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Procedia - Social and Behavioral Sciences 187 (2015) 359 – 363

PSIWORLD 2014

Psychological aspects of male infertility. An overview1

Joja O. D. a, b, 2 , Dinu D.a, Paun D.a
a
C. I. Parhon Institute of Endocrinology, 34-36 Aviatorilor Blvd., Bucharest, 011863, Romania
b
Titu Maiorescu University, Faculty of Psychology, 187 Calea VăFăreúti., Bucharest, 040051, Romania

Abstract

Current literature indicates that in high-income countries some 15% of heterosexual couples experience difficulties conceiving, in
up to half of these cases infertility is attributable to the male partner. Research findings - mostly focused upon women - suggest
that women develop more distress when facing infertility, but that may be a construct influenced by gender stereotypes. Men are
also psychologically affected by infertility, displaying impaired self-esteem and inadequacy in relation to their societal role,
eventually feeling responsible for denying their wives a child. Further developments will focus upon effective psychosocial
interventions, including refined counseling approaches for couples undergoing ART treatments.
© 2015
© 2015TheTheAuthors.
Authors.Published
Publishedby by Elsevier
Elsevier Ltd.Ltd.
This is an open access article under the CC BY-NC-ND license
Peer-review under responsibility of the Scientific Committee of PSIWORLD 2014.
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the Scientific Committee of PSIWORLD 2014.
Keywords: male infertility; male distress; counseling for infertility

1. Introduction

In a recent review study, Fisher and Hammarberg (2012) indicated that in high-income countries approximately
15% of heterosexual couples experience difficulties conceiving, and in up to half of these couples, infertility is
attributable to the male partner. In the low and lower-middle income countries, the prevalence of infertility in
couples is thought to be higher because of undetected and untreated reproductive tract infections (Inhorn, 2009).
Psychological aspects of infertility in men have been a matter of significantly less research than that in women.
Most of the existing studies investigated women’s reactions to male infertility, while few studies examined couples
facing male’s infertility and the psychological experiences of men (Fisher & Hammarberg, 2012). Distress

1
A first part of this study, containing the medical approach is in press: Paun D., Dinu D. and Joja O. Male Infertility – a medical
approach, Revista Romana de Bioetica
2
Oltea-Daniela Joja. Tel.: +4-021-317-0607; fax: +4-021-317-0607.
E-mail address: oltea_joja@yahoo.com

1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of the Scientific Committee of PSIWORLD 2014.
doi:10.1016/j.sbspro.2015.03.067
360 O.D. Joja et al. / Procedia - Social and Behavioral Sciences 187 (2015) 359 – 363

assessments on infertile men are compared to those of infertile women, and only few studies considered comparisons
to men who are not impaired by infertility (Kedem, Milkulincer, Nathanson & Bartoov, 1990; Greil, 1997). As
though, approaches are mainly reinforcing the belief that women are prominently reacting to the distress of infertility
and to the impact of assisted reproductive technologies (ART) treatments, which address women’s body. Studies of
infertile couples were mostly conducted one year after considering pregnancy, or when starting the (ARTs)
treatments or during the treatments. Most of the studies focused upon the stress encountered by women or by couples
during treatment, exploring the distress induced by infertility, its lasting effects and how different coping
mechanisms may influence the psychological wellbeing and eventually the treatment outcomes (Cousineau &
Domar, 2007).
Some follow-up assessments (Fisher & Hammarberg, 2012) tackle the question of how couples are coping with
the distress when they do not benefit from the treatments, they are staying without children or they are eventually
considering adoption. Follow-up studies on men are mainly based upon interviews and such qualitative assessments
are difficult to operationalize for comparing data to women.
Considering this research background, the present study will be detailing data concerning the psychological
impact of infertility in men, taking into account the implications of different research designs. Finally, we will
conclude regarding more promising areas of research that have been suggested by different studies and upon some
psychosocial aspects concerning infertility in Romania.

2. State of the Art

Men can be affected by infertility in several ways, as Fisher and Hammarberg (2012) are indicating: through
receiving a diagnosis of their own infertility, through being the partner of a woman who is infertile or through being
part of a couple with unexplained infertility. Therefore, the psychological impact of infertility is being differentiated
in research studies according to these criteria.
One important factor which might considerably moderate the impact of infertility is the desire of parenthood,
perceived differently by women and men. Conforming to the gender stereotype in traditionally oriented societies,
women are presumed to desire children. Accordingly they appear to experience more distress if that desire is not
being accomplished. At the same time infertility in men tends to have different effects, as they will be rather
“disappointed but not devastated by the inability to have a child” (Greil, 1997). Also, according to the gender
stereotype, through supporting their wives men appear to be suppressing their emotions (Berg & Wilson, 1991), a
tendency which might also result in the under-reporting of actual levels of infertility-related distress among men
(Greil, 1997). Beyond gender-specific expectations there are other moderating factors of the desire of parenthood,
such as age, marital status, parity, culture, religious beliefs and the degree of reproductive autonomy and access to
contraception in a particular setting, which will also influence the psychological impact of infertility (Hadley &
Hanley, 2011).
All over, the question if men are less prone to the infertility distress is a topic which might progressively be
shifting in the era of extended ART treatments. Hence, recent literature is tackling how couples are reacting in the
face of prolonged ART treatments and how they might cope with that stress. Possibly, the next step will be enlarging
the border of ethical approaches to aspects which are now emphasized by media: conventional in vitro fertilization
(IVF) is not effective in cases of severe male infertility, and therefore couples with this diagnosis will have to
consider adoption or the use of donor sperm, which might be “particularly difficult to contemplate because of the
asymmetrical genetic relationship they would have to their children” (Merill, 2011). One other important
psychosocial case is that of the intracytoplasmic sperm injection (ICSI) which may help couples with men factor
infertility to be their children’s natural parents but one of the possible consequences might be the genetically
transmitted male infertility (Silber & Repping, 2002).
Most of the available research data indicate women’s greater overt distress in response to infertility,
independently of the cause of infertility (Edelman & Connoly, 2000). As Edelman and Connoly (2000) put it, data
indicating more distress reactions in women may reflect differences in the way men and women have been
socialized, how they learned to cope with and to express negative affect. Upon investigating 110 infertile couples,
Guerra, Llobera, Veiga and Barri (1998) concluded that psychiatric morbidity was significantly associated with the
number of treatment cycles and with female gender in the whole study group (both with and without referral to the
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service of psychosomatic medicine), as well as with the type and length of infertility in the non-referred group. Few
studies concluded that men are not less impaired by their infertility than women, but some authors refer to the myth
according to which the fact that “women react more adversely to infertility than their partners is overly influenced by
outdated gender stereotyping and is unsupported by research data” (Edelman & Connolly, 2000).
The results of more recent studies with sophisticated methodological designs showed that the emotional impact of
infertility may be quite balanced: men suffer as well, and this has to be addressed in infertility counseling too
(Wischman & Thorn, 2013). The way we are expressing our feelings is basically linked to a learning history and
therefore culturally determined. In many cultures, male infertility remains a stigmatized condition and is associated
with a lack of masculinity. For men, this may result in secrecy surrounding diagnosis, sometimes to the point where
the female partner takes the blame for the couple’s inability to conceive (Greil, 1997).
The stress background of male infertility usually refers to life style cues as smoking tobacco or marijuana,
drinking habits, weight and eating habits, and a complete lack of exercise, because of the lowering effects of
testosterone blood levels and steroids intake. Lifestyle approaches also include vitamins intake and avoiding
exposure to toxins. The stress research was during the ’90s and still is now one of the core topics of male infertility
research. Unfertile couples may easily cope with common day to day stressors, but coping with infertility issues,
including the ART treatments, may be considerably more difficult (Beutel et al., 1999).
A series of studies showed that infertile men display lower rates of self-esteem, higher anxiety and more somatic
symptoms than fertile men (Glover, Gannon, Sherk & Abel, 1999; Kedem, Milkulincer, Nathanson & Bartoov,
1990). Such distress may persist 18 months after treatment, regardless of whether a live birth was achieved (Glover,
Gannon, Sherk & Abel, 1999). Furthermore, some men experience transient episodes of impotence and sexual
performance anxiety when confronted with infertility (Saleh, Ranga, Raina, Nelson, & Agarwal, 2003). It appears
that emotional stress and marital difficulties are increased in couples where the infertility lies with the man (Barratt
& Cooke, 1987; Beutel et al., 1999). In-depth interviews suggested that when faced with infertility, men may
experience considerable distress linked to low self-esteem and social stigma, and that it is likely to be increased in
men with male-factor infertility than in men with unexplained or female-factor infertility (Webb & Daniluk, 1999;
Throsby & Gill, 2004).
Beutel et al. (1999) investigated couples undergoing IVF or ICSI treatments (ejaculated, epididymal or testicular
spermatozoa), identifying sex differences and risk factors for depression. Authors analyzed the responses of a one-
year cohort of couples who retrospectively sent questionnaires, with successful couples being more likely to
participate in the study. As yet discussed in literature, retrospective data concerning the distress induced by infertility
are likely to be biased by the responders’ inherent selection and are therefore to be considered with caution. In this
study results indicated, as expected, that treatment-related distress was generally higher for women than for men.
Men reported marginally elevated depression scores compared to their controls, and the treatment by ICSI carried
some additional burdens for men: they reported a greater subjective responsibility for the infertility, the impact of
childlessness on daily life, treatment-related stress and time demands. The study also revealed for couples some
factors suggesting more proneness to depression, like an unsuccessful treatment outcome, repeated treatment cycles,
a low socioeconomic status, foreign nationality and for women a lack of partner support. These factors might be
particularly considered for guiding psychological counseling in infertile couples.
Cousineau and Domar (2007) reviewed research and indicated that men are psychologically affected by
infertility, experiencing impaired self-esteem and inadequacy in relation to their societal role, eventually feeling
responsible for denying their wives a child (Wright et al., 1991; Carmeli & Birbaum-Carmeli, 1994). Data on North
American couples indicated that men tend to use fewer coping strategies overall (Cousineau and Domar, 2007). The
one used specifically was coping by increasing their involvement in work and other activities. Also, men appeared to
be more optimistic and problem-solving-oriented, rather than using social support (Jordan & Revenson, 1999), and
they negotiated the transition to a childless lifestyle more easily than their wives did, who found it more difficult to
resolve the dilemma of infertility (Domar & Siebel, 1997).
Concluding we will have to admit that women appear only to develop more distress when facing infertility, and
that this is a construct overly influenced by an outdated gender stereotyping and unsupported by research data.
Future research upon the psychological impact of male infertility will increasingly consider factors beyond genetics,
physiology and lifestyle, particularly exploring couples’ reactions and their coping in the context of the treatments.
362 O.D. Joja et al. / Procedia - Social and Behavioral Sciences 187 (2015) 359 – 363

As emphasized by Cousineau and Domar (2007) further research is needed to understand the association between
distress and fertility outcome, as well as effective psychosocial interventions.

3. Some concluding remarks concerning Romania’s issues on in-fertility

Data concerning infertility among the Romanian population are inconsistent, while extrapolated statistics are not
reliable (Rightdiagnosis.com). Romania has been an EU member since 2007, and the city population is quickly
evolving into one with the characteristics of the Western societies. Paternity is a core concern according to the
traditional values cherished in Romania, something men are very proud of. Infertility is traditionally considered an
unhappy destiny, a fate with God’s will, eventually taken with resignation. The new ART, which were recently
introduced in Romanian hospitals, brought much hope to children-desiring couples, implicitly changing people’s
perception.
While many couples in the Western society consider and often decide in favor of adoption, even when having
one’s own biological child(ren), in Romania it is rather uncommon and generally biased. Despite the fact that among
the EU states Romania is the country with the highest rate of abandoned children, Romanian couples are not among
those with high rates of adoption. Adoption issues are marked by a certain mistrust, while “generativity” appears to
be less valued. Generativity was defined by Erik Erikson (1950) as a psychosocial developmental stage, when adults
essentially care for and are contributing to the next generation. Such investments may be endorsed upon the
community and not only in one’s one family. It is a stance of creativity and productivity, as Erikson puts it, and a
social-cognitive opening up. Such a stance is difficult to be integrated into a very traditional society marked by the
Romanian Orthodox Church. With the help of the church, the society provided a social construct which links
infertility merely to the absence of completing one’s human destiny. This has led to an individual lack of
responsibility towards abandonment and to the society’s very limited concern with its abandoned children. This lack
of concern for the community is reflected in the fact that abandoned children and adoption issues are no topic for
politicians or media. Another highly relevant socio-cultural aspect of this issue is that the patriarchal character of the
Romanian society is still strongly supported by the Romanian Orthodox Church. Accordingly, the media and the
society solely blame mothers for abandoning their children, usually ignoring fathers’ responsibility.
Chances are that the problem of abandoned children will be regarded with more concern if “fathering” is asserted
more responsibility, a trend that should be supported by the media, the politicians and the Romanian Orthodox
Church. In addition, a shift towards increased responsibility in fathers could lead to lower rates of abandonment.

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