Adjustment to infertility: the role of intrapersonal and ...

Human Reproduction, Vol.24, No.4 pp. 906 – 912, 2009
Advanced Access publication on December 23, 2008
doi:10.1093/humrep/den462
ORIGINAL ARTICLE Psychology and counselling
Adjustment to infertility: the role
of intrapersonal and interpersonal
resources/vulnerabilities
N.N. Mahajan1,2,5, D.A. Turnbull1, M.J. Davies2, U.N. Jindal3,
N.E. Briggs4 and J.E. Taplin1
1School of Psychology, University of Adelaide, SA 5005, Australia 2Discipline of Obstetrics and Gynaecology, University of Adelaide, SA 5005,
Australia 3Department of Gynaecology, Gynecological and Fertility Research Centre, Chandigarh 160020, India 4Discipline of Public Health,
University of Adelaide, SA 5005, Australia
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5Correspondence address. 3/32, Marleston Avenue, Ashford 5035, Australia. Tel: þ61-8-83514220; E-mail: neha.mahajan@adelaide.edu.au
background: Great variability exists in the degree of adjustment to infertility, which in turn is known to influence wellbeing. The main
objective of this study is to identify intrapersonal [neuroticism, adult attachment style (AAS), perceived internal control, meaning of parent-
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hood and intrinsic religiosity] and interpersonal (social support and marital adjustment) associates of adjustment to infertility.
method: A cross-sectional analysis of 85 consecutive heterosexual women, attending three infertility clinics in northern India during July
2005 – March 2006, participated in the study. A range of scales were used to measure the intrapersonal and interpersonal attributes. The
degree of adjustment to infertility was assessed using the Fertility Adjustment Scale. The data were analysed using multiple regression.
results: The intrapersonal model (49.3%) explained a larger proportion of variance than did the interpersonal model (28.4%). Percep-
tion of children as necessary for marital completion, and the avoidance type of AAS was associated with poorer adjustment and constituted
intrapersonal vulnerabilities. In contrast, intrinsic religiosity, sexual satisfaction and familial support were associated with better adjustment
by guest on March 17, 2011
and were identified as helpful intrapersonal and interpersonal coping resources.
conclusions: The findings of the study highlight the merit of understanding intra- and interpersonal attributes for achieving better
wellbeing outcomes. These findings would also prove valuable for researchers and practioners involved in designing and implementing psy-
chosocial interventions.
Key words: assisted reproductive technologies / psychosocial / psychological adjustment / infertility / developing countries
Introduction
the death of a spouse, others do not rate it as highly (Dohrenwend
and Dohrenwend, 1981; Freeman et al., 1985). The variability in the
Infertility is often experienced as a biopsychosocial crisis accompanied
extent of adjustment may reflect the underlying variation in intraperso-
by adverse cognitive-behavioural and affective outcomes, such as over-
nal and interpersonal resources/vulnerabilities that influence the indi-
generalization of the loss of control over reproduction to other
vidual’s interpretation of, and capacity to cope with, a stressful
aspects of life (Mahlstedt, 1985; Clarke et al., 2006), hopelessness
situation like infertility (Ensel and Lin, 1991).
(Filetto and Makuch, 2005), feelings of unfulfillment, inability to plan
However, our understanding of psychosocial factors, particularly
for the future and compromised ability to find alternate goals and
intrapersonal and interpersonal factors that define one’s capacity to
meaning in life (Meyers et al., 1995), social withdrawal (Higgins,
adjust to infertility remains limited due to negligible research in this
1990), anxiety and depression (Kee et al., 1990). These adverse out-
field. Only one study has made a limited examination of factors associ-
comes are symptoms of the lack of adjustment to infertility. Adjust-
ated with adjustment to infertility (i.e. age, education, duration of infer-
ment refers to the individual’s capacity to cognitively process the
tility and duration of treatment, social comparison operationalized as
possibility of having or not having a child, and the likely advantages
own versus others chances of treatment success, social influence
and disadvantages of either outcome, as well as their ability to compe-
operationalized as influence of knowing other recipients’ of treatment,
tently manage their behavioural and emotional responses to infertility.
positive affect and negative affect) (Durning and Williams, 2004). This
The degree of adjustment varies across individuals. While some indi-
study found that age and negative affect were the only two variables
viduals experience infertility as the most distressing life event akin to
associated with the level of adjustment to infertility. However, the
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Intra- and interpersonal resources for better outcomes
907
direction of relationship was not clearly specified. Thus, the aim of the
consent was either received by the researcher or a member of the
present study is to identify intrapersonal and interpersonal factors
team of physicians involved in the treatment. Cross-sectional data were
associated with the variation in the degree of adjustment to infertility
collected from the participants using questionnaires, which were given
among women commencing an IVF/ICSI cycle. It was hypothesized
to the patients personally and were expected to be completed within 2
weeks. Two follow-up phone calls were made to participants who did
that the intrapersonal and interpersonal models will significantly
not return the completed questionnaires to ensure that the data were
explain the variability in the degree of adjustment noted among
received prior to ovarian stimulation, i.e. before the actual commence-
these women.
ment of the treatment cycle. The completed questionnaires were returned
The variables in intrapersonal as well as interpersonal models were
by all the participants.
selected on the basis of the past evidence regarding their associations
with the level of distress, depression and anxiety experienced by those
Measure
diagnosed with infertility. The association with distress, depression and
Socio-demographic characteristics were obtained using a specially
anxiety was chosen as a criteria for the inclusion in the model, because
designed questionnaire and biomedical characteristics were obtained
of the previously noted association between negative affect and adjust-
from the patient records. Intrapersonal and intrapersonal attributes
ment to infertility (Durning and Williams, 2004) as well as the under-
were assessed with the following psychometric questionnaires.
standing that less than optimum adjustment to life stressors are often
accompanied by depressed mood, anxiety and overall distress (Kaplan
Assessment of intrapersonal attributes
et al., 1994). The intrapersonal model included neuroticism (Verhaak
Neuroticism
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et al., 2005), perceived internal locus of control (Abbey et al., 1992a,
The neuroticism scale of NEO-Personality Inventory (NEO-PI-RTM, Costa
b), adult attachment style (AAS) (Mikulincer et al., 1998), meaning of
and McCrae, 1992) was used to measure the individual’s tendency to
parenthood (MOP) (Edelmann et al., 1994) and religiosity (Domar
experience negative affect and the emotional stability in the face of stress-
et al., 2005); while the interpersonal model included social support
ful situation without becoming unnerved. The scale consists of 48 items
and marital adjustment (Andrews et al., 1991; Matsubayashi et al.,
rated on a 5-point, Likert-type scale ranging from strongly disagree to
2004).
strongly agree. Higher score on the scale indicates higher neuroticism.
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Understanding factors that influence adjustment is essential for
The neuroticism scale has high reported reliability (0.92 – 0.93) and validity
guiding pre-emptive actions and interventions that can be undertaken
(Costa and McCrae, 1992).
to improve adjustment to infertility; this, in turn, will influence the well-
being of patients (Johnston, 1987; Hawton and Kirk, 1990).
Perceived internal locus of control
The Perceived Internal Locus of Control scale (P-I-Control) (Abbey et al.,
1992a, b) was developed for infertility research and consists of a 5-item
Materials and Methods
Likert-type scale ranging from strongly disagree to strongly agree. It
measures the extent to which individuals believe that they determine
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Participants
what happens in their lives. Lower score on the scale reflects higher
A consecutive sample of 85 women was recruited from among the 91 eli-
P-I-Control. The reported Cronbach alpha is 0.79 (Abbey et al., 1992a,
gible IVF women who were registered for their first IVF/ICSI cycle at any
b) and also has good face validity.
of the two private clinics in Chandigarh, or the ART Clinic of the Army
Research and Referral Hospital, New Delhi, India. The total number of
Adult attachment style
first IVF/ICSI cycles performed during the time of the study was 91.
AAS was measured using the Adult Attachment Style Questionnaire
The overall recruitment period was between July 2005 and March 2006.
(AAQ) (Simpson et al., 1996). Participants were asked to rate the items
The clinics did not enter into the study simultaneously. Therefore, the
according to how they typically feel about their romantic partner in
recruitment period for each of the three clinics was different. All partici-
general. The questionnaire consisted of 17 individual items; 8 for avoid-
pants: qualified for the medical criterion of infertility; were in a heterosex-
ance (Avoidant-AAS) and 9 for ambivalence (Ambivalent-AAS) measured
ual relationship; had sufficient facility with the English language to be able
on a 7-point Likert-type scale. Higher scores on the avoidance dimension
to complete psychometric questionnaires and had not undergone psycho-
reflect greater negative perception of others and the tendency to avoid or
logical or psychiatric treatment for psychological conditions associated
withdraw from close and intimate relationships. Higher scores on the
with infertility. Reasons for non-participation were noted in informal
Ambivalence dimension reflects the extent to which individuals perceive
talks with the women. These include lack of time (n ¼ 3), lack of interest
themselves unfavourably, particularly in regards to their relationships and
in the ongoing research (n ¼ 2) and partner had concerns about participat-
the extent to which they are preoccupied with issues of abandonment,
ing (n ¼ 1). Two women (n ¼ 2) used donated oocytes for the IVF cycle
loss and partner’s level of commitment. Lower scores on both scales
and were thus excluded during analyses. Thus, the final sample consisted
further defined greater attachment security. The reported Cronbach
of 85 women. The overall participation rate was 93.4%.
alpha for women is 0.74 on the Avoidance index and 0.76 for the Ambiva-
lence index (Simpson et al., 1996).
Procedure
The study was approved by two separate human research ethics commit-
Meaning of parenthood
tees. These were the Human Research Ethics Committee at University of
The MOP scale (Edelmann et al., 1994) was developed for infertility
Adelaide, Australia; the Human Research Ethics Committee of PGIMER
research and consists of nine statements that measure the strength of
(The Post Graduate Institute of Medical Education and Research), Chandi-
three different factors. The first factor (MOP-1) measures the extent to
garh, India. Following the registration for the IVF/ICSI, patients were pro-
which children are perceived as a natural expectation for an adult. The
vided with a consent package (which included a patient information sheet,
second factor (MOP-2) measures the extent to which children are per-
a participant consent form and a participant complaint form). Informed
ceived as a natural expectation of marriage and necessary for marital

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908
Mahajan et al.
completion. The third factor (MOP-3), measures the extent to which con-
positive and six negative statements that aim to tap degree of adjustment
ception and impregnation act as a confirmation of sexual identity. The
such as: ‘I will always feel unfulfilled if I am unable to have my own child’; I
responses were rated using a 5-point Likert-type scale. The higher score
will continue with treatment/investigations until I succeed in having a
reflects greater motivation for parenthood due to a particular factor.
child’; ‘I think life could be rewarding either with or without the children’.
The scale has good factorial validity (three factors i.e. MOP-1, MOP-2
The effect of response set has been minimized by using both positively and
and MOP-3 with Eigen value ,1); further, inter-factor correlations
negatively worded statements. A high score on the FAS questionnaire indi-
between scale items and female distress range from 0.12 to 0.82, and
cates poor adjustment. It has a Cronbach alpha of 0.85 and test-retest
inter-factor correlations between scale items and marital problems
reliability of 0.88 (P , 0.001). Furthermore, it has demonstrated concur-
reported by females range from 20.09 to 20.61, all of which indicates
rent validity with the Hospital Anxiety and Depression Scale as well as
good overall construct validity. The information on the reliability of the
other measures of infertility distress (Glover et al., 1999).
scale has not been published (Edelmann et al., 1994).
Statistical analyses
Intrinsic religiosity
The analyses were done using the Statistical Package for Social Sciences
Intrinsic religiosity (I-Religiosity) was measured using the ‘Age Universal’
(SPSS) for Windows version 13 and SAS 9.1 (SAS Institute Inc., Cary,
Intrinsic Religiosity subscale of the Intrinsic/Extrinsic—Revised Scale’
NC, USA).
(Gorsuch and McPherson, 1989). The scale consists of eight items measur-
(1) Following descriptive analyses of the sample, potential confounders for
ing intrinsic religiosity on a 5-point Likert-type scale. Higher scores indicate
the FAS were identified and assessed using one-way analysis of var-
greater acceptance of religion as a valuable end in itself. The I-Religiosity
iance and t test. Variables considered included age, infertility etiology,
subscale has high reliability (0.83) (Gorsuch and McPherson, 1989).
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type of infertility (primary versus secondary), level of education, occu-
pational status and current job situation. Potential for confounding was
Trait anxiety
not found for any of these variables, and hence were not considered
Trait anxiety (T-anxiety) refers to an individual’s tendency to get anxious.
further in any analysis.
It measures proneness to anxiety as a personality trait. This was measured
(2) Two separate multiple regression analyses were used to analyse the
using the Trait Anxiety subscale of the State-Trait Inventory (STAI) (Spiel-
relative predictive value of the nine independent intrapersonal vari-
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berger et al., 1983) consisting of 20 items rated on a 4-point Likert-type
ables and the six independent interpersonal variables for predicting
scale. Higher scores indicate greater anxiety. The scale has satisfactory
adjustment as measured by the FAS. The assumptions of linearity,
reliability and validity (Spielberger et al., 1983).
normal distribution of residuals and consistent variance of residuals
were tested and found to be satisfactory for both regression analyses.
Assessment of interpersonal characteristics
Marital relationship quality
Results
The 20-item Maudsley Marital Questionnaire (Arrindell et al., 1983) was
used to assess the quality of couples’ marital relationships. It consists of
The fertility adjustment of the participants
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three subscales: marital satisfaction (10 items), sexual satisfaction (five
items) and general life satisfaction with the partner (five items). The
The scores of the study participants on FAS were normally distributed.
responses were recorded on a 9-point Likert-type scale with higher
The average score on FAS was: mean ¼ 47.29, SD ¼ 11.43, SEM ¼
scores indicating greater adjustment problems. The scale has satisfactory
1.24.
reported reliability and validity (Arrindell et al., 1983).
Biomedical and socio-demographic
Social support
characteristics
Social support was measured with the Multi-dimensional Scale of
The biomedical and socio-demographic characteristics of the women
Perceived Social Support (MMPSS) (Zimet et al., 1988). It measures the
participants (n ¼ 85) in the study are presented in Table I.
individual’s subjective assessment of social support adequacy from
three specific sources: family (SS-FAM), friends (SS-FRI) and significant
others (SS-SO). The scale consists of 12 items, with four items for each
Intrapersonal attributes and degree of adjustment to infertility
of the three specific sources. The responses are marked on a 7-point
Table II summarizes the results of multiple linear regression analysis on
Likert-type scale, with higher scores reflecting greater perception of
nine independent intrapersonal variables in order to determine the
social support adequacy. It has good internal reliability (0.88), strong
relative predictive value of these variables in predicting the extent of
factorial validity and moderate construct validity (Zimet et al., 1990;
adjustment to infertility.
Dahlem et al., 1991).
Multiple linear regression analysis indicated that overall 49.3% of
Assessment of adjustment to infertility
variance in FAS was explained by all of the intrapersonal variables
taken together. However, of all the variables in the model, only
The Fertility Adjustment Scale (FAS) (Glover et al., 1999) was the main
MOP-2 (b ¼ 1.46, t ¼ 3.13, P ¼ 0.003), I-Religiosity (b ¼ 20.45,
outcome measure used to measure the extent of adjustment to infertility,
t ¼ 23.45, P ¼ 0.0009) and Avoidant-AAS (b ¼ 0.29, t ¼ 2.14, P ¼
particularly the degree of acceptance of the condition of infertility, its
0.04) were found to significantly influence the FAS scores. There
treatment and treatment-related eventualities. Adjustment here does
was a positive relationship between the MOP-2 and FAS scores,
not refer to the final acceptance of the childless status or waning of the
desire for a biological child, rather it reflects the ability to cognitively, beha-
and Avoidance-AAS and FAS scores. That is, increase of 1 unit in
viourally and affectively process the possibility of either having or not
the scores of MOP-2 results in 1.46 unit increase in FAS scores, an
having a child. The scale consists of 12 statements and the response
increase of 1 unit in the scores of Avoidance-AAS resulted in 0.29
options are spread across a 6-point Likert-type scale. There are six
unit increase in FAS scores after the impact of other variables in the

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Intra- and interpersonal resources for better outcomes
909
model was adjusted. In contrast, there was an inverse relationship
Discussion
between the scores for I-Religiosity and FAS scores, i.e. an increase
of 1 unit in the intrinsic religiosity resulted in 0.45 unit decrease in
The study examined the role of intrapersonal and interpersonal attri-
FAS scores.
butes in explaining the variability in degree of adjustment to infertility
In summary, the results show that avoidant type of AAS and
among women about to commence an IVF/ICSI cycle. The strengths
the greater perception of children as important and necessary to
of the study include a high participation and response rate, which mini-
marital completion is associated with lesser adjustment to infertility.
mizes the opportunity for sampling bias. Furthermore, simultaneous
Higher I-Religiosity, in contrast, is associated with better adjustment
inclusion of various intra- and interpersonal attributes provided us
to infertility.
with a unique opportunity to identify the relative salience of the
various intrapersonal as well as intrapersonal attributes in explaining
the variability in the degree of adjustment to infertility. The limitations
of the study were the cross-sectional design, which precludes defini-
Interpersonal attributes and degree
tive conclusions regarding the direction of relationships, and the rela-
of adjustment to infertility
tively small sample size and consequent inability to cross validate the
Table III shows the results of multiple linear regression analysis of the
finding. However, retrospective power analysis indicated that the
interpersonal variables that was done to determine the relative predic-
study has greater than 80% power to detect R2 ¼ 0.3 for a model
tive value of these variables in predicting the extent of adjustment to
with nine variables (as is the case of intrapersonal model in this
infertility.
study). Similarly, there was greater than 80% power to detect R2 ¼
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The results reveal that overall 28.4% of variance in the FAS scores
0.2 in a model with six variables (as is the case of interpersonal
was explained by the interpersonal variables in the model. However,
model in this study). Nevertheless, having demonstrated the feasibility
only the perception of familial support (b ¼ 20.49, t ¼ 22.46, P ¼
of this line of inquiry, a priority for subsequent research is to replicate
0.02), and degree of sexual satisfaction (b ¼ 0.30, t ¼ 2.04, P ¼
the findings across a range of populations, since cultural conventions
0.04) in a marriage were found to have a significant effect after adjust-
may influence the salience of various intrapersonal factors, and to
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ing for all other variables. This suggests that a substantial amount of
cross validate the findings with larger samples.
variance in FAS scores may be explained by perception of familial
A wide variation was noted in the degree of adjustment to infertility
support and sexual satisfaction.
among women examined in this study. The noted variability was sub-
In summary, it may be concluded that the decrease in sexual satis-
stantially explained by the underlying variations in the intrapersonal
faction and a reduced perception of familial support was associated
attributes (particularly intrinsic religiosity, avoidance type of AAS
with a decrease in adjustment to infertility.
and perception of children as necessary for marital completion) and
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Table I Biomedical characteristics of the study population
Biomedical/socio-demographic characteristics (n 5 85)
.............................................................................................................................................................................................
Count
Percentage
Count
Percentage
.............................................................................................................................................................................................
Female age
Duration of marriage
30 years
29
34.12
1 – 3 years
9
10.59
30.1 – 33 years
21
24.71
3.1 – 6 years
35
41.18
33.1 – 36 years
22
25.88
6.1 – 9 years
14
16.47
36.1 – 39 years
4
4.71
9.1 – 12 years
13
15.29
39.1 – 42 years
7
8.24
12.1 – 15 years
10
11.76
.42 years
2
2.35
.15 years
4
4.71
Duration of infertility
Infertility type
1 – 3 years
26
30.59
Primary
64
75.29
3.1 – 6 years
31
36.47
Secondary
21
24.71
6.1 – 9 years
12
14.12
Diagnosis
9.1 – 12 years
7
8.24
Both male and female factor
38
44.71
12.1 – 15 years
8
9.41
Female factor
33
38.82
.15 years
1
1.18
Male factor
14
16.47
Job situation
Educational qualification
Home duties
43
50.59
Below bachelors degree
17
20.00
Employed (Part-time)
6
7.06
Bachelors degree
30
35.29
Employed (Full-time)
36
42.35
Above bachelors degree
38
44.71

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Mahajan et al.
Table II Summary of multiple linear regression analyses of intrapersonal variables predicting the extent of adjustment
to infertility
Variables in model
Variable summary
Model summary
.................................................................
............................................................
(b)
t value
P-value
R2
F
P-value
.............................................................................................................................................................................................
0.4930
4.57
0.035
Ambivalent-AAS
20.02
20.16
0.87
Avoidant-AAS
0.29
2.14
0.04
T-anxiety
0.16
1.24
0.22
Neuroticism
0.05
0.85
0.40
MOP1
20.38
20.78
0.44
MOP2
1.46
3.13
0.003
MOP3
0.61
1.62
0.11
P-I-Control
20.04
20.16
0.87
I-Religiosity
20.45
23.45
0.0009
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Interpretation of scores: (1) Unlike the scores on other scales in the intrapersonal model, a lower score on the scale measuring P-I-Control indicates higher perceived internal control.
(2) Lower scores on Fertility Adjustment Scale means better Adjustment to Infertility. b, parameter estimates; Ambivalent-AAS, ambivalent-adult attachment style; Avoidant-AAS,
avoidant-adult attachment style; MOP, meaning of parenthood; T-anxiety, trait anxiety; P-I-Control, perceived internal control; I-Religiosity, intrinsic religiosity.
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Table III Summary of multiple linear regression analyses of interpersonal variables predicting the extent of adjustment
to infertility
Variables in model
Variable summary
Model summary
.................................................................
............................................................
(b)
t-value
P-value
R2
F
P-value
.............................................................................................................................................................................................
0.2841
4.17
0.0445
SS-SO
20.26
21.36
0.18
by guest on March 17, 2011
SS-FRI
20.02
20.11
0.92
SS-FAM
20.49
22.46
0.02
Marital satisfaction
20.12
21.07
0.29
General life satisfaction
0.30
1.09
0.28
Sexual satisfaction
0.30
2.04
0.04
b, parameter estimates; SS-SO, social support from significant others; SS-FRI; social support from friends; SS-FAM, social support from family.
interpersonal attributes (namely perception of familial support and
Given that infertility is a low control situation (Terry and Hynes,
sexual satisfaction) of these women.
1998) where little can be done to influence the nature of outcome,
It was found that intrinsically religious women were better adjusted.
patients’ capacity for acceptance of infertility and positive reappraisal
The finding aligns with the findings from previous studies that intrinsic
of infertility may have been vital for adaptation to infertility
religiosity facilitates coping with negative life event (Sherkat and Reed,
(Mendola et al., 1990).
1992; Woods and Ironson, 1999) and that intrinsic religiosity is associ-
A previous empirical study (Schmidt et al., 2005) has noted that
ated with religion-based appraisal of critical events (Batson et al.,
meaning-based coping (i.e. finding positive meaning in infertility) is a
1993) and in turn with wellbeing. The finding of this study indicates
significant predictor of lesser personal, marital and social problems
the possibility that intrinsically religious women may have had adaptive
resulting from infertility among women. A need for future research
belief system that facilitates acceptance of infertility as a broader divine
to find predictors’ of meaning-based coping was identified in the
plan, rather than as a challenge to fundamental aspects of personal
above-mentioned study. The current study has identified a positive
identity. The religious based appraisal of infertility may have encour-
association between intrinsic religiosity and adjustment to infertility.
aged a positive interpretation of infertility and acceptance of infertility
The two findings together make a strong case for the need to evaluate
and afforded them an opportunity to perceive infertility as an oppor-
if better adjustment to infertility among intrinsically religious women is
tunity for higher goals (Batson et al., 1993) such as looking after chil-
due to their greater capacity for meaning-based coping (i.e. positive re
dren who need help (Sewpaul, 1999).
appraisal and acceptance of infertility).

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Intra- and interpersonal resources for better outcomes
911
Furthermore, it was found that avoidantly attached women were
and those who perceive good familial support were better adjusted
more poorly adjusted to infertility. The finding is consistent with the
to infertility suggesting that these are essential resources. Given that
previous finding that an insecure type of AAS constitutes a vulner-
infertility is often experienced as an existential crisis (Cousineau
ability factor for psychological symptoms, relationship impairment
et al., 2006), the findings underscore the value of training therapists
and cognitive functioning (Feeney, 1998; Mikulincer and Florian,
to use a patient’s religiosity factor to help them rework the
1998; Rholes et al., 1998). In the absence of a prospective evaluation,
meaning of infertility so as to achieve an adaptive interpretation of
we cannot ascertain whether sequelae following the diagnosis of infer-
infertility. Further, it also found that avoidantly attached women
tility could have unfavourably shifted the attachment style of infertile
have reduced adjustment, indicating that an ‘avoidant type of adult
women over a period of time by increasing dispositional limitations
attachment style’ constitute barriers to adjustment to infertility. The
of avoidantly attached women, such lower self esteem, fear of inti-
finding of this as a vulnerability factor points to the need for further
macy, perception of self as less physically attractive, and ineffective
research to understand if infertility can unfavourably alter AAS of
communication and coping skills (Hazan and Shaver, 1987; Collins
infertile women by reducing self-esteem. Secondly, it may also be
and Read, 1990; Feeney and Noller, 1990; Simpson et al., 1996;
valuable to investigate, if the proactive role of securely attached hus-
Meyers, 1998; Bogaert and Sadava, 2002; Davis et al., 2006), and
bands can guard against unfavourable shifts in attachment style.
thereby made them even more vulnerable and less adjusted.
Future research in this area has potential for providing ways to
Furthermore, since perception of self as worthy of love is a main
promote secure patterns of attachment and consequently reduce vul-
determinant of one’s attachment style, it is possible that, in a few
nerabilities. The noted association between ‘perception of familial
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extreme cases, infertile women who were previously securely
support’ and adjustment to infertility suggests the value of investigating
attached could have become avoidantly attached as a result of
how families can be made more supportive to enhance adjustment to
decline in ‘perception of self as worthy of love’ (Downey et al.,
infertility.
1989; Oddens et al., 1999).
Overall, the findings of the study are potentially valuable inputs for
It was also found that women who perceived children as necessary
those involved in infertility care, particularly the therapists and those
for marital completion (i.e. MOP-2) were relatively less adjusted. This
associated with improving the health care delivery system.
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finding is contradictory to the findings of a previous study that
reported a lack of significant relationship between ‘perception of chil-
dren as necessary for marital completion’ and life appraisal as well as
Acknowledgements
emotional reaction following IVF failure (Newton et al., 1992). It could
We are grateful to all the participants in the study for entrusting us
be argued that the divergent findings may be attributed to the fact that
with their valuable personal information.
Indian women examined in this study were living in a highly pronata-
listic social environment (Roy et al., 2000). The prevailing pronatalistic
social beliefs and norms could have substantially limited the scope and
by guest on March 17, 2011
Funding
the opportunity to reassess the salience of children in marriage and life
at large for these women. Perhaps, this constitutes the most reason-
The study was funded from Endeavour International Postgraduate
able explanation for the noted association between adjustment to
Research Scholarship (IPRS) by Australian Government Department
infertility and the ‘perception that children are essential for marital
of Education, Science and Training.
completion’.
Besides the intrapersonal associates of adjustment to infertility dis-
cussed above, the study has brought forward a positive association
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