Effectiveness of Counselling Techniques.pdf

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Table of Contents
CHAPTER ONE: INTRODUCTION................................................................. 5
1.1 Background to the Study........................................................................ 5
1.2 Statement of the Problem....................................................................... 8
1.3 Objectives of the Study............................................................................. 9
1.4 Research Questions.............................................................................. 10
1.5 Research Hypotheses ........................................................................... 11
1.6 Basic Assumption ................................................................................ 12
1.7 Significance of the Study ..................................................................... 13
1.8 Scope and Delimitation of the Study.................................................... 15
CHAPTER TWO: REVIEW OF RELATED LITERATURE........................... 16
2.1 Introduction ......................................................................................... 16
2.2 Conceptual Framework........................................................................... 16
2.2.1Concept, Meaning and Nature of Infertility........................................... 16
2.2.2 Causes of Infertility.............................................................................. 17
2.2.3 Genetic causes of Infertility.................................................................. 19
2.2.4 Age as a factor of infertility ................................................................. 20
2.2.5 Medical Causes of Infertility................................................................ 23
2.2.6 Treatment of infertility......................................................................... 28
2.2.7 Medical Remedy to Infertility .............................................................. 28
2.2.8 Usage Rate of ART.............................................................................. 33
2.2.9 Psychological Distress Associated Infertility........................................ 33
2.2.10 Counselling in the Context of Infertility............................................. 38
2.3.1 Concept, Meaning and Definition of Anxiety....................................... 40
2.3.2 Psychological Treatment of Anxiety Disorder...................................... 43
2.3.3 Concept, Meaning and Definition Depression................................... 44
2.3.4 Psychological Treatment Procedure for Depression ............................. 46
2.3.5 Concept and Meaning of Cognitive restructuring................................. 48
2.3.6 The origin and function of cognitive distortions................................... 50
2.3.7 The process of cognitive restructuring.................................................. 51

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2.3.8 Concept and Meaning of Brainstorming............................................ 53
2.3.9 Overview of Process in Brainstorming counselling groups ............... 55
2.3.10 Procedures in Brainstorming Counselling Technique........................ 57
2.4 Theoretical Framework for the Study...................................................... 58
2.4.1 Aaron Beck Theory of Cognitive Behavioral Therapy ......................... 61
2.4.2 Evaluation of Cognitive Behavioral Therapy ....................................... 64
2.4.3 Albert Ellis Rational Emotive Behavior Therapy (REBT).................... 65
2.4.4 Pattern of Psychological dysfunction as explain by Ellis...................... 70
2.4.5 Overview of Psychological adjustment in rational emotive therapy ..... 71
2.4.6 Goals of counselling Intervention in REBT.......................................... 72
2.5.1 Sigmund Freud Psycho-sexual Theory................................................. 74
2.5.2 Piaget's theory of cognitive development.......................................... 76
2.5.3 Assimilation and accommodation cognitive development.................... 78
2.6 Empirical Related Literature Review ...................................................... 87
2.6.1 Studies in cognitive-behaviour therapy and psychological distress
among infertile women ................................................................................. 91
2.6.2 Studies on Brainstorming and Psychological Distress....................... 93
2.6.2 Summary............................................................................................ 102
2.6.3 Gap in Literature................................................................................ 107
CHAPTER THREE: METHODOLOGY ....................................................... 109
3.1 Introduction g .................................................................................... 109
3.2 Research Design ................................................................................ 109
3.3 Control of Extraneous Variables........................................................ 110
3.4 Population.......................................................................................... 111
3.5 Samples Size and Sampling Techniques ............................................ 111
3.6.1 Instrumentation............................................................................... 112
3.6.2 Validity of the Research Instrument................................................ 113
3.6.3 Pilot Testing.................................................................................... 114
3.6.4 Reliability of the Research Instrument............................................ 114
3.7 Procedure for Data Collection............................................................... 115
3.8 Treatment Procedure............................................................................. 115

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3.9 Procedure for Data Analysis .............................................................. 116
CHAPTER FOUR: DATA ANALYSIS: PRESENTATION AND
DISCUSSION OF RESULTS ........................................................................ 117
4.1 Introduction ....................................................................................... 117
4.2 Demographic Characteristics of Respondents ....................................... 117
4.3 Answers to research questions ........................................................... 121
4.4 Hypotheses Testing............................................................................... 129
4.5 Summary of Major Findings .............................................................. 143
4.6 Discussion of Major Findings ............................................................ 144
CHAPTER FIVE: SUMMARY, CONCLUSION, RECOMMENDATIONS
AND SUGGESTIONS FOR FURTHER STUDIES....................................... 151
5.1 Introduction .......................................................................................... 151
5.2 Summary............................................................................................... 151
5.3 Conclusions ....................................................................................... 152
5.4 Recommendations from the study...................................................... 153
References...................................................................................................... 157
Appendix........................................................................................................ 174

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CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Infertility primarily refers to the inability of a person to contribute to
conception. It may also refer to a state of a woman who is unable to carry
pregnancy to full term. From demographers’ point of view, infertility refers to a
state of childlessness in a population of women of reproductive age. From
epidemiological point of view, infertility is described based on trying to become
pregnant or trying for a pregnancy in a population of women exposed to
probability of conception. For many couples, the problem of infertility
diagnosis and treatment is one of life’s stressful circumstances that often prompt
some couples to result to behavioural problems such as irrational beliefs, and
stress. There may be feelings of anxiety about which treatment options are best
and whether or not it will work.
Infertility is a problem among women of reproductive age especially in
African societies, Nigeria inclusive. In some cases infertile women are
sometimes confronted with the social consequences of childlessness, since child
is/(children are) most often the greatest security a woman has in such societies.
On this background infertile women are seen as losing out whatever security
that having a child/ children could provide.
Human procreation is highly valued in Africa in general and Nigeria in
particular. Children ensure that the family lineage does not die. Again, children
play a crucial role in supporting their parents either financially or practically.
For women, childbearing enables them to stabilize their marriage and to form
closer bond with the family. Marriages are therefore contracted for the purpose
of reproduction. However, not all marriages are blessed with children. Some
couples are unable to procreate despite regular unprotected sexual intercourse
for a year or two. To overcome infertility, some of the women with infertility
challenges seek medical treatment, while others try traditional medicine.
Infertility is associated with social, economic and psychological consequences.
Psychological consequences exist in the form of psychological distress such as
depression, anxiety, hopelessness, low-self esteem and social isolation or
withdrawal. Infertility is a severely distressing experience for women with
infertility challenge. Depression as one of the major construct in this study is a
form of behaviour disorder. Depression is considered as one of the main

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psychological disorders associated with infertility, and it may significantly affect
the life of infertile individual. Depression has been described as severe
despondency and dejection, accompanied by feelings of hopelessness and
inadequacy, and condition of mental disturbance, typically with lack of energy
and difficulty in maintaining concentration or interest in life. According to
Hofmann (2011), sometimes depressed infertile women often exhibit: low
mood, loss of interest or pleasure in daily activities, feeling of guilt, or low self-
worth, disturbed sleep, loss of appetite, low energy and poor concentration.
Depression related to infertility challenges may affect infertility treatment and
hope for the future, it may also influence mutual relationship of the affected
individual.
Anxiety is another major construct in this study is a form of behaviour
disorder, is another emotional reaction to infertility challenge is anxiety. Anxiety
has been defined as a feeling of tension, apprehension, or fear that result from
the anticipation of danger. This danger may be either internal or external.
Anxiety (also called angst or worry is a subjective psychological and
physiological state characterized by somatic, emotional, cognitive and
behavioural components. It is the displeasing feeling of fear and concern. Gerald
(2008) writes that the root meaning of the word anxiety is 'to vex or trouble'; in
either presence or absence of psychological stress, anxiety can create feelings of
fear, worry, uneasiness, and dread. Ohman, (2000) reported that, it is also
associated with feelings of restlessness, fatigue, concentration problems, and
muscle tension.
The occurrence of anxiety among women with infertility challenge may
be cyclical and coincide with phases of the treatment cycle. It maybe
precipitated by specific event such as a family holiday or the announcement of a
family member’s friend’s pregnancy or delivery. According to Klock (2011)
anxiety has psychological consequences on infertility and it may play significant
role in the life of an infertile person and could consequently affect the mutual
relationship and quality of life of such individuals.
Psychological distress can contribute to low pregnancy rates, poor
physical health and low productivity. This creates the need to put in place
counselling services to help women with infertility challenges cope with
psychological distress. This assertion is in line with the observation made by
Nieuwenhuis, Odukogbe, Theobald, and Liu (2009:7) who studied the impact of
infertility on infertile men and women in Ibadan, Oyo State of Nigeria and found
that infertility had more psychological effects on women with infertility
challenges than their male counterparts. Consequently, they recommended that
“psychological support services should be made available to women with

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infertility challenges and that the available resources should not be used to
subsidize infertility treatment but should focus on the prevention of infertility
and psychological support.” Thus, there is an urgent need for psychological
intervention using counselling services to help women with infertility challenges
deal with the distress relating to infertility.
The effect of counselling on psychological distress may be related to the
personal characteristics of women with infertility challenges such as age and
type of infertility (primary/secondary) and this therefore, requires investigation.
Counselling may be described as an interpersonal process based on theoretical
framework and techniques in order to bring about change in clients in a skilful
and systematic way. Counselling in the context of infertility involves educating
clients about effective ways of managing the psychological distress of infertility
as well as information given. People wanted information for various reasons.
These included wanting to understand more about their condition and treatment
options, where to go for treatment, what they were putting their bodies through
and what their chances of success were. People gathered information from a
variety of sources clinics, support groups, books, leaflets, television and radio.
Their information needs often changed as treatment progressed for example
research into IUI being replaced by IVF, or weighing up options when deciding
whether to continue or stop treatment. People were also keen to hear from other
couples about what it was like to go through treatments, and how other people
coped.
Counselling is a potent approach for reducing psychological distress. In
this study cognitive restructuring counselling and brainstorming counselling
techniques are the two treatment interventions used to investigate into
effectiveness of counselling services to assist women with infertility challenges
to cope with psychological distress. Cognitive restructuring was originally
developed by Ellis (2003), It is a psychotherapeutic process of learning to
identify and dispute irrational or maladaptive thoughts. There are many methods
used in cognitive restructuring, which usually involve identifying and labelling
distorted thoughts, Socratic questioning, thought recording, identifying cognitive
errors, examining the evidence (pro-con analysis or cost-benefit analysis),
understanding idiosyncratic meaning/semantic techniques, reattribution, guided
imagery and listing rational alternatives (Huppert, 2009).
Brainstorming is a popular counselling technique that helps individuals to
generate solution(s) to a problem or problems. It is particularly useful when a
client/individual wants to break out of stale, established pattern of thinking and
decision making, so that such client/individual can develop new ways of looking
at things, foster and enhance communication skill. Brainstorming counselling

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technique helps clients to overcome issues that can make group problem solving
a sterile and unsatisfactory process. Brainstorming is often used in a generic
sense to describe groups who generate ideas. For example, Moran, Talbot,
Benson (1990) defined brainstorming as “a group process in which group
members collectively contribute their ideas in a creative atmosphere” Although
the term has come into popular use, facilitators should know its precise meaning
and history. Brainstorming combines a relaxed, informal approach to problem-
solving with lateral thinking. It asks that people come up with ideas and
thoughts that can at first seem to be a bit crazy. The main concept in
brainstorming is that some of the ideas generated can be crafted into original,
creative solutions to the problem that an individual trying to solve, while others
can spark still more ideas. Thus, this study attempts to compare the effectiveness
of cognitive restructuring and brainstorming is assisting women with infertility
challenge cope and manage psychological distress associated with infertility
challenge.
1.2 Statement of the Problem
Infertility as indicated in the background is a huge problem for couples
especially women in the Kogi State of Nigeria. The desire of many young
women to become parents may be influenced by the premium placed on children
by society. In Africa, children are highly valued for social, cultural and
economic reasons. Infertile and childless women in Africa are therefore
confronted with a series of societal discrimination and stigmatization which may
lead to psychological disorders such as anxiety and depression.
Women of childbearing age suffer psychological disturbances or distress
when diagnosed as infertile. Psychological distress may increase when treatment
is prolonged without success. Infertility treatment has also been found to
contribute to depressed mood and increased rates of anxiety. Consequently,
some patients may discontinue treatment not because of diminished interest in a
biological child but because they feel psychologically unable to continue. In
Nigeria, professional counselling is not a regular feature of medical practice.
Medical doctors/personnel only offer bio-medical treatment to infertile patients
but their psychological/ emotional needs are not catered for or addressed. This
form of healthcare is not consistent with the World Health Organization’s
(1948) definition of health which states that health is a state of complete
physical, mental and social well-being and not merely the absence of disease or
infirmity. This implies that psychological needs of women with infertility
challenges should be addressed in the healthcare system in this country, by
putting in place counselling intervention for women experiencing psychological

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distress due to infertility in established health institutions. Psychological distress
can affect the physical health of women with infertility challenges and this may
put another burden on family members and the healthcare system. More
importantly, there is a positive relationship between psychological health and
pregnancy rates. This means that improvement in psychological health may
increase pregnancy rates (Miller, 2012).
Psychological intervention using counselling techniques are considered
necessary to assist women with infertility challenges to cope with the
psychological distress associated with infertility. Hence the researcher decides to
use cognitive restructuring and brainstorming counselling techniques to manage
psychological distress among women with infertility challenges in Lokoja State
with the view to improving physical health and pregnancy rates.
1.3 Objectives of the Study
The objectives of the study were as follows:
1. To find out the difference in the pre-test and post test anxiety level among
women with infertility challenges that are exposed to cognitive
restructuring and those in the control group
2. To find out the difference in the pre test and post test depression level
among women with infertility challenges that are exposed to cognitive
restructuring and those in the control group.
3. To determine the difference in the pre test and post test anxiety level
among women with infertility challenges that are exposed to
brainstorming and those in the control group.
4. To investigate the difference in the pre test and post test depression level
among women with infertility challenges that are exposed to
5. To ascertain the differential effect of cognitive restructuring and
brainstorming counseling technique on anxiety level among women with
infertility challenges.
6. To determine the differential effect of cognitive restructuring counseling
and brainstorming counselling techniques on depression level among
women with infertility challenges.
7. To investigate differences in the pre-test and post test means score on
anxiety level among women with infertility challenges that are exposed to
cognitive restructuring/brainstorming counseling techniques and those in
the control group
8. To investigate differences in the pre-test and post test means score on
depression level among women with infertility challenges that are

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exposed to cognitive restructuring/brainstorming counseling techniques
and those in the control group.
9. To determine the differential effect of cognitive restructuring technique
on anxiety level among women with primary or secondary infertility
challenge.
10.To determine the differential effect of cognitive restructuring technique
on depression level among women with infertility challenges.
11.To determine the differential effect of brainstorming technique on anxiety
level among women with infertility challenges.
12.To determine the differential effect of brainstorming technique on
depression level among women with infertility challenges.
1.4 Research Questions
The following research questions were raised to guide the effectiveness of
investigation of this research:
Question One: What is the difference in the pre- test and post -test anxiety
level among women with infertility challenges that are exposed to cognitive
restructuring and those in the control group?
Question Two: What is the difference in the pre-test and post-test
depression level among women with infertility challenges that are exposed
to cognitive restructuring and those in the control group?
Question Three: What difference exists in the pre-test and post-test anxiety
level among women with infertility challenges that that are exposed to
brainstorming and those in the control group?
Question Four: What difference exists in the pre-test and post test
depression level among women with infertility challenges that are exposed
to brainstorming and those in the control group?
Question Five: What is the differential effect of cognitive restructuring and
brainstorming counseling techniques on anxiety level among women with
infertility challenges?
Question Six: What is the differential effect of cognitive restructuring and
brainstorming counseling technique on depression level among women with
infertility challenges?
Question Seven: What difference exist in the pre-test and post-test means
score on anxiety level among women with infertility challenges that are
exposed to cognitive restructuring/brainstorming counseling techniques and
those in the control group?
Question Eight: What difference exist in the pre-test and post-test means
score on depression level among women with infertility challenges that are

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exposed to cognitive restructuring/brainstorming counseling techniques and
those in the control group?
Question Nine: What is the differential effect of cognitive restructuring
technique on anxiety infertility challenge level among women with primary
and secondary infertility challenge?
Question Ten: What is the differential effect of cognitive restructuring
technique on depression level among women with primary infertility
challenging those with secondary infertility challenge?
Question Eleven: What is the differential effect of brainstorming technique
on anxiety level among women with primary infertility challenge and those
with secondary infertility challenge?
Question Twelve: What is the differential effect of brainstorming technique
on depression level among women with primary infertility challenge and
those with infertility challenge?
1.5 Research Hypotheses
The following null hypotheses were formulated and statistically tested in
relation to the research topic.
H01: There is no significant difference in the pre test and post test anxiety
level among women with infertility challenges that are exposed to
cognitive restructuring and those in the control group.
H02: There is no significant difference in the pre test and post test depression
level among women with infertility challenges that are exposed to cognitive
restructuring and those in the control group.
H03: There is no significant difference in the pre- test and post test anxiety
level among women with infertility challenges that are exposed to
H04: There is no significant difference in the pre test and post test depression
level among women that are exposed to brainstorming and those in the
control group.
H05: There is no significant effect of cognitive restructuring and
brainstorming counseling techniques on anxiety level among women with
H06: There is no significant effect of cognitive restructuring and
brainstorming counseling techniques on depression level among women with
H07: There is no significant difference in the pre test and post test means
score on anxiety level among women with infertility challenges that are

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exposed to cognitive restructuring and brainstorming counseling techniques
H08: There is no significant difference in the pre test and post test means
score on depression level among women with infertility challenges that are
exposed to cognitive restructuring and brainstorming counseling techniques
H09: There is no significant difference in the effect of cognitive restructuring
technique on anxiety level among women with primary infertility challenge
and those with secondary infertility challenge.
H010: There is no significant difference in the effect of cognitive
restructuring technique on depression level among women with primary
infertility challenge and those with secondary infertility challenge.
H011: There is no significant difference in the effect of brainstorming
technique on anxiety level among women with primary infertility challenge
and those with secondary infertility challenge.
H012: There is no significant difference in the effect of brainstorming
technique on depression level among women with primary infertility
challenge and those with secondary infertility challenge.
1.6 Basic Assumption
The basic assumptions of the study are:
1. Psychological distresses such as anxiety, depression, social isolation,
social withdrawal, helplessness and hopelessness are often associated with
2. The two counselling techniques: cognitive restructuring and
brainstorming will assist in managing anxiety associated with infertility
challenges.
3. The two counselling techniques: cognitive restructuring and
brainstorming will assist in managing depression associated with
4. One of the treatments will be more effective than the other in managing
anxiety associated with infertility challenges.
5. One of the treatments will be more effective than the other in managing
depression associated with infertility challenges.
6. It is assumed that women with infertility challenges that are exposed to
cognitive restructuring counselling sessions would experience significant
levels of reduction in their anxiety level and learn appropriate ways of
managing anxiety related to infertility challenges.

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cognitive restructuring counselling sessions would experience significant
levels of reduction in their depression level and learn appropriate ways of
managing depression related to infertility challenges.
brainstorming counselling sessions would experience significant levels of
reduction in their anxiety level and learn appropriate ways of managing
anxiety related to infertility challenges.
brainstorming counselling sessions would experience significant levels of
reduction in their depression level and learn appropriate ways of
managing depression related to infertility challenges.
10.Cognitive restructuring counselling technique will assist women with
primary infertility challenges or secondary infertility challenges to
manage anxiety level.
11.Cognitive restructuring counselling technique will assist women with
primary infertility challenges or secondary infertility challenges to
manage depression level.
12.Brainstorming counselling technique will assist women with primary
infertility challenges or secondary infertility challenges to manage anxiety
level.
13.Brainstorming counselling technique will assist women with primary
infertility or secondary infertility challenges to manage depression level.
14. Cognitive restructuring and brainstorming counselling techniques will
assist women who had married for number of years to manage anxiety
level
15.Cognitive restructuring and brainstorming counselling techniques will
assist women who had married for number of years to manage depression
level.
1.7 Significance of the Study
It is expected that the findings of this research would be useful to
counselors, medical doctors, infertile women, curriculum planners and
researchers. Professional counselors can utilize cognitive restructuring and
brainstorming counselling techniques in managing psychological distress of
their infertile clients.
The knowledge and research on effectiveness of cognitive restructuring
and brainstorming counselling techniques in managing psychological distress
among women with infertility challenges can serve as a useful tool for

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clinicians, gyneacologists and Obstetricians women with infertility challenges,
counselling psychologists and family therapists in that the recommendations will
help them to understand the underlining causes of psychological distress
associated with infertility challenge as well as to provide interventions and
coping skills along with medical treatment procedure.
For best practices, counsellors through the report of this study are more
enlightened on the more effective intervention for treating psychological distress
associated with infertility challenges. Findings from this study showed that
professional counsellors have a lot to do in assisting women with infertility
challenges cope and in managing psychological distress experiences during
infertility treatment procedure.
For instance, the treatment packages prepared for counselling women with
infertility challenges that participated in this research could be a great resource
when providing psychological intervention for individuals with infertility
challenges, whether on individual or group basis. The study impacted on the
participants particularly those in the two experimental groups (cognitive
restructuring and brainstorming) to understand their psychological distress and
to consciously reconstruct their thinking pattern as well as brainstorm on
alternative way to overcome infertility challenges rather than dwelling on
negative feelings about the inability to contribute to conception.
In addition, medical doctors may find the results of this research useful.
The results of this research will serve as an additional basis to look into the
possibility of introducing professional counselling into medical practice in the
area of infertility counselling for infertile woman. In addition, women with
infertility challenges would learn skills from the study after reading the results
of this research work and this may assist them to manage psychological distress.
For example, when women with infertility challenges read and understand the
treatment package, it would help them to have a realistic view of the causes of
infertility and this will go a long way in assisting them to seek for information
about treatment options and to deal effectively with psychological distress.
Furthermore, this study will serve as a valuable source of information to
various personnel in different institutions in counselling profession and
curriculum planners would also see the need to include counselling in the
medical and nursing curricular in Nigeria when they get access to the results of
study. Finally, researchers could find the study very relevant. The results and the
literature reviewed may serve as related literature to future researchers
undertaking similar research.

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1.8 Scope and Delimitation of the Study
The scope of this study covered only the use of cognitive restructuring
and brainstorming counselling techniques in managing psychological distress
(anxiety and depression) among women with infertility challenges. The
psychological distress or disturbances to be covered in this study are depression
and anxiety. This is because it has been consistently observed that these are the
major emotional problems experienced by most women with infertility
challenges. Other psychological disturbances such as low self-esteem, social
isolation, hopelessness and helplessness are excluded from this study. The
investigation was carried out among literate women with infertility challenges
that are registered in selected government health institutions in Kogi State.
Hence, women with infertility challenges who are receiving infertility treatment
in private health institutions are excluded from this study. Data for the study
were generated through the administration of self-reporting inventories.
This study is delimited to women with infertility challenges that are
assessing infertility treatment at the federal medical centre Lokoja and Kogi
state specialist hospital Lokoja, the choice of these hospitals sterns from the fact
that these health institutions are easily accessible to majority of citizens in Kogi
State.
The selection of literate women with infertility challenge was due to the
nature of research instrument since the researcher adopted standardized research
instrument developed by Aaron Beck. Age range of subjects’ ranges from 19
years to 50 years was due to the fact that increase in age do affect fertility rate
among women.

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CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 Introduction
This chapter deals with the conceptual, theoretical and empirical literature
concerning the study, under listed topics are reviewed:
Conceptual Frame work
Concept of Infertility
Counselling in the Context of Infertility
Concept of Depression
Concept of Anxiety
Concept of Cognitive Restructuring Counselling Technique
Concept of Brainstorming Counselling Technique
Theoretical Framework
Aaron Beck Theory of cognitive Behaviour Therapy
Albert Ellis Theory of Rational Emotive Behaviour Therapy
Empirical Review
Gap in Literature
Summary
2.2 Conceptual Framework
2.2.1Concept, Meaning and Nature of Infertility
Infertility is defined as the inability to obtain and sustain a pregnancy after
12 months of regular unprotected sexual intercourse. Generally, infertility falls
into two; primary and secondary infertility. Primary infertility is a condition that
the individuals had no history of fertility, in other words the couples never
previously experienced an established pregnancy, on the other words secondary
infertility is a condition that existed before a visit one or more pregnancies that
may be either childbirth or abortion and has been followed by lack of
fertilization.
According to Turek and Pera (2001) infertility is a common human health
problem, almost as common as diabetes mellitus and that approximately 10-15%
of couples of reproductive age are reported to be infertile. Demographers have

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modified the epidemiological definition of infertility and thus define infertility
as the inability of a non-contraception sexual active woman to have life birth.
Infertility is typically defined as the inability to conceive a child after
actively trying to do so for at least one year. It has been estimated that infertility
affects 10% - 15% of couples of child bearing age in United States. According
to Mc Quillan, Greil, White Jacob (2003) this based on the number of
people who turn to medical specialists when they are having trouble getting
pregnant. Infertility is estimated to affect 10-12% of couples worldwide,
according to US census Bureau, (2006).
Caren, Revenson (1999) wrote that infertility is a disease that affects
more than 80 million worldwide with marked regional variations, infrequency
and etiology. Infertility is perceived as a problem across virtually all cultures
and societies and affects an estimated 10%-15% of couples of reproductive age.
In recent years, the number of couple seeking treatment dramatically increased
due to factors such as postponement of child bearing among women.
Infertility Statistics/Prevalence
Mc Arthur (2007) reported that:
i. One in six couples is infertile in 40 percent of case the problem rests
with the male, in 40 percent with the female, ten percent with both
partners, and in a further ten percent of cases, the cause is unknown.
ii. Fertility problem strike one in three women over 35 years of age.
iii. One in 25 males has low sperm count and one in 35 is sterile.
iv. For healthy couples in their twenties having regular unprotected sex,
the chance of becoming pregnant each month is 25 percent.
v. The chance of conceiving in an IVF cycle is on average around
20percent (this varies according to individual circumstances).
vi. More than one percent of births in Australia involve the use of assisted
reproductive technologies (A.R.T)
vii. 10 to 20 percent of American couples experience infertility, according
to US news of world report in 2010.
Chandra, Martinez, Mosher, Abma Jones (2005) reported that in the United
State, an estimated 10.2% women between the ages of 15 to 44years, or about
6.2million women, have unpaired fertility and the incidence is increasing, the
report added that number of infertility women is expected to reach 6.3 million
by the year 2019 and may be as high as 7.7million in 2025.
2.2.2 Causes of Infertility
A couple is considered clinically infertile only when pregnancy has not
occurred after at least 12 months of regular sexual activity without the use of

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contraceptives. Farley, (2003) reported that many factors such as infection,
environmental, genetic and even dietary in origin can contribute to infertility.
Different factors or conditions can reduce human fertility, factors / conditions
such as:
i. Infectious diseases (sexual transmitted infections (STIS) including
HIV, other reproductive tract infections, mumps that develop after
puberty in men).
ii. Anatomical endocrine, genetic, or immune system problems
iii. Aging
iv. Medical procedures that bring infection into a women’s upper
reproductive tract.
Sexual transmitted infections are a major cause of infertility. Left
untreated Gonorrhea and Chlamydia can infect fallopian tubes the uterus, and
ovaries. Gonorrhea and Chlamydia can scar women’s fallopian tubes, blocking
eggs from travelling down the tubes to meet sperm. Men can have scarring and
blockage in the sperm duct (epididymis) and urethra from untreated gonorrhea
and Chlamydia.
In women, common causes of infertility include tubal or pelvic disorder,
such as endometriosis, ovulatory disorder/ dysfunction or anatomical problems.
In men, infertility can be caused by the presence of dilated blood vessels around
the testicles (varioceles) blockage or absence of the spermatogenic tubules from
infection or congenital absence of the vas deferens and low or no sperm count
(oligospermia) and (azoospermia) respectively from testicular failure. Genetic
causes of infertility can lead to either defects in sperm or egg production or
result in defects in anatomical development within the reproductive tract.
According to Okonofua (1997) abortion and promiscuity or waywardness during
youth are consistent beliefs about causes of infertility among Nigerians. It is
widely believed that abortions and Dilation Curette (D C) when performed
by ‘quack’ practitioners may cause infertility. Other identified causes are
infections, notably sexually transmitted infections, many people belief that use
of exogenous hormones will eventually disrupt the body‘s natural functions and
lead to infertility. Belief in supernatural causes of infertility is wide-spread
bordering on ideas such as witchcraft, and that curse can be placed on either or
both the couple, or as a result of a vow a woman may took in an earlier life not
to bear children, and belief in reincarnation. There is also the belief in the
phenomenon of “ogbanje” where-by a woman repeatedly gives birth to a child
who is not destined to live beyond the first birthday. Other perceived causes of
infertility identified are; blood incompatibility, which can be regarded as
biological plausible. This may represent a misinterpretation, immunological

19
incompatibility or sickle cell disease. Male factors such as man ability to have
an erection, and sexual intercourse meant that the male would be fertile while
watery sperm “may lead to infertility”. Perceived causes of infertility
among Yoruba’s Nigeria as reported by Okonofua et al (1997) are: Promiscuity
and Abortion in Women Abortion, promiscuity (premarital sex), and use of
contraceptives.
v) Un-explain infertility
Practice Committee of the American Society for Reproductive Medicine,
[PCASRM] (2006) in Gurunath , Pandian, Anderson Bhattacharya
(2011)Reported that:
“Health care providers diagnose a woman with unexplained
infertility when the infertility examination shows that
ovulation is occurring with no obvious abnormality, the
fallopian tubes are unobstructed, and there are adequate
numbers of motile sperm. About 30% of cases of infertility
in women cannot be explained, and that more advanced
testing may determine the cause of infertility”.
When a specific cause is not determined for women and when male
infertility has also been ruled out, the health care provider may begin treatment
to improve the chances of conception and then progress to more complex
fertility treatments.
2.2.3 Genetic causes of Infertility
Problems with egg and sperm production, a frequent cause of infertility
are the production of sex or gem cells (sperm or oocytes) in fewer than normal,
number or of poorer than normal quality. Gem cell production is complex and
differs from that of any other cell type. Normal body (somatic) cell replicate by
a process termed mitosis, in which identical daughter cells are created no
reduction in chromosome number occurs, however when gem cells replicate, the
process involves an extra cell division that reduces the number of chromosomes
from 46(diploid) to 23 (haploid) cell to gives rise to four haploid progenitors.
In female only one ovum is produced from this process, the remaining
three cell products become non-functioning polar bodies. This sex cell
replication pathway is termed meiosis. Sometimes genetic infertility associated
with egg production problems, including some of the common conditions that
directly alter the development of oocytes in the ovary are:
Ͳ Turner syndrome
Ͳ Premature ovarian failure

20
Ͳ Mutations in the Follicle Stimulating hormone (FSH) receptor.
Turner syndrome as a well studied disorder that is associated with
structural abnormalities or absence of an X chromosome. Most women with
Turner syndrome have a fairly characteristic appearance of short stature, webbed
neck, shield chest and an increased carrying angle elbow, associated with
primary amenorrhea (absence of menses) throughout life. The ovarian of women
with Turner syndrome are described as “streek” ovaries, in that they lack
oocytes and the normal associated follicular structures. In approximately 60% of
Turner women, the karyotypes can show variable mosaicism in X or Y
chromosome abnormalities (i.e 45, X / 46, XY).
2.2.4 Age as a factor of infertility
According to McArthur (2007) for a fertile couple in their twenties having
regular unprotected sex, the chance of conceiving each month is only 25 percent.
The ability of the woman’s ovaries to release eggs ready for fertilization
declines with age; the health of a woman’s eggs declines with age. As a woman
ages, she is more likely to have health problems that can interfere with fertility,
similarly a woman’s risk of having miscarriage increases with age. The man’s
age is thought to play a role, the medical definition of infertility focuses on the
women and that a woman under 35 is considered infertile if she fails to become
pregnant after 12 months of regular unprotected sex, but for those over 35, the
threshold is six months instead of twelve.
US news (2007) reported that a woman’s age is the single most important
risk factor for fertility. Women are most fertile on their teens and twenty’s and
that fertility may begin to decline slightly in the late 20’s and declines more
rapidly in the late 30s. Adetoro (2004) reports on age as factor of infertility, and
that in a 2002 analysis of pregnancy rates based on conception on the day of
ovulation, suggested that women between ages 19-26 years have twice the
pregnancy rate as those between 35-39years.
Table 2.1: Chances for Pregnancy by Age
Age Fertility %
Up till 34 years 90%
By age 40 years Declining to 67%
By age 45 years Declining to 15%
Source: World Health Organisation (2004)

21
Other factors according to Farley, (2003) are:
Anatomical problems
Endocrinoligical problems
Genetic problems
Immunological problems
Increasing age
Infections and parasitic diseases
Genital tuberculosis
Malaria
Schistosomiasis
Malnutrition
Potentially harmful substances
Pesticides
Tobacco, alcohol, or caffeine
Reproductive tract infections
Post abortion infections
Postpartum infections
Sexually transmitted infections
Ebomoyi Adetoro (1991) reported that “research results showed
unknown cause of infertility do account for up to 14 percent of the couples. In
all regions of the world, the largest proportion of remaining diagnoses could be
attributed to infection. In particular, women who reported a history of sexually
transmitted infections (STIs) had higher rates of infertility than women who did
not. In fact, STIs are recognized as the most common preventable cause of tubal
infertility. STIs such as Chlamydia infection or gonorrhea in the lower genital
tract can ascend into the upper genital tract, causing Pelvic Inflammatory
Disease (PID) that can produce inflammation, scarring, and eventual blockage of
the fallopian tubes. The WHO study report (2000) also showed that in every
region of the world, a history of postpartum or post abortion complications was
associated with blockage of both fallopian tubes. In addition, the percentage of
women with both fallopian tubes blockage generally increased if the women had
even ever been pregnant, given birth, or had an abortion, regardless of whether
complications occurred. Unsafe obstetric practices during delivery or abortion
could introduce infections that can lead to PID or other problems that hinder
conception. Many cases of infertility after delivery or abortion may, however,
still be due to STIs. If a woman has gonorrhea or Chlamydia infection during
pregnancy, her estimated risk of PID increases 50 percent to 100 percent if she
either gives birth or has an abortion. In these cases, instruments used during
obstetric procedures could carry existing infections into the upper genital tract.

22
Arowojolu reported that “many patients do not understand what is causing their
fertility problems and that “There is also a lot of mystique surrounding
infertility”. Because childbearing is viewed as a natural part of adult life, some
have explained infertility as supernatural. It has been labeled an act of God, a
punishment from unhappy ancestors, or the result of witchcraft. In an urban
slum area of Bangladesh, nearly half of 120 men and women surveyed said evil
spirits caused female infertility.
Another common misconception is that some forms of contraception
cause infertility. Anjani, C (2013) reported that because contraceptives prevent
pregnancy, they may mask underlying fertility problems, but they do not cause
infertility. The risk of long-term impaired fertility after using any contraceptive
method is low, and fertility usually returns immediately or shortly after
contraceptive discontinuation (see table 2.1). In fact, by preventing unintended
pregnancy and thus the potential for either postpartum or post abortion
infections, all contraceptives can help prevent infertility and improve the
chances that women will become pregnant when they choose to do so.
Table 2.2: Contraception and Return to Fertility
Contraceptive Time to Return of
Fertility
Abstinence Immediate
Condoms (male and female) Immediate
Female barrier methods, other than condoms Immediate
Implants Immediate
Injectables
Combined monthly Immediate
Progestin-only
Depot-medroxyprogesterone acetate (DMPA) Average 10 months
Norethisterone enanthate (NET-EN) Average 10 months
Intrauterine devices Immediate
Oral contraceptives Immediate
Sterilization No return to fertility
Source: World Health Organization (2010)
Male and female hormones also play significant role as part of causes of
infertility. The pituitary gland, located at the base of the brain, makes hormones
that stimulate the reproductive organs. According to McArthur (2007) in men,
the pituitary hormones tell the testicle to produce sperm and testosterone.
Sperm moves from the testicle into the epididymis, which sits on top of the
testicle and is like a bridge between the testicle and the vas deferens, the tube

23
that carries sperm to the penis. The sperm matures in the epididymis, which has
very high levels of testosterone. As it matures, it gains the ability to penetrate
the egg and gains motility. Then the sperm moves into the vas and is ejaculated
from there in liquid called semen.
McArthur (2007) reported that in women, the pituitary gland releases
hormones, including Follicle-Stimulating Hormone (FSH) and Luteinizing
hormone (LH) that control the monthly reproductive cycle and stimulate the
ovary to make estrogen and progesterone. Egg development begins before
women are even born, and baby girls are born with about 2 million eggs in their
ovaries – all the eggs they will never make. Eggs are enclosed in follicles in the
ovaries. Every month, hundreds of those follicles are destined to either ovulate
or die. Only one egg, or sometimes two, is released per month. From the
ovaries, the egg travels to the fallopian tubes, into the uterus, and is shed during
menstruation if it is not fertilized, the processes involved illustrate the vital role
of hormone in infertility.
2.2.5 Medical Causes of Infertility
Infertility is not a simple disorder with one cause. McArthur (2007) noted
that for a pregnancy to occur, a long series of events must happen and in the
right order. Disruption in any of these processes can lead to infertility. The
female must produce a healthy, mature egg and the ovary must release it. After
release, the egg must travel toward the fallopian tube so that it may be fertilized
by the sperm. The male must produce a sufficient number of normal sperm that
must be released from the penis and enter the vagina at the appropriate time
during the menstrual cycle. It is only during this fertile time that the cervical
mucus allows sperm to ascend through the cervix and into uterus. Finally, the
fertilized egg must travel to the uterus and implant in the endometrial (the
uterine lining), which will nourish its further development. In some cases,
couples who are unable to conceive simply are not having intercourse enough or
are not having intercourse during the woman’s fertile time.
The most common reason for infertility overall is the woman’s age,
ESHRE (2011) reported that fertility generally starts to decline in the late 20s,
with a more dramatic decline from the late 30s. Other factors that can contribute
to female infertility include ovulation disorders such as polystic-ovarian
syndrome (which involves high levels of female hormones and irregular or no
menstruation), endometriosis (in which uterine lining tissue grows in places
where it doesn’t belong), and additional problems with the uterus or other
reproductive structures. Diseases of the pituitary or hypothalamus glands can
also interfere with the production of hormones. Stress, poor diet, smoking and

24
alcohol can also contribute to infertility. Some overweight women with
infertility challenges will find they are able to get pregnant after they lose
weight. This is particularly true for women with polycystic ovarian syndrome.
The most common male cause for infertility is a varicocele, a varicose vein in
the scrotum. Although doctors understand many causes of infertility, there are
still cases in which both partners seem to be perfectly healthy and fertile but are
unable to conceive. Each of these causes highlighted above are discussed in
detail below.
Ovulation Disorders is another causes, some women do not ovulate regularly.
This can make getting pregnant more challenging. Women with ovulation
disorders are usually aware that they may have irregular unpredictable periods,
or may have very long intervals between periods. There are three main
categories of ovulation disorders: polycystic ovarian syndrome (PCOS), ovarian
failure, and hypothalamic amenorrhea. Despite the name, polycystic ovarian
syndrome has nothing to do with cysts. It has that name because when you
examine women who have PCOS with ultrasound, they have what look like tiny
cysts on their ovaries. These specks are actually immature eggs. Women with
PCOS may have irregular periods or may not menstruate at all. They tend to
have high levels of male hormones, and they have facial hair, acne, or other
testosterone-related symptoms.
In ovarian failure, the ovaries simply stop working. This may happen in
menopause, but it can also happen earlier. Women with premature ovarian
failure have high levels of follicle-stimulating hormone (FSH) in their blood.
Hypothalamic amenorrhea is a common problem in athletes, ballerinas, or other
women who train very hard. “Amenorrhea” means having no periods.
“Hypothalamic” means it is related to the hypothalamus, a region of the brain
that is sensitive to stress. Very intense physical training or emotional stress can
affect menstruation. Eating disorders are another common cause of
hypothalamic amenorrhea. It can also be caused by a brain tumor or brain
surgery that affects the hypothalamus.
Ovulatory disorders are one of the most common reasons why women are
unable to conceive, and account for 30% of women’s infertility. Fortunately,
approximately 70% of these cases can be successfully treated by the use of
drugs such as Clomiphene and Menogan/Rpronex. The causes of failed
ovulation can be categorized as follows:
1. Hormonal Problems
These are the most common causes of anovulation. C.D.C (2010) noted that
‘the process of ovulation depends upon a complex balance of hormones and

25
their interactions to be successful, and any disruption in this process can hinder
ovulation’ and that there are three main sources causing this problem:
Failure to produce mature eggs: In approximately 50% of the cases of
anovulation, the ovaries do not produce normal follicles in which the eggs can
mature. Ovulation is rare if the eggs are immature and chance of fertilization
becomes almost nonexistent. Polycystic ovary syndrome, the most common
disorder responsible for this problem, includes symptoms such as amenorrhoea,
hirsutims, anovulation and infertility. This syndrome is characterized by a
reduced production of Follicle Stimulating Hormone (FSH) and normal or
increased levels of Luteinizing Hormone (LH), oestrogen and testosterone. The
current hypothesis is that the suppression of FSH associated with this condition
causes only partial development of ovarian follicles, and follicular cysts can be
detected in an ultrasound scan. The affected ovary often becomes surrounded
with a smooth white capsule and is double its normal size, this may prevent
pregnancy, Stanback, Twun-Baah (2001).
Malfunction of the hypothalamus: The hypothalamus is the portion of the
brain responsible for sending signals to the pituitary gland, which in turn sends
hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg
maturation. If the hypothalamus fails to trigger and control this process,
immature eggs will result. This is the cause of ovarian failure in 20% of cases
Malfunction of the pituitary gland: The pituitary’s responsibility lies in
producing and secreting FSH and LH. The ovaries will be unable to ovulate
properly if either too much or too little of these substances is produced. This
can occur due to physical injury, a tumor or if there is a chemical imbalance in
the pituitary.
2. Scarred Ovaries: Physical damage to the ovaries may result in failed
ovulation. For example, extensive, invasive, or multiple surgeries, for
repeated ovarian cysts may cause the capsule of the ovary to become
damaged or scarred, such that follicles cannot mature properly and
ovulation does not occur. Infection may also have this impact.
3. Anovulation: This presents a rare and as of yet unexplainable cause of
anovulation. Some women cease menstruation and begin menopause
before normal age. It is hypothesized that their natural supply of eggs has
been depleted or that the majority of cases occur in extremely athletic
women with a long history of low body weight and extensive exercise.
There is also a genetic possibility for this condition.
4. Follicle Problems: Although currently unexplained, “Unruptured follicle
syndrome” occurs in women who produce a normal follicle, with an egg

26
inside of it, every month yet the follicle fails to rupture. The egg,
therefore, remains inside the ovary and proper ovulation does not occur.
5 Egg Quality Disorders
Some women produce poor-quality eggs. The reasons are often not
known. Hormonal or reproductive disorders like endometriosis may contribute,
or eggs could be defective because of a woman’s genetics or something she has
been exposed to in the environment. Doctor usually cannot offer an explanation
for poor-quality eggs, and the only option for these women may be in vitro
fertilization using an egg donor.
In women, problems of ovulation account for most cases of infertility.
Without ovulation, there are no eggs to be fertilized. Other causes of infertility
challengess include blocked fallopian tubes and physical problems with the
uterus, including uterine fibroids. Factors that can negatively affect a woman’s
fertility include poor diet, athletic training, being overweight or underweight,
tobacco smoking, use of alcohol or drugs, sexually transmitted diseases,
radiation and chemotherapy treatment for cancer, and health problems that cause
hormone changes, age is another factor, more a factor for women than for men,
age can affect the women’s ability to have children.
6 Blocked Fallopian Tubes
The fallopian tubes are the passage through which an egg moves from the
ovaries to the uterus. The fallopian tubes are sensitive to scarring and can be
blocked as a result of infection, endometriosis, or scar tissue from previous
surgery. This can make the fallopian tube unable to transport an egg into the
uterus or sperm from the uterus to the egg. Tubal disease affects approximately
25% of infertile couples and varies widely, ranging from mild adhesions to
complete tubal blockage. Treatment for tubal disease is most commonly surgery
and, owing to the advances in microsurgery and lasers, success rates (defined as
the number of women who become pregnant within one year of surgery) are as
high as 30% overall, with certain procedures having success rates up to 65%.
The main causes of tubal damage include:
1. Infection caused by both bacteria and viruses and usually transmitted
sexually, these infections commonly cause inflammation resulting in
scarring and damage. A specific example is Hydrosalpnix, a condition in
which the fallopian tube is occluded at both ends and fluid collects in the
tube.
2. Abdominal Diseases: The most common of these are appendicitis and
colitis, causing inflammation of the abdominal cavity which can affect the
fallopian tubes and lead to scarring and blockage.

27
3. Previous Surgeries: This is an important cause of tubal disease and
damage. Pelvic or abdominal surgery can result in adhesions that alter the
tubes in such a way that eggs cannot travel through them.
4. Ectopic Pregnancy: This is pregnancy that occurs in the tube itself and,
even if carefully and successfully overcome, may cause tubal damage and
is a potentially life-threatening condition.
5. Congenital Defects in rare cases, women may be born with tubal
abnormalities, usually associated with uterus irregularities.
Sexually transmitted diseases can cause Pelvic Inflammatory Disease
(PID). Scarring from PID can block the fallopian tubes or damage them so they
cannot pick up an egg from the ovary. Since PID has no symptoms in up to 50
percent of cases, many women will not know that they have had this infection.
Endometriosis, in which the tissue that lines the uterus grows in other parts of
the belly cavity, can also block the fallopian tubes. In some cases, a blockage
can cause a hydrosalpinx, a fallopian tube filled with fluid. That fluid can leak
out of the tube into the uterine cavity, which may make the uterus inhospitable
to an embryo. Doctors do not yet know exactly how the fluid affects fertility,
but removing the fallopian tube sometimes helps.
Uterine Anomalies is another problem causing infertility, it may be problems a
woman is born with or that develop over time. IPPF (2007) reported that ‘there
can be congenital problems where the uterus does not form properly, so the
uterine cavity cannot carry a pregnancy to term. This usually leads to
miscarriages rather to an inability to get pregnant in the first place. In some
women, the opening to the fallopian tube may not form correctly, or the cervix
may not form correctly. These are relatively rare abnormalities. Some uterine
anomalies develop as women get older. This could include scar tissue, polyps,
fibroids, or other growths that affect the endometrium or the cavity of the uterus,
or interfere with implantation. Fibroids are non-cancerous tumors that grow in
the uterus. They are extremely common; some 30 to 50 percent of women of
reproductive age have fibroids, and fibroids are rarely the culprit in infertility.
Women having infertility treatment may not need to have fibroids removed.
Additional Factors
1. Other variables that may cause infertility in women:
• At least 10% of all cases of female infertility are caused by an abnormal
uterus conditions such as fibroid, polyps, and adnomyosis may lead to
obstruction of the uterus and fallopian tubes
• Congenital abnormalities, such as septet uterus, may lead to recurrent
miscarriages or the inability to conceive.

28
• Approximately 3% of couples face infertility due to problems with the
female’s cervical mucus. The mucus needs to be of a certain consistency
and available in adequate amounts for sperm to swim easily within it. The
most common reason for abnormal cervical mucus is a hormone
imbalance, namely too little estrogen or too much progesterone.
2. Behavioural Factors: it is well-known that certain personal habits and
lifestyle factors impact health: many of these same factors may limit a
couple’s ability to conceive. Fortunately, however, many of these
variables can be regulated to increase not only the chances of conceiving
but also one’s overall health.
• Diet and Exercise: Optimal reproductive functioning requires both proper
diet and appropriate levels of exercise. Women who are significantly
overweight or underweight may have difficulty becoming pregnant.
2.2.6 Treatment of infertility
Infertility can be treated with medication, surgery, artificial insemination,
or assisted reproductive technology (ART) in many cases, these treatment
option are combined using medications to stimulate ovulation in female infertile
patient. Additional choice of treatment option for infertile couples include the
use of gestational surrogates to carry the baby to term when the couples wants
one or both parents to be genetically related to the baby. For infertile couples for
whom genetic ties are not important, adoption is another alternative.
2.2.7 Medical Remedy to Infertility
Findings the cause or causes of a women’s infertility challenges can be an
emotionally draining process. The physician usually begins with males, by
testing his semen, to look at the number, shape, and movement of the sperm.
Testing of male hormone levels also may also be part of the diagnostic workup.
For the woman, doctors will cheek to see whether she is ovulating by doing
blood test and an ultra-sound of the ovaries. Further diagnostic test are done to
cheek for physical scarring, adhesion and disease
Although advances in medical treatment for infertility have greatly
increased the number of options available to infertile couples, the process of
seeking, receiving and financing medical treatment is still quite stressful,
McNaughton- Cassill, Bostwick, Arthur, Robinson Neal, (2002). The
diagnosis and initial treatment of infertility may include planning intercourse
according to basal body temperature, undergoing post coital examinations of
cervical music, and collecting semen specimens by masturbation, couples often

29
report both anxiety and embarrassment when undergoing such procedures
treatment may also require the ingestion or injections of medications which can
have significant side effects Champagne, (2006), one or both members of the
couple may require surgical procedures, which although generally safe, can lead
to health complications as well as stress, and depression (Salzer, Winkelbach,
Leweke, Leibing, Leichsenring, (2011). Pursuing medical approaches to
infertility often require travel, time off from work, and can generate extensive
financial debt as treatment are not always covered by insurance.
McQuuillan, Greil, White Jacob (2003) noted that
“in addition to generating numerous medical concerns
infertility has also been strongly related to psychological
distress, and that infertility is often considered a life crisis
and has been shown to be a cross cultural crisis”.
Some of infertile couples often experience depression, anxiety, isolation,
anger, guilt and shame. Such stress may persist for years, and be exacerbated
each time a treatment or procedure is unsuccessful. Mental distress is also
common sequelae of infertility, and can even result in divorce. Causes of marital
dissatisfaction can include the impact of infertility concerns and treatment of
sexual functioning. Differences in emotional distress and coping style may also
contribute to communication problem within the couple, according to Domar et
al., (2000) the rising number of couples dealing with infertility, and the
increasing complexity of available medical treatment, some researchers suggests
that infertility treatment programs should include a psychological treatment
component such treatment may take the form of individual therapy, focus on
addressing the relationship between infertile couple, long-term adjustment to
infertility, and acute reaction to fail treatment procedures, couples approaches to
communication issues, mental adjustment, and sexual satisfaction.
When initial treatment for infertility is unsuccessful, couples may decide
to try advanced reproduction technologies such as Invitro-fertilization (IVF).
IVF is a complex and invasive process which involves hormonal manipulation
consisting of the use of injectable fertility drugs to stimulate the development of
multiple Oocytes, Oocytes retrieval, and fertilization of (incomplete statement).
Assisted Reproductive Technology (ART) is another medical approach to
infertility treatment. According to Illmensee, Levanduski, Vidali, Husami
Goudas (2009) Assisted Reproductive Technology (ART), is a general term
referring to methods used to achieve pregnancy by artificial or partially artificial
means. It is reproductive technology used primarily in infertility treatments.
Some forms of ART are also used in fertile couples for genetic reasons. ART is
also used in couples who are discordant for certain communicable diseases, e.g.

30
AIDS, to reduce the risk of infection when a pregnancy is desired. The term
includes any reproductive technique involving a third party e.g. a sperm donor.
Examples of ART include in vitro fertilisation, intracytoplasmic sperm injection
(ICSI), cryopreservation, and intrauterine insemination (IUI). There is yet no
strict definition of the term. Usage of the ART mainly belongs in the field of
reproductive endocrinology and infertility. The Centers for Disease Control and
Prevention (CDC)( 2000)—defines ART to include all fertility treatments in
which both eggs and sperm are handled. In general, ART procedures involve
surgically removing eggs from a woman's ovaries, combining them with sperm
in the laboratory, and returning them to the woman's body or donating them to
another woman. According to CDC, ARTs do not include treatments in which
only sperm are handled (i.e., intrauterine—or artificial—insemination) or
procedures in which a woman takes medicine only to stimulate egg production
without the intention of having eggs retrieved. While there is no consensus on
the definition, generally the process of intercourse is bypassed either by
insemination (for example, artificial insemination) or fertilization of the oocytes
in the laboratory environment (i.e., in vitro fertilization).
ART procedures are mainly fertility medication, as well as ART
techniques that use more substantial and forceful interventions, of which in vitro
fertilization (IVF) and expansions of it (e.g. OCR, AZH, ICSI, ZIFT) are the
most prevalent. (ART) procedure sometime involves the use of donor sperm or
previously frozen embryos. Donor eggs can be used for women who cannot
produce health eggs. Also donor eggs or donor sperm are used when the woman
or man has a genetic disease that can be passed on to the baby. However, there
are also other manual ART, not necessarily dependent on IVF (e.g. PGD, GIFT,
SSR). Most fertility medication is agents that stimulate the development of
follicles in the ovary. Examples are gonadotropins and gonadotropin releasing
hormone, according to, PCASRM (2008), in vitro fertilization (IVF) is the
technique of letting fertilization of the male and female gametes (sperm and
egg) occur outside the female body. Techniques usually used in vitro
fertilization Ethics Committee of the American society for reproductive
medicine (2009) include:
• Transvaginal Ovum Retrieval (OCR) is the process whereby a small needle
is inserted through the back of the vagina and guided via ultrasound into the
ovarian follicles to collect the fluid that contains the eggs.
• Embryo transfer is the step in the process whereby one or several embryos
are placed into the uterus of the female with the intent to establish a
pregnancy.

31
Assisted Zona Hatching (AZH), is an expansions of IVF, the following are
techniques that generally require methods of in vitro fertilization. Assisted Zona
Hatching (AZH) is performed shortly before the embryo is transferred to
the uterus. A small opening is made in the outer layer surrounding the egg in
order to help the embryo hatch out and aid in the implantation process of the
growing embryo.(see figure 1)
Figure 1: Intracytoplasmic sperm injection (ICSC)
Intracytoplasmic sperm injection (ICSC) is beneficial in the case of male
factor infertility where sperm counts are very low or failed fertilization occurred
with previous IVF attempt(s). The ICSI procedure involves a single sperm
carefully injected into the center of an egg using a micro needle. This method is
also sometimes employed when donor sperm is used. Other forms of infertility
treatment are:
a) Autologous endometrial coculture is a possible treatment for patients who
have failed previous IVF attempts or who have poor embryo quality. The
patient's fertilized eggs are placed on top of a layer of cells from the patient's
own uterine lining, creating a more natural environment for embryo
development.
b) In Zygote Intrafallopian Transfer (ZIFT), egg cells are removed from the
woman's ovaries and fertilized in the laboratory; the resulting zygote is then
placed into the fallopian tube.
c) Cytoplasmic transfer is the technique in which the contents of a fertile egg
from a donor are injected into the infertile egg of the patient along with the
sperm.
d) Egg donors are resources for women with no eggs due to surgery,
chemotherapy, or genetic causes; or with poor egg quality, previously
unsuccessful IVF cycles or advanced maternal age. In the egg donor
process, eggs are retrieved from a donor's ovaries, fertilized in the laboratory
with the sperm from the recipient's partner, and the resulting healthy
embryos are returned to the recipient's uterus.

32
e) Sperm donation may provide the source for the sperm used in IVF
procedures where the male partner produces no sperm or has an inheritable
disease, or where the woman being treated has no male partner.
f) A gestational carrier is an option when a patient's medical condition
prevents a safe pregnancy, when a patient has ovaries but no uterus due to
congenital absence or previous surgical removal, and where a patient has no
ovaries and is also unable to carry a pregnancy to full term.
g) Preimplantation Genetic Diagnosis (PGD) involves the use of genetic
screening mechanisms such as Fluorescent In Situ Hybridization (FISH) or
Comparative Genomic Hybridization (CGH) to help identify genetically
abnormal embryos and improve healthy outcomes.
h) Embryo splitting can be used for twinning to increase the number of
available embryos.
Other forms of Assisted Reproduction Techniques do not necessarily
involve IVF, such as:
i) In gamete intrafallopian transfer (GIFT) a mixture of sperm and eggs is
placed directly into a woman's fallopian tubes using laparoscopy following
transvaginal ovum retrieval.
ii) Sex selection is the attempt to control the sex of offspring to achieve a
desired sex. It can be accomplished in several ways, both pre- and post-
implantation of an embryo, as well as at birth. Pre-implantation techniques
include PGD, but also sperm sorting.
iii) Artificial insemination (AI) is when sperm is placed into a female's uterus
(intrauterine) or cervix (intracervical) using artificial means rather than by
natural copulation. This can be a very low-tech process, performed at home
by the woman alone or with her partner.
iv) Conception devices, such as a conception cap are used to aid conception by
enhancing the natural process. Conception caps are used by placing semen
into a small conception cap, then placing the cap onto the cervix. This holds
the semen at the cervical protecting the semen from the acidic vaginal
secretions and keeping it in contact with the cervical mucus.
v) Artificial insemination by donor is used in situations where the women do
not have a partner with functional sperm. Instead, a sperm donor supplies the
sperm.
vi) Surrogacy, where a woman agrees to become pregnant and deliver a child for
a contracted party. It may be her own genetic child, or a child conceived
through in vitro fertilization or embryo transfer using another woman's ova.
vii) Reproductive surgery, treating e.g. fallopian tube obstruction and vas
deferens obstruction, or reversing a vasectomy by a reverse vasectomy.

33
In surgical Sperm Retrieval (SSR) the reproductive urologist obtains sperm
from the vas deferens, epididymis or directly from the testis in a short outpatient
procedure. By cryopreservation, eggs, sperm and reproductive tissue can be
preserved for later IVF.
2.2.8 Usage Rate of ART
Illmense, et al (2009) Assisted reproductive technology procedures
performed in the U.S. has more than doubled since 10 years ago, with 140, 000
procedures in 2006, resulting in 55,000 infants born. In Australia, 3.1 percent of
babies now born are a result of ART.
Risks associated with ART
The majority of IVF-conceived infants do not have birth defects.
However, some studies have suggested that assisted reproductive technology is
associated with an increased risk of birth defects. In the largest U.S. study,
which used data from a statewide registry of birth defects, Hansen, Bowen,
Milme, Klerk, Kurinczuk (2005) reported that 6.2% of IVF-conceived children
had major defects, as compared with 4.4% of naturally conceived children
matched for maternal age and other factors (odds ratio, 1.3; 95% confidence
interval, 1.00 to 1.67).The main risks are:
• Genetic disorders
• Low birth weight.
• Preterm birth.
Sperm donation is an exception, with a birth defect rate of almost a fifth
compared to the general population. It may be explained by that sperm banks
accept only people with high sperm count.+
2.2.9 Psychological Distress Associated Infertility
Psychological distress has been describe as the end result of factors such
as, psychogenic pain, internal conflicts, and external stress that prevent a person
from self-actualization and connecting with significant others. According to
Chandra, Martinez, Mosher Jones (2005), family therapists have shown
increasing interest in understanding the effects of infertility on individual
behaviour. Chandra, Martinez, Mosher Jones (2005), described infertility as
potentially devastating event on the psychologically wellbeing of people
involved as well as the effects that infertility has on couples relationships and
that most infertile couples questioned the nature of their partners relation, such
responses has been described an indication of third level crisis. Level three
crises or third level crisis can fracture the foundation of a couple’s personal
sense of efficacy and the basic assumptions on which their partners agreed as

34
they designed and negotiate their marriage. In line with the definition of level
three or third level crisis infertility can induce or can be an earth-shattering
event that forces a couple to re examine their core assumptions about who they
are and what their relationship means.
Cousineau Domar (2007) reported that lack of understanding from
family members/friends is one of the most difficult barriers that infertile couples
face. In addition to unsupportive relationships, infertile couples often have to
deal with serious cultural issues, such as the expectation that a woman be
mother, ideas that are strong and compelling, permeating the entertainment,
media, religious practice and community life, and that differences occur between
couples who were fertile and those who were not fertile, with the spouses in
infertile couple relationship reporting depression, problem with self efficacy,
and increased level of anxiety. The depressive symptom that is most commonly
reported among infertile couple is a cyclical pattern of “hope and despair”,
meaning that each month the couple has “renewed hope” that this month will be
“the month” to get pregnant. The intensity of this cycle may be enhanced by
medical visits and procedures designed to increase pregnancy possibility but
when the wife’s menstrual period starts, then the couples hope quickly dissipate,
this is often followed by depression and sometimes anger toward each other and
hostility directed toward women who have borne children. In the process of
cyclical pattern of hope, women are more likely (than men) to fell blue, and
sometimes experience periods of decreased self-efficiency.
Burns (2007) reported that spouses’ perception of infertility affected their
quality of life, and that one spouse’s perception of the event had a reciprocal
oscillating fashion. When couple (spouses) attach similar meanings to the events
(infertility) the couples are more likely to adapt to the situation, and therefore
decrease the level of overall crisis/disruption. Unsupported social interactions do
have significant effect on depression level and overall psychological distress in
women with infertility challengesIn some culture, when women with infertility
challenges attempted to connect with friends and family members they were
often rebuffed, this made some women with infertility challenges to experience
feelings of rejection, resulting in a sense of stigmatization and isolation, low
sense of social support from close family members.
Reported that most couple often feel like they were on a roller coaster,
frequently had to return to square one particularly following a miscarriage or
failed medical procedure, some are worried about sense of running out of time,
some expressing frustration, anger at God, their partners, and friends, feeling of
guilt, others struggled between hope and hopelessness.

35
Wanting and having a child or children are natural and normal behaviours,
these constitute religious and civic moral responsibilities and do reflect sexual
competence, in some culture having children is viewed as the meaning of
marriage. Domar, Zuttermeister, Seibel, Benson, (1992) ported that many people
feel that parenthood is an integral part of their development as adults and is
needed to be complete partners in marriage.
Pointed out that advertising agent, magazine stories, new products, the
attitudes and questions of relatives and acquaintances cater to the expectation
that adults in our society are expected to become parents. Infertility is perceived
as a stressful life situation that influences an individual’s psychological
adjustment in accordance with the resources he or she has available. Schmidt,
Christensen Holstein (2005) reported that: from mental health perspective,
infertility is considered among the more serious life stressors. Reports on studies
showed that effect of infertility is detrimental to individual wellbeing as well as
on mental satisfaction. Schmidt , Christensen, Holstein (2005) added that
tension, depression, anger, decrease in sexual functioning, mood disturbances,
cognitive disturbances expressed in excessive worrying and a tendency for self-
blame, low energy level, and overreacting, and sometimes frequent responses
among infertile couple/women.
Leibum (1993) reported infertility to be a serious source of stress and
anxiety that causes some women with infertility challenges to feel offended,
lower body image, and decrease psychological and financial resources and in
some cases result into marital problems.
Van Balen Gerrits (2001) noted that psychosocial problems arisen from
infertility are most often reported to be distress, dressing, anxiety, sexual
problems marital and social adjustment loss of control, lowered self-esteem.
Demyttenaere, Bonte, Gheldof, Vervaeke, Meulman, Vanderschuerem,
d’Hooghe (1998) reported that the psychological symptom as well as the
anxieties and depression scores in women with infertility challenges are similar
to those in medical disorder such as cancer, cardiac rehabilitation and
hypertension. Ulrich Weatrherall (2000) wrote that all adults especially
women are targeted by assertions that a person’s social value is linked to
procreation, and that most women experience considerable pressure to bear or
raise children. This pressure may become nearly intolerable at times when
parents, relatives and society members convey the notion that women “owe”
their family children. Motherhood is still emphasized as women’s primary social
role. Adetoro Ebomoyi (1991) stated that the struggle to become fertile and
bear one’s own biological child / children is a heart wrenching one; a woman’s
social worth is extricable linked to her ability to achieve biological motherhood.

36
Alexandra (2010) reported that women with infertility challenges exhibit
significantly higher psychopathology in the form of tension, hostility, anxiety,
depression, self-blame, in some societies/ cultures strong social stigma attached
to infertility cause women to blame themselves for infertility and that in some
culture, infertile woman are excluded from certain social activities and
traditional ceremonies.
Caren Revenson (1999) reported that women with infertility challenges
are believed by the men to have lived unhealthy past with repeated transmitted
diseases precipitations their current condition. The report added that women
bear the brunt of infertility and are stigmatized even when the male adamants
refused medical examination. Women undergo a lot of mental, emotional,
psychological and physical pressure and often times falling prey to charlatans in
their arduous quest for fertility. Report by Odidika (2009) added that some
women with infertility challenges admitted going through emotional and
psychological crisis with a feeling of worthlessness especially in company of
their peers. They feel lonely in the midst of friends and relatives, some say that
their future remain uncertain without a child/ children for their husband. Some
are with feelings and thoughts that erode their self-confidence and this make
them withdrawn. Some women experience humiliation from husband relations
especially mother –in laws. Some women with infertility challenges who may be
luckier in terms of spousal support and compassion still feel worthless in
themselves and unworthy for their husbands. They may become depressed with
some fatalistic desires. To some, the problem of infertility erodes women of
basic human dignity and rights.
Original investigations into the psychological aspects of infertility focused
on individual psycho pathology (particularly in women), sexual dysfunction, and
infertility specific distress. According to Reed (2001) early research on
infertility was largely based on theoretical speculations or anecdotal information
rather than scientifically rigorous investigations. Added that much of the
researches focused on psychological distress and in recent decades an increasing
number of infertility counselors acting as researchers improve overall quality
and quantity of studies related to infertility in the areas of impact of stress on
infertility, gender differences in responses to infertility, cross-cultural issues and
complicating medical conditions in infertility. Emotional stress experience by
infertile patient, upon diagnosis of infertility for most of the couples means a
growth of psychological strain that has to be coped with. Salzer, Winkelbach,
Leweke, Leibing, Leichsenring, (2011) (2001) reported that infertile patient
do go through several unpleasant stages; such as
1. The hope of getting pregnant

37
2. Then the realization that either the man is sterile or the woman cannot
become pregnant
3. The psychological reaction that is triggered. Specifically, two reactions
are conceivable: either childlessness is not accepted as fate or it is
considered a reason to find a new orientation in life.
During infertility medical treatments, infertile patients often experience a
variety of extreme emotional responses as they are faced with repeated high
hopes of pregnancy crushed by the failure to conceive month after month.
Sometimes, those undergoing infertility treatments might feel over looked by
medical staff, or insensitively managed, or overwhelmed by an array of invasive
and expensive procedures. Domar (2000): Reported that:
Parenthood is one of the major transitions in adult life for both men and
women. The stress of the non-fulfillment of a wish for a child has been
associated with emotional sequelae such as anger, depression, anxiety, mental
problems, sexual dysfunction and social isolation. Couples experiencing stigma,
sense of loss, and diminished self-esteem in the setting of their infertility. For
women going through this perception, counselling services will be appropriate.
Marcia Balen (2010) reported that one of the most intriguing aspects of
the study of infertility is its relationship with psychology. For example, since
Biblical times, it has been noticed that involuntarily childless women, such as
Sarah, the wife of Abraham, Hanna, wife of Elikanna, frequently showed
behavior that would be interpreted today as a sign of psychological problems.
Marcia Balen (2010) reported further that various ideas about the origin of
infertility existed among people in many culture, one of these ideas was the idea
that, in one way or the other, the woman caused her own infertility, for instance
through bad behavior or a disturbed mind, ideas that are considered to be
psychosocial in nature.
According to Peterson, Newton Rosen (2003) for men, acceptance of a
childless lifestyle result in increased marital adjustment, but for women, the
stress of infertility influences their perception of the marriage, and they diminish
mental adjustment as the course of treatment for infertility lengthens. When the
members of a couple perceive equal levels of infertility related stress they may
exhibit better mental adjustment than couples who differ in their perception of
the stress cause by their infertility. Okonofua et al (1997) reported that: women
are more likely to suffer the social consequences of infertility; they suffer
physical and mental abuse, neglect, abandonment, economic deprivation and
social ostracism as a result of infertile status. The psychological distress or
disturbances to be discussed in this section are anxiety and depression. The

38
nature, signs and symptoms and psychological treatment/management of each
distress are discussed.
2.2.10 Counselling in the Context of Infertility
Infertility is associated with increased psychological/emotional distress
such as decreased self-esteem, depression, grief and anxiety. Counselling can be
used as an adjunct service to enable women with infertility challenges cope with
the psychological changes they are experiencing. Boivin et al (2001:1301)
posited that “Fertility clinics should therefore aim to address the psychosocial
and emotional needs of their patients as well as their medical needs.” According
to these authors, counselling involves the use of psychological interventions
based on specific theoretical frameworks. It is typically delivered by someone
having received training in the mental health professions such as psychology,
social work and counselling. They added that counselling might include
individual and couple therapy. The content of counselling may differ depending
on the patient and the treatment choice but will usually involve at least some
form of information and implication counselling, support or therapeutic
counselling. Information and implication counselling might focus on ensuring
that individuals understand the different psychosocial issues involved in the
treatment choice whereas therapeutic counselling might involve an
understanding of the emotional consequences of childlessness.
Boivin et al (2001) identified three populations who might benefit from
and/or require counselling. The first group represents the majority of patients
seen by the researcher. These are patients who experience very high levels of
distress. The distress may be manifested in different ways (e.g. depression,
anxiety), but is generally perceived by the patient as being overwhelming and
difficult to manage. The purpose and objective of counselling in such cases will
vary depending on the source of distress. But in general, the counselling
objectives are as follows:
i) Enable the expression of emotions
ii) Identify the cause(s) of distress
iii)Provide intervention(s) to minimize distress and help patients better
manage distress
iv) Discuss high-risk personal, situational, social and treatment linked factors
which may predispose or trigger high distress.
v) Help the individual cope with [repeated] treatment failure (Boivin et al
2001:1302)
The second groups of patients who use counselling are those couples
requiring donated gametes, surrogacy and/or adoption to achieve parenthood.

39
So-called third-party reproduction is thought to provoke psychological and
emotional issues that go beyond the counselling issues involved in treatments
not requiring a third-party. The counselling objectives in third party
reproduction as outlined by Boivin et al (2001: 1303) include the following:
a) Help couples acknowledge and come to terms with the implications of
using third party reproduction as an alternative to family creation
b) Ensure the well-being of the parent who will not be genetically related to
the child
c) Counsel on secrecy/openness towards the future child and social network
about the use of third party reproduction
d) Discuss the legal issues, medical risks, religious and cultural
considerations of using third party reproduction
e) Ensure the decision to donate or become a surrogate was free from
coercion (familial, financial)
f) Make an informed decision on whether or not to pursue adoption and the
implications of being a parent of an adopted child
g) Help couples make the transition from using medical treatment to achieve
parenthood to choosing adoption
h) Discuss issues involved in integrating adopted child into families where
other children already exist.
The final groups of patients who benefit from counselling are those who
seek fertility services because of their social circumstances rather than their
medical status, single and lesbian women who use donated spermatozoa or gay
men who use surrogacy fall in this category. While these individuals will also
face the general issues described for third party reproduction, they also face
issues that are specific to ‘social’ infertility. Additional objectives for
counselling in social infertility are outlined for couples who are considering
adoption below:
i) Counselling on how to integrate the child into the family and social
environment
ii) Help lesbian couples legitimize their desire to have a child and discuss
fears and anxieties concerning the effect their sexuality and decision to
use insemination may have on the future welfare of the child (e.g. stigma,
rejection of parent etc).
iii)Help couples construct their family structure by discussing the sharing of
parental responsibilities, assignment of parental roles and the position of
the non-biological mother
iv) Discuss the legal status of the child and non-biological mother

40
v) Discuss consequences of the absence of a father in child and family
development
Counselling tips for single women without partners are listed below:
i) Assess the well-being of the women
ii) Help single women come to terms with the unfulfilled wish to parent a
child without a loved one
iii)Discuss the social and economic implications/consequences of choosing
to become a single parent
iv) Discuss the effect of becoming a mother at an older age on the treatment
and parenting experience (Boivin et al 2001: 1303).
2.3.1 Concept, Meaning and Definition of Anxiety
Anxiety has been defined as a feeling of tension, apprehension, or fear
that result from the anticipation of danger. This danger may be either internal or
external. All humans do experience anxiety from time to time, but anxiety does
not seriously impair on interpersonal functioning or individuals do experience
anxiety to such an extreme degree for such a long period of time that it
significantly disrupts their daily lives. Anxiety (also called angst or worry) is a
subjective psychological and physiological state characterized by somatic,
emotional, cognitive, and behavioral components. It is the displeasing feeling of
fear and concern. Gerald (2008) writes that the root meaning of the word anxiety
is 'to vex or trouble'; in either presence or absence of psychological stress,
anxiety can create feelings of fear, worry, uneasiness, and dread. Ohman,
(2000) reported that, it is also associated with feelings of restlessness, fatigue,
concentration problems, and muscle tension. However, anxiety should not be
confused with fear, which is more of a dreaded feeling about something which
appears intimidating and can overcome an individual. Anxiety is considered to
be a normal reaction to a stressor. It may help an individual to deal with a
demanding situation by prompting them to cope with it. However, when anxiety
becomes overwhelming and distressing to the sufferer, it may fall under the
psychiatric classification of an anxiety disorder. Anxiety may be confused with
fear. However, fear evoked by a real danger, while anxiety is worry or
overreaction to a situation that is only perceived as menacing.
Anxiety is a mood, also known as Generalized Anxiety Disorder (GAD),
which can occur without an identifiable triggering stimulus. It is called
generalized because the remorseless worries are not focused on any specific
threat; Schacter (2009) noted that they are, in fact, often exaggerated and
irrational. As such, it is distinguished from fear, which is an appropriate
cognitive and emotional response to a perceived threat. Additionally, fear is

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