Received Date: June 25, 2014; Accepted Date: October 10, 2014; Published Date: October 17, 2014
Citation: Marzieh Kargar Jahromi, Somayeh Ramezanli (2015) Coping with infertility: An Examination of Coping Mechanisms in Iranian Women with Infertility . J Psychiatry 18:188. doi: 10.4172/Psychiatry.1000188
Copyright: © 2015, Jahromi et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Introduction: Due to increased global population and higher age of marriage, number of infertile couples is increasing. Prevalence of infertility is different in different countries. Some data shows that there are about 80 million infertile couples worldwide. In Iran estimations indicate that there are about two million infertile couples. Method: A systematic search was conducted to identify English language publications providing original data on infertility, psychological consequences and coping mechanism in infertile women. Result: For many couples, infertility is undeniably a major life crisis and psychologically stressful. The distress of infertility and its medical treatment is reported to affect different aspects of each partner's personal and the couple's life. First, the experience of infertility often leads to important boundary ambiguity within the relationship and family structure and increases feelings of anxiety, guilt, somatization and depression. Secondly, the diagnostic procedures and medical treatment frequently represent an unforeseen source of stress for the majority of couples undergoing it. Failure to cope with the stressful situation hampers females to reasonably thinking and problem solving coping strategy. The result show that with increasing psychological disorders symptom, the extent of emotional coping strategies will increase too. Infertile people use emotional coping strategies more due to lack of control on life events, low self-esteem, low social support and high level of stresses. Other studies showed that when an event have high level of threat, person evaluate it as more important issue, then attention will be focused on the emotions instead of the problem itself, then the person use emotional coping strategy more . Conclusion: With regard to the fact that certain coping strategies have different impacts on individuals' mental health, it is important to understand which forms of coping strategies are used more frequently by infertile women
Coping Mechanisms; Emotional; Global population
Cousineau, and Domar, indicates that infertility is a main problem in fertility health that has different physical, psychological and social dimensions . Due to increased global population and higher age of marriage, number of infertile couples is increasing. Prevalence of infertility is different in different countries. Some data shows that there are about 80 million infertile couples worldwide. In Iran estimations indicate that there are about two million infertile couples . Here is no precise information on the incidence of infertility in Iran, but, it is estimated that about 22% of Iranian women experience primary infertility . Infertility has been found to yield psychological and social consequences, and the female partner tends to be more adversely affected than her male counterpart . For many couples, infertility is undeniably a major life crisis and psychologically stressful [5,6]. The distress of infertility and its medical treatment is reported to affect different aspects of each partner’s personal and the couple’s life. First, the experience of infertility often leads to important boundary ambiguity within the relationship and family structure  and increases feelings of anxiety, guilt, somatization and depression [8-11]. Secondly, the diagnostic procedures and medical treatment frequently represent an unforeseen source of stress for the majority of couples undergoing it . Failure to cope with the stressful situation hampers females to reasonably thinking and problem solving coping strategy. The result show that with increasing psychological disorders symptom, the extent of emotional coping strategies will increase too. Infertile people use emotional coping strategies more due to lack of control on life events, low self-esteem, low social support and high level of stresses . Other studies showed that when an event have high level of threat, person evaluate it as more important issue, then attention will be focused on the emotions instead of the problem itself, then the person use emotional coping strategy more .
With respect to the fact that, ability to become fertile has a great significant, but also, so far, no research was done with the subject of importance of coping strategy in infertility women, Therefore in this review article we examine the psychological problem with infertility and how the infertile women cope with infertility?
This systematic review was performed in 2014 reviewing all studies published in Medline, ISI Web of knowledge and Scopus, as well as abstract books on this subject, regardless of the type of study, its publication status, language, sex of individuals, or treatment protocols. We also corresponded with the authors of cited references for more resources and references. The primary objective of this review was a systematic evaluation of coping strategy in infertility. Other emotional implications of infertility were included as a secondary objective. The research strategy involved general and specific terms in relation to couples’ infertility and their coping strategy including (emotional and problem based method) and "emotional consequence" in infertility. All manuscript titles generated by the data bases search were read. In addition, the bibliographies of retrieved manuscripts were searched for further references. Only publications accessible through Jahrom university libraries were considered for inclusion.
Psychological problem with infertility
Infertility is a major tension in life, imposes much stress on couples and can threat psychological health of them by effect on quality of married life, fear of possible divorce, decreasing intimacy, despair and depression or other psychological disorders like anxiety, irritability, lack of self-efficacy, sexual disorders etc. [15,16]. Psychological effects of infertility on life of infertile couple are concomitant with tensions between families and also dissatisfaction of their marriage [17,18]. Ghazanfari et al have found that psychic pressures and worries resulting from infertility have a direct effect on physiological functions of body which ultimately leads to a negative effect on fertility . Omoaregba et al indicated that the prevalence of probable psychological distress was significantly higher among the infertile group compared with their fertile counterparts (p<0.001) . Shaker et al. have the same idea, and mention that, compared with fertile women; infertile women have higher odds of self-reported depression . Substantial evidences point that problems resulting from infertility and inappropriate coping strategies might be a factor which helps exacerbate infertility .
Depression is one of the main psychological problems in infertile individuals, which has a noticeable impression on all aspects of their life . As Peterson et al have reported in their study, infertility stress which is linked with depression and psychological distress, can lead to premature dropout from medical treatments and unresolved feelings of loss and grief . Hariiyan et al. have found that 58% of 100 infertile women, to some extent, are suffering from depression . 25% of infertile women will get depression following IVF unsuccessful treatment . Infertile couples experience the resultant tension of depression individually and cooperatively. Such tension may lead to mental problems .
Ramezanzadeh has shown that, in comparison to fertile women, infertile women experience more anxiety and depression . Aghanwa et al. reported in their research that 7.29% of infertile women suffer from depression and anxiety disorder . In fact, psychological factors not only can cause infertility, but also can lead to different psychological issues .
For those dealing with fertility issues, in addition to the stressors related to the experience of involuntary childlessness itself, medical treatment is often additionally quite taxing. Care may involve multiple and invasive treatment cycles that are commonly unsuccessful, economically and personally draining, and generally without a clear endpoint in the absence of parenthood [27-29]. The relationship between stress and infertility forms a vicious circle in which they intensify each other. Infertile couples, who know they are the cause of infertility, blame themselves. This guilty feeling might increases the stress and make the problem worse . By development of infertility treatments and more complicated methods, stress will increase and may affect the results of treatment. Many similar studies have shown a significant relation between stress and the treatment results. Inflexible infertility treatment programs, long and time-consuming treatments, expenses and painful treatments (especially when they fail), all cause an intense stress in couples .
Psychological factors and difficulties coping with the emotional demands of treatment have been implicated in the high rates of treatment dropout [26-28]. For example, Hammarberg et alreported that women who did not become pregnant through assisted reproductive treatments (ART) cited psychosocial factors as principle reasons for discontinuation of medical treatment including having “had enough” (66%), “emotional costs” (64%), “not being able to cope with treatments” (42%), and “physical demands” (39%),.
Coping with infertility
Infertility as a psychological stressor can threat health of infertile people; but the extent of its effects is depended to cognitive and defense skills of people . It can be implied that any good or bad changes in life requires a type of further compatibility. Strategies to encounter these changes in life and the resultant tension vary in different individuals regarding different situations . Psychological health experts believe that the reaction of people in the stressful situations and also the level of stress that each event causes are influenced by different social and personal factors . Studies have often considered each variable in stress separately and noted mutual relations. There are many evidences [35,36] which show that personal coping methods, level of support, level of hope are important factors influencing the infertility stress. Author’s views in coping definition are arranged on a continuum with two opposite poles in two sides; in one hand it is believed that coping means how people overcome their problems  and in two other poles there is Folkman and Lazarus theory which defines coping stressful, regarding environmental conditions and environment management quality . Coping strategies are collection of one’s cognitive and behavioral efforts which are used to interpret, analyze, and reform a stressful condition, resulting in the reduction of its discomfort” .
Two main coping strategies are:
Emotional coping strategies, including efforts to set emotional consequences of stressful incident and keep the emotional and sentimental balance by controlling resultant emotions from stressful conditions.
Problem centered coping strategies including one’s effective acts with respect to stressful conditions, and is trying to remove or change the source of stress .
Dynamism is known as the common feature of problem-centered coping strategies. Dynamism provides requisite equipment's for active coping with stressful situations. This condition needs person’s all potential abilities for opposite coping and solving the problem, and increases his success probability .
Another feature of people who use problem-centered coping strategies is the low level of tension. On the other side, denial and passivity are two characteristics of those who ineffective emotion-centered coping strategies. Denial of stressful situations and inability to use potential abilities and initiative will cause the occurred problem left unsolved, which leads to dissatisfaction of the person .
Problem centered strategies
Social support demand: describes efforts seeking informational and emotional support. Available external sources function as barriers for people in stress processes. Some studies reported that a lack of social support can be a source of stress .
Social support is defined as the level of receiving kindness and companionship and attention of family members, friends and others . In mid 1970s, there was an increasing interest in studying the role of social support as an external coping source. Perceived social support as an effective source in stress process means that one can receive others' help if he/she needs it . Social support is consisted of those social sources which a person has perceived or been suggested . Perceived social support is one of the most common scales used for social support which is the perception of the person of the availability of others' support such as family and friends. Perceived social support signifies the cognitive evaluation of the availability and adequacy of support . The main function of the perceived social support is that mental evaluation and expecting support help the person to believe that he is respected and is part of a network of mutual duties . In coping with infertility, seeking social support is an important coping mechanism used by couple treated for infertility. In the process of seeking social support from friends and family, infertile couple sometimes has to reveal some confidential information of their life .
Personality type: Evidences show that personality is related to both stress and method of coping with stress [46,47]. For example, regarding the coping method, it is clear that people with different personality traits show different coping methods and different levels of vulnerability in experiencing a stressful situation [48,49]. Lazarys and Folkman emphasized that personality predicts the emotional reaction to stressful experiences by affecting the perception of threat or loss and the accompanying emotional and psychological reactions [50,51]. Personality predicts the stressful experiences of a person in different situations by means of a relation with the important collection of coping and evaluation [52,53].
Responsibility: accepting self-role in problem which is always accompanied by an effort to place everything in the right place.
Thoughtfully solving the problem: describes thoughtful problem-centered efforts for changing the situation which is followed by solving the problem.
Double positive evaluation: efforts which adds positive meaning by focusing on personal growth.
Encounter coping: describes aggressive efforts done to change the situation and has some levels of hostility and risk-taking.
Avoidance: cognitive efforts to make yourself alone and minimizing the importance of situation.
Continence: describes efforts which set one's emotions and actions.
Escape: describes dream thoughts and cognitive efforts in order to avoid the problem.
Many studies of coping with life stressors, including health problems, have found that women use more emotion-focused coping strategies than men. In parallel fashion, men report more instrumental or problem-focused coping efforts. Research has found that emotion-focused problem-solving is both less effective and leads to poorer mental health outcomes than problem-focused coping .
According to the theory of Dahlquist many researchers have argued that the effectiveness of a coping strategy is related to the duration and nature of the stressful situation . Avoiding strategies are more effective as a primary reaction to the cause of stress when the emotional arousal is high and the situation is out of control. In chronic cases, when alertness or taking action is needed, approaching strategies can be more effective. In a meta-analysis done by Jordan and Ronson, it has been shown that women use more emotion-focused coping method in case of their infertility . Peterson et al. investigated the relationships between specific coping strategies assessed by the Ways of Coping Questionnaire, infertility-specific stress, and depression. They observed that the Social Support Seeking (SSS) and Problem Solving (PPS) coping subscales were negatively related to infertility-specific distress and depression . In a study, Bento and his colleagues found that appraisal of high controllability was related to adopting active coping strategies. The use of more passive and less active coping strategies has also been found to be related to psychological distress in patients with chronic illnesses [57,58].
In some cultures and societies such as Iran, there is a relatively high pressure on women to have a child . In such cultures, children are an important source of social desirability. They represent the creation of family bonds that link individuals, couples and generations to each other . Therefore, infertility can have a devastating effect on women's mental health. With regard to the fact that certain coping strategies have different impacts on individuals' mental health, it is important to understand which forms of coping strategies are used more frequently by infertile women. This study highlights the importance of coping strategies in improving the mental health of women with fertility problem. The clinical interventions for infertile individuals may need to promote awareness about the usefulness of coping strategies