Keywords infertility - emotion - social support - anxiety - depression - counselling
Palavras-chave infertilidade - emoção - apoio social - ansiedade - depressão - aconselhamento
Introduction
Infertility is one of the major problems in gynecology, and is defined as the inability
to become pregnant with regular sexual intercourse for more than one year without
the use of birth control methods.[1 ]
[2 ] It has been estimated that 8% to 12% of couples worldwide,[3 ] and 11.2% to 14.1% of Iranian couples,[4 ] have experienced infertility. The inability to become pregnant profoundly affects
the various aspects of the lives and relationships of infertile couples.[5 ]
[6 ]
Infertile couples may be at risk of developing mental health problems.[7 ] Impulsive behavior, anger and frustration, anxiety, loss of control over sexual
feelings, and vulnerability are observed among infertile individuals.[1 ]
[2 ] The prevalence of psychological problems among them is between 25% and 60%. The
incidence of depression and anxiety in these individuals is significantly higher than
in fertile individuals and the general population.[8 ]
Studies[9 ]
[10 ] have shown that couples who underwent in-vitro-fertilization (IVF) treatments showed
more emotional and anxiety disorders and had lower scores in psychological areas than
controls. In a study by Huppelschoten et al. (2013),[11 ] infertile women and their sexual partners needed appropriate and adequate psychological
support at all stages of treatment. Ashraf et al. (2014)[12 ] found that infertility reduces the various aspects of quality of life of infertile
women. Mosalanejad et al. (2012)[13 ] showed that cognitive-behavioral therapy (CBT) reduces the stress of infertile women
and increases the adaptation to mental problems caused by infertility. Soltani et
al. (2014)[14 ] also concluded that focused emotional therapy can reduce depression, anxiety, and
stress in infertile couples, and Faramarzi et al. (2013)[15 ] found that CBT could be a reliable alternative to fluoxetine to reduce the stress
caused by infertility.[14 ]
[15 ]
Several studies[1 ]
[14 ] have shown that emotionally-focused therapy can decrease the amount of depression,
anxiety, and stress in infertile couples. Infertility counseling is also a special
approach to manage emotional problems associated with infertility, and it is a guide
for husbands and wives to relieve their anxiety, hatred, anger, and dissatisfaction.[1 ]
[16 ] The goal of infertility counseling is to help couples develop successful coping
strategies to deal with the short- and long-term outcomes of infertility, resolving
and understanding the issues related to it, and finding a more satisfying lifestyle.[17 ]
[18 ] The chances of success with assisted reproductive techniques are higher when the
mental state of couples is in balance. To moderate the mental state, drug interventions
may interfere with assisted reproductive techniques or require regular and long-term
use. Consultation and psychotherapy are non-medical interventions that can reduce
the negative effects of depression and emotional problems.[19 ] Different studies[14 ]
[20 ] found that couples therapy can be effective for the mental health of women with
biopsychosocial problems. In addition, most counselling interventions require the
participation of the patients for several sessions. Regarding the condition of our
population and location of our psychosocial program, planning for the minimum number
of sessions was necessary. Therefore, infertility counselling was adopted based on
international guidelines with an eclectic approach to the women's biopsychosocial
issues regarding the couple's infertility.[9 ]
To increase the chances of fertility and reduce mental conflicts, given the high prevalence
of infertility, the lack of psychosocial support, and insufficient scientific information
provided to infertile women, family counseling in the management of infertile couples
seems critical.[21 ] The present study was conducted to investigate the effect of counseling on different
emotional aspects of infertile women.
Methods
Study Design
The present randomized clinical trial was designed to investigate the effect of counseling
on different emotional aspects of infertile women referred to Afzalipour Hospital
Infertility Center in Kerman, Iran, from October to December 2016. Afzalipour Hospital
Infertility Center is the only public center that offers special services for infertility
in Kerman province. Couples who were willing to participate in the study and met the
inclusion criteria were included.
We included in the study couples with primary infertility (regardless of the cause)
who were referred for treatment for the first time and did not receive psychiatric
or psychological treatment. The exclusion criteria were the spontaneous occurrence
of pregnancy during the counseling sessions, or couples who missed two out of the
six counseling sessions.
According to a previous study[22 ] with a type II error of 20%, and according to
the sample size was estimated as 60 couples. it means 30 couples in each control and
intervention group. They were selected based on convenience sampling, and were randomly
allocated to the intervention and control groups. During the intervention, three couples
were excluded because they did not attend all the meetings, and two couples were excluded
due to the absence of the husbands. In the following counseling group, new couples
who met the criteria were included in the study to replace those excluded. In the
control group, there were no dropouts during the study ([Fig. 1 ]).
Fig. 1 CONSORT Flowchart of the selection of participants for the study.
Instruments
We used multiple questionnaires. The demographics questionnaire contained questions
regarding age, gender, level of schooling, time since contraceptive discontinuation,
number of children, length of contraceptive use, type of birth control method, causes
of infertility (female or male), and history of psychiatric problems before infertility.
The Screening on Distress in Fertility Treatment (SCREENIVF) questionnaire was developed
by Verhaak et al. (2005),[23 ]
[24 ] and it contains 34 items divided into 4 subscales that include state anxiety, trait
anxiety, depression, social support, and cognitions regarding fertility problems.
Anxiety was assessed with questions 1through 10 of the Spielberg Questionnaire. Depression
was assessed with questions 11through 17 of the Beck Depression Inventory. Social
support was assessed with questions 18 through 22 of the Social Participation Questionnaire.
Failure to accept infertility problems was assessed with questions 23 through 28,
and acceptance of infertility problems were assessed with questions 29 through 34,
of the IVF Patient Recognition Questionnaire. The cut-off scores were as follows:
depression – ≤ 4; anxiety – ≤ 24; cognitions regarding fertility problems – ≤ 14;
and social support – ≤ 15. All dimensions have a high degree of reliability. The Cronbach
alpha (α) for depression, anxiety, helplessness, and cognitions regarding fertility
problems were of 0.82, 0.88, 0.87, 0.92, and 0.89 respectively.[25 ]
[26 ]
[27 ] The SCREENIVF correctly identified 69% of the total of patients who presented clinically-significant
emotional difficulties and 77% of those who did not. The original version of the SCREENIVF
showed excellent reliability in all scales (Cronbach α between 0.82 and 0.92).[28 ]
To compose the Persian version of the SCREENIVF, we performed forward and backward
translations of the validated Portuguese version of the questionnaire, which showed
reliability in all dimensions (Cronbach α ≥ 0.70, except depression among men: α = 0.66).[27 ] The reliability of the translated questionnaire was confirmed through the application
of a pretest with the participation of 50 people and a posttest after 2 weeks, with
a Cronbach α of 0.7 and an intraclass correlation coefficient (ICC) of 0.74.
Procedures
The present study was approved by the local Ethics Committee of Kerman Medical University
(IR.KMU.REC.1395.678IR). After obtaining the necessary permissions from the head of
Afzalipour Hospital Infertility Center, the researcher invited all infertile couples
who met the inclusion criteria to participate in the study, which was conducted from
October to December 2016.
The couples were assigned to the intervention or control groups according to the day
of referral to the infertility center. In the even days of the first week, they were
assigned to the intervention group, and, in the odd days, they were assigned the control
group, and the opposite was done in the following week.
The researcher explained the purpose of the study to the participants and obtained
written informed consent. The couples were also assured that the collected information
was confidential and would only be used for research purposes. Then, they were asked
to answer the questionnaire for the pretest. There was no blinding in the research
process.
Each of 6 counseling sessions, lasting 45 minutes, were held in a suitable room at
the Infertility Center and conducted by a trained midwife.
The infertility group counseling, which was based on guidelines issued by Boivin and
Kentenich,[9 ] was composed of a combination of psychological training, supportive counseling,
and cognitive-behavioral counseling. The content of the infertility counseling sessions
is shown in [chart 1 ].
Chart 1
Content of the infertility counseling sessions
Session
Content
One
Outlining sessions' goals, introducing female and male genital system and fertility
mechanism, and causes of infertility
Two
Acquaintance with the benefits and side effects of assistaned reproductive therapies
(ART),
Three
Acquaintance with mental disorders caused by infertility problems
Four
Acquaintance with all possible support systems during infertility
Five
Training enriching relationships, relaxation, and coping techniques
Six
Decision-making about therapy continuation, discontinuation, and replacement of options
The control group received routine care, and after post test, the counseling sessions
were held for them. At the end of the last session, the posttest was applied both
groups. The pre- and posttest questionnaires were filled out by the researcher.[29 ]
[30 ]
Ethical Considerations
The present article is the result of a dissertation approved by Kerman University
of Medical Sciences under the code of ethics number IR.KMU.REC.1395.678 and the clinical
trial code number IRCT2017080124866N4, and it was supported by the research deputy
of Kerman University of Medical Sciences. The purpose of the study was explained to
the subjects, and they were included after signing the written informed consent.
Statistical Analysis
Data were analyzed using the Statistical Package for the Social Sciences (IBM SPSS
Statistics for Windows, IBM Corp., Armonk, NY, United States) software, version 19.0.
Descriptive statistics (frequency, percentage, mean, and standard deviation) were
used to detail the characteristics of the sample. The Chi-squarde test was used to
determine the consistency of the two groups in terms of demographic variables. If
parametric conditions were present (normal distribution and equality of variances),
parametric statistical tests (dependent t -test for the comparison of the groups and paired t -test for the comparison of the groups before and after the test) were used. Otherwise,
the non-parametric equivalents (Mann-Whitney and Wilcoxon tests) were used. Values
of p < 0.05 were considered statistically significant.
Results
The mean age of the participants was 33.39 ± 5.67 years, and the level of schooling
of most of them was incomplete high school among the intervention group, and complete
high school among the control group. Most female participants were housewives in both
groups. All studied couples had primary infertility and no children. The mean duration
of the infertility was three years. On average, couples used various birth-control
methods for 12.01 ± 4.58 months. Regarding the infertile subjects in both groups,
men were the majority (34.15%). None of the subjects reported history of psychiatric
diseases (depression, obsession, or anxiety) before they became aware of the infertility.
Based on the Chi-squared test, there were no significant differences among the sample
in terms of gender, age, and level of schooling at the time of inclusion in the study,
so the two groups were homogeneous regarding demographics ([Table 1 ]).
Table 1
Demographics of the study sample
VariablesIntervention group – n (%)
Control group –n (%)
p -value
Age (years)
20–29
30–39
40–50
20 (33.3)
15 (25.0)
0.15
33 (55.0)
32 (53.3)
7 (11.7)
13 (21.7)
Gender
Female
Male
30 (50)
30 (50)
1.00
30 (50)
30 (50)
Level of schooling
Incomplete high school
Complete high school
Complete higher education
24 (40)
18 (30)
0.36
17 (28.3)
25 (41.7)
19 (31.7)
17(28.3)
Infertile subject
Man
Woman
Both
Unknown cause of infertility
20 (33.3)
21 (35)
0.45
20 (33.3)
19 (31.7)
13 (21.7)
11 (18.3)
7 (11.7)
9 (15)
Different dimensions of the emotional status of infertile women were compared between
two groups. The decrease in the depression score after the counseling in the intervention
group was statistically significant (p ≤ 0.0001). There was a significant increase in the mean score for social support
after the counseling in the intervention group (p ≤ 0.0001). The results showed that counseling had an effect on the the mean scores
of intervention group for cognitions regarding fertility problems (p = 0.001). The changes in the mean scores for anxiety were not significant (p = 0.35) after counselling. The differences between thegroups are shown in [Table 2 ]. There were no statistically significant differences between the groups regarding
the total score for the emotional status (p = 0.47).
Table 2
Mean scores on the subscales of emotional satus for the two study groups
Subscale
Intervention group
Control group
p -value[* ]
Anxiety
25.03 ± 3.09
24.58 ± 3.72
0.41
Depression
1.55 ± 1.92
4.46 ± 4.13
> 0.0001
Social support
15.73 ± 3.41
13.43 ± 3.01
< 0.0001
Cognitions regarding fertility difficulties
26.48 ± 3.05
25.40 ± 4.11
0.38
Total score
68.80 ± 6.38
7.66 ± 67.88
0.47[* ]
* Paired T-Test.
Discussion
Infertility counselling had different effects on different dimensions of the emotional
status of infertile women. A comparison regarding depression showed that infertility
counseling was able to reduce the level of depression. Karami et al. (2018)[31 ] reported that muscle relaxation training had an impact on depression, anxiety, and
stress, and Talaei et al. (2014)[32 ] reported that cognitive behavioral therapy was effective in decreasing depression
and psychological problems, among infertile women. The reason for this consistency
in results could be the provision of similar counseling sessions in the present and
in other studies[26 ]
[31 ] Many studies[6 ] have reported the negative effects of infertility on marital adjustment and satisfaction,
depression, and quality of marital life. Counseling helps couples process their feelings
and reach a comfortable state; as a result, their quality of life increases and leads
to a decrease in the levels of depression.[26 ]
In the intervention group, the mean scores after counseling regarding the social support
subscale were significantly different from those of the control group. The results
of the present study were consistent with those of the study of Adl (2016),[33 ] a quasi-experiment on “the effectiveness of group psychotherapy based on the quality
of life and perceived social support in infertile women”. Social support is defined
as the perceived level of kindness, companionship and attention received from family
members, friends and others. The main function of the perceived social support is
that the person feels they are respected and part of a network of mutual duties.[34 ] One of the main goals of infertility counseling is that patients understand their
therapeutic choices and receive enough emotional support to cope with the outcomes
of infertility. This empowerment increases their satisfaction and decreases the incidence
of negative reactions.[1 ]
Regarding the anxiety subscale, the results indicated that counseling had no effect
on infertile women, which is in disagreement with the results of other studies, such
as those on the effect of acceptance and commitment therapy, by Rahimi et al. (2018),[35 ] and on the use of acupuncture, by Hassanzadeh Bashtian et al. (2016).[36 ]
Although group infertility counseling was conducted for couples during 6 sessions
lasting it seems that the lack of suitable accommodations for non-resident patients
in the city, and the economic problems faced by young people could be the reason for
the ineffectiveness of counseling on general anxiety. Also, since it was participants'
first time at our specialized center, it seems that the lack of familiarity with it,
as well as with the medical staff and the therapeutic processes, and their concerns
about the possible outcomes also affected their levels of anxiety.
As for the subscale of cognitions regarding fertility problems, counseling was effective,
which is in agreement with the results of the study by Kheirkhah et al. (2014),[37 ] who reported that group counseling was effective in helping the subjects adapt to
infertility. Perhaps the reason for this consistency was the provision of infertility
psychological counseling by a trained researcher which was similar in both studies.
Psychotherapy and counseling are effective in reducing many psychological problems,
improving the quality of life, and they help couples accept the reality of their lives
and face the upcoming challenges.[26 ]
The results of the present study are not consistent with those of recent studies.
Loucks (2015),[38 ] in a study on “group therapy as a social response to infertility”, reported that
the treatment had an effect on the emotional status of couples. Soltani et al. (2014),[14 ] in a quasi-experiment, reported that emotionally focused therapy had a positive
effect on the couples' emotional distress. In a randomized clinical trial, Mosalanejad
et al. (2012)[13 ] reported that CBT with emotional disclosure had an effect on the mental health status
of infertile women. The reason for this inconsistency could be the different sample
sizes, the type of intervention, and the differences in the gender distribution of
the sample. In the study by Loucks[38 ], which was conducted with interviews, there was a potential for a positive bias.
In the study by Soltani et al.[14 ], the intervention was only conducted among women. It should be noted that women
can be more influenced than men, and starting the infertility treatment usually takes
time, and affects the emotional status of women, and makes them more anxious, so he
conducted his study only on women.[14 ]
The present study was conducted with couples. Since the emotional issues are deep,
they require more detailed counseling and a lot more time. One of the reasons that
counseling is not effective in improving the score for the overall emotional status
is that the number of training sessions is low in proportion to the depth of the problem.
Also, due to the subjects' age and their emotional development and stability at this
age, it is expected that changes will not easily occur and cannot be easily addressed
during the counseling sessions. Furthermore, because of the existing culture and the
influence and interference of families in terms of fertility and infertility, it seems
that education and counseling to couples are not enough to change their emotions.
Conclusion
The findings of the present study show that infertility counseling did not affect
the total score for the emotional status of infertile couples, but improved the cognitions
regarding fertility problems, social support, and depression, and did not improve
the levels of anxiety. According to the results, counseling is one of the ways of
improving the psychological state of infertile couples. We suggest that, from the
time of diagnosis and initiation of treatment, coherent and regular planning should
be considered to provide more comprehensive education and counseling to improve all
aspects of the emotional status.
