Pregnancy and childbirth are typically associated
with positive emotions. Evidence suggests that the
anxiety and depression associated with infertility are
similar to those associated with other serious medical
conditions, such as cancer and human immunodeficiency
virus (HIV) (
The psychological aspect of infertility is much
more difficult diagnose and treat. This is one of the
greatest issues for many couples (
Infertility should be considered a bio-psychosocial
crisis, with psychological counseling being an
integral part of a multidimensional solution (
It is a chance for clinical specialists in the
field of mental health to treat couples dealing
with infertility (
Due to the high prevalence of psychiatric disorders
in infertile women, doctors, psychiatrists, and
psychologists should look more carefully for both
early detection and treatment of these disorders
This is a randomized clinical trial on 80 infertile women chosen by simple sampling in the Jahrom Gynecology Clinic, affiliated with Jahrom University of Medical Sciences.
Infertility was defined as at least one year of unprotected coitus without conception. Women who met the inclusion criteria were recruited to our study. All participants who had primary infertility, with no somatic and psychiatric problems, who were residents of Jahrom, ages 20-40 years, had a valid cell phone number, were able to read and write, and who were interested in participating in regular group meetings were selected for our study. All patients signed a consent form to participate in our study and there was no obligation for them to participate in this research. The Institutional Ethics Committee approved the study protocol.
A total of 80 infertile women consecutively included in infertility therapy or other ART were randomly allocated either to the cognitive-behavioral treatment (CBT) group or to the control group.
In the first two sessions, 16 patients were absent and some did not complete the entire questionnaire, therefore the study continued with two groups of 32 patients in the CBT group and 33 in the control group. 12 meetings were provided for a period of 3 months, as a 2 hour weekly meeting.
The group therapy used in this study addressed causes of infertility and aimed to teach participants how to recognize and challenge negative thoughts and irrational beliefs. Also CBT group therapy, included cognitive reconstructing, negative thought blocking, spirituality (finding the meaning of life in the heart of the problem), and the behavioral techniques included muscle relaxation, birth exercises, imagination(replacing negative thoughts with positive thoughts in mind), self-disclosure and biofeedback in group, 2 hours weekly to 12 sessions. All of participants received positive massages about cognitive reconstructing; changing negative thoughts and how to induce positive thoughts about their infertility and brief messages regarding the results of the session. All participants had emotional disclosure in 30 sessions. Participants expressed positive or negative feelings about their problems and their peers could give them feedback. In some sessions, participants painted their feelings by means of art therapy for emotional disclosure. All paintings were analyzed by expert specialists and participants individually received feedback from group leaders about their emotions. Participants also presented positive and negative emotional feelings about their problems as a written task or expressed them in a group.
At the beginning of each session and in two additional
sessions, we used interactive animation videos
about the infertility medical approach and specialists
responded to personal questions about the infertility
The contents of interventions among three psychiatric approaches
|Cognitive reconstructing, stress reductionin group||10 sessions|
|Decreasing negative thoughts and feelings,expressing them by various methods||12 sessions|
|Giving information, stress reduction,organizing treatment plan||2 sessions|
Differences in mean scores of Depression Anxiety Stress Scales (DASS) test within groups before and after intervention
|Depression||14 (2.38)||8 (2.62)||10.33||0.000|
|Stress||11.93 (3.74)||11.41 (3.21)||0.93||0.35|
|Total||30.22 (3.22)||29.89 (3.23)||0.22||0.87|
The Depression Anxiety Stress Scales (DASS)
test was used to collect data. This test is the shortform
of the DASS-21, which served as a standard
reference. The DASS-21 is a 21-item exam
designed to measure the three negative affective
states of depression, anxiety, and stress. According
to Lovibond and Lovibond, "The depression
scale assesses dysphoria, hopelessness, devaluation
of life, self-deprecation, and lack of interest
or involvement, anhedonia and inertia. The anxiety
scale assesses autonomic arousal, situational
anxiety, and subjective experience of anxious affect.
The stress scale assesses difficulty relaxing,
nervous arousal, and being easily upset or agitated, irritable, or over-reactive and impatience." (
The Penn State Worry Questionnaire (PSWQ)
was used in both clinical and non-clinical situations
Data were analyzed by SPSS statistical software version-18 (SPSS Inc; Chicago, IL) for analyzed the demographics characteristics applied descriptive statistics. Also, for assessed the hypothesis of research used the paired t test to compare mean of variation in two groups, and analysis of covariance (ANCOVA) to compare means of variation between two groups.
Informed consent was taken from patients and the study protocol was approved by the Institutional Ethics Committee of Jahrom University of Medical Sciences.
The current study included 33 infertile women in the treatment group and 32 infertile women in the control group. The demographic characteristics of the study groups showed no significant difference between the treatment and control groups for age (p=0.43), education (p=0.13), duration of infertility, and etiology of infertility (p=0.26).
The age of women ranged from 20-30 years in 18 cases in the treatment group and 31-40 years in 19 patients in the control group (p=0.43). The highest range was 19 (59.4%) in the treatment group and 18 (58.1%) in the control group.
The education level was similar in the treatment and control groups (p=0.13). There were 62 patients (81.25%) in both groups that had a diploma while 18 patients (21.9%) had secondary education or less.
Mean infertility duration in the treatment group was 12 years and in the control group was 16 years; there was no significant difference between the groups (p=1).
According to the etiology of infertility, female factor infertility was observed in 18 patients (56.2%) in the treatment group and 16 patients (51.6%) in the control group. Male factor infertility was observed in 3 patients (9.4%) in the treatment group and 7 (22.6%) in the control group. The cause of infertility was similar in both groups (p=0.26).
Results of the DASS are presented in
There was a significant difference between the
DASS mean score after intervention in the groups
as the level of stress in the treatment group decreased
more than the control group. This result
was confirmed by the analysis of covariance test
(ANCOVA; p=0.001, T=0.14; F=0.14, p=0.002;
Other results showed psychological intervention in the treatment group significantly decreased the PSWQ score from 33.25 ± 12.24 to 27.31 ± 13.50 (p=0.004).
The PSWQ score in the control group was 34.19
± 8.80 at baseline and 34.45 ± 8.23 at the end of the
study. This difference was not significant (p=0.65;
Difference of the mean score of the PSWQ in two
groups was significant after intervention (p=0.01)
and this result was confirmed by ANCOVA (p=
Differences in mean Dpression Anxiety Stress Scales (DASS) score between groups after intervention
|DASS||Treatment group||Control group||T||F||P|
|8.84 (2.65)||11.41 (3.21)||0.14||10.32||0.001***||002***|
|23.93 (6.78)||26.62 (7.61)||0.12||2.07||0.15*||0.15**|
* Independent t test, ** ANCOVA test, *** p=<0.05.
Differences in mean score of Penn State Worry Questionnaire (PSWQ) within groups before and after intervention
* Independent t test, ** ANCOVA test, *** p=<0.05.
Differences between mean score of Penn State WorryQuestionnaire (PSWQ) between groups
* t test, ** ANCOVA, *** p=<0.05.
The current study showed that using a psychological approach such as a CBT or E cognitive message with self-disclosure has a significant impact on psychological distress and improved infertile women’s mental health.
Many studies have investigated the effect of the
psychiatric approach on infertile women. Since
new methods are constantly being introduced in
the field of infertility, the psychological issue has
recently become an important issue that needs to
be addressed (
In one study, it has been reported that providing information about the technical aspects of infertility treatment can facilitate coping with infertility and medical treatments. This information can be given from booklets, interactive films, and multimedia. Although the internet is the fastest and easiest way to obtain information on infertility and related treatments, there is the possibility of wrong or misleading information.
Telephone counseling can be useful in providing specific information about infertility, but in difficult
psychological issues it is not a substitute for
face-to-face counseling (
Studies have confirmed our results, showing
the impact of interactive multimedia on infertile
psychological distress. Multimedia methods
may act as a novel and real intervention for infertile
patients, which can be a solution in cases
of limited local access to educational and support
We used paintings as a method of expressing feelings. Some research has shown the effect of this method in lowering the negative emotions of infertile women.
Art therapy is an inexpensive, non-pharmacological
intervention associated with decreased
levels of hopelessness and depression in subfertile
women. It also provides insight into the meaning
and emotional implications of subfertility for patients
and caregivers (
Other studies state that self-psychology therapy
provides a valuable framework for the therapist,
given the profound and multiple narcissistic assaults
on self-esteem, consolidation of identity,
developmental aspirations, and other self attributes
which infertility causes. The therapist’s empathy
becomes the primary tool of both understanding
and alleviating suffering resulting from
Using multimedia and the internet significantly
reduced the depression level of clinically distressed
and depressed participants. Internet-based
interventions have been show to be promising new
approaches for infertile patients (
In many studies, cognitive behavioral approaches have been shown to be effective for individuals dealing with anxiety and assist infertile patients in challenging and coping with anxiety.
While some research findings have demonstrated
that psychiatric interventions (behavioral, cognitive,
psychotherapy) increase the rate of pregnancy, others
have not found improved pregnancy rates, but noted
decreased rates of depression and anxiety (
In the absence of clinical and mental disorders,
the use of psychological approaches can increase
chances of pregnancy in patients. Using a psychological
approach is a proper treatment, especially
for those who are not receiving medical
Stress management is an effective treatment and
should be offered to patients before, during, and
after undergoing the additional stress of assisted
conception treatments (
Some studies have stated that both psychotherapy
and CBT are well-established treatments for
depression and anxiety (
Several studies have demonstrated the importance
of the mind–body connection and fertility
Some studies have shown that various psychological
treatments can make a contribution to lower
stress, but they rarely increase the possibility of
Pakenham and Rinaldis (
In our study there was a wide age range of between 20-40 years. This might have confessional result, as women in their 40s may have more depression compared with women in their 20s because of the possibility of being infertile for a longer time.
Additional factors such as women’s social
skills and their perception of their own mothers’
acceptance or rejection could cause depression
Typically, group therapy involves a group of individuals with a similar struggle, sitting together and talking about their lives and concerns under the guidance of a certified counselor. According to the results and in attention to the effect of this approach to infertile psychological distress, we suggest psychological approaches associated with other new methods which can help couples to handle their problem. This approach can also help to improve mental health status in infertile women.