Archives of Gynecology and Obstetrics (2020) 302:423–430

https://doi.org/10.1007/s00404-020-05614-2

GENERAL GYNECOLOGY

Social support, self‑efficacy, cognitive coping and psychological

distress in infertile women
Anaum Khalid1   · Saima Dawood2

Received: 19 January 2020 / Accepted: 19 May 2020 / Published online: 26 May 2020
© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose  The aims of this research were to investigate the relationship of social support, self-efficacy and cognitive coping
with psychological distress, as well as, to determine the mediating role of self-efficacy and cognitive coping between social
support and psychological distress in infertile women of Pakistan.
Methods  This cross-sectional study was conducted to recruit 158 infertile women from six hospitals of Lahore, Pakistan. A
demographic questionnaire, multidimensional scale of perceived social support, infertility self-efficacy scale, coping strate-
gies questionnaire and depression anxiety stress scale were used to assess the study variables.
Results  The results found that significant other, family and friends support was negatively associated with depression, anxi-
ety and stress, however, no relationship was found between friends support and anxiety. Self-efficacy and active-practical
coping had negative, whereas, avoidance-focused coping had positive relationship with depression, anxiety and stress.
Active-distractive coping was negatively and religious-focused coping was positively associated with depression. Mediation
analyses revealed that self-efficacy mediated the effect of social support on depression, anxiety and stress, but no mediation
was found between friends support and anxiety. Moreover, avoidance-focused coping mediated the link between social sup-
port and depression, as well as, between significant other support and anxiety.
Conclusion  Social support, self-efficacy, active-practical coping and active-distractive coping had significant negative asso-
ciations with psychological distress. Hence, structured programs should be developed to enhance societal acceptance and to
reduce the negative attitude of people towards infertility.

Keywords  Infertile women · Cognitive coping · Social support · Self-efficacy · Psychological distress

Introduction 30% of couples facing childlessness are determined to have

Infertility is a disease of the reproductive system followed
by the failure to achieve a clinical pregnancy after 1 year of
having regular sexual intercourse without using any means
of birth control [1]. In 2012, researchers estimated preva-
lence of and trends in infertility in 190 countries and territo-
ries. It was concluded that globally, the infertility rate was 42
million in 1990 which increased up to 48 million in 2010 [2].
In Pakistan, the prevalence rate of infertility was reported as
22% (4% primary and 18% secondary infertility) [3]. Up to
* Anaum Khalid
anaum.khalid@yahoo.com
1
Riphah Institute of Clinical and Professional Psychology,
Riphah International University, Lahore, Pakistan
2
Centre for Clinical Psychology, University of the Punjab,
New Campus, Lahore, Pakistan
idiopathic reasons of their infertility [4]. Among organic
factors ovulatory disorders are considered as responsible for
more than half of the causes of infertility [5]. Another study
explored the most common organic causes of infertility in
couples were ovulatory disorders including hyperprolactine-
mia (32%); endometriosis (15%); pelvic adhesions (11%);
tubal blockage (11%) and other tubal abnormalities (11%)
[6].
Infertility may stem from an issue with either male or
female, or combined factors can lead towards childless-
ness. In Iran, the causes of infertility were reported as
43.5% female factors; 34% male factors; 17% both male and
female factors and 8.1% unexplained factors [7]. Infertil-
ity is a disease burden which creates emotional instability
characterized by depression, stress and anxiety in both men
and women. However, it has been observed that women face

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424
more severe psychological effects of infertility than men [8,
9].
In Pakistani society, the blame of childlessness is auto-
matically shifted on a woman. People do not even bother
to investigate the reasons of infertility. Hence, infertility
threatens a woman’s status in family leading towards severe
consequences such as mental and emotional disturbances,
divorce and deprivation from her inheritance. In Pakistan,
infertile women faced greater psychological stress due to
physical (70%) and verbal abuse (60%) [10]. However,
high self-efficacious infertile couples take active measures
as seeking relevant consultation and contact related agen-
cies for child adoption or undergo fertility-treatment [11].
Infertile women are more prone to seek social support by
means of communicating with spouse, family, friends and
other people about infertility to come up with a solution
[12]. Furthermore, infertile women use various ways of
cognitive coping strategies, mostly use problem-focused
coping i.e., planning, seeking professional help and advice,
as well as, positive reinterpretation and growth to manage
their distress [13]. Religious faith and spirituality also help
them to render the level of distress related to infertility [14].
In contrast using maladaptive coping mechanisms such as
active-avoidance, denial or escape coping causes more frus-
tration and psychological distress because it diverts an indi-
vidual’s attention away from the problem of infertility [15].
In addition, many researches enlightened the role of effec-
tive psychotherapies to overcome distress related to infer-
tility as cognitive decentering from thoughts and feelings
by means of increasing mindfulness and acceptance skills.
It helps infertile women to experience non-judgmental and
objective view towards self to decrease depression and anxi-
ety, as well as, to improve self-compassion and self-efficacy
[16]. Furthermore, stress management [17], interpersonal
and supportive therapy [18], cognitive behavioral therapy
[19, 20] and art therapy [21] has also been proved useful in
reducing psychological distress in people with infertility.
The primary aim of the present study was to evaluate
the relationship of social support, self-efficacy and cogni-
tive coping with psychological distress in infertile women
belonged to Pakistani society. The secondary aim was to
investigate the mediating role of self-efficacy and cognitive
coping between social support and psychological distress.
Materials and methods
Participants and procedure
This cross-sectional study was conducted from April to
December, 2017. The sample size of 158 infertile women
was computed through post hoc G-power analysis by assum-
ing a medium effect size, a power of 0.95 and an alpha value
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Archives of Gynecology and Obstetrics (2020) 302:423–430
of 0.05. Purposive sampling was used to collect the sam-
ple from six hospitals of Lahore, Pakistan including Lady
Atchison Hospital (n = 12); Ganga Ram Hospital (n = 28);
Services Institute of Medical Sciences (n = 30); Mid City
Hospital (n = 40); Surgimed Hospital (n = 30) and Sheikh
Zayed Hospital (n = 18). The homogeneity of the partici-
pants’ characteristics was maintained by selecting only those
who were eligible for the inclusion criteria of the research.
As of inclusion criteria, age of the participants was ranged
from 21 to 40 years, duration of marriage was at least 2 years
and both husband and wife were living together. The couples
were willing to conceive and not taking any precautionary
measure. They were under treatment at the time of inter-
view by means of either taking medications or receiving
any other medical procedure as IVF. Infertile women having
HIV/AIDS, cancer, epilepsy or seizures, as well as, psycho-
logical disorders (psychosis, posttraumatic stress disorder,
obsessive–compulsive disorder and eating disorders) were
excluded from the study.
A pilot study was conducted on 13 participants to assess
the availability and feasibility of the sample and resources.
Since there was no significant issue reported, so data col-
lection for the main study was done, as well as, data col-
lected during piloting were also included in the main study.
Furthermore, a total of 147 infertile women met the inclu-
sion criteria during the main study, out of which two par-
ticipants refused to complete the questionnaires due to time
constraints. Hence, the final sample was comprised of 158
infertile women in which 13 participants were selected from
the pilot study and 145 from the main study.
Written consent was obtained from authors of all ques-
tionnaires used in the study, respective authorities of the
hospitals and from all of the participants took part in the
study. All participants willingly signed the consent form
after knowing about the details of the study and related con-
fidentiality. In addition, they were also briefed that obtained
information would be used only for research purposes. On
average, 20–25 min were taken by the participants to com-
plete all questionnaires.
Measurements
Socio‑demographic questionnaire
A socio-demographic questionnaire was developed by the
researchers to get information about age, education, dura-
tion of marriage, duration of treatment, self-employment
and monthly income. Information about having any past or
present history, or medical/treatment records of HIV/AIDS,
cancer, epilepsy or seizures was also gathered by the par-
ticipants. Self-developed questions based on DSM V criteria
were used to screen out psychological disorders (psychosis,
Archives of Gynecology and Obstetrics (2020) 302:423–430 425
posttraumatic stress disorder, obsessive–compulsive disorder
and eating disorders) [22].
Multidimensional scale of perceived social support (MSPSS)
Social support was measured through MSPSS [23]. In the
present research, Urdu version of this scale [24] was used
to assess perceptions of social support from three main
sources: significant other, family and friends. The scale has
total 12 items with 4 items in each subscale. Each item is
rated on 7 point Likert scale of 1–7, ranging from ‘very
strongly disagree’ to ‘very strongly agree’. Higher scores
indicate more support provided by significant other, family
and friends. In the present study, Cronbach’s alpha values
for subscales of significant other, family and friends support
were 0.92, 0.80 and 0.97, respectively.
Infertility self‑efficacy scale (ISES)
The perception of self-efficacy in women taking infertil-
ity treatment was assessed by ISES [25]. It is a 16 items
instrument. The items are rated on 9 point Likert scale of
1–9, ranging from ‘not at all confident’ to ‘totally confident’.
Higher scores on the scale indicate higher self-efficacy. The
scale was in English language; hence, it was translated into
Urdu language after granted permission from the authors.
Forward and backward translations were done by the guide-
lines and procedure mentioned in linguistic validation meth-
odology by MAPI institute [26]. The internal consistency of
the scale was 0.94.
Coping strategies questionnaire (CSQ)
Cognitive coping was assessed by CSQ [27] in terms of
four domains: active-practical coping (16 items); active-
distractive coping (9 items); avoidance-focused coping (24
items) and religious-focused coping (13 items). The scale
has total 62 items that are measured on 5 point Likert scale
of 1–5, ranging from ‘do not use it at all’ to ‘use it quite a
lot’. Higher scores indicate more usage of related coping
strategy by infertile women. The scale has adequate psycho-
metric properties, in the present study, Cronbach’s alpha of
the subscales ranging from 0.67 to 0.71.
Depression anxiety stress scale (DASS‑42)
Psychological distress was measured through DASS-42 [28].
A translated Urdu version of the scale [24] was used in the
present study. It measures three negative emotional states:
depression, anxiety and stress. It has 42 items in total. Each
subscale consisted of 14 items and each item is rated on 4
point Likert scale of 0–3, ranging from ‘did not apply to
me at all over the last week’ to ‘applied to me very much or
most of the time over the past week’. Higher scores indicate
higher level of severity of depression, anxiety and stress.
In the present study, Cronbach’s alpha values for subscales
of depression, anxiety and stress were 0.88, 0.75 and 0.83,
respectively.
Statistical analysis
Research data were analyzed using SPSS version 21.0.
Descriptive statistics were used to assess frequencies, per-
centages, mean and standard deviation of demographic
characteristics of the participants. Pearson product moment
correlation coefficient was employed to determine the rela-
tionship of social support, self-efficacy and cognitive coping
with psychological distress. SPSS Macro PROCESS (model
4) was used to evaluate mediating effects of self-efficacy and
cognitive coping between social support and psychological
distress (Fig. 1). The level of significance was set at p value
< 0.05.
Results
Demographic characteristics
A total of 158 women with infertility were selected from six
hospitals of Lahore city by the researchers. Demographic
details are given in Table 1. Age range of the participants
was 21–40 years with an average of 29.08 years. The mean
duration of marriage was 5.59 years (2–14 years) and the
mean duration of treatment was 4.05 years (1–12 years).
Mostly infertile women were undergraduate (55%); had no
self-employment (74%) and had monthly income less than
or equal to 20,000 “PKR” (39%).
Correlation analysis results
Table 2 indicates that social support and self-efficacy had
negative relationship with depression, anxiety and stress,
except no relationship was found between friends support
and anxiety. Hence, infertile women experienced less psy-
chological distress when greater social support was being
provided to them. Moreover, infertile women with high
self-efficacy also have low psychological distress. The
results revealed that infertile women who used more active-
practical coping experienced low depression, anxiety and
stress, whereas, high depression, anxiety and stress were
found in those who frequently used avoidance-focused cop-
ing. Furthermore, active-distractive coping was negatively,
whereas, religious-focused coping was positively associated
with depression.
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426 Archives of Gynecology and Obstetrics (2020) 302:423–430

Fig. 1  Model of the mediation

role of self-efficacy and cogni- Infertility self-efficacy
tive coping (active-practical
coping, active-distractive cop-
ing, avoidance-focused coping
and religious-focused coping)
between social support (signifi- Active-practical coping
cant other, family and friends)
and psychological distress
(depression, anxiety and stress)
in infertile women

Social Psychological
support distress

Active-distractive
coping

Avoidance-focused
coping

Religious-focused
coping

Table 2  Inter-correlations between social support, self-efficacy, cog-

nitive coping and psychological distress
Table 1  Demographic characteristics of participants with infertility Research independent variables Psychological distress
(n = 158)
Depression Anxiety Stress
Demographic variables M (SD) n (%)
Significant other support − 0.42** − 0.38** − 0.30**
Age (years) 29.08 (5.05)
Family support − 0.44** − 0.35** − 0.34**
Duration of marriage (years) 5.59 (3.21)
Friends support − 0.33** − 0.14 − 0.23**
Duration of treatment (years) 4.05 (2.95)
Self-efficacy − 0.59** − 0.48** − 0.57**
Education
Active-practical coping − 0.20* − 0.21** − 0.26**
 Undergraduate 87 (55.1)
Active-distractive coping − 0.19* − 0.14 − 0.14
 Graduate 25 (15.8)
Avoidance-focused coping 0.45** 0.35** 0.39**
 Post-graduate or above 46 (29.1)
Religious-focused coping 0.17* 0.08 0.09
Self-employment
 Yes 41 (25.9) *p < 0.05; **p < 0.01
 No 117 (74.1)
Monthly income (PKR)
Mediating effects of self‑efficacy and cognitive
 ≤20,000 62 (39.2)
coping
 ≤40,000 28 (17.7)
 ≤60,000 20 (12.7)
For mediation analyses, the steps suggested by Baron and
 ≤80,000 9 (5.7)
Kenny were followed to determine the relationship between
 >80,000 39 (24.7)
the study variables [29]. The only significant results of direct
PKR Pakistan currency and total effects are presented in Table 3. Self-efficacy and

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Archives of Gynecology and Obstetrics (2020) 302:423–430 427

Table 3  Total and direct effects of social support on depression, anxiety and stress
Paths Depression Anxiety Stress
2 2
Coeff R F Coeff R F Coeff R2 F

Significant other support→self-efficacy 1.14*** 0.19 5.15*** 1.14*** 0.19 5.15*** 1.14*** 0.19 5.15***
Self-efficacy→psychological distress − 0.35*** − 0.20*** − 0.30***
Significant other support→avoidance-focused coping − 0.65* 0.19 5.00*** − 0.65* 0.19 5.00***
Avoidance-focused coping→psychological distress 0.19** 0.12*
c1 (Significant other support→psychological distress) − 1.28*** 0.29 8.92*** − 0.92*** 0.19 4.89*** − 0.77*** 0.21 5.77***
c′1  (Significant other support→psychological distress) − 0.80*** 0.51 12.74*** − 0.59** 0.34 6.12*** − 0.30 0.41 8.48***
Family support→self-efficacy 0.83*** 0.19 4.94*** 0.83*** 0.19 4.94*** 0.83*** 0.19 4.94***
Self-efficacy→psychological distress − 0.34*** − 0.21*** − 0.30***
Family support→avoidance-focused coping − 0.57** 0.20 5.41***
Avoidance-focused coping→psychological distress 0.18**
c2 (Family support→psychological distress) − 0.91*** 0.28 8.30*** − 0.59*** 0.16 4.80*** − 0.57*** 0.21 5.69***
c′2 (Family support→psychological distress) − 0.53** 0.50 12.26*** − 0.38** 0.32 5.79*** − 0.26 0.42 8.59***
Friends support→self-efficacy 0.32* 0.16 3.92*** 0.32* 0.16 3.92***
Self-efficacy→psychological distress − 0.39*** − 0.32***
Friends support→avoidance-focused coping − 0.41*** 0.24 6.76***
Avoidance-focused coping→psychological distress 0.18*
c3 (Friends support→psychological distress) − 0.33** 0.21 7.76*** − 0.18* 0.17 4.32***
c′3 (Friends support→psychological distress) − 0.18 0.48 11.19*** − 0.05 0.41 8.23***

c Total effect of independent variable on dependent variable, c′ direct effect of independent variable on dependent variable, df (12, 145); number
of bootstrap re-samples, 10,000
*p < 0.05; **p < 0.01; ***p < 0.001

cognitive coping were taken as mediators between social
support (significant other, family and friends) and psycho-
logical distress (depression, anxiety and stress). In case
of depression, direct effects of subscales of social support
on self-efficacy and avoidance-focused coping were sig-
nificant. Furthermore, self-efficacy and avoidance-focused
coping also had significant direct effects on depression.
Total effects of social support given by significant other
(c1 = −1.28, p < 0.001); family (c2 = −0.91, p < 0.001) and
friends (c3 = −0.33, p < 0.01) on depression were signifi-
cant. After including mediators in the model, self-efficacy
and avoidance-focused coping acted as partial mediators
as the strength of direct effects of significant other sup-
port ( c′1 = −0.80, p < 0.001) and family support ( c′2 = −0.53,
p < 0.01) on depression got decreased but were still signifi-
cant. However, self-efficacy and avoidance-focused coping
fully mediated the relationship between friends support and
depression as after adding mediators, direct effect of friends
support on depression became non-significant ( c′3 = −0.18,
p > 0.05).
In case of anxiety, the results showed significant direct
effects of significant other support on self-efficacy and
avoidance-focused coping, as well as, these two media-
tors also had significant direct link with anxiety. Fam-
ily support had significant direct effect on self-efficacy
and direct effect of self-efficacy on anxiety was also
significant. Total effects of significant other (c1 = −0.92,
p < 0.001) and family support (c2 = −0.59, p < 0.001) on
anxiety were significant. After adding mediators in the
model, self-efficacy acted as partial mediator between
social support (significant other and family) and anxi-
ety, whereas, avoidance-focused coping acted as partial
mediator between significant other support and anxiety.
These results indicated partial mediation as after introduc-
ing mediators in the model, direct effects of significant
other support ( c′1 = −0.59, p < 0.01) and family support
( c′2  = −0.38, p < 0.01) on anxiety got decreased yet were
still significant.
In case of stress, direct effects of significant other, fam-
ily and friends support on self-efficacy were significant and
self-efficacy also had significant direct effects on stress.
Total effects of significant other support (c 1 = −0.77,
p < 0.001); family support (c 2 = −0.57, p < 0.001) and
friends support (c3 = −0.18, p < 0.05) on stress were sig-
nificant. When mediators were added in the model, direct
effects of significant other support ( c′1 = −0.30, p > 0.05);
family support ( c′2 = −0.26, p > 0.05) and friends support
( c′3 = −0.05, p > 0.05) on stress became non-significant,
indicating self-efficacy fully mediated the relationship
between social support (significant  other, family and
friends) and stress.

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428
Discussion
The present research investigated the relationship of
social support, self-efficacy, and cognitive coping with
psychological distress in infertile women. In addition, the
mediating effects of self-efficacy and cognitive strategies
between social support and psychological distress were
also explored. The results showed that social support pro-
vided by significant other, family and friends had negative
relationships with depression, anxiety and stress. However,
no relationship was found between friends support and
anxiety in infertile women. These findings are consistent
with previous researches that indicated social support as
an important source of reducing distress related to infertil-
ity because infertile couples found satisfactory solutions
by sharing their problems with others [30]. Moreover, the
reason of non-significant relationship between friends sup-
port and anxiety can be attributed to the factor that in
Pakistani culture, infertile women may not like to share
their problems of infertility with their friends or even with
colleagues at workplace because of feeling embarrassment
and shame. Furthermore, the present study explained nega-
tive associations between self-efficacy and psychological
distress. Previous researches validated these results that
high self-efficacious infertile women experienced less
depression, anxiety and stress [31]. Prior studies also sup-
ported the findings of this study that healthy coping strat-
egies helped infertile women to strengthen their mental
health and reduce the level of distress. By active-practical
coping they sought assistance or information that could
help them to cope more efficiently and effectively with
distress and prolonged sense of threat related childless-
ness. For example, having contact with other infertile peo-
ple to seek solutions or finding other possible alternatives
such as adopting a child to replace the wish of parenthood
[15]. The present study found that infertile women expe-
rienced more psychological distress when used maladap-
tive avoidance-focused coping. Previous literature also
revealed that coping strategies related distraction, escape
and avoidance caused more depression, anxiety and stress
in infertile women. Ineffective coping mechanisms lead
infertile women to avoid discussion related to infertility
and spend more time in isolation [32]. However, the pre-
sent study indicated that infertile women experienced less
depression when used active-distractive coping. These
findings are inconsistent with previous researches where
a positive relationship was found between these two vari-
ables [33]. The discrepancy in results can be due to the
reason that active-distractive coping reduces the level of
distress on short-term basis such as involving in leisure
activities, sleeping and going out with others. Moreover,
the present study showed religious-focused coping had
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Archives of Gynecology and Obstetrics (2020) 302:423–430
positive relationship with depression as supported by
previous researches that infertile women used less reli-
gious-focused coping. The reasons can be their negative
and weak religious beliefs as prior literature found that
infertile women experienced high depression and anxiety
because their prayers were not being answered by God
[34]. Another plausible explanation can be that religious
women experience more psychological distress because
their religious communities emphasize on motherhood as
the ultimate outcome of marriage [35].
The results of mediation analyses revealed significant
indirect effects of significant other, family and friends
support on depression, anxiety and stress by considering
self-efficacy as mediator, however, no mediating effects of
self-efficacy was found between friends support and anxiety.
These results showed that social support helped in reduction
of psychological distress in those infertile women who had
high self-efficacy. Previous researchers suggested that self-
efficacy mediated the relationship between social support
and depression as self-efficacy got increased when social
support was being provided to infertile women and this sense
of security reduced depression in them. Hence, support from
parents and peers plays considerable role to enhance self-
efficacy by promoting the person’s perceptions of self-worth
which reduces psychological distress in infertile people [36].
The present study found that avoidance-focused coping sig-
nificantly mediated the relationship of social support (sig-
nificant other, family and friends) with depression, as well
as, between significant other support and anxiety. Previous
literature showed the significant role of social support in
reduction of psychological distress through problem-focused
coping (task-oriented coping, emotion-oriented coping, and
avoidance-focused coping) [37]. Another study found that
family support reduced stress when infertile women engaged
in avoidance-focused coping. Although active-avoidance
coping is primarily used as protective and defensive strategy,
yet it leads toward the persistence of problem. The initial
paradoxical effects may be seemed as beneficial for infer-
tile women who perceive their family available to support
them, which render their efforts to find possible solutions
for their problem. Hence, families may provide comfortable
place which leads infertile women to lower their insecurities
related to infertility [38].
Limitations of the present research are as follows:
firstly, this study was carried out only on infertile women
and no male participants were included in the study,
hence, results can be generalized only on the population
of infertile women. Furthermore, another study should be
designed to rule out the relationship of social support,
self-efficacy and cognitive coping with psychological dis-
tress in male infertile participants as infertility is a shared
stressor for both males and females [39]. Secondly, the
assessment tools were with closed-ended questions which
Archives of Gynecology and Obstetrics (2020) 302:423–430 429
did not allow participants to give extra information about
concerned areas. Qualitative research can be more ben-
eficial to collect more detailed information about study
variables in future. Thirdly, psychological distress related
to infertility could not be separated with distress due to
the experience of infertility treatment. Fourthly, the pre-
sent research focused only on those infertile women who
were under treatment related to infertility; hence, results
may not be generalized to infertile women not receiving
infertility treatment.
In conclusion, social support and self-efficacy helped
infertile women to experience less psychological distress
related to infertility. Active-practical coping was power-
ful coping strategy for infertile women to attenuate the
level of depression, anxiety and stress by finding solutions
for their childlessness. Moreover, active-distractive cop-
ing also reduced depression in infertile women. However,
infertile women who engaged in avoidance-focused cop-
ing and religious-focused coping experienced more psy-
chological distress. Hence, structured programs should be
developed to enhance societal acceptance and to reduce the
negative attitude of people towards infertility. The facility
of counseling and other psychological services should be
provided to infertile couples to enhance their self-efficacy,
problem solving and conflict resolution skills, as well as,
to educate them about helpful coping strategies to reduce
distress related to infertility.
Acknowledgements  We owe greatest gratitude to authors of all ques-
tionnaires used in the research, authorities of all hospitals, as well as,
the study participants for their cooperation to willingly participate in
the study.
Author contributions  AK conceptualized and designed the study, col-
lected and analyzed the research data, as well as, wrote the manuscript.
SD supervised the research project. The manuscript was revised and
approved by all authors.
Funding  This research did not receive any grant from funding agencies
in the public, commercial or not-for-profit sectors.
Data availability  The data are available from the corresponding author
on reasonable request.
Compliance with ethical standards  17. Mori A (2009) Supporting stress management for women
Conflict of interest  The authors report no conflict of interest.
Ethical approval  The study was approved by Departmental Doctorate
Program Committee of Riphah Institute of Clinical and Professional
Psychology (RICPP), Riphah International University Lahore, Paki-
stan. RICPP has ethical body as Departmental Academics and Research
Committee (DARC) and the present study was thoroughly analyzed by
DARC according to the ethical guidelines approved by APA 6.
Informed consent  Informed written consent was completed by all
participants.
References
1. World Health Organization (2009) Women and health: today’s
evidence tomorrow’s agenda. Geneva.
2. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Ste-
vens GA (2012) National, regional, and global trends in infertil-
ity prevalence since 1990: a systematic analysis of 277 health
surveys. PLoS Med 9(12):e1001356
3. Sami N, Ali TS (2012) Perceptions and experiences of women in
Karachi, Pakistan regarding secondary infertility: results from a
community-based qualitative study. Obstet Gynecol Int Article
ID:108756.
4. Practice committee of the American society for reproductive
medicine (2006) Effectiveness and treatment for unexplained
infertility. Fertil Steril 86(5):S111–S114
5. Unuane D, Tournaye H, Velkeniers B, Poppe K (2011) Endo-
crine disorders & female infertility. Best Pract Res Clin Endo
crinol Metab 25(6):861–873
6. Weiss RV, Clapauch R (2014) Female infertility of endocrine
origin. Arq Bras Endocrinol Metabol 58(2):144–152
7. Parsanezhad M, Jahromi BN, Zare N, Keramati P, Khalili A,
Parsa-Nezhad M (2016) Epidemiology and etiology of infertility
in Iran, systematic review and meta-analysis. J Women’s Health
Issue Care 2(6).
8. Chehreh R, Ozgoli G, Abolmaali K, Nasiri M, Mazaheri E
(2019) Comparison of the infertility-related stress among
couples and its relationship with infertility factors. IJWHR
7(3):313–318
9. Kissi YE, Romdhane AB, Hidar S, Bannour S, Idrissi KA,
Khairi H, Ali BBH (2013) General psychopathology, anxiety,
depression and self-esteem in couples undergoing infertility
treatment: a comparative study between men and women. Eur J
Obstet Gynecol Reprod Biol 167(2):185–189
10. Sami N, Ali TS (2006) Psychosocial consequences of secondary
infertility in Karachi. J Pak Med Assoc 56(1):16–22
11. Cousineau TM, Domar AD (2007) Psychological impact of
infertility. Best Pract Res Clin Obstet Gynaecol 21(2):293–308
12. Fido A (2004) Emotional distress in infertile women in Kuwait.
Int J Fertil Womens Med 49:24–28
13. Durak M (2007) The relationship between cognitive appraisal
of stress, coping strategies and psychological distress among
correctional officers: personal and environmental factors. Dis-
sertation, Middle East Technical University
14. Domar AD, Penzias A, Dusek JA, Magna A, Merarim D, Nielsen
B, Paul D (2005) The stress and distress of infertility: does spir-
ituality help women cope? Sex Reprod Menopause 3(2):45–51
15. Lechner L, Bolman C, Dalen AV (2006) Definite involuntary
childlessness: associations between coping, social support and
psychological distress. Hum Reprod 22(1):288–294
16. Galhardo A, Cunha M, Pinto-Gouveia J (2013) Mindfulness-
based program for infertility: efficacy study. Fertil Steril
100(4):1059–1067
undergoing the early stages of fertility treatment: a cluster-
randomized controlled trial. Jpn J Nurs Sci 6(1):37–49
18. Koszycki D, Bisserbe JC, Blier P, Bradwejn J, Markowitz J
(2012) Interpersonal psychotherapy versus brief supportive
therapy for depressed infertile women: first pilot randomized
controlled trial. Arch Womens Ment Health 15(3):193–201
19. McNaughton-Cassill ME, Bostwick JM, Arthur NJ, Robinson
RD, Neal GS (2002) Efficacy of brief couples support groups
developed to manage the stress of in vitro fertilization treat-
ment. Mayo Clin Proc 77(10):1060–1066
20. Mosalanejad L, Khodabakshi KA, Jamali S (2012) Effect of
cognitive behavioral therapy in mental health and hardiness of
13

430
infertile women receiving assisted reproductive therapy (ART).
Iran J Reprod Med 10(5):483–488
21. Streeter K, Deaver S (2018) Art therapy with women with infertil-
ity: a mixed-methods multiple case study. Art Ther J Am Art Ther
Assoc 35(2):60–67
22. American Psychiatric Association (2013) Diagnostic and statisti-
cal manual of mental disorders, 5th edn. Arlington.
23. Zimet GD, Dahlem NW, Zimet SG, Farley GK (1998) The mul-
tidimensional scale of perceived social support. J Pers Assess
52(1):30–41
24. Zafar N, Kausar R (2015) Psychosocial implications of early
father separation for adolescents and their mothers. J Indian Acad
Appl Psychol 41(2):323–333
25. Cousineau TM, Green TC, Corsini EA, Barnard T, Seibring AR,
Domar AD (2006) Development and validation of the infertility
self-efficacy scale. Fertil Steril 85(6):1684–1696
26. Acquadro C, Conway K, Giroudet C, Mear I (2012) Linguistic
validation manual for health outcomes assessments, 2nd edn.
Lyon, France, Mapi Institute
27. Kausar R, Munir R (2004) Pakistani adolescents’ coping with
stress: effect of loss of a parent and gender of adolescents. J Ado-
lesc 27:599–610
28. Lovibond SH, Lovibond PF (1995) Manual for the depression
anxiety stress scale, 2nd edn. Psychology Foundation, Sydney
29. Baron RM, Kenny DA (1986) The moderator-mediator variable
distinction in social psychological research: conceptual, strategic
and statistical considerations. J Pers Soc Psychol 51:1173–1182
30. Qadir F, Khalid A, Medhin G (2015) Social support, marital
adjustment, and psychological distress among women with pri-
mary infertility in Pakistan. Women Health 55(4):432–446
31. Batinic B, Lazarevic J, Dikic SD (2017) Correlation between self-
efficacy and well-being, and distress in women with unexplained
infertility. J Eurpsy 4(1):899
13
Archives of Gynecology and Obstetrics (2020) 302:423–430
32. Peterson B, Newton CR, Rosen KH, Skaggs GE (2006) Gen-
der differences in how men and women referred with in vitro
fertilization (IVF) cope with infertility stress. Hum Reprod
21(9):2443–2449
33. Gourounti K, Anagnostopoulos F, Potamianos G, Lykeridou K,
Schmidt L, Vaslamatzis G (2012) Perception of control, coping
and psychological stress of infertile women undergoing IVF.
Reprod Biomed Online 24(6):670–679
34. Boadi MO, Asante KO (2017) Psychological health and religious
coping of Ghanaian women with infertility. Biopsychosoc Med
11:20–27
35. Pargament K, Feuille M, Burdzy D (2011) The Brief RCOPE:
current psychometric status of a short measure of religious coping.
Religions 2(1):51–76
36. Saltzman KM, Holahan CJ (2002) Social support, self-efficacy,
and depressive symptoms: an integrative model. J Soc Clin Psy-
chol 21(3):309–322
37. Mousavi SS, Karimi S, Kokabi R, Piryaei S (2013) Mediating role
of resilience and problem-oriented coping strategy in the rela-
tionship between of social support and psychological distress in
infertile women. TJEAS 3(20):2660–2667
38. Martins MV, Peterson BD, Almeida VM, Costa ME (2011) Direct
and indirect effects of perceived social support on women’s infer-
tility-related stress. Hum Reprod 26(8):2113–2121
39. Peterson BD, Pirritano M, Christensen U, Schmidt L (2008) The
impact of partner coping in couples experiencing infertility. Hum
Reprod 23(5):1128–1137
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