The inability to have children strikes at the heart of a man's masculinity and can give rise to feelings of failure and guilt, writes Michael Kelly
MUCH HAS been written about in-vitro fertilization (IVF) and the tremendous physical and emotional burden it puts on women.
But because the cause of infertility can be attributed at least partly to the male partner in about 50 per cent of cases, it means that these highly invasive treatments are essentially used as a way of 'treating' male fertility impairments.
Understandably perhaps, given what the female partner has to go through, there is typically very little discussion about the emotional impact of treatment on the male.
This impact may be particularly acute in male-factor infertility where a man may feel his partner has to undertake an intensely difficult treatment regime to address a problem for which he feels responsible.
"Fertility treatment by its nature focuses on the female," says Róisín Venables, a counsellor at the HARI unit in the Rotunda Hospital.
"In some incidences, for example where there is a very low sperm count or no sperm at all, men may need to have a procedure to extract sperm. But by and large, fertility treatment is a woman's thing.
"It's one of the things I say a lot to women - that the spotlight is on them because they have a uterus and ovaries. Certainly where there is male factor there are men who find that hard to deal with."
Apart from initial examinations to determine the cause of infertility, male involvement in treatment is limited to a supportive, almost observational role. In terms of physical procedures, the man is required to provide semen samples - while this may be an embarrassing ordeal for some men, it still represents a marginal involvement when compared to the battery of invasive physical procedures, scans, blood tests and injections which the woman has to face.
Playing a supporting role is difficult psychological territory for men, according to Dr David Walsh, director and consultant gynaecologist at the Sims International Fertility Clinic, particularly since the typical male response to a problem is to "do something" about it.
"They can certainly feel left out of it and semi-detached. A lot of men will deal with this very well and be very supportive for their partners. In some cases though, particularly if they perceive themselves to be the problem, they can either go in on themselves or become very aggressive to the point of being unpleasant with staff."
Before and during fertility treatment, both partners are likely to experience a common set of emotions such as depression, despair, anger and frustration. In addition, each partner typically has to deal with emotions which are gender-specific.
For men, the inability to have children strikes at the heart of their masculinity and can therefore manifest itself in feelings of inadequacy, failure, guilt and lack of control.
In that context, and given the fact that men are notoriously uncomfortable consulting physicians on health issues in general, it is not surprising that attending a fertility clinic is a deeply daunting prospect for many men.
Women make the initial contact with a fertility clinic in approximately 70 per cent of cases and it is common for them to undergo a full range of preliminary fertility tests (eg hormone, ovulatory function, and fallopian tube examinations) before the male partner has even had a simple semen analysis.
"The thing that strikes you is that at meetings, the woman almost always sits in the chair that's closest to you," according to Walsh.
"They are the locus of control in the decision and the men are there in a supporting role. The men don't want to engage with me typically," he says.
"I would say that in less than 5 per cent of cases do you see a reversal of those roles. In some cases the men are definitely there under duress and in others the men don't come at all which puts the women in an impossible position."
While the attendance of both partners at appointments is recommended, men often absent themselves from the more "routine" visits during the treatment cycle.
According to Venables, women often attend day-to-day procedures like scans and blood tests alone, often for very practical reasons (for instance, the man might not be able to get the time off work).
"The men have to be 100 per cent on board. If we suspect that a couple are not on the same page we will help them get through that and sometimes that means deferring treatment until they are. For example, if one partner wants more treatment and the other doesn't, that is a huge thing."
Feedback from male partners in post-treatment studies highlights the fact that fertility clinics can compound the sense of detachment for men by leaving them sitting in reception while the female partner is receiving treatment.
"Absolutely, I think that can happen in fertility clinics and I am sure it happens here too," says Venables.
"In a busy clinic there are time issues and space considerations and, in some cases, there are privacy considerations for the woman. That can of course contribute to men asking themselves, 'why the hell am I here?'"
There are different attitudes, she says, among men with regard to the provision of a semen sample.
"It is deeply embarrassing for some men. There could be 10 or 12 people in the reception area, everyone knows where the sample room is and the man has to come back out carrying the sample with him," she says.
"Some men are not in the least embarrassed by that and others are literally trembling. In some cases they can't produce at all. I think for most it becomes quite clinical, a means to an end."
While women will typically have a network of people they can discuss their feelings with during treatment, men are notoriously reluctant to share such complex emotional problems. Involving men in pre- and post-treatment counselling is therefore vital, according to Venables, to give them a forum to air their views.
"I think men can be hugely frustrated and feel helpless because they can't do more," she says.
"But we always remind men that they are absolutely crucial to the process - you cannot have a process without them. I often say to men that they could provide a supporting role by cooking and cleaning at home. That usually gets a laugh but in some ways it's a serious thing - women have babies because men are there to help them. They provide emotional, financial and practical support - it's no different in a treatment cycle."
The good news in all this is that 30-40 per cent of couples who undergo IVF treatment in Ireland have a successful outcome.
"Regardless of outcome, it is a shared problem which brings most couples even closer than they were," says Walsh.
"I think if a couple can come through fertility treatment together it is a huge testament to the strength of their relationship. It means that they can cope with anything."
Understanding men's relunctance to talk about fertility issues
Men are reluctant to discuss infertility and account for only 15 per cent of callers to the National Infertility Support and Information Group, according to the group's chairwoman, Helen Browne. The group posted a notice on its website and e-mailed members requesting men to get in contact in relation to this article for example, without response.
"Even when men do call the helpline, they are doing so on behalf of their partners and not for themselves," she says.
"It could be that their partner is not feeling well and the men are ringing to check with us whether it is serious enough for them to contact the clinic."
The situation is slightly different, she says, with their bi-monthly support group meetings in Cork and Dublin where it is roughly 60/40 women and men. "I think the women persuade men to come along for the first meeting, but they don't tend to come along after that. When they do come, the men are on the quiet side."
In cases where there is male factor infertility or where the infertility is unexplained, women often tell the group that the problem is with them, even though Browne might be aware that this is not the case.
"They are trying to protect the man I think. The difficulty is that men feel that they are expected to carry on the family tree by having biological children. Their masculinity is tied up in fertility."
While men are reluctant to call the helpline, many women will call worried about their partner.
"They will tell me that he's finding it difficult to cope. When their masculinity is thrown in to question, many men will react by overcompensating - they throw themselves in to work or in to hobbies.
"In some cases the woman will tell us that a partner who is never angry is suddenly losing his cool a lot.
"I think it is difficult for men to express their emotions anyway, but during the treatment they don't want to get in to it, because they see what their partner is going through and they want to be strong for them."
• NISIG Support Line - 1890 647 444 (Monday to Friday, 7.15pm- 9.15pm)