604 research paper

Running head: INFERTILITY & CULTURE 1

The Effects of Infertility on Relationship Quality in Different Cultures

Anastasia Theisen

Northern Illinois University

INFERTILITY & CULTURE 2

The Effects of Infertility on Relationship Quality in Different Cultures

Introduction and Justification

Infertility is defined as the reduced ability to conceive a child and the inability to carry a

child to term, or complete a full pregnancy (Oregon Reproductive Medicine, n.d.). Infertility

affects as many as 6-27% of women and 9.4-12% of men in the United States, with older women

and African American women more likely to experience infertility than younger women and

Caucasian women (Chandra, Copen, & Stephen, 2013); These men and women are often

involved in romantic relationships. Expectations of romantic relationships in this society usually

include marriage and at least one child; family members often expect that their recently married

relatives will soon conceive. Therefore, the pressure to produce a child can be overwhelming for

a couple, even more so if they find that they are unable to do so.

The inability to conceive a child can be quite stressful for a couple and can lead to an

abundance of relational issues as well as mental health issues, especially if the couple greatly

desired children (McDaniel, Doherty, & Hepworth, 2014; Tao, Coates, & Maycock, 2012; Amor

et al, 2008; Kilmartin, 2009). The experience of the couple and the infertile individual may differ

depending on who the infertile partner is, why he or she is infertile, how badly the couple wanted

a child, and if the couple can afford to seek alternatives (McDaniel, Doherty, & Hepworth,

2014). Differences in responses regarding the infertility diagnosis can also be seen according to

gender. Women are typically found to be more distraught when given the news of their or their

partner’s infertility, while men tend to take the news in silence (McDaniel, Doherty, &

Hepworth, 2014). The alternatives to an infertility diagnosis are quite expensive and can lead to

their own mental health or relational conflicts, and some individuals may have a religious

aversion to some of the infertility procedures (McDaniel, Doherty, & Hepworth, 2014;


Marquardt, Glenn, & Clark, 2010; Akker, 2007). Given the amount of stress that can result from

a diagnosis of infertility, it is important to examine how this affects the quality of the couple

relationship.

While there have been many studies conducted that examine the effects of infertility on

both relationship quality and the individual, there are very few studies that have been conducted

that take into a account those from different cultural backgrounds. Certain countries, such as

India, place a heavy emphasis on reproduction, and many cultures greatly emphasize the

importance of carrying on the family lineage (Mahalingam, Haritatos, & Jackson, 2007).

Hispanics and Latinos are typically very family-oriented and place a great deal of importance on

family (Miranda, Bilot, Peluso, Berman, & Meek, 2006). Therefore, looking at how infertility

would affect a couple of these backgrounds is very important.

Given that, in many cultures, it is the woman’s job to provide a family for her husband

and to produce children, particularly males, a diagnosis of infertility for these women can be

extremely devastating and can have lasting consequences (United Nations Publication, 2010).

There are many social implications that infertility can lead to for both men and women

depending on the culture from which they come; they could be subject to being an outcast, may

be alienated from other family members, and may be shunned from their community (Kilmartin,

2009; United Nations Publication, 2010). Looking at how a diagnosis of infertility can differ in

psychological reactions across the different cultures and seeing how the couple relationship is

then affected is a necessary avenue of study in order to implement ways to assist these couples in

a clinical setting.


Statement of the Research Problem & Hypothesis

The purpose of this study is to examine how an infertility diagnosis affects the

relationship quality in the romantic relationship, as well as to examine how these responses differ

according to the cultural and ethnic backgrounds of the individuals in the couple relationships. It

is hypothesized that there will be significant differences in relationship quality in regards to the

infertility diagnosis according to culture. Relationship quality is the dependent variable in the

study, with culture and infertility/no infertility being independent variables.


Review of the Literature

Men and Women’s Reactions to Infertility Diagnosis

In regards to an infertility diagnosis, men and women may react differently to a diagnosis

of infertility. The rate of infertility in regards to males and females is about the same, with

approximately 1/3 of the causes being male-related, 1/3 being female-related, and the remaining

percentage of causes being unidentifiable or are a combination of male and female causes

(McDaniel, Doherty, & Hepworth, 2014). Much of the differences in reactions to a diagnosis of

infertility relates to gender norms and how males and females are socialized to behave and react

in certain situations. Depending on the gender of the person in the couple relationship that is

receiving the infertility diagnosis, the reactions can differ and the couple relationship and

satisfaction of the relationship can differ based on the response.

Men’s reactions to infertility diagnosis

According to McDaniel, Doherty, & Hepworth (2014), men may appear to be

emotionally unaffected when first receiving news of infertility; the reaction displayed has been

categorized as “silent” or “accepting.” Unfortunately, much of this may be related to how men

are socialized. The socialization of men is vastly different than the socialization of women in

many cultures, and although socialization does of course vary according to culture and each

culture emphasizes different aspects of self, men in the cultures of study in this article, which are

Western, African American, Latino/Hispanic, and Asian, are taught to be strong and masculinity

is often emphasized.

In the Western culture, men are typically socialized to value qualities such as emotional

strength and are frequently criticized in their early childhoods for expressing emotions, often

being met with the phrase “boys don’t cry” (Kilmartin, 2009). Men in the western part of the


world are encouraged to solve their problems with actions and are taught that emotional

expressiveness is unmasculine (Kimartin, 2009). In African American and Latino/Hispanic

cultures, men are expected to be strong and to be a provider of strength for their families (Corr &

Corr, 2012). Men in Asian cultures are often socialized to keep emotions private and to resist

displays of emotion in public; this socialization may prevent these men from properly grieving

(Corr & Corr, 2012). These socialization techniques of the men in the major cultures being

studied in this article (Western, African American, Latino/Hispanic, and Asian) as to why some

men often react to the news of infertility with a quiet acceptance.

In addition to the emphasized quality of strength, reproduction is often an expectation of

males in many cultures. In fact, there are biologically based theoretical perspectives on male

promiscuity that have to do with the desire to reproduce (Kilmartin, 2009). It is evident

throughout the histories of many countries that much of the pressure on males was to produce a

male heir, often to take over the throne in societies in which there was a monarchy or to carry on

the family name. The desire for a male heir was also because women’s families often had to bear

the expenses of the weddings, a tradition which is upheld in many cultures today. Asian cultures

tend to especially desire a male child; some families would go so far as to commit female

infanticide (Ding & Hesketh, 2005).

The mental health implications of males who receive news of infertility may feel guilty,

angry, depressed, or be consumed with self-hatred due to their inability to provide their wives or

partners with a child; they may feel as though they are not living up to their obligations and

duties as sexual partners and may feel less masculine than men who do not have problems related

to infertility (Kilmartin, 2009). These mental health implications can significantly impact the

relationship quality of the couple and the satisfaction that the partners feel in their relationship.


Women’s reactions to infertility diagnosis

Upon hearing news of infertility, it is common for women to be, or at least appear to be,

emotionally devastated at the news of infertility (McDaniel, Doherty, & Hepworth, 2014). The

reason for this could lie heavily in the ways in which women are socialized according to culture.

In most of the major cultures being examined in this article, women are typically encouraged to

express their emotions and be more open about their feelings (Parkins, 2012). The exception to

this may be Asian cultures, in which women are socialized to keep emotions private and to resist

displaying emotion in public (Corr & Corr, 2012). In most cultures, women are typically taught

to deal with their issues by examining their feelings as opposed to men who are often taught to

take action (Kilmartin, 2009). Because women are generally taught that it is acceptable for them

to display their emotions, they may feel more comfortable expressing their feelings on an

infertility diagnosis.

The socialization of females in many cultures puts a heavy emphasis on having children

and becoming a mother, and the gender-based activities girls are introduced to at a young age

usually include babysitting, homemaking, and caregiving. Most cultures place high expectations

on women to be competent mothers, and in some cultures women are taught that it is extremely

important for women to bear children in order for them to provide for their families (United

Nations Publications, 2010). Women are also told that there is an expiration date on their ability

to produce healthy children; this coupled with the social expectations of having a family can

make infertility an especially difficult diagnosis to receive (McDaniel, Doherty, & Hepworth,

2014). Common reactions of women in regards to news of infertility include depression, anxiety,

and grief; Unfortunately, many healthcare professions are oftentimes unaware of the mental


health implications if this diagnosis, which can be especially severe in the case of a miscarriage

(Kong, Lok, Lam, Yip, & Chung, 2010).

Reason for Infertility

Depending on why the partner is infertile, the reaction of both partners and the

satisfaction of the couple relationship could potentially change. The causes of infertility may be

biological and unpreventable, voluntary, the result of the use certain medications, or could even

be the result of certain lifestyle choices. All of these different causes can lead to different

reactions and feelings about the infertility diagnosis.

Biological

The biological causes of infertility vary depending on the gender. For men, these causes

can include sperm production or function issues, sexual problems such as premature ejaculation,

the blockage of the epididymis, exposure to chemicals or toxins which can cause hypoglandism

or the malfunction of the pituitary gland, or damage to the reproductive organ (Mayo Clinic

Staff, 2014). Potential biological causes of infertility for women include injury to the female

reproductive system, polycystic ovary syndrome in which the ovaries produce an abundance of

androgen and not enough estrogen or progesterone, Hyperprolactinemia in which there is an

excess of the hormone prolactin, an abnormal shape of the uterus, blockage of the fallopian tube,

endometriosis, early menopause, and certain disorders such as diabetes (Mayo Clinic Staff,

2014). Biological causes of infertility can lead to feelings of hopelessness due to the

unpreventable and unchangeable nature of most of them (McDaniel, Doherty, & Hepworth,

2014). In addition, if the infertility is caused by a partner’s genetic anomaly, feelings of anger at

his or her family as well as feelings of guilt may arise (McDaniel et al., 2014).


Voluntary

Voluntary causes of infertility include vasectomies for men or a tubal ligation for women,

in which the fallopian tubes are intentionally blocked (Mayo Clinic Staff, 2014). While it may

seem as though less severe psychological implications would accompany a voluntary cause of

infertility, these procedures can indeed have important psychological after effects. In a study

conducted by Amor, Rogstad, Tindall, Moore, Giles, and Harvey in 2008, it was found that many

factors played into a man’s decision to get a vasectomy, including lifestyle choices, personal

issues, pressure from peers or family members, and the media. Even for those men who engaged

in a voluntary vasectomy procedure, the majority felt less masculine and suffered from

psychological implications such as depression or anxiety as a result (Amor et al., 2008). As for

women, even if they undergo a voluntary tubal ligation procedure, they may come to regret the

choice years later and therefore suffer major psychological after effects (McDaniel, Doherty, &

Hepworth, 2014).

Medications

The use of anti-depressants, especially SSRIs, can fragment sperm DNA and cause

problems related to erectile dysfunction and ejaculation (Brezina, Yunus, & Zhao, 2011). Men

who receive an infertility diagnosis due to their use of antidepressants may feel unmasculine,

weak, guilty, or shamed (Brezina et al., 2011). Because those who have mental disorders such as

depression or anxiety are often looked down on and considered weak, men may feel especially

shamed because of their “inability” to align with the social perception of needing to display

strength coupled with the negative perception of mental disorders (Angermeyer & Dietrich,

2005). For women, medications typically cause only temporary infertility (McDaniel, Doherty,

& Hepworth, 2014).


Lifestyle choices

There are certain lifestyle choices that could potentially lead to an infertility diagnosis,

including excess smoking or drinking, STDs or STIs, and eating disorders (McDaniel, Doherty,

& Hepworth, 2014). While some may disagree with the placement of eating disorders in this

section, it is placed here because it is preventable and best fits this particular category. If lifestyle

choices are the reason behind infertility, the implications on both the individual and the

relationship can be especially severe. Feelings of guilt or shame may emerge, and the diagnosis

may feel more like a punishment (McDaniel et al., 2014). The partner may feel angry toward the

infertile partner and the relationship could henceforth become strained.

Culture Influences/Differences & Views on Infertility

The researchers understand that there is a distinct difference between race and culture; we

define culture as the values and ideals that the individual prescribes to. Therefore, culture in this

study is subjective, meaning the researchers will ask the participants which culture they most

closely align with; there will be examples of the ideals and values of each culture given to the

participant.

Western culture is most prominent in European countries as well as the United States,

though there is a little bit of Western culture present in almost all societies today (van der Wal,

2008). Western cultures predominantly value individualism, or the needs and wants of the

individual over the collective group (van der Wal, 2008). Self-sufficiency and success are major

attributes in this culture as well; wealth and status are considered of importance (van der Wal,

2008). While marriages are still celebrated and viewed positively in Western cultures, marriages

are occurring at later ages and couples are less concerned with having children right away or at

all (Orchard, 2001). With the values of individualism, career, and wealth emphasized and the


idea of children and family being of lesser importance or concern, those in Western cultures may

not react as strongly as individuals from other cultures when hearing news of infertility.

Additionally, considering the fact that most in the Western culture value progressivism and

modernism, individuals in this culture are able to pursue options like adoption or infertility

treatments without fear of backlash from friends or family members or concerns of the morality

of the procedures (McDaniel, Doherty, & Hepworth, 2014).

Individuals who identify in the African American culture often put a high emphasis on

caring for family members (Corr & Corr, 2012). The African American culture also emphasizes

relationships within the community, and these relationships are often treated as though they are

familial (Corr & Corr, 2012). Marriages within this culture are typically thought of as marriages

between entire families as opposed to simply between a man and a woman (Barbarin, 2002).

Women in the African American culture are typically expected to care for other members of the

family and receive a lot of responsibility and pressure to be caregivers (Burton, 2007). In a way,

these families operate from a collectivist perspective and often view the needs of the group over

the needs of the individual. Women in this culture are taught to express their feelings, while the

males are typically socialized to be strong and to be providers (Corr & Corr, 2012). Given this

information, couples who identify with the African American culture may react more strongly to

news of infertility than other cultural couples, and the relationship could suffer.

Those who identify with the Hispanic culture often have a collectivist point of view, in

which the needs of the family or group are placed above the needs of the individual (Ruiz, 2005).

Many Hispanic individuals also value pleasant relationships, self-worth, respect, and family

(Ruiz, 2005). Harmonious relationships are desired as opposed to difficult, negative

relationships; negative behaviors such as criticizing, confronting, or talking down that is


exhibited by an individual in a relationship is strongly discouraged in this culture (Ruiz, 2005).

Families are a major aspect and of extreme importance in this culture; these individuals believe

in emotional or material support, the reliance on other family members, and the modeling of

behaviors after others in the family (Ruiz, 2005). Women in this culture are typically socialized

to display emotions and to be caregivers for others in the family; men in this culture are

socialized to be strong or “macho” and to be providers (Corr & Corr, 2012). Based on this

information, the reaction of a couple at the news of infertility would most likely be quite

negative due to the importance of family, but given the emphasis on mutual support between

family members, the relationship may not suffer from news of infertility but may actually

improve due to the mutual support each partner is receiving.

Those who identify with the Asian culture usually adhere to distinct values. While the

Asian culture tends to place emphasis on collectivism, or the needs of the group over the needs

of the individual, they also place a high emphasis on success and self-reliance and tend to avoid

seeking help in situations (Corr & Corr, 2012). Familial relationships, while important in a sense,

tend to be disconnected due to the emphasis that is placed on self-reliance and emotional control

(Corr & Corr, 2012). However, there is a high emphasis placed on having children, especially

males, so that the family name can be carried on (Corr & Corr, 2012). Due to these quite

conflicting values, the reaction to the news of infertility could be one of muted sadness; however,

the relationship satisfaction between the couple could potentially decline due to feelings of

shame and pressure from family members to have children.

Infertility Diagnosis & Couple’s Relationship Quality

Relationship quality can be defined in this review as the subjective evaluation each

partner has regarding how well the relationship seems to be working and how happy he or she is


with the current state of the relationship (Fincham & Rogge, 2010). Relationship quality can

decline due to decreased sexual satisfaction, as sex can begin to feel like a chore that must be

done in order to produce a child, financial difficulties if the couple attempts to undergo fertility

treatments or decides to adopt, a fear of abandonment, which can be especially prominent if the

fertility is caused by rising age, anger at the infertile partner (Tao, Coates, & Maycock, 2012).

The strain on the relationship can also be due to outside pressure from family members or friends

on the couple to have a child. The financial, social, and personal strain that is placed on these

relationships can severely impact and decrease the quality if the couple is unable to work through

the difficulties or provide each other with mutual support (Tao et al., 2012).

The researchers expect there to be a decline in relationship quality after a diagnosis of

infertility and that the decline will differ based on culture. The researchers also expect that the

gender of the individual with the diagnosis and the reason for the infertility diagnosis will play a

significant role in the relationship quality as well, with biological causes, lifestyle choices, and

medications more prominently affecting relationship quality than voluntary causes. The

researchers expect that the gender of the person receiving the infertile diagnosis will more

directly impact personal reactions as opposed to relationship quality.

Summary of Review of the Literature

While cultures socialize their men and women to value different things, the four cultures

being tested in this study place high emphasis on family and tend to socialize their men to value

strength and their women to value childrearing. However, with the emphasis on western culture

shifting toward a more individualistic perspective, there may be less significant impacts on

western couples than on couples that come from the other cultures. Many additional factors can

influence how one reacts to the news of infertility, those being the cause of the infertility and the


gender of the individual receiving the diagnosis. The researchers suspect that the cause of

infertility will impact the couple relationship, while the gender of the individual will more

prominently affect the individual’s reaction and psychological health.


Methods

Participants

The participants will be couples in which one of the partners has received a diagnosis of

infertility from a gynecologist or a physician while in the relationship with his or her current

partner. Because the idea behind this study is to gather information regarding how relationship

satisfaction is impacted by the news of an infertility diagnosis and how that impact varies across

cultures, it is imperative that the participants have already been in the relationship prior to

receiving news of an infertility diagnosis and still be in that relationship at the time the study is

conducted. A stipulation for inclusion in this study is that participants had to be in a

monogamous, romantic relationship with their partners for at least 6 months or longer; another

stipulation is that participants could be no younger than 18 years of age and no older than 40

years of age, which would ensure that the couples are within typical child-bearing age. A

preference for the study is that couples be married, though that is not a stipulation. It is also

preferred that the pairs of couples be from the same cultural background, though that is not a

stipulation. The reason behind this is to maintain continuity between couples, as individuals from

different cultural backgrounds may have different values regarding children and relationships.

Intra-culture couples are therefore preferred.

There will also be a comparison group of individuals years 18 – 40 who have been with

their partners for 6 months or longer and do not have a diagnosis of infertility. These participants

will also have to be in a monogamous, romantic relationship, and the same preferences will

apply to this control group, again in order to maintain continuity between couples in regards to

their cultural backgrounds. The control group will be able to provide a comparison group to the

participants who have received an infertility diagnosis in order to compare relationship


satisfaction scores between couples who have received a diagnosis of infertility and couples who

have not.

Prior to the collection of the data and the beginnings of the research process, a form will

be submitted to the Institutional Review Board (IRB) at Northern Illinois University; this will

allow the researchers to gain permission to use human subjects in this study. Because the consent

forms will be signed online, there will be no need to send these to participants beforehand.

Procedure

This study will use a variation of both convenience and snowball sampling techniques.

Therapists and clinical psychologists from a wide range of states and locations in the United

States will be given information about the study and will be asked to recommend clients who are

seeking marital, couples, or individual therapy and who have had a diagnosis of infertility and

then inform the clients of the study. The researchers will also contact gynecologists and

physicians who work with infertility patients and will be asked to inform these clients of the

study and recommend them to participate. This is in the hopes that a wide-range of participants

from a variety of cultural backgrounds will be interested in participating.

As for the control group, these couples will also be selected using snowball sampling in

order to maintain continuity for the study. Individuals will be asked to refer intra-culture couples

to participate in this study; these individuals will also be from a wide range of states and

locations in the United States, again in the hopes of obtaining a wide-range of couples from a

variety of cultural backgrounds so that the control group will be similar to the clinical group.

The participants of the study will be able to access the questionnaires through an

approved online psychological website and a social media website, where they will be required

to review the conditions for participations and digitally sign an informed consent form before


proceeding. Participants will then encounter a basic demographic questionnaire. Following this

questionnaire, there will be three additional questionnaires designed to measure relationship

satisfaction and cultural affinity; these three questionnaires will be in randomized order. Once

the participants have completed the forms, they will be debriefed and given information on the

purpose of this particular study.

Measures/Instruments

A total of three questionnaires will be used in this study; one will gather demographic

information and will include questions regarding the participant’s culture and adherence to

cultural norms. The other questions on the questionnaire are designed to gather information

regarding the participant’s age, biological sex, the length of his or her current relationship, the

marital status of the participant, the approximate date that he or she received news of the

infertility diagnosis, why the individual is infertile (i.e., what caused the individual to become

infertile), and the sexual orientation of the participant. I will be using this demographic

information to make inferences regarding the effect of the culture on an infertility diagnosis.

Refer to C1 for the demographics questionnaire.

One of the scales designed to measure relationship satisfaction is entitled the Realistic

Experiences Questionnaire and was developed by Miller & Teddar (2011). This questionnaire

asks the participant questions related to how well he or she believes his or her partner

communicates, how much he or she trusts his or her partner, and other related questions. This

questionnaire breaks down the responses in nine different categories: maintenance behaviors,

commitment to the relationship, the quality of the communication between partners, the conflict

resolution skills of the partners, the amount of self-disclosure in the relationship, the subjective

amount of affection, the certainty and security the participants feel in their respective


relationships, the roles the participants play in their respective relationships, and the subjective

amount of equity within the relationship. The scale of this questionnaire will be slightly altered

in order to include more choices and will range from Strongly Disagree to Strongly Agree with

three in-between options to choose from. The Reality Questionnaire, developed by Miller &

Teddar (2011), has a total of 45 questions with 5 in each of the 9 categories. Some of the items

will be reverse scored, and all of the questions will be score coded, with Strongly Disagree = 1,

Disagree = 2, Neutral = 3, Agree = 4, and Strongly Agree = 5. In order to get a participant’s

score, the items must be added together and then divided by the total number of questions, which

for this scale would be 45. As with the RAS scale, a higher score indicates a higher satisfaction

with the relationship, and a lower score indicates a lower satisfaction with the relationship.

Examples of the questions from this scale include, “I do not feel comfortable disclosing what I

need or want from our relationship” and “My partner tries to understand why I am upset.” Refer

to appendix C2 for more information on this questionnaire and C4 for more information as to

which categories the questions were in.

The other questionnaire designed to measure relationship satisfaction in this study is

called the Relationship Assessment Scale (RAS) and was developed by Hendrick in 1988.

Hendrick’s Relationship Assessment Scale (RAS) is comprised of seven questions and uses a

Likert-typed to assess the answers of the participants. Items 4 and 7 on the scale are reverse

scored, and the questions are score-coded, with A=1, B=2, C=3, D=4, and E=5. Adding the

scores together and diving by seven, which is the total number of items, determines the mean

score. A higher score indicates a higher satisfaction with or a better subjective view of the

participant’s relationship. Refer to C3 for more information on this scale. Two questionnaires for

relationship satisfaction will be utilized because the RAS is a widely used instrument to measure


relationship satisfaction, but the Realistic Experiences Questionnaire is more detailed and

provides more thorough information. These questionnaires are randomized for the participants so

that the researchers could rule out previous exposure to like questions as a limitation of the

study. The length of time to complete these surveys is approximately 45 – 60 minutes.

Data Analysis

Design and methodology

This research design is anticipated to be a survey research design, due to the fact that the

researchers are unable to control for the variables of infertility or culture and the participants will

therefore be pre-assigned to groups. The alpha score or p value for this study will be set at <

0.05.

Treatment of data

The analysis of this data must be a univariate model due to the fact that there are two

independent variables, culture and infertility diagnosis. The researchers will therefore be using a

factorial ANOVA test to see whether a combination of the two independent variables (infertility

and culture) can predict the outcome of the dependent variable (relationship satisfaction). This

model is able to analyze the effects of the categorical independent variables on the continuous

dependent variable.

Hypothesis testing

The hypothesis of this study is that there will be significant differences in relationship

satisfaction in regards to a diagnosis of infertility according to culture. This could lead to the

conclusion that, because of the differences in cultural values in the areas of family, the

importance of children, and the different cultural views of the roles of men and women should

play in relationships, some couples from certain cultures may be significantly more impacted by


the news of infertility and thus experience a more significant drop in relationship satisfaction

than couples from other cultures. The researchers also expect there the be a significant difference

in relationship quality according to infertility diagnosis, regardless of culture. The cultural values

will be derived from the demographic questionnaire as will the information on fertility. The

dependent variable to be examined in this study is relationship satisfaction, which will be

gathered from the RAS and the Reality Questionnaires. These scores will be analyzed and then

compared to the cultural values to which the participant prescribes as well as whether or not that

individual has an infertility diagnosis.


Limitations

The way that the sample will be collected poses potential limitations for this study.

Snowball and convenience sampling methods are not random sampling, and therefore the sample

could be skewed or biased because not everyone in the population had an equal chance of being

selected. It would also be difficult to have all of the different cultures, Western, African

American, Hispanic/Latino, and Asian, be equally represented, which is another limitation that

this study potentially poses. A third possible limitation of this study is that many who have had

problems with infertility may be unwilling to disclose that information and thus by unwilling to

participate in the study; the clinical sample may therefore be difficult to come by.

Future research for this study should focus on expanding the definitions of couples and

possibly look into how same sex couples are affected by news of infertility. Future research

could also potentially add the variable of how badly the couple wanted a child; this could

increase the negative feelings associated with the news of infertility and therefore decrease the

satisfaction within the couple relationship. Future research should also examine the reasoning

behind the infertility diagnosis and how that impacts the couple relationships. The differences

could potentially impact the couple relationship in different ways, as voluntary reasons could

have a more negative impact than biological reasons that are unpreventable. Finally, an

important area of future research involves how infertility treatments affect the couple

relationship. Different methods of infertility treatments could potentially negatively impact the

psychological functioning of the individual.

In sum, future studies should look at addressing these limitations and examining the

different methods of infertility treatments and how they could potentially impact the couple

relationship. This area of research could provide clinicians with different methods when working


with couples in a clinical setting. Working with couples who have experienced infertility have

their own sets of challenges that clinicians should be aware of. Providing a clinical model to

work with when treating couples who have experienced infertility would be the next step and

what future research should focus and build on.


References

Akker, O.B.A. (2007). Psychosocial aspects of surrogate motherhood. Human Reproduction

Update, 13(1), 53-62.

Amor, C., Rogstad, K.E., Tindall, C., Moore, K.T.H., Giles, D., & Harvey. P. (2008). Men’s

experiences of vasectomy: A grounded theory study. Sexual and Relationship Therapy,

23(3), 235-245

Angermeyer, M. C., & Dietrich, S. (2006). Public beliefs about and attitudes towards people with

mental illness: A review of population studies. Acta Psychiatrica Scandinavica, 113(3),

163-179.

Barbarin, O. (2002). Characteristics of African American families [PowerPoint slides]. Retrieved

March 24, 2015 from

http://ssw.unc.edu/rti/presentation/pdfs/aa_families.pdf

Brezina, P.R., Yunus, F.N., & Zhao, Y. (2011). Effects of pharmaceutical medications on male

fertility. Journal of Reproduction and Infertility, 13(1), 3-11.

Chandra, A., Copen, C.E., & Stephen, E.H. (2013). Infertility and impaired fecundity in the

United States, 1982-2010: Data from the national survey of family growth. National

Health Statistics Reports, 67, 1-18.

Corr, C.A., & Corr, D.M. (2012). Death & dying, life & living (7th ed.). Belmont, CA:

Wadsworth Cengage Learning.

Ding, Q. J., & Hesketh, T. (2006). Family size, fertility preferences, and sex ratio in China in the

era of the one child family policy: Results from national family planning and

reproductive health survey. BMJ, 333, 371-373.

Fincham, F.D., & Beach, S.R. H. (2010). Marriage in the new millennium: A decade in


review. Journal of Marriage and the Family, 72, 630-649.

Hendrick, S. S. (1988). A generic measure of relationship satisfaction. Journal of Marriage &

the Family, 50(1), 83 – 98. Doi: 10.2307/352430 (R. A. Scale).

Kilmartin, C. (2009). The masculine self (4th ed.). Cornwall-on-Hudson, NY: Sloan Publishing,

Inc.

Kong, G.W.S., Lok, I.H., Lam, P.M., Yip, A.S.K., & Chung, T.K.H. (2010). Conflicting

perceptions between health care professionals and patients on the psychological

morbidity following miscarriage. Australian and New Zealand Journal of Obstetrics and

Gynecology, 50, 562-567.

Mahalingam, R., Haritatos, J., & Jackson, B. (2007). Essentialism and the cultural psychology of

gender in extreme son preference communities in India. American Journal of

Orthopsychiatry, 77(4), 598-609

Marquardt, E., Glenn, N.D., & Clark, K. (2010). My daddy’s name is donor: A new study of

young adults conceived through sperm donation. West Chester, PA: Broadway

Publications.

Mayo Clinic Staff (2014). Diseases and conditions: Infertility causes. Mayo Clinic. Retrieved

March 20, 2015 from

http://www.mayoclinic.org/diseases-conditions/infertility/basics/causes/con-20034770

McDaniel, S.H., Doherty, W.J., & Hepworth, J. (2014). Medical family therapy and integrated

care (2nd ed.). Washington, D.C.: American Psychological Association.

MedlinePlus. (2014). Vasectomy. U.S. National Library of Medicine and National Institutes of

Health. Retrieved July 28, 2014, from

http://www.nlm.nih.gov/medlineplus/vasectomy.html


Miller, J., & Tedder, B. (2011). The discrepancy between expectations and reality: Satisfaction

in romantic relationships (Unplublished dissertation). Hanover College, Indiana.

Miranda, A. O., Bilot, J. M., Pelsuso, P. R., Berman, K., & Van Meek, L. G. (2006). Latino

families: The relevance of the connection among acculturation, family dynamics, and

health for family counseling research and practice. The Family Journal, 14(3), 268-273.

Orchard, B. (2001). Family & relationships: A culture of divorce. Vision.com. Retrieved March

24, 2015, from

http://www.vision.org/visionmedia/article.aspx?id=472

Parkins, R. (2012). Gender and emotional expressiveness: An analysis of prosodic features in

emotional expression. Griffith Working Papers in Pragmatics and Intercultural

Communication, 5(1), 46-54.

Ruiz, E. (2005). Hispanic culture and relational cultural theory. Journal of Creativity and Mental

Health, 1(1), 33-455.

Tao, P., Coates, R., & Maycock, B. (2012). Investigating marital relationship in infertility: A

systematic review of quantitative studies. Journal of Reproduction and Infertility, 13(2),

71-80.

United Nations Publications (2010). The world’s women 2010: Trends and statistics. Herndon,

VA: United Nations, Department of Economic and Social Affairs

van der Wal, K. (2008). Europe, idea of a continent: The quest for the European identity. Limes,

1(2), 148-159.


APPENDIX B

INFORMED CONSENT DOCUMENT

Title of Study: The effects of infertility on relationship quality in different cultures

Investigators: Anastasia Theisen, Graduate StudentNorthern Illinois University

This is a research study. Please take your time in deciding if you would like to participate. Please feel free to ask questions at any time.

INTRODUCTION

The purpose of this study is to learn more about how cultural beliefs affect the relationship quality of a couple following a diagnosis of infertility.

DESCRIPTION OF PROCEDURES

If you agree to participate in this study, your participation will last for approximately (and no longer than) 1 hour. During the study you may expect the following study procedures to be followed:

You will be asked to answer questions on the computer or on paper. These questions will ask you various questions about your current romantic relationship, particularly the quality. In addition, you will be asked about your cultural beliefs.

At the end of the study, the experimenter will provide a debriefing explaining in more detail the purpose and goals of the current research. You should feel free to ask any questions or express any concerns you may have regarding the research.

PARTICIPANTSParticipants are those who have experienced a diagnosis of infertility with their current partner, whom they have been in a romantic relationship with for at least 6 months. Participation in this study is completely voluntary. You can end your participation at any time. If you decide to not participate in the study or leave the study early, it will not result in any penalty or loss of benefits to which you are otherwise entitled.

RISKS

There are minimal foreseeable risks from participating in this study. Some of the questions ask about personal information, including sexual orientation, race and religion, and maybe somewhat uncomfortable to answer. However, you are free to skip any question you wish if it makes you uncomfortable to answer it.


BENEFITS

If you decide to participate in this study there may be no direct benefit to you apart from what you learn about psychological research. It is hoped that the information gained in this study will benefit society by helping psychologists better understand how a diagnosis of infertility affects those from different cultures in different ways.

COSTS AND COMPENSATION

You will not have any costs from participating in this study. There is no compensation for completing this study.

CONFIDENTIALITY

Records identifying participants will be kept confidential to the extent permitted by applicable laws and regulations and will not be made publicly available. To ensure confidentiality to the extent permitted by law, the following measures will be taken:

Participants will be randomly assigned a unique ID number, which will be noted on all of their materials. Once the data are collected, any information that links the name of the participant to their ID number will be destroyed. Data will be stored in a cabinet in the supervising faculty member’s laboratory space, which is kept locked. Data will be retained until all are collected, entered, and analyzed. If the results are published, your identity will remain confidential. We will take all reasonable steps to protect your identity. Consistent with the American Psychological Association rules, the data will be retained for 5 years after publication, but your identity will never be associated with your responses.

QUESTIONS OR PROBLEMSYou are encouraged to ask questions at any time during this study. For further information about the study contact Anastasia Theisen, Master’s Candidate at 618-946-6085, [email protected].

******************************************************************************PARTICIPANT SIGNATURE

I have read the material above, and any questions I asked have been answered to my satisfaction. I understand a copy of this form will be made available to me for the relevant information and phone numbers. I realize I may withdraw without prejudice at any time. Participant’s Name (printed)


APPENDIX C1

DEMOGRAPHICS

The information you provide in this questionnaire is completely confidential, so please answer honestly. YOU CAN SKIP ANY QUESTION YOU DO NOT WISH TO ANSWER. If you have questions, feel free to ask the experimenter for clarification.

BASIC INFORMATIONAge: ________ Gender/sex: _______

Marital Status: ________ Sexual orientation: __________

1) What is your romantic partner’s race/ethnicity? _________________2) What is your romantic partner’s gender/sex _____________________3) How long have you been dating your current partner? (please fill in the number of

months and years – for example, 2 months, 1 year) Months Years

4) How long ago did you or your partner receive a diagnosis of infertility? ______

5) What was the reasoning behind the infertility diagnosis? ________

6) What culture would you say best describes your beliefs?Asian: Collectivist; good of the group over good of the individual; emotions are a private

experience; self-reliance; importance of childrenWestern: Individualist; good of the individual over good of the group; self-sufficiency and

success are important; careers over having children; progressivismHispanic/Latino: Collectivist; good of the group over good of the individual; harmonious

relationships are important; family is very important; emotional support; women are caregivers.

African American: Collectivist; good of the group over good of the individual; high emphasis on caring for family members; community members are considered family; women are caregivers

Asian: _________ Hispanic/Latino: _________

Western: _______ African American: ________

7) How strongly would you say you adhere to your cultural beliefs?1 2 3 4 5 6 7 8 9 10


APPENDIX C2

REALITY QUESTIONNAIRE

In my current relationship:

I do not feel comfortable disclosing what I need or want from our relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am under-benefited.Strongly Disagree Disagree Neutral Agree Strongly Agree

I feel like my partner is romantically interested in me.Strongly Disagree Disagree Neutral Agree Strongly Agree

I see a future with my partner.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am fully committed to my partner.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner attempts to make our interactions enjoyable.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner is willing to do things with my friends or family.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner is not willing to compromise.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am confident about myself as an intimate partner.Strongly Disagree Disagree Neutral Agree Strongly Agree

I feel that I should be able to disclose intimate, personal things about myself withouthesitation.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner and I feel the same way about each other.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner displays an appropriate amount of affection towards me.Strongly Disagree Disagree Neutral Agree Strongly Agree


My partner’s feelings are as strong for me as mine are for them.Strongly Disagree Disagree Neutral Agree Strongly Agree

I do not feel my partner is committed to me.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner and I use open communication.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am patient and forgiving of my partner.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner and I work together to solve conflicts.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am happy with my role in the relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner sincerely reveals to me their feelings and experiences.Strongly Disagree Disagree Neutral Agree Strongly Agree

I expect the same standard of behavior from my partner as they expect of me.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am happy with the amount of physical affection.Strongly Disagree Disagree Neutral Agree Strongly Agree

I do not want my relationship to last.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner is strongly motivated to devote their time and effort to our relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner listens to me.Strongly Disagree Disagree Neutral Agree Strongly Agree

I feel like my partner does things to maintain our relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner tries to understand why I am upset.


Strongly Disagree Disagree Neutral Agree Strongly AgreeI am happy with my partner’s role in the relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

I intimately disclose who I really am, openly and fully.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner does not contribute as much to our relationship (financially) as I do.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner compliments me often.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am strongly motivated to devote time and effort.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner often discusses our future together.Strongly Disagree Disagree Neutral Agree Strongly Agree

I feel comfortable voicing my preferences in the relationship.Strongly Disagree Disagree Neutral Agree Strongly Agree

I am not very motivated to be involved.Strongly Disagree Disagree Neutral Agree Strongly Agree

I feel comfortable letting my partner know when I am upset.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner is not dependable.Strongly Disagree Disagree Neutral Agree Strongly Agree

As a whole, my partner’s disclosures about our relationship are more positive thannegative.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner supports me in my endeavors as much as I support them.Strongly Disagree Disagree Neutral Agree Strongly Agree

I do not feel cared for.Strongly Disagree Disagree Neutral Agree Strongly Agree


I am certain my feelings for my partner will not change.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner keeps their promisesStrongly Disagree Disagree Neutral Agree Strongly Agree

My partner does not try to understand my needs.Strongly Disagree Disagree Neutral Agree Strongly Agree

I experience honesty from my partner.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner and I are able to successfully reach conflict resolution.Strongly Disagree Disagree Neutral Agree Strongly Agree

My partner feels responsible for their part.Strongly Disagree Disagree Neutral Agree Strongly Agree


APPENDIX C3

RELATIONSHIP ASSESSMENT SCALE

Please mark on the answer sheet the letter for each item which best answers that item for you.

How well does your partner meet your needs?A B C D EPoorly Average Extremely well

In general, how satisfied are you with your relationship?A B C D EUnsatisfied Average Extremely satisfied

How good is your relationship compared to most?A B C D EPoor Average Excellent

How often do you wish you hadn’t gotten in this relationship?A B C D ENever Average Very often

To what extent has your relationship met your original expectations:A B C D EHardly at all Average Completely

How much do you love your partner?A B C D ENot much Average Very much

How many problems are there in your relationship?A B C D EVery few Average Very many

NOTE: Items 4 and 7 are reverse scored. A=1, B=2, C=3, D=4, E=5. You add up the items and divide by 7 to get a mean score.


APPENDIX C4REALITY QUESTIONNAIRE (CATEGORIES)

In my current relationship:

[Self-disclosure]1. I do not feel comfortable disclosing what I need or want from our relationship.2. I feel that I should be able to disclose intimate, personal things about myself withouthesitation.3. My partner sincerely reveals to me their feelings and experiences.4. I intimately disclose who I really am, openly and fully.5. As a whole, my partner’s disclosures about our relationship are more positive thannegative.

[Equity]1. I am under-benefited.2. My partner and I feel the same way about each other.3. I expect the same standard of behavior from my partner as they expect of me.4. My partner does not contribute as much to our relationship (financially) as I do.5. My partner supports me in my endeavors as much as I support them.

[Affection]1. I feel like my partner is romantically interested in me.2. My partner displays an appropriate amount of affection towards me.3. I am happy with the amount of physical affection.4. My partner compliments me often.5. I do not feel cared for.

[Relational certainty/security]1. I see a future with my partner.2. My partner’s feelings are as strong for me as mine are for them.3. I do not want my relationship to last.4. I am strongly motivated to devote time and effort.5. I am certain my feelings for my partner will not change.

[Commitment]1. I am fully committed to my partner.2. I do not feel my partner is committed to me.3. My partner is strongly motivated to devote their time and effort to our relationship.4. My partner often discusses our future together.5. My partner keeps their promises.

[Quality of communication]1. My partner attempts to make our interactions enjoyable.2. My partner and I use open communication.3. My partner listens to me.


4. I feel comfortable voicing my preferences in the relationship.5. My partner does not understand my needs.

[Maintenance behaviors]1. My partner is willing to do things with my friends or family.2. I am patient and forgiving of my partner.3. I feel like my partner does things to maintain our relationship.4. I am not very motivated to be involved.5. I experience honesty from my partner.

[Conflict resolution]1. My partner is not willing to compromise.2. My partner and I work together to solve conflicts.3. My partner tries to understand why I am upset.4. I feel comfortable letting my partner know when I am upset.5. My partner and I are able to successfully reach conflict resolution.

[Role in relationship]1. I am confident about myself as an intimate partner.2. I am happy with my role in the relationship.3. I am happy with my partner’s role in the relationship.4. My partner is not dependable.5. My partner feels responsible for their part.* One item out of each of the nine factors was phrased in such a way that they can be reversed

scored.

604 research paper

Documents

effects of infertility

infertility culture

infertility diagnosis

diagnosis of infertility

justification infertility

partners infertility

couple relationship

relationship quality