Emotional Costs of Infertility

Of the many of nature’s miracles, one of them is definitely the ability to procreate. For some women, it defines the essence of womanhood, for others it may be a natural transition in an intimate relationship. For men, it indicates their ability to carry their lineage forward. 

In many parts of the world, couples may choose a career over parenting. Compared to earlier times, not having a child is becoming less stigmatized and acceptable. However, for couples actively planning a child or for a woman who really would wish to experience pregnancy, fertility issues can lead to significant emotional turmoil and conflicts in interpersonal relationships.

Puberty and Fertility

Puberty brings about significant changes in a woman’s body. Each month, a group of eggs grows in small, fluid-filled sacs (follicles) inside her ovaries. Out of these, one egg erupts from the follicle (ovulation) and travels to the fallopian tube. On the other hand, the lining of the uterus thickens to welcome the egg. The egg stays in the fallopian tube for about 24 hours waiting for a sperm to fertilize it. If there is no sperm (e.g., no intercourse, poor sperm quality, etc.), the egg moves to the uterus and disintegrates. The changes in hormones lead to the shedding of the uterus lining and your periods start. 

Usually, a woman has a 28-30 days cycle. The first day of the period is counted as the “first” day of the fertility cycle, which usually lasts from three to six days. The egg is produced between the 12^th – 17^th days of the cycle, which is the “most fertile period”.  And after about 14-15 days, the lining of the uterus starts shedding, which is the start of another menstrual cycle. 

What is fertilization - If one sperm manages to reach the fallopian tube and burrows into the egg, fertilization occurs and the egg changes so that no more sperm can get it. At the time of fertilization, the baby’s gene and sex are determined (Y chromosome from sperm = boy; X chromosome from sperm = Girl). Yes! You guessed it correctly, the male is responsible for the sex of the child and not the woman. 

What is implantation - Within 24 hours, the egg starts dividing into multiple cells and moves to the uterus where it attaches itself to the lining of the uterus (implantation). Within three weeks, the baby’s nerve cells begin to form. 

What is Infertility

Infertility is usually considered when a woman is not able to get pregnant even after one year of having unprotected sexual intercourse. Globally, infertility is on the rise. According to a recent study, approximately 30 million couples in the country suffer from infertility.

Causes of Infertility

The reason for infertility can be one or both partners. In one-third of the cases, it is the men; in another one-third, it’s the woman and in the remaining, it is either both partners or no identifiable cause. Causes of infertility are varied and can range from medical (as well as psychological).

Medical Causes of Infertility

The causes of infertility in males may include: 

1. Abnormal sperm production
2. Premature ejaculation
3. Blockage in testes
4. Genetic disorders like cystic fibrosis
5. Poor Sperm quality
6. Over-exposure to environmental toxins (e.g., pollution, smoking, alcohol or drug use, radiation, etc.)
7. Damage due to cancer or its treatment

The causes of infertility in females may include: 

1. Hormonal disorders (e.g., polycystic ovary syndrome, hyperprolactinemia, that is, too much prolactin, thyroid problems or diabetes. 
2. Uterine or cervical abnormalities such as fibroids blocked fallopian tubes.
3. Pelvic inflammatory disease, which may prevent the fertilized egg from implanting in the uterus.
4. Early menopause, that is, by 40 years of age
5. Vaginismus or pain during intercourse

Psychological Causes of Infertility

The psychological causes of infertility may include:

1. Fear of pregnancy and childbirth
2. Fear of parenthood
3. Excessive stress
4. Underlying mental health issues, like depression or anxiety
5. Poor interpersonal relationship between the couple
6. Extra-marital affair
7. Frequency of sexual intercourse
8. Poor Work-Life balance

Psychological or Emotional Effects of Infertility 

Infertility affects the couple as a whole. For men, it may include:

• Low self-esteem due to the inability to impregnate a woman or continue the family lineage
• Feelings of loneliness and alienation
• Sense of unfulfillment as he is unable to pass on his genes or characteristics to their child

For a woman, it may lead to:

• Loss of control
• Psychological void due to unfulfilled maternal instinct
• Alienation from other women
• Sense of worthlessness
• Loneliness
• Fear of future and absence of social security
• Lower self-esteem

Apart from the gender differences in psychological reactions to infertility, there are certain commonalities as well. The individual diagnosed with infertility or the couple together may go through various stages as listed below:

Stage 1: Usually the first stage is of shock and disbelief, followed by denial. The couple may attribute infertility to external factors that they can control, e.g., frequency of having sexual intercourse. 

Stage 2: Once the realization sets in that it’s a condition that is not under their control, it leads to anxiety and despair especially in the person diagnosed with the condition. He/she may be afraid of being left by the spouse, social ostracization, or medical procedures like tests and their results. Anxiety may also be precipitated due to fear of loss of womanhood or manhood. 

Stage 3: As the time duration increases or the individual goes through one set of treatment to another, anger, disappointment or resentment may start setting in. The couple may ask, “why us?” The anger fluctuates between that on oneself (e.g., why did I postpone the decision to have a child?”) or on the partner. The individual/couple may feel resentful towards others who have children and may isolate themselves from friends and family, which further accentuates their emotional issues. 

Stage 4: As the treatment for infertility begins, the individual or couple may feel a complete loss of control or violation of their private lives as everything is monitored from the menstruation cycles to the frequency of sex. Then, they might negotiate in forms of “If I get pregnant then…”. Families may undergo religious rituals, excessive praying, making promises to refrain from certain pleasures if treatment is successful. 

Stage 5: Gradually, guilt starts setting in. The individual diagnosed with infertility may feel guilty for depriving their partner of parenthood. They may develop apathy, motivation, inability to derive pleasure from activities, isolation, etc. Depression may set in as the individual moves between self-blame and anger. Every menstruation cycle brings with itself the loss of the “unborn child”. 

Stage 6: In a healthy couple, the last stage is that of acceptance, wherein the couple accepts the reality of not being able to have a child. They may begin by reconnecting with their partners, making the decision of living without a child or trying other methods like adoption or surrogacy and focus on fostering a fulfilling life for themselves in other ways.

Although infertility is not a life-threatening illness, the individual/couple goes through the grief similar to that experienced when we lose someone we love. In fact, in the latter type of grief, one gets the support and empathy of family and friends. However, in the former, also known as “disenfranchised grief”, the individual/couple does not get the required support and the woman is actually stigmatized and shunned by others. 

Infertility and Mental Illness

Of all the women presenting in an Infertility Clinic, approximately 50% have a diagnosable mental health condition. Depression and anxiety are prominent conditions. It has been seen that depression usually sets in after 1-2 years of diagnosis as the hope for conceiving a child starts dwindling. It has also been seen that both men and women are likely to become addicted to alcohol or drugs as a way of coping with stress. 

Coping with Emotional Costs of Infertility

Some things are not under our control, but other things are out of which one of the most important is taking care of oneself and dealing with stress. Stress is not only the effect of infertility but also the cause of it; hence it becomes a vicious cycle. Following are some tips that can be helpful for the individual and/or the couple:

• Making healthy lifestyle changes – nutritious food, avoidance of drugs and alcohol, and regular exercise 
• Practice relaxation through yoga, meditation, breathing exercises, and muscular relaxation
• Having a social support system around family and friends
• Talk out your feelings. Keeping emotions bottled up only increases the problem. You can always talk to Wysa.
• Reconnecting with your partner (e.g., having heart-to-heart talks, going on dates or vacations, finding hobbies that can be done together, playing games)
• Do not make sex a chore. Keep it as a pleasurable activity
• Distract yourself by cultivating a hobby or focusing on work and not remaining preoccupied with conception
• Work on “acceptance” – some things are beyond our control and accepting them can be peaceful
• Be optimistic -  but also realistic
• Start planning a life ahead – e.g., going for other methods for having a child like IVF, adoption, surrogacy, etc. 
• Reconnect with yourself by working on activities you love, learning a new skill or finding things to love about yourself. 

However, at times, the emotional turmoil can be too much to handle by yourself and then professional help is required. Here are some warning signs:

• Depression: a persistent feeling of sadness or irritability, lack of interest in pleasurable activities, tiredness, regrets and guilt, withdrawn behavior, crying spells, self-dislike, negative thinking, death wishes or suicidal ideas. 
• Anxiety: Frequent episodes of restlessness, increased heart-beat, a sense of dread, sweating or trembling of the body, feeling of loss of control or dizziness
• Increased conflict between the couple
• Difficulty sleeping or sleeping excessively
• Significant changes in weight (increase or decrease)

“Yesterday is history, tomorrow is a mystery, and today is a gift... that's why they call it present”

Master Oogway from Kung Fu Panda

Why does infertility cause so much emotional pain?

Infertility is similar to the loss of a loved one. Only that, here a person or object is not lost. But it’s the control of your life or your ability to make a decision about having or not having a child is lost. For many individuals, it may be fear of not being able to extend the family lineage, for others it may be the fear of being left alone in old age and for many others, it is simply not having the pleasure of parenthood.

Does infertility cause depression?

Yes, infertility can cause depression as the individual diagnosed with the condition may blame him/her self, regret previous decisions taken, feel alone socially and also may be undergoing tremendous family or social pressures. It may also cause fear of being left by the spouse. 

Can mental health affect fertility?

Yes, various studies have shown that mental health issues like stress and anxiety are not only the effect but also the cause of infertility. Stress causes the release of a hormone called cortisol, which can inhibit the sperm or egg quality and can also cause miscarriages.

Does the pain of infertility go away?

Yes, just like any other loss, the pain of infertility also goes away as the individual fully accepts the reality and moves on to find meaning in life through other activities, e.g., adopting a child, doing charitable work, re-establishing bonds with their partner, etc. 

What are the consequences of infertility to marriage?

Infertility can break or make a marriage. Typically, once the diagnosis is revealed to the couple, quarrels can be expected. The couple may engage in blame-games, arguments and anger outbursts. As each partner tries to deal with the news in their own way, they may become distant from the partner. Studies have shown that extra-marital affairs or divorces may also be a consequence of infertility. However, couples who are able to move beyond the anger and anxiety and work together to solve the issues can re-establish and strengthen their bond.

What percentage of couples have fertility problems?

According to the Centre for Disease Control and Prevention (CDC), about 6% of married women in the age group of 15-44 years reported infertility. Alarmingly, a study by the World Health Organization reports that in a developing country, one of every four couples report fertility issues.

Can a marriage survive infertility?

Yes, it can, depending on the willingness and maturity of both the partners and the support system offered by the family.

Does infertility lead to divorce?

Yes, it may due to various reasons- 
a) either one or both partner do not wish to stay with each other due to increased conflicts
b) Family pressurizes the “fertile” spouse to move out of the marriage
c) “Infertile” partner may decide to move out of the marriage

What age does a woman stop being fertile?

A woman’s fertility peaks in 20s and starts declining in 30s. After attaining 40 years, a woman’s chances of becoming pregnant decrease significantly. And once the woman reaches menopause (usually between 45-55 years of age), she cannot bear children.