|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2020 | Volume
: 36
| Issue : 4 | Page : 321-326 |
|
Psychological aspects of infertility: A comparative study
Nigesh Kalorath1, Tilottama Mukherjee2
1 National Career Service Center for Differently Abled, DGE, Ministry of Labour and Employment, Hyderabad, Telangana, India
2 Department of Psychology, University of Calcutta, Kolkata, West Bengal, India
| Date of Submission | 06-Feb-2020 |
| Date of Decision | 28-Feb-2020 |
| Date of Acceptance | 04-Jun-2020 |
| Date of Web Publication | 31-Dec-2020 |
Correspondence Address:
Mr Nigesh Kalorath
National Career Service Center for Differently Abled, DGE, M/o Labour and Employment, NSTI Campus, Shivam Road, Vidyanagar, Hyderabad - 500 007, Telangana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijsp.ijsp_21_20
Introduction: Psychosocial aspects of infertility in couples are of much relevance. This paper attempts to compare psychological factors that may play a role in couples with and without infertility. The main objectives are to examine the differences concerning marital quality, attachment styles, and defense styles of infertile and fertile couples. Methods: A total of 60 individuals (30 infertile couples and 30 matched fertile couples) were assessed through administering the personal information schedule, Marital Quality Scale, Attachment Style Questionnaire, and Defense Style Questionnaire-40. General Health Questionnaire-28 was administered in the fertile couples to rule out psychiatric morbidity. Results: Statistical analyses revealed that infertile couples differed from fertile couples on marital quality dimensions of understanding, satisfaction, trust, role functioning, despair, and rejection. On the attachment style, component of preoccupation with relationships and the use of immature defenses such as acting out and displacement. Conclusions: This research identified several psychological dimensions related to fertility. Understanding these factors may be helpful for the couples, their family members, and practitioners, with regard to the psychological and social needs related to infertility.
Keywords: Attachment style, couple, defense style, infertility, marital quality
How to cite this article:
Kalorath N, Mukherjee T. Psychological aspects of infertility: A comparative study. Indian J Soc Psychiatry 2020;36:321-6 |
| Introduction | |  |
Infertility is a major adversity in the lives of millions of people worldwide. Studies show, globally, one out of seven couples has complications to conceiving, an incidence rate similar to most countries.[1] However, it is also to be noted that the prevalence rate varies across studies. For example, studies show the prevalence rates of 0.6%–3.4% for primary infertility and 8.7%–32.6% for secondary infertility.[2] Considering becoming parents is a critical objective of marriage[3] as well as vital normative notions of adult life in societies across the world,[4] not being able to have children can lead to several psychological, emotional, and behavioral issues in the life of the affected couples.[5],[6],[7],[8]
This may lead couples to consider infertility as a major catastrophe.[9],[10] Studies show that diagnosis of infertility may lead to severe emotional distress,[11] marital instability,[12],[13] and increased mental health issues, including depression, anxiety, low self-esteem, and aggression.[11] It is also found that men and women are similarly affected by infertility, and the same is true for the negative impact on their psychological health. The review of the existing literature points to the significance of gaining more insights into the lives of individuals with infertility. Specifically, the authors focused on understanding marital quality, attachment styles, defense styles, and cognitive styles among infertile couples and on comparing the findings with that of couples without infertility.
| Methods | | |
Sample
The study included 60 participants, i.e., 30 married couples, in two groups. There were 15 couples in one group (n = 30) diagnosed with infertility who were compared with 15 fertile couples in the other group (n = 30). Participants were recruited using convenient sampling from a fertility clinic in Kolkata city. Treatment-seekers meeting inclusion-exclusion criteria were contacted for consent to participate in the study for 3 months. The participants in both groups were matched on age, education, occupation, language, family system, domicile, and income.
Inclusion and exclusion criteria for participants
Participants within the age range of 25–45 years, a minimum of 12 years of education, ability to read and write English, married for at least 2 years, and diagnosed with infertility based on the WHO criteria[14] were included in the study. Participants with at least one child were included in the fertility group. For both groups, those with a developmental disability, chronic medical illness, past or present history of psychiatric illness, sexually transmitted diseases, those who have attained menopause, and individuals with secondary infertility were excluded.
Measures
Personal information schedule was prepared by the investigators to elicit information on sociodemographic details.
General Health Questionnaire-28 (GHQ-28)[15] was used as a screening tool to rule out psychiatric comorbidity among all the participants. This scale gives a measure of common mental health problems/domains of depression, anxiety, somatic symptoms, and social withdrawal. The response option for the items in the scale includes, “not at all,” “no more than usual,” “rather more than usual,” and “much more than usual,” (scoring from 0 to 3, respectively). Scores above four are considered to achieve a “psychiatric caseness.” Numerous studies have investigated the reliability and validity of the GHQ-28 in various clinical populations. Test-retest reliability reported to be high (0.78–0.09),[16] and inter-rater and intra-rater reliability have both shown to be excellent (Cronbach's ά 0.9–0.95).[17] The GHQ has both content validity and construct validity.
Marital quality was assessed using the Marital Quality Scale.[18] It is a multi-dimensional scale in English language. Factor structure identified over and done with factor analysis, shows 12 factors and these are understanding, rejection, satisfaction, affection, despair, decision-making, discontent, dissolution potential, dominance, self-disclosure, trust, role functioning comprising of 6, 9, 5, 6, 2, 6, 2, 1, 2, 3, 1, and 4 items, respectively. Two questions/items do not represent any factors. The scale has 50 questions in a statement from a 4 point rating scale (U = Usually, S = Sometimes, R = Rarely, N = Never). The scale has 28 positively worded items and 22 negatively phrased items. The scale has higher internal consistency (coefficient alpha = 0.91) and high test-retest reliability.
Attachment styles were measured using the Attachment Style Questionnaire[19] which is a self-reported questionnaire, a six-point Likert scale with 40 items. The five dimensions of the scale are confidence, preoccupation with relationships, relationships as secondary (to achievement), discomfort with closeness, and need for approval. The only dimension of secure attachment is confidence. The other four are dimensions of various insecure attachment styles. The internal consistency (Cronbach's alpha) was reported to be 0.80, and test-retest reliability over 10 weeks was found to be 0.76.[19]
Defense Style Questionnaire[20]: It is a self-report measure that was used to assess the defense styles of the participants.. Andrews et al.[21] simplified the instrument into 40 questions related to 20 defense mechanisms among which four defenses are associated with the mature factor (sublimation, humor, anticipation, and suppression), four are related to the neurotic factor (undoing, pseudoaltruism, idealization, and reaction formation), and 12 are associated with the immature element (projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalization, and somatization). The internal consistency scores of the mature, neurotic, and immature defense styles are 0.70, 0.61, and 0.83, respectively. Furthermore, these three defense styles have acceptable split-half reliability and test-retest reliability coefficients.
Procedure
The study was conducted on a sample of 30 married couples who came for consultation in a fertility clinic in Kolkata city. A group of 15 fertile couples having at least one child was also selected from the same town. For the present research study, through a purposive sampling technique, the sample was selected based on the unique characteristics of infertility and fertility. Convenience sampling was involved in selecting respondents primarily based on their availability and willingness to respond. For inclusion in the infertile group members, the married couples who were visiting the clinics were selected based on fulfilling the inclusion and exclusion criteria. For inclusion in the fertile group members, couples who belong to Kolkata with matching demographic features were approached separately at their residence by the researcher, briefly oriented regarding the research. Written informed consent for participation was sought from all the individual participants. Willing participants were included based on inclusion and exclusion criteria and further screened on GHQ-28, and those who scored below cut off scores were chosen for the study sample. Data collected during the study were analyzed using SPSS version 16.0 (IBM, New York, USA).[22]
| Results | | |
Sample characteristics and preliminary statistics
Descriptive information about the participants in this study is presented in [Table 1] and [Table 2]. | Table 1: Mean and standard deviations of the scores obtained from the infertile group (women, men, and total) and fertile group (women, men, and total) for age
Click here to view |
 | Table 2: Significance of the difference between the mean of age variable for infertile and fertile couples groups
Click here to view |
Participants in this study ranged from 26 to 44 years of age; the mean age of the infertile group was 31.83, while the mean age for the fertile group was 34.63 [Table 1].
There was a significant difference in the mean rank of age between infertile couples and fertile couples [Table 2].
A comparative profile of infertile and fertile couples on the study variables
The results [Table 3] show that infertile couples have a significantly better understanding, satisfaction, trust, and role functioning than the fertile couples. Results further show that infertile couples have substantially higher despair and rejection than fertile couples. | Table 3: Significance of the difference between the mean of subjects for marital quality as total and dimensions of marital quality for infertile and fertile couples group
Click here to view |
The results [Table 4] indicate that there is a significant difference between the two groups concerning a dimension of attachment style, namely preoccupation with relationships. Infertile couples have a higher preoccupation with relationships than their fertile counterparts. | Table 4: Significance of the difference between the mean of subjects for attachment style for infertile and fertile couples group
Click here to view |
The results [Table 5] indicate that the infertile couples use both acting out and displacement to a more significant extent as compared to their fertile counterparts. | Table 5: The significance of the difference between the mean of subjects for the use of defense mechanisms for infertile and fertile couples group
Click here to view |
| Discussion | | |
The current study found that infertile couples had a significantly better understanding, satisfaction, trust, and role functioning compared to fertile couples. This finding is inconsistent with the existing literature and warrants further exploration. One possible explanation may be that infertility treatment often includes some sort of psychological support,[23],[24],[25] promoting well-being among the couples seeking treatment. Nevertheless, better understanding, satisfaction, trust, and role functioning are found to have a significant role in promoting well-being among married couples,[26],[27] emphasizing the need for comprehensive psychological support provided for couples seeking infertility treatments. Moreover, studies have shown that the individual's marital relation is related to other characteristics such as socioeconomic status,[28] personality,[29] mental health,[30] communication,[31], and duration of the marriage.[32] The above factors directly or indirectly influence the marital relationship of both the infertile males and females. When both partners perceive the issue of childlessness as a common problem, they may support each other with better understanding, satisfaction, trust, and role functioning – the interactions between couples that may be more important for marital quality than social or personal traits.[33] The present finding may be attributed to the fact that infertility is a mutual condition, and both partners shared the experience of childlessness.[34]
The study finds higher despair and rejection among infertile couples. Guerra et al. affirm “Infertility is a deeply distressing experience for many couples.”[8] Thus, in general, the likelihood of presenting despair and rejection feelings among infertile couples are higher than fertile couples; this was put forward by a study led by Mahlstedt, he postulated that “infertility sometimes is accompanied by existential crises and emotional tensions such as anxiety, suppressed anger, frustration, inferiority feeling, depression, rejected feeling, and despair.”[35]
The study also finds that infertile couples have a higher preoccupation with relationships than their fertile counterparts. This could arise from a feeling of inadequacy and incompleteness that may be complicated further by infertility. Their crisis makes them seek social support and acceptance, which, in a way, keeps them preoccupied with relationships. The result supports that the hypothesis was based on the general observation that infertile couples are more anxious than fertile couples. Editor of World Health Forum[36] argues that in India if infertile couples are provided with emotional support from their near and dear ones, it is likely to comfort them. Findings further indicate that the infertile couples use acting out and displacement to a more significant extent as compared to their fertile counterparts. The meaninglessness reflected by childlessness may lead to severe emotional conflicts. Infertile couples deal with their emotional conflicts and internal or external stressors by actions, rather the reflections or feelings or by shifting their strong emotional components and feelings from one object or idea to another. However, the defensive “acting out” is not synonymous with “bad behaviour” because, in infertile couples, this behavior is related to their unresolved emotional conflicts. Infertile couples also use displacement at a higher level when compared with their fertile comparable. Thus, this suggesting that the immature defenses function as individual adaptation methods for alleviating distress that occurs in relational contexts.[37]
The current study found that fertile couples use devaluation more than infertile couples do. Being infertile, they may tend to help understand each other's loss and not blame themselves or “devalue” themselves for childlessness. Rather, the anxiety invoked by the underlying conflict may be chosen to be displaced. The age factor, coupled with the pressure of rearing children, may give rise to the “midlife crisis.” In the current study, the mean age for the fertile couples was found to be significantly higher than the infertile couples. According to Erikson,[38] the stage of young adulthood is marked by the crisis of intimacy versus isolation, where the struggle is between the expression of intimacy and feeling of self-absorption. As infertile group falls in this stage, instead of devaluing themselves, they may tend to be seeking intimacy, as also suggested by their preoccupation with relationships. Instead of involving in the self-defeating behavior of devaluing themselves, they may tend to seek an intimate relationship. Although the fertile group also falls in the same stage, yet their mean age suggests that they are in middle adulthood, according to Erikson's theory, i.e., middle adulthood, marked by the crisis of generativity versus stagnation. However, no particular reason may be attributed to this finding currently, and further exploration may provide insights into the reason behind this finding.
Limitations of the study
As with the majority of infertility research, the current study is limited by its use of convenient sampling of couples who are undergoing treatments. This sampling method fails to capture many infertile couples who do not have the resources to pursue infertility treatments or who choose not to undergo any infertility treatment. This filtered out individuals belong to the lower socioeconomic strata of the society from the study. Convenient sampling, while increasing the homogeneity, made it difficult to comment on the implications of the present findings to a diverse sample facing similar issues. Further, this research did not address all the psychological factors related to infertility.
Implications
The present study would support the community and mental health professionals to recognize the underlying psychological components of infertility. It may benefit couples and their family members who are unaware of this regard. A broad-based awareness of infertility and its secondary effects on couples should be given greater importance. A need for informational programs on infertility regarding its psychological aspects and its management is felt strongly. Thus, the starting of counseling centers for the help of infertile couples is very crucial.
| Conclusions | | |
The present study indicates significant differences between infertile and fertile couples on different dimensions of marital quality. Infertile couples have better understanding, satisfaction, decision making, trust, and role functioning in the marital relationship than their fertile counterparts. Infertile couples experience a higher level of despair and rejection than fertile couples and are more preoccupied with relationships than fertile couples. Infertile couples use displacement and acting out to a greater extent than fertile couples, and devaluation to a lesser extent than their fertile counterparts. Thus, the study concludes with a note that psychological mechanisms related to infertility need further exploration. Couples may benefit from the specific recommendations of psychological interventions so that those who are suffering from the unbearable psychological pain due to the involuntary childlessness can move at least one step forward to the path of parenthood.
Acknowledgments
The author appreciates all those who participated in the study and helped to facilitate the research process.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | World Health Organization. Infertility: A Tabulation of Available Data on Prevalence of Primary and Secondary Infertility. Programme on Maternal and Child Health and Family Planning, Division of Family Health. Geneva: World Health Organization; 1991. p. 1-60.  |
| 2. | Mascarenhas MN, Cheung H, Mathers CD, Stevens GA. Measuring infertility in populations: Constructing a standard definition for use with demographic and reproductive health surveys. Popul Health Metr 2012;10:17. |
| 3. | Lee SH, Kuo BJ. Chinese traditional childbearing attitudes and infertile couples in Taiwan. Image J Nurs Sch 2000;32:54. |
| 4. | Cook EP. Characteristics of the biopsychosocial crisis of infertility. J Couns Dev 1987;65:465-9. |
| 5. | Aflatoonian A, Baghianimoghadam B, Partovi P, Abdoli A, Hemmati P, Tabibnejad N, et al. A new classification for female infertility. Clin Exp Obstet Gynecol 2011;38:379-81. |
| 6. | Burns LH, Covington S, editors. Infertility Counselling: A Comprehensive Handbook for Clinicians. New York: Parthenon; 1999. |
| 7. | Tuschen-Caffier B, Florin I, Krause W, Pook M. Cognitive-behavioral therapy for idiopathic infertile couples. Psychother Psychosom 1999;68:15-21. |
| 8. | Guerra D, Llobera A, Veiga A, Barri PN. Psychiatric morbidity in couples attending a fertility service. Hum Reprod 1998;13:1733-6. |
| 9. | Berk A, Shapiro JL. Some implications of infertility on marital therapy. Fam Ther 1984;9:36-47. |
| 10. | Burns LH, Covington SN. Infertility Counseling: A Comprehensive Handbook for Clinicians. New York: Parthenon; 1999. p. 149-76. |
| 11. | Crick NR, Grotpeter JK. Relational aggression, gender, and social-psychological adjustment. Child Dev 1995;66:710-22. |
| 12. | Jumayev I, Harun-Or-Rashid M, Rustamov O, Zakirova N, Kasuya H, Sakamoto J. Social correlates of female infertility in Uzbekistan. Nagoya J Med Sci 2012;74:273-83. |
| 13. | Direkvand Moghadam, Delpisheh A, Khosravi A. Epidemology of female infertility; A review of literature. Biosci Biotech Res Asia 2013;10:559-67. |
| 14. | World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems 2004: Tenth Revision. 2004:2nd ed Geneva. |
| 15. | Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med 1979;9:139-45. |
| 16. | Robinson RG, Price TR. Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke 1982;13:635-41. |
| 17. | Failde I, Ramos I, Fernandez-Palacín F. Comparison between the GHQ-28 and SF-36 (MH 1-5) for the assessment of the mental health in patients with ischaemic heart disease. Eur J Epidemiol 2000;16:311-6. |
| 18. | Shah A. Clinical validity of marital quality scale. Nimhans Journal 1995;13:23-31. |
| 19. | Feeney J, Noller P, Hanrahan M. Assessing adult attachment. In: Sperling MB, Berman WH, editors. Attachment in Adults: Clinical and Developmental Perspectives. New York: Guildford Press; 1994. |
| 20. | Bond MP. The development and properties of the defense style questionnaire. In: Conte HR, Plutchik R, editors. Ego Defenses: Theory and Measurement. New York: Wiley; 1995. p. 202-20. |
| 21. | Andrews G, Singh M, Bond M. The defense style questionnaire. J Nerv Ment Dis 1993;181:246-56. |
| 22. | Levesque R. SPSS Programming and Data Management: A Guide for SPSS and SAS Users. 4 th ed.. Chicago, III: SPSS Inc.; 2007. |
| 23. | ESHRE Task Force on Ethics and Law. III. Gamete and embryo donation. Hum Reprod 2002;17:1407-8. |
| 24. | Emery M, Béran MD, Darwiche J, Oppizzi L, Joris V, Capel R, et al. Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routine pre-IVF counselling. Hum Reprod 2003;18:2647-53. |
| 25. | British Infertility Counselling Association. About BICA. Available from: http://www.bica.net/about. [Last accessed on 2020 May 11]. |
| 26. | Casad BJ, Salazar MM, Macina V. The real versus the ideal: predicting relationship satisfaction and well-being from endorsement of marriage myths and benevolent sexism. Psychol Women Q 2014;39:119-29. |
| 27. | Flora J, Segrin C. Relational well-being and perceptions of relational history in married and dating couples. J Soc Pers Relatsh 2003;20:515-36. |
| 28. | Conger RD, Conger KJ, Elder GH Jr., Lorenz FO, Simons RL, Whitbeck LB. Family process model of economic hardship and adjustment of early adolescent boys. Child Dev 1992;63:526-41. |
| 29. | Chen Z, Tanaka N, Uji M, Hiramura H, Shikai N, Fujihara S, et al. The role of personalities in the marital adjustment of Japanese couples. Soc Behav Pers Int J 2007;35:561-72. |
| 30. | Afifi TO, MacMillan H, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Mental health correlates of intimate partner violence in marital relationships in a nationally representative sample of males and females. J Interpers Violence 2009;24:1398-417. |
| 31. | Ting-Toomey S. An analysis of verbal communication patterns in high and low marital adjustment groups. Hum Commun Res 1983;9:306-19. |
| 32. | Bradbury TN, Fincham FD, Beach SRH. Research on the nature and determinants of marital satisfaction: A decade in review. J Marriage Fam 2000;62:964-80. |
| 33. | Booth A, Johnson DR. Declining health and marital quality. J Marriage Fam 1994;56:218-23. |
| 34. | Kie colt-Glaser JK, Malarkey WB, Chee M, Newton T, Cacioppo JT, Mao HY, et al. Negative behavior during marital conflict is associated with immunological down-regulation. Psychosom Med 1993;55:395-409. |
| 35. | Mahlstedt PP. The psychological component of infertility. Fertil Steril 1985;43:335-46. |
| 36. | Singh AJ. Support for infertile couples. World Health Forum 1996;17:176-7. |
| 37. | McMahon C, Barnett B, Kowalenko N, Tennant CJ. Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insecure attachment style. Journal of Affective Disorders 2005;84:15-24. |
| 38. | Erikson EH. Childhood and society. Science 1950;13:253. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|
Search Pubmed for