JOURNAL OF SEX & MARITAL THERAPY, 41(6), 610–625, 2015

Copyright 
C Taylor & Francis Group, LLC
ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/0092623X.2014.958789

The Impact of Infertility on the Psychological Well-Being,

Marital Relationships, Sexual Relationships, and Quality
of Life of Couples: A Systematic Review
Bronya Hi-Kwan Luk
School of Nursing, The University of Hong Kong, Hong Kong

Alice Yuen Loke

School of Nursing, The Hong Kong Polytechnic University, Hing Hom,
Hong Kong, Hong Kong

The purpose of this systematic review was to identify, with supporting evidence, the effect of infertility
on couples. MEDLINE, PsycINFO, and CINHAL Plus articles were searched for relevant studies
(2000–2014) published in English. Twenty articles were included in this review. The results showed
that infertility affected couples in the following four aspects of their life: psychological well-being,
marital relationships, sexual relationships, and quality of life. There is evidence that infertility has a
negative effect on the psychological well-being and sexual relationships of couples, but the evidence
is inconclusive for the effect on marital relationships and quality of life.

Infertility is a condition when couples fail to conceive naturally after 12 months of regular
sexual intercourse without contraceptives (Practice Committee of the American Society for
Reproductive Medicine, 2008; Zegers-Hochschild et al., 2009). Infertility can originate from the
man, the woman, or both. Of the cases of infertility, 40% can be attributed to women, 40% to
men, 10% to both parties, and 10% to unknown causes (Hong Kong Society for Reproductive
Medicine, 2009).
With the notion that childbearing is a natural and essential part of married life, couples who
fail to conceive face pressure from family members and the people around them. Infertility can
also have a negative effect on infertile couples, affecting such aspects of their life as their marital
relationship (Onat & Beji, 2012a), sexual satisfaction (Ramezanzadeh, Aghssa, Jafarabadi, &
Zayeri, 2006), and psychosocial well-being (Cousineau & Domar, 2007).
Studies have shown that infertile women seem to feel more stress about their condition than do
infertile men (Lee & Sun, 2000; Peterson, Newton, Rosen, & Schulman, 2007). This is because,
in most cultures, infertility is regarded as a serious failure on the part of the woman to fulfill her
role as a woman (Chan, Ng, Chan, Ho, & Chan, 2006; Lee & Sun, 2000; Onat & Beji, 2012b).

Address correspondence to Alice Yuen Loke, GH518, School of Nursing, The Hong Kong Polytechnic University,
Hong Kong. E-mail: alice.yuen.loke@polyu.edu.hk
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 611

Infertile women often feel that the responsibility falls on them to reproduce and thereby carry on
the family line, and they feel inadequate as women if they are unable to bear children (Loke, Yu,
& Hayter, 2012).
The birth in 1978 in the United Kingdom of Louise Brown, the first baby conceived through
in vitro fertilization, has given hope to many infertile couples. Infertility is treated in health
service institutions; the cost is high, and treatment may span many months or years (Onat
et al., 2012b). This may cause infertile couples to become even more prone to suffering from
depression and feelings of shame, and to resort to dysfunctional coping strategies, as well as to
exhibit lower scores in the measures of protective psychological functioning (Galhardo, Cunha, &
Pinto-Gouveia, 2011). In seeking assisted reproductive therapy, women often undergo numerous
invasive procedures. The drugs and hormones used to treat infertility may also have various
psychological side effects. The times when egg retrieval, embryo transfer, and pregnancy test that
follow the in vitro fertilization procedure are carried out are all recognized as periods of high
stress for couples, expecially the woman (Quant et al., 2013).
Four systematic reviews have been conducted on the effect of infertility on the psycholog-
ical well-being, quality of life, and marital relationships of couples, as well as on the ethical
issues involved (Chachamovich et al., 2010; Greil, 1997; Leyser-Whalen, Temple, & Phelps,
2012; Tao, Coates, & Maycock, 2012). The participants included couples and women who had
not undergone treatment, couples and women undergoing in vitro fertilization/intracytoplasmic
sperm injection/assisted reproductive therapy, couples and women whose attempts at in vitro
fertilization/intracytoplasmic sperm injection/assisted reproductive therapy had failed, and cou-
ples and women who had quit trying to undergo in vitro fertilization/intracytoplasmic sperm
injection/assisted reproductive therapy. The effect of infertility and its treatment on couples is
multi-faceted. All of these previous reviews included the studies on the effects of treatment on
couples. The effect of infertility itself and the effect of the treatment process and its effects need to
be differentiated. Thus, this systematic review focuses purely on the effect of infertility on couples.

Aim and Objective

The objective of this review of the relevant literature is to identify, with supporting evidence, the
effect of infertility on couples who suffer from the condition.

METHOD

A comprehensive search was conducted of the electronic databases of MEDLINE, PsycINFO, and
CINHAL Plus for papers published in English between 2000 and 2014 that focused specifically on
the effect of infertility on couples, including men and women. The keywords that were searched
included: infertility AND anxiety OR depression OR psychological OR psychological stress OR
quality of life (QoL) OR marital OR sexual relationship. Papers focusing on treatment or in vitro
fertilization/intracytoplasmic sperm injection/assisted reproductive technology were excluded,
as the stress of couples undergoing assisted reproductive technology and its effects could be
different. Four more studies were identified by going through the reference lists of the selected
papers and conducting an author search. A total of 340 papers were retrieved, plus the 4 articles
from the author search. Figure 1 illustrates the search process involved in identifying the relevant
literature.
612 LUK AND LOKE

Studies were included if they (a) were published in peer-reviewed journals; (b) presented orig-
inal findings; (c) included infertile couples, men and/or women; (d) adopted validated measures;
(e) involved couples who had not initiated the treatment process.
After duplicate studies were removed, 267 articles remained. The titles and abstracts of the
267 studies were screened according to the criteria for inclusion. Excluded were articles not on
infertility (n = 121), animals (n = 1), the treatment of infertility (n = 16), non-research articles
(n = 29), non-English articles (n = 17), articles relating to cancer (n = 6), surrogacy (n = 9),
causes of infertility (n = 3), violence in intimacy (n = 1), and chlamydia and endometriosis
(n = 13). A total of 216 articles were removed, leaving 51 articles.
The full texts of the 51 studies were assessed for eligibility, and 31 articles were excluded. The
31 excluded studies were articles about treatment (n = 6), articles that did not discuss the effect
of infertility (n = 10), articles on finding the causes of infertility (n = 3), studies that used an
invalidated inventory (n = 2), studies where the inventory for the measurement was not clearly
stated (n = 9), and studies on inventory validation (n = 1). In the end, 18 quantitative studies and
two qualitative studies were included in the review.

FIGURE 1 Flow diagram on identifying the literature.

 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 613

Two reviewers independently appraised the quality of the included studies and extracted data
from each of the studies using a standard format, which included information on the literature,
study design, sample size, instrument, and findings.

Quality Assessment

The quality of each eligible quantitative article was assessed by the two reviewers independently
using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines
(University of Bern, 2009). The guidelines for cross-sectional and case-control studies, which
comprise 22 items, were adopted to assess the quality of the literature. Each item was give a
score of one if the study met that criterion, and a score of zero if the study had an insufficient
or no description of the item. The total maximum score was 22. Studies scoring 75% or more
of the maximum attainable score (≥17 points) were considered to be of high quality. Studies
scoring between 50 and 75% (11–16 points) were rated as being of moderate quality, and those
with scores lower than 50% (≤10 points) were considered to be of low quality. After the quality
assessment of the 18 identified quantitative studies was conducted, no low quality studies were
found, while two thirds of the studies (12 out of 18) were considered to be of high quality. Six of
the identified studies were classified as being of moderate quality. The distribution of the scores
is listed in Table 1.

TABLE 1
Summary of Overall Results

Quantitative study
Psychological Marital Sexual Quality of
Reference impact relationship relationship life Quality of evidence Score

Albayrak et al., 2007  High 17

Alhassan et al., 2014  Moderate 14
Ahmadi et al., 2011  High 17
Drosdzol & Skrzypulec,   High 18
2008
Drosdzol & Skrzypulec,  High 19
2009a
Drosdzol & Skrzypulec,  High 18
2009b
Dyer et al., 2009  Moderate 16
Fassino et al., 2002  High 18
Gao et al., 2013   High 18
Hentschel et al., 2008  High 17
Khademi et al., 2008  High 17
Lau et al., 2008  High 18
Lee & Sun, 2000    Moderate 13
Matsubayashi et al., 2004  Moderate 13
Noorbala et al., 2009  Moderate 13
Onat et al., 2012b   High 19
Oskay et al., 2010  High 17
Wicshmann et al., 2001  Moderate 14

Note. Two studies were qualitative and had a score of 9 (Loke et al., 2012) and 7 (Nieuwenhuis et al., 2009).
614 LUK AND LOKE

In assessing the quality of the two qualitative studies, the reviewer adopted the Evidence-Based
Nursing guide to evaluating qualitative research studies (Russell & Gregory, 2003). There are
nine items in the appraisal guide. Studies scoring 50% or more of the maximum attainable score
(≥5 points) were considered to be of high quality, whereas scores lower than 50% (≤4 points)
were considered indicative of low quality. After the quality appraisal, both studies were deemed
to be of high quality. The distribution of the scores is also listed in Table 1.
For the two qualitative studies, the research questions were clearly stated, the research ap-
proaches applied were appropriate for the purpose of the study, the phenomena were clearly
described, the findings were presented in a way of logical, consistent, and easy to follow. The
study conducted in Nigeria did not report on the fertility history of the people from the community
(Nieuwenhuis, Odukogbe, Theobald, & Liu, 2009).

RESULTS

Characteristics of the Selected Studies

All of the 20 studies included in this review were published in peer-review journals. There were
8 cross-sectional studies, 10 case-control studies, and 2 qualitative studies. The identified studies
represent a diverse population from thirteen countries, with five studies conducted in Europe
(Germany, Italy, and Poland), six in the Middle East (Iran and Turkey), five in East Asia (China,
Hong Kong, Japan, and Taiwan), three in Africa (Ghana, Nigeria, and South Africa) and one in
South America (Brazil). The numbers of participant was 7,923 in these studies, with sample size
ranged from 11 to 1,468.
The literature focused on four aspects of the effect of infertility on couples: psychological well-
being, marital relationship, sexual relationship, and quality of life (Table 1). Nine quantitative
studies focused on the psychological effect of infertility, one on marital relationships, three on
sexual relationships, and one on quality of life. Four studies focused on more than one aspect,
with one study examining both quality of life and sexual relationships, one covering quality of
life and marital relationships, one addressing the effect on psychological well-being and sexual
relationships, and one focusing on the effect on psychological well-being and marital and sexual
relationships.
The results of the literature review are listed in five tables: the effect of infertility
on the psychological well-being (Table 2), marital relationship (Table 3), sexual relation-
ship (Table 4), quality of life (Table 5) of couples, and summary of the qualitative studies
(Table 6).

Psychological Effect of Infertility

Of the 18 quantitative studies, 11 focused on the psychological effect of infertility on couples. Four
focused solely on infertile women, three on infertile men, and four on both infertile partners. For
easy reference, the studies have been summarized according to study design, samples, instruments
adopted, and findings (Table 2).
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 615

TABLE 2
Summary of the Effect of Infertility on the Psychological Well-Being of Couples

Reference Design Sample size Instrument Findings

Infertile women
Matsubayashi et al., Cross-sectional 101 infertile HADS Infertile Japanese women were
2004 (Japan) women suffering from emotional disorders.
Feeling stress and lacking the
support of their husbands were the
key sources of anxiety and
depression among infertile Japanese
women.
Alhassan et al., 2014 Cross-sectional 100 infertile BDI The prevalence of depression among
(Ghana) women the infertile women was high,
especially among those aged 26 and
above, the less educated, those with
primary infertility, as well as those
who had been diagnosed as infertile
more than 3 years ago.
Albayrak et al., 2007 Case-control 151 infertile STAI The state and trait anxiety scores of
(Turkey) women, 151 the infertile women were higher
fertile women than those of the controls. The trait
as the control anxiety scores among infertile
women increased with the duration
of their marriage.
Noorbala et al., 2009 Case-control 150 fertile SCL-90 The results showed that 44% of
(Iran) women, 150 infertile and 28.7% of fertile women
infertile had a psychiatric disorder. Infertile
women women who were housewives were
at a higher risk of developing
psychiatric disorders than those
who were working women.
Infertile men
Ahmadi et al., 2011 Cross-sectional 114 infertile men BDI Depression among infertile Iranian
(Iran) men is very much higher than
among infertile men in Western
countries.
Dyer et al., 2009 Cross-sectional 120 infertile SCL-90-R When compared with fertile controls,
(South Africa) men, 120 infertile men experienced elevated
fertile men levels of psychological distress.
Higher mean levels of distress were
observed in the study group across
the entire range of the applied
instrument.
Gao et al., 2013 Case-control 1,468 infertile SAS, SDS Anxiety and depression were more
(China) men, 942 prevalent among infertile than
fertile men fertile men.

Infertile couples
Lee & Sun, 2000 Cross-sectional 59 infertile Self- Wives scored significantly higher in
(Taiwan) couples invented distress levels than husbands; this
scale means that infertile wives are more
distressed than their spouses.
(Continued on next page)
616 LUK AND LOKE

TABLE 2
Summary of the Effect of Infertility on the Psychological Well-Being of Couples (Continued)

Reference Design Sample size Instrument Findings

Wischmann et al., Case-control 564 infertile SCL-90-R There were no remarkable differences
2001 (Germany) couples in psychological variables between
the infertile couples and a
representative sample, except that
the infertile women had higher
scores on the depression and anxiety
scales.
Fassino et al., 2002 Cross-sectional 156 infertile HAM-A, Levels of anxiety and depression are
(Italy) couples, 80 HAM-D, higher in the two groups of infertile
fertile couples STAXI subjects than in the controls, for
both men and women.
Drosdzol & Case-control 206 infertile BDI, BAI A larger percentage of infertile women
Skrzypulec, 2009a couples, 190 (35.44%) scored above the cutoff
(Poland) fertile couples point for severe symptoms of
depression than fertile women
(19.47%). In the case of anxiety, the
total prevalence among infertile
women was significant (15.53%).
Among the male groups, there was a
comparable frequency of negative
results for depression and anxiety
and their intensity.

Note. HADS = Hospital Anxiety and Depression Scale, BDI = Beck Depression Inventory, BAI = Beck Anxiety
Inventory, POMS = Profile of Mood States, SCL-90 = Symptom Checklist 90, HAM-A = Hamilton Anxiety Rating Scale,
HAM-D = Hamilton Depression Rating Scale, STAXI = State-Trait Anger Expression Inventory, SAS = Self-Rating
Anxiety Scale, SDS = Self-Rating Depression Scale.

Psychological Effect of Infertility on Women

Four studies investigated the psychological effect of infertility on women. Two studies only
included infertile women in the sample, while the other two included both infertile and fertile
women for comparison. The four studies explored women’s depression or anxiety levels using
different inventories: the Hospital Anxiety and Depression Scale (Matsubayashi et al., 2004),
the Beck Depression Inventory (Alhassan, Ziblim, & Muntaka, 2014), the Spielberger State and
Trait Anxiety Inventory (Albayrak & Günay, 2007), and the Symptom Checklist 90 (Noorbala,
Ramezanzadeh, Abedinia, & Naghizadeh, 2009).
The two studies that explored the psychological effect of infertility on infertile women found
that the women suffered from depression and emotional disorders (Alhassan et al., 2014; Mat-
subayashi et al., 2004). The study of infertile women in Ghana indicated that more than 60%
of these women suffered from depression. Motherhood is the only way for women in Ghana to
enhance their status within their family and community (Alhassan et al., 2014). The stigma of
childlessness is so great in Ghana that infertile women are socially isolated and neglected even
by their husbands and extended family, leading to depression. Another study conducted in Japan
indicated that there is a significant association between anxiety and depression among infertile
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 617

Japanese women and a lack of support from their husband and feelings of stress in the women
(Matsubayashi et al., 2004).
The other two studies that compared infertile with fertile women showed that the infertile
women experienced higher levels of distress, anxiety, depressive disorders, and psychiatric dis-
orders than did the fertile women (Albayrak et al., 2007; Noorbala et al., 2009). A study reported
that 44% of infertile and 28.7% of fertile women had a psychiatric disorder (p < .001), a nearly
twofold difference (Noorbala et al., 2009). Using the Symptom Checklist 90, the highest mean
scores in infertile women were found to be on the paranoid ideation, depression, and interpersonal
sensitivity scales (Noorbala et al., 2009).

Psychological Effect of Infertility on Men

Three studies investigated the psychological effect of infertility on men. One study included
infertile men only, and two included both infertile and fertile men for comparison. Different
psychological assessment scales were used, including the Beck Depression Inventory (Ahmadi
et al., 2011), the revised Symptom Checklist 90 (Dyer, Lombard, & Van der Spuy, 2009), the
Self-Rating Anxiety Scale, and the Self-Rating Depression Scale (Gao et al., 2013).
Among the 114 infertile Iranian men who completed the Beck Depression Inventory, 42.9%
were diagnosed with depression. The depression rate among these infertile men was very much
higher than among those in Western countries (Ahmadi et al., 2011). The two studies that
compared infertile and fertile men had a similar result, which was that infertile men experienced
higher levels of psychological distress than fertile men (Dyer et al., 2009; Gao et al., 2013).
The results of these studies of male infertility highlighted the importance of also including male
partners in the management of infertility in order to address the specific psychological needs of
couples.

Psychological Effect of Infertility on Couples

There are four studies on the psychological effect of infertility on couples, namely two cross-
sectional (Lee & Sun, 2000; Fassino, Piero, Boggio, Piccioni, & Garzaro, 2002) and two case-
control studies (Drosdzol & Skrzypulec, 2009a; Wischmann, Stammer, Scherg, Gerhard, &
Verres, 2001). The scales used were the revised Symptom Checklist 90 (Wischmann et al.,
2001); the Hamilton Anxiety Rating Scale, the Hamilton Depression Rating Scale, the State-Trait
Anger Expression Inventory (Fassino et al., 2002), and the Beck Depression Inventory and Beck
Anxiety Inventory (Drosdzol & Skrzypulec, 2009a). One study used self-invented scales (Lee &
Sun, 2000).
The study conducted in Taiwan showed that infertile wives are more distressed than infertile
husbands (Lee & Sun, 2000). A study in Germany of the psychological characteristics of infertile
couples found that infertile women had higher scores on the depression and anxiety scales than
infertile men (Wischmann et al., 2001).
A study that compared the psychological condition of infertile couples and fertile couples
showed that infertile couples exhibited higher levels of depression and anxiety (Drosdzol &
Skrzypulec, 2009a). According to the results of the study, nearly 36% of infertile women scored
above the cutoff point for severe depression, compared with about 20% of fertile women. A
higher proportion of infertile women suffered from anxiety compared with the fertile controls
618 LUK AND LOKE

(15.53% vs. 7.89%). Although depression and anxiety were found to be somewhat less se-
vere in men than in women, infertile men also demonstrated more depression and anxiety than
fertile men (Drosdzol & Skrzypulec, 2009a). Levels of anxiety and depression were higher in
infertile than in fertile couples in Italy (Fassino et al., 2002). The conclusion is that infertile
couples have higher levels of stress than fertile couples, and wives suffer from higher levels of
stress, anxiety, and distress than do their husbands.

Effect of Infertility on Marital Relationships

Only three studies were identified that focused on the effect of infertility on marital relationships
(Table 3). The studies used the Index of Marital Satisfaction (Drosdzol & Skrzypulec, 2009b),
the Dyadic Adjustment Scale (Onat et al., 2012b), and a self-invented scale (Lee & Sun, 2000)
to measure marital relationships.
The outcomes of some studies were controversial. One study found that among infertile
Chinese couples in Taiwan, wives were less satisfied than their husbands were with their marriage
(Lee & Sun, 2000). This study showed that wives were more worried than their husbands about
being accepted by their in-laws. In Chinese society, in-laws from the husband’s side hold an
influential position in a marriage (Lee & Sun, 2000). Members of the husband’s family are often
aggressive in their efforts to break up a childless marriage, whereas the wife’s family gives the
infertile couple little trouble, even when male infertility is the cause of the childlessness (Lee &
Sun, 2000). Therefore, it is not surprising that the wives in this study expressed less satisfaction
than did their husbands about being accepted by their in-laws (Lee & Sun, 2000).
It is interesting that some studies found that infertile couples have a significantly better re-
lationship than fertile couples (Drosdzol & Skrzypulec, 2009b). Another study, conducted in
Turkey, comparing the marital compatibility of couples of both groups, found that the infertile
couples had significantly higher Dyadic Adjustment Scale scores than did the couples in the
control group (Onat et al., 2012b). This indicated that not only did infertility not have a negative

TABLE 3
Summary of the Effect of Infertility on Marital Relationships

Reference Design Sample size Instrument Findings

Lee & Sun, 2000 Cross-sectional 59 infertile Self-invented This study found that wives
(Taiwan) couples questionnaire were less satisfied than
their husbands with their
marriage.
Drosdzol & Case control 206 infertile Index of Marital A significantly better
Skrzypulec, 2009b couples, 190 Satisfaction partner relationship was
(Poland) fertile couples found among infertile
women than with fertile
women.
Onat & Beji, 2012b Case control 58 infertile Dyadic This study detected no
(Turkey) couples, 51 Adjustment significant differences
fertile couples Scale between the infertile and
control groups in terms
of their DAS scores.
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 619

effect on the marital relationship of infertile couples, but that the quality of their marital rela-
tionship was even higher than that of fertile couples. Better marital functioning among infertile
couples when compared with the fertile controls might be explained by the ability to talk about
their fertility problems and plans for the future. The feelings of commitment and loyalty, and
a closer relationship with greater emotional intimacy between partners strengthened the marital
relationships of the infertile couples (Drosdzol & Skrzypulec, 2009b).

Effect of Infertility on the Sexual Relationship of Couples

Six quantitative studies that focused on the effect of infertility on the sexual relationship of
couples were identified (Table 4). The studies used different inventories to measure sexual
function and the relationship of the couples: the Female Sexual Function Index (Drosdzol &
Skrzypulec, 2008; Hentschel et al., 2008; Oskay, Beji, & Serdaroglu, 2010); the International
Index of Erectile Function (Drosdzol & Skrzypulec, 2008; Gao et al., 2013), and the Female
Sexual Function Index and the intravaginal ejaculatory latency time (Gao et al., 2013), and a
self-invented inventory (Lee & Sun, 2000).
Among the six identified studies, two focused solely on women, comparing infertile women
with fertile women (Hentschel et al., 2008; Oskay et al., 2010), one focused solely on infertile
man (Gao et al., 2013), two studied infertile couples including both women and men (Khademi,
Alleyassin, Amini, & Ghaemi, 2008; Lee & Sun, 2000), and one compared infertile and fertile
couples, men and women (Drosdzol & Skrzypulec, 2008).
Five of the six studies identified negative effect of infertility on sexuality on infertile men and
women. A study reported that the prevalence of sexual dysfunction was higher in infertile women
than that of the fertile control group (Oskay et al., 2010). Sexual dysfunction in infertile women
was found to be associated with age, partner’s age, duration of marriage, duration of infertility,
and duration of treatment and frequency of intercourse (Oskay et al., 2010). A study on Chinese
couples found that although wives’ sexuality distress from infertility was similar to that of the
husbands, but wives showed higher level of sexual dissatisfaction than did their husbands (Lee
& Sun, 2000). Infertile women showed higher sexual dysfunction compared with their husbands
(Lee & Sun, 2000; Oskay et al., 2010). While the prevalence of sexual dysfunction and degree of
erectile problem in infertile men was reported to be high from studies in China, Poland and Iran
(Drosdzol & Skrzypulec, 2008; Gao et al., 2013; Khademi et al., 2008).
However, there is one study found that infertility has no effect on sexuality of infertile
women. The study found that women from infertile couples who want to get pregnant and fertile
women seeking surgical sterilization presented similar scores for sexual function (Hentschel et al.,
2008).
These findings suggest that overall, the incidences of sexual and psychological problems in
infertile couples were higher than those in fertile couples.

Effect of Infertility on the Quality of Life of Couples

Three studies were found that focused on the effect of infertility on the quality of life of couples
(Table 5). Two studies used the Short Form-36 Health Survey as a measuring scale (Drosdzol
& Skrzypulec, 2008; Lau et al., 2008), and one adopted the World Health Organization Quality
of Life Scale (Onat et al., 2012b). The results on whether infertility affects the quality of life
620 LUK AND LOKE

TABLE 4
Summary of the Effect of Infertility on the Sexual Relationship of Couples

Reference Design Sample size Instrument Findings

Infertile women
Oskay et al., 2010 Case control 308 infertile FSFI The rate of women who had reported the
(Turkey) women, 308 presence of a sexual problem in their
fertile women male partner was significantly higher
in the infertile group (P < .05). The
prevalence of sexual dysfunction in
infertile women was higher than in
the fertile control group.
Hentschel et al., 2008 Case control 96 infertile FSFI Infertile women and fertile women who
(Brazil) women, 119 want to undergo surgical sterilization
women have similar sexual satisfaction
seeking tubal scores.
ligation

Infertile men
Gao et al., 2013 Case control 1,468 infertile IELT, IIEF, The incidences of premature ejaculation
(China) men, 942 PEDT and erectile dysfunction in the
fertile men infertile group were significantly
higher than those in the fertile group.

Infertile couples
Lee & Sun, 2000 Cross-sectional 59 infertile Self-invented The sexual distress of wives due to
(Taiwan) couples scale infertility was similar to that of the
husbands, but wives showed more
general sexual dissatisfaction than did
their husbands.

Khademi et al., 2008 Case control 100 infertile SFQ, IIEF The prevalence of dysfunction in
(Iran) couples arousal-sensation and
arousal-lubrication was found to be
higher among the infertile Iranian
population than the results reported
for the normal Iranian population.
The prevalence of any degree of
erectile dysfunction was higher than
the prevalence reported for the normal
population and infertile men.
Drosdzol & Case control 206 infertile FSFI, IIEF Clinical sexual dysfunctions were not
Skrzypulec, 2008 couples, 190 significantly more common among
(Poland) fertile couples infertile women than among fertile
women. Clinically relevant erectile
dysfunctions were diagnosed in
23.9% of infertile men and in 13.7%
of the controls. Male infertility had
the most significant negative effect on
men’s sexual functioning.

Note. FSFI = Female Sexual Function Index, IIEF = International Index of Erectile Function, IELT = Intravaginal
Ejaculatory Latency Time, PEDT = Premature Ejaculation Diagnostic Tool, SFQ = Sexual Function Questionnaire.
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 621

TABLE 5
Summary of the Effect of Infertility on the Quality of Life of Couples

Reference Design Sample size Instrument Findings

Drosdzol & Skrzypulec, Case control 206 infertile Short Form-36 The quality-of-life parameters in all
2008 (Poland) couples, 190 Health Survey categories were generally lower
fertile couples for infertile women than for
those of the control group.
Lau et al., 2008 (China) Cross-sessional 192 infertile Short Form-36 More than 30% believed that
couples Health Survey childless couples could not live
well, 80% desired to have a child
very badly, more than 60% put
pressure on themselves or their
spouse because of infertility, and
more than half felt pressured
when having sex. Furthermore,
19.8% of men and 37.5% of
women felt that infertility is
humiliating for women.
Onat et al., 2012b Case control 58 infertile World Health The quality-of-life scores of the
(Turkey) couples, 51 Organization infertile group in all
fertile couples Quality of subdimensions of the
Life Scale quality-of-life scale were
significantly higher than those of
the control group. There were no
gender differences in quality of
life for infertile couples.

of couples were inconsistent. The two studies that adopted the Short Form-36 Health Survey
reported a lower level of quality of life among infertile couples (Drosdzol & Skrzypulec, 2008;
Lau et al., 2008), while the study that adopted the World Health Organization Quality of Life
Scale found that the quality of life score was higher among the infertile group (Onat et al., 2012b).
The study conducted in Poland found that infertile women who are older, have a lower level
of education, and are occupationally inactive tend to have a lower quality of life (Drosdzol &
Skrzypulec, 2008). The study conducted in rural China found that 80% of infertile couples who
badly wanted a child felt that they could not live well without a child, and indicated that infertility
is a major concern for them (Lau et al., 2008).
However, one study reported an increase in quality of life among infertile couples and con-
cluded that this was because the couples had shared the crisis of infertility for a long time, as more
than two-thirds of the couples had been married for more than five years (Onat et al., 2012b). In
summary, the effect of infertility on the quality of life of infertile couples is inconclusive.

Findings From the Qualitative Studies

The findings of the two qualitative studies are listed in Table 6. Both studies focusing on the
effect of infertility showed that couples suffered from social stigma (Nieuwenhuis, Odukogbe,
Theobald, & Liu, 2009). Infertile couples reported feelings of incompleteness, guilt, shame, and
622 LUK AND LOKE

TABLE 6
Summary of the Qualitative Studies

Reference Design Sample size Instrument Findings

Loke et al., 2012 Qualitative 7 infertile Collaizi’s phe- Infertile couples reported feelings of
(Hong Kong) women, 4 nomenological incompleteness, guilt, shame, and
infertile men methods isolation from the fertile world.
These couples acknowledged that
subfertility affected their marital
relationship and regretted not
getting treatment earlier. Some
found ways of replacing their loss
and coping with their situation, and
some rationalized it by finding
reasons why it was good to be
childless.
Nieuwenhuis Qualitative 8 infertile Participatory Infertility is stigmatized. Women lack
et al., 2009 women, 7 Learning and support from the extended family,
(Nigeria) infertile men Action tools while men suffer because of the
impact of infertility on themselves
and the psychological impact on
their wives. Infertile men focused
on the economic impact of
infertility, while infertile women
focused on the psychological
impact. The psychological
reactions were often in response to
the intense social pressure to
become pregnant and to comments
from other family members and
relatives.

isolation from the fertile world (Loke et al., 2012). In Nigeria, the psychological disturbances
faced by infertile men and women are often inextricably related to the social effect. Infertile
women worried about their situation and felt depressed, sometimes to the point of feeling suicidal
(Nieuwenhuis et al., 2009). The psychological effect was found to be more prevalent in infertile
women (Loke et al., 2012; Nieuwenhuis et al., 2009). These results are in alignment with the
psychological findings of the quantitative studies.
The infertile couples also indicated that infertility affected their marital relationship and
regretted not getting treatment earlier in Hong Kong (Loke et al., 2012). The situation in Nigeria
was even worse, with frequent mention being made of husbands taking another wife as a response
to infertility (Nieuwenhuis et al., 2009).

DISCUSSION

Infertility is one crisis or hurdle along the journey of marriage. It is can be a painful and stressful
experience for both partners. The diagnosis of infertility is a critical time when a marriage could
 INFERTILITY AND PSYCHOLOGICAL WELL-BEING OF COUPLES 623

be at stake. A study in China reported that infertile couples were two times more likely to divorce
than were the fertile couples (Che & Cleland, 2002). Mutual support and consideration of partners
are the best ways to cope with infertility for marital adjustment (Peterson, Newton, Rosen, &
Schulman, 2006). A husband’s support may protect a woman against negative thoughts, thereby
saving their marriage (Albayrak & Guünay, 2007; Lee & Sun, 2000).
Lack of support from a husband will increase the stress level of an infertile woman
(Matsubayashi et al., 2004). Infertile women who were not satisfied with the support from
their husband had higher mean scores for anxiety than infertile women who were satisfied with
their husband’s support (Albayrak and Guünay, 2007). In the Chinese family, the wife would be
extremely anxious about responses from her husband’s family, especially if her husband is the
eldest or only son (Lee & Sun, 2000). It was reported that when a husband does not give enough
support to his wife, she would become distress and less satisfied with the marriage.
However, if couples learn to support each other, this experience will bring them closer together
and strengthen the marital relationship. It has been confirmed that infertile women have reported
better marital functioning than have the fertile controls (Drosdzol & Skrzypulec, 2009b). A
couple’s ability to talk about their fertility problem and their plans for the future can lead to
strengthened feelings of commitment and loyalty, and a closer relationship with greater emotional
intimacy (Drosdzol & Skrzypulec, 2009b). Marital compatibility is also a factor that affects the
quality of life of couples (Onat et al., 2012b).
To conclude, since mutual support, especially support and consideration from the husband
are the best ways to preserve the quality of a marriage and to get through the negative effects
of infertility, any intervention for infertile couples should focus on the marital relationship,
particularly on the issue of support from both partners.

Limitations

This review has some limitations. First, the physical, social, and financial effects of infertility
on couples were not included in this review. Second, the reviewer chose only to review only
English-language papers. It has been suggested that results are more likely to be published in
English-language journals if the results are statistically significant; thus, language selection may
be a source of bias. Last, because of the heterogeneous instruments used in the studies to measure
the psychological well-being, marital relationship, sexual relationship, and quality of life, it is
impossible to conduct a meta-analysis for comparison.

Conclusion

The findings of the review show that infertility has a psychological effect and alters the sexual
and marital relationships of infertile couples. Regardless of diverse population and culture, the
effects of infertility on couples are not population specific or cultural bounded.
Among the 20 studies included in this review, more studies focused on the psychological effect
(n = 11) and sexual relationship (n = 6) of the infertile couples, and less on marital (n = 3)
and quality of life (n = 3). Further studies should be conducted on marital and quality of life to
provide a comprehensive picture of the effect of infertility on couples.
624 LUK AND LOKE

Therefore, a future study should focus on interventions to relieve the psychological burden of
infertility and improve the sexual and marital relationships of couples. Interventions to strengthen
partnership support among couples will be an essential topic in the future.

ACKNOWLEDGMENT

This article was derived from part of Ms. Bronya Hi-Kwan Luk’s doctoral study at the Hong
Kong Polytechnic University.

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