Infertility and Sexuality
from the book How to Have a Baby:
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:
- Trying to get pregnant
- Investigation and diagnosis
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
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
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
"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
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."
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
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.
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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