Social and psychological support of couples in treating infertility (case study of the polish research)

Introduction. Demographic aspect of the problem

Developed countries are currently experiencing a steady increase in the number of infertile families. The prevalence of infertility in European countries is on average about 14%. In modern realities, this problem is becoming increasingly relevant, and it appears to researchers, most likely, as a demographic problem, rather than a medical-social and socio-psychological one. Its demographic content is that infertility causes a general decline in the birth rate, a decrease in the population in general and the labor force in particular.

The total birth rate in the Republic of Poland is 1.45 (2020), while it was 2.28 at the end of the 20th century (1980). In the European Union, this figure is 1.61. In Russia – 1.489 (2020), which shows a decrease in relation to the previous five years (1.76 – in 2016) and a practical return to its values of the mid-1990s.

Poland and Russia are characterized by a tendency of increasing age of women giving birth

(a shift towards the age categories of women – 25–29 and 30–34 years) [1]. Attributing the planning of the first pregnancy to the third or fourth decade of a woman’s life is one of the main reasons for the development of impaired fertility and a decrease in the birth rate.

The deterioration of the reproductive characteristics of the population in the 21st century has reached a level that can limit the birth rate in society. According to the World Health Organization, 60–80 million couples in the world are not able to conceive a child without medical care. In Poland, this problem affects 1.2–1.3 million couples [2; 3]. In Russia, from 15–18% (about 4.5–5 million) 1. A high proportion of childless couples should be considered a “reserve for the birth of desirable children”, as well as as an opportunity to “increase the reproductive potential of the population” 2. This situation is problematic for many industrial states and is among the priorities of national programs. The change of the traditional type of population reproduction to the modern one actualizes the problem of the realization of individual reproductive capabilities [4; p. 69]. It is now coming to the forefront of the demographic policy of many countries. In these conditions, one of the measures that contribute to the growth of fertility is the use of the potential of infertile couples by treating infertility with the help of assisted reproductive technologies (for example, in vitro fertilization – IVF).

The purpose of the study is to analyze the situation with the treatment of infertile couples using assisted reproductive technologies in the Republic of Poland and the Russian Federation in the context of the perception of socio-psychological support provided to couples (using case study of a Polish study).

Socio-psychological and medico-social aspects of the problem of infertility treatment

According to the World Health Organization’s (WHO) methodological approach, infertility is the inability to get pregnant after 12 months or more of regular sexual intercourse [5].

Taking into account the time when a woman is unable to become pregnant, infertility is divided into primary and secondary. Primary infertility is defined as the absence of pregnancy or difficulty in conceiving. On the other hand, secondary infertility refers to the situation when a woman is not able to get pregnant after previously giving birth to a child. Another criterion for classifying infertility refers to its causes: female factor infertility, male factor infertility, infertility of both partners, and idiopathic infertility3 [6; 7].

The causes of infertility include, among others, chronic or “civilization” diseases (for example, oncology), social and cultural changes. Increasingly more women decide to become mothers later, which may also reduce their chances of having children. Other important factors involve: unhealthy lifestyle and habits; e.g, wrong diet, little physical activity, or the inability to handle stress and tensions [7; 8].

Female infertility, which is influenced, among others, by the psycho-neuro-endocrine system, consists in the inability to become pregnant or the inability to carry a pregnancy to term [2]. Taking into account etiology, female infertility can be caused by endocrine (various organic and functional disorders), anatomical, cervical (inflammatory diseases, immunological infertility) factors, and a factor of unknown origin.

Male infertility can be caused by idiopathic (unknown origin), endocrine, infectious factors, as well as obturation and other causes [7]. Male infertility can be divided into congenital and acquired [8; 9].

Overall, WHO identifies 22 factors of female and 16 factors of male infertility. At the same time, there is a combined effect of factors of physical ill-health, social, and psychological distress [10].

Being diagnosed with infertility is an extremely difficult experience for a couple, which may be compared to a crisis or traumatic situation. This situation is the most traumatic for women. In recent years, psychological and medical research has been actively studying the strategies of behaviour of women suffering from infertility. They can be classified as:

• 1.    Experiencing infertility as a critical life situation . The process of experiencing this problem includes four types of critical situations (stress, frustration, conflict, crisis). “For many married couples, infertility is one of the main life crises and a psychologically stressful event” [9]. Infertility stress affects the personal life of each partner, negatively affects the safety of family relationships, increases

• 2.    Coping with the adverse effects of stress (coping strategies) used by women in experiencing infertility [13]. The basic coping strategies, according to the theory of coping behaviour by R. Lazarus and S. Volkman [14; 15], are: “problem solving”, “search for social support”, “avoidance”⁴.

feelings of anxiety and guilt, reduces self-esteem and mood in general. American researchers have found that women are characterized by such types of experiences as avoiding conversations about infertility, searching for hidden meanings in this situation, immersion in their own experiences, and the desire to share the burden of this problem with someone [10].

Due to unsuccessful attempts to have children, more and more couples seek medical help. Treatment of infertility to achieve a pregnancy and give birth to a healthy baby, begins with a careful diagnosis and depends on the cause of infertility which is diagnosed [16]. A healthy lifestyle, proper diet, optimal BMI, quitting smoking, reducing alcohol and caffeine intakes, are also very important in treating infertility. In the case of endocrine problems, it is crucial to balance hormone levels.

The need for assisted reproductive technologies is increasing. There are quite a lot of them in modern medicine: in vitro fertilization (IVF), ICSI (injection of sperm into the cytoplasm of an oocyte (egg), cryopreservation of germ cells, embryos and tissues of reproductive organs, the use of donor embryos, surrogacy, etc. The most effective method of assisted reproduction is in vitro fertilization by IVF with subsequent embryo transfer (ET) [6].

The availability of assisted reproductive technologies is estimated by the number of ART cycles per 1 million people. In contemporary Europe, this figure averages 1,500 IVF cycles per 1 million people (in Denmark – 3,000, in the Czech Republic – 2,500 cycles, etc.), resulting in 3–6% of the total number of pregnancies.

The efficiency of these technologies in 26 European countries is on average 36.5% (in the world, for comparison, 15–20%). At the same time, in Poland – 29%, which is slightly lower than general European statistics5. In Russia – 38.5%, according to the report of the RAHR6 register for 2016.

Social and psychological support in the treatment of infertility

Infertility is becoming an increasingly common and serious problem. This is due to chronic and civilizational diseases, environmental pollution, and sociocultural changes. The inability to have a child is a biological, psychological, and social problem [2]. Many authors emphasize the problem of alienation of infertile people and the consequences: for example, stigmatization, which leads to depression and isolation [2, 17, 18, 19]. Therefore, the inability to have children can lead to a decrease in self-esteem, a sense of loss, a lack of acceptance, and a sense of meaninglessness, to a deterioration in relations between partners and other people. All this, in turn, increases the level of anxiety, depression and stress. The research notes that women and men react differently to news about their infertility and treat treatment differently. Common to women and men is increased anxiety and a tendency to depression, as well as low selfesteem. Moreover, such patients tend to experience a loss of their identity; they feel that they are not able to live normally and build relationships [20].

That is why couples who are being treated for infertility should be considered people experiencing a crisis, and those who need serious support and professional help [21; 22]. Infertility treatment is a complex, long, and complex process in which couples experience strong emotions. Studies conducted by various authors show that social support plays an important role in the prevention of post-traumatic stress disorder and the consequences of chronic stress that patients with infertility may experience [23].

Communication between partners and their willingness to understand each other are extremely important in infertility treatment. High perceived support and mutual understanding increase their satisfaction with the relationship and positively influence the process of trying to achieve a pregnancy. Social and emotional support are key aspects. They reduce stress and anxiety, which can negatively affect fertility or the maintenance of pregnancy.

In addition to diagnostic and therapeutic measures, the support provided by the medical staff is extremely important. The mental state of both partners can greatly affect the effectiveness, duration, and prospects of treatment. Therefore, the role and scope of medical support is extremely important [23].

In the literature, it is often noted that infertility is not perceived as a disease, but as the absence of a desired condition. Therefore, infertility has a social side, and it becomes a stressful situation for those who are faced with the problem. Thanks to the support provided, infertile couples can feel sympathy and understanding from their relatives and receive professional help from specialists [23].

Social support is a multidimensional concept, hence the attempts that are made to define it, are often based on particular elements that constitute social support. In practical terms, support is usually understood as help to another person in a difficult, stressful or critical situation from other people (relatives, acquaintances, friends), society (employees of organizations (for example, medical), the working collective (work colleagues), etc., social enterprises (foundations, trade unions, NPOs, etc.). Social support involves material, informational, or emotional help [24; 26].

Psychological assistance is provided within the framework of reproductive psychology, one of the areas of which is the problems associated with the use of assisted reproductive technologies7.

Emotional support is the most commonly identified type of support. It involves showing empathy, understanding, maintaining and maintaining calm, or expressing concern, and depends on the nature of the relationship between the individual and an environment [27; 28].

Another type of support is informational (cognitive), which helps a person experiencing a difficult situation to understand it. It includes providing information or recommendations that can help solve the problem, as well as information about how, where and to who to turn for help [28].

The material type of support consists in the possibility of implementing the IVF procedure within the framework of the HE (for example, in Russia such a measure has been in effect since 2013).

The efficiency of psychological care for women and couples with difficulties with conception is confirmed by many scientific studies in the world. The importance of this problem is also supported at the supranational level. For example, the European Society for Human Reproduction and Embryology (ESHRE) has a Section on Psychology and Counselling, the main purpose of which is to increase the knowledge of specialists about the needs of patients in psychological care and to solve their psychosocial problems. A number of European countries have implemented a whole system of psychological support for patients in IVF programs. Some of this care, for example in the UK, is included in the standard of treatment, which significantly improves the results.

The researchers note that in Russia, until recently, a predominantly medical approach to the treatment of infertility prevailed8. However, today almost all reproductive clinics employ psychologists. The effectiveness of psychological support is evidenced by Russian studies [29]. During the examination of more than 350 Russian women who applied to the National Medical Research Center of Obstetrics, Gynaecology, and Perinatology named after Ac. V. I. Kulakov, it was revealed that during psycho-correction among patients, emotional experiences are reduced and the results of treatment are significantly improved. Thus, in the group of women who attended classes with psychologists, the frequency of pregnancy was higher than in the control group: 39% vs. 26%, respectively. That is, competent psycho-correction work allows not only achieving improvements in the emotional sphere of patients, but also increasing the frequency of pregnancy.

Similar results were obtained in a Polish study conducted by Malina A. and Suvalskaya-Barantsevich D. [30] in a group of 98 respondents with infertility problems. It showed that the higher the level of perceived social support, the higher the statistically significant indicator in the mental well-being of respondents from its various aspects (self-acceptance, personal development, life goal, autonomy, control over the environment and positive relationships with other people). This study further revealed the dependence of the mental well-being of respondents undergoing infertility treatment on emotional support: the higher the level of support, the higher the psychological state is.

The importance of support for the well-being of pregnant women from the high-risk group is noted in a similar survey by Polish scientists Koss J., Rudnik A., Bidzan M. [31].

Materials and Methods

The authors formulated the following research hypotheses for assessing social support:

H.1. The couples treated for infertility, value support from their family and partner high, and they feel this support.

H.2. The level of support received from medical staff has an important influence on how support is perceived.

H.3. Women have a greater need for support than men.

H.4. Couples differ in terms of how much they are involved in support-seeking.

We used the following research tools in the study:

• 1)    the individual questionnaire and survey questionnaire developed by the authors;

• 2)    the Berlin Social Support Scales (BSSS) developed by Ralf Schwarzer and Ute Schulz [26].

The study was conducted among couples treated for infertility. Online diagnostic tests were carried out on the internet forums which support infertile couples. The respondents were informed how to complete the tests, and that these were anonymous and would be used for research purposes only. By submitting a questionnaire, they consented to take part in the study. 39 couples of childbearing age participated in the study. The respondents were divided into 4 groups based on their age. This is shown in Table 1 below.

The majority of female respondents (41.03%) were under the age of 30, followed by those aged 30–35 – 14 women (35.90%). Five women (i.e., 12.82%) were aged 36-40, and four (10.26%) were over 40 years old.

In the group of male respondents, the majority (17 respondents, which constitutes 43.59%) were aged 30–35, followed by those under 30 (11 respondents; 28.21%). Five males were over 40 (i.e., 12.38%), and six (15.38%) were aged 36-40.

Table 1. Age of respondents (in years)

Age	Females		Males
	Number	%	Number	%
< 30 years	16	41.03	11	28.21
30–35	14	35.90	17	43.59
36–40	5	12.82	5	12.38
> 40 years	4	10.26	6	15.38
Total	39	100	39	100

Source: hereinafter: data of a study conducted in the Republic of Poland (no. = 78 people).

Table 2. The presence of children before the start of infertility treatment

Previous children	Females		Males
	Number	%	Number	%
Yes	7	17.95	8	20.51
No	32	82.05	31	79.49
Total	39	100	39	100

Most couples participating in the study were married – 27 (i.e., 69.23%). 12 individuals (30.77%) were in a partner relationship.

Table 2 shows data on the presence of children before the start of infertility treatment. The data obtained show that the majority of female (82%) and male (79%) respondents did not have children before the start of infertility treatment. About a fifth of women (18%) and men (21%) have already had children before they decided to undergo infertility treatment.

Results

Based on the results, it can be concluded that most couples (62% – 24 couples) in the study group suffered from infertility from 1 to 5 years. One third of respondents (28%) suffered from infertility for over 5 years. The shortest duration of infertility (less than 6 months) was reported by 4 couples (10%). No studied couples indicated the duration period of between 6 months and 1 year (Tab. 3).

Another important aspect of the analysis is to determine the cause of infertility (Tab. 4) .The results of the survey of married couples indicate that the majority of respondents have idiopathic infertility as a cause (31%). It should be noted that in modern society, in conditions of high stress factors, poor ecology, the problem of idiopathic infertility, that is, infertility of unclear etiology, is

Table 3. Duration of infertility in the study group

Duration of infertility	Number	%
Up to 6 months	4	10.26
From 6 months to 1 year	0	0.00
From 1 to 5 years	24	61.54
Over 5 years	11	28.21
Total	39	100

Table 4. Diagnosis of married couples in the study group

Cause of infertility Number % Male factor infertility 10 25.64 Female factor infertility 11 28.21 Infertility of both partners 6 15.38 Idiopathic infertility 12 30.77 Total 39 100 very relevant. It is diagnosed when a couple passes a full examination and it is impossible to determine the causes of the problem.

On the second position, according to the survey results, female infertility (28%) and, next, male infertility (26%). A smaller proportion of the couples who took part in the study (15%) were treated for infertility of both partners.

As mentioned earlier, infertility treatment is a long process, lasting from several months to more than a decade (for example, on average, 0.5–15 years for women and 0.5–12 years for men) [26]. Table 5 shows the data on the duration of infertility treatment in the examined couples.

The research demonstrates that 18 couples in the study group were treated for infertility from 1 to 5 years (46%). The shortest duration of infertility treatment (up to 6 months) concerned 12 couples (31%). Eight couples (21%) were treated for infertility for the period of between 6 months and

1 year). The longest period of infertility treatment (over 5 years), was indicated by one couple (3%).

For the treatment of infertility, the majority of couples (56%) in the study group resorted to such assisted reproductive technology as IVF-ICSI (in vitro fertilization). In other cases (44%), another technology was used – intrauterine insemination.

Based on the results of the study, it can be stated that 62% of female and 64% of male respondents are convinced that in vitro fertilization is an innovative and effective method of infertility treatment (Tab. 6). About a third of women and the same number of men (that is, 33% in each group) believe that in vitro fertilization is effective, but controversial. Only two women (5%) and one man (3%) recognize in vitro fertilization as an innovative method that contradicts their beliefs.

The study shows (Tab. 7) that more than a third of respondents highly assesses the support of the family in the treatment of infertility (31% of women

Table 5. Duration of infertility treatment

Duration of treatment	Number	%
Up to 6 months	12	30.77
From 6 months to 1 year	8	20.51
From 1 to 5 years	18	46.15
Over 5 years	1	2.56
Total	39	100

Table 6. Attitude to in vitro fertilization in the study group

Opinions about IVF	Females		Males
	Number	%	Number	%
It is a novel and effective method of infertility treatment	24	61.54	25	64.10
It is an effective but controversial method of infertility treatment	13	33.33	13	33.33
It is a novel method, but it is against my beliefs	2	5.13	1	2.56
Total	39	100	39	100

Table 7. Perception of family support in the study group

Support level Females Males Number % Number % 1 – none 3 7.69 1 2.56 2 – low 7 17.95 2 5.13 3 – average 10 25.64 16 41.03 4 – good 7 17.95 9 23.08 5 – very good 12 30.77 11 28.21 Total 39 100 39 100 and 28% of men gave a rating of 5 points out of 5 possible). Another 16 people (7 women and 9 men) rated it with four points (18 and 23%, respectively). The combined assessment of positive perception is 49% for the female half of the respondents and 51% for the male half.

The average level of support was noted by 26% of women and 41%of men, and low scores were given by 18% of women and 5% of men. At the same time, 8% of women and 3% of men said that they do not receive any support from the family.

Comparing the level of perception of family support in the male and female groups, we can conclude that the majority of women (31%) note a very high level of support from the family (5 points), while in the male group, 41% of respondents perceive it as average (3 points). This indicates the gender characteristics of the perception of support and gives reason to judge that men, experiencing emotions, as a rule, try to contain them, coping with the problem on their own.

Based on these results, it can be argued that support is very important for every partner experiencing a difficult situation of infertility treatment. Insufficient or weak support can increase stress levels, feelings of insecurity, and feelings of ineffective treatment (Tab. 8).

The results showed that the majority of respondents (56% among women and 51% among men) stated a very good level of support from their partner (5 points). Seven women (18%) and 13 men (33%) describe their partner’s level of support as good (4 points). Only five women (13%) and six men (15%) claimed that their partner’s support was average (3 points), while five women (13%) rated their partner’s level of support in the infertility treatment process as low (2 points).

The level and quality of support received from a partner, who is the closest person, is extremely important, especially in case of infertility treatment. It gives a sense of security and confidence, thereby strengthening the ability to cope with treatment-related stress. Lack of support or low support increase the feeling of stress and helplessness.

The analysis conducted, based on the results shown in Table 9 , relates to the subjective perception of the support received from the medical staff. The majority of respondents rated the level of support of

Table 8. Perception of support received from a partner in the study group

Support level	Females		Males
	Number	%	Number	%
1 – none	0	0.00	0	0.00
2 – low	5	12.82	0	0.00
3 – average	5	12.82	6	15.38
4 – good	7	17.95	13	33.33
5 – very good	22	56.41	20	51.28
Total	39	100	39	100

Table 9. Perception of support received from medical personnel in the study group

Support level Females Males Number % Number % 1 – none 4 10.26 0 0.00 2 – low 0 0.00 2 5.13 3 – average 12 30.77 9 23.08 4 – good 12 30.77 13 33.33 5 – very good 11 28.21 15 38.46 Total 39 100 39 100 medical personnel as very good (5 points) and high (4 points). 11 women (28%) and 15 men (38%) in the study group rated the level of this support as very good, while 12 women (31%) and 13 men (33%) rated it as good. Care and support from medical staff was rated as average by 12 women (31%) and nine men (23%). Two men (5%) rated the level of support from medical staff low, while four women (10%) said they received no support.

The majority of couples who took part in the study, notice and appreciate support they receive both from their family, partner and medical staff. However, there are some individuals who do not notice this support or minimise its scope. This is quite common especially in difficult and stressful situations, such as infertility treatment. Individuals may not notice the support they receive, expect too much support, or they may not appreciate it. Having trust in medical staff and medical procedures that are used in infertility treatment, enables the patients to accept their situation and increases their belief that they are strong enough to cope with it [31]. Nurses, midwives and doctors who take care of couples treated for infertility, should pay attention to the quality of assistance and support they provide, as this influences a patient’s sense of security and treatment [25].

Most respondents assessed support received from medical staff as very good (5 points) and good (4 points). 11 women (i.e., 28.21%) and 15 men (i.e., 38.46%) in the study group, perceived support from medical staff as very good; whereas 12 women (30.77%) and 13 men (33.33%) stated that it was good. Assistance and support from medical staff were viewed as average by 12 women (i.e., 30.77%) and 9 men (i.e., 23.08%). Few respondents: 2 men (i.e., 5.13%) assessed medical staff support as low and 4 women (i.e., 10.26%) felt that they had received no support.

The findings (Tab. 10) concerning the need for support show that the mean value in the group of male respondents was 10.93 (min = 7, max=14), while it was 12.43 for female respondents (min = 7, max = 14). This result indicates that women display a higher need for support in a difficult life situation, which confirms the proposed hypothesis.

Table 11 below complements the results given, as it indicates significance of results for the need for support among respondents depending on their gender. Statistical analyses indicate that female respondents showed a significantly higher need for support both from the family, partner, and medical staff during infertility treatment, as compared to their male partners (p = 0.001).

Table 10. Need for support among women and men who undergo infertility treatment

Variable	T-test for dependent samples (Worksheet 83) Marked differences are significant when p < 0.05000
	Mean Value	Standard deviation	Significant deviation	Difference	Standard deviation difference
Need for support among men	10.92308	2.144572
Need for support among women	12.43590	2.149601	39	-1.51282	2.683986

Source: own calculations.

Table 11. Need for support among men and women, statistical significance

Variable	T-test for dependent samples (Worksheet 83) Marked differences are significant when p < 0.05000
	t	df	p	Confidence -95.000%	Confidence + 95.000%
Need for support in men & need for support in women	-3.51997	38	0.001139 **	-2.38287	-0.642773
Source: own calculations.

Table 12. Support-seeking during infertility treatment among women and men

Pair of variables	Wilcoxon signed-rank test (Worksheet 83) Marked results are significant when p < 0.05000
	N Significance	T	Z	P
Support-seeking among men and support-seeking among women	32	149.5000	2.141029	0.032272 *
Source: own calculations.

Table 12 presents the results concerning support-seeking during infertility treatment in the study group.

Statistical analyses indicate that female respondents were more likely to be involved in support-seeking both from the family, partner, and from medical staff, as compared to their partners (p = 0.03).

Discussion and Conclusions

The laws of demography say that every case of infertility is a loss of potential births, confirming that this is a problem not only for a family, but for society [33]. Therefore, investments in assisted reproductive technologies (ART) are becoming one of the ways of improving the demographic situation in countries.

Research findings have shown that couples treated for infertility, rank support from their family and partner high, and that they experience this support.

It can also be concluded that the level of support received from medical personnel significantly affects the perception of this support.

In a difficult situation such as infertility treatment, female respondents show statistically significantly higher need for support (p = 0.001) than male respondents. This is also confirmed in the literature, which points out that women are more likely to benefit from social support than men. It is also connected with the fact that women are more likely to notice this support.

Our findings indicate that the couples have different degrees of involvement in social support seeking. Female respondents are significantly more likely to get involved in support-seeking (p = 0.03) than their male partners. The analysis of research and literature shows, for example, that supportseeking is lower among couples treated for infertility (M=13.96) than among cancer patients (M=15.34) [23]. This may be caused by the fact that women feel more responsible than their partners for solving infertility problem. On the other hand, it is women that often attract more attention from those who provide support. Moreover, it is women that are more often studied by those who conduct research on the needs of couples treated for infertility [19; 24; 25]. Reproductive health is the most important component of the health of society as a whole [34], and timely identification and prompt resolution of existing problems in this area is required.

To sum up, it should be pointed out that social support has a significant impact on preventing mental disorders among people treated for infertility. It enables infertile couples to accept and reconcile with the diagnosis, which in turn facilitates infertility treatment. Therefore, it is extremely important that patients treated for infertility are provided with social support, and medical personnel establishes therapeutic contact with them [17].