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The effect of supportive counseling on self-esteem of infertile women after in vitro fertilization (IVF) failure: a randomized controlled trial study

BMC Psychology volume 12, Article number: 408 (2024) Cite this article

Abstract

Background

The unsuccessful treatment of infertility can lead to heightened levels of negative emotions, which are often associated with various psychological consequences. These consequences may include a decrease in self-confidence, feelings of loneliness, reduced self-esteem, and even discontinuation of treatment. Therefore, it is crucial to implement interventions that can help improve these consequences for women who have experienced IVF failure. The present study aimed to examine the effect of supportive counseling on self-esteem of infertile women after IVF failure.

Methods

this randomized clinical trial study was conducted on 63 infertile women after IVF failure, referred to Milad Infertility Center in Mashhad in 2021. In the intervention group, the researcher provided individual supportive counseling sessions. These sessions took place over a span of four weeks, with each session lasting 60 min (One session every week). Data collection was conducted both before and one month after the study using Eysenck self-esteem Questionnaire. Data were analyzed using SPSS25, as well as statistical tests such as chi-square, independent t-test, Paired t-test and Mann-Whitney tests. A significance level of less than 5% was considered.

Results

The study found no significant difference in mean scores of self-esteem between the two groups before the study (p = 0.823). However, after one month, the intervention group had significantly higher self-esteem scores (24.3 ± 18.55) compared to the control group (21.74 ± 5.62) (p = 0.043) Moreover, Based on the Within-group comparison, there was a 2.43 ± 3.24 point increase in self-esteem scores of the intervention group after one month, while the control group showed a -0.33 ± 3.72 point decrease.

Conclusion

Supportive counseling was found to be effective in improving self-esteem following IVF failure. As a result, it can be recommended as an effective, affordable, and low-risk counseling approach for women who have experienced IVF failure. By offering supportive counseling, it is possible to help prevent and alleviate the psychological consequences associated with IVF failure.

Trial registration

This research project was registered at the Iranian Registry of Clinical Trials with code IRCT20210407050883N1- Date of registration 2021-05-25.

Peer Review reports

Introduction

Infertility is considered a crisis in life and is associated with various social, physical, psychological, and financial challenges [1]. According to the World Health Organization, infertility is defined as a reproductive system disorder that results in the inability to conceive after 12 months or more of regular unprotected intercourse [2, 3]. Research indicates that the prevalence of infertility ranges from 3.5 to 16.7% in developed countries and from 6.9 to 9.3% in less developed countries [4]. In Iran, the overall frequency of primary infertility is 5.2%, secondary infertility is 3.2%, and the overall average of infertility is 13.2% [5].

Infertility complications are highly prevalent, and with significant advancements in infertility treatment, many couples facing infertility aspire to become parents [6]. The three primary approaches to treating infertility include drug treatment, surgery, and assisted reproductive methods (ART) [7]. Among the various assisted reproductive methods, in vitro fertilization (IVF) is one of the most commonly used techniques. The use of IVF was doubled from 2000 to 2013 [7]. According to Donckers et al. (2011), the success rate after each IVF cycle was 18% [8]. In Iran, the success rate of assisted reproductive methods has been reported to be 23.94% [9].

In women undergoing infertility treatment, a negative pregnancy test result often intensifies the psychological consequences they experience [10, 11]. These individuals commonly report symptoms of anxiety, anger, withdrawal, and depression, as well as a decrease in self-confidence [12, 13], In particular, it has been widely recognise that both members of infertile couples pursuing treatment may perceive significant levels of anxiety and depression, that may deeply impact on their lives, as well as treatments success and follow-up. Therefore, infertility research made increasing efforts to identify variables influencing psychological health outcomes of infertile couples such as gender, age, educational level and employment status in influencing the infertility-related stress process. In particular, female gender, increasing age low educational level and unemployed status are signifcantly related with higher risk of reporting psychological health outcomes disorders [14]. Also reduced self-esteem and even discontinuation of treatment following unsuccessful outcomes [15].

Self-esteem refers to an individual’s overall evaluation of their own worth as a human being. This self-evaluation significantly affects a person’s psychological well-being. High self-esteem acts as a protective factor, enabling individuals to cope with psychological pressures and effectively navigate negative and stressful life events without experiencing excessive negative emotions or disintegration [16]. Self-esteem was negatively associated with depression and anxiety. In other words, self-esteem could affect the effects of infertility-related stress on depression and anxiety. Specifically, self-esteem mediated and moderated the effects of infertility-related stress on depression and anxiety [17]. The study conducted by Elyasi .F et al. (2021) demonstrated that addressing the psychological needs of infertile individuals was an essential component for successful infertility treatment [18]. Additionally, among infertile couples, the most common reason for discontinuing treatment after negative results is the psychological burden associated with these outcomes [19]. Furthermore, Ebrahimzadeh et al. (2019) indicated that inadequate support for patients following unsuccessful treatment overshadowed any support provided during the course of treatment [20].

Support and a positive and empathetic relationship with a supporter are crucial for individuals to adapt to stressful situations and facilitate their recovery [21]. Having an active support system can help individuals regain their lost self-confidence and cope more effectively with crises, thereby reducing the pressure caused by these challenging circumstances [22, 23].

Supportive counseling is an approach used to assist individuals who are experiencing a crisis or temporary state of confusion. Its purpose is to help individuals achieve better adaptation to stressful situations by strengthening their abilities through reassurance, explanation, guidance, encouragement, and providing a safe space for emotional release. The ultimate goal of supportive counseling is to enhance clients’ self-confidence and independence in decision-making [24, 25].

Infertility threatens the mental health of couples by reducing self-confidence and self-esteem and makes them vulnerable mentally, therefore psychological interventions such as counseling are needed to help couples to improve their mental health and increase their self-esteem. One of the uses of supportive counseling is for people who are in a crisis or temporary state of turmoil, such as failure in infertility treatment, so due to the high rate of treatment discontinuation after IVF failure and the subsequent psychological consequences, including reduced self-esteem, and the lack of similar studies, the present study aimed to examine the effect of supportive counseling on self-esteem of infertile women after IVF failure, with hypotheses that supportive counseling can improve women’s self-esteem after infertility treatment failure.

Materials and methods

This study received approval from the ethics committee (in accordance with the Declaration of Helsinki) of Mashhad University of Medical Sciences with code (IR.MUMS.NURSE.REC.1400.010) and was registered at the Iranian Registry of Clinical Trials with code IRCT20210407050883N1.

The inclusion criteria for participants in the study were as follows: a diagnosis of primary infertility, Iranian nationality and residency in Mashhad, a minimum education level of elementary school, absence of any known medical conditions, a negative pregnancy test following the first IVF, possession of a smartphone or electronic device with internet connectivity, non-use of cigarettes and alcoholic beverages, and absence of mental illness.

The exclusion criteria included occurrence of stressful events during the study and participation in other educational and counseling sessions during the study. The data collection tools used in the study included a questionnaire on demographic characteristics and infertility, as well as the Eysenck self-esteem Questionnaire.

The Eysenck self-esteem Questionnaire consists of 30 questions, which can be answered as yes with a score of 1 or no with a score of 0. In the scoring method, responses associated with self-esteem receive a score of 1, while no points are allocated to responses concerning feelings of inferiority. A higher score indicates a higher level of self-esteem. The validity of this questionnaire was confirmed in the study of Moghadam et al. using the content validity method and the reliability of this questionnaire was confirmed based on the study of Heydari et al. with Cronbach’s alpha coefficient of 0.86. [26, 27].

The researcher visited the Milad Infertility Center daily in order to gather data. Women who visited the center in Mashhad for IVF treatment and met the inclusion criteria were selected for the study. Participants were randomly assigned into the intervention and control groups using a random sequence generated by site www.randomization.com. Small cards indicating the respective group names were prepared and placed in sealed envelopes according to this sequence. Upon the inclusion of each eligible participant, the envelope was opened, and they were assigned to the corresponding group mentioned on the card.

Before the study, the women completed the questionnaire on demographic characteristics and infertility-related information and the Eysenck self-esteem Questionnaire. These questionnaires were self-reported by the participants.

In the intervention group, infertile women received four individual supportive counseling sessions in addition to the routine care provided by the center. Two of these sessions were conducted in person (the first and fourth sessions), while the other two sessions were conducted virtually (the second and third sessions). Each session took place once a week, with a duration of 60 min. The face-to-face sessions were held at the Milad Infertility Center in Mashhad.

During each counseling session, the researcher allocated a total of 45 min for guidance and discussion, and the remaining 15 min were used to summarize content and determine the timing of the next session. The content was tailored to the goals and steps of supportive counseling. Here is a breakdown of the content covered in each session:

  1. 1.

    The first session began with establishing positive and empathetic communication with the clients, followed by an explanation of the research topic and objectives. Supportive techniques such as active listening, empathy, and reassurance were utilized to address any misunderstandings or doubts the patients had. Potential abilities were highlighted, and information was provided to reduce mental pressure. The Jacobsen relaxation technique was trained, and clients were assigned homework to practice the technique daily. The session concluded with a summary of the topics discussed and coordination for the next meeting.

  2. 2.

    The second and third session involved providing feedback on the content of the previous sessions and reviewing the homework which was about last sessions assigned. Clients were given permission to express their emotions. The counselor used guidance techniques to explain various forms of assisted reproduction and treatment protocols. Encouragement and persuasion techniques were employed by presenting statistics on the success of assisted reproductive methods, sharing experiences of successful mothers, and conducting interviews with successful mothers. The sessions concluded with a summary of the topics discussed and coordination for the next session.

  3. 3.

    The fourth session began with feedback on the content of the previous session. Techniques for emotional disclosure and release were practiced. The supporting counseling continued through active and empathetic listening and promoting a positive and unconditional outlook on life. Practice of the Jacobsen relaxation technique was reinforced. Additionally, during the study, ten-minute telephone follow-ups were conducted to remind clients of the next session and address any questions they had.

Infertiled women in the control group received routine care provided in the Milad Infertility Center, which included phone calls about how to proceed with the treatment process. Four weeks after the study, the women of two groups completed the Eysenck self-esteem Questionnaire.

Data were analyzed using SPSS25, as well as statistical tests such as chi-square, independent t-test, Paired t-test and Mann-Whitney tests. A significance level of less than 5% was considered.

Results

The participants in the two groups were similar in terms of a range of demographic and infertility characteristics, including age, education level and occupation (of both the wife and husband), income, duration of marriage, the duration of infertility diagnosis and treatment, the cause of infertility and the type of assisted reproductive treatments received (p > 0.05) (Table 1).

There was no significant difference in mean score of self-esteem between the two groups before the study (21.75 ± 4.72 vs. 22.03 ± 5.26, P = 0.823). However, after one month, the intervention group had significantly higher self-esteem scores (24.3 ± 18.55) compared to the control group (21.74 ± 5.62) (p = 0.043).

The results of within-group comparison showed that in the intervention group, the mean score of self-esteem after the intervention (24.3 ± 18.55) was significantly higher than before the intervention(21.75 ± 4.72) (p < 0.001) But in the control group, the mean score of self-esteem before the study (22.03 ± 5.26) was significantly higher than after the study (21.74 ± 5.62) (p = 0.048), there was a 2.43 ± 3.24 point increase in self-esteem scores of the intervention group after one month, while the control group showed a -0.33 ± 3.72 point decrease (p = 0.015) (Table 2).

Table 1 Demographic and infertility characteristics of infertile women in the intervention and control groups
Full size table
Table 2 Total mean (SD) scores of self-esteem among infertile women in the intervention and control groups
Full size table

Discussion

The results of the present study demonstrated a statistically significant difference in self-esteem between the intervention and control groups four weeks after the study concluded. Furthermore, the mean self-esteem score in the intervention group increased significantly after the study, indicating the effectiveness of supportive counseling in improving self-esteem. It is worth noting that the mean self-esteem score in the intervention group was significantly lower before the study compared to after the study. Conversely, the control group had a significantly higher mean self-esteem score before the study compared to after the study. These results suggest the positive effect of supportive counseling on self-esteem levels in the intervention group.

Counseling interventions that address the psychological and social needs of infertile individuals can be beneficial [28]. Supportive interventions, by increasing self-esteem, have the potential to improve adaptation skills and promote overall health [29,30,31,32]. Supportive counseling specifically aims to enhance optimal psychological function by rehabilitating and strengthening individuals’ abilities to manage their lives, while also fostering self-respect and self-confidence [33]. It helps individuals become aware of their limitations, both personal and therapeutic, while maximizing self-esteem. Supportive counseling, with its integrated approach, can be tailored to meet the specific needs of each individual, making it applicable in various medical and rehabilitative settings [34]. Also it should be noticed that men as partners have an important role on the treatment process. Men may experience infertility indirectly through the impact that it has on their partners. Martins, M V et al(2014) in their study reinforce the need to involve the male partner throughout the whole treatment process and for couple-based interventions when providing infertility counseling [35].

Regarding the effect of supportive counseling, Galvin el al (2010) demonstrated that it reduced postpartum depression in mothers [21]. Similarly, Manne el al (2007) found that supportive counseling reduced depression symptoms in women with cancer [36].

Rahimi el al (2021) in their study entitled " Effect of Hope-oriented group counseling on mental health of infertile women with failed IVF cycles: a randomized controlled trial” which was conducted on 60 women with failed IVF cycles visiting Infertility showed that Hope-oriented group counseling was effective in reducing stress and depression and improving quality of life in these women. The results are consistent with the present study and the reason for this similarity can be the similar statistical population with similar beliefs and culture, as well as the structure of counseling sessions and the way they are conducted [37].

The results of the study by Angelika Szatmari el al (2022) in Hungary showed that Paramedical counselling joining an infertility treatment programme alone had a positive role in reducing depressive symptoms and in the increase of self-esteem among infertile men, but receiving additional paramedical counselling throughout the treatment programme resulted in the decrease of anxio-depressive symptoms, besides the elevation of the level of self-esteem, with a significantly higher decrease in the state anxiety compared to not receiving this additional paramedical counselling [38].

However, Kong et al. (2014). focused on the effect of supportive counseling on distress levels in women after abortion and did not show significant changes in distress levels. The reason for the contradictory results of this study with the current one can be the difference in the cultural structure of different societies and the way of participation of the research units or the target society. In Kong’s study, the target population is women who have had an abortion, which may have been voluntary and desired by them, and for this reason, it is different from the infertile women who consisted the research units of the current study and they are eager for a successful and healthy pregnancy [39].

It should be known that one of the main goals of supportive counseling is to increase patients’ self-awareness and self_steem about the nature of their disease and how to control and adopte with it. It can also be said that supportive counseling about patients’ self-steem behaviors leads to increased knowledge and awareness, improved quality of life, reduced anxiety, increased client satisfaction, reduced morbidity, and increased patient participation in health care programs and patient independence in daily activities.

The effective and low-cost counseling method for women in need of support after IVF treatment failure which is done by midwives is one of the advanteges of the present study. Also, due to the referral of a large number of infertile couples from different areas of Mashhad to the Milad Infertility Center, the results of the present study can be generalized to the whole society. One of the limitations of the present study is the personal characteristics and psychological condition of people, which have an important effect on counseling sessions and also the duration of the research as well as the response of the participants that could not be controlled completely. However, assigning people in two groups randomly solves this limitation very much. Due to obtaining information such as demographic characteristics, data related to infertility and history of medical diseases from the research units and checking the accuracy of their statements, it was not possible to blind the research units during the consultation sessions.

Conclusion

The present study is the first to investigate the impact of low-cost and effective counseling provided by midwives for women following IVF failure. The selection of the Milad Infertility Center adds to the generalizability of the results, as it serves as a referral center for individuals from Razavi Khorasan province and neighboring provinces.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ARTs:

Assisted reproductive technologies

IVF:

In vitro fertilization

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Acknowledgements

This article was extracted from a research project (code: 991970). Hereby, we would like to express our appreciation to Mashhad University of Medical Sciences.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or nonprofit section.

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Authors and Affiliations

  1. School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

    Manijeh Shafaghi, Golnaz Sadat Ahmadinezhad & Seyed Reza Mazloum

  2. Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

    Fatemeh Zahra Karimi

  3. Department of Midwifery, School of Nursing and Midwifery, Mashhad University Medical of Medical Sciences, Mashhad, Iran

    Fatemeh Zahra Karimi

  4. Department of Psychology, Faculty of Education and Psychology, Ferdowsi University of Mashhad, Mashhad, Iran

    Haniye Zarif Golbar Yazdi

  5. School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

    Malihe Afiat

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Contributions

Conception and design: MSH, FZK, SRM, HZG, MA Literature search, Data acquisition, Analysis and interpretation of data: All authorsCritical revision of the manuscript: All authors.

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Correspondence to Fatemeh Zahra Karimi.

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This research project was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran, with code (IR.MUMS.NURSE.REC.1400.010) and was registered at the Iranian Registry of Clinical Trials with code IRCT20210407050883N1- Date of registration 2021-05-25. Written informed consent was obtained from all participants, in accordance with the Declaration of Helsinki.

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Shafaghi, M., Ahmadinezhad, G.S., Karimi, F.Z. et al. The effect of supportive counseling on self-esteem of infertile women after in vitro fertilization (IVF) failure: a randomized controlled trial study. BMC Psychol 12, 408 (2024). https://doi.org/10.1186/s40359-024-01914-3

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