1. Introduction
Infertility is defined as inability to conceive pregnancy despite regular sexual intercourse for more than a year without the use of contraceptives [1, 2], which affects various aspects of the life in infertile couples [3]. According to the World Health Organization, quality of life (QoL) is defined “an individual’s understanding of their position in life in context of the cultur and value systems in which they live is relation to their goals, expectations, standards, and concerns” [7]. About 32% of women in early infertility stages may be at risk for mental health problems [11]. The effect of psychotherapy on improving satisfaction and QoL in infertile women has been shown in different studies [6]. It is necessary to use specific and effective counseling to reduce the psychological and social problems of infertile women. Therefore, the present study aims to investigate the effect of infertility counseling on the QoL of infertile couples based on a couple therapy approach.
2. Materials & Methods
This is a randomized clinical trial (Code: IRCT2017080124866N4). The study population consists of all infertile couples referred to an infertility treatment clinic in Kerman province, Iran. They had primary infertility seeking treatment for the first time and had not received psychiatric or psychological treatments. Exclusion criteria were the occurrence of pregnancy during counseling sessions or being absent from two counseling sessions. Sampling was done using a convenience method. In this regard, 30 couples were randomly assigned into the intervention group and 30 couples to the control group. The control group received routine treatment during six sessions of counseling for couples in the intervention group. The Fertility Quality of Life (FertiQoL) questionnaire was used to measure QoL. It has 24 items rated on a 5-point Likert scale and four subscales of the emotional, mind-body, relational, and social [21]. At the end of the last session [27, 28], the post-test assessment was conducted in both groups. Data were analyzed in IBM SPSS software v. 19.
3. Results
According to Chi-square test results, there was no statistically significant difference in gender, occupation, age, and level of education between groups at baseline (P>0.05) and the two groups were homogeneous in terms of demographic characteristics (Table 1).


Comparing the pretest QoL scores of infertile couples in the intervention (59.70±13.04) and control (58.15±12.39) groups, results showed no significant difference before counseling (P=0.55). The post-test score of QoL in the intervention and control groups was 70.56±6.49 and 57.76±12.26, respectively which was significantly different (P<0.0001). The QoL score in the intervention group before and after counseling was different, which was statistically significant (P <0.0001). It indicates the improvement of QoL in the intervention group compared to the control group (Table 2).


4. Discussion & Conclusion
The results of the present study showed that the infertility counseling was able to improve the QoL of infertile couples. The findings are consistent with the results of previous studies including Hakim et al.’s study on the effect of preparatory psychological counseling couples for medically assisted reproduction [29]. Namdar et al. showed that the QoL of infertile women in social dimension is low [38]. Farshi et al. examined the effect of self-care counseling on psychological disorders and QoL in infertile woman, and showed that the counseling improved the emotional and relational aspects of QoL [39]. Haica et al.’s study showed that the combination of music therapy with psychological intervention improved the emotional and social dimensions QoL, but had no effect on its relational domain [40]. This is consistent with the present study.
Counseling can improve the QoL, reduce anxiety, increase knowledge, enhance perception of goals in life, improve adaptive behaviors and patient adjustment, and prevent spending high costs for treatment. It can be concluded that the infertility counseling used in our study can improve the QoL of infertile women and subsequently cause their more satisfaction and cooperation in infertility treatment.

Ethical Considerations
Compliance with ethical guidelines
This study was registered with the ethics code IR.KMU.REC.1395.678 and clinical trial code number IRCT2017080124866N4 in Kerman University of Medical Sciences.

Funding
This study was extracted from the MA. thesis of first author at Department of Midwifery, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman. It was funded by Kerman University of Medical Sciences.

Authors' contributions
Conceptualization: Tayebeh Mokhtari Sorkhanii and Katayoun Alidousti; Methodology and data collection: Tayebeh Mokhtari Sorkhani and Atefeh Ahmadi; Data analysis: Moghaddameh Mirzaee; writing, editing & review: All authors.

Conflicts of interest
The authors declare no conflict of interest

Acknowledgements
The authors would like to thank the Vice-Chancellor for Research of Kerman University of Medical Sciences, and all couples participated in this research for their support and cooperation.
 

References

1. Vetriselvi V. Infertility & Counselling. Int J Nurs Educ. 2013; 5(2):229. [DOI:10.5958/j.0974-9357.5.2.101]
2. Mezreji HS, Toozandehjani H. Efficacy of group reality therapy on anxiety in infertile women undergoing treatment with assisted reproductive techniques IUI. Mediterr J Soc Sci. 2016; 7(3):127-37. [DOI:10.5901/mjss.2016.v7n3s3p127]
3. Manouchehri K, Zandipour T, Pourshahriari T, Mirdamadi SR. [The study of effectiveness of cognitive, emotive, behavioral group counseling on mental health of infertile women (Persian)]. J Couns Res Dev. 2007; 5(20):9-22. [Link]
4. De Berardis D, Mazza M, Marini S, Del Nibletto L, Serroni N, Pino MC, et al. Psychopathology, emotional aspects and psychological counselling in infertility: A review. Clin Ter. 2014; 165(3):163-9. [PMID]
5. Karimi FZ, Taghipour A, Latifnejad Roudsari R, Kimiaee SA, Mazloum SR, Amirian M. [Psycho - social effects of male infertility in Iranian women: A qualitative study (Persian)]. Iran J Obstet Gynecol Infertil. 2016; 19(10):20-32. [Link]
6. Seyedi Asl ST, Sadeghi K, Bakhtiari M, Ahmadi SM, Nazari Anamagh A, Khayatan T. Effect of group positive psychotherapy on improvement of life satisfaction and the quality of life in infertile woman. Int J Fertil Steril. 2016; 10(1):105-12. [PMID]
7. Xiaoli S, Mei L, Junjun B, Shu D, Zhaolian W, Jin W, et al. Assessing the quality of life of infertile Chinese women: A cross-sectional study. Taiwan J Obstet Gynecol. 2016; 55(2):244-50. [PMID]
8. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess. 1985; 49(1):71-5. [PMID]
9. Shah R, Kulhara P, Grover S, Kumar S, Malhotra R, Tyagi S. Contribution of spirituality to quality of life in patients with residual schizophrenia. Psychiatry Res. 2011; 190(2-3):200-5. [PMID]
10. Anderson K, Nisenblat V, Norman R. Lifestyle factors in people seeking infertility treatment - A review. Aust N Z J Obstet Gynaecol. 2010; 50(1):8-20. [PMID]
11. Hashemi S, Simbar M, Ramezani-Tehrani F, Shams J, Majd HA. Anxiety and success of in vitro fertilization. Eur J Obstet Gynecol Reprod Biol. 2012; 164(1):60-4. [PMID]
12. Ried K, Alfred A. Quality of life, coping strategies and support needs of women seeking Traditional Chinese Medicine for infertility and viable pregnancy in Australia: A mixed methods approach. BMC Womens Health. 2013; 13:17. [PMID]
13. Ashraf DM, Ali D, Azadeh DM. Effect of infertility on the quality of life, a cross- sectional study. J Clin Diagn Res. 2014; 8(10):OC13-5. [PMID]
14. Rashidi B, Montazeri A, Ramezanzadeh F, Shariat M, Abedinia N, Ashrafi M. Health-related quality of life in infertile couples receiving IVF or ICSI treatment. BMC Health Serv Res. 2008; 8(1):186. [PMID]
15. Keramat A, Masoomi SZ, Mousavi SA, Poorolajal J, Shobeiri F, Hazavhei SMM. Quality of life and its related factors in infertile couples. J Rese Health Sci. 2013; 14(1):57-64. [Link]
16. Namavar Jahromi B, Mansouri M, Forouhari S, Poordast T, Salehi A. Quality of life and its influencing factors of couples referred to an infertility center in Shiraz, Iran. IInt J Fertil Steril. 2018; 11(4):293-7. [PMID]
17. Piché ML, Babineau V, Robitaille J, Lachance É, Ruchat SM. Lifestyle-related factors associated with reproductive health in couples seeking fertility treatments: Results of a pilot study. Int J Fertil Steril. 2018; 12(1):19-26. [PMID]
18. Baniaghil AS, Zarei Abolkheir A, Keshavarz A, Ahmadi SM, Vakili MA. [The effect of integrated third-party reproduction counseling on egg donation recipients’ attitude towards assisted reproductive techniques (Persian)]. Iran J Obstet Gynecol Infertil. 2017; 19(36):1-10. [Link]
19. Khayata GM, Rizk DEE, Hasan MY, Ghazal-Aswad S, Asaad MAN. Factors influencing the quality of life of infertile women in United Arab Emirates. Int J Gynecol Obstet. 2003; 80(2):183-8. [DOI:10.1016/S0020-7292(02)00387-9]
20. Karabulut A, Özkan S, Oğuz N. Predictors of fertility quality of life (FertiQoL) in infertile women: Analysis of confounding factors. Eur J Obstet Gynecol Reprod Biol. 2013; 170(1):193-7. [PMID]
21. Huppelschoten AG, van Duijnhoven NT, Hermens RP, Verhaak C, Kremer JA, Nelen WL. Improving patient-centeredness of fertility care using a multifaceted approach: Study protocol for a randomized controlled trial. Trials. 2012; 13:175. [PMID] [PMCID]
22. Hsu PY, Lin MW, Hwang JL, Lee MS, Wu MH. The fertility quality of life (FertiQoL) questionnaire in Taiwanese infertile couples. Taiwan J Obstet Gynecol. 2013; 52(2):204-9. [PMID]
23. Maroufizadeh S, Ghaheri A, Omani Samani R. Factors associated with poor quality of life among Iranian infertile women undergoing IVF. Psychol Health Med. 2017; 22(2):145-51. [PMID]
24. Santoro N, Eisenberg E, Trussell JC, Craig LB, Gracia C, Huang H, et al. Fertility-related quality of life from two RCT cohorts with infertility: Unexplained infertility and polycystic ovary syndrome.Hum Reprod. 2016; 31(10):2268-79. [PMID]
25. Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): Factor structure, internal consistency and construct validity. BMC Public Health. 2009; 9:341. [PMID]
26. Miri M, Aizadeh M, Moasheri N, Ataee M, Moodi M. [The effects of relationship enrichment program on compatibility and marital satisfaction of infertile couples (Persian)]. J Health Lit Res. 2016; 1(1):53-60. [Link]
27. Mosalanejad L, Rasekh Jahromi A, Sobhanian S. Efficacy of spiritual group psychotherapy on the infertility consequences: A randomized clinical trial. Zahedan Journal of Research in Medical Sciences. 2014; 16(9):34-9. [Link]
28. Faramarzi M, Pasha H, Esmailzadeh S, Kheirkhah F, Heidary S, Afshar Z. The effect of the cognitive behavioral therapy and pharmacotherapy on infertility stress: A randomized controlled trial. Int J Fertil Steril. 2013; 7(3):199-206. [PMID]
29. Hakim LZ, Newton CR, MacLean-Brine D, Feyles V. Evaluation of preparatory psychosocial counselling for medically assisted reproduction. Hum Reprod. 2012; 27(7):2058-66. [PMID]
30. Li J, Long L, Liu Y, He W, Li M. Effects of a mindfulness-based intervention on fertility quality of life and pregnancy rates among women subjected to first in vitro fertilization treatment. Behav Res Ther. 2016; 77:96-104. [PMID]
31. Domar AD, Gross J, Rooney K, Boivin J. Exploratory randomized trial on the effect of a brief psychological intervention on emotions, quality of life, discontinuation, and pregnancy rates in in vitro fertilization patients. Fertil Steril. 2015; 104(2):440-51 e7. [PMID]
32. Moshrefi Z. [The effectiveness of positive psychotherapy on body image and quality of life in infertile women (Persian)]. Paper presented at: The first International Conference on Modern Research in The Field of Education and Psychology and social studies of Iran. 13 June 2016; Qom, Iran. [Link]
33. Zarbakhsh M, Shoahasani Z, Zahiri Z, Hafshjani F, Khademi M. [Effects of stress management training and problem solving on quality of life and life expectancy among infertile women (Persian)]. Pajouhan Sci J. 2013; 11(4):1-10. [Link]
34. Masoumi SZ, Khani S, Kazemi F, Kalhori F, Ebrahimi R, Roshanaei G. Effect of marital relationship enrichment program on marital satisfaction, marital intimacy, and sexual satisfaction of infertile couples. Int J Fertil Steril. 2017; 11(3):197-204. [Link]
35. Najafi M, Soleimani A, Ahmadi KH, Mahboubi M. [Investigating the effectiveness of emotion-focused couple therapy (EFT) on increasing the compatibility of infertile conflicted couples and its role in sexual satisfaction and quality of life (Persian)]. J Clin Care. 2014; 2:6-50. [Link]
36. Maschi MS, Sodagar S, Jomehri F, Hosseinzadeh Taghvai M, Forootan M. [Effectiveness of cognitive- behavioral therapy on pain intensity and stress coping styles in patients with gastric wound (Persian)]. J Arak Uni Med Sci. 2020; 23(6):860-71. [DOI:10.32598/jams.23.6.6164.1]
37. Appleton TC, Baetens P, Baron J, Bitzer J, Boivin J, Corrigan E, et al. Guidelines for counselling in infertility. Special interest group‘psychology and counselling’. Belgium: European Society of Human Reproduction and Embryology; 2002. [Link]
38. Namdar A, Naghizadeh MM, Zamani M, Yaghmaei F, Sameni MH. Quality of life and general health of infertile women. Health Qual Life Outcomes. 2017; 15(1):139. [PMID]
39. Farshi N, Hasanpour S, Mirghafourvand M, Esmaeilpour K. Effect of self-care counselling on depression and anxiety in women with endometriosis: A randomized controlled trial. BMC Psychiatry. 2020; 20(1):391. [PMID]
40. Haica C, Ene F. Music therapy associated with psychological intervention effect on infertile patients quality of life. Romanian J Psychol Stud. 2019; 12-9. [Link]