Document Type : Original Article
1 Student Research Committee, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2 Research Center for Evidence-Based Health Care, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
3 Research Center for Psychiatry and Behavioral Sciences, Department of Clinical Psychology, Mashhad University of Medical Sci- ences, Mashhad, Iran
4 4Research Center for Management and Social Factors Influencing Health, Department of Biostatistics, Faculty of Public Health, Mashhad University of Medical Sciences, Mashhad, Iran
Infertility is defined as the failure to achieve a clini.
cal pregnancy after 12 months or more of unprotectedsexual intercourse (
The waiting period of the result of IUI treatment,
refers to the time interval between the IUI operationand the time of the pregnancy test (
One of the interventions designed to help people
cope with the medical waiting period is the Positive
Reappraisal Coping Intervention (PRCI). The PRCI
is based on positive reappraisal coping strategies, and
use of this intervention helps people emphasize the
positive aspects of the situation (
Problem Solving Skills training (PSS) is a psychological
intervention, which aims to help individuals
adapt more effectively to stressful problems in life
This randomized control clinical trial involved 108 women, referred to the Milad Infertility Treatment Centre in Mashhad for IUI treatment. Sampling for the trial was undertaken after the research had been approved by the Ethics Committee of Mashhad University of Medical Sciences (Registration number: IRCT2016020926490N1) and consent obtained from the officials of Milad Infertility Treatment Centre. In order to prevent the dissemination of information between the groups were considered at three different times, so that after the completion of the sampling in a group, sampling was started in the other group. The manner of assignment was in this way that first the groups’ names were written on paper, then according to the draw, the first time interval was assigned to the control group, for the second period the PRCI group and for the third period PSS group was assigned. Available sampling method was applied in each group.
The sample size was calculated based on Cohen’s (1987) table, and considering a power of 80%, a confidence level of 95%, and an effect size of 70%, we determined 33 individuals to be required in each group. To take into account a 10% loss, we determined that 36 individuals were required for each group. Inclusion criteria for the study were: Iranian nationality, 18-40 years of age, ability to read and write, primary infertility, and obtaining a score less than 28 on the General Health Questionnaire (GHQ 28). Exclusion criteria for the study were: consumption of any psychoactive drug, occurrence of any stressful and unpleasant incidents over the past 6 months, suffering from medical illness, obtaining a depression score higher than 28 on the Beck Depression Inventory, cancellation of IUI treatment cycle, failure to participate in all training sessions, and unwillingness to continue cooperation in the research.
The instruments used in this trial included: a questionnaire on demographic and infertility-related information, the beck depression inventory, GHQ-28, daily monitoring forms, positive coping thoughts cards, and a checklist for implementing problem-solving skills. The questionnaire on demographic and infertility-related information consisted of questions about: age, level of education, employment status, duration of marriage, family income, duration of infertility, duration of treatment, number of times the participant had undergone IUI and IVF, cause of infertility, treatment seeking, expectancy of successful treatment, and the cost of treatment. The beck depression inventory contains 21 questions with answers scored between 0 and 3. The minimum possible score on the depression questionnaire is zero and the maximum is 63, classified as follows: minor depression 0-13, mild depression 14-19, moderate depression 20- 28, and severe depression 29-63.
The GHQ 28 is a questionnaire containing 28 questions
that measure physical symptoms, anxiety, insomnia, social
dysfunction, and severe depression. The answers are
on a four-point Likert scale. The threshold score for this
questionnaire is 28 and a score higher than 28 is a sign
of susceptibility to mental disorders. The daily monitoring
form was designed by Ockhuijsen et al. (
The positive coping thoughts card contains 10 statements based on the positive reappraisal coping strategy. The PRCI group repeated the positive thoughts at least twice a day during the waiting period. The validity of the qualitative content of this trial was assessed as follows: after the preparation and translation of the questionnaires (demographic data and information related to infertility, daily monitoring forms, positive coping thoughts cards, and check list of problem solving skills) under the supervision and guidance of professors in counseling, the questionnaires were reviewed by seven experts and professors from the Mashhad University of Medical Sciences. The final tools used incorporated the necessary revisions suggested by the experts. The reliability of the beck depression inventory (α=0.83), GHQ28 (α=0.83), and daily monitoring form (α=0.74) were ascertained using Cronbach’s alpha. Infertile women who visited the centre to plan their IUI treatment and who fulfilled the inclusion criteria for the study were recruited into the trial. PSS sessions and the PRCI sessions were performed by the researcher after confirmation of the researcher’s ability by a specialized consultant with a Ph.D. in clinical psychology.
In first session in the PSS group, which was on days 2-3 of the menstrual cycle, we discussed infertility and the IUI treatment process, the research objectives and how to conduct the sessions, and the role of using PSS in dealing with the problems of life. The participants were then asked to write a list of problems that they have had during the course of their IUI treatment and determine the most important issue. In the second session, on days 9-12 of the menstrual cycle, the participants were asked to suggest solutions to their problems using a brainstorming method which they were taught in the session and prepare a list of the solutions that came to mind. During the third session, on days 14-15 of the menstrual cycle, the participants discussed the disadvantages and advantages of implementing the solutions arrived at in the second session. Following the discussion they made a list of the disadvantages and advantages of implementing each of the solutions and chose the best solution. The participants were also taught how to evaluate the effectiveness of a solution and advised of the possibility of returning to the previous step in case a solution was deemed to be ineffective. They were asked to implement this PSS in dealing with their daily problems during the waiting period, and record their efforts in the checklist for implementing PSS.
The first session of the PRCI group was held on days 2-3 of the menstrual cycle. We discussed infertility, the IUI treatment process, the research objectives, types of coping strategy, and the positive reappraisal coping strategy. The second session was held on days 9-12 of the menstrual cycle. In this session we explained the ten statements on the positive coping thoughts card using examples and showed participants how to complete the daily monitoring form. The Participants were then asked to repeat the positive coping thoughts at least twice a day during waiting period. Control group participants received the center’s routine care, and presented themselves at Milad Infertility Treatment Center on days 2-3, 9-12, and 14-15 of the menstrual cycle to undergo an ultrasonography and determine any remedial measures for the IUI treatment. The beck depression inventory was completed by all the three groups on the 10th day of the waiting period. Depression score means were compared between the three groups before the intervention and on the 10th day of the waiting period.
After collection and coding, the data were entered into the computer and analyzed using SPSS version 16, with P<0.05 considered statistically significant. The normality of the quantitative variables was determined using the Kolmogorov-Smirnov test. If the variables were normal parametric statistics were used, otherwise the non- parametric equivalent was used. Means, frequencies and standard deviations were used to describe the characteristics of the participants in each of the three groups. To compare depression between the three groups we used the ANOVA test and the paired t test for intra-group comparisons of depression if the data were normal. In the case of non-normal data the Kruskal-Wallis test and Wilcoxon tests were used.
Data were obtained from 34 individuals in the control
group, 34 individuals in the PSS group, and 35 individuals
in the PRCI group. Two individuals in the control
group and one individual in the PRCI group were excluded
from the study due to the cancellation of their
treatment program, and in the PSS group one individual
was excluded from the study due to the cancellation of
their treatment program, and one individual in the was
excluded due to her unwillingness to continue participating
in the research (
There was no significant difference between participants
in the three groups in terms of level of education
(P=0.853), the woman's occupation (P=0.364), cause of
infertility (P=0.824), experience of using assisted reproductive
techniques (P=0.410), and paying for the treatment
(P = 0.392,
According to the paired t test and comparison of mean
scores for depression in the two time intervals; before the
intervention and on the 10th day of the waiting period (a
within-group comparison), the mean score for depression
showed a significant decrease in the PSS group (P<0.001)
and PRCI group (P=0.002), and a significant increase in
the control group (P=0.007,
The stages of the intervention.
Descriptive statistics for infertile women undergoing IUI treatment in the three intervention groups: control, PSS, and PRCI group.
|Control n(%)||PSS n(%)||PRCI n(%)|
|Education level||Elementary school||7 (19.4)||4 (11.1)||2 (5.6)||X2=0.31|
|Middle school||5 (13.9)||6 (16.7)||4 (11.1)||df=2|
|High school||8 (22.2)||11 (30.6)||16 (44.4)||P=0.853a|
|University||16 (44.5)||15 (41.6)||14 (38.9)||-|
|Woman's occupation||Housewife||30 (83.3)||30 (83.3)||25 (69.4)||ExactX2=4.42|
|Office employee||5 (13.9)||5 (13.9)||6 (16.7)||P=0.364b|
|Student||1 (2.8)||1 (2.8)||5 (12.9)||-|
|Cause of infertility||Male factor||4 (11.1)||4 (11.4)||5 (16.7)||-|
|Female factor||10 (27.8)||14 (40)||16 (41.7)||-|
|Joint factor||9 (25)||8 (20)||7 (19.4)||ExactX2=3.01|
|Unknown factor||13 (36.1)||10 (28.6)||8 (22.2)||P=0.824b|
|Prior use of assisted reproductive techniques||None||17 (47.2)||20 (55.6)||19 (52.7)||-|
|IUI||14 (38.9)||9 (25)||13 (36.1)||-|
|IVF||0 (0.0)||0 (0.0)||1 (2.8)||ExactX2=0.39|
|Other||5 (13.9)||7 (19.4)||3 (8.4)||P=0.410b|
|Paying for treatment||Not at all||2 (5.6)||4 (11.1)||2 (5.6)||-|
|Low||6 (16.7)||8 (22.2)||4 (11.1)||X2=1.87|
|Relatively high||13 (36.1)||12 (33.3)||15 (41.7)||df=2|
|High||8 (22.2)||8 (22.2)||11 (30.6)||P=0.392a|
|Very high||7 (19.4)||4 (11.1)||4 (11.1)||-|
IUI; Intrauterine insemination, PSS; Problem-solving skills, PRCI; Positive reappraisal coping intervention, IVF; In vitro fertilization, a; Kruskal-Wallis, b; Fisher’s exact test, and df; degrees of freedom.
Comparing the mean and standard deviation of depression scores before the intervention and on the tenth day of the waiting period of the result of IUI treatment in the control, PSS, and PRCI groups
|Depression||Group||One-way ANOVA test result|
|Control Mean ± SD||PSS Mean ± SD||PRCI Mean ± SD|
|Before the intervention||17.38 ± 9.96||19.13 ± 8.67||18.55 ± 9.00||F=0.33 P=0.716|
|Tenth day of waiting period of IUI treatment||21.7 ± 11.42||12.52 ± 8.05||13.14 ± 9.7||F=9.29 P<0.001|
|Mean changes before the intervention and on the tenth day of waiting period of IUI treatment||-4.88 ± 9.46||5.94 ± 7.38||2.19 ± 10.17||F=15.87 P<0.001|
|Results of paired-t test||t=-2.867 P=0.007||t=4.286 P<0.001||t=3.278 P=0.002|
IUI; Intrauterine insemination, PSS; Problem-solving skills, PRCI; Positive reappraisal coping intervention, t; Statistics of the test, and F; Statistics of the test.
The ANOVA test results showed that there was no significant
difference in mean depression score between the three
groups (P=0.716) before the intervention. However, on the
10th day of the waiting period of the result of IUI treatment,
there were significant differences between the mean depression
scores of the three groups (P<0.001). The results of the
Tukey’s post hoc test showed that there were significant
differences in mean depression scores between the control
and the PSS group and also the control and the PRCI group
In the present study, depression increased in the control
group during the waiting period of the result of IUI treatment.
This is consistent with the results of studies conducted
by Boivin and Lancastle (
In our study, the mean depression score decreased in the
PRCI group and PSS group. But, in a study by Ockhuijsen
et al. (
In a study by Kordi et al. (
Despite the fact that infertility treatments are stressful,
infertile women expressed little desire to use the proposed
psychological interventions. The reasons mentioned were
as follows: fear of attending consultation sessions, loss of
personal privacy, the cost of consultation, and ineffectiveness
of the consultation process (
The PRCI is a new intervention based on positive reappraisal
coping strategies for medical waiting periods,
whose implementation does not need an in-person visit
to the advisor, and which is affordable (
Among the strengths of this study are the adaptability of the training sessions to the therapeutic program intended for the participants. A limitation of our study is that the trial was not double-blind, which introduces the possibility of observer bias. However, the fact that our findings are consistent with those of other studies in the field means that this is unlikely to have had a major impact on our results.
As the results of this study found the impact of PRCI and PSS on depression during the waiting period of the result of IUI treatment were the same, it is suggested both interventions can be used, if facilities are available, to help infertile women reduce the depression generated by the waiting period and increase their adaptability.