ATTITUDE AND INFERTILITY

Infertility can have a serious impact on both the psychological well-being and the social status of women in the developing world. As a result of their infertile status, they suffer physical and mental abuse, neglect, abandonment, economic deprivation and social ostracism as well as exclusion from certain social activities and traditional ceremonies. This becomes particularly traumatic with previous pregnancies that end in abortions, stillbirths and neonatal/infant deaths or in live births of daughters only. A survey conducted in Southern Ghana revealed that the majority (64%) of women felt stigmatized, and that higher levels of perceived stigma were associated with increased infertility-related stress as well as lower levels of education, (Donkor and Sandall J., 2007).

Insufficient family income, poor quality of life, life stress, and discontentment with daily routines as well as ‘bad’ relationships with family members (husband, mother- and father-in-law) are significant correlates of female infertility. Infertile women are more likely to underestimate the importance of sexual intimacy, and have a negative attitude towards sex, (Schmidt, 2010). Female infertility is associated with various social correlates leading to higher remarriage rates and to further complicating the problem of infertility. Thus, a correction of women’s basic attitudes and their relationships to their surrounding social habitat should be an essential component of any program of infertility management.

In America, strong social stigma attached to infertility and machismo attitudes create a dynamic where women blame themselves for infertility. In the Far East, Confucian texts recognize three elements that control reproduction, a male component, a female, and an element which comes from both male and female. Infertility however is usually blamed on women and often seen as retribution for past wrong doing either on the part of the man, woman or one's ancestors. When attempting to explore infertility from a social science perspective it is vital to investigate local perceptions in order to capture a culturally relevant understanding of infertility, (Strauss, Appelt and Ulrich, 1992). While there are some global similarities in perceptions regarding infertility, such as the pervasive notion that women are usually to blame for unwanted childlessness, there is also variation in perceived causation and significance.
Infertility interferes with one of the most fundamental and highly prized human activities and thus presents a major life challenge to those who desire children. The condition brings up issues related to the health and well-being of individuals, couples and society as a whole. Infertility almost always leads to decreased levels of personal well-being and for many individuals it causes significantly more severe consequences. The burden of infertility includes psychological, social and physical suffering, (Donkor and Sandall J., 2007). Documented consequences include: anxiety, depression, lowered life satisfaction, frustration, grief, fear, guilt, helplessness, reduced job performance, marital duress, dissolution and abandonment; economic hardship, loss of social status, social stigma, social isolation and alienation, community ostracism, physical violence and where treatment is available uncomfortable, painful or life-threatening medical interventions. In most areas of the world women's well-being appears to be more seriously affected by infertility than men's, (Greil, 1997).

The reasons why infertility may be difficult for individuals and couples to accept vary. To understand the consequences of infertility both the reasons why children are desired and the importance of having children must be examined (Strauss, Appelt and Ulrich, 1992). In the West, having children is widely viewed as a choice to be weighed carefully with other life goals. Personal happiness and the possibility of giving and receiving love within the parent-child relationship play into the decision of having a child. Because of widely held beliefs in individualism, free choice, and control over one's life, unwanted childlessness causes frustration for Western couples that may not be experienced in the same way in other societies, (Schmidt, 2010). In other locations, personal happiness is no less important, but not having children is seldom viewed as an option. Adherence to social norms, desire and need for social security, power and perpetuity are often cited reasons for having a family in developing countries. In countries with no social security system, many families depend on children for economic survival and childless couples risk severe economic deprivation and social isolation without children to assist them in old age, (National Center for Health Statistics, 1982).

Women's bodies, especially in developing countries, are frequently the locus through which social, economic, and political power is exercised. Where the role or status of women is defined by their reproductive capacity, as when womanhood is defined by motherhood, infertility can have significant social repercussions including unstable marriages, domestic violence, stigmatization and in severe cases, ostracism. Infertile women in developing countries may suffer life-threatening physical or psychological violence when having children is a woman's only chance to improve her status in her society or family, (Donkor and Sandall J., 2007).

The effects of involuntary childlessness vary by location. In Asia, being childless has more negative social, cultural, and emotional repercussions for women than perhaps any other condition which is not immediately life threatening. A study in Andhra Pradesh, India reported that 70% of women experiencing infertility would be punished with physical violence for their "failure" and nearly 20% of these women reported that they suffered severe violence at the hands of their husbands as a result of being childless, (Schmidt, 2010). Some Indian women have reported not being allowed to hold new-born relatives or participate in infant naming ceremonies because of superstitious fears that a new child will die in the arms of an infertile woman. In Andhra Pradesh infertile women reported feeling isolated and ashamed with actual and anticipated rude comments at social functions forcing some women into social reclusion.

A study of female infertility in Tanzania found that women experience many grave hardships and serious social consequences as a result of infertility. In this setting marriage is considered an exchange of productive and reproductive capacities between a woman and her husband's family. The main aim of marriage is reproduction and an infertile woman is considered a "loss" in both reproductive and economic terms, (Schmidt, 2010). Both men and women greatly desire children and no one chooses a life without them. A large family is needed because infant mortality is high and life spans are limited due to lack of health care. Children also provide economically for their parents in old age and improve their parent's status in the domestic hierarchy. Consequences of infertility in this setting include diminished identity and status, stigmatization. Infertility can engender spousal neglect and a withdrawal of economic support; it almost always signals the end of marriage through divorce or abandonment. If the marriage is not ended a husband will often take an additional wife in the hopes of proving his fertility and producing children. Other consequences include unpleasant or dangerous traditional remedies undertaken in the hopes of curing infertility such as eating feces and inducing vomiting, (Greil, 1997).

Infertility engenders harsh consequences on personal and social levels with women often receiving the blamed for a couple's inability to have children. The consequences of involuntary childlessness on men are regrettably understudied however.

Research has shown that infertility affects millions of people worldwide although no reliable information is available about the prevalence of infertility in Kenya. The anecdotal reports and scant research regarding infertility in Kenya focus on the traditional understanding of infertility as a curse, the causes and social consequences of infertility, and society’s negative attitude towards women with infertility, (Donkor and Sandall J., 2007).

Infertility places a huge psychological burden on the infertile couple, especially on the woman, and it may lead to depression, suicidal tendencies, and other pathologic psychological conditions. Infertility is surrounded by many mistaken beliefs about its causes, such as witchcraft and possession by evil spirits, and these beliefs negatively affect its management. Evil forces and supernatural powers were widely held as causes of infertility. In Kuwaiti women, mostly educated blamed infertility on nutritional, marital, and psychosexual factors, but those who are not literate blamed their infertility on supernatural causes, such as evil spirits, witchcraft, and God’s retribution, (Schmidt, 2010).

The risk factors for infertility include smoking, obesity, alcohol consumption, advanced maternal age, sexually transmitted infections, and many others. Increasing the level of knowledge of these factors may help to decrease the incidence of infertility by allowing couples to avoid certain risk factors that might lead to it. This knowledge may also help wider society to understand and empathize with the infertile couple, which may lead to a decrease in the psychological burden to those affected. Because infertility is a taboo subject, people accumulate many misconceptions about reproductive health and fertility all over the world, (National Center for Health Statistics, 1982).

Most researchers conclude that infertility is a more stressful experience for women than it is for men. Few studies have explored the effect of a gender-specific infertility diagnosis on the responses of couples, (Greil, 1997). Previous studies reported more negative feelings about infertility and more psychiatric distress among men with male factor infertility compared to men in couples receiving other diagnoses . A study in Taiwan comparing the differences in responses from husbands and wives based on an infertility diagnosis, reported that husbands, regardless of the diagnosis, showed no differences in psychological responses. Only wives with diagnosed female infertility expressed higher distress to infertility than their husbands, and wives experiencing a diagnosed male infertility, (Donkor ES, Sandall J., 2007).

Because of inadequate pension provisions retired people still have to earn their living, which means that children play a crucial role in supporting them, either financially or practically. The experienced social sufferings of women due to childlessness are difficulties concerning integration into the family-in-law and their powerless status in the community without children. Mainly eldest sons and daughters-in-law are being pushed to have children as soon as possible to secure the lineage. The mothers-in-law in particular demand that the daughters-in-law will be examined and be treated unless there is proof for male infertility. Husbands need to be persuaded by their wives to visit a doctor. Besides the 'negative' pressure, family- in-laws also suggests ways to conceive such as traditional food and medicine, and sources of western treatment. This advice may be encouraging to some couples, but may also bring too much pressure, stress and psychological harm.

Adoption may serve as an alternative strategy for those affected couples, yet has not been fully explored and integrated into management schedules. A study showed that, while most childless couples had heard of adoption, they were not clear about the processes or legalities (Ezugwu et al., 2002). And, while its acceptance may be poor, over two-thirds of respondents in a community-based study in South- Eastern Nigeria preferred child adoption to traditional management options for infertility such as adultery, polygamy, surrogacy, acceptance of childlessness and divorce and remarriage (Onah & Ogbuokiri, 2002). Focus group discussions (FGD) with community members in another study indicated that they view adoption as a socially-responsive gesture, rather than as treatment for infertility (Oladokun et al., 2009).
Cultural and communal acceptability appears to have strong influences on people’s attitude to child adoption. Making the procedures less tortuous may ease the process. Again, lessons can be learnt from others to institute post-adoption care as part of the whole adoption process. According to Aniebue & Aniebue (2008) it would be essential in view of all the socio-cultural factors militating against abortion in our environment, to ensure enduring success of the program. Measures like advocacy, community mobilization and enactment of supportive laws will help in promoting acceptability of child adoption.

Being a parent is a normative assumption of adult life in any society. Most couples who experience infertility consider it a major crisis (Burns, 1999). From the beginning of time, the command “Be fruitful and multiply” remains a permanent truth for most societies (Lee & Kuo, 2000). In every society a woman’s childbearing ability is often closely linked to her status as a woman, so that when a woman is infertile she may feel unfeminine. Due to the inability of childbearing, many women fear separation from their partners. Fear of losing attraction and self-worth make them even depressed (Greil, 1997).

Most of the couples when faced with the crisis of infertility go through a chain of emotional changes that can be harmful to the couple (Crick, Casas, & Mosher, 1997). Depression is a common reaction to this problem. It is the response to the excessive losses and prolonged stress created by the infertility process. Infertile couples may have feelings of failure, loss, disappointment, and betrayal. Infertile couples’ sadness can transform into sorrow or grief especially for the loss of the child of their dreams or the imagined experiences one could share with a child (Ardenti, Campari, Agazzi, & La Sala, 1999).

Anxiety is another common response associated with infertility (Crick et al.,1997). Women especially feel anxiety and stress each month when trying to conceive. Every month upon the beginning of a new menstrual cycle, a woman is reminded of yet another failure (Haynes & Miller, 2003). Moreover, when the couple remains infertile for a long time and goes through infertility treatments, this may evoke anxiety about the outcome of the treatment. The couple may also become socially isolated (Unisa, 1999).

As the diagnosis of infertility has a tremendous negative impact on the well being of a couple, feelings of anger, frustration, and aggression often accompany it (Crick et al., 1997). Hormonal changes during treatment may also affect the emotions of infertile men and women. Aggression increases when the success is not there at the end of every month starting the menstrual period (Boivin, 2003). Rohrlick (1998) pointed out gender differences in aggression level in infertility.
When males feel powerless and experience low self-esteem they try to reclaim it through aggressive behavior. On the other hand, for females, aggression is a transitory loss of self-control arising out of high stress, social pressure and extreme sense of guilt (Greil, 1997).

Coping with or responding to infertility may be linked to societal attitudes towards childlessness. Family physicians who were surveyed in Germany were found to be judgemental of involuntary childless couples and attributed their childlessness to personal behaviour or way of life . In the Caribbean and elsewhere, involuntary childlessness has been attributed to an act of God, punishment for sins of the past, prolonged use of contraceptives, distinct dietary habits, and the result of witchcraft. Individuals who are thought to be infertile are generally ostracized and relegated to an inferior status in Jamaican society and stigmatized with labels such as mule, barren, not really a man or forsaken by God, (Donkor and Sandall J., 2007).

The existing negative attitudes and beliefs about infertility are bound to contribute to a couples’ sense of despair, distress and morbidity. A review of many literatures reveals that many of the studies examining stress associated with infertility have focused on women who were infertile, and did not include either men or couples who were infertile in their population. These studies, using prospective data collecting design, have concluded that infertility is stressful for women and when infertile men’s reactions have been compared to women, less distress and negative effects have been reported, (Schmidt, 2010) . Studies on the stress of infertility have also attempted to differentiate the grief experience for men and women and have found that women are more likely to blame themselves and to describe a greater sense of loss of control. On the other hand, men’s responses tend to be related to their partner’s self-esteem. Men may also engage in extra-marital affairs and are likely to experience sexual dysfunction manifested as erectile dysfunction, ejaculatory disorders, loss of libido and a decrease in the frequency of intercourse, (Greil, 1997).

Seeking medical advice and engaging in wishful-thinking, namely, hoping for a miracle and fantasizing about the outcome are the strategies most commonly used. The least reported strategies include avoiding being around pregnant women or children and eating, smoking or drinking more. When examined by gender, both men and women used wishful thinking strategies and seeking advice most often and to a lesser extent emotion-focused coping. Women generally used all three types of strategies more often than men, (National Center for Health Statistics, 1982). The strategies that men used more often are those that allowed them to avoid talking about their experience, namely keeping feelings to them- selves and making self better by eating, drinking or smoking, along with the specific problem-solving strategy of using alternative medicine. In addition, although both genders seldom reported seeking sympathy from others, men were more likely to accept sympathy and understanding from others compared to women.

Men and women will use a combination of escape-avoidance, seeking support and active problem-solving strategies and women will use all to a greater degree than their partners. Additionally, research has shown that couples cope effectively with the stress of infertility when they accept their condition and then take purposive action that helps them to adjust. Actively seeking information, a commonly used strategy is associated with decreased reports of psychological distress by childless couples and therefore seems to be one of the more effective strategies for coping with infertility, (Schmidt, 2010).

There is a widely accepted stereotype that women experience emotions more readily and with less self-control than men and that women feel emotions more intensely than men. It is anticipated therefore that more women than men will use strategies that allow them to vent their feelings. Although compared to other coping strategies, emotion-focused strategies are not frequently used by women, (Greil, 1997). Women are more likely than men to talk about their feelings and significantly more women ruminate about their experience. On the other hand, men used techniques that may have helped them to avoid dealing directly with their feelings until they were better capable of doing so. Men would delay confirmation of the infertility, and it is generally the women who would not only talk about their feelings but request help from a medical practitioner and actively seek information from the internet and pass it on to their partners.

While men and women both frequently use a combination of strategies to cope, namely, avoidance coping and active-problem solving, and to a lesser extent, emotion-focused coping, there are gender differences in their choice and frequency of use. Coping strategies are not homogenous or gender-specific. Individuals may use different avoidance techniques, such as, fantasizing about the outcome to deal with some situations and avoiding talking about the problem to deal with others, (Schmidt, 2010). Also, some may share their feelings with others at a particular stage of their grief experience but do more active problem-solving at other stages. While becoming actively involved in problem-solving is an effective strategy, dwelling on the experience (emotion- focused coping) results in self-blame and isolation for some women, thereby, increasing their risk for heightened distress and despair.

Information on personal values and attitudes does increase knowledge on determinants of childbearing intentions and decision-making, although not all hypotheses concerning the association or direction of the association, between certain attitudes and fertility intentions are confirmed. Religious values, as well as work-related attitudes and individualistic values appear to have little bearing on childbearing intentions, while various attitudes towards children are related to intentions to have (more) children, (Greil, 1997). In addition, a conservative familistic attitude is related to intentions as well as gender role attitudes. People with limited knowledge about fertility may engage in ineffective behaviors that could delay seeking effective interventions.
According to Schmidt, (2010), a pastor once preached that barren women are barren because of their attitude. That bad attitudes cause a chemical imbalance that is keeping them from reproducing. There have been many theories about the causes of infertility, but this one floored people not only because of the pure ignorance of the statement, but more so, because a pastor — a person of authority — a person who is supposed to be discerning and sensitive to the members of his congregation — would have the audacity to make such a ludicrous claim, (Schmidt, 2010).
Before expounding on the causes of barrenness from the pulpit, it is recommended that we consult with the experts. The Bible might be a good place to start. Plenty of the most famous people in the Bible had bad attitudes and most of them reproduced. Several of the most revered, godly people in the Bible (Moses comes to mind) experienced infertility. Interesting that although bad attitude is not proven to be one of the medical causes of infertility, some studies do link stress and infertility. Could it be that hapless congregants feel just a teensy bit stressed when their pastors announce that their bad attitudes are the reason they can’t get pregnant?
You may feel guilty, sad, or angry because you are having trouble conceiving a child. You may begin to feel envious of other couples who are pregnant or have children. You may be tired of having sex on a scheduled basis, (Donkor and Sandall J., 2007). These feelings are completely normal but you should try to not let them take over your life. Childless couples should keep things in perspective and ask for support.
The first stage of the reaction to infertility is surprise. Most couples assume that pregnancy will occur soon after discontinuing contraception because most have spent their sexual lives trying to avoid pregnancy. Couples scrutinize their behaviors, habits, and lifestyle to try to understand why they have not been able to conceive. They also examine the timing, frequency, and technique of intercourse to explain why they have not been able to conceive. If the couple has told others of their attempts to get pregnant, they may be the recipients of well-intentioned advice from friends and family, (Schmidt, 2010). Chief among these recommendations are just relax, and they will get pregnant. Also, others may tell them to get more rest, eat a balanced diet, restrict certain foods and beverages, and cut down on exercise. Couples usually try these things to feel as if they are doing all they can to improve their fertility. Couples try over-the-counter ovulation prediction kits to precisely determine when ovulation is occurring so that intercourse can be properly timed. They may be overly concerned about orgasm or whether leakage of sperm out of the vagina has affected their attempts to conceive, (Okonofuaa, Harrisb, Odebiyic, Kaned and Snowb, 1997). They may have intercourse in uncomfortable positions, more frequently than they desire, and the woman may stay in the supine position after intercourse because she feels it will help aid conception. The common theme among couples who exhibit these behaviors is that they consider themselves inherently fertile but unable to conceive because of circumstances. They believe they can still control their fertility, and the identification of them as infertile has not yet occurred.
When these modifications in lifestyle or intercourse technique are unsuccessful, both the man and woman may examine their past for clues as to the cause of their infertility. Women often assume that they are the cause of the infertility and search their past for a potential cause. Women who have had a sexually transmitted disease or previous abortion may be convinced that the infertility is a result of those events. This may lead them to feel guilty and question their worthiness as a wife and a potential mother. Less often the man may wonder if a past medical condition, medication, or habit may be compromising his fertility. When the couple continues to have difficulty conceiving, most seek medical advice and treatment, including trying to find an explanation for their problem, (National Center for Health Statistics, 1982).
As a result, a couple seeking advice regarding fertility comes into their physician's office with a specific need to know why they are infertile to explain or ameliorate the guilt that they feel. They often want to determine the possible role of past behaviors in their infertility. For example, a woman who had an elective abortion and fears it may have caused her infertility may become obsessed with blaming herself for the infertility until she can be reassured by her physician that the two events are unrelated, (Peterson, Newton and Rosen et al., 2006). For some women, obsessive thoughts and ruminations about infertility infiltrate their daily lives and threaten their ability to function at work or at home. The ruminations are an attempt to understand and control the guilt they feel. When a medical basis for infertility has been discovered, the infertile partner usually feels a sense of guilt that they have compromised their spouse's ability to have a child. Carried to the extreme, particularly if the marriage is not strong to begin with, the infertile partner may actively threaten to leave the marriage to free their spouse to procreate with someone else. Alternatively, the fertile partner may engage in actions to influence the dissolution of the marriage, (Donkor and Sandall J., 2007).
Another emotional reaction to infertility is depression. The occurrence of depression among infertile women is well documented. The depression may be cyclical and coincide with phases of the treatment cycle, or it may be acute and precipitated by a specific event, such as a family holiday or the announcement of a family member's or friend's pregnancy. Fortunately, for most women the depression is short-lived, (Litt, Tennen and Affleck et al., 1992). Chronic depression caused by infertility may generalize to other areas of a woman's life. She may communicate less or argue more with her spouse, function poorly on the job or at school, or have severe anxiety and agitation. Sometimes, the depression is camouflaged and the couple may consciously or unconsciously sabotage their own attempts to conceive so as to diminish the chance for disappointment. For example, he or she may purposely avoid intercourse at mid cycle to avoid the postmenstrual depression that stems from repeated failure.
The feeling of depression is compounded by the loss of control over one's life that many infertile couples experience. For many couples who have been able to achieve almost any goal they have set for themselves, the inability to conceive a child may be the first time when they have lost control of their lives, (Schmidt, 2010). To compensate, they may wrestle with the infertility team for control over their infertility testing and treatment. For some couples, this attempt to control every aspect of their infertility testing or treatment may be a defense mechanism against their profound sense of helplessness.
At some time during the infertility evaluation and treatment, couples may feel intense anger. They may argue that life has treated them unfairly and that their infertility is unjust. They may become intensely angry when they see individuals, whom they believe undeserving, achieve a pregnancy with little or no effort, (Donkor and Sandall J., 2007). They may feel very angry when they hear a pregnant woman display disgust or unhappiness with her pregnancy; when they see women with an unwanted pregnancy seeking an abortion; or when they observe a mother or father abusing their child.
Infertile couples may displace their anger toward others, such as family and friends, who, from the viewpoint of the infertile couple, may not be particularly sensitive to the emotional pain they are feeling. Unfortunately, anger displayed toward family and friends may drive away those who are in the best position to provide emotional support for the infertile couple. One partner may also become very angry with the other if they sense that he or she does not feel the same degree of emotional pain or have the same intense desire to overcome the infertility. The more distressed partner may place unrealistic demands on the other and become very angry if he or she is unable to meet these expectations, (Freeman, Boxer and Rickels et al., 1985). The significant differences in how men and women deal with infertility may be particularly noticeable at this time. When infertile couples direct their anger at the medical team, it is often difficult for the team to avoid becoming angry and defensive. Angry couples are often characterized by the treatment team as being difficult. Frequently, it is the office staff, not the physician, who bears the brunt of the patient's anger. Therefore, it is not uncommon for the nursing or office staff to be aware first of a couple who are handling their infertility poorly. It is important for the health care team to realize that the couple's intense feelings of anger really often mask feelings of pain, anxiety, and fear.
The infertile person has a loss of self-esteem by repeatedly attempting to achieve a desired goal (having a baby) but failing to achieve it. When unable to have a child, the failure challenges and may begin to erode their self-esteem. The problem can be significantly worse when the individual has been highly successful in other areas of life and has not developed the coping skills to deal with failure and loss, (Schmidt, 2010).
A second loss can be the real or feared loss of important relationships. This includes the marital relationship and relationships with family and friends. The marital relationship can be strained or lost because of fears that the fertile partner will leave the infertile partner. Even though a couple is working together toward a common goal, the emotional pain associated with infertility and the stress of the evaluation and treatment may make it difficult for each individual to provide the necessary emotional support for each other, (Donkor and Sandall J., 2007). Unfortunately, this occurs at a time when each needs the emotional support and intimacy provided by the other. When they cannot meet each other's needs, each partner may withdraw and isolate themselves.
An additional strain on the relationship may be the changes in the couple's sex life. Several writers have noted that infertile couples have sexual difficulties. Sex may become a reminder of the couple's failure to have a child. The increased intrusion into the sexual habits of the couples by the medical team's recommendation for timed intercourse, frequent intercourse, or limited intercourse may make sex feel like a chore, (Schmidt, 2010). The intimacy and pleasure usually derived from sexual relations may be identified as another loss by the couple.
In addition to marital difficulties, the infertile couple may also experience strain in relationships with family and friends. They may isolate themselves from their family and friends because they consider infertility a private problem that they are uncomfortable sharing. They may also often feel misunderstood when they do share their feelings, (Domar, Broome, Zuttermeister P et al., 1992). They assume and believe that no one else can understand the true intensity of their emotional pain. Unfortunately, they are often right. When they hear over and over that all they need to do is relax and they will conceive, they begin to withdraw. They may stop attending family celebrations, such as baby showers, christenings, Mother's Day, or religious holidays when other family members may bring their children with them. The couple begins to feel left out and stops associating with those who have children. Friends who are pregnant may also be avoided by the infertile couple because they are a reminder that others can get pregnant with ease. The infertile woman's loss of relationships can deprive her of social support, which can compound feelings of isolation and depression, (Schmidt, 2010).
A third loss related to infertility is the loss of health. The female patient may spend a great deal of time in the infertility clinic for tests and treatments, (Greenfeld, Mazure andHaseltine F et al., 1984). Although she is not really sick, she may begin to identify with the sick role and begin to feel that her physical health is compromised. In addition, women may also report feeling ill because of the side effects of some of the hormonal medications used to enhance fertility.
A fourth loss is the potential loss of financial security. According to National Center for Health Statistics (1982), Infertility treatment, especially in countries that do not mandate insurance coverage of infertility treatment, can be extremely expensive, with one cycle of in vitro fertilization (IVF) in the USA costing between $10,000 and $15,000. An associated problem is the concern about job security for women. Because women are often the primary focus of the evaluation or treatment, they often have to miss considerable amounts of work. This may place their job in jeopardy. In addition, they often fear telling their employer the reason for their absences, because the employer may assume the treatment will be successful and the woman will be leaving her job. If the employer assumes that the woman will be leaving her job to have a child, the woman may become vulnerable to being laid off or dismissed (Burns and Covington, 1999).
Women who used escape as a coping strategy experienced greater distress. In a study of infertility-related stress, coping and gender, Peterson et al. found that women used more accepting responsibility, seeking social support and avoidance coping than men. Men used more distancing, self-control and planful problem-solving than women. Women reported greater levels of overall infertility-related distress, (Schmidt, 2010).
A commonly felt emotion is the shock and disbelief that anyone could be experiencing infertility. It is most difficult to accept it can happen to you. Usually people plan their lives and establish dreams towards the future which may include having children. The thought of dealing with infertility doesn't enter into the scheme of life's goals and can therefore be quite challenging. Although the focus of attention centers on the medical or physical aspects of dealing with infertility, the emotional impact sometimes plays a secondary role. However, having a realistic attitude and expectation when dealing with any difficulty or challenge is vitally important and can affect the ultimate outcome, (Burns and Covington, 1999)

There are many ways that stress might influence infertility. Though stress usually does not start out as the primary cause of infertility, the stress of dealing with infertility can become a compounding factor in successful treatment, (Greenfeld, Mazure and Haseltine F et al., 1984). Foremost, the stress of infertility is psychological, and the body reacts to this with the same Stress Response as to physical danger. Without adequate release or care, we internalize this tension in a depressive state.

It's easy to understand that the emotional losses of infertility lead to depression in many women and couples. Also, the medications involved in infertility treatment contribute to mood instability and depression: enough estrogen and you feel good; too much or too little, and you feel awful. Estrogen is a precursor of serotonin, a mood elevating neurotransmitter in the brain. Artificially spiking estrogen may cause the brain to shut down estrogen receptors to maintain biochemical equilibrium, (Schmidt, 2010). Overtime, brain chemistry may become exhausted by the game of catch-up, leading to depression.

An often cited study by the Harvard School of Mind/Body Medicine showed that women in infertility treatment for an average of two years have depression levels equal to patients with chronic or terminal illness, such as cardiac disease or cancer, (Shatford, Hearn and Yuzp et al., 1988). Depression affects the same centers in the brain (the hypothalamus and pituitary gland) that control our reproductive hormones. Studies also show that when depression is effectively treated with either a support group or mind/body group, conception rates more than double.
Women are typically seen, by others as well as themselves, as the emotional caretakers or providers of the relationship. Women typically feel responsible not only for everyone's bad feelings, but also for anything bad that happens. When women try to repress feelings, their emotions can become more ominous until they finally feel out of control. Their emotions can become a monster about to swallow them whole, (Schmidt, 2010).
Women in infertile couples often protect their husbands from their own pain and feelings of failure by taking much of the responsibility for the treatments upon themselves. When it is suggested that men accompany their wives for appointments, couples get concerned about issues like income loss, use of time, etc. While these concerns are usually relevant and important, they also serve the purpose of protecting husbands from their own responsibility in the conception process and from their own feelings, which could easily be intensified by so much contact with the medical process, (Shatford, Hearn and Yuzpe et al., 1988).
Men are traditionally seen as the financial providers of the relationship and are responsible for protecting the family from real or imagined dangers. Men usually feel more threatened expressing themselves since they have often been conditioned to repress their emotions. They are trained to be more instructional to take charge, to make decisions and to think without being sidetracked by emotions, (Schmidt, 2010).
Males in infertile couples often feel overwhelmed by the intensity of their partner's emotions as well as an inability to access their own. They tend to focus their energy back into their work, a place where they feel they can have more success.
As a result of taking responsibility for the emotional impact of the infertility, the woman experiences intense feelings, such as pain, anger, fear, etc., which, combined with the messages that her way of dealing with things is in some way dysfunctional or crazy, causes her to feel an anxious depression. As feelings spill out, she feels out of control and doesn't really know how to ask for what she needs, especially from the husband she is struggling so hard to protect. She may yearn for an emotional connection/interaction at one moment and in the next withdraw emotionally from her husband when she fears she has disappointed him, (Mai, Munday and Rump, 1972).
Men find themselves in a position where, regardless of how well they've been trained to solve problems, they are helpless to make this situation better for the woman and, as a result, may give off messages that she is too emotional or sensitive, hoping that this will calm her down. The wife hears this as criticism of her coping and care taking skills rather than as an expression of her husband's fears. This is the time when couples cling together for dear life, feeling that they've failed in the most basic of all roles: reproduction. Couples are hesitant to admit problems in their marriage, feeling that having difficulty coping would mean that their marriage is also a failure, (Schmidt, 2010).

REFERENCES
Abbasi-Shavazi. (2000a). National trends and social inclusion: Fertility trends and differentials in the Islamic Republic of Iran, paper presented at the IUSSP Conference on: Family Planning in the 21st Century, 61–21 January, Dhaka.

Burns LH, Covington S. (1999): Psychology of infertility. Burns L, Covington S (eds), Infertility Counseling: A Comprehensive Handbook for Clinicians. pp 3-25. New York: Parthenon.

Domar A, Broome A, Zuttermeister P et al. (1992), The prevalence and predictability of depression in infertile women. Fertil Steril.

Donkor ES, Sandall J. (2007), The impact of perceived stigma and mediating social factors on infertility-related stress among women seeking infertility treatment in Southern Ghana. Soc Sci Med; 65: 1683–1694.

Freeman EW, Boxer AS, Rickels K et al. (1985), Psychological evaluation and support in a program of in vitro fertilization and embryo transfer. Fertil Steril.

Greenfeld D, Mazure C, Haseltine F et al. (1984) ,The role of the social worker in the in vitro fertilization program. Soc Work Health Care 198

Greil AL. (1997), Infertility and psychological distress: a critical review of the literature. Soc Sci Med; 45:1679–1704.

Homan GF, Davies M, Norman R. (2007), The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatments: a review. Hum Reprod Update; 13: 209–223.

Is infertility just a woman’s problem? New York MedicineNet, Inc.; 2012 [02 January 2012]; Available from: http://www.medicinenet.com/infertility/article.htm.

Khaidarova FA. (2007); Medico-biologic aspects of infertile marriage in the region of Fergana valley. Problemi biologii i medicini; 1: 119–122.

Litt M, Tennen H, Affleck G et al. (1992), Coping and cognitive factors in adaptation to in vitro fertilization failure. J Behav Med.

Mai FM, Munday RN, Rump E. (1972), Psychosomatic and behavior mechanisms in psychogenic infertility, Br J Psych

National Center for Health Statistics (1982), Reproductive Impairments Among Married Couples. United States Vital and Health Statistics, Public Health Service. Washington, DC: US Government Printing Office.

Okonofuaa FE, Harrisb D, Odebiyic A, Kaned T, Snowb RC (1997). The social meaning of infertility in Southwest Nigeria. Health Transition Review.

Peterson BD, Newton CR, Rosen KR et al. (2006), Gender differences in how men and women who are referred for IVF cope with infertility stress. Human Reprod; 21:2443-2449

Reading A. Sexual aspects of infertility and its treatment (1993), Infertil Reprod Med Clinic North Am

Schmidt L. (2010), Psychosocial Consequences of Infertility and Treatment In: Reproductive Endocrinology and Infertility: Integrating Modern Clinical and Laboratory Practice, edited by DT Carrell, CM Peterson. pp. 93–100, Springer Science and Business Media.

Shatford L, Hearn M, Yuzpe A et al. (1988), Psychological correlates of dysfunctional infertility diagnosis in an in vitro fertilization program. Am J Obstet Gynecol

Strauss B, Appelt H, Ulrich D. (1992); Relationship between psychological characteristics and treatment outcome in female patients from an infertility clinic. J Psychosom Obstet Gynecol