The Relationship Between Social Support Perceived by Infertile Couples and Their Mental Status

Background: Infertility is a dicult process that affects couples psychologically. Providing adequate social support is important in terms of reducing the psychological problems experienced by infertile couples by facilitating compliance with the treatment. Aim/ Objective: This study evaluated the relationship between the mental status of couples receiving infertility treatment and their perceived social support. Methods: The study was descriptive study consisted of 148 infertile couples who received infertility treatment at the InVitro Fertilisation Center between January and April 2018 in a university hospital in Antalya. 148 infertile couples who received infertility treatment at the data of the research were gathered through a questionnaire for determining socio-demographic and infertility related characteristics of the couples receiving infertility treatment, Multidimensional Scale of Perceived Social Support, Brief Symptom Inventory. Results: In the study, the average age of infertile women was 31.4±5.6 and that of men was 34.5±5.2. The mean Multidimensional Scale of Perceived Social Support score of the women was determined to be 62.6±14.2, whereas that of the men 59.2± 14.2. The mean score received by the women from depression subscale of Brief Symptom Inventory was determined to be 10.2±8.9, and the mean score received by the men 6.7±6.6. A strong negative relationship between the total Multidimensional Scale of Perceived Social Supportscore and the Brief Symptom Inventory subscale mean scores (p<0.01). Conclusions: As a result of the research, as the social support levels perceived by couples receiving infertility treatment increased, their symptoms of anxiety, depression, negative self-perception, somatization, and hostility was determined to decrease.


Background
Infertility is de ned as the absence of pregnancy or the inability to continue pregnancy, although couples who want to have children have regular sexual intercourse (at least three or four times a week) for at least one year without using any contraception method [1]. Infertility is a life crisis with cultural, religious, and class aspects that brings psychological, sexual, and social problems along with itself for couples [2]. This crisis affects 10-15% of couples at reproductive age in the world and 10-20% of married couples in Turkey [3]. Infertility diagnosis and treatment process is a di cult and long process that affects couples physically, psychologically, and nancially. In this process, couples may experience stress, panic, and intense emotional pressure. However, in societies where femininity is seen as equivalent to motherhood and man as equivalent to productivity, fertility is accepted as the indicator of the individual's sexual identity. The society's exclusion of women who do not have children and questioning the masculinity of their husbands can negatively affect the mental health and quality of life of the couples, leading them to face problems such as depression, anxiety, decrease in sexual desire and deterioration in marital relations [5][6][7][8][9][10]. Studies show that both couples experience psychological problems in the treatment of infertility, but women experience more stress, guiltiness, and responsibility than men [11][12][13].
In the treatment process, where couples' anxiety levels are very high, social support is also very important for couples and the success of the treatment. Providing adequate social support facilitates the adjustment of infertile couples to treatment and can reduce the psychological problems they experience [6,14]. In the study of Slade et al. (2007), it was found that stigma perception was associated with low social support for both genders. In the same study, it is stated that as social support decreases, anxiety, depression, and infertility stress increase [8]. In a study conducted by Dilek and Beji (2012) with 80 couples who received infertility treatment at least once, it was determined that 75.0% of women and 43.8% of men believed that psychological support would increase the performance of the procedures [4].
In a study conducted by Martins et al. (2014) with couples receiving infertility treatment, it was found that infertility stress factor was caused by low spousal support for women and men, and low family support for women was also effective in experiencing stress [7]. Determining the stress levels of the couples and the problems they experience in all stages of infertility treatment and determining the solution suggestions will make important contributions to the couples to have a healthier treatment process and to increase the success of the treatment [12]. The purpose of care in the infertility treatment process is to evaluate the physical, psychological, and social conditions of the spouses, to determine the problems and needs in this area, and to provide appropriate care according to these needs [15]. Nurses are the most important health professionals who will detect changes in couples' needs and provide information and social support [1]. Along with the role of infertility nurses in medical care, they have the roles such as psychological support, quality assurance, coordinator, trainer/consultant, patient rights advocate, supporter, manager, and researcher [15]. The fact that nurses take a holistic approach and activate their social support systems in the treatment process of the infertile couple is very important for both members of the couples struggling with infertility problems.
As far as obtained from the literature, it is noteworthy that there is limited number of studies on the social support and mental states of infertile couples where they are dealt with together. In this context, in the research; it was aimed to determine the relationship between mental states and social support of couples who are in the process of infertility treatment and to draw attention to the importance of this issue. Thus, this information to be added to the literature will guide nurses, who are health professionals, in education and consultancy services. In addition, by raising the awareness of infertile couples and their relatives and by mobilizing social support systems, the mental problems of the couples can be reduced.

Study design, setting and ethics
The study was a descriptive design. This research was carried out to determine the relationship between the mental status of couples receiving infertility treatment and their perceived social support. The study, all the participants were couples who applied to the IVF center of the university hospital in Antalya, Turkey between January and April 2018. The sample of the study consisted of 148 infertile couples who received infertility treatment in the IVF Center of a University Hospital in Antalya, Turkey between January -April 2018 and volunteered to participate in the research. The aims and the methods used in our study were explained to the couples before they participated in the study, and they were assured that the results of the study would be used only for to intended purposes. The research was approved by the ethical committee of MEUSB (2017/57). Institutional permit was obtained with the decision number 15618811-302.14.04.

Socio-demographic Data Form
The data collection form which was titled "Socio-demographic Data Form" was developed in the light of the literature [1,4,5,12]. Family, Friend, and Signi cant Other subscales, respectively. Additionally, test-retest reliability of 0.85 has also been obtained. The Turkish validity and reliability study of the scale was conducted by Eker and Arkar in 2001. The high score indicates that perceived social support is high. The low score points to the absence of perceived support, a scarcity of support, or deprivation of support [12]. Cronbach's alpha coe cient of the total score was found to be 0.89 in this study.

Brief Symptom Inventory
Brief Symptom Inventory (BSI) is a Likert type scale comprising 23 items graded between 0 to 4. The high value of the total scoreobtained from the scale shows the increase of mental symptoms (Şahin et al., 2002). In our study, the coe cients calculated for the subscales regarding the internal consistency of the scale were found to be between 0.73 and 0.85.

Data collection
Data collection tools were applied to 148 infertile couples who received infertility treatment at a University Hospital between January and April 2018 and accepted to participate in the research. The purpose of the research was explained to the couples. The data collection tools were applied to the couples, by visiting the IVF center everyday.

Statistical analysis
The data were analyzed using SPPS V 20 software. Prerequisites such as variables, homogeneity of variances, and normality were evaluated using Shapiro-Wilk test and Levene's test. Two groups were compared using the Student's t-test and three or more groups were compared using the Tukey test. The value of p<0.05 was accepted for the signi cance level of the tests. Frequency, percentage, median (maximum-minimum), mean, and standard deviation values were used as descriptive statistics. The relations between the scales were evaluated through the Pearson Correlation Coe cient.

Results
The mean age of women participating in the study was 31.4±5.6 and that of men was 34.5±5.2. It was found that approximately half of the women (41.2%) were university graduates and 39.9% were working and 35.8% of the men were high school graduates and almost all of them (91.2%) were working. It was determined that 70.9% of the women and 70.3% of the men participating in the study stated that their incomes were equal to their expenses. It was determined that the majority of the couples (96.6%) participating in the study had nuclear family structure (Table 1).
Within the scope of the study, the average duration of infertility of couples, who wanted to have children, was 4.4±3.1, and it was determined that 51.4% of them could not have children in 1-3 years. However, the mean duration of treatment was 2.9±3.0, and it was found that 53.4% of them had been treated for 1-3 years. When the causes of infertility of the couples are examined, it is seen that approximately half (47.3%) are caused by other (unexplained) causes, 23.0% from sperm failure, 17.6% from Polycystic Ovary Syndrome, and 12.2% from ovarian failure.
In our study, it was found that women's anxiety subscale mean score was 7.9±8.3, that men's anxiety subscale mean score was 5.3±5.4, that women's depression subscale mean score was 10.2±8.9 that men's depression subscale mean score was 6.7±6.6, that negative personality subscale mean score of women was 6.6±7.0, that negative personality subscale mean score of men was 5.7±6.0 ( Table 2).
The MSPSS total score average of the women participating in the study is 62.6±14.2, the total score average of the men is 59.2±14.2. Mean scores of MSPSS sub-dimensions of women receiving infertility treatment; were found to be 24.2±4.6 in the family sub-dimension, 20.1±6.4 in the friend sub-dimension, and 18.3±6.8 in the special person sub-dimension. Mean scores of the MSPSS sub-dimensions of men were found to be; 23.3±5.1 in family subscale, 19.3±5.8 in friend subscale, and 16.6±6.6 in special person subscale ( Table 3).
The relationship between the Brief Symptom Inventory and its sub-dimensions and the total mean scores obtained from MSPSS is given in Table IV. It was found that as the perceived social support levels of the couples increased, the symptoms of anxiety, depression, negative self, somatization, and hostility decreased. It was found that as the mean scores of MSPSS increased, their score from the Brief Symptom Inventory was strongly and negatively affected (r=-0.766, p<0.01) ( Table 4).

Discussion
Infertility treatment process, situations such as uncertainty, anxieties for the future, hopelessness, and insu cient social support can cause mental problems in couples. Perceived social support is very important for couples to cope with this di cult process. Many studies emphasize that as the level of social support perceived by infertile couples increases, their psychological problems decrease and treatment success increases [15][16][17]. In this context, considering that social support given to couples may reduce mental problems and positively affect the success of treatment, it is thought that it is important to address the mental problems and social support of the couples together.
In our study, it was found that the anxiety, depression, and negative personality scores as SSI subscales of women, who received infertility treatment were higher compared to their husbands. As a result of the study conducted by Patel et al. done with infertile couples, it was found that women were more stressed, anxious, and depressed than their husbands [18]. In the study conducted by Omani et al., it was observed that women experienced more moderate level anxiety, depression, and stress than men [19]. In a similar study conducted by Aldemir et al., it was reported that women experienced more anxiety than men [20]. In the study of Keramat et al., it was found that infertile men had a better mental state than their spouses [21]. In the study conducted by El Kissi et al., it was determined that women experienced more anxiety, worry, and depression compared to their husbands [5]. In the study conducted by Çoban and Dinç, it was found that infertile women showed more depressive symptoms than men [22]. In the study conducted by Boadi and Asenta, it was determined that infertile women had high anxiety, somatization, and depression scores [16].
In the study conducted by Moghadam et al., it was found that depression is seen as more common in women compared to men [23]. In the study of Dilek and Beji, it was found that infertile couples participating in the study were emotionally affected by this situation during the treatment process, and that women experienced more emotional problems than their husbands [4].
Similar results were found in our study and it is an eye-catching nding that is in parallel with the literature. This situation can be explained by the fact that the social pressure and stigmatization, with which women are exposed, is higher than men, regardless of the fact that the cause of this infertility is stemming from whom. At the same time, it is thought that women's mental conditions' being worse than men might stem from the facts that women's bodies are exposed to more severe invasive and traumatic procedures than their husbands in the treatment of infertility, and from the hormonal drugs used by women during the treatment process.
Infertility is a di cult process in which individuals face an unexpected situation and disruption in future plans. The social support they perceive from their relatives is very important for couples to cope with this di cult process [24]. In our study, it was found that infertile women had a total MSPSS score of 62.6±14.2, and that infertile men had 59.2±14.2 (Table 3). As a result of our research, it was determined that the perceived social support level of women is higher than men. In the study conducted by Aldemir et al. with couples who received infertility treatment, it was found that the mean MSPSS total score was 71.91±12.17 in women and 70.38±11.71 in men [20]. In the study conducted by Martins et al. (2014), it was found that the perceived social support levels of women were higher [7]. In the study done by Sreshthaputra et al., it was determined that women have better social support than men [25]. These studies show similarity to the ndings of our study. This situation can be explained by the fact that women share their feelings with their husbands, family, or friends more than men, that they are more social and that they can use social support systems well.
Infertility is a complex life crisis for couples. The perceived social support levels by couples may affect their coping with infertility problems. It is thought that sharing feelings, thoughts, and problems experienced by infertile couples with family members, friends or a counselor reduces the experienced stress [24]. As a result of the statistical analysis performed in our study, it was found that there was a negative weak and severe relationship between all sub-dimensions of SSI and all sub-dimensions of MSPSS and total score (p<0.01). It was found that as the perceived social support levels of the couples increased, the symptoms of anxiety, depression, negative self, somatization, and hostility decreased. In the study conducted by Altıntop and Kesgin, it was found that as the level of social support in infertile couples increased, their state/trait anxiety levels decreased [11]. The study conducted by Patel et al. found that low social support projected infertility stress in couples receiving infertility treatment [18]. In the research conducted by Malina and Pooley; it has been found that as the social support decreases, the happiness of the couples and the realization of pregnancy as a result of the treatment are negatively affected [17]. As a result of 12 studies examined by Chow et al., it was found that psychosocial interventions generally improved the mental state, marital relations, and pregnancy rates of infertile couples [15]. In the study of Yazdani et al., a positive relationship was found between the use of different coping strategies by infertile couples and their perceived social support systems [26]. In the study conducted by Aldemir et al., it was found that as couples' perceived social support increased, anxiety and depressive symptoms decreased [20]. In the study done by Ilerisoy, it was found that family support was the most important coping mechanism in which couples share the di culties they experience when diagnosed with infertility and their negative feelings they experienced during the treatment process [27]. In the study conducted by Martins et al in Portugal with an infertile couple, it was found that the stress factor of infertility was caused by low spousal support for women and men, and that low family support for women was also effective in experiencing stress. In the study conducted by Martins et al. with women who received infertility treatment, it was found that perceived family support may have a strong effect on women coping with infertility stress [7]. In the study conducted by Slade et al., it was found that the perception of stigma was associated with low social support for both genders, and it was determined that anxiety, depression, and infertility stress increased as social support decreased [8].
The importance of social support in coping with psychological problems experienced by infertile couples during the treatment process has been emphasized in many studies. In studies conducted with infertile couples, it was found that as the perceived level of social support increases, the psychological problems they experience decrease. The result of our research is similar to the literature. In this context, the fact that infertile couples, who are in a crisis period of their lives, receive social support from their spouses, families, and friends has an important place in order to be able to overcome the di cult treatment process in a healthy way. As a result of our research, it can be thought that people use social support resources in stressful situations and get positive effects. In addition, the positive perception of social support during the treatment process can be explained with the fact that they do not feel the fear of abandonment thanks to the social support they receive from their spouses, that the couples regain con dence and belief in themselves, that they feel themselves well and valuable, that they experience a sense of de ciency less or none, that they ignore stigmatization and loss of status and that they apply appropriate coping strategies.

Conclusions
In line with the results obtained from the research, the following recommendations have been developed to improve the mental state of infertile couples and to increase their social support systems during the treatment process.
It is recommended the fact that the nurse determines the perceived social support factors of the couples during the treatment process and provides the necessary emotional support, The fact that nurse evaluates the changes in the mental state of the couples during the treatment process and takes steps to improve them, Explaining the importance of social support to the family, spouse, and friends of couples receiving infertility treatment and helping to develop the perceived social support systems of the couples in this process, Examining the perceived social support levels of infertile couples and the affecting factors with qualitative studies.

Declarations
The dataset generated and/or analyzed during the current study are not publicly available due to privacy but are available from the corresponding author on reasonable request.

Ethical approval and consent to participate
The research can be generalized to couples who received infertility treatment between 17 January -27 April 2018 in Akdeniz University IVF Center outpatient clinic. Data are based on participant reports.
Institutional permit was obtained with the decision number 15618811-302.14.04. Interviewers informed respondents of the nature and purpose of each survey, voluntary participation, and anonymity as well as confdentiality of information collected at the beginning of the interview. Respondents were asked to give verbal consent before proceeding, and verbal consent was obtained before conducting interview with Consent for publication Not applicable.