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THE LEVEL OF STRESS AND COPING STRATEGIES OF FEMALES AMONG THE SUBFERTILE COUPLES IN

A SELECTED HOSPITAL IN MADURAI DISTRICT, TAMILNADU.

A DISSERTATION SUBMITTED TO THE TAMILNADU

DR. M.G.R MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT OF THE REQUIREMENT

FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING.

MARCH-2010

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THE LEVEL OF STRESS AND COPING STRATEGIES OF FEMALES AMONG THE SUBFERTILE COUPLES IN

A SELECTED HOSPITAL IN MADURAI DISTRICT, TAMILNADU.

BY

V. SOPHIA MARY STELLA

A DISSERTATION SUBMITTED TO THE TAMILNADU

DR. M.G.R MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILLMENT OF THE REQUIREMENT

FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING.

MARCH-2010

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NAME OF THE STUDENT: V. SOPHIA MARY STELLA.

REGISTER NUMBER: 30085423

NAME OF THE COLLEGE: MATHA COLLEGE OF

NURSING, VANPURAM, MANAMADURAI,

SIVAGANGAI DISTRICT- 630 606.

BATCH: 2008-2010

MARCH-2010.

SUBMITTED TO: THE TAMILNADU

DR.M.G.R. MEDICAL

UNIVERSITY.

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MATHA COLLEGE OF NURSING

(Affiliated to the TN Dr.M.G.R. Medical University),

VANPURAM, MANAMADURAI – 630 606.

SIVAGANGAI DISTRICT, TAMILNADU.

CERTIFICATE

This is the bonafide work of Mrs. V.SOPHIA MARY STELLA, M.Sc., Nursing (2008 – 2010 Batch) II year student from Matha College of Nursing, (Matha Memorial Educational Trust) Manamadurai – 630 606, submitted in partial fulfilment for the Degree of Master of Science in Nursing, under the Tamilnadu Dr. M. G. R.

Medical University, Chennai.

SIGNATURE: ………..

Prof. (Mrs.) JEBAMANI AUGUSTINE., M.Sc., (N), R.N., R.M.,

Principal,

Matha College of Nursing, Manamadurai.

COLLEGE SEAL:

MARCH – 2010

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A STUDY TO DETERMINE THE LEVEL OF STRESS AND COPING STRATEGIES OF FEMALES AMONG THE

SUBFERTILE COUPLES IN INFANT JESUS HOSPITAL IN MADURAI DISTRICT, TAMILNADU.

Approved by the dissertation committee on: ……….

PROFESSOR IN NURSING RESEARCH: ______________________

Prof.(Mrs.).JEBAMANI AUGUSTINE, M.Sc.,(N).R.N.,R.M., Principal cum HOD, Medical Surgical Nursing,

Matha College of Nursing, Manamadurai.

PROFESSOR IN CLINICAL SPECIALITY: ……….

Prof.(Mrs.)THAMARAI SELVI, M.Sc.,(N).,R.N.,R.M., Professor in Obstetric & Gynecology Nursing,

Matha College of Nursing, Manamadurai.

MEDICAL EXPERT : ……….

Dr. CHALICE RAJA THILAK, M.B.B.S., M.S(O.G), Infant Jesus Hospital,

105,106, South Veli Street, Madurai-625 001

A DISSEERTATION SUBMITTED TO THE TAMILNADU DR. M. G. R MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILMENT OF THE

REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING

MARCH-2010.

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ACKNOWLEDGEMENT

I wish to express my heartfelt gratitude to God Almighty for the abundant grace, love, wisdom, knowledge, strength and blessings in making this study towards its successful and fruitful outcome.

I wish to express my sincere thanks to Mr. P. Jeyakumar., M.A.,B.L., Founder, Chairman and Correspondent, Mrs. Jeyabackiam Jeyakumar., M.A., Bursar, Matha Memorial Educational Trust, Manamadurai, for their support, encouragement and providing the required facilities for the successful completion of the study.

I am extremely grateful to Prof. Mrs. Jebamani Augustine.,M.Sc.,(N)., R.N., R.M., the Principal, and the H. O. D of Medical Surgical Nursing, in Matha College of Nursing, Manamadurai, for her elegant direction and valuable suggestions for completing this study.

It is my pleasure to express my sincere thanks and deep appreciation to Prof. Mrs. Sabeera Banu., M.Sc.,(N)., PhD, the Vice Principal and the H. O. D of Obstetrics and Gynecological Nursing., for her valuable suggestion, guidance, encouragement and support throughout my work..

I express my sincere thanks to Prof. Mrs. Kalai Guru Selvi., M.Sc., (N)., additional Vice Principal and H. O. D of Child Health Nursing in

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Matha College of Nursing, Manamadurai, for her valuable guidance and support throughout this study.

I express my sincere thanks to my esteemed guide Prof.Mrs.

Thamarai Selvi., M.Sc., (N), for her support, guidance, valuable suggestions and her great effort throughout to complete the study successfully.

I extend my special thanks to Dr. Indra Raja, M.B.B.S., F.A.M.S., D.G.O., and Dr. Chalice Raja Thilak, M.B.B.S., M.S (O.G), for their valuable suggestions and guidance and also for granting me permission to conduct the study in their hospital.

My thanks to all the participants for extending their cooperation in the study.

I am thankful to all the Librarians of Matha College of Nursing, Manamadurai for their help and assistance in obtaining the literature.

My sincere and special thanks to Dr. Duraisamy., M. Phil., Ph.D., (Biostatistics), T. Jeyarajasekar, M.Phil., (Biostatistics) for giving necessary guidance for statistical analysis and presentation of data.

I specially thank Kalvi Institute of Computer Education faculty Miss. Saranya who helped me to complete the computing work.

I also express my thanks to the editor Mr. G. Ravichandran MA., B.Ed., M.Phil, for editing and his valuable suggestions; and the computer

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technicians for their help and untiring patience in printing the manuscript and completing the dissertation work..

I have no words to express the extreme love, care, support and inspiration given by my beloved husband Mr. G.Robinson Antony Raj and my beloved mother Mrs. Amalorpava Lilly Vincent and affectionate brothers Mr. Edwin and Mr. Michael for their constant support. They have expressed a true display of devotion. I owe a great deal of them for helping me to achieve the goal of this higher education.

It will not be fare if I forget to thank my lovable father and mother-in-laws who supported me by their prayers and encouraged me in the spiritual path.

I thank all my friends and my batch mates for their cooperation and support throughout this study.

As a final note, my sincere thanks and gratitude to all those who directly helped in successful completion of this dissertation.

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TABLE OF CONTENTS

CHAPTERS CONTENT Page

No.

CHAPTER – I INTRODUCTION 1

Need for the study 4

Statement of the problem 7

Objectives 7

Hypotheses 8

Operational definitions 9

Assumptions 10

Limitations 11

Projected outcomes 11

Conceptual Framework 12

CHAPTER-II REVIEW OF LITERATURE 15 Studies related to the subfertility and its

consequences. 15

Studies related to coping with the stress of

subfertility. 25

CHAPTER– III RESEARCH METHODOLOGY 36

Research approach 36

Research design 36

Setting of the study 36

Population 37

Sampling 37

Criteria for Sample Selection 37

Selection of the tool 38

Development of the tool 38

Description of the tool 38

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Scoring procedure 39

Testing of the tool 41

Pilot study 41

Data collection procedure 42

Plan for data analysis 43

Protection of subject rights 43 CHAPTER – IV ANALYSIS AND INTERPRETATION OF

DATA 44

CHAPTER – V DISCUSSION 47

CHAPTER – VI

SUMMARY, IMPLICATIONS, RECOMMENDATIONS AND CONCLUSIONS

87

Summary 87

Major findings of the study 88 Implications for nursing practice 90 Implications for nursing education 90 Implications for nursing administration 90 Implications for nursing research 91

Recommendations 91

Conclusion 92

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LIST OF TABLES

Table No TITLE Page

No 1 Frequency and percentage distribution of the

samples according to the selected demographic variables.

46

2 Frequency and percentage distribution of the level of stress in females among the subfertile couples.

61

3 Frequency and percentage distribution of the coping strategies of females among the subfertile couples.

63

4 Correlation between the stress and coping strategies.

66

5 Association between the level of stress and the selected demographic variables.

67

6 Association between the coping strategies and the selected demographic variables.

71

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LIST OF FIGURES

Figure No

TITLE Page No

1 Modified conceptual framework based on Health Belief Model (Rosenstoke’s and becker-1974).

14

2 Percentage distribution of samples according to the age

51

3 Percentage distribution samples according to the religion

51

4 Percentage distribution of samples according to the educational status

52

5 Percentage distribution of samples according to the occupation

52

6 Percentage distribution of samples according to the family income per month

53

7 Percentage distribution of samples according to the age at menarche

53

8 Percentage distribution of samples according to the age at marriage

54

9 Percentage distribution of samples according to the number of years since married

54

10 Percentage distribution samples according to marital status

55

11 Percentage distribution of samples according to type of marriage

55

12 Percentage distribution of samples according to type of family

56

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13 Percentage distribution of samples according to place of living

56

14 Percentage distribution of samples according to social support system

57

15 Percentage distribution of samples according to reason for subfertility

57

16 Percentage distribution of samples according to type of subfertility

58

17 Percentage distribution of samples according to number of hospital attendance

58

18 Percentage distribution of samples according to duration of therapy for subfertility

59

19 Percentage distribution of samples according to nature of therapy currently undergoing

59

20 Percentage distribution of samples according to frequency of intercourse

60

21 Percentage distribution of level of stress of females among the subfertile couples

62

22(a) Percentage distribution of active avoidance coping level

64

22(b) Percentage distribution of active confronting coping level

64

22(c) Percentage distribution of passive avoidance coping level

65

22(d) Percentage distribution of meaning based coping level

65

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LIST OF APPENDIX

Appendix No LIST OF APPENDIX

I

Letter seeking experts opinion for content validity

II

List of experts consulted for validity of research tool

III

Letter seeking permission to conduct study

IV

Interview guide in English and Tamil -Demographic data

- Stress assessment scale - Modified coping scale

V

Self instructional module (SIM) regarding subfertility and the ways of coping with stress (English and Tamil)

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ABSTRACT

INTRODUCTION:

Subfertility is a stressor that affects the subfertile couples more, especially the women. Coping of women among the couples with the unfulfilled desire for a child is affected by numerous variables. The purpose of this study is to determine the level of stress and coping strategies of 60 females among the subfertile couples, using the quantitative research approach, descriptive research design and purposive sampling technique.

STATEMENT OF THE PROBLEM:

A study to determine the level of stress and coping strategies of females among the subfertile couples in Infant Jesus Hospital in Madurai district, Tamilnadu.

OBJECTIVES:

1. To assess the level of stress in females among the subfertile couples.

2. To assess the coping strategies in females among the subfertile couples.

3. To assess the relationship between the level of stress and coping strategies in females among the subfertile couples.

4. To find out the association between the level of stress in females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

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5. To find out the association between the coping strategies used by the females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

HYPOTHESES:

H1: There will be a significant relationship between the level of stress and coping strategies in females among the subfertile couples.

H2: There will be a significant association between the level of stress in females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

H3: There will be a significant association between the coping strategies used by the females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital

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attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

ASSUMPTIONS:

1. Psychological and emotional factors can cause reproductive failure.

2. Stress and subfertility often have a circular relationship, and they can aggravate each other.

3. There are many stress management techniques to cope with stress.

4. Patients who are better able to cope with stress have higher pregnancy rates.

5. “Stress of modern life” is blamed for all ills including subfertility.

6. Blaming the couple for being stressed out further increases stress level and decreases fertility.

7. The woman is the more verbal and emotional partner among subfertile couples.

8. Women victim blaming is popular in subfertility.

MAJOR FINDINGS OF THE STUDY:

1. The researcher found that about forty (80%) females among subfertile couples had moderate stress, eleven (18.33%) had severe stress and one (1.66%) had mild stresses.

2. The active avoidance coping was mild in 16(26.66%), moderate in 44 (73.33%).

3. The active confronting coping was mild in one (1.66%), moderate in 44(73.33%), and good in 15(25%).

4. The passive avoidance coping was mild in 22(36.66%) and moderate in 38(63.33%).

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5. Meaning based coping was moderate in 13(21.66%) and good in 47(78.33%).

6. There was a weekly positive correlation between the level of stress and active avoidance, passive avoidance coping.

7. There was a negative correlation between the level of stress and active confronting, meaning based coping.

8. There was a significant association between the level of stress and selected demographic variables such as age, age at marriage, type of subfertility, and nature of therapy currently undergoing.

9. There was a significant association between the active avoidance coping and the selected demographic variable such as number of hospital attendance.

10. There was a significant association between the active confronting coping and the selected demographic variable such as the type of marriage and the type of subfertility.

11. There was a significant association between the passive avoidance coping and the selected demographic variable such as religion.

12. There was a significant association between the meaning based coping and the selected demographic variable such as number of years since married and reason for subfertility.

RECOMMENDATIONS:

On the basis of the findings of the study, it is recommended that,

1. A similar study may be replicated on large samples with different demographic variables.

2. A similar study may be conducted to assess the stress and coping of males among subfertile couples.

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3. A similar study may be conducted to identify the effectiveness of structural teaching program in overcoming stress and develop good coping strategies.

4. A comparative study may be conducted to assess the stress and coping strategies in rural and urban areas.

5. A comparative study may be conducted to assess the stress and coping strategies between females and males among subfertile couples.

CONCLUSION:

Experiencing subfertility can be an extremely painful experience especially for women. It’s an experience they never expected to go through, and many are often left feeling inadequate as women. As motherhood is primarily a female instinct, the inability to bear a child affects the woman’s identity itself. Men and women generally respond to subfertility differently. Generally, while men are concerned about subfertility, it may be less crucial to their self-esteem and identity. Also, handling the emotional impact of subfertility may be more difficult for them because they are not used to voicing and sharing these types of concerns and they are taught to bottle up their feelings. On the other hand, women frequently accept the label of subfertile as a key aspect towards the woman and it is often she who has to bear the brunt of its impact. They tend to feel more stressed about subfertility. They worry about it and it’s usually never far from their thoughts.

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CHAPTER-I

INTRODUCTION

“Courage, it would seem, is nothing less than the power to overcome danger, misfortune, fear, injustice, while continuing to affirm inwardly that life with all its sorrows is good; that everything is meaningful even if in a sense beyond our understanding; and that there is always tomorrow.” – Dorothy Thompson.

Subfertility is the inability to conceive and carry a child to term gestation when the couple has chosen to do so. It increases as the woman ages, especially after age 40 years. In the United States, about 20% of subfertility causes are unexplained; of the 80% that causative factors are known, about 40% is related to female causes, 40% is related to male causes, and 20% is attributable to both male and female causes. Common etiologic factors of subfertility include decreased sperm production, ovulation disorders, tubal occlusion, and endometriosis. The investigation of subfertility is conducted systematically and simultaneously for both male and female partners. The couples relationship dynamics, sexuality, and ability to cope with the psychological and emotional effects caused by diagnostic procedures and treatment of subfertility must be considered in the plan of care. Most subfertility cases are treated with conventional medical and surgical therapies; less than 3% are treated with in vitro fertilization. Reproductive alternatives for family building include IVF- ET (in vitro fertilization – embryo transfer), GIFT (gamete intrafallopian transfer), ZIFT (zygote intrafallopian transfer), oocyte donation, embryo donation, TDI (therapeutic donor insemination), surrogate motherhood, and adoption.

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The belief that subfertility is a psychologically mediated condition is long-standing. As an example, the Bible (1 Sam 1:1-28) describes Hannah, wife of Elkanah, as despondent and anorexic; she conceives only after she prayed and it is promised by a high priest that her wish will be granted. Psychological stress appears to be more common in the partner with the fertility problem. Subfertile couples, who are under stress because of their subfertility, start blaming themselves for their subfertility. This increases their stress levels and further aggravates the problem! As one mind-body expert has said, “Stress causes illness which causes more stress and that causes more illness”, most subfertile couples are under considerable stress in the areas of personal, social, family, and financial. Hardly surprising – when we want to get something and we cannot, stress is a perfectly normal and natural response. Thus, it’s obvious that subfertility causes stress.

Stress is a normal physical response to events that comes in many forms and affects people of all ages and all walks of life. The factors affecting stress level are physical health, quality of our interpersonal relationships, commitments and responsibilities on hand, expectations of available social support we receive, and recent major changes or traumatic events. Some stressors are particularly associated with certain age groups or life stages.

The common symptoms of stress are mood swings, trouble concentrating, feeling tense and jumpy, crying spells, and loss of energy or enthusiasm, back pain, stiff neck, headaches, gastrointestinal disturbances fatigue, increased blood pressure, heart palpitations, sleeping problem, problems with relationships, shortness of breath , weight gain or loss, and teeth grinding.

Chronic stress can lead to serious health problems. It can raise blood pressure, suppress the immune system, increase the risk of heart

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attack and stroke, contribute to infertility, and speed up the aging process.

Long term stress can even rewire the brain, leaving us more vulnerable to anxiety and depression.

Subfertility is an experience that continually fluctuates in intensity and direction, so that at different times persons may have different needs and experience different emotions. There are no set “stages” in this experience, and, while, at one time, their emotions can be mystifying and frighteningly intense, at another time, they may simply feel numb. There may be moments when the fact of being subfertile dictates every facet of their life. The way persons learn to deal with the experience of subfertility will also be different at different times. At times persons may find that the pain they experience is very destructive, but at others they may find it a useful motivating force in their life. It is important to acknowledge that emotional, responses to subfertility vary greatly, as do different people’s methods of coping with them. Each person has to find his or her own way of coping with the infertility situation, and sometimes might need help to accomplish this.

The relationship between stress and subfertility is still poorly understood today. While there is little doubt that subfertility causes considerable stress, the question whether stress can cause subfertility, and whether stress reduction can enhance pregnancy rates in subfertile couples, is still very controversial.

Even though stress of subfertility is often unavoidable, there are many steps that the persons can take to decrease the pain. Everyone’s response to subfertility is different depending on individual situations, emotional strengths, coping methods and personality. Persons are confronted with the emotional impact of subfertility before, during, and after treatment. It is better to prepare themselves for these difficult

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periods, so that with emotional support and mental preparation, people can successfully reduce the potential pain of subfertility.

NEED FOR THE STUDY:

“God, grant me the serenity to accept the things I cannot change, the courage to change the things I can change, and the wisdom to know the difference.” - Reinhold Niebuhr.

According to a statistics report by WHO, there is about 20 million infertile couples in India. About 30-40 percent of these cases involve infertility in men while 10-15 percent of cases involve problems in both men and women. Oligospermia, or low sperm count, is a leading cause of infertility among men.

There is medical evidence that suggests that decreasing male fertility is the result of modern living. A study by the NGO, Population Council (1997) found that stress lowers sperm count by overwhelming cells that make the male hormone, testosterone.

The infertility statistics of KJIVF-test tube babies and laparoscopy centre, in India shows that one in six couples is infertile. The 40 percent cases, the problem lies exclusively with the male, 40 percent with the female, 10 percent with both partners, and in a further 10 percent of cases, the cause is unknown. Fertility problems strike one in three women over 35. One in 25 males have a low sperm count, and one in 35 are sterile.

The research statistics of Delhi IVF- Fertility research centre-test tube baby clinic says that infertility afflicts thousand’s of married couple’s leading to untold mystery and frustration. In India 15-20% of the married couple’s in their fertile age group, are the sufferers, and it is on the increase because of urbanization, pollution, stress, chemical exposure,

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competitiveness, career orientation, late settlement in life etc. and by the present statistics it is about 20%.

According to the National Centre for Health Statistics and Centre for Disease Control and Prevention, about 12 percentage of women (7.3million) in the United States aged 15-44 had difficulty getting pregnant or carrying a baby to term in 2002.

A famous physician, Sir William Osler once said that human beings have two basic desires – to get and to beget. To have an own family is a universal dream. This dream can become a nightmare for the subfertile couple and learning that they have a subfertility problem can cause painful and difficult emotions. Subfertility is like a chronic illness that uses up a large amount of couples resources – emotional and financial – and involves the expenditure of a considerable amount of time, money, physical and emotional energy. It often creates one of the most distressing life crises that a couple has ever experienced together.

The long term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that subfertility can create great emotional upheaval for most couples.

It is common among subfertile couples for the woman to be the much more verbal and emotional partner. This often leads to the woman thinking and talking incessantly about infertility, and her whole world revolves around how to have a baby. Woman talks (or complains or screams or cries) about it and wishes the husband could feel the intensity of her pain. The husband tries to be supportive, but never seems to be able to do or say the right thing, so he gets “put off and shut off” and refuses to talk about it-exacerbating the tension even more.

A study conducted to identify gender differences in coping responses and the association between coping and psychological distress

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in couples undergoing In Vitro Fertilization treatment at the university of the West Indies. Of the couples, 52 were placed in a counseling program, based on the random selection of one of every three couples who signed up to undergo IVF treatment during that period. As one female client declined to participate in the study, the sample consisted of 26 men and 25 women, 52% of whom had completed secondary education, 44%

tertiary education, and 37% were 38 years and older. The majority of the couples had been trying for more than seven years to have a child (42%).almost half of the men (46%, n=12) had a child from a previous relationship and 11 women were presently in a relationship in which their partner had a child. On the other hand, 17 %( n=4) of the women had children from a previous relationship and one man reported that in his current relationship his partner had a child. A female-factor as the problem causing the infertility was identified by 39% of the participants and a male-factor by 33%, while 14% identified both partners as contributing and 14% claimed lack of knowledge. No one attributed the cause of their infertility to folklore or cultural myths such as the result of witchcraft. Some persons however questioned whether the infertility was due to the advancing age of the woman or a previous abortion. Women’s fears about not having a child were centered primarily on them not feeling complete as a woman and not having a child to look after them in their old age. Some women described, for example, a fear of ‘being called barren’, or ‘not having fulfilled my purpose as a woman, not giving husband a child’, and ‘will have no one to take care of me’. For men, their fears revolved around them having an incomplete family as well as concern for their partner’s mental health (“my wife will be sad, depressed”) (POTTINGER, AM, et al., 2006).

It is useful to develop constructive ways of coping with the stress of subfertility. Many programs have focused on the mind – body

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relationship for the subfertile couple, and have reported gratifying successes.

Regarding this study, the investigator also views the subfertility as a major problem in our society. Though technologies and treatment aspects have improved, the awareness regarding the subfertility is still not improved. The basic knowledge about this problem is inadequate among the people and as the result, the couples are becoming “most neglected silent minority”. Persons are stigmatized with subfertility and most of the time their stresses become unnoticed. The investigator has personal clinical experience of attending many couples with subfertility especially the women, because whether they are affected or not, they seek the medical help most of the time. This is due to the wrong belief among people that the female is the person of the reason for the infertility. More over women have greater level of stress, related to their problem comparing to men. So the investigator decided to conduct a study on this regard to know the level of stress and help them to achieve good coping strategies.

STATEMENT OF THE PROBLEM:

A study to determine the level of stress and coping strategies of females among the subfertile couples in Infant Jesus Hospital in Madurai district, Tamilnadu.

OBJECTIVES:

1. To assess the level of stress in females among the subfertile couples.

2. To assess the coping strategies in females among the subfertile couples.

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3. To assess the relationship between the level of stress and coping strategies in females among the subfertile couples.

4. To find out the association between the level of stress in females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

5. To find out the association between the coping strategies used by the females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

HYPOTHESES:

H1: There will be a significant relationship between the level of stress and coping strategies in females among the subfertile couples.

H2: There will be a significant association between the level of stress in females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of

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marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

H3: There will be a significant association between the coping strategies used by the females among the subfertile couples and selected demographic variables such as age, religion, age at marriage, number of years married, marital status, type of marriage, educational status, occupation, income, type of family, place of living, social support systems, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, and frequency of intercourse.

OPERATIONAL DEFINITIONS:

Level of stress:

Stress is a personal or subjective feeling of being threatened by various forms of stimuli like experience of subfertility, which produces mental tension and or physiological reaction and leads to distress and suffering in the form of anxiety, fear, frustration, headache, mood changes, palpitations etc., which can be assessed by using a stress assessment scale.

Coping strategies:

These are the ways of getting adjusted with the existing problem of subfertility, using certain skills or techniques consist of coping mechanisms, meditation, yoga, exercises, relaxation techniques and which can be assessed by using a modified coping scale containing four

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major strategies like active avoidance coping, active-confronting coping, passive-avoidance coping, and meaning-based coping.

Females among subfertile couples:

The inability of the females among subfertile couples to achieve pregnancy, after 12 months of unprotected sexual relationship with the partner or failure to conceive after medically unsuccessful treatment, and attending the clinic for treatment, regardless of the reason and types of subfertility.

ASSUMPTIONS:

1. Psychological and emotional factors can cause reproductive failure.

2. Stress and subfertility often have a circular relationship, and they can aggravate each other.

3. There are many stress management techniques to cope with stress.

4. Patients who are better able to cope with stress have higher pregnancy rates.

5. “Stress of modern life” is blamed for all ills including subfertility.

6. Blaming the couple for being stressed out further increases stress level and decreases fertility.

7. The woman is the more verbal and emotional partner among subfertile couples.

8. Women victim blaming is popular in subfertility.

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LIMITATIONS:

1. Only females among the subfertile couples were included.

2. The study period was only 4-6 weeks.

3. The sample size was 60 females among the subfertile couples.

PROJECTED OUTCOMES:

1. This study was proposed to determine the level of stress and coping strategies in females among the subfertile couples.

2. This will help the midwife to learn and to assess the level of stress and coping strategies used by the females among the subfertile couples and manage appropriately.

3. The outcome would also indicate that the female partner among subfertile couples learns and develops effective coping strategies.

4. It will help the midwives to use appropriate coping strategies to reduce the level of stress in females among the subfertile couples in the hospital or any other infertility institutions.

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CONCEPTUAL FRAMEWORK

The conceptual framework adapted for this study is from the Health Belief Model given by Rosen stock’s and Becker (1974). It is one of the psychological models that attempts to explain and predict health behaviors. This is done by focusing on the attitude and beliefs of individuals, and is one of the most widely used conceptual frameworks for understanding health behavior. This conceptual framework has three major components such as individual perception, modifying factors, and the likelihood of action.

INDIVIDUAL PERCEPTION:

The first component of this model is the individual’s perception of severity to disease. Perceived severity is defined as one’s belief or opinion of how serious a condition and its consequences are. In this study, the perception of females among the subfertile couples regarding subfertility is thought to be influenced by certain demographic variables such as age, religion, educational status, occupation of the woman, family income per month, age at menarche, age at marriage, number of years since married, marital status, type of marriage, type of family, place of living, social support system, reason for subfertility, type of subfertility, number of hospital attendance, duration of therapy for subfertility, nature of therapy currently undergoing, frequency of intercourse. Each woman’s perception may vary with the variables.

MODIFYING FACTORS:

The modifying factors in this study indicate the level of stress and coping strategies used by the females among the subfertile couples. The level of stress is assessed by using a stress assessment scale, and the

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coping strategies are assessed by using a modified coping scale. The level of stress may be mild, moderate, severe and very severe. Based on their level of stress, they may use different coping strategies like active avoidance coping, active confronting coping, passive avoidance coping, meaning based coping. The high use of active avoidance coping and passive avoidance coping indicate that the level of stress is high. And the high use of active confronting coping and meaning based coping indicate that the level of stress is low. The level of stress and coping strategies can be modified through self instructional module.

LIKELIHOOD OF ACTION:

Likelihood of action refers to perceived benefits of preventive action minus perceived barriers of preventive action. Here, the perceived benefits of preventive action refer to one’s belief in the efficacy of the advised action to reduce the risk or seriousness of impact. Perceived barriers of preventive action are defined as one’s belief or opinion of the tangible and psychological costs of the advised behaviors. In this study, the individual’s perceived barriers are identified as the level of stress and coping strategies. In order to reduce the level of stress and improve good coping strategies of females among infertile couples, the investigator planned a self instructional module regarding subfertility, and the ways of coping with the stress.

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Figure 1

Individual Perception

Females among the subfertile couples Demographic Variables

Age Religion

Educational Status

Occupation of the Woman Family income per month Age at menarche

Age at marriage

Number of years since married Marital Status

Type of Marriage Type of family Place of living

Social Support System Reason for Subfertility Type of Subfertility

Number of hospital attendance Duration of therapy for

subfertility

Nature of therapy currently undergoing

Frequency of intercourse

Modifying Factors

Stress

Mild Moderate

Severe Very Severe

Coping Strategies Active Avoidance Coping Active Confronting Coping Passive Avoidance Coping Meaning Based Coping

Mild Coping Moderate Coping

Good Coping

Self instructional module

regarding subfertility and ways of coping

i h

MODIFIED CONCEPTUAL FRAMEWORK BASED ON ‘HEALTH BELIEF MODEL’

(Rosenstocke’s and Becker, 1974)

Likelihood of Action

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CHAPTER II

REVIEW OF LITERATURE.

The investigator carried an extensive review of literature relevant to the research topic to gain insight and collected maximum information for laying the foundation of the study.

The review of literature is presented under the following headings:

I. Studies related to the subfertility and its consequences.

II. Studies related to the coping with the stress of subfertility.

I.STUDIES RELATED TO THE SUBFERTILITY AND ITS CONSEQUENCES.

Reder F, et al., (2009) conducted a study to assess the links between the diagnosis of infertility, medical care and the sexuality of the couples treated with Assisted Reproductive Techniques (ART). The impact of infertility had been observed in various fields related to sexual intercourse: sexual desire and satisfaction, frequency of intercourse, sexual disorders as well as marital relationship and more generally the patient’s experience of this medical follow-up. These effects were studied in the light of various factors, such as sex and age, number of children and years of ART as well as the type of protocol and the origin of infertility. The study revealed that the marital relationship is preserved as well as the pleasure felt during intercourse. However, the couples expressed a reduction of their sexual desire, linked to a loss of spontaneity that can be related to the strategies they set up to maximize their chances of pregnancy and to medical care.

Schmidt L, (2009) conducted a study to find out social and psychological consequences of infertility and assisted reproduction and

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the research priorities. The lifetime prevalence of infertility in representative population-based studies from industrialized countries is 17-28%, and on average, 56% of individuals affected seek medical advice. Infertility, as well as being a medical condition, has a social dimension; it is a poorly-controlled, chronic stressor with severe long- lasting negative social and psychological consequences. Although infertility can lead to severe strain in a couples’ relationship, it can also have a potentially positive effect. Appraisal-oriented coping strategies including emotional coping are associated with reduced stress in infertility. Long-term studies of involuntary childless women following unsuccessful treatment show that although most adjust well psychologically, their childlessness is a major theme of their lives. Most studies are based on cross-sectional studies among couples seeking fertility treatment and focus on individual characteristics, for example, stress level, anxiety and symptoms of depression. There is a lack of studies investigating the impact of infertility and its treatment on social relations and of studies which have used the couple as the unit of analysis. More large-scale, long-term prospective cohort studies which address the social as well as psychological consequences of infertility are needed.

Ohl J, et.al, (2009) conducted a study to assess the impact of infertility and all the more Assisted Reproductive Techniques on marital relations and sexuality. The study was based on a questionnaire distributed in their centre and on a review of literature. Their inquest showed that both partners keep a good relationship in their couple and support each other. But, whereas pleasure during intercourse was little affected, many couples feel a reduction of their desires. This diminution of sexual desires, also noted in literature, can be explained by medical requirements intrusive for intimacy and also by strategies settled by the

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couples themselves during intercourse in order to optimize the chance of pregnancy. Medical staff should take into consideration eventual sexual difficulties of the couples. Making them aware that their intimate life must remain or become again an end in itself, and not only a way procreation, often permits a beneficial change of behavior.

Zorn B, et al., (2008) conducted a study to evaluate whether psychological factors in males affect semen quality and pregnancy. In 1076 men of infertile couples, psychological factors, i.e. exposure to acute stress, coping with stress, the WHO (five) Well-Being Index and the Zung’s Anxiety Scale Inventory scores were assessed by a questionnaire at the time of semen analysis. Relationships between psychological factors and semen quality (sperm concentration, rapid and progressive motility and normal morphology) were assessed. In 353 men with infertility duration of < or = 1.5 years, sperm concentration > or = 5 x 10(6) sperm/mL and a female partner with a laparoscopically confirmed tubal patency, we looked prospectively for relations between psychological factors and the occurrence of a natural pregnancy at a 6- month follow-up (n = 124), and first-trimester loss (n = 18). Anxiety trait, found in 19% of men, was related to previous in vitro fertilization/intracytoplasmic sperm injection attempts (p = 0.014), cigarette intake (p = 0.006), alcohol intake (p = 0.026) and sexual difficulties (p< 0.001). Regression analyses indicated a significant positive relationship between the level of sperm concentration and the WHO (five)Well-Being Index score, each successive score number accounting for a 7.3% increase in sperm concentration (p = 0.039), whereas no correlation was found between psychological factors and sperm rapid progressive motility and normal morphology. Poorer coping with stress was related to the occurrence of a first-trimester miscarriage (p = 0.016) in the female partner. Possible depression in males is related

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to decreased sperm concentration, and poor coping with stress is associated with increased occurrence of early miscarriage.

Sreshthaputra O, et al., (2008) conducted a study to assess infertility-related stress among men and women and to examine its relationship with the level of perceived social support. The Fertility Problem Inventory (FPI) and the Personal Resource Questionnaire (PRQ) were translated into Thai and used to assess the level of infertility-related stress and perceived social support, respectively, in 238 infertile subjects.

The global FPI scores for men and women were 154.2 +/- 18.3 and 154.7 +/-22.6, respectively. (p >0.05). There was no significant difference in their perceived social support (PRQ scores = 137.8 + 14.0 and 134.0 +/- 16.7 respectively). A significant negative correlation (r = -0.1894; p <

0.001) existed between global stress and social support in women, but not in men. Thai infertile couples experienced a high level of stress. Unlike previous studies from Western countries, there was no gender difference in infertility-related stress.

Chang SN, et al., (2008) conducted a study to explore the essential structure of family stress among hospitalized women receiving infertility treatment with Ovarian Hyperstimulation Syndrome. When hospitalization is necessary for infertile women with Ovarian Hyperstimulation Syndrome, they face health-illness transition stress and their families are traumatized by the pressure of hospitalization. Most literature on infertility treatment has dealt with the infertile women’s physio-psychological reactions, the impact on the couples’ relationships and the influence of social support on infertile couples. A descriptive phenomenological design consistent with Husserl’s philosophy. Ten married couples from a Taipei medical centre participated in the study.

All the couples were receiving infertility treatment because the female partners were suffering from moderate or severe Ovarian

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Hyperstimulation Syndrome and this required hospitalized. An open in- depth interview technique encouraged parents to reflect on their experience, which raised their feelings to a conscious level. Data were analysed using Colaizzi’s approach. The study explored infertile women’s experiences from the couples’ perspectives and the results identify the overall stresses that the family faces. Five themes emerged from the study, namely, the stress of ‘carrying on the ancestral line’, the psychological reactions of the couple, a disordering of family life, reorganization of family life and external family support. The results demonstrated that the experience of family stress involves impacts that the range across the domains of individual, marital, family and social interactions and there is a need to cope with these when the wife is hospitalized for moderate to severe Overian Hyperstimulation Syndrome.

The findings indicated that nurses should provide infertile couples with family-centred perspectives that are related to Chinese cultural family values. Nurses should supply information on infertility treatment and assist couples to cope with their personal and family stress.

Wischmann T (2005) conducted a study on various psychosocial interventions have been recommended for infertile persons, but it remains unclear what their implications are, and if some of them might even be harmful under certain circumstances. A survey is given of papers concerning the usefulness of psychosocial support in infertility. Providing procedural information concerning the technical aspects of infertility investigation probably facilitates coping with infertility and with assisted reproductive techniques. This information can be given in the form of booklets or educational films. Using the Internet is a fast and easy way to obtain information on infertility and its treatment, but with the risk of getting wrong or misleading information. Telephone counseling can be helpful in providing specific information about the infertility workup but

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it cannot replace face-to-face counseling on distressing psychosocial issues. Attendance at support groups can be recommended to strengthen coping abilities. Psychosocial counseling and psychotherapy are definitely effective in reducing negative affect, mostly within a short period of time (less than 10 sessions). Pregnancy rates are unlikely to be affected by psychosocial interventions. Infertility counseling and support groups seem to be the most efficient psychosocial interventions in infertility. Therefore, infertility counseling should be available at all stages of medical therapy, and it should be free of charge for the persons attending it. Course, content and goals of the infertility counseling should be made transparent. The efficacy of support groups has to be evaluated more systematically. Several methodological questions have to be solved yet, and the generalizability of these results is still restricted.

Matsubayashi H, et al., (2004) conducted a study to assess the relationship between the anxiety and depression of infertile Japanese women and their thought processes and emotional well-being with regard to their infertility. A cross-sectional questionnaire was administered to 101 infertile Japanese women who visited the infertility clinic at Tokai University. Inventories included the Hospital Anxiety and Depression Scale (HADS) and our original infertility questionnaire, which is composed of 22 questions to assess attitudes and emotional status in facing the stigma of infertility. After factor analysis, comparison between the HADS and the infertility questionnaire was made with simultaneous multiple regression analyses. Anxiety and depression in childless Japanese women were significantly associated with lack of husband’s support and feeling stress.

Tuil WS, et al., (2003) conducted a study on the internet introduces new ways to deal with stress. However, it is unclear how its resources are used in everyday life. Using a web-based personal health

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record (PHR), we observed the patient’s online behavior and linked this to distress, theories on dealing with stress and demographics. Between 2004 and 2007, all viewed web-pages were logged and categorized into 14 content types. Behavioral styles were elicited using factor analysis.

These behavioral styles were subsequently correlated to data on demographics, coping mechanisms and distress from the female partner of the first 53 patient couples that used the PHR. One thousand and fifty patient couples viewed 5, 88, 887 web pages during their first treatment cycle. Factor analysis elicited three online behavioral styles explaining 66.9% of all variance in usage of the website: an ‘individual information style’, a ‘generic information style’ and a ‘communication style’. The

‘individual information style’ correlated negatively to having paid employment (Spearman = -0.364, P = 0.007) and emotional coping mechanisms (Spearman = -0.305, P = 0.028). The ‘communication style’

correlated positively to having paid employment (Spearman = 0.318, P = 0.021) and anxiety (Spearman = 0.381, P = 0.005). IVF patients show three types of online behavior. Only limited correlations exist between these styles and demographics, coping mechanisms or distress. When planning a website or portal for IVF patients, content should be adopted accordingly.

Yu YC, et al., (2003) conducted a study on Infertile women suffer chronic stress, which may negatively impact their parenting relationships if they succeed in bearing children later. The purpose of this study was to explore the parenting stress of mothers attending assisted a reproductive program and to compare it with the parenting stress of mothers with natural pregnancies. A purposive sampling method was used to recruit 54 mothers attending an In Vitro Fertilization/Embryo Transfer and Tubal Embryo Transfer program at an infertility center in central Taiwan. Three instruments were used to collect data: the Demographic Data Form,

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Parenting Stress Index-Short Form and Family Adaptation Partnership Growth Affective Relation Index. The data were analyzed by descriptive and inferential statistical methods. (1) The results indicated that the highest average score in parenting stress for mothers receiving reproductive technology was for “parental distress”. These results revealed that the main source of parenting stress was their parental role.

(2) Family function varied significantly with parenting stress. (3) Parenting stress was significantly greater in mothers with natural pregnancy than in mothers attending the assisted reproductive program.

Recommendations for clinical application and future research are also made. The implications of the study may be used to assist infertile women in coping with parenting roles. Furthermore, a qualitative study is suggested to understand the factors which cause parenting stress.

Folkvord S, et al., (2002) conducted a study on male infertility in sub-Saharan Africa. Sub-Saharan countries tend not to research male infertility because of economic reasons and, possibly, the psychological denial of the problem. The participants in the present study were 311 men with infertility problems who had been referred to the Andrology Clinic of the University of Zimbabwe. They were investigated by means of a clinical interview, a clinical examination, semen analysis and various endocrine tests. It was found that 78% of the respondents had ever had a sexually transmitted disease. Most of the respondents reported that their infertility caused them stress and reported signs of mild depression. Most men mentioned also to seek treatment based on traditional methods. Men blamed that their wife was the reason of their childlessness. This study shows the importance of understanding both the cultural and the medical aspects of male infertility. Male infertility is a significant medical and psychological problem in Zimbabwe. Men should promptly be diagnosed and treated for STIs. Health education and teaching people about STDs

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and HIV in general about this are essential to the process of preventing male infertility.

Nene UA, et al., (2001) conducted a study in Indian society infertility and sexual dysfunction which are stigmatized characteristics.

The aim of the study was to explore which label couples who have both complaints, prefer to describe their situation, and whether gender differ occur in this preference. A total of 40 couples – all clients of the reproductive health clinic of the King Edward Memorial Hospital in Pune because of problems with infertility and sexual dysfunction – participated in this study. Data were collected by means of interviews. The findings show that sexual activity decreased as the number of childless years increased. However, the interspouse-relationship gets stronger and more supportive. The couples never revealed their sexual dysfunction to others.

When the husband was sexually dysfunctional, the couples preferred to label their situation as ‘infertility’ in order to avoid stigma. Issues that are related to sexual dysfunction, sexual behavior, inter-spouse relationship and communication are important aspects into the reality of an infertile couple’s life. In planning the treatment, clinicians should give more attention to the specific cultural context of these aspects.

Wischmann T, et al., (2001) conducted a study to identify differences in psychological characteristics between couples with fertility disorders, especially idiopathic infertility, and a representative sample. A total of 564 couples were examined using psychological questionnaires pertaining to sociodemographic factors, motives for wanting a child, dimensions of life satisfaction and couple relationships, physical and psychic complaints, and a personality inventory. Specific to their sample was the high educational level of the couples, and the large number with idiopathic infertility (27% of all diagnoses). There were no remarkable differences in psychological variables between the infertile couples and a

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representative sample, except that the infertile women showed higher scores on the depression and anxiety scales. Couples with idiopathic infertility showed no remarkable differences in the questionnaire variables compared with couples with other medical diagnoses of infertility. A typical psychological profile for infertile couples could not be identified using standardized psychometric rating methods. This may be an effect of the specific characteristics of their sample. 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.

Nasseri M (2000) conducted a study on A 74-item especially developed and validated questionnaire for Iranian culture was administered three times to 37 Iranian infertile couples and 10 fertile couples acting as control group, namely, initial consultation, during treatment, and on completion of treatment. In view of parallel data also reported for Western patients interest centered on the results of two out of the five factors measured by the questionnaire, i.e., Psychological Stress and Social Behavior. Analysis generally showed significantly high stress and social withdrawal for the patient group, particularly at initial consultation and after an unsuccessful treatment cycle as compared to the control group. Moreover, men whose partners eventually conceived scored significantly lower on stress than men whose partners did not conceive. Similar results have also been reported for Western infertile patients.

Fido A. (1999) conducted a study to assess the relationship between the psychological factors and the experience of infertility in Arab women. The researcher postulated that with all important causal

“confounders” such as age, gender, education and general health status controlled, any significant difference in psychological profile can be attributed to infertility. An Arabic version of the Hospital Anxiety and

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Depression Scale (HADS) was used to examine the psychological status of 120 Kuwaiti infertile women and an age-matched sample of 125 healthy pregnant women as a control group. Compared with an age- matched pregnant control sample, the infertile women exhibited significantly higher psychopathology in all HADS parameters in the form of tension, hostility, anxiety, depression, self-blame and suicidal ideation.

The illiterate group attributed the causes of their infertility to supernatural causes, such as evil spirits, witchcraft and God’s retribution, while the educated group blamed nutritional, marital and psychosexual factors for their infertility. Faith and traditional healers were the first treatment choice among illiterate women, while the educated women opted for an infertility clinic for treatment. Childlessness resulted in social stigmatization for infertile women and placed them at risk of serious social and emotional consequences. The prevalence and severity of psychological distress in that sample of infertile Kuwaiti women indicate the appropriateness of referring those patients for psychological evaluation. Programs successful in dealing with infertility in Kuwait need to include establishment of a community-based intervention strategy to educate people about infertility and to give guidelines for treatment.

II.STUDIES RELATED TO THE COPING WITH THE STRESS OF SUBFERTILITY.

Peterson BD, et al., (2008) conducted a study to examine the impact of partner coping in couples with infertility. Since infertility is a shared stressor, examining the impact of partner coping is particularly relevant. Data were based on a questionnaire in a consecutive sample of 1169 women and 1081 Danish men prior to beginning assisted reproduction treatment. Multilevel modeling using the Actor Partner Interdependence Model and follow-up analysis of variance were used to

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examine the couple as the unit of analysis. A partner’s use of active- avoidance coping was related to the increased personal, marital and social distress for men and women. A woman’s use of active-confronting coping was related to increased male marital distress. And a partner’s use of meaning-based coping was associated with decreased marital distress in men and increased social distress in women. Although understudied, partner coping patterns play a key role in a partner’s ability to cope with the infertility experience. Physicians and mental health providers can help couples to understand the coping strategies that lead to increased and decreased partner distress.

Cousineau TM, et al., (2007) conducted a study on the goal was to develop and test the effectiveness of a brief online education and support program for female infertility patients. A randomized-controlled trial was conducted. Using a Solomon-four group design, 190 female patients were recruited from three US fertility centres and were randomized into two experimental and two no-treatment control groups. The psychological outcomes assessed included infertility distress, infertility self-efficacy, decisional conflict, marital cohesion and coping style. Program dosage and satisfaction were also assessed at four weeks follow-up. Women exposed to the online program significantly improved in the area of social concerns (P = 0.038) related to infertility distress, and felt more informed about a medical decision with which they were contending (P = 0.037).

Trends were observed for decreased global stress (P = 0.10), sexual concerns (P = 0.059), distress related to child-free living (P = 0.063), increased infertility self-efficacy (P = 0.067) and decision making clarity (P = 0.079). A dosage response was observed in the experimental groups for women who spent > 60 min online for decreased global stress (P = 0.028) and increased self efficacy (P = 0.024). This evidence-based health program for women experiencing infertility suggests that a web-based

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patient education intervention can have beneficial effects in several psychological domains and may be a cost effective resource for fertility practices.

POTTINGER, AM, et al., (2006) conducted a study to identify gender differences in coping responses and the association between coping and psychological distress in couples undergoing In Vitro Fertilization treatment at the university of the West Indies. The reports of strategies used by the participants to cope with the stress of infertility are:

seeking medical advice and engaging in wishful-thinking, namely, hoping for a miracle and fantasizing about the outcome were the strategies most commonly used by more than 75% of participants. The least reported strategies included ‘avoiding being around pregnant women or children’

and ‘eating, smoking or drinking more’. When examined by gender, both men and women used wishful thinking strategies and seeking advice most often and to a lesser extent emotion-focused coping. Women generally used all three types of strategies more often than men. The strategies that men used more often were those that allowed them to avoid talking about their experience, namely ‘keeping feelings to themselves’ and ‘making self better by eating, drinking or smoking’, along with the specific problem-solving strategy of using alternative medicine. In addition, although both genders seldom reported seeking sympathy from others, men were more likely to accept sympathy and understanding from others compared to women.

Schmidt L, et al., (2005) conducted a study to evaluate a patient education programme focused on improving communication and stress management skills among couples in fertility treatment. In total, 37 couples completed the intervention. Two teachers conducted all the five courses offered. The effectiveness regarding communication and infertility-related stress was assessed by questionnaires immediately

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before (time T1) and after the intervention (time T2). Seeking of information and professional support was assessed at a 12-month follow- up (time T3); response rates were: T1, 93.2%, T2, 85.1%, T3, 74.3%.

Data were compared at baseline (T1) and at the 12-month follow-up (T3) with a prospective cohort of Danish people in fertility treatment. There were no differences in infertility-related stress at base line between the two groups studied. They estimated the bi-directional changes in communication, e.g., changes from talking often to talking less frequently and vice versa. More intervention participants started to talk often with their partner about infertility and its treatment after the intervention compared to those who stopped to talk often. Women and men changed occurrence, frequency and content of communication with close other people. Among women marital benefit increased significantly. Infertility- related stress was not reduced significantly. Significantly more intervention participants than in the comparison group had contacted support groups, a psychologist and/or agencies for adoption at the 12- month follow-up. The intervention resulted in important perceived improvement in the participants’ competence to actively manage changes in marital communication and in communication in different social arenas.

Tarabusi M, et al., (2004) conducted a study to determine whether a cognitive-behavioral group treatment could lead to a decrease of psychological distress in couples waiting for assisted reproduction. Fifty consecutive couples included in the waiting list for IVF-EF or ICSI were randomly allocated either to receive Cognitive-Behavioral Treatment (CBT Group) or just waiting (Observation Group). The group is formed by 8-10 couples; 12 meetings are provided for a period of 4 months. Two psychometric tests have been administered (Symptom Rating Test and Westbrook Coping Scales) at baseline and after 4 months. At baseline,

References

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