Infertility can bring about a great deal of stress. In the past, the focus was on whether psychological stress or psychopathology (abnormal behavior) prevented conception, especially for women. Now that the organic (biological) causes of infertility are better understood, the number of couples with unexplained infertility has decreased, which means there is less emphasis on mysterious psychological causes of infertility.

Stress can theoretically interfere with pregnancy directly, through hormonal effects, or indirectly, by hurting a couple's capacity to have effective sexual intercourse or to follow the complex instructions and sexual prescriptions in medical treatment. However, the major focus of mental health care for infertile couples is to help them cope with the emotional impact of infertility treatment.

The “normal” stress of infertility treatment

Why is psychological distress a normal state while someone is going through infertility treatment?

A diagnosis of infertility is always stressful. Some men or women might already know or suspect that they are infertile; for example, if they have had cancer chemotherapy or endometriosis. For others, the failure to conceive a child is very much a surprise. Many couples do not realize that in about 40 percent of infertile couples, a male factor contributes to the problem.

The following issues can emotionally influence couples who have been diagnosed as infertile and/or who might be considering infertility treatment:

  • Uncertainty about the success of fertility treatment
  • Grief associated with the infertility diagnosis
  • Feeling of losing control
  • Loss of self-esteem
  • Financial strain
  • Marital stress
  • Sexual pressure
  • Family pressure

Uncertainty about success of fertility treatment

One of the most difficult issues surrounding infertility is the uncertainty about whether treatment will be successful. Going through diagnostic tests and then trying to conceive for a number of ovulation cycles is an emotional roller coaster of hope and disappointment for many couples.

Spouses sometimes have trouble agreeing on which fertility option to try: adoption, gamete donation, high technology treatments, etc. After many different treatments have been tried unsuccessfully, partners also need to agree on when to give up. However, often there is just one more, possibly more expensive medical treatment that holds some promise of working.

Infertility: Source of grieving

Many people do not recognize that infertility is a source of grieving. The loss of a child who was wanted and imagined but never conceived is a legitimate loss, much like suffering a miscarriage or a stillborn baby. The issues include the following:

  • Feeling of losing control: A “typical” couple in an infertility program is in their early- to mid-30s, with two white collar or professional careers. Typically, when they've worked hard, they've always achieved their goals. With infertility, however, no matter how hard the couple might work at conceiving and how carefully they follow the doctor’s instructions, they have limited control over the outcome. It is this loss of control that is so difficult.
  • Loss of self-esteem: Many men and women feel a loss of self-esteem when they discover they have an infertility problem. They feel less valuable as a spouse and might even doubt whether they are a “real” man or woman. Of course, gender and sexuality do not depend on fertility, but feelings do not always respond to logical thinking. Many couples find it painful to be around children, especially at family gatherings. They also might have to deal with questions from parents about why there are no grandchildren.
  • Financial strain: Because infertility treatments may not be covered by insurance, many couples have to pay part or all of the costs, which often puts a financial strain on families. Coverage for mental health services is also often poor, making couples reluctant to seek additional help.
  • Marital stress: A diagnosis of infertility can affect a marriage relationship. Often the spouse who is infertile fears that the partner will leave and find someone who is able to have children. Sometimes, if only one partner is infertile, he or she will even try to persuade the spouse to get a divorce. Once infertility treatment has begun, one spouse might feel that the other is less motivated to succeed. This creates tremendous anger. Sometimes the stress on the relationship is so great that one spouse will have an affair to prove his or her self-worth or even to demonstrate fertility with someone else.
  • Sexual pressure: The demand to have intercourse at the proper times can provoke frustration when one partner has a business trip, is working late, or just cannot get in the mood for sex. Couples who go through cycles of sex-on-demand often find that lovemaking loses its spontaneity and playfulness. Sex becomes a chore to be performed at mid-cycle only. Sometimes the pressure to perform is so great that a man has trouble with erection or is unable to ejaculate.

Most couples dread the postcoital test, in which intercourse must be scheduled just before a visit to the infertility clinic. Even providing a semen sample through masturbation can be an unpleasant and anxiety-provoking experience.

For some couples, erection or ejaculation problems are actually causes of infertility and need to be treated with medical or psychological therapies. Women might have trouble getting aroused, so vaginal dryness or muscle tension make intercourse painful. Unfortunately, gel lubricants that could make sex more comfortable interfere with the movement of the sperm through the vagina. It is common to have distracting thoughts about the infertility during sex, further reducing the pleasure of lovemaking.

There is no scientific evidence that having an orgasm during intercourse will increase a woman's chance of conceiving. Some infertility specialists might even tell couples to use special sexual techniques that are not scientifically proven to enhance fertility, such as telling men to try to ejaculate on a very deep thrust, or telling women to hold their legs up for half an hour after intercourse so that semen will remain deep in the vagina.

  • Family pressure: Sometimes one or both sides of the family pressures the couple to have children. Spouses might also disagree on telling anyone about the infertility problem, or they might disagree on how much to confide in parents or siblings. This can be an especially difficult issue if the couple chooses to use a sperm or egg donor to conceive.

Some of the common concerns include: Should anyone outside the couple know? Should the child be told about the gamete donation? There is no right or wrong answer, but these issues can add stress.