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This is to certify that the

thesis entitled

THE RELATIONSHIP BETWEEN IMPACT, COPING
STRATEGIES, AND LENGTH OF INFERTILITY

presented by

Patty Jo Hopkins

has been accepted towards fulfillment
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Master of Sciencedegree in Nursing

 

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1/98 WWW“

THE RELATIONSHIP BETWEEN IMPACT, COPING
STRATEGIES, AND LENGTH OF INFERTILITY

BY
Patty Jo Hopkins

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

THE RELATIONSHIP BETWEEN IMPACT, COPING
STRATEGIES, AND LENGTH OF INFERTILITY

BY
Patty Jo Hopkins

A nonexperimental descriptive secondary data analysis
was completed to examine the impact, types and effectiveness
of coping strategies, and length of infertility upon
infertile women. Forty-four infertile women who had
undergone at least one gonadotropin ovulation induction
treatment cycle completed two questionnaires designed to
determine impact and coping strategies. The impact of
infertility was low to mild and did not significantly differ
by length of infertility. There was much overlap between
types of coping strategies used in the Initial phase and
those used in the Intermediate and Late phases. Women in
all phases of infertility hoped things would get better.
Overall effectiveness of coping strategies was low. The
strategy that was most effective throughout all phases of
infertility was talking the problem over with someone who
had been in a similar situation. Supportant coping styles
showed a positive relationship with effectiveness in all
groups, however Late phase showed significantly less
effectiveness than Intermediate. Implications for clinical

practice include education and counseling throughout each

phase of infertility.

Copyright by
Patty Jo Hopkins
1998

To my husband, Ken, for his constant encouragement
and belief in my abilities. To our daughters,
Lindsey Jean and Maegen whose miraculous

births renewed faith in all of us.

iv

ACKNOWLEDGMENTS

My special appreciation to my chairperson, Rachel
Schiffman, PhD, for her patience, encouragement, and expert
academic guidance. Thank you to Jacqueline Wright, MSN, for
your encouragement and participation in my endeavor. A very
special thank you to Linda Keilman, MSN, for your

unrelenting encouragement, support, and advice.

TABLE OF CONTENTS

LI ST OF TABLES 0 O O C O O O O O C 0
LIST OF FIGURES . . . . . . . . . . .

INTRODUCTION . . . . . . . . .
Background . . . . . . . . .
Statement of the Problem . . . .

Conceptual Definition . . . . . . . .
Impact of Infertility . . . . .
Types of Effectiveness of Coping
Length of Infertility . . . . .

Conceptual Model . . . . . . . . . .

Review of Literature . . . . . . . .
Impact of Infertility . . . . .

Coping Strategies and Effectiveness

Length of Infertility and Impact

Summary . . . . . . . . . . .
Methods . . . . . .
Design . . . .
Sample . . . . . . .
Instruments . . . . .
Operational Definitions
Data Analysis . . . . . .
Human Subjects . . .
Assumptions .
Limitations

Results . . . . . . . . . . . . . . .
Sample . . . . .

Impact of Infertility by Length of Infertility
Types of Coping Strategies and Length of

Infertility . . . . . . . . .

Effectiveness of Coping Strategies and Length

of Infertility . . . . . . . . .

vi

Strategies

Page
viii

O
uraF'

Qtnébb

11
14
17

21
21
22
22
23
27
27
28
28

TABLE OF CONTENTS (cont.)

Discussion . . . . . . . . . . . .

Sample . . . . . . . . . . . . .

Impact of Infertility . . . . . .
Types of Coping Strategies . . . .
Use of Coping Strategies . . . . .
Effectiveness of Coping Strategies
Coping Strategies . . . . . . . .
Theoretical Framework . . . . .

Implications . . . . . . . . . . . . .

Major Findings . . . . . . . . . .

LIST OF REFERENCES . . . . . . . . . .

APPENDICES

Appendix A .

Appendix B . .
Appendix C . . .
Appendix D . . .

vii

33
33
36
38
40
41
44
44

46
46

57

6O
62
66
67

Table

Table
Table

Table

Table

Table

LIST OF TABLES

Eight Coping Styles on the Jalowiec

Coping Scale . . . . . . .

Impact of Infertility . . .

Rank Order of “often used” Strategies

Means, Standard Deviations,
Use . . . . . . . . . .

Rank Order of *very helpful" Strategies

Means, Standard Deviations,
For Effectiveness . .

viii

and F Values for

and F Values

Page

LIST OF FIGURES

Figure 1: Conceptual Model of Coping

ix

INTRODUCTION

Background

For most couples, pregnancy is a naturally occurring
event. For those couples who face infertility, the
consequential treatment and outcome can be devastating.
With advancing technology, infertility treatment can last
from six months up to 10 years for those who can financially
and emotionally endure the often disappointing results
(Becker & Nachtigall, 1994). Experimental treatments and
difficult procedures create a highly stressful experience
and can test coping skills (Blenner, 1992). Effective
coping is, in part, determined by the type of coping
strategies utilized as well as available resources and
previous problem solving skills. Coping strategies and
effectiveness of those strategies are also impacted by the
length of infertility. It is predicted that unique coping
strategies are utilized and effectiveness of those
strategies differ with length of infertility. The purpose
of this study was to investigate the relationship between
impact of infertility, types of coping strategies used
during this stressful experience, the effectiveness of those

coping strategies, and length of infertility.

2

For the 15-20% of couples affected by infertility
(Christensen, 1986; Mahlstedt, 1994; Menning, 1980; Phipps,
1993; Steward & Glazer, 1986), the impact of infertility
associated with long-term infertility treatments is not to
be minimized. Infertility is a life long experience with
ever-lasting wounds (Balen & Trimbos-Kemper, 1994). Women
experience greater levels of psychological distress than men
as a direct consequence to infertility (Abbey, Andrews, &
Halman, 1991; Beaurepaire, Jones, Thiering, Saunders, &
Tennant, 1994; Berg & Wilson, 1991; Cook, Parsons, Mason, &
Golombok, 1989; Halman, Andrews, 8 Abbey, 1993; Hynes,
Callan, Terry, & Gallois, 1992; Laffont & Edelmann, 1994;
Litt, Tennen, Affleck, & Klock, 1992; Morrow, Thoreson, &
Penney, 1995; Phipps, 1993; Reading, Chang, & Kerin, 1989;
Tarlatzis, Tarlatzis, Diakogiannis, Bontis, Lagos,
Gavriilidou, & Mantalenakis, 1993). Therefore, women show a
greater impact resulting from the infertility experience and
associated treatment measures, exhibiting higher distress
behaviors and using a greater variety of coping strategies
during this process.

Hammer-Burns (1987) defines infertility as “the
inability to conceive or carry a pregnancy to live birth
after one year of normal sexual intercourse without
contraceptives” (p. 359). While many women are referred to
infertility specialists for advanced treatment, diagnosis
often occurs in the primary care setting. Due to the

complex emotional, educational, physical, and adaptive needs

3

of this population, the Advanced Practice Nurse (APN) is in
an ideal situation to intervene during all phases of the
infertility experience in both the primary care setting and
while undergoing specialty care. The APN can provide
education, information, resources, support, and act as an
advocate for women during this experience.
Statement_of_£rohlem

The impact of infertility is discussed in the
literature; however, the relationship to length of
infertility has not been clearly developed. Women
experience a significant psychological impact as a result of
the infertility experience. Importantly, this impact
employs different coping strategies as infertility
lengthens. While some coping strategies are discussed in
the literature, most are generalized to the infertile
couple, few are related to the length of infertility, and
none relates specifically to the effectiveness of the coping
strategy and the length of infertility treatment phenomenon.
Therefore, given the impact of infertility and the limited
information about coping, the research questions were:
1. What is the association of length of infertility and

perceived impact of infertility?
2. What is the relationship between length of infertility

and types of coping strategies utilized by infertile

women?

4

3. What is the relationship between length of infertility
and coping strategies infertile women perceive to be
most effective in dealing with their infertility?

If associations are positive between length of
infertility and the stated independent variables, the
results could prove powerful in planning care for the
infertile population. Specifically, a generalized protocol
could be devised which focuses on coping strategies specific
to length of infertility.

Conceptual Definitions

The variables, impact of infertility, types and
effectiveness of coping strategies, and length of
infertility have been defined multiple ways in the
literature. For the purpose of this study, the variables
were defined and discussed as follows.

I l E I E !.].l

Involuntary childlessness is an unanticipated event
that often results in difficult psychosocial consequences
which include guilt, sorrow, isolation, powerlessness, and
loss of self-esteem (Phipps, 1993). For women, the
psychological risks are great. Women pursue medical
treatment despite known health risks out of responsibility
for child-bearing (Becker & Nachtigall, 1994). Women are
subject to societal expectations to bear children and

therefore experience greater impact when conception is not

possible.

5

Women place greater significance on having children
than men (Halman et al., 1993). Women show frequent
behaviors of depression, hostility, and interpersonal
sensitivity during and following infertility treatment
(Bernstein, Mattox, & Kellner, 1988). Women feel a sense of
failure during menses, are reluctant to discuss infertility
issues with family and friends (Prattke & Gass-Sternas,
1992), and describe infertility as a continuous struggle
with a loss of the pregnancy, mothering, and child
experience (Phipps, 1993). Women experience increased
levels of depression with decreased self-esteem and self-
confidence with failed in vitro fertilization (IVF) cycles
(Beaurepaire et al., 1994; Hynes et al., 1992), experience
more disruption in their social, personal, and sex lives
than men, feel more responsible for and stress from the
infertility problem (Abbey et al., 1991), and experience
more stress regarding childlessness (Brand, 1989).

Prolonged stress depletes the individual of internal
resources and requires more diverse and externally focused
coping strategies for positive adaptation. For the purposes
of this study, impact of infertility was defined as any

cognitive or behavioral consequence which taxed the

resources of the individual.
I 3 BEE !' E : . 5! l .

Coping skills are learned processes and aid the
individual to adapt to stressors. Coping encompasses all

coping strategies used without regard to the final outcome.

6

Lazarus and Folkman (1984) describe two functions of coping;
problem-focused coping which is managing the demands with
the environment which is causing the distress, and emotion-
focused coping which is described as regulating the
emotional response to the demand. In effective coping,
problem-focused and emotion-focused coping complement each
other. 'Various coping strategies are used by the individual
based upon the immediate need of problem-solving or emotion-
focused coping, whichever need is greater. Effectiveness is
determined by the individual based upon positive outcomes.

Coping strategies are referred to by Jalowiec (1987) as
actions taken to deal with stressors. Jalowiec (1987)
identifies sixty individual coping strategies. These
individual strategies comprise eight different coping
styles. These styles are confrontive, evasive, optimistic,
fatalistic, emotive, palliative, supportant, and self-
reliant coping strategies. Confrontive coping styles refer
to facing the problem and problem-solving. Evasive styles
refer to avoidant or evasive activities used to cope with a
stressor. Optimistic styles refer to positive thinking and
outlook as well as positive comparisons. Conversely,
fatalistic styles include pessimism, hopelessness, and
feeling little control in coping with the stressor. Emotive
styles include expressing and releasing emotions and
ventilating feelings. Palliative styles include trying to
control or reduce distress by using behaviors to make the

person feel better. Supportive styles refer to the use of

7
personal, professional, and spiritual support systems.
Self-reliant styles refer to dealing with the stressor by
oneself rather than depending upon others.

These eight coping styles as described by Jalowiec
(1987) can be categorized to fit with Lazarus and Folkman's
(1984) functions of coping. Confrontive, supportant, and
self-reliant coping styles might fit into problem—focused
coping. Evasive, optimistic, fatalistic, emotive, and
palliative coping styles might best fit emotion-focused
coping as described in the Lazarus and Folkman (1984). For
the purpose of this study, type and effectiveness of coping
strategies was defined as any cognitive or behavioral action
categorized into confrontive, evasive, optimistic,
fatalistic, emotive, palliative, supportant, or self-reliant
used by the infertile woman to enable her to cope with her
infertility and which we found to be useful.

I I] E I E I°J°l

Length of infertility is defined in the literature as
number of IVF cycles, number of years of infertility, number
of years of treatment, or simply as an implied length of
time. Infertility is described as a crisis situation
whereby the infertile person experiences stages of surprise,
denial, anger, isolation, guilt, grief, and hopefully
resolution in their attempt to cope with this life event
(Menning, 1980).

Berg and Wilson's (1991) study defines length of

infertility as stages. Stage one represents the first year

8
which includes diagnosis and initial treatment. Stage two
represents the second year which includes medical
investigation and hope for success. Stage three represents
year three and beyond and include advanced treatment.

Beaurepaire et al. (1993) defines length of infertility
by number of IVF cycles. Reading et al. (1989) as well as
Laffont and Edelmann (1994) define length of infertility in
number of years of treatment. .

For the purposes of this study, length of infertility
was defined as a process with specific phases. The Initial
phase encompasses the initial shock reaction as a response
to diagnosis, information seeking, and the impact resulting
from diagnostic testing and preliminary treatment. The
Intermediate phase encompasses the need for further
information seeking regarding treatment options and
prognoSis, focuses on communication skills, and identifies
external resources. The Late phase encompasses prolonged
.length of infertility and strategies to maintain the marital
relationship, restore self-esteem, and bring about
resolution with a positive outcome.

Conceptual Model

Roy's Theory of Adaptation provides a framework which
can be adapted to incorporate the impact of infertility,
type and effectiveness of coping strategies, and length of
infertility (see Figure 1). The person is an adaptive
system which interacts constantly with the changing

environment thereby encountering stimuli or inputs. The

ENVIRONMENT
INPUTS

 

Adaptation Process

  
 
  
 
   
 
 
 
    

External stimuli
Internal stimuli

Length of
Infertility

f

 

 

Cognator

OUTPUTS

 

        
    

Functioning ‘ Self-Concept

IMPACT OF
INFERTILITY

Role Inter-
Function

Types of coping
strategies

Effectiveness of
coping strategies

 

 

 

Regulator

Person

 

 

 

 

Feedback

Figure 1. Conceptual model of coping with infertility based

on Roy's Theory of Adaptation. Adapted from Fithatrick,
J.J. and Whall, A.L. (1989).

10
envirgnment encompasses all internal and external stimuli
which affect the behavior and develOpment of persons and
groups (Meleis, 1991).

Utilizing Roy's Adaptation Theory, the length of
infertility is classified as an input that the person, as an
adaptive system, must process through self-appraisal of
one's resources, beliefs, and well-being resulting in types
of coping strategies and effectiveness of coping strategies.
The length of infertility precipitates an adaptation process
(self-appraisal) according to Roy's theory. The next step
in the adaptation process is the processing of the impact of
infertility through both the regulator and the cognator
mechanisms which can present a physical and/or symbolic
disruption in behavior and/or functioning which require
coping (Meleis, 1991). The impact of infertility is
directly effected by the length of infertility.

As the impact of infertility is processed through the
regulator which includes physiological functioning and
perception of self concept, and the cognator mechanisms
which includes alterations in role functioning and
interdependence, it is channeled through the specific modes
of adaptation (effectors). These modes share a common
proponent: impact of infertility. The person's perception
of the impact of infertility and the length of infertility
determines the specific individual coping strategies. While
impact may effect types and effectiveness of coping

strategies, this study did not study those effects. The

11
direct relationship between length of infertility and impact
are the focus of this study.

Length of infertility directly determines the types of
coping strategies used and the effectiveness of the coping
strategies. Ineffective coping strategies demand the need
for nursing to potentiate coping mechanisms (Meleis, 1991).

Review of Literature

In reviewing the overall body of literature on
infertility, there are five studies (Abbey et al., 1991;
Halman et al., 1993; Laffont & Edelmann, 1994; Phipps, 1993;
Stanton, 1992) that explore the impact of infertility.

Seven studies (Davis & Dearman, 1991; DeHaan, 1995;
Edelmann, Connolly, & Bartlett, 1994; Hynes et al., 1992;
Litt et al., 1992; Morrow, Thoreson, & Penney, 1994; Prattke
& Gass-Sternas, 1992) examine coping strategies and
effectiveness. Five studies (Beaurepaire et al., 1993; Berg
8 Wilson, 1991; Laffont & Edelmann, 1994; Reading et al.,
1989; Wilson, 1979) explore impact associated with length of
infertility. For most of these studies, the length of
infertility is defined, but the identified coping strategies
and/or effectiveness of the strategies are not directly
related to the specific length of infertility.

I l E I E !.].l

Women's perceptions of the impact of infertility (Abbey
et al., 1991; Halman et al., 1993; Hynes et al., 1992;
Laffont & Edelmann, 1994; Litt et al., 1992; Stanton, 1992)

is clearly described in the literature. Abbey et al. (1991)

12

interviewed 275 couples, 170 with primary infertility, in
early stages of treatment where the length of infertility
averaged 34 months (IVF and gamete intrafollopian transfer
(GIFT) couples were excluded). Results emphasized the
greater impact upon women. The study concluded that wives
reported more personal, social, and sexual stress, and
placed greater emphasis upon having children than their
husbands. Consistent with these findings are Prattke and
Cass-Sternas (1992) study results of artificial insemination
donor (AID) participants. Overall, women reported higher
impact associated with aid. Litt et al. (1992) concluded
that women who showed escape as a coping mechanism following
an unsuccessful IVF cycle were more likely to have used
ineffective coping. They also reported impact as feeling a
loss of control in their lives resulting from infertility.

More recently, Halman et al. (1993) completed a data
analysis of a previous study in 1988 of 161 infertile
couples who were interviewed to investigate the source of
their infertility problem, importance of children, stress of
infertility treatment, number and acceptance of tests and
treatments received, length of time expected to conceive,
and ideal number of children desired. Inclusion criteria
were having been seen by an infertility specialist, self-
perception of infertility, and not having participated in
IVF. Results were similar to those of Abbey et al. (1991)
in that women's impact of infertility resulted in a higher

level of stress and women held a greater importance to

13
having children. Additionally, Hynes et al. (1992) showed
impact of infertility in women undergoing IVF included
greater depression and lower self-esteem four to six weeks
following an IVF procedure, and lower self-confidence
overall.

The impact of infertility was also investigated by
Phipps' (1993) qualitative phenomenological study of eight
couples which identified impact of infertility and specific
coping strategies but did not define length of infertility
or the effectiveness of each coping strategy. The inclusion
criteria was not stated, although those who participated in
IVF or support groups were excluded. Similar to Abbey et
al. (1991) and Halman et al. (1993) where women experienced
higher stress levels, women reported an impact of over-
whelming struggle of loss, emptiness, anger, sorrow,
isolation, and loss of control over their bodies. Laffont
and Edelmann's (1994) study of 117 women and 101 men who had
undergone at least one IVF treatment showed consistent
results of impact of infertility with those of Abbey at al.
(1991), Phipps (1993), and Halman et al. (1993) of increased
disruption, stress, and alteration in thought processes
throughout the IVF treatment cycle.

These studies identify the impact of infertility on
women which range from broad, such as personal, social, and
sexual stress (Abbey et al., 1991; Prattke & Gass-Sternas,
1992), higher stress levels in general (Halman et al., 1993;

Hynes et al., 1992), increased disruption, stress, altered

14

thought processes, to more specific impact as described by
Phipps (1993) and Litt et al. (1992) such as struggle of
loss, emptiness, anger, sorrow, and loss of control.
Laffont and Edelmann (1994) discuss a mean length of
infertility with a general impact.

: . 5! l . 1 EEE l'

Further research focuses on coping and coping
strategies, most of which are in responses to (IVF) or donor
artificial insemination (DAI). Multiple authors have
identified coping strategies (Davis 8 Dearman, 1991; DeHaan,
1995; Edelmann, Connolly, 8 Bartlett, 1994; and Prattke 8
Gass-Sternas, 1992). Only a few (DeHaan, 1995; Edelmann,
Connolly, 8 Bartlett, 1994; Litt et al., 1992; Prattke 8
Gass-Sternas, 1992) identified length of infertility, but
not in relationship to types of coping strategies. DeHaan
(1995) studied effectiveness of coping strategies but did
not study the relationship between either types of coping
strategies or length of infertility.

Type_gf_5;rategy. Davis and Dearman (1991) conducted a
qualitative research study which investigated coping
strategies of infertile women. Six consistent coping
strategies were used during this challenging process. These
types of coping strategies.included distancing self from
infertility reminders, regaining control, being the best,
finding hidden meaning, acknowledging feelings, and sharing
with other. Effectiveness of strategies were not studied.

Similarly, Edelmann, Connolly, and Bartlett (1994) report

15
that women experienced more depression and engaged in more
problem and emotion-focused coping. Women use distraction,
direct action, catharsis, social support, and religion with
a higher frequency than men (Edelmann et al., 1994). Women
identified cognitive coping strategies through gaining
information, seeking support, reading, verbalizing, and
focusing on the positives of not being pregnant (Phipps,
1993).

In Morrow, Thoreson, and Penney's (1995) study of 215
participants (125 being women) which focused on predictors
of psychological distress (impact), gender specific coping
strategies were identified. Participants had received
medical treatment for infertility a mean length of 3.12
years (SD=2.61 years). There was no breakdown of length of
infertility. Women used more self-blame and avoidance,
informational and emotional support seeking, and cognitive
restructuring coping strategies. Effectiveness of these
coping strategies was not measured. In the Litt et al.
(1992) study of women and unsuccessful IVF cycles, results
show that women used more escape-avoidance, problem-solving,
and confrontive coping strategies. Escape avoidance is a
negative coping strategy most often association with
depression, anger, mood disturbance, confusion, and tension-
anxiety. The range of infertility was one to thirteen years
with a breakdown of 25% of women having completed 0-6 AID
cycles, nine of the women having completed 7-12 cycles and

six had completed 12 cycles or more.

16

DeHaan (1995) investigated the impact of infertility,
coping strategies used, and the effectiveness of coping
strategies used by infertile women. The sample was
comprised of 44 nulliparous women who had received at least
one Metrodin or Pergonal treatment cycle. Length of
infertility ranged from 1-15 years with a mean of 4.6 years.
Optimistic and confrontive coping styles were most
frequently used. The strategies most often used were geared
towards optimism by hoping that things would improve and
infertility would resolve. These coping strategies were not
related to the length of infertility. Infertile women
attempted to gain information and education, and tried to
keep busy and maintain a normal lifestyle despite the
disruption caused by their infertility.

Many different types of coping strategies are
identified in the literature: distancing self, regaining
control, being the best, finding hidden meaning,
acknowledging feelings, and sharing with others (Davis 8
Dearman, 1991). Distraction, direct action, catharsis,
social support, and religion are identified by Edelmann et
al. (1994). Seeking support, reading, verbalizing, and
focusing on positives are identified by Phipps (1993).
Self-blame, avoidance, information and emotional support
seeking are identified by Morrow et al. (1995). Optimism,
gaining information, education, keeping busy, and
maintaining a normal lifestyle are discussed by DeHaan

(1995).

17

Effectiyeness_of_senins_5trategies- In the one study
which captures effectiveness (DeHaan, 1995), the most
effective coping strategy reported by infertile women was
sharing their experiences with other infertile women. Also
effective was gaining information about their problem,
maintaining a sense of humor, and sharing infertility
experiences with family and friends (DeHaan, 1995).

Effective coping strategies include sharing
experiences, gaining information, maintaining sense of
humor, and sharing infertility experiences with family and
friends. Ineffective coping strategies include escape
avoidance behaviors which are associated with depression,
anger, mood disturbance, confusion, and tension anxiety.
I I] E I E l']'! i I I

In additional studies of the relationship between
psychological impact and the length of infertility, the
definitions of length of infertility are inconsistent.
Length of infertility has been defied as either number of
Pergonal/IVF cycles or as number of years of infertility or
treatment. Reading et al. (1989) conducted a study
involving 37 women undergoing IVF and/or endometrial
transfer (ET) during the beginning of the cycle, at day
eight of treatment, and at the conclusion of treatment. A
comparison group of ten women who were not pregnant or
attempting to conceive were assessed at days 10-12 and days
26-28 in their menstrual cycle. The length of infertility

ranged from 0.8 to 4 years, and the length of treatment was

18
0 to 10 years (M=3-3 years). Results of impact of
infertility indicated that subjective distress, depression,
anger, fatigue, and confusion increased during the IVF
cycle. With subsequent IVF cycles, tension vigor, and
fatigue were higher than the initial IVF cycle. Generally,
distress levels rose with length of infertility although
these women who perceived control over their treatment
reported less distress.

Laffont and Edelmann's (1994) study reported a mean of
3.4 years ($D=3.0) of infertility treatment prior to an IVF
cycle with 79% having two to nine IVF attempts. Results of
impact were that women showed higher levels of stress
throughout all phases of the IVF cycle than men except
during replacement of embryos.

As Reading et a1. (1989) and Beaurepaire et al. (1993)
studies indicate, impact intensified as length of
infertility increased, Berg and Wilson's (1991) study
provides specific areas of impact in relation to defined
lengths of infertility. Stages are defined as year 1 or
Stage 1 which represents diagnosis and initial treatment,
year 2 or Stage 2 which represents some medical
investigation and offers hope of success, and year 3 and
beyond or Stage 3 which represents advanced investigational
procedures with guarded success. Inclusion criteria was a
twelve month period of attempting to conceive, receiving

medical treatment for infertility, no children living in the

19
home, and participation of spouses. Length of infertility
ranged from one month to ten years.

The relationship of impact to length of infertility are
as follows. Psychological strain was borderline for Stage
1, normative for Stage 2, and symptomatic in Stage 3.
Depressive symptoms followed suit with moderate elevations
in Stage 1, normal in Stage 2, and markedly elevated in
Stage 3. Also, Stage 3 participants showed higher levels of
depression, anxiety, and hostility. Interpersonal
sensitivity was moderately elevated in Stages 1 and 3.
Similar to Stage 3 participants, Beaurepaire et al.'s (1993)
study of new and repeat cycle patients undergoing IVF/ET
where length of infertility was measured by the number of
IVF/ET cycles indicated that anxiety, depression,
neuroticism, guilt, and control were higher in repeat cycle
women than in inductee women. Overall, women showed higher
levels of anxiety, external locus of control, dependency,
and guilt than men. The most significant finding was that
repeat cycle women showed higher levels of depression than
inductee women.

Specific impact was identified by Wilson (1979) showing
a sequence of emotional changes occurring during a
progressive length of infertility. The first response was
disbelief and denial to the diagnosis of infertility. The
second response was depression, anger, and altered self-
image where the patient stated feelings of embarrassment,

and inadequacy which resulted in self-doubt and altered

20
self—image. The third response was optimism which enabled
the patient to seek treatment and share experiences with
others. The fourth response was desperation where the
patient often bargains with the physician for unconventional
types of treatment therapies. The fifth response was
depression. This occurred after unsuccessful treatment or
infertility was absolute. Similar to Stage 3 in Berg and
Wilson's (1991) study, the final response was acceptance
which results in acceptance of childlessness. In this
study, stages of impact are implied without identification
of a defined length of infertility.

These studies address the relationship between the
impact of infertility and the length of infertility.
However, as is the case in the Reading et al. (1989) and
Beaurepaire et al. (1993) studies, the impact was not
correlated to a specific length of infertility but rather to
a general mean length of either number of years or IVF
cycles. Differentiation of impact at specific lengths of
infertility is difficult. Impact seems to increase in
relationship to a mean length of infertility. Berg and
Wilson (1991) do specifically correlate impact with defined
stages of length of infertility. Wilson (1979) identifies
an implied progression of impact over an unidentified length
of infertility.

Summary
The literature addresses many of the emotional efforts

resulting from the infertility experience. If these

21
emotional responses are equated to impact, then the
literature shows many similarities. Length of infertility
is not consistently defined in the literature. Some studies
use number of IVF or Pergonal cycles, while other studies
use number of years. Other than Berg and Wilson (1991),
specific durations of length of infertility are not defined.
While there is literature that addresses the impact of
infertility, coping strategies, and effectiveness of these
strategies used by infertile women, there is little research
which investigates the relationships between the impact of
infertility or the specific coping strategies used and the
specific length of infertility. Methods for obtaining data
were interviews or questionnaires which may have inherent
issues such as interviewer bias or interpretation
difficulties with terminology. Instruments show acceptable
reliability. Sample sizes ranged from 16 to 275 with most
over 100 resulting in acceptable generalizability. The
intent of this study was to investigate these relationships
and begin to fill the gaps in the body of literature
regarding types and effectiveness of coping strategies and
length of infertility.
Methods

Design

This study was a non-experimental descriptive secondary
analysis of data from DeHaan's (1995) primary study of
infertile women. DeHaan (1995) investigated the perceived

impact of infertility on infertile women, identification of

22

coping strategies infertile women used, and which coping
strategies women perceived to be most effective.
Sample

The sample for this secondary analysis included the 44
infertile women from the primary study who obtained medical
treatment at a University based Reproductive Endocrinology
practice in the Midwest. The women comprised a convenience
sample who self-referred for the primary study in a phased
enrollment from July through September of 1994. Inclusion
criteria included the ability to read and understand English

and at least one unsuccessful cycle with Metrodin or

Pergonal.
Instruments

The Infertility Questionnaire (IFQ) (Bernstein, Potts,
8 Mattox, 1985) is a 21 item, self report questionnaire
which uses a five-point Likert scale from (1) errengly
disagree to (5) errengly_egree to measure the impact of
infertility in three areas: self-esteem, guilt and blame,
and sexuality (see Appendix A). Bernstein et al. (1988)
reported test-retest reliability to be 0.92. DeHaan (1995)
reported Cronbach's alpha of 0.83 for the self-esteem sub
scale, 0.72 for blame and guilt sub scale, and 0.79 for
sexuality sub scale and a total test alpha of 0.88

The Jaloweic Coping Scale (JCS) was used to measure the
types and effectiveness of coping strategies used by
infertile women (see Appendix B). The 60 item, self report

questionnaire uses a 4-point Likert scale for (0) neyer_need

23
to (3) eflenJeed in response to the question “how often you
used each coping method?,;and (0) ner_nelpfn1 to (3) helpful
in response to the question “how helpful was it". This
questionnaire is a non-specific measurement of stressors
which necessitates the user and/or researcher to indicate
the stressor. DeHaan (1995) labeled the stressor as
“infertility” for the purposes of the primary study.
Validity of coping strategies was established by a research
panel examination. Research panel agreement was as follows;
supportant, 94%, confrontive, 86%, evasive, 85%, palliative,
76%, optimistic, 72%, fatalistic, 67%, self reliant, 66%,
emotive, 54%. Reliability was computed by Cronbach alpha.
Total use alpha was .86 and total effectiveness alpha was
.90 indicating acceptable reliability.
: I' J E E' °!'

Impeet_ef_lnferriliry. The perceived impact of
infertility in women was measured by the IFQ (Bernstein et
al., 1985) (see Appendix A). This 21-item questionnaire
measures the effect of infertility on self-esteem (questions
1-8), blame and guilt (questions 9-13), and sexuality
(questions 14—21). Total score indicates the overall
impact. Bernstein et al. (1985) indicate mean scores for
low distress (1 to 3) and mild to moderate distress (3.1 to
4). Scores for all sections were totaled and divided by 21
for a mean score (DeHaan, 1995).

W. Types

and effectiveness of coping strategies were measured by the

24
JCS (see Appendix B). Individual coping strategies scored
as “most used” and “very helpful” were identified for each
category of length of infertility. Types of coping
strategies were grouped into eight styles according to the
JCS: confrontive, evasive, optimistic, fatalistic, emotive,
palliative, supportant, and self-reliant (see Table 1). Use
and effectiveness mean scores were calculated for each of
the eight coping styles. High scores indicate high use and
effectiveness, while low scores indicate low use and
effectiveness.

Length_ef_lnferriliry. Length of infertility was
grouped into three specific time categories. Berg and
Wilson (1991) suggest that the first year represents the
period of diagnosis and initial treatment, the second year
represents medical investigation and hope for success, and
the third year and beyond to include advanced treatment.

Due to the secondary study data which included a range of
infertility from 1 to 15 years, the time stages needed to be
extended to incorporate Berg and Wilson's (1991) concepts of
stages. For the purpose of this study, Initial phase
included years 0 through 2, Intermediate phase included
years 3 through 5, and Late phase included years 6 through
15. Years of infertility and number of treatment cycles
were collected by self-report on the demographics

questionnaire in the primary study (see Appendix C).

Table 1.

EHI:.EI] H ].:.E]

25

 

1.

Confrontive Coping Styles

4.

13.

16.
25.
27.
29.
33.
38.
43.
45.

Thought out different ways to handle the
situation.

Tried to look at the problem objectively and see
all sides. -
Tried to keep the situation under control.

Tried to change the situation. .

Tried to find out more about the problem.

Tried to handle things one step at a time.

Tried to work out a compromise.

Set up a plan of action.

Practiced in your mind what had to be done.

Learned something new in order to deal with
problem.

Evasive Coping Styles

7.
10.

14.
18.
20.

21.
28.
35.
40.
48.
55.

56.
58.

Tried to get away from the problem for a while.
Tried to put the problem out of your mind and
think of something else.

Daydreamed about a better life.

Tried to get out of the situation.

Told yourself that the problem was someone else's
fault.

Waited to see what would happen.

Slept more than usual.

Let time take care of the problem.

Put off facing up to the problem.

Tried to ignore or avoid the problem.

Told yourself that this problem was really not
that important.

Avoided being with people.

Wished that the problem would go away.

Optimistic Coping Styles

2.
5.
30.
32.

39.
47.
49.

50.
S4.

Hoped that things would get better.

Told yourself that things could be much worse.
Tried to keep your life as normal as possible.
Told yourself not to worry because everything
would probably work out fine. '
Tried to keep a sense of humor.

Thought about the good things in your life.

Compared yourself with other people who were in
the same situation.

Tried to think positively.
Tried to see the good side of the situation.

26

TABLE 1 (cont.)

4.

Fatalistic Coping Styles

9.
12.

23.

60.

Expected the worst that could happen.

Accepted the situation because very little could
be done.

Resigned yourself to the situation because things
looked hopeless.

Told yourself that you were just having some bad
luck.

Emotive Coping Style

1.
8.
24.
46.

51.

Worried about the problem.
God mad and let off steam.
Took out your tensions on someone else.

Did something impulsive or risky that you would
not usually do.

Blamed yourself for getting into such a situation.

Palliative Coping Style

3.
6.
26.
34.
44.
53.

Ate or smoked more than usual.

Exercised or did some physical activity.
Used relaxation techniques.

Took a drink to make yourself feel better.
Tried to keep busy.

Took medications to reduce tension.

Supportant Coping Styles

11.
15.

17.
42.

59.

Talked the problem over with family or friends.
Talked the problem over with a professional person
(such as a doctor, nurse, minister, teacher,
counselor)

Prayed or put your trust in God.

Talked the problem over with people who had been
in a similar situation.

Depended on others to help you out.

Self-reliant Coping Styles

19.
22.
31.

37.
41.

52.
57.

Kept your feelings to yourself.

Wanted to be alone to think things out.

Thought about how you had handled other problems
in the past.

Told yourself that you could handle anything no
matter how hard.

Tried to keep your feelings under control.
Preferred to work things out yourself.

Tried to improve yourself in some way so you could
handle the situation better.

 

27

mm

The relationship between the dependent variable length
of infertility and the independent variables of the impact
of infertility, types of coping strategies used, and the
effectiveness of coping strategies were analyzed.
Descriptive statistics such as frequency, means, and
standard deviations were calculated for all variables.

Specifically, for research question number one which
explored the association of length of infertility (dependent
variable) to the perceived impact of infertility
(independent variable) ANOVA was used. For research
questions two and three which explored the relationship
between length of infertility (dependent variables) and
types and effectiveness of coping strategies, rank order by
frequency of “most often" and “very helpful” responses by
each phase of length of infertility with a textual analysis
of similarities and differences of the results was used.
ANOVA was used for mean use and effectiveness scores by
length of infertility groups for the eight coping styles.
The significance level was set at .05 for all analyses.
HumaLSnbjects

DeHaan's (1995) primary study was approved by
University Committee on Research Involving Human Subjects.
Subjects anonymity was assured by the lack of subjects'
names on questionnaires (see Appendix C) and no identifying
links between questionnaires and mailing list. Implied

consent was obtained through the return of completed

28
questionnaires. Approval of this study was obtained from
the University Committee on Research Involving Human
Subjects prior to data analysis (Appendix D). It was not

possible to identify any subjects. Data were provided by

code numbering.
Assnmntinns

For the purpose of this study, the following
assumptions were made:
1. Respondents completed questionnaires honestly.
2. Data collection and entry were complete and accurate.
Limitations

Limitations of this study included limited
generalizability of results to the general population due to
the small sample size. Individual differences in coping
styles, coping skills, ad available resources are unable to
be differentiated. The limited cross-sectional nature of
the study (all women had high school education with 41.5%
being college educated, implied high socioeconomic level
making affordability of specialty care possible) makes
generalizability of study results applicable to this section
of the population only. Long term individual effects of the
infertility experience cannot be determined which might

yield useful data regarding individual changes over time in

coping methods.

29
Results

Sammie

Forty-three of the 44 women in the sample returned
demographic data. These women ranged in age from 25 to 46
years (M:34.3), had a 1-15 year length of infertility
history (M=4.6), were married 86% (n338), and were all
nulliparous. Most of the women had additional education
beyond high school with 39% receiving 13-17 years of school
and 41.5% receiving 18-24 years of school. Metrodin or
Pergonal cycles ranged from 1 to 11 (M=4.3) (DeHaan, 1995).
I l E I E !.].l l I I] E I E !.].l

The majority of women were in the Intermediate length
group and all mean impact scores were indicative of low or
mild distress (Table 2). No significant differences were
found between total impact scores and length of infertility
(£3.17, p=.84).
I E : . 5! l . i I I] E I E I'J'l

nest Eregnenrly used strategies. Women in all phases
of infertility used “hoped things would get better” with
high frequency (see Table 3). All individual coping
strategies in the Intermediate phase were identified in
Initial phase. Similarities exist in the individual coping
strategies utilized in Initial and Intermediate phases of
infertility such as “tried to think positively”, “worried
about the problemfl,“keep your life as normal as possible"
and.‘tried to keep busy”. Similarities also exist in the

individual coping strategies utilized in the Initial and

3O

 

 

 

 

 

 

 

 

 

Table 2.

InnastJLInfertility

Length Mean SD n

Initial 2.93 .29

Intermediate 2.98 .37 24

Late 3.04 .49 11

Table 3.

Infertilitx

Initial Phase n=8

Item Label Percent
30 Keep your life as normal as possible 87.5
58 Wishes that the problem would go away 75.0
1 Worried about the problem 62.5
2 Hoped things get better 62.5

25 Tried to change the situation 62.5

27 Tried to find out more about the problem 62.5

29 Tried to handle things one step at a time 62.5

44 Tried to keep busy 62.5
50 Tried to think positively 62.5

Intermediate Phase n=24

Item Label Percent
2 Hoped things get better 66.7
50 Tried to think positively 66.7
1 Worried about the problem 58.3
30 Keep your life as normal as possible 58.3
44 Tried to keep busy 58.3

Late Phase n=11

Item Label Percent
2 Hoped things get better 90.9
4 Thought out solutions 81.8
25 Tried to change the situation 72.7
58 Wished that the problem would go away 72.7
27 Tried to find out more about the problem 63.6

 

31
Late phases of infertility such as ”tried to change the
situation" and “tried to find out more about the problem”.
Initial phase seems to encompass most of the coping
strategies used in both the Intermediate and Late phase. In
the Initial phase, women also used two strategies “tried to
change the situation" and “tried to handle things one step
at a time" which were not used by the other phases. Late
phase was the only group to use:“thought out solutions”.
While there is overlap between Initial and Intermediate and
Initial and Late, there was much less similarity between
Intermediate and Late phase infertility.
Types_gf_£eping_fitylee. Of the eight coping styles

defined by JCS, none showed a significant relationship with
length of infertility indicating that while use of
individual coping strategies can be identified, coping
styles are not used with any frequency during each phase of
infertility (see Table 4).

‘ ‘Q‘ o 09.0 .‘ -o- 0.00. -.e o o g '-

Meet_£ffeeriye_§rreregiee. There was minimal overlap

between length of infertility and effectiveness of
individual coping strategies. Women in all phases reported
ftalked with family and friends”las an effective strategy.
Discussing infertility with someone who had been in a
similar situation was effective for women in both the
Initial ad Intermediate phases of infertility; “Tried to
set a plan of action” was used by both Initial and Late.

Faith in God and information seeking were unique to

32

 

 

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.4 manna

33

Intermediate and Late phase. The remaining strategies were
unique to each phase of infertility: Initial” “keep your
life as normal as possible" and “tried to distract yourself",
Intermediate, “tried to keep a sense of humor” and “physical
activity”, Late, “learned something new about problem”,
“thought out solutions", “tried to change the situation”, and
“tried to think positively” (see Table 5).

EIi2Ctixensss_9£_flgning_5tyles. Overall mean
effectiveness for all styles was low. Evasive, Fatalistic,
Self reliant, and Emotive means are between “not helpful”
and “slightly helpful". Supportant, Confrontive,
Palliative, and Optimistic are between “slightly helpful“ to
“fairly helpfulf. Of the eight coping styles only the
Supportant coping style showed significant differences
between groups by length of infertility. Post hoc test
using Scheffe method showed that the difference between
Intermediate phase and Late phase was significant which may
have resulted from the low subject number in Late phase (see

Table 6).

Discussion
Sample
The women studied in this study had a mean age of 34.3,
a mean length of infertility of 4.6 years with a 1-15 year
range, and were nulliparous. Most of the women were
educated beyond high school with 41.5% receiving 18-24 years
of school. DeHaan's (1995) primary study included the same

sample. In reviewing the literature, many of the study

34

 

 

 

 

 

 

Table 5.
Infertility
Initial Phase n=8

Item Label Percent
11 Talked with family and friends 37.7
30 Keep your life as normal as possible 37.7
36 Tried to distract yourself 37.7

38 Set up plan of action 37.7
42 Talked the problem over with someone who

had been in a similar situation 37.7
Intermediate Phase n=24
Item Label Percent
42 Talked the problem over with someone who
had been in a similar situation 50.0

27 Tried to find out more about the problem 41.7

39 Tried to keep a sese of humor 37.5

6 Physical activity 33.3

11 Talked with family and friends 33.3

17 Prayed or put trust in God 33.3

Late Phase n=11

Item Label Percent
45 Learned something new about problem 36.4

4 Thought out solutions 27.3

11 Talked with family and friends 27.3

17 Prayed or put trust in God 27.3

25 Tried to change the situation 27.3

27 Tried to fid out more about the problem 27.3

29 Tried to handle things one step at a time 27.3

38 Set up-a plan of action 27.3

50 Tried to think positively 27.3

 

35

 

 

 

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so. «4. en.~ Ams.veo.a Amm.cmm.a Amm.vsa.a ucmfiamu “Hum
54. as. en.~ .Nm.vms. 26>.VHm. Afio.voe. onumfiamume
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«a. me. ae.~ .vm.vem.H Ame.vms.s Ase.vmm.s m>wuconocoo
no. mm.m mn.~ Ans.vmm.a tom.vmo.~ Aos.vmm.a accuseddsm
m w ud any a am; a 3.3 a
mums mumwemsnmucH HaauficH masum
NHHHHMHMHQH

.6 «Hana

36
samples consisted of infertile couples. For those studies
using infertile women, inclusion criteria was not always
stated although most include those women undergoing IVF
procedures. Demographics on age, educational level,
previous children, or employment status were not
specifically discussed for comparison.
W

The means for all phases of infertility indicate that
women responded.5neutralf'to the questions asked in the IFQ.
Since this questionnaire is designed to measure impact upon
self-esteem, guilt/blame, and sexuality as a result of
infertility, these women did not show significant impact in
these areas.

Bernstein et al. (1985) established scores of 1 to 3 to
indicate low distress, while mean scores of 3.1 to 4
indicate mild to moderate distress. The mean scores across
all lengths of infertility were similar indicating low
distress. The impact of infertility remains stable
throughout the length of infertility, with only a slight
rise in Late phase. These results are not consistent with
results from previous studies. Reading et al. (1989) found
an increased distress level with length of infertility and
progressive IVF cycles. Beaurepaire et al. (1993) also
found impact to intensify as length of infertility
increased. Berg and Wilson (1991) reported symptomatic

strain, markedly elevated depressive symptoms, and higher

37
levels of anxiety and depression as length of infertility
increased.

Perhaps one explanation for the low distress scores
might be the anticipation of these women to experience a
delay in conception since the mean age of the women was
34.3, with a range of 25-46. If women anticipate a delay,
they may be more accepting of the time delay in conception
and of medical intervention. Maybe the delay indicates less
importance of having children. Since this sample was
comprised of educated women, these women may have known not
to blame or feel guilty. Women with higher education levels
may be better problem-solvers which can decrease the impact
of infertility. Career goals may have attributed to life
satisfaction, increased self esteem, or served as a
distractor. Almost all of the women (n=38) were married
which may decrease the impact of infertility. In addition,
this sample was cross-sectional and not longitudinal;
therefore, changes over time could not be determined.

Women receiving care at this specific site may have had
their issues addressed by their health care provider. Maybe
questions were answered sufficiently and comprehensive
information was provided. Perhaps issues related to self-
esteem, guilt/blame, and sexuality were addressed by support
persons in the site. Resources for these women may have
been provided through support groups, written information,

or through individual counseling.

38
I E : . 5! I .

Mest_Eregnenrly_ueed_srretegies. During the Initial
phase of infertility the diagnosis is made, initial
treatment takes place, and usually hope is greatest for
conception. It is not surprising that the two most “often
used“ coping strategies are “keep your life as normal as
possible” and “wishes that the problem would go away”.
Wilson (1979) discusses the disbelief and denial that
accompanies diagnosis of infertility. Certainly, the
strategies identified here may be a response to diagnosis.
Many women hope that the diagnosis is erroneous and that
pregnancy will be spontaneous. Women also “worried about
the problem?,“hoped things get betterfl.“tried to change the
situationfl,“tried to find out more about the problemf,
“tried to handle things one step at a time”, and “tried to
keep busy”. This sample of women show problem-solving
approaches with the strategies “tried to change the
situation", “tried to find out more about the problem”, and
“tried to handle things one step at a time". ‘These problem-
solving approaches may be a result of their educational
level or of individual coping characteristics. The coping
strategies “worried about the problem” and “hoped things
would get better” are a natural response to the initial
impact of infertility. These coping strategies of
information seeking (Morrow et al., 1995), keeping busy, and
maintaining a normal lifestyle (DeHaan, 1995) are consistent

with those found in the literature.

39

Women in the Intermediate phase of infertility
indicated that they used some of the same coping strategies
as were used in the Initial phase. Women in the
Intermediate phase of infertility seem to be more accepting
of the situation. They are no longer'“trying.to change the
situation” or “wishes the problem would go away". This
Intermediate phase often brings increased disruption in
daily activities resulting from medication or treatment
regimens, office appointments, or even surgical
intervention. Optimism enables the person to seek treatment
and share experiences with others (Wilson, 1979). Optimism
is also identified as a coping strategy by both Phipps
(1993) and DeHaan (1995). These coping strategies appear to
be directed towards minimizing daily disruption, ensuring
positive thinking, and staying focused on daily life. Women
continue to “worry about the problem” as they struggle to
achieve a pregnancy.

Interestingly, women in the Late phase of infertility
use strategies such as “tried to change the situation",
“wished the problem would go away”, and.“tried to find out
more about the problem" that were also used in the Initial
phase of infertility. “Hoped things get better” was used in
all phases of infertility. Unique to this Late phase was
the strategy'“thought out solutions". ‘Women must decide
about the use of experimental treatments, alternative
parenting such as artificial donor or adoption, or whether

to end treatment all together. Wilson (1979) discusses the

40
bargaining that occurs during later stages of infertility
for unconventional treatment and the acceptance process of
remaining childless.

Women identify individual coping strategies used
throughout the length of infertility, many of which remain
the same through the entire experience. “Hoped things would
get better"was used through all three phases indicating
that these women experienced hope in all phases of length of
infertility. “Thought out solutions”‘was used exclusively
during the Late phase indicating the women's thoughts
towards resolution.

WW

Mean scores for confrontive and optimistic indicate
these styles were “sometimes used”, while the remainder
indicate:“seldom usedf. None of the coping styles were
“often used”. Initial phase means are somewhat lower than
Intermediate and Late phase which could have resulted from
the lower number of subjects in this group. Standard
deviations are low indicating little variance from the mean
score. While many individual coping strategies were
identified asthoften usedf, coping styles were not different
with length of infertility indicating that a specific coping
style was not used during any of the phases of length of
infertility. Rather a limited variety of individual coping
strategies within the styles were used during all phase of
infertility which could suggest that a specific style of

coping is not used at any one time based upon the low level

41
of use. Perhaps some of the coping strategies used are not
identified on the JCS suggesting that women may have used
other types of coping strategies then those identified.
BEE Ii E : . S! ! .

Mest_Effeetiye_Stretegiee. During the Initial phase
which encompasses the initial shock reaction, diagnosis, and
impact resulting from diagnostic testing and preliminary
treatment, support from family and friends and from those
who can share personal experience can help to cope with the
infertility diagnosis and treatment regimens. Family and
friends can acknowledge feelings and instill hope. Sharing
of experiences can help the women to prepare for further
diagnostic procedures or treatment regimens. Strategies
such as “keep your life as normal as possible", “tried to
distract'yourself", and “set up a plan of action” allow the
individual to problem solve, minimize disruption in daily
life, and attempt to minimize self-absorption. Perhaps this
sample had many social support systems and close, supportive
family members that resulted in increased effectiveness of
these strategies. These specific strategies may have shown
a greater effectiveness for this sample group due to their
higher educational level, career pursuits, problem-solving
abilities, and strong family support. It is important to
note that while some individual coping strategies were more

effective than others, the overall frequency of “very

helpful" Was low.

42

The Intermediate phase encompasses the need for further
information seeking regarding treatment options and
prognosis, focuses on communication skills, and identifies
external resources. Women in the Intermediate phase of
infertility shared two coping strategies perceived ast“very
helpfulf‘with women in the Initial phase. These two ‘
strategies are “talked the problem over with someone who had
been in' a similar situation” and “talked with family and
friends”. 'These two strategies which are supportant
behaviors, continue to be perceived as somewhat effective as
duration of infertility lengthens. Again, this may be
attributed to a strong spousal or family support system for
this sample. Other perceived effective coping strategies
include “tried to find out more about the problem", “tried to
keep a sense of humor”, “physical activity", and “prayed or
put trust in God?. These strategies perceived as effective
were consistent with DeHaan's (1995) findings. Gaining
information, maintaining a sense of humor, and sharing
infertility experiences with family and friends were‘
perceived as effective coping strategies in her study. None
of these coping strategies were identified as “most used" in
the Initial phase. Information gathering about treatment
regimens including IVF, additional medical interventions, or
perhaps specialty services can help the women to prepare
herself and determine a plan with appropriate problem
solving techniques. The benefits of physical activity can

help to alleviate mental and physical stress. Faith can

43

help to instill a sense of hope and strength while
alleviating stress. Information gathering becomes more
important as interventions become more complicated and
experimental.

The Late phase encompasses prolonged length of
infertility and strategies to maintain the marital
relationship, restore self-esteem, and bring about.
resolution. During the Late phase of infertility, women
identify nine coping strategies as “very helpful? although
effectiveness was low. Specific to this phase are “thought
out solutions" and “tried to change the situation”. Both of
these strategies are:“very helpful? during the Late phase.
“Talked with family and friends” and “prayed or put trust in
Godficontinue to be useful in the Late phase as well as the
Intermediate phase of infertility. “Set up a plan of
action" was perceived as effective in both the Initial and
Late phase of infertility. During the Initial phase of
infertility, setting a plan of action refers to diagnostics
and initial treatment regimes. During the Late phase of
infertility, setting a plan of action may refer to more
experimental treatment regimes, alternative parenting such
as adoption, or abandonment of treatment. Again in the Late
phase, women may need to determine a plan of action in terms
of an end-point and a plan to bring resolution.

The overall effectiveness of individual coping
strategies is low indicating that none of the coping

strategies are remarkably effective. Perhaps none of the

44
strategies showed effectiveness since the only acceptable
outcome is conception, which these strategies could not
provide.
EEE l' E : . 5! 1

Evasive, fatalistic, and emotive coping styles indicate
that women found them to be between “not helpful" to
“slightly helpful“.' The remainder of the coping styles were
found to be between “slightly helpful” to “fairly helpful".
None of the coping styles were indicative of “very helpful“.
Standard deviations are very low indicating little variance
from the mean. Of the eight coping styles, only Supportant
showed any significance. The mean score is lower in Late
phase and significantly different from Intermediate phase.
Supportant coping styles seems to be only “slightly helpful"
during Late phase. Those supportant coping strategies
viewed as “slightly helpful" to “fairly helpful” are
perceived as less effective as duration of infertility
increases. Perhaps women in Late phase infertility stop
using coping strategies that show such low effectiveness.
Went}:

Findings from this study support the theoretical
framework. Length of infertility is classified as the
input. As length of infertility is processed through the
cognator and regulator, the perception of impact occurs.
The impact of infertility is low to mild distress over the
entire length of infertility. Women in Initial and

Intermediate phases of infertility experience the same

45
impact, while women in Late phase experience a slightly
higher, but not significant, distress level. i

The relationship between length of infertility (input)
and types of coping strategies (output) is positive. There
appears to be overlapping of types of coping strategies in
the Initial and Intermediate phases. Those women
experiencing Initial phase of infertility uSed two
strategies significant to this phase of infertility» “tried
to find out more about the problem” and “tried to think
positively”. Women experiencing Late phase infertility
shoed a significant relationship with the coping strategy
“tried to change the situation” specific to this phase.
Those women in the Initial and Intermediate phases of
infertility chose similar coping strategies such as “worried
about the problemfl,“hoped things get betterfi,“keep your
life as normal as possibleflt“tried to keep busyfi,“tried to
think positively” which were directed at minimizing
disruption, maintaining hope, and problem-solving.

The relationship between length of infertility (input)
and effectiveness of coping strategies (output) is positive
as well. Women in the Initial phase perceived.9keep you
life as normal as possible”,“tried to distract yourself”,
and.“set up a plan of actionT‘as effective coping
strategies. Women in the Intermediate phase perceived
“tried to find out more about the problemfi,“tried to keep a
sense of humor”, “physical activity", and “prayed or put

trust in Godfias effective coping strategies. During both

46
the Initial and Intermediate phases of infertility, women
perceived.“talked with family and friends" as the most
effective coping strategy. Women in the Late phase of
infertility used mostly Supportant coping strategies.

As the person experiences each phase of infertility,
there is an adaptation process which determines the impact
of infertility. In this particular study, the impact of
infertility was the same for each phase of infertility. In
the model length of infertility is directly related to the
type of coping strategies used. While there was some
overlap between each phase of infertility, there were
individual coping strategies that were used only during a
specific phase of infertility. Length of infertility also
directly influenced the types of coping strategies perceived
to be effective. While overall effectiveness was low,
individual effective coping strategies were specific to each
phase of infertility. Therefore, this study generally
supports the direct relationship between length of
infertility and impact of infertility, and length of
infertility and types and effectiveness of coping

strategies.

Implications
M . E' 3'
The mean impact score across groups of length of
infertility was low to mild with a slight increase in Late
phase. No significant differences were found between total

impact scores and length of infertility. Women in all

47
phases of infertility used “hoped things would get better”
with high frequency. In the Initial phase, women used two
strategies “tried to find out more about the problem” and
“tried to think positively“. None of the coping styles were
“often usedf. Overall effectiveness of individual
strategies by length of infertility is low with generally
low effectiveness ratings by style. Women in all phases
reported “talked with family and friends” as an effective
strategy. None of the coping styles are indicative of’“very
helpful”.

The impact of infertility, although low throughout all
phases of infertility, has important implications for both
women and health care professionals in the primary care and
specialty areas. For women whose characteristics are
similar to this sample, the Advanced Practice Nurse (APN)
can assist the woman through acknoweldgement of the woman's
existing coping strategies and resources and of the impact
upon daily activities. The APN can also give reassurance
that the impact throughout the entire length of infertility
may remain low.

For women who are seen in the primary care setting,
health questionnaires should include an area which addresses
infertility. For those women who are at risk for
infertility or are experiencing infertility, open ended
questions directed at how they are feeling about their
infertility should be asked. Generalized assessment of

support systems, spousal response, feelings related to

48
medical intervention, as well as emotional and physical
health should be included during each visit.

Both within the primary care setting and the specialty
setting, assessment should include feelings related to self-
esteem such as feelings about their bodies, perceived
attractiveness, physical and emotional competency, and
feelings of femininity. Further assessment of guilt or
blame issues such as feelings about guilt for the
infertility, feelings of blame from spouse, feelings of
punishment, or blaming spouse for infertility. Additional
assessment should include feelings regarding the women's
perception of sexuality, sexual enjoyment, changes in
purpose of sexual activity, and sexual desire of self and
spouse. The APN should address issues relating to self-
esteem, guilt or blame, and sexuality within the primary
care setting at each visit in an effort to educate, provide
support, and problem-solve to prevent an increaSe in impact
in these areas.

Within the primary care setting the APN might encourage
positive self-talk, communication with spouse regarding
feelings of self-esteem, and encouragement to recognize
accomplishments in the work environment to enhance self-
esteem. Open, honest communication with spouse regarding
guilt or blame should be encouraged. The APN can assist
with role modeling with family or social inquiries, instruct
in effective communication techniques, provide counseling,

and provide objective data regarding medical information to

49
alleviate guilt or blame. Open communication is also
effective with issues surrounding sexuality. Since the
impact of sexuality is low, counseling and problem solving
can be provided by the APN. The APN can educate other staff
members including nurses, physician, and ancillary persons
regarding sensitivity with these women.

General interventions such as meditation or including
time in daily schedule for personal hobbies can be discussed
within the primary care setting in an effort to decrease the
impact of infertility. Most importantly, the APN can
educate, role model, and provide information regarding
communication techniques with significant others, health
care professionals, and friends.

Since disruption in daily schedules can occur as a
result of frequent appointments or medication regimes such
as Pergonal injections, women need to plan for this
disruption. Discussing employment options to accommodate
for these needs might prove helpful. Within the specialty
care setting, scheduling appointments early or late in the
work day can be beneficial.

Women in the Initial phase of infertility, consistently
maintained hope through thinking positively and educating
themselves by trying to find out more about the problem of
infertility. The APN in both the primary care and specialty
care settings can encourage hopeful thinking by emphasizing
the positive elements of the situation, while remaining

objective and honest about risks and success rates. The APN

50
can play an active role in education by providing written
information in the form of pamphlets for both clients and
family members, providing current references on the topic,
and providing information about other individuals who may
offer a personal perspective. In recognizing the initial
shock of diagnosis, denial reaction, and feelings of
hopelessness in controlling the situation, the APN
recognizes that women use worry, denial, and attempts to
change the situation as coping strategies. These are normal
reactions to a stressful event and the APN can provide
support and encouragement during this phase, while
remembering that the impact upon these women is low.

During the Intermediate phase of infertility women
continue to worry indicating the need for continued support
by the APN in both the primary care and specialty settings
One of the most powerful and effective methods to offer
support is by listening and acknowledging the feelings of
these women. APN's can encourage women to verbalize or ask
questions as appropriate, by phone or by appointment. As
with the Initial stage of infertility, women continued to
maintain hope ad keep life as normal as possible. The APN
can assist with scheduling to accommodate work schedules.

Since women in the Late phase of infertility appear to
be gaining control by attempting to change the situation and
thinking about solutions, the APN can help foster problem-
solving. The APN in the specialty setting might ask about

future plan for infertility, any alternative plans for

51

parenting such as adoption, status of current resources, or
thoughts about willingness to remain childless. The APN can
continue to provide information to meet the women's efforts
to find out more about the problem. Most importantly, the
APN must promote hope--hope of resolution with or without
conception. In both the primary care and specialty setting,
the APN must remember that women in late phase infertility
are at risk for depression and need to be followed closely.

All of the eight coping styles were “seldom used" to
“sometimes used" none were “often used”. With this
knowledge, the APN recognizes that a limited variety of
coping strategies seem to be used during all lengths of
infertility. Offering a specific coping style would not
meet the needs of the infertile women in any phase of
infertility. Emphasis should be with the individual types
of coping strategies as discussed previously.

2 While many coping strategies are utilized during the
Initial phase of infertility, social support, normalcy in
daily life, distraction, and developing a plan of action are
perceived to be any more effective, although all show low
effectiveness. Knowing that social support can be
beneficial in all phases of infertility, the APN in both the
primary care and specialty setting can educate and encourage
women regarding the usefulness of sharing feelings with
family and trusted friends, or talking with someone who has
been in a similar situation. The APN in the primary care

setting can initiate a support group which would include

52
both women and their support persons. Including family and
friends in a support group may provide a more realistic
picture of the types of coping strategies which are
perceived as effective. Family members could identify
topics that would increase their understanding of the
infertility experience and offer suggestions for them to be
more supportive to these women. Experts could be brought in
to discuss topics of interest to increase understanding.

Women need to be encouraged to set up a plan of action
including accommodation of treatment regimes, how to deal
with social inquiries, financial considerations, and any
limits of the infertility treatment options. Knowing that
keeping your life as normal as possible was identified as
effective, but often difficult to do, the APN in the
specialty setting can emphasize the effectiveness of keeping
daily life as normal as possible while making allowances for
treatment goals. Distraction can be effective in
alleviating the distress. Making time for special events
such as dinners out, weekend get-a-ways, or vacations can
serve as distracters.

In addition to talking the problem over with someone
who had been in a similar situation, talking with family and
friends, and educating oneself which are carried over from
the Initial phase, keeping a sense of humor is perceived as
somewhat effective. The APN in the specialty setting can
encourage women to allow themselves to laugh or find humor

in daily life or during infertility regimes. Knowing that

53

women identified prayer or trust in God, the APN in the
primary setting might suggest that attending religious
activities is perceived as a source of support. Inservices
regarding the emotional needs of the infertile woman could
be presented to interested clergy in the community by the
APN. Allowing women to pray before inseminations or
laparoscopy procedures is a supportive intervention. The
APN might encourage physical activity to minimize distress
such as group aerobics, softball teams, or other activities
which give the women an opportunity to socialize without the
infertility link. Running, walking, or yoga might be more
appropriate for women who prefer quiet time.

Women continue to perceive social support, trust in
God, educating oneself, and positive thinking as effective.
The APN in the specialty setting should focus on problem-
solving techniques and goal setting behaviors for these
women. Women need guidance and support in thinking out
solutions and setting a plan of action for both further
treatment regimes and infertility goals. The APN must fully
support those that opt for investigational treatment in
their efforts to conceive, and those who wish to end their
quest. For those who are overwhelmed by treatment options,
past failures, financial tolls, and emotional exhaustion,
handling things one step at a time can prove effective. The
APN can help the women to focus only on the next step
instead of the whole picture, for example, focus on getting

through the Pergonal injections, then focus on the surgical

 

54
procedure. Since overall effectiveness of coping strategies
was low, the APN in the primary care setting needs to follow
infertile women closely to identify difficulty in coping.

Although overall effectiveness of coping styles are
low, ranging from “slightly helpful” to “fairly helpful”, the
APN in both the primary care and specialty setting might
decide to focus on Supportant interventions for women during
all phases of infertility recognizing that effectiveness is
shown although low. While supportant coping styles are
“fairly helpful” in Intermediate phase, they are closer to
“slightly helpful” in Late phase. Supportant coping styles
refer to using personal, professional, and spiritual support
systems. Use of family or friends, health care
professionals or ministers, putting trust in God, or talking
with others who have been in a similar situation are
strategies which can be suggested by the APN. For women in
the late phase, the APN should first assess the
effectiveness of support since trust was low and
significantly different from the Intermediate phase.

Overall implications include recognition of low impact
of women with similar characteristics undergoing infertility
treatment. Health care professionals need to provide
support and information whenever contact occurs in the
primary care setting or in specialty services. Health care
professionals have a responsibility to keep abreast of the

current research regarding infertility and coping. Both

55

undergraduate and graduate programs should include the topic
for infertility in the curriculums.
ImnlitatieannLEurtheLResearch

There are many future options for research in the area
of infertility. Further research should focus on
replication of the primary study to determine if similar
results occur. Larger sample sizes with more diversity in
age, race, educational backgrounds, and religious .
backgrounds. Samples should be taken from multiple clinical
sites. Samples should include spouses, significant others
in the case of lesbian couples, single women, and women who
have had previous pregnancies or children to determine if
impact changes or if types or effectiveness of coping
strategies are different in response to differing support
systems. Samples might be categoriZed by type of procedures
or types of medication used. Use of different
questionnaires designed to measure impact as well as use and
effectiveness of coping strategies to determine if other
impact is present in addition to self-esteem, guilt/blame,
or sexuality. Perhaps different types of coping strategies
are used or are more effective than those indicated on the
JCS. Longitudinal studies would prove beneficial in
determining the changes in the use of coping strategies and
perceived effectiveness over time with differing support
systems, treatments, and individual characteristics. For

example, do women with previous children who experience

56
secondary infertility exhibit a different impact than women
without children or previous pregnancies?

Additional research should focus on coping related to
various treatment regime such as Clomid only, Pergonal only,
IVF, AID, or lack of treatment regime. Emphasis on further
research should focus on effectiveness of coping strategies
along the entire continuum of infertility since little is
found in the literature.

In conclusion, infertile women in this study
experienced a low amount of distress over the entire length
of infertility. Women often hoped things get better during
all phases of infertility. Talking with family and friends
was the common effective coping strategy throughout all
phases of infertility. Supportant coping style showed
significant with all phases of infertility with the lowest
effectiveness in Late phase. The APN can significantly
impact the coping process of infertile women through
education and counseling during different phases of
infertility. Importantly, all health care professionals
must remember to acknowledge that each women is an
individual with specific responses to distress, and with her

own set of effective coping strategies given her unique set

of circumstances.

LI ST OF REFERENCES

 

LIST OF REFERENCES

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Beaurepaire, J., Jones, M., Theiring, P., Saunders, D.,
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Becker, G., 8 Nachtigall, R. D. (1994). Born to be a
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Cook, R., Parsons, J., Mason, B., 8 Golombok, S.
(1989). Emotional, marital and sexual functioning in
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infertility 1cnrnal_cf_Benroductixe_and_Infant_Bs¥chnlns¥1
1, 87- —93.

Cook, R. (1993). The relationship between sex role and

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Davis, S.C., 8 Dearman, K.N. (1991). Coping strategies
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and_Neonatal_Nnrsing1_ZQ(3). 221-249-

DeHaan, P. (1995). ' ° ' ' ° '

and_effeetiyeness. Unpublished manuscript, Michigan State
University at East Lansing.

Edelmann, R. J. Connolly, K. J., 8 Bartlett, H. (1994).

Coping strategies and psychological adjustment of couples
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13(4), 355- -364.

Fitspatrick, J.J., 8 Whall, A.L. (1989). Connecticut:
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Halman, J., Andrews, F. M. 8 Abbey, A. (1993). Gender
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and_ueonatal_uursingi_23(7). 593-599-

Hammer- -Burns, M. A. (1987). Infertility as boundary

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Hynes, G.J., Callan, V.J., Terry, D.J., 8 Gallois, C.
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Mahlstedt, P.P. (1994). Psychological issues of

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Morrow, K., Thoreson, R. W., 8 Penney, L. L. (1995L

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Stewart, 5., 8 Glazer, G. (1986). Expectation and
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Maternal:Child2Nursing_Journall_15(2). 103- -116-

Tarlatzis, I., Tarlatzis, B.C., Diakogiannis, I.,
Bontis, J., Lagos, S., Gavriilidou, D., 8 Mantalenakis, S.
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counleS- Human_Benrcduction1_8(3). 396-401-

APPENDIX A

6C)

IFQ

Instructions: Please circle the number closest to the reaction that most

accurately expresses your current feelings.

 

 

A“3V°’= 5tr°n817 Agree Neutral Disagree Strongly
Agree. Disagree
Circle: 5 4 3 2 1
l. I feel bad about my body because of our inability to have a child.
5 4 3 2 1
2. Since our infertility I feel I can do anything as well as I used to.
S 4 3 2 1
3. I feel I am as attractive as before our infertility.
S 4 3 2 l
4. I feel less masculine/feminine because of our inability to have a child.
. s 4 3 z 1
5. Compared with others. I feel I am a worthwhile person.
5 4 3 2 l
6. Lately. I feel I am sexually attractive to my partner.
5 4 3 2 l
7. I feel I will be incomplete as a man/woman if we cannOt have a child.
5 4 3 2 l
8. Having an infertility problem makes me feel physically incompetent.
s 4 3 2 1
9. I feel guilty about somehow causing our infertility.
S 4 3 2 l
10. I wonder if our infertility problem is due to something I did in the past.
5 4 3 2 l
11. My spouse makes me feel guilty about our problem.
5 4 3 2 l
12. There are times when I blame my partner four our infertility.
S 4 3 2 1
13. I feel I am being punished because of our infertility.
S 4 3 2 1

l4. Lately. I feel I am able to respond to my spouse sexually.
S 4 3 2 1

6].

 

 

(CONTINUED)
Answer: Strongly Agree Neutral Disagree Strongly
Agree Disagree
Circle: 5 4 3 2 1
IS. I feel sex is a duty. not a pleasure.
S 4 3 2 1
16. Since our infertility problem, I enjoy sexual relations with my spouse.
5 4 3 2 l

17. We have sexual relations for the purpose of trying to conceive.

S 4 3 2 l

18. Sometimes I feel like a "sex machine" programmed to have sex during
the fertile period.

5 4 3 2 l

19. Impaired fertility has helped our sexual relationship.
5 4 3 2 l

20. 'Our inability to have a child has increased my desire for sexual relations.
S 4 3 2 l.

21. Our inability to have a child has decreased my desire for sexual relations.

5 4 3 2 l

APPENDIX B

62

0 I977, l987 AM. Jalowiec. PhD, RN Study a

 

JALOWIEC COPING SCALE

 

 

 

This questionnaire is about how you cope with stress and tension. and what you do to
handle stressful situations. In particular. I am interested in how you have coped with the

stress of:

 

This questionnaire lists many different ways of coping with stress. Some people use a

lot of different coping methods: some people use only a few.

You will be asked two questions about each different way of coping with stress:

v

 

Part A

How often have you used that coping method to handle the stress listed above?

For each coping method listed. circle one number in Part A to show how often you have

used that method to cope with the stress listed above. The meaning of the numbers in
Part A is as follows:

0 a. never used

1 - seldom used

2 - sometimes used
3 - often used

Part B

If you have used that coplng method, how helpful was It In dealing with that stress?

For each coping method that you have used. circle.a number in Part B to show how

helpful that method was in coping with the stress listed above. The meaning of the
numbers in Part 8 is as follows:

0 u not helpful

i a. slightly helpful
2 a fairly helpful
3 = very helpful

If you did not use a particular coplng method, then do not circle any number in
Part 8 for that coping method.

 

 

 

63

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

|2L Waited to see what would happen

.—

 

 

  
  
 
  

wanted to be alone to think things
out 0 l 2

. Resigned yourself to the situation
. because things looked hopeless

 

 

Part A Part B
How often have you used It you have used
each coplng method? that coping methad'
COPING METHODS how helpful was it?
Never Seldom Sometimes Often Not Slightly Fairly v."
Used Used Used Used Helpful Helpful Helpful Helpful
1. Worried about the problem 0 f 2 3 D t 2 3
2. Hoped that things would get better 0 t 2 3 0 . . l 2 3
3. Ate or smoked more than usual 0 l 2 3 0 f 2 3
4. Thought out different ways to
handle the situation 0 l 2 3 O l ' 2 3
5. Told yourself that things could be
on worse a l 2 3 0 l 2 3
6. Exercised or did some physical
activity . D l 2 3 0 f 2 3
7. Tried to get away from the problem
for a while 0 l 2 3 0 l 2 3
8. Got mad and let off steam 0 l 2 3 0 l 2 3
9. Expected the worst that could
happen 0 l 2 3 0 l 2 3
to. ‘Tried to put the problem out of your
mind and think of something else 0 t 2 3 0 l 2 3
ft. Talked the problem over with family
or friends 0 t 2 3 O l 2 3
12. Accepted the situation because very
little could be done 0 1 2 3 0 t 2 3
13. Tried to look at the problem
obiectively and see all sides 0 l 2 3 0 l 2 3
t4. Daydreamed about a better life 0 t 2 3 l o i 2 3
is. Talked the problem over with a
professional person (such as a
doctor. nurse. minister. teacher. 0 t 2 3 0 l 2 3
counselor)
ls. Tried to keep the situation under
control 0 1 2 3 0 i 2 3
| 17. Prayed or put your trust in God 0 l 2 3 l D 1 2 I 3 I
18. Tried to get out of the situation 0 l 2 a | o l 2 3 I
‘ l9. Kept your feelings to yourself 0 l 2 3 I 0 l 2 3
20. Told yourself that the problem was
someone else‘s fault D l 2

 

 

 

 

64

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part A . Pen 8
flow often have you used if you have used
each coplng method? that coping method,
COPING METHODS ‘ how helpful was it?
Never Seldom Sometimes Often Not My Fifty Very
Used Used Used Used Habit! Nobel Help“ Helpful

24. Took out your tensions on someone

else 0 f 2 3 f 2
25. Tried to change the situation 0 t 2 3 t 2 a
26. Used relaxation techniques 0 f 2 3 t
27. Tried to find out more about the

problem 0 f 2 3 f 3
28. Slept more than usual 0 f 2 3 f 3
29. Tried to handle things one step at a '

time D f 2 3 O l 2 3
30. Tried to keep your life as normal as

possible and not let the problem 0 f 2 3 0 f 2 3

interfere
3i. Thought about how you had handled 7

other problems in the past 0 l 2 3 O i 2 3
32. Told yourself not to worry because

everything would work out fine i 2 1
33. Tried to work out a compromise l 2 1
34. Took a drink to make yourself feel

better i 2 l
35. Let time take care of the problem i 2 3 f
36. Tried to distract yourself by doing

something that you enjoy 0 f 2 3 0 f 2 3
37. Tdfd yourself that you could handle '

anything no matter how hard 0 f 2 3 D t 2 3
38. Set up a plan of action 0 t 2 3 D t 2 3
39. Tried to keep a sense of humor 0 f 2 3 0 f 2 3
40. Put off facing up to the problem 0 l 2 3 D l 2 3
4f. Tried to keep your feelings under

control 0 f 2 3 0 l 2 3
42. Talked the problem over with

someone who had been in a similar 0 l 2 3 O i 2 3

situation
43. Practiced in your mind what had to

be done 0 f 2 3 0 f 2
44. Tried to keep busy 0 l 2 3 f
45. Learned something new in order to

deal with the problem 0 l 2 3 O l 2 3
46. Did something impulsive or risky

that you would not usually do 0 1 2 3 o t 2 3

 

 

 

65

 

Part A Part a
How often have you used if you have used
each coping method? that coplng method,
COPING METHODS how helpful was in

NeverdeolISooletilneIOilen Not Sightly Filly Vuy
Usedlieed tlsedllsedfiehftliielpitlllebfllflebu

 

47. Thought about the good things in

 

 

 

 

 

 

 

 

 

your life 0 t 2 3 0 f
48. Tried to ignore or avoid the problem 0 t 2 3 0 l
49. Compared yourself with other
peeple who were in the same 0 f 2 3 0 f 2 3
shuauon
SO. Tried to think positively D f 2 3 O f 2 3
St. Blamed yourself for getting into -
such a situation 0 t 2 3 D f
52. Preferred to work things out yourself 0 t 2 3 0 l
53. Took medications to reduce tension 0 f 2 3 0 t
54. Tried to see the good side of the
situation 0 t 2 3 o f 2 3
55. Told yourself that this problem was
really not that important 0 f 2 3 0 f
56. 'Avoided being with people 0 i 2 3 O f

 

57. Tried to improve yourself in some

way so you could handle the D l 2 3 0 l 2 3
situation better

 

58. Wished that the problem would go
away 0 l 2 3 0 l

59. Depended on others to help you out 0 l 2 3 0 i 2 3

 

 

60. Told yourself that you were just
‘ having some bad luck 0 f 2 3 0 f 2 3

 

 

 

 

 

if there are any other things you did to handle the stress mentioned at the beginning.
that are not on this list, please write those coplng methods In the spaces below. Then

circle how often you have used each coplng method. and how helpful each coplng
method has been.

 

 

 

61. l 2 3 O l 2 3
62. l 2 3 0 l 2 3
63. l 2 3 0 l 2 3

 

 

 

 

 

“one“ 4'80

APPENDIX C

66

DEMOGRAPHICS

How old were you on your last birthday?

Race: l-white, Z-black, 3=hispanic, 4-oriental, S-American Indian,
6-other

How many years of school have you completed?

 

Occupation (job title):

 

Marital Status: l-single, Zsmarried, 3=separated/divorced,
4-widowed

How long have you been trying to achieve a pregnancy?

 

How many Metrodin or Pergonal cycles haVe you tried including your
current treatment course?

1, 2, 3, 4, S, 6, 7, 8, 9, 10, more than 10

APPENDIX D

GRADUATE

flflfififlll
FAX: fill/4324i“

muse-seem
mews-sir
(Melba

Maxim
MW“

 

    
 
 
  
 

€Y7

MICHIGAN STATE

UNIVERSITY

 

February 23. 1993

r0: Rachel P. Schiffman
A230 Life Sciences

RE: IRBI: 98-069
TITLE: THE RELATIONSHIP BETWEEN IMPACT. COPING,
STRATEGIES AND LENGTN OE INFERTILITY
REVISION REQUESTED: N/A
CRTEGORY'

. l-E
APPROVAL DATE: 02/17/90

The University cos-uttee on Research Involving Human Subjects‘lOCRIhS)
review of this project is complete. I am pleased to advase that the
rights and welfare of the human subjects appear to be adequately .
pgotected and methods to obtain informed consent are ap ropriate.

‘bgrefore. the OCRINS approved this project and any rev sions listed
VG.

neuewnn: UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be nd one year must use the green renswal
form (enclosed with e original a roval letter or when a
project is renewed) to seek gsdate certification. There is a
maximum of four such expedit renewals ssible. Investigators
wishi to continue a project beyond the time need to submit it
again or complete revaew.

REVISIONS: UCRIRS must review any changes in rocedures involving_human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal.form. ro
revise an approved protocol at an 0 her time during the yoar
send your written request to the. IRS Chair. requesting revised
approval and referencing the progect's IRS h and title. Include
in your request a description of the change and any revised
ins ruments. consent forms or advertisements that are applicable.

PROELflfS/
CHAN

638: Should either of the following arise during the course of the
work. investi ators must noti UCRIHS promptly: 51) problems
(unexpected e de effects, comp ainta. e c.)_involv1ng uman
subjects or (2) changes in the research enVIronment or new
information indicating greater risk to the human subsects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help please do not hesitate to contact us
at (517)355-2180 or sax (517ld i- 171.

Sincerely.

l.

avid 8. “ti
UCRIHS Chair

DEH:bed

 
  

ght.gPh.D.
/

cc: Patty Jo Hopkins

 

"‘IIIIIIIIIIIIIIIIIII“