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Chapter 35
Infertility and Sexuality

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Infertility brings about many changes in a couple's relationship. It may bond you closer together in unspoken sadness and hope - and allow mutual support and understanding which leads to a sharing never before experienced. Or it may bring out feelings of resentment, of guilt, and of despair. As the initial months of investigations turn into frustrating years it is not surprising that sex quickly loses many of its associations with pleasure and becomes instead an activity with a purpose.

Failure to conceive certainly destroys self esteem, self worth and sexuality. All these negative feelings are reflected in the bedroom, which is, after all, where all the 'problems' started.

The psychological effect of a diagnosis of infertility on sexuality has largely to do with the self image. Fertility is one very basic expression of sexuality. The man with six sons in many cultures has more status than a man who has borne none - he is considered to be more potent, more virile.

The emotional response to a diagnosis of infertility is a grief reaction. It involves many losses: those of potential children and the family planned and dreamed about, genetic continuity, the experience of conception, pregnancy and birth, the gift of grandchildren to one's own parents, the central meaning of one's life plan and marriage, and the procreative potential in sexual relations. It is common for a woman to feel "less of a woman" and a man "less of a man", at least for a time, when faced with infertility. Many men describe feeling a "dud", "sexual failure" and many other expressions relating to feeling emasculated.

Women, too, often feel their sexuality threatened when faced with the possibility of not becoming pregnant. Women are probably more powerfully socialised into the expectation that they will reproduce than are men. When this is thwarted, there is often the feeling of having failed as a "proper woman", as shown in this statement:

"I saw the blood (of the menstrual period) today. I feel weak and tearful. All the strength I'd thought I'd acquired just seems to have drained away. The discomfort serves as a reminder of my failure. For many women menstruation is a sign of femininity and potential for motherhood. All it signifies to me is my failure".

And another comment about sexual attractiveness:

"I have always been told I was pretty. I like the way I look, and I feel confident in social situations. After my pelvic surgery, the doctor told me he had never seen a worse mess of adhesions in his life. He said it looked like a little kid had been let loose with a pot of glue and stuck everything all together. I am ugly on the inside and pretty on the outside. I would gladly have the reverse if it would make me a baby."

There are significant periods which impinge on feelings about sexuality of the couple faced with infertility. These are:

  1. Trying to get pregnant
  2. Investigation and diagnosis
  3. Treatment
  4. Menopause

1. Trying to get pregnant

The usual advice for a couple trying to start a family is to have unprotected sexual intercourse for at least twelve months before having fertility investigations. This waiting period can be nerve-wracking ! Doubts about one's fertility almost always result in a heightened awareness of signs of fertility that surround us. Pregnant friends, noisy children in markets, media coverage of new reproductive technologies, hints from eager parents wanting grandchildren - all these can begin to erode the sexual self-confidence of the couple wishing to have children. Inevitably, sexual intercourse is timed for the fertile time of the woman's cycle. Spontaneity goes out the window as the sexual life of a couple comes to be associated month after month with procreating and the failure to conceive. Men often come to feel like a stud bull, and women may feel it is pointless to engage in sexual activity when it is unlikely to result in pregnancy.

2. Investigation and diagnosis

Those not faced with infertility would be staggered by the number, complexity, and invasiveness of medical procedures that a couple with a fertility problem go through in their search for an answer to why pregnancy is not occurring. As one patient put it - " It's like donating your body to science while you're still alive!"

A basic procedure is the Basal Body Temperature Chart. Although useful from a medical point of view, it is also the surrendering of some very personal information about oneself, as shown by this quote:

"There is no inner recess of me left unexplored, unprobed, unmolested. It occurs to me when I have sex, what used to be beautiful and very private is now degraded and very public. I bring my chart to the doctor like a child bringing a report card. Tell me, did I pass ? Did I ovulate ? Did I have sex at all the right times as you instructed me?"

The Temperature chart becomes a way of ruling one's life - and ruining one's sex life. It is also a public declaration of making love. With the desire for a child becoming increasingly frustrated, life can become an endless maze of temperature changes, ovulation calculations, timing of sex and the disappointing signs of one's menstrual onset. Anxiety, depression and fighting over sex can often be traced to this source. "Ordinarily my husband was the instigator of sex. During my fertile time, I felt I had to seduce him. What quite often happened was that we'd end up fighting instead of making love."

"It was pretty hard to feel an urge to make love when your wife is expecting a command performance."

It is not just the physical charting but the mental charting (which may continue indefinitely) that is a source of stress, even if the partner is not aware of what is happening.

"One of the things that freaked me out about charting my temperature was the accompanying need for the X's. I guess that is what brought home to me that we had stopped making love as frequently as we had used to."

"The ultimate moment for me was when I found myself 'cheating' on the charts. I put in a few more X's here and there to make things look good...then I said to myself, " Good heavens - has it come to this ?"

"At first it was quite exciting - I felt as if I was actually doing something. We would both look at the chart and go for, say, six X's in a row - in fact our frequency of intercourse increased I'm sure. By now we've gone through the stage of 'saving up sperm' and have hit the stage of almost total abstinence. I put in an occasional X so that the nurse doesn't get the impression that there's something wrong with our marriage."

Providing a sample for semen analysis can also be stressful:

"I looked around desperately for something to turn me on - there was nothing - not even soap. After 15 minutes I gave up - literally sore as hell."

Most men feel their masculinity is 'on the line' when having this done, sometimes to the extent of being unable to produce the specimen. It is not uncommon for the man to become impotent for a short time while he is undergoing such procedures.

"The first time it happened I thought - here it is - middle age. I'll never get it up again."

While post-coital tests are painless and physically unobtrusive, many find them very difficult because they intrude so much on your relationship. There's the need to comply with a specific time, the rush to the surgery or clinic to keep the appointment, the embarrassment and real fear of 'failure' if all does not proceed as had been 'instructed'.

"They told us to make love first thing in the morning and then come in. Well, what if you don't feel like it ? We're dreadful in the morning. We put the alarm on at 6 o'clock and we had the kettle on to make coffee...making love was the last thing we felt like doing...he hated it and I hated making him do it."

The power play dynamics in the doctor-patient relationship takes on a new dimension when fertility is being investigated. Couples are desperate to find an answer to their difficulties and hence are compliant and rarely let the clinician know they are under stress ("not coping"). They must expose the most intimate aspects of their lives - their sexual relationship and their desire to have children.

"There's a coyness about the way doctors handle sex. It's as if infertility has nothing to do with sex, yet it's everything to do with it. I never know whether I want them to assume that I don't have problems, or whether I want them to ask me if I do have any difficulties."

3. Treatment

A couple's decision to commence a treatment programme, such as IVF or Donor Insemination signifies hope and excitement that they can overcome infertility and produce children like everyone else. However, like the investigative period, it again signals a further, if not more intense, invasion of their sexuality and sexual relationship.

Once accepted on to an IVF programme, most women are confronted at each attempt with the barriers to becoming pregnant, to become mothers, and thereby expressing a major aspect of "femaleness". The low pregnancy rate - about 35% per treatment cycle - means most will leave the programme with a reconfirmed sense of failure, at least for a short time, and certainly if they have had little emotional support.

The use of donor sperm to cause a pregnancy, as in a donor insemination programme where the male partner is infertile, brings home to the man his inability to reproduce. Some of the feelings of inadequacy may have been worked through during the period following diagnosis, but it is not uncommon for these feelings to be rearoused when the programme actually begins. At most infertility clinics, the men are encouraged to be present while their wives are being inseminated. Some even do the insemination themselves (a painless and simple medical procedure). This encourages bonding between the couple at this time, and especially gives value to the participation of the husband in the act of the conception of their child.

During IVF treatment, after the embryo transfer , most doctors will advise patients not to have intercourse. However, this does not mean that you cannot have sex ! Sex does not always mean putting a penis in the vagina and you can use your imagination to give each other sexual pleasure in other ways for example, by mutual masturbation.

With nearly all forms of infertility treatment, rarely is the infertility cured, and clearly not where donor egg or sperm is used. For example, women with blocked fallopian tubes who become pregnant on an IVF programme, still face further IVF attempts if they wish to become pregnant again. A feeling of defectiveness may remain despite pregnancy and a live birth.

4. Menopause

Menopause is a time when all women are confronted by their sexual identity, simply because the physical signs of being a woman are changing forever. It is a difficult time of adjustment for many women, and for those with infertility it means saying goodbye, yet again, to motherhood.

It is useful to ventilate feelings of frustration, anger, and feeling "taken over", as your sexuality gets trampled upon throughout the course of investigation and treatment. This will restore a sense of personal worth. Remember that it is normal, expected and almost inevitable that your sex life will take a beating for a time.

It is useful at this stage to join a support group or talk to a counsellor - who can help you to separate sex from reproduction - perhaps by throwing away the temperature chart for a while, or taking a break in the middle of a treatment programme to have a romantic holiday.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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