Abstract: We conducted a descriptive study to evaluate the stressors and coping strategies of 150 infertile women presenting to Tabriz Al-Zahra Hospital since Aug. 2000 to Feb. 2002. Tiredness due to frequent trips to the clinic was the most common physical stressor in 67.3% of cases with severe and very severe intensities; and anxiety about effectiveness of treatment was the most common mental stressor in 87.3% of cases with severe and very severe intensities. Of affection-oriented coping strategies, praying and trust in GOD was the most used coping strategy (79.3%). Of the problem-oriented coping strategies, accepting the situation was used always in 74%. Psychosocial stressors were more frequent in comparison with physical stressors. So, obviating the affective problems of infertile women will have significant role in decrease of their stress and anxiety.
INTRODUCTION
Pregnancy and childbirth typically are associated with positive emotions (Geller, 2004). However, infertility is a significant medical problem that affects many couples (Makar and Toth, 2002). Approximately 10 to 15% of childbearing-age couples experience infertility. Infertility has multiple aspects, including physical, emotional, financial, social and psychological effects (Sherrod, 2004). Experience of infertility is a stressful condition itself, becoming particularly traumatic with previous pregnancies ending up in abortions, stillbirths and neonatal/infant deaths (Sami and Ali, 2006).
Receiving a diagnosis of infertility is a significant life crisis (Alesi, 2005). Feelings of grief and loss are very common as couples come to terms with the fact that they are not able to conceive. Infertility may result in a decrease in quality of life and an increase in marital discord and sexual dysfunction. The burden of infertility is physical, psychological, emotional and financial (Monga et al., 2004). Other coping strategies to cope with the reality of prolonged childlessness are Denial coping strategies (Van den Akker, 2005).
For many couples, infertility is undeniably a major life crisis and psychologically stressful (Mogobe, 2005; Schmidt et al., 2005a). Different emotional coping styles between men and women may add to what is an already stressful time (Alesi, 2005). However, the literature suggests that infertility is more stressful for women than for men (Wischmann et al., 2001) and on the other hand, most of therapeutic procedures are performed on females causing more anxiety and depression (Mehta and Anand Kumar, 2005).
Infertility itself has been reported to cause depression in women (Noble, 2005). Studies have found infertile women to be more neurotic, dependent and anxious than fertile women, experiencing conflict over their femininity and fear associated with reproduction. Other studies have similarly come to negative conclusions regarding the relationship between psychologic factors and infertility. Infertility is frequently perceived by the couple as an enormous emotional strain and counseling may prove helpful as a part of the initial infertility evaluation, an adjunctive measure during treatment, or a final measure to help patients cope with acceptance of their infertility problem (Schmidt et al., 2005b).
The examples other of potent stressors for couples include multiple diagnostic tests and examinations, multiple medical and fertilization-assisted therapies and their physical and mental complications, long-term therapies and low degree of their successfulness as well as economic problems caused by these treatments (Rajvir et al., 2000).
Because fertility has cultural and social importance (especially for women), the study of infertility is very important. For some couples, the infertility crisis can be seen as a cumulative trauma, which indicates that these couples have a marked need for infertility counseling (Wischmann et al., 2001). This study evaluates physical, mental and social stressors of infertile women and discusses about affection-focused and problem-oriented coping strategies, in order to infertile couples being supported psychosocially and helped to cope with the problem by the best strategies.
MATERIALS AND METHODS
This is a descriptive study in which 150 infertile women presenting to Tabriz Al-Zahra hospital since Aug. 2000 to Feb. 2002 were selected by convenience sampling and were evaluated. The data were collected by regular interview and questionnaire with closed-response questions. Of 31 questions in the questionnaire, 7 were related to physical stressors and 24 were related to psychosocial. The options were regulated according to the »5-scores Likert scale« as Never, Mild, Moderate, Severe and Very severe. To reach to our first goal (determination of physical stressors and their intensity), the following scaling was applied as the options of this section questions: scores 1 to 5 for options Never, Mild, Moderate, Severe and Very severe, respectively.
Then, the total achieved scores for 7 questions were classified as Mild (total scores of 7-13), Moderate (14-20), Severe (21-27) and Very severe (28-35). To reach to the second goal (determination of psychosocial stressors and their intensity), we used the same method; and to reach to the third goal (assessment of coping strategies), the 40-item Jalowiec scale (including 25 affection-oriented and 15 problem-oriented coping strategies) was used.
Also, to determination of quality of using from problem-oriented strategies, 15 questions of this section were classified regarding maximum and minimum application on range of 15-75; that is, Rarely (15-29) Occasionally (30-44), Often (45-59) and Always (60-75).
To determination of scientific reliability of data collecting tool, the Split-half method was used. Thus, in the first stage of sampling, the questions were completed by 10 persons; then terminal coefficient was achieved for questions related to stressors and coping strategies by Spearman-Brown equation. This coefficient was 0.85 and 0.89 for stressors and coping strategies, respectively. Also, χ2-test was used for determination of relationships between some individual and social factors and physical and psychosocial stressors.
RESULTS
Of psychosocial factors, age, academic acquisition, occupation, mate age, mate academic acquisition, mate occupation, the age in marriage, duration of marriage, race, location of life, family financial situation, duration of infertility, history of medical diseases, infertility in the first degree relatives and insurance coverage, were assessed. According to the results, the majorities of patients was in 25-32 years age group with mean age of 27.59 years and were housekeeper, with 1-6 years duration of infertility and under insurance coverage. Of all cases, 86.7% had infertility with known cause with related to ovary in 65.3%. Medication therapy and intrauterine insemination (IUI) had been performed in 48%.
Table 1 indicates that tiredness due to frequent trips to the clinic is the most common physical stressor (67%.3) with severe and very severe intensities and multiple blood drawing is the lowest 47.3% in Nevers.
Table 2 indicates that physical stressors had Moderate intensity in the most of patients (66.4%) and Very severe intensity in the minimum of patients (0.7%). Anxiety about effectiveness of therapy was the most frequent psychosocial stressor (87.3%) with Severe and Very severe intensities and lack of insurance coverage was the lowest psychosocial stressor with 88% of Nevers.
This table also indicates that in the most of patients (52.7%) the psychosocial stressors have Severe intensities and very severe stressors are seen in the lowest (4.7%).
According to the results, in the most of the patients the intensity of physical and psychosocial stressors was Moderate and Severe, respectively.
Table 3 indicates that the most of patients uses from affection-oriented strategies (15.3%), in occasionally. Also, the majority of them (84.4%) with often uses from problem-oriented strategies and Rarely use from these strategies was not seen in any of cases.
| Table 1: | Frequency of physical stressors among infertile women presenting to Tabriz Al-Zahra Hospital |
| Table 2: | Frequency of physical and psychosocial stressors according to their intensity in infertile women |
| Table 3: | Frequency of affection-oriented and problem-oriented coping strategies used in infertile women |
| Table 4: | Relationships of some individual and psychosocial factors with intensity of stressors |
The relations of individual and psychosocial factors with intensity of stressors are listed in Table 4.
DISCUSSION
Stress and anxiety are known to impair fertility both in men and women. Stress is defined as physical or mental tension, strain or pressure. It is a very generic term and can encompass anything from occupational pressures to infertility itself as well as its treatment. Therefore, it has not been easy to study the relationship between stress and infertility (Hjollund et al., 2004a, b; Eskiocak et al., 2005a).
There are a great differences between individuals as well as cross-cultural differences in the results obtained by using the same psychological tests to evaluate the level of stress that is being experienced by patients. Clearly, there is a need to define what tests are to be used to study stress and the coping strategies (Eskiocak et al., 2005b). Once such information becomes available it would be easy to identify specific therapies to alleviate stress and restore fertility (Mehta and Anand Kumar, 2005).
Approximately 20% of reproductive age couples have difficulty conceiving or maintaining an established pregnancy (Eskiocak et al., 2005b). Infertility may result in a decrease in quality of life and an increase in marital discord and sexual dysfunction (Monga et al., 2004).
In a study by Monga et al. (2004) couples seeking treatment for infertility were asked to complete standardized validated questionnaires assessing quality of life (Quality of Well-Being Scale-Self Administered, version 1.04), marital adjustment (Locke-Wallace Marital Adjustment Test) and sexual function (Brief Index of Sexual Functioning for Women and International Index of Erectile Function for men). Couples seeking elective sterilization served as the control subjects. They concluded that women in infertile couples reported poor marital adjustment and quality of life compared with controls (Monga et al., 2004). Men may experience less intercourse satisfaction, perhaps because of the psychological pressure to try to conceive or because of the forced timing of intercourse around the woman's ovulatory cycle (Monga et al., 2004). Infertility stresses may last for years and be aggravated when the treatment fails to cause pregnancy (McNaughton-Cassill et al., 2000).
The number of couples experiencing unwanted childlessness will continue to grow. A study showed that although ever more couples are undergoing in vitro fertilization (IVF) treatment, this fertilization-assisted technique is successful in only 13.9% of attempts. An unfulfilled wish for a child can have both negative emotional effects on individual partner and consequences for the couple's relationship. Women in particular suffer from the psychological stress that can be caused by infertility; they are more anxious, depressed and have a decreased self-esteem than their partners. The desire to counteract these emotional strains and to enhance the quality of life is increasing and accordingly requests for counseling services are on the rise. Studies have shown that various psychological treatments can often contribute to reducing stress but they do rarely increase the possibility of pregnancy (Wischmann, 2005).
Anxiety about effectiveness of treatment was identified as the most frequent psychosocial stressor. This finding is consistent with the result of Boivin and Takefman (1995) study which suggested that expectation for result of treatment and initiation of menstruation is the greatest stressor stage in the treatment of infertility.
Because the majority of cases (76%) were under insurance coverage, the lack of insurance coverage was not a major stressor for them. However, the problems related to treatment cost are due the fact that the majorities of infertility services are expensive and does not supported by insurance companies.
Psychosocial stressors were more stress-generating than physical stressors. The treatment of infertility is often difficult, time-consuming and expensive including some physical interventions, but mental stressors for couples and their effects on life quality are more important (Shu-Hsin, 2003).
Indeed, mental aspects of infertility are more difficult to be tested and treated (Ozkan and Baysal, 2006; Cousineau et al., 2006). The most of studied patients had used always from three affection-oriented coping strategies including praying and trust in GOD, anxiety and weeping. The great use from praying and trust in GOD in studied patients can indicate the religious and cultural background of them. Weeping, also is one of the 3 most common coping strategies in patients. The women stated that they have been wept often because of their infertility and in order to be relieved. This result is somewhat consistent with study of Davis and Dearman (1991) in which weeping is one of strategies used by infertile women. The patients have not used from relaxation techniques probably because of non-familiarity with these methods.
Of problem-oriented strategies, accepting the situation was identified as the most commonly used strategy. Davis and Dearman (1991) identified six ways of coping with infertility: 1) increasing the space or distancing oneself from reminders of infertility, 2) instituting measures for regaining control, 3) acting to increase self-esteem by being the best, 4) looking for hidden meaning in infertility, 5) giving in to feelings and 6) sharing the burden with others. They state that many patients regain relaxation by searching for these meanings and considering that this situation is divine will; and they believe that if GOD wants they will have child ultimately (Davis and Dearman, 1991).
According to the results obtained from this study, tiredness due to frequent trips to the clinic was identified as the most common physical stressor. Davis and Dearman (1991) state that frequent trips to the clinic for assessment are severely exhausting, causing disturbance in women’s diurnal order. In majority of patients, the intensity of physical stressors was moderate. Boivin and Takefman (1995) suggest that the women try to suppress their stress during the treatment and this is a coping strategy against mental stress of expectation duration for treatment result.
Recognition of the distressing character of infertility diagnosis and treatment has led to the development of several psychosocial interventions for infertile couples (Lemmens et al., 2004). However, several studies focused on the psychological disorder associated with IVF, suggest that treatment for infertility and IVF, can cause the symptoms of anxiety and depression in 10-50% of women (Boivin and Takefman, 1995; Caruso et al., 2000). Patients underwent IVF, often are anxious and become depressed if the treatment procedure fails to cause fertility (Boivin and Takefman, 1995; Caruso et al., 2000). Wischmann (2005) reported that 25% of women became depressed after failured IVF.
There is a subgroup of seriously stressed couples requiring professional psychological help. Therefore, qualified further education for gynecologists is necessary to ensure that such couples can be identified and referred for psychological care where necessary. Psychosocial counseling should be offered at any stage of infertility treatment and not only when treatment fails. As has been pointed out, it might be useful to provide written information on common emotional/psychological reactions to infertility and information about coping with this condition. For those couples whose coping resources are inadequate and/or depleted, counselors must make efforts to contact such patients individually to discuss the potential benefits of using counseling and/or participating in support groups. Instructions for psychosocial counseling are given in the ‘Guidelines for Counseling in Infertility’ (Wischmann et al., 2001; Boivin et al., 2001).
Although most health care professionals are more aware of problems related to physical aspects of infertility, the difficulties and needs that arise from the emotional aspects are often more significant for couples. Thus, it is crucial that health care professionals, particularly nurses, understand these needs (Sherrod, 2004).
CONCLUSIONS
According to the results of this study, the infertile women are susceptible to physical and psychosocial stressors due to infertility and its treatment and they use from affection-oriented and problem-oriented coping strategies. Thus, the presence of an individual having sufficient opportunity and interest to deal with affective problems of infertile women will have significant role in decrease of their stress and anxiety, causing that the treatment of infertility to be favored for them.
The family physicians and gynecologists are in a unique position to provide patient education, begin initial evaluation, make appropriate referrals and offer ongoing counseling and support to couples who experience problems with fertility.