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A Psychosociological Study Of Fertile And Infertile Marriages

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A Psychosociological Study Of Fertile And Infertile Marriages

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Content This dissertation has been 64-5152 microfilmed exactly as received CARR, Genevieve Delta, 1913- A PSYCHOSOCIOLOGICA L STUDY OF FERTILE AND INFERTILE MARRIAGES. University of Southern California, Ph. D ., 1963 Sociology, family U niversity Microfilms, Inc., Ann Arbor, M ichigan Copyright by GENEVIEVE DELTA CARR 1964 A PSYCHOSOCIOLOGICAL STUDY OF FERTILE AND INFERTILE MARRIAGES by Genevieve Delta Carr A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Sociology) June 1963 U N IV E R S IT Y O F S O U T H E R N C A L IF O R N IA G R A D U A TE S C H O O L U N IV E R S IT Y PA RK LO S A N G E L E S 7 . C A L IF O R N IA This dissertation, ‘written by Gsnevi eve. .Delta. .Carr. ........... under the direction of h Dissertation C o m mittee, and approved by all its members, has been presented to and accepted by the Graduate School, in partial fulfillment of requirements for the degree of D O C T O R O F P H I L O S O P H Y Deait Date 'M . A - * 1 7 f k 3 .. ... KJ DISSERTATION COMMITTEE Chairman TABLE OF CONTENTS LIST OF TABLES Page iv Chapter I. THE PROBLEM I Statement of the Problem Historical Background of Infertility Physiological Aspects of Infertility Significance of the Problem Hypotheses Organization of Remainder of the Study Introduction The Wife The Husband The Couple Summary Limitations of Previous Studies III. RESEARCH METHODOLOGY AND TECHNIQUES .... 54 Sample Interviewing Procedure Instruments Used Scale Construction and Scoring Scoring the MMPI Statistical Procedures Summary II. REVIEW OF THE LITERATURE 21 IV. RESULTS 110 Statistical Findings Examination of Hypotheses Summary V. SUMMARY AND CONCLUSIONS 155 ii iii Page Summary Limitations of the Study Conclusions Suggestions for Future Research APPENDIX 1.......................................... 172 APPENDIX II......................................... 134 APPENDIX III. .................................... 194 BIBLIOGRAPHY ...................................... 199 LIST OF TABLES Table Page 1. Ages of Husbands and Wives of Fertile and Infertile Marriages, by Percentages . . . 56 2. Religious Affiliation of the Fertile and Infertile Couples by Percentages ..... 57 3. Educational Backgrounds of Husbands and Wives of Fertile and Infertile Marriages by Percentages............................. 59 4. Average Monthly Incomes of Husbands of Fertile and Infertile Marriages by Percentages ............................. 60 5. Weighted Marital Adjustment Scale Used in Present Study, Adapted from Wallace . . . 77 6. 'Weighted Sexual Adjustment Scale Constructed for Present S t u d y........................ 82 7. Weighted Sexual Responsiveness Scale Constructed for Present Study, Husband's S c o r e ..................................... 83 8. Weighted Sexual Responsiveness Scale Constructed for Present Study, Wife's S c o r e ..................................... #5 9. Weighted Father and Mother Relationship Scales Constructed for Present Study . . . SS 10. Weighted Psychological Background Factor Scale Constructed for Present Study . . . 93 11. Comparison of Five MMPI Scales Derived by Three Different Methods Using Scores Obtained by Thirteen Husbands and Thirteen Wives ............................ 98 12. Analysis of Two Methods for Deriving Five MKPI Scales as Compared with the Most iv V age 101 112 113 1H 115 116 117 119 120 122 123 127 128 Accurate Method ........................... Differences between the Sexual Relationship Scores of Fertile and Infertile Groups . . Husbands of Fertile and Infertile Marriages Classified According to Intensity of Sexual Responsiveness .................... Differences in Answers by Husbands of Fertile and Infertile Marriages to Question Relative to Strength of Sex Drive Differences between the MMPI Scores of Husbands of Fertile and Infertile Marriages .................................. Differences between the MMPI Scores of Wives of Fertile and Infertile Marriages . Differences between the MMPI Scores of Couples of Fertile and Infertile Marriages Differences between Fertile and Infertile Groups According to Number of K Scores Greater than 19 ........................... Comparisons of Ranks of the Sc Scale with Other MMPI Scales for Husbands of Fertile and Infertile Marriages .................. Scale Pairs which Characterize the MMPI Profiles of Infertile Husbands in Plus- Plus and Minus-Minus Directions with Critical Ratios of the Difference . . . . Number of Husbands and Wives of Fertile and Infertile Marriages Obtaining Specified High Points on MMPI ........... Differences between the Father and Mother Relationship Scores of Fertile and Infertile Groups ........................... Differences between the Psychological Background Scales of Fertile and Infertile Groups ....................................... vi Table Page 25. Differences in the Husband-Wife Dominance Patterns of Fertile and Infertile Marriages 129 26. Coefficients of Correlation between Measure ments of Personality, Marital Adjustment, and Sexual Relationship within Fertile and Infertile Groups ........................... 132 27. Coefficients of Correlation between Measure ments of Childhood Adjustment and Other Specified Scales within Fertile and Infertile Groups ........................... 139 2&. Differences between Specified Scores of Husbands and Wives in Fertile and Infertile Marriages ...................... 1^3 CHAPTER I THE PROBLEM Statement of the Problem Marriage counselors, gynecologists, and others concerned with problems of infertility and sterility have set forth the hypothesis of psychogenic factors being of etiological significance, especially in cases of involuntary childlessness not attributable to anatomic or biochemical abnormalities. Such a theory is supported when the wife of an infertile couple has become pregnant subsequent to counseling or psychotherapy of one or both mates. The usual theorizing and speculation that occurs in a new area of invest^! gat ion seems to be exaggerated in this instance because of difficulties inherent in infertility. Not only are two individuals involved but their relationship as well. Likewise, for each of these three variables, there are physiological and psychological factors involved and the interaction of these factors. In a few conditions, of course, it is possible for a medical diagnosis of sterility to be made on the basis of unmistakable pathology. Most physicians differentiate 1 between "sterility" and "infertility." Strictly speaking, sterility is regarded as a permanent state of infertility. Ford and his associates feel that "the generally accepted criteria for the diagnosis of functional or psychogenic sterility may be too rigid. . . . and that the demarcation between organic and psychogenic sterility becomes indefinite indeed," since they found that a psychogenic factor was present in most of their infertile patients regardless of the presence or absence of organic pathology (24:465). The difficulty of differentiating between somatogenesis and psychogenesis is also alluded to by a discussant of a recent article. J. Robert Willson suggests substituting "the psychogenic factor in infertility" (10:98) for "psychogenic infertility"— a concept used by Bos and Cleghorn in the article. The problem is even more difficult because the studies of various investigators indicate that many pathological conditions previously considered to be organic (such as anovulation, nonpatent tubes, defective endometria, "hostile" cervical secretions and faulty spermatogenesis) may be psychogenic in origin. Benedek criticizes the tendency to dichotomize symptoms which originate in organic pathology and those with emotional pathology because she feels that "since internal stresses can be reduced and/or exacerbation of stresses alleviated through symptom formation, any symptom may be considered an attempt to safeguard the organic- psychic equilibrium" (4:527). Because of the complexities involved, it seemed to be contraindicated, to investigate psychological factors in infertile couples as being of sole etiological nature. For purposes of this study, it did seem feasible to analyze the degree of relationship between psycho- sociological factors and infertility regardless of "organic" or "functional" etiology. The purpose of this study is to compare the psychological adjustment, sexual relationship, and marital adjustment of married individuals and couples who are infertile with those who are fertile. Historical Background of Infertility A study of the history of civilization reveals that sterility and/or infertility has been regarded as a problem for mankind, ranging from a misfortune to a reproach or serious offense. In the Bible the writer of Genesis records that Rachel threatened her husband, Jacob, with death if he did not give her children, and he became enraged because she was trying to blame him (d:Genesis 30:22-23). According to the Bible, the Lord had shut up Hannah's womb, and she felt a great deal of bitterness, intensified by the provocation of her husband's other wife. When Eli, the Priest, saw her praying very emotion ally in the temple about it with only her lips moving, he accused her of drunkenness. After she had assured him that she was not drunk, he told her that God would grant her petition. Hannah was no longer "sad," and she conceived the next night when her husband, Elkanah, "knew” her (S:I Samuel 1:5-20). Another better-known Biblical allusion to a barren marriage is the story of Zacharias and Elisabeth who were both well along in years. An angel is reported to have given Zacharias the "glad tidings" that Elisabeth was to conceive and John the Baptist was subsequently born to them (S:Luke 1:7-24). The first known recorded admission of a possible male factor in sterility is found in Deuteronomy 1:8: "There shall not be male or female barren among you or your cattle" (8). The meaning of infertility for people and cultures throughout history and the attempts of primitive people to solve the problem have been covered by various investi gators. Because of the thoroughness of these reports (21, 32, 47t 53, 63, #3, 92), only a brief summary will be presented in this review. Sterility has been regarded with displeasure by: religious groups, the state, social groups, and the family. Almost without exception, society has disapproved of infertility to the extent of incorporating ways of handling it into their laws. In some societies an infertile marriage represented a divine displeasure as evidenced by the laws of Moses, ancient Rome and Mohammed and as evidenced in other societies by the use of religious rituals, incantations, prayers, offerings to certain gods and other mystic procedures. The Israelites Greeks, Albanians, Turks, Balinese, and others hated, disgraced and mistreated infertile women to such an extent that many of the women were forced to commit suicide. Even at the present time among the Talmudists, the Slavs, and some American Indian tribes sterility may be used as grounds for divorce just as it was in ancient Rome (92:5). A great variety of superstitious beliefs have been advanced to account for the cause and cure of infertility, usually with the burden of both borne by the wife. They still exist among some primitive tribes and races. Among other things, sterility has been attributed to: unfaithfulness, sexual intercourse with evil spirits, divine displeasure, enchantment, and the innocent eating of the "fruits of sterility" (92:5). The techniques for curing sterility have been equally mystical and superstitious. A special rite performed in connection with the ripening of figs was held in ancient Rome. Certain wells in Scotland and England were felt to have therapeutic powers, mainly because water was known to affect agriculture beneficially. A household god, the size and shape of an infant, was nursed and sung to by barren women of the Maoris, various Indian tribes, the Japanese and others (63:90). Other superstitious cures for infertility used by wives have been the carrying of a charm which was usually phallic shaped; using aphrodisiacs, love potions, and baths; being shown straw effigies of death; and organotherapy, or the eating of organs such as the heart, the liver, the blood, the ovaries and the testicles (92:5). In fact, there are those who question the extent to which rationality has been achieved by contemporary investiga tors. Buxton and Southam quote Jeffcoate as considering the subject of psychogenic sterility nto be obscured by clouds of fantasy, wishful thinking, false promise, and quack remedy, as much today as it was in the days of love potions and fertility amulets" (42:204). A more objective approach was taken to the problem by at least some individuals in Greece. Hippocrates is credited for blaming sterility on: (1) malposition of the cervix, (2) excessive smoothness of the lining of the womb, (3) obstruction of the os, (4) profuse menstruation, and (5) prolapsus uteri (63:97). Endocrine abnormalities as evidenced by poor secondary sexual development and a male voice in the female were regarded as indicative of sterility in Hippocrates1 time as well as among the primitive Talmudists and Chinese (92:6) . For the most part, the female was regarded as responsible for an infertile marriage, but male respon sibility was recognized by some of the Greeks such as Pythagoras, Socrates, Aristotle, and Plato who attributed some cases to abnormalities of the seminal fluid. Ancient Chinese physicians also recognized the husband as the potential cause of a sterile marriage. It was not until the nineteenth century, however, that Berthold proved the effect of the removal of the testicles on physical and psychologic reactions and paved the way for modern endocrine therapy (92:6, 9). In spite of the discoveries of the nineteenth and twentieth centuries, however, the study of infertility was neglected. In 191.2, Guttmacher (33:1) observed that there was not one single large city that had adequate facilities for a thoiough investigation of each case. The American Society for the Study of Sterility was founded in 1941, and in 1950, the appearance of the first volume of its official journal, Fertility and Sterility. represented the first periodical devoted specifically to the clinical aspects of infertility. Physiological Aspects of Infertility Human reproduction is a complicated process with the birth of a baby the culmination of the perfect func tioning of all aspects of this process. Tyler lists five known requisites for normal fertility in the female: 1. Normally functioning ovaries, in which there is cyclic maturation of a graafian follicle with ovulation and subsequent corpus luteum formation, 2. A normal uterus reactive to stimulus of the sex' hormones, 3. A patent and receptive genital tract, which permits adequate migration of sperm and egg and subsequent travel of the egg to its site of nidation, 4. Protection and nourishment of the developing embryo, and 5* Safe delivery. The four requisites listed for normal fertility in the male are: 1. Production of adequate numbers of sperm, 2. Secretion of a fluid medium favorable for conveyance of sperm, 3* A patent ductile tract, permitting transport of the sperm into the vaginal canal, and 4. Adequate performance of coitus. (109:3) Only a brief review will be presented in this study of the sequence of events involved in conception. In order for healthy sperm to develop, the testicles must be in a normal position in the scrotum. Inside the testicle is a series of small canals called the seminif erous tubules where the sperm develop, undergo mitotic division and partially mature. These tubules come together in larger tubes called the epididymis where the maturation of the sperm continues. From here, the sperm pass into the vas deferens. Adjoining the vas deferens are the seminal vesicle and the prostate gland which produce activating secretions for the sperm. The sperm and secretions unite to form semen which is ejaculated forcefully through the urethrae at the time orgasm occurs. This process of ejaculation in itself is somewhat complex involving cerebrocortical and spinal neurologic factors as well as adequate androgenic functioning (109:lS). Even after the sperm are deposited in the vagina, they are in a physiologically hostile environment, but the buffering capacity of the semen offsets this handicap to a large extent so that an adequate number of sperm survive long enough to enter the favorable environment of the uterus through the cervix. It is important, however, for spermigratlon to be prompt, because the sperm lose their viability quickly in the vagina. There is controversy relative to the sperm concentration necessary for conception to take place. Although the American Society for the Study of Sterility considers twenty to forty million spermatozoa per milli liter as being normal limits, many cases have been reported in which pregnancies have occurred with extremely low concentration of sperm (109:14). In the female, normally functioning ovaries release an ovum once a month into the peritoneal cavity from whence it migrates into the fimbriated end of the 10 fallopian tube. "Peritoneal currents," are known to be operative-In this process and there may be chemical aspects, as well as active participation of the fallopian tube. Through the culdoscope, Decker (17) observed the contraction of the ovarian ligaments at the time of ovulation which served to bring the ovary into contact with the fimbria of the tube. The ovum proceeds through the tube where it may be fertilized and carried by peristaltic action into the uterus where, if fertilized, the fertilized ovum or zygote elaborates enzymes to help erode the surface of the endometrium and nidation takes place. The endocrine glands in both the female and male play a very important part in reproduction. The anterior pituitary gland which is influenced by the hypothalamus secretes gonadotropic hormones which stimulate the ovary. During the first half of the menstrual cycle, the follicle- stimulating hormone causes a graafian follicle to grow and to secrete the estrogenic hormone. Midway in the menstrual cycle, the follicle-stimulating hormone and the luteinizing hormone cause ovulation and subsequent development of the corpus luteum, which in turn secretes progesterone. Pro liferation of the endometrium takes place during the first half of this cycle as a result of the influence of the estrogenic hormone. During the second half, secretory changes of the endometrium occur in preparation for 11 nidation as a result of hormones from the corpus luteum. If pregnancy takes place, the corpus luteum develops and provides important hormones throughout pregnancy (109:4-5). In the male, the anterior pituitary gland influences the testes by the secretion of gonadotrophic hormones. The follicle-stimulating hormone stimulates and maintains sperm development, and the luteinizing hormone stimulates the secretion of the male sex hormone, testos terone, which in turn influences the seminal vesicles and their functioning (109:6). In a process as intricate as this, the possibil ities for failure of conception and subsequent delivery are multitudinous. Rock (60) lists twenty-two pathologies of the female pelvis alone which have been associated with infertility and on the basis of this, Jones (43) calculates that various combinations of these twenty-two would amount to over four million possibilities. This does not Include the male factor in infertility, which has been estimated as being responsible for 21 to 65 per cent of childless marriages (74:299). On the basis of data obtained for 1,032 cases of infertility at the Mayo Clinic, Wilson (119) claims that in 60 per cent of infertile marriages definite causes can be ascertained and that the responsibility is divided equally between the males and females. In addi tion, many psychological factors occur in both male and female, other than those which have a physically 12 demonstrable effect on the reproductive systems. Buxton and Southam are forced to conclude that "so many factors are involved in infertility that the variables are almost insurmountable" (13:4). Significance of the Problem Not only has involuntary sterility been a problem for mankind historically, it continues to affect an estimated S.3 to 19.5 per cent of the total married population. A number of authorities feel that it is reasonable and conservative to place the estimate of infertile couples at 10 per cent (13:7). In order to obtain a more comprehensive demological analysis of infertility, Buxton and Southam combined the results of ten studies with a total of 9,595 fertile patients. The length of time required for conception to occur for this cumulative group was as follows: 65 per cent of the women had conceived by the end of six months, SI per cent by the end of one year, 90.5 per cent by the end of the second year, and the remaining 9.5 per cent required more than two years. If the definition of infertility proposed by the American Society for the Study of Sterility is accepted that "a marriage is to be considered barren or infertile when pregnancy has not occurred after a year of coitus without contraception," 19 per cent of the composite of 9,595 patients were 13 considered infertile during the period of time after the first year and before conception occurred {13i7)• Most married couples who have not tried to prevent conception start questioning their fertility potential within six months to a year after initiating attempts. There were 332 couples out of 1,977 couples in the Indianapolis Study who did not have a birth even though some of them reported wanting one but not being able to for physiological reasons. It was not possible to ascertain whether the remainder were childless for voluntary reasons but medical estimates were made that 59.3 per cent of thes.e 332 couples were childless because of impaired fecundity 1117). In 1943, Taylor (10$) estimated that 300,000 married couples fail yearly to achieve desired parenthood. In a relatively recent study (25) in which 2,713 young married women were interviewed relative to the past and prospective growth of their families, it was found that approximately one-third of the couples were subfecund.* The total population of the United States, therefore, probably includes six million white couples (since the study included only white couples) with the wife between ♦The authors, Freedman etal., define "subfecun dity" as the presence of physical impairment which reduces the capacity to have children in the future and they include not only couples for whom childbearing is impossible but also those whose ability appears to be significantly below normal. the ages of eighteen and thirty-nine who are limited either voluntarily or involuntarily in their ability to have children. These investigators also found that this limitation is not related to any social and economic group but is true for all major socio-economic groups in the population. They emphasize the impossibility of any investigator estimating accurately and exactly the incidence of sterility. Even the reports of medical personnel are biased because of the difficulty of accurate diagnosis and the fact that only the "subfecund" who have health problems or want a child come to the attention of physicians (25:13-20). There is some evidence to indicate that the attitude toward childlessness has changed among married couples. Whereas it was found in the Indianapolis Study conducted in 1941 that approximately 40 per cent of the couples with no child had wanted none and had used contraception regularly, Grablll et al. reported in 1953 that the percentage childless among women (15 to 44 years old) who had ever married in the United States decreased from 26.5 per cent in 1940 to 13.1 per cent in 1954 (29:50). In the aforementioned study of 2,713 women, the investigators felt that "there are good indications that substantially fewer couples want to have no children" (25:47). Fifteen per cent of the 2,713 couples in the study had no births; 3 per cent of these were fecund but 15 only 9 fecund couples (less than 1 per cent of the total sample) indicated that they definitely intended to have no children, and of the 51 childless couples married 15 years or longer, only 4 per cent were fecund. Obviously, some infertile couples who desire children are "definitely sterile," a category which contained 10 per cent of the 2,713 couples aforementioned. Of the 2&3 couples in this category, 243 were assigned because they had had operations, and the remainder claimed that a physician had found the reproductive organs of either the husband or wife inadequate or damaged (25:460). On the basis of the follow-up of 1,56# infertility patients, Buxton and Southam conclude that "some kind of very significant psychological factors play a part in infertility" (13:209). A simple analysis of the time relationship between conception and the first few clinic visits of those patients who ultimately became pregnant, showed that 16 per cent became pregnant within one month of their first clinic visit, 24 per cent by the end of their second month of investigation, and that 3& patients (26 of whom had been infertile for two or more years) were pregnant upon arrival at the clinic. In a series of 1,575 cases, Sharman obtained nearly the same percentage of pregnancies at the end of three months with "nothing done" therapy as he did with three other groups in which medical treatment was utilized. 16 He concludes that "a psychological effect was possible in all four groups” (90:604). In another large series of cases, Stone and Ward (100) found that 24 per cent of the 500 infertile patients gave evidence of psychogenic infertility. These patients became pregnant shortly after admission, following orienta tion lectures on anatomic and physiologic aspects of sterility, and the diagnostic tests and treatments deemed necessary. It was felt that these sessions brought about a change in emotional attitude, a release of fear and tension and a better acceptance of the situation. Probably the most significant factor involved in the problem of infertility is human suffering. Despite their genuine efforts over a period of months or years, these infertile couples have been unable to have children of their own. Their marriages are sometimes threatened to the point of divorce. Although adequate documentation is lacking and the "findings" are too general to be regarded as conclusive, Popenoe's evaluation may be meaningful. He feels that there is a definite relationship between infertility and stability and happiness in marriage and he claims that more than one-half of the couples who seek divorce are childless and that the majority of infertile couples eventually apply for divorce (75*310). However, it is not only the marriage relationships which suffer; the individuals involved in the marriage very 17 often manifest feelings of frustration, discouragement, and inadequacy. The writer’s interest in this problem was evoked while engaged in some research at the Planned Parenthood Center of Los Angeles where "family planning" includes not only conception control but an infertility clinic. In some instances, the physicians determined a physio* logical basis for the condition and either corrected it, if possible, or advised the couple that pregnancy was Impossible and, if the couple appeared to be potentially good parents, recommended adoption. In those instances in which the physicians were unable to locate any organic or physiological cause for the infertility, there were implications of significant social and psychological problems. The possibility occurred to this writer that Important differences in characteristics other than physical ones might be demonstrated by comparing this latter type of infertile couple with fertile couples. Hypotheses The research hypothesis for this study assumes that there are significant differences in the psychosocio- loglcal characteristics of individuals in an infertile marriage as compared with those in a fertile marriage. The more specific working hypotheses are as follows: I. The sexual relationship reported by husbands and wives in fertile marriages is better than that reported by those in infertile marriages. II. The scores obtained by husbands and wives in fertile marriages on various scales of the MMPI differ significantly from those obtained by husbands and wives in infertile marriages. III. Marital adjustment scores of husbands and wives in fertile marriages are significantly higher than those of husbands and wives in infertile marriages. IV. The childhood relationships with mothers and fathers reported by husbands and wives in fertile marriages are better than those reported by husbands and wives in infertile marriages. V. The wives in fertile marriages are less dominant than those in infertile marriages as reported by the husband and wife in the respective marriages. VI. Measures of personality, marital adjustment, and sexual adjustment are positively correlated for both fertile and infertile individuals. Organization of Remainder of the Study The problem of infertility has been presented, traced historically, and described physiologically in this 19 chapter. Its significance has been noted, and hypotheses have been proposed. The next chapter presents an extensive review of the literature relative to psychosociological aspects of infertility. A short introductory section is followed by a review of the literature which is divided according to the categories into which it seems to fall naturally: the wife, the husband, and the couple. Early references to the problem, theoretical formulations and empirical studies are included within each of these sections. The concluding part of the chapter is an evaluation by the writer of the limitations of previous studies. The research design of the study and the population of the experimental group of infertile couples and the control group of fertile couples are described in Chapter III. Subsequently, a description is given of the three instruments which were used in the study: the Minnesota Multiphasic Personality Inventory, the Marriage Question naire, and the Fertility Study Psychological Data Sheet. Finally, the procedure followed in collecting the data is presented. The results of the investigation are given in Chapter 17. The statistics utilized in analyzing the data are presented and then related to the hypotheses. Other empirical findings of interest that were not covered by the hypotheses are also included in this chapter. 20 The last chapter summarizes the various aspects of the study and postulates conclusions. Limitations which seem to be implicit or explicit for the study are dis- cussed. Finally, as a natural outgrowth of the findings of this study, suggestions for future research are made. A List of References is followed by a number of Appendices which include copies of the Marriage Question naire, and the Fertility Study Psychological Data Sheet, as well as supplementary tables of MMPI coded profiles. CHAPTER II REVIEW OF THE LITERATURE Introduction Behavior based on superstitious or mystic beliefs such as offerings to certain gods, prayers, eating of special foods, use of aphrodisiacs, carrying of charms, may have been successful at times in curing infertility or people would not have continued using them. If so, these "cures" represent psychosomatic phenomena. Psycho- somatically, the catharsis and the reassurance which Eli, the priest, gave to Hannah may have relieved the tension responsible for her infertile condition. She conceived immediately thereafter. Scientific recognition has not been given to psychosociological aspects of infertility until recent years. Indeed the psychosomatic approach to any aspect of medicine is relatively recent. let there were fore runners who presaged the role of psychological factors either as etiological or symptomological in infertility. In 1923, Groddeck observed that: ... it often happens so— that a woman longs with all her heart to have a child, and yet remains unfruitful, not because her husband or she herself is sterile, but because there is a tide in the 21 22 Es Cego3 which refuses to turn. • . . And this tide flows so mightily that when there is a possibility of conception, when the seed is actually within the vagina, it prevents fertilization. (30:22) But scientific investigations of these factors had not yet attained maturity. Heiman's analysis of sixteen papers published between 1950 and 1959 dealing with psychological or emotional aspects of infertility compelled him to conclude even at such a recent date that there is na dearth of well planned, systematic studies as to the extent to which emotional factors contribute to infertilityn (37:247). Probably the most frequently mentioned evidence of psychogenic infertility are the instances in which pregnancy follows adoption (10, 46, 49» 79). Outstanding is 0rrfs (69) well-known case study in which conception followed adoption. However, there have been a number of studies which question the validity of this position. On the basis of data gathered on 202 adoptive couples, Hanson and Rock (35) question the therapeutic effect because the incidence of spontaneous cure of infertility without adoption was not significantly lower than that of parents with adopted children. In another carefully controlled study, Banks et al. found that 11 out of 31 couples who adopted a child had no physical or emotional basis for infertility, and yet not one became pregnant during a period ranging from one 23 to nine years following adoption. Only 1 of the 27 couples who were able to conceive had a normal delivery within 5 years following adoption. Since this represents only 3.7 per cent and the incidence of spontaneous cures of infertility without adoption is as high as 10 per cent, these investigators also question this position (1). Bender's study (3) of 6S0 infertile women lent support to the studies of Banks, Hanson, and Rock when it was found upon follow-up that one-half of the 46 per cent conception rate was due to time and chance; and of the 16 couples who had adopted a baby, only 2 adoptions were followed by a first pregnancy. Another follow-up study (110) of 100 couples who had adopted children showed that only 4 per cent conceived within a two-year time interval and 10 per cent .conceived if the time period was extended. These authors do not feel that adoption frequently leads to pregnancy. Although Turner et al. agree that the number of pregnancies follow ing adoption in their study of 750 sterile couples was not as high as might be expected if "adoption were as good a 'trigger* mechanism as is popularly supposed" (103:1196), they feel that the 13 pregnancies (out of 74 couples who adopted children) which occurred within 6 months of adoption suggest a psychosomatic influence. There is some clinical evidence, however, to demonstrate the effect which psychological factors have on other gynecological functions. Pseudocyesis, or false pregnancy, in which menstruation ceases and other typical manifestations of a pregnant state occur— even to the point of the patient experiencing labor pains and being admitted to a hospital for delivery— is probably tha most dramatic illustration. "Kriegsamenorrhoe," another condition in which the menses cease, occurs when pregnancy would be such a social or economic disaster for the woman that she develops intense fear. A more direct indication of psychogenic factors is the now frequently stated observation that there is a 50 per cent reduction in fertility in schizophrenics and epileptics (51:282). Psychogenesis is generally accepted as a possible etiological factor in infertility by most physicians engaged in treating Infertility. But a number of specialists in the field allude to the complexity of the relationship between psychogenesis and somatogenesis and the problem of differentiating between the two. Rutherford et al. express regrets that they "cannot classify patients as either organic or functional problems" (85:130). They feel that conflict within one of the mates or within the marriage relationship itself is decisive in the development of tubal spasms, anovulatory cycles, hostile secretions of the cervix and other dysfunctions. Grreenhill, in a fore word to a book (52:v), states that treating the psyche and soma separately may adversely affect the patient. 25 Another aspect of the complexity of the problem is treated by Peterson (72:287) who feels that emotional factors may be operative on one or more levels in infer tility: physiologically in their effect on endocrinolog ical or tubal functioning; coitally by disturbing the sexual adjustment of the couple; and interpersonally by disrupting marital adjustment. Research emphasis in this field seems to fall into the following categories: the wife; the husband; and the couple. The Wife As the wife was more frequently held responsible when physiological factors were first investigated, so with the investigation of psychological factors. The psychoanalytic school of thought took the lead in formu lating theories and presenting case histories relevant to psychological factors in infertility in women. Probably Deutsch (18) was responsible for the theoretical formula tion most widely acclaimed and utilized. 3he postulated five main types of psychogenic sterility: the physically and psychologically immature woman, the motherly woman whose husband needs her motherliness and is not ready for fatherhood, the woman devoted to her own erotic life or to an emotionally-determined interest, the masculine- aggressive woman, and the emotionally disturbed woman. 26 Many articles and studies, some of which will be mentioned subsequently, have been based partially or entirely on Deutsch's formulation (9, 51, 59, 60, 6l). Investigators at the Menninger Clinic were also aware of psychological factors in infertility at an early date. Certain physical malfunctions of the reproductive tract, known to be responsible for infertility, were suspected of being of psychogenic origin in some instances. Menstrual disturbances, uterine prolapse, cystocele, and fibromyomata are mentioned by Karl Menninger (65) in one article as physical manifestations of a disturbed psycho sexuality. In a later publication (64) he presents a case in which, on the basis of strong evidence, a fatal uterine hemorrhage was presumed to have been caused by emotional factors. He also reports instances of pelvic muscle hypotonicity as witnessed in prolapse and near prolapse, asthenic dystocia and obstetrical lacerations in which emotional factors were traced. In substantiation, Menninger refers to the theories of several German investi gators: Kehrer (45) who maintains that women with satisfying sexual lives do not develop fibroids and who advocates the prevention of fibroid developments by psychotherapy; Wengraf (116) who reports four cases which not only uphold Kehrer*s theory but who indicates that fibroids can be cured by psychotherapy; and Heyer (39) who postulates that continued unrelieved excitement might 27 often result In hyperemia which Is diagnosed as endome tritis. The case histories and investigations relative to psychological factors in infertility in women range from broad generalisations such as "immature personality,n "chronic anxiety," and "psychosomatic adequacy," to more specificity in diagnosis such as "fear of pregnancy," "hostile identification with the mother," and "personal unworthiness." Benedek considers infertility as a "somatic defense against the stresses of pregnancy and motherhood" (4:527). Ford et al. studied a group of twenty-four infertile women, of whom nine were functionally infertile and compared the results with a group of "normal" fertile women. They found that "a psychogenic factor was present in most infertile patients whether organic pathology was present or not" (24:460). In a study of 750 sterile couples at the Duke University School of Medicine, the wives were "psychosomatically evaluated" and those wives who were judged to be "psychosomatically adequate" had a slightly higher incidence of pregnancy (103). Mandy and Mandy accept Benedek*s somatic defense concept previously mentioned and observe that "chronic failure to adapt to the demands of mature interpersonal relationships" (59:263) has been evidenced by infertile women in all aspects of life. They feel that the typical infertile woman’s immature dependent personality is demonstrated in types one and four of Deutsch’s groups: (1) the physically and emotionally immature, or (4) "masked" in the aggressive and masculinely competitive. Kroger (50) mentions the same broad classifications of Deutsch except he does not soften the latter type with a "mask." Personality studies of cases of psychogenic sterility by Wittkower and Wilson (121) revealed that these patients were characterized by juvenile facies and • physiques, withdrawn personalities as children, parental overprotection, inferiority feelings, and grasping for sympathy and affection. A feeling of "personal unworthi ness" is cited by a team of doctors as being a common trait of the infertile woman patient and they emphasize psychic influence in anovulation and defective endometria Although there are numerous possibilities for psychological conflicts which a disturbed personality may feel relative to pregnancy, Bos and Cleghorn (10) feel that only two basic emotions are involved: a fear of pregnancy or a rejection of it. In a book worthy of its title, Psychosomatic Gynecology (52), unconscious rejection of pregnancy, chronic anxiety, and fear of pregnancy are mentioned as causes of sterility, as well as the uncon scious awareness of the time of ovulation.+ The authors, ♦Knight (49) also mentions unconscious awareness of the time of ovulation as a possible factor. 29 Kroger and Freed, postulate that this awareness operating together with a fear of pregnancy may cause some women to avoid coitus during ovulation. In a study by Rommer and Rommer which focused on the emotional aspects of infertility, 90 private gyneco logical patients representing 30 each of "never sterile," "persistently sterile," and "previously sterile" were interviewed personally and given a questionnaire in order to obtain psychiatric and personal background material (Si). The Rommers found significant differences between the groups as to the extent of premarital coitus with men other than the husband: 3 per cent of the persistently sterile, 13 per cent of the previously sterile, and 30 per cent of the never sterile had had premarital sexual relationships with men other than the husband. These differences were interpreted to mean that the never sterile group showed less guilt-ridden attitudes toward sex, with the ultimate result that the emotional conflicts which developed long before marriage and long before any question of fertility was raised, were manifested in personality problems. Relative to the general attitudes toward sex, the Rommers found that dissatisfaction with coitus was admitted by 63 per cent of the persistently sterile, 53 per cent of the previously sterile, but only 33 per cent of the never sterile groups (81). The infertile woman's relationship to her mother 30 received attention from several authorities. Groddeck hypothesized that: People who hate their mothers create no children for themselvea, and that is so far true that one may postulate of a childless marriage, without further inquiry, that one of the two partners is a mother- hater. (30:5) Benedek et al. (5) noted that a hostile mother identifica tion existed in psychosomatically sterile women. In a psychoanalytic study of five couples, Rubenstein (&2) concluded that the wives all had a central problem in their hostile identification with their mothers. Four of the five wives became pregnant as a result of the analysis. Benedek and Rubenstein collaborated with others (5) in a study in which the primary purpose was to investi gate the emotional factors operative in six women who failed to conceive after undergoing artificial insemination several times. They felt that the developmental conflicts with the mother were reactivated as a result of the frustration of having husbands with inadequate sperm and were, therefore, responsible for the current mood. But they were not willing to attribute the infertility to these conflicts. A much more significant conclusion emerged from this study and is discussed in the section related to "The Couple.1 ** *Cf. p. 46 31 A number of studies have appeared in the literature which refer to some aspect of the wife's attitude toward the feminine role. Rutherford and his associates refer to the "grave conflict over femininity because of a hostile dependency bondage to a mother image" (#4:259) and the possibility of imitation of the male role. Blum (9) attributes psychogenic sterility to the anxiety which is Induced by a woman's perceiving herself as a child and the maternal figure as "malevolent." A rejection of femininity evidenced by disturbed psychosexuality was postulated as an etiological factor in infertility as early as 1939 by Karl Menninger (65:523). In a later publication, William Menninger observed that a wife may reject the feminine role and "make an unconscious masculine identification with such strong masculine striving that femininity and childbearing are rejected as incompatible with their psychological makeup" (66:15). The "masculine protest" is given prime importance as an emotional factor by Popenoe (76) who makes suggestions to physicians for treating this kind of infertility patient. During the past few years, three unpublished doctoral dissertations have been based on psychological factors in infertility. Two of the studies had twenty women in both the experimental and control groups and the other study had fifteen in each group. The Rorschach was utilized by all of the investigators, the TAT by two of them, an autobiographic questionnaire by one and a personal interview by another. Using experienced Rorschach judges, Eisner (21) found a significant amount of agreement among them that the Rorschachs of the infertiles contained more emotional disturbance than the fertiles. Brody's (11) test protocols, rated by judges, substantiated some of the hypotheses made by him relative to the three variables of: hostility directed against the mother, unconscious repudiation of femininity, and unconscious fear and guilt related to sex. In the third doctoral study by Laitman (53)* judges rated each subject for seventy-eight personality variables. The infertile females were differentiated from the fertile females in their attitudes toward their fathers and mothers and in the extent to which they depend on others for encouragement and emotional support. Buxton and Southam found a wide variation in the socio-economic backgrounds as well as the physical and psychological characteristics of their patients. The approach and attitude of these patients are quite similar and the importance of feelings of guilt in the psycho dynamics of infertility is emphasized: . . . These patients frequently seem resentful of their condition, even more so, for instance, than patients who suffer from some "explainable" malady; and with a somewhat defensive attitude they discuss their situation as though they had somehow been victimised. . . . Since in our civilization feelings of guilt 33 about sexual activity are about as common as sexual activity itself, and since fertility is elementally sexual biologically, any fertility failure may well be associated in the patient's mind with some aberra tion of sexual activity that she does not care to discuss. (13:25) These authors contend that guilt feelings may be linked to some sexual activities in the past which are Irrelevant to the present problem of infertility. Perkins (71) concurs completely, designating subconscious guilt feelings because of past Indiscretions as a possible psychological factor in infertility. The psycho-social implications of treating infertility before investigating the emotional stability of the patient is mentioned by a number of authors (13, 50, 60, 64> 115)* They contend that the patient's ability to withstand the demands and stress of pregnancy as well as subsequent motherhood should be thoroughly Investigated by the physician instead of his uncritically accepting the woman's desire for a child as a command. Kroger cites an unpublished study by Dunbar (20), a pioneer in the field of psychosomatic medicine, in which she observed that the personality profiles of sterile women closely resemble those of the group characterised by frigidity. Kroger does not feel that this is a valid finding, however, because of the high incidence of frigidity in Western civilization (50:534). There are others who do concur with Dunbar. Although they 34 acknowledge that many women become pregnant in spite of frigidity, Buxton and Southam (13:3®) suspect that orgasm capacity may be of Importance in some cases of infertility. This belief is extended by deWatteville (115:17) who mentions the importance of orgasm for sperm migration into the uterus, especially when the sperm are of poor quality. As early as 1939, Menninger (651521) compared sterility with frigidity as representing the failure of normal biological functioning. A phenomenon labeled the "blighted conception" indicates the importance which two investigators, Peberdy and Smith, ascribe to the orgasm (70:116). They feel that occasionally the development of * orgasm in the wife has led to conception because the only "coital dysfunction"* previously had been the lack of orgasm on the part of the wife. Probably Deutsch (IB) sums up the importance of a wife's response to coitus much more succinctly when she refers to sexual intercourse as the first act of motherhood. Seminal reflux is a condition which occurs when there is a lack of sphincter activity of the female pars copulandi which results in the sperm deposit being spilled after intercourse. Stern (9^:543) feels that this may be due to rejection rather than to a relaxing dysfunction and postulates that it may indicate ambivalence toward *Cf. p. 4^1 35 conception. Michael attributes vaginal reflux of sperm to psychogenic muscular spasm, by means of which the wife "rejects the unwanted partner" (67:276). Regardless of the motive for postcoital douching, the "Indianapolis Study"* showed that DFCO (douching for cleanliness only) postponed conception to an important degree. The average time from marriage to the first conception for the 434 "relatively fecund" couples who had not attempted to delay the first pregnancy, was about 26 months for the 61 DFCO wives and 7 months for the remaining 373 wives (117). In his theory of ambivalence toward conception, Stern (96:542) includes postcoital douching along with seminal reflux as being incompatible with insemination. Since ovulation is facilitated by the gonadotrophic hormones of the pituitary, it is apparent why the neuro- endocrine approach to the problem of psychogenic infer tility has received increasing recognition during the past two decades. Benedek and Rubenstein (6) were the first to formulate the theory that there is a definite interrelation between the psychosexual development of the *This study was done over a period of several years by a group of social scientists and reported in various issues of the Milbank Memorial Fund Quarterly. Although 1,977 couples were Included in the survey or Social and Psychological Factors Affecting Fertility, not much attention was paid to psychological aspects of infertility. 36 individual and the cyclic secretion of ovarian hormones. One of the conclusions which Selye made as a result of his studies on stress relates to the "shift in pitultarv-hormone production." The pituitary gland has to produce so much ACTH (adrenocorticotrophic hormone) during stress that it must cut down on the production of other hormones which are less urgently needed in times of emergencies. The gonadotrophic hormones are among those affected (89:176). Heiman credits Fisher, Ingram, and Ransom (37:165) with being the first to link the hypothalamus with repro duction when they discovered that prolonged labor, maternal and fetal deaths many times followed hypophysectomy. Another source, Rakoff (78), credits Klinefelter et al. (48:529) for contributing the first significant evidence relating psychogenic factors to ovarian function. The ovarian dysfunction was accounted for by a "syndrome of hypothalamic hypoestrinism" in which the hypothalamic- pituitary mechanism failed to release the luteinizing hormone necessary to act synergestically with FSH on the ovary to stimulate the secretion of estrogen. Kamman (44), Kelley (46), and Robbins (79) were responsible for further exploration and specificity. Kelley referred to the hypothalamic nuclei as being integrating centers for the efferent impulses which reach the reproductive system not only from the external world 37 but from within the body, such as the endocrines (46:213). Robbins felt that the physiological processes of the generative function were as vulnerable as other functions to somatic dysfunction due to emotional conflicts (79:41). Then in 1943, on the basis of certain psychological and physiological considerations, Friedgood concluded that, "there is a functional pathway from the cerebral cortex through the diencephalon and adenohypophysis to the ovaries and uterus" (26:397). In 1949, MacLean’s conception of the "visceral brain" (59) (previously known as the limbic lobe or rhinencephalon) with its visceral and emotional functions, was responsible for stimulating a great deal of interest in its Implications for infertility. In 1952, Kroger speculated that "psychosomatic sterility may be the impairment of the genital organs as a result of the subtle influence of the ’visceral brain1 or subcortex" (50:542), due to its capability of performing as an automatic pilot in directing repressed nervous energy to a target organ. Mention is made of the potential importance of the neuro-endocrine theories by Kroger and Freed (52:233) who cite a number of foreign investigators, as well as Kamman (44), Friedgood (26), Menninger (64), Knight (49), Benedek (6), Robbins (79), and Dunbar (19). In a compre hensive book on Human Infertility, published in 195^, the 33 authors refer more confidently to the "fertility potential being compromised" by the direct effect of the limbic lobe, because: . • . the adenohypophysis, kingpin of the whole endocrine system, is in such intimate anatomical and Tascular, if not neural, contact between the limbic lobe and the hypothalamus that we may strongly suspect that it is within this area that emotional stimuli may play havoc with sensitive and delicate hypophyseal-ovarian relationships as well as relationships between the hypophysis and other target glands such as the adrenal and thyroid. (13:210) Several investigators have recently reported their findings relative to psychological factors in anovulation. On the basis of clinical experience, Rutherford et al. (37) conclude that anovulation is more often a symptom of a serious emotional disturbance than a defect of the endocrine system. As a result of a psychological evalua tion in which five highly sensitive and well-regarded tests were used, Piotrowski (73:19) concludes that the emotions play an Important role in anovulation as evidenced by the fact that anovulatory women are more tense and disturbed emotionally than healthy women. A third report by Loftus (56) is based on the psychodynamics evidenced by five anovulatory, amenorrhoeic young women who underwent psychotherapy with spontaneous menstruation resulting. nA lack of healthy maternal identification owing to a guilt-inducing, rage-evoking mother" (56:27) was found to be a common pattern. Stauder and Tscherne (97) are cited by deWatteville 39 as having reported the seven cases of women who were so traumatized by the loss of a child during delivery or by accident that the production of gonadotrophins was impaired as evidenced by anovulatory cycles and normal genital findings. In all seven cases, psychotherapy was followed by pregnancy. Because of the concentration on hormones in research on infertility, Stallworthy was prompted to caution against neglecting ”the role of the autonomic nervous system in maintaining the harmony of the female genital tract, the most ’hysterical* portion of a woman’s anatomy” (96:177). In a discussion of the extensive effects of the hypothalamic-endocrine system in coordinating processes in the organism involving the endocrine and autonomic nervous systems, Cleghorn mentions birth and reproduction among other processes. He refers to the hypothalamus and pituitary as: . . . a central regulating servomechanism responding on the one hand to influences originating peripherally in the form of sensory stimuli or alterations in the secretion of the target glands and on the other to central stimuli In the form of events of emotional significance at both the conscious and unconscious level. (15:367) In a quite recent discussion of the significance of psychoendocrine etiology in infertility, Hochstaedt et al. (41) note that of the #12 infertile patients who were found to have endocrinological pathology, 61 per cent 40 had emotional disturbances considered as etiologically important. These authors even contend that the endocrine response need not have been to an emotional experience of current or recent origin but to one which occurred much earlier in life, such as in adolescence. The discovery of the functioning of the hypotha lamic cells as a source of the neurosecretory substance oxytocin is regarded by Heiman (37) to be one of the most important developments of recent years. Experimentation with animals and observations of human females indicate that this hormone is influential in uterine contractions, lactation, and coitus. Heiman contends that even when a woman desires pregnancy, the necessary oxytocin might not be released if she were afraid of intercourse or child birth. Heiman points out that experiments on animals Indicate that reflex peristalsis of the uterus and tubes is as Important as the movement of the sperm. Therefore, he concludes, wif it can be confirmed that before and during intercourse a reflex contraction of the uterus and the tubes take place via the release of oxytocin" (37:174), practical use could be made of this in infertility by administering it prior to intercourse and artificial insemination. Heiman feels that oxytocin may play an important function in reproduction for the male, also, but research has just begun in that area (37:171). The interdependence of hormone and nervous control is pointed out by Rutherford et al. (34:265) in a discussion of dyskenesias* present in the uterus, tubes, or ragina as a result of emotional disorders. Various investigators report dyskenesia of the reproductive organs in which the normal contractions of the musculature is impaired. In an experimental study in which Bickers (7) observed and compared the functioning of dysmenorrheic uteri with normal uteri, he demonstrated that during their potentially fertile periods, some infertile women have a * dyskenesia of the myometrium. He concludes that this may be important in the absence of any other factor since a "uterine muscle contractions are definitely related to spermigration" (7:346). As a result of his observations of the contractions of the ovarian ligaments previously mentioned,** Decker conjectures that an alteration of the contractile function of this ligament might well be a psychogenic factor in infertility (17:259). Kroger and Freed state that autonomic imbalance produces uterine irritability and tubal spasm which may be a "relatively permanent condition in tense individuals, and is one of the principal psychosomatic factors causing *Dyskenesia is defined in the Hew Gould Medical Dictionary as "impairment of the power of voluntary motion.1 * **Cf. p. 10. 42 not only psychogenic sterility, but also ectopic pregnancy" (52:2d4). They liken this condition of irritability to the bronchial, gastrointestinal and bladder spasms which some nervous, tense individuals have almost constantly as a result of an imbalance in the autonomic nervous system. Another type of functional impairment of the genital tract which they mention relates to the way in which the ovum travels down the tube. If this is accomplished by peristaltic action of the tube and its cilia, as suspected, this action may also be affected by dyskenesia of psycho genic origin. The Husband As indicated previously, most investigators of psychological factors in infertility have concentrated their attention on the wives of infertile couples. Buxton and Southern express surprise that psychiatrists have not paid more attention to psychogenetlc factors in the male of an infertile marriage: Perhaps hypothalamic oligospermia may be as much of a clinical entity as hypothalamic amenorrhea, and perhaps the male with peritubular fibrosis or decreased rate of spermatogenesis may have the same high incidence of psychiatric disturbance and malad justment as has been reported in the pelvic syndrome and in various studies of amenorrheic and infertile women. (13:63) Bos and Cleghorn (10) also feel that psychogenic factors in the male may be important in infertility and should no longer be Ignored. 43 In the previously mentioned analysis of sixteen studies,* Heiman (37) found that a thorough physiologic studv had been made of both the husband and wife and that a psychological evaluation had been made for the wives only in all of the studies. These ranged from a very superficial type of questioning to a complete psychoanaly sis. But there was no psychological evaluation of the husbands in any of the studies. Groddeck did not avoid considering psychological factors in the male. He stated that nwhat is true of the woman in this matter of childlessness may also be alleged of the man** (30:23), and he specified such psychological manifestations as sterile semen and lack of erection. Impotence, incomplete erection, and premature ejaculation are mentioned by many authorities as psychological factors much more frequently now. Lane-Roberts et al. (54) not only describe premature ejaculation as a factor in the infertility of many couples but ascribe it generally to anxiety. In 194&, Lane-Roberts et al. published a book, Sterility and Impaired Fertility (54), in which impotence, "partial" impotence, and "functional impairment of ejacula tion" are mentioned. Impotence is attributable in most instances, they believe, to psychological difficulties *Cf. p. 22. 44 although it may sometimes be the result of some organic lesion. These investigators found upon questioning that some husbands reveal a faulty attitude toward the subject of sex. A husband might indicate that he has intercourse because he or his wife, or both, want a child and yet he can’t understand why his erections are not sufficient. A condition which Lane-Roberts calls "partial impotence" (54:24) is accorded much greater importance because even though strong erection and successful penetration occur, there is no emission. Buxton and Southam (13:205) also feel that impotence is almost always a psychological factor. An even more insidious form of male infertility occurs when there is an emission in which the vas deferens takes little part. Lane-Roberts and associates refer to this as "functional impairment of ejaculation" (54*32), Evidently referring to the same phenomenon, deWatteville (115ilB) mentions the occurrence of a "pseudoejaculate" containing few or no sperm, because of spastic contractions of the vas deferens and the seminal vesicles. No sperma tozoa can be found in the wife's cervix after coitus in many cases even though sperm are plentiful in the mastur- batory specimens. Fischer (23:467) points out that the male may be responsible for psychogenic sterility even though the sperm count is good when measured by a random specimen. 45 He concludes that this does not insure that the same count is present during intercourse at the time of ovulation because the sperm count may then be altered through anxiety and psychic stimuli just as the vaginal and cervical secretions and other reproductive functions are altered in the female. Fischer cites Cary as reaching a similar conclusion: "The spermatogenesis of some males is very sensitive to changes in constitutional and nervous energy" (23:469). Walker and Strauss report that, "an exceptional cause of psychogenic male sterility is due to spasm of the muscle constrictor urethrae with retrograde effusion of the sperm into the urine" (113:16). Spastic contractions of the ductus deferens and the seminal vesicles are more frequent psychogenic manifestations in the male, according to deWatteville, In which case, "the pseudo-ejaculate, consisting of the accessorial secretion only, will contain some poorly mobile or immobile spermatozoa, or none at all" (115:16). Relative to the influence of emotions on the gonads, deWatteville (115) believes males as well as females are affected. He cites two European references: Wolfromm (122) attributes oligospermia to anxiety and tension in some instances; and Stieve (99) reports an example of spermatogenesis being hindered by psychogenetic causes— the autopsies of men who had been tried and 46 executed shortly after committing rape showed complete inhibition of spermatogenesis due to direct nervous inhibition from a fear of death rather than to hormonal causes. Selye points out that there is a diminution of the sexual urge and sperm-cell formation in men as a result of the effect of stress on the production of gonadotrophic hormones by the pituitary (09:176). Laitman (53), in his doctoral study, found that the infertile male group regard their mothers in a more favorable light than their fathers, are more fearful of their mother1s censure, and resist authority less than the fertile males. The Couple Rubinfs claim that "the concept of a sterile marriage in contradistinction to a sterile female has gained fuller recognition in this century" (03:391), applies more to the physiological aspects of sterility. In a recent book (13) on the subject of infer tility, one chapter is titled "The Couple as a Unit," in which psychological and interpersonal factors are considered. Buxton and Southam, the authors, state that many times absurd reasons motivate couples to go to a doctor with an infertility problem. Buxton and Southam who are physicians and specialists in the field of infertility maintain that they sometimes discover mutual attitudes of deep-seated hostility or other serious emotional conflicts which not only could be causing the infertility but which contraindicate an infertility study unless further psychological investigation is undertaken (13:27). The investigation by Benedek, Rubenstein, et al. relative to the failure of artificial insemination in six patients resulted in the conclusion that so-called "transi tory n infertility is conjugal in nature: The psychic economy of infertility creates a vicious circle between the marital partners. The influence of the husband's infertility upon his wife's propaga tive and emotional household is evident. Some of the ways of this interaction have been demonstrated in these cases. It is more difficult to prove what some of our cases indicated, that the frigidity of the wife affects the propagative function of the husband similarly. Thus infertility might be the result of the emotional interaction between the marital partners. (5:497) Heiman is adamant, also, in his position on the importance of the conjugal nature of the problem of infertility. He believes that a thorough investigation should involve the study of the husband and wife organ ically and psychologically, both as individuals and as partners in a marriage and he concludes that from this standpoint "research into the causes of infertility has not yet begun" (33:251). A recently published study by Peberdy and Smith divides psychogenic infertility into two subdivisions: 43 (1) "coital* in which dysfunctions of coital behavior and performance are basic to the infertility; and (2) "psycho somatic infertility" in which emotional conflicts not related to coitus become expressed somatically (70:112). The importance of the first classification is evidenced by the fact that 71 couples out of a series of 112 couples with suspected psychogenic infertility had significant coital dysfunction. Virginity certainly suggests some sort of psycho logical aberration when found in a married woman. Of the % 71 couples with coital dysfunction in Peberdy and Smith's study, 16 of the wives were virgins and 7 had experienced less than 5 intromissions during a long period of marriage (70:112). Stallworthy found that 4 to 5 per cent of a series of married women complaining of infertility were virgins (96:172). In 5 out of the 25 couples in a study by Sturgis et al., there was found to be "improper performance of the sex act" (101:525). Lane-Roberts et al. attribute a great deal of importance to the husband's techniques in ade quately preparing the wife for coitus because as a result of arousal sexually cervical secretion is increased and the spermatozoa are better able to ascend in the uterus (54:2d). Siegler (93:19) maintains that even the mixture of the secretions in the vaginal mortar by the phallus is preparation for the most favorable sperm reception. The 49 male orgasm occurring at the termination of this act and the female orgasm inducing early sleep assures that biochemical relationships will not be disturbed. Psychosomatic infertility as a result of disturbed bodily secretions is suggested by Kroger and Freed (52: 285). They believe that just as anxiety modifies salivary and gastric secretions, so may the chemical and physical properties of the secretions in contact with the sperm and ovum be modified. A generalized psychological approach was taken by Sturgis et al. (101) in their use of a psychiatric screen ing interview with both the husband and wife of every couple entering Peter Bent Brigham Hospital in Boston with an infertility problem. In a study of forty couples, they found that out of the twenty-five who saw a psychiatrist, seventeen had fears and fantasies about pregnancy which might have been responsible for the infertility and only two of the entire group were deemed to be without serious emotional conflicts. In their book directed to infertile couples, Portnoy and Saltman mention tension, over-anxiety, and emotional difficulties as important factors in causing infertility (77:160). Conversely, the failure to conceive, these authors maintain, may be the cause of emotional difficulties with the subsequent development of sexual maladjustment. "Prolonged mental strain and worry" is regarded as important by Siegler (92:43) who recommends investigation of both husband and wife for developmental anxieties and conflicts and premarital attitudes which may be exerting an influence on sexual adjustment and general marital adjustment. Peberdy and Smith have developed the category of "rejection infertility" because they have observed that one or both of the spouses so frequently reject parenthood on some ldvel of consciousness (70:114). Although generalized references of this type have been made relative to the marital adjustment of infertile couples, no actual studies of the relationship of marital adjustment and infertility have been found in this search of the literature. Summary A number of facts seem to emerge from this review of the literature relative to psychosociological aspects of infertility. There are indications that the suspicion that a psychogenetic origin is responsible for some cases of infertility goes back to early civilization. The historical background of this belief has been traced from naive superstitious beliefs to the present scientific approach. The decision to divide the chapter into the categories of the wife, the husband, and the couple was made after a perusal of the literature revealed that the 51 various articles and books seem to fall naturally Into this schema. The large number of references makes summarizing of the findings difficult, however. The tendency for fragmentation in approaching the problem of infertility is evidenced by the original emphasis on the wife and on physiological factors, with the focus moving to the husband if the wife seemed to pass anatomic and biochemical tests of fertility. More recently, the infertile couple has come to be regarded as a unit— not only physiologically but psychologically. This is in keeping with the wholistic or "patient as a person" approach in medicine generally— here, the whole being the married pair. A variety of interpretations have emerged from the psychological investigations of the wives of infertile marriages, depending somewhat upon the investigator's frame of reference, the methodology employed and the instruments utilized. Both conscious and unconscious attitudes and mechanisms have been explored relative to personality maturity and functioning, such as: rejection, ignorance or guilt feelings relative to sexuality; fear and anxiety; feelings of personal inadequacy; aggressive ness; and rejection of the feminine role. The importance of anxiety and unrealistic attitudes toward sexuality on the part of husbands in infertile marriages has been advanced as a significant factor in physiological and coital functioning. Obviously, the consideration of infertility as a function of the marriage complicates investigation but it represents a more realistic approach to the problem. In this context, infertility has been attributed to the coital relationship, emotional problems related to the interaction of the two personalities and even to physio logical interaction--especially of a psychosomatic or biochemical nature. Some of the studies are of a distinct neuro endocrinological nature. Progress has been made steadily along these lines since Benedek and Rubenstein presented their pioneer study in 1939. Much research is being conducted about the very complicated relationships and interrelationships of the endocrine system, the autonomic nervous system, the cortex, the hypothalamus, and the reproductive organs. It becomes increasingly clear that disturbances of the secretory processes as well as the presence of dyskenesias are many times functional rather than organic. Limitations of Previous Studies Many of the "studies" which have been mentioned fall into one of three categories: (1) theoretical presentations which offer postulations based on inference, (2) specific formulations relative to etiology resulting 53 from intensive work with a few cases— most of which are from the psychoanalytic school of thought, and (3) "scien tific" studies which are deficient in fulfilling one or more of the necessary criteria for a scientific study. The first two categories mentioned, of course, include studies of a descriptive or case history nature. This type of study is of definite, recognized value and represents a natural step in the development of a scien tific approach to any area of investigation. The third group includes studies with defects in the basic research design, with samples which are nonrepresentative or too small, with poorly constructed instruments, or with inadequate or Incorrectly used statistical techniques. With few exceptions, a major limitation is the concentration of effort on studying the wives of infertile marriages rather than the husbands and wives as couples or even as individuals united in marriage. Infertility is, undoubtedly, complex in nature and the psychological and psychosomatic aspects had not even been considered by the medical profession until approxi mately twenty-five years ago. In spite of this, consider able progress has been, and is being made, as mentioned previously in the summary of the literature.* *Cf. pp. 50-52. CHAPTER III RESEARCH METHODOLOGY AND TECHNIQUES i This study grew out of a mutual research effort initiated in 1955 by the Los Angeles County Fertility Society and James A. Peterson, Ph.D., of the University of Southern California. The Society underwrote the initial pilot study which consisted of a survey of relevant literature and the preparation o,f research instruments. After this initial work was completed, the present writer became the chief investigator. Sample The sample consists of forty-nine infertile couples and a control group of forty-six fertile couples. Although more than fifty interviews were obtained from both fertile and infertile couples, it was necessary to discard some of the interviews because of incomplete information. Actually, in comparison with previous objective studies of psychological factors in infertility, these samples are quite large— representing more than twice as many as the largest of the previous studies. The forty-nine couples in the experimental group had no children born of* their present marriage and had 54 been actively trying to have a child for at least one year. Actually, all but two of the infertile couples had been trying for pregnancy for at least two years. Each of the forty-six couples in the control group had at least two children. Many had three and others ranged as high as seven children. The fertile group of subjects were obtained from three sources: obstetrical patients and their husbands from the caseloads of physicians, couples who had enrolled in a class for parent education, and couples who were utilizing the conception control services of the Planned Parenthood Center of Los Angeles. The infertile group was obtained from both the infertility clinic of the Planned Parenthood Center of Los Angeles and a private infertility clinic. In this way, it was possible to match the groups rather closely on the following variables 1. Age— The ages of the infertile group ranged between 21 and 33 years for the wives and between 22 and 47 years for the husbands. The average ages were 23.6 and 31.0 years respectively. For the fertile group, the wives1 ages ranged from 20 to 40 years, and the husbands1 from 22 to 44 years, with average ages of 23.7 and 31.5 years respectively. Table 1 presents the ages of husbands and wives for both the fertile and infertile groups by percentages. Thirty-three, or more than two-thirds of the wives of infertile marriages were under 30 years of 56 TABLE 1 AGES OF HUSBANDS AND WIVES OF FERTILE AND INFERTILE MARRIAGES, BT PERCENTAGES Wives Husbands Age Fertile Marriages N-46 Infertile Marriages N-49 Fertile Marriages N-46 Infertile Marriages N-49 20-24 21.7 16.3 13.0 6.1 25-29 34.6 51.0 26.3 36.6 30-34 32.6 20.4 23.9 26.6 35-39 6.7 12.3 26.3 20,4 40-44 2.2 • • 6.5 4.1 45-49 • # • • e e 2.0 100.0 100.0 100.0 100.0 age, ten were 30-34, only six were 35-39, and none were 40 or over. All but three of the husbands in each group were under 40 years of age at the time of the interview, and approximately three-fourths of those of infertile marriages were under 35 years. Inasmuch as the age of the wife is considered to be an important variable in the ability to conceive, the ages of the wives of infertile marriages are of particular interest for this study. The age 6f the control group is of importance for this study mainly because individuals of approximately the same age 57 tend to have similar test-taking attitudes and possibly to have reached somewhat comparable levels of emotional and marital adjustment. 2. Race— Each group contained eight Negro couples. This, of course, means that there were forty-one Caucasian couples in the infertile group as compared with thirty-eight in the fertile group. 3* Religion— As shown in Table 2, a diversity of religious affiliation existed in both groups. Although TABLE 2 RELIGIOUS AFFILIATION OF THE FERTILE AND INFERTILE COUPLES BY PERCENTAGES Religious Affiliation Fertile Marriages N-46 Infertile Marriages N-49 Protestant 41.3 49.0 Catholic 23.9 12.2 Jewish 15.2 20.4 Interfaith 13.0 12.2 None 2.2 2.1 Protestant-None 4.4 4.1 100.0 100.0 there were eleven Catholics in the infertile group as compared to six in the fertile group, this did not 53 represent a significant difference. Even if it had, it would not be likely to create a bias in the results to the extent that the reverse situation would have. Since the Catholic religion places such an emphasis on procre ation of children as the foremost reason for sexual inter course, Catholic couples with infertile marriages might be expected to develop intense psychological reactions, such as tension, anxiety, and guilt. A. Education— The percentages of husbands and wives achieving specified levels of educational achieve ment are presented in Table 3. Among the husbands, nineteen of the fertiles and twenty-one of the infertiles had a high school education or less, twenty-five of the fertiles and twenty-six of the infertiles had some college or had completed college, and tvo of each group had taken graduate work. The mean number of years of education for the husbands of the fertile group was 13.5 and of the infertile group, 13.3. A similar proportion of wives fell into the same categories: twenty-three of the fertiles and twenty-seven of the infertiles having had a high school education or less and twenty-three of the fertiles and twenty-two of the infertiles having had •some college or having completed college. However, the most meaningful comparison results from an inspection of the tables which show percentages within these two categories of high school and college. Only 19.5 per cent of the 59 fertile wives as compared with 34-.£ per cent of the fertile husbands had completed college and 16.4 per cent of the infertile wives as compared to 33.3 per cent of the infertile husbands had completed college. The fertile wives had an average of 12.95 years of education and the infertile wives of 13.04 years. TABLE 3 EDUCATIONAL BACKGROUNDS OF HUSBANDS AND WIVES OF FERTILE AND INFERTILE MARRIAGES BY PERCENTAGES Wives Husbands Educational Background Fertile Marriages N-46 Infertile Marriages N-49 Fertile Marriages N-46 Infertile Marriages N-49 Graduate degree e e e e 4.4 4.1 College graduation 19.5 16.4 30.4 34.7 Partial college training 30.5 23.6 23.9 13.4 High school graduation 36.9 44.9 26.1 30.6 Partial high school 10.9 3.1 3.7 10.2 Junior high school 2.2 2.0 6.5 2.0 100.0 100.0 100.0 100.0 5. Income— Table 4 presents the average monthly earnings of the husbands during the last half of their marriage. The information was obtained in this form TABLE 4 AVERAGE MONTHLY INCOMES OF HUSBANDS OF FERTILE AND INFERTILE MARRIAGES BY PERCENTAGES Average Monthly Income Husbands of Fertile Marriages N-46 Husbands of Infertile Marriages N-49 Less than $400 17.4 26.6 ♦400-$599 32.6 40.6 $600-$799 21.7 6.2 $S00-$1000 13.1 6.1 More than $1000 15-2 10.2 Student or unknown • * 6.1 100.0 100.0 because of the way in which the question was phrased in the Marriage Questionnaire: 22. The average income per month during the first half of your marriage was: husband 4 : wife $_____ • During the last half: husband 4 : wife $___. Obviously these averages represent varying lengths of time depending on the number of years the individual couples had been married, so that averages for the total 61 infertile group or fertile group are relatively meaning less. The average monthly income was $522 for the infer tile husbands and $625 for the fertile husbands. The in comes for the infertile group ranged from $150 to $1500 and for the fertile group from $300 to $1200. Fourteen of the infertile and 5 of the fertile husbands had monthly incomes under $400, 20 of the infertile and 15 of the fertile had incomes between $400 and $600, 4 of the infertile and 10 of the fertile had incomes between $600 and $500, 3 of the infertile and 6 of the fertile had incomes between $500 and $1000, 5 of the infertile and 7 of the fertile had incomes in excess of $1000, and the remaining 3 infertiles were 3tudents or their incomes were unknown. Although only 7 of the fertile wives were working, almost one-half, 24, of the infertile wives were gainfully employed. This is considerably higher than the national average of 32.3 per cent of wives with outside employment (112:214). Interviewing Procedure Five individuals served as interviewers. Two were professors from the University of Southern California who were acting in their capacity as marriage counselors at a private infertility clinic. Ten of the forty-nine infertile couples included in the study were interviewed by them. Nine additional couples at the private clinic completed the questionnaires but were not interviewed. 62 The present writer administered from one to three of the questionnaires to many of the thirty-eight individuals, representing nineteen couples at the private clinic. Despite this, the Pertility Study Psychological Data Sheet was not completed by six of the infertile husbands and two of the infertile wives. Two of the interviewers were graduate students enrolled in the doctoral program for marriage counselors at the University of Southern California and were serving their externships at the Planned Parenthood Center of Los Angeles. Together, they interviewed seven infertile couples. The remaining twenty- three infertile couples and all of the forty-six fertile couples were interviewed by the present writer. The interview with the marriage counselor, including the completion of the three forms, was regarded by the infertile group of couples as a necessary part of their infertility study at both the private clinic and the Planned Parenthood Center of Los Angeles. They were not advised that the material would be used for research purposes. Inasmuch as the couples felt that this might be helpful in correcting their infertility problem, there was good motivation in most instances for them to cooperate fully. There was one obvious exception to this and a few suspected exceptions on the part of husbands who were involved in the investigation of their infertile marriage merely because of the wifefs insistence. 63 All of the interviewers were given the same instructions as to procedure. Each couple was to be interviewed together and individually for the purpose of obtaining specific information in addition to the question naire items. The subjects were to fill in the question naires individually in the presence of the interviewer and without assistance from the mate. The subjects were to be assured confidentiality. Only the interviewer and the physician would have access to the material and under no circumstances would any information be made accessible to the mate. The chronology followed was to have the Fertility Study Psychological Data Sheet and the Marriage Questionnaire completed before the personal interview so that any omissions or answers needing elaborations could be followed up by the interviewer. An entirely different situation was encountered in procuring interviews with fertile couples. The original research design specified that the fertile couples were to be procured from the patient caseloads of physician members of the Los Angeles County Fertility Society who were interested in the research and willing to obtain cooperation from some of their "fertile" patients in participating in the study. One of the obstetricians who indicated interest was very conscien tious and was responsible for referring eleven of the fertile couples included in the study. Three additional 64 physicians were responsible for seven more couples. It proved to be too difficult and time-consuming to procure subjects in this manner, however, and it was necessary to find different sources for the control group of fertile couples. One source of couples came from a parent educa tion instructor who contacted various couples who had attended her classes and fulfilled the criterion of having borne two or more children with their present mate. Four of the fertile couples emanated from this source. The final source of fertile couples, and a very important one because of the desire to match the two groups as closely as possible on a socio-cultural level, was the Planned Parenthood Center of Los Angeles. The other sources had provided couples who were from average or above average socio-economic levels but it was neces sary to have some fertile couples who would correspond economically with some of the lower socio-economic level couples who were interviewed at the Infertility Clinic of the Planned Parenthood Center. The staff at this Center was most cooperative and the obvious procedure seemed to be to solicit volunteers from the Conception Control Service of the Center. A number of approaches were attempted. Inasmuch as the intention was to match certain variables like race, education, and income as closely as possible, the active files on conception control patients were searched and invitations mailed to those fulfilling 65 the requirements to participate in na study which would be helpful to their marriage relationship through consul tations with a professional marriage counselor." This approach was not successful, so the investigator decided to be present at the Center on those days when new concep tion control cases were being accepted. Each case history blank was examined and when the criteria for the afore mentioned variables were satisfied, the investigator talked with the prospective subject about participation in the study. Since these fertile couples did not have a strong motive like the infertile group to cooperate in the study, an appeal was made to "altruistic" motives. Furthermore, it was necessary for the husband to accompany the wife, and baby-sitting was a problem for some. Since "altru istic" motives are many times weak in lower socio-economic groups, the Director of the Center suggested the entice ment of offering to place them on the then-preferred "pill program"* as soon as possible, instead of on the usual waiting list, if the couple consented to come to the Center together to participate in the study. Because the husband as well as the wife was *At that time, so many patients wanted to take the conception control pills in preference to the other methods offered by the Center that it was sometimes necessary to wait for a period of four to six months for the opportunity. included in the study, it was necessary many times to conduct the interview in the evening. The couples, both fertile and infertile, from the Planned Parenthood Center of Los Angeles, and the private infertility clinic went to those respective clinics for the interview. The interviews of the fertile couples procured through private physicians or the parent education classes, however, were conducted in the homes of these couples. At first, an attempt was made to have them go to their physician9s office or some other conveniently located professional office but this did not prove efficacious because of transportation and baby-sitting problems as well as the fact that they were "donating" their services. In order to make these home visits, it was necessary for the investigator to travel as far as thirty-five miles. One couple happened to live about two miles from the investi gator 9s home but the average distance was approximately twenty-five miles. The procedure followed was for the investigator to introduce herself by a telephone call to the wife explaining the study and the requirements for participa tion* These requirements included such items as having at least two children by the present mate, having the husband as well as the wife involved in the interview and in completing the three questionnaires, and the ability to devote an entire evening of at least three hours to the task. It was stressed that a cooperative attitude on the part of both mates was extremely Important to the outcome of the study and unless they could both partici pate willingly, it was best for them to decline. The investigator would then request the wife to talk it over with her husband and expect a telephone call from the investigator at a future specified date for a final answer and to schedule a specific evening for the house call. In some instances the wife was quite willing and eager to participate in the study but the husband, due to suspi ciousness, or lack of interest or time, refused to cooperate. In only one instance was there lack of cooperation after the investigator arrived at the home. The couple had thought that the study had something to do with the Rh factor--a problem encountered in their marriage and one in which they were so deeply ego-involved that they had almost a missionary zeal relative to that specific problem but a complete disinterest for "simple" infertility problems. The hospitality and cooperation in most of the homes of the fertile couples was a rewarding experience in itself. Inasmuch as the investigator attempted to arrive by 7:00 P.M., the children were usually still awake and curious. This provided an opportunity to obtain firsthand knowledge of the family interaction and role structure. 68 The initial task for the investigator upon entering the home, obviously, was to establish rapport with the family in order to promote relaxation and the utmost cooperation in the interview. After a few minutes of casual conversation, the purpose of the study was reviewed, the mechanics of the interview explained, complete anonymity assured, and any questions which the couple might have were answered, if possible. If the children were still up and around, it was suggested that the investigator talk with one of the mates while the other one put the children to bed. Whenever possible, the couple was interviewed together first in order to get background information relative to their courtship and marriage. Then while the investigator was talking with them individually about personal background factors, the other would be in a separate part of the house (out of sight and sound if possible) filling out the question naires. This not only facilitated the interviewing timewise but fulfilled the prerequisites of confiden tiality and lack of collaboration on the part of the couple in completing the questionnaires. During the personal interview, the investigator utilized the "funnel approach" of going from less resistive areas to those usually associated with more resistance (14:346). This technique not only serves as orientation but is motivational because the respondent 69 becomes more personally involved in the topic of conversa tion. There were no refusals to answer certain questions nor even indications of reticence. In fact, a few individuals used this opportunity as a catharsis or confession of extramarital activities of which their mates were unaware.* Before leaving the home, the investigator always looked over the completed questionnaires to determine if there were any omissions or answers which needed elabora tion. In virtually every interview with a fertile couple, some statement was voluntarily made at the end of the evening that this scrutiny of their personal lives and marital relationship had been very worthwhile and had given them an opportunity to gain some perspective. In many instances, questions or problems relative to the marriage or the children were brought up for the consider ation of the "marriage counselor." *In analyzing the motivations which individuals have to be interviewed, Cannell and Kahn mention two major types. The first type has relevancy for the infertile group in that the interviewer may help the individual to achieve some goal or bring about some change. The motiva tion for the fertile group in this study is reflected more in the second type of motivation which "depends more directly upon the personal relationship between the interviewer and the respondent" (14:337). These authors feel that in talking with an understanding and accepting person about something in which he is interested or in which he is involved, the respondent realizes "a direct gratification or catharsis" (14:37$) somewhat resembling a counseling relationship. 70 Instruments Used Of the three instruments used, one was a paper and pencil test and the other two were questionnaires.* Inasmuch as the intent of the study was to compare psycho logical, marital, and sexual adjustment of Infertile and fertile individuals, it was necessary to utilize instru ments intended to accomplish this purpose. Two of these instruments, the Minnesota Multiphaslc Personality Inventory (36) and the Locke Marltal-Adjustment Test (55) are quite familiar to investigators in psychology and sociology. All but the first page of the other instrument, the "Fertility Study Psychological Data Sheet" was a modification of a form once used by the Psychology Depart ment Clinic at the University of Southern California for their intake work. The instruments utilized in this study were chosen in preference to projective tests— the Rorschach being the instrument used in the three previously mentioned research studies**— because of the greater ease of quantification and comparison with paper and pencil tests. Another *In a book devoted to research methodology, interviewing and questionnaires are recognized "as powerful Instruments for social research and the range of their usefulness is steadily widening" (14:331)* The authors maintain that the major problem of the inability or unwillingness of the respondent to communicate can be surmounted partially or entirely by interviewing skills, ingenious instruments and knowledgeable analyzing. **Cf. p. 31. 71 Important consideration was the self-administration feature, even though an interviewer was available at all times if questions arose. Minnesota Multlphasic Personality Inventory Commonly referred to as the MMPI, the Minnesota Multlphasic Personality Inventory was chosen as the basic personality test because of its validity, utility, and meaningfulness. It is empirically derived and validated and, despite the fact of its questionnaire form, it is regarded by many psychologists as "essentially an objec- tive--projective test rather than a subjective one" (40: 19). Another important consideration in this study is the fact that personality inventories stressing self- ratings and based on the internal consistency approach have shown the greatest lack of correlation with marriage adjustment criteria. Swan surmounted this problem in his study by utilising the MMPI because "its construction provides some empirical validation of self-rating items" (104:239). The MMPI clinical scales are measures of some of the personality traits defined in the classifications of the American Psychiatric Association— namely, hypochon driasis, reactive depression, hysteria, social psychopathy, paranoia, psychasthenia, schizophrenia, and hypomania. 72 There are also ▼alidity scales and scales for personality characteristics in addition to the clinical scales. The ▼alidity scales used are as follows: 1. The L score— measures the degree to which the subject may attempt falsification of the scores by choosing the most socially acceptable response. 2. The F score— serves as a check on the pertinence and rationality of the subject's responses to the test items and his carefulness in answering. 3* The K score--measures the test-taking attitude of the subject and the degree of his defensiveness, as well as acting as a suppressor variable to enhance the discriminatory power of five of the clinical variables. The following clinical scales were used: 1. The Hypochondriasis Scale (Hs)— measures the amount of abnormal concern about bodily functions. 2. The Depression Scale (D)— measures the depth of the clinically recognized symptom or symptom complex, depression, as evidenced by a feeling of uselessness and a pessimistic attitude toward the future. 3. The Hysteria Scale (Hy)— measures the degree of conversion-type hysteria symptoms. 4. The Psychopathic Deviate Scale (Pd)— measures the absence of deep emotional response, inability to profit from experience, and disregard of social mores. 5. The Interest Scale (Mf)— measures the tendency 73 toward masculine or feminine interests. 6. The Paranoia Scale (Pa)— measures the extent of suspiciousness, oversensitivity and delusions of persecution. 7* The Psychasthenia Scale (Pt) — measures the extent of behavior of a phobic or compulsive nature. S. The Schizophrenia Scale (Sc)— measures the extent of bizarre and unusual thoughts or behavior. 9. The Hypomania Scale (Ma)— measures the degree of overproductivity in thought and action. Scales used in addition to the validity and clinical scales are: 1. The Dependency Scale (De)--measures the extent of need for a security system oriented towards external sources of support (i.e., people or objects) (27)- 2. The Manifest Anxiety Scale (M.A.S.)— measures the extent of manifest anxiety symptoms (106). 3. The Neuroticism Scale (Ne)— differentiates normals from neurotics of mixed diagnoses (120). 4. The Sex Attitude Scale (S.A.)*--measures the degree of healthy attitudes toward sex. 5. The Ego Strength Scale (Es)— measures adapt ability and personal resourcefulness (2). 6. The Dominance Scale (Do)— measures degree of *Cf. p. ^0 74 personal dominance in a face-to-face situation (2d). Although there are 566 items in this inventory, there is a "Shortened Version" vrhich is described in the Manual (36:11). This version consists of only the first 366 items and was used in this study. Marriage Questionnaire This questionnaire is a modified form of the Locke Marital-Adjustment Test which was originally developed for Locke's study (55)« The modified form contains fifty-eight questions, some of which have several parts.* In addition to the Marital-Adjustment Scale, the measures of dominance, of sexual adjustment and sexual responsiveness were also based largely on answers to some of the questions in this form. Fertility Study Psychological Data Sheet For the fertile group of subjects, this form was titled "Fertility Study" and for the infertile group, "Infertility Study."** This instrument was developed in order to obtain background Information, personal data relative to psychogenic conditioning factors and sample composition material. In addition, some of the items in *See Appendix I. **See Appendix II. 75 this form were utilized in constructing an anxiety scale, an index of the individual’s relationship to his or her father and mother, and an index of psychological back ground. Scale Construction and Scoring The Wallace Adjustment Scale (114) was chosen for use as an index of marital adjustment. The fifteen items used by Wallace in his scale were the ones found to be most significant in the Burgess-Cottrell, Terman, and Locke studies of marital adjustment. Inasmuch as only fourteen of these items were included in the modified form of the Marriage Questionnaire used in the present study, these fourteen were used in constructing a marital- adjustment index, using the weightings which Wallace had given (114:121-122). The success of Wallace’s attempt to construct a * reasonably valid and reliable marital-adjustment scale by utilizing relatively few items has been demonstrated by its use in numerous research studies during the past fifteen years. High reliability, as shown by a coefficient of +.90, was computed by the split-half technique and corrected by the Spearman-Brown formula (114:179). The validity of the test was also shown to differentiate be tween persons who are well-adjusted and those who are maladjusted in marriage (114:1&0-1S3)• Th® fourteen items 76 from Wallace's marital-adjustment scale with their respec tive weights are shown in Table 5. The category "neither giving in" under item 44 in the Marriage Questionnaire used in this study was not included in Wallace's study, but the investigator felt warranted to assign a weight of 0 to this. Although Wallace's scale included the following item: "Do you confide in your mate: Almost never_____; rarely_____; in most things : in everything ," item 33 relative to talking things over with the mate seemed similar enough to warrant substituting it for the above, using the same weights. Inasmuch as there are no known pencil and paper tests to measure the "sexual relationship" in a marriage, it was necessary to devise indices for this study because of the obvious importance of this aspect of marriage for fertility. Consequently, five indices were developed* One scale was constructed for measuring "sexual adjustment" and another for measuring "sexual responsiveness" by using certain items from the questionnaires and assigning arbitrary, common-sense weights. The rationale for this type of weighting has been justified by research. Burgess and Cottrell (11:67) demonstrated that differences in weighting do not seem to affect the validity of a scale. They used Terraan's statistical method of weighting on their sample and correlated the new scores obtained with TABLE 5 WEIGHTED MARITAL ADJUSTMENT SCALE USED IN PRESENT STUDY ADAPTED FROM WALLACE* 27. Have you ever wished you had not married: frequently 0 : occasionally 3 : rarely & ; never 15 . 2fS. If you had your life to live over again, do you think you would: marry the same person 15 : marry a different person 0 ; not marry 1 . 29. Do you and your mate engage in outside interests together: all of them 10 ; some & : very few 3 : none of them 0 32. In leisure time husband prefers to be: "on the go"_____; to stay at home . Wife prefers to be: "on the go" ; to stay at home . (If checked "stay at homew t o r both, 10 points; *on the go" for both, 3 points; disagreement, 2 points.) 33. During marriage have you in general talked things over with your mate: almost never 0 : now and then 2 : almost always 10 ; always 10 . 43. State approximate extent of agreement or disagreement between you and your mate on the following items. The examples should be considered as only one of many topics which come under each point. Please place a check opposite every item. - s i -o TABLE 5— Continued Check one Column for Each Item Below Always Agree Always Disagree Almost Always Agree Occa sionally Disagree Fre quently Disagree Almost Always Disagree Handling family finances (Example: installment buying) 5 0 4 3 2 1 Matters of recreation (going to dances) 5 0 4 3 2 1 Demonstrations of affection (frequency of kissing) a 0 6 4 2 1 Friends (dislike of mate's friends) 5 0 4 3 2 1 Intimate relations (sex relations) 15 0 12 . 9 4 1 Ways of dealing with in-laws 5 0 4 3 2 1 - " J A o» TABLE $— Continued Check one Column for Each Item Below Always Agree Always Disagree Almost Always Agree Occa sionally Disagree Fre quently Disagree Almost Always Disagree Conventionality (right, good, or proper conduct) 5 0 4 3 2 1 Aims, goals and things believed to be important in life 5 0 4 3 2 1 44. When disagreements have arisen, they usually have resulted in: husband giving in 0 : wife giving in 2 ; agreement by mutual give and take 10 : neither giving in 0 . aFourteen of the original fifteen items were used. Numbers of the above items refer to the numbers of the respective items as they appear in the Marriage Questionnaire used in the present study. See Appendix. 80 scores obtained by arbitrary weighting. The correlation was +.90. This finding was given further credence by Guttman (34) who found that the weights assigned by judges, providing they were in the right direction, correlated over +.90 with several statistical techniques of weighting when utilized for the "adjustment in engagement" scale used by Burgess and Wallin. "Sexual adjustment" was intended to be a function of the sexual relationship within the marriage whereas "sexual responsiveness" was regarded as a measure of libido or sexual "drive," oftentimes negatively referred to as impotency in the male and frigidity in the female. The "Sexual Adjustment Scale" as constructed and weighted in this study is shown in Table 6. The first three items, it will be noted, were taken from the Marriage Question naire and the other two from the Psychological Data Sheet. A "Sexual Responsiveness Scale" was constructed in the same way. For this scale, however, an individuals score was obtained by combining his answer to certain items from the Marriage Questionnaire with his mateTs answers to certain other items from the same form as shown in Tables 7 and 8. In addition to the scales devised to measure "sexual adjustment" and "sexual responsiveness," a "Sexual Attitudes Scale" was constructed by combining a number of items which were included in the MMPI and were closely 31 related to "sexual attitudes." The following twenty-four items were included in the scale and those responses are shown which were scored as indicative of a positive sexual attitude. 15. Once in a while I think of things too bad to talk about. (F) 20. My sex life is satisfactory. (T) 36. I seldom worry about my health. (T) 37. I have never been in trouble because of my sex behavior. (T) 51. I am in Just as good physical health as most of my friends. (T) 69. I am very strongly attracted by members of my own sex. (F) 101. I believe women ought to have as much sexual freedom as men. (T) 133. I have never indulged in any unusual sex S ractices. (T) uring the past few years I have been well most of the time. (T) 163. I do not tire quickly. (T) 179. I am worried about sex matters. (F) 139. I feel weak all over much of the time. (F) 199* Children should be taught all the main facts of sex. (T) 203. I like to flirt. (F) 231. I like to talk about sex. (T) 241. I dream frequently about things that are best kept to myself. (F) 242. I believe I am no more nervous than most others. (T) 297* I wish I were not bothered by thoughts about sex. (F) 302. I have never been in trouble because of my sex behavior. (T) 310. My sex life is satisfactory. (T) 314. Once in a while I think of things too bad to talk about. (F) 320. Many of my dreams are about sex matters. (F) 324. I have never been in love with anyone. (F) 363. At times I have enjoyed being hurt by someone I loved. (F) Another index of the husbands’ sexual responsive ness or potency was based on the answers to item number 53 TABLE 6 WEIGHTED SEXUAL ADJUSTMENT SCALE CONSTRUCTED FOR PRESENT STUDYa 43. State approximate extent of agreement or disagreement between you and your mate on the following items. The examples should be considered as only one of many topics which come under each point. Please place a check opposite every item: Check one Column for Each Item Below Always Agree Always Disagree Almost Always Agree Occa sionally Disagree Fre quently Disagree Almost Always Disagree Intimate relations (sex relations) 15 0 12 9 4 1 49. Does fear of having children make sex intercourse less enjoyable: Yes 0 ; no & . 53. During marriage, with how many persons other than your mate have you had sex intercourse: none 5 ; one 3 : a few 0 ; many Q . 9. Are you much concerned with your present adjustment to sex? Yes 0 ; no 10. (Gradations between extremes could be calculated.) 11. Do you regard yourself as a tense person? Yes ; no . If so, does the tension and anxiety interfere with satisfactory consummation oF the sexual act? Yes 0 ; noJL.- aItems 43, 49, and 53 are from the Marriage Questionnaire. Items 9 and 11 «. correspond with the same numbers for the fertile group and with items 3 and 10 respec- 70 tively for the infertile group on the Psychological Data Sheet. TABLE 7 WEIGHTED SEXUAL RESPONSIVENESS SCALE CONSTRUCTED FOR PRESENT STUDY* HUSBAND'S SCORE Wife's answers to: 55. What do you think is the degree of sex satisfaction which your mate has with you: en.lovable 1 ; very en.ioyable 2 : tolerated 0 : disgust- ing -1 : very disgusting -2 . 57. Has the average number of times of intercourse per month from the time of marriage until the present: increased greatly 3 : increased 3 : remained the same 2 ; decreased some 1 ; decreased greatly 0 ; ceased entirely -2 . 5#. Do you feel that the strength of your sex interest, as compared with that of your mate, is: very much greater -3 : much greater -2 ; about the same -1 ; much less Intense 1 ; very much less 2 . Husband's answers to: 50. Before marriage, with how many persons did you have sex intercourse: none -1 : one 1 ; a few 2 ; many 2 52. During marriage have you desired sex intercourse with some other one than your mate: very frequently 1 ; frequently 1 ; sometimes 1 ; rarely 1 ; never 0 . ^ w TABLE 7— Continued 54. What is the degree of your sex satisfaction with your mate: enjoyable 1 ; very enjoyable 2 : tolerated -1 ; disgusting -2 ; very disgust ing- ^ . 56. Have you ever refused sex intercourse when your mate desired it: fre- Quentlv -2 : sometimes -1 ; rarely 0 ; never 1 . 57. Has the average number of times of intercourse per month from the time of marriage until the present: increased greatly 3 : increased 3 ; remained the same 2 ; decreased some 1 ; decreased greatly" -1 . 53. Do you feel that the strength of your sex interest, as compared with that of your mate is: very much greater 3 ; much greater 3 ; about the same -3 : much less intense -4 ; very much less -5 . aThe numbers of the above items are the same as the numbers of the corresponding items in the Marriage Questionnaire. $5 TABLE g WEIGHTED SEXUAL RESPONSIVENESS SCALE CONSTRUCTED FOR PRESENT STUDY* WIFE1S SCORE Wife13 answers to: 51. Did you have sex intercourse with your mate before marriage: yes 1 : no 0 . 54. What is the degree of your sex satisfaction with your mate: enjoyable 1 : very en.lovable 2 ; tolerated -1: disgusting -2: very disgusting -2. 56. Have you ever refused sex intercourse when your mate desired it: frequently -1: sometimes 0 : rarely 1 : never 2 . 57. Has the average number of times of intercourse per month from the time of marriage until the present: increased greatly 3 : increased 3 ; remained the same 2 : decreased some 1 : decreased greatly -1. 55. Do you feel that the strength of your sex interest, as compared with that of your mate, is: very much greater 3 ; much greater 2 ; about the same 1 : much less intense 0 ; very much less -1. Husband’s answers to: 55. What do you think is the degree of sex satisfaction which your mate has with you: en.joyable 1 : very en.joyable 2 ; tolerated Q : disgusting -HI 57. Has the average number of times of intercourse per month from the time of marriage until the present: increased greatly 3 ; increased 3 : remained the same 2 : decreased some 1 ; decreased greatly -1. 5fS. Do you feel that the strength of your sex interest, as compared with that of your mate, is: very much greater -1; much greater 0 : about the same 1 : much less intense 2 . aThe numbers of the above items are the same as the numbers of the respective items in the Marriage Quest ionnaire. 86 on the Marriage Questionnaire: Do you feel that the strength of your sex interest, as compared with that of your mate, is: very much greater : much greater ; about the same ; much less intense ; very mucKless . Because of the physiological and social beliefs about the stronger intensity of male sexual drives as compared with female, and because of the positive ego value which men attach to their sexual virility, it seems likely that if a man in our society is willing to describe himself as having the same or less intense "strength of sex interest," in comparison with his wife, this is an accurate report. The husbandsf answers to this question were analyzed by construction of a contingency table. The fifth index of "sexual relationship" was also obtained by development of a contingency table. The scores for the "Sexual Responsiveness Scale" were divided into "stronger" and "weaker" groups. The responsiveness score had a possible range of -10 to + 1&. A cutting score of +5 was used so that all scores below that were defined as being in the "weak responsiveness" group and those +5 or over as being in the "strong responsiveness" group. Although the MMPI Manifest Anxiety Scale (M.A.S.) was determined for each of the subjects in this study, certain items from the Psychological Data Sheet were regarded to be such obvious anxiety indicators that they were used to develop another measure of anxiety. It is #7 referred to subsequently throughout the study as the "Anxiety Scale." A possible range of scores from zero to six resulted from giving an answer of "yes" a score of one and an answer of "no" a score of zero for each of the following items on pages two and six of the Data Sheet: Do you regard yourself as a tense person? Do you have any habits that worry you? Do you sometimes worry about your personal appearance? Do you sometimes worry about what other people think about you? Do you worry about your intelligence? Have you ever "gone to pieces" over anything? Since an individual’s relationship with his or her parents is regarded by some authorities as being of impor tance in infertility, scales were constructed and weighted arbitrarily in an attempt to measure "mother relationship" and "father relationship" as shown in Table 9. The first item is number 7 on the Marriage Questionnaire, and the remaining items are from the Psychological Data Sheet. In determining the score for the mother relationship, columns C and F were used from item 7 and items 9» 12, 13, and 14 from the other questionnaire. In determining the score for the father relationship, columns B and E were used from item 7 and items 9, 10, 11, and 14 from the other questionnaire. TABLE 9 WEIGHTED FATHER AND MOTHER RELATIONSHIP SCALES CONSTRUCTED FOR PRESENT STUDY® 7. Indicate the amount of conflict and affection which was present between the following persons before your marriage: Degree of Conflict and Affection Conflict Affection (A) Father and Mother (B) You and Father (C) You and Mother (D) You and Your Mate (E) You and Father (F) You and Mother (G) You and Your Mate (H) Father and Mother None 0 0 0 0 Very little -3 -3 3 3 Moderate -5 -5 5 5 A good deal -7 -7 7 7 Very great -10 -10 10 10 00- 00- TABLE 9— Continued 9. From your point of view, characterize your father and your mother as you experienced them in childhood by placing a check mark (/) on the horizontal lines at any point which best indicates how you really felt about your father, and an I mark at any point on the horizontal lines which best indicates how you felt about your mother. FIRST MAKE TOUR RATINGS ON ALL OF THE ITEMS WITH RESPECT TO TOUR FATHER AND THEN GO BACK AND MAKE THE RATINGS FOR TOUR MOTHER. Just 2 1 0 -1 -2 Unjust t i t I t Fair 2 1 0 -2 Unfair t ! f 1 i Severe -2 -1 0 1 2 Mild t J t t . t Stingy -2 -1 0 1 2 Generous i • I i i Brutal -2 -1 0 1 2 Kind ! - t t T i Loving 2 1 0 — 1 -2 Rejecting t _ J 1 I . Strong 2 1 0 -2 Weak t t I 1 t Hostile -2 -1 0 1 2 Friendly i J 1 t t TABLE 9— Continued Domineering -1 1 2 1 -1 Submissive ! t » 1 t Clever 2 1 0 -1 -2 Dull i i i i Educated 2 1 0 -1 -2 Uneducated i t f ! T Mean to Father Kind to Father (Mother) -2 -1 0 1 2 (Mother) t i t 1 T Mean to Brother -2 -1 0 1 2 Kind to Brother i i 1 t t Mean to Sister -2 -1 0 1 2 Kind to Sister t L ! t » Hates Father Loves Father (Mother) -2 -1 0 1 2 (Mother) t » I 1 i Nervous -2 -1 0 1 2 Controlled t t t f Emotional -2 -1 0 1 2 Calm t t 1 t t Industrious 2 1 0 -1 -2 Lazy i t t » t TABLE 9— Continued Drunk - 2 - 1 0 1 2 Sober i i 1 1 i Clean 2 1 0 - 1 -2 Untidy t i t t t Poor - 2 1 2 1 - 2 Wealthy t t I t Lots of fun 2 1 0 - 1 - 2 Grim i i t t t___ Demanded High Standards - 1 0 1 - 1 - 2 Did not care t * t t t Punished Fre quently -2 -l 1 1 0 Never punished t i I I t Beat Me - 2 -l 0 1 2 Never Touched Me t i t 1 t Employed ( - 2 ) * > 2 ( - 1 ) l 0 ( 1 ) - 1 C M C M 1 Not Employed t i 1 t t Attended Church 2 l 0 - 1 - 2 Did not Attend Church _ r _______ L 1 t i TABLE 9— 'Continued 10. Did your father do anything that you particularly resented or did not like? Tes_;i no 0 . 11. What was it? (Describe briefly) -1 for each item 12. Did your mother do anything that you particularly resented or did not like? Yes -5 no 0 . 13. What was it? (Describe briefly) -1 for each item. 14. Parents still married: 5 divorced: 0 separated: 3 dead: 0 aItem 7 corresponds with same number on Marriage Questionnaire and remaining items correspond with those on pages 2 and 3 of the Psychological Data Sheet. ^Numbers in parentheses are for mother relationship score. \o N> Recognition of the importance of a psychological background factor in infertility was acknowledged by the construction of the scale shown in Table 10. TABLE 10 WEIGHTED PSYCHOLOGICAL BACKGROUND FACTOR SCALE CONSTRUCTED FOR PRESENT STUDYa S. My childhood on the whole was: very happy 0 : happy 0 : about averagely happy 0 : unhappy 5 : very unhappy 10 . Id. Following is a list of common childhood mental health problems. Please check those which as far as you can remember, apply to or have applied to you. Temper tantrums 5 Strong hates 5 Strong fears 5 . Running away from home 5 Afraid of Father 5 Afraid of Mother 5 Afraid of Sister 5 of Brother 5 . of Uncle 1 , of Aunt 1 of teacher 2 Attacks of fainting 5 Extreme destructiveness 5 Twitchings of the muscles of the face 5 Epileptic seizures 5 Convulsions 5 Badly injured as a baby_____ . Complicated birth_____ . Severe spankings or other severe punishments 5 Playing frequently with sex organs 1 Daydreaming all the time 5 Swollen glands_______. Blow on the head, or other severe head injury_____ . Enuresis (Involuntary bed-wetting after the age of 7 years) 5 94 TABLE 10--Continued Severe headaches 5 Difficulty in sleeping well 5 Bottle fed______. Breast fed . 19. As a child were you extremely healthy? 0 Average 1 Poor 3 Sick most of the time 5 aItem 8 corresponds with the same number in the Marriage Questionnaire; items 18 and 19 with the same numbers on page 4 of the Psychological Data Sheet. The element of role dominance in infertile marriages has been accorded a great deal of attention. One of the additional MMPI scales utilized in this study was the Dominance Scale. However, item number 36 in the Marriage Questionnaire seemed to present another possi bility of measuring dominance of roles in the marriages: 36. In the following chart there is a list of activities in which the husband or wife may take the lead, that is, one is more dominant than the other. We want information on three married couples; you and your mate; your mother and father; and your mate18 mother and father. Indicate in the proper space whether the husband or the wife tends to take the lead. If in a given activity both the husband and wife are about equal, put a check for both. Your Marriage Your Parents1 Marriage Mate!s Parents’ Marriage Activities Wife Takes Lead Husband Takes Lead Mother Takes Lead Father Takes Lead Mate1s Mother Takes Lead Mate1s Father Takes Lead Making family decisions 95 Activities Your Marriage Your Parents1 Marriage Mate’s Parents’ Marriage Wife Takes Lead Husband Takes Lead Mother Takes Lead Father Takes Lead Mate’s Mother Takes Lead Mate* s Father Takes Lead Disciplining children Handling family money Affectionate behavior Religious behavior Recreation behavior Meeting people For purposes of obtaining an analysis of role dominance, only the answers in the first two columns under "Your Marriage" were analyzed. All of the activity categories were included except "disciplining children" since, obviously, the infertile couples could not check this. For the other six activities, the number of checks were counted under the heading "wife takes lead" and those 96 under "husband takes lead" for each of the husbands and wives. If an individual had within one of an equal number of checks under both headings, his evaluation was deemed to be "democratic." If a difference of more than one check appeared under "wife takes lead" than under "husband takes lead," the marriage from that individuals frame of reference was considered to be "wife-dominated" and if the number of checks occurred in a reverse proportion, it was considered to be "husband-dominated." Scoring the MMPI The scoring of the MMPI validity and clinical scales followed as closely as possible the procedures as outlined in the Manual (36:10). However, since the Shortened Version had been used for practical reasons and since it was desirable to obtain corrected, more discrimi natory scores for five of the scales by adding the proper percentage of the K score to the raw scores of the vari ables, it was necessary to devise a means of extrapolating the K score. Table VTII in the Manual (36:16) shows the T scores which are applicable for specified raw scores when the five scales (Hypochondriasis, Psychopathic Deviate, Psychasthenia, Schizophrenia, and Hypomania) have not been corrected for K. Since 23 out of a total 30 K items appear in the first 366 items of the MMPI, it seemed possible that an 97 extrapolated K score for each of the subjects might result in more nearly accurate T scores for the five scales than by using Table VIII in the Manual. Caldwell who studied under Hathaway at the University of Minnesota and has been specializing in the MMPI for years, was consulted regarding this, and was in full accord with the idea of extrapolating the K score.* Although it was not required, 26 of the 190 subjects had completed the 566 items of the test, so it was possible to use the results from these answer sheets to compare the accuracy of the two approaches to scoring. In Table 11 is shown the T scores for the five MMPI scales which require a K correction of the raw scores if Table VII in the Manual is to be used. Each scale has three columns of T scores. Those in column 1 were derived from the raw scores obtained on the Shortened Version without a correction for K and with Table VIII in the Manual as the basis for conversion from raw scores to T scores. In column 2 appear the most accurate T scores— those based on the completion of 566 items so that the actual K correction could be added to the raw scores with Table VII being used for conversion to T scores. Column 3 presents the T scores which were obtained by extrapolation of the K score obtained in 23/30 of the items, applying ♦Personal conversation of the investigator with Alex Caldwell, Ph.D., on October 11, 1961, at the Neuro psychiatric Institute of the UCLA Medical Center. TABLE 11 COMPARISON OF FIVE MMPI SCALES DERIVED BY THREE DIFFERENT METHODS USING SCORES OBTAINED BY THIRTEEN HUSBANDS AND THIRTEEN WIVES* MMPI SCALE Subject Hs Pd Pt Sc Ma (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) H-l 51 52 52 70 71 71 59 64 64 56 61 61 79 83 83 H-2 42 44 41 73 74 74 39 40 36 44 43 44 39 to f * " \ 38 H-3 44 52 52 60 67 67 43 52 54 49 61 63 57 60 60 H-4 60 65 62 53 60 60 54 60 53 52 57 55 52 53 53 H-5 60 44 41 63 64 64 50 56 52 53 61 57 75 78 78 H-6 51 59 57 50 57 57 43 60 56 44 55 51 39 40 40 H-7 47 47 44 53 53 53 66 73 71 64 71 69 63 65 63 H-8 49 39 41 45 43 41 57 54 50 43 42 33 34 30 30 H-9 51 49 52 50 50 53 50 43 52 56 57 61 68 68 70 \o ox H-10 44 41 39 60 60 57 56 56 52 55 55 51 61 60 60 TABLE ll--Continued MMPI SCALE 1 Subject Hs Pd Pt Sc Ma (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) H-ll 44 57 59 50 62 62 46 66 69 44 63 65 52 53 53 H-12 42 44 44 50 55 53 41 46 42 40 46 42 52 55 53 H-13 40 49 49 53 62 60 33 50 43 40 53 51 43 45 45 W-l 39 46 42 42 43 43 36 43 33 39 47 43 41 43 40 W-2 43 51 51 53 60 60 42 53 53 39 49 49 34 35 35 W-3 52 52 43 53 53 43 52 53 46 50 51 44 52 50 50 W-4 50 43 43 56 53 53 52 50 43 47 43 41 63 63 63 W-5 43 42 39 44 43 41 52 53 50 42 40 37 45 43 43 W-6 54 54 54 53 55 57 60 60 63 57 55 53 59 53 53 W-7 41 52 52 40 43 43 34 43 43 40 55 55 59 65 65 W-3 43 44 ’ 39 44 43 41 45 45 40 40 40 35 45 45 43 * W-9 50 46 46 53 53 53 62 53 56 62 53 57 59 53 55 TABLE 11--Continued MMPI SCALE Subject Hs Pd Pt Sc Ma (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) (1) (2) (3) W-10 4* 51 50 53 60 57 50 53 51 50 54 52 57 58 58 W-il 43 43 46 73 69 69 60 61 53 52 51 47 6$ 68 68 W-12 45 54 54 51 57 57 42 55 55 38 49 49 43 45 45 W-13 43 60 53 49 60 57 33 43 45 39 55 52 37 40 38 •Column 1 under each scale refers to the score obtained from Table VIII in the Manual which is based on the Shortened Version of 366 items; column 2 refers to the score obtained from Table VII in the Manual which is based on the complete form of 566 items and includes the correction for K; column 3 refers to the T score obtained by extrapolation with K scores obtained by the individual on the Shortened Version and then using Table VII. 101 the resulting K correction to the five scales and using the Manual's Table VII for conversion to T scores. The comparison of the methods showed that the scores obtained for all five scales by extrapolation of the K score approximated the most accurate scores (using the K correction derived from the completed 566 item form) much more closely than did the T scores obtained by using the conversion Table VIII in the Manual. The following table shows the total point differences for the 26 subjects, both arithmetically and algebraically, between columns 1 and 2 and columns 3 and 2 of Table 11. Column 1 was subtracted from column 2 for each subject and for each scale, and column 3 was subtracted from column 2. TABLE 12 ANALYSIS OF TWO METHODS FOR DERIVING FIVE MMPI SCALES AS COMPARED WITH THE MOST ACCURATE METHOD Total Point Differences in T Scores of Specified MMPI Scales Between Table VIII and Table VII Between ted and Extrapola- Table VII Hs Pd Pt Sc Ma Hs Pd Pt Sc Ma Minus direction 99 34 149 129 40 37 29 62 61 14 Plus direction 40 19 11 19 12 7 5 12 11 2 Arithmetically 139 103 160 143 52 44 34 74 72 16 Algebraically 59 65 133 110 26 30 24 50 50 12 102 As is clearly indicated, the method of extrapo lating the K score and making the K correction for the 5 scales approximates the accuracy of Table VII in the Manual for each of these scales much more closely than using Table VIII in the Manual. In fact, the scores obtained by extrapolating were closer to the score obtained by using Table VII in the Manual for IS out of the 26 individuals on 3 of the scales— Hs, Pd, and Sc, for 16 of the 26 individuals on the Pt scale and for 19 individuals on the Ma scale. In 3 additional instances, the scores obtained by using the 2 methods were identical. Even though this method of obtaining the T scores for the 5 scales required a great deal more time than simply referring to Table VIII in the Manual, it was used for this study because of its greater accuracy. The only scales used in this study containing items beyond the 366 of the Shortened Version were K and the additional scales of Dominance, Dependency, Ego Strength, and Manifest Anxiety. The additional scales were scored according to the procedures specified by their authors.* All of the items in the Neuroticism Scale were contained in the Shortened Version of the MMPI but for the other additional scales the following proportions were contained in the Shortened Version: 20/23 of the items in *Cf. p. 73. 103 the Dominance Scale; 67/36 of the items in the Dependency Scale; 1*2/63 of the items in the Ego Strength Scale, and 35/50 of the items in the Manifest Anxiety Scale. Because of this, the raw scores of each of these scales instead of the T scores were used for purposes of comparison between the fertile and infertile groups. Statistical Procedures The Western Data Processing Center, a division of the Graduate School of Business Administration of the University of California at Los Angeles, makes its computer facilities available for research projects of faculty and students from participating institutions, including the University of Southern California. Other services, including consultation relative to the program ming and data processing of the research project, facili tate the effective use of the processing equipment. For purposes of this study, the data acquired for both the experimental and control groups of subjects were punched on IBM cards, the appropriate programs for processing the data were either chosen or devised, and the IBM 709 electronic computer was used to calculate the statistics. A card which bore information relative to the variables was punched for each of the 190 subjects in the sample. In addition, a card which contained combined scores was punched for each of the 95 couples. 104 The conviction that the couple as an interacting unit is of extreme importance was expressed statistically by combining the scores of husband and wife into couple scores. The rationale for this was derived from two sources. Swan used couple scores in a study of marriage adjustment (102) and Caldwell recommended its use in this way.* In order to test statistically whether the differences between the distributions, proportions and the means of certain variables of the experimental and the control groups were significant, the critical ratio (X)» chi-square (X.^) and Kolmogorov-Smirnov (K-S) tests were used. The critical ratio and some of the chi-square tests, especially those based on contingency tables, were computed by the investigator. These tests afford criteria which enable the investigator to determine the likelihood that the differences are due to chance. The chi-square and Kolmogorov-Smirnov tests are nonparametric tests. Siegel describes a nonparametric statistical test as being one whose "model does not specify conditions about the parameters of the population from which the sample was drawn" (91:31). He points out in addition that fewer assumptions are made as compared ♦Personal conversation of the investigator with Alex Caldwell, Ph.D., on October 11, 1961, at the Neuro psychiatric Institute of the UCLA Medical Center. 105 with those associated with parametric tests and that the measurements required are not as stringent. Guilford states that: By definition, a chi square is the sum of ratios (any number can be sunned). Each ratio is that between a squared discrepancy or difference and an expected frequency. The discrepancy is between an obtained frequency and a frequency expected on the basis of the hypothesis we are testing. (31:223-229) The second nonparametric test used in this study is the Kolmogorov-Smirnov test. It is concerned with the degree of agreement between the distribution of a set of sample values (observed scores) and some specified theoretical distribution. It determines whether the scores in the sample can reasonably be thought to have come from a population having the theoretical distribu tion. . . . Briefly the test involves specifying the cumulative distributions which would occur under the theoretical distribution and comparing that with the observed cumulative frequency distribution. The theoretical distribution represents what would be expected under H0. The point at which these two distributions, theoretical and observed, show the greatest divergency is determined. Reference to the sampling distribution indicates whether such a large divergency is likely on the basis of chance. That is, the sampling distribution indicates whether a divergence of the observed magnitude would probably occur If the observations were really a random sample from the theoretical distribution. (91:4#) The Kolmogorov-Smirnov test has a number of advantages over the chi-square test. When samples are small, it is not necessary to combine adjacent categories, as in the case of the chi-square test, before computation is possible. When samples are so small that chi-square is not applicable, the K-S test may still be used. The K-S test is sensitive to all kinds of differences and is 106 regarded as the most powerful of all nonparametric tests (91:51). It was necessary for the investigator to choose a level of confidence as being significant for this study. "The choice of a standard level of significance depends very much on the risk we take of being wrong in making a statistical inference" (31:216). If one is studying the effects of a drug suspected of inducing drastic changes physically or emotionally, a high level of significance is demanded. In this study, it was not deemed necessary to set the level of significance as high as .01 because there was no important theoretical issue or potential danger involved. The level of confidence chosen as being significant for this study was .05. This was considered as quite sufficient for purposes of studying psycho- sociological factors in infertility. This means that the difference between the fertile and infertile groups was regarded as being significant if there were five chances or less in a hundred that it was due to a sampling error. McNemar even suggests reserving judgment about final rejection of an hypothesis between the .10 and .05 levels of confidence. He feels that: "This, in effect, introduces a region of indecision, or calls for a post ponement of decision until the experiment is repeated or more data are collected" (63:70). Pearson’s product-moment coefficient of correlation 107 (r) was used to test the degree of association, i.e., to what extent certain variables are related. Although a slight degree of relationship is evidenced by a coeffi cient as low as .20, a coefficient of ,1+0 or more is generally regarded as necessary for indicating a really meaningful or substantial relationship. One of the computer programs at the Western Data Processing Center had an output format for the Kolmogorov- Smirnov and chi-square tests. Many of the statistics and tables in Chapter IV are taken from the output thus derived. The University of California at Los Angeles Medical Center staff member who prepared the computer program suggested that the significance level be regarded as "nominal,” i.e., as an approximation. In explaining, he stated that if each significance level represented the only variable being tested between the groups, it would be accurate. The larger the number of samples run, the greater the probability would be of the specified divergency being true. However, it was emphasized that the error is always in the "safe direction” even when the sample size is small.* An approach called "configural analysis,” developed by Sullivan and Welsh (102), was used for analyzing MMPI inventories. Essentially, this method is ♦Personal conversation of the investigator with John R. B. Whittlesey, January 28, 1963. 10 B a comparison of the ranks of the clinical scales obtained i from two groups of individuals. Rank comparisons are made by assigning plus, minus, and equal signs: the higher of two scales is assigned a plus, the lower a minus, and an equal if they are within one T-score point of each other. A test of significance is then applied to the totals of the pluses, minuses, and equals for each of the scale comparisons. The configural analysis approach is based on the superiority of the inter-scale comparison over intra-scale comparison. Sullivan and Welsh (102:313) contend that a much better differentiation between an experimental and control group results by their rank comparison method than by comparing the single scales of individuals. It is the difference between taking a wholistic approach and an atomistic approach. Summary In this chapter, the sample consisting of an experimental group of forty-nine infertile couples and a control group of forty-six fertile couples was described. The two groups were found to be comparable in terms of certain variables such as age, race, income, education, and religion. Details were given relative to the inter viewers and the interviewing procedure, including techniques of enlisting subjects and developing rapport. 109 A description was made of the three instruments utilized in the study: the Minnesota Multiphasic Person ality Inventory (MMPI), the Marriage Questionnaire, and the Fertility Study Psychological Data Sheet. The scales and indices which were derived from these instruments and the techniques for scoring were then presented. The letter included a complete rationale and description of the technique developed, for purposes of this study, of scoring the MMPI. In conclusion, the statistical procedures were discussed. Acknowledgment was given to the Western Data Processing Center for use of its facilities, and the ways in which the facilities were utilized for purposes of this study were explained. » CHAPTER IV RESULTS This chapter presents the statistical findings of the study followed by an examination of the six hypotheses postulated in Chapter I. The hypotheses are reviewed and discussed in accordance with the implications of the experimental results. Statistical Findings Inasmuch as comparisons of averages or means may be deceptive, increased attention has been accorded by research workers to standard deviations, distribution curves and other characteristics of data. This study required even more refinement of analytical procedures due to the inherent defensiveness of the infertile group in responding to the questions. The dynamics of infertil ity seemed to cause distortion in some of the scales which could only be circumvented by devising more sensitive approaches to the analysis. The experimental and control groups were divided into three subgroups: husbands, wives, and couples. This is in accord with the fact that infertility may be attributable to malfunctioning on the part of the husband 110 Ill or the wife or to the marital couple as an interacting unit. Comparison of the sexual relationship measurements o£ husbands and wives in fertile and infertile marriages Five indices were devised to measure sexual relationship factors in marriage. Three of these were scales: the "Sexual Adjustment Scale," the "Sexual Responsiveness Scale," and the "Sexual Attitudes Scale." Table 13 gives the means, the Kolmogorov-Smirov statistic, the chi-square approximation and the significance levels for these scales for the three subgroups: husbands, wives, and couples. No significant differences were found between the fertile and infertile groups for any of these sexual relationship scores when they were examined as simple distributions. Further examination of the "Sexual Adjustment" and "Sexual Attitudes" scales did not produce anything significant either. When the Sexual Responsiveness scores were divided into "stronger" and "weaker" groups, however, in the form of a contingency table, a significant difference was revealed. As shown in Table 14, of the 46 fertile husbands, 34 fell in the strong responsiveness group and only 26 of the 49 infertile husbands rated comparably. This represents a significant difference statistically with a chi-square of 4.43. A chi-square of 3.34 is 1X2 TABLE 13 DIFFERENCES BETWEEN THE SEXUAL RELATIONSHIP SCORES OF FERTILE AND INFERTILE GROUPS Sexual Relation ship Scale Mean of Fertile Group (N-46) Mean of Infertile Group (N-49) Kolmogorov- Smirnov Statistic Chi- Square Approx.® Signif icance Level Husbands Adjustment 35.30 36.55 -21.30 3.33 .20 Responsive ness 7.20 5.93 20.S3 4.03 .20 Attitudes 20.13 20.06 5.72 .31 .90 Wives Adjustment 34. 28 36.70 -19.57 3.52 .20 Responsive ness 3.24 3.54 -15.35 2.36 .40 Attitudes 19.35 13.94 7.19 .49 .SO Couples Adjustment 70.09 72.97 -19.35 3.20 .30 Responsive ness 15.43 14.52 13.03 3.05 .30 Attitudes 39.43 39.00 S.12 .63 .30 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic. It is regarded as a "nominal" chi-square statistic. Cf. p. 107. 113 significant at the .05 level of confidence. TABLE 14 HUSBANDS OF FERTILE AND INFERTILE MARRIAGES CLASSIFIED ACCORDING TO INTENSITY OF SEXUAL RESPONSIVENESS Sexual Responsiveness Scores Fertile Infertile Number Percentage Number Percentage Less than +5 12 26 23 47 +5 or over 34 74 26 53 46 100 49 100 The final index of sexual relationship was an analysis of the husbands1 sexual responsiveness or "potency" as determined by the husbands1 answers to item number 58 on the Marriage Questionnaire relative to the intensity of sex interest in comparison with the mates1 sexual responsiveness. The resulting contingency table (Table 15) showed that 39.1 per cent of the fertile husbands compared with 20.4 per cent of the infertile husbands indicated the strength of their sex interest as being greater than their wives1. This was significantly different at the .05 level with a chi-square of 4.00 and a critical ratio of 1.99. This evaluation was confirmed by the wives. Of the fertile wives, 34.3 per cent felt 114 their husbands had greater sex interest than they did as contrasted with 24.5 per cent of the infertile wives. TABLE 15 DIFFERENCES IN ANSWERS BY HUSBANDS OF FERTILE AND INFERTILE MARRIAGES TO QUESTION RELATIVE TO STRENGTH OF SEX DRIVE Strength of Sex Interest Compared With Mate Fertile Infertile Number Percentage ft umber Percentage Much greater or very much greater 16 39.1 10 20.4 About the same 27 5*3.7 36 77.6 Much less or very much less 1 2.2 1 2.0 46 100.0 49 100.0 Comparison of the MMPI scores of husbands and wives in fertile and infertile' marriages’ Again, comparisons of the various MMPI scale distributions of scores as shown in Tables 16, 17, and IS were made for the three subgroups: husbands, wives, and couples. A significant difference at the .025 level of confidence was found between the husbands of fertile marriages and those of infertile marriages on the Neuroticism scale. It was in an unexpected direction, 115 TABLE 16 DIFFERENCES BETWEEN THE MMPI SCORES OF HUSBANDS OF FERTILE AND INFERTILE MARRIAGES MMPI Scale Mean of Fertile Group (H-46) Mean of Infertile Group (N-49) Kolmogorov- Smirnov Statistic Chi- Square Approx.* Signif icance Level L 3.61 3.32 -3.47 .66 .80 F 4*00 3.51 11.40 1.23 .60 K 15*15 16.57 -16.55 2.60 .30 Hs 52.93 49.37 13.06 3.09 .30 D 56.20 54.22 11.62 1.26 .60 Hy 56.4S 56.04 10.S3 1.11 .60 Pd 55*57 55.31 -5.90 .33 .90 Mf 57.61 59.3S -18.32 3.19 .30 Pa 52.22 51.63 9.72 .90 .70 Pt 51.67 52.53 -14.64 2.03 .40 Sc 50.07 52.63 -18.94 3.41 .20 Ma 53.33 53.27 11.71 1.30 .60 M.A.S. 7.33 6.31 16.42 2. 56 .30 Ne 4.54 3.27 29.19 8.09 .025 Es 32.35 32.16 9.63 .88 .70 Do 13*33 13.37 9.94 .94 .70 De 14.13 13.35 9.67 .89 .70 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic and is regarded as a "nominal” chi-square statistic. 116 TABLE 17 DIFFERENCES BETWEEN THE MMPI SCORES OF WIVES OF FERTILE AND INFERTILE MARRIAGES MMPI Scale Mean of Fertile Group (N-46) Mean of Infertile Group (N-49) Kolmogorov- Smirnov Statistic Chi- Square Approx.a Signif icance Level L 3.^7 4.55 -17.30 2.64 .30 F 3.76 3.57 13.96 I.65 .40 K 13..43 15.04 -21.76 4.50 .20 Hs 50.70 49.71 15.04 2.15 .40 D 53.70 54.20 -14.73 2.06 .40 Hy 54.15 55.92 -14.37 1.96 .40 Pd 51.76 52.62 -6.12 .63 .60 Mf 47.70 47.71 -7.36 .51 .60 Pa 54.76 52.94 16.94 3.41 .20 Pt 51.22 51.24 12.20 1.41 .50 Sc 50.93 50.39 12.20 1.41 .50 Ma 52.26 50.10 15.66 2.33 .40 M.A.S. 10.30 9.06 17.30 2.64 .30 Ne 5.67 4.76 24.27 5.59 .10 Es 29.22 29.39 -10.25 1.00 .70 Do 13.20 13.37 -12.60 1.51 .50 De 16.00 15.51 21.25 4.29 .20 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic, and is regarded as a "nominal" chi-square statistic. 117 TABLE 13 DIFFERENCES BETWEEN THE MMPI SCORES OF COUPLES OF FERTILE AND INFERTILE MARRIAGES MMPI Scale Mean of Fertile Group (N-46) Mean of Infertile Group (N-49) Kolmogorov- Smirnov Statistic Chi- Square Approx.a Signif icance Level L 7.43 3.37 -12.32 1.56 .50 F 7.73 7.03 16.10 2.46 .30 K 23.59 31.61 -23.03 5.03 .10 Hs 53.63 49.03 22.27 4.71 .10 D 59.35 53.43 10.96 1.14 .60 Hy 60.63 61.96 -22.23 4.69 .10 Pd 57.33 53.12 -12.33 1.44 .50 Mf 55.30 57.63 -14.24 1.92 .40 Pa 56.93 54.76 13.35 1.69 .50 Pt 52.39 53.73 -23.34 5.17 .10 Sc 51.00 53.02 -21.16 4.25 .20 Ma 55.57 53.37 14.29 1.94 .40 M.A.S. 17.63 15.39 19.61 3.65 .20 Ne 10.41 3.04 19.96 3.73 .20 Es 61.57 61.55 13.34 1.32 .50 Do 27.02 26.73 -10.33 1.11 .60 De 32.13 23.36 13.94 3.41 .20 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic, and is regarded as a "nominal" chi-square statistic. 116 however, because the Neuroticism scores were higher for the fertile group than for the infertile. The difference between the means for a number of the comparisons seemed to be verging on the *05 level of significance so the critical ratio test of significance was applied as an additional check on the chi-square results. The only scale which revealed a difference approaching the critical ratio of 1.96 required for a .05 level of confidence was that of 1.81 for the differ ences between the means on the K score for the couples. By taking a different approach to the K score analysis, however, through use of a contingency table, it was determined that there was a significant difference between the fertile and infertile groups in the number of K scores equal to or greater than 20 for both wives and couples. In fact, the differences between the number of K's for the wives was significant at the .01 level of confidence. A raw score of more than 19 on K is generally regarded as indicative of excessive defensiveness. The same type of analysis was used with the validity scales L and F, for which scores greater than 6 and 16 respectively are considered as excessive devia tions. A significant difference was found between the fertile and infertile wives for the number of L scores greater than 6. Four of the fertile and 12 of the infertile wives had such scores and the critical ratio 119 TABLE 19 DIFFERENCES BETWEEN FERTILE AND INFERTILE GROUPS ACCORDING TO NUMBER OF K SCORES GREATER THAN 19 Subgroup Fertile Infertile Critical Ratio Signif icance Level Husbands 11 17 1.17 Not sig. Wives 4 16 2.67 .01 Couples 14 25 2.04 .05 was 2.05, which is significant at the .05 level of confi dence. Cuadra states that: A person showing even moderate elevation on the L score will over-conventionalize his own position. This seems to confirm the impression of most clinical workers that the scale does not merely measure "lying” but rather a rigidity of personality and lack of insight. (16:253) When high, both L and K are indicators of one or another form of defensiveness so that, in a sense these are clinical scales as well as validity scales. The results of the "configural analysis"* of the profiles for the 95 husbands, showing only the comparisons of the Schizophrenia Scale with all others, are shown in Table 20. All other scales were compared in the same way but the Schizophrenia Scale for the husbands was chosen for illustration because it contained more scale pairs ♦Cf. p. 107 120 characterizing the infertile group. TABLE 20 COMPARISONS OF RANKS OF THE Sc SCALE WITH OTHER MMPI SCALES FOR HUSBANDS OF FERTILE AND INFERTILE MARRIAGES Scale Pairs Infertile Fertile Differences + - - + - - + - - Sc-Hs 31 16 2 17 27 2 14a -llb 0 Sc-D 21 26 2 16 27 3 5 - 1 -1 Sc-Hy 13 35 1 15 23 3 -2 7 -2 Sc-Pd 24 24 1 9 35 2 15b -llb -1 Sc-Mf 15 32 2 13 33 0 2 - 1 2 Sc-Pa 23 23 3 17 27 2 6 - 4 1 Sc-Pt 26 21 2 16 29 1 10 - 3 1 Sc-Ma 24 25 0 13 26 2 6 - 1 -2 Significant at the .05 level of confidence. ^Significant at the .01 level of confidence. "Configural analysis" obtained from the two groups of fertiles and infertiles, revealed four scale pairs which characterized them in both the plus-plus and the minus-minus direction at a significant level. This occurred in the comparisons of the scales for the two groups of husbands. Although Sullivan and Welsh (102:310) 121 accept as "signs" only those differences which separate i two groups in both the plus-plus and minus-minus direc tions at the .05 level, it seemed worthwhile for purposes of this study also to note those which were separated in only one direction at the .05 level. The scale pairs which characterize the profiles of the infertile husbands and wives in one or both directions at a significant level are presented in Table 21. Since a critical ratio of 1.96 is significant at the .05 level and one of 2.5& at the .01 level, four of those for the husbands are at a significant level of confidence in both directions for purposes of this study. The meaning of these relationships can best be explained by taking one of them as an illustration. For example, the comparison of the Sc and Hs scales showed that there were thirty-one infertile as compared with seventeen fertile husbands who had a higher score on Sc than on Hs and there were sixteen infertile compared with twenty-seven fertile husbands obtaining a lower score on Mf than on D. The two scales for the remaining two husbands were equal. These differences resulted in critical ratios of 2.57 and 2.60 respectively, as shown. For the wives, there were a number of comparisons which were significant in one of the directions or were between a .05 and .10 level of significance. Another meaningful approach to the MMPI results, 122 TABLE 21 SCALE PAIRS WHICH CHARACTERIZE THE MMPI PROFILES OF INFERTILE HUSBANDS IN PLUS-PLUS AND MINUS-MINUS DIRECTIONS WITH CRITICAL RATIOS OF THE DIFFERENCE Critical Ratio Scale Pairs Plus-Plus Minus-Minus Direction Direction Husbands Sc higher than Hs 2. 57a 2.60b Sc higher than Pd 3.01b 2.73b Sc higher than Pt l.S0c 1.94a Hy higher than Hs 2.40a 3,00b Mf higher than D 2.19a 2.50a Mf higher than Hy 1.72° l.S3c Mf higher than Pa 1.73c 1.36 Wives Hy higher than Hs 1.63c .40 D higher than Pa 1.27 1.96a D higher than Hs 1.74c 1.33 aA critical ratio of 1.96 is significant at .05 level. bA critical ratio of 2.5B is significant at .01 level. cThis is between a significance level of .05 and .10. 123 as suggested by Caldwell,* is by comparison of the high points in the groups. Table 22 shows the distribution of high points obtained on the MMPI scales for each of the fertile and infertile groups. Although no significant TABLE 22 NUMBER OF HUSBANDS AND WIVES OF FERTILE AND INFERTILE MARRIAGES OBTAINING SPECIFIED HIGH POINTS ON MMPI MMPI Scale Husbands Wives Fertile Infertile Fertile Infertile N«46 N-49 - N-46 N-49 Hs 5 1 3 • • D 11 7 4 9 Hy 7 11 8 13 Pd 8 7 9 8 Pa 3 If 11 6 Pt 1 3 6 5 Sc 1 4 2 3 Ma . 10 12 3 5 differences were found between the two groups at the .05 level of confidence, it was interesting to compare the number of wives obtaining high points on three of the ♦Personal conversation of the investigator with Alex Caldwell, Ph.D., of the Neuropsychiatric Institute at the UCLA Medical Center, October 11, 1961. 124 scales: 9 infertiles as compared with 4 fertiles had "depression” as the highest point, 13 infertiles but only 3 fertiles had "hysteria" as the highest, and 11 fertiles had "paranoia” in comparison with 6 infertiles. Among the husbands, 11 infertiles and 7 fertiles obtained their high point on "hysteria," but the reversal was true for "depression." The best technique for comparing personality configurations of individuals who have taken the MMPI is not by single traits but it is rather by converting the T scores of all the individual records to a coding system (36:13) so that the investigator can tell at a glance the most prominent trait or traits, those which are deviant, and those which are within normal range. Inasmuch as the coded profiles for the MMPI are so important for inter preting individual protocols as well as for identifying patterns among the clinical scores for groups, a complete list of the coded profiles for the 190 individuals divided by fertility status and sex is included in Appendix III. The reason for including these profiles is the hope that these may be helpful to future investigators of infertil ity who utilize the MMPI by enabling them to add the MMPI results of the present study to those of their samples. Judges were not used in this study because the value of such an approach is questioned by so many experts in the field of MMPI test interpretation. According to 125 Sullivan and Welsh (102:303) one problem in the use of judges is the wide variation in their ability to sort protocols, and the fact that in many studies, judges have not been able to sort profiles at better than a chance level. Caldwell* recommended the use of statistics and other analytic approaches rather than judges. Comparison of the marital acT ustment scores of husbands ana wives in fertile and infertile marriages No significant differences were found to exist between the marital-adjustment test scores for husbands, wives, or couples. In fact, the direction of the differ ences was higher scores for the infertile groups. However, the degree of defensiveness manifested in the L and K scores of the infertiles makes suspect the highly visual items of the Locke Marital Adjustment test as a valid measure of marital adjustment between these two groups. As a matter of fact, with a range in scores between 39 and 123, twenty-two of the infertile wives as compared with thirteen of the fertile wives had scores of 70 or above. Similarly among the husbands who had the same range of scores, the infertile group had seventeen scores of 70 and above as compared with eight of the fertile group. Undoubtedly, the infertile individuals had more of ♦Personal conversation of the investigator with Alex Caldwell, Ph.D., October 11, 1961. 126 a tendency to rationalize or actually tell a falsehood in answer to the questions on the Marriage Questionnaire because they felt they had more at stake. They were eager to have children and they might have been reluctant to present a picture of marital maladjustment which would prejudice the infertility clinic as to their desirability as parents. A comparison of the differences between husband- wife marital-adjustment scores for the two groups did not yield anything significant. Twenty-three of the infertile and twenty-five of the fertile wives had scores greater than their husbands, twenty-three of the infertile and nineteen of the fertile wives had scores less than their husbands1 and the remainder of three and two respectively had equal scores. The extent of these differences algebraically was +299 and -235 score points for the infertile wives as compared to +254 and -223 for the fertile wives. Averages of +6.1 and -4.3 for the differ ences were found for the infertiles and +5.5 and -4.3 for the fertiles. Comparison of childhood relation ship scores with mothers ancf fathers and the psychological background scores of hus bands and wives Inasmuch as a more favorable relationship with the parent was indicated by a higher score, the infertile 127 groups of husbands and wives reported a better relation ship with their fathers and mothers than the fertile groups. In fact, the difference between the father relationship scores of the fertile and infertile husbands was significantly higher for the infertile group, as shown in Table 23. TABLE 23 DIFFERENCES BETWEEN THE FATHER AND MOTHER RELATIONSHIP SCORES OF FERTILE AND INFERTILE GROUPS Mean of Mean of Kolmogorov- Chi- Signif Scale Fertile Infertile Smirnov Square icance Group Group Statistic Approx.a Level Husbands Father rela tionship 17.67 22.66 > -30.00 6.72 .05 Mother rela tionship 22.50 24.SB -17.10 2.16 .40 Wives Father rela tionship 15.52 21.79 -25.26 4.29 .20 Mother rela tionship 19.41 22.13 -24.19 4.26 .20 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic. It is regarded as a "nominal" chi-square statistic. 128 A more favorable childhood was reported by the infertile groups as shown by the comparison of the "Psycho logical Background" scales in Table 24. For this scale, the higher scores represented a more adverse situation. TABLE 24 DIFFERENCES BETWEEN THE PSYCHOLOGICAL BACKGROUND SCALES OF FERTILE AND INFERTILE GROUPS Subgroup Mean of Fertile Group Mean of Infertile Group Kolmogorov- Smirnov Statistic Chi- Square Approx.a Signif icance Level Husbands 11.61 7.72 24.17 5.19 .10 Wives 13.28 9.30 19.57 3.52 .20 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic. It is regarded as a "nominal" chi-square statistic. Comparison of the husband-wife dominance patterns in fertile and infertile marriages The MMPI scores for Dominance (Do) included in the tables on pages 115, 116, and 117 did not show any signif icant differences for any of the subgroups. The other approach for determining dominance, however, by analyzing the answers to question number 36 in the Marriage * Questionnaire was more productive. In the first part of Table 25, "Couple Evaluation," the data was categorized according to which was the dominant mate only if both 129 TABLE 25 DIFFERENCES IN THE HUSBAND-WIFE DOMINANCE PATTERNS OF FERTILE AND INFERTILE MARRIAGES Dominance Number of Number of Fertiles Infertiles Critical Pattern N-46 N-49 Ratio Couples* Evaluation Husband dominated 14 11 Not sig. Wife dominated 7 15 1.7Sa Democratic 5 13 1.95b Disagreement 20 10 2.43b Husbands* Evaluation Husband dominated 23 16 1.72a Wife dominated 12 IS Not sig. Democratic 11 15 Not sig. Wives* Evaluation Husband dominated 19 15 Not sig. Wife dominated 16 20 Not sig. Democratic 11 14 Not sig. aThis is significant at a level between .10 and .0$. bA critical ratio of 1.96 is significant at the .05 level. 130 husband and wife agreed. The remainder were placed in the category "disagreement." Fifteen infertile couples compared with seven fertile couples rated the wife as dominant in more areas than the husband, eleven infertile and fourteen fertile couples rated the husband as more dominant, and democratic marriages were indicated by thirteen infertile and five fertile couples. Finally, in only ten of the infertile marriages but in twenty of the fertile marriages there was disagreement as to the pattern of dominance in the marriage. This proportion represents a significant difference at approximately the .01 level of confidence between the number of fertiles and infertiles disagreeing as to dominance. As indicated in Table 25, the differences between the two groups for the category "democratic" is at a significance level of .05 for all practical purposes, and "wife dominated" is between a .05 and .10 level of confidence. In the second and third parts of Table 25, the dominance pattern is categorized according to the frame of reference of each mate. For instance, if the husband thought he was more dominant but his wife felt the marriage was democratic, in the table showing the husband's evalua tion, this was placed in the category "husband-dominated" whereas in the part showing the wife's evaluation, it was placed in the "democratic" category. Among the fertile group, more husbands and wives individually rated their 131 marriages as being husband-dominated than wife-dominated. Conversely, the infertile group of husbands and wives rated more marriages as being wife-dominated. The evalua tion of the husbands in which twenty-three fertile husbands but only sixteen infertiles rated themselves as dominant and twelve fertile husbands as compared with eighteen infertiles rated their wives as dominant was significant at a level of confidence between .05 and .10. The critical ratio was 1.72. Relationship between measurements of personality, marital adjustment, and sexual relationship within fertile and infertile groups' Inasmuch as there were numerous measurements involved in the study— eighteen measures of personality, a marital adjustment index, and three scales related to the sexual relationship— there were all gradations of correlation. Table 26 shows the coefficients of correla tion for the couples, wives, and husbands of the fertile and infertile groups in all instances where there was a coefficient of correlation of ±.40 or more between two variables for any one of the six subgroups. This does not include relationships between MMPI scales because there were many of these with moderate or high correlations. There is extensive literature on this aspect of the MMPI scales. The one MMPI scale compared with other MMPI scales is the one devised for purposes of this study, the TABLE 26 COEFFICIENTS OF CORRELATIONS BETWEEN MEASUREMENTS OF PERSONALITY, MARITAL ADJUSTMENT, AND SEXUAL RELATIONSHIP WITHIN FERTILE AND INFERTILE GROUPS Scale Comparisons Fertile Group Infertile Group Husbands Wives Couples Husbands Wives Couples M. Adj.a-Sex Adj. .30 .30 .35 .56 ;49 .57 M. Adj.-Anxiety -.IS -.OS -.05 -.36 -.45 -.37 M. Adj.-S.A.b .44 .21 .33 .23 .27 .45 M. Adj.-Scc -.43 -.IS -.36 -.20 -.31 -.09 M. Adj.-Pdc -.34 -.14 -.40 -.20 -.25 -.16 M. Adj.-Ptc -.44 -.33 -.43 .01 -.31 -.13 Sex Adj„-S.R.d -.39 .51 .16 -.16 .35 .23 Sex Adj.-Dec -.23 -.55 -.43 -.07 -.03 -.10 Sex Adj.-M.A.S.C -.25 -.60 -.54 -.17 -.07 -.25 Sex Adj.-Nec -.24 -.44 -.42 .02 -.06 -•27 C Sex- Adj.-S.A.c .37 .51 .51 .25 .17 .23 TABLE 26— Continued Scale Comparisons Fertile Group Infertile Group Husbands Wives Couples Husbands Wives Couples Sex Adj.-Dc -.34 -.25 -.41 .10 -.10 1 . 0 Sex Adj.-Anxiety -.20 0 r * \ • 1 -.26 -.40 -.43 -.46 M.A.S.-S.R. .29 -.20 -.02 -.02 -.42 to H • 1 S.A.-Esc .37 .29 .36 .33 .33 .46 S.A.-Doc .31 .43 .45 .27 .37 to V Hsc-S.R. .17 .004 .14 -.35 to • 1 -.41 Dc-S.A. t * 0 -.21 -.39 -.09 -.52 -.24 PaC-S.R. -.16 .16 .00 -.31 -.29 -.45 Abbreviation for Marital Adjustment. ^Abbreviation for Sexual Attitudes. CMMPI scale. H* j \ j J Abbreviation for Sexual Responsiveness. ^ 134 "Sexual Attitudes" scale. Some of the scales which were shown to be nega tively correlated were "positively" related, i.e., a high score is indicative of a favorable direction for some of the scales whereas the reverse is true for other scales. "Desirability" increases with an increase in the score for the following scales: the Marital Adjustment Index, the Father Relationship Scale, the Mother Relationship Scale, the Sexual Adjustment Scale, the Sexual Responsiveness Scale, the Sexual Attitudes Scale, and the MMPI Ego Strength Scale. The MMPI scales for measuring Dominance and Dependency are purported to measure degrees of each of these traits so that psychologically either an extremely low or extremely high score would be undesirable. An inverse relationship exists between desirability and size of score for: the remaining MMPI scales--Hs, D, Hy, Pd, Mf, Pa, Pt, Sc, Ma, M.A.S., Ne, L, F, and K; the Anxiety Scale (based on the Psychological Data Sheet); and the Psychological Background scale. A correlation of ±.40 to ±.70 is regarded as "moderate" and is indicative of a substantial relationship between two variables. A moderate correlation in this study between two variables among the six subgroupings of fertile and infertile occurred in diversified and erratic patterns. Inspection of Table 26 discloses that there were 135 very few instances in which the correlations between the same two variables for both the fertile and infertile groups were consistent. In other instances, of course, there were actual contradictions with positive and nega tive correlations appearing among the subgroups for the same two variables. In two instances, there was a substantial relation ship between two variables for all of the infertile sub groups. The relationship between the Marital Adjustment Scale and the Sexual Adjustment Scale was one example of this with the rfs for the infertile groups of husbands, wives, and couples being .56, .59, and .57, and for the fertile group, .30, .30, and .35, respectively. Despite the fact that these are all positive correlations, those for the fertile group represented only low correlations as compared with the substantial relationship evidenced by the infertile groups. The Sexual Adjustment Scale also showed a consistent correlation with a low Anxiety score as determined by the Psychological Data Sheet for all of the infertile groups. This relationship was not as pronounced in the fertile subgroups. For the infertile groups, the rfs were greater than .35 between the Marital Adjustment Index and low Anxiety score, and between the Sexual Responsiveness score and a low MMPI Hypochondriasis score. For the fertile groups, the Marital Adjustment scores correlated .35 or more with low Psychasthenia scores. Coefficients of correlation amounting to ±.40 or more were revealed for 11 wives (6 fertile and 5 infertile) and for 5 husbands (3 fertile and 2 infertile). It is particularly interesting to note the correlations which occurred between the sexual relationship scores and certain MMPI scores for the fertile wives. A favorable score on the Sexual Adjustment Scale had a substantial relationship with low scores on the MMPI scales for Dependency, Manifest Anxiety, and Neuroticism and with favorable scores on the two other scales measuring sexual relationship, i.e., Sexual Responsiveness and Sexual Attitudes. In addition, a favorable Sexual Attitudes score had a substantial relationship with a higher MMPI Dominance Scale. The rfs for the infertile group of wives were not significant for any of these. In fact, the ones having to do with Dependency, Manifest Anxiety and Neuroticism had r’s of .07 or less, and those in which two aspects of the sexual relationship were compared, i.e., Sexual Adjustment with Sexual Responsiveness and Sexual Adjustment with Sexual Attitudes, had r’s of .35 and .17, respectively. By contrast, for the infertile wives, different scales had significant correlations with sexual relation ship measurements. There was only one of these for each of the sexual relationship measurements. The Sexual 137 Adjustment scores showed a substantial relationship with a low Anxiety score as determined by the Psychological Data Sheet not only for the infertile wives but for the husband and couple subgroups. An example of an isolated high correlation was one of -.52 between the Sexual Attitude Scale and the MMPI Depressive Scale for the infertile wives. In comparison, there was a correlation of -.21 for the fertile wives, -.09 for the infertile husbands, and -.30 for the fertile husbands. In other * words, this means there was a closer relationship between the scale measuring good sexual attitudes and a low depressive score for the infertile wives than for any other group. The infertile wives also received the highest correlation between a favorable Sexual Responsive ness score and a low Manifest Anxiety score on the MMPI: -.42 compared with -.02 for the infertile husbands and .29 and -.20 for the fertile husbands and wives respec tively. The fertile husbands had several substantial relationships between Marital Adjustment scores and other scores. A favorable Marital Adjustment score had r*s of .40 or greater with a positive Sexual Attitudes score and low scores on the MMPI Schizophrenia and Psychasthenia scales. None of these relationships applied to the infertile husbands. Despite the fact that the differences between the 13S fertile and infertile subgroups for some of these coeffi cients of correlation seem to be large, very few of them have critical ratios of 1.96 or more which is necessary for significance at the .05 level of confidence. The critical ratios which met or almost met this criterion between the coefficients of correlation for the wives were: Sexual Adjustment scores with Dependency scores, 2.73; Sexual Adjustment scores with M.A.S. scores, 2.92; Sexual Adjustment scores with Neuroticism scores, 1.93; and Marital Adjustment scores with Anxiety scores, 1.&9. This was true for the differences between the fertile and infertile husbands for the r/s of the Marital Adjustment scores and the Psychasthenia scores with a critical ratio of 2.17. Although the rfs for the couples have also been shown in Table 26, an attempt has not been made to interpret them because of the questionable nature of their validity. An interpretation of the r1s for husbands and wives seems much more meaningful, especially because of the erratic nature in which the correlations of signifi cance occur among these subgroups. The scales relative to reported mother relation ship, father relationship, and psychological background during childhood are not included in Table 26 for two reasons: the major objectives of the study was to compare marital adjustment, sexual adjustment, and personality 139 measurements; and these scales are especially suspect by reason of their derivation without adequate validating procedures and because of the obvious effect on them of the infertile individuals1 extreme defensiveness. They are presented in Table 27, however, in order to assure a complete presentation of r1 a of .40 or greater between the variables. All of the fertile subgroups as well as the infertile wives had coefficients of correlation showing a TABLE 27 COEFFICIENTS OF CORRELATION BETWEEN MEASUREMENTS OF CHILDHOOD ADJUSTMENT AND OTHER SPECIFIED SCALES WITHIN FERTILE AND INFERTILE GROUPS Fertile Infertile Scale .Comparisons Hus bands Wives Cou ples Hus bands Wives Cou ples Mth. Rel.-Fth. Rel.® -.10 .10 .07 .50 .27 .32 Mth. Rel.-Hsb -.2S .20 .21 -.07 -.41 .04 Mth. Rel.-Psych. Bkgrd.c -.22 -.24 -.32 -.22 -.45 — • 4a Psych. Bkgrd.-Dob -.15 -.32 —. 46 -.21 -.35 -.44 Psych. Bkgrd.- Fth. Rel. -.49 -.47 -.50 -.13 —. 4S -.33 Abbreviations for Mother Relationship and Father Relationship. bAn MMPI Scale. Abbreviation for Psychological Background Scale. 140 substantial relationship between the Father Relationship scores and the Psychological Background scores, indicating that those reporting a good childhood relationship with their fathers also reported a favorable psychological background during childhood. The infertile wives showed a substantial relationship between a reported good mother relationship and two other scales— a favorable Hypochon driasis Scale on the MMPI and a favorable Psychological Background Scale; and the infertile husbands between a reportedly good mother and father relationship during childhood. Analysis of anxiety among husbands and wives oT fertile and infertile* marriage’ s Anxiety, especially on the part of the wife, has long been regarded as a prime cause of infertility by physicians, psychologists, marriage counselors and the laity. For purposes of this study, an attempt was made to determine anxiety by the use of various indices. Although the Manifest Anxiety Scale was not signif icantly different between any of the experimental and control groups, the direction of the differences was toward higher Manifest Anxiety scores for the fertile groups. For the Anxiety Scale based on the answers to questions 10, 12, 14, 16, and IS on page 6 of the Psychological Data Sheet, the scores for the fertile wives 141 and couples were actually significantly higher than the respective infertile groups. Likewise, the MMPI Depression Scale scores did not yield any significant differences. An analysis of the questions relative to anxiety concerning the infertility, however, revealed a consider able amount of specificity of anxiety among the infertile wives. In answer to the latter half of question 4 on the Psychological Data Sheet, "How anxious are you about becoming pregnant?" thirty-two of the forty-seven infertile wives who completed the Psychological Data Sheet answered "very," "extremely," or with an equally strong adjective, and ten responded "moderately," "somewhat," "slightly," or in similar terms. Only fourteen husbands answered the question: nine of these tended toward intense anxiety and the other five toward little anxiety. The results obtained from the weighted scale which was based on the answers to the first seven questions of the Psychological Data Sheet were meaningful. For the forty-seven infertile wives, the scores ranged between 4 and 33 with a mean of 11.Si. The score of 33 was an isolated instance with only five scores falling between 20-25 and the remainder under 20. Thirty-one of the forty-seven scores were equal to or more than 9 which corresponds with the analysis of the answers to the specific question about anxiety. Obviously, the infertile groups could not be compared with the fertiles on the Data 142 Sheet answers to the questions on the first page because the questions were based specifically on the infertile condition. Other evidences of anxiety on the part of the infertile wives appeared in a comparison of their M.A.S. scores with those of their husbands. These are described in the following section. Comparison of husbands* scores witn wives’ scores in fertile" and infertile marriages Some statistics which were obtained on the differences between mates in the two main groups of fertile and infertile revealed some interesting relation ships which are presented in Table 2S. There was a significant difference at the .025 level between the scores for the infertile wives and husbands on the MMPI scale for Manifest Anxiety. This indicated that the anxiety level as measured by this scale was significantly higher for the infertile wives than for their husbands. Another scale which showed a high level of significance between the infertile groups was the MMPI Ego Strength Scale. The husbands1 scores exceeded their wives’ to such an extent that a significance level of .005 was recorded. For the fertile group, the Ego Strength Scale showed an even higher degree of significance— the husbands’ scores being significantly higher at the .0005 143 level, but the M.A.S. scores were not significantly different for the mates. TABLE 23 DIFFERENCES BETWEEN SPECIFIED SCORES OF HUSBANDS AND WIVES IN FERTILE AND INFERTILE MARRIAGES Husbands1 Wives1 Kolmogorov- Chi- Signif Scale Smirnov Square icance Mean Mean Statistic Approx.® Level Fertile Group Sexual respon siveness 7.20 3.24 -23.91 5.26 .10 M.A.S. 7.33 10.30 -21.74 4.35 .20 Es 32.35 29.22 43.43 17.39 .0005 D 56.20 53.70 30.43 3.52 .025 Anxiety 1.91 3.26 -39.13 14.09 .001 ' Infertile Group Sexual respon siveness 5.93 3.54 -47.92 22.04 .0005 M.A.S. 6.31 9.03 -30.61 9.13 .025 Es 32.16 29.39 36.73 13.22 .005 D 54.22 54.20 14.29 2.00 .40 Anxiety 1.76 2.49 -20.00 3.43 .20 aThis represents two degrees of freedom because it is based on the Kolmogorov-Smirnov statistic, and is regarded as a "nominal* chi-square statistic. 144 The difference between the scores obtained by the infertile husbands and wives on the Sexual Responsiveness Scale was significant at the .005 level with the wives having the higher score. For the fertile groups, the wives* scores were also higher than their husbands* but only at the .10 level of significance. An unexpected significant difference appeared between the MMPI Depression scores for the fertile groups, the husbands having higher scores than the wives at the .025 level. Conversely, the fertile wives had higher scores on the Anxiety Scale derived from page 6 of the Psychological Data Sheet than their husbands with a .001 significance level. Although there was not a significant difference between the husbands and wives of the infertile group on the Depression Scale and the Anxiety Scale the differences were in the same direction as those for the fertile group with the wives having higher scores for Anxiety and the husbands for Depression. Examination of the Hypotheses Hypothesis I "The sexual relationship reported by husbands and wives in fertile marriages is better than that reported by those in infertile marriages.** Inasmuch as "sexual relationship" seemed to be a very generalized concept, various factors which might comprise this concept were U 5 considered and analyzed. "Sexual responsiveness" on the part of the male is often referred to as "potency." Two of the techniques which were devised for determining sexual "potency" or "libido" for the husbands revealed that a significantly greater number of fertile than infertile husbands fell in a "strong" responsiveness group sexually. First, as a result of dividing the Sexual Responsiveness scores into "weak" and "strong" responsive ness, it was found that a significantly higher number of infertile than fertile husbands fell into the "weak" responsiveness group. Second, in answering question number fifty-eight on the Marriage Questionnaire, a significantly larger percentage of fertile husbands than infertile husbands evaluated the strength of their sex interest as being greater than that of their wives. The wives1 answers to the question confirmed this finding. Another finding which was of interest in the context of sexual relationship resulted from the configural analysis of the MMPI, in which the Interest (Mf) Scale was higher than the Depression (D) Scale for a significantly greater number of infertile than fertile husbands. This means that the infertile husbands had more of a tendency to have basic interest patterns of a feminine nature than a tendency toward depressiveness in comparison with the fertile husbands. A comparison of the scores obtained by husbands 146 and wives of both groups also supports the hypothesis that infertile husbands have a weaker libido. The significant difference at the .005 level between the Sexual Respon siveness scores for the infertile husbands and wives was considerably higher than the .10 level of significance between the same scores for the fertile husbands and wives. Although a significant difference was not demon strated between the scores for fertile and infertile wives on any of the sexual relationship scales, examination of the questionnaires and the personal interview material * disclosed a great deal of dissatisfaction with the sexual relationship among the wives of infertile marriages in contrast to those of the fertile marriages. Whereas the fertile wives seemed to have a minimum of complaints, even to the extent of 40 of the 46 reporting orgasms all or part of the time, 23 (or nearly one-half) of the wives of infertile marriages reported such difficulties as premature ejaculation and loss of erection on the part of their husbands, fatigue, poor sexual techniques, extramarital affairs and other indications of poor adjustment. It should also be remembered that 9 couples of the infertile group were not interviewed personally; very possibly there were some among these who would have had complaints. Although on a subjective level, this comparison of complaints between the wives of the two groups must be considered. In fact, because of the extreme defensiveness 147 manifested by the infertile group in answering the ques tions on the questionnaires, these subjective observations may have more validity than the more "objective" scales. The first analysis of the sexual relationship scores as indicated in Table 13 proved to be inconclusive. However, when four-fold contingency tables were made of the husbandsf scores, differences proved to be signifi cant . * Hypothesis II "The scores obtained by husbands and wives in fertile marriages on various scales of the MMPI differ significantly from those obtained by husbands and wives in infertile marriages." Only one significant difference was found to exist between the fertile and infertile groups on the MMPI scales when the statistical measure ments were applied in the usual way to distributions of scores rather than to scores to which a cutting point had been applied so that a contingency table could be con structed. The one significant difference referred to above was found on the Neuroticism scores for the husbands. The fertile husbands scored higher than the infertile. There were significant differences on two validity scales for the wives. A significantly greater number of the infertile wives had L and K scores above the cutting *Cf. p. 113 148 points of 6 and 19, respectively. The infertile couples' scores were also found to be significantly higher than the fertiles for K. The MMPI Manual states that a high K score represents "defensiveness that verges upon deliberate distortion in the direction of making a more 'normal' appearance" (36:18). The Lie score is described in the Manual as being a measurement of "the degree to which the subject may be attempting to falsify his scores by always choosing the response that places him in the most acceptable light socially" (36:18). The infertile wives and couples were apparently defensive about their social and personal normality. As a result of "configural analysis," it was found that there were five MMPI relationships which separated the infertile from the fertile husbands: the Sc Scale was found to be higher than the Hs, Pd, and Pt Scales; the Mf Scale higher than the D Scale; and the Hy higher than the Hs Scale for a significantly greater number of infertile husbands than fertile husbands. The schizo phrenia trait (Sc) which in marriage would be indicative of seclusiveness and withdrawal emotionally from the mate was more pronounced than three other traits in the infertile husbands as compared with the fertiles. The other three traits were: hypochrondiasis (undue concern about health), psychopathic deviation (disregard of social mores and lack of deep emotional response), and 149 psychasthenia (obsessive-compulsive behavior and/or fears). There was a greater tendency toward femininity of interests (Mf higher) than toward lack of self-confidence or pessi mism as expressed by the Depression Scale for a signifi cantly larger number of infertile husbands than fertile husbands. The extent of Hysteria (Hy), indicating a tendency to displace emotional disturbance in physical symptoms, was more pronounced than Hypochondriasis (Hs) in a significantly larger number of infertile than fertile husbands. The Manual describes the hysterical cases as being "more immature psychologically than any other group” (36:19)* Differentiation is made by describing the hypochondriac as being more vague about his complaints and of not showing as much evidence as the hysteric of having avoided an unacceptable situation because of his symptoms. Hypothesis III "Marital Adjustment scores of husbands and wives in fertile marriages are significantly higher than those of husbands and wives in infertile marriages." The results of the study showed that there were no significant differences in the Marital Adjustment scores of husbands, wives or couples in fertile marriages and those in infertile marriages. However, the degree of defensiveness manifested in the L and K scores of the infertiles makes 150 suspect the highly visual items of the Marriage Question naire as a valid measure of marital adjustment between these two groups. Hypothesis IV "The childhood relationships with mothers and fathers reported by husbands and wives in fertile marriages are better than those reported by husbands and wives in infertile marriages." The scores which were based on the reported relationship with the father during childhood were significantly higher for the husbands of the infertile group than for those of the fertile group but not for the wives. The scores based on the reported relationship with the mother during childhood did not reveal any significant differences at the required level of confidence for any of the groups. The direction of the differences, however, was favorable for the infertile groups. The extreme defensiveness of the infertile individuals was probably responsible for this outcome, also. Hypothesis V "The wives in fertile marriages are less dominant than those in infertile marriages as reported by the husband and wife in the respective marriages." The two differences of role dominance which proved to be signif icant, occurred in the evaluation by the couples. The 151 number of fertile couples disagreeing as to which one played the dominant role in the marriage was greater than the infertiles to an extent approaching the 1 per cent level of confidence. The number of infertile couples evaluating the marriage as democratic was significantly greater than the number of fertiles at the 5 per cent level of confidence. The disagreement regarding role dominance might be interpreted as evidence of more spontaneous role playing and greater ego strength on the part of the fertiles. Although the differences between the number of fertile and infertile husbands who evaluated their marriages as husband-dominated was not quite at the required level of confidence for this study, it seems obvious that judgment should be reserved.* There is a definite tendency among the husbands for the fertiles as compared with the infertiles to feel that they make the decisions in marriage. There were no significant differences in the MMPI Dominance Scale for any one of five different groupings: fertile wives with infertile wives; fertile husbands with infertile husbands; fertile couples with infertile couples; fertile wives with fertile husbands; and infertile wives with infertile husbands. *Cf. p. 106. Hypothesis VI "Measures of personality, marital adjustment, and sexual adjustment are positively correlated for both fertile and infertile individuals." Some definite tendencies and potential meanings seemed to emerge from the relationships within fertile and infertile subgroups. Regardless of the fertility status or of sexual subgroup ing (i.e., male or female), marital adjustment and sexual adjustment bore a fairly high relationship to each other, but this relationship was considerably more substantial for all of the infertile groups. The fact that favorable Sexual Adjustment scores and low Anxiety Scale scores were related for all of the groups, but much more substantially so for all of the infertile groups, may indicate that these are important relationships among the individuals in this study regardless of fertility status but that among the infertile individuals the importance is greatly intensified. A comparison of the patterning of correlations for the wives indicated that favorable sexual relationship scores had more substantial relationships with other personality variables and with each other for the fertile wives. This is consistent with logical expectations. Conversely, the almost complete lack of, or very slight relationship between, some of these variables for the infertile wives seems inconsistent with expectations. 153 The significant relationships for the latter group had to do with favorable sexual relationship scores and low Anxiety, M.A.S., and D scores. In other words, the emphasis was on a good sexual relationship being closely related to a lack of anxiety and/or depression for the infertile wives. The patterning of the relationships between variables for the husbands also revealed some interesting comparisons. The substantial relationships between high Marital Adjustment scores and favorable scores for sexual attitudes, schizophrenia, and psychasthenia indicated that there was more relationship between the marriage adjust ment and certain personality traits for the fertile husbands than for the infertiles. The latter had substantial relationships only in the two correlations aforementioned and held in common with all of the infertile subgroups, i.e., the relationship of favorable Sexual Adjustment scores with favorable Marital Adjustment scores and low Anxiety Scale scores. Summary In this chapter, the results which were obtained by applying various methods of analysis and statistical procedures have been presented. In conformity with the basic etiological frame of reference described previously, the experimental and control groups have been compared in three subgroups: husbands, wives, and couples. Following this presentation of statistical findings, the six hypotheses of the study were examined and evaluated. Hypotheses III, IV, and V were rejected. They related to marital adjustment scores, dominance patterns, and child hood relationships with fathers and mothers as reported by the subjects. The other hypotheses relating to aspects of sexual relationship, personality, and intragroup relationships were validated in part. In the next and final chapter, the study is summarized, limitations of the study are discussed and conclusions are postulated. Finally, suggestions for future research are made. CHAPTER V SUMMARY AND CONCLUSIONS Summary This study was an attempt to analyze the degree of relationship between psychosociological characteristics and infertility. More specifically, it was concerned with comparing the marital adjustment, sexual relationship, and personality characteristics of individuals in infertile marriages with individuals in fertile marriages. The historical background of infertility was traced and shown to have been a problem revealed in the earliest records of civilization. The continuing socio logical and psychological significance of the problem in contemporary society was described. A description of the complicated processes of reproduction and conception was presented, indicating that infertility can occur in multitudinous ways. An extensive review of relevant literature was presented which included both theoretical formulations and empirical studies categorized according to their major emphasis: wife, husband, or couple. An evaluation of previous studies indicated that much careful research has 155 156 been done, and that the present approach by investigators is to regard infertility as a function of the marriage. Most of the studies, however, continue to be of a descrip tive or case-history nature. The characteristics of the control group of forty- six husbands and wives of fertile marriages and the experimental group of forty-nine husbands and wives of infertile marriages were described and shown to be relatively well matched in terms of age, race, religion, education and amount of income. The interviewing procedure was described along with information relative to sources of the sample populations, the individuals doing the interviewing, and operational considerations. The three instruments used in the study were: the Minnesota Multiphasic Personality Inventory (MMPI) to determine psychological characteristics; a modified form of the Locke Marital Adjustment Test (called here the "Marriage Questionnaire") for measuring marital adjustment, sexual adjustment, and certain other aspects of the marital relationship; and a "Fertility Study Psychological Data Sheet" for obtaining background information and personal data relative to psychogenic conditioning factors as well as any anxiety specifically related to the infertile condition. These instruments were described as to validity, and the construction and scoring of various scales were discussed in detail. 157 The various types of statistical techniques utilized to analyze the data were discussed: the chi- square, the Kolmogorov-Smirnov test, and the critical ratio for determining the significance of differences between two distributions of scores, two means, two coefficients of correlation, or two proportions; and the coefficient of correlation for determining association or meaningful relationships. The use of computer facilities at the Western Data Processing Center and the use of some of their programs for facilitating this statistical analysis was described. The statistical results of these analyses have been presented and the hypotheses examined. Significant results were not forthcoming when the means or distribu tions of scores for the variables of any two groups were compared. However, by analyzing answers to individual questions, by applying cutting points so that the scores could be placed in contingency tables, by making rank comparisons of MMPI scales through configural analysis, and by comparing scores between the mates within a group, i.e., fertile or infertile, some significant results were obtained. Hypotheses III, IV, and V were rejected regardless of analytic method. However, the other hypotheses relating to aspects of sexual relationship, personality characteristics, and intragroup relationships were validated in part. These findings of Chapter IV are now examined in more detail. The results obtained from five indices of sexual relationship were described and interpreted. Two of the techniques which were devised for determining "potency” or "libido" for the husbands revealed that a significantly greater number of fertile than infertile husbands fell in a "strong" responsiveness group sexually. Concerning the sexual relationship, numerous complaints were reported by the infertile wives in contrast to the satisfaction and fulfillment generally reported by the fertile wives. The MMPI results for the various subgroups were compared and analyzed. A higher Neuroticism score was evidenced for the fertile group of husbands than for the infertile group, and no attempt was made to interpret this. By the use of contingency tables it was disclosed that the number of validity scales, L and K, greater than the cutting scores of 7 and 20, respectively, for the infertile wives were significantly higher than for the fertiles. Scores greater than 6 for L or 19 for K are indicative of excessive defensiveness. Both L and K are felt to measure somewhat different aspects of one psycho logical characteristic, namely, a tendency to see oneself in a very favorable light and to assume an overly perfect attitude, according to Cuadra (16:251). According to the Manual, excessive L and K scores mean that subsequent scores are falsified in order to defend psychological 159 weaknesses and raises concern about "the whole problem that prompted the testing in the first place" (36:23). By applying configural analysis to the MMPI scores, it was found that the relationship of the Sc Scale to the Hs, Pd, and Pt Scales and of the Mf Scale to the D Scale was significantly higher for the infertile group of husbands than for the fertile group. This seemed to indicate that the infertile husbands had more of a tendency toward the emotional withdrawal represented by Sc than toward undue concern over health (Hs), disregard of social mores (Pd), and compulsive or phobic behavior (Pt). In addition, the infertile husbands indicated more femininity of interests.(Mf) than of being depressed or pessimistic (D). The most immature of psychological traits, hysteria (Hs) rather than hypochondriasis (Hy) was more a charac teristic of the infertile than the fertile husbands. An analysis of scores for Marital Adjustment, Father Relationship, Mother Relationship, and Psychological Background revealed one significant difference between the subgroups of husbands, wives, and couples. The infertile group of husbands had significantly higher scores on the Father Relationship scores than the corresponding fertile group did. However, the direction of the differences for all the other score comparisons was more favorable for the infertile subgroups. This was interpreted as meaning that the infertile groups of husbands and wives reported a 160 better marital adjustment and a more favorable childhood background including their relationship with fathers and mothers than the fertile groups did. These discrepancies were tentatively ascribed to the extreme defensiveness of the infertile group. A significant difference appeared in the couple evaluation of the marital dominance patterns for the experimental and control groups with more disagreement between the fertile couples and more evaluations of "democratic" by the infertile group. It was suggested that this might be due to more spontaneity and ego strength on the part of the fertiles. Regardless of whether the evaluation was derived from husband, wife, or couple, considerably more of the infertile marriages were rated as being wife-dominated and more of the fertile marriages as husband-dominated. Although the difference was not significant for purposes of this study, the tendency for wife-domination among the infertiles was so pronounced (i.e., between the .05 and .10 level of confidence), reservation of judgment was recommended in accord with McNemar's suggestion.* Comparisons were made between variables within the fertile and infertile subgroups. It was pointed out that although Sexual Adjustment scores had at least a moderate *Cf. p. 106 relationship with high Marital Adjustment scores and low Anxiety Scale scores for all subgroups, their relationship for the infertile subgroups was significantly higher, indicating that the importance of the relationship of these variables for the infertile groups was intensified. Interesting patterns emerged from other comparisons. Logical expectations that favorable sexual relationship scores would be closely related to each other and to other personality variables were confirmed for the fertile wives but not for the infertiles. It was found that, instead, the infertile wives had a close relationship between favorable sexual relationship scores and a lack of anxiety and/or depression. A description was given of the close relationship for fertile husbands between high Marital Adjustment scores and three other scores--positive Sexual Attitudes, and low Sc and Pt scores--indicating that a good marital adjustment was concomitant with favorable attitudes toward sex, emotional warmth, and a lack of fears and compulsions. Additional statistical findings not related specifically to the hypotheses but of apparent significance were presented. The incongruity between the results obtained from an analysis of anxiety specifically related to the infertile condition and the anxiety as measured by the various scales was described. Although the scales revealed no significant differences between the fertile 162 and infertile groups, a majority of the infertile wives reported considerable specificity of anxiety relative to their infertility. The other additional findings described were concerned with the differences which were significant between mates. As measured by the M.A.S., the infertile wives were shown to have more anxiety than their husbands. Both the fertile and infertile husbands had greater ego strength than their wives on the basis of the Es Scale of the MMPI. The fertile wives had greater anxiety than their husbands on the basis of scores obtained from the Data Sheet Anxiety Scale, but the husbands exhibited greater depressive tendencies with higher scores than their wives on the D Scale of the MMPI. Limitations of the Study The manner in which the sample was obtained might be considered as a limiting factor. The infertile groups in this study were in the process of starting treatment for their infertile condition and so were not representa tive of all infertile couples, many of whom have no desire to receive help or are unable to obtain treatment. The method of selection of the control group also had limita tions because some of the controls were motivated by a desire to be included in the npill program” at the Planned Parenthood Center. A. study using a random sample would be preferred. Another limitation is the method of collecting the data. There were five different interviewers for the infertile group, so that consistency of approach and of the content of interview material is questionable. This investigator actually was responsible for the complete interviewing of all of the fertile group of individuals and for one-half of the infertile group. At appropriate times during the personal interview by this investigator certain questions were routinely included relative to aspects of early instruction concerning sex and reproduc tion and specific questions about the history of the couplefs sexual relationship during marriage as well as frequency of intercourse. This latter question was found to be of considerable importance because several of the infertile couples reported frequencies as few as once every month or two. The attitudes of mothers, other relatives and close friends concerning sex, pregnancy, and childhood were elicited from the wives. If interview material of this type had been available for the entire group of infertiles so that comparisons could have been made with the fertile group, some significant findings might have been forthcoming. The time required to complete the instruments and the verbal part of the interview was entirely too long. The Marriage Questionnaire and Fertility Study Psychological Data Sheet were too lengthy. Much of the information obtained on them was not used or even needed to satisfy the requirements of the basic research design. Most individuals needed at least two and one-half hours to complete the questionnaires and some required three or more hours. The time requirements for the personal interview depended somewhat on the subject^ talkativeness or need for reassurance about their problem but could not be consummated satisfactorily in less than an hour. Not only could the questionnaires have been shortened but some of the questions could have been simplified. Most indi viduals, even those who had attended college, were confused by question nine on page two of the Data Sheet relative to childhood relationships with parents. In fact, the validity of the findings concerning reported relationships with mother and father could be questioned on this basis as well as on the basis of the defensiveness of the infertile group. One of the assumptions basic to this study was that certain personal and interpersonal factors such as marital adjustment, sexual relationship and childhood relationship with parents can be measured by question naires. Implicit in this assumption are other assumptions relative to various types of bias: that the reported behavior was the actual behavior, that the information was accurate and unbiased by memory, deliberate 165 falsification or lack of comprehension. If an individual's ego is involved, he may withhold or distort information. The MMPI was considered to be an adequate instrument for measuring personality characteristics of the fertile and infertile individuals for purposes of comparison. It would have been advisable, however, to secure answers to the first 411 items rather than the first 366 items because of the K Scale. Although this was rectified by extrapolating the K score, the results could not be exact. The very trait, defensiveness, which this scale measures was responsible for questioning the use of the instrument for individuals in infertile marriages. Conclusions In the present study an attempt was made to determine whether relationships could be established between infertility and certain factors relating to marital adjustment, sexual relationship, and psychological or personality functioning. Within the limitations of this study, the findings seemed to show: 1. The problem of infertility itself is of utmost importance, both psychologically and philosophically, to millions of people, and factors of an intrapsychic or interpersonal nature are unquestionably responsible for, and/or related to, a large number of infertile marriages. 166 According to Freedman et al., "progress in eliminating such fecundity impairments is important to reducing the unhappiness of millions of couples unable to have as many children as they want" (25:400). The importance of this problem is not diminished by demological considerations. Buxton and Southara contend that despite the population explosion: It is the inalienable right of a couple to make their own decision about having children. . . . Each one of them has the same instinctual drives for food, clothing, shelter, and reproduction regardless of environmental crowding. . . . The prevention of over population does not rest in the slightest in the elimination of the treatment of infertility; it rests basically in provision for and education in techniques of family control. (13:221) 2. The nature of the relationship between infertility and psychosociological factors is extremely complex. At the present stage of development in this area, it is premature to discuss etiological relationships. Even in those instances in which the etiology is anatomic or biochemical, personality or interpersonal disturbance may be concurrent with the infertile condition— either attributable to it or contributing to it. The relationship seems to be reciprocal in many instances. 3. The wives in infertile marriages are more defensive about psychological weaknesses and more desirous of exhibiting socially acceptable standards than the wives in fertile marriages. This effort to appear completely normal, of course, relates to the psychodynamics of 167 infertility itself, i.e., the intense desire to be like others and the strivings for success— success being symbolized by pregnancy. A sociological and anthropological climate exists in which reproductive couples are commended and infertile couples are frequently criticized whether their barrenness is self-inflicted or not. . . . This social attitude added to the instinctual drive previously mentioned places the infertile couple, and especially the infertile women, on the defensive and may produce deep feelings of inadequacy and guilt. (13:215) A. The husbands in infertile marriages are less potent sexually than those in fertile marriages. Since the husband is necessarily quite intimately involved in determining any interaction within the marriage, the entire sexual relationship is therefore suspect. The increased recognition that the husband is often responsible for infertility but, in many instances for unknown reasons, was evidenced in a series of 736 couples in which 45.5 per cent indicated reduced fertility on the part of the husband. The investigators concluded that: Most infertile husbands are entirely normal from the standpoint of masculine characteristics. Etio logical factors are not evident in a high percentage of cases. Approximately one-third of the patients fall into a category of "cause unknown," while a similar number show bilaterally small testes, often of obscure etiology. (111:97) 5. The wives in infertile marriages give evidence of having more sexual responsiveness than their husbands do. Apparently, the husbands in infertile marriages present more deviations in sexual responsiveness than the i6a wives and the wives tend to complain about the sexual relationship. 6. The dominance pattern reported by infertile couples is different from that reported by fertile couples. Fertile couples are more likely to disagree about the pattern and infertile couples are more likely to class the marriage as democratic. One of the types of infertile women which Helene Deutsch (15:112) postulates in her analysis is the masculine-aggressive woman. The definite tendency toward wife domination in the infertile marriages to a point approaching the significance level for this study shows the need for further investigation even though a conclusion cannot be set forth at this time. 7. The wives of infertile marriages show evidences of anxiety specifically associated with the condition of infertility. 5. The wives of infertile marriages have signifi cantly higher M.A.S. scores on the MMPI than their husbands. 9. The infertile husbands are characterized by a tendency toward a lack of emotional warmth rather than by hypochondriacal or asocial tendencies (as indicated by the configural analysis of the Sc, Hs, and Pd Scales of the MMPI). 10. There is a substantially close relationship between certain aspects of a favorable sexual relationship 169 and a lack of anxiety for the infertile wives. 11. A good marital adjustment reported by fertile husbands has a substantial relationship with a lack of behavior of a compulsive or phobic nature. 12. The sexual adjustment reported by wives in fertile marriages when favorable has a substantial rela tionship with a lack of neurotic!sm, dependency needs, and manifest anxiety as measured by the MMPI. 13. The husbands of both fertile and infertile marriages have greater ego strength than their wives. Suggestions for Further Research There is a dearth of scientific research in this area of psychosociological factors in infertility. Many studies of an experimental nature are definitely needed. Some of the suggestions which seem to emerge as a result of this study are: 1. Further investigation of some of the variables in this study by combining results from a new investiga tion with those from this study. To accomplish this, it is suggested that the instruments to be used include the first 411 items on the MMPI (so that all items necessary to score the K will be included), and only those items from the Marriage Questionnaire and the Psychological Data Sheet needed to obtain the scoring information for the following scales: Sexual Responsivensss, Dominance, and 170 Anxiety. This would be a statistical advantage because of increasing the size of the samples and decreasing the number of the variables. Those variables to be investi gated first are: Sexual Responsiveness, using all of the various techniques of this study, such as contingency tables, and intragroup as well as intergroup analysis; the MMPI Scales— K, L, Sc, Mf, Df Hy, Ne, De, M.A.S., and Pt, using all of the methods of this study such as configural analysis, high point analysis, and contingency tables; the Dominance Scale as derived from the Marriage Question naire; and the Anxiety Scale derived from the Psychological Data Sheet items. 2. The need for more adequate and sensitive devices for measuring interpersonal and intrapsychic dynamics is apparent. If these could be determined or developed, there are certain areas which emerge on the basis of this study, as having a potentially important relationship to the syndrome of infertility. The partic ular areas which seem to warrant further investigation are the sexual relationship with special emphasis on the potency of the husband; the dominance pattern in the marriage;* the anxiety and defensiveness either engendered by or resulting in the infertility; and a lack of emotional warmth on the part of infertile husbands. These variables *Cf. p. 95 171 were found to be significant at the .05 level of confi dence or within the reserved-judgment area as defined by McNemar.* Another set of MMPI scales which might be pertinent are the "subtle" (S) and "obvious" (0) keys developed by Wiener (lid). These are especially meaning ful when there is a large component of defensiveness. The D, Hy, Pd, Pa, and Ma Scales are categorized according to S or 0 and it has been found that an individual’s exces sive defensiveness in any of these areas is revealed by a high S and a low 0. 3. A longitudinal study of infertile couples starting at the time when they first enter an infertility clinic. In addition to the medical evaluation, there should be an evaluation of personality and marital rela tionship by a marriage counselor. On the basis of the initial medical findings, those with an obvious anatomical or biochemical reason for infertility should be placed in separate categories according to prognosis and treat ability. Subsequent categorization of those continuing in treatment, of course, would be based on success or failure of the infertility treatment. *Cf. p. 106. APPENDIX I MARRIAGE QUESTIONNAIRE 1. Year of birth ____ . Male_____ . Female_____ . White . Colored . 2. Number of times married Number of divorces 3. Number of your brothers and sisters Were you the oldest child: yes ; no____Were you the youngest child: yes_____ ; no_____ . 4. Number of brothers and sisters of your mate_____ . Was your mate the oldest child: no_____; yes______. Was your mate the youngest child: yes____ ; no______ . 5. Put an (0) to indicate marital status of your parents at time of your marriage and (X) to indicate the marital status of your mate’s parents; married (both living)_____; separated______; divorced_____ ; both dead ; one dead . 6. Do you feel that in your parental home you: never had your own way about anything_____ ; usually had your own way_____ ; had your own way about everything 7. Indicate the amount of conflict and affection which was present between the following persons before your marriage: Degree of Conflict and Affection Conflict Affection Father and Mother You and Fa ther You and Mother You and Your Mate You and Fa ther You and Mother You and Your Mate Father and Mother None 173 174 Degree of Conflict and Affection Conflict Affection Father and Mother You and Fa ther You and Mother You and Your Mate You and Fa ther You and Mother You and Your Mate Father and Mother Very little Moderate A good deal Very great 3. My childhood on the whole was: very happy_____; happy ; about averagely happy ; unhappy ; very unhappy . 9. Before marriage was the attitude of your parents toward your mate one of approval ; indifference ; disapproval ; did not know . 10. If at any time during marriage you lived with your parents or your mate’s parents: a. Did you dislike this: very much____ ; some : did not mind it_______; enjoyed it___; enjoyed it very much . b. Did you reveal this feeling to your mate: yes ; no . c. Did your mate dislike this: very much : some ; did not mind it_____; enjoyed it ; enjoyed it very much_____. 11. The length of time you knew your mate before marriage was: less than one month_____ 3 months_____ 175 12. 13. 14. 15. 16. 17. IS. 19. 6 months. 9 months’ 1 year * 2 years__ 3 years_____ 5 years_____ 5 to 10 years since childhooT The length of time between your engagement and your marriage was: less than 1 month 1 year_____ 3 months_____ 6 month s_____ 9 months_____ 2 years_____ 3 years over 3 years. by Where married: at home ; at church_____ judge ; at minister's home ; by justice of the peace ; elsewhere . Check all the following married your mate: Common interests_____ To please parents_____ Love___ Lon eliness_____ Economic security_____ Pregnancy To have children reasons why you think you To escape your own family. To take care of children^ Due to intoxication____ To be looked up to Ey friends_____ To satisfy sex desires___ To have a home___ Total number of different houses in which you have lived during your marriage . Your occupation at time of marriage. Your occupation during marriage_______________________ If wife worked during marriage, did husband: approve ; disapprove . During your marriage: a. Who in the family worked outside the home for money: wife ; husband ; both . b. The chief breadwinner was: irregularly employed ; always employed but continually changing jobs regularly employed in seasonal work ; regularly employed the year around . c. The longest period of employment of the chief breadwinner was: 3 months or less_____; 6 months to 1 year ; 1 to 2 years ; over 2 years 20. 21. 22. 23. 24. 25. 26. 27. 2$ . 29. 176 d. Did the chief breadwinner of the family have an extended period of unemployment of: 3 to 6 months_____ ; 6 months to 1 year_____ ; 1 to 2 years ; 2 years_____ ; over 5 years_____ . The combined savings of both husband and wife: a. At time of marriage was: none_____ ; $200 or less ; $200 to $1000_____ ; over $1000_____ . b. At present time is: none : $200 or less____ ; $200 to $1000_____ ; over $loQ6 During marriage has either mate carried life insurance: Yes Wo______; Size of policy $_____ ; Is insurance carried at present? Yes No ; Size of policy $____ . The average income per month during the first, half of S our marriage was: husband $ ; wife $ uring the last half: husband $ * ; wife $ On the whole do you feel that the total income has met the economic needs of the family: very adequately ; adequately : inadequately : very inadequately_____ . Number of times borrowed money during marriage: ; Amount borrowed $_____ . As far as managing the affairs of the home is concerned do you feel that the wife has been: very satisfactory______; satisfactory______ ; unsatisfactory ; very unsatisfactory_____. Do you feel that the husbandTs efforts to provide for the economic needs of the family have been: very satisfactory______; satisfactory______ ; unsatisfactory ; very unsatisfactory_____. Have you ever wished you had not married: frequently _____; occasionally______; rarely_____ ; never_____ . If you had your life to live over again, do you think you would: marry the same person ; marry a different person ; not marry . Do you and your mate engage in outside interests together: all of them_____ ; some_____ ; very few_____ ; none of them 177 30. Put an (0) for yourself and (X) for your mate to indicate the number of friends during marriage. a. of the same sex: almost none_____; a few ; several____ ; many . b. of the opposite sex: almost none_____; a few ; several ; many_____. 31. The number of friends you and your mate have in common: almost none ; a few ; several_____ many_____. 32. In leisure time husband prefers to be: "on the go" ; to stay at home ; Wife prefers to be: . "on the go"____ ; to stay at home_____. 33. During marriage have you in general, talked things over with your mate: almost never ; now and then______; almost always ; always . 3U. Do you kiss your mate every day ; now and then ; almost never ; If so, do you kiss: as a matter of duty ; or because of real affection 35. Put an (0) to show your feeling and an (X) to show the feeling of your mate toward the following during your marriage. Place an (0) and an (X) opposite every item: Activities Enjoy Very Much Enjoy Indifferent Tolerate it in Mate Open Conflict Reading Playing cards Gambling Drinking Movies 173 Activities Enjoy Very Much Enjoy Indifferent Tolerate it in Mate Open Conflict Dancing Parties Church Listen to radio Music Politics Sports 36. In the following chart there is a list of activities in which the husband or wife may take the lead, that is, one is more dominant than the other. We want information on three married couples; you and your mate; your mother and father; and your mate's mother and father. Indicate in the proper space whether the husband or the wife tends to take the lead. If in a given activity both the husband and wife are about equal, put a check for both. Your Marriage Your Parents' Marriage Mate's Parents' Marriage Activities Wife Takes Lead Husband Takes Lead Mother Takes Lead Father Takes Lead Mate's Mother Takes Lead Mate's Father Takes Lead Making family decisions 179 Your Marriage Your Parents’ Marriage Mate’s Parents’ Marriage Activities Wife Takes Lead Husband Takes Lead Mother Takes Lead Father Takes Lead Mate’s Mother Takes Lead Mate’s Father Takes Lead Disciplining children Handling family money Affectionate behavior Religious behavior Recreation behavior Meeting people 37. Do you think that your intelligence, as compared to that of your mate is: more_____ ; less_____ ; equal 3&. Do you feel that in comparison to your mate you are: superior ; inferior_____ ; equal 39. Check any of the following things which you think have caused serious difficulties in your marriage: 1. Mate’s attempt to control my spending money____ 2. Other difficulties over money_____. 3. Religious differences . 4. Different amusement interests____ . 130 5. 6. 7. 3. 9. 10. 11. 12. 13. 14. 15. 16. 17. 13. 19. 20. 21. 22. 23. 24. Lack of mutual friends__ Constant bickering Interference of in-laws Lack of mutual affection(no longer in love) Unsatisfying sex relations . Selfishness and lack of cooperation . Adultery Desire to have children . Sterility of husband . Sterility of wife . Venereal Disease Mate'paid attention (become familiar with) to another person . Desertion . Nonsupport . Drunkenness . Gambling 111 health Mate sent to .{ail . Cruelty to step-children_ Other reasons _______ * 40. Underline the two things in the above list which you think have caused the greatest conflict in your marriage. 41. What things annoy and dissatisfy you most about your marriage?______________________________________________ 42. What things in your marriage satisfy you moat?. 43. State approximate extent of agreement or disagreement between you and your mate on the following items. The examples should be considered as only one of many topics which come under each point. Please Diace a check opposite every item: Check one Col. for Sach Item Below Always Agree Always Dis agree Almost Always Agree Occa sionally Disagree Fre quently Dis agree Almost Always Dis agree Handling fam ily finances 181 Check one Col. for Bach Item Below Always Agree Always Dis agree Almost Always Agree Occa sionally Disagree Fre quently Dis agree Almost Always Dis agree (Example: installment buying) Matters of recreation (going to dances) Religious mat ters (dif ferent reli gious views) Demonstrations of affection (frequency of kissing) Friends (dis like of mate's friends) Intimate rela tions (sex relations) Do you get on each other's nerves around the house 1#2 Check one Col. for Bach Item Below Mways Agree Always Dis agree Almost Always Agree Occa sionally Disagree Fre quently Dis agree Almost Always Dis agree Ways of deal ing with in-laws The amount of time that should be spent together Table manners Conventionality (right, good, or proper conduct) Aims, goals and things believed to be important in life 44. When disagreements have arisen, they usually have resulted in: husband giving in_____ ; wife giving in ; agreement by mutual give and take_____ ; neither giving in . 45. During your present marriage how many times have you left your mate because of conflict How many times has your mate left you . How long was the longest time of separation: years ; months_____ days . 46. Do you feel that your mate is overly jealous about your talkingi dancing, or other kinds of association with those of the opposite sex:__yes______;_no_____ . 47. 4a. 49. 50. 51. 52. 53. 54. 55. 56. 57. 5a. ia3 Do you resent this? yes ; no . Do you feel that your mate is over-modest and shy in attitudes toward sex: very much ; a good deal ; some ; very little ; not at all . Have birth control methods been used:__yes______; no . Does fear of having children make sex intercourses less enjoyable:__yes______; no______. Before marriage, with how many persons did you have sex intercourse:__none______; one ; a few_____ many . Did you have sex intercourse with your mate before marriage: yes_____; no During marriage, have you desired sex intercourse with some other one than your mate: very frequently _____ ; frequently_____ ; sometimes______; rarely_____ ; never_____ . During marriage, with how many persons other than your mate have you had sex intercourse: none______; one______; a few_____ ; many_____. What is the degree of your sex satisfaction with your mate: enjoyable ; very enjoyable : tolerated _____ ; disgusting______; very disgusting______. What do you think is the degree of sex satisfaction which your mate has with you: enjoyable______; very enjoyable ; tolerated ; disgusting______; very disgusting_____ . Have you ever refused sex intercourse when your mate desired it: frequently ; sometimes ; rarely _____ ; never______. Has the average number of times of intercourse per month from the time of marriage until the present: Increased greatly : increased______; remained the same ; decreased some ; decreased greatly _____ ; ceased entirely______. Do you feel that the strength of your sex interest, as compared with that of your mate, is: very much greater_____ ; much greater ; about the same______; much less intense_____; very much less______. APPENDIX II INFERTILITY STUDY Intensive Personal Data Sheet INSTRUCTIONS: (Please read carefully before filling out this questionnaire.) In order to facilitate your infertility study, it would be helpful if you would answer as many of the questions asked in the following questionnaire as you can. All of the answers are confidential and will be kept in professional confidence by the consulting psychologist, his colleagues and the staff. THE HUSBAND AND WIFE MUST FILL THIS OUT INDEPENDENTLY AND WITHOUT CONSULTING WITH ONE ANOTHER. CVieck, circle or fill in the appropriate answer. PERSONAL DESCRIPTION Date: Name___________________ ___________ ______ Sex: M F__ Last First Middle Address________________________________ _____ Phone:________ Married to I II III IV mate; Have children by (Circle correct no.) former mate(s). Date and Place of birth:___________________ U.S. Citizen__ Religion: . Active___________ Inactive____ INFERTILITY DATA 1. How many different doctors have you visited in working on this problem? 2. How many years have you been actively trying to have a child?___________ 3. How depressed do you get when you think about this problem?___________ 4. How depressed do you get at the onset of the menses 1S5 I 186 because of this problem?_______________ How anxious are you about becoming pregnant? 5. Do you often cry about not being pregnant?____________ Are you tense about it?__________ 6. Does talk on the part of other couples about their children upset you?__________ How much?_______________ Does seeing babies or young children upset you very much?_________________________________. 7. Have any of the requirements for getting pregnant such as intercourse at the rise of the temperature caused any difficulty in your sexual adjustment? How? ______________________ . 8. Are you much concerned with your present adjustment to sex? __ ______. 9. As you look back over your early childhood, do any instances involving sexual matters come to your mind? Yes No 187 FERTILITY STUDY Intensive Personal Data Sheet INSTRUCTIONS: (Please read carefully before filling out this questionnaire.) In order to facilitate this study, it would be helpful if you would answer as many of the questions asked in the following questionnaire as you can. All of the answers are confidential and will be kept in professional confidence by the consulting psychologist, his colleagues and the staff. THE HUSBAND AND WIFE MUST FILL THIS OUT INDEPENDENTLY AND WITHOUT CONSULTING WITH ONE ANOTHER. Check, circle or fill in the appropriate answer. PERSONAL DESCRIPTION Date: Name____________________________________ Sex: M Last First Middle Address Phone: Married to I II III IV mate; Have children by (Circle correct no.) former mate(s). Date and Place of birth:___________________U.S. Citizen__ Religion: . Active__________ Inactive____ DATA ON PAST PREGNANCIES 1. How soon after marriage did you want your first baby?_____________________ . 2. How soon after marriage did you have your first baby?_____________________ . 3. Did you worry at any time about not becoming pregnant ?_____________________. L. How depressed did you get because you were not pregnant ?___________________ 5. Do you remember getting particularly depressed at the time of menstruation because you were not pregnant? How depressed?_____________________ . ids Did you ever cry because of not being pregnant?___ Did you ever seek medical help to become pregnant? Did your concern to become pregnant ever interfere or upset your sexual life?____________________ . Are you much concerned with your present adjustment to sex?____________________ . As you look back over your early childhood, do any instances involving sexual matters come to your mind? Yes No . Do you regard yourself as a tense person? Yes____ no ____; if so, does the tension and anxiety interfere with satisfactory consummation of the sexual act? TELL US SOME THINGS ABOUT YOUR PARENTS: 1. Father's name:______________________ Occupation_________ 2. Father's birthplace:_____________Living? yes_____ no Age:_____ 3. What languages does or did your father speak?_________ 4. Mother's name:______________________Occupation_________ 5. Mother's birthDlace_____________Living? yes_____ no Age:_____ 6. What languages does or did your mother speak?_________ 7. No. of living brothers No. of living sisters_____ d. If your brothers and sisters are married indicate how many children they each have? 9. From your point of view, characterize your father and your mother as you experienced them in childhood by placing a check mark (</) on the horizontal lines at any point which best indicates how you really felt about your father, and an X mark at any point on the horizontal lines which best indicates how you felt about your mother. FIRST MAKE YOUR RATINGS ON ALL OF THE ITEMS WITH RESPECT TO YOUR FATHER AND THEN GO 6. 7. S. 9. 10. 11. 139 BACK AND MAKE THE RATINGS FOR YOUR MOTHER. W us 1/ t Fair * T T t t T t un.iuat f t Unfair Severe . » » Mild Stingy i 1. . t t * Generous Brutal » 1 I . , Kind Loving t « « Rejecting Strong ♦ _ J » * t Weak Hostile i I t » t Friendly Domineering « 1 t , t Submissive Clever * I t , __ Dull Educated . t » t t Uneducated Mean to Father (Mother) t t Kind to Father t (Mother) Mean to Brother f t t Kind to Brother Mean to Sister 1 * t Kind to Sister Hates Father (Mother) * t » Loves Father , (Mother) Nervous » 1 1 i t Controlled Emotional t 1 I i • Calm Industrious . 1 » . i Lazy Drunk t I t * » Sober Clean , I t , , Untidy Poor * 1 » , , Wealthy Lots of fun » t i t * Grim Demanded High Standards . ___I________ I ______ Did Not * » Care 10. 11. 12. 13. 14. 15. 16. 17. 13. 190 Punished Fre quently , , Never , , , Punished Beat Me , . , , Never Touched Me Employed , . , , .Not Employed Attended Church ----1 _ * ----- Did not Attend , . Church Did your father do anything that you particularly resented or did not like? yes no_____. What was it? (Describe briefly) Did your mother do anything that you particularly resented or did not like? yes no_____. What was it? (Describe briefly) Parents still married:____ divorced:_____ separated: _ • Father remarried: Mother remarried:_____. Did any of your brothers or sisters do anything that you resented deeply? yes no . If so, describe briefly: Following is a list of common childhood mental health problems. Please check those which as far as you can remember, apply to or have applied to you. Temper Tantrums:_____. Strong Hates: . Strong Fears: . Running away from home: . Afraid of Father: . Afraid of Mother:_____. Afraid of Sister:_____, of Brother:_____, of Uncle:_____, of Aunt:_____ , of teacher:_____ . Attacks of fainting:_____ . Extreme destructiveness: . Twitchings of the muscles of the face:______. Epileptic seizures:_____ . Convulsions: . Badly injured as a baby:_____ . Complicated birth:_____ . Severe spankings or other severe punishments:_____ . Playing frequently with sex orgaps:_____ .__Daydream ing all the time: Swollen glands:_____ . Blow on the head, or other severe head injury:_____ . Enuresis (Involuntary bed-wetting after the age of 7 years): . Severe headaches: . Difficulty in sleeping well:_____ . Bottle fed:_____ . Breast fed:_____ . 19. As a child were you extremely healthy?_____ , Average , Poor:______, Sick most of the time:_____ . A FEW QUESTIONS ABOUT YOUR SCHOOL AND COLLEGE DAYS: 1. Did you like to go to school? yes______ no_____. 2. What did you like most about it? 3. Did you ever join in playground activities? yes_____ no_____ . 4. Did you feel you were popular with other children? yes_____ no_____ . 5. Were you detested by other children? yes no_____ 6. Did the teachers like you? yes no . 7. Did you like your teachers? yes_____ no_____ . 8. What teacher did you like most in all your school 192 career? 9. What did you like about him or her? A FEW QUESTIONS CONCERNING YOUR PERSONAL ADJUSTMENT AT THE PRESENT TIME: 1, To what groups or organizations do you now belong as a member? 2. What activity or activities, either work or play do you gain real enjoyment and satisfaction from? 3. Do you read a daily newspaper regularly? yes_____ no______. With which part of the daily newspaper do you spend the most time?: Sports Foreign affairs Social news_____ , Local News Crime_______ Large advertisements , Classified advertisements______, Business news_____ , Pictures_____ , Funnies______, Other:____________________________________. 4. What national magazines do you read regularly? 5. If you had time, money, etc., in what activities would you like to engage? 6. If you had two full continuous hours of leisure every day, what would you do? 7. What are your chief hobbies and amusements? S. In what area of your personal life do you find most difficulty in adjusting? 9. Why do you think this difficulty exists? 10. Do you have any habits that worry you? 193 11. If yes, what would you most like to change or get rid of? 12. Do you sometimes worry about your personal appearance? 13. If yes, what part of your personal appearance worries you specifically? 14. Do you sometimes worry about what other people think about you? 15. If yes, explain further: 16. Do you worry about your intelligence? 17. If yes, what is the basis of your worry? IS. Have you ever ngone to pieces" over anything? 19. If so, what was It that upset you so? 20. Do you like other people? 21. Do you think other people are: friendly_____ , indifferent , unfriendly_____ , toward you? 22. Do you have any difficulty which you would like to discuss? Describe it here briefly. 23. Have you ever asked for any help or guidance in your personal affairs? 24. Whom have you asked? 25. What help did you receive? 26. What did it do for you? 27. Have you anything which you wish to discuss specifically with the consulting psychologist? APPENDIX III CODED MMPI PROFILES OF HUSBANDS AND WIVES OF 46 FERTILE MARRIAGES Husbands Wives 914’3628- w 1 29-31 ” 738- ■312 9l-2it 32-5^ 9-28731 23164-9 93^12 39421 - 2 27-31^ 211367-9 942^81: 9-768 29-31 4678- 28634 * 6-183 286-9 34-8J 2 * 7IJP9 -8749 16 (59) 4 5:9 (80) 1 7:16 (65) 5 4:21 (82) 1 2:10 (74) 3 3:8 (57) 4 7:9 (65) 2 3:14 (69) 4 4:12 (65) 4 7:9 (61) 3 4:21 (47) 3 3:14 (61) 5 3:14 (39) 2 7:5 (67) 1 4:9 (43) 5 1:10 (59) 3 8:8 (67) 3 2:16 (49) 5 2:16 (53) 4 13:9 (59) 4 5:20 (49) 3 7:13 (35) 0 7:17 (67) 3 3:18 (82) 4 7:23 (47) 5 1:21 (69) 8 3:22 (45) 4 1:22 (49) 1 4:8 (63) 5 4:17 (51) 5 1:21 (53) 6 4:14 (45) 3 2:23 (53) 10:2:18 (57) 4: 2:18 (55) 2: 1:13 (65) 2:1:16 (65) 1:4:18 (63) 5: 4:12 982*4763 3^186-47 (45) 3 7 12 (37) 1 4 16 (51) 6 7 17 (43) 4 3 22 (53) 2 2 13 (39) 4 8 10 (53) 3 3 18 (45) 3 6 14 (45) 5 8 12 (37) 2 4 12 (68) 5 6 17 (32) 5 4 14 (45) 2 2 13 (49) 2 8 4 (47) 5 6 17 (66) 4 1 12 (34) 4 7 10 (57) 4 2 12 (49) 6 4 12 (39) 5 1 12 (53) 5 3 13 (39) 2 1 8 (43) 4 4 18 (49) 1 3 17 (53) 4 2 17 (45) 5 4 9 (43) 4 0 20 (53) 8 1 16 (45) 3 1 13 (43) 9 3 22 (26) 6 3 14 (51) 3 3 16 (51) 3 4 4 (41) 3 0 17 (70) 6 6 14 (53) 1 1 5 (55) 3 2 21 (39) 7 3 20 195 196 Husbands '43-9 '493-26 V7 4 S 381 m r ' 16To9^T' '52f: 56 (59) 4:5:21 (43) 3:1:19 (53) 2:3:26 (63) 2:4:14 (65) 2:6:17 (47) 2:4:13 (45) 7:5:6 (41) 7:4:17 Wives 9'67.6-3 (51) 2:9:5 (51) 4:2:13 (51) 2:2:16 (51) 2:3:16 (45) 3:4:5 (49) 3:7:7 (59) 3:6:5 (51) 7:4:6 197 CODED MMPI PROFILES OF HUSBANDS AND WIVES OF 49 INFERTILE MARRIAGES Husbands Wives 3118467- *38T47- * 9r_ -4735163 *6-91 9*34-6 *231473 *4639- *65^71 *9-23 *326-7319 9*43-16 72*633- : » - 9 t679- *39-2 *13 49- * 346^ 12-9 2 * 6 T = $ T *2-913 73*6912- 9* 33J6-2 *927^-1336 34*372916- *2-913 * 3268-9 *349-1 *4323-69 21-2 (65) 5 1 26 (69) 6 2 23 (55) 5 3 21 (61) 7 2 14 (76) 6 5 16 (53) 0 6 12 (55) 4 5 14 (47) 5 5 19 (53) 5 4 16 (45) 3 0 17 (59) 3 3 12 (49) 5 3 14 (73) 1 3 13 (57) 2 2 18 (69) 2 4 16 (71) 3 4 16 (61) 3 5 4 (57) 2 5 17 (55) 2 2 25 (53) 3 2 13 (61) 5 2 14 (74) 0 3 13 (65) 1 5 19 (67) 2 0 8 (74) 4 5 24 (49) 3 1 10 (63) 6 1 20 (57) 3 3 3 (53) 5 3 21 (61) 3 1 14 (73) 1 4 14 (61) 4 4 20 (55) 4 11:14 (47) 3 1 22 (53) 4 3 24 (53) 0 2 10 (61) 4 2 5 (45) 7 4 20 (45) 4 2 13 (69) 3 4 20 (57) 5 1 17 (55) 7 4 22 >3 J-917 4J3-713 * 34168^79 *3-96 * 21634-21 *6 47) 5 0:21 41) 7 1:23 51) 6 3:23 51) 7 1:14 47) 7 3:21 39) 4 4:14 45) 3 4:10 57 2 5:10 51) 3 3:9 45) 4 5:22 43) 10:2:21 49) 5 6:11 80) 2 2:13 51) 3 2:23 39) 2 2:14 47) 1 4:10 51) 1 0:9 53) 4 3:5 37) 2 1:20 32) 6 3:15 51) 7 5:21 47) 2 9:10 37) 2 10:13 37) 3 2:9 57) 2 5:12 59) 6 9:3 34) 4 3:20 51) 5 12:12 53) 2 1:17 45) 3 5:10 45) 9 1:25 45) 2 2:21 53) 3 5:14 43) 6 3:14 45) 7 1:21 63) 3 5:11 55) 3 8:8 57) 3 1:17 49) 10tl:22 53) 6:■4:20 55) 3: 5:13 49) 3: 0:13 19^ Husbands Wives 4'-7913 59 4:5:16 (65) 2:7:14 (69) 10:3:22 (63) 1:1:21 (55) 4:3:20 (71) 6:6:13 (61) 5:5:10 '<^32-9 2617^1-9 -72 -63 -7 43 3:3 20 (34) 4:2 19 (22) 7:7 12 (53) 5:3 17 (53) 3:3 14 (37) 3:3 19 (55) 5:3 5 \ LIST OF REFERENCES LIST OF REFERENCES 1. 2. 3. 4. 5. 6. 7. S. 9. 10. 11. Banka, A. L., Rutherford, R. N., and Coburn, W. A. Fertility following adoption. Fertility and Sterility. 1961, 12:433-42. Barron, Frank. An ego-strength scale which predicts response to psychotherapy. Journal of Consulting Psychology. 1953, 17:327-33. Bender, S. End-results in treatment of primary sterility. Fertility and Sterility. 1953, 4:34-43. Benedek, Theresa. Infertility as a psychosomatic defense. Fertility and Sterility. 1952, 3:527-41. Benedek, Therese, et al. Some emotional factors in infertility. Psychosomatic Medicine. 1953. 15:433- 93. Benedek, Therese, and Rubenstein, B. B. Ovarian activity and psychodynamic processes. I. The ovulation phase. Psychosomatic Medicine. 1939, 1:245-70. Bickers, William. Patterns of uterine motility in relation to spermigration. Fertility and Sterility. 1951, 2:342-46. Blum, Lucille H. Sterility and the magic power of the maternal figure. Journal of Nervous and Mental Diseases. 1959, 123:40X^37 Bos, Carlo, and Cleghorn, R. A. 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ETinneapolis: University of Minnesota Press, 1956, pp. 235-54. Decker, Albert. Culdoscopic observations on the tubo-ovarian mechanism of ovum reception. Fertility and Sterility. 1951, 2:253-59. Deutsch, Helene. Motherhood. (The psychology of women. Vol. 2.) New York: Grune and Stratton, T945. Dunbar, Flanders. Emotions and bodily changes. 3d ed. New York: Columbia University Press, 1946, _____ . Psychosomatic aspects of genito-urinary and gynecological problems: with special reference to frigidity and infertility. Unpublished data. Eisner, Betty. Some psychological differences on the Rorschach between infertility patients and women with children. Unpublished Ph.D. dissertation, University of California at Los Angeles, 1956. Engel, E. T. Diagnosis of sterility. Springfield, Illinois: Thomas, 1946. Fischer, Irving C. Psychogenic aspects of sterility. Fertility and Sterility. 1953, 4:466-71. Ford, E. S. C., etal. A psychodynamic approach to the study of infertility. 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Creator Carr, Genevieve Delta (author)

Core Title A Psychosociological Study Of Fertile And Infertile Marriages

Degree Doctor of Philosophy

Degree Program Sociology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,sociology, individual and family studies

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Advisor [illegible] (committee chair), [illegible] (committee member), Seward, Georgene H. (committee member)

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