Couples Therapy

If you're reading this, chances are that you and your partner are feeling challenged by infertility and, at some point, you might even begin to question the integrity or meaning of your relationship. It might go something like this, "If we can't have children, maybe we aren't meant to be married." Or "If we can't have children, who are we? Are we a real family?"

Let me try to reassure you from the outset that these thoughts are entirely normal, but they are also not true. Our biological and genetic functions do not care about our character and do not determine the meaning and value of our relationships. However, it is hard not to take such private and intimate matters personally, and we all misapply this logic at some point or another.

Here are some reasons for the increased tension between men and women when coping with infertility:

Gender Differences in Communication

In her insightful book You Just Don't Understand, Deborah Tannen, PhD, sums up the differences between male and female styles of communication as follows: men prefer what she calls "report talk," which focuses on the facts about the subject; they use their knowledge of facts to establish a hierarchy in relationships. Conversely, women prefer "rapport talk," focusing on their feelings about the subject; women use conversation to establish more lateral (rather than hierarchical) relationships with others. Along the same lines, studies show that men tend to dominate public conversations (ie., in boardrooms, business meetings, classrooms, etc) whereas women tend to be more comfortable with and dominate private conversations (eg., between friends, partners, and family members).

Applying these differences in communication styles to the sensitive subject of infertility, you can see where the trouble starts. Infertility is deeply personal and private, a domain in which most men are not that comfortable exposing themselves, certainly not in the frequent discussions women are fond of, and absolutely not with others outside their marriage. She wants and needs to talk to feel understood and connected with her partner; he needs to put his emotional world in order before he can reach out. Consequently, women tend to express and define the emotional tenor of the relationship in dealing with infertility. Men believe that their primary role is to support their partners; but when carried too far, they may feel left out altogether.

If this is happening in your relationship, you are perfectly normal. Under stress, we all regress to our more familiar styles of relating and communicating. To create more balance and open communication, I suggest the tried and true "Twenty-Minute Rule": Instead of women talking frequently and endlessly about the issue, set up only twenty minutes a day to devote time to the subject. Each partner gets ten minutes to talk uninterruptedly about their view of the subject while the other attentively listens. Then switch roles. The goal is not to persuade your partner to your way of thinking. It is most important to remember that each person merely wants to feel heard and understood. Once that happens, individuals become softer in their positions and more compromise is possible.

Gender Differences in the Doctor's Office

Gender differences in communication styles become painfully clear in the doctor's office. This private domain is one in which women tend to dominate over their partners. Men tend to perceive the doctor/patient relationship as hierarchical: the doctor is the expert and in charge. From the moment he walks into the doctor's office, your guy is in the one down position; it's humiliating, even if doesn't say so. Women, on the other hand, are looking for partnerships; they usually don't feel the power conflict that men do. Studies consistently show that when it comes to medical issues, women make the first medical appointments in dealing with infertility, and they make most of the follow-up visits as well; they ask more questions than their male partners; and female patients spend more time with the doctor than do male patients. The result: She takes over the infertility treatment plan and is the captain of the team.

If this is happening in your relationship, you can equalize this imbalance with some of the following steps: Sit down together and prepare for the visit: what do you each want to get from the doctor? If you can't prepare for the doctor's visit together, each partner should write out their own list of questions and take them to the visit. Both partners should go to the initial visit and form an opinion and relationship with the doctor. If only one can go, the other should provide a list of questions or concerns of their own; the doctor's responses should be written down and shared later. At the beginning of a treatment cycle, make a calendar of scheduled injections and office visits for each of you.

Gender Differences in Perceiving the Problem

In When Empty Arms become a Heavy Burden, Glahn and Cutrer cite a 1985 study in which 15% of men and 50% of women said that infertility was "their greatest burden ever." This is still true today: even though the diagnosis of infertility factors is evenly split between men and women, women view this issue as more impactful in their lives and self-image than do men. One reason for this is biological: the female reproductive system has a limited supply of eggs and time is pressing on. Another reason is sociological: most women expect to become mothers from childhood, when they began playing mommy with their dolls. Choosing not to have children is one thing, but being unable to conceive and bear children is quite another. The wound is deep in the psyche.

Gender Differences in Social Relationships

In general, men value privacy in personal matters and are less open about these issues when talking to others. Conversely, women value disclosure and use it to build support. Think about it in your case: how many people have you or your partner spoken to about your fertility problems? How many family members or friends know? How many people in your workplace know?

When it comes to disclosing your family building struggles to others, it very much matters who has been diagnosed with what problem: we're talking about people's private medical information here, as well as their self-image. Yet couples who keep everything to themselves are cutting themselves off from vital support and help. Keeping everything inside your relationship may protect your privacy but also increase the pressure between the two of you, and reinforce any sense of alienation you have from others. Thus, it is critical that you sit down together and make a list of folks with whom you can discuss your personal issues.

Sexuality and Infertility

People tend to confuse infertility with sexuality. The terms "sterile man" or "barren woman" are unappealing and emotionally hurtful. When we internalize these images, we feel wounded and unattractive as well. Old stereotypes persist that people without children must have sexual issues: he can't "get it up" or she must be "cold or frigid."

The truth is that these days, sexual issues are rarely a cause of infertility. It's rather the reverse: dealing with infertility affects people's sex lives. More than half of the couples dealing with infertility experience a decrease in sexual activity as well as a less satisfying sex life. They also report more sexual problems related to anxiety, depression, and medication side effects, such as less sex drive, erectile dysfunction, premature ejaculation, and lack of orgasm.

Successful Strategies

• Partnership Mentality: "We're in this together." "We're on the same side." "Partners share the problem 50:50 but each is 100% responsible for their own part."
• Discuss with whom you can share your situation. Respect partner's need for privacy while meeting your needs for support. Getting outside help puts less pressure on your relationship.
• . Define what you can and cannot control. Don't expect to control either yours or your partner's feelings. Each person wants to feel understood.
• When you feel overwhelmed, resist letting discussions about infertility consume your time together. Limit yourselves to ten minutes each of respectfully listening to the other without interrupting. ("Twenty Minute Rule")
• Don't mistake differences in communication styles as differences of intention.
• Make differences in decision-making and communication an asset rather than a threat.
• Create a "Family Building Plan" early on and reassess it at each stage.
• Create a center of your life separate from infertility.
• Focus on positive life lessons. Through resolving their infertility, many couples report improvements in communication, self-esteem, and maturity. Overall, they feel that their marriage is stronger.

Consider Couples Therapy When:

• You feel isolated with your problem & need external support.
• You disagree on a treatment plan or adoption path.
• Either you or your partner are clinically depressed and need a safe treatment setting in addition to your individual support.
• You are handling marital conflict poorly or in destructive ways.
• Create a "Family Building Plan" early on and reassess it at each stage.
• The integrity of your relationship feels threatened by the stressors or identity challenges of infertility treatment.