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:
- Trying
to get pregnant
- Investigation
and diagnosis
- Treatment
- 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
ot 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.
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