Contemp Fam Ther (2009) 31:3451 DOI 10.

1007/s10591-008-9077-z ORIGINAL PAPER

The Infertility Resilience Model: Assessing Individual, Couple, and External Predictive Factors
Aaron F. Ridenour Jeremy B. Yorgason Brennan Peterson

Published online: 24 September 2008 Springer Science+Business Media, LLC 2008

Abstract Resilience in couples experiencing infertility is critical to decrease the impact of infertility-related stress and sustain positive interactions and collective perceptions in couples. The Infertility Resilience Model (IRM) presented in this article provides a framework within which various individual, couple, and external factors that inuence resilience can be understood. Although numerous approaches have been applied to infertility, few of them have examined resilience and the interconnections between individual, couple, and external inuences. The concepts and connections within the model can be used by clinicians for assessment and interventions when working with couples facing infertility. Keywords Infertility Resilience Couples Theoretical model

Infertility is dened as the inability to attain a successful pregnancy after 12 consecutive months of regular, unprotected sexual intercourse (Watkins and Baldo 2004). Although studies indicate somewhat different trends, ndings are generally conclusive that around 15% of reproductive couples face stress caused by infertility (Spector 2004). Among couples confronted with reproductive problems, 50% will likely never bear children (Spector 2004). Consequently, infertility is a stressor involving critical implications for many couples attempting to have a biological child.
A. F. Ridenour (&) Brigham Young University, 722 Wymount Terrace, Provo, UT 84604, USA e-mail: cicau@hotmail.com J. B. Yorgason School of Family Life, Brigham Young University, 2079 JFSB, Provo, UT 84602, USA e-mail: jeremy_yorgason@byu.edu B. Peterson Department of Psychology, Marriage and Family Therapy Program, Chapman University, One University Drive, Orange, CA 92866, USA e-mail: bpeterson@chapman.edu

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Previous research has identied negative outcomes in relation to infertility-related stress, as well as several inuential factors that facilitate positive outcomes at the individual and couple levels. A number of different approaches have been used to understand the experiences of couples faced with infertility. Some of these models include stress and coping (Zucker 1999), the close relationship model of infertility (Higgins 1990), selfdiscrepancy theory (Kikendall 1994), object relations (Greenbaum 2005), self-regulation (Benyamini et al. 2004), the relational model of development (Gibson and Myers 2000), a medical/family systems approach (McDaniel et al. 1992), and attachment (Amir et al. 1999). Each of these applications provides insightful perspectives on the experiences of those facing infertility, yet few of them consider individual, relational, and environmental inuences together. Furthermore, although these approaches consider adaptation to infertility, few discuss processes and outcomes in terms of resilience, or developing strengths in the face of adversity (Boss 2007). In this article we analyze specic factors identied in the literature that may assist couples in coping and building resilience when faced with infertility. We present the Infertility Resilience Model (IRM), which incorporates individual, couple, and external factors. This model provides research-based guidelines for assessing couples level of resilience as related to infertility.

The Infertility Resilience Model (IRM): A Brief Overview The theoretical foundation of the IRM is based on assumptions of the double ABC-X model developed by McCubbin and Patterson (1982) and the family resilience framework developed by Walsh (2002). Specically, family stressors interact with perceptions, resources, and coping strategies, which lead to family adaptation or resilience outcomes. In a discussion of how family stress theory and family resilience are theoretically compatible, Patterson (2002) suggests that three main ideas be included: rst, exposure to signicant risk should be demonstrated; second, protective factors should be identied; and third, the operational denition of resilience needs to specify resilience as either a process or an outcome, and it needs to include a description of the unit of analysis (individual, couple, or both). With regard to risk, couples may experience infertility stress at different levels, yet for the purposes of our model, we focus on couples who meet the clinical denition of infertility. Regarding protective factors, we must consider both couple- and individual-level resources. For example, couple protective factors may include relationship quality prior to experiencing infertility, couple communication skills, and access to infertility treatments and information. Individual protective factors could include mental health and religiosity/spirituality. With regard to the denition of resilience, we examine both couple processes of resilience and resilient outcomes for couples. Also, we consider both individual- and couple-level factors in assessing resilience. In summary, we draw upon the previously established frameworks of family stress theory and family resilience to develop our model with the purpose of helping clinicians to explore resilience and to assess coping strategies among infertile couples. A conceptual representation of the IRM is illustrated in Fig. 1. The complexity of experiences surrounding infertility is represented in the model by external, couple, and individual factors. At the broadest level, there are external factors that inuence couple resilience. These may include inuences that relate to both individual and couple perceptions of infertility. In other words, they inuence interpretations of particular stressors and available resources. Furthermore, non-shared external inuences accompany

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*External Influences affecting the Husband

Husbands Perception

Collective Interaction

Collective Perception

Wifes Perception
*External Influences affecting the Wife

Fig. 1 Conceptual Representation of the Infertility Resilience Model. *External/Environmental Inuences include geographic location, diagnosis, socioeconomic status, social support, education, ethnicity, duration of infertility, religiosity, and cultural inuences (these inuences may be shared or non-shared)

the construction of ideological foundations from which individuals create personal beliefs and develop coping strategies in response to stress. The husband and wife may share similar cultural or ethnic backgrounds, but may differ in terms of age, family of origin, and/or religious afliation. In the current research, we examine external factors that inuence individual perceptions and interpretations as well as couples collective perceptions. Adjacent to and shaped by external factors in the IRM are individual perceptions, interpretations, and coping strategies. Individuals unique perceptions within the marital relationship can be shaped by different gender backgrounds and experiences (Berghuis and Stanton 2002; Greil et al. 1988; McDaniel et al. 1992). The current review includes the primary inuences of individual perceptions and interpretations in relation to external and couple factors. Next in the IRM are collective interactions and perceptions of couples experiencing infertility-related stress. This particular aspect of the model focuses on the congruence of partner perceptions as well as marital interactions between partners, resulting in the couples collective perception. Perceptions and meaning are important elements of the family stress literature. Patterson and Garwick (1994) suggest that meaning is derived at multiple levels, including (a) how individuals perceive the demands of their situation versus their capabilities; (b) the ways they view their relationships; and (c) the ways they see themselves in relation to the world around them. At the individual level, the demands of infertility are often perceived as outside of ones control. At the couple level, perceptions of the relationship can be altered by infertility-related stress. In relation to a couples world view, infertility-related stress can lead to paradigm shifts where expectations for life are altered (Day 2005).

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The nal part of the model represents couples resilience. Couple resilience to infertility may be dened as a process, such as relationship cohesion or positive communication during the ambiguous times following diagnosis. For example, resilience may be displayed by remaining close as a couple despite failure to conceive a child, or becoming accustomed to the idea that one will never have children. Indeed, some have suggested that it may be the couples with higher marital quality that seek infertility treatment in the rst place (Peterson et al. 2006a). Resilience to infertility also may be considered as an outcome of the interconnections between the external factors, individual inuences, and collective interactions and perceptions, which will be discussed. Consequently, resilience depends on the individuals and couples ability to effectively modify previous views, resulting in acceptance of infertility regardless of existent external inuences or infertility treatment outcomes.

The Infertility Resilience Model (IRM): A Review of the Literature External Inuences External inuences are those factors outside of the individual and couple that are associated with how individuals and couples cope with and adapt to infertility. External factors are often socially based, such as family and community support, cultural and ethnic expectations, religiosity, and socioeconomic status. They also may be medically based, such as the inuence of diagnosis (e.g., male factor vs. female factor infertility), duration of infertility, interactions with medical personnel, and the cost and geographic proximity of infertility treatment. In some ways, social support from family and community can be positive when a couple faces infertility, while in other ways that support can be negative. Regarding the positives, families and communities can, and often do, provide emotional, nancial, spiritual, and other types of support. For example, research indicates that partners of women who coped with infertility by seeking social support reported less distress (Stanton et al. 1991). Although positive family and community support is given to couples facing infertility, much of the related literature focuses on challenges within families and communities. For example, well-intended relatives providing unsolicited advice (such as to relax) to an infertile couple may do more harm than good, leading the couple to feel increased frustration and feelings of personal failure. Families and communities help to dene the experience of infertility for couples. Not having children can inuence patterns such as feelings of generativity or a loss of family and community future, failure in differentiating from ones family of origin or not being seen as adults, an imbalance in parental or community attention (or both) to families with children, strained sibling and peer relations as similar developmental stages are no longer shared, family and community members not knowing how to respond to infertility, and infertile couples avoiding child-centered family activities (Burns 1987; McDaniel et al. 1992; Meyers et al. 1995a). In summary, the source of support for couples facing infertility can also be the very source of strain. Some have labeled this paradox as the double-edged sword of social support (Revenson et al. 1991). Cultural and socioeconomic issues also are becoming recognized as important in understanding couples experiences of infertility. First, culture and socioeconomic status inuence rates of infertility and treatment-seeking behaviors. Specically, non-whites with lower income have a greater likelihood of experiencing infertility, yet they are less likely to

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seek treatment because of its expense (Becker et al. 2006; Greil 1997; Jain 2006). Becker and colleagues (2006) indicated that respondents in their study were able to seek only a basic level of care for infertility due to nancial constraints. Also, in a study of 1,500 women seeking infertility treatment, Jain (2006) found that African American women sought treatment after a longer period of infertility (4 years), as compared to their Caucasian counterparts (3 years). Although medical and mental health professionals are working to adapt infertility treatments to t cultural or ethnic traditions (Hynie and Burns 2006), little research has been conducted with low-income families of any minority background as research studies are often conducted with infertile individuals who have sought treatment (Greil 1997). Among the few studies conducted with minority populations, cultural inuences in African American and Latino/Hispanic groups emerge as paramount. First, in a phenomenological study of eight low-income African American couples, Phipps (1998) reports the culturally based challenges of infertility, which may have been heightened by (a) the centrality of children in African American families (see also Crosbie-Burnett and Lewis 1993); (b) the medias focus on increasing rates of birth control for African Americans in response to the large number of female-headed families who care for numerous children; and (c) the lack of nancial resources for infertile African American couples that may limit their access to treatment. Similarly, in a study of 118 Latino/Hispanic respondents seeking infertility treatment, Becker et al. (2006) indicated that Latino couples experienced cultural strain and stigma when diagnosed with infertility. They suggest that infertility created pressure for both men and women, often threatening the stability of couple relationships. In contrast to culturally related challenges, couples in Phipps (1998) study reported nding comfort, hope, and meaning of their infertility in their faith in God. Similarly, Becker and colleagues (2006) indicated that some respondents in their study sought out non-traditional treatments that were culturally based, such as humoral medicine (e.g., massage, herbal remedies), and that women continued their efforts and hope to conceive until they reached menopause (p. 882). In other words, despite the difculties of infertility, couples in these studies were resilient in their marital relationships and in life as they maintained faith in a higher power, sought available treatments, and maintained hope for conception. A further example of the tension between positive and negative support is found in the research examining religious support of couples experiencing infertility. Religious and spiritual beliefs provide hope and comfort for some (e.g., Phipps 1998), yet may lead to self-doubt and diminished self-esteem in others (Peterson et al. 2007a). From a social perspective, Smith and Smith (2004) suggest that infertile couples may experience increased levels of stress and depression when they are actively engaged in religious practices due to the focus and attention given to families with children. Likewise, Berghuis and Stanton (2002) found that less reliance upon religious coping was associated with decreased depressive symptoms. Thus, similar to family support, religious and spiritual support may provide either positive or negative inuences for couples facing infertility. In summary, family and community support likely occurs in many situations, providing a positive external inuence for couples facing infertility. At the same time, numerous infertility-related challenges present in todays society may add to the existing burden. Medically based factors are also important. External inuences from a medical perspective include the inuence of diagnosis (e.g., male factor vs. female factor infertility), duration of infertility, interactions with doctors and nurses, and the geographic proximity and availability of infertility treatment services. The inuence of diagnosis has been linked with increased distress in men and women, with men experiencing more distress if a

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male-factor diagnosis is made compared to the distress of women who have been diagnosed with female-factor infertility (Petok 2006). Nachtigall et al. (1992) found that men with a male factor infertility diagnosis experience a stronger negative emotional response to infertility when compared to men without a diagnosis. In terms of duration, by the time couples are referred to a Reproductive Endocrinologist (RE), they typically have been through basic infertility treatments for several years and are quite familiar with the stresses and strains associated with infertility. When referred to an RE, couples have to learn new interaction patterns with physicians and nurses. They may nd increased cooperation and support from a doctor specializing in the eld, or they may feel unsupported if they perceive themselves as just another set of infertility patients undergoing assisted reproductive technologies. Geographic factors also play a role. In urban areas that have large populations, infertility clinics are more numerous. In such situations, the strain of leaving work for appointments, traveling to the doctors ofce, and maintaining frequent contact with the staff may be minimized compared to couples in rural areas where the nearest treatment center is more than 60 miles away.

Individual Perceptions, Interpretations, and Coping Strategies Individual Perceptual Construction Although individual perceptions represent a small part of the IRM, they are a crucial factor in deciphering meaning in relation to infertility-caused stress. Individual perceptions comprise diverse factors including the associated meaning given to a stressor, ways a particular stressor may lead individuals to alter their identity, the adaptability or exibility of the individual to accommodate disequilibrium, and ways previously conceived perceptions are reevaluated (Benyamini et al. 2004; Brothers and Maddux 2003; Maillet 2003; Walsh 2002). The associated meaning given to infertility-related stress can be dissected into three primary components including the attached denition, the value placed on the stressor, and the individual understanding of the disruption. According to Myers and Wark (1996), the denition that is cognitively constructed in response to infertility is important in understanding individual perceptions. For many adults, childbearing provides considerable meaning, status, and fulllment of responsibility while also satisfying societal expectations (Burns 1987; Meyers et al. 1995b). As such, the unexpected emergence of infertilityrelated stress represents, in most cases, the alteration or loss of a crucial life goal for the hopeful childbearing couple (Brothers and Maddux 2003; Burns 1987; Maillet 2003; McDaniel et al. 1992; Meyers et al. 1995a). As a result, the prospect of infertility retains a heightened associated value for couples, thus affecting individual meaning. In addition, individual meaning of a particular stressor is inuenced by related causes, consequences, and associated locus of control (Benyamini et al. 2004). Both adaptive and maladaptive strategies may be used to cope with infertility. Infertile individuals sometimes express resilience to infertility by increasing personal knowledge about infertility, through medical examination and evaluation, and by considering the consequences or future implications for their lives as a result of infertility (Meyers et al. 1995a; Walsh 2002). Berghuis and Stanton (2002) suggest that coping strategies employing positive reinterpretation, emotional processing, and emotional expression are linked with lower depressive symptoms. Furthermore, Austenfeld and Stanton (2004) indicate that an emotional approach is effective for discrete emotions and various modes of emotional

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expression (p. 1356). Thus, emotional regulation and expression seem important in decreasing infertility-related stress. A less adaptive coping strategy is noted where both spouses take responsibility for the infertility. For example, Peterson and colleagues (2006a) suggest that increased levels of depression and infertility stress resulted when both partners accepted a high degree of responsibility. In other words, depressive symptoms were lower when only one partner expressed higher responsibility, and when both partners expressed low responsibility. These ndings are interesting given that eighty percent of the infertility diagnoses were attributable to women in that study, yet in nearly 28% of the sample, both spouses reported high levels of responsibility (p. 230). Thus, despite knowing to which partner the infertility diagnosis is related, both spouses may take responsibility. Furthermore, although diagnosis of infertility is gender-based, the externalization of infertility has been argued as a plausible solution to decreasing levels of acceptance of responsibility among infertile couples (Stammer et al. 2002). Couples also can be counseled to view infertility as a shared problem to be jointly worked through together. Viewing the problem in this way serves to discourage one or both partners from taking complete responsibility for the infertility. Perceptions of infertility are linked to cognitive evaluations of self, spouse, and spouses perceptions (Kikendall 1994; Meyers et al. 1995b). Considering that fertility during adulthood is an anticipated experience (Burns 1987), infertility-related stress requires individuals to redene their identities (McDaniel et al. 1992). The unexpected diagnosis of infertility may cause individuals to develop an infertile identity reective of self-perception (Meyers et al. 1995b). According to McDaniel et al. (1992), the diagnosed infertile partner may experience feelings of guilt, often doubting his or her spouses affection. Furthermore, infertile individuals may fear their spouses departure in hopes of locating a more favorable childbearing partner (Meyers et al. 1995b; Becker et al. 2006). Redenition and reevaluation relative to individual perceptions are common among infertile couples. According to Meyers et al. (1995a), infertility challenges deeply held beliefs, self-identity, adequacy, and competence (p. 224). In fact, for some individuals, the possibility of childlessness undermines the core ideology of marital relationships (Burns 1987), leading couples to reevaluate previously conceived ideals concerning the institution of marriage itself (Day 2005). Gerrity (2001) and Meyers et al. (1995b) argue that parenting potential is a crucial determinant of initial partner evaluation. Furthermore, partners may begin unintentionally to reevaluate present interactions with their spouses. This redenition of marital interaction is evident in relation to couples sexual relationship. Several studies support the perceived alterations of sexual intimacy that occur among infertile couples (Burns 1987; McDaniel et al. 1992; Meyers et al. 1995a, b; Myers and Wark 1996; Peterson et al. 2007b). According to both Meyers et al. (1995a) and McDaniel et al. (1992), sexual activity in response to infertility-related stress becomes a chore, lacking in spontaneity, pleasure, and sexual desire. Additionally, unfullling sexual intimacy may be the result of couples efforts to achieve the single goal of successful pregnancy (Myers and Wark 1996). Interventions that focus on strengthening the marital relationship may be benecial given common infertility-related challenges to sexual bonds. For example, if a couple experiences sexual stress as a result of infertility, clinicians can normalize this stress as an expected outcome based on what is known in the infertility literature. Clinicians also can educate patients regarding the expected loss of spontaneity and passion that are commonly experienced by couples scheduling their sexual activity. Finally, couples undergoing advanced reproductive treatments may be counseled to take a break from scheduled

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relations to decrease anxiety and sexual stress during the treatment process since conception occurs outside of the body (Peterson et al. 2007b). In summary, as individuals construct their meaning of infertility, alter their preconceived identity, and reevaluate both previously developed cognitive interpretations and present couple interactions effectively, adaptability or resilience can result. The changes in individual perceptions associated with infertility require exibility (Walsh 2002), allowing couples to either retain the hope and optimism of pregnancy and childbirth despite the ambiguity of their situation, or to consider alternative pathways such as adoption or childlessness. Gender Differences in Coping Methods Recent research suggests that men and women differ in their perceptions and responses to infertility, including coping strategies and emotional responses (Greil et al. 1988; Jordan and Revenson 1999; Peterson et al. 2003, 2006b; Schneider and Forthofer 2005). Gender differences are rst manifested during initial reactions to infertility, where women tend to experience a more acute reaction than men (Ferber 1995). Although men initially are optimistic about their situation, women may experience persistent disappointment, despair, and depression (Meyers et al. 1995a). A plausible explanation for these initial differences may be that women perceive childbearing as a fundamental part of life (McDaniel et al. 1992). Hart (2002) notes that women who suffer from heightened levels of anxiety have the tendency to be more pessimistic towards attaining successful pregnancy. Furthermore, women displayed increased levels of agitation in response to infertility treatments. Fluctuating hormones may offer another possible explanation for gender differences in initial responses. Despite the several depressive symptoms displayed by women, research suggests that women use some positive coping strategies to a greater degree than men, including positive reappraisal and seeking social support (Jordan and Revenson 1999). For example, meaning-based coping, one type of positive reappraisal, occurs when couples dealing with infertility give new meaning to their infertility experience. Peterson et al. (2008) found that when husbands used meaning-based coping, it was associated with increased marital distress, yet when wives used this type of coping, it was indicative of decreased marital distress. The researchers attribute these gender differences to men sometimes moving more quickly than their wives to nd new meaning, which may lead to increased strain on the wife, who may need more time. However, when the wife reaches this level of coping, the husband may be more ready to move forward. Clinical techniques that may facilitate positive reappraisal include normalizing and reframing infertility-related stress, externalizing the infertility so that couples do not see themselves as the problem, and encouraging mindful acceptance of infertility-related thoughts and feelings (Peterson et al. 2007a). Social support is a critical aspect of womens coping strategies in response to infertilityrelated stress. According to McDaniel et al. (1992), women are more successful in adjusting to infertility when a conding relationship with their husbands is facilitated. Also, through successful connections with both their husbands and others, women are able to construct more accurate perceptions about themselves and feel an increased sense of energy and self-worth (Gibson and Myers 2000). Although Berghuis and Stanton (2002) suggest that women employ all types of positive coping strategies more often than men, a recent study by Peterson and colleagues (2006b) analyzed the coping strategies of men and women using relative as opposed to raw coping scores and found that men coped with infertility using more self-controlling coping,

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distancing, and planful problem solving, whereas their female counterparts employed confrontive coping, seeking social support, and accepting responsibility to a greater degree. Meyers et al. (1995a) suggest that men favor action over conversation, while women desire association through conversation. This difference in coping styles seems linked to a wifes need to process feelings through conversation with her husband, while a husband may prefer more autonomous coping and cognitive problem-solving strategies (Ferber 1995). Also, in initial response to infertility-related stress, men report denial and distancing as a form of copingoften withdrawing from their wives, but noticing their partners reactions to infertility before their own (Meyers et al. 1995a). As a result of these specic perceptions, men often consider their wives pain as the most difcult aspect of infertility (McDaniel et al. 1992). However, as infertility persists, some men may suffer from decreased self-esteem, feelings of perceived personal failure, and may obsess about their adequacy as a man (McDaniel et al. 1992, p. 108). According to Hart (2002), semen quality also signicantly declined over time, resulting in an inverse relationship with psychological stress and the experience of infertility (pp. 3435). Among less adaptive types of coping, men are more likely than women to use avoidance as a form of coping with infertility (Berghuis and Stanton 2002). Avoidance can cause heightened levels of stress and depressive symptoms among infertile couples (Peterson et al. 2006a). Furthermore, Berghuis and Stanton (2002) suggest that the use of avoidance or distancing is strongly correlated between husbands and wives. When one partner used avoidance as a coping strategy, the other partner had the tendency to use avoidance to the same degree. Depressive symptoms in response to infertility-related stress may decrease when partners do not employ avoidance as a coping strategy.

Couple Interactions and Congruent Couple Perceptions Couple interactions and congruent couple perceptions are both integral factors related to resilience in facing infertility. These processes are reciprocal in nature, with each inuencing the other in couple relationships. Couple Interactions as Communication Processes Communication is essential to decreasing depressive symptoms and infertility-related stress among infertile couples (Stammer et al. 2002; Peterson et al. 2006a). Without effective couple communication and interaction, the onset of unexpected infertility among hopeful childbearing couples may cause them to employ negative coping strategies on an individual level, thus leading to maladaptive interactions between partners (Higgins 1990). Couple communication processes among those facing infertility are crucial, as Gerrity (2001) asserts that the spouse becomes the only form of social support when experiencing infertility-caused stress. Three primary couple communication strategies have been targeted by various researchers: open emotional sharing, marital evaluation, and shared decision making. Open emotional sharing is a crucial component of positive communication. It is especially important that couples mutually share, as partners must rely on each other for most of their emotional support and understanding (Andrews et al. 1991, p. 239; Gerrity 2001). Considering that emotional stability among infertile couples may be in uctuation between hope and disappointment from month to month (Greil et al. 1988), open communicative processes may be difcult to establish. Possibly as a result of instability, couples facing

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infertility often experience feelings of anger, denial, depression, and frustration towards their situation, as well as feelings of shame and guilt within the marital relationship (Ferber 1995; Gerrity 2001; Hart 2002; Maillet 2003). Without positive communicative interactions between partners, couples may experience feelings of loneliness, desertion, and eventual social isolation, thus increasing depressive symptoms (Ferber 1995; Gerrity 2001). According to Stammer et al. (2002), couples may instinctively gravitate towards one end of a communication spectrum when suffering from infertility: harmoniously enmeshed [or] antagonistically enmeshed (p. 115). Thus, couples experiencing infertilityrelated stress should actively pursue and cultivate positive communication patterns, which will in turn facilitate healthy marital relationships and interactions by unambiguously communicating complaints and hopes to their partners while specically identifying personal differences and seeking understanding of those differences (Stammer et al. 2002). Couples consequently may gravitate towards the harmoniously rather than the antagonistically enmeshed end of the communication spectrum. Marital evaluation is a second crucial component of experienced communicative processes in couple interactions. Marital evaluation is the aspect of couple communication where congruency of individual perceptions occurs and unied couple perceptions are formed. For example, individual perceptions relating to marital satisfaction can be discussed and evaluated between partners. Research suggests that infertility-related stress tends to be related to greater distress for wives than husbands, an incongruence that can lead to marital dissatisfaction (Greil et al. 1988; Peterson et al. 2003). Thus, couples experiencing infertility-related stress may discuss their relationship interactions, allowing partners to understand the others interpretation of their situation. Ramications of differing marital evaluations by husbands and wives could include a decrease in sexual satisfaction, increased frustrations, and lack of communication (Greil et al. 1988; Hart 2002; Stammer et al. 2002). In summary, frequent evaluations of the marital relationship among couples facing infertility will likely increase the couples ability to address common challenges. The third communicative process that facilitates positive interactions among partners is shared decision-making. The critical nature of unied decision-making responsibilities in response to infertility-related stress is a common theme in the literature (Greil et al. 1988; Myers and Wark 1996; Walsh 2002). Research conducted by Myers and Wark (1996) indicates that women experienced heightened levels of marital dissatisfaction when they started infertility treatments without their partners. Similarly, Greil et al. (1988) assert that women experience increased agitation over their partners lack of commitment to decisionmaking responsibilities. Therefore, it seems paramount for partners to collaborate in infertility-related decision making. Furthermore, Walsh (2002) reports that negotiation and compromise are signicant factors that can improve the decision-making process to facilitate resilient outcomes. Congruent Perceptions as Communication Processes Congruent perceptions among couples experiencing infertility are not easily attained. Greil et al. (1988) suggest that couples suffering from infertility often do not fully understand the personal perspectives of their spouses. Kikendalls (1994) application of Higgins (1987) self-discrepancy theory to the experience of infertility further substantiates the complexity of couple and self perceptions, emphasizing that self-perceptions can be inuenced by various self and partner expectations. Research related to perceptual interpretation and to empathetic reciprocity informs the congruent perceptions component of the IRM.

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Although perceptions initially develop within individuals, collective perceptions and congruence of cognitive interpretations develop as individual meanings merge through collective interactions. According to Walsh (2002) and Benyamini et al. (2004), the formation of individual perceptions begins with the meaning, value, and identity the individual associates with a particular stressor. Regarding infertility, couples share a common goal with similar expectations. When couples experience unexpected infertility, continuity within their marital relations is disrupted (Becker 1994), and the development of new meanings, values, and identity result. Throughout this process, discontinuity within the relationship may occur as individual perceptions change. Thus, interdependence exists between individual and collective perceptions. Also, according to Walsh (2002), empathetic reciprocity represents one of the critical aspects of family resilience. Empathic reciprocity is woven throughout recent studies on infertility (Ferber 1995; Gibson and Myers 2000). Although empathy, in itself, describes intrinsic personal perception and reection, empathetic reciprocity requires a two-way interaction. Mutual empathy compels individuals to shift from a self-centered perspective to a seless, more altruistic perspective, which in turn may allow individuals to increase their understanding of themselves, their spouses, and their relationships (Gibson and Myers 2000). Congruence among couple perceptions is a critical aspect in gauging the success of mutuality within the marital relationship, especially in relation to infertility. One partner may perceive his or her own efforts as empathetic, but will be negated if the other partner fails to share this perception. In situations of resilience, both spouses recognize mutual commitment, nurturance, and respect to facilitate perceived effective communicative processes (Walsh 2002). Just as individual and collective perceptions represent separate inuences yet are interdependent in nature, so too are couple interactions and congruent perceptions interrelated in the IRM. Couple interactions and concurrent perceptions are intertwined in bidirectional ways. Pre-existent couple perceptions can affect how partners interact with each other, and the outcome of those interactions may lead couples to modify previously conceived cognitive constructs. Thus, couple perceptions and couple interactions are mutual, and are critical in understanding resilience relative to infertility-related stress.

Implications for Therapeutic Intervention When couples feel overwhelmed by infertility-related circumstances, therapeutic intervention may be necessary. The positive inuence of counseling in situations of infertility is indicated in several studies (Domar et al. 2000; Jordan and Revenson 1999; Meyer 2005). Each aspect of the model provides insight into assessment of specic circumstances, as well as the overall functioning and response of couples to infertility (see Appendix A for specic questions clinicians can use to assess each aspect of the IRM). In relation to external factors, the social and family environments of the infertile couple are important areas of consideration for therapists (Strauss 2002). In many cases, the potential emotional, nancial, and spiritual support that families and communities may provide in response to infertility is increased when couples are able to openly share their situation with outside sources. Accordingly, clinicians should encourage couples to consider openly discussing infertility with people in their social support network, such as family and friends. Furthermore, Strauss (2002) suggests that assessing the potential positive or negative impact of these resources may give therapists increased clarication and understanding when constructing effective interventions tailored to specic situations.

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Both Jennings (1995) and Strauss (2002) assert that effective intervention includes the assessment of the social meanings attached to childlessness and the function and value of marriage and children within a given society. Thus, infertility education may increase understanding of infertility implications for couples psychological health and assist in eliminating the social stigma generally attached to childless families. Communities could further implement nancial aid programs to assist low-income couples desiring infertility treatments. In relation to medically based assistance, therapists may assist couples facing infertility by increasing awareness of possible resources and treatment options (Stammer et al. 2002). Furthermore, clinicians can discuss prospects for a future without children with couples coping with infertility-related stress. The assessment of the meanings that individuals give to their experiences with infertility, and the internalization of social norms, is an important consideration for therapists in providing effective intervention (Jennings 1995; Strauss 2002). Thorough assessment of individual perceptions not only allows the therapist to understand individual circumstances, alterations to personal identity, and gender differences among infertile couples coping strategies, but also can clarify ways individual differences may affect couple interactions and the success of congruent couple perceptions. In addition, perceptual congruency can be assessed by comparing individual evaluations regarding self and spouse and recognizing signicant consistencies or differences between them. Jordan and Revenson (1999) suggest that effective intervention must consider differences between men and women. Professionals, therefore, should be careful in employing universal assessments of individual experiences and perspectives, and should consider the variability of infertile couples circumstances. Strauss (2002) supports this caution, suggesting that intervention should be focused toward a patients personal plans, wishes, and motives and not toward the counselors desires. Internalization is another important application of infertility assessment that clinicians should consider. As previously discussed, the negative effect of accepting responsibility for infertility can be detrimental to both individual psychological well-being and marital interactions. Also, internalization may prevent congruency of perceptions between husbands and wives. Therapists can assist in externalizing responsibility for infertility, alleviating pressure that is placed on an individual or couple that is beyond their own control. However, if a medical diagnosis already has been determined, externalization may be difcult to accomplish, considering that one or both partners are physically responsible for the infertility. Nevertheless, clinicians can help couples to externalize aspects of infertility, such as diagnosis, where nothing in the couples power can be done to change the situation. Therapeutic intervention most often has been recommended at the couple level (Benazon et al. 1992; Pasch and Christensen 2000; Strauss 2002). For example, Domar and colleagues (2000) indicate that couples therapy can lead to decreased depressive symptoms, mood disturbance, marital distress, and anxiety while being linked to psychological health and stress management skills. Furthermore, addressing specic marital domains such as sexuality, communication, and partnership (Strauss 2002) may assist therapists in assessment and treatment of marital interactions, couple distress, and how relational experiences affect individual functioning (Pasch and Christensen 2000). Pasch and Christensen (2000) suggest that effective intervention should help couples increase acceptance, tolerance, and understanding between each other. Specically, open emotional sharing and shared decision-making responsibilities may be helpful for couples. Improved communication may allow infertile couples to gravitate towards successful couple interaction while decreasing chances of marital distress.

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Appropriate clinical use of the IRM involves considering that each couples situation is unique and that their experiences may not coincide directly with the model as currently specied. Furthermore, parts of the model may require expansion as fertility technology advances, and as more knowledge is acquired concerning perceptions, interactions, and external inuences. For example, cultural inuences related to infertility vary widely, and should be explored and considered in future research. Although the denition of infertility likely will remain constant, methods for interpreting and predicting resilience relative to infertility-related stress will transform as technology, interventions, and societal values change.

Implications for Future Research External Factors According to Maillet (2003), examining the interconnections between complex external systems, such as family, community, and religious organizations, and couples marital adjustment to infertility-related stress may provide insight into couples experience of infertility. Cultural issues, including social expectations, the inuence of social class, gender-specic responses, and emotional sensitivity in response to infertility, represent one complexity that requires further research (Austenfeld and Stanton 2004; Becker t al. 2006; Molock 1999; Peterson et al. 2007a). Cross-cultural studies are one way to increase understanding of both the universal and culture-specic components of infertility and peoples responses to it (Peterson et al. 2007a, p. 256). Studies of existing social support networks of individuals experiencing infertility also are underrepresented in the research literature (Maillet 2003). Mintle (1995) states that future research should include non-familial sources. Furthermore, in relation to individual factors, research is needed to assess the various types of social support available and the interconnections between these supports and coping strategies (Gerrity 2001). Research exploring specic medical factors is also needed. First, the assessment of couples coping processes in relation to the experience of secondary infertility treatments, such as articial insemination (Peterson et al. 2006a), is needed. Second, the associations between individual perceptions and successful infertility treatments need to be further explored (Benyamini et al. 2004). Third, the relationships between medical personnel and couples seeking infertility treatments need further examination (Maillet 2003). Individual Perceptions Future assessments need to clarify the relationships among emotion-focused coping, emotional responses to infertility, and the effectiveness of emotion-focused interventions for diverse individuals and couples experiencing infertility (Austenfeld and Stanton 2004). In addition, research conducted by Jordan and Revenson (1999) suggests that little analysis of gender differences has been performed in the study of cognitive construction and behaviors in response to infertility. By examining specic gender differences among infertile couples, therapists may be able to identify women who are particularly susceptible to negative infertility-related outcomes (Kikendall 1994). Further research also must examine the inuence of personality factors related to infertility coping strategies (Austenfeld and Stanton 2004).

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Collective Perceptions Few assessment tools have been generated to measure congruency among couple perceptions. One study conducted by Peterson et al. (2003) specically sought to assess couple congruency, yet they suggest that (a) the denition of couple congruency needs to be claried; (b) both quantitative and qualitative research studies specically evaluating perceptual congruence are needed; (c) assessment tools designed to measure congruence need to be developed; and (d) collective congruence among underrepresented populations must be researched. Longitudinal Research By studying infertile couples over time, researchers may evaluate alterations among couples coping strategies (Peterson et al. 2008), possible long-term effects, and couples marital adjustment to infertility-related stress (Maillet 2003). Longitudinal research is needed to evaluate the effectiveness of various types of psychological intervention during diverse stages of the infertility process (Domar et al. 2000). For example, women who are experiencing the initial stages of infertility do not need to adapt to a childless lifestyle as do women following failed fertility treatments (Benyamini et al. 2004). Longitudinal studies examining the impact of partner coping on personal, marital, and social infertility stress in Danish couples over a 5-year time period are currently underway (Peterson et al. 2008).

Conclusion The growing body of literature on the experience of infertility provides valuable information that clinicians can use in their encouragement of resilient outcomes for individuals and couples. Although numerous approaches have been applied to understanding different aspects of infertility, the IRM adds to the infertility literature by including interconnections between individual, couple, and external inuences. The needs of couples experiencing infertility can be assessed by specically examining social and medically based environmental inuences; individual determinants of associated meaning including changes in identity, adaptability, and perceptual reevaluations; couple communicative processes such as open emotional sharing and marital evaluation; and couples collective perceptions. Although adaptation of the IRM may be needed as technology advances and unique circumstances arise, therapists can use the model to effectively evaluate and promote couple resilience on an environmental, individual, and collective level, thus increasing couples adaptation and adjustment to this unexpected life stressor.

Appendix A
Sample assessment questionnaire based on the infertility resilience model External inuences: 1. Who do you talk to about your desire for a child and your treatment, and how does it help you?a 2. Do you feel under pressure when friends and acquaintances become pregnant?a 3. If you chose not to have children, how do you imagine it will affect your relationship with your family and friends?b

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Appendix continued
4. Sometimes infertility can lead a spouse to feel conicting or torn loyalties between family-of-origin members and ones spouse. How have your relationships with family-of-origin members changed or stayed the same since you have experienced infertility?d 5. Do you feel that becoming a parent represents a certain status within our society?d Individualistic perceptions, interpretations, and coping strategies: 1. What have you done to help yourself handle the situation better?a 2. Is having a child a means of attaining status in your families and in society?b 3. Is it wise to make a decision if your partner still has reservations?b 4. How does each of you imagine your individual lives will be different if you had children?b 5. Are there times you still think about the infertility?b 6. What worries do each of you have about sharing your feelings about the infertility?b 7. Do you feel personally responsible for the infertility?d 8. Do you feel that having a child gives meaning to your life? Do you feel that having a child is a responsibility that you must fulll?d 9. Does childbearing represent a crucial goal in your life?d Collective interactions: 1. Has anything changed sexually with your partner since you have wanted a child?a 2. In what areas do you support each other and what do you still wish for in your relationship?a 3. When was the last time the two of you discussed the infertility?b 4. How do you see your relationship if you were unable to have children?c 5. How has the closeness between you and your spouse changed during this experience?d Congruent couple perceptions: 1. Which of you feels more strongly about having children? How long are you willing to keep trying?b 2. Who is more eager to repeat the next procedure, you or your doctor?b 3. Who is more worried about putting your savings at risk?b 4. Which one of you is more inclined to speak about it with the other?b 5. Who is more interested in a life without children?b 6. If I asked your spouse what rst attracted him to you, what do you think he would say?c 7. What has been the most difcult part of infertility for your spouse?d 8. Are you more concerned about your spouses well-being in response to infertility than your own?d 9. Do you feel that your spouse understands how you feel about the infertility? Do you understand how your spouse feels about the infertility?d
a b c d

Denotes references taken from Strauss (2002, pp. 109, 131133) Denotes references taken from Diamond et al. (1999, pp. 6465, 68, 8990, 125, 130, 153, 183, and 205) Denotes questions taken from Jennings (1995, p. 106) Denotes questions developed by the authors of the current paper

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