Is a dyadic stressor experienced as equally distressing by both partners? The case of perceived fertility problems

Abstract

Using data from a population survey, this article explores whether perceptions of having a fertility problem among 926 U.S. couples in heterosexual relationships (women aged 25–45 and male partners) are associated with distress. Most couples did not perceive a fertility problem (58%). In almost a third (30%) of the couples, only women perceived a fertility problem; in 4%, only the men; and in nearly a fifth (19%), both perceived a problem. Adjusted for characteristics associated with fertility problems and depressive symptoms, those who perceived a problem exhibited significantly more depressive symptoms than those who did not. Fertility problems are sometimes experienced as individual because in some couples only one partner perceives a problem or has higher distress in response to their own rather than to their partners’ perceived problems. For women, fertility problems are experienced as a couple phenomenon because women were more distressed when both partners perceive a problem. The perception of fertility problems is gendered in that women were more likely to perceive a problem than men. Furthermore, men are most distressed when they perceive a problem and their partner does not.

Keywords

Couples depressive symptoms infertility life course multilevel-models stress process survey research

Researchers have long recognized that we can learn more about the experiences of married and cohabiting couples by treating the dyad rather than the individual as the unit of analysis (Kenny et al., 2006). Stressful situations or events that affect both partners of a couple—either directly or indirectly through spillover from one partner to the other—have been called “dyadic stressors” (Randall & Bodenmann, 2009). Prior research has examined depressive symptoms as an important outcome variable in studies of couples coping with dyadic stressors (ten Brummelhuis et al., 2010). Even if only one partner experiences a stressor, both partners can experience consequences (Townsend et al., 2001). In heterosexual couples, gendered differences in responses to one’s own stress may have important implications for one’s partner’s depressive symptoms (Kouros & Cummings, 2010; Revenson et al., 2005).

Infertility, defined by most physicians as no conception after 12 months or more of recurrent, unprotected intercourse (Vander Borght & Wyns, 2018), is a prime example of a dyadic stressor (Berghuis & Stanton, 2002). Regardless of who has the reproductive problem, both partners in the couple experience the lack of a live birth within the context of the dyad, and medical providers typically consider infertility a “couple” phenomenon. It is not clear, however, whether both partners necessarily perceive themselves as having a fertility problem (Johnson & Johnson, 2009). There are several reasons why partners might or might not share a perception of a fertility problem. It could be that only one partner has a biomedical barrier but that both share the desire for a child. Perhaps only one partner wants a child even though both are aware of a biomedical barrier. In addition, many people do not have an accurate perception of the medical criteria for infertility (Benyamini, 2011); therefore people might perceive a problem even if they do not meet criteria. People might not perceive a problem if they meet criteria but do not want a child (Johnson et al., 2019). Thus, whether or not fertility problems are experienced as a couple phenomenon is an open question.

Guided by stress process theory and the life course perspective, we analyze infertility as a dyadic stressor produced by an inability to achieve a life course goal. This study explores the following questions: Does perceiving a fertility problem matter for one’s own or one’s partner’s depressive symptoms? Are depressive symptoms higher when both or only one partner compared to neither perceives a fertility problem? Do the answers to these questions depend on gender? To answer these questions, we conduct a multi-level modeling analysis on a sample of 926 women and their male partners from the probability-based U.S. National Survey of Fertility Barriers (NSFB; https://digitalcommons.unl.edu/sociologyfacpub/721). Couples belong to one of four fertility problem groups: (1) neither partner perceived, (2) both perceived, (3) only she perceived, or (4) only he perceived a fertility problem.¹ In couples in which both partners perceive a fertility problem it is likely that partners share a dyadic stressor and are therefore likely to have higher distress than partners in couples in which neither partner perceives a problem.

Literature review

Theoretical background

Our analysis of infertility as a dyadic stressor is guided by stress process theory (Au, 2017; Pearlin et al., 1981) and the life course perspective (Elder et al., 2003). Stress occurs when people experience a gap between events or circumstances, called stressors, and their perceived resources to cope. The basic tenets of stress process theory can be briefly summarized: (1) Stressors are built into social structures; people are exposed to stressors based on the roles they play, the statuses they occupy, and the resources they possess. (2). Stress proliferates across social domains (from one role to another) within individuals. Stress also proliferates from one person to another among role partners. (3) Stressors often function through their effect on self-concept. Thus, the effect of stressors depends upon values, goals, and expectations. (4) The relationship between stressors and health outcomes is mediated by coping and by resources, including social support and degree of sense of mastery. (5). Stress can affect physical and mental health in multiple ways. In stress process theory, stressors need not be events but can also be “non-events” or failures to achieve life goals (Aneshensel, 1992). Koropatnick et al. (1993) have explicitly identified infertility as just such a stressful non-event. If infertility blocks the goal of a wanted child, then it qualifies as a stressor and is therefore likely to be associated with elevated distress compared to those who do not experience a stressor (Pearlin et al., 1981).

Unlike stress process theory, which focuses on health outcomes, the life course perspective can be seen as a general perspective on social life. The life course perspective emphasizes the importance of viewing behavior in historical and biographical contexts (Elder et al., 2003). In the life course perspective, researchers assume that earlier actions affect later actions to create unique trajectories across transitions. In addition, the life course perspective assumes that people have agency and can plan their lives but that choices are constrained by social norms and socially available resources. Life course theory also stresses the importance of “linked lives,” or the idea that one’s own life course shapes and is shaped by the lives of others, especially those in relationships. Life course norms in the U.S. stress the importance of parenthood (Abma & Martinez, 2006; Morgan & Rackin, 2010), and both motherhood (McQuillan et al., 2008) and fatherhood (Tichenor et al., 2011) are important statuses and valued roles. If parenthood is a desired social status, then infertility can be understood as a barrier to achieving an important life goal (Greil et al., 2014) and an unwelcomed interruption to an expected life course (Matthews & Martin Matthews, 1986).

Stress process theory and the life course perspective are fully compatible because life course transitions are often a source of stress and because the effect of stress on individuals depends on life course goals and expectations. Both perspectives also account for the potentially dyadic nature of stressful experiences within the couple context.

Fertility problems and depressive symptoms

It is common to use depressive symptoms as an outcome in stress process research. Numerous clinic-based studies find that women with infertility have higher depressive symptoms than women without infertility (e.g. Miles et al., 2009). In a population-based study, McQuillan et al. (2003) found that women with infertility and without children report significantly higher distress levels compared to those with children (with or without infertility). Fewer studies focus on men with infertility. A longitudinal study in Denmark (Peronace et al., 2007) concluded that infertility is stressful for men regardless of the infertility source (male factor, female factor, combined, or unexplained). In contrast, Monga et al. (2004) discovered that men in couples with infertility do not differ from men in couples without infertility on psychological well-being, but the sample was very small.

Various survey measures of self-reported fertility problems have been used in population studies. One measure relies upon medical criteria by using a period of 12 months of regular, unprotected intercourse without pregnancy as the indicator for infertility (e.g. Chandra et al., 2013; Greil et al., 2010). Other measures are based on perceptions of one’s own fertility rather than medically defined infertility (e.g. Gemmill, 2018; Polis & Zabin, 2012). Many women who meet medical criteria for infertility do not perceive themselves as infertile (White et al., 2006). Conversely, women may perceive a fertility problem even if they do not qualify as infertile by the medical definition (Greil et al., 2014). Self-perception measures better match lay constructions of infertility (Benyamini, 2011). Lowry et al. (2020) found that a self-perception measure had a larger association with depressive symptoms among women than a measure of meeting medical criteria. In the current study, we use a self-perception measure of fertility problems because our focus is on the subjective experience of fertility problems.

Couple perspectives on fertility problems and depressive symptoms

As noted above, stress process theory posits that stress proliferates from one person to members of that person’s role set, including partners in couples. Studies of couples seeking medical treatment for infertility focus on people who presumably share a blocked goal and are therefore particularly likely to experience infertility as a dyadic stressor (e.g. Martins et al., 2014). Nonetheless, partners in couples seeking fertility treatment often differ in their coping strategies, and this can have implications for individual and partner distress (e.g. Benyamini et al., 2009; Kim et al., 2018; Péloquin et al., 2018; Shreffler et al., 2017). Such studies of clinic patients, however, cannot capture the likely different experiences of those who experience infertility but do not seek treatment (Chandra et al., 2014). Thus, it is important to explore the extent to which perceiving fertility problems is a shared experience in a sample of couples that includes both those who have and have not sought treatment.

One social structure that shapes the stress process is gender (Pearlin, 1989). Fertility problems are gendered in several ways. The drama of infertility is played out in the woman’s body because it is women who experience menses, who are the subjects of most fertility treatment, and who ultimately become pregnant (or not). Furthermore, the social construction of parenthood in U.S. society presumes that parenthood is more central to women’s than men’s identities (England, 2010). Several studies have found that infertility is more distressing for women than men (Benyamini et al., 2009; Wichman et al., 2011). Barnes (2014) studied couples with male infertility and found that the men did not necessarily see their infertility as a threat to their identities. A population-based study found that, among those who initially intended to have a child, no longer intending was associated with higher depressive symptoms for women, but not for men (White & McQuillan, 2006). Maximova and Quesnell Vallée (2009), however, found no difference in distress between men and women who experienced unintended childlessness.

In ethnographic research, Greil (1991) found that men were most distressed if they had the physiological problem but that women were equally distressed regardless of which partner had a reproductive impairment. Other studies have suggested that women experience fertility problems as a direct threat to identity, whereas men experience infertility more indirectly through the effect it has on their wives (Greil et al., 2018; Péloquin et al., 2018). To assess whether gender shapes the experience of fertility problems, it is ideal to study both partners in the same heterosexual relationship to allow adjustment for all couple characteristics. The current study advances stress process theory and the life course perspective by exploring the extent to which infertility is experienced as a dyadic stressor, with a particular eye toward the gendered nature of fertility barriers.

Characteristics associated with fertility problems and distress

Many studies of couples’ responses to fertility problems have emphasized coping strategies or the cognitive structure of the infertility experience (e.g. relationship between self-blame and distress) (Kim et al., 2018; Péloquin et al., 2018). In keeping with stress process theory and the life course perspective, we emphasize measures of social structural, attitudinal, and life course factors in our models of perceived fertility problems and depressive symptoms. Marriage may make lack of conception more salient because marriage is often seen as a signal to have children (e.g. Elder et al., 2003). Marriage is also associated with better health and less social isolation (Koball et al., 2010), factors associated with lower depressive symptoms. Primary infertility (infertility before having a child) is associated with higher odds of perceiving a problem than secondary infertility (infertility after having a child) (Greil et al., 2011b; Moreau et al., 2010). In addition, women with primary infertility exhibit higher levels of distress than women with secondary infertility (Epstein & Rosenberg, 2005; Verhaak et al., 2005).

Prior research suggests that social capital is associated with the ability to cope with infertility. Among women with infertility, more education and higher age are associated with lower distress (Greil et al., 2011b; Vizheh et al., 2015). More economic hardship is associated with higher levels of distress (Phelan et al., 2004), and lower incomes mean fewer options for responding to fertility barriers (Bell, 2014). Race/ethnicity is also associated with depressive symptoms (Rushton et al., 2002). Higher religiosity (Mahajan et al., 2008; Mishra et al., 2017) and social support (Martins et al., 2014) are associated with lower distress among women with infertility. Women (McQuillan et al., 2008) and men (Tichenor et al., 2011) vary in the importance they place on parenthood, and higher importance of parenthood has been found to be associated with higher depressive symptoms among women with infertility (Greil et al., 2011a). Medical help-seeking for fertility problems is associated with even higher distress than fertility problems alone (Greil et al., 2011a). Including individual and couple characteristics provides a way to assess if the relationship between perception of fertility problems and depressive symptoms among couples is mediated or spurious.

Statement of the problem

We simultaneously model the association of perception of a fertility problem with depressive systems for partners, adjusted for control variables, and estimate whether the associations are the same for both partners. Based upon the expectation that infertility is a dyadic stressor representing a blocked life course goal, we propose the following hypotheses:

H1a: If fertility problems are experienced as a couple phenomenon, couples will be more likely to be in the “both” or “neither” categories than in the “her” and “him” categories.

H1b: If fertility problems are experienced as an individual problem, the distribution of problem perception will mirror patterns of biomedical infertility (a third her, a third him, and a third both) (Greil et al., 2014).

H1c: If fertility problems are experienced as a woman’s issue, couples will disproportionately be in the “her” category.

H2a: If fertility problems are experienced as a couple phenomenon, both partners will have elevated depressive symptoms if either partner perceives a fertility problem, compared to couples in the “neither’ category.

H2b: If fertility problems are experienced as an individual problem, the partner that perceives a problem will be more likely have elevated depressive symptoms compared to couples in the “neither” category.

H2c: If fertility problems are experienced as a woman’s issue, women will be more likely to have elevated depressive symptoms compared to those in which neither perceives, regardless of which partner perceives a fertility problem.

Sample

The NSFB conducted telephone interviews with a probability-based sample of 4,787 U.S women aged 25 to 45 during the years 2004–2007. This survey also collected information about 932 male partners of these women: all partners of women who had or were at risk for infertility were contacted as well as 25% of the partners of women classified as “not at risk” for fertility. Out of all partners contacted, 47% participated in the study. The study had institutional review board approval.

Methodological information can be accessed at:

https://www.icpsr.umich.edu/icpsrweb/DSDR/studies/36902#bibcite. The estimated response rate (American Association for Public Opinion Response Rate R4 calculation) for the sample is 53.0% for the screening question, which is typical for Random Digit Dialing telephone surveys conducted in recent years (McCarty et al., 2006). Extensive comparisons with Census data indicate that the sample is mostly representative of women aged 25–45 in the U.S. The analytic sample consists of all 926 couples for whom data on both partners were available.

Concepts and measures

The outcome variable is depressive symptoms, as measured by the 10-item modified version of the Center for Epidemiologic Studies–Depression Scale (CES-D) (Andresen et al., 1994; Radloff, 1977). Both partners were asked to respond to items such as the following: “In the past two weeks…I was bothered by things that don’t usually bother me;” “I felt depressed;” and “My sleep was restless.” Permitted responses ranged from 0 (never or rarely) to 3 (all of the time). Cronbach’s alpha for the CES-D scale in the NSFB is .78. To minimize skew, we logged the depressive symptoms scale; the size and direction of coefficients were similar to those in the unlogged version.

The focal independent variable is perceived a fertility problem and is measured by answers of “yes” or “maybe” to the following: “Do you think of yourself as someone who has, has had, or might have trouble getting pregnant (women)/fathering a child (men)?” and/or “Do you think of yourself as someone who has or has had fertility problems?” Because both partners were asked the questions, couples were assigned to one of the groups described above: (1) neither, (2) both, (3) her, or (4) him. We do not include data on which partner met medical criteria for infertility in the analysis because the measure is not available for the men and our focus is on perceptions, and previous research has shown that it is unnecessary to include perception and biomedical measures (Lowry et al., 2020). Based upon rationales described above, we controlled for several characteristics (cohabiting vs. married, age, parental status, relationship length, education, race/ethnicity, religiosity, social support, importance of parenthood, and medical contact for help getting pregnant). Because more questions were asked of the women than the men, we measured couple-level control variables using women’s reports. For variables that may differ for partners within the same couple, we used measures for each partner (See Table 1 for more details about control variables).

Table 1.

Control variables used in the analysis.

Name	Description
Relationship Status^a	Indicator for Cohabiting (reference is married).
Relationship Length^a	Duration of the relationship in years.
Economic Hardship^a	Responses range from rarely to usually. “During the last 12 months (1) how often did it happen that you had trouble paying bills? (2) how often did it happen that you did not have enough money to buy food, clothes, or other things your household needed?” and (3) how often did it happen that you did not have enough money to pay for medical care?” (α = .82). Higher scores indicate greater hardship.
Parent^b	Indicator for at least one child (reference is no children).
Age	Measured in years (for women only)
Education^a	Years of formal schooling. Also created dichotomous variable: 1 = BA or higher, 0 = less.
Race/Ethnicity^b	Standard US Census wording. Indicator variables for Black, Hispanic, or Asian (reference is White). Participants choosing more than one category were classified as Hispanic first, then Black, then Other, then White.
Religiosity^b	Responses vary by measure: 1) “How often do you attend religious services?” 2) “About how often do you pray?” 3) “How close do you feel to God most of the time?” and 4) “In general, how much would you say your religious beliefs influence your daily life?” The items were standardized and averaged (α = .77). Higher scores indicate greater religiosity.
Social Support^b	Responses range from often to never: “How often is each of the following kinds of support available to you if you need it?” Example, “Someone to give you good advice about a crisis?” (α = .83 for women, α = .80 for men). Higher scores indicate greater perceived social support.
Importance of Parenthood^b	Responses range from strongly agree to strongly disagree: (1) “Having children is important to my feeling complete as a woman/man,” (2) “I always thought I would be a parent,” (3) “I think my life will be or is more fulfilling with children,” and (4) “It is important for me to have children.” Responses range from not very to very important: (5) Mean of available items (α = .79 for women, α = .86). Higher scores indicate higher importance of parenthood.
Medical Contact^b	Indicator for “yes”; reference is “no”. “Have you ever been to a doctor or a clinic to talk about ways to help have a baby?”

a) Women report for the couple; b) Men and women report for themselves.

Analytical approach

Having data for both partners allows estimation of individual and couple dimensions of perceiving a fertility problem. We used a multilevel model approach (Raudenbush & Bryk, 2002) to estimate a measurement model for partners’ psychological distress (Level 1 model), with the resulting latent variable measures of his and her distress as the couple level outcomes at Level 2. We followed an approach proposed by Barnett et al., (1993) for cross-sectional couple data that increases the power and precision of the estimates and allows the simultaneous analysis of both partners. We describe this approach in detail in an online supplement Appendix A.

This method produces estimates of coefficients for all variables for his and her depressive symptoms and a test of whether the focal coefficients are significantly different from one another, adjusted for the other variables in the model, using equality constraints (Windle & Dumenci, 1997). The equality constraints approach maximizes the potential of finding a gender difference by minimizing the standard error of the model (Barnett et al., 1993). Finally, consistent with Raudenbush and Bryk’s (2002) suggestion, we ran all the models using both full and restricted maximum likelihood estimation. There were slight differences between estimation procedures; we therefore report the more conservative estimate of restricted maximum likelihood (all models are available upon request). We used HLM 7.0 for our statistical analyses.

Results

Table 2 shows descriptive statistics and the results of post-hoc statistical tests of specific group comparisons using chi-square (for proportions) and Analysis of Variance (ANOVA) tests (for means). In most couples, neither partner perceived a fertility problem (537/926 = 58%). In about a third of the couples (34%), only one of the partners perceived a problem. In a few (8%) couples, both partners perceived a fertility problem. Consistent with H1a, partners in most couples (58% + 8% = 66%) agreed about their fertility status. In contrast to Hypothesis 1b, which predicted that perceptions of fertility problems would be proportionately distributed, among the 389 couples in which either or both partners perceived a problem, most of the couples consisted of only the women perceiving a problem (71%), and few consisted of only men (9%) or both (19%) perceiving a problem. Consistent with H1c, fertility problems were more salient for women than men among couples in which at least one partner perceived a problem.

Table 2.

Descriptive statistics for couple by categories of fertility problem status.

Who Perceived a Problem?
	Neither(0)(n = 537)		Only Self: Women(1)(n = 278)		Only Self: Men(2)(n = 36)		Both(3)(n = 75)		Total(N = 926)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Depressive Symptoms (W)	.40	.25	.49	.28	.42	.25	.52	.27	.44	.26	***a
Depressive Symptoms (M)	.35	.23	.34	.24	.50	.26	.44	.29	.36	.25	***b
Cohabiting (v. Married)	.08		.06		.17		.04		.07
Years in a Relationship	7.59	6.17	8.35	5.83	8.42	6.50	9.72	5.61	8.02	6.06	*c
Economic Hardship (W)	1.38	.62	1.45	.71	1.37	.52	1.61	.84	1.42	.67	*c
# of Children (W)	1.44	1.41	1.11	1.19	1.25	1.32	.99	1.20	1.29	1.33	***d
Mother	.68		.61		.61		.55		.65		*c
Father	.70		.66		.53		.47		.66		***c
Women’s Age	33.50	6.03	35.35	5.76	35.33	6.24	36.56	5.62	34.37	6.01	***d
Men’s Age	35.86	7.19	37.69	7.63	36.56	8.25	39.25	7.66	36.71	7.48	***d
Education (W)	15.55	2.63	15.54	2.83	14.69	2.23	15.42	2.89	15.50	2.70
Woman has at least BA (v. Less)	.60		.56		.44		.55		.58
White (W)	.73		.72		.75		.85		.74
Black (W)	.09		.11		.08		.04		.09
Hispanic (W)	.12		.13		.17		.05		.12
Other (W)	.05		.04		.00		.05		.05
White (M)	.74		.75		.78		.84		.75
Black (M)	.09		.12		.08		.05		.09
Hispanic (M)	.13		.09		.14		.08		.11
Other (M)	.05		.04		.00		.03		.04
Religiosity (W)	−.05	.89	−.04	.92	−.31	1.03	−.29	1.07	−.08	.92
Religiosity (M)	.02	.85	.01	.83	−.14	.91	−.15	1.00	.00	.86
Social Support (W)	3.78	.44	3.69	.53	3.68	.66	3.59	.61	3.74	.50	*e
Social Support (M)	3.48	.73	3.40	.74	3.21	.84	3.39	.78	3.44	.74
Importance of Parenthood (W)	3.22	.77	3.31	.73	3.09	.72	3.24	.80	3.24	.76
Importance of Parenthood (M)	3.24	.70	3.24	.65	2.92	.75	3.13	.69	3.22	.69	*e
Medical Contact (W)	.07		.53		.11		.69		.26		***f
Medical Contact (M)	.04		.40		.22		.69		.21		***f

Note: National Survey of Fertility Barriers Wave 1 2004–2006; Random sample of women (& male partners) U. S.

Note: (W) = Women’s report (M) = Men

Note; ANOVA for continuous variables; Chi square for categorical variables.

Note: Post Hoc Tests (0 = neither, 1 = self only (woman), 2 = self only (man), 3 = both

a. 0 = 2; 0 < 1,3, b. 0 = 1; 0 < 2,3; 0, 1, 3 < 2, c. 0 > 3

d. 0 > 1,2, 3, e. 0 > 2, f. 0 < 1,2, 3;2 < 1,3; 1 < 3

At the bivariate level, the results support H2b because the level of depressive symptoms differed significantly by fertility problem category for women and men (F = 6.48, p = .000). Post hoc tests indicated that depressive symptoms were significantly lower for those in the “neither perceived” category than for the “self-perceived” categories (includes “both”), but not different for the “other perceived” categories. Among women, the most distressed category was “both,” but for men, it was “him”, providing support for H2c and partial support for H2a.

Table 2 also provides bivariate-level information about the relevance of the control variables included in the multivariate models. In contrast to the prediction based on the life course perspective that fertility issues would be more salient for married than cohabiting couples, there are similar percentages of couples who cohabit in each fertility perception category. Because birth rates vary by race/ethnicity and education level, we anticipated, but did not find, differences by fertility problem group. Couples in which both partners perceived a problem had significantly longer relationships, higher economic hardship, lower social support (for women), and were less likely to be parents than couples in which neither partner perceived a problem. Couples in the “neither” category had more children and were younger than the couples in the “her” or “both” categories. Couples in the “him” category had lower importance of parenthood scores than those in the other statuses. Very few (7% of women and 4% of men) in the “neither” category said they ever talked to a doctor about ways to get pregnant. A significantly higher percentage of couples in which both partners perceived a problem talked to a doctor than those in the other categories.

The coefficients for the women and men partners are listed in separate columns for the same multilevel model (see Table 3; Models 1 and 2 include both partners). The gender of “self” and “partner” depend upon the column being read (women or men). Model 1 includes the fertility problem indicators only, and Model 2 adds the remaining independent variables. The intercepts indicate the average log depressive symptoms for members of couples in which neither partner perceives a fertility problem. As the note in Table 3 indicates, women (B = .41) have significantly higher depressive symptoms than men (B = .35).

Table 3.

Multilevel model results: Women and men partners’ logged depressive symptoms by couple perceptions of a fertility problem status.

	Women Partners						Men Partners
	Mode 1 (W)			Model 2 (W)			Model 1 (M)			Model 2 (M)
	Unst. Coeff.	SE	P	Unst. Coeff.	SE	P	Unst. Coeff	SE	P	Unst. Coeff.	SE	P
Intercept	.40	.01	<.001	.41	.02	<.001	.35	.01	<.001	.35	.02	<.001
Couple Status^
Both Perceive	.12	.03	<.001	.10	.04	.008	.09	.03	.010	.08	.04	.023
Only Self Perceived	.08	.02	<.001	.08	.02	<.001	.14	.05	.003	.12	.04	.006
Only Part. Perceived	−.01	.04	.890	−.03	.05	.563	−.01	.02	.556	−.02	.02	.356
Control Variables
Cohabits				−.01	.03	.790				.09	.03	.009
Years in a Relationship				.00	.00	.161				.00	.00	.406
Econ. Hardship (W)				.10	.01	<.001				.05	.01	<.001
Mother (ref: not)				.02	.03	.522				−.02	.03	.460
Father (ref: not)				−.01	.03	.846				.02	.03	.446
Age (W)				.00	.00	.411				.01	.00	.012
Age (M)				.00	.00	.642				.00	.00	.017
Education (W)				−.01	.00	.100				.00	.00	.507
Race/Eth (Ref: White)
Black (W)				.02	.06	.735				.02	.06	.746
Hispanic (W)				.00	.03	.901				.03	.03	.388
Black (M)				−.07	.06	.245				.00	.06	.986
Hispanic (M)				−.02	.03	.598				−.05	.03	.154
Religiosity (W)				−.04	.01	<.001				.00	.01	.812
Religiosity (M)				.03	.01	.042				−.02	.01	.088
Social Support (W)				−.02	.02	.206				.01	.02	.383
Social Support (M)				−.04	.01	<.001				−.03	.01	.004
Imp. of Parent. (W)				.00	.01	.928				.01	.01	.336
Imp. of Parent. (M)				.00	.02	.956				.00	.02	.835
Medical Contact (W)				.01	.03	.798				.00	.03	.868
Medical Contact (M)				−.04	.03	.196				.00	.03	.904
	S.D.	Var	P	S.D.	Var	p	S.D.	Var	P	S.D.	Var	p
Level 2 (Couple) U	.21	.04	<.001	.19	.04	<.001	.19	.04	<.001	.18	.03	<.001
Level 1 (Measure) e	.22	.05		.22	.05

^(Ref: Neither Perceived)

Note: S.D. = Standard Deviation; Var = Variance Components; P = P-Value;

(W) = Women’s report; (M) = Men’s report

Models use Restricted Maximum Likelihood Estimation (RMLE)

Equality constraints indicate significantly worse fit when men’s and women’s “Both” and “Self” coefficients are constrained to be equal but not the “other perceived”:

Both perceive a problem: chi-square = 15.98; df = 2, p < .001

Own perception on own distress: chi-square = 25.20; df = 2. p < .001

Other perceives on own distress: chi-square = .36; df = 2, p-value = > .500

If only the partner perceived a problem, the respondent did not have elevated depressive symptoms compared to couples in which neither perceived a problem; therefore, the results do not support H2a that fertility problems are experienced as a couple phenomenon. There is support, however, for H2b that fertility problems are experienced as individual problems, because only the partner that perceived a problem (self only or both partners) had elevated depressive symptoms compared to couples in which neither partner perceived a problem.

In contrast to H2c, men and women, rather than only women, had elevated depressive symptoms (8 to 12% higher) in couples in which both partners perceived a problem. In couples in which only one partner perceived a problem, partners who perceived the problem had elevated distress, and the coefficients for the men were significantly higher (12%) than for the women (8%), as indicated by a significantly worse fit when the coefficients were constrained to be equal for women and men (Chi-square = 10. 83; df = 2, p-value = .005). Distress levels were higher for men whose partners did not share their perception of a fertility problem than for women in the parallel situation. Women’s and men’s log depressive symptoms were moderately correlated in couples (i.e. Tau correlation was .258 in the unadjusted model and .217 in the model adjusted for all of the other variables).

Several of the control variables were associated with women’s and men’s depressive symptoms. For men only, those cohabiting had higher depressive symptoms than those who were married, and higher age was associated with higher depressive symptoms. For both men and women, higher economic hardship was associated with higher depressive symptoms. Higher religiosity was associated with lower depressive symptoms among women but higher depressive symptoms among men. There were “cross-over” effects for some variables (e.g. religiosity and social support), in that a higher score for one’s partner was associated with one’s own higher depressive symptoms.

Discussion

Guided by stress process theory and the life course perspective, we analyzed perceived fertility problems as a dyadic stressor. From these perspectives, fertility problems can be conceptualized as a stressful “non-event” and an inability to achieve a life course goal. Although lack of conception manifests in only one partner’s body, it is potentially a dyadic stressor with implications for both partners. Simultaneously analyzing both partners in a couple provides a rigorous examination of the relevance of gender and partners for the association of perceived fertility problems and depressive symptoms.

The results suggest that the dyadic stressor of perceived fertility problems is not always experienced as a couple phenomenon (partial support for H1a). There are some couple dimensions to perceived fertility problems. First, in the majority (66%) of couples, partners report the same fertility status. Agreement occurred, however, primarily among those who did not perceive a problem (58%), with only 8% of both partners in couples reporting a fertility problem (lack of support for H1b). Of the 34% of couples in which only one partner perceived a problem, most of the “perceivers” were women (89%). Partners agreed overall, but among couples in which either partner perceived a problem, fertility problems were mostly the concern of women (support for H1c).

Stress process theory suggests that stress transfers across social relationships. Yet the association in the current study between perceiving a problem or not and depressive symptoms suggests a more complicated story (partial support for H2a and b). For both women and men, perceiving fertility problems was associated with higher levels of depressive symptoms than not perceiving a problem, but there was no association between one’s partner’s perception of fertility problems and one’s own depressive symptoms. That individuals in couples in which only the partner perceives a problem do not have elevated distress suggests that, if both partners do not share the problem, it does not become a shared couple experience. The findings from the current population based study support the assertion from stress process theory that stress is associated with mental health and provide insights about the dyadic dimensions of the stressor.

The relevance of fertility problems for distress is shaped by gender and whether both partners perceive a problem or not. The association between fertility problem perception and depressive symptoms was larger for women when both partners perceived a problem and for men when only the man perceived a problem. Granted, couples in which only men perceive a problem are relatively rare, but the size of the coefficient (12% higher on the log depressive symptoms scale) and the fact that it is statistically significant suggests a robust association.

The sample for this study differs from prior research (e.g. White & McQuillan, 2006) because the women and men are members of the same couple. White and McQuillan (2006) found that relinquishing fertility intentions is associated with higher distress among women but not men, but they did not account for partner perceptions and thus may have missed aspects of men’s experiences. Greil et al. (2018) used a sample of 425 couples in which the women met medical criteria for infertility in the NSFB to study relationship satisfaction. They found that women in couples with infertility have lower relationship satisfaction when either partner or both partners self-identify as having a fertility problem, but that men who self-identify as having a fertility problem did not have lower relationship satisfaction. Thus, when relationship satisfaction is the outcome, there is evidence that fertility problems are experienced as a couple phenomenon. Relationship satisfaction is by its very nature a dyadic phenomenon, but depressive symptoms might have a more pronounced individual component. Both studies provide evidence that perception of a fertility problem varies by gender. Again, the current study demonstrates that fertility issues can be not only a personal stressor but also a relational stressor. In this way, stress may accumulate in that the fertility barrier not only blocks a life course goal but also initiates a new relational stressor.

Other studies have focused on fertility-specific distress (e.g. Peterson et al., 2006) and found higher scores in couples that took greater personal responsibility for the fertility problem than those who took less personal responsibility. Fertility-specific stress was lower in couples in which only women had high responsibility. Péloquin et al. (2018) found that, among couples enrolled in fertility treatment, women were more likely to blame themselves for their infertility. In addition, one’s own self-blame was related to one’s own level of depressive symptoms, women’s self-blame was related to partner’s depressive symptoms, and women who blamed their partners for infertility had higher levels of depressive symptoms than women who did not blame their partners. Thus, even with slightly different measures, other studies have found some couple-level and some individual-level associations between fertility problems and measures of distress.

Studies of samples that have more details on the source of fertility problems find higher stress among couples facing male factor compared to female factor infertility (Lykeridou et al., 2009), but other studies have not found this (Johnson & Fleddarjohann, 2012; Peronace et al., 2007; Verhaak et al., 2005). Based upon interviews with couples seeking medical help for infertility (Greil, 1991), men were most distressed if they had the physiological problem, but women were equally distressed regardless of which partner had a reproductive impairment.

Our analysis controls for whether or not couples made medical contact for help getting pregnant, but future research could better elucidate the role of medical help-seeking for psychological distress. Perception of a fertility problem usually follows but can also lead to self-identification after making medical contact (Johnson et al., 2019). We know of no research on the role of medical help-seeking and how much partners share a perception of a problem. In the current sample, the same proportion of men and women in couples in which both perceived a problem also reported making medical contact (69%). The high percentage of both partners making medical contact in the “both perceive” group lends some support for the idea that infertility is more likely to be viewed as a couple phenomenon in clinical settings.

Cross-sectional data limits our ability to assess causal ordering. We assume that perception of fertility problems precedes depressive symptoms. Lack of information about which partner (or both) has a biological barrier to fertility limits our ability to fully explore the interplay between physiological and perceived barriers. In addition, access to a measure of whether partners ever discussed infertility would enhance our assessment of how much infertility is a dyadic phenomenon. Having so few men who perceived a problem when their partners did not limits confidence in the generalizability of this group, as does the restriction to men who were partnered with women in our primary sample, but the focus on ascertaining the degree of “coupleness” necessitated this approach.

A broader definition of psychological distress, such as including substance use and anger, might show different patterns, particularly between men and women, because of gender norms for expressing emotions (Martin et al., 2013). Furthermore, the measure of fertility problems refers to perception in the past and present, but the measure of depressive symptoms refers to the 2 weeks prior to the interview. Consequently, for some respondents, the fertility problem was only in the past and is not a current issue (e.g., if they conceived with or without assistance, adopted, or decided to be childfree). Therefore, our analyses may underestimate associations between fertility problems and distress. In addition, our data set did not include reliable evidence on the duration of episodes of infertility. The importance of understanding individual and couple dimensions of biomedical and perceived fertility issues for various psychosocial outcomes requires investment in population data collection that is longitudinal, links partner data, incorporates medical test data on specific fertility barriers, and includes multiple measures of distress.

Even with these limitations, this study is the first to provide a population-based investigation of the implications of the relationship between perception of a fertility problem and depressive symptoms at the couple level. We can thus generalize beyond treatment-seekers and make comparisons between couples in which only one partner perceived a problem and those in which both or neither do. Our results show that infertility is a couple phenomenon because most couples agree on their perception of infertility. It is gendered as well because, among the couples who perceive fertility problems, women tend to perceive problems disproportionately more often compared to men. However, the connection between perceived infertility understood as a stressor and depressive symptoms is by and large an individual phenomenon. In other words, participant’s depressive symptoms were connected to one’s fertility problems but not to the fertility problems of one’s partner. The relationship between perceived infertility and depressive symptoms is both gendered and dependent upon the couple context. The psychological consequences for men and women depend upon whether or not the problem is shared (higher distress for women) or not (higher distress for men).

We have thus shown that people in the U.S. with perceived fertility problems respond to those problems as individuals, as members of a dyad, and as men and women. Medical and mental health professionals helping those with fertility problems should therefore assess, and not assume, how much partners share the experience. Those working with couples with infertility need to understand that infertility is a couple phenomenon that nonetheless could influence partners in distinct ways. From a theoretical point of view, our findings highlight the need to approach fertility problems as a dyadic stressor that people nonetheless experience in individual ways. Our findings also illustrate the utility of examining response to blocked goals from a viewpoint that combines stress process theory with the life course perspective.

Supplemental material

Supplemental Material, Couples_JSPR_Appendix_A_Methodological_Details_citation_(003) - Is a dyadic stressor experienced as equally distressing by both partners? The case of perceived fertility problems

Supplemental Material, Couples_JSPR_Appendix_A_Methodological_Details_citation_(003) for Is a dyadic stressor experienced as equally distressing by both partners? The case of perceived fertility problems by Julia McQuillan, Arthur L. Greil, Anna Rybińska, Stacy Tiemeyer, Karina M. Shreffler and Colleen Warner Colaner in Journal of Social and Personal Relationships

Footnotes

Authors’ note

An earlier version of this work was presented at the European Population Council meeting in Brussels, Belgum in 2018.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by an NICHD grant R01-HD044144 “Infertility: Pathways and Psychosocial Outcomes” to Lynn White and David R. Johnson (Co-PIs).

ORCID iDs

Julia McQuillan

Colleen Warner Colaner

Open research statement

As part of IARR’s encouragement of open research practices, the author(s) have provided the following information: This research was not pre-registered. The materials used in the research can be obtained at:

Supplemental material

Supplemental material for this article is available online.

Note

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