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We grow up wondering what kind of parent we will be when our turn comes. We discuss, plan, deliberate and sometimes argue with our partners about when is the right time. Our parents are hinting, subtly or not so subtly, about grandchildren. We may wait a few years in order to finish our studies or purchase a new house in preparation. We make sure to use birth control despite the inconvenience and unpleasant side effects in order to prevent an unwanted pregnancy. So it comes as a shock when we decide the time is right and nothing happens; with all of our concern about “when” to have a baby, it never crossed our mind to question “if” we are able to. And we realize we may be one of approximately 15% of couples who experience fertility problems.

So begins the process of medical examinations, scheduled sex, or fertility treatment. Many life decisions go on hold as uncertainty sets in. In some cases a diagnosis will be made for one of the partners. Other couples will fall into the group of “unexplained infertility” cases. For those with more luck the problem may be resolved relatively quickly and cause minimal disturbance, but for many it becomes a profound life crisis. Those who have not experienced it often have little understanding of what a deeply disturbing experience infertility can be. In fact, many women maintain that it was the most upsetting experience they had encountered in their lifetime.

The process of infertility treatment is often an emotional roller coaster alternating between feelings of hope and despair. Each round of treatment brings new hope, and in many cases, loss. Each miscarriage is doubly painful because there is no way to express one’s grief or attain closure: no ceremony, no funeral, just prepare for the next round. Couples experience feelings of anxiety, depression and helplessness that often turns to anger - anger towards oneself, one’s partner, family, friends, doctors - but mostly anger at an unfair situation in which one has little control. The couple struggling with infertility tends to see fertility everywhere around them: pregnant women, newborn celebrations, parents with toddlers...all of which may arouse strong feelings of envy that soon turn to guilt.

Couples often feel ambivalent about sharing what they are experiencing with family, friends and colleagues. On the one hand they desperately need support and understanding. On the other, they often meet with reactions that they find frustrating or hurtful. Because they are in life crisis, they are particularly vulnerable to perceived indifference or insensitivity. To be fair, others do not always know how to relate to a couple undergoing fertility treatment. As with divorce or abortion, people do not know if it is better to inquire or respect the couple’s privacy. They wonder “Should I bring it up? Should I ask what is happening? Should I give advice, encouragement or consolation?” In their uncertainty and discomfort they may miss the mark - not ask at all, be intrusive or even provide superficial advice. They may even unconsciously pull away during the crisis. This can be a profoundly painful experience for a couple.

In time, many couples become increasingly isolated. They may stop sharing with others in order to avoid raising hopes and expectations that will force them to face new rounds of questions. They may even begin to avoid social occasions such as family get-togethers that might expose them to difficult questions or arouse painful feelings. Naturally, partners increasingly turn to each other for emotional support and understanding. In some cases this helps strengthen and consolidate the relationship. But often, since both partners are in ongoing crisis and stretched to the limit, they do not have the emotional resources to support one another. They may be experiencing disturbing feelings of anger, guilt or disappointment with themselves or their partners. They may withhold their feelings for fear that they could hurt their partners or damage the relationship. For example, a husband diagnosed with a fertility problem may feel guilt over “depriving” his wife of a child. He may harbor fears of abandonment or fears that she will remain secretly resentful. Alternatively, a wife might experience irrational feelings of anger at her husband’s lack of motivation to pursue fertility treatment. When partners withhold their feelings in an effort to avoid conflict they may eventually find themselves estranged from one another.

Another reason that couples have trouble understanding and supporting one another is that men and women react very differently to infertility. In general, women tend to be more emotionally disturbed by the experience. They tend to exhibit more anxiety and depression and feel more isolated. This may be partly due to the fact that the process of conception and childbirth plays out in the woman’s body: it is her ovulation cycle; she carries the fertilized egg and she will feel the growth or loss of the embryo in her womb. And this may explain why women tend to take on more responsibility for fertility treatment, from scheduling sex to scheduling appointments with the doctors even when the problem is diagnosed as male infertility.

Men’s emotional reactions are more varied and usually less intense than women’s. Men often feel they are expected to be stoic, strong and supportive. And society reinforces this. For instance, after a failed treatment or miscarriage, others may say “give my condolences to your wife” forgetting that the man too is grieving. As a result, men are less likely to acknowledge and share many of their deepest feelings. Men also cope differently from women: they tend to invest their energy in work and other pursuits. They try to “get on with things”. The difference in how men and women react to and cope with infertility can lead to misunderstanding and conflict between spouses.

The question is not if fertility problems will affect a couple’s sex life but how. Most experience sexual dissatisfaction or dysfunction at some point in the process. In some cases infertility spoils the sexual experience until after the crisis is resolved. Any of the factors discussed thus far - anxiety, depression, anger, guilt, negative body image, fatigue, scheduled sex - is more than enough to dampen desire or contribute to sexual dysfunction. It is common for both men and women to lose libido and capacity for orgasm during this period. Whereas a woman can accept sex passively and have an orgasm or not, a man is under pressure to achieve orgasm despite what he may be feeling. In some cases stress, anxiety and depression can cause men to experience erectile dysfunction.

The surest way to take the spontaneity and enjoyment out of something is to make it an obligation. You may passionately love chocolate, but if you were repeatedly forced to eat a box of chocolates whether you crave it or not, you would eventually find it a distasteful, negative experience. And so it often happens with scheduled sex. Couples find it hard to enjoy sex when it becomes so goal-oriented. Even when one partner feels spontaneous desire, he/she may repress it because a “command performance” is expected in the coming days. It may come as no surprise then that many couples report some of their worst fights around the time of ovulation. Sex may even become the arena in which couple conflicts play out: who is carrying the weight of the treatment, differences in motivation for a child or fertility treatment, or feeling unsupported.

An infertility crisis can lead to powerful, disturbing and confusing feelings about one’s body. It is often experienced as a blow to a person’s sexual self-image and self-esteem. It is not uncommon for a woman in fertility crisis to describe her genitals or uterus as “empty”, or as “a black hole where things keep dying”, or for a man to feel “defective” or “impotent”. Unfortunately, these negative feelings are not confined to reproductive function; they can spread to one’s self-image and make one begin to feel unattractive and sexually undesirable. Many have difficulty taking pleasure in their bodies, particularly in the very part that has become the source of negative feelings and conflict. 

During the crisis, couples may feel that what was once their private domain – their bodies and sex life - has been turned inside out to the world. It may feel like an invasion of privacy and a threat to one’s dignity. Sexuality loses its mystique and many couples wonder, “Will we ever enjoy sex again?” It is painful for them to see what was once a natural, spontaneous expression of love become regimented, tense or empty. Sex that was once romantic may be reduced for a time to an act as perfunctory and uninspiring as brushing ones teeth. Men and women alike express sadness around the loss of sexual connection with their partners.

It is unfortunate that couples do not receive adequate guidance upon commencing this process. Though there is no escaping certain hardships, couples who educate themselves concerning the emotional effects of infertility may avoid certain pitfalls. For instance, it is crucial for partners to express their feelings to one another and not to sugarcoat them. Partners will experience many powerful and disturbing feelings that they need to acknowledge. That being said, it is important to recognize and respect differences in the way men and women react to and cope with infertility. A husband does not have to share the intensity of a wife’s desire for children in order to love and support her. If there are differences in motivation to have a child or to pursue treatment it is important to be clear at the outset. Pushing a spouse into a major life decision is a big responsibility that may lead to serious repercussions later. However, once a decision has been made, it is essential for both partners to share responsibility for treatment.

It is crucial that couples avoid becoming isolated. However, they must weigh the pros and cons of when, how much and with whom to share. Sometimes couples must tell others how they would like them to relate. For instance, some couples will tell an intrusive parent “Stop asking every time we talk. We’ll promise to call and tell you when something is new”. Family and friends who want to be supportive need to learn about the emotional effects of infertility in order to understand how serious and painful this period can be. They will then be better prepared to listen and offer understanding and sympathy, rather than pity or superficial advice. When one is unsure, one can always ask a couple how they would like one to relate to the issue.

Lastly, couples must prepare to deal with prolonged uncertainty. At times they must be strong and determined; at others they must allow themselves to acknowledge and express frustration and helplessness. They must learn to grieve losses that are not tangible - loss of self-image, sex life, social support, loss by miscarriage - rather than carry on like nothing happened.

Years after fertility treatment many couples still bear the emotional scars of their experience. For instance, a husband may have passively participated in fertility treatment rather than expressing his reservations about having a child. Today, the wife still resents the fact that she felt alone in the process and responsible for shouldering the burden, whereas the husband feels she did not take his wants or needs into account. Another example is a husband insisting that the couple keep his diagnosis and the fertility treatment private. The couple struggled alone for years with no support from family and friends. These couples have come to realize that it was not enough to have endured the infertility crisis. Although the difficult period has passed what remains today is the imprint of how they coped and related to one another.

Eli Karlen is a clinical psychologist and certified sex therapist working in the Galilee. www.karlen.co.il