Introduction

The infertility is a stressful live event which cause a high impact on the different areas of life: personal, work, family, social, physical, as well as sexual and relationships with a partner (Greil et al., 2010; Vioreanu, 2021). Infertile couples are subject to greater stress and have a greater risk of developing psychological disorders compared with healthy couples (Simionescu et al., 2021). The most common emotions were ‘sadness’ at diagnosis and ‘anxiety’ during treatment (Boivin et al., 2022). The meta-analysis undertaken by Fallahzadeh et al. (2019) on 11 selected articles between 2005 and 2017 concludes that the infertile subjects undergo more anxiety and depression than the fertile ones. However, no consensus of results was found in studies about fertility and psychopathological disorders (Greil et al., 2010). Huppelschoten et al. (2013) showed that both members of the infertile couple are vulnerable to different sources of psychological stress and develop distinct resources to cope with them. Patients may either have or lack the resources that allow them to adapt to or better affront chronic illnesses like infertility. Psychosocial factors define one’s capacity to adjust to infertility and they were classified by Mahajan et al. (2009) in intrapersonal and interpersonal factors which helps people cope with infertility. The research about infertility in the last decades have redirected attention to the study of psychosocial variables associated to the adjustment of this illness (Peterson et al., 2006; Shen et al., 2004; Thompson et al., 2012). Reviewing the literature, risk and protective psychosocial factors that had been found associated to emotional adjustment in infertility are the characteristics of personality, coping strategies, followed by social support and marital satisfaction (Darolia & Ghosh, 2022; Gourounti et al., 2010; Maroufizadeh et al., 2019; Rockliff et al., 2014). The most common personality subscale explored was neuroticism which is positively associated with anxiety and depression in different moments of the IVF treatment. To the contrary, trait optimism was the only personality factor found to be associated with lower levels of distress, specifically with lower depression following a negative pregnancy test (Rockliff et al., 2014). The most evaluated coping strategy was avoidance and escape (Cunha et al., 2016; Galhardo et al., 2019). The couples who use disproportionally maladaptive coping strategies, such as escape/avoidance, are predisposed to anxiety and depression symptoms (Faramarzi et al., 2013). Others negative associations coping strategies with distress were problem focused/solving and perceived social support (Mohammadi et al., 2018). Accordingly, infertile women were more likely to recur to seeking social support and escape/avoidance when compared with men, whereas men used greater amounts of self-control and problem-solving (Zurlo et al., 2020).

There is evidence that infertility has a negative effect on the psychological well-being and sexual relationships of couples (Luk & Loke, 2019). The review by Kiani et al. (2020) revealed that most studies show that marital quality of infertile couples decreases, and this can be related to the couple’s anxiety symptoms. However, other studies that exploring marital satisfaction reported no significant relationships between this psychosocial factor and emotional adjustment (Rockliff et al., 2014).

There is a growing interest in possible gender differences in associations between psychosocial variables and emotional adjustment in infertility (Ying et al., 2015). There are discrepancies in the results when analysing the influence of gender on the impact of infertility. Although, in general, it has been shown that women present more emotional maladjustment after an infertility diagnosis, these differences may be mitigated and may even disappear depending on the areas considered. There is greater consensus that women score higher in the area of emotional maladjustment (Chamorro et al., 2021; Ramírez-Uclés et al., 2015), but this difference has not been found in other areas like complying with treatment (Lopes et al., 2014). Women and men have also been found to differentiate in their willingness to achieve parenthood (Chachamovich et al., 2009). However, the differences that may exist compared to fertile people are less studied. Therefore, in the present study we explore a) whether there are sex and group differences (infertile vs fertile) in emotional adjustment and personality, dispositional optimism, coping strategies, personal and interpersonal resources, and marital satisfaction; b) as a main objective, the modulator role of the set of psychosocial variables associated with emotional maladjustment grouped into internal factors (personality, dispositional optimism, coping strategies, and personal resources) and external factors (marital satisfaction and interpersonal resources), and c) whether these modulator factors are exclusive to infertile people. For this reason, a comparison group of fertile couples has been selected. The information on the specific modulator factors of emotional adjustment will provide the opportunity to offer a preventive and specific guide to psychological support, which contributes to promoting the well-being of infertile people.

Method

Participants and procedure

This cross-sectional study was carried out in a private gynecological and reproductive medical center in Spain. Participants were selected consecutively as they arrived at the clinic and met the inclusion criteria. The total sample used was 174 heterosexual participants. The infertile group consisted of 99 individuals. The comparison fertile group included 75 routine-care gynecological patients who were not undergoing any form of fertility treatment and were not pregnant at the time the survey and had no history of assisted reproduction treatment. The final sample was made up of 139 participants, because 35 of them dropped out (13 refused to participate, 7 did not fill out the questionnaires, 11 were not in a stable relationship and 4 suffered a serious chronic illness). No significant statistical differences in sociodemographic and medical variables were found between them and the rest of the sample. Inclusion criteria were: a) all participants were legally married or living with a partner in a heterosexual relationship; b) over 18 years older; c) they were able to understand the questionnaires and; d) they had no major medical or psychopathological disorders, e) the whole sample lived in a capital city or its surrounding area.

The psychological assessment was performed in each group by the same researchers on days with appointments for assisted reproduction patients and selected only the first two cases. On the same day, other two first cases attending routine gynecological examination were selected. After the gynecologic visit, the psychologist explained the aims of the study (including issues of confidentiality, the right to refuse participation at any time without any loss of optimal treatment) and got informed consent from all individual participants. The participants were interviewed individually and answered the questionnaires in the presence of one of the researchers, who made sure that they understood the instructions, the items, the questions and, if necessary, answered any questions or doubts raised by the subjects. The study was approved by the Research Ethics Committee of the National Distance Education University (UNED).

Measures and instruments

A constellation of psychological instruments created or adapted and validated in Spain were selected:

Assessment of Emotional Adjustment to Infertility

The Emotional Maladjustment and Adaptive Resources in Infertility Questionnaire (DERA) (Moreno-Rosset et al., 2008) was applied as it is an infertility specific questionnaire created and validated in Spain, with different formats for men and women. It has 48 items covering four factors: emotional maladjustment, personal resources, interpersonal resources, and adaptive resources. The Cronbach alpha coefficient of the global scale is 0.85 and for each of the subscales is 0.90, 0.57, 0.78 and 0.74, respectively. In the present study the ordinal Alpha coefficient was 0.77. Other characteristics and psychometric data can be consulted in Jenaro et al. (2008) and Moreno-Rosset et al. (2009) respectively.

Assessment of internal factors

The short version of The Big-Five Questionnaire (BFQ) (Caprara et al., 1995; Spanish adaptation by Bermúdez et al., 1990a), was used and consisted of 30 items, 6 for each of the dimensions: energy, conscientiousness, emotional stability, agreeableness, and openness. The internal consistency factors of the Spanish short version are 0.75, 0.79, 0.87, 0.73 and 0.76, respectively. For the sample of the present study the ordinal Alpha coefficient was 0.74.

The Life Orientation Test-Revised (LOT-R) (Scheier et al., 1994; Spanish adaptation by Otero-López et al., 1998) that measures the generalized disposition for the expectation of positive results was administered. The LOT-R includes 10 items, three statements about optimism, three on pessimism and four distractor items. The internal consistency using Cronbach’s alpha coefficient was 0.73, and the average discrimination index was 0.48 (Cano-García et al., 2015). In the present study the ordinal Alpha coefficient was 0.42.

The Ways of Coping Revised (WOC-R) (Lazarus & Folkman, 1984; the short Spanish version of Bermúdez et al., 1990b) was applied to assess coping strategies. It is made up of 22 items to evaluate confrontation, distancing, self-control, seeking social support, positive reappraisal, planful problem solving and escape/ avoidance. The internal consistency coefficients range between 0.61 and 0.79. In the present study the ordinal Alpha coefficient was 0.63.

The Personal Resources subscale of DERA was used and includes 11 items to evaluate individual resources to cope with stressful situations related to maintaining a favorable state of health.

Assessment of external factors

Psychological Wellbeing in the Couple Scale (EBP) (Sánchez-Cánovas, 2007). Created and validated in Spain with different formats for men and women, assess marital satisfaction. It consists of 15 items which describe personal attitude in relation to sexuality and other relations in the couple. The internal consistency coefficient is 0.88. For the sample of the present study the ordinal Alpha coefficient was 0.51.

The Interpersonal Resources subscale of DERA was used. It consists of 11 items related to the perception of support from significant beings (friends and family) and, in addition, loving and sexual relationships with the couple as another element that can be understood as evidence of support between couples.

Statistical analysis

We carried out multivariate inferential analysis (MANOVAS) and univariate analysis (ANOVAS). In all cases, the partial “eta square index (η2p)” was used to calculate the effects size and to evaluate the magnitudes of the obtained differences (Cohen, 1998). We also take into consideration Pearson correlation analysis with the aim to determine the variables that have more significant correlations with the emotional adjustment variable in the infertile group. Finally, we performed two regression analysis to determine the estimators of emotional maladjustment in both infertile and fertile people. The software used was IBM SPSS Statistics Version 25.

Results

Sample characteristics

The infertile group consisted of 84 participants, 46 women and 38 men. The average age of women was 33.36 (SD = 4.06), and that of men was 33.81 (SD = 3.28). The educational level was 33.3% with primary studies, 27.3% with secondary studies and 39.4% had received higher education. Female infertility was 25%, male infertility 28.57%, mixed was 7.14%, idiopathic was 7.14%, and 32.14% had not been diagnosed. Primary infertility was 94%, secondary 6%, and the average duration of the infertility period was 34.56 months. Some 76.2% of participants that had been diagnosed had undergone one assisted reproduction treatment. The fertile group was 55 participants taken from the general population, 30 women and 25 men. The women’s average age was 31.63 (SD = 7.45) and the men’s was 35.44 (SD = 8.23). Sample homogeneity has been shown in the age, educational level, and gender variables through the T test for independent samples.

Multivariate and univariate analyses

Initially, an inferential study has been carried out to find out if there are sex differences (women vs men) and group (infertile vs fertile) in emotional adjustment, and the other variables selected. The MANOVA carried out on the DERA showed a significant effect on the Group variable (Wilks’Lambda = 0.827; F(4, 132) = 6.907; p = 0.000; η2p = 0.173). The independent ANOVAs also indicated a significant effect on the variables Emotional maladjustment (F(1, 135) = 4.446; MCe = 193.779; p = 0.037; η2p = 0.032) and Personal resources (F(1, 135) = 10.036; MCe = 18.678; p = 0.002; η2p = 0.069). People with infertility reported higher levels in both dimensions.

Considering the variables Group and Sex as independent variables and the scales of the short version of BFQ as the dependent variables, the MANOVA results draws to confirm that no significant effect in either main effects or in interaction. In LOT-R, a bifactorial ANOVA was carried out. Significant effects were not found in the case of dispositional optimism.

The MANOVA carried out on the different scales of the WOC–R questionnaire showed that there is a significant effect for the group variable (Wilks’Lambda = 0.918; F(7, 129) = 2.640; p = 0.035; η2p = 0.211), for the sex variable (Wilks’Lambda = 0.934; F(7, 129) = 2.309; p = 0.041; η2p = 0.114) and for the interaction Group x Sex (Wilks’Lambda = 0.947; F(7,129) = 2.025; p = 0.047; η2p = 0.121). The independent ANOVAs carried out on the subscales indicate significant effects of the Group variable, with infertile participants showing lesser degrees of Confrontive coping (F(1, 135) = 6.342; MCe = 3.065; p = 0.013; η2p = 0.045), Seeking social support (F(1, 135) = 3.834; MCe = 4.482; p = 0.035; η2p = 0.048) and Positive reappraisal (F(1, 135) = 3.768; MCe = 2.670; p = 0.049; η2p = 0.043) than the fertile group. This analysis revealed a significant effect of Sex on the Seeking social support variable (F (1, 135) = 4.240; MCe = 4.482; p = 0.041; η2p = 0.030), hence all the women show higher levels of support seeking than the men. An interaction of Group x Sex on the Self-control variable (F (1, 135) = 4.896; MCe = 5.825; p = 0.029; η2p = 0.035), was also encountered. The analysis of the interaction through the T test for independent samples confirm that women in the infertility group show higher levels of Self-control than men (T(82) = -1.90; p = 0.042; η2p = 0.040).

Finally, to measure the effect of wellbeing in the couple (EBP), a bifactorial ANOVA was carried out. The results indicated that infertility does significantly affect psychological wellbeing in the couple, demonstrating that infertile people having lower levels F(1, 134) = 6.639; MCe = 98.813; p = 0.011; η2p = 0.047 than the fertile participants (Table1).

Table 1 Descriptive statistics for all scales by genders and groups
Full size table

Correlation and regression analyses

The correlations analyses indicated that the Emotional maladjustment in infertile individuals correlates significantly in a positive way with Escape/avoidance (r = 0.357; p = 0.001), and in a negative way with Emotional stability (r = -0.236; p = 0.030), Openness (r = -0.219; p = 0.046), Confrontive coping (r = -0.268; p = 0.014), Planful problem solving (r = -0.346; p = 0.001), Personal resources (r = -0.303; p = 0.005), Interpersonal resources (r = -0.350; p = 0.001), Adaptive resources (r = -0.400; p = 0.000), Psychological wellbeing in the couple (r = -0.473; p = 0.000) and Dispositional optimism (r = -0.604; p = 0.000).

In order to determine the predictive value on emotional maladjustment, after the correlations were obtained, multiple linear regression analyses (stepwise) were carried out for each one of the sample groups, considering the predictive variables which make up the internal and external factors.

With respect to the internal variables, the ANOVAs obtained showed the global statistical significance of the emotional maladjustment variable and the internal estimators combined in the infertile group (F (3, 80) = 29.142; MCe=105.74; p = 0.000), explaining these variables as 52.2% of the variance (R2 = 0.522), and in the fertile group (F (3, 51) = 18.637; MCe = 79.153; p = 0.000), in this case 52.3% of the variance (R2 = 0.523).

As seen in Table 2, in the infertile group, the significant internal variables are: Dispositional optimism (T = -7.299; p = 0.000), Escape/avoidance (T = 3.253; p = 0.002) and Personal resources (T = -2.179; p = 0.032). In the fertile group, the variables Dispositional optimism (T = -2.500; p = 0.015), Escape/avoidance (T = 4.094; p = 0.000) and Openness (T = -3.729; p = 0.000) are significant.

Table 2 Correlation and regression analyses
Full size table

Regarding external variables, the ANOVAs obtained show a statistical significance in the relation of the variable emotional maladjustment for both the infertile group (F(1, 81) = 18.505; MCe = 176.822; p = 0.000) and the fertile group (F (1, 53) = 20.073; MCe=115.80; p = 0.000). In the infertile group, the significant variable is Psychological wellbeing in the couple (T = -4.302; p = 0.000) explaining 18.6% of the variance (R2 = 0.186), while in the fertile group, it is the Interpersonal resources variable (T = -4.480; p = 0.000) that explains 27.5% of the total variance (R2 = 0.275) (Table 2).

Discussion and conclusion

The current study found that infertile individuals differ to fertile couples and shows higher levels of emotional maladjustment and more personal resources than the fertile group, although differences with respect to gender have not been found. Therefore we, like other authors (Casu & Gremigni, 2016), cannot conclude that the infertility problem affects women more than men. In line with other studies (Peterson et al., 2014; Yazdani et al., 2016) we found less use of confrontive coping strategies, social support seeking and positive reappraisal in the infertile group. Infertility is a chronic illness which affects one’s sense of coherence and one´s life goals. This makes infertility difficult to reinterpret and endow it with a positive meaning. Furthermore, the infertile group presents lower levels of marital satisfaction, as highlighted by Kiani et al. (2020). In line with the results obtain by Gourounti et al. (2012), infertile women report a higher employment of the self-controlling strategy. These results contradicted those of Zurlo et al. (2020), who encountered that the group that used this strategy was the men’s. This may reveal the capacity of men and women to perceive the maladjustment in their emotional state and the necessity to control them in order to concentrate their efforts on strategies which are more focused on the problem itself. Both infertile and fertile women utilize social support more frequently than men. Consequently, it seems that the seeking of social support is a strategy generically used by women and, not specific by infertile women (Babore et al., 2017; Mohammadi et al., 2018).

The results of the present study also indicate that internal factors explain the major variance on emotional maladjustment. The external factors, however, just reach an acceptable level. Therefore, vulnerability of the participants to emotional maladjustment is invariably linked to their personal way of understanding and responding to the infertility situation, although the interpersonal aspects may help to increase the perception of wellbeing. Mahajan et al. (2009) find results tending in that same direction. However, this does not seem to be found exclusively in infertile individuals, since fertile respondents report similar results in this study. Therefore, internal factors are not the only moderator role of emotional maladjustment in infertile people, and this result is a relevant contribution in our research.

Concerning internal variables, coping strategies prove themselves to be an important estimator of emotional maladjustment in the samples analyzed, because the escape strategy increases the vulnerability in the infertile participants (Galhardo et al., 2019). However, is also associated with the emotional maladjustment in fertile individuals.

We found similar results in relation to optimism. There was an inverse relationship between the scores for dispositional optimism and emotional maladjustment in infertile people (Rockliff et al., 2014), and also in the fertile individuals at the present research.

The internal factors that appear independently associated with the infertile or the fertile group are personal resources and openness, respectively. We believe that this difference can be attributed to the personal resources subscale of the DERA that indicate an active attitude, such as keeping up the effort to achieve objectives and solving problems, characteristics which acquire special importance in patients who must undergo assisted reproduction treatment to get that desired child. However, for fertile participants, accommodating oneself to vital circumstances seems to depend more on flexibility and aptitude for analysis from a creative and novel perspective (openness). In this manner, it may be confirmed that the resources put into practice depend on the characteristics of the situation and how they are interpreted and assessed (Lazarus & Folkman, 1984).

External factors prove that the quality of the couple's relationship is associated with emotional adjustment in infertility. Other studies highlighted similar results (Gana & Jakubowska, 2016; Luk & Loke, 2019). In infertile couples, well-being in the relationship explained an additional part of the variance in emotional maladjustment, while in fertile participants, interpersonal resources acquire greater relevance. This denotes the special importance that the relationship itself acquires for the well-being of the infertile couple (Benyamini et al., 2009; Holley et al., 2015; Ying et al., 2015). However, other studies exploring marital quality did not report a significant relationship between this external factor and emotional adjustment (Rockliff et al., 2014).

A large body of research has studied the moderating roles between psychosocial factors and emotional maladjustment in infertile patients, but few studies have compared them with fertile individuals. In this preliminary study we found that, both fertile and infertile people develop similar resources to maintain their emotional balance in stressful situations. In addition, the specific psychosocial risk and protective factors in infertile people are found. The findings of this study add to the literature the need, in future studies, for the inclusion of a comparison group of fertile people to study the moderating factors of emotional adjustment, which would avoid an erroneous interpretation of the results for the infertile situation.

From a therapeutic perspective, our study identifies factors that may be incorporated into psychosocial prevention programs and programs design for psychological intervention in infertility (Martínez-Borba et al., 2022). Prevention detects "high risk" couples and, therefore, decreases psychopathology (which means less therapeutic effort and personal suffering). The psychological intervention should focus specifically on internal and external aspects that can provide effective coping strategies to both the participants individually and as couple. Consequently, and as in the case of fertile people, the therapeutic effort in infertile couples should focus on replacing or modifying the use of avoidance strategies and the promotion of dispositional optimism, and it will be essential to promote the personal resources and the increase of the marital satisfaction on the couple.

The main limitation of this study is its transversal nature in researching couples. Emotional adjustment and its relation to personality, dispositional optimism, coping strategies, personal resources, interpersonal resources and marital satisfaction may change according to the different stages of the assisted reproductive treatment. Secondly, the relatively small size of the sample, may reduce the statistical power to detect relationships among variables that could appear with the use of a larger sample. It also prevented analyzing the influence of variables related to medical aspects and the duration of illness and its subsequent treatment. A third limitation is that the sample is from a single private gynecological clinic, which limits the generalisability of the results to the universe of couples with infertility problems. Despite these limitations, we want to highlight the importance of having included a comparison group, that the research was carried out with standardized and validated self-report instruments and that the psychological evaluation was applied individually and independently to each of the participants, controlling the social desirability. In addition, our findings provide modulators of emotional adjustment that are used by both infertile and fertile people and identify key psychosocial modulators that could be used specifically for psychological support in infertile people.