Human Reproduction Vol.20, No.10 pp. 2858–2865, 2005 doi:10.

1093/humrep/dei127
Advance Access publication June 24, 2005.

A new quality-of-life measure for men experiencing

involuntary childlessness

S.Schanz1,6, I.T.Baeckert-Sifeddine5, C.Braeunlich1, S.E.Collins2, A.Batra2, S.Gebert3,

M.Hautzinger4 and G.Fierlbeck1
1
Departments of Dermatology, 2Psychiatry and Psychotherapy,3Gynaecology, Eberhard-Karls-University, D-72076 Tübingen, Germany,
4
Department of Clinical and Physiological Psychology, Eberhard-Karls-University, D-72072 Tübingen, Germany, and 5Fertility Center

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Aalen D-73430 Aalen, Germany
6
To whom correspondence should be addressed. E-mail: stefan.schanz@med.uni-tuebingen.de

BACKGROUND: Infertility may considerably reduce quality-of-life. Many of the existing generic quality-of-life
measures, which often focus on physical impairments, do not represent the specific complaints of infertile patients. In
this article, we report on the development and validation of the TLMK (Tübinger Lebensqualitätsfragebogen für
Männer mit Kinderwunsch), an instrument for measuring quality-of-life in male patients with involuntary childlessness.
METHODS: The first version of the questionnaire, which consisted of 91 items, was administered to 275 men who
attended andrology and gynaecology clinics for fertility evaluations. After the questionnaires were scored, item analysis
and reduction, principal component analysis and internal consistency analyses were conducted. RESULTS: The final
version of the TLMK consists of 35 items in four scales and provides an internally consistent quality-of-life profile for men
experiencing involuntary childlessness. Convergent and discriminant validity was supported through the correlation of the
TLMK scales with established questionnaires on life satisfaction (FLZ) and partnership (PFB). CONCLUSION: The
TLMK provides information about the quality-of-life in men experiencing involuntary childlessness and was found to
be easy to administer and acceptable to patients. It may be used to assess patients’ baseline and ongoing quality-of-
life during fertility treatment and as an outcome variable in the evaluation of integrated psychological counselling.

Key words: male infertility/quality-of-life/questionnaire development

Introduction Specifically, men appear to experience less psychological dis-

Infertility is a major life crisis for many couples (Leiblum and
Greenfield, 1997). It can cause emotional stress and a range of
psychological reactions including depression and anxiety
(Wischmann et al., 2001; Fassino et al., 2002; Chen et al.,
2004), as well as jealousy, social isolation and, particularly in
men, feelings of sexual inadequacy and sexual dysfunction
(Irvine, 1996). However, couples may be affected by infertility
in many different ways, which may depend on age, gender,
stage of fertility treatment, or medical diagnosis.
General questionnaires are often used to assess depression,
stress or anxiety in infertile patients (Cook, 1993; Dhillon
et al., 2000; Wischmann et al., 2001). While these instruments
offer valid and reliable measurement of patients’ general psy-
chological state, these questionnaires may not represent all the
unique problems of patients experiencing involuntary child-
lessness. It has also been pointed out that very few studies have
included male partners in the assessment of problems encoun-
tered by infertile couples (Daniluk, 1997). Studies that have
included both genders have indicated that the psychological
response to infertility is different for men and women (Wright
et al., 1991; Beutel et al., 1999; Hjelmstedt et al., 1999).
tress than women. Other studies, however, have demonstrated
that male-factor infertility is more stressful for the couple than
female-factor infertility (Mikulincer et al., 1998) and that the
diagnosis of male-factor infertility may markedly impair men’s
well-being (Kedem et al., 1990; Nachtigall et al., 1992). It has
also been suggested that psychological distress may further
decline semen quality (Clarke et al., 1999), although this find-
ing has not been supported by other investigations (Schilling
et al., 1999; Wischmann, 2003; Hjollund et al., 2004). Consid-
ering the mixed findings regarding men’s psychological
response to infertility, further research must be conducted with
instruments that are relevant, valid and reliable.
Quality-of-life assessment has been established in many
medical disciplines as an important evaluation criterion.
Although it is difficult to define quality-of-life, there is a sci-
entific consensus that its assessment should include aspects of
health status, psychological well-being, and physical and social
functioning (Aaronson, 1988; Price, 1996). Based on these
considerations, many generic instruments for the measurement
of health-related quality-of-life have been developed in the last
decade (Jenkinson et al., 1993; Power et al., 1999). These

2858 © The Author 2005. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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instruments, however, were predominantly designed for patients
with diseases that result in impairment of physical functioning
and reduced daily activity level, and thus do not address the
specific problems encountered by patients experiencing invol-
untary childlessness.
Several questionnaires have been developed to assess differ-
ent psychological issues surrounding infertility. Although these
measures may provide physicians and researchers with helpful
information concerning psychological adjustment (Glover
et al., 1999), coping (Lee et al., 2000) and stress (Newton
et al., 1999), no current questionnaires measure quality-of-life
aspects from the perspective of male patients experiencing
infertility. In discussing their own measure, the Fertility Prob-
lem Inventory (FPI), Newton et al. (1999) indicate that poten-
tial gender differences in coping with infertility and a potential
lack of sensitivity to male concerns may complicate the assess-
ment of infertility-related stress. The FPI, however, does not
take into account gender-specific differences.
Further, the ‘fertility adjustment scale’ (FAS) (Glover et al.,
1999), which assesses psychological adjustment to infertility,
does not assess general quality-of-life aspects but rather focuses
on ‘desire to have a child.’ Moreover, this questionnaire does
not include gender-specific items. The interpretability of this
instrument is also limited by the fact that the published article
does not include a principal components analysis to preliminar-
ily assess scale validity. The Coping Scale for Infertile Couples
was developed to assess coping with infertility within the con-
text of a couple’s relationship (Lee et al., 2000). This research
team also acknowledges that the responses of husbands and
wives on various scales of their instrument reflect a clear gender
difference in coping with infertility. These findings suggest that
a gender-specific measure may be important to fully capture the
impact of infertility on quality-of-life.
Questionnaires in the German literature, such as the Desire
to Have a Child Questionnaire (FKW; Hölzle and Wirtz, 2001)
and the Questionnaire on Motives for Wanting Children
(LKM; Brähler et al., 2001), were developed to assess reasons
for wanting a child and expectations of parenthood. The Infer-
tility Distress Scale (Pook and Krause, 2002) was designed and
evaluated to measure infertility related distress. These ques-
tionnaires, however, do not focus specifically on the effects of
infertility on patients’ quality-of-life. Thus, although other
measures addressing the topic of infertility and related psycho-
logical factors have been made available in the literature, phy-
sicians and researchers may benefit from a questionnaire that
assesses a range of quality-of-life aspects and takes into
account a gender-specific perspective on infertility. The goal of
the current study was therefore to design and assess a quality-
of-life questionnaire for men facing infertility.
Materials and methods
TLMK development
The questionnaire was developed in three steps. First, 10 patients par-
ticipated in semi-structured interviews conducted by two andrologists
at the andrology clinic in Tübingen, Germany. Patients were asked
which infertility-related problems affected their daily life. Based on
Quality-of-life measure for childness men
the information collected in these interviews and a systematic review
of the scientific literature, eight infertility and quality-of-life domains
were defined: psychological well-being; social contacts; physical
complaints; partner relationship; sexual relationship; desire for a
child; gender identity; and treatment satisfaction. In a second step, four
clinical experts (two andrologists and two gynaecologists) selected
and, where necessary, translated 120 items from general quality-of-
life instruments, including the Munich Quality-of-life Dimension List
(MLDL; Heinisch et al., 1991) and the semi-structured interviews,
which dealt with the previously defined domains found in the infertil-
ity literature review (Connolly et al., 1992; Cook, 1993; Muller et al.,
1999; Schilling et al., 2000). Following a review for item redundancy,
a pool of 91 items was submitted. Finally, the four clinical experts
worked independently to subjectively categorize the selected items
into the eight rationally derived scales. Differences in the ratings were
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discussed and agreement reached about the categorization.
The resulting Tübingen Quality-of-life Questionnaire for Men with
Involuntary Childlessness (Tübinger Lebensqualitätsfragebogen für
Männer mit Kinderwunsch, TLMK) was designed to assess quality-of-
life over a four-week time frame. Responses were made on a 1 to 5 Lik-
ert scale with the score of ‘1’ representing a low and ‘5’ a high level of
agreement with the item; higher overall scores indicate a lower quality-
of-life. To minimize response bias, some items were reverse coded
(marked with an * in Table II). To maximize the acceptability of the
questionnaire, special attention was aimed at the appropriateness and
comprehensiveness of item wording. Two additional, open-ended items
at the end of the questionnaire assessed participants’ opinions about the
relevance and acceptability of the TLMK. The question ‘Were any
important aspects of involuntary childlessness not covered by this ques-
tionnaire?’ was posed to establish whether major areas affected by
involuntary childlessness were assessed by the instrument. The question
‘Did you find any questions to be uncomfortable?’ obtained information
about patient acceptability of the questionnaire.
Participants
The first version of the TLMK was tested on male patients who
attended the andrology and gynaecology clinics at the University
of Tübingen Medical Centre. Of the eligible patients (n = 400),
275 participants (68.75%) gave informed consent and com-
pleted the study. The mean age was 35.1 years. On average,
participants had been trying to conceive for 3.9 years (see
Table I for sociodemographic characteristics). A few patients
Table I. Sociodemographic characteristics of the participants
Characteristics n (%) Mean Range SD 95%
confidence
interval
Age (years) 35.1 25–72 5.5 34.4–35.7
Time spent trying to 3.9 0.5–20 3.1 3.5–4.3
conceive (years)
Highest educational level .
No graduation 6 (2)
Secondary school 154 (56)
University-entrance 115 (42)
diploma
Total 275
Marital status
Married 252 (92)
Unmarried 23 (8)
Total 275
2859
S.Schanz et al.

(n = 39; 14%) had experienced assisted reproduction tech- Results

niques previously but, for most participants, this was the begin- Item analysis and item discrimination
ning of the infertility diagnostic phase. Participants fulfilled
The response rate for each item did not fall below 97.5%. In
the following criteria: sufficient knowledge of the German lan-
the assessment of item discrimination, part/whole correlations
guage; and presence of involuntary childlessness for at least
were conducted for the single items to the total scale into
half a year. Because we wanted to include patients in the prim-
which the item was categorized. For this criterion, a coefficient
ary diagnostic phase, we accepted participants experiencing at
of r = 0.40 is generally considered sufficient (Nie et al., 1970;
least 6 months of involuntary childlessness (or trying to con-
Bortz and Döring, 2002). Items with r < 0.40 were eliminated;
ceive) instead of adhering to the World Health Organization
this reduced the number of items from 91 to 53 (see Table II).
(WHO) definition of a one-year duration. Only six patients
(2%), however, had been trying to conceive for less than one
Measure acceptability
year (four patients for 9 months and two patients for 6 months).
The exclusion criterion in this study was the presence of a The two open-ended questions at the end of the instrument
concerning the relevance and acceptability of the questionnaire

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severe psychiatric disorder, which was assessed by asking
patients whether they had a current or lifetime diagnosis of a were answered by 136 patients (49.5%). In response to these
severe psychiatric disorder. As no participants met this exclu- questions, only six participants criticised aspects of the ques-
sion criterion, all participants who gave informed consent were tionnaire or made suggestions for modifications.
invited to participate and were included in these analyses.
Factor structure
Additional measures Exploratory factor analysis was employed using the principal
component analysis (PCA) method with a varimax rotation and
A sociodemographic questionnaire was designed for the cur-
extraction of factors with Eigenvalues >1. All items evincing
rent study to assess participants’ age, duration of involuntary
good discrimination value (see section headed Item analysis
childlessness, educational level and marital status.
and item discrimination) were included in the factor analysis.
The questionnaire of partnership (PFB; Hahlweg et al., 1982)
Analyses indicated that 12 factors were extracted and
assesses general quality of partnership. It consists of 30, four-
accounted for 65% of the variance. Consistent factor loadings
point items, which are categorized into the three scales: conflict
were demonstrated (Table III) for the preselected scales: desire
behaviour; tenderness; and communication. On the scale conflict
for a child (Eigenvalue 15.03); sexual relationship (Eigenvalue
behaviour, higher scores indicate less satisfaction with the part-
3.90); gender identity (Eigenvalue 3.12); physical complaints
nership, while on the scales tenderness and togetherness/com-
(Eigenvalue 1.29); treatment satisfaction (Eigenvalue 1.10);
munication, higher scores indicate more satisfaction with the
and social contacts (Eigenvalue 1.03). Apart from the partner
partnership. Previous analyses have evinced adequate scale
relationship items, which loaded on three different factors
reliability, with Cronbαch’s ranging from 0.88 to 0.93 and six-
(Eigenvalues 1.90, 1.73 and 1.35) and the items 6, 11 and 12 of
month test–retest reliability ranging from r = 0.68 to 0.83
the psychological well-being scale (Eigenvalue 1.81), items
(Hahlweg et al., 1982).
loaded consistently on the factors into which they were origi-
The questionnaire of life satisfaction (FLZ; Fahrenberg
nally categorized.
et al., 2000) assesses satisfaction with a variety of aspects of
An item re-categorization was performed based on the factor
daily life, particularly in connexion with the subjective experi-
loadings. It is generally agreed that factor loadings >0.32 are
ence of illness. Seventy, seven-point items are grouped into 10
sufficient to establish factor membership (Tabachnick and
scales: health; professional life; financial situation; leisure and
Fidell, 2001) and items loading below this point were elimi-
hobbies; marriage and partnership; self-esteem; sexuality;
nated (see Table III for factor loadings). The PCA indicated
social life; relationship to own children; and living situation.
that items 6, 11 and 12 had the highest factor loadings on the
Higher scores indicate more satisfaction with the respective
first factor and were therefore excluded from the psychological
areas. Cronbαch’s ranges from 0.82 to 0.94 for the individual
well-being scale and included in the desire for a child scale.
scales (Fahrenberg et al., 2000). For this study, the scales rela-
Items 48 and 49 were excluded because they did not show rel-
tionship to own children and living situation were excluded
evant factor loadings for the scales into which they had been
because they did not seem appropriate for our patient group.
categorized and the items’ face validity seemed inappropriate
The instruments PFB and FLZ were used to establish conver-
for the factors they loaded on. Physical complaints, social con-
gent validity for the current questionnaire.
tacts and treatment satisfaction scales consisted of only two
items each and were therefore eliminated. The items of the
Procedure partner relationship scale loaded on three different factors. This
Physicians in the andrology and gynaecology clinics recruited scale was therefore excluded due to its empirical inconsistency.
interested participants during their first fertility appointment. The final version of the questionnaire consists of 35 items in
After obtaining informed consent, physicians gave participants four scales, all showing acceptable factor loadings (lowest
the questionnaire packet, instructed them to respond to the value 0.36).
questionnaires openly and independently, and to mail them Most intercorrelations between the final TLMK scales were
back anonymously or put them in a box in the clinic especially moderate in size (Table IV). A high intercorrelation was found
prepared for this procedure. between the scales desire for a child and gender identity (r = 0.69).
2860
 Quality-of-life measure for childness men

Table II. Item analysis and internal consistency of the final questionnaire

Dimension Cronbαch’s Item number Abbreviated content of items Mean score Item-total scale
correlation

Desire for a child 0.92 1 Not being able to father a child is distressing to me. 2.37 0.79
2 I can’t achieve happiness without a child. 1.25 0.62
3 I feel hurt when others make remarks about our childlessness. 2.27 0.69
4 I feel upset when I see a perambulator 1.61 0.66
5 I consider infertility a personal shortcoming. 1.45 0.65
6 I feel down. 1.83 0.73
7* I am coping well with our difficulties conceiving. 1.96 0.65
8 My life revolves around trying to have children. 1.76 0.63
9 Planning for our future has been hindered by our difficulties 1.96 0.64
conceiving.
10 I avoid contact with people who have children. 1.64 0.63
11 The psychological stress interferes with work, leisure activities. 1.51 0.64

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12 I feel like giving up. 1.45 0.60
13 Certain aspects of my relationship with my partner have become less 1.21 0.52
important since we have had problems conceiving.
Sexual relationship 0.83 14 My partner and I have less sex when she is not ovulating. 1.93 0.67
15 The stress of trying to conceive decreases feelings of tenderness for 1.52 0.74
my partner.
16 The desire to have a child decreases my sexual desire for my partner. 1.54 0.70
17 We have less sex when my partner is ovulating. 1.49 0.48
18 Sex is a chore. 1.63 0.54
19 I feel like I’m under pressure when my partner is ovulating. 1.82 0.51
20 I feel less satisfied after sex than I used to. 1.19 0.43
Gender identity 0.89 21 I feel less masculine than other men I know. 1.50 0.72
22 I am afraid of sexual failure with my partner. 1.44 0.65
23 I feel less successful as a man. 1.47 0.71
24 I feel like a failure because of our problems conceiving. 1.64 0.74
25 I feel like I am not meeting expectations as a man. 1.70 0.74
26 I feel guilty for having let my partner down 1.66 0.68
27 I have feelings of low self-worth around women. 1.26 0.59
28 My ability to achieve a sufficient erection has decreased. 1.25 0.50
Psychological well-being 0.84 29* I can better my life situation. 2.29 0.61
30* I can enjoy the good things in life. 2.15 0.68
31* I have a good sense of humour about life. 2.14 0.68
32 I have lost interest in things I used to enjoy. 1.30 0.53
33* I am able to relax. 2.77 0.56
34* I am satisfied with my life. 2.41 0.59
35 I have difficulties with planning and problem-solving. 1.36 0.56

The items are arranged in the scales revealed from factor analysis. Items 36–53 were excluded after factor analysis. The original German items were translated into
English by a native English speaker and were back translated by a native German speaker to confirm translation accuracy.
*Items that are reverse coded.

However, the items of both scales clearly loaded on different
factors in the PCA with the exception of item 24, which loaded
on factor 1 (desire for a child; loading = 0.56) and factor 3
(gender identity; loading = 0.60), see Table III.
Reliability
Internal consistency is an important criterion of reliability and
is reflected in the coefficient Cronbαch’s (Cronbαch, 1951).
By convention, values for Cronbαch’s >0.70 indicate accepta-
ble internal consistency of a scale (Bortz and Döring, 2002).
As shown in Table II, the four scales of the TLMK showed
good internal consistency, with Cronbach’s coefficients rang-
ing from 0.83 (sexual relationship) to 0.92 (desire for a child).
Convergent and discriminant validity
In order to establish convergent and discriminant validity for
the TLMK, correlations between selected scales of the TLMK
and the FLZ and PFB were considered (see Table IV for all
correlations). Given the large number of tests included, a
Bonferroni correction was applied to correct for potential α
inflation. The corrected significance level for P = 0.05 was P =
0.001. It should be noted that higher scores on the FLZ scales
and the PFB tenderness and togetherness/communication
scales indicate positive statements and that higher scores on the
TLMK scales and the PFB scale conflict behaviour indicate
negative statements.
Convergent validity
People with higher scores on the FLZ scale sexuality report
more positive views of their physical attractiveness and are
more satisfied with their sexual contacts and sexual relation-
ship (Fahrenberg et al., 2000). We therefore hypothesized a
negative correlation with the TLMK scale sexual relationship,
which our analyses confirmed. The FLZ scalesexuality was
also negatively correlated with the TLMK scale gender iden-
tity, which measures aspects of sexual functioning and gender
role (see Table IV for correlations). High scores on the FLZ
scale self-esteem indicate satisfaction with outward appear-
ance, skills, vitality and self-view, whereas low scores indicate
physical impairment and depressed mood (Fahrenberg et al.,
2000). Thus, the negative correlation of this scale with the
2861
S.Schanz et al.

Table III. Matrix of the PCA using varimax rotation with Kaiser normalization

Components and rationally derived scales

1 2 3 4 5 6 7 8 9 10 11 12
Desire Sexual Gender Psychological Partner Partner Partner Physical Treatment Social
for a child relationship identity well-being relationship relationship relationship complaints satisfaction contacts

1 0.820
2 0.739
3 0.702
4 0.698
5 0.685
6 0.673
7 0.628 0.354
8 0.623
9 0.616

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10 0.570
11 0.549
12 0.499
13 0.413 0.377
14 0.793
15 0.741
16 0.735
17 0.674 0.376
18 0.495 0.338 0.340
19 0.369 0.393
20 0.364 0.322
21 0.330 0.728
22 0.364 0.627
23 0.410 0.605
24 0.560 0.604
25 0.469 0.603
26 0.427 0.584
27 0.340 0.583
28 0.475 0.529
29 0.730
30 0.713
31 0.654
32 0.632
33 0.463 0.376
34 0.452 0.366
35 0.413 0.451
36 0.353 0.707
37 0.702
38 0.653
39 0.803
40 0.637
41 0.437 0.535
42 0.722
43 0.605
44 0.377 0.330 0.422
45 0.377 0.386 0.377
46 0.767
47 0.720
48 0.361 0.686
49 0.356 0.607
50 0.830
51 0.818
52 0.787
53 0.376 0.420

Factor loadings > 0.32 are included.

TLMK scale psychological well-being met our expectations
(see Table IV). The PFB scale togetherness/communication
assesses a couple’s common activities and focuses on solidar-
ity and communication skills (Hahlweg et al., 1982). Because
this scale reflects the common goal of conceiving a child, the
negative correlation with the TLMK scale desire for a child
met our expectations. The TLMK scales desire for a child and
gender identity showed moderate correlations with the PFB
scale tenderness, which assesses verbal and physical acts of
tenderness between partners. The conflict behaviour scale of
the PFB measures a behavioural style that works against con-
flict resolution. It was hypothesized that this scale would be
moderately positively correlated with the sexual relationship
scale of the TLMK, and this moderate correlation was observed

2862
 Quality-of-life measure for childness men

The TLMK provides a potentially helpful addition to the

Table IV. Correlation of TLMK, FLZ and PFB scales
previously published questionnaires in the literature (Bernstein
TLMK scales et al., 1985; Glover et al., 1999; Newton et al., 1999). The
TLMK assesses quality-of-life in connection with male infer-
Desire for Sexual Gender Psychological
a child relationship identity well-being tility from a male perspective. The exclusively male sample
and gender-specific items involved in this study address the
TLMK scales: problem highlighted by Lee et al. (2000) and Newton et al.
Sexual relationship 0.43*
Gender identity 0.69* 0.51* (1999), i.e. that potential gender differences in coping with
Psychological 0.60* 0.36* 0.50* infertility and a lack of sensitivity to gender-specific concerns
well-being may obscure the psychological impact of childlessness and
FLZ scales:
Health −0.29* −0.22* −0.25* −0.41* infertility. Further trials are currently being conducted to dem-
Professional life −0.27* −0.25* −0.29* −0.37* onstrate differences between the TLMK and a variation of the
Financial situation −0.19 −0.16 −0.29* −0.27* measure tailored to women. They will also explore whether: (i)
Leisure and hobbies −0.15 −0.17 −0.13 −0.27*

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Marriage/partnership −0.20 −0.36* −0.26* −0.34* these questionnaires are able to discriminate among different
Self-esteem −0.28* −0.27* −0.32* −0.46* patient groups (e.g. between cases of male- and female-factor
Sexuality −0.22* −0.53* −0.43* −0.34* infertility or among different infertility treatment procedures);
Social life −0.33* −0.25* −0.25* −0.30*
PFB scales: and (ii) the instruments are sensitive enough to reflect changes
Tenderness −0.43* −0.25* −0.47* −0.14 in quality-of-life during the course of treatment (e.g. after treat-
Conflict behaviour 0.21 0.38* 0.21* 0.24* ment failure).
Togetherness/ −0.58* −0.33* −0.52* −0.29*
communication Some limitations of the current study and the TLMK warrant
mention. First, analyses revealed low mean scores for most of
Bonferroni corrections were applied to control for potential α inflation. The the scales (Table II). This finding was particularly surprising in
corrected α level for P = 0.05 was P = 0.001.
*P < 0.05. the case of sexual relationship and gender identity. It is pos-
sible that social desirability influenced participants’ responses,
in the current sample (r = 0.38). The above correlations indicated especially given the personal nature of these topics. This effect
relationships between some of these scales, but these were has been documented previously and particularly for responses
moderate in size indicating that the scales represent separate at the beginning of infertility treatment (Berg, 1994), which
dimensions. Thus, these correlations support the convergent was the case in our study. That being said, our observations are
validity between the TLMK scales and related constructs. consistent with some reports in the literature. In a recent study,
Wischmann et al. (2001) found few score differences between
Discriminant validity infertile couples and a reference population on the Partnership
Because they measure dissimilar constructs, the FLZ scales Questionnaire (PFB), the Life Satisfaction Questionnaire
professional life, financial situation, and leisure and hobbies (FLZ), the Symptom Checklist (SCL-90-R), and the Giessen
were not expected to correlate with the TLMK subscales of test (GT). Moreover, several investigations found gender dif-
desire for a child and sexual relationship. In fact, professional ferences on infertility-related distress and quality-of-life, and
life evinced moderate correlations with the TLMK scale scores indicated that women may be more affected by infertility than
(see Table IV). However, the correlations between the TLMK men (Andrews et al., 1991; Stanton et al., 1991; Newton et al.,
scales desire for a child and sexual relationship, and the FLZ 1999; Goldschmidt et al., 2003).
scales, financial situation and leisure and hobbies, were not The relatively low mean scale scores may also have resulted
significantly correlated. These findings partially support the from a lack of instrument sensitivity for this population. On the
TLMK’s discriminant validity. other hand, select items displayed relatively high means, and
may thus represent marked impairments in specific areas of
quality-of-life (e.g. report of difficulties relaxing, feeling dis-
Discussion tressed by infertility). Further validation studies with TLMK
The current study is a report on the development of the TLMK, will have to be conducted with a reference population to estab-
a questionnaire for measuring quality-of-life specific to men lish general population norms for this measure and to allow for
experiencing involuntary childlessness. This instrument con- further tests of instrument sensitivity and criterion validity.
tains 35 items and consists of four scales: psychological well- Future studies may also compare information assessed by gen-
being; sexual relationship; desire for a child; and gender identity. eral quality-of-life measures and the TLMK to determine
Preliminary psychometric evaluation showed good internal whether the infertility-specific nature of the measure provides
consistency for the four scales. Construct validity was sup- unique and useful information about men with involuntary
ported by exploratory factor analysis and item-total scale cor- childlessness.
relations, while convergent and discriminant validity were Next, it should be noted that the average education level of
partially supported by correlations of the TLMK scales with participants in this study was relatively high (42% university-
related constructs from other established instruments, specifi- entrance diploma), which may call into question the representative
cally the PFB (Hahlweg et al., 1982) and the FLZ (Fahrenberg nature of this sample. However, this proportion is representa-
et al., 2000). The TLMK was also easy to administer and tive of the population of male patients typically undergoing
acceptable to patients. infertility diagnosis in the University of Tübingen Medical
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S.Schanz et al.
Centre andrology clinic, of whom 35–43% report having this
level of education.
The final version of the TLMK questionnaire contains many
elements of infertility-related distress. Other facets of quality-
of-life covered by general measures, such as physical com-
plaints or social contacts, may appear under-represented.
Although these aspects were included in the primary item pool,
most did not meet the item entry criterion (discrimination value
>0.40). The distress reflected in some areas of quality-of-life as
measured by the TLMK may be more relevant to male patients
experiencing involuntary childlessness than those included in
general quality-of-life questionnaires. In order to confirm the
male-specific nature of the questionnaire, a future study will
need to compare the factor structure across gender using, for
example, a multiple-group confirmatory factor analysis.
Unlike some other infertility questionnaires, the TLMK does
not contain a personal relationships’ factor, although aspects of
this field are included in the desire for a child and sexual rela-
tionship scales. Some items pertaining to personal relationships
(i.e. social contacts scale) were included in the original meas-
ure but did not meet the entry criterion in the item selection.
After the factor analysis, the social contacts scale consisted of
only two items and was therefore excluded from the TLMK.
The exclusion of the social contacts scale may be a methodo-
logical artefact and future studies may further evaluate the
importance of such a scale.
The results of this study revealed lower than expected scores
and thus support the premise that men experiencing involun-
tary childlessness should be de-pathologized (Boivin et al.,
2001). However, the results also indicate that some patients are
vulnerable to certain sources of psychological distress. The
current study has revealed important aspects of patients’ psy-
chological well-being that should be assessed regularly during
infertility evaluation and treatment. If necessary, such prob-
lems may be addressed by referral to psychological treatment
according to the guidelines established in this field (Boivin
et al., 1995).
This study introduced the TLMK, a new questionnaire for
measuring quality-of-life in male patients experiencing invol-
untary childlessness and represented the first step in the psy-
chometric evaluation of the TLMK. The questionnaire evinced
adequate internal consistency as well as construct, discriminant
and convergent validity. Future studies may establish further
psychometric properties of this measure such as sensitivity to
detect change and criterion validity. This questionnaire may be
integrated into research and clinical batteries to establish base-
line levels of quality-of-life for these patients and to evaluate
the efficacy of psychological interventions designed to
improve their quality-of-life.
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Submitted on August 6, 2004; resubmitted on May 3, 2005; accepted on May
13, 2005
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