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Patterns of suffering and social interactions in infertile men: 12 months afterunsuccessful treatmentLaura A. Peronace a; Jacky Boivin a; Lone Schmidt ba School of Psychology, Cardiff University, Cardiff, Wales, UK b Institute of Public Health, University of

Copenhagen, Copenhagen, Denmark

Online Publication Date: 01 January 2007

To cite this Article Peronace, Laura A., Boivin, Jacky and Schmidt, Lone(2007)'Patterns of suffering and social interactions in infertilemen: 12 months after unsuccessful treatment',Journal of Psychosomatic Obstetrics & Gynecology,28:2,105 114To link to this Article: DOI: 10.1080/01674820701410049URL: http://dx.doi.org/10.1080/01674820701410049

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Patterns of suffering and social interactions in infertile men:12 months after unsuccessful treatment

LAURA A. PERONACE1, JACKY BOIVIN1, & LONE SCHMIDT2

1School of Psychology, Cardiff University, Cardiff, Wales, UK, and 2Institute of Public Health, University of Copenhagen,

Copenhagen, Denmark

(Received 17 January 2007; accepted 6 April 2007)

AbstractResearch shows that men diagnosed with male factor infertility experience more suffering than men with infertility due toother causes, and that it is socially unfavourable to be diagnosed with male factor infertility resulting in secrecy surroundingdiagnosis, sometimes to the point that women take the blame for the couples infertility. We investigated mental and physicalhealth, support, and psychological and social stress in men (N 256) prior to and after 12 months of unsuccessful treatmentaccording to their diagnosis: unexplained, female factor, male factor, or mixed. Results suggest that men do not differ bydiagnosis on any of the variables tested. When treatment was not successful, all men showed increased suffering in the formof decreased mental health, increased physical stress reactions, decreased social support, and increased negative social stressover time. These findings indicate that involuntary childlessness is difficult for all men, and is not dependent on with whomthe cause lies. There was also a high level of agreement between couples and medical records on the cause of the couplesfertility arguing against the idea that women take the blame for male factor infertility.

Keywords: Infertility, diagnosis, distress, stress, support, secrecy, male factor

Introduction

Male factor infertility is involved in up to 50% of all

cases of infertility but there is a limited amount of

research that examines the effect of a male factor

diagnosis on a mans physical and psychological well-

being. The research that does exist has generated two

main propositions with regards to men and male

infertility. First, men with male factor infertility are

proposed to suffer more compared to men with other

infertility diagnoses [14]. Second, male factor

infertility is proposed to have such a social stigma

that it produces much negative social stress, and a

culture of secrecy and protectiveness to the extent that

women sometimes even take the blame for the

couples childlessness [57].

It has been reported that mens experience of male

factor infertility was more intense then that of men

with female factor infertility [3], in that the former

reported higher levels of infertility distress [2], and

increased anxiety over time [4]. Kedem [1] found that

men with suspected male factor infertility reported

increased self-blame, lower self-esteem and increased

social isolation compared to men without suspected

male infertility. Other studies do not find a difference

according to diagnosis in male well-being. For

example, Lee [2] found that distress, marital and

sexual satisfaction did not differ according to diag-

nosis. Connolly [4] reported an increase rather than a

decrease in overall physical health in men with male

factor infertility. Van Balen [7] did not find any

differences among diagnostic groups with respect to

how their social network reacted to their diagnosis,

and most infertile men reported positive reactions

when they disclosed to others.

These variations in research findings may be due to

methodological issues, in particular to the fact that

studies tend to be cross-sectional and make assess-

ments at different time points in the medical

experience, for example at the time of diagnosis

[1,8,9], during treatment [2,3,10] or at other time

points [11,12] making it difficult to delineate the

source of the stress. These findings highlight the need

for longitudinal evaluations. Given the considerable

amount of time couples now spend in treatment, it

would be important to assess the effect of diagnosis on

male well-being, especially in couples who are

unsuccessful with treatment. Many studies have

shown that couples report significant distress when

treatment fails [1317]. Van Balen [18] reported that

Correspondence: Jacky Boivin, School of Psychology, Cardiff University, Cardiff, Wales, CF10 3AT, UK. Tel: 44 (0)2920 874007.E-mail: boivin@cardiff.ac.uk

Journal of Psychosomatic Obstetrics & Gynecology, June 2007; 28(2): 105114

ISSN 0167-482X print/ISSN 1743-8942 online 2007 Informa UK Ltd.DOI: 10.1080/01674820701410049

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couples with long-term infertility, who have faced

much treatment failure, report higher levels of

depression, low satisfaction with their sex lives, and

low levels of well being. In the present study we

examined whether men with a male factor diagnosis

experienced a greater increase in distress in a 12

month period of unsuccessful treatment than did men

with other diagnoses.

Van Balen proposed that spouses may be motivated

to protect each other from the stigma of infertility and

this may be particularly true when the infertility was

due to a male factor [7]. One of the key features of

social stigma described by Goffman [19] is a discre-

dited moral status. Couples have reported feeling

morally judged with regards to their infertility and

decisions to use assisted reproductive technologies

[20]. Negative comments have included such things

as infertility is an act or even punishment from God

[20]. In support of Goffmans theory Carmeli [5]

reported that it was common for couples to report

secrecy and misdirection with regards to their infertility

diagnosis. For example, women reported telling family

and friends that the source of the couples infertility

was hers when, in fact, the diagnosis was male factor. It

has also been reported that men perceive infertility to

be more socially acceptable for a women than for a

man [6]. In addition, men reported feeling that there

was social support for infertile women whereas they felt

ridiculed [5]. In the present study we examined the

stigma of male infertility in a number of ways. First, if

couples were more motivated to protect each other,

one would expect disagreements to exist between self-

reported diagnosis and diagnosis indicated by the

spouse but more importantly by the medical records,

especially in male factor infertility. Van Balen [7]

found that 38% of couples disagreed with medical

records with regards to their diagnosis. Second, men

with male factor infertility would be less likely to talk to

other people regarding their infertility and reasons for

their infertility as compared to men with any other

infertility. Third, if stigma is an issue one would also

expect men with male factor infertility to receive less

understanding and more negative comments from

those around them than men with any other infertility

diagnosis.

The nature of the relationship between social

environment and psychological well-being is still

unclear. Although it is well accepted that they interact

[21], the direction of that interaction it is less clear.

Some have found that social support predicts psycho-

logical well-being and health [22] or even buffers the

effects of stress on physical and mental health [23]

whereas others have found the reverse in that chronic

personal stress has a negative impact on the social

environment [24]. To address this issue we examined

to what extent personal and social stress at the start of

treatment predicted mental health and perceptions of

the social environment 12 months later.

The aims of the present longitudinal study were to

investigate the issues of suffering and the negative

social environment experienced by men with male

factor infertility in a sample of men who were

unsuccessful with treatment. Men were participating

in the Copenhagen Multi-Centre Psychosocial In-

fertility (COMPI) research program, which is a

longitudinal psychosocial investigation of infertile

couples in Denmark (see Schmidt et al. [25] and

Boivin et al. [26]). Mental health, fertility problem

stress, coping and social support were assessed at the

onset of treatment and 12 months later, and com-

pared in men across four diagnostic groups. Based on

the research reviewed it was hypothesized that the

stigma of male factor infertility would manifest in

greater reporting inaccuracies with respect to diag-

nosis and more suffering and social stress in men with

male factor infertility compared to men with other

diagnoses. Further, we predicted that pre-treatment

psychological and social stress would predict these

same variables at 12 months follow-up.

Methods

Sample

The final sample consisted of 256 Danish men whose

partners had not become pregnant during a 12

month period of treatment and who had participated

in the first (Time 1 [T1]) and 12-month follow-up

assessment (Time 2 [T2]) in the COMPI research

program. The sample represented 77.6% of non-

pregnant couples (N 330) in the COMPI project(N 818), with remaining men (n 74) from non-pregnant couples not eligible because they had not

responded to the question regarding their diagnosis

in the T1 questionnaire.

Men in the final sample had been infertile longer

than men in pregnant couples in the COMPI sample

(n 488) (t(1,659) 5.67 p5 0.05: M 4.37, SD2.37; M 3.97, SD 1.86, respectively) and hadattempted more treatment cycles (t(1,659) 50.18p5 0.001), M 2.59, SD 1.34; M 1.85, SD1.28, respectively) in the 12 month duration of this

study. No other differences were found between

men in subsequently pregnant versus non-pregnant

couples.

Materials

The COMPI questionnaire booklet contains numer-

ous questions about health, support, stress, and

coping with infertility (see Schmidt et al. [25] for a

more detailed description of materials). Only those

questions relevant to the present study are described.

All questionnaires were translated into Danish and

then back translated into English unless validated

Danish versions already existed. Translations were

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done by two people independently, back-translated

into English by two other people, and finally com-

pared for conceptual correspondence. Differences

were resolved by a third native English speaker.

In the present study, internal reliability was mea-

sured by Chronbach alpha coefficients and was above

0.70, and considered good for all measures.

Sociodemographic and medical information. These

questions were used to obtain demographic (e.g.,

age, years married, children, social position) infor-

mation. Also included focus on being a parent (e.g.,

Having a child is very important to me) which

contained three items rated on a five-point likert-

scale from strongly disagree (1) to strongly agree

(5)). Medical information included diagnosis, num-

ber of years of infertility, previous treatment experi-

ence, number of treatment cycles in the last 12

months).

Fertility problem stress. The Fertility Problem Stress

Inventory [27,28], was designed to assess overall

disruption and stress created by fertility problems in

relation to specific life domains. Subscales included

Personal stress which contained six items , Social

stress which contained four items, and Marital

stress which contained four items (see Boivin et al.

[26] for a more detailed description of the subscales).

Items were rated on two different likert-scales, five-

point and four point respectively (i.e., either strongly

disagree (1) to strongly agree (5) or none at all

(1) to a great deal (4)). For all variables, higher

scores indicated greater FP stress. The range was 6

26 for the personal subscale, 416 for the social

subscale, and 418 for the marital subscale.

Mental and physical health. General mental health was

assessed using the nine-item mental health and

energy-vitality subscale of the Short-Form-36 Inven-

tory (SF-36:[29,30]). Participants were asked about

their mental health and energy levels over the past

four weeks and rated each statement (e.g., Have you

been a very nervous person) on a six-point response

key ranging from all of the time (6) to none of the

time (1). The validity of the SF-36 subscales has

been established in numerous medical populations

[31]. Higher scores on this measure indicated better

mental health (possible range 954).

Physical health was assessed using a nine-item

Physical stress reactions subscale of the Stress

Profile questionnaire [32] and an additional two

items from the Pennebaker PILL inventory [33].

Items on this subscale assessed a variety of physical

reactions (e.g., racing heart, muscle tension)

which could occur as a result of stressful situations.

The measure has shown good psychometric proper-

ties: it has high internal reliability and can discrimi-

nate between groups experiencing high and low work

stress [32]. Participants indicated how frequently

they experienced each symptom in the past four

weeks using a five-point response key ranging from

very often (5) to never (1). The total score was

used for analyses with higher scores indicating more

physical stress reactions (possible range 145).

Coping. The 19-items used for this measure were

adapted from the Ways of Coping (WOC) Checklist,

a process-oriented measure of coping derived from

Lazarus and Folkmans transactional model of stress

[3436] (See Schmidt et al. [37] for a more detailed

description). Participants were requested to rate each

item according to how they coped with infertility

using a four-point response key ranging not used

(1) to used a great deal (4). Higher scores on this

factor indicated more coping effort, possible range

from 519.

Social environment. Social relations were assessed

using 4 items from the theoretical model of support

and strain derived in the Danish Longitudinal

Health Behaviour Study [38]. Social relations were

examined using two 4-item variables; support and

understanding from those around you (i.e., spouse,

family, friends), and negative reactions and com-

ments from those around you. Both were assessed

using a five point likert-scale ranging from always

(5) to never (1) with higher scores indicating greater

understanding or more negative comments.

Openness about infertility. Mens willingness to discuss

their infertility with people around them was assessed

for three types of information: not being able to have

children, reasons why they could not have children,

and emotional feelings. Categorical responses were

scored on a three-point response key: (1) not to other

people, (2) only to close people, (3) to most people I

know.

Treatment cycles and outcome. At the 12-month

follow-up, participants were asked to detail their

treatment experiences since completing the first ques-

tionnaire. First, participants were asked to indicate

the types of treatments they had received and the

number of treatment cycles they had undergone.

Second, participants were asked to indicate whether

they had achieved a pregnancy or not and if they had,

whether their partner was currently pregnant or had

delivered.

Diagnostic information. Data about diagnosis was

collected from three sources. First, men were asked

to indicate the cause of their fertility problems by

checking one or more of the following: my partners

tube(s) is/are blocked, my partner has irregular

ovulation or anovulation, I have decreased sperm

quality, no cause was proven, other. Four categories

Suffering and support in infertile men 107

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were derived from this information, and which

determined to which diagnostic group the couple

was assigned for the purposes of analysis. The

unexplained group was assigned if only no cause

was proven was indicated, the female factor group

was assigned if my partners tube(s) is/are blocked

and/or my partner has irregular ovulation or

anovulation was indicated, the male factor group

was assigned if I have decreased sperm quality was

indicated, the mixed group was assigned if a com-

bination of female factor and male factor were

indicated. Second, diagnostic information was

also obtained from the spouse who separately com-

pleted this questionnaire item. Finally, for a subset

of men, (n 90), the factual diagnosis as recordedby medical doctors was extracted from patients

medical charts.

Procedure

Infertility clinics were contacted to enlist their

participation in the COMPI project. Interested

clinics were given a presentation that detailed what

would be required of clinic staff and patients. All

clinics (n 5) agreed to distribute questionnaires.Clinics were provided with all necessary materials

including questionnaire booklets for men and women

as well as pre-addressed, stamped envelopes for the

return of completed questionnaires. Couples re-

ceived questionnaires approximately two weeks prior

to treatment (T1) and again 12 months later (T2).

Spouses were instructed to complete questionnaires

separately, within 10 days of receipt and to post the

completed questionnaires in the envelopes provided.

Participants who did not wish to participate returned

an enclosed non participating form. If the ques-

tionnaires or non participating forms were not re-

ceived, participants were sent a maximum of two

reminders at 10-day intervals. Data for this study

were collected between January 2000 and August

2001 (T1) and between January 2001 and August

2002 (T2).

The Scientific Ethical Committee of Copenhagen

and Frederiksberg Municipalities assessed the study;

the study complied with ethical standards according

to the Helsinki II declaration. The Danish Data

Protection Agency also approved the study.

Data analysis

Analysis of Variance (ANOVA) was used to assess

differences between diagnostic groups in age, years

married, years infertile, focus on being a parent,

previous treatment experience, number of treatment

cycles in the 12 month study period. For the

categorical or ordinal variables whether you have

children or not, social position, and do you talk to

other people regarding your infertility, chi-squared

was computed (w2). To assess change over time, a 4(Diagnosis: Unexplained, Female, Male, Mixed)6 2(Time: T1, T2) mixed model ANOVA was com-

puted with time as the repeated measure. The

dependent variables for these analyses were: mental

health, physical stress symptoms, negative com-

ments, understanding, coping, and personal, social

and marital fertility problem stress. Regression was

used to assess the relationship between mental well

being (i.e., SF-36) and social environment (i.e.,

support and understanding, negative comments).

Time 2 social environment was predicted from Time

1 mental health, after controlling for Time 1 social

environment female age and years infertile. Time 2

mental health was predicted from Time 1 social

environment controlling for Time 1 mental health,

female age and years infertile. The alpha level was set

at p5 0.05.

Results

Concordance about diagnosis among men,

their partner and doctors

Men were categorized into four groups based on their

self-reported diagnosis on the questionnaire, as

described previously. The distribution according to

self-reported diagnosis was: unexplained (n 81,31.6%); female (n 79, 30.9%); male (n 75,29.3%), and mixed (n 21, 8.2%). The diagnosisreported by men was not significantly different (w2(3,n 330) 5.71, p 0.126) from the diagnosis givenby their partner. Overall there was 87.9% (n 225)agreement between spouses. In the 12.1% of couples

who disagreed, 2.7% disagreed about unexplained

diagnosis, 3.5% disagreed about female factor

diagnosis, 5.1% disagreed about male factor diag-

nosis, and 0.8% disagreed about mixed diagnosis. In

the sub-sample where medical records could be

obtained mens self-reported diagnosis did not differ

significantly from the diagnosis reported in the

medical records (w2(3, n 90) 2.76, p 0.430)with agreement in 80% of the cases. Of the 20% of

men who disagreed with the medical records, 2.2%

disagreed about unexplained diagnosis, 4.4% dis-

agreed about female factor diagnosis, 5.6% disagreed

about male factor diagnosis, and 7.8% disagreed

about mixed diagnosis.

Demographic and medical characteristics

Table I shows summary statistics for sample socio-

demographic and medical characteristics. Overall

there were no differences between diagnostic groups

on any of these variables.

Overall men were in their mid 30 s, (M 34.0years old, SD 5.0 years). Couples had been marriedalmost 8 years (M 7.6 years, SD 3.7 years),

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the majority of couples had no children either to-

gether or from previous relationships (77.7%,

n 199). Most men (93.4%, n 239) were employedand were skilled or white collar workers (60.9%,

n 156). Also, men were moderately to highlyfocused on being a parent (M 12.9, SD 2.2).

There was no significant difference between dia-

gnostic groups according to medical information.

The average duration of infertility was (M 4.3,SD 2.4) years, with a range of51 year to 16 years.Prior to the start of the present study couples had had

previous treatment mainly consisting of intrauterine

insemination (86.7% of the treated sample, n 222)but also in vitro fertilization/intracytoplasmic sperm

injection (IVF/ICSI) (13.3% of treated sample,

n 34) or both. In the male factor infertility group,5.3% (n 4) had used insemination with donorsperm. In terms of treatment during the 12-month

study period, the majority of couples, 91.8%

(n 275) underwent IVF or ICSI treatment. Theaverage number of treatment cycles was (M 2.6,SD 1.3) and ranged from 1 to 8, and was notstatistically different between diagnostic groups.

Personal, social, and marital stress

Figure 1 shows personal, social, and marital stress over

time by diagnostic category. For personal stress there

was no significant main effect of time or diagnostic

category (F(1, 245) 0.32, p 0.57; F(3, 245)1.02, p 0.38, respectively), nor was there an interac-tion (F(3, 245) 0.54, p 0.65). Social stress sig-nificantly increased over time (F(1, 245) 17.79,p 0.006) but diagnosis (F(3, 245) 1.25, p 0.16)and the interaction (F(3, 245) 0.716, p 0.54) werenot significant. Marital stress significantly increased

over time (F(1, 245) 20.56, p 0.000) but the maineffect of diagnosis (F(3, 245) 1.18, p 0.32) and theinteraction (F(3, 245) 0.42, p 0.74) were notsignificant.

Mental health, physical stress symptoms and coping

The results revealed that for mental health there was

a main effect of time (F(1, 247) 16.45, p5 0.001)where mental health decreased after 12 months

of treatment failure. The main effect of diagnosis

(F(3, 247) 0.81, p 0.49) and the interaction werenot significant (F(3, 247) 0.81, p 0.35) for thisvariable (Table I).

Table I also demonstrates that after 12 months of

treatment failure physical stress symptoms increased

for all groups (F(1, 248) 10.61, p5 0.001), with nodifferences among diagnostic groups (F(3, 248)0.30, p 0.83), and no significant interaction(F(3, 248)0.94, p 0.42).

Finally, coping effort increased over time

(F(1, 249) 57.47, p5 0.001), but there was no

Table I. Summary statistics for sociodemographic, medical, mental and physical health, and coping variables by diagnostic group.

Unexplained Female Male Mixed

Variables n81 n79 n 75 n21

Demographics

Male agea (M, SD) 34.3 (4.74) 34.2 (5.09) 33.4 (4.52) 33.5 (6.72)

Years married (M, SD) 8.30 (4.10) 7.12 (3.64) 7.49 (3.35) 7.67 (3.51)

Previous children (n, % yes) 21 25.93 21 26.58 13 17.33 2 9.52

Social position (n, %) Unemployed 5 6.17 4 5.06 6 8.00 2 9.52

Unskilled 13 16.05 22 27.85 16 21.33 5 23.81

Skilled 56 69.14 45 56.96 43 57.33 12 57.14

Professional-Executive 7 8.64 8 10.13 10 13.33 2 9.52

Medical

Years infertilea (M, SD) 4.46 (1.95) 4.31 (2.32) 4.01 (2.54) 5.48 (3.16)

Treatment experience prior

to the study (n, %)

Conventional 74 91.36 68 86.08 62 82.67 18 85.71

IVF/ICSI 7 8.64 11 13.92 13 17.33 3 14.29

Treatment cycles in the 12 month

study period (n, %)

Conventional 8 9.88 5 6.33 7 9.33 1 4.80

IVF/ICSI 73 90.12 74 93.67 68 90.67 20 95.20

Psychological and Physical Health

Physical Health (M, SD) T1 13.00 (3.92) 13.11 (4.30) 13.47 (4.42) 13.90 (4.56)

T2 14.20 (5.77) 13.37 (5.12) 14.58 (5.29) 13.62 (4.44)

Mental Health (M, SD) T1 43.96 (6.76) 44.83 (6.41) 43.80 (5.86) 43.33 (10.02)

T2 41.25 (8.77) 43.46 (6.94) 42.27 (7.83) 43.43 (7.90)

Coping effort (M, SD) T1 10.27 (1.46) 10.27 (2.07) 10.77 (1.48) 10.75 (1.91)

T2 11.11 (1.81) 11.23 (1.72) 11.39 (1.74) 11.04 (1.77)

Focused on being a parent (M, SD) 12.8 (2.11) 12.9 (2.39) 13 (2.08) 12.9 (2.12)

SD, standard deviation; T1, time 1; T2, time 2; M, Mean.

Suffering and support in infertile men 109

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significant main effect of diagnostic category

(F(3, 249) 1.62, p 0.29), or interaction(F(3, 249) 1.03, p 0.38) (Table I).

Social environment

Figure 2 shows the mean values (+SE) for negativecomments where the main effect of time (F(1, 231)21.53,p50.001), diagnosis (F(3, 231) 3.1,p50.05)and the interaction (F(3, 231) 2.93, p50.05)were significant. Follow-up tests revealed that the

unexplained group received more negative comments

over time then did the female and male factor groups

(p50.05).Figure 2 also shows the mean values (+SE) for

understanding experienced by the men where

there was a main effect of time (F(1, 231) 205.8,p5 0.001). Men reported less understanding overtime but there was no significant main effect of dia-

gnostic category (F(3, 231) 1.18, p 0.32) orinteraction (F(3, 231) 1.57, p 0.20).

Chi-square revealed that there were no differences

between groups on the willingness of men to talk to

people around them; the majority of men preferred to

talk only to close people about not being able to have

children (n 147, 57.4%), reasons why they couldnot have children (n 154, 60.2%), and emotionalfeelings (n 133, 52%).

Relationship between social environment and mental

health

Results of the regressions revealed that poorer

mental health at Time 1 (70.177 t(227)71.93, p5 0.05) predicted more negative commentsat Time 2 after controlling for age, years infertile and

negative comments at Time 1 (F(4, 230) 12.66,p5 0.01). Poorer mental health at Time 1 alsomarginally predicted less understanding at Time 2

after controlling for age, years infertile and under-

standing at Time 1 (F(4, 230) 2.09, p 0.083).The regressions analysis predicting Time 2 mental

health from Time 1 social environment were not

significant.

Discussion

Three principal findings emerged from this investi-

gation. First, there was no evidence to support the

idea that there was more stigma or protectiveness

among men with male factor infertility. Second, men

with male factor infertility did not suffer more than

men with other diagnoses, and all men showed

increased suffering over time when treatment was not

successful. These findings indicate that infertility and

failed treatment are a challenge and emotionally

demanding for most men.

One main finding was that most men were open

about their fertility problems. Past research has

shown poor agreement between husbands and wives

report of infertility medical information [7,39]

particularly for recall of information related to male

factor infertility [5]. One cause of this discrepancy

may be the desire of couples to protect the man from

the stigma of infertility [7]. In the present investiga-

tion agreement was high between spouses and

between men and physicians reports, in the 20% or

so of cases where disagreement existed there was no

evidence of greater dispute in the group of men with

male factor infertility. We also found that men across

diagnostic groups reported equal levels of talking to

other people (e.g., close friends, family) about their

Figure 2. Mens mean scores of support variables, negative comments and understanding at Time 1 and after 12 months of treatment at

Time 2 by infertility diagnosis. Asterisk demotes a statistical significance between T1 and T2 across all groups (p5 .001). Cross denotesstatistical significance between unexplained group, and male and female groups (p5 .05).

Suffering and support in infertile men 111

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infertility, its causes and its emotional impact on their

lives at Time 1 when social environments were

reported as being supportive. Together these results

would suggest that most men, including those with

male factor infertility, were open about their fertility

problems.

These findings diverge from those of previous

research, and this may be due to several factors. First,

a discrepancy between spouses or between patient

and medical records may be due to miscommunica-

tion rather than to secrecy. For example, Van Balen

[7] found that 38% of couples could not recall the

correct diagnosis after speaking with their phy-

sicians. Today couples may be more informed about

fertility issues compared to a decade ago, for example

through greater use of the internet to access fertility

information therefore leading to more accurate

knowledge among patients [40]. Second, if the

possible use of donor sperm and the subsequent

withholding of that information from potential off-

spring was the reason for secrecy in past work [41],

then the low incidence of treatment with donor sperm

in our study (i.e., 5%) may explain why there is more

openness about diagnostic information in our

work compared to before the use of ICSI became

conventional.

A second main finding of the study was evidence

that mens social network became more negative and

less supportive over time, with greater overall social

stress. It has previously been found that depending

on the social group investigated (family and close

friends) social support is overall positive [7]. This

study finds evidence in line with these findings

however, due to the longitudinal nature of this

design we also demonstrated that social support

was not stable and in fact deteriorated over time for

all men, particularly men with unexplained infertility.

It has previously been reported that personality,

social behaviour, and anxiety levels change in men

with unexplained infertility [42], and that women

with unexplained infertility are more depressed and

more anxious than controls [43]. However, other

studies report no differences between unexplained

infertility versus other infertility diagnosis in couples

[44,45], which is more consistent with the majority

or results found here. Overall our results show that

men perceive their social environment to be less

supportive over time.

A third main finding was that across all diagnostic

groups, suffering increased over time when treatment

was not successful indicating that suffering was not

specific to male factor diagnosis or disproportionate

for this group. Suffering included psychological

deterioration as evidenced by increased general

mental anguish (e.g., despondency, irritation) and

physical stress reactions (e.g., muscle weakness,

chest pain) and a concomitant increase in the coping

effort required to manage fertility problems. This

pattern of results indicates that it is persistent

involuntary childlessness that is taxing and leads to

suffering and not simply the self-blame of being the

cause of the couples infertility, as would be

suggested if men with male factor infertility suffered

more then men with other diagnoses.

An important issue to address, given the parallel

deterioration in psychological suffering and social

environment is to what extent these two life aspects

impact on each other. The link between psychological

and social suffering is likely to be bi-directional.

DeLongis [21] found people with unsupportive social

environments were more likely to experience somatic

problems. Also, Cohen and Wills [23] found that

social support attenuated or buffered the effects of

stressful events and others have found that support

was predictive of well-being [22]. However, Thoits

[46] reported that some stressful events could result

in a loss of social support. Specifically chronic stress

(e.g., depressive symptoms, death of a close family

member) can lead to increased cost for the social

network eventually leading to reduced social support.

In the present study, it was found that the causal path

was stronger for the influence of mental health on

perceptions of the surrounding environment (e.g.,

negative comments and understanding). A persistent

lack of treatment success and the increased emotional

suffering which it causes may act as a chronic stressor

that places a great burden on social networks. This

burden may cause a breakdown in social support

eventually contributing to further increased stress

over time.

In conclusion our findings contribute to the much

needed research on mens reaction to infertility and

infertility diagnosis. Our results showed that men

with male factor infertility do not suffer more then

men with infertility due to other causes. When

treatment is not successful mens physical and

mental health deteriorates, as well as, their suppor-

tive environments. Also, we did not find evidence to

suggest that secrecy exists with regard to diagnosis. It

is important that mens suffering regardless of

diagnosis be recognised and dealt with. This research

combined with the findings that increased stress can

predict treatment outcomes [26] suggest that it is

important to conduct further investigation regarding

interventions on suffering which may then lead to

increase in treatment success.

Acknowledgement

The Infertility Cohort is a part of The Copenhagen

Multi-centre Psychosocial Infertility (COMPI)

Research Programme initiated by Dr L.Schmidt,

University of Copenhagen, 2000. The programme is

a collaboration between the public Fertility Clinics at

Brdstrup Hospital; Herlev University Hospital;

The Juliane Marie Centre, Rigshospitalet; Odense

112 L. A. Peronace et al.

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University Hospital. This study has received support

from the Danish Health Insurance Fund (Jnr. 11/

09797), the Else and Mogens Wedell-Wedellsborgs

Fund, the manager E. Danielsens and Wifes Fund,

the merchant L. F. Foghts Fund, and the Jacob

Madsen and Wife Olga Madsens Fund. We would

also like to thank Cardiff University and Serono

International for their contributions.

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Current knowledge on this subject

. Some research has suggested that men with male factorinfertility suffer more then men with other diagnoses

and that there is much social stigma associated with

male factor infertility.

. A culture of secrecy exists with regards to male factorinfertility and women sometimes take the blame for the

couples infertility regardless of the diagnosis.

What this study adds

. All men suffer equally regardless of diagnosis.

. If treatment is not successful, social environmentdeteriorates for all men.

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