What do unsuccessful couples have in common?

On the psychological situation of unwanted childless couples

Unwanted childlessness is when pregnancy has not occurred after one to two years of regular, unprotected sexual intercourse. This affects around 15% of couples, in Germany around 2 million couples (around every 6th to 7th marriage is involuntarily childless).

Newer treatment techniques in reproductive medicine, such as IvF (in vitro fertilization) or ICSI (intra-cytoplasmic sperm injection), have now become an essential part of sterility treatment. The couple's individual chance of having their own child depends on the severity of the fertility disorder and, above all, on the woman's age. Expecting pregnancy in the first cycle is unrealistic. After all, even in a healthy, young couple, the pregnancy rate is no higher than 20 to 30% per cycle. After exhausting all therapeutic options, around 60 to 80% of all couples who see a doctor for involuntary childlessness can be helped to have their own child.

But not only unwanted childlessness, but also its treatment is associated with a considerable amount of stress. The willingness of the affected couples to take on these burdens often reflects the considerable suffering that arises from involuntary childlessness. Psychological side effects of sterility are, for example, emotional reactions (grief, depression, “emotional crises”, frustration, feelings of guilt, anger etc.), shaking of self-confidence (identity problems, “loss of control” over life planning), changes in the couple relationship and in sex life as well as changes in social interactions (e.g. social withdrawal, avoidance of contact with pregnant women, with young families, etc.).

Since the beginning of sterility treatment and especially since the possibility of extracorporeal fertilization has existed, a great deal of attention has been paid to the medical or “technical” aspects of the treatment. The investigation of psychological aspects, however, was in the background from the start. To this day, nothing has changed significantly.

In the early days of reproductive medicine, psychoanalysts mainly looked at the question of the extent to which the couples who “absolutely” wanted to have a child were “pathological children”. Pathological personalities or neurotic conflicts (e.g. an ambivalent relationship to one's own mother, an unconscious rejection of pregnancy, etc.) were not infrequently made responsible for the unwanted childlessness, especially for the so-called idiopathic sterility (i.e. in cases where there are no causes for sterility could be found). This attitude towards fertility patients is also often reflected in the press.

In recent years, however, it has been shown again and again that fertility patients are ultimately nothing more than a section of the “normal population” that pathological deviations do occur, but not more often than in general. Our own studies of a total of 1,033 fertility patients (546 women, 487 men) as part of the Bonn psychiatric-psychological project on the side effects and consequences of in vitro fertilization also led to similar results.

Couples affected by childlessness generally show no relevant abnormalities (e.g. personality, partnership, attitude to sexuality, pregnancy and childbirth, etc.). Any differences that arise (for example to women who became pregnant in the “normal” way and their husbands) are most likely to be seen as a result of childlessness (such as the less impartial attitude to sexuality) or as a selection effect of the couples who become pregnant decide on fertility treatment (e.g. higher performance orientation, more positive attitude towards pregnancy, etc.).

As part of the Bonn project, among other things, the extent of depression and anxiety in the involuntarily childless couples was examined. A quarter of the male and a quarter of the female patients showed above-average depression values.

In this last group of patients in particular, there was a significant correlation with a large number of mostly negative affective reactions in connection with sterility as well as modes of experience that make coping with unwanted childlessness even more difficult. For example, patients who had high levels of depression experienced severe emotional crises after the diagnosis of sterility and more frequent negative changes in self-esteem and sexual life, withdrew more frequently from social contacts, but also more frequently experienced negative reactions in their social environment. There were more motives for desire to have children in which the child is assigned an important role in its own emotional experience (e.g. “so as not to be alone in old age”) or norm-related motives (“a child belongs to it”).

This group also found more patients who were themselves the cause of childlessness, as well as people who had already made specific preparations for the child (e.g. set up a children's room). Overall, they are more burdened by the current situation, are under greater pressure (e.g. because of age), are at the same time more pessimistic about the success of the treatment and more anxious about the birth.

All working groups that deal with sterility and its treatment have found that experiencing unwanted childlessness and coping with this problem, through to attempting a solution in the form of artificial insemination, can represent a considerable emotional burden for those affected. Our own research on this topic showed that an “unsuccessful” IvF cycle is experienced by most women with significant negative emotional reactions, while only a minority of women surveyed (23%) said it wasn't that bad, they also did not expect a pregnancy. Nevertheless, for the majority of women (77%) the desire to have children remained the same, in 3.4% the desire to have children was even stronger (“after the egg had fertilized, I have the feeling that I am very close”).

An unsuccessful attempt at treatment can also be an essential step in coping with “final” childlessness; after all, approx. 14% of women state that their desire to have children is beginning to be relativized after an unsuccessful treatment cycle. Another result of the survey also fits, namely that 74% of 180 patients who were asked about this several years after completing fertility treatment stated that they would go the same way again (76% of patients with children, 66% of patients without children , 58% of patients with adopted children).

In this context it should be pointed out that it is also important to address the “end of treatment” for the final coping, so that the couples concerned have the opportunity to prepare very specifically for life alternatives.

Other important aspects of psychological or psychotherapeutic support for childless couples are the discussion of possible ambivalences with regard to the desire to have children at the beginning of treatment and again and again during treatment, the anticipation of an unsuccessful treatment with the development of alternative life perspectives as well as care with the aim of minimizing Accompanying and sequelae.

In individual cases, the specific recommendation of a “break in therapy” can be useful - namely when it becomes apparent that the woman concerned is getting more and more into a cycle of depressive reactions, stress and feelings of insufficiency and that the couple is already focusing on the desire to have children has led to a long-term neglect of other interests.

Unfortunately, only a few affected patients seek support or help from psychotherapists or rarely accept the corresponding treatment offers. One of the reasons for this is certainly the aforementioned “labeling” of fertility patients as “pathological” or “selfish”. Institutionalizing psychosomatic care as a natural part of reproductive medicine treatment would be ideal.

Further contributions by the author can be found here in our family handbook


Prof. Dr. med. Anke Rohde
University Hospital Bonn
Gynecological psychosomatics
Sigmund-Freud-Str. 25th
53105 Bonn