In general, the term infertility refers to when a couple have failed to conceive, despite having had regular, unprotected sex for one year.

Infertility is a common problem. In the U.S, around 6% of married women aged between 15 and 44 years fail to achieve pregnancy after one year and about 12% of that age group, regardless of marital status, have impaired fecundity – the ability to conceive or carry a pregnancy to term. Around 5% of couples in developed countries experience primary infertility, which describes an inability to conceive in the first place, or secondary fertility, which refers to when a woman has given birth previously but is currently unable to conceive or carry a pregnancy to term.

Various treatments are available to help infertile couples, ranging from medications that regulate ovulation through to surgical procedures to treat endometriosis, for example, and assisted conception, which may be intrauterine insemination (IUI) or in vitro fertilization (IVF).

Experts had previously thought that only around half of all problems with fertility were physical in origin, with the remainder being unexplained or a result of psychosomatic issues on the woman’s part. However, research now shows that the majority of infertility cases have a physical origin, which may involve one partner or both. In around one-third of cases, the problem lies with the man, in one-third it lies with the woman and in around one tenth of cases, both partners have a fertility issue. In 10 to 20% of cases, no cause of the infertility can be established and the problem is classed as unexplained.

Although the cause of infertility is generally physiological, the resulting stress and heartache, often due to the emotional physical effects of infertility treatments, can have a huge psychological impact. One study involving 200 couples visiting a fertility clinic showed that about 50% of the women and 15% of the men described infertility as the most distressing experience of their lives. Another study of 488 women who completed questionnaires before taking part in a stress reduction initiative, concluded that infertile women experienced the same degree of depression and anxiety as people diagnosed with high blood pressure, cancer or recovering from myocardial infarction.

Less research exists into the psychological impact on men, although studies to date have shown that men tend to report less feelings of distress than women. However, one study found that men’s reactions to infertility may depend on which partner is diagnosed with a fertility problem. When the problem lies with the female, men do not report feeling the same degree of distress as women do, but men who find out they are themselves infertile report the same levels of depression and low self-esteem as females do.

Some contributing factors to the depression and anxiety felt as a result of infertility include medication side effects, financial concerns and uncertainty about treatment outcomes. Typical emotional reactions include shock, depression, grief, frustration, decreased confidence, low self-esteem and loss of a sense of control over the future. This can have detrimental effects on relationships, not only with a partner, but with friends and family who may inadvertently cause distress by offering opinions and advice. A couple may begin to avoid interaction with friends or family who have children or are pregnant. They may also experience sexual dysfunction as a result of anxiety and other marital problems.

Medication side effects

The medications used to treat infertility can cause a range of psychological side effects. The estrogen drug clomiphene, commonly prescribed to boost ovulation, can cause disrupted sleep, anxiety, irritability and mood swings. Some other drugs can lead to mania, depression and disrupted thought processes. Both clinicians and patients may find it difficult to pinpoint whether the side effects are psychological or caused by medications, but it is essential to identify the cause in order to determine how to proceed.

Financial concerns

Infertility treatments can be extremely costly. In the U.S, the average cost is around $8,000 for a cycle of IVF and around $3,000 to $5,000 for the fertility drugs required for each cycle. Among individuals who cannot afford these costs or are not covered by insurance, not having access to treatment can contribute to feelings of hopelessness and helplessness. Even people who do have insurance may find the coverage is limited and that they must pay significant amounts.

Uncertainty about treatment outcomes

Generally, treatment interventions are effective in about half of cases, although the likelihood of successes decreases with increasing age. Patients who learn that treatment has been successful may feel overjoyed, but may also need to familiarise themselves with the new roles and pressures they will face. Some women may have experienced miscarriages before and feel anxious about whether they will be able to carry the pregnancy to term.

If a treatment fails, a couple may be overwhelmed with distress and grief, especially among individuals in Western countries where the cultural assumption tends to be that hard work and persistence always leads to achievement and success. It can also be difficult for couples to know when they should stop treatment. Often, one partner will want to cease treatment before the other partner does, which can put strain on the relationship.

Many patients eventually have to come to terms with making a transition from wanting their own children to accepting that this is no longer possible and that the only remaining options are adoption or facing childlessness.