UMEÅ UNIVERSITY MEDICAL DISSERTATIONSNew Series No. 152

From the Department of Obstetrics and Gynecology, University of Umeå,Umeå, Sweden

PSYCHOLOGICAL AND SOCIAL ASPECTS OF TUBAL INFERTILITY

A Longitudinal Study of Infertile Women and Their Men

by

Ann Lalos

Umeå University Umeå 1985

PSYCHOLOGICAL AND SOCIAL ASPECTS OF TUBAL INFERTILITY

A L o n g i t u d i n a l S tu dy o f I n f e r t i l e Women and T h e i r Men

av

Ann La lo s

Socionom

I n s t i t u t i o n e n f ö r O b s t e t r i k och Gynekologi Umeå U n i v e r s i t e t , S-901 87 Umeå

AKADEMISK AVHANDLING

som med v e d e r b ö r l i g t t i l l s t å n d av Med ic in ska F a k u l t e t e n v i d Umeå U n i v e r s i t e t f ö r a v l ä gg a n de av do k to r s examen i me d i c i n sk v e t e n s k a p kommer a t t o f f e n t l i g e n f ö r s v a r a s i Sal B, 9 : e vån , by 1D (nya t a n d l ä k a r h ö g s k o l a n ) , R e g i o n s j u k h u s e t , Umeå, f r e ­dagen den 15 november 1985, kl 0 9 . 0 0 .

Avhand l i ngen b a s e r a s på f ö l j a n d e r a p p o r t e r :

I La lo s A, L a l o s 0 , J a c o b s so n L, von S c h o u l t z B. A p sy ch o ­s o c i a l 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 e c o u p l e s b e f o r e s u r ­g i c a l t r e a t m e n t o f t h e f e m a l e . J Psychosom O b s t e t Gynae­co l 1 9 8 5 ; 4 : 8 3 - 9 3 .

I I La lo s A, La lo s 0 , J a c o b s so n L, von S c h o u l t z B. P sycho ­l o g i c a l r e a c t i o n s t o t h e med i ca l i n v e s t i g a t i o n and s u r ­g i c a l t r e a t m e n t o f i n f e r t i l i t y . Gynecol O b s t e t I n v e s t1985, i n p r e s s .

I I I La lo s A, La lo s 0 , J a c o b s so n L, von S c h o u l t z B. The p s y ­c h o s o c i a l imp ac t o f i n f e r t i l i t y two y e a r s a f t e r comp le t ed s u r g i c a l t r e a t m e n t . Ac ta O b s t e t Gynecol Scand 1985, i n p r e s s .

IV La lo s A, L a l o s 0 , J a c o b s so n L, von S c h o u l t z B. D e p r e s s i o n , g u i l t and i s o l a t i o n among i n f e r t i l e women and t h e i r men.J Psychosom O b s t e t Gynaecol 1985 , a c c e p t e d f o r p u b l i c a t i o n .

V La lo s A, J a c o b s s o n L, La lo s 0 , von S c h o u l t z B. The wish t ohave a c h i l d - a p i l o t - s t u d y o f i n f e r t i l e c o u p l e s . Acta Psych Scand , i n p r e s s .

ABSTRACT

L a l o s , A. PSYCHOLOGICAL AND SOCIAL ASPECTS OF TUBAL INFERTILITY -

A L o n g i t u d i n a l S tudy o f I n f e r t i l e Women and T h e i r Men.

Umeå Univ. Med. D i s s . , New S e r i e s No 152, 1985. ISSN 0346 -66 12 .

Al l t h i r t y women who were t o undergo m i c r o s u r g i c a l t r e a t m e n t f o r t u b a l i n f e r t i l i t y i n 1981 and t h e i r men were i n v e s t i g a t e d . Over a p e r i o d o f 2 y e a r s f o u r i n t e r v i e w s were pe r f o rm ed w i th t h e women and two w i th t h e i r men. A q u e s t i o n n a i r e , semi s t r u c t u r e d i n t e r v i e w s , symptom c h e c k ­l i s t and t h e Eysenck P e r s o n a l i t y I n v e n t o r y were u s e d . Dur ing t h i s l o n g i ­t u d i n a l s t u d y t h e c o u p l e s ' b ac k g r ou nd , c u r r e n t s i t u a t i o n and e mo t i on a l and s o c i a l impa c t o f t h e i n f e r t i l i t y p rob l e m were i n v e s t i g a t e d . The p s y c h o l o g i c a l and s o c i a l e f f e c t s o f t h e med i ca l i n v e s t i g a t i o n and t r e a t ­ment have been d e s c r i b e d . E x p e c t a t i o n s and hopes a bo u t t h e f u t u r e a f t e r u n s u c c e s s f u l s u r g i c a l t r e a t m e n t and t h e need o f p r o f e s s i o n a l p s y c h o ­s o c i a l c o u n s e l l i n g have been n o t e d . F u r t h e r m o r e , t h e e x t e n t o f p s y c h o ­l o g i c a l r e a c t i o n s c o m p a t i b l e w i th a c r i s i s p a t t e r n ha s been i d e n t i f i e d and c l a s s i f i e d . F i n a l l y , o v e r t m o t iv e s f o r hav in g a c h i l d have been s t u d i e d .

The i n f e r t i l e c o u p l e s g e n e r a l l y d id n o t d i f f e r w i th r e s p e c t t o p s y c h o ­s o c i a l b a c kg ro un d , c u r r e n t l i f e s i t u a t i o n , p s y c h i a t r i c a nam ne s i s o r p e r s o n a l i t y c h a r a c t e r i s t i c s when compared w i t h a p p a r e n t l y normal r e f e ­r e n c e g r o u p s . S e v e ra l d e l e t e r i o u s e mo t i on a l and s o c i a l e f f e c t s o f t h e i n f e r t i l i t y were found bo th b e f o r e and 2 y e a r s a f t e r t h e s u r g i c a l t r e a t ­men t . The women a d m i t t e d t o s u f f e r i n g such e f f e c t s more f r e q u e n t l y t h an t h e men. The p a r t n e r s ' f e e l i n g f o r e ach o t h e r were g e t t i n g worse 2 y e a r s a f t e r t h e o p e r a t i o n . The re was a l s o a t e n d e n c y t o a d e t e r i o r a t i o n i n o p i n i o n s ab ou t m a r i t a l r e l a t i o n s h i p s . Most o f t h e ment a l symptoms r e ­co rd e d co u ld be c l a s s i f i e d i n t e rm s o f d e p r e s s i o n , g u i l t and i s o l a t i o n , which a l l a r e p a r t s o f t h e r e a c t i v e p h a s e o f t h e common c r i s i s p a t t e r n . The c r i s i s o f i n f e r t i l i t y , howeve r , d i f f e r s f r om t h e common t r a u m a t i c c r i s i s ; i t i s more p ro l o n g e d and t h e r e a r e o f t e n r e p e a t e d c r i s i s r e a c ­t i o n s . N e g a t i v e e f f e c t s on t h e c o u p l e s ' s e xua l l i f e were r e p o r t e d by a l l i n d i v i d u a l s . The med ica l i n v e s t i g a t i o n and s u r g i c a l t r e a t m e n t o f i n f e r ­t i l i t y i n f l u e n c e d t h e c o u p l e s ' mutual r e l a t i o n s h i p and s ex u a l l i f e n e g a ­t i v e l y .

I n t r a p s y c h i c and i n t e r p e r s o n a l m o t iv e s o f c h i l d w i s h were dominan t among bo th women and men. A c e n t r a l mo t ive was t h a t a c h i l d i s an u l t i m a t e e x p r e s s i o n o f l o v e be tween a man and a woman. The m o t iv e s o f t h e i n f e r ­t i l e c o u p l e s g e n e r a l l y d i d n o t d i f f e r f r om t h o s e o f t h e r e f e r e n c e g ro u p s .

Most o f t h e c o u p l e s had d i f f i c u l t y i n working t h e i r way t h r o u g h and f i n ­d in g a s o l u t i o n t o t h e i r i n f e r t i l i t y p rob l em by t h e i r own means . R e l a ­t i v e s and f r i e n d s f a i l e d t o f u l f i l a s u p p o r t i v e f u n c t i o n . The im p o r t a n c e o f hav in g t h e p o s s i b i l i t y o f p r o f e s s i o n a l p s y c h o s o c i a l c o u n s e l l i n g and s u p p o r t p a r a l l e l w i th t h e i n v e s t i g a t i o n and t r e a t m e n t were s t r e s s e d by a l l p a r t i c i p a n t s .

Key w o r d s : t u b a l i n f e r t i l i t y - p s y c h o s o c i a l c h a r a c t e r i z a t i o n - r e a c t i o n s t o t r e a t m e n t - s exu a l l i f e - m a r i t a l r e l a t i o n s h i p - i n f e r t i l i t y c r i s i s - c h i l d w i s h - c o u n s e l l i n g .

Ann L a l o s , D ep ar tm en t o f O b s t e t r i c s and G yn eco lo g y , U n i v e r s i t y o f Umeå,S-901 85 Umeå, Sweden.

UMEÄ UNIVERSITY MEDICAL DISSERTATIONS

New S e r i e s No. 152

From t h e Depar tment o f O b s t e t r i c s and Gyneco logy ,

U n i v e r s i t y o f Umeå, Umeå, Sweden.

PSYCHOLOGICAL AND SOCIAL ASPECTS OF TUBAL INFERTILITY

A L o n g i t u d i n a l S tudy o f I n f e r t i l e Women and T h e i r Men

by

Ann Lai os

Umeå U n i v e r s i t y

Umeå 1985

ABSTRACT

L a l o s , A. PSYCHOLOGICAL AND SOCIAL ASPECTS OF TUBAL INFERTILITY -

A L o n g i t u d i n a l S tud y o f I n f e r t i l e Women and T h e i r Men.

Umeå Univ . Med. D i s s . , New S e r i e s No 152 , 1985. ISSN 0346 -66 12 .

Al l t h i r t y women who were t o undergo m i c r o s u r g i c a l t r e a t m e n t f o r t u b a l i n f e r t i l i t y i n 1981 and t h e i r men were i n v e s t i g a t e d . Over a p e r i o d o f 2 y e a r s f o u r i n t e r v i e w s were p e r f o rm ed w i t h t h e women and two w i th t h e i r men. A q u e s t i o n n a i r e , semi s t r u c t u r e d i n t e r v i e w s , symptom c h e c k ­l i s t and t h e Eysenck P e r s o n a l i t y I n v e n t o r y were u s e d . Dur ing t h i s l o n g i ­t u d i n a l s t u d y t h e c o u p l e s ' b a ck g ro un d , c u r r e n t s i t u a t i o n and emo t i ona l and s o c i a l impa c t o f t h e i n f e r t i l i t y p rob l em were i n v e s t i g a t e d . The p s y c h o l o g i c a l and s o c i a l e f f e c t s o f t h e medi ca l i n v e s t i g a t i o n and t r e a t ­ment have been d e s c r i b e d . E x p e c t a t i o n s and hopes ab o u t t h e f u t u r e a f t e r u n s u c c e s s f u l s u r g i c a l t r e a t m e n t and t h e need o f p r o f e s s i o n a l p s y c h o ­s o c i a l c o u n s e l l i n g have been n o t e d . F u r t h e r m o r e , t h e e x t e n t o f p s y c h o ­l o g i c a l r e a c t i o n s c o m p a t i b l e w i th a c r i s i s p a t t e r n ha s been i d e n t i f i e d and c l a s s i f i e d . F i n a l l y , o v e r t m o t iv e s f o r hav ing a c h i l d have been s t u d i e d .

The i n f e r t i l e c o u p l e s g e n e r a l l y d i d n o t d i f f e r w i th r e s p e c t t o p s y c h o ­s o c i a l b ac k g r ou nd , c u r r e n t l i f e s i t u a t i o n , p s y c h i a t r i c anamn es i s o r p e r s o n a l i t y c h a r a c t e r i s t i c s when compared w i th a p p a r e n t l y normal r e f e ­r e n c e g r o u p s . Se v e r a l d e l e t e r i o u s em o t ion a l and s o c i a l e f f e c t s o f t h e i n f e r t i l i t y were found bo th b e f o r e and 2 y e a r s a f t e r t h e s u r g i c a l t r e a t ­men t . The women a d m i t t e d t o s u f f e r i n g such e f f e c t s more f r e q u e n t l y t h an t h e men. The p a r t n e r s ' f e e l i n g f o r e ach o t h e r were g e t t i n g worse 2 y e a r s a f t e r t h e o p e r a t i o n . The re was a l s o a t e n d e n c y t o a d e t e r i o r a t i o n i n o p i n i o n s ab ou t m a r i t a l r e l a t i o n s h i p s . Most o f t h e ment a l symptoms r e ­co rd ed co u l d be c l a s s i f i e d i n t e r m s o f d e p r e s s i o n , g u i l t and i s o l a t i o n , which a l l a r e p a r t s o f t h e r e a c t i v e p h a s e o f t h e common c r i s i s p a t t e r n . The c r i s i s o f i n f e r t i l i t y , however , d i f f e r s f r om t h e common t r a u m a t i c c r i s i s ; i t i s more p ro l o n g e d and t h e r e a r e o f t e n r e p e a t e d c r i s i s r e a c ­t i o n s . N e g a t i v e e f f e c t s on t h e c o u p l e s ' s exua l l i f e were r e p o r t e d by a l l i n d i v i d u a l s . The med ica l i n v e s t i g a t i o n and s u r g i c a l t r e a t m e n t o f i n f e r ­t i l i t y i n f l u e n c e d t h e c o u p l e s ' mutual r e l a t i o n s h i p and s e xu a l l i f e n e g a ­t i v e l y .

I n t r a p s y c h i c and i n t e r p e r s o n a l m o t iv e s o f c h i l d w i s h were do minan t among bo th women and men. A c e n t r a l mo t iv e was t h a t a c h i l d i s an u l t i m a t e e x p r e s s i o n o f l o v e be tween a man and a woman. The m o t iv e s o f t h e i n f e r ­t i l e c o u p l e s g e n e r a l l y d i d n o t d i f f e r f r om t h o s e o f t h e r e f e r e n c e g ro u p s .

Most o f t h e c o u p l e s had d i f f i c u l t y i n work ing t h e i r way t h r o ug h and f i n ­d ing a s o l u t i o n t o t h e i r i n f e r t i l i t y p rob l em by t h e i r own means . R e l a ­t i v e s and f r i e n d s f a i l e d t o f u l f i l a s u p p o r t i v e f u n c t i o n . The im p o r t an ce o f h av i ng t h e p o s s i b i l i t y o f p r o f e s s i o n a l p s y c h o s o c i a l c o u n s e l l i n g and s u p p o r t p a r a l l e l w i th t h e i n v e s t i g a t i o n and t r e a t m e n t were s t r e s s e d by a l l p a r t i c i p a n t s .

Key w o r d s : t u b a l i n f e r t i l i t y - p s y c h o s o c i a l c h a r a c t e r i z a t i o n - r e a c t i o n s t o t r e a t m e n t - s exua l l i f e - m a r i t a l r e l a t i o n s h i p - i n f e r t i l i t y c r i s i s - c h i l d w i s h - c o u n s e l l i n g .

Ann L a l o s , D epartm en t o f O b s t e t r i c s and G yn eco log y , U n i v e r s i t y o f Umeå,S-901 85 Umeå, Sweden.

To MARIA and SOFIA

who - h o p e f u l l y - w i l l be

mo t he r s i n t h e 2 1 s t c e n t u r y

ORIGINAL PAPERS

Thi s t h e s i s i s ba sed on t h e f o l l o w i n g p a p e r s , which a r e r e f e r r e d t o i n

t h e t e x t by t h e i r roman n u m e r a l s .

I La lo s A, La lo s 0 , J a c o b s so n L, von S c h o u l t z B. A p s y c h o s o c i a l

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

o f t h e f e m a l e . J Psychosom O b s t e t Gynaecol 1 9 8 5 ; 4 : 8 3 - 9 3 .

I I La lo s A, La lo s 0 , J a c o b s s o n L, von S c h o u l t z B. P s y c h o l o g i c a l

r e a c t i o n s t o t h e med i c a l i n v e s t i g a t i o n and s u r g i c a l t r e a t m e n t

o f i n f e r t i l i t y . Gynecol O b s t e t I n v e s t 1985, i n p r e s s .

I I I La lo s A, La lo s 0 , J a c o b s so n L, von S c h o u l t z B. The p s y c h o s o c i a l

impac t o f i n f e r t i l i t y two y e a r s a f t e r com p l e t e d s u r g i c a l t r e a t ­

men t . Act a O b s t e t Gynecol Scand 1985, i n p r e s s .

IV La lo s A, La lo s 0 , J a c o b s so n L, von S c h o u l t z B. D e p r e s s i o n , g u i l t

and i s o l a t i o n among i n f e r t i l e women and t h e i r men. J Psychosom

O b s t e t Gynaecol 1985, a c c e p t e d f o r p u b l i c a t i o n .

V La lo s A, J a c o b s so n L, La lo s 0 , von S c h o u l t z B. The wish t o have

a c h i l d - a p i l o t - s t u d y o f i n f e r t i l e c o u p l e s . Acta Psych Scand ,

i n p r e s s .

4

CONTENTS

INTRODUCTION 6

AIMS OF THE STUDY 13

SUBJECTS

I n f e r t i l e c o u p l e s 14

R e f e r e n c e g ro u p s 14

METHODS

I n t e r v i e w s 16

Eysenck P e r s o n a l i t y I n v e n t o r y 18

Symptom c h e c k l i s t 18

Mot ive l i s t 18

S t a t i s t i c a l methods 19

RESULTS AND DISCUSSION

P s y c h o s o c i a l c h a r a c t e r i z a t i o n 20

M a r i t a l r e l a t i o n s h i p 22

Sexual l i f e 23

Emot ional and s o c i a l imp ac t o f i n f e r t i l i t y 24

P s y c h o l o g i c a l r e a c t i o n s t o med i ca l i n v e s t i ­g a t i o n and s u r g i c a l t r e a t m e n t 27

The c r i s i s o f i n f e r t i l i t y 30

C h i l dw i s h 35

Need o f c o u n s e l l i n g 38

CONCLUSIONS 41

GENERAL SUMMARY 43

ACKNOWLEDGEMENTS 45

REFERENCES 47

5

INTRODUCTION

The p rob l e m o f i n f e r t i l i t y i s as o ld a s c i v i l i z a t i o n i t s e l f ( 8 0 ) , and

t h e c h i l d l e s s m a r r i a g e ha s a lways been c o n s i d e r e d a g r e a t m i s f o r t u n e .

In G e n e s i s , man i s t o l d t o be " f r u i t f u l and m u l t i p l y " , and i t i s s a i d

t h a t c h i l d r e n a r e a g i f t f rom God. R e l i g i o u s , c u l t u r a l and s o c i a l v a ­

l u e s have a l l s e t a premium on f e r t i l i t y . B a r r e n n e s s has been viewed

as a c u r s e by t h e gods ( 4 7 ) . The s t u d y o f o t h e r c u l t u r e s and c i v i l i z a ­

t i o n s r e v e a l s t h a t h i s t o r i c a l l y , t h e l o t o f t h e i n f e r t i l e woman has

n o t been a happy one ( 2 4 ) . T r a d i t i o n a l l y , i n f e r t i l i t y has been r e g a r ­

ded a s t h e woman's p ro b l em . U n t i l t h e t u r n o f t h e p r e s e n t c e n t u r y , she

was s u b j e c t e d t o numerous h u m i l i a t i o n s and c u s t o m a r i l y she a l o n e was

blamed f o r t h e i n f e r t i l i t y ( 7 1 ) . Only i n t h e l a s t 25 y e a r s ha s t h e male

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

g a t i o n , and knowledge o f mal e f a c t o r s s t i l l l a g s f a r beh in d knowledge

o f f e m a le f a c t o r s i n t h i s d i s o r d e r ( 3 3 ) .

P r eg na n cy i s p r o b a b l y t h e mos t d r a m a t i c , s t r i c t l y f e m a l e b i o l o g i c a l e v e n t

- one t h a t i s mea n i ng f u l n o t o n l y b i o l o g i c a l l y , bu t c u l t u r a l l y , i n t e r -

p e r s o n a l l y , and i n t r a p s y c h i c a l l y a s wel l ( 1 ) . F e r t i l i t y i s an i n t e g r a l

p a r t o f a woman's i d e n t i t y and r o l e s ( 6 3 ) . Women a s s o c i a t e f e r t i l i t y

w i th f e m i n i n i t y , s e x u a l i t y , body image and s e l f - e s t e e m (47 , 53 , 73 , 8 0 ) .

I n f e r t i l i t y c an c r e a t e f e e l i n g s o f p h y s i c a l i n f e r i o r i t y which can o v e r ­

shadow a l l o t h e r p e r s o n a l and s o c i a l v a l u e s .

For t h e mal e i t ha s been p o s t u l a t e d t h a t he has an i n s t i n c t i v e u r g e

beyond t h e s exua l d r i v e : t h i s i s t h e need t o f a t h e r a c h i l d ( 5 ) . F a t h e r ­

hood, a s a de ve lop m en ta l p h a s e , ha s been c h a r a c t e r i z e d a s hav ing few

s i g n i f i c a n t d i f f e r e n c e s from m a t e rn a l b on d in g . C h i l d r e n a t t a c h t o emo­

t i o n a l l y a v a i l a b l e f a t h e r s , j u s t a s t h e y do t o m o t h e r s . F a t h e r l i n e s s ,

l i k e m o t h e r l i n e s s , ha s two p r ime s o u r c e s o f m o t i v a t i o n : t h e f a t h e r ' s

i d e n t i f i c a t i o n w i t h h i s c h i l d and t h e f a t h e r ' s i d e n t i f i c a t i o n w i th h i s

own f a t h e r ( 3 9 ) . T e n d e r n e s s , g e n t l e n e s s , t h e c a p a c i t y f o r empathy and

em o t ion a l c l o s e n e s s , a r e human c h a r a c t e r i s t i c s t h a t a p p l y t o f a t h e r s

and mo th e r s a l i k e . The a d u l t who e x p e r i e n c e s t h e t r a uma o f i n f e r t i l i t y

ha s t o cope w i th t h e l o s t i d e a l o f o n e s e l f as a b i o l o g i c a l p a r e n t . For

some, t h i s means abandon ing a l l hope o f i m m o r t a l i t y ( 4 7 ) .

6

I n f e r t i l i t y , t h e i n a b i l i t y t o a c h i e v e a p r e g n a n c y w i t h i n one y e a r o f ha ­

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

a p r e g n a n c y t o l i v e b i r t h , i s a p rob l em t h a t a f f e c t s an e s t i m a t e d one

c o u p l e i n s i x o f c h i l d b e a r i n g age (2 , 3 0 , 47 , 5 4 ) . A c c o r d i n g l y , ab o u t 10

m i l l i o n c o u p l e s i n t h e USA o r a t l e a s t 100 000 c o u p l e s i n Sweden a r e i n ­

f e r t i l e ( 12 , 4 7 , 5 5 ) . Medical r e s e a r c h and c l i n i c a l t r e a t m e n t o f i n f e r ­

t i l i t y have bo th made g r e a t s t r i d e s i n r e c e n t y e a r s , i n d i s c o v e r i n g and

c u r i n g p ro b l em s o f f e m a le and male i n f e r t i l i t y . Of t h o s e c o u p l e s who seek

t r e a t m e n t , a p p r o x i m a t e l y 80 % w i l l r e c e i v e a d e f i n i t i v e d i a g n o s i s o f i n ­

f e r t i l i t y c a u sed by some o r g a n i c p a t h o l o g y ( 7 2 ) . In a p p r o x i m a t e l y 5 -1 0 %

o f a l l c o u p l e s who a r e m e d i c a l l y h e a l t h y , no c a u s e o f t h e i n f e r t i l i t y

c an be d e t e r m i n e d . The ma j o r c a u s e s o f i n f e r t i l i t y a r e : ma le f a c t o r 30 -

35 %, t u b a l f a c t o r 30 -35 %, c e r v i c a l f a c t o r 20 % and hormonal f a c t o r 15 %

( 4 3 ) . Tubal p a t h o l o g y r e p r e s e n t s o v e r 50 % o f t h e c a u s e s o f i n f e r t i l i t y

i n t h e f e m a le ( 3 2 ) . A f t e r t u b a l s u r g e r y by m i c r o s u r g i c a l t e c h n i q u e , a pp ­

r o x i m a t e l y 30 % o f t h e women a c h i e v e a f u l l - t e r m p r eg na n cy (18 , 5 0 ) .

A d i a g n o s i s o f p sy c h o g e n i c i n f e r t i l i t y was v e r y commonly a p p l i e d i n p a s t

y e a r s when no o r g a n i c c a u s a t i v e a g e n t c o u ld be i d e n t i f i e d ( 3 0 ) . As r e ­

c e n t l y a s 20 y e a r s ag o , 40 - 50 % o f i n f e r t i l i t y c a s e s were t h o u g h t t o be

t h e r e s u l t o f em o t io na l f a c t o r s ( 2 7 ) . I n f e r t i l e c o u p l e s were d e s c r i b e d as

ha v in g t y p i c a l p e r s o n a l i t y t r a i t s t h a t r e s u l t e d i n t h e i r i n a b i l i t y t o co n ­

c e i v e . I t i s assumed t h a t p s y c h o l o g i c a l f a c t o r s c an c a u s e i n f e r t i l i t y by

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

f a c i n g i n t o aw a re n es s ( 19 , 4 0 , 5 1 ) . Emot iona l s t r e s s a s s o c i a t e d w i th t h e

i n f e r t i l i t y s t a t e o r r e s u l t i n g f rom a l ong and demanding i n f e r t i l i t y e v a ­

l u a t i o n may e x e r t i t s i n f l u e n c e t h r o u g h au tonomic o r n e u r o e n d o c r i n e c o n ­

t r o l o f t h e r e p r o d u c t i v e p r o c e s s ( 5 6 , 6 5 ) . More r e c e n t l y t h e i n c r e a s e d

u n d e r s t a n d i n g o f n e u r o e n d o c r i n o l o g y , as wel l a s o t h e r adv an ces i n t h i s

f i e l d , ha s r e du ce d supposed e m o t i on a l f a c t o r s a s a c a u s e o f i n f e r t i l i t y

t o l e s s t h a n 5 % ( 6 6 ) . I d e n t i f i c a t i o n o f t h e r o l e o f p s y c h o l o g i c a l f a c t o r s

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

d i s t i n g u i s h c a u s e f rom e f f e c t when s t u d y i n g t h e em o t io na l f a c t o r s r e l a t e d

t o t h e p ro b l e m . However, i t a p p e a r s mos t l i k e l y t h a t t h e em o t io na l p r o b ­

lems among i n f e r t i l e c o u p l e s a r e more o f t e n a r e s u l t o f i n f e r t i l i t y r a t h e r

t h a n i t s c a u s e (23 , 42 , 51 , 66 , 6 7 ) .

7

I t seems t h a t most s t u d i e s on t h e p s y c h o s o c i a l a d j u s t m e n t o f i n f e r t i l e

i n d i v i d u a l s have been c o n ce rn ed more w i t h p s y c h o l o g i c a l f a c t o r s i n t h e

e t i o l o g y o f i n f e r t i l i t y t h an w i th t h e p s y c h o l o g i c a l s e q u e l a e . T h i s n a r ­

row f o c u s on " u n e x p l a i n e d " i n f e r t i l i t y may wel l d i s t r a c t a t t e n t i o n f rom

t h e p ro b l em s o f t h e m a j o r i t y ( 4 ) . P r e v i o u s r e p o r t s on i n f e r t i l e c o u p l e s

whose c h i l d l e s s n e s s was ca us ed by some o r g a n i c p rob l em sa y l i t t l e ab ou t

t h e c o u p l e s ' b ac k g r ou nd , c u r r e n t l i f e s i t u a t i o n , p e r s o n a l i t y c h a r a c t e ­

r i s t i c s and menta l s t a t u s . The em o t i on a l and s o c i a l imp ac t o f t h e i n f e r ­

t i l i t y p rob l em on t h e f e m a le b e f o r e t u b a l s u r g e r y i s n o t wel l known.

F u r t h e r m o r e , t h e ma n ' s r o l e i n i n f e r t i l i t y has o n l y r e c e n t l y been r e g o c -

n i z e d and t h e r e i s l i t t l e i n f o r m a t i o n ab o u t t h e im pa c t o f c h i l d l e s s n e s s

on t h e m a l e . The s t a r t i n g p o i n t o f t h e p r e s e n t s t u d y ha s been t o i n v e s -

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

o f i n f e r t i l e c o u p l e s where a d i a g n o s i s o f t u b a l damage had been e s t a b ­

l i s h e d ( p a p e r I ) .

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

r e p r o d u c t i v e y e a r s seem t o have l e d t o an i n c r e a s i n g number o f i n f e r t i l e

c o u p l e s ( 2 , 3 0 ) . The p o s t p o n i n g o f i n t e n d e d c o n c e p t i o n i n c r e a s e s t h e p o s ­

s i b i l i t y o f i n f e r t i l i t y . The maximum f e r t i l e age f o r bo th men and women

i s a p p r o x i m a t e l y 25 y e a r s , w i t h a d e c l i n e a f t e r age 30 ( 3 0 ) . I n c r e a s i n g

age i n women i s a s s o c i a t e d w i th l o n g e r u se o f b i r t h c o n t r o l p i l l s and

p o s s i b l e su b s e q u e n t hormonal d i s t u r b a n c e s , a h i g h e r r a t e o f p e l v i c d i ­

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

o f p e l v i c i n f e c t i o n . L i k e w i s e , a s men g e t o l d e r , t h e y run an i n c r e a s e d

r i s k o f e x po su r e t o ha rmful e n v i r o n m e n t a l a g e n t s and d r u g s , a s wel l as

an i n c r e a s e d l i k e l i h o o d o f c o n t r a c t i n g some d i s e a s e t h a t co u ld i n d i r e c t ­

l y i m p a i r f e r t i l i t y ( 2 ) .

I n f e r t i l i t y seems t o have become a r e l e v a n t s o c i a l and med ica l c o n c e rn ( 3 0 ) .

The re a r e f a c t o r s c o n t r i b u t i n g t o i n c r e a s i n g demands f o r an i n f e r t i l i t y

s e r v i c e . Not o n l y i s t h e r e an i n c r e a s i n g number o f i n f e r t i l e c o u p l e s , bu t

i t seems t h a t a l a r g e p r o p o r t i o n o f t h e s e c o u p l e s a r e s e e k i n g h e l p . F u r ­

t h e r m o r e , t h e s o c i a l en v i r on m e n t seems t o be more demanding i n t h e 1980s ,

f rom a g e n e r a t i o n t h a t e x p e c t s t o c o n t r o l f e r t i l i t y ( 2 ) . The demand f o r

co mp re h en s i ve f e r t i l i t y management w i l l no do ub t c o n t i n u e t o i n c r e a s e .

8

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

f r u s t r a t i o n and i n a d e q u a c y and show s i g n s o f e m o t ion a l d i s t r e s s ( 4 , 6 ,

7 , 44 , 6 6 ) . Whi l e t h e so m a t i c i n v e s t i g a t i o n i s a c o m p a r a t i v e l y s im p l e

and n o n - t r a u m a t i c p r o c e s s f o r t h e man, f o r t h e woman i t i s c o m p l i c a t e d

and o f t e n combined w i th p a i n ( e . g . h y s t e r o s a l p i n g o g r a p h y ) and s u r g i c a l

r i s k s ( e . g . l a p a r o s c o p y ) . The i n f e r t i l i t y i t s e l f and t h e med i ca l p r o c e s s

evoke many f e e l i n g s . The med ica l i n v e s t i g a t i o n and t r e a t m e n t a r e u s u a l l y

a t ime -c ons um in g and p r o t r a c t e d p r o c e s s . P r e v i o u s s t u d i e s have been b a ­

sed m a i n ly on o b s e r v a t i o n s / i n t e r v i e w s / q u e s t i o n n a i r e s pe r f o rm ed on one

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

t o t h e m edi ca l i n v e s t i g a t i o n and s u r g i c a l t r e a t m e n t o f i n f e r t i l i t y were

s t u d i e d l o n g i t u d i n a l l y o v e r a p e r i o d o f 2 y e a r s ( p a p e r I I ) .

D e s p i t e cha n g i n g v iews on f a m i l y s i z e and a l a r m i n g r e p o r t s ab ou t o v e r p o ­

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

s t i l l w i d e l y a c c e p t e d ( 8 ) . A l a r g e p a r t o f o u r l i v e s i s c e n t e r e d a round

r e p r o d u c t i o n , p a r e n t h o o d , and t h e r a i s i n g o f a f a m i l y . Th e re a r e many

b i o l o g i c a l , c u l t u r a l and r e l i g i o u s d e t e r m i n a n t s ( 1 1 ) . These a t t i t u d e s and

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

c o n c e i v e b u t c a n n o t do s o . A l though t h e c h i l d l e s s c o u p l e i s more s o c i a l l y

a c c e p t a b l e i n modern s o c i e t y , t h e r e i s , n e v e r t h e l e s s , a d i s t i n c t g roup o f

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

( 6 6 ) . The p r e s s u r e s , o v e r t o r c o v e r t , t a k e many fo rms and most c o u p l e s

w i l l e x p e r i e n c e them e x e r t e d by t h e i r own f a m i l y , f r i e n d s , a c q u a i n t a n c e s

- and even s t r a n g e r s ( 1 4 , 4 9 ) . T h i s p r e s s u r e c an have s e r i o u s e f f e c t s on

t h e s e c o u p l e s ' s e xua l l i f e , such a s l o s s o f l i b i d o , i n h i b i t i o n o f o rga sm,

and impo ten ce (3 , 26 , 28 , 52 , 68 , 7 6 ) . For many c o u p l e s i n v o l u n t a r y c h i l d ­

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

cy i n o n e ' s p e r s p e c t i v e o f t h e f u t u r e , a l a c k o f p u r p os e i n l i f e . The re i s

a l s o a f e a r o f h av i ng t o r e l y e n t i r e l y on s t r a n g e r s i n o l d age and a f e a r

o f u n b e a r a b l e l o n e l i n e s s upon t h e l o s s o f t h e m a r i t a l p a r t n e r ( 8 ) . I nv o ­

l u n t a r y c h i l d l e s s n e s s can be d e s c r i b e d a s an i n v i s i b l e ha n d i c a p ( 5 4 ) .

These n e g a t i v e p s y c h o l o g i c a l , s e xu a l and s o c i a l e f f e c t s o f i n f e r t i l i t y

may d i s a p p e a r once t h e c o u p l e have g o t t h e number o f c h i l d r e n t h e y d e s i r e .

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

t r e a t m e n t o f t u b a l i n f e r t i l i t y ( 8 2 ) . I t i s n o t known how t h e y d ea l w i th

9

t h i s s i t u a t i o n . One p u rp o s e o f t h i s s t u d y ha s t h e r e f o r e been t o i n v e s t i -

g a t e t h e p s y c h o l o g i c a l , s exu a l and s o c i a l imp ac t o f i n f e r t i l i t y 2 y e a r s

a f t e r u n s u c c e s s f u l s u r g i c a l t r e a t m e n t o f t u b a l i n f e r t i l i t y ( p a p e r I I I ) .

Today t h e a b i l i t y t o c o n t r o l f e r t i l i t y i s o f t e n t a k e n f o r g r a n t e d , bo th

i n t h e med i ca l p r o f e s s i o n and by t h e p u b l i c a t l a r g e . The a dv en t o f s a f e

and e f f e c t i v e methods o f c o n t r a c e p t i o n has made p o s s i b l e c o n t r o l i n one

d i r e c t i o n ; bu t t h e c o n v e r s e , t h a t one can somehow i n f l u e n c e f e r t i l i t y in

o r d e r t o a c h i e v e p r e g n a n c y , does n o t h o l d t r u e ( 2 0 ) . Many c o u p l e s now

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

o f c a r e e r , r e s i d e n t i a l s i t u a t i o n and ma j o r f i n a n c i a l i n v e s t m e n t s - measu­

r i n g a l l f a c t o r s and w a i t i n g u n t i l t h e moment t o s t a r t a f a m i l y i s e x a c t ­

l y r i g h t ( 5 4 ) . Most c o u p l e s i n t h e i r c h i l d b e a r i n g y e a r s a r e a ccus tomed

t o t h i n k i n g i n t e r m s o f p r e v e n t i n g p r e g n a n c y , whe rea s t o c o n c e i v e and

have a c h i l d i s t a k e n f o r g r a n t e d . They u s u a l l y assume t h a t t h e y can

have c h i l d r e n i f and when t h e y d e s i r e ( 5 5 ) . I t h a s been s u g g e s t e d t h a t

when a man and a woman become i n c r e a s i n g l y aware t h a t r e p r o d u c t i o n i s d e ­

l ay e d and p e r h a p s even u n a t t a i n a b l e , t h e i r em o t ion a l r e a c t i o n s w i l l f o l ­

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

by Cap!an ( 1 7 ) . T h i s c r i s i s i s c h a r a c t e r i z e d by d e f i n i t e p s y c h o l o g i c a l

s t r e s s and b e h a v i o u r a l chang es which p u t t h e c o u p l e a t r i s k f o r ma l ada p ­

t i v e i n t r a p s y c h i c and i n t e r p e r s o n a l co n se q u en ce s i n c o n j u n c t i o n w i th t h e

p o s s i b l e c o n t i n u e d f a i l u r e t o c o n c e i v e ( 3 0 ) . The c o u p l e o f t e n f a c e an

e mo t i ona l t u r m o i l ( 6 6 ) , and t h e c r i s i s mus t be d e a l t w i th i n d i v i d u a l l y as

wel l a s w i t h i n t h e m a r i t a l r e l a t i o n s h i p ( 4 7 ) . The p rob l em o f i n f e r t i l i t y

evokes many f e e l i n g s i n t h e c o u p l e , and t h e f i r s t r e a c t i o n seems t o be one

o f s h oc k , s u r p r i s e , d i s b e l i e f and d e n i a l ( 47 , 55 , 79 , 8 0 , 8 1 ) . T h e r e a f t e r ,

f e e l i n g s o f f r u s t r a t i o n , a n g e r , l o s s o f c o n t r o l and a n x i e t y u s u a l l y a r i s e

( 10 , 47 , 55 , 8 0 ) . S ubs equ en t r e a c t i o n s o f t e n i n c l u d e f e e l i n g s o f g u i l t ,

em b a r r a s s m en t , d i s a p p o i n t m e n t , i s o l a t i o n , g r i e f , d e p r e s s i o n and mourning

(10 , 11, 22, 47 , 55 , 6 2 ) . The p s y c h o l o g i c a l t r auma o f i n f e r t i l i t y has been

d e s c r i b e d m a i n ly on t h e b a s i s o f c l i n i c a l o b s e r v a t i o n s on one s i n g l e o c ­

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

s t u d y was t h e r e f o r e u n d e r t a k e n t o e l u c i d a t e w he t he r - and i f so t o what e x ­

t e n t - p s y c h o l o g i c a l r e a c t i o n s c o m p a t i b l e w i th a c r i s i s p a t t e r n co u ld be

i d e n t i f i e d i n a g roup o f women w i th t u b a l i n f e r t i l i t y and t h e i r men d u r i n g

t h e c l i n i c a l i n v e s t i g a t i o n and t r e a t m e n t ( p a p e r IV) .

10

The wish t o r e p r o d u c e o n s e l f , t o have a c h i l d o f o n e ' s own, i s a p p a r e n t ­

l y some th ing f u n d a m e n t a l l y human. The c h i l d w i s h i s o f t e n complex and d i f ­

f i c u l t t o d e f i n e ; o v e r t and c o v e r t m o t iv e s a r e bo th i n v o l v e d i n p r o c r e a ­

t i o n . To become a p a r e n t i s i n many c a s e s p r o o f o f t h e a b i l i t y t o f u l f i l

a normal b i o l o g i c a l f u n c t i o n and p r o v i d e s e x p r e s s i o n o f t h e need t o c o n ­

f i r m t h e r e l a t i o n s h i p be tween a man and a woman. There i s o f t e n a combi ­

ned i n t e r n a l u r g e t o i n c r e a s e s e l f - c o n f i d e n c e and s e l f - f u l f i l m e n t , and

an e x t e r n a l p r e s s u r e f r om r e l a t i v e s , f r i e n d s and s o c i a l c i r c l e s . Thus ,

t h e wish t o s t a r t a f a m i l y mus t be s een bo th f rom t h e p o i n t o f v iew o f

t h e s o c i a l c o n t e x t o f t h e i n d i v i d u a l and t h e i n d i v i d u a l ' s p a s t h i s t o r y

( 1 3 ) .

Q u i t e a l o t i s known a b ou t t h e m o t iv e s beh ind t h e wish n o t hav ing a baby .

Th i s ha s been s t u d i e d i n c a s e s o f a p p l i c a t i o n s f o r l e g a l a b o r t i o n , s t e r i ­

l i z a t i o n and r e g a r d i n g t h e u s e o f c o n t r a c e p t i v e s ( 36 , 38 , 58 , 6 9 ) . How­

e v e r , i t i s a s t o n i s h i n g t o f i n d how l i m i t e d i s t h e l i t e r a t u r e on t h e mo­

t i v e s f o r h av in g a baby (15 , 25 , 4 8 , 71, 7 5 ) . T h i s q u e s t i o n seems t o be

so funda me n ta l t h a t i t i s s e ldom o r n e v e r r a i s e d . In s o c i o l o g y , p s yc h o l o g y

and economy t h e r e a r e s e v e r a l e x p l a n a t o r y model s r e g a r d i n g human r e p r o d u c ­

t i v e b e h a v i o u r . The c l o s e r t h e s e model s g e t t o a h o l i s t i c v i ew , t h e more

t h e y a r e made up o f a s y n t h e s i s o f t h e d i f f e r e n t s c i e n t i f i c t h e o r i e s ( 25 ,

70 , 7 1 ) . The re i s a r i s k t h a t t h e e x i s t e n t i a l p rob l em o f i n f e r t i l i t y i n

many c a s e s d e v e lo p s i n t o a m a i n ly medica l p rob l em which sh ou ld be s o l v e d

by med i ca l i n t e r v e n t i o n , such a s t u b a l p l a s t i c s u r g e r y , h e t e r o l o g o u s i n ­

s e m i n a t i o n o r i n v i t r o f e r t i l i z a t i o n . I n f e r t i l e c o u p l e s and o t h e r s t o o

have d i f f e r e n t m o t i v e s f o r t h e i r wish t o have a ba by , and t h i s i s c o n c e i ­

v a b l y o f im p o r t a n c e f o r t h e u n d e r s t a n d i n g and t r e a t m e n t o f p rob l ems which

migh t dev e l op d u r i n g t h e i n v e s t i g a t i o n p e r i o d and f o l l o w i n g t h e t r e a t m e n t

o f i n f e r t i l i t y . T h e r e f o r e one p u rp o s e o f t h e p r e s e n t i n v e s t i g a t i o n was t o

s t u d y t h e wish o f i n f e r t i l e c o u p l e s t o have a c h i l d b e f o r e and 2 y e a r s a f ­

t e r t u b a l s u r g e r y i n t h e woman (p a p e r V) .

S t u d i e s on t h e p s y c h o l o g i c a l imp ac t o f i n f e r t i l i t y have i n c l u d e d t h e use

o f p r o j e c t i v e t e s t s , p e r s o n a l i t y t e s t s and c l i n i c a l o b s e r v a t i o n s . These

s t u d i e s a r e c h a r a c t e r i z e d e i t h e r by g i v i n g c o u p l e s q u e s t i o n n a i r e s i n q u i ­

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

11

(81) o r by c o n d u c t i n g o pen -en ded i n t e r v i e w s ( 9 ) . The i n v e s t i g a t i o n s a r e

u s u a l l y ba se d on o b s e r v a t i o n s a t one s i n g l e s e s s i o n . A l though i n f e r t i l i t y

a f f e c t s t h e c o u p l e s a s an e n t i t y , t h e s am p le s have u s u a l l y co nc e rn ed wo­

men and o n l y t o a v e r y l i m i t e d e x t e n t c o u p l e s . Moreove r , c om p a r i s o ns have

m o s t l y been drawn w i th o t h e r c o u p l e s hav in g c h i l d r e n (41 , 51 , 5 7 ) . Des­

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

a n e c d o t a l r e p o r t s o f c l i n i c i a n s ( 20 , 4 7 , 53 , 5 4 ) , as wel l a s d e s c r i p t i v e

s t u d i e s on c o u p l e s un de rg o i ng t r e a t m e n t f o r i n f e r t i l i t y . To i n v e s t i g a t e

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

p r o s p e c t i v e and l o n g i t u d i n a l . Th i s d e s i g n i s needed t o v e r i f y t h e n a t u r e

o f t h e emo t i ona l d i s e q u i l i b r i u m e x p e r i e n c e d by i n f e r t i l e c o u p l e s . The s t u ­

d i e s need t o i n c l u d e men a s wel l a s women t o make p o s s i b l e and c o m p le t e

ex a m i n a t i o n o f t h e im p ac t o f i n f e r t i l i t y on t h e i n d i v i d u a l and t h e c o u p l e .

12

AIMS OF THE STUDY

T h i r t y i n f e r t i l e women w i th t u b a l damage and t h e i r men were i n v e s t i g a t e d .

The a ims o f t h e p r e s e n t s t u d y we re :

- t o e l u c i d a t e c u r r e n t l i f e s i t u a t i o n , s o c i a l ba ck g ro un d ,

p e r s o n a l i t y c h a r a c t e r i s t i c s , p s y c h i a t r i c anamn es i s and

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

t h e woman;

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

med i ca l i n v e s t i g a t i o n and t r e a t m e n t ;

- t o i n v e s t i g a t e t h e p s y c h o l o g i c a l , s exua l and s o c i a l im­

p a c t o f i n f e r t i l i t y b e f o r e and 2 y e a r s a f t e r u n s u c c e s s ­

f u l s u r g i c a l t r e a t m e n t ;

- t o e l u c i d a t e w he th e r and i f so t o what e x t e n t p s y c h o l o g i ­

ca l r e a c t i o n s c o m p a t i b l e w i th a c r i s i s p a t t e r n c o u ld be

i d e n t i f i e d ;

- t o s t u d y o v e r t m o t iv e s t o have a c h i l d b e f o r e and 2 y e a r s

a f t e r t u b a l s u r g e r y .

13

SUBJECTS

I n f e r t i l e c o u p l e s

Dur ing a p e r i o d o f one y e a r (1981) a l l women who were t o unde rgo s u r g i c a l

t r e a t m e n t f o r i n f e r t i l i t y a t t h e Depar tment o f O b s t e t r i c s and Gyneco logy ,

Umeå U n i v e r s i t y , were a sked t o p a r t i c i p a t e i n t h e s t u d y . All t h e 30 women

and 29 men were w i l l i n g t o c o - o p e r a t e . One man c l a im ed t h a t i n f e r t i l i t y

was n o t a p robl em f o r him and t h a t he had no t i m e t o p a r t i c i p a t e i n t h e

s t u d y . The mean and median age o f t h e women was 29 y e a r s ( r a n g e 21 -34 )

and f o r t h e men, 30 y e a r s ( r a n g e 2 4 - 5 3 ) .

Twelve women had n e v e r c o n c e i v e d , w h i l e t h e r e s t had a t some t i m e p r e ­

v i o u s l y been p r e g n a n t . E ig h t women had e x p e r i e n c e d a normal p r e g n a n c y and

some had had an e c t o p i c p r e g n a n c y , s p o n t a n e o u s o r l e g a l a b o r t i o n . Ten o f

t h e c o u p l e s were l i v i n g w i th a c h i l d a t home, and f i v e were t h e c h i l d ' s

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

t h e whole group was a bo u t 5 y e a r s ( r an ge 2 - 1 2 ) . A f t e r a t l e a s t one y e a r

o f u n s u c c e s s f u l e f f o r t s t o c o n c e i v e , t h e y had und e rgone v a r i o u s r o u t i n e

i n v e s t i g a t i o n s such a s semen a n a l y s i s , d e t e r m i n a t i o n o f o v u l a t i o n , p o s t -

c o i t a l o r / a n d p e n e t r a t i o n t e s t s , a s we l l a s l a p a r o s c o p y ( somet imes h y s t e -

r o s a l p i n g o g r a p h y ) d u r i n g 2 y e a r s . When t u b a l damage was d i a g n o s e d as t h e

c a u s e o f t h e i n f e r t i l i t y , t h e p a t i e n t s had t o w a i t ab o u t 18 months f o r t h e

s u r g i c a l t r e a t m e n t be c a u se o f t h e l i m i t e d r e s o u r c e s t o dea l w i th t h e nu ­

merous p a t i e n t s t r e a t e d a t o u r c e n t r a l i n f e r t i l i t y c l i n i c . Some women we­

r e i n fo rmed abou t t h e t u b a l damage and s u b s e q u e n t i n f e r t i l i t y f o l l o w i n g

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

One man d id no t want t o a t t e n d t h e f o l l o w - u p i n t e r v i e w ; he had o b t a i n e d a

d i v o r c e . Thus, t h e p a r t i c i p a n t s i n c l u d e d i n t h e s t u d y 2 y e a r s a f t e r t h e

s u r g e r y were 30 women and 28 men. Wi th in 2 y e a r s a f t e r t h e t u b a l s u r g e r y ,

4 c o u p l e s had a c h i e v e d a normal p r e g n a n c y . At t h e l a s t i n t e r v i e w , 3 coup ­

l e s had r e c e n t l y d i v o r c e d .

R e f e r e n c e g roups

Some o f t h e r e s u l t s were compared w i th d a t a p r e v i o u s l y o b t a i n e d f rom a

group o f p r e g n a n t women. A t o t a l o f 101 c o n s e c u t i v e women a t t e n d i n g t h e

14

a n t e n a t a l c l i n i c d u r i n g t h e f i r s t t r i m e s t e r o f p r e gn an cy were a sked t o

c o m p le t e a q u e s t i o n n a i r e which was i n p a r t i d e n t i c a l w i th t h a t o f t h e

p r e s e n t s t u d y , c o v e r i n g p s y c h o s o c i a l s i t u a t i o n and bac k g r ou nd . Al l wo­

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

The r e s u l t s o f t h e symptom c h e c k l i s t were compared w i th t h o s e o f two r e ­

f e r e n c e g roup s o f 66 a p p a r e n t l y h e a l t h y med ica l s t u d e n t s (28 women and

38 men) and 34 women f rom t h e h o s p i t a l s t a f f and t h e i r men.

A g roup o f 30 p r e g n a n t women who had d ec id e d t o go t h r o u g h w i th t h e i r

p r e g n a n c y and t h e i r men answered t h e same l i s t o f m o t iv e s f o r ha v ing a

baby a s d id t h e i n f e r t i l e g ro u p . Moreover , t h e group o f 101 p r e g n a n t wo­

men p l a n n i n g t o go t h r o u g h w i t h t h e i r p r e g n an cy a l s o answered t h e same

l i s t o f m o t iv e s a s t h e i n f e r t i l e g roup when coming f o r t h e i r f i r s t me d i ­

ca l e x a m i n a t i o n . F u r t h e r m o r e , t h e same l i s t was g i v e n t o a g roup o f 459

women a p p l y i n g f o r l e g a l a b o r t i o n and t h e y were a sked t o r e p o r t t h e mo­

t i v e s t h e y would c o n s i d e r i f t h e y were t o become p r e g n a n t i n a n o t h e r

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

15

METHODS

I n t e r v i e w s

Over a p e r i o d o f 2 y e a r s , f o u r i n t e r v i e w s were pe r f o rm ed w i th t h e women

and two w i th t h e i r men (F ig 1 ) . A l t o g e t h e r 177 i n t e r v i e w s were pe r f o rm ed

- a l l co ndu c t e d by t h e same i n v e s t i g a t o r ( A . L . ) . Eack i n t e r v i e w l a s t e d

f o r ab o u t 1 . 5 - 2 h o u r s . Al l were pe r f o rm ed a t t h e Depar tmen t o f O b s t e t ­

r i c s and Gynecology i n Umeå, w i t h an e x c e p t i o n f o r 3 c o u p l e s who a t t h e

fo l l o w - u p i n t e r v i e w 2 y e a r s a f t e r s u r g e r y had moved so f a r away t h a t

t h e s e were co n duc t e d i n t h e i r home towns . A s t a n d a r d i z e d q u e s t i o n n a i r e

and semi s t r u c t u r e d i n t e r v i e w s were u s e d . Be fo r e t h e i n v e s t i g a t i o n s t a r t e d ,

t h e method was t e s t e d on two i n f e r t i l e c o u p l e s (= f o u r i n t e r v i e w s ) , and

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

Fig i . General design o f the p resen t study.

Interviews

I 2 3

Infertility investigation

Second-lookTubal surgery

2 years a f t e r tubal surgery

At t h e f i r s t i n t e r v i e w a l l t h e 59 s u b j e c t s p a r t i c i p a t e d i n an i n d i v i d u a l

i n t e r v i e w abou t one month b e f o r e t h e r e c o n s t r u c t i v e t u b a l s u r g e r y . The

two p a r t n e r s i n each c o u p l e were i n t e r v i e w e d s e p a r a t e l y b u t on t h e same

day . I n i t i a l l y a s t a n d a r d i z e d q u e s t i o n n a i r e c o v e r i n g a ge , m a r i t a l s t a t u s ,

number o f c h i l d r e n , e d u c a t i o n , economy, g rowing -up c o n d i t i o n s , p s y c h i a t ­

r i c h i s t o r y and f a m i l y r e l a t i o n s was c o m p l e t e d . T h e r e a f t e r a semi s t r u c ­

t u r e d i n t e r v i e w was c a r r i e d o u t f o c u s i n g on t h e f o l l o w i n g t o p i c s : t h e

16

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

s o c i a l l i f e , emo t ion a l r e a c t i o n s and menta l symptoms ca u sed by t h e i n f e r ­

t i l i t y , a t t i t u d e s t o w a rd s o t h e r s ' c h i l d r e n , t ow a rd s p r e g n a n t women and t o

r e l a t i v e s and f r i e n d s , t h e m o t iv e s f o r h av in g a baby , o p i n i o n s a b ou t adop ­

t i o n , when i n f e r t i l i t y was r e c o g n i z e d as a p ro b l em , how t h e f i r s t medi ca l

c o n t a c t was i n i t i a t e d , t h e e x p e r i e n c e o f t h e i n f e r t i l i t y i n v e s t i g a t i o n and

i t s i n f l u e n c e on t h e i r r e l a t i o n s h i p and s e xua l l i f e , and e x p e c t a t i o n s abou t

t h e s u r g i c a l t r e a t m e n t .

The s econd i n t e r v i e w was semi s t r u c t u r e d and pe r fo rme d o n l y w i th t h e 30

women on one o f t h e f i r s t p o s t o p e r a t i v e d a y s . The p u rp o s e was t o r e g i s t e r

t h e i r emo t ion a l s t a t u s and p s y c h o l o g i c a l r e a c t i o n s p o s t o p e r a t i v e ! y . Al l

t u b o p l a s t i e s were con d uc t e d by t h e same s u r g e o n , t h u s a l l women were t o l d

t h e ou tcome o f t h e s u r g i c a l t r e a t m e n t by t h e same p h y s i c i a n .

The t h i r d i n t e r v i e w was c a r r i e d o u t a bo u t one month l a t e r a t s e c o n d - lo o k

l a p a r o s c o p y and i n c l u d e d o n l y t h e 30 women. The main p u r p o s e was t o e v a ­

l u a t e t h e womens' r e a c t i o n s t o t h e g i ve n i n f o r m a t i o n a b ou t t h e p r o s p e c t s

o f s u c c e e d i n g w i th a p r e g n a n c y .

The f o u r t h i n t e r v i e w i n c l u d e d a l l t h e 30 women and 28 o f t h e i r men and

was pe r f o rm e d a b o u t 2 y e a r s a f t e r t h e t u b a l s u r g e r y . The i n t e r v i e w was

s e m i s s t r u c t u r e d and a g a i n t h e two p a r t n e r s i n each c o u p l e were i n t e r v i w e d

s e p a r a t e l y b u t on t h e same da y . The f o l l o w i n g main t o p i c s were d i s c u s s e d :

ch anges i n t h e c o u p l e s ' s i t u a t i o n s i n c e t h e f i r s t i n t e r v i e w , e . g . p r e g ­

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

t a l h e a l t h , s exu a l l i f e , emo t i ona l r e a c t i o n s and mental symptoms c au se d

by t h e i n f e r t i l i t y , e f f e c t s o f i n f e r t i l i t y on s e l f - c o n f i d e n c e , m a r i t a l r e ­

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

n an t women, t o r e l a t i v e s and f r i e n d s , a t t i t u d e s t o t h e medi ca l i n v e s t i g a ­

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

o p e r a t i o n upon t h e i r mutua l r e l a t i o n s h i p , s exua l l i f e and s e l f - c o n f i d e n c e

and p o s s i b l e f u t u r e s o l u t i o n s o f t h e i r i n f e r t i l i t y p ro b l em .

17

Eysenck P e r s o n a l i t y I n v e n t o r y

At t h e f i r s t and f o u r t h i n t e r v i e w t h e p a r t i c i p a n t s comp le t ed t h e Ey­

senck P e r s o n a l i t y I n v e n t o r y ( E P I ) , Form A (29) t o e v a l u a t e t h e i r p e r ­

s o n a l i t y s t r u c t u r e . The EPI m ea su re s two d i f f e r e n t p e r s o n a l i t y d imen­

s i o n s : " N e u r o t i c i s m " , which i s an e x p r e s s i o n o f t h e t e n d e n c e t o e m o t i o ­

nal l a b i l i t y and a n x i e t y r e a c t i o n s o f v a r i o u s k i n d s , and " E x t r o v e r s i o n "

me as u r i ng ou twa rd d i r e c t e d n e s s and i m p u l s i v e n e s s . The EPI s c a l e " E x t r o ­

v e r s i o n " d e s c r i b e s a s o c i a b l e p e r s o n w i th many f r i e n d s , be in g an im p u l ­

s i v e i n d i v i d u a l , c a r e f r e e and e a s y g o i n g . The t y p i c a l i n t r o v e r t pe r s o n

keeps f e e l i n g s u nd e r c o n t r o l , l i v e s a we l l o r d e r e d l i f e and i s r e l i a b l e .

Symptom c h e c k l i s t

The p r e s e n c e o f v a r i o u s ment a l symptoms d u r i n g t h e 6 months p r i o r t o

t h e f i r s t and f o u r t h i n t e r v i e w was r e c o r d e d by u s i n g a symptom c h e c k l i s t .

The l i s t compr i s ed 30 symptoms and was e s s e n t i a l l y t h e same a s t h a t used

by Uddenberg and o t h e r s i n p r e v i o u s s t u d i e s ( 7 4 ) . All p a r t i c i p a n t s i n d i ­

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

i n s omnia and f e e l i n g s o f d e p r e s s i o n and l o n e l i n e s s . For c o m p a r i s o n , t h e y

were a l s o a sked t o e s t i m a t e t h e p r e s e n c e o f t h e same symptoms d u r i n g

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

Mot ive l i s t

At bo th t h e f i r s t and f o u r t h i n t e r v i e w , a l l p a r t i c i p a n t s were a sked abou t

why t h e y wanted t o have a c h i l d . I n i t i a l l y t h e y answered an open q u e s t i o n

abo u t t h e i r m o t i v e s . T h e r e a f t e r t h e y were a sked t o choo se a t mos t 5 f rom

36 d i f f e r e n t m o t iv e s t o have c h i l d r e n . The m o t iv e s were s e l e c t e d from p r e ­

v io u s s t u d i e s and t h e i n v e s t i g a t o r s 1 own e x p e r i e n c e . The m o t i ve l i s t was

f i r s t t e s t e d among 20 women on t h e h o s p i t a l s t a f f and 20 male s t u d e n t s

f rom t h e U n i v e r s i t y School o f S o c i a l Work and t h e r e a f t e r r e v i s e d b e f o r e

u se i n t h e s t u d y .

A pa r t f rom t h e i n e v i t a b l e im pac t o f t h e i n t e r v i e w - c o n t a c t s d u r i n g t h i s

l o n g i t u d i n a l i n v e s t i g a t i o n , t h e c o u p l e s d id no t r e c e i v e any o t h e r p r o f e s ­

s i o n a l s u p p o r t f r om s o c i a l wo rke r s o r p s y c h o l o g i s t s .

18

S t a t i s t i c a l me thods

S t a t i s t i c a l s i g n i f i c a n c e s were a s s e s s e d by t he Mann-Whitney U - t e s t , t h e2

Wilcoxon m a t c h e d - p a i r s r a n k s t e s t and by t h e X - t e s t w i t h Y a t e s ' c o r r e c ­

t i o n where a p p r o p r i a t e . The r e l a t i o n s h i p s be tween v a r i a b l e s were c a l c u ­

l a t e d a s p roduc t -momen t c o r r e l a t i o n c o e f f i c i e n t s .

19

RESULTS AND DISCUSSION

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

e x p e r i e n c e o f c h i l d l e s s n e s s t o o d i s p a r a t e t o j u s t i f y g e n e r a l i z a t i o n s . The

i n t e n t i o n i s n o t t o make t h e f i n d i n g s o f t h i s s t u d y r e p r e s e n t a t i v e o r comp­

r e h e n s i v e f o r t h e whole group o f i n f e r t i l e c o u p l e s . The s t u d y i s r a t h e r t h e

r e s u l t o f a p s y c h o l o g i c a l and s o c i a l a n a l y s i s ba sed on p e r s o n a l i n t e r v i e w s

o f a r a t h e r sma l l b u t s p e c i f i c g roup o f i n d i v i d u a l s w i th t h e same p rob l em

" t u b a l i n f e r t i l i t y " and who unde rwen t t h e e x p e r i e n c e o f " s u r g i c a l t r e a t ­

me n t " .

In t h e p r e s e n t l o n g i t u d i n a l s t u d y , f o u r i n t e r v i e w s were p e r f o rm ed w i th t h e

women and two w i t h t h e i r men; a l l were co n du c t e d by t h e same i n v e s t i g a t o r .

In o t h e r i n v e s t i g a t i o n s c o m pa r i s on s have m o s t l y been made w i th o t h e r coup ­

l e s hav in g c h i l d r e n (41 , 51 , 5 7 ) . In t h i s s t u d y , howeve r , i n t e r e s t ha s

p r i n c i p a l l y c e n t e r e d on t h e i n t e r p e r s o n a l and i n t r a - i n d i v i d u a l c h a n g e s .

Compar i sons have been made m a i n ly be tween t h e i n f e r t i l e women and t h e i r

men and each s u b j e c t was u sed a s h i s / h e r own c o n t r o l . S ev e r a l s u b j e c t i v e

v a r i a b l e s were i n v o l v e d r e g a r d i n g t h e woman, t h e man, and t h e complex d y ­

namics o f t h e c o u p l e ' s mutua l r e l a t i o n s h i p . Th i s f a c t ha s made i t impos­

s i b l e t o f i n d an a p p r o p r i a t e c o n t r o l g ro u p .

PSYCHOSOCIAL CHARACTERIZATION (P ape r I )

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

mean d u r a t i o n o f 7 y e a r s ( r a n g e 2 - 1 4 ) . Seven women a l r e a d y had a c h i l d

o f t h e i r own and 9 o u t o f t h e 29 men were f a t h e r s , o f t e n i n p r e v i o u s r e ­

l a t i o n s h i p s . Ten c o u p l e s had one c h i l d l i v i n g a t home. F ive o f t h e coup ­

l e s had a b i o l o g i c a l c h i l d t o g e t h e r and 1 c o u p l e had a d op t e d a c h i l d .

Most o f t h e p a r t i c i p a n t s d e s c r i b e d a harmon ious c h i l d h o o d and j ud ged

t h e i r p r e s e n t r e l a t i o n s h i p and s e xua l l i f e as "ha rmon ic " o r " a c c e p t a b l e " .

Most o f them c o n s i d e r e d t h e i r economic s i t u a t i o n and o c c u p a t i o n as s a ­

t i s f a c t o r y . The p r e s e n t s o c i a l s i t u a t i o n and p s y c h o s o c i a l backg round i n

t h e i n f e r t i l e women were q u i t e s i m i l a r t o t h o s e o f a r e f e r e n c e group o f

101 p r e g n a n t women. The good p s y c h o l o g i c a l background and c u r r e n t s i t u a ­

t i o n o f t h e s e i n f e r t i l e c o u p l e s m ig h t have c o n t r i b u t e d t o and enhanced

20

t h e f e e l i n g t h a t t h e i r l i v e s were empty and l o n e l y w i t h o u t c h i l d r e n . They

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

t e r l y found t h e m s e l v e s v i c t i m s o f an i n v i s i b l e h a n d i c a p .

The p a r t i c i p a n t s had a r e m a r k a b l y l a r g e number o f s i b l i n g s , be in g 3 .1

(mean) f o r t h e women and 3 . 4 f o r t h e men i n c o n t r a s t t o t h e a v e r a g e o f

o n l y one f o r t h e Swedish p o p u l a t i o n ( 3 5 ) . Apa r t f r om 3 i n d i v i d u a l s who

were t h e o n l y c h i l d , t h e numbers o f s i b l i n g s r ange d be tween 1 and 12. Va­

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

d u r i n g c h i l d h o o d (74 , 80) and c l e a r l y t h i s background f a c t o r co u ld add

t o t h e emo t i ona l bu rden o f i n f e r t i l i t y .

E ig h t women r e p o r t e d p r e v i o u s men t a l d i s o r d e r s , 4 d u r i n g a d o l e s c e n c e , and

4 i n a d u l t h o o d . Four had been t r e a t e d a s i n - p a t i e n t s a t a p s y c h i a t r i c c l i ­

n i c , b u t n o t d u r i n g t h e p a s t 6 y e a r s . Four o f t h e men r e p o r t e d p r e v i o u s

men ta l d i s o r d e r s , 2 a s a d u l t s , and bo th had been t r e a t e d a s i n - p a t i e n t s .

Thus , i n 11 c o u p l e s a t l e a s t one p a r t n e r had a p s y c h i a t r i c anamnes i s o f

c l i n i c a l r e l e v a n c e . The re i s no i n d i c a t i o n t h a t t h e p a r t i c i p a n t s e x h i b i t

an i n c r e a s e d p s y c h i a t r i c m o r b i d i t y compared w i th a normal p o p u l a t i o n .

For i n s t a n c e , compared w i t h a g roup o f women f rom an u rba n p o p u l a t i o n in

Go thenbu rg i n Sweden ( 6 4 ) , t h e i n f e r t i l e women d id n o t d i f f e r a s r e g a r d s

i n - p a t i e n t o r o u t - p a t i e n t c a r e d u r i n g t h e l a s t 6 y e a r s p r i o r t o t h e i n v e s ­

t i g a t i o n .

P r e v i o u s r e p o r t s t h a t i n f e r t i l e p a t i e n t s i n g e n e r a l do n o t e x h i b i t more

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

a r e s u p p o r t e d by t h e p r e s e n t s t u d y (31 , 4 2 , 51 , 67 , 7 8 ) . Ac co rd ing t o t h e

r e s u l t s o f t h e Eysenck P e r s o n a l i t y I n v e n t o r y (EPI) Form A, b e f o r e and 2

y e a r s a f t e r t h e o p e r a t i o n , t h e p a r t i c i p a n t s d id no t d i f f e r f rom a norma­

t i v e c o n t r o l g roup ( 2 9 ) , no r f rom a r e f e r e n c e group o f a p p a r e n t l y s t a b l e

women ( 3 7 ) , o r a g roup o f m i l i t a r y c o n s c r i p t s ( 4 6 ) . They d i f f e r e d d i s ­

t i n c t l y f r om n e u r o t i c and c l i n i c a l l y d e p r e s s e d p a t i e n t s ( 4 5 ) . The men we­

r e s c o r i n g r a t h e r low on t h e n e u r o t i c i s m s c a l e bo th b e f o r e and 2 y e a r s

a f t e r t h e t u b a l s u r g e r y , and a t t h e f i r s t i n t e r v i e w t h e women were s c o ­

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

21

The o c c u r r e n c e o f men t a l symptoms on t h e symptom c h e c k l i s t (Appendix 4 a , 4 b )

showed no s i g n i f i c a n t change i n t h e t o t a l number o f symptoms d u r i n g t h e

2 y e a r s o f i n v e s t i g a t i o n , e i t h e r among t h e women o r among t h e men. Acco r ­

d in g t o t h e s e l f - r a t i n g , h a l f o f t h e i n f e r t i l e women had f i v e o r more

d i f f e r e n t symptoms r e p r e s e n t i n g v a r i o u s a s p e c t s o f men t a l i m b a l a n c e .

Seen a s a g roup t h e women had more menta l symptoms t h a n t h e men b e f o r e

and 2 y e a r s a f t e r t u b a l s u r g e r y . They a l s o had more symptoms t h a n women

on t h e h o s p i t a l s t a f f , b u t d i d n o t d i f f e r f r om a g roup o f med i ca l s t u ­

d e n t s . As a g r o u p , t h e i n f e r t i l e c o u p l e s d id no t d i f f e r f rom t h e two r e ­

f e r e n c e g r o u p s . Even 2 y e a r s a f t e r t h e o p e r a t i o n t h e mos t p ro m in e n t symp­

toms among t h e women were i r r i t a b i l i t y , f a t i g u e , d e p r e s s i o n and r e s t ­

l e s s n e s s .

The p s y c h i a t r i c a n a m n e s i s , EPI r e s u l t s and t h e r e s u l t s o f t h e symptom

c h e c k l i s t r e v e a l t h a t t h e i n f e r t i l e c o u p l e s do n o t seem t o have any s p e ­

c i f i c p e r s o n a l i t y t r a i t s . The menta l symptoms and e m o t io na l p rob l ems i n

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

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

MARITAL RELATIONSHIP (P ap e r s I and I I )

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

sh ip a s " v e r y good" o r "good" b e f o r e t h e o p e r a t i o n . T h e i r r e - e v a l u a t i o n ,

however , 2 y e a r s a f t e r t h e o p e r a t i o n showed a c l e a r t r e n d t ow ar d s a d e t e ­

r i o r a t i o n . F ive c o u p l e s had d i s c u s s e d a s e p a r a t i o n and 3 o f t h e s e d i v o r ­

ced l a t e r . Rega rd in g t h e c o u p l e s a s an e n t i r e g ro u p , no s t a t i s t i c a l l y s i g ­

n i f i c a n t chang es c o u ld be co n f i rm e d t h a t migh t have been due t o t h e smal l

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

t i n g i n o u r s t u d y had su cce ede d i n l i v i n g t o g e t h e r i n s p i t e o f a p r o t r a c ­

t e d i n f e r t i l i t y p rob l em - which i s an i n d i c a t i o n t h a t t h e i r m a r i t a l r e ­

l a t i o n s h i p had been s t a b l e . A l though t h e p rob l em o f i n f e r t i l i t y i s a

burden f o r t h e r e l a t i o n s h i p , c h i l d l e s s m a r r i a g e s i n t h e m s e l v e s do no t

seem t o be unhappy . Our f i n d i n g s a r e s u p p o r t e d by p r e v i o u s s t u d i e s ( 41 ,

6 1 ) .

Conce rn ing t h e p a r t n e r s * f e e l i n g f o r e ach o t h e r , howeve r , a s t a t i s t i c a l l y

s i g n i f i c a n t d e t e r i o r a t i o n was n o t i c e d , e s p e c i a l l y on t h e p a r t o f t h e men.

22

Only 13 o f 24 men r e p o r t e d 2 y e a r s a f t e r t h e o p e r a t i o n t h a t he was d e e p ­

l y fond o f h i s p a r t n e r , w h i l e a l l c on f i rm e d t h e same f e e l i n g 2 y e a r s e a r ­

l i e r . A p o s s i b l e e x p l a n a t i o n co u l d be t h e f a c t t h a t b e f o r e t h e o p e r a t i o n ,

deep empathy and t e n d e r s h a r i n g o f f e e l i n g s c h a r a c t e r i z e d mos t o f t h e

c o u p l e s , b e s i d e s t h e f a c t t h a t t h e y were ho p e fu l o r c o nv in ce d t h a t t h e y

would su cce ed w i th a p r e g n a n c y a f t e r t h e o p e r a t i o n . A f t e r 2 y e a r s w i t h ­

o u t any p r e g n a n c y , f e e l i n g s o f g r i e f i n c r e a s e d , e s p e c i a l l y among t h e men.

They t r i e d t o m a i n t a i n t h e i m p r e s s i o n o f be in g c o m f o r t i n g and o p t i m i s t i c ,

b u t t h e y co u ld n o t c o n s o l e and s u p p o r t t h e i r women t o t h e same e x t e n t as

p r e v i o u s l y . Th is p r o b a b l y r e s u l t e d i n t h e dev e lopmen t o f a wounded emo­

t i o n a l c o n t a c t be tween t h e m a t e s . D i s t u r b a n c e s i n t h e em o t i on a l c o n t a c t

between t h e p a r t n e r s had a l r e a d y been r e p o r t e d b e f o r e t h e o p e r a t i o n and

a t e n d e n c y t ow ar d s an a g g r a v a t i o n cou ld be no t e d 2 y e a r s l a t e r . The ma j o ­

r i t y o f t h e p a r t i c i p a n t s had t h e f e e l i n g t h a t t h e y co u ld n o t o p e n l y show

s a d n e s s and d i s a p p o i n t m e n t i n t h e p r e s e n c e o f t h e i r p a r t n e r . As f a r a s we

know, such o b s e r v a t i o n s have n o t been d e s c r i b e d i n t h e l i t e r a t u r e p r e v i o u s ­

l y , p o s s i b l y due t o t h e f a c t t h a t mos t o f t h e i n v e s t i g a t i o n s have been

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

male p a r t n e r .

The m a j o r i t y o f t h e c o u p l e s c o n s i d e r e d t h a t t h e i n f e r t i l i t y p rob l em a f f e c ­

t e d t h e i r r e l a t i o n s h i p bo th b e f o r e and 2 y e a r s a f t e r t h e o p e r a t i o n . Th i s

i n f l u e n c e was e i t h e r n e g a t i v e , depe nd ing on c o n f l i c t s a s s o c i a t e d w i th

t h e i r i n f e r t i l i t y and some t imes w i th d r aw a l f r om each o t h e r , o r p o s i t i v e

b e c a u s e o f an i n c r e a s e d empathy which improved m a r i t a l s a t i s f a c t i o n . The

number o f men, however , who r e p o r t e d a n e g a t i v e e f f e c t o f t h e i n f e r t i l i t y

on t h e m a r i t a l r e l a t i o n s h i p had i n c r e a s e d s i g n i f i c a n t l y 2 y e a r s a f t e r s u r ­

g e r y (P < 0 . 0 5 ) .

SEXUAL LIFE (P ap e r s I , I I and I I I )

Sexual d i s t u r b a n c e s and s e xua l i n f e r i o r i t y may be t h e mos t complex o f t h e

many em o t io na l p rob l ems w i th which an i n f e r t i l e c o u p l e ha s t o d e a l . A l ­

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

a s "ha rmon ic " o r " a c c e p t a b l e " , t h e y had s i g n i f i c a n t l owe r r a t i n g s t h a n

t h e r e f e r e n c e g roup o f p r e g n a n t women ( P < 0 . 0 5 ) . The o v u l a t i o n i n v e s t i ­

g a t i o n w i th b a s a l body t e m p e r a t u r e r e c o r d s (BBT) im p l i ed a f r u s t r a t i o n t o

23

most o f t h e c o u p l e s ' s e x ua l l i f e bec a us e t h e y used i t t o p l a n i n t e r c o u r ­

s e . "Sex on demand" was a bu rden and t h e m a j o r i t y r e p o r t e d t h a t i t had

a n e g a t i v e i n f l u e n c e on s a t i s f a c t i o n . A p p a r e n t l y c o u p l e s w i th a p r e v i o u s ­

l y s a t i s f a c t o r y s ex u a l l i f e may d e ve lo p a s e x ua l d y s f u n c t i o n as a r e ­

s u l t o f t h e p r e s s u r e and a n x i e t y a r i s i n g f rom t h e i r i n f e r t i l i t y and even

as a r e s u l t o f t h e i n v e s t i g a t i o n and t r e a t m e n t ( 7 , 26 , 28 , 66 , 7 6 ) .

The c o u p l e s ' s e x ua l l i f e d e t e r i o r a t e d d u r i n g t h e 2 y e a r s a f t e r t h e o pe ­

r a t i o n - s i g n i f i c a n t l y so among t h e women. Th i s c o u ld be due t o d i s t u r ­

ban ces i n mutual e mo t io na l c o n t a c t . Many c o u p l e s a l s o s t a r t e d w i th p l a n ­

ned i n t e r c o u r s e s a f t e r t h e o p e r a t i o n , which a l s o had a bad e f f e c t on

s e x ua l l i f e . At t h e t i m e o f t h e f i r s t i n t e r v i e w , o n l y 3 c o u p l e s f ound i t

w o r th w h i l e t o have p l a n n e d i n t e r c o u r c e s , wherea s a f t e r t h e o p e r a t i o n 22

c o u p l e s d id s o . The n e g a t i v e i n f l u e n c e on s e xua l l i f e was most p ro n ou n ­

ced among t h e women. One e x p l a n a t i o n may be t h a t t h e women f e l t r e s p o n ­

s i b l e f o r t h e c h i l d l e s s n e s s , and a t t a c h e d f e r t i l i t y t o f e m i n i t y , s e x u a ­

l i t y and s e l f - e s t e e m (47 , 63 , 7 3 ) . O f t e n women a r e u n a b l e t o l e t t hem­

s e l v e s go c o m p l e t e l y i n t h e i r own sexu a l r e s p o n s e s b e c a u s e t h e y a r e ob ­

s e s s e d w i th t h e " i d e a o f a c h i l d " and b e l i e v e t h a t t h e s ex ua l a c t i t s e l f

i s u s e l e s s i f i t s p u r p o s e i s no t p r o c r e a t i o n ( 3 ) . Of t e n t h e r e i s a t r e ­

mendous b u i l d - u p o f hope and t e n s i o n t oward t h e end o f t h e woman' s c y c l e

and when t h e m e n s t r u a l f l o w b e g i n s , many women a r e p lun ged i n t o a de ep ,

a c u t e d e p r e s s i o n ( 5 3 ) . A v i c i o u s c y c l e o f e m o t io n a l t e n s i o n — -> sexu a l

p r o b l e m s > em o t io n a l t e n s i o n was o f t e n c r e a t e d w i t h i n t h e c o u p l e . I t

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

when t h e y have t o f a c e t h e p rob l em o f i n f e r t i l i t y . A d e t a i l e d s e xua l

anam ne s i s f o l l o w e d by r e g u l a r d i s c u s s i o n s ab ou t s e x ua l a c t i v i t y and s a ­

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

l i t y may h e l p t o r e d u c e t h e n e g a t i v e e f f e c t s c a use d by t h e i n f e r t i l i t y

i t s e l f and p l a n n e d i n t e r c o u r s e ( 3 3 ) . The e a r l y r e c o g n i t i o n o f im p a i r e d

l i b i d o , i n h i b i t i o n o f o rg a s m s , o r s i g n s o f impo tence may p r e v e n t t h e e s ­

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

EMOTIONAL AND SOCIAL IMPACT OF INFERTILITY (P a p e r s I , I I and IV)

I n f e r t i l i t y ha s s e v e r e em o t io n a l and s o c i a l e f f e c t s . A f t e r ab o u t one y e a r

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

24

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

The c o u p l e s were a sked s p e c i f i c a l l y a bo u t e mo t i on a l and s o c i a l e f f e c t s

wh ich , i n t h e i r own o p i n i o n , were due t o t h e i r i n f e r t i l i t y p ro b l e m, bo th

b e f o r e and 2 y e a r s a f t e r t h e o p e r a t i o n . On compar ing t h e d u r a t i o n o f i n ­

f e r t i l i t y w i t h t h e number o f em o t ion a l and s o c i a l e f f e c t s , no c o r r e l a ­

t i o n co u ld be found e i t h e r i n t h e women (R = 0 . 1 2 ) o r i n t h e men (R =

0 . 1 7 ) . Moreover , no s i g n i f i c a n t d i f f e r e n c e s i n t h i s a s p e c t c o u l d be

found among t h o s e who had p r e v i o u s l y bo rn e a c h i l d , compared w i th t h o s e

who had n o t . The women and men r e p o r t e d g r i e f , p e r i o d i c d e p r e s s i o n , i r r i -

t a b i l i t y and f e e l i n g s o f i n f e r i o r i t y t o be t h e mos t common emo t i ona l r e ­

a c t i o n s ca use d by t h e i r i n v o l u n t a r y c h i l d l e s s n e s s (T a b l e 1 ) . S i x t e e n o f

t h e women e x p r e s s e d f e e l i n g s o f g u i l t b ec au se o f t h e i r i n f e r t i l i t y . The­

se d a t a a g r e e c l o s e l y w i t h c l i n i c a l e x p e r i e n c e f rom i n f e r t i l i t y c o u n s e l ­

l i n g (5 4 , 8 0 ) .

TABLE I EMOTIONAL AND SOCIAL EFFECTS OF INFERTILITY AS REPORTED BY 30 WOMEN AND 29 MEN

Women Men

EmotionalGrief 22 15Depression during menstruation 21 5Irritability 21 7Guilt 16 3Inferiority 14 2Aggressiveness 8 2Sleep disturbances 8 2Anxiety 6 2Sexual aversion 13 1

SocialIsolation 21 10No genuine emotional support from relatives and friends 26 25No one to talk to 5 20Aversion towards pregnant women 25 12Aversion towards children 9 2

Total reported effects 215 110

At t h e t i m e o f t h e f i r s t i n t e r v i e w a l l women knew t h a t t h e i r t u b a l d a ­

mage was t h e c a u s e o f t h e c o u p l e ' s i n f e r t i l i t y . T h e r e f o r e i t i s n o t

s u r p r i s i n g t h a t t h e women r e p o r t e d more emo t i ona l e f f e c t s t h a n t h e men,

25

bo th b e f o r e and 2 y e a r s a f t e r t h e t u b a l s u r g e r y ( p < 0 . 0 1 ) . F e e l i n g s

o f g r i e f , however , were r e p o r t e d i n a b ou t 90 % o f t h e c a s e s , among bo th

t h e women and t h e men a t t h e l a s t i n t e r v i e w . Th e re was no s i g n i f i c a n t

i n c r e a s e i n t h e t o t a l number o f symptoms among t h e women and t h e men 2

y e a r s a f t e r s u r g e r y . In s p i t e o f cha ng ing a t t i t u d e s and t r e n d s t ow ard s

e q u a l i t y be tween t h e s e x e s , p a r e n t h o o d i s s t i l l a s s o c i a t e d more c l o s e l y

w i th t h e f e m a l e r o l e , and f e r t i l i t y seems t o be c o m p a r a t i v e l y more impor ­

t a n t f o r a woman's s e l f - e s t e e m ( 33 , 63 , 7 3 ) . T h e r e f o r e women o f t e n f e e l

more r e s p o n s i b l e when a t t e m p t s t o a c h i e v e a p r e g n a n c y a r e u n s u c c e s s f u l .

D e p re s s i o n d u r in g t h e m e n s t r u a l p e r i o d was r e p o r t e d a t t h e l a s t i n t e r v i e w

by 93 % o f t h e women who had f a i l e d t o a c h i e v e p r e g n a n c y .

Adve r se f e e l i n g s t o w ar ds p r e g n a n t women ( e . g . s a d n e s s , j e a l o u s y and agg ­

r e s s i o n ) were ve ry common among t h e i n f e r t i l e women. O n e - t h i r d o f t h e men

a l s o had s i m i l a r f e e l i n g s . F u r t h e r m o r e , c o n t a c t s w i th o t h e r p e o p l e * s

c h i l d r e n co u l d evoke f r u s t r a t i o n , u n h a p p in e s s and f e e l i n g s of i n j u s t i c e ,

and t h e r e f o r e some women and a few men t r i e d t o av o id such c o n t a c t s . Two

y e a r s l a t e r t h e number o f women who r e p o r t e d such f e e l i n g s had i n c r e a s e d ,

and t h e d i f f e r e n c e between t h e women and men became s i g n i f i c a n t ( P < 0 . 0 1 ) .

These f i n d i n g s d i f f e r f r om t h o s e o f some p r e v i o u s s t u d i e s . Van Keep found

t h a t 90 % o f a group o f c h i l d l e s s c o u p l e s had a f a v o u r a b l e a t t i t u d e t o

o t h e r p e o p l e ' s c h i l d r e n and t h e y l i k e d be ing i n t h e i r company ( 4 1 ) . In

ou r s t u d y t h e men o f t e n t r i e d t o app roach o t h e r p e o p l e ' s c h i l d r e n , w h i l e

women wanted t o a vo id t hem. T h i s f i n d i n g i s i n a g r eem en t w i th t h e s t u d y

o f Mai e t a l . ( 5 1 ) .

Most o f t h e i n f e r t i l e c o u p l e s , p a r t i c u l a r l y t h e men, f ound i t v e r y d i f f i ­

c u l t t o t a l k t o o t h e r s a bo u t t h e i r i n f e r t i l i t y p ro b l e m . As many as 20 o f

t h e men had "no one t o t a l k w i th " b u t t h e i r i n f e r t i l e p a r t n e r . I t i s a l s o

r e m a r k a b l e t h a t a s i g n i f i c a n t i n c r e a s e i n g r i e f among t h e men was r e p o r ­

t e d 2 y e a r s a f t e r t h e o p e r a t i o n . The c o u p l e s g e n e r a l l y f e l t t h a t r e l a t i ­

ves and f r i e n d s c o u ld no t f u l f i l a s u p p o r t i v e f u n c t i o n r e g a r d i n g t h e p s y ­

c h o l o g i c a l p rob l em o f i n f e r t i l i t y . At t h e l a s t i n t e r v i e w o n l y 4 women and

4 men c o n s i d e r e d t h a t t h e y r e c e i v e d g e n u i n e emo t i ona l s u p p o r t f rom t h e i r

r e l a t i v e s and f r i e n d s , and some even e x p e r i e n c e d t h e s e c o n t a c t s a s b u r d e n ­

some. T h i s m ight be a r e s u l t o f t abo o among p e o p l e a s r e g a r d s i n f e r t i l i t y .

26

Most o f t h e i n f e r t i l e c o u p l e s , p a r t i c u l a r l y t h e men, o f t e n found i t d i f ­

f i c u l t t o t a l k w i t h o t h e r s a b o u t t h e i r c h i l d l e s s n e s s . Moreover , i t seems

t h a t many p e o p l e av o id t a l k i n g ab o u t t h e i r own c h i l d r e n i n t h e p r e s e n c e

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

and p o s s i b l e s u p p o r t f rom r e l a t i v e s and f r i e n d s .

PSYCHOLOGICAL REACTIONS TO THE MEDICAL INVESTIGATION AND SURGICAL TREAT­

MENT ( P a p e r I I )

In mos t c o u p l e s t h e woman was t h e f i r s t t o r e c o g n i z e t h e i n f e r t i l i t y a s a

p rob l e m and t o i n i t i a t e open d i s c u s s i o n s on t h e s u b j e c t . She a l s o a r r a n ­

ged t h e f i r s t med i ca l c o n t a c t . The p a t i e n t s ' d e l a y a f t e r t h e p rob l em had

been i d e n t i f i e d was up t o 2 y e a r s . The main r e a s o n s f o r t h e i r h e s i t a t i o n

t o s eek med ica l he lp we re f e a r o f a f i n a l n e g a t i v e d i a g n o s i s and a f e a r

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

v e s t i g a t i o n and t r e a t m e n t .

BBT r e c o r d i n g s

The o v u l a t i o n i n v e s t i g a t i o n w i th BBT r e c o r d s meant f r u s t r a t i o n i n t h e

s exua l l i f e o f most c o u p l e s . Twenty women had u sed BBT a l s o a s a way t o

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

o f t h e women d e c l a r e d t h a t t h e y were s t i l l e x t r e m e l y aware o f p h y s i c a l

ch ang es d u r i n g t h e m e n s t r u a l c y c l e . O n e - t h i r d o f t h e men a l s o b e l i e v e d

t h e y knew e x a c t l y when o v u l a t i o n was e x p e c t e d . The e f f e c t s on s ex ua l

l i f e o f p l a n n e d i n t e r c o u r s e a c c o r d i n g t o BBT were n e g a t i v e i n a l l co up ­

l e s . The p l a n n i n g o f t e n made i n t e r c o u r s e a bu rd en and somet imes ca u sed

s exua l a v e r s i o n , l a c k o f o rga sm, f r i g i d i t y and im p o t e nc e . O n e - t h i r d

t h o u g h t t h a t p l a n n i n g was more d i f f i c u l t f o r t h e man, and o n e - t h i r d f o r

t h e woman. Sexual l i f e had become " s e x on demand" i n s t e a d o f " s ex on d e ­

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

t i o n has d e c l i n e d s i n c e t h e dev e lopmen t o f new t e c h n i q u e s f o r hormonal

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

s hou ld be u sed w i t h c a u t i o n and o n l y when a b s o l u t e l y n e c e s s a r y .

Semen a n a l y s i s

Semen a n a l y s i s i s an i m p o r t a n t and p h y s i c a l l y n o n - t r a u m a t i c e x a m i n a t i o n

f o r t h e man. H a l f o f t h e men, however , e x p e r i e n c e d t h i s e x a m i n a t i o n a s

27

p s y c h o l o g i c a l l y d i f f i c u l t . F e e l i n g s o f shame, em b a r r a s s m en t , d e g r a d a t i o n

and s t r e s s were f r e q u e n t l y d e s c r i b e d among t h e 29 men. They found t h e en ­

v i r o nm en t o f t h e h o s p i t a l u n n a t u r a l and u n p l e a s a n t , and t h e y o f t e n had

d i f f i c u l t y i n p ro d u c i n g an e j a c u l a t e . In a p r e v i o u s c l i n i c a l s t u d y , 26 %

o f t h e men r e f u s e d t o have t h e i r semen a n a l y s e d ( 1 6 ) . F e e l i n g s o f worry

and a n x i e t y we re common b e f o r e t h e ou tcome o f t h e a n a l y s i s was known.

The f a c t t h a t t h e i n f o r m a t i o n a bo u t t h e f i n a l r e s u l t was o f t e n g i v e n by

t h e g y n e c o l o g i s t t o t h e woman, o r even i n some c a s e s f a i l e d t o a p p e a r ,

added t o t h e n e g a t i v e e x p e r i e n c e . I f f rom t h e b e g in n i n g o f t h e i n f e r t i l i ­

t y i n v e s t i g a t i o n t h e man becomes an i n t e g r a l p a r t , t h e g y n e c o l o g i s t can

i n fo rm and m o t i v a t e him p e r s o n a l l y .

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

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

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

t u b a l s u r g e r y was i n a d e q u a t e . A t t em p t s were made by t h e su r geon n o t t o

c a u s e e x a g g e r a t e d hopes a b ou t t h e r e s u l t s o f t h e s u r g i c a l t r e a t m e n t . In

s p i t e o f t h e s e a t t e m p t s , 19 women and 19 men s t i l l had g r e a t and s o m e t i ­

mes u n r e a l i s t i c e x p e c t a t i o n s o f f u t u r e p r e g n a n c i e s and c h i l d r e n . I t seems

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

t i o n , w h i l e t h e y " f o r g o t " t h e n e g a t i v e p a r t s . Such r e p r e s s i o n i s p ro n o u n ­

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

o f a n x i e t y on l e a r n i n g and t h e f a c t t h a t h igh p r o p o r t i o n s o f s u r g i c a l p a ­

t i e n t s e x p e r i e n c e m o d e r a t e t o h igh l e v e l s o f p r e o p e r a t i v e a n x i e t y ( 5 9 ) .

B e fo re t h e o p e r a t i o n , 43 o u t o f t h e 59 i n d i v i d u a l s b e l i e v e d t h a t i f t h e

p r o g n o s i s was found t o be e x t r e m e l y p o o r , t h e n i t would p r o b a b l y be b e t ­

t e r f o r them t o be i n fo rm ed t h a t t h e y had no cha nc e o f c o n c e i v i n g a t a l l .

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

ment and d e s p a i r t h a n knowing t h a t t h e r e was s t i l l c a u s e f o r hope even

though t h e c h an c es were e x t r e m e l y s l i m .

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

B e fo re t h e t u b a l s u r g e r y , more t h a n h a l f o f t h e women and o n e - t h i r d o f

t h e men were an x io u s and a f r a i d . Se ven t ee n women had unde rgone one o r

more p r e v i o u s l a p a r o t o m i e s and many had n e g a t i v e e x p e r i e n c e s . Im me d i a t e ly

28

a f t e r t h e o p e r a t i o n , most o f t h e women e x p e r i e n c e d a f e e l i n g o f r e l e a s e

anc* s a t i s f a c t i o n . Many women c o n s i d e r e d t h a t t h e p s y c h o l o g i c a l s u f f e r i n g

was wor se t h a n t h e p h y s i c a l p a i n and c o m p l i c a t i o n s . A c o u p l e o f days a f ­

t e r t h e o p e r a t i o n , o n e - t h i r d o f t h e women were found t o have b r i e f p e ­

r i o d s o f u n ex p e c t ed d e p r e s s i v e f e e l i n g s when t h e y r e a l i z e d t h a t t h e y had

a r e a l cha n ce o f becoming p r e g n a n t . Nine o f them were p r i m a r i l y i n f e r t i ­

l e . They f e l t e x t r e m e l y s a d , wept a l o t and want ed t o be a l o n e . A p o s ­

s i b l e e x p l a n a t i o n c o u ld be an am b i v a l e n ce c o n c e r n i n g t h e i r r e a l m o t i v e s

t oward hav in g a ba by , which some a l s o r e v e a l e d . Such a m b i v a l e nc e i s com­

mon among f e r t i l e women and men, b u t m ig h t be a f o r b i d d e n t h o u g h t f o r

t h e i n f e r t i l e c o u p l e .

In 26 women a s e c o n d - lo o k l a p a r o s c o p y was done one month a f t e r t h e o p e ­

r a t i o n . Most women a f t e r w a r d s had f e e l i n g s o f r e l i e f b e c a u s e t h e t r e a t ­

ment was co m p le t e d and t h e y had i n c r e a s e d t h e i r p o s s i b i l i t i e s o f c o n c e i ­

v i n g . The f i n a l i n f o r m a t i o n ab o u t t h e p r o g n o s i s o f t h e i r i n f e r t i l i t y was

g i v e n by t h e su r ge o n h i m s e l f a f t e r t h e l a p a r o s c o p y . The i n f o r m a t i o n v a ­

r i e d and most o f t h e p a r t i c i p a n t s t h o u g h t i t was a d e q u a t e . T w e n t y - s i x

women and 19 men, o v e r e s t i m a t e d t h e p r o s p e c t s o f hav ing a c h i l d o f t h e i r

own. Most c o u p l e s were v e ry o p t i m i s t i c and t h e y had e x a g g e r a t e d hopes

f o r t h e f u t u r e management o f t h e i n f e r t i l i t y p r o b l e m . H a l f o f t h e p a r t i ­

c i p a n t s e x p e c t e d a p r e g n a n c y w i t h i n one month a f t e r t h e s e c o n d - lo o k l a ­

p a r o s c o p y and t h e m a j o r i t y (80 %) w i t h i n 6 mon t hs . T h i s can i l l u s t r a t e

t h e phenomenon o f d e n i a l c a u sed by t h e g r e a t wish f o r a c h i l d . As long

a s t h e c o u p l e s know t h a t t h e y s t a n d a cha nc e o f hav ing t h e i r own c h i l d ­

r e n - even t hough t h i s cha n ce i s smal l - t h e y d e l a y c o n f r o n t a t i o n and

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

f o r e t h e g y n e c o l o g i s t sh ou l d n o t t r y t o " c o n s o l e " t h e c o u p l e by o v e r ­

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

r e l e v a n t e x a m i n a t i o n s . Many o f t h o s e who d id n o t succe ed w i t h a p r e g n a n ­

cy had e v i d e n t p s y c h o l o g i c a l p ro b l em s a l r e a d y w i t h i n one y e a r a f t e r t h e

o p e r a t i o n .

F u t u r e c o n s i d e r a t i o n s

In s p i t e o f t h e c o u p l e s ' p r o t r a c t e d i n f e r t i l i t y and t h e p s y c h o l o g i c a l

p ro b l e m s c au se d by t h e i n v e s t i g a t i o n and t r e a t m e n t , s t i l l 2 y e a r s a f t e r

29

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

were w i l l i n g t o do w h a t e v e r r e q u i r e d t o succee d w i th a p r e g n a n c y , e . g .

f u r t h e r e x a m i n a t i o n s , o p e r a t i o n s , o r i n v i t r o f e r t i l i z a t i o n . F ive wo­

men and 6 men s t i l l hoped t o succee d w i th a p r e g n a n cy w i t h o u t any f u r t h e r

med i ca l h e l p . F iv e women and 5 men were c o n s i d e r i n g a d o p t i o n . Only 3 wo­

men and 2 men had r e s i g n e d t h e m s e l v e s t o t h e s i t u a t i o n , b u t a l l o f t h e s e

had a l r e a d y g o t a c h i l d p r i o r t o t h e o p e r a t i o n . Th i s o b s e r v a t i o n i l l u s t ­

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

somet imes hampered by t h e p e r s i s t e n t hope f o r a m i r a c l e ( 8 ) . The d e v e l o p ­

ment o f new t e c h n i q u e s , such as i n v i t r o f e r t i l i z a t i o n can a l s o make i t

n e a r l y i m p o s s i b l e t o succee d w i th t h e a c c e p t a n c e o f pe rm an en t c h i l d l e s s ­

n e s s . The c o u p l e s ' f u t u r e c o n s i d e r a t i o n s co n c e r n i n g s o l u t i o n s o f t h e i n ­

f e r t i l i t y p rob l em showed t h a t a b ou t 70 % had n e i t h e r succeed ed no r t r i e d

t o a t t a i n any s o l u t i o n t o t h e i n f e r t i l i t y p rob l em 2 y e a r s a f t e r u ns ucc es

f u i s u r g i c a l t r e a t m e n t .

I t i s o b v io u s f rom t h e p r e s e n t s t u d y t h a t t h e med i ca l p r o c e d u r e ha s p s y ­

c h o l o g i c a l s i d e e f f e c t s which may p r ovo ke a n x i e t y and i n some c o u p l e s

e x a c e r b a t e t h e bu rden o f i n f e r t i l i t y . S e v e ra l n e g a t i v e e f f e c t s on t h e ma­

r i t a l r e l a t i o n s h i p , s e xu a l l i f e and em o t ion a l s t a t u s were cau sed by t h e

med i ca l management .

THE CRISIS OF INFERTILITY (P ap e r IV)

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

i n f e r t i l e c o u p l e s o v e r a p e r i o d o f 2 y e a r s c an be c l a s s i f i e d i n t e r m s o f

d e p r e s s i o n , g u i l t and i s o l a t i o n . These syndromes a r e p a r t s o f t h e r e a c t i v e

THE CRISIS OF INFERTILITY

p h a s e o f t h e g e n e r a l c r i s i s r e a c t i o n where f o u r main p h a s e s hav e been

i d e n t i f i e d p r e v i o u s l y (17 , 2 1 ) : 1) an i n i t i a l p h a s e ( s ho ck , s u r p r i s e ,

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

30

d e p r e s s i o n , i s o l a t i o n , 3) an a d a p t i v e p h a s e ( a c c e p t a n c e ) , and 4) a r e s o ­

l u t i o n p h a s e ( p l a n n i n g o f f u t u r e s o l u t i o n s ) . The m a j o r i t y o f t h e women

i n t h e p r e s e n t s t u d y were j u d g ed t o be i n t h e r e a c t i v e p h a s e o f t h e

c r i s i s a t t h e f i r s t i n t e r v i e w and many o f them were s t i l l i n t h i s p h a s e

2 y e a r s l a t e r . Thus , i t seems t h a t t h e c r i s i s o f i n f e r t i l i t y d i f f e r s

f r om t h e common t r a u m a t i c c r i s i s where t h e d u r a t i o n o f t h e r e a c t i v e p h a ­

se i s u s u a l l y 6 weeks o r l e s s ( 17 , 21, 5 4 ) . F ig s 2 and 3 i l l u s t r a t e t h e

d i s t r i b u t i o n o f t h e women and men i n t h e f o u r p h a s e s o f t h e c r i s i s r e ­

a c t i o n a t t h e i n t e r v i e w s b e f o r e and 2 y e a r s a f t e r t h e s u r g i c a l t r e a t ­

ment , a c c o r d i n g t o t h e i n v e s t i g a t o r s ' j u d g em en t .

Fig 2 . Distribution of the women in the four phases of the crisis reaction before (n* 3 0 ) and two years a f te r ( n - 2 6 ) the surgical trea tm en t.

I I Before operation100

9 0

8 0

7 0 6 0 5 0

4 0

3 0

20

Two years a f te r the operation *

Initial phase Reactive phase Adaptive phase Resolution phase

* Four women with normal pregnancies following trea tm ent were omitted from the postoperative classification.

Fig 3 . Distribution of the men in the four phases of the crisis reaction before (n = 2 9 ) and two years a f te r (n « 2 4 ) the surgical treatm ent.

%

100 9 0

8 07 0

6 05 0

4 0

3 0

20IO

I I Before operation

ß^Z äT w o years a f te r \Z r///A the operation

Initial phase Reactive phase Adaptive phase Resolution phase No crisis

The r e a c t i o n p a t t e r n o f t h e men seems t o lag f a r be h i n d t h a t o f t h e wo­

men. Most o f t h e men were i n t h e i n i t i a l p h a s e a t t h e f i r s t i n t e r v i e w ,

w h i l e 2 y e a r s l a t e r t h e m a j o r i t y had r e ac h ed t h e r e a c t i v e p h a s e . At bo th

i n t e r v i e w s , 1 /3 o f t h e men had no a p p a r e n t symptom o f a c r i s i s , and n e a r ­

l y a l l o f them had become f a t h e r s p r e v i o u s l y . I t i s r e m a r k a b l e t h a t i n

o n l y 1 /4 o f t h e c a s e s a t t h e f i r s t i n t e r v i e w and i n 1 /3 a t t h e l a s t i n ­

t e r v i e w were t h e ma te s i n t h e same p h a s e . Th i s e a s i l y i nduced m i s u n d e r ­

s t a n d i n g s and p ro b l em s i n t h e m a r i t a l r e l a t i o n s h i p , and q u i t e o f t e n t h e

ma te s needed p r o f e s s i o n a l he lp t o e l u c i d a t e t h e s e c i r c u m s t a n c e s .

D e p re s s i o n

V ar i ous e x p r e s s i o n s o f d e p r e s s i o n we re a common f i n d i n g , bo th b e f o r e and

2 y e a r s a f t e r t u b a l s u r g e r y . Whi l e a few women had long p e r i o d s o f deep

d e p r e s s i o n , s h o r t b u t r e c u r r e n t e p i s o d e s were more common. Two y e a r s a f ­

t e r u n s u c c e s s f u l s u r g e r y , 93 % o f t h e women f e l t d e s p e r a t e , e x t r e m e l y

sad and d i s a p p o i n t e d a t t h e o n s e t o f t h e m e n s t r u a l b l e e d i n g . D e p re s s i o n

co u ld a l s o be p rovo ked by s o c i a l e v e n t s l i k e f a m i l y c e l e b r a t i o n s and

when c l o s e r e l a t i v e s and f r i e n d s had a bab y . Many women s u f f e r e d f rom

g r i e f and d e s p a i r be c a u se o f t h e i r i n v o l u n t a r y c h i l d l e s s n e s s . They be ­

come e m o t i o n a l l y v u l n e r a b l e and were e a s i l y i r r i t a t e d . Mourning was no t

o n l y a b ou t t h e wish f o r a c h i l d t h a t ne v e r seemed t o g e t f u l f i l l e d , b u t

a l s o ab o u t t h e l o s s o f l i f e s t y l e and f u t u r e p r o s p e c t s t h e y had hoped f o r .

Many women e x p r e s s e d t h e i r l o s s o f t h e e x p e r i e n c e o f a p r e g n an cy and t h e

b e a r i n g o f a c h i l d . Two y e a r s a f t e r s u r g i c a l t r e a t m e n t , 2 women r e v e a l e d

t h a t t h e y had had s u i c i d a l t h o u g h t s . A p a r t f rom t h e bu rden o f i n f e r t i l i ­

t y , t h e s e 2 a l s o had an i n c o m p a t i b l e m a r r i a g e and a p r e v i o u s p s y c h i a t ­

r i c an am n e s i s .

A few days a f t e r t h e t u b a l s u r g e r y 10 women had a p o s t o p e r a t i v e s t a t e

o f d e p r e s s i o n , which l a s t e d f o r a few days and f o r a few women i t p e r ­

s i s t e d f o r some weeks . A l though t h e y were c o n t e n t w i th t h e i r improved

p r o s p e c t s o f c o n c e i v i n g , t h e y f e l t s a d , c r i e d and want ed t o be a l o n e .

Nine o f t h e women were p r i m a r i l y i n f e r t i l e and 3 d i v o r c e d l a t e r . The

men had s i g n i f i c a n t l y f e w e r d e p r e s s i v e symptoms t h a n t h e women. However,

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

n i f i c a n t l y (P < 0 . 0 1 ) . Almost a l l c o u p l e s f e l t t h a t i n f e r t i l i t y cou ld

32

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

o f d e p r e s s i o n o f t e n p rovo ke d a n x i e t y , a s t h e y b e l i e v e d i t co u ld r e d u c e

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

Gui I t

Al l t h e women knew a t t h e t i m e o f t h e f i r s t i n t e r v i e w t h a t t h e i r t u b a l

damage was t h e c a u s e o f t h e c o u p l e ' s i n v o l u n t a r y c h i l d l e s s n e s s . H a l f o f

t h e women had s t r o n g f e e l i n g s o f g u i l t and l a ck o f s e l f - c o n f i d e n c e b e ­

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

v i o u s l e g a l a b o r t i o n s , v e n e r e a l i n f e c t i o n s , o r u s e o f c o n t r a c e p t i v e s .

F e e l i n g s o f g u i l t were found t o d i s t u r b t h e r a p p o r t be tween p a r t n e r s .

Only 10 men f e l t t h a t t h e y c o u l d o p e n l y e x p r e s s t h e i r own d i s a p p o i n t m e n t

and g r i e f t o t h e i r p a r t n e r . The o t h e r s u s u a l l y b e l i e v e d t h a t t h i s would

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

avoicëd e x p r e s s i n g t h e i r own f e e l i n g s . During t h e p e r i o d o f t h e p r e s e n t i n ­

v e s t i g a t i o n t h e c o u p l e s had i n c r e a s i n g d i f f i c u l t y i n t a l k i n g o p e n l y a bo u t

t h e i r i n v o l u n t a r y c h i l d l e s s n e s s . Two y e a r s a f t e r t h e o p e r a t i o n , o n l y o ne -

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

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

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

common s p o n t a n e o u s comments we re "Now I have done my p a r t " o r "No one can

b lame me f o r n o t hav ing t r i e d " . Some f e l t more f e m i n i n e and co m p l e t e as

women, and h a l f o f them t h o u g h t t h a t i f t h e c h i l d l e s s s t a t e were t o p e r ­

s i s t , i t would a t l e a s t be somewhat l e s s d i f f i c u l t t o b e a r . I t was a l s o

i m p o r t a n t f o r t h e women t o p r o v e t o t h e i r own p a r e n t s and r e l a t i v e s t h a t

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

I s o l a t i o n

S o c i a l i s o l a t i o n was a l s o common among t h e i n f e r t i l e c o u p l e s . T w o - t h i r d s

o f t h e women and h a l f o f t h e men f e l t b e f o r e t h e t u b a l s u r g e r y t h a t t a l k ­

i ng w i t h o t h e r p e o p l e ab o u t i n f e r t i l i t y was v e r y d i f f i c u l t . I n v o l u n t a r y

c h i l d l e s s n e s s was c o n s i d e r e d a p r i v a t e and d e l i c a t e p rob l e m t h a t nobody

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

t o a v o i d open d i s c u s s i o n s and t o co nc ea l t h e i r p ro b l e m . Some c o u p l e s even

t r i e d t o keep t h e t u b a l s u r g e r y a s e c r e t . They c l a im e d t h a t t h e i r p r e v i o u s

33

e x p e r i e n c e s f rom f r a n k and open d i s c u s s i o n s were m a i n ly u n p r o d u c t i v e .

The g r e a t m a j o r i t y d id no t e x p e r i e n c e any g e n u i n e s u p p o r t o r h e l p f rom

r e l a t i v e s and f r i e n d s . Some d e s c r i b e d how t h e y t r i e d t o f oo l t h e i r

f r i e n d s by p r e t e n d i n g t o be a c t i n g happy and c o n t e n t o r how t h e y a v o i ­

ded s o c i a l g a t h e r i n g s so a s no t t o d i s t u r b t h e c h e e r f u l a t m o s p h e re .

To o n e - t h i r d o f t h e women, mee t i ng o t h e r p e o p l e ' s c h i l d r e n had become

so p a i n f u l t h a t t h e y a c t i v e l y t r i e d t o avo id such s i t u a t i o n s . Meet i ng

p r e g n a n t women was even more bu rdensome, a s r e p o r t e d by 25 women and

12 men a t t h e f i r s t i n t e r v i e w . They f e l t t h a t l i f e had d e a l t u n f a i r l y

w i th them and t h e y f e l t j e a l o u s , g o t a n g ry , s a d , d e p r e s s e d and o f t e n

had s l e e p d i s t u r b a n c e s . F e e l i n g s o f i s o l a t i o n were a l s o a p p a r e n t w i t h -

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

and b e h a v i o u r , and somet imes t ook a q u i t e o p p o s i t e o p i n i o n ab ou t ad op ­

t i o n , how i n f e r t i l i t y had i n f l u e n c e d t h e i r r e l a t i o n s h i p , t h e i r e xpe ­

r i e n c e o f t h e i r m a r r i a g e and s exu a l l i f e . They had i n c r e a s e d d i f f i c u l ­

t y i n f r a n k l y d i s c u s s i n g t h e i r i n f e r t i l i t y p rob l em and t h e i r f e e l i n g s

t o w ard s t h e i r p a r t n e r and t h e i r s exua l l i f e became g r a d u a l l y more n eg a ­

t i v e d u r i n g t h e 2 y e a r s o f t h e s t u d y . H a l f o f t h e women d e s c r i b e d a t

t h e l a s t i n t e r v i e w how t h e y dreamed n e a r l y c o n s t a n t l y and l onge d f o r a

c h i l d , w h i l e t h e men seemed l e s s o cc u p i e d by such t h o u g h t s .

On compar ing t h e syndromes o f d e p r e s s i o n , g u i l t and i s o l a t i o n among

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

and g u i l t seemed t o be r a t h e r s i m i l a r i n t h e two g r o u p s . P r i m a r i l y i n ­

f e r t i l e women, howeve r , t e n d e d t o e x p e r i e n c e more o f t e n i n f e r i o r i t y ,

l a c k o f s e l f - c o n f i d e n c e , s o c i a l i s o l a t i o n and i n s u f f i c i e n t s u p p o r t f rom

r e l a t i v e s and f r i e n d s . On compar ing men who a l r e a d y had a c h i l d w i th

t h o s e who had n o t , t h e g e n e r a l i m p r e s s io n g a i n e d was t h a t d e p r e s s i o n ,

g u i l t and i s o l a t i o n seemed t o be l e s s f r e q u e n t among t h e " f a t h e r s " . The

f e e l i n g o f g r i e f , howeve r , was r a t h e r s i m i l a r in bo th g r o u p s .

The m a j o r i t y o f t h e women seemed t o e x p e r i e n c e bo th a t r a u m a t i c c r i s i s

c au sed by t h e knowledge t h a t t h e i r f a l l o p i a n t u b e s we re d e f e c t i v e , and

a dev e lo pm en t a l c r i s i s c aus ed by t h e i r i n a b i l i t y t o r e p r o d u c e . The men

d i d no t e x p e r i e n c e t h e same k ind o f t r a u m a t i c c r i s i s , s i n c e a l l o f them

34

knew t h a t t h e y were f e r t i l e . They d i d e x p e r i e n c e , howeve r , a d e v e l o p ­

menta l c r i s i s c a use d by t h e i n a b i l i t y t o have a c h i l d w i th t h e i r

s e and by n o t be ing a b l e t o f u l f i l t h e i r e x p e c t a t i o n s and d r ea m s . Thus ,

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

p r o t r a c t e d and r e p e a t e d . F r e q u e n t l y a new e v e n t ( e . g . e c t o p i c p r e g n a n c y ,

m i s c a r r i a g e , a c u t e l a pa r o to m y) would p r e v e n t e d t h e a d a p t a t i o n t o and

r e s o l u t i o n o f t h e p r e v i o u s t r a u m a . T h e r e f o r e , many women r ema ined i n a

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

r a l c h a n g e s , b u t i n some c a s e s t h e r e i s a p r o s p e c t o f p o s i t i v e g rowth and

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

fu l r e s o l u t i o n o f t h e c r i s i s o f i n f e r t i l i t y may mean t h a t c o u p l e s c hoo se

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

c a r e e r and s o c i a l p a r t i c i p a t i o n . O th e r s ch o os e a d o p t i o n i n o r d e r t o

s h a r e t h e i r l o v e w i t h a c h i l d , c o nv in c e d t h a t be in g a p s y c h o l o g i c a l -

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

r e a r i n g .

CHILDWISH ( P a p e r V)

Mot ives o f i n f e r t i l e c o u p l e s

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

a c h i l d . The mos t f r e q u e n t sp o n t a n e o u s answer was " i t i s j u s t a f e e l i n g " .

A few had o b v io u s d i f f i c u l t y i n g i v i n g a more p r e c i s e a n s w e r . A f t e r t h e

f i r s t v a g u e ly e x p r e s s e d answ er , t h e p a r t i c i p a n t s g r a d u a l l y s t a r t e d t o

d e s c r i b e how t h e y f e l t t h a t some th ing was m i s s i n g , t h e y l ove d c h i l d r e n ,

f e l t empty w i t h o u t them and want ed t o have somebody t o l i v e f o r , t h e y

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

c h i l d r e n , i t i s t h e meaning o f l i f e , and i t would be good f o r t h e i r ma­

r i t a l r e l a t i o n s h i p . They t h o u g h t t h a t t h e i r a n x i e t y f o r g e t t i n g o l d a n d /

o r dy ing would be s t i l l e d i f t h e y had c h i l d r e n . Many s a i d t h a t ha v in g

c h i l d r e n " i s t h e meaning o f l i f e " o r t h a t "we d o n ’ t f e e l l i k e a r e a l f a ­

m i ly w i t h o u t c h i l d r e n " . The wi sh t o have a c h i l d o f o n e ' s own " f l e s h and

b lood" which would r e s e m b le t h e m s e l v e s and t h e one t h e y l o v e d , was com­

monly d e s c r i b e d . " C h i l d r e n a r e f un - h a p p i n e s s and c h i l d r e n go t o g e t h e r "

was a l s o v e r y f r e q u e n t l y e x p r e s s e d . Some s a i d t h a t t h e y e x p e r i e n c e d t h e i r

m o t iv e s a s e g o i s t i c - t h e c h i l d would s a t i s f y t h e i r own n e e d s .

35

Those who had g o t a c h i l d p r e v i o u s l y o f t e n d e s c r i b e d how t h e y were t o o

immature when t h e y g o t t h e i r f i r s t c h i l d . They a l s o w i shed t o g e t a

s i b l i n g f o r t h e e a r l i e r c h i l d . Ha l f o f t h e men and t w o - t h i r d s o f t h e wo­

men b e l i e v e d t h a t t h e r e was a d i f f e r e n c e i n c h i l d w i s h be tween men and

women. Almost a l l t h o u g h t t h a t women had a g r e a t e r c h i l d w i s h t h a n men.

The r e a s o n s f o r wanting a c h i l d were comp!ex and i n d i v i d u a l . A p p a r e n t l y

t h e r e a r e no s i m p l e answ er s t o t h e q u e s t i o n o f c h i l d w i s h .

The mos t f r e q u e n t mo t i ve on t h e l i s t among t h e women was t h a t a c h i l d

was " an e x p r e s s i o n o f l o v e be tween man and woman" and f o r t h e men " t o

have somebody t o l i v e f o r " . Two y e a r s a f t e r t h e o p e r a t i o n t h e women men­

t i o n e d t h r e e t i m e s a s o f t e n t h a t a c h i l d i s " t h e meaning o f l i f e " . No

ch an ge s i n m o t iv e s among t h e men were found a t t h e l a s t i n t e r v i e w .

In 20 o u t o f t h e 30 c o u p l e s one spou se gave a t l e a s t one m o t iv e which

was sh a r ed between t h e two. The mos t common e x p e c t a t i o n a b o u t how a c h i l d

would change t h e m s e l v e s was t h a t t h e y would f e e l more "happy and c o n t e n t " .

The c o u p l e s ' s p e c i f i e d answer s f r om t h e open q u e s t i o n and t h e m o t iv e l i s t

m i gh t be c l a s s i f i e d i n t o f o u r g ro u ps a s p h i l o s o p h i c a l , s o c i o - c u l t u r a l ,

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

d i f f i c u l t t o s e p a r a t e f r om one a n o t h e r and t h e r e a r e c o v e r t as wel l as

o v e r t m o t iv e s f o r hav in g a baby and n o t i n f r e q u e n t l y t h e r e i s a c o n f l i c t

be tween t h e s e l e v e l s . To t h e p h i l o s o p h i c a l m o t iv e s m igh t be r e f e r r e d t h e

wish t o make o n e s e l f l i v e f o r e v e r t h r ou gh o n e ' s own c h i l d r e n , i t i s t h e

meaning o f l i f e o r o f God t h a t man sh ou ld r e p r o d u c e h i m s e l f . To s o c i o ­

c u l t u r a l m o t iv e s co u ld be r e f e r r e d t h e wish t o become p r e g n a n t b e c a u s e i t

i s a s o c i a l l y h i g h l y va lu e d f u n c t i o n , i t s a t i s f i e s t h e need o f s o c i e t y

f o r new c i t i z e n s , h a v i n g c h i l d r e n i s a way t o a c h i e v e a s o c i a l p o s i t i o n

f o r bo th men and women i n most c u l t u r e s . To i n t e r p e r s o n a l m o t iv e s c o u l d

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

t i o n s h i p . The c h i l d i s t h e v i s i b l e and c o n c r e t e e x p r e s s i o n o f l o v e be tween

a man and a woman. I t m ig h t a l s o be s een a s a p ro m i s e o f l a s t i n g f a i t h f u l ­

n e s s . To i n t r a p s y c h i c m o t iv e s c o u ld be r e f e r r e d p e r s o n a l , i n d i v i d u a l mo­

t i v e s . To have c h i l d r e n o f o n e ' s own migh t be a c o n f i r m a t i o n o f o n e ' s own

36

s exua l i d e n t i t y , and an e x p e r i e n c e o f and a d e m o n s t r a t i o n o f i n d e p e n ­

de n c e . Through t h e c h i l d t h e r e i s a p o s s i b i l i t y t o r e - e x p e r i e n c e o n e ' s

own c h i l d h o o d and t o i d e n t i f y o n e s e l f w i th o n e ' s p a r e n t s . I f a l l mo­

t i v e s on t h e l i s t were d i v i d e d i n t o g ro up s c o n s i s t i n g o f " p h i l o s o p h i ­

ca l m o t i v e s " , " s o c i o - c u l t u r a l m o t i v e s " , " i n t e r p e r s o n a l m o t i v e s " and

" i n t r a p s y c h i c m o t iv e s " i t i s c l e a r t h a t t h e i n t r a p s y c h i c and i n t e r p e r ­

sona l m o t iv e s c o u ld do mi na t e f o r bo th men and women.

Mot ive s i n r e f e r e n c e g r o u p s

The m o t iv e s among t h e i n f e r t i l e c o u p l e s were compared w i t h t h e m o t iv e s

o f a group o f p r e g n a n t women and t h e i r men, a g roup o f p r e g n a n t women

w i t h o u t t h e i r p a r t n e r and a g roup o f women s e e k i n g l e g a l a b o r t i o n . The

mos t common m o t iv e f o r hav in g a baby i n a l l t h e s e g ro u p s was t h e c o n c e p t

t h a t a c h i l d i s t h e u l t i m a t e e x p r e s s i o n o f l o v e between a man and a wo­

man. The men had a l s o v e r y f r e q u e n t l y t h e i d e a t h a t t h e y wan ted a c h i l d

t o make t h e i r l i f e wor th l i v i n g ( " t o g e t somebody t o l i v e f o r " o r " h a ­

v ing c h i l d r e n i s t h e meaning o f l i f e " ) . I t seems t h a t t h e i n f e r t i l e coup ­

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

g a r d s t h e i r m o t i v e s f o r hav ing a c h i l d . The p r e s e n t i n v e s t i g a t i o n has

e a r l i e r shown t h a t t h e i n f e r t i l e women d i d n o t d i f f e r f r om o t h e r s in

t h e i r p e r s o n a l i t y s t r u c t u r e a s measu red w i th t h e Eysenck P e r s o n a l i t y I n ­

v e n t o r y . T h e i r wish t o have a c h i l d i s p r o b a b l y no more n e u r o t i c t h a n

o t h e r s . The same i s o b v io u s a l s o c o n c e r n i n g t h e i r men.

Adop t ion

The re was g r e a t emphas i s on hav ing a c h i l d o f o n e ' s own f l e s h and b loo d

among t h e p a r t i c i p a n t s i n t h i s s t u d y . As a c o n se qu en ce t h e w i l l i n g n e s s

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

n o t v e r y g r e a t . B e fo re t h e o p e r a t i o n one c o u p l e had ad op t ed a c h i l d and

5 o t h e r c o u p l e s were a t t e m p t i n g t o a d o p t . Two y e a r s l a t e r 2 c o u p l e s had

been s u c c e s s f u l i n a d o p t i n g a c h i l d and 4 c o u p l e s were s t i l l t r y i n g t o

a d o p t . H a l f o f t h e women and o n e - t h i r d o f t h e men were g e n e r a l l y p o s i ­

t i v e t o a d o p t i o n . The g e n e r a l o p i n i o n t ow ard s a d o p t i o n i n t h e group

was somewhat more p o s i t i v e 2 y e a r s a f t e r t h e o p e r a t i o n . The men were g e ­

n e r a l l y l e s s p o s i t i v e t o a d o p t i o n t h a n t h e women.

37

The wish t o have a c h i l d needs t o be s t u d i e d more s y s t e m a t i c a l l y and more

g e n e r a l l y . Knowledge o f t h e m o t iv e s why a p e r s o n / c o u p l e want s c h i l d r e n

m ig h t r e v e a l p o s s i b l e ways t o h e l p them dea l w i t h t h e i r c h i l d l e s s n e s s and1

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

e x a m p l e , i f t h e m o t iv e s a r e m o s t l y i n t r a p s y c h i c i t m igh t be u s e f u l t o f o c u s

on a more e g o s u p p o r t i v e p s y c h o t h e r a p y . I f t h e w i she s a r e more i n t e r p e r s o n a l

i t m i gh t be more r e a s o n a b l e t o work on t h e m a r i t a l r e l a t i o n s h i p . M o t i va ­

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

n e c e s s a r y t o deve lop more v a l i d , r e l i a b l e and s o p h i s t i c a t e d methods t h a n

t h o s e u sed i n t h i s s t u d y .

NEED OF COUNSELLING (P a p e r s I I , I I I and IV)

The p r e s e n t s t u d y c l e a r l y shows t h a t ment a l symptoms and em o t io na l c o n f l i c t s

a r e common among c o u p l e s where a p u r e l y so m a t i c d i a g n o s i s , i . e . o f t u b a l d a ­

mage, ha s been e s t a b l i s h e d . The im p o r t a n c e o f hav ing t h e p o s s i b i l i t y o f p s y ­

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

t i o n and t r e a t m e n t were s t r e s s e d by a l l p a r t i c i p a n t s i n t h i s s t u d y . Th i s has

a l s o been emphas ized p r e v i o u s l y ( 1 1 ) . The v a s t m a j o r i t y o f t h e i n d i v i d u a l s

(26 women and 19 men) a d m i t t e d a t t h e end o f t h i s s t u d y t h a t t h e y would have

a c c e p t e d t h i s he lp i f i t had been o f f e r e d them. The main t o p i c s t h e y w ished

t o r e c e i v e help w i th were : p ro b l em s i n t h e m a r i t a l r e l a t i o n s h i p and s exua l

l i f e , c r i s i s and o t h e r p s y c h o l o g i c a l r e a c t i o n s co n n e c t e d w i th t h e i r i n f e r t i ­

l i t y . Some c o u p l e s a l s o s t r e s s e d t h e i r need o f he lp t o g e t r i d o f t h e i r p e r -

manent a n x i e t y a b o u t su cc ee d i n g w i t h a p r e g n a n c y and t o d i s c u s s a l t e r n a t i v e

s o l u t i o n s t o t h e i r i n v o l u n t a r y c h i l d l e s s n e s s . However, o n l y 20 % o f t h e

i n d i v i d u a l s a g r e ed t o p a r t i c i p a t e i n group s e s s i o n s w i th o t h e r i n f e r t i l e

c o u p l e s .

Medical investigation & trea tm en t withpsychological asocialcounselling

Crisis

infertility

38

The c r i s i s o f i n f e r t i l i t y i s v e r y complex and d i f f i c u l t t o work t h r o ug h

and i n many c a s e s t h e need f o r p r o f e s s i o n a l s u p p o r t was o b v i o u s . Most

o f t h e men f o r i n s t a n c e , had no one b u t t h e i r i n f e r t i l e p a r t n e r t o t a l k

w i th a b o u t t h e i n f e r t i l i t y p r o b l e m . A l though i t s c a u s e was found i n t h e

woman, t h e i n f e r t i l i t y i s a p ro b l em f o r bo th p a r t n e r s and e x e r t s c o n s i ­

d e r a b l e s t r e s s on t h e m a r i t a l r e l a t i o n s h i p . The c o u p l e s ' i n a b i l i t y t o

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

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

Th i s s t u d y ha s shown, howeve r , t h a t t h e p a r t n e r s do n o t a lways s h a r e t h e

same e x p e r i e n c e o f t h e imp ac t o f i n f e r t i l i t y . For exam p le , i n n e a r l y h a l f

o f t h e c o u p l e s t h e man and t h e woman d id n o t e x p e r i e n c e t h e i n f l u e n c e o f

i n f e r t i l i t y on t h e i r m a r i t a l r e l a t i o n s h i p i n t h e same way. Somet imes t h e

ma t e s had c o m p l e t e l y o p p o s i t e e x p e r i e n c e s . The c o u n s e l l i n g sh o u l d t h e r e ­

f o r e be d e s i g n e d f o r bo th t h e i n d i v i d u a l and t h e c o u p l e . Major g o a l s f o r

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

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

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

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

i n an a c u t e p s y c h o l o g i c a l c r i s i s a n d / o r d e p r e s s i o n . I t i s i m p o r t a n t t h a t

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

med i ca l s t a f f . P a t i e n t s sh ou ld f e e l t h a t t h e i r r e a c t i o n s a r e n o t o n l y

a c c e p t e d and t o l e r a t e d , b u t a l s o common and sh a r e d by many o t h e r i n f e r ­

t i l e c o u p l e s . Some g y n e c o l o g i s t s may f e e l t h a t t h e management o f emo­

t i o n s i s n o t t h e i r r e s p o n s i b i l i t y and t h a t t h e i r t a s k i s t o dea l m a i n ly

w i th so m a t i c p r o b l e m s . O th e r g y n e c o l o g i s t s , a l t h o u g h t h e y would l i k e t o

c o n s i d e r t h e who le p s y c h o s o c i a l c o n t e x t , c l a i m t h a t t h e r e i s t o o l i t t l e

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

p r o b l e m s . The r o l e o f t h e p h y s i c i a n i s t o u n d e r s t a n d , t r e a t and c u r e .

When t h e med ica l t r e a t m e n t o f i n f e r t i l i t y f a i l s , t h e c o u p l e and t h e phy ­

s i c i a n bo th become f r u s t r a t e d (56 , 7 7 ) . T h e r e f o r e d u b io u s i n v e s t i g a t i o n s

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

f e r i n g , a r e o f t e n r e p e a t e d . Only when t h e p h y s i c i a n ha s overcome h i s /

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

n ing p r o c e s s ( 34 , 6 0 ) . When a l l t h e r a p e u t i c e f f o r t s have p rove d u n s u c ­

c e s s f u l , many g y n e c o l o g i s t s would p r e f e r t o g i v e f i n a l i n f o r m a t i o n and

39

t o t e r m i n a t e f u r t h e r i n v e s t i g a t i o n s and t r e a t m e n t s . Th is may be r e a s o ­

n a b l e i n mos t c a s e s , i n o r d e r t o s t i m u l a t e a c o n f r o n t a t i o n w i th t h e

e x i s t e n t i a l p rob l em o f i n f e r t i l i t y and t o i n i t i a t e t h e deve lo pm en t o f

a l t e r n a t i v e s o l u t i o n s . However, i t need n o t n e c e s s a r i l y mean t e r m i n a ­

t i o n o f a l l c o n t a c t s w i th t h e i n f e r t i l e c o u p l e , and many o f t h e p a r t i ­

c i p a n t s e x p r e s s e d t h e i r need f o r f u r t h e r c o n t a c t w i th t h e r e s p o n s i b l e

p h y s i c i a n . The p rob l em o f i n f e r t i l i t y demands a h o l i s t i c a p p r o a c h . Body

and mind a r e i n s e p a r a b l e ( 1 0 ) . T h e r e f o r e i n f e r t i l e c o u p l e s d e s e r v e t o

be managed by an a s t u t e and e m p a t h e t i c p h y s i c i a n and a s k i l l e d s o c i a l

and men ta l h e a l t h p r o f e s s i o n a l . A ma j o r goa l o f t h e p s y c h o l o g i c a l mana­

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

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

Ac co rd ing t o t h e p r e s e n t s t u d y , t h e f o l l o w i n g f a c t o r s a r e i m p o r t a n t i n

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

o f t h e medi ca l p r o c e d u r e : t h e i n v e s t i g a t i o n s h ou ld be a s co mp re he n s i v e

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

t i g a t i o n s l i k e BBT r e c o r d i n g s h ou ld be a v o i d e d ; one p h y s i c i a n sh ou ld be

r e s p o n s i b l e and d e v o t e s u f f i c i e n t t im e f o r c o u n s e l l i n g and i n f o r m a t i o n ;

t h e man shou l d be an i n t e g r a t e d p a r t f rom t h e b e g in n i n g and t h r o u g h o u t

t h e i n v e s t i g a t i o n and t r e a t m e n t ; a t h o r o u g h s exu a l anam ne s i s s ho u l d be

t a k e n and d u r i n g t h e s u b s e q u e n t v i s i t s , d i s c u s s i o n s a bo u t t h e s exu a l

l i f e sh ou l d be i n i t i a t e d ; p r o f e s s i o n a l p s y c h o s o c i a l c o u n s e l l i n g sh ou l d

be o f f e r e d t o a l l p a t i e n t s d u r i n g and a f t e r t h e med i ca l p r o c e s s ; t h e

c o u p l e s shou l d have a f o l l o w - u p c o n t a c t w i th t h e r e s p o n s i b l e p h y s i c i a n

ab ou t one y e a r a f t e r t h e t r e a t m e n t p rog ram has been ende d . Moreover , i t

i s i m p o r t a n t t h a t t h e med i ca l s t a f f d e a l i n g w i th i n f e r t i l e c o u p l e s have

an e m p a t h e t i c and u n d e r s t a n d i n g a t t i t u d e . Such a h o l i s t i c app r oac h may

p r e v e n t o r a l l e v i a t e em o t io n a l and p s y c h o l o g i c a l d i s t u r b a n c e s c au se d by

t h e med i ca l i n v e s t i g a t i o n and t r e a t m e n t .

To a l l e v i a t e t h e p s y c h o l o g i c a l t rauma, c a u se d by t h e i n f e r t i l i t y i t s e l f ,

more e x t e n s i v e ch an ge s a r e needed c o n c e r n i n g ou r a t t i t u d e s and a p p r o a ­

ch es t o c h i l d b e a r i n g and p a r e n t i n g . S o c i e t y u s u a l l y r e g a r d s f e r t i l i t y

as s e l f - e v i d e n t and t h e r e i s l i t t l e p r e p a r a t i o n f o r t h e p o s s i b i l i t y o f

i n f e r t i l i t y . I t i s t h e p r e s e n t g e n e r a t i o n ' s r e s p o n s i b i l i t y t o p r e p a r e

t h e c h i l d r e n o f t o d a y w i t h t h e a t t i t u d e o f "v f you have c h i l d r e n . . . . '

r a t h e r t h a n "when you a r e go ing t o have c h i l d r e n . . . . " .

40

CONCLUSIONS

The p s y c h o s o c i a l background and c u r r e n t s o c i a l s i t u a t i o n o f i n f e r ­

t i l e c o u p l e s were q u i t e s i m i l a r t o t h o s e o f t h e r e f e r e n c e g ro u p .

P s y c h i a t r i c a n a m n e s i s , EPI r e s u l t s and t h e r e s u l t o f t h e symptom

c h e c k l i s t show t h a t i n f e r t i l e c o u p l e s n o t seem t o have any t y p i c a l

p e r s o n a l i t y t r a i t s t h a t c l e a r l y d i s t i n g u i s h them f rom o t h e r s . The

menta l symptoms and emo t io na l p rob l ems a p p e a r r a t h e r t o r e f l e c t

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

The c o u p l e ' s m a r i t a l r e l a t i o n s h i p was q u i t e s t a b l e . The impa c t o f

t h e i n f e r t i l i t y , however , o f t e n ca u sed a d e t e r i o r a t i o n i n t h e p a r t ­

n e r s ' f e e l i n g s f o r each o t h e r .

Coupl e s w i th a p r e v i o u s l y s a t i s f a c t o r y s exu a l r e l a t i o n s h i p may

de v e l op a s exu a l d y s f u n c t i o n a s a r e s u l t o f t h e p r e s s u r e and a n x i e ­

t y a r i s i n g f rom t h e i r i n f e r t i l i t y , and a l s o a s a r e s u l t o f t h e me­

d i c a l i n v e s t i g a t i o n and t r e a t m e n t .

The med i ca l i n v e s t i g a t i o n and t r e a t m e n t o f i n f e r t i l i t y ha s p s y c h o ­

l o g i c a l s i d e e f f e c t s which may p rovo ke a n x i e t y and i n some c o u p l e s

even i n c r e a s e t h e bu rden o f i n f e r t i l i t y .

The m a j o r i t y o f t h e c o u p l e s had no s o l u t i o n t o t h e i r i n f e r t i l i t y

p rob l e m 2 y e a r s a f t e r t r e a t m e n t was c o m p l e t e d .

Most o f t h e symptoms among t h e p a r t i c i p a n t s co u ld be c l a s s i f i e d i n

t e r m s o f d e p r e s s i o n , g u i l t , and i s o l a t i o n .

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

s i s ; i t i s more p r o l o n g e d and t h e r e a r e o f t e n r e p e a t e d c r i s i s

r e a c t i o n s .

41

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

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

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

a r e needed d u r i n g and a f t e r t h e med i ca l i n v e s t i g a t i o n and t r e a t ­

men t .

The i n f e r t i l e c o u p l e s 1 m o t iv e s t o hav ing a baby do n o t d i f f e r

f r om t h o s e o f t h e r e f e r e n c e g r o u p s . The most common m o t iv e i s

t h a t a baby i s t h e u l t i m a t e e x p r e s s i o n o f l o v e between a man

and a woman.

GENERAL SUMMARY

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

r e s p e c t t o p s y c h o l o g i c a l and s o c i a l back g ro un d , c u r r e n t l i f e s i t u a t i o n ,

n e u r o t i c i s m o r p e r s o n a l i t y c h a r a c t e r i s t i c s when compared w i th a p p a r e n t l y

normal r e f e r e n c e g r o u p s . The p a r t i c i p a n t s ' p e r s o n a l i t y c h a r a c t e r i s t i e s

a s r e g a r d s n e u r o t i c i s m and e x t r o v e r s i o n d i d no t chang e d u r i n g t h e i n v e s ­

t i g a t i o n p e r i o d o f 2 y e a r s .

The emo t iona l and s o c i a l impac t o f t h e i n f e r t i l i t y was i n v e s t i g a t e d , and

s e v e r a l d e l e t e r i o u s em o t io n a l and s o c i a l e f f e c t s were found bo th b e f o r e

and 2 y e a r s a f t e r t h e s u r g i c a l t r e a t m e n t . G r i e f , d e p r e s s i o n , g u i l t , f e e ­

l i n g s o f i n f e r i o r i t y and i s o l a t i o n were commonly r e p o r t e d . P r e g n a n t wo­

men and o t h e r p e o p l e s ' c h i l d r e n o f t e n evoked n e g a t i v e f e e l i n g s . The wo­

men a d m i t t e d t o s u f f e r i n g such e f f e c t s more f r e q u e n t l y t h a n t h e men.

The p a r t n e r s ' f e e l i n g s f o r each o t h e r were g e t t i n g wor se 2 y e a r s a f t e r t h e

o p e r a t i o n . The re was a l s o a t e n d e n c y t o a d e t e r i o r a t i o n i n o p i n i o n s a bo u t

m a r i t a l r e l a t i o n s h i p s , b u t no s t a t i s t i c a l l y s i g n i f i c a n t change co u ld be

fo u n d . At t h e f i n a l i n t e r v i e w t h e women r e p o r t e d a d e t e r i o r a t i o n o f

s exua l l i f e and t h e men found t h a t t h e m a r i t a l r e l a t i o n s h i p was s u f f e ­

r i n g i n c r e a s i n g l y due t o t h e f e r t i l i t y p ro b l em . N e g a t i v e e f f e c t s on t h e

c o u p l e s ' s exua l l i f e we re r e p o r t e d by a l l i n d i v i d u a l s and were o f t e n a s ­

s o c i a t e d w i th t h e p l a n n i n g o f i n t e r c o u r s e . Semen a n a l y s i s was p s y c h o l o ­

g i c a l l y u p s e t t i n g and f e e l i n g s o f shame and d e g r a d a t i o n were common.

F ea r and a n x i e t y were i n c r e a s e d b e f o r e r e c o n s t r u c t i v e t u b a l s u r g e r y and

p o s t o p e r a t i v e d e p r e s s i o n was o b s e r v e d . Most c o u p l e s o v e r e s t i m a t e d t h e i r

ch an ce s o f c o n c e i v i n g . The med ica l i n v e s t i g a t i o n and s u r g i c a l t r e a t m e n t

o f i n f e r t i l i t y i n f l u e n c e d t h e c o u p l e ' s mutual r e l a t i o n s h i p and s exua l

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

depend n o t o n l y on t h e i n f e r t i l i t y i t s e l f , b u t a l s o on t h e l o n g l a s t i n g

and t i me -c on sum in g i n v e s t i g a t i o n and t r e a t m e n t p r o c e s s .

Most o f t h e symptoms r e c o r d e d i n t h i s l o n g i t u d i n a l s t u d y c o u l d be c l a s ­

s i f i e d i n t e rm s o f d e p r e s s i o n , g u i l t and i s o l a t i o n . These syndromes a r e

p a r t s o f t h e r e a c t i v e p h a s e o f t h e common c r i s i s p a t t e r n . G e n e r a l l y

43

sp e a k i n g t h e women s u f f e r e d more and more s e v e r e d e p r e s s i v e symptoms

t h a n t h e men. F e e l i n g s o f g u i l t were a l s o more common among t h e women.

R e l a t i v e s and f r i e n d s d i d no t g i v e g e n u i n e s u p p o r t , a c c o r d i n g t o t h e

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

l onge d and i n h i b i t i n g , e s p e c i a l l y among t h e women. Most o f t h e i n f e r ­

t i l e c o u p l e s had d i f f i c u l t y i n working t h e i r way t h r o u g h and f i n d i n g

a s o l u t i o n t o t h e c r i s i s o f i n f e r t i l i t y by t h e i r own means . Most o f

t h e women were found t o be i n t h e r e a c t i v e p h as e o f t h e i r c r i s i s and

many were s t i l l i n t h i s p h as e 2 y e a r s o r more l a t e r . At t h e l a s t i n ­

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

o n e - t h i r d o f them s t i l l had no a p p a r e n t symptoms o f any c r i s i s r e a c t i o n .

The i n t r a p s y c h i c and i n t e r p e r s o n a l m o t iv e s o f w an t i n g a c h i l d were d o ­

mi na n t among b o t h t h e women and t h e i r men. A c e n t r a l m o t i ve was t h a t a

c h i l d i s an u l t i m a t e e x p r e s s i o n o f l o v e be tween a man and a woman. The

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

t h e r e f e r e n c e g r o u p s . I t would seem t h a t t h e c h i l d w i s h i n i n f e r t i l e

c o u p l e s i s no more n e u r o t i c t h a n i n o t h e r s .

The im p o r t a n c e o f hav ing t h e p o s s i b i l i t y o f p r o f e s s i o n a l p s y c h o s o c i a l

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

were s t r e s s e d by a l l p a r t i c i p a n t s i n t h i s s t u d y . A l though t h e c a u s e

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

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

44

ACKNOWLEDGEMENTS

I wish t o e x p r e s s my s i n c e r e g r a t i t u d e t o a l l t h o s e who made t h i s work

p o s s i b l e and i n p a r t i c u l a r t o :

THE INFERTILE COUPLES who p a r t i c i p a t e d i n t h e s t u d y , f o r r e v e a l i n g a

p a r t o f t h e i r mos t i n t i m a t e t h o u g h t s and e x p e r i e n c e s . W i thou t t h e i r

c o - o p e r a t i o n and i n t e r e s t t h i s s t u d y would have been i m p o s s i b l e .

LARS JACOBSSON, P r o f e s s o r a t t h e Depar tmen t o f P s y c h i a t r y and

BO von SCHOULTZ, A s s o c i a t e P r o f e s s o r a t t h e Depar tment o f O b s t e t r i c s

and Gy neco logy , my t e a c h e r s and s u p e r v i s o r s f o r t h e i r v a l u a b l e s u p ­

p o r t and i n t e r e s t . I w i l l a lways remember o u r f r u i t f u l d i s c u s s i o n s

a round t h e k i t c h e n t a b l e ;

INGEMAR JOELSSON, P r o f e s s o r a t t h e Depar tment o f O b s t e t r i c s and Gyne­

c o l o g y , f o r h i s p o s i t i v e c r i t i c i s m and v a l u a b l e s u p p o r t ;

MARTIN EISEMANN, D. Med. S c i . , f o r s t i m u l a t i n g d i s c u s s i o n s and s k i l f u l

a s s i s t a n c e w i th t h e s t a t i s t i c a l a n a l y s i s ;

BENGT-ÄKE ARMELIUS, A s s o c i a t e P r o f e s s o r , f o r e x p e r t a d v i c e w i th t h e

a n a l y s i s o f t h e Eysenck P e r s o n a l i t y I n v e n t o r y ;

MARGARETHA LINDH, f o r e x c e l l e n t s e c r e t a r i a l a s s i s t a n c e and g en e r o u s

h e lp t h r o u g h o u t t h e y e a r s ;

MARGARETHA BERGSTEN, f o r s k i l f u l s e c r e t a r i a l a s s i s t a n c e ;

BIRGITTA HAMMARSTRÖM, B . S c . , f r om t h e U n i v e r s i t y Computer C e n t r e ,

f o r p r o f e s s i o n a l comp u te r work;

COLLEAGUES and STAFF a t t h e Depa r tmen t o f O b s t e t r i c s and Gyneco logy ,

f o r t h e i r c h e e r f u l s u p p o r t d u r i n g workaday l i f e ;

45

MARIA and SOFIA, f o r t h e i r h a p p i n e s s and l o v e which made me u n d e r s t a n d

a l o t ab ou t t h e e x i s t e n t i a l q u e s t i o n o f t h e c h i l d w i s h .

L a s t , bu t n o t l e a s t , some words t o yo u , OTHON. B e s id e s s k i l f u l g u i ­

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

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

word o f c o m p l a i n t . You have f u l l y u n d e r s t o o d my d e s i r e t o go on w i th

my work. I w i l l a lways be g r a t e f u l t o you .

Thi s s t u d y was s u p p o r t e d by g r a n t s and s c h o l a r s h i p s f r om t h e F a c u l t y o f

M e d i c in e , Umeå U n i v e r s i t y .

46

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P sycho l Worn Q 1 9 7 9 ; 4 : 9 7 - 1 1 3 .

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JAMA 1 98 3 ; 25 0 : 23 27 -2 33 1 .

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