility clinic for semen analysis with a control group of 30 men without known fertility problems. They found that the infertile men had significantly lower self-esteem and were more anxious than the controls. Wright et al. studied 449 couples who were assessed for infertility on their first clinic attendance and found that the men were significantly more distressed than average. In another study by Morrow et al., 65% of the male partners of infertile couples scored above the normative mean on the Global Severity Index subscale of the Symptom Checklist 90-Revised, indicating that they suffered greater psychological distress than men in the general population.
Other studies have even identified clinically significant levels of distress. McEwan et al. reported clinically significant scores on the General Health Questionnaire (a screening measure for psychological distress) in 13% of their sample of 45 men from couples with different types of infertility. Glover et al. carried out a longitudinal study of subfertile men attending a specialist clinic. At the initial consultation, they were found to be highly anxious, with 51% scoring in either a borderline or a clinical range on the Hospital Anxiety and Depression Scale. They blamed themselves for their fertility problems and felt less of a man because of them. They considered their life satisfaction to be less than it would be if they were able to father a child. Measures of mood, life-satisfaction, and self-blame were unchanged at 6-week and 18-month follow-up.
Not all studies have found elevated levels of distress, however. Raval et al. conducted individual interviews to evaluate distress in 47 couples attending an infertility clinic with various diagnoses. They found that, compared with control groups, the male scores were “unremarkable.” Nevertheless, most studies agree that infertility has a range of negative psychological consequences for men including anxiety, psychological distress, dissatisfaction, and self-blame.
Comparison of Men and Women
Most studies have indicated that psychological consequences of infertility are worse for women than men, irrespective of whether it is due to male or female factor(s). Women had greater overall intensity of emotional response to subfertility. They were also both more depressed and distressed than subfertile men. In addition, women perceived their relationship with their partner as more adversely affected.
In interviews with 174 primary infertile couples versus 74 presumed-to-be-fertile couples, it was found that infertile wives perceived having children as more important and being subfertile as more stressful than their husbands. Furthermore, men in the infertile group reported greater home-life stress than men in the control group. They also found that both infertile and presumed-to-be-fertile women experienced more depression and lower self-esteem than their husbands. Collins et al. examined perceptions of infertility and treatment stress in a consecutive series of 200 couples entering an in vitro fertilization treatment program. Using an unpublished measure called the Infertility Reaction Scale, they found that women had significantly higher scores than men, suggesting that they experienced greater emotional and social effects of infertility than did men.
Not all studies, however, have found women to be more distressed. Stanton et al. developed a scale to measure infertility specific distress in a study of 54 subfertile couples. They found that although women acknowledged more distress specific to infertility than their partners, there was no difference between men and women in their general emotional distress.
Berg et al. found no difference in the level of emotional strain, marital adjustment, or sexual satisfaction between men and women in their study of 104 infertile couples, but they did identify differences in the context of distress for men and women. Women were more likely than men to report having a child as being important to them, to locate the cause of their infertility as being within them, and to feel that their infertility was a punishment for something they had done. Women experienced more discomfort than men in the presence of fertility-related stimuli. Also, men were less likely than women to reveal their fertility problem to relatives or individuals outside the family.
Sexual Functioning and Marital Relationship
Andrews et al. conducted separate interviews with 157 infertile couples and found that fertility-related stress was associated with decreases in sexual self-esteem, satisfaction with own sexual performance, and frequency of intercourse. The negative association between this stress and frequency of intercourse was greater for husbands than for wives.
Kedem et al. found that men with partners with an identified fertility problem had a higher incidence of sexual dysfunction than did those men whose partners had no problems. Elstein reported a decrease in libido when sexual function became primarily a reproductive process and intercourse was reduced to a goal-oriented exercise in semen delivery. In a study of 51 couples attending a fertility clinic for postcoital testing, Drake and Grunert found that 10% of the men reported sexual dysfunction (inability to maintain an erection or ejaculatory failure) during their partner’s ovulation but at no other time during the menstrual cycle. It may be that for these couples, the influence of “this-is-the-night syndrome” is even greater, with the goal-oriented nature of intercourse being emphasized.
Raval et al. reported changes in sexual functioning over time, with a peak in problems following recognition of infertility but prior to treatment. Overall, however, there was no significant difference between the incidence of sexual dysfunction in the sample and rates in the general population. This supports the hypothesis of Drake and Grunert that the mild and acute nature of mid-cycle sexual dysfunction is not detectable by standard assessment techniques. Berger found that 10 out of 16 couples interviewed after the husband was discovered to be azoospermic reported a period of impotence lasting between one and three months following the discovery, suggesting that sexual dysfunction in men with fertility problems is not solely the result of pressure to achieve a pregnancy.
A number of authors have looked at the impact of infertility on relationships, particularly on marital and sexual satisfaction. Several studies and reviews have concluded that satisfaction with the relationship remains high, even in the presence of sexual dysfunction. Greater satisfaction has been found to be associated with longer periods of trying to conceive and with men’s acceptance of a childless lifestyle; however, greater marital difficulties have been found to be associated with male-factor infertility, and some have reported that fertility-related stress increased marital conflict.
Change Over Time
The following sections examine the impact of continuing subfertility and psychological outcomes of pregnancy following fertility problems.
There have been few long-term follow-up studies of those undergoing fertility investigation and treatment. Slade et al. interviewed couples attending a subfertility clinic four months after their initial appointment and again three years later. Of the original 47 couples, 25 took part in the follow-up, and, of these, 14 had continuing subfertility. The majority of couples with continuing subfertility had a male-factor problem. The authors found that psychological functioning did not improve over time if there was continuing infertility. They also reported deterioration in both the marital relationship and the sexual relationship and found evidence of a decline in the men’s self-esteem, suggesting a more negative emotional outcome in men where a male-factor problem has been identified. This is supported by Connolly et al. who compared attendees at an infertility clinic at first visit and after seven months. Based on the General Health Questionnaire, they found increased distress in men (N= with a male-factor problem.
Pregnancy as an Outcome
In the aforementioned Slade et al. study, 11 couples had produced their own biological child at three-year follow up. No change was found in mood or self-esteem for women regardless of whether or not they had continuing fertility problems. Men who subsequently became fathers, however, showed an improvement in self-esteem. From their cohort of infertile couples, Abbey et al. found that the women experienced greater benefits of parenthood than did the men. Both partners had reduced marital well-being on becoming parents; men also reported decreased home-life stress (but not the women). Abbey et al. suggested that after years of trying to have a child, previously infertile men may be more sensitive to their changed household responsibilities and their wives’ expectations of their performance in the home. In an 18-month longitudinal study of 165 couples, of whom 48 became pregnant, Benazon et al. found that marital functioning decreased as treatment progressed. Marital distress was greater in those who did not conceive than those who did. Glover et al. reported follow-up data on 50 male subfertility clinic attendees, comparing outcomes in those men whose partners became pregnant and those who remained childless. At initial clinic visits, there was no difference between the groups. At 18-month follow-up visits, there was a significantly greater positive change in life-satisfaction scores in the pregnant as against the nonpregnant group.
Although there are some inconsistencies among these studies, some general conclusions may be drawn. Continuing infertility is stressful (partly as a consequence of ongoing treatment), but many couples adapt well to their childless state and enjoy a good relationship and average levels of satisfaction with life. Having a child satisfies some needs, such as that of men to demonstrate their fertility, but brings its own stresses. Such stresses are, of course, a natural concomitant to parenting, but an important (and as yet unanswered) question is the extent to which they may be increased by an overly idealized view of parenthood developed over many years of unsuccessful attempts.