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EFFECT OF MULTIFACETED INTERVENTION ON STRESS

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AND SELF HELP ABILITIES AMONG COUPLES SEEKING

TREATMENT FOR INFERTILITY

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y.Fi
aPrD
tiebrr
acsl

APARNA S
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Govt.College of Nursing, Kozhikode

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DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT

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OF THE REQUIREMENTS FOR THE DEGREE OF

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MASTER OF SCIENCE IN NURSING

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KERALA UNIVERSITY OF HEALTH SCIENCES

2018
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EFFECT OF MULTIFACETED INTERVENTION ON STRESS

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AND SELF HELP ABILITIES AMONG COUPLES SEEKING

TREATMENT FOR INFERTILITY

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By

y.Fi
APARNA S

aPrD
Dissertation submitted to the

KERALA UNIVERSITY OF HEALTH SCIENCES

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Thrissur

In partial fulfillment of the requirements for the degree of

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MASTER OF SCIENCE IN NURSING

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OBSTETRICS AND GYNAECOLOGICAL NURSING

Under the guidance of

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Dr. GEETHAKUMARY V P
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Govt.College of Nursing

Kozhikode
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2018

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DECLARATION BY THE CANDIDATE

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I hereby declare that this dissertation entitled Effect of multifaceted

intervention on stress and self help abilities among couples seeking treatment for

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infertility is a bonafide and genuine research work carried out by me under the

guidance of Dr. Geethakumary V P, Professor, Govt. College of Nursing,

Kozhikode.

y.Fi
aPrD
tiebrr
APARNA S
acsl
.cn
nwM

Kozhikode

25.06.2018
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CERTIFICATE BY THE GUIDE

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This is to certify that the dissertation entitled Effect of multifaceted

intervention on stress and self help abilities among couples seeking treatment for

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infertility is a bonafide research work done by Aparna S in partial fulfillment of the

requirements for the degree of Master of Science in Nursing.

y.Fi
aPrD Dr. GEETHAKUMARY V.P, MN, PhD, LLB
tiebrr
Professor

Govt. College of Nursing

Kozhikode
acsl
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Kozhikode

25.06.2018
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ENDORSEMENT BY THE PRINCIPAL

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This is to certify that the dissertation entitled Effect of multifaceted

intervention on stress and self help abilities among couples seeking treatment for

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infertility is a bonafide research work done by Aparna S in partial fulfillment of the

requirements for the degree of Master of Science in Nursing.

y.Fi
aPrD Prof. PONNAMMA K.M, MSc (N)
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Principal

Govt. College of Nursing

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Kozhikode
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Kozhikode
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25.06.2018
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COPY RIGHT

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DECLARATION BY THE CANDIDATE

I hereby declare that the Kerala University of Health Sciences, Thrissur shall

nE
have the rights to preserve, use and disseminate this dissertation in print or electronic

journal format for academic / research purpose.

y.Fi
aPrD APARNA S
tiebrr
acsl
.cn
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Kozhikode

25.06.2018
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ACKNOWLEDGEMENT

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Accomplishment of the study owes much to the encouragement, support and

guidance of many. In the preparation of this dissertation the investigator had worked

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with a great number of people whose contribution in various ways deserves special

mention. It is a pleasure to mention gratitude to them all in this humble

acknowledgement.

y.Fi
aPrD
The investigator expresses her sincere gratitude to Prof. Ponnamma K.M.,

Principal, Govt. College of Nursing, Kozhikode for her valuable support for the

successful completion of the study.

tiebrr
The present study has been completed under the guidance of

Dr. Geethakumary V.P., Professor, Govt. College of Nursing, Kozhikode. The

investigator whole heartedly expresses her sincere gratitude for her excellent and
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timely guidance, constructive criticism, scholarly advice, encouragement and

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immense support throughout the study.

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The investigator is immensely obliged to Dr. Sabeena Thomas, Professor,

Govt. College of Nursing, Kozhikode for her scholarly corrections, valuable help and

constant support for the successful completion of the dissertation.

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The investigator thankfully remembers Dr. Sreedevi J, Associate Professor,

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Govt. College of Nursing, Kottayam for her great suggestions and encouragement in

the study. The investigator is also thankful to Mrs. Sindhu Kizakkeppattu, Assistant
a te

Professor, Govt. College of Nursing, Kozhikode for her timely advice and valuable

suggestions throughout the study.

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Very heartfelt thanks to Mrs.Seenath K P, Associate Professor, Govt. College

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of Nursing, Kozhikode, for her generous support and prime contribution towards the

completion of this study.

The investigator is also thankful to Mrs. Saramma V V, Associate Professor,

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Govt. College of Nursing, Kozhikode for her valuable suggestions and constant

encouragement.

y.Fi
It is the investigator’s unavoidable duty to express the heartiest gratitude to

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Dr. Biju George, Assistant Professor, Department of Community Medicine, Medical

College, Kozhikode, for the enormous guidance and priceless support rendered in the

statistical analysis of the study. The investigator is extremely thankful to the members

of scientific review committee and institutional ethics committee for permitting her to
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conduct the study.

She also extend her gratitude to Mrs.Laly K S, Associate Professor,

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Mrs. Rassiya K K, Assistant Professor, Mrs.Vijayasree K V, Assistant Professor,

Mrs.Saritha S, Assistant Professor , Mrs. Babitha E K, Assistant Professor,

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Mrs. Sulochana V A, Assistant Professor and Mrs. Jisha M, Assistant Professor

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for all the support for the completion of study. The investigator also expresses her

sincere gratitude to all the faculty of Govt. College of Nursing, Kozhikode, for their

suggestions, critical observations and encouragement.

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The investigator expresses her sincere gratitude to all the participants for their
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willingness who participated in the study and for their whole hearted co-operation
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during the study. She is grateful to the staff nurses of Infertility unit for their

cooperation.

She expresses her sincere thanks to all the experts who willingly helped her
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through content validation as well as translation and re-translation of the tool.

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The investigator owes sincere thanks to the library staff, Govt. College of Nursing,

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Kozhikode for their generous support and co-operation throughout the study.

The investigator thankfully remembers the members of Prayag DTP centre,

Medical College, Kozhikode for their kind co operation and sincere concern offered

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throughout the study.

Words fail to express her sincere gratitude to her classmates, seniors and

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juniors for their constant encouragement and positive criticism.

aPrD
The investigator is obliged to her parents and other family members for their

great support and encouragement throughout the study.

The investigator is obliged to all the members involved directly or indirectly in

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this study for their kind help and support in successful completion of this study.

Last but not the least the thanks God almighty for giving her the strength and
acsl

opportunity to carry out this study.

.cn
nwM

APARNA S

Kozhikode
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25.06.2018
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ABSTRACT

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The present study was conducted to evaluate the effect of multifaceted
intervention on stress and self help abilities among couples seeking treatment from
infertility unit, Institute of Maternal and Child Health, Kozhikode. The objectives

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were to assess the level of stress, assess the self help abilities, evaluate the effect of
multifaceted intervention on stress and self help abilities and find out the correlation
between stress and self help abilities among couples seeking treatment for infertility.

y.Fi
The conceptual frame work was based on Sr. Callista Roy’s system adaptation model

aPrD
and quantitative approach with pre experimental – one group pre test-post test design
was used. The tools were questionnaire to collect the socio personal data and
knowledge on infertility, rating scale to assess interpersonal relationship with partner,
sexual health and social interaction, Perceived Stress Scale to assess the stress and
rating scale to assess the consequences of the fertility problem among couples with
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infertility. 40 couples were selected by consecutive sampling based on inclusion
criteria. After the pre test, multifaceted intervention which include planned teaching,
relaxation training and personal guidance was given to the couples. Post tests were
conducted on 15-20th day after the pre test. The data were analysed using descriptive
acsl

and inferential statistics. The results showed that there was a significant difference in
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perceived stress (p<0.01), score based on consequence of fertility problem (p<0.01),

knowledge score (p<0.001) and score on IPR, sexual health and social interaction
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(p<0.001). There was a significant association of consequence of fertility problem

with age and history of fertility investigation (p<0.05). There was a significant
correlation between perceived stress with IPR, sexual health and social interaction
among participants. There was a significant correlation between consequence of
fertility problem with IPR, sexual health and social interaction among participants.
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The study concluded that the multifaceted intervention was effective in strengthening
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the knowledge, IPR, sexual health, social interaction and reducing the stress among
couples seeking treatment for infertility. The findings have implications in nursing
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practice, education, administration and research.

Key words: multifaceted intervention; self help abilities; couples seeking

treatment for infertility; selected variables.
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TABLE OF CONTENTS

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List of tables

List of figures

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List of appendices

Chapters Title Page No.

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1. INTRODUCTION 1-14

2. REVIEW OF LITERATURE 15-30

3. METHODOLOGY 31-40
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4. ANALYSIS AND INTERPRETATION 41-75

5. RESULTS 76-83

6. DISCUSSION, SUMMARY AND CONCLUSION 84-96

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REFERENCES 97-101
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APPENDICES 102-200
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LIST OF TABLES

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Sl No. Title Page

No.

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1 No. of couples attended infertility unit, Institute of Maternal and 5

Child Health from 2013-2016

2 Frequency distribution and percentage of participants based on 42

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age

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3 Frequency distribution and percentage of participants based on 44

educational status and occupation

4 Frequency distribution and percentage of participants based on 45

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type of family, place of residence and economic status

5 Frequency distribution and percentage of participants based on 46

Body Mass Index

acsl

6 Frequency distribution and percentage of participants based on 46

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history of fertility investigation

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7 Frequency distribution and percentage of participants based on 48

duration of treatment for infertility and history of Assisted

reproductive technology (ART)

8 Frequency distribution and percentage of participants based on 50

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stress scores
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9 Minimum score, maximum score, mean and Standard Deviation 51

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of stress score of participants before and after multifaceted

intervention
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Sl No. Title Page

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No.

10 Frequency distribution and percentage of participants based on 53

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the score on response to consequence of fertility problem

11 Minimum score, maximum score, mean and Standard Deviation 54

of stress score on response to consequence of fertility problem of

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participants before and after multifaceted intervention

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12 Frequency distribution and percentage of husbands based on 55

response related to the consequence of fertility problem

13 Frequency distribution and percentage of husbands based on 56

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response related to stress as a consequence of fertility problem

14 Frequency distribution and percentage of wives based on 57

response related to the consequence of fertility problem

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15 Frequency distribution and percentage of wives based on 58

response related to stress as a consequence of fertility problem

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16 Frequency distribution and percentage of participants based on 60

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the knowledge score

17 Frequency distribution and percentage of participants based on 61

the score on interpersonal relationship with partner, sexual health

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and social interaction

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18 Minimum, Maximum, mean and SD of stress scores on self help 62

ability of participants before and after multifaceted intervention

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19 Significance difference between mean stress scores of 65

participants before and after intervention

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Sl No. Title Page

No.

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20 Significance difference between mean score on self help abilities 67

of participants before and after intervention

21 Association between perceived stress among participants and 69

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selected variables

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22 Association between consequence of fertility problem among 70

participants and selected variables

23 Association between self help abilities among participants and 72

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selected variables

24 Correlation between perceived stress and self help abilities 74

among participants
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25 Correlation between consequence of fertility problem and self 75

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help abilities among participants

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LIST OF FIGURES

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Sl No. Title Page No.

1 Conceptual framework for the study to evaluate the effect of 14

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multifaceted intervention on stress and self help abilities among

couples seeking treatment for infertility based on Sr. Callista

Roy’s Adaptation Model.

y.Fi
2 Schematic representation of the study 33

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3 Distribution of participants based on the religion 43

4 Distribution of participants based on the duration of living 47

together
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LIST OF APPENDICES

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Sl No. Title Page

No.

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SECTION A : ENGLISH

A Approval letter from Institutional Ethics Committee 102

B Permission letter from head of the department, obstetrics and 103

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gynaecology, IMCH

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C Certificate of relaxation programme training from Patanjali yoga 104

research centre

D List of experts for content validity 105

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E Informed consent- English 107

F Tool 1 - Questionnaire to assess self help abilities among couples 108

with infertility
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G Tool 2 - Rating scale to assess interpersonal relationship with 117

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partner, sexual health and social interaction.

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H Tool 3 - Tool to assess stress among couples with infertility - 119

Perceived Stress Scale (PSS)

I Tool 4 - Rating scale to assess the consequences of the fertility 121

problem among couples with infertility

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J Lesson plan on infertility - causes, risk factors and life style 123
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modifications, preparedness for fertility studies, treatment and

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follow up

K List of abbreviations 152

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Sl No. Title Page

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No.

SECTION B : MALAYALAM

L Informed consent 153

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M Tool 1 - Questionnaire to assess self help abilities among couples 154

with infertility

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N Tool 2 - Rating scale to assess interpersonal relationship with 164

aPrD
partner, sexual health and social interaction.

O Tool 3 - Tool to assess stress among couples with infertility - 166

Perceived Stress Scale (PSS)

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P Tool 4 - Rating scale to assess the consequences of the fertility 168

problem among couples with infertility

Q Lesson plan on infertility - causes, risk factors and life style 170
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modifications, preparedness for fertility studies, treatment and

follow up
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CHAPTER 1

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INTRODUCTION

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Background of the problem

Need and significance of the study

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Statement of the problem

Objectives

Operational definitions
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Assumptions

Hypotheses
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Conceptual framework
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CHAPTER 1

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INTRODUCTION

Nature has bestowed women with the capability of producing children. Having

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a baby is exciting, demanding, rewarding, emotionally satisfying and fulfilling. In

most cultures, fertility and desire to have children are highly important and considered

y.Fi
as the most basic human motivation. Giving birth to a child and being parents are the

aPrD
essential foundations of the family.1 Parenthood is undeniably one of the most

universally desired goals in adulthood, and most people have life plan including

children. However, not all couples who desire a pregnancy will achieve one
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spontaneously and a proportion of couples will need medical help to resolve

underlying causes of infertility.

Infertility is the inability of a person, animal or plant to reproduce by natural

acsl

means. It is usually not the natural state of a healthy adult organism, except notably
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among certain eusocial species. In humans, infertility may describe a woman who is
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unable to conceive as well as being unable to carry a pregnancy to full term. There are

many biological and other causes of infertility, including some that medical

intervention can treat.2 Estimates from 1997 suggest that worldwide "between three

and seven per cent of all [heterosexual] couples or women have an unresolved
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problem of infertility. Many more couples, however, experience involuntary

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childlessness for at least one year: estimates range from 12% to 28%.3 " 20-30% of
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infertility cases are due to male infertility, 20-35% are due to female infertility, and

25-40% are due to combined problems in both parts.4 In 10-20% of cases, no cause is

found.4 The most common cause of female infertility is ovulatory problems which

generally manifest themselves by sparse or absent menstrual periods.5 Male

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infertility is most commonly due to deficiencies in the semen, and semen quality is

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used as a surrogate measure of male fecundity.6

Infertility is “a disease of the reproductive system defined by the failure to

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achieve a clinical pregnancy after 12 months or more of regular unprotected sexual

intercourse (and there is no other reason, such as breastfeeding or

postpartum amenorrhoea). Primary infertility is infertility in a couple who have never

y.Fi
had a child. Secondary infertility is failure to conceive following a previous

aPrD
pregnancy. Infertility may be caused by infection in the man or woman, but often

there is no obvious underlying cause.7

All over the world infertility has affected an estimated 10%-15% of couples of
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reproductive age. They further state that the stress of the non-fulfillment and wish for

a child has been associated with emotional consequences like anger, depression,

anxiety, marital problems and feelings of worthlessness among the couples.8

acsl

Background of the study

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Infertility is a global health issue, affecting approximately 8-10 percent of

couples worldwide. In some societies of sub Saharan Africa (known as the infertility

belt) one third of all couples are unable to conceive during their reproductive lives.

Infertility is not merely a health problem it is also a matter of social injustice and
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inequality. It can threaten a women’s identity, status and economic security and
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consequently, be a major source of anxiety leading to lowered self esteem and a sense
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of powerlessness.8

India accounts for nearly to 5 to 10 million of infertile couples and this

number is constantly rising at the rate of 5 percent every two years. WHO
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epidemiological studies (2000) quoted the prevalence rates for infertility in India as

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3% in primary and 8% in Secondary infertility. The study further explained that,

globally poor countries have higher rates of infertility rates than wealthy countries.

The highest infertility rates up to 50 percent are found in some countries of sub

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Saharan Africa.8

Infertility can have serious consequences for female well-being in a culture

y.Fi
which prizes reproduction, preventing her from achieving her desired family size, and

aPrD
exposing her to various kinds of emotional harassment or marital disharmony. The

health services are rarely comprehensive enough to provide access to reliable

information, sympathetic counselling and services to infertile couples. What is

tiebrr
required is a sound referral system for infertile couples, along with primary health

care, which can provide basic information and counselling.8

acsl

The diagnosis of infertility is always stressful. Some women may already

know or suspect that they are infertile. The following factors can emotionally
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influence couples; having been diagnosed as infertile, uncertainity about the success
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of fertility treatment, grief associated with infertility diagnosis, feelings of losing

control, loss of self-esteem, financial strain, marital stress, sexual pressure and family

pressure.8
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The WHO guidelines concerning the psycho-social aspects of infertility,

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clearly state that beyond diagnosis and clinical interventions should include attention

to the psychological aspects of fertility disorders and that attention should be paid to
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enhance the quality of life of infertile couples. Therefore, it is necessary to have better

understanding of marital relationship in infertility, and an examination of its

associated factors.10
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Need and significance

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Parenting is viewed by most of the couples as their central role in life. Mother,

father and child constitute the elements of a family. Many couples, reaching a certain

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point in their relationship decide to become a father and mother and attempt to

conceive. After 5-6 months of unprotected intercourse most women conceive.

However for about 15% of women pregnancy does not occur. There is so much stress

y.Fi
and distress when one wants a baby and is unable to conceive.

aPrD
Infertility is considered to be problematic; the need for a woman to have a

child remains basic. Motherhood continues to be defined as an individual woman's

treatment in the community, her self-respect and her understanding of womanhood.

tiebrr
Motherhood is a phase where an individual woman gets treatment well from the

society, gains self respect and better understanding of her own womanhood.11
acsl

Infertility is always stressful and it also creates effects on social interaction

and interpersonal relationship among the couples. Childless couples experience

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stigma and social isolation. Infertility disrupts the basic social unit, family and thereby
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the domestic wellbeing. Strengthening of psycho social aspects are very important

among couples with infertility. If the couples are adequately prepared; helps to reduce

the anxiety and improve the self care abilities. Infertility and its treatment always
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create stress. So it is necessary to improve the coping abilities among them. The
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coping abilities are influenced by many physical and psychological factors. Better

understanding of these factors, proper education and counselling is mandatory to

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strengthen these abilities among couples with infertility.

Institute of Maternal and Child Health (IMCH) is the biggest obstetrical and
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paediatric centre in north Kerala in Government sector with a total of 1050 beds. The

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institution is accessed by five districts of Kerala state (Malappuram, Kozhikode,

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Kannur, Wayanadu and Kasargode) with 100% occupancy. The infertility unit renders

diagnostic and treatment services since 2013 and the no. of couples seeking treatment

for infertility is presented in Table 1.

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Table 1

No. of couples attended infertility unit, IMCH from 2013-2016

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aPrD
Year No. of couples attended infertility unit

2013 99

2014 234
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2015 687

2016 1870
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Table 1 shows that the total no. of couples seeking treatment from infertility
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clinic is increasing year by year.

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The investigator conducted informal interview with couples seeking treatment

from infertility unit. Majority of the couples expressed their concern regarding the

measures to be adopted for a successful pregnancy outcome. Couples expressed their

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difficult experience to undergo various investigations due to lack of knowledge and

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the distress associated with it. Hence this study is selected with the intension of

helping the couples to undergo diagnostic and treatment procedures with ease. This
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can be achieved by providing adequate information to the couples and teaching

relaxation technique which help in reducing the stress. If the couples are adequately
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prepared to undergo the investigations and treatment they can face the treatment and

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follow up effectively.

Purpose of the study

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The purpose of the study is to evaluate the effect of multifaceted intervention

on stress and self help abilities among couples with infertility attending infertility

clinic, Institute of Maternal and Child Health, Kozhikode. Infertility and its

y.Fi
management are stress producing situations for the couples seeking treatment for

aPrD
infertility. The study is intended to relieve stress and provide necessary information

on infertility, causes, risk factors, life style modifications, preparation for fertility

studies, follow up and treatment. The study also intended to provide personal
tiebrr
guidance with a view to strengthen self guided confidence to help themselves to

undergo investigations and infertility treatment.

Statement of the problem

acsl

A study to evaluate the effect of multifaceted intervention on stress and self

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help abilities among couples seeking treatment from infertility unit, Institute of
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Maternal and Child Health, Kozhikode

Objectives

1. Assess the level of stress among couples seeking treatment for infertility
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2. Assess the self help abilities of couples seeking treatment for infertility
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3. Evaluate the effect of multifaceted intervention on stress and self help abilities

of couples seeking treatment for infertility

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4. Find out the association between stress among couples seeking treatment for

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infertility with selected variables

5. Find out the association between self help abilities among couples seeking

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treatment for infertility with selected variables

6. Find out the correlation between stress and self help abilities among couples

seeking treatment for infertility

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Operational definitions

Effect : refers to the result of multifaceted intervention on stress and self help abilities

among couples seeking treatment for infertility as measured by Perceived Stress Scale
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(PSS), questionnaire and rating scale.

Multifaceted intervention : refers to set of interventions intended to reduce stress

acsl

and strengthen self help abilities of couples seeking treatment from infertility unit. It

include 2 sessions of planned teaching of 45 and 25 minutes and personal guidance

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session of 15-20 mts duration.

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Session 1 is on infertility, causes, risk factors, life style modifications,

preparation for fertility studies, follow up and treatment imparted through lecture and

discussion with the help of power point slides on the first day of registration.
d wi

Session 2 is on relaxation techniques to be followed by the couples daily for 15-

w

20 minutes for 2 weeks imparted through lecture, discussion, demonstration and

a te

return demonstration.

Personal guidance refers to an interactive session intended to clarify the

doubts of couples and reinforcement for regular follow up.

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Self help abilities : refers to the perception of self guided knowledge regarding

d it
infertility, causes, risk factors and life style modifications, preparedness for fertility

studies, treatment and follow up assessed by questionnaire and social interaction,

interpersonal relationship with partner, and sexual health as measured by rating scale

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Stress : refers to a state of mental or emotional strain or tension experienced by the

couples seeking infertility treatment as measured by Perceived Stress Scale (PSS) and

y.Fi
rating scale on consequences of the fertility problem.

aPrD
Infertility : Infertility is defined as a failure to conceive or progressed to successful

pregnancy within one or more years of regular unprotected coitus.

tiebrr
Couples seeking treatment for infertility : Husband and wife seeking treatment for

infertility.

Selected variables : refers to participant characterestics such as age, religion,

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educational status, occupation, type of family, income, place of residence, BMI,

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duration of living together, history of fertility investigations, duration of treatment and

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history of ART.

Assumptions

 Couples with infertility experience stress.

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 Relaxation technique helps to reduce stress among couples with infertility.

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 Adequate preparation to undergo investigations, treatment and follow up,

a te

reduce stress and strengthen the self help abilities of couples in seeking

infertility treatment among couples.

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Hypotheses

d it
H1 : There is significant difference in the mean score of stress among couples seeking

treatment for infertility before and after multifaceted intervention.

nE
H2 : There is significant difference in the mean score of self help abilities among

couples seeking treatment for infertility before and after multifaceted intervention.

y.Fi
H3 : There is a significant association between stress of couples seeking treatment for

aPrD
infertility with selected variables.

H4 : There is significant association between self help abilities of couples seeking

treatment for infertility with selected variables.

tiebrr
H5 : There is significant correlation between stress and self help abilities among

couples seeking treatment for infertility.

acsl

Conceptual framework
.cn

The conceptual framework of the study is based on Sr. Callista Roy’s

nwM

Adaptation system model. Roy’s model focuses on the concept of adaptation of the

person. Her concepts of nursing, person, health and environment are all interrelated to

this central concept. According to this model, individual is considered as a holistic

adaptive system. The adaptive system is characterized by input, control, output and
d wi

feedback process. The system is in constant interaction with internal and external
w

environment. The environment is the source of variety of stimuli that either threaten
a te

or promote the person’s unique wholeness.

The person’s major task is to maintain integrity in face of these environmental

stimuli. The stimuli which influence the adaptive process can be focal, contextual or
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residual. These three types of stimuli act together and influence the adaptation level,

d it
which is a person’s ability to respond positively in a situation.

According to Roy’s Adaptation Model, focal stimuli are the stimuli that are

nE
immediately confronting the system and one to which the person must make an

adaptive process. Contextual stimuli are all other stimuli existing in the situation that

strengthen the effect of focal stimuli. Residual stimuli are the trait, attitude, believes,

y.Fi
which may affect the focal stimuli, but whose effect is unknown. These three types of

aPrD
stimuli act together and influence the adaptation level, which is a person’s ability to

respond positively in a situation.

The adaptation is mediated by the regulator, cognator coping mechanisms. The

tiebrr
coping mechanism of regulator subsystem occurs through neural, hormonal, chemical

and endocrine process and the coping mechanism of cognator subsystem occurs
acsl

through cognitive emotive process. Roy proposes that behavioural responses of these

two subsystems can be observed in any of four adaptive modes physiological, self
.cn

concept, role function and interdependence modes. Either an adaptive response in one
nwM

or more modes influences adaptation in other modes.

Physiological adaptive mode represents physiological response to

environmental stimuli. Physiological integrity is the adaptive response of this mode.

d wi

Self concept mode refers to psychological and spiritual aspects of the person.
w

A person’s self-concept consist of all believes and feelings that one has formed about
a te

himself. The self-concept changes over time and guide ones actions and is formed

both from internal perception and perception of others. Psychic integrity is the goal of

self-concept mode.
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Role function mode identifies the pattern of social interaction of the person in

d it
relation to others. The social role integrity is the goal of role function mode.

Interdependence mode involves one’s relation with significant others and support

system. Affectionate support from the peer group, family and society is the goal of

nE
interdependence mode.

The adaptive system (persons) output is a response that may be adaptive or

y.Fi
ineffective. Adaptive responses are those that contribute to adaptation goals.

aPrD
Ineffective responses do not support these goals. Output responses can be both

external and internal. Thus these responses are the person’s behaviours. They can be

observed, intuitively reported by the person.

tiebrr
In the present study, couples seeking treatment for infertility are the persons

who form the adaptive system with the focal, contextual and residual stimuli. Focal
acsl

stimuli is the diagnosis of infertility, diagnostic and treatment procedures. Contextual

stimuli affecting the focal stimuli are duration of infertility, duration of treatment,
.cn

type of treatment, level of stress among couples, self help abilities among couples
nwM

include knowledge regarding infertility, interpersonal relationship, social interaction,

sexual health, socioeconomic status and education. Residual stimuli is socio personal

variables which contribute to the development of maladaptive responses. The three

types of stimuli act together and influence the adaptation level of the couples seeking
d wi

treatment for infertility and modulated by coping mechanisms such as cognator or

w

regulator subsystems.
a te

The study is intended to evaluate the effect of multifaceted intervention on

stress and self help abilities among couples seeking treatment for infertility.

Multifaceted intervention include planned teaching, relaxation technique and personal

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guidance. Multifaceted interventions which helps the couples to adapt through

d it
physiological, self concept, role function and interdependence modes. The present

study is an attempt to evaluate the effect of multifaceted intervention on stress and

self help abilities which help the couples to strengthen the self help abilities and

nE
reduce the stress and to the utilization of coping mechanisms which bring about

changes in their physiological, self concept, role functions and interdependence

y.Fi
adaptive modes. This will invariably help the couples to develop adaptive responses.

aPrD
The adaptation which they attain enable them to become an integrated whole.

According to Roy ultimate goal is to enhance integration. Assessment of knowledge

regarding infertility among the couples and the nursing interventions include planned

teaching, relaxation training, and personal guidance will help the couples to
tiebrr
strengthen the self help abilities and reduce the stress, thus helping to achieve a

positive outcome.
acsl

This study observes the response of couples to multifaceted intervention in

.cn

physiological, self-concept, role function, and interdependence modes. Endocrine

nwM

imbalances, anatomical defects, infection, sedentary life style, food habits are

expressed through physiological mode. In self concept mode, adaptation with the

diagnosis of infertility and acceptance by family members can be observed. Affection

and intimacy among the couples and family support are operated through
d wi

interdependence mode. The couple’s role as husband, wife, son and daughter can be
w

expressed in role performance mode. The study is intended to make a change through
a te

regulator and cognator.

After the intervention output is expecting through adaptive or maladaptive

response. The adaptive responses expected include good knowledge regarding

re

infertility and its management and adequately prepared for fertility studies, treatment

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or
and follow up, good interpersonal relationship and social interaction, improved sexual

d it
health and reduced level of stress. The maladaptive responses expected are poor

knowledge regarding infertility and its management and inadequately prepared for

fertility studies, treatment and follow up, poor interpersonal relationship and social

nE
interaction, poor sexual health and increased level of stress. Conceptual framework of

the present study is shown in figure 1.

y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
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r
14

to
INPUT

D in
di
SYSTEM
OUTPUT
Focal stimuli

E
Regulator

.
 Diagnosis of infertility Adaptive responses

r Pary
 Diagnostic and treatment


F
Good knowledge regarding
procedures
infertility and its
management and
Contextual stimuli
Role adequately prepared for
Physiol fertility studies, treatment
 Duration of infertility function
ogical and follow up

tebr
 Duration of treatment mode mode
Couples  Good interpersonal
 Type of treatment seeking relationship and social
 Level of stress among treatment interaction
couples for infertility  Improved sexual health

csli
 Self help abilities among  Reduced level of stress
Self –
couples concept Interdep
 Knowledge regarding endance

cna
mode
infertility mode
w. M
 Interpersonal relationship Maladaptive responses
 Social interaction  Poor knowledge
 Sexual health regarding infertility and
ww i n
 Socioeconomic status Cognator its management and
 Education inadequately prepared for
NURSING ACTIONS - MULTIFACETED INTERVENTIONS fertility studies, treatment
ed

Residual stimuli and follow up

 Planned teaching – infertility, causes, risk factors, life  Poor interpersonal
style modifications, preparation for fertility studies,
 Socio personal relationship and social
follow up and treatment
variables  Relaxation technique – to reduce the stress interaction
at

 Personal guidance  Poor sexual health.

 Increased level of stress
re

Fig 1. Conceptual framework for the study to evaluate the effect of multifaceted intervention on stress and self help

14
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abilities among couples seeking treatment for infertility based on Sr. Callista Roy’s Adaptation Model
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CHAPTER 2

d it
REVIEW OF LITERATURE

Prevalence, causes and risk factors of infertility

nE
Stress and effect of relaxation technique to reduce the stress among couples with

infertility

y.Fi
aPrD
Self help abilities and effect of intervention to strengthen the self help abilities

among couples with infertility

a. Knowledge regarding infertility among couples with infertility

tiebrr
b. Interpersonal relationship, sexual health and social interaction among

couples with infertility.

acsl
.cn
nwM
wd wi
a te
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CHAPTER 2

d it
REVIEW OF LITERATURE

The researcher has gone through extensive literature review and the related

nE
literature from journals, books, unpublished dissertation and online articles organized

and presented under the following headings.

y.Fi
 Prevalence, causes and risk factors of infertility

aPrD
 Stress and effect of relaxation technique to reduce the stress among couples

with infertility
tiebrr
 Self help abilities and effect of intervention to strengthen the self help abilities

among couples with infertility

c. Knowledge regarding infertility among couples with infertility

acsl

d. Interpersonal relationship, sexual health and social interaction among

.cn

couples with infertility.

nwM

Prevalence, causes and risk factors of infertility

Infertility is considered as a major health care problem of different

communities. The high prevalence of this issue doubled its importance. Although
d wi

many studies have been conducted on the prevalence of infertility in the world,
w

because infertility is increasing and the life style is changing. Knowing the frequency
a te

of different causes of infertility in every region is important and can be effective in

manager decisions.12

A study was conducted to understand the levels, patterns and determinants of

re

infertility in India using data from the National Family Health Survey. The data show

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that the levels of infertility in India are not alarmingly high. It finds that 2.3 per cent

d it
of the women in India are infertile. Although the overall prevalence of infertility is 2.3

per cent, there are regional variations in infertility levels. The prevalence of infertility

is highest in the Southern regions and lowest in Northern regions. The variation across

nE
the States shows that prevalence of infertility is highest in Goa followed by Andhra

Pradesh. The determinants of infertility with respect to various socio-economic,

y.Fi
biological and life style related factors have any significant role in determining the

aPrD
levels of infertility. The impact of infertility on the women’s life is also substantial.

Therefore, infertility can definitely be considered an important public health issue

with wider social implications.13

tiebrr
A survey was conducted to study the risk factors affecting female infertility in

South Indian districts of Tamil Nadu and Kerala. About 150 married couples in

Kanyakumari, 165 in Thirunelveli, and 204 in Thiruvananthapuram were randomly

acsl

interviewed to ascertain the prevalence of infertility. Data were collected from the
.cn

patients contacting the Department of Obstetrics and Gynecology in infertility

nwM

clinics. In Kanyakumari district, the incidence of female infertility was 45.67%, male

infertility 54.33%, 82.48% were primarily and 17.52% secondarily infertile. In

Thirunalveli district the incidence of female infertility was 46.54% and male

infertility was 57.76%. In Thiruvananthapuram district the incidence of female

d wi

infertility was 44.67% and male infertility was 61.09%. Biological and social factors
w

including stress due to economic status, religious attitudes, age of marriage,

a te

urbanization leading to modernization, higher literacy, contraceptive usage and

nuclear families play a significant role in lowering fertility.9

A study was conducted to estimate the prevalence of current infertility in

re

Canada. Data from the infertility component of the 2009–2010 Canadian Community

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Health Survey were analyzed for married and common-law couples with a female

d it
partner aged 18–44. Prevalence and odds ratios of current infertility were estimated

by selected characteristics. Estimates of the prevalence of current infertility ranged

from 11.5% to 15.7%. Each estimate represented an increase in current infertility

nE
prevalence in Canada when compared with previous national estimates. Couples with

lower parity (0 or 1 child) had significantly higher odds of experiencing current

y.Fi
infertility when the female partner was aged 35–44 years versus 18–34 years. Lower

aPrD
odds of experiencing current infertility were observed for multiparous couples

regardless of age group of the female partner, when compared with nulliparous

couples. The study suggests that the prevalence of current infertility has increased

since the last time it was measured in Canada, and is associated with the age of the
tiebrr
female partner and parity.14

A cross sectional population based study was conducted on calibrated

acsl

prevalence of infertility in 30 to 49 year old women according to different approaches.

.cn

The prevalence of women with difficulties in conceiving differed widely according to

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the measurement approach adopted. A face-to-face cross-sectional population-based

survey was carried out among 443 women aged between 30 and 49 years residing in

Huelva, southern Spain. Self-reported information was gathered on socio-

demographic data, pregnancy history, time required to become pregnant and

d wi

perception of difficulties in becoming pregnant. Eight approaches to the estimation of

w

infertility prevalence were considered. The response rate was 61.05%. Among 30 to
a te

49 year old Spanish women, 1.26% had a clinical diagnosis of infertility, 17.58% did

not achieve pregnancy in 1 year (1-year infertility), 8.22% perceived difficulties in

procreation (subjective infertility), 6.12% had not succeeded in having biological

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children (primary infertility) and 11.33% had not been able to have another biological

d it
child (secondary infertility).15

A study was conducted to assess the Prevalence of primary and secondary

nE
infertility from tertiary center in eastern Saudi Arabia. It was a retrospective study and

conducted on all the patients attending the infertility clinics at King Fahd Hospital of

the University in Alkhobar, Saudi Arabia. The data were collected from the

y.Fi
Quadramed Filing system and medical charts. The data from these 457 patients were

aPrD
analyzed. The overall prevalence of infertility was 18.93%. Three hundred sixty-eight

(80.5%) presented with primary infertility.16

A study was conducted on the epidemiological and etiological aspects of

tiebrr
infertility in Yazd province of Iran. The objective of the study was to assess the

prevalence of both primary and secondary infertility and demographic characteristics

acsl

of it. They studied 5200 married defined couples in 260 randomized clusters. These

couples were interviewed based on using a structured questionnaire. Among these

.cn

couples, 277 cases of infertility were encountered and the overall prevalence of
nwM

infertility was 5.52% . In total 170 couples (3.48%) had primary and 107 (2.04%) had

secondary infertility. The prevalence of infertility in rural and urban areas was 5.3%

and 6.8% respectively. The study concluded that lower total prevalence of infertility

in our people compared to the other countries. Furthermore, there was significant
d wi

difference in infertility prevalence between geographic parts of the province. Female

w

factors and among them ovarian disorders were the main cause of infertility in central
a te

part of Iran.17
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Stress and effect of relaxation technique to reduce the stress among couples with

d it
infertility

A case control study was conducted on Depression, anxiety and stress among

nE
female patients of infertility. The purpose of this study was to find out prevalence of

depression, anxiety and stress among females suffering from infertility. One hundred

females suffering from infertility as study subjects and 100 females accompanying

y.Fi
them as controls were randomly selected from infertility clinic at Arif Memorial

aPrD
Teaching Hospital, Lahore, Pakistan. Validated Urdu version of Depression, anxiety,

stress scale (DASS) was used for assessment of depression, anxiety and stress scores.

Results show that 79% of the patients with infertility had some degree of depression
tiebrr
and 49% of the study group subjects had moderate to severe degree of depression and

10% had extremely severe depression. This was higher compared to control group

where only 9% had mild depression and no subjects were found having higher
acsl

degrees of depression. There was high prevalence of depression, anxiety and stress
.cn

among females suffering from infertility compared to females in control group

nwM

(p<0.05). The investigator concluded that depression, anxiety and stress are very

common among females suffering from infertility.18

A study was conducted to characterize the distribution of stress levels that may

be experienced by married couples suffering from infertility at the Yasmin IVF

d wi

Clinic – Dr. Cipto Mangunkusumo General Hospital Jakarta. Sixty-three infertile

w

patients who came to Yasmin IVF Clinic were given a self-assessment questionnaire
a te

(self-reporting questionnaire = SRQ 20) to assess the presence of the stress. Out of the

of the 63 infertile patients in this study, 14 (22.3%) were experiencing stress, whereas

49 (77.7%) were not showing symptoms of stress. The duration of infertility showed a
re

significant correlation with the level of stress experienced by the patients (p < 0.05). It

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was concluded that Twenty-two percent of infertile patients in the Yasmin IVF Clinic

d it
experienced stress mainly associated with the duration of their infertility.19

A study was conducted to assess the Psychological predictor variables of

nE
emotional maladjustment in infertility. The objective of this study is to find out

emotional maladjustment in infertile people. A sample of 101 participants with an

infertility diagnosis (51 males and 50 females) were assessed. The resulting model

y.Fi
explained 71.1% of total variance, resulting in gender as an important moderating

aPrD
variable and trait anxiety, state anxiety, negative affect, and low interpersonal

resources as strong predictors of emotional maladjustment in infertile people. These

results provide guidance in selecting the most appropriate psychological support and
tiebrr
treatment for the emotional adjustment of infertile women and men.20

A study was conducted for defining the perceived stress among infertile
acsl

couples and its social-individual predictors among infertile Couples Referring to

Infertility Center of Alzahra Hospital in Tabriz. This study is a sectional one which
.cn

was done on 322 infertile couples referring to the infertility center at Alzahra Hospital
nwM

in Tabriz. Sampling method was available. The gathering data instruments included

social-individual particulars questionnaire and perceived stress scale (PSS)

questionnaire. The findings of the research showed that mean (standard deviation) of

perceived stress among women was 27.4 (6.0) and 25.9 (5.3) among men out of 0-56
d wi

grade range and there was statistically significant difference between men and women
w

due to perceived stress (P<0.001). The results of this research showed higher
a te

perceived stress among women compared to men; therefore it is necessary to provide

approaches for reducing the perceived stress focusing on its predictive variables for

recovering the couple’s mental status.21

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A study conducted to examine the level of infertility stress, marital

d it
adjustment, depression and quality of life in infertile couples and assess the actor and

partner effects in these areas using the actor-partner interdependence model. This

cross-sectional study was conducted on 121 infertile couples. Data were collected using

nE
the following questionnaires: the Fertility Quality of Life, Fertility Problem Inventory,

Revised Dyadic Adjustment Scale, and Beck Depression Inventory. There was a

y.Fi
gender difference in infertility stress, depression and quality of life. Infertility

aPrD
stress had actor and partner effects on the quality of life. Marital adjustment had an

actor effect on the quality of life for the wives. Depression had actor and partner

effects on quality of life for the wives, but only an actor effect for the husbands.

Researchers concluded that the study found that there were actor and partner effects
tiebrr
of infertility stress, marital adjustment and depression on the quality of life in infertile

couples.22
acsl

A study was conducted at Iran to assess the effect of relaxation techniques to

.cn

ease the stress in infertile women. This was a semi-experimental and clinical trial
nwM

study. Participants randomly divided into two groups. At the beginning, the stress

scores were assessed in both groups using Newton's infertility stress questionnaire.

Independent t-test showed that the total stress score did not have a significant

difference in groups before the intervention (p > 0.05) whereas independent t-test
d wi

indicated a significant difference in stress scores between the two groups after the
w

intervention (p < 0.05). Stress score was higher in the control group in comparison
a te

with the intervention group. Researcher conclude that relaxation technique can reduce

the stress score in infertile women as a complementary and alternative medicine

method.23
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A study was conducted on impact of a Structured Yoga Program on Anxiety in

d it
Infertility Patients. The objective of this study is to assess whether a structured yoga

intervention can decrease anxiety levels measured by the Spielberger State Trait

Anxiety Inventory (STAI) in patients with infertility. A prospective feasibility study

nE
was conducted among one hundred eleven participants undergoing infertility

treatment. All subjects self-selected to participate in the control group or the yoga

y.Fi
group and completed the Spielberger StateTrait Anxiety Inventory at baseline and at a

aPrD
six week follow up. It found that the mean state and trait anxiety scores were

significantly lower in the yoga group versus the control group (p<0.014 and p<0.001

respectively). The study concluded that mean state and trait anxiety levels were

significantly lower after a structured six week yoga intervention in patients with
tiebrr
infertility. These results suggest that yoga may have a beneficial role in reducing

anxiety in patients with infertility. Ideally this may translate to decreased drop out and
acsl

increased ability for patients to be successful.24

.cn

A study conducted to evaluate the effects of stress management training on

nwM

perceived stress in infertile women undergoing IVF in infertility treatment center in

Shiraz. This was a randomized clinical trial with pretest - posttest on infertile women

undergoing IVF fertility center in Shiraz. 70 infertile women were chosen with

available sampling inclusion criteria and randomly divided into two groups test (35
d wi

women) and control (35 women). For the test group ten sessions and each session for
w

1.5 hour of stress management training were provided and the control group did not
a te

receive any mental health services. Both groups completed the perceived stress

infertility questionnaire before and after the intervention. After data collection the

statistical software SPSS (version 16) was used and the tests of covariance,
re

multivariate and univariate on (p<0.05) level were analyzed. Data analysis showed

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that between two groups of test and control, there is a significant difference for

d it
reduction of stress and stress management training has impact on the improvement of

perceived stress in infertile women but they will not improve the outcome of

fertilization.25

nE
Self help abilities and effect of intervention to strengthen the self help abilities

among couples with infertility

y.Fi
aPrD
Self help abilities are the ability to try new things, gaining confidence in new

situation and build up of self esteem and independence. Here the couples should be

adequately prepared to undergo the investigations and treatment with confidence.

Proper instructions and adequate education strengthen the self help abilities.
tiebrr
a. Knowledge regarding infertility among couples with infertility

A study conducted to assess the Knowledge about infertility risk factors,

acsl

fertility myths and illusory benefits of healthy habits in young people. This study
.cn

assessed fertility knowledge more broadly in young people and investigated three
nwM

areas of knowledge, namely risk factors associated with female infertility (e.g.

smoking), beliefs in false fertility myths (e.g. benefits of rural living) and beliefs in

the illusory benefits of healthy habits (e.g. exercising regularly) on female fertility.

The sample consisted of 110 female and 39 male postgraduate and undergraduate
d wi

university students (average age 24.01, SD 5 7.81). Knowledge scores were based on
w

a simple task requiring the participants to estimate the effect a factor would have on a
a te

group of 100 women trying to get pregnant. The study results showed a significant

main effect of factor (p < 0.001) and post hoc tests revealed that young people were

significantly better at correctly identifying the effects of risks compared with null
re

effects of healthy habits (p < 0.001) or fertility myths (p < 0.001). It was concluded

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that young people are aware that the negative lifestyle factors reduce fertility but

d it
falsely believe in fertility myths and the benefits of healthy habits.26

A descriptive study conducted to assess the knowledge on infertility among

nE
women attending gynaec OPD, SGRD hospital, Vallah, Sri Amritsar, Punjab. 100

infertile women were selected by using convenience sampling technique. Self

structured knowledge questionnaire was used to assess the knowledge on infertility

y.Fi
among women. Present study revealed that the majority of women 79(79%) had

aPrD
average knowledge on infertility, they scored 9.00-17.00. 15(15%) of them had poor

knowledge, they scored < 8.00 and only 6(6%) of them had good knowledge, they

scored 18.00-26.00. The level of knowledge showed significant association (p<0.01)

tiebrr
with educational status, occupational status, monthly income, age at marriage while

rest of the variables showed non significant association.27

acsl

A study conducted on Reproductive knowledge and patient education needs

among Indonesian women infertility patients attending three fertility clinics. This
.cn

cross-sectional survey was conducted among 212 female Indonesian infertility

nwM

patients. Infertility consultants were cited as the most useful source of information by

65% of respondents, 94% understood that infertility results from male and female

factors, 84% could distinguish between infertility and sterility, and 70% could

identify their fertility window. However, demand for further knowledge of

d wi

reproduction and infertility was expressed by 87%. Patient’s knowledge of the causes
w

and treatment of infertility was extremely poor. Two key causes of infertility,
a te

advanced age and untreated sexually transmissible infections, were not named. Only

19% of patients had received written information. The study revealed the need for

expanded infertility patient education among women patients accessing fertility care
re

in Indonesian clinics.28

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A study conducted to examine fertility knowledge and childbearing intentions

d it
held by Portuguese people and their use and perceived usefulness of information

sources on fertility. Participants were recruited using a random-route domiciliary

approach. A total of 2404 individuals aged 18–45 were asked to complete a structured

nE
questionnaire evaluating socio-demographic characteristics, childbearing intentions,

fertility knowledge and information-gathering sources regarding fertility. In total,

y.Fi
95.5% of the participants indicated the desire to have children in the future and 61.7%

aPrD
reported that having children would contribute to life satisfaction. Participant’s

knowledge regarding fertility was poor. Women, the participants who were older than

25, the participants with longer education and the participants with higher income

exhibited the greatest levels of knowledge of fertility, although this knowledge was
tiebrr
only slightly enhanced in these subgroups. Although Portuguese men and women

reported the desire to have children in the future, their knowledge regarding fertility
acsl

and infertility risk was poor. In addition, participants used more general sources of

information, such as website, but not specialized sources, such as their doctors.29
.cn
nwM

A study was conducted in North Nigeria to assess the knowledge on infertility

among infertile women. The objective was to evaluate the knowledge, perception and

treatment seeking behaviour of infertile women in Bauchi, northern Nigeria. Four

hundred and six infertile women were surveyed in two hospitals using a structured
d wi

questionnaire. The ages of the respondents ranged from 19 to 42 years with a mean
w

age of 30.5 years (SD: ± 5 years). Many (81%) of the respondents had poor
a te

knowledge of risk factors for infertility and over 80% believed in supernatural causes.

The women who had secondary level of education or higher (4.78, CI: 2.35-9.71,

p < 0.001) and those who were employed (3.08, CI: 1.44-6.58, p = 0.04) had
re

significantly better knowledge compared to those who had lower level of education

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and were unemployed. Almost three-quarters (n = 299, 73.6%) believed that women

d it
bear the blame for infertility and 40.4% see it as a reason for the man to take another

wife. Half of the women felt the woman alone should seek for treatment and only

28% reported hospital as their site of initial treatment. Most (n = 370, 91%) felt

nE
infertility should be given priority in public hospitals and 308 (76%) believed the

government should pay for infertility services as done for other reproductive health

y.Fi
(RH) services. Researchers concluded that there is low level of knowledge of

aPrD
infertility among infertile women in Bauchi and women bear the blame for

infertility.30

b. Interpersonal relationship, sexual health and social interaction among couples

tiebrr
with infertility.

A study conducted to assess marital relationship in the context of infertility,

acsl

using data from infertile individuals or both couples. A literature search was

undertaken using multiple databases (Medline, PsycInfo and Scopus) to identify and
.cn

synthesize all relevant literature. All studies in the systematic review were confirmed
nwM

using specific inclusion criteria; the methodological quality of these studies were

examined according to a checklist. Of the potential 794 articles, 18 studies were

included in the final analysis, of which 6 were graded as high quality and 12 as

moderate. The results indicated male factor infertility did not have a negative marital
d wi

impact. In addition, infertile male participants expressed higher marital satisfaction

w

than their wives. Infertile females had significantly less stable marital relationship
a te

compared to fertile females, which was associated with their socio-demographics and

treatment experience.10
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or
A cross sectional study conducted with the objective to assess Quality of Life

d it
(QoL) of infertile Chinese women and determine the specific factors adversely

affecting QoL for improving the care and treatment compliance of infertile women. It

was cross-sectional study on a randomized, demographically matched, controlled

nE
population of infertile married Chinese women to determine their demographic,

menstrual, family stress, and infertility characteristics and then applied the World

y.Fi
Health Organization QoL Instrument (WHO QoL-100) to determine which factors

aPrD
would be associated with significant QoL differences between infertile women and

their demographically matched fertile controls. The study results showed that Infertile

women showed lower QoL scores in the facets of spirituality/religion/personal beliefs,

self-esteem, financial resources, and accessibility to and quality of health and social
tiebrr
care, as well as increased pain and discomfort, while also experiencing positive QoL

adjustments in terms of mobility, daily living activities, work capacity, sexual

acsl

activity, freedom, physical safety, security, and transport. It concluded that married

infertile Chinese women had significantly lower overall and comprehensive QoL
.cn

scores, as well as higher anxiety scores, compared with fertile controls.31

nwM

A study was conducted to determine the factors affecting the psychosocial

problems of infertile Turkish women and to identify their coping strategies. The study

employed a descriptive qualitative approach and conducted in-depth interviews to

d wi

examine the psychosocial problems faced by infertile Turkish women. The

w

participants were selected in two stages. In the first stage, 118 women diagnosed with
a te

primary infertility completed a personal information form and the Fertility Problem

Inventory (FPI). In the second stage, in-depth interviews (lasting 45 & 90 minutes)

were conducted with 24 (age 20 to 41 years) infertile women randomly selected from
re

the groups formed according to their FPI global stress levels determined in Stage 1.

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Content analysis was used to examine the qualitative data. The results comprised nine

d it
main themes regarding the psychosocial problems encountered by women and the

methods used to overcome these problems. These included the meaning attributed to

being childless, negative self-concept, perceived social pressure, perceived social

nE
support, psychological symptoms, social withdrawal and isolation, spiritual coping,

cherishing hope/restructuring life, and adopting traditional methods. Social pressure

y.Fi
and stigma were common. Infertility was found to negatively affect the participant’s

aPrD
self-perception and view of life. The women used spiritual methods for overcoming

stress and avoiding society, as well as traditional fertility remedies. It was concluded

that infertile women suffer from various psychosocial problems because of infertility

and they adopt emotion-focused coping methods.32

tiebrr
A case control study was conducted at G.R. Doshi and K.M. Mehta Institute of

Kidney Diseases and Research Centre (IKDRC) - Dr. H.L. Trivedi Institute of
acsl

Transplantation Sciences (ITS), India to find the incidence and prevalence of female
.cn

sexual dysfunction in infertile females and its correlation with infertility. Total of 500
nwM

patients in the age group of 24–42 years participated in the prospective study. In the

study 170 (63.67%) patients in the infertile group (n = 267) had female sexual

dysfunction (FSD) as compared to108 (46.35%) in the fertile group (n = 233), which

is statistically significant (p< 0.0001). Most common dysfunction observed was

d wi

arousal (70%) in infertile patients. Common dysfunctions observed in fertile females

w

were desire (40%) and orgasm (40%). FSD was significantly higher in infertile
a te

females of the 31–37 years age group (p< 0.002), while more common in fertile

females of >42 years of age (p <0.0001). Higher female sexual dysfunction was

observed in illiterate infertile females (p = 0.039). Among the pathological factors

re

endometriosis was the statistically significant factor associated with female sexual

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dysfunction and infertility (p < 0.0001). No significant correlation in duration of

d it
infertility or type of infertility was observed with female sexual dysfunction. Female

sexual dysfunction as the cause or the effect should be ascertained in infertility.33

nE
A study was conducted to assess the sexual impact of infertility in women

undergoing fertility treatment. This study is a cross-sectional analysis of women in

infertile couples seeking treatment at academic or private infertility clinics. In total,

y.Fi
809 women met the inclusion criteria, of whom 437 (54%) agreed to participate and

aPrD
382 completed the sexual impact items. Most of the infertility was female factor only

(58.8%), whereas 30.4% of infertility was a combination of male and female factors,

7.3% was male factor only and 3.5% was unexplained infertility. In bivariate and
tiebrr
multivariate analyses, women who perceived they had female factor only infertility

reported greater sexual impact compared with woman with male factor infertility

(p< 0.01). Respondents who were younger than 40 years experienced a significantly
acsl

higher sexual impact than respondents older than 40 years (p < 0.01). When stratified
.cn

by primary and secondary infertility, respondents with primary infertility overall

nwM

reported higher sexual impact scores. In women seeking fertility treatment, younger

age and female factor infertility were associated with increased sexual impact and

thus these women are potentially at higher risk of sexual dysfunction.34

The literature reveals that 8-10% of couples experience some form of

d wi

infertility problem. On a worldwide scale 50-80 million people suffer from infertility.
w

The literature also reveals that prevalence of current infertility has increased. Thus
a te

infertility can be considered as an important helath issue with wider implications.12-17

The couples with infertility attending the clinic have psychological distress and need

for psychological improvement. It also reveals that relaxation training and

re

interventions helps to reduce the stress among couples with infertility.18-25

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Most of the couples attending the infertility clinic lack knowledge on different aspects

d it
of infertility and its management. They also have problems in social interaction and

relationship with partner. Appropriate education and counselling improves the self

help abilities.26-34 The literature review insists to conduct a follow up survivorship

nE
study to assess the stress and self help abilities of couples seeking treatment for

infertility.

y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
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CHAPTER 3

d it
METHODOLOGY

Research approach

nE
Research design

Variables

y.Fi
aPrD
Schematic representation of the study

Setting of the study

Population
tiebrr
Sample and sampling technique

Inclusion criteria
acsl

Exclusion criteria
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nwM

Tool

Development of tool

Description of tool
d wi

Content validity
w

Reliability of tool
a te

Pilot study

Data collection process

Plan for data analysis

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CHAPTER 3

d it
RESEARCH METHODOLOGY

This chapter deals with the research methodology adopted for the present

nE
study, which includes research approach, design, setting of the study, sample and

sampling technique, development of research tool, pilot study, data collection process,

y.Fi
and plan for data analysis.

aPrD
Research approach

The present study was aimed at evaluating the effect of multifaceted

intervention on stress and self help abilities among couples seeking treatment for
tiebrr
infertility. In view of research problem and objectives this study used an

experimental approach. The group was provided with multifaceted intervention.

acsl

Research design
.cn

For the present study, pre experimental – one group pre test-post test design was
nwM

adopted since data collection is done only from a single group before and after

multifaceted intervention. There is no randomized or control group. The design is

abbreviated as

O1 X O2
wd wi

O1 – Observation of the stress and self help abilities among couples seeking treatment

for infertility before multifaceted intervention

a te

X – Multifaceted intervention – Include planned teaching on infertility, causes, risk

factors, life style modifications, preparation for fertility studies, follow up and
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treatment, relaxation technique and personal guidance.

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O2 - Observation of the stress and self help abilities among couples seeking treatment

d it
for infertility after 15-20 days of multifaceted intervention

Variables

nE
Multifaceted intervention is the independent variable

Stress and self help abilities among couples seeking treatment for infertility are the

y.Fi
dependant variables

aPrD
Extraneous variables include age, religion, education, occupation, type of family,

income, place of residence, BMI, duration of living together, history of fertility

investigation, duration of treatment and history of ART.

tiebrr
Schematic representation of the study is presented in figure 2
acsl
.cn
nwM
wd wi
a te
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r
33

to
D in
di
Variables

E
Population

.
and Tools EXTRANEOUS

r Pary
Couples seeking VARIABLES

F
treatment for Sociopersonal data -
Independant Outcome
infertility Questionnaire Age
variable
Setting Stress Religion
Reduction in
Multifaceted
 stress

tebr
Infertility Unit, Perceived stress intervention Education
Institute of Maternal assessed by PSS  PSS
 Planned Occupation
and Child Health,  Consequence of  Rating scale
Kozhikode teaching –
fertility problem Type of family

csli
On infertility,
assessed by causes, risk
Sample Income
rating scale factors, life
Strengthening the

cna
Couples with style modifi- Place of residence
Self help abilities cations, self help abilities
infertility attending
w. M preparation BMI
infertility unit  Knowledge  Questionnaire
for fertility
assessed by studies,  Rating scale Duration of living together
Sampling
questionnaire follow up and
ww i n
procedure
 IPR, social treatment History of fertility
Consecutive interaction and  Relaxation investigation
technique
ed

sampling social health

assessed by  Personal Duration of treatment
Sample size guidance
rating scale History of ART
at

40 couples
re

33
Figure 2 : Schematic representation of the study
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Setting of the study

d it
The study was conducted in Infertility unit of Institute of Maternal and Child

Health, Kozhikode. This institute is the biggest state government owned tertiary care

nE
reffered centre with 1050 beds, which offers maternal and child health to people from

northern districts of Kerala. The infertility unit renders diagnostic and treatment

services since 2013. The average daily census of Infertility unit is more than 25. This

y.Fi
institute was selected for study because of the easy availability of the sample and easy

aPrD
access to the institution.

Population
tiebrr
In this study population consists of couples seeking treatment for infertility.

Sample and sampling technique

acsl

In the present study sample consists of 40 couples seeking treatment for

infertility, attending infertility unit, Institute of Maternal and Child Health,

.cn

Kozhikode.
nwM

Sample size is calculated by

= (Z+Z)2 * SD2 Z = 1.96 ; Z = 0.84 ; SD=34 ; d=15

d2
d wi

= (1.96+0.84)2 * 342 = 40
w

152
a te

Study referred Mahboubeh Valiani et al. The effect of relaxation techniques to ease

the stress in infertile women.23

Participants were selected by consecutive sampling technique based on inclusion

re

criteria

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Inclusion criteria

d it
Couples with infertility

 willing to participate in the study

nE
 able to read Malayalam/English

Exclusion criteria

y.Fi
aPrD
 Any of the partner with mental illness

Tool

Development of the tool

tiebrr
The tool was developed based on the research problem. Review of literature

was done and suggestions of experts were utilized. The tool was prepared on the basis
acsl

of objectives of the study. The investigators personal and clinical experience along

with discussion with experts in the nursing and medical field helped in the
.cn

development of the tool. The following tools were used to collect the data.
nwM

Tool 1 – Questionnaire to assess self help abilities among couples with infertility

Section A - Socio-personal data

d wi

Section B - Knowledge on infertility, causes, risk factors and life style modifications,
w

preparedness for fertility studies, treatment and follow up

a te

Tool 2 – Rating scale to assess interpersonal relationship with partner, sexual health

and social interaction.

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Tool 3 – Tool to assess stress among couples with infertility - Perceived Stress Scale

d it
(PSS)

Tool 4 – Rating scale to assess the consequences of the fertility problem among

nE
couples with infertility

Description of the tool

y.Fi
The following tools were used to collect the data for evaluating the effect of

aPrD
multifaceted intervention on stress and self help abilities among couples seeking

treatment for infertility.

Tool 1 - Questionnaire to assess self help abilities among couples with infertility. The
tiebrr
tool contains 2 sections. Section A is to assess the sociopersonal and clinical data of

couples seeking treatment for infertility. Section B is the questionnaire to assess the

knowledge of participants on infertility, causes, risk factors and life style

acsl

modifications, preparedness for fertility studies, treatment and follow up. It contains
.cn

20 questions. The maximum score of the tool is 20 and minimum score is 0. Based on
nwM

the score the knowledge on infertility is arbitrarily classified into

Poor (0-9), Average (10-15) and Good (16-20)

Tool 2 - Rating scale to assess interpersonal relationship with partner, sexual health
d wi

and social interaction. The tool contains 15 items. The items are rated under 3 points
w

0 – Disagree , 1 – Uncertain, 2 –Agree

a te

Distribution of items is as follows

1. Interpersonal relationship with partner and sexual health – 11 items

2. Social interaction – 4 items

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Based on the score the interaction is arbitrarily classified into

d it
Poor (16-30), Average (9-15) and Good (0-8).

Tool 3 – Perceived stress scale (PSS) is to assess the stress among couples seeking

nE
treatment for infertility. PSS is a standardized tool to assess the stress level. It

contains 10 items to assess the feelings and thoughts during last 2-3 weeks. It is a 5

point rating scale and the rating is as follows

y.Fi
aPrD
0 - never 1 - almost never 2 - sometimes 3 - fairly often 4 - very often

The maximum stress score is 40 and the minimum is 0. Based on the stress score the

stress is categorized as follows

tiebrr
No stress (0-7), Low stress (8-11), Average stress (12-15), High stress (16-20) and

Severe stress (21-40)

acsl

Tool 4 – Rating scale to assess the consequence of the fertility problem among the

participants. Based on the score the stress is graded as

.cn
nwM

No stress (49 – 59), Low stress (37 – 48), Average stress (25 – 36), High stress

(12 – 24) and Severe stress (0 – 11).

Content validity
d wi

After receiving preliminary corrections from guide, tools along with the
w

teaching plan was given to 13 experts from different fields to ensure the content
a te

validity. Among them, 9 experts from obstetric and gynaecologic nursing specialty,

two experts from medical field and 2 experts of clinical psychologist. The experts

were requested to give their opinions and suggestions regarding the relevance,

adequacy and appropriateness of the tool, lesson plan and the content of audio CD.
re

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or
Some modifications were done in the tool based on the suggestions obtained from the

d it
experts.

Reliability of the tool

nE
The reliability of an instrument is the degree of consistency with which it

measures the attributes it is supposed to measure. Reliability of the tools were tested

using Chronbach’s alpha. The reliability coefficient was found to be 0.60 for the

y.Fi
aPrD
questionnaire to assess the knowledge, 0.78 for the rating scale to assess the assess

interpersonal relationship with partner, sexual health and social interaction, 0.60 for

perceived stress scale and 0.88 for rating scale to assess the consequences of the

fertility problem among couples with infertility. Hence the tools were found reliable
tiebrr
for the study.

Pretesting
acsl

Malayalam version of the tool was administered to 2 couples similar to study

.cn

population, conducted at infertility unit of institute of maternal and child health,

nwM

Kozhikode on 16/01/2018. The problems were discussed with guide and corrections

were made and finalized the tool.

Pilot study
d wi

After getting permission, the pilot study was conducted from 17/01/2018 to
w

03/02/2018. After explaining the purpose of the study and obtaining willingness to

participate data were collected before and after multifaceted intervention from 4
a te

couples seeking treatment from infertility unit, IMCH, Kozhikode. Data were

tabulated and analysed using descriptive statistics. Pilot study revealed the
re

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or
appropriateness of the methodology selected and clarity of the tool. The collected data

d it
were amenable to statistical analysis and the study was found feasible.

Data collection process

nE
After getting approval from Institutional Ethics Committee Government

College of nursing, Kozhikode and approval from KUHS, permission for data

collection was obtained from HOD, Department of Obstetrics and Gynaecology,

y.Fi
aPrD
Institute of Maternal and Child Health, Kozhikode. The data collected from

40 couples from 22/02/2018 to 23/3/2018.

The investigator visited the infertility unit on all clinic days from Monday to
tiebrr
Saturday. Identified couples based on inclusion criteria, introduces herself and

established rapport with them. After initial interaction, the purpose of the study was

explained. The willingness to participate the study ensured and informed consent was
acsl

obtained. Confidentiality of the data was assured to all participants. On an average of

3-5 couples selected every day for data collection using consecutive sampling
.cn

technique. The pretest was done from 22/02/18 to 06/03/18 and post test started on
nwM

08/03/18 and completed on 23/03/18.

Tool was administered on each subject individually and data were collected. .

Tool for assessing self help abilities and stress were given first. It was taken 5 minutes
d wi

for socio personal data and 15 minutes for knowledge questionnaire and 10 minutes
w

for rating scale. Then they filled the tool for stress within 15 minutes. After that
a te

intervention is given through sessions. A break was given in between teaching session

and relaxation training.

Intervention schedule as follows

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Session 1 – Teaching on causes, fertility studies, preparation, follow up and treatment

d it
is given with the help of power point slides.

Session 2 – Taught relaxation technique through demonstration. And Audio was given

nE
to the participants and proper instructions given. A schedule is also provided to ensure

the practice of relaxation technique.

Session 3 – Personal guidance session – in this clarified the doubts of participants.

y.Fi
aPrD
A schedule to assess the practice of relaxation technique was given. The daily practice

of relaxation technique from their home is ensured and follow up is done through

phone calls. Post test was done using the same tool after 15-20 days.
tiebrr
Plan for data analysis

The following plan of Descriptive and inferential statistics using statistical

acsl

software was formulated

 Socio personal data – frequency percentage.

.cn
nwM

 Stress, self help abilities – frequency percentage, mean and standard deviation.

 t test to assess the significance of difference in stress and self help abilities

before and after multifaceted intervention.

d wi

 Chi-square test to find out association between stress and selected variables.
w

 Chi-square test to find out association between self help abilities and selected
a te

variables.

 Pearson correlation to find the relationship between stress and self help

abilities
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CHAPTER 4

d it
ANALYSIS AND INTERPRETATION

Section 1 :Socio personal variables of participants

nE
Section 2 :Stress among participants before and after multifaceted

intervention

y.Fi
aPrD
Section 3 :Self help abilities among participants before and after

multifaceted intervention

Section 4 :Effect of multifaceted intervention on stress and self help

tiebrr
abilities among participants

Section 5 :Association between stress among participants with

selected variables
acsl

Section 6 :Association between self help abilities among participants

.cn

with selected variables

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Section 7 :Correlation between stress and self help abilities among

participants
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CHAPTER 4

d it
ANALYSIS AND INTERPRETATION

nE
The data from 40 couples were collected. It was organized, tabulated, and

subjected to descriptive and inferential statistical analysis with the help of 18th version

of the SPSS software. The findings of the study were presented under the following

y.Fi
headings.

aPrD
Section 1 :Sociopersonal variables of participants

Section 2 :Stress among participants before and after multifaceted

tiebrr
intervention

Section 3 :Self help abilities among participants before and after

multifaceted intervention
acsl

Section 4 :Effect of multifaceted intervention on stress and self help

.cn

abilities among participants

nwM

Section 5 :Association between stress among participants with selected

variables

Section 6 :Association between self help abilities among participants with

d wi

selected variables
w

Section 7 :Correlation between stress and self help abilities among

a te

participants
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Section 1 :Sociopersonal variables of participants

d it
This section deals with socio-personal characteristics of participants. Socio-

personal variables includes age, religion, educational status, occupation, type of

family, income, place of residence, BMI, duration of living together, history of fertility

nE
investigations, duration of treatment and history of ART. The findings are presented in

tables 2-7 and figures 3-6.

y.Fi
Table 2

aPrD
Frequency distribution and percentage of participants based on age

(n=80)
tiebrr
Age (in years) Husband(n=40) Wife(n=40)

f (%) f (%)
acsl

18-25 0(0) 8(20)

.cn

26-35 17(42.5) 27(67.5)

nwM

36-45 23(57.5) 5(12.5)

Table 2 shows that 42.5% of husbands belong to the age group of 26-35 years, 57.5%

husbands belong to the age group of 36-45 years, 8% of wives belong to the age
d wi

group of 18-25 years, 67.5% of wives belong to 26-35 years and 12.5% wives belong
w

to 36-45 years.
a te
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Distribution of participants based on the religion shown in figure 3

d it
80

nE
70

60
Percentage

50

y.Fi
40 Husband
Wife

aPrD
30

20

10

0
Hindu Muslim Christian
tiebrr Religion

Figure 3: Distribution of participants based on the religion

acsl

Figure 3 shows that 72.5% participants were Hindus, 22.5% participants were

Muslims and 5% were christians.

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nwM
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Table 3

d it
Frequency distribution and percentage of participants based on educational
status and occupation (n=80)

nE
Sample characterestics Husband(n=40) Wife(n=40)

f (%) f (%)

y.Fi
Educational status

aPrD
Primary 6(15) 2(5)

Secondary 18(45) 10(25)

Higher secondary 10(25) 11(27.5)

tiebrr
Degree and above 6(15) 17(42.5)

Professional/technical 0(0) 0(0)

acsl

Occupation

Unemployed 1(2.5) 28(70)

.cn

Manual labor 24(60) 1(2.5)

nwM

Private sector 13(32.5) 10(25)

Government sector 2(5) 1(2.5)

Table 3 shows that 45% of husbands had secondary education and 25% of husbands
d wi

had higher secondary education, 42.5% wives had degree/above education and 27.5%
w

wives had higher secondary education. It also shows that 60% husbands had manual
a te

labour, 32.5% husbands working in private sector, 70% wives were unemployed and

25% wives working in private sector.

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Table 4

d it
Frequency distribution and percentage of participants based on type of family

and place of residence and economic status (n=40)

nE
Sample characterestics Couples

f (%)

y.Fi
aPrD
Type of family

Nuclear family 38(47.5)

Joint family 42(52.5)

tiebrr
Extended family 0(0)

Place of residence
acsl

64(80)
Rural
.cn

Urban 16(20)
nwM

Economic status

APL 26(32.5)
d wi

BPL 54(67.5)
w

Table 4 shows that 52.5% participants belong to joint family and 47.5% belong to
a te

nuclear family. It also shows that 80% of participants belong to rural area, 67.5% of

participants belong to BPL category and 32.5% belong to APL category.

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Table 5

d it
Frequency distribution and percentage of participants based on BMI (n=80)

BMI(kg/m2) Husband(n=40) Wife(n=40)

nE
f (%) f (%)

<18.5 0(0) 1(2.5)

y.Fi
18.6-24.99 22(55) 31(77.5)

aPrD
25-29.9 14(35) 7(17.5)

>30 4(10) 1(2.5)

tiebrr
Table 5 shows that 55% of husbands and 77.5% of wives belong to 18.6-24.99, 35%

of husbands and 17.5% of wives belong to 25-29.9, 10% of husbands and 2.5% of
acsl

wives belong to >30 and 2.5 % of wives belong to <18.5.

Table 6
.cn
nwM

Frequency distribution and percentage of participants based on history of fertility

investigation (n=80)

History of fertility investigation Husband(n=40) Wife(n=40)

d wi

f (%) f (%)
w

Yes 25(62.5) 25(62.5)

a te

No 15(37.5) 15(37.5)

Table 6 shows that 62.5% of participants had history of fertility investigation and
re

37.55 of participants had no history of fertility investigation.

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Distribution of participants based on the duration of living together shown in figure 4

d it
Duration of living together

nE
20%

y.Fi
1-2 years

aPrD
50% 3-5 years
Above 5 year

30%
tiebrr
acsl

Figure 4 : Distribution of participants based on the duration of living together

.cn

Figure 4 shows that 50% of participants had above 5 years of duration of living
nwM

together, 30% belong to 3-5 years and 20% belong to 1-2 years.
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Table 7

d it
Frequency distribution and percentage of participants based on duration of

treatment for infertility and history of Assisted reproductive technology (ART)

nE
(n=40)

Sample characterestics Couples

y.Fi
aPrD
f (%)

Duration of treatment for infertility in yrs

Below 1 20(25)
tiebrr
1-2 10(12.5)

3-5
24(30)
acsl

Above 5
26(32.5)
.cn
nwM

History of ART

Yes 12(15)

No 68(85)
d wi

Table 7 shows that 32.5% of participants had above 5 years of duration of treatment
w

for infertility, 30% of participants belong to 3-5 years, 12.5% belong to 1-2 years 25%
a te

belong to below 1 year. It also shows that 15% of participants had history of ART and

85% of participants had no history of ART.

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Section 2 :Stress among participants before and after multifaceted

d it
intervention

This section deals with assessment of stress among participants before and

nE
after multifaceted intervention. Findings are presented in 2 sections.

Section A – This section deals with findings based on the score obtained in the PSS.

Stress is graded based on score as

y.Fi
aPrD
 No stress - 0-7

 Low stress - 8-11

 Average stress - 12-15

tiebrr
 High stress - 16-20

 Severe stress - 21-40

Findings are presented in table 8 and 9

acsl
.cn
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Table 8

d it
Frequency distribution and percentage of participants based on stress scores

(n=80)

nE
Husband(n=40) Wife(n=40)

y.Fi
Stress Score Before After Before After

aPrD
range intervene intervene intervene intervene
tion tion tion tion

f(%) f(%) f(%) f(%)

tiebrr
No stress 0-7 0(0) 1(2.5) 0(0) 0(0)

Low stress 8-11 3(7.5) 7(17.5) 3(7.5) 4(10)

Average stress 12-15 16(40) 15(37.5) 5(12.5) 8(20)

acsl

High stress 16-20 14(35) 16(40) 17(42.5) 21(52.5)

Severe stress 21-40 7(17.5) 1(2.5) 15(37.5) 7(17.5)

.cn
nwM

Table 8 shows that 17.5% of husbands and 37.5% of wives had severe stress, 35% of

husbands and 42.5% of wives had high stress and 40% of husbands and 12.5 % of

wives had average stress before intervention. After intervention 2.5 % of husbands
d wi

and 17.5% of wives had severe stress, 40% of husbands and 52.5% of wives had high
w

stress and 37.5% of husbands and 20% of wives had average stress
a te
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Table 9

d it
Minimum score, maximum score, mean and SD of stress score of participants

before and after multifaceted intervention (n=80)

nE
Husband (n=40) Wife (n=40)
Stress score
Mini Maxi Mean (SD) Mini Maxi Mean(SD)

y.Fi
mum mum mum mum

aPrD
Before 9 25 16.42 (4.05) 8 31 18.77 (4.8)
intervention

After 6 25 15.07 (3.93) 9 30 17.55(4.27)

intervention
tiebrr
Table 9 explains that minimum stress score before intervention for husbands is 9 and
acsl

maximum is 25 with a mean of 16.42 and SD of 4.05. The minimum score after

intervention for husbands is 6 and maximum is 25 with a mean of 15.07 and SD of

.cn

3.93. The minimum score before intervention for wives is 8 and maximum is 31 with
nwM

a mean of 18.77 and SD of 4.8. The minimum score after intervention for wives is 9

and maximum is 30 with a mean of 17.55 and SD of 4.27.

wd wi
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Section B

d it
Section B - This section deals with findings based on the score on response to

consequence of fertility problem. Stress is graded as

nE
 No stress – 49 – 59

 Low stress – 37 – 48

 Average stress – 25 – 36

y.Fi
aPrD
 High stress – 12 – 24

 Severe stress – 0 – 11

The findings are presented in tables 10 to 15

tiebrr
acsl
.cn
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Table 10

d it
Frequency distribution and percentage of participants based on the score on

response to consequence of fertility problem (n=80)

nE
Stress score Husband (n=40) Wife (n=40)
based on
response to Score Before After Before After

y.Fi
consequence range intervention intervention intervention intervention

aPrD
of fertility
problem f (%) f (%) f (%) f (%)
No stress 49-59 14(35) 19(47.5) 12(30) 13(32.5)

Low stress 37-48 8(20) 10(25) 14(35) 16(40)

tiebrr
Average stress 25-36 12(30) 10(25) 10(25) 11(27.5)

High stress 12-24 6(15) 1(2.5) 4(10) 0(0)

Severe stress 0-11 0(0) 0(0) 0(0) 0(0)

acsl
.cn

Table 10 shows that 15% of husbands and 10% of wives had high stress, 30% of
nwM

husbands and 25% of wives had average stress, 20% of husbands and 35% of wives

had low stress before intervention. After intervention 2.5% husbands had high stress,

25% of husbands and 27.5 % of wives had average stress and 25% of husbands and

40 % of wives had low stress and 47.5% husbands and 32.5% of wives had no stress.
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Table 11

d it
Minimum score, maximum score, mean and SD of stress score on response to

consequence of fertility problem of participants before and after multifaceted

nE
intervention (n=80)

Husband(n=40) Wife(n=40)
Stress

y.Fi
score Minimum Maximum Mean Minimum Maximum Mean

aPrD
(SD) (SD)

Before 16 59 40.12 21 59 40.75

intervention (12.9) (10.07)

tiebrr
After 17 59 42.72 25 59 41.92

intervention (11.27) (9.91)

acsl
.cn

Table 11 shows that minimum stress score before intervention for husbands is 16 and
nwM

maximum is 59 with a mean of 40.12 and SD of 12.9. The minimum stress score after

intervention for husbands is 17 and maximum is 59 with a mean of 42.72 and SD of

11.27. The minimum stress score before intervention for wives is 21 and maximum is

59 with a mean of 40.75 and SD of 10.07. The minimum score after intervention for
d wi

wives is 25 and maximum is 59 with a mean of 41.92 and SD of 9.91.

w
a te
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Table 12

d it
Frequency distribution and percentage of husbands based on response related to

the consequence of fertility problem (n=40)

nE
Response

Consequence of fertility
Agree Neither agree Disagree
problem
nor disagree

y.Fi
aPrD
f(%) f(%) f(%)

Life has changed very much

22(55) 4(10) 14(35)
because of the fertility

problem
tiebrr
Life has been disrupted
15(37.5) 9(22.5) 16(40)
because of this fertility
acsl

problem

Fertility problem is very

24(60) 5(12.5) 11(27.5)
.cn

stressful
nwM

Table 12 shows that 55% of husbands had agreed that their life had changed very
d wi

much because of the fertility problem, 10% neither agree nor disagree 35% disagree.
w

And 37.5 % of husbands agreed that their life has been disrupted because of the

fertility problem, and 22.5% neither agree nor disagree. It also shows that 60% of
a te

husbands agreed that fertility problem is very stressful and 12.5% neither agree nor

disagree.
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Table 13

d it
Frequency distribution and percentage of husbands based on response related to

stress as a consequence of fertility problem (n=40)

nE
Response
Consequence of fertility A great Some Not at all
problem deal
f(%) f(%) f(%)
How much stress has your

y.Fi
fertility problem placed on the

aPrD
following?

a. Marriage/partnership 6(15) 13(32.5) 21(52.5)

b. Sex life 3(7.5) 19(47.5) 18(45)

tiebrr
c. Relationship with family 6(15) 15(37.5) 19(47.5)

d. Relationship with family 8(20) 13(32.5) 19(47.5)

in law
acsl

e. Relationship with friends 4(10) 14(35) 22(55)

.cn

f. Relationship with 6(15) 16(40) 18(45)

workmates
nwM

g. Relationship with people 8(20) 14(35) 18(45)

with children

h. Relationship with 3(7.5) 15(37.5) 22(55)

pregnant women
d wi

i. Physical health 5(12.5) 17(42.5) 18(45)

w

j. Mental health 9(22.5) 18(45) 13(32.5)

a te

k. Financial condition 11(27.5) 18(45) 11(27.5)

Table 13 shows that 15% of husbands had great stress on marriage/partnership, 7.5%

had great stress on sex life, 15% had great stress on relationship with family, 20% had
re

great stress on relationship with family in law, 10% had great stress on relationship

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with friends, 15% had great stress on relationship with workmates, 20% had great

d it
stress on relationship with people with children and 7.5% had great stress on

relationship with pregnant women. It also shows that 12.5% had great stress on

physical health, 22.5% had great stress on mental health and 27.5% had great stress

nE
on financial condition.

Table 14

y.Fi
aPrD
Frequency distribution and percentage of wives based on response related to the

consequence of fertility problem (n=40)

Response
tiebrr
Consequence of fertility
Agree Neither agree Disagree
problem
nor disagree

f(%) f(%) f(%)

acsl

Life has changed very much

23(57.5) 6(15) 11(27.5)
because of the fertility
.cn

problem
nwM

Life has been disrupted

19(47.5) 7(17.5) 14(35)
because of this fertility
problem

Fertility problem is very

28(70) 5(12.5) 7(17.5)
stressful
d wi

Table 14 shows that 57.5% of wives had agreed that their life had changed very much
w

because of the fertility problem, 15% neither agree nor disagree. And 47.5% of wives
a te

agreed that their life has been disrupted because of the fertility problem and 17.5%

neither agree nor disagree. It also shows that 70% of participants agreed that fertility

problem is very stressful.

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Table 15

d it
Frequency distribution and percentage of wives based on response related to

stress as a consequence of fertility problem (n=40)

nE
Response
Consequence of fertility
problem A great deal Some Not at all

y.Fi
f(%) f(%) f(%)

aPrD
How much stress has your fertility
problem placed on the following?
4(10) 17(42.5) 19(47.5)
a. Marriage/partnership

b. Sex life 3(7.5) 15(37.5) 22(55)

tiebrr
c. Relationship with family 5(12.5) 19(47.5) 16(40)

d. Relationship with family 6(15) 13(32.5) 21(52.5)

acsl

in law

e. Relationship with friends 3(7.5) 17(42.5) 20(50)

.cn

f. Relationship with 0(0) 20(50) 20(50)

nwM

workmates

g. Relationship with people 3(7.5) 17(42.5) 20(50)

with children

h. Relationship with pregnant 5(12.5) 14(35) 21(52.5)

d wi

women
w

i. Physical health 4(10) 22(55) 14(35)

a te

j. Mental health 9(22.5) 21(52.5) 10(25)

k. Financial condition 11(27.5) 18(45) 11(27.5)

Table 15 shows that 10% of wives had great stress on marriage/partnership, 7.5% had
re

great stress on sex life due to fertility problem, 12.5% had great stress on relationship

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with family 15% had great stress on family in law, 7.5 % had great stress on

d it
relationship with friends. It also shows that 7.5% had great stress on relationship with

people with children, 12.5% had great stress on relationship with pregnant women,

10% had great stress on physical health, 22.5% had great stress on mental health and

nE
27.5% had great stress on financial condition.

Section 3 :Self help abilities among participants before and after

y.Fi
multifaceted intervention

aPrD
This section deals with assessment of self help abilities among participants

before and after multifaceted intervention. Self help abilities are measured in different

components such as knowledge, IPR, sexual health and social interaction.

tiebrr
Based on the score obtained in the questionnaire, knowledge is graded as

 Poor Knowledge – 0-9

acsl

 Average Knowledge – 10-15

.cn

 Good Knowledge – 16-20

nwM

Based on the score obtained in the rating scale to assess interpersonal relationship

with partner, sexual health and social interaction are graded as

 Poor – 16-30
d wi

 Average – 9-15
w

 Good – 0-8
a te

The findings are presented in tables 16 to 18

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Table 16

d it
Frequency distribution and percentage of participants based on the knowledge

score (n=80)

nE
Husband (n=40) Wife (n=40)

Knowledge Score Before After Before After

y.Fi
range intervention intervention intervention intervention

aPrD
f (%) f (%) f (%) f (%)
Poor 0-9 2(5) 0(0) 0(0) 0(0)

Average 10-15 24(60) 20(50) 8(20) 5(12.5)

tiebrr
Good 16-20 14(35) 20(50) 32(80) 35(87.5)
acsl

Table 16 shows that 35% of husbands and 80% of wives had good knowledge, 60% of

husbands and 20% wives had average knowledge and 5% of husbands had poor
.cn

knowledge before intervention. After the intervention, 50% of husbands and 87.5% of
nwM

wives had good knowledge and 50% of husbands and 12.5% of wives had average

knowledge.
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Table 17

d it
Frequency distribution and percentage of participants based on the score on

interpersonal relationship with partner, sexual health and social interaction

nE
(n=80)

Husband (n=40) Wife (n=40)

y.Fi
IPR,

aPrD
Sexual Score Before After Before After
health and range intervention intervention intervention intervention
social
interaction f (%) f (%) f (%) f (%)
tiebrr
Poor 16-30 11(27.5) 7(17.5) 14(35) 6(15)

Average 9-15 17(42.5) 14(35) 20(50) 24(60)

Good 0-8 12(30) 19(47.5) 6(15) 10(25)

acsl
.cn

Table 17 shows that 30% husbands and 15% wives had good interaction, 42.5% of
nwM

husbands and 50% of wives had average interaction and 27.5% of husbands and 35%

of wives had poor interaction before the intervention. It also shows that after the

intervention 47.5% husbands and 25% wives had good interaction, 35% of husbands
d wi

and 60% of wives had average interaction and 17.5% of husbands and 15% of wives
w

had poor interaction.

a te
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Table 18

d it
Minimum, Maximum, mean and SD of stress scores on self help ability of

participants before and after multifaceted intervention

nE
(n=80)

Husband (n=40) Wife (n=40)

Score

y.Fi
Minimum Maximum Mean Minimum Maximum Mean

aPrD
(SD) (SD)

Knowledge
Before 7 19 14.25 10 19 15.15
intervention (2.47) (2.03)
tiebrr
After 13 20 17.05 13 20 17.77
intervention (1.88) (1.91)
acsl

IPR,
.cn

Sexual
health and
nwM

social
interaction
Before 4 23 11.92 3 26 13.9
intervention (5.26) (5.24)
d wi

After 2 21 10.97 2 23 12.57

w

intervention (5.06) (4.51)

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Table 18 explains that minimum knowledge score before intervention for

d it
husbands is 7 and maximum is 19 with a mean of 14.25 and SD of 2.47. The

minimum knowledge score after intervention obtained for husbands is 13 and

maximum is 20 with a mean of 17.05 and SD of 1.88. The minimum knowledge score

nE
before intervention for wives is 10 and maximum is 19 with a mean of 15.15 and SD

of 2.03. The minimum knowledge score after intervention for wives is 13 and

y.Fi
maximum is 20 with a mean of 17.77 and SD of 1.91.

aPrD
This table also explains that minimum score on IPR, sexual health and

social interaction before intervention for husbands is 4 and maximum is 23 with a

mean of 11.92 and SD of 5.26. The minimum score on IPR, sexual health and social
tiebrr
interaction after intervention for husbands is 2 and maximum is 21 with a mean of

10.97 and SD of 5.06. The minimum score on IPR, sexual health and social

interaction before intervention for wives is 3 and maximum is 26 with a mean of 13.9
acsl

and SD of 5.24. The minimum score on IPR, sexual health and social interaction after
.cn

intervention for wives is 2 and maximum is 23 with a mean of 12.57 and SD of 4.51.
nwM
wd wi
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Section 4 :Effect of multifaceted intervention on stress and self help abilities

d it
among participants

In order to evaluate the effect of multifaceted intervention, following null hypothesis

nE
were stated and tested at 0.05 levels as shown in table 19 to 20

H0: There is no significant difference in the mean score of stress among couples

seeking treatment for infertility before and after multifaceted intervention at 0.05

y.Fi
aPrD
level of significance.

In order to find out the significance of difference in stress before and after

multifaceted intervention, the data were subjected to paired ‘t’ test and the findings
tiebrr
are presented in table 19.
acsl
.cn
nwM
wd wi
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Table 19

d it
Significance difference between mean stress scores of participants before and

after intervention (n=80)

nE
Husband (n=40) Wife (n=40)
Stress
Mean SD t p-value Mean SD t p-value
value value

y.Fi
aPrD
Perceived
stress

Before 18.77 4.8

16.42 4.05
intervention
tiebrr
3.28 0.002** 3.72 0.001***

After 17.55 4.27

15.07 3.93
intervention
acsl
.cn

Consequence
of fertility
nwM

problem

Before 40.75 10.07

40.12 12.9
intervention

-2.98 0.005** -3.01 0.005**

d wi

After 41.92 9.91

42.72 11.27
w

intervention
a te

** Significant at 0.01 level

***significant at 0.001 level

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Table 19 shows that there was significant difference between mean stress scores

d it
among couples seeking treatment for infertility before and after the multifaceted

intervention at 0.001 level. Hence the null hypothesis was rejected at 0.001 level and

it can be concluded that there was significant difference in stress scores among

nE
couples seeking treatment for infertility before and after the multifaceted intervention.

H0: There is no significant difference in the mean score of self help abilities among

y.Fi
couples seeking treatment for infertility before and after multifaceted intervention

aPrD
at 0.05 level of significance.

In order to find out the significance of difference in self help ability scores before and

after multifaceted intervention, the data were subjected to paired ‘t’ test and the
tiebrr
findings are presented in table 20.
acsl
.cn
nwM
wd wi
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Table 20

d it
Significance difference between mean score on self help abilities of participants
before and after intervention
(n=80)

nE
Husband (n=40) Wife (n=40)
Self help
ability Mean SD t p-value Mean SD t p-value
value value

y.Fi
aPrD
Knowledge

Before 14.25 2.47 15.15 2.03

intervention

-11.38 0.000*** -11.94 0.000***

tiebrr
After 17.05 1.88 17.77 1.91
intervention

IPR, sexual
acsl

health and
social
interaction
.cn

Before 11.92 5.26 13.9 5.24

nwM

intervention

3 0.005** 3.75 0.001***

After 10.97 5.06 12.57 4.51

intervention
d wi

** Significant at <0.01 level

w

*** Significant at 0.001 level

a te

Table 20 shows that there was significant difference between mean self help ability

scores of couples seeking treatment for infertility before and after the intervention at

0.001 level. Hence the null hypothesis was rejected at 0.001 level and it can be
re

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or
concluded that there was significant difference in self help ability score among

d it
couples seeking treatment for infertility before and after multifaceted intervention.

nE
Section 5 :Association between stress among participants with selected

variables

y.Fi
This section deals with analysing the association between stress among

aPrD
participants with selected variables.

Following null hypotheses was stated and tested at 0.05 levels in table 21 and 22 using

‘Chi-square’ test.
tiebrr
H0: There is no significant association between stress scores of couples seeking

treatment for infertility with selected variables.

acsl
.cn
nwM
wd wi
a te
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Table 21

d it
Association between perceived stress among participants and selected variables

(n=80)

nE
Socio personal
Husband (n=40) Wife (n=40)
variables

χ2 df p-value χ2 df p-value

y.Fi
Age 2.19 3 0.53 4.28 6 0.63

aPrD
Religion 1.53 6 0.95 4.05 6 0.66

Education 4.78 9 0.85 10.15 9 0.33

Occupation 7.2 9 0.61 8.78 9 0.45

tiebrr
Type of family 1.52 3 0.67 6.44 3 0.09

Economic status 0.33 3 0.95 2.03 3 0.56

Place of residence 0.95 3 0.81 6.61 3 0.08

acsl

BMI 5.96 6 0.42 5.4 9 0.79

Duration of living 6.68 6 0.35 2.17 6 0.90

together
.cn

History of fertility
nwM

3.93 3 0.26 6.13 6 0.40

investigation

Duration of
treatment for 9.4 9 0.40 5.84 9 0.75
infertility

History of ART 0.71 3 0.87 3.89 3 0.27

wd wi

The data presented in the table 21 indicates there was no association of perceived stress

with selected variables as the computed p value is more than 0.05 level. Hence the null
a te

hypothesis was accepted.

re

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Table 22

d it
Association between consequence of fertility problem among participants and

selected variables (n=80)

nE
Socio personal
Husband (n=40) Wife (n=40)
variables

χ2 df p-value χ2 df p-value

y.Fi
aPrD
Age 9.6 3 0.02* 1.39 6 0.96

Religion 6.34 6 0.38 7.54 6 0.27

Education 11.42 9 0.24 8.95 9 0.44

Occupation 6.07 9 0.73 7.51 9 0.58

tiebrr
Type of family 3.81 3 0.28 3.65 3 0.30

Economic status 1.76 3 0.62 3.39 3 0.33

acsl

Place of residence 7.29 3 0.06 3.28 3 0.34

BMI 4.74 6 0.57 9.54 9 0.38

.cn

Duration of living 4.48 6 0.61 3.71 6 0.71

nwM

together

History of fertility
7.61 3 0.05* 9.34 6 0.15
investigation

Duration of
d wi

treatment for 13.72 9 0.13 9.78 9 0.36

w

infertility
a te

History of ART 6.9 3 0.07 3.02 3 0.38

*significant at 0.05 level

re

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or
The data presented in the table 22 indicates there was association of

d it
consequence of fertility problem with age and history of fertility investigation as the

computed p value is less than 0.05 level. Hence the null hypothesis was rejected for

these variables. There was no significant association of consequence of fertility

nE
problem with religion, education, occupation, type of family, economic status, place

of residence, BMI, duration of living together, duration of treatment for infertility and

y.Fi
history of ART. Therefore the null hypothesis was accepted for these variables.

aPrD
Section 6 :Association between self help abilities among participants with

selected variables
tiebrr
This section deals with analysing the association between self help abilities of

participants with selected variables.

acsl

Following null hypotheses was stated and tested at 0.05 levels in table 23 using
.cn

‘Chi-square’ test.
nwM

H0: There is no significant association between self help ability scores of couples

seeking treatment for infertility with selected variables .

wd wi
a te
re

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Table 23

d it
Association between self help abilities among participants and selected variables

(n=80)

nE
Socio personal
Husband (n=40) Wife (n=40)
variables

χ2 df p-value χ2 df p-value

y.Fi
aPrD
Knowledge

Age 2.29 2 0.31 1.03 2 0.59

Religion 1.99 4 0.73 0.14 2 0.93

Education 7.45 6 0.28 3.16 3 0.36

tiebrr
Occupation 7.89 6 0.24 2.54 3 0.46

Type of family 0.18 2 0.91 0.90 1 0.34

acsl

Educational status 0.38 2 0.82 0.11 1 0.73

Place of residence 1.16 2 0.56 0.62 1 0.42

.cn

BMI 4.28 4 0.36 2.17 3 0.53

nwM

Duration of living 1.55 4 0.81 0.00 2 1.00

together

History of fertility
1.37 2 0.50 2.50 2 0.28
investigation
d wi

Duration of
w

treatment for 6.17 6 0.40 5.81 3 0.12

a te

infertility

History of ART 1.67 2 0.43 0.78 1 0.37

re

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Socio personal
Husband (n=40) Wife (n=40)
variables

d it
χ2 df p-value χ2 df p-value

IPR, sexual health

nE
and social
interaction
Age 2.30 2 0.31 0.78 4 0.94

y.Fi
Religion 6.29 4 0.17 0.85 4 0.93

aPrD
Education 10.6 6 0.10 5.71 6 0.45

Occupation 4.80 6 0.57 7.97 6 0.24

Type of family 0.38 2 0.82 0.18 2 0.91

tiebrr
Economic status 1.15 2 0.56 4.68 2 0.09

Place of residence 0.23 2 0.88 0.95 2 0.62

BMI 4.12 4 0.38 7.78 6 0.25

acsl

Duration of living 3.73 4 0.44 5.67 4 0.22

.cn

together
nwM

History of fertility
2.50 2 0.28 2.21 4 0.69
investigation

Duration of
treatment for 4.57 6 0.60 4.23 6 0.64
infertility
d wi

History of ART 0.42 2 0.81 1.51 2 0.46

w

The data presented in the table 23 indicates there was no association of self help
a te

abilities among couples seeking treatment for infertility with socio personal variables

as the computed p value is more than 0.05 level. Hence the null hypothesis was

accepted.
re

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Section 7 :Correlation between stress and self help abilities among

d it
participants

H0: There is no significant correlation between stress and self help abilities among

nE
couples seeking treatment for infertility.

Karl Pearson correlation coefficient test was used to find out the correlation between

stress and self help abilities among couples seeking treatment for infertility.

y.Fi
aPrD
Table 24

Correlation between perceived stress and self help abilities among participants

(n=80)
tiebrr
Husband (n=40) Wife (n=40)

Perceived stress
‘r’ p-value ‘r’ p-value
acsl

Knowledge -0.126 0.439 -0.159 0.326

.cn

IPR, sexual health 0.447 0.004* 0.498 0.001**

and social
nwM

interaction

*significant at 0.05 level

**significant at 0.001 level

d wi

Data represented in table 24 indicates that the computed Pearson correlation coefficient
w

‘r’ value for the relationship between perceived stress and knowledge among husbands
a te

is -0.126, perceived stress and IPR, sexual health and social interaction is 0.447. It also

indicates that the computed Pearson correlation coefficient ‘r’ value for the

relationship between perceived stress and knowledge among wives is -0.159, perceived
re

stress and IPR, sexual health and social interaction is 0.498. Hence null hypothesis was

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rejected at 0.05 levels and it can be concluded that there was significant correlation

d it
between perceived stress and self help abilities among participants.

Table 25

nE
Correlation between consequence of fertility problem and self help abilities

among participants (n=80)

y.Fi
Consequence of Husband (n=40) Wife (n=40)

aPrD
fertility problem
‘r’ p-value ‘r’ p-value

Knowledgetiebrr 0.241 0.134 0.203 0.208

IPR, sexual health -0.442 0.004* -0.527 0.000**

and social interaction

*significant at 0.05 level

acsl

**significant at 0.001 level

.cn
nwM

Data represented in table 25 indicates that the computed Pearson correlation

coefficient ‘r’ value for the relationship between consequence of fertility problem and

knowledge for husbands is 0.241 and consequence of fertility problem and IPR,

sexual health and social interaction is -0.442. It also indicates that the computed
d wi

Pearson correlation coefficient ‘r’ value for the relationship between consequence of
w

fertility problem and knowledge for wives is 0.203 and consequence of fertility
a te

problem and IPR, sexual health and social interaction is -0.527. Hence null hypothesis

was rejected at 0.05 levels and it can be concluded that there was significant

correlation between consequence of fertility problem and self help abilities among

participants.
re

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or
CHAPTER 5

d it
RESULTS

Objectives

nE
Hypotheses

Results

y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
re

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CHAPTER 5

d it
RESULTS

This chapter deals with the major findings of the present study. Present study

nE
was undertaken to evaluate the effect of multifaceted intervention on stress and self

help abilities among couples seeking treatment for infertility.

y.Fi
Objectives

aPrD
1. Assess the level of stress among couples seeking treatment for infertility

2. Assess the self help abilities of couples seeking treatment for infertility
tiebrr
3. Evaluate the effect of multifaceted intervention on stress and self help abilities

of couples seeking treatment for infertility

acsl

4. Find out the association between stress and self help abilities among couples

seeking treatment for infertility with selected variables

.cn

5. Find out the correlation between stress and self help abilities among couples
nwM

seeking treatment for infertility.

Hypotheses
d wi

H1 : There is significant difference in the mean score of stress among couples seeking
w

treatment for infertility before and after multifaceted intervention.

a te

H2 : There is significant difference in the mean score of self help abilities among

couples seeking treatment for infertility before and after multifaceted intervention.

H3 : There is a significant association between stress of couples seeking treatment for

re

infertility with selected variables.

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H4 : There is significant association between self help abilities of couples seeking

d it
treatment for infertility with selected variables.

H5 : There is significant correlation between stress and self help abilities among

nE
couples seeking treatment for infertility.

Results

y.Fi
Following are the major findings of the present study

aPrD
Section 1 : Distribution of participants based on sociopersonal variables

 Among the participants 42.5% of husbands belong to the age group of 26-35

years, 57.5% husbands belong to the age group of 36-45 years, 8% of wives
tiebrr
belong to the age group of 18-25 years, 67.5% of wives belong to 26-35 years

and 12.5% wives belong to 36-45 years.

acsl

 The study reveals that 72.5% participants were Hindus, 22.5% participants

were Muslims and 5% were christians.

.cn
nwM

 Among the participants 45% of husbands had secondary education and 25% of

husbands had higher secondary education, 42.5% wives had degree/above

education and 27.5% wives had higher secondary education.

 The study reveals that 60% husbands had manual labour, 32.5% husbands
d wi

working in private sector, 5% working in Government sector, 70% wives were

w

unemployed and 25% wives working in private sector.

a te

 The study results shows that 52.5% participants belong to joint family and

47.5% belong to nuclear family. It also shows that 80% of participants belong

to rural area.
re

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 68% participants belong to BPL category and 32% belong to APL category.

d it
 The study results shows that 55% of husbands and 77.5% of wives belong to

18.6-24.99, 35% of husbands and 17.5% of wives belong to 25-29.9, 10% of

husbands and 2.5% of wives belong to >30 and 2.5 % of wives belong to

nE
<18.5.

 62.5% participants had history of fertility investigation and 37.55% of

y.Fi
participants had no history of fertility investigation.

aPrD
 50% of participants had above 5 years of duration of living together, 30%

belong to 3-5 years and 20% belong to 1-2 years.


tiebrr
Among the participants 32.5% of participants had above 5 years of duration of

treatment for infertility, 30% of participants belong to 3-5 years, 12.5% belong

to 1-2 years 25% belong to below 1 year.

acsl

 The study results shows that 15% of participants had history of ART and 85%
.cn

of participants had no history of ART.

nwM

Section 2 :Stress among participants before and after multifaceted

intervention

 Before intervention 17.5% of husbands and 37.5% of wives had severe stress,
d wi

35% of husbands and 42.5% of wives had high stress and 40% of husbands
w

and 12.5 % of wives had average stress. After intervention 2.5 % of husbands

and 17.5% of wives had severe stress, 40% of husbands and 52.5% of wives
a te

had high stress and 37.5% of husbands and 20% of wives had average stress

 The minimum stress score before intervention for husbands is 9 and maximum

is 25 with a mean of 16.42 and SD of 4.05. The minimum score after

re

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intervention for husbands is 6 and maximum is 25 with a mean of 15.07 and

d it
SD of 3.93. The minimum score before intervention for wives is 8 and

maximum is 31 with a mean of 18.77 and SD of 4.8. The minimum score after

intervention for wives is 9 and maximum is 30 with a mean of 17.55 and SD

nE
of 4.27.

 Based on response to consequence of fertility problem 15% of husbands and

y.Fi
10% of wives had high stress, 30% of husbands and 25% of wives had average

aPrD
stress, 20% of husbands and 35% of wives had low stress before intervention.

After intervention 2.5% husbands had high stress, 25% of husbands and

27.5 % of wives had average stress and 25% of husbands and 40 % of wives
tiebrr
had low stress and 47.5% husbands and 32.5% of wives had no stress.

 The minimum stress score before intervention for husbands is 16 and

maximum is 59 with a mean of 40.12 and SD of 12.9. The minimum stress

acsl

score after intervention for husbands is 17 and maximum is 59 with a mean of

42.72 and SD of 11.27. The minimum stress score before intervention for
.cn

wives is 21 and maximum is 59 with a mean of 40.75 and SD of 10.07. The

nwM

minimum score after intervention for wives is 25 and maximum is 59 with a

mean of 41.92 and SD of 9.91.

 Based on consequence of fertility problem 55% of husbands had agreed that

d wi

their life had changed very much because of the fertility problem, 37.5 % of
w

husbands agreed that their life has been disrupted because of the fertility

problem and 60% of husbands agreed that fertility problem is very stressful.
a te

 The study results shows that 15% of husbands had great stress on

marriage/partnership, 7.5% had great stress on sex life, 15% had great stress

on relationship with family, 20% had great stress on relationship with family
re

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in law, 10% had great stress on relationship with friends, 15% had great stress

d it
on relationship with workmates, 20% had great stress on relationship with

people with children and 7.5% had great stress on relationship with pregnant

women. It also shows that 12.5% had great stress on physical health, 22.5%

nE
had great stress on mental health and 27.5% had great stress on financial

condition.

y.Fi
 Based on the consequence of fertility problem 57.5% of wives had agreed that

aPrD
their life had changed very much because of the fertility problem, 47.5% of

wives agreed that their life has been disrupted because of the fertility problem

and 70% of participants agreed that fertility problem is very stressful.


tiebrr
The study reveals that 10% of wives had great stress on marriage/partnership,

7.5% had great stress on sex life due to fertility problem, 12.5% had great

stress on relationship with family 15% had great stress on family in law, 7.5 %
acsl

had great stress on relationship with friends. It also shows that 7.5% had great

stress on relationship with people with children, 12.5% had great stress on
.cn

relationship with pregnant women, 10% had great stress on physical health,
nwM

22.5% had great stress on mental health and 27.5% had great stress on

financial condition.

Section 3 :Self help abilities among participants before and after

d wi

multifaceted intervention
w

 Before intervention 35% of husbands and 80% of wives had good knowledge,
a te

60% of husbands and 20% wives had average knowledge and 5% of husbands

had poor knowledge. After the intervention, 50% of husbands and 87.5% of
re

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wives had good knowledge and 50% of husbands and 12.5% of wives had

d it
average knowledge.

 Before intervention 30% husbands and 15% wives had good interaction,

42.5% of husbands and 50% of wives had average interaction and 27.5% of

nE
husbands and 35% of wives had poor interaction. After the intervention 47.5%

husbands and 25% wives had good interaction, 35% of husbands and 60% of

y.Fi
wives had average interaction and 17.5% of husbands and 15% of wives had

aPrD
poor interaction.

 The minimum knowledge score before intervention for husbands is 7 and

maximum is 19 with a mean of 14.25 and SD of 2.47. The minimum

tiebrr
knowledge score after intervention obtained for husbands is 13 and maximum

is 20 with a mean of 17.05 and SD of 1.88. The minimum knowledge score

before intervention for wives is 10 and maximum is 19 with a mean of 15.15

acsl

and SD of 2.03. The minimum knowledge score after intervention for wives is

13 and maximum is 20 with a mean of 17.77 and SD of 1.91.

.cn

 The minimum score on IPR, sexual health and social interaction before
nwM

intervention for husbands is 4 and maximum is 23 with a mean of 11.92 and

SD of 5.26. The minimum score on IPR, sexual health and social interaction

after intervention for husbands is 2 and maximum is 21 with a mean of 10.97

d wi

and SD of 5.06. The minimum score on IPR, sexual health and social
w

interaction before intervention for wives is 3 and maximum is 26 with a mean

of 13.9 and SD of 5.24. The minimum score on IPR, sexual health and social
a te

interaction after intervention for wives is 2 and maximum is 23 with a mean of

12.57 and SD of 4.51.

re

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Section 4 :Effect of multifaceted intervention on stress and self help abilities

d it
among participants

 There was significant difference between mean stress scores among couples

nE
seeking treatment for infertility before and after the multifaceted intervention.

It can be inferred that multifaceted intervention is effective to reduce the stress

among couples seeking treatment for infertility.

y.Fi
 There was significant difference between mean score of self help abilities of

aPrD
couples seeking treatment for infertility before and after the multifaceted

intervention. It can be inferred that multifaceted intervention is effective to

improve the self help abilities among couples seeking treatment for infertility.
tiebrr
Section 5 :Association between stress among participants with selected

variables
acsl

 There was no significant association between perceived stress and socio-

.cn

personal variables of the participants.


nwM

There was association of consequence of fertility problem with age and history

of fertility investigation. There was no significant association of consequence

of fertility problem with religion, education, occupation, type of family,

economic status, place of residence, BMI, duration of living together, duration

d wi

of treatment for infertility and history of ART.

w
a te
re

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Section 6 :Association between self help abilities among participants with

d it
selected variables

 There was no significant association between self help abilities and

nE
sociopersonal variables of the participants.

Section 7 :Correlation between stress and self help abilities among

y.Fi
participants

aPrD
 There was no significant correlation between perceived stress and knowledge

among participants and there was significant correlation between perceived

stress and IPR, sexual health and social interaction among participants.
tiebrr
 There was no significant correlation between consequence of fertility problem

and knowledge among participants and there was significant correlation

between consequence of fertility problem and IPR, sexual health and social
acsl

interaction among participants.

.cn
nwM
wd wi
a te
re

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or
CHAPTER 6

d it
DISCUSSION, SUMMARY AND CONCLUSION

nE
Discussion

y.Fi
Summary

aPrD
Conclusion

Nursing implications
tiebrr
Limitations

Recommendations
acsl
.cn
nwM
wd wi
a te
re

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CHAPTER 6

d it
DISCUSSION, SUMMARY AND CONCLUSION

This chapter deals with the major findings of the study and related discussion,

nE
summary, conclusion, nursing implication, limitations and recommendations for

future studies.

y.Fi
Present study was under taken to evaluate the effect of multifaceted

aPrD
intervention on stress and self help abilities among couples seeking treatment from

infertility unit, Institute of Maternal and Child Health, Kozhikode.

Discussion
tiebrr
Present study used a pre experimental one group pre test post test design to

evaluate the effect of multifaceted intervention on stress and self help abilities among
acsl

couples seeking treatment for infertility. Consecutive sampling was used to select

participants based on inclusion criteria. Questionnaire was used to collect the socio
.cn

personal data and knowledge on infertility, causes, risk factors and life style
nwM

modifications, preparedness for fertility studies, treatment and follow up. Rating scale

to assess interpersonal relationship with partner, sexual health and social interaction,

Perceived Stress Scale (PSS) and rating scale were used to assess the stress and
d wi

consequences of the fertility problem among couples with infertility.

w

In the present study perceived stress scores obtained for husband is 16.42
a te

(SD = 4.05) and for wives is 18.7 (SD = 4.8). It indicate that there is higher stress

among wives compared to husbands. These results were found matching with the

findings of a study conducted for defining the perceived stress among infertile couples
re

and its social-individual predictors among infertile Couples Referring to Infertility

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Center. In this study stress was assessed by the PSS and the mean stress scores among

d it
women was 27.4 (6.0) and 25.9 (5.3) among men. That is higher stress among women

than men.21

nE
In the present study paired t test showed that there is significant difference in

stress scores among couples seeking treatment for infertility before and after the

multifaceted intervention (p<0.001). Thus it suggests that relaxation technique can

y.Fi
reduce the stress among couples seeking treatment for infertility. These results were

aPrD
found matching with the findings of a study conducted at Iran to assess the effect of

relaxation techniques to ease the stress in infertile women. In this study Independent

t-test showed that the total stress score did not have a significant difference in groups
tiebrr
before the intervention (p > 0.05) whereas independent t-test indicated a significant

difference in stress scores between the two groups after the intervention (p < 0.05).

Thus it concluded that relaxation technique can reduce the stress score in infertile
acsl

women.23
.cn

In the present study it is found that 35% of husbands and 80% of wives had
nwM

good knowledge, 60% of husbands and 20% wives had average knowledge and 5% of

husbands had poor knowledge before intervention. After the intervention, 50% of

husbands and 87.5% of wives had good knowledge and 50% of husbands and 12.5%

of wives had average knowledge. These findings are in concordance with a study
d wi

conducted to assess the knowledge on infertility among women attending gynaec

w

OPD. In this study majority of women (79%) had average knowledge on infertility,
a te

15% of them had poor knowledge, only 6(6%) of them had good knowledge.27

In the present study it is found that there is no significant association between

knowledge and sociopersonal variables of the participants (p>0.05). These findings

re

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are not in concordance with a study conducted to assess the knowledge on infertility

d it
among women. The study revealed that the level of knowledge showed significant

association (p<0.01) with educational status, occupational status, monthly income,

age at marriage while rest of the variables showed non significant association.27

nE
Summary

Present study was undertaken to evaluate the effect of multifaceted

y.Fi
aPrD
intervention on stress and self help abilities among couples seeking treatment from

infertility unit, Institute of Maternal and Child Health, Kozhikode. The objectives of

the study are to assess the level of stress among couples seeking treatment for

infertility, assess the self help abilities of couples seeking treatment for infertility,
tiebrr
evaluate the effect of multifaceted intervention on stress and self help abilities of

couples seeking treatment for infertility, find out the association between stress
acsl

among couples seeking treatment for infertility with selected variables, find out the

association between self help abilities among couples seeking treatment for infertility
.cn

with selected variables and find out the correlation between stress and self help
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abilities among couples seeking treatment for infertility.

Conceptual frame work for the present study was based on Sr.Callista Roy’s

system adaptation model. The literature reviewed for the present study were organized
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under the headings of prevalence, causes and risk factors of infertility, stress and
w

effect of relaxation technique to reduce the stress among couples with infertility and

self help abilities and effect of intervention to strengthen the self help abilities among
a te

couples with infertility. Present study used a pre experimental – one group pre test-

post test design to evaluate the effect of multifaceted intervention on stress and self

help abilities among couples seeking treatment for infertility. Study included 40
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couples attending infertility unit. The consecutive sampling technique was used to

d it
select participants based on inclusion criteria.

Questionnaire was used to collect the socio personal data and knowledge on

nE
infertility, causes, risk factors and life style modifications, preparedness for fertility

studies, treatment and follow up, rating scale to assess interpersonal relationship with

partner, sexual health and social interaction, Perceived Stress Scale (PSS) to assess

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the stress and rating scale to assess the consequences of the fertility problem among

aPrD
couples with infertility. The investigator’s clinical and personal experience also

helped in the development of the tool. The content validity of the tool was ensured

with the help of experts from nursing and other related fields. Reliability of the tool
tiebrr
was checked by chronbach’s alpha which was found to be 0.60 for the questionnaire

to assess the knowledge, 0.78 for the rating scale to assess the assess interpersonal

relationship with partner, sexual health and social interaction, 0.60 for perceived
acsl

stress scale and 0.88 for rating scale to assess the consequences of the fertility
.cn

problem among couples with infertility.

nwM

The pilot study was conducted among 4 couples with infertility attending the

infertility unit, Institute of Maternal and Child Health, Kozhikode. The data collection

was performed from 22/02/2018 to 23/3/2018. On an average of 3-4 couples with

infertility were selected on every day Investigator personally collected the

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sociopersonal data by using questionnaire, assessed the knowledge using the

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questionnaire, IPR, sexual health and social interaction using the rating scale, stress
a te

using the perceived stress scale and consequences of the fertility problem using rating

scale. A schedule to assess the practice of relaxation technique was given. The daily

practice of relaxation technique from their home is ensured and follow up is done
re

through phone calls. Post test was done using the same tool after 15-20 days.

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After analysis following major results obtained were:

d it
 Among the participants 42.5% of husbands belong to the age group of 26-35

years, 57.5% husbands belong to the age group of 36-45 years, 8% of wives

nE
belong to the age group of 18-25 years, 67.5% of wives belong to 26-35 years

and 12.5% wives belong to 36-45 years.

 The study reveals that 72.5% participants were Hindus, 22.5% participants

y.Fi
aPrD
were Muslims and 5% were christians.

 Among the participants 45% of husbands had secondary education and 25% of

husbands had higher secondary education, 42.5% wives had degree/above

tiebrr
education and 27.5% wives had higher secondary education.

 The study reveals that 60% husbands had manual labour, 32.5% husbands

working in private sector, 5% working in Government sector, 70% wives were

acsl

unemployed and 25% wives working in private sector.

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 The study results shows that 52.5% participants belong to joint family and
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47.5% belong to nuclear family. It also shows that 80% of participants belong

to rural area.

 67.5% of participants belong to BPL category and 32.5% belong to APL

category.
d wi

 The study results shows that 55% of husbands and 77.5% of wives belong to
w

18.6-24.99, 35% of husbands and 17.5% of wives belong to 25-29.9, 10% of

a te

husbands and 2.5% of wives belong to >30 and 2.5 % of wives belong to

<18.5.
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 62.5% of participants had history of fertility investigation and 37.55 % of

d it
participants had no history of fertility investigation.

 Fifty percentage of participants had above 5 years of duration of living

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together, 30% belong to 3-5 years and 20% belong to 1-2 years.

 Among the participants 32.5% of participants had above 5 years of duration of

treatment for infertility, 30% of participants belong to 3-5 years, 12.5% belong

y.Fi
aPrD
to 1-2 years 25% belong to below 1 year.

 The study results shows that 15% of participants had history of ART and 85%

of participants had no history of ART.

tiebrr
 Before intervention 17.5% of husbands and 37.5% of wives had severe stress,

35% of husbands and 42.5% of wives had high stress and 40% of husbands

and 12.5 % of wives had average stress. After intervention 2.5 % of husbands
acsl

and 17.5% of wives had severe stress, 40% of husbands and 52.5% of wives
.cn

had high stress and 37.5% of husbands and 20% of wives had average stress
nwM

 Based on response to consequence of fertility problem 15% of husbands and

10% of wives had high stress, 30% of husbands and 25% of wives had average

stress, 20% of husbands and 35% of wives had low stress before intervention.

After intervention 2.5% husbands had high stress, 25% of husbands and 27.5
d wi

% of wives had average stress and 25% of husbands and 40 % of wives had
w

low stress and 47.5% husbands and 32.5% of wives had no stress.
a te

 Based on consequence of fertility problem 55% of husbands and 57.5% of

wives had agreed that their life had changed very much because of the fertility

problem, 37.5 % of husbands and 47.5% of wives agreed that their life has
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been disrupted because of the fertility problem and 60% of husbands and 70%

d it
of wives agreed that fertility problem is very stressful.

 Before intervention 35% of husbands and 80% of wives had good knowledge,

60% of husbands and 20% wives had average knowledge and 5% of husbands

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had poor knowledge. After the intervention, 50% of husbands and 87.5% of

wives had good knowledge and 50% of husbands and 12.5% of wives had

y.Fi
average knowledge.

aPrD
 Before intervention 30% husbands and 15% wives had good interaction,

42.5% of husbands and 50% of wives had average interaction and 27.5% of

husbands and 35% of wives had poor interaction . After the intervention
tiebrr
47.5% husbands and 25% wives had good interaction, 35% of husbands and

60% of wives had average interaction and 17.5% of husbands and 15% of

wives had poor interaction.

acsl

 There was significant difference between mean stress scores among couples

seeking treatment for infertility before and after the multifaceted intervention.
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It can be inferred that multifaceted intervention is effective to reduce the stress

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among couples seeking treatment for infertility.

 There was significant difference between mean score of self help abilities of

couples seeking treatment for infertility before and after the multifaceted
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intervention. It can be inferred that multifaceted intervention is effective to

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improve the self help abilities among couples seeking treatment for infertility.

 There was no significant association between perceived stress and socio-

a te

personal variables of the participants.

 There was association of consequence of fertility problem with age and history

of fertility investigation. There was no significant association of consequence

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of fertility problem with religion, education, occupation, type of family,

d it
economic status, place of residence, BMI, duration of living together, duration

of treatment for infertility and history of ART .

 There was no significant association between self help abilities and

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sociopersonal variables of the participants.

 There was no significant correlation between perceived stress and knowledge

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among participants and there was significant correlation between perceived

aPrD
stress and IPR, sexual health and social interaction among participants.

 There was no significant correlation between consequence of fertility problem

and knowledge among participants and there was significant correlation

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between consequence of fertility problem and IPR, sexual health and social

interaction among participants.

acsl

Conclusion
.cn

The study was aimed at evaluating the effect of multifaceted intervention on

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stress and self help abilities among couples seeking treatment from infertility unit,

Institute of Maternal and Child Health, Kozhikode.

 Before intervention 17.5% of husbands and 37.5% of wives had severe stress,
d wi

35% of husbands and 42.5% of wives had high stress and 40% of husbands
w

and 12.5 % of wives had average stress. After intervention 2.5 % of husbands

and 17.5% of wives had severe stress, 40% of husbands and 52.5% of wives
a te

had high stress and 37.5% of husbands and 20% of wives had average stress

 Based on response to consequence of fertility problem 15% of husbands and

10% of wives had high stress, 30% of husbands and 25% of wives had average
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stress, 20% of husbands and 35% of wives had low stress before intervention.

d it
After intervention 2.5% husbands had high stress, 25% of husbands and 27.5

% of wives had average stress and 25% of husbands and 40 % of wives had

low stress and 47.5% husbands and 32.5% of wives had no stress.

nE
 Before intervention 35% of husbands and 80% of wives had good knowledge,

60% of husbands and 20% wives had average knowledge and 5% of husbands

y.Fi
had poor knowledge. After the intervention, 50% of husbands and 87.5% of

aPrD
wives had good knowledge and 50% of husbands and 12.5% of wives had

average knowledge.

 Before intervention 30% husbands and 15% wives had good interaction,
tiebrr
42.5% of husbands and 50% of wives had average interaction and 27.5% of

husbands and 35% of wives had poor interaction. After the intervention 47.5%

husbands and 25% wives had good interaction, 35% of husbands and 60% of
acsl

wives had average interaction and 17.5% of husbands and 15% of wives had

poor interaction.
.cn
nwM

 There was significant difference between mean stress scores among couples

seeking treatment for infertility before and after the multifaceted intervention

(p<0.001).

 There was significant difference in self help ability score among couples
d wi

seeking treatment for infertility before and after multifaceted intervention

w

(p<0.001).
a te

 There was no significant association between perceived stress and socio-

personal variables of the participants (p>0.05).

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 There was association of consequence of fertility problem with age and history

d it
of fertility investigation (p<0.05). There was no significant association of

consequence of fertility problem with religion, education, occupation, type of

family, economic status, place of residence, BMI, duration of living together,

nE
duration of treatment for infertility and history of ART (p>0.05).

 There was no significant association between self help abilities and

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sociopersonal variables of the participants (p>0.05)

aPrD
 There was no significant correlation between perceived stress and knowledge

among participants and there was significant correlation between perceived

stress and IPR, sexual health and social interaction among participants. There
tiebrr
was no significant correlation between consequence of fertility problem and

knowledge among participants and there was significant correlation between

acsl

consequence of fertility problem and IPR, sexual health and social interaction

among participants.
.cn

Nursing implications
nwM

The findings of the study have implications in nursing practice, nursing

education, nursing administration and nursing research.

d wi

Nursing practice
w

The infertility is very stressful and counseling is an essential component in the

a te

treatment for infertility. The impacts of infertility can vary from person to person and

from couples to couples. So many lacks the knowledge regarding the different aspects

of infertility and some are suffered from relationship problems and social effects. So
re

counseling is mandatory in treating with couples coming for infertility treatment.

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Nurses need to be aware of the physical as well as the psychological needs of the

d it
couples with infertility. Also adequate preparation of the couples to undergo the

investigations helps them to gain confidence in undergoing the treatment. So nurses

can prepare them accordingly will also help to reduce the stress and improve the

nE
effectiveness of the treatment.

The nurses along with other professionals and non professionals have much to

y.Fi
do for such patients especially on psychological aspects of couples. She must be able

aPrD
to provide informations and counselling for these couples. Also she can increase the

opportunities for education within infertility consultations.

tiebrr
Nursing Education

The findings of the study can fill the gap in the body of knowledge and

provide a scope to include more specific plan of care in the nursing curriculum. The
acsl

nursing students must be well trained in the care of couples with infertility attending
.cn

the infertility unit on educational and psycho social aspects. Present study can
nwM

contribute more to the nursing curriculum focusing on the psycho-social aspect. A

standardized infertility patient education curriculum can be developed, incorporating

patient’s priorities as well as gaps in existing knowledge. The nurse educator can use

the findings of the present study to develop adequate skill, knowledge and attitude in
d wi

students to give individualized care for the patients. Psycho-social education and
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counseling for couples with infertility and related research studies are becoming one
a te

of the important aspects in the discipline of maternity nursing. So it should be

incorporated with the nursing curriculum in Obstetrics and gynaecological nursing.

Students can organize workshops, symposium, and other educational programmes on

re

updates on infertility management.

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Nursing Administration

d it
Nurse administrators must view the plan of care for couples with infertility

attending the infertility unit for strengthening the self help abilities and reducing the

nE
stress in other same population. Nurse administrator can plan and arrange for in

service education and special training programs on infertility counselling and stress

reduction among couples with infertility. Nurse administrators should arrange medical

y.Fi
camps and health education schedules for screening and increasing the awareness on

aPrD
infertility for young couples living in the community.

Nurse administrators can arrange periodical gathering of the couples with

tiebrr
infertility to share their physical, emotional, social and financial issues and should

find solutions for the issues. Nurse administrators should encourage the staff to

conduct research studies on effect of interventional programs to increase the self help
acsl

abilities and to reduce the stress among infertility couples.

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Nursing Research
nwM

The study findings can be incorporated in to other research works for better

outcome. This work can be used as a reference for the methodology by the beginners

in this field. The present study used a self-developed tool to collect socio personal
d wi

data and self help abilities. (knowledge, IPR, sexual health and social interaction) and
w

standardised tools for assessing the stress (perceived stress and consequence of

fertility problem) among couples attending the infertility unit The tool was found to
a te

be relevant and feasible in assessing the stress and self help abilities. Hence the tool

can be standardized for the present setting and can be further used for similar studies.
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The findings of the study can be used as a basis for further research studies in this

d it
field.

Limitations

nE
 The findings of the study can only be generalized to limited population due to

the smaller sample size.

y.Fi
Recommendadtions

aPrD
 A similar study can be conducted with a larger sample size in different setting

for generalization of findings.


tiebrr
A comparative study can be done to assess the stress and self help abilities of

couples with infertility attending the infertility unit for the first time and

among the couples undergone treatment for infertility for several times.
acsl

 Studies can be conducted to test other interventions to increase the self help

abilities and reduce the stress among couples seeking treatment for infertility.
.cn

 A descriptive study can be conducted to assess the perceived treatment

nwM

experience among couples attending the infertility unit.

 A longitudinal study can be done to assess the stress and pregnancy rate

among couples seeking treatment for infertility.

wd wi

 A qualitative study can be conducted to assess the reasons for stress and

coping strategies among couples with infertility attending the infertility unit.
a te
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29. Almeida-Santos T , Melo C, Macedo A, Moura-Ramos M. Are women and

d it
men well informed about fertility? Childbearing intentions, fertility knowledge

and information-gathering sources in Portugal. Reproductive Health .2017;

14:91. Available from : DOI 10.1186/s12978-017-0352-z.

nE
30. Dattijo L, Andreadis N, Aminu B, Umar N, Black K. Knowledge of Infertility

Among Infertile Women in Bauchi, Northern Nigeria. IJWHR. 2016;4

y.Fi
(3):103–109.

aPrD
31. Xiaoli S, Mei L, Junjun B, Shu D, Zhaolian W, Jin W, Wanli S. et.al.

Assessing the quality of life of infertile Chinese women: a cross-sectional

study. TJOG. 2016;55: 244-250.

32. Karaca A, Unsal G. Psychosocial Problems and Coping Strategies among

tiebrr
Turkish Women with Infertility. Asian Nursing Research 2015;9:243-250.

33. Aggarwal RS, Mishra VV, Jasani AF. Incidence and prevalence of sexual
acsl

dysfunction in infertile females. Middle East Fertility Society

Journal.2013;18:187–190. Available from: http://dx.doi.org/10.1016/j.mefs.

.cn

2013.02.003.
nwM

34. Winkelman WD, Katz PP, Smith JF, Rowen TS. The Sexual Impact of

Infertility Among Women Seeking Fertility Care. Sex Med 2016;4:190-197.

wd wi
a te
re

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or
APPENDIX A

d it
APPROVAL LETTER FROM INSTITUTIONAL ETHICS

COMMITTEE

nE
y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
re

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or
APPENDIX B

d it
PERMISSION LETTER FROM HEAD OF THE DEPARTMENT,

OBSTETRICS AND GYNAECOLOGY, IMCH

nE
y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
re

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or
APPENDIX C

d it
CERTIFICATE OF RELAXATION PROGRAMME TRAINING

FROM PATANJALI YOGA RESEARCH CENTRE

nE
y.Fi
aPrD
tiebrr
acsl
.cn
nwM
wd wi
a te
re

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or
APPENDIX D

d it
LIST OF EXPERTS FOR CONTENT VALIDITY

1 Mrs. Seenath K P 5 Mrs. Jyothi K Divakaran

nE
Associate Professor Assistant Professor

Govt.College of Nursing Govt. College of Nursing

y.Fi
Kozhikode Alappuzha

aPrD
2 Prof. Soya Kattil 6 Prof. Sreeja G Pillai

Vice Principal Professor

tiebrr
Baby Memmorial College of Govt. College of Nursing, ACME

Nursing, Kozhikode Pariyaram

acsl

3 Mrs. Jalaja K N 7 Mrs. Jisha M

Associate Professor Assistant Professor

.cn

Govt.College of Nursing Govt. College of Nursing

nwM

Alappuzha Kozhikode

4 Mrs. Giggy John 8 Dr. Biju George

d wi

Assistant Professor Assistant Professor

w

Govt. College of Nursing Department of Community

Thrissur Medicine
a te

Govt. Medical College, Kozhikode

re

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9 Dr. Sreedevi J 13 Mr. Ratheesh S R

d it
Associate professor Clinical psychologist

Govt.College of Nursing IMHANS

Kottayam Kozhikode

nE
10 Dr. Priya N

y.Fi
Assistant Professor

aPrD
Department of Obstetrics &

Gynaecology

Govt. Medical College, Kozhikode

tiebrr
11 Dr. Abdul Salam

HOD, Department of Clinical

acsl

Psychology

IMHANS ,Kozhikode
.cn
nwM

12 Dr. S Vinayachandran

Professor

Department of Obstetrics &

d wi

Gynaecology
w

Govt. Medical College, Kozhikode

a te
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APPENDIX E

d it
INFORMED CONSENT

In signing this document, I am giving my consent to be a participant for the

nE
research study conducted by Aparna S, MSc Nursing student, Government College of

Nursing, Kozhikode. I understand that I will be a part of the research study that

focuses on Effect of multifaceted intervention on stress and self help abilities among

y.Fi
aPrD
couples seeking treatment for infertility .

I have been informed that my willingness to participate in this study is entirely

voluntary and even during the course of study I can withdraw from the study. I have
tiebrr
been told that my awareness to the questions will not be published for any other

purpose and will be kept confidential. I also have been informed that I have no

financial commitment for this study.

acsl

If I have any question about the study or about my right as a study participant,
.cn

Aparna S (Ph no. 8547910673) is the person I should contact.

nwM

I will honour all agreements

Investigators signature: Participant’s signature :

Name & address: Aparna S Name and address :

d wi

MSc Nursing student

w

Govt. College of Nursing,

a te

Kozhikode

Place :

Date :
re

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or
APPENDIX F

d it
TOOL 1

QUESTIONNAIRE TO ASSESS SELF HELP ABILITIES AMONG COUPLES

nE
WITH INFERTILITY

Instructions to the participants

y.Fi
 Answer all the questions

aPrD
 Read the questions carefully which is listed in the schedule
 Put a tick () mark against the appropriate response or fill up
 The items 8,9 and 10 is measured by the investigator

SECTION A
tiebrr
SOCIO PERSONAL DATA

Name of husband :
acsl

Name of wife :

Contact number :
.cn
nwM

Husband Wife

1. Age (in years)

1.1 18 – 25 ( ) ( )

1.2 26 – 35 ( ) ( )
d wi

1.3 36 – 45 ( ) ( )
w
a te

2. Religion

2.1 Hindu ( ) ( )

2.2 Muslim ( ) ( )
re

2.3 Christian ( ) ( )

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or
2.4 Others Specify -------------------------

d it
3. Educational status

3.1 Primary ( ) ( )

nE
3.2 Secondary ( ) ( )

3.3 Higher secondary ( ) ( )

y.Fi
3.4 Degree and above ( ) ( )

aPrD
3.5 Professional/technical ( ) ( )

4. Occupation

4.1 Unemployed ( ) ( )
tiebrr
4.2 Manual labor ( ) ( )

4.3 Private sector ( ) ( )

acsl

4.4 Government sector ( ) ( )

4.5 Others Specify

.cn
nwM

5. Type of family

5.1 Nuclear family ( ) ( )

5.2 Joint family ( ) ( )

5.3 Extended family ( ) ( )

wd wi

6. Economic status
a te

6.1 APL ( ) ( )

6.2 BPL ( ) ( )
re

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or
7. Place of residence

d it
7.1 Rural ( ) ( )

7.2 Urban ( ) ( )

7.3 Others ( ) ( )

nE
8. Height (in cm)

8.1 151 – 160.9 ( ) ( )

y.Fi
aPrD
8.2 161 – 170 ( ) ( )

8.3 > 170 ( ) ( )

9. Weight (in kg)

tiebrr
9.1 25 – 35.9 ( ) ( )

9.2 36 – 50.9 ( ) ( )

51 – 65
acsl

9.3 ( ) ( )

9.4 > 65 ( ) ( )
.cn
nwM

10. BMI (kg/m2)

10.1 < 18.5 ( ) ( )

10.2 18.6 – 24.99 ( ) ( )

d wi

10.3 25 – 29.9 ( ) ( )
w

10.4 >30 ( ) ( )
a te

11. Age at marriage (in years) ---------------------

12. Duration of marital life in years ----------------------

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13. Duration of living together in years

d it
13.1 1–2 ( ) ( )

13.2 3–5 ( ) ( )

13.3 Above 5 ( ) ( )

nE
14. Any history of fertility investigations?

y.Fi
14.1 Yes ( ) ( )

aPrD
14.2 No ( ) ( )

15. Duration of treatment for infertility in years

15.1 Below 1 ( ) ( )
tiebrr
15.2 1–2 ( ) ( )

15.3 3–5 ( ) ( )
acsl

15.4 Above 5 ( ) ( )
.cn

16. Any history of use of ART

nwM

16.1 Yes ( ) ( )

16.2 No ( ) ( )
d wi

If yes, how many times

w

16.1.1 1 ( ) ( )

16.1.2 2 ( ) ( )
a te

16.1.3 3 ( ) ( )

16.1.4 More than 4 ( ) ( )

re

If yes, from where? --------------

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SECTION B – KNOWLEDGE ON INFERTILITY, CAUSES, RISK FACTORS
AND LIFE STYLE MODIFICATIONS, PREPAREDNESS FOR FERTILITY

d it
STUDIES, TREATMENT AND FOLLOW UP

Instructions

nE
 Read all the items carefully
 Answer all questions
 Put a tick () mark against the appropriate response

y.Fi
 Each correct response carries 1 mark

aPrD
. Husband Wife
1 What is infertility?
a. Infertility is the failure to conceive within two to three ( ) ( )
tiebrr
months of regular unprotected coitus
b. Infertility is the absence of childbirth ( ) ( )
c. Infertility is the failure to conceive within one or more
years of regular unprotected coitus ( ) ( )
acsl

d. Infertility is the failure to conceive after first sexual ( ) ( )

intercourse
.cn
nwM

2 What is the cause of female infertility?

a. Lack of ovulation ( ) ( )
b. Use of sanitary pads ( ) ( )
c. Excessive leucorrhoea ( ) ( )
d. Intercourse during menstruation ( ) ( )
wd wi

3 What is the cause of male infertility?

a. Lack of size of penis ( ) ( )
a te

b. Increased sperm motility ( ) ( )

c. Decreased testosterone ( ) ( )
d. Low sperm count ( ) ( )
re

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or
4 What is ovulation?
a. It is the release of ovum from the ovary ( ) ( )

d it
b. Regular bleeding ( ) ( )
c. Increasing the breast tenderness ( ) ( )
d. Shedding of endometrium ( ) ( )

nE
5 When does ovum release occurs in normal menstrual cycle(28
days)?

y.Fi
a. First day of menstruation ( ) ( )

aPrD
b. Before menstruation ( ) ( )
c. 14th day of menstruation ( ) ( )
d. When bleeding stops ( ) ( )

6 How many times ovulation occurs in a month?

tiebrr
a. Once ( ) ( )
b. Two times ( ) ( )
c. Three times ( ) ( )
acsl

d. More than five times ( ) ( )

.cn

7 How long ovum survives after ovulation?

a. 12 hours ( ) ( )
nwM

b. 24 hours ( ) ( )
c. 48 hours ( ) ( )
d. 72 hours ( ) ( )

8 How many sperms are released during sexual intercourse?

d wi

a. Only one ( ) ( )
w

b. 100 ( ) ( )
c. 1000 ( ) ( )
a te

d. Millions ( ) ( )
re

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or
9 How long sperm survives after ejaculation?
a. 24-72 hours ( ) ( )

d it
b. 10-12 hours ( ) ( )
c. 2-3 hours ( ) ( )
d. 9-15 hours ( ) ( )

nE
10 What is fertilization?
a. Sexual intercourse only ( ) ( )

y.Fi
b. Union of sperm and ovum ( ) ( )

aPrD
c. Release of ovum from the ovary ( ) ( )
d. Ejaculation ( ) ( )

11 Which is the most appropriate time for sexual intercourse for

getting pregnant?
tiebrr
a. Between 10th and 16th day of regular menstrual cycle ( ) ( )
b. Before menstruation ( ) ( )
c. Between 1st and 5th day of menstruation ( ) ( )
acsl

d. Immediately after bleeding stops ( ) ( )

.cn

12 Which is the common test done for male infertility?

a. Semen analysis ( ) ( )
nwM

b. Blood examination ( ) ( )
c. Stool examination ( ) ( )
d. Urine examination ( ) ( )

13 Which are the common tests done for female infertility?

d wi

a. Urine test, Chest X ray ( ) ( )

w

b. Hormonal test, Scanning ( ) ( )

c. Chest X ray, stool examination ( ) ( )
a te

d. Stool examination, urine test ( ) ( )

re

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or
14 Which is the most appropriate time for collecting the semen
for semen analysis?

d it
a. Immediately after sexual intercourse ( ) ( )
b. 2-5 days after sexual intercourse ( ) ( )
c. 1 week after sexual intercourse ( ) ( )

nE
d. 1 month after sexual intercourse ( ) ( )

15 What are the blood investigations to be done before semen

y.Fi
analysis?

aPrD
a. HIV ( ) ( )
b. HBsAg ( ) ( )
c. HCV and VDRL ( ) ( )
d. All of the above ( ) ( )
tiebrr
16 When does the blood investigations need to be repeated in
males?
a. 1 week ( ) ( )
acsl

b. 2 weeks ( ) ( )
c. 6 month ( ) ( )
.cn

d. 12 months ( ) ( )
nwM

17 What is the appropriate time for doing ultrasonography and

follicular study in females?
a. Irrespective of menstruation ( ) ( )
b. Before menstruation ( ) ( )
c. 2-5 days of menstruation ( ) ( )
d wi

d. After menstruation ( ) ( )
w
a te
re

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or
18 Which among the following is the risk factor for infertility in
males?

d it
a. Cold environment ( ) ( )
b. Use of spicy foods ( ) ( )
c. Use of tight pants and undergarments ( ) ( )

nE
d. Humid environment ( ) ( )

19 Which of the following habits are not a risk factor of

y.Fi
infertility?

aPrD
a. Healthy dietary pattern and regular exercise ( ) ( )
b. Smoking and alcoholism ( ) ( )
c. Use of tight pants and undergarments ( ) ( )
d. Fast food and soft drinks ( ) ( )
tiebrr
20 What are the treatment options for infertility?
a. IUI ( ) ( )
b. IVF ( ) ( )
acsl

c. Artificial insemination ( ) ( )
d. All of the above ( ) ( )
.cn
nwM

Answer key

1) c 2) a 3) d 4) a 5) c 6) a 7) b 8) d 9) a 10) b 11)a

12)a 13) b 14) b 15) d 16) c 17) c 18) c 19) a 20) d

wd wi

Scoring Key
a te

Poor Knowledge – 0-9

Average Knowledge – 10-15

Good Knowledge – 16-20

re

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or
APPENDIX G

d it
TOOL 2

RATING SCALE TO ASSESS INTERPERSONAL RELATIONSHIP WITH

nE
PARTNER, SEXUAL HEALTH AND SOCIAL INTERACTION

Instructions

y.Fi
 Read the following statements carefully

aPrD
 Respond to all questions

 Put tick mark () against your appropriate answers

 For each statement choose from the following alternatives:

tiebrr
0 – Disagree , 1 – Uncertain, 2 –Agree

Sl Statements

Uncertain
Disagree
acsl

Agree
No.

1 Being a parent is more important for me than having

.cn

a satisfying career
nwM

2 I can’t show my partner how I feel because it will

make him/her feel upset

3 I could talk with my partner about our fertility

problem
d wi

4 Having sex is difficult, because I feel disappointed

w

after sex
a te

5 During sex, all I can think about is wanting a child

6 If we miss a appropriate best time to have sex, I feel

sad and angry
re

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or
7 I can’t imagine us ever separating because of
infertility

d it
8 Sometimes I feel so much pressure and tension
because of having no children

nE
9 When we talk about our fertility problem, my partner
seems comforted by my comments

10 I am afraid of handling questions about infertility

y.Fi
with my partner

aPrD
11 Me and my partner affectionate with each other even
though we have fertility problem

12 Family get together and social functions are difficult

tiebrr
for me

13 I find it hard to spent time with friends who have

young children
acsl

14 I find it hard to spent time with friends who are

pregnant
.cn

15 When I see families with children, I feel left out

nwM

NB: Reverse your scores for questions 3,9 and 11. On these questions change the
score like this: 0 = 2, and 1 = 1
d wi

Items
w

3. Interpersonal relationship with partner and sexual health – 1 to 11

4. Social interaction – 12 to 15
a te

Scoring key
Poor – 16-30
Average – 9-15
re

Good – 0-8

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or
APPENDIX H

d it
TOOL 3

TOOL TO ASSESS STRESS AMONG COUPLES WITH INFERTILITY –

nE
PERCEIVED STRESS SCALE (PSS)

Instructions

y.Fi
 Read all the questions carefully

aPrD
 The questions in this scale ask you about your feelings and thoughts during the
last 2-3 weeks
 In each case you will be asked to indicate your response by placing tick ()
mark on appropriate columns
tiebrr
 Although some of the questions are similar, there are differences between
them and you should treat each one as a separate question
 For each question choose from the following alternatives:
acsl

0 - never 1 - almost never 2 - sometimes 3 - fairly often 4 - very often

Sl 0 1 2 3 4
.cn

No.
1 How often have you been upset because of something that
nwM

happened unexpectedly?

2 How often have you felt that you were unable to control
the important things in your life?

3 How often have you felt nervous and stressed?

d wi

4 How often have you felt confident about your ability to

handle your personal problems?
w

5 How often have you felt that things were going your way?
a te

6 How often have you found that you could not cope with
all the things that you had to do?

7 How often have you been able to control irritations in

your life?
re

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or
8 How often have you felt that you were on top of things?

d it
9 How often have you been angered because of things that
happened that were outside of your control?

10 How often have you felt difficulties were piling up so

high that you could not overcome them?

nE
NB:

y.Fi
aPrD
 First, reverse the scores for questions 4, 5, 7, and 8. On these 4 questions,

change the scores like this:

0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0.
tiebrr
Scoring key
acsl

Level of stress Score

.cn

No stress - 0-7
nwM

Low stress - 8-11

Average stress - 12-15

High stress - 16-20

wd wi

Severe stress - 21-40

a te
re

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or
APPENDIX I

d it
TOOL 4

RATING SCALE TO ASSESS THE CONSEQUENCES OF THE FERTILITY

PROBLEM AMONG COUPLES WITH INFERTILITY

nE
Instructions

 Read the following statements carefully

y.Fi
 Respond to all questions

aPrD
 Please put tick () mark in the best suitable response

Sl Strongly Somewhat Neither Somewhat Strongly

No agree agree agree disagree disagree
nor
1 2 disagree 4 5
tiebrr
3
1 My life has changed
very much because of
the fertility problem
acsl

2 My life has been

disrupted because of
this fertility problem
.cn

3 It is very stressful for

nwM

me to deal with this

fertility problem

4 How much stress has your fertility problem placed on the following?

A Some A little None

great at all
d wi

deal
1 2 3 4
w

a. Your marriage / partnership?

a te

b. Your sex life?

c. Your relationships with your family?
d. Your relationships with your family
in law?
e. Your relationships with friends?
re

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or
f. Your relationships with workmates?
g. Your relationships with people with

d it
children?
h. Your relationships to pregnant
women?

nE
i. Your physical health?
j. Your mental health?
k. Your financial condition?

y.Fi
aPrD
Scoring key

No stress – 49 – 59

Low stress – 37 – 48
tiebrr
Average stress – 25 – 36

High stress – 12 – 24
acsl

Severe stres – 0 – 11
.cn
nwM
wd wi
a te
re

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APPENDIX J

E
.
r Pary
LESSON PLAN ON INFERTILITY

F
tebr
csli
cna
w. M
ww i n
ed
at
re

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LESSON PLAN ON INFERTILITY

E
.
r Pary
F
Topic : Infertility – causes, risk factors and life style

modifications, preparedness for fertility studies,

Name of Student Teacher : Aparna S
treatment and follow up

tebr
Group : Couples attending Infertility Unit
Method of Teaching : Lecture Cum Discussion No. of members : 8-12

AV aids : Power point slides on infertility, causes, risk factors, Duration : 45 minutes

csli
Venue : Institute of Maternal and Child Health,
fertility studies, treatment, follow up and life style

cna
Kozhikode
modifications
w. M
Central Objective : On completion of the class the group will
ww i n

describe various aspects of infertility and

apply this knowledge in their life with a

ed

positive attitude
at
re

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Specific Objectives : On completion of the class, the group members

E
.
 describe reproductive system

r Pary
F
 enlist the factors essential for conception
 define infertility
 explain the causes of infertility


tebr
enlist the risk factors of infertility
 describe fertility studies for male and female
 explain treatment options for infertility

csli
 describe the follow up
 explain the life style modifications

cna  describe the sexual health in infertility

w. M  describe the interpersonal relationship and social interaction among couples with infertility
ww i n
ed
at
re

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Specific Content Time Teacher’s Learner’s Evaluation

E
.
Objectives activity activity

r Pary
F
INTRODUCTION 2 min Introduces Listen

Childbearing is an extremely important event in every

tebr
human’s life. It is widely accepted that human existence reaches
completeness through a child. In our society individuals are committed
in relationships like marriage with the goal of procreation. As years

csli
advances, infertility rate also grows. Infertility is a global health issue
that affects between 60 million to 80 million people worldwide. In

cna
Kerala, 15-20% of the couples suffer from infertility. Many of the
w. M
couples do not have adequate knowledge regarding infertility. Adequate
knowledge regarding basics of fertility, early identification of factors
ww i n
contributing to infertility, advanced technology, diagnostic measures
and treatment modalities will result in pregnancy in 50% cases.
ed
at
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E
.
REPRODUCTIVE SYSYTEM

r Pary
F
Describe  Male Reproductive system 7 min Explains Listen and
reproductive with the help observes the
system of power slides

tebr
point slides

csli
cna
w. M
ww i n
Male reproductive system consists of testes,
epididymis, vas deferens, ejaculatory duct, seminal vesicles, prostate
gland and penis. The sperms produced by the cells in the testes will be
ed

stored in epididymis and ejaculated through the urethra during

intercourse. A normal erection is required prior to normal ejaculation.
at

Millions of sperms are released during ejaculation

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.
 Female reproductive system Explains the Listen

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female

F
reproductive
system

tebr
What are the
main female
reproductive

csli
organs?

Female reproductive system consists of external

cna
genitalia, vagina, cervix, uterus, fallopian tubes and ovaries. Ovaries
w. M
produce eggs. Fallopian tubes are the two tubular structures on either
side of the uterus which carry sperms towards the site of fertilization at
ww i n

its distal part. The finger like projections at the distal end of fallopian
tube is known as fimbria. Uterus has one cavity inside where the fetus
ed

grows. The internal lining of the uterine cavity is known as

endometrium which sheds out during each menstrual bleeding and then
at

regrows.
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.
 Menstrual cycle Explains the Listen,

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menstrual observe

F
The normal menstrual cycle is 28 days long it can vary from cycle with slides and
21-35 days. Menstrual bleeding phase lasts for 2-7 days. In the normal the help of ask doubts
menstrual cycle, an egg develops each month within one of the ovaries. power point

tebr
Ovulation is the process of release of ovum from the ovary. Ovulation slides
happens between 12th-16th days of the cycle. The life span of ovum is Answer to
only 24 hours. the

csli
During sexual intercourse sperm will be deposited in the questions
posterior part of vagina and they will survive for 24-72 hours in female

cna
genital tract. The egg is then carried towards into the fallopian tube by
w. M
fimbria, to sperm (hopefully). Out of millions of sperms, only one sperm
will get entry into ovum for fertilization. After fertilization it is known
ww i n
as zygote and then embryo. Embryo is carried towards the uterine cavity
by fallopian tube for implantation. If fertilization/implantation does not
occur, menstrual bleeding follows.
ed
at
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FACTORS ESSENTIAL FOR CONCEPTION

E
.
Enlist the  Healthy spermatozoa should be deposited high in the vagina at 3 min Explains Listen

r Pary
factors or near the cervix with the help

F
essential for  The spermatozoa should have adequate motility. of power
conception  The motile spermatozoa should ascend through the cervix into point slides Which are
the uterine cavity and fallopian tubes. the factors

tebr
 There should be ovulation. essential for
 The fallopian tubes should be patent and oocyte should be conception?
picked up by fimbriated end of tube

csli
 The spermatozoa should fertilize the oocyte at the ampulla of the
tube.

cna
 The embryo should reach the uterine cavity after 3-4 days of
w. M fertilization.
 The endometrium should be receptive for implantation.
ww i n

Define DEFINITION 1 min Defines Listen What is

infertility Infertility is defined as the failure to conceive within one or infertility?
ed

more years of regular unprotected coitus. Primary infertility is infertility

in couple who have never had a child. Secondary infertility is failure to
at

conceive following a previous pregnancy.

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CAUSES OF INFERTILITY

E
.
r Pary
Explain the Infertility can be caused by problems affecting either the 10 min Explains Listens

F
causes of female or male or combination of both and unknown causes. with the help
infertility Approximately 25% of patients with infertility problems have more than of power
one cause. point slides

tebr
MALE CAUSES OF INFRTILITY
The male is directly responsible for about 30-40% cases of
infertility. There are many possible causes for male infertility.

csli
1. Sperm abnormality What are the
 Complete absence of sperm: no sperm being produced by testes causes of

cna or blockage of vas or ejaculatory duct preventing sperm from infertility in

w. M appearing in the ejaculate. Testicular failure can be due to males?
mumps, congenital or late correction or non correction of
ww i n
undescended testes or impotence.
 Sperm of reduced number and / or quality: it may be due to
ed

damage to the sperm forming cells (infection, trauma, smoking,

alcohol etc.). Increased temperature around scrotum due to hot
environment of occupation, long driving, varicocele and use of
at

tight undergarments decrease in sperm count and motility.

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Infection in the male glands (STDs) also impairs normal

E
.
production of sperms.

r Pary
2. Sexual difficulties: Erection and ejaculatory problems will

F
result in failure to deposit sperm high in vagina.
3. Physical illness (diabetes mellitus, spinal cord damage,
malnutrition etc.) will reduce spermatogenesis.

tebr
4. Medicines include anti hypertensives, anti psychotics,
cytotoxic drugs, nitrofurantoin ,cimetidine will hinder
spermatogenesis.

csli
5. Hormonal disharmony, chromosomal abnormalities and
immunological factors will contribute infertility by testicular

cna failure or reduce sperm production.

w. M Explains the Listens and
FEMALE CAUSES OF INFRTILITY female ask doubts
ww i n
The females accounts for 40-55% of causes of infertility. They causes of
are given below. infertility What are the
1. Structural abnormalities of the reproductive organs: fibroid causes of
ed

uterus, poly cystic ovarian disease, uterine congenital anomalies infertility in

will contribute to infertility and prevent implantation. females?
at

2. Disorder of ovulation: Most common reasons are poly cystic

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ovaries, weight changes, hormonal abnormalities (Hyper

E
.
prolactinaemia, Thyroid disorder etc) and premature Explains Listen

r Pary
menopause.

F
3. Damage to fallopian tube will prevent the egg and sperm
coming together. The patency of fallopian tube may get
damaged due to infection (PID, TB) or adhesion from previous

tebr
operations.
4. Endometriosis: Endometriosis is the abnormal presence of
endometrium in sites other than uterine cavity. It presents as

csli
severe dysmenorrhoea, ovarian cysts, infertility and chronic
pelvic pain.

cna
5. Disease condition: Medical illnesses like thyroid gland
w. M problems, diabetes mellitus, hypertension, liver and kidney
disease and genito urinary disease like pelvic inflammatory
ww i n
disease, sexually transmitted diseases, frequent vaginal
infections, recurrent urinary tract infection also contribute to
infertility.
ed

6. Advanced age: A women’s fertility peaks in the early and mid

twenties, after which it start to decline, with this decline being
at

accelerated after age 35. However, the exact estimate of

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chances of women to conceive after a certain age is not clear,

E
.
with research giving differing results. The chance of a couple to

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successfully conceive at an advanced age depends on many

F
factors, including the general health of women and the fertility
of male partner.
7. Body weight and eating disorders: 12% of all infertility cases

tebr
are result of women either being under weight or over weight.
Fat cells produce estrogen, in addition to the primary sex
organs. Too much body fat causes production of too much

csli
estrogen and the body begins to react as if it is on birth control
limiting the odds of getting pregnant. Too little body fat causes

cna insufficient production of estrogen and disruption of menstrual

w. M cycle. Both under and over weight women have irregular cycle
in which ovulation does not occur or is inadequate.
ww i n

COMBINED CAUSES OF INFRTILITY

Combined factors are the presence of factors both in male and
ed

female partners causing infertility. They are infrequent intercourse, lack

of knowledge of coital techniques and timing of ovulation, anxiety, use
at

of lubricants during intercourse which may be spermicidal.

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.
Enlist the RISKFACTORS 5 min Explains Listen What are the

r Pary
risk factors  In males risk factors of

F
of infertility infertility in
 Family history males?
 Varicocele

tebr
 Infections
 Medications
 Tight undergarments

csli
 Driving vehicles for long distance
 Smoking

cna
 Alcohol consumption
w. M  Radiation
 Stress
ww i n
 Keeping mobile phones in pocket
 Medical condition – Obesity, hypercholesterolemia
(increased blood cholesterol), diabetes (increased blood
ed

sugar level), hypertension (high BP), anemia, malnutrition

(zinc and vitamin C)
at
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 In females Explains the Listen

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riskfactors

F
 Increased age in females
 Obesity
 Tension and anxiety

tebr
 Family history
 Medications - Contraceptives, steroids, antihypertensives
 Immunological factors

csli
 Medical condition – Obesity, hypercholesterolemia
(increased blood cholesterol), diabetes (increased blood

cna sugar level), hypertension (high BP), anemia, malnutrition

w. M (zinc and vitamin c)
ww i n
Describe FERTILITY STUDIES
fertility
studies for Almost always both male and female factors can contribute to a 7 min Explains Listen
ed

male and couple’s infertility. Identification of cause is necessary for the treatment with the help
female of infertility. Both partners come at the first visit. Detailed general and of power
at

reproductive history of couple must be taken prior to investigations. point slides

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.
INVESTIGATIONS FOR MALE Explain the Listen and

r Pary
1. Semen analysis investiga- observe the

F
Semen analysis has a very important role in the tions in slides
evaluation of male infertility. It is a simple diagnostic test in the males with
initial evaluation of an infertile couple. According to WHO the the help of

tebr
sperm analysis report is considered normal if, total volume of not less powerpoint
than 2 ml, total sperm count of not less than 20 millions/ml, total slides
sperm motility of not less than 50%.

csli
Preparedness for semen analysis What are the
 Minimum of 2 to 3 days abstinence from sexual activity is preparations

cnarequired before collecting semen sample for analysis. ie., semen needed
w. M should be collected after 2-5 days of sexual intercourse before semen
 Husband should do the serological tests like HIV, HBsAg, HCV analysis?
ww i n
and VDRL and come with the results for semen analysis.
 The collection bottle should be clean from dust, pollutants and
chemicals. The entire sample should be collected in the
ed

collection bottle. It can be collected by masturbation or while

during sexual intercourse. The collection bottle should be
at

securely closed.
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 Result of semen analysis will be obtained only after 4 days.

E
.
 Blood investigations should be repeated after 6 months. ( HIV,

r Pary
HBsAg. HCV and VDRL).

F
2. Blood hormone assays will help in identification of the
causes of abnormalities in sperm production.
3. Testicular biopsy done to identify the problems related to

tebr
sperm production and its morphology.
4. Scanning of scrotum aid in detection of varicocele.

csli
INVESTIGATION DONE IN FEMALE Explains the Listen
investiga-

cna
1. Blood and urine study will help to identify the hormonal tions done in
w. M problems, ovarian reserve etc. females
2. Ultrasonography-transvaginal/trans abdominal (follicular
ww i n
study)
Ultrasonographic study of development of follicle What are the
in ovary along with endometrial development.The purpose of a investigations
ed

follicular study is to confirm that a follicle is developing at the done in

correct time in the cycle and is releasing the egg, in other words females?
at

confirm ovulation.
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Preparedness for Ultrasonography (follicular study)

E
.
 Follicular study/ ultrasonography should be done in 2-5 Explains Listen

r Pary
days of menstruation.

F
 It is necessary to empty the bladder before going for
scanning
 Serial USG is required – Minimum 3 scans taken. First

tebr
scanning will be done in 2-5 days of menstruation; 2nd
and 3rd will be done 3 and 14 days respectively after the
first scan.

csli
 Timing of any further visits will be advised after each
scan.

cna
3. Hysterosalpingoigram – It is radiographic visualization of
w. M uterine cavity and fallopian tube by injecting a radio opaque dye
into the uterine cavity.
ww i n
4. Laparoscopy – It is the visualization of abdominal cavity
through a telescope (5mm/10mm), inserted through a small ‘key
hole’ incision made below umbilicus. The procedure will be
ed

done under anesthesia.

5. Hysteroscopy – It is the visualization of interior of the uterine
at

cavity by using an endoscope inserted through the cervical canal

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under anesthesia. Uterine cavity will be distended with saline or

E
.
glycerin depending on the type of procedure.

r Pary
6. Cervical mucosa study will be conducted to detect the problems

F
of survival of sperm in female genital tract.

Explain TREATMENT FOR INFERTILITY

tebr
treatment Majority of the factors leading to infertility can be treated 10 min Explains Listen
options for and treatment depends on the cause identified in couples. with the help
infertility Psychological readiness and co-operation of couple are essential for of power

csli
the success of treatment. point slides

cna
FEMALE TREATMENT OPTIONS
w. M In some case, medication can improve or correct
underlying medical conditions that make it difficult to conceive. For What are the
ww i n
example women with endometriosis, cervical infections, poly cystic female
ovarian disease, or hormonal imbalance can be treated with treatment
medications, thus easing barriers to conception. options?
ed

When a women has blocked or damaged fallopian tubes,

surgery to repair them is an example of treatment aimed at curing
at

infertility.
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Ovulation induction will be done in women for maturation of

E
.
more than one ovum, so that it increases the chance of fertilization of

r Pary
more ovums.

F
MALE TREATMENT OPTIONS Explain the Listen
Drugs are prescribed for the improvement of sperm male

tebr
production and its motility. Sometimes drugs are prescribed for treatment
erectile or ejaculatory problems. Varicocele surgical correction will options
aid in better sperm production. What are the

csli
Direct aspiration of testicular tissue (TESA, PESA) will be male
done to collect sperm when there is obstruction in the out flow or treatment

cna
low count of sperm. options
w. M available?
TECHNOLOGICAL ADVANCEMENT IN INFERTILITY
ww i n
TREATMENT
Assisted reproductive techniques
 IUI: Intrauterine Insemination
ed

Intrauterine insemination or IUI is the artificial

insertion of sperm directly into the uterine cavity. The sperm
at

is always processed before insemination. This helps to

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inseminate the sperm directly into the uterine cavity at a

E
.
precisely determined time to ensure the sperm is as close to

r Pary
egg at the time it is released and to by-pass any possible

F
hostile effect of the cervical mucosa on the sperm. The
chances of a pregnancy resulting are between 7-10% per
treatment cycle. The chances will vary according to the

tebr
individual circumstances of the couple. Normally IVF will be
done after three failed IUI treatments.
Preparedness for IUI: Explain the Listen and

csli
 Screening ( HIV, HBsAg, HCV, VDRL) should be preparedness ask doubts
done before IUI. for IUI and

cna  It is very important that each of the partners arrive on clarify

w. M time so the IUI procedure can be performed soon after doubts
the sperms are washed and prepared for IUI.
ww i n
 Appropriate time for IUI is 2-3 days after sexual
intercourse. It will maximize the quality of semen for
IUI.
ed

 Partially full bladder is essential for IUI.

 It is advised to relax in the exam room for 10 minutes
at

before getting dressed.

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.
 IVF-ET (In Vitro Fertilization and Embryo Transfer) and Explains Listen

r Pary
ICSI (Intra Cytoplasmic Sperm Injection) IVF

F
In vitro fertilization or IVF is the fertilization
outside the human body and replacement of the fertilized
ovum back inside the cavity of the uterus. Through ICSI, the

tebr
sperm is injected in to the ovum. This process otherwise
called as test tube baby.
As egg freezing technology improves, it may also

csli
be used by patients who are undergoing in vitro fertilization
(IVF) treatment. Women who produce excess eggs may

cna eventually be able to select to freeze their eggs unfertilized,

w. M rather than freezing fertilized embryo.
Embryo cryopreservation is used most often to
ww i n
store good quality excess embryo resulting from an IVF-ICSI
treatment cycle. Embryos are created after an in vitro
fertilization cycle where eggs are retrieved and then placed
ed

with sperm.
If women’s womb not has any capacity to carry
at

embryo, the couple can think about surrogacy. Preconception

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medical care and counseling is advisable for all those

E
.
planning a pregnancy;failure of which the couple may choose

r Pary
to remain childless or consider adoption, or non –spousal

F
sperm options unless and until both partner are agreeable.

Preparedness for IVF-ET Explain the Listen and

tebr
 Do not wear contact lenses and do not use lotion or preparedness obseve the
perfumes (odour releasing products). for IVF with slides
 Avoid journey in two wheelers. the help of

csli
 Bring white cloths and blouse on the day of powerpoint
procedure. It should be washed in hot water and slides

cna ironed.
w. M  Instruct not to eat or drink after midnight the day
before procedure.
ww i n
 Spouse will be directed to collect the semen just
before the procedure
 The retrieval takes approximately 10-15 minutes
ed

 After the procedure it may experience menstrual like

cramping, tenderness and vaginal spotting. It is
at

normal.
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 It is possible to eat and drink when fully recovered

E
.
from the effect of anaesthesia and can leave the clinic

r Pary
after voiding.

F
Describe the FOLLOW UP
follow up 1 min Explains Listen

tebr
Routine follow up is essential for the effective treatment of
infertility. Blood investigations (HIV, HBsAg, HCV & VDRL) should
be repeated after 6 months. Follicular study dates should be obtained

csli
accordingly and proper follow up should be taken for each procedures.

Explain the

cna
LIFE STYLE MODIFICATIONS
life style
w. M  Body Weight
modifications Obesity is associated with infertility and a lower 9 min Explains Listen
ww i n
pregnancy rate. Women with a very low body mass index with the help
(BMI) also are more likely to experience infertility. In men, of power
obesity is also associated with infertility — sperm count and point slides
ed

motility have been shown to be lower in obese men. Weight

loss has been shown to improve semen parameters. Erectile
at

dysfunction is more common in obese men.

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Eating a balanced and nutritious diet, fruits and vegetables

E
.
(plenty of folates), and maintenance of normal body weight

r Pary
are associated with better fertility prospects.

F
 Exercise Which are
Regular exercise will help to reduce excessive fat the life style

tebr
accumulation in the body and thus aid in reduction and modifications
prevention of obesity. needed for
Explains the Listen prevention of

csli
 Caffeine Intake life style infertility?
Excessive caffeine intake (>500 mg/day) appears to be modification

cna associated with a delay in time to conception. Consumption

w. M
of moderate amounts of caffeine (200-300 mg/day) has been
associated with lower pregnancy rates and higher rates of
ww i n
miscarriage. In one study, pregnancy rates were reduced in
women consuming greater than 50 mg of caffeine daily.
ed

There is little data on the impact of caffeine on male fertility.

 Alcohol Consumption
at

Extreme alcohol intake has been associated with

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decreased fertility. Heavy alcohol consumption in men is

E
.
associated with decreased sperm count, motility, and percent

r Pary
of normal appearing sperm. Semen parameters have been

F
shown to improve after three months of abstinence from
alcohol.

tebr
 Smoking Explains Listen
There is strong evidence that nicotine negatively
effects fertility. It has been suggested that women who smoke

csli
add ten years to their reproductive ages—a 30 year old
smoker has the reproductive potential of a 40 year old!

cna Smoking in men negatively impacts sperm quantity and

w. M quality
ww i n
 Cell Phones and undergarments
The use of cell phones may decrease sperm
ed

concentration and motility as well as normal appearance. The

abnormalities seemed to be directly related to the amount of
use. For males, it is better to avoid tight undergarments like
at

jeans. Driving the vehicle for long distance will increase

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temperature to scrotum thus impairs sperm production.

E
.
Keeping the mobile phones in the pockets of pants increase

r Pary
oxidative stress and aid in infertility. Exposure to hot

F
environment in place of living and working should be
avoided to have more and health sperm production and
survival.

tebr
Describe the SEXUAL HEALTH IN INFERTILITY 2 min Explains Listen
sexual health

csli
in infertility Couples experiencing infertility often find their sex life really
suffers. Infertility creates a sense of pressure to have sex according to a

cna
defined timeline.
w. M Infertility may interact with a couple’s or individual’s sexuality
and sexual expression in two main ways. Sexual problems may be
ww i n
caused or exacerbated by the diagnosis, investigation, and management
of infertility (or subfertility), or they may be a contributory factor in
childlessness. Any examination of a couple’s difficulty in conceiving
ed

must include overt and clear questioning about their sexual activity.
For some couple, one or two failures during intercourse begins
at

a vicious circle of fear of failure, with anxiety leading to further failures.

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Partners may also develop arousal difficulties because of anxiety or

E
.
distress. Some individuals feel that their partner seems to want them

r Pary
only when there is a chance of conception, and sexual activity can then

F
become a battleground for issues of power and control.
Couples with infertility on treatment are advised to practice sexual
intercourse on alternate days. Between 10th and 16th day of regular

tebr
menstrual cycle is the most appropriate time for the couples to engage in
sexual intercourse for getting pregnant.

csli
Describe the INTERPERSONAL RELATIONSHIP AND SOCIAL 2 min Explains Listens
interpersonal INTERACTION AMONG COUPLES WITH INFERTILITY
relationship

cna
and social
w. M Infertility has various psychological and psychosomatic effects,
interaction especially among women. The most common effects are distress,
ww i n
among depression, anxiety, reduced self esteem, somatic complaints, reduced
couples with libido and a sense of blame and guilt. The latter is the main reason for
infertility disturbed interpersonal relationship and decreased social interaction.
ed

Relationships may suffer – not only the primary relationship with or

partner, but also with friends and family members. People who have no
at

children receive less social support and a less substantial framework for
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independent living compared with those who have children. Couples

E
.
dealing with infertility may avoid social interaction with friends who are

r Pary
pregnant and families who have children. Childless couples are far away

F
from social gatherings and family get together.

How to strengthen?

tebr
 Counselling – especially to increase coping strategies, or to help
with making decisions.
 Family strength to be improved by together at meal time, picnic

csli
and campaigns.
 Promote genuine liking, respecting each other, strong

cnacommitment and effective communication

w. M
 Specific types of therapy may also be useful. For example
interpersonal therapy – which focuses on improving
ww i n
relationships or resolving conflicts with others.
 Increased availability of information on treatments, advanced
technologies including success rates and support groups.
ed

 Raising public awareness of fertility problems: their causes, and

possible treatments.
at
re

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CONCLUSION

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1 min Explains Listen

F
Having a child is a major life event for any individual couple.
When this is proving difficult to achieve, and require medical
intervention, it can feel a major crisis. This emotional ‘up and downs’

tebr
experienced by those trying for a baby and undergoing treatments are
well recognized within the field of infertility. Adequate knowledge
about basics of fertility, early identification and correction of

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contributing factors of infertility will aid in spontaneous conception.
Thus brings happiness to the family.

cna
w. M
RECAPITULATION
1. What is infertility?
ww i n
2. Which are the causes of infertility?
3. Which are the factors that create fertility problems?
4. What are the investigations available for infertility?
ed

5. What are the treatment options for infertility?

6. What are the life style modifications needed for the prevention
at

of infertility?
re

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APPENDIX K

d it
LIST OF ABBREVIATIONS

IMCH Institute of Maternal and Child Health

nE
OBG Obstetrics and gynaecology

WHO World Health Organization

y.Fi
aPrD
IUI Intra uterine insemination

IVF In vitro fertilization

IPR Interpersonal relationship

tiebrr
ART Assisted reproductive technology

APL Above poverty line

acsl

BPL Below poverty line

.cn
nwM

STD Sexually transmitted disease

OPD Outpatient department

PSS Perceived stress scale

d wi

BMI Body mass index

w

SPSS Statistical package for social sciences

a te
re

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APPENDIX L

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APPENDIX M

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APPENDIX O

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APPENDIX P

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2 min Introduces Listen

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female

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reproductive
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infertility

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female ask doubts

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risk factors
w. M
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
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