The longitudinal impact of partner coping in couples following 5 years of unsuccessful fertility treatments

Transcription

1 Human Reproduction, Vol.24, No.7 pp , 2009 Advanced Access publication on March 15, 2009 doi: /humrep/dep061 ORIGINAL ARTICLE Psychology and counselling The longitudinal impact of partner coping in couples following 5 years of unsuccessful fertility treatments B.D. Peterson 1,5, M. Pirritano 2, U. Christensen 3, J. Boivin 4, J. Block 1, and L. Schmidt 3 1 Department of Psychology, Chapman University, One University Drive, Orange, CA 92866, USA 2 Orange County Health Care Agency Medical Services Initiative, USA 3 Department of Social Medicine, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO Box 2099, DK-1014 Copenhagen K, Denmark 4 School of Psychology, Cardiff University, Psychology Building, Park Place, Cardiff, Wales, UK 5 Correspondence address. Tel: þ ; Fax: þ ; bpeterson@chapman.edu background: Because there is a lack of longitudinal research examining the impact of partner coping in couples experiencing infertility, we know very little about the long-term nature of coping with infertility and how partner coping strategies impact personal, marital and social distress. methods: Participants were Danish men and women about to start a cycle of assisted reproduction treatment who were followed for a 5 year period of unsuccessful treatments. Multilevel modeling using the actor partner interdependence model was used to examine the couple as the unit of analysis. results: Active and passive avoidance coping strategies were significantly related to increased personal, marital and social distress at the individual and partner level. Meaning-based coping strategies were related to decreases in a woman s individual distress and her partner s marital distress. conclusions: Partner coping strategies have a significant impact on the other member of the couple over time in men and women undergoing infertility treatments over a 5 year period. Physicians and mental health professionals can educate men and women regarding the ineffectiveness of avoidance coping strategies as well as the beneficial nature of finding new meaning and life goals while experiencing the stress of infertility. Key words: longitudinal / infertility stress / coping / couples / APIM Introduction Coping with the stress of infertility is a topic that has received considerable attention from researchers, physicians and mental health professionals over the past several decades (Peterson et al., 2006a; Schmidt et al., 2005a). When a couple experiences infertility, they encounter changes in their familial, social and personal relationships (Newton et al., 1999). In addition, couples may re-examine their need to be biological parents and question long-held beliefs and assumptions about their identity. The aggregate weight of these unexpected strains can produce infertility-related stress in one or both partners (Newton et al., 1999). How the couple responds to these stressors has implications for both individuals and the couple. In order to adequately respond to stress, couples use coping strategies, or behavioral or emotional efforts used to manage change and regain control of their lives (Lazarus and Folkman, 1984). Men and women cope with infertility in different ways with women consistently reporting increased use of coping strategies when compared with men (Jordan and Revenson, 1999). A meta-analysis of studies examining specific gender differences in coping with infertility found that, when compared with their partners, women used more escape-avoidance coping, engaged in more social support seeking and used more positive reappraisal coping (Jordan and Revenson, 1999). A more recent study examining relative coping found that women referred for IVF treatment coped using proportionately greater amounts of escape-avoidance, confrontive coping, accepting responsibility and social support seeking, whereas men used greater amounts of distancing, self-controlling coping and planful problem-solving (Peterson et al., 2006a). Similar gender differences and the increased reporting of coping behaviors in women were also found in a meta-analysis & The Author Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please journals.permissions@oxfordjournals.org

2 Longitudinal impact of partner coping strategies 1657 examining men and women coping with other life stressors including work, caregiving and chronic illness (Tamres et al., 2002). Over the past decade, there has been an increased emphasis on studying the relational nature of coping with infertility using the couple as the unit of analysis. These analyses provide a more complete and accurate picture of the impact of coping. By examining the couple as the unit of analysis, researchers can understand the impact that one partner s coping has on the other. These studies have consistently found that partner coping is related to individual distress and that partner coping impacts men and women in different ways, and they have significantly added to the infertility literature base (Stanton et al., 1992; Levin et al., 1997; Mikulincer et al., 1998; Peterson et al., 2003, 2006b, 2008). Dyadic analyses have also been used to highlight important relational dynamics and coping patterns in couples dealing with chronic illness such as cancer (Berg and Upchurch, 2007). Although the number of studies examining the impact of partner coping has increased, there have been very few studies that have examined this issue longitudinally. Berghuis and Stanton (2002) examined the longitudinal impact of coping and depressive symptoms in couples following a failed insemination attempt. They found that both individual and partner coping were significantly related to distress. Specifically, avoidant coping used prior to insemination predicted increased distress after a failed insemination attempt, whereas approach-oriented coping was predictive of a more favorable adjustment. They also found that women who were low in emotional-approach coping benefited from their partner s use of it. Other longitudinal studies not specifically related to coping, but within the infertility literature, have found that: anxiety and depression increased in women 6 months following failed treatments (Verhaak et al., 2005), infertility-stress had direct and indirect effects on treatment outcome (Boivin and Schmidt, 2005), couple relationships were strong and stable 1 year following failed IVF treatments (Sydsjö et al., 2005), and couples successfully adjusted to infertility 3 years following failed treatments (Daniluk, 2001; Daniluk and Tench, 2007). Although there have been a number of studies in the infertility literature using longitudinal designs, there is a need for more studies examining the longitudinal impact of partner coping on individual distress in couples experiencing infertility. Such studies are valuable because they assess the interactions between partners to see if an individual s stress levels can be accounted for by a partner s coping strategies. A new method of data analysis called the actor partner interdependence model (APIM; Kenny et al., 2006; Fig. 1) can be effective in analyzing data from such studies. The APIM allows for the simultaneous estimation of actor effects (individual effects) and partner effects (the effects of another closely associated person) to shared stressors in dyads, thus providing a more complete picture of how coping is related to stress in couples. In the infertility literature, two recent studies have used the APIM in their data analysis: Peterson et al. (2008) used the same sample as the present study to examine the partner effect of coping with infertility prior to undergoing infertility treatment and Benyamini et al. (in press) studied how perceptions of infertility are related to psychological adjustment in men and women. A body of research that uses the APIM, to examine the impact of one partner s coping on the stress of the other partner, is also accumulating outside of the infertility literature (Butterfield and Lewis, 2002; Rayens and Svavarsdottir, 2003; Cook and Kenny, 2005; Rogers et al., 2005). Figure 1 General model of actor and partner effects of coping strategy on distress. In the current study, we have examined the longitudinal impact of partner coping in men and women undergoing fertility treatments and link our results to previously established baseline findings, by using the APIM (Peterson et al., 2008). We examined the impact of four types of coping [active-avoidance strategies (e.g. avoiding pregnant women or children); active-confronting strategies (e.g. showing feelings, asking others for advice); passive-avoidance strategies (e.g. hoping for a miracle) and meaning-based strategies (e.g. growing as a person in a good way; finding other goals in life)] on personal, marital and social distress in men and women experiencing failed fertility treatments over a 5 year time period. Materials and Methods Setting Denmark provides a tax-financed, comprehensive health-care system with equal, free and easy access to high-quality assisted reproductive technology (ART). In 2002, 6.2% of the national birth cohort was composed of children conceived with some kind of assisted reproduction (Nyboe Andersen and Erb, 2006), and in 2007, this proportion increased to 8.0% ( 20th October 2008). This study is part of The Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme (Schmidt et al., 2003; Schmidt, 2006), which is a prospective longitudinal cohort study on a large population of infertile couples in fertility treatment initiated in Year The study was approved by the Danish Data Protection Agency and was assessed by the Scientific Ethical Committee of Copenhagen and Frederiksberg Municipalities who had no objections. The COMPI cohort comprised consecutively all new couples initiating fertility treatment with intrauterine insemination (IUI), in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in four large public hospital-based tertiary fertility clinics and one large private clinic in Denmark from 1 January 2000 to 1 August Procedure All new couples entering one of the five fertility clinics for the first time received a sealed envelope immediately before their first treatment attempt (T1). The envelope contained information about the study, a baseline questionnaire, a form for declaration of non-participation in the study and a stamped, pre-addressed return envelope for each spouse. The baseline questionnaires were returned to the last author (L.S.) who was not employed at any of the fertility clinics. The non-responders received up to two written reminders. In total, 2812 fertility patients

3 1658 Peterson et al. (1406 couples) received a baseline questionnaire for each partner and 80.0% (n ¼ 2250) participated (1169 women, 83.1%; 1081 men, 76.9%). Non-participants were significantly older, and female nonparticipants were more likely to have tubal occlusion. Among male non-participants, more were about to start ICSI treatment (for a detailed non-participants analyses, see Schmidt et al., 2003; Schmidt, 2006). In total, 44 participants were lost by 1 year follow-up (T2) (38 participants whose identity was not registered at T1, 4 participants whose address could not be traced, 1 participant who had died and 1 who suffered from a severe brain injury). In total, 2206 participants received the 1 year follow-up questionnaire and 1934 (87.7%) responded (1025 women, 89.4%; 909 men, 85.8%). There were no significant differences between the 1 year follow-up participants and non-participants among either women or men according to the baseline (T1) values of the COMPI Fertility Problem Stress Scales or the COMPI Coping Strategy Scales. At 5 year follow-up (T3), 72 were lost to follow-up (56 whose address could not be traced, 16 who had died or whose partner had died). In total, 2134 received the 5 year follow-up questionnaire and 1481 (69.4%) responded (834 women, 75.0%; 647 men, 63.3%) after up to two written reminders. Measures The COMPI fertility problem stress scales Fertility-related stress was measured using 14 items concerned with the strains related to infertility produced in the personal, social and marital domains, as previous research has shown that infertility taps into these different arenas (Schmidt, 1996; Greil, 1997; Tjørnhøj-Thomsen, 2005). Seven of these items were taken from The Fertility Problem Stress Inventory (Abbey et al., 1991), as this instrument covers all three domains; the remaining seven items were developed from The Psychosocial Infertility Interview Study (Schmidt, 1996). The items were developed in relation to the three domains (Schmidt et al., 2003). Afterwards, the items were factor analyzed to produce a set of parsimonious factors, and strain in relation to the three different domains was confirmed. The (i) Marital stress subscale (four items) assessed the extent to which infertility had produced strain on the marital and sexual relationships (e.g. infertility has caused thoughts about divorce ). The (ii) Social stress subscale (four items) assessed the stress infertility had produced on social relations with family, friends and workmates (e.g. infertility has caused stress in my relationships with family and friends ). The (iii) Personal stress subscale (six items) tapped into the stress infertility had produced on the person s life and on mental and physical health (e.g. it is very stressful for me to deal with this fertility problem ). The response key for the subscales personal stress, social stress and two items from marital stress was a four-point scale from (1) none at all to (4) a great deal. The response key for the remaining two items from marital stress was a five-point Likert response key from (1) strongly disagree to (5) strongly agree. Items from the different subscales were summed to produce total scores. Higher scores indicated more marital, social and personal stress. See Table I for means and standard deviations (SD). The COMPI coping strategy scales As recommended by Folkman and Lazarus (1988) and Costa et al. (1996), we developed a coping questionnaire specifically aimed at measuring coping strategies in relation to a specific stressor: infertility. This 29-item questionnaire was developed using three sources: (i) items were adapted from the 66-item Ways of Coping Questionnaire (WOCQ), a process-oriented measure of coping derived from Lazarus and Folkman s transactional model of stress (Lazarus and Folkman, 1984; Folkman and Lazarus, 1988); (ii) Folkman s (1997) later revision of the coping model with the inclusion of the new concept, meaning-based coping; and (iii) Table I Male and female mean distress at baseline, 1 and 5 years Baseline... 1 year... 5 years... Mean SD Mean SD Mean SD... Personal distress Male Female Marital distress Male Female Social distress Male Female items developed from a qualitative interview study (Schmidt, 1996). Items for the coping questionnaire were selected from WOCQ only if this specific way of coping was clearly revealed in the qualitative interview transcripts (Schmidt, 1996). In total, 18 items were selected from WOCQ, and seven of these were re-formulated to focus on the specific stressor of infertility. Further, we developed 11 items based on the results from the interview study. These 29 items covered a wide range of responses the participants may have engaged in when dealing with the fertility problem. The items were categorized into four subscales based on their conceptual content: (i) active-avoidance strategies (e.g. avoiding pregnant women or children); (ii) active-confronting strategies (e.g. showing feelings, ask others for advice); (iii) passive-avoidance strategies (e.g. hoping for a miracle); and (iv) meaning-based coping (e.g. growing as a person in a good way, finding other goals in life) (Schmidt et al., 2005b). The response key was (1) not used, (2) used somewhat, (3) used quite a bit and (4) used a great deal. The subscales comprised items that were significantly intercorrelated. Ten of the 29 items did not fit the scales, and we excluded them from the analyses. On the final measure, active-avoidance coping was covered by four items, active-confronting by seven items, passive-avoidance by three items and meaning-based coping by five items. Only when the participants had answered at least half of the items in a subscale did we include their response for that subscale. A confirmatory factor analysis showed goodness-of-fit-index (GFI) ¼ 0.88 for the entire model. When subscales were removed from the model one at a time, the GFIs were Data analysis The analyses were longitudinal, following couples across three waves of data collection: baseline, 1 and 5 years. Dyadic growth curve models were created using multilevel modeling techniques (Kenny et al., 2006; Kashy and Donnellan, 2008). In order to conduct the analyses, the data were structured so that each line contained data for one individual at one time point, with a variable included that defined the couple (i.e. dyad), a variable that identified the individual and a variable that coded for time. In growth curve modeling, the decision of which time point should be coded zero is not arbitrary because it affects the interpretation of later results (Singer and Willet, 2003). For the current analyses, the baseline time point was coded as zero as the starting point where the couple initiated a treatment period. Multilevel analyses, which involve more than one regression model calculated at different levels of a nested design, were conducted. In the current set of analyses, the

4 Longitudinal impact of partner coping strategies 1659 individual level was nested within the couple level. Multilevel analyses estimate the model independently at each of these levels. Because multiple models are constructed at each level of the nested design, the analysis is able to use all available data without having to use listwise deletion across the entire analysis. Because of this, when data were available for only one partner, they were included in the individual level analyses, but not the couple level analyses. The design of the analysis is very similar to a multiple regression with one dependent variable and a set of predictor (or independent) variables. The dependent variables in the current study were three different types of infertility-related stress (personal, marital and social), and the independent variables were the four coping strategies and time. Interaction effects with time were also examined for the gender, actor and partner effects. Multilevel analyses were conducted for each combination of dependent and independent variables, resulting in 12 analyses. These analyses provide unstandardized estimates of path coefficients for actor and partner effects. Analyses were also conducted to determine if there were significant differences in the strength of the actor and partner effects. One of the principal challenges in running the multilevel dyadic growth models that sets them apart from cross-sectional models is the increase in parameter estimates that are possible (i.e. more random effects are available to be included in the models), and the resulting difficulty in finding models that will actually run. To discover the best model, analyses were run starting with the saturated model (the model including all possible random effects) and gradually refining them until the optimal model emerged. In some instances, models designed only to estimate the variance of components were run. This served as a diagnostic tool for determining if there was in fact any unexplained variance to be estimated in particular variables. If it was determined that there was not any unexplained variance in an independent variable to be estimated by the model (a situation that inevitably results in the model s inability to converge), that variable was fixed in subsequent models. Results Sample characteristics In total, 1169 women and 1081 men who were members of consecutively referred couples undergoing fertility treatments completed the baseline questionnaires (T1). At the 1 year follow-up (T2), there were 552 males and 592 females who still had no child. At the 5 year follow-up (T3), there were 133 males and 201 females who had not had achieved parenthood either after a treatment-related pregnancy, a spontaneous conception or adoption, or a current pregnancy and who were still partnered with the same partner at inclusion (samples at each time point contained an unequal number of men and women because when data were available for both partners, they were included in the couples analysis, whereas when data were available for only one partner, they were included in the individual level analyses but not in the couple level analyses). At baseline, participants had been infertile for 4 years [women 4.1 years (SD ¼ 2.3); men 4.1 years (SD ¼ 2.2)] and 57.8% had been in fertility treatment (most frequently IUI) prior to inclusion in COMPI. Men were also significantly older than women, with a mean age of 34.4 versus 32.0 years, respectively (t ¼ 17.6, P, 0.001). At 5 years, couples had been trying to have a child for an average of 9.1 years. Men continued to be significantly older than women, with a mean age of 40.1 versus 37.4 years, respectively (t ¼ 4.4, P, 0.001). Couples reported receiving an average of 4.3 fertility treatments over the 5 year period. For those still trying to have children at 5 years, 35.3% of men and 32.8% of women attributed the infertility to men, whereas 41.8% of women and 41.4% of men attributed the infertility to women. In terms of social position, 25% of participants were from a high social position (professionals, executives and medium level white collar employees), 52% were from a medium social position (low level white collar employees and skilled workers) and 23% were from a low social position (unskilled and semiskilled workers and participants receiving social benefits). Baseline models and longitudinal distress levels Table I presents the mean levels of personal, marital and social distress at the three time points. Table II presents the findings from the baseline models that were used to determine the growth curve for subsequent analyses that would include covariates. The baseline models provide an estimate of the mean for males and females as well as an estimate of the slope of the growth curve. The significant means indicate that these means were significantly different from zero. The significant negative slope for males and females on personal distress indicates that personal distress decreased across the 5 years of the study. Social distress did not change significantly during the study period. The significant positive slope for males and females for marital distress indicates that marital distress increased across the 5 years of the study. Significant gender differences indicate that women had higher scores on personal and social distress than men at baseline and 5 years. The significant time effects for personal distress and marital distress simply reiterate the significant male and female slopes. The lack of significant gender by time interactions indicates that the slope of the growth curves did not significantly differ for males and females. Multilevel model: significant actor and partner effects Figure 1 provides a visual depiction of the general model of actor and partner effects and their influence on male and female distress. When a significant female partner effect is found, it indicates the existence of a relationship between a male partner s coping strategy and the female partner s personal, social or marital distress. Similarly, when Table II Two-intercept and interaction growth models for personal, martial and social distress Personal Martial Social distress distress distress... Male mean 5.23*** 3.93*** 1.63*** Female mean 8.44*** 4.09*** 2.39*** Male slope 20.23*** 0.27*** 0.04 Female slope 20.19** 0.33*** 0.09 Gender 1.60*** 0.15** 0.45*** Time 20.22*** 0.30*** 0.07** Gender by time ***P, 0.001; **P, 0.01.

5 1660 Peterson et al. a significant male partner effect is found, it highlights the relationship between a female partner s coping strategy and the male partner s distress. Table III presents the significant actor and partner effects for each coping strategy by personal, marital and social distress over time. Unstandardized beta coefficients (b) are reported. Comparisons of the relative contribution of independent variables can be made since all variables are measured on the same response scale. Active-avoidance coping For active-avoidance, there were significant actor effects on personal, marital and social distress. The positive actor effects for men and women indicate that greater use of active-avoidance predicted greater personal, marital and social distress across time for both men and women. There were also significant partner effects for males and females on personal and social distress, indicating that a partner s use of increased active-avoidance coping was related to increases in his or her partner s levels of personal and social distress. This was also true for marital distress, but only for women: the increased use of active-avoidance in men increased levels of marital distress in women. There was one interaction between time and the female actor effect. Follow-up ordinary least squares (OLS) regression analyses showed that over time, the actor effect for women was strengthened. This indicates that over time, the relationship between the use of the active-avoidance coping strategy and greater social distress increased. No other interactions between either partner or actor effects with time were significant, indicating that the strength of all other actor and partner effects remained constant across time. Active-confronting coping For active-confronting, there was a significant actor effect for social distress and an actor by time effect for men and marital distress. There was also a significant male partner effect for marital distress and a male partner by time effect for marital distress. Follow-up OLS regression analyses indicated that for the actor effect, there was a significant increase in the strength of the effect at 5 years. Thus, for the partner effect, a female s increased use of activeconfronting coping strategies was related to increased male marital distress over time. Passive-avoidance coping For personal distress, there was a significant actor effect for men and women and a significant partner effect for women. There were also significant interactions between time and the actor effect for women; this indicated an increase in the strength of the female actor effect over time. For marital distress, there was a significant actor effect for men and a significant partner effect for females, indicating that a male s use of passive avoidance was related to his own and his partner s increased marital distress. For social distress, there were significant actor effects for men and significant interactions between the actor and partner effects over time for women, meaning that with an increased actor effect for women, there was a concomitant decrease in the partner effect. Meaning-based coping For personal distress, there was a significant negative actor effect for females, indicating that the increased use of meaning-based coping was related to decreased personal distress. There was, however, an interaction between the gender and the actor effects, indicating that although the increased use of meaning-based coping decreased female personal distress, for males this was not the case. There was no effect of meaning-based coping on the personal distress of men. For marital distress, there was a significant female actor effect and a significant male partner effect, indicating that a female s use of meaning-based coping was related to a decrease in both her and her partner s marital distress. There was also a significant positive male actor effect for social distress indicating that for men, greater use of meaning-based coping strategies was related to increased social distress. Discussion The current study highlights the impact of partner coping strategies on personal, marital and social distress in a sample of men and women undergoing unsuccessful fertility treatments over a 5 year period. Given the lack of longitudinal studies examining the impact of partner coping on infertility distress, it is difficult to make direct comparisons to findings of previous studies (Berghuis and Stanton, 2002). However, key findings from this study confirm that active and passive avoidance coping are consistently associated with poorer personal outcomes for the individual and their partner, and that meaning-based coping strategies are more beneficial for women than for men at both the individual and the partner levels. These findings can benefit both physicians and mental health professionals by underscoring the importance of coping over time, but also by addressing the significant long-term impact of one partner s coping on his or her partner s infertility-related distress. When examining distress levels over time, women reported greater amounts of personal distress when compared with men, yet personal distress decreased significantly for both men and women over time at similar rates. This is consistent with a wide range of studies indicating that women report greater amounts of infertility-related distress when compared with men (Slade et al., 1997; Newton et al., 1999). This is likely due to the fact that the experience of infertility is so closely linked to the female identity, and because the female s body is the main focus of fertility treatment (Morrow et al., 1995; Peterson et al., 2007). The longitudinal model was valuable, in that it allowed us to see that over time, both male and female personal distress levels decreased at similar rates. This finding supports a previous study which found that adaptation of men and women to failed fertility treatments was similar, and that couples report less distress over time, potentially because they have more psychological space to respond to the life transition (Daniluk and Tench, 2007). The results are also consistent with a recent systematic review among women in IVF treatment showing that the long-term prognosis for people undergoing treatment was generally positive with,25% of women showing sub or clinical levels of anxiety or depression (Verhaak et al., 2007a). Time also predicted a significant increase in marital distress for both men and women. As with personal distress, there were no significant gender differences over time, highlighting the reciprocal nature of the

6 Longitudinal impact of partner coping strategies 1661 Table III Actor and partner effects of coping style on distress over time Personal distress Martial distress Social distress... Active-avoidance Actor effects Male 0.79*** 0.39*** 0.38*** Female 0.89*** 0.30*** 0.30*** Actor effect by gender Male actor effect by time Female actor effect by time ** Partner effects Male 0.23*** * Female 0.44*** 0.21*** 0.23*** Partner effect by gender 0.10* ** Male partner effect by time * 0.00 Female partner effect by time Active-confronting Actor effects Male * Female Actor effect by gender Male actor effect by time ** 0.00 Female actor effect by time Partner effects Male * Female Partner effect by gender Male partner effect by time * Female partner effect by time Passive-avoidance Actor effects Male 0.35*** 0.19*** 0.16*** Female 0.28*** Actor effect by gender Male actor effect by time Female actor effect by time 0.07* * Partner effects Male Female 0.21** 0.11* 0.08 Partner effect by gender Male partner effect by time Female partner effect by time * Meaning-based Actor effects Male ** Female 20.23*** 20.12** Actor effect by gender 20.12** 20.07* 20.06* Male actor effect by time Female actor effect by time Continued

7 1662 Peterson et al. Table III Continued Personal distress Martial distress Social distress... Partner effects Male * 0.00 Female Partner effect by gender Male partner effect by time Female partner effect by time ***P, 0.001; **P, 0.01; *P, marital relationship in experiencing the stress of infertility. It is important to note that our study did not specifically measure marital adjustment or satisfaction, but rather marital distress (e.g. stress placed on the marriage, stress on sexual relations). Therefore, it is difficult to generalize findings on marital distress to other studies examining the construct of marital adjustment. Although a large number of studies show that marital adjustment is strong in men and women experiencing infertility before and after treatments (Schmidt et al., 2005c; Sydsjö et al., 2005), some studies have shown that time can play a role in decreasing satisfaction. For example, Berg and Wilson (1991) found in a cross-sectional study that marital satisfaction was strong for couples during the first 2 years of treatments, but significantly lower in the third year, proposing that advanced stages of infertility and treatments not only take a toll on the individual, but also upon the couple. Holter et al. (2006) studied the short-term psychological impact of IVF treatment and found that at the time of treatment, a couple s relationship was strengthened because of the treatment process, but that further treatments might cause problems in the relationship. This may be due to a couple s reliance on one another for emotional support throughout the treatment process, which may erode over time. In our study, increased marital distress could have to do with men and women s differing desires in treatment continuance. In a study of 45 couples experiencing failed IVF treatment, Sydsjö et al. (2005) found that nearly three-quarters of women wanted to undergo further IVF treatments, whereas the majority of men did not intend to. Although the current study did not examine this construct directly, gender differences regarding desired continuance or cessation of treatment may play a role in the increase of marital distress over time. The longitudinal model also allowed us to examine the long-term impact of various coping strategies, and the impact these coping strategies have on infertility-related distress. When examining the impact of partner coping on distress over time, active-avoidance coping, passive-avoidance coping and meaning-based coping produced noteworthy results. In our baseline analysis, we found that active-avoidance coping strategies had significant actor and partner effects on personal, marital and social distress (Peterson et al., 2008). In the current study, the actor effects for males and females on each type of distress are significant, indicating that a male or female s use of active-avoidance coping predicted higher levels of individual distress over time, and supporting previous studies showing that active-avoidance coping is related to increased individual distress (Peterson et al., 2006a). When examining partner effects, a partner s use of active avoidance was related to increased personal and social distress in men and women, and increased marital distress in women over time. In their longitudinal study of partner coping over time, Berghuis and Stanton (2002) also found that a partner s avoidant coping strategies were related to greater distress. Contrary to what couples attempt to achieve, namely relief from the stress through actively avoiding situations and reminders of infertility, the findings from this study clearly show that using active-avoidance coping strategies over time does not ultimately help one s level of personal distress, neither at the individual nor at the partner level. Physicians and mental health professionals can help men and women reduce their levels of active-avoidance coping by educating patients regarding the paradoxical nature of this ineffective coping strategy, specifically that the more they avoid the stressor, the greater distress both they and their partner are likely to report. The findings related to passive avoidance varied greatly from baseline to Year 5. At baseline, there were no significant partner effects for passive-avoidance coping (Peterson et al., 2008). At that time, we hypothesized that the non-significant impact of the partner effect was likely due to the unexpressed nature of the coping strategy, and that because of this, partners may not be aware of one another s use of passive avoidance. In the current study, there was a male actor effect for passive avoidance on personal, marital and social distress, and a female actor effect for personal distress. There was also a female partner effect for personal and marital distress. This finding showed that men s use of passive-avoidance coping strategies (e.g. relying on a miracle and feeling the only thing they could do about infertility was wait) was linked with increased personal, marital and social distress for themselves, and increased personal and marital distress for their partners. One possible explanation for this is that a man s use of passive avoidance over time goes against the typical male role of problem-solver, and although he is taking action through treatments, his coping strategy lacks belief that his actions will make a difference. A meta-analysis on the association of coping to physical and psychological health outcomes based in studies using either the Lazarus and Folkman Revised WOCQ or Vitiliano s Ways of Coping Checklist showed that wishful thinking was inversely associated with psychological well-being (Penley et al., 2002). The measurement of wishful thinking is overlapping with our subscale for passive-avoidance coping and the meta-analysis and hence supports our results among a population of infertile people.

8 Longitudinal impact of partner coping strategies 1663 The impact of meaning-based coping over time was also noteworthy. When a woman used this strategy, it had a beneficial effect on her personal and marital distress, and also on her partner s marital distress. This is a significant finding because it is rare to find coping strategies that are significantly related to decreased distress (Jordan and Revenson, 1999). This finding is even more important given the earlier findings that marital distress increases over time. When a woman engages in meaning-based coping, she reports that the experience of infertility helped her grow as a person, find other goals in life and ultimately think about infertility in a positive light. In other words, women in these couples may more successfully integrate the experience of infertility into their identity a crucial developmental task when coping with this life transition (Peterson et al., 2007). Further, when Folkman (1997) introduced the concept of meaningbased coping, she stressed that meaning-based coping sustained the coping process by generating positive emotions. The decreased marital distress may be related to a woman s expanded focus on other life activities, which removes some of the shared burdens that infertility places on her and her partner and that lead to increased marital distress over time. Women who found new life goals following treatments also reported less anxiety and depressive symptoms (Verhaak et al., 2007b). Meaning-based coping has also been shown to be effective for couples in adapting to other life stressors including coping with experience of breast cancer (Skerrett, 1998). As couples redefine and work through the complexities of this difficult life stressor, they have increased opportunities to develop new forms of communication, jointly solve problems and increase their levels of interpersonal intimacy (Skerrett, 1998). Men and women should be aware of the positive impact of meaning-based coping, while also being aware that it may take time to implement this coping strategy. Gender differences in the pacing and timing of treatment may be related to men and women s unwillingness to redefine the stress of infertility at the beginning of treatment (Peterson et al., 2008). Also men and women in the COMPI cohort have different reasons for seeking treatment and significantly more men than women have sought treatment for their partner s sake (Schmidt et al., 2003). It may take time to experience the benefits of meaning-based coping because they may only come when a person has addressed the many complicated questions and stressors presented through the infertility experience (e.g. why did this happen to me, will my family and social relationships ever be the same and what new activities will make life more meaningful?). Although the benefit of this coping strategy is obvious for women, it is important to note it cannot be rushed and may be a long-term process. The COMPI scales used in this study have not yet been validated in large-scale psychometric studies. However, the measures were adopted from existing scales and developed after in-depth qualitative interviews with Danish fertility patients. In addition, both measures were stressor specific to infertility and were not instruments measuring general stress and coping. Future research studies which examine the process of change in couples and the stages of coping with infertility are increasingly necessary to better understand this issue. We are hopeful that this study will lead to future research examining the impact of coping within the greater social context of infertility. Previous research on the psychosocial factors associated with infertility has found several gender differences in how men and women respond to infertility. These differences include men and women s differences for seeking treatment, gender differences in communication and coping strategies, differences in depression and anxiety levels following treatments, and the impact of infertility on men and women s identities. These factors are embedded within the social context in which we live and the roles and responsibilities related to childbearing and childcare may differ greatly for men and women (e.g. the dual-bread-winner society, differences in maternal/paternal leave, differences in role expectation of motherhood and fatherhood). Future studies which explore how infertility, gender and their respective consequences are interwoven in cultural and societal expectations would be valuable. In conclusion, this longitudinal analysis supports baseline findings and also adds to the existing knowledge regarding the impact of coping with infertility over time. It is clear that active- and passive-avoidance coping strategies are related to increased distress over time at the individual and partner levels. In addition, a woman s use of meaning-based coping benefits her and her partner s marriage over time, particularly at a time when their marital relationship may be under duress. This study helps illustrate that partner coping strategies are related to distress over time, and this knowledge can benefit physicians and mental health professionals who work directly with couples coping with the stress of infertility. Acknowledgements This study is part of The Copenhagen Multi-Centre Psychosocial Infertility Research Program (COMPI) initiated by Dr Lone Schmidt, University of Copenhagen, The programme is a collaboration between the public fertility clinics at Braedstrup Hospital; Herlev University Hospital; Copenhagen University Hospital, Rigshospitalet; Odense University Hospital. 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