Journal of Reproductive and Infant Psychology

ISSN: 0264-6838 (Print) 1469-672X (Online) Journal homepage: http://www.tandfonline.com/loi/cjri20

A psychological study of male, female related and

unexplained infertility in Indian urban couples

Devika De, Prasanta Kumar Roy & Sujit Sarkhel

To cite this article: Devika De, Prasanta Kumar Roy & Sujit Sarkhel (2017): A psychological study
of male, female related and unexplained infertility in Indian urban couples, Journal of Reproductive
and Infant Psychology, DOI: 10.1080/02646838.2017.1315632

To link to this article: http://dx.doi.org/10.1080/02646838.2017.1315632

Published online: 26 Apr 2017.

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Journal of Reproductive and Infant Psychology, 2017
https://doi.org/10.1080/02646838.2017.1315632

A psychological study of male, female related and

unexplained infertility in Indian urban couples
Devika Dea, Prasanta Kumar Roya  and Sujit Sarkhelb
a
Department of Clinical Psychology, Institute of Psychiatry, Kolkata, India; bDepartment of Psychiatry, Institute
of Psychiatry, Kolkata, India

ABSTRACT ARTICLE HISTORY

Objective: The study intended to see the impact of infertility on Received 9 June 2016
experience of emotional trauma, belief pattern and formation of Accepted 11 January 2017
psychopathology and also to explore the psychopathology with
KEYWORDS
respect to degree of infertility related stress impact among male, Primary infertility; emotional
female and unexplained factor infertility in couples suffering from impact; psychopathology;
primary infertility. irrational belief
Design: This was a clinic-based, cross-sectional comparative study
based on a consecutive sampling method.
Subjects: Sixty couples were studied of whom 10 couples had
male-related infertility (MF), 10 had female-related infertility (FF)
and 10 unexplained infertility (UF). Another 30 fertile couples were
also included as comparative group (CG) after matching on certain
sociodemographic variables with the clinical groups.
Measures: Impact of Event Scale, Symptom Checklist-90 Revised and
Irrational Belief Scale were used.
Results: The impact of emotional trauma and irrational belief was
greatest in the male-related infertility couples, and somatisation in the
unexplained group, whereas depression and interpersonal sensitivity
were higher in the female-related infertility couples. An impact of
moderate to severe infertility-related stress on depression and
irrational beliefs was also observed. Gender difference was evident
with respect to psychopathology and types of infertility.
Conclusion: The impact of infertility is evident with respect to
psychopathology with differential impact of various types of infertility
groups among Indian couples.

Introduction
According to the World Health Organisation (WHO), the prevalence of primary infertility in
India is between 3.9% and 16.8% (World Health Organisation, 2004). A WHO evaluation of
Demographic and Health Surveys (DHS) data (2004) estimated that more than 186 million
ever-married women of reproductive age in developing countries or one in every four cou-
ples were maintaining a ‘child wish’ as they are affected by infertility.
In India, infertility is a hidden social problem where the females and not the males are
held solely responsible for this lifetime problem of having no child (National Family Survey

CONTACT  Prasanta Kumar Roy  prasanta.roy@gmail.com

© 2017 Society for Reproductive and Infant Psychology
2   D. DE ET AL.

PSYCHOSOCIAL VARIABLES
7

4
Male
3
Female
2

0
Love Marriage Arrange Psychiatric Physical Smoking Alcohol
Marriage Illness Illness

Figure 1. Distribution of psychosocial variables among males and females in the three clinical groups.

2005–2006). Traditionally, having children is mandatory in terms of family happiness and

many people still think of infertility as a ‘woman’s problem’, although there is a trend towards
a decline in fertility rate both in developed and developing countries. The latest Indian
Census (2011) showed that in Kolkata, a metro city in India, Total Fertility Rate (TFR), or the
number of children born to women aged 15–49, had plummeted to 1.2, the lowest among
all districts in India (FRONTLINE, August 2012, Volume 29, Issue 16). This trend is consistent
with most of the industrialised cities worldwide and may be attributed to various factors
such as change in lifestyle, increased obesity, increased awareness of using contraception,
environmental factors related to urbanisation, decision to delay having a child due to soci-
oeconomic factors, increased career options for women, etc. (Nargund, 2009; Pande,
Malhotra, & Namy, 2012). Couples/women are delaying starting a family, which has led to a
true decline in their fertility levels due to ovarian ageing and related reasons leading to
reduced chance of conception (Menken, Trussell, & Larsen, 1986).
Previous studies focused mainly on life-as-a-whole, self-efficacy, marriage, intimacy, health
and coping strategies in couples unable to conceive (Sexton, Byrd, & von Kluge, 2010). Studies
were also conducted on causality of infertility, feelings of hopelessness and global attribution
which were found to be related to sexual inadequacy (Lukse & Vacc, 1999). Research suggests
men and women differ with respect to their psychological response to infertility, although
they might be affected equally when aetiological factors lie with them (Malik & Coulson,
2008; Nachtigall, Becker, & Wozny, 1992). Smith et al. (2009) found that male partners among
couples with perceived isolated male-factor infertility reported a lower sexual and personal
quality of life compared with male partners of couples without perceived male-factor infer-
tility. It was also observed that social strain was highest among couples with an unknown
aetiology for their infertility; however, there is a scarcity of studies on the known and
unknown factors associated with infertility which affects a couple’s life in various ways.
Studies that focused on the male and female factors contributing to infertility along with
the gender differences found in couples undergoing infertility treatment and their individual
differences in the perception of their problem.
An important area of discussion is the possible causal link between psychopathology and
infertility. In fact, it is unclear if psychological symptoms arise from infertility or are related
 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY   3

to the psychological features of the individual before treatment. The psychodynamic oriented
model supported by some literature evidences, rejected by many authors (Monga,
Alexandrescu, Katz, Stein, & Ganiats, 2004), and the stress hypothesis considered infertility
as a psychosomatic disorder (Peterson, Newton, Rosen, & Skaggs, 2005). A contrasting model
hypothesised that emotional states, social and psychosomatic features is secondary to infer-
tility, as a result of experiencing loss of pregnancy, loss of a potential children, loss of genetic
continuity and loss of a life goal (psychological sequel model) (Greil, 1997).
Earlier studies did not focus on both partners and all three aetiological factors (male
factor, female factor and unexplained factor) and the differences in their individual impact
(White & McQuillan, 2006). There is also growing interest into infertility by the psychological
specialities under behavioural medicine where psychological management is considered
to improve fertility rate (Hammerli, Znoj, & Barth, 2009). For example, a Mind/Body pro-
gramme for enhancing fertility by Dr Alice Domar focuses on how changing perception or
negative belief related to life may be helpful (Domar, Seibel, & Benson, 1990). Thus, this study
was conducted to explore the impact of infertility on the experience of emotional trauma,
dysfunctional belief pattern and psychopathology among male-factor (MF), female-factor
(FF) and unexplained-factor (UF) infertility in couples suffering from primary infertility.
Dysfunctional beliefs lead to poor choices in coping strategies. The formulation of the
patient’s dysfunction is based on his or her internal experiences and how those experiences
are distorted through negative beliefs, assumptions, inferences and conclusions.

Methods
This was a cross-sectional comparative study and followed a purposive sampling method.
There were four groups consisting of couples staying together, male factor (MF, 10 couples),
female factor (FF, 10 couples), unexplained factor (UF, 10 couples) and matched fertile com-
parative group (CG, 30 couples) between 25 and 40 years, without a history of IVF or other
mode of treatment and no history of past or present psychosis or substance abuse. The mean
age of the females in all four groups seeking treatment was 32.12 ± 4.42 years, whereas for
males it was 34.28 ± 4.33 years.
Within the clinical population 85% were Hindus and 15% Muslims, 81.7% belonging to
urban area and 18.3% percent belonging to suburban area, with 28.3% living in joint families
with the parents and 71.7% living in nuclear families. Among the male members 66.7% were
in service, 33.3% were involved in business. However, among the female members 20% were
homemakers, the remaining 80% were either in service or business.

Measures
The following tools were used.
Semi-structural clinical data sheet: this included age of marriage, consent of marriage,
past history of psychiatric illness, history of major of physical illness, history of smoking,
history of alcohol and drugs, negative sexual experience, fear related to pregnancy or child
rearing, previous history of miscarriage or still birth, previous trial with infertility treatment
and professional stress.
Mini International Neuropsychiatric Interview 5 (MINI; Sheehan & Lecrubier, 2006): the
MINI was designed as a brief structured interview for the major Axis I psychiatric disorders
4   D. DE ET AL.

in DSM-IV and ICD-10. Validation and reliability studies have been done comparing the MINI
to the SCID-P and the CIDI. The results of these studies show that the MINI has acceptably
high validation and reliability scores, but can be administered in a much shorter period of
time. The modules I (Alcohol), J (Substance dependence, non-alcohol) and K (Psychotic dis-
orders and mood disorders with psychiatric features) were administered to rule out substance
abuse and psychosis in the subject. MINI diagnoses were found to have very good kappa
values and sensitivity was 0.70 or greater for the categories.
Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979): the IES is a broadly applicable
self-report measure designed to assess current subjective distress for any specific life event
or trauma (Corcoran & Fischer, 1994; Horowitz et al., 1979). The tool is based on clinical studies
of psychological response to stressful events. There are two subscales reflecting two common
psychological response to stress: avoidance and intrusion. Intrusion involves ‘unbidden
thoughts and images, troubled dreams, strong pangs or waves of feelings, and repetitive
behavior’ and avoidance involves ‘ideational constriction, denial of meanings and conse-
quences of the event, blunted sensation, behavioral inhibition or counter-phobic activity,
awareness of emotional numbness’ (Horowitz et al., 1979). The split-half reliability was high
(r = 0.86). Internal consistency of the subscales, calculated using Cronbach’s Alpha, was also
high (Intrusion = 0.78, avoidance = 0.82). Scores of IES can further be divided into four cat-
egories according to severity of trauma impact; these are subclinical trauma, mild trauma
impact, moderate trauma impact and severe trauma impact. A high level of trauma impact
may often give rise to post-traumatic stress disorder.
Symptom Check List-90-Revised (SCL-90-R): the SCL-90-R (Derogatis, 1994) is a revised
and updated version of the Hopkins Symptom checklist and the SCL-90. The SCL-90-R is a
90-item self-report symptom inventory designed primarily to reflect the psychological symp-
tom patterns of psychiatric and medical patients. It is a measure of current, point-in-time
psychological symptom status, not a measure of personality. The scale assesses depression,
anxiety, phobic anxiety, psychoticism, obsessive compulsive disorder, somatisation, inter-
personal sensitivity, hostility, and paranoid ideation. The scale has high internal reliability
with alpha coefficients ranging from 0.79 to 0.9. In terms of validity, a large number of
published reports indicate that the SCL-90-R performs better than most instruments in both
assessment and in measuring changes following treatment.
Irrational Belief Scale (Malouff & Schutte, 1986): Albert Ellis believed that emotional and
cognitive disorder is the result of unreasonable and irrational beliefs of a person and if he
or she learns to increase his or her rational beliefs and decrease irrational thoughts, then he
or she may be released from mental, emotional and behavioural disorders. In Ellis’ viewpoint,
people are radically rational; dealing with their problems is possible by improving people’s
thoughts and their perception (Kaokebisiyoki, Aminyazdi, Yousefi, & Modaresh, 2010).
Irrational beliefs may intensify anxiety and make the person fall in to a vicious circle. Irrational
assessment of an event in life brings about misplaced anxiety in a person, and then the
person regards this anxiety as a sign of a problem; and this problem, in turn, enhances irra-
tional evaluation. In Ellis’ viewpoint, there are 10 irrational beliefs which are as follows: 1,
demand for approval; 2, high self-expectation; 3, blame proneness; 4, frustration reaction;
5, emotionality irresponsibility; 6, anxious over-concern; 7, problem avoidance; 8, depend-
ency; 9, help lessens for change; and 10, perfectionism (Moradi, Bahrami, & Akhgar, 2010).
These beliefs may influence the mental health of persons and their long-term presence
would cause anxiety (Ellis & Harper, 1961). Malouff and Schutte (1986) found the internal
 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY   5

consistency of the scale assessed by Cronbach’s alpha was 0.80 and the two-week test–retest
reliability was 0.89. Validity studies have found that scale scores are associated with scores
on other measures of irrational beliefs (Malouff & Schutte, 1986).
Procedure: informed consent was taken and the modules I, J and K of MINI were used as
a screening tool for ruling out substance abuse and psychosis in the subjects, following
which the other tools were individually administered in the following order: sociodemo-
graphic data sheet, semi-structured clinical data sheet, IES, SCL-90-R and Irrational Belief
Scale.
Patients were recruited from the BIRTH Infertility Clinic in the city of Kolkata, India by an
infertility specialist and the first author. Patients were had been taking treatment at the
BIRTH clinic for their infertility for at least 1 year. All patients recruited had volunteered to
participate in the study and there was no rejection or discontinuation. The CG couples were
recruited from a community with a similar socioeconomic background. Fertile couples had
at least one child.
Ethical approval was obtained from the Research and Ethics Committees at The Institute
of Psychiatry and at The Institute of Post-Graduate Medical Education and Research, Kolkata,
India in June 2015.
Analysis: descriptive statistics were calculated for each of the groups using chi-square,
mean and standard deviation (SD). Means were calculated to estimate the trend in data and
to summarise the typical value of the data set, and SD was calculated to see the spread of
scores within the data set. ANOVA was conducted to analyse the differences among group
means and their associated procedures (such as ‘variation’ among and between groups).

Results
The chi-square test was done for various categorical demographic and clinical variables
(Table 1) to determine whether there was a significant difference between the four groups
(MF, FF, UF and CG) on the basis of sociodemographic details (Residence, Religion, Profession,
Consent of marriage, History of psychological illness, History of physical illness, Smoking,
Alcohol, Negative sexual experiences, Fear of pregnancy and Professional stress). Figure 1
shows some of the psychosocial variables in the infertility groups.
Four groups were compared to see the nature of psychopathology in each group (Table 2).
All infertility subjects were subclassified based on their severity of trauma reaction due to
infertility as measured by IES. Severity of trauma (subclinical, mild, moderate and severe)
due to infertility was evaluated with their association with psychopathology. Table 3 shows
the distribution of the score across the four severity categories.
Table 4 shows the 4 × 3 × 2 (impact group, study group, gender) factorial design based
on the IES score which was divided into four parts: subclinical, mild, moderate and severe,
three study groups (MF, FF and UF) and gender (male and female) to see their independent
effect on psychopathology including interaction effect.
For the variable impact of event, significant difference has been found between the four
divisions (subclinical, mild, moderate and severe) (p = 0.0001) accounting for 90% variance
(Table 4). Post-hoc analysis indicates a significant difference between the UF and MF and FF
groups (p = 0.0001) with the highest score in the MF, followed by FF and least in the UF group
(Table 2, post-hoc data not shown). With respect to gender differences for the same variable,
females have scored higher in the FF and UF group, whereas males have scored higher in
the MF group.
6   D. DE ET AL.

Table 1. Comparison of demographic and psychosocial variables across the four study groups.
Subcatego-
Variables ries MF FF UF CG χ2 (df = 3) p
Residence Urban 12 (60%) 14 (70%) 12 (60%) 60 (100%) 27.829 0.000
Suburban 8 (40%) 6 (30%) 8 (40%) 0
Family Joint 6 (30%) 10 (50%) 6 (30%) 12 (20%) 6.731 0.081
Nuclear 14 (70%) 10 (50%) 14 (70%) 48 (80%)
Profession Service 10 (50%) 9 (45%) 9 (45%) 28 (46.7%) 0.671 0.995
Business 7 (35%) 6 (30%) 7 (35%) 20 (33.3%)
Housewife 3 (15%) 5 (25%) 4 (20%) 12 (20%)
Religion Hindu 14 (70%) 12 (60%) 16 (80%) 60 (100%) 24.314 0.000
Muslim 6 (30%) 8 (40%) 4 (20%) 0
Consent of marriage Love 8 (40%) 8 (40%) 8 (40%) 37 (61.7%) 5.635 0.131
Arrange 12 (60%) 12 (60%) 12 (60%) 23 (38.3%)
History of psychiatric No 20 (100%) 20 (100%) 20 (100%) 60 (100%) 0
illness Yes 0 0 0 0
History of physical illness Yes 7 (35%) 7 (35%) 6 (30%) 15 (25%) 1.170 0.760
No 13 (65%) 13 (65%) 14 (70%) 45 (75%)
History of smoking Yes 11 (55%) 11 (55%) 12 (60%) 34 (56.7%) 0.136 0.987
No 9 (45%) 9 (45%) 8 (40%) 26 (43.3%)
History of alcohol Yes 9 (45%) 13 (65%) 14 (70%) 30 (50%) 4.040 0.257
No 11 (55%) 7 (35%) 6 (30%) 30 (50%)
Negative sexual Yes 9 (45%) 8 (40%) 6 (30%) 14 (23.3%) 4.259 0.235
experience No 11 (55%) 12 (60%) 14 (70%) 46 (76.7%)
Fear of pregnancy Yes 6 (30%) 6 (30%) 6 (30%) 0 21.176 0.000
No 14 (70%) 14 (70%) 14 (70%) 60 (100%)
Professional stress Yes 13 (65%) 14 (70%) 13 (65%) 43 (71.7%) 0.508 0.917
No 7 (35%) 6 (30%) 7 (35%) 17 (28.3%)

Table 2. Comparison of male factor, female factor and unexplained factor and fertile comparative group
showing means and standard deviations.
MF (n = 20) FF (n = 20) UF (n = 20) CG (n = 20)
Variables M ± SD M ± SD M ± SD M ± SD
Impact of event total 47.3 ± 14.1 37.9 ± 18.9 17.5 ± 11.9
Somatisation 20 ± 14.15 18.95 ± 14.91 23.45 ± 12.68 12.9 ± 7.69
Obsessive compulsive 9.55 ± 10.59 11.65 ± 8.33 16.3 ± 9.6 12.37 ± 6.79
Interpersonal sensitivity 23.7 ± 7.99 24.65 ± 7.51 22.3 ± 8.6 13.72 ± 6.43
Depression 32.8 ± 14.36 35.35 ± 11.93 26.3 ± 14.66 16.2 ± 9.96
Anxiety 20.9 ± 10.99 25.9 ± 9.75 22.45 ± 9.29 15.22 ± 7.3.3
Anger hostility 14.1 ± 6.3 14.55 ± 4.29 14.65 ± 6.14 6.9 ± 4.22
Phobic Anxiety 6.85 ± 6.32 6.1 ± 6.3 10.7 ± 6.09 6.55 ± 4.79
Paranoid ideation 3.8 ± 3.53 6.45 ± 6.07 5.6 ± 3.42 3.08 ± 2.96
Psychoticism 0.9 ± 1.71 1 ± 2.15 2.6 ± 3.08 1.03 ± 2.38
Global severity index 1.53 ± 0.29 1.68 ± 0.45 1.66 ± 0.36 1.02 ± 0.21
Irrational belief 68.45 ± 15.51 61.75 ± 24.04 50.25 ± 20.1 15.15 ± 9.18

For the variable somatisation, significant difference has been found between the genders
(males and females) (p = 0.0001) accounting for 38% variance (Table 4). Post-hoc analysis
indicates (not in the table) a significant difference between MF and the CG (p = 0.022) as
well as the UF and the CG (p = 0.0001) with higher scores in the UF group as compared to
the CG. With respect to the gender differences in the four groups, the females scored higher
than the males.
For the variable interpersonal sensitivity, significant difference were found between the
genders (males and females) (p = 0.0001) accounting for 30% variance (Table 4). Post-hoc
analysis indicates (not in the table) a significant difference between FF and the CG (p = 0.0001),
 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY   7

Table 3.  Impact of event in terms of trauma experience and distribution was seen across the three
groups, whereas psychopathology and irrational belief was seen across the four groups.
IES-subclinical IES-mild IES-moderate IES-severe
Variables M ± SD M ± SD M ± SD M ± SD
Somatisation 18.33 ± 12.64 19.07 ± 14.06 23.14 ± 15.2 21.39 ± 13.64
Obsessive compulsive 14.11 ± 6.13 11.71 ± 9.84 12.57 ± 12.03 12.3 ± 10.38
Interpersonal Sensitivity 24.33 ± 6.91 18.5 ± 8.57 25.79 ± 5.24 24.96 ± 8.47
Depression 26.89 ± 17.33 24.36 ± 11.08 34 ± 11.28 36.09 ± 14.22
Anxiety 23.22 ± 10.67 19.36 ± 8.52 26.71 ± 7.79 23.08 ± 10.09
Anger hostility 13.44 ± 6.75 15.43 ± 4.78 12.86 ± 6.04 15.17 ± 5.31
Phobic anxiety 12 ± 7.63 6.64 ± 5.34 8 ± 5.96 6.96 ± 6.64
Paranoid ideation 4.44 ± 3.64 5.64 ± 3.82 5.36 ± 4.24 5.35 ± 5.62
Psychoticism 1.67 ± 2.65 2.29 ± 3.31 1.29 ± 2.58 1.09 ± 1.68
Global severity index 1.59 ± 0.38 1.45 ± 0.36 1.72 ± 0.33 1.69 ± 0.38
Irrational belief 43.78 ± 20.12 50.93 ± 20.36 68 ± 17.03 67.39 ± 19.72

MF and CG (p = 0.0001), as well as the UF and the CG (p = 0.0001) with relatively higher scores
in the FF group as compared to the MF, UF and CG (Table 2). With respect to the gender
differences in the four groups, the females have scored higher than the males.
For the variable anger hostility, significant difference were found between the genders
(males and females) (p = 0.001) accounting for 22% variance (Table 4). Post-hoc analysis
indicates a significant difference between MF, FF, UF and the CG (p = 0.0001). With respect
to the gender differences in the four groups, the males have scored relatively higher than
the females.
For the variable paranoid ideation, significant difference has been found between the
groups (MF, FF, UF) (p = 0.017) accounting for 17% variance (Table 4). Post-hoc analysis indi-
cates a significant difference between FF and the CG (p = 0.006) with the highest score in
the FF group.
For the variable global severity, significant difference was found between the genders
(males and females) (p = 0.0001) accounting for 46% variance (Table 4). Post-hoc analysis
indicates a significant difference between FF and the CG (p = 0.0001) with the highest scores
in the FF group. Females have scored higher than males in all clinical groups; however, no
significant difference has been noticed in the CG for global severity.
For irrational belief, significant difference was found between the genders (males and
females) (p = 0.0001) accounting for 26% variance (Table 4). Post-hoc analysis indicates a
significant difference between CG and the other three clinical groups (p = 0.0001) and
between FF and UF (p = 0.046). Females have scored higher on irrational belief than males
in all clinical groups.

Discussion
The current study found that the majority of the couples resided in urban areas: MF, FF, UF,
CG (60%, 70%, 60%, 100%, respectively). A greater percentage of couples belonging to the
urban area could be because their coverage met their needs better in the infertile sample
as indicated by a greater satisfaction with their health care.
In the current study, 70% of the couples belonging to the MF group were Hindus, 30%
were Muslims; 60% of the couples of the FF group were Hindus whereas 40% were Muslims;
and 80% of the couples of the UF group were Hindus and 20% were Muslims. These findings
8   D. DE ET AL.

Table 4. Interaction between group and gender, group and the subcategories of impact of event, gender
and the subcategories of impact of event and group, gender and subcategories of impact of event on
clinical variables.
Mean
Variable Source square F P Partial eta squared
Impact of event –total GENDER 2.185 .056 .813 .001
IESCAT 6173.128 159.363 .000 .902
GENDER * IESCAT 17.533 .453 .717 .025
Somatisation GROUP 95.060 .764 .472 .034
GENDER 3336.779 26.826 .000 .384
IESCAT 41.034 .330 .804 .022
GROUP * GENDER 40.269 .324 .725 .015
GROUP * IESCAT 105.214 .846 .504 .073
GENDER * IESCAT 66.198 .532 .663 .036
GROUP * GENDER * IESCAT 40.357 .324 .572 .007
Obsessive compulsive disorder GROUP 126.871 1.314 .279 .058
GENDER 105.704 1.095 .301 .025
IESCAT 7.999 .083 .969 .006
GROUP * GENDER 34.308 .355 .703 .016
GROUP * IESCAT 64.142 .664 .620 .058
GENDER * IESCAT 45.693 .473 .703 .032
GROUP * GENDER * IESCAT 177.563 1.839 .182 .041
Interpersonal sensitivity GROUP 27.461 .726 .490 .033
GENDER 988.544 26.124 .000 .378
IESCAT 73.572 1.944 .137 .119
GROUP * GENDER 43.481 1.149 .326 .051
GROUP * IESCAT 3.987 .105 .980 .010
GENDER * IESCAT 31.761 .839 .480 .055
GROUP * GENDER * IESCAT 66.516 1.758 .192 .039
Depression GROUP 206.625 1.817 .175 .078
GENDER 2083.229 18.318 .000 .299
IESCAT 146.810 1.291 .290 .083
GROUP * GENDER 3.287 .029 .972 .001
GROUP * IESCAT 138.233 1.216 .318 .102
GENDER * IESCAT 228.801 2.012 .126 .123
GROUP * GENDER * IESCAT .476 .004 .949 .000
Anxiety GROUP 126.746 1.377 .263 .060
GENDER 134.886 1.466 .233 .033
IESCAT 72.987 .793 .505 .052
GROUP * GENDER 194.501 2.113 .133 .089
GROUP * IESCAT 142.496 1.548 .205 .126
GENDER * IESCAT 41.451 .450 .718 .030
GROUP * GENDER * IESCAT .045 .000 .983 .000
Anger hostility GROUP 26.630 1.058 .356 .047
GENDER 304.349 12.090 .001 .219
IESCAT 32.231 1.280 .293 .082
GROUP * GENDER 39.790 1.581 .218 .068
GROUP * IESCAT 8.573 .341 .849 .031
GENDER * IESCAT 13.496 .536 .660 .036
GROUP * GENDER * IESCAT 81.779 3.248 .079 .070
Phobic anxiety GROUP 14.219 .388 .681 .018
GENDER 40.465 1.103 .300 .025
IESCAT 4.106 .112 .953 .008
GROUP * GENDER 11.441 .312 .734 .014
GROUP * IESCAT 76.012 2.072 .101 .162
GENDER * IESCAT 48.519 1.322 .280 .084
GROUP * GENDER * IESCAT 1.679 .046 .832 .001
Paranoid ideation GROUP 90.663 4.514 .017 .174
GENDER 14.083 .701 .407 .016
IESCAT 16.892 .841 .479 .055
GROUP * GENDER 20.054 .999 .377 .044
GROUP * IESCAT 3.533 .176 .950 .016
GENDER * IESCAT 35.936 1.789 .163 .111
GROUP * GENDER * IESCAT 3.251 .162 .689 .004
 (Continued)
 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY   9

Table 4. (Continued)
Mean
Variable Source square F P Partial eta squared
Psychoticism GROUP 7.146 1.260 .294 .055
GENDER .004 .001 .978 .000
IESCAT 1.885 .333 .802 .023
GROUP * GENDER 11.094 1.957 .154 .083
GROUP * IESCAT 9.992 1.762 .154 .141
GENDER * IESCAT 13.179 2.324 .088 .140
GROUP * GENDER * IESCAT 3.616 .638 .429 .015
Global severity index GROUP .147 2.320 .110 .097
GENDER 2.306 36.326 .000 .458
IESCAT .060 .945 .427 .062
GROUP * GENDER .054 .845 .437 .038
GROUP * IESCAT .022 .350 .843 .032
GENDER * IESCAT .030 .480 .698 .032
GROUP * GENDER * IESCAT .007 .114 .737 .003
Irrational belief GROUP 356.627 1.125 .334 .050
GENDER 4705.550 14.846 .000 .257
IESCAT 123.902 .391 .760 .027
GROUP * GENDER 45.756 .144 .866 .007
GROUP * IESCAT 249.554 .787 .540 .068
GENDER * IESCAT 84.985 .268 .848 .018
GROUP * GENDER * IESCAT 117.334 .370 .546 .009

can be corroborated with the actual population distribution of Hindus (80.5%) and Muslims
(13.4%) in India (Census, 2011, Government of India, Ministry of Home Affairs).
In this research, the global psychological impact has been found to be different in the
three clinical groups and the possibility of having psychological morbidity as assessed by
the Global Severity Index was greatest in the FF group. Women often begin to imagine
themselves as mothers long before actually trying to have children, and this is certainly
influenced by implicit cultural and societal messages that idealise motherhood. When this
imagined self of a mother, however tentative, is withdrawn, it may result in feeling a loss of
control, threatening her imagined future, causing her to doubt her womanhood, and feeling
like an assault on her ability to self-actualise (Levin, Sher, & Theodos, 1997). This could lead
to depression.
Grief reactions are common among infertile couples; however, these normal grief reac-
tions may prolong into pathological grief leading to major depression (Huppelschoten et
al., 2012). Depressed patients exhibit low mood, loss of interest or pleasure in daily activities,
feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concen-
tration. The feeling of depression is compounded by the loss of control over one’s life that
many infertile couples experience. The authors have observed that, for many couples who
have been able to achieve almost any goal they have set for themselves, the inability to
conceive a child may be the first time they have lost control of their lives. To compensate,
they may wrestle with the infertility team for control over their infertility testing and treat-
ment. For some couples, this attempt to control every aspect of their infertility testing or
treatment may be a defence mechanism against their profound sense of helplessness. When
a woman fails to reproduce, it affects her psychological state. Gradually a time comes when
she feels as if she has no control on her body. In addition, feelings of guilt and self-blame
may lead to depression. Infertile women might feel guilty because they are incapable of
giving birth owing to some past behaviour, especially involvement in sex at early ages, any
premarital relationship or abortion (Collins, Barnhart, & Schlegel, 2008).
10   D. DE ET AL.

The UF group was found to have a higher tendency towards somatisation in comparison
to the other groups and females reported more somatic complaints than men. Somatisation
reflects distress arising from perceptions of bodily dysfunction, pain and discomfort of mus-
cles. This could be due to the inability to manage stress, express and communicate distress
and a cry for help. Similar findings were found in the past by Ghaemi and Forousarih (2010).
High scores in the UF group can be explained by the sense of powerlessness and hopeless-
ness and this might have attributed to the somatisation tendency (Chatterjee, Gon
Chowdhury, Dey, & Poddar, 2010). Earlier studies found that the couples with no clear aeti-
ology for infertility experienced the most social strain, resulting in greater somatisation
tendency (Smith et al., 2009). Vyas, Advanikar, Hathi, Vyas and Parikh (2002) opined these
psychological conflicts could result in medically unexplained infertility too. However, it is
not clear to the authors whether the somatisation tendency was pre-existing or an outcome
of the infertility problem.
In the current study both organic and functional infertile couples reported more irrita-
bility, resentment and hostility with feelings of inadequacy and inferiority, particularly in
comparison with other people. Chiba et al. (1997) reported there is higher possibility that
this strong anger might sometimes be denied in cases of infertility. Self-doubt and marked
discomfort during interpersonal interactions might become evident. This includes the marital
relationship and relationships with family and friends. The couple may become more sen-
sitive regarding the reactions of their partner. Poddar, Sanyal and Mukherjee (2014) also
reported problems in attachment in females with infertility where they express discomfort
with the closeness and more preoccupation about relationships. Interpersonal issues may
be more prominent with the FF due to fear of rejection where the female suffers maximum
interpersonal loss. This might help explain why in the current study the authors have also
found that couples with FF infertility are more paranoid or suspicious.
Perceptions of more severe consequences, a longer timeline and lower controllability
have been found to contribute to greater distress and lower well-being (Katiraei, Haghighat,
Bazmi, Ramezanzadeh, & Bahrami, 2010). It was observed that individuals’ perceptions influ-
enced partner’s psychological adjustment. Building on Ellis’ theory, in such cases the anxiety
caused by an irrational belief changes into a big problem which has nothing to do with
reality (Dhaliwal, Gupta, Gopalan, & Kulhara, 2004). These beliefs may influence mental health
and their long-term presence is thought to cause anxiety (Ellis & Harper, 1961). In the current
study higher irrational belief in the clinical groups is evident which might have clinical impli-
cations in helping to understand the elevated score on anxiety, depression, anger and other
psychopathology (Jones & Trower, 2004; McDermut, Haaga, & Bilek, 1997). It is also observed
that irrational belief is higher where impact of stress related to the diagnosis is moderate to
severe.
The study has a number of limitations. Sample size estimation was not calculated based
on the population to claim the proper representation. Also, the sample was collected only
from one clinic; therefore, a particular stratum could only be included. The data were col-
lected at one time point; as a result, we could not evaluate changes in psychological mani-
festations over time. Finally, this research depended on self-report findings and information
from other sources could not be obtained to confirm the findings of the self-report.
However, this particular study had a number of strengths, for example, it included all
three primary infertility groups, i.e. male-factor infertility, femal-factor infertility, unex-
plained-factor infertility and a control group (fertility group). Most infertility studies focus
 JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY   11

on the female partner, whereas this study collected data from both partners, and finally we
controlled psychosocial confounders through matching of the sample to minimise error.

Conclusion
The impact of infertility is evident with respect to psychopathology with differential impact
of various types of infertility groups. In developing countries like India, psychological needs
related to infertility have not been addressed adequately. This study will enable psychological
practitioners and also fertility clinicians to consider the needs of infertile couples.
Understanding of the role of irrational belief and severity of trauma in the formation of
various psychological distress will be of help in formulating a psychological intervention.

Disclosure statement
No potential conflict of interest was reported by the authors.

ORCID
Prasanta Kumar Roy   http://orcid.org/0000-0001-9738-2786

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