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Human Reproduction, Vol.24, No.7 pp. 1656– 1664, 2009 Advanced Access publication on March 15, 2009 doi:10.

1093/humrep/dep061

ORIGINAL ARTICLE Psychology and counselling

The longitudinal impact of partner coping in couples following 5 years of unsuccessful fertility treatments
B.D. Peterson1,5, M. Pirritano 2, U. Christensen 3, J. Boivin 4, J. Block 1, and L. Schmidt 3
1 Department of Psychology, Chapman University, One University Drive, Orange, CA 92866, USA 2Orange County Health Care Agency Medical Services Initiative, USA 3Department of Social Medicine, Institute of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO Box 2099, DK-1014 Copenhagen K, Denmark 4School of Psychology, Cardiff University, Psychology Building, Park Place, Cardiff, Wales, UK 5

Downloaded from humrep.oxfordjournals.org by Agnes Horvath Hajdu on February 9, 2011

Correspondence address. Tel: þ 1-714-744-7915; Fax: þ 1-714-997-6780; E-mail: bpeterson@chapman.edu

background: Because there is a lack of longitudinal research examining the impact of partner coping in couples experiencing infertility, we know very little about the long-term nature of coping with infertility and how partner coping strategies impact personal, marital and social distress. methods: Participants were Danish men and women about to start a cycle of assisted reproduction treatment who were followed for a 5 year period of unsuccessful treatments. Multilevel modeling using the actor–partner interdependence model was used to examine the couple as the unit of analysis. results: Active and passive avoidance coping strategies were significantly related to increased personal, marital and social distress at the
individual and partner level. Meaning-based coping strategies were related to decreases in a woman’s individual distress and her partner’s marital distress.

conclusions: Partner coping strategies have a significant impact on the other member of the couple over time in men and women undergoing infertility treatments over a 5 year period. Physicians and mental health professionals can educate men and women regarding the ineffectiveness of avoidance coping strategies as well as the beneficial nature of finding new meaning and life goals while experiencing the stress of infertility.
Key words: longitudinal / infertility stress / coping / couples / APIM

Introduction
Coping with the stress of infertility is a topic that has received considerable attention from researchers, physicians and mental health professionals over the past several decades (Peterson et al., 2006a; Schmidt et al., 2005a). When a couple experiences infertility, they encounter changes in their familial, social and personal relationships (Newton et al., 1999). In addition, couples may re-examine their need to be biological parents and question long-held beliefs and assumptions about their identity. The aggregate weight of these unexpected strains can produce infertility-related stress in one or both partners (Newton et al., 1999). How the couple responds to these stressors has implications for both individuals and the couple. In order to adequately respond to stress, couples use coping strategies, or behavioral or emotional efforts used to manage change and

regain control of their lives (Lazarus and Folkman, 1984). Men and women cope with infertility in different ways with women consistently reporting increased use of coping strategies when compared with men (Jordan and Revenson, 1999). A meta-analysis of studies examining specific gender differences in coping with infertility found that, when compared with their partners, women used more escape-avoidance coping, engaged in more social support seeking and used more positive reappraisal coping (Jordan and Revenson, 1999). A more recent study examining relative coping found that women referred for IVF treatment coped using proportionately greater amounts of escape-avoidance, confrontive coping, accepting responsibility and social support seeking, whereas men used greater amounts of distancing, self-controlling coping and planful problem-solving (Peterson et al., 2006a). Similar gender differences and the increased reporting of coping behaviors in women were also found in a meta-analysis

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free and easy access to high-quality assisted reproductive technology (ART). In 2002. thus providing a more complete picture of how coping is related to stress in couples. Procedure All new couples entering one of the five fertility clinics for the first time received a sealed envelope immediately before their first treatment attempt (T1). showing feelings. 2006b. 2008). researchers can understand the impact that one partner’s coping has on the other. 2008). 2006). 2011 In the current study..org by Agnes Horvath Hajdu on February 9. Kenny et al. The non-responders received up to two written reminders. By examining the couple as the unit of analysis. and in 2007. Daniluk and Tench.) who was not employed at any of the fertility clinics. Peterson et al. The baseline questionnaires were returned to the last author (L. we have examined the longitudinal impact of partner coping in men and women undergoing fertility treatments and link our results to previously established baseline findings. Other longitudinal studies not specifically related to coping. 2003. there have been very few studies that have examined this issue longitudinally. this proportion increased to 8. by using the APIM (Peterson et al. 2007). growing as a person in a good way. 2007). In total. avoidant coping used prior to insemination predicted increased distress after a failed insemination attempt.g.. Rayens and Svavarsdottir.. 2005). This study is part of The Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme (Schmidt et al.g. 2003. comprehensive health-care system with equal.2% of the national birth cohort was composed of children conceived with some kind of assisted reproduction (Nyboe Andersen and Erb. pre-addressed return envelope for each spouse. is also accumulating outside of the infertility literature (Butterfield and Lewis. hoping for a miracle) and meaning-based strategies (e. Such studies are valuable because they assess the interactions between partners to see if an individual’s stress levels can be accounted for by a partner’s coping strategies. Downloaded from humrep. and couples successfully adjusted to infertility 3 years following failed treatments (Daniluk. The envelope contained information about the study. active-confronting strategies (e. Although there have been a number of studies in the infertility literature using longitudinal designs. 1) can be effective in analyzing data from such studies. which is a prospective longitudinal cohort study on a large population of infertile couples in fertility treatment initiated in Year 2000. a form for declaration of non-participation in the study and a stamped. A body of research that uses the APIM.Longitudinal impact of partner coping strategies 1657 examining men and women coping with other life stressors including work. to examine the impact of one partner’s coping on the stress of the other partner. These studies have consistently found that partner coping is related to individual distress and that partner coping impacts men and women in different ways. 1998. A new method of data analysis called the actor –partner interdependence model (APIM. (2008) used the same sample as the present study to examine the partner effect of coping with infertility prior to undergoing infertility treatment and Benyamini et al. Levin et al.dk. avoiding pregnant women or children). 2006.oxfordjournals. and they have significantly added to the infertility literature base (Stanton et al. 2812 fertility patients . Schmidt. Figure 1 General model of actor and partner effects of coping strategy on distress. 1992.. 20th October 2008). 2001. marital and social distress in men and women experiencing failed fertility treatments over a 5 year time period. couple relationships were strong and stable 1 year following failed IVF treatments (Sydsjo ¨ et al. Over the past decade. In the infertility literature. Specifically. Mikulincer et al. passive-avoidance strategies (e. 2005). 2005). a baseline questionnaire. The COMPI cohort comprised consecutively all new couples initiating fertility treatment with intrauterine insemination (IUI). 2005. Berghuis and Stanton (2002) examined the longitudinal impact of coping and depressive symptoms in couples following a failed insemination attempt. caregiving and chronic illness (Tamres et al. 2005). Fig. infertility-stress had direct and indirect effects on treatment outcome (Boivin and Schmidt. 2006). They found that both individual and partner coping were significantly related to distress.S. Cook and Kenny. The study was approved by the Danish Data Protection Agency and was assessed by the Scientific Ethical Committee of Copenhagen and Frederiksberg Municipalities who had no objections. Materials and Methods Setting Denmark provides a tax-financed. 2002. Dyadic analyses have also been used to highlight important relational dynamics and coping patterns in couples dealing with chronic illness such as cancer (Berg and Upchurch. in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in four large public hospital-based tertiary fertility clinics and one large private clinic in Denmark from 1 January 2000 to 1 August 2001. whereas approach-oriented coping was predictive of a more favorable adjustment... 6.g. asking others for advice). have found that: anxiety and depression increased in women 6 months following failed treatments (Verhaak et al. there has been an increased emphasis on studying the relational nature of coping with infertility using the couple as the unit of analysis. Rogers et al. We examined the impact of four types of coping [active-avoidance strategies (e.. The APIM allows for the simultaneous estimation of actor effects (individual effects) and partner effects (the effects of another closely associated person) to shared stressors in dyads. two recent studies have used the APIM in their data analysis: Peterson et al. 2002). 2003.0% (www. there is a need for more studies examining the longitudinal impact of partner coping on individual distress in couples experiencing infertility. finding other goals in life)] on personal. (in press) studied how perceptions of infertility are related to psychological adjustment in men and women. They also found that women who were low in emotional-approach coping benefited from their partner’s use of it.fertilitetsselskab. but within the infertility literature. These analyses provide a more complete and accurate picture of the impact of coping....g. 1997. Although the number of studies examining the impact of partner coping has increased..

. 2003).38 8.. Seven of these items were taken from The Fertility Problem Stress Inventory (Abbey et al........7%) responded (1025 women. 1081 men. In the current set of analyses. 85. 83. growing as a person in a good way. When subscales were removed from the model one at a time... hoping for a miracle).. friends and workmates (e.g.4%....... 1984. 4 participants whose address could not be traced... items developed from a qualitative interview study (Schmidt. Marital distress Social distress Downloaded from humrep.31 0.27 0.73 5. 1991). 89.36 0.. 1988)....... ‘infertility has caused stress in my relationships with family and friends’)... (2) used somewhat. we developed 11 items based on the results from the interview study.. 2003. Non-participants were significantly older.... 63..64 0.. and female nonparticipants were more likely to have tubal occlusion.14 0. SD 5 years Mean .. Data analysis The analyses were longitudinal.91.48 1... a process-oriented measure of coping derived from Lazarus’ and Folkman’s transactional model of stress (Lazarus and Folkman.. see Schmidt et al.16 0..28 4. SD .36 0. 2206 participants received the 1 year follow-up questionnaire and 1934 (87. dyad). and seven of these were re-formulated to focus on the specific stressor of infertility.org by Agnes Horvath Hajdu on February 9.. Items for the coping questionnaire were selected from WOCQ only if this specific way of coping was clearly revealed in the qualitative interview transcripts (Schmidt..44 4. Among male non-participants... 1996).15 8.. 1 and 5 years.10 0.. Table I Male and female mean distress at baseline.69 2.. 75...23 0.0%. In total.. 1 and 5 years Baseline Mean Personal distress Male Female Male Female Male Female 5. The (i) Marital stress subscale (four items) assessed the extent to which infertility had produced strain on the marital and sexual relationships (e. with a variable included that defined the couple (i.. 18 items were selected from WOCQ. a variable that identified the individual and a variable that coded for time. (ii) active-confronting strategies (e... passive-avoidance by three items and meaning-based coping by five items.oxfordjournals. were conducted. Peterson et al.. 1996).64 7.31 0.. active-avoidance coping was covered by four items. The response key for the remaining two items from marital stress was a five-point Likert response key from (1) strongly disagree to (5) strongly agree.34 0. There were no significant differences between the 1 year follow-up participants and non-participants among either women or men according to the baseline (T1) values of the COMPI Fertility Problem Stress Scales or the COMPI Coping Strategy Scales.18 Measures The COMPI fertility problem stress scales Fertility-related stress was measured using 14 items concerned with the strains related to infertility produced in the personal. 16 who had died or whose partner had died).. avoiding pregnant women or children)...... and we excluded them from the analyses..88 for the entire model.. 2006). The subscales comprised items that were significantly intercorrelated..63 1... 2011 0. Kashy and Donnellan.46 1.... The items were categorized into four subscales based on their conceptual content: (i) active-avoidance strategies (e... (ii) Folkman’s (1997) later revision of the coping model with the inclusion of the new concept... The (iii) Personal stress subscale (six items) tapped into the stress infertility had produced on the person’s life and on mental and physical health (e.e.. the items were factor analyzed to produce a set of parsimonious factors. social and marital domains..... 2003)..3%) after up to two written reminders. and strain in relation to the three different domains was confirmed..... In order to conduct the analyses... 76..... Tjørnhøj-Thomsen..09 0. which involve more than one regression model calculated at different levels of a nested design. finding other goals in life) (Schmidt et al.. as this instrument covers all three domains.... social stress and two items from marital stress was a four-point scale from (1) none at all to (4) a great deal.. 2006. Ten of the 29 items did not fit the scales. ask others for advice). the GFIs were . These 29 items covered a wide range of responses the participants may have engaged in when dealing with the fertility problem. The (ii) Social stress subscale (four items) assessed the stress infertility had produced on social relations with family....0% (n ¼ 2250) participated (1169 women.1%.4%) responded (834 women. meaning-based coping... following couples across three waves of data collection: baseline.11 0. 0.42 0. the data were structured so that each line contained data for one individual at one time point.24 4. more were about to start ICSI treatment (for a detailed non-participants analyses. In total. A confirmatory factor analysis showed goodness-of-fit-index (GFI) ¼ 0. The items were developed in relation to the three domains (Schmidt et al. 1 participant who had died and 1 who suffered from a severe brain injury). In total. the baseline time point was coded as zero as the starting point where the couple initiated a treatment period.. 72 were lost to follow-up (56 whose address could not be traced. See Table I for means and standard deviations (SD).. ‘it is very stressful for me to deal with this fertility problem’)... 2134 received the 5 year follow-up questionnaire and 1481 (69. 647 men... the decision of which time point should be coded zero is not arbitrary because it affects the interpretation of later results (Singer and Willet.. 1996.31 5..22 4. Greil.. active-confronting by seven items... Only when the participants had answered at least half of the items in a subscale did we include their response for that subscale.. the remaining seven items were developed from The Psychosocial Infertility Interview Study (Schmidt. ‘infertility has caused thoughts about divorce’). Items from the different subscales were summed to produce total scores..81 2.. 2008).g.16 4. 2005b). 1996).. SD 1 year Mean . Higher scores indicated more marital. Further... social and personal stress. On the final measure. (1996).g. The response key was (1) not used. showing feelings.. and (iv) meaning-based coping (e. Schmidt... The response key for the subscales personal stress. 909 men.......g. and (iii) . For the current analyses. Dyadic growth curve models were created using multilevel modeling techniques (Kenny et al.1658 (1406 couples) received a baseline questionnaire for each partner and 80. In growth curve modeling..19 .9%)..67 2.17 0.. At 5 year follow-up (T3). the The COMPI coping strategy scales As recommended by Folkman and Lazarus (1988) and Costa et al... 44 participants were lost by 1 year follow-up (T2) (38 participants whose identity was not registered at T1.. (iii) passive-avoidance strategies (e.. In total. 2005)...g. 1997.8%)... we developed a coping questionnaire specifically aimed at measuring coping strategies in relation to a specific stressor: infertility. This 29-item questionnaire was developed using three sources: (i) items were adapted from the 66-item Ways of Coping Questionnaire (WOCQ). (3) used quite a bit and (4) used a great deal.....17 5...25 0. as previous research has shown that infertility taps into these different arenas (Schmidt.25 0.g. Afterwards.g.. Folkman and Lazarus. Multilevel analyses......

. they were included in the individual level analyses but not in the couple level analyses)..org by Agnes Horvath Hajdu on February 9.33*** 0... executives and medium level white collar employees).09*** 0.. The design of the analysis is very similar to a multiple regression with one dependent variable and a set of predictor (or independent) variables. 1169 women and 1081 men who were members of consecutively referred couples undergoing fertility treatments completed the baseline questionnaires (T1). When a significant female partner effect is found... **P .04 0. marital and social). Men were also significantly older than women..00 Social distress 1. The significant time effects for personal distress and marital distress simply reiterate the significant male and female slopes.. Downloaded from humrep..23*** 2 0. 0.03 .. and the independent variables were the four coping strategies and time. In terms of social position. Interaction effects with time were also examined for the gender.01..1 years (SD ¼ 2.001).Longitudinal impact of partner coping strategies 1659 treatments over the 5 year period. . For those still trying to have children at 5 years. there were 133 males and 201 females who had not had achieved parenthood either after a treatment-related pregnancy..6.001.. To discover the best model. Social distress did not change significantly during the study period.07** 0.09 0.. Multilevel analyses estimate the model independently at each of these levels. P ....4.. they were included in the couples analysis..45*** 0.... individual level was nested within the couple level.19** 1.. The significant negative slope for males and females on personal distress indicates that personal distress decreased across the 5 years of the study... a spontaneous conception or adoption. martial and social distress Personal distress Male mean Female mean Male slope Female slope Gender Time Gender by time 5. social or marital distress. men 4. This served as a diagnostic tool for determining if there was in fact any unexplained variance to be estimated in particular variables. Table II presents the findings from the baseline models that were used to determine the growth curve for subsequent analyses that would include covariates... Because of this... Couples reported receiving an average of 4. Similarly. The significant means indicate that these means were significantly different from zero.3 fertility Multilevel model: significant actor and partner effects Figure 1 provides a visual depiction of the general model of actor and partner effects and their influence on male and female distress. One of the principal challenges in running the multilevel dyadic growth models that sets them apart from cross-sectional models is the increase in parameter estimates that are possible (i...27*** 0.1 versus 37... when data were available for only one partner.. Because multiple models are constructed at each level of the nested design.. Men continued to be significantly older than women.93*** 4. more random effects are available to be included in the models).. P . Significant gender differences indicate that women had higher scores on personal and social distress than men at baseline and 5 years.. 52% were from a medium social position (low level white collar employees and skilled workers) and 23% were from a low social position (unskilled and semiskilled workers and participants receiving social benefits).63*** 2.8% had been in fertility treatment (most frequently IUI) prior to inclusion in COMPI..e. respectively (t ¼ 17.0 years. At the 1 year follow-up (T2)... 0. when Table II Two-intercept and interaction growth models for personal.39*** 0. respectively (t ¼ 4. Multilevel analyses were conducted for each combination of dependent and independent variables.....4 years.... 2011 Results Sample characteristics In total..15** 0.. 0...30*** 0.23*** 8.22*** 0. At the 5 year follow-up (T3).. These analyses provide unstandardized estimates of path coefficients for actor and partner effects..8% of women and 41. If it was determined that there was not any unexplained variance in an independent variable to be estimated by the model (a situation that inevitably results in the model’s inability to converge).... At baseline. and the resulting difficulty in finding models that will actually run...1 years.oxfordjournals.. there were 552 males and 592 females who still had no child. with a mean age of 40. couples had been trying to have a child for an average of 9.. 25% of participants were from a high social position (professionals.01 Martial distress 3... Baseline models and longitudinal distress levels Table I presents the mean levels of personal.. resulting in 12 analyses... analyses were run starting with the saturated model (the model including all possible random effects) and gradually refining them until the optimal model emerged.. The dependent variables in the current study were three different types of infertility-related stress (personal..4% of men attributed the infertility to women. that variable was fixed in subsequent models. The lack of significant gender by time interactions indicates that the slope of the growth curves did not significantly differ for males and females.. Analyses were also conducted to determine if there were significant differences in the strength of the actor and partner effects. it indicates the existence of a relationship between a male partner’s coping strategy and the female partner’s personal...3% of men and 32.60*** 2 0.. The significant positive slope for males and females for marital distress indicates that marital distress increased across the 5 years of the study. In some instances.. At 5 years. the analysis is able to use all available data without having to use listwise deletion across the entire analysis. participants had been infertile for  4 years [women 4.. marital and social distress at the three time points.1 years (SD ¼ 2. or a current pregnancy and who were still partnered with the same partner at inclusion (samples at each time point contained an unequal number of men and women because when data were available for both partners.. whereas 41.001)... whereas when data were available for only one partner. but not the couple level analyses. actor and partner effects.3). ***P . models designed only to estimate the variance of components were run..4 versus 32... with a mean age of 34.44*** 2 0.2)] and 57.. 35. they were included in the individual level analyses. The baseline models provide an estimate of the mean for males and females as well as an estimate of the slope of the growth curve.....8% of women attributed the infertility to men... 0.

there were no significant gender differences over time. greater use of meaning-based coping strategies was related to increased social distress.oxfordjournals. Thus. highlighting the reciprocal nature of the Active-confronting coping For active-confronting. 2011 Discussion The current study highlights the impact of partner coping strategies on personal. Passive-avoidance coping For personal distress. There was also a significant male partner effect for marital distress and a male partner by time effect for marital distress. there was a significant increase in the strength of the effect at 5 years. Follow-up ordinary least squares (OLS) regression analyses showed that over time. the actor effect for women was strengthened. yet personal distress decreased significantly for both men and women over time at similar rates. this indicated an increase in the strength of the female actor effect over time. a female’s increased use of activeconfronting coping strategies was related to increased male marital distress over time. indicating that although the increased use of meaning-based coping decreased female personal distress. but only for women: the increased use of active-avoidance in men increased levels of marital distress in women. it highlights the relationship between a female partner’s coping strategy and the male partner’s distress. There were also significant interactions between time and the actor effect for women. key findings from this study confirm that active and passive avoidance coping are consistently associated with poorer personal outcomes for the individual and their partner.. Time also predicted a significant increase in marital distress for both men and women. When examining distress levels over time. 1995. 1999). there was a significant negative actor effect for females. Peterson et al. and that meaning-based coping strategies are more beneficial for women than for men at both the individual and the partner levels. indicating that a male’s use of passive avoidance was related to his own and his partner’s increased marital distress. 2007). and because the female’s body is the main focus of fertility treatment (Morrow et al. This finding supports a previous study which found that adaptation of men and women to failed fertility treatments was similar. for males this was not the case. Follow-up OLS regression analyses indicated that for the actor effect. Newton et al. an interaction between the gender and the actor effects. marital and social distress across time for both men and women. however. Table III presents the significant actor and partner effects for each coping strategy by personal. indicating that the increased use of meaning-based coping was related to decreased personal distress. The longitudinal model was valuable. However.. marital and social distress in a sample of men and women undergoing unsuccessful fertility treatments over a 5 year period. Active-avoidance coping For active-avoidance. Given the lack of longitudinal studies examining the impact of partner coping on infertility distress. For marital distress. 25% of women showing sub or clinical levels of anxiety or depression (Verhaak et al. For social distress. 2007a). There was one interaction between time and the female actor effect.. There was also a significant positive male actor effect for social distress indicating that for men. there were significant actor effects on personal.1660 a significant male partner effect is found. meaning that with an increased actor effect for women. As with personal distress. The results are also consistent with a recent systematic review among women in IVF treatment showing that the long-term prognosis for people undergoing treatment was generally positive with . Downloaded from humrep.org by Agnes Horvath Hajdu on February 9. This was also true for marital distress. 1997. in that it allowed us to see that over time. There was. there was a significant actor effect for men and women and a significant partner effect for women. the relationship between the use of the active-avoidance coping strategy and greater social distress increased. there was a significant actor effect for social distress and an actor by time effect for men and marital distress.. and that couples report less distress over time. but also by addressing the significant long-term impact of one partner’s coping on his or her partner’s infertility-related distress. Meaning-based coping For personal distress. Peterson et al. Comparisons of the relative contribution of independent variables can be made since all variables are measured on the same response scale. potentially because they have more psychological space to respond to the life transition (Daniluk and Tench. there were significant actor effects for men and significant interactions between the actor and partner effects over time for women. This is likely due to the fact that the experience of infertility is so closely linked to the female identity. indicating that the strength of all other actor and partner effects remained constant across time. indicating that a female’s use of meaning-based coping was related to a decrease in both her and her partner’s marital distress. 2002). No other interactions between either partner or actor effects with time were significant. there was a concomitant decrease in the partner effect. for the partner effect. These findings can benefit both physicians and mental health professionals by underscoring the importance of coping over time. indicating that a partner’s use of increased active-avoidance coping was related to increases in his or her partner’s levels of personal and social distress. women reported greater amounts of personal distress when compared with men. There were also significant partner effects for males and females on personal and social distress. 2007). marital and social distress. Unstandardized beta coefficients (b) are reported. There was no effect of meaning-based coping on the personal distress of men. . This is consistent with a wide range of studies indicating that women report greater amounts of infertility-related distress when compared with men (Slade et al. both male and female personal distress levels decreased at similar rates. For marital distress. marital and social distress over time. it is difficult to make direct comparisons to findings of previous studies (Berghuis and Stanton. there was a significant female actor effect and a significant male partner effect.. there was a significant actor effect for men and a significant partner effect for females. The positive actor effects for men and women indicate that greater use of active-avoidance predicted greater personal. This indicates that over time.

.......09 0.08 0..06 0....02 0...02 0.01 2 0.00 2 0.00 2 0.00 0.....01 2 0.44*** 0.01 0...02 0.00 2 0..01 2 0..05** Martial distress Social distress ...08* 0.02 2 0.02 0.........05 0.09** 2 0....02 0.......06 0..01 0.07* 0.10* 2 0.03 0..........02 0.11* 0..05* 0.Longitudinal impact of partner coping strategies 1661 Table III Actor and partner effects of coping style on distress over time Personal distress Active-avoidance Actor effects Male Female Actor effect by gender Male actor effect by time Female actor effect by time Partner effects Male Female Partner effect by gender Male partner effect by time Female partner effect by time Active-confronting Actor effects Male Female Actor effect by gender Male actor effect by time Female actor effect by time Partner effects Male Female Partner effect by gender Male partner effect by time Female partner effect by time Passive-avoidance Actor effects Male Female Actor effect by gender Male actor effect by time Female actor effect by time Partner effects Male Female Partner effect by gender Male partner effect by time Female partner effect by time Meaning-based Actor effects Male Female Actor effect by gender Male actor effect by time Female actor effect by time 0.02 0..........06* 0.05 2 0....04 0...30*** 2 0...23*** 0.30*** 2 0..02 0...........04 0.08 2 0..12** 2 0.02 0.00 0....35*** 0.org by Agnes Horvath Hajdu on February 9. Downloaded from humrep..03 2 0.01 2 0.01 2 0..23*** 0.00 0.28*** 2 0...02 2 0....16*** 0..02 0..02 0...01 0.03 0....01 0..02 0....07* 0......89*** 0..01 2 0.................38*** 0...03 2 0.03 0.04* 0..03 Continued ..06 0. 2011 0.......01 2 0.19*** 0.12** 0.06* 0......03 0.02 2 0...02 0.00 2 0.....06 0......00 0.07** 0....05 0..21*** 0.05 2 0.02 0..03 0....00 0.06 0...04 0...00 0.79*** 0.oxfordjournals..23*** 2 0..........01 0..04* 0..39*** 0.00 2 0..01 0....04** 0..07* 0..05 2 0.10 0...00 2 0.03* 0..04 2 0.21** 0.......02 0..08 0.02 0.

.. 2006a).g.. There was also a female partner effect for personal and marital distress. the greater distress both they and their partner are likely to report.... proposing that advanced stages of infertility and treatments not only take a toll on the individual.....02 0. 0. 2005c.. Although the current study did not examine this construct directly. it is difficult to generalize findings on marital distress to other studies examining the construct of marital adjustment.. ... Berg and Wilson (1991) found in a cross-sectional study that marital satisfaction was strong for couples during the first 2 years of treatments....... 2008). and although he is taking action through treatments. At that time.. some studies have shown that time can play a role in decreasing satisfaction. In their longitudinal study of partner coping over time.05..... but rather marital distress (e... Therefore. marital and social distress... a partner’s use of active avoidance was related to increased personal and social distress in men and women.....01.08* 2 0. For example.. *P .00 Downloaded from humrep. Holter et al. (2006) studied the short-term psychological impact of IVF treatment and found that at the time of treatment.. It is important to note that our study did not specifically measure marital adjustment or satisfaction. At baseline. his coping strategy lacks belief that his actions will make a difference... This may be due to a couple’s reliance on one another for emotional support throughout the treatment process... stress on sexual relations). gender differences regarding desired continuance or cessation of treatment may play a role in the increase of marital distress over time....... The findings related to passive avoidance varied greatly from baseline to Year 5.... Martial distress Social distress . and a female actor effect for personal distress. In the current study...... marital and social distress (Peterson et al..1662 Peterson et al... but significantly lower in the third year.. When examining partner effects.. 2002).... In our baseline analysis...... This finding showed that men’s use of passive-avoidance coping strategies (e..... there was a male actor effect for passive avoidance on personal.... we hypothesized that the non-significant impact of the partner effect was likely due to the unexpressed nature of the coping strategy.. In the current study... namely relief from the stress through actively avoiding situations and reminders of infertility........ and supporting previous studies showing that active-avoidance coping is related to increased individual distress (Peterson et al.... marital and social distress for themselves. partners may not be aware of one another’s use of passive avoidance. One possible explanation for this is that a man’s use of passive avoidance over time goes against the typical male role of problem-solver. which may erode over time. In a study of 45 couples experiencing failed IVF treatment.... active-avoidance coping. 2011 marital relationship in experiencing the stress of infertility.... passive-avoidance coping and meaning-based coping produced noteworthy results...g.. 2005)....org by Agnes Horvath Hajdu on February 9.00 0.....oxfordjournals.... (2005) found that nearly three-quarters of women wanted to undergo further IVF treatments... Contrary to what couples attempt to achieve........ A meta-analysis on the association of coping to physical and psychological health outcomes based in studies using either the Lazarus and Folkman Revised WOCQ or Vitiliano’s Ways of Coping Checklist showed that wishful thinking was inversely associated with psychological well-being (Penley et al. Sydsjo ¨ et al... and increased marital distress in women over time.... we found that active-avoidance coping strategies had significant actor and partner effects on personal. Table III Continued Personal distress Partner effects Male Female Partner effect by gender Male partner effect by time Female partner effect by time ***P .02 0.......04 2 0. 2 0. the findings from this study clearly show that using active-avoidance coping strategies over time does not ultimately help one’s level of personal distress.......01 0.. neither at the individual nor at the partner level.04 0.. **P .02 0.. a couple’s relationship was strengthened because of the treatment process.. 2008)... but that further treatments might cause problems in the relationship.. but also upon the couple. The longitudinal model also allowed us to examine the long-term impact of various coping strategies... relying on a miracle and feeling the only thing they could do about infertility was wait) was linked with increased personal.. 0....01 0...... In our study.... Sydsjo ¨ et al. Physicians and mental health professionals can help men and women reduce their levels of active-avoidance coping by educating patients regarding the paradoxical nature of this ineffective coping strategy......02 0.... there were no significant partner effects for passive-avoidance coping (Peterson et al..00 2 0..06 0. the actor effects for males and females on each type of distress are significant. The measurement of wishful thinking is overlapping with our subscale for passive-avoidance coping and the meta-analysis and hence supports our results among a population of infertile people.... When examining the impact of partner coping on distress over time..... and increased personal and marital distress for their partners. indicating that a male or female’s use of active-avoidance coping predicted higher levels of individual distress over time....... and that because of this. stress placed on the marriage.... and the impact these coping strategies have on infertility-related distress. whereas the majority of men did not intend to... specifically that the more they avoid the stressor..02 2 0.... Berghuis and Stanton (2002) also found that a partner’s avoidant coping strategies were related to greater distress.. 0.. Although a large number of studies show that marital adjustment is strong in men and women experiencing infertility before and after treatments (Schmidt et al.. increased marital distress could have to do with men and women’s differing desires in treatment continuance.....001....03 0.

Foghts Fund. When a woman used this strategy. the merchant L. Gender’s role in responses to infertility. As couples redefine and work through the complexities of this difficult life stressor. 2008). the manager E. Boivin J. jointly solve problems and increase their levels of interpersonal intimacy (Skerrett.Longitudinal impact of partner coping strategies 1663 to infertility.F. Psychological functioning across stages of treatment for infertility. they have increased opportunities to develop new forms of communication. Meaning-based coping has also been shown to be effective for couples in adapting to other life stressors including coping with experience of breast cancer (Skerrett. The impact of meaning-based coping over time was also noteworthy. Psychol Bull 2007.. Women’s and men’s perceptions of infertility and their associations with psychological adjustment: a dyadic approach. when Folkman (1997) introduced the concept of meaningbased coping. Gender differences in the pacing and timing of treatment may be related to men and women’s unwillingness to redefine the stress of infertility at the beginning of treatment (Peterson et al. Fertil Steril 2005. Previous research on the psychosocial factors associated with infertility has found several gender differences in how men and women respond Downloaded from humrep. Rigshospitalet. Stanton AL. Benyamini Y. Berg BJ. Andrews FM.70:433 – 438. Wilson JF.. It is clear that active. 1998). Herlev University Hospital. Psychol Women Q 1991. These differences include men and women’s differences for seeking treatment. In addition. The COMPI scales used in this study have not yet been validated in large-scale psychometric studies. 2007b). Upchurch R. Copenhagen University Hospital. In other words. Women who found new life goals following treatments also reported less anxiety and depressive symptoms (Verhaak et al. and the engineer K. and also on her partner’s marital distress. why did this happen to me. Halman LJ. this longitudinal analysis supports baseline findings and also adds to the existing knowledge regarding the impact of coping with infertility over time.and passive-avoidance coping strategies are related to increased distress over time at the individual and partner levels. 1999). the measures were adopted from existing scales and developed after in-depth qualitative interviews with Danish fertility patients. gender differences in communication and coping strategies. find other goals in life and ultimately think about infertility in a positive light.org by Agnes Horvath Hajdu on February 9. This finding is even more important given the earlier findings that marital distress increases over time. The programme is a collaboration between the public fertility clinics at Braedstrup Hospital. References Abbey A. Berg CA. 1998). Odense University Hospital. However. It may take time to experience the benefits of meaning-based coping because they may only come when a person has addressed the many complicated questions and stressors presented through the infertility experience (e. 2000. 133:920– 954.14:11– 26. it is important to note it cannot be rushed and may be a long-term process. Danielsen and Wife’s Fund. Also men and women in the COMPI cohort have different reasons for seeking treatment and significantly more men than women have sought treatment for their partner’s sake (Schmidt et al. the Jacob Madsen and Wife Olga Madsen’s Fund. Schmidt L. and the impact of infertility on men and women’s identities. particularly at a time when their marital relationship may be under duress. A developmental-contextual model of couples coping with chronic illness across the adult life span. In addition. When a woman engages in meaning-based coping. Br J Health Psychol 2009.g. This study helps illustrate that partner coping strategies are related to distress over time.. Funding This study has received support from the Danish Health Insurance Fund (J.14:1 – 16. gender and their respective consequences are interwoven in cultural and societal expectations would be valuable. which removes some of the shared burdens that infertility places on her and her partner and that lead to increased marital distress over time. Berghuis JP. Rohde and Wife’s Fund.15:295 – 316. 2007). both measures were stressor specific to infertility and were not instruments measuring general stress and coping. it had a beneficial effect on her personal and marital distress.g. a woman’s use of meaning-based coping benefits her and her partner’s marriage over time. J Consult Clin Psychol 2002. Men and women should be aware of the positive impact of meaning-based coping. The decreased marital distress may be related to a woman’s expanded focus on other life activities. Adjustment to a dyadic stressor: a longitudinal study of coping and depressive symptoms in infertile couples over an insemination attempt. We are hopeful that this study will lead to future research examining the impact of coping within the greater social context of infertility. differences in depression and anxiety levels following treatments. and this knowledge can benefit physicians and mental health professionals who work directly with couples coping with the stress of infertility.. women in these couples may more successfully integrate the experience of infertility into their identity—a crucial developmental task when coping with this life transition (Peterson et al. These factors are embedded within the social context in which we live and the roles and responsibilities related to childbearing and childcare may differ greatly for men and women (e. Although the benefit of this coping strategy is obvious for women. Future studies which explore how infertility. J Behav Med 1991. she stressed that meaning-based coping sustained the coping process by generating positive emotions. nr. In conclusion. differences in role expectation of motherhood and fatherhood). 2003).oxfordjournals. . Future research studies which examine the process of change in couples and the stages of coping with infertility are increasingly necessary to better understand this issue. Infertility-related stress in men and women predicts treatment outcome 1 year later. differences in maternal/paternal leave. the dual-bread-winner society. 11/097-97). she reports that the experience of infertility helped her grow as a person. will my family and social relationships ever be the same and what new activities will make life more meaningful?).83:1745 – 1752.A. while also being aware that it may take time to implement this coping strategy. 2011 Acknowledgements This study is part of The Copenhagen Multi-Centre Psychosocial Infertility Research Program (COMPI) initiated by Dr Lone Schmidt. University of Copenhagen. Kokia E. Further. Gozlan M. the Else and Mogens Wedell-Wedellsborgs Fund. This is a significant finding because it is rare to find coping strategies that are significantly related to decreased distress (Jordan and Revenson.

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