IN VITRO FERTILIZATION

Transcription

1 FERTILITY AND STERILITY VOL. 75, NO. 6, JUNE 2001 Copyright 2001 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. IN VITRO FERTILIZATION Psychopathology, personality, and marital relationship in patients undergoing in vitro fertilization procedures Paola Salvatore, M.D., a Simonetta Gariboldi, M.D., b Ada Offidani, M.D., c Francesco Coppola, M.D., c Mario Amore, M.D., a and Carlo Maggini, M.D. a Instituto di Clinica Psichiatrica, University of Parma, Parma, Italy Objective: To compare the psychopathology, personality features, and marital relationships of women undergoing in vitro fertilization (IVF) with those of control patients, and to compare IVF inductees with program veterans. Design: Cross-sectional clinical study. Setting: A university hospital. Patient(s): One hundred and one women undergoing IVF treatment. Intervention(s): Psychometric tests were administered at first visit (baseline) of index treatment cycle. Main Outcome Measure(s): Achievement of pregnancy. Result(s): Women undergoing IVF show higher levels of anxiety and emotional tension than do controls. Although the infertile women showed no abnormal personality dimensions, the IVF group did have a particular psychological profile and a different marital relationship pattern when compared with the control participants. Between IVF veterans and inductees, there are significant differences with respect to psychopathology, psychological dimensions, and couple dynamics. The achievement of pregnancy is not associated with any special psychopathological, personality, or marital characteristics among the IVF women. Conclusion(s): The most crucial period in IVF procedures may immediately follow the end of the first cycle because of the high risk of patients dropping out of the program. To determine the most effective supporting therapies for women undergoing fertilization procedures it could be useful to consider the psychological and relational differences between veterans and inductees. (Fertil Steril 2001;75: by American Society for Reproductive Medicine.) Key Words: IVF, partnership, psychopathology, personality features, supportive therapies Received August 7, 2000; revised and accepted December 22, Reprint requests: Carlo Maggini, M.D., Istituto di Clinica Psichiatrica, Universitá di Parma, Ospedale Ugolino da Neviano, piazzale Matteotti 9, Parma, Italy (FAX: ; psichiat@unipr.it). a Instituto di Clinica Psichiatrica, University of Parma. b School of Psychiatry, University of Parma. c Infertility Center of Obstetrics and Gynecology Clinic, University of Parma /01/$20.00 PII S (01) Infertility, the inability to conceive after 1 or 2 years of regular unprotected sexual intercourse (1, 2), is frequently a source of emotional trauma for infertile couples. Their psychological reactions depend on their basic personality structure, their unique coping strategies, their preexisting level of psychopathology, and their environmental support (3). Even when infertile women have been described as neurotic, dependent, anxious, or emotionally distressed, such personality traits and emotional disturbances have never been demonstrated to be the major cause of their infertility, although life stress may indirectly affect neuroendocrine functions (2, 4 10). The psychological distress tends to increase during in vitro fertilization (IVF) treatment. The stage-like nature of the procedure is considered a stressful experience, especially when the duration of infertility lengthens and patients experience repeated failures to conceive (11 20). Currently available data from studies on women undergoing IVF are ambiguous. Some investigators have reported that women experience high levels of psychological distress, anxiety, and depression, as well as marital difficulties and changes in sexual functioning (11 13, 21 25) during IVF treatment; other studies have not found any relevant levels of psychopathology (4, 26 29). However, the latter data may reflect some methodological biases: 1) IVF programs offer infertile women a hope of having a child, so they may feel less depressed, anxious, and helpless; 2) only emotionally adjusted women in happier marriages 1119

2 choose to confront the emotional stress of IVF treatment; and 3) unselected control groups of volunteers and routinecare gynecology patients may experience many psychological maladjustments or health problems. The purpose of our study was to investigate whether women undergoing infertility treatment differ from a control group of healthy women with regard to psychiatric symptoms, personality characteristics, sexual satisfaction, and marital relationship dynamics. Because anxiety and depression are considered causes for early drop-out after the first IVF cycle and for lower pregnancy rates (12, 13, 30), clinical psychological evaluations may lead to the identification of adequate psychological support therapies that can complement IVF procedures. MATERIALS AND METHODS All of the women consecutively admitted to the Infertility Center of the Obstetrics and Gynecology Clinic of the University of Parma, Italy, from January 1998 to May 1999 for the IVF program were considered for our study. Women met the inclusion criteria if 1) they had attempted pregnancy for at least 24 months without conception; 2) they were in a steady relationship with a partner; 3) they were younger than 42; and 4) they did not show uterus abnormalities at the hysterosalpingraphy. Patients with a history of pregnancy termination, spontaneous abortion, or live birth were not excluded. The approval of the university review board was obtained for this protocol, and a total of 101 women participated in the study after giving informed consent. The control group consisted of 75 routine-care gynecology patients who were not undergoing any form of fertility treatment. No women who presented for treatment other than routine care (such as unwanted pregnancy, irregular periods, abdominal pain, or endometriosis) were included in the control group. All of the study participants completed the following questionnaires. 1. The General Health Questionnaire (GHQ-30), 30 items for the assessment of psychological distress (31). 2. The Symptom Check List (SCL-90), 90 items for the evaluation of psychopathological symptoms (32). 3. The Personality Disorders Questionnaire (PDQ-R), for the assessment of the personality disorders according to the DSM III-R criteria (33). 4. The Matussek Questionnaire, for the evaluation of the couples partnership (34). 5. The Minnesota Multiphasic Inventory (MMPI), for the measurement of psychological functioning (35). Questionnaires were administered to the infertile women as part of the pretreatment evaluation and to the control participants as part of their routine-care evaluation. The GHQ-30, SCL-90, MMPI were self-administered by the participants at home, and the Matussek Questionnaire was administered by trained psychiatrists who were blinded to the results of the psychopathological and personality scales. The tests were evaluated by other trained psychiatrists on the staff of the Psychiatric Clinic of Parma University. Expert psychiatrists were also part of a psychoeducational component of the treatment procedures, providing emotional and psychotherapeutic support to the IVF patients throughout the treatment period. Statistical Analysis Comparisons between the groups were made with the chi-square test for categorical variables and with the twotailed Student t test and one-way analysis of variance with the Scheffé post-hoc analysis for numerical variables. Data are presented as mean SD for numerical variables and in percentage for categorical variables. The data analysis was performed with the use of SPSS for Windows 8.0 (SAS Institute, Inc., Cary, NC). RESULTS Sample A total of 101 infertile women (mean age years; range 26 to 42 years) and 75 control participants (mean age years; range 21 to 39 years) (t 8.2; P.001) were enrolled in the study. The education level and occupation were similar among the patients and controls (data not shown). The patients infertility conditions were categorized as mechanical (uterus damage), idiopathic (unknown), male factor, and hormonal (ovulation and endometriosis). Male factor infertility was present in the 35.1% of the couples, mechanical infertility in the 32.1%, hormonal infertility in 1.9%, and idiopathic infertility in the 1.5%. The mean duration of infertility was years, ranging from 1 to 14 years. To differentiate IVF program veterans and inductees, the number of IVF cycles was obtained for each patient, ranging from zero to five. Psychological Assessment Neither the patients or the controls showed significant differences in their levels of psychological distress, as demonstrated by the total score of the GHQ-30 ( vs ). Nor was there any significant rate of personality disorders for the patients, compared with controls (9.6% vs. 9.3%). On the SCL-90, the anxiety score was significantly higher in patients than in controls (Table 1). On the MMPI, the patients compared with controls showed significantly higher scores in hysteria (Hy scale), depression (D scale), and hypochondriasis (Hs scale) and lower scores in masculinity femininity (Mf scale) and schizophrenia (Sc scale). Thus, the IVF patients appeared to be characterized by a seductive and manipulative personality, a dramatic and excessive way of expressing emotions (Hy scale), and a tendency to read their physical symptoms in an abnormal and unrealistic manner (Hs scale). Patients also seemed to em Salvatore et al. Psychopathology, marital aspects, and IVF Vol. 75, No. 6, June 2001

3 TABLE 1 SCL-90 and MMPI scores in IVF subjects and controls. Variables Patients t-test P value Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Anger, hostility Phobia Paranoid ideation Psychoticism L F K Hypochondriasis Depression Hysteria Psychopatic deviation Masculinity-femininity Paranoia Psychoastenia Schizoprenia Mania Social introversion Salvatore. Psychopathology, marital aspects, and IVF. Fertil Steril body the feminine roles of passivity, dependency, and sensitivity (Mf scale) (see Table 1). To evaluate the couples partnerships, the Matussek Questionnaire explored the sexual relationship, aggression in the couple, and roles in the relationship (Table 2). For emotional relationship towards partner the IVF patients expressed idealization, desire for more emotional contact, and propensity to feel emotional stagnation; in contrast, the controls showed satisfaction with their emotional contacts and a positive emotional attitude. In the area of Sexual Relationship the IVF patients reported less general satisfaction, placed less blame on their partner s sexual problems, and had more desire for pregenital tenderness than did the controls. In the indirect aggression towards partner field, the patients expressed more chronic nagging, a reproachful attitude, a tendency to elaborate intrigues, and a view of themselves as passive victims in the relationship; the controls expressed more irony and cynicism. Within the selfesteem in the relationship area, patients were less sensitive, less vulnerable, and less easily hurt by partners; the controls had a more balanced self-esteem. In the roles in the relationship field, the controls were better able to alternate between fusion and autonomy, domination and submission, and male and female roles. Finally, we assessed the women on the basis of the duration of infertility and the number of IVF attempts. Among the IVF patients, duration of infertility was positively related to the K scale (psychological defenses) (P.04), to the L scale (lie) (P.009), and to the Hs scale (hypochondriasis) (P.02) of the MMPI. On the Matussek Questionnaire, women with a long history of infertility reported more desire for emotional contact and closeness (76.9%), fewer requests for pregenital tenderness (100%), and less exclusive focus on partner (65%) than did the women with a shorter experience of infertility (66.7%, P.04; 54.5%, P.03; 68.8%, P.04, respectively). We compared the patients who were at their first IVF cycle (I inductees) with those who had previously undergone IVF treatments (V veterans) within the infertile group. The SCL-90 somatization scale and the MMPI Hs (hypochondriasis) and Hy (hysteria) dimensions were negatively related to the number of IVF cycles (respectively, P.02; P.03; P.01). The SCL-90 Anxiety scale (P.04) and the MMPI Hy (hypocondriasis), Hs (hysteria) and Pa (paranoia, suspiciousness, distrust, and a sensitive attitude) dimensions (P.002, P.008, and P.03, respectively) were significantly higher in the patients at the first cycle. On the Matussek Questionnaire, there were no differences between patients at their first and those at their subsequent cycles. Regarding outcome findings, there were no significant differences in psychopathological scales (GHQ-30 and SCL-90) or personality characteristics (PDQ-R) between the patients who had successful and unsuccessful IVF treatments. On the Matussek Questionnaire, FERTILITY & STERILITY 1121

4 TABLE 2 Matussek Questionnaire s results in subjects and controls. Explored areas and items No. of patients (%) No. of controls (%) 2 P value Emotional relationship towards partner a Emotional attitude towards partner Idealizing Mainly positive emotional attitude Emotional ambivalence Desire for more emotional contact Wants more emotional contact Wants less emotional contact Is satisfied with the emotional contact Feeling of emotional stagnation in the relationship Yes No Sexual relationship to the partner a General satisfaction in the sexual relationship Yes No Blames partner for her own sexual problems Yes No Great desire for pregenital tenderness in the relationship Yes No Indirect aggression towards partner a Chronic nagging Yes No Irony, cynism Yes No Self-pity, feels a victim Yes No Intrigues Yes No Guilt feelings and reproachful attitude Guilt feelings towards partner Reproachful attitude towards partner Both guilt feelings and reproachful attitude Neither guilt feelings nor reproachful attitude Self-esteem in the relationship a Self-esteem where partner is concerned Exaggerated self-esteem, arrogance Low self-esteem, feelings of unworthiness Balanced self-esteem (Continued) 1122 Salvatore et al. Psychopathology, marital aspects, and IVF Vol. 75, No. 6, June 2001

5 TABLE 2 (Continued) Explored areas and items No. of patients (%) No. of controls (%) 2 P value Sensitive, vulnerable, and easily hurt by partner Yes No Roles in the relationship a Fusion with partner Life revolves around partner Would like partner s life to revolve around her Alternates between the two roles No fusion with partner Domination of the partner Dominates partner Lets partner dominate her Alternates between two roles No domination of or submissiveness Male-female distribution of roles Has the traditional male role Has the traditional female role Alternates between the two roles No such division of roles a Areas of interest Salvatore. Psychopathology, marital aspects, and IVF. Fertil Steril the women who had had positive IVF outcomes showed a statistically significant difference in their less exclusive closeness with partners and their search for friendships and social contacts (positive outcome 50% vs. negative outcome 19%, P.039). DISCUSSION The results of this study indicate that both the women undergoing IVF treatment and the control participants manifested a certain level of aspecific distress (GHQ-30 scores higher than 5), but the IVF women showed higher levels of anxiety and emotional tension than did the controls (higher scores in SCL-90). No significant differences between women who were undergoing IVF treatment and the control participants were found regarding the prevalence of personality traits and disorders according to DSM III-R criteria. The MMPI profiles (36) indicate that there are no abnormal symptomatic aspects or personality dimensions exhibited by infertile women in comparison with the controls. Nevertheless, the IVF group did have a specific psychological profile. Our results showed that the IVF women were more prone to abnormal psychological reactions with hypochondriac concerns and beliefs about bodily illness and/or malfunctions (hypochondriasis subscale). The IVF women demonstrated traits of shyness, reserve, high sensitivity, pessimism, and a sense of distrust (depression subscale). The IVF women, moreover, appeared dependent on and prone to delegate decisions and responsibilities to their partners (masculinity femininity subscale); their emotional conflicts and lack of emotional defenses caused ambivalent behaviors and manifested as a seductive style of communication (hysteria subscale). What emerged was a stereotypical female profile of passivity and sensitivity. Our data concerning psychopathological symptoms agree with those of Hynes et al. (11) and Oddens et al. (21) who reported a significant increase in anxiety among IVF women compared with controls, yet they contrast with those of Downey et al. (4) and Beutel et al. (14), who did not find different levels of psychopathology between IVF women and controls. With regard to personality, our data confirm other studies (8, 37) that failed to find abnormal traits and/or personality disorders in IVF patients. The findings of our study generally indicate that aspecific levels of anxiety are elevated in IVF patients, but neither depression nor personality disorders were pathological in our sample in comparison with the control group. As for levels of anxiety our data are consistent with most of the studies that found in IVF women high levels of psychological distress (12, 21, 24). Regarding depression and personality disorders our results confirm those studies that didn t find FERTILITY & STERILITY 1123

6 elevated levels of psychopathology in these areas (22, 26, 27). Our data from the MMPI are in accordance with the study by Freeman et al. (38) concerning the absence of pathological levels of emotional distress and the presence of lower scores in Mf subscale in IVF women. However, we did not find comparable high scores on the Ego-Strength Scale that would indicate a high level of social adjustment and an ability to face stressful situations. Our profile of dependent and insecure women also differs from that of Moreno et al. (26) who, by means of Cattel s Questionnaire, found that infertile women were more dependent, conformist, disciplined, and able to adapt to new situations than their partners. Our data also show that, in comparison with controls, infertile women are more symbiotic and prone to idealize their partners, but feel unsatisfied with their emotional and sexual relationships. They desire pregenital tenderness and emotional closeness more than the healthy study participants. In addition, the IVF women tend to maintain role rigidity within the couples relationship, to be indirectly aggressive, and to experience feelings of victimization and reproachful attitudes toward their partners compared with controls. To evaluate the changes of inner experience after multiple IVF attempts, we compared infertile women veterans of IVF procedures and women at their first attempt (inductees). The results indicated that veterans show a decreased desire for sexual closeness and an increased emotional contact with their social environment, despite the persistence of the need for emotional fusion with the partner. Consistent with these data are those of Newton et al. (25), Kedem et al. (39), and Hynes et al. (11) who found that women undergoing multiple IVF treatments and experiencing numerous failures were more capable of social adjustment. Assessing the emotional impact of repeated IVF failures, Newton et al. (25) and Kedem et al. (39) found that women were prone to look for more emotional and social support. According to Moreno et al. (26), veterans need a more intense emotional relationship with others. In our sample, inductees reported a higher score of anxiety (SCL-90) and a more pronounced proneness to somatization, hypochondriac concerns, and adjustment rigidity than veterans. These results seem to confirm those of the literature indicating that anxiety levels decrease from the first IVF procedure to the following ones (20, 24). Johnson et al. (24) pointed out that women at their last IVF attempt show marked anxiety symptoms, as this treatment may represent their real last possibility to procreate. Nevertheless, our data are not consistent with those studies that reported a significant increase of depressive features in veterans after repeated IVF failures (13). The low levels of depression in our sample may indicate that emotional frustration from the recurrences of failed IVF attempts does not cause a depressive condition, but rather could bring about an improvement in adjustment strategies. This improvement is evidenced by the decrease of neurotic features (such as somatization and hypochondriasis) and by the achievement of emotional maturity in the partnership, indicated by replacing symbiotic attitudes with social extraversion. As Mao and Wood (12) have proposed, the crucial step in IVF procedures may be represented by the period immediately following the end of the first cycle. According to these investigators, anxiety and depression experienced during this phase may cause a premature drop-out from treatment and lead the couple to desist from any further attempt. In light of this hypothesis, the first IVF cycle might be regarded as a natural screening process through which women undergoing infertility treatments will be able to structure most of their effective coping strategies. Other causes of early drop-outs might be financial reasons; fortunately, in Italy IVF treatment administered free of charge is partially subsidized by the public health care system, so financial concerns don t generate additional anxiety and depression. Our study shows some methodological biases, such as the relatively small sample size and the lack of a period for follow-up evaluation permitting a test/retest procedure. However, the comparison with a control group and the evaluation of emotional and relational attitudes within the marital relationship have allowed us to identify some practical tools and treatment approaches for women undergoing IVF treatment. From a therapeutic point of view, it could be useful to consider the psychological and relational differences between veterans and inductees. With the inductees it is necessary to explore both the psychopathological areas that will eventually be involved (anxiety, depression, and somatization) and the emotional and relational dynamics within the couple to avoid a premature withdrawal from the treatment and to induce a faster process of learning coping strategies. With veterans, therapeutic interventions could be focused on partnership dynamics and improvement in coping behaviors to compensate for the distress experienced from the waning possibility of a pregnancy. References 1. Mosher WD, Pratt WF. Fecundity and infertility in the United States, Advance data from vital and health statistics, No Hyattsville, MD: National Center for Health Statistics, Rosenthal M. Women and infertility. Psychopharmacol Bull 1998;34: Rosenthal M, Goldfarb J. Infertility and assisted reproductive technology. An update for mental health professionals. Harv Rev Psychiatry 1997;5: Downey J, Yingling S, McKinney M, Husami N, Jewelewicz R, Maidman J. Mood disorders, psychiatric symptoms, and distress in women presenting for infertility evaluation. Fertil Steril 1990;52: Rosenthal M. Psychiatric aspects of infertility and assisted reproductive technologies. Infertil Reprod Med Clin North Am 1993;4: Rubinow DR, Roca CA. Infertility and depression. Psychosom Med 1995;57: Lapane KL, Zieler S, Lasater TM, Stein M, Barbout MM, Hume AL. Is a history of depression symptoms associated with an increased risk of infertility in women? Psychosom Med 1995;57: Salvatore et al. Psychopathology, marital aspects, and IVF Vol. 75, No. 6, June 2001

7 8. Eldelmann RJ, Connolly KJ. Psychological aspects of infertility. Brit J Med Psychol 1986;59: Garcia CR, Freeman EW, Rickels K, Wu C, Scholl G, Galle PC, Boxer AS. Behavioral and emotional factors and treatment responses in a study of anovulatory infertile women. Fertil Steril 1985;44: Stoleru S, Teglas JP, Fermanian J, Spira A. Psychological factors in the etiology of infertility: a perspective cohort study. Hum Reprod 1993; 8: Hynes GJ, Callan VJ, Terry DJ, Gallois C. The psychological wellbeing of infertile women after a failed IVF attempt: the effects of coping. Br J Med Psychol 1992;65: Mao K, Wood C. Barriers to treatment of infertility by in vitro fertilization and embryo transfer. Med J Aust 1984;140: Thierring P, Beaurepaire J, Jones M, Saunders D, Tennant C. Mood state as a predictor of treatment outcome after in vitro fertilization/ embryo transfer technology (IVF/ET). J Psychosom Res 1993;37: Beutel M, Kupfer J, Kirchmeryer P, Kende S, Kohn FM, Schroeder- Printzen I, et al. Treatment-related stresses and depression in couples undergoing assisted reproductive treatment by IVF or ICSI. Andrologia 1999;31: Barnea ER, Tal J. Stress-related reproductive failure. J In Vitro Fert Embryo Transf 1991;8: Lalos A, Lalos O, Jacobsson L, Von Schoultz B. Depression, guilt and isolation among infertile women and their partners. J Psychosom Obstet Gynaecol 1986;5: Leiblum SR, Kemmann E, Lane MK. The psychological concomitants of in vitro fertilization. J Psychosom Obstet Gynaecol 1987;6: Mahlstedt PP, MacDuff S, Bernstein J. Emotional factors and the in vitro fertilization and embryo transfer process. J In Vitro Fert Embryo Transf 1987;4: Johnson WI, Oke K, Speirs A, Clarke GA, McBain J, Bayly C. Patient selection for in vitro fertilization: physical and psychological aspects. Ann NY Acad Sci 1985;442: Berg BJ, Wilson JF. Psychological functioning across stages of the infertility investigation. J Behav Med 1991;14: Oddens BJ, Tonkelaar I, Nieuwenhuyse H. Psychosocial experiences in women facing fertility problems: a comparative survey. Hum Reprod 1999;14: Eugster A, Vingerhoets AJ. Psychological aspects of in vitro fertilization: a review. Soc Sci Med 1999;48: Lukse MP, Vacc NA. Grief, depression, and coping in women undergoing infertility treatment. Obstet Gynecol 1999;93: Johnson WI, Oke K, Speirs A, Clarke GA, McBain J, Bayly C, et al. Patient selection for in vitro fertilization: physical and psychological aspects. Ann NY Acad Sci 1985;442: Newton CR, Hearn MT, Yuzpe AA. Psychological assessment and follow-up after in vitro fertilization: assessing the impact of failure. Fertil Steril 1990;54: Moreno JR, Garcia CV, Garcia Merita ML, Tortajada Martinez MG. Personality characteristics analysis in couples undergoing artificial insemination. Hum Reprod 1994;9: Paulson JD, Haarmann BS, Salerno RL, Asmar P. An investigation of the relationship between emotional maladjustment and infertility. Fertil Steril 1988;49: Haseltine FP, Mazure C, De L Aune W, Greenfeld D, Laufer N, Tarlatzis B, et al. Psychological interviews in screening couples undergoing in vitro fertilization. Ann NY Acad Sci 1985;442: Freeman EW, Rickels K, Tausig J, Boxer A, Mastroianni L, Tureck RW. Emotional and psychosocial factors in follow-up of women after IVF-ET treatment. Acta Obstet Gynecol Scand 1987;66: Demyttenaere K, Bonte L, Gheldof M, Vervaeke M, Meuleman C, Vanderschuerem D, D Hooghe T. Coping style and depression level influence outcome in in vitro fertilization. Fertil Steril 1998;69: Goldberg D. G.H.Q. (General Health Questionnaire): the detection of psychiatric illness by questionnaire. London: Oxford University Press, Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric rating scale preliminary report. Psychopharmacol Bull 1973;9: Hyler JE, Skodol AE, Kellman D, Oldham GM, Rosnick L. Validity of the personality diagnostic questionnaire revised (PDQ-R): comparison with two structured interviews. Am J Psychiatry 1988;147: Matussek P, Luks O, Seibt G. Partner relationships of depressives. Psychopathology 1986;19: Hathaway SR, McKinley JC. Minnesota Multiphasic Personality Inventory. Firenze: Organizzazioni Speciali, Hathaway SR, McKinley JC. User s guide for the Minnesota Report. Minneapolis: Interpretiv Scoring Systems, Callan VJ, Hennessey JF. Emotional aspects and support in in vitro fertilization and embryo transfer programs. J In Vitro Fert Embryo Transf 1988;5: Freeman EW, Boxer AS, Rickel K. Tureck R, Mastroianni L. Psychological evaluation and support in a program of in vitro fertilization and embryo transfer. Fertil Steril 1985;43: Kedem P, Mikulincer M, Nathanson Y. Psychological aspects of male infertility. Br J Med Psychol 1990;63: FERTILITY & STERILITY 1125