Infertility is a global phenomenon, which is not only a health problem but a psychosocial and public health concern characterized by the lack of clinical pregnancy followed by regular unprotected sex for 12 months (1-4). Nowadays, one-fifth of couples in the world are infertile, and two million sterile couples are added to them each year (5, 6). Infertility is divided into two types: primary infertility, where no pregnancy has occurred beforehand, and secondary infertility, where pregnancy does not necessarily lead to a living birth (7). Infertility is a multifactorial problem, with about one-third of infertility cases related to women, one-third to men, and one-third to unknown factors or both men and women (8).
Infertility can have major effects on couples' life, including marital satisfaction. Marital satisfaction denotes how the expectations of sex partners from each other are met, which can have a detrimental effect on couples' minds and bodies if diminished (9). The essential purpose of libido is reproduction and childbearing; therefore, sexual satisfaction is strongly affected by infertility. According to studies, 80% of infertile people have conjugal disorders such as marital dissatisfaction, impaired interpersonal relationships, sexual dissatisfaction, decreased libido, and negative affective problems (10). Marital satisfaction is a condition where the wife and husband have mostly a satisfied and happy sense (11). Most of the time, infertile couples have no problem with sexual function, but their sexual relationship is disrupted by emotional stress and conflict over childbearing, which contributes to marital dissatisfaction (12, 13).
  It has long been claimed that men are more satisfied than women, which has been supported by several studies (14). There is evidence indicating that the correlation between marital satisfaction and gratify-cation from men differs from that of women (15). Depression and anxiety are more common in women than in men, in whom traits such as loss of confidence, depression, anxiety, shame, and guilt appear. Some investigations have shown that if infertility is linked to the malefactor, it can have a greater negative impact on couples' sexuality, while others have identified infertility as a distressing experience for women because maternity has been accepted as the main role for women. Many infertile women say that they cannot imagine a childless life, while men express a different feeling (16). According to the studies, various variables are related to the marital satisfaction trend and occasionally to mental health over time. According to World Health Organization (WHO), mental health is described as the capability to produce a peaceful relationship with others, alter the social and personal environment, resolve conflict successfully, and manage personal interests through a fair, logical, and proper method (17). Thus, mental health is the compatibility of individuals with the surrounding world, causing effective wellbeing and happiness (18).
Deviation from a society's norms is related to various emotional problems. Thus, it is essential to represent the men's and women's mental health status over their marital life (19). During the process of infertility treatment, couples have to go through the infertility crisis together and participate in long-term therapies, make joint decisions and share emotions, leading to equal or even greater marital satisfaction of them relative to fertile couples (20). The present work aimed at investigating the correlation between marital satisfaction and mental health in infertile couples who were referred to Kosar Infertility Center, Iran. Here, a framework was mainly proposed for further actions for solving marital conflicts and problems.

 

Study Design and Setting

This descriptive-analytical study was performed in Kosar Infertility Center, Urmia, in the northwest of Iran, in 2018.

Participants

Using simple random sampling, our target popu-lation consisted of all infertile couples referring to Kosar Infertility Center of Motahari Medical Center in Urmia. According to the previous article (21), the sample size was estimated as 155 (r₀ = 0.2, α = 0.05, β = 0.05) for each gender utilizing G*Power 3.1. The total calculated sample size was 310 for the study. Considering an attrition rate of 20%, a total of 372 patients (186 infertile couples) entered the study. The inclusion criteria were willing to participate; age between 20- 40 years; marriage duration of <5 years; primary infertility; not having medical diseases such as cardiovascular and pulmonary disease, hypoth-yroidism, hyperthyroidism, epilepsy, diabetes; not having drug and alcohol addiction. Unwilling to continue the participation was regarded as the exclusion criteria.

Data Collection

Data were collected using an Enrich Marital Satis-faction Questionnaire, demographic questionnaire, and General Health Questionnaire (GHQ-28). Patients filled out questionnaires under the supervision of a senior researcher. The demographic questionnaire included age, marriage age, level of education, occupation status, residual status, outcome level, infertile factor, and time of infertile.
The 47-question short form of Enrich Marital Satisfaction Questionnaire developed by Olson & Fowers (1993) was used (22), which has 12 sub-scales: Idealistic Distortion (3 questions), Marital Satisfaction (7 questions), Personality Issues (3 questions), Communication (4 questions), Conflict Resolution (4 questions), Financial Management (4 questions), Leisure Activities (4 questions), Sexual Relationship (4 questions), Children and Parenting (4 questions), Family and Friends (4 questions), Equalitarian Roles (2 questions), and Religious Orientation (4 questions). All the items should be responded to on a 5-point Likert scale (1 for completely agree, 2 for agree, 3 for not agree not disagree, 4 for disagree, and 5 for completely disagree). The scores were within the range of 47 to 235, where a higher score represents a greater marital satisfaction. The Persian version of this tool is valid for the Iranian population, which is examined based on the Cronbach's alpha of 0.95 (23).
The participants' mental health was determined using a General Health Questionnaire (GHQ-28), which included 28 questions considering all age groups. Four subscales were included in the questionnaire: anxiety, somatic symptoms, insomnia, depression, and social dysfunction. The Likert method was used to score this questionnaire; in this method, the maximum obtained score was 84. The questionnaire's cut-off point was 23. Hence, the people with mental health problems possessed scores of > 23. The examination was assessed by Palahang et al. in 1996, and its validity was determined as 91%. (24).
We used convenience sampling to recruit the infertile couples who were referred to the Kosar Infertility Center to have a physician's appointment. The infertile couples meeting the inclusion criteria were considered eligible participants. The lead researcher then invited them to contribute to the study. When the infertile couples agreed to contribute to the study, he clarified the objectives, phases, and length of the work and responded to their concerns and questions. He also assured them about the confidentiality of their information and their privacy. Next, the questionnaires were filled by them under the supervision of a researcher while waiting for a physician's appointment.

Ethical Consideration

This article was extracted from a research project approved by the Ethics Committee of the university receiving the code: (IR.UMSU.REC.1396.321).

Statistical Analysis

All 186 infertile couples were included in the analysis. In this work, the normal distribution of data was determined using the Kolmogorov–Smirnov test. In the present study, to conduct data analysis, SPSS version 25.0. (SPSS Inc., Chicago, Ill., USA) was used along with inferential and descriptive statistics. We utilized percentage and frequency for qualitative variables in descriptive statistics and the mean and standard deviation for normal quantitative variables. In inferential statistics, using Chi-square and spearman tests, we assessed the association between mental health and marital satisfaction in infertile couples.