The Open Psychology Journal




ISSN: 1874-3501 ― Volume 12, 2019
REVIEW ARTICLE

Psychological Distress and Coping Mechanisms in Infertile Couples



Norbert Pásztor1, *, Borbála Eszter Hegyi1, Edina Dombi1, Gábor Németh1
1 Department of Obstetrics and Gynecology, University of Szeged, Szeged, Hungary

Abstract

Numerous motivational and strong emotional intentions can be found in the background of the desire for a child. Hence unintended childlessness gives rise to a severe psychological burden to both members of the couple. In the literature, several studies are involved in the exploration of this subject, albeit most of them bring into focus the differences of psychological liabilities between the genders. A smaller proportion of these papers examined the psychological aspects affecting couples, and just a very small number of studies investigated the psychological aspects in men. Nevertheless, most of the studies proved that although the psychological aspects in women can be more significant compared to their partner, the psychological burden of infertile men are obviously above the population average. Several different, gender-specific coping-mechanisms have been identified, which tend to be less successful in men compared to women. The acquirement of proper coping mechanisms could be more emphasized during the psychotherapeutic part of reproductive treatment.

Keywords: Infertility, Depression, Coping, Anxiety, Supportive psychotheraphy, Psychological distress.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 169
Last Page: 173
Publisher Id: TOPSYJ-12-169
DOI: 10.2174/1874350101912010169

Article History:

Received Date: 31/03/2019
Revision Received Date: 30/07/2019
Acceptance Date: 24/08/2019
Electronic publication date: 30/09/2019
Collection year: 2019

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© 2019 Pásztor et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Obstetrics and Gynecology, University of Szeged, H-6725 Szeged, Semmelweis str 1, Hungary;
Tel: +36704530892; E-mail: norbert.pasztor@gmail.com






1. INTRODUCTION

Today, in the developed countries, one of the biggest reproductive health challenges is the high rate of childlessness and infertility. Despite the fact that in the last hundred years the world population has increased almost five times mainly as a result of the increasing population in the developing countries, the birth rates of the developed societies are continuously decreasing [1Warren SG. Can human population be stabilized? Earths Futur 2015; 3(2): 82-94.
[http://dx.doi.org/10.1002/2014EF000275]
].

The studies distinguish between the aspects of involuntary childlessness and voluntary childlessness. The reason for decreasing birth rates in advanced industrial countries is mostly because of social and economic factors, and a large part is also due to personal choice. Miettinen and Szalma found that the rate of European people of reproductive age who were voluntarily childless was generally between 1-6%. The most decisive reason, for both women and men, was the lack of a relationship [2Miettinen A, Szalma I. Childlessness intentions and ideals in Europe Finnish Yearbook of Population Research 2014; 49: 31-55.]. A subsequent Hungarian study showed that the role of this most decisive factor decreased in a timespan of ten years; in 2001, 67% of single women had no child, and ten years later, 51% were childless [3Szabó L. The childlessness extends in Hungary: Every 5th women in a capitel lives without a child. Korfa Népesedési Hírlevél 2015; 15(1): 1-4.]. Despite this favorable trend, the fertility rate is still stagnating or dropping in the developed countries. What can be the cause of the radical decrease in childbearing? On many occasions, it is difficult to distinguish between the voluntary and involuntary childlessness, since the late, conscious childbearing, generally occurring between the age of 35-40 years, can easily lead to reproductive health problems [4Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care. Hum Reprod 2007; 22(6): 1506-12.
[http://dx.doi.org/10.1093/humrep/dem046] [PMID: 17376819]
].

The desire of having a child is an instinctive, complex motivation. Unintended childlessness can put serious psychosocial weight on the affected couple [5Wichman CL, Ehlers SL, Wichman SE, Weaver AL, Coddington C. Comparison of multiple psychological distress measures between men and women preparing for in vitro fertilization. Fertil Steril 2011; 95(2): 717-21.
[http://dx.doi.org/10.1016/j.fertnstert.2010.09.043] [PMID: 21067728]
]. There are many ways to approach the emotional aspects of infertility. It is questionable whether this psychological burden is a consequence of infertility, or it was present previously, or it appears as a cause of childlessness. If we count it as a consequence, the question arises which phenomenon can be its direct source: a desire for incapable childbearing, or assisted reproduction treatments, the diagnosis itself, patient stigmatization, or a reaction to the partner’s behavior. In the literature, many studies deal with this subject, but most of them focus on the differences between genders, and most of these papers consider the women’s aspect as more significant [6Fisher JR, Hammarberg K. Psychological and social aspects of infertility in men: An overview of the evidence and implications for psychologically informed clinical care and future research. Asian J Androl 2012; 14(1): 121-9.
[http://dx.doi.org/10.1038/aja.2011.72] [PMID: 22179515]
]. Most authors agree that the members of the couple affect each other psychologically and they are facing infertility as a couple [7Cserepes RE, Kőrösi T, Bugán A. Characteristics of infertility-specific quality of life in Hungarian couples. Orv Hetil 2014; 155(20): 783-8.
[http://dx.doi.org/10.1556/OH.2014.29867] [PMID: 24819187]
].

The aim of this paper is to review the literature regarding the psychological aspect of infertility, paying special attention to depression, anxiety and coping strategies in infertile couples.

2. METHODS

In the preparation of this study, a research was conducted in the databases SCOPUS, PubMed, EMBASE using the keywords ‘infertility’, ‘depression’, ’Beck depression inventory’, ‘BDI’; ‘infertility’, ’anxiety’ ‘Spielberger’, ‘STAI’; ‘infertility’, ‘coping mechanism’. Similar keywords were used in Hungarian in the Matarka database. Only papers in English or Hungarian were included. For the basis of this summary, self-survey studies were selected with at least 100 patients using Spielberger Anxiety Type Inventory (STAI) and Beck Depression Inventory (BDI) from the last nineteen years. Papers from earlier years were included only if they were judged as containing fundamental data or definition of the topic. The studies examining coping strategies used the Conflict Resolution Survey, as it is the most commonly used questionnaire in daily clinical practice. Studies on special populations (e.g. patients with endometriosis, polycystic ovary syndrome, etc.) were excluded.

3. RESULTS

We found 162 articles regarding infertility and depression, 43 articles on the topic of anxiety and infertility and 58 papers dealing with coping mechanism in infertility. After applying our inclusion and exclusion criteria, altogether 25 articles were analyzed. The comparison studies mostly discussed the aspects of psychological differences between genders, a smaller part of the research was focused on the aspect of psychological burden on couples, and only some research emphasized the emotional burden on males separately.

3.1. Motivations Behind Childbearing

Infertility is determined as an inability to become pregnant within one year despite regular unprotected sexual intercourse. If the woman is older than 35 years, the diagnosis of infertility can be established after 6 months. Between 8-15% of couples in the reproductive age are reported to be affected by infertility [8ACOG Committee. Infertility workup for the women’s health specialist. ACOG Committee Opinion No. 781. Obstet Gynecol 2019; 133: 377-84.
[http://dx.doi.org/10.1097/AOG.0000000000003271]
].

Infertile women and men form an applicable group for observing motivations of becoming parents. These motivations may remain hidden in healthy couples, but in infertile patients, it manifests itself as unfulfilled desire [9Dyer S, Mokoena N, Maritz J, van der Spuy Z. Motives for parenthood among couples attending a level 3 infertility clinic in the public health sector in South Africa. Hum Reprod 2008; 23(2): 352-7.
[http://dx.doi.org/10.1093/humrep/dem279] [PMID: 18063652]
]. Childbearing motivations include age, relationship status, social-cultural expectations, striving for equality, religious and economic reasons [10Edelmann RJ, Humphrey M, Owens DJ. The meaning of parenthood and couples’ reactions to male infertility. Br J Med Psychol 1994; 67(Pt 3): 291-9.
[http://dx.doi.org/10.1111/j.2044-8341.1994.tb01797.x] [PMID: 7803320]
]. Several studies compared men’s motivation for fatherhood with women’s motivation to become a mother [6Fisher JR, Hammarberg K. Psychological and social aspects of infertility in men: An overview of the evidence and implications for psychologically informed clinical care and future research. Asian J Androl 2012; 14(1): 121-9.
[http://dx.doi.org/10.1038/aja.2011.72] [PMID: 22179515]
, 11Mynarska M, Rytel J. From motives through desires to intentions: Investigating the reproductive choices of childless men and women in Poland. J Biosoc Sci 2018; 50(3): 421-33.
[http://dx.doi.org/10.1017/S0021932017000190] [PMID: 28566101]
, 12Carone N, Baiocco R, Lingiardi V. Single fathers by choice using surrogacy: Why men decide to have a child as a single parent. Hum Reprod 2017; 32(9): 1871-9.
[http://dx.doi.org/10.1093/humrep/dex245] [PMID: 28854718]
]. In an Australian study, Fisher et al. studied men who were diagnosed with infertility more than five years ago. Of these men, 84% showed a desire of having a baby at least as strong as their female partner did, and less than half thought that involuntary childlessness affected women more strongly than it did men [13Fisher JR, Baker GH, Hammarberg K. Long-term health, well-being, life satisfaction, and attitudes toward parenthood in men diagnosed as infertile: Challenges to gender stereotypes and implications for practice. Fertil Steril 2010; 94(2): 574-80.
[http://dx.doi.org/10.1016/j.fertnstert.2009.01.165] [PMID: 19342027]
]. Also, there is another study from South Africa, which shows that men are seriously affected emotionally by infertility. For men in infertile couples, there were three motivations for having a child: being happy, the experience of fatherhood, and striving for a better quality of life [9Dyer S, Mokoena N, Maritz J, van der Spuy Z. Motives for parenthood among couples attending a level 3 infertility clinic in the public health sector in South Africa. Hum Reprod 2008; 23(2): 352-7.
[http://dx.doi.org/10.1093/humrep/dem279] [PMID: 18063652]
].

3.2. Depression and Anxiety

In the course of involuntary childlessness, psychological differences are the feedback response due to the stress of this crisis situation [14Greil AL, Slauson-Blevins K, McQuillan J. The experience of infertility: A review of recent literature. Sociol Health Illn 2010; 32(1): 140-62.
[http://dx.doi.org/10.1111/j.1467-9566.2009.01213.x] [PMID: 20003036]
]. We can differentiate this distress into intrapersonal and interpersonal aspects [15Szigeti J, Konkoly B. The psychological aspects of infertility: A review of the literature. Magyar Pszichológiai Szemle 2012; 67(3): 561-80.
[http://dx.doi.org/10.1556/MPSzle.67.2012.3.8]
]. In the literature, depression, anxiety and problematic self-evaluation are mostly emphasized as the expressions of the intrapersonal aspects. Interpersonal consequences can be problems in the relationship, unsatisfied sexuality, or possibly a decrease in the frequency of sexual intercourse. According to Szigeti, these interpersonal difficulties - such as marriage conflicts - lead to a decrease in subjective well-being [15Szigeti J, Konkoly B. The psychological aspects of infertility: A review of the literature. Magyar Pszichológiai Szemle 2012; 67(3): 561-80.
[http://dx.doi.org/10.1556/MPSzle.67.2012.3.8]
].

Regarding childless couples, the most frequent psychological disorders are anxiety and depression, hence a significant part of the literature focuses on these symptoms [7Cserepes RE, Kőrösi T, Bugán A. Characteristics of infertility-specific quality of life in Hungarian couples. Orv Hetil 2014; 155(20): 783-8.
[http://dx.doi.org/10.1556/OH.2014.29867] [PMID: 24819187]
]. Generally, studies highlight a stronger emotional burden on women, but it can also be underlined that their male counterparts are in an inferior psychological condition compared to men in the general population [6Fisher JR, Hammarberg K. Psychological and social aspects of infertility in men: An overview of the evidence and implications for psychologically informed clinical care and future research. Asian J Androl 2012; 14(1): 121-9.
[http://dx.doi.org/10.1038/aja.2011.72] [PMID: 22179515]
, 16Drosdzol A, Skrzypulec V. Depression and anxiety among Polish infertile couples-an evaluative prevalence study. J Psychosom Obstet Gynaecol 2009; 30(1): 11-20.
[http://dx.doi.org/10.1080/01674820902830276] [PMID: 19308778]
-19Schaller MA, Griesinger G, Banz-Jansen C. Women show a higher level of anxiety during IVF treatment than men and hold different concerns: A cohort study. Arch Gynecol Obstet 2016; 293(5): 1137-45.
[http://dx.doi.org/10.1007/s00404-016-4033-x] [PMID: 26884350]
]. Edelmann studied the depression and anxiety levels of 246 infertile couples in England. According to his results, men's depressive and anxiety scores were significantly lower than their female counterparts [20Edelmann RJ, Connolly KJ. Gender differences in response to infertility and infertility investigation: Real or illusory. Br J Health Psychol 2000; 5: 365-75.
[http://dx.doi.org/10.1348/135910700168982]
]. Volgsten et al. found that 10.9% of infertile women suffer from major depression, while only 5.1% of men are affected. In the same patient group, 14.8% of women and 4.9% of men showed symptoms of anxiety [21Volgsten H, Skoog Svanberg A, Ekselius L, Lundkvist O, Sundström Poromaa I. Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment. Hum Reprod 2008; 23(9): 2056-63.
[http://dx.doi.org/10.1093/humrep/den154] [PMID: 18583334]
]. In a recent research, we found surprisingly low levels of depression and anxiety scores in men at the start of the fertility workup, suggesting that infertility evaluation and treatment may play a role in the emergence of psychological symptoms [22Hegyi BE, Kozinszky Z, Badó A, Dombi E, Németh G, Pásztor N. Anxiety and depression symptoms in infertile men during their first infertility evaluation visit. J Psychosom Obstet Gynaecol 2019; 9: 1-7.
[http://dx.doi.org/10.1080/0167482X.2018.1515906] [PMID: 30624134]
].

Some of the studies on men alone aimed to assess the psychological state of infertile men through the involvement of a healthy control group. In Poland, Drosdzol et al. compared 188 infertile male patients aged between 20-45 to the male members of 190 couples of the same age, who had at least one child. According to their results, the scores of infertile men for both psychological disorders were higher than those of fertile patients, with 15.6% of subjects suffering from mild depression [16Drosdzol A, Skrzypulec V. Depression and anxiety among Polish infertile couples-an evaluative prevalence study. J Psychosom Obstet Gynaecol 2009; 30(1): 11-20.
[http://dx.doi.org/10.1080/01674820902830276] [PMID: 19308778]
]. Similar results have been reported by a Finnish study comparing the psychological status between 2291 randomly selected men, some of whom had experienced, and some of whom had never experienced involuntary childlessness [23Klemetti R, Raitanen J, Sihvo S, Saarni S, Koponen P. Infertility, mental disorders and well-being-a nationwide survey. Acta Obstet Gynecol Scand 2010; 89(5): 677-82.
[http://dx.doi.org/10.3109/00016341003623746] [PMID: 20196679]
]. In a Hungarian study, a relation was identified between the signs of depression and a deterioration in the quality of life [24Cserepes RE, Bugán A. Impact of depressive symptomatology in Hungarian infertile couples. Psychiatr Hung 2015; 30(1): 50-9.
[PMID: 25867888]
]. In both sexes, the partner’s depressive symptoms can further increase the infertility-related concerns. However, men are even more concerned about their sexual life, if their spouses suffer from mild depression [24Cserepes RE, Bugán A. Impact of depressive symptomatology in Hungarian infertile couples. Psychiatr Hung 2015; 30(1): 50-9.
[PMID: 25867888]
]. Similar results were documented in an Italian study. Chiaffarino et al. evaluated 1000 couples undergoing assisted reproductive treatment [25Chiaffarino F, Baldini MP, Scarduelli C, et al. Prevalence and incidence of depressive and anxious symptoms in couples undergoing assisted reproductive treatment in an Italian infertility department. Eur J Obstet Gynecol Reprod Biol 2011; 158(2): 235-41.
[http://dx.doi.org/10.1016/j.ejogrb.2011.04.032] [PMID: 21641108]
]. The study used a self-filled survey to measure the socio-demographic background and psychological state of the couples. According to their results, 14.7% of women showed anxiety, and 17.9% had depressive symptoms, while men had the same symptoms at 4.5% and 6.9%. However, the study also highlighted other contexts: women with depressive and anxiety symptoms generally had partners with symptoms of anxiety. Depressed and anxious men often had a female partner with problematic psychological status. Gender differences in depression and anxiety levels were confirmed in a South-Korean study, as well. Quality of life was lower, infertility distress and depression scores were higher in women. Moreover, significant actor-partner effects were observed, as the wife’s infertility-related stress had a negative impact on the husband’s quality of life [26Kim JH, Shin HS, Yun EK. A dyadic approach to infertility stress, marital adjustment, and depression on quality of life in infertile couples. J Holist Nurs 2018; 36(1): 6-14.
[http://dx.doi.org/10.1177/0898010116675987] [PMID: 29436974]
].

3.3. Coping Mechanisms

Any cognitive or behavioral effort can be considered as a coping mechanism that is used by the individual to deal with an external or internal influence that is judged to outweigh or subvert current personal resources [27Boross O, Pléh Cs. Introduction to Psychology 2004.]. According to the transactional approach, behavior is the result of a continuous interaction between the individual and the environment, and the coping mechanism is one of the key variables which modulates this transaction under difficult adaptation conditions [27Boross O, Pléh Cs. Introduction to Psychology 2004.]. Infertility can be considered as a difficult situation to adapt to since it is associated with serious loss experience [15Szigeti J, Konkoly B. The psychological aspects of infertility: A review of the literature. Magyar Pszichológiai Szemle 2012; 67(3): 561-80.
[http://dx.doi.org/10.1556/MPSzle.67.2012.3.8]
]. Loss, because the infertile couple loses the feeling of expecting a child, the joy of raising a child, and the acknowledgement of people. They face the failure to meet their personal expectations and fear hopelessness for the future, which they have to reshape and rebuild. In such a situation, the success of further progression is not only contributed by the psychological well-being of the individual, but also by the adaptive coping strategy of the situation [28Lakatos E, Pápay N. Paradigms in the interpretation of infertility [Paradigmák a meddőség értelmezésében] 2014. [Hungarian]]. In the literature, usually problem-solving (rational) and emotional-centered coping strategies are distinguished. The problem-solving coping mechanisms actively change or eliminate the circumstances that directly trigger stress, while emotion-centered coping mechanisms control the emotions provoked by the stressful life situations [29Folkman S, Lazarus R. Manual for the Ways of Coping questionnaire [Research Edition] 1988.-31Jahromi MK, Ramezanli S. Coping with infertility: An examination of coping mechanisms in iranian women with infertility. J Psychiatry 2015; 18: 1-5.]. If we see the environment as changeable, we use problem-solving strategies, if we define it unchangeable, we prefer emotion-centered approach [27Boross O, Pléh Cs. Introduction to Psychology 2004., 32Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol 1986; 50(5): 992-1003.
[http://dx.doi.org/10.1037/0022-3514.50.5.992] [PMID: 3712234]
]. However, responses to specific stressors are extremely varied. The success of any coping may depend on both the situation and the characteristics of the person involved [27Boross O, Pléh Cs. Introduction to Psychology 2004.]. In order to assess coping strategies, self-reporting questionnaires can be used, including the most widespread Conflict Resolution Questionnaire (Ways of Coping Questionnaire) as finalized by Folkman and Lazarus [29Folkman S, Lazarus R. Manual for the Ways of Coping questionnaire [Research Edition] 1988.]. Over the past few decades, many authors have connected involuntary childlessness, as a hardly adaptable condition with the coping mechanisms [30Cunha M, Galhardo A, Pinto-Gouveia J. Experiential avoidance, self-compassion, self-judgment and coping styles in infertility. Sex Reprod Healthc 2016; 10: 41-7.
[http://dx.doi.org/10.1016/j.srhc.2016.04.001] [PMID: 27938872]
, 31Jahromi MK, Ramezanli S. Coping with infertility: An examination of coping mechanisms in iranian women with infertility. J Psychiatry 2015; 18: 1-5., 33Lazarus RS. From psychological stress to the emotions: A history of changing outlooks. Annu Rev Psychol 1993; 44: 1-21.
[http://dx.doi.org/10.1146/annurev.ps.44.020193.000245] [PMID: 8434890]
-35Nagy E, Nagy BE. Coping with infertility: Comparison of coping mechanisms and psychological immune competence in fertile and infertile couples. J Health Psychol 2016; 21(8): 1799-808.
[http://dx.doi.org/10.1177/1359105314567206] [PMID: 25616427]
]. Peterson et al. used WOCQ (Ways of Coping Questionnaire) to discover coping mechanisms among infertile couples [34Peterson BD, Pirritano M, Christensen U, Schmidt L. The impact of partner coping in couples experiencing infertility. Hum Reprod 2008; 23(5): 1128-37.
[http://dx.doi.org/10.1093/humrep/den067] [PMID: 18325885]
]. 1169 women and 1081 men were involved in their research, their subjects were all facing infertility. On the basis of their study, four basic dimensions were drawn: active-avoidance, active-confronting, passive-avoidance, and meaning-based. The active-avoidance type person is definitely keeping away himself from any situation that would resemble the failure of childbearing. The active-confronting people express their emotions, seek help, and get advice from their fellow peers. The passive-avoidance type waits and hopes for change, and finally the meaning-based person seeks the cause and meaning of infertility, giving an optimistic outlook to what has happened. Based on their research, it has been proven that whichever gender is involved; the active-avoidance personality correlates with higher intrapersonal and interpersonal distress. The active-confronting people using emotional expressions primarily burden their partner, and the use of such a coping mechanism involves a higher level of relationship distress. Mostly, active-confronting patients can gain benefits from online groups. These communities can provide support, empathy and patients can share their experiences [36Malik SH, Coulson NS. Coping with infertility online: An examination of self-help mechanisms in an online infertility support group. Patient Educ Couns 2010; 81(2): 315-8.
[http://dx.doi.org/10.1016/j.pec.2010.01.007] [PMID: 20144521]
].

The goal of Hungarian research was to analyze the psychological status of infertile Hungarian couples. They assessed the typical coping strategies and marital co-operation. Gender differences were clearly identified. Men were more inclined to have a meaning of life-seeking strategy. According to the conclusion of their results, this seemed to be a successful coping mechanism in which the individual could face and was able to tolerate the distress of involuntary infertility [37Cserepes RE, Kollár J, Sápy T, Wischmann T, Bugán A. Effects of gender roles, child wish motives, subjective well-being, and marital adjustment on infertility-related stress: A preliminary study with a Hungarian sample of involuntary childless men and women. Arch Gynecol Obstet 2013; 288(4): 925-32.
[http://dx.doi.org/10.1007/s00404-013-2835-7] [PMID: 23553201]
]. Typical gender-specific coping strategies were demonstrated in the study of Peterson et al., too. Men's typical coping mechanism was distancing and self-control, while women preferred seeking professional support, seeking social support, and taking responsibility [38Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how men and women who are referred for IVF cope with infertility stress. Hum Reprod 2006; 21(9): 2443-9.
[http://dx.doi.org/10.1093/humrep/del145] [PMID: 16675482]
]. Taking these gender-specific coping strategies into account, it is possible that the psychological involvement of infertile men is under-measured in the research studies.

According to Schmidt and Holnstein; having wrong spousal communication and using the avoiding coping strategy involves significantly higher infertility-specific distress in both genders [39Schmidt L, Holstein BE, Christensen U, Boivin J. Communication and coping as predictors of fertility problem stress: Cohort study of 816 participants who did not achieve a delivery after 12 months of fertility treatment. Hum Reprod 2005; 20(11): 3248-56.
[http://dx.doi.org/10.1093/humrep/dei193] [PMID: 16006458]
]. For an infertile couple, it may be essential to choose a coping strategy to reduce distress. Adequate coping mechanisms should be considered for psychotherapeutic treatment of infertility.

3.4. Cultural Attributes

Comparative, cross-cultural researches are scarce in the literature regarding the psychological aspects of infertility. In most communities, childbearing is closely connected to womanhood [40Inhorn MC, van Balen F, Eds. Infertility around the globe 2002.], and undoubtedly contributes to the good quality of men’s life [9Dyer S, Mokoena N, Maritz J, van der Spuy Z. Motives for parenthood among couples attending a level 3 infertility clinic in the public health sector in South Africa. Hum Reprod 2008; 23(2): 352-7.
[http://dx.doi.org/10.1093/humrep/dem279] [PMID: 18063652]
]. Infertile women share a common experience, like anxiety, depression, stigmatization, self-blaming, regardless the cultural environment [41Batool SS, de Visser RO. Experiences of infertility in british and pakistani women: A cross-cultural qualitative analysis. Health Care Women Int 2016; 37(2): 180-96.
[http://dx.doi.org/10.1080/07399332.2014.980890] [PMID: 25535774]
]. However, in the developed countries, as a consequence of safe contraceptive methods, childbearing has become a matter of choice [42McDonnell EJ. Me, you and us: Intimate relationships and the question of children. J Sociol (Melb) 2012; 48: 132-48.
[http://dx.doi.org/10.1177/1440783311413483]
]. Families are smaller, and as a result, infertility remains mainly a private issue. In contrast, in developing countries, a family is typically extended, with strong interpersonal relations [41Batool SS, de Visser RO. Experiences of infertility in british and pakistani women: A cross-cultural qualitative analysis. Health Care Women Int 2016; 37(2): 180-96.
[http://dx.doi.org/10.1080/07399332.2014.980890] [PMID: 25535774]
]. Childbearing is strongly expected by the relatives too, hence infertility is considered not only a personal but a family failure. Similar pressure is placed on the husband as well, which can cause negative attitude towards his partner [43Guz H, Ozkan A, Sarisoy G, Yanik F, Yanik A. Psychiatric symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol 2003; 24(4): 267-71.
[http://dx.doi.org/10.3109/01674820309074691] [PMID: 14702887]
]. In some countries, up to 50% of women report negative reactions from their partners, or family members, or even the social environment [43Guz H, Ozkan A, Sarisoy G, Yanik F, Yanik A. Psychiatric symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol 2003; 24(4): 267-71.
[http://dx.doi.org/10.3109/01674820309074691] [PMID: 14702887]
, 44Chang SN, Mu PF. Infertile couples’ experience of family stress while women are hospitalized for ovarian hyperstimulation syndrome during infertility treatment. J Clin Nurs 2008; 17(4): 531-8.
[PMID: 17331094]
]. Coping responses to the problem of infertility may display different patterns depending on the cultural environment. Religious coping, passive avoidance, fatalistic attitude are more common in developing countries, while in high-income countries patients often seek information and support online, and they trust the medical solution of their childlessness [36Malik SH, Coulson NS. Coping with infertility online: An examination of self-help mechanisms in an online infertility support group. Patient Educ Couns 2010; 81(2): 315-8.
[http://dx.doi.org/10.1016/j.pec.2010.01.007] [PMID: 20144521]
, 41Batool SS, de Visser RO. Experiences of infertility in british and pakistani women: A cross-cultural qualitative analysis. Health Care Women Int 2016; 37(2): 180-96.
[http://dx.doi.org/10.1080/07399332.2014.980890] [PMID: 25535774]
]. From the cross-cultural observations, it can be concluded, that several psychological aspects of infertility are common in all the patients, but significant cultural differences exist. These differences have to be taken into account in research, and in therapy as well [41Batool SS, de Visser RO. Experiences of infertility in british and pakistani women: A cross-cultural qualitative analysis. Health Care Women Int 2016; 37(2): 180-96.
[http://dx.doi.org/10.1080/07399332.2014.980890] [PMID: 25535774]
].

3.5. Supportive Psychotherapy

The literature highlights depressive and anxiety symptoms in connection with infertility-specific distress, regardless of the economy level of the country where the couples live [16Drosdzol A, Skrzypulec V. Depression and anxiety among Polish infertile couples-an evaluative prevalence study. J Psychosom Obstet Gynaecol 2009; 30(1): 11-20.
[http://dx.doi.org/10.1080/01674820902830276] [PMID: 19308778]
, 21Volgsten H, Skoog Svanberg A, Ekselius L, Lundkvist O, Sundström Poromaa I. Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment. Hum Reprod 2008; 23(9): 2056-63.
[http://dx.doi.org/10.1093/humrep/den154] [PMID: 18583334]
, 23Klemetti R, Raitanen J, Sihvo S, Saarni S, Koponen P. Infertility, mental disorders and well-being-a nationwide survey. Acta Obstet Gynecol Scand 2010; 89(5): 677-82.
[http://dx.doi.org/10.3109/00016341003623746] [PMID: 20196679]
, 26Kim JH, Shin HS, Yun EK. A dyadic approach to infertility stress, marital adjustment, and depression on quality of life in infertile couples. J Holist Nurs 2018; 36(1): 6-14.
[http://dx.doi.org/10.1177/0898010116675987] [PMID: 29436974]
, 28Lakatos E, Pápay N. Paradigms in the interpretation of infertility [Paradigmák a meddőség értelmezésében] 2014. [Hungarian], 43Guz H, Ozkan A, Sarisoy G, Yanik F, Yanik A. Psychiatric symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol 2003; 24(4): 267-71.
[http://dx.doi.org/10.3109/01674820309074691] [PMID: 14702887]
, 45Terzioglu F. Anxiety of infertile men who undergo genetic testing for assisted reproductive treatment. J Psychosom Obstet Gynaecol 2007; 28(3): 147-53.
[http://dx.doi.org/10.1080/01674820701322095] [PMID: 17577757]
-47Naab F, Brown R, Heidrich S. Psychosocial health of infertile Ghanaian women and their infertility beliefs. J Nurs Scholarsh 2013; 45(2): 132-40.
[http://dx.doi.org/10.1111/jnu.12013] [PMID: 23731032]
]. The need for psychotherapeutic support can be verified through various tests and surveys. Depression can be screened with the Beck Depression Inventory, while anxiety is generally measured using the Spielberger State-Trait Anxiety Inventory. Both tests are self-administered questionnaires, so they can be easily used in the clinical setting. It is also beneficial to assess the general well-being of the infertile couple, which can be measured using the WHO General Welfare Index, or the widely used Quality of Life Scale (QOLS). The Fertility Quality of Life (FertiQL) is a more specific test, which summarizes the quality of life associated with fertility. Fertility Problem Inventory (FPI) focuses on infertility-related distress, higher scores indicate the presence of anxiety and increased distress.

The congruent conclusion of the studies is that patients suffering from an infertility crisis need psychological support. Several researches proved the necessity and usefulness of psychotherapeutic intervention. In their study, Domar et al. compared the psychological status of infertile patients treated with cognitive-behavioral and group therapy with patients not receiving any type of therapy. The study considered depressive and anxiety symptoms, marital distress, and lifestyle characteristics. The treated individuals achieved significantly better psychological results than the control group [48Domar AD, Clapp D, Slawsby EA, Dusek J, Kessel B, Freizinger M. Impact of group psychological interventions on pregnancy rates in infertile women. Fertil Steril 2000; 73(4): 805-11.
[http://dx.doi.org/10.1016/S0015-0282(99)00493-8] [PMID: 10731544]
]. In contrast, Hämmerli et al. in a meta-analysis, found that psychotherapy did not bring a clear improvement in the psychological status of the infertile group. However, the rate of conceiving increased significantly as a result of mental support [49Hämmerli K, Znoj H, Barth J. The efficacy of psychological interventions for infertile patients: A meta-analysis examining mental health and pregnancy rate. Hum Reprod Update 2009; 15(3): 279-95.
[http://dx.doi.org/10.1093/humupd/dmp002] [PMID: 19196795]
]. Based on the increasing data, professional psychological counseling should be an integral part of the infertility treatment.

CONCLUSION

Growing evidence suggests that more attention should be paid to the psychological aspects of infertility, for both men and women, thereby increasing not only the chance for conceiving, but allowing the person to get closer to a healthy physical, mental, social and spiritual state. The data for infertile women are clear, their psychological status is inferior compared to their fertile counterparts. Considering social interactions and the known gender-specific coping mechanisms, we can assume that the psychological aspect of infertile men is under-measured in the literature. It is unquestionable that every assisted reproduction center should have a psychologist, as a full-time team member.

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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