Małgorzata Pawelec
1, Jolanta Pietras
2, Danuta Wątroba
2,
Andrzej Karmowski
1, Bogusław Pałczyński
1, Mikołaj Karmowski
1,
Krzysztof Łątkowski
1, Łukasz Terpiłowski
The Emotional Disorders of Infertile Couples
Zaburzenia emocjonalne u niepłodnych par
¹1st Clinic of Gynecology and Obstetrics, Wroclaw Medical University, Poland ² Medical College LZDZ in Legnica, Faculty of Nursing, Poland
Abstract
Background. In Poland infertility still has a huge impact on the marriage, partners’ feelings and sexual behavior. Objectives. The aim of this study was to find out what percentage of the infertile population has emotional and sexual problems due to childlessness, how they prefer to describe them, and how the reproductive health service can solve them.
Material and Methods. An anonymous survey was conducted among 150 infertile couples – patients of the 1st Clinic of Gynecology and Obstetrics and the private surgeries of its medical staff. All couples complained of pri-mary infertility. For 50 couples it was the first visit and 100 couples were already undergoing treatment. The data was collected by means of interviews.
Results. Of 112 participants, 65 patients showed evidence of impaired social adjustment, 62 patients complained of significant emotional disturbance, 45 patients reported sexual dysfunction secondary to their infertility and 56 patients reported deterioration in the marital relationship.
Conclusions. Issues that are related to the inter-spousal relationship and communication are a very important aspect of infertility. Polish infertile couples find it very difficult to have a frank discussion of fertility issues and to show affec-tion to the spouse, which results in the decrease in intercourse frequency and frequency of feeling desire and willing-ness to initiate sexual intercourse. As the most important factors that would contribute to reducing the psychological problems of infertile couples, the respondents indicated the availability of all methods of infertility treatment, which should all be paid for by the national health service system (Adv Clin Exp Med 2011, 20, 5, 641–645).
Key words: infertility, couples, distress, sexual dysfunction, emotional stress.
Streszczenie
Wprowadzenie. Wśród polskich pacjentów niepłodność ma ogromny wpływ na funkcjonowanie małżeństw, wza-jemne uczucia i życie seksualne.
Cel pracy. Procentowe oszacowanie zaburzeń emocjonalnych i seksualnych wynikających z bezdzietności. Omówienie, jak bezdzietne pary opisują te problemy i jak służba zdrowia może pomóc niepłodnym parom w ich rozwiązaniu. Materiał i metody. Przeprowadzono anonimową ankietę wśród 150 niepłodnych par leczących się w I Klinice Ginekologii i Położnictwa we Wrocławiu oraz w prywatnych gabinetach autorów artykułu.Wszystkie pary były diagnozowane jako pierwotnie niepłodne. Dla 50 z nich była to pierwsza wizyta u ginekologa w związku z niepłod-nością, a 100 par było już w trakcie leczenia niepłodności. Dane z wywiadu oraz ankiety zostały poddane analizie. Wyniki. Wśród 112 osób, które udzieliły odpowiedzi 65 miało upośledzone przystosowanie społeczne, 62 – znaczą-ce zaburzenia emocjonalne, 45 zgłaszało wtórne zaburzenia seksualne, 56 – osłabienie uczuć małżeńskich. Wnioski. Ważnym skutkiem niepłodności jest pogorszenie się relacji międzypartnerskich. Polskie pary niemo-gące mieć potomstwa nie potrafią szczerze rozmawiać ze sobą o niepłodności i okazywać swoich uczuć, co pro-wadzi do zmniejszenia aktywności seksualnej, czułości i ograniczania zachowań inicjujących stosunki seksualne. Respondenci za najważniejsze czynniki, które zmniejszyłyby ich problemy psychologiczne związane z niepłodnoś-cią uważają dostępność wszystkich metod leczenia niepłodności oraz ich refundację przez narodowy system opieki zdrowotnej (Adv Clin Exp Med 2011, 20, 5, 641–645).
Słowa kluczowe: niepłodność, pary, smutek, dysfunkcja seksualna, stres emocjonalny.
Adv Clin Exp Med 2011, 20, 5, 641–645 ISSN 1230-025X
ORIGINAL PAPERS
Infertility is a frequent problem in all coun-tries, affecting about 10% of the population [1–3]. It is not only a problem of gynecology but also of psychiatry, psychology and sociology.
Psychological factors are among the possible causes of infertility and at the same time infertility has psychological consequences[2]. Women with infertility are significantly more likely to have de-pression or a history of dede-pression, with the first depressive episode occurring prior to the diagno-sis of infertility [4].
In Poland infertility still has a huge impact on marriage, partners’ feelings and sexual behavior [5–7]. Sexual intimacy is profoundly affected by in-fertility [8]. Inin-fertility and its treatment can be dev-astating for the couple [9]. The infertile couple is full of frustration and disappointment if a pregnan-cy is not easily achieved [10]. All issues are always discussed in terms of marital infertility. Regardless of which of the partners is treated, the emotional effects of frustration due to the unmet need to be a parent affect both partners. Clinical reports sug-gest a high incidence of psychological problems in this population [11]. The emotional reactions of one partner always affect the behavior and feelings of the other partner, that is, impede or aggravate them, although the kind of effect varies from couple to couple. Some couples strengthen their relation-ships, while in others the relations deteriorate and the marriage bond is weakened. It has been prov-en that the effect of childlessness is depprov-endprov-ent on many factors, which include the personality of the spouses, resistance to frustration, social support and the relationship between the two parties before the crisis. In less affluent countries, the problem of in-fertility and childlessness is more pronounced than in Western societies, owing to different cultural circumstances [12]. Also, access to infertility treat-ment is often limited by low income. For example, in Poland many medical procedures are very expen-sive and are not covered by the healthcare system.
The aim of this study was to find out about the kinds of emotional distress, psychological problems and infertility-related concerns in patients who vis-ited gynecologists. The authors were particularly in-terested in changes of sexual attitudes, depression, anxiety, guilt, tension in the relationship and isola-tion as a result of diagnosed infertility, as well as in the influence of the availability of advanced repro-ductive technologies and the time of the treatment on mutual relations between partners.
Material and Methods
An anonymous survey was conducted among 150 infertile couples reporting to gynecologists –
the authors of the study. They used the Hospital Anxiety and Distress Scale (HADS) [13], adding questions to it referring to sexual life, methods of infertility treatment, income and educational background. All couples complained of primary infertility. 50 couples were at an infertility clinic for the first time and 100 couples were already undergoing treatment. After putting together the interview and questionnaire data, the authors tried to identify recurring factors affecting the partners’ feelings and behavior towards each other.
Results
112 participants responded to the survey (the response rate was 37%), including 37 complete pairs. 32 couples had already seen a clinical psy-chologist. For the rest of the respondents, it was the first time they were asked questions about the emotional problems and marital reactions to the infertility. Of 112 participants, 62 complained of significant emotional disturbance (greater than 10 on the Hospital Anxiety and Depression Scale), with the ratio of women to men 3 to 1; 65 patients showed evidence of impaired social adjustment, 45 patients reported sexual dysfunction secondary to their infertility, 18 patients had primary sexual dysfunction, 56 patients reported deterioration in their marital relationship (Fig. 1). When asked to identify the most important factors adversely af-fecting their marriage, the respondents in 50% of cases indicated the problem of distance between partners, in 49% a sense of isolation in marriage, problems with having a frank discussion of fertility issues, and the difficulty in showing affection to the spouse, which resulted in the drop of intercourse frequency (71%), and lower frequency of feeling desire and willingness to initiate sexual intercourse (89%) (Fig. 2). This was particularly apparent in women, of whom about 65% reported self-blame and less life satisfaction and self-esteem.
changes in sexual behavior included: in about 18% of the couples, finding another sexual partner, about 43% noted a weakening of emotional close-ness, 32% lack of pleasure in having sex, replaced by waiting for conception, in about 61% sex was no longer a field of experimentation and innovation and became a routine physiological and social ac-tivity. The study showed that after one year of diag-nosed infertility, the average intercourse frequency dropped by half compared to the period before the diagnosis. Frequency of desire and a willingness to initiate sexual intercourse also dropped. None of the patients who split up with their spouse called infertility a direct reason for parting, indicating in-stead the factors such as lowering of desire, finding another partner and emotional abandonment.
Discussion
Present study demonstrates that finding the cause of infertility (the etiological factors) does not result in a complete disappearance of psychologi-cal problems, which is different than reported by other authors [11].
The response rate was 37%, which compared with a 38% response rate in a similar study in the
UK, shows there is similar openness of respondents [13]. Of 112 participants, 62 complained of signifi-cant emotional disturbance (greater than 10 on HADS), which is much more than in other studied populations, although the ratio between men and women remains the same [13]. The higher inci-dence in Poland may be the result of social factors: first, because the inability to have children is by many people considered a kind of flaw, and second, because of the social, cultural and religious profile of the population under study in Poland (e.g., rural vs. urban inhabitants). This is difficult to establish, as other publications usually do not describe in detail the kind of population under study, usually limiting the description to the phrase that the study involved the patients of some clinic in a certain area of the country. In some societies, infertility and sex-ual dysfunction are felt as stigmatizing [14]. Present study also confirms the findings of other publica-tions that sexual activity decreased as the number of childless years increased [14]. What these results do not confirm is the occurrence of strengthening and more supportive interspousal relationships connected to the prolongation of childlessness, re-ported by other authors [14].
In studied population, the number of divorc-es increased with the number of years of waiting 0 20 40 60 80 100 120
number of patients
total significant emotional disturbance secondary sexual dysfunction deterioration in marital relationship 0 10 20 30 40 50 60 70 80 90 % drop
frequency of desire and willingness to initiate sexual intercourse frequency of intercourse distance between partners
isolation in marriage
Fig. 1. The results of emotional stress in infertile population Ryc. 1. Objawy stresu emocjonal-nego wśród niepłodnych par
for the child. Also in this population, one of the main reasons of emotional stress turns out to be the socioeconomic status of couples which does not allow them to intensify the treatment or use in vitro fertilization, which is similar to other popula-tions [15, 16]. Advances in assisted reproductive technologies such as IVF can give hope to many couples when the treatment is available [17]. Es-pecially among men, strong positive association is observed between income and education and aver-age offspring count [15]. For reasons of social jus-tice, the diagnosis and treatment of infertility for couples with low income should be free. Childless-ness among them often leads to severe psychologi-cal and social suffering [12]. Many scientific soci-eties recommend fertility clinics for those infertile couples who ask for more psychological support. There are education programs focused on improv-ing communication and lowerimprov-ing stress among in-fertile couples in developed countries [18]. Present results show that it is important to know about the psychological problems among infertile patients and there is a demand for knowledge on how to manage depression symptoms related to infertility and infertility treatment [19]. Psychiatrists or oth-er health care professionals can educate patients about stress and depression symptoms, about the side effects of infertility treatment medications and the impact they have on psychological well-being, and about long-term emotional status con-nected with gestation, gamete donation etc. [17, 20]. Evidence is emerging for links between the stress of fertility treatment and patient drop-out and pregnancy rate [17]. Also, stress management skills help to allow the patients to change the oc-currence, frequency and content of communica-tion [8, 9, 18]. Especially among women, these
skills were felt to benefit marriage and warm the relationship [18].
Psychological well-being makes it possible to avoid grief, depression and stress [20]. Clinicians practicing in infertility should bring awareness to their patients’ sexual function [8]. As present re-sults show, acknowledging that sexual function is a valuable part of relationship makes it easier to warm the relationship and contributes to making conception more likely. Further research is needed to understand the association between distress and fertility outcome, as well as effective psychological management [17].
The authors concluded that in planning the treatment of infertility, clinicians should pay atten-tion to psychological problems and support their pa-tients in avoiding sexual dysfunction, deterioration of the interspousal relationship and cultural stigma-tization. As assisted reproductive technologies can give hope to many people, the mere prospect of the availability of in vitro fertilization (brought about by cost-free treatment of infertility, the availability of infertility clinics or the economic status of the in-fertile couple) becomes a means of preventing these disorders. If the partners have access to effective in-fertility treatment, they tend to undergo fewer emo-tional changes. Childlessness leads to a decrease in sexual activity and sexual dysfunction secondary to the infertility. Distress, depression, anxiety, guilt, tension in the relationship, frustration, the demol-ishing of the relationship, a lack of family bonds, and loss of purpose in one’s professional career are among the most commonly perceived consequenc-es of infertility. Sexuality is strongly connected with self-esteem, depression and anxiety. Secondary sexual dysfunction leads to divorces, loss of sexual intimacy and enjoyment.
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Address for correspondence:
Małgorzata Pawelec
1st Department and Clinic of Obstetrics and Gynecology Wroclaw Medical University
Chałubińskiego 3 50-368 Wrocław Poland
Tel.: +48 602 253 158 E-mail: [email protected]
Conflict of interest: None declared
