PSYCHOSOMATIC AND SEXUAL DISORDERS IN INFERTILE COUPLES
Department of Obstetrics and Gynecology, Hôtel Dieu - 1, Place de l’Hôpital,
69002 Lyon, France
Learning of one’s infertility can often generate depression and lack of sexual desire. Work-ups and treatments can interfere with the couple’s intimacy, and the body image of each partner. Sometimes the final arrival of a child cannot completely repair felt psychological failure.
Infertile couples need special psychological care not only because of the pain of not having a child, but also to bear the tests and treatments (2,4,5,6,7,8) which can have a hard psychological impact. Infertility can threaten adult status and sexual identity. It can generate a reshuffle of personality; couple bonds may also change. Achieving a pregnancy becomes the sole aim for the couple and the medical team. But in fact, psychosomatic disorders may disturb the pregnancy, when the couple is looking for an imaginary child, to resolve other problems. The real child may then generate an additional adaptation in the couple that is still deeply disturbed by the infertility.
The diagnosis of infertility: psychological aspects
The semen needed for a spermiogram should be collected by masturbation which can be disturbing to infertility patients. Men may have an erection failure at this time. Masturbation is still often a taboo and the setting is not erotic. Men may fear the judgement of the biologist regarding their semen, especially if the biologist is a man. Men identify with their semen: if their spermatozoa move too slowly, or have morphological abnormalities, they feel threatened in their self-esteem. Azoospermia obliges them to rebuild another concept of their virility. Impotence may also appear and may last several months (1). Partners sometimes cannot accept oligospermia or azoospermia and become aggressive. Guilt over their felt inadequacy can make impotence persist. In this context, some men suffer scrotal pain, asthenia and depression. They often describe the impression of having a " cold penis ". Investigation of women’s infertility can also be difficult to bear for the two partners. For example, using a thermometer each morning can interfere with sexual desire; intercourse is no longer spontaneous when imposed by the temperature curve, or the state of cervical mucus. Intimacy is threatened. The physician explores the woman’s body by clinical examination, hysterography, laparoscopy, and ultrasonography. The power of the medical team over her body is limitless, and many men sense that physicians are stealing or raping their wives (5). Women also suffer from this situation, and many women describe a lack of sexual desire after experiencing tests.
The diagnosis of infertility
The revelation of sterility disrupts the individual’s life course, as well as that of the couple and of the family. The break in filiation can be experienced as a kind of death. One of the components of love in a couple is the ability to imagine the partner as a potential parent. This is one reason why infertile couples are obliged to cross a crisis period. In most cases, the partners stay together and achieve a new balance. In some cases, however, they decide to divorce and this can occur during an achieved pregnancy or after the birth of a child.
Psychological and social consequences of infertility
In our society, normal couples must have children. The family of each partner may often inquire about family building. Infertile couples may not be considered as adult by their own parents. At work, they may have fewer rights: for example, they may not be granted certain holidays or material advantages because of childlessness. They complain about social exclusion. Women and men are often depressed with psychosomatic manifestations such as: abdominal or stomach pains, dyspepsia, headache, premenstrual tension, dyspareunia, mastodynia, and so on.
In the case of idiopathic infertility, psychological causes may play a role. There is no particular psychological profile associated with the risk. Some life events may be reported by women such as strong conflicts with their mother, accidental pregnancies in the close family, or a child death (3).
Special fears may be expressed: a child’s arrival could split the couple, or change their life; the woman might discover her inability to mother, and become dangerous to the baby; becoming a mother might generate conflict with other persons (her mother, her husband...). Some women fear pregnancy and childbirth. These obstacles can be unconscious and often disappear in the course of psychotherapy.
Medical treatment of infertility can generate a multiple pregnancy. Twins and triplets usually are well-accepted and multiple pregnancy may be a successful way of " repairing " infertility.
Artificial insemination with the partner’s semen can be more difficult to bear when there is a confusion between sexual intercourse and the act of medical insemination. Women may refer to " the pregnancy I obtained with Dr X ". Infertile couples complain about the time of uncertainty waiting for menses to occur or not. Women often report psychosomatic symptoms like nausea, bloated stomach, weight increase, breast tenderness, and drowsiness, as if they experience pregnancy. The onset of menses generates dysphoria.
Artificial insemination with donor semen obliges the infertile couple to build a new concept of paternity. It does not really treat the man’s sterility but only the lack of a child. The couple shares the pregnancy and the childbirth, two fundamental life events; men may take unusually special care of the child, born in this manner (8). Many women report fantasies of adultery in spite of donor anonymity and confidentiality. Couples often wonder if they should explain its origin to their child. Some of them cannot accept their infertility and maintaining secrecy is then a way to deny the disability. Others fear being rejected later by the child. Couples who choose adoption have the same doubts.
Assisted reproduction has completely changed the medical and social representation of conceiving a child. Now everybody can see it on television, especially young children who know that they were born through this technology. This experience can generate psychological disturbances. Couples often complain about destruction of their intimacy; women speak of " medical rape " and seduction strategies and erotic games may disappear. Couples may carry on having intercourse, in order to maintain the illusion of natural conception, but with little sexual desire. Many women report vaginal dryness, dyscomfort or pain at penetration, and anorgasmy. Men complain of " sexual boredom ", erection failure, premature ejaculation, and reduced pleasure. They also report the impression of being rejected by the medical team as soon as they have handed over their semen. During the consultation, the physician usually discusses with the woman, rarely with the husband. Men can have difficulty to assume their role as partner and potential father. The whole medical team must pay attention to them, in order not to destroy the couple’s balance.
Pregnancy after a long period of infertility
Infertile couples often believe that all their problems arise from their childlessness, especially disagreements. They believe that the child will resolve everything. In fact, in all couples, whether fertile or infertile, a child’s birth disturbs the balance, rekindling old conflicts from childhood in the two partners, generating fears and raising emotional stakes, but this phenomenon increases with the duration of infertility. That is the reason why couples need psychological help, not only during the treatment, but also all through the pregnancy and even after birth. Some infertile couples have established a special balance to bear their infertility and are unable to make a place for the child. The child’s arrival can cleave a couple. In those cases, special psychotherapy is needed.
Infertility disturbs self-esteem, sexual identity and body image of each partner. The couple is obliged to establish a new balance in order to bear the emotional and social consequences of this kind of disability. Exams and treatment can spoil the intimacy and the balance of the couple. Sexuality may lose first its erotic place and, if assisted reproduction is needed, may completely disappears. Emotional pain of the two partners can be expressed in psychosomatic as well as sexual problems. Both will require regular psychological help, in addition to simple, but clear, medical information about the reasons for their infertility, and the tests and treatment which are offered but not imposed. Achieving a pregnancy is not the only goal, but also preparing a physically and mentally healthy home for the child.
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