The Effects on Infertility on the Couple Relationship

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CHAPTER II LITERATURE REVIEW

Historical Review

The earliest published research examining the link between psychological distress and infertility began in the 1950’s. Fisher (1953, as cited in Insler & Lunefeld, 1993) stated that, “psychogenic infertility can be defined as sterility in a couple in whom no pathology or dysfunction can be demonstrated by any method available to us today” (p. 3). Labandiabar (1959) and Kostic (1960) (as cited in Seibel & Taymor, 1982) examined the possible relationship between sterility and frigidity. Eisner (1963) sought to understand the perceived psychological differences between fertile and infertile women using a Rorschach test with 20 infertile females. She noted that all of the women exhibited emotional disturbances and concluded that between 40-50% of infertile cases were caused by emotional factors. Other researchers at this time believed that infertile men and women showed signs of psychosexual maladjustments (Dawkins & Taylor, 1961; Sandler, 1959, as cited in Seibel and Taymor, 1982).
Studies examining this hypothesis continued into the 1970’s. Mai and Rump (1972) studied whether infertile men and women were neurotic. Mozley (1976, as cited in Seibel and Taymor, 1982) proposed that infertility could be caused by unconscious motivations on the part of the infertile individual and that infertility “could be considered a defense against dangers inherent in the reproductive functioning” (p. 137).
These studies formed the basis of the psychogenic hypothesis which proposed that infertility was caused by the psychological and personality characteristics of men and women. Researchers continued to adhere to this theory up until the mid 1980s. However, as infertility increased in its prevalence, more research was conducted, and the hypothesis was examined more closely, it was found that the most carefully designed studies revealed no differences between the personality traits of infertile women compared to non-infertile women, and where differences were found, it was impossible to link the cause of the difference to the infertility (Greil, 1997).
The literature advocating the psychogenic hypothesis was limited by several factors including “failure to use systematic measures combined with an over-reliance on clinical impression, . . . a virtually exclusive focus on female’s infertility, and assumptions of the direction of causality without any clear evidence” (Greil, 1997, p. 1680). These factors contributed to a false impression that infertile men and women were responsible for their own infertility on account of their psychological attitudes and personality characteristics. Seibel and Taymor (1982) were among the first to report that advances in neuroendocrinology and other medical technologies revealed that only approximately 5% of emotional factors were directly related to infertility in men and women. In relation to the psychogenic hypothesis, they commented, “although many authors have noted increased psychological problems among infertile couples, few have provided evidence that these problems were a cause of infertility rather than the result of it” (p. 144).
In 1989, Wright and colleagues reported that through 1986, only 30 controlled studies had been conducted examining the link between psychological distress and infertility. However, since the mid 1980’s, there has been a significant increase in the amount of research addressing this issue. As noted earlier, Greil (1997) reported that over the past twenty years a minimum of 94 quantitative articles and 26 qualitative articles have been published examining psychological distress and infertility. These studies have specifically addressed the issues of the personality differences between infertile and non-infertile men and women, differences in distress between infertile and non-infertile men and women, longitudinal studies of infertility distress, and gender differences in the experience of infertility. Although these studies are not without their limitations, namely the use of convenience samples and an overemphasis on women, they have provided a rich theoretical base from which to study the link between infertility and psychological distress.
The following literature review examined many of the articles which link psychological distress to infertility, giving special attention to those which examine the couple as the key unit of analysis. The review also examined the specific link between infertility and depression, the effect of infertility on couple and marital relationships, and how men and women differ in their emotional responses to the stress of infertility. A brief review of the research regarding the influence of infertility diagnosis was also included.

The Impact of Infertility on Psychological Functioning

As stated earlier, research studies in the past 15 years have advanced the literature base regarding the emotional impact of infertility on couples and individuals. Several studies have confirmed that infertility is associated with emotional responses such as depression, anxiety, guilt, social isolation, and decreased self-esteem in both men and women (Abbey, et al., 1991; Greil, 1997; Sadler & Syrop, 1998). Although the association between infertility and these emotional disturbances has been shown, there has been little research examining the specific nature of these variables in relation to infertility. Methodologic limitations such as flawed study designs and small sample sizes have limited the effectiveness of researchers in examining this issue.
Connolly, Edelman, Cooke, and Robson (1992) conducted a key study exploring the impact of infertility on psychological functioning. Using 116 couples recruited from an infertility clinic, participants completed the Eysenck Personality Questionnaire (EPQ), the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), Dyadic Adjustment Scale (DAS), Interpersonal Support Evaluation List (ISEL), and BEM Sex Role Inventory (BSRI).
Analyses were conducted using three stepwise multiple regression analyses to determine the best predictors of psychological disturbances in both men and women. For males, the only predictor was a diagnosis of male-factor infertility which was predictive of increased anxiety. For females, increased interpersonal support was predictive of lower anxiety, and trait anxiety was related to depression. Additional analyses were conducted using multifactor analysis of variance for depression, general health, and the quality of the couple’s relationship, using within subject variables of time and between subject variables of diagnosis and gender. Participants’ depression scores were analyzed among five sub-groups (male factor diagnosis, female factor diagnosis, male and female causes, unexplained, and pregnant) at the initial and the follow-up assessments. The authors noted that “the scores show little evidence of change over the intervening period, and in general they are low (e.g., not highly depressed). There is a significant gender difference, which would be expected on the basis of population data which shows that females generally have higher depression scores [than men]” (p. 463). Analysis of marital adjustment revealed that scores “remained relatively constant between the assessments with no indication of any significant differences” (p. 464). The authors concluded that the two major findings from the study revealed first, there was “little evidence of psychopathology” in study participants for the first seven to nine months of infertility treatments. Second, they concluded that marital relationships of infertile couples pursuing infertility treatments were relatively stable. Indicators of lower depression scores in the study were in conflict with other findings (Link & Darling, 1986, as cited in Connolly, et al. 1992).
In a recent qualitative study, Williams (1997) examined the psychological effects of infertility on women. Five women were interviewed in a pilot study and 10 women were interviewed for the research study. Williams conducted open-ended interviews and used inductive methods of analysis. She found that 11 themes emerged universally from the women participating in the study: negative identity, worthlessness/inadequacy, lack of personal control, anger/resentment, grief/depression, anxiety/stress, lower life satisfaction, envy of other mothers, loss of the dream of co-creating, emotional roller coaster, and isolation. With regards to grief and depression, each woman noted that every menstrual period represented a “loss that was irretrievable, that pushed them closer to the end of their hopes” (p. 15). Women reported grieving and feeling a loss that was incomparable with any other they had experienced in their lives. Williams reported that many of the women presented symptoms of clinical depression including insomnia, fatigue, change in eating patterns resulting in weight loss or gain, and feeling helpless and hopeless. Many of the women refused to take credit for other accomplishments in their life and still took responsibility for the infertility, even when it was diagnosed in the husband.

Infertility and Depression

In the general population, major depression is twice as prevalent in women as it is in men (Llewellyn, Stowe, and Nemeroff, 1997). Many authors have reported that depression is a common consequence of infertility (Domar & Seibel, 1990; Leader, Taylor, & Daniluk, 1984; as cited in Domar, Broome, Zuttermeister, Seibel, and Friedman, 1992). However, the exact nature of this relationship has been understudied (e.g., severity, directionality). Only a few articles exist that directly examine the relationship between depression and infertility. While these findings are helpful in furthering our understanding between these variables, the majority of studies examining infertility and depression have been limited to female populations.
Domar and colleagues (1992) conducted a study examining the prevalence rates and predictability of depression in infertile women. Three hundred seventy-six infertile participants were recruited for the study from an infertility treatment center. A control group of fertile women was obtained through patients from a hospital based gynecological practice. Participants were asked to complete two depression measures, the Center for Epidemiological Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI). The CES-D scale “was specifically designed for research. It is intended to measure symptoms of depression rather than general distress” (p.1159). The BDI was used to measure the “intensity of depression” among study subjects. Participants were also asked to complete a demographic form measuring age, duration of infertility, length of infertility treatments, past treatments, primary or secondary infertility, infertility diagnosis, and history of psychotherapy. To appropriately assess depression levels in study subjects, “cut off scores of 16 for the CES-D and 9 for the BDI were utilized to indicate the presence of depression symptoms, according to the respective test guidelines” (p. 1160).

I. INTRODUCTION
Statement of the Problem
Theoretical Framework
Family Systems Theory
Family Stress and Coping Theory
Rationale
Addressing Gaps in the Research
Research Questions
II. LITERATURE REVIEW
Historical Review
The Impact of Infertility on Psychological Functioning
Infertility and Depression
Role of Gender in Response to Infertility
Female Emotional Response to Infertility
Male Emotional Response to Infertility
Social Considerations
Diagnosis
The Effects on Infertility on the Couple Relationship
Infertility and Marital Adjustment
Studies Examining the Couple as the Unit of Analysis
III. METHODS
Design of the Study
Study Participants and Procedures
Data Collection Instruments
Fertility Problem Inventory (FPI)
Dyadic Adjustment Scale (DAS)
Beck Depression Inventory (BDI)
Data Cleaning and Analysis
Unit of Analysis
IV. RESULTS
Introduction
Profile of the Sample
Relationship Between Couple Differences, Depression, and Marital Adjustment
Examining the Ability of Couple Differences to Predict Depression and Mar Adj.
Congruence Between Couples and its Relationship to Depression and Mar. Adj.
V. DISCUSSION
Summary of Key Findings
Social Concern
Sexual Concern
Relationship Concern
Infertility-Related Stress, Depression, and Marital Adjustment
Study Limitations
Clinical Relevance
Treatment Implications
Suggested Future Research
REFERENCES
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EXAMINING THE CONGRUENCE BETWEEN COUPLES’ PERCEIVED INFERTILITY-RELATED STRESS AND ITS RELATIONSHIP TO DEPRESSION AND MARITAL ADJUSTMENT IN INFERTILE MEN AND WOMEN

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