Iran Journal of Nursing

Introduction
Infertility is one of the global health issues that, in addition to the financial burden, places a psychological burden on couples. Stress, anxiety, and depression are among the most common mental disorders of infertile women. The difficulty of treatment and high costs increase stress, and there is a need to improve resilience to make it easier to tolerate. Emotional Freedom Technique (EFT) tapping is one of the stress reduction strategies that can be helpful for these women. The present study aims to determine the effect of EFT tapping on the stress and resilience of infertile women in Iran. 

Methods 
This randomized clinical trial study was conducted from February to August 2023 on 98 infertile women referring to public and private clinics in Bandar Abbas, Iran, randomly divided into intervention and control groups. Participants in the intervention group received group EFT tapping in 4 sessions with a one-week interval. In the first session, the severity of stress was rated from 0 (no stress) to 10 (severe stress). In the second session, the karate chop point (located below the little finger) was tapped, or the point in 3 cm from the collarbone was rubbed while asking the patient to say three times: “Despite this problem, I am ok, and I accept myself.” In the third session, the negative part of the sentence (“Despite this problem”) was repeated on each point, and each point (located at the beginning of the eyebrow, the end of the eyebrow, below the eye, below the nose, below the lip, collarbone, below the chest, below the armpit, next to the thumb, near the index finger, near the middle finger, and near the little finger) was tapped seven times with the tip of the index finger or with the two index and middle fingers, and the sentence was corrected and repeated. 
One tap on one of the points on both sides of the body was sufficient. In the fourth session, the subjects tapped the Gamut point (between the little finger and ring finger on the back of the hand) with their index and middle fingers while asking them to do the following exercises: 1- open eyes, 2- close eyes, 3- eyes down to the right, 4- eyes down to the left (while holding the heads straight), 5- roll eyes clockwise, 6- roll eyes counter-clockwise, 7- hum a short song for two seconds, 8- count from one to five, and 9- hum the same song for two seconds. In the final session, the tapping of the points was repeated as described in the third session, and the severity of the problem was assessed again. If the stress severity decreased but not reach a zero point, the steps would be repeated, and the sentence would be changed to: “Even though I still have this problem, I deeply and completely accept myself.” 
The data collection tools included a sociodemographic form (surveying the age and education of the woman, the age and education of the husband, the occupation of the woman and husband, family income level, housing status, duration of marriage, economic status, duration of infertility, cause of infertility), Newton’s fertility problem inventory (FPI), and the Connor-Davidson resilience scale (CD-RISC). The FPI is a 46-item instrument with 5 domains: Social concerns (items 1-10), sexual concerns (items 11-18), relationship concerns (items 19-28), rejection of childfree lifestyle (items 29-36), and need for parenthood (items 37-46). The items are scored on a Likert scale from 1 (strongly disagree) to 6 (strongly agree). The items 1, 2, 5, 6, 10, 12, 13, 21, 28, 29, 30, 31, 33, 34, 35, 36, 43 have reversed scoring from 1 (strongly agree) to 6 (strongly disagree). 
The total score ranges from 46 to 276. The CD-RISC is a 25-item scale scored on a Likert scale from 0 (completely false) to 5 (always true) with a total score ranging from 0 to 100, with a higher score indicating greater resilience. Its five constructs are personal competence, trust in one’s instincts/tolerance of negative affect, positive acceptance of change/secure relationships, control, and spirituality. The validity of the questionnaires was confirmed by the professors from the School of Nursing and Midwifery, Iran University of Medical Sciences. Cronbach’s alpha values obtained for the FPI and CD-RISC were 0.767 and 0.863, respectively. The questionnaires in Persian were completed by the participants before and after the intervention. 
Data analysis was performed in SPSS software, version 16. The qualitative variables were reported in frequency and the quantitative variables in mean and standard deviation. The chi-square test and Fisher’s exact test were used to examine the difference between the two groups in the qualitative variables, while independent t-test and analysis of covariance were used to compare quantitative variables. 

Results
There was no statistically significant difference between the two groups in FPI score before the intervention (P=0.055). After the intervention, the FPI score in the intervention group was significantly lower (P<0.001). The mean scores of FPI before and after the intervention were 168.06±34.06 and 134.59±26.02 in the intervention group and 155.26±31.08 and 156.83±31.28 in the control group, respectively. The effect size of the intervention on stress was 0.714.
The mean CD-RISC score before and after the intervention was 26.64±20.13 and 82.97±9.63 in the intervention group, and 83.71±30.33 and 71.04±12.95 in the control group, respectively, indicating a significant increase in the resilience of the intervention group compared to the control (P<0.001). The effect size of the intervention on resilience was 0.753.

Conclusion
The EFT can reduce the stress of infertile women and increase their resilience. This cost-effective, safe, and easy method can be recommended by the medical staff to infertile women for better resilience and stress reduction.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1401.335) and was registered by the Iranian Registry of Clinical Trials (ID: IRCT20220820055755N1).

Funding
This paper was extracted from the master’s thesis of Marzieh Torabi funded by Iran University of Medical Sciences.

Authors' contributions
Investigation and sampling: Marzieh Torabi and Zahra Khashavy; Writing, supervision, review: Masoomeh Kheirkhah; Data analysis: Shima Haghani.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all the women who participated in this study and the staff of hospitals in Bandar Abbas city for their cooperation in this study.


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