Document Type : Original Article
Authors
1 Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran
2 East Nursing and Midwifery Research Center, Birjand and Midwifery College, Birjand University of Medical Sciences, Birjand, Iran
3 Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
Abstract
Keywords
As a natural stage of life and one of the most important
aims of each marital bond, fertility, reproduction and
breeding are considered the basis of human survival (
Infertility is a common clinical problem which, as estimated by the World Health Organization (WHO), has
affected about 60 to 80 million couples all over the world
and its prevalence is estimated to be around 10 to 15%,
worldwide. Meanwhile, this problem is more prevalent
in developing countries (
Having the features of a traumatic event including the
length of time, complicated condition, unpredictability
and uncontrollability, infertility creates a full-scale crisis
in the lives of infertile couples, and has been described as
a global health problem with physical, mental and social
dimensions (
The person who is not able to have children or experi.
ence the natural reproduction process is called “infertile”
and this may trigger psychological problems especially in
the Iranian culture where parents and relatives have a key
role in the couple’s life; under this condition, infertility
can be considered as one of the worst experiences of life
(
Most Iranian infertile couples face a type of stigma and
consider themselves as a misfit in the community due to
the inability to have their own children (
Adjustment to infertility refers to changing the viewpoint
and attitude of an infertile person towards infertility
problems, treatments and possible outcomes. Fertility
Adjustment Scale (FAS) was introduced by Glover et al.
(
In this scale, adjustment is defined as an appropriate
management of behavioral, mental and emotional responses
to infertility (
After evaluation of the validity and reliability of this
scale, it has been used for investigating the psychological
consequences of infertility treatment in infertile couples
(
This is a cross-sectional study conducted on 40 infertile and 40 fertile women (with or without children) in Birjand, east of Iran from November 2016 to January 2017. Fertility/infertility was diagnosed by a gynecologist, and the participants were selected from the available subjects who completed the FAS.
Given that there has been no similar study in Iran, and
the desirable conditions for conducting the pilot study
were not known, hence the sample size was estimated
with a sensitivity of 0.85 and a specificity of 0.70. Also,
as there was no infertility center in the city of Birjand,
the patients and healthy subjects (women with a history
of having children) were selected from those referring to
obstetricians’ clinics. The inclusion criteria involved being
infertile, completion of the informed consent for participation,
being within the age range of 18-45 years and
having the ability to read and write. According to previous
studies (
In the present research the terms, adjustment, fertility and infertility were selected as the search keywords. Documents were obtained from scientific databases such as PubMed, Science Direct, Medline, Embase, Scopus and Google Scholar as well as Persian electronic resources namely, SID, Irandoc, Iran-Medex and Magiran. One of the main aims of this step was to examine the possibility of existence of a Persian version of this scale, but no such version was found.
Translation and back-translation method was used in
this step (
In order to evaluate the face and content validity of
the tool, the translated draft was handed to 2 obstetricians,
3 nursing experts and 4 gynecologists working
in the Faculty of Medicine and Faculty of Nursing and
Midwifery. In order to determine the content validity of
the questions of the above mentioned questionnaire, the
experts group was asked to judge the suitability of every
question based on a 3-point Likert scale. Then, using the
face and content validity indicators, the beneficial questions
were selected. At this point, the content validity
ratio (CVR) was calculated for each statement by the
following equation (
Where, ne is the number of the experts who considered
the question as necessary and N is the total number of the
experts. The obtained value for each question was then
compared with the Lawshe Table criterion for 9 experts
which equaled to 0.77 (
EFA was utilized for evaluating the presence of possible
subscales and the construct validity, using the
principal component analysis and varimax orthogonal
rotation. In this procedure, before performing the
exploratory factor analysis, the Kaiser-Meyer-Olkin
(KMO) index was evaluated and Bartlett test was done.
The EFA can be performed if the KMO index is >0.5
and the Bartlett test P value is <0.05. In addition, the
explained variance indicators (>0.6), eigenvalues (>1)
and rotated factor loadings (>0.4) were used for selecting
the components (
Reliability of the questionnaire in terms of internal consistency
was assessed using Cronbach’s alpha coefficient.
This index ranges from 0 to 1, and values close to 1 indicate
better reliability. Cronbach’s alpha of more than >0.7
reflects a good internal reliability (
Fertility adjustment questionnaire was developed in
1999 by Glover et al. (
The demographic information checklist included the following variables: age of patients, job of patients, length of marriage, length of infertility, length of treatment, age of mates and job of mates. These variables were compared between the two fertile and infertile groups, using Chi-square and Mann-Whitney tests.
The Ethics Committee of Birjand University of Medical
Sciences approved the present study (approval
No. IR.BUMS.REC.1395.210). Afterwards, written informed
consent was obtained from each patient, showing
that the participants were recruited voluntarily and
with full knowledge and could quit the study at any
time and this would not have an impact on their treatment
process. Moreover, they were informed that the
information will be reported in a general manner, without
revealing the patients’ personal information. Also,
the written authorization was obtained from Glover et
al. (
The collected data were entered into the SPSS software, version 18 (SPSS, Inc., Chicago, IL, USA). The mean, standard deviation, percentage and indicators of reliability and validity were assessed. Moreover, normality of the demographic variables was examined, using Kolmogorov- Smirnov test, and non-parametric tests were used for comparing the two groups.
A total of 80 patients divided into two groups of 40 fertile
or infertile subjects who completed the FAS questionnaire.
The mean (± SD) of demographic and clinical variables
is reported in
Demographic and clinical variables
| P value | Fertile n=40 Mean (SD) | Infertile n=40 Mean (SD) | Variable | |
|---|---|---|---|---|
| Age of patients (Y) | 28.6 (1.0) | 27.6 (1.0) | 0.487 | |
| Age of mates (Y) | 32.1 (0.8) | 31.4 (0.9) | 0.592 | |
| Length of marriage (Y) | 5.5 (0.6) | 5.3 (0.8) | 0.903 | |
| Length of infertility (Y) | 3.2 (0.4) | -- | -- | |
| Lenght of treatment (months) | 18.7 (3.3) | -- | -- | |
| Job of patients | n (%) | n (%) | ||
| Housewife | 34 (85.0) | 25 (62.5) | 0.020 | |
| Employee | 5 (12.5) | 6 (15.0) | ||
| University student | 1 (2.5) | 9 (22.5) | ||
| Job of mates | ||||
| Employee | 9 (22.5) | 17 (42.5) | 0.116 | |
| Self-employed | 24 (60.0) | 21 (52.5) | ||
| Worker | 7 (17.5) | 2 (5.0) | ||
Explanatory factor analysis
| Item number and descriptor | Factor loading | Eigenvalue | Percentage of variance | Cumulative (%) |
|---|---|---|---|---|
| Factor 1 | ||||
| 5. I have made plans for a possible future life without a child* | 0.72 | 2.80 | 23.55 | 23.55 |
| 6. I will always feel unfulfilled if I am unable to have my own child | 0.64 | |||
| 7. I think I could adjust to a future life without a child* | 0.66 | |||
| 8. I am sure that I can continue my normal life activities* | 0.76 | |||
| 10. I think life could be rewarding either with or without children* | 0.69 | |||
| Factor 2 | ||||
| 1. I will continue with investigations/treatment until I succeed in having a child | 0.73 | 1.3 | 16.62 | 40.17 |
| 3. I cannot plan for the future until I know for certain whether or not I can have a child | 0.40 | |||
| 4. I want a child of my own more than anything else in life | 0.72 | |||
| Factor 3 | ||||
| 2. There are both advantages and disadvantages to having a child* | 0.82 | 1.1 | 11.80 | 52.06 |
| 9. I cannot imagine a future without a child | 0.51 | |||
Content validity was examined using CVR and the obtained
values for the questions were in the range of 0.7
to 0.8. Construct validity was assessed using EFA. The
results showed that the KMO index was about 0.68, Bartlett’s
Chi-Square test result was 126.0, and the P value
was less than 0.001. The results indicated the sufficiency
of samples to perform this procedure. A total of 3 eigenvalues
was more than 1, which justifies approximately
52.0% of the cumulative variations. Since the orthogonal
varimax rotation method was utilized, factors with non-
shared components were identified. All factor loadings
were greater than 0.3. The first factor involved questions
5, 6, 7, 8 and 10; the second factor involved questions 1, 3
and 4; and the third factor involved questions 2 and 9, as
explained in Table 2. The correlation coefficient between
the first factor and the second and third factors were 0.12
and -0.02, respectively, and the correlation coefficient between
the second and the third factors was -0.01. Spearman’s
correlation coefficient showed no significant relationship
(
Reliability of the tool was evaluated using two methods. First, the correlation between the statements and the total score was evaluated and the statements with low insignificant correlations were excluded. In the second method, a Cronbach’s alpha coefficient value was utilized to show the internal consistency of the tool. According to the first method, statement 7 had low correlation (0.14) with the fertility adjustment total score which was not statistically significant. Besides, Cronbach’s alpha coefficient value for the questionnaire was 0.62, which was promoted to 0.65 after eliminating statement 7. Following the elimination of statement 4, Cronbach’s alpha value increased to 0.68, which is close to the 0.7 criteria.
The mean (± SE and range) of fertility adjustment total
scores in the infertile group and the control group were
43.2 (1.2 and 27-57) and 42.3 (1.5 and 18-57), respectively
(P=0.623). Also, the mean (SD) of each of the statements
for the infertile group is reported in
Mean ± SE item scores and item-to-total correlations for the Total score of Fertility Adjustment Scale
| Item | Mean (SE) | Item to total correlation |
|---|---|---|
| 1. I will continue with investigations/treatment until I succeed in having a child | 5.7 (0.1) | 0.40 |
| 2. There are both advantages and disadvantages to having a child* | 2.6 (0.2) | 0.26 |
| 3. I cannot plan for the future until I know for certain whether or not I can have a child | 3.8 (0.3) | 0.43 |
| 4. I want a child of my own more than anything else in life | 5.3 (0.2) | 0.44 |
| 5. I have made plans for a possible future life without a child* | 4.8 (0.2) | 0.43 |
| 6. I will always feel unfulfilled if I am unable to have my own child | 4.7 (0.2) | 0.76 |
| 7. I think I could adjust to a future life without a child* | 4.9 (0.2) | 0.52 |
| 8. I make sure that I carry on with my normal life activities* | 3.8 (0.3) | 0.70 |
| 9. I cannot imagine a future without a child | 4.4 (0.3) | 0.61 |
| 10. I think life could be rewarding either with or without children* | 2.8 (0.3) | 0.63 |
*; Reverse-scored
Correlation of demographic and clinical variables with Total score of Fertility Adjustment Scale
| Item | Correlation coefficient | P value |
|---|---|---|
| Age of patient | -0.11 | 0.325 |
| Job of patient | -0.06 | 0.548 |
| Age of husband | -0.12 | 0.275 |
| Job of husband | 0.008 | 0.941 |
| Marriage time | -0.03 | 0.782 |
| Infertility time | 0.12 | 0.447 |
| Treatment time | 0.10 | 0.520 |
Infertility creates a full-scale crisis in infertile couples
lives, and it has been described as a global health problem
with physical, mental and social dimensions. Having
a tool for evaluation of the maladjustment of spouses
with respect to pregnancy is of great importance. This
useful tool can be used to measure the maladjustment of
infertile women or men (
Evaluation of the correlation of each item with the total
adjustment score using Cronbach’s alpha coefficient
showed that by eliminating the two questions of "I cannot
talk to my husband about the possibility of not having
a baby" and "I feel like I am losing my life month by
month", the reliability of the tool reached the acceptable
level of 0.68 and finally we had a 10-question 3-component
reliable scale for measuring the adjustment to infertility.
Arsalan and OKUMUS (
Due to the time constraints and lack of sufficient human resources, it was not possible to collect data from all patients. Almost all participants in this study completed the questionnaire. The subjects were recruited from patients referring to specialists’ offices; hence, it can be said that our subjects formed a representative sample.
Considering the problems faced by infertile couples and the Iranian culture unique features on the issue, nowadays, the consequences of infertility have attracted special attentions, and tools like FAS can be useful for evaluating the psychological problems caused by infertility. Based on the obtained CVR for different items and the conducted exploratory factor analysis, this tool can be considered a valid scale for screening individuals referring to clinics for receiving psychological counseling on infertility problems. As a clinical tool, it can be the starting point for the couples’ psychotherapy sessions, which somewhat specifies the way they look at the infertility issue.
In this pilot study, the infertility adjustment tool was given
to 80 patients in two groups of 40 fertile and 40 infertile
women. The results showed that in the infertile women
group, no significant correlation was observed between the
fertility adjustment total score and the patient’s age, age of
the mate, length of marriage, length of infertility (year), and
length of treatment (month). Furthermore, no relationship
was observed between the fertility adjustment total score
and the job of patients and job of mates. Lack of relationship
between this score and the mentioned demographic
variables indicated that this scale is indeed a useful tool
for measuring the psychological adjustment. Results were
similar to those reported by Arsalan and OKUMUS (
Further clinical studies on larger population are needed to standardize the information obtained by using this tool in different medical centers. It is suggested that this questionnaire should be used in infertility treatment centers as the first step to provide the couple’s with a better understanding of each other’s point of view, and also an initial screening for the physician and health care team to understand psychological status of patients.
The results of this study revealed that Persian infertility adjustment scale is an appropriate tool for the analysis of psychological reactions towards infertility problems and the consequences of treating this social-clinical problem.
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