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Infertility is a major life crisis for any couple. As most reproductive health professionals know, infertility is extremely stressful, causing such serious psychological reactions as anxiety, depression, social isolation, sexual dysfunction, marital discord and feelings of unworthiness. In turn, these reactions will negatively influence an individual’s personal, interpersonal, social and occupational functioning.

Infertility is considered a “couple problem”, because regardless of which partner is found to be responsible for the reproductive failure, both partners are implicated, and both are necessary for its treatment. Nonetheless, it is believed that about 30% of infertility is caused by male factors, such as deficiencies in sperm production and blockages in the sperm delivery system. However, because historically more attention has been focussed in treating female infertility, male factor problems have typically been circumvented rather than treated directly.

The psychological literature has paralleled this pattern and focused more on the emotional sequelae of women’s response to infertility than that of the male. This attention is due also to the fact that women are perceived to experience greater losses (such as gestation, birth and breast feeding) during infertility than men. In addition, socio-biology theory proposes mothering to be a more integral part of a women’s identity and or physiological needs than fathering. Whether or not a paternal drive or instinct exists, remains controversial.

In general, the man’s reaction to infertility has been viewed by mental health professionals as taking less of an emotional toll than his partner’s. His reaction to his own infertility is often construed as interdependent with his partner’s. Thus if she is coping well with it, he will follow accordingly. However, if she is having a difficult time, then his emotional stability will be compromised. His primary role is often relegated to that of hand-holder, in charge of providing support for his partner during her grieving process. Little room is left for dealing with his own feelings of loss and sadness. This conforms to society’s gender expectations in which men are not given permission to express deep feelings of loss; on the contrary, they are encouraged to suppress emotions. Thus, together society and the medical profession inadvertently conspire to ignore or underestimate the man’s responsibility and role in the infertility process.

Although there is a paucity of psychological studies that examine male infertility they concur, nonetheless, that a significant proportion of infertile men do experience myriad psychological wounds, including low self-esteem, a loss of virility, a change in self-image, and a loss of sexual appetite. Just like his female counterpart, the infertile male experiences feelings of inadequacy, failure and guilt. One study found that 80% of 100 infertile men reported guilt feelings both about their perceived inability to prove their manhood and to fulfil their partners’ desires to have children. Infertile men suffer from episodes of depression, anxiety, sleep disturbances and anger. Their shame can lead to detachment from the marriage, causing breakdowns in communication and commitment. Secondary psychological disorders such as substance abuse, mood disorders and sexual dysfunction are not uncommon consequences.

The reactions of the woman to her partner’s infertility can range from compassion, to shame, to deep resentment. She may have a need to protect him or blame him. For some women, sexual interest decreases, for they feel there is no point to lovemaking; for others, sexual appetite increases because they have a need to reinforce their mate’s sexual attractiveness. Many women often feel guilty that they do not share their partner’s failure in the reproductive process. Because the emphasis for pregnancy is on women in our society, many women are more comfortable with taking the responsibility for the couple’s infertility in front of families and friends. Since it is often difficult for the man to carry the burden of the couple’s infertility, a cover-up is considered desirable by each partner and agreed to non-verbally. This is usually the time when secrecy is set into place, which will likely impact on a couple’s decision-making process for treatment choices.

Medical recommendations to resolve male infertility problems can be classified into three categories; surgical or medical therapy, donor insemination (DI), and assisted reproductive technologies (ART). Psychological research and consultation have been most implicated with the latter two recommendations. It is these alternatives to natural conception that I will review in terms of their psychological challenges.

Donor Insemination

DI was first documented in medical journals in 1890 in the USA and 1793 in Britain. The first reported case of DI in Canada was in Toronto in 1950. It is estimated currently that DI results in 30,000 to 40,000 births every year. Although this therapy has a long history of success (70-80% success rate over six months) it also has a long history of low social acceptance and secrecy which have resulted in limited data or information on whether any psychological difficulties arise from this choice for family-building. The few descriptive studies that exist do agree, however, that DI couples have a lower incidence of divorce and that on the surface no significant differences exist on adjustment parameters between DI families and fertile families. In a longitudinal study out of Europe, no differences were found in children conceived via IVF, DI and naturally.

Clinical experience cautions, however, in order to insure couples adjust well to this life decision, spouses, especially the husbands, give themselves time to come to terms with their infertility before beginning a regimen of DI. All too often physicians present couples with the news of male infertility concurrently with reassurances that DI is an obvious solution to this dilemma. The underlying implication is that the couple can accomplish their goal of having a child without anyone knowing about the man’s infertility. The man often agrees too quickly because of his own guilt in preventing his partner the experience of pregnancy, genetic continuity, etc., and to alleviate his own feelings of shame and failure. He is motivated to choose a fast solution to avoid the depths of his own pain. This is counter to psychological theory which contends that one needs to experience feelings of grief and loss to put them to rest. Pushing such feelings underground will only give them more power later on. Unresolved infertility could lead to marital disharmony and a poor parent-child relation, wherein the DI child serves as a constant reminder of that which the husband has tried desperately to forget. In light of these potential landmines, it is recommended that all couples considering DI as a form of family building receive “Implications Counselling”. Implications counselling is a form of psychoeducational counselling in which the aim is to enable all parties concerned to understand the short- and long-term ramifications of DI for themselves, their family and any children born as a result.

The most hotly debated topic in the psychological literature on DI concerns disclosure or privacy/secrecy that is whether it is in the DI family’s best interest to be open about how they were formed, or whether the donor children should never be told of the circumstances of their births. There is no definitive answer on this, although the American Society of Reproductive Medicine (ASRM) recently published a position paper in which based on research findings they support the practice of disclosure as being in the best interest of the gamete-conceived child (2004), Today, most sperm banks offer identity-release options to their users. Countries such as Sweden and New Zealand instituted policy mandating donor identification in the 1980’s. However, proponents of both sides of this controversy make convincing arguments.

Privacy/secrecy is still the norm. Klock (1997) found rates of disclosure were consistent across countries with only a minority, 12-30%, disclosing. Advocates of privacy argue that the social father is the true parent and that rearing a DI child is the same as raising one’s own genetic offspring. If DI is kept secret there is no risk that the offspring will ever suspect otherwise, thereby differentiating it from the adoption model. Furthermore, issues such as stigmatization of the father, abandonment issues for the offspring, identity confusion, negative social reaction and awkwardness in how and when to tell the child, are all avoided. They further argue that nurture plays more of a role in shaping a child than nature.

The disclosure side argues fundamentally that an awareness of one’s genealogy is a basic human right and should not be denied for any reason. They postulate that in the era of genetic mapping children will inevitably learn their genes are different from their parents and thus should hear it first in a positive and open manner from their patents. Since divorce is commonplace today (a tumultuous time when in anger parents reveal the origins of their child’s conception), and more and more medical conditions are being found to have a genetic base, the chances of a DI offspring finding out the truth increases twofold. There is data to suggest that there are better times to talk to a child about his origins than others (i.e., learning during adolescence can be damaging) and that openness allows more control in terms of how and when to disclose.

Disclosure supporters also contend that secrets in a family undermine trust, and that on some level the family system is adversely affected by attempts at concealing. It is believed that in secrecy the male-female relationship gets realigned with the woman having more power and the man becoming weaker and more passive and that the children feel the undercurrents of these tensions and interpret unspoken messages. They claim that once a secret is in place the keepers of it are forced to carry it to their graves or risk the consequences of revealing it under adverse conditions. As a psychologist, my role in counselling infertile couples in their decision-making process is to ensure they are given accurate and well-established information on the pros and cons of their options, without pressure or evaluation. Raising a DI family can be a positive and rewarding one if the parents have worked through their loss, have accepted the differences in their unique family situation and have made efforts to understand their partner’s feelings and the special concerns of their children.

Assisted Reproductive Technologies

The ARTs allow us to expand our notion of the family without undermining its basic tenet. The fact that some infertile couples can realize their goal of forming a biological family when heretofore such as possibility was denied them, serves to strengthen the family unit. In vitro fertilization (IVF) offers a chance to produce a child for those men who are sub-fertile, that is, have a low sperm count, poor sperm motility or morphology. Overall, there is much evidence to show that women react more intensely to IVF than men. Research has shown that prior to IVF, women report more anxiety and depression, and after treatment failure depressive symptomatology is less common in men. More surprising, are recent findings which show that men and women are similar in terms of how they respond to different stages of an IVF cycle. For example, both husbands and wives responded to oocyte retrieval and transfer with increased optimism and feelings of emotional closeness with their partners, while for both, the pregnancy test is accompanied by feelings of acute distress and social isolation.

IVF combined with Intracytoplasmic Sperm Injection (ICSI) is a procedure that offers hope for men who have no sperm in their ejaculate, or who have very poor sperm count or motility. It is the process by which one sperm is injected into the centre of one egg to increase the chances of fertilization. As in IVF, if fertilization is achieved, the embryos are transferred into the women’s uterus after two days. At this time most centres are achieving pregnancy rates of 40 to 45% per cycle.

Many fertility specialists were predicting that ICSI would mark the end of donor sperm for heterosexual couples. For most sterile men it is nothing short of a miracle. However, realistically speaking, ICSI does not mark the end of male infertility and the psychological sequelae that follow such a diagnosis. Perhaps in their overzealousness to offer hope to their male patients, doctors may portray ICSI as a panacea to male infertility. From a psychological perspective this can be a mistake. ICSI is not a cure for infertility, though it can be a cure for biological childlessness.

Whether the couple eventually chooses ICSI or DI, the infertile man’s self-concept remains unchanged; from his point of view he is still unable to impregnate on his own, he continues likewise to view himself as deficient, and carries the responsibility for his partner not being able to conceive naturally. Therefore, the infertile man and his partner are still required to resolve their feelings of being infertile before availing themselves of such a treatment option as ICSI.

Furthermore, ICSI carries its own risks and considerations that must be examined. ICSI is an intrusive medical procedure that is time consuming, work disrupting and may involve surgery for the man. His partner must undergo extensive hormonal preparation which may carry their own side-effects and risks. Finally there is a large financial burden that must be taken into account (on average $1000 – 1500 over and above the cost of IVF vs. $500.00 for DI).

It is noteworthy that recently in my practice I have been consulted by couples who have children through DI and chose to keep it a secret and now are considering trying ICSI. They agonize that their children will detect a difference in attitude or resemblance between themselves and these potential offspring. They also worry that friends or family will figure out their children’s true birth circumstances if they now opt for ICSI. Several feel weighed down by the burden of their secret and its possible enlargement.

In conclusion, there are clearly more choices available to couples with male infertility compared with years gone by. However, there is no shortcut whereby one can bypass the emotional processes of loss and resolution. This emotional journey first must be confronted and put in perspective in order to profit and benefit from the many medical options available. No matter how a couple chooses to form its family, as long as children are brought into their lives with pride and not shame, resolution and not unhealed wounds, the families will thrive and flourish.