Coping strategies and psychological adjustment of couples presenting for IVF

Copyright c 1994 Elsevier Saence Ltd Prmted in Great Britatn. All rights reserved 0022-3999,‘94 $7.00 + 00

Pergamon

COPING STRATEGIES AND PSYCHOLOGICAL ADJUSTMENT OF COUPLES PRESENTING FOR IVF ROBERT J. EDELMANN,* KEVIN J. CONNOLLY? and HELEN BARTLETT? (Received

24 March

1993; accepted

in revisedform

8 October

1993)

Abstract-The study was designed to examine the extent to which the psychological profiles of couples entering an IVF programme were influenced by evidence of previous fertility, the history of fertility investigations, the diagnosis made, and the coping strategies adopted. A sample of 152 couples was administered a number of standardized psychological instruments and a coping strategies questionnaire. They showed little variation from the normative range on the standardized measures. There was little evidence of differences between couples referred for primary or secondary infertility, between those with some evidence of fertility and those with none, or between different diagnostic groups. In relation to coping strategy, for women at least, taking direct action appears to be effective if it is associated with some degree of acceptance of one’s position. For males, the picture is less clear, though direct action and acceptance again appear to be effective coping strategies.

INTRODUCTION

IT HAS often been argued that long-standing infertility has a negative effect on psychological functioning, which results in emotional distress [l] and marital problems [2]. However, many of these claims are based upon anecdotal reports, or derived from non-standardized measures or from investigations which have failed to use suitable controls. Investigations comparing infertile with fertile individuals have revealed few, if any, differences on measures of anxiety or depression [3, 41 and suggest that the marital relationships of the infertile couples studied are quite stable [5]. Such differing findings are probably due, in part, to the methodological issues alluded to above, and in the case of state measures may reflect factors, such as the stage of investigation or treatment at which couples are examined. Thus, some have suggested that anxiety is a major problem for couples embarking upon infertility treatment [6, 71. Indeed, a number of authors have suggested that emotional difficulties may be more pronounced in patients undergoing in vitro fertilization (IVF) since the procedure is often considered to be a ‘last chance’ for a biological child [8,9]. However, studies that have used a variety of both state and trait measures to assess couples proposing to embark on IVF have commonly found that their scores did not differ either from normative data or from those of fertile controls. Thus, Newton et al. [IO] reported anxiety scores to be within the normal range for couples embarking on IVF treatment and Hearn et al. [I l] who assessed 300 couples (consecutive admissions to their IVF programme) obtained scores indicative of good marital relationships. They found also that measurements of depression, anxiety, emotional adjustment and coping gave scores that corresponded closely to those of a normative sample. In a

*Department tDepartment

of Psychology, of Psychology,

University University

of Surrey, Guildford GU2 5XH, U.K of Sheffield, Sheffield SlO 2UR, U.K.

355

356

R.J.

EDELMANN

et al.

further study, Chan et al. [12] report psychological profiles (personality, anxiety, psychiatric morbidity and depression) for 112 couples consecutively enrolled in their IVFjGIFT programme. The profiles were found to be similar to those of pregnant Chinese women. For the most part, however, these studies have tended to treat IVF couples as a homogeneous group, ignoring both their past fertility history and the variance in their adaptability to threatening events. Thus, one might assume that couples of proven fertility, those who have achieved a pregnancy without medical intervention, even if the pregnancy was not carried to term, might be more positive and hence less anxious about IVF. A similar case could be made for couples who have had a relatively short history of sub-fertility and associated medical investigations. In addition, patients entering IVF programmes do so having been given various diagnoses. The couples can be broadly grouped into four sub-sets as follows: (1) those diagnosed with a male factor; (2) those diagnosed with a female factor; (3) those diagnosed with male and female factors; and (4) an unexplained group which has been offered no diagnosis so far. There is evidence suggesting that a diagnosis of male infertility may present the couple with particular difficulties [4, 131, while the continuing uncertainty of unexplained infertility places a greater strain on both partners and their relationship than does a definite diagnosis [14]. Finally, coping style is likely to influence psychological adjustment. The use of avoidance coping strategies has been associated with greater emotional distress in infertile couples [6, 151 and in couples who have failed to conceive as a result of IVF [16]. Given these observations, it would not be surprising to find great variability both within and between investigations reporting psychological evaluations of couples entering IVF programmes. The aim of the present study was to conduct a comprehensive psychological evaluation of couples entering an IVF programme, paying particular attention to variability in the psychological profile in relation to fertility history and coping strategies adopted. In view of the evidence in the existing literature, it was hypothesized that psychological distress would be elevated in couples with: (i) no evidence of previous fertility; (ii) a long history of infertility investigations; (iii) a diagnosis of male infertility; and (iv) those who adopted avoidance coping strategies.

METHOD Participants

The initial sample consisted of 155 couples who were consecutive referrals to an IVF clinic, none of whom had any prior experience of IVF treatment. Three couples declined to participate, giving a final sample of 152. For 101 couples, organic causes for their infertility had been diagnosed. In twenty-six (19.6%) cases, reproductive failure was attributed to the male alone and in fifty-seven (37.5%) cases, to the female alone. In a further eighteen (1I .8%) cases, both the male and female members of the pair were found to have difficulties which contributed to the failure to reproduce. Forty-one per cent of female partners (N = 63) had some evidence of previous fertility compared with 35.5% of male partners (N = 54). Twentyseven per cent of couples in the study (N = 41) had evidence of their fertility in their present relationship. The period over which the couples had been attempting to conceive ranged from 6 months to 15 yr (mean 5.4 yr; SD 3. I). The duration of infertility investigations ranged from 3 months to 14 yr (mean 3.5 yr; SD 2.4). The mean age of the sample was 32 yr (range 23-43 yr; SD 4.1) for females and 34 yr (range 21 53 yr; st> 5.6) for males. Social class distributions, determined on the basis of the male’s occupation [17] reflected a bias towards the upper end of the distribution, the percentage of the sample in each social class was: 1. 24; II, 15; III, 38; IV. 11: v. 12.

357

Coping strategies in IVF Measure.7

Patients provided basic demographic data and information on fertility history. They were also asked to complete two single item five-point rating scales assessing the impact of infertility on their marital and sexual relationship (from 1 = major impact, to 5 = no impact). In addition, they completed the following standard psychological measures. Eysenck Personality Questionnaire (EQP). The EPQ is made up of ninety questions to be answered yes or no. These are grouped into four sets comprising: psychoticism (P), extroversion (E), neuroticism(N) and Lie (L) scales [18]. G&era/ Health Questionnaire (GHQ). The GHQ is a self-administered screening instrument designed to detect psychiatric morbidity in the community. In its original form, it consisted of sixty items. The thirtyitem scale (GHQ-30) was used in the study reported here [ 191. State-Trait Anxiety Inventory (STAIj. The test comprises two different sets of twenty questions describing feelings of tension, worry or apprehension. One set of questions deals with how the respondent feels now (state) and the other with how they generally feel (trait) [20]. Self-Esteem Scale (SES). This scale consists of ten items to which respondents indicate on a four-point scale the extent to which they agree/disagree that each of the ten statements applies to them, high scores are indicative of poor self-esteem [21]. ProJile of Mood Slate-Bipolar Form (POMS). This involves self assessment on six dimensions: composed-anxious; agreeableehostile; elateddepressed; confident&unsure; energetic-tired; and clearheadedconfused; each represented by a bipolar rating [22]. Coping Strategies Questionnaire (CSQ). This questionnaire identifies eight coping strategies (distraction, redefining the situation, direct action, catharsis, acceptance, seeking social support, relaxation and religion) together with a brief description of each category. It was developed by Stone and Neale [23] and in its original form individuals were asked to indicate by yes/no responses the strategies they used to deal with daily traumas. In the present study, participants were asked to indicate for each strategy whether or not this was one they generally used to help them deal with the difficulties presented by infertility. Procedure All the couples were assessed on their first visit to the clinic before their consultation with the centre’s medical staff, both male and female partners attended. The investigation, which was explained to them in a letter making the first clinic appointment, was conducted with the informed consent of the participants.

RESULTS

Standard psychological measures The results from the standardized psychometric measures, along with the appropriate normative data, are presented in Table I. State-trait anxiety scores for males closely match the data available for working adults [20]. Although the scores for females are slightly elevated relative to the normative data on working adults, they are closely similar to data presented by Speilberger et al. for college and high school students. The state-trait anxiety scores also match well those reported by Edelmann er al. [24] for a comparable sample of infertile patients. The GHQ scores for the present sample are slightly lower than those reported by Edelmann et al. [24] for both the parents of nursery school children (proven fertility) and an infertile sample. The Rosenberg self-esteem scores are similar to those reported by Mayhew and Edelmann [25] for female undergraduates. The EPQ and POMS scores for both males and females resemble normative data [I 8, 221. Overall, the scores obtained by couples electing for IVF show little deviation from available normative and comparable data. Fertility history Brief details

of any previous

pregnancy

involving

either the male or female,

are

358

R. J. EVMMANN TABLE l.-MEANS,

STAMIAKU

et al.

L~I'VIATIONS AND NORMATIVE SCORES FOR STAN,>AKI)MIXSCKES

Fcmalc

partners

Male partners mean

Measure STAI sub-scales: I State anxiety 2 Trait anxiety

GHQ Rosenberg

Self-Esteem

Scale

24.49

9.32

152

20.

27.15

4.81

152

31.14

1.80 13.05 12.40 10.46

I .52 4.66 4.89 4.55

151 151 151 151

45.02 (19) 47.66 (27) 49.05 (23) 46.34 (19) 49.84 (20) 49.65 (24)

8.Y7

I51

x.39

151

8.77

151

7.51

151

7.54

151

9.32

I51

152 152

POMS sub-scales: I Composed-Anxious

152 152

3 Elated~-Depressed

152

4 Confident

152

Unsure

36.97 34.22

I52

152 I52 I52

Hostile

152 152

42.89 3x.74

EPQ sub-scales: 1 Psychoticism 2 Extraversion 3 Neuroticism 4 Lie

2 Agreeable

9.62 X.06

151 151

5 Energetic~ Tired

152

6 Clear-headed-Confused

I52

SO

9.41 6.57

35.2 34.x

35.7 34.x

8.07

26.5

22.6

5.19

28.6

2.84 13.80 7.81 8.43

2.17 4.67 4.68 4.07

2.6 12.6 12.7 7.7

52. I3 (25) 49.76 (28) 53.65 (27) 54.64 (25) 53.66 (24) 54.59 (27)

x.44

population norm 22.6

8.02

27.6

8.82

23.2

x.42

21.9

X.46

20. I

9.64

24.1

I7

Mean scores for the POMS sub-scales are based on raw scores for each partner. given in parentheses below the mean scores.

corrected

3.5 13.2 9.x 6.X

scores are

presented in Table II. It should be noted that these categories are not mutually exclusive. To examine the data more closely, the participants were divided into four sub-sets as follows: group 1: showing no evidence of past fertility for either female (N = 89) or male (N = 105); group 2: a past miscarriage, ectopic pregnancy or still birth reported by either the female (N = 21) or her partner (N = 24): group 3: in which a termination was reported by female (N = 11) or her partner (N= 1); and group 4: where a pregnancy carried to term was reported by the female (N = 31) or her partner (N = 22). The four female groups and three male groups (the male group 3 with an N of 1 was excluded), were compared on measures of state anxiety, self esteem, mood

TABLE

Details of pregnancy Full-term Miscarried Terminated Ectopic Stillbirth

II.

EVIDENCE

OF FEKTILITY

Female N 31 22 19 20 3

AMONGST

partners % 20.4 14.5 12.5 13.2 2.0

COUPLES

Male partners N % 27 21 2 20

I

17.8 13.8 1.3 13.2 0.7

359

Coping strategies in IVF

state and the two single item ratings for impact of infertility on the couples’ marital and sexual relationships. There were no significant between group differences. To explore the relationship between how long a couple had been trying to have a child. and also how long they had been undergoing treatment, correlations were calculated between these variables and scores on state anxiety, self esteeem, mood state and ratings for the impact of infertility on the couples’ marital and sexual relationships. Correlations with state anxiety, self-esteem and mood state were nonsignificant. Small but significant correlations were obtained between the length of time a couple had been trying to conceive and the number of years they had been undergoing treatment, with measures of the impact of infertility on the marital relationships for females (v = 0.18, p < 0.05 and r = 0.17, p < 0.05 respectively) and between the time trying to conceive with the impact of infertility on the sexual relationship for males (r = 0.16, p < 0.05). This finding suggests that the longer the period couples spend attempting to resolve their problem, the less the impact on aspects of their relationship. Cause

ef infertilitJ1

The participants were divided into four sub-groups dependent upon whether their infertility remained (1) unexplained or whether reproductive failure was attributed to (2) the male, or (3) the female, or (4) both male and female partners. Males and females in these four sub-groups were then compared separately on measures of state anxiety, self-esteem, mood state and the two single item ratings for impact of infertility on couples’ marital and sexual relationships. In the case of females there was a significant main effect for the two impact ratings (F = 2.5, p < 0.05; F = 4.2, p < 0.01). The cause of infertility located with herself rated as being the most likely to impact on the marital relationship while a diagnosis of either male or female infertility was more likely to impact on the sexual relationship. In the case of males there was a significant main effect for the confident-unsure sub-scale of the POMS (F = 2.9, p < 0.05) and the impact on the sexual relationship (F = 2.6, p < 0.05). A diagnosis of male infertility related to lower confidence while a diagnosis of female infertility was most likely to impact on the couple’s sexual relationship. The mean scores of the four groups on these measures are presented in Table III. Coping The extent to which the various coping strategies were used by the couples is shown in Table IV. There is a broad similarity between males and females concerning the strategies used; for both sexes the most commonly used method is direct action. This accords with the fact that the couples are actively engaged in pursuing treatment, that is in taking action to change their state, often over a period of several years. The low TABLE III. -VARIABLES

SHOWING

DIFFERENCESIN RELATIONTO DIAGNOSTIC Unexplained

Impact on marital relationship (F) Impact on sexual relationship (F) Confident-Unsure POMS (M) Impact on sexual relationship (M)

2.6 2.6 53.27 2.32

CLASS

Male

Female

Both

2.6 1.8 52.83 I.91

1.9 I.8 59.55 1.65

2.5 2.7 54.45 1.78

360

R. .I. EDELMANN et al. TABLE IV.-PERCENTAGE OF MALES AND FEMALES WHO USED THE VARIOUS COPING STRATEGIES strategy Distraction Redefinition Direct Action Catharsis Acceptance Social Support Relaxation Religion

Female

Males

78 6X 86 76 24 85 48 24

63 68 78 45 22 5x 55 16

frequency with which couples simply accept their problem is congruent with a genera1 commitment to action. In order to examine the results further, the relationship between the coping strategies used (dependent variables) and state anxiety, self-esteem and mood state (independent variables) was analysed by canonical variate analyses [26, 271 for males and females separately. This analysis is an extension of multiple regression analysis with one dependent variable to multiple regression with more than one dependent variable. The fundamental idea is that through least squares analysis two linear composites are formed, one for independent and one for dependent variables. The correlations between these two composites is the canonical correlation. If there is more than one source of covariation in the two sets of variables being analysed then more than one canonical correlation can be found. For females. the first four canonical variates produced meaningful patterns of weights. These accounted for 87% of the variance (see Table V). The standardized coefficients for the canonical variates for the dependent and independent variables are given in Table V. Assuming 0.3 as a salient cut-off, the first canonical variate emphasizes infrequent use of distraction and acceptance, but frequent use of direct action and religion. This relates to the anxious and tired dimensions of the POMS sub-scales and also to the agreeable, elated and confident dimensions. The second canonical variate emphasizes infrequent use of redefinition and social support as coping strategies but frequent use of direct action and acceptance. This relates to low GHQ scores and to the composed, agreeable, elated, energetic and clear-headed dimensions of the POMS. The third canonical variate emphasizes infrequent use of catharsis but frequent use of redefinition, acceptance and religion. This relates to low state anxiety and low GHQ scores and to the composed, agreeable, elated, confident and energetic sub-scales of the POMS. The fourth canonical variate emphasizes infrequent use of relaxation and frequent use of acceptance. It relates to low state anxiety scores and to the composed, confident, energetic and clear-headed dimension of the POMS. For women at least, it seems that some element of acceptance is related to better adjustment; indeed, direct action may only represent a positive step if it is associated with some degree of acceptance of one’s position. For males, the first four canonical variates provided meaningful patterns of weights. These accounted for 90% of the variance. The standardized coefficients for the canonical variates for the dependent and independent variables are given in Table

Coping TABLE

V.-CANONICAL

VARIATES:

strategies

STANDARDIZED CANONICAL

in

361

IVF

COEFFICIENTS

FOR FEMALES,

Canonical

Dependent variables distraction redefinition direct action catharsis acceptance social support relaxation religion Independent variables STAI-state

EIGENVALUES

AND

CORRELATIONS variate

1

2

3

4

- 0.81 0.10 0.45 - 0.20 - 0.36 0.08 - 0.16 0.39

0.12 - 0.67 0.41 0.09 0.61 - 0.32 0.15 0.14

- 0.02 0.50 0.14 - 0.59 0.39 0.21 0.11 0.42

- 0.13 0.26 0.17 0.07 0.52 - 0.23 - 0.80 - 0.17

0.00

- 0.63 - 0.52 - 0.27

- 0.34 - 0.27 0.23

SES POMs sub-scales Composed-Anxious Agreeable-Hostile Elated-Depressed Confident-Unsure Energetic-Tired Clear-headed-Confused

0.06

0.24 - 0.45 - 0.01

- 0.76 0.60 0.42 0.44 - 0.01 0.09

0.37 0.54 0.33 0.11 0.37 0.44

0.44 0.33 0.57 0.39 0.40 0.18

0.40 0.28 0.20 0.78 0.43 0.67

eigenvalues percentage variance cumulative percentage canonical correlation

0.17 38.1 38.1 0.38

0.11 25.3 63.4 0.32

0.07 15.0 78.4 0.25

0.04 8.4 86.8 0.19

GHQ

- 0.24

variance

VI. Again, assuming 0.3 as a cut-off, the first canonical variate emphasizes infrequent use of relaxation but frequent use of distraction. It relates to the depressed and unsure dimensions of the POMS sub-scales and also to the clear-headed dimension. The second canonical variate emphasizes infrequent use of direct action and relaxation but frequent use of redefinition. It relates to high state anxiety levels, to the anxious dimension of the POMS and also to the confident and energetic dimensions. The third canonical variate emphasizes infrequent use of social support along with frequent use of distraction, catharsis and acceptance. It relates to a low level of state anxiety, high self-esteem and to the composed dimension of the POMS. The fourth canonical variate emphasizes infrequent use of catharsis and frequent use of redefinition, direct action, acceptance and social support. This relates to high state anxiety but low GHQ scores and high self-esteem and to the composed, elated and also hostile dimensions of the POMS. Although the pattern of results is less clear for males than for females, some element of acceptance appears to play a part in adjustment. Redefinition and direct action also seem to have some importance.

DISCUSSION

The finding that couples show little deviation from normative standardized measures used is in accord with both our own previous

data on the results [4, 241

362 TABLE VI.

R. J. EDELMANN et al. CANONICAL

VARIATES: STANDARDIZED COEFPICIENTSFOR MALES. EIGFNVALUES Aw (‘ORRELATES

Canonical

Independent STAI-state

~ -

variate

2

3

4

0.49 0.29 0.04 0.29 0.02 0.18 0.68 0.04

- 0.05 0.75 - 0.51 ~ 0.04 0.00 0.04 ~ 0.49 - 0.02

0.44 0.1 I - 0.14 0.40 0.50 ~- 0.64 0.25 - 0. I5

0.03 0.34 0.33 - 0.94 0.37 0.30 0.29 0.18

0.26 0.05 0.11

0.59 - 0.03 0. I3

- 0.39 0.04 - 0.55

0.96 ~ 0.51 ~ 0.32

I

Dependent variables distraction redefinition direct action catharsis acceptance social support relaxation religion

CANONK-AI.

variables

GHQ SES POMs sub-scales Composed-Anxious Agreeable Hostile Elated&Depressed Confident-Unsure Energetic Tired Clear-headed-Confused

0.16 - 0.22 - 0.78 ~ 0.71 0.28 1.47

- 0.x7 0.25 ~ 0.22 0.79 0.30 0.12

0.51 0.02 - 1.02 0.08 0.22 - 0.34

0.80 - 0.70 0.32

eigenvalues percentage values cumulative percentage canonical correlation

0.24 30.6 30.6 0.44

0.18 23.8 54.4 0.39

0.17 21.5 75.9 0.38

0.1 I 14.2 90.2 0.31

variance

0.25 0.06 0.10

and other studies that have used similar measures with couples admitted to IVF programmes [l&12]. Most recent available evidence thus suggests that infertile couples are psychologically well adjusted. It is of course possible that only well adjusted couples get as far as seeking medical help in their efforts to conceive, in other cases, the relationship may be too vulnerable to withstand further strain occasioned by more investigations. This postulated self-selection effect may be taken a step further in relation to IVF programmes. Each diagnostic investigation or treatment stage is likely to provoke anxiety and, occasionally, some distress. It is important that investigators who refer to anxiety and distress occasioned by infertility [28. 291 do not create the impression that this is anything other than an entirely normal reaction to the difficult circumstances encountered from time to time by well adjusted couples. This point is also reflected by the fact that there was little difference between couples who had evidence of past fertility compared to those with no evidence of their fertility, or between those referred for TVF because of primary or secondary infertility. The couples are well adjusted and there is no indication of damage to the marital or sexual relationship as the period over which the couples have been trying to conceive or undergoing treatment lengthens. Indeed, such evidence as we have suggest a lessened impact over time.

Coping

strategies

in IVF

363

The failure to find any substantive difference between diagnostic groups appears to contrast with our previous findings which suggested that male infertility may create particular difficulties for the couple concerned [4, 131. However, it should be borne in mind that although the diagnosis differed between couples, the treatment did not. In each case, the couple were hoping for a child biologically related to both of them. The findings of elevated distress in cases of male infertility may well be related to the fact that donor insemination (DI) is likely to be perceived by these men as the only available treatment which would result in a child genetically unrelated to the father. It is hardly surprising that taking direct action is the coping strategy most frequently used by couples who have elected for IVF, clearly it is consonant with their behaviour. Whether the decision to take direct action serves to make a couple psychologically vulnerable in the event of IVF failure is a matter of interest. For women at least, it seems that direct action may only represent a positive step if it is associated with some degree of acceptance of one’s position. In the case of males, the picture is less clear; while direct action and acceptance appear to be positive coping strategies, a redefinition of the situation also seems to play an important role. Previous studies of coping style in relation to IVF have assessed patients subsequent to IVF failure [16,30]. Drawing on Lazarus and Folkman’s [3 l] cognitive model of coping, these studies found that avoidance coping was associated with a poor outcome. The cognitive model of coping emphasizes the distinction between active, problem focused strategies and avoidant, emotion focused strategies. The former are adaptive in controllable situations, the latter in uncontrollable situations, although the literature provides only equivocal support for such a hypothesis. Although the coping strategies described in the present study do not fall exactly into these sets, direct action is clearly an example of problem focused coping, while acceptance represents a more emotionally based style. Entering an IVF programme reflects elements of both controllable and uncontrollable events and circumstances-the couple exercise control over whether or not to seek treatment, but they have little control over its outcome. At the outset of treatment, the most adaptive coping may thus involve elements of behavioural attempts to deal with the situation by taking direct action, while, at the same time, realistically appraising the situation which leads to an element of acceptance. Such acceptance may involve an acknowledgement by the couple that they may ultimately remain childless without at the same time losing their optimism about the outcome [7, 321. Following the failure of treatment by IVF, emotionally focused coping may then be more effective in dealing with the associated distress. Whether the most effective coping strategy differs at various stages of IVF treatment is clearly an area which warrants further consideration and investigation. In conclusion, the evidence seems to suggest that while infertility treatment is no doubt emotionally demanding, couples presenting for IVF are, in general, well adjusted. Their stable psychological profile in general, appears not to be affected by past fertility history. This stability may be partly due to a process of self selection, whereby only those who feel able to meet the emotional demands reach this stage of infertility treatment. Acknowledgemenrs-The work reported was supported by a research grant from the Department of Health. The authors are grateful to Professor I. D. Cooke, Dr E. Lenton and Mrs S. Pike for help and advice and to Dr Sean Hammond for statistical guidance.

364

R. J. EDELMANN et

al.

REFERENCES 1. KRAFT AD, PALUMBOJ, MITCHELLD, DEAN C, MEYERS S, WRIC;HT-SCHMIDTA. The psychological dimension of infertility. Am J Orthopsychiarr.~ 1980; 50: 618. 2. DKAKE TS, GRUNER~ M. A cycle pattern or sexual dysfunction in infertility investigations. Fertil Steril 1979; 32: 542-545.

of the relationship between 3. PAULSONJD, HAARMANN BS, SALERNORL, ASMR P. An investigation emotional maladjustment and infetility. Ferti/ Steril 1988; 49: 258-262. 4. CONNOLLY KJ, EDELMANNRJ, COOKE ID, ROBSON J. The impact of infertility on psychological functioning. J Psychosom Rrs 1992; 36: 459468. needs, emotional and relationship problems in couples 5. SHAW P, JOHNSTON M, SHAW R. Counselling awaiting IVF. J Ps~chosom Ohsfer Gynaecol 1988; 9: 171-180. marital and sexual problems in couples 6. COOK R. PARSONS J. MACON B, GOLOMROK S. Emotional, embarking upon AID and IVF treatment for infertility. / Reproduct Infant Psycho/ 1989; 7: 87-93. 7. JOHNSTON M, SHAW R, BIRD D. “Test-tube baby” procedures: Stress and judgements under uncertainty. Psycho1 Health 1987; 1: 25-38. and social aspects of in vitro fertilization. J 8. DENNERXEIN L, MORSE C. A review of psychological Psychosom

Obstetr Gynaecol

1988; 9: 159- 170.

9. GREENFELD D, MAZURE C, HASELT~NEFP, DECHERNEY AN. The role of the social worker in the in vitro fertilization program. Social Work in Health Care 1983; 10: 71 ~79. assessment and follow-up after in vitro 10. NEWTON CR, HEARN MT. YUZPE AA. Psychological fertilization: assessing the impact of failure. Ferfil Sreril 1990; 54: 879. 886. characteristics of in vitro fertilization Il. HEARN NT, YUZPE AA, BROWN SE, CASPER RF. Psychological participants. Am J Obstet Gjnaecol 1987; 156: 269-274. 12. CHAN YF, O’Hou KM, WONG A, So WK, Ho PC, TSOI MM. Psychosocial evaluation in an IVF,GIFT program in Hong Kong. J Reproduct Irzfant Psycho1 1989; 7: 67-77. 13. CONNOLLY KJ, EUELMANN RJ, COOKE ID. Distress and marital problems associated with infertility. J Reproduct

Infant Psycho1

1987; 5: 49- 57.

to infertility. J Ahnorm P.~ychol 1987; 96: 108 14. MCEWAN KL, COSTELLO CG. TAYLOR PJ. Adjustment 116. to infertility. J Sot Clin 15. STANTONAL, TENNENH, AFFLECKG, MENDOLA R. Coping and adjustment Psycho1 1992; 11: l-13. to in vitro 16. LITT MD, TENNEN H, AFFLECK G, KLOCK S. Coping and cognitive factors in adaptation fertilization failure. J Beha\) Med 1992; 15: 171 187. 17. OPCS. Classification qf Occupations. London: HMSO. 1980. 18. EYSENCKHJ, EYSENCKSBG. Manual qf the Eysenck Personulifj~ Quesriounuire. London: Hodder & Stoughton, 1985. 1978. 19. GOLVBERG D. Manual of the Genercd Health Questionnaire. Oxford: NFER-Nelson, CD, GORSUCH RL, LUSHENE R. The Slate Trait Anxiety Invenrorj, Manuol. Palo Alto: 20. SPEILBERC~ER Consulting Psychologists Press, 1970. Princeton: Princeton University Press, 1965. 21. ROSENBERGM. Society, and the Adolescent Se!flmage. San Diego: 22. LORR M, MCNA~R DM. Munual ,/i)r the Prqfile of Mood States (Bi-polar Form). Educational and Industrial Testing Service, 1984. 23. STONEA, NEALE JN. New measure of daily coping: Development and preliminary results. J Per.ron SW Psycho1 1984; 46: 892-906.

infertility: Some findings. J 24. EUELMANN RJ, CONNOLLY KJ, COOKE ID. ROHSON J. Psychogenic P.sychosom Oh.stet Gynaecol 199 1; 12: 163 168. beliefs and coping strategies in relation to eating 25. MAYHEW R, EDELMANN RJ. Self-esteem, irrational problems in a non-clinical population. Person India Diff 1989; 10: 58 I -584. 26. MARASCUILO LA. LEVIN DR. Multivariate Stcrti.sric.s in the Sociul Sciences: if Re.vrurcher’s Guide. California: Brooks Cole, 1983. 27. HAIR JF, ANDERSON RE. TATHAM RL. BLACK WL. Multivtrriare Dater Ano/>,.vi.~.New York. Maxwell MacMillan, 1992. evaluation and 28. FREEMAN EW. BOXER AS. RIC.KELS K, TURE(.K R, MASTROIANNI L. Psychological support in a program of in vitro fertilization and embryo transfer. Fertil Stcril 1985; 43: 48-53. 29. BLENNERJL. Stress and mediators: Patients’ perceptions of infertility treatment. Nurs Re.v 1992; 41: 9297. wellbeing of Infertile women after a 30. HYNES GJ. CALLAN VJ. TERRY DJ, GALLOISC. The psychological failed IVF attempt: the effects of coping. Br .I Med Ps.vcho/ 1992; 65: 269 278. 31. LAZARUS RS, FOLKMAN S. Stres.r, Apprrtisol. and Coping. New York: Springer, 1984. 32. REAOINC;AE. Decision making and in vitro fertilization: The influence of emotional state. J Ps~hosonr Oh.v/c/ G_vnaecol 1989: 10: 107~-112.