Iran Journal of Nursing

Introduction
Infertility is associated with conflicts, aggression, anger, divorce, isolation, and hopelessness. For many couples, it is considered a big and stressful life event. There is a direct relationship between infertility and domestic conflict. Domestic conflict is more common in infertile women than fertile women. Since infertile couples face a number of problems in their marital relationship, problem-solving skills and coping with these problems are essential to avoid experiencing domestic conflict. The use of problem-solving skills training (PSST) has been used in several studies for reducing, controlling, or fighting domestic conflict in pregnant women. However, there is scant research on the effectiveness of PSST in infertile women experiencing domestic conflict. On the other hand, few interventional studies have been conducted on domestic conflict against infertile women in Iran. Therefore, the current study aims to evaluate the effect of PSST on the exposure to domestic conflict in Iranian infertile women.
Materials & Methods
This is a quasi-experimental study with a pre-test/post-test design using a control group. The study population consists of all infertile women experienced domestic conflict and referred to the infertility clinic of Shahid Akbarabadi Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. The minimum sample size for each group was determined 40. Therefore, 80 infertile women were selected and randomly assigned to intervention (n=40) and control (n=40) groups block randomization method. The intervention received four two-hour sessions of PSST weekly in Akbarabadi Hospital. To collect the data, a three-part questionnaire was used. The first part surveys demographic characteristics (Age, educational level, occupation, years of living with husband, and household income level), The second part surveys obstetric characteristics (number of pregnancies, number of abortions, having stillbirths, history of medication therapy, history of treatment with assisted reproductive techniques such as IUI and IVF, and history of failed treatment). The third part was the Revised Conflict Tactics Scale with 36 items and five subscales of physical assault (12 items), psychological aggression (8 items), sexual coercion (4 items), sustained injury (6 items), and negotiation for solving conflicts (6 items). The samples completed the questionaries before and two months after the end of the training. Data analysis was performed in SPSS software, version 16 using t-test, chi square test, Fisher’s exact test, Mann-Whitney U test, and Wilcoxon test.
Results
Of 80 participants, 38 in each group were finally participated. Their mean age was 33.94±4.04 years in the intervention group and 32.6±6.13 years in the control group. Twenty-three (60.5%) in the control group and 16 (47.1%) in the intervention group had diploma, and 29 (76.3%) in the control group and 23 (67.6%) in the intervention group were housewives. Regarding the years of living with husband, 19 (50%) in the control group and 13 (38.2%) in the intervention group reported 5-9 years. The household income level was mostly moderate; 28 (73.7%) in the control group and 19 people (55.9%) in the intervention group. The two groups were not significantly different in terms of demographic characteristics (age, educational level, occupation, years of living with husband, and household income level) and obstetric characteristics. The incidence of psychological aggression before training was 60.5% in the control group and 55.9% in the intervention group; after training, it was 84.2% in the control group and 79.4% in the intervention group. Mann-Whitney test results did not show a significant difference in psychological aggression between the two groups before (P=0.774) and after PSST (P= 0.973). The result of Wilcoxon test showed that in the control (P=0.001) and intervention (P=0.026) groups, the mean of psychological aggression after PSST was significantly higher than that before PSST. 
The incidence of physical assault and sexual coercion before training were 23.7% and 21.1% in the control group and 25.5% and 23.5% in the intervention group; after training, they were 23.7% and 15.8% in the control group and 17.6% and 14.7% in the intervention group, respectively. Based on the results of Mann-Whitney U test, there was no statistically significant difference between the two groups in physical assault and sexual coercion neither before nor after PSST (P>0.05). The results of Wilcoxon test showed that the means of physical assault and sexual coercion after PSST was not significantly different in any groups after PSST compared to pretest scores (P>0.05).  
Discussion
The effectiveness of PSST in reducing physical assault and sexual coercion was not significant anu groups. The exposure to psychological aggression increased in the two groups after PSST. The women’s lack of familiarity with the concepts and examples of domestic conflicts at baseline and the use of online method for providing PSST due to the COVID-19 pandemic may be the reasons for ineffectiveness of PSST regarding psychological aggression. It can also be due to the negative effect of quarantine during the COVID-19 pandemic or due to their increased awareness and sensitivity to the issue of domestic conflicts (Hawthorne effect). In some studies, problem-solving skills were taught to the couples along with other skills. it should be assessed whether PSST without teaching other educational programs can be effective or not. Further studies are recommended by providing PSST via face-to-face method and using higher sample size. Of course, various factors such as the current economic and social conditions of society can affect the incidence of conflicts between couples, the effect of which should be examined in future studies using other statistical tests.

Ethical Considerations
Compliance with ethical guidelines
This study was conducted with the permission of the Ethics Committee of Iran University of Medical Sciences with code IR.IUMS.REC.1399.1171.

Funding
This study was extracted form a master thesis, and was funded by Iran University of Medical Sciences (Grant number: 99-2-3-19047).

Authors' contributions
Fahimeh Ranjbar: study design, supervision and data analysis, Maryam Mirahmadian: data collection, holding training sessions, writing the draft of the article, Shima Haqhani: data analysis, Maryam Maadi: holding training sessions and data analysis. All authors revised the draft critically and have approved the final manuscript.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Shahid Akbarabadi Clinical Research Development Unit (ShACRDU), Iran University of Medical Sciences (IUMS), Tehran, Iran for their collaboration throughout the period of study . 

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