Jooumal of Psychmomtic Printed in Great Britain.
Research. Vol. 36, No
1992. 0
THE IMPACT
KEVIN J. CONNOLLY,* (Received
5, pp. 459-468,
0022-3999/92 $S.oO+.M) 1992 Pergamon Press Ltd
OF INFERTILITY ON PSYCHOLOGICAL FUNCTIONING ROBERT J. EDELMANN,? IAN D. COOKE and JILL ROBSON*
26 June
1991; accepted
in revised form 6 November
1991)
Abstract-To explore the impact of infertility on psychological functioning 130 couples presenting with primary infertility were assessed at their initial visit to an infertility clinic. Of these, 116 couples were assessed on a second occasion some 7-9 months later when in most cases the medical tests were complete. Measures of personality, psychopathology, percel.vedsocial support, sex role identity and marital state were obtained from both partners. The set was subsequently divided into five subgroups on the basis of the diagnosis made or the outcome (female cause, male cause, female and male cause, unexplained and pregnant). The results show little evidence of psychopathology in the sample, depression scores remained low throughout the period of investigation. The results also indicated stable marital relationships. Scores on tests of anxiety and psychiatric morbidity declined between the first and second assessment except in the case of men who were diagnosed with a fertility problem. The implications of these findings are discussed in the increased use of donor insemination which circumvents rather than treats the problem of male infertility. INTRODUCTION
the past 20 yr or so a number of clinical observations and anecdotal reports have been devoted to the impact of infertility on the psychological wellbeing of the couples involved. For example, Menning [ 11 argued that infertility is, ‘a complex life-crisis, psychologically threatening and emotionally stressful’. For many no doubt this is so, though the degree of stress and the extent of the threat perceived by the individual will vary as will the individual’s response to the situation. Elsewhere Menning [2] has drawn attention to possible parallels between the psychological consequences of infertility and general grief reactions. Berger [3, 41 goes so far as to suggest that, ‘a sense of despair must plague every couple who seek help with an infertility problem.’ Other authors [5-71 refer to health problems, loss of self esteem, feelings akin to mourning, depression, guilt and frustration, all associated with failure to conceive. That infertility is a deeply distressing experience for many couples cannot be denied. Freeman et al. [ 81 found that half of their sample of infertile couples described infertility as the most upsetting experience of their lives, while 80% of Mahlstedt et al’s [9] sample reported that their experience of infertility was either stressful or extremely stressful. Other studies have reported evidence of elevated anxiety levels or depression scores for some infertile patients when compared with controls. Thus Link and Darling [lo] found that 40% of women and 16% of men had scores indicative of clinically significant depression and Harrison et al. [ 111 reported higher state anxiety scores for women but not for men in infertile partnerships OVER
*Department of Psychology, University of Sheffield, U.K. tDepartment of Psychology, University of Surrey, U.K. University Department of Obstetrics and Gynaecology, Jessop Hospital for Women, Address correspondence to Professor K. J. Connolly, Department of Psychology, Sheffield, Sheffield, SlO 2TN, U.K. 459
Sheffield, U.K. University of
460
K. J.CONNOLLY
et al.
when compared with controls. Other studies, however, have revealed few if any differences between infertile individuals and fertile controls on measures of anxiety and depression [ 121. The uncertain and often rather muddled picture which emerges from the literature reflects a number of methodological inadequacies. First, there is a naive tendency to treat infertile couples as if they were a homogeneous group. Second, psychological measurements made at different stages in a series of medical investigations which have been going on for varying periods have been compared uncritically. Moreover very few studies have assessed patients before infertility investigations were begun. The impact of infertility on psychological functions is plainly a complex matter influenced by a number of variables including: the investigative procedures involved; the duration of the infertility; the diagnosis if any which is made and the quality of a couple’s relationship. The timing of psychological assessments in relation to various investigative and treatment procedures is also an important matter. Baseline assessments made before medical investigations begin are rare, which means that most studies fail to address the question of whether reported differences between fertile and infertile populations reflect inherent differences rather than a response to the investigatory process and/or diagnosis per se. Also, given that the majority of patients will have been struggling to cope with their failure to conceive for about 2 yr before referral to a specialist clinic [ 131 it would not be surprising if they were showing some signs of distress. The infertile couples described in this report were assessed at the time of their first attendance at the infertility clinic. When compared with three fertile groups they showed little evidence of differences on measures of psychopathology, with the exception of higher state anxiety for the infertile patients [ 141. Further, in four individual cases re-examined around 9 months after the initial assessment, there was a tendency for anxiety to have decreased [ 151. A further problem arises in connection with reports in the literature that male infertility presents particular difficulties for the couple concerned. Satisfaction with testing and treatment is reported to be less for both partners in cases where the male was diagnosed as subfertile [ 161 In a retrospective survey of over 800 couples, Connolly et al. [ 17 ] reported greater emotional and marital difficulties for both men and women in those cases where the cause of the infertility was diagnosed to the man. Related to this Berger [ 181 found a 63% incidence of transient impotence (lasting l-3 months) following the discovery of azoospermia in a sample of 26 males. Others have argued that the continuing uncertainty of unexplained infertility (i.e. where a cause has not been identified at the conclusion of the various medical investigations) places a greater strain upon both partners and their relationship than does a definite diagnosis, even when this is unfavourable. Thus McEwan et al. [ 191 found that undiagnosed women showed poorer adjustment although other studies report few differences between diagnosed and undiagnosed women [ 17, 201. Again these variations in the findings probably reflect methodological differences between the various investigations; differences in sample size, the timing of assessments and in the nature of the measures made. Others have argued that certain factors such as sex role discrimination and social support act as buffers against stress and may thus partially protect the infertile individual from attendant psychological difficulties. In this respect infertile patients
Impact of infertility investigations
461
sharing their difficulties with a partner rather than seeking social support outside the partnership show less emotional distress [ 191. The probable resilience of such supportive relationships is noted by Raval er al. [21] who found a reduction in the reporting of marital problems by couples after they had attended an infertility clinic. With regard to sex role identity, Roos and Cohen [ 221 suggest that those with strong masculine characteristics show least psychological distress in relation to stressors. The situation is clearly complicated because coping with a personal threat (a diagnosis of one’s own infertility) has different implications to coping with a threat to one’s partner (a diagnosis of one’s partner’s infertility). In one of the few longitudinal studies so far carried out Moller and Fallstrom [ 231 investigated the consequences of infertility on the psychological wellbeing of 71 couples. Using both interview and questionnaire data they found that in the case of couples who had not achieved a pregnancy at follow up (18 months after the initial clinic attendance) there was an increase in feelings of depression and failure, an increase in anxiety and in emotional disturbance assessed by self report. Moller and Fallstrom distinguished between couples who achieved a pregnancy and those who did not but they did not link psychological consequences to diagnosis. The study reported here was designed to investigate the impact of infertility by assessing a couple on two occasions; first on their initial attendance at the clinic before any medical investigations were begun, and second, approximately 9 months later when in most of the cases the diagnostic tests were completed. The two assessments separated in time in this way, enabled the effects of the investigative procedures and the patients’ experience to be teased out. To our knowledge, this is one of very few studies presenting a longitudinal evaluation of a couples’ reactions to infertility investigations and the only one which does so in relation to diagnostic outcome. The investigation focused particularly on measures of psychopathology and marital interaction, though the relationship of measures to personality characteristics, social support and the individual’s sex role identity was also examined. MATERIALS
AND METHODS
Participants The initial sample consisted of 130 couples presenting with primary infertility. These were consecutive referrals to a specialist infertility clinic. From the initial set 116 couples maintained contact with the clinic over the ensuing year during which time a series of medical investigations was carried out. Complete data sets were obtained on the 116 females but only 107 males completed all the tests. For 76 couples organic causes for their infertility were diagnosed. In 39 cases reproductive failure was attributed to the male alone and in 9 cases to the female alone. In a further 28 cases both the male and female members of a pair were found to have difficulties which contributed to the failure to reproduce. The female diagnoses were; tubal problems 9, ovulatory disorders 17, endocrine problems 3, endometriosis 8. Male diagnoses were; azoospermia 6, oligozoospermia 16, teratozoospermia 14, asthenozoospermia 3 1. Azoospermia represents a zero sperm count and consequently the male is unable to father a child; the three following categories represent various sperm abnormalities and hence a varying chance that the male may be able to father a child. A comparison of men diagnosed with azoospermia (N = 6) was made with those diagnosed with oligozoospermia, teratozoospermia and asthenozoospermia (N = 61) on each of the measures taken at the initial assessment. No significant differences were found (Mann-Whitney U). Of the remaining 40 couples, 22 (19%) conceived over the period of the study and 18 (15.5%) remained unexplained. For comparison purposes five sub-groups were identified: (i) female cause; (ii) male cause; (iii) female and male cause; (iv) unexplained; and (v) pregnant. The mean age of the sample was 28 yr for females and 30 yr for males. Social class distribution, determined on the basis of the male’s occupation [24] reflected a slight bias towards the upper end of the distribution (the percentage of the sample in each social class was: I, 10; II 25; III, 44; IV, 16; V, 5).
462
K. J. CONNOLLY
et al
Basic demographic information was obtained from a structured interview conducted at the time of the initial assessment. At this initial assessment participants also completed the following questionnaires and inventories f;v.cerrck Perxmality Quesrionnaire (EPQ). The EPQ is made up of 90 items to be answered yes or no. These are grouped into four sets comprising; psychoticism (P), extroversion (E), neuroticism (N) and lie (L) scales. The instrument has been widely used and has established validity and reliability [25] Gmrrul Health Quesrionnaire (GHQ). The GHQ is a self-administered screening instrument designed to detect psychiatric morbidity in the community. In its original form it consisted of 60 items, the 30 item scale (GHQ-30) was used in the study reported here. The instrument has established validity and reliability [ 261 BeckDepression Inventory (BDl), The BDI consists of 2 1 multiple choice items describing behavioural signs of depression each of which is to he rated on a scale of O-3. Higher scores indicate a greater severity of depression. The scale has been widely used with both clinical and non-clinical populations and it has established validity and reliability 1271. &are-Twit Anxiety Inventory (STAI). The test comprises two sets of the same 20 questions describing feelings of tension, worry or apprehension. One set of questions deals with how the respondent feels now (state) and the other with how they generally feel (trait). The scale has been widely used and information on validity and reliability is available 1281. Dyadic Adjustmenr Scale (DAS). The DAS is a 32-item scale for assessing the quality of a marital 01 other long-term relationship. It has adequate reliability and validity [ 291 Iriferpersrintrl SupporrEvaluufion List (ISEL). The ISEL consists of 40 items each rated true or false to indicate perceived availability of potential social resources. The scale has not yet been widely usled but the author\ report that it has good reliability and validity [30] It comprises four sub-scale% relating to self-esteem. tangible support, appraisal and belonging. BEM Ser Role Invenforv (ESRI). The BSRI consists of 60 items each rated on a xale of l-7 used to indicate the individual’s degree of masculinity and femininity. The scale has been widely used and information on reliability and validity is available [3 I ] The first assessment was made at the beginning of the couple’s initial visit to the infertility clinic. 4hout 7 months later all the couples in the initial sample who could be contacted and who had not withdrawn from the study were visited at home for a follow-up assessment. At the follow-up assessment participants were again given these texts with the exception of the EPQ and the trait component of the STAI. A comparison was made between those participants who completed the study and those who did not on the data obtained at the initial assessment, no significant differences were found on any of the psychological variables measured at the initial clinic visit (Mann-Whitney U).
RESULTS In an initial examination of the results the variables derived from the questionnaires, in addition to the five diagnostic categories, were used in three separate stepwise multiple regression analyses to select the best predictors of state anxiety, BDI and GHQ scores obtained at the second assessment. Separate analyses were made for males and females. For males one predictor variable was significant. The diagnosis of a male problem was related to higher state anxiety (R = 0.29, R* = 0.08, F = 10.3, p < 0.01) and higher GHQ scores (R = 0.22, R2 = 0.05,F = 5.8, p < 0.05). In the case of females two predictor variables were significant. The tangible support sub-scale of the ISEL was related to lower state anxiety (R = 0.23, R2 = 0.05,F = 6.30, p < 0.05) and trait anxiety was related to higher depression scores (R = 0.20, R2 = 0.04, F = 4.7, p < 0.05). To examine the impact of the investigations and diagnosis four three-way MANOVAS were performed on the data for each of: state anxiety; depression; general health; and the quality of the couple’s relationship. In each case the within subject variable was time (initial vs follow-up assessment) while the two between subject variables were cause (male vs female, vs male and female. vs unexplained, vs pregnant) and gender (male vs female).
Impact
of infertility
investigations
463
Mean state anxiety scores on initial and follow-up assessment for the five subgroups into which the sample was divided are shown in Table I. There are significant effects due to time (Fl,214 = 23.5; p < O.OOl), and gender (F1,214 = 11.9; p < 0.001) and a significant interaction of time and gender (Fl,214 = 7.2; p < 0.001). Both males and females were less anxious overall at the follow-up assessment (state anxiety scores were 33.4-30.7, and 40.3-31.7 for males and females at initial and follow-up assessment respectively). Within this, however, post hoc comparison of the means revealed significant variations. Specifically those cases where the cause of the infertility had been diagnosed to the male showed an increase in anxiety over time. At follow-up these cases had state anxiety scores significantly greater than men where the cause of infertility had been diagnosed either to both partners or where it remained unexplained @ < 0.05). In the case of females where the cause was diagnosed either to the male or to both partners, anxiety decreased significantly between the initial and follow-up assessments 0, < 0.05).
TABLE
I.-MEAN
STATE A7
ANXIE-r~
SCORES
FOLLOW-UP
Subgroup
IN
FOR MEN
AND
RELATION
TO DIAGNOSIS
Female cause
Male cause
Mean
Initial assessment
SD
Follow-up assessment
SD
Mean
AT TIME
OF INITIAL
ASSESSMENT
AND
OR OUTCOME
Male and female cause
N=9
N = 39 Gender
WOMEN
N=28
Unexplained
N=
Pregnant
18
N = 22
M
F
M
F
M
F
M
F
M
F
33.3 8.3
39.9 11.5
33.8 11.2
42.2 18.8
32.7 8.9
42.9 10.8
30.4 6.4
39.8 10.1
36.2 9.8
37.2 13.5
36.8 12.6
30.7 11.9
29.0 8.6
28.2 14.9
29.6 11.3
34.7 9.0
26.2 13.1
29.2 5.9
32.1 9.4
35.5 10.0
Scores on the Beck Depression inventory for the five subgroups at the initial and follow-up assessments are shown in Table II. The scores show little evidence of change over the intervening period, and in general they are low. There is a significant gender difference (Fl.217 = 6.6; p < 0.01) which would be expected on the basis of population data which shows that females generally have higher depression scores.
TABLE
BDI
H.-MEAN
SCORES
OF MEN
RELATION
Subgroup
Male cause
AND
WOMEN
INITIAL
AND
Female cause
N = 39 Gender
ON
TO DIAGNOSIS
AND
Male and female cause
N=9
I,OI_LOW-UP
ASSESSMENT
IN
OUTCOME
N = 28
Unexplained
N=
19
Pregnant
N = 22
M
F
M
F
M
F
M
F
M
F
3.9 5.1
4.7 3.9
2.7 3.5
5.4 3.3
5.0 5.3
6.1 5.3
4.5 3.8
5.3 5.1
5.4 4.2
7.6 17.6
5.7 4.2
6.5 5.9
Initial assessment
Mean SD
4.0 4.8
5.8 5.6
4.3 6.4
7.5 7.6
Follow-up assessment
Mean SD
4.8 5.0
4.7 5.2
3.0 4.2
6.9 7.6
-
464
K. J. CONNOLLY
etul
Table III gives the scores for males and females within the five subgroups on the GHQ at initial and follow-up assessment. There are significant effects due to time (Ft,215 = 10.2; p < O.Ol), gender (Ft,2t5 = 6.2; p < 0.01) and significant interactions of gender and cause (F4,215 = 2.3; p < 0.05) and gender by time (Fl,~ts = 4.3; p < 0.05). Both men and women had lower scores at follow-up than at the initial assessment (21.6-20.5 and 26.2-21 .O for males and females respectively). Within this, however, post hoc comparison of the means revealed significant variations. Again only in the case of men where a male problem was diagnosed did GHQ scores increase between the initial and follow-up assessments, so that by the follow-up these men were scoring significantly higher on the GHQ than those in the unexplained group (p < 0.05). In the case of women where a female cause of the reproductive difficulty was identified or where it was unexplained, GHQ scores decreased significantly between the initial and follow-up assessments 0, < 0.05). TABLE
III.-MEAN
GHQ
SCORES OF MBN AND WOMEN AT INITIAL AND RELATlON 10 DlACNOSlS AND OUTCOME
Subgroup
Male callse
Female cause
N = 39
Male and female cause N = 28
N-9
FOLLOW-UP
ASSESSMENT
Unexplained
N=
LN
Pregnant
18
N = 22
M
F
M
F
M
F
M
F
M
F
Initial assessment
Mean SD
21.7 8.7
21.5 11.2
20.1 5.0
28.5 12.5
22.9 8.3
24.4 9.3
19.3 7.5
25.1 9.4
23.8 9.5
25.7 6.8
Follow-up assessment
Mean SD
24.8 Il.6
21.3 9.3
18.4 5.2
20.4 15.3
20.8 8.7
22.1 10.2
16.1 7.3
17.8 5.8
22.4 10.7
23.5 10.4
Gender
Scores on the Dyadic Adjustment Scale revealed that marital adjustment remained relatively constant between the assessments with no indication of any significant differences, see Table IV. These data are indicative of generally very stable relationships suggesting that the partners manage well the various strains of the investigatory processes. TABLE
IV.-MEAN
SCORES ON DYADIC ADJUSTMENT SCALE FOR MEN AND WOMEN FOLLOW-UP ASSESSMENT IN RELATION TO DIAGNOSIS AND OUTCOME
Male cause
Subgroup
N= Gender Mean
Female cause
Male and female cause
N=9
39
N=28
AT INITIAL AND
Unexplained
N=
18
Pregnant
N = 22
M
F
M
F
M
F
M
F
M
F
Initial assessment
SD
110.6 10.8
113.4 12.9
109.2 12.1
114.6 8.9
113.4 13.5
112.4 16.1
114.5 15.1
116.3 11.7
110.4 10.9
113.4 12.2
Follow-up assebsment
Mean SD
112.3 11.8
112.9 12.6
109.4 9.9
119.4 10.2
110.0 17.3
117.8 11.7
113.9 12.8
112.8 10.2
109.3 15.4
109.1 10.7
At the follow-up assessment there was a good degree of correspondence between measures of anxiety, depression and psychiatric morbidity. For males the correlations
Impact
of infertility
investigations
465
between the various scores were; GHQKTAI r = 0.68; GHQ/BDI r = 0.63; STAI/ BDI r = 0.456 and for females, GHQ/STAI r = 0.60; GHQ/BDI r = 0.32; STAUBDI r = 0.37. In each case the correlations are significant, p < 0.001. Given these results state anxiety was selected as a general outcome measure for use in further analysis. To explore the data further the top and bottom quartiles from the range of state anxiety scores were identified and the data for these men and women were extracted from the total data set. For the lower quartile there were 26 males and 29 females with state anxiety scores at follow-up ranging from 20-29 for males, and 20-25 for females. The corresponding information for the upper quartile was 27 males with state anxiety scores of 41-64, and 28 females scoring between 38 and 63. These two subsets of most and least anxious patients were then compared on EPQ, ISEL, BSRI and DAS measures made at the initial assessment. In the case of both males and females those from the high state anxiety quartiles had significantly higher neuroticism scores (males, low 7.2; high 10.2, t = 2.04, p < 0.05; females low 11.1, high 13.6, t = 2.11, p < 0.05) and higher trait anxiety scores (males, low 32.3, high 37.6, t = 2.12, p < 0.05; females, low 35.6, high 39.5, t = 2.04, p < 0.05). Men with state anxiety scores in the upper quartile had significantly lower marital adjustment scores at the time of the initial assessment (low males 116.4, high males 108.8, t = 2.4, p < 0.05). When state anxiety scores were examined in relation to diagnosis/outcome there was in the case of females a fairly even spread of the five diagnostic subgroups between the upper and lower state anxiety quartiles. In the case of males with anxiety scores in the upper quartile there was a preponderance of male infertility problems. Six of the 26 males (22%) in the low state anxiety quartile were diagnosed as being infertile compared with 16 of the 27 (60%) in the high anxiety quartile. Of the remaining individuals in the low anxiety group; two were diagnosed as female problems and in seven cases both the man and the woman were diagnosed as contributing, five were unexplained at the end of the investigations and six had become pregnant. The corresponding figures for the high anxiety group were one female problem, five male and female problems, two remained unexplained and three couples achieved a pregnancy. DISCUSSION
Two principal findings emerge from this investigation. First there is little evidence of psychopathology, at least in the short term (over a period of about 7-9 months), among this sample of couples seeking treatment for infertility. The 232 individuals surveyed are in general well adjusted and they enjoy good stable relationships with their partners. Secondly, those individuals who are likely to fare least well appear to be: (i) those men and women who are dispositionally neurotic or anxious; and (ii) men whose marriages are less well adjusted and who are diagnosed as responsible for the fertility difficulty. The results indicating stable marital relationships are in line with findings from previous reports [ 321. This observation may reflect a number of factors. First there may be an element of self selection in that only those couples with stable relationships actually get as far as seeking specialist medical help in dealing with their failure to have children. In this context Raval et al. [ 2 1 ] suggest that because these couples
466
K. J.CONNOLLY
et al.
are actively engaged in trying to resolve their difficulties the process of investigation itself may be beneficial for their relationship. Leiblum ef al. [ 331 have also argued that infertility may serve to improve a marital relationship by bringing a couple closer together via their shared problem. Infertility, however, is only likely to have supportive side effects in the case of stable marital relationships where the problem is acknowledged by both partners as one that they share. McEwan et al. [ 191 reported that infertile couples who shared a problem within their relationship showed less distress than those who sought outside support. This point may be reflected in the results presented here by the fact that males from initially less stable relationships are more likely to be anxious subsequent to the series of medical investigations. Statistically it is also likely that a greater proportion of these men will themselves be the cause of the infertility and this may be more difficult for the couple to treat as a problem common to them both. In fact male infertility may create particular psychological difficulties. The pattern of generally low depression scores and the overall decrease in GHQ and state anxiety scores over the course of the investigation is contrary to some previous findings which suggest elevated depression and anxiety associated with infertility [ lo] . These and other differences in the findings reported in the literature may reflect the timing of the psychological assessments themselves. At the outset of an investigation elevated anxiety is not unusual, and it is likely to be a common enough response to the couple’s failure to have children. The fact that anxiety subsequently decreases lends support to the idea that the initially high levels are a consequence rather than a cause of infertility [ 141. Although each diagnostic investigation undertaken is likely to occasion some anxiety for the couple involved, the fact that they are actively engaged in trying to resolve their difficulty may serve to reduce anxiety overall. It should also be borne in mind that the two assessments were made in different settings; the first in the clinic, the second in the patient’s home. If anxiety is raised simply by attendance at a clinic it seems likely that the effect would occur regardless of diagnosis. However, an exception to the general trend towards decreased anxiety at the second assessment is provided by those men who were diagnosed as infertile or subfertile. If we assume that the decrease in anxiety is merely a consequence of the second assessment being conducted in the couples’ home, the elevated anxiety levels of these men is even more striking. Indeed it would appear that in general state anxiety, depression and GHQ scores are lower at follow up for those cases where the difficulty is diagnosed to the female and those in which both male and female present with a problem. The picture is similar even for cases of unexplained fertility compared with couples who have conceived since the first assessment. That childbearing itself is not without its own anxieties is easily overlooked when the focus of attention is infertility. This may be particularly so for couples who eventually succeed in conceiving, either naturally or through medically aided means, after many years of trying. In their efforts to have children such couples may develop unreasonable expectations about themselves as parents. Difficulties associated with a diagnosis of male infertility have been reported in previous studies [ 17, 341 and may relate to a number of issues. First, unlike the treatments available for several kinds of female infertility, the only ‘treatment’ for many cases of male fertility at present is donor insemination (DI) which in effect circumvents rather than treats the infertility. That is to say, it provides a means for
Impact of infertility investigations
467
the couple to have a child genetically related to the mother but not the father. Secondly, infertility and virility often become confused in relation to difficulties of male origin, so that as Mahlstedt [ 351 commented, the man who is unable to father a child may feel that others doubt his masculinity. The possibility that male infertility is associated with particular psychological difficulties clearly warrants further investigation. Indeed, it is a particularly important issue given the increasing use made of donor insemination. In the case of donor insemination because the biological identity of one parent is known beyond doubt, there is a danger of some psychological imbalance being created in the relationship between the natural mother, the social father and the child. It has been argued that donor insemination may be a source of conflict for some couples with the child serving as a constant reminder to the man of his infertility [ 361. In our view couples should be given time to adjust to their diagnosis before being encouraged or even allowed to pursue donor insemination. It is also desirable that some form of psychological support and counselling be made available to help them to reach an appropriate decision. Recent legislation in the U.K. acknowledges the need to make available psychological counselling in all clinics which offer donor insemination or in vitro fertilization but this does not extend to clinics which only undertake investigations for reproductive failure. As the findings presented here suggest, although most couples show a favourable response to investigations, those who are dispositionally anxious may fare less well. Identifying at an early stage those individuals who are less likely to be more vulnerable would enable limited counselling resources to be targeted towards those in greater need. Acknowledgenzenfs-The acknowledged.
work
was
supported by a research grant from Birthright
which
is gratefully
REFERENCES Child Welfare 1975; 54: 454-460. 1. MENNING BE. The infertile couple: A plea for advocacy. 2. MENNING BE. The emotional needs of infertile couples. Ferril Steril 1980: 34: 313-319. in a reproductive biology clinic. Fertil Steril 1977; 28: 3. BERGER DM. The role of the psychiatrist 141-145. A psychiatrist’s perspective. Can J Psych& 1980; 25: 553-539. 4. BERGER DM. Infertility: 5. BRESNICKEK. A holistic approach to the treatment of infertility. In Infertility: Medical, Emofional and Social Considerations (Edited by MAZOR MD, SIMONS HF). New York: Human Sciences Press, 1984. 6. PFEFFERN, WOOLLET A. The Experience of Infertility. London: Virago Press, 1983. responses to infertility. Clin Obstet Gynec 1984; 27: 760-766. 7. KEYE WR. Psychosexual and 8. FREEMAN EW, RICKELS K, TAUSIG J, BOXER A, MASTOIANNI L, TURECK RW. Emotional psychological factors in follow-up of women after IVF-ET treatment: A pilot investigation. Acta Obstef Gynecol Stand 1987; 66: 517-521. 9. MAHLSTEDT PP. MACDUFF S, BERNSTEIN J. Emotional factors and the in vitro fertilization and embryo transfer process. J In Vitro Fertil Embryo Tram 1987; 4: 232-236. 10. LINK PW, DARLING CA. Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital 7’her 1986; 12: 46-59. 11. HARRISON RF, O’MOORE AM. O’MOORE RR, ROBB D. Stress in infertile couples. In Fertility and Sterility (Edited by BUNNAR J, THOMSON W). Lancaster: MTP Press, 1984. 12. PAULSON JD, HARRMANN BS, SALERNO RL, ASMR P. An investigation of the relationship between emotional maladjustment and infertility. Fertil Steril 1988; 49: 258-262. the patient’s first approach to the medical 13. EDELMANN RJ, CONNOLLY KJ, COOKE ID. Infertility: profession. Pracfitioner 1988; 232: 202-206. 14. EDELMANN RJ, CONNOLLY KJ, COOKE ID, ROBSON I. Psychogenic infertility: some findings. J Psychosom Obstet Gynaecol 199 1: 12.
468
K. .I. CONNOLLY et a[.
15. EDELMANN RJ, CONNOLLY KJ, ROBSON J. The impact of infertility and infertility investigations: Four case illustrations. J Reprod Infanr Psychol 1989; 7: 113-119. 16. OWENS DJ, READ MW. Patients’ experience with and assessment of subfertility testing and treatment. J Reprod Infant Psychol 1984;; 2: 7-17. 17. CONNOLLY KJ, EDELMANN RJ, COOKE ID. Distress and marital problems associated with infertility. J Reprod Infant Psycho1 1987; 5: 49-57. 18. BERGER DM. Impotence following the discovery of azoospermia. Fertil Steril 1980b; 34: 154-156. 19. MCEWAN KL, COSTELLO CG, TAYLOR PJ. Adjustment to infertility. J Abnorm Psycho1 1987; 96: 108-l 16. 20. BRAND HJ. Psychological stress and fertility. Part 2. Psychometric test data. Br J Med Psychol 1982; 55: 385-388. 21. RAVAL F, SLADE P, BUCK P, LIEBERMAN BE. The impact of infertility on emotions and the marital and sexual relationship. J Reprod Infant Psycho1 1987; 5: 221-234. 22. Roos PE, COHEN LH. Sex roles and social support as moderators of life stress adjustment. J Pers Sot Psycho1 1987; 52: 576-585. 23. MOLLER A, FALLSTROM K. Psychological consequences of infertility: a longitudinal study. Psychosom Obstet Gynaecol 1991; 12: 27-45. 24. OPCS. Classijicafion of Occuparions. London: HMSO, 1980. 25. EYSENCK HJ. EYSENCK SBG. Manual of the Eysenck Personality Questionnaire. London: Hodder & Stoughton, 1975. 26. GOLDBERG D. Manual of the General Health Questionnaire. Oxford: NFER-Nelson, 1978. 27. BECK AT. Depression: Causes and Trearment. Philadelphia: University of Philadelphia Press, 1972. 28. SPEILBERGER CD, GORSUCH RL, LUSHENE R. The State-Trait Anxiety Inventory Mcmual. Palo Alto: Consulting Psychologists Press, 1970. 29. SPANIER GB. Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976; 38: 15-28. 30. COHEN S, MERMELSTEIN R, KAMARK T, HOBERMAN HM. Measuring the functional component of social support. In Social Support: Theory, Research and Application (Edited by SARASON S, SARASON LR). Dordrecht: Martinus Nijhoff, 1985. 3 1. BEM SL. Manualfor the Bern Sex Role Invenrory. Palo Alto: Consulting Psychologists Press, 1981. 32. SHAW P, JOHNSTON M, SHAW R. Counselling needs, emotional and relationship problems in couples awaiting IVF. J Psychosom Obsret Gynaecol 1988; 9: 171-180. 33. LEIBLUM SR, KEMMANN E, LANE MK. The psychological concomitants of in vitro fertilization. J Psychosom Obstet Gynaecol 1987; 6: 165-167. 34. KEDEM P, MIKULINCER M. NATHANSON YE, BARTOV B. Psychological aspects of male infertility. Br J Med Psycho1 1990; 63: 73-80. 35. MAHLSrEDT PP. The psychological components of infertility. Fertil Sferil 1985; 43: 3355346. 36. EDELMANN RJ. Psychological aspects of artificial insemination by donor. J Psychosom Obstet Gynnecol 1989; 10:3-13.
Research. Vol. 36, No
1992. 0
THE IMPACT
KEVIN J. CONNOLLY,* (Received
5, pp. 459-468,
0022-3999/92 $S.oO+.M) 1992 Pergamon Press Ltd
OF INFERTILITY ON PSYCHOLOGICAL FUNCTIONING ROBERT J. EDELMANN,? IAN D. COOKE and JILL ROBSON*
26 June
1991; accepted
in revised form 6 November
1991)
Abstract-To explore the impact of infertility on psychological functioning 130 couples presenting with primary infertility were assessed at their initial visit to an infertility clinic. Of these, 116 couples were assessed on a second occasion some 7-9 months later when in most cases the medical tests were complete. Measures of personality, psychopathology, percel.vedsocial support, sex role identity and marital state were obtained from both partners. The set was subsequently divided into five subgroups on the basis of the diagnosis made or the outcome (female cause, male cause, female and male cause, unexplained and pregnant). The results show little evidence of psychopathology in the sample, depression scores remained low throughout the period of investigation. The results also indicated stable marital relationships. Scores on tests of anxiety and psychiatric morbidity declined between the first and second assessment except in the case of men who were diagnosed with a fertility problem. The implications of these findings are discussed in the increased use of donor insemination which circumvents rather than treats the problem of male infertility. INTRODUCTION
the past 20 yr or so a number of clinical observations and anecdotal reports have been devoted to the impact of infertility on the psychological wellbeing of the couples involved. For example, Menning [ 11 argued that infertility is, ‘a complex life-crisis, psychologically threatening and emotionally stressful’. For many no doubt this is so, though the degree of stress and the extent of the threat perceived by the individual will vary as will the individual’s response to the situation. Elsewhere Menning [2] has drawn attention to possible parallels between the psychological consequences of infertility and general grief reactions. Berger [3, 41 goes so far as to suggest that, ‘a sense of despair must plague every couple who seek help with an infertility problem.’ Other authors [5-71 refer to health problems, loss of self esteem, feelings akin to mourning, depression, guilt and frustration, all associated with failure to conceive. That infertility is a deeply distressing experience for many couples cannot be denied. Freeman et al. [ 81 found that half of their sample of infertile couples described infertility as the most upsetting experience of their lives, while 80% of Mahlstedt et al’s [9] sample reported that their experience of infertility was either stressful or extremely stressful. Other studies have reported evidence of elevated anxiety levels or depression scores for some infertile patients when compared with controls. Thus Link and Darling [lo] found that 40% of women and 16% of men had scores indicative of clinically significant depression and Harrison et al. [ 111 reported higher state anxiety scores for women but not for men in infertile partnerships OVER
*Department of Psychology, University of Sheffield, U.K. tDepartment of Psychology, University of Surrey, U.K. University Department of Obstetrics and Gynaecology, Jessop Hospital for Women, Address correspondence to Professor K. J. Connolly, Department of Psychology, Sheffield, Sheffield, SlO 2TN, U.K. 459
Sheffield, U.K. University of
460
K. J.CONNOLLY
et al.
when compared with controls. Other studies, however, have revealed few if any differences between infertile individuals and fertile controls on measures of anxiety and depression [ 121. The uncertain and often rather muddled picture which emerges from the literature reflects a number of methodological inadequacies. First, there is a naive tendency to treat infertile couples as if they were a homogeneous group. Second, psychological measurements made at different stages in a series of medical investigations which have been going on for varying periods have been compared uncritically. Moreover very few studies have assessed patients before infertility investigations were begun. The impact of infertility on psychological functions is plainly a complex matter influenced by a number of variables including: the investigative procedures involved; the duration of the infertility; the diagnosis if any which is made and the quality of a couple’s relationship. The timing of psychological assessments in relation to various investigative and treatment procedures is also an important matter. Baseline assessments made before medical investigations begin are rare, which means that most studies fail to address the question of whether reported differences between fertile and infertile populations reflect inherent differences rather than a response to the investigatory process and/or diagnosis per se. Also, given that the majority of patients will have been struggling to cope with their failure to conceive for about 2 yr before referral to a specialist clinic [ 131 it would not be surprising if they were showing some signs of distress. The infertile couples described in this report were assessed at the time of their first attendance at the infertility clinic. When compared with three fertile groups they showed little evidence of differences on measures of psychopathology, with the exception of higher state anxiety for the infertile patients [ 141. Further, in four individual cases re-examined around 9 months after the initial assessment, there was a tendency for anxiety to have decreased [ 151. A further problem arises in connection with reports in the literature that male infertility presents particular difficulties for the couple concerned. Satisfaction with testing and treatment is reported to be less for both partners in cases where the male was diagnosed as subfertile [ 161 In a retrospective survey of over 800 couples, Connolly et al. [ 17 ] reported greater emotional and marital difficulties for both men and women in those cases where the cause of the infertility was diagnosed to the man. Related to this Berger [ 181 found a 63% incidence of transient impotence (lasting l-3 months) following the discovery of azoospermia in a sample of 26 males. Others have argued that the continuing uncertainty of unexplained infertility (i.e. where a cause has not been identified at the conclusion of the various medical investigations) places a greater strain upon both partners and their relationship than does a definite diagnosis, even when this is unfavourable. Thus McEwan et al. [ 191 found that undiagnosed women showed poorer adjustment although other studies report few differences between diagnosed and undiagnosed women [ 17, 201. Again these variations in the findings probably reflect methodological differences between the various investigations; differences in sample size, the timing of assessments and in the nature of the measures made. Others have argued that certain factors such as sex role discrimination and social support act as buffers against stress and may thus partially protect the infertile individual from attendant psychological difficulties. In this respect infertile patients
Impact of infertility investigations
461
sharing their difficulties with a partner rather than seeking social support outside the partnership show less emotional distress [ 191. The probable resilience of such supportive relationships is noted by Raval er al. [21] who found a reduction in the reporting of marital problems by couples after they had attended an infertility clinic. With regard to sex role identity, Roos and Cohen [ 221 suggest that those with strong masculine characteristics show least psychological distress in relation to stressors. The situation is clearly complicated because coping with a personal threat (a diagnosis of one’s own infertility) has different implications to coping with a threat to one’s partner (a diagnosis of one’s partner’s infertility). In one of the few longitudinal studies so far carried out Moller and Fallstrom [ 231 investigated the consequences of infertility on the psychological wellbeing of 71 couples. Using both interview and questionnaire data they found that in the case of couples who had not achieved a pregnancy at follow up (18 months after the initial clinic attendance) there was an increase in feelings of depression and failure, an increase in anxiety and in emotional disturbance assessed by self report. Moller and Fallstrom distinguished between couples who achieved a pregnancy and those who did not but they did not link psychological consequences to diagnosis. The study reported here was designed to investigate the impact of infertility by assessing a couple on two occasions; first on their initial attendance at the clinic before any medical investigations were begun, and second, approximately 9 months later when in most of the cases the diagnostic tests were completed. The two assessments separated in time in this way, enabled the effects of the investigative procedures and the patients’ experience to be teased out. To our knowledge, this is one of very few studies presenting a longitudinal evaluation of a couples’ reactions to infertility investigations and the only one which does so in relation to diagnostic outcome. The investigation focused particularly on measures of psychopathology and marital interaction, though the relationship of measures to personality characteristics, social support and the individual’s sex role identity was also examined. MATERIALS
AND METHODS
Participants The initial sample consisted of 130 couples presenting with primary infertility. These were consecutive referrals to a specialist infertility clinic. From the initial set 116 couples maintained contact with the clinic over the ensuing year during which time a series of medical investigations was carried out. Complete data sets were obtained on the 116 females but only 107 males completed all the tests. For 76 couples organic causes for their infertility were diagnosed. In 39 cases reproductive failure was attributed to the male alone and in 9 cases to the female alone. In a further 28 cases both the male and female members of a pair were found to have difficulties which contributed to the failure to reproduce. The female diagnoses were; tubal problems 9, ovulatory disorders 17, endocrine problems 3, endometriosis 8. Male diagnoses were; azoospermia 6, oligozoospermia 16, teratozoospermia 14, asthenozoospermia 3 1. Azoospermia represents a zero sperm count and consequently the male is unable to father a child; the three following categories represent various sperm abnormalities and hence a varying chance that the male may be able to father a child. A comparison of men diagnosed with azoospermia (N = 6) was made with those diagnosed with oligozoospermia, teratozoospermia and asthenozoospermia (N = 61) on each of the measures taken at the initial assessment. No significant differences were found (Mann-Whitney U). Of the remaining 40 couples, 22 (19%) conceived over the period of the study and 18 (15.5%) remained unexplained. For comparison purposes five sub-groups were identified: (i) female cause; (ii) male cause; (iii) female and male cause; (iv) unexplained; and (v) pregnant. The mean age of the sample was 28 yr for females and 30 yr for males. Social class distribution, determined on the basis of the male’s occupation [24] reflected a slight bias towards the upper end of the distribution (the percentage of the sample in each social class was: I, 10; II 25; III, 44; IV, 16; V, 5).
462
K. J. CONNOLLY
et al
Basic demographic information was obtained from a structured interview conducted at the time of the initial assessment. At this initial assessment participants also completed the following questionnaires and inventories f;v.cerrck Perxmality Quesrionnaire (EPQ). The EPQ is made up of 90 items to be answered yes or no. These are grouped into four sets comprising; psychoticism (P), extroversion (E), neuroticism (N) and lie (L) scales. The instrument has been widely used and has established validity and reliability [25] Gmrrul Health Quesrionnaire (GHQ). The GHQ is a self-administered screening instrument designed to detect psychiatric morbidity in the community. In its original form it consisted of 60 items, the 30 item scale (GHQ-30) was used in the study reported here. The instrument has established validity and reliability [ 261 BeckDepression Inventory (BDl), The BDI consists of 2 1 multiple choice items describing behavioural signs of depression each of which is to he rated on a scale of O-3. Higher scores indicate a greater severity of depression. The scale has been widely used with both clinical and non-clinical populations and it has established validity and reliability 1271. &are-Twit Anxiety Inventory (STAI). The test comprises two sets of the same 20 questions describing feelings of tension, worry or apprehension. One set of questions deals with how the respondent feels now (state) and the other with how they generally feel (trait). The scale has been widely used and information on validity and reliability is available 1281. Dyadic Adjustmenr Scale (DAS). The DAS is a 32-item scale for assessing the quality of a marital 01 other long-term relationship. It has adequate reliability and validity [ 291 Iriferpersrintrl SupporrEvaluufion List (ISEL). The ISEL consists of 40 items each rated true or false to indicate perceived availability of potential social resources. The scale has not yet been widely usled but the author\ report that it has good reliability and validity [30] It comprises four sub-scale% relating to self-esteem. tangible support, appraisal and belonging. BEM Ser Role Invenforv (ESRI). The BSRI consists of 60 items each rated on a xale of l-7 used to indicate the individual’s degree of masculinity and femininity. The scale has been widely used and information on reliability and validity is available [3 I ] The first assessment was made at the beginning of the couple’s initial visit to the infertility clinic. 4hout 7 months later all the couples in the initial sample who could be contacted and who had not withdrawn from the study were visited at home for a follow-up assessment. At the follow-up assessment participants were again given these texts with the exception of the EPQ and the trait component of the STAI. A comparison was made between those participants who completed the study and those who did not on the data obtained at the initial assessment, no significant differences were found on any of the psychological variables measured at the initial clinic visit (Mann-Whitney U).
RESULTS In an initial examination of the results the variables derived from the questionnaires, in addition to the five diagnostic categories, were used in three separate stepwise multiple regression analyses to select the best predictors of state anxiety, BDI and GHQ scores obtained at the second assessment. Separate analyses were made for males and females. For males one predictor variable was significant. The diagnosis of a male problem was related to higher state anxiety (R = 0.29, R* = 0.08, F = 10.3, p < 0.01) and higher GHQ scores (R = 0.22, R2 = 0.05,F = 5.8, p < 0.05). In the case of females two predictor variables were significant. The tangible support sub-scale of the ISEL was related to lower state anxiety (R = 0.23, R2 = 0.05,F = 6.30, p < 0.05) and trait anxiety was related to higher depression scores (R = 0.20, R2 = 0.04, F = 4.7, p < 0.05). To examine the impact of the investigations and diagnosis four three-way MANOVAS were performed on the data for each of: state anxiety; depression; general health; and the quality of the couple’s relationship. In each case the within subject variable was time (initial vs follow-up assessment) while the two between subject variables were cause (male vs female, vs male and female. vs unexplained, vs pregnant) and gender (male vs female).
Impact
of infertility
investigations
463
Mean state anxiety scores on initial and follow-up assessment for the five subgroups into which the sample was divided are shown in Table I. There are significant effects due to time (Fl,214 = 23.5; p < O.OOl), and gender (F1,214 = 11.9; p < 0.001) and a significant interaction of time and gender (Fl,214 = 7.2; p < 0.001). Both males and females were less anxious overall at the follow-up assessment (state anxiety scores were 33.4-30.7, and 40.3-31.7 for males and females at initial and follow-up assessment respectively). Within this, however, post hoc comparison of the means revealed significant variations. Specifically those cases where the cause of the infertility had been diagnosed to the male showed an increase in anxiety over time. At follow-up these cases had state anxiety scores significantly greater than men where the cause of infertility had been diagnosed either to both partners or where it remained unexplained @ < 0.05). In the case of females where the cause was diagnosed either to the male or to both partners, anxiety decreased significantly between the initial and follow-up assessments 0, < 0.05).
TABLE
I.-MEAN
STATE A7
ANXIE-r~
SCORES
FOLLOW-UP
Subgroup
IN
FOR MEN
AND
RELATION
TO DIAGNOSIS
Female cause
Male cause
Mean
Initial assessment
SD
Follow-up assessment
SD
Mean
AT TIME
OF INITIAL
ASSESSMENT
AND
OR OUTCOME
Male and female cause
N=9
N = 39 Gender
WOMEN
N=28
Unexplained
N=
Pregnant
18
N = 22
M
F
M
F
M
F
M
F
M
F
33.3 8.3
39.9 11.5
33.8 11.2
42.2 18.8
32.7 8.9
42.9 10.8
30.4 6.4
39.8 10.1
36.2 9.8
37.2 13.5
36.8 12.6
30.7 11.9
29.0 8.6
28.2 14.9
29.6 11.3
34.7 9.0
26.2 13.1
29.2 5.9
32.1 9.4
35.5 10.0
Scores on the Beck Depression inventory for the five subgroups at the initial and follow-up assessments are shown in Table II. The scores show little evidence of change over the intervening period, and in general they are low. There is a significant gender difference (Fl.217 = 6.6; p < 0.01) which would be expected on the basis of population data which shows that females generally have higher depression scores.
TABLE
BDI
H.-MEAN
SCORES
OF MEN
RELATION
Subgroup
Male cause
AND
WOMEN
INITIAL
AND
Female cause
N = 39 Gender
ON
TO DIAGNOSIS
AND
Male and female cause
N=9
I,OI_LOW-UP
ASSESSMENT
IN
OUTCOME
N = 28
Unexplained
N=
19
Pregnant
N = 22
M
F
M
F
M
F
M
F
M
F
3.9 5.1
4.7 3.9
2.7 3.5
5.4 3.3
5.0 5.3
6.1 5.3
4.5 3.8
5.3 5.1
5.4 4.2
7.6 17.6
5.7 4.2
6.5 5.9
Initial assessment
Mean SD
4.0 4.8
5.8 5.6
4.3 6.4
7.5 7.6
Follow-up assessment
Mean SD
4.8 5.0
4.7 5.2
3.0 4.2
6.9 7.6
-
464
K. J. CONNOLLY
etul
Table III gives the scores for males and females within the five subgroups on the GHQ at initial and follow-up assessment. There are significant effects due to time (Ft,215 = 10.2; p < O.Ol), gender (Ft,2t5 = 6.2; p < 0.01) and significant interactions of gender and cause (F4,215 = 2.3; p < 0.05) and gender by time (Fl,~ts = 4.3; p < 0.05). Both men and women had lower scores at follow-up than at the initial assessment (21.6-20.5 and 26.2-21 .O for males and females respectively). Within this, however, post hoc comparison of the means revealed significant variations. Again only in the case of men where a male problem was diagnosed did GHQ scores increase between the initial and follow-up assessments, so that by the follow-up these men were scoring significantly higher on the GHQ than those in the unexplained group (p < 0.05). In the case of women where a female cause of the reproductive difficulty was identified or where it was unexplained, GHQ scores decreased significantly between the initial and follow-up assessments 0, < 0.05). TABLE
III.-MEAN
GHQ
SCORES OF MBN AND WOMEN AT INITIAL AND RELATlON 10 DlACNOSlS AND OUTCOME
Subgroup
Male callse
Female cause
N = 39
Male and female cause N = 28
N-9
FOLLOW-UP
ASSESSMENT
Unexplained
N=
LN
Pregnant
18
N = 22
M
F
M
F
M
F
M
F
M
F
Initial assessment
Mean SD
21.7 8.7
21.5 11.2
20.1 5.0
28.5 12.5
22.9 8.3
24.4 9.3
19.3 7.5
25.1 9.4
23.8 9.5
25.7 6.8
Follow-up assessment
Mean SD
24.8 Il.6
21.3 9.3
18.4 5.2
20.4 15.3
20.8 8.7
22.1 10.2
16.1 7.3
17.8 5.8
22.4 10.7
23.5 10.4
Gender
Scores on the Dyadic Adjustment Scale revealed that marital adjustment remained relatively constant between the assessments with no indication of any significant differences, see Table IV. These data are indicative of generally very stable relationships suggesting that the partners manage well the various strains of the investigatory processes. TABLE
IV.-MEAN
SCORES ON DYADIC ADJUSTMENT SCALE FOR MEN AND WOMEN FOLLOW-UP ASSESSMENT IN RELATION TO DIAGNOSIS AND OUTCOME
Male cause
Subgroup
N= Gender Mean
Female cause
Male and female cause
N=9
39
N=28
AT INITIAL AND
Unexplained
N=
18
Pregnant
N = 22
M
F
M
F
M
F
M
F
M
F
Initial assessment
SD
110.6 10.8
113.4 12.9
109.2 12.1
114.6 8.9
113.4 13.5
112.4 16.1
114.5 15.1
116.3 11.7
110.4 10.9
113.4 12.2
Follow-up assebsment
Mean SD
112.3 11.8
112.9 12.6
109.4 9.9
119.4 10.2
110.0 17.3
117.8 11.7
113.9 12.8
112.8 10.2
109.3 15.4
109.1 10.7
At the follow-up assessment there was a good degree of correspondence between measures of anxiety, depression and psychiatric morbidity. For males the correlations
Impact
of infertility
investigations
465
between the various scores were; GHQKTAI r = 0.68; GHQ/BDI r = 0.63; STAI/ BDI r = 0.456 and for females, GHQ/STAI r = 0.60; GHQ/BDI r = 0.32; STAUBDI r = 0.37. In each case the correlations are significant, p < 0.001. Given these results state anxiety was selected as a general outcome measure for use in further analysis. To explore the data further the top and bottom quartiles from the range of state anxiety scores were identified and the data for these men and women were extracted from the total data set. For the lower quartile there were 26 males and 29 females with state anxiety scores at follow-up ranging from 20-29 for males, and 20-25 for females. The corresponding information for the upper quartile was 27 males with state anxiety scores of 41-64, and 28 females scoring between 38 and 63. These two subsets of most and least anxious patients were then compared on EPQ, ISEL, BSRI and DAS measures made at the initial assessment. In the case of both males and females those from the high state anxiety quartiles had significantly higher neuroticism scores (males, low 7.2; high 10.2, t = 2.04, p < 0.05; females low 11.1, high 13.6, t = 2.11, p < 0.05) and higher trait anxiety scores (males, low 32.3, high 37.6, t = 2.12, p < 0.05; females, low 35.6, high 39.5, t = 2.04, p < 0.05). Men with state anxiety scores in the upper quartile had significantly lower marital adjustment scores at the time of the initial assessment (low males 116.4, high males 108.8, t = 2.4, p < 0.05). When state anxiety scores were examined in relation to diagnosis/outcome there was in the case of females a fairly even spread of the five diagnostic subgroups between the upper and lower state anxiety quartiles. In the case of males with anxiety scores in the upper quartile there was a preponderance of male infertility problems. Six of the 26 males (22%) in the low state anxiety quartile were diagnosed as being infertile compared with 16 of the 27 (60%) in the high anxiety quartile. Of the remaining individuals in the low anxiety group; two were diagnosed as female problems and in seven cases both the man and the woman were diagnosed as contributing, five were unexplained at the end of the investigations and six had become pregnant. The corresponding figures for the high anxiety group were one female problem, five male and female problems, two remained unexplained and three couples achieved a pregnancy. DISCUSSION
Two principal findings emerge from this investigation. First there is little evidence of psychopathology, at least in the short term (over a period of about 7-9 months), among this sample of couples seeking treatment for infertility. The 232 individuals surveyed are in general well adjusted and they enjoy good stable relationships with their partners. Secondly, those individuals who are likely to fare least well appear to be: (i) those men and women who are dispositionally neurotic or anxious; and (ii) men whose marriages are less well adjusted and who are diagnosed as responsible for the fertility difficulty. The results indicating stable marital relationships are in line with findings from previous reports [ 321. This observation may reflect a number of factors. First there may be an element of self selection in that only those couples with stable relationships actually get as far as seeking specialist medical help in dealing with their failure to have children. In this context Raval et al. [ 2 1 ] suggest that because these couples
466
K. J.CONNOLLY
et al.
are actively engaged in trying to resolve their difficulties the process of investigation itself may be beneficial for their relationship. Leiblum ef al. [ 331 have also argued that infertility may serve to improve a marital relationship by bringing a couple closer together via their shared problem. Infertility, however, is only likely to have supportive side effects in the case of stable marital relationships where the problem is acknowledged by both partners as one that they share. McEwan et al. [ 191 reported that infertile couples who shared a problem within their relationship showed less distress than those who sought outside support. This point may be reflected in the results presented here by the fact that males from initially less stable relationships are more likely to be anxious subsequent to the series of medical investigations. Statistically it is also likely that a greater proportion of these men will themselves be the cause of the infertility and this may be more difficult for the couple to treat as a problem common to them both. In fact male infertility may create particular psychological difficulties. The pattern of generally low depression scores and the overall decrease in GHQ and state anxiety scores over the course of the investigation is contrary to some previous findings which suggest elevated depression and anxiety associated with infertility [ lo] . These and other differences in the findings reported in the literature may reflect the timing of the psychological assessments themselves. At the outset of an investigation elevated anxiety is not unusual, and it is likely to be a common enough response to the couple’s failure to have children. The fact that anxiety subsequently decreases lends support to the idea that the initially high levels are a consequence rather than a cause of infertility [ 141. Although each diagnostic investigation undertaken is likely to occasion some anxiety for the couple involved, the fact that they are actively engaged in trying to resolve their difficulty may serve to reduce anxiety overall. It should also be borne in mind that the two assessments were made in different settings; the first in the clinic, the second in the patient’s home. If anxiety is raised simply by attendance at a clinic it seems likely that the effect would occur regardless of diagnosis. However, an exception to the general trend towards decreased anxiety at the second assessment is provided by those men who were diagnosed as infertile or subfertile. If we assume that the decrease in anxiety is merely a consequence of the second assessment being conducted in the couples’ home, the elevated anxiety levels of these men is even more striking. Indeed it would appear that in general state anxiety, depression and GHQ scores are lower at follow up for those cases where the difficulty is diagnosed to the female and those in which both male and female present with a problem. The picture is similar even for cases of unexplained fertility compared with couples who have conceived since the first assessment. That childbearing itself is not without its own anxieties is easily overlooked when the focus of attention is infertility. This may be particularly so for couples who eventually succeed in conceiving, either naturally or through medically aided means, after many years of trying. In their efforts to have children such couples may develop unreasonable expectations about themselves as parents. Difficulties associated with a diagnosis of male infertility have been reported in previous studies [ 17, 341 and may relate to a number of issues. First, unlike the treatments available for several kinds of female infertility, the only ‘treatment’ for many cases of male fertility at present is donor insemination (DI) which in effect circumvents rather than treats the infertility. That is to say, it provides a means for
Impact of infertility investigations
467
the couple to have a child genetically related to the mother but not the father. Secondly, infertility and virility often become confused in relation to difficulties of male origin, so that as Mahlstedt [ 351 commented, the man who is unable to father a child may feel that others doubt his masculinity. The possibility that male infertility is associated with particular psychological difficulties clearly warrants further investigation. Indeed, it is a particularly important issue given the increasing use made of donor insemination. In the case of donor insemination because the biological identity of one parent is known beyond doubt, there is a danger of some psychological imbalance being created in the relationship between the natural mother, the social father and the child. It has been argued that donor insemination may be a source of conflict for some couples with the child serving as a constant reminder to the man of his infertility [ 361. In our view couples should be given time to adjust to their diagnosis before being encouraged or even allowed to pursue donor insemination. It is also desirable that some form of psychological support and counselling be made available to help them to reach an appropriate decision. Recent legislation in the U.K. acknowledges the need to make available psychological counselling in all clinics which offer donor insemination or in vitro fertilization but this does not extend to clinics which only undertake investigations for reproductive failure. As the findings presented here suggest, although most couples show a favourable response to investigations, those who are dispositionally anxious may fare less well. Identifying at an early stage those individuals who are less likely to be more vulnerable would enable limited counselling resources to be targeted towards those in greater need. Acknowledgenzenfs-The acknowledged.
work
was
supported by a research grant from Birthright
which
is gratefully
REFERENCES Child Welfare 1975; 54: 454-460. 1. MENNING BE. The infertile couple: A plea for advocacy. 2. MENNING BE. The emotional needs of infertile couples. Ferril Steril 1980: 34: 313-319. in a reproductive biology clinic. Fertil Steril 1977; 28: 3. BERGER DM. The role of the psychiatrist 141-145. A psychiatrist’s perspective. Can J Psych& 1980; 25: 553-539. 4. BERGER DM. Infertility: 5. BRESNICKEK. A holistic approach to the treatment of infertility. In Infertility: Medical, Emofional and Social Considerations (Edited by MAZOR MD, SIMONS HF). New York: Human Sciences Press, 1984. 6. PFEFFERN, WOOLLET A. The Experience of Infertility. London: Virago Press, 1983. responses to infertility. Clin Obstet Gynec 1984; 27: 760-766. 7. KEYE WR. Psychosexual and 8. FREEMAN EW, RICKELS K, TAUSIG J, BOXER A, MASTOIANNI L, TURECK RW. Emotional psychological factors in follow-up of women after IVF-ET treatment: A pilot investigation. Acta Obstef Gynecol Stand 1987; 66: 517-521. 9. MAHLSTEDT PP. MACDUFF S, BERNSTEIN J. Emotional factors and the in vitro fertilization and embryo transfer process. J In Vitro Fertil Embryo Tram 1987; 4: 232-236. 10. LINK PW, DARLING CA. Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital 7’her 1986; 12: 46-59. 11. HARRISON RF, O’MOORE AM. O’MOORE RR, ROBB D. Stress in infertile couples. In Fertility and Sterility (Edited by BUNNAR J, THOMSON W). Lancaster: MTP Press, 1984. 12. PAULSON JD, HARRMANN BS, SALERNO RL, ASMR P. An investigation of the relationship between emotional maladjustment and infertility. Fertil Steril 1988; 49: 258-262. the patient’s first approach to the medical 13. EDELMANN RJ, CONNOLLY KJ, COOKE ID. Infertility: profession. Pracfitioner 1988; 232: 202-206. 14. EDELMANN RJ, CONNOLLY KJ, COOKE ID, ROBSON I. Psychogenic infertility: some findings. J Psychosom Obstet Gynaecol 199 1: 12.
468
K. .I. CONNOLLY et a[.
15. EDELMANN RJ, CONNOLLY KJ, ROBSON J. The impact of infertility and infertility investigations: Four case illustrations. J Reprod Infanr Psychol 1989; 7: 113-119. 16. OWENS DJ, READ MW. Patients’ experience with and assessment of subfertility testing and treatment. J Reprod Infant Psychol 1984;; 2: 7-17. 17. CONNOLLY KJ, EDELMANN RJ, COOKE ID. Distress and marital problems associated with infertility. J Reprod Infant Psycho1 1987; 5: 49-57. 18. BERGER DM. Impotence following the discovery of azoospermia. Fertil Steril 1980b; 34: 154-156. 19. MCEWAN KL, COSTELLO CG, TAYLOR PJ. Adjustment to infertility. J Abnorm Psycho1 1987; 96: 108-l 16. 20. BRAND HJ. Psychological stress and fertility. Part 2. Psychometric test data. Br J Med Psychol 1982; 55: 385-388. 21. RAVAL F, SLADE P, BUCK P, LIEBERMAN BE. The impact of infertility on emotions and the marital and sexual relationship. J Reprod Infant Psycho1 1987; 5: 221-234. 22. Roos PE, COHEN LH. Sex roles and social support as moderators of life stress adjustment. J Pers Sot Psycho1 1987; 52: 576-585. 23. MOLLER A, FALLSTROM K. Psychological consequences of infertility: a longitudinal study. Psychosom Obstet Gynaecol 1991; 12: 27-45. 24. OPCS. Classijicafion of Occuparions. London: HMSO, 1980. 25. EYSENCK HJ. EYSENCK SBG. Manual of the Eysenck Personality Questionnaire. London: Hodder & Stoughton, 1975. 26. GOLDBERG D. Manual of the General Health Questionnaire. Oxford: NFER-Nelson, 1978. 27. BECK AT. Depression: Causes and Trearment. Philadelphia: University of Philadelphia Press, 1972. 28. SPEILBERGER CD, GORSUCH RL, LUSHENE R. The State-Trait Anxiety Inventory Mcmual. Palo Alto: Consulting Psychologists Press, 1970. 29. SPANIER GB. Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage Fam 1976; 38: 15-28. 30. COHEN S, MERMELSTEIN R, KAMARK T, HOBERMAN HM. Measuring the functional component of social support. In Social Support: Theory, Research and Application (Edited by SARASON S, SARASON LR). Dordrecht: Martinus Nijhoff, 1985. 3 1. BEM SL. Manualfor the Bern Sex Role Invenrory. Palo Alto: Consulting Psychologists Press, 1981. 32. SHAW P, JOHNSTON M, SHAW R. Counselling needs, emotional and relationship problems in couples awaiting IVF. J Psychosom Obsret Gynaecol 1988; 9: 171-180. 33. LEIBLUM SR, KEMMANN E, LANE MK. The psychological concomitants of in vitro fertilization. J Psychosom Obstet Gynaecol 1987; 6: 165-167. 34. KEDEM P, MIKULINCER M. NATHANSON YE, BARTOV B. Psychological aspects of male infertility. Br J Med Psycho1 1990; 63: 73-80. 35. MAHLSrEDT PP. The psychological components of infertility. Fertil Sferil 1985; 43: 3355346. 36. EDELMANN RJ. Psychological aspects of artificial insemination by donor. J Psychosom Obstet Gynnecol 1989; 10:3-13.
