This paper explores the intimate dynamics of male infertility in Lahore, at the intersection of cultural norms, masculinity, and reproductive health in Pakistan. I draw upon in-depth interviews with couples pursuing fertility treatment at a private clinic. Male infertility produces a cascade of relational vulnerabilities flowing from the profound destabilising impact of male infertility on masculine identity. These relational vulnerabilities are within the couple and extend to their wider families, who respond to the couple’s challenges by attributing infertility to the wife, and encouraging divorce or polygamous remarriage. Within couples, I detail the complexities of spousal communication regarding infertility. The couple’s economic and moral interdependence with wider kin adds further layers of relational vulnerability, flowing from the financial challenges of pursuing treatment. I reveal a spectrum of responses to these relational vulnerabilities among couples, ranging from those on the brink of marital breakdown to those whose bonds are strengthened by resilience. I complicate influential recent optimistic readings of the scope for infertility to destabilise hegemonic masculinities and produce new ‘emergent’ masculinities predicated on companionate conjugality. Inequitable, out-of-pocket access to fertility services plays a crucial role in how couples navigate the challenges of infertility. Mediating these impacts necessitates critical public health perspectives underscoring health equity and social justice, requiring an undoing of two-dimensional gender injustices.
In Lahore, Pakistan, patriarchy lays the seeds of strife in certain households where the unspoken reality of male infertility – a biomedical diagnosis shrouded in societal stigma – threatens to shred the fabric of marital intimacy. The diagnosis of male infertility pushes against deeply-ingrained gender roles, expectations and beliefs in Pakistan. For married men, unexpected reproductive failure threatens dominant constructions of masculinity in terms of virility. Meanwhile, burdened by patriarchal expectations to conceive, and shouldering the blame for their husbands’ infertility, their wives’ positions and roles within the family are jeopardized. Together, in their shared hope of materialising their dream of parenthood, these couples embark on their treatment journey – one that is coupled with both despair and hope. This paper explores the relational vulnerabilities flowing from reproductive incapacity in Pakistan: borrowing the words of Banerjee (2020, p.6, p.33), the gendered vulnerabilities of ‘frayed relational threads’ undoing the weave between husbands and wives, as well as the ‘broken social relational worlds’ of their wider webs of kin.
The impact of male infertility on marital relationships and wider familial dynamics is shaped by the threat that male infertility, in particular, poses to dominant masculinities and femininities. As such, the paper engages with Marcia Inhorn’s (2012) exploration of Arab men facing infertility, whom she sees as the vanguard of challenging the patriarchal norms of the Middle East. By exploring the relational vulnerabilities flowing from infertility in the Pakistani context, I highlight the diversity of experiences of Pakistani couples with male infertility and illuminate factors that shape the responses of infertile men and their partners. The emergence of new forms of masculinity in Pakistan, predicated on companionate conjugality, becomes one possibility, but this is a delicate re-negotiation, and not universally adhered to or accepted.
In South Asia, infertility affects an estimated 22% to 29% of couples of reproductive age (Agarwal et al. 2015), referring to those who are unable to conceive after 12 months of regular, unprotected intercourse. Among these infertility cases, male factor infertility is identified in approximately 2.5% to 12% of couples. However, this figure may be an underestimation, as infertility in men is often underdiagnosed due to limited access to male reproductive health services and the widespread assumption that infertility is primarily a female issue (Agarwal et al. 2015). Despite the uncertainty surrounding these statistics, they suggest that a significant number of couples navigate the challenges of infertility in Pakistan. Among the array of available treatments, Assisted Reproductive Technologies (ARTs) are a growing contemporary solution to the pervasive issue of infertility in Pakistan (Mumtaz et al. 2013). The cutting-edge biomedical reproductive interventions offered at private fertility clinics in Lahore, Islamabad, and Karachi include advanced procedures like In Vitro Fertilization (IVF), where eggs and sperm are combined outside the body, and Intracytoplasmic Sperm Injection (ICSI), a technique involving the direct injection of a single sperm into an egg for fertilization.
The application of these technologies is shaped by religious, cultural, and societal norms. In Sunni Muslim countries like Pakistan, the practice of ARTs is governed by religious and ethical guidelines that strictly prohibit third-party involvement in reproduction (Inhorn & Tremayne 2012). Unlike some other contexts, where donor sperm, eggs, or embryos may be used, Islamic jurisprudence in Sunni traditions permits IVF only when both gametes come from a legally married couple. Surrogacy and any form of third-party gamete donation are forbidden. This restriction significantly narrows the options available to couples facing male-factor infertility, as donor sperm remains legally unavailable. Consequently, infertile men face heightened societal and familial pressures to pursue alternative strategies to fulfil reproductive expectations.
Importantly, infertility treatments, often necessitating multiple cycles to achieve a successful pregnancy, are financially burdensome in Pakistan, and result in substantial out-of-pocket expenses, even for couples with insurance coverage, precluding access to these technologies to couples from all but the most privileged socio-economic classes. The context of economically inequitable access to infertility treatment in Pakistan, as elsewhere (Inhorn & Patrizio 2015) forms the backdrop to couples’ reproductive vulnerabilities, necessitating a critical public health perspective underscoring health equity and social justice (Pillen 2023).
Before turning to detail the study methods and setting, the context of the inquiry to male infertility and masculinities in Pakistan, marriage, and economic and moral interdependence with wider kin is laid out.
Scholarship in Pakistan reiterates the popular wisdom that the institution of marriage transcends the mere union between two individuals and becomes an enduring nexus between two families. The dominant patri-virilocal norm dictates that wives relocate to cohabit with their husband’s extended kin. Such a domestic arrangement engenders life course vulnerabilities for women, as they enter their husband’s family in the relationally weak position of an incoming bride, but simultaneously establishes a profound social and economic interdependence between the conjugal unit and the husband’s extended family. Despite the couples in this study belonging to the upper socio-economic strata, the practice of patrilocality persists.
In Pakistan, economic privilege and higher education do not necessarily translate into a shift toward neolocal living arrangements, as family cohesion and interdependence remain central expectations. Even well-educated women view moving into the husband’s family home as a normative duty rather than a negotiable choice (Maqsood 2021). Moreover, residing with the husband’s kin reinforces economic security and facilitates shared caregiving responsibilities, particularly in households where women are expected to manage both professional and domestic obligations. This persistence of patrilocality, even among privileged classes, underscores the patriarchal family norms that continue to define marital relationships and gender roles in Pakistan. The gendered vulnerabilities inherent to this predicament form the context in which the couples in this study navigate the challenges posed by infertility.
The cultural dynamics of masculinity are critical mediating processes in the marital experiences of couples facing male infertility. In a society where notions of ‘real manhood’ are deeply ingrained, Pakistani men must undertake careful negotiations to maintain or adapt their masculine identities when confronted with infertility. Masculinity and reproduction remain deeply interconnected in patrilineal societies like Pakistan, where lineage is transmitted through the male line (the Islamic concept of nasl, see Clarke 2008). The ability to father children is not just a biological function, but a critical marker of masculine identity and achievement of social status. Male infertility therefore carries a heavier stigma than female infertility, as it disrupts the continuation of family lineage and threatens the stability of kinship structures. In a society where kinship retains its traditional structure, an infertile man faces not only personal distress but also significant social consequences, including pressure from extended family. This rigid linkage between masculinity and reproduction intensifies the emotional and relational strains that couples experience, shaping the varied responses to infertility explored in this study.
Conceptual frameworks of ‘hegemonic masculinity’ (Connell 2005) and ‘multiple masculinities’ (Connell 1995) acknowledge the diverse manifestations of masculinity and enable nuanced exploration of the responses of men experiencing infertility. Equally important context are constructions of femininity, in ways relational to, and supportive of, dominant masculinities. Gaunt (2013) conceptualizes the ‘provider-dependent’ paradigm, asserting that society evaluates men’s social value through their capacity to financially support their families. This paradigm resonates with specific Pakistani constructions of masculinity and femininity. While men are expected to be the primary breadwinners, dominant constructions of femininity require women to inhabit domestic and caregiving roles, placing significant emphasis on motherhood, and uphold the family honor. These normative expectations are not just prescriptive; they are also highly restrictive. Gender roles and expectations, deeply ingrained within the cultural, historical, and religious landscape of Pakistani society, shape and constrain the experiences of both men and women, particularly in the context of infertility.
Extant research on infertility in Pakistan underscores the profound influence of traditional gender roles and cultural norms on the experiences of female-factor infertility and its implications for marital dynamics. Studies highlight that traditional expectations assign women the roles of mothers and caregivers, while men are expected to be providers; the struggle with infertility, under these norms, leads to substantial emotional distress and strains on marital bonds, particularly affecting women who face challenges in fulfilling their prescribed roles (Mumtaz et al. 2013). Sami et al. (2006) shed further light on the blame and stigma associated with infertility, underscoring that women in Pakistan bear the primary burden of responsibility for fertility and reproduction. Due to the premium that Pakistani society places on the birth of children, Sami et al. (2006) also found infertility to cause significant marital discord and emotional strain. Similarly, Papreen Nahar’s (2021) ethnographic research on infertility and childlessness in Bangladesh offers a comparatiave lens, illustrating those anxieties surrounding divorce are deeply embedded in patriarchal family structures in Islamicate South Asia. Nahar argues that women’s reproductive capacity becomes central to their marital security, as the stigma of infertility often results in social isolation or pressure for the husband to remarry.
While existing sociological research has not specifically addressed male-factor infertility in Pakistan, studies conducted in other contexts offer further valuable insights into the potential relational vulnerabilities that may flow from male-factor infertility (Coëffin-Driol & Giami 2004, Hosseinpoor et al. 2022). These include relational vulnerabilities flowing from the financial strains of pursuing treatment (see Dupree 2018, Al-Kandari & Alenezi 2020, Njagi et al. 2023), Against this picture, on the other hand, Jamali Gandomani’s (2022) research on Iran suggested that not all couples succumbed to male infertility’s negative effects; some demonstrate adaptability and navigate the emotional turmoil without significant damage to their bond. Similarly, Gauri Pathak (2019) highlights the shifting landscape of companionate marriage in India, where conjugal expectations are increasingly framed around emotional intimacy rather than solely reproductive success. However, Pathak notes that these emergent ideals often coexist with enduring patriarchal pressures, producing tensions within marriages facing infertility. Most influentially, Marcia Inhorn’s (2012) work on Arab men facing infertility offers the concept of ‘compassionate conjugalities’, capturing marital predicaments where shared hardship nurtures deeper empathy and strengthens the marital bond. She sees infertility as a potential catalyst for unexpected egalitarian and companionate transformations within marriages. In contrast, the interviews analysed in this paper reveals a range of responses among Pakistani couples, from those whose marriages are on the verge of breakdown to those whose bonds are strengthened by resilience. My research context tempers Inhorn (2012)’s more optimistic claims regarding the potential for infertility to catalyse positive transformations in masculinity and conjugality. In line with a critical public health lens, I call for further research on how social, economic and political conditions mediate the relational vulnerabilities that flow from male-factor infertility.
This qualitative study was conducted at the Lahore Institute of Fertility and Endocrinology (LIFE), a renowned fertility clinic located within Hamid Latif Hospital. LIFE holds historical significance as the birthplace of Pakistan’s first test-tube baby in 1989. Known for its cutting-edge technology and high-quality services, LIFE predominantly serves middle and upper-middle-class patients. The clinic played a pivotal role in shaping the dynamics of the research. The collaboration and assistance of the clinic’s staff were indispensable for the research. The clinic staff furnished me with a private room, allowing for confidential, open, and candid conversations with the couples undergoing fertility treatment. Employing a purposive sampling strategy, I carefully attended to participants’ wider social positionings to understand the study’s specificities. Within this exclusive hospital setting, the participants primarily belonged to higher socio-economic and privileged positions in Pakistani society. While this allowed for a focused exploration of their experiences, it also highlights the specificity of their experiences, such that my findings regarding the couples’ relational vulnerabilities would require corroboration against less socio-economically privileged contexts, precluding me from making any comprehensive claims regarding infertility in Pakistan. The data analysed in this article derive from my doctoral research at Monash University. The study received ethics approval from the Monash University Human Research Ethics Committee (Project ID: 16782). All participants provided informed consent prior to participation, and pseudonyms are used throughout to ensure confidentiality and anonymity
My research spanned several months, allowing me to establish rapport and trust with participants and immerse myself in the hospital setting. Interviews were conducted with couples clinically diagnosed with male infertility who were undergoing IVF treatment at LIFE. These in-depth interviews, lasting over an hour, took place in a relatively private and comfortable environment within the clinic. The interviews took place within the clinical premises of LIFE. Despite the clinical context, participants exhibited remarkable openness and willingness to share their intimate stories. The open-ended and unstructured interview technique encouraged free-flowing discussions about individuals’ experiences, expertise, and viewpoints. An extensive set of open-ended questions in Urdu, progressively moving from broad to specific topics, was included in the interview guide. Importantly, the interviews analysed below are a subset drawn from the broader pool of interviews I conducted during my doctoral research. In this paper, I focus specifically on the ten interviews where both husbands and wives participated, which provided nuanced shared, and divergent, explorations of couples’ experiences of male infertility.
In the joint interviews between husbands and wives, the presence of both spouses in these interviews introduced significant ethical considerations. While the couple interviews were valuable in capturing shared narratives, they also posed the challenge of producing a ‘joint’ couple narrative. Power dynamics within the couple shaped the balance of the interview deferentially towards the husbands, but wives typically presumed health-seeking to be their prerogative and held forth on these subjects. The individual perspectives of the husband and wife could sometimes differ. In such cases, it was crucial for me to be mindful of apparent discrepancies and not treat one spouse as a spokesperson for both.
The paper reports on the study findings under three main sections detailing the impact of male-factor infertility on marital relationships, infertility communication within couples, and the economic and moral interdependence of couples within extended kin networks, shedding light on the ways in which financial difficulties and familial guidance add layers of relational vulnerability.
It was evident from my interviews that reproductive norms and beliefs assigned blame and responsibility for infertility to female partners, even in cases of male-factor infertility. This unwarranted burden on women was further perpetuated by family members, including parents and in-laws. In some instances, infertile men were encouraged to contemplate divorce or consider polygamous remarriage, exacerbating the relational vulnerabilities faced by couples, like the one exemplified by Nadia and her husband. Her testimony encapsulates the deep-seated anxieties borne by couples in such circumstances. As she stated:
Although it is not my fault, I fear divorce.... I constantly feel like our relationship is sitting on a ticking time bomb.
Nadia’s fear of divorce reflects a broader pattern of gendered vulnerability within patriarchal societies, where women face disproportionate blame for childlessness and anxieties surrounding divorce (see Nahar 2021). As her relationship is tested by external pressures for divorce or polygamy, her fear ultimately stems from societal expectations that still prioritize reproductive success over companionship (cf. Pathak 2019). While Nadia protests that infertility is not her ‘fault’, by which she means that this was not a female-factor infertility diagnosis, she expresses a deep-seated fear of divorce. In Pakistan, the spectre of marital dissolution looms large, particularly for women, where divorce, readily accessible with greater ease for men, remains a potent threat. This terrain becomes more uneven when layered with the stigma attached to infertility, particularly when it falls upon the wife. For Nadia, the possibility of marital abandonment becomes amplified by the persistent shadow of polygamous second marriages, viewed by some as a culturally sanctioned ‘solution’ for male-factor infertility. Her fear therefore extends beyond the individual level, reflecting the deeper anxieties woven into the fabric of family structures and gender dynamics in Pakistani society. The metaphor that Nadia employed, ‘sitting on a ticking time bomb’, encapsulates the precariousness and uncertainty that she, like many others in similar circumstances, navigated in her marital relationship. The failure to acknowledge male-factor infertility and the associated societal pressure for divorce or polygamous remarriage significantly shaped their predicament, further emphasizing that married Pakistani couples operate within a milieu heavily moulded by the wider family context.
Wives like Nadia bear the brunt of societal anxieties surrounding childlessness. Yet the strain does not rest solely on their shoulders. Men, too, grapple with the suffocating grip of hegemonic masculinity in Pakistan, where virility is inextricably linked to fertility. Junaid’s experience echoes this pressure:
My family puts a lot of pressure on me to divorce and remarry, assuming that infertility is my wife’s fault. It is very frustrating sometimes but I know that divorce is not the right solution.
This familial pressure on Junaid underscores that hegemonic masculinity, deeply entwined with the role of the provider, positions male infertility as a direct threat to masculine identity. In the context of male infertility, the ‘provider-dependent’ paradigm (Gaunt 2013) collapses, as reproductive incapacity converges with economic expectations. Junaid’s experience exemplifies that the pressure to divorce and remarry stems not only from his inability to reproduce but also from his perceived failure to fulfil the societal expectation of securing lineage – a role that defines his identity as a husband and provider. Junaid further added:
It’s like your manhood itself is on trial, judged by your ability to fulfil it through fatherhood.
Similarly, Imran expressed:
There’s this constant feeling of needing to prove something... like if you can’t impregnate your wife, then of what good is your masculinity?
Imran painted a stark picture of fragility, where a man’s worth would be measured by his ability to deliver the ultimate symbol of manhood – a child. Such sentiments underscore the trial men face, their masculinity on the line. Yet amidst this pressure, in some cases significant resilience still emerged. Despite facing familial turmoil and scorn, some men in this study, like Junaid, resisted the pressure to discard their wives. Instead, they chose compassion and support, forging a bond strengthened by shared hardship (as with Inhorn 2012). This counter-narrative, where men reject easy solutions and prioritize their commitment, offers a glimpse into the complexities of masculinity beyond the rigid confines of hegemonic ideals.
Whilst Nadia and Junaid emphasized the ‘ticking time bomb’ and pressures, other couples shared how their journey through infertility had deepened their connection. Sidra expressed:
The weight of infertility and the fear of divorce is straining our relationship at times. But my husband has been incredibly supportive.
Sidra’s husband Aqeel also reflected on how their marriage had been strengthened by their struggles:
Infertility has brought moments of despair. It’s been a challenging path, but it has also forged a stronger bond between us.
While the pressure to conceive was overwhelming, there were also instances of compassion and resilience, where couples found solace and connection in their shared endeavour to conceive.
As couples faced the challenges of infertility, addressing these issues through open communication appeared key to upholding a resilient and healthy relationship. Saira poignantly encapsulated this:
There is a constant need for support and understanding because it never feels enough.
Like other wives, Saira bore a significant burden in the realm of reproduction, as cultural norms traditionally place the responsibility for conceiving and bearing children on her. This compelled Saira to feelings of isolation, frustration, and hopelessness. Inadequate empathy and understanding from friends and family further intensified these feelings. Wives like Saira, who are the primary caregivers and emotional pillars for their husbands, navigated through societal pressures and personal distress. The absence of acknowledgment and support compounded the difficulties faced by these wives, leaving them to navigate the emotional and societal complexities largely on their own. This lack of recognition further contributed to the invisibility of their struggles, both within the household and in the wider discourse on infertility.
At the same time, infertile men have emotional needs too, which are overlooked in the medical and societal realms. Men grappling with infertility faced their own set of challenges. The expectations of stoicism and emotional resilience placed upon men in this context contributed to a lack of acknowledgment of their vulnerabilities. As Qasim said:
People think men don’t get affected by infertility, but it’s tough. You can’t just open up about it. It’s like an unspoken rule. You end up dealing with it on your own because there’s this idea that men should be strong and not show it bothers them.
As Qasim explains, the expectation that men should embody strength as providers and remain emotionally unaffected by fertility issues created a barrier to him recognising and addressing his emotional needs. This was the case with Rabia and Dawood, whose interview also indicated inhibited spousal communication:
I often feel angry and frustrated with the situation and then we end up arguing. (Rabia)
Her husband Dawood struggled with feelings of anger as well, but also hesitated to talk about it even to those within his social circle, including his wife. Containing his feelings appeared to be a masculine act:
I hope that I just fix this (childlessness), but I can’t as it is out of my control. My failure in doing so, often makes me angry and frustrated, but I don’t want to burden Rabia with my feelings. (Dawood)
In a third couple, Sadaf expressed her emotions openly:
I get overwhelmed by the stress and pressure of fertility treatments.
Her husband, Mehmood, also struggled with the stress of fertility treatments, but he was less vocal about it. During their interview, Mehmood stated the masculine expectation to be strong and contained:
I feel like I’m supposed to be strong for Sadaf, but the whole process is just so overwhelming. We are stuck between hope and failure. I’m afraid to burden her with my feelings and appear as someone weak.
The preceding quotes are suggestive of gender differences in expressing emotional vulnerabilities surrounding infertility. Sadaf and Rabia explicitly recounted a dearth of support or attentiveness when conversing with their husbands about the emotional difficulties they were undergoing due to infertility. Conversely, the husbands found themselves inundated by the magnitude of emotions exhibited by their wives. These gendered communication patterns are corroborated by spouses Javed and Anaika:
I want to support my wife through our struggle with infertility, but sometimes I feel like I don’t know how to. It’s hard for me to express my emotions in the way she needs me to, and I can see that it makes her feel alone and unheard.(Javed)
I know my husband loves me and wants to be there for me, but sometimes it feels like he doesn’t understand what I’m going through. I wish we could communicate more openly about our feelings, but it’s hard when we express ourselves so differently. It can be isolating to go through this together, but feel like we’re not connecting. (Anaika)
Javed’s statement conveys his apparently sincere desire to support his wife, yet he acknowledges his difficulty in expressing his emotions in a way that Anaika could comprehend and relate to. Anaika expressed the feelings of frustration and isolation that arose because of the couple’s difficulties in communicating about their situation. While she recognizes her husband’s love and support, they struggled to achieve open emotional communication. This lack of emotional alignment compounds the emotional burden that infertility already imposes on couples, leading to additional stress and strain on the relationship.
In navigating the challenges of infertility, Javed and Anaika faced not only internal struggles but also external pressures from their extended family. The responses from extended family members went beyond the question of financial support and ventured into advising drastic measures like divorce and remarriage. The blame, usually directed towards the wife, further intensified the emotional turmoil within the family. Couples faced unwelcome advice and societal pressures, often rooted in deeply ingrained patriarchal norms. The specter of marital dissolution, sometimes instigated by family members who readily blamed women for the infertility, loomed large. This external pressure added a layer of tension to the vulnerabilities within the couple, making it a multifaceted challenge that extended beyond their relationship.
In Pakistan, couples confront substantial economic challenges when endeavoring to pursue fertility treatments, particularly for elaborate procedures such as IVF. Men described how traditional gender roles dictate that men bear the primary financial responsibility for infertility treatments, aligning with their perceived role as the family’s breadwinners. Consequently, men often shouldered a substantial portion of the financial burden associated with fertility treatments. The financial responsibility became even more pronounced in cases where couples required multiple treatment cycles, leading to a considerable accumulation of expenses, up to tens of thousands of dollars. The combination of traditional gender expectations and the financial strain of fertility treatments created gendered relational vulnerabilities compounding the challenges faced by couples in the study. One of the participants Burhan, who was clinically diagnosed with male infertility, articulated the profound impact of this vulnerability, stating:
The financial stress of infertility is overwhelming. I had to dip into my savings and even take out loans from family relatives to pay for treatments. All in the hope that every single rupee invested will make a difference if we conceive.
His wife Saira added,
We thought we were prepared for the cost of these treatments, but it just keeps adding up. It’s like we’re never able to get ahead.
In addition to the cost of treatments, couples also faced other financial challenges, such as the cost of travel to and from treatment appointments and the cost of time off work to attend appointments. These additional expenses added up quickly. The financial strain that couples experience in this context reflects broader global patterns of infertility-related hardship. Marcia Inhorn’s (2015) research on IVF in Dubai introduces the concept of ‘reproductive exiles’ – couples who cross borders in search of more affordable and accessible fertility treatments due to the exorbitant costs in their home countries. While the couples in this study did not migrate across national boundaries, their experiences reflected the same processes, producing reproductive exile within Pakistan. The out-of-pocket expenses, combined with societal pressures to conceive, pushed couples into cycles of debt and financial dependency on extended kin.
Financial decisions were transacted within the moral fabric of familial relationships. To seek financial aid in the context of infertility treatment carried profound reputational and emotional implications that shaped and influenced the dynamics within the extended family. For these couples, the act of seeking financial assistance extended beyond mere economic transfer to encompass symbolic gestures of support, loyalty, and interconnectedness. The exchange of financial assistance within the familial sphere was laden with cultural meaning, signifying a shared responsibility and a collective approach to addressing challenges within the family. At the same time, the act of seeking and providing financial aid created a difficult web of expectations, obligations, and potential judgments within extended families. Ahmed and Sana borrowed money from their extended family members to cover the cost of their treatment. As Sana said:
While I felt grateful for the support, I couldn’t escape the feeling that it came with expectations. It’s as if we now owe them something in return, beyond just the money.
While Sana was appreciative of the assistance, she articulated the burden of unspoken expectations that accompanied such financial aid. To receive financial help led to a sense of indebtedness and the anticipation of future obligation. Furthermore, in Pakistani society, where men are regarded as the primary providers for their families, financial dependence on others is perceived as an encumbrance on men’s ability to fulfill their traditional masculine roles as the family breadwinners. Ahmed articulated his sense of failure here:
You know, to seek financial support from others is not easy for a man in Pakistan. It is seen as a threat to his honor and pride. But, given our circumstances, we had no choice.
For Ahmed, the act of seeking financial assistance from extended family members posed a profound challenge to his masculine identity. When couples such as Ahmed and Sana turn to their extended family for financial assistance, they had to also manage the fine line between preserving their privacy and making their vulnerability known. Couples who are unable to afford these treatments were forced to make difficult choices about their financial future, such as dipping into savings or taking on debt. These choices have long-term financial strain for these couples. Rabia echoed this sentiment, stating:
Every time we pay for a treatment, it feels like we’re taking one step forward and two steps back financially. It is a costly struggle.
The expenses incurred during infertility treatments have long-term implications affecting the financial stability and goals of such couples. Nevertheless, despite the exorbitant costs, my interviewees believed that the benefits of this investment were commensurate with their parenthood aspirations. Participants continued to pursue fertility treatments in the hope of conceiving successfully. As Yasmin shared,
We’ve taken on so much debt just to pay for these treatments. It feels like it’s never going to end.
Qasim explains:
We just want a family so badly, but it feels like we’re sacrificing everything else just to pay for these treatments.
Another husband, Malik, states:
It’s a constant struggle to balance our financial obligations with the cost of these treatments. It feels like we’re always making sacrifices.
These findings highlight the complex interplay between the financial struggles of infertile couples, culturally embedded notions of providerly masculinity, and wider familial dynamics.
Within the tangle of intimate dynamics surrounding male infertility in Pakistan, this paper has described how male infertility introduces frictions that engender relational vulnerabilities in couple relationships, vulnerabilities which test the core of marital relationships. In navigating these frictions, a spectrum of responses among couples emerged. This spectrum showcases the ability of some couples to adapt and evolve in the face of reproductive misfortune and the uncertain pressures of treatment-seeking. Open spousal communication appeared to be an important mediator of these responses. Wider family were a double-edged influence, sometimes compounding the relational vulnerabilities of couples by urging divorce or polygamous remarriage, and sometimes extending financial assistance for treatment, although this created further emotional burdens for couples due to the masculine weakness implied by asking for money.
The interviews highlight the extent to which male infertility inflicted profound disruption to the masculine identity of men in Pakistan, where dominant cultural expectations of masculinity in terms of virility weigh heavily on them. Reciprocally, dominant constructions of femininity also weighed heavily on women. While the traction of normative constructions is evident, this research also reveals some emergent dynamism of cultural norms. The emergence of new forms of masculinity predicated on companionate conjugality – as influentially highlighted by Marcia Inhorn (2012) – emerges as one possibility requiring careful negotiation. However, from those teetering on the brink of a marital breakdown to those whose bonds have been strengthened by resilience, the couple responses to male infertility in Pakistan are as diverse as the couples themselves. Furthermore, it is important to recall the selectivity of my interviewees, as bearers of socio-economic privilege in Pakistan, and also as representative of couples who pursue fertility treatment at an exclusive private establishment like LIFE. Therefore, my conclusions underscore the need for further research exploring the nuances of masculinity across diverse social strata in Pakistan.
In probing the conditions that shape relational vulnerabilities in the face of infertility, it is crucial to underscore the limited access to reproductive health services and fertility treatments in Pakistan. Like elsewhere (Inhorn & Patrizio 2015), fertility treatments in Pakistan remain predominantly available to wealthier, urban elites, leaving many couples without access to necessary reproductive care. The necessity to seek financial assistance from extended family members added nuanced complexities to the financial and interpersonal aspects of infertility treatment in the context of an out-of-pocket payment system. It implicates familial relationships and introduces expectations, obligations, and potential judgments within extended families. Borrowing money further challenged the men’s masculine identities, as it is perceived as a deviation from the traditional expectation of being the family’s primary breadwinner.
The pivotal factors of equitable access to, availability, and affordability of fertility services play a crucial role in how couples navigate the challenges of infertility. This necessitates a critical public health perspective, as emphasized by Pillen (2023), underscoring a profound commitment to health equity and social justice, recognizing the influence of historical and contemporary social, economic, and political structures on health outcomes. Building upon this perspective, Fraser’s (2007) two-dimensional approach to gender justice is germane. This seeks to transform both a conventional gender division of labor and androcentric patterns of cultural value: ‘Only an approach that redresses the cultural devaluation of the “feminine” precisely within the economy (and elsewhere) can deliver serious redistribution and genuine recognition’ (Fraser 2007, p. 34). This denotes how the relational vulnerabilities faced by infertile couples necessitate redress through broad-scale transformations of social justice and health equity in Pakistan.
This article is based on my PhD thesis completed at Monash University. I am grateful to my supervisors, Alan Petersen and Andrea Whittaker, for their invaluable guidance and support throughout the research and writing process. I also wish to thank Kaveri Qureshi for her substantial input in editing this article. I am indebted to the couples who generously shared their experiences, and to the staff at the Lahore Institute of Fertility and Endocrinology for facilitating access to participants and providing a private space for interviews.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
The author declares no conflicts of interest.
Uzair Amjad https://orcid.org/0009-0009-8819-6100
Agarwal, A., Mulgund, A., Hamada, A., & Chyatte, M. R. (2015) A unique view on male infertility around the globe. Reproductive Biology and Endocrinology, 13(1), 37. https://doi.org/10.1186/s12958-015-0032-1
Al-Kandari, A.M., & Alenezi, A. (2020) Cost burden of male infertility investigations and treatments: A survey study. Urology Annals. 12(4), 314-318. doi: 10.4103/UA.UA_48_20.
Banerjee, D. (2020) Enduring cancer: Life, death and diagnosis in Delhi. Duke University Press.
Clarke, M. (2008) New kinship, Islam, and the liberal tradition: Sexual morality and new reproductive technology in Lebanon. Journal of the Royal Anthropological Institute, 14(1), 153–169. https://doi.org/10.1111/j.1467-9655.2007.00483.x
Coëffin-Driol, C., & Giami, A. (2004) The impact of infertility and its treatment on sexual life and marital relationships. Journal de Gynécologie Obstétrique et Biologie de la Reproduction, 33(8), 591-598. https://doi.org/10.1016/j.gyobfe.2004.06.004
Connell, R. W. (1995) Masculinities. University of California Press.
Connell, R. W. (2005) Change among the gatekeepers: Men, masculinities, and gender equality in the global arena. Signs: Journal of Women in Culture and Society, 30(3), 1801-1825. doi/full/10.1086/427525
Dupree, J. M. (2018) Insurance coverage of male infertility: What should the standard be? Translational Androlology & Urology, 7(S3), S310-S316. doi: 10.21037/tau.2018.04.25
Fraser, N. (2007) Feminist politics in the age of recognition: A two-dimensional approach to gender justice. In N. Fraser, Scales of justice: Reimagining political space in a globalizing world (pp. 23–41). Columbia University Press.
Gaunt, R. (2013) Breadwinning moms, caregiving dads: Double standards in social judgments of gender norm violators. Journal of Family Issues, 34(1), 3-24. https://doi.org/10.1177/0192513X12438686
Hosseinpoor, M., Masoumi, S. Z., Kazemi, F., Soltani, F., & Ahmadpanah, M. (2022) Investigating the effect of couple-centered counseling by Gottman method on the intimacy of infertile couples referring to the infertility ward of Fatemieh hospital, Hamadan, Iran in 2020: A quasi-experimental study. BMC Psychiatry, 22, 581. https://doi.org/10.1186/s12888-022-04228-z
Inhorn, M. C. (2012) The new Arab man: Emergent masculinities, technologies, and Islam in the Middle East. Princeton University Press.
Inhorn, M. C. (2015) Cosmopolitan conceptions: IVF sojourns in global Dubai. Duke University Press
Inhorn, M. C., & Patrizio, P. (2015) Infertility around the globe: New thinking on gender, reproductive technologies, and global movements in the 21st century. Human Reproduction Update, 21(4), 411–426. https://doi.org/10.1093/humupd/dmv016
Inhorn, M., & Tremayne, S. (2012) Islam and assisted reproductive technologies: Sunni and Shia perspectives. Berghahn Books.
Maqsood, A. (2021) Love as understanding: Marriage, aspiration, and the joint family in middle-class Pakistan. American Ethnologist, 48(1), 93–104. https://doi.org/10.1111/amet.13000
Mumtaz, Z., Shahid, U., & Levay, A. (2013) Understanding the impact of gendered roles on the experiences of infertility amongst men and women in Punjab. Reproductive Health, 10(3). https://doi.org/10.1186/1742-4755-10-3
Nahar, P. (2021) Childlessness in Bangladesh: Intersectionality, suffering and resilience. Routledge.
Njagi, P., Groot, W., Arsenijevic, J., Dyer, S., Mburu, G., & Kiarie, J. (2023) Financial costs of assisted reproductive technology for patients in low-and middle-income countries: A systematic review. Human Reproduction Open, 2. https://doi.org/10.1093/hropen/hoad007
Pathak, G. (2019) ‘They think of a family only in their thirties’: Gendered subfertility and emergent intimate modernities in India. Journal of the Royal Anthropological Institute, 25(4), 778–792. https://doi.org/10.1111/1467-9655.13131
Pillen, H. (2023) Critical public health. In P. Liamputtong (Ed.), Handbook of social sciences and global public health (pp. 1–16). Springer. https://doi.org/10.1007/978-3-030-96778-9_10-1
Sami, N., & Ali, T. S. (2006) Psycho-social consequences of secondary infertility in Karachi. The Journal of the Pakistan Medical Association, 56(1), 19-22. https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/276/
Journal of Critical Public Health, Volume 2 (2025), Issue 3 CC-BY-NC-ND