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Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority
Infertility continuing education MFT CEUs

Section 26
New Methods for More Effective Stress Reduction

CEU Question 26 | CEU Test | Table of Contents
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

The experience of infertility creates negative economic, physical, social, and psychological effects, especially for women. This often results in multiple stresses and needs for coping in these women. Because the manner in which women cope with these experiences are not fully understood, existing counseling interventions fail to adequately meet the needs of women experiencing infertility. Eighty-three women receiving varied services at assisted reproduction clinics participated in a study of the relationship between the use of social coping resources, growth-fostering relationships, and infertility stress. The results support the use of social coping resources for coping with infertility stress. In addition, the results indicate the usefulness of understanding the types of growth-fostering relationships that can be an additional resource for helping counselors conceptualize women's experiences and design effective interventions to help women cope with infertility stress.

The Relational Model of Development proposes that women are relational beings and grow in, through, and toward relationship (Jordan, 1995; Jordan, Kaplan, Miller, Stiver, & Surrey, 1991). Connection to others, through growth-fostering relationships, is central to the psychological well-being of women. As a consequence, women's experiences in relationships may be used to promote their psychological well-being. The Relational Model has been applied in counseling with individuals, couples, families, and groups who are experiencing a variety of issues (Bergman, 1991; Fedele & Harrington, 1990; Jordan, 1995; Miller & Stiver, 1997; Philipson, 1993), including infertility (Gibson & Myers, 2000; Schiller, 1997). However, an empirical link between growth-fostering rela tionships used in coping and improvement in women's psychological well-being has not been established. If a positive correlation between these factors exists, this link could provide a basis for counselors to develop specific interventions to help decrease women's infertility stress.

In this article, the results of a study investigating the use of growth-fostering relationships and social coping resources by infertile women are presented. The primary purpose of the study was to determine the relationship between the use of social coping resources, growth-fostering relationships, and the amount of infertility stress reported by infertile women. The main research question was whether social coping resources and growth-fostering relationships would account for a significant variance in infertility stress. Additional research questions included: What is the relationship between: the use of social coping resources and growth-fostering relationships in infertile women, the use of social coping resources and the amount of infertility stress reported by infertile women, and  the use of growth-fostering relationships and the amount of infertility stress reported by infertile women?

The population of interest included women who had been diagnosed as infertile and were receiving treatment intended to help them conceive. Permission to recruit participants was granted from two major assisted-reproduction and technology medical clinics in the Southeast. At each site, all of the women who met the criteria for primary or secondary infertility were asked to volunteer for the study, regardless of the type of treatment they were receiving, the type of infertility they were experiencing, or their age. Participants were solicited by the nursing coordinators and staff nurses at each site, all of whom had been briefed on the study and the procedures for recruitment and administration of instruments. After consent was obtained, participants received envelopes that contained three questionnaires, a demographic form, and instructions for completing the packet. Although they were encouraged to complete their packets while at the clinic, participants were allowed to take the packets home and return them via mail or return visit to the clinic.

A total of 100 women were asked to participate in the study, of whom 83 completed the surveys described below. Thus the overall response rate was 83%. Among the participants, 94% identified themselves as White, 1% as Black, and 1% as Asian. The mean age for the women was 34 years old, with 45% being in the 30–34 year old range, 29% in the 35–39 year range, 16% being in the 27–29 year range, and 10% being over the age of 45. Approximately 95% reported they were married, and 5% reported not being married (n = 4) at the time they completed the survey.
The majority (55%) of the participants reported having a college education, with 29% having completed a graduate degree. Eight percent reported a high school education only, and 7 % reported completing post-graduate school. In regard to income, 42% reported incomes above $99,000, 10% between $90,000 and $99,000, 10% between $80,000 and $89,999, and 10% between $60,000 and $69,999. Overall, 83% reported primary infertility status, and 17% reported secondary infertility status.

Over one third of the participants (39.8%) reported that they were receiving in vitro fertilization treatment for infertility. Thirteen percent reported receiving artificial insemination as their only treatment with 9.6% reporting that they received injectable hormones as their sole treatment. Other treatment types that represented less than 8% of the participants for each type of treatment included controlled ovarian stimulation, artificial insemination with hormones, Clomid, artificial insemination with injectable hormones, artificial insemination with controlled ovarian stimulation, diagnostic laparoscopy, frozen embryo transfer, or reversed tubal ligation. Just under two thirds (60%) reported that their fertility problem was female factor, 12% reported male factor as their infertility problem, 13% reported an unexplained infertility problem, and 12% reported a combination of female and male factor infertility problems.

Participants were asked to identify sources of social support, specifically the gender of a peer sought for support and the type of community group they looked to for support. The majority of participants chose a female peer (92%), while only four participants (5%) chose a male peer, and 4% indicated no preference. Community preferences for social support included: work (46%), religious group (24%), school (16%), support group (4%), volunteer activity group (1%), hobby group (1%), or no choice (8 %).

Data Analyses
Frequencies were computed for all demographic data. The primary research question was examined using regression analysis. Pearson Product Moment correlations were computed to test three secondary research questions

A multiple regression analysis was used to estimate the amount of variance in infertility stress that can be accounted for by the use of social coping resources, growth-fostering relationships, partner support, and family support. All of the variables accounted for a significant amount of the variance in infertility stress (R² = .37, p = .0001) and contributed significantly to the prediction of infertility stress. In an examination of the standardized beta coefficients, the standardized beta coefficient of social coping resources appears to contribute the most to the prediction of the variance in infertility stress (standardized beta = −.53, p = .002) when growth-fostering relationships, partner support, and family support are held constant. Growth-fostering relationships (standardized beta = .34, p = .04), partner support (standardized beta = −.27, −.03), and family support (standardized beta = −.25, p = .04) contributed somewhat equally to the prediction of variance in infertility stress when the other variables were held constant. However, the standardized beta coefficient for growth-fostering relationships was positive while the other variables' beta coefficients were negative. Furthermore, the R square change values resulted in F changes that were significant for social coping resources (F change = 10.87,p = .002), Partner Support (F change = 11.37, p = .001), and Family Support (F change = 4.48, p = .04).

Pearson Product Moment Correlations were calculated to examine the relationships between social coping resources and growth-fostering relationships, social coping resources and infertility stress, and growth-fostering relationships and infertility stress. A strong (and significant) positive correlation was found between social coping resources and growth-fostering relationships (r = .74, p = .01). Significant negative correlations were found between social coping resources and infertility stress (r = −.35, p = .001) and between growth-fostering relationships and infertility stress (r = −.16, p = .05). These results supported hypotheses two, three and four. Although positive correlations were not originally hypothesized between social coping resources and partner and family support, and between growth-fostering relationships and partner and family support, analyses of these relationships indicated significant positive correlations between social coping resources and partner support (r = .31,p = .006) and between growth-fostering relationships and partner support (r = .19, p = .05).

This study examined the relationships among social coping resources, growth-fostering relationships, and infertility stress in women participating in fertility treatments at urban medical clinics. The findings indicate that both social coping resources and growth-fostering relationships contribute significantly to the variance in infertility stress, with infertility stress decreasing as social coping resources increase. This finding is consistent with the findings of earlier research on the positive effects of social coping on emotional health (Boyce et al., 1998, Dalgard, Bjork, & Tambs, 1995; Komproe, Rijken, Ros, & Winnubst, 1997; Lee, 1997), especially in infertile women (Fouad & Fahje, 1989). Furthermore, partner support and family support contribute significantly to the prediction of the variance in infertility stress. Based on these results, it is clear that family and partner supports are very important coping resources for women coping with infertility stress.

Upon closer examination of the results, social coping resources and growth-fostering relationships may have been assessing similar constructs. The strong positive correlation between the two variables (r = .74, p = .01) is consistent with literature that supports the relationship between them (Connor, Powers, & Bultena, 1979; Genero, Miller, Surrey, & Baldwin, 1992; Jordan, 1997; Liang et al., 1998).). Although the correlation is not strong enough to suggest multicollinearity, the regression statistics should be interpreted with caution due to the potential adverse effects of correlated independent variables on the estimation of those statistics (Pedhazur, 1997). For example, an examination of the standardized beta coefficients revealed that all of the coefficients were negative with the exception of growth-fostering relationships. Based on these results, an increase in the score for growth-fostering relationships means an increase in the score for infertility stress. However, this is not theoretically sound if growth-fostering relationships and social coping resources are assessing the same construct. Furthermore, the amount of variance in infertility stress that is accounted for by social coping resources and growth-fostering relationships may actually be smaller than what is reported in the current analysis. In other words, coping resources may be overshadowing the impact of the specific growth-fostering relationships being used as coping resources by infertile women, not allowing for a better understanding of these relationships. However, the usefulness of social coping resources, partner and family support should not be overlooked. There is strong support for using these coping methods in dealing with infertility-related stress.

As is true of all studies using self-report measures, the possibility of bias in responding must be considered a potential limitation in interpreting the present findings. The sensitive nature of infertility issues is an additional possible confound; however, the procedures for recruitment of participants were designed to help overcome these limitations by motivating participants to provide information to help health care providers enhance the quality of services provided during their infertility treatment program. In addition, although the sample for this study was relatively small and restricted to one geographic region of the country, the proportional representation of demographic factors (e.g., economic level, marital status, infertility status, type of infertility, and type of treatment) was consistent with many studies that have been conducted at specialized infertility treatment centers (Abbey et al., 1991; Brand, 1989; Jones & Hunter, 1996; McEwan et al., 1987; Raval, Slade, Buck, & Lieberman, 1987; Wright, Allard, Lecours, & Sabourin, 1989). As a consequence, the findings may provide evidence of trends that further researchers may want to evaluate more closely.

It was interesting to note that differences in the variables of interest did not emerge based on any of the demographic variables of interest for the study. In particular, the nature or type of infertility problem was not related to infertility stress. Rather, the fact of infertility itself was the major issue, and the presence of growth-fostering relationships, social, partner, and family support were the major factors resulting in stress reduction for all of the women who responded. These findings have implications for counseling practice as well as further research.

As noted earlier, counseling interventions with infertile women have met with only limited success. Counselors can use the findings of this study to design interventions that have the potential to be effective by using social coping resources as part of their treatment plans. Understanding the types of social coping resources will help counselors understand the needs of their infertile clients and how these resources can alleviate stress related to infertility. Counselors can begin to model these resources by creating growth-fostering relationships with their clients. Additionally, counselors can encourage clients to identify peers and communities that either provide or have the potential to provide these types of relationships. Because family and partner support were found to be important in coping with infertility, counselors may want to help their infertile clients through either couples and family counseling, or both.

Further research is needed to better understand the social coping resources that are beneficial in alleviating infertilitystress in women. It would be helpful to replicate the results of the present study with larger sample sizes that are inclusive of a wide variety of demographic factors. It would be interesting to include both males and females in studies on the effects of the use of social coping resources and growth-fostering relationships on infertility stress as well as persons of different ethnic backgrounds and sexual orientation. Learning more about the use of social coping resources and growth-fostering relationships by both infertile men and women can increase counselors' awareness of the needs of this population and provide a knowledge base for designing effective counseling interventions.
- Gibson, Donna M., Myers, Jane E.; The Effect of Social Coping Resources and Growth-Fostering Relationships on Infertility Stress in Women; Journal of Mental Health Counseling; Jan 2002; Vol. 24; Issue 1.

The Relationship between Stress and Infertility

- Rooney, K. L., & Domar, A. D. (2018). The relationship between stress and infertility. Dialogues in clinical neuroscience, 20(1), 41–47.

Personal Reflection Exercise #12
The preceding section contained information about a study of social coping and infertility stress.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Casu, G., Zaia, V., Fernandes Martins, M. d. C., Parente Barbosa, C., & Gremigni, P. (2019). A dyadic mediation study on social support, coping, and stress among couples starting fertility treatment. Journal of Family Psychology, 33(3), 315–326.

Galst, J. P. (2018). The elusive connection between stress and infertility: A research review with clinical implications. Journal of Psychotherapy Integration, 28(1), 1–13.

Kang, X., Fang, M., Li, G., Huang, Y., Li, Y., Li, P., & Wang, H. (2021). Family resilience is a protective buffer in the relationship between infertility-related stress and psychological distress among females preparing for their first in vitro fertilization–embryo transfer. Psychology, Health & Medicine.

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How does the Relational Model of Development propose women grow in a relationship? Record the letter of the correct answer the CEU Test.

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