Artificial reproductive techniques (ART) have advanced a great deal over the course of the last 30 years or so and treatment for infertility or sub-fertility has become more easily accessible to “ordinary” couples, both through the national health service (e.g., NHS in the UK) and private fertility clinics world-wide. Alongside the technical advances in assisted reproduction, there has been a burgeoning in literature about the psychological difficulties associated with the inability to conceive a child when a couple wishes to do so, as well as the psychological distress consequent on undergoing any treatment necessary, whether this is successful or not [1–5].

In addition to the impact of stress on the quality of life of any individuals undergoing treatment for reproductive difficulties, there is the very important issue of how to screen for and manage the mental health of patients who have a pre-existing significant mental illness (usually moderate to severe anxiety and mood disorders, but also more serious and enduring conditions such as mood related and schizophrenia-like psychoses) or those who develop such illnesses during the course of treatment with ART or after the delivery of a much wanted and long-awaited child (or children, in the case of twin or triplet pregnancies).

The biochemical changes that occur in the pituitary as a result of the “down-regulation” and “up-regulation” of the ovulation cycle in women and the subsequent use of large quantities of hormones for stimulating the production of ova in preparation for egg harvesting and IVF are likely to be significant in the aetiology of first onset severe mood disorders and mood related psychoses, as well as the trigger for recurrent episodes in those with pre-existing illnesses of this kind [6]. However, a review and discussion of this topic is beyond the scope of this chapter. Therefore I will briefly discuss the issue of screening for a personal or family history of moderate to severe mood disorders and psychoses, before going on to describe some anthropological and socio-cultural considerations that may help health professionals to understand a couple’s or an individual patient’s response to the stresses of infertility (or sub-fertility) and treatment for this with ART. I will end with a number of clinical scenarios, which demonstrate the way in which patients may present to the treating fertility specialist, whilst they are attempting to conceive, or to a family physician, obstetrician, midwife or psychiatrist, in pregnancy or postpartum.

Those working in the United Kingdom will be familiar with the kind of screening pro-forma used by midwives at booking for antenatal care, which prompt them to ask a pregnant woman about a personal or family history of mental health problems and more serious mental illness, as the NICE guidelines for antenatal and postnatal mental health, first published in 2007, and updated in 2015, recommend this [7, 8]. Over the last 10 years, and longer than this in areas at the forefront of developing Obstetric Liaison and Perinatal Psychiatric Services, such screening methods have been used to identify those women who are at increased risk of developing a significant mental illness during the course of their pregnancy or in the early weeks after delivery of a child, whether this be a relapse of a pre-existing serious mental disorder, most often mood related, or the first onset of such an illness. It is noteworthy that the latter group of women often have a strong family history of serious mood disorder or psychosis and their genetic vulnerability to these conditions seems to be impacted on by the physiological changes that occur in late pregnancy and early postpartum, leading to a greatly increased risk for first onset psychosis at this time in their lives [9–11].

Ideally a woman who has a pre-existing serious mental illness, who is taking maintenance treatment for this, should have access to pre-conceptual advice about the management of her psychiatric disorder and treatment, in case of an accidental or planned pregnancy. This is particularly relevant to fertility treatments with ART, where there is time for advanced planning. It is to be hoped that such individuals would contact their general practitioner before starting ART or at least on the discovery of a pregnancy rather than waiting for screening in antenatal clinic, allowing for an early psychiatric review or assessment (ideally from a psychiatrist with experience in the sub-speciality of Perinatal Psychiatry or from another mental health professional working in a specialised multi-disciplinary Perinatal Psychiatric Service) and to advise them about the use of psychotropic medication and treatment planning for the remainder of the pregnancy and the early weeks after delivery [12, 13]. For those women who are currently well and not taking medication, screening at around 12 weeks gestation allows for assessment by the beginning of the second trimester of pregnancy, so that the patient and her family know how any emerging symptoms, recurring or new in onset, can be managed robustly, in order to reduce the impact of serious mental illness on the woman and her baby, during pregnancy and afterwards.

The screening that has been developed for antenatal identification of women with a potential for becoming significantly mentally unwell in pregnancy and afterwards, is also useful when a woman or a couple attend a fertility clinic, so that plans can be made for any potential relapse of symptoms during the course of treatment with ART. There may be fertility clinics where such programmes exist and those accessing them feel comfortable enough to reveal their personal or family history of psychiatric disorder. However, I have come across a number of patients who were asked questions about their personal or family history of mental illness, but who chose not to reveal this, for the fear that they would not be able to access the fertility treatment they so desperately wished for; their mental state subsequently deteriorated in pregnancy or the weeks after giving birth, leading them to present acutely to Psychiatric Services. Having talked to a number of colleagues working as fertility specialists locally, my personal experience is that questions about a past history of mental health problems are not asked routinely. Given the potential for difficulties both during treatment with ART and any pregnancy conceived, consideration should be given to making this a formal part of the pre-treatment assessment, so that fertility specialists can work closely with colleagues in Obstetric Liaison or Perinatal Psychiatry in their area, to ensure that patients undergoing fertility treatment receive the same kind mental health care and support as those who present to antenatal clinic following natural conceptions [6, 14].

Perhaps many people would say, or at least think, that anthropological and socio-cultural considerations are not relevant in the twenty-first century. The rapid developments in and spread of communication technologies (be they satellites which beam radio and television programmes into once remote towns and villages, or mobile phones, for which there are apparently an estimated seven billion subscriptions around the world) have led to a “globalisation” of scientific ideas and understandings once felt to belong exclusively to those raised in technologically advanced nations. However, it is my experience of living and working in a very multicultural city in the United Kingdom that even when individuals are educated to a level that would include some basic facts about human biology and physiology, their understanding of fertility and what will lead to conception, is influenced by things other than their formal education.

Religious teachings, which in certain communities of all the world’s major religions, may be taken from texts many centuries old, may influence individuals in their beliefs about procreation. For others, there may be cultural traditions or folk-myths that underlie their understanding about such matters, and they continue to hold these ideas, passed on to them by parents, grandparents and members of the larger community, despite their education in an urban environment in their own or an adopted country. Then again, for some people, traditional beliefs and ideas may be replaced by “modern” or “scientific” explanations about their bodies and the world around them, only to re-surface at times of acute distress or active mental illness (and then these ideas may be described by those treating them, according to a strictly medical model, as “over-valued” ideas or “delusional” beliefs). I have therefore included some ethnographic material in this section, related to beliefs and practices that may now be considered outmoded and irrelevant, but which nevertheless may continue to influence the ideas of individuals with their origins in these communities and geographical locations.

As stated in the introduction above, the subject of infertility has generated a vast literature in biomedicine, and this has been fuelled by the rapid development of artificial reproductive technology (ART) since the 1970s, although artificial insemination by donor (AID) in humans was first performed successfully in 1799 and has been used consistently in Western biomedical practice since the 1920s [15]. There had been relatively little written about infertility and reproductive morbidity in general in the field of medical anthropology until the early 1990s [16]. This is in sharp contrast to the wide ranging exploration of human reproduction by anthropologists with regards to theories of conception across cultures, fertility and birthing practices and more recently, with a rising world population, the thorny issue of family planning.

In a world that is seen as overpopulated, the distress and suffering of those unable to conceive for whatever reason, is largely submerged. Inhorn argues that the gap in medical anthropological knowledge about infertility will become even more important in the light of the increasing incidence of reproductive failure worldwide [16]. One cited example of this trend is of selected populations in the AIDS endemic “infertility-belt” of Central Africa. In this region not only has there been a high mortality from AIDS, but other sexually transmitted infections (STIs) such as gonorrhoea and genital chlamydial infections cause secondary infertility thereby further threatening depopulation. In this region, one-third to one-half of couples are infertile [17, 18], compared to an average of one in six couples in the USA and Europe. Inhorn further argued that there are major gender issues surrounding reproductive morbidity: “Women worldwide appear to bear the major burden of reproductive setbacks of all kinds” [16]. This is in terms of blame for reproductive failure as well as shouldering the engendered personal grief and frustration, marital strain, social stigma and ostracism [1, 19]. This remains the case in the twenty-first century [18]. Where ART is available, although it holds out the hope of a “cure,” it can also be a great iatrogenic source of further distress, both physical and psychological.

Despite widely differing geographical and cultural milieus, women’s experience of infertility is a shared one in which the normative pressures are to conceive. For those who cannot, there is fear, anxiety and isolation generated at times by a sense that the problem is so shameful that it should be kept a secret [1] from family and friends, the very people who would usually be a source of support. Women are described across cultures going to great lengths to overcome what is seen as “their” infertility. The endless search for treatment may take the form of elaborate locally practised de-polluting or fertility enhancing rituals or “high-tech,” invasive ART. Globally, societies give pre-eminence to women’s role as mother and it is women’s bodies that are seen as the locus of the “disease” of infertility. Even when there is a male factor involved in a couple’s inability to conceive, men in many cultures find this hard to acknowledge, such is the socio-cultural determination that infertility is always women’s fault [18, 20]. Therefore it is women’s bodies that are most often the site of surveillance and intervention. Women are most often stigmatized whether it is they who are infertile or not [16, 18, 21].

Studies across cultures show how intimately infertility is linked with other important areas of social life. Kinship, marriage, divorce, inheritance, household residence patterns, economic productivity, gender relations, notions of body, health and illness are examples of the domains involved. Exploring infertility leads to the discovery of many important fertility related beliefs. Theories about how conception occurs and how it may be prevented, intentionally or unintentionally, lead to an understanding of attitudes towards contraception and its perceived dangers. These theories may also shed light on what is believed to cause infertility and what measures are taken to rectify the situation. Infertility highlights the importance societies give to parenting and children and the perceptions of risk and risk-taking with regards to the body and its reproductive processes. In many cultures, infertility is not just a threat to the individual but also a threat to the extended family [18, 19], the community [22], and society itself.

Natural fertility depends on a set of biological variables: monthly probability of conceiving, uterine receptivity, duration of breast-feeding in the post-partum period and the incidence of sterility. All of these factors are modified by cultural practices and social circumstances [23]. There is considerable variation between societies in the age at which women are allowed to marry or become sexually active. Societies may practice monogamy, polygyny, or polyandry. Extra-marital sex may or may not be permissible. Divorce and residence patterns and the economic climate (when and where it may be necessary for large numbers of men to live away from home for long periods, as migrant workers) will also affect a group’s natural fertility.

In societies that practice polyandry the procreative ability of the husbands is limited by the fertility of their one wife. Although this is a less common arrangement than polygyny, it has the advantage of masking any male infertility factors that may exist as long as the wife herself is fertile. In polygynous arrangements, for the wives, there is the reduced probability that coitus will take place during days of the cycle when conception may occur. This may be accentuated when, as often happens with groups of women living together, their menstrual cycles become synchronous. Access to the husband can be a source of friction between co-wives, particularly if one is thought to be favoured above others. When infertility exists in these circumstances a wife may accuse a co-wife of “stealing” her chances of conceiving [24, 25]. Male infertility will be more obvious too in polygynous marriages, if successive wives fail to conceive.

Extra-marital sex may also be a factor influencing a group’s natural fertility. Male infertility could be masked if a wife chose to look outside the marriage to help her conceive. The structure of some societies seems to allow for this. For instance, amongst the Nuer, a husband and his lineage received the fertility of a woman’s womb in return for paying the bride-wealth. Any child which is issue of that womb is of the lineage regardless of who the genitor is. Adultery is considered illegal but not immoral. Fines of cattle imposed on the discovery of adultery are returned if a healthy child is born as a result of it. Otherwise, payment of cattle could be seen as a legitimatization fee and give the genitor a claim on the child [25]. In most societies, however, there are harsh penalties for extra-marital sex. The importance of the husband in having sole sexual access to the wife to ensure paternity is seen as paramount. The notions of honour and shame in studies of Mediterranean culture exemplify this. Women are fields to be fenced off and only ploughed by the owner [26].

There is little consensus across cultures and even within groups about the relative contributions of males and females to conception and fetal growth [23]. These ideas are dependent to some degree on whether a society is organized according to matrilineal or patrilineal patterns. Education plays a part but even in societies where there is universal schooling, all people do not share a similar model. In one American study, women from a low socio-economic group attending antenatal classes demonstrated a poor knowledge of aspects of bodily function such as menstruation, conception, its timing, the function of contraception and ideas about how STIs might be contracted. Ideas about how infertility might come about also vary greatly ranging from beliefs about the heating or cooling properties of food consumed by a woman, to physical damage occurring to a woman’s womb if sexual intercourse takes place at the wrong time in her menstrual cycle [23].

A common theme in theories of conception is that the fetus is made up of semen and maternal blood. The Nayars of Kerala share common South Indian ethno-physiological beliefs about reproduction. These are that male and female alike produce sexual fluids. For fertilization to occur both partners must achieve orgasm so that these fluids can be ejaculated into the uterus, to mix and produce a bubble, (kumili) or sprout (mulai) that develops into an embryo. The Nayars believe the sexes contribute equally in terms of the fluids that go to make up the embryo. However, women are believed to possess more of the divine procreative force (ṡakti) as personified by Ṡakti, the feminine aspect of the Sanskritic god, Ṡiva. This ṡakti is enhanced and harnessed by heat accumulating asceticism (tapas), in the form of abstinence, devotion, suffering and sacrifice. Married women focus their ṡakti for their husbands’ wellbeing through steadfastness and devotion. This religious belief and the fact that, historically, these groups practised polyandry (which would mask male infertility and highlight female infertility) could be reasons why infertility is still defined amongst them as a woman’s failure. It is highly stigmatizing for the afflicted woman but also for her maternal kin, whose duty it is to protect her from dangerous forces that would impede her fertility, such as the wrath of gods and demons, or disharmony within the extended family.

Amongst the Aowin of south-west Ghana, social relationships are seen as a central issue in infertility. This misfortune is seen as a result of troubled relations with the spirit world and said to stem from acts of an individual that have angered the gods. Pollution (efeya) can be acquired by not observing traditional purificatory practices, by neglecting to give the gods appropriate offerings or by bearing animosity towards others (such as co-wives, husband or neighbours). This same pollution can prevent a woman from conceiving [22]. Yet other interferences in the procreative process are seen by African peoples as coming from outside themselves. These external agents are most often “witches” and their patrons. As in common with many other African cultures such as the Giriama of East Africa [27] and the Bangangte of Cameroon [24], the Aowin believe that reproductive morbidity of all kinds can be caused by various forms of witchcraft. Not only can a woman be made infertile by the power of witchcraft but also the envy of a barren woman can make her a witch and thus dangerous to other women’s fertility.

Mediterranean [26] and Northern Indian ideas [28] use the metaphor of the active, male seed implanted in the inert, female field. This ideology may be driven by the patrilineal structure of these societies. Infertility for them can only result from the barrenness of the soil in which the seed is planted. Women unable to reproduce are seen as inauspicious. In many parts of India, they are barred from taking part in sacred ceremonies. In some parts of India, infertile women are even thought to have the effect of blighting crops and being able to adversely affect the health of other women’s children (in common with the African belief about infertile women as harmful witches).

Beliefs about how infertility may occur vary across cultures, but as can be seen from the examples discussed above, there are some common themes in the form of pollution acquired through not observing socio-religious rules. The remedies employed to “cure” infertility are legion and women may take a pluralistic approach to treatment. World-wide, they are as likely to go to spiritual healers and traditional herbalists as they are to biomedical practitioners. This section of the discussion will concentrate on spiritual and traditional healing methods employed in some of the societies mentioned above. Some long-standing, more pragmatic, socially sanctioned alternatives to ART will also be examined briefly, and the discussion of ART in this context will be limited to AID, a technique that is more widely available and perhaps more affordable than IVF and other related, more technically difficult procedures available only in fertility clinics.

Amongst the Nayars of South India pampin tullal is a ritual performed daily over 1–3 weeks as a remedy of the curse of the serpent deities (the curse being infertility of one or more members of the group, taravatu). The goal of this ritual is fertility and auspicious prosperity achieved through worship of the serpent god by two taravatu women who act as proxy for the well-being of the group. In a successful ritual, the deity’s presence is achieved when the two women go into a trance and become possessed by the god. During the trance taravatu members may pray to and speak to the deity and afterwards receive his blessing. The women who enact the ritual must be unattached so that they can focus their sakti for the benefit of the group. More mature women (who are single through being separated, divorced or widowed) are often “chosen” for possession by the deity. In this way, women who are generally disenfranchised are able to highlight grievances or disharmonies within the group that would otherwise remain unaddressed.

Pragmatic solutions to the problem of infertility have long been sanctioned by many societies. In many parts of Africa fostering by close relatives who are childless is common practice. The fostered child will know who his genetic parents are but will carry the name of his foster parents. Legal adoption is less common in many African and Asian settings. Surrogacy is another solution to infertility that has been used throughout history. There is the biblical example of Abraham and his wife Sarah who have a child by Sarah’s handmaid (Genesis, Chapter 16, verses 1–4). In some societies, an infertile woman will select a co-wife from amongst her maternal kin or natal village, thus sharing something of the child born to the co-wife. Amongst the Nuer, women unable to have children of their own are allowed to trade in order to collect a bride-wealth and marry another woman. The woman who is the “husband” then chooses men from her kin or neighbours to father children by the woman who is the “wife.” Children born of these unions are known by the name of the “woman-husband” and they call her “father” [25].

Surrogacy becomes more of a prickly subject when male infertility is involved. In Africa, as in many other parts of the world, the use of AID in many men’s minds is tantamount to their womenfolk committing adultery. For the women, the anonymity of the sperm donor is a major obstacle to the use of AID. They fear they may unwittingly commit incestuous adultery (incest in the African context being broader) and thereby endanger the outcome of the pregnancy. A traditional African alternative to AID is natural insemination by donor. A husband may give unspoken consent for his wife to seek another man from the community to father a child. In some cases, the infertile spouse may choose the donor from amongst his close relatives or friends. The identity of the real genitor is then known to and accepted by the putative genitor and those who share the family secret [20].

The use of natural surrogacy for male infertility problems is also referred to in Indian literature sources. Niyoga is the ancient Hindu practice of lawful cohabitation of a childless wife with her husband’s brother or a Brahmin of “good character.” In the Hindu epic “Mahabharata,” the sage Vyasa sires a son by each of his dead brother’s wives at the request of his mother [29]. Later in the same source, Pandu, who has been cursed to die if he lies with any of his wives, suggests to them that they have children by the “grace of a Brahmin.” These Indian legends have left behind folk myths that in turn have been incorporated into modem literature and film art about India and Pakistan [30–32].

ART is either unavailable or the cost of it is such that it is inaccessible to the majority of infertile couples across the world [18]. Even where it is an option, it is often viewed with suspicion. This is particularly so when there is a need for gamete donation. For many people, men who donate sperm have been seen as somehow deviant and possibly self serving and therefore to be discouraged. On the other hand women who donate eggs, a procedure that has only become possible relatively recently, are felt to be behaving altruistically [33]. It is not surprising therefore that where male infertility is a factor, AID as a form of treatment is often unacceptable. Even in countries where there is a long history of using AID, there can be difficulties. A follow up study in New Zealand that looked at couples up to 10 years after a child had been born revealed there was little consensus between partners as to what they would tell a child about its origins [34]. A study carried out prior to the amendments to the Human Fertilization and Embryology Act (HFEA) in the United Kingdom in 2008 [35] showed that both gamete donors and recipients had significant anxieties about the proposed changes to the Act, which would mean that offspring would be able to access information about their genetic parents, once they reached the age of 18 years.

The descriptions above are not merely a collection of exotica. I have treated White British and European women who have echoed the fears of their African or South Asian peers, as they talked of the envy of female relatives or friends who have fertility problems and how this envy may in some way blight a pregnancy achieved with great difficulty. I have also treated women who have failed to conceive despite repeated interventions with ART, who sadly described the change they observed in female relatives and friends who on conceiving themselves, avoided revealing this news until it was no longer possible to keep it a secret, not out of consideration for the childless woman, but out of some atavistic fear that somehow her lack would become theirs.