Abstract
Background
Couples undergoing artificial insemination by donor semen(AID) represent a unique group of infertility patients, the relationship between fertility pressure and attachment styles remains unclear. To investigate the fertility pressure and attachment dimensions in artificial insemination by donor semen(AID) couples, and develop an Actor-Partner Interdependence Model (APIM) for patient care.
Methods
This study is a cross-sectional study. From June to September 2021, couples who were about to receive AID treatment in our hospital were assessed using the Fertility Problem Inventory, and the Experiences in Close Relationships(ECR). Dyadic analysis applying the APIM was used.
Results
A total of 448 valid questionnaires were recovered, the effective response rate was 94.9%. The average score of men’s fertility pressure was higher than that of women’s(P = 0.021). The score of male attachment anxiety was higher than that of females(P = 0.038). Attachment avoidance(β = 0.46) and attachment anxiety(β = 0.33) in wives significantly impacted their fertility pressure. Attachment avoidance(β = 0.17) and attachment anxiety(β = 0.52) in husbands significantly impacted their fertility pressure. The attachment avoidance of wives’ had a significant impact on the husbands’ fertility pressure(β = 0.11).
Conclusion
Overall, the study revealed that in the couples who use donor sperm to expect pregnancy, the male has higher fertility pressure. Insecure attachment can cause more severe fertility pressure, fertility pressure is also affected by one’s partner.
Keywords: Actor partner interdependence model, Attachment, Donor artificial insemination, Infertility, Stress, Male infertility
Introduction
Artificial insemination by donor (AID) is a technique that introduces donor sperm into the female reproductive tract through nonsexual intercourse, allowing the sperm to combine with an oocyte to achieve fertilization and thus, conception [1]. Couples undergoing AID represent a unique group of infertile patients, and it was observed that most infertility treatments negatively affect their physical and mental health and quality of life. Studies have shown that long-term infertility can lead to a reduced quality of life [2, 3]. A related study in China found that the divorce rate among infertile couples was 2.2 times higher than among fertile couples [4]. Owing to factors such as causes of infertility, mindsets, and individual differences, the psychological states of infertile women and men are slightly different.
Previous studies found that spouses with secured attachment relationships, experience higher relationship satisfaction [5]. Interestingly, men with higher levels of attachment anxiety and attachment avoidance report more social, sexual, and relationship problems along with general infertility pressure [3]. Psychological trauma caused by infertility has become a significant problem for family as well as the society. So far, with couples, there are some studies on the influence of fertility pressure and attachment styles on couples [6, 7].
The utilization of heterologous techniques may lead to greater severity of psychological issues among couples undergoing AID. An increasing number of studies believe that the interaction between husbands and wives should be emphasised to address the problems of patients undergoing assisted reproductive technology (ART). Infertility is a situation that couples experience together and should be called a ‘common disease’ in today’s day and age. Psychological research on infertility has moved from the individual to the couple level.
This study aimed to investigate the attachment dimensions and fertility pressures of couples with male infertility. It further aimed to develop an actor–partner interdependence (APIM) model and provide a theoretical foundation for targeted psychological interventions for infertile couples for future clinical treatment.
Materials and methods
Questionnaire survey
Research objects
Couples who received artificial insemination with donor sperm in a reproductive hospital in Shandong Province from June 2021 to September 2021 were selected as the research subjects. The basic information questionnaire, the Fertility Pressure Scale (FPI Scale) and the Experiences in Close Relationships (ECR) were used to conduct questionnaire surveys on assisted pregnancy couples.
According to the Sample calculation principle proposed by Castro Alves et al. [8], our study including a total of 5 variables of general data, 5 dimensions of fertility pressure, and 2 dimensions of intimate relationship questionnaire. Considering 20% deletion, the sample size was finally determined to be no less than 144 couples.
Inclusion criteria
①Couples received artificial insemination with donor sperm; ②The age ranged from 20 to 45 years; ③Both spouses voluntarily participated in this study with no cognitive impairment.
Exclusion criteria
①Combined with other serious physical diseases; ②Patients who have previously suffered from mental disorders or mental retardation; ③Couples who cannot complete a valid questionnaire.
Questionnaire collection
The purpose, significance, and methods of the survey were explained to the couple in a unified instruction language during the waiting period for the patients. The couples went to a separate room to fill out the questionnaire, and each item was set as a required answer. The investigator answered the patient’s questions on the spot. During the data collection process, the ethical principles of voluntary, informed consent, and confidentiality were followed.
Survey items
Socio-demographic data
Gender, education, employment status, residence, monthly family income, duration of marriage.
Fertility pressure scale (FPI scale)
The FPI scale is a tool specially designed by Newton et al. [9] in Canada to evaluate the fertility-related stress of infertile patients. A total of 46 items were included, including 5 dimensions of social pressure (10 items), sexual pressure (8 items), marital relationships (10 items), the need for parenthood (10 items) and rejection of a child-free lifestyle (8 items). The total score ranges from 46 to 276, with higher scores indicating higher fertility related stress. The Cronbach’s α of the questionnaire was 0.912 for the wives and 0.903 for the husbands. The Kaiser-Meyer-Olkin(KMO) values of ECR scale were 0.850 for husband and 0.867 for wife. Bartlett’s spherical test was P < 0.001.
Experiences in close relationships
Attachment was measured using the Chinese version of the Experiences in Close Relationships (ECR) questionnaire. It consisted of two dimensions, attachment avoidance and attachment anxiety, with a total of 36 items. The seven-point scoring method is adopted, and the results provide scores on the two dimensions of attachment avoidance and attachment anxiety. The Cronbach’α coefficient of the questionnaire was 0.876 for the wives and 0.886 for the husbands. The KMO values of FPI scale were 0.887 for husband and 0.865 for wife. Bartlett’s spherical test was P < 0.001.
The four attachment styles were calculated from the scores of attachment anxiety and attachment avoidance, which were divided into four styles: The secure attachment style (low anxiety, low avoidance), the preoccupied attachment style (high anxiety, low avoidance), the avoidant attachment style (low anxiety, high avoidance), and the anxious-avoidant attachment style (high anxiety, high avoidance) [10].
Statistical analysis
Statistical method
SPSS26.0 was used for statistical analysis. Socio-demographic data were described by frequency and percentage. The data with normal distribution of quantitative data were expressed as mean ± standard deviation (x ± s). The comparison of fertility stress and attachment style between couples was performed by paired sample t test. Pearson correlation analysis was used to analyze the relationship among couples’ attachment type and fertility pressure. P < 0.05 was considered as statistically significant.
APIM model construction
Amos 24.0 was used to construct the “APIM” and process data.
Results
A total of 472 questionnaires were distributed, and 24 invalid questionnaires with regular answers and unpaired answers were excluded. A total of 448 valid paired questionnaires were recovered, with an effective recovery rate of 94.9%.
Socio-demographic data of couples
This questionnaire collected the relevant socio-demographic data of the couples who would receive AID, including: gender, age, education, employment status, residence, monthly family income and duration of marriage, as shown in Table 1.
Table 1.
Socio-demographic data
| domains | Men(n = 224),n(%) | Women(n = 224),n(%) | |
|---|---|---|---|
| education | low education background | 72(32.1) | 85(37.9) |
| high education background | 152(67.9) | 139(62.1) | |
| employment status | job-waiting | 28(12.5) | 77(34.4) |
| full-time job | 181(80.8) | 134(59.8) | |
| part-time job | 15(6.7) | 13(5.8) | |
| residence | city | 94(42.0) | 85(37.9) |
| town | 56(25.0) | 65(29.0) | |
| rural | 74(33.0) | 74(33.0) | |
| monthly family income | < 3000yuan | 13(5.8) | 13(5.8) |
| 3000-5000yuan | 67(29.9) | 67(29.9) | |
| 5001-8000yuan | 70(31.3) | 70(31.3) | |
| 8001-10000yuan | 30(13.4) | 30(13.4) | |
| > 10000yuan | 44(19.6) | 44(19.6) | |
| duration of marriage | < 1 years | 11(4.9) | 11(4.9) |
| 1-5years | 110(49.1) | 110(49.1) | |
| 5-10years | 77(34.4) | 77(34.4) | |
| > 10years | 26(11.6) | 26(11.6) |
low education background: Including elementary, middle and high schools
high education background: Including junior college, undergraduate, master, doctor
Fertility pressure scale
The average score of men’s fertility pressure was higher than that of women’s (P = 0.021), and men’s scores in rejection of a child-free lifestyle (P = 0.020) and need for parenthood (P < 0.001) were higher than women’s. But in other dimensions, there was no statistically significant difference between males and females (P > 0.05). The score of attachment avoidance was not significantly different between men and women, but the score of male attachment anxiety is higher than that of female (P = 0.038), as shown in Table 2.
Table 2.
The difference in fertility pressure and attachment styles between men and women
| Women(n = 224) | Men(n = 224) | P | |
|---|---|---|---|
| age | 30.5 ± 4.3 | 31.5 ± 4.9 | 0.024* |
| social pressure | 23.9 ± 7.6 | 24.8 ± 8.1 | 0.208 |
| sexual pressure | 16.8 ± 6.1 | 16.5 ± 5.8 | 0.535 |
| marital relationship | 22.4 ± 7.2 | 22.7 ± 7.3 | 0.663 |
| need for parenthood | 39.0 ± 8.3 | 42.3 ± 8.8 | < 0.001*** |
| rejection of child-free lifestyle | 29.4 ± 7.7 | 31.1 ± 7.3 | 0.020* |
| Total fertility pressure score | 131.4 ± 26.8 | 137.3 ± 26.6 | 0.021* |
| attachment avoidance | 2.6 ± 0.8 | 2.6 ± 0.8 | 0.772 |
| attachment anxiety | 3.3 ± 0.9 | 3.5 ± 1.1 | 0.038* |
* indicate statistical signifificance at P < 0.05
*** indicate statistical signifificance at P < 0.001
Attachment styles
A total of secure attachment (219 cases), preoccupied attachment (105 cases), avoidant attachment (90 cases), and anxious-avoidant attachment (34 cases). There were significant differences in social pressure, sexual pressure, the need for parenthood with four different attachment styles (P < 0.05). Patients with a secure attachment style had the lowest average scores in all dimensions. The total fertility pressure score of secure attachment type patients was significantly lower than that of the other styles (P < 0.0001). The scores of attachment avoidance and attachment anxiety were also significantly lower than other styles (P < 0.0001), as shown in Table 3.
Table 3.
Results for the four different attachment styles
| secure (n = 219) | anxious-avoidant (n = 105) |
preoccupied (n = 90) |
avoidant (n = 34) |
P | ||
|---|---|---|---|---|---|---|
| age# | 30.77 | 31.44 | 31.19 | 31.15 | 0.651 | |
| social pressure# | 20.94 | 29.31 | 26.38 | 25.26 | < 0.001*** | |
| sexual pressure# | 13.74 | 20.92 | 18.12 | 18.29 | < 0.001*** | |
| marital relationship& | 18.54 | 28.28 | 24.60 | 24.88 | < 0.001*** | |
| need for parenthood& | 38.24 | 42.33 | 45.38 | 38.21 | < 0.001*** | |
| rejection of child-free lifestyle& | 29.27 | 31.10 | 31.76 | 29.74 | 0.032* | |
| Total fertility pressure score# | 120.72 | 151.94 | 146.23 | 136.38 | < 0.001*** | |
| attachment avoidance# | 2.10 | 3.53 | 2.53 | 3.45 | < 0.001*** | |
| attachment anxiety& | 2.77 | 4.05 | 4.49 | 2.73 | < 0.001*** | |
* indicate statistical signifificance at P < 0.05
*** indicate statistical signifificance at P < 0.001
#Chi-square test; &non-parametric test
Pearson correlation analysis
As presented in Table 4, pearson correlation analysis was performed on couples’ attachment dimensions and fertility pressure. Attachment avoidance was found to be positively related to attachment anxiety (P < 0.01). Attachment avoidance and attachment anxiety were all positively related to fertility pressure (P < 0.01).
Table 4.
Pearson correlation about couples’ attachment style and fertility pressure
| A | B | C | D | E | F | |
|---|---|---|---|---|---|---|
| A | 1 | |||||
| B | 0.598** | 1 | ||||
| C | 0.520** | 0.416** | 1 | |||
| D | 0.425** | 0.306** | 0.184** | 1 | ||
| E | 0.303** | 0.451** | 0.202** | 0.442** | 1 | |
| F | 0.244** | 0.244** | 0.224** | 0.627** | 0.429** | 1 |
A: wives’ fertility pressure B: wives’ attachment avoidance C: wives’ attachment anxiety D: husband’s fertility pressure E: husband’s attachment avoidance F: husband’s attachment anxiety
APIM model
An actor-partner interdependence model of attachment dimensions and fertility pressure was developed. According to the path coefficient results of the original model, we deleted the non-significantly correlated paths, including the effects of wives’ attachment anxiety on husbands’ fertility pressure; the effects of husbands’ attachment avoidance and attachment anxiety on wives’ fertility pressure. The modified model is shown in Fig. 1.
Fig. 1.
actor-partner interdependence model of attachment dimensions and fertility pressure
The results of the path coefficient showed that wives’ attachment avoidance(β = 0.46, p < 0.001) and attachment anxiety(β = 0.33, p < 0.001) have a significant impact on wives’ fertility pressure; husband’s attachment avoidance (β = 0.17, p = 0.003) and attachment anxiety (β = 0.52, p < 0.001) have a significant impact on husbands’ fertility pressure. With regard to partner effects, the wives’ attachment avoidance (β = 0.11, p = 0.044) positively predicted their husbands’ fertility pressure.
Discussion
According to insufficient statistics, nearly one million infertile Chinese families received AID treatment for conception [11]. This is a negative psychological experience for infertile couples [1]. In contrast to previous studies [12], some research suggests that fertility pressure is generally higher for wives in infertile couples than for husbands. However, our findings suggest that there are differences based on sex in fertility pressure among couples, with husbands facing a higher amount of fertility-related stress than wives. Unlike previous studies on infertile couples, our study specifically focused on couples with male infertility, undergoing donor sperm treatment. Additionally, a prior study noted, Chinese male infertility patients experience significantly higher fertility pressure than foreign patients [13]. Historically, medical institutions in China have primarily focused on diagnosis and treatment, neglecting the psychological support required for patients with infertility. This lack of support could explain the greater fertility pressure experienced by infertile men in China than in other countries.
Male infertility can affect a man’s self-esteem, sexual performance, and confidence [14; 15]. A study conducted in the United States also showed that after diagnosis, male patients with infertility suffered from lower self-esteem, lower life satisfaction, increased pain, and heightened anxiety [16]. Our study also showed that husbands had significantly higher scores than wives in the dimensions of rejection of a child-free lifestyle and the need for parenthood. Contrastingly, patients in other countries have a more prominent sexual dimension [17]. In the Chinese society, having an offspring is considered to be extremely important as per the native culture. Influenced by the idea of continuing family bloodlines, Chinese people have a stronger desire for children than people in other countries. They believe that procreation is not just about having children, but more importantly, about the passing on their genes and leaving their bloodline behind. When Chinese male patients know that they are infertile, the changes in their inner feelings and painful experiences are often more intense than those experienced by their wives. Influenced by traditional Chinese concepts and social opinions, infertility often makes patients feel a strong sense of stigma, leading to feelings of self-guilt, self-accusation, and low self-esteem. In a survey of 192 infertile couples in China, 19.8% of men and 37.5% women considered infertility to be a shameful experience that had a significant impact on their quality of life [18]. This effect may be more severe in donor-inseminated couples.
A growing number of studies have shown that the stress of infertility and its treatment can have a significant impact on the quality of life of infertile couples [19]. Studies have shown that infertile couple suffer from severe anxiety and depression [20]. Furthermore, Bayley et al. [21] found that attachment anxiety was associated with infertility pressure in both men and women, and Van den Broeck et al. [22] suggested that attachment anxiety was a predictor of psychological distress in couples undergoing IVF and ICSI treatment for the first time.
A study by Thoma ME et al. [23] showed that most patients with infertility experience significant psychological pressure, which affects family relations leading to a marital crisis. In a comparative study of AID and artificial insemination by husbands (AIH), couples opting for AID showed higher levels of depression, anxiety, obsessive traits, hostility, interpersonal separation, and high life stress [6]. A recent study showed that anxiety attachment was associated with a lower quality of life, while avoidance attachment was negatively associated with success in women undergoing ART [24]. Some studies have shown that infertile men are particularly prone to depression, anxiety and stress along with greater physical and psychological distress [25; 26]. When a man is diagnosed with infertility, it causes significant psychological trauma to him, activating his sense of worthlessness, helplessness, pessimism, and despair; it causes strong self-denial and self-blame in him. In such situations, husbands pay excessive attention to their wives’behaviour and even show a demanding or assertive attitude, which aggravates attachment anxiety. Previous reports have also shown that infertile couples with higher levels of attachment anxiety and avoidance report more social, sexual, and relationship problems and higher infertility stress [3]. In general, situations such as personal embarrassment, public opinion, donor status, and quality of married life are situations that both couples worry about [27]. Regarding AID technology, many infertile couples have varying degrees of concerns, especially about the health of the sperm donor and whether their offspring will have defects. In addition, the husband may have the subjective feeling of being cheated, which will increase his mental burden.
Most male infertility patients cope with avoidance and depression, which not only creates emotional and physical stress for themselves but also affects the discussion of fertility issues between couples. There are many misunderstandings and contradictions regarding fertility issues, which affect women’s mental health and cause tension in couples’ relationships. Galhardo et al. [28] pointed out that, compared with other infertile women, the psychological burden of women receiving AID treatment is more complex and obvious. The traditional concept of fertility in China states that the responsibility for pregnancy mainly lies with women and ascribes the cause of infertility to women [29]. This leaves women with a misunderstanding of infertility as they bear the burden of protecting their husband’s privacy and reputation without being able to explain it to others. Due to the specificity of the semen source, female patients with AID experience enormous psychological, social, and moral pressures.
A previous meta-analysis reported that while there were sex-based differences in the experience of infertility in many areas, both men and women experienced tense marriages. Partner support is an important factor in the development of infertility [30]. Donarelli et al. [3] concluded that there was a significant correlation between the dimension of attachment and the stress of infertility, and that the attachment dimension affects the impact of cross-partner stress on couples with infertility. The results of this study suggest that a secure attachment style is better in terms of fertility pressure and attachment scores, similar to the findings of Mikulincer et al. [31].
Kenny et al. [32] in their study, proposed the actor–partner interdependence model (APIM). The model has been used to study the marital quality of couples, parent-child relationships, and relationships between patients and their family caregivers [33, 34]. The APIM is an innovative binary analysis method suitable for the study of infertility, which can estimate the influence of individual characteristics and those of an individual’s partner on outcome variables.
Both anxiety and avoidance attachment were found to be associated with increased stress between couples. Secure attachment protects the mental health of both men and women. From a dyadic perspective, it has been observed that female attachment avoidance is linked to male infertility pressure and relationship concerns [3], which aligns with our findings using the APIM model. When husbands are diagnosed with infertility, avoidance tendencies can hinder their ability to provide emotional support. Wives’ emotional indifference, reluctance to confide, and a lack of trust in the relationship make it challenging for husbands to understand their wives’attitudes.
Rockliff et al. [35] found that the use of escapist coping strategies is associated with increased emotional distress. Attachment-avoiding wives were anxious about children born to donor sperm and expressed undue concerns about their future lives and whether their husbands would accept unrelated children. These concerns can reduce wives’willingness to bear children, make them inconsistent with their husbands regarding the need for parenthood, and exhibit escape strategies for bearing children. Thus, the husband does not feel the wifes’ support in bearing children, which increases the fertility pressure.
For a long time, couples receiving AID treatment comprised a special group of infertile couples. The results of our study emphasise male involvement and reinforce the duality of the treatment process. The current meta-analysis suggests that psychosocial interventions for couples to treat infertility may be effective in reducing psychological distress and improving clinical pregnancy rates [36]. Couples who are unable to provide mutual support and those who are dissatisfied with their response may be more vulnerable to AID treatment. Before receiving AID treatment, medical personnel should actively monitor patients and assess their fertility pressure and attachment styles.
However, our study has several limitations. First, the sample size was small and limited to a reproductive centre in Shandong Province; therefore, the study sample was not widely representative. Second, this was a cross-sectional study, and the data cannot reflect dynamic changes in fertility pressures among infertile couples. Longitudinal studies and follow-up are necessary to further validate and discuss the results.
In future studies, a multi-hospital, multi-regional, or even multi-country joint study should be conducted. Furthermore, long-term follow-ups of the marital quality of sperm donors are scarce, and related longitudinal studies should be conducted in the future.
Our study suggests that there are gender differences in fertility stress and attachment anxiety among couples who undergo donor insemination. Donor semen use is a psychological concern for infertile men. Attachment avoidance and anxiety were significantly positively correlated with fertility pressure. The present study supports the idea that wives’ attachment avoidance can affect their husbands’ fertility pressures. Future research should aim to conduct additional studies with diverse populations and settings.
Acknowledgements
We thank all authors for help in performing the literature search and extracting the data.
Abbreviations
- AID
Artificial insemination by donor
- APIM
The Actor-Partner Interdependence Model
- ECR
The Experiences in Close Relationships
- ART
Assisted reproduction treatment
- AIH
Artificial insemination by husband
Author contributions
HQ and YF: Study design and conception; HQ and YF and XZ: data analysis and manuscript writing; XH and GL: data acquisition and data analysis; LY and LG: data interpretation. All authors approved the final version of the manuscript for submission. All authors read and approved the final manuscript.
Funding
This study was supported by the Projects of medical and health technology development program in Shandong province(2018WS346).
Data availability
The data are available from the corresponding author upon reasonable request.
Code Availability
Not applicable.
Declarations
Ethical approval and consent to participate
The study has been approved by the Institutional Review Board (IRB) of the Reproductive Hospital affiliated to Shandong University (2020-69). Moreover, informed consent was obtained from all the participants. Participants who read and signed the consent form were included in the study. All experiments were performed in accordance with relevant guidelines and regulations (declarations of helsinki).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Li Ge, Email: geli1128@163.com.
Yuying Fang, Email: fangyuying0916@163.com.
References
- 1.Zhen Y, Zhang Y, Shi C, et al. The study of related factors of clinical pregnancy of artificial insemination by donor. Chin J Family Plann Gynecotokology. 2019;11(5):77–80. 10.3969/j.issn.1674-4020.2019.05.19. [Google Scholar]
- 2.Han GLZJX, et al. A moderated mediation model of perceived stress, negative emotions and mindfulness on fertility quality of life in women with recurrent pregnancy loss[J]. Qual Life Res. 2020;29(7):1775–87. [31]. [DOI] [PubMed] [Google Scholar]
- 3.Donarelli, Zaira. Lo Coco Gianluca,Gullo Salvatore,et al.Are attachment dimensions associated with infertility-related stress in couples undergoing their first IVF treatment? A study on the individual and cross-partner effect.[J]. Hum Reprod (Oxford England). 2012;27(11):3215–25. [DOI] [PubMed] [Google Scholar]
- 4.Che Y, Cleland J. Infertility in Shanghai:prevalence, treatment seeking and impact[J]. J Obstet Gynecol. 2002;22(6):643–8. [DOI] [PubMed] [Google Scholar]
- 5.Mikulincer M, Florian V. (1998). The relationship between adult attachment styles and emotional and cognitive reactions to stressful events.
- 6.Pozza A, Dèttore D, Coccia ME. Quality of life and infertility stress in homologous and heterologous medically assisted reproduction: the role of common and specific psychopathological traits. Perspect Psychiatr Care. 2021;57(2):717–25. 10.1111/ppc.12603. [DOI] [PubMed] [Google Scholar]
- 7.Ngai FW, Loke AY. Relationships between infertility-related stress, family sense of coherence and quality of life of couples with infertility. Hum Fertil (Camb). 2022;25(3):540–7. 10.1080/14647273.2021.1871781. [DOI] [PubMed] [Google Scholar]
- 8.Castro Alves L, Kendall MC. Sample size and the establishment of safety in perioperative medicine. Tamaño muestral y establecimiento de la seguridad en la medicina perioperatoria. Actas Urol Esp (Engl Ed). 2018;42(9):610. 10.1016/j.acuro.2018.05.007. [DOI] [PubMed] [Google Scholar]
- 9.Peterson BD, Newton CR, Rosen KH, Schulman RS. Coping processes of couples experiencing infertility. Fam Relat. 2006a;55:227–39. 10.1111/j.1741-3729.2006.00372.x--54. [Google Scholar]
- 10.Maestre-Lorén F, Castillo-Garayoa JA, López-I-Martín X, Sarquella-Geli J, Andrés A, Cifre I. Psychological distress in Erectile Dysfunction: the moderating role of attachment. Sex Med. 2021;9(5):100436. 10.1016/j.esxm.2021.100436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Luo L, Wang H, Qiao J, et al. A new ethical reflection on intermarriage between offsprings of Artificial Insemination by Donor(AID)[J]. Chin Med Ethics. 2011;24(2):226–7. [Google Scholar]
- 12.Amutawa YM, AlGhareeb M, Daraj LR, Karaidi N, Jahrami H. A systematic review and Meta-analysis of the Psychiatric morbidities and Quality of Life Differences between Men and Women in infertile couples. Cureus. 2023;15(4):e37327. 10.7759/cureus.37327. Published 2023 Apr 9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Moura-Ramos M, Gameiro S, Canavarro MC, Soares I. Assessing infertility stress: re-examining the factor structure of the Fertility Problem Inventory. Hum Reprod. 2012;27(2):496–505. 10.1093/humrep/der388. [DOI] [PubMed] [Google Scholar]
- 14.Nachtigall RD, Becker G, Wozny M. The effects of gender-specifific diagnosis on men’s and women’s response to infertility. Fertil Steril. 1992;57:113–21. [PubMed] [Google Scholar]
- 15.Kedem P, Mikulincer M, Nathanson YE, Bartoov B. Psychological aspects of male infertility. Br J Med Psychol. 1990;63:73–80. [DOI] [PubMed] [Google Scholar]
- 16.Smith JF, Walsh TJ, Shindel AW, et al. Sexual, marital, and social impact of a man’s perceived infertility diagnosis. J Sex Med. 2009;6(9):2505–15. 10.1111/j.1743-6109.2009.01383.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lotti F, Maggi M. Sexual dysfunction and male infertility. Nat Rev Urol. 2018;15(5):287–307. 10.1038/nrurol.2018.20. [DOI] [PubMed] [Google Scholar]
- 18.Lau JTF, Wang Q, Cheng Y, Kim JH, Yang X, Tsui Y, H. Infertility-related perceptions and responses and their associations with quality of life among rural Chinese infertile couples. J Sex Marital Ther. 2008;34(3):248–67. 10.1080/00926230701866117. [DOI] [PubMed] [Google Scholar]
- 19.Blake L, Casey P, Jadva V, Golombok S. Marital stability and quality in families created by assisted reproduction techniques: a follow-up study. Reprod Biomed Online. 2012;25(7):678–83. 10.1016/j.rbmo.2012.09.006. [DOI] [PubMed] [Google Scholar]
- 20.Yazdani F, Kazemi A, Fooladi MM, Samani HR. The relations between marital quality, social support, social acceptance and coping strategies among the infertile Iranian couples. Eur J Obstet Gynecol Reprod Biol. 2016;200:58–62. 10.1016/j.ejogrb.2016.02.034. [DOI] [PubMed] [Google Scholar]
- 21.Bayley TM, Slade P, Lashen H. Relationships between attachment, appraisal, coping and adjustment in men and women experiencing infertility concerns. Hum Reprod. 2009;24(11):2827–37. 10.1093/humrep/dep235. [DOI] [PubMed] [Google Scholar]
- 22.Van den Broeck U, D’Hooghe T, Enzlin P, Demyttenaere K. Predictors of psychological distress in patients starting IVF treatment: infertility-specific versus general psychological characteristics. Hum Reprod. 2010;25(6):1471–80. 10.1093/humrep/deq030. [DOI] [PubMed] [Google Scholar]
- 23.Thoma ME, McLain AC, Louis JF, et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach[J]. Fertil Steril. 2013;99(5):1324–e13311. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Renzi A, Di Trani M, Solano L, et al. Success of assisted reproductive technology treatment and couple relationship: a pilot study on the role of romantic attachment. Health Psychol Open. 2020b;7(1):2055102920933073. 10.1177/2055102920933073. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Makara-Studzińska M, Limanin A, Anusiewicz A, et al. Assessment of Quality of Life in men treated for infertility in Poland. Int J Environ Res Public Health. 2022;19(5):2950. 10.3390/ijerph19052950. Published 2022 Mar 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Simionescu G, Doroftei B, Maftei R, et al. The complex relationship between infertility and psychological distress (review). Experimental Therapeutic Med. 2021;21(4):306. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Patel A, Sharma PSVN, Kumar P. Psychosocial aspects of Therapeutic Donor Insemination. J Hum Reprod Sci. 2018;11(4):315–9. 10.4103/jhrs.JHRS_108_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Galhardo A, Pinto GJ, Cunla M, et al. The impact of shamed self-judgment on psychopathology in infertile Patients[J]. Hum Reprod. 2011;26(9):2408–14. 10.1093/humrep/der209. [DOI] [PubMed] [Google Scholar]
- 29.Chachamovich JR, Chachamovich E, Zachia S, Knauth D, Passos EP. What variables predict generic and health-related quality of life in a sample of Brazilian women experiencing infertility? [J]. Hum Reprod. 2007;22(7):1946–19522. [DOI] [PubMed] [Google Scholar]
- 30.Ying LY, Wu LH, Loke AY. Gender differences in experiences with and adjustments to infertility: a literature review. Int J Nurs Stud. 2015;52(10):1640–52. 10.1016/j.ijnurstu.2015.05.004. [DOI] [PubMed] [Google Scholar]
- 31.Mikulincer M, Florian V, Cowan PA, Cowan CP. Attachment security in couple relationships: a systemic model and its implications for family dynamics. Fam Process. 2002;41(3):405–34. 10.1111/j.1545-5300.2002.41309.x. [DOI] [PubMed] [Google Scholar]
- 32.KENNY D A, COOK W. Partner effects in relationship research: conceptual issues, analytic difficulties, and illustrations[J]. Personal Relationships. 1999;6(4):433–48. [Google Scholar]
- 33.Van Der Merwe E, Greeff AP. Infertility related-stress within the marital relationship. Int J Sex Health. 2015;27:522–31. 10.1080/19317611.2015.1067275. [Google Scholar]
- 34.Gana K, Jakubowska S. Relationship between infertility-related stress and emotional distress and marital satisfaction. J Health Psychol. 2016;21:1043–54. 10.1177/1359105314544990. [DOI] [PubMed] [Google Scholar]
- 35.Rockliff HE, Lightman SL, Rhidian E, Buchanan H, Gordon U, Vedhara K. A systematic review of psychosocial factors associated with emotional adjustment in in vitro fertilization patients. Hum Reprod Update. 2014;20:594–613. 10.1093/humupd/dmu010--53. [DOI] [PubMed] [Google Scholar]
- 36.Frederiksen Y, Farver-Vestergaard I, Skovgård NG, Ingerslev HJ, Zachariae R. Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ Open. 2015;5(1):e006592. Published 2015 Jan 28. 10.1136/bmjopen-2014-006592==56 [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data are available from the corresponding author upon reasonable request.
Not applicable.