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Psicologia, Saúde & Doenças

Print version ISSN 1645-0086

Psic., Saúde & Doenças vol.11 no.2 Lisboa  2010


Psychosocial adjustment in infertility: a comparison study of infertile couples, couples undergoing assisted reproductive technologies and presumed fertile couples


Mariana Moura­-Ramos1,5, Sofia Gameiro1,2, Isabel Soares3, Teresa Almeida Santos4 & Maria Cristina Canavarro1

1Faculdade de Psicologia e Ciências da Educação da Universidade de Coimbra, Coimbra, Portugal.

2Fertility Studies Research Group, School of Psychology, Cardiff University, U.K.

3Escola de Psicologia, Universidade do Minho, Portugal.

4Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

5Universidade Lusíada do Porto, Porto, Portugal.


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The aim of the present study was to investigate psychosocial adjustment and infertility related stress of infertile couples and couples undergoing Assisted Reproductive Technologies (ART). In a cross sectional study, 148 couples were recruited: 79 couples undergoing ART, 25 infertile couples in their first medical appointment in an infertility centre and no previous ART treatments and 44 childless couples in reproductive age without infertility history. Measures assessed emotional adjustment, quality of life, marital relationship and infertility stress. Couples were the focus of the analysis. Results indicated that couples undergoing ART presented more adjustment difficulties, especially women. No significant differences were found in marital adjustment, although ART couples idealized their marital relationship to a higher degree. Results are discussed in terms of clinical implications and future research directions.

Keywords: Assisted Reproductive Technologies; emotional adjustment; infertility; In Vitro fertilization; marital relationship, quality of life.


Ajustamento psicossocial na infertilidade: um estudo comparativo de casais inférteis, casais a realizar tratamentos de reprodução medicamente assistida e casais presumidamente férteis


O objectivo deste estudo foi investigar o ajustamento psicossocial e o stress associado à infertilidade em casais inférteis e casais que recorreram à Reprodução Medicamente Assistida (RMA). Neste estudo transversal, a amostra foi constituída por 148 casais: 79 casais a realizar tratamento de RMA, 25 casais inférteis, sem tratamentos de RMA anteriores, na sua primeira visita a um serviço de infertilidade e 44 casais em idade reprodutiva, sem filhos e sem história de infertilidade. Foi avaliado o ajustamento emocional, a qualidade de vida, a relação conjugal e o stress associado à infertilidade. Os resultados indicaram que os casais, principalmente as mulheres, que estão a realizar um tratamento de RMA apresentam maiores dificuldades de ajustamento. No que se refere ao relacionamento conjugal, de um modo geral não foram encontradas diferenças, apesar de os casais que recorreram à RMA tenderem a idealizar mais o seu relacionamento conjugal. As implicações clínicas e futuras áreas de investigação são discutidas.

Palavras-­chave: Ajustamento emocional e relacional, infertilidade, fertilização In Vitro, qualidade de vida, reprodução medicamente assistida.

Infertility is clinically defined as the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (Zegers-Hochschild et al., 2009). It is estimated that infertility affects 9% to 10 % of the population world­wide (Boivin, Bunting, Collins, & Nygren, 2007) and a similar prevalence was found in Portugal (Silva-­Carvalho & Santos, 2009). At least one­-third of couples experien­cing infertility will recur to Assisted Reproductive Technology (ART) to achieve pa­renthood. Undergoing ART can be an emotional and physical burden, affecting emotional adjustment, quality of life (QoL) and marital quality in infertile couples (Eugster & Vingerhoets, 1999). Assessing psychosocial adjustment to ART is im­portant due to its impact in treatment dropout rates (Brandes et al., 2009; Rajkhowa, McConnell, & Thomas, 2006) and to the hypothesized impact of emotional status on treatment outcome. Indeed, some research has shown that psychological distress du­ring treatment affects treatment outcome (Demyttenaere, Nijs, Evers­-Kiebooms, & Koninckx, 1992; Smeenk, Verhaak, Stolwijk, Kremer, & Braat, 2004). In order to in­vestigate how couples adjust to infertility and ART treatments, we compared emo­tional adjustment (emotional reactivity and psychological distress), quality of life, relational adjustment (marital quality and intimacy) and infertility stress between three different groups: a group of couples undergoing ART, a group of infertile cou­ples in their first appointment in an infertility clinic and a group of presumed fertile couples.


The psychosocial impact of infertility

Infertility has been considered a major life crisis in couples, representing the inability to fulfil an important goal in couples’ life: the wish to bear a child. It has been reported that infertile couples can experience emotional and relational difficul­ties due to infertility diagnosis and its treatment, namely high emotional reactivity and psychological distress, impairment in quality of life, marital problems, and infertility stress and concerns (Cousineau & Domar, 2007; Watkins & Baldo, 2004).

Emotional reactivity and psychological distress have been the two main di­mensions assessed in couples’ emotional adjustment to infertility, although some in­consistencies in results have been found. The majority of studies have found that couples, but mainly women, do present higher levels of anxiety and depression than controls (Callan, 1987; Fassino, Pierò, Boggio, Piccioni, & Garzaro, 2002; Wang et al., 2007; Wischmann, Scherg, Strowitzki, & Verres, 2009), although the prevalence of psychological disturbance has no clinical relevance (Anderson, Sharpe, Rattry, & Irvine, 2003; Chachamovich et al., 2009; Nelson, Shindel, Naughton, Ohebshalom, & Mulhall, 2008). It is clear, then, that infertility is associated with some emotional distress, but with no clinical relevance (Greil, 1997; Verhaak et al., 2007).

Even though there is no severe emotional disturbance among infertile couples, se­veral studies have shown that QoL is usually affected by infertility. Fekkes et al. (2003) assessed QoL with the Hopkins Symptoms Checklist (Derogatis, Lipman, Rickels, Uh­lenhuth, & Covi, 1974) and the Sickness Impact Profile (Bergner, Bobbitt, Carter, & Gilson, 1981), in terms of emotional, social, physical and cognitive functioning, to con­clude that young infertile men and women experienced more social and emotional pro­blems than a comparison group of people from the general population, and these differences were smaller for men. Another study (Drosdzol & Skrzypulec, 2008) found lower QoL scores in infertile women compared with presumed fertile women in all di­mensions assessed (i.e. general health, health change, physical functioning, role physi­cal, emotional role limitation, social functioning, bodily pain, vitality and mental health). Similar results were found by Monga, Alexandrescu, Katz, Stein and Ganiats (2004) and Nelson et al. (2008). In another study (Chachamovich et al., 2009), results indica­ted that infertile couples presented lower QoL in the physical, psychological and social relationships domains and higher QoL in environmental domain than healthy controls. Women presented higher QoL in the social relationships domain and lower QoL in psy­chological domain than their partners.

In summary, studies indicate that infertile couples present lower QoL than con­trols, although there are discrepancies in dimensions affected. Nevertheless, Ragni et al. (2005) found that although women reported lower QoL than men regarding social functioning, mental health and emotional role limitation, both men and women did not differ from Italian normative data. The authors suggest that gender differences in QoL were not due the infertility problem, but because women tend to report lower scores of health related QoL (Ragni et al., 2005).

Regarding the marital relationship, the field literature points out some incon­sistencies in findings, with some studies reporting the stability of the marital rela­tionship (Sydsjo, Ekholm, Wadsby, Kjellberg, & Sydsjo, 2005), while other suggested that infertile couples are more (Callan, 1987) or at least equally satisfied (Wischmann et al., 2009) with their marriage than presumed fertile couples, and some others re­ported lower scores of marital satisfaction than controls (Monga et al., 2004; Wang et al., 2007).

There is also some evidence that the infertility problem causes marital benefit (Holter, Anderheim, Bergh, & Moller, 2006; Schmidt, Holstein, Christensen, & Boi­vin, 2005), because infertility is a shared problem, forcing partners to communicate and share feelings about the problem and possible solutions, which promotes close­ness and intimacy to the relationship (Greil, Porter, & Leitzo, 1989). Men seem to re­port higher marital adjustment than women (Slade, Emery, & Lieberman, 1997), although they also feel to a higher degree that treatment affected their marital rela­tionship before and during treatment (Holter et al., 2006).

Although marital quality is usually high in infertile couples, infertility may have a detrimental effect on the couple’s sexual relationship, due to the scheduling and the lack of spontaneity of intercourse, the invasion of privacy by the medical team and because intercourse is a constant reminder of the couple’s inability to conceive (Greil et al., 1989). Indeed, studies focusing in the sexual relationship reported more sexual difficulties and lower sexual satisfaction in infertile women and men than controls (Drosdzol & Skrzypulec, 2008; Monga et al., 2004), although not indicating psy­chosexual problems (Slade et al., 1997).

The use of standardized measures to assess psychosocial adjustment is impor­tant to allow for comparisons of infertile couples with normative data and control groups. However, to better capture the experience of infertility, some studies have also focused on infertility related stress and concerns. Newton, Sherrard and Glavac (1999) found that men and women who reported greater infertility global stress also reported higher levels of depression. Specifically, more symptoms of distress were highly correlated with social, sexual and relationship concerns. Relationship and se­xual concerns were related to problems in the marital adjustment. Infertility global stress was also associated with anxiety in both men and women. Similarly, in Fekkes et al. study (2003), a higher level of irrational beliefs about parenthood was related to higher levels of problematic functioning.

In a study assessing infertility concerns (Anderson et al., 2003), more of one quarter of women endorsed infertility related concerns about life satisfaction, control over life, self esteem, sexuality and self blame (in men, this happen only related to life satisfaction), and as in Newton et al. study (1999) total concern score was rela­ted to depression.

In summary, studies indicate that infertile couples experience some emotional difficulties, not clinically relevant, and have good and stable marital relationships, ne­vertheless reporting a deleterious effect of infertility in QoL, sexual dimension of the marital relationship and infertility stress.


ART treatment and its impact on the wellbeing of couples

A substantial amount of infertile couples will recur to ART to achieve parent­hood. Undergoing ART is expensive (Mazure & Greenfeld, 1989), time consuming, interferes with professional life (Bouwmans et al., 2008) and is emotionally and phy­sically demanding (Eugster & Vingerhoets, 1999). These procedures require a sti­mulation stage (self injected hormonal treatment and monitoring through regular ovarian ultrasounds and blood analysis), oocyte retrieval and embryo transfer stage, two weeks waiting period and a final a pregnancy test, to assess treatment outcome, even though clinical pregnancy needs to be confirmed later by a vaginal ultrasound (for more detailed description of the treatment, see Boyle, Vlahos, & Jarow, 2004; Santos & Moura-Ramos, 2010). Therefore, when considering emotional assessment before or during ART procedures, the precise phase of the treatment when the asses­sment occurs may affect research results.

In Reading, Chang and Kerin study (1989), women were assessed in the day 8 of the stimulation phase and results indicated that 20% of women presented clinical signs of anxiety and depression and scored higher on fatigue and lower in vigour than controls group. Similarly, another study (Volgsten, Skoog Svanberg, Ekselius, Lundkvist, & Poromaa, 2008) found that about 30% of infertile women and 10% of infertile men fulfilled criteria for a depressive and/or anxiety disorder during the oo­cyte retrieval stage and Yong, Martin, and Thong (2000) reported similar anxiety sco­res the days before oocyte retrieval and pregnancy test. In a study that aimed to examine daily emotional, physical and social reactions in men and women during all the IVF or ICSI treatment (Boivin & Takefman, 1996), results found that distress but also optimism were higher during oocyte retrieval and the embryo transfer stage and on the pregnancy test day. The authors consider that the uncertainty related to treat­ment procedures is the most important determinant of reactions during IVF, namely trying to find out if each stage has passed was successful. The authors also highligh­ted that although women are more distressed than their partners, the type and pattern of couple’s reactions were very similar, and differences that were found, namely hig­her reported in fatigue in women, can be explain by the procedures per se (Boivin et al., 1998).

In summary, although couples entering treatment are in general well adjusted (Eugster & Vingerhoets, 1999), there is a great variability in adjustment along the treatment (Boivin & Takefman, 1996) (Eugster & Vingerhoets, 1999; Greil, 1997; Hammarberg, Astbury, & Baker, 2001; Verhaak et al., 2007). It is then expected that assessments carried out during treatment will indicate higher distress than assessment prior or in the beginning of the treatment.


Research on infertility and ARTin Portugal

Although the use of ART has been widely undertaken in Portugal since 1985, its legal framework has just recently been approved in 2006 (Law no. 32/2006), re­gulated in 2008 (Decree no. 5/2008) and further developed in 2009 (Judgment no. 101/2009). Similarly, financial Government assistance to couples undergoing ART only began in July of 2009 (Order no.10910/2009), after the collection of the data which served as basis for this paper.

Until recently, there were few studies on infertility and ART in Portugal and very few were dedicated to the psychological experience. Studies published have fo­cused on characterization of oocyte donors (Pereira & Leal, 2005) and of pregnancy and transition to parenthood after ART (Gameiro, 2009; Gameiro, Moura­-Ramos, Canavarro, & Soares, 2009, 2010). The first sociological approach to infertility and the first epidemiological study about its prevalence in Portugal were also published recently (Remoaldo & Machado, 2008; Silva-­Carvalho & Santos, 2009). Therefore, there has been a recent but growing interest about infertility in Portugal, although there are still few studies concerning the psychological adjustment of infertile cou­ples, both before and while they are undergoing treatment.

In the present study, we examined the psychosocial adjustment of three groups of Portuguese couples: infertile couples, couples undergoing ART and presumed fer­tile couples. The group of presumed fertile couples was included for reference pur­poses. Adjustment was assessed with measures of emotional reactivity and psycho­logical distress, quality of life, marital quality and infertility stress. Specifically, first we aimed to compare the three groups regarding women and men’s emotional and marital adjustment and quality of life. We considered the couple as the unit of ana­lysis so that the interdependence that is known to exist between two members of a couple could be accounted for (Kenny, Kashy, & Cook, 2006). Second, we aimed to identify the dimensions of psychosocial distress and infertility stress that best discri­minate between groups.

For our first aim, we defined the hypotheses for group differences in our study as follows:

1. There will be differences in emotional adjustment among the three groups: Couples undergoing ART will present higher positive and negative emotional reac­tivity than presumed fertile couples. Infertile couples will present higher negative emotionality than presumed fertile couples. Women will present higher negative emo­tional reactivity than men; Couples undergoing ART are expected to present higher psychological distress than infertile and presumed fertile couples, and this difference is expected to be higher for women.

2. Infertile couples and couples undergoing ART will present lower QoL than presumed fertile couples.

3. Infertile couples and couples undergoing ART will present higher marital quality and intimacy than presumed fertile couples. Infertile couples and couples un­dergoing ART will present higher difficulties in sexual relationship than presumed fer­tile couples;

4. Infertile couples will present higher infertility stress than presumed fertile. For our second aim, we defined our hypothesis as follows:

5. Emotional adjustment dimensions and quality of life will discriminate cou­ples undergoing ART from the other groups;

6. Higher marital satisfaction will discriminate infertile couples and couples un­dergoing ART from presumed fertile;

7. Worse adjustment of women will contribute to discriminate between couples undergoing ART from infertile and presumed fertile couples.




A total 174 women and 148 men responded to the assessment protocol. Because both partners participation was required to perform dyadic analysis, 148 couples were included in final sample. All couples were married or cohabiting for at least one year. Three different groups were composed: 79 couples undergoing ART (ART Group), 25 infertile couples (Infertile Group) attending their first medical appointment in an infertility medical centre, and 44 presumed fertile couples (PF Group). Sample cha­racteristics are presented in Table 1.


Table 1

Participants’ characteristics


Couples undergoing ART and Infertile couples were older than PF couples. ART couples have been longer in a relationship when compared with Infertile and PF couples. There were also differences related to years of education and so­cioeconomic status. Infertile couples had the lower years of education and PF group had the largest proportion of couples from the medium level of socioeco­nomic status.



Socio­-demographic and clinical form. This form included socio­-demographic data (age, length of relationship, years of education, profession and socioeconomic status) and clinical data (infertility duration, infertility cause and number of previous ART treatments). Socioeconomic status (SES) was measured using a standardized classification developed for Portuguese population, considering low, medium and high categories (Simões, 1994). Clinical information regarding infertility history and treatment procedures was obtained from the patients’ medical records.

Emotional adjustment was assessed with the Emotional Assessment Scale and the Depression, Anxiety and Somatization subscales of the Brief Symptom Inventory.

The Emotional Assessment Scale (EAS) (Carlson et al., 1989; Portuguese ver­sion by Moura­-Ramos, 2006) is a 24­item (emotions) scale where subjects are asked to mark how much they feel at the moment on a 10 cm analogical scale. The Portu­guese version of the scale revealed seven factors: anxiety, happiness, fear, guilt, anger, surprise and sadness, with good internal consistency reliability and good construct va­lidity (cf. Moura­-Ramos, 2006). Cronbach alpha coefficients ranged from .80 to .89 for ART group, .75 to .84 for infertile group and .63 to .91 for the PF group. In the present study, surprise was not considered because of low internal consistency in one group (α<.60).

The Brief Symptom Inventory (BSI) (Derogatis, 1993; Portuguese version by Canavarro, 1999). In this 53­item scale, participants were asked to assess the fre­quency of specific symptoms during the past week on a 5­point scale (0­Never to 5­Very often). In the present sample, subscales Cronbach alpha coefficients ranged from .76 to .96 for ART group, .82 to .98 for infertile group and .71 to .95 for the PF group.

Quality of life (QoL) was assessed with the World Health Organization Quality of Life Bref instrument ­WHOQoL­bref (WHOQoLGROUP, 1995; Portuguese Ver­sion by Vaz Serra et al., 2006). This is a 5­point scale with 26 items that assess QoL in relation to four specific domains (physical, psychological, social relationships and environment). In the present sample, Cronbach alpha coefficients for subscales ran­ged from .71 to .80 for ART group, .73 to .86 for infertile group and .64 to .81 for the PF group.

Marital quality was assessed with the ENRICH Marital Inventory (ENRICH) and personal validation, communication and open to the exterior Scale (PAIR).

The ENRICH (Olson, Fournier, & Druckman, 1983; Portuguese version by Lou­renço, 2006) is a multidimensional scale with different facets contributing to overall satisfaction in marital relationship. It comprises 109 items with a 5­point scale that provides summed scores of the women and men’s evaluation of their relationship. Cronbach alpha coefficients ranged from .69 to .82 for ART group, .68 to .83 for in­fertile group and .72 to .79 for the PF group. In the present study, egalitarian roles subscale was not used due to low internal consistency (α<.60).

The PAIR (Schaefer & Olson, 1981; Portuguese version by Moreira, Amaral, & Canavarro, 2009) assesses the degree of intimacy in a dyadic relationship in a 36­item 5­point scale. The Portuguese version has three factors: personal validation, com­munication and open to the exterior. The PAIR also includes a conventionality scale to assess social desirability in the subjects’ responses. Cronbach alpha coefficients ranged from .69 to .85 for ART group, .83 to .89 for infertile group and .78 to .85 for the PF group. Communication and open to the exterior subscales were not used in this study because of low internal consistency scores in one of the groups (α<.60).

Infertility Stress was assessed with the Fertility Problem Inventory (FPI) (New­ton et al., 1999; Portuguese version by Moura­-Ramos, Gameiro, & Canavarro, 2008). In this 46­item scale, participants are asked to rate how much they agree or disagree with fertility related concerns or beliefs and responses are given in 6­point scale. In the present sample, Cronbach alpha coefficients for these subscales ranged from .72 to .82 for ART group and .74 to .78 for infertile group. Relationship concern and re­jection of childfree lifestyle subscales were not used because of low internal consis­tency in one of the groups (α<.60). This scale was not administered to the PF Group.



Participants from ART and infertile groups were invited to participate in the study during a routine appointment with the psychologist at the Genetics and Human Reproduction Service in Coimbra University Hospitals and Reproductive Medicine in the Vila Nova de Gaia Central Hospitals. Ethical approval was obtained from both hospitals’ Research Ethics Committees. Participants from the infertile group were re­cruited during their first appointment in the Hospital, to which they had been refer­red to due to inability to conceive after for more than one year. Couples undergoing ART procedures were recruited in the beginning of ART, during hormonal simulation phase (6th­8th day). At these points, information regarding infertility or ART pro­cess was given to the couples and participation in the study was asked. Study parti­cipants did not received psychological intervention. Inclusion criteria were age (18 years or older), history of infertility and literacy skills to complete the assessment protocol. PF couples were recruited from general population by convenience proce­dures. Inclusion criteria were having between 20­40 years, being childless and not being pregnant or trying to get pregnant at that moment.

When recruiting participants, a full explanation of the research objectives, the participants’ role and the researchers’ obligations was given. If participants agreed to collaborate, they filled out an informed consent form.


Data analyses

Data analyses were performed using the couple as a unit. The database was res­tructured in order to consider each couple as the subject of the analysis and each part­ner score was a different variable. Analysis of covariance using the General Linear Model (GLM) for Repeated Measures were performed, more specifically MANCO­VAs (for multivariate analysis) and ANCOVAs (for total scores), with Group (1 – ART, 2 – Infertile, and 3 – PF) as the between­-subjects factor and Gender (1 ­Women, 2 ­Men) as the within­ subjects factor, so that within couple differences could be ex­plored (Kenny et al., 2006). Years of education and SES were inserted as covariates in all the analysis. Age and length of relationship were not inserted as covariates be­cause were considered as defining characteristics of the groups.

Pillai’s trace criterion was used because of its robustness with unequal samples sizes (Tabachnick & Fidell, 2007). When effects were found, post­-hoc analysis using Bonferroni procedures were performed to detect group and gender differences.

Effect sizes are presented in all analysis using partial eta squares (ηp2), which can be interpreted as the proportion of total variation attributable to the factor, par­tialling out (excluding) other factors from the total non-error variation. Effects sizes were considered: η2 = .01 a small effect size, .06 a medium effect size and .14 large effect size (Kittler, Menard, & Phillips, 2007). Post­hoc power calculations demons­trated that the achieved sample size was sufficient to detect medium to large effects [f=.30, p<.05, power = .90, G*Power 3] (Faul, Erdfelder, Lang, & Buchner, 2007). Significance level used was .05. However, because small effects would not be de­tected, marginally significant differences (p<0.1) will also be reported and discussed. Finally, to identify the best dimensions that help to classify group membership, three discriminant function analyses (DFA) were performed.



There were no significant differences in any adjustment measures between women whose spouses did or did not participate in the study (data not presented). Table 2 presents the descriptive (estimated marginal means, accounting for the co­variates, and standard errors) of adjustment measures and multivariate and univariate main and interaction effects. Means ± standard deviations for significant results for men and women are presented in text.


Table 2

Descriptives, Multivariante Main and Interaction Effects and Univariate analysis


Emotional reactivity

The multivariate group effect for emotional reactivity was significant, indicating that ART couples have higher anxiety and fear than PF couples. There was also a within­-subjects multivariate effect, indicating that women presented higher anxiety than men [44.30±2.18 vs. 38.34±2.07, respectively]. A multivariate Gender X Group interaction effect with marginally significant trend was also found, indicating that ART women presented higher fear and anger than ART men [Fear: 32.35±2.90 vs. 21.33±2.25, p<.05; Anger: 24.69±3.06 vs. 15.87± 2.20, p<.001, respectively].


Psychological distress

About 15.6% of ART and 12.0% of infertile women scored above norms (con­sidered Mean ± 1 Standard Deviation) in anxiety, against 4.2% of presumed fertile women. In depression, these percentages were 16.5%, 20% and 13.6%, respectively. Although indicating higher prevalence of depression in infertile couples and anxiety in ART women, differences were not statistically significant. Similar results were found in men.

No multivariate group effect was found. A gender main effect was found, indi­cating that women presented higher levels of somatization, depression and anxiety than men [Somatization=.64±.06 vs. .38± .04; Depression=.85±.07 vs. .61±.05, An­xiety=.91±.07 vs. .62±.04, respectively]. These gender effects were classified by in­teractions effects. Univariate analysis indicated that ART women have higher scores on somatization [Somatization=.78±.08 vs. .37± .05; F (1,74) = 33.36, p<.001, ηp2= .31] than ART men. Women in ART and PF groups reported higher depression than men [ART Group: .98±.09 vs. .55± .06, respectively, F (1,78) = 29.183, p≤..001, ηp2= .27] and PF group: .78±.09 vs. .54± .07, respectively, F (1,43) = 5.296, p≤.05, ηp2= .11]. The same results were found in anxiety [ART Group: 1.08±.08 vs. .58± .05; res­pectively, F (1,78) = 43.276, p≤.001, ηp2= .36; PF Group: =.83±.07 vs. .64±.07 res­pectively; F (1,43) = 4.103, p≤.05, ηp2= .09]. Noteworthy, gender differences were much larger and significant in ART group than in PF Group. No gender differences were found in Infertile Group.


Quality of life

No differences were found between groups. However, a gender main effect and a Gender X Group interaction effect were found. Gender differences show that women had lower QoL in Psychological domain than men [73.46±2.18 vs. 78.10±1.3, respectively]. A Gender X Group interaction effect was found, indicating that ART women had lower QoL in physical domain than ART men [75.92±1.50 vs. 82.14±1.22, respectively, F(1,74) =15.804, p≤.001, ηp2 = .18].


Marital relationship

A main effect for Group was found in idealistic distortion. Post hoc comparisons indicated that couples undergoing ART presented higher levels of social desirability when compared to PF couples (p=.022). Similarly, a marginally significant trend was found when comparing infertile couples and PF (p=.066), pointing in the same direction.

Regarding marital satisfaction, a marginally significant group main effect was found, indicating that couples undergoing ART presented higher scores than presu­med fertile couples (p=.065).

A group main effect marginally significant trend was found. Univariate analysis in­dicated that there were significant differences in religious orientation between ART and infertile couples when compared to PF couples (p=.003 and p=.002), respectively.


Intimacy in the relationship

A main effect for group was found in conventionality, indicating that ART cou­ples presented higher scores than PF couples (p=.036). In personal validation, a gen­der main effect was found, indicating that women presented higher scores than men [43.59±.66 vs. 41.87±.74, respectively].


Infertility stress

A group main effect was found in the global stress, indicating that infertile group

presented higher stress than ART couples (p=.002). A multivariate gender effect mar­ginally significant was found, indicating that women presented more social concerns than men [24.61±1.04 vs. 22.21±.93, respectively].


Identification of the dimensions discriminating among groups

Only variables that presented group main effects or interaction effects in pre­vious MANOVAs were included in the DFA model. Variables were considered to discriminate among groups if they loaded on the structure matrix above .3 (Tabach­nick & Fidell, 2007).


Table 3

Discriminant functions between ART group, Infertile group and Presumed Fertile group


The best discriminating variables between ART group and PF group are related to emotional reactivity in women, namely anxiety and fear, partially confirming our first and sixth hypothesis. Religious orientation in both partners was also a discrimi­nant factor. This discriminant function allowed for the correct identification of 87.7% of the ART Group and 68.2% of the PF group. Concerning the comparison of cou­ples undergoing ART and Infertile couples, infertility global stress in both partners was the best discriminant factor. The discriminant factor allowed the correct identi­fication of 94.9% of the ART group and 64% of the infertile group. Religious orien­tation of both partners and women’s marital satisfaction discriminated Infertile and presumed fertile couples, allowing for the correct identification of 60% and 84.1% of cases, respectively. Our hypothesis 5 was partially confirmed.



The present study aimed at describing the adjustment of Portuguese infertile couples and couples undergoing ART. For this purpose we used a couple based ana­lytical approach with a comparative design. The main finding of our study was that couples undergoing ART presented more emotional adjustment difficulties. This has proved to be especially true for women undergoing ART, who presented higher ne­gative emotionality, more depressive, anxious and somatic symptoms and lower phy­sical quality of life than their spouses. In summary, undergoing ART procedures may cause high physical discomfort and emotional distress in both members of the cou­ple but especially in women, who are subjected to most treatment procedures. The re­sults suggest that treatments may be demanding event for couples, but especially for women, and that they may thus beneficiate more from professional help during this phase.

When comparing infertile couples with presumed fertile couples, there are more similarities than differences. Results suggest no differences in couples’ adjustment, with the exception of marital quality. As previously hypothesized, results suggest that infertile couples and couples undergoing ART are more satisfied with their marital sa­tisfaction than presumed fertile. Additionally, both infertile couples and couples un­dergoing ART presented higher scores in religious orientation, which reflects a more conservative conception of life and religious values (Olson et al., 1983), which was an important dimension discriminating among group membership, suggesting that, for couples suffering from infertility, traditional roles of parenthood may be of foremost importance.

Nevertheless, when studying adjustment to ART treatment, some differences were salient, confirming our hypotheses. Women undergoing ART procedures pre­sented higher levels of somatic symptoms and low physical quality of life. This may be due to the treatment effects, because by the time of this assessment women are un­dergoing hormonal stimulation and other medical procedures, which may cause phy­sical discomfort and pain (Boivin et al., 1998; Boivin & Takefman, 1996). Additionally, women undergoing ART and those presumed fertile women are more depressed and anxious than their partners. Although this can be interpreted as a illu­sory gender effect, as suggested by Edelmann and Conolly (2000), differences are much higher in couples undergoing ART, suggesting that heightened emotional dis­turbance may be due to the impact of undergoing ART treatment. It is important to acknowledge that women are usually much more involved with the treatment be­cause they are the ones who are submitted to most of the medical procedures and are more frequently in contact with the fertility centre, and therefore, it is expected its im­pact to be higher. Nevertheless, even considering that a considerate amount of parti­cipants presented emotional disturbance, these results were not significantly different from controls, as reported by other studies (Anderson et al., 2003; Chachamovich et al., 2009; Nelson et al., 2008).

The impact of ART treatment seems to affect much more the emotional adjus­tment than other areas of the couples’ life. Indeed, no differences were found in so­cial relationships or environmental domains and the differences in marital quality are indicative of a better relationship in couples undergoing ART when compared to pre­sumed fertile couples, suggesting that infertility and ART do not have a negative im­pact in marital quality, but, conversely, my enhance partnership and intimacy in the relationship (Greil et al., 1989), mainly for couples undergoing ART, which, as sug­gested by these authors, have had to communicate and to work on solutions to the in­fertility problem.

However, although these findings confirm our hypothesis, they should be in­terpreted cautiously due to the infertile and undergoing ART couples’ tendency to respond in a social desirable manner. The tendency, already described elsewhere (Greil, 1997), although not found in Wischmann et al. (2009) study , was reported by participants in our study: when assessing their marital relationship and intimacy, both couples undergoing ART and infertile presented higher levels of idealistic distortion and conventionality than presumed fertile couples. Although idealization of the part­ner can be an important ingredient of couples’ satisfaction (Murray, Holmes, & Grif­fin, 1996), we should not exclude that results concerning marital satisfaction could be partially explained by a tendency to present a better relationship.

In summary, our results are consistent with the occidental field literature, sug­gesting there are more similarities than differences in infertile and presumed fertile couples (Greil, 1997; Verhaak et al., 2007). Additionally, undergoing ART seems to be a very demanding experience, affecting emotional reactivity and causing great distress, although without clinical relevance and not affecting other areas of couples’ life. As described in the literature, infertility may cause marital benefit, leading to higher marital satisfaction among infertile couples. However, this may be truer in couples with longer infertility and more treatment experiences, who have learnt to cope better with their childlessness, and to experience less distress and more inti­macy, than couples just entering in infertility medical setting (Fekkes et al., 2003; Greil et al., 1989).

The use of two different groups of infertile couples and a group of presumed fer­tile couples, different measures of psychosocial adjustment and infertility stress, na­mely general and infertility specific measures, and a design accounting for the non-indenpendence of the couples’ scores are three major strengths of the present paper. Additionally, because no previous research on psychosocial adjustment of Por­tuguese infertile couples’ recurring to ART had been published, our results contribu­ted to a better understanding of the Portuguese infertile couples and couples recurring to ART.

However, some limitations should also be addressed. First of all, it has been acknowledged that there is great variability in adjustment to infertility and ART, de­pending on age, duration of infertility, number of previous treatments, years of edu­cation, so future research should focus on the impact of these variables in psychological and marital adjustment. Additionally, the small sample sizes in each group can highly limit the generalization of the present results. The small sample size also reduced power in the analysis, only allowing the detection of medium to large effects and therefore not identifying small effects, which can inflate the risk of Type II error (accepting a false null hypothesis). To reduce type II error, marginally signi­ficant linear trends were reported, allowing to hypothesize that differences would have been found if the sample was larger.

Our results can have important implications for clinical practice with couples re­ferred to ART. Even considering that before entering treatment couples have similar adjustment compared to controls, the initiation of the treatment accentuates some ad­justment difficulties, namely in women. The impact of the invasive medical procedu­res and the constraints in professional life associated with expectancies related to the success of the treatment highlight patients’ negative emotions like anxiety and stress. Fertility centre healthcare providers should develop efforts to minimize emotional dif­ficulties among couples recurring to IVF in order to promote a better adjustment to IVF procedures, by providing psychoeducative information regarding the IVF process, na­mely its physical and emotional demands; because there is great variability in couples’ adjustment, efforts should be made to target interventions to the couples’ needs. De­creasing psychological distress and negative emotionality during treatment can be im­portant in reducing dropout rates and in improving IVF success rates (Demyttenaere et al., 1992; Smeenk, Verhaak, Eugster, & van Minnen, 2001). Future research should ad­dress effects of different treatment strategies in psychosocial impact (Verberg et al., 2008) and other predictors of adjustment during the IVF procedure. Recognition of all the factors that have an impact on couples’ adjustment can help professionals designing intervention strategies targeted to the identified needs.



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Este trabalho recebeu apoio da Fundação para a Ciência e Tecnologia (FCT­SFRH/BD/23152/2005, SFRH/BPD/63063/2009, FEDER/POCTI–SFA–160–192).


Recebido em 30 de Maio de 2009/ Aceite em 1 de Novembro de 2010