Why are couples satisfied with infertility treatment?*

Transcription

1 FERTILITY AND STERILITY Vol. 59, No.5, May 1993 Copyright 1993 The American Fertility Society Printed on acid-free paper in U.S.A. Why are couples satisfied with infertility treatment?* L. Jill Halman, Ph.D.t:j: Antonia Abbey, Ph.D.t Frank M. Andrews, Ph.D.tll The University of Michigan, Ann Arbor, and Wayne State University, Detroit, Michigan Objective: To determine which factors relate to satisfaction with infertility treatment. Design: A prospective structured interview research design was used. Setting: In-person and telephone interviews were conducted. Participants: Wives and husbands from 185 couples in southeastern Michigan with primary infertility were studied. Main Outcome Measures: There were two main outcome measures: how satisfied people were with the infertility treatment they received and why they were satisfied. Results: Both men and women were satisfied with the infertility treatment they had received. The most frequently mentioned reasons for satisfaction were the technical skills and the emotional support of infertility specialists. Both men and women advised infertility specialists to be compassionate and share information with their patients. Spouses' satisfaction with treatment was the greatest predictor for both men and women. For men, using escape as a coping skill was a negative predictor for treatment satisfaction. For women, personal control and the number of infertility treatments received were other predictors for treatment satisfaction. Conclusions: As hypothesized, a variety of psychosocial factors were related to treatment satisfaction. Contrary to expectation, treatment costs and how long respondents had been trying to have a child were not related to treatment satisfaction. This study's results suggest that physicians and their staff should pay particular attention to their patients' emotional needs, to their patients' understanding of procedures explained to them, to discussing adoption with their patients, to involving men more in the infertility treatment, and to assisting women to have more control over their course of treatment. Fertil Steril1993;59: Key Words: Infertility, treatment satisfaction, psychosocial factors, gender differences Received August 10, 1992; revised and accepted January 13, * Supported by grant HD from the National Institute of Child Health and Human Development, Bethesda, Maryland. t Institute for Social Research, The University of Michigan. :j: Reprint requests: L. Jill Halman, Ph.D., Institute for Social Research, The University of Michigan, 3038 Survey Research Center, Ann Arbor, Michigan Department of Community Medicine, Wayne State University. II Department of Population Planning and International Health, School of Public Health, The University of Michigan. Although it is estimated that approximately 8 of married couples in the United States today experience fertility problems (1), not all infertile couples actually seek medical treatment. Approximately 51 of the people with primary infertility and 22 of the people with secondary infertility eventually do seek treatment (2). Technological developments over the last 20 years have improved physicians' ability to diagnose and treat various causes of infertility. Although these advances have improved couples' chances of successfully conceiving a child, they also present many new issues and decisions for these couples to address. Previous research has explored the stresses that couples presented with fertility problems and undergoing treatment have experienced (3-7). Although some people experience successful treatment early in the treatment process with relatively few 1046 Halman et al. Satisfaction with infertility treatment

2 and nonintrusive interventions being needed, other couples may experience years of treatment with many interventions, some of which are complex, invasive, and expensive. Treatment costs and number of tests and treatments received have correlated highly with the stress associated with fertility problems (8). Some authors describe the difficulties that the time necessary for treatment imposes on the lives of infertile couples, such as time off work and travel to attend appointments (9). Others describe the stress created by continually focusing on the infertility treatment and the couple wondering if this is the month they will finally become pregnant (10, 11). Given the number of people seeking infertility treatment, satisfaction with medical treatment is a logical next step to explore. Authors have shown that distressed patients were found to report more dissatisfaction with health care services received than nondistressed patients (12). Physician conduct (13), humaneness and technical quality of medical care (14), and sensitivity and environmental comfort (15) have also been shown to be highly indicative of patient satisfaction with care. Because patient satisfaction has been shown to be a good predictor of a patient's compliance with treatment and premature termination of treatment (16), it would seem that an exploration of patient reactions to infertility treatment would be helpful. This study examines men's and women's satisfaction with the infertility treatment they have received, their explanations for their satisfaction, their advice to infertility specialists, and predictors for their satisfaction with treatment, such as methods of coping with their fertility problem and their own sense of control over the resolution of their fertility problem. MATERIALS AND METHODS Study Participants This study was designed as a three-wave panel study with annual data collection in 1988, 1989, and Couples with primary infertility were principally recruited from all but one of the major infertility treatment centers in southeastern Michigan. Eighty-one percent ofthe eligible people participated in the study. Eligibility was defined as married, no previous children by either member of the couple, white, middle class, and not yet having tried IVF or GIFT. Middle class was defined as having at least a high school education and an annual gross income in the range of $20,000 to $100,000. Married white middle class couples were selected because this has been shown to be the majority of people seeking infertility treatment in the United States (17). Having a relatively homogeneous group of respondents allowed more sophisticated analyses to be conducted with a smaller number of cases. Couples who had not yet received IVF or GIFT were selected because we wanted to follow couples who were relatively early in the treatment process. The remaining couples were recruited from nonmedical sources, such as marriage license applicants, the Endometriosis Association, RESOLVE, newspaper advertisement, and referrals from other study participants, in descending order. Patients who fit this study's eligibility criteria were asked by their physicians if they were willing to participate in a university study of marriage, family, and childbearing issues. The physicians explained that the patients' receipt of treatment was not contingent on their participation in the study. To supplement the sample, self-help group members were recruited through an article printed in their organization's monthly newsletter, 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 sample of the previous year's marriage license applicants from the county in which most participants lived were also sent a letter inviting them to participate. The couples who were recruited from physicians and the couples who were recruited from other sources were similar in respect to their age, education, income, length of marriage, the length of time they had been trying to have a child, and the number of physicians they had seen. 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. The ethical guidelines of the American Psychological Association were followed throughout the study. The majority (87) of the infertile couples in the study during the first wave of data collection met the standard medical definition of infertility, i.e., 1 year of regular unprotected sexual intercourse without conceiving or the inability to carry a pregnancy to term. The remaining couples had been trying to conceive for <1 year, believed they were having difficulty having a child, and had already sought the services of an infertility specialist. These couples Vol. 59, No.5, May 1993 Halman et al. Satisfaction with infertility treatment 1047

3 were included in the data analysis because we were interested in examining satisfaction with infertility treatment for all people receiving such treatment. Separate in-person interviews were conducted with 185 infertile couples during the first wave of data collection. During 1989 and 1990, telephone interviews were conducted with the couples who had initially been interviewed in One hundred eighty-one and 174 couples who had been infertile in 1988 were interviewed in 1989 and 1990, respectively. Only couples who were continuing to receive infertility treatment were asked specific questions about their treatment in subsequent waves. Many couples either gave birth during the course of the study, adopted a child, or gave up trying to have a child. In 1989, which was the second wave of data collection, 103 husbands and 107 wives were asked questions about their satisfaction with infertility treatment; in 1990, which was the third wave of data collection, 80 husbands and 83 wives were asked questions about treatment satisfaction. The discrepancies between wives and husbands considering themselves actively seeking treatment show that respondents were giving answers that reflected their own beliefs and demonstrate the independence of the data collected from wives and husbands. For the purposes of this study, individuals had to consider themselves as continuing to actively seek treatment before they were asked questions about their treatment satisfaction. Although the words infertile and infertility are used in this paper, these words were not used during the interviews with couples. Infertile couples described their unease with these terms in pilot testing; they believed these words created a sense of finality. Instead, the phrase "fertility problem" was used, which was a more comfortable phrase for them to hear and use. Demographics At the time of the initial data collection, the women ranged in age from 22 to 42, with an average age of 32 (SD, 4.1); the men ranged in age from 23 to 44, with an average age of 34 (SD, 3.8). Women had completed an average of 2.5 years of college, and men had completed an average of 3 years of college. The couples had been married an average of 6 years and had an 1987 annual income in the range of approximately $55,000. Both men and women averaged 2.5 years trying to have a child and had seen an average of 2.4 physicians. Table 1 Cumulative Number of Tests for Married Couples With Primary Infertility From 1988 to 1990 Parental status in 1990 Livebirth (n = 59) Adoption (n = 14) Pregnant (n = 10) Still trying to have a child (n = 76) Gave up trying to have a child (n = 15) Total (n = 174) Men 2.5 (0 to 10)* 6.1 (1 to 11) 3.9 (1 to 12) 6.2 (0 to 19) 4.2 (0 to 11) 4.7 (0 to 19) * Values are means with ranges in parentheses. Women 7.0 (0 to 30) 15.4 (0 to 40) 14.9 (2 to 41) 16.7 (0 to 48) 11.7 (4 to 34) 12.8 (0 to 48) Table 1 shows the cumulative number of tests received over the three waves of data collection. The cumulative number of tests was measured by asking people at each data collection which medical procedures they had received in the last year to diagnose their particular fertility problem and the specific number of times they had received each procedure up to a maximum of five times per year. These numbers were then summed for each person over the entire data collection. The men and women were divided into five groups, depending on their parenthood status at the time of the last data collection in These groups included those with a livebirth, those who adopted, those who were pregnant, those who were still trying to have a child, and those who had given up trying to have a child. This table shows that women received more tests than men across all categories shown, a finding that is consistent with other research findings (18). Those women who adopted, who were pregnant, or who were still trying to have a child received the most tests; those with a livebirth had received the least number of tests. This may be showing that the majority of women who are successful in having a livebirth either do so relatively early in their treatment, causing fewer tests to be performed and/ or they may have a more easily diagnosed and treated problem. Measures The variables and scales used in the analyses in this report are described next. These include satisfaction with infertility treatment, advice to physicians, escape/avoidance coping, problem-solving coping, perceived personal control, and number of treatments received. All of these describe the data collection in Satisfaction with Treatment Respondents were asked, "We want to find out how you feel about the professional treatment you 1048 Halman et al. Satisfaction with infertility treatment

4 have received for your fertility problem. Overall, how would you say you feel?" Scores were measured on a 5-point Likert-type scale with 1 being very dissatisfied with the treatment they received to 5 being very satisfied. Respondents were then asked, "Can you briefly tell me why you answered that way?" Responses to this open-ended question were later summarized into several major categories, such as technical skills and information provided. The major categories were developed by the research team after examining the responses received from the respondents. The inter-rater agreement, which included clear-cut definitions of the categories provided and independent judgments of the coding staff, was 98. Advice to Physicians Respondents were specifically asked, "What advice would you give to physicians who treat patients with fertility problems?" Responses to this openended question were later summarized into several major categories, such as need to be compassionate and improve staff operations. The major categories were developed by the research team after examining the responses received from the respondents. The inter-rater agreement, which included clear-cut definitions of the categories provided and independent judgments among the coding staff, was 98. Escape/Avoidance Coping Measurement of this concept was based on the Folkman and Lazarus' Ways of Coping scale (19). A four-item Likert-type scale ranging from "not at all" to "a great deal" was used to measure how much the respondents used avoidance strategies such as fantasizing, hoping for a miracle, and wishing the situation would go away. Reliability, as measured by Cronbach's coefficient a, was Problem-Solving Coping Respondents were asked a series of three questions based on items developed by Folkman and Lazarus (19}. This four-item Likert-type scale measured problem-solving coping behavior, such as analyzing the situation, doubling efforts to make things work, and making an action plan. The Cronbach a was Perceived Personal Control Respondents were asked a series of five questions based on previous work by Abbey and Andrews (20). A five-item Likert-type scale ranging from strongly agree to strongly disagree included items asking respondents how much their life had worked out the way they wanted it to, how much they could run their life the way they wanted to, how much they carried out the plans they made, how much they felt in control of their lives, and how much they could do anything they set their minds to. The Cronbach a was Number of Treatments Respondents were read a list of commonly used treatments and asked if they were currently using that treatment, had used that treatment in the past, or had never used that treatment. Men's and women's lists shared some treatments if both partners were involved in that treatment, such as artificial insemination with the husband's sperm; their lists had some treatments listed separately if only that gender could receive that specific treatment, such as lysis for endometriosis. Men and women could also list any other treatments they were receiving or had received that were not on the printed list. The treatments ever received were then summed for each member of the couple separately. RESULTS Overall, wives and husbands were relatively similar in their satisfaction with treatment. The wives had a mean score of 3.8 in 1989 and 3. 7 in The husbands had a mean score of 3.5 in 1989 and 3.6 in Scores ran from 1, very dissatisfied to 5, very satisfied. There was not much change between 1989 and 1990, with both husbands and wives remaining somewhat satisfied. Explanations for Treatment Satisfaction Table 2 contains explanations for men's and women's satisfaction or dissatisfaction with infertility treatment. The responses reflect those people who were still trying to have a child in Both men and women showed the same hierarchy of responses, rating technical skills as their highest consideration. These included such things as, "My doctor is thorough," "my doctor is competent," "my doctors are doing all they can." Emotional responses of the physician, such as "my doctor cares about me," "... is warm, calm, supportive;" or on the negative side, "my doctor is insensitive," "... lacks compassion," "pays more attention to (one spouse) Vol. 59, No.5, May 1993 Halman et al. Satisfaction with infertility treatment 1049

5 Table 2 Explanations for Satisfaction or Dissatisfaction With Infertility Treatment Among Married Couples With Primary Infertility in 1990 Technical skills* Emotional responses Office staff Information provided Trust in physician Provision of counseling or referral to such * Multiple mentions allowed. Men Women (n = 81) (n = 83) than (the other)," rated second but were stated by considerably fewer respondents. For example, 89 of men stated technical skills were the basis of their rating, and 27 stated it was the physician's emotional response. Trust in physician was one of the least frequently spontaneously mentioned responses. Study participants who were still trying to have a child or had given up trying to have a child were asked what advice they would give to physicians who treat patients with fertility problems. Table 3 shows the advice infertile men and women would give to physicians who treat patients with fertility problems. Both men and women advised infertility specialists to be compassionate, which was the most frequently mentioned response to this open-ended question with 40 of the men and 48 of the women stating this. Information sharing, such as explaining options or treatment plans better or taking the time to ask or answer questions, was rated second with 26 of the men and 36 of the women giving this advice. The next two categories were to improve office staff operations, with 14 of the men and 17 of the women giving this advice, and to use more effective treatment, with 12 of the men and 15 of the women giving this advice. Eleven percent of the women wanted an infertility specialist to spend more time with them, whereas 5 of the men gave this advice. One difference between men and women was that 5 of the women advised infertility specialists to provide referrals to a support group for their patients, whereas none of the men gave this advice. The second most commonly mentioned advice was to share information with patients. Examination of the questionnaires of the people giving this response raises questions concerning how well informed they were about their treatment. The most common specific complaint was that physicians needed to explain the plan of treatment to the individual patient. Respondents said such things as follows: "Be freer with information." "Let people know what (the physicians) plan on doing." "Set up a plan of action and let the patient know beforehand." "Give an overview of procedures and what is going to be done." "Be sure the patient understands what you are prescribing and what the long-term plan is." "Be more explicit." "Let (the patient) know exactly what is going on." "Leave no doubts." The second specific recommendation was that respondents wanted to have all the options available to them explained, including adoption. As one respondent said, "Give the patient all possibilities and alternatives, such as adoption." Several other specific suggestions included the following: "Use layman's terms." "Ask questions of the patient to see if they understand." "Review the risks involved." "Prepare patients for lack of success." "Give Table 3 Advice to Infertility Specialists From Married Couples in 1990 Advice Need to be compassionate* Share information Improve office staff operations Use more effective treatment Be honest, open Nothing different Respect individual differences Spend more time with patient Include both spouses Tell patient when to stop treatment * Multiple mentions allowed. Men (n = 77) Women Advice (n = 81) Need to be compassionate 48 Share information 36 Improve office staff operations 17 Use more effective treatment 15 Spend more time with patient 11 Be honest, open 7 Nothing different 6 Respect individual differences 5 Include both spouses 5 Refer to support group 5 Tell patient when to stop treatment Halman et al. Satisfaction with infertility treatment

6 Table 4 Stepwise Multiple Regression of Predictors of Husbands' Satisfaction With Infertility Treatment in 1990 Step Variable entered {3 at step 5 1 Spouses' treatment satisfaction Escape coping Personal control No. of treatments Problem-solving coping Fraction of explained variance at each step Significance at step 5 Adjusted Unadjusted reasonable expectations." "Involve nurses in information sharing." Predictors for Patient Satisfaction Tables 4 and 5 show the results of stepwise forward multiple regressions exploring predictors of patient satisfaction with infertility treatment. Although we examined other variables that have been previously shown to predict fertility stress and that we had thought would contribute to patient satisfaction, such as how long respondents had been trying to have a child, the total costs incurred from treatment, and the total number of tests received during treatment, these were not found to be even moderately associated with treatment satisfaction (all r were <0.20). Instead, escape coping, problemsolving coping, personal control, the number of treatments received and spouses' satisfaction with treatment were found to have the highest correlations with treatment satisfaction. A stepwise forward regression was used because this was a preliminary analysis and because we wanted to use the most conservative model possible. In this way, we could examine the change in the variance associated with the addition of each separate variable. Table 4 shows the predictors of husbands' satisfaction. The predictors explaining the most variance were spouses' treatment satisfaction, escape coping, and personal control. Although spouses' treatment satisfaction was the most significant predictor, escape coping and personal control contributed additional amounts of explained variance. The more satisfied their wives were with the infertility treatment they had received, the more husbands were satisfied with the treatment. The less men used escape coping, the more satisfied they were with treatment. The more control men felt they had, the more satisfied they were with infertility treatment. These predictors cumulatively explained 25, 27, and 28 of the variance after adjusting for the sample size. The additional two variables did not add to the amount of explained variance. Table 5 shows the predictors of wives' satisfaction. Slightly more of the variance could be explained for wives than for husbands. In this table, spouses' treatment satisfaction, personal control, and number of treatments cumulatively explained 25,29, and 31 of the adjusted variance. Although spouses' treatment satisfaction was the only significant predictor at step 5, personal control was significant at P.::; 0.05 at steps 2 and 3. Although the number of treatments was not a significant predictor, it did add to the percentage of the variance explained. The more satisfied husbands were with infertility treatment Table 5 Stepwise Multiple Regression of Predictors of Wives' Satisfaction With Infertility Treatment in 1990 Fraction of explained variance at each step Significance Step Variable entered {3 at step 5 at step 5 Adjusted Unadjusted 1 Spouses' treatment satisfaction Personal control No. of treatments Problem-solving coping Escape coping Vol. 59, No.5, May 1993 Halman et al. Satisfaction with infertility treatment 1051

7 and the more control the wives felt over their fertility problem, the more satisfied women were with treatment. The fewer treatments the wives received for their fertility problem, the more satisfied they were with the treatment. When the stepwise multiple regressions were conducted without the spouses' satisfaction with infertility treatment being included, the variables predicting satisfaction with infertility treatment remained the same. This shows that if the spouses' treatment satisfaction is controlled, coping skills, sense of personal control, and the number of infertility treatments received impact on satisfaction with treatment in the same way. DISCUSSION This study has shown that patients tend to be generally satisfied with the infertility treatment that they are receiving or have received. As was shown in Table 2, a person's confidence in the technical skills of their treating physician was the greatest explanation for satisfaction with treatment when people were asked this question directly. This seems to show that people value the technical skills of their physician the most and are willing to receive less emotional satisfaction or information about their treatment if they believe the infertility treatment will eventually be successful and yield a child for them. This is contradictory with what has been previously thought about peoples' judgments about their health care. Others have shown that resolution of a disease or a practitioner's manner and communication pattern will have the greatest explanation for satisfaction with treatment (21). It may be that infertile patients are a unique population who are better informed about infertility treatment than other types of patients. This may be why they rate technical skills so highly. Or, as has been stated by others, people may not really judge the technical quality of care they receive, but rather they judge how the care they do receive is given (22). If the care they receive is delivered in a friendly and competent manner, people judge the specialist as having high technical skills. Finally, one could conclude that people receiving infertility treatment may be very open and receptive to various treatments ifthey have faith in a specific physician's ability to treat them successfully. This has implications for physicians and their staff working with these couples. Physicians and their staff need to recognize the vulnerability of the couples they are treating and pay particular attention to their patients' emotional needs and their understanding of procedures explained to them. Infertile couples in this study advised infertility specialists to show more compassion and share more information about their treatment. This may be related to infertile persons' explanations for their satisfaction with care. Previous studies have shown that people receiving infertility treatments experience high levels of stress (8, 23). The stress experienced may interfere with a person's ability to understand and retain explanations about their care and plans for treatments. Professionals treating these people may need to pay particular attention to this and verify that their clients understand what is being said. Questions to evaluate understanding of a previously given explanation or outlined treatment of care and repetition of these explanations may need to be given to ensure that the entire message is being received. Infertile people also need and have requested that adoption alternatives be discussed with them by their infertility specialist. Assumptions may be made that a couple seeking infertility treatment has already decided not to adopt or that they will seek adoption consultation through another source. However, the repeated statements about the need for adoption to be addressed imply that infertile couples need to have this alternative discussed and given legitimacy as an alternative by their infertility specialist. Concerns about lack of information about treatment and its prognosis and the lack of information about alternative interventions such as adoption by people receiving treatment have been found by other researchers (24). Several caveats are necessary before the implications of the stepwise forward multiple regression results are discussed. 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 social variables described in this study are causal predictors of satisfaction with treatment, such a conclusion cannot be made with cross-sectional data. The manner in which we collected the data about patient satisfaction with infertility treatment did not allow us to examine causality but rather allowed us to examine correlations and associations. We are 1052 Halman et al. Satisfaction with infertility treatment

8 theorizing the direction of the association. Longitudinal research about patient satisfaction with infertility treatment is needed to show causality. As we examined predictors of satisfaction with infertility treatment by gender, we were surprised to find that some predictors that we had hypothesized to impact on treatment satisfaction did not have the association we had expected. These predictors included such measures as treatment costs, the number of medical practices visited, the length of time trying to have a child, the acceptability of an individual's prescribed treatment to that individual, and a couple's annual income. Instead, we found that coping skills, such as escape/avoidance and problem solving, a personal sense of control, and the spouses' satisfaction with infertility treatment related to treatment satisfaction the most. The number of treatments received, which was expected to relate to treatment satisfaction, did so in this analysis. There were similarities and differences between men and women. For men, the wives' satisfaction with treatment, escape coping, and personal control were the strongest predictors of treatment satisfaction. Allowing men to feel more control over the solution to their fertility problem and helping them to face the problem rather than avoiding it may increase their satisfaction with treatment. Assisting men to participate in the infertility treatment, which frequently involves only their wives, may also help them to be more satisfied with treatment. A complaint made by men has been that infertility treatment seems to focus on their wives and that this makes them feel left out of the process. This finding supports those statements. Among women, their husbands' satisfaction with treatment, the wives' higher feeling of control over their fertility problem, and the number of treatments received associated highly with the wives' satisfaction with infertility treatment. These findings have the same implications for women as they do for men. That is, if a woman feels more control over the solution of the couple's fertility problem through such activities as involvement in making decisions about when to begin a treatment or which treatment to use, a woman's satisfaction with treatment will increase. The finding that the husbands' satisfaction with treatment associates so strongly with the wives' satisfaction with treatment further supports involvement of the husband in treatment. The finding that receiving more treatments impacted negatively on women's satisfaction with treatment may be showing women's frustration with continuing toreceive treatments and not yet conceiving. This would then impact negatively on treatment satisfaction. Although the (3 for number of treatments (0.10 for men and for women) were relatively similar, they loaded differently in the stepwise forward regression. In summary, we found that infertile couples are generally satisfied with their treatment but did have valuable, constructive suggestions for health care practitioners involved in providing infertility treatment. Some predictors for treatment satisfaction were shared by spouses, such as the spouse's satisfaction with treatment and a sense of personal control. However, there were also differences between genders. These differences need to be recognized. By addressing the concerns raised by recipients of infertility treatment, infertility specialists and their staff can improve their clients' satisfaction with the care they receive. REFERENCES 1. Mosher WD, Pratt WF. Fecundity and infertility in the United States: incidence and trends. Fertil Steril 1991;56: Office of Technology Assessment: Infertility: medical and social choices. Washington DC: US Government Printing Office, 1988:3-6, publication number OTA-BA Menning BE. The emotional needs of infertile couples. 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9 14. Hall JA, Dornan MC. What patients like about their medical care and how often they are asked: a meta-analysis of the satisfaction literature. Soc Sci Med 1988;27: Blenner JL. Stress and mediators: patients' perceptions of infertility treatment. Nurs Res 1992;41: Ware JE, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eva! Program Plann 1983;6: Mosher WD, Pratt WF. Fecundity and infertility in the United States, In: Advance data from vital and health statistics of the national center for health statistics, No 192, Dec 4, Hyattsville, MD: National Center for Health Statistics. 18. McGrade JJ, Tolor A. The reaction to infertility and the infertility investigation: a comparison of the responses of men and women. Infertility 1981;4: Folkman S, Lazarus RS. If it changes it must be a process: study of emotion and coping during three stages of a college examination. J Pers Soc Psycho! 1985;48: Abbey A, Andrews FM. Modeling the psychological determinants of life quality. Soc Ind Res 1985;16: Taylor SE. Health psychology. New York: Random House, Ben-Sira Z. Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory. J Health Soc Behav 1980;21: Andrews FM, Abbey A, Halman LJ. Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples. Fertil Steril1992;57: Sabourin S, Wright J, Duchesne C, Belisle S. Are consumers of modern fertility treatments satisfied? Fertil Steril 1991;56: Halman et al. Satisfaction with infertility treatment