The psychological influence of gender infertility diagnoses among men about to start IVF or ICSI treatment using their own sperm

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1 Human Reproduction Vol.22, No.9 pp , 2007 Advance Access publication on June 27, 2007 doi: /humrep/dem189 The psychological influence of gender infertility diagnoses among men about to start IVF or ICSI treatment using their own sperm H. Holter 1,3, L. Anderheim 1, C. Bergh 1 and A. Möller 2 1 Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital/Sahlgrenska, Institution of Clinical Sciences, Göteborg University, SE Göteborg, Sweden; 2 Nordic School of Public Health, PO Box 12133, SE Göteborg, Sweden 3 Correspondence address. Tel: þ ; Fax: þ ; herborg.holter@vgregion.se BACKGROUND: The aim of the present study was to investigate the psychological influence of gender infertility diagnoses among men in couples about to start their first IVF or ICSI treatment. METHODS: The study was a part of a prospective study of 65 men with male infertility diagnosis and 101 men in couples with female, mixed and unexplained infertility diagnoses. Of the 200 men invited, 166 agreed to participate (83% response rate). The men answered questionnaires concerning psychological and social factors on three occasions, at the information meeting held 2 4 weeks prior to first treatment, 1 h before oocyte retrieval and 2 weeks after the pregnancy test. RESULTS: The main findings of this study gave no indication that male infertility influenced men negatively concerning their experience of infertility, view of life and relationships and psychological well-being. We found that men with a male factor infertility diagnosis reacted in a similar way as compared with men in couples where the diagnosis was female, mixed or unexplained infertility. CONCLUSIONS: In general, men are well adjusted with regard to a first IVF/ICSI treatment cycle, independent of gender infertility diagnoses. Keywords: infertility; male factor; men; IVF/ICSI; psychological well-being Introduction The development of the intracytoplasmic sperm injection (ICSI) technique in the early 1990s (see Palermo et al., 1992) represented a major step forward in enabling infertile men to father a biological child. Before the introduction of ICSI, several studies indicated that men with male infertility experienced more negative emotional responses than did men in couples with female, mixed or unknown infertility. Nachtigall et al. (1992) found that men with male infertility experienced perceived loss of physical potency and poor self-esteem and feelings of stigma. Connolly et al. (1987, 1992) found elevated distress in cases of male infertility and assumed that male infertility could create particular difficulties for the couple. Glover et al. (1994) reported high anxiety levels before the first consultation at a male sub-fertility clinic and concluded that the patients experienced a high level of psychological distress. Results from more recent studies, after the introduction of ICSI, found less psychological distress in relation to male infertility. Pook et al. (2002) and Pook and Krause (2005) found no impact of infertility diagnoses on distress scores either among men attending an andrological clinic for fertility workup or at follow up some months later. Nor did Dhillon et al. (2000) find any difference in psychological well-being and coping between fertile men with currently pregnant wives and men with unexplained or male infertility in couples undergoing insemination. When studying men undergoing their first IVF or ICSI treatment with daily monitoring, Boivin et al. (1998a) found, in a small study, that the mens psychological reactions were similar except that the ICSI patients showed marginally more anticipatory anxiety on the days prior to oocyte retrieval, possibly attributable to the uncertainty of fertilization. Studies comparing women and men have found women react more strongly overall (Beaurepaire et al., 1994; Boivin et al., 1998b; Hjelmstedt et al., 1999; Verhaak et al., 2005; Holter et al., 2006). Kowalcek et al. (2001) found that men with male infertility activate coping strategies less often than men with idiophatic, female or mixed infertility, but concluded that gender and role expectations can make the women become the sole sufferers in the context of this type of treatment. Newton et al. (1999) reported higher global stress and more social and sexual concern in both men and women in couples with male infertility than in couples with female infertility, # The Author Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please journals.permissions@oxfordjournals.org 2559

2 Holter et al. but also that women experienced greater global stress overall than men. In a study from Taiwan, Lee et al. (2001) compared infertility distress, marital and sexual satisfaction among husbands and wives related to gender infertility diagnoses. No differences were noted among husbands regardless of male or female diagnosis, but they found higher distress among wives with female infertility. However, some studies in this field suggest that mens experiences of infertility are connected to threats to their masculinity, potency and manhood as well as feelings of role failure (Nachtigall et al., 1992; Mahlstedt, 1994; Edelmann et al., 1994), and Glover et al. (1998) propose: That subfertile men are anxious suggests that their experience is perceived more in terms of threat than loss (p. 1406). These views may depend on socially constructed gender roles as well as biological reality. Gannon et al. (2004) investigated media reports concerning male infertility and found that the media construct stereotypical masculinity and male infertility is conflated with impotence. It might thus be anticipated that even after the use of ICSI, male factor infertility could influence mens psychological well-being and experience of infertility. Although most psychosocial infertility studies include both partners, few studies in this field actually focus on mens experience of infertility and treatment. In this study, we concentrate on men in couples about to start their first IVF/ICSI treatment. The aim of the study was to investigate whether a male infertility diagnosis had any influence on their experience of infertility, view of life, relationships, self-image and psychological well-being as compared with men in couples where the diagnosis was female, mixed or unexplained infertility. Information was gathered before and during treatment and after the result of the pregnancy test, whether positive or not. Materials and Methods Design This study was part of a larger, prospective, longitudinal study in which couples, both men and women, were followed during their first IVF treatment by means of questionnaires administered on three occasions, before, during and after treatment. The patients were recruited between March 1999 and June 2002 at the Reproductive Unit, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Sweden. The study was approved by the Ethics Committee of Göteborg University. Procedure All patients scheduled to start their first IVF or ICSI treatment received written information about the study a week before the introduction and information group meeting, which was held 2 4 weeks prior to the first treatment. Exclusion criteria were inadequate fluency in the Swedish language and participation in other studies. At the information meeting, people who were interested in participating in the study were asked to stay and answer the first questionnaire. Of the 200 couples invited, 166 agreed to participate (83% 2560 participation rate). Reasons for not participating included lack of time and lack of interest. The second questionnaire was given to the couples to fill in about 1 h before oocyte retrieval, and the third questionnaire was sent by mail in a stamped, pre-addressed envelope 2 weeks after the result of the pregnancy test. Each spouse was asked to answer the questionnaire separately without communicating with her or his partner. In this paper, we only present the results for men. Participants A total of 166 men participated in the study, 65 men diagnosed with a male infertility and 101 men in couples with female, mixed or unexplained infertility. Patient characteristics are given in Table 1. No significant differences were observed between the groups. No individual in either group had children in their current relationship. Three men in the male infertility group and two men in the female/mixed/unknown infertility group had undergone previous IVF treatment at other clinics. Eight men in the male infertility group and 10 men in the female/mixed/unknown infertility group had present physical diseases i.e. asthma, epilepsy, gastrointestinal disorders and hypertension. Two men in the male infertility group and four men in the female/mixed/unknown infertility group had an ongoing psychological condition i.e. depression and anxiety disorders. The pregnancy rate after the first treatment cycle was 36.9% in the male factor group and 33.7% in the female/mixed factors group (Table 1). Measurements The Psychological General Well-Being index Psychological well-being during recent weeks before entering the study was measured using the Psychological General Well-Being index (PGWB) (Dupuy, 1984). The PGWB contains 22 items divided into 6 sub-scales: anxiety, depressed mood, positive wellbeing, self-control, general health and vitality. The index scores can be totaled to form a global overall score, and the scores can be divided into these six dimensions. Each item is ranked 1 6, and the higher the value, the greater the well-being. Norm values from the Swedish population matched for age and gender are available (Dimenäs et al., 1996). The PGWB has shown satisfactory reliability and validity (Dupuy, 1984; Wiklund et al., 1995). The difference between the ideal life and the real-life situation The accord between wanted and actually life situation was measured using seven items concerning the mans perceptions of the correspondence between how he wanted his life to be and how he thought it was in terms of work, leisure time, contact with friends and family, relationship with partner, sex life and life in general. Visual analogue scale 0 10 was used: 0 ¼ very good accord and 10 ¼ no accord. Optimism versus pessimism Optimism was captured using two questions: (i) what do you think will be the results of the treatment you are about to start? and (ii) how do you describe yourself as an optimist or a pessimist? Visual analogue scale 0 10 was used: 10 ¼ absolutely optimistic and 0 ¼ absolutely pessimistic. The meaning of reproduction The perception of the point of reproduction was estimated using six items covering aspects of self-imagine, meaningfulness and affinity (Möller and Fällström, 1991). Visual analogue scale 0 10 was used: 0 ¼ no, not at all and 10 ¼ yes, much.

3 Psychological effect of male infertility diagnosis Table 1: Demographic information and treatment outcome for men with a diagnosis of male factor infertility and men in couples with other infertility diagnoses (female, mixed and unexplained factors) Male factors Age (years) Mean SD Range Diagnostic category of infertility Male factor n ¼ 65 Female factor n ¼ 58 Mixed factors n ¼ 24 Unexplained n ¼ 19 Duration of infertility (years) Mean SD Range Waiting time for treatment (months) Mean SD Range Previous treatments at n ¼ 3 n ¼ 2 other clinics Children Previous relationship n ¼ 6 n ¼ Current relationship n ¼ 0 n ¼ 0 Education, n (%) Primary education 6 (9.2) 11 (10.9) Secondary education 47 (72.3) 59 (58.4) College/university 12 (18.5) 31 (30.7) Occupation, n (%) Working 60 (92.3) 92 (91.1) Full-time job 59 (90.8) 87 (86.1) Part-time job 0 (0.0) 5 (5.0) Studying 2 (3.1) 4 (4.0) Unemployed 3 (4.6) 4 (4.0) Disability pension 0 (0.0) 1 (1.0) Residence, n (%) Urban area 38 (58.5) 71 (70.3) Suburban or rural area 27 (41.5) 30 (29.7) Health, n (%) Previous physical disease/illness 11 (16.9) 8 (7.9) Previous mental 2 (3.1) 4 (4.0) disease/illness Present physical 8 (12.3) 10 (9.9) disease/illness Present mental 2 (3.1) 4 (4.0) disease/illnes Treatment, n (%) IVF 10 (15.4) 63 (62.4),0.000 ICSI 55 (84.6) 38 (37.6),0.000 Embryo transfer, n (%) 58 (89.2) 81 (80.2) Clinical pregnancy per started cycle, n (%) 24 (36.9) 34 (33.7) The influence of family and friends attitudes towards the childlessness The impact of the intimates was evaluated using four questions e.g. How important do you think it is for your parents that you have children? and How much are you influenced by your parents attitudes? Visual analogue scale 0 10 was used: 0 ¼ not at all and 10 ¼ very much. Psychological effects of infertility were measured using 14 items (guilt, success, anger, contentment, frustration, happiness, isolation, confidence, anxiety, satisfaction, depression, powerlessness, competence and control) (Edelmann and Connolly, 1998; Anderheim et al., 2005; Holter et al. 2006). These items seek to capture aspects of experiences often expressed by infertility patients. The items were formulated as questions like To what extent have you had the following feelings the last few days: guilt, success, etc.? These items are both summarized and analysed separately. Each item was graded 1 5. Low values indicate greater well-being. Relationship with partner The respondent s relationship with his or her partner was evaluated by means of two questions: Do you feel that childlessness has caused problems in your marriage? and Is talking to each other more difficult now than it was before infertility became an issue? These items were also graded 1 5 (1 ¼ not at all, 5 ¼ very much). Professional support The need for professional support was covered by two questions: (i) have you ever had contact with a psychologist or other professional counsellor to talk about the strain of childlessness? and (ii) if not, do you think such contact would have been valuable? Only PGWB has been tested in a strict psychometric way. The other questions have good face validity, are based on experience from clinical practice and research and have good discrimination capacity. Data analyses In the results, we present two groups: (i) men with male factor infertility and (ii) men in couples with all other infertility diagnoses, because when we analysed male factor against separate female, mixed and, we did not find any differences. Means, standard deviations, medians and ranges were used for descriptive statistics. Mann Whitney U test was used for group comparisons of continuous and ordinal scale variables. Interaction between groups and time were performed with Mann Whitney U-test. A sample size calculation was performed according to the following: Assuming a mean score of 30.0 and with a SD of 8.0 in Psychological effects of infertility in the female/mixed factor group, it was possible to detect a difference in score of 4.0 if 64 patients in each group were included (b-level 0.20, a-level 0.05). Assuming a mean score of and a SD of 12.0 in PGWB in the female/mixed factor group, it was possible to detect a difference in score of 6.0 if 64 patients in each group were included (b-level 0.20, a-level 0.05). A linear multiple regression analysis was performed on the dependent variable. The following variables were tested for independence: age, infertility factor diagnoses, duration of infertility, waiting time for treatment, previous children, work, college/university education, residence, physical and psychological health, sum PGWB, the six items estimating the meaning of reproduction, the four questions covering the influence of family and friends and the seven items measuring the differences between the ideal life and the real-life situation. All tests were two-sided and a,0.05 was considered significant. SPSS software (version 12.0) and SAS software (version 8.2) were used. Results Before treatment Psychological well-being measured using PGWB indicated good psychological health for both men in the male infertility group and men in the female/mixed/unknown infertility 2561

4 Holter et al. group, with values comparable with Swedish reference values (Dimenäs et al., 1996). There were no significant differences between men in the two groups concerning depressed mood, anxiety, positive well-being, self-control, general health or vitality before treatment (Table 2). The difference between the ideal life and the real-life situation Men in both groups found quite good accord between how they wanted life to be and how it actually was concerning work, leisure time, contact with friends and relatives, sex life and life in general (Table 3). A significant difference was found concerning contact with friends and acquaintances. Men in the male infertility group reported significantly less accord between ideal life and real life (P ¼ ) concerning contact with friends and acquaintances as compared with men in the female/mixed/unknown infertility group. Men in both groups reported good accord to their desires concerning the relationship with their partner (Table 3). Optimism versus pessimism There was no significant difference between the male infertility group and the female/mixed/unknown infertility group regarding optimism versus pessimism. Both groups reported quite optimistic answers to the two questions used; the mean was around 8 on VAS scale The meaning of reproduction Questions related to experiences of infertility proved no differences between the two groups of men. There were no differences between men with and without male infertility diagnosis concerning what they perceived as the point of reproduction (Table 4). Men in both groups stressed the need for a child to feel happiness, to experience life as meaningful and to have goals in life fulfilled. The mean values for these were on a visual analogue scale The mens need to have a child to feel like a man among men was graded by all the men as The influence of family and friends attitudes towards the childlessness Both groups reported that parents, parents-in-law, relatives and friends had very little influence on their attitude towards Table 3: Differences between the ideal life and the real-life situation Do you find good accord between how you want your life to be and how it actually is concerning... Work 4.1 (2.9) 3.3 (2.5) Leisure time 3.4 (2.6) 2.7 (2.1) Contact with friends 4.1 (2.4) 3.2 (2.4) and acquaintances Contact with relatives 3.9 (2.8) 3.5 (2.3) Relation in general 1.4 (1.6) 1.5 (1.5) with your partner Your sex life 2.7 (2.3) 2.5 (2.4) Your life in general 2.4 (1.8) 2.4 (2.0) Visual analogue scale 0 10, where 10 ¼ no accord and 0 ¼ very good accord. Values are means, standard deviations and s. childlessness. However, the men in both groups rated the importance to their parents that they had children as high, mean 6.6 (2.8) in the male infertility group and 6.1 (2.8) in the female/mixed/unknown infertility group (Table 5). No significant differences were found between the groups when analysing the 14 items measuring the psychological effects of infertility. The mean scores in both groups were low, indicating high levels of well-being (Table 6). Relationship with partner On questions related to childlessness and possible problems in the relationship, including communication difficulties, both groups indicated that they had very few problems. The participants relationships with their partner was measured by answers on a scale of 1 (not at all) to 5 (very much) to two questions. Both groups had a mean value of 1.9 (1.0 SD in male infertility group and 0.9 SD in the female/ mixed/unknown infertility group) to the question: do you feel that childlessness has caused problems in your marriage?. For the question: Is talking to each other more difficult now than before infertility became an issue? the mean value was 1.3 (0.8 SD) in the male infertility group and 1.2 (0.6 SD) in the female/mixed/unknown infertility group (NS). Table 2: General psychological well-being as evaluated with PGWB Graded 1 6 Table 4: Meaning of reproduction covering aspects of self-image, meaningfulness and affinity Total score (12.5) (11.5) Depressed mood 16.4 (2.0) 16.4 (1.8) Anxiety 23.9 (3.7) 23.3 (3.7) Positive well-being 17.4 (3.2) 17.7 (2.6) Self-control 15.6 (2.0) 15.7 (1.8) General health 16.1 (1.9) 16.1 (2.2) Vitality 17.4 (2.8) 17.5 (3.0) High score indicates high levels of well-being. Values are means, standard deviations and s. (Possible range of total score ) Do you feel you must have children to be able to feel... Satisfied with your self? 4.0 (3.2) 4.7 (3.2) Life is meaningful 5.4 (2.8) 5.9 (3.0) Your goals in life are 5.3 (3.2) 5.9 (3.0) fulfilled Like a man among men 3.9 (3.2) 4.4 (3.4) Happy 5.9 (2.9) 6.1 (3.2) Like a whole person? 4.8 (2.9) 4.9 (3.5) Visual analogue scale 0 10, where 0 ¼ not at all and 10 ¼ very much. Values are means, standard deviations and s. 2562

5 Psychological effect of male infertility diagnosis Table 5: The influence of the attitudes of family and friends How important do you think is it for your parents that you have children How much are you influenced by your parentś attitudes? How much are you influenced by your parents-in-lawś attitudes? How much are you influenced by other peopleś (relatives, friends) attitudes to your childlessness? 6.6 (2.8) 6.1 (2.8) (2.6) 2.0 (2.3) (2.4) 2.3 (2.6) (2.4) 3.0 (2.8) Visual analogue scale 0 10, where 0 ¼ not at all and 10 ¼ very much. Values are means, standard deviations and s. In the multiple regression analysis, the variables working (P ¼ 0.005), part-time job (P ¼ 0.008), high score on PGWB (P, 0.000), little influence of the attitudes of parents (P ¼ 0.001) and good accord between the ideal life and the real-life situation in relation in general with partner (P ¼ 0.034) showed significant positive correlations with low scores on the dependent variable. The variable male infertility showed no independent correlation. Thus well-being, as measured by Effects on infertility was not significantly influenced by male factor infertility when adjusting for possible confounders. During treatment With regards to the answers to the 14 items of The effects of infertility on the day of oocyte retrieval for women and giving a sperm sample for men, a day we could expect to be stressful, Table 6: Psychological effects of infertility Graded 1 5 Total score 30.6 (7.3) 30.4 (7.4) Guilt 1.7 (1.0) 1.5 (0.7) Success 2.8 (0.8) 3.0 (0.9) Anger 1.6 (0.9) 1.7 (0.8) Contentment 2.8 (0.8) 2.8 (0.8) Frustration 2.1 (1.0) 2.1 (0.9) Happiness 2.5 (0.8) 2.5 (0.7) Isolation 1.5 (0.8) 1.6 (0.8) Confidence 2.4 (0.8) 2.4 (0.9) Anxiety 2.1 (0.9) 2.1 (1.0) Satisfaction 2.7 (0.8) 2.6 (0.8) Depression 1.3 (0.6) 1.5 (0.8) Powerlessness 2.1 (1.1) 2.0 (1.2) Competence 2.6 (0.9) 2.5 (0.9) Control 2.8 (1.0) 2.6 (0.8) Low values indicate greater well-being. Values are means, standard deviations and s. Possible range of total score especially for men with male infertility, we did not find any significant differences in the answers given between the two groups (data not shown). Reactions after treatment Two weeks after the pregnancy-test after the first treatment cycle, the men answered the third questionnaire and a subgroup analysis was performed on the men in couples where no pregnancy was achieved: 41 men in the male infertility group (63%) and 67 men in the female/mixed/unknown infertility group (66%). Small differences were found between the groups in this analysis, in both directions. Thus even after failure to achieve a pregnancy, we found no indication that men with male factor infertility reacted more negatively than men in couples with other types of infertility (data not shown). No significant differences were found when interactions between group and time were analysed for questionnaire one versus two, two versus three and one versus three (data not shown). Professional support Approximately 9% of all the men in the subgroup where pregnancy was not achieved had experience of contact with a psychologist or other professional counsellor, and of those with no experience of such contact, 24% of the men in the male infertility group and 33% of the men in the female/mixed/unknown infertility group answered that they thought such a contact would have been valuable. This difference was however not significant. Discussion The main findings of this study indicate no evidence for the hypothesis that male infertility influences men more negatively than men in couples with female/mixed/unknown infertility. We found that men with the diagnosis male factor infertility reacted in a similar way as when the infertility was of female, mixed or unknown origin. This finding ought to be valuable to know for men starting IVF/ICSI treatment and could contribute to a reduction in stress. This is a prospective study, and we have not mixed the responses of men and women or different stages or methods in this result, but concentrated the study on men about to undergo their first assisted reproductive method treatment. When analysing male factor against separate female, mixed and, we did not find any differences. Hence, the analyses were conducted comparing men with male factor only against all other groups of infertility diagnoses to increase the power of the study, even if such a design could be regarded a weakness. The reason we did not find any differences between the two groups of men may have to do with our methods of measurement. Future research should focus on mens experience of infertility and treatment, investigating the impact of coping strategies and measurement methods, related to the treatment options and to gender roles in society today. Another explanation for not finding any differences due to infertility 2563

6 Holter et al. diagnoses may be the fact that male infertility is no longer synonymous with being unable to father a genetic child. The main problem, childlessness and the possible solution, treatment, is equal regardless of infertility factor for all men studied. It is obvious that the introduction of ICSI has revolutionized the treatment of male factor infertility and thereby probably also improved the psychological well-being of males as reflected in this study. In relation to this, it could be worth studying infertile men with azoospermia about to undergo donor insemination or donor IVF. Studying the issue of genetics in relation to infertility treatments may give quite different results. We only studied the men before and soon after the first treatment. At the time of the first treatment all possibilities remain open, as opposed to after the last treatment. Pook and Krause (2005) found that distress rises significantly in men after treatment lasting.17 months and after experiencing treatment failure, whereas no impact was identified for the diagnoses of male infertility. They concluded that treatment and the ongoing childlessness was the problem, not the diagnosis. Further studies investigating long-term effects of treatment failure related to infertility diagnoses are needed. Our findings are positive, in the sense that it does not seem to be very threatening to the life and personality of a man to be infertile today. However, the positive answers may also reflect a tendency of giving positive answers to these kind of psychological questions. Infertility is a private matter; you want to stand out as a well-adjusted person, especially as a man, and you also want to stand out as a presumptive good parent and a positive patient. In this study, 34/200 couples declined to participate. Of those who refused to participate, the reason for refusal was reported to be lack of time and emotional strain in the present situation. The results presented here may thus show less of strong emotional reactions than may have been seen if these men had also participated. One important limitation with psychological studies, as well as with all observational studies, is selection bias i.e. that well-adjusted people tend to participate more often than people less well adjusted. It may also be assumed that couples entering and concluding fertility treatment in general are well adjusted and capable of handling the strain of infertility investigations and waiting time. In spite of no differences being observed between men with and without male factor infertility diagnoses, and in spite of no damaging reactions being observed in the subgroup of men studied after failed infertility treatment, 24% of the men in the male infertility group and 33% of the men in the female/ mixed/unknown infertility group, who had no previous contact with a psychologist thought it would have been useful to receive counselling. Pook et al. (2001) suggest that one reason male patients seek counselling is that they feel responsible for the infertility. We interpreted the desire for counselling as a need for support when dealing with infertility and treatment irrespective of infertility diagnosis. Even if both men and women seeking IVF treatments seem to be psychologically well functioning, infertility is still an existentially demanding situation for those who are affected. Infertile couples generally put quite a lot of energy into reacting to and coping with their infertility, and they need support in this 2564 respect. It is also worth noting that even if the mean values indicate good well-being, some men experience infertility as an emotional burden. Because of the existential and specific problems related to infertility and its treatments, we find it appropriate to suggest professional counselling as a natural part of infertility treatments for all patients. Even when most of the recent psychosocial infertility studies mostly include both partners, the women tend to be in focus. The women are most exposed during treatments and report stronger reactions both to infertility and treatment overall. In this context, men may see their role as a partner in a relationship more than as participants in their own right. Women own this problem and men see themselves as supporting women. They see their own problems as related to the womens problems (Mahlstedt, 1994). This might influence the mens answers although they respond individually and anonymously. Some studies claim that there are no gender differences, but see the same pattern in mens and womens reactions to infertility and treatment, although women react more strongly (Holter et al. 2006; Boivin et al. 1998b). However, there is a risk that ignoring the impact of gender roles may lead to insufficient knowledge about mens experience of infertility. Edelmann and Connolly (2000) found no gender differences, but suggested Differences of this kind may be primarily a function of the methodology adopted, the findings reflecting simply a tendency for women to express their feelings more readily to a stranger than are their partners. (p. 372). Methods of measurement may favour the female type of expression, and it may be necessary to develop new questionnaires to elicit information about the male gender role in terms of reactions and expressions in order to discover the effects of infertility on men. It has been suggested that the needs of men and women in relation to infertility have to be studied and treated separately (Pook et al., 2001; Glover et al., 1998). In conclusion, we found no evidence that a diagnosis of male infertility influences mens experience of infertility, view of life, relationship and psychological well-being at the time of a first IVF/ICSI treatment cycle. Men in this situation seem generally well adjusted before starting their first infertility treatment, independently of which partner has the infertility diagnosis. Acknowledgements We would like to thank Mattias Mohlin for statistical assistance. This study was supported by grants from the Vardal Foundation and Sahlgrenska Academy. We also thank the Organon company for financial support. References Anderheim L, Holter H, Bergh C, Möller A. Does psychological stress affect the outcome of in vitro fertilization? Hum Reprod 2005;20: Beaurepaire J, Jones M, Thiering P, Saunders D, Tennant C. Psychosocial adjustment to infertility and its treatment: male and female responses at different stages of IVF/ET treatment. J Psychosom Res 1994;38: Boivin J, Skoog-Svanberg A, Andersson L, Hjelmstedt A, Bergh T, Collins A. Distress level in men undergoing intracytoplasmic sperm injection versus in-vitro fertilization. Hum Reprod 1998a;13:

7 Psychological effect of male infertility diagnosis Boivin J, Andersson L, Skoog-Svanberg A, Hjelmstedt A, Collins A, Bergh T. Psychological reactions during in-vitro fertilization: similar response pattern in husbands and wives. Hum Reprod 1998b;13: Connolly KJ, Edelmann RJ, Cook ID. Distress and marital problems associated with infertility. J Reproduct Infant Psychol 1987;5: Connolly KJ, Edelmann RJ, Cooke ID, Robson J. The impact of infertility on psychological functioning. J Psychosom Res 1992;36: Dhillon R, Cumming CE, Cumming DC. Psychological well-being and coping patterns in infertile men. Fertil Steril 2000;74: Dimenäs E, Carlsson G, Glise H, Israelsson B, Wiklund I. Relevance of norm values as part of the documentation of quality of life instruments for use in upper gastrointestinal disease. Scan J Gastroenterol 1996;31(Suppl. 221):8 13. Dupuy HJ. The Psychological General Well-Being (PGWB) index. In: Wenger NK, Mattson ME, Furber CF, Ellison J (eds). Assessment of Quality of Life in Clinikal trials of cardiovascular Therapies. New York: Le Jack Publications Inc, 1984, Edelmann RJ, Connolly KJ. Psyclogical State and Psychological Strain in Relation to Infertility. J Community Appl Soc Psychol 1998;8: Edelmann RJ, Humphrey M, Owens DJ. The meaning of parenthood and couple reactions to male infertility. Br J Med Psychol 1994;67: Edelmann RJ, Connolly KJ. Gender differences in response to infertility and infertility investigation: Real or illusory. Br J Health Psychol 2000;5: Gannon K, Glover L, Abel P. Masculinity, infertility, stigma and media reports. Soc Sci Med 2004;59: Glover L, Gannon K, Sherr L, Abel PD. Psychological distress before and immediately after attendance at a male sub-fertility clinic. J Roy Soc Med 1994;87: Glover L, Abel PD, Gannon K. Male subfertility: is pregnancy the only issue? Br Med J 1998;316: (Editorials). Hjelmstedt A, Andersson L, Skoog-Svanberg A, Bergh T, Boivin J, Collins A. Gender differences in psychological reactions to infertility among couples seeking IVF- and ICSI-treatment. Acta Obstet Gynecol Scand 1999;78: Holter H, Anderheim L, Bergh C, Möller A. First IVF treatment short-term impact on psychological well-being and the marital relationship. Hum Reprod 2006;20: Kowalcek I, Wihstutz N, Buhrow G, Diedrich K. Coping with male ifertility gender differences. Arch Gynecol Obstet 2001;265: Lee T-Y, Sun G-H, Chao S-C. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod 2001;16: Mahlstedt PP. Psychological issues of infertility and assisted reproductive technology. Uro Clin North Am 1994;21: Möller A, Fällström K. Psychological factors in the aetiology of infertility: a longitudinal study. J Psychosom Obstet Gynaecol 1991;12: Nachtigall RD, Becker G, Wozny M. The effects on gender-specific diagnosis on meńs and womeńs response to infertility. Fertil Steril 1992;57: Newton CR, Sherrard W, Glavac I. The fertility problem inventory: measuring perceived infertility-related stress. Fertil Steril 1999;72: Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet 1992;340: Pook M, Röhrle B, Tuschen-Caiffer B, Krause W. Why do infertile males use psychological couple counselling? Patient Educ Couns 2001;42: Pook M, Krause W. The impact on treatment experiences on the course of infertility distress in male patients. Hum reprod 2005;20: Pook M, Krause W, Drescher S. Distress of infertile males after fertility workup A longitudinal study. J Psychosom Res 2002;53: Verhaak CM, Smeenk JMJ, van Minnen A, Kremer JAM, Kraaimaat FW. A longitudinal, prospective study on emotional adjustment before, during and after consecutive fertility treatment cycles. Hum Reprod 2005;20: Wiklund I, Halling K, Långström G. The Psychological General Well-Being (PGWB) Index, a reliable tool for use in cross-cultural multicentre clinical trials. Qual Life Res 1995;4:503. Submitted on March 16, 2007; resubmitted on May 22, 2007; accepted on May 29,