Infertility: a psychobiological model
In general, issues concerning infertility are defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse or following repeated miscarriages, ectopic pregnancy or perinatal loss (Zegers-Hochschild et al. 2009). A systematic review of the scientific bibliography showed that 48,5 million couples worldwide face infertility issues (Mascarenhas et al. 2012). Infertility causes have been attributed to male factors (30%), female factors (30%) and specific traits of each couple (20%). The remaining 20% is attributed to undefined causes (Callahan et al. 2003). Biological causes include ovulatory dysfunction, endometriosis, oligoasthenozoospermia as well as genetic factors. Psychological factors are also considered as fertility impediments, affecting the successful outcome of medical approaches. Therefore, the psychological component should be examined and dealt with -when deemed necessary- during the diagnostic assessment as well as throughout any fertility treatment (Demyttenaere et al. 1998).
Psychological Causes of Infertility
Concerning the psychological causes of infertility, the model of psychogenic infertility prevailed in the 1950s and 1960s; a model that demoted the significance of biological factors. However, the primacy of psychological factors against biological/organic subsided with the progress of scientific knowledge and technology (van Balen, 2002), albeit several of those factors are still considered of importance. High levels of anxiety, depressed mood, low self-esteem, negative body image, performance anxiety, guilt, contradictory emotions that rise from motherhood/fatherhood and economic insecurity, among others, are key factors that affect the manifestation of problems concerning infertility (Apfel & Keylor, 2002; Keylor & Apfel, 2010). For instance, anxiety and mental status affects spermatogenesis in men, with studies demonstrating that both sperm quality and quantity decrease due to stress, while increasing with mental well-being (Pook et al. 1999).
Psychological consequences of Infertility (Leon, 2010)
The most significant psychological aspect of infertility are the psychological consequences themselves that successively lead to decreased success rate of biological modulations for its treatment. Hence, even though psychological factors may have not had an impact on the onset of infertility, there are still multiple ways they contribute to the continuation of infertility and its accompanying impact.
The medical diagnosis of infertility, as an experience, is emotionally disturbing for both men and women. Human nature dictates that the ability to bear children is granted, in order for individuals to relate well to each other. A potential infertility diagnosis will overturn life quality standards and usually an individual would feel unprepared for such event. Like every major stressful incident, it induces a cascade of emotions, such as anger, shame, guilt, the feeling of losing control of their own bodies and/or their lives, as well as, a pervading sense of helplessness, despair and devastation.
In the meantime, a fear of social stigma may appear with isolation and alienation from close friends and family, a behavior that deprives the protective benefit of social interaction. Difficulties could also arise through a limited understanding of both the problem and the treatment from the close friends and family, thus affecting the support they provide for the couple.
At the same time, the couple could face hardships in their relationship. Accusations, anger, disappointment and frustration may appear in a relationship, while sexual intercourse could become part of a routine, missing spontaneity and pleasure. Therefore a notable rise may be observed in sexual dysfunction as a result of performance anxiety, unstable mood and guilt, all of which negatively affect the success rate of conceiving.
Infertility can severely affect self-esteem and psychological inner balance, as it may alter the perception of oneself and their partner’s. It is worth mentioning that despite being an overall painful experience, both genders show significant differences in terms of individual reactions and psychological processing.
Gender Differences in Psychological Effects of Infertility
Women usually react to infertility problems with emotions and behaviors that resemble those in loss and grieving, such as melancholy, sentimentality, irritability, guilt and self-blame. On the contrary, men’s reactions reveal more anxiety than depressing feelings. However, the degree and length of the psychological effects on men varies and depends on whether a male factor is present. Men with an infertility factor may view infertility as a threat to their self-esteem and masculinity, resulting on the emergence of feelings and behaviours such as helplessness, anger outbursts, withdrawal and isolation or even attempts of self-relief through alcohol or substance use (Nachtigall et al. 1992). Studies have demonstrated that for few men these symptoms are persistent even after successful reproduction (Glover & Abel, 1998). In general, men are keen into denying, suppressing and/or hiding their emotional vulnerability in a social context (Pollack, 1998), therefore they may be experiencing devastating feelings due to infertility that they are reserved to communicate towards their partner, their attending physician and their social environment as a result of shame. Additionally, the constant suppression of negative emotions has been found to affect the function of the immune system, rendering an individual more prone to physical illnesses (Keylor & Apfel, 2010). In general, men tend to downgrade the personal effect they face due to infertility, both internally (to themselves) and externally (to others). (Harrison et al. 1986).
On the contrary, women tend to experience and express more openly on infertility issues than men, as motherhood is considered an integral part of their feminine identity and nature (Whiteford & Gonzalez, 1995). In particular, women may show a higher degree of reaction than men, with depression, loss of self-esteem, self-blame, shame and life fulfillment (Greil, 1997). It is often reported that infertility affects a woman’s perception of herself, creating a feeling of having lost control of their own bodies and that they no longer believe they live in a fair and predictable world (Kauffman, 2002). It is worth mentioning that women frequently show those types of expressions in cases of male factor infertility as well (Inhorn, 2003).
The aetiology of infertility mainly concerns biological/organic factors. However, similar to every physical and mental disease where there is a dialectic ratio and interaction between soul and body, psychological causes can be detected in infertility as well. Stress, anxiety, depression, contradictory emotions concerning motherhood/fatherhood, guilt, couple dysfunction and more, may lead to the manifestation of such problems. Even in cases that psychological factors have a low impact, this unpredictable and painful experience often triggers negative emotions, dysfunctional handling and mental health issues. Self-image may be compromised, affecting self-esteem, the relationship of the couple and in sequence close friends and family interactions. All of the above may aggravate the psychological background of infertility, hindering an effective medical approach to the problem.
A prompt and reliable evaluation of the psychological parameters, as well as the inclusion of psychological counseling in the medical plan -if deemed necessary- could contribute significantly in the best possible results of the fertility treatment (Demyttenaere et al. 1998).
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