Relationship between coping/attachment styles and infertility-specific distress in Iranian infertile individuals: A cross-sectional study

Abstract Background Infertility has been recognized as a stressful clinical condition, significantly affecting couples' emotional functioning. Objective To investigate the relationship between coping/attachment styles and infertility-specific distress (ISD) in infertile participants. Materials and Methods Atotal number of 240 infertile participants (120 women and 120 men) who attend the Outpatient Infertility Clinic in Sari, Iran between February and October 2017 were selected using the convenience sampling method. Data were collected using a questionnaire addressing sociodemographic variables. In addition, coping and attachment styles were evaluated via the Coping Strategies Questionnaire and the Revised Adult Attachment Scale by Collins and Read (1990); respectively. Ultimately, the Infertility Distress Scale was used to assess ISD. Results The mean ISD score was 42.53 ± 9.63. Secure and insecure attachment styles were observed in 37.9% and 62.1% of the cases, respectively. There was a significant difference among ISD and different groups of attachment styles (p = 0.001) and emotion-focused coping style (p = 0.021). However, no significant relationship was found between problem-focused coping style and ISD (p = 0.985). Conclusion Considering the relationship between coping/attachment styles and ISD, it was recommended to implement stress prevention and coping education within the framework of coping/attachment theories for infertile individuals.


Introduction
Infertility, defined as a failure to conceive within 1 yr of unprotected sex (1). According to the World Health Organization, the worldwide prevalence rate of infertility is about 15% (2).
Infertility can negatively influence individuals' psychological functions. (4). In view of that, negative social attitudes may be directed toward infertile individuals. (5), since no control over one's life can be among the most problematic consequences of infertility (6). A bidirectional relationship has been thus far documented between infertility and distress. On the other hand, distress has been established as a major factor inflicting serious harm to general health status (7), as well as fertility performance (8).
It has been reported that coping with distress can improve fertility in both women and men (9). Anxiety is an important psychological factor influencing infertility outcomes (10). In this respect, attachment refers to a relatively stable emotional bond between children and their mothers or other human beings interacting with children. Bowlby and colleagues have accordingly suggested that individuals' attachment styles could shape their adjustment approaches towards stressful experiences (11).
The three major attachment styles include secure, insecure-avoidant, and insecureanxious/ambivalent (11). Individuals with different attachment styles seek to regulate their emotions and confrontations in such ways expressing their beliefs about themselves and others (12,13).
Attachment, as an individual characteristic, also affects infertile couples' mental and psychological reconciliation (14). Besides, studies have reported a significant relationships between individuals' attachment styles and infertility-specific distress (ISD) (1). Infertility has been correspondingly associated with anxiety and distress-induced avoidance in infertile people and even in those expecting infertility (1,15).
According to Folkman and Lazarus, coping with stress is a psychological and behavioral effort to either overcome or tolerate stress or to minimize its effects (16). Coping strategies are comprised of two main styles. First, emotion-focused coping style that involves attempts to relieve negative emotional responses associated with distress such as fear, excitement, and frustration. Second, problem-focused coping style, that denotes psychological-based processing of actions and information (17). It has been established that infertility provokes distress. Because of their inability to control life events, decisionmaking problems, low self-esteem, and excessive stress, the emotion-focused coping style is more frequently exploited by infertile women (18).

Inclusion and exclusion criteria
The inclusion criteria were individuals who

RAAS
The RAAS was primarily developed by Collins and Read (26). Theoretically, the given scale is

IDS
The IDS was developed by Akyüz and colleagues in their study on Turkish infertile

Statistical analysis
The statistical analysis was performed using

Participants' sociodemographic characteristics
A total number of 240 infertile individuals were recruited in the present study, with a mean age of 33.23 ± 6.85 yr ranging from 18 to 61 yr; the mean age of female and male participants being 32.00 ± 6.51 and 34.47 ± 6.98 yr; respectively. While the mean infertility duration was 6.06 ± 5.02 yr (ranging from 1 to 28 yr), the mean number of children was 4.96 ± 2.06.  (Table I).

Attachment styles
In this study, 37 and men (63.3%) in the present study (Table II and III). The Chi-square test also showed similar frequency distributions in the four sub-categories between men and women. In other words, the attachment styles were independent of gender (p = 0.613).

Relationship between ISD and sociodemographic variables
The levels of ISD were significantly different among the different levels of income, age groups, and in women. Such differences were related to the comparisons between age groups < 29 and > 50 yr, as well as between those of 30 and 39, and 40 and 49 yr. On the other hand, no statistically significant difference was observed in the levels of ISD comparing the different age groups in infertile men. Also, there were no significant differences in the ART groups (Table   IV).

Relationship between ISD and coping styles
No statistically significant relationships were seen between ISD and problem-focused coping style neither in general (p = 0.98) nor in women (p = 0.765) and men (p = 0.827). However, a statistically significant relationship was observed between ISD and emotion-focused coping style in total (p = 0.021) and in men (p = 0.259, Table   V).

Relationship between ISD and attachment styles
The In men, a significant difference was found in the levels of ISD comparing those with secure versus anxious attachment styles (Table   VI).

Relationship between ISD and sociodemographic variables
In Anxiety scale had been further used to examine anxiety and distress in infertile individuals (32).
While they had reported no anxiety in 50.5% of their participants, mild, moderate, severe, and very severe anxieties had been described in 19%, 17.5%, 11%, and 2% of the participants, respectively (32).
In a cross-sectional study in Turkey on 100 infertile women and 100 healthy controls, the mean anxiety and depression scores had been slightly but not significantly higher in infertile women than fertile partners (33). Furthermore, infertile women had represented greater physical and psychological disabilities and poorer quality of life (33).
In the present study, the highest and the lowest levels of ISD were observed in the age groups of 30-39 and 40-49 yr. Likewise, there were statistically significant differences in the levels of ISD between different age groups in infertile women but not in men, indicating higher ISD in younger women. This might be due to lower life experience, lower ability to adapt to infertility, as well as higher distress toward early pregnancies in younger women. But in another study about factors associated with infertility distress of infertile women, no statistically significant linear relationship was found between the woman's age and the IDS score. (34).
According to another survey in Turkey, selfreported disability had been higher among young infertile women (33). Nevertheless, no significant differences had been reported comparing ISD between different age groups in the study by Ramos and colleagues (35).
In the present study, no statistically significant difference was detected between men and women in terms of ISD. These findings were in line with the investigation by Donarelli and colleagues (22). In addition, Alosaimi

Relationship between coping styles and ISD
Overall, a significant relationship was identified between ISD and emotion-focused coping style. The higher levels of ISD in individuals However, no significant differences had been reported in the marital conflicts regarding secure and avoidance attachment styles (42). In their study on 275 women with primary infertility, Besharat and colleagues had further shown that secure attachment style was related to higher coping ability in infertile women (43). This is while avoidant and ambivalent attachment styles had predicted weaker coping abilities in a recent report (43). This was similar to the findings of the present study regarding a significant relationship between anxiety and avoidance dimensions of attachment style and ISD.

Limitations
As one of the major limitations of this study, no control group (i.e., fertile couples with children) was incorporated. Other limitations included small sample size, unavailability of participants' medical history, administration of questionnaires instead of interviews for data collection, and use of a singlecenter study.

Implications for practice
The findings of this study can be used by healthcare staffs working in infertility clinics.

Conclusion
Considering the relationship between coping/attachment styles and ISD, it is recommended to implement stress prevention and coping education within the framework of coping/attachment theories for infertile individuals.