Gender differences in the adjustment to infertility have been widely discussed in the literature, namely focusing on differences between men and women regarding psychological symptoms and emotional responses and on differences attributed to parenthood. Findings document that in general women reported higher emotional difficulties than men in almost every stages of infertility (Holter, Anderheim, Bergh, & Moller, 2006; Markestad et al., 1998), although patterns of reactions along the infertility experience are similar (Boivin et al., 1998). When examining gender differences on the importance attributed to parenthood, no differences have been found (Moura‐Ramos, Gameiro, Canavarro, Soares, & Santos, 2012). As a result, it has been argued that gender differences on the adjustment to parenthood may be due not to different experiences of infertility and ART, but due to differences in expressing and reporting emotional difficulties (Edelmann & Connolly, 2000). However, we should also consider that unintended childlessness may have a different meaning for men and women (Berg, Wilson, & Weingartner, 1991) and therefore a different impact on their adjustment to infertility and assisted reproduction. Consequently, it may be that the processes by which their distress is affected are different.
The present study
In this study, we investigated the association between infertility history (i.e., duration of infertility and number of previous ART treatment cycles) and emotional adjustment in couples undergoing ART. More specifically, this study investigated the indirect effect of infertility history on emotional adjustment through influencing representations of the importance of parenthood and childlessness, while accounting for gender differences in those effects. We aim to clarify some inconsistencies observed in the literature regarding the role of infertility history on the emotional adjustment of infertile couples. Understanding how patients'
infertility history relates to their emotional adjustment during ART treatment will contribute to a more comprehensive view of the adjustment process to infertility. This understanding may help fertility health care services to identify patients who are at higher risk for emotional distress and stages at which patients may need more support and to delineate targeted interventions to the patients.
Indirect effects of history of infertility on men and women's emotional adjustment
The results of the present study underline that adjustment to infertility is a highly personal experience, influenced by previous experience and by each person's own representations of the importance of parenthood in their own lives. Indeed, duration of infertility and number of past ART treatments only affected adjustment indirectly, by affecting men and women's representations of parenthood.
The number of previous ART treatments influenced men's adjustment but not their partner's. Men in couples who had undergone a greater number of treatment cycles attributed a lower importance to parenthood and had fewer symptoms of depression and anxiety. A higher number of previous treatments, as suggested by Boivin et al. (1995), may have confronted patients with the increasingly more probable prospect of childlessness, promoting its acceptance and reducing their distress, which is underlined by the indirect effect found in the study. At the time the sample was recruited, ART in public settings in Portugal was limited to three cycles, unless otherwise clinically recommended. Men undergoing more treatment cycles could have adjusted their expectations to more easily accept future childlessness. These men may have perceived themselves as having diminished options to achieve parenthood, due to financial (having to move to private clinics) or medical reasons (lower chances of conceiving after three cycles, Pinborg, Hougaard, Andersen, Molbo, and Schmidt, 2009), resulting in less emotional difficulties. According to Lazarus and Folkman (1984), the persistence of a chronic stressor (such as repeated failures in pursuing treatment to achieve pregnancy) can give the opportunity to address its demands, by developing new goals and replacing or reappraising old ones. However, this response pattern was not found for women. The number of previous ART cycles did not affect women's emotional adjustment directly or indirectly, and it was not associated with representations regarding the importance of parenthood in one's life. This result was surprising, as it would be expected that past treatment failure would be associated with emotional adjustment (Boivin et al., 1995).
According to this argument, it could also be considered that longer infertility would be associated with lower distress; however, this did not occur. The pattern of association between duration of infertility and couples' emotional distress was clearly distinct, as this association was positive and curvilinear, apart from the effect on women's depression. Men with longer infertility reported higher importance for parenthood, which was associated with their anxiety and depressive symptoms. Duration of infertility was not associated with the number of previous ART treatment cycles; therefore, we can presume that some couples had periods of time during which their infertility was untreated and unresolved. This may have increased their emotional difficulties by sustaining expectations regarding treatment and by not allowing for the confrontation of treatment failure. Conversely, depression tended to be lower in women with longer infertility, namely those trying to get pregnant for more than 6 years. Considering that couples in our study were entering treatment, which is a moment of high uncertainty and hope, it can be expected that anxiety is heightened but feelings of loss, which are related depression, may be decreasing after a long‐time experiencing infertility. Nevertheless, this result was surprising and future studies should clarify this issue.
In summary, these results suggest that the resolution and acceptance of the infertility condition occurs not after a long duration of infertility but as a consequence of the experience of repeated ART treatment failure. It seems that it is the process of dealing with treatment failure, confronting couples with childlessness, leads couples to reappraise their life goals and expectations for the future. Couples, who have difficulty envisioning themselves in the future without children and believe that parenthood is the major goal of their life, tend to experience psychological distress when entering treatment. Previous research has shown that this distress is accentuated if they experience failure (Verhaak, Smeenk, Evers et al., 2005; Verhaak, Smeenk, van Minnen, Kremer, & Kraaimaat, 2005). Early detection of these difficulties can be important for professionals to help couples dealing with this distress.
Gender differences on the effects of history of infertility on emotional adjustment
This study showed that the number of previous ART cycles and the duration of infertility affected women's and men's adjustment differently. Having undergone a higher number of treatment cycles may have confronted men with the increasingly more probable prospect of childlessness, promoting its acceptance and reducing their distress, but it did not occur with women, who probably envision every new ART cycle as a moment of hope for achieving pregnancy. This is coherent with past research that underlines that men are more prone to consider treatment termination (Greil, Leitko, & Porter, 1988; Sydsjo, Ekholm, Wadsby, Kjellberg, & Sydsjo, 2005), which may translate in easiness to accept future childlessness when compared to women (Peddie, van Teijlingen, & Bhattacharya, 2005; Volgsten, Skoog Svanberg, & Olsson, 2010). These results should be interpreted considering the specificities of the Portuguese social and cultural context, which shapes gender roles and expectations regarding parenthood. Indeed, as other southern European countries, Portugal has rooted traditional views on family and gender roles (Nishioka, 2003) and is conservative regarding parenthood and children. Indeed, although children are equally important for men and women (Aboim, 2007), they play a core role in women's identity making more difficult for them to accept future childlessness.
Examining the effect of duration of infertility in men's and women's adjustment also underlines how the processes of adjusting can be different among couple partners. While it is clear that being unsuccessfully trying to get pregnant is associated with an increase in psychological symptoms, with a tendency to accentuate in the later years, women's depressive symptoms are an exception. To interpret these results, we should bear in mind that data were collected in the beginning of treatment, which is a moment of heightened hope and expectations (Benyamini, 2003). In this situation, women who have been infertile for a long time but are now in treatment may exacerbate positive emotions (hope, optimism) and diminishing depressive symptoms. In men, the process was the opposite, which may be the result of a lower involvement with the treatment procedures, preventing the experiencing of positive emotions that occur in the beginning of the treatment after several years infertile, associated with a lower use of positive reframing in that situation in order to better adapt to it (Jordan & Revenson, 1999). These results underline how different may be the experience of undergoing assisted reproduction treatments and that couple members may cope differently with past experiences. Nevertheless, more studies are needed to further explore the different mechanisms affecting men and women's adjustment to infertility.
Strengths and limitations
A major contribution of the present study was the test of nonlinear and indirect associations contributing to the effect of infertility history on emotional adjustment in couples entering ART. Albeit several studies have previously examined the influence of clinical variables on couples' adjustment, these results contributed to highlight the process by which that influence operates. The inclusion of both couple members within a dyadic design that explores the experiences of both men and women while controlling for the non‐independence of couples' scores (Kenny et al., 2006) was an important contribution, as it allows studying the specificities of adjustment in men and women while controlling for the interdependence of their experience.
The identification of infertility history as a significant predictor of emotional adjustment is an important contribution because it allows health care providers to direct their attention to more specific characteristics of infertile couples presenting for ART and to target their interventions in order to meet the specific needs of each couple. Additionally, it highlights the importance of referral of infertile patients to fertility clinics in due time.
In addition to the aforementioned contributions, several limitations of the present study are worth noting. The sample size is small, which reduces the power to detect a significant effect; therefore, small effects could have been detected if the sample was larger. The cross‐sectional design does not allow the establishment of causality. Future studies should focus on investigating the impact of infertility history in couples' long‐term adjustment and in different stages of ART treatment. Lastly, when interpreting these results, it is important to take into consideration the regulation constraints of ART in Portugal, as the law regulating assisted reproduction was developed in 2006 and fully applied since 2009. Therefore, when participants from this study started to try to get pregnant, the referral routine was not well established, and the timely referral for the fertility care would largely depend on the geographical zone of residence of the patients and on each medical centre approach.
Implications for research and clinical practice
The results of our study have several implications for research and for clinical practice with infertile couples. First, studies directed at further investigating the impact of infertility history on adjustment should consider the nonlinearity of the associations between these variables. It is noteworthy that some of the linear or direct associations that were tested were non‐significant, which would have led us to conclude that history of infertility did not have any impact on the couples' adjustment. It is then important to explore more complex patterns of associations. Second, our results highlight individual variability in the experience of infertility and ART treatments, which was related to the past experience on infertility and to the different meanings attributed to parenthood and childlessness. Indeed, although recognized as a stressful life event for all couples, undergoing ART treatments may impose distinct demands on couples depending on their previous infertility history. Therefore, patients at different treatment phases may require different types and levels of support. Additionally, results underline the role of sociocultural differences that may shape the importance attributed to parenthood. Therefore, these results can be translated in recommendations for health care, namely (1) to develop health policies to ensure that couples who meet the criteria for infertility diagnosis are directed to infertility centres in a timely manner; (2) that psychosocial interventions directed at couples who present emotional difficulties when entering an ART programme consider their previous infertility history and discuss all treatment scenario possibilities and consequences; (3) to discuss the meaning of parenthood and childlessness with couples, to adjust their expectations regarding treatment; and (4) to assure that fertility care takes into account cultural, social, and religious differences that are known to affect the importance attributed of parenthood and therefore the adjustment to infertility.
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