Iran Journal of Nursing

Introduction
Infertility is one of the major reproductive problems and is defined as the inability to conceive after one year of sexual intercourse, without using any method of pregnancy prevention. Infertility can cause stress and many negative psychological reactions including depression, anxiety, worry, anger, shame, jealousy, loneliness, despair, hopelessness, decreased self-esteem, emotional imbalance, feelings of sexual inadequacy, sexual dysfunction, and decreased sexual satisfaction. Infertile women usually face more family and social problems and are more stressed than men. Infertility stress has many symptoms similar to post-traumatic stress disorder. It includes the interaction between physical conditions causing infertility, medical interventions, reactions of others, and individual/mental characteristics, and may remain for years and recur with any diagnostic or therapeutic intervention. In addition to drug therapy, infertile women should pay serious attention to the impact of psychological and sociological factors. They should be able to regulate mental pressures and manage emotional reactions using a set of cognitive processes, which is called the cognitive emotion regulation skill. In fact, cognitive emotion regulation includes the strategies used to reduce, increase or regulate emotional experiences. It seems that cognitive behavioral therapy can be effective in this field. The goal of this intervention is to modify irrational thoughts and beliefs, misinterpretations, and cognitive errors and have a feeling of control over life, facilitating self-talk and increasing coping skills. Considering the important role of cognitive emotion regulation in the psychological state of infertile women and the lack of intervention to deal with the infertility stress in infertile women, this research aims to evaluate the effectiveness of cognitive-behavioral infertility stress coping training on the cognitive emotion regulation of infertile women in Iran.

Methods 
This is a quasi-experimental study using a pre-test/post-test/two-month follow-up design. The study population consists of infertile women referred to infertility treatment centers and visited specialists in Kermanshah, Iran in 2022. The inclusion criteria were consent to participate in the research, obtaining a high score in the infertility stress test (>190), and not receiving psychological treatments within 3 months before the intervention. The exclusion criteria were absence from more than two training sessions and incomplete responses to the questions. To determine the sample size, Fleiss’s sample size calculation formula was used. Based on the equation, a sample size of 12.07 was obtained, which was considered to be 20 for each group. Therefore, 40 eligible infertile women were selected using a convenience sampling method and randomly divided into two groups of intervention and control group. The measurement tools included Newton’s fertility problem inventory and Garnefski and Kraaij’s cognitive emotion regulation questionnaire (CERQ) with nine components of Self-blame, Acceptance, Rumination, Positive refocusing, Refocus on planning, Positive reappraisal,  Putting into perspective, Catastrophizing, and Blaming others. The intervention group received the cognitive-behavioral infertility stress coping training program at 12 90-min sessions, developed by Ghobadi et al. The control group was put on the waiting list. At the end of the training session, both groups were re-evaluated. The collected were analyzed using descriptive statistics and repeated measures analysis of variance (ANOVA) in SPSS software, version 24.

Results
There were significant differences between the two groups in the CERQ components (P<0.05). There was a significant increase in the scores of the intervention group compared to the control group. The results of ANOVA to investigate the effects of time showed that the effect of time on the CERQ and its components was significant (P<0.05). There was a significant difference between the three stages of pre-test, post-test, and follow-up. The effect size was 91.3%. The results of the Bonferroni post hoc test indicated a significant difference from the pre-test to the follow-up phase in the intervention group.

Conclusion
 The cognitive-behavioral infertility stress-coping training program can improve the cognitive emotion regulation of infertile women. This program, by providing effective techniques for stress management, problem-solving, acceptance and for increasing patience, and strengthening the relationship with God, can help infertile women to reduce their irrational thoughts at any time, increase their distress tolerance and satisfaction with their lives, and be more hopeful about treatment and the future.

Ethical Considerations
Compliance with ethical guidelines
This study has ethical approval from the Islamic Azad University, Sanandaj Branch (Code: IR.IAU.SDJ.REC.1402.060).

Funding
This article was extracted from a PhD thesis in General Psychiatry at the Faculty of Literature and Humanities, Islamic Azad University, Sanandaj Branch. This study did not receive any financial support from funding organizations in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization and methodology: Samaneh Ghobadi and Keyvan Kakabrai; Data collection and analysis, and writing: Samaneh Ghobadi; Supervision: Keyvan Kakabrai and Mahmoud Goodarzi; Review and editing: Keyvan Kakabrai.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all the infertile women who participated in this research and the gynecological and infertility experts for their cooperation in this study.



References

1. Greil AL, McQuillan J, Burch AR, Lowry MH, Tiemeyer SM, Slauson-Blevins KS. Change in motherhood status and fertility problem identification: Implications for changes in life satisfaction. J Marriage Fam. 2019; 81(5):1162-73. [DOI:10.1111/jomf.12595] [PMID] [PMCID]
2. Rezvani F, Vaziri S, Lotfi Kashani F. [Developing a structural model of infertility stress based on emotional schemas, couple conflict, self-effort with the mediation of social support (Persian)]. J Psychiatr Nurs. 2018; 7(4):75-83. [Link]
3. Kim JH, Shin HS, Yun EK. A dyadic approach to infertility stress, marital adjustment, and depression on quality of life in infertile couples. J Holist Nurs. 2018; 36(1):6-14.  [DOI:10.1177/0898010116675987] [PMID]
4. Bräuner EV, Nordkap L, Priskorn L, Hansen ÅM, Bang AK, Holmboe SA, et al. Psychological stress, stressful life events, male factor infertility, and testicular function: A cross-sectional study. Fertil Steril. 2020; 113(4):865-75. [DOI:10.1016/j.fertnstert.2019.12.013] [PMID]
5. Starabadi M, Amirfakhrai A, Keramati K, Samavi AV. [Effectiveness of acceptance and commitment therapy on stress and depression in infertile couples (Persian)]. Women Stud. 2019; 11(31):25-40. [DOI:10.30465/ws.2020.5344]
6. Kim M, Moon SH, Kim JE. Effects of psychological intervention for Korean infertile women under In Vitro Fertilization on infertility stress, depression, intimacy, sexual satisfaction and fatigue. Arch Psychiatr Nurs. 2020; 34(4):211-7. [DOI:10.1016/j.apnu.2020.05.001] [PMID]
7. Nehra A. Role of neuropsychology in continuum of health care in neurological conditions. Neurol India. 2019; 67(2):404-9. [DOI:10.4103/0028-3886.258013] [PMID]
8. Strauss AY, Kivity Y, Huppert JD. Emotion regulation strategies in cognitive behavioral therapy for panic disorder. Behav Ther. 2019; 50(3):659-71. [DOI:10.1016/j.beth.2018.10.005] [PMID]
9. Zvolensky M, Jardin C, Farris SG, Kauffman B, Bakhshaie J, Garey L, et al. Gut interpretations: How difficulties in emotion regulation may help explain the relation of visceral sensitivity with depression and anxiety among young adults with gastrointestinal symptoms. Psychol Health Med. 2018; 23(7):840-5. [DOI:10.1080/13548506.2018.1455984] [PMID]
10. Loevaas MES, Sund AM, Lydersen S, Neumer SP, Martinsen K, Holen S, Reinfjell T. Does the transdiagnostic EMOTION intervention improve emotion regulation skills in children? J Child Fam Stud. 2019; 28:805-13. [DOI:10.1007/s10826-018-01324-1]
11. Tavakoli H, Akbari B, Salari A. [Effectiveness of group cognitive-behavioral therapy on the cognitive emotion regulation strategies and psychological flexibility in patients with non-cardiac chest pain (Persian)]. Yafte. 2020; 22(2):131-43. [Link]
12. Golshani F, Hasanpour S, Mirghafourvand M, Esmaeilpour K. Effect of cognitive behavioral therapy-based counseling on perceived stress in pregnant women with history of primary infertility: A controlled randomized clinical trial. BMC Psychiatry. 2021; 21(1):278. [DOI:10.1186/s12888-021-03283-2] [PMID] [PMCID]
13. Ashrafian F, Sadeghi M, Rezaei F, Kazemi Rezaei SV. [The effect of an integrated approach of positive cognitive behavioral therapy on sexual satisfaction and marital adjustment of infertile women (Persian)]. J Nurs Midwifery. 2020; 18(7):597-607. [DOI:10.29252/unmf.18.7.597]
14. Zare H, Abbaspour P, Yousefi F. [The role of problem-solving and cognitive restructuring skills training on cognitive emotion regulation strategies and family functioning in infertile women (Persian)]. J Cogn Psychol Psychiatry. 2015; 2(1):81-93. [Link]
15. Hashemi F, Fili AR, Safarinia M. The effectiveness of stress management skills training (cognitive-behavioral) on the mental health of infertile women. Health Psychol. 2014; 3(12):58-69. [Link]
16. Chobforoshzadeh A, Kalantari M, Molavi H. [The effectiveness of cognitive behavioral therapy for stress management on the quality of life of infertile women (Persian)]. Iran J Gynecol Obstet Infertil. 2011; 14(1):14-21. [DOI:10.22038/ijogi.2011.5789]
17. Askari P, Saedi S. [Educational effectiveness of immunization against stress on the quality of life of infertile women (Persian)]. Thought Behav. 2012; 6(24):28-19. [Link]
18. Latifnejad Roudsari R, Rasolzadeh Bidgoly M, Mousavifar N, Modarres Gharavi M. [Investigating the effect of collaborative infertility counseling on the perceived stress of infertile women undergoing IVF treatment (Persian)]. Iran J Women Midwifery Infertil. 2010; 14(4):31-22. [DOI:10.22038/ijogi.2015.5766]
19. Garnefski N, Rieffe C, Jellesma F, Terwogt MM, Kraaij V. Cognitive emotion regulation strategies and emotional problems in 9 - 11-year-old children: The development of an instrument. Eur Child Adolesc Psychiatry. 2007; 16(1):1-9. [DOI:10.1007/s00787-006-0562-3] [PMID]
20. Hasani J. [Investigating the validity and reliability of the short form of the cognitive regulation of emotion questionnaire (Persian)]. J Res Behav Sci. 2011; 9(4):229-40. [Link]
21. GHobadi S, Kakabraee K, Goudarzi M. [The effectiveness of cognitive-behavioral coping training package with infertility stress on distress tolerance and cognitive regulation of emotion in infertile women (Persian)]. J Ilam Uni Med Sci. 2024; 32(5):106-23. [Link]
22. Li G, Zhao D, Wang Q, Zhou M, Kong L, Fang M, Li P. Infertility-related stress and quality of life among infertile women with polycystic ovary syndrome: Does body mass index matter? J Psychosom Res. 2022; 158:110908. [DOI:10.1016/j.jpsychores.2022.110908] [PMID]
23. Karimi F, Zargarshirazi F. [The effectiveness of cognitive-behavioral therapy on cognitive emotion regulation and distress tolerance in women with substance-dependent spouses (Persian)]. Res Addict. 2024; 17(70):175-94. [DOI:10.61186/etiadpajohi.17.70.175]
24. Foroughameri M, Hatami M, Rafieipour A, Niknam M. [Investigating the effectiveness of cognitive-behavioral therapy on infertility stress and health-promoting behaviors of infertile women (Persian)]. Commun Health. 2017; 15(3):65-75. [DOI:10.22123/chj.2021.272564.1676]

25. Starabadi M, Amirfakhrai A, Keramati K, Samavi AV. [Efficacy of cognitive- behavioral therapy (CBT) on the infertility stress and depression in the infertile couples (Persian)]. Med J Mashhad Univ Med  Sci. 2021; 61(6):3127-36. [DOI:10.22038/mjms.2021.17962]
26. Delpasand T, Ahadi H, Jamhori F. [The effectiveness of stress management training (cognitive-behavioral strategies) on perceived stress and ivf outcome in women with infertility (Persian)]. Med J Mashhad Univ Med  Sci. 2022; 65(4):1975-83. [DOI:10.22038/mjms.2022.22876]
27. Poursadeg Z, Azemuodeh M. [The effects of life skills training on cognitive emotional regulation strategies of pregnant mothers (Persian)]. Commun Health J. 2019; 13(2):56-64. [DOI:10.22123/chj.2019.194233.1325]
28. González-Fernández S, Fernández-Rodríguez C, Mota-Alonso MJ, García-Teijido P, Pedrosa I, Pérez-Álvarez M. Emotional state and psychological flexibility in breast cancer survivors. Eur J Oncol Nurs. 2017; 30:75-83. [DOI:10.1016/j.ejon.2017.08.006] [PMID]
29. Mérida-López S, Extremera N, Rey L. Emotion-regulation ability, role stress and teachers' mental health. Occup Med. 2017; 67(7):540-5. [DOI:10.1093/occmed/kqx125] [PMID]
30. Shabannezhad A, Fazlali M, Mirzaian B. [The mediating role of emotion regulation difficulty in the relationship between psychological flexibility and loneliness in infertile women (Persian)]. Iran J Psychiatr Nurs. 2020; 9(4):74-83. [Link]
31. Rezaei SM, Safara M, Mousavinejad SM. [The role of infertility stress and defeat in predicting the quality of infertile women's marital relationship (Persian)]. Qom Univ Med Sci J. 2020; 15(2):140-9. [DOI:10.52547/qums.15.2.140]