Citation
Predictors of negative affect in female infertility clinic patients

Material Information

Title:
Predictors of negative affect in female infertility clinic patients
Creator:
Jordan, Caren B., 1971-
Publication Date:
Language:
English
Physical Description:
viii, 77 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Depression ( mesh )
Infertility, Female -- psychology ( mesh )
Reproductive Techniques -- psychology ( mesh )
Research ( mesh )
Women -- psychology ( mesh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph.D)--University of Florida, 2001.
Bibliography:
Bibliography: leaves 70-76.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Caren B. Jordan.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
78536904 ( OCLC )
ocm78536904

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PREDICTORS OF NEGATIVE AFFECT IN FEMALE INFERTILITY CLINIC
PATIENTS
By
CAREN B. JORDAN
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
2001

ACKNOWLEDGMENTS
This paper is dedicated to my parents, Arthur and K. Christa Jordan, whose work
ethic and sacrifice were instrumental in my decision to pursue a career in the health
professions. Not only are they strong, positive role models in my life, they provided me
with immeasurable emotional support during my education and upbringing. I would like
to extend a heartfelt thank you to my friends that I met in Gainesville, FL (Mark and
Rachel Dunnagan, Jonathan and Jennifer Hubbell, John and Amy Lagae, John and Jill
Ramsier, and Rick Yost) who helped me to achieve balance and provided me with
tremendous social support during my graduate education. Each one of you served
instrumental roles in my personal and professional development.
I would like to give special thanks to Dr. Tracey Revenson, for her continued
guidance and support throughout my graduate education. Special thanks also go to my
classmates and peers at the University of Florida (in particular, Steve Anton, Guido
Urizar, and Caroline Danda) for their friendship and support. I will treasure our times of
laughter, tears, and perseverance. The completion of this study would not be possible
without the instrumental support of the reproductive endocrinologists (Dr. R. Stan
Williams, Dr. Simon Kipersztok, and Dr. Alice Rhoton-Vlasek) and nursing staff at the
Park Avenue Women’s Center, as well as the women who participated in my study.
I wish to extend my sincerest appreciation to the esteemed members of my
doctoral committee, Dr. James Algina, Dr. Suzanne Johnson, Dr. Samuel Sears, and Dr.
R. Stan Williams, for their guidance and support throughout my graduate training.
11

Finally, I would like to thank my dissertation chairwoman, Dr. Cynthia Belar. She has
been a mentor in every sense of the word, demonstrated by her level of dedication and
enthusiasm to the field of psychology. The support and guidance she has provided me,
on both a personal and professional level, are qualities that I will value and hope to
emulate in my career.
m

TABLE OF CONTENTS
page
ACKNOWLEDGMENTS ii
LIST OF TABLES vi
ABSTRACT vii
INTRODUCTION 1
Psychological Functioning and Infertility 1
Variables Affecting Self-Reported Distress 6
Social Desirability 6
Optimism 7
Expectations 8
Infertility-Specific Stress 11
Summary and Rationale for the Study 12
HYPOTHESES 14
METHOD 16
Participants 16
Procedures 17
Measures 17
RESULTS 21
Initial Analyses 21
Descriptive statistics 21
Analyses 25
Model Testing 26
DISCUSSION 45
Strengths 49
Limitations 51
IV

Clinical Implications 52
Future Directions 53
APPENDIX A INCLUSION CRITERIA AND RECRUITMENT INSTRUCTIONS....55
APPENDIX B TREATMENT HISTORY QUESTIONNAIRE 56
APPENDIX C FPI 58
APPENDIX D LOT 64
APPENDIX E MCSD 65
APPENDIX F STATE INF 67
APPENDIX G BDI 68
APPENDIX H PHYSICIAN QUESTIONNAIRE 69
REFERENCES 70
BIOGRAPHICAL SKETCH 77
v

LIST OF TABLES
Table Page
Table 1. Group Differences for Demographic Variables and Treatment History Variables
Between Responders and Non-Responders (without replacing missing data) ....29
Table 2. Physicians’ Report of the Cause of Infertility (N=104) 30
Table 3. Current Treatment (N=105) 31
Table 4. Past Treatment History of Study Participants (N=105) 32
Table 5. Means and Standard Deviations for Psychological Measures (N=105) 34
Table 6. Frequencies Distribution of Scores on the Psychological Measures (N=105) 35
Table 7. Correlations Among Observed Variables 37
Table 8. Items Placed on Each Indicator: LOT, MCSD, FPI, State INF & BDI 38
Table 9. Correlations Among Observed Variables 40
Table 10. Standardized Factor Loadings of Indicators for Latent Variables 41
Table 11. Correlations Among Latent Variables 42
vi

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
PREDICTORS OF NEGATIVE AFFECT IN FEMALE INFERTILITY CLINIC
PATIENTS
By
Caren B. Jordan
August 2002
Chairman: Cynthia D. Belar, Ph.D., ABPP
Major Department: Clinical and Health Psychology
Background: Research has indicated that infertility is perceived as stressful and
psychologically distressing. The main objective of this study was to investigate
differences in reported symptoms of negative affect in infertility patients, specifically
how social desirability, optimism, duration of time trying to conceive, and number and
types of treatments predicted self-reports of infertility-specific stress, state anxiety and
depression. The relationship between patient expectations and distress was also
examined.
Method: Female infertility patients were administered questionnaires regarding
treatment history, treatment expectations, depression, state anxiety, social desirability,
optimism, and infertility-specific stress. Their physicians reported estimations of
treatment success and cause of infertility.
Analyses: Structural equation modeling (SEM) on data from 105 patients
Vll

examined the degree of association between the independent exogenous variables (social
desirability, optimism, time trying to conceive, and treatment history) and each of three
dependent endogenous variables (infertility-specific stress, state anxiety, and depression).
Results: Scores on measures of social desirability, optimism, infertility-related
stress, state anxiety, and depression were, in general, similar to published norms. On
average, patients reported a 65% chance of success for this treatment cycle, although
physicians indicated a 15% chance of success. Optimism had the strongest effect on
latent infertility-specific stress. Infertility-specific stress had the strongest effect on latent
state anxiety regarding infertility. Optimism had the strongest effect on latent depression.
Both depression and infertility-specific stress had strong effects on patient-physician
difference. Hypotheses related to optimism and duration of time trying to conceive on
infertility-specific stress and the influence of number of ART treatments and infertility-
related stress on state anxiety were supported. Depression is affected by optimism, social
desirability, and infertility-specific stress. It was hypothesized that depression would
have the greatest influence on patient-physician scores, yet it seems that infertility stress
has the same magnitude of influence as depression.
Conclusion: In general, the sample did not report high levels of negative affect,
but social desirability does impact report of depression. However, 17% indicated
clinically significant levels of depression, yet only three individuals were in
psychological treatment, suggesting a significant proportion of depressed patients might
be undetected. Optimism seems to be related to all indicators of negative affect.
vm

INTRODUCTION
Psychological Functioning and Infertility
Infertility has been added to the list of life stressors encountered in middle
adulthood for many individuals. Infertility is defined as the inability to conceive a
pregnancy after one year of engaging in sexual intercourse without contraception
(Mosher & Pratt, 1990). Accordingly, 10% of the reproductive age population, or
approximately 6.1 million women, are infertile (American Society for Reproductive
Medicine, 1998). The rate of primary infertility and the rate among younger women are
increasing although the overall rate of infertility in the U.S. is not (Abma, Chandra,
Mosher, Peterson, & Piccinino, 1997). Some suggested factors for the increase in
infertility in these groups include the increased frequency of venereal diseases,
childbearing postponement until the late 30s and early 40s, and the use of particular
contraceptives, such as IUDs. In addition, the development of advanced medical
technologies may have increased the recognition of infertility in this population through
an increased rate of seeking services (Stanton & Dunkel-Schetter, 1991).
Stanton and Bums (1999) describe trends in the investigations of the psychology
of infertility. Initially, the focus was on intrapsychic conflicts which assumed a causal
connection between psychological conflicts and somatic functioning to account for the
infertility. Infertility was presumably caused by neurotic anxiety that was deeply seated
in the woman. The next phase, beginning in the 1970s, was characterized by research
1

2
that demonstrated psychological distress was a result of the stress of the diagnosis of
infertility and its treatment, rather than the cause of infertility in and of itself. Research
began to focus on the emotional responses associated with infertility including the
physical manifestations of the distress such as anovulation or altered hormonal
functioning, reactions to particular medical treatments, and gender differences in
responding to infertility. Some of this research is described in the next section.
The latest phase of the literature development has been more recent research
utilizing a biopsychosocial model that supports interactions among biopsychosocial
components. The biopsychosocial model of illness and health has provided a useful
conceptual framework for examining a variety of chronic illnesses including infertility.
The biopsychosocial model is composed of and takes into account the importance of
biological, psychological, and social influences on the onset, course, and treatment of
infertility. In this model, each individual has biological, psychological, and social
contributors to his or her health status. The biological subsystem consists of the
physiological processes, the psychological subsystem refers to the behaviors, cognitions
and emotions of the individual, and the social subsystem refers to the interpersonal
relationships of the individual and the sociocultural context. This model assumes an
interaction and interplay among the body, mind, and environment (Stanton & Bums,
1999). Wright and colleagues (1989) examined hypotheses regarding potential links
between psychosocial distress and infertility in a review of controlled research. They
concluded that patients treated in clinics demonstrated significantly higher levels of
psychosocial distress than control groups. The control groups were subjects who were
currently pregnant or normal couples that had not previously been pregnant. However,

3
none of the studies reviewed by Wright and colleagues examined participants before the
medical work-up or diagnosis. Wright and colleagues also concluded that the research
had many methodological flaws and could not provide conclusive results (Wright, Allard,
Lecours, and Sabourin, 1989).
Consistent with the biopsychosocial model, the fertility status for some
individuals may be influenced by environmental stress or other psychological factors
(Stanton & Bums, 1999). The functioning of the hypothalamic-pituitary-adrenal axis has
been found to be influenced by stressful conditions in animals and humans. In the
infertility population, high levels of distress may cause tubal spasms and hormonal
abnormalities in the levels of endorphins and prolactin. Demyttenaere and colleagues
(1988) found in a sample of women undergoing donor sperm insemination that those with
higher levels of trait anxiety took longer to conceive and were more likely to miscarry
than those with lower anxiety levels. Other researchers found increased conception in
infertile women after decreasing infertility-related anxiety (Rodriguez, Bermudez, Ponce
de Leon, & Castro, 1983). Wasser and colleagues (1993) have suggested a connection
between psychosocial distress and ovarian dysfunction (Wasser, Sewall, & Soules, 1993).
Their study suggested that certain aspects of psychosocial stress, such as lack of social
support, were related to hormonally based infertility. Harrison and colleagues (1987)
found a link between stress and semen quality during IVF attempts in that stress has a
adverse effect on sperm count, motility, and morphology.
Negative affect and infertility. Although the specific pathways between the
psychosocial and biological aspects of infertility have not been fully determined, it is well
supported that infertility is perceived as stressful and can be psychologically distressing.

4
Infertility is described as a stressful time that may have long-lasting effects on the
psychological well-being of each partner as well as on the marriage (Dunkel-Schetter &
Lobel, 1991; Leiblum, 1997; McEwan, Costello, & Taylor, 1987; Stewart & Glazer,
1986). Infertility has been associated with feelings of anxiety (Dunkel-Schetter & Lobel,
1991), depression (Valentine, 1986), anger (Phipps, 1993), denial (Menning, 1980),
frustration (Mahlstedt, Macduff, & Bernstein, 1987), isolation (Mahlstedt, 1985),
personal and social failure (Seibel & Taymour, 1982), loss of control (Mahlstedt, 1985;
Mahlstedt et al., 1987; Phipps, 1993), diminished self-worth and life quality (Andrews,
Abbey, & Halman, 1991), and grief (Mahlstedt, 1985; Menning, 1980).
An important note is that the literature is a mixture of clinical anecdotal studies,
professional opinions, and empirical studies from clinical populations. These reports and
studies reveal varying amounts of distress experienced by infertile individuals. In
general, infertile individuals or couples tend to be portrayed as much more
psychologically distressed in clinical anecdotes than in empirical studies that assess a
broader range of couples seeking infertility treatment. Although infertile women reported
more distress than their partners, it should be noted that their distress was not always
clinically significant on anxiety and depression measures (Dunkel-Schetter & Lobel,
1991; Stanton & Danoff-Berg, 1995). In fact, a number of reviews have concluded that
empirical evidence did not support the hypothesis that there are many predictable
reactions to infertility (Stanton & Bums, 1999).
However, two negative affects have been commonly reported in the literature:
feelings of anxiety and depression. For example, Freeman and colleagues (Freeman et
al., 1985) reported that 48% of the women in their sample stated that infertility was the

5
most upsetting experience in their lives as compared to previous stressful experiences
including death of a loved one or divorce. Both the physical demands of treatment and
the emotional aspects of infertility have been noted to be associated with higher rates of
self-reported anxiety and depression (Klock, Chang, Hiley, & Hill, 1997; Lukse & Vacc,
1999; Mazure, De l’Aune, & DeChemey, 1988). However, since the infertility
population is generally a psychologically normal population, more sensitive measures
may be required to detect distress. For example, anxiety and depression may change
from baseline and may affect medical treatment but are not necessarily at clinically
significant levels. However, there still may be stress-related emotional difficulties
present.
The experience of infertility itself and the medical diagnosis and treatment have
been found to be psychological distressing (Menning, 1980; Wright et al., 1989;
Edelmann, 1990; Mazure, Takefinan, Milki, & Lake-Polan, 1992). In particular, the
length of time trying to conceive and the number of assisted reproductive technology
(ART) treatments have been largely ignored. With both of these variables, the individual
faces continued failure of not attaining his or her desired goal. As a result, these
individuals may feel more distressed as their infertility experience goes on and they
continue to be in medical treatment for this condition. Two other factors that have been
neglected in the infertility research are social desirability and optimism. Social
desirability has been demonstrated in the other research areas to be a response bias that
can affect the detection of emotional stress in self-report ratings. Optimism may also
affect the experience of anxiety and depression. Further study of these factors may shed
light on the conflicting evidence from previous studies of negative affect.

6
Variables Affecting Self-Reported Distress
Social Desirability
Although it is common to use self-report measures to evaluate the level of anxiety
and depression, self-report alone is not necessarily an accurate method of assessing
anxiety and depression because it requires that people be aware of their level of distress
and be willing to report it. In fact, one study demonstrated that many infertility patients
deny anxiety and underreport their depressive symptoms by as much as one standard
deviation below the mean for the general medical and surgical populations (Mazure et al.,
1988; Mazure, Greenfeld, De l’Aune, Laufer, Polan, DeChemey, & Haseltine, 1984).
Low accuracy in self-reporting for infertility patients has been theorized to be linked to
fears of displeasing medical personnel, receiving disapproval from those in charge of
treatment, and being dropped from treatment if they report too high levels of distress
(Mazure et al., 1988; Mazure et al., 1984; Schreiber, 1985). In fact, Mazure and her
colleagues (1988) noted that 38% of her sample reported low levels of anxiety and high
scores on a measure of social desirability, so there may be a group of patients with
emotional distress that have not been detected by self-reported anxiety alone.
Social desirability is an important factor that may mediate the quality of
information provided by infertile patients being assessed for medical treatment. For
example, in other medical populations such as chronic pain patients, it has been shown
that patients with greater social desirability response bias reported less depression and
anxiety but higher pain levels, thus apparently emphasizing physical symptoms
(Deshields, Tait, Gfeller, & Chibnall, 1995). Social desirability has been labeled a stable
trait, which has been defined as the “need of subjects to obtain approval by responding in
a culturally appropriate and acceptable manner” (Crowne & Marlowe, 1960, p. 353).

7
Previous research has demonstrated that self-disclosure is affected by sensitivity
to social desirability across various subject groups (Deshields et al., 1995). Social
desirability response bias may be influenced by state variables such as timing of the
evaluation and whether the individuals would like to make a good impression on the
clinician. These authors concluded that it is important for clinicians to realize that social
desirability may be a possible source of bias and suggest that they should use questions
about an individual’s psychological state that normalize distress and not be negatively
worded. Generalizing from other medical populations, it may be that infertility patients
may acknowledge some symptoms of depression and anxiety but describe these
symptoms as very minimal and not interfering with their lives. If patients fear that they
are perceived as distressed, they may underreport their symptoms. Infertility patients
may feel less comfortable with endorsing psychological difficulties for fear of
jeopardizing their chances for medical services.
Optimism
Another factor that can be related to self-reported distress is optimism. Optimism
is defined by Scheier and Carver (1985) as the expectation of positive outcomes.
Optimists generally expect things to go their way and believe that more good things will
happen to them. Optimism is relatively stable across time and context, and optimists’
positive expectations are not limited to a particular domain or setting.
Optimism has been tied to more effective coping with health-related stressors
(Segerstrom, Taylor, Kemeny, & Fahey, 1998; Stanton & Snider, 1993). Research has
demonstrated that optimism predicted lower distress over time in patients experiencing
heart attacks, coping with positive HIV status, and early-stage breast cancer (Salovey,
Rothman, & Rodin, 1998). Optimists cope differently with stressors and experience less

8
negative mood (Segerstrom et al., 1998). For example, dispositional optimists, those who
have generalized positive outcome expectancies, have demonstrated less mood
disturbances in response to different health stressors such as breast cancer biopsy
(Stanton & Snider, 1993). These findings may be attributed to the beliefs of the
optimists that there will be resolution of the discrepancies between their goals and their
current status which may minimize negative mood states such as depression (Carver &
Scheier, 1985).
Infertility offers an opportunity to evaluate whether a dispositionally optimistic
orientation affords emotional benefits as a buffer of negative affect. Infertile individuals
often have no experience in a situation in which the outcome is uncertain and the crisis
unfolds over time. These are the conditions under which generalized expectancies rather
than specific outcome expectancies should influence behavior and well-being. However,
only one study within the infertility literature has examined the potential psychological
benefits of a generalized optimistic orientation. Litt, Tennen, Affleck, and Klock (1992)
found that infertile women (all with female factor diagnosis) who were dispositionally
optimistic experienced less distress following a failed IVF attempt.
In summary, optimism is an important trait that can provide insight into how some
experience negative affect associated with infertility. Optimism has been linked to more
effective coping with health stressors and less negative mood.
Expectations
Researchers have suggested that expectation is associated with mental health.
According to Scheier and Carver (1987), individuals’ behaviors and actions are impacted
by their beliefs about the probable outcomes of their behaviors and actions. This idea
can be linked to the psychological theories of motivation (e.g., Bandura, 1977).

9
Bandura’s (1977) definition of outcome expectancy is the belief of a person that a
specific behavior or action will result in a desired outcome. Scheier and Carver (1987)
describe expectancies as determinants of behavior. Desired outcomes that are seen as
reachable and attainable are continued to be sought after even when it is difficult.
However, efforts are reduced when outcomes are seen as unattainable. Outcome
expectancies can be seen as a determinant between these behaviors of continued effort
and giving up (Scheier & Carver, 1987). Scheier & Carver (1992) describe global
expectancies as dispositional optimism which has been discussed in the previous section.
In this section, the focus will be on situation-specific expectancies, particularly
expectations in achieving pregnancy.
In what Taylor and Brown (1988) describe as a positive illusion, people believe
that positive outcomes are more likely to happen to them than to others and negative
events are less likely. Taylor and colleagues have suggested that this illusion promotes
well-being both physically and mentally. The literature suggests that mood may affect
expectations with depressed individuals having realistic expectations while non-
depressed individuals have unrealistic optimistic expectations about the future (Taylor &
Brown, 1988).
In the infertility literature, research findings have varied in studies that have
examined patient expectations in achieving pregnancy, i.e., estimates of success. IVF
patients have been found to overestimate their chance of pregnancy (Callan &
Hennessey, 1986; Daniels, 1989; Johnston, Shaw & Bird, 1987). Johnston and
colleagues hypothesized that the patients’ overestimates were a result of the publicity in
vitro fertilization and embryo transfer had received (Johnston et al., 1987). The

10
underpinning of their hypothesis was the availability heuristic (Tversky & Kahneman,
1974). The use of this heuristic is linked with the overestimation of newsworthy events
such as causes of death like floods and accidents since rare events are more commonly
reported. IVF patients may be deriving their estimates of success from the highly
published successes such as the multiple births in Iowa and Texas in the late 1990s. In
other research, McEwan, Costello, & Taylor (1987) found both over- and
underestimation of the chance of pregnancy by female infertility patients. The different
findings may be a result of a wider diversity of treatment history and treatments in the
latter study while only IVF patients on their first trial were included in the former one.
Glover and colleagues (1996), in a sample of male infertility patients, found that
perceptions and expectations about achieving pregnancy were inaccurate and
overestimations.
All of the above mentioned studies (Johnston et al., 1987; McEwan et al., 1987;
Glover et al., 1996) also examined the relationship between mood state and expectations.
Johnston et al. (1987) found no correlation between anxiety and overestimation.
However, they did find that more optimistic expectations were positively correlated with
hopefulness. McEwan and colleagues (1987) found that distressed women were more
likely to underestimate the chance of pregnancy while overestimates were more likely to
be from non-distressed women. Glover and colleagues (1996) found that there was no
overall correlation between depression or anxiety and unrealistic expectations. They
suggested that more realistic outcome estimates may be associated with lower distress in
their male infertility sample.

11
In sum, positive expectations have been linked to better mental health. In the
infertility literature, studies have shown conflicting evidence as to whether patients over-
or underestimate their chances of success in achieving pregnancy. A more systematic
approach to this question may be beneficial to the literature.
Infertility-Specific Stress
Infertility has been described as a chronic and uncontrollable stressor that can
give rise to psychological distress. Infertility-specific stress is being operationalized and
measured in this study as how stressful an individual rates his or her concerns (i.e.,
sexual, social, and need for parenthood) regarding his or her difficulty having a child.
Infertility-specific stress can come from a variety of avenues for the individual. Sources
of infertility-specific stress may include self-rejection, spousal criticism or rejection,
familial disappointment and pressure as well as intrusive, expensive, and time-consuming
diagnostic process (Wright et al., 1989). Once a diagnosis is found, the treatment can be
equally as stressful. It may continue over an extended period of time at significant out-
of-pocket expenses, which does not always lead to a desirable outcome. In a review of
the controlled research, Wright and his colleagues (1989) found that infertile patients
currently undergoing treatment or being evaluated for treatment are more psychologically
distressed than control subjects who were currently pregnant or normal couples that had
not previously been pregnant.
Traditionally in this literature, stress in infertility patients has been measured with
several general psychological measures that examine anxiety, depression, and personality
(Newton, Sherrard, & Glavac, 1999). These standardized measures offer advantages
given the extensive data on their reliability and validity but may not be sensitive to the
disease-specific stress. Infertility-specific stress may affect the individuals’ ratings of

12
anxiety and depression despite their positive outlook of outcome and their need for
approval from medical staff. In the present study, measurement of infertility-related
stress is posited as a mediator; its measurement will advance knowledge and the
understanding of negative affect in this population. Infertility-related stress may be
underlying the association among optimism, social desirability, length of time trying to
conceive, number of treatments and self-reported levels of anxiety and depression in
infertile individuals.
Summary and Rationale for the Study
The psychological problems which have been most commonly investigated in the
infertility literature are anxiety and depression. Yet there are important factors that may
influence infertility patients’ experiences and reports of distress such as social desirability
and optimism that have not been sufficiently studied. Social desirability response bias
may lead patients to underreport their negative affect symptoms, and thus they may be at
greater risk for distress than detected through self-report methods alone. However, if
clinicians are aware of the patient’s higher need for approval from the medical staff, then
the medical staff can be aware of the possibility of undetected problems in their clinical
management. Optimism is also an important factor in examining negative affect
associated with infertility. Optimism, as a disposition, may benefit those with health-
related stressors. Infertility treatment variables, including length of time trying to
conceive and number of treatments, may also affect distress levels. Individuals who face
infertility for a longer period of time and have repeated losses, i.e., failed treatment
cycles, may be more distressed. Finally, the findings in the infertility literature pertaining

13
to expectations about treatment success have varied according to the subpopulation
examined.
The main objective of this study was to begin to understand the differences in
reported symptoms of negative affect in infertility patients. Primarily, the study
examined how social desirability, optimism, duration of time trying to conceive, and
number and types of treatments predicted self-reports of infertility-specific stress, state
anxiety, and depression. Another objective of this study was to study the relationship
between patient expectations and distress. This study also sought to add valuable
information to the current literature by systematically examining self-reporting bias
variables in the infertility population. It is important to identify the variables related to
negative affect experienced by infertile individuals in order to develop the most effective
type of intervention.

HYPOTHESES
1) It was hypothesized that infertility-specific stress would be influenced by
optimism, social desirability, duration of time trying to conceive, number of ART
treatments, and number of non-ART treatments. It was hypothesized that stress ratings
would be higher for those individuals who had lower optimism ratings, lower social
desirability, longer duration trying to conceive, and a higher number of ART treatments.
2) It was hypothesized that state anxiety regarding infertility would be influenced
by optimism, social desirability, duration of time trying to conceive, number of ART
treatments, number of non-ART treatments, and infertility-specific stress. It was
hypothesized that anxiety ratings would be higher for those individuals who had lower
optimism ratings, lower social desirability, longer duration trying to conceive, and a
higher number of ART treatments. The relationship between state anxiety regarding
infertility and infertility-specific stress was examined in order to estimate the indirect or
direct effect of the stress on anxiety.
3) It was hypothesized that depression would be influenced by optimism, social
desirability, duration of time trying to conceive, number of ART treatments, number of
non-ART treatments, and infertility-specific stress. It was hypothesized that depression
would be higher for those individuals who have lower optimism ratings, lower social
desirability, longer time seeking treatment, and a higher number of ART treatments. The
relationship between depression and infertility-specific stress was examined in order to
estimate the indirect or direct effect of the stress on depression.
14

15
4) It is hypothesized that depression would have the strongest influence on the
estimation of treatment success. Those individuals with higher ratings of depression and
lower optimism ratings will indicate more accurate estimations of treatment success.

METHOD
Participants
Female infertility patients visiting two reproductive endocrinology clinics in
central Florida were approached for this study. Subject involvement was voluntary and
no compensation was offered for participation. In order to be admitted into the study,
participants were required to meet the following criteria: 1) be at least 21 years of age, 2)
be able to understand spoken and written English, and 3) have a formal diagnosis of
infertility given by the reproductive endocrinologists.
Of the 164 questionnaire packets distributed for the study, 53 (32.3%) patients did
not return their materials and two questionnaire packets were unidentifiable. One hundred
nine (66.5%) packets were returned. Data from four patients were not used, resulting in a
total sample of 105 for analysis. Two of the excluded patients did not meet inclusion
criteria because they did not have a formal diagnosis of infertility and 2 patients received
the packet twice. One hundred (95%) respondents were seen by 1 of 3 reproductive
endocrinologists at the Park Avenue Women’s Clinic. For 40 of the non-responders,
treatment history and demographic information were obtained through medical record
review. Responders were compared to non-responders by independent samples t-tests as
shown in Table 1. Non-responders were not significantly different from study
participants in relation to age, partner’s age, relationship duration, total time trying to
conceive, total time seeking medical treatment for infertility, physician’s expectation for
success in treatment, and number and types of medical treatments, with three exceptions:
16

17
Responders experienced more cycles of donor insemination (p < .05), ovulation induction
(p < .05) and infertility surgeries (p < .001).
Procedures
During an office visit, patients were asked to participate in a study examining the
psychological factors experienced in a reproductive endocrinology clinic population.
Participants were informed that all responses would be confidential (with the exception of
suicidal intent) and to ensure anonymity, subject numbers were used to identify each
patient’s responses. The Institutional Review Board (IRB) at the University of Florida
Health Science Center approved this study and all procedures for ethical research were
followed.
Measures
All participants were asked to complete several pencil-and-paper instruments
including Treatment History Questionnaire (THQ), Beck Depression Inventory (BDI),
State Anxiety Regarding Infertility (State INF), Marlowe-Crowne Social Desirability
Scale (MCSD), Life Orientation Test (LOT), and Fertility Problem Inventory (FPI).
The physicians were asked to complete a 2-item questionnaire immediately
following the office visit. The physician questionnaire consists of (1) a question
regarding estimation of treatment success during a current treatment cycle on a scale of 0
to 100% and (2) the medical cause of infertility that was diagnosed for this patient.
(1) Treatment Historv(THQ~). The Treatment History Questionnaire is an
investigator-developed questionnaire consisting of general information questions (age,
partner’s age, relationship duration, total time trying to conceive, total time seeking
medical treatment for infertility, and if seeking psychological treatment), treatment
questions (past treatment types, number of cycles, whether pregnancy was achieved, live

18
births, and multiple pregnancies, and current medical treatment), and estimations about
the probability of success in achieving pregnancy during this treatment cycle on a scale
from 0 to 100%. The patient and physician expectations were later used to calculate a
difference score.
(2) Depression (BDI). The Beck Depression Inventory (BDI; Beck, Rush, Shaw,
& Emery, 1979) is a 21-item measure designed to assess global negative affect.
Respondents were asked to rate, on a three point Likert scale ranging from 0 to 3, the
intensity of symptoms and attitudes of depression. A meta-analysis of several studies
examining the BDI’s internal consistency yielded a mean coefficient alpha of .81 for
nonpsychiatric patients (Beck, Steer, & Garbin, 1988). Numerous published studies of
the psychosocial status of infertility patients have included the BDI (e.g., Stewart et al.,
1992; McQueeney et al., 1997;Takefinan et al., 1990). Participants were asked to
complete this measure to measure their negative affect. (Participants who expressed
suicidal ideation were immediately referred for psychological consultation.) Cronbach’s
alpha for the current sample was .90.
(3) State anxiety regarding infertility (State INF). The State-Trait Anxiety
Inventory (STAI; Spielberger et al., 1983) is an instrument of two 20-item scales
designed to assess state and trait anxiety. The 10-item scale to assess state anxiety was
used only. Modified instructions were used to ask respondents how they feel “right now”
in regard to how anxious they are about trying to conceive. The scale has been found to
have high internal consistency, .86 to .95 (Spielberger & Krasner, 1988).
Previous infertility research (Mazure et al., 1984) had measured self-reported
anxiety via the standard Spielberger State-Trait Anxiety Inventory. Many participants

19
denied anxiety, with the mean score one standard deviation below the norms for the
general medical and surgical populations. Mazure and colleagues suggested that this type
of response is an indicator of inaccurate reports of low anxiety or diminished self¬
perception of anxiety (Mazure et al., 1988). Participants were asked to complete the state
anxiety measure with modified instructions to assess their State anxiety regarding
infertility levels. The Cronbach’s alpha for the State INF scale in the current study was
.96.
(4) Social Desirability (MCSDV The Marlowe-Crowne Social Desirability Scale
(MCSD; Crowne & Marlowe, 1960) is a 33-item instrument designed to assess the need
for approval by describing either desirable but uncommon behaviors or undesirable but
common behaviors. Respondents were asked to answer “True” or “False” to 18 items
keyed in the true direction and 15 in the false direction. Scores range from 0 to 33, with
higher scores representing higher need for approval. Test-retest reliability (30 days) was
reported as .88, suggesting that the MCSD is reasonably stable over time. Internal
consistency alpha coefficients ranged from .73 to .88, suggesting moderate consistency
(Crowne & Marlowe, 1964). Participants were asked to complete this measure to assess
their social desirability. Cronbach’s alpha for the current sample was .84.
(5) Dispositional Optimism (LOTI. The Life Orientation Test (LOT; Scheier &
Carver, 1985) is a 12-item scale designed to measure dispositional optimism which is
defined as generalized positive outcome expectancies. Four items are positively phased
(“In uncertain times, I usually expect the best”), and four are negatively phrased (“If
something can go wrong for me, it will). The four additional items are fillers.
Respondents indicate their agreement with each item on a 5-point scale ranging from

20
strongly agree (1) to strongly disagree (5). Moderate internal consistency was reported,
mean coefficient alpha of .76. Test-retest reliability (30 days) was reported as .79,
suggesting that the LOT is reasonably stable over time. Cronbach’s alpha for the social
desirability scale in this study was .81.
(6) Infertility-specific stress (FPD. The Fertility Problem Inventory (FPI;
Newton, Sherrard, & Glavac, 1999) is a 46-item questionnaire designed to assess
perceived infertility-related stress. Respondents indicated their agreement with each item
on a 6-point scale ranging from strongly agree to strongly disagree.
A composite measure of global stress derived by summing across all items was
used in the analyses. For global stress, high internal consistency has been reported, with
a mean coefficient alpha of .93. Cronbach’s alpha for total score in the current study was
.91. Test-retest reliability (30 days) for global stress was reported as .83 for women.
Convergent validity has also been established for both depression (as measured by the
BDI) and state anxiety (as measured by the STAI). The correlation coefficient for
convergent validity for depression and global stress was reported as .60 for women. The
correlation coefficient for state anxiety and global stress was reported as .37 for women.
The correlation coefficient for state anxiety and global stress in the current study was .47
and .54 for the depression and global stress.

RESULTS
Initial Analyses
Descriptive statistics
Means and standard deviations for characterizing study participants are provided
in Table 1. For the responders that data were available, the mean age was 35.06 years
(range 23 to 46) and they had been trying to get pregnant for 39.9 months on average
(range 2 to 170). These women on average had been seeking medical treatment for
infertility on average for 26.6 months (range 1 to 170). The mean age of the partners
was 37.60 years (range 25 to 61) and the relationship duration was on average 104
months (range 12 to 264). The majority of the sample (n=91, 86.7%) was classified as
Caucasian with additional 4.8% characterized as Black/African American, and data
unavailable for 8 respondents. Physicians reported the cause of infertility was female
factor for 69 responders (66.3%), male factor for 13 (12.5%), both male and female factor
for 14 (13.5%) and unexplained for 8 (7.7%), as shown in Table 2. Compared to the
infertility literature, there were a higher percentage of female factor infertility diagnoses
in this sample.
As shown in Table 3, the sample was predominantly undergoing non-ART
treatments (81%) which included donor insemination, artificial insemination, ovulation
induction, superovulation, and infertility surgery. Nineteen percent reported undergoing
IVF or IVF with donor eggs.
21

22
Past treatment history is provided in Table 4. The most common past treatment
was superovulation (38.1%), followed by ovulation induction (33.4%). Approximately
14% of the participants had undergone donor insemination in the past. Less than 7% of
the sample had received IVF and other treatments in the past. Only 1% of the participants
had undergone IVF with donor eggs previously. Six pregnancies were conceived by
superovulation but only one live birth. Thirteen pregnancies were achieved by ovulation
induction, resulting in only four live births. Four individuals (3.8%) reported achieving a
pregnancy with donor insemination; however, only two (1.9%) produced live births.
For the seven participants that received IVF, two pregnancies were achieved with
only one live birth. For IVF with donor eggs, three pregnancies were achieved but no
live births. Most of the respondents received infertility surgery (79.0%). For the 28
infertility surgeries performed, four pregnancies were achieved with only one live birth.
Regardless of treatment, no multiple pregnancies were reported by the sample.
For the entire sample, only nine live births were reported. They had been trying
to conceive on average for approximately three years. In terms of seeking medical
treatment, the sample as a whole had been seeing a reproductive endocrinologist for
approximately two years. Despite being in medical treatment for two years, the sample
experienced on average only two ovulation induction cycles and one superovulation
induction cycle. The majority had not received advanced treatment (i.e., IVF).
The means and standard deviations of the psychological measures are shown in
Table 5. In comparison with the normative data, the sample had similar scores of social
desirability, optimism, and depression. On average, patients reported a 65% chance of

23
success for this treatment cycle. However, the physicians indicated on average, a 15%
chance of success.
Table 6 provides the frequencies of scores on the psychological measures. The
majority of the respondents (75.2%) reported experiencing average amounts of infertility-
specific stress. An additional 16.2% reported moderately to very high infertility-specific
stress. On the infertility-related anxiety measure (State INF), 33.4% of the respondents,
indicated experiencing below average levels of state anxiety, when compared to State
STAI norms. In addition, 30.5% and 20.0% reported experiencing within one and two
standard deviations above average, respectively. Also, 15% of the participants reported
experiencing state anxiety symptoms more than two standard deviations above the mean
on the State STAI. On the global depression scale, most participants (61.0%) indicated
that they experienced minimal levels of depressive symptoms. Thirty-eight percent of the
sample reported experiencing mild to moderate symptoms, and one individual reported
severe symptoms.
On the optimism measure (LOT), 58.6% of the sample reported at or below
average amounts of optimism. Twenty-six respondents (25.0%) indicated above average
levels of optimism within one standard deviation of the mean. An additional 15.4% of
the respondents indicated optimism levels above average within two standard deviations,
and one individual above two standard deviations.
On the social desirability scale (MCSD), the mean for sample (17.7) was slightly
above the normative mean (15.5). However, 39.1% of the sample indicated at or below
average levels of social desirability. An additional 20.1% indicated social desirability
levels within one standard deviation. Also, 10.4% of the responders reported high levels

24
of social desirability, as indicated by scores that were at least two standard deviations
above the mean.
For patient expectations of treatment success, the findings were more varied. On
a scale of 0 to 100% chance of success, 22.9% of the sample indicated that they believed
they had less than a 50% chance of success. An additional 37.5% indicated that their
expectations were between 50 and 75% as well as another 16.7% reported their success to
be 76-99%. It should be noted that 22 participants (22.9%) indicated that they believed
that they had greater than 99% chance of success during this treatment cycle.
For physician expectations of treatment success, the findings were more
consistent and limited in range. The majority (84.6%) of the patients received ratings of
less than 25% chance of success from their physicians. An additional 13.5% received
ratings of 26-49% chance of success.
In order to assess the differences between patient and physician expectations for
treatment success, a difference score was calculated by subtracting the physician’s
expectation for that patient from the patient’s expectation for the treatment cycle. The
differences between patient and physician expectations are also listed in Table 6. Four
participants (4.2%) indicated that they believed their chances to be less than the
physician, demonstrated by the negative differences. The remainder of the sample (n=92)
indicated a higher chance of success than the physician, suggested by the higher
differences.
Of the 105 responders, 3 individuals (2.9%) indicated that they were currently in
psychological treatment, all in individual therapy. It should be noted that 7 individuals
did not respond to this item on the questionnaire.

25
Table 7 presents the zero-order correlations for the observed variables (total
scores of predictor variables and outcome variables) under study. Infertility-specific
stress was associated with optimism, social desirability, state anxiety, depression, and
total time trying to conceive. Depression was associated with infertility-specific stress,
optimism, social desirability, state anxiety, total time trying to conceive, and patient-
physician difference for treatment success. State anxiety was associated with infertility-
specific stress, optimism, social desirability, depression, and number of ART treatments.
The patient-physician difference for treatment success was associated with optimism,
depression, total time trying to conceive, and number of ART treatments. The correlation
between optimism and social desirability was of modest magnitude.
Analyses
Structural equation modeling (SEM) is a technique for estimating the parameters
of a model and testing the fit of the model to a data set. SEM can be used to address the
impact of measurement error on the analysis by using multiple indicators to define latent
variables. In the current research, multiple indicators were constructed from the BDI,
State-INF, MCSD, LOT, and FPI to define latent depression, state anxiety, social
desirability, optimism, and fertility problem variables, respectively.
The following procedure was used to construct the indicator variables. For each
instrument (e.g., MSCD) a principal component analysis, with one component, was
conducted. The items were ranked in descending order in terms of the principal
component loadings. From among the top three items, one was randomly assigned to
each of three subscales (for the LOT two subscales were created, because the LOT has a
small number of items due to four filler items). This process was repeated until all items
on a scale were assigned to a subscale and then repeated for all remaining scales. The

26
process is similar to conducting an item analysis and using the results to construct
subscales that are close to equivalent measures of the variable measured by the entire set
of items. The subscales were then used as indicators of the latent variables. For example,
the three MCSD subscales were indicators for the latent social desirability variable.
Table 8 lists the factor loadings by item numbers for the measures.
The Mplus (Version 2.01) program was used (Muthen & Muthen, 2001) to
conduct the SEM analyses, in part because it employs full information maximum
likelihood (FIML) estimation to estimate the model when there are missing data.
Alternative techniques are to eliminate cases with missing data, to use an ad hoc
procedure for imputing the missing data, or to use multiple imputation (Schaefer, 1997), a
statistically rigorous imputation procedure. FIML uses all the available data but does nor
require imputation of any missing data and is less complex to implement than is multiple
imputation. Table 9 presents the correlations for the multiple indicators of the latent
variables.
Model Testing
Measurement model. The measurement model is a confirmatory factor analysis
model: Each indicator variable was hypothesized to load on the latent variable it was used
to define. For example, the two indicators constructed from the MCSD scale loaded on
the latent social desirability variable. The measurement model yielded x2 (103,
N=105)=l 37.972, p< .05, CFI=0.97 , SRMR=.039. Although the chi square indicated the
model could be further improved, the CFI and SRMR meet the Hu and Bentler (1999)
criteria for adequate fit. Standardized factor loadings are presented in Table 10.

27
Table 11 presents the correlations among the latent variables and total time trying
to conceive, number of ART and Non-ART treatments, and patient-physician differences
on treatment success. These correlations are consistent with the observed variable
correlations.
Structural model. In the next stage of analysis, the model with infertility-specific
stress as a mediator was examined. In this model the effects of total time trying to
conceive, number of ART and Non-ART treatments, social desirability, and optimism on
anxiety, depression, and patient-physician differences on treatment success are mediated
by infertility specific stress. That is, total time trying to conceive, number of ART and
Non-ART treatments, social desirability, and optimism are postulated to have only
indirect effects on anxiety, depression, and patient-physician differences on treatment
success. In contrast to the measurement model, this mediation model implies predictions
about the magnitude and pattern of the correlation coefficients among the latent variables
and total time trying to conceive, number of ART and Non-ART treatments, and patient-
physician differences on treatment success. The model fit statistics were y2 (118,
N=105)=209.048, p< .001, CFI=0.93, SRMR= .095. The CFI and the SRMR do not
quite meet the Hu-Bentler criteria. In addition, the chi-square statistics indicate a
significant decrement in fit, y2 (5, N=105)=72, p< .05, indicating that the predictions of
the mediating model are not tenable.
The structural model was revised by adding the direct relationships from total
time trying to conceive, number of ART and Non-ART treatments, social desirability,
and optimism to anxiety, depression, and patient-physician differences on treatment
success. The complete model, depicted in Figure 1, is statistically equivalent to the

28
measurement model and therefore must fit as well as the measurement model. Its
components can be summarized as follows (Figure 1). Optimism had the strongest effect
on latent infertility-specific stress ((3 = - .50). Also, total time trying to conceive (P = .25)
had an effect on latent infertility-specific stress. Infertility-specific stress had the
strongest effect on latent state anxiety regarding infertility (P = .41). Also, the number of
ART treatments (P= -.19) had an effect on latent state anxiety regarding infertility. The
effect of latent infertility-specific stress (P = .24) was comparable to the effect of social
desirability (p = - .26) on latent depression, although optimism had the strongest effect (P
= -.45). Both depression and infertility-specific stress had strong effects on patient-
physician difference (P = -.37 and P = .37 respectively). Patient-physician difference was
also effected by optimism (P = .32), number of ART treatments (P = - .37) and total time
trying to conceive (P = -.26). The model accounted for 59.9% of the variance for latent
depression, for 41.2% of the variance for patient-physician difference, for 38.4% of the
variance for infertility-specific stress, and for 36.1% of the variance for state anxiety
regarding infertility.

Table 1. Group Differences for Demographic Variables and Treatment History Variables Between Responders and Non-Responders
(without replacing missing data)
Variable
n
Responders
M SD
n
Non-ResDonders
M SD
df
t
Age (years)
103
35.06
4.68
52
35.30
5.16
153
.29
Partner’s Age (years)
98
37.60
6.94
41
37.09
6.69
137
-.40
Relationship Duration (months)
99
104.13
52.04
32
97.72
48.73
129
-.62
Total Time Trying to Conceive
99
39.89
31.01
34
49.94
36.04
131
1.56
(months)
Total Time Seeking Medical
100
26.61
27.07
33
29.61
30.38
131
.54
Treatment (months)
# of Donor Insemination Cycles
104
.84
2.57
40
.25
1.43
123.8a
-1.74*
# of Ovulation Induction Cycles
104
2.12
4.12
40
.50
1.60
142a
-3.40***
# of Superovulation Induction
104
1.15
1.95
40
1.02
2.08
142
-.35
Cycles
# of In Vitro Fertilization Cycles
104
.09
.34
40
.05
.22
142
-.62
# of In Vitro Fertilization with
104
.04
.39
40
.00
.00
142
-.62
Donor Eggs Cycles
# of Infertility Surgeries
104
.27
.58
40
.00
.00
103 a
-4.75***
# of Other Treatment Cycles
104
.27
1.25
40
.00
.00
142
-1.36
Physicians’ Expectations
104
.15
.12
51
.18
.18
728
1.15
to
'O
Note. * p<.05. *** p<.001. “Equal variances are not assumed.

30
Table 2. Physicians’ Report of the Cause of Infertility (N= 104)
Cause of Infertility n %
Female factor 69 66.3
Malefactor 13 12.5
Both female and male factor 14 13.5
Unexplained 8 7.7

31
Table 3. Current Treatment (N=l05)
Current Treatment
n
%
DI
11
10.5
01
16
15.2
Superovulation with IUI
41
39.1
Artificial Insemination (Husband)
3
2.9
DI & 01
3
2.9
DI, 01, & Infertility Surgery
1
1.0
DI, 01, & Superovulation with IUI
2
1.9
01 & Superovulation with IUI
1
1.0
01 & Infertility Surgery
1
1.0
Superovulation & Infertility Surgery
1
1.0
IVF (including GIFT & ZIFT)
17
16.2
IVF (with donor eggs)
3
2.9
Not in Treatment but Undergoing Diagnostics
2
1.9
Undetermined
2
1.9
Note. DI= Donor Insemination; 01 = Ovulation Induction, IUI = Inter-uterine
Insemination; IVF = In Vitro Fertilization; GIFT = Gamete Intrafallopian Transfer; ZIFT
= Zygote Intrafallopian Transfer.

32
Table 4. Past Treatment History of Study Participants (N:
Treatment
n
%
Superovulation
# of Cycles
0
65
61.9
1-5
34
32.4
6-9
6
5.7
# Pregnancies Achieved
0
99
94.3
1
6
5.7
# Live Births
0
104
99.0
1
1
1.0
Ovulation Induction
# of Cycles
0
71
67.6
1-5
17
16.2
6-10
13
12.4
>10
5
4.8
# of Pregnancies Achieved
0
92
87.6
1
9
8.6
2
3
2.9
4
1
1.0
# of Live Births
0
101
96.2
1
4
3.8
Donor Insemination
# of Cycles
0
91
86.7
1-5
7
6.7
6-10
5
4.8
>10
2
1.9
# of Pregnancies Achieved
0
101
96.2
1
4
3.8
# of Live Births
0
103
98.1
1
2
1.9
105)
(Table 4 continues)

(Table 4 continued)
Treatment
33
n °&
Other Treatment
# of Cycles
0
98
93.3
1-10
7
6.7
# Pregnancies Achieved
0
104
99.0
5
1
1.0
# Live Births
0
105
100
In Vitro Fertilization
# of Cycles
0
98
93.3
1
5
4.8
2
2
1.9
# Pregnancies Achieved
0
103
98.1
1
2
1.9
# Live Births
0
104
99.0
1
1
1.0
In Vitro Fertilization with Donor Eggs
# of Cycles
0
104
99.0
4
1
1.0
# Pregnancies Achieved
0
104
99.0
3
1
1.0
# Live Births
0
105
100
1
1
1.0

34
Table 5. Means and Standard Deviations for Psychological Measures (N=105)
Psychological Measure
n
Current Sample
M SD
Published
M SD
MCSD Total
105
17.7
5.9
15.5
4.4a
LOT Total
104
20.3
5.7
21.4
5.2b
FPI Total
105
138.5
31.6
134.4
33.8C
State INF Total
105
42.2
14.3
36.2
11.0d>e
BDI Total
105
8.9
7.4
10.9
8.1f
Patient Expectation of Success (%)
96
65
30
Physician Expectation of Success (%)
104
15
12
Note. MCSD = Marlowe-Crowne Social Desirability Scale; LOT = Life Orientation Test;
FPI= Fertility Problem Inventory; State INF = State Anxiety Regarding Infertility; BDI =
Beck Depression Inventory. a Crowne & Marlowe, 1964. bScheier & Carver, 1985.
cNewton et al., 1999.d Published norms for the State-Trait Anxiety Inventory, State
Version. cSpeilberger et al., 1983. fBeck et al., 1988.

35
Table 6. Frequencies Distribution of Scores on the Psychological Measures (N=105)
Psychological Measure n %
FPI Total
<97 (Low)
9
8.6
97-167 (Average)
79
75.2
168-204 (Moderately High)
13
12.4
>204 (Very High)
4
3.8
State INF Total
0-3.20
1
1.0
3.21-14.20
0
0.0
14.21-25.20
13
12.4
25.21-36.20
22
21.0
36.21-47.20
32
30.5
47.21-58.20
21
20.0
58.21-69.20
13
12.4
69.21-80.20
3
2.9
BDI Total
0-9 (minimal)
64
61.0
10-16 (mild)
23
21.9
17-29 (moderate)
17
16.2
30-63 (severe)
1
.9
LOT Total (N=104)
0.-5.80
0
0.0
5.81-11.00
8
7.7
11.01-16.20
20
19.2
16.21-21.40
33
31.7
21.41-26.60
26
25.0
26.60-31.80
16
15.4
31.81-37.00
1
1.0
MCSD Total
0-2.3
0
0.0
2.3-6.70
5
4.8
6.71-11.10
10
9.5
11.11-15.50
26
24.8
15.51-19.90
22
20.1
19.91-24.30
31
29.5
24.31-28.70
8
7.6
28-71-33.10
3
2.8
(Table 6 continues)

36
Table 6. continued
Psychological Measure
n
%
Patient Expectation of
Success (N= 96)
0-25%
13
13.5
26-49%
9
9.4
50-75%
36
37.5
76-99%
16
16.7
>99%
22
22.9
Physician Expectation of
Success (N= 104)
0-25%
88
84.6
26-49%
14
13.5
50-75%
1
1.0
76-99%
1
1.0
>99%
0
0.0
Difference between Patient
and Physician Expectations of
Success (N=95)
<0%
4
4.2
0-19%
13
13.7
20-29%
5
5.3
30-39%
10
10.5
40-49%
12
12.6
50-59%
8
8.4
60-69%
13
13.7
70-79%
7
7.4
80-89%
7
7.4
90-97%
16
16.8
Currently in Psychological
Treatment (N=98)
No
95
96.9
Yes
3
3.1
Note. FPI= Fertility Problem Inventory; State INF = State Anxiety Regarding Infertility;
BDI = Beck Depression Inventory; LOT = Life Orientation Test; MCSD = Marlowe-
Crowne Social Desirability Scale; State INF = State Anxiety Regarding Infertility; BDI =
Beck Depression Inventory.

Table 7. Correlations Among Observed Variables
1
2
3
4
5
6 7
8 9
l.FPI Total
2. LOT Total
-.49**
3. MCSD Total
-.23*
.21*
4. State INF Total
.47**
-.42**
-.26**
5. BDI Total
.54**
-.60**
-.40**
.50**
6. TOTTRY
.29**
-.06
-.06
.05
.20*
7. NONART
.15
-.13
-.11
.01
.17
.19
8. ART
-.02
.13
.07
-.22*
-.17
.04 -.18
9. DIFF
-.18
.37**
.16
-.18
-.40**
-.29** -.07
-.27** —-
Note. * p< .05. ** p<.01. FPI= Fertility Problem Inventory; LOT = Life Orientation Test; MCSD = Marlowe-Crowne Social
Desirability Scale; State INF = State Anxiety Regarding Infertility; BDI = Beck Depression Inventory; TOTTRY = Total Time Trying
to Conceive; NONART = Total # of Non-ART Treatments; ART = Total # of ART Treatments; DIFF = Patient-Physician Difference
for Expectation of Treatment Success.

38
Table 8. Items Placed on Each Indicator: LOT, MCSD, FPI, State INF & BDI
LOT
LOT Indicator 1
4
5
11
8
LOT Indicator 2
12
9
3
1
MCSD
MCSD Indicator
MCSD Indicator
MCSD Indicator
1
2
3
30
7
14
21
8
4
5
15
19
31
28
6
18
12
11
3
33
27
13
32
17
26
24
20
10
16
23
1
25
29
2
9
22
FPI
FPI Indicator 1
FPI Indicator 2
FPI Indicator 3
39
27
35
43
20
19
44
14
10
40
30
9
7
8
12
45
13
17
3
22
31
11
38
36
18
37
6
1
21
24
4
42
16
46
33
32
15
23
2
5
26
41
28
34
29
25
(Table 8 continues!

39
(Table 8 continued)
State INF
State INF
State INF
State INF
Indicator 1
Indicator 2
Indicator 3
15
2
10
1
5
16
20
8
19
11
17
18
7
4
6
12
3
9
13
14
BDI
BDI Indicator 1
BDI Indicator 2
BDI Indicator 3
3
7
1
5
15
8
13
17
2
12
4
10
20
6
9
14
11
16
18
21
19
Note. LOT = Life Orientation Test; MCSD = Marlowe-Crowne Social Desirability Scale;
FPI= Fertility Problem Inventory; State INF = State Anxiety Regarding Infertility; BDI =
Beck Depression Inventory.

Table 9. Correlations Among Observed Variables
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17 18
l.FPI 1
—
2. FPI 2
.80**
—
3. FPI 3
.82"
.81"
—
4. LOT 1
-.47"
-.43**
-.41**
....
5. LOT 2
-.41"
-.45**
-.43**
.78**
....
6. MCSD 1
-.16
-.19
-.22*
.21*
.11
—
7. MCSD 2
-.11
-.20*
-.22*
.21*
.21*
.60"
—
8. MCSD 3
-.14
-.19
-.20*
.18
.13
.65**
-.63**
....
9. STATEINF1
.46"
.38"
.41**
-.45**
-.35**
-.29**
-.26"
-26**
—
10. STATEINF2
.42"
.38**
.40"
-.41**
-21**
-21**
-.15
-.16
.88**
—
11. STATEINF3
.51"
.46**
.44**
-.46**
-.33**
-.17
-.15
-.11
.88**
.88**
....
12. BDI 1
.39**
.45**
.41**
-.48**
-.50**
-.35**
-.30**
-.29**
.49**
.43**
.43**
—
O
13. BDI 2
.47"
.543**
.48**
-.51**
-.54**
-.25*
-.23*
-.23*
.42**
.37**
.40**
.81**
—
14. BDI 3
.48**
.50**
.47**
-.55**
-.54**
-.42**
-.38**
-.49**
.52**
.46**
.50**
.74**
.74**
....
15. TOTTRY
.23*
.30**
.28**
-.04
-.08
-.08
-.03
-.03
.06
.05
.02
.24*
.22*
.07
—
16. NONART
.15
.15
.13
-.14
-.11
-.03
-.08
-.19
.05
-.02
.00
.13
.20*
.14
.19
—
17. ART
-.03
.01
-.05
.09
.16
-.02
.14
.09
-.23*
-.22*
-.18
-.14
-.14
-.18
.04
-.18
—
18. DIFF
-.16
-.18
-.14
.33**
.37**
.09
.10
.23*
-.20
-.16
-.15
-.36**
-.36**
-.39**
-.29**
-.07
-.27**
Note. * p< .05. ** p<.01. FPI= Fertility Problem Inventory; LOT = Life Orientation Test; MCSD = Marlowe-Crowne Social
Desirability Scale; State INF = State Anxiety Regarding Infertility; BDI = Beck Depression Inventory; TOTTRY = Total Time Trying
to Conceive; NONART = Total # of Non-ART Treatments; ART = Total # of ART Treatments; DIFF = Patient-Physician Difference
for Expectation of Treatment Success.

41
Table 10. Standardized Factor Loadings of Indicators for Latent Variables
Observed
Latent Variables
Variables
FPI
LOT
MCSD
STATE
INF
BDI
FPI
FPI1
.897
FPI 2
.894
FPI 3
LOT3
.905
LOT 1
.897
LOT 2
MCSD
.864
MCSD 1
.781
MCSD 2
.765
MCSD 3
State INF
.832
STATEINF 1
.939
STATEINF 2
.931
STATEINF 3
BDI
.943
BDI 1
.883
BDI 2
.899
BDI 3
.848
Note. FPI= Fertility Problem Inventory; LOT = Life Orientation Test; MCSD =
Marlowe-Crowne Social Desirability Scale; State INF = State Anxiety Regarding
Infertility; BDI = Beck Depression Inventory.a LOT had only two subscales created.

Table 11. Correlations Among Latent Variables
1
2
3
4
5
6 7 8 9
1. Latent FPI
2. Latent LOT
3. Latent MCSD
4. Latent State INF
5. Latent BDI
-.55**
-.25*
.51**
.59**
.24*
_ 44**
-.67**
-.26*
-.45**
.54**
6. TOTTRY
.30**
-.07
-.06
.05
.21*
7. NONART
.16
-.14
-.14
.01
.19
.19
8. ART
-.03
.14
.09
-.22*
-.18
.04 -.18
9. DIFF
-.14
.38
.20
-.16
-.42**
-.28 -.08 -.26*
Note. * p< .05. ** p<.01. FPI= Fertility Problem Inventory; LOT = Life Orientation Test; MCSD = Marlowe-Crowne Social
Desirability Scale; State INF = State Anxiety Regarding Infertility; BDI = Beck Depression Inventory; TOTTRY = Total Time Trying
to Conceive; NONART = Total # of Non-ART Treatments; ART = Total # of ART Treatments; DIFF = Patient-Physician Difference
for Expectation of Treatment Success.
«>

Figure 1. Structural model of the impact of social desirability, optimism, duration of time trying to conceive, and number and
type of medical treatments on infertility-specific stress, state anxiety, depression, and treatment success expectations
Note. All paths significant at p_< .05. MCSD = Marlowe-Crowne Social Desirability Scale; LOT = Life Orientation
Test; TOTTRY = Total Time Trying to Conceive; ART = Total # of ART Treatments; NON ART = Total # of Non-
ART Treatments; FPI= Fertility Problem Inventory; State INF = State Anxiety Regarding Infertility; BDI = Beck
Depression Inventory; DIFF = Patient-Physician Difference for Expectation of Treatment Success.
U>

LOT
4^
4^
-.26

DISCUSSION
The current study sought to investigate the predictors of negative affect in
infertility patients. In general, the sample did not report high levels of negative affect,
illustrated by their mean scores on the psychological measures. In terms of sample
characteristics, these women have been trying to get pregnant for about three years and
seeking infertility treatment for about two years. These women, on average, have
experienced two ovulation induction cycles and one superovulation cycle in the past.
These findings suggest that these women have not yet proceeded to more advanced
treatments, such as IVF, and thus are in the earlier stages of medical treatment. In
general they had higher expectations for treatment success in comparison to their
physicians.
1) The findings of this study support the first hypothesis that infertility-
specific stress is influenced by optimism and duration of time trying to conceive.
However, there was no evidence to support the hypothesis that social desirability as well
as the number and type of medical treatments affected infertility-specific stress. It
appears that infertility-stress ratings were higher for those individuals who had lower
optimism ratings, and longer time trying to conceive. The finding that distress increases
over time is consistent with existing research (Berg & Wilson, 1991; Domar, Clapp,
Slawsby, Kessel, Orav, & Freizinger, 2000). Perhaps it can be theorized that a history of
medical treatment plays a role in other aspects of negative affect and may not be reported
as infertility-specific stress.
45

46
2) As stated in the second hypothesis, state anxiety regarding infertility
appears to be influenced by the number of ART treatments and infertility-related stress.
However, there was no evidence to support the hypothesis that optimism, social
desirability, duration of time trying to conceive, and number of Non-ART treatments
affected state anxiety regarding infertility. Women with fewer treatment cycles of ART
and higher infertility-specific stress reported higher state anxiety symptoms. An
explanation for these findings may be that the women become less anxious as a result of
their familiarity with the medical staff and treatment as well as their belief that the
treatment is going to be successful for them. As hypothesized, infertility-related stress
appears to affect the patients’ ratings of anxiety despite their optimism. However,
infertility-related stress is not a complete mediator for optimism on state anxiety
regarding infertility. Social desirability appears not to be mediated by infertility-specific
stress not have an effect on state anxiety. The findings suggest that number of ART
treatments and infertility-specific stress each have a direct effect on state anxiety.
3) As expected in the third hypothesis, depression seems to be influenced
by optimism, social desirability, and infertility-specific stress. However, depression is not
influenced directly by duration of time trying to conceive or number and types of
treatment. Women with lower ratings of optimism, lower ratings of social desirability,
and higher infertility-related stress reported higher levels of depression. Perhaps those
women who are reporting fewer depressive symptoms are more sensitive to the social
desirability bias. Alternatively, optimism may have a buffer effect on negative affect. As
hypothesized, infertility-related stress appears to affect the patients’ ratings of depression
despite their optimism and their social desirability response bias; however, infertility-

47
related stress is not a complete mediator for such variables on depression. The findings
suggest that optimism and social desirability each have a direct effect on depression.
4) Lastly, patient-physician difference scores were influenced by
optimism, duration of time trying to conceive, number of ART treatments, infertility-
specific stress, and depression. It was hypothesized that depression would have the
greatest influence on the difference scores, yet it seems that infertility-specific stress has
the same magnitude of influence as depression. Women with higher ratings of optimism,
shorter time trying to conceive, fewer ART treatments, higher infertility-related stress,
and lower depression scores had higher difference scores, indicating a greater
discrepancy between patient and physician. The findings suggest that these women, who
are in the early stages of infertility treatment, are still optimistic and hopeful that the
treatment will provide the results that they want. These overestimations may, in some
way, help these women cope with treatment but the impact of overestimation on
treatment outcome is not known. The finding regarding depression and estimations
suggest that those individuals who are more depressed appear to have less optimistic and
unrealistic, expectations of treatment success compared to their physicians, i.e., they
actually appear more realistic. However, it is unclear as to why higher infertility-related
stress is associated with higher difference scores. Perhaps these women are so stressed
that they are in denial and believe that the treatment will be successful.
In summary, the first objective was to examine optimism, social desirability,
infertility-specific anxiety, and depression in a sample of female infertility patients
currently in medical treatment. The sample appears to be generally a psychologically
normal population in terms of negative affect, illustrated by mean scores within one

48
standard deviation of published norms for social desirability, optimism, infertility-related
stress, state anxiety, and depression. These findings support previous research that has
suggested that there are few divergences from normal levels among infertility patients
(Dunkel-Schetter & Lobel, 1991). To date, there are only two reviews of studies
examining the links between psychological distress and infertility, with each presenting
slightly different findings (Dunkel-Schetter & Lobel, 1991; Wright et al., 1989). Dunkel-
Schetter & Lobel (1991) used more rigorous criteria for the inclusion of studies as well as
compared studies according to methodology for their review of the literature as compared
to the review by Wright et al. (1989). Perhaps another interpretation of the findings may
be low accuracy in the self-reporting of depression due to patients’ social desirability
response bias. Although 44% of the sample indicated at or below average levels of social
desirability, 33% of the patients expressed greater social desirability bias, suggested by
scores at least 2 standard deviations above the normative mean. An explanation for this
underreporting, as speculated by other studies, may be the patients’ fear of the being
dropped from medical treatment or receiving disapproval from medical staff (Mazure et
al., 1988; Mazure et al., 1984).
Given that optimism has been linked to more effective coping with health
stressors and less negative mood, optimism was included in this study to examine its
potential psychological benefits. It appears that optimism had both direct and indirect
effects on the measured indicators of negative affect. The overall findings suggest that a
dispositionally optimistic orientation can be a buffer of negative affect. The sample’s
optimism is also highlighted in their ratings of treatment success. On average, the
patients indicated that they had a 65% chance of success during this treatment cycle.

49
These research findings support other studies that have found that the weight of evidence
is that patients overestimate their chance of pregnancy (Callan & Hennessey, 1986;
Daniels, 1989; Johnston, Shaw & Bird, 1987). However, these previous studies have
examined expectations in various infertility populations including IVF and male factor
patients. There seems to be no significant correlation between state anxiety and
estimations of success, findings which supports another previous study (Johnston et al.,
1987). However, there does appears to be a significant correlation between expectations
and depression as well as expectations and optimism. These findings support earlier
research (Taylor & Brown, 1988) that suggests that mood may affect expectations with
depressed individuals having realistic expectations while non-depressed individuals have
optimistic expectations about the future.
Strengths
This study makes a number of contributions to the literature. According to
Dunkel-Schetter & Lobel (1991), there are 11 studies that have examined the
psychological reactions to infertility using standard measures with no control groups. As
they have noted, the studies vary in terms of study characteristics and quality. The
current study is the largest study examining only infertile women; only two other studies
have larger samples and these examined couples (Hearn, Yuzpe, Brown, & Casper,
1987; Freeman, Boxer, Rickels, Tureck, & Mastroianni, 1985). Hearn and colleagues
(1987) found normative levels of anxiety and depression in 300 couples awaiting IVF
treatment. Freeman and colleagues (1985) found scores for anxiety and MMPI in the
normal range for 200 couples entering IVF treatment. Garcia, Freeman, Rickels, Wu,
Scholl, Galle, & Boxer (1985) found non-clinically significant levels of anxiety and
)

50
depression in 49 infertile women in a clinical drug trial. According to Dunkel-Schetter &
Lobel (1991), the smaller and less scientifically rigorous studies that used less established
measures found variations from the norms on standard measures. The current study
supports the previous research in that the sample as a whole is not above clinical
significance for the negative affect measures; however, many individuals are indicating
some degree of distress.
Past research has typically used standard measures of anxiety and depression to
measure negative affect. This study combined a standard measure of depression with a
specific infertility stress measure as well as a standard measure of anxiety modified to
examine state-specific anxiety. This approach appears to utilize the strengths of the
standard measures, in terms of their validity and reliability, while using measures that are
sensitive to the stress associated with infertility. The results of this study are convergent
with previous research in that infertility is perceived as psychologically stressful.
Previous research has suggested that the social desirability bias has played a role
in the self-report of negative affect symptomatology. Again, this study has attempted to
gain some knowledge as to how the desire to present oneself in a positive light may
impact their symptoms. The current study has demonstrated that social desirability does
have an impact of self-reported severity level of symptoms of depression.
A number of previous research studies have sampled infertility patients that are
either awaiting or involved in IVF treatment (Dunkel-Schetter & Lobel, 1991). The
current study did include a subsample of IVF patients (19%); however, the majority of
the respondents were receiving non-ART treatments, suggesting more generalizability of

51
the findings since the majority of infertility patients receive the non-ART treatments and
a smaller percentage reach IVF.
Finally, the statistical analyses used can be seen as a relative strength. The
structural equation modeling has been useful in understanding the simultaneous effects of
optimism, social desirability, length of time trying to conceive, number of non-ART and
ART treatments on infertility-specific stress, depression, state anxiety, and patient-
physician difference scores of treatment success.
Limitations
Similarly, this study had a number of methodological limitations. Firstly, although
one of the larger studies to date, the sample is small which limits statistical power.
Secondly, respondents were self-selecting and not randomly selected which can impact
the generalizability of the findings. Additionally, this sample may not be representative
of the entire infertility population, given that the study did not access non-users of
infertility services, public clinics, or ethnic minority groups. Although socioeconomic
status was not specifically collected as a demographic variable, it may also play a role in
generalizability. The majority of previous studies (including this one) have sampled
Caucasian, middle to high socioeconomic status patients and have largely failed to
capture minority populations and lower socioeconomic status patients in their samples.
Another shortcoming of the current study is the failure to control for medical
diagnosis of infertility which could impact the generalizability of the results. Also, no
open-ended questions or clinical interviews were used as measures. These measures may
have facilitated further understanding through qualitative data.

52
Of note, the physicians were instructed to give their estimation of treatment
success in this treatment cycle. The participants were instructed to give their estimations
right now. Patients may have misinterpreted the instuctions and given their estimations
for their lifetime.
Clinical Implications
The results of this study provide reproductive specialists with a number of
implications for clinical practice. First, physicians could discuss the common reactions to
the diagnosis and treatment beforehand, perhaps allowing the patients to feel more
comfortable with endorsing psychological difficulties later. Despite most of the sample
being in the normal range for depression, 17% of the sample indicated clinically
significant levels of depression, yet only three individuals were in psychological
treatment, suggesting a significant proportion of depressed patients having been
undetected. Although, the sample was generally psychologically healthy by their mean
scores on psychological measures, they may still continue to be distressed and have
difficulties coping with their infertility.
The findings of this study also suggest that a social desirability response bias
especially affects self-report of depressive symptoms. Perhaps clinicians can ask patients
specific questions about their mood and reactions to the diagnosis and treatment. The
impact of social desirability might be even stronger in the real world clinical setting.
This study examined social desirability under anonymous conditions allowing patients to,
hopefully, report symptoms honestly.
In addition, the findings of this study highlight the discrepancy between patients’
beliefs of success and physicians’ reports. These discrepancies may highlight a

53
breakdown in patient-provider communication or more emotion-focused coping (i.e.,
denial and avoidance) on the part of the patient. However, it has been suggested that
optimism may buffer the infertility stress and be related to better mental health and
adjustment to the stress. As mentioned earlier, patients’ overestimation may be a result of
their lack of time in treatment and optimistic viewpoint. Perhaps, the discrepancies may
be related to better mental health in the short-term but it is unclear about the long-term
benefits of the overestimations.
For mental health professionals, given that optimism and social desirability seem
to be significant influences on the levels of affect self-report instruments, providers could
incorporate optimism and social desirability into assessment batteries. By having a
assessment battery, mental health professionals can provide feedback to the reproductive
specialists and patients as to the warning signs of increased or undetected distress.
Future Directions
Future studies should sample a more heterogeneous population of patients in
order to be able to generalize findings. For example, studies should include a range of
individuals in infertility treatment, from diagnostic work-up through various treatments to
individuals who are no longer in treatment. Further, samples should be taken from clinics
not solely based in university-settings. We need more knowledge about non-users of
specialty based infertility services, as well as lower socioeconomic status and minority
populations. Given that infertility is an unfolding and evolving process and treatment,
future research should utilize a longitudinal design. This design will allow researchers to
understand further the warning signs of maladaptive coping to infertility. As mentioned
earlier, there are several longitudinal factors that may be relevant, including long-term

54
adaptation and coping with infertility. Studies with comparison groups can also provide
insight into the unique stressors of infertility. A comparison group may allow researchers
to tease apart the stress of infertility treatment from other life stressors. Another
methodological suggestion is to include infertile men. As previous research has
suggested, men tend to cope differently with health stressors. By gaining knowledge
about how men differ from women, clinical practice may be affected.
Additionally, the findings suggest that standard measures should be tailored to a
greater degree to gain knowledge about the specific distress associated with infertility.
To complement the standard measures, observational measures and clinical interviews
may provide useful anecdotal information from patients. Lastly, physiological measures
could be included in order to gain more objective information about infertility-specific
stress. Specifically, hormones levels could be gathered in order to provide objective
ratings and allow researchers to compare self-report subjective ratings with the
physiological objective measures.
Research examining the predictors of negative affect in female infertility patients
is still evolving. This investigation is the first study to examine the effects
simultaneously of optimism, social desirability, medical treatment variables on infertility-
specific stress, state anxiety, depression, and treatment success expectations.

APPENDIX A
INCLUSION CRITERIA AND RECRUITMENT INSTRUCTIONS
The study of the psychological stress of trying to get pregnant: Recruitment Instructions
Inclusion criteria:
Formally diagnosed female patient (given by Park Avenue Women’s Clinic
Physicians)
Established medical treatment plan
Present for an office visit
At least 21 years of age
Understands spoken and written English
Instructions:
If patients meet all of the above-mentioned criteria, please ask them if they would
like to participate before they see the physicians:
“Would you be willing to participate in a research study examining the stresses of trying
to get pregnant? If you choose to take part in the study, you will be asked to sign a
consent form and to complete a study packet containing psychological questionnaires.
The questionnaires ask about your feelings and your experiences with trying to get
pregnant. The questionnaire packet should take approximately 45 minutes to complete.
The questionnaire packet is assigned an ID number and your responses will not be given
to your physician. Your participation is voluntary and will not affect your medical
treatment if you refuse. “
55

APPENDIX B
TREATMENT HISTORY QUESTIONNAIRE
ID#_
Date
Date of Birth: / / Partner’s Date of Birth: / /
Duration of relationship with partner? years months
How long have you been trying to get pregnant? years months
How long have you been seeking medical treatment for problems in reproduction?
years months
What kinds of treatment have you undergone in the past (prior to coming to Park Avenue
Women’s Center (PAWC) and while at PAWC, prior to today’s visit)?
Treatment
#
cycles
#
pregnancies
achieved
#
live
births
Multiple
Pregnancies
(Yes/No)
Donor insemination
Ovulation induction for failure to
ovulate
Superovulation with IUI
IVF (including GIFT & ZIFT)
IVF (with donor eggs)
Infertility surgery
Other:
What treatment are you currently receiving?
Donor insemination
Ovulation induction for failure to ovulate
Superovulation with IUI
IVF (including GIFT & ZIFT)
IVF (with donor eggs)
Infertility surgery
Other:
56

57
Are you currently in psychological treatment? Yes No
IF YES: What treatment are you receiving?
individual therapy
marital therapy
group therapy
medication
Please indicate on a scale of 0-100% chance of becoming pregnant, how likely you think
it is that you and your partner will achieve pregnancy.
Thank you for your time and participation.

APPENDIX C
FPI
ID #:
The following statements express different opinions about a fertility problem. Please circle the number next to the statement to show
how much you agree or disagree with it. If you have a child, please answer the way you feel right now, after having a child. Please
mark every item.
Strongly
Disagree
Moderately
Disagree
Slightly
Disagree
Slightly
Moderately
Agree
Strongly
Agree
1. Couples without a child are just as happy as
those with children.
1
2
3
4
5
6
2. Pregnancy and childbirth are the two most
important events in a couple’s relationship.
1
2
3
4
5
6
3. I find I’ve lost my enjoyment of sex because
of the fertility problem.
1
2
3
4
5
6
4. I feel just as attractive to my partner as
before.
1
2
3
4
5
6
5. For me, being a parent is a more important
goal than having a satisfying career.
1
2
3
4
5
6
6. My marriage needs a child (or another child).
1
2
3
4
5
6

Strongly
Disagree
Moderately
Disagree
Slightly
Disagree
Slightly
Agree
Moderately
Strongly
7. I don’t feel any different from other members
1
2
3
4
5
6
of my sex.
8. It’s hard to feel like a true adult until you
2
3
4
5
6
have a child.
9. It doesn’t bother me when I’m asked
1
2
3
4
5
6
questions about children.
10. A future without a child (or another child)
would frighten me.
v;,: -,1- f
2
3
4
5
6
11.1 can’t show my partner how I feel because it
1
2
3
4
5
6
will make him/her feel upset.
12. Family don’t seem to treat us any differently.
1
2
3
4
5
6
13.1 feel like I’ve failed at sex.
1
2
3
4
5
6
14. The holidays are especially difficult for me.
L
2
3
4
5
6
15.1 could see a number of advantages if we
1
2
3
4
5
6
didn’t have a child (or another child).

Strongly
Disagree
Moderately
Disagree
Slightly
Disagree
Slightly
Agree
Moderately
Agree
Strongly
Agree
16. My partner doesn’t seem understand the
way the fertility problem affects me.
1
2
3
4
5
6
17. During sex, all I can think about is wanting
a child (or another child).
1
2
3
4
5
6
18. My partner and I work well together
handling questions about our infertility.
1
2
3
4
5
6
19.1 feel empty because of our fertility
problem.
1
2
3
4
5
6
20.1 could visualize a happy life together,
without a child (or another child).
1
2
3
4
5
6
21. It bothers me that my partner reacts
differently to the problem.
1
2
3
4
5
6
22. Having sex is difficult because I don’t want
another disappointment.
1
2
3
5
6
23. Having a child (or another child) is not the
major focus of my life.
1
2
3
4
5
6
24. My partner is quite disappointed with me.
: iSiiil
2
3
4
5
6

25. At times, I seriously wonder if I want a
child (or another child).
Strongly
Disagree
1
Moderately
Disagree
2
Slightly
Disagree
3
Slightly
Agree
4
Moderately
Agree
5
Strongly
Agree
6
26. My partner and I could talk more openly
with each other about our fertility problem.
1
2
3
4
5
6
27. Family get-togethers are especially difficult
for me.
1
2
3
4
5
6
28. Not having a child (or another child) would
allow me time to do other satisfying things.
1
2
3
4
5
6
29.1 have often felt that I was bom to be a
parent.
1
2
3
4
5
6
30.1 can’t help comparing myself with friends
who have children.
1
2
3
4
5
6
31. Having a child (or another child) is not
1
2
3
4
5
6
necessary for my happiness.
32. If we miss a critical day to have sex, I can
1
2
3
4
5
6
feel quite angry.

33.1 couldn’t imagine us ever separating
because of this.
Strongly
Disagree
1
Moderately
Disagree
2
Slightly
Disagree
3
Slightly
Agree
4
Moderately
Agree
5
Strongly
Agree
6
34. As long as I can remember, I’ve wanted to
1
2
3
4
5
6
be a parent.
35.1 still have lots in common with friends who
1
2
3
4
5
6
have children.
36. When we try to talk about our fertility
problem, it seems to lead to an argument.
1
2
3
4
5
6
37. Sometimes I feel so much pressure, that
1
2
3
4
5
6
having sex becomes difficult.
38. We could have a long, happy relationship
without a child (or another child).
1
2
3
4
5
6
39.1 find it hard to spend time with friends who
1
2
3
4
5
6
have young children.
40. When I see families with children I feel left
out.
||.' fjjg
2
3
4
5
6

41. There is a certain freedom without children
that appeals to me.
Strongly
Disagree
1
Moderately
Disagree
2
Slightly
Disagree
3
Slightly
Agree
4
Moderately
Agree
5
Strongly
Agree
6
42.1 will do just about anything to have a child
(or another child).
1
2
3
4
5
6
43.1 feel like friends or family are leaving us
behind.
1
2
3
4
5
6
44. It doesn’t bother me when others talk about
their children.
1
2
3
4
5
6
45. Because of infertility, I worry that my
partner and I are drifting apart.
1
2
3
4
5
6
46. When we talk about our fertility problem,
my partner seems comforted by my
comments.
1
2
3
4
5
6
Reproduced with permission of the author.

APPENDIX D
LOT
Please indicate your level of agreement with each of the statements below by circling your
response.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
1. In uncertain times, I
usually expect the best.
0
1
2
3
4
2. It’s easy for me to relax.
0
1
2
3
4
3. If something can go wrong
for me, it will.
0
1
2
3
4
4.1 always look on the bright
side of things.
0
1
2
3
4
5. Pm always optimistic about
my future.
0
1
2
3
4
6.1 enjoy my friends a lot.
0
1
2
3
4
7. It’s important for me to keep
busy.
0
1
2
3
4
8.1 hardly ever expect things to
go my way.
0
1
2
3
4
9. Things never work out the
way I want them to.
0
1
2
3
4
10.1 don’t get upset too easily.
0
1
2
3
4
11. I’m a believer in the idea
that “every cloud
has a silver lining”.
0
1
2
3
4
12.1 rarely count on good
things happening to me.
0
1
2
3
4
64

APPENDIX E
MCSD
Listed below are a number of statements concerning personal attitudes and traits. Read
each item and decide whether the statement is true or false as it pertains to you.
1. Before voting I thoroughly investigate the qualifications of all the
candidates.
True
False
2. I never hesitate to go out of my way to help someone in trouble.
True
False
3. It is sometimes hard for me to go on with my work if I am not encouraged.
True
False
4. I have never intensely disliked anyone.
True
False
5. On occasion I have had doubts about my ability to succeed in life.
True
False
6. I sometimes feel resentful when I don’t get my way.
True
False
7. Iam always careful about my manner of dress.
True
False
8. My table manners at home are as good as when I eat out in a restaurant.
True
False
9. If I could get into a movie without paying and be sure I was not seen, I
would probably do it.
True
False
10. On a few occasions, I have given up doing something because I thought too
True
False
little of my ability.
11. I like to gossip at times.
True
False
12. There have been times when I felt like rebelling against people in authority
True
False
even though I knew they were right.
13. No matter who I’m talking to, I’m always a good listener.
True
False
14. I can remember “playing sick” to get out of something.
True
False
15. There have been occasions when I took advantage of someone.
True
False
16. I’m always willing to admit it when I make a mistake.
True
False
17.1 always try to practice what I preach.
True
False
65

66
18. I don’t find it particularly difficult to get along with loud-mouthed, True False
obnoxious people.
19. I sometimes try to get even, rather than forgive and forget.
True
False
20. When I don’t know something I don’t at all mind admitting it.
True
False
21. I am always courteous, even to people who are disagreeable.
True
False
22. At times I have really insisted on having things my own way.
True
False
23. There have been occasions when I felt like smashing things.
True
False
24. I would never think of letting someone else be punished for my
wrongdoings.
True
False
25. I never resent being asked to return a favor.
True
False
26. I have never been irked when people expressed ideas very different from my
own.
True
False
27. I never make a long trip without checking the safety of my car.
True
False
28. There have been times when I was quite jealous of the good fortune of
others.
True
False
29. I have almost never felt the urge to tell someone off.
True
False
30. Iam sometimes irritated by people who ask favors of me.
True
False
31.1 have never felt that I was punished without cause.
True
False
32. I sometimes think when people have a misfortune they only got what they
deserved.
True
False
33. I have never deliberately said something that hurt someone’s feelings.
True
False

APPENDIX F
STATE INF
Directions: A number of statements which people have used to describe
themselves are given below. Read each statement and then circle the appropriate value to
the right of the statement to indicate how you feel right now, that is, at this moment
regarding your difficulty in trying to get pregnant. There are no right or wrong answers.
Do not spend too much time on any one statement but give the answer which seems to
describe your present feelings best.
Due to copyright, only five actual test items from the STAI may be included.
Reproduced by permission of the publisher, Mind Garden.
67

APPENDIX G
BDI
Due to copyright, only two actual test items from the BDI may be included.
Reproduced by permission of the publisher, The Psychological Corporation.
68

APPENDIX H
PHYSICIAN QUESTIONNAIRE
Patient ID #
Date:
Questionnaire for Physicians
What cause of infertility was diagnosed for this patient?
Female factor
Male factor
Both female and male factor
Unexplained
What did you advise this patient on the likelihood of achieving pregnancy during
this treatment cycle (month) on a scale of 0-100% chance of becoming pregnant?
%
Thank you for your time and participation.

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BIOGRAPHICAL SKETCH
Caren B. Jordan was bom in Paterson, New Jersey, in 1971 to Arthur and K.
Christa Jordan. Caren was raised in Newfoundland, New Jersey, and graduated from
Neumann Preparatory High School in June 1989. Caren received her Bachelor of
Sciences degree in biology and Bachelor of Arts degree in psychology, from Boston
College in Chestnut Hill, Massachusetts in May 1993. Caren received her Master of Arts
degree in psychology, from New York University in New York, New York, in May 1996.
She was later accepted to the College of Health Professions, Department of Clinical and
Health Psychology, at the University of Florida to pursue a Ph.D. degree in clinical
psychology. Caren will be completing her clinical internship training at the University of
Chicago Medical Center in partial fulfillment of the requirements for the Doctor of
Philosophy degree. Caren’s future career goals are to engage in clinical and research
activities within an academic medical setting, focused in the health promotion of women.
77

I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
U
Cynthi^p. Belar, Chair
Professor of Clinical and Heath
Psychology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
is Algina
fessor of Educator
Psychology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
SLaA ICC tkMkkbl r4l(uü>r¿
Suzanne B J Johnson
Professor of Clinical and Heath
Psychology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy
>amuel F. Sears
Associate Professor of Clinical and Heath
Psychology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
'JtLu
R. Stanford Williams
Professor of Obstetrics and Gynecology

This dissertation was submitted to the Graduate Faculty of the College of Health
Professions and to the Graduate School and was accepted as partial fulfillment of the
requirements for the degree of Doctor of Philosophy.
August 2002
Dean, College of Health Professions
Dean, Graduate School

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