Psychosocial, treatment, and demographic predictors of the stress associated with infertility*

Transcription

1 FERTILITY AND STERILITY Copyright" 1992 The American Fertility Society Vol. 57, No. 1, January 1992 Printed on acid-free paper in U.S.A. Psychosocial, treatment, and demographic predictors of the stress associated with infertility* Antonia Abbey, Ph.D.t:l: L. Jill Halman, Ph.D.* II Frank M. Andrews, Ph.D.* II Wayne State University, Detroit, and Institute for Social Research and School of Public Health, The University of Michigan, Ann Arbor, Michigan Objective: To determine which psychosocial, treatment, and demographic factors relate to the amount of perceived stress that infertile women and men experience. Design: A cross-sectional, structured interview research design was used. Setting: In-person interviews were conducted in study participants' homes. Participants: Wives and husbands from 185 couples in Southeastern Michigan with primary infertility were studied. Main Outcome Measures: A nine-item rating scale of perceived stress associated with infertility was the outcome measure. Results: For both women and men, stress was significantly positively correlated with treatment costs and number of tests and treatments received; stress was significantly negatively correlated with confidence that one will have a child and perceived control. For women only, attitudes about infertility treatments, importance of children, attributions of responsibility to physicians, and social support also significantly related to perceived stress. For men only, income, number of physicians seen, and self attributions of responsibility also significantly related to perceived stress. Conclusions: As hypothesized, a variety of treatment characteristics and psychosocial factors were related to experienced stress. Contrary to expectation, demographic factors such as age and number of years married were not related to experienced stress. This study's results suggest that attempts by health care providers to increase patients' sense of control, optimism (within realistic limits), and social support should reduce stress. Fertil Steril 1992;57:122-8 Key Words: Stress, gender differences, treatment characteristics, psychosocial factors, infertility Clinicians and researchers consistently report that infertile couples view their status and treatment as extremely stressful (1-7). Parenting is viewed by Received April 18, 1991; revised and accepted September 11, *Supported by grant R01 HD from the National Institute of Child Health and Human Development, Bethesda, Maryland. t Department of Community Medicine, Wayne State University. ~Survey Research Center, Institute for Social Research, University of Michigan. Reprint requests: Antonia Abbey, Ph.D., Department of Community Medicine, School of Medicine, Wayne State University, 4201 Saint Antoine, Detroit, Michigan II Department of Population Planning and International Health, University of Michigan. 122 Abbey et al. Stress and infertility most Americans as a central life role, and the thought of not achieving it can be very upsetting ( 4, 8). Women, in particular, traditionally have been raised to view motherhood as their primary adult role. Many infertile women say that they cannot imagine a life that does not include children and that their childless status makes it difficult to maintain friendships with other women who have children (9). Several authors have found that infertile husbands were less disappointed than their wives were at the thought of not having children (10, 11). Infertility medical tests and treatments are also highly stressful (3, 4). The initial medical interview focuses on the couple's sexual performance and history including frequency of sexual intercourse, premarital and extramarital relationships, previous

2 pregnancies including abortions and miscarriages, attitudes about sex, and usual sexual practices (2). As Keye (2) observed, "such questions may be seen by the patient as threatening, embarrassing, intrusive, demeaning, and even inappropriate" (p. 761). Side effects from medication, recovery from surgery, time loss at work because of frequent physicians' appointments, and the high financial costs of infertility treatments have all been described as stressful by members of infertile couples (4). Although infertility is stressful for most individuals, it is clear from the literature that infertility is more devastating for some individuals than for others. The perspective of Folkman et al. (12) on stress and coping helps explain individual differences in perceived stress. As Folkman and her colleagues observed (12), appraisal moderates the relationship between events and experienced stress. Individuals ask themselves the question "Am I in trouble?" (12), and their answer to that question determines if the event is perceived as benign, harmful, threatening, or challenging. Stress should be high only when the situation is perceived as harmful or threatening, and the individual feels she or he has insufficient resources to cope effectively. Based on previous infertility and psychosocial research, there are a host of personal and social factors that are hypothesized to influence how infertile individuals appraise their situation. The relationships between the perceived stress associated with infertility and demographic (age, number of years married, income), treatment (number of years trying, physicians seen, tests and treatments received), and psychosocial variables (importance of children, confidence, perceived control, attributions, social support) were explored in a study of 185 infertile couples. Men's and women's data were analyzed separately so that gender differences in the predictors of stress could be examined. MATERIALS AND METHODS Study Participants Separate in-person interviews were conducted with both wives and husbands in 185 couples (370 individuals). Couples with primary infertility were principally recruited from infertility specialists. All but one of the major infertility practices in Southeastern Michigan agreed to collaborate with this study. Eighty-one percent of the eligible nominees participated in the study (n = 170). Eligibility criteria were as follows: (1) married; (2) no previous children by either member of couple; (3) have not tried in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT); (4) white; and (5) middle class (defined as having a high school income and 1987 household income in the range of $20,000 to $100,000). Only childless couples were included because the stress associated with infertility may differ for couples with and without children. Patients who had tried IVF and GIFT were omitted because at the time these were considered treatments of last resort, and for the broader purposes of this study, patients who were relatively early in the treatment process were desired. White, middle-class couples were used because this is the sociodemographic profile of couples most likely to seek treatment for infertility (13). Having a relatively homogeneous group of respondents allows more sophisticated analyses to be completed with a smaller number of cases. Fifteen infertile couples were recruited from nonmedical sources. Four couples came from RESOLVE (a self-help group for infertile individuals); 5 couples came from the Endometriosis Association (a selfhelp and information group for individuals with endometriosis); 1 couple came from newspaper advertisements; 1 couple came from a referral from a study participant; and 4 couples came from marriage license applicants. Eighty-seven percent (n = 162) of the infertile couples included in this study met the standard medical definition of infertility which is 1 year of unprotected sexual intercourse without conceiving or carrying a child to term. The remaining 23 couples had been trying to conceive a child for <1 year (7 months on average) but were being treated by an infertility specialist. Sometimes individuals with known physical problems related to infertility (e.g., endometriosis) or with wives older than age 35 will seek and receive treatment before 1 year has elapsed. Procedures Patients who fit this study's eligibility criteria were asked by their physician if they were willing to participate in a university study of marriage, family, and childbearing issues. To supplement the sample, midway through the recruitment period selfhelp group members were recruited through an article printed in their organization's monthly news letter, and advertisements were placed in several local newspapers. Study participants were sent a letter asking if they knew of any eligible couples who would be interested in participating. A sampling of the previous year's marriage license applicants from the county in which most study participants lived was also sent a letter inviting them to participate. Vol. 57, No. 1, January 1992 Abbey et al. Stress and infertility 123

3 Couples who agreed to participate were sent a brochure describing the study and then they were contacted by a professional interviewer from the Survey Research Center at the University of Michigan. Separate 1-hour, in-person interviews were conducted with each member of the couple. Husbands and wives were usually interviewed on the same day, and neither was able to hear the other's responses. The ethical guidelines of the American Psychological Association were followed throughout the study. Although the words infertile and infertility are used in this paper, these words were not used with the couples who participated in the research. Pilot testing indicated that the term infertile connoted a sense of finality that the study participants found unsettling. Instead, in the interview the term fertility problem was used. Demographic Profile of Study Participants Table 1 provides a summary of the demographic characteristics of these infertile couples. The infertile women interviewed for this study ranged in age from 22 to 42. The infertile men ranged in age from 23 to 44. These couples had been married for a mean time of six years. The mean annual1987 household income reported by these couples was in the range of $40,000 to $49,999. Men averaged 3 years of college education and women averaged 2! years of college education. Ninety-nine percent of the men and 92% of the women were active participants in the labor force. Approximately 40% of the men reported being Catholic, 30% were Protestant, 7% were Jewish, and 20% had no religious preference. (The remaining 3% had another religious preference.) Approximately 46% of the women were Catholic, 35% were Protestant, 6% were Jewish, and 11% had no religious preference. (The remaining 2% had another religious preference.) Couples had been trying to have a child from 3 months to 6 years; the mean length of time trying was 2! years. These couples had seen one to six physicians about their fertility problem. The mean number of physicians seen was 2.4. As discussed in the literature, wives had received significantly more tests and treatments than had their husbands (see Table 1). Measures The scales and items discussed in the analyses reported in this paper are described here. Indicators of stress, sociodemographics, treatment character- Table 1 Demographic Profile of Study Participants Women Men (n = 185) (n = 185) Age (y) Length of time married (y) 6 6 Education (y) 2.5 of college 3 of college Household income ($) 40,000-49,999 40,000-49,999 Length of time trying to have a child (y) No. of physicians seen No. of tests received No. of treatments received Paired t (184) = 10.62, 11.19, P's < istics, attitudes about treatment and children, perceived control, attributions, and social support are included in this report. Fertility Problem Stress A series of nine questions assessed the amount of stress and disruption the fertility problem had produced overall and in various domains of respondents' lives during the last 12 months. Three items assessed overall stress (experienced disruption, life change, and stress). The remaining six items referred to specific life domains (physical health, mental health, marriage, sex life, finances, relations with others). These domains were selected based on previous research and pilot interviews with infertile couples. These items were answered using 5-point, Likerttype scales with response options that ranged from none at all to a great deal. Cronbach's coefficient alpha was Sociodemographics Respondents were asked their year of birth and marriage. They were also asked to report their total household income in 1987 (the data was collected in 1988) using an 8-point scale with categories ranging from <$15,000 to >$75,000. Previous and anticipated fertility treatment expenses (not covered by health insurance) were separately assessed on 6- point scales with code categories ranging from <$100 to $10,000 or more. Treatment Characteristics Respondents were asked how long they had been trying to have a child and how many physicians they had seen about their fertility problem. Respondents were read a list of common infertility tests and asked how many times they had received each. They were also read a list of common treatments and asked if 124 Abbey et al. Stress and infertility

4 they were using each one now, had used it in the past, or had never used it. Men's and women's lists of treatments had some common items (e.g., artificial insemination with husband's sperm requires participation from both husband and wife) and some different items (e.g., surgery for a varicocele for men; surgery for endometriosis for women). The number of tests and treatments received were separately summed. Attitudes About Infertility Treatments Respondents' attitudes about 11 common infertility treatments were assessed on 5-point Likerttype scales with response options ranging from strongly opposed to personally using if needed to strongly in favor of personally using if needed. Based on factor analyses, four factors emerged. This paper will focus on the 4-item factor that included items on the use of donor sperm and surrogacy arrangements because these are the types of interventions that people find most controversial (14, 15). This scale had a Cronbach alpha of Children Using a 5-point, Likert-type scale, respondents were asked how confident they were that they (or their wife) would bear a child of whom they both were the biological parents. A three-item importance of children scale was developed to assess the value of children and parenting to respondents (e.g., it's hard for me to imagine a life without children). Responses were made on 5- point, Likert-type scales with options that ranged from strongly disagree to strongly agree. The Cronbach alpha was Perceived Control A five-item perceived personal control scale was developed by the research team based on previous research (16). Responses were made on 5-point Likert-type scales with response options ranging from strongly disagree to strongly agree. This scale had a Cronbach alpha of Attributions of Responsibility Respondents were asked about the extent to which they thought that they, their spouse, and their physician were responsible for their fertility problem. Answers were made on 5-point, Likert-type scales with response options that ranged from not at all to extremely. Vol. 57, No.1, January 1992 Social Support A four-item short form of Sarason and co-workers' (17) satisfaction with social support measure was used. It assessed study participants' overall satisfaction during the past 12 months with the social support available to them from network members. Respondents rated how satisfied they were with how much they could count on others to accept, care, console, and relax them using 5-point, Likert-type scales with response options ranging from very dissatisfied to very satisfied. The Cronbach alpha was Bivariate Analyses RESULTS Table 2 presents Pearson's product-moment correlation coefficients between fertility problem stress and the psychosocial, treatment, and demographic variables described in the measures section. Results are presented separately for women and men. Considering first the sociodemographic variables, age and number of years married were uncorrelated with fertility problem stress for women and men. Income was significantly negatively correlated with fertility problem stress only for men. The greater the household income, the less fertility problem stress men experienced. Past and future treatment costs were positively correlated with fertility problem stress for both sexes. The greater the treatment costs, the more stress women and men experienced. Past costs were a stronger correlate for women, whereas future costs were a stronger correlate for men. Contrary to prediction, the length of time people had been trying to have a child was not significantly correlated with fertility problem stress. The number of physicians seen for the fertility problem was significantly positively related to stress only for men. The number of infertility tests and treatments were significant predictors of fertility problem stress for both women and men. Attitudes about infertility treatments involving donors and surrogates were significantly negatively related to fertility problem stress for women. That is, the more women were opposed to these interventions, the greater their fertility problem stress, presumably because they were concerned that these strategies might be their only options for having a child. For both women and men, the more confident they were that they would be able to bear a child biologically related to both of them, the lower their fertility Abbey et al. Stress and infertility 125

5 Table 2 Correlations Between Fertility Problem Stress and Psychosocial Variables Separately for Women and Men Fertility problem stress and: Women Men Age No. of years married Income a Past treatment costs 0.24a 0.19a Anticipated future treatment costs b How long trying to have a child No. of physicians seen a No. of tests received 0.32b 0.26b No. of treatments received 0.23a 0.26b Attitudes about infertility treatments (AID and surrogacy) -0.24a Confidence one will have a child -0.27b -0.33b Importance of children 0.24a 0.11 Perceived personal control -0.52b b Attributions of responsibility to self a Attributions of responsibility to spouse Attributions of responsibility to physicians 0.23a 0.18 Satisfaction with network social support -0.30b a P < b p < problem stress. For women only, the more important children were to them, the greater their fertility problem stress. Perceived personal control was the strongest correlate of fertility problem stress for both sexes. Increased perceived control was significantly related to decreased stress. Attributions of responsibility to the self were significantly positively correlated with fertility problem stress for men, whereas attributions of responsibility to the physician were significantly positively correlated with fertility problem stress for women. Attributions of responsibility to one's spouse were unrelated to stress. Satisfaction with network social support was significantly correlated with fertility problem stress for women. The greater the social support satisfaction, the lower the fertility problem stress. Multiple Regression Analyses Multiple regression analysis was used to examine the combined effects of demographic, treatment, and psychosocial factors on fertility problem stress. Those variables in Table 2 significantly related to fertility problem stress for either men or women were included as predictor variables. A series of analyses was conducted, gradually eliminating variables, until all the predictors in the equation had significant betas. Again, analyses were completed separately for women and men. As can be seen in Table 3, the set of predictors that emerged for women and men was somewhat different. For both sexes, personal control and confidence one will have a child were significant negative predictors of fertility problem stress. For women, the importance of children, the number of tests received, and attributions of responsibility to the physician were also significant positive predictors of stress. For men, the number of physicians seen, future treatment costs, and income were also significant predictors of fertility problem stress. These predictor variables explained more than one third of the variance in fertility problem stress for both women and men. DISCUSSION Several caveats are necessary before the implications of this study's results are described. First, the infertile couples interviewed for this study were not randomly sampled; instead, they were primarily white, middle-class, married couples seeking treatment from an infertility specialist. Descriptive information was provided about study participants to document the types of people to whom these results might generalize. Second, although it is assumed that the personal and social variables described in this study are causal predictors of fertility problem stress, such a conclusion cannot be made with cross-sectional data. Two additional annual waves of data are being collected. When multiple waves of data are available, causal direction will be easier to determine. Some of these relationships are expected to be bidirectional. For example, as described in this paper, infertile indi- Table 3 Multiple Regression Analyses Predicting Fertility Problem Stress Separately for Women and Men Predictors of fertility problem stress for women Personal control Confidence one will have a child Importance of children No. of tests received Attributions of responsibility to physician Predictors of fertility problem stress for men Personal control Confidence one will have a child No. of physicians seen Future treatment costs Income a p < O.Ql. b p < Beta -0.40a -0.13b 0.16a 0.19a 0.12b R 2 = a -0.22a 0.16b 0.27a -0.18b R 2 = Abbey et al. Stress and infertility

6 viduals' initial satisfaction with the availability of network social support may lead them to appraise their situation as less threatening. Over time, however, if interactions with social network members are not perceived as helpful, then perceived stress is expected to increase (and perceptions of social support to decrease). As predicted, sociodemographic, treatment, personal, and social factors related to infertile men's and women's perceptions of stress. Income (men only), treatment costs, number of tests and treatments, confidence one will have a child, importance of children (women only), personal control, and satisfaction with network support (women only) were the variables most strongly related to the stress infertile individuals experienced. Contrary to prediction, age, number of years married, and number of years trying to have a child were not related to fertility problem stress. For couples who are actively seeking medical treatment, these variables are not important predictors of stress. Men's traditional responsibility for wage earning may explain the stronger relationship between income, number of physicians seen (each of whom orders additional tests and provides another bill), anticipated treatment costs, and men's fertility problem stress as compared with women's. As one male study participant stated, "The prices are outrageous... I had Hodgkin's disease and the charges were not what these are." Despite the fact that most of the women in this study worked for pay, men may feel more responsible for providing financial resources and thus may experience more stress when their income seems less than necessary to cover anticipated treatment expenses. Women, who received the majority of tests and treatments, were more stressed by them. One female study participant succinctly stated, "on Pergonal you're a slave." Even a relatively routine procedure, such as taking one's basal body temperature, is perceived as burdensome and provides a daily reminder to women of the existence of their fertility problem. Women report feeling like a failure if the physician observes that they failed to keep up their temperature charts or to have intercourse on the appropriate days (2). Most tests and treatments focus on the woman's body, even if the physical problem is not hers. For example, artificial insemination with donor sperm (AID) is necessitated by the husband's low sperm count but requires only the wife's physical participation. This medical focus on the woman's body may expla!n why attributions of responsibility to the physician were a significant predictor of women's fertility problem stress. Women's frequent Vol. 57, No. 1, January 1992 contacts with physicians may create dissatisfaction with the quality of care received, thus leading women to hold the physician partially responsible for the problem. Although such a response may be difficult for the physician to understand, these feelings should not be ignored. They signal that the patient's current stress level is high and that she may need a respite from the aspects of treatment that she finds most upsetting (4). Women receive and value social support more than men do (17). Thus, access to support may be a more important factor in women's appraisal of potentially threatening situations as compared with men's. In the correlation analyses, support was a significant predictor only for women. These results have several clinical implications. Physicians and other health care providers working with infertile patients should help them maintain a sense of personal control over their lives. Giving infertile patients as much flexibility as possible when scheduling appointments, requiring temperature charts only when necessary, assisting patients to make informed choices, and reminding them of the aspects of their treatment and lives that they can control should reduce infertile patients' stress. Providing patients with a sense of confidence and optimism about their long-term chances also will reduce their stress. This is not meant to imply that infertile couples should be given false hopes. Many of the participants in our study stated that they wanted the physician to be honest with them about their chances of being successful and to let them know when it was appropriate to consider options such as adoption. As one respondent said, "provide us with realistic expectations." Patients' attitudes about the types of treatment they are likely to require also need to be assessed. If patients have moral or religious qualms about certain treatments, stress will be increased unless the health care provider acknowledges and addresses these issues (15). Finally, the adequacy of infertile patients' available social support can be determined. Many infertility patients have found support in self-help groups (4, 18). For example, one of our female study participants indicated that "she didn't blame herself anymore" after joining a support group. But another female study participant stated "I didn't like RESOLVE; it made me cry." Support groups may be most helpful for infertile individuals who lack network or spouse support. Attention to infertile patients' specific personal and social circumstances can reduce the stress these patients experience in their attempts to have a child. Abbey et al. Stress and infertility 127

7 Acknowledgments. The authors thank the physicians and staff of the medical clinics who provided access to their patients, the Southeastern Michigan Resolve and Endometriosis Associations, the Oakland County Clerk's Office, and most of all, the individuals who provided the information reported here. REFERENCES 1. Daniluk JC. Infertility: intrapersonal and interpersonal impact. Fertil Steril 1988;49: Keye WR Jr. Psychosexual responses to infertility. Clin Obstet Gynecol 1984;27: Link PW, Darling CA. Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital Ther 1986;12: Mahlstedt PP. The psychological component of infertility. Fertil Steril 1985;43: McCormick TM. Out of control: one aspect of infertility. J Obstet Gynecol Neonatal Nurs 1980;9: Wright J, Duchesne C, Sabourin S, Bissonnette F, Benoit J, Girard Y. Psychological stress and infertility: men and women respond differently. Fertil Steril1991;55: Berg BJ, Wilson JF. Psychological functioning across stages of treatment for infertility. J Behav Med 1991;14: Matthews AM, Matthews R. Beyond the mechanics of infertility: perspectives on the social psychology of infertility and involuntary childlessness. Fam Relat 1986;35: Miall CE. Perceptions of informed sanctioning and the stigma of involuntary childlessness. Deviant Behav 1985;6: Greil AL, Leitko TA, Porter KL. Infertility: his and hers. Gender Society 1988;2: Van Keep P A, Schmidt-Elnerdoff H. Involuntary childlessness. J Biosoc Sci 1975;7: Folkman S, Schaefer C, Lazarus RS. Cognitive processes as mediators of stress and coping. In: Hamilton V, Warbuston DM, editors. Human stress and cognition: an information processing approach. London: Wiley, 1979; Henshaw SK, Orr MT. The need and unmet need for infertility services in the United States. Fam Plann Perspect 1987;19: Shiloh S, Larom S, Ben-Rafael Z. The meaning of treatments for infertility. J Appl Soc Psychol1991;21: Reading AE, Sledmere CM, Cox DN. A survey of patient attitudes towards artificial insemination by donor. J Psychosom Res 1982;26: Pearlin LI, Menaghan EB, Lieberman MA, Mulby JT. The stress process. J Health Soc Behav 1981;22: Sarason BR, Sarason la, Hacker TA, Basham RB. Concomitants of social support: social skills, physical attractiveness, and gender. J Pers Soc Psychol1985;49: Abbey A, Andrews FM, Halman LJ. The importance of social relationships for infertile couples' well-being. In: Stanton AL, Dunkel-Schetter C, editors. Perspectives from stress and coping research. New York: Plenum, 1991: Abbey et al. Stress and infertility