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Influence of Personal Resources on the Individual Well Being of Married Females Experiencing Infertility

Permanent Link: http://ufdc.ufl.edu/UFE0042400/00001

Material Information

Title: Influence of Personal Resources on the Individual Well Being of Married Females Experiencing Infertility
Physical Description: 1 online resource (143 p.)
Language: english
Creator: Hanney, Heather
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: being, coping, counseling, fertility, infertility, marriage, obstetrics, pregnancy, well
Human Development and Organizational Studies in Education -- Dissertations, Academic -- UF
Genre: Marriage and Family Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy INFLUENCE OF PERSONAL RESOURCES ON THE INDIVIDUAL WELL-BEING OF MARRIED FEMALES EXPERIENCING INFERTILITY By Heather Lynne Hanney December 2010 Chair: Ellen Amatea Major: Marriage and Family Counseling The purpose of the study was to examine the contribution of women s use of three styles of coping, marital satisfaction, use of 3 infertility-specific coping strategies, age, and number of treatments in predicting the individual well-being of married females currently being treated for infertility. A secondary purpose was to identify whether there were differences in coping processes, marital satisfaction, infertility-specific coping strategies, and individual well-being for women of different age groups and number of treatment groups. The study was grounded in Crisis Theory, Transactional Theory of Stress and Coping, and the Developmental Theory of Infertility. A total of 282 women took part in an online survey. No participants elected to complete the paper-based version of the survey. The survey consisted of 4 measures and a demographic questionnaire including the Coping Inventory for Stressful Situations (CISS), the Index of Marital Satisfaction (IMS), the Mental Health Inventory-5 (MHI-5), and the Coping Scale for Infertile Couples (CSIC). The data was analyzed using a 3 x 3 factorial MANOVA, a 3 x 3 factorial ANOVA and stepwise regression. Results of the MANOVA indicated there was no interaction or main effect for the multivariate combined variable. The factorial ANOVA found an interaction between age group and number of treatments group for the subscales of Emotion (CISS) and Space (CSIC) subscales. Stepwise regression found the subscales of Emotion, Avoidance, Space, Task, and IMS score scores were significant predictors of individual well-being. Findings suggest women between the ages of 30 and 33 had the highest scores on the subscales of Emotion and Space in coping with infertility. Findings also suggested the scores on the subscales of Emotion, Avoidance, IMS, Space, and Task may be used as predictors of individual well-being. Avoidance and Task were found to be negative predictors of well-being while Emotion, high marital satisfaction and Space were found to be positive predictors of individual well-being. The results of the study are presented, limitations addressed, and the implications for theory, counseling practice, and future research are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Heather Hanney.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Amatea, Ellen S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042400:00001

Permanent Link: http://ufdc.ufl.edu/UFE0042400/00001

Material Information

Title: Influence of Personal Resources on the Individual Well Being of Married Females Experiencing Infertility
Physical Description: 1 online resource (143 p.)
Language: english
Creator: Hanney, Heather
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2010

Subjects

Subjects / Keywords: being, coping, counseling, fertility, infertility, marriage, obstetrics, pregnancy, well
Human Development and Organizational Studies in Education -- Dissertations, Academic -- UF
Genre: Marriage and Family Counseling thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy INFLUENCE OF PERSONAL RESOURCES ON THE INDIVIDUAL WELL-BEING OF MARRIED FEMALES EXPERIENCING INFERTILITY By Heather Lynne Hanney December 2010 Chair: Ellen Amatea Major: Marriage and Family Counseling The purpose of the study was to examine the contribution of women s use of three styles of coping, marital satisfaction, use of 3 infertility-specific coping strategies, age, and number of treatments in predicting the individual well-being of married females currently being treated for infertility. A secondary purpose was to identify whether there were differences in coping processes, marital satisfaction, infertility-specific coping strategies, and individual well-being for women of different age groups and number of treatment groups. The study was grounded in Crisis Theory, Transactional Theory of Stress and Coping, and the Developmental Theory of Infertility. A total of 282 women took part in an online survey. No participants elected to complete the paper-based version of the survey. The survey consisted of 4 measures and a demographic questionnaire including the Coping Inventory for Stressful Situations (CISS), the Index of Marital Satisfaction (IMS), the Mental Health Inventory-5 (MHI-5), and the Coping Scale for Infertile Couples (CSIC). The data was analyzed using a 3 x 3 factorial MANOVA, a 3 x 3 factorial ANOVA and stepwise regression. Results of the MANOVA indicated there was no interaction or main effect for the multivariate combined variable. The factorial ANOVA found an interaction between age group and number of treatments group for the subscales of Emotion (CISS) and Space (CSIC) subscales. Stepwise regression found the subscales of Emotion, Avoidance, Space, Task, and IMS score scores were significant predictors of individual well-being. Findings suggest women between the ages of 30 and 33 had the highest scores on the subscales of Emotion and Space in coping with infertility. Findings also suggested the scores on the subscales of Emotion, Avoidance, IMS, Space, and Task may be used as predictors of individual well-being. Avoidance and Task were found to be negative predictors of well-being while Emotion, high marital satisfaction and Space were found to be positive predictors of individual well-being. The results of the study are presented, limitations addressed, and the implications for theory, counseling practice, and future research are discussed.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Heather Hanney.
Thesis: Thesis (Ph.D.)--University of Florida, 2010.
Local: Adviser: Amatea, Ellen S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2011-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2010
System ID: UFE0042400:00001


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1 INFLUENCE OF PERSONAL RESOURCES ON THE INDIVIDUAL WELL BEING OF MARRIED FEMALES EXPERIENCING INFERTILITY By HEATHER LYNNE HANNEY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFI LLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2010

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1 2010 Heather Lynne Hanney

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2 ce and unconditional love that has a llowed me to fulfill this dream You are in my heart always.

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3 ACKNOWLEDGMENTS I would first like to thank the amazing women who took the time to complete my survey and lend their wisdom to the fields of counseling and infertility. I would also like to thank the University of Florida and the Gator Nation for providing me with over a decade of priceless experienc e, both personal and academic. Next, I would like to thank my committee members for their commitment to me and to my work throughout my studies at the Uni versity of Florida. I would like to thank my chair, Dr. Ellen Amatea, for her incredible support, guidance, and understanding throughout my graduate career, which I truly cherish. I never could have done this without her. I would also like to thank Dr. Peter Sherrard for being a tremendous mentor to me and unknowingly instilling confidence in abilities I never knew I had. I thank Dr. Silvia Doan for her encouragement through this process and for her trust in my work with the Family Clinic. I also thank Dr. Suzanna Smith, with whom I have had the longest professional relationship at UF, for helping me to choose this career path th rough her inspiring teachings. My colleagues, friends, and family members have provided me with endless support throughout my studies and have believed in me and encouraged me through the ups and downs. I thank Betsy Pearman, for her endless knowledge and tireless efforts to make this process orth, no words can describe the love and respect I have for each of you. You have been there through every step providing knowledge, encouragement, accountability, and, of course, a great deal of fun. To Christy Akly Siddiqui, you have been my best frien d for over 10 years and I am so lucky ear, and of course, for providing me with a fabulous place to stay on every trip to Gainesville.

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4 I must thank my parent s, Laura Lee and Dennis Hanney, for their never ending love and support. I thank my mother for providing me with an example of unmatched strength, passion, perseverance, and unconditional love. She is the most amazing woman I have ever known. I thank my father for showing me the importance of achievement and determination and for being lucky to ha ve such wonderful parents. Most importantly, I would like to thank my husband and best friend, Brian Rask. Though he never anticipated the length or difficulty of this journey, he loved and supported me through every aspect of the process. I am eternally grateful for his constant love, sensitivity, and truly un ique sense of humor that kept m e balanced each and every day.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .............. 3 LIST OF TABLES ................................ ................................ ................................ .......................... 8 DEFINITION OF TERMS ................................ ................................ ................................ ............. 9 ABSTRACT ................................ ................................ ................................ ................................ .. 11 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ................. 13 Scope of the Problem ................................ ................................ ................................ ............. 14 Theoretical Framework ................................ ................................ ................................ .......... 16 Crisis Theory ................................ ................................ ................................ .................. 16 Stress and Coping Theory ................................ ................................ .............................. 19 The Developmental Theory of Infertility ................................ ................................ ....... 20 Vari ables ................................ ................................ ................................ ................................ 22 Need for the Study ................................ ................................ ................................ ................. 22 Purpose ................................ ................................ ................................ ................................ .. 24 Research Questions ................................ ................................ ................................ ................ 24 Organization of the Study ................................ ................................ ................................ ...... 25 2 REVIEW OF LITERATURE ................................ ................................ ................................ 26 Infertili ty ................................ ................................ ................................ ................................ 27 Infertility Defined ................................ ................................ ................................ ........... 27 Infertility Statistics ................................ ................................ ................................ ......... 27 Causes of Infertility ................................ ................................ ................................ ............... 28 Historical Views ................................ ................................ ................................ ............. 28 Present Views ................................ ................................ ................................ ................. 29 Diagnosis o f Infertility ................................ ................................ ................................ ........... 31 Medical Treatment of Infertility ................................ ................................ ............................ 33 Medical Treatment in the Past ................................ ................................ ........................ 33 Medical Treatment Today ................................ ................................ .............................. 34 Future Advances in Infertility Treatment ................................ ................................ ....... 35 Treatment Options ................................ ................................ ................................ ................. 36 Drug and Hormone Therapy ................................ ................................ ........................... 36 Surgical Repair ................................ ................................ ................................ ............... 37 Artificial Insemination ................................ ................................ ................................ .... 39 Assisted Reproductive Technologies (ART) ................................ ................................ .. 39 In Vitro Fertilization ................................ ................................ ................................ ....... 40 Gamete Intrafallopian Transfer (GIFT)and Zygote Intrafallopian Transfer (ZIFT) ...... 41 Sperm and Egg Donation ................................ ................................ ................................ 41

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6 Gestational Carrie rs and Surrogacy ................................ ................................ ................ 42 Alternative Treatments ................................ ................................ ................................ ... 42 Side Effects and Risks of Treatment ................................ ................................ .............. 43 Ethical Concerns of Treatment ................................ ................................ ....................... 45 Cost of Treatment ................................ ................................ ................................ ........... 47 Adoption and the Choice to Remain Childless ................................ ............................... 48 Emotional Impact of Infertility ................................ ................................ .............................. 50 Impact on the Woman ................................ ................................ ................................ .... 50 Impact on th e Man ................................ ................................ ................................ .......... 52 Impact on the Couple ................................ ................................ ................................ ...... 53 Coping Mechanisms ................................ ................................ ................................ ....... 55 Social Vie ws of Infertility ................................ ................................ ................................ ..... 56 Social Context Influences ................................ ................................ ............................... 56 Lack of Support ................................ ................................ ................................ .............. 57 Cultural Expectations and Social Stigma ................................ ................................ ....... 58 Myths About Infertility ................................ ................................ ................................ .......... 60 Therapy for Infertility ................................ ................................ ................................ ............ 61 Summary ................................ ................................ ................................ ................................ 63 3 METHODOLOGY ................................ ................................ ................................ ................ 65 Research Design and Relevant Variables ................................ ................................ .............. 65 Coping Styles ................................ ................................ ................................ .................. 66 Marital Satisfaction ................................ ................................ ................................ ........ 66 Infertility Specific Coping Strategies ................................ ................................ ............. 67 Age ................................ ................................ ................................ ................................ 67 Infertility Treatment Stage/Group ................................ ................................ .................. 67 Individual Well being ................................ ................................ ................................ ..... 68 Population and Sample ................................ ................................ ................................ .......... 68 Sampling and Study Participants ................................ ................................ ........................... 70 Instrumentation ................................ ................................ ................................ ...................... 72 Coping Inventory for Stressful Situations ................................ ................................ ....... 72 Index of Marital Satisfaction ................................ ................................ .......................... 74 Mental Health Inventory 5 ................................ ................................ ............................. 75 Coping Scale for Infertile Couples ................................ ................................ ................. 76 Demographic Questionnaire ................................ ................................ ........................... 77 Data Collection Procedures ................................ ................................ ................................ ... 78 Research Hypotheses ................................ ................................ ................................ ............. 81 Data Analy sis ................................ ................................ ................................ ......................... 82 Summary ................................ ................................ ................................ ................................ 87 4 RESULTS ................................ ................................ ................................ .............................. 90 Sample Demographics ................................ ................................ ................................ ........... 90 Age ................................ ................................ ................................ ................................ 91 Income ................................ ................................ ................................ ............................ 91 Level of Education ................................ ................................ ................................ ......... 92

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7 Ethnic/Cultural Identification ................................ ................................ ......................... 92 Location ................................ ................................ ................................ .......................... 92 Fertility Treatments Used ................................ ................................ ............................... 93 Stage of Treatment ................................ ................................ ................................ ......... 95 Measurement Properties of the Study Instruments ................................ ................................ 96 Coping Inventor y for Stressful Situations ................................ ................................ ....... 96 Mental Health Inventory 5 ................................ ................................ ............................. 97 Index of Marital Satisfaction ................................ ................................ .......................... 97 Coping Scale for Infertile Couples ................................ ................................ ................. 98 Research Questions and Hypotheses Analysis ................................ ................................ .... 100 Research Questi on 1 ................................ ................................ ................................ ..... 100 Factorial MANOVA analysis ................................ ................................ ................ 101 Factorial ANOVA analysis ................................ ................................ ................... 101 Research Question 2 ................................ ................................ ................................ ..... 102 Summary ................................ ................................ ................................ .............................. 103 5 DISCUSSION ................................ ................................ ................................ ...................... 111 Evaluat ion of Research Questions ................................ ................................ ....................... 111 Limitations of the Study ................................ ................................ ................................ ...... 117 Implications ................................ ................................ ................................ ......................... 120 Implications for Theory ................................ ................................ ................................ 121 Implications for Counseling Practice ................................ ................................ ........... 122 Summary ................................ ................................ ................................ .............................. 123 APPE NDIX A DEMOGRAPHIC DATA FOR M ................................ ................................ ........................ 125 B PHYSICIAN LETTER ................................ ................................ ................................ ........ 127 C FLYER ................................ ................................ ................................ ................................ 128 D POSTING FOR INTERNET CHAT ROOMS ................................ ................................ .... 129 E COVER LETTER PAPER ................................ ................................ ................................ 130 F CONSENT FORM PAPER ................................ ................................ ............................... 131 G CONSENT FORM INTERNET ................................ ................................ ........................ 132 LIST OF REFERENCES ................................ ................................ ................................ ............ 133 BIOGRAPHI CAL SKETCH ................................ ................................ ................................ ...... 142

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8 LIST OF TABLES Table page 3 1 Factor Loadings for Coping Scale for Infertile Couples ................................ .................... 88 3 2 Comparison of Lee Study and Current Study Reliability ................................ .................. 89 4 1 Descriptive Data for Study Participants ................................ ................................ ........... 104 4 2 Frequency of Participants By Age ................................ ................................ ................... 104 4 3 Frequency of Participants By Reported Income ................................ .............................. 105 4 4 tional Level ................................ ................................ 106 4 5 Frequency of Participants By Ethnic Group ................................ ................................ .... 106 4 6 Descriptive Data for Infertility Treatments ................................ ................................ ...... 10 7 4 7 Properties of the Coping Inventory for Stressful Situations ................................ ............. 107 4 8 Properties of the Mental Health Inventory 5 ................................ ................................ ... 107 4 9 Properties of the Index of Marital Satisfaction ................................ ................................ 107 4 10 Properties of the Coping Scale for Infertile Couples ................................ ....................... 107 4 11 Factorial Analysis of Variance By Age Group and Number of Treatments Group ......... 108 4 12 Means and Standard Deviations for Age Group ................................ .............................. 108 4 13 Means and Standard Deviations for Treatment Group ................................ .................... 108 4 14 Means and Standard Deviations By Age Group and Treatment Group ........................... 109 4 15 Estimated Marginal Means for Pairwise Comparisons ................................ .................... 109 4 16 Correlation Matrix of Regression Predictor Variable ................................ ...................... 109 4 17 Model Summary for Mental Health Inventory 5 ................................ ............................. 110 4 18 Model Coefficients for Mental Health Inventory 5 ................................ ......................... 110

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9 DEFIN ITION OF TERMS Avoidance oriented coping Refers to the mental changes made and activities designed to avoid stressful situa tions (Endler & Parker, 1999). Ass isted Reproductive Technologies (ART) Comprises the newest area of infertility treatment and gener ally refers to a treatment for infertility in which both sperm and egg are removed from each partner to attempt fertilization (Hart, 2002). Coping The ever changing cognitive and behavioral attempts to control the external and/or internal demands perceive d as strenuous or beyond the control of the individ ual (Lazarus & Folkman, 1987). Crisis Refers to a state of ins tability and disorganization in which coping strategies used in the past are ineffective (Slaikeu, 1990). Emotion oriented coping A response thought to be successful or unsuccessful in reducing stress oriented toward self (Endler & Parker, 1999). High tech methods Higher cost more invasive treatments for infertility. These methods are also known as Assisted Reproductive Tech nology (ART) (Will iams, 2000). Indiv idual well being The self perceptions and level of stress and strain experienced by a n individual (Gladding, 2001). In vitro fertilization (IVF) An embryo transfer procedure in which the egg is fertilized by the sperm outside of the bod y in a laboratory dish. Once the egg is fertilized, it is implanted directly into the uterus to further develop (American Society for Reproductive Medicine, 2003). Infertility The inability of a woman to achieve conception after a year of unprotected int ercourse (Hart, 2002) Low technology methods Treatments for infertility that are generally lower in cost and do not involve surgery. Often included in this category are fertility drugs for women and men, artificial insemination and donor insemination (W illiams, 2000).

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10 Marital satisfaction A mental state reflecting the individual perceived benefits versus perceived costs of marriage. When benefits outweigh costs, a higher degree of satisfaction exists (Shackelford & Buss, 2000). Primary infertility The inability to have ever achieved conception or carried a pregnancy to term (Doherty & Clark, 2002) Secondary infertility The inability to conceive after having carried at least one pregnancy to term in the past (Doherty & Clark, 2002). Stage of infertil ity treatm ent The number of treatments a woman or couple has u sed in an attempt to conceive. Task oriented coping The emphasis on tasks and using planning or deliberateness in addressing pr oblems (Endler & Parker, 1999).

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11 Abstract of Dissertat ion Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy INFLUENCE OF PERSONA L RESOURCES ON THE I NDIVIDUAL WELL BEING OF MARRIED FEMALES EXPE RIENCING INFERTILITY By Heather Lynne Hanney December 2010 Chair: Ellen Amatea Major: Marriage and Family Counseling of coping, marital satisfaction, use of 3 infertility specific coping strategies, age, and number of treatments in predicting the individual well being of married females currently being treated for infertility. A secondary purpose was to identify whether there were differences in coping processes, marital satisfaction, inf ertility specific coping strategies, and individual well being for women of different age groups and number of treatment groups. The study was grounded in Crisis Theory, Transactional Theory of Stress and Coping, and the Developmental Theory of Infertilit y. A total of 282 women took part in an online survey. No participants elected to complete the paper based version of the survey. The survey consisted of 4 measures and a demographic questionnaire including the Coping Inventory for Stressful Situations ( CISS ) the Index of Marital Satisfaction ( IMS ) the Mental Health Inventory 5 ( MHI 5 ) and the Coping Scale for Infertile Couples ( CSIC ). The data was analyzed using a 3 x 3 factorial MANOVA, a 3 x 3 factorial ANOVA and stepwise regression. Results of th e MANOVA indicated there was no interaction or main effect for the multivariate combined variable The factorial ANOVA found an interaction between age group and number of treatments group for the subscales of Emotion ( CISS ) and Space ( CSIC )

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12 subscales S tepwise regression found the subscales of Emotion Avoidance Space Task and IMS score scores were significant predictors of individual well being Findings suggest women between the ages of 30 and 33 had the highest scores on the subscales of Emotion a nd Space in coping with infertility. Findings also suggested the scores on the subscales of Emotion Avoidance IMS Space and Task may be used as predictors of individual well being Avoidance and Task were found to be negative predictors of well being while Emotion high marital satisfaction and Space were found to be positive predictors of individual well being The results of the study are presented, limitations addressed, and the implications for theory, counseling practice, and future research are discussed.

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13 CHAPTER 1 INTRODUCTION her house this morning hoping to conceive a child through in vitro fertilization. She had spent the past 5 years using a variety of means to conceive and had also spent thousands of dollars in the process. Lisa and her husband came from large families with many siblings and were hoping to raise a large family of their own. They had come to a point at which they felt drain ed and hopeless. The energy and money they have put into fertility treatments have put a strain on her, their marriage, and her mental health. In addition to the disappointment of failed attempts to conceive, she is constantly tired, experiences f requent mood swings, and has considerable pain from the daily shots she must take This scenario illustrates many of the challenges faced by women experiencing infertility. The process of fertility treatment can be a difficult struggle not only for a woman, but also for her partner. Women can anticipate a time period during treatment where consistent motivation and patience are greatly needed. However, most women are not prepared for the possibility of enduring years of attempts, a variety of treatment methods, and in many cases, an unsuccessful outcome (Salakos, Roupa, Sotiropoulou & Grigoriou, 2004). Moreove r, women may be unaware of the effects these treatments may have on their individual well being and on the quality of their marital relationship Typical reactions to infertility and treatment may include guilt, anxiety, depression, isolation and rela tion ship strain (Hart, 2002). Often infertility is the f irst major crisis a woman faces in her marital relationship, and constitutes the first true test of the strength of the relationship (Eunpu, 1995). How do women cope with the stress of infertility and in fertility treatment without jeopardizing their relationship satisfaction? Many women feel a loss of control over their lives during this period (Mazor & Simons, 1984). Women may question their individual goals and expectations as well as their role withi n their marital relationship (Corson, 199 9) They doubt their previous perspectives on life and how this problem will affect them in the future (Hart, 2002). They may feel distance

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14 from their partner as well as isolation from their social support system (Imeson & McMurray, If these differences are not addressed, they may create sources of conflict between marital partners d uring this period (Me rari, Chetrit & Modan, 2002). Although women regularly face issues of infertility, researchers have not focused on the treatment experience of females and its impact on the marital relationship. Instead most researchers have examine d the physical health of women experiencing infertility and infertility treatment or their emotional responses to this process ( Peterson, Newton & Rosen, 2003 ). In many cases, women in long term relationships have been exposed to various stressors and str uggles. They have discovered ways to cope with these challenges and have developed the necessary skills to do so (Eunpu, 1995). These coping skills are dramatically tested during the period of infertility and it is imperative for each woman to either str engthen existing skills or develop new, more effective ways of coping with the stress of infertility (Leiblum, 1997). In this specific coping strategies on the ind ividual well being of women in different stages of fertility treatment will be examin ed. Scope of the Problem After marriage, parenthood is considered by many women of childbearing age to be the next step in the family life cycle. What often is not consid ered is the possibility of infertility. Infertility can be defined as the inability to conceive after one year of unprotected intercourse (6 months if the woman is over age 35) (Hart, 2002). In the United States, 1 out of 10 women, or more than 6 million annually, struggle with infertility (Hammond, 2001). Infertility is often viewed as a medical problem to be handled by physicians as well as an issue experienced

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15 exclusively by women (Dayus, Rajacich & Carty, 2001). Acknowledged far less often is the em otional experience of a woman struggling with infertility (Corson, 199 9) In addition, very little information is available concerning the impact of infertility on both the woman and the couple As a result, mental health practitioners have limited infor mation as to how to help this population (Eunpu, 1995). Many researchers have concluded that the experience of infertility is more difficult for women than for men, mainly because women are typically the subjects of a multitude of tests, procedures and, of course, they carry the child if treatment is successful. The emotional struggles women face during this time can range from feelings of helplessness and a lack of control to doubts about the essence of their womanhood (Cudmore, 2005). If the woman decid es to seek treatment for infertility, she may begin cycles of medical treatments ranging from low technology methods such as oral fertility drugs and artificial insemination to more highly invasive assisted reproductive technologies (ART) such as in vitro fertilization (IVF) (Williams, 2000). Throughout these treatments, women can experience significant physical side effects such as hot flashes, mood swings, breast sensitivity, headaches, anxiety, vertigo, nausea, weight gain and exhaustion (Diamond, Kezur Mey ers, Scharf & Weinshel, 1999). Although infertility represents a significant challenge for women, men also experience difficulty during this time (Cudmore, 2005). The extent of medical testing for infertility in males is usually semen analysis (i.e. determining normality if at least 20 million sperm are present within a one milliliter sample) (Mazor & Simons, 1984). Infertility treatment for males is typically limited to administration of fertility drugs similar to those taken by females (Williams, 2000). Many men report feelings of isolation from family and friends as well as physical isolation from their wives during many phases of infertility treatments (Imeson & McMurray,

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16 1996). Men also report struggling with some of the same feelings of help lessness and frustration as their spouses. Some men experience feelings of failure, doubting their own masculinity and loss of power (Mazor & Simons, 1984). In some cases, these feelings may even lead to episodes of impotence (Hart, 2002). Though the ma le perspective will not be examined in this study, it is important to consider when discussing the female experience as it has a significant impact on the marital relationship created by both partners. uring a period of infertility. In a quantitative study assessing psychopathology in infertile women, the experience of infertility was reported to be the first major crisis experienced in their marital relationships (Edelmann & Connolly, 1998). Women wer e forced to make a multitude of difficult decisions as to whether they would seek fertility treatments and how they would manage gender differences in their emotional reactions to infertility (Myers & Wark, 1996). Researchers have reported some women can also experience a decline in satisfaction with their physical relationship during infertility treatment due to a strictly regimented intercourse schedule to create higher chance of conception (Ramezanzadeh, 2006). To maintain the quality of their marriage, women must find ways to manage these new conflict within the relationship. Yet limited research exists regarding the effective and non effective coping strategies women use during fertility treatment and how these strategies are well being Theoretical Framework Crisis Theory Three theoretical frameworks were used to guide this study. The first of these is crisi s theory. As discussed earlier, infertility often represents the first major crisis a woman

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17 experiences. Menning (1975) refers to infertility as a significant life crisis with the ability to threaten psychological and emotional stability Other authors studying infertility also share these views. Hence, crisis theory provides a conceptual framework for understanding the nature of the crisis wome n may encounter (Barker, 1984). According to Slaikeu (1990), crisis is a condition of distress and disorganiza tion. During a crisis, the individual is unable to manage the state with previously successful methods of problem solving and either successfully adapt to the situation or experience a breakdown in functioning. According to crisis theory, every woman def ines the crisis differently. One woman may experience a crisis during a particularly stressful phase or event, while another woman may adjust to this same event or phase with little to no stress. In other words, c risis is individually defined. Crisis rep resents a time of extreme stress for a woman; and it is usually not avoidable. It may also provide an opportunity for necessary changes within a relationship that might not occur without that crisis (Pittman, 1987). A crisis can either lead to progress o relationship (Cohen, Claiborn & Specter, 1983). The goal for counseling practitioners is to guide women so their crisis experience can repres ent a time of positive change. In this theory, crises are categorized by type, maturatio nal (normative) or situational (non normative) (Cohen et al., 1983) Maturational crises refer to developmental stages through the course of life. These crises are generally common, universal experiences, such as puberty, marriage, or parenthood (Turner & West, 2002). Situational crises are unanticipated and external. For example, infertility, divorce, chronic illness, or poverty would each be categorized as situational crises. Once a crisis is identified and categorized, it can be effectively assessed When this is achieved and stress takes on a tangible nature, cha nge can occur (Pittman, 1987).

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18 Within this framework, each of the above mentioned examples represents a precipitating event in the evolution of a crisis. This event marks the identifiable beginning of a potential crisis. What differentiates the event or situation as a crisis for one woman versus another is individual perception (Slaikeu, 1990). In the experience of infertility, one woman may feel a diagnosis of infertility is a sign they were not meant to be parents. Another woman may perceive methods to conceive a child. The first woman may perceive infertility as a crisis while the second wom an perceives it as a manageable stressor. Thus the individual perceptions of the situations differentiate a man ageable stressor from a crisis. Caplan (1964, as cited in Cohen et al., 1983) described the general process of responding to a crisis as a three stage developmental sequence. In the first stage, a precipitating event brings about feelings of anxiety. To cope with these feelings, women rely on the coping mechanisms that have been successful in the past in managing stress. In stage two, when prev iously used methods of coping fail, there is an increase in anxiety and tension. During the third stage, emergency coping skills are developed and tried in an effort to alleviate stress. If these new skills fail to meet the needs of the woman, a breakdow n in functioning will occur. If the skills are successful, the woman is able to manage the stress and experiences progress in the development of a stable relationship. One major tenet of crisis theory is the focus on disequilibrium. Disequilibrium, as a reaction to crisis, is a severe emotional upset. Some common feelings of this reaction are tension, incompetence, and helplessness (Slaikeu, 1990). Disequilibrium begins to occur in the first stage of a crisis reaction. If balance is unable to be achiev ed in the event of crisis, disequilibrium will be exacerbated to event ually damage the relationship.

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19 Stress and Coping Theory A second theoretical framework that guided this study is stress and coping theory. The transactional theory of stress and coping, developed by Richard S. Lazarus and Susan Folkman, outlined the experience of stress and how individuals appraise it It also describes the coping processes individuals use to manage stress (Jordan & Revenson, 1999). The difference between traditional m odels of stress and the transactional theory of stress and coping is the focus on process and change rather than a static and structural view of stress. The process explored in this framework relies on the specific, unique experience of the woman in stres s whereas previously studied models relied on typical reactions to stress seen under similar circumsta nces (Lazarus & Folkman, 1984). In the transactional theory of stress and coping, the person and environment engage in a bidirectional relationship, with each one equally impacting the other (Lazarus & Folkman, 1984). The person and environment constantly interact, developing new meanings in the process. Much like systemic approaches, transactional theory finds it impossible to understand stress by only s tudying the person or the environment. It is the interactions and transactions between the two that create positive or negative events and most importantly, create stress (Lazarus & Folkman, 1987). The transactional theory views stress as part of a larger picture of emotions. From this perspective, stress constitutes a negative relationship between the person and environment (Lazarus & Folkman, 1987). The experience of stress often includes emotions such as fear, shame, guilt, and anger. Stress is based on the specific assessment of the event, unique to the experience and appraisal by the person experiencing the event. It cannot be defined by what has brought on stress in the past or what may do so in the future (Lazarus & Folkman, 1984). The

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20 adjustmen t to stress experienced by a woman is based on available resources, developed meanings, and coping processes (Peterson et al., 2003). According to Lazarus and Folkman (1984) coping is defined as the ever changing cognitive and behavioral attempts to contr ol the external and/or internal demands perceived as strenuous or beyond the control of the individual. It is comprised of three key features; the actual actions of the woman, the context, and how the efforts made during this time change and adapt as the stressful event develops and unfolds. Coping processes are not inherently positive or negative. In fact, the same processes of coping applied in different circumstances may produce varied psychosocial outcomes (Jordan & Revenson, 1999). The study of cop ing within this framework has solely focused on process, referring to the constant change through time and situation. This process does not refer to the reactions or efforts made by the woman in the past, but what is actually happening during the present event (Lazarus & Folkman, 1987). Thoughts and actions displayed during times of stress are contextual, changing from one type of experience to another. Coping efforts are also contextual, based on the transactional relationship between the individual and his/her environm ent (Lazarus & Folkman, 1984). The process of coping has been of interest to researchers conceptualizing infertility as a process crises experienced by women (Lee, Sun, Chao & Chen, 2000). The nature of the infertility experience can be constant, erratic, and medically or personally unmanageable. It may also increase the need for new or revised coping efforts (Jordan & Revenson, 1999). This study will examine the coping processes and marital satisfaction reported by females experiencing infertility and their relationship to individual well being The Developmental Theory of Infertility The final framework that guided this study is the developmental theory of infertility. Diamond et al. (1999) proposed five phases of infertility in which particular issues with

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21 distinctive features are clustered together in each phase. These phases are known as: (a) dawning, (b) mobilization, (c) immersion, (d) resolution, and (e) legacy. In the Dawning phase, women are beginning to have an awareness of possible infertility. Most women have been attempting to conceive for at least several months, if not more than one year but have not been formally diagnosed as infertile This phase comes to an end once the woman seeks medical treatment. During the mob ilization phase, women begin a series of diagnostic tests. This involves frequent exposure to medical professionals, revealing medical histories, and submitting to a multitude of reproductive tests. It is at this time that a formal diagnosis of infertili ty is given by a medical professional. The immersion phase begins as women undergo further testing and start medical treatments for infertility. During this phase, women are kept in a constant state of limbo from month to month. Women begin each month w ith a renewed hope that their fertility treatments will be successful and they will be able to conceive, moving forward to the next stage in the life cycle, parenting. It is a battle between hope and despair coupled with a loss of privacy and control duri ng treatments, anticipatory grief of being a childless woman and in some cases, the onset of marital turmoil. Toward the end of the Immersion phase, Assisted Reproductive Technologies (ART), such as in vitro fertilization, gamete donation, and surrogacy, become re alistic options for treatment. The fourth phase, Resolution, occurs when women have repeatedly experienced failure with various treatment options. Three possible outcomes result from these failures: (a) ending medical treatment, (b) mourning the loss of having a biological child, and (c) refocusing on alternative life paths. During this phase, women decide whether to pursue adoption, or choose to be childless The final phase in this developmental framework is the Legacy phase. During this

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22 time the experience of infertility comes to a close and women must face the fact that they are unable to have a biologically related child Among some women, problems within the marital relationship arise. Other women may find a renewed sense of commitment and maturity within the marriage as a result of the infertility experience. It is the latter experience in which relationships are strengthened through this difficult process. In this study the coping styles and marital satisfaction of women at different stages of the infertility treatment process will be examined. The various stages of infertility treatment will be operationalized by determining the number of treatments each woman has experienc ed. Variables The study examined differences in the coping st yles, marital satisfaction, infertility specific coping strategies, and individual well being of women in different stages of treatment. This study also examined the relationship among nine predictor variables and one outcome variable. The predictor vari ables include: three types of coping styles, marital satisfaction, three infertility specific coping strategies, age, and number of fertility treatments experienced. The outcome variable was perceived individual well being of women undergoing fertility tr eatment In addition; descriptive information was collected on the study sample that included: ( a ) age, ( b ) ethnicity, ( c ) level of education, ( d ) income, ( e ) time of awareness of infertility problem, ( f ) time since diagnosis of infertility, ( g ) extent of treatments for infertility, and ( h ) geographic locati on. Need for the Study Many researchers in the area of infertility have examined aspects of the treatment experience; the medical perspective, the treatment available, the emotional responses, and the s tress experienced by women It is known that women and men manage/cope with the experience of infertility in very different ways (Merari et al., 2002). It is also known that infertility has the potential to strengthen marital satisfaction or create marit al distress (Watkins &

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23 Baldo, 2004). Finally, it is known that the experience can have a significant impact on the physical and emotional health of a woman (Goetzl & Harford, 2005). What is less known is how l satisfaction influence her individual well being. This study examines nine possible predictors of female psychological well being: (a) three coping styles, (b) level of marital satisfaction (c) three infertility specific coping strategies (d) ag e, and (e) stage of treatment. The information gained through this study will be useful to a variety of professionals. Medical professionals in contact with women experiencing infertility will be able to recognize red flags and refer them to the appropriate s ervices if needed. The research will also be of use to women in the midst of infertility treatments. Women with this issue frequently do a great deal of research on the topic, educating themselves about infertility, the causes, effects, and treatment opt ions (Mazor & Simons, 1984). With so much focus on the physical and medical aspects, psychological stability and intimate relationships can be easily overlooked. With the information gathered from this study, women will be better equipped to manage the s tress of infertility and may be more likely to address any decline in their well being that they experience. Practitioners in the field of counseling will benefit from the knowledge gained from the study and the potential to identify a new approach to coun seling women through the crisis of infertility. Counselors working with women in this field will not only be able to identify potential problems but will have the opportunity to better prepare women for this experience. By understanding the factors contr individual well being counselors can assist women in strengthening their use of more effective coping mechanisms and in strengthening their marital relationship. They may also help them to unders tand their individual coping style and what the implications of that style are during

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24 infertility and infertility treatment. Lastly, therapists can help women gain a better perception of the additional factors contributing to a decline in psychological we ll being and how they might combat this potential resul t. Purpose of coping, their marital satisfaction, their use of three infertility specific coping strategies, thei r age, and treatment stage in predicting the individual well being of married females experiencing infertility. A secondary purpose was to identify whether there were differences in coping processes, marital satisfaction, infertility specific coping strat egies, and individual well being in women at different stages of infertility treatment. The study sample included heterosexual married women of typical child bearing age (18 45) currently participating in infertility treatments in the United States. A cr oss sectional survey method was used to examine married females experiencing infertility using various fertility treatments The primary variables included in this study were (a) 3 coping styles, (b) the level of marital satisfaction, (c) 3 infertility sp ecific coping strategies used (d) perception of individual well being (e) stage of fertility treatment, and (f) ag e. Research Questions The following research questions were addressed in this study: RQ 1 : Are there differences by age and stage of treatmen t in the styles of coping ( T ask oriented, E motion oriented, and A voidance oriented), levels of marital satisfaction, infertility specific coping strategies ( S pace C ontrol and B eliefs ), and individual well being of women engaged in infertility treatment? RQ 2 : What influences do the three styles of coping ( T ask oriented, E motion oriented, or A voidance oriented), the level of marital satisfaction, the three infertility specific coping

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25 strategies ( Space Control and Beliefs ), the number of fertility treatmen have in predicting the level of individual well being of women engaged in infertility treatment? Organization of the Study Literature related to the purpose of the study is discussed in C hapter 2. Chapter 3 provides a review of the methodology used to design and implement the study. It also describes the variables of the study in more detail. Chapter 4 presents the results obtained from the study. Chapter 5 presents a detailed discussion of the research findings and their implicat ions for further research in this area.

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2 6 CHAPTER 2 REVIEW OF LITERATURE The literature reviewed for this study addresses infertility and the emotional impact of infertility. Literature describing the causes, diagnosis, and medical treatment of infer tility is reviewed as is literature on treatment options. This review focuses on the experiences of infertility of the individual woman, her partner, and the couple. Literature examining psychological morbidity during infertility, social perceptions abou t infertility and parenthood, the influence of gender expectations, treatment options, the impact of the experience on each individual and the couple, coping styles, and the role of counseling during the process and treatment of infertility is also discuss ed. In addition, literature describing societal views on infertility is presented. Although experience, it is important to have an understanding of the perspective on infertility to apprec iate the differenc es between males and females. Having a child is the dream of many women and biologically what females were designed to do. Deciding to have a child involves preparation, anxiety, and countless thoughts about what kind of person the child will be During the pregnancy, dreams are formed about parenthood and goals are established for the future of the child. All of these things are part of both a psychological and social transition to parenthood delineating a shift in thinking and roles f or individuals and couples. Unfortunately, not every couple makes this transition smoothly. Infertility can create obstacles to the transition and create new and unpredictable stressors arising in the couple relationship, testing its strength and stabili ty. Despite the preparation most couples make for parenthood, rarely is a couple prepared for the difficulties of infertility and the physical and emotional stress experienced by the woman

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27 Women appear to experience infertility in a variety ways. Some w omen survive the struggles involved in infertility and emerge stronger and more confident in their relationships. Other women are unable to withstand the stressors placed on them and experience a decline in marital satisfaction and a breakdown in their re lationship with their partner. Differing personal resources in women are significant in influencing their ability to move successfully through the well being of three strategies, and (c) marital satisfaction, when at varying treatment stages and age s. Infertility Infertility Defined Infertility can be defined as the inability of a man, w oman or couple to conceive a child or the inability to carry a child to live birth (Day u s et al. 2001; Hammond, 2001; Jordan & Revenson, 1999; Nordenberg, 1997; Peterson et al., 2003; Smith & Smith, 2004; Watkins & Baldo, 2004). This diagnosis is typical ly given after one year of unprotected intercourse not resulting in conception (Edelmann & Fielding, 1998 ; Smith & Smith ). Infertility can be separated into two categories: primary infertility and secondary infertility. Primary infertility is defined as the inability to conceive a first child. Secondary infertility is the inability to conceive a child following the live birth of one child (Smith & Smith ). Infertility Statistics Some discrepancy exists as to the number of individuals and couples affected by infertility. According to several researchers, approximately 8 % to 10% of the United States population, or 6 million people per year, struggle with infertility (Hammond, 2001; Hart, 2002; Eunpu, 1995; Jordan & Revinson, 1999). This statistic results in approximately 6 million women in the United States (Hammond). One researcher estimated the prevalence at 12% of

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28 couples of childbearing age experiencing infertility (Elliot, 1998). Other researchers have reported that 1 in 6 couples in the United Stat es experience infertility (Holditch Davis, Sandelowski & Harris, 1999; Peterson et al., 2003, Schneider & Forthofer, 2005). Yet other researchers estimate the occurrence of infertility to be between 8% and 15% (Edelmann & Fielding, 1998, Wilcox & Rossi, 2 002). For the purpose of this study, the estimated percentage of couples experiencing infertility is between 8% and 17%, ba sed on the available research. Many couples believe conceiving a child will be an effortless process. In actuality, couples only ha ve a 30% chance of conceiving in a single month with consistent, unprotected intercourse (Hammond, 2001). For 80% of couples, conception occurs within 1 year of unprotected intercourse (Hammond). Although it is a common belief that infertility is a femal e problem, between 30% and 50% of infertility problems are due to male factors (Elliot, 1998). Another study estimated the percentage at 40% (Hammond ). Causes of Infertility Historical Views Current research on the causes of infertility reveals a dramatic ally different picture from those emphasized in the past. Historically, infertility was linked to psychological problems rather than physical issues. This was due to the limited resources researchers had to conduct infertility testing and due to the infl uence of psychoanalytic perspectives of personality and psychopathology (Eunpu, 1995). In one example, Rubenstein (1951) described infertility as a psychological problem using a gynecological label. Cook (1987) noted the root of infertility was previousl concerning motherhood, femininity, immaturity, and hatred of their own mothers. During that era researchers compared fertile and infertile women, and found that infertile w omen had a higher degree of emotional disturbance, psychotic presentation, and schizoid

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29 tendencies (Eisner, 1963). One study reported that infertile women had an increased frequency of hysteria, aggressive personality disorders, difficulties in sexual rel ationships, a nd greater ambivalence (Mai Munday, & Rump 1972). Slade (1981) described infertile women as having restricted attitudes toward sexual issues and greater overall guilt. Due to limited diagnostic capacities, no organic cause of infertility w as reported in ove r half of the presented cases. Today, with improvements in infertility research and diagnostic testing, experts believe that psychological factors are not a cause of infertility, but often are a result of the experience of infertility. I nfertility is currently believed to result from an organically based cause in approximately 90% of cases and those causes may be due to either female and/or male factors (Eunpu, 1995 ). Present Views Current research presents a long list of causes for infer tility, almost all of which are organically based and attributable to both male and female factors. In the majority of cases, the cause lies with one or the other person; however approximately 10 20% of infertility diagnoses are attributable to a combinat ion of both male and female factors (Fisch, 2005) In 25% of infertility cases, couples have more than one contributing factor such as endometriosis and tubal blockage ( Hart, 2002; Kenigsberg, 2006). There are many female factors contributing to infertili ty. Nordenberg (1997) found ovulation disorders, pelvic inflammatory disease, surgery for ectopic pregnancy, endometrioses, and fallopian tube blockage as some contributors to infertility (Meadows, 2004). Other factors include irregular menstruation, a h istory of miscarriage, and infection. Hypothalamic dysfunction, chronic disease, pituitary abnormality, thyroid dysfunction, ovarian dysfunction, adrenal dysfunction, luteal phase defect, immunologic factors, coital factors, peritoneal factors, tubal fact ors, cervical factors and reluctant ovum syndrome may also contribute to infertility

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30 (Trantham, 1996). Kenigsberg (2006) also cited uterine problems such as fibroids, polyps, and uterine structural pro blems as other common factors. Equally common contribu tors to infertility are male factors. Some of these include erectile dysfunction, reproductive tract infections, clogged ejaculatory ducts, and varicoceles (Fisch, 2005). Other factors are attributable to the male sperm. Low sperm count, problems with q uality of sperm, and the ability of sperm to reach and penetrate the female egg may also contribute to infertility (Hart, 2002; Kenigsberg, 2006; Meadows, 2004; Watkins & Baldo, 2004). Elliot (1998) described some cases of male factor infertility as a res ult of spinal cord injuries and azoospermia. Azoospermia refers to a lack of sperm in the ejaculate. Hypogonadism occurs when testosterone levels are abnormally low. Both primary and secondary hypogonadism may contribute to infertility in addition to an drogen insensitivity, and altered sperm transport (Jose Miller, Boyden, & Frey, 2007). Other contributors include severe medical illness, such as mumps, severe testicular injury, diabetes, prostate or urethrine surgery, tumor, or impotence (Nordenberg, 19 97). Lifestyle and environmental factors may also play a part in infertility. Fisch (2005) cited smoking, diabetes, prescription medication, sedentary lifestyle, high cholesterol and injury as direct contributors to erectile dysfunction. Exposure to toxi ns such as pesticide, use of contraceptives, sexually transmitted diseases (STDs), prevalent use of antidepressants, steroids, alcohol, and drug use, such as mariju ana, may all affect fertility ( Nordenb erg, 1997; Stanton & Dunkel Schetter, 1991; Trantham, 1996). Severe emotional or physical stress may also affect stress may interfere with ovulation. In many cases, physical dysfunction affects infertility and

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31 c an be intensified by emotional stressors; however, many of the procedures included in the infertility treatment process can also be stre ssful themselves (Cook, 1987). A final cause of infertility widely discussed in recent years is due to delayed childbirt h. Societal norms may encourage women to focus on their career early in life, rather than motherhood and this has had an effect on fertility. Although society perceives an increase in infertility rates, in actuality, very few changes have been seen over time. However, there has been a large increase in infertility among women delaying childbirth until the mid to late 30s and early 40s (Jordan & Revenson, 1999; Stanton & Dunkel Schetter, 1991 ; Trantham, 1996 ). According to Fisch (2005), the rate of wome n bearing their first child after the age of 35 has increased by 116%. The rate of first time fathers over 35 has increased by 50%. In infertility, the number of viable eggs is not as important to the process as the age of the eggs. Chromosomal and meta bolic abnormalities are far more common among older eggs, resulting in either infertility or miscarriage (Kenigsberg, 2006). Another major cause for concern with more mature eggs is the increased chance of birth defects due to various abnormalities (Fisch ). With increased age, fertility declines at a significant and rapid pace. At the age of 35 36 years, women are almost always recommended to an infertility specialist within one month of attempted conception. After 37, a specialist is considered an esse ntial part of the process (Kenigsberg). Diagnosis of Infertility Securing a diagnosis of infertility is often a long and tedious process. The procedures involved can be stressful, time consuming, costly, and may take years to complete (Eunpu, 1995). The diagnostic process is usually started after one year of unprotected sexual intercourse without conception (Glazer & Cooper, 1988). This process includes a complete medical history for both male and female partners followed by a complete physical examinati on based on the

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32 medical history (Fisch, 2005). The progression of diagnosis can take from 3 months to a year or references (Stephenson, 1992). The initial phase of diagnosis begins with a complete medical history taken from bo th the woman and her partner The female medical history includes questions about the menstrual cycle, past attempts at conception, frequency of intercourse, birth control history, weight, age, history of miscarriage, heart disease, trauma, and current me dication (Kenigsberg, 2006; Hammond, 2001). Lifestyle is also included in the medical history with attention to habits such as: drinking, smoking, recreational drug use, and exposure to toxic chemicals (Stephenson, 1992). The male medical history include s many of the same questions in addition to involvement in previous pregnancies, previous surgery, hernia, undescended testes, difficulty maintaining an erection, and history of illness (Kenigsberg). The medical and sexual histories are discussed both as a couple and individually (Stephenson). Further testing and examination is based on the medical histori es gathered from each partner. Diagnosis for females continues after the medical history is taken with a variety of tests and procedures. A basic physi cal exam is completed, assessing for perforated hymen, normal functioning in the fallopian tubes, ovaries, cervix, uterus, and clitoris, vaginal infections, tears, polyps, infection, endometriosis, tumors, routine blood and urine tests, and a pap smear (Eu npu, 1995; Hammond, 2001; Stephenson, 1992). Other diagnostic testing includes basal body temperature (BBT) charting completed by the woman every morning before getting out of bed (Glazer & Cooper, 19 8 8). Ovulation testing includes an endometrial biopsy, serum progesterone blood test, a series of ultrasounds, and LH and FSH (hormones) surge urine tests (Stephenson, 1992). A hysterosalpingogram, also known as a tubogram follows. This procedure involves passing dye through the cervix and into the uterus, to test the functioning of the fallopian tubes.

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33 This procedure is known to be very painful for women (Field & Mar c k, 1994 ; Glazer & Cooper ). Laparoscopy, a procedure in which an incision is made in the navel, and a laparoscope is inserted through this op ening to search for abnormalities and endometriosis is another step in the diagnostic process (Hammond). Another procedure common for the female is an endometrial biopsy, to determine proper ovulation and endometrial quality (Field & Mar c k ; Glazer & Coope r ). This procedure is also known to result in a great deal of physical pain. Male partners must also be tested to determine the cause of infertility in the couple. After a complete medical history is taken, a thorough physical examination seeks to rule o ut a variety of physical causes. Undescended testes, presence of variocele, testicular tumors or cysts, size and consistency of prostate, evidence of sexually transmitted diseases, infection, pubic hair, and baseline lab studies are all studied to ensure proper reproductive functioning (Hammond, 2001; Eunpu, 1995 ). Medical Treatment of Infertility Medical Treatment in the Past The first recorded assisted reproductive treatment procedure was performed in 1790 by a British physician, John Hunter (da Motta & Serafini, 2002). Since then, infertility treatment has made tremendous advances. In the past, the only option to most couples not able to conceive was adoption, since very little was known about infertility and even less about its treatment (Glazer & Coo per, 1988). The first artificial insemination was performed in 1909, marking a breakthrough in fertility technology (Mulrine, 2004). Many of the limitations in the early years of infertility research were due to limited diagnostic capabilities. In the m ajority of cases, a diagnosis of unexplained infertility was given (Eunpu, 1995). Most research during this time focused on female psychopathology as the most likely contributor to the diagnosis of infertility (Rubenstein, 1951). The male partner was nev er included in the diagnostic investigation,

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34 resulting in misdiagnosis at least 40% of the time, based on the inf ormation known today. The 1950 s marked a milestone in infertility treatment as husbands began to be included in diagnostic te sting (Johansson & Berg, 2005). The first national fertility survey took place in 1965, establishing infertility rates at the time between 10 13% (American Society for Reproductive Medicine, 200 3 ). In 1978, fertility treatment changed drastically after the successful intr oduction of assisted reproductive technology (ART) resulted in the birth of a baby girl, Louise Brown, in the United Kingdom (Adamson, 2009). Use of ART in the United States began in 1981 and includes gamete intrafallopian transfer (GIFT), zygote intafall opian transfer (ZIFT) and in vitro fertilization (IVF) (Hart, 2002). Each year, new breakthroughs are made in the field of infertility and new treatments become available to patients seeking conception. The success rates have improved dramatically and ri sks have lessened. In addition, the ability to accurately diagnose not only infertility but also the cause has led to greater success in all areas of treatmen t. Medical Treatment Today Infertility treatment today encompasses a wide range of options for bo th men and women. These options are selected after a variety of considerations have been made; often focusing most on diagnosis, prognosis, and financial means (Gibson & Myers, 2000). In approximately 80 to 90% of diagnosed cases of infertility, drug the rapies or surgical procedures are an effective treatment Less than 3% of cases need more advanced and higher cost treatments such as in vitro fertilization (Fisch, 2005). Although this percentage seems low, it is important to consider the advances in re productive technology have allowed the number of babies born through ART to quadruple in the past 10 years (Mulrine, 2004). In 1994, the number of ART babies born in the United States was approximately 11,000. In 2001, this number rose to over 40,000 (Mu lrine).

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35 The process of diagnosing the cause of infertility has also advanced significantly in recent years ; however, a focus on female factor causes remains. Because the focus still lies on the woman infertility continues to go undetected in ma ny cases. Due to the lack of testing or limited testing for male infertility, most men never become aware of their fertility problem (Fisch 2005). In addition to the limited diagnoses for males, treatment options in male factor infertility are also mini mal. Treatment choices for women are generally more varied and tend to be more invasive than those for men. These treatments also come with a higher cost than those available to men (Gibson & Myers, 2000). Descriptions of the most common fertility treat ments used today are addressed in a subsequent section of this literature revi ew. Future Advances in Infertility Treatment Advancements in the treatment of infertility are due to significant research in the area. There is a variety of treatment options cu rrently available or in the process of development. Some advancement focuses on fine tuning existing treatments. One example, uterine receptivity, or identifying the most effective time for implantation, will likely become more precise. Another example, freezing eggs, will become a more reliable practice (Kenigsberg, 2006). Tubal ovum es are blocked (Stephenson, 1992). Further advances in research will make this a more widely used and effective procedure. Research in human male gamete physiology anticipates a better understanding of cellular and molecular aspects, leading to advanceme nts in the treatment of male factor infertility (da Motta & Serafini, 2002). In the future, reproduction without sperm may be possible, as researchers look to find an agent with the ability to turn sperm production on and off with no impact on the testicl e (Kenigsberg). Presently in the United States, the use of infertility treatments has become quite prevalent with approximately 1 in 100 babies conceived

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36 through these measures. The problem, however, lies in the lack of regulation in the industry, result ing in the need for more rigorous data collection and reporting, as well as more extensive research on the risks of various treatments (Mulrine, 2004). Treatment Options Treatment of infertility begins after a thorough diagnosis has resulted in a clearly d efined cause. Approximately 80 90% of couples seeking a diagnosis for infertility will reach this definite diagnosis (Eunpu, 1995). Of this group approximately 50 70% will successfully conceive (Holditch Davis et al., 1999). After the testing period has ended, a physician will present the best options to treat the diagnosed problem. With the vast number of options available in modern day medicine, many factors must be considered including the financial, emotional, and social consequences involved with e ach type of treatment (American Society for Reproductive Medicine, 2003). The most commonly used options available for infertility today include drug and hormone therapies, surgical repair, and assisted reproductive technologies (ART). Between 80 and 90% of infertility cases are treated with either drugs or surgery or a combination of the two (Nordenberg, 1997). In most cases ART is begun once drugs and surgery have proven to be unsuccessfu l. Drug and Hormone Therapy In the United States today, approxima tely 1.8 million women are currently using infertility medication (Gibson & Myers, 2000). The main reasons for using fertility drugs are to boost ovulation, encourage ovulation away from a known blockage, increase the chances of success with intrauterine inseminations (IUI), generate multiple eggs each month or help to produce the amount of eggs necessary for in vitro fertilization (Kenigsb e rg, 2006). Examples of drugs considered hormone stimulators include Clomid, Pergonal, Metrodin and Humegon, commonly prescribed to women with ovulati on problems (Nordenberg, 1997).

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37 When drug therapy in pill form is ineffective, hormonal therapy (HT), given in administered injections, may be used to improve the hormonal stimulation needed to conceive (Watkins & Baldo, 20 04). Gonadotropins are an example and are administered by injection at home by the patient or her partner. Egg production is carefully monitored by the fertility clinic through consistent ultrasounds in order to use this therapy in conjunction with human chorionic gonadotropin (hCG) and trigger ovulation (Goetzl & Harford, 2005). Injectable follicle and mature eggs (Kenigsberg, 2006). Human menopausal gonadotrop in (hMG) releases FSH and luteinizing hormone (LH) to directly stimulate the ovaries after a pituitary gland failure (Mayo Clinic staff, 2009). Drug and hormone therapy are the most common first steps in the process of fertility treatment as the risks inv olved are fairly low and they come at a reasonable price in comparison to more invasive treatments Surgical Repair Microsurgery and laser surgery are commonly used to diagnose and repair problems such as end ometriosis, distortions of the f allopian tube, a nd unexplained infertility. procedures to assess and repair dysfunction of the fallopian tube (da Motta & Serafini, 2002). Laparoscopy is a preferred procedure for women with no known cause of infertility or for a known and surgically correctable problem (Hammond, 2001). In treating tubal peritoneal disease, laparoscopy has become the preferred alternative to more invasive laparotomies (da Motta & Serafini). In a study o f laporoscopy use with women diagnosed with unexplained infertility in Tokyo, it was found that laporoscopy was not only more cost effective than ART, but also resulted in a higher pregnancy rate in women under 30 than ART (Nakagawa et al., 2007). Laparos copic surgery can also be used as a pre treatment to IVF. For example, by using

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38 this technique to remove hydrosalpinges associated with tubal infertility, IVF has a higher success rate (Farquar & Johnson, 2004). It also seems that advances in laparoscopi c surgery for distal tubal disease are generating comparable success rates to IVF (da Motta & Serafini). Laparoscopy may also be effective in vaporizing endometrial implants and lyse adhesions or to cauterize adhesions. It is most commonly performed in t he early stages of the menstrual cycle and is generally an o utpatient procedure (Hammond). Hysterosalpingography (HSG) is a procedure performed by a radiologist where the shape and patency of the uterus and fallopian tubes are investigated. During the pro cedure, a radiographic dye is inserted into the uterus to diagnosis uterine malformation or tubal occlusion (Hammond, 2001). If a blockage is discovered, a catheter is used by an interventional radiologist to open proximally occluded tubes (Baramki, 2005) Obstructions may also be treated with tubal cannulation or ballon tuboplasty (Hammond, 2001). Some research has found the rate of pregnancy is increased following HSG. It is suspected that the dyes used in this procedure may provide a therapeutic effe ct by clearing tubes of mucus plugs, reducing adhesions, or may have an anti bacterial effect by eliminating tubal infections (Hammond, 2001). Although some believe that the precision of HSG is questionable, the latest procedures developed for assessment of tubal disease may be able to improve quality. Some of these include falloposcopy, microlaparoscopy and transvaginal hydrolaparoscopy (Swa rt et al ., 1995). Surgical repair may also be used to treat male factor infertility One of the most common uses i n this area is to treat a variocele or poor semen quality by improving blood drainage from the testicle (Hammond, 2001). When surgery is performed to repair damage or deformities in the ovaries, fallopian tubes, uterus, or with male factor infertility, it is done so only if the chances of restoring fertility are high (Nordenberg, 1997 ).

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39 Artificial I nsemination Artificial insemination is a procedure in which sperm is placed directly into the female reproductive system. The two most common insemination proc edures can be performed through intracervical insemination (ICI), where sperm is deposited at the end of the vagina near the cervix, or intrauterine insemination (IUI), where sperm is deposited in the uterus (Kenigsberg, 2006). ICI involves the injection of collected semen into the external cervix (Hunter & DeCherney, 1999). Though ICI is the first form of insemination developed and has often proved effective, its use has been superseded by IUI in the majority of cases where insemination is appropriate. IUI is typically used for male factor infertility or unexplained infertility and can be performed naturally or with the assistance of ovulation stimulating drugs (Granne & Childa, 2009). It is also considered to be the first line of treatment to use with a variety of infertility diagnoses due to its low cost, safety and significant success rates (Hunter & DeCherney). In this procedure, the sperm is inserted directly into the uterus at the time of ovulation (Watkins & Baldo, 2004). The pregnancy rate for IUI varies depending on maternal age and diagnosis, but generally ranges between 8% and 60% (da Motta & Serafini, 2002). Both ICI and IUI are relatively painless procedures that do not require anesthetic and are often used before attempting IVF in order t o create a more natural conception process (Watkins & Baldo ). Assisted Reproductive Technologies (ART) Assisted Reproductive Technology (ART) comprises the newest area of infertility treatment and generally refers to a treatment for infertility in which bo th sperm and egg are removed from each partner to attempt fertilization. ART was first used in the United States in 1981 (Hart, 2002). Technical advances made in this area over the last two decades have combated unexplained infertility, age related infer tility, low sperm count, and physical limitations, among many other complications (Wootton, 2000). These advances have made ART

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40 far more popular than ever before in infertility treatment. In fact, the number of babies born through ART saw a dramatic rise of 94% between 1996 and 2001 (Kenigsberg, 2006). ART is generally pursued once less invasive options such as drug therapy or surgical repair have been exhausted. A variety of Assisted Reproductive Technologies (ART) are available today and most commonly include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT) and a combination of IVF and GIFT (Gi b son & Myers, 2000 ). In Vitro Fertilization In vitro fertilization accounts for the majority of ART pro cedures, reported at 71.8% (Hart, 2002). IVF is an artificial reproductive procedure in which eggs and sperm are combined s uterus (Kenigsberg, 2006). The use of IVF has risen dramatically since the first successful IVF birth took place in the UK in 1978 (Ponjaert Kristoffersen, 2005). It has become a viable solution for irreparable tubal disease, endometriosis, and cervica l and immunological factors preventing natural conception as well as male factor infertility and unexplained infertility (da Motta & Serafini, 2002). Though rates of success vary significantly depending on individual factors such as age and diagnosis, it does allow for at least some chance of pregnancy where there was previously none. Pregnancy rates for women over forty using this procedure are small, but ranging between 5% and 7% (Gibson & Myers, 2000). Rates for women under the age of 40 range between 15% and 40% (da Motta & Serafini, 2002). In the future, these rates may continue to rise as they have for the last thirty years since IVF began. Continued research has made it possible to improve aspects of the IVF process for higher rat es of success as time goes on. The process of IVF is broken down into 4 steps. In the first step of treatment, the

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41 viable options (Kenigsberg, 2006). After close monitoring an d meticulous timing, laparoscopy is used to remove the eggs from the ovaries and place them with pre washed sperm in a glass culture dish (Ponjaert Kristoffersen, 2005). If successful fertilization takes place in the dish, the resulting embryos are implan ted in the uterus or frozen for use at a later date (Gibson & Myers, 2000). Gamete Intrafallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT) Gamete intrafallopian transfer (GIFT) refers to a process where eggs and sperm are removed from the b ody, mixed, and placed directly into the fallopian tubes (Watkins & Baldo, monitored (IVF.com 2007 ). Occytes are then retrieved under general anesthesia usin g laparoscopy (Hammond, 2001). Once ova are evaluated for maturity and sperm are obtained and n to occur naturally (IVF.com 2007 ). Zygote intrafallopian transfer (ZIFT) is generally used to treat blockages in fallopian tubes that have prevented the sperm from normally binding to the egg (Toner, 2002). The process is almost identical to that of GIFT, however, sperm fertilize the egg in vitro and the resulting embr yo is transferred to the fallopian tubes (Hammond, 2001). GIFT and ZIFT, though both procedures produce significant rates of pregnancy and live births, have become less commonly used in favor of IVF, which produces equal or better rates of pregnancy and l ive births (Toner, 2002) Sperm and Egg Donation Donor eggs or sperm are typically used when the female or male has difficulty producing viable eggs or sperm of their own. These donations are taken from someone other than the

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42 partner (Watkins & Baldo, 200 4). Donor eggs are often chosen as a result of female age or hormonal deficiencies preventing egg production. Using a donor egg will often reduce the risk of chromosomal abnormalities and increase the chance of conception (Goetzl & Harford, 2005). Donor sperm is typically used if the male is diagnosed with azoospermia, severe oligospermia, or asthenospermia that has not been treated successfully (Hammond, 2001 ). Gestational Carriers and Surrogacy Gestational carriers are used when a woman cannot physical ly carry a child but is able to embryo is implanted into the uterus of the gestational carrier (American Society for Reproductive Medicine, 2003). Surrogacy becom es an option when the female does not produce eggs or her eggs are compromised in some way. It gives couples the option of allowing a Reproductive Medicine, 2003 ). When using a surrogate, a couple forms a contract with a woman stating that after she has conceived, carried the pregnancy, and delivered the child, all parental rights are given to the commissioning couples (Raziel et al., 2005). Surrogacy is often c onsidered a last resort before considering adoption as it not only prevents a biological link to both parents, but the woman is not able to carry the child during pregnancy (Gibson & Myers, 2000). Each of these options should be researched and considered at length before making a decision as a variety of emotional complications could arise for either partner when a third party is involved in some way with the conception and carrying of the chil d. Alternative Treatments Infertile couples are now able to cho ose from a variety of traditional medical treatment options for infertility. Some persons may not be successful with these treatments while others do not feel comfortable with traditional treatment options. There are many alternative treatment

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43 options fo r couples seeking to conceive a child. While many are available, acupuncture and traditional Eastern medicines boast substantial success for infertility and seem to be the most common ly used alternative practices. Acupuncture has been reviewed by several studies, each finding it to be a highly effective treatment for infertility (Zhang & Fay, 2005). Some studies have found acupuncture causes an increase in blood flow to the reproductive organs, improving the quality of eggs (Howard, 2006) Acupuncture al so claims to stimulate ovulation by increasing levels of progesterone and regulating other female hormone levels (Zhang & Fay). A correlational relationship has been found in using acupuncture as a complement to IVF treatment (Anderson, Haimovici, Ginsbur g, Schust & Wayne, 2007). Women are turning to acupuncture more frequently as a way to create optimal health and balance for their bodies prior to fertility treatment or to conceive naturally (Howard, 2006). It is important to consider there is still a n eed for research to establish the efficacy of acupuncture in the treatment of infertility as there is little research to support a causal relationship between acupuncture and infertility treatment success (Anderson et al., 2007 ). Side Effects and Risks of Treatment Medical advances in the area of infertility have made great strides. Women and couples previously unable to conceive a child are now able to do so with the help of medicine and technology. Unfortunately, with these advances come risks and ethic al concerns needing to be addressed pri or to committing to treatment. Most of the side effects involved with treatment are female related, as women are typically on the receiving end of treatment. The most minor but significant side effects of treatment i nclude, but are not limited to: nausea, headaches, loss of hair, flushing, and abdominal bloating (Fisch, 2005). Other side effects include wide mood swings, appetite change, breast tenderness, pelvic fullness, and soreness at injection sites used for dru g therapy (Kenigsb e rg,

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44 2006). Weight gain and adult acne were also noted as undesirable side effects (Imeson & McMurray, 1996). Pelvic fullness, abdominal bloating, and severe cramping are often a sign the ovaries are enlarged by over stimulation, someti mes resulting in a cancelled cycle of treatment to avoid potential harm (Goetzl & Harford, 2005). One of the most important moderate to severe risks is the increased chance of multiple pregnancies resulting from several treatment options (Fisch, 2005). Wh ile this may be considered a blessing for some couples with the resources for only a limited number of fertility treatments, problems do arise if too many embryos are formed. Multiple babies carried during pregnancy increase the risks of complications, es pecially with three or more (Goetzl & Harford, 2005). In this case, couples must often choose to terminate one or more pregnancies in order to improve the chance of success for the remaining fetuses (Kenigsb e rg, 2006). Another risk detrimental to the wom en in the trea tment process is depression associated with a variety of treatment options in addition to the constant changing in emotions when treatments fail (Imeson & McMurray, 1996). Depression and other emotional reactions to infertility will be d iscu ssed later in the chapter. There are risks involved in all forms of infertility treatment. The risks involved in drug therapy include: ovarian neoplasia, dyspareunia, osteoporosis, and ovarian hyperstimulation (Hammond, 2001). In surgical repair, the big gest risk is infection (Nordenb e rg, 1997). ART involves each of the risks described above as well as miscarriage or very early preterm labor, leading to long term health concerns for the baby (Goetzl & Harford, 2005). The risk for congenital abnormalitie s, or birth defects is two times greater in babies conceived through IVF than those conceived naturally (Fisch, 2005). These birth defects include, but are not limited to,

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45 overgrowth, speech impairment, balance and movement problems, and reti nal tumors (K enigsb e rg, 2006). The risks described should be carefully considered before beginning treatment. Although some women and couples believe the greatest risk of treatment is not having a baby at all, it is important to recognize the impact that a reproductiv e technology can have on both the physical and emotional aspects of the individual and couple. It should also be remembered that the research on physical and emotional aspects of reproductive technology is new and evolving, making it difficult to accurate ly predict the long term effects on both mother and child (Eunpu, 1995). Whatever the chosen treatment(s) may be, the partners need to research and deliberate on the process and possible effect to be prepared for possible complications and outcome s. Ethic al Concerns of Treatment Infertility treatment brings a range of new possibilities to infertile women and couples hoping to have a child. Unfortunately, these possibilities also bring ethical concerns that surround the treatment for infertility. The ethi cs of treatment, religious pressures, the rights of the embryos and conceived fetuses and the professional responsibilities of medical professionals must all be taken into account to ensure a high standard of care and respect for human rights. Currently, there is very little control over the practice of infertility treatment in the United States (Granne & Childa, 2009). Few guidelines have been put into place regarding treatment and there exists no national policy or law regarding frozen embryos (Holbrook 1990). This is an area where laws and regulations are necessary to ensure proper treatment as well as preserve the rights of all parties involved in the process. In fact, the United Kingdom currently leads the world on quality control for infertility t reatment. Two organizations have been developed to regulate the practice of medical treatment and to ensure the welfare of the resulting fetuses

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46 These organizations are the Human Fertilisation and Embryology Authority (HFEA) and the National Care Standa rds Commission (NCS C) (Jenkins & Corrigan, 2004). Religion plays a large role in the decisions couples make to treat infertility. Today, the Catholic Church allows couples to seek treatment; however, the church forbids reproductive technology where medica l techniques are substituted for intercourse (Zimmerman, 2009). Some fundamental Protestants believe the use of donor sperm to be adultery, producing an illegitimate child (Stephenson, 1992). Because of these concerns, a number of infertility specialists have become available in the United States that treat patients in accordance with the teachings of the church (Zimmerman). It remains an area of confusion for many patients who must walk a fine line between their religious views and their desire for a ch ild, often forgoing these beliefs in order to conceive. Another ethical issue is the individual rights of not only the children born through assisted reproduction but also embryos produced through the process. One concern centers on the secrecy involved i n fertility treatment, specifically with the use of donor eggs or sperm. In these cases the truth about true biological origins is often kept from the child (Holbrook, 1990). This can become a problem in a variety of circumstances, especially if the chil d were to learn of his or her origins accidentally. The treatment of embryos in assisted reproduction is also an area of concern where there are multiple views regarding their use and destruction. For example, many Catholics and Protestants view the disc arding of unneeded embryos as abortion (Stephenson, 1992). Because the United States lacks legislation in this area, there is no limit on the number of embryos allowed for use at one time in ART and no standard for what to do with those that are left over (Holbrook, 1990).

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47 Ethical treatment of patients by medical professionals is also a significant topic of concern in the treatment of infertility. A common occurrence among infertility clinics is inaccurate or misleading published information about success rates of IVF (Holbrook, 1990). This creates a sense of false hope for many individuals and couples wanting children and can encourage them to spend more money than necessary on a particular treatment that may not be as effective as presumed. There is a lso a great deal of pressure placed on infertility specialists to maximize the chances of success during treatment by using higher than normal doses of ovary stimulating drugs (Granne & Childa, 2009). This can significantly increase the chances of multipl e births resulting in a variety of high risk factor s. Cost of Treatment Infertility is not only an emotionally draining experience, but can be financially draining as well. The cost of infertility treatment can range between $50 to $15,000 for a single tr eatment for each hormone induced menstrual cycle and several cycles of treatment are often needed (Gibson & Myers, 2000). The increase in the use of fertility treatments and the new options available have resulted in a dramatic increase in the amount of m oney spent on infertility treatments each year. From 1999 to 2004, spending on IVF alone rose by 50%, bringing spending to over $1 billion per year (Mulrine, 2004). The average treatment costs available to men are approximately $3,500, while treatment co st for women are dramatically higher (Gibson & Myers, 2000). For example, the average cost per cycle of in vitro fertilization (IVF) ranges between $7,000 and $ 15,000 (Wilcox & Rossi, 2002). Some insurers may cover the full cost of diagnostic tests and tr eatment for infertility; however, it is far more common to not have insurance coverage for infertility (Kenigsberg, 2006). Approximately 85% of insured persons in the United States do not have policies covering IVF, thus forcing most couples to pay out of pocket for each treatment as most insurance

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48 companies view infertility treatment as an elective procedure (Gibson & Myers, 2000). In other cases, health insurance will cover IVF but will refuse to cover far less expensive low technology methods of treatm ent often involving male factor infertility (Fisch, 2005). Fortunately, more medical loans and shared risk programs for infertility are becoming available each year granting patients a partial or full refund if the treatment is unsuccessful (Kenigsberg). Fertility clinics have also taken steps to help the patients financially by offering incentives such as multiple IVF attempts for a single fee and money back guarantees (Mulrine, 2004). It is very important for couples to research not only their own ins urance coverage, but also existing programs to provide financial assistance while progressing through various treatments. Research, planning, and an analysis of anticipated costs can help to offset the financial strain couples often experience through thi s proces s. Adoption and the Choice to Remain Childless The myriad of treatment options for infertility has made pregnancy possible for many women unable to conceive on their own Unfortunately, for 30% 40% of infertile couples, the only option for becom ing parents is to adopt a child (Corson, 1999 ; Daniluk & Hurtig Mitchell, 2003 ). It is estimated 81% of couples adopting a child do so after a struggle with infertility (Ivaldi, 2000). This statistic makes it clear that infertility and adoption are often closely linked. For many couples, adoption can provide a way to alleviate the negative impact of infertility and create the potential to fulfill the dream of having a family (Daniluk & Hurtig Mitchell). Letting go of the hopes of being biological parent s in favor of becoming adoptive parents can be a difficult task and is not always achieved (Daly, 1990). However, research has found that once a couple has made a conscious decision to adopt, the biological/genetic link to the child is no longer an import ant factor in parent child bonding (Akker, 2001 a ).

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49 Adoption can involve a long waiting process during which agencies attempt to create the best match between baby and parents while also keeping the best interest of the birth mother and/or father in mind (C udmore, 2005). The evaluation process by adoption professionals can be long and complex with no guarantee of receiving a child in the end and at times an indefinite waiting period (Holditch Davis et al., 1999). The process is often extended due to the li mited number of babies available for adoption in the United States. Potential parents must decide if raising a child from birth rather than later in life is more important to them tha n having a family of any kind. Although adoption can create hope, it can also become an emotionally complicated experience for couples. With an adopted child also comes a significant amount of loss felt by the adoptive couple as well as the biological mother or parents who have chosen to give up their child (Cudmore, 2005). Couples must grieve the loss derived from their infertility and the expectations they once had about their ideal family. This proves difficult, especially for women, and a history of infertility has been associated with risk factors such as parenting prob lems and depression in the woman (Berg & Wilson, 1991). It is extremely important for a woman to fully transition through the grieving process before receiving a child through adoption as her ability to form a secure, healthy attachment with the adoptive child could be compromised if she has not resolved her feelings and moved on fr om her infertility experience. Adoption represents a wonderful alternative to biological parenthood for infertile couples; however, some infertile couples ma ke a choice to remai n childless, coming to this decision after exhaustive, yet unsuccessful, efforts in both infertility treatment and the process of adoption. Others make this decision at some point during the treatment process. The difficulty in making this decision is no t only the reality of giving up the dream of parenthood, but also

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50 managing the social views and pressures they will experience from those around them. The social view of infertility and the importance of parenthood will be discussed later in the literatur e review. Emotional Impact of Infertility Impact on the Woman In most cases, women endure a greater burden during infertility than men, as they bear most of the responsibility for treatment (Gibson & Myers, 2000 ; Watkins & Baldo, 2004 ). Women generally en dure the greater physical impact during infertility with a multitude of tests, drug treatment s and surgical procedures. In addition, they experience the pain of miscarriage and the reality of a menstrual period each month as treatments fail (Watkins & Ba ldo, 2004). They can experience transformations in their body image, self confidence and general emotional well being (Imeson & McMurray, 1996). It is also not uncommon for women during this time to deny their desire for children to friends and family me mbers (Cudmore, 2005). This is often done in an attempt to avoid conversations about children and hide their experience of infer tility from those around them. Women tend to be at a greater risk for psychological disruptions as result of infertility than m en and find the treatment process more difficult to manage (Holditch Davis et al., 1999). In fact, a study reviewed by Edelmann and Connolly (1998) found that 50% of the women interviewed about their infertility experience felt it was the most upsetting e xperience of their lives. As a result of infertility, women often experience a lack of control, feelings of helplessness, and an overall heightened degree of emotional distress (Eunpu, 1995). Stress during infertility can have a significant impact on ps ychological functioning as well as physical health. In fact, the stress experienced during infertility, especially by the woman can take such a physical toll that it can negatively impact the chance of conception (Eunpu, 1995).

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51 The incidence of depressio n among infertile women is substantially higher than fertile women (Holditch Davis et al., 1999). One contributor to feelings of depression is the overwhelming sense of loss experienced during this time. This loss is similar to the grief experienced afte r the loss of a loved one, as it not only represents the loss of a potential child and dream of parenthood, but also loss of self due to the decline in self esteem, self confidence, security, and perception of health ( Day u s et al., 2001; Eunpu, 1995; Gibso n & Myers, 2000). Other losses felt include loss of body functioning, personal identity, and genetic heritage of a potential child (Stephenson, 1992; Gibson & Myers, 2000). These feelings of loss tend to increase proportionately to the length of time spe nt in treatment (Salakos et al., 2004). Other contributors to depression are the physical changes the woman experiences as she is given a multitude of hormone stimulating medications. These medications are used not only as an initial treatment for infert ility, but are also used in conjunction with almost every common treatment thereafter including insemination and ART. Side effects of medications often include headaches, nausea, mood swings, emotional outbursts, and distractibility (Watkins & Baldo, 2004 ). Each of being and lead to a greater risk of depression. The types of psychological distress described above are generally experienced at similar levels by both men and women as a result of male or fema le factor infertility (Holditch Davis et al., 1999). There is, however, variation dependent upon age. Younger women tend to experience higher levels of stress than older women, especially if there is an unknown cause of infe rtility (Watkins & B aldo, 2004), possibly because older women feel a greater sense of acceptance over circumstances beyond their control (or maybe having other arenas of their lives than possible motherhood in which they have experienced accomplishment). Psychological impact also seems to vary in accordance with length of treatment. The longer treatment is

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52 extended without success, the higher the degree of experienced stress (Salakos et al., 2004). It might be presumed that impact could also vary depending on the type of tr eatment used. It is, however, difficult to substantiate this assumption as there is little research comparing the psychological impacts of treatment. This would be difficult to discern as treatment modalities are not necessarily attempted in a linear ord er, but rather are used based on diagnosis. Given the demanding nature and significantly higher cost of IVF treatment, one might believe that this type of treatment would generate greater levels of stress (Merari et al., 2002). Still, there is no existin g evidence supporting this notion and it should be noted that the stress could be attributed more to the meaning associated with childlessness than to the physical process of treatmen t. Impact on the Man In infertile couples, the experience is often overlooked and undervalued, as most medical and emotional attention is focused on the woman This is surprising, considering that one study found 40% of infertility in couples can be attributable to the male partner (Hart, 2002). It is important to reco gnize that men are significantly affected by infertility whether they or their partner, are the reason for the infertility There is little focus placed on the impact of infertility on the man because reactions often differ significant ly. Though the male experience is not a part of this study, it is important to include this perspective in this literature review in order to have an accurate comparison between t he male and female experience. Typical ly, reactions to infertility inc lude avoidance and denial (Abbey, Andrews & Halman, 1991). These reactions often result in a failure by men to seek supportive relationships during this time, which can be a main predictor of marital discord (Band, Edelmann, Avery & Brinsden, 1998). The re are several possible reasons for this behavior, one of which is shame. It has been found that in cases where infertility is attributable to the male,

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53 were common among those sampled. In some cases, female partners took responsibility for the in fertility to spare the man the humiliation of sharing that information with family o the degree that feelings of powerlessness arose, resulting in episodes of impotence or even promiscuity (Syme, 199 7). Impact on the Couple Infertility places a great deal of stress and demand on the couple relationship (Day u s et al., 2001). It has been found to decrease satisfaction in the marital and sexual relationship, increasingly after the second year of treatment (Holditch Davis et al., 1999). It represents a developmental crisis faced by couples that affects every area of their lives and is often their first crisis faced together as a couple (Eunpu, 1995). This type of crisis can dislodge short and long term life plans and expectations for the couple (Hunter, 1994). It can be seen as a threat to the relationship that has no clear solution and ha s the ability to bring out unresolved i ssues from the Couples experiencing infertility react individually, and together as a couple, in a variety of ways. Some couples feel a sense of isolation from their normal support system. At times, e ach partner can also feel isolated from the other due to a lack of understanding, communication, and overall stress (Eunpu, 1995). Some individuals begin to question their desire to remain married without children (Field & Marck, 1994) In some cases, inf ertility can bring out an increase in acting out behaviors such as adultery, substance abuse, and eating disorders (Eunpu, 1995). The common goal of these behaviors is to regain control over their lives and find pleasure in areas where it has been lost du e to reproductive difficulties (Myers & Wark, 1996). Couples who do not properly address their feelings and needs during this time may face severe

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54 consequences. For example, the rate of suicide and divorce for childless couples is double that of couples with children (Eunp u, 1995; Smith & Smith, 2004). After long periods of treatment, both women and men can experience significantly high levels of depression and dissatisfaction in their relationship (Schmidt, 2006). The frustration experienced with each f ailed treatment contributes to the level of stress, as does the amount of time spent on exams and treatment, the financial burden, and the decision of when to stop treatment (Watkins & Baldo, 2004). Throughout the process, if one partner places blame on t he other for their infertility, distress between them can further inc rease (Watkins & Baldo, 2004). Communication within a couple plays a vital role in the stability of the relationship. Because infertility is sometimes the first major crisis a couple has faced, they may not have had enough time to establish good communication and conflict resolution patterns between them (Eunpu, 1995). When one partner isolates him or herself from the other, diverting their energy to family of origin or career, the other partner may disengage further increasing the amount of stress on the marriage (Myers & Wark, 1996). Another common problem in communication is the difference in gender response. Often, a woman finds comfort in verbally expressing her pain and sadness w ith her partner. When her husband feels uncomfortable with this type of exchange, he may withdraw emotionally, creating heightened stress for him self and feelings of isolati on for his wife (Eunpu, 1995). The sexual relationship shared within the couple ma y be significantly impacted during infertility. Treatment often results in a loss of affection and closeness during intimacy, replacing it with chronicling and scheduling of intercourse for the sole purpose of conception (Eunpu, 1995). The pressure on th e sexual relationship and loss of privacy can easily result in a decrease in desire and male or female sexual dysfunction (Watkins & Baldo, 2004). Infertility can begin

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55 to make each individual feel sexually inadequate and defective, losing a connection wi th their sexual id entities (Myers & Wark, 1996). Although infertility can be traumatic for some couples, it can bring others closer (Mulrine, 2004). Couples who have shown the least amount of disruption to the marital relationship have reported higher sel f esteem, increased marital satisfaction, acceptance of the reality of their infertility and ability to reframe the problem (Watkins & Baldo, 2004). In fact, the greatest predictors of marital stability through infertility include marital commitment, natu re of decision making, coping skills, and intimacy (Myers & Wark, 1996). Couples who are strong in each area may actually strengthen their marriage through the crisis of infertilit y. Coping Mechanisms The coping mechanisms used by individuals and couples through the infertility experience can have either a positive or negative impact. Positive, healthy coping mechanisms promote good communication, strengthen the system of support, and allow for easier decision making. Negative coping skills can break dow n communication and bring on higher levels of stress anxiety, and dissatisfaction. A positive coping mechanism often seen in women experiencing infertility is the seeking of emotional support. The woman creates a support circle often centered on the husb and, but also extending to family members as well as other women who have shared in the experience (Merari et al., 2002). Emotional expression is another positive mechanism that has actually been associated with success of treatment. Planful problem solv ing, positive reappraisal and approach oriented coping are other positive mechanisms that tend to predict better adjustment to infertility and are most associated with females (Schmidt, 2006). In a quantitative study by Merari et al. (2002), it was found that coping mechanisms of repression and denial of the infertility experience are associated with higher levels of anxiety and can sometimes have a

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56 negative impact on the clinical treatment. Other mechanisms with negative impacts include avoidance and fai lure to communicate (Schmidt, 2006). These findings suggest that t he need for healthy and effective coping skills is high for both individuals and couples experiencing infertility as they play a vital role in the development of emotional balance, acceptan ce, and adjustmen t. Social Views of Infertility Social Context Influences Most available research has examined the physiological aspects of infertility and overlooked the emotional experience as well as the established meanings surrounding the experience ( Imeson & McMurray, 1996). In focusing on individual experience, the research literature has also failed to examine how the individual impact of infertility affects the marital relationship (Peterson et al., 2003). In addition there is little to no resea rch focusing on the impact on the extended family members of infertile individuals and couples. It is noteworthy that few of the major textbooks on marital counseling discuss infertility as a relevant issue within the marital relationship (Eunpu, 1995). In the context of treatment, very few researchers have discussed the emotional experience for couples of engaging in IVF treatment despite the fact that it is the most extensive and expensive process of all available treatments (Glazebrook, Cox, Oates & N dukwe, 1999). These facts make the need for research on the emotional impact of infertility and treatment apparent. For women, the impact can be severe because w omen most often take on the physical and psychological burden s of fertility treatment. Exist ing research on the physiological and medical aspects of the infertility experience and process provides a great deal of knowledge for professionals and couples. However, it is also important for couples, families, th erapists, and medical personnel to be aware of how the emotional reactions involved

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57 can impact an individual and the couple relationship, as well as the possible success of treatments Lack of Support One of the most difficult aspects of infertility and treatment is the social isolation experi enced by the couple. The subject of infertility is often kept secret and it is difficult to cope with the social pressure from friends and family to have children (Imeson & McMurry, 1996). Many couples may not feel comfortable sharing their infertility e xperiences with those in their supportive circles, relying solely on the support within the couple (Hart, 2002). It seems most infertile couples resist publicizing their experience with infertility. An estimated 3.5 million couples progress through infer tility testing and treatment without the support of their families and social systems (Myers & Wark, 1996). Couples often feel misunderstood by friends and family members. Due to the lack of understanding from their support system, many couples believe t heir friends and family would not know what to say if the issue of infertility was discussed (Watkins & Baldo, 2004). Without this support, the emotional load of infertility can take a significant toll on the couple. It is important for counselors workin g with infertile women and couples to be aware of these statistics and appreciate their vital role in the emot ional health of their clients. The lack of social support from family members and friends for infertile couples is somewhat expected by those choo sing to keep their infertility private. It often comes as a surprise to also find a lack of support among the medical professionals involved with the infertility treatment Occasionally, infertile couples will work with staff of a fertility clinic who en courage the couple to reflect upon their experience and discuss feelings of grief or failure when treatments are unsuccessful Unfortunately, most fertility clinics do not offer these services (Cudmore, 2005). It is important to recognize that the goal o f medical personnel is to

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58 cater to the medical needs of the patient and not the emotional needs. Although this is an important distinction, the lack of research in the area of emotional response to infertility and need for emotional support are also contr ibutors to the lack of support. Medical personnel cannot address an issue with their patients they know little about. It is important for research to be conducted in this area and be made available to medical personnel working directly with infertile wom en and couples. Cultural Expectations and Social Stigma Regardless of how far society has come in accepting alternative families, s ocietal expectations for women and men are still to marry and then procr eate biologically and naturally (A kker, 2001 b ). The term pronatalist ideology was developed to capture this belief. Pronatalist 2005; p 337). Though it is a term used to describe the impact on men and wome n, its assertions are more often aimed at women, since women consistently experience a greater degree of pressure to bear and or/raise children (Fisher, 1992). Our culture places great value on a Women may c onsider their bodies to be unproductive due to infertility and they see themselves as social failures (Jones, 2001). Even the Bible takes a stance on the importance of parenthood instructing people to go forth, multiply, and have children These stateme nts may seem dramatic but they contribute to the pressure felt by women to be fertile (Watkins & Baldo, 2004). Many women have reported that when faith based or socially based messages such as these were spread in their presence, they were left feeling cu rsed, insignificant, uncomfortable, and experienced psychological d istress (Smith & Smith, 2004). The last four decades have brought a significant shift in the expectations, rights, and roles of women in society. Still, bearing children and becoming a mot her is emphasized as an

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59 important, if not primary role for women in society (Jordan & Revenson, 1999). Females are socialized from childhood to be mothers more than any other social role (Stephenson, 1992). Parenthood is considered a desirable social sta ndard by most people as a way of promoting family heritage and abiding by the traditional view of what a family should be (Dayu s et al., 2001). After the first year of marriage, couples often experience pressure to have children and this only increases by the third and fourth year (Gibson & Myers, 2000). Some women try to conceal their struggle by denying the desire for children and involving themselves in other interests or avoiding social gatheri ngs (Hart, 2002). Infertility prevents couples from achiev ing the social standard of a traditional family. As a result, the embarrassment, shame, and guilt they feel about not being able to conceive on their own often discourages them from socializing with couples with children or attending family events (Merari et al., 2002). Just the sight of parents and children together, combined with the social pressure to create the same ideal can be overwhelming. In turn, childless women are often excluded from events involving children, leading to an involuntary separa tion from social support ( Imeson & McMurray, 1996). The social stigma of infertility and childlessness often leads to feelings of a spoiled identity inadvertently guiding couples into social isolation (Hart, 2002). Infertility is not only a cause of stres s and frustration, but it also includes a great deal of pressure and secrecy for many couples. The social stigma of infertility is often great enough that couples will choose to keep their method of conception a secret from many, if not all, of their frie nds and family. In a study of British families using embryo donation, two thirds of the parents reported they had no intention of revealing conception details to their children because it was far more important to maintain the appearance of a natural preg nancy to the outside world

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60 (Wren, 2004). It has also been observed infertile couples will reveal only those aspects of treatment which resemble ordinary and traditional family ideology (Akker, 2001 b ). This secrecy is cause for concern as it may result in detrimental effect on all involved with special concerns for the child if he or she were to learn of its origins accidentall y. Myths A bout Infertility A common misconception is that infertility rates have dramatically risen over the last few decades. In contrast, infertility rates have remained steady since the first infertility survey was administered in the 1960s, at a rate of 10 13% (Hart, 2002). Over the past 25 years, infertility rates among couples of childbearing age have been fairly stable (Meyer s Weinshel, Scharf, Dezur, & Rait 1995) One explanation for this perceived rise in rates is that the diagnostic criteria has changed. Prior to 1975, patients were diagnosed with infertility after 5 years of unprotected intercourse (Meyer, 1997). In 1 975, the criteria changed to 24 months, and later changed again in 1988 to 12 months by the Office of Technology Assessment (Meyer, 1997). In addition, infertility treatment has identified more individuals struggling with the issue than was possible i n th e past (Kenigsberg, 2006). Another myth surrounding infertility involves the female assuming sole blame for the inability to conceive, an idea prevalent even in recent American culture (Watkins & Baldo, 2004). From the 1940s to the 1960s infertility was b lamed on a unconscious fear of sexuality, neuroses, psychological impairment, or ambivalence toward motherhood (Klempner, 1992). Theories behind this myth of neuroses or psychological impairment have attributed infertility to female emotional prob lems, claiming women were either too anxious or too conflicted to conceive (Smith & Smith, 2004). Along similar lines, women conceiving after adopting a child have been told the presence of a child in the home lessened the emotional disturbance of the wom an allowing her to conceive naturally. In reality, similar percentages of

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61 women conceive after adoption as those who continue to pursue treatment options eventually resulting in conception (Snarey, Son, Kuehne, Hauser, & Vaillant, 1987). It is important to realize that the causes of infertility are equally shared between men and women (Nordenberg, 1997). The notion is that men of all ages have an equal chance at fathering a child This is simply not true. With an increase in age, males experience a dec line in the amount and quality of their sperm (Fisch, 2005). Myths about infertility also extend into areas such as religion and punishment. It has been alleged women delaying motherhood in favor of career aspirations suffer the consequence of infertility ( Faludi, 1992 ) Infertility has also been viewed as a departure from standards of masculinity and femininity, an unseen disability, or worse yet a curse from God (Greil, 1991). This curse or punishment from God might be attributed to a variety of decis ions made within the like they had had too many sexual partners in the past or perhaps it is a result of a previous abortion (Watkins & Baldo, 2004). In real ity previous termination of pregnancy is a highly unlikely cause of infertility (Kenigsberg, 2006 ). Therapy for Infertility The need for therapeutic care through the process of infertility is high. In fact, it was reported by Schmidt (2006) that couples were typically satisfied with the level of medical care received but felt a need for greater patient centered or psychosocial care Women, specifically tend to seek out psychosocial support during infertility and feel it is one of the most important aspec ts of the process behind the actual treatment (Salakos et al., 2004). Although therapy is sought out more by woman than men, most couples find at least a few therapy sessions beneficial through out the infertility process (Fisch, 2005). The benefits have been similar whether provided in an individual, couple, or group therapy basis (Kenigsberg, 2006).

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62 Therapists fulfill a vital role for individuals and couples experiencing infertility. In some cases, therapy can serve as the primary outlet for women and c ouples to express their negative reactions to infertility (Myers & Wark, 1996). It can also create a safe environment for couples to express their fears and frustrations about the treatments, their relationship, and the choices they plan to make as indivi duals and as a couple (Watkins & Baldo, 2004). Therapists can help the couple to explore their sense of meaning in life and determine how their perspectives have changed since infertil ity (Watkins & Baldo, 2004). Therapy can also help to strengthen the s exual relationship and assist the couple in determining when to discontinue medical treatment for infertility (Eunpu, 1995). Therapists working in the field of infertility must develop kn owledge specific to the field such as the diagnostic and treatment mo dalities in current use, as these methods are continually changing with new research (Eunpu, 1995). Therapists must also be familiar with the financial costs of various procedures and testing as financial stress can take a significant toll on individual w ell being and couple satisfaction. Therapists should have a keen sense of the gender differences of men and women with regard to emotional expression and attitude as these differences can lead to serious problems in communication within the couple (M erari et al., 2002). Infertility can be addressed in therapy on an individual, couple or group basis. Individual therapy for infertility generally focuses on building strengths, coping skills and psychological and emotional functioning (Eunpu, 1995). Couple therapy for infertility aims to strengthen communication and conflict resolution skills (Eunpu, 1995). Group therapy focuses on psychoeducation and skills building (Schmidt, 2006). In any setting, it is important for the

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63 therapist to assess for suicidali ty in each individual as there is a higher risk of this issue during infert ility (Watkins & Baldo, 2004). The ultimate goal of a therapist working with an infertile woman or couple is to help them through the stresses and sense of loss experienced so as to assist them to develop a greater sense of strength ( Eunpu, 1995; Watkins & Baldo, 2004). This is achieved by focusing on several specific areas with their clients. Therapists should address the need for education about the experience as well as the typi cal reactions associated with infertility (Schmidt, 2006). This gives clients a greater sense of preparedness for what they might face. Therapists must also work with the individual and/or couple to help them maintain an emotional balance through treatme nt by developing open communication (Schneider & Forthofer, 2005). Building coping skills and stress management techniques will also contribute to a greater sense of balance and acceptance. The therapist should help the couple to establish a positive sup port system and social network to be a source of comfort rather than distress (Smith & Smith, 2004). One of the most important decisions couples face after deciding to begin treatment is to determine the ending point of treatment (Fisch, 2005). Therapist s aid couples in this decision making process and help them to consider a variety of implications. It is assumed that the incidence will increase in which therapists are sought by couples experiencing infertility treatment as both medical professionals an d patients become further educated on the emotional effects of infertility on individual, couple, and physical well being. Summary Infertility represents a trying experience for women of both a physical and emotional nature. It challenges the beli ef system, sense of self, role identity, physical and emotional strength, and sense of security. Some women are able to find new strength in their experience, while others can easily break down. Statistics show that infertility affects a

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64 significant numb er of individuals and couples. Because of its prevalence, it has warranted tremendous research, allowing for new technologies to embrace the struggle and challenge the natural outcomes. History has shown significant changes to the belief system associate d with infertility as well as grea t strides in medical advances. Infertility has a long list of causes that can be attributed to both female and male factors. In some cases, no known cause can be determined. Although we have seen a rise in the number of persons seeking infertility treatment in recent years, in all likelihood, this rise may be the result of women choosing to delay childbirth, as the actual rate of infertility among younger aged women has not changed substantially. The diagnostic process f or infertility involves several phases and can be time consuming and costly. Treatment options range from minimally invasive drugs and procedures, to surgically involved, high tech methods of assisted reproduction. Each of these options comes with a vari ety of risk factors, side effects, and significant cost s as well as ethical considerations. When treatment options come to an end couples may decide to adopt a child or remain childless. The emotional impact of infertility is significant for both indivi duals and couples, but tends to be greater among women social stigma surrounding infertility, misconceptions, and the importance of parenthood in our society. It is of benefit to individuals and couples to seek out therapeutic support during the infertility process in order to build positive communication patterns, establish healthy coping skills, and create a greater sense of balance and a cceptance of their experience.

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65 CHAPTER 3 METHODOLOGY Th e purpose of the study was to investigate the influence of certain personal resources on the perceived individual well being of women experiencing different fertility treatments. More specifically, the influences of perceived marital satisfaction, individ ual well being three coping styles, and three infertility specific coping strategies were examined. This chapter presents the methodology used in the study including the design of the study, study variables, study population and sampling procedures, inst rumentation, data collection and data analysis procedures, research hypotheses, and methodological limitation s. Research Design and Relevant Variables A cross sectional survey research design using comparative and correlational methods was employed for thi s study. A cross sectional design refers to a study based on data gathered at one specific time, rather than a longitudinal study in which data are gathered over a period of time (Cherry, 2000). A cross sectional study seeks to measure individuals in a v ariety of different developmental or age stages at one point in time rather than following the individuals over a number of years or a length of time. In this study, the responses of women of differing ages and at different stages of infer tility treatment were examined. An advantage of cross sectional research is that sample attrition is not an issue, as the data are collected at one point in time (Gall, Gall, & Borg, 2006). While cross sectional design research studies are simple in design and execution, they can yield important data and information about a phenomenon and inform future resea rch (Gall et al., 2006). Data was collected from the participants on ten study variables These included the use of three coping styles ( Task oriented coping Emotion oriented coping and Avoidance oriented coping ) ; marital satisfaction ; three types of infertility specific coping strategies ( Space ; Control ;

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66 and Beliefs ) ; ; number fertility treatments used ; individual well bein g Coping Styles The coping styles of participants were measured by The Coping Inventory for Stressful Situations ( CISS ) (Endler & Parker, 1999), a 48 item scale measuring the three coping styles, Task Emotion and Avoidance The Task oriented coping sty le subscale measures the emphasis the respondent places on tasks and use of planning and deliberateness in addressing problems The Task oriented subscale consists of 16 items with a reported Cronbach alpha coefficient of .90 (Tirre, 2004 ). The Emotion o riented coping style subscale has 16 items and a reported Cronbach alpha coefficient of .86 (Endler & Parker). The Emotion oriented subscale items measure responses aimed at reducing emotional stress. Responses might include becoming overly emotional, ge tting angry, getting upset, or getting tense. The Avoidance oriented subscale consists of 16 items measuring mental changes and activities designed to avoid stressful situations. People might use distraction through engaging in unrelated tasks or social diversions or by removing oneself from the stressful situation by spending time with friends or other tasks. The Avoidance subscale has a reported Cronbach alpha of .82 (Tirre, 2004) Marital Satisfaction Marital Satisfaction was measured by the Index of Marital Satisfaction (IMS) (Hudson, 1993). The IMS is a 25 item scale intended to measure the level of satisfaction reported in a marital relationship. IMS scores can range from 0 100 with lower scores indicating a higher level of satisfaction with the r elationship due to the way the items are scored. The IMS has a high level of concurrent validity as well as strong evidence of known groups validity and good construct validity (Touliatos Perlmutter, Straus, & Holder 2001). It has a Cronbach coefficien t alpha of = .96, representing excellent internal consistency and a low standard error of

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67 measurement at 4.0 (Touliatos et al., 2001). The IMS perspective on their satisfaction with their marital relationshi p. Infertility Speci fic Coping Strategies The infertility specific coping strategies used by women undergoing treatment were measured using the Coping Scale for Infertile Couples ( CSIC ) (Lee et al., 2000). The CSIC is a 15 item scale identifying particular coping strategies used to manage the stress of infertility. Coping strategies are divided into three subsections: Space Control and Beliefs The CSIC utilizes a 5 point Likert type response scale ranging from Never (1) to Almost Always (5). In this study, Space refers to how infertile women acted and reacted in various situations. Control describes the way infertile women control their lives and themselves. Beliefs are intentional strategies used to engage in behaviors that create a sense of being at their best. Reli ability data for the CSIC can be found in Table 3 1. Age Respondents were asked to provide their actual age in years. The study asked for age as a continuous variable so a mean could be calculated. B ased on the age at which women typically marry and are most fertile, survey respondents were grouped into three age groups as follows: 18 29 (age group = 1), 30 33 (age group = 2), and 34 + years of age (age group = 3). For example, all of the female respondents reporting their age between 18 and 29 will be g rouped in age group 1. The age group categories were established in order to most evenly distribute the data for analysi s. In fertility Treatment Stage/Group Treatment options recommended by physicians do not generally follow a predictable sequence from le ss to more invasive, due to variation in diagnosis and patient/doctor preference. Therefore, in order to best assess the intensity of the infertility experience for each participant,

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68 Respondents were asked to provide the number of different fertility trea tments used thus far Number of treatments group used the reported count of treatments in each type of fertility treatment and the variable was treated as an interval or continuous level of measurement (see Appendix A). The number of treatments was summe d to create a total number of treatments There was no way to know in advance how many treatments women would report and the number might have ranged from as few as 1 to perhaps 20 or more. Based on the data, the number of treatments group was categorize d as follows: 1 to 6 treatments (group = 1), 7 to 12 treatments (group = 2), and 13+ treatments (group = 3). These categories were created in order to most evenly distribute the data for analysis. Individual Well being An additional variable was the parti well being as measured by the Mental Health Inventory 5 (MHI 5 ) a subscale of the SF 36 (Ware & Sherbo u rne, 1992). Individual well being consists of the self perceptions and level of stress and strain experienced by an individual (Glad ding, 2001). Instructions ask the respondent to indicate how they have felt and how things have been during the past four weeks. Population and Sample The population to whom this study was generalized were female adults of childbearing age (approximately 18 45) who are in legally married heterosexual relationships and are participating in infertility treatment. Boivin, Bunting, Collins, and Nygren (2007), estimated the prevalence of infertility to be between 3.5% and 16.7% in developed countries using mul ti nation population surveys of 172,413 women. Stephen and Chandra (2000), using data from the 1995 National Survey of Family Growth (a representative survey of 10,847 women aged 15 44), found that 1,210 women at the time of the interview reported fertili ty problems. Multivariate statistical modeling was used to identify the characteristics associated with their use of infertility

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69 services. O f the women who had obtained some form of infertility services, the most common services received by the women wer e: advice (60%), diagnostic tests (50%), medical help to prevent miscarriage (44%), and drugs to induce ovulation (35%) (Stephen & Chandra, 2000). The most recent statistics from the National Center for Health Statistics (2009) reported 7.4% of married wo men (2.1 million) in the United States between the ages of 15 and 44 are infertile. The total number of w omen in the age group who have ever sought treatment for infertility is 7.3 million. Participants in the study were required to meet the following cri teria. First, participants were required to have received a formal diagnosis of infertility from a physician according to the following definition of infertility: at least one year of unprotected intercourse without achieving conception (6 months if the w oman is over age 35) (Hart, 2002). Participants were also required to be receiving some type of infertility treatment (drugs, surgery, or in vitro fertilization) under the supervision of a physician specializing in obstetrics and gynecology (OB/GYN) durin g the time of data collection. The fertility treatment required for participation in the study was either a low technology or high technology method of treatment or some combination of both. As discussed in Chapter 1, low technology methods refer to the use of fertility drugs and/or insemination whereas high technology methods include the use of in vitro fertilization, donor eggs or embryos, and/or surrogacy methods (Williams, 2000). Studies have shown that women experiencing infertility and undergoing f ertility treatment of any type may experience elevated levels of stress (Edelmann & Connolly, 1998). This factor, combined with the potential for a number of different types of fertility treatments to be utilized by a particular participant, has led the r esearcher to examine the total number of treatments rather than the type of treatment

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70 Sampling and Study Participants A convenience sample was used in the study. Convenience sampling is a sampling method in which participants are selected for their acce ssibility, availability, and ability to meet the criteria for inclusion in the study (Gay & Airasian, 2000). Convenience sampling is a non probability method of sampling and meets the purpose of the study and sets parameters for participation (Gall et al. 2006). Subjects were recruited to participate in the study using a convenience snowball sampling method. Snowball sampling occurs when a series of referrals are made among a circle of people with some type of common bond (Berg, 1988). When a study is examining a sensitive topic, this type of sampling method is particularly effective in locating members of a specific population (Hendricks & Blanken, 1992). It can be used as both an informal way of finding participants as well as a formal method of maki ng inferences about the population of interest (Faugier & Sargeant, 1997). Subjects were recruited from three different sources. First, patients from several obstetrics/gynecological (OB/GYN) practices and fertility clinics in southeast Florida were invit ed to participate during their scheduled visits to these facilities. Access to these facilities was gained through developing professional connections between the researcher and the staff physicians who share a common interest in research within the field of infertility. The study was explained to the OB/GYNs and nurses at each facility. Informational flyers developed by the researcher ( see Appendices B and C) were distributed at these fertility clinics and cooperating OB/GYNs shared information about th e study with their patients upon request. In exchange for participating in the recruitment of the study sample, these physicians are to receive a copy of the final results of the study. A second method by which participants were recruited was through cont act with local infertility support groups in Southeast Florida and in the southeastern portion of the United

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71 States ( see Appendices B and C). The third method of participant recruitment consisted of contacting members of Internet infertility support group s and Internet infertility resource websites ( see Appendix D). RESOLVE (www.resolve.org) is one such online website providing support groups, educational programs, and opportunities to contact and meet with others experiencing infertility. RESOLVE offers local programs with opportunities to learn from professionals, hear personal stories, and explore options for addressing infertility. RESOLVE has organizations, professionals and volunteers across the United States. RESOLVE organizations in Alabama, Flo rida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee were contacted to solicit participants for the study. Several other internet support forums were contacted as well to solicit participation from chat room and online support group me mbers. These forums included, but were not limited to, FertilityConnect.com, FertileThoughts.com, FertilityNeighborhood.com, FertilityTies.com, INCIID.org, DailyStrength.org, ConceivingConcepts.com, FCSupport.org, FertilityCommunity.com, AmericanPregnancy .org, Conceive.com, and TheAFA.org. The proposed sample size for this study must have been of a size that would meet requirements for data analysis. Cohen (1992) posits researchers need to consider sample size so they obtain a sufficient number of study p articipants for the analysis to be effective. According to Cohen, using a multiple regression analysis with nine predictor variables requires a group of 107 to attain power = .80 and a medium effect size with a probability level of p =.05. The researcher also conducted a factorial MANOVA with the study data. According to Cohen (1992), 160 participants were needed to attain a power =.80, a medium effect size with a probability level of p =.05. Effect size refers to the size of the relationship between va riables while power is a measure of the ability of the study to detect significant differences or

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72 relationships, if there are any. Studies with a power of .80 have an 80% chance of identifying an effect if there is one (Cohen, 1992). Probability of p = 05 is the criteria for accepting or rejecting the null hypothesis and making a Type I or Type II error in incorrectly accepting or rejecting the hypothesis. In other words, 95% of the time you would be correct in accepting or rejecting the null hypothesis Based on Cohen (1992), the statistical analyses require the study to have a minimum of 134 participants. Instrumentation The questionnaires or surveys used in the study were composed of four different instruments assessing the study variables. These we re: (a) t he Coping Inventory for Stressful Situations (Endler & Parker, 1999), (b) the Mental Health Inventory 5 ( MHI 5 ), (c) the Index of Marital Satisfaction (Hudson, 1993), (d) the Coping Scale for Infertile Couples (Lee et al., 2000) and (e) a demogra phic questionnaire ( see Appendix A) developed by the researcher requesting general demographic information about the participant, as well as specific information regarding age, number of fertility treatments, and amount of time since trying to conceive. E ach measure is described bel ow. Coping Inventory for Stressful Situations The Coping Inventory for Stressful Situations ( CISS ) (Endler & Parker, 1999) is a 48 item scale measuring three coping styles. The CISS addresses Task oriented coping, Emotion orien ted coping and Avoidance oriented coping. While Endler and Parker noted that the Avoidance coping subscale could be subdivided into distraction and social diversion subscales, the A voidance subscale was conceptualized as one dimension in this study. The CISS utilizes a 5 point Likert type response scale ranging from Not At All (1) to Very Much (5) asking respondents to assess how much they used a particular activity in dealing with a stressful or difficult situation. Norms for the CISS are reported as m eans and standard deviations for each

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73 subscale for males ( n = 249) and females ( n = 288). Endler and Parker noted that normative data should be used cautiously in interpreting CISS scores when assessing individuals from specific cultures or contexts. The cultural or specific situational context needs to be taken into account when interpreting the scores and the context of women coping with infertility may be considered a unique cultural or situational context. The Task oriented subscale measures emphasis on tasks and using planning or deliberateness in addressing problems. The Task oriented subscale consists of 16 items with a reported Cronbach alpha coefficient of = .90 (Tirre, 2004 ) The Emotion oriented subscale has 16 items and a reported Cronbach coefficient alpha of = .86 (Endler & Parker, 1999). The items in the subscale measure responses thought to be successful or unsuccessful in reducing stress oriented towards self. Responses might include becoming overly emotional, getting angry, getting upset, or getting tense. The Avoidance subscale consists of 16 items measuring mental changes and activities designed to avoid stressful situations. People might use distraction through engaging in unrelated tasks or social diversions or removing onesel f from the stressful situation by spending time with friends or other tasks The Avoidance subscale has a reported Cronbach alpha of = .82 (Tirre, 2004 ) The developers of the CISS have reported construct validity through factor analysis and correlations with social desirability, the Ways of Coping Questionnaire (Folkman & Lazarus, 1988), the Basic Personality Inventory (Jackson, 1989 ), the Beck Depression Inventory the Minnesota Multiphasic Personality Inventory (Hathaway & McKinley, 1989) and other personality inventories (Tirre, 2004 ) In reviewing the assessment, Tirre noted that the CISS was developed using sound instrument cons truction processes, had been tested for construct validity, and measures what it intended to measure as well as being grounded in theory. High scores in the subscale of Task oriented coping refer to the use of cognitive or behavior problem solving

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74 techniq ues used during stressful situations. Individuals scoring high in the area of Emotion oriented coping respond to stress with self preoccupation, expressive outbursts, or imagination. Avoidance coping implies management of stress by relying on social supp ort systems and distractio n. Index of Marital Satisfaction relationship. Marital satisfaction includes the role that individuals play within the marital relationship, level of affection for one another, level of commitment to the relationship, and their level of happiness with these aspects. The Index of Marital Satisfaction ( IMS ) (Hudson, 1993) is a 25 item scale intended to measure the level of satisfaction in a mari tal relationship. The IMS uses a 7 point Likert type response scale of None of the Time (1) Very Rarely (2), A Little of the Time (3), Some of the Time (4), A Good Part of the Time (5), Most of the Time (6), and All of the Time (7). IMS scores can range from 0 to 100 with lower scores indicating a higher level of satisfaction with the relationship due to the way the items are scored. The IMS will be used to IMS was scored in accordance with scoring instructions (Hudson). The IMS has a high level of concurrent validity as well as strong evidence of known groups validity and good construct validity (Touliatos et al., 2001). It has a Cronbach coefficient alpha of = .96, representing excellent internal consistency and a low standard error of measurement at 4.0 (Touliatos et al., 2001). Fisher and Corcoran (2007) reported that the norming group for the IMS included single and married individuals, clinical and non clinical participants, and students and non students; however, no actual norms were available (Fisher & Corcoran). Concurrent validity was established through correlation with the Locke Wallace

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75 Marital Adjustment Test with which it should not correlate, and correlates significantly with several measures with which it should correlate such as sexual 2). Mental Health Inventory 5 well being consis ts of the self perceptions and level of stress and strain experienced by an individual (Gladding, 2001). Individual well being was measured using the Mental Health Inventory 5 ( MHI 5 ) a subscale of the SF 36 (Ware & Sherbo u rne, 1992). The mental health i tems were answered using a 5 point Likert type response scale of All of the Time (1), Most of the time (2), Some of the T ime (3), A L ittle of the T ime (4), and None of the T ime (5). Instructions asked the respondents to indicate how they have felt and how things have been during the past four weeks. The MHI 5 is scored in accordance with instructions (Ware & Sherbo u rne). The instrument developers have reported a Cronbach alpha of .88 for this subscale indicating a fairly high level of internal consistenc y (Ware, K osinski, & Keller, 1994). Other researchers have reported internal consistency reliability coefficients ranging from 0.67 to 0.95 (Means Christensen Arnau, Tonidandel, Bramson, & Meagher 2005). Validity studies have generally concurred with th e meaning of high and low scores on the SF 36 subscales (Ware, Snow, Kosinski & Gandek 1993) Previous studies have provided evidence of content, criterion, construct and predictive validity (Ware et al., 1994). The mental health subscale of the SF 36 has been shown to be valid through factor analysis (Ware et al., 199 3) changes in severity of depression (Beusterien Steinwald, & Ware 1996), drug treatment, and depression therapy (Coulehan, Schulberg, Block, Madonia, & Rodrigues (1997). The SF 36 was normed on 2,474 individuals representative of the population and norms are available for different countries. Norms are reported as means and standard deviations (Kagee, 2001).

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76 Coping Scale for Infertile Couples Individuals use a variety of coping strate gies to manage stressful situations. Women undergoing treatment for infertility rely on their coping strategies to ease the specific stressors infertility can produce. The particular coping strategies used by women undergoing treatment were measured usin g the Coping Scale for Infertile Couples ( CSIC ) (Lee et al., 2000). The Coping Scale for Infertile Couples ( CSIC) (Lee et al., 2000) consists of 15 items utilizing a 5 point Likert type response scale of Never (1), Rarely (2), Sometimes (3), Most of the T ime (4), and Almost Always (5). The CSIC was developed and initially tested in Taiwan. Four subscales were originally identified in this administration through factor analysis and expert panel and were named Increasing Space, Regaining Control, Being the Best and Sharing the Burden The reported test retest reliability was between .71 and .73. However, the participants used in this initial evaluation of the CSIS included both men and women who were residents of Taiwan. For the present study, with parti cipants primarily from the United States, the Cronbach alphas using the original subscales were: Increasing Space = .664, Regaining Control = .475, Being the Best = .310, and Sharing the Burden = .290. It appeared this arrangement of the items on the CSIS was not viable and further analysis would be necessary. It is possible the CSIS was originally written i n Mandarin and might have lost some of the essence of the measure in translation and the present study did not use both genders. The present study included only women and the majority of the women were located in the United States ( n = 202, 89.0%). Thus, a factor analysis was completed to determine whether the items would remain in the same subscales with a different group of participants. A principal components factor analysis with a varimax rotation was completed and the findings indicate that there wer e three viable subscales with the items all loading at .30 and above on one and only one

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77 factor or subscale (see Table 3 1). The items accounted for 10.71% of the variance. The first subscale or factor was the same as the original; however, the other fac tors were different from the original. Analysis of participant responses to items on the new subscales revealed that the Cronbach alphas increased (see Table 3 1) for the three subscales. Table 3 2 presents a comparison of reliability between the origina subscales were renamed and used in further analysis. The first subscale was named Space and consisted of 5 items. The Space subscale was defined as how infertile women acted and reacted in various situati ons. The second subscale was named Control and consisted of 5 items. Control was defined as how infertile females control their lives and themselves. The third subscale was named Beliefs and consisted of 5 items. The Beliefs subscale was defined by wha t infertile women believed would help them deal with their infertility. The Cronbach alpha reliability coefficients improved and ranged from .664 to .610. While this is not high, reliability is relative and the alphas are acceptable for an instrument of this type. The items in the CSIC subscales were summed to create subscale scores and used in further analys is. Demographic Questionnaire A demographic questionnaire ( see Appendix A) was developed to collect descriptive information on study participants. This questionnaire gathered information about the individual traits and characteristics of each participant including age in years (continuous), ethnicity (categorical), level of education (categorical), income (continuous), location where the respondent i s currently living (categorical), amount of time since first attempt at conception measured in months (continuous), and number of different types of fertility treatments used thus far (continuous). This information assisted the researcher in determining a dditional commonalities and differences among females experiencing infertility as well as grouping and describing the participants. Fertility treatment frequently ranges from less invasive to more

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78 invasive; however, fertility treatment can also be depende nt upon physician preference and/or patient request. While there are some general steps in the treatment of infertility, patients might request in vitro fertilization (IVF) prior to progressing through other treatment options simply to shorten the process and probably because they could afford the procedure. There may also be women coming to IVF treatment after years of fertility treatments or there may be women utilizing IVF for reasons other than infertility. Because the treatment options recommended b y physicians may not follow a predictable sequence from less to more invasive, the total number of treatments experienced by the study participants will be assessed. The study asks participants (Yes/No) what type of treatment (medical education or counsel ing, medication/drugs/hormones, surgical repair, artificial insemination, sperm/egg donation, and/or in vitro fertilization) they had used and the number of times they had participated in the type of treatment ( see Appendix A). Data Collection Procedures D uring the last several decades, numerous innovations in survey design, data collection, and methodology have emerged, such as utilization of the telephone for data collection (Dillman, 2000). Along these lines are the more recent innovations of the comput er and the Internet. Using the Internet to conduct surveys has the potential to change survey methodology once again. E mail or Web surveys not only eliminate costs associated with postage, paper, mailing, and data entry, they also make it possible to ov ercome international boundaries, increase sample size, and significantly shorten the time required to collect data (Dillman, 2000). Learning the software necessary to construct an Internet system for collecting data can be time consuming and difficult (Di llman, 2000); however, the www.surveymonkey .com website permits the researcher to format a survey fairly easily. This site also provides the ability to collect both text and numerical data and return the data in a format usable to the researcher. Interne t surveys offer several advantages over traditional mailed paper and pencil surveys in both survey construction

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79 and data collection. The researcher is able to format the background colors and font to make the survey more user friendly. The researcher is also able to determine whether the respondent can skip questions or must answer all of them (http://www.surveymonkey.com). The respondent can provide informed consent by clicking a box and, since no names are used, all responses are confidential ( http://w ww.surveymonkey .com). Respondents are able to complete demographic data, such as age, gender, ethnicity, and other information. The Internet also makes it possible to post the survey to different web sites to inform people interested in the topic that th e survey is web sites, and web sites addressing or containing information on infertility. As opposed to paper and pencil surveys mailed through the postal service, Internet surveys give the researcher control over which items and the number of items a respondent can see at any time (Dillman, 2000). As a result there are several advantages to using web based, or Internet surveys in research. Some of the bene fits include the ability to gain access to large samples, low cost of implementation, and timeliness of data collection. Internet surveys also allow for access of hard to reach populations, such as the population examined by the present study (Whittier, S eeley, & Lawrence, 2004). Paper/pencil surveys can be cumbersome to complete, time consuming, and expensive. The researcher has no control over how the respondent completes the survey or the order in which items are completed The respondent might compl ete a paper survey but neglect to return it or inadvertently skip items on the paper version. In this study, both an Internet and a paper mode of delivery were available to study participants. Participants had the opportunity to choose the format most con venient and comfortable for them. According to Dillman (2000), this type of mixed mode survey provides the researcher with the ability to compensate for the weaknesses of each method used for data

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80 collection. An entirely Internet based survey might produ ce a high risk of survey error since the percentage of United States citizens with computer access may be as low as 67% (Dillman, 2000). It is important for the study to reflect an accurate view of the sample population, requiring that participants with o r without computer/Internet access be given an oppor tunity to complete the survey. The study was approved by the Institutional Review Board of the University of Florida prior to data collection to ensure the protection of study participants involved in the study. After receiving permission from directing physicians of OB/GYN practices and support from group facilitators, participants were recruited through fliers placed in the facilities. Participants were also recruited from Internet websites through onl ine postings in Internet chat rooms (see sample posting in Appendix D), support groups, and bulletin boards with a link to the online research packet website. A flyer was also provided to group facilitators and participants to share and distribute contain ing the research packet web address for those potential participants who were more comfortable using an internet format to complete the survey. Anonymity was maintained throughout the recruitment process to ensure personal privacy for each participant. Ea ch participant who agreed to take part in the study was given access to either the online survey packet or the paper based survey packet. Both survey formats included an introductory cover letter about the survey (see Appendix E), an informed/implied cons ent section ( see Appendices F and G), and the survey questionnaire. This questionnaire was comprised of the measures discussed previously in add ition to a demographic measure. The informed consent section in each survey informed the participants of the ri sks and benefits of taking part in the study. Participants were not able to gain access to the online questionnaire without agreeing to the terms of the informed consent on the web page. Responses

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81 to the questionnaire were anonymous to ensure truthfulnes s and more accurate responses. Participant confidentiality was maintained at all times of the data collection and analysis periods. of the study and the disc w ill be destroyed after three years. Paper copies of the survey packet were to be mailed in a stamped addressed envelope to the researcher and electronic data was to be kept in an electronic format until being downlo aded from the Internet website. The data gathered in this study was analyzed using the Statistical Package for the Social Sciences v. 17 (SPSS). The data collected on line was stored during the data collection phase in the survey website database. At the completion of data collection, the data was downloaded and transferred to SPSS. The data collected through paper based surveys were to be manually entered into SPSS by the researcher and paper forms were to be stored separately from the consent forms Consent forms and paper surveys were dest royed by using a cross cut shredder at the conclusion of the study and data kept in a digital format were to be destroyed at the end of three year s. Research Hypotheses The following research questions and hypotheses were addressed in this study. RQ 1 Are there differences by age and stage of treatment in the styles of coping ( T ask oriented, E motion oriented, and A voidance oriented ), levels of marital satisfaction, infertility specific coping strategies ( S pace, C ontrol and B eliefs ), and individual well bei ng of women engaged in infertility treatment? HO 1 : There are no significant differences by age and stage of treatment in the three styles of coping ( T ask oriented, E motion oriented or A voidance oriented ), the levels of marital satisfaction, infertility sp ecific coping strategies ( S pace, C ontrol and B eliefs ), or individual well being reported by women en gaged in infertility treatment.

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82 RQ 2 : What influences do the three styles of coping ( T ask oriented, E motion oriented, or A voidance oriented), the level of m arital satisfaction, the three infertility specific coping strategies ( S pace, C ontrol and B eliefs have in predicting the level of individual well being of women engaged in infertility treat ment? HO 2 : There is no significant contribution made by each style of coping ( Task Emotion and Avoidance ), the level of marital satisfaction, infertility specific coping strategies ( Space Control and Beliefs age to the prediction of the level of individual well being of women engaged in infertility treatment. Data Analysis The data analysis for the study consisted of the following steps. First, descriptive statistics (mean, median, mode, and frequency) were c omputed for the sample demographics and the total and subscale scores of the CISS, IMS, MHI 5, and CSIC to assess the internal consistency of these instrume nts. Once the preliminary data analysis had been completed and the subscales determined to be valid and reliable, the items in the subscales were summed to create subscale scores. The calculated subscale or total scale scores were used in all fur ther ana lysis. The first research question posed in the study asked whether there were differences in the responses of different age groups of women participants or among women at different stages of infertility treatment on the subscale scores of the CISS, IMS, M HI 5, and the CSIC The independent variables were number of treatments and age. The dependent variables were CISS, IMS, MHI 5, and CSIC scores. A probability level of p = .05 was used as the criteria for accepting or rejecting the null hypothesis. The study asked women their age and this continuous variable was grouped into a categorical variable using fertility data from the American Society

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83 for Reproductive Medicine (ASRM) (2003). The ASRM noted infertility increases with age and even though women a re healthier, fertility still will decrease with age. The study asked for age as a continuous variable so a mean could be calculated. Based on the age at which women typically marry and are most fertile, survey respondents were grouped into three age gro ups as follows: 19 29 (age group = 1), 30 33 (age group = 2), and 34+ years of age (age group = 3). For example, all of the female respondents reporting their age between 19 and 29 were grouped in age group 1. Number of treatments group used the reported count of treatments in each type of fertility treatment and the variable was treated as interval or continuous level of measurement (see Appendix A). The number of treatments was summed to create a total number of treatments. There was no way to know in advance how many treatments women would report, as the number might have ranged from as few as 1 to perhaps 20 or more. Based on the data collected, the number of treatments groups was as follows: 1 to 6 treatments (group = 1), 7 to 12 treatments (group = 2), 13+ treatments (group = 3). Since there are two independent variables and several dependent variables, a factorial multivariate analysis of variance (MANOVA) was used as the analysis to answer research question one. Like analysis of variance (ANOVA) MANOVA is designed to test the significance of group differences; however, MANOVA can include several dependent variables, typically measuring similar constructs. The assumptions of MANOVA are: observations are randomly sampled and independent of each o ther, the dependent variable follows a multivariate normal distribution, there is homogeneity of the covariance matrices or homoscedasticity, and there is a linear relationship between the dependent variables (Mertler & Vannatta, 2001). The assumption of independence is primarily a design issue. Multivariate normality implies the distribution of the means of each dependent variable and all linear combinations of dependent

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84 variables are normally distributed. Univariate normality and bivariate plots were u sed to assess multivariate normality. It should be noted that multivariate normality is a condition of homoscedasticity and the Box test was used to assess homoscedasticity. There needs to be some degree of linearity between the dependent variables and t hey need to share some common conceptual meaning (Stevens, 1992). Linearity was assessed through the use of bivariate scatterplots. If both variables in a pair are normally distributed and linearly related, the shape of the scatter plot would be expected to be elliptical Using several dependent variables allows researchers to obtain a more holistic view and a more detailed description of the topic under investigation. The idea stems from the concept that it is difficult to precisely separate out and me asure specific traits and multiple measures of a common characteristic are more likely to be representative of the characteristic. It should be noted that ANOVA and MANOVA are fairly robust to violations of normality provided the violation is created by s kewness and not by outliers (Tabachnick & Fidell, 2006) homogeneity of the covariance matrices and if homogeneity is violated, the statistic was used to interpret the results of the multivariate a nalyses. The second research question asked whether age, CISS subscales ( Task, Emotion, and Avoidance ), IMS score, CSIC subscales ( Space, Control, and Beliefs ) and number of fertility treatments, predict individual well being Regression analysis was u sed to address this question Regression analysis is not causal in nature and has as its purpose the development of an equation for predicting values on a dependent variable (DV) for members of a group. The independent variables were CISS scores ( Task, E motion, and Avoidance ), IMS scores, CSIC scores ( Space, Control, and Beliefs ) age, and number of treatments ; and the dependent or outcome variable was individual well being In multiple regression, a set of predictor variables (IVs) are selected as

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85 poten tial predictors of a dependent variable, as is the case in this study. Multiple regressions are an extension of simple linear regression involving more than one predictor variable. It is used to predict the value of a single DV from a weighted linear com bination of IVs. In this study, a series stepwise multiple regression analysis, or what is sometimes referred to as a statistical multiple regression, was used. When there are multiple predictor variables, a statistical multiple regression is used to det ermine which specific IVs make a contribution to the model (Mertler & Vannatta, 2001). Methods of regression include: forward, stepwise, and backward methods of entering and keeping variables in the model. In using a stepwise selection method, tests are performed at each step to determine the significance of each IV already in the equation as if it were the last to be entered. If a variable is entered into the analysis measuring much the same construct as another, a reassessment of the variables may conc lude that the first variable is no longer contributing anything to the analysis. In a stepwise selection procedure, the variable would then be dropped out of the analysis even though it might have been a good predictor at one time. The variable may no lo nger be found to provide a substantial contribution to the model (Mertler & Vannatta, 2001). After ascertaining the data are appropriate for regression analysis and checking for multicollinearity, the multiple regression procedure was completed using a pr obability level of p=.05 as the level of significance. The first issue in multiple regression is the selection of a set of measures suitable for predicting the DV. One problem with the use of multiple regression analysis is the possible existence of multi collinearity. Multicollinearity is a problem arising when there are moderate to high intercorrelations among predictor variables. The problem lies with the possibility there may be two or more variables measuring essentially the same information (Glass & Hopkins, 1996 ) Not only do you not gain much by adding variables to a regression analysis measuring the same

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86 thing, but multicollinearity can cause problems with the analysis itself. Stevens (1992) pointed out three reasons for why multicollinearity can cause problems: (a ) multicollinearity limits the size of the R since the IVs are going after much the same variability in the DV; (b ) multicollinearity can cause difficulty because individual effects are confounded when there is overlapping information; a nd (c ) multicollinearity tends to increase the variances of the regression coefficients resulting in unstable prediction equations. The simplest method of diagnosing multicollinearity is to investigate high intercorrelations among the IV predictor variabl es. A second method is to inspect the variance inflation factor (VIF) (Mertler & Vannatta, 2001). VIF indicates whether there is a strong linear relationship between a predictor and all other predictors (Stevens, 1992). Stevens also notes there is no st andard rule but VIF values greater than 10 are generally cause for concern. Hence, intercorrelations were computed for all variables and were checked to ensure multicollinearity does not present a problem in the analysis. If multicollinearity does exist, a variable may be deleted or variables may be combined to create a single construct. Variables correlated at r = .70 and above should not be included in the same analysis and one variable would need to be omitted or a composite score created from the red undant variables (Tabachnick & Fidell, 2006). The data for the regression analysis was also checked to ensure it met the assumptions of regression. These include: 1) the independent variables are fixed (the same values would be found if the study were rep licated), 2) the IVs are measured without error, 3) the relationship between the IVs and the DV is co linear, 4) the mean of the residuals for each observation on the DV is zero, 5) errors on the DV are independent, 6) errors are not correlated with the IV 7) variance across all values of the IV is constant, and 8) errors are normally distributed (Mertler & Vannata, 2001). The assumptions were verified through examination of residual scatter plots,

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87 assessment of linearity, inspection of normality through skewness, kurtosis, and Kolmogorov Smirnov statistics, and inspection of the data dasticity. Multiple regression analysis served as the statistical analysis to be used for the second research question posed by this study a nd is appropriate for use in predictive studie s. Summary The purpose of this study was to explore the contributions of personal coping resources to the individual well being of females undergoing infertility treatment, and to determine if there are differe individual well being A sample of women who were being treated for infertility was drawn from OB/GYN practices and fertility clinics in South Florida as well as from lo cal and Internet infertility support groups. Participants were give the option to complete a paper and pencil or Internet based survey that includes the Coping Inventory for Stressful Situations The Index of Marital Satisfaction the Mental Health Invent ory 5 the Coping scale for Infertile Couples and a demographic questionnaire. Data were analyzed using MANOVA and multiple regression analyses. The results of the study are presented in Chapter 4 and conclusions from these results are discussed in Chap ter 5.

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88 Table 3 1. Factor Loadings for Coping Scale for Infertile Couples Space Control Beliefs 3 I stop attending get togethers filled with children 0.706 2 I stop attending baby showers 0.672 5 I don't discuss my inability to conceive with my family or relatives 0.636 1 I keep myself very busy to forget the fact that I don't have a child 0.624 4 other than my spouse 0.599 12 I try to change the places, position, and times when I en gage in sex with my spouse in order to increase sexual pleasure 0.681 13 I confide my feeling to my spouse and try to understand how my spouse feels 0.646 10 I continually remind myself not to get depressed and to have hope for a successful pregnancy 0.644 11 Although I cannot control my infertility, I keep myself in the best condition by controlling my weight, diet and appearance 0.694 9. I keep a positive attitude and a positive discourse with myself. 0.466 14 I wear sexy underwear to cre ate a romantic environment 0.647 8 The reading related to infertility let me know that some of the emotions I feel are typical for infertile patients. 0.621 6 I read as much as possible from books on infertility 6.217 7 I believe the more I know, the more I can deal with my problem. 0.560 15 I confide my frustrations, disappointments, fears and hopes with other infertile parents. 0.421

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89 Table 3 2. Comparison of Lee Study and Current Study Reliability Lee Study Current Study Lee Scales Current Study Scales Scales Reliability Alpha Reliability Alpha Scale Reliability Alpha Increase space .78 .664 Space .664 Recognize emotions .71 .475 Control .627 Being the best .73 .310 Beliefs .610 Share burden .72 .290

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9 0 CHAPTER 4 RESU LTS The purpose of the study was to examine the contribution of three styles of coping, marital satisfaction, three infertility specific coping strategies, age, and treatment stage in predicting the individual well being of married females experiencing inf ertility. The study also identified differences in coping processes, marital satisfaction, and individual well being for women at different stages of infertility treatment. In this chapter, the results from the survey of a total of 282 married women expe riencing infertility are presented. First, the respondents participating in this study are described. A discussion of the methods used to analyze the data produced by this survey is followed by the descriptive statistics for the study variables. Lastly, analyses. Sample Demographics A total of 430 women began the survey by accepting the informed consent. Of that group, 282 women opted to begin the survey; howe ver, only 236 of the participants completed all of the survey in it s entirety. Participants were not required to answer every question and some participants chose not to respond to all of the items. Participants were asked to provide information about th eir age, level of education, ethnic/cultural identification, income and location. Participants were also asked to provide information specific to their experience with infertility. This information included the amount of time that had elapsed since first attempting conception, the amount of time since they first recognized their infertility problem, the amount of time since they first sought a diagnosis of infertility from medical personnel, and the amount of time spent receiving treatment for infertility Also included in this infertility specific demographic information was information on the types of fertility treatment used by the

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91 participant as well as the number of times each of these types of treatments were used. The study flyer and internet post ing advertised the study specifically to married females who were currently receiving treatment for infertility and each of these specifications were presented in bold font. Therefore it was assumed by the researcher that all participants were married fem ales who were currently receiving treatment for infertility. Table 4 1 provides descriptive data for study participant s. Age Participants ranged in age from 19 to 48. The average age of respondents was 31.94 ( SD = 4.791). Table 4 2 presents the frequenc y of participants by age. Participants were grouped into three age groups as follows: 19 29 (age group = 1), 30 33 (age group = 2), and 34+ years of age (age group = 3). The majority of participants were in age group 2 (30 33) (39.1%, n = 100). The next most common age group was group 3 (34+) with 31.3% ( n = 80), followed by group 1 (19 29) with 29.7% ( n = 76). A total of 26 participants did not report their age. Income The household income level reported by participants ranged from $5,000 per year to $ 1,000,000 per year. The average income of respondents was $109,995.74 per year ( SD = 99788.301). Frequency of participants by reported income is presented in Table 4 3. Participant income was ca tegorized into six groups: $0 $29,000 (group 1), $30,000 $59,000 (group 2), $60,000 $89,000 (group 3), $90,000 $119,000 (group 4), $120,000 $149,000 (group 5) and $150,000 + (group 6). The majority of participants had incomes that placed them in group 3 (29.2%, n = 69). The remaining participant income responses were divided between group 4 (21.2%, n = 50) and group 6 (19.1%, n = 45). Groups 2 and 5 equally accounted for 13.6% ( n = 32) of participant income level responses, while group 1 accounted for 3.4% ( n = 8) of income level responses. A total of 47 participants did not report their household incom e.

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92 Level of Education There was a wide range of educational levels among participants with the majority reporting a 4 year Bachelors Degree (35.9%, n = 94). The next most common response was a Masters D egree (26.3%, n = 69), followed by Some College (did not graduate) (10.7%, n = 28), Associates Degree (9.2%, n = 24), and an equal number who indicated they had earned a High School Diploma or a Professional degree (e.g. J D M D etc ) (5.3%, n = 14). The remaining participants reported their level of education as Doctoral (Ph.D., Ed.D., etc. ) (3.8%, n = 10) and Specialists Degree (3.4%, n = 9). Table 4 level. Twenty participants chose not to provid e their level of educatio n. Ethnic/Cultural Identification The majority of the sample reported their ethnic/cultural identification as Caucasian (89.2%, n = 231), followed by Mixed Cultural/Ethnic (3.1%, n = 8), an equal number of Hispanic and Asian/Pacifi c Islander (2.3%, n = 6), African American (1.2%, n = 3), and Caribbean (0.4%, n = 1). The remaining participants reported their ethnic/cultural identification as Other (1.5%, n = 4). Table 4 5 presents the frequency of participants by ethnic group. Twe nty three participants chose not to identify their ethnic/cultural backgrou nd. Location The locations of participants were diverse, reaching a wide range of areas in the United States as well as several international locations. The researcher divided the locations into 10 groups based on their region. The regions used to group participants were: (a) New England, (b) Mid Atlantic, (c) East North Central, (d) West North Central, (e) South Atlantic, (f) East South Central, (g) West South Centra l, (h) Mountain, (i) Pacific and (j) International. The states included in the New England group were Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and Connecticut. The states comprising the Mid

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93 Atlantic group included New York, Pennsylvan ia and New Jersey. The states in the East North Central group included Wisconsin, Michigan, Illinois, Indiana and Ohio. The states comprising the West North Central group included Missouri, North Dakota, South Dakota, Nebraska, Kansas, Minnesota and I owa. The states in the South Atlantic group included Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia and Florida. The states in the East South Central group included Kentucky, Tennessee, Mississ ippi and Alabama. The states in the West South Central group included Oklahoma, Texas, Arkansas and Louisiana. The states in the Mountain group included Idaho, Montana, Wyoming, Nevada, Utah, Colorado, Arizona and New Mexico. The states in the Pacifi c group included Alaska, Washington, Oregon, California, and Hawaii. Participants from locations outside of the United States were placed into the International group. Of the 227 participants who reported their location 4.8% ( n = 11) were in the New Eng land group, 11.5% ( n = 26) were in the Mid Atlantic group, 11.9% ( n = 27) were in the East North Central group, 8.4% ( n = 19) were in the West North Central group, 25.1% ( n = 57) were in the South Atlantic group, 6.2% ( n = 14) were in the East South Centra l group, 5.3% ( n = 12) were in the West South Central group, 3.5% ( n = 8) were in the Mountain group, 12.3% ( n = 28) were in the Pacific group and 11% ( n = 25) were in the International group. Fifty five participants did not provide a response for their location. Fertility Treatments Used Participants were asked to identify the fertility treatments they have used and how many times each of those treatments were used. Table 4 use of fertility treatments. Thes e treatments included Medical Education and/or Counseling, Medication/Drugs/Hormones, Surgical Repair, Artificial Insemination, Sperm/Egg Donation and In Vitro Fertilization. Fifty eight percent ( n = 145) had received Medical Education and/or

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94 Counseling. Of this group, 25.6 % ( n = 34) had received this treatment 1 time, 24.1% ( n = 32) had received this treatment 10 or more times, 16.5% ( n = 22) received this treatment 3 times, 15% ( n = 20) had received this treatment 2 times, and an equal 6.8% ( n = 9) ha d received this treatment 4 and 5 times. Of the remaining participants who had used Medical Education and/or Counseling, 3.8% ( n = 5) had used the treatment 5 times and 1.5% ( n = 2) had used it 8 times. Thirty two participants chose not to provide a resp onse for their use of Medical Education and/or Counseling. Table 4 1 provides the descriptive data for infertility treatments. The next treatment option to choose was Medication/Drugs/Hormones. Two hundred fifty two participants chose to answer this ques tion and 88.9% ( n = 224) responded that they had received this treatment. Of those who had received this treatment, 25.2% ( n = 55) had received the treatment 10 or more times, 15.6% ( n = 34) had received it 3 times, 14.2% ( n = 31) had received it 1 time, 10.6% ( n = 23) had received it 4 times, 10.1% (n = 22) had received it 2 times, and 7.3% ( n = 16) had received it 5 times. Six percent ( n = 13) of participants had received the treatment 8 times, followed by 5% ( n = 11) who had received it 7 times, 4.1% ( n = 9) who had received it 6 times, and 1.8% ( n = 4) who had received it 9 times. Thirty participants chose not to provide a response for their use of Medication/Drugs/Hormones. Surgical Repair was the next treatment option. Two hundred forty one partici pants chose to answer this question and 36.9% ( n = 89) responded that they had received this treatment. Of those who had used Surgical Repair, 64.7% ( n = 55) had used the treatment 1 time, 21.2% ( n = 18) had used the treatment 2 times, 5.9% ( n = 5) had us ed the treatment 3 times, and an equal percentage of participants ( 2.4% n = 2) had used the treatment 4, 5, and 6 times. The remaining participants (1.2%, n = 1), used the treatment 10 or more times. Forty one participants chose not to provide a respons e for use of Surgical Rep air.

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95 Artificial Insemination was another treatment option choice. Two hundred eighty two participants chose to answer this question and 47.7% ( n = 116) responded that they had used this treatment. Of those who had used Artificial Insemination, 25.9% ( n = 29), had used this treatment 2 times, 21.4% ( n = 24) had used this treatment 1 time, 19.6% ( n = 22) had used this treatment 3 times, 14.3% ( n = 16) had used this treatment 4 times, 7.1% ( n = 8) had used this treatment 5 times, 6.3 % ( n = 7) had used this treatment 6 times, 2.7% ( n = 3) had used this treatment 7 times, 1.8% ( n = 2) had used this treatment 10 or more times, and 0.9% ( n = 1) had used this treatment 8 times. Thirty nine participants chose not to provide a response for use of Artificial Insem ination. Two hundred thirty one participants provided a response for their use of Sperm/Egg Donation and 5.2% ( n = 12) had used this treatment. Of this group, 50% ( n = 6) used this treatment 1 time. An equal percentage of participa nts (8.3%, n = 1) had each used the treatment 3, 4, 5, 6, 7, and 10 or more times. Fifty one participants chose not to provide a response for th eir use of Sperm/Egg Donation. In Vitro Fertilization was the final treatment option choice. Two hundred forty five participants chose to answer this question and 38.4% ( n = 94) had used this treatment. Of those that had used In Vitro Fertilization, 50% ( n = 45) had used the treatment 1 time, 25.6% ( n = 23) had used the treatment 2 times, 10% ( n = 9) had used the treatment 3 times, and 5.6% ( n = 5) had used the treatment 4 times. An equal percentage of participants had used the treatment 5 and 6 times (3.3%, n = 3) and 7 and 9 times (1.1%, n = 1). Thirty seven participants chose not to provide a response for the ir use of In Vitro Fertilization. Stage of Treatment The stage of infertility treatment refers to the number of treatments a women or couple has used in an attempt to conceive. In this study, the stage of treatment was determined by the

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96 number of treatmen ts a woman had used thus far. The number of treatments was summed to create a total number of treatments used by each participant. The women in this study had participated in between 1 and 41 different treatments ( M = 10.90, SD = 7.28 ) with a median of 9 .00 treatments. Hence participants were divided into three groups according to thei r number of treatments. Group 1 was composed of women who had experienced between 1 to 6 treatments, group 2 with women who had experienced between 7 t o 12 treatments (gro up = 2), and g roup 3 consisted of women who had experienced 13 or more treatments Group 1 accounted for 38.8% ( n = 95) of number of treatment responses. Group 2 accounted for 31.0% ( n = 74) of number of treatment responses. Group 3 accounted for 30.2% ( n = 74). Thirty seven participants chose not provide a response for number of treatment s. Measurement Properties of the Study Instruments This study on women undergoing fertility treatments asked the study participants to complete four different measures ( CISS, IMS, MHI 5, and CSIC ) and set of demographic questions. The measurement properties and scoring used for each instrument are presented below. Coping Inventory for Stressful Situations The Coping Inventory for Stressful Situations (CISS) (Endler & P arker, 1999) consists of 48 items using a 5 point Likert type response scale of Not at All (1) to Very Much (5). The CISS has 3 subscales, Avoidance, Task and Emotion each consisting of 16 items. A factor analysis of the CISS items was conducted to ens ure the items and subscales were viable for this group of individuals. Each of the items fell into the subscales proposed by Endler and Parker. Reliability was also computed for each of the subscales using a Cronbach alpha and was comparable to reported reliability coefficients (Tirre, 2004) Table 4 7 presents the measurement properties of the CISS Scores for the Task Avoidance and Emotion subscales, which were calculated by

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97 summing across the 16 items in each subscale and then using the subscale scor e in all further analyses. As shown in table 4 3, the Avoidance Emotion and Task subscales had acceptable reliability for this group of women Cronbach alpha reliabili ty coefficients ranged from .758 to .903 Mental Health Inventory 5 The Mental Health Inventory 5 ( MHI 5 ) consists of 5 items measuring the self perceptions and level of stress and strain experienced by an individual (Gladding, 2001). The MHI 5 is a subscale of the SF 36 (Ware & Sherbo u rne, 1992). MHI 5 items were answered using a 5 poin t Likert type response scale of All of the Time (1), Most of the Time (2), Some of the T ime (3), A L ittle of the Time (4), and None of the Time (5). Two items (1 and 2) on the MHI 5 were reversed scored to All of the Time (5), Most of the Time (4), Some o f the T ime (3), A L ittle of the Time (2), and None of the Time (1). Scoring for the MHI 5 uses a specific transformation formula converting the lowest and highest possible scores to 0 and 100 respectively as follows: actual raw score lowest score poss ible divided by the possible raw scored range times 100. For example, the lowest possible score is 5 and the highest possible score is 25 with a possible raw score range of 20. This transformation procedure puts the MHI 5 on a 0 to 100 measurement scale. Table 4 4 presents the descriptive characteristics of the MHI 5 for this group of females. As can be seen in Table 4 8, the reliability Cronbach alpha coefficients are similar to prior reports of reliability and are fairly high, indicating a high level of internal consistency and reliability. Factor analysis confirmed that the MHI 5 assessed one construct Index of Marital Satisfaction The Index of Marital Satisfaction (IMS) (Hudson, 199 3) consists of a unitary scale of 25 items. There are no viable su bscales contained in the IMS The IMS

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98 contentment or satisfaction in a marital relationship. The IMS uses a 7 point Likert type response scale of None of the T ime (1) Very Rarely (2), A Little of the Time (3), Some of the Time (4 ), A Good Part of the Time (5), Most of the Time (6), and All of the Time (7). IMS scores can range from 0 to 100 with lower scores indicating a higher level of satisfaction with the relationship due to the way the items are scored There are 13 reverse coded items in the IMS (items 1, 3, 5, 8, 9, 11, 13, 16, 17, 18, 20, 21, and 23) coded as None of the T ime (7) Very Rarely (6), A Little of the Time (5), Some of the Time (4), A Good Part of the Time (3), Most of the Time (2), and All of the Time (1). Tab le 4 9 presents the measurement properties of the IMS Scoring of the IMS is accomplished by first reverse scoring the 13 items and summing the items (reversed and not reversed). This sum is subtracted from the number of completed items, multiplying this figure by 100 and dividing the number of items completed times 6. This produces a range of 0 to 100 with higher scores indicating a greater magnitude or severity of problems. As can be seen in the Table, the calculated Cronbach alpha for this group of f emales was high and comparable to previously reported administrations of the IMS sca le. Coping Scale for Infertile Couples The CSIC is a 15 item scale identifying particular coping strategies used to manage the stress of infertility. In the original versi on of this measure coping strategies were divided into 4 subscales ( Increasing Space, Regaining Control, Being the Best, and Sharing the Burden ). This measure was originally developed in Taiwan and the initial evaluation included both men and women, all o the United States and were solely female. The scales did not appear to be viable as they did not factor like the Lee et al. scales and the Cronbach alpha reliability coefficien ts were very low as presented in Table 3 2. Therefore, the researcher adapted the measure to the current population of interest and three viable subscales were created. Factor analysis was used to identify three

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99 subscales. The items on each subscale wer e summed to create a score and test reliability. The three subscales used in the adapted version of the CSIC for the purpose of this study were: Space, Control, and Beliefs Further explanation of the process used to adapt this measure was described in C hapter 3. In this adapted version, the CSIC maintained the use of a 5 point Likert type response scale ranging from Never (1) to Almost Always (5). Table 4 10 presents the measu rement properties of the CSIC The Space subscale refers to how infertile wom en acted and reacted in various situations. The Control subscale describes how infertile females control their lives and themselves. The Beliefs subscale was defined as what infertile women believed would help them manage their infertility. Each subscal e consisted of 5 items. The developers of the original CSIC reported moderate reliability ( = .78 to .72) and validity according to preliminary results. Test retest was r = .73, assessed over a 2 week interval, supporting reliability stability. Moderate reliability was shown in all four subscales as well as the total scale using a coefficient alpha suggesting that the set of items in each of the four subscales was relatively homogenous ( Lee et al., 2000). The Cronbach alphas using the original subscales were: Increasing Space = .664 ; Regaining Control .475 ; Being the Best = .310 ; and Sharing the Burden = .290. An analysis of the adapted version of the CSIC used in this study found the Cronbach alpha improved for the three subscales. Cronbach alpha reliability coefficients ranged from .664 to .610. While this is not high, reli ability is relative and the alphas are acceptable f or an instrument of this type. The four instruments used in the study were analyzed and their measurement properties examined. It was deemed advisable to re factor analyze the CSIC scale to identify usefu l and meaningful subscales with acceptable internal consistency and reliability. The four scales and

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100 subsequent subscales demonstrated acceptable to high internal consistency for this group of infertile femal es. Research Questions and Hypotheses Analysis Research Question 1 The first research question for the study was: Are there differences by age and stage of treatment in the styles of coping ( T ask oriented, E motion oriented, and A voidance oriented), levels of marital satisfaction, infertility specific coping strategies ( Space, Control and Beliefs ), and individual well being of women engaged in infertility treatment? This was formulated into the following null hypothesis: There are no significant differences by age and stage of treatment in the three s tyles of coping ( T ask oriented, E motion oriented, or A voidance oriented), the levels of marital satisfaction, infertility specific coping strategies ( Space Control and Beliefs ), or individual well being reported by women engaged in infertility tr eatment. Research Q uestion 1 was addressed through the use of a multivariate ANOVA statistic, MANOVA. MANOVA tests the combined dependent variable to assess whether there is a difference in the combined multivariate variable. This was followed by the use of a se ries of ANOVAs to determine whether there were significant differences by age/stage for each of the dependent variables. A probability level of p = .05 or less was used as the criteria for accepting or rejecting the null hypothesis based on the results fr om the MANOVA and the univariate ANOVAs cond ucted as a part of the MANOVA. The independent variables were age group and number of treatments group and the dependent variables were the subscale scores of the CISS ( Task, Avoidance, and Emotion ), the MHI 5 sc ore, the IMS score, and the subscale scores of the CSIC ( Space, Control, and Beliefs ). The independent variables of number of treatments and age were grouped as categorical variables. Participant responses of Age ranged from 19 to 48 years of age and wer e grouped as

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101 19 29 ( n = 76, 29.7%), 30 33 ( n = 100, 39.1), and 34 or more years of age ( n = 80, 31.3%). Number of treatments ranged from 1 to 41 and were grouped as 1 6 treatments ( n = 92, 38.8%), 7 12 treatments ( n = 74, 30.2%), and 13 or more treatments ( n = 76, 31.0%). The assumptions of MANOVA were assessed, the Box test for equality of the covariance matrices was found to be acceptable ( p = .394), and bivariate correlations among the dependent variables ranged from r = .119 to r = .33 3 Factorial M ANOVA a nalysis The factorial MANOVA analysis using two independent variables of age group and treatment group indicated there was no statistically significant interaction between age group and number of treatments for the combined multivariate dependent va riable [ Wilks = .839, F (332, 908) = 1.261, p = .153 ] Further inspection found there was no statistically significant main effect results for the multivariate combined dependent variable for number of treatment groups [ Wilks = .931, F (16, 448) = 1 .261, p = .431 ] and for the multivariate combined dependent variable for age group [ Wilks = .898, F (16, 448) = 1.541, p = .080 ] The null hypothesis was not rejected for an interaction between age group and treatment group and for the multivariate com bined variable main effects for age group and treatment group. Factorial ANOVA a nalysis As shown in Table 4 11, the results of a series of factorial ANOVAs testing for an interaction between age group and treatment group for each individual dependent varia ble. The factorial ANOVA also tested for age group and treatment group main effects and was reported if the interaction was not statistically significant There was a statistically significant interaction between age group and number of treatments for th e CISS Emotion subscale, F (4, 231) = 2.733, p = .030. There was also a statistically significant interaction for the Space subscale of the CSIC

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102 scale, F (4, 231) = 4.389, p = .002 The null hypothesis was rejected for Emotion and Space as there was a si gnificant interaction between age group and treatment group. Post hoc pairwise programmed tests found there were significant differences for the Emotion ( p = .050) and Space ( p = .002) subscales for number of treatment group 3 (13+) and age group 2 (30 33 ) and the number of treatment s group 3 (13+) and age group 3 (34+). All other pairwise comparisons were non significant ( p = >.05). There were no statistically significant main effects for age group or treatment group. Table 4 11 presents the results of the series of factorial analyses for all of the dependent variables and Tables 4 12 and 4 13 presents the means and standard deviations by age group and treatment group. Table 4 14 presents the means and standard deviations for age and treatment group co mbined. Table 4 15 presents the significant estimated marginal means for Space and Emotion for the significant pairwise compariso ns. Research Question 2 The second research question for the study was: What influences do the three styles of coping ( Task or iented, Emotion oriented, or Avoidance oriented), the level of marital satisfaction, the three infertility specific coping strategies ( Space, Control, and Beliefs ), the number of vidual well being of women engaged in infertility treatment? This was formulated as the following null hypothesis: There is no significant contribution made by each style of coping ( T ask, E motion, and A voidance ), the level of marital satisfaction, the inf ertility specific coping strategies used ( Space, Control, and Beliefs ), the number of fertility to predict the level of individual well being of women engaged in infertility treatment. Research Q uestion 2 asked if participant three coping subscales ( Task, Avoidance, and Emotion ) their IMS score their scores on the subscales of the CSIC ( Space,

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103 Control, and Beliefs statistically significant pre dictors of MHI 5 scores. A stepwise multiple regression analysis was used to address this question. Stepwise regression seeks to find the best combination of variables to predict the dependent variable. The assumptions of regression were assessed and fo und to be acceptable. Colinnearity was not a problem among the variables as the VIF and Tolerance were well within acceptable ranges. Table 4 16 presents the correlation matrix of regression predictor variables. Results of the regression analyses resulte d in a five step model for predicting scores on the MHI 5 The final regression results indicated the overall model predicted individual well being, R = .618, R 2 = .382, R 2 adj = .368, F (1, 234) = 4.679, p = .032, and accounted for 38.2% of the variance i n individual well being. The statistically significant predictors were the Emotion c oping subscale the Avoidance c oping subscale the IMS score the Space subscale score of the CSIC, and the Task subscale of the CISS ( s ee table 4 10) Hence, the null hy pothesis was rejected. Age and number of treatments were not statistically significant predictors to the model nor were Control and Beliefs of the CSIC scale Since theses were not statistically significant in the stepwise model, they are not reported in the t ables A summary of the five model steps is presented in Table 4 17. Table 4 18 presents the significant model coefficien ts. Summary In this chapter, the results of a survey of married females currently receiving treatment for infertility were pres ented. A description of the study participants was given along with an wered by providing a detailed explanation of the results of the data analysis. In C hapter 5, the results will

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104 be discussed as well as the study limitations and implications for theory, counseling practice and policy. In addition, recommendations for futu re research will be presente d. Table 4 1. Descriptive Data for Study Participants N o Minimum Maximum Mean SD Age 256 19 48 31.94 4.791 Income 236 5,000.00 1,000,000.00 109,953.39 99,577.88 Table 4 2 Frequency of Participants B y Age Age N Percent age 19 1 4 20 1 4 23 1 4 24 7 2.7 25 11 4.3 26 11 4.3 27 3 10 2 28 21 8.2 29 20 7.8 30 30 11.7 31 30 11.7 32 24 9.4 33 16 6.3 34 12 4.7 35 14 5.5 36 4 1.6 37 20 7.8 38 4 1.6 39 69 2. 3 40 5 2.0 41 4 1.6 42 3 1.2 43 5 2.0 45 2 .8 48 1 .4

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105 Table 4 3. Frequency of P articipants B y R eported I ncome Income N Percentage 5 000 1 .4 15 000 1 .4 22 000 1 .4 25 000 1 .4 27 000 3 1.3 30 000 1 .4 35 000 4 1.7 40 000 2 .8 41 000 5 2.1 42 000 1 .4 44 000 1 .4 45 000 1 .4 50 000 4 3.0 51 000 7 .4 55 000 5 2.1 56 000 1 .4 60 000 12 5.1 61 000 1 .4 65 000 5 2.1 66 000 1 .4 69 000 1 .4 70 000 13 5.5 73 000 2 .8 75 000 15 6.4 78 000 1 .4 80 000 12 5.1 85 000 6 2.5 90 000 12 5.1 91 000 1 .4 95 000 3 1.3 99 999 1 .4 100 000 26 11.0 105 000 1 .4 110 000 6 2.5 120 000 13 5.5 124 000 1 .4 1 25 000 4 1.7 130 000 4 1.7 140 000 6 2.5 142 000 1 .4 145 000 2 .8 147 000 1 .4 150 000 14 5.9

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106 Table 4 3. Continued Income N Percentage 160,000 2 .8 165,000 1 .4 170,000 2 .8 175,000 2 .8 180,000 3 1.3 190,000 1 .4 195,000 1 .4 200,000 6 2.5 220,000 1 .4 225,000 1 .4 230,000 1 .4 250,000 4 1.7 285,000 1 .4 300,000 2 .8 380,0 00 1 .4 1,000,000 2 .8 Table 4 Level of Completed Education N Percentage Elementary Middle 10 0 .0 High School 47 5.3 Some College (did not graduate) 28 10.7 Associate Degree (2 year) 24 9.2 Bachelor (4 year) 94 35.9 Masters Degree 69 26.3 Specialists Degree 9 3.4 Doctoral Degree (Ph D. Ed D.+ ) 10 3.8 Professional Degree (J.D. M.D.) 14 5.3 Table 4 5. Frequency of Participants By Ethnic Group Ethnic Group N Percentage Caucasian 23 1 89.2 Hispanic 6 2.3 Caribbean 1 .4 African American 3 1.2 Asian/Pacific Islander 6 2.3 Mixed Cultural/Ethnic 8 3.1 Other 4 1.5

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107 Table 4 6. Descriptive Data for Infertility Treatments N Minimum Maximum Mean SD Educat ion 133 1 10 4.41 3.480 Medical 218 1 10 5.37 3.348 Surgery 85 1 10 1.72 1.444 Artificial 112 1 10 3.06 1.914 Egg Donor 12 1 10 3.42 3.029 InVitro 90 1 9 2.08 1.582 Table 4 7. Properties of the Coping Inventory for Stressful Situations N No of Items Mean SD Range Study Alpha Prior Alpha Task 282 16 54.08 11.82 5 80 .903 .90 Avoidance 282 16 45.09 10.07 10 80 .758 .82 Emotion 281 16 46.32 11.56 1 80 .875 .86 Table 4 8. Properties of the Mental Health Inventory 5 N No of Item s Mean SD Range Study Alpha Prior Alpha MHI 5 278 5 32.84 15.825 0 70 .872 .88 Table 4 9. Properties of the Index of Marital Satisfaction N No of Items Mean SD Range Study Alpha Prior Alpha IMS 268 25 17.07 14.46 0 100 .952 .96 Table 4 10. Properties of the Coping Scale for Infertile Couples N No of Items Mean SD Range Study Alpha Space 264 5 13.65 4.38 5 25 .664 Control 264 5 15.56 3.29 5 25 .627 Beliefs 264 5 19.29 3.39 5 25 .610

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108 Table 4 11. Factorial A nalysis of V ariance B y A ge G roup and N umber of T reatments G roup Age by Treat ment Age Group Treat ment Group IMS F (2, 231) = .295, p = .861 F (2, 231) = 1.854, p = .159 F (2, 231) = 1.957, p = .144 Task F (2, 231) = .568, p = .671 F ( 2, 231) = .546, p = .580 F (2, 231) = .16 4, p = .849 Emotion F (2, 231) = 2.733 p = .030 F (2, 231) = .967, p = .382 F (2, 231) = .142, p = .868 Avoidance F (2, 231) = .523 p = .719 F (2, 231) = 1.802, p = .167 F (2, 231) = .180, p = .835 MHI 5 F (2, 231) = .502, p = .734 F (2, 231) = 1.466, p = .233 F (2, 231) = .007, p = .993 Space F (2, 231) = 4.389, p = .002 F (2, 231) = 2.524, p = .082 F (2, 231) = .790, p = .455 Control F (2, 231) = .348, p = .845 F (2, 231) = .707, p = .494 F (2, 231) = 2.017, p = .135 Beliefs F (2, 231) = .812, p = .812 F (2, 231) = .322, p = .725 F (2, 231) = .306, p = .737 Table 4 12. Means and S tandard D eviations for A ge G roup Age 19 29 Age 31 33 Age 34+ M SD M SD M SD IMS 15.75 13.10 15.06 12.56 20.32 17.35 Task 53.13 11.23 54.30 11.75 55.48 10.35 Emot ion 46.35 11.97 47.64 10.57 45.22 11.92 Avoidance 47.20 8.66 44.56 8.92 44.71 10.42 MHI 5 34.16 15.89 34.30 15.52 29.91 15.98 Space 14.23 4.29 14.33 4.13 12.89 4.66 Control 15.84 3.33 15.25 3.22 15.63 3.26 Beliefs 19.60 3.10 19.20 3. 22 19.56 2.96 Table 4 13. Means and S tandard D eviations for T reatment G roup 1 5 Treatments 7 12 Treatments 13+ Treatments M SD M SD M SD IMS 14.81 12.43 15.79 12.32 20.66 17.99 Task 54.73 10.93 53.47 12.19 54.63 10.47 Emotion 46.92 11.57 46.31 10.77 46.38 11.95 Avoidance 45.52 9.72 45.06 9.09 45.63 9.31 MHI 5 33.30 14.67 32.84 14.89 32.47 18.23 Space 13.55 4.24 14.00 4.22 13.98 4.73 Control 19.26 3.24 19.32 3.22 19.68 2.86 Beliefs 16.41 3.06 16.21 3.16 16.42 2.93

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109 Tabl e 4 14. Means and Standard Deviations By Age Group and Treatment Group Treatment 1 6 Treatment 7 12 Treatment 13+ M SD M SD M SD EMOTION Age 19 29 48.00 12.58 44.68 9.82 45.15 14.28 Age 30 33 44.94 8.94 46.98 10.90 52.03 10.85 Age 34+ 48.16 13.32 46.56 12.30 42.52 10.35 SPACE Age 19 29 12.88 4.58 15.00 3.91 15.76 Age 30 33 13.67 3.98 13.57 4.09 16.15 3.98 Age 34+ 14.37 4.12 13.31 4.48 11.64 4.70 Table 4 15. Estimated Marginal M eans for Pairwise Compa risons Emotion Space Mean Mean Number treatment 1, Age group 1 48.00 12.88 Number treatment 1, Age group 2 44.94 13.67 Number treatment 1, Age group 3 48.16 14.37 Number treatment 2, Age group 1 44.68 15.00 Number treatment 2, Age group 2 46.97 13 .57 Number treatment 2, Age group 3 46.56 13.13 Number treatment 3, Age group 1 45.15 15.76 Number treatment 3, Age group 2* 52.03 16.15 Number treatment 3, Age group 3* 42.52 11.64 Number treatment 3 Age g roup 2 differed from Number of treatment 3 Age g roup 3, Emotion p = .050, Space p = .002 Table 4 16. Correlation Matrix of Regression Predictor Variable IMS Task Emotion Avoidance Space Control Beliefs Age Treat IMS 1.00 Task .051 1.00 Emotion .277 .121 1.00 Avoi dance .159 .311 .164 1.00 Space .049 .121 .248 .222 1.00 Control .312 .276 .304 .157 .065 1.00 Beliefs .258 .192 .074 .139 .046 .222 1.00 Age .146 .107 .121 .124 .117 .016 .048 1.00 Treat .213 .014 .022 .071 .071 .090 .084 .264 1.00

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110 Table 4 17. Model Summary for Mental Health Inventory 5 Step R R 2 R 2 adj F Df p 1a .530 .281 .278 93.136 1, 238 <.001 2b .575 .331 .325 17.548 1,237 <.001 3c .597 .356 .348 9.186 1,236 .003 4d .608 .369 .359 5.000 1,235 .026 5e .618 .382 .368 4.679 1,234 .032 a = Emotion b = Emotion Avoidance c = Emotion Avoidance IMS d = Emotion Avoidance IMS Space e = Emotion Avoidance IMS Space Task Table 4 18. Model C oefficients for Mental Health Inventory 5 B T P Bivariate r P artial r Emotion .616 .444 7.603 <.001 .530 .445 Avoidance .224 .133 2.363 .019 .154 .153 IMS .194 .178 3.270 .001 .327 .209 Space .459 .127 2.301 .022 .299 .149 Task .166 .117 2.163 .032 .140 .140

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111 CHAPTER 5 DISCUSSION The experience o f infertility is generally an unexpected crisis for a woman that can test the strength of her marital relationship and her emotional stability (Eunpu, 1995). Infertility has the potential to strengthen the relationship between a woman and her partner or c reate significant distress in the marriage (Watkins & Baldo, 2004). Aside from the physical implications, infertility also has the potential to impact the female to a point where she may be at a greater risk for psychological distress, and experience a de crease in self esteem and body image, and a general decline in her emotional well being (Imeson & McMurray, 1996). Many researchers have evaluated the impact of infertility on the physical and emotional health of women. Several researchers have also exam ined the ways in which men and women cope with infertility. Limited research has been available that evaluated possible predictors of individual well being for females in the process of infertility treatment. This study examined the following possible pr edictors of female individual well being: (a) general coping style, (b) level of marital satisfaction (c) infertility specific coping strategies, (d) age, and (e) stage of treatment. Additionally, the study sought to examine whether there was a main effec t or interaction between age group and number of treatments group on the scales and subscales used in the study. Presented in this chapter are the study limitations, discussion of the results, implications, and recommendations for future research that evo lved from the researc h. Evaluation of Research Questions This study of married females currently receiving treatment for infertility included 282 women ranging in age from 19 to 48 with an average age of 31.94. The range of ages of the participants was in teresting as they were relatively young to middle aged. The concentration of women in the 30 33 age group appears to be indicative of women realizing their biological

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112 clocks are running and if they want to have children they need to ensure they get pregna nt and may be using infertility treatments to help them reach their goal. The females were predominantly Caucasian (89.2%), and were well educated, holding a Bachelors (84%) degree or higher. These women were for the most part well educated and the assum ption could be made they have had careers and are now attempting to have children before it is too late. They may ha ve also put off having children due to educational and career aspirations and now need the assistance of infertility doctors as they age an d get older and possibly b eyond their reproductive years. Each participant completed a survey comprised of instruments measuring (a) coping styles ( CISS ), (b) level of marital satisfaction ( IMS ), (c) individual well being ( MHI 5 ), (d) infertility specific coping skills ( CSIC ), and (e) a demographic questionnaire. It was interesting to note that the women participating in the study reported between 1 and 41 incidences of different types of infertility treatments. Sixty eight women had undergone 1 2 invasiv e and expensive in vitro treatments in their efforts to have a child while 22 women had undergone in vitro treatments between 3 and 9 times. The women in the study had tried many different methods of getting pregnant many different times. Scores were comp allowing investigation of the relationship among these variables. Regression analysis was used well being Fac torial MANOVA and a factorial ANOVA were used to test for differences among the women by age and stage of treatment. A probability level of p = .05 or less was used as the criteria for accepting or rejecting the null hypotheses. Regression was used to te st the predictive hypothesis

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113 A probability level of p = .05 or less was used as the criteria for accepting or rejecting the regression null hypotheses. The first hypotheses examined significant differences by age group and number of treatments group for CISS ( Emotion, Avoidance, and Task ), the IMS the CISC ( Space, Beliefs, and Control ), and the score on the MHI 5 A MANOVA was used as the statistic to test for differences by age group and number of treatments group on the combined multivariate variable. MANOVA allows the testing of the overlap of multiple dependent variables and may be useful when comparing treatments or groups based on different characteristics, in the case of this st udy, age group and number of treatments. MANOVA is effective when a treatment or characteristic may affect participants in more than one way and allows the researcher to obtain a more holistic view and more detailed description of the variables in the inv estigation. The idea of a MANOVA stems from the fact that it is difficult to obtain a measure of any trait such as self esteem, achievement, etc. from any one variable. Thus, multiple measures of variables representing a common characteristic are likely to be more representative of the common characteristic or variable. In a multivariate situation, the dependent variables are treated as a combination, testing whether the mean differences among the groups on a combination of dependent variables are signif icant. A part of the MANOVA testing is the creation of a new dependent variable and this new variable is the linear combination of the original measured variab les (Mertler & Vannatta, 2001). The MANOVA findings for the study indicated there was no signifi cant interaction or main effect for age group or treatment group The factorial ANOVA follow up analysis indicated there were no significant differences on the individual variables for age group or

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114 number of treatments; however, there was a significant in teraction between age group by treatment group for Emotion and Space The ages for the women participating in the study ranged from 19 to 48 with the largest group of women being between 30 and 33. The number of treatments was shown to increase as the wom en got older. As noted in Table 4 9, as the females aged and had more treatment, their scores on the Emotion subscale increased from 44.94 to 52.03, the highest mean score on this subscale for any group. The Emotion subscale purports to measure emotional reactions to reduce stress such as self blaming, self preoccupation, and fantasizing, some of whom may not be effective in reducing stress (Tirre, 2004). Higher scores on the Emotion subscale are indicative of a higher level of using these types of self blaming behaviors more than others. Oftentimes, emotional expression is seen as a positive coping mechanism for women going through treatment that may actually be associated with higher treatment success (Schmidt, 2006). Feelings of self blame, failure, and decline in self esteem associated with the behaviors depicted in the Emotion coping subscale are common reactions to the process of infertility and can be related to a combination of the emotional stress felt during the process of treatment as well as physical and hormonal reactions to the treatments themselves (Watkins & Baldo, 2004). The concern in this case is the potential effect these behaviors can have on the success of treatment as very often, stress and emotional strain experienced during infer body that it could negatively impact the chanc e of conception (Eunpu, 1995). It is important to clarify that although high scores on the emotions subscale may be seen as negative, they are indicative of better ind ividual well being This is likely due to a variety of factors. The Emotion subscale measured responses to stress that included becoming overly emotional, getting angry, getting upset, or getting tense. In many cases, these might seem like

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115 unhealthy res ponses to a given situation, however, they can also be viewed as cathartic responses that allow the individual to release emotion that may have been building within them. Responses that are considered appropriate and healthy in one circumstance may be unh ealt hy in another, and vice versa. The older the woman and the higher the number of treatments, the higher the woman scores in the Emotion subscale, especially among age group 2 (30 33). It is important to note that while this is the case, the 34+ age gro up showed substantially less use of emotion coping behaviors, as compared to the higher scores in the 30 33 age group. According to Watkins and Baldo (2004), younger women tend to experience higher levels of stress as compared to older women. This drop i n scores after age 34 may be due to greater experience and time spent in the control that often comes with age or other sources of self identity. There was also a Space strategy subscale of the CSIC Participants who have high scores on the Space subscale tend to create a greater degree of space between themselves and their infertility problem. This in volves distancing themselves from children and not discussing the infertility problem with friends and family members. This subscale is consistent with the literature on female reaction to infertility as often times, women will deny their desire for child ren to friends and family members in order to avoid perceived awkward conversations and to hide the experience (Cudmore, 2005). The data indicates that women in the 30 33 age group reported using this set of strategies more often than the other two age gr oups, with women in the 19 29 age group close behind. Older women (34+) with a greater amount of treatments used Space significantly less often, perhaps showing a greater grasp of more effective coping and relying more often on interactions with others an d

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116 surrounding themselves with social support. In addition, women in the 13+ treatment group use space most often as a way of coping with their infertility problem. coping, level of marital satisfaction, 3 infertility specific coping strategies, age, and number of fertility treatments to predict their individual well being score. Using a stepwise multiple regression, it was determined that Emotion coping, Avoidance c oping, IMS, Task and Space, scores were significant predictors of individual well being. Task and Avoidance were negatively related to well being and Emotion Space and IMS were positively related to mental well being The five variables accounted for 38.2% of the variance in MHI 5 scores for individual well being. However, the Emotion subscale accounted for the largest percentage of the variance or 28.1%. The data suggest there are other variables not measured in this study that may also account for the mental health status of women participating in infertility treatments. Scores lower than 52 56 on the MHI 5 ( Ware & Sherbo u rne, 1992) are considered to be indicative of poor mental health reflecting for this group of women how infertility may be affec ting their mental health. Considering the variability found in the Emotion subscale of the CISS it is not too surprising Emotion score was the predictor variable accounting for most of the variance in this regression analysis. Avoidance and Task from the CISS were negatively related to MHI 5 scores indicating as one score went up the other went down. Marital satisfaction and Space both contributed positively to the regression formula and are indicative of how women being treated for infertility deal with their infertility and the impact this has on their overall mental health. The women participating in the study were more inclined to use Emotion based skills in predicting their overall mental health. Their marital satisfaction and Space strategies serv ed to impact

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117 mental health positively while Avoidance and Task were more negative in predicting overall well being It was somewhat surprising that age and treatment stage were not significant predictors of well being and that coping styles and strategies served as much better predictors. It is also interesting that emotion based coping would be considered a positive predictor of well being and task focused coping considered a negative predictor. The literature on coping skills generally speculates the op posite effect with each style of coping. Perhaps the experience of infertility is unique as coping styles and strategies used in other situations would bring about different results. The tenets of Stress and Coping Theory are most consistent with this fi nding as it posits that coping processes are not inherently positive or negative. What is positive in one circumstance may be negative in another (Jordan & Revenson, 1999). What is also interesting to speculate is what other factors may be impacting or p redicting the mental well being of infertile women that were not included in this stu dy. Limitations of the Study Although an effort was made to design a study that was generalizable to the population of interest, some limitations exist in the current stud y design. The first limitation of the study sample used is in the convenience snowball sampling method used to gather participants. This method may not have produced as fully accurate a representation of this population as might have a probability sample There may have also been specific characteristics of the sample itself that may have affected the results and created biased estimates, based on the fact that they volunteered to participate Volunteers tend to be intrinsically different from non volun teers. They tend to be more highly educated, seek social approval, have a higher social status, be more unconventional, and be less authoritarian and less conforming (Gall et al., 2006) There are

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118 however, limited resources to locate women in fertility t reatment as the subject has a social stigma that deters women from openly discussing their struggle in open forums. Another limitation of the study is its design. The cross sectional design used investigated the impact of the variables at only one point i n time, rather than longitudinally. If the variables are perceived as ever changing, it would be necessary to conduct a longitudinal study to gain a more accurate picture of the construct over a period of time. The study is also correlational in nature a nd therefore the relationships identified between the variables cannot imply causation. Moreover, the relationships among these variables may potentially be influenced by variables not investigated in this study. For example, participants whose scores on the MHI 5 indicated poor individual well being may have a long history of depression unrelated to infertility. Another design related limitation is in the self report format required in the study. Though the survey was available in both paper based and Internet based form, all participants chose to use the Internet based option. Therefore, it is impossible to know for certain that the person who responded truly met the requirements for participation and that their respo nses were completely accurate. Fo r example, it was difficult to verify whether participants recruited from online resources had received a formal diagnosis of infertility from a physician rather than a self prescribed diagnosis as study is completely dependent upon their self report. The responses may be susceptible to social desirability bias. It is a human trait to want to make ourselves look better than we really are or to present ourselves in a socially desira ble way (Gall et al. ) A further limitation may exist in the instrumentatio n used in the study, particularly that of the CSIC This measure was developed in Taiwan and originally tested on couples, rather than only women. Because of its international origination, the measure was most likely written in Mandarin. There may have been some problems with the translation between Mandarin and

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119 English, possibly causing miscommunications for English speaking participants. The original testing on couples rather than women may also have presented issues when using it with the present stu from this study revealed a different factor structure from that originally proposed by the test developers. Non response may have been seen as a limitation in this stu dy. There are two main reasons for this issue. The main areas of participant non response were noted in the demographic questionnaire. Several questions asked participants to provide information such as location, age, and income. In these cases of non response, it is likely that participants either felt uncomfortable providing this information or did not want to answer potentially identifying information, given that the survey was anonymous. Other questions asked participants about the types of treatme nts they have used thus far. In these cases of non response, participants either had not received that particular treatment or were uncomfortable confirming their use of certain treatments. Although the issue of infertility has become much more widely di scussed, it is still an issue surrounded by significant secrecy. For example, in a case where a participant has used sperm or egg donation, it might be likely for her to want to keep that information private. A final limitation was that the study would no t reflect the general demographics of infertile women in the United States. Participant responses may have been skewed in only representing individuals of a higher socioeconomic status due to the high cost of infertility treatment and the limited insuranc e coverage for these procedures. Women in a lower socioeconomic status may experience many of the same emotions and frustrations as those who can afford treatments, but may not be able to engage in such extensive treatments. This study focused solely on infertile women currently receiving treatment. It is important to note that

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120 women receiving infertility treatment are typically of a higher socioeconomic status, due to the high cost of treatment. Therefore, this study may not be representative of infert ile women in general, but is likely representative of infertile women receiving treatment in the area of socioeconomic statu s. Implications The findings of the present study yield implications for theorists studying the psychological impact of infertility, for professionals who work with infertile women or couples, and for researchers who study the impact of infertility. An issue that arose during the data analysis phase of this research was the number of infertility treatments the participants had used th us far. Several women in the study had used over 30 different infertility treatments in an attempt to conceive. In fact, 1 participant had used over 40 treatments. Little, if any, research exists on the number of treatments and the duration of time that women and couples are willing to persist through in order to have a baby. Future studies may investigate the relationship between amount of treatments used and the effect they can have on physical and emotional health. Another study might examine the re lationship between number of treatments and motivation for parenthood or importance of having a biologically related child. In this study, the researcher invited only married, heterosexual females to participate. Future studies might investigate the same variables in homosexual women in committed relationships or unmarried women in committed relationships. In reviewing the data and in gaining feedback from study participants, it was found that marriage was not a necessary step to take before attempting co nception through fertility treatment. Another area to examine might be single women hoping to become single mothers through fertility treatment. As trends in our society change, it has become more socially acceptable for a woman to have a non marital chi ld.

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121 A final area for future research is based upon the data collected on age as related to treatment. It seems that women between 30 and 33 had received a significantly higher number of treatments than those in the 19 29 year old age group. Though age is a major factor and likely cause of infertility, it would also be interesting to investigate the social views of motherhood as related to a particular age cohort. Future studies could examine the relationship between age and socia l pressure to become a mo ther. Implications for Theory Three theoretical frameworks were used to guide the present study. These included Crisis Theory, the Transactional Theory of Stress and Coping (Lazarus & Folkman, 1987) and the Developmental Theory of Infertility (Diamond et al., 1999). Crisis theory asserts that a crisis is a condition of distress and disorganization (Slaikeu, 1990). In many cases, infertility is seen as the first major crisis a woman experiences What differentiates the event as a crisis or a manageable st combat crisis individually, coping skills must be used, tested, and refined in order to successfully alleviate the stress. Pittman (l987) theorized that a crisis confronting a couple provides an opportunity for nece ssary changes to be made that may have not occurred without it. When coping skills are not properly utilized individually and changes are not made as a couple, the individual is at risk for disequilibrium, commonly including feelings of tension, incompete nce and helplessness. The precipitating event before potential crisis in this study is the diagnosis of infertility. Crisis theory has relevance within this study as seen in the interactions between coping styles and strategies used to manage the stress of infertility and their individual well being or perhaps, risk of disequilibrium. Women with higher levels of marital satisfaction and higher scores in the area of space were more likely to maintain more positive well being, or be at a lower risk for di sequilibrium. Women with higher scores on the subscales of Avoidance and

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122 Task were more likely to maintain poorer well being, placing them at a h igher risk for disequilibrium. The transactional theory of stress and coping posits it is the interactions bet ween the person and their environment that have the potential to create stress. Within this study, the theory states that the adjustments made by the woman in reaction to the experienced stress is based on available resources, coping processes and develop ed meanings. In this study these coping strategies she uses, and other demographic factors such as education level, income, and location. It is the combinati on of these areas that create her personal environment, contribute to her individual well being and serve to prevent a significant degree of stress. The final theory guiding this study is the developmental theory of infertility developed by Diamond et al. (1999). The theory proposes five phases of infertility known as: (a) dawning, (b) mobilization, (c) immersion, (d) resolution, and (e) legacy. According to this theory, the women who participated in this study could all be clustered into the immersion p hase of infertility. In this phase, the woman has already received a formal diagnosis of infertility and has begun further testing and medical treatments. This phase involves a constant state of limbo from month to month, therefore, the combination of va riables in this study will determine whether her transition into the resolution phase has been one of lesser or greater strai n. Implications for Counseling Practice Providing psychological therapy to individuals dealing with infertility has become more and more prevalent. It is now quite common for women or couples with infertility to seek therapy for assistance through the experience. However, they often seek counseling once the experience has taken a negative toll on their individual well being or on th eir relationship with their partner. The results of this study can provide a helpful framework for therapists and

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123 medical professionals working in the field of infertility as well as infertile women. It provides an g signs, that may assist all three of these groups in predicting a possible decline in individual well being before a woman reaches a true state of crisis wi th her infertility experience. The study identified five significant predictors of individual well being : (a) use of Emotion oriented coping, (b) use of Avoidance oriented coping, (c) score on the IMS, (d) use of strategies of increasing Space and (e) use of Task oriented coping strategies. Participants with high scores on the subscales of Avoidance a nd Task were more likely to have poorer degrees of individual well being while those with higher levels of marital satisfaction and higher scores on the subscales of Emotion and Space had better individual well being Counselors and medical professionals that become aware of these predictors may be able to use this information to assess the individual well being of their patients and clients and take preventative steps, such as a physician referring a patient for counseling to help them improve their well being before it becomes detrimental to their physical or emotional health. Few assessment tools are available to therapists to assess infertility specific issues arising in their clients. The Coping Inventory for Stressful Situations and the Index of Mar ital Satisfaction may service as good tools for therapists to use with infertile women. Therapists may be able to use the scores from each of these inventories to cater their work with these clients to strengthen the areas that best predict positive well being and reduce the coping skills and strategies that are shown to be ineffective at maintaining well being Summary This chapter provided a discussion of the sample demographics, results, study limitations, and implications for future research, theory, a nd practice. Overall, the findings indicated a significant association between age and the subscales of Emotion, Space, and Beliefs The

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124 findings further suggested that Avoidance and Task behaviors were negative predictors of individual well being while high marital satisfaction and use of Space were positive predictors of individual well being These findings expand on the body of literature related to infertility, mental health, and counseling. Future studies can focus on a variety of factors related to the current research to better describe the population and their infertility experience. An understanding of how age impacts coping as well as positive and negative predictors of well being serve as an insightful tool for therapists into the experience of their infertile female client s.

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125 APPENDIX A DEMOGRAPHIC DATA FOR M Will you please share some information about yourself and your fertility treatments Thank you so very much! Your age _______________________ Your Completed Educational Level Elementary/Middle School Masters degree High School Specialists degree Some college (did not graduate) Doctorate (e.g. PhD., Ed D, etc.) Associates degree (2 year) Professional (e.g. J.D., Medical) Bachelors degree (4 year) Yo ur Ethnic/Cultural Identification Caucasian Asian/Pacific Islander Hispanic Native American Caribbean Mixed Cultural/Ethnic African American Other ________________________ Your approximate household income ___________________ _____ In what city and state do you currently live? __________________________ When did you begin unprotected sex for the purpose of conceiving a child? (for example Month 10 Year 2002) Month ____ Year_______ When did you become aware of an infe rtility problem? Month ____ Year_______ When did you first seek a diagnosis for an infertility problem? Month ____ Year_______ When did you begin treatment for infertility? Month ____ Year_______ What fertility treatments have you used to tre at infertility? (please answer for all that apply) Medical Education and Yes No number of times ____________ Counseling Medication/Drugs/Hormones Yes No number of times ___________ Surgical Repair Yes No number of times _________ Artificial Insemination Yes No number of times ____________ Sperm/Egg Donation Yes No number of times ____________

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126 In Vitro Fertilization Yes No number of times ___________

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127 APPENDIX B PHYSICIAN LETTER Dear D octor, I am a doctoral student in the Department of Counselor Education at the University of Florida. I would like to ask for your assistance in my research study to investigate the influence of supportive factors in the emotional well being of women cur rently undergoing treatment for infertility. I will be conducting a survey of married women between the ages of 18 and 45 currently receiving treatment of any type for infertility. I am asking for your permission to make information about this survey ava il able to your current patients. Participants will be asked to complete a brief survey (approximately 15 20 minutes) evaluating coping mechanisms, marital satisfaction, and demographic information as related to individual well being. Participants may com plete this survey in an Internet or paper based form. Participation in the study is anonymous and there is little to no risk involved. In exchange for your assistance with this research, I would be happy to provide you with the research findings at the c onclusion of the study. If you would like to know more information about this study or would like to offer your assistance, please feel free to contact Heather Hanney, Ed.S., LMHC at 561 319 8299 or hlh1@ufl.edu. Thank you for your consideration, Heat her Hanney, Ed.S., LMHC Doctoral Candidate University of Florida

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128 APPENDIX C FLYER Infertility Research Study Be part of an important infertility research study! Are you a married woman between 18 and 45 years of age? Are you currently receiving tr eatment for infertility? If you answered YES to these questions, you may be eligible to participate in a research study evaluating the impact of infertility treatment. The purpose of this research study is to investigate the impact of infertility treatme nt on the emotional well being of women. Participants are being asked to complete a brief survey available online or in paper form Your participation will benefit the areas of medicine and counseling as well as other women and couples experiencing infer tility. If you would like to take the survey online just click on this link ( http://www.surveymonkey.com/s/infertility ) If you would prefer a paper copy please contact me. This study i s being conducted by Heather Hanney, a doctoral candidate in the Counselor Education department of the University of Florida. Please contact Heather Hanney at 561 318 8299 or hlh1@ufl.edu for further information.

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129 APPENDIX D POSTING FOR INTERNET CHAT ROOMS PARTICIPATE IN A RESEARCH STUDY If you are a married woman between the ages of 18 and 45 currently undergoing treatment for infertility, you are invited to participate in a research study to evaluate the impa ct of infertility on your personal and emotional well being Participants are being asked to complete a brief survey available online or in paper form Your participation will benefit the areas of medicine and counseling as well as other women and couple s experiencing infertility. To take the survey online simply use this link: http://www.surveymonkey.com/s/infertility If you would prefer a paper copy please contact me. If you have a ny questions, please contact Heather Hanney, Ed.S., LMHC at 561 319 8299 or hlh1@ufl.edu by September 30, 2010.

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130 APPENDIX E COVER LETTER PAPER D ear Potential Participant, I am writing to invite you to parti cipate in a study of women currently undergoing treatment for infertility that I am conducting for my doctoral dissertation at the University of Florida This being during treatment for inf ertility. I am asking women throughout the southeastern United States to take a brief survey regarding their experiences during fertility treatment. Results from the survey will help to medical and counseling professionals to gai n a better understanding of the emotional experience of a woman through this process to help them provide more comprehensive care to their patients. The results will also allow women and couples going through the process of treatment to be able to better prepared for the experience. It is my belief that you have a unique perspective that is valuable to the advancement of medicine and counseling and to the development of new knowledge about how women and couples progress through treatment for infertility. Your answers to this survey will be anonymous, and your participation in this study is voluntary You have the option to complete the survey online or through regular mail In either format, the study should take approximately 15 20 minutes to complete If you wish to complete the survey on line, please type the following web site address into your browser: http://www.surveymonkey.com/s/infertility If you wish to complete the enclose d paper based survey, please return it in the enclosed envelope Please ensure that you have read the enclosed informed consent and indicated that you agree to participate. If you have any questions about this study, I would be happy to answer them for y ou I can be reached via e mail at hlh1@ufl.edu or at phone number 561 319 8299 Thank you very much for participating in this important stud y! Sincerely, Heather Hanney, Ed. S., LMHC Doctoral Candidate University of Florida

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131 APPENDIX F CONSENT FO RM PAPER Dear Participant, Thank you for taking the time to participate in this research study The purpose of this study is to individual well being of mar ried females currently experiencing infertility. The information you provide can potentially benefit the fields of medicine and counseling as well as other women experiencing infertility. If you agree to volunteer in this study, you will be asked to comp lete a survey consisting of four sections. The first section consists of a demographic questionnaire consisting of basic background information. In the second section, you will be asked to provide information regarding the ways in which you cope with str essful situations. The third section will include questions about your current marital relationship. Lastly, you will be asked about the amount of emotional stress and strain you have r ecently experienced. Completing this survey is voluntary You may w ithdraw your consent at any time without any penalty You do not have to answer any questions you do not wish to answer Your responses will be anonymous, since your name or contact information will not be connected to any of your data. Please respond a s honestly and thoroughly as possible There are no anticipated risks to you fo r participating in this survey. In order to thank you for taking the time to complete this survey, I would like to provide you with a summary of the results of this study upon the completion of this research project If you wish to request a summary of the results, please send an e mail to hlh1@ufl.edu, including the where you would like the summary to be mailed Your request for the results of the study will not be connected to your responses and will remain confidential There are no other benefits to you f or participating in this study. If you have any questions concerning the survey, please contact me by e mail at hlh1@ufl.edu Alternatively, you may contact my supervis or, Dr. Ellen Amatea at the Department of Counselor Education, University of Florida, P.O. Box 117046, 1215 Norman Hall, Gainesville, FL, 32611 7046; phone (352) 273 4322; e mail: eamatea@coe.ufl.edu Questions or concerns about the rights of participants in this study can be directed to the UFIRB Office, Box 112250, University of Florida, Gainesville, FL, 32 611 2250; phone (352) 392 0433. have read and under stand the procedure described above and voluntarily agree to participate in this survey Once you have indicated your consent, you may b egin the survey. Thank you once again for your time! Sincerely, Heather Hanney, M.Ed., Ed.S. Doctoral Candidate Princ ipal Investigator

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132 APPENDIX G CONSENT FORM INTERNET Dear Participant, Thank you for taking the time to participate in this research study The purpose of the study criptive variables in predicting the individual well being of married females currently experiencing infertility. The information you provide will potentially benefit the fields of medicine and counseling as well as other w omen experiencing infertility. I f you agree to volunteer in this study, you will be asked to complete a survey consisting of four sections. The first section consists of a demographic questionnaire consisting of basic background information. In the second section, you will be asked to provide information regarding the ways in which you cope with stressful situations. The third section will include questions about your current marital relationship. Lastly, you will be asked about the amount of emotional stress and strain yo u have recen tly experienced. Completing this survey is voluntary You may withdraw your consent at any time without any penalty You do not have to answer any questions you do not wish to answer Your responses will be anonymous, since your name or contact informat ion will not be connected to any of your data. Please respond as honestly and thoroughly as possible There are no anticipated risks to you fo r participating in this survey. In order to thank you for taking the time to complete this survey, I would like to provide you with a summary of the results of this study upon the completion of this research project If you wish to request a summary of the results, please send an e mail to hlh1@ufl.edu, including the address where you would like the summary to be m ailed Your request for the results of the study will not be connected to your responses and will remain confidential There are no other benefits to you for participating in this study If you have any questions concerning the survey, please contact me by e mail at hlh1@ufl.edu Alternatively, you may contact my supervisor, Dr. Ellen Amatea at the Department of Counselor Education, University of Florida, P.O. Box 117046, 1215 Norman Hall, Gainesville, FL, 32611 7046; phone (352) 273 4322; e mail: eamate a@coe.ufl.edu Questions or concerns about the rights of participants in this study can be directed to the UFIRB Office, Box 112250, University of Florida, Gainesville, FL, 32611 2250; ph one (352) 392 0433. page one of your survey, you are stating that you have read and understand the procedure described above and voluntarily agree to participate in this survey Once you have indicated your consent, you may begin the survey Please include this informed con sent in the envelope in which yo u return your completed survey. Thank you once again for your time! Sincerely, Heather Hanney, M.Ed., Ed.S. Doctoral Candidate Principal Investigator To state that you have read and understand the procedure described ab ove and voluntarily agree to Once you click on the button, you will be taken to the beginning of the survey.

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133 LIST OF REFERENCES Abbey, A., Andrews, F. M., & Halman, L. J. (1991). The impo rtance of social relationships for being. In: A. L. Stanton & C. Dunkel Shetter (Eds.), Infertility; p erspective from s tress and c oping r esearch ( pp. 61 68). New York: Plenum Press. Adamson, G. D. (2009). Global cultural and socioe conomic factors that influence access to assis ted reproductive technologies. (4), 351 358. Akker, O. B. A. (2001 a ). Adoption in the a ge of reproductive technology. Journal of Reproductive and Infant Psychology, 19 (2), 147 159. Akker, O. (2001 b ). The acceptable face of parenthood: The relative status of biological and cultural interpretations of offsp ring in infertility treatment. Psychology, Evolution & Gender, 3 (2), 137 153. American Soci ety for Reproductive Medicine (ASRM) (2003). Age and fertility: A guide for patients Retrieved from http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/ Patient_Resources/Fact_Sheets_and_Info_Booklets/agefertility.pdf Anderson, B. J., Haimovici, F., Ginsburg, E.S ., Schu st, D. J., & Wayne, P. M. (2007). In vitro fertilization and acupuncture: C linical e fficacy and mechanistic basis. Alternative Therapies, 13 (3), 38 48. Band, D., Edelmann, R., Avery, S., & Brinsden, P. (1998). Correlates of psychological distress in relation to male infertility. B ritish Journal of Health Psychology, 3 245 256. Baramki, T. (2005). Hysterosalpingography. Fertil Steril, 83 (6), 1595 1606. Barker, R. L. (1984). Treating couples in crisis: Fundamentals and practice in marital therapy. New York: The Free Press. Berg, B. J. & Wilson, J. F. (1991). Psychological functioning across stages of treatment for infertility. Journal of Behavioral Medicine, 14 11 26. Berg, S. (1988). Snowball sampling. Encyclopedia of Statistical Sciences 8 529 532. Beusterien, K. M., Stei nwald, B., & Ware, J. E. (1996). Usefulness of the SF 36 Health Survey in measuring health outcomes in the depressed elderly. J Geriatr Psychiatry Neurol ; 9 (1), 13 21 Boivin, J. Bunting, L., Collins, J. & Nygren, K. (2007). International estimates of infertility prevalence and treatment seeking: Potential need and demand for infertility medical care. Retrieved March 16, 2009, from http://humrep.oxfordjournals.org/cgi/content/ abstract/22/6/1506

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142 BIOGRAPHICAL SKETCH Heather Lynne Hanney was born in Norristown, Pennsylvania. The only child of Dennis and Laura Lee Hanney, she spent her first 4 years in Fayetteville, North Carolina, th en moved to Florida where she grew up in Palm Beach Gardens and Jupiter. She graduated from The Benjamin School in 1997. She received her Bachelor of Science degree in psychology in 2001, her Master of Education and Specialist in Education degrees in marria ge and family therapy in 2004. Heather began her doctoral studies marriage and family therapy at the University of Florida in 2004. Along with her studies, she worked with Meridian Behavioral Healthcare in Gainesville, FL as an emergency screener and Alternate Family Care and the Parent Child Center in Palm Beach County as a child and family therapist. Heather was an instructor for the Family & School Colla boration course in the College of Education for 2 semesters, assistant clinical coordinator for the Advanced Family Clinic in the Department of Counselor Education, and served as a teaching assistant for two masters level courses in Counselor Education. S he received her Doctor of Philosophy in marriage and family therapy from the University of Florida in 2010. Heather married Brian Rask in 2008 currently resides in South Florida. She works as a child and family therapist for the Parent Child Center in Riv iera Beach and maintains a private practice in Palm Beach Gardens. She received her Ph.D. from the University of Florida in the fall of 2010