Ken Gannon, a psychologist at St Barts and the Royal London Hospital in east London, has researched the emotional effects of infertility on men and women. He and his colleagues found high levels of psychological distress in both sexes, in line with previous research, but, more important, the type of distress differed between the sexes.
"We found that subfertile men were more likely to suffer from anxiety, whereas subfertile women were more likely to be depressed," he says. "The levels of anxiety in men are really very high. About 50 per cent of them have clear clinical symptoms."
This means, he says, that mainstream fertility counselling, which usually follows a bereavement model by acknowledging feelings of loss, may be less appropriate for men than for women.
"Men may feel less like grieving, and more threatened by their subfertility," he says. "There is a powerful feeling that their identity as men is under attack. They also know that society confuses potency, in the sense of the ability to have sex, with fertility."
This makes it hard for men even to acknowledge their distress to themselves. Dr Sammy Lee, a reproductive physiologist at London's Portman Clinic, says that men may react to this huge blow to their self-esteem by isolating themselves from other people and going into complete denial.
"Too many infertile men don't realise that their greatest asset is their partner, who can give them so much support if they'll only let her. Sometimes I get a call from a woman who seeks counselling on behalf of her man - he'll be in the background, chipping in, and I'm counselling him through her. Or he may even be watching the football on TV at the same time."
Nicky Wesson helps to run a support group for infertile couples. "It's daunting for men to come along to a group," she says. "They feel like outcasts - as if they can't talk to anyone. Even communication within the couple is difficult."
It is not surprising that things are the way they are, though, says Dr Lee. Infertility treatment tends to focus on the female, whether or not it is she who has the physical problem. "Men are absent in the clinic, except for the times when they're being treated, or producing a sample. We reduce them to the role of sperm providers.
"It's typical of the way men's feelings are sidelined throughout everything to do with pregnancy and birth," agrees Ken Gannon. "It's the same after a miscarriage. Most of the concerns are directed to the woman, whereas the man may need support, too."
Yet male fertility is a factor in at least half of the one in six couples who have problems. Male subfertility is increasing. Cases of disorders of the male reproductive tract have doubled in the last 30 to 50 years, and there has been an overall fall in sperm counts.
Various environmental reasons have been put forward as a possible cause, including chemical pollution, and, in the case of individuals, substance abuse. "Heavy cocaine use can be extremely damaging to the body's ability to produce sperm," says Dr Lee. And, more startlingly, he also speculates that there may be a physiological link between the way men feel about themselves in a changing world, and their hormones. "Men are in crisis," he says. "They see women in power, and in management positions above them, and they haven't learnt to cope with it yet. If we could investigate, I think we'd find an effect on their sperm production - these ladies bite your balls."
Some of the more dramatic advances in fertility treatment help men, especially men with a low sperm count. Intracytoplasmic sperm injection (ICSI), for example, injects a single sperm into the egg. There is now work being done on extracting a sample of sperm from the testes, and then treating it to zap up its fertility. However, as Marsali Macdonald, a counsellor from Nurture (Nottingham University Research and Treatment Unit in Reproduction), says, new breakthroughs can be a curse as well as a blessing. "It can mean it's difficult to know when to get off the treatment treadmill. It's like the lottery. If you try one more time, could this be the month you strike lucky?"
The cost of fertility treatment may also add to the stress. 75 per cent of couples pay for at least some of their treatment. The patchy availability of NHS services means that it is "treatment by postcode" for some . One man, delighted to be the father of triplets after successful treatment at Nurture, told the Derby Evening Telegraph that he reckoned their children had cost them, all told, pounds 50,000, including his wife's loss of earnings after having had to give up work to undergo treatment.
The Family Planning Association's new booklet, "Infertility Tests and Treatment", acknowledges the effect that infertility has on relationships, including sexual relations. Speaking for men as well as women, it says, "it can be very easy to despair, or to get so anxious about having a child, that nothing else seems to matter."
That was the case with Paul, 36, from London, a catering supplier. Paul has azoospermia - he produces no sperm. "When I got the diagnosis, after two sperm tests, I was really very angry," he says. "Then the anger turned to profound feelings of failure. My wife Rosie and I followed up every possible lead. I had hormone injections for months. Then I had a course of Chinese herbs. But nothing made any difference. I felt that my whole world was being ruled by my infertility. Life was becoming a treadmill of injections, tests, clinic appointments. I wasn't in control."
Paul found that counselling was useful in helping him and his wife decide it was time to stop. "We wanted to take back control, and return to what we had at the start of our marriage - our life as a couple. Now, we accept we won't ever have children, but while we can't say we're happy about it, it doesn't rule our lives any more. If people ask, `how many children do you have?' I just say, `none, I can't have any'. A few years ago, I might not have been able to say that without being emotional."
Issue: 01922 722888; Child, the National Infertility Support Network: 01424 732361. Nurture: 0115 9709490. For the Family Planning Association booklet, which has a useful list of contacts plus treatment information, send pounds 1.50 to FPA Publications dept, PO Box 1078, East Oxford DO, Oxford OX4 5JE. `Alternative Fertility Treatments' by Nicky Wesson (Vermilion, pounds 8.99), `Counselling in Male Infertility' by Dr Sammy Lee (Blackwell Science, 1996)Reuse content