infertility and psychological distress

8/13/2019 Infertility and Psychological Distress

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e r g a m o n Soc. Sci . Med. Vo l. 45, No. 11, pp. 1679-1704, 1997© 1997 ElsevierScience Ltd . All rights reserved

PI I : S02 77-9 536 (97) 001 02-0 Pr in ted in Great Br itain0277-9536/97 $17.00 + 0.00

INFERTILITY AND PSYCHOLOGICAL DISTRESS: A

CRITICAL REVIEW OF THE LITERATURE

A R T H U R L . G R E I L

Divis ion of Soc ia l Sciences, A lf red Univers i ty , 1 Saxon Dr ive A lf red , NY 14802, U.S.A.

A b s t r a c t - - T h i s essay reviews the literature on the social psychological impact of infer tility, payingspecial atten tion t o the relationship b etwe en gender and the infer tility experience. I t is conv enien t todivide the literature into ar ticles which explore the possibility that infer tility may have psychologicalcauses (Psychogenic Hypothes is ) an d those which exam ine the psychologica l consequences of in fe r t i l i ty(Psychologica l Consequences H ypothes is ) . The psychogenic hypothes is is now re jec ted by m os tresearchers, but a related hypothesis , which ~;tates that s tress m ay be a cau sal fact or in infer tility, is

wor thy of explora t ion . The descr ip t ive l i te ra ture on the psychologica l consequences of in fe r t i l i ty pre -sents infer tility as a devastating experience, especially for women. Attempts to test the psychologicalconseq uences hypothesis hav e prod uced m ore equiv ocal results . In general, s tudies which look for psy-chopathology have not found signif icant differences between the infer tile and others. Studies whichemploy measures of s tress and self-esteem have found signif icant differences. The psychological conse-quences l i te ra ture is charac te r ized by a number of f laws , inc luding over sampling of women, smallsample s ize, non- representa t ive samples, f a i lure to s tudy those w ho have no t sought t r ea tmen t , p r imit ivestatis tical techniqu es, and an over-relian ce on self-reports . Studies on infer tility and psyc hologic al dis-t ress need to take in to cons idera t ion b oth the dura t ion of in fer t i l ity and the du ra t ion of tr ea tment .F inding an appropr ia te se t o f "contro ls" is a par t icu la r ly in trac tab le problem for th is a rea of r esearch .In general, the psycho logica l distress literatu re shows little regard fo r t h e s o c i a l c o n s t r u c t i o n o f i n f e r t i -

l i t y . By tak ing wha t should be und ers tood as a charac te ris t ic of a s o c i a l s i t u a t i o n and t rans forming i tin to a n i n d i v i d u a l t r a i t , the literature presents what is essentially a medical model of the psycho-socialimpac t of in fer ti li ty. Mo s t r esearchers conc lude tha t in fe r t il i ty is a more s tress ful exper ience for wom enthan i t i s for men. M os t s tud ies have found tha t the re la t ionship be tween gender and infe r t il i ty d ist ress

is no t a f fec ted by which par tner has the reproduc t ive impairment . Future research needs to be be t te rinformed by theore t ica l cons idera t ions . Schola r s need to pay more a t ten t ion to the way the exper ienceof infe r t i li ty is condi t ioned by soc ia l s t ruc tura l r eal it ies . New ways need to be deve loped for be t te r tak-ing in to acco unt the processua l na ture of the infe r t i l i ty exper ience . Ef for ts need to be m ake to inc ludeunder - s tudied por t ions of the infe r t i le popula l ion . F ina l ly , more e f for t needs to be made to be t te r in te -gra te the em pir ica l s tudy o f the exper ience of in fe r t i li ty with im por tan t soc ia l po l icy ques tions. © 1997Elsevier Science Ltd. A ll r ights reserved

K e y w o r d s - - i n f e r t il i t y , psychological, distress, review

INTRODUCTION

T h i s e s s a y r e v i e w s t h e l i t e r a t u r e o n t h e s o c i a l

p s y c h o l o g i c a l a s p e c t s o f i n fe r t i l i t y , p a y i n g s p e c i a l

a t t e n t i o n t o t h e r e l a t i o n s h i p b e t w e e n g e n d e r a n d

t h e i n f er t i l it y ex p e r i e n ce . A n u m b e r o f a u t h o r s h a v e

c o m p l a i n e d a b o u t t h e r e l a t iv e n e g le c t o f t h e s o c ia l

p s y c h o l o g i c a l d i m e n s i o n s o f i n f e rt i l i ty i n t h e l i t e r a-

t u r e . F o r e x a m p l e , W r i g h t , A l l a r d , L e c o u r s , a n d

S a b o u r i n [ 1 ] r e p o r t e d i n a l i t e r a t u r e r e v i e w t h a t

t h e y w e r e a b l e t o l o c a t e o n l y 3 0 " c o n t r o l l e d " s t u -

d i e s o v e r t h e t w e n t y y e a r p e r i o d e n d i n g i n 1 ' 9 8 6 .

B u t , i f t h e r e w a s a s h o r t a g e o f s t u d ie s o n s o c i al a n d

e m o t i o n a l a s p e c t s o f i n f e rt i l it y u p t o a b o u t t e n

y e a r s a g o , t h i s i s n o l o n g e r t h e c a s e . A t t e a s 1 : 9 4

q u a n t i t a t i v e a r t i c l e s a n d 2 6 q u a l i t a t i v e a r t i c l e s o n

t h i s t h e m e h a v e b e e n p u b l i s h e d s i n c e 1 9 8 6 . I n f a c t ,

b e c a u s e o f t h e s h e er v o l u m e o f s t u d ie s w h i c h n o w

e x i s t, t h i s r e v i e w w i l l b e l i m i t e d t o s t u d i e s o f t h e

e x p e r i e n c e o f i n f e r t i l i t y p u b l i s h e d s i n c e 1 9 80 .

W h a t f o l lo w s , th e n , i s a n a t t e m p t t o s u m m a r i z e

t h e p r e s e n t s t a te o f o u r k n o w l e d g e a b o u t t h e i n f er t i-

l i t y e x p e r i e n c e a s w e l l a s t o p r o v i d e a c r i t i c a l r e v i e w

o f t h e q u a l i t y o f r e s e a r c h o n t h e s o c i a l p s y c h o l o g i -

c a l d i m e n s i o n s o f i n fe r t i l i ty . T h i s e s s a y b e g i n s w i t h

a b r i e f d i s c u s s io n o f l i t e r a tu r e i n v e s t i g a t i n g t h e

p o s s i b i li t y t h a t i n f e r ti l i t y m a y h a v e p s y c h o l o g i c a l

o r i g i n s b e f o r e t u r n i n g t o a f u l l e r d i s c u s s i o n o f

r e s e a rc h o n t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f i n fe r -

t i l i t y . A t h i r d s e c t i o n d e a l s w i t h i n v e s t i g a t i o n s o f

g e n d e r d i f f e r e n c e s i n t h e s o c i a l a n d e m o t i o n a l c o n -

s e q u e n c e s o f i n f e r t il i t y . A s t h e d i s c u s s i o n p r o -

g r e s s e s , i t w i l l b e c o m e c l e a r t h a t a t t e m p t s t o

e x p l o r e t h e p s y c h o l o g i c a l c o r r e l a te s o f i n f e r ti l i ty

h a v e p r o d u c e d e q u i v o c a l r e s u lt s . T h i s i s d u e , i n

p a r t , t o t h e e x i s t e n c e w i t h i n t h e l i t e r a t u r e o f a n u m -

1679



1680 Arth ur L. Greil

be r o f me tho do log ica l f laws , bu t i t wi ll be a rgued

tha t t he t heore t i ca l sh or t com ings o f t h i s l it e ra tu re

a r e p e r h a p s a s i m p o r t a n t a p r o b l e m , e v e n t h o u g h

these have rece ived cons ide rab ly l e ss a t t en t ion . The

essay wi l l conc lude wi th sugges t i ons rega rd ing how

f u t u r e r e s e a rc h o n t h e p s y c h o l o g i c a l c o n s e q u e n c e s

of i n fe rt i li t y migh t be imp roved .

B E Y O N D T H E P S Y C H O G E N I C H Y P O T H E S I S

A l t h o u g h s o m e a r t i c l e s d o n o t m a k e t h e i r

a ssumpt ions c l ea r , i t i s conven ien t t o d iv ide t he l i t -

e ra tu re i n to a r t i c l e s which exp lore t he poss ib i l i t y

tha t i n fe r t i l i t y may have psycho log ica l causes (psy-

c h o g e n i c h y p o t h e s i s ) a n d t h o s e w h i c h e x a m i n e t h e

psycho log ica l consequences o f i n fe r t i l i t y (psycho-

l o g i c a l c o n s e q u e n c e s h y p o t h e s i s ) . U p t h r o u g h t h e

m i d - 1 9 8 0 ' s , t h e p s y c h o g e n i c m o d e l w a s c l e a r l yd o m i n a n t [ 2 - 8 ] . T h i s m o d e l w a s b a s e d o n t h e

assum pt ion th a t m any cases o f in fe r ti li t y , e speci a l ly

n o n - o r g a n i c i n f e r t i l i t y , a r e c a u s e d b y a n u n c o n -

s c i o u s r e s i s t a n c e t o m o t h e r h o o d o n t h e p a r t o f

in fe rt i le w om en.

T h e c r i t i qu e o f t h e p s y c h o g e n i c h y p o t h e s i s

Thi s l i t e ra tu re has been o f t en c r i t i c i zed fo r a

n u m b e r o f r e as o n s i n c l u d i n g t h e u s e o f c o n v e n i e n c e

samples , a t endency to a ssume tha t i n fe r t i l e women

in t he rap y were repre sen t a t i ve o f a l l in fe r ti l e

women, f a i l u re t o use sys t ema t i c measure s com-b ined wi th an ove r - re l i ance on c l i n i ca l impress ions ,

f a i l u r e t o s p e c i f y t h e m e c h a n i s m b y w h i c h p s y c h o -

log i ca l s t a t e s were p re sumed to have an impac t on

phys io log i ca l func t ion ing , f a i l u re t o use con t ro l

g roups , a v i r t ua l l y exc lus ive focus on fema le i n fe r t i -

l it y, and a ssum ing the d i rec t i on o f causa l it y wi tho u t

any c lear evidence [9-18] .

T a b l e 1 p r o v i d e s a s u m m a r y o f s tu d i es w h i c h

have looked fo r pe r sona l i t y d i f fe rences be tween the

in fe r t i l e and the non- in fe r t i l e . Most ca re fu l ly

des igned s tud i e s have found tha t pe r sona l i t y

measure s a re unab le t o d i s t i ngu i sh be tween in fe r t i l eand non- in fe r t i l e popu la t i ons [1 , 19-31] . I t ha s a l so

b e e n f o u n d t h a t p e r s o n a l i t y m e a s u r e s a n d p s y c h o -

log i ca l d i s t r e ss measure s canno t gene ra l l y d i s -

t i ngu i sh be tween ind iv idua l s wi th "o rgan ic"

infer t i l i ty ( infer t i l i ty wi th an ident i f ied physiological

source ) and " func t iona l " i n fe r t i l i t y (unexp la ined o r

" id iopa th i c " i n fe r t i l i t y ) [1 , 20] . Nor have psycho-

log i ca l measure s been ab l e t o d i f fe ren t i a t e t hose

in fe r t i l e coup le s who even tua l ly become pregnan t

f rom those who do no t [21 , 32] . Where d i f fe rences

have been found , i t i s usua l ly imposs ib l e t o demon-

s t ra t e t ha t psych o log ica l d is t r e ss i s the causa l f ac to r

[33 , 34] . Seve ra l r ecen t s t ud i e s do , howeve r , p rov ides o m e s u p p o r t f o r t h e p s y c h o g e n i c h y p o t h e s i s .

S to l e ru e t a L [ 1 8 ] f o u n d , i n o n e o f t h e f e w p r o s p e c -

t i ve s tud i e s o f psycho log ica l a spec t s o f i n fe r t i l i t y ,

t ha t ce r t a in ma le psycho log ica l f ac to r s d id d i s -

t in g n i s h c o u p l e s w h o a c h i e v e d a p r e g n a n c y w i th i n a

y e a r o f t e s ti n g f r o m t h o s e w h o d i d n o t .

S t r e s s a s a c a u s a l f a c t o r

I t i s sa fe t o say t ha t t he psychogen ic hypo thes i s i s

now re jec ted by most researchers [4, 8 , 11, 16, 35] .

In fac t , some recen t wr i t e r s [36 , 37] have com-

p l a in e d o f a n u n w i ll in g n e s s o n t h e p a r t o f s c h o l a rs

to g ive t he psychogen ic hypo thes i s se r ious cons ide r -

a t i o n . T h e r e h a v e b e e n , h o w e v e r , s o m e a t t e m p t s t o

rev ive t he psychogen ic hypo thes i s i n r ecen t yea r s .

A s t o r a n d P a w s o n [ 3 8 ] a r g u e t h a t p e r s o n a l i t y

m e a s u r e s d o n ' t r e a ll y g e t a t t h e i ss u e o f u n c o n s c i o u s

mot iva t ion and tha t t he re fo re nega t ive f i nd ings

u s i n g t he s e m e a s u r e s d o n ' t r e a ll y r e fu t e t h e h y p o t h -

e s i s . Some wr i t e r s a re r ep l ac ing the psychodynamic

v e r s io n o f t h e p s y c h o g e n i c h y p o t h e s is w i t h a h y -

po thes i s based on the i dea t ha t s t r e ss causes i n fe r t i -

l i ty [33, 34, 37, 39, 40] . Fa i lu re to f ind pers ona l i tyd i f fe rences be tween peop le wi th fu nc t iona l i n fe r ti l it y

and o rgan ic i n fe r t i l i t y doesn ' t necessa r i l y speak to

the s t r e ss hypo thes i s .

G i v e n t h e g e n e r a l i m p o r t a n c e o f t h e r e l a ti o n s h ip

be tween s t r e ss and hea l th , i t i s no t unreasonab le t o

suspec t t ha t s t r e ss may be causa l ly l i nked to i n fe r t i -

l i t y . Th i s v i ew has no t been popu la r i n r ecen t yea r s

wi th re sea rche rs , counse lo r s , o r t he i n fe r t i l e t hem-

se lves , p r imar i l y because t he psychogen ic i n t e rp re t -

a t i on o f i n fe rt i li t y has com e to be seen a s a

mechan i sm fo r min imiz ing the rea l i t y o f t he su f fe r -

i ng a ssoc i a t ed wi th i n fe r t i l i t y and a s a means o fb l aming v i c t ims fo r t he i r own suf fe r ing . To the

in fe r t i l e and those who sympa th i ze wi th t hem, t he

psychogen ic hypo thes i s , i n e i t he r i t s c l a ss i ca l fo rmu-

l a t i on o r i n t he s t r e ss ve r s ion , ha s come to seem

l ike a r e i t e ra t i on o f ne ighb or ly adv ice (e.g . "Re lax ,

t a k e a v a c a t i o n ; y o u ' l l g e t p r e g n a n t i n n o t i m e . ") i n

scho lar ly guise .

Neve r the l e ss , i t i s impor t an t no t t o d i smi ss t he

s tr e ss h y p o t h e s i s o u t o f h a n d . A s t u d y b y D o m a r e t

al . , [41] o f 52 i n fe r t il e wo me n w ho p a r t i c ipa t ed i n a

1 0 - w e e k b e h a v i o r a l t r e a t m e n t p r o g r a m i n c l u d i n g

r e l a x a t i o n r e s p o n s e t r a i n i n g a n d s t r e s s m a n a g e m e n tt echn iques i s o f pa r t i cu l a r i n t e re s t i n t h i s r ega rd .

N o t o n l y d i d t h e w o m e n s h o w s i gn i fi c an t d ec l in e s i n

psych o log ica l d is t r e ss a f t e r pa r t ic ipa t i ng i n t h i s p ro -

g r a m , b u t 1 6 ( 3 2 % ) o f t h e m b e c a m e p r e g n a n t.

B e c a u s e t h i s s t u d y d i d n o t i n c l u d e a c o n t r o l g r o u p

and because t hese women were aggress ive ly pursu-

ing medica l t r ea tment whi l e pa r t i c ipa t i ng i n t he

b e h a v i o r a l t r e a t m e n t p r o g r a m , i t w o u l d b e p r e m a -

tu re t o say t ha t t h i s s t udy demonst ra t e s e i t he r t ha t

t h e p r o g r a m w a s r e s p o n s i b l e f o r t h e 3 2 % p r e g n a n c y

rate or tha t s t ress i s causal ly re la ted to infer t i l i ty .

B u t th e w o r k o f D o m a r e t a L d o e s d e m o n s t r a t e t h a t

t he s t r e ss hypo thes i s mer i t s fu r the r i nves t i ga t i on .B o i v i n a n d T a k e f m a n [ 4 2 ] m e a s u r e d d a i l y s tr e ss

l e v e l s a m o n g 4 0 w o m e n u n d e r g o i n g I V F a n d d i s -

c o v e r e d t h a t t h o s e w h o d i d n o t b e c o m e p r e g n a n t

experienced higher st ress levels. However , di ffer-



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i



1682 Arth ur L . Grei l

e n c e s i n d i s t r e s s l e v e l s d i d n o t e m e r g e u n t i l f e e d -

b a c k o n t h e p r o s p e c t s o f s u c c e s s f o r a g i v e n I V F

c y c l e b e c a m e a v a i l a b l e . T h e a u t h o r s i n t e r p r e t t h i s

a s e v i d e n c e t h a t s t r e s s i s a c o n s e q u e n c e r a t h e r t h a n

a c a u s e o f i n f e r t i li t y . I n a s t u d y t h a t u t i l iz e d a n

i n g e n i o u s r e s e a r c h d e s i g n b u t i s m a r r e d b y t h e u s e

o f a v e r y s m a l l s a m p l e , W a s s e r [ 3 7 , 4 0 ] c o m p a r e d

f o u r g r o u p s o f w o m e n : ( 1 ) a n a t o m i c a l l y i n f e r t i l e

w o m e n ; ( 2 ) w o m e n w i t h m i l d a n a t o m i c s y m p t o m s ;

( 3) t h o s e w i t h i n f e r t i l it y r e l a t ed t o h o r m o n a l p r o -

b l em s ; a n d ( 4 ) w o m e n w i t h t h e s a m e p h y s i c a l c o n -

d i t i o n s a s t h o s e i n g r o u p 3 b u t w h o w e r e n o t

s e e k i n g t o a c h i e v e p r e g n a n c y . T h e f a c t t h a t w o m e n

i n g r o u p s 3 a n d 4 d i s p l a y e d h i g h e r s t r e s s s c o r e s

l e a d s W a s s e r t o c o n c l u d e t h a t s o m e t y p e s o f i n fe r t i-

l i ty may be s t re s s - re l a t ed . Seve ra l wr i t e r s [33 , 34 ,

4 3 , 44 ] h a v e s u g g e s t e d t h a t t h e p h y s i o l o g i c a l m e -

d i a t o r b e t w e e n s t r es s a n d f e m a l e f e r t il i t y m a y b e e l -

e v a t e d p r o l a c t i n l e v e ls .S o m e r e s e a r c h e r s h a v e e x p l o r e d t h e p o s s i b i l i t y

t h a t s t r e s s m i g h t b e a c a u s a l f a c t o r i n m a l e i n f e r t i -

l i ty . I n a p a n e l s t u d y o f 28 c o u p l e s , S l a d e et a l . [45]

f o u n d t h a t p o o r m o o d a n d l o w s e lf e s t e em o n t h e

p a r t o f h u s b a n d s w a s p r e d i ct i v e o f p r e g n a n c y o u t -

c o m e s 3 y e a r s l a t e r . H a r r i s o n e t a l . [ 3 9 ] f o u n d , i n a

s t u d y o f 5 0 0 m e n w h o s e p a r t n e r s w e r e u n d e r g o i n g

I V F t r e a t m e n t , t h a t s e m e n q u a l i t y w a s lo w e r d u r i n g

t r e a t m e n t c y c l e s t h a n a t o t h e r t i m e s , b u t s t r e s s w a s

n o t m e a s u r e d d i r e c t l y . A c c o r d i n g t o t h e a u t h o r s ,

t h is m a y m e a n t h a t s t r es s a s s o c i a te d w i th I V F t r e a t -

m e n t m a y d e p r e s s s e m e n q u a l i t y . I n w o r k c i t e da b o v e , S t o l e r u et a l . [ 1 8 ] s u g g e s t t h a t t h e r e l a t i o n -

s h i p b e t w e e n s t re s s a n d i n f e r ti l it y m a y b e m o r e o f

a n i s s ue f o r m e n t h a n f o r w o m e n .

A t l e a st o n e t e a m o f r e s e a rc h e r s h a v e a r g u e d f o r a n

i n t e r a c t i v e m o d e l i n s t e a d o f t h e c u r r e n t " e i t h e r / o r "

a p p r o a c h w h i c h a s s u m e s t h a t i n f e r ti l i ty m u s t e i t h e r

c a u s e p s y c h o l o g i c a l d i s t r e s s o r b e c a u s e d b y i t [ 1 4] .

THE PSYCHOLOGICALCONSEQUENCES OFINFERTILITY A P P R O A C H

D e s c r i p t i v e l i t e r a t u r e

M o s t c o n t e m p o r a r y s t u d i e s a s s u m e t h a t i n f e r t i l i t y

i s t h e s o u r c e , r a t h e r t h a n t h e c a u s e , o f p s y c h o l o g i c a l

d i s t r e s s , a n d t h e s e s h a l l r e c e i v e t h e r e m a i n d e r o f

o u r a t t e n t i o n . A l t h o u g h s o m e s t u d i e s c o m b i n e b o t h

a p p r o a c h e s , i t i s c o n v e n i e n t t o d i v i d e t h e l i t e r a t u r e

i n t o t w o t y p e s : ( 1 ) d e s c r i p t iv e l it e r a t u r e , b a s e d o n

i n d u c t i v e m e t h o d o l o g i e s , w h i c h t r i e s t o c h a r a c t e r i z e

t h e n a t u r e o f t h e i n f e r t i l i t y e x p e r i e n c e , a n d ( 2 )

a t t e m p t s t o t e s t t h e h y p o t h e s i s t h a t i n f e r t i l i t y c a u s e s

p s y c h o l o g i c a l d i s t re s s .

T h e d e s c r i p t i v e l i t e r a t u r e o n t h e e x p e r i e n c e o f

i n f e r t i l i t y i s p r i m a r i l y b u t , n o t e x c l u s i v e l y , q u a l i t a t -

i v e i n n a t u r e . S o m e a u t h o r s [ 4 6- 5 3] h a v e c o n d u c t e d

s e m i - s t r u c t u r e d i n t e r v i e w s w i t h i n f e r t i l e w o m e n ,

w h i l e o t h e r s [ 5 4 - 7 3 ] h a v e i n t e r v i e w e d c o u p l e s . S t i l l

o t h e r s [ 2 4 , 2 9 , 7 4 - 7 8 ] h a v e u s e d q u e s t i o n n a i r e s a s a

m e a n s o f e l i c it i n g c o m m e n t s f r o m t h e i n f e r ti l e

a b o u t t h e i r e x p e r i e n c e s .

T a k e n a s a w h o l e , t h e d e s c r i p t i v e l i t e r a t u r e p r e -

s e n t s a p i c t u r e o f i n f e r t i li t y a s a d e v a s t a t i n g e x p e r i -

e n c e, e s p e ci a l ly f o r w o m e n . F o r e x a m p l e , M a h l s t e d t

et a l . [ 7 7 ] , i n a s t u d y o f 6 3 i n f e r t i le w o m e n a n d 3 7

i n f er t il e m e n , f o u n d t h a t 9 6 % o f t h e ir r e s p o n d e n t s

r e p o r t e d f e e l i n g f r u s t r a t i o n , 8 1 % r e p o r t e d f e e li n g s

o f h o p e l e s s n e s s , 8 2 % s a i d th e y w e r e d e p r es s e d , a n d

6 5 % r e p o r t e d a n g e r . A m o n g t h e d o m i n a n t t h e m e s

t h a t e m e r g e f r o m t h e d e s c r i p t i v e l i t e r a t u r e o n t h e

i n f e r t i l i t y e x p e r i e n c e a r e :

1 . I n f e r t i l i t y a s a c e n t r a l f o c u s f o r i d e n t i t y ,

es pec ia l ly fo r w om en [48, 49 , 58 , 60] .

2 . F e e l in g s o f l o s s o f c o n t r o l a n d a t t e m p t s t o

rega in con t ro l [54 , 73 , 77] .

3 . F e e l in g s o f d e f e c t i v e n e s s a n d r e d u c e d c o m p e -

t e n c e , es pec ia l ly fo r w om en [71, 77] .

4 . S t a t u s l e s s n e s s and am big u i ty [50 , 58 , 60 , 70 , 79].

5 . S t r e s s o n m a r i t a l a n d s e x u a l r e l a t i o n s a t t h e

s a m e t i m e t h a t t h e r e e x i s t s a c o u n t e r - t e n d e n c y

f o r i n f e r t i l i t y t o " p u l l c o u p l e s t o g e t h e r " [ 24 , 2 9,

58, 65, 71, 78].

6 . F e e l i n g s o f a l ie n a t io n f r o m t h e f e r t il e w o r M

[29, 51, 58, 68, 71, 78].

7 . A s ens e o f s o c i a l s t i g m a [46, 47, 51, 53, 58, 59,

68, 8 0 ] .

8 . D i f f ic u l t y d e a l i n g w i t h i n f e r t i l i t y a t t h e l e v e l o f

m e a n i n g [58, 62].

9 . I m m e r s i o n i n the t rea tmen t p roces s [52 , 79 , 81] .

1 0 . S t r e s s f u l n a t u r e o f t h e t r e a t m e n t p r o c e s s i t s e l f

[52, 55, 56, 81-83].

11. S t r a i n e d r e l a ti o n s h i ps w i t h h e a l t h c a r e p r o v i d e r s

[55, 58].

O n e o f t h e s t r e n g th s o f m u c h o f t h e q u a l i t a ti v e

l i t e r a t u r e o n i n f e r t i l i t y i s t h a t i t a n a l y z e s t h e e x p e r i -

e n c e o f i n f e r t i l i t y w i t h i n i t s s o c i a l c o n t e x t , p a y i n g

s p e c i a l a t t e n t i o n t o g e n d e r r o l e s [ 5 3 , 6 0 , 6 6 ] , f a m i l y

s t r u c t u r e a n d c o u p l e r e l a t i o n s h i p s [ 5 8 ] , t h e e f f e c t s

o f m e d i c a l in s t i t u ti o n s [ 5 5 ] a n d t h e i m p o r t a n c e

of rep roduc t ive t echno logy [50 , 68 , 69 , 72 , 84] in

s h a p i n g r e a c t i o n s t o i n f e r t i l i t y .

T e s t in g t h e p s y c h o l o g i c a l c o n s e q u e n c e s h y p o t h e s i s

T h e b u l k o f s t u d ie s o n s o c i a l -p s y c h o l o g i c a l

a s p e c t s o f i n f e r t i l i t y c o n s i s t o f a t t e m p t s , u t i l i z i n g

q u a n t i t a t i v e m e t h o d s , t o t e s t t h e h y p o t h e s i s t h a t

i n f e r t i l i t y i s a s o u r c e o f p s y c h o l o g i c a l d i s t r e s s b y

c o m p a r i n g t h e p s y c h o l o g i c a l c h a r a c t e r i s t i c s o f t h e

i n f e r t i l e p o p u l a t i o n t o t h o s e o f t h e p o p u l a t i o n a t

l a r g e . T w o d i f f e r e n t s t r a t e g i e s h a v e b e e n e m p l o y e d .

S o m e r e s e a r c h e r s h a v e u s e d s t a n d a r d i z e d m e a s u r e s

t h a t h a v e b e e n n o r m e d o n t h e g e n e r a l p o p u l a t i o n i n

o r d e r t o s e e i f i n f e r t i l e i n d i v i d u a l s s c o r e d i f f e r e n t l y

t h a n t h e p o p u l a t i o n a t l a r g e w h il e o t h e rs h a v e c o m -

p a r e d i n f e r t i l e i n d i v i d u a l s t o n o n - i n f e r t i l e c o n t r o l s .

T h e r e s u lt s o f s u ch s t u d i e s h a v e b e e n s o m e w h a t

e q u i v o c a l . T w o r e c e n t r e v i e w s o f t h i s l i t e r a t u r e h a v e

c o m e t o d i a m e t r i c a l ly o p p o s e d c o n c l u s io n s . D u n k e l -



Infertility and psych ological distress 1683

S c h e t t er a n d L o b e l [ 8 5 ] c o n c l u d e t h a t t h e q u a n t i t a t -

i ve l i t e ra tu re does no t conf i rm the a sse r t i ons made

in t he desc r ip t i ve l i t e ra tu re . On the o the r hand ,

W r i g h t e t a l . [ l ] cons ide r t he a sse r t i on t ha t t he

in fe rt i le a re m ore p sycho log ica l l y d i s t r e ssed t h an

the gene ra l popu la t i on t o have a f i rm bas i s i n t he

e v id e n c e . P a r t o f th e p r o b l e m m a y b e t h a t p s y c h o -

l o g ic a l st re s s m a y b e " i n t h e e y e o f t h e b e h o l d e r . "

I f a n i n f e rt il e s a m p l e s c o r e s h i g h e r t h a n t h e n o r m

o n o n l y o n e s u b s c a l e o f a p s y c h o l o g i c a l t e s t w i t h

s ix subsca l e s , i s t ha t t o be coun ted a s a po in t i n

favor o f t he psycho log ica l d i s t r e ss hypo thes i s o r a s

a p o i n t a g a i n s t i t ? D u n k e l - S c h e t t e r a n d L o b e l

e m p h a s i z e t h e f a c t t h a t m o s t m e a s u r e s o f p s y c h o -

log i ca l s t r e ss do no t d i s t i ngu i sh i n fe r t i l e i nd iv idua l s

f r o m o t h e r s , w h i l e W r i g h t e t a l . p o i n t o u t t h a t v i r -

t ua l l y eve ry s tudy has found d i f fe rences be tween the

in fe r t i l e and the non- in fe r t i l e on a t l e a s t one

measure .

R e v i e w i n g t h e p s y c h o l o g i c a l d i s t re s s f i n d i n g s

A s m e n t i o n e d p r e v i o u s l y ( in t h e d i s c u s s i o n o f t h e

p s y c h o g e n i c h y p o t h e s i s ) , m o s t s t u d i e s w h i c h h a v e

u s e d p e r s o n a l i t y m e a s u r e s h a v e f a i l e d t o u n c o v e r

many pe rsona l i t y d i f fe rences be tween in fe r t i l e and

fe r ti l e g rou ps [1 ] . Bu t t o sa y t ha t i n fe rt i le coup le s

d o n o t h a v e p e r s o n a l i ty d i s o r d e r s i s, o f c o u r s e n o t

to say t hey do no t expe r i ence psycho log ica l d i s t r e ss .

F o r e x a m p l e , a l t h o u g h t h e 2 0 0 I V F w o m e n s t u d i e d

b y F r e e m a n e t a l . [ 2 4 ] h a d n o r m a l s c o r es o n t lh e

M M P I , 4 8 % o f th e m s a i d th e y c o n s id e r e d i n fe r ti li tyto be t he w ors t exp e r i ence o f t he i r l i ve s .

T a b l e 2 p r o v i d e s a s u m m a r y o f s t u d i e s w h i c h

h a v e a t t e m p t e d t o e v a l u a t e t h e p s y c h o l o g i c a l c o n -

s e q u e n c e s h y p o t h e s i s . T h e m a j o r i t y o f s t u d i e s

e m p l o y i n g s t a n d a r d i z e d m e a s u r e s o f g en e r a l

psych o log ica l d i s t re ss have e i t he r show n tha t

i n fe r t i l e coup le s d i f fe r mode ra t e ly f rom norms

ove ra l l [34 , 86-92] o r t ha t t hey d i f fe r on a t l e a s t

some subscales, especia l ly those re la ted to int ( .~r

pe rsona l sens i t i v i t y and depre ss ion [4 , 74 , 75 , 93-

95] . S tud i e s which do no t show such d i f fe rences

a r e u s u a l l y c h a r a c t e r i z e d b y u n o r t h o d o x d e s i g ndecisions [19, 96] or by a focus on very speci f ic

sub-popula t i ons , such a s IVF pa t i en t s [23 , 25 , 97]

o r t h o s e u n d e r g o i n g d o n o r i n s e m i n a t i o n [ 3 2 ] . B u t

the re have been some ca re fu l ly done s tud i e s 17 ,

98 , 99] t ha t have p roduced anomalous re su l t s .

D o w n e y e t a l . [76 ] fou nd tha t t he 59 i n fer t il e

women pa t i en t s t hey s tud i ed d id no t d i f fe r s i gn i f i -

c a n t l y f r o m t h e 3 5 g y n e c o l o g i c a l p a t i en t s t h e y

used a s con t ro l s , bu t t ha t 7 5% of t he in fe r ti le

w o m e n f e l t t ha t i n fe r t i l i t y had adve rse psycho log i -

ca l effec ts on them.

S t u d i e s u s i n g s t a n d a r d i z e d m e a s u r e s o f depression a r e s p l i t a b o u t e v e n l y b e t w e e n t h o s e w h i c h

f ind t he i n fe r t i l e t o expe r i ence norma t ive l eve l s o f

depressive symptoms [7, 22, 25, 30, 76, 94, 95, 99,

1 0 0 ] , a n d t h o s e w h i c h h a v e f o u n d m o d e r a t e l y

h i g h e r d e p r e s s i o n s c o r e s t h a n i n t h e g e n e r a l p o p u -

la t ion [4, 74, 92, 93, 102-105] . Those who have dis-

cove red ev idence o f e l eva t ed l eve l s o f depre ss ion

a m o n g t h e i n f e r t i l e h a v e n o t g e n e r a l l y f o u n d t h a t

this is clinically significant. A rec en t art icle by

D o w n e y a n d M c K i n n e y [ 7 5 ] r e p o r ts e q u i v oc a l f in d -

ings which pe rhaps i l l us t ra t e t he confused s t a t e o f

o u r c u r r e n t k n o w l e d g e a b o u t d e p r e s s i o n a m o n g t h e

infer ti le . The se auth ors f ou nd tha t the 118 infer t i le

w o m e n t h e y s t u d i e d d i d n o t s c o r e h i g h e r o n t h e d e -

p r e s s io n s u b s c a l e o f th e B r i e f S y m p t o m I n v e n t o r y

t h a n 8 3 c o n t r o l s b u t t h a t b o t h g r o u p s s c o r e d h i g h e r

t h a n p u b l i s h e d n o r m s . A n d , w h i l e i n f e r t i l e w o m e n

and con t ro l s had s imi l a r h i s to r i e s wi th rega rd t o de -

pre ss ion , t he i n fe r t i l e women were cur ren t ly expe r i -

e n c i n g m o r e d e p r e s s i v e e p i s o d e s . D o w n e y a n d

McKinney cha rac t e r i ze t he i r i n fe r t i l e sample a s

" d i s t r e s s e d b u t n o t i m p a i r e d . "

Stud ie s us ing measure s o f se l f -e s t eem have a l so

sp l i t r e l a t i ve ly even ly be tween those which havefound tha t t he i n fe r t i l e score l ower on such

measures t han the non- in fe r t i l e [94 , 95 , 97 , 106 ,

109] and those w hich have f oun d the i n fe rt il e t o

hav e nor ma t ive levels o f se l f-esteem [19, 23, 30, 75,

76 , 110 , 111] . S tud i e s us ing s t and a rd i zed measure s

o f m a r i t a l s a t i s f ac t io n h a v e t e n d e d t o f i n d t h a t m a r -

i t a l sa t i s fac t i on among the i n fe r t i l e i s a s h igh [76 ,

96 , 105 , 108 , 112 , 113] o r h ighe r [75, 97 , 100] t han

tha t o f non- in fe r t i l e i nd iv idua ls . The m a jor i t y o f

s tud i e s o f sexua l sa t i s fac ti on and re l a t ed concep t s

have gene ra l l y found few d i f fe rences be tween the

infer t i le an d o thers [7, 32, 75, 95, 98, 99, 105 , 113 -116], bu t t he re a re som e excep t ions [ l l l , 117-119].

S tud i e s o f i n fe r ti l it y and mar i t a l and sexua l sa t i s fac -

t i o n a r e s u m m a r i z e d i n T a b l e 3 .

W h a t g e n e r a l i z a t i o n s c a n w e m a k e b a s e d o n

th i s b r i e f examina t ion o f t he psycho log ica l d i s -

t ress l i te ra ture? Evidence for the dist ressing

psycho log ica l consequences o f i n fe r t i l i t y does no t

a p p e a r t o b e a s o v e r w h e l m i n g i n t h e p s y c h o l o g i -

ca l dist ress l i te ra ture as i t i s in the descr ipt ive l i t -

e ra tu re . Al though the psycho log ica l d i s t r e ss

l i t e ra tu re does no t speak wi th one vo i ce , i t may

be sa fe t o a sse r t t ha t t he i n fe r t i l e seem to be d i s -t r e s s e d c o m p a r e d t o o t h e r i n d i v i d u a l s b u t n o t i n

a c l i n i ca l l y s ign i f i can t way . Fur the r , t he re i s some

reason to be l i eve t ha t t he psycho log ica l d i s t r e ss

l i te ra ture i s t rying to te l l us tha t the infer t i le di f-

f e r f r o m o t h e r s o n t h o s e m e a s u r e s t h a t o n e

migh t p red i c t ba sed on the desc r ip t i ve l i t e ra tu re .

S tud i e s have found no s ign i f i can t d i f fe rences

be tween in fe r t i l e and non- in fe r t i l e popu la t i ons

wi th rega rd t o pe r sona l i t y , bu t t he desc r ip t i ve l i t -

e r a t u r e g i v e s u s n o g o o d r e a s o n t o e x p e c t t h a t

t h i s would be t he ca se. In t e rms o f gene ra l

psycho log ica l func t ion ing , t he re i s some ev idence

for t he ex i s t ence o f d if fe rences wi th rega rd t o

measu re s o f depre ss ion , anx ie ty , and se lf -e s teem.

When i t comes t o mar i t a l r e l a t i ons and sexua l i t y ,

t he f i nd ings f rom the psycho log ica l d i s t r e ss l i t e ra -

tu re a re pe rhaps no t wha t t he desc r ip t i ve l i t e ra -



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1688 Ar thu r L. Gre il

t u r e m i g h t h a v e l e d u s t o e x p e c t . T h i s i s s u e w i l l

b e a d d r e s s e d b r i e f ly b e l o w .

Methodological and theoretical &sues

T h e l a c k o f c o n s i s t e n t f i n d i n g s f r o m t h e p s y c h o -

l o g i c a l d i s t r e s s li t e r a t u r e m a y b e , i n p a r t , r e l a t e d t o

m e t h o d o l o g i c a l s h o r t c o m i n g s . T h e p s y c h o l o g i c a l

c o n s e q u e n c e s l i t e r a t u r e h a s b e e n d e s c r i b e d a s

" f r a u g h t w i t h f l a w s " [9 8 ]. O n e i m p o r t a n t s h o r t c o m -

i n g o f t h i s l i t e r a t u r e i s a n o v e r e m p h a s i s o n w o m e n

[2 , 3 , 8 , 10 , 83 , 112 , 116 , 121 , 122] . T h i s s i tua t ion

h a s c h a n g e d d r a m a t i c a l l y i n t h e p a s t s e v e r a l y e a r s ;

m o s t r e c e n t s t u d i e s h a v e l o o k e d a t b o t h p a r t n e r s o f

i n f er t il e c o u p l e s. A n o t h e r p r o b l e m t h a t h a s p l a g u e d

many s tud ie s i s s ma l l s ample s i ze [1 , 4 , 88 , 95 , 97-

9 9 , 1 2 1 ] . T h i s , t o o , h a s b e e n i m p r o v i n g i n r e c e n t

yea rs . T he re i s s t i l l a t endency fo r s tud ie s to fa i l t op r o v i d e e v i d e n c e t h a t t h e s a m p l e s i z e i s a d e q u a t e t o

t h e t y p e o f a n a l y s i s b e i n g a t t e m p t e d [ 92 , 1 2 3] .

M a n y o f t h e s tu d i e s u n d e r c o n s i d e r a t i o n a r e

c h a r a c t e r i z e d b y t h e u s e o f p r i m i t i v e s t a t i s t i c a l t e c h -

n i q u e s [ 9 2 , 1 2 3 ] . T h i s h a s b e e n c h a n g i n g a s w e l l;

m a n y r e c e nt s t u d ie s a r e e m p l o y i n g m o r e s o p h i s ti -

ca te d me tho do l og ie s [106 , 107, 120 , 124~128]. T he re

h a s b e e n a h e a v y r e l i a n c e o n s e l f - r e p o r t s w h i c h

b r i n g w i t h t h e m t h e t h r e a t o f s o c i a l d e s i r a b i l i t y b i a s

[34, 85, 116 , 129] . T h i s i s , o f cours e , no t un ique to

s t u d i e s o f t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f i n f e r t i -

l i t y b u t i s , r a t h e r , a p r o b l e m f o r m a n y s o c i a lp s y c h o l o g i c a l m e a s u r e s . T h e r e i s , h o w e v e r , s o m e

r e a s o n t o b e l i e v e t h a t t h i s d a n g e r m a y b e g r e a t e r

f o r i n f e r t i l e c o u p l e s t h a n o t h e r i n d i v i d u a l s [ 3 4 ]. T h e

t h r e a t o f s o c i a l d e s i r a b i l i t y b i a s m a y a l s o b e g r e a t e r

i n c l i n i c s a m p l e s b e c a u s e c o u p l e s m a y f e e l p r e s s u r e

t o a p p e a r " n o r m a l " i n o r d e r t o m a k e s u r e h e a l t h

c a r e p r o f e s s i o n a l s w i l l t r e a t t h e i r i n f e r t i l i t y a s a

m e d i c a l , r a t h e r t h a n a p s y c h o l o g i c a l , p r o b l e m a n d

b e c a u s e c o u p l e s m a y s u s p e c t t h a t g a i n i n g a c c e s s t o

h i g h - t e c h t r e a t m e n t s m a y i n v o l v e f o r m a l o r i n f o r -

m a l p s y c h o l o g i c a l s c re e n i n g .

Problems in sampling

S t u d i e s o f th e p s y c h o l o g i c a l c o n s e q u e n c e s o f

i n f e r t i l i t y h a v e b e e n g e n e r a l l y c h a r a c t e r i z e d b y n o n -

r e p r e s e n t a t i v e s a m p l e s [ 9 7 ] . T h i s i s a s p e c i a l p r o -

b l e m i n t h e s t u d y o f t h e s o c i a l a n d p s y c h o l o g i c a l

c o r r e l a t e s o f i n f e r t i l i ty b e c a u s e t h e r e a p p e a r s t o b e

s o m u c h v a r i a b i l i t y i n t h e e x p e r i e n c e o f i n f e r t i li t y

[ 85 , 1 3 0 ] . S a m p l e s a r e u s u a l l y d r a w n f r o m i n f e r t i l i ty

c l i n ic s , o r f r o m R e s o l v e , a n a t i o n a l i n f e r t i l i t y s u p -

p o r t g r o u p ; p a t i e n t s i n in vitro f e r t i l i z a t i o n ( I V F )

p r o g r a m s a r e l ik e w i se h e a v i ly o v e r - s a m p l e d . S t u d i es

d o n o t o f t e n t a k e t h e d i f f e r e n t s o u r c e s o f s a m p l e s

i n t o a c c o u n t i n i n t e r p r e t i n g e v i d e n c e . B e r g a n d

W i l s o n [ 4 ] f o u n d t h a t R e s o l v e m e m b e r s m a y r e p o r t

m o r e d i s t r e s s t h a n o t h e r i n f e r t i l e c o u p l e s .

C o n v e r s e l y , i t a p p e a r s t h a t I V F c o u p l e s m a y r e p o r t

l e s s d i s t re s s tha n o th e r in fe r t i l e cou p le s [31 , 97 , 101 ,

1 1 0 , 1 14 , 1 3 1 ] . A s w e h a v e a l r e a d y s e e n , t h i s f a c t

m a y s e rv e t o c o n f o u n d o u r i n t e r p r e t a t i o n o f t h e

p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e . H i g h a t t r i t i o n a n d

r e f u s a l r a t e s m a y m a k e s a m p l e s e v e n l e s s r e p r e s e n -

t a t i v e o f t h e i n f e r t i l e p o p u l a t i o n a s a w h o l e [ 1 23 ].

S a m p l e s a r e o f t e n d r a w n f r o m v o l u n t e e r s , w h o

m i g h t w e l l e x p e r i e n c e d i f f e r e n t l e v e l s o f p s y c h o l o g i -

c a l d i s t r e s s t h a n t h o s e w h o c h o o s e n o t t o v o l u n t e e r .

I n a d d i t i o n , p e o p l e w h o d r o p o u t o f t r e a t m e n t a r e

u s u a l l y l e f t u n s t u d i e d . T h e s e p e o p l e m a y w e l l r e p o r t

d i f f e r e n t le v e ls o f d i s t r e s s t h a n t h o s e w h o r e m a i n i n

t r e a t m e n t .

B u t t h e b i g g e s t p r o b l e m w i t h r e g a r d t o s a m p l i n g

i s t h a t p e o p l e w h o d o n o t s e e k t r e a t m e n t h a v e b e e n

l e f t t o t a l l y u n s t u d i e d . S i n c e a l m o s t h a l f o f i n f e r t i l e

c o u p l e s d o n o t s e e k t r e a t m e n t [ 1 3 2 ] , t h i s r e p r e s e n t s

a s e r i o u s o m i s s i o n [ 4 , 9 2 ] . W i t h o u t s t u d y i n g n o n -

t r e a t m e n t s e e k e r s, i t is e x t r e m e l y d i f f ic u l t t o s o r t t h e

e f fe c ts o f i n f e r t i l i t y f r o m t h e e f f e c ts o f i n f e r t i l i tyt r e a t m e n t . A n d s i n c e n o n - t r e a t m e n t s e e k e r s h a v e

d i f fe r e n t d e m o g r a p h i c p r o f i l es t h a n t r e a t m e n t s ee -

k e r s , i t i s i m p o s s i b l e t o g e n e r a l i z e f r o m s t u d i e s o f

t r e a t m e n t s e e k er s [ 4 ]. A n o t h e r i ss u e o f c o n s i d e r a b l e

i m p o r t a n c e i s t h a t n o n - w h i t e s a n d t h o s e w i t h l o w e r

i n c o m e s r e m a i n v i r t u a l ly u n s t u d i e d [ 4 ] , t h o u g h

t h e s e g r o u p s a r e o v e r - r e p r e s e n t e d a m o n g t h e i n f e r -

t i le [ 13 2 , 1 3 3 ] . W h i l e n o n - w h i t e s a n d t h o s e w i t h

l o w e r i n c o m e s a r e m o r e l i k e l y t o b e i n f e r t il e , t h e y

a r e l e s s l i k e l y t o r e c e i v e t r e a t m e n t [ 1 3 3 - 1 3 5 ] a n d a r e

t h e r e f o r e l e s s l i k e l y t o b e c o m e t h e s u b j e c t s o f

re s ea rch .I n a n a t t e m p t t o e x a m i n e p s y c h o l o g i c a l a n t e c e-

d e n t s t o i n f e r t i l i t y , S t o l e r u et al. [ 1 8 ] r e c r u i t e d

c o u p l e s t h r o u g h t h e p r e s s . S u c h a s t r a t e g y m i g h t

a l s o b e u s e d t o l o c a t e i n f e r t i l e i n d i v i d u a l s w h o h a v e

n o t s o u g h t o r r e c e iv e d t r e a t m e n t . O f c o u r s e , t h i s

a p p r o a c h b r i n g s w i t h i t i t s ow n s e t o f s a m p l i n g p r o -

b l e m s c e n t e r i n g a r o u n d t h e i s s u e o f s e l f - se l e c t io n .

T h e i d e a l s t r a t e g y w o u l d b e t o e m p l o y r a n d o m

s a m p l e s o f p e o p l e w h o s e i n f e r ti l it y i s u n k n o w n , b u t

t h i s w o u l d r e q u i r e e x t r e m e l y l a r g e s a m p l e s a n d

w o u l d b e q u i t e c o s t l y . P e r h a p s a m o r e p r a c t i c a l

s t r a t e g y f o r i n c l u d i n g i n f e r t i l e i n d i v i d u a l s n o t s e e k -i n g t r e a t m e n t w o u l d b e t o " p i g g y b a c k " s t u d i e s o f

t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f i n f e r t i l i t y o n t o

s t u d ie s b e i n g c o n d u c t e d f o r a n o t h e r p u r p o s e .

Cross-cultural variation

R e l a t e d t o t h e i s s u e o f r e p r e s e n t a t i v e n e s s o f

s a m p l e s i s t h e q u e s t i o n o f c r o s s - c u l t u r a l v a r i a t i o n .

T h e p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e i s v e r y m u c h

a n i n t e r n a t i o n a l l i t e r a t u r e , w i t h s t u d i e s b e i n g

r e p o r t e d f r o m t h e U . S . , C a n a d a , t h e U n i t e d

K i n g d o m , S w e d e n , S w i t z e r l a n d , G e r m a n y , I s r a e l ,

a n d o t h e r s o c i e t ie s . H o w e v e r , t h e q u e s t i o n o f h o w

d i f f e r e n t n a t i o n a l o r c u l t u r a l c o n t e x t s m i g h t s h a p e

t h e e x p e r i e n c e o f i n f e r t i l i t y i s v i r t u a l l y n e v e r

a d d r e s s e d [ [ 4 ] ; f o r e x c e p t i o n s , s e e R e f s [ 1 1 8 ] a n d

[136]].



Infer tility and psychological distress 1689

T h e t e m p o r a l d i m e n s io n

A n o t h e r m e t h o d o l o g i c a l p r o b l e m i n t h e s t u d y , a f

t h e p s y c h o l o g i c a l co n s e q u e n c e s o f i n f e r t i l it y h a s t o

do with t iming [4, 5 , 11, 12, 22, 42, 76, 85, 92].

I n f e r t i l i t y i s n o t a s t a b l e t r a i t b u t a p r o c e s s w i t h a n

u n c e r t a i n t r a j e c t o r y . S t u d i e s o f t h e e x p e r i e n c e o fi n f e r ti l it y m u s t t a k e t h e t e m p o r a l f a c t o r i n t o

a c c o u n t . I t i s c r u c i a l to k n o w w h e r e i n d i v i d u ~. ls

b e i n g s t u d i e d s t a n d i n t h e i n f e r t i l i t y p r o c e s s . T h e r e

e x i s t s s o m e e v i d e n c e t h a t t h e e f f e c t s o f i n f e r t i l i t y

vary over t ime [5, 29, 39, 42, 45, 94, 104, 112, 116,

1 3 7 - 1 39 ] . I f c a r e i s n o t t a k e n t o c o n t r o l f o r d u r -

a t i o n o f i n f er t i li t y a n d d u r a t i o n o f t r e a t m e n t , w h a t

a p p e a r t o b e d i f fe r e n c es b et w e e n i n d i v i d u a l s m a y b e

a r t i f a c t s o f d i f f e r e n c e s i n d u r a t i o n . T h e e f f e c t s o f

t i m e o n t h e e x p e r i e n c e o f i n f er t i li t y m a y w e l l n o t b e

l i n e a r [ 5 , 1 0 4 ] ; t h e r e f o r e , s t u d i e s w h i c h t r e a t t h e

d u r a t i o n m e a s u r e a s a c o n t i n u o u s l i n e a r v a r i a b l em a y o v e r l o o k i m p o r t a n t r e l a t i o n s h i p s .

A r e c e n t s t u d y b y H y n e s e t a l . [ 9 4 ] p o i n t s o u t

j u s t h o w c r u c i a l t h e i s s u e o f t i m i n g c a n b e . H y n e s

e t a l . a d m i n i s t e r e d q u e s t i o n n a i r e s m e a s u r i n g d e -

p r e s s i o n a n d s e l f - e st e e m t o b o t h 1 00 in f e r t i l e

w o m e n i n a n I V F p r o g r a m a n d 7 3 p r e s u m e d f e r t i l e

c o n t r o l s o n t w o s e p a r a t e o c c a s i o n s 6 w e e k s a p a ~ t .

A t t h e f i r s t tr i a l , t h e r e w e r e n o s i g n i f i c a n t d i f f e r -

e n c e s in d e p r e s s i o n o r s e l f - e s t e e m b e t w e e n t h e i n f e r -

t i l e w o m e n a n d t h e c o n t r o l s ; a t t h e t i m e o f t ]a e

s e c o n d t r i a l , a f t e r t h e i n f e r ti l e w o m e n h a d l e a r n e d

t h a t t h e i r a t t e m p t a t I V F w a s u n s u c c e s s f u l , t h e r ew e r e s i g n i f i c a n t d i f f e r e n c e s i n b o t h d e p r e s s i o n a n d

s e l f -e s t e e m . T h e e x p e r i e n c e o f i n f e r t i l i t y h a s b e e n

a p t l y d e s c r i b e d a s a r o l l e r c o a s t e r o f r a i s e d h o p e s

f o l l o w e d b y t r a g i c d i s a p p o i n t m e n t . T h e H y n e s e t a l .

s t u d y d e m o n s t r a t e s b o t h h o w i m p o r t a n t a n d h c ~ w

d i f f i c u l t i t i s t o p r o p e r l y t a k e t i m e i n t o a c c o u n t i n

s t u d i e s o f t h e e x p e r i e n c e o f i n f e r t i l i t y .

I n e x a m i n i n g t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f

i n f e r t i l i ty , t h e r e a r e a c t u a l l y t w o t e m p o r a l v a r i a b l e s

t h a t n e e d t o b e c o n s i d e r e d : d u r a t i o n o f i n f e r t i l i t y

a n d d u r a t i o n o f t r e a t m e n t . T h e t w o m a y w e l l b e r e-

l a t e d t o p s y c h o l o g i c a l s t r e s s i n v e r y d i f f e r e n t w a y s

a n d m a y e v e n i n t e r a c t . F o r e x a m p l e , i t i s n o t a t a l l

f a r f e t c h e d t o e n t e r t a i n t h e p o s s i b i l i t y t h a t i n f e r t i l i t y

s t r e s s w i l l d i m i n i s h o v e r t i m e f o r t h o s e w h o a r e n o

l o n g e r s e e k i n g t r e a t m e n t b u t n o t f o r t h o s e w h o a r e

s t i l l a c t i v e l y p u r s u i n g t r e a t m e n t . I n a d d i t i o n , t l a e

q u e s t i o n o f w h e t h e r o r n o t t r e a t m e n t s w e r e s u c ce s s-

f u l n e e d s t o b e c o n s i d e r e d . T h e l i t e r a t u r e i n i t s p r e -

s e n t s t a t e d o e s n o t p e r m i t a n y d e f i n i t i v e

g e n e r a l i z a t i o n c o n c e r n i n g t h e e f f e c t o f d u r a t i o n o f

i n f e r ti l it y o r d u r a t i o n o f t r e a t m e n t o n p s y c h o l o g i c a l

d i s t re s s .

T o m o v e o n t o a n o t h e r m e t h o d o l o g i c al p r o b l e m

c h a r a c t e r i s t i c o f t h e l i t e r a t u r e b e i n g c o n s i d e r e d ,

m o s t s t u d ie s h a v e b e e n c r o s s - s e c t i o n a l r a t h e r t h a n

longi tudinal in des ign [18, 35, 37, 42, 92, 98, 1C,2,

119 , 121 , 123 , 140] . T h i s , o f cou rs e , m ake s i t d i f f i-

c u l t t o s o r t o u t c a u s e a n d e f f e c t . I n a d d i t i o n , a l a , : k

o f p r e - t r e a t m e n t d a t a m a k e s i t d if f ic u lt t o s o r t o u t

t h e e f f e c ts o f i n f e r t i l i t y f r o m e f f ec t s o f t r e a t m e n t

[ 2 2 , 9 2 ] . T h e m a j o r i t y o f t h e l o n g i t u d i n a l s t u d i e s

t h a t h a v e b e e n d o n e u s e a v e r y s h o r t t i m e f r a m e .

T h e w o r k o f A b b e y , A n d r ew s , a n d H a l m a n [1 05 ,

107 , 117 , 120-128 , 141] i s a no tab le exce p t ion in

t h a t t h e a u t h o r s s t u d i e d t h e i r p a n e l a t t h r e e i n t e r -

v a l s a y e a r a p a r t . H i r s c h a n d H i r s c h [ 1 3 7 ] a d m i n i s -

t e r e d q u e s t i o n n a i r e s t o 3 3 i n f e r t i l e c o u p l e s f o u r

t i m e s a t 9 - m o n t h i n t e r v a l s . B u t , a s B o i v i n a n d

T a k e f m a n [ 4 2 ] h a v e s h o w n , s a m p l i n g a t f r e q u e n t

i n t e r v a l s o v e r a s h o r t e r t i m e p e r i o d c a n a l s o

u n c o v e r i m p o r t a n t d a t a . S t o l e r u e t a l . [ 1 8 ] a r e

e x c e p t i o n a l in h a v i n g d e v e l o p e d a r e s e a rc h d e s i g n

t h a t m a k e s i t p o s s i b l e t o d i s t i n g u i s h t h e e f f e c ts o f

t i m e f r o m t h e e f f e c t s o f t r e a t m e n t . T a b l e 4 .

S u m m a r i z e s s tu d i e s d e a l i n g w i th t h e t e m p o r a l

d i m e n s i o n .

T h e q u e s t i o n o f c o n t r o ls

T e s t i n g t h e p s y c h o l o g i c a l c o n s e q u e n c e s m o d e l

n e c e s s a r i l y e n t a i l s c o m p a r i n g t h e i n f e r t i l e t o n o n -

i n f er t il e p o p u l a t i o n s . N e i t h e r o f t h e t w o m e t h o d s o f

c o m p a r i s o n g e n e ra l ly u s e d - - u s i n g s t a n d a rd i z e d

m e a s u r e s a n d u s i n g c o n t r o l g r o u p s - - i s w i t h o u t i t s

p r o b l e m s . S t a n d a r d i z e d m e a s u r e s m a y n o t b e s uf fi-

c i e n t l y s e n s i t i v e o r s p e c i f i c t o t h e p r o b l e m s o f i n f e r -

t i l i ty to a d e q u a t e l y r e f le c t t h e e x p e r i e n c e o f

in fe r t i l i t y [4 , 5 , 74 , 85 , 129] . T h i s i s pe rh ap s w hy the

d e s c r i p t i v e l i t e r a t u r e y i e l d s m o r e c o n s i s t e n t r e s u l t s

t h a n d o t h e " c o n t r o l l e d " s t u d i e s . T h i s m a y b e a ne s p e c ia l l y s e r io u s p r o b l e m w i t h r e g a r d t o m e a s u r e s

o f s e x u a l it y . W i t h r e g a r d t o c o n t r o l g r o u p s , i t i s n o t

r e a d il y a p p a r e n t w h a t a n a p p r o p r i a t e c o n t r o l g r o u p

w o u l d b e . M o s t o f t e n p r e g n a n t w o m e n a r e u s e d .

T h e s e m i g h t n o t b e t h e m o s t a p p r o p r i a t e c h o i c e [4 ,

9 2 ]. T h e r e a r e , l i k ew i s e , p r o b l e m s w i t h o t h e r g r o u p s

c o m m o n l y s e le c t ed a s c o n tr o l s , s u c h a s m o t h e r s , t h e

v o l u n t a r i l y c h i l d l e s s , o b s t e t r i c a l a n d g y n e c o l o g i c a l

pa t i e n t s , an d co l l ege s tud en t s [92 , 94 , 123] .

F o r o b v i o u s r e a s o n s , s t u d i e s w h i c h i n v o l v e c o n -

t r o l s t y p i c a l l y u s e g e n e r a l m e a s u r e s o f p s y c h o l o g i c a l

d i s t r e s s r a t h e r t h a n m e a s u r e s s p e c i f i c a ll y d e s i g n e dt o m e a s u r e d i s t r e s s r e l a t e d t o i n f e r t i l it y . T h e a p p a r -

e n t g r e a t e r s e n s i t i v i t y o f s p e c i f i c m e a s u r e s s u g g e s t s

t h e i r u t i l i ty ( a l t h o u g h s o m e m i g h t c l a i m t h a t s p e c if i c

m e a s u r e s a r e b i a s e d r a t h e r t h a n s e n s i t i v e ) . T h e f a c t

t h a t s p e c if i c m e a s u r e s o f i n f e r t i l i t y s t r e ss t e n d t o

c o r r e l a t e s t r o n g l y w i t h s t a n d a r d i z e d m e a s u r e s i s

a n o t h e r p o i n t i n f a v o r o f s p e c i fi c i n f e r t i l i t y m e a s u r e s

[ [74, 78 , 128 , 14 1 , 142] ; s ee Re f . [92] fo r an excep -

t i o n ] . I n s t r u m e n t s d e v e l o p e d b y A b b e y e t a l . [106,

107, 117, 120, 124-128], Berns te in e t a l . [ 7 4 ] , a n d

S a b e t e l l i e t a l . [ 7 8] s e e m w o r t h y o f a t t e n t i o n .

A b b e y , A n d r e w s , a n d H a l m a n [ 1 0 6, 1 0 7, 1 17 ,

1 2 0 , 1 2 4 - 1 2 8 ] h a v e c o m e u p w i t h o n e i m a g i n a t i v e

s o l u t i o n t o t h e q u e s t io n o f h o w t o c o n d u c t a c o n -

t r o l l ed s t u d y w i t h o u t h a v i n g t o r e l y o n s t a n d a r d i z e d

m e a s u r e s w h i c h m a y n o t f u ll y c a p t u r e t h e e x p e r i -

e n c e o f in f e r t i l it y . T h e s e a u t h o r s c o m p a r e d 1 85



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Infertility and psycho logical distress 1693

i n f e r t i l e c o u p l e s t o 9 0 p r e s u m e d f e r t il e c o u p l e s . T h e

i n f e r t i l e c o u p l e s w e r e a s k e d t o r e s p o n d t o a s e r ie s

o f q u e s t i o n s r e l a t e d t o " f e r t i li t y p r o b l e m s t r e ss . " T o

o b t a i n c o m p a r a b l e d a t a f r o m t h e p r e s u m e d f e r t i l e

c o n t r o l s , t h e r e s e a r c h e r s a s k e d t h e m q u e s t i o n s

a b o u t s t r e s s r e l a t e d t o w h a t e v e r r e s p o n d e n t s i d e n t -

i fi ed a s t h e i r " b i g g e s t p r o b l e m . "

I t i s n o t c l e a r t h a t i n c l u d i n g c o n t r o l s o r s t a n d a r -

d i z e d m e a s u r e s i s a s c r u c i a l a s i t i s s o m e t i m e s m a d e

o u t t o b e . I f t h e p u r p o s e o f t h e p s y c h o l o g i c a l d i s -

t r e s s l i t e r a t u r e i s t o " t e s t " o r v e r i f y t h e c l a i m s m a d e

i n t h e d e s c r i p t i v e l i t e r a t u r e , t h e n w e n e e d t o p a y

s p e c i a l a t t e n t i o n t o w h a t i t is t h e d e s c r i p t i v e st u d i e s

a r e a c t u a l l y c l a i m i n g . T h e d e s c r i p t i v e l i t e r a t u r e

a s s e r t s t h a t t h e e x p e r i e n c e o f i n f e r t i l i t y i s s tr e s s f u l

a n d i d e n t i t y - t h r e a t e n i n g - - i n s h o r t t h a t i n f e r t i li t y i s

a d i f f i c u l t s i t u a t i o n t o l i v e w i t h . T h e d e s c r i p t i v e l i t -

e r a t u r e d o e s n o t a s s e rt t h a t i n f e rt i le p e o p l e a r e p s y -

c h o l o g i c a l l y b e t t e r o r w o r s e o f f t h a n a n y o t h e rg r o u p o f p e o p l e ; i t i s s i m p l y t r y i n g t o c h a r a c t e r i z e

t h e s i t u a t i o n o f b e i n g i n f e r t i l e . T a k e t h e a p p a r e n t

c o n t r a d i c t i o n b e t w e e n t h e d e s c r i p t i v e l i t e r a t u r e a n d

t h e p s y c h o l o g i c a l l i t e r a t u r e o n m a r i t a l r e l a t i o n s , f o r

e x a m p l e . T h e d e s c r i p t i v e l i t e r a t u r e r e p o r t s t h a t

i n f e r t i l i t y p r e s e n t s i t s e l f a s a c r i s is f o r c o u p l e s , b u t

i t d o e s n o t n e c e s s a r i l y f o l l o w f r o m t h i s t h a t i n f e r t i l e

c o u p l e s s h o u l d b e e x p e c t e d t o h a v e w o r s e m a r r i a g e s

t h a n o t h e r c o u p l e s . I n f a c t, m a n y o f t h e c o u p l e s

i n t e rv i e w e d b y G r e i l [ 5 8 ] s a i d t h a t i n f e r ti l it y h a d

b r o u g h t t h e m c l o s e r t o g e t h e r . T h e f a c t th a t t h e

p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e d o e s n o t r e v e a l t h ei n f e rt i le to h a v e m o r e p r o b l e m s w i t h r e l a t i o n s h i p s

d o e s n o t r e a l l y c o n t r a d i c t t h e c h a r a c t e r i z a t i o n o f

i n f e r t i l i t y a s a c h a l l e n g e to r e l a t i o n s h i p s . N o r d c e s

t h e f a c t t h a t n o t a l l s t u d i e s s h o w t h e i n f e r t i l e t o

s c o r e h i g h e r t h a n c o n t r o l s o n s p ec i fi c m e a s u r e s o f

p s y c h o l o g i c a l d i s t r e s s m e a n t h a t i n f e r t i l i t y i s n o t a

s t r e s s fu l e x p e r i e n c e .

C o n c e p t u a l s h o r t c o m i n g s

T h e r e a r e c o n c e p t u a l p r o b l e m s w i t h m u c h o f th e

p s y c h o l o g i c a l d i st r e s s li t e r a t u r e t h a t a r e a s i m p o r t -

a n t a s t h e m e t h o d o l o g i c a l p r o b l e m s d i sc u s s eda b o v e . B y a n d l a r g e , M a r t i n M a t t h e w s a n d

M a t t h e w s ' [ 8 ] a s s e r t i o n t h a t t h e r e h a s b e e n l i t t l e

e f f o rt a t t h e o r y d e v e l o p m e n t a n d l i t t l e a t t e m p t t o

i n t e g r a t e d a t a o n t h e p s y c h o s o c i a l i m p a c t o f i n f e r ti -

l i t y w i t h g e n e r a l s o c i a l p s y c h o l o g i c a l t h e o r y i s s t i l l

c o r r e c t . T h e t w o e x c e p t i o n s t o t h i s s t a t e m e n t a r e

q u a l i t a t i v e w o r k , c o m i n g o u t o f s y m b o l i c i n t e r a c -

t i o n i s t o r g r o u n d e d t h e o r y p e r s p e c t i v e s [ 4 8 , 5 0 , 5 8 ,

6 5 , 70 , 7 9, 1 4 3 ] , a n d a s m a l l g r o u p o f s c h o l a r s w h o

a r e t r y i n g t o u t i li z e i n s ig h t s f r o m t h e c o p i n g a n d

c o g n i t i v e a p p r a i s a l l i t e r a t u r e s [ 2 3 , 4 5 , 8 9 - 9 1 , 9 4 ,

106, 130, 131, 139, 144-147].

I n g e n e r a l , t h e p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e

s h o w s l i t t l e r e g a r d f o r t h e s o c i a l c o n s t r u c t i o n o f

i n f e r t i l i t y . T h e l i t e r a t u r e t a k e s w h a t s h o u l d b e

u n d e r s t o o d a s a c h a r a c t e r i s t i c o f a s o c i a l s i t u a t i o n

a n d t r a n s f o r m s i t i n t o a n indiv idual t ra i t . T o p u t i t

a d i f f e r e n t w a y , t h e p s y c h o l o g i c a l d i s t r e s s li t e r a t u r e

t a k e s t h e q u e s t i o n , " I s i n f e r t i l i t y s t r e s s fu l ? , " a n d

t r a n s f o r m s i t i n t o t h e q u e s t i o n , " A r e t h e i n f e r t i l e

d i s t r e s s e d ? " I n d o i n g s o , i t p r e s e n t s w h a t i s e s s e n -

t i a ll y a m e d i c a l m o d e l o f t h e p s y c h o - s o c i a l i m p a c t

o f i n f e r t i l i t y . P s y c h o l o g i c a l d i s t r e s s i s p r e s e n t e d a s

o n e m o r e s y m p t o m o f i n fe r t il e p a t i e n t s w h i c h m e d i -

c a l p r o f e s s i o n a l s m a y t r e a t . T h u s , o n e r e c e n t a r t i c l e

w a s e n t i t l e d " P s y c h o l o g i c a l M o r b i d i t y i n

U n e x p l a i n e d I n f e r t i l i t y " [1 4 8 ] a n d a n o t h e r w a s

c a l l e d " M o o d D i s o r d e r s , P s y c h i a t r i c S y m p t o m s ,

a n d D i s t r e s s i n W o m e n p r e s e n t i n g f o r I n f e r t i l i t y

E v a l u a t i o n " [ 9 2 ]. I n t h i s w a y , o u r a t t e n t i o n i s

d i v e r t e d f r o m t h e s o c i a l c o n d i t i o n s w h i c h s h a p e t h e

e x p e r i e n c e o f i n f e r t i l i t y t o i n d i v i d u a l s r e g a r d e d i n

r e l a t i v e s o c i a l i s o l a t i o n a n d t o t h e i n d i v i d u a l t r a i t s

w h i c h m a y e n h a n c e o r i m p e d e t h e i r a b i li t y t o c o p e .

A t a p r a c t i c a l l e v el , o u r a t t e n t i o n i s s h i f t e d a w a y

f r o m w a y s i n w h i c h t h e t r e a t m e n t o f i n f e r t i l i t ym i g h t b e i m p r o v e d t o a s e a r c h f o r w a y s t o h e l p t h e

i n f e r t i l e a d j u s t t o a n i m p e r f e c t s y s t e m .

T h i s m e d i c a l iz e d a p p r o a c h t o i n f e r t i l it y is

r e f l e c t e d i n a t e n d e n c y w i t h i n t h e l i t e r a t u r e t o t h i n k

o f i n f e r t i li t y , n o t a s a s o c i a l s ta t u s , b u t a s a p h y s i o -

l o g i c a l st a t e . T h u s , B e r n s t e i n et a l . [ 9 3 ] r e f e r t o

p r e g n a n t i n f e r t i l e c o u p l e s a s " p r e v i o u s l y i n f e r t i l e "

e v e n t h o u g h e v i d e nc e sh o w s t h a t t h e p r e g n a n t i n f e r -

t i l e s t i l l t h i n k o f t h e m s e l v e s a s i n f e r t i l e a n d t h a t

t h e y d i s p l a y l e v e l s o f d i s t r e s s s i m i l a r t o t h o s e o f

o t h e r i n f e r t i l e c o u p l e s . B r a n d e t a l . [19, 20] use as

t h e i r " f e r t i l e " c o n t r o l g r o u p w o m e n w h o a r e m e m -b e r s o f i n f e r t il e c o u p l e s b u t w h o t h e m s e l v e s h a v e

n o d i a g n o s e d r e p r o d u c t i v e i m p a i r m e n t , e v e n t h o u g h

e v i d e n ce s u g g e st s th a t s u c h w o m e n t h i n k o f t h e m -

selves as infert i le [58, 60].

P e r h a p s i t is b e c a u s e t h e y a c c e p t a m e d i c a l m o d e l

o f i n f e r t i l i t y s t re s s t h a t r e s e a r c h e r s d o n ' t s e e m t h a t

c o n c e r n e d t h a t c e r t a i n e t h n i c g r o u p s a n d s o c i a l

c l as s es h a v e b e e n i g n o r e d . I f o n e d o e s n o t c o n c e p t u -

a l i z e in f e r t i l i t y a s b e i n g s o c i a l l y c o n s t r u c t e d , o n e

m i g h t n o t s t o p t o t h i n k t h a t d i f f e re n t g r o u p s m i g h t

c o n s t r u c t i t d i f f e r e n t l y .

Q u a l i t a t i v e v s . q u a n t i t a t i v e

T h i s l e n g t h y c r i t i q u e o f t h e ( m o s t l y q u a n t i t a t i v e )

p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e s h o u l d n o t b e m i s -

t a k e n f o r a c l a i m t h a t t h e ( m o s t l y q u a l i t a t i v e )

d e s c r i p t i v e l i t e r a t u r e i s w i t h o u t f l a w s . D e s c r i p t i v e

l i t e r a t u r e s h a r e s m a n y o f t h e s a m e f l a w s f o u n d i n

t h e p s y c h o l o g i c a l d i s t r e s s l it e r a t u r e , s u c h a s s m a l l

s a m p l e s i z e , o v e r - r e p r e s e n t a t i o n o f w h i t e , m i d d l e -

c l a s s, t r e a t m e n t s e e k e r s , a n d a l a c k o f a t t e n t i o n t o

t h e q u e s t i o n o f w h e r e r e s e a r ch s u b j e c t s s t a n d o n t h e

t e m p o r a l t r a j e c t o r y o f t h e i n f e r ti l it y ex p e r ie n c e . I n

a d d i t i o n , t h e q u a l i t a t i v e l i t e r a t u r e i s s e r i o u s l y w e a -

k e n e d b y a n o v e r - r e l ia n c e o n r e t r o sp e c t i v e ac c o u n t s .

S t i l l , B e r g [ 4 ] m a y b e r i g h t t o p o i n t o u t t h a t m u c h

o f t h e m o s t i n s i g h t f u l w o r k o n i n f e r ti l it y h a s b e e n

q u a l i t a t i v e .



1694 Ar thur L. Gre il

G E N D E R A N D T H E E X P E R I E N C E O F I N F E R T I L I T Y

T h e r e a r e b y n o w a n u m b e r o f s tu d i e s t h a t h a v e

e x p l o r e d t h e q u e s t i o n o f h o w t h e e x p e r i e n c e o f

i n f e r t i l it y m a y d i f f e r f o r w o m e n a n d m e n . T h e s e

s t u d i e s a r e v i r t u a l l y u n a n i m o u s i n t h e c o n c l u s i o n

t h a t i n f e r t i l i ty is a m o r e s t r e s sf u l e x p e r i e n c e f o rwomen than i t i s for men [5, 11, 24, 29, 32, 39, 58,

60, 69, 74, 77, 88, 90, 92, 93, 98, 102, 105-107, 116,

1 1 7 , 1 2 0 , 1 2 1 , 1 2 8 , 1 2 9 , 1 4 0, 1 4 6 , 14 9 -1 5 1] . I t

a p p e a r s t h a t s t u d i e s u s in g m e a s u r e s s p e c i f ic t o i n f e r -

t i l i t y r e v e a l g r e a t e r g e n d e r d i f f e r e n c e s t h a n d o s t u -

d i e s u s i n g m o r e g e n e r a l m e a s u r e s o f p s y c h o l o g i c a l

d i s t r e s s . T a b l e 5 . S u m m a r i z e s s t u d i e s t a k i n g g e n d e r

i n t o a c c o u n t .

B a s i c f i n d i n g s

S t u d i e s h a v e f o u n d t h a t , c o m p a r e d t o i n f e r t i l e

m e n , i n f e r t il e w o m e n :

1. scor e low er on se lf-e s teem [6, 58, 70, 74, 78, 92,

102, 109, 145, 151]

2 . a re more depres s ed [5 , 29 , 74 , 90 , 93 , 98 , 102 ,

105, 106, 116, 15 0, 152]

3 . rep or t low er l i fe s a t i s fa c t ion [6 , 106 , 113 , 150].

4 . a r e m o r e l i k e l y to b l a m e t h e m s e l v e s f o r t h e i r

in fe r t i l i t y [5 , 85 , 106 , 127 , 14 5 , 147]

5 . a r e m o r e l i k e l y t o r e g a r d c h i l d l e s s n e s s a s u n a c -

cep tab le [5 , 142]

6 . a r e m o r e l i k e l y t o a v o i d c h i l d r e n , p r e g n a n t

w o m e n , a n d o t h e r r e m i n d e r s o f t h e " f er t i le

world" [5, 29, 58, 60, 78]

7 . a re m ore l ik e ly to in i t i a t e t rea tm en t [55, 58 , 60 ,

72, 81,145, 149]

8 . ar e m o r e l ik e l y t o s e e k o u t i n f o r m a t i o n a b o u t

inf ert i l i ty [5 , 58, 60]

9 . a re l e s s inc l ined to s top t rea tmen t [58 , 60]

1 0. a r e m o r e l i k e l y t o f i n d t h a t a c h i e v i n g p a r e n t -

h o o d p r o v i d e s a " r e m e d y " f o r t h e n e g a ti v e c o n -

s equenc es o f in fe r t i l i t y [125 , 126]

R e s u l t s c o n c e r n i n g m a r i t a l a n d s e x u a l s a t i s f a c t i o n

a r e l e s s c l e a r - c u t , w i t h s o m e e v i d e n c e s u g g e s t i n g

tha t w om en a re l e s s s a t i s f i ed tha n m en [2 , 78 , 121 ,1 4 2 , 1 5 0 ] w h i l e o t h e r e v i d e n c e s u g g e s t s t h a t t h e r e i s

no difference [5, 92, 96, 109, 113, 114]. I t appears

t h a t , w i t h i n t h e m a r i t a l r e l a t io n s h i p , w o m e n r e p o r t

t h a t t h e y p r o v i d e m o r e s u p p o r t , r e c e iv e m o r e s u p -

p o r t , a n d a r e m o r e s a t i sf i ed w i t h t h e s u p p o r t t h e y

rece ive tha n a re the i r hus ban ds [102 , 126 , 141].

S o m e r e s e a r c h e r s h a v e e x p l o r e d t h e q u e s t i o n o f

w h e t h e r t h e r e s p o n s e t o i n f e r t i l i t y m a y b e a f f e c t e d

b y w h i c h p a r t n e r h a s t h e r e p r o d u c t i v e i m p a i r m e n t .

T h e m o s t c o m m o n a n s w e r t o t h i s q u e s t i o n i s " n o "

[2 , 22 , 88 , 90 , 93 , 105 , 153] . Seve ra l qua l i t a t ive s tu -

d ie s [55 , 58 , 60 , 65] have conc luded tha t men a re

m o r e d i s t r e s s e d b y i n f e r t i l it y w h e n i t is t h e y w h oh a v e t h e r e p r o d u c t i v e i m p a i r m e n t b u t t h a t w o m e n

a r e e q u a l l y d i s t r e s s e d w h e t h e r t h e y h a v e t h e r e p r o -

d u c t i v e i m p a i r m e n t o r n o t . B u t f o u r s t u d i e s h a v e

f o u n d t h a t w o m e n , t o o , a r e a f f ec t ed b y w h o h a s t h e

r e p r o d u c t i v e i m p a i r m e n t [ 9 9, 1 0 4 , 1 2 7 , 1 4 2 ] .

F i n a l l y , C o n n o l l y e t a l . [ 1 4 0 ] a s s e r t t h a t m a l e f a c t o r

i n f e r t i l i ty l e a d s t o h i g h e r r a t e s o f m a r i t a l d i s t r e s s

fo r bo th hus bands and wives [ s ee a l s o Re f . [45] ] ,

b u t a m o r e r e c e n t s t u d y b y t h e s a m e r e s e a r c h t e a m

[ 2 3 ] r e a c h e d l e s s c l e a r - c u t c o n c l u s i o n s . S p a c e d o e s

n o t p e r m i t t r e a t m e n t o f th e l i t e r a t u r e o n g e n d e r

d i f f e re n c e s i n c o p i n g s t y l e s a n d r e l a t e d i s s u e s.

I n t e r p r e t i n g t h e g e n d e r a n d i n f e r t il i ty l i t e ra t u r e

A f e w a u t h o r s h a v e a t t e m p t e d t o d r a w g e n e r a l

c h a r a c t e r i z a t i o n s o f th e g e n d e r a n d i n f e r t i l i t y l i t e r a -

t u r e . U l b r i c h e t a l . [ 1 4 2 ] a r g u e t h a t t h e t r a n s i t i o n t o

n o n - p a r e n t h o o d i s s m o o t h e r f o r m e n t h e n w o m e n .

Gre i l and h i s a s s oc ia te s [58 , 60] a rgue tha t the e f fec t

o f i n f e r t i l it y o n w o m e n i s m o r e " d i r e c t " , w h i l e t h e

e f fe c t o f i n f e r t i l i ty o n m e n i s m e d i a t e d t h r o u g h t h e i r

r e l a t i o n s h i p s w i t h t h e i r w i v e s . A n d r e w s e t a l . [117]

r e p o r t t h a t , f o r w o m e n , t h e r e i s a b i g d i f f e r e n c eb e t w e e n i n f e r t il i ty a n d o t h e r p r o b l e m s , w h i l e m e n

a r e a f f e c t e d b y i n f e r t i l i t y i n m u c h t h e s a m e w a y

t h a t t h e y a r e a f f e c t e d b y o t h e r p r o b l e m s . I t i s i m -

p o r t a n t f o r r e s e a r c h e r s t o m o v e b e y o n d t h e q u e s -

t i o n o f w h o s e i n f e r t i l i ty i s " w o r s e " t o b e g i n t o

d i s c u s s t h e w a y s i n w h i c h w o m e n ' s a n d m e n ' s e x -

p e r i e n c e s o f i n f e r t i l i t y d i f f e r [4 , 5 ] . A recen t s tudy

b y C a r m e l i a n d B i r e n b a u m - C a r m e l i [ 8 3 ] h i g h l ig h t s

s o m e o f t h e w a y s i n w h i c h i n f e r ti l it y m a y b e p a r -

t i c u l a r l y s t r e s s f u l f o r m e n a n d s t r e s s e s t h e w a y s i n

w h i c h m e n a r e m a r g i n a l i z e d i n t h e i n f e r t i li t y t r e a t -

m e n t p r o c e s s.I n t e r p r e t a t i o n s o f t h e d a t a o n i n f e r ti l it y a n d g e n -

d e r u s u a l l y f o c u s o n d i f f e r e n c e s i n g e n d e r r o l e s a n d

c o p i n g s t y l e s a n d o n d i f f e r e n c e s i n t h e w a y i n f e r t i -

l i t y t r e a t m e n t a f f ec t s w o m e n a n d m e n [ 58 , 6 0 , 1 0 2,

1 21 ]. T h e f a c t t h a t g e n d e r r o l e s a r e m o r e i m p o r t a n t

i n c o n d i t i o n i n g t h e e x p e r i e n c e o f i n f e r t i li t y t h a n t h e

q u e s t i o n o f w h i c h p a r t n e r h a s t h e r e p r o d u c t i v e

i m p a i r m e n t i s s i g n i f i c a n t b e c a u s e i t s h o w s t h a t w h a t

i s e s s e n t i a l l y a s o c i a l v a r i a b l e c a r r i e s m o r e w e i g h t

t h a n a m e d i c a l f a c to r . T h a t g e n d e r r o l e s a n d g e n d e r

i d e n t it i e s a p p a r e n t l y c o n t r i b u t e t o t h e s h a p i n g o f

t h e i n f e r t i l i t y e x p e r i e n c e l e n d s f u r t h e r s u p p o r t t ot h e n o t i o n t h a t i n f e r t i l i ty i s b e s t u n d e r s t o o d a s a

s o c i a l l y c o n s t r u c t e d p r o c e s s r a t h e r t h a n a s a m e r e l y

p h y s i c a l c o n d i t i o n .

M e t h o d o l o g i c a l i s s u e s

S e v e r a l p o i n t s w i t h r e g a r d t o m e t h o d o l o g i c a l

i s su e s r e l a t e d to t h e q u e s t i o n o f g e n d e r a n d i n f e r t i -

l i t y a r e w o r t h y o f n o t e . F i r s t , a n d t h i s m a y b e a

r e a s o n w h y s o m a n y r e s e a r c h e r s h a v e m o v e d i n t h i s

d i r e c t i o n , t h e c o n t r o l g r o u p i s s u e i s l e s s o f a p r o -

b l e m w h e n d o i n g i n t e r n a l c o m p a r i s o n s . A p a r t i c u -

l a r l y s e r i o u s c o n c e r n i s t h e f a c t t h a t t h e r e i s

e v i d e n c e t h a t c o u p l e s , s c o r e s o n d i s t r e s s s c a l e s a r ecor re la t ed [78 , 91 , 125 , 126 , 128] ; the re fo re , s tud ie s

w h i c h u s e c o u p l e s a m p l e s t o c o m p a r e m e n a n d

w o m e n m a y b e u n d e r - r e p o r t i n g t h e r e a l e x t e n t o f

t h e d i f f e r e n c e s t h a t e x i s t b e t w e e n g e n d e r s . L i n k a n d



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Infertility and psychological distress 1699

D a r l i n g [ 1 1 3 ] h a v e r e p o r t e d t h a t w o m e n w h o s e h u s -

b a n d s r e f u s e d t o b e s t u d i e d w e r e m u c h m o r e d i s -

t r e s s e d t h a n o t h e r w o m e n i n t h e i r s a m p l e .

T h e r e f o r e , s t u d i e s o f g e n d e r d i f f e r e n c e s i n i n f e r t i l i t y

b a s e d o n c o u p l e s a m p l e s m a y b e m i s s i n g t h e r e a l

e x t e n t o f f e m a l e / m a l e d i f f e r e n c e s .

T h e r e i s s o m e r e a s o n t o s u s p e c t t h a t s o c i a l d e : fi r -

a b i l i t y b i a s m i g h t b e m o r e o f a f a c t o r f o r i n f er t il e

m e n t h a n i t is fo r i n f e r ti l e w o m e n . L a l o s e t a l . [29]

a n d H a r r i s o n e t a l . [ 3 3 ] f o u n d t h a t m e n i n i n f e r t i l e

c o u p l e s h a d h i g h e r " l i e " s c o r e s t h a n t h e i r p a r t n e r s .

B e r g [ 4 ] s u g g e s t s t h a t i n f e r t i l e m e n m a y h a v e : a

s t r o n g e r t e n d e n c y t h a n i n f e rt i le w o m e n t o p r e s e n t

f a v o r a b l e i m a g e s o f t h e m s e l v e s t o r e s e a r c h e r s ~ m d

c l i n i c ia n s . T h u s , i t i s h a r d t o k n o w t o w h a t e x t e n t

r e p o r t e d d i f fe r e n ce s a r e a r t i f a c t s o f m e n ' s u n w i l l in g -

n e s s to a d m i t t o p s y c h o l o g i c a l d i s t r e s s.

A l t h o u g h m a n y r e s e a r c h e r s h a v e p u r p o r t e d t o

s t u d y i n f e r t i l e " c o u p l e s " , o n l y a f e w h a v e a c t u a l l y

u s e d t h e c o u p l e a s t h e u n i t o f a n a l y s i s [ 7 8, 9 1 , 1 1 1 ,

1 2 8, 1 4 2 , 1 4 4 ] . I t i s i m p o r t a n t w h e r e f e a s i b l e t o

t r e a t t h e c o u p l e a s t h e u n i t o f a n a l y s i s in s t u d i es o f

t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f i n f e r ti l it y b e c a u s e

a n i n d i v i d u a l ' s r e s p o n s e i s l i k e l y t o b e d i a l e c t i c a l l y

r e l a t e d t o t h e r e s p o n s e o f t h a t i n d i v i d u a l ' s p a r t n e r .

W h i l e f r o m a m e d i c a l p o i n t o f v i e w i n f e r ti l it y i s a

p h y s i c a l c o n d i t i o n o f a n i n d i v i d u a l , f r o m a s o c i a l

c o n s t r u c t i o n i s t p o i n t o f v ie w i n f e r t i l i t y i s a s h a r e d

r e a l i t y o f c o u p l e s s h a p e d b o t h b y m e d i c a l v a r i a b l e s

a n d b y a s p e c if i c s o c i a l c o n t e x t .

T h e s a m e p r o b l e m s w i t h s a m p l e r e p r e s e n t a t i ~ v e -n e s s t h a t e x i s t f o r t h e p s y c h o l o g i c a l d i s t r e s s l i t e r a -

t u r e a s a w h o l e s t i l l r e m a i n a s p r o b l e m s f o r t h e

l i t e r a t u r e o n g e n d e r a n d i n f e r t i l i t y . A s w i t h t h e

p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e i n g e n e r a l , n o n -

t r e a t m e n t s e e k e r s a r e i g n o r e d , a n d n o n - w h i t e s a n d

l o w e r e c o n o m i c g r o u p s a r e s ti ll u n d e r - r e p r e s e n t e d .

OTHER ISSUES

S o m e s t u d i e s i n t h e p s y c h o l o g i c a l d i s t r e s s l i t e r a -

t u r e h a v e a d d r e s s e d t h e q u e s t i o n o f w h e | h e r

p s y c h o l o g i c a l d i s t r e s s is a f f e c t ed b y d i a g n o s i s o rt y p e o f i n f e r t i l i t y . T h e b u l k o f t h e e v i d e n c e s u g g e s t s

t h a t s p e c i fi c d i a g n o s i s d o e s n o t a f f e c t p s y c h o l o g i c a l

d i s t re s s [ [87 , 93] ; fo r an excep t ion , s ee Re f . [154] ] ,

b u t t h a t u n d i a g n o s e d , o r " i d i o p a t h i c , " i n f e r t i L l i t y

m a y b e p a r t i c u l a r l y s t r e s s f u l [ 88 , 9 8, 9 9] . M o s t s t u -

d i e s w h i c h h a v e c o m p a r e d p r i m a r y a n d s e c o n d a r y

i n f e r ti l it y h a v e f o u n d t h i s d i s t in c t i o n t o b e u n r e -

l a t e d t o l e v e l s o f p s y c h o l o g i c a l d i s t r e s s [2 3, 7 5 , 8 8 ,

104 , l l 0 , 119 , 142] . Sev e ra l s tud ie s ha ve f ou nd 1 :ha t

i n f e rt i le w o m e n w h o h a v e b e c o m e p r e g n a n t a r e

s i m i l a r i n t e r m s o f l e v e l o f d i s t r e s s t o i n f e : r t i l e

w o m e n w h o h a v e n o t c o n c e i v e d [6 , 9 3 , 1 5 5 ] , b u t a

r e c e n t s t u d y [ 1 2 1 ] h a s f o u n d t h a t p r e g n a n c y d o e s

r e d u c e t h e p s y c h o l o g i c a l d i s t r e s s o f i n f e r t i l i t y .

S a n d e l o w s k i e t a l . [ 6 7 , 6 9 ] a r g u e v e r y c o n v i n c i n g l y

t h a t p r e g n a n c y i s a v e r y d i f f e r e n t e x p e r i e n c e f o r

i n f e rt i le w o m e n t h a n i t i s f o r t h o s e w h o h a v e n e v e r

h a d d i f f i c u lt y c o n c e i v i n g . A g a i n , t h e i n f l u e n c e o f t h e

s o c i a l s t a t u s o f i n f e r t i l i t y s e e m s t o o u t w e i g h t h e

e f f ec t s o f m e d i c a l v a r i a b l e s .

A n u m b e r o f o t h e r i s s ue s w h i c h m a y i n f lu e n c e

p s y c h o l o g i c a l d i st r e ss a m o n g i n f e rt i le c o u p l e s a n d

w h i c h h a v e b e e n a d d r e s s e d b y s o m e s t u d i e s a r e

b e y o n d t h e s c o p e o f t h i s p a p e r . T h e s e i n c l u d e c o p -

i n g s t y l e s a n d s t r a t e g i e s , c o g n i t i v e a p p r a i s a l s , a n d

caus a l a t t r ib u t i on s [23 , 45 , 88-91 , 126 , 131 , 146 ,

1 47 , 1 5 6 ] , f a c t o r s m e d i a t i n g t h e r e l a t i o n s h i p

b e t w e e n i n f e r t i l i t y a n d p s y c h o l o g i c a l d i s t r e s s [8 7 ,

107, 111, 117, 120, 125, 126, 128], m ot iv at io ns for

h a v i n g c h i l d r e n [ 1 5 7 - 1 6 0 ] , t h e r o l e o f s o c i a l s u p p o r t

[37, 40, 88, 102, 125, 126, 141, 146, 161 ], an d s ex-

ro le o r i en ta t ions [5 , 96] .

CONCLUSIONS AND SUGGESTIONSFOR FUTURERESEARCH

W h i l e i t c a n n o l o n g e r b e s a i d t h a t t h e p s y c h o -

l o g i c a l i m p a c t o f i n f e r t i l it y i s a n e g l e c t e d a r e a o f

r e s e a rc h , m e t h o d o l o g i c a l a n d c o n c e p t u a l p r o b l e m s

h a v e p r e v e n t e d r e s e a r c h o n t h i s s u b j e c t f r o m b e i n g

f u l l y s a t i s f a c t o r y . L y i n g b e h i n d m a n y o f t h e s e p r o -

b l e m s i s t h e t e n d e n c y t o a p p r o a c h t h e p r o b l e m

f r o m a m e d i c a l i z e d p o i n t o f vi e w r a th e r t h a n f r o m

a b r o a d e r s o c i a l - s t r u c t u r a l v a n t a g e p o i n t . F o c u s i n g

o n t h o s e e x p e r i e n c i n g i n f e r t i l i t y a s p a t i e n t s r a t h e r

t h a n a s s o c i a l a c t o r s h a s i m p e d e d p r o g r e s s i n u n d e r -

s t a n d i n g t h e p s y c h o l o g i c a l c o n s e q u e n c e s o f i n f e r ti -

l i t y i n s e v e r a l d i s t i n c t w a y s .F i r s t o f a l l , a p p r o a c h i n g i n f e r ti l it y as p r i m a r i l y a

m e d i c a l c o n c e r n h a s l i m i t e d r e s e a r c h e r s ' a b i l i t y t o

g e n e r a l i z e a b o u t t h e s u b j e c t s o f t h e i r r e s e a r c h .

R e s e a r c h e r s h a v e r e l i e d t o o h e a v i l y o n c o n v e n i e n c e

s a m p l e s d r a w n f r o m p a t i e n t p o p u l a t i o n s . B e c a u s e

o f t h is , w e k n o w n e x t t o n o t h i n g a b o u t a l a r g e p o r -

t i o n o f t h e i n f e r t i l e , t h o s e w h o d o n o t s e e k t r e a t -

m e n t . S i n c e w o m e n a r e m o r e l i k e l y t o r e c e i v e

t r e a t m e n t f o r i n f e rt i li t y t h a n m e n a n d s i n ce m a n y

s t u d ie s f o c u s o n l y o n p a t i e n t s a n d n o t o n t h e i r p a r t -

n e r s, w e k n o w m o r e a b o u t i n f e r t il e w o m e n t h a n

a b o u t i n f e r t i l e m e n . B e c a u s e tr e a t m e n t - s e e k i n g isi n f l u e n c e d b y s u c h s o c i a l v a r i a b l e s a s r a c e , c l a s s ,

a n d r e g i o n , o u r k n o w l e d g e i s c o n c e n t r a t e d o n

w h i t e , m i d d l e - c l a ss u r b a n i t e s . E v e n a m o n g t h i s

g r o u p , t h e r e i s a t e n d e n c y t o f o c u s o n t h o s e w h o

a r e p u r s u i n g I V F a n d o t h e r " h i g h - t e c h " t r e a t m e n t

o p t i o n s a t t h e e x p e n s e o f th e m a j o r i t y w h o h a v e

n o t r e c e i v e d s u c h t r e a t m e n t s . T h e o v e r - r e l i a n c e o n

c l i n i c s a m p l e s m e a n s t h a t w e a r e l e t t i n g a s e l e c t

g r o u p o f t h e i n f e r ti l e, w h o a r e a l m o s t c e r t a i n l y n o t

r e p r e s e n t a ti v e o f t h e i n f e rt i le p o p u l a t i o n a s a w h o l e ,

s p e a k f o r t h e w h o l e g r o u p .

S e c o n d , f o c u s i n g o u r a t t e n t i o n o n i n f e r t i l i t y

p a t i e n t s r a t h e r t h a n o n i n f e r t i l e p e o p l e m a k e s i t

h a r d e r t o r e a c h f i r m c o n c lu s i o n s . A s l o n g a s w e r e l y

o n c l i n i c - b a s e d s a m p l e s , i t w i l l b e q u i t e d i f f i c u lt t o

s e p a r a t e t h e p s y c h o l o g i c a l c o n se q u e n c e s o f i n f e r ti -

l i ty f r o m t h e p s y c h o l o g i c a l c o n s e q u e n c es o f t r e a t -



1700 Arth ur L. Gre i l

m e n t . A n d , a s l o n g a s w e re l y o n c l i n ic s a m p l e s ,

r e s e a r c h o n i n f e r t i l i t y a n d p s y c h o l o g i c a l d i s t r e s s i s

l i k e l y t o b e h a m p e r e d b y a n a r t i f i c i a l l y s h o r t e n e d

t i m e f ra m e . O u r t e n d e n c y is to s t a r t t h i n k i n g a b o u t

t h e i n f e rt i l e w h e n t h e y b e c o m e p a t i e n t s a n d t o s t o p

t h i n k i n g a b o u t t h e m w h e n t h e y l e a v e t h e c li n i c.

T h u s , q u e s t i o n s a b o u t t h e e a r l y s t a g e s o f t h e i n f e r t i -

l i ty p r o ce s s a r e o n l y a s k e d r e t r o s p e c t iv e l y , a n d

q u e s t i o n s a b o u t t h e l o n g - t e r m c o n s e q u e n c e s o f

i n f e r t i l it y a r e s e l d o m a s k e d a t a l l .

T h i r d - - a n d t h i s is p e r h a ps t h e m o s t i m p o r t a n t

p o i n t t h i s e s s a y h a s t o m a k e - - a n o v e r l y m e d i c a l i z e d

a p p r o a c h t o t h e p s y c h o l o g ic a l c o n s e q u e n c e s o f

i n f e r t i l it y l e a d s u s t o a s k t h e w r o n g q u e s t i o n s .

I n s t e a d o f a s k i n g h o w t h e i n f e r t i le e x p e r i e n c e i n f e r -

t i l it y i n t h e i r e v e r y d a y l i ve s , t h e p s y c h o l o g i c a l l i t e r a -

t u r e a s k s w h e t h e r t h e y a r e m o r e o r l e s s d i s t r e s s e d

t h a n o t h e r g r o u p s o f p e o p le . I n s t e a d o f v i ew i n g t hein fe r t i l i t y e x p e r i e n c e a s a s o c i a l l y c o n s t r u c t e d l i f e c r i -

s i s , t h e p s y c h o l o g i c a l d i s t r e s s l i t e r a t u r e t r a n s f o r m s

i t i n t o a n i nd i v i dua l t ra i t , p r e s e n t i n s o m e i n d i v i d -

u a l s t o a g r e a t e r e x t e n t t h a n o t h e r s . U n t i l r e s e a r c h

i s g u i d e d b y a m o r e h o l i s t i c a n d s o p h i s t i c a t e d t h e o r -

e t i c a l f r a m e w o rk , t h e r e su l t o f e f fo r t s i n t h i s f i e ld

w i ll r e m a i n d i s a p p o i n t i n g .

S e v er a l r e c o m m e n d a t i o n s a b o u t t h e p r o p e r d i r e c -

t i o n f o r f u t u r e r e s e a r c h o n t h e e x p e r i e n c e o f i n f e r t i -

l i ty s e e m t o b e i n o r d e r . F i r s t a n d f o r e m o s t ,

r e s e a r c h n e e d s t o b e b e t t e r i n f o r m e d b y t h e o r e t i c a l

c o n s i d e r a t i o n s . R e s e a r c h e r s n e e d t o b e m o r e c l o s e l yg u i d e d b y t h e o r y i n d e s i g n i n g s t u d i e s a n d s e l e c t i n g

m e a s u r e s . S e c o n d l y , s c h o l a r s n e e d t o p u l l a w a y

f r o m t h e i r o v e r - r e l i a n c e o n a " p s y c h o l o g i c a l t r a i t "

a p p r o a c h a n d p a y m o r e a t t e n t i o n t o t h e w a y t h e e x -

p e r i e n c e o f i n f e r t i l i t y i s c o n d i t i o n e d b y s o c i a l s t r u c -

t u r a l r e a l i t i e s . T h i r d , d e s c r i p t i v e a n d q u a l i t a t i v e

r e s e a r c h s h o u l d n o t b e d i s m i s s e d a s i t s o m e t i m e s i s

a s b e in g m e r e l y " a n e c d o t a l . " Q u a n t i t a t i v e a n d

q u a l i t a ti v e r e se a r ch b o t h h a v e a c o n t r i b u t i o n t o

m a k e t o o u r u n d e r s t a n d i n g o f th e e x p e ri e n ce o f

i n f e r ti l i ty . F o u r t h , n e w w a y s n e e d t o b e d e v e l o p e d

f o r b e t t e r t a k i n g i n t o a c c o u n t t h e p r o c e s s u a l n a t u r eo f t h e i n f e r t i li t y e x p e r i e n c e. M o r e a t t e n t i o n n e e d s

t o b e p a i d t o t h e e f f e ct s o f d u r a t i o n o f i n f e r t i li t y ,

t h e e x p e r i e n c e o f t r e a t m e n t , a n d t h e i n t e r p l a y o f

t h e s e t w o . F i f t h , w e n e e d m o r e s t u d i e s o f :

1. p r o c e s s e s o f i n f e r t i l i t y d e c i s i o n - m a k i n g ;

2 . a c t u a l i n t e r a c t i o n ( b e t w e e n p a r t n e r s i n i n f e r t i l e

c o u p l e s , p a t i e n t s a n d h e a l t h c a r e p r o v i d e r s , e t c . )

r a t h e r t h a n o u r p r e s e n t a l m o s t c o m p l e t e r e l i a n c e

o n i n t e rv i e w s a n d q u e s t i o n n a i r e s ;

3 . t h e i n s t i t u t i o n a l c o n t e x t s o f t h e e x p e r i e n c e o f

i n f e r t i l it y a n d t h e d e l i v e r y o f i n f e r t i l i ty s e r vi c es ;

4 . c r o s s - c u l t u r a l a n d h i s t o r i c a l v a r i a t i o n i n t h e e x -p e r i e n c e o f i n f e r t i l i t y a n d i n f e r t i l it y t r e a t m e n t ;

5 . s t u d i e s o f i n f e r t i l i ty c a r e - g i v e r s a n d t h e r o l e t h e y

p l a y i n c o n s t r u c t i n g t h e e x p e r i e n c e o f i n f e r t i l i t y

a s w e l l a s s t u d i e s o f i n f e r t i l e c o u p l e s t h e m s e l v e s ;

6 . s t u d ie s t h a t i n c l u d e su c h u n d e r - s t u d i e d p o r t i o n s

o f t h e in f e rt i le p o p u l a t i o n a s t h o s e w h o d o n o t

s e ek t r e a t m e n t , n o n - w h i t e s , a n d t h o s e w h o a r e

n o t e c o n o m i c a l l y w e l l - of f .

F i n a l l y , m o r e e f f o r t n e e d s to b e m a d e t o b e t t e r

i n t e g r a t e t h e e m p i r i c a l s t u d y o f t h e e x p e r i e n c e o fi n f e r t i l it y w i t h i m p o r t a n t s o c i a l p o l i c y q u e s t i o n s ,

s u c h a s t h e q u e s t i o n o f n a t i o n a l h e a l t h c a r e p o l i c y

a n d t h e d e b a t e o v e r n e w r e p r o d u c t i v e t e c h no l o g y .

Acknowledgements- -This is a revised version of a paperpresented at the annual meeting of the Society for theStudy of Soc ia l Problems on I1 Aug ust 1 993 in Miam iBeach, FL. I am grateful to Barbara J. Berg and JudithN. Lasker for their helpful suggestions.

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