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Human Reproduction, Vol.24, No.2 pp. 378–385, 2009 Advanced Access publication on December 1, 2008 doi:10.1093/humrep/den401

ORIGINAL ARTICLE Psychology

Psychosocial characteristics of women and men attending infertility counselling† T. Wischmann 1,3, H. Scherg 1, Th. Strowitzki 2, and R. Verres 1 1 Centre for Psychosocial Medicine, Institute of Medical Psychology, University of Heidelberg, Bergheimer Strasse 20, D-69115 Heidelberg, Germany 2Department of Gynaecological Endocrinology and Reproductive Medicine, Women’s Hospital, University of Heidelberg, Heidelberg, Germany

Correspondence address. E-mail: tewes.wischmann@med.uni-heidelberg.de

table of contents

........................................................................................................................... † † † † † † †

Introduction Materials and Methods Results Discussion Acknowledgements Funding References

background: Little is known about the psychosocial characteristics of infertile couples seeking psychological help. This study describes couples attending infertility counselling. methods: Questionnaires pertaining to socio-demographic factors, motives for wanting a child, lay aetiology of their infertility, dimensions of life and partnership satisfaction, and a complaints list were completed by 974 women and 906 men. Of those who indicated an openness to counselling, almost half actually attended infertility counselling, and two groups, ‘no counselling’ (358 women and 292 male partners) and ‘taking up counselling’ (275 women and 243 male partners), were therefore compared. results: More couples with stressful life events were found in the counselling group. For women taking up counselling, psychological distress, in the form of suffering from childlessness and depression as well as subjective excessive demand (as a potential cause for infertility), was higher in comparison to women not counselled. The higher distress for men in the counselling group was indicated by relative dissatisfaction with partnership and sexuality and by accentuating the women’s depression.

conclusions: Infertile couples seeking psychological help are characterized by high levels of psychological distress, primarily in women. The women’s distress seems to be more important for attending infertility counselling than that of the men. Key words: psychology / counselling and couple therapy / life satisfaction / infertility

Introduction In the majority of cases, involuntary childlessness has a strong impact on the emotional situation of infertile couples (Menning, 1980). Many women consider infertility to be the most serious emotional crisis of their life (Freeman et al., 1985). Reproductive medical treatment can involve major additional emotional stress (Boivin and Takefman,

1995), which often increases with the number of unsuccessful treatment trials (Beutel et al., 1999). For 15– 20% of these couples, the emotional distress is so serious that they need psychological counselling (Boivin et al., 1999). Several studies have indicated that women suffer more seriously from involuntary childlessness than their male partners (e.g. Daniluk, 1988; Berg and Wilson, 1991; Stanton and Dunkel-Schetter, 1991;

†Presented in part at the 22nd Annual Meeting of the European Society of Human Reproduction and Embryology, Prague, Czech Republic, 18 –21 June 2006.

& The Author 2008. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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Characteristics of infertility counselling attendees

counselling in their study showed higher scores for depression and anxiety (as well as higher numbers of impaired sperm parameters) compared with 134 unselected infertility patients. Female partners were not investigated in this study. The aim of our cross-sectional study was to describe psychosocial characteristics of infertile women and men indicating openness towards psychological counselling and actually taking up psychological help in contrast to couples indicating openness towards counselling but not using this opportunity which was offered to all of them.

Materials and Methods Design of the study and sample size The study was carried out in two phases. In the first phase (from May 1994 to November 1996), all infertile couples (without pregnancy after at least 1 year of trying to get pregnant) contacting the Heidelberg University Women’s Hospital for the first time were asked to complete a set of questionnaires. All couples were routinely offered psychological counselling at the Institute of Medical Psychology. In the second phase (from December 1996 to July 1999), this offer was extended to include all infertile couples in the region seeking psychological help, regardless of the clinic or medical practice in which they were given medical treatment, and of diagnosis or the stage of medical treatment. The entire study consisted of 1039 women and 949 men. Questionnaires fully suitable for evaluation remained for 974 women and 906 men. Our counselling intervention followed a two-step approach. First, two counselling sessions were offered to discuss possible stress connected with infertility and, if necessary, to inform the participants about further psychological help available. Where indicated, and if the couple expressed the need for more psychological assistance, we offered a subsequent 10 h of couple therapy. The framework of the counselling and the couple therapy is described in detail in Wischmann et al. (2002) and in Stammer et al. (2004). The acceptance rate for counselling (34%) could be computed only in the first part of the study with the defined basic population of n ¼ 564 couples. With regard to all infertile patients contacting the University Women’s Hospital for the first time, we assume that at least 17% of these patients actually received our counselling offer because the percentage of returned questionnaires was 50%. Medical records were also available for 526 couples of this group only. A female factor only was diagnosed in 36% of these couples, and a male factor was diagnosed only in 16% of the couples. Medical findings had been established for both partners in 21% and 27% of the couples were diagnosed as idiopathically infertile (Wischmann et al., 2001). All couples in the study indicated their consent to participate. The attendance of counselling or couple therapy sessions was independent of medical treatment measures. It was voluntary and free of charge for all couples. All questionnaires had code numbers and were free of personal data of the couples (e.g. names or birthdays), so that the analysis could be done anonymously. The design of this study and the selection of these questionnaires were approved by the Ethics Committee of the Medical Faculty of Heidelberg University.

Measures Comprehensive reviews show that infertility can affect nearly all psychological aspects of a person’s life, such as self-esteem, partnership, life satisfaction, mood and social relations (Greil, 1997; Eugster and Vingerhoets, 1999; Henning and Strauß, 2002). In this study, a set of approved questionnaires pertaining to socio-demographic factors, motives for wanting

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Wright et al., 1991; Abbey et al., 1992; Wischmann et al., 2001) and that they are more receptive to psychological counselling than men (Baram et al., 1988; Daniluk, 1988; Wischmann et al., 2001; Wischmann, 2008) because they are more predisposed than men to adopting a coping strategy based on social support (Abbey et al., 1992; Stanton et al., 1992). However, there are only a small number of studies in which infertile couples attending psychosocial counselling have been compared with couples who do not make use of this offer. Shaw et al. (1988) studied 60 infertile couples, of whom 52% expressed the wish for extensive counselling. No psychological differences were found between women who expressed such a wish and those who did not. Men who asked for counselling showed more (trait and state) anxiety, more ‘hopefulness’ concerning the outcome of medical treatment, and they described their partnership as more harmonious than those who ‘refused’ an offer of group counselling. In a study by Paulson et al. (1988), 27 of 150 infertile women actively sought counselling during the investigation. However, this group showed no differences in the scores achieved in psychological tests compared with the remainder. Edelmann and Conolly (1987) retrospectively investigated some 600 women and men at an infertility clinic and described gender-specific predictors for the expression of a need for help. For males, the variables guilt, frustration, marital problems and lack of confidence were established for potential attendance of professional counselling sessions. For females, the variable isolation replaced the frustration felt by males. Further indications on the psychosocial characteristics of couples before infertility counselling arose from interventional studies in the framework of the German infertility research network. The study by Pook et al. (2000) investigated 86 couples with (idiopathic) andrological sterility interested in cognitive-behavioural therapy for stress reduction. While women showed slightly higher depression tendencies compared with the norm values of the questionnaires, men also displayed slightly higher anxiety and somatization. The authors pointed out, however, that these differences had no clinical significance and that the quality of partnership was rated as high. Only 17 of the couples in this study actually took up the couple therapy. In the study by Strauß et al. (2000), the 61 women and 51 men attending counselling showed lower scores for various areas of life satisfaction and more psychological and somatic complaints compared with a group of 89 women and 86 men not involved in the counselling study. However, statistical details were not provided. Ho¨lzle et al. (2002) indicated that infertile patients taking up couple counselling (n ¼ 74 women and men) were slightly less satisfied with sexuality, self-esteem and attractiveness and showed more depressive symptoms than a comparison group of 570 patients undergoing in vitro fertilization (IVF) treatment. In this study, data of women and men were not analysed separately. The findings on the psychosocial characteristics of infertile women and men before infertility counselling are inconsistent because of different psychological measurements and different samples (couples who are willing to attend counselling versus couples taking up or already in counselling or psychotherapy). So it still remains unclear what psychosocial characteristics couples attending counselling display compared with the couples who do not (Edelmann and Conolly, 1986; Golombok, 1992; Boivin, 1997). The first results on men actually taking up infertility counselling came from the study of Pook et al. (2001). The 94 male patients who participated in couple


380 a child, dimensions of life satisfaction and couple relationships, physical and psychological complaints, life events and a personality inventory was applied. As described in Wischmann et al. (2001), the selection of the questionnaires given below was the result of several consensus meetings of the members of the German infertility research network.

satisfaction with the different areas of life. The internal consistencies (Cronbach’s a) of the scales vary between 0.82 and 0.94. (vi) The German version (Franke, 1995) of the Symptom Check List 90 (SCL-90-R; Derogatis et al., 1976) encompasses 90 items assessed for severity on a five-point scale (0 ¼ not at all, 4 ¼ extremely). Evaluation is undertaken in terms of (a) nine thematic subscales (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger/hostility, phobic anxiety, paranoid ideation, psychoticism) and (b) three global categories comprising the Global Severity Index (fundamental psychological stress), the Positive Symptom Distress Index (intensity of response), and the Positive Symptom Total (number of stress-inducing symptoms). The Psychoticism scale was disregarded for methodological reasons (Wischmann et al., 2001, p. 1757). Higher scores on the scales of the SCL-90-R mean a higher degree of pathology. Cronbach’s a of the scales vary between 0.79 and 0.89. (vii) A personality questionnaire, the ‘Giessen Test’ (GT; Beckmann et al., 1991), is geared to partner assessment and inquiring after selfimage concepts (‘How I see myself’; self-evaluation) and image of the partner (‘How my partner sees me’; evaluation by the partner). The 40 bipolar items are grouped in five scales: (a) Social Response, where low scores indicate negative social response (e.g. unattractive) and high scores indicate positive social response (e.g. attractive); (b) Dominance, with the poles dominant (e.g. likes being domineering) and submissive (e.g. likes being submissive); (c) Self-Control, with the poles uncontrolled (e.g. able to let go) and compulsive (e.g. unable to let go); (d) Basic Mood, with the poles hypomanic (e.g. lets anger out) and depressive (e.g. suppresses anger); and (v) Permeability, with the poles permeable (e.g. trustful) and retentive (e.g. mistrustful). The mean of Cronbach’s a for the scales is 0.86. GT data were collected in the first 2 years of the study only, therefore leading to smaller sample sizes. (viii) A questionnaire on stress-inducing events in the couples’ lives (FLS; Wischmann, 1998) was included. Alongside various sociodemographic features of the parents and siblings, this questionnaire also inquired into specifics of the family status of the parents (separation, divorce, death and the year in which these occurred). Three open-response questions were included, each with example items, related to (previous and present) stressful events in the family of origin and in the respondents own childhood. In each of these openresponse questions, the patients were asked to indicate duration (from-to), intensity (on a scale 1 ¼ little stress to 7 ¼ strong stress) and person affected. The naming of stressful events was categorized by means of a rating system. Subsequently, responses to the questions on the FLS enquiring into instances of stress in the family of origin and problems in childhood were classified as ‘early’ stress if such an event occurred before the age of 16 years and a score 5 was recorded on the Stress scale. Persons who indicated two or more events were classified as ‘vulnerable’.

Statistical methods The data were evaluated using the statistic program SAS for Windows 9.1. Statistical analysis included x 2-test for frequency differences and t-tests for the comparison of the mean scores for the two groups of couples (‘not counselled’ and ‘taking up counselling’) on the psychological scales. To assess the ‘clinical’ relevance of differences between the two groups, effect sizes (ES) were calculated by the differences between the means of the two groups divided by the common standard deviation within these two groups. ES between 0.20 and 0.50 were designated as small, between 0.50 and 0.80 as medium and .0.80 as large (Cohen, 1988).

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(i) The documentation sheet for socio-demographic data (SOZIODAT; E. Bra¨hler et al., unpublished) includes demographic and sociological information, i.e. questions on age, family status, duration of partnership, educational and professional status, residential status and occupational stress. This questionnaire was used for the description of the samples. (ii) In the questionnaire on the case history of the desire for a child (‘Fragebogen zur Kinderwunschanamnese’, KWA; C. Ho¨lzle, unpublished), the participants were asked how long they have been wanting a child, their acceptance of various potential kinds of infertility treatment (including ‘counselling’ and ‘psychotherapy’) with the response options ‘yes’, ‘no’ and ‘don’t know’, and their subjective assessment of their pregnancy chances with or without treatment, respectively. The questionnaire was supplemented with the following two questions: ‘How strong is your wish for a child right now?’ (i.e. ‘Intensity of desire for a child’; a five-point rating scale ranging from 0 ¼ not at all to 4 ¼ very strong) and ‘How stressed do you feel by the unfulfilled desire for a child?’ (i.e. ‘Suffering from childlessness’; a seven-point rating scale ranging from 0 ¼ not stressed at all to 6 ¼ extremely stressed). (iii) The questionnaire on the desire for a child (‘Fragebogen zum Kinderwunsch’, FKW; Ho¨lzle and Wirtz, 2001) was designed to identify expectations and apprehensions in connection with pregnancy, birth and parenthood, using 20 rating questions (1 ¼ not at all, 5 ¼ very strong). A factor analysis of the FKW generated three factors: (a) enhancement of self-esteem (example item: ‘I find the idea of being able to create new life wonderful’; Cronbach’s a ¼ 0.77), (b) emotional stabilization (example item: ‘I would be very lonely without a child’; Cronbach’s a ¼ 0.80) and (c) ambivalences about parenting, partnership, career and self-realization (example items: ‘I am afraid of the demands made by a child’, or ‘A child might interfere with my career prospects’; Cronbach’s a ¼ 0.73). (iv) The questionnaire on subjective theories concerning the cause of infertility (‘Fragebogen zur subjektiven Ursachentheorie’, SUBURS; Goldschmidt et al., 1998) was used to assess lay beliefs concerning aetiologies of infertility. It includes 36 example ratings for the statement ‘Our involuntary childlessness could be co-determined by . . . ’. Each is measured on a five-point rating scale ranging from 0 (¼ surely not) to 4 (¼ quite sure). These items belong to the dimensions psychosocial, naturalistic, health behaviour, partnership and sexuality, and fate. A factor analysis of the SUBURS generated two factors, which were gender independent: (a) subjective excessive demand (example items: ‘. . . others putting pressure on us’ or ‘. . . my depressed mood’) and (b) causes related to partnership and sexuality (example items: ‘. . . unsolved conflicts between us’ or ‘. . . our unfulfilled sexuality’). Higher scores on the two scales of the SUBURS mean higher subjective stress. The internal consistencies (Cronbach’s a) are 0.88 for the first scale and 0.82 for the second scale. (v) The questionnaire on life satisfaction (‘Fragebogen zur Lebenszufriedenheit’, FLZ; Fahrenberg et al., 2000) measures various aspects of life satisfaction. Information on satisfaction in different areas of life is elicited by means of 63 seven-point items on the scales Health, Professional and Vocational Life, Financial Situation, Leisure and Hobbies, Marriage and Partnership, Self-Esteem, Sexuality and Living Situation. Higher scores on the scales indicate more

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To identify the variables most significant for the allocation to one of the two groups, stepwise discriminant analyses were computed.

Results

Discussion This study demonstrates that the degree of psychological distress on women as a result of involuntary childlessness (and the side-effects of reproductive treatment) seems to be the crucial factor in the decision to take advantage of infertility counselling. The women in our study suffered notably from the unfulfilled desire for a child and from depression, whereas their partners were (at the time in question) relatively dissatisfied with the sexuality and the couple relationship and seemed to worry about their partners’ depression. Both were receptive to a psychosocial perspective on the potential causes of infertility. Women tended to see the causes as stemming more from subjective excessive demand, while their partners suspected that they derived from current problems in partnership and sexuality. These results support the impression of counsellors that women are depressed by the infertility problem and feel unattractive, whereas their male partners appear helpless concerning the womens’ mood and somewhat unsatisfied. This typical allocation and polarization of roles within the couple can be seen often in infertility counselling (Newton, 1999; Wischmann et al., 2002). As the results of the discriminant analysis show, it was mainly the psychological distress on the part of the women that seems to be the strongest factor in the decision to seek psychological assistance. These findings are consistent with those from other projects of the German infertility research network (Strauß et al., 2000; Ho¨lzle et al., 2002). This is probably due to the fact that the same instruments were used in these studies. Hence, this supports the validity of the findings. Another interpretation of this role allocation is given by Cousineau and Domar (2007) inasmuch as the men may suffer silently in efforts to support their wives, and therefore indicate less psychological distress in questionnaire scales. Our results are not directly comparable with the studies by Paulson et al. (1988), Shaw et al. (1988), Edelmann and Conolly (1986), Pook et al. (2000) and Schmidt et al. (2003), as these studies inquired into the potential likelihood of couples availing themselves of assistance

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Of the entire sample, 633 women (65%) and 535 men (59%) indicated openness towards psychological counselling on the KWA. However, these data were obtained from both phases of the study, and participants in the second stage included patients, at any stage of treatment, who sought psychological help. From those indicating an openness to counselling, two groups were compared here for their measurements: (i) the 358 women and 292 male partners from couples who did not take up any counselling or therapy later (group ‘not counselled’), and (ii) the 275 women and 243 male partners from couples who attended counselling/psychotherapy (group ‘taking up counselling’). Table I lists the mean scores on the psychological scales in the two comparison groups and the results of x 2-test and t-tests as well as ES computation. For reasons of clarity, only differences with ES  0.20 will be specified in the results section. Couples who took up counselling were notable for their higher level of education. Of the women in this group, 38% had a university degree or similar. For the men, the corresponding figure was 54%. Both partners estimated their chance of getting a child as the result of infertility treatment as marginally lower than women and men in the group ‘not counselled’. Women in the counselling group were about 1 year older than women not being counselled (all ES small). For women attending counselling or couple therapy, remarkable psychological findings were higher scores on ‘depression’ in the GT partner image (ES ¼ 0.46), suffering from childlessness (KWA; ES ¼ 0.44) and on the SUBURS scales ‘subjective excessive demand’ and ‘partnership/sexuality’ as well as lower ‘social response’ in the GT self-image (all ES . 0.30). Furthermore, women in counselling showed lower scores in satisfaction with ‘self-esteem’, ‘professional/vocational’, ‘sexuality’ and ‘partnership’ (FLZ), but all differences showed small ES. All of the women’s higher levels of ‘depression’ in SCL-90-R and GT (self-image) and of ‘obsessive/compulsive’ in SCL-90-R had small ES too. Women in the counselling group were seen as less positive resonant and more retentive by their male partners in the GT partner images as well (both with small ES). For the men, the differences between the two groups were less pronounced. Men taking up counselling showed lower scores for satisfaction with ‘sexuality’ (ES . 0.30) and ‘partnership’ in the FLZ and higher scores on the SUBURS scales ‘partnership/sexuality’ as a potential cause for infertility. In the self-image of the GT, these men saw themselves as more retentive. All of the men’s variables showed small ES only. Women and men with higher stress scores on the FLS were more frequent in the group ‘taking up counselling’: 36.2% of the vulnerable women (versus 24.1% of the other women; P , 0.01) and 39.2% of the vulnerable men (versus 25.9% of the other men; P , 0.001) were found in this group (Wischmann et al., 2001). For the couples where medical records were available, there were no differences in the psychosocial variables between the two groups (data not shown). To further concentrate the results, two stepwise discriminant analyses were computed with each data record including both female and male variables, first for all psychological scales with GT scales excluded because of different sample sizes, and then a second one for the GT

scales only. To keep the number of missing values low, 16 couples with missing values for more than 15 scales were excluded. For the remaining couples, missing values were replaced by sex-specific mean scores. Thus, we obtained a data set comprising 431 couples. Only psychological variables with statistically significant differences between the two groups [marked with asterisk(s) in Table I] were included in the discriminant analyses. The significance level for inclusion or removal of variables was set at P , 0.05. The variables selected for the discrimination between the two groups (questionnaires without GT) were two variables of the women: ‘suffering from childlessness’ [partial F(1, 428) ¼ 11.93, P ¼ 0.0006] and the SUBURS variable ‘partnership/sexuality’ as a potential cause of infertility [partial F(1, 428) ¼ 9.76, P ¼ 0.0019]. The variable selected by discriminant analysis of the GT data only was women’s ‘depression’ in the GT partner image [partial F(1, 227) ¼ 13.85, P ¼ 0.0002]. Variables of the men were not selected in any of the two discriminant analyses. Therefore, the variables most significant for the allocation to one of the two groups were (in this order): women’s ‘depression’ in the GT partner image, women’s ‘suffering from childlessness’ and women’s subjective beliefs that difficulties in ‘partnership/sexuality’ might cause infertility.


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Table I Comparison of sociographic and psychological variables from women/men not counselled and women/men taking up counselling Variables/scales

Women

.....................................................................

Not counselled (n 5 358)

Taking up counselling (n 5 275)

Men

....................................................................

Not counselled (n 5 292)

Taking up counselling (n 5 243)

............................................................................................................................................................................................. Questionnaire on socio-demographic data (SOZIODAT) Age (years)

32.43 + 4.26

33.45 + 3.98**

34.87 + 5.45

35.31 + 5.22

University degree

25%

38%**

41%

54%*

Questionnaire on the case history of the desire for a child (KWA) Suffering from childlessness (0–6)

4.08 + 1.42

4.66 + 1.13***

3.13 + 1.57

3.28 + 1.39

Intensity of desire for a child (0–4)

3.37 + 0.76

3.39 + 0.80

3.18 + 0.78

3.11 + 0.83

Duration of desire for a child (years)

4.36 + 3.01

4.50 + 2.70

4.32 + 3.07

4.34 + 2.62

60%

54%**

66%

59%**

20%

22%

29%

30%

20.38 + 0.99

20.22 + 1.04

20.31 + 0.99

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Chance with treatment Chance without treatment

Questionnaire on motives for wanting a child (FKW) Enhancement of self-esteem

20.22 + 0.95

Emotional stabilization

20.26 + 0.95

20.25 + 0.87

20.31 + 0.91

20.39 + 0.89

Ambivalences

0.01 + 1.01

0.18 + 1.08

20.09 + 1.06

0.01 + 1.04

Questionnaire on lay aetiologies (SUBURS) Subjective excessive demand

0.30 + 0.62

0.54 + 0.75***

20.05 + 0.55

0.03 + 0.54

Partnership/sexuality

0.19 + 0.79

0.46 + 0.88***

0.22 + 0.78

0.45 + 0.85**

Questionnaire on life satisfaction (FLZ) Health

20.13 + 0.80

20.29 + 0.97*

0.16 + 0.70

0.13 + 0.82

Professional/vocational

0.24 + 0.72

0.05 + 0.86**

0.22 + 0.72

0.23 + 0.70 0.62 + 0.69

Financial situation

0.53 + 0.71

0.50 + 0.76

0.58 + 0.66

Leisure

20.04 + 0.94

20.04 + 0.91

20.13 + 0.97

20.03 + 0.82

Marriage/partnership

0.48 + 0.66

0.34 + 0.77*

0.43 + 0.64

0.30 + 0.68*

Self-esteem

20.12 + 0.97

20.36 + 1.01**

0.13 + 0.84

0.02 + 0.86

Sexuality

0.44 + 0.83

0.24 + 0.84**

0.41 + 0.71

0.16 + 0.85***

Friends, acquaintances, relatives

20.10 + 0.92

20.24 + 1.02

20.03 + 0.92

20.18 + 0.88

Living situation

0.31 + 0.84

0.25 + 0.92

0.30 + 0.84

0.37 + 0.75

Symptom checklist (SCL-90-R) Somatization

53.14 + 13.09

53.44 + 13.24

52.23 + 11.43

51.78 + 12.79

Obsessive/compulsive

51.43 + 12.55

54.13 + 14.55*

49.86 + 10.50

51.11 + 11.64

Interpersonal sensitivity

51.91 + 12.69

54.48 + 14.15*

49.88 + 11.47

50.95 + 11.16

Depression

53.02 + 13.43

56.58 + 15.42**

49.83 + 10.92

51.78 + 12.09 51.26 + 11.16

Anxiety

53.44 + 13.78

54.57 + 14.27

51.90 + 10.99

Anger-hostility

52.93 + 13.53

54.63 + 14.25

52.01 + 12.32

53.13 + 12.72

Phobic anxiety

51.64 + 15.74

53.43 + 16.79

50.04 + 11.85

49.48 + 11.46

Paranoid ideation

51.49 + 12.71

53.19 + 13.93

51.31 + 12.15

51.45 + 11.99

Global severity index

52.23 + 14.20

54.85 + 15.47

50.02 + 12.19

51.60 + 13.06

Positive symptom distress index

52.12 + 11.06

54.36 + 12.43

50.14 + 8.32

50.10 + 7.80

Positive symptom total index

52.17 + 13.04

54.34 + 12.98

51.34 + 12.19

51.93 + 12.27

Giessen Test (GT, self-images) a Social response

49.73 + 10.46

46.26 + 9.82**

50.63 + 8.14

49.44 + 7.36

Dominance

47.92 + 10.58

47.81 + 10.15

48.81 + 9.11

49.67 + 9.17

Self control

51.08 + 10.19

50.32 + 9.73

51.66 + 9.18

51.64 + 8.58

Basic mood

55.47 + 11.17

58.25 + 10.13*

50.11 + 9.84

50.53 + 9.42

Permeability

45.15 + 10.51

47.14 + 11.39

47.97 + 9.56

50.44 + 8.64*

Continued


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Characteristics of infertility counselling attendees

Table I Continued Variables/scales

Women

.....................................................................

Not counselled (n 5 358)

Taking up counselling (n 5 275)

Men

....................................................................

Not counselled (n 5 292)

Taking up counselling (n 5 243)

............................................................................................................................................................................................. Giessen Test (GT, partner images) a Social response

52.13 + 9.24

49.08 + 9.40**

53.33 + 9.22

51.99 + 10.03

Dominance

47.79 + 9.78

49.28 + 10.26

47.25 + 11.55

46.91 + 10.53

Self control

53.29 + 9.83

54.61 + 9.74

52.39 + 10.08

51.54 + 9.91

Basic mood

59.97 + 9.75

64.46 + 9.65***

43.00 + 11.11

44.19 + 11.02

Permeability

43.97 + 11.15

46.20 + 9.23*

49.66 + 11.50

49.08 + 11.01

Values are mean + SD. Mean of reference population ¼ 0 for FLZ, FKW and SUBURS and 50 for SCL-90 and GT; SD of reference population ¼ 1 for FLZ, FKW and SUBURS and 10 for SCL-90 and GT. a Participants not counselled: n ¼ 207 women and n ¼ 160 men; participants taking up counselling: n ¼ 149 women and n ¼ 132 men. *P , 0.05; **P , 0.01; ***P , 0.001; mean differences with ES  0.20 are marked bold for participants taking up counselling.

As in most studies on psychological interventions for infertility patients, the characteristics of patients before counselling remained unclear for couples from lower social strata or for couples with a different mother tongue. Above all, the results of this study say nothing about psychosocial characteristics of infertile couples not seeking at least brief medical treatment. Also, the counselling and therapy were offered expressly for couples. This obviously restricts the relevance of our findings for those infertile men/women preferring individual or group counselling/therapy or self-help groups.

Clinical implications It is fair to assume that the need for psychosocial counselling for involuntarily childless couples will increase in the coming years. This is partly due to the increasing recourse to reproductive treatment in the western world (Nyboe Andersen et al., 2008). To facilitate the attendance, a lowthreshold counselling offer should be available for women and men at any stage of infertility treatment, especially at the beginning and upon its (unsuccessful) completion. As Boivin et al. (1999, p. 1390) have pointed out, couples ‘may want reassurance that psychosocial services would be available if needed, even though such services may never be used’. Written information or video presentations about common emotional and psychosocial reactions to infertility in women and men, about coping with this condition and about typical issues in infertility counselling should be provided to the couples from the beginning of infertility treatment on. Course, content and goals of the infertility counselling should so be made transparent (Wischmann, 2008). To identify ‘vulnerable’ couples, it could be useful to develop a checklist with typical statements of couples in infertility counselling (such as ‘My wife is devastated for days after the onset of the menstrual period. As her partner I feel only helpless and I withdraw completely’). Summarizing their affirmative answers, infertile women and men could evaluate their need for infertility counselling. These items could also be part of key questions in the doctors’ examination of the infertile couple (Kentenich et al., 2002).

Implications for research Since ‘the traditional stress models with their individual nature do not fully appreciate the dyadic context of infertility’ (Pasch, 2001,

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from psychological interventions, rather than concentrating on patients actually taking up counselling. As in the study by Strauß et al. (2000), psychological counselling and/or therapy was taken up notably by couples with a higher level of education. This corresponds to general findings regarding the acceptance of psychotherapy. Participants from the middle and upper classes are more likely to be receptive to psychological counselling and notably psychotherapy than participants from lower social classes (Seligman, 1995). About one-third of the couples from the Women’s Hospital chose the low-threshold counselling offer of two sessions. This acceptance rate is higher than the rate of 20% frequently referred to in the literature (Boivin, 1997). There are a number of likely reasons for this. The offer of psychological counselling was integrated into the reproductive treatment programme from the outset, e.g. via information booklets, frequent joint information events on medical and psychological aspects of fertility disorders and reports on the ‘Heidelberg Fertility Consultation Service’ in the local media. If psychosocial infertility counselling is an integral part of the treatment, and its goals and course are made transparent before it starts, acceptance rates up to 80% can be reached (Emery et al., 2003). In addition, the medical service in our study included not only traditional medical treatment for infertility but also complementary methods (such as naturopathy or acupuncture), which may have been attractive for infertile couples interested in less ‘invasive’ approaches, including psychological counselling. This hypothesis is supported by the finding that a very large proportion of the couples were receptive to the idea of psychological counselling and/or naturopathy (Wischmann et al., 2001). On the other hand, we must bear in mind the fact that the sample consisted exclusively of couples who were at least minimally interested in psychological issues and consequently prepared to fill out the questionnaires. This study has some limitations. It does not examine a homogeneous set of participants (e.g. couples embarking on IVF treatment only) but rather a heterogeneous group of infertile couples at different stages of medical diagnostics and treatment, couples undergoing ‘natural’ and ‘conventional’ infertility treatment, and couples from private medical practices and from the University hospital. Furthermore, the high proportion of academics in our sample means that the results of this study cannot readily be generalized to other settings.


384 p. 562), it is necessary to consider the couples’ evaluation of the infertility distress. As our study could show, the partner image of the women’s depression was much more accentuated than the women’s self-image of her depression. In further studies on the impact of infertility distress therefore, questionnaires concerning the couples’ views should be administered. Prospective study designs could help to show if psychological distress emphasized by the partner might be a ‘predictor’ variable for uptaking infertility counselling.

Acknowledgements We are grateful to the patients for their willingness to participate in the study.

This study was funded by the German Federal Ministry of Education and Research as a part of the research network ‘Psychosomatic Diagnosis and Counselling/Therapy for Fertility Disorders’ (grants 01KY9305 and 01KY9606).

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