Abstract Infertility is a stressor that affects the infertilecouple. Coping of infertile couples with the unfulfilleddesire for a child is affected by numerous variables. Depending on the diagnose is the patients were assignedto four groups: Group 1: female infertility (infertilewomen of fertile men), Group 2: infertility of the men,Group 3: infertility of both partners, Group 4: idiopathicsterility). One hundred and ten infertile couples were investigated with the Freiburg questionnaire of Copingwith Illness. Compared to their partners, the women ofinfertile couples report a higher feature rating in thecales “depressional coping” and “self-distraction andself-stabilisation”. Women of infertile couples showlower feature ratings compared to the standardised col-lective of patients with chronic somatic disease only onthe scale “religiousness and search for meaning”. Invol-untarily childless men activate all coping strategies to asmaller extent than the reference sample. The experi-ence of infertility is greatly affected by gender and theassociated role expectations.

Keywords Infertile couples · Coping · Gender · In-vitro fertilization · Assisted reproductive technologies(ART)

Introduction

A considerable number of couples have an unfilfilledwish for a child. Infertility is a stressor that affects theinfertile couple. This puts great psychological demandson the individual and the couple. From a medical pointof view, infertility is defined as the inability to conceiveafter two years of engaging in sexual intercourse withoutcontraception (WHO). The psychosocial functioning is

affected by the experience of infertility. Infertility is de-scribed nearly universally as an extremely stressful timethat may have enduring effects on the marriage as wellas on each partner’s well-being [7]. Coping involves“constantly changing cognitive and behavioural effortsto manage specific external and/or internal demands thatare appraised as taxing or exceeding the resources of theperson” [8].

Coping is the collective term for all attempts to dealwith stress situations. Coping behaviour is thus a connecting link between stress and impairment [5]. The difficulty in considering the unfulfilled wish for achild results from the following fact: “on the one hand,infertility is a medical problem. It often involves many years of diagnostics and treatment. On the other hand, infertility is not felt to be life-threatening,in contrast to chronic illnesses [2]. The condition of the unfulfilled desire for a child cannot be classified as a deviation from a clinically defined norm. It is not the physical pain, but social, cultural and emotionalaspects which play a crucial role in how infertility isexperienced [1].

Psychological aspects on the pathogenesis of infertili-ty and how it is coped with were for a long time relatedonly to female infertility. Whereas some results on howwomen cope with infertility are available, little is knownabout how men cope with the unfulfilled wish for achild.

It can be supposed that different role expectations ap-plied to women and men work here – as a mixture be-tween subjective feeling and ratings – due gender rolestereotypes.

Up to now, there are few investigations on the subjec-tive feelings of couples with regard to the cause of theirinfertility special to male infertility.

The present study investigates the following:

1. Do women and men of infertile couples differ in theircoping strategies?

2. Do women and men of infertile couples differ in theircoping strategies according to the cause of infertility?

I. Kowalcek (✉ ) · N. Wihstutz · G. Buhrow · K. DiedrichDepartment of Obstetrics and Gynaecology, Medical University of Lübeck, Ratzeburger Allee 160, D-23538 Lübecke-mail: kowalcek@t-online.deTel: ++49-451-5002155, Fax: ++49-451-5002192

Arch Gynecol Obstet (2001) 265:131–136 © Springer-Verlag 2001

O R I G I N A L A RT I C L E

I. Kowalcek · N. Wihstutz · G. Buhrow · K. Diedrich

Coping with male infertilityGender differences

Received: 12 March 2001 / Accepted: 16 March 2001

Material and methods

Sample

Couples who presented for a first interview in the infertility clinicof the Department of Gynecology and Obstetrics at the MedicalUniversity of Lübeck (Head: Prof. K. Diedrich, MD) were in-cluded in the study. Of a total of 154 questionnaire folders handedout 104 (67.5%) could be included in the evaluation. Incompletequestionnaires were excluded from the total calculation. The cou-ples were subdivided into four groups (Table 1) with regard to theorganic cause of infertility (Group 1: infertile woman, fertile man;Group 2: infertile man, fetile woman; Group 3: infertility in bothpartners; Group 4: idiopathic infertility).

Recording the coping strategies

Coping with the unfulfilled wish for a child is registered with the“Freiburg Questionnaire on Coping with Illness” (FreiburgerFragebogen zur Krankheitsverarbeitung, FKV) of F.A. Muthny[1]. In the present study, the abbreviated form (FKV-LIS) for self-appraisal is used. It comprises 35 items. On a five-step Likertscale (1=“does not apply at all”, 5=“very highly applicable”), thetwo partners can specify separately the extent to which the state-ment applies to them. The evaluation is made by forming the meanof five factor-analytically based scales which enables the record-ing of clinically relevant modes of coping: F1: depressional cop-

ing, F2: active problem-oriented coping, F3: self-distraction andself-stabilisation, F4: religiousness and search for meaning andF5: trivialisation and wishful thinking. The criteria of test quality(objectivity, reliability and validity) are acceptable.

Statistical analysis

The data were analysed both descriptively and inferentially, withthe statistical program “SPSS” (Release 6.0) (Statistical Packagefor Social Sciences) in collaboration with the Institute of MedicalStatistics and Documentation at the Medical University of Lübeck,Head: Dr. Friedrich). Depending on the scale level and the distri-bution characteristics of the data, parametric (t-test) and nonpara-metric (U-test) methods are used. The Wilcoxon Matched-PairsSigned-Ranks Test for dependent variables are used. A level ofp=0.05 (*) was accepted as the level of statistical significance.

Results

Coping strategies infertile women and men

Compared to the reference sample, the degree of mani-festation of the coping modi of women and men with un-fulfilled wish for a child is listed in Table 2 in the sub-scales: F1 depressional coping, F2 active problem-ori-ented coping, F3 distraction and self-stabilisation, F4 re-igiousness and search for meaning and F5 trivialisationand wishful thinking. In the t test for unlinked randomsamples, involuntarily childless women differ from thereference population in favour of a lower feature ratingto a significant extent merely on the scale F4 (religious-ness and search for meaning) (Table 3). In the otherscales, a significant variation is not shown between in-voluntarily childless women and the reference sample.Men of infertile couples show significant lower meanvalues than the reference sample on all scales of theFreiburg Questionnaire on Coping with Illness (Table 4).Compared to the men, women show a higher feature rat-ing in all five subscales of the Freiburg Questionnaire on

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Table 1 Investigated couples in the different groups according tothe cause of infertility

Group Number Relative [n] percentagea

[%]

1. Female infertility 13 12.52. Male infertility 55 52.93. Infertility of both 31 29.84. Infertility, idiopathic 5 4.8Total 104

a The relative percentage includes couples which belonged to anyof the subgroups (n=104)

Table 2 Results in the sub-scales of the “Freiburg Ques-tionnaire of Coping with Illness” for the reference sample and infertile couples

Subscale Reference sample Infertile couples

Total sample Women Men(patients with dialysis, heart infarction, MS)

F1: Depressional coping n=947 n=104 n=102mean 1.96 mean 2.09 mean 1.61SD 1.18 SD 0.84 SD 0.56

F2: Active problem-orientierted coping n=947 n=103 n=102mean 3.35 mean 3.24 mean 3.06SD 1.34 SD 0.89 SD 0.94

F3: Self-distraction and self-stabilisation n=947 n=105 n=101mean 2.94 mean 2.91 mean 2.53SD 1.26 SD 0.91 SD 0.88

F4: Religiosness and search for meaning n=947 n=103 n=100mean 2.77 mean 2.17 mean 2SD 1.38 SD 0.71 SD 0.61

F5: Trivialisation and wishful thinking n=947 n=105 n=100mean 2.29 mean 2.33 mean 2.05SD 1.37 SD 1.01 SD 0.8

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Table 3 Coping of involuntari-ly childless women comparedto the reference sample (two-tailed t-test for indepen-dent samples with unequalvariances)

Reference sample Women of Significance(patients with dialysis, infertile couplesheart infarction, MS)

F1: Depressional coping n=947 n=104 p=0.151mean 1.96 mean 2.09SD 1.18 SD 0.84

F2: Active problem-orientierted n=947 n=103 p=0.262coping mean 3.35 mean 3.24

SD 1.34 SD 0.89

F3: Self-distraction and n=947 n=105 p=0.758self-stabilisation mean 2.94 mean 2.91

SD 1.26 SD 0.91

F4: Religiosness and search n=947 n=103 p=0.000a

for meaning mean 2.77 mean 2.17SD 1.38 SD 0.71

F5: Trivialisation and n=947 n=105 p=0.713wishful thinking mean 2.29 mean 2.33

SD 1.37 SD 1.01a Significant

Table 4 Coping of involuntari-ly childless men compared tothe reference sample (two-tailed t-test for indepen-dent samples with unequalvariances)

Reference sample Men of Significance(patients with dialysis, infertile couplesheart infarction, MS)

F1: Depressional coping n=947 n=102 p=0.000a

mean 1.96 mean 1.61SD 1.18 SD 0.56

F2: Active problem-orientierted n=947 n=102 p=0.006a

coping mean 3.35 mean 3.06SD 1.34 SD 0.94

F3: Self-distraction and n=947 n=101 p=0.000a

self-stabilisation mean 2.94 mean 2.53SD 1.26 SD 0.88

F4: Religiosness and search n=947 n=100 p=0.000a

for meaning mean 2.77 mean 2SD 1.38 SD 0.61

F5: Trivialisation and n=947 n=100 p=0.009a

wishful thinking mean 2.29 mean 2.05SD 1.37 SD 0.8

a Significant

Table 5 Coping of involuntari-ly childless couples: compari-son between women and men(U-Test)

Involuntarily Involuntarily Significancechildless women childless men

F1: Depressional coping n=104 n=102 p=0.000a

mean 2.09 mean 1.61SD 0.84 SD 0.56

F2: Active problem-orientierted n=103 n=102 p=0.218coping mean 3.24 mean 3.06

SD 0.89 SD 0.94

F3: Self-distraction and n=105 n=101 p=0.005a

self-stabilisation mean 2.91 mean 2.53SD 0.91 SD 0.88

F4: Religiosness and search n=103 n=100 p=0.122for meaning mean 2.17 mean 2

SD 0.71 SD 0.61

F5: Trivialisation and n=105 n=100 p=0.084wishful thinking mean 2.33 mean 2.05

SD 1.01 SD 0.8a Significant

Coping with Illness. The difference proves to be signifi-cant on the scale F1 (depressional coping) and also onthe scale F3 (self-distraction and self-stabilisation) in theU test. A tendency to higher feature rating in the womenis shown in the scale F5 (trivialisation and wishful think-ing) (p=0.084, Table 5).

Coping strategies of infertile women and men in relationto the cause of their infertility

On average, the involuntarily childless women of allgroups show a higher feature rating than their partners inall scales (Table 6) irrespective of the partner to whomthe cause of the infertility must be ascribed. The sole ex-

ception from this is the scale F2′′ (active problem-orient-ed coping) in group 2 (subfertility: men) in which themen show slightly higher mean values than the women.

The feature ratings in the subscales are listed sepa-rately for men and women in the individual groups (G1:infertility of the women, G2: infertility of the men, G3:infertility of both, G4: infertility idiopathic) in Table 7.In group 1 (infertility only women), there is a significantdifference in the mean value between women and men inthe scale F2 (active problem-oriented coping) (p=0.008).The women in this group take a more active part in deal-ing with the unfulfilled wish for a child than the men. Atthe same time, the women in this group are significantlymore depressive in coping (F1) (p=0.011) with the unful-

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Table 6 Coping strategies of infertile women and men in relation to the cause of their infertility

Group Subgroup F1 Depressiv F2 Active F3 Distract F4 Religion FKV 5 Trivial

Female infertility 1.1 women n=12 n=12 n=12 n=12 n=12mean 2.4 mean 3.55 mean 3.28 mean 2.33 mean 2.57SD 0.93 SD 0.75 SD 0.76 SD 0.54 SD 1.17

1.2 men n=12 n=12 n=12 n=12 n=12mean 1.50 mean 2.85 mean 2.32 mean 2.13 mean 1.86SD 0.45 SD 0.57 SD 0.77 SD 0.6 SD 0.66

Male infertility 2.1 women n=51 n=50 n=52 n=50 n=52mean 1.91 mean 3.04 mean 2.7 mean 2.06 mean 2.24SD 0.77 SD 0.98 SD 0.98 SD 0.75 SD 0.94

2.2 men n=49 n=49 n=48 n=47 n=47mean 1.64 mean 3.1 mean 2.54 mean 1.94 mean 2.08SD 0.62 SD 0.88 SD 0.94 SD 0.5 SD 0.82

Infertility both 3.1 women n=30 n=30 n=30 n=30 n=30mean 2.22 mean 3.37 mean 3.1 mean 2.23 mean 2.24SD 0.87 SD 0.75 SD 0.79 SD 0.73 SD 0.99

3.2 men n=30 n=30 n=30 n=30 n=30mean 1.61 mean 3.26 mean 2.6 mean 1.93 mean 2SD 0.51 SD 1.1 SD 0.9 SD 0.69 SD 0.85

Infertility idiopathic 4.1 women n=5 n=5 n=5 n=5 n=5mean 2.56 mean 3.72 mean 2.92 mean 2.32 mean 3SD 0.88 SD 0.98 SD 0.87 SD 0.39 SD 1.41

4.2 men n=5 n=5 n=5 n=5 n=5mean 1.56 mean 2.76 mean 2.48 mean 2.24 mean 2SD 0.38 SD 0.86 SD 0.9 SD 0.59 SD 0.74

Subscales of the Freiburg Questionnaire of Coping: F1 depressional coping; F2 active problem-oriented coping; F3 self-distraction andself-stabilisation; F4 religiosness and search for meaning; F5 trivialisation and wishful thinking

Table 7 Coping strategies ofinfertile women and men in relation to the cause of their infertility. Wilcoxon Matched-Pairs Signed-Ranks Test

F1 Depressiv F2 Active F3 Distract F4 Religion F5 Trivial

Group 1 n=11 n=11 n=11 n=11 n=11Female inf. p=0.011a p=0.008a p=0.028a p=0.097 p=0.051

Group 2 n=47 n=46 n=47 n=45 n=47Male inf. p=0.045a p=0.802 p=0.407 p=0.371 p=0.403

Group 3 n=29 n=29 n=29 n=29 n=29Inf. both p=0.002a p=0.668 p=0.02a p=0.02a p=0.146

Group 4 n=5 n=5 n=5 n=5 n=5Inf. idiop. p=0.08 p=0.144 p=0.281 p=0.715 p=0.144

a SignificantSubscales of the Freiburg Questionnaire of Coping: F1 depressional coping; F2 active problem-oriented coping; F3 self-distraction and self-stabilisation; F4 religiosness and search for meaning; F5 trivialisation and wishful thinking

filled wish for a child and show a significant differencecompared to their partner in the subscale F3 (self-dis-traction and self-stabilisation) (p=0.028). A tendency togreater trivialisation and to wishful thinking (F5)(p=0.051) compared to the men is shown in the womenof this group. In the scale F4: (religiousness and searchfor meaning), this tendency also applies even though to alesser extent (p=0.097, Table 7).

If one considers the couples in whom a cause of theunfulfilled wish for a child can only be found in the man(group 2), it is also shown here that the woman copieswith the problem with significantly more depression (F1)than her husband (p=0.045; Table 7). No significant dif-ference in the feature rating is shown in the remainingfour scales.

A significant difference in the mean value in the fea-ture rating of the subscales F1 (depressional coping), ispresent in favour of a higher feature rating in women(p=0.02, Table 7) in group 3 (both partners contribute to the cause of the infertility). The mean values also dif-fer significantly between the two sexes in favour of ahigher feature rating in women in scale F3 (self-distrac-tion and self-stabilisation) (p=0.02) and F4 (religious-ness and search for meaning) (p=0.02). On the remainingtwo scales the difference is not found to be significant(Table 7).

In group 4 (infertility idiopathic), a significant differ-ence in the feature rating was not shown between menand women in the individual subscales. A tendency to-wards a higher feature rating in the women is howeverfound on the subscale F1 (depressional coping) (p=0.08,Table 7).

Discussion

Women of the random sample investigated activate cop-ing strategies comparable to those of the chronically illapart from the feature rating in the subscale “religious-ness and search for meaning”. The marked deviation ofinfertile women to low values on the scale “religiousnessand search for meaning” compared to the reference sam-ple is an indication that the affected persons today nolonger accept their unfulfilled desire for a child as beingfate. It must be borne in mind that these are people whoseek help at a centre of reproductive medicine.

The men investigated differ from the reference popu-lation in a highly significant way on all scales of theFreiburg Questionnaire on Coping with Illness. Com-pared to chronically ill patients, all coping strategies areless pronounced in these men. The question arises as towhether all coping strategies were indeed of as little helpto the men as they report. Owing to the broad dimension-ality of the FKV-LIS, which comprises both the cogni-tive, emotional and actional planes of coping with dis-ease [11], it appears if anything improbable that none ofthe coping strategies specified in the FKV-LIS are appli-cable to the men. It seems more likely that the problemof the unfulfilled desire for a child is not perceived as

such by the men (Myrtek et al. 1994). It is hence also not important for them to develop and employ copingstrategies.

Collins et al. [4] also found that infertile women ac-tive more coping strategies then their partners and antici-pated more stress. They however thought men are psy-chologically affected by the unfulfilled wish for a childas the women but are less open about it. Before differ-ences in the way the two sexes cope with the unfulfilleddesire for a child are discussed. In dealing with the involuntary childlessness, the depressive component is more pronounced in the women than in the men. Mahlstedt [10] points to the difficulty of dealing with theanger triggered by infertility. The suppressed anger issometimes manifested in depression: Phipps [13] reportsthat in connection with the experienced feeling of power-lessness the men tend to turn their anger against themedical system and the treating physicians to a greaterextent than their female partners. Compared to their part-ners, women show highly significantly more “self-dis-traction and self-stabilisation” as a strategy for copingwith the unfulfilled desire for a child. They are moreconcerned to establish distance from themselves and theproblem of the involuntary childlessness than the men.This becomes comprehensible if it is assumed that wom-en are affected more severely by the unfulfilled desirefor a child than their partners. No significant differencewas found between the sexes with regard to employmentfor an active problem-oriented strategy to cope with in-fertility. This coping strategy is most often employed byboth men and women. However, it is still predominantlythe woman who takes the initiative in consulting a doctor[6].

If the infertility is attributable to a purely gynaeco-logical cause, men and women show marked differencesin their coping strategies: women report significantlymore active problem-oriented coping in their approachto the unfulfilled desire for a child. At the same time,they cope with the problem more depressively and withmore distraction and self-stabilisation compared to theirpartner. The differences found are also statistically sig-nificant in this respect. On the remaining subscales thereis also a tendency towards higher feature ratings forwomen compared to their partners. If the women alonecontribute to the cause of the infertility a higher copingeffort is thus notable, as has also been described byBernt et al. [3].

Unexpectedly, fertile women of infertile men (G2)cope more depressively with the unfulfilled desire for achild than their partners. The sexes in the group of pure-ly male infertility do not differ appreciably from eachother in the degree of manifestation of other coping strat-egies. Although the women do not attribute to the causeof infertility from a physical point of view, they activatecoping strategies to the same extent as their partners, andindeed cope more depressively with the unfulfilled de-sire for a child than the men. It is not solely the somaticcomponent of this infertility which appears to play a rolefor the women. Social, cultural and emotional aspects

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play a crucial role in the experience of infertility. Mahlstedt [10] regards couples with a purely male causeof infertility as especially vulnerable. Since men willspeak loss about personal things, the men with disturbedfertility mostly kept their emotional distress to them-selves. The woman is torn between the desire to supportthe partner and anger directed against him (as the causeof the problem). She attempts to protect him from thestigma attached to male subfertility. Thus the coupletends to isolation [10].

If both partners contribute to the cause of the infertili-ty from a somatic point of view, they do not show anyrelevant variations in coping strategies in an active prob-lem-oriented coping and in trivialisation and wishfulthinking. However, there are highly significant differ-ences in the sexes in the other coping strategies: womencope more depressively with the unfulfilled wish for achild. They are more concerned to take their minds offthings and to build themselves up. On the subscale “reli-giousness and search for meaning” a higher feature rat-ing is also present. Differences between the sexes in theway in which they cope with the unfulfilled desire for achild are manifested when both partners contributed ascauses of the undesired childlessness. Above all, the de-fensive coping strategies are used to a greater extent bywomen than by men.

Conclusion

It appears appropriate in view of the results reported inthis paper to take into consideration which partner is thecause of the infertility from a somatic point of viewwhen looking after infertile couples. It is a question ofthe different strategies in dealing with the unfulfilled de-sire for a child. However, there is the danger that theman with the unfulfilled desire for a child denies con-

comitant problems and that the woman becomes the solesuffener in the context of treatment. Active involvementof the partners is therefore absolutely necessary [4].

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