Abstract
Introduction
Infertility is a stressful state that may decrease attachment between spouses. Marital intimacy is a real need in infertile women.
Aim
The aim of this study was to evaluate marital intimacy and predictive factors among infertile women in Northern Iran.
Materials and Methods
This cross-sectional study was conducted at Fatemeh Zahra Infertility and Reproductive Health Center of Babol Medical Sciences University in 2014. A total of 221 infertile women participated in this study. The instrument used in this research was Marital Intimacy Need Questionnaire (MINQ). Statistical analyses was performed using linear and logistic regression with p<0.05 indicating statistical significance.
Results
An 88.5% of infertile women had good marital intimacy. The mean and standard deviation of the marital intimacy was 349.11±49.26 and in marital intimacy domains including: emotional (42.28±7.23), psychological (41.84±7.59), intellectual (42.56±7.46), sexual (42.90±7.41), physical (43.59±6.96), spiritual (51.61±8.06), aesthetic (42.66±6.75), and social intimacy (42.59±6.89). The highest mean of marital intimacy domains is related to spirituality in infertile women. Physical and sexual domains had the high mean in infertile women. The lowest mean in marital intimacy domains was psychological intimacy. There was a significant correlation between the domains of marital intimacy. The strongest correlation was between the physical and sexual intimacy (r=0.85). There was a significant inverse association in marital intimacy with the age difference of spouses (p<0.01), and tobacco use (p<0.02). There was a statistically significant association in the marital intimacy with husband’s occupation, and cause of infertility (p<0.02).
Conclusion
Early screening and psychosocial intervention strategies suggest in the setting of female infertility to identify and prevent the predictive factors that may cause marital conflict.
Keywords: Couple intimacy, Marital intimacy need questionnaire, Marital relationship, Sexual intimacy
Introduction
Marital intimacy occurs when spouses express their ideas, emotions, and demands together, and is a real need for humans. It is an interactional procedure in interrelated dimensions of emotional, intellectual, psychological, sexual, physical, spiritual, aesthetic, and social intimacy [1,2]. Sharing positive and negative feelings, fears, concerns, secrets, ideas, lovely thoughts, sex dreams, religion, spirituality, and daily experiences with one’s spouse is an important aspect of a successful marriage. The relationship between a woman and her husband should be based on a healthy and dynamic relationship to develop intimacy [1-3]. The review of literature indicated that marital intimacy and its domains had important roles in married adjustments, and were important predictors of general life satisfaction [4]. Lack of intimacy and affection between partners is a critical factor in most marital conflicts and distress [2]. Poor marital intimacy is one of the most important reasons for divorce, and is a main concern in psychology and counseling fields [5,6]. Studies have shown that several factors could affect the intimacy between couples [6]; infertility may be one of the factors affecting marital satisfaction [7]. In fact, infertility is a public health issue across the world, and impacts the stability of individuals and interpersonal relationships [8]. Also, marital intimacy is one of the key issues of couple adjustment and can have an effect on infertility. Therefore, perception of the aspects of marital intimacy in infertile women is necessary. Results of studies about couple relationships in infertility are unclear and conflicting. Some studies reported that infertile couples have poor satisfaction within themselves and experience psychological consequences such as stress, depression, poor marital adjustment, and marital conflicts, which have inverse effects on fertility [9,10], while other studies revealed that infertility is as bilateral situation, and both the female and male shared infertility crisis. Therefore, infertility had a positive effect on marital intimacy [11]. A review of literatures showed that demographic characteristics such as the women’s age, the husband’s age, the age difference between the couple, educational levels, occupations, duration of infertility, type of infertility, and duration of marriage were other factors contributing to marital intimacy [12-14]. Screening and identifying risk factors that threaten marital intimacy and devoting attention to women with infertility can be effective steps towards increasing marital intimacy and stability, strengthening family bonds, and successfully treating infertility. Therefore, seeking both clinical identification and scientific studies in marital intimacy is critical when researching infertility. This study focused on evaluating of marital intimacy and predictive factors among infertile women in Northern Iran.
Materials and Methods
This cross-sectional study was conducted at Fatemeh Zahra Infertility and Reproductive Health Research Center of Babol Medical Sciences University in 2014. Of the 230 eligible infertile women, 221 agreed to participate in the study and answered the questionnaires. Study duration was five months. Inclusion criteria were history of >12 months of infertility, capable of reading and writing, living with husband, without any previous sterility, not having remarriage in men or women, not having foster child. Exclusion criteria were physical and psychiatric problems, experiencing a major change in living for the past three months (difficult sickness or death in the family), currently using psychotropic and antidepressant medications, not having a stable sexual life for four preceding weeks.
This study was approved by the ethics committee of the Babol University of Medical Sciences. Informed consent was obtained from each subject before enrolling in the research.
The study protocol was explained to the participants. Then, the infertile women received self completion questionnaires. Investigators were available if additional information about the questions was requested.
Demographic and personal characteristics such as the woman’s age, the husband’s age, the age difference between the couple, educational levels, economic status, occupations, current settlement type, duration of marriage, duration of infertility, type of infertility, and cause of infertility was obtained using a self-constructed questionnaire.
Marital intimacy was assessed via Iranian version of Marital Intimacy Needs Questionnaire Bagarozzi (IV-MINQ) [1,15] in the participants of this study. It contains 41 items scored on a ten-point Likert scale. There are eight dimensions of intimacy including emotional, psychological, intellectual, sexual, physical, spiritual, aesthetic, and social intimacy. The α-Cronbach of reliability for the tool was 0.94. In a similar study in Iran indicated that Cronbach’s alpha measurement was 0.92 [13].
Statistical Analysis
Statistical analysis were performed using Regression models. Simple and multiple linear regressions in continuous and logistic regression in categorical variables were applied to detect predictor factors in marital intimacy among infertile women. Data analyses was done using SPSS software (version 21.0) with p <0.05 indicating statistical significance.
Results
Approximately 96.4% of eligible subjects (n=221) accepted to participate in this study. The main reason for sampling loss was the lack of willingness of infertile women to answer questions about marital intimacy.
Most of infertile women were housekeepers, while their husbands were self-employed. The economic status in the most infertile women was moderate level. The majority of the infertile women lived in urban areas and had primary infertility. The highest educational level in most of the infertile women and their husband’s was diploma. There was a statistically significant difference between the educational levels in couples. A university education was more in wives than their husband’s (p<0.05). The duration of marriage in most infertile women was less than five years. The cause of infertility in the most of infertile women was described as male factor. Nearly half of infertile women had been reported using Assisted Reproductive Techniques (ART). The most of infertile women had treatment effort for the first time in the center. A small percentage of infertile women were tobacco users. The demographic characteristics of the study sample are shown in [Table/Fig-1].
[Table/Fig-1]:
Demographic characteristics and marital intimacy in infertile women.
| Parameter | Values | Parameter | Values |
|---|---|---|---|
| Age (years) | 27.93±5.64 | Husband Educational status | |
| Partner age (years) | 31.87±5.43 | Low literate | 29(131%) |
| Age difference of spouses (year) | 3.95±4.42 | High school | 69(31.2%) |
| Duration of marriage (years) | 6.27±4.04 | Diploma | 75(33.9%) |
| <5 | 97(43.9%) | University | 48(21.7%) |
| 5-10 | 88(39.8%) | Treatment effort** | |
| >10 | 36(16.3%) | First time | 138(63.1%) |
| Duration of Infertility (years) | 4.19±3.54 | Several times | 81(36.9%) |
| <2 | 47(21.3%) | Infertility type | |
| 2-5 | 106(48%) | Primary | 162(73.3%) |
| >5 | 68(30.8%) | Secondary | 59(26.7%) |
| Occupation | Infertility cause* | ||
| Housekeeper | 184(83.3%) | Associated with female factors | 38(17.3%) |
| Employed | 37(16.7%) | Associated with male factors | 82(37.3%) |
| Husband Occupation | Associated with Female and male factors | 34(15.4%) | |
| Unemployed | 7(3.2%) | Unexplained factors | 66(30%) |
| Worker | 67(30.3%) | Coitus count* | |
| Employee | 38(17.2%) | 1-2 times in month | 14(6.4%) |
| Self-employed | 107(48.4%) | 1-2 times in week | 112(50.9%) |
| Other | 2(.9%) | 3-4 times in week | 79(35.9%) |
| Current settlement type* | >4 time in week | 15(6.8%) | |
| Urban | 124(56.4%) | Previous ART use* | |
| Rural | 96(43.6%) | Yes | 91(41.4%) |
| Economic status | no | 129(58.6%) | |
| Low | 52(23.5%) | ||
| Moderate | 147(66.5%) | Marital Intimacy | 349.11±49.26 |
| High | 22(10%) | Emotional intimacy | 42.28±7.23 |
| Tobacco user | Psychological intimacy | 41.84±7.59 | |
| Yes | 11(5%) | Intellectual intimacy | 42.56±7.46 |
| No | 210(95%) | Sexual intimacy | 42.90±7.41 |
| Educational status* | Physical intimacy | 43.59±6.96 | |
| Low literate | 27(12.3%) | Spiritual intimacy | 51.61±8.06 |
| High school | 45(20.5%) | Aesthetic intimacy | 42.66±6.75 |
| Diploma | 88(40%) | Social intimacy | 42.59±6.89 |
| University | 60(27.3%) |
Values are mean±SD or number (percentage).
The values do not add up to 221 because of the one subject didn’t respond to this question (missing values).
The values do not add up to 221 because of the two subjects didn’t respond to this question (missing values).
The result of present study showed that 88.5% of infertile women had good marital intimacy, 11% moderate, and 0.5% weak. The mean and standard deviation of the marital intimacy was 349.11±49.26. The highest mean of marital intimacy domains was related to spirituality in infertile women. Physical and sexual domains had the high mean in infertile women [Table/Fig-1]. The lowest mean in marital intimacy domains related to psychological and then emotional intimacy.
There was a significant correlation between the domains of marital intimacy. The strongest correlation value was found between the physical and sexual domains (r=0.85). There were the high correlation value between the domains of intellectual with emotional intimacy (r=0.82), and also intellectual with psychological (r=0.80) [Table/Fig-2].
[Table/Fig-2]:
Marital intimacy domains inter correlations (Pearson r: range = −1.00 − +1.00).
| Emotional | Psychological | Intellectual | Sexual | Physical | Spiritual | Aesthetic | Social | |
|---|---|---|---|---|---|---|---|---|
| Emotional | 1 | |||||||
| Psychological | 0.77 | 1 | ||||||
| Intellectual | 0.82 | 0.80 | 1 | |||||
| Sexual | 0.63 | 0.64 | 0.72 | 1 | ||||
| Physical | 0.58 | 0.61 | 0.71 | 0.85 | 1 | |||
| Spiritual | 0.58 | 0.55 | 0.63 | 0.66 | 0.67 | 1 | ||
| Aesthetic | 0.52 | 0.53 | 0.60 | 0.55 | 0.57 | 0.65 | 1 | |
| Social | 0.62 | 0.65 | 0.66 | 0.64 | 0.67 | 0.62 | 0.65 | 1 |
Correlation is significant at the 0.001 level (2-tailed).
There was not a significant association between the marital intimacy and age, husband’s age, duration of marriage, duration of infertility, level of education, husband’s level of education, economic status, job condition, current settlement type, previous using ART, coitus count, type of infertility, and treatment effort. After adjusting others variables, there was a conversely significant association between marital intimacy with the age difference of spouses (p<0.01), and also using tobacco (p<0.02). Another finding in the research was a significant association between causes of infertility with the marital intimacy. When the cause of infertility is related to both “female and male” factors, the risk of poor marital intimacy was 3.74-fold higher than the unknown cause of infertility (p <0.02). In addition, there was a statistically significant association between the marital intimacy and husband’s occupation. The marital intimacy scores were lower when husbands were unemployed or worker than when the husbands had other job (p<0.05) [Table/Fig-3].
[Table/Fig-3]:
Linear and logistic regression analysis of marital intimacy with the other variables in infertile women.
| Factors | Simple linear Regression | multiple Linear Regression | |||||||
|---|---|---|---|---|---|---|---|---|---|
| B Standardized | R2 | p-value | 95%Ci | B Standardized | p-value | 95%CI | |||
| Low | Up | Low | Up | ||||||
| Age | 0.056 | 0.003 | 0.415 | -0.682 | 1.648 | Constant | 0.000 | 315.086 | 405.715 |
| Husband age | -0.087 | 0.008 | 0.203 | -1.983 | 0.423 | .009 | 0.922 | -1.645 | 1.816 |
| Agedifference of spouses | -0.178 | 0.032 | 0.008 | -3.457 | -.516 | -.171 | .019 | -3.507 | -0.312 |
| Duration of marriage | -0.072 | 0.005 | 0.293 | -2.487 | 0.753 | -.170 | 0.186 | -5.112 | 1.001 |
| Duration of Infertility | -0.011 | 0.0001 | 0.871 | -2.004 | 1.698 | 0.139 | 0.211 | -1.095 | 4.925 |
| Tobacco user | -0.148 | 0.022 | 0.028 | -63.109 | -3.557 | -.151 | .025 | -63.504 | -4.312 |
| Binary Logistic Regression | |||||||||
| Factor | OR | p-value | 95%%CI | ||||||
| Low | Up | ||||||||
| Housing | Owner | ||||||||
| Tenant | 0.57 | 0.29 | 0.205 | 1.608 | |||||
| Job condition | Unemployed | ||||||||
| Employed | 0.67 | 0.54 | 0.190 | 2.382 | |||||
| Treatment effort | First time | ||||||||
| Several times | 1.82 | 0.09 | 0.777 | 3.279 | |||||
| Educational level | <diploma | ||||||||
| >diploma | 1.48 | 0.43 | 0.559 | 3.901 | |||||
| Husband education | <diploma | ||||||||
| >diploma | 1.12 | 0.80 | 0.472 | 2.633 | |||||
| Infertility type | Primary | ||||||||
| Secondary | 2.23 | 0.07 | 0.931 | 5.362 | |||||
| Current settlement type | Urban | ||||||||
| Rural | 1.61 | 0.27 | 0.689 | 3.784 | |||||
| Economic status | High(R*) | 0.79 | |||||||
| Low | 1.56 | 0.60 | 0.297 | 8.16 | |||||
| Moderate | 1.16 | 0.85 | 0.247 | 5.472 | |||||
| ART | Yes | ||||||||
| No | 0.96 | 0.93 | 0.407 | 2.274 | |||||
| Coitus | Weekly | ||||||||
| Monthly | 2.38 | 0.21 | 0.614 | 9.205 | |||||
| Infertility cause | Associated with unexplained factors(R*) | 0.02 | |||||||
| Associated with female factors | 1.76 | 0.811 | 0.310 | 4.463 | |||||
| Associated with male factors | 0.69 | 0.563 | 0.202 | 2.388 | |||||
| Associated with female/male factors | 3.74 | 0.021 | 1.221 | 11.231 | |||||
OR = Odds ratio; CI = Confidence interval; R =Reference
Discussion
According to the findings, most infertile women had favourable marital intimacy. Studies by Fooladi E et al., showed that there was an overall decline in marital adjustment in infertile couples. In fact, cooperating and sharing responsibilities between spouses in the process of infertility treatment may increase the couples interest in each other and have a positive effect on their relationships [16]. However, other studies showed that infertile women had a number of stressors and were at high risk for marital conflict, less marital satisfaction, and poor marital adjustment [9,17,18].
The results of the present study showed that the highest mean of marital intimacy domains is related to spirituality in infertile women. Physical and sexual domains had a high mean in infertile women. Basically, spiritual intimacy is important for marital intimacy, and has a direct effect on marital satisfaction. Poor marital satisfaction and divorce were more common in marriages with no religious intimacy than in marriage with religious devotion [19]. Sexual behaviour constitutes the foundation of intimacy structure. The satisfaction from sexual communication had a unique contribution to intimacy of romantic relationships [1,6]. Sexual satisfaction had an important function in marital satisfaction [20]. One possible explanation for this finding is that Iranian couples need more spiritual and physical intimacy dimensions due to the cultural-social customs.
The data obtained revealed that the lowest mean in marital intimacy domains is related to psychological and then emotional measures in infertile women. Basically, infertility is an unique medical challenge, and the experience of infertility influences the infertile couple with deep psychological and emotional tensions [21]. The problem of infertility causes a crisis in a couple’s life, and the emotional and psychological aspects of infertility can be very difficult [10], leading to poor marital intimacy. Therefore, emotional adjustment is vital for good interpersonal communication [22], and more attention to psychological and emotional factors is necessary for marital intimacy in infertile women.
According to the present study, there was significant correlation between the domains of marital intimacy. Basically, dimensions of marital intimacy are related, and have important roles in the establishment and persistence of marital intimacy [1]. Carney R reported that all eight domain of intimacy are related with one another. If one domain is missed, couples will lack the intimacy. Each type of marital intimacy improves the other and the inclusion of all types of intimacy in a marriage is the ideal. Therefore, all eight aspects must be continually elevated in status [23].
Our findings showed that the strongest correlation value was between the domains of physical and sexual intimacy. Similar findings were reported by Bagarozzi D, who showed optimum sexual intimacy is achieved by body contact and physical closeness with the spouse [1].
Another study showed that intimacy is determined depending on the level of commitment and physical closeness that person experienced in the relationship with the spouse [6]. There was a significant correlation between physical intimacy and marital satisfaction [13].
This study revealed a high correlation value between the intellectual domain and the emotional and psychological domains. Oulia N et al., showed that marital intimacy was determined according to the level of cognitive and emotional closeness that a person has in a relationship with his spouse and satisfaction of emotional communication was effective in marital intimacy [6]. Persistence of marital intimacy can be reinforced by special emotional relation [1].
The present study found a significant inverse association in marital intimacy with the age difference of spouses. When the age difference of couples was greater, poor marital intimacy was observed more often in infertile women, which is consistent with the findings of the study by Rahmani A et al., who reported a significant relationship between the age difference of spouses and marital satisfaction. Couples who had a smaller age difference were more satisfied with their marital life [20]. It seems that lack of consistency in couples needs more attention than age proportion in marriage.
The gathered data showed that the use of tobacco has a negative effect on marital intimacy. Studies in the literature showed tobacco use may lead to marital disruptions and divorce. Addiction caused failure of intimate relationships and could also reduce intimacy and sexual satisfaction [20,24].
Our study showed that when husbands were unemployed or worker, the marital intimacy scores were lower than when the husbands had other jobs. Studies in the literature have also shown that one of the factors affecting intimacy and marital satisfaction is occupation. Better jobs for the husband, higher social status, and a more favourable financial situation are associated with improved sexual satisfaction and marital intimacy. Unemployment and having jobs with low income can have a significant impact on marital intimacy. There was a significant association between daily job stressors (particularly after a heavy work load) with marital problem. There was greater marital anger when husbands had more negative social interactions at work [13,25].
According to the present project, when both “female and male” factors related to the aetiology of infertility, the risk of low marital intimacy was greater. Similar to our study, when the cause of infertility was attributed to both men and women, the marital and sexual satisfaction scores were lower in women [26].
In this study, there was no significant association between marital intimacy and age, husband’s age, duration of marriage, duration of infertility, educational level, husband’s educational level, economic status, job condition, settlement type, previous using ART, or coitus count in infertile women. Similar studies indicated no association between individual and reproductive characteristics such as occupation, age, duration of infertility, or infertility type with marital satisfaction [13,14].
Limitation
As infertile women in this study from a population that entirely consisted of Muslim women, therefore, the religious and cultural differences may have an impact on the result of study. The sample size was small; therefore, the findings of study could not be generalized to the general Iranian infertile women.
Conclusion
There were the risk factors responsible for poor marital intimacy among infertile women. Therefore, early screening and service support suggested in infertility treatment process.
Author Contribution
All authors collaborated in this study. Authors PH, BZ and FM performed the design of the study. Analysis was completed by authors PH and BZ. All authors read and confirmed the final manuscript.
Acknowledgments
We would like to thank the research deputy of the Babol University of Medical Science and the staff of Fatemeh Zahra Infertility and Reproductive Health Research Center, Babol, Iran, and also all study subjects for their cooperation. We would like to thank Dr. Evangeline “Vangie” Foronda (PhD) to edit English of the article.
Financial or other Competing Interests
None.
References
- [1].Bagarozzi D. Enhancing intimacy in marriage, a clinician's guide. 2th ed. philadelphia, brunner ed: routledge; 2001. [Google Scholar]
- [2].Karimi S, Hasani M, Soltani Z, Dalvand MR, Zohdi MH. Effects of communication skills training on increasing intimacy between male teachers and their spouses:A case study in Baane City. J Basic Appl Sci Res. 2012;2(3):3653–59. [Google Scholar]
- [3].Carlson J, Sperry L. Marital Intimacy:Assessment and Clinical Considerations. Routledge: Dennis A Bagarozi, Capture 6; 2015. The Intimate Couple. [Google Scholar]
- [4].Randall AK, Bodenmann G. The role of stress on close relationships and marital satisfaction. Clinical Psychology Review. 2009;29:105–15. doi: 10.1016/j.cpr.2008.10.004. [DOI] [PubMed] [Google Scholar]
- [5].Kardan-Souraki M, Hamzehgardeshi Z, Asadpour I, Mohammadpour RA, Khani S. A review of marital intimacy-enhancing interventions among married individuals. Glob J Health Sci. 2015;8(8):5310–19. doi: 10.5539/gjhs.v8n8p74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Oulia N, Fatehizadeh M, Bahrami F. The study of effectiveness of instruction marital enrichment on increasing of marital intimacy. Journal of Family Research Sum 2006. 2006;2(6):119–35. [Google Scholar]
- [7].Iris A, Aydogan Kirmizi D, Taner CE. Effects of infertility and infertility duration on female sexual functions. Arch Gynecol Obstet. 2013;287(4):809–12. doi: 10.1007/s00404-012-2633-7. [DOI] [PubMed] [Google Scholar]
- [8].Burns LH, Covington SN. Infertility counseling:A comprehensive handbook for clinicians. 2nd ed. Cambridge: Cambridge University Press; 2006. [Google Scholar]
- [9].Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T. Impact of infertility on quality of life, marital adjustment, and sexual function. Urology. 2004;63(1):126–30. doi: 10.1016/j.urology.2003.09.015. [DOI] [PubMed] [Google Scholar]
- [10].Faramarzi M, Pasha H, Esmaelzadeh S, Jorsarai G, Aghajani Mir MR, Abedi SH. Is coping strategies predictor of anxiety and depression in couple infertile? Health. 2013;5(3):643–49. [Google Scholar]
- [11].Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth DR, Passos EP. Agreement on perceptions of quality of life in couples dealing with infertility. J Obstet Gynecol Neonatal Nurs. 2010;39(5):557–65. doi: 10.1111/j.1552-6909.2010.01168.x. [DOI] [PubMed] [Google Scholar]
- [12].Tao P, Coates R, Maycock B. Investigating marital relationship in infertility:a systematic review of quantitative studies. J Reprod Infertil. 2012;13(2):71–80. [PMC free article] [PubMed] [Google Scholar]
- [13].Motavalli R, Ozgoli G, Bakhtiari M, Alavi Majd H. Marital satisfaction and marital intimacy in employed and unemployed pregnant women of ardebil city. Journal of Ardabil University of Medical Sciences. 2010;34:315–24. [Google Scholar]
- [14].Peyvandi S, Mohammadpour RA, Hosseini SH, Daneshpoor SMM, Qolami N. The prevalence of depression, anxiety and marital satisfaction and related factors in infertile women referred to infertility clinics of Sari city in 2008. Journal of Mazandaran University of Medical Sciences 2006. 2011;20(80):26–32. [Google Scholar]
- [15].Etemadi O, Navabinejad S, Ahmadi S, Farzad V. The effect of couples therapy by method of Imago therapy in increasing marital intimacy referred to counseling center in the Isfahan city. News and Research Counseling. 2006;5(19):9–22. [Google Scholar]
- [16].Fooladi E, Danesh MM, Kashfi F, Khani S, Mohammadpor RA. Study of infertile husbands'and wives'point of view to infertility and marital adjustment in patients referring to Royan infertility center of Tehran in 2005. Journal of Mazandaran University of Medical Sciences. 2006;16(55):131–37. [Google Scholar]
- [17].Keskin U, Coksuer H, Gungor S, Ercan CM, Karasahin KE, Baser I. Differences in prevalence of sexual dysfunction between primary and secondary infertile women. Fertility and Sterility. 2011;96(5):1213–17. doi: 10.1016/j.fertnstert.2011.08.007. [DOI] [PubMed] [Google Scholar]
- [18].Masoumi SZ, Garousian M, Khani S, Oliaei SR, Shayan A. Comparison of quality of life, sexual satisfaction and marital satisfaction between fertile and infertile couples. Int J Fertil Steril. 2016;10(3):290–96. doi: 10.22074/ijfs.2016.5045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].Brandt S. Religious homogeny and marital satisfaction:couples that pray together, stay together. J of Family Relation. 2003;44(4):469–77. [Google Scholar]
- [20].Rahmani A, Khoei EM, Gholi LA. Sexual satisfaction and its relation to marital happiness in iranians. Iranian Journal of Public Health. 2009;38(4):77–82. [Google Scholar]
- [21].Pasha H, Faramarzi M, Esmailzadeh S, Kheirkhah F, Salmalian H. Comparison of pharmacological and no pharmacological strategies in promotion infertility self –efficacy of infertile women. Iran J Reprod Med. 2013;11(6):495–502. [PMC free article] [PubMed] [Google Scholar]
- [22].Bloch L, Haase CM, Levenson RW. Emotion regulation predicts marital satisfaction:More than a wives'tale. Emotion. 2014;14(1):130–44. doi: 10.1037/a0034272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23].Carney R. Physical Intimacy and Spiritual Intimacy - Can the Two Really Go Together? 2010. [updated 2010; cited]. Available from: http://EzineArticles.com/expert/Dr._Randy_Carney/221711 .
- [24].Leonard KE, Smith PH, Homish GG. Concordant and discordant alcohol, tobacco, and marijuana use as predictors of marital dissolution. Psychol Addict Behav. 2014;28(3):780–89. doi: 10.1037/a0034053. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [25].Story LB, Repetti R. Daily occupational stressors and marital behaviour. Journal of Family Psychology. 2006;20(4):690–700. doi: 10.1037/0893-3200.20.4.690. [DOI] [PubMed] [Google Scholar]
- [26].Lee TY, Sun GH, Chao SC. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod. 2001;16(8):1762–67. doi: 10.1093/humrep/16.8.1762. [DOI] [PubMed] [Google Scholar]