European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 185–189

General psychopathology, anxiety, depression and self-esteem in couplesundergoing infertility treatment: a comparative study between men and women§

Yousri El Kissi a,*, Asma Ben Romdhane a, Samir Hidar b, Souhail Bannour a, Khadija Ayoubi Idrissi a,Hedi Khairi b, Bechir Ben Hadj Ali a

a Department of Psychiatry, Farhat Hached Hospital, Sousse, Tunisiab Obstetrics and Gynecology Department, Farhat Hached Hospital, Sousse, Tunisia

A R T I C L E I N F O

Article history:

Received 4 August 2012

Received in revised form 8 December 2012

Accepted 13 December 2012

Keywords:

Infertility

Psychopathology

Anxiety

Depression

Self-esteem

Gender

Psychological stress

A B S T R A C T

Objective: To compare measures of psychological distress between men and women undergoing ART in

the Unit of Reproductive Medicine ‘‘UMR’’ in the Department of Obstetrics and Gynecology at ‘‘Farhat

Hached’’ Hospital in Sousse, Tunisia.

Study design: We conducted a gender comparative study of psychological profile in infertile couples.

Recruitment was done during period from January to May 2009. 100 infertile couples with primary

infertility were recruited. Scores of general psychopathology, depression, anxiety and self-esteem were

evaluated. We administrated questionnaires on psychological factors among infertile couples before

starting a new infertility treatment cycle. Psychological factors included the symptom check-list (SCL-

90-R), the hospital anxiety and depression scale (HAD-S) and the Rosenberg self-esteem scale (RSE).

Result(s): Infertile women had higher scores than their spouses in the three global scores of the SCL-90-R

and in several items such as somatisation, obsessive symptoms, interpersonal sensitivity and phobias.

Scores of HADS were higher among women for both depression and anxiety. Scores of self-esteem were

lower among women.

Conclusion(s): Women endorsed higher psychological distress than men across multiple symptoms

domains: general psychopathology, anxiety, depression and self esteem.

� 2012 Elsevier Ireland Ltd. All rights reserved.

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European Journal of Obstetrics & Gynecology andReproductive Biology

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1. Introduction

Infertility is defined as the inability to achieve a pregnancy afterat least one year of regular unprotected sexual intercourse [1].According to the World Health Organization (WHO) 8–10% ofcouples experience difficulties in conceiving [1], and several recentstudies emphasize the increase in infertility frequency [2,3].Infertility causes psychological trauma for most couples, oftenexperienced as the most stressful event in their lives [2]. Inaddition to the psychological impact of infertility, the treatments,ranging from medical monitoring to hormonal remedies and invitro fertilisation (IVF), place physical, economical and emotionalburdens on couples [4]. The mental health of infertile couples hasan impact on their ability to cope with treatment, pregnancy, andparenting after successful treatment [5,6]. Individuals according to

§ Where the work was done: The Unit of Reproductive Medicine ‘‘UMR’’ in the

Department of Obstetrics and Gynecology at ‘‘Farhat Hached’’ Hospital in Sousse,

Tunisia.

* Corresponding author at: Centre Hospitalo-universitaire, Farhat Hached, 4000

Rue Ibn El Jazzar, Sousse, Tunisia. Tel.: +216 73 219 508; fax: +216 73 223 702.

E-mail address: yousri.elkissi@rns.tn (Y. El Kissi).

0301-2115/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ejogrb.2012.12.014

their basic personality structure, coping strategies, pre-existinglevel of psychopathology, environment support [7], culturalcontext [8] and gender [9] will perceive the experience ofinfertility differently. Several studies, have evaluated the psycho-logical profile of infertile couples. The prevalence of psychologicaldistress ranges from 48% to 96% in women presenting withinfertility [10,11].

Most studies have analyzed the symptoms of depression andanxiety among women only, but some studies have dealt withthese symptoms in both women and men. These studies havefound that women use proportionately greater amounts ofconfrontative coping, accepting responsibility, seeking socialsupport and escape/avoidance when compared with men, whereasmen use proportionately greater amounts of distancing, self-controlling and painful problem-solving [12,13]. In an Italianstudy, 14.7% of women had anxiety symptoms and 17.9%depressive symptoms, whereas only 4.5% of men had anxietysymptoms and 6.9% depressive symptoms [14]. Moreover, anAmerican study [15] that compared multiple measures ofpsychological distress between men and women preparing forIVF found that psychological distress scores were higher amongwomen than men for symptoms of depression, state anxiety,

Y. El Kissi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 185–189186

infertility specific distress, and general perceived stress. Anotherstudy found that women reported higher levels of depressionwhen compared to men [16]. In an English study, total well-beingscore was higher among men and levels of anxiety and depressionwere higher among women [17]. The lack of studies on differencesbetween genders and the concentration of studies on Westernpopulations motivate new research involving different psycholog-ical aspects of infertility for both partners and on different types ofpopulations. The present study aimed to assess the psychologicalresponse including general psychopathology, anxiety, depressionand self-esteem in a sample of Tunisian infertile couples, and tocompare it between men and women.

2. Materials and methods

This is a cross-sectional study.

2.1. Subjects

The sample included 100 infertile couples admitted betweenJanuary and May 2009 to the Unit of Reproductive Medicine ‘‘UMR’’in the Department of Obstetrics and Gynecology at ‘‘FarhatHached’’ Hospital in Sousse, Tunisia. The sample size was basedon previous similar studies that assessed psychological profile inaround 100 infertile couples [16–18]. Couples were consecutivelyrecruited. They had primary infertility according to the definitioncurrently accepted by the WHO [1] and were candidates forassisted reproductive technologies (ART).

Infertile couples were informed of the voluntary and anony-mous character of the survey. Consent was also given by bothpartners of the infertile couples. All subjects were asked to respondto a questionnaire that was developed for all participants andwhich included demographic and clinical characteristics such asage, level of education, residential location, duration of marriage,consanguinity, and history of psychiatric or organic morbidity.Data regarding duration of infertility and its masculine or feminineaetiology were also collected.

Couples were seen for the first time together (presentation,information and general data collection) and then separately forthe psychological assessment. At time of assessment, the diagnosisof infertility had already been presented and explained to thecouple by the gynaecologist.

Table 1Demographic and clinical data.

T

Mean age

Education level Illiterate

Primary

Secondary

University

Occupation No occupation

Laborers

Executive officials

Management officials

Location Rural 4

Urban 5

Family history of psychiatric disorders Depressive Disorder

Anxiety Disorder

Schizophrenia

Other

Personal somatic disorders 30 (15%)

Personal psychiatric disorders 6 (3%)

2.2. Psychological assessment

A psychiatrist trained in psychometry carried out psychologicalassessment. We used a battery of standardized scales.

The Symptom Checklist (SCL-90-R) [19] consists of 90 items forthe evaluation of psychopathological symptoms. It includes 10subscales assessing somatisation, obsessive-compulsive symp-toms, interpersonal sensitivity, depression, hostility, phobias,paranoid traits, psychotic features and various symptoms. Eachitem is rated on a five-point scale of severity. In addition to thescores of subscales, we considered:

� GSI: Global Severity (total score = total number of items)� PST: Diversity of symptoms (number of items whose rating > 0)� PSDI: Degree of discomfort (total score by PST)

The participants also filled out the hospital anxiety anddepression scale (HAD-S) [20]. The HADS is a self-administeredrating scale composed of 14 items, seven for anxiety and seven fordepression. It was developed to identify cases of anxiety anddepression disorders among patients in non-psychiatric hospitalclinics. Each item is rated on a four-point scale ranging from 0 to 3.Anxiety and depression scores are obtained by summing up thescores of the seven items, yielding values between 0 and 21. TheHAD-S also provides a categorical breakdown into three levels: 0–7: non-cases; 8–10: doubtful cases and 11–21: cases. By focusingon psychological symptoms, the HADS avoids the confoundingeffect of physical symptoms in detecting anxiety and depressionamong subjects with somatic illness.

The scale of self-esteem by Rosenberg (SEA) [21] is a widelyused instrument for the measurement of global self-esteem. Itincludes 10 questions whose answers range from 1 to 4. The totalscore ranges from 10 to 40. The higher the score is, the better self-esteem is.

2.3. Statistical analysis

All data analyses were performed using the Statistical Packagefor Social Sciences (SPSS 11.0). Statistical comparisons were madebetween men and women. Continuous variables were comparedby the use of an independent t-test and are displayed as mean andstandard deviation (SD). Frequencies were compared betweengroups by chi-square test. The Fisher exact test was used for the

otal (200) Women (100) Men (100) p

35.71 � 5.39 32.69 � 4.91 38.74 � 5.87 < 10�3

9 (4.5%) 8 (4%) 1 (0.5%) NS

78 (39%) 38 (19%) 40 (20%)

68 (34%) 29 (14.5%) 39 (19.5%)

45 (22.5%) 25 (12.5%) 20 (10%)

57 (28.5%) 56 (28%) 1 (0.5%) < 10�3

88 (44%) 23 (11.5%) 65 (32.5%)

35 (17.5%) 14 (7%) 21 (10.5%)

20 (10%) 7 (3.5%) 13 (6.5%)

3% – –

7% – –

5% (10) 6% (6) 4% (4) NS

0.5% (1) 0% (0) 1% (1) NS

4.5% (9) 6% (6) 3% (3) NS

1.5% (3) 2% (2) 1% (1) NS

NS

1 (0.5%) 5 (2.5%)

Table 2Consequences and attitudes towards infertility.

Consequences and attitudes

towards infertility

Total Women Men p

Investigations considered to

be exhausting and tiring (%)

Yes 87.5 83 74 NS

No 21.5 17 26

Consequences of infertility on

the couple relationship (%)

Without 32.5 25 40 0.009

Tensions 36 34 38

Deleterious 31.5 41 22

Talking about difficulties (%) Yes 49 62 36 <10�3

No 51 38 64

Request for psychological care (%) Yes 62.5 77 48 <10�3

No 37.5 23 52

Y. El Kissi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 185–189 187

comparison of low values. Statistical significance was defined asp < .05.

3. Results

Only five couples did not agree to participate in the study. Theresponse rate was 95.23%. Demographic and clinical data areshown in Table 1. The etiology of infertility was male in 50% ofcases, female in 21%, both male and female factors in 15% andunknown in 14% of cases. Mean duration of infertility was5.19 � 4.62 years, and mean time since first medical advice was1.27 � 1.03 years.

A total of 87.5% of couples thought that investigations wereexhausting and tiring, without significant differences betweenwomen and men. More women than men, however, spoke of theirdifficulties related to infertility (62% vs. 36%, p < 10�3) andbelieved that a request for help psychological care could helpthem cope (77% vs. 48%; p < 10�3) (Table 2).

The scores of SCL-90 are shown in Table 3. Women had higherscores than men in global scores and in different dimensions:somatisation, obsessional symptoms, interpersonal sensitivity andphobia. More women than men were in the ranges of doubtfulcases and cases according to HAD-S, both for anxiety anddepression, as shown in Table 4. Also, the mean score of self-esteem was lower in women than men (34.01 � 6.11 vs.36.19 � 5.07; p = 0.007).

4. Comment

Our data support the conclusion that infertility is associatedwith psychological distress for both women and men. Incomparison to their spouses, women more frequently experiencedpsychological distress across multiple domains: consequences andattitudes towards infertility, general psychopathology, depression,anxiety and self-esteem.

Our study has focused not on individuals but on infertilecouples, with a panel of assessment tools exploring several aspectsof psychological functioning. It also has the advantages ofproposing a comparison between men and women and of havingbeen performed in a different social and cultural background thanprevious studies.

For the sake of uniformity, we focused exclusively on coupleswith primary infertility. It is known that secondary infertility hasfewer effects on the psychological experience of infertile couples[22,23]. In addition, we have only enrolled couples starting a newcycle of ART, because psychological impact is dependent on thestage of medical care [23].

Couples taking part in this study presented a high rate of maleinfertility (50% and 21% in female cases). This male predominance

Table 3Sores of SCL-90.

SCL-90-R Total

GSI 0.57 � 0.36

PST 30.89 � 40.69

PSDI 1.59 � 0.35

Somatisation 0.52 � 0.43

Obsessive-compulsive symptoms 0.61 � 0.50

Interpersonal sensitivity 0.72 � 0.44

Hostility 0.82 � 0.66

Phobic anxiety 0.36 � 0.37

Paranoid ideation 0.56 � 0.56

Psychoticism 0.27 � 0.34

GSI: Global Severity (total score = total number of items).

PST: Diversity of symptoms (number of items whose rating > 0).

PSDI: Degree of discomfort (total score by PST).

was also found in the studies of Chiaffarino et al. [14] Verhaak et al.[24] and Holter et al. [25], but Khayata et al. [26] found apredominance of female etiology responsible for infertility in49.1% of 269 women enrolled in their study. This could be due tothe predominance of laborers in our sample (44%), since a previousstudy showed an association between male infertility and industryand construction jobs [27].

The mean duration of infertility was 5.19 � 4.62 years. Thisperiod varies in the literature. Chen et al. [28] reported a duration ofinfertility of 3.1 � 2.8 years. Klonoff-Kohen et al. [2] reported aduration of 4.06 � 3.02 years. Ragni et al. [29] found that 74.7% oftheir patients had infertility duration less than five years. Oneexplanation of the longer duration of infertility in our sample is thatthe investigation was carried out in a referral center that treatscouples, often after multiple previous attempts.

In our study, 87.5% of infertile couples found the investigationof infertility tiring without significant differences between womenand men. Several studies have focused on the nature of thestressful and demanding infertility treatments [30,31]. ART arecomplex and cumbersome to perform. On the physical level, sometechniques cause pain, such as oocyte aspiration or testicularbiopsy. Others, such as hormonal treatments, cause side effects[9,22] for both men and women. Moreover, ART are experienced ina tense atmosphere with a fear of failure at each attempt. A couplewho is trying to conceive will therefore experience feelings offrustration and uncertainty [9,32].

Among infertile couples in our sample, 77% of women and 48%of men requested concomitant psychological treatment to medicaltreatment of infertility. Wischmann et al. [33] who found that72.5% of women and 61.8% of men were interested in psychologicalsupport during treatment, reported almost similar results.According to Revidi [9], 75% of patients who experienced at least

Women Men p

0.68 � 0.42 0.45 � 0.26 <10�3

35.40 � 15.12 25.39 � 12.81 <10�3

1.65 � 0.35 1.53 � 0.34 0.016

0.66 � 0.46 0.38 � 0.35 <10�3

0.72 � 0.54 0.50 � 0.42 0.002

0.83 � 0.49 0.61 � 0.37 0.001

0.77 � 0.57 0.87 � 0.74 NS

0.54 � 0.50 0.18 � 0.27 <10�3

0.64 � 0.56 0.66 � 0.57 NS

0.31 � 0.38 0.23 � 0.29 NS

Table 4Scores of HAD-S.

HADS parameters Total (n = 200) Women (n = 100) Men (n = 100) p

Anxiety score 7.38 � 4.15 5.74 � 3.65 4.14 � 3.45 0.002

Depression score 4.67 � 3.35 3.65 � 2.97 2.56 � 2.35 0.005

Anxiety levels Non cases (%) 51 30 72 <10�3

Doubtful cases (%) 24 32 16

Cases (%) 25 38 12

Depression levels Non cases (%) 76.5 67 86 0.002

Doubtful cases (%) 18 23 13

Cases (%) 5.5 10 1

Y. El Kissi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 185–189188

one IVF, request care before starting a new attempt. Themotivations for help seeking, however, differ between men andwomen. Women find that support is useful because it explainstheir reactions and approves them, while men are looking forpractical information and advice [32].

Infertile women had higher scores in global scores of SCL-90-Rthan their spouses. In traditional societies such as ours, conceptionand childbirth are perceived as part of women’s responsibilities[34]. This fact was also observed in Japanese society where womenare often viewed as responsible when a couple is infertile [35].Thus, the failure of these processes results in greater impact onwomen than men. Besides, mean score of ‘‘interpersonal sensitivi-ty’’ was higher in women than in men, which would suggest thatinfertile women experience more frequently feelings of inferiorityand inadequacy in relation to others, and anticipation ininterpersonal relationships. Moreover, diagnosis and therapeuticprocedures are more invasive and painful in women [8,9,22],which could explain the difference in ‘‘somatisation’’ score.

Berg et al. [36], in a study assessing the psychological profile of104 infertile couples through the SCL-90-R, reported that womenhad higher scores of somatisation than men, but no differences inglobal scores and scores of other dimensions. Wischmann et al.[33] also reported, in 545 couples, that only PSDI score was higherin women. Wright et al. [37], in a study enrolling 449 infertilecouples, found that infertile women had higher scores than men onthe hostility SCL-90-R subscale.

Scores of the HAD-S were significantly higher among infertilewomen than men, for both anxiety and depression. Moreover,scores of self-esteem were significantly lower among women.Several studies have reported a high prevalence of anxiety anddepression among infertile couples [14,15], often with higherscores in women than in their partners. Wischmann et al. [15],when assessing depression and anxiety, found that both womenand men experienced infertility-specific psychological distress inthe context of IVF, but women endorsed clinically significantsymptom severity. Chiaffarino el al. [14] found that 14.7% ofwomen had anxiety symptoms and 17.9% of them had depressivesymptoms, whereas 4.5% of men had anxiety symptoms and 6.9%of them had depressive symptoms. Lee et al. [38] found thathusbands’ self-esteem was higher than that of the wives.

Studying patients undergoing IVF has limited these studies,however. Indeed, IVF would be more appropriate to femaleinfertility and other studies have showed that the etiology ofinfertility influences psychological responses [35]. Ogawa et al., ina Japanese study, found that patients with knowledge of their malepartner’s infertility had lower anxiety scores on the HADS thanpatients who did not have such knowledge [35]. We tend toconclude that higher rates of depression and anxiety in womencould be thus explained by the concentration of most studies onpatients undergoing IVF, but this finding is not approved by allauthors. Nachtigall et al. [39], when assessing perception of loss,role failure and self-esteem, found no differences among women in

their emotional response to infertility regardless of whether afemale or male infertility factor was present, whereas men with amale factor experienced more negative emotional response toinfertility than men without a male factor. Moreover, Pinto-Gouveia et al. [40] found that infertile couples presentedsignificantly higher scores on depression and lower scores inpsychological flexibility/acceptance and self-compassion than thecontrol group. Thus, women tended to use a less emotional/detached coping style and perceived themselves as less confidentto deal with infertility than men.

Other studies [12,13,15,17] tried to explain the psychopatho-logical mechanisms of psychological distress in infertile couples.They assumed that coping strategies and attachment differ bygender as there is a difference in appraisal of infertility betweenwomen and men. Women perceive their infertility more as threatand loss than men, which increases their distress. These genderdifferences of psychopathological mechanisms could explain theconcordance of our results to those found in Western countries.Indeed socio-cultural context is only one of multiple factors thatare involved in the development of coping strategies but could notexplain all factors.

The present study has some limitations such as the smallsample size and the high proportion of male infertility. Anotherimportant limitation is that we have not considered the etiology ofinfertility, which is an important factor to take into account whenstudying psychological impact of infertility by gender, especially inour society where women are particularly vulnerable to socialpressure. Finally, we have not studied the psychological dimen-sions depending on the duration of infertility, which is anotherimportant factor [41].

Our data support the conclusion that infertility could have agreater psychological impact in women than men. Furtherlongitudinal studies with larger sample sizes are required toclarify variations in mental health by gender, controlling for otherfactors in order to plan interventional strategies taking intoaccount the psychological support requested by infertile couples.

References

[1] World Health and Organization. Recent advances in medically assisted repro-duction. WHO technical report series 820. Geneva: WHO Publications; 1992.

[2] Klonoff-Cohen H, Chu E, Natarajan L, Sieber W. A prospective study of stressamong women undergoing in vitro-fertilization on gamete intra fallopiantransfer. Fertility and Sterility 2001;76:675–87.

[3] Wirtberg I, Moller A, Hogstrom L, Tronstad SE, Lalos A. Life 20 years afterunsuccessful infertility treatment. Human Reproduction 2007;22:598–604.

[4] Cwikel J, Gidron Y, Sheiner E. Psychological interactions with infertility amongwomen. European Journal of Obstetrics Gynecology and Reproductive Biology2004;117:126–31.

[5] Hammarberg K, Fisher JRW, Wynter KH. Psychological and social aspects ofpregnancy, childbirth and early parenting after assisted conception: a system-atic review. Human Reproduction Update 2008;14:395–414.

[6] Repokari L, Punamaki RL, Poikkeus P, et al. The impact of successful assistedreproduction treatment on female and male mental health during transition toparenthood: a prospective controlled study. Human Reproduction 2005;20:3238–47.

Y. El Kissi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 185–189 189

[7] Rosenthal M, Goldfarb J. Infertility and assisted reproductive technology an updatefor mental health professionals. Harvard Review of Psychiatry 1997;5:169–72.

[8] Mimoun S. Les multiples interactions entre l’infertilite et la sexualite. Contra-ception Fertilite Sexualite 1993;21:251–4.

[9] Revidi P, Beauquier-Macotta B. Problematiques psychiques dans les aidesmedicales a la procreation. Encycl Med Chir 2008. Psychiatrie/Pedopsychia-trie; 37-204-G-40.

[10] Freeman EW, Boxer AS, Rickels K, Tureck R, Mastroianni Jr L. Psychologicalevaluation and support in a program of in vitro fertilization and embryotransfer. Fertility and Sterility 1985;43:48–53.

[11] Mahlstedt PP, Macduff S, Bernstein J. Emotional factors and the in vitrofertilization and embryo transfer process. Journal of in Vitro Fertilizationand Embryo Transfer 1987;4:232–6.

[12] Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how menand women who are referred for IVF cope with infertility stress. HumanReproduction 2006;21:2443–9.

[13] Bayley TM, Slade P, Lashen H. Relationships between attachment, appraisal,coping and adjustment in men and women experiencing infertility concerns.Human Reproduction 2009;24:2827–37.

[14] Chiaffarino F, Baldini M, Scarduelli C, et al. Prevalence and incidence ofdepressive and anxious symptoms in couples undergoing assisted reproduc-tive treatment in an Italian infertility department. European Journal of Ob-stetrics Gynecology and Reproductive Biology 2011;158:235–41.

[15] Wichman C, Ehlers S, Wichman S, Weaver A, Coddington C. Comparison ofmultiple psychological distress measures between men and women preparingfor in vitro fertilization. Fertility and Sterility 2011;65:717–21.

[16] Peterson BD. The relationship between coping and depression in men andwomen referred for in vitro fertilization. Fertility and Sterility 2006;85:802–4.

[17] Van den Broeck U, Thomas D’Hooghe T, Enzlin P, Demyttenaere K. Predictors ofpsychological distress in patients starting IVF treatment: infertility-specific versusgeneral psychological characteristics. Human Reproduction 2010;25:1471–80.

[18] Berg BJ, Wilson JF. Psychiatric morbidity in the infertile population: a recon-ceptualization. Fertility and Sterility 1990;53:654–61.

[19] Derogatis LR, Lipaman RS, Covi L. SCL-90: an outpatient psychiatric rating scalepreliminary report. Psychopharmacology Bulletin 1973;9:13–25.

[20] Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. ActaPsychiatrica Scandinavica 1983;67:361–70.

[21] Rosenberg M. Society and the adolescent self-image. Princeton, New Jersey:Princeton University Press; 1965.

[22] Goeb JL, Ferel S, Guetta J, Dutilh P, Dulioust E, Guibert J, et al. Vecus psycho-logiques des demarches d’assistance medicale a la procreation. Annales Med-ico-Psychologiques 2006;164:781–8.

[23] Eugster A, Vingerhoets AJ. Psychological aspects of in vitro-fertilization. SocialScience and Medicine 1999;48:575–89.

[24] Verhaak CM, Smeenk JMJ, Nahius MJ, Kremer J, Braat DDM. Long-term psy-chological adjustment to IVF/ICSI treatment in women. Human Reproduction2007;22:305–8.

[25] Holter H, Anderheim, Berg C, Moller A. First IVF, treatment-short-term impacton psychological well being and the marital relationship. Human Reproduc-tion 2006;21:3295–302.

[26] Khayata GM, Rizk DEE, Hasan MY, Ghazal-Aswad S, Asaad MAN. Factorsinfluencing the quality of life of infertile women in United Arab Emirates.International Journal of Gynaecology and Obstetrics 2003;80:183–8.

[27] Sheiner EK, Sheiner E, Carel R, Potashnik G, Shoham-Vardi I. Potential associa-tion between male infertility and occupational psychological stress. Journal ofOccupational and Environmental Medicine 2002;44:1093–9.

[28] Chen TH, Chang SP, Tsai CF, Juang KD. Prevalence of depressive and anxietydisorders in an assisted reproductive technique clinic. Human Reproduction2004;19:2313–8.

[29] Ragni G, Mosconi P, Baldini MP, Somigliana E, Vegetti W, Caliari I, et al. Health-related quality of life and need for IVF in 1000 Italian infertile couples. HumanReproduction 2005;20:1286–91.

[30] Verhaak CM, Smeenk JMJ, Eugster A, Van Minnen A, Kremer J, Kraaimaat F.Stress and marital satisfaction among women before and after their first cycleof in vitro-fertilization and intracytoplasmic sperm injection. Fertility andSterility 2001;76:525–31.

[31] Anderheim L, Holter H, Bergh C, Moller A. Does psychological stress affect theoutcome of in vitro fertilization? Human Reproduction 2005;20:2969–75.

[32] Boivin J. A review of psychosocial interventions in infertility. Social Scienceand Medicine 2003;57:2325–41.

[33] Wischmann T, Scherg H, Showitzki T, Verres R. Psychosocial characteristics ofwomen and men attending infertility counselling. Human Reproduction2009;24:378–85.

[34] Atighetchi D. Islamic tradition and medically assisted reproduction. Molle-cular Cell Endocrinology 2000;169:137–41.

[35] Ogawa M, Takamatsu K, Horiguchi K. Evaluation of factors associated with theanxiety and depression of female infertility patients. BioPsychoSocial Medi-cine 2011;5:15.

[36] Berg BJ, Wilson JF. Psychiatric morbidity in the infertile population: a recon-ceptualization. Fertility and Sterility 1990;53:654–61.

[37] Wright J, Duchesne C, Sabourin S, Bissonnette F, Benoıte J, Girard Y. Psychoso-cial distress and infertility: men and women respond differently. Fertility andSterility 1991;55:100–8.

[38] Lee TY, Sun GH. Psychosocial response of Chinese infertile husbands andwives. Archives of Andrology 2000;45:143–8.

[39] Nachtigall RD, Becker G, Wozny M. The effects of gender-specific diagnosis onmen’s and women’s response to infertility. Fertility and Sterility 1992;57:113–21.

[40] Pinto-Gouveia J, Galhardo A, Cunha M, Matos M. Protective emotional regula-tion processes towards adjustment in infertile patients. Human Fertility2012;15:27–34.

[41] Domar AD, Broome A, Zuttermeister PC, Seibel M, Friedman R. The prevalenceand predictability of depression in infertile women. Fertility and Sterility1992;58:1158–66.