Stimulating fertility awareness: the importance of getting the language right.

While education about fertility is not intrinsically controversial, finding the right language to communicate the topic can be challenging, as there are several risks of unintended negative effects such as dissonance, anxiety, culpability, and stigma due to social norming. In this article, we share some of our learnings from promoting fertility awareness in the hope that they will inspire further debate and research on this topic. Starting from the ethical principles of respect for reproductive autonomy, avoiding harm (in terms of stigma or anxiety) and inclusivity, we have formulated five recommendations: (i) frame fertility awareness messages with (reproductive) autonomy in mind and aim to be inclusive of those who do not represent the traditional nuclear family; (ii) be empathetic and steer clear of blame; (iii) avoid scaremongering and offer a positive angle; (iv) give due consideration to both women and men in fertility health messaging; and (v) tailor the messages to particular contexts and audiences and develop resources in close collaboration with the target groups.

The Role of Attachment Anxiety and Attachment Avoidance on the Psychosocial Well-being of Infertile Couples.

This study's objective was to explore the mediating role of attachment orientation in infertile women and their partners as a mediator of the relationship between need for parenthood and psychosocial well-being. Ninety participants (45 couples) undergoing in vitro fertilization completed self-report questionnaires that assessed representations of the importance of parenthood, attachment orientations, and psychosocial well-being. Path analysis was used to examine the direct and indirect effects. The results indicated that women's attachment anxiety mediated the effect of need for parenthood on the psychological well-being of themselves and their partner. Although causality cannot be assumed, this study highlights the importance of considering attachment orientations and related strategies of emotion regulation in clinical settings and the need to address the meaning of parenthood for promoting couples' well-being.

The infertility trap: how defeat and entrapment affect depressive symptoms.

STUDY QUESTION: Does the perception of failure without a solution or way forward of infertile couples have a mediator role between the importance couples attribute to parenthood and depressive symptoms? SUMMARY ANSWER: The perception of failure without a solution or way forward, assessed by feelings of entrapment and defeat, mediates the effect of the importance of parenthood on depressive symptoms of infertile men and women. WHAT IS KNOWN ALREADY: Research has documented that the heightened importance of parenthood affects infertile couples' adjustment to infertility and medical treatments. However, it remains unclear which psychological mechanisms and perceptions may underlie the association between having parenthood as a nuclear aspect of life and presenting depressive symptoms related to difficulties in accomplishing that important life goal. Although these links have been scantly addressed in infertility, previous studies have pointed to the role that perceptions of defeat and entrapment have in several psychopathological conditions. STUDY DESIGN, SIZE, DURATION: The study was cross-sectional. Couples pursuing medical treatment for their fertility problems were invited to participate by their doctors in several public and private clinics. Data collection took place between July 2009 and 2011. PARTICIPANTS/MATERIALS, SETTING, METHODS: One hundred forty-seven infertile couples consented to participate in the study. Both couple members (147 women and 147 men) completed a set of self-report instruments for the assessment of depressive symptoms, perceptions of defeat and entrapment, importance of parenthood and rejection of a childfree lifestyle. Analyses were conducted through Structural Equation Modeling and followed a dyadic analysis strategy, allowing for controlling the interdependence of the data. MAIN RESULTS AND THE ROLE OF CHANCE: The hypothesized tested model showed a very good fit to the data [(χ(2) = 68.45, P = 0.014, comparative fit index = 0.98, standardized root-mean-square residual = 0.06 and root mean square error of approximation = 0.06] and explained 67 and 58% of the variability in depressive symptoms in women and men, respectively. Results revealed that the importance of parenthood does not have a direct effect on depressive symptoms of infertile men and women, but an indirect effect, by affecting the perception of having failed and not being able to solve it or move forward [women: estimate for indirect effect: 0.38 (bias corrected (BC) 95% confidence interval (CI) = 0.25; 0.56; P < 0.001); men: estimate for indirect effect: 0.23 (BC 95% CI = 0.06; 0.40; P = 0.013)]. LIMITATIONS, REASONS FOR CAUTION: The study was cross-sectional, which does not allow for the establishment of causality. Another limitation is the heterogeneity of the sample, as participants were recruited at various stages of their fertility care. In addition, due to the specific nature of the variables, further studies are needed to establish exactly how the relationship between defeat and entrapment and depression operates, as the mechanism may be bidirectional. WIDER IMPLICATIONS OF THE FINDINGS: This study emphasizes the role of perceptions of defeat and entrapment on the psychological adjustment to infertility and assisted reproduction. These emotional processes should be taken into consideration and targeted in psychological interventions of couples undergoing medical treatments for infertility. In fact, although parenthood may be perceived as a core purpose for many couples dealing with difficulties in conceiving, it is only when these difficulties are experienced as failures without a resolution and as inescapable, that couples are prone to develop depressive symptoms. STUDY FUNDING/COMPETING INTERESTS: This research has been supported by the first author Ph.D. Grant (SFRH/BD/68392/2010), sponsored by the Portuguese Foundation for Science and Technology (FCT). The authors have no conflict of interests. TRIAL REGISTRATION NUMBER: N/A.

Assessing infertility stress: re-examining the factor structure of the Fertility Problem Inventory.

BACKGROUND: Research has documented that fertility problems can negatively affect the life of infertile patients, by imposing an obstacle to one important life goal: the achievement of parenthood. The Fertility Problem Inventory (FPI) proposes a comprehensive approach in assessing infertility stress, by measuring the impact on social, marital and sexual life dimensions and the importance of parenthood in infertile patients' life. This study examined the factor structure of the FPI, testing two alternative models using confirmatory factor analysis. METHODS: A sample of 209 infertile patients was recruited in two public hospital departments of assisted reproduction technology. Measures included the FPI, the Brief Symptom Inventory and the ENRICH Marital Inventory. RESULTS: Results confirmed the original measurement model of the instrument but suggested that the inclusion of an intermediate conceptual level resulted in a better fit to the model (χ²84= 147.89, P< 0.001) i.e. the instrument assesses infertility stress by assessing two main conceptual domains: the impact of infertility in infertile patients' life and representations about the importance of parenthood. The instrument revealed measurement and structure invariance and construct validity by correlating with other measures assessing similar constructs. CONCLUSIONS: This approach to the FPI has important contributions for research and clinical practice by distinguishing between the impact of infertility on different dimensions of a couple's' life and representations about the importance of parenthood, therefore extending the utility of the FPI in research and clinical practice.

The indirect effect of contextual factors on the emotional distress of infertile couples.

Few studies were dedicated to study the role of contextual factors, such as the socioeconomic status and urban or rural residence in emotional distress of infertile couples. This study aimed to explore the impact of contextual factors on emotional distress, either directly or by affecting the importance of parenthood in one's life, which in turn affects emotional distress. In this cross-sectional study, 70 couples recruited during hormonal stimulation phase prior to in vitro fertilisation completed clinical and sociodemographic forms and self-report questionnaires assessing representations about the importance of parenthood and emotional distress. Path analysis using structural equation modelling was used to examine direct and indirect effects among variables. Results indicated that socioeconomic status and place of residence had an impact in emotional distress by affecting the representations about the importance of parenthood in one's life. Gender differences were found regarding model paths, suggesting that the social context may have a stronger influence on women's emotional distress than on their partners' distress. When delineating psychological interventions, health care providers should consider that cultural values about children and parenthood contribute to shape the infertility experience.

Parental investment in couples who conceived spontaneously or with assisted reproductive techniques.

BACKGROUND: It has been suggested that couples who conceive with assisted reproductive technologies (ART) invest more in their child than those who conceive spontaneously. This study examined how parental investment in the child (PIC) varied as a function of method-of-conception, gender and other contextual variables, i.e. prenatal depression, social support and satisfaction with the marital relationship. METHODS: A total of 39 couples who conceived with ART and 34 couples who conceived spontaneously completed self-report questionnaires about depression, marital satisfaction and social support at their 24th pregnancy week and about PIC 4 months after the partum. Data were analysed with multilevel regression analyses. RESULTS: Results showed that method-of-conception and gender did not predict parental investment. There was a strong association between spouses on parental investment and investment was associated with couples' satisfaction with their marital relationship and the amount of support they perceived from their network. CONCLUSIONS: Investment in children depends on the marital relationship and support perceived from family members and friends and not on how the child was conceived nor on the gender of the parents.