Document Type : Original Article
1 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
Infertility is medically defined as “the failure to achieve
a clinical pregnancy after 12 months or more of regular unprotected
sexual intercourse” (
Many of the phenomena studied by scientists in social
and behavioural sciences are dyadic in nature and include
research on man-woman dyads and parent-child dyads. The
observations that arise from such designs are interdependent
rather than independent; however, in this case, independence
refers to independence from dyad to dyad (
Most studies that investigate the relationships between
psychological distress and marital satisfaction in couples
with infertility use the individual as the unit of analysis.
Although valuable, these researches fail to show the impact
that partner distress has on individual marital satisfaction.
Since infertility is a shared problem, it is particularly relevant
to examine the impact of partner distress (
This was a cross-sectional study of a sample of couples
with infertility from Tehran, Iran. Patients were recruited
from the Infertility Treatment Centre of Royan Institute, a
referral centre for infertility treatment in Tehran, Iran (
The Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran, approved this study. The participants were informed of the aim of the study and were assured of confidentiality. After signing a consent form and agreement to participate, the couples with infertility completed the questionnaires.
The ENRICH Marital Satisfaction Scale (EMS Scale)
is a 10-item self-report instrument designed to measure
marital satisfaction (
The Perceived Stress Scale-4 item (PSS-4) is a short
form of the PSS that measures the degree to which situations
in one’s life over the last month are appraised as
unpredictable, uncontrollable, and overloaded. Each item
is scored on a 5-point Likert scale that ranges from 0
(never) to 4 (very often). Total scores range from 0 to 16,
with higher scores indicating higher levels of stress (
Comparison of demographics characteristics, perceived stress, and marital satisfaction for husbands and wives were made using the McNemar test and paired sample t test. Pearson’s correlation coefficient was used to examine the correlation among the study variables.
We used the APIM with distinguishable dyads to determine
the impact of husbands’ and wives’ perceived
stresses on their own marital satisfaction, as well as their
spouse’s marital satisfaction (
Actor-Partner Interdependence Model (APIM) of perceived stress and marital satisfaction.
Em; Actor effect of husband’s perceived stress on his own marital satisfaction, Em; Actor effect of wife’s perceived stress on her own marital satisfaction, Pfm; Partner effect of the husband’s perceived stress on his wife’s marital satisfaction, Pmf; Partner effect of the wife’s perceived stress on the husband’s marital satisfaction, Em and Ef; Residual errors on marital satisfaction for men and women, respectively, *; P<0.05, and ***; P<0.001.
Three different methods can be used to estimate the
APIM: pooled regression modelling, multilevel modelling,
and structural equation modelling (SEM). According
to Kenny et al. (
where Ym is the husband’s marital satisfaction, Yf is the wife’s marital satisfaction, Xm is the husband’s perceived stress, and Xf is the wife’s perceived stress. In the first equation, Em refers to the effect of the husband’s perceived stress on his own level of marital satisfaction (actor effect) and the partner effect, Pmf, is the effect of the wife’s perceived stress on her partner’s marital satisfaction. Since the dyad is the unit of analysis, the sample size in this analysis is the number of couples (n=141).
A useful attribute of SEM approach is that it allows
model constraints to be placed and tested in the APIM
framework. For example, this approach can test whether
the husband’s actor effect is equal to the wife’s actor
effect (Em=Em) and subsequently measure the degree to
which this constraint significantly worsens the model
In order to compute a chi-square difference test, the difference of the chi-square values of the two models (constrained and unconstrained) in question is taken as well as the difference of the degrees of freedom.
In the current study, all preliminary analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). APIM analysis was performed using Mplus software version 6.12 (Muthén and Muthén, Los Angeles, CA, USA).
The demographic and clinical characteristics of the
men and women dyads are presented in
As presented in
Perceived stress in husbands was correlated with both
their own marital satisfaction (r=-0.393, P<0.001) and
their wives’ marital satisfaction (r=-0.325, P<0.001). Perceived
stress in wives was also correlated with both their
own marital satisfaction (r=-0.469, P<0.001) and the husband’s
marital satisfaction (r=-0.319, P<0.001) (
Demographic and clinical characteristics of the men and women dyads (n=141 couples)
|Variable||Men||Women||Test statistic||P value|
|Age (Y)||34.92 ± 6.35||29.82 ± 6.00||t(140)=12.88||<0.001|
|Non-academic||96 (68.1)||85 (60.3)|
|Academic||45 (31.9)||56 (39.7)|
|Duration of marriage (Y)||7.37 ± 4.40||-|
|Duration of infertility (Y)||4.85 ± 3.76||-|
|Cause of infertility|
|Male factor||51 (36.2)||-|
|Female factor||30 (21.3)||-|
|Failure of previous treatment|
|History of abortion|
|Type of infertility|
Data are presented as mean ± SD and n(%).
Comparisons in marital satisfaction between men and women, and perceived stress (n=141 couples)
|Perceived stress||5.83 ± 2.80||6.33 ± 2.81||2.06||0.042|
|Marital satisfaction||39.31 ± 6.56||39.26 ± 6.70||0.09||0.925|
a; Test statistic. Values are presented as mean ± SD.
Correlations among predictors and outcomes in dyads for men and women (n=141 couples)
|1 Perceived stress in males||1|
|2 Marital satisfaction in males||-0.393||1|
|3 Perceived stress in females||0.462||-0.319||1|
|4 Marital satisfaction in females||-0.325||0.423||-0.469||1|
All correlations were significant at the 0.001 level.
According to Table 4 the results for the APIM indicated that the husband’s perceived stress as well as the wife’s perceived stress exhibited an actor effect on their marital satisfaction (ß=-0.312, P<0.001, ß=-0.405, P<0.001, respectively). With regard to partner effects, only the woman’s perceived stress had a partner effect on the husband's marital satisfaction (ß=-0.174, P=0.040). Although the partner effect of the husband’s perceived stress on the wife's marital satisfaction was not significant (ß=-0.138, P=0.096), women whose husbands had higher levels of stress were more likely to have poorer marital satisfaction.
We used the equality constraint tests to compare actor
effects as well as partner effects for men and women by
examination of the chi-square difference test. Constraining
the actor effects to be equal did not significantly worsen the
model fit ((χ2(
Actor and partner effects of perceived stress on marital satisfaction in couples with infertility (n=141)
|β (95% CI)||ta||P value||β (95% CI)||ta||P value|
|Actor’s stress||-0.31 (-0.48, -0.15)||3.77||<0.001||-0.41 (-0.56, -0.25)||5.22||<0.001|
|Partner’s stress||-0.17 (-0.34, -0.01)||2.05||0.040||-0.14 (-0.30, 0.02)||1.67||0.096|
a; Test statistic.
To the best of our knowledge, this study is the first of its kind to use the APIM to examine the impact of actor and partner stress on marital satisfaction in a sample of couples with infertility. Although the majority of researches that have examined psychological distress and marital satisfaction both in infertile and fertile couples assessed the actor effect of stress on marital satisfaction, there are increasing calls to investigate the partner effect of these variables. Since infertility is a shared problem within the couple, both men and women need to be involved and considered as a dyad.
As expected, perceived stress among the wives was
higher than their husbands, which suggested that women
tend to perceive stressful life events as less controllable
than men and generally seem to be more affected in terms
of negative life consequences. Another explanation for
this difference could be that generally, particularly in Iran
or Middle Eastern countries, childbirth is considered the
women's duty and infertility is considered a disease in
women. The burden of infertility is mostly on women.
This result has supported the findings of previous studies
The current study has found the actor effect of perceived
stress on marital satisfaction. In other words, the greater
level of stress that is perceived by either men or women
contributes to lower marital satisfaction for themselves.
This is in line with a study of patients with infertility in
France, in which the predictive effects of infertility-related
stress on both emotional and marital distress have
been confirmed (
The most important finding of the current study was the link between an individual’s perceived stress and their partner’s marital satisfaction. In accordance with our expectation, we found that a woman’s perceived stress negatively impacted the man’s marital satisfaction. Contrary to our expectation, our study did not confirm a strong partner effect of a man’s perceived stress on marital satisfaction, although the impact of the husband’s perceived stress on his wife’s marital satisfaction was marginal.
Our results indicated that the actor effects and partner effects of perceived stress on the marital satisfaction were similar for both men and women. Although the levels of perceived stress differed between men and women, the associations between stress and marital satisfaction were not substantially different between them. This finding might indicate that both members of couples with infertility share a similar mechanism through which perceived stress influences marital satisfaction.
This study has several limitations that should be considered when interpreting the results. First, the generalizability of the results might be affected by the fact that it was a single-centre study with a relatively small sample size. Second, because of the cross-sectional nature of the study design, causal inferences could not be made. In addition, this study relied on self-reported data that might be prone to social desirability bias. Despite these limitations, this study has provided valuable information regarding the actors and partner effects of perceived stress on marital satisfaction in men-women dyads that experience infertility.
The findings demonstrate that partner effects are present in couples with infertility and support the idea that a person’s perceived stress can impact his or her partner’s marital satisfaction. Psychological interventions that target a reduction of perceived stress and enhancement of marital satisfaction in the context of infertility should treat the couple as a unit.