There can be little doubt in the mind of anyone who is dealing with, or who has dealt with being unable to produce a child, that the experience of infertility and the long, arduous, invasive and costly medical investigations and fertility treatments – take a tremendous physical, emotional, financial, and sometimes even spiritual toll on infertile individuals and on their relationships.   Infertility affects a person’s feelings about themselves – their masculinity or femininity, their self worth, their self esteem, their body.  It affects their relationships with others – their fertile friends, their family members, their co-workers, and their spouse.  And inevitably, it affects their sexuality and sexual relationship with their partner – in terms of their sexual self worth, their sexual desire, and the satisfaction they get from being intimate with their partner. 

However much pleasure couples derive from their initial efforts to produce a child, infertility and the prolonged pursuit of medical fertility treatments appear to have a negative impact on couples’ sex lives – during and even after they stop pursuing treatment.   During infertility treatments 50% to 60% of couples report significant decreases in their sexual satisfaction, with levels of satisfaction deteriorating even more the longer couples are involved in treatment.  This is especially the case for couples whose levels of sexual satisfaction were not high, or who were experiencing sexual problems in their relationship prior to infertility.   Women in particular report significant negative changes in terms of decreased sexual desire, difficulties in getting aroused, problems in achieving orgasm, lack of foreplay, and painful intercourse.  Some women are plagued by intrusive thoughts and memories during lovemaking – often associated with the invasive and sometimes humiliating medical investigations and fertility treatments.  Twenty to 30% of men going through infertility treatments experience episodes of sexual dysfunction – most commonly impotence and premature ejaculation.  And in a study I conducted with 65 infertile couples after they had terminated their medical efforts to produce a child, sexual dissatisfaction continued to be reported by the majority of participants in the study.  Although many couples felt their marriages were stronger as a consequence of having “survived” infertility, sexuality was the one area in their relationships that most couples felt had never fully recovered following medical fertility treatment – in terms of returning to their pre-infertility levels of sexual spontaneity, pleasure, and overall satisfaction.

It is important therefore, for couples who are trying to have a child, to understand why and how sexuality can be negatively affected by a diagnosis of infertility and the procedures involved in the medical investigations and treatment of infertility.  Given the very negative long-term sexual toll that infertility appears to take on many couples’ sexual relationships, suggestions are provided in this article on ways couples can avoid some of the common pitfalls and keep their sexual relationships vital and satisfying during the stresses and challenges of coping with infertility.

Why Does It Happen?

Most relationships change over time in terms of sexual frequency, intensity, and levels of satisfaction.  All couples experience changes in their sex lives – with sexual frequency tending to decline over time and most couples falling into routines in terms of when and where they have sex, who initiates, and what usually happens. These are normal changes that occur in most relationships – and if they become troublesome for couples, they usually require some work and attention to put right.  Keeping sexual passion and intimacy alive in any relationship requires energy. Basically you get out of it what you put into it.

But the changes in sexual desire and frequency that are typical in the life of any couple, are different than the changes that result from infertility and medical treatment.

There are many reasons why a diagnosis of infertility and medical fertility investigations and treatments can have a negative impact on a couple’s sex life.   Perhaps the most common and obvious problem when couples are trying to get pregnant is that the purpose and goals of sex change.  Prior to trying to have a family, sex for most couples is about playfulness and the delightful exploration of each other’s bodies with the sole objective of giving and receiving pleasure.  However, when couples are trying to produce a child, the goal of sex changes from recreation to procreation.  Having sex is no longer a spontaneous act based on mutual desire, lust and passion.  Rather, something that once was a great source of pleasure and fun becomes a task that has to be done based on the calendar – on the two or three days of each menstrual cycle when the woman is ovulating and can become pregnant.  Sex becomes focused on intercourse – on egg meeting sperm – rather than on the many erotic pleasures that are part of a full and satisfying sex life.           

In the beginning, some couples find that sex focused on trying to create a new life together – on becoming parents and taking their relationship to the next level – is very exciting and intense.  However, as the months go by without a pregnancy, sex for the purpose of trying to produce a child becomes an act associated with repeated failure – failure that plays itself out each month in the woman’s body.  Couples begin to feel that no matter how much energy or enthusiasm or effort they invest in trying to get pregnant – it likely isn’t going to happen.  They probably won’t get pregnant.  Month after month, the outcome is the same – understandably reducing the desire to keep climbing between the sheets together and have sex.  After all, who would want to keep pursuing a goal that in spite of their best efforts, they seem unable to achieve?  Who wants to feel like a failure?

This is especially true for the partner identified with the fertility problem who usually feels like a double failure since it is their body and reproductive system that isn’t functioning “properly.”   As well as feeling physically “defective,” because fertility is so closely linked with sexuality, the person with the identified problem often feels sexually deficient in being unable to do one of the most basic and most important things in life – producing a child.  Men often feel ashamed of their inability to produce motile, healthy sperm in sufficient quantities, and women blame themselves when their eggs, tubes or uterus aren’t viable.  Both men and women feel guilty for letting their partners down.  It is very difficult to feel good about sharing your body and being intimate with your partner when the feelings that have come to be associated with your body and your sexuality are shame, guilt, self blame and failure. 

Under these circumstances, sex, and the feelings of shame, guilt, and failure associated with being infertile, become something to be avoided.  Over time infertile couples often find that they rarely make love anymore, except during the woman’s fertile period.  And even then, partners often find themselves staying later at the office or stopping for a few extra drinks after work, or picking a fight just before going to bed, to avoid having to have sex…to avoid all the negative feelings that have come to be associated with sex.  While understandable, such avoidance only exacerbates the problem – as feelings of anger and resentment can begin to fester and the woman or man start to question their partner’s investment in, and commitment to having a child. And if it is difficult to want to be intimate with one’s partner when sex engenders feelings of failure and shame, or when a person feels like their body has let them down, or when sex feel like work, feelings of anger and resentment are even more toxic in dousing the flames of sexual desire. It is extremely difficult for most men and women to perform sexually, much less want to perform sexually, when they are feeling angry or resentful with their spouse.

Finally, and not surprisingly, the medical investigations and treatments that couples must endure over the course of months and even years in their efforts to produce a child, take a tremendous toll on the sex lives of most infertile couples.  The questions asked by nurses and physicians are pointed and invasive.  How many sexual partners did they have in the past?  Have they ever had an abortion or sexually transmitted disease?  How often do they have intercourse? Does the man get an erection and ejaculate while inside his partner?  How frequent are her periods and how long do they last?  What is her flow like? The majority of tests and examinations are focused on the male partner’s genitals and the female partner’s reproductive organs.  They are poked, prodded, examined, tested, x-rayed, and biopsied.  Making a baby becomes a clinical process … one that isn’t even remotely intimate. What once was private and intimate between a couple, becomes public and clinical.  It is pretty difficult for a woman or man to feel good about themselves or their bodies, much less to go home and have spontaneous, uninhibited sex with each other, after he has had to masturbate into a sterile cup or has had a biopsy on his testicles, or she has had a speculum and catheter inserted into her vagina and cervix or superovulation medication injected into her belly.  

What Can Couples Do?

In light of the very real strains and distress of being infertile and the realities of the invasive medical investigations and treatments, some sexual problems and dissatisfaction are inevitable for all the reasons discussed above. However, there are things couples can do to lessen the potential negative impact that infertility and medical intervention can take on their sex lives.  The following recommendations can go a long way towards reducing the negative impact of infertility, and can help couples maintain the sexual vitality, pleasure and intimacy that are an important and cherished part of their relationships. 

Body Love

Sex is about a lot of things.  It runs the gamut of feelings, means different things at different times, and has a multitude of purposes. But the one constant is that sex is enacted with our bodies – through touching, holding, caressing, kissing, and sharing the most intimate physical contact.  When you feel like your body has been under assault through all the fertility testing and treatment, or when you have put on weight from the medications, or when you feel your body has failed you in your efforts to produce a child, it can be very difficult to share this part of yourself with your partner. 

It is imperative, then, that you take care of, and stay connected with your body throughout the process of trying to conceive – if you are to get any enjoyment out of being sexual with your partner.  That means making self care – nutrition, sleep, and regular exercise – a priority.  On top of working and fitting medical appointments into your life – not to mention the sheer exhaustion of the process of coping with infertility – it may seem like there just is no time for anything else.  But in fact, this is one investment that is bound to net great rewards.  When you make a point of taking care of your body, you inevitably end up having more energy to cope with the strains (and disappointments) of treatment, and more energy for, and interest in being intimate with your partner.   

Also, from the outset of trying to find medical solutions to your fertility problems, you and your partner should educate yourselves about what is involved before going for tests or treatment procedures.  It is always easier to cope with something if you know what to expect (the HSG being a good example of this).  You would be well advised to ask the doctors and nurses for information on the diagnostic and treatment procedures, to read books, to watch informational treatment videos, and to go on-line to find out more about what is involved in the tests you are facing and the treatments that are being recommended.  You and your partner should also assert yourselves in terms of your needs and your rights to protect your dignity (e.g., insisting on privacy during consultations and procedures, asking that instruments be warmed before they are inserted, requesting that your partner be allowed to be present, etc.). The more you and your partner can do to maintain your dignity and sense of choice and agency, the greater the likelihood that you both will get through the treatment process with the least amount of damage to your self esteem, body image and sex life.

And when you don’t feel good about your body, it can be good to turn to your partner for help – being sure to tell them how you feel, and what you need.  Feeling the gentle touch and caress, and being in the arms of the person you love, can go a long way in helping you to feel better about yourself and your body. 

Separate Sex for Procreation from Sex for Recreation

Although a certain amount of work sex can’t be avoided when you are trying to get pregnant, it is important to limit those “goal-directed” encounters to the specific time of the month when you are likely to be ovulating.  If you are like most infertile couples, you usually know exactly where you are in your cycle at any time. In fact, one of the burdens of infertility is an almost obsessive focus on the menstrual cycle, and one of the indicators that infertility is no longer taking up as much space in your life is the fact that you no longer automatically know what day of the menstrual cycle it is.  Inevitably, when you are forced to have intercourse because you’re ovulating or taking fertility drugs – not because you feel like making love – it is likely to feel like an obligation.  But love-making doesn’t have to feel like an obligation the rest of the month.  After all, there are 365 days in the year and only 2 or 3 days during any month when you can get pregnant.  That means there are approximately 329 days of the year when fertility is not a possibility, and ideally should not be an issue.   

During those few “fertile” days, you and your partner would be well-advised to use fantasy, erotica, and any other forms of sexual stimulation that works for you, to get through and ideally even enjoy the task at hand.  It can be helpful to create rituals around “baby-making nights” – making these particular encounters different and distinct from your other intimate times together throughout the rest of the month.  It is easier if you both are able to acknowledge the purpose of having sex at that time of the month, and where possible, to add some humor and fun to these encounters.  When you’re having sex because you have to, not because you want to, it can be helpful to change the setting.  If you have a spare room in you home or apartment, you might consider having sex in that room – or maybe on the living room couch during baby-making nights – leaving you bedroom for your more erotic and intimate sexual encounters during the non-fertile times of the month.

During the other 329 days of the year when making a baby isn’t possible, you need to avoid the tendency to say, “to heck with it, why bother having sex, we can’t get

pregnant anyway.”  Instead, you need to make a point of enjoying each other and enjoying sex for all the varied purposes it serves in you lives and in you relationship – for pleasure, validation, intimacy, fun, connection, excitement, and as a way of expressing caring and love.  This may require that you step outside of the box of what is “normal” and “typical” in your sex life.  It may mean giving yourselves permission to step out of you comfort zone and incorporating new and exciting activities into you sexual play such as body massage or erotic movies.  It may mean changing old patterns by having sex at different times of the day and in settings other than the bedroom at night when the lights are out – or changing who initiates the encounter.  As noted earlier, in any long-term relationship, sex can become routine and it can be difficult to keep things exciting and vital.  Add infertility to the mix, and that becomes even more the case.  So whatever you can do together to bring back the romance, fun and excitement to your intimate encounters – will be well worth the effort – while you are dealing with infertility, and long after when you no longer are hoping to get pregnant. 

Beyond Intercourse

In most cultures of the world whether someone is considered to be “sexually active” is directly connected to whether they are having intercourse.  In fact, intercourse is considered thesexual act – with virtually all other erotic, sensual, and sexual interchanges and activities being categorized as foreplay – things that lead up to the main event of intercourse.  Intercourse can, under conditions of personal choice and agency, be a wonderfully exciting and fulfilling aspect of sexuality.  However, as noted above, when trying to produce a child and coping with infertility and medical treatments, intercourse frequently becomes associated with work, obligation, and failure.  And when it is the expected and inevitable outcome of all sexual encounters, it can become oppressive, unsatisfying, and something to be avoided.

That being the case, it is very helpful if you and your partner can move beyond the mind-set that intercourse is sex, and that all other erotic and intimate activities must inevitably lead to intercourse.  There is an enormous range of pleasurable, intimate, sensual and erotic activities that you can enjoy other than intercourse – activities such as kissing, caressing, massaging, fondling, holding, licking, sucking, tasting, watching, reading, etc. – activities that often are as satisfying and enjoyable whether or not they end in one or both partners having an orgasm. These activities are not part of the traditional sexual script and when disconnected from the expectation that they will lead to intercourse and orgasm, they do not have the same associations with obligation, expectation, and failure that characterizes intercourse when you are trying to have a baby.

Consequently, one very effective way to maintain passion, desire and sexual intimacy in your relationship while dealing with infertility, is to clearly designate certain times during the month – when ovulation is not occurring – as times for exploring and engaging in intimate activities together that are NOT expected to lead to, or end in intercourse.  Because the social link between sex and intercourse is so firmly embedded in our cultural beliefs about what constitutes normal and fulfilling sex, this disconnect can, in the beginning, be difficult to achieve.  That being the case, it is sometimes easiest at first to designate one particular night of the week as your “intimacy without intercourse (IWI)” night – a night when the only goals of your interactions are intimacy, exploration, pleasure, and connection.  You can get some great ideas and suggestions on the many ways couples can pleasure each other in Lonnie Barbach’s book “For Each Other.”  Some of the basic books on Tantric Sex can also be a good source of idea on non-intercourse ways of enhancing the erotic and intimate parts of your relationship.

Communication

The relationship is the context or container for sex and intimacy within any marriage or committed partnership.  Dealing with the inability to have children can place tremendous strain on the healthiest of relationships.  Although surviving infertility often results in bringing couples closer together, the process of coping with the ongoing stresses of infertility and medical treatment can test the metal of even the best of relationships.  Misunderstandings are common, and social isolation from the rest of the fertile world, while adaptive in some respects, can place even more pressure on each partner to be there for, and to understand, the needs, feelings and desires of the other. 

The pain of treatment failure and the distress of being unable to have a child will at times make it difficult to even speak to your partner, much less wanting to have sex.  If you are angry or frustrated with your partner, it is unlikely that you are going to want to make love or have sex.  If you feel he or she doesn’t understand how you feel, or doesn’t appreciate what you need – having just given a sperm sample or received the results of a negative sperm analysis, or having recently been through a particularly uncomfortable or unpleasant test or treatment, or having found out that treatment has been unsuccessful – you may find it difficult to be in the same room together. 

If you are to get through the experience of infertility and medical treatment with your sex life in tact, it is going to require that you pay serious attention to your relationship.  Through the stresses and incredible strains and disappointments of trying to have a child together, you’ll need to nurture and take care of each other and your relationship.  You’ll need to remember that the reason you are upset is because you care enough about your partner to want to become parents and raise a child together.  You’ll need to remember that part of your distress is because you want to share the experience of creating a life with your partner and seeing the things you love about him or her reflected in your child, and you’re afraid you’re not going to have that experience. And you’ll need to remember that although you may handle the stresses differently, and although at times you may not express yourselves in the same ways, or seem equally invested in the process of trying to have a child – you are in this together. 

That being said, it is imperative that you communicate with each other – about your needs, desires, wants and fears – about your relationship, about infertility, and about your sex life.  It is important that you not expect your partner to know how you are feeling or what you need. When you want to be held or caressed but not make love – you need to say so and not assume that your partner knows that – or why you feel that way.  It is important that you not expect your partner to share or express the same feelings, at the same time, and in the same way as you – or to assume that she or he should feel the same way as you do.  For your partner, the sexual release of orgasm might be important, while for you the physical contact and intimacy of holding each other might be what you need.  Or one or both of you might need some physical space from each other. And it is important to recognize that sex may well have very different meanings to the two of you, at different times. For one of you sex on a particular evening or day may be about intimacy and connection, while for the other it may be about the release of stress and tension – different purposes and meanings, but both are equally valid. 

The key to communicating effectively about your emotional and sexual needs is not to assume that you know what your partner wants, or is thinking or feeling.  Don’t make assumptions – and don’t assume she or he can or should be able to read your mind.  Infertility places unbelievable stress on most relationships, and touches at the core of what it means to be a man or woman and what it means to be a couple.  Negotiating the waters of infertility is uncharted territory for you both, and you are both doing your best, within your personal and collective resources, to find a way to cope with infertility while trying to keep your relationship in tact and your sex life alive.  So be kind to yourself and to your partner – talk, listen, don’t assume, don’t expect, and give each other the benefit of the doubt.   

Early Intervention

Not surprisingly, if your sex life was satisfying and vital prior to dealing with infertility, you’re likely to fair better throughout the medical treatment process.  You may still struggle with the lack of intimacy and burden of work sex.  But when your sex life starts to falter, you and your partner will be able to fall back on and incorporate the sexual and erotic activities that used to give you pleasure, and comfort, and joy – prior to the intrusion of infertility in your lives and in your relationship.  It may take a conscious effort on your part and on the part of your partner, but at least you have a vital sexual history to be able to build on during the more difficult times of dealing with infertility.

On the other hand, if you didn’t experience a lot of sexual desire or pleasure, or if you experienced problems in your sexual relationship prior to infertility, or if sex was never a particularly vital or important component of your intimacy – there is a greater likelihood that you’ll experience sexual dissatisfaction and that the difficulties in your intimate life will be exacerbated when faced with the stresses of infertility.  The obligation of having to perform sexually upon demand and the indignities of the medical treatment process may present quite a challenge for you and your partner.  You may have outstanding relationship issues that are also playing themselves out in your sexual relationship and getting in the way a more satisfying intimate relationship. 

As noted above, the longer you are involved in pursuing treatment, the greater the likelihood that your sexual relationship will suffer. And once lost, it appears to be extremely difficult for to recapture the passion and pleasure and satisfaction that may once have characterized your intimate relationship.  That being said, if you felt your sex life could have used some attention prior to dealing with infertility, it is a good idea to get some professional help before getting too far into the infertility treatment process.  The same holds if you find during treatment that infertility is destroying what once was a vital and healthy part of your relationship.  Or if you find that you’re at loggerheads with your partner and unable to communicate.  With some professional assistance from a marital and sex therapist, not only is your sex life likely to improve, but your overall relationship will likely become stronger and more satisfying as a result of counseling.

Conclusion

Infertility can and often does challenge relationships at their very core.  And certainly, sexual intimacy is one very important and core aspect of most relationships.  It can be destroyed by infertility, it will certainly be challenged by infertility, but with attention and nurturing and understanding, it can also be enriched – in terms of greater intimacy and deeper connection. 

Judith C. Daniluk, Ph.D. is a professor in the Department of Educational and Counselling Psychology at the University of British Columbia and clinical consultant to Genesis Fertility Centre in Vancouver, Canada,  She specializes in infertility and sexuality, and is the author of numerous articles on sexuality and infertility, including The Infertility Survival Guide:  Everything You Need to Know to Cope with the Challenges, while Maintaining Your Sanity, Dignity, and Relationship, as well as Women’s Sexuality Across the Lifespan:  Challenging Myths, Creating Meanings.