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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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• 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.
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• 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
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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
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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.
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• 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
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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
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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.
