Infertility and Psychological Well-Being: The Interplay of Post-Traumatic Growth and Affective Personality Types in Infertile Lebanese Muslim Women

Abstract

Defined as the incapacity to conceive despite regular unprotected intercourse over a period of 1 year [2], infertility has garnered attention in the literature due to its association with mental health challenges. [...]over the past two and a half decades, a discernible shift in perspective of infertility impact on mental health has emerged. Multiple studies have suggested that infertility could have plausible effects on women’s mental health and emotional well-being. Each participant, in an anonymous manner, completed a comprehensive booklet, comprising informed consent, measures, debriefing information elucidating the study’s topic and objectives, and a background survey encompassing details such as age, education, employment status, household income in US dollars for ease of comparison with other countries, infertility duration, and infertility diagnosis.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Introduction

Infertility, encompassing the diagnosis and treatment modalities such as in vitro fertilisation (IVF), presents a substantial burden on both physical and psychological well-being. Emerging as a global disability affecting 15% of couples, its rates soar up to 22.5% in the Middle East region [1]. Defined as the incapacity to conceive despite regular unprotected intercourse over a period of 1 year [2], infertility has garnered attention in the literature due to its association with mental health challenges. Recent studies have shown that women with infertility are more commonly diagnosed with depression, eating disorders, and anxiety. Add to that, psychiatric disorders, namely, depression cannot only affect the fertility potential of a woman but also negatively impact the fertility treatment outcome [3]. However, over the past two and a half decades, a discernible shift in perspective of infertility impact on mental health has emerged. Multiple studies have suggested that infertility could have plausible effects on women’s mental health and emotional well-being. A good number of infertile women report enhanced relationship satisfaction, improved partner intimacy, and positive changes in general [4–6]. This transition is posited as a manifestation of positive psychological growth, often identified as post-traumatic growth (PTG) [7]. PTG represents a transformative process or a shift in personality that can lead to improved relationships, newfound life possibilities, heightened life appreciation, and a greater sense of personal strength [8, 9]. This adaptive response to negative traumatic experiences is believed to be influenced by individual personality traits/determinants and resilience, serving as mechanisms that mitigate the stress associated with infertility and foster psychological growth [9–11]. Understanding the role of personality determinants that affect PTG and the individual’s adaptation to trauma had been lately the interest of the personality psychology field [12]. To note, one of the classifications of personality types is the affective personality type (APT) [13]. It is a combination of the positive affect (PA) and negative affect (NA) mood dimensions which are two central concepts that play a vital role in trauma resolution in the positive psychology field. The different combinations of PA and NA values form four APTs: self-actualizing (i.e., high PA and low NA), high-affective (i.e., high PA and high NA), low affective (i.e., low PA and low NA), and self-destructive (i.e., low PA and high NA) personalities [13].

The existing literature emphasises the impact of PA, NA, and APT on individuals’ reactions and coping mechanisms in stressful situations [14, 15]. As an example, flying squad policemen, food product employees, and victims of violence with high NA and PA or high-affective personalities reported higher PTG when compared to other APTs including self-actualizing personalities, while self-destructive personalities reported the lowest levels of PTG [13, 16, 17]. These results implied that NA might have an important role in trauma resolution in different populations. It was suggested that PA and NA play a role in thriving after trauma through the positive transformational coping of PA and the negative transformational coping of NA. This could explain how high-affective personalities have a high level of functioning because of the utilization of both positive and negative transformational coping unlike self-actualizing personalities [17]. For individuals navigating the challenging terrain of infertility and IVF, these experiences constitute stressful traumas, potentially impeding PTG through the transformational coping of NA.

Studies focusing on Arab women have shed light on the prevalent stigma and embarrassment associated with infertility diagnoses, hindering women from seeking fertility treatment and limiting their PTG [18–20]. By delving into the intricacies of PA, NA, and APT within the context of PTG among infertile Lebanese Muslim women undergoing IVF treatment, our study is poised to bridge a critical gap in the existing literature. In Lebanon, a Middle Eastern country marked by a dominant Arab Muslim masculine culture, limited attention has been devoted to unravelling the dynamics between APT and PTG in the realm of female infertility. The study contributes to this discourse by examining the interplay between APT and PTG in the specific context of infertile Lebanese Muslim women undergoing IVF.

Hypothesis 1.

We anticipate PA and NA being significant predictors of PTG in the studied population.

Hypothesis 2.

We anticipate a significant association between the different APTs and PTG in the studied population.

2. Data and Methods

A purposive sample was utilised in the administration of a cross-sectional exploratory quantitative survey within the Infertility Unit at the American University of Beirut Medical Centre (AUBMC). Infertile Lebanese Muslim women undergoing IVF treatment were invited to participate in the study by their treating IVF physician. Each participant, in an anonymous manner, completed a comprehensive booklet, comprising informed consent, measures, debriefing information elucidating the study’s topic and objectives, and a background survey encompassing details such as age, education, employment status, household income in US dollars for ease of comparison with other countries, infertility duration, and infertility diagnosis. Additionally, the booklet included the Post-traumatic Growth Inventory (PTGI) and the Positive and Negative Affect Schedule Short Form (PANAS-SF). The administration of booklets occurred in English, given the participants’ proficiency in English as a second language.

Inclusion criteria involved women of childbearing age (between 18 and 49 years old, $\mathit{M}=\mathbf{32.29}$, $\mathbf{S}\mathbf{D}=\mathbf{7.07}$) undergoing IVF treatment and grappling with infertility for over 3 years to ensure the emergence of PTG [21]. Exclusion criteria encompassed the presence of physical disabilities that could intensify stress related to infertility diagnosis, previously diagnosed with severe mental illness, or recent trauma.

Approval for the study was granted by the Internal Review Board (IRB) of the American University of Beirut. The ethical approval number is OGY.GG.15.

2.1. PTGI

The PTGI constitutes a comprehensive 21-item assessment tool meticulously crafted to gauge the extent of PTG after a distressing event, specifically focusing on the context of infertility in our study. These 21 items are thoughtfully slotted into five distinct factors, namely, relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. The respondents were tasked with the evaluation of each item within the 21-item inventory through a judiciously designed six-point Likert scale ranging from 0 to 5, resulting in an aggregate score capped at 105.

The PTGI, serving as a pivotal instrument in our study, has achieved widespread recognition and validation across various linguistic and cultural contexts. This validation encompasses languages such as Spanish, Chinese, Dutch, Japanese, Bosnian, Hebrew, Danish, Hungarian, Portuguese, and German. This cross-cultural validation underscores the robust applicability and reliability of the PTGI in diverse settings, enriching the comprehensiveness of our investigation into the psychological dynamics associated with infertility-induced stress.

2.2. PANAS-SF

To delineate the participants’ personalities, we employed the PANAS-SF, a psychometric tool developed by Thompson in 2007 [22], designed to measure both PA and NA. Serving as a concise iteration of the Positive and Negative Affect Schedule (PANAS) formulated by Watson et al. in 1988 [23], the PANAS-SF is recognised internationally for its reliability. Comprising 10 self-report items, it offers a succinct assessment of NA and PA, distributing these factors across two dimensions. The first factor encapsulates five PA items—active, determined, attentive, inspired, and alert—while the second factor includes five negative affect items—afraid, nervous, upset, hostile, and ashamed. Respondents provided their evaluations for each item on a five-point Likert scale, ranging from 1 (never) to 5 (always), culminating in a total score of 25 for each factor.

Utilising the scoring from PANAS-SF for PA and NA, participants were then placed into distinct APTs, as per the framework established by recent studies. These APTs include the self-fulfilling type characterised by high PA and low NA, the high affective type with elevated scores in both PA and NA, the low affective type marked by low PA and NA, and the self-destructive type exhibiting low PA and high NA. This classification system provides a nuanced understanding of participants’ affective profiles, enabling a more comprehensive analysis of their emotional dispositions in the context of infertility and IVF treatment.

The four APTs are presented in Table 1.

Table 1

The different APTs based on PA and NA scoring in PANAS-SF.

APT	PA score	NA score
Self-fulfilling (self-actualising)	≥ 18	≤ 14
High affective	≥ 18	≥ 14
Low affective	< 18	< 14
Self-destructive	< 18	≥ 14

2.3. Statistical Analysis

In this exploratory investigation, the analysis refrained from adjusting for multiple testing, following the approach proposed by Frane [24]. Nonetheless, a judicious examination was conducted, emphasising the verification of underlying assumptions, including but not limited to multicollinearity, outliers, normality, linearity, homoscedasticity, and independence of residuals. To elucidate the impact of APTs on PTG and compare the mean PTG scores across the four APTs, a one-way ANOVA was employed. Subsequently, the Hochberg post hoc test was applied to identify any discernible differences in PTG scores, especially in cases of unequal sample sizes among APTs. PTG served as the dependent variable, while the four APTs functioned as independent variables. Additionally, Kendall’s tau and Pearson’s correlation analyses were utilised to explore the relationship between PTG and demographic variables. Furthermore, a hierarchical multiple regression analysis was undertaken to forecast the association between PTG and PA and NA. Similarly, another hierarchical multiple regression model was employed to predict the correlation between PTG and the varied APTs.

3. Results

Out of the 337 infertile women initially approached, 106 participants agreed to partake, yielding a response rate of 31.4%. The participants in the study had a mean age of 32.29 years. Despite 49% of respondents holding at least a bachelor’s degree, a substantial 67% were unemployed, and 44% reported an income below $1000 per month. A comprehensive overview of the demographic data is available in Table 2. Classification based on PA and NA scores resulted in four APTs. The Self-fulfilling personality type was predominant, constituting 45% of the participants. Table 3 provides an overview of PTG-I, PANAS-SF scores, and the distribution of the four APTs within the studied population. The PTG score in the studied population was 72.45.

Table 2

Demographic data of the participants.

Variable	$\mathit{n}=\mathbf{106}$
Age (years)	$$32.29\pm 7$$
Infertility duration (years)	$$6.58\pm 3.6$$
Employment: $n$ (%)
Employed	35 (33%)
Unemployed	71 (67%)
Education level: $n$ (%)
less than high school education	16 (15.1%)
completed high school	26 (24.5%)
completed college degree	12 (11.3%)
completed a bachelor’s degree or higher	52 (49.1%)
Infertility diagnosis $n$ (%)
Female factor	28 (26.4%)
Male factor	38 (35.8%)
Mixed factor	18 (17%)
Unexplained infertility	22 (20.8%)
Household income: $n$ (%)
Less than $1000/month	47 (44.3%)
$1000/month to $2000/month	34 (32.1%)
$2000/month to $5000/month	22 (20.8%)
$5000/month to $10,000/month	3 (2.8%)

Table 3

PGTI, PANAS-SF scores, and APT of the participants.

Variables	Value	PGT score M (SD)	$\mathit{n}$ (%) $\mathit{n}=\mathbf{106}$	$\mathit{p}$ value
PANAS-SF
PA&	$$19.73\pm 3.83$$
NA&	$$12.68\pm 3.87$$
PTGI score@		72.45 (17.16)
APT				0.01a
Self-fulfilling (actualising)		83.54 (11.8)	48 (45.3%)
High affective		71.85 (15.89)	26 (24.52%)
Low affective		65.22 (11.07)	9 (8.49%)
Self-destructive		52.83 (9.17)	23 (21.69%)

^@Total score of 105.

^&Total score of 25.

^a: Significant value.

ANOVA analysis unveiled significant variations in PTG scores linked to APTs, denoted by F $\mathbf{3},\mathbf{102}=\mathbf{33.02}$, $\mathit{p}<\mathbf{0.01}$, $\mathit{\eta }\mathbf{2}\mathit{p}=\mathbf{0.49}$. The subsequent post hoc Hochberg test indicated noteworthy distinctions in PTG scores among the different APTs. Specifically, self-actualising personalities exhibited significantly higher PTG scores compared to high-affective, low-affective, and self-destructive personalities ($\mathit{p}<\mathbf{0.01}$), while self-destructive personalities displayed the significantly lowest overall PTG scores ($\mathit{p}<\mathbf{0.01}$; refer to Table 3 for details).

3.1. Association of Study Variables

3.1.1. PTG and Demographics

The findings revealed a significant positive association between PTG, and employment, education, and household income as shown in Table 4.

Table 4

Correlation coefficient values between PTG and demographics ($n=106$).

Demographic	PTG	Household income	Employment	Education level	Infertility diagnosis	Age	Infertility duration
PTG	1	0.26${}^{\ast \ast }$	0.26${}^{\ast \ast }$	0.34${}^{\ast \ast }$	0.01	0.04	0.01
Household income		1	0.13	0.35${}^{\ast \ast }$	0.22${}^{\ast \ast }$	___	___
Employment			1	0.49${}^{\ast \ast }$	−0.06	___	___
Education level				1	0.11	___	___
Infertility diagnosis					1	___	___
Age						1	0.45${}^{\ast \ast }$
Infertility duration							1

${}^{\ast \ast }$Correlation is significant at the 0.01 level (2-tailed).

For Hypothesis 1, asserting that PA and NA would be significant predictors of PTG, a hierarchical multiple regression was conducted. Demographics were introduced in Step 1, explaining 22.3% of the variance in PTG. Upon incorporating PA and NA values in Step 2, the model’s overall variance explanation increased to 59.1%, F $\mathbf{8},\mathbf{97}=\mathbf{19.93}$, $\mathit{p}<\mathbf{0.001}$. The additional 36.8% variance in PTG was elucidated by PA and NA after accounting for demographics. The results indicated that PA emerged as a significant positive predictor of PTG ($\mathit{\beta }=\mathbf{0.55}$, $\mathit{p}\mathit{r}\mathbf{2}=\mathbf{0.71}$, $\mathit{p}<\mathbf{0.001}$), while NA emerged as a significant negative predictor of PTG ($\mathit{\beta }=-\mathbf{0.24}$, $\mathit{p}\mathit{r}\mathbf{2}=-\mathbf{0.51}$, $\mathit{p}<\mathbf{0.001}$) (refer to Table 5).

Table 5

Hierarchical multiple regression analysis of the significant predictors of PTG for Hypothesis 1: predicting PTG from PA/NA.

Predictor	PTG
	$\mathit{\Delta }{\mathit{R}}^{\mathbf{2}}$	ẞ
Step 1	0.267${}^{\ast \ast }$
Control variablesa
Step 2	0.355${}^{\ast \ast }$
Positive affect		0.55${}^{\ast \ast }$
Negative affect		−0.24${}^{\ast \ast }$
Total $R^2$	0.62${}^{\ast \ast }$
$$\mathit{n}$$	106

^aControl variables included age, infertility duration, household income, education level, employment, and infertility diagnosis.

${}^{\ast }\mathit{p}<\mathit{0.05}$.

${}^{\ast \ast }\mathit{p}<\mathit{0.01}$.

Moving to Hypothesis 2, which proposed that APTs, specifically self-actualising, high-affective, and low-affective personalities, would be significant predictors of PTG, another hierarchical multiple regression was employed. APTs were created through median split dichotomization, and each APT was coded accordingly. Demographics explained 22.3% of the variance in PTG. Upon entering the three APTs in Step 2, the model explained 49.9% of the total variance, $\mathit{F}\mathbf{9},\mathbf{96}=\mathbf{12.63}$, $\mathit{p}<\mathbf{0.001}$. The three APTs accounted for an additional 27.6% of the variance in PTG, after controlling for demographics. The results indicated that self-actualising personality was the first significant positive predictor of PTG ($\mathit{\beta }=\mathbf{0.39}$, $\mathit{p}\mathit{r}\mathbf{2}=\mathbf{0.51}$, $\mathit{p}<\mathbf{0.001}$), and high-affective personality was the second significant positive predictor of PTG ($\mathit{\beta }=\mathbf{0.39}$, $\mathbf{p}\mathbf{r}\mathbf{2}=-\mathbf{0.03}$, $\mathit{p}<\mathbf{0.001}$). However, low-affective personality did not emerge as a significant predictor of PTG in this model ($\mathit{\beta }=\mathbf{0.14}$, $\mathit{p}\mathit{r}\mathbf{2}=-\mathbf{0.19}$, $\mathit{p}>\mathbf{0.05}$) (see Table 6).

Table 6

Hierarchical multiple regression analysis of the significant predictors of PTG for Hypothesis 2: predicting PTG from APTs.

Predictor	PTG
	$\mathit{\Delta }{\mathit{R}}^{\mathbf{2}}$	ẞ
Step 1	0.26${}^{\ast \ast }$
Control variablesa
Step 2	0.27${}^{\ast \ast }$
Self-actualizing personality		0.78${}^{\ast \ast }$
High-affective personality		0.39${}^{\ast \ast }$
Low-affective personality		0.14
Total $R^2$	0.54${}^{\ast \ast }$
$$\mathit{n}$$	106

^aControl variables included age, infertility duration, household income, education level, employment, and infertility diagnosis.

${}^{\ast \ast }\mathit{p}<\mathit{0.01}$.

4. Discussion

Our results showed a low participation rate with only 1/3 of the approached patients agreeing to take part. Almost half of the respondents had the self-actualising personality type who had significantly higher PTG scores among the four APTs. As expected, PA and NA were found to be significant predictors of PTG, hence supporting Hypothesis 1. The self-actualising personality was found to be the most significant predictor of PTG, while only the low APT did not emerge as a significant predictor of PTG.

The low participation rate could be precipitated by the social stigma that infertile women face, hence shying away from sharing their opinions. It is unfortunate that up to this date, women diagnosed with infertility suffer from variable forms of psychological/domestic physical violence, marital problems, social isolation/exclusion, and partial deprivation including being disregarded by family members and relatives and reducing social interactions with the infertile woman up to the extent of social alienation [25]. A recent study has also shown that Muslim women diagnosed with infertility suffer from identity crisis as well as low self-esteem and depression [26].

The PGT score documented in our study is 72.45 with SD of 17.16. This value is considered to be on the higher end of the reported PTG scores (40–83) [27] similar to the PTG score of Chinese infertile patients ($\mathit{M}=\mathbf{64.81}$, $\mathbf{S}\mathbf{D}=\mathbf{16.20}$) [28]. Our results showed that PA had a positive significant association while NA had a negative significant association with PTG. These outcomes were consistent with the already published data about PA prediction of PTG and the positive correlation between PA and the adversarial growth in infertile women [28]. In the latter study, the authors found that resilience and social support promote PA which in turn helps the patients perceive negative events such as infertility as less threatening and hence achieve PTG [28, 29]. Add to that, a recent study showed that husbands’ resilience also promoted the PTG of their wives in the setting of infertile couples highlighting the importance of treatment approaches of the couple per se and not individually [30]. Previous studies suggested that PA can help overcome aversive events and achieve individual growth through the utilization of PA in decreasing NA, and consequently reduce distress through positive emotions [29].

In the present study, patients of different APTs experienced variable degrees of PTG. In our model, the self-actualizing (self-fulfilling) personality was found to be the most significant predictor of PTG with the highest PTG scores among the 4 APTs ($\mathit{M}=\mathbf{83.54}$, $\mathbf{S}\mathbf{D}=\mathbf{11.8}$). These findings were in line with the outcomes of Norlander et al. [13]. However, our results differed from other previous publications where high-affective and not self-actualizing personalities predicted the highest scores of PTG for male and female victims of violence and for male food product employees and flying squad policemen [16, 17]. A possible explanation for the discrepancies might be the way patients respond to different types of stressors, the severity of the stressor as well as potential gender differences in how the stressor is perceived. Given that the PTG scores in infertile patients are higher than in the other populations studied (cancer patients, motor vehicle accident survivors, etc.) as already mentioned, different levels of interactions between PA and NA (i.e., different APTs) might be needed to attain PTG. On another level, it is known that women are less resilient and have a lower quality of life when diagnosed with infertility as compared to their husbands’[28, 30]. This might be precipitated by the social stigma and blame that women are subjected to by the society due to the inability to bare children especially in the societies where procreation is of high importance such as the Middle Eastern countries [20]. Add to that, the importance of having social support as well as good marital relationships in attaining the personal growth has been documented in multiple studies [30, 31]. Thus, the lack hereof might increase the influence of NA which supports the broaden-and-build theory that proposed that PA can serve as a marker of flourishing to achieve psychological growth and NA can serve as a direct adaptive benefit for survival in threatening events [32]. As a result, we postulate that having high levels of PA and NA (i.e., self-actualizing APT) becomes important in attaining PTG specifically in infertile patients.

Furthermore, we found a positive correlation between PTG and household income, educational level, and employment. These findings coincide with the findings of a recent study from China reporting improved PTG post COVID as well as parents of premature infants and cancer survivor patients [33–35]. Household income, education, and employment might have the ability to increase women’s PTG in their fertility treatments, especially with the relatively high costs of IVF treatments [36].

The research design acknowledges the scarcity of studies exploring the interplay between APT and PTG in the context of infertile Lebanese Muslim women—a population embedded in a Middle Eastern culture characterised by a dominant Arab Muslim masculine culture. The study’s motivation, as outlined in the introduction, is grounded in the observed literature gap, contributing to the existing body of knowledge while guiding physicians and infertility specialists in providing holistic care. This is of outmost importance given the stigmatisation and social pressure as well as the relational aggression that infertile women might face when diagnosed with infertility [37]. On the other hand, providing the patients with social support, relationship support with resilient husbands, and addressing the emotional well-being of the patients as a couple could improve the personal growth of the infertile patients.

Of the strength of our study is that it addresses a literature gap, exploring the experiences of infertile Lebanese Muslim women. Cultural context adds richness, emphasising the need for culturally sensitive interventions. In practical terms, our findings guide healthcare professionals in tailoring interventions for diverse emotional responses and personality types in infertile patients, enhancing overall well-being. In essence, this study contributes to understanding PTG in infertile women, thereby placing the emphasis on the interconnectedness between emotional states and personality traits. It takes a step toward a holistic, culturally informed approach for supporting those undergoing IVF treatment.

One of the limitations of our study is that it was performed in one IVF centre in the capital of Lebanon—Beirut. It also targeted only Muslim women which limits the generalisability of the findings of this study to infertile patients of other confessions and religious believes. Add to that the truthfulness of the self-reported variables that would be difficult to evaluate. Nevertheless, given that this is the first study of its kind in the Middle East to the best of our knowledge, we believe that the findings of this study can lay the foundation for future, more elaborate nationwide studies targeting the infertile population.

5. Conclusion

In conclusion, this study delves into the complexities of PTG among infertile Lebanese Muslim women undergoing IVF. Our findings highlight the significance of emotional states, with PA and NA predicting PTG. The study aligns with contemporary perspectives on mood dimensions shaping responses to traumatic events, emphasising holistic emotional well-being in infertility. APT exploration reveals distinctive patterns, focusing on individual traits in adapting to infertility challenges. Differences in PTG among APTs underscore psychological growth complexity. Notably, self-actualising and high-affective personalities are significant PTG predictors, placing the emphasis on adaptive traits in infertility stressors.

Author Contributions

All authors contributed to the study’s conception and design. Material preparation: Anastasia A. Salame. Fatin Khalifeh and Ghina Ghazeeri performed data collection and analysis. The first draft of the manuscript was written by Fatin Khalifeh, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. All authors met the ICMJE criteria.

Funding

The authors received no specific funding for this work.

Acknowledgments

With his permission, we would like to acknowledge the efforts of Mr Stamatis Elntib in supporting the study conception and design.

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