Psychological Issues in Male Factor Infertility

Janet Takefman, PH.D

Fall 2008

 

Infertility is a major life crisis for any couple or individual. As most mental health professionals in this field know, infertility and its treatment are extremely stressful, causing such serious psychological reactions as anxiety, depression, social isolation, sexual problems, 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 must contribute to its remedy. Nonetheless, it is believed that at least 50% of infertility is caused by male factors, such as deficiencies in sperm production and blockages in the sperm delivery system. Specifically, statistics show that 33% of problems can be traced directly to male origins, 33% to pure female-factor infertility and 33% to a combination of male- and female-factor infertility. However, historically more attention has been focused on treating female infertility than male factor problems. One reason for this is the number of specialists that practice reproductive medicine. The American Society of Reproductive Medicine (ASRM) reported that in 2007, 65% of its membership was made up of obstetricians and gynecologists, whereas less than 10% were urologists or andrologists. Typically, male infertility treatment has been circumvented rather than treated directly. Examples would include using donor sperm with insemination, or combining ICSI (intracytoplasmic sperm injection) with IVF, for which only one living sperm is required per egg.

 

The psychological literature has paralleled this pattern of ignoring male- related issues and has focused more on the emotional sequelae of women’s responses to infertility. This is due partly to the fact that women are perceived to experience greater losses (such as gestation, birth and breast feeding) during infertility than men. Furthermore, in stressful treatment processes such as IVF, most of the difficult procedures like egg collection and hormonal injections fall upon the female. In addition, socio-biological theory proposes mothering as more integral to a woman’s identity and physiological needs than fathering is to a man’s identity. 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, he will follow accordingly. However, if she is having a difficult time, then his emotional stability will be compromised. He is often primarily relegated to the role 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, society and the medical profession combined 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 do concur that a significant proportion of infertile men do experience a myriad of psychological wounds. These can include guilt, shame, anger, and isolation, a sense of personal failure, lowering of self-esteem, feelings of inadequacy, change in self- and sexual self- image, and a loss of sexual appetite. Males also report feeling specific losses when infertile, such as loss of genetic continuity and passing on the family name, loss of male sexual identity, loss of their ability to control their own lives, and loss of their ability to provide for their partners. Then of course there is the anticipatory and performance anxiety that is more often than not present when men must produce a semen sample for analysis or treatment. One study found that 80% of 100 infertile men reported guilty feelings, both about their perceived inability to prove their manhood and to fulfill their partners’ desires to have children (Schover et al, 1992). Consequently, infertile men can suffer from episodes of depression, anxiety, sleep disturbances and sexual difficulties. Furthermore, their feelings of inadequacy have been shown to lead to detachment in the marriage, with breakdowns in communication and commitment. Secondary psychological disorders, such as substance abuse and sexual dysfunction, are not uncommon occurrences.

 

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 as they feel there is no point to lovemaking; for others, sexual appetite increases because they have a need to reassure their spouses about continued sexual attractiveness. Because the emphasis for pregnancy is on women in our society, many women seem more comfortable with outwardly taking responsibility for the couple’s infertility in front of families and friends. Conversely, since it is difficult for the man to carry the burden of the couple’s infertility publicly, a cover-up takes place, often without either partner overtly expressing agreement to this strategy. This is usually the time when secrecy is set into place, which can impact a couple’s decision-making process for treatment choices, for example, deciding to use donor sperm without any intention of disclosing the truth to family, friends and the potential offspring.

 

Medical recommendations to resolve male infertility can be classified into three categories: surgical or medical therapy, donor insemination (DI), and assisted reproductive technologies (ARTs). The most common causes of male infertility include, in order of prevalence, varicocele (38%), idiopathic (23%), and obstruction (13%) (Chan, 2007). Psychological research has been applied mainly to the fallout resulting from the use of DI and ARTs, and so only these will be examined in terms of their emotional challenges.

 

 

DI was first documented in medical journals in 1884 in the USA and 1793 in Britain. The first reported case of DI in Canada was in Toronto in 1950. It is estimated that DI results in 10,000 – 20,000 births every year in Canada and 100,000 in the USA (Thorn, 2006). Note that this number is more than double the birth rate of IVF babies annually.

 

Although DI has a long history of success (70-80% success rate over six months) it also has a long history of low social acceptance, stigmatization and secrecy, which have resulted in limited data 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 than national averages. Furthermore, longitudinal studies found no significant differences on adjustment parameters between DI-conceived children and naturally conceived children (Brewaeys, 1996).

 

Clinical experience cautions, however, that in order to ensure that couples adjust well to this life decision, spouses, especially the husbands, must 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 concurrent 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 depriving his partner of the experience of pregnancy, genetic continuity, etc., as well as to alleviate his own feelings of shame and failure. He is motivated to choose a fast solution in order to avoid the depths of his own pain. This is counter to basic psychological intuit, which contends that one needs to experience feelings of grief and loss in order to put them to rest. Pushing such feelings underground will only give them more power later on. Unresolved feelings could lead to marital disharmony and distant parent-child relations, wherein the DI-conceived child serves as a constant reminder to the father of that which he 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 counseling.’ Implications counseling is a form of psycho-educational counseling in which the objective is to help all parties involved to examine the short- and long-term ramifications of DI for themselves, their families and any children born as a result. In fact the Act Respecting Assisted Reproductive Technologies that was passed in Canada in 2004 has the mandate that all couples receiving ART treatments receive infertility counseling prior to beginning treatment.

 

The most hotly debated topic in the psychological literature on DI concerns whether it is best for the parents of a DI-conceived child to be open about the circumstances of the child’s birth, or whether the donor child should be raised to believe the conception was natural. This is referred to as the disclosure versus privacy/secrecy issue. There is no definitive answer on this, although the Ethics Committee of the American Society of Reproductive Medicine (ASRM) published a position paper in which, based on the overwhelming evidence, it recommended the practice of disclosure as being in the best interest of the donor-conceived child (ASRM, 2004). Today, all major sperm banks in Canada offer identity-release options to their users, meaning the potential parents can select a donor who has agreed in principle to reveal his identity to the child when the child reaches the age of adulthood should it request such information. Countries such as Sweden, the United Kingdom, Germany, Australia and New Zealand have all instituted policies making the use of anonymous donor sperm illegal. However, proponents of both sides of the disclosure/privacy debate make convincing arguments.

 

Recent research indicates that privacy/secrecy is still the norm, although the trend is clearly changing toward disclosure. Klock (1997) found that rates of disclosure were consistent across countries, with only a minority, 12-30%, disclosing. However, more recent studies in New Zealand, Sweden, Germany and Great Britain show these rates have increased to 40 – 70% (Thorn, 2006). 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 the situation from adoption, where the lack of a visible pregnancy makes openness inevitable. 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. Supporters argue further that nurture plays more of a role in shaping a child than nature and so the DNA of the child is of little import.

 

In contrast, the disclosure side argues that, fundamentally, an awareness of one’s genealogy is a basic human right and should not be denied for any reason. Those holding this view postulate that in the era of genome mapping, children born today will certainly learn that their genes are different from their parents’ one day, and thus should hear it first, and in a positive and open manner, from their parents. Divorce is commonplace today, and brings about a tumultuous time when, in anger, parents often reveal the origins of their child’s conception. More and more medical conditions are being found to have a genetic basis as well, and given these factors, the chances of DI offspring finding out the truth increases exponentially. Finally, there are clinical findings that suggest there are better times to talk to a DI child about his origins than others (for example, learning this truth during adolescence can be damaging), and that openness allows more control in terms of how and when to share this information.

 

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 suggested that in secrecy the couple relationship gets realigned, with the woman holding more power and the man becoming weaker and more passive, and that the children feel the undercurrents of these tensions and interpret and misattribute unspoken messages. The problem with a secret of this nature is that once it is in place the keepers are forced to carry it to their graves, which can be burdensome, or risk the consequences of revealing it under adverse conditions.

 

As a psychologist, my role in counseling infertile couples in their decision-making process is to ensure they are given accurate and reliable information on the pros and cons of disclosure issues, without pressure, judgment or coercion. Raising a DI family is generally a positive and rewarding experience, providing the parents have worked through their loss, have accepted the differences in their unique family situation and have made efforts to understand their partners’ feelings and the special concerns of their children.

 

 

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, who have a low sperm count, poor sperm motility or morphology. For instance, for natural conception, over 50 million sperm are necessary for fertilization to occur; for artificial insemination or intrauterine insemination (IUI), the number of sperm needed to effect fertilization is over 10 million, while for IVF the number required is only over 1 million sperm (Chan, 2007).

 

From an emotional perspective, there is an abundance of evidence to show that women react more intensely to IVF than men. Prior to IVF, women report more anxiety and depression, and after treatment failure, depressive symptoms are less common in men than women. Even more surprising, recent findings show that men and women are actually very similar in terms of how they respond to different stages of an IVF cycle. For example, both husbands and wives respond to oocyte retrieval and transfer with increased optimism and feelings of emotional closeness to each other. For both, the two week waiting period and pregnancy test are accompanied by feelings of acute distress and social isolation, although these feeling are more severe in women.

 

IVF combined with Intracytoplasmic Sperm Injection (ICSI) is a procedure that offers hope for men who have very poor sperm. It is the process by which one sperm is injected into the centre of one egg to instigate fertilization. If the male has no sperm at all in his ejaculate, doctors can extract sperm with a needle from a testicle under anaesthetic[NL1] , and if sperm is still not retrieved, the doctor can take a biopsy of testicular tissue, which sometimes has sperm attached. This procedure is called testicular sperm extraction (TESE). As in IVF, if fertilization is achieved, the embryos are transferred into the women’s uterus after three days. Many clinics now find that their clinical pregnancy rates for ICSI are higher than those achieved using conventional IVF methods.

 

Many fertility specialists predicted that ICSI would mark the end of donor sperm for heterosexual couples. For most infertile men, it is nothing short of a miracle. However, this has not come to pass, primarily because of the cost associated with ICSI, which can run anywhere from $2000 to $10,000 over and above the cost of IVF, versus approximately $500 - $1000 for DI. Moreover, ICSI does not mark the end of the psychological costs that follow a diagnosis of male infertility. Perhaps in their overzealousness to offer hope to their male patients, doctors may portray ICSI as a panacea to male infertility. But 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, and likewise, he continues to view himself as defective. He carries the responsibility for his partner’s not being able to conceive naturally. Therefore, even while availing themselves of such treatment options as ICSI, the infertile man and his partner are still obliged to resolve their feelings as an infertile couple.

 

In conclusion, there are clearly more choices available to couples with male infertility compared to years gone by. However, there exists no shortcut whereby one can bypass the emotional processes of loss and resolution. This emotional journey must be confronted and put in perspective in order to profit and benefit from the many medical therapies 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.

 

I conclude with a quote from Beyond the Best Interests of the Child:

 

For the child, the physical realities of his conception and birth are not the direct cause of his emotional attachment. This attachment results from day-to-day attention to his needs for physical care, nourishment, comfort, affection, and stimulation.

 

 

References:

 

American Society for Reproductive Medicine. Ethics Committee Report: Informing offspring of their conception by gamete donation. Fertil Steril, 2004; 81: 527-31.

 

Brewaeys, A. Review: Donor insemination, the impact on child and family development. J Psychosom Obster Gynecol 1996; 17: 1-17.

 

Chan, P. Methods of Improving Male Fertility, In Men and ART: The missing voice. Fortieth Annual Postgraduate Program, American Society for Reproductive Medicine, 2007.

 

Goldstein, J, A. Freud, & A. J. Soinit, Beyond the Best Interests of the Child. New York: Free Press, 1979.

 

 Klock, S. To tell or not to tell. The issue of privacy and disclosure. In S. Leiblum, (ed.) Infertility; Psychological issues and Counselling Strategies. New York: Wiley and Sons, 1997; 167-88.

 

Schover, L. R., S. Richards & R. L. Collins. Psychological aspects of donor insemination: Evaluation and follow-up of recipient couples. Fertil Steril, 1992; 57: 583-90.

 

Thorn, P. Recipient counseling for donor insemination. In Covington, S & Hammer Burns, L, (eds.) Infertility Counselling: A Comprehensive handbook for clinicians: 2^nd Edition. New York: Cambridge University Press, 2006; 305-18.