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Human Reproduction Vol.17, No.11 pp.

2986–2994, 2002

Anxiety, depression and anger suppression in infertile couples: a controlled study
` 1, S.Boggio1, V.Piccioni2 and L.Garzaro1 S.Fassino1,3, A.Piero
1Department

of Neurosciences, Psychiatric Institute and Clinic, University School of Medicine, via Cherasco 15, CAP 10126, Turin and 2Department of Obstetrics and Gynaecology, ‘S. Anna’ Hospital of Turin, Italy whom correspondence should be addressed. E-mail: secondo.fassino@unito.it

3To

BACKGROUND: Although several authors have suggested an important pathogenic role for psychosocial factors in ‘functional’ infertility, the extent to which depression, anxiety and expressed emotional patterns correlate to infertility is not yet clear. METHODS: This study included 156 infertile couples (recruited at intake) and 80 fertile couples, whose personal characteristics were recorded. They were examined using scales for the evaluation of the degree of psychopathology [Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D)], and anger expression [State–Trait Anger Expression Inventory (STAXI)]. The 156 infertile couples were then subdivided into groups based on the cause of infertility (‘organic’, ‘functional’ or ‘undetermined’). The psychometric evaluation was double-blind with respect to the causes of infertility. RESULTS: Differences emerged in the degree of psychopathology between ‘organic’ and ‘functional’ infertile subjects and fertile controls. In women, logistic regression identified three variables able to predict the diagnosis subtype; these variables are HAM-A, HAM-D, and tendency toward anger suppression. In men, anger did not emerge as a predictor for diagnosis, whereas HAM-A and HAM-D did. CONCLUSIONS: The ‘functional’ infertile subjects of this sample showed particular psychopathological and psychological features, independent from the stress reaction following the identification of the cause of infertility.
Key words: anger/emotional distress/infertility/psychopathology/psychosomatic factors

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Introduction The relationship between emotional distress and infertility has been studied by several authors (Wright et al., 1989; Greil, 1997), but it is clear that attempts to explore the psychological correlates of infertility have produced mixed results. The lack of uniform results in the literature is due to the several methodological problems of such a complex field of investigation (Greil, 1997). A relevant problem deals with the theoretical model of reference; studies dealing with the psychological features of infertility are based on two contrasting theoretical models that consider psychopathology as a cause for infertility or as a consequence of this disorder respectively. Both of these models have been investigated in descriptive as well as quantitative studies, but these, however, suffer from great methodological flaws (Greil, 1997). The first model (psychodynamic-oriented) emphasizes the role of psychogenic elements among the causes of infertility (‘psychogenic’ hypothesis); this model, in its original version, is today rejected by many authors (Greil, 1997), even if some literature evidence does support this hypothesis (Storelu et al., 1993). Recently, some authors have replaced this model with the ‘stress hypothesis’ (Wasser et al., 1993; Christie, 1994; Wassar, 1994). The stress hypothesis is embraced also by those 2986

who consider infertility as a psychosomatic disorder (Kemeter, 1988; Facchinetti et al., 1992; Gallinelli et al., 2001); they have outlined the impact of emotional states and of the ability of coping with stress (Demyttenaere et al., 1992) on the neuroendocrinological state (Demyttenaere et al., 1994; Hendrick et al., 2000), on pregnancy rates (Domar et al., 1992a), and on treatment outcome for assisted conception (Boivin and Takefman, 1995; Klonoff-Cohen et al., 2001). Many investigators have also tried to demonstrate a causal link between psychopathology and infertility, but results are contradictory; some authors did not find significant differences (Downey et al., 1989; Downey and McKinney, 1992), whereas others reported greater degrees of interpersonal distrust and maturity fear (Fassino et al., 2002b), anxiety and dissatisfaction (O’Moore et al., 1983; Demyttenaere et al., 1989), depression (Kemeter, 1988), and a tendency toward somatization (Schmidt et al., 1994) in women with ‘functional’ infertility. The second model is fostered by those supporting the theory that psychological distress is secondary to infertility. They hold that the experience of infertility imposes profound emotional distress on the individual and the couple (Stoleru et al., 1996; Bringhenti et al., 1997) and underline that this condition is a constant source of psychological (Moller and Fallstro ¨ m, 1991) and social stress (Greil, 1997).
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2001) and of those disorders that are expressed through the body.org by guest on February 9. including poorly adaptive psychological functioning. Fassino et al. 1998). 1992.. 2001). 1999. Notwithstanding the interest shown by several authors. in women. Wischman et al. Moreover. which is the most studied of these.. certain aspects must be considered: (a) couples with a ‘functional-psychogenic’ infertility were only those with both partners having no certain organic disorder. 1991).. 2001). 2987 Downloaded from humrep. however. in the case of unsuccessful treatment (Newton et al. with strong theoretical bases (e. in fact. Considering the recommendations found in the literature bearing on research design. 1997. 1992). 1997). who stressed the importance of considering anger both as a changeable emotional condition (emotional state) and as a trait (Spielberger. Slade et al.. a prevalence that is twice that found in the general population (Domar et al. (v) the cross-cultural variation. Lavoie et al. (ii) infertile couples’ strong desire for social acceptability through childbearing and the influence of this desire on the answers to self-administered questionnaires (Demyttenaere et al. for anger it is difficult to state whether anger levels and expressions are consequences of the stressful condition experienced by those who do not succeed in conceiving a child or instead are predisposing factors for this condition. In fact. 1998). 1998). 2011 .oxfordjournals. and (vi) the influence of knowing whether the infertility is due by a male or female factor on the expression of anger in the couple (Demyttenaere et al. 1994). but sometimes these seem to be denied (Chiba et al. 1998). 1992b. Spielberger (1996) emphasized the fact that individuals are very different in the way they suppress or express anger. (ii) to identify this subgroup and to avoid the risk of overlapping with ‘organic’ infertility.. when they were still unaware of the cause of infertility and did not know which partner was infertile. the study was designed on the basis of some methodological and theoretical assumptions: (i) if a ‘functional–psychogenic’ infertility exists.. 2001). 1999. defining the individual’s predisposition toward anger. even when psychiatric disorders are not evident. hopelessness. and anger (Ardenti et al. 1992). Several descriptive studies in infertile couples suggested a greater susceptibility to anxiety and depression (Dunkel-Schetter and Lobel..... In particular. Because these couples are exposed to the same stressor (infertility) the finding of different levels of anxiety. results in the literature are not definitive and consistent (Greil. depression. Thus. 1996). 1995). For stressors and related emotions. 2001). has been assessed according to the conceptualization of Spielberger... 2001) and therapeutic procedures required (Hunt and Monach. State– Trait Anger Expression Inventory: STAXI) (Spielberger. Matsubayashi et al. There is strong agreement that emotional distress for the infertile couple may arise from the unsuccessful attempts to conceive a baby (Moller and Fallstrom. (e) the study used standardized tests. Demyttenaere et al. otherwise the doubts of several authors on the subject are difficult to explain.... are a source of stress for the couple (Boivin et al. Moreover. as well as from the long diagnostic (Lee et al. Hammarberg et al. whereas some authors believe that infertile women can be distressed. 1992.. 1991. it is important to know that they change according to the duration of infertility. 1990. Wischmann et al. (b) subjects with minimal or uncertain organic disorders (‘undetermined’ group) were excluded. at present there is no general agreement about the role of anxious–depressive symptomatology in the pathogenesis and course of infertility. 1999). 1997. 1999). (d) subjects were studied at intake. 1996).. Oddens et al. some authors indicate that the outcome of these treatments is also influenced by the degree of anxiety and depression (Thiering et al. who make a great emotional investment in these treatments (Hammarberg et al. 1999) are common in infertile couples undergoing IVF treatment.. (iv) type of control group used.. (iii) subject selection. this is another methodological problem (time of observation). Sadness.. 2001). it also depends also on the ability of the couple to cope with this condition (Hynes et al. 1997) and in the cycles following the first attempt (Boivin et al.... 1994) were excluded: they were considered as all the other medical illnesses. Oddens et al. 2001) and by negative affect (Bevilacqua et al...Infertility and psychopathology Despite some evidence that depressive symptoms in infertile couples are so common as to reach. which is not necessarily enough to describe a full-syndrome psychiatric disorder. depressed mood (Berg and Wilson. Moreover. most of the controlled studies did not find significant differences between infertile couples and fertile controls (Dunkel-Schetter and Lobel. 1990). many studies underscore that treatments for assisted conception. depression. it may involve a selected group of a small number of couples. even if some of these situations might be correlated to psycho-neuro-endocrinological stress (Demytteneare et al. others highlight the relevance of psychological consequences such as anxiety (Dhillon et al. Trait-anger depends on the frequency of anger experiences. 2000. at present little has been written about whether differences exist regarding anxiety. 2000. involving important biological repercussions on the organism (Raikkonen et al.. 2000). and particularly IVF. 1997): (i) the greater attention to given to infertile women rather than to the infertile couple. Other important methodological problems are (Greil. even in the context of psychological distress. 1999. depression and anger might suggest a role of these elements in the pathogenesis of ‘functional’ infertility. anxiety (Slade et al.. In addition. Beutel et al.g.. 1995). Oddens et al. in its multifaceted nature. Smeenk et al. Anger. 1997). the normal variation of psychological functioning can significantly influence fertility (Facchinetti et al. and anger management in couples with certain organic causes of infertility (‘organic’ infertility) and those with infertility due to certain non-organic causes (‘functional’ causes). though not in a clinically significant way (Downey and McKinney.. The inability to express anger is typical of psychosomatic disorders (Fava and Sonino.. infertile couples often experience strong anger and anxiety... 1997) or repressed (Facchinetti et al. (c) Axis I disorders (DSM-IV) (American Psychiatric Association. Bringhenti et al. 1999). and lower self-esteem (Newton et al. 1997). 2001) as a factor that reduces the ability to conceive (Sanders and Bruce. 1991.. The emotional distress is particularly great when waiting for treatment outcome (Boivin et al. 1993..

for women. each couple was administered the SCID assessment and visited by a psychiatrist who was unaware of the couple’s fertility status. Study design and procedures The following protocol. 156 (90. which were unlikely to result in infertility (Guzick et al.e. after all the subjects had been assessed by gynaecological and andrological clinical examinations. and not waiting for a treatment for infertility (i.).org by guest on February 9. aged 18–41 years. ~25% had mild endometriosis. and. almost 50% had mild or unilateral tube damage. 29 couples were in the functional group. 2011 2988 . The second group (fertile controls) consisted of 114 fertile couples recruited by public nursery schools in and around the district of Turin during 1999–2001. progesterone assay. etc.. Thus. This study was designed to identify a subgroup of infertile couples in whom psychopathological and psychological elements (particularly with regard to anger management) play a role in the pathogenesis. Seven couples were excluded because of age. All subjects were guaranteed anonymity during the data processing phase. 32 couples were excluded. In summary. Both members of the couple were then interviewed by an expert psychiatrist to assess the presence of Axis I disorders (American Psychiatric Association. Infertility diagnosis The couples were considered infertile when they had unsuccessfully tried to conceive a child with natural methods for ജ1 year. The group of infertile subjects was then divided into three subgroups: the first group (‘organic’ infertility) included couples whose infertility was due to ascertained organic causes. aimed at allowing the identification of a group of functional infertility as definite as possible with respect to the hypothesis of a ‘functional– psychogenic’ origin. polycystic ovary. 1996). and seven couples for eating disorders. 12 because they had already received treatment for their infertility (four had succeeded in conceiving a child). For men. Moreover. The objectives of this study were to verify the possibility of different anxiety and depression levels and anger management in individuals with ‘organic’ infertility and in those with ‘functional’ infertility. depression and anger levels. In this way. The high number of subjects included in the third group can be explained because of the accuracy of the diagnostic assessment. STAXI scores may be influenced by depressive and psychotic Axis I disorders (Spielberger. biopsy of the endometrium and laparoscopy. Seventy per cent of the eligible couples (n ϭ 80 couples) completed the study protocol. 1995). compared with fertile controls. which was not enough to explain prolonged periods of infertility.S... This group was selected from all available couples between the ages of 18 and 45 years. Italy. married. All subjects were asked for informed written consent to participate in the study. post-coital test. 1994). according to the diagnostic criteria outlined by the Practice Committee of the American Society for Reproductive Medicine (Guzick et al. The third group included couples whose results showed physical damage or endocrine anomalies.Fassino et al. not receiving treatment. instead of the reproductive disorders of a psychiatric population. This selection aimed at avoiding the confounding effect that some of these features might have on the assessment of anxiety. The assessment of psychiatric disorders was conducted with the Structured Clinical Interview for DSM-IV (SCID-I) (First et al. a double-blind procedure between the two specialists was carried out. these anomalies were a spermiogram revealing the presence of asthenozoospermia or bradykinesia of a light/mild degree. 10 because infertility had lasted Ͼ2 years. disorders (Axis I of DSM-IV). 12 for major depression. the sample considered eligible for the study included 172 infertile couples (344 subjects). and 25% had other diagnoses (luteal phase deficiency. The first contact of the couples was with a specialist in obstetrics and gynaecology. the infertile sample finally included 156 couples of whom 56 couples were in the organic group. The infertility diagnosis was confirmed within 3 months. and 71 couples were in the undetermined group. Only the couples matching the following inclusion criteria participated in the study: Italian (for the language knowledge). infertility was defined as ‘functional’.. The second group (‘functional’ infertility) included couples in which both members had negative results for all the examinations performed. Italian. no previous diagnosis of infertility). Infertility was considered due to organic causes when at least one of the clinical examinations was positive in a member of the couple. married. Thirty-two couples with at least one member with an Axis I disorder were then excluded from the study. Recruitment of infertile couples The infertile couples were recruited for the study during the assessment phase before the causes of infertility were ascertained (intake). 1995). The recruited subjects made an appointment with the psychiatrist to be interviewed and to complete the STAXI. seven because one of the partners was not Italian. six couples refused to take part in the study. where needed. Sixteen couples did not properly complete the psychological test or dropped out during the diagnostic evaluation phase suggested by gynaecologists. nine because they had already received a diagnosis of infertility. The objective of such selection was to allow the study of the psychological and psychopathological features correlated with infertility.oxfordjournals. At that point. Materials and methods Subjects Two groups of subjects were recruited for this study. having at least one child (aged 1–6 years). 1998). The hypothesis is that in such individuals psychological functioning might have a role among the various causes of infertility. absence of current clinical psychiatric Downloaded from humrep. On the same day. seminal liquid examination. 1998) in one or both of the partners. In these cases. (f) tests evaluated by the interviewer should be used (and the interviewer should be unaware of the causes of infertility). as evaluated with Structured Clinical Interview for DSM-IV Axis I disorders: SCID-NP (not-patient) (First et al. Thus. including sessions and clinical examinations. The first group included 172 infertile couples recruited from 255 couples consecutively admitted between December 1999 and July 2001 to the outpatient department for diagnosis and care of fertility disturbances at St Anna Hospital in Turin. two couples were excluded because one member was diagnosed with psychotic symptoms. and to assess psychosocial and symptomatological features independently associated with infertility subtype (‘organic’ or ‘functional’). hysterosalpingography. 11 couples for anxiety disorders.7%) of the 172 couples eligible for the study completed the protocol. During the recruitment procedure. was approved by the Institutional Review Board of St Anna Hospital before the study was performed. first conception attempt (ഛ2 years). We excluded this group (‘undetermined’ group) from further analysis because it was not possible to ascertain for certain whether the cause of infertility was definitely ‘organic’ or definitely ‘functional’.

18–24 moderate. The χ2-test was used to assess the likelihood of an association among infertility subtype. and T-Anger/R (items 14. The age. 25. which measures the general disposition toward angry feelings (angry temperament).. 2011 Results Descriptive analysis of the sample of infertile couples The final sample consisted of 156 infertile couples. 1960). 1996). 18. 1 ϭ doubtful to mild. defining cut-off scores for the severity of depression: Ͼ25 severe.92) and interrater reliability (alpha coefficient ϭ 0.f. items 23. 3 ϭ moderate to severe. Downloaded from humrep. Also the HAM-A is a rating scale that is filled in by the interviewer. HAM-D. and seven high class (12. No association emerged when the two groups of infertile women were considered separately (d. alpha test–retest (ϭ 0. they were subdivided into the three aforesaid groups.628. 34. In general. Participants rate themselves on 4-point scales for each item. non-significant). 1998). 36. 6–14 mild anxiety. 24. T-Anger/T (items 11–13. The total score is a reliable index of the pervasiveness of depression (Guy. 16). and fertile subjects. Ͼ15 severe anxiety. and 16 (28. This analysis was performed with one-way analysis of variance (ANOVA) and post-hoc t-test (Duncan test). the 71 couples of the ‘undetermined’ infertility group included 12 (17%) with an uncertain condition for both partners. the Bonferroni correction) were not used for two reasons: (i) cogent arguments against the practice for exploratory studies have been put forward (Rothman. Psychosocial characteristics and infertility subtype The comparison (ANOVA) involved three groups: infertile ‘organic’ subjects. The final scale. which measures the frequency with which angry feelings are suppressed. 1986). 41). 44). used in its 21-item version (Guy. On the other hand. On the basis of the clinical examinations and the specialist visit. STAXI) among the three groups (infertility with ‘organic’ ascertained causes. which measures the frequency of the expression of anger toward other people or objects in the environment. 32. These features support the use of the HAM-D scale in every diagnostic setting (Hamilton. 1 ϭ probable or mild. Measures Hamilton Rating Scale for Depression (HAM-D) The HAM-D is a rating scale for depression. 35 (49. gives a general index of the expression of anger.Infertility and psychopathology Several authors have. 20). the 5-point scale items use a rating of 0 ϭ absent. 40. AX/EX (AX-IN ϩ AX-OUT ϩ AX-Con ϩ 16). 1976).7%) couples with both partners affected by organic lesions responsible for infertility. 42. on the basis of the study objectives. In each case. educational level. Anger Expression-Out (AX-OUT. 1959) is known and widely used as well as the HAM-D. 2 ϭ definite. which measures the tendency to express anger when one is criticized (reaction to criticism). 1976). ‘functional’ infertility. 27. many authors consider such couples as ‘functionally’ infertile. and HAM-D subscales are presented in Tables I and II respectively. 31. P Ͻ 0. in the group with 2989 . The STAXI has been validated on a variety of normal and clinical populations and has good psychometric properties (Spielberger. Finally. infertile ‘functional’ subjects.96).7%) couples with male infertility. Second.org by guest on February 9. The association was then verified with the χ2-test. items 22.5%). 38.7%) with ‘undetermined’ female and ‘functional’ male. It is a point of reference for all depression scales. The 3-point scale items used a rating of 0 ϭ absent. infertility with exclusion of organic causes or ‘functional’ infertility. functional infertility was diagnosed only for couples where somatic causes were not ascertained for both partners with the available diagnostic techniques. 2 ϭ mild to moderate. and inter-rater reliability (ϭ 0. 33. The first 17 items are the most important ones. 15 low class (26. and 24 (33. 35. 39. It measures the intensity of anger as an emotional state (State-anger ϭ first 10 items) and the disposition toward anger as a personality trait (Trait-anger). and fertile controls) was made. expressed. 29.8%).7%) couples were middle class. The Trait-anger (items 11–20) scale contains two subscales. 4. The interviewer was adequately trained in the use of the rating scale. Cut-off scores are as follows: 0–5 no anxiety. Additional scales include Anger Expression-In (AX-IN. 1998). Last. In the organic infertility group.93). 4 ϭ very severe. and these two questionnaires share some items. two stepwise logistic (by block method) regressions (women and men separately) attempted to determine the presence. Statistical analyses All data analyses were performed using the Statistical Package for Social Sciences (SPSS. The HAM-A consists of 14 items. and results obtained by the three groups of women and corresponding groups of men on the STAXI.59. 37. higher scores indicate a greater level of anger and its suppression or expression. of independent factors that might discriminate significantly between ‘organic’ and ‘functional’ infertility groups. which measures the frequency of attempting to control the expression of anger. 26. 1983).92). The 21 items are rated on either a 5-point (0–4) or 3-point (0–2) scale. assessing either the intensity of their angry feelings or the frequency with which anger is experienced. however. 1996) consists of 44 items that are divided into six scales and two subscales. to grant good internal consistency (alpha coefficient ϭ 0.oxfordjournals. State–Trait Anger Expression Inventory (STAXI) The STAXI (Spielberger. Ͻ7 no depression. suppressed. HAM-A. 34 (60. A rating of 4 is usually reserved for extreme symptoms. 28. First. who were unaware of the causes of their infertility problem at the time they were administered the tests. in fact.3%) with ‘undetermined’ male and ‘functional’ female. which has high internal consistency (coefficient alpha ϭ 0. the association between the socioeconomic level of the couples and the diagnosis was evaluated (‘organic’ infertility. and (ii) data dredging was avoided by conducting only preplanned analysis (Grove and Andreason. 15. The 56 couples of the organic group included six (10. or controlled. 8–17 mild. 1982).6%) with female infertility. fertility and the socioeconomic level of the couple. it has been widely adopted and has good validity and inter-rater reliability (Cicchetti and Prusoff. each with a score ranging from 0 (absence) to 4 (very severe). 34 (60. and fertility). 30. items 21.92). educational level) and psychopathological features (HAM-A. 43). The interviewer was adequately trained in the use of this rating scale. Corrective measures for the post-hoc test (e. The 29 couples of the ‘functional’ infertility group were all made up of partners free of organic lesions.g. underscored that most ‘undetermined’ infertilities cannot be defined as ‘psychogenic’ (Demyttenaere et al. χ2 ϭ 2. among the variables studied. a comparison for sociodemographic characteristics (age. Hamilton Rating Scale for Anxiety (HAM-A) The HAM-A (Hamilton. and Anger Expression-Control (AX-Con.

69 13.73 Ϯ 8.101 0.399 0.37 Ϯ 4.62 Ϯ 5. FIW ϭ functional infertile women.13 9. which allowed a correct classification of the 97.10 Ϯ 3.7% of the cases. Table I.30 21. in the group of fertile couples 54 (67. After including personal (educational level.61 22.94 Ϯ 6.6%) were middle class. B A A.41 Ϯ 1.73 CM (n ϭ 80) C 33.33 Ϯ 3.89 0.76 25. see the Table I.222 0. CW ϭ fertile women. Comparison of organic infertility.34 Ϯ 1.87 Ϯ 4.26 14.33 6.70 6.58 15.51 1. and fertility: the male sample OIM (n ϭ 56) A Age Education level HAM-A HAM-D STAXI S-ANG T-ANG T-ANG/T T-ANG/R AX-IN AX-OUT AX-CON AX-EX aF FIM (n ϭ 29) B 31.88 11. and four (13. HAM-A ϭ Hamilton Anxiety.153 0.99 3.75 Ϯ 2.37 12.330 0.51 4. functional infertility.2%) low class.3 0.68 6. five (17.78 2.16 CW (n ϭ 80) C 31.81 Ϯ 7. 2011 bSignificant and P value obtained with ANOVA.39 Ϯ 2.63 11.76 11.29 22.19 23.32 13.68 29.51 Ϯ 2.60 12.732 0.078 Ͻ 0.02 Ϯ 5.24 11.36 17.20 Ϯ Ϯ Ϯ Ϯ Ϯ Ϯ Ϯ Ϯ 3. functional infertility.89 11.62 17.2%) low class.70 12.37 11.86 Ϯ 2.74 15.923 2.02 16.70 12.000 Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ 0.000 Ͻ 0.488 0.94 4.58 Ϯ 3. T-ANG/T ϭ general predisposition to feel or express anger without a specific reason.95 8.04 6. SANG ϭ intensity of anger as an emotional state.82 11.S.53 Ϯ 3. and fertility: the female sample OIW (n ϭ 56) A Age Education level HAM-A HAM-D STAXI S-ANG T-ANG T-ANG/T T-ANG/R AX-IN AX-OUT AX-CON AX-EX aF FIW (n ϭ 29) B 29.63 Ϯ 4. HAM-D.924 5.98 9.17 Ϯ 2.022 Ͻ 0.47 Ͻ 0.10 Ϯ 1. STAXI) in different steps.07 3. AX/IN ϭ suppressed anger.11 Ͻ 0.27 11.23 Ϯ 1.68 Ϯ 5.05) with Duncan test. T-ANG/R ϭ tendency to express anger provoked by criticism.10 13.00 17.008 0.124 – C C B C B – – – – – – – – Ͼ Ͻ Ͼ Ͻ Ͻ A.33 Ϯ 3.111 Ͻ 0.45 13. functional infertility.78 Ϯ 2. HAM-D ϭ Hamilton Depression.71 11.37 Ϯ 6.68 18.98 Ϯ 2.44 7.12 13.96 12.92 Ϯ 1.60 3. AX/OUT ϭ anger expressed toward other people or objects in the environment. and 13 (16.55 0. for the other abbreviations.46 13.342 0. Psychological factors associated with ‘organic’ or ‘functional’ infertility A stepwise logistic regression was designed to determine whether there were predictive variables of ‘functional’ versus 2990 ‘organic’ fertility in infertile women.24 1.08 Ϯ 5. B – – B Ͼ A. a three-variable model was obtained (HAM-A. After including personal (educational level.69 Ϯ 4.93 Ϯ 1. B A – C Ͼ A.4 501.09 17.48 Ϯ 1.002 – – C B C B Ͻ Ͼ Ͻ Ͻ A.11 2.oxfordjournals.146 Ͻ 0.31 1.85 15.79 Ϯ 3. STAXI ϭ State–Trait Anger Expression Inventory.05) with Duncan test.55 Ϯ 6.2%) high class.34 6. age) and psychopathological variables (HAM-A. Table II.94 649.31 Ϯ 1. B AϾC A.2 841. T-ANG ϭ angry temperament.27 Ϯ 4. C AϾCϾB B Ͼ C.00 Ϯ 9.32 Ϯ 7.16 Fa Pa Post-hocb 33. HAM-D.000 Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ Ͻ 0. A Downloaded from humrep.81 24.24 15. OIW ϭ organic infertile women.10 4.91 Ϯ 4.11 2.84 14.48 Ϯ 2. OIM ϭ organic infertile men.000 Ͻ 0.39 5.97 Ϯ 9.89 348.06 Ϯ 3.07 Ϯ 1. post-hoc comparisons (alpha level Ͻ 0.37 Fa Pa Post-hocb 30. AX-IN).08 Ϯ 1.00 6.04 13.72 Ϯ 1.07 6.65 16.55 11.004 0.89 6.000 0.12 Ϯ 3.60 Ϯ 7.17 21.63 12.org by guest on February 9.8%) high class. Comparison of organic infertility.50 Ϯ 4.05 18. age) and psychopathological variables .27 11.37 Ϯ 3. Finally. Another stepwise logistic regression was designed to determine whether there were predictors of functional versus organic fertility in infertile men. 20 couples (69%) were middle class.312 1.48 15.001 0.109 0.45 Ϯ 7.69 Ϯ 9.51 Ϯ 4.12 13.2 0.58 Ϯ 4. FIM ϭ functional infertile men. C A Ͻ B.35 22.73 23.89 Ϯ 4.59 2.21 Ϯ 1.21 Ϯ 2.69 13. 13 (16. B A bSignificant and P value obtained with ANOVA.399 0. CM ϭ fertile men. B A. post-hoc comparisons (alpha level Ͻ 0.46 11.18 7.44 Ϯ 2.93 10.51 Ϯ 2.82 Ϯ 3.44 4.92 Ϯ 5.94 3. AX/CON ϭ anger control.22 1.86 Ϯ 2. AX/EX ϭ general index of the expression of anger.28 Ϯ 6.95 Ϯ 5.Fassino et al.72 Ϯ 7.10 25.79 Ϯ 8.719 2.79 11.

the role psychological functioning plays in infertility. the kind of control group.f.. 2001). which is well described in the literature (Greil. The first objective of the study was the assessment of anxiety.10 1.66 Stepwise logistic regression: d. STAXI) in different steps. however. both in men and women. previous treatments.711 χ2 (Wald) 7..67 0. after reducing the heterogeneity of the infertility sample and distinguishing two subgroups. Bringhenti et al.00–0. infertility duration. results are similar (Table III). and the exclusion from the statistical analysis of subjects with ‘undetermined’ infertility. in men or women. anger. ‘functional’ infertility. 1999..5% of the cases. This finding of a more angry temperament in fertile women is difficult to explain.15 15.. the following variables were considered. and (ii) the way anger is expressed is different in the three groups of women such that women with functional infertility experience higher levels of anger. 1997). Stepwise logistic regression: prediction of infertility status in women and men Gender Variable Parameter estimate 1. which allowed a correct classification of 89.63 P OR 95% CI Women Men HAM-A HAM-D AX-IN HAM-A HAM-D Ͻ Ͻ Ͻ Ͻ Ͻ 0.36 4. which is frequent in infertile women (Facchinetti et al. Presented are significance level (P). and (ii) there are differences also between subjects with organic and functional infertility. Wischmann et al. are a little higher than normal baseline when compared with cut-off scores in HAM-A (Hamilton. it clearly emerges that women with functional infertility have less 2991 Downloaded from humrep. support the findings by some authors (Domar et al.42 –0. the following evidence emerged (Tables I and II): (i) anxiety and depression levels are higher in the two groups of infertile subjects than in controls. etc.01 4. In fact. which. Kee et al.54–4. that is.16 0.) were controlled through the study design. both men and women with ascertained organic causes scored higher on HAM-D than did those for whom organic causes have been excluded (‘functional’). and fertility).0064 0. Greil. Matsubayashi et al. 2000.85 10. beyond the common stress reaction associated with the repeated failure of the attempts to conceive a baby. 1999.oxfordjournals. the odds ratio (OR) and the 95% confidence intervals (CI) of the significant independent predictors of the binary outcome variable of organic infertility versus functional infertility. depression.. 1992b.0017 0. the second without (‘functional’ infertility). Wischmann et al. it should be underscored that this study is only in part comparable with others in the literature because of the study design and particularly the double-blind procedure. a two-variable model was obtained (HAM-A. and difficulties in expressing angry feelings. Because this comparison entailed the assessment of psychopathological features such as anxiety. type of factor responsible for infertility.. These two models are shown in Table III. HAM-D). 1997. depression and anger in infertile couples (Klock and Maier. whereas women with organic infertility have lower anger levels also with respect to controls (Table I).15 0. whereas greater levels of depression seem to predict ‘organic’ infertility (even if in this case the confidence range for OR intersects zero).org by guest on February 9. and socioeconomic levels. Thus.87 9. 1997): age. 2001). the sample selection. years of schooling. Oddens et al. depression and anger.54 –0.. The differences in the anxious–depressive symptomatology between infertile and fertile subjects. the comparison showed that (i) fertile women have a temperament more inclined to anger than the two groups of infertile women. 1991. 2011 . double-blind with respect to the diagnosis of infertility subtype. First of all.44 6. Discussion This report deals with a subject widely debated in literature. it was hypothesized that.19–5. For abbreviations see Table I. For men.. On the other hand. 1997. 1994). but the model does not include the tendency to anger repression. 1976)... 2001).49 3. higher degrees of anxiety and tendency to anger repression seem to be predictors of ‘functional’ infertility. but it is possible that the greater tendency of infertile women toward the expression of negative feelings might protect them from the excessive somatization (Schmidt et al.0087 0.. The comparison of anger among the three groups of men showed differences neither in degrees of anger nor in management of aggressive feelings (Table II). with the former scoring higher on HAMD and the latter on HAM-A.32–0. selection/inclusion criteria.74 2. Other potential confounding elements (cross-cultural variation. the first with ascertained organic causes (‘organic’ infertility). from the comparison among the three groups of men and women (‘organic’ infertility. according to the results of the logistic regression. In particular.979 1. (HAM-A. ϭ 1. for women. however. is often suppressed. 1959. In women. HAM-D. 1960) and HAM-D (Guy. who instead displayed greater degrees of anxiety (HAM-A). As already stated by other authors (Greil. Women with an angry temperament seem to have fewer reproductive difficulties. which.0014 0.Infertility and psychopathology Table III. These data will be discussed later.68 0. but they are not consistent with those obtained by others (Wright et al. 2001). there is a greater pre-existing psychological vulnerability in couples who are infertile from functional causes. and the confounding variables in several studies are probably the basis of these differences (Smeenk et al.37 3. along with the significances and odds ratios (OR). 1989. 1992). Regarding the anxious–depressive symptomatology. being generally accepted that they can be associated with different degrees of anxiety.66–3.0001 4.

Wischmann et al. there is a greater psychological vulnerability to stressors linked with the conception of a child. 1994)]. . 4th edn. and Dr Carla Gramaglia for their help in this work. we would like to thank Dr Giuseppe Rocca for the statistical support. Downloaded from humrep.. Domar et al. Smeenk et al. which are still used by only a few infertile couples (Boivin et al.. studies on subjects undergoing treatment have demonstrated that anxiety may influence the pregnancy rates (Facchinetti et al. typical of passive. there is an OR whose confidence interval intersects zero. are not matched in empirical research by the finding of significant differences (Facchinetti et al. AX-IN) in women and two (HAM-A. infertile women are likely to have a temperament more inclined to passivity. often associated with depressive features (Svrakic et al. the intervention of a specialist (Stewart et al. HAM-D) in men as independent predictors with regard to infertility subtype. the accurate selection of the sample. American Psychiatric Association. beyond the distress that is consequent to the failure of repeated attempts to conceive a baby. they suppress anger more often and have a lesser control over it. Kee et al. as described below. Acknowledgements We would like to thank Prof. The second objective of the study was to identify variables able to discriminate whether a subject belonged to the group of infertility with organic or functional causes. 1993). the importance of anxious symptomatology with respect to infertility is supported. which might predispose to infertility. this trait has shown a peculiar correlation with the tendency toward anger suppression (as 2992 evaluated by AX-In. It is Harm Avoidance.. 1992. More caution is needed in discussing the data about depression in women. depression and tendency toward anger suppression in infertile women. Carlo Campagnoli. This is the reason that sometimes the impressions of clinicians dealing with reproductive disorders. anxious. 2011 References American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders. The logistic regression (Table III) identified three variables (HAM-A. differences in methods and sampling make it difficult to compare and generalize these results and to make further inferential analyses. 2001). a STAXI subscale). HAM-A seems to be an important independent predictor of functional infertility. In particular. decreases the possibility of generalizing the results obtained. it is clear that many of the results obtained regarding psychopathology in subjects with ‘unexplained’ or ‘idiopathic’ infertility depend on the inclusion/exclusion criteria of the studies and on the study plan and design.. In women the presence of anxious traits (subthreshold with respect to a full-syndrome anxiety disorder) and the tendency to suppress anger imply a 3–4-fold greater probability to have a diagnosis of ‘functional’ infertility than a diagnosis of ‘organic’ infertility (see OR in Table III). assessed according to a psychobiological model [Temperament and Character Inventory (TCI) (Cloninger et al. Moreover. whereas in the men. is able to predict at 97% (in this sample) the diagnosis of organic or functional infertility. It should be mentioned that no differences emerged in age or educational level in the three groups of women.. 2000). 2001)... Previous studies on another sample of infertile couples (Fassino et al. Thus. adaptive anger management than fertile women and those with organic infertility. 1999)... with anger suppression being peculiar to psychosomatic disorders. Of course. The different results between men and women seem to support the better coping abilities and lower distress about the infertility in men than in women as reported in the literature (Dhillon et al. is able to predict organic infertility versus functional infertility. 1999. This hypothesis seems to be supported by the evidence that the triad of high anxiety. targeting specifically the anxious–depressive symptomatology and psychosomatic features.oxfordjournals. Moreover.Fassino et al. However... 2001). Dr Clementina Peris. For this subgroup. although logistic regression suggests a strong significance of this variable as a predictor for diagnosis. through anxious–phobic and psychosomatic reactions (Stauber. the results obtained in the present study have limits due to the complexity of the subject (Greil. because data in the literature are not consistent. This result is in contrast with the opinion of many authors who suggest an association of higher educational level and lower reproductive potentialities (Wischmann et al. Anna’ Hospital of Turin for the professional collaboration. HAM-D.. 2001)... Also for men. and avoiding people.. DC. improving the accessibility to these interventions.. 1997. supporting the data obtained from another sample with a different psychometric assessment (Fassino et al. is necessary even without a full-syndrome psychiatric disorder (Axis I of DSM-IV). 2002). mostly in women with functional infertility. which is likely to play an important role in the onset and course of functional infertility. 1992. whereas the data about anger lose their significance. 1997) and cannot be considered definitive. according to the authors of TCI. even if necessary for the study design. there is also a poorly adaptive psychological functioning. it is possible to suggest the hypothesis that. 2000). In eating disorders (Fassino et al. 2002) have outlined that the temperamental component of personality. fertile men displayed a higher educational level than the two groups of infertile men. outlining the importance of counselling and psychotherapeutic treatment of couples who require consultation for fertility disorders. and the presence of a greater anxiety psychopathology increases the probability of being a man with ‘functional’ infertility by 5-fold (see OR in Table III). However.org by guest on February 9. 2001). Further studies might explain and support this evidence. which. Washington. The use of logistic regression aimed to evaluate which of the differences at the ANOVA between the two groups of infertile subjects were still significant after excluding the internal correlation among the variables considered. Thus.S. it would be possible to decide more accurately which couples should be the target of psychological counselling (Boivin et al. Because patients and therapists did not know a priori the causes underlying infertility. Even in this case the data about depression are uncertain. the results do suggest the possibility of identifying a subgroup of infertile subjects where. and the Department of Obstetrics and Gynaecology of ‘S. 1988). If further studies supported this evidence. is a psychobiological trait related to the serotoninergic system.

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