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230 DISCUSSION The present study was carried out to explore the different psychological aspects or changes that may occur in a couple after being diagnosed with a problem of inability to conceive. Infertility can be understood as the inability to produce child after 12-months or more of normal sexual activity. Infertility in itself is not a pathological state but is an indicative of a problem that is inhabiting pro-creation and that requires proper understanding of the problem as well as counseling and therapy. Since infertility has such great consequences to the social, emotional, physical, and economic well-being for many couples, it was felt that the most significant psychological consequences of infertility should be studied keeping in view to prevent them through counseling. The study further aimed at to check the differences in the levels of depression, anxiety, self-esteem, aggression, marital satisfaction and sexual satisfaction of infertile and fertile couples. The phenomena of infertility and its psychological effects were also investigated with reference to demographic variables such as gender, age, education, family living system i.e. nuclear versus joint, area to which they belong i.e. urban versus rural, language, income they earn monthly, and infertility diagnosed in one partner or in both. Furthermore, the study was also focused to find out the relationships of variables i.e. depression, anxiety, self-esteem, aggression, marital satisfaction and sexual satisfaction with each other. The research was conducted in three parts, in part I the scales used in the study were adapted and translated into Urdu. Psychometric properties of these scales were also determined. To measure the levels and sources of depression and anxiety, Beck Depression Inventory, (1961) and Beck Anxiety Inventory, (1993) by Beck, were indigenously developed that have been used successfully in many researches. These scales were modified through committee approach for the specific purposes of the 231 present research. Aggression Questionnaire developed by Buss and Perry (1992) was used to measure the aggression level of infertile and fertile couples. To measure the self-esteem, marital satisfaction and sexual satisfaction, Index of Self Esteem, Index of Marital Satisfaction and Index of Sexual Satisfaction respectively developed by Hudson (1982) were used. The process of adaptation and translation has been discussed in part 1 of this research. The empirical data showed that these scales have sufficient reliability and validity, and can be used confidently for the present research purposes. Part II of the present research was conducted on a relatively small sample. The objective of part II of the present study was pre-testing of all the scales developed in part I and to find out the flaws that may interfere in the findings of main study. Part III is comprised of the main study. This part deals with the main objectives of the research. This study was carried out with a relatively larger sample using the scales adapted and translated in part I of the present research. Psychometric Properties of Urdu-Versions of BDI, BAI, AQ, ISE, IMS, and ISS The data collected from the respondents were subjected to reliability and validity to check the psychometric properties of all the relevant scales that are implied in the current research. Alpha reliability coefficients (Table 16) yielded internal consistencies for all scales that ensure that all the Urdu versions of the scales used in the study are highly reliable measures of depression, anxiety, self-esteem, aggression, marital satisfaction and sexual satisfaction. Inter-correlations between all the scales were also computed. The data showed highly significant positive correlations among these scales implying that all the variables measured by these scales were closely related. Correlation Matrix (Table 17) revealed that Beck Depression Inventory and Beck Anxiety Inventory are positively 232 correlated with each other and Index of Marital Satisfaction showed the highest correlation with Index of Sexual Satisfaction. These findings are also supported by the evidences found in the further analysis that the infertile couples, who are depressed, are also anxious and infertile couples who are in satisfying marriages would also be sexually satisfied. Validity estimates for all scales were also found satisfactory. The construct validity of each scale is evident in the item-total correlations with the over all scale (Table 18). The correlations of the items of each scale with its over all scale point in the same direction while emphasizing the construct validity of Urdu-versions of BDI, BAI, AQ, ISE, IMS, and ISS as all the correlations were found to be significant. This indicates that all the scales are measuring the same constructs as supposed to measure. Levels and Sources of Depression, Anxiety, Self-Esteem, Aggression, Marital Satisfaction and Sexual Satisfaction in Fertile and Infertile Couples The major purpose of the current research was to ascertain the levels and causes of marital and sexual satisfaction, depression, anxiety, self-esteem, aggression, and self esteem in fertile and infertile couples. To identify levels of all variables, frequency distributions and cumulative percentages were computed. The percentile ranks were computed to find out the cut off scores for mild, moderate and high levels of these different variables. The criterion for cut off scores was ±1 SD from the mean. Scores falling on 25th and 75th percentiles were determined as cut of points for all measures. The scores up to 25th percentile were considered as low levels of measures, the scores above 75th percentile were considered as high levels of measures and rest of the scores were considered as moderate levels of measures. When the procedure was done to determine the cut off points for the Aggression Questionnaire, the scores of 57 and 80 were found that fall on 25th and 233 75th percentiles respectively. The scores of 57 falling on 25th percentile were considered as low levels of aggression, the scores at and above 80 falling on 75th percentile were considered as high levels of aggression and rest of the scores were considered as moderate levels of aggression (Table 19). For the group of high levels of aggression, the frequency of infertile couples is 46.20% that is greater than the frequency for low and moderate levels of aggression (18.50%, 35.30%) respectively (Table 21). The results also revealed that frequency is high within the group of high levels of aggression for infertile couples i.e. 46.20% when compared to the frequency of fertile couple’s i.e.17.50% within the same group of high levels of aggression (Table 22). The result also supports the hypothesis that infertile couples have high levels of aggression as cited in review of literature. Those couples who are victims of infertility exhibits more anger, anxiety, sorrows, and psychological stress as compared to fertile couples. (Crick et al., 1997). Cut off scores for Beck Depression Inventory determined by Beck for the original version of BDI were used for the identification of mild, moderate and high levels of depression of infertile and fertile sample. The scores up to 18 were considered as low levels of depression, the scores ranging from 19 to 29 were considered as moderate levels of depression and scores ranging from 30 to 63 were taken as indicative of high levels of depression. The results indicate that frequency of infertile couples (19.5%) is high within the group of high level of depression. as compared to the frequency of fertile couples (6.2%) within the group of high levels of depression (Table 21 & 22) and remaining individuals exhibit from low to moderate level of depression. 234 For the determination of mild, moderate and high levels of anxiety of infertile and fertile sample, cut off scores for Beck Anxiety Inventory as indicated by Beck for the original version of BAI were entertained. The scores up to 15 were considered as low levels of anxiety, the scores ranging from 16 to 25 were considered as moderate levels of anxiety and scores ranging from 26 to 63 were considered as high levels of anxiety. Frequencies and cumulative percentages of infertile couples’ scores on Beck Anxiety Inventory also demonstrate the high frequencies of infertile couples i.e. 25.7% that lies in the group of high level of anxiety whereas it was 10.5% for fertile group in the group of high level of anxiety (Table 21 & 22). The result supports the hypothesis that was based on general observation that infertile couples are more anxious as compared to fertile couples and the review of literature e.g. the Editor of World Health Forum (1996) argues that in India, the infertile couples for an early treatment because of the stigmatization in the society would adversely affected the marital and sexual lives of the couples. He pleads that if such couples are provided with emotional support from their near and dear one, it is likely to help them. As for as the cut off points for the Index of Self-Esteem, Index of Marital Satisfaction and Index of Sexual Satisfaction were concerned, Hudson (1981), the developer of all these three measures, had given a clinical cutting score of 30. That is it generally found that persons who obtain a score above 30 have a clinically significant problem in the area being measured. While those who score below 30 are generally free of such problems. Frequency distributions of infertile couples regarding their self-esteem shows that frequency of infertile couples is high within the group of low levels of self- esteem (77 %) this frequency is also greater than that of the frequency of fertile 235 couples (51%) within this group (Table 23 & 24). The comparison of levels of self- esteem between the sample of infertile and fertile couples showed the greatest difference in the levels of self-esteem of both groups.. It is supporting the hypothesis that infertile couples show comparatively less degree of self-esteem to fertile couples as described in literature review that every infertile couple in comparison of fertile couples, has low self-esteem at some time in his life. They might feel bad after diagnosing the problem of infertility. Criticism can make them feel bad. Infertile men and women often criticize themselves. They may feel like they aren't good enough unless they're perfect (Blascovich, & Tomaka, 1991). The levels of marital and sexual satisfaction were also found significantly different between both the groups of infertile and fertile couples. The couples after being diagnosed with infertility tend to have less marital satisfaction according to Bryant and Conger (1999). It was also hypothesized in the present research and is supported by the results of frequency distribution and cumulative percentages. Hence the frequency of infertile couples on the index of marital satisfaction is high 48.2% within the group of lower levels of marital satisfaction. This frequency is also higher as compared to the frequency of fertile couples (26.5%) within this group of lower marital satisfaction (Table 23 & 24). This may coincide with study conducted by Tuschen-Caffier et al. in 1999 as cited in literature review. According to them, inability to conceive and its medical treatment adversely affect the marital and sexual satisfaction in couples that leads to less frequency of sexual contacts. Tuschen-Caffier concluded in the study that infertile couples reported less satisfaction with their marriages and sexual lives compared to fertile group. These results are also in accordance with the findings of present study. The analysis of the sexual satisfaction of the infertile couples is also same as has been discussed for the marital satisfaction. Infertile couples with high frequency (53.2%) fall in the category of lower sexual satisfaction, while the frequency for 236 fertile couples (32.5%) within the same group of lower sexual satisfaction is low (Table 23 & 24). Comparison with frequency of fertile group is also revealing that infertile couples demonstrate less sexual satisfaction than fertile couples. Review of the literature also presented the data for these findings that inability to conceive is going to adversely affect the marital and sexual satisfaction (Wright et al., 1991). It is stated that cut off points used in the study are not absolute and has to be continuously validated for different groups of populations. It is further stated that part of the literature may favor our conclusion. It showed that established norms for all the measures used in the present study are in line with the findings of various studies discussed in literature reviewed. Differences in Depression, Anxiety, Aggression, Self-Esteem, Marital and Sexual Satisfaction Exhibited By Infertile and Fertile Couples The results are analyzed on the basis of the assumptions that infertile couples show high degree of anxiety and sorrow as compared to fertile couples. Infertile couples are more likely to feel low self-esteem and angry than fertile couples. Furthermore, it was assumed that infertile couples also have significantly sharper rates of declining marital and sexual satisfaction than that of fertile couples. The first hypothesis of the study, which sates that depression will be more common in infertile couples than in fertile couples, has been supported in the present study (Table 38). The findings are in tune with previous studies conducted by Anate, and Akeredolu (1995) who reported that the inability to conceive is correlated with social isolation, severe sense of guilt, anxiety and depression, and it further adversely affect the level of self esteem in infertile couples. There may be many plausible reasons for these findings that can be put forward by arguing that Coryell et al. (1998) followed infertile couples who never suffered from any psychopathology, within the 4 237 years of time period 12% of the sample had an onset of major depressive episodes. It is apparent from the study that infertility is not necessarily the part of the past history of the people suffering from depression but it is the result of infertility and as compared to fertile couples the ratio is high for infertile couples to develop depression. These differences between infertile and fertile couples are also significant as to convince the reader of the credibility of the finding of present study. The second hypothesis that infertile couples will display more anxious behavior as compared to fertile couples, is supported from the findings of the present study (Table 39). There is a significant difference between fertile and infertile couples in showing their anxiety. Infertile couples reported more intense feelings of anxiety when compared to fertile couples. The result is in favor of the findings of the work of Argyle and Roth (2002) (as discussed in chap: Anxiety) who reported that the effects of infertility and infertility treatment on quality of life always result in anxiety and distress. Highly significant differences were found to be on anxiety inventory, which are in congruity with our cultural values and the process of parenthood role socialization. As in our culture married couples in general and infertile couples also under severe social pressures to meet the expectations of performing traditional feminine and masculine roles particularly with reference to their sexual roles and their ability to produce children. It is a social pressure on the young couples to act according to traditional roles. Short intervals between generations are a result of the pressures on young couples to be sexually active and to bear children early as a means of finding social acceptance and long-term security. The third hypothesis of this study stated that infertile couples are more likely to engage in aggression than fertile couples. This hypothesis has been likely supported 238 through this study (Table 40). This finding can be justified by taking into consideration the central features of the studies by Babcock et al. (1993) (as indicated in chapter Aggression). According to that, it is found that infertility is associated with the risk of subsequent aggressive acts among couples with or without a history of aggressive behavior. It is found that there is a significant positive relationship between the infertility and aggressive behavior. Research in psychological and sociological fields asserts that violence, aggression and stress are acquired behaviors in response to frustration particularly resulted from infertility. Aggressive behavior occurs when couples stop a treatment. Within hours of stopping treatment, couples may show some features of aggression. Failure of treatment causes an increased stress on the whole body even though there seems to be a lessening of stress. Among those with aggressive personalities, perception of infertility changes in the parts of the brain that control social response, thinking and planning. The differences may explain why some infertile couples tend to be more aggressive than fertile couples. “Infertile couples will show lower degree of self-esteem than fertile couples” was the fourth hypothesis of this study that has been supported by the findings of this study (Table 41). The hypothesis was postulated keeping in view the previous studies conducted by Greil in 1997 who reported in a review article on “Infertility and psychological distress” that infertility affects self-esteem of infertile couples. The acceptance of this hypothesis can be justified by considering that infertile couples can have a negative self image, and concerns about their physical appearance and potency as compared to fertile couples. Such couples are going to face the problems as they attempt to adjust to their marital and sexual lives. The findings again provides empirical support for the study conducted by Anate and Akeredolu (1995) as cited in literature review who reported that the inability to conceive is positively correlated 239 with lower level of self esteem, high levels of depression and anxiety, extreme social isolation, and severe sense of guilt. The fifth hypothesis of the study that speculates a decline in marital satisfaction as a consequence of infertility has been confirmed for infertile sample but not for fertile sample. The hypothesis stated that infertile couples express less marital satisfaction than that of fertile couples. The strongest empirical evidence for validation of the hypothesis for infertile sample comes from the significant difference between infertile and ferrite’s score on the Index of Marital Satisfaction (Table 42). This suggests that infertile couples have lower tendency to be satisfied with marriages than fertile couples. The rationale for this finding is quite logical consistent with the findings of study conducted by Blascovich and Tomaka in 1991 to measure psychosocial effects of infertility who analyzed that infertile persons report less contentment, lower levels of marital and sexual satisfaction, and lower self-esteem over time. Distress caused by infertility may impair fertility by lessening marital and sexual satisfaction, affecting adversely the frequency of sexual contacts and may impair the quality of sperm in the males. (Tuschen-Caffier et al. 1999). Another finding in this regard is related to sexual satisfaction. Sexual satisfaction will be lower in infertile couples than in fertile couples, was sixth hypothesis of the study which was supported (Table 43). The hypothesis was made in accordance with Van Zyl,’s findings (1987l) about infertile couples who report that their inability to conceive has serious negative effects on their lives, particularly their sexual and marital relations The acceptance of the hypothesis might be attributed to the fact (as indicated in chapter sexual satisfaction) that the majority of couples reported conflict, low 240 sexual satisfaction, gap in communication, conflicts upon mode of medical treatment, absence of sympathy and empathy (Andrews et al., 1991). Gender Differences in Depression, Anxiety, Aggression, Self-Esteem, Marital and Sexual Satisfaction Reported by Infertile Couples An important objective of this study was to take cognizance of the gender differences in the levels of depression, anxiety, self-esteem, aggression, marital and sexual satisfaction of infertile couples. The study revealed interesting patterns of the gender differences in terms of all these psychological changes that occur in couples after being diagnosed with problem of infertility, which explained how do men and women differ in their levels and magnitudes of depression and anxiety, how do they differ in feeling self-esteem and in expressing aggression, and how do they show different patterns of satisfaction with their marriages and sexual lives while simultaneously highlighting the different path of relationship among these six constructs for each gender. Interesting gender differences were emerged as a result of the t-test analysis of the depression (Table 45). It was hypothesized that infertile women will display more depression as compared to infertile men. Results indicated that men and women differ significantly in having depression after being diagnosed with a problem of infertility. Women were found to be more likely to demonstrate more depression as compared to men when they remain childless. This finding is in tune with the findings of the study published in 1993 by White et al. (as indicated in review of literature), who reported that women who continually face the disappointment of not conceiving month after month, show more frequent signs of grief, depression and anxiety. Research about the relationship of infertility with depression explained that depression is a normal reaction to the experience of infertility. Compared with men, depression is 241 commonplace among women facing infertility. Females experience more anxiety, anger, sense of guilt, nervousness and depression as compared to males. Studies have shown that the level of depression while experiencing infertility is close to females than males. The grounds on which these findings can be defended entail the process of gender role socialization through which women learn that they would have to produce baby. Every society emphasizes the importance of childbearing ability. One of the important tasks for couple after marriage is to have children (Lee & Kuo, 2000). Childless women feared that their partners would abandon them, and separate them. A women who is found to be involved in a role of mother, when diagnosed with infertility, becomes depressed whereas no such moods exists for a man indulged in the same practices. Our gender role practices allow women to be involved in the role of parenthood must after marriage it is considered as a feminine behavior about which a female should boast within the sphere of her social group. This clarifies why women are more likely to demonstrate depression mood as compared to men. It is commonly accepted that more women are depressed than men. The ratio appears to be about two depressed women to every depressed man. Women use medical facilities more often than men, they visit a physician more frequently and for milder symptoms than men do. Thus it may only appear that more women are depressed because more of them come in for treatment. Even more interesting, the onset of depression in both men and women which formerly was most frequent during the mid-forties, seems to be moving back in time. Young adulthood is now becoming the most frequent time for depression. But, women show a higher rate than men. This sex difference has been found not just in the United State or Western Europe, but worldwide. This also may coincide with the work of Blazer (1989) who reported that 242 women develop significant levels of depression after only a few months of trying to have a baby The most striking difference was evident in the analysis of anxiety for infertile men and women (Table 46). A significant gender difference was found in the scores of anxiety that suggests that infertile women are more likely to exhibit the anxious behavior as compared to infertile men. Again the patterns of gender role in our culture emerge as the most plausible reason for this difference as explained while discussing the gender differences in terms of depression. Women’s likelihood of demonstrating anxious behavior is meaningfully related to our culture and the process of gender role socialization. The finding provides empirical support for the research discussed in review literature, conducted by Tarlatzis et al. (1993). The authors concluded that females and males reacted to the burden of not having children in different ways. Women reported more intense feelings of anxiety and depression compared to men. Argyle and Roth’s (2002) line of reasoning (as indicated in chapter Anxiety) that the effects of infertility and infertility treatment on quality of life always result in anxiety and distress No detectable gender difference was found in terms of aggression when the data pertaining to aggression were subjected to t-analysis (Table 47). Since aggression in this study, was conceptualized as a personality trait, it should be distributed in the population in accordance with the normal curve irrespective of gender that seems to have no direct bearing upon such a personality trait as aggression. Non significant gender difference found on aggression measure, suggests that aggressive behaviors resulting due to infertility are evenly engrossed by infertile men and women. For most couples, infertility doesn't cause them to be aggressive. However, it is possible that people who are prone to being aggressive may become more aggressive as a result of their hopeless feelings of infertility. This finding of present study may coincide with 243 the findings of Tavris (1988) (as discussed in chapter Aggression). The researches could not explain the differences of the responses in the expression of anger by males and females. It is also recognized that both infertile men use aggression as means of exercising control over other people because for them by subjugating other they can regain their self-esteem. On the other hand for a female the experience of powerlessness results in a severe sense of guilt. Males usually do not develop sense of guilt. A significant difference associated with self-esteem between infertile men and women was to be the expected finding. This difference can be explained in terms of gender role socialization as discussed pertinent to gender differences in depression and anxiety. As discussed earlier that infertile women are more likely to exhibit high degree of depression and anxiety as compared to infertile men that also posit a threat to the low self-esteem of infertile women. Through this expected relationship, it was hypothesized that infertile women being more depressed and more anxious compared to infertile men also demonstrate low self-esteem when compared to infertile men. Subtle patterns of gender differences emerged through the analysis of self-esteem for infertile men and women (Table 48). The finding can be explained in terms of our cultural values and specifically in context of gender role socialization. Most of our women are taught to have a motherhood role after being married but when they are diagnosed with infertility and have perception of failure to produce baby, they become depressed and feel low self-esteem. This clarifies why women compared to men are most likely to experience low self-esteem. The result is consistent with another review by Woods et al. (1991) (as indicated in review literature) that covers women's emotional responses to infertility. The authors describe that Describes that inability to conceive adversely affects females' self image and 244 level of self esteem and this results into a great sense of alienation, frustration and grief. If they are provided right kinds of treatment strategies that would affect their mind set positively. There are three ways in which health care professionals can facilitate the affected females by increasing females level of self esteem by providing emotional support from the society and family' and by working with those coping mechanisms that will decrease their level of psychological imbalance. A credible justification for this finding is that in our society, for women, it is considered important that perhaps women experience more stress than men because their lives contain more stressful events. The picture of the stressful life of a homemaker or a woman trying to combine homemaking with a career is well known, so far, however, research has not shown that women experience more frequent stressful events than men or that they experience them as being more stressful. However, at the same levels of stress, women report symptom of low self esteem intensities about twenty-five percent higher than men, while one might conclude that women are more free to express symptoms than men because our culture expects men to “keep a stiff upper lip” while women are allowed to be emotional. The rejection of this hypothesis can be justified by considering the constituent element of aggression and it is now necessary to develop different theoretical formulations to understand infertile men's and women's aggression. Expressive theories for women categorically assert that females have to control their instinctual behavior otherwise they have to face social ostercization. On the other hand theoretical formulations for men assert that males use aggression because they are being benefited by it (Campbell, 1993). The results pertaining to the hypothesis about the gender differences in marital satisfaction offer unexpected findings. It was hypothesized that women are least 245 satisfied with their marriages as compared to infertile males. This hypothesis has not been supported through this study (Table 49). A surprising yield of this study was that no differences were found between infertile males and females regarding their marital satisfaction. The failure to find a difference between men and women can be attributed to the fact that females face physical abuse or the threat of another wife by their husbands due to their inability to produce children. Socially they became outcast and has to face humiliations at the family gatherings. The results are not in line with previous researches. As Glover et al. (1999) argued that female members of couples experiences marital and sexual dissatisfaction than their males. as described in chapter Marital Satisfaction The hypothesis was made while considering the fact that primarily women’s reaction to infertility without an examination of how the other member of the couple is reacting to the same event or how each partner's experience is affecting the other partner is always a decline in their marital satisfaction (Greil, 1997). Similarly, infertile men & women had not shown different patterns of sexual satisfaction (Table 50). The data do not support the hypothesis that infertile men and women would differ in their sexual satisfaction. Result of this analysis does not indicate that infertile women are less likely to sexually satisfy as compared to men. The results pertaining to gender differences in marital and sexual satisfaction are in contrast with the findings of Affect and Disord, (2003) as indicated in review literature who evaluated the differences in psychological distress, marital satisfaction, and sexual satisfaction. He reported that husbands revealed more distress in marital and sexual satisfaction as compared to wives. The rejection of this hypothesis might be attributed to the fact (as discussed in chapter Sexual Satisfaction) that some of the couples reported that infertility problem 246 actually improve their relationship that may lead to sexual satisfaction (Hurlbert et al., 1993). Both the gender, male female are equally victim of more anxiety, low self esteem, blame and isolation and this can lead to sexual inadequacy particularly when the real cause lies with the males.(Webb & Daniluk, 1999). As mentioned earlier while discussing the inter-scale correlations for all six measures used in present study, infertile couples who are depressed would be definitely more anxious as found high correlation between depression and anxiety scales (Table 17). The assumption has been supported by the findings of present study. A common thread that emerged from Dr. Domar’s research (1999) is the fact that depression lifted in patients during infertility. In fact it appears that depression is more closely associated with infertility than anxiety. It does seem that when depression reduces in a group of very depressed infertile women, the conception rate increases. Another finding can be rationalized by the fact that infertile couples who are in depression and anxiety would have the feelings of low self-esteem as found highly positive correlations among depression, anxiety and low self-esteem (Table 17). The findings are suggestible for the support of these assumptions that infertile couples with high degree of depression and anxiety are more likely to have low self-esteem. Infertile couples’ likelihood of demonstrating marital satisfaction is also involved in sexual satisfaction that is meaningfully related to the fact about those couples who are in satisfying marriages are also in state of satisfaction with their sexual lives. Infertile Couple’s Overall Profile Irrespective Of Family System on Urdu Versions of BDI, BAI, AQ, ISE, IMS, and ISS Within the context of family system, we have only two family systems present in our family settings i.e. nuclear and joint living systems. The family system in 247 Pakistan is closely intertwined one. A family in Pakistan is different from American and European families in innumerable countenances such as culture, ways of living, regards for elders combined family system, and a remoter and stronger contact with each other (Mohsin, 1990). When data were further analyzed to explore the phenomenon of psychological aspects of infertility on the dimension of family system i.e. nuclear and joint family system, no one difference was found statistically significant (Table 51). It was noted that infertile couples from different family systems did not differ on the measure of depression. Infertile couples from nuclear and joint family system also showed no difference on the measure of anxiety implying that family system does not appear to contribute to depression and anxiety of infertile couples as it was hypothesized. At the same time infertile couples from nuclear and joint families have similar kind of finding for their self-esteem. It suggests that family environment differing from each other for infertile couples, does not contribute to the sense of low self-esteem of infertile couples. Similarly, the aggressive behavior of infertile couples as resulting due to infertility has nothing to do with different kinds of family systems i.e. nuclear and joint families. It means that infertile couples belonging to nuclear or joint family system did not differ in showing aggression. Hence the hypothesis that infertile couples from joint families would be less satisfied with their marriages was also rejected. Marital satisfaction can be conceptualized simply as a stressor in the home environment to which infertile couples are exposed. It was assumed that due to a lot of responsibilities in a joint family system and expectations from other family members, infertile couples feel under pressure and stressed all the time that may lead to low degree of marital satisfaction to them, but the findings of the study did not support the assumption. On the contrary, when these results are conceived in the cultural context peculiar to 248 Pakistani family system, it seems that other elderly members present in the family such as grand parents etc, may fulfill emotional needs of infertile couples. In the presence of grand parents and so-called authority figures do not use corporal punishment for infertile, hence, family system does not seem to play an important role in declining marital satisfaction of infertile couples. The difference in experiencing the sexual satisfaction between infertile couples from nuclear and joint families was also identified non-significance. It was also another important assumption of the present study that family system would contribute to the lower level of sexual satisfaction. The hypothesis concerning the statement that infertile couples exposed to nuclear families are less likely to feel sexual satisfaction as compared to infertile couples exposed to joint families, has not been supported by the findings of present study. The rejection of the hypothesis might be attributed to the fact that infertile couples in nuclear family system might influenced by autonomy and relatedness In the context of family autonomy means the degree of independence and individuality and freedom experience by the partners (Rankin-Esquer et al., 1997) whereas relatedness is basically the experience of closeness and confidence between the partners. Both these factors are significantly correlated not only with each other but also an indicative of adjustment and the level of satisfaction in the partners. Whereas, infertile couples in joint family system might develop the sense of sharing and intimacy with their family members, that can have positive influences on their marital adjustment and sexual satisfaction. Infertile Couple’s Overall Profile Irrespective of Areas to which They Belong, on Urdu Versions of BDI, BAI, AQ, ISE, IMS, and ISS Another hypothesis was formulated about the area to which infertile sample belong. It was assumed that infertile couples would have significant differences 249 irrespective of residential area to which they belong, in displaying their moods of depression, intensity of anxiety, level of self-esteem, and magnitude of aggression, degree of marital and sexual satisfaction. The results of our research showed that infertile couples have significant differences in their scores on AQ-Urdu with regard to area but non-significant differences were found on BDI, BAI, ISE, IMS and ISS,. The data were analyzed by dividing infertile couples into two groups; the infertile couples living in rural area and infertile couples living in urban area. It is our general observation that infertile couples from rural area may be psychologically more disadvantaged due to the problem of infertility as compared to infertile couples from urban area. The findings of the study partially supported the hypothesis (Table 52). It suggested that infertile couples of rural areas were more engaged in aggression than infertile couples of urban areas. Age wise Differences in Depression, Anxiety, Aggression, Self esteem, Marital and Sexual Satisfaction of Infertile sample Aging is one of those processes which affect everyone differently. Response to aging is usually slow and pains taking. Physical decline begins at early adulthood, but it is late in the life when people become aware of it. Many sensory abilities such as visual acuity, auditory accuracy, muscle strength and reaction time diminish gradually. In the old age the onset of a threatening ailment like depression, anxiety, self-esteem, aggression, marital and sexual satisfaction may have an adverse impact on the sufferer. The old age may be detrimental to the psychological aspects of infertility. An inferential analysis of the present study regarding age suggests that aging itself is associated with much maladjustment after onset of infertility. It was hypothesized that aging will be negatively related to the consequences of infertility. It 250 means that infertile couples with different age levels will demonstrate the different levels of depression, anxiety and aggression. It was also assumed that infertile couples would less likely to have self-esteem, marital and sexual satisfaction. The findings are inconsistent with our hypothesis except for the aspect of sexual satisfaction. Contrary to our hypothesis, findings proposed that factor of age are not associated with varying degrees of depression, anxiety, self-esteem, aggression and marital satisfaction (Table 54). Only for sexual satisfaction, age has been found a significant associated factor particularly for the age group of 56-65 years old when compared to younger age group of 26-35 years old and 36-45 years old (Table 55). They had significantly sharper rates of declining sexual satisfaction than did the younger age group who remained childless The proposed rationale for this result is; most people assume that it is optional to produce children whenever they wanted. But after spending considerable time in this assumption when they decide to have children they feel frustrated.. A highly prevalent feeling of older people with infertility is loss of sexual satisfaction. Age stratification varies from culture to culture. Some of the women facing infertility problem tried extramarital contacts to produce a bay but a significant member of such women adopted children. Women reported intense feelings of sorrow and jealousy because they were deprived from some very significant aspects of social life. Education wise Differences in Depression, Anxiety, Aggression, Self esteem, Marital and Sexual Satisfaction of Infertile sample The data of the present study were further analysed from other dimensions to study all those situations and emotional upheavals that couples seeking infertility treatment may ever experience. that is more crucial to be studied. This analysis was performed to see whether the infertile couples belonging to different educational 251 levels slightly differ in their depression, anxiety, self-esteem, aggression, marital and sexual satisfaction. It was clearly considered that different educational levels would contribute to the psychological facets of infertility. The results of One Way Analysis of Variance for scores of infertile on BDI, BAI, ISE and ISS showed non significant effect of education (Table 57). The findings implied that the infertile sample belonging to different educational levels did not differ in depicting their depression, anxiety, self-esteem and sexual satisfaction. The results concerning the same hypothesis further showed significant differences among the six groups of different educational level on the measures of aggression and marital satisfaction. It was hypothesized that aggression and marital satisfaction would be in different patterns for different groups of infertile people belonging to different categories of education. The findings of the present research supported the hypothesis which implied that different groups of respondents showed different degree of aggression and marital satisfaction. The findings of post-hoc (Table 58) test, performed to knowing which groups are distant to each other on Aggression Questionnaire summarized that infertile sample with matric qualification and infertile sample with post graduate qualification depicted different patterns of aggressive behavior. Similarly the findings for marital satisfaction indicated the significant difference between infertile sample that are below matric and infertile sample with F.A qualification (Table 59). On the basis of these findings it can be concluded that below matric group is less likely to have marital satisfaction as compared to the sample of F.A qualification. Income wise Differences in Depression, Anxiety, Aggression, Self-Esteem, Marital and Sexual Satisfaction Inflicted by Infertile Couples 252 In Pakistani social set up one finds a sharp contrast in families, on the one hand belonging to very high and, on the other hand belonging to very low income The data were further analyzed to explore the role of income level to which infertile couples are exposed, in their depression, anxiety, self-esteem, aggression, marital and sexual satisfaction. It was hypothesized that infertile couples having different income levels would differ in depicting their depression, anxiety, self-esteem, aggression, marital and sexual satisfaction but the results of the study did not confirm this assumption (Table 61). Concerning the hypothesis about depression of infertile couples of different income groups, it was noticed that income level was not the significant factor of depression for infertile couples. These conclusions do not go with our assumptions that the infertile couples with different income level will show the different patterns of psychological changes that may occur in couples after being announced infertile couples. The findings related to differences in depression, anxiety, self-esteem, aggression, marital and sexual satisfaction toward the infertile couples of different income level did not show any evidence of differential treatment. This indicates that different psychological aspects of infertile couples were not contingent upon the income of infertile couples. Since infertility has such great consequences to the social, emotional, physical, and economic well-being for many couples but the findings suggested that the role of income level was not significant for infertile couples facing varying degrees of depression, anxiety, self-esteem, aggression, marital and sexual satisfaction. It means that consequences of infertility are prevalent equally in all groups suggesting that income level is not associated with psychological aspects of infertility. 253 Language wise Differences in Depression, Anxiety, Aggression, Self-Esteem, Marital Satisfaction and Sexual Satisfaction of Infertile sample It seems to be important to give attention to enduring and significant aspect of our society that may flourish with reference to these results. Most evident in this regard is language. Language tells us a great deal about a culture. In contrast to some other culture, language permeates all parts of society. The data were further analyzed to see the impact of language on depression, anxiety, self-esteem, aggression, marital and sexual satisfaction resulted due to infertility in couples. The effect of language of infertile couples on their psychological states has never been investigated as thoroughly by the researches, although it was considered that different languages can contribute to different levels of depression, anxiety, self-esteem, aggression, marital and sexual satisfaction. The analysis showed the vital role of language particularly for the measures of depression, anxiety and sexual satisfaction (Table 63). The findings of the present study suggested that the infertile couples of Urdu and Punjabi languages differed in terms of depression. Results indicate that Urdu speaking respondents are more likely to be depressed as compared to Punjabi speaking respondents (Table 64). The results further indicated that the difference in displaying anxiety between Urdu language group and Punjabi language group was highly significant, which implies that Urdu group reported more anxiety when compared to Punjabi group (Table 65). A credible justification for this finding can be supported by the evidence as discussed in the correlation analysis of all measures to be studied in the present study that depression and anxiety are highly positively correlated with each other. It explains that people who are depressed are more likely to have anxiety. This assumption is supported by the findings of effect of language on depression and anxiety which suggest that the 254 group of Urdu language feels higher level of anxiety, depression simultaneously. as compared to group of Punjabi language. As for as the finding related to sexual satisfaction is concerned, the results indicated significant impact of language on sexual satisfaction (Table 66). The hypothesis pertaining to the difference in the degree of sexual satisfaction of infertile couples has been supported by the findings of present study. The inferential analysis suggested the surprisingly difference found between Saraiki and Punjabi language groups. The finding entails the interpretation that both groups differ in their sexual satisfaction and Saraiki are less likely to be satisfied as compared to Punjabi group. Infertile Couple’s Overall Profile Irrespective of Perception of Infertility Reason Diagnosed in Couples On Urdu-Versions of BDI, BAI, AQ, ISE, IMS, and ISS The data of the present study were further analyzed from another aspect for which the infertile sample were grouped into four categories on the basis of knowing the cause of infertility present in respondent, in his/her partner, in both, or in non of them. Planned comparisons were selected and it was hypothesized that the partners who have been identified with a cause of infertility will show the greater signs of depression, anxiety, and low self-esteem, and high aggression, low marital and sexual satisfaction. The results are consistent with the hypothesis only for self-esteem and sexual satisfaction (Table 67). The findings showed that the partners who are identified with cause of infertility have significant differences on the Index of self-esteem and Index of sexual satisfaction as compared to other partners who have never been identified with cause of infertility. These results supported the hypothesis which implies that 255 partners identified with cause are more likely to have low self-esteem and low sexual satisfaction than other partners who are with no cause of infertility. Although impotence and infertility are two different states, it has been reported by the mental health professionals that when male come to know about his infertility because of weak and dead sperms they are likely to experience temporary impotence. The same can happen to female and they also experience sexual frigidity by knowing about their infertility. Fertility and sexuality are sociologically related with each other. Many women who are unable to conceive may experience being not a real woman and the same may happen to the males as well. Although virility has nothing to do with the fertility yet male with weak or dead sperm may experience sexual inadequacy. As for as the hypothesis is concerned about male/female-factor infertility, it was assumed that couples diagnosed with male-factor infertility would experience more psychological changes when compared with the sample of those couples who are diagnosed with female-factor infertility. The results of present study indicated that both groups of sample have significant differences in experiencing anxiety, self- esteem and sexual satisfaction. It suggested that the male-factor infertility is more distressing for couples as compared to the female-factor infertility for couples. The number of infertile couples is increasing all over the world. It is not surprising that over 3 millions people are seeking treatment for their infertility in North America every year. The treatment for infertility is not only costly but it affects the people emotionally and in some cases it can affect their relationship adversely. In past years, difficulties with fertility were usually attributed to the female partner. However, it is now commonly known that the male factor plays a significant role. In fact, recent medical practice and research indicates that male infertility is the sole 256 cause in 30 - 40 % of all infertility cases. In another 10 - 15 %, a combination of male and female factors contributes equally. Infertility investigations should therefore always include a thorough assessment of both partners. The emotional and psychological impact of male infertility is often underestimated. Counseling and support by an infertility team, for both partners, is recommended to help limit the potentially devastating emotional impact. Descriptive analysis of reasons for infertility showed that inability to conceive can be caused by disorders found in the couples (40%), in women alone (23.5%) or in the male partner alone (28%). In some of the cases no real cause for infertility is observed (08.50%). This may coincide with the percentage ratio studied by ESHRE Capri Workshop (1996) as discussed in chapter Physiological Aspects of Infertility. Summary of Regression Analysis for Variables Predicting Depression, Anxiety, Aggression, Self-Esteem, Marital and Sexual Satisfaction of Infertile Couples The data of present research were further analyzed to explore the predicting ability of all variables such as depression, anxiety, aggression, self-esteem, marital and sexual satisfaction. For these variables no hypothesis was formulated because we could not find empirical evidence for the relationship of these variables with each other except depression with anxiety and the relationship between marital and sexual satisfaction. Supportive evidences for both kinds of relationship have already been discussed in terms of correlation matrix among variables. However, it was observed during the data collection that these variables have significant importance for each other. So data were analyzed to explore the empirical evidences. The regression analysis performed to determine the impact of variables such as anxiety, aggression, self-esteem, marital and sexual satisfaction on depression, showed the highly significant impact of anxiety, aggression and self-esteem on 257 depression. The findings highlight the fact that anxiety and self-esteem are significant factors contributing towards depression (Table 69). As argued by Blascovich and Tomaka (1991), infertile couples who report low self-esteem also report less contentment and more anxiety. Through this finding, a new surprising yield has been come to under study that aggression is also another significant factor that may lead to depression. The results shown above may lead us to conceptualize the importance of. significant relationships among depression, anxiety aggression and self-esteem. The literature review has also revealed the empirical support for these findings. As Anate and Akeredolu, (1995) reported that the inability to conceive is related with psychological problems particularly social isolation, extreme sense of guilt, higher level of anxiety and depression, and low level of self-esteem in both genders. When data were analyzed to investigate the effect of depression, anxiety, aggression and self-esteem on marital and sexual satisfaction of infertile couples, it was found, hence the marital and sexual satisfaction are positively correlated with each other which implies that couples who are in satisfying marriages would have sexual satisfaction. The results further indicated that lower level of self-esteem of infertile couples is a significant indicator for their declines in marital and sexual satisfaction (Table 73 & 74). Regression analysis conducted to find the impact of all variables on marital satisfaction showed the significant effects. Sexual satisfaction and self-esteem are found significant for marital satisfaction which indicated that both of the factors are significant predictors of marital satisfaction (Table 73). The regression analysis performed to determine the importance of variables contributing towards self-esteem showed a predominant role of depression, anxiety and, marital and sexual satisfaction. The highest β weight is an indicative of lower self-esteem (Table 72). This finding is 258 supportive of prior researches as cited in literature review. Affect and Disord (2003) evaluated the differences in psychological distress, marital satisfaction, and sexual satisfaction. He concluded that distress caused by infertility resulted in less marital and sexual satisfaction might be a strongest phenomenon for lowering the self-esteem. Qualitative Analysis of Semi-Structured Interviews with Infertile Sample Interviews with 60 men and 60 women were conducted to investigate common perceptions of the causes of infertility, impact of childlessness, and where men and women commonly seek care. Both men and women perceived infertility in women to be caused by evil spirits or physical problems and infertility in men to be the result of psychosexual problems and physical problems. The interviewees perceived herbalists and traditional healers to be women’s best treatment option. For men, however, remarriage was thought to be the best option, followed by seeking help from herbalists and .indigenous experts. It is interesting to observe that most of the participants irrespective of their age, gender and education believed that infertility is caused by a super-natural phenomena particularly sorcery, witchcrafts and curses. When it was further explored they also sighted some other causes of infertility such as promiscuity, use of contraceptives and abortions. In most of the cases infertility was attributed to females but when it was discussed with them they also came to realize that infertility can be caused by the dead or weak sperms of males. Whenever there is a problem of infertility it is initially discussed by the elderly female members of the family who may at times recommend some harmful herbal treatments they may also visit “Peers” and some other traditional healers and that is likely to affect the health of females as well as males. Kidney failure is very common because of this inadequate method of 259 treating infertility. It is strongly recommended that treatment of childlessness should be a part of primary health care. Female perception of infertility was also examined through interviews, very few women had any idea about real cause of infertility 84% of the respondents were of the view that child birth is basically an issue of divine will. Those women who sought proper treatment for infertility range from 20% to 50%. 52% of the infertile women consulted traditional Muslim healers like "peers" and "aamils ". 38% consulted herbalist and other forms of "Tib-e-younani" significant percentages visited scared places like Bahauddin Zakariya tomb, Data Darbar of Lahore, Baba Farid-u- din tomb at Pakpatten. Infertile females had a great sense of insecurity they apprehended that their husband would take another wife or may just abandon them. In some of the cases males physically abuse their wives or their infertility. Infertile women were scared of social functions because they were generally humiliated for their being infertile. 20% of infertile women reported that they did not go for the proper medical treatment because of its high costs. Women seeking infertility treatment usually waited an average of 3 years after their marriage and majority of the respondents have gone for different courses of treatment. Family and relatives support childless females to find out a solution in our matrilineal society. Mostly infertile females go to the traditional and herbal healers. If they become fail, nearly half of them go to the hospital where they found the treatment options very low in number and haphazard. Females talk about their infertility in traditional ways, as result of hold by spirits, a negative match between the partners’ blood. Extramarital sexual relations are common to such kind of females to have a pregnancy, and some females adopted a child. All women reported the 260 feelings of sadness and jealousy, and felt lonely because they were excluded from some important activities and ceremonies in our societies. . Nevertheless, four areas are important that restrict access to IVF (In Vitro Fertilization) at the local level in developing countries: lack of knowledge and education about reproductive biology, class systems, gender dynamics, and local religious restrictions. So it is concluded that because of cultural and economic constraints, IVF will never be a feasible option for most couples experiencing infertility in developing countries. Since infertility has such great consequences to the social, emotional, physical, and economic well-being for many couples, the key is to prevent the most significant preventable cause of infertility-reproductive tract infections. It was analyzed that for the low income group, infertility treatment is very expensive and that forces infertile couples to consult quacks (coax) "peers", and these people are generally exploited by inadequate health professionals (like "shamons") it is recommend that such couples may be provided with appropriate information about their problem and the treatment of that problem. It has been further observed that unsafe abortion practices also result into infertility. Through the effective use of mass media infertile couples may be made aware of their problems and can escape exploitation from "peers" "magicians" and "shamons". Trying to decide when to stop is very difficult. They feel guilty for not trying everything available, even though emotionally they wonder whether they can take any more disappointment. They feel the stress of wanting to quit all this desperate trying. ART (Advance Reproduction Technology) generates its own momentum. Patients speak of the heightened intensity of life during ART. On the one hand, new treatment opportunities can mitigate emotional distress because the couple is offered another 261 opportunity for conception. However, the stepwise progression through the protocol can propel patients and treatment staff alike to move to more complex steps without stepping back to adequately consider the broader view of the decision, for example, the increasingly complex ethical dilemmas, and of the many levels of secrecy that may ensue. As the momentum of patients’ emotional and financial investment increases, it becomes more and more difficult to make the decision to stop treatment. In the quest to help people, we can forget that part of treatment decisions may be helping individuals through the difficult decisions regarding a possibly childless life in the future. Exciting advances in technology hold the promise of increased conception rates. For many, it will mean the realization of their hopes for children. But for those unable to conceive even with improved technology, the promise will prove to be only an illusion, and we may see a corresponding increase in distress. Advances in reproductive technology may afford increased control over reproduction. But belief in this control can prove to be illusory for those unable to conceive, heightening the distress they experience in a world where even the others who are infertile are conceiving. With the increase in choice will come to the increased burden of choice, which may affect the quality of life and psychological well-being for everyone involved? Patients can choose the style of counseling that best suits their needs whether individual counseling, couple counseling or group counseling. The word infertility has a devastating effect upon majority of individuals. Even those people who were highly advocated may accept it rationally but it becomes very difficult for them to accept it emotionally. Their relationship can be adversely affected particularly their level of marital and sexual satisfaction. This is recommended that partners should openly communicate with each other, understand each other's problem and take anonymous decision for the resolution of the problem. 262 Conclusion The present study may be considered a pioneering research in studying psychological aspects of infertility with specific reference to Pakistani cultural context. The study focused the emotional changes that occur in couples after being diagnosed with a problem of infertility that was mostly neglected and least heard. The present study has identified several dimensions related to infertility and its psychological effects. Major conclusions of the study are given below. • In line with the main hypothesis of this study, the results indicated that infertile couples tend to demonstrate higher levels of depression, anxiety, aggression, and lower levels of self-esteem, marital satisfaction and sexual satisfaction as compared to fertile couples. • Findings of the gender differences suggested that males and females have no differences in their levels of aggression and, marital and sexual satisfaction. However, infertile females tend to have higher levels of depression, anxiety and low levels of self-esteem as compared to infertile males. • Results concerning educational levels indicated that infertile people with matric qualifications are more aggressive as compared to infertile people with post graduate qualifications and infertile people with bellow matric qualifications are in less satisfying marriages as compared to infertile people with F.A qualifications. • It was also found that age of subjects has no effect on their levels of depression, anxiety, aggression, self-esteem and marital satisfaction except on sexual satisfaction. It means that infertile people with age groups of 26-35 and 36 to 45 are less satisfied with their sexual life as compared to infertile people with age of 56 to 65 years. 263 • Contrary to our assumptions, the data provided the evidence that income, family system and rural/urban area do not play important roles in deterioration of emotional disturbances of infertile couples. Only one difference is to be found significant on aggression regarding rural/urban areas. These findings suggested that infertile couples from rural areas are more engaged in aggressive behaviors as compared to infertile couples from urban areas. • The findings further showed the positive role played by language for depression, anxiety and sexual satisfaction but non-significant effect of language on aggression, self-esteem and marital satisfaction. It means that sample of Urdu language are more likely to be depressed and anxious as compared to Punjabi speaking sample. Results also showed that effect of language is contributing in the differences of sexual satisfaction of Punjabi and Saraiki speaking sample. • The study yielded important findings that the partner who is diagnosed with cause of infertility is likely to have less sexual satisfaction and low self-esteem as compared to other partner with no cause of infertility. • The findings of this study were also suggestive of this fact that the couples, who have the male-factor infertility, are more anxious and have a decline in their level of self-esteem and sexual satisfaction as compared to couples having females-factor infertility. • The regression analysis showed that anxiety, aggression and self-esteem are significant predictors of depression while marital and sexual satisfaction has no significant impact on depression. • Anxiety is regressed upon depression and aggression. Since all the other factors are not significantly associated with anxiety. 264 • Aggression is regressed upon depression, anxiety, self-esteem and marital satisfaction and the result of sexual satisfaction has been found non significance. • Depression, aggression, marital satisfaction and sexual satisfaction have significant impact on Self Esteem. Results also showed that the factor of anxiety is not significantly associated with self-esteem. • Marital Satisfaction is highly regressed upon aggression, self-esteem and sexual satisfaction. Results also suggested that depression and anxiety are not the functions of martial satisfaction hence the results are found non significant. • Sexual Satisfaction is regressed upon self-esteem and marital satisfaction. Since all the other factors are not significantly associated with sexual satisfaction. Limitations While the overall findings of the present research were encouraging, it is important to acknowledge its limitations as well. The following are some of the limitations of present research. • The sample used in the present research is not large enough to represent the whole population of infertile couples in Pakistan. As described earlier in literature review that infertility affects one in six couples (17%) of childbearing age (Ulbrich et al., 1990) and more than 5 million couples in the United States can be classified as having a substantial infertility-related problem and at least 8% of married couples will be initially unsuccessful in their attempts to have a biological child (Collins et al., 1993). The unavailability of the exact statistics about infertile couples in Pakistan was a 265 major restriction in selecting a representative sample of this kind of population. • Unwillingness of the participants to participate in the present research because of the sensitivity of the issue of infertility that has a tremendous impact on the well being of a couple, is another limitation for taking representative sample. It is reasoned earlier that infertility is often a lonely and confusing battle for couples, so the scarcity of resources restricted to select the sample based on convenience sampling instead of a nationally representative one. • The study was restricted to the habitants of some big cities of province of Punjab. The research can not be generalized to the infertile couples of the whole country, especially those who hold traditional values and where gender roles are more specified and strictly imposed like in other provinces of Pakistan. • Review of the literature revealed that most of the researches on studying the psychological aspects of infertility were conducted in the Western and European cultures. So, the findings can not be generalized to non-western societies. The present research was not a cross-cultural research in the true sense, as the Pakistanis are with a variety of values. But the present research was just limited to infertile people of Punjab. But the differences in overall responses of infertile couples suggest that cultural differences could make big differences among them in showing their psychological reactions towards the problem of infertility. • As it has been reasoned earlier that the non-availability of assessment instruments for the measurement of the levels of depression, anxiety, aggression, self-esteem, marital and sexual satisfaction of infertile couples 266 made the task of the present research quite hectic and lengthy. It was realized while conceiving the design of the research that an exploration into such a sensitive issue of infertility would not be completed unless some basic tools for the assessment of depression, anxiety, aggression, self-esteem and, marital and sexual satisfaction were adapted and translated into Urdu. Because there were no other reliable instruments except of depression and anxiety available for this purpose. Although, the sufficient psychometric properties of the adapted and translated scales were determined but still a lot of analysis can be computed to standardize the scales and to find out the norms of the scales. However, it stands relevant and reliable to the cultural peculiarities of Pakistani society with reference to this sensitive issue of psychological consequences of infertility. • Most importantly, depending on the heterogeneity and complexity of sample, no one research questionnaire or approach to study this sensitive issue of psychological changes due to infertility could possibly provide the full scope of knowledge that is needed to understand fully its dynamics. The main weakness of the present study was that qualitative research was shifted to quantitative one to confirm or reject the findings of study statistically. However, an unstructured interview was conducted to collect the qualitative data but it was not fully advantageous to meet the objectives of study. Suggestions In the light of limitations and across the wide implications of present research, following are the some suggestions for future researchers regarding the betterment of research work. 267 • Nevertheless, the present study has significantly contributing in assessing the psychological aspects of infertility such as depression, anxiety, aggression, self-esteem, marital and sexual satisfaction with peculiar reference to Pakistani cultural context. It is suggested that more researches should be carried out with a larger sample from different provinces of Pakistan with reference to infertility and its psychological effects. A larger sample belonging to different areas of Pakistan may give a better insight into infertility and its related psychological problems. A broad based awareness of infertility and its resultant effects on couples should be given a higher priority for maximum benefit to the infertile couples. • Although, the sufficient psychometric properties of the adapted and translated scales were determined but it needs more validation studies to strengthen the psychometric properties of all the scales. For further research a national sample may be included in the study. It will help particularly, to establish norms, concurrent validity and reliability of the scales. So it is suggested to compute further analysis with a larger and representative sample to prove its strength. • The phenomena of psychological aspects of infertility should be explored from qualitative methods of research as well. Case study method would be best to take a deep insight for presenting a different and cultural specific picture of infertile couples with peculiar reference to Pakistani society set up. • A need for informational programs on infertility regarding its psychological aspects and its management is felt strongly. Most important is the implementation of counseling centers for the guidance of infertile couples. Counseling centers should be established where psychological problems 268 related to infertility could be reported and psychological help should be available. Implications of the Study Apart from the findings of the present research, the study has number of implications in areas related to infertility. • The present study, tried to take into consideration the crucial issue of infertility, the most neglected area in psychological research in Pakistan with respect to infertility. Nevertheless, the present research may be considered a pioneering in the area of infertility. The present research has opened new venues for research in the area of infertility and its psychological aspects while taking into account certain other factors. • The findings of the study has explored the issue of psychological aspects of infertility from different dimensions and it has also been fruitful in indicating further areas of empirical interests from cultural and methodological point of view. The present research may further help to understand the phenomena of infertility from other perspectives and may suggest some different kinds of contributing factors such as adoption of a child, divorce in couple due to infertility and husband’s second marriage because of remaining childless. Another area which needs research is studying the effect of the working and non-working status of infertile females on their social relations. It may be worth trying to study the other factors in relation to infertility for future research. • The study has made major contribution to the area of infertility as well as psychological interventions as it has provided six indigenously adapted and translated scales. These scales may be used as reliable measures for the assessment of depression, anxiety, aggression, self-esteem and, marital and 269 sexual satisfaction of couples in clinical settings when they come to counseling. The findings of the present study may help in establishing stress interventions and management techniques. • Measurement instruments provided by this study based on well researched and validated constructs will enable the future researchers to deal more effectively with this sensitive issue of infertility. • The results of the present study may provide a unique issue for further research in this area and a lot of research is to be carried out to strengthen the findings of present study. The issue of psychological aspects of infertility has to be further strengthened by employing larger and representative sample from various regions of Pakistani population. • The scales can provide statistics about infertile couples with respect to their psychological state after being diagnosed with problem of infertility. The present study is first of its kind and the findings of the pilot and main study would help the public and counseling psychologists to understand about underlying factors of infertility. It may help in missing awareness of couples and their family members in this regard. Public may not be aware of the harm they can cause the infertile couples. They are simply unaware of the psychological and emotional needs of them and are also unaware of that infertile couples always demand social support which they only can provide them.
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