Infertility: intrapersonal and interpersonal impact

Transcription

1 FERTILITY AND STERILITY Copyright The American Fertility Society Vol. 49, No.6, June 1988 Printed in U.S.A. Infertility: intrapersonal and interpersonal impact Judith C. Daniluk, Ph.D. * Department of Counselling Psychology, Faculty of Education, University of British Columbia, Vancouver, British Columbia, Canada Few experimentally rigorous studies have been conducted to determine the emotional impact of the infertility investigation on the infertile couple. In response to the deficit in rigorous experimental research, a longitudinal, exploratory study of 43 primary infertile couples was conducted. The study was conducted to determine if changes occurred in the marital relationships, sexual satisfaction, and levels of psychologic distress of the couples in the study as they progressed through the medical investigation of their infertility. Changes were assessed based on sex, diagnostic information, and time spent trying to conceive. Results indicated that significant distress was experienced by couples during the initial medical interview and at the time of diagnosis. Relationship quality did not appear to deteriorate as a result of the medical investigation; however, questions were raised regarding the sexual relationships of couples receiving an unexplained infertility diagnosis. Fertil Steril 49:982, 1988 With only 5% of the world's married population choosing to remain voluntarily childless, it would appear that achievement of the parenthood role continues to be a major life goal for many men and women. The importance of attaining such a goal has been reinforced over the centuries, with parenthood being viewed as a necessary criterion for personal fulfillment, social acceptance, achievement of full adult status, religious membership, sexual identity, and psychologic adjustment.1,2 Fertility is assumed to be a basic human right and parenthood a necessary developmental milestone. An estimated 17% of the couples who attempt to reproduce, however, experience problems with their fertility, either conceiving or carrying a viable pregnancy or both.3 In spite of successful medical intervention for 50% to 60% of the couples accessing specialized medical care,4 the search for answers may take years before the receipt of a defini- Received November 25, 1987; revised and accepted February 29,1988. * Reprint requests: Judith C. Daniluk, Ph.D., Department of Counselling Psychology, Faculty of Education, University of British Columbia, 5780 Toronto Road, Vancouver, B.C. V6T 1L2, Canada. tive diagnosis. In most cases, the couple must undergo extensive and invasive medical testing. With receipt of a diagnosis, couples may be required to make decisions regarding relatively controversial forms of treatment such as artificial insemination with donor semen (AID) or in vitro fertilization (IVF). Substantial reference has been made to the "crisis" that may be precipitated in the infertile couple's life as a result of their infertility experience. 5,6 Negative consequences have been reported in terms of sexual functioning and satisfaction,7-9 marital satisfaction and adjustment,l -13 and psychologic distress.9,10,12,14-16 Research directed at examining the "impact" of infertility on the couple and their relationship has been fraught with methodologic flaws and hampered by a lack of rigorous, scientific research proceduresy-19 Of the studies that have been conducted in an attempt to experimentally determine the impact of the infertility experience on the lives and relationships of men and women, few have been longitudinal assessments, utilizing standardized measurements and including sufficient sample sizes to verify the prevalence, extent, and duration of psychologic or relationship difficulties or both experienced by the infertile couple.17,20,21 In fact, 982 Daniluk Infertility: psychological impact Fertility and Sterility

2 more questions have been raised than have been answered by this literature, in terms of determining the specific problems and needs of infertile men and women. Purpose MATERIALS AND METHODS In response to the deficit in rigorous experimental research, the author conducted a longitudinal, exploratory study of 63 primary infertile couples who were undergoing medical investigation of their fertility problems. The research was conducted for the purpose of determining (1) if changes occurred on the dependent measures of symptomatic psychologic distress, marital adjustment, relationship quality, and sexual satisfaction for the men and women who were involved in the study; (2) at which point or points during the medical investigation such changes occurred; (3) the nature of the changes; and (4) whether the changes were different for men than for women. The author further attempted to assess the impact of diagnostic information on the dependent measures. The impact of the infertility investigation was also examined with respect to the amount of time the couples had spent trying to conceive prior to attaining expert medical care and in terms of the receipt of information regarding the partner in whom the organic source of the couple's fertility problem was identified. Sample Sixty-three couples attending a Canadian Endocrine Infertility Clinic for fertility-related concerns were voluntarily recruited for participation in the study based on (1) the mutual consent of both partners, (2) having not received a previous diagnosis for their fertility concerns, (3) having had no previous parenting experience, (4) their involuntary infertility, and (5) having had no previous history of psychiatric diagnosis or treatment or present consumption of mood-altering drugs. Of the 63 couples initially recruited, 12 voluntarily withdrew during the study, and 7 couples were dropped from the study because of prolonged problems in reaching a medical diagnosis. A review of th~ data would appear to suggest that demograpnic factors were not influential in determining which couples completed the study. Procedure Data were gathered through the use of six questionnaires that were administered independently to Vol. 49, No.6, June 1988 both members of each couple immediately after the initial medical visit, 4 weeks later during medical testing, within 1 week of diagnosis, and at 6 weeks after diagnosis. The SCL-90-R provided a global measure of the symptomatic psychological distress levels of the participants as well as providing levels of distress on nine primary symptom dimensions.22 Coefficient alphas of between 0.77 and 0.90 have been reported for the 9 symptom dimensions of the SCL-90-R, attesting to the internal consistency of this measure. SCL-90-R test-retest coefficients for different time periods reportedly range from 0.78 to High convergent and discriminant validity have been demonstrated between the SCL-90-R and the MMPI and between the SCL-90-R and the Middlesex Hospital Questionnaire. The Relationship Change Scale (RCS) was utilized to provide a measure of the general improvement or deterioration in the general quality of the couples' relationships between testing sessions.23 Areas of investigation included in the scale consist of questions regarding relationship satisfaction, communication, trust, intimacy, sensitivity, openness, and understanding, although only one overall change score is calculated on the basis of these dimensions. These areas would appear to be particularly sensitive to the changes that reportedly occur in the relationship of couples experiencing infertility. The Marital Adjustment Test (MAT) served as a measure of the couples' accommodation to their partner at the time of each of the four testing sessions.24 High reliability is claimed for the test as determined by the split-half technique, corrected for by the Spearman Brown Formula, which produced a reliability coefficient of Factor analysis of the instrument supports the internal consistency of the MAT, with scores for each factor found to be stable over a 2-year, test-retest interval. Changes in the participants' perceived levels of satisfaction with their sexual relationships were measured through the use of the Index of Sexual Satisfaction (ISS).25 The ISS is reported to have a discriminant validity of 0.76, a construct validity of 0.68, and high factorial validity. An experimenter-generated questionnaire provided subjective information on the subjects' impressions of the need for, nature, and timing of psychologic intervention in the area of infertility. The instruments were selected on the basis of their brevity and reported reliability and validity. Each instrument was counterbalanced, in terms of presentation, from one testing session to the next. The first set of questionnaires was completed by the Daniluk Infertility: psychological impact 983

3 couples immediately after their initial medical consultation, while both members of the couple were available to consent to participate in the study. The remaining three sets of questionnaires were completed by the couples and returned by mail. The subjective evaluation questionnaire was completed at the conclusion of the final testing session. Treatment of the Data Primary analysis of the data was conducted with the BMDP computer program 4V statistical software package for univariate and multivariate analysis of variance (MANOVA). The BMDP4V package was selected because of the flexibility and comprehensiveness of the MANOV A program, for the ability of the package to handle more than one dependent measure in the multivariate repeated measurements analysis, and because of the program's unique usage of a cell-weighting system to specify hypotheses to be tested, particularly with respect to adjustment for unequal n cell size. The BMDP4V package was also utilized to test the simple main effects when significant interactions were found between the variables being tested. Post-hoc testing for significant main effects was carried out utilizing the Newman-Keuls method of testing the difference between all possible pairs of means. Raw scores were utilized in the analysis of all dependent measures in the study, with the exception of the General Symptom Index (GSI) and nine subscales of the SCL-90-R, where raw scores were converted to area t-scores for the purpose of analysis. Wilk's Lambda multivariate test criteria are reported as the choice of significant test for the multivariate F. In cases where the multivariate F was not found to be significant and the univariate F did reach significance, the univariate F, being sometimes more powerful, is reported and interpreted with caution. RESULTS Results of the multivariate analysis of variance of the scores obtained by the 86 participants across the four testing sessions, on the ISS, MAT, RCS, and GSI may be found in Table 1, with the nine SCL-90-R subscale scores for each session being reported in Table 2. Sexual Satisfaction Analysis of the data appears to suggest that the levels of sexual satisfaction of the 86 participants in the study, were not significantly differentiated at a P :s; 0.05 level, across the four testing sessions, on the basis of sex, diagnostic information, identified etiologic source, or time spent trying to conceive!... Table 1 Multivariate Analysis of Scores Obtained by Participants on the ISS, MAT, ReS, and GSI Over the Four Test Sessions Mean SD MS F P Multivariate L ratio Index of sexual satisfaction Session Session Session Session Marital adjustment test Session Session Session Session Relationship change scale Session Session Session Session General symptom index Session Session Session Session n = 86. P s univariate df 3,255. multivariate df 12, Daniluk Infertility: psychological impact Fertility and Sterility

4 Table 2 Multivariate Analysis of the Scores Obtained by Participants on the Nine Subscales of the SCL-90-R, Over the Four Test Sessions Mean SD MS F P Multivariate L Ratio 2.69 O.OOOOb Somatization: Session b Session Session Session Obsessive-compulsive: Session O.OOOOb Session Session Session Interpersonal sensitivity: Session O.OOOOb Session Session Session Depression: Session b Session Session Session Anxiety: Session b Session Session Session Hostility: Session Session b Session Session Phobic anxiety: Session Session Session Session Paranoid ideation: Session b Session Session Session Psychoticism: Session O.OOOOb Session Session Session n = 86. a P:s; univariate df 3,255. b p:s; multivariate df 27,722. levels of the participants in each of the categories. Important to note, however, were the high mean sexual satisfaction scores obtained by the partici- pants who received a neutral diagnosis of unex- plained infertility, indicating a greater degree of sexual dissatisfaction among these men and before seeking specialized medical care. The mean scores of the participants in all of the categories under investigation remained within the sexually satisfied range ofthe ISS scale «30), although relatively large standard deviation scores serve to suggest wide variability in the sexual satisfaction Vol. 49, No.6, June 1988 Daniluk Infertility: psychological impact 985

5 Table 3 Analysis of Scores Obtained by Participants in the Three Diagnostic Categories on the ISS Positive Negative Neutral Mean SD Mean SD ISS Session Session Session Session Positive n = 60. Negative n = 14. Mean SD MS F P , Neutral n = 12. df6,249. women, relative to the ISS scores obtained by the participants who received positive diagnostic information indicating a treatable etiology and those who received negative diagnostic information indicating physical abnormalities not subject to treatment intervention (see Table 3). Marital Adjustment and Marital Change Analysis of the data suggest that the marital adjustment of the 86 participants, as measured by the MAT, was not significantly differentiated at a P :0;; 0.05 level, across the four testing sessions, on the basis of the sex of the participants, the receipt of specific diagnostic information, the identification of etiologic source, or the time couples spent trying to conceive before attending the clinic. Significant differences were observed, however, between the MAT scores of the 43 male participants, as compared with the 43 female participants, with the women in the study consistently reporting better "accommodation to their partners" than the men in the study (P :0;; 0.05). The MAT scores of the males and females did not differ significantly "across" the four testing sessions, however, suggesting that any sex differences remained relatively constant across time, while not appearing to be affected by the medical infertility investigation. Relatively large standard deviation scores on the MAT for each of the group variations under investigation serve to suggest considerable variability in the perceived marital adjustment of the participants, with a review of the raw data indicating a range in MAT scores from 35 points on the lower end of the continuum to 153 points on the higher end. The mean relationship change scores obtained by all but the male participants who received a negative diagnosis (indicating an etiology for which treatment was unavailable) consistently indicated positive relationship changes for the participants in each of the categories under investigation, as reflected by mean scores of 82 or greater. 986 Daniluk Infertility: psychological impact Psychologic Distress Scores obtained by the participants on the general symptom index of the SCL-90-R were not observed to differ significantly across the four testing sessions on the basis of diagnosis, identified etiologic source, or time spent trying to conceive prior to seeking expert medical care. Significant differences were observed, however, at a P :0;; 0.01 level, between the scores obtained by the 86 participants on the GSI across the four testing sessions (see Table 1), with the most significant levels of distress being experienced by the men and women at the time of the initial medical interview (P :0;; 0.05). Differences in the psychological distress experienced by the participants across the four testing sessions were observed to be manifest at a P :0;; 0.05 level of significance, on the symptom dimensions of somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, paranoid ideation, and psychoticism (see Table 2). Post-hoc testing served to indicate significantly higher first session distress scores on each of these dimensions, as compared with scores reflecting significantly less distress during medical testing, at the time of diagnosis and at 6 weeks postdiagnosis (p:o;; 0.05). Female participants were observed to exhibit substantially higher levels of symptomatic psychologic distress than the male subjects at the time of diagnosis, as indicated by elevated GSI scores (P :0;; 0.07). These sex differences between the psychologic distress levels of the male and female participants were demonstrated in the significantly elevated scores obtained by the female participants on the obsessive compulsive scale (P :0;; 0.05), the depression scale (P :0;; 0.07), and the psychoticism scale (p:o;; 0.01) at the time of diagnosis. Significant differences were also observed between the scores obtained by the participants identified as having an organic fertility problem compared to those who were not identified as being the source of the couple's fertility problem, with the "identified" partici- Fertility and Sterility

6 Table 4 PIQ Responses of the Men and Women Who Completed the Study Men Women Both 1. Based upon your infertility experince, do you believe that there is a need for psychologic services in this area? YES 95.3% 97.7% 96.6% NO If YES, at what point during the infertility investigation do you feel the provision of psychologic services would be most helpful? PREDIAGNOSIS 13.5% 20.6% 17.4% DURING MEDICAL TESTING IMMEDIATELY FOLLOWING DIAGNOSIS SEVERAL WEEKS AFTER DIAGNOSIS DURING TREATMENT ALL OF THE ABOVE If you were to have sought the aid of a psychologist for your fertility related concerns, would you have preferred to have been seen: INDIVIDUALLY 10.2% 28.8% 20.4% ASA COUPLE IN A GROUP WITH OTHER COUPLES IN A SAME SEX GROUP IN A MIXED SEX GROUP If you had been provided with the opportunity to receive psychologic assistance at any point during your infertility investigation, would you have availed yourself of these services? YES NO 53.5% 72.1% 62.8% Male n = 43 Female n = 43 "". pants reporting significantly higher levels of depression at the time of diagnosis (P s 0.05), as well as elevated levels of psychoticism and obsessivecompulsive behavior (although not at a significant level). Subjective Participant Impressions Results of the response made by participants to the experimenter-generated questionnaire may be found in Table 4. DISCUSSION Disruption of the couple's sexual life and subsequent sexual dissatisfaction or sexual dysfunction during the medical work-up and treatment of infertility have been consistently reported throughout the infertility literature. 7-9 It is important to note that sexual satisfaction and sexual functioning may well represent two different dimensions of a couple's sexual relationship, with a measure of sexual "satisfaction" such as the ISS being a measure of an individual's subjective level of satisfaction with his or her sexual relationship, as opposed to being a measure of his or her sexual functioning. Keeping this difference in mind, it would appear from the results of the present study that the medi- cal infertility investigation, and the intrusive procedures involved in such a workup, were not in themselves influential in altering the levels of sexual "satisfaction" reportedly experienced by the men and women who were undergoing such an extensive medical investigation. Rather, wide variability in the ISS scores obtained by participants in the study suggests that a percentage ofthe infertile participants were experiencing dissatisfaction in their sexual relationships before any specific medical intervention. This was particularly the case for the eight couples in the study who were diagnosed as having no identifiable source for their inability to conceive. Couples in this category indicated considerably greater dissatisfaction with their sexual relationships, even before the receipt of an unexplained infertility diagnosis. While caution should be taken in drawing a causal connection between psychosexual problems and infertility, the consistently higher mean ISS scores obtained by the participants in the present study who were diagnosed as having no identifiable organic etiology to their fertility problems and the identification of couples in this group who were very dissatisfied with their sexual relationships may well suggest the need for further research into the sexual relationship of the infertile couple, as Vol. 49, No.6, June 1988 Daniluk Infertility: psychological impact 987

7 may the wide variability in the ISS scores obtained by the participants in each of the categories under investigation. The results of the present study, while remaining speculative, concur with those of other researchers,7-10,17 in suggesting that an extensive sexual history and assessment may be particularly facilitative in identifying couples whose sexual relationships may be in difficulty. Medical intervention in the case of the sexually dissatisfied or dysfunctional couple may need to be altered, with time being taken to assist these couples in dealing with such sexual difficulties, before or subsequent to any medical testing. Without information regarding the levels of marital adjustment within the relationships of the participants prior to their participation in the study, it is impossible to determine whether the "experience" of infertility itself impacted positively or negatively on the marital relationships of the men and women involved. However, what can be assessed from the results of the study is that the "medical intervention" into the relationships of these 43 couples was not influential in altering the marital adjustment of the couples in a positive or negative manner. Although in isolated cases the infertility investigation coincided with changes in the marital adjustment of particular men and women in the study, as in the case of one male whose MAT scores ranged from 151 points in the first testing session, to 113 in the second, to 115 in the third, and to 116 in the fourth session, this type of change in MAT scores only appeared to occur in isolated cases. For the majority of the participants, the infertility investigation did not coincide with positive or negative changes in their levels of marital "adjustment." Such intervention, in fact, appeared to enhance the perceived quality of the infertile couples' relationships, as demonstrated by RCS scores that consistently indicated positive relationship changes for the participants. The differences reported by the couples in terms of consistent marital adjustment throughout the medical investigation, while experiencing enhanced relationship quality, may be accounted for by the fact that the MAT and the RCS measure different aspects of marital functioning. Whereas the MAT measures marital "adjustment" based on such dimensions as philosophic, familial, and financial agreement, the RCS attempts to measure such dimensions as intimacy, commitment, communication, and trust. Although the medical infertility investigation did not appear to impact on the way couples dealt with finances, friends, family, or leisure, it did appear to increase participants' perceived levels of trust, intimacy, and communication within their relationships. As such, the implementation of action in terms of attempting to find a solution to their fertility concerns may well have been regarded as a positive influence on the relationships of these couples who had been trying, unsuccessfully, to have a child. In terms of the intrapersonal impact, results of the present study indicate that the infertility investigation appeared to be significantly more stressful for the participants at the time of the initial medical interview, with the level of psychologic distress experienced by the men and women in the study generally subsiding as the medical investigation proceeded. The receipt of positive, negative, or neutral diagnostic information did not appear to be a factor related to the stress levels of the participants, neither did the amount of time the couples had spent trying to conceive before their attendance at the clinic. For the female participants, however, the receipt of diagnostic information appeared to be somewhat more stress inducing, with such distress being manifest in significantly elevated depression, obsessive-compulsive, and psychoticism scores, thereby substantiating previous research findings. 1O,1l,14-16 Depression has been reported as a common symptomatic reaction to infertility, with the female member of the infertile couple often being found to elicit higher levels of depression than the male.5,12,14,16 The higher depression levels of the female subjects in the current study may well be related to the fact that the majority of the participants in the study who were identified as having reproductive abnormalities were women. Significantly increased depression scores were also reported at the time of diagnosis by those individuals who were identified as having an organic fertility problem, as opposed to those who were not, thereby lending support for the contention that sex differences at the time of diagnosis were most likely related to the fact that the majority of female participants were identified as being the physiologic source of the couple's problem. As such, the higher levels of depression reported for the female patients may well have been related to the larger number of fertility problems of a female origin, which were identified at the point of diagnosis. The reasons for the observation of differences between the scores of the males and the females on the Obsessive-Compulsive and Psychoticism dimensions of the SCL-90-R following diagnosis, however, remain uncertain. Considering the potential relatedness of the nine symptoms dimen- 988 Daniluk Infertility: psychological impact Fertility and Sterility

8 sions, it would appear that caution should be taken in attempting to interpret the meaning of differences such as these, particularly since the scores obtained by the participants in each of the categories under investigation were not observed to be within the positive diagnosis range. At no time did the mean symptomatic psychologic distress scores of the participants in any of the categories under investigation reach the level of a positive diagnosis or "caseness,"22 although mean distress scores ranging from the 30th percentile to the 84th percentile across the four testing sessions would appear to suggest that many of the men and women in the study were experiencing some degree of psychologic distress. Therefore, while the infertility investigation did not generally appear to result in extreme or incapacitating distress for the men and women in the study, the participants did appear to be experiencing a degree of symptomatic psychologic distress as they progressed through the various stages of the investigation. It remains unclear as to whether the psychologic distress experienced by particular individuals in the study was intense enough to be debilitating or to require the assistance of a mental health professional. The impact of extensive "treatment" on the psychologic distress levels of the infertile couple also remains to be determined. Although the mean marital adjustment, sexual satisfaction, and psychologic distress scores of the participants in the study remained in the adjusted range and the quality of the relationships of these couples was reported to improve as the infertility investigation progressed, a substantial majority of the men and women who participated in this research indicated that there was a need for the provision of psychologic services in the area of infertility. Although only 53% of the male participants and 72.1 % of the female participants reported that they personally would have availed themselves to such services had the opportunity been provided, 95.3% ofthe men and 97.7% of the women felt that the provision of such services would have helped in meeting the needs of the infertile couple. Several respondents commented on the need to know that there was someone available other than their physician who could answer their questions, help them express their feelings, and help them to deal with their "lack of control" during this time. Other participants expressed a need to know if their thoughts and feelings were "normal" responses to the infertility experience and to share with other couples their questions, fears, and feelings regarding the infertility investigation, infertil- ity treatment, and the available alternatives for parenting. Some participants referred to their feelings of "isolation" and "helplessness" and to their desire to have someone other than their spouse with whom to share with concerns. It is interesting to note that the time ofthe initial medical interview and the time of diagnosis were perceived by many of the participants as being when the provision of psychologic services would have been most beneficial. These times correspond to the two testing periods that were identified as being the most stressful for the men and women in the study, in terms of their levels of symptomatic psychologic distress. The value of a psychologic interview at the outset of the medical infertility investigation has been consistently emphasized in the literature to assist couples in dealing with their anxiety, to inform them of what they may physically and emotionally expect during the work-up, to explore the possibility of sexual and lor marital problems that may be affecting the couple, and to provide the couple with an element of control over their lives at this time.5,6,10,12,16,18 Intervention at the time of diagnosis has also been recommended and would appear to be helpful in aiding the couple to deal with the implications of the diagnostic information that they receive and in assisting them in their exploration of alternatives and in their decision -making. 5,6,12 The majority of participants in the study felt that they would have preferred to have been counseled as a couple with reference being made by some men and women to infertility as being a "couple's problem" and not a problem ofthe individual. These results again concur with the vast majority of infertility literature, in which recommendations are made for counseling both members of the infertile couple, particularly in cases where marital or sexual difficulties are being experienced by the couple, or where procedures such as artificial insemination or in vitro fertilization are available options. Although it is impossible to determine how many individuals in the present study would have actually accepted the services of a psychologist while undergoing the infertility investigation, it would appear that these men and women perceived the infertility experience as being a stressful and difficult enough time in their lives to warrant the availability of psychologic services concurrent with the medical services with which they were provided. REFERENCES 1. Veevers JL: Childless by Choice, Scarborough, Ontario, Butterworth, 1980 Vol. 49, No.6, June 1988 Daniluk Infertility: psychological impact 989

9 2. Deutsch H: The Psychology of Women: Motherhood, Vol. 2. New York, Bantam Books, Corson SL: Conquering Infertility. Norwalk, CT, Appleton Century-Crofts, Leader A, Taylor PJ, Daniluk J: Infertility: Clinical and psychological aspects. Psychol Annu 14:461, Bresnick ER: A holistic approach to the treatment of the crisis of infertility. J Marit Fam Ther 7:181, Menning BC: The social impact of infertility. Nurs Clin North Am 17:155, Hamer PM, Bain J: Ejaculatory incompetence and infertility. Fertil Steril 45:384, Fagan PJ, Schmidt CW, Rock JA, Damewood MD, Halle E, Wise TN: Sexual functioning and psychologic evaluation of nitrofertilization couples. Fertil Steril 46:668, Lalos A, Lalos 0, Jacobsson L, von Schoultz B: Psychological reactions to the medical investigation and surgical treatment of infertility. Gynecol Obstet Invest 20:209, Lalos A, Lalos 0, Jacobsson L, von Schoultz B: A psychosocial characterization of infertile couples before surgical treatment of the female. J Psychosom Obstet Gynecol 4:83, Morse C, Dennerstein L: Infertile couples entering an invitro fertilization programme: A preliminary survey. J Psychosom Obstet GynecoI4:19, Link PW, Darling CA: Couples undergoing treatment for infertility: Dimensions of life satisfaction. J Sex Marital Ther 12:46, Shapiro CH: The impact of infertility on the marital relationship. Social Casework 63:387, McKewan KL, Costello CG, Taylor PJ: Adjustment to infertility. J Abnorm Psychol 96:108, Valentine DP: Psychological impact of infertility: Identifying issues and needs. Soc Work Health Care 11:61, Lalos A, Lalos 0, Jacobsson L, von Schoultz B: Depression, guilt and isolation among infertile women and their partners. J Psychosom Obstet GynecoI5:97, Noyes RW, Chapnik EM: Literature on psychology of infertility: A critical analysis. Fertil Steril15:543, Bresnick E, Taymore M: The role of counselling in infertility. Fertil Steril 32:154, Seibel MM, Taymore M: Emotional aspects of infertility. Fertil Steril 37:137, Pantesco V: Nonorganic infertility: Some research and treatment problems. Psychol Rep 58:731, Edelmann RJ, Connolly KJ: Psychological aspects of infertility. Br J Med Psychol 59:209, Derogatis LR: SCL-90-R administration, scoring and procedures manual, Vol. 2. Baltimore, Clinical Psychometric Research, Schlein G, Guerney B: Relationship change scale in relationship enhancement, Edited by BG Guerney. San Francisco, Jossey-Bass, 1977, p Locke HJ, Wallace KM: Short marital adjustment and prediction tests: Their reliability and validity. Marriage and Family Living 21:251, Hudson W: Index of sexual satisfaction. The Clinical Measurement Package. Illinois, Dorsey Press, 1982, p Daniluk Infertility: psychological impact Fertility and Sterility