This study demonstrated an increased negative sexual and personal impact for male partners in couples with isolated male factor infertility. This effect was independent of age, partner age, race, religion, educational level, employment status, prior pregnancy, and prior paternity. These findings suggest that men who perceive themselves to be the sole contributor to the couple’s infertility feel less in control of their lives, less able to meet their goals, and more personally responsible for their fertility problems. Furthermore, this group of men has lower sexual satisfaction, more feelings of sexual failure, and less enjoyment of sexual activity. The magnitude of these differences suggests a clinically significant as well as a statistically significant difference [18
Interestingly, the group of men who did not know their diagnosis and men with isolated male factor infertility appeared to feel the greatest social impact; however, the 95% confidence intervals were too wide to convincingly rule out the possibility of no effect. These findings suggest that these men have problems discussing fertility concerns with friends and family, have problems with others understanding their concerns, and avoid social situations because of their fertility problems.
Although many studies have demonstrated a negative marital impact of male factor infertility, this was not observed in this analysis. A recent longitudinal 12-month study of infertile couples who failed management with IVF [19
] demonstrated that male factor infertility was not an independent predictor of physical or emotional distress; however, in that same study, emotional, marital, and physical stress increased for all groups over time. There are several possibilities why no difference was observed between infertility subgroups and marital impact in the present study. It may be that perception of infertility etiology does not significantly affect the quality of a couple’s marriage. While, in theory, a larger sample size might have allowed for the detection of a true underlying difference, it seems clear from these data that differences in marital impact scores were almost nonexistent. Alternatively, marital strain may develop over time and men with newly diagnosed infertility may begin to experience increasing marital strain over time as seen in the study by Peronace et al. Furthermore, the questions asked in this study may have ascertained different features of marital strain than those evaluated in the present study.
Infertility may place significant stress on a man’s social and marital relationships [15
]. Couples often feel that they lose control of the fertility process and over their own bodies [20
]. Infertility stress and unsuccessful treatment can result in significant negative marital effects [20
]. In a study of 256 couples treated unsuccessfully with IVF, male partners were found to have increased marital and social stress, decreased overall mental health, increased physical and social stress, and increased coping effort [19
]. No differences in risk of problems/stress were found between different etiologies of infertility, although not knowing
the reason for infertility had the greatest negative social impact.
Male partners of infertile couples may have worse overall mental health relative to normative data [11
]. Infertility in general is a risk factor for poorer mental health, but the diagnosis of male factor infertility has been associated with even greater risk for psychosocial problems and decreased quality of life. On average, men with male factor infertility have lower self-esteem and greater feelings of stigma and loss compared to men without male factor infertility [23
]. Furthermore, men who are diagnosed as responsible for the couple’s infertility report lower overall life satisfaction, heightened distress, and higher treatment-related anxiety after being diagnosed as the party responsible for the couple’s infertility [25
The underlying quality of marriage may influence or predispose men to personal, marital, or sexual strains; these problems may be unrelated to and predate the diagnosis of infertility. Strong marriages may help to protect individuals from the psychosocial stressors of an infertility diagnosis and subsequent treatment [26
]. Men with preexisting anxiety, depression, or dysfunctional coping styles may be at increased risk for psychosocial dysfunction when faced with the difficulties of this treatment [25
It has been shown that the interplay of stressors and coping mechanisms within each couple play a significant role in determining overall psychosocial impact [21
]. It is interesting to note that at study enrollment, in couples with male and female factor infertility, men did not experience greater impacts on their Personal, Social, Sexual, or Marital Impact scores compared with men without male factor infertility. Couples may have been supporting each other more actively in this group. Spousal support has been shown to be very important in coping with the stresses of an infertility diagnosis [21
]. A large study of the coping styles of men and women undergoing IVF found that women chose confronting, accepting responsibility, seeking social support, and escaping/avoiding styles more often than did men [32
]. They also found that men and women with escape/avoidance coping mechanisms had the highest levels of infertility-related stress.
Our results demonstrate an association between infertility and psychosocial impact, but causality cannot be definitively inferred from this analysis. While it seems most plausible that the diagnosis of infertility leads to negative psychosocial impact, a temporal association between psychological dysfunction and subsequent determination of semen analysis abnormality has been demonstrated [33
]. Poorer semen quality has been found in men under stress [34
]. Furthermore, it has been demonstrated that significantly worse fertility outcomes are seen for men and women with the highest psychological stress [36
]. If psychosocial impact is associated with worsened fertility outcomes, it would have significant implications for the treatment of infertile men.
Several limitations of our study merit mention. Our results suggest that the mechanism underlying the relationship between a man’s perception of infertility diagnosis and decreased quality of life is not significantly related to socioeconomic, demographic, or prior fertility characteristics. Despite these observations, this population may not adequately reflect a population of infertile men who have a lower socioeconomic status. It may be that imperfect measurement of these variables or inadequate sample size made it impossible to adequately adjust for these factors. Residual confounding by some of these variables might account for some portion of the differences identified. For example, our nonwhite sample size was too small to convincingly rule out different cultural experiences as an explanation for the differences seen, and differing cultural experiences have been shown to affect the experience of infertility [37
]. The validation process for this study did not evaluate the gender-specific implications of using female interviewers. While it is possible that male study participants did not accurately respond to female interviewers, we suspect that this potential bias had only a small effect. We did not adjust for baseline differences in psychological profiles or coping styles that might explain the differences we observed. This study also demonstrated a lower prevalence of isolated male factor infertility (12%) than in other studies (20–40%) [38
], likely representing the recruitment of couples based on the presentation of women to reproductive endocrinology clinics. Furthermore, only 15% of men in this study had been evaluated by a urologist prior to enrolling in this study. It is possible that men evaluated by a urologist would experience a lower psychosocial impact as a result of detailed discussion of the meaning of an infertility diagnosis. It is also possible that men without male factor infertility were more likely to participate, resulting in a higher prevalence of men less affected by the strains of male factor infertility. Inclusion of a broader sample of men may have resulted in larger differences than those identified in this data.
Male partners in infertile couples who feel that they are solely responsible for the couple’s infertility are at a higher risk for sexual, emotional, and psychological strain relative to men without this belief. Careful patient counseling and education regarding etiology and treatment options decreases the anxiety faced by infertile men [39
]. Feelings of control improve with timely reporting of test results, description of the diagnostic and treatment process, and clear estimates of the time commitment necessary for treatment [42
]. Reproductive care providers should screen their male patients for sexual, relationship, and other psychosocial problems and offer appropriate treatment or referral should they arise. This intervention may significantly decrease the amount of psychosocial strain experienced by men with an infertility diagnosis.