Psychological Needs of Patients Undergoing Infertility Treatment and Nurses' Support

This dissertation explores the psychological needs of patients or couples undergoing infertility treatment and how nurses can provide support. The study finds that patients require motivation and mental health support, with women needing additional mental support. Psychological support is crucial for successful treatment.

Dissertation
Table of Contents
ABSTRACT
Chapter 1 INTRODUCTION
Chapter 2 METHODOLOGY
2.1 Search Strategy
2.2 Critiquing Tool
2.3 Limitations
2.4 Decision on Articles
2.5 Main themes
Chapter 3 CRITICAL REVIEW OF DATA
Chapter 4 DISCUSSION AND SERVICE IMPROVEMENT PLAN
REFLECTION
CONCLUSION
REFERENCE
APPENDIX 1
APPENDIX 2
APPENDIX 3
APPENDIX 4
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APPENDIX 5
REFERENCES
References
ABSTRACT
Purpose – to identify the psychological needs of patients or couples who are undergoing
infertility treatment and how nurses can overcome challenges.
Methods – A critical review of qualitative and quantitative data from articles and journals.
Findings- The main psychological needs of patients or couples are motivation and mental health
support. They want to get relief from stress and anxiety. Moreover, women highly need mental
support from nurses as they get demotivated after undergoing infertility treatment. Besides that,
social and psychological support has been required by couples. It has been stated that in order to
access supplementary services psychological support is needed.
Conclusion – It is summarised that psychological support is required to patient during infertility
treatment. This will enable in meeting their needs and successful treatment of infertility. Here,
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Watson theory of human care can be used. It will be useful in decreasing stress. Alongside,
counselling sessions can also be provided to them to enhance psychological support. In addition
to it, theory of human caring decreases negative impact of infertility on women or couples.
Through that, it will be easy to deal with patients.
Summary:
What is known on subject already?
In recent times, infertility issue is highly rising among the women. This is making them unable to
give birth to child. However, women who have gone through infertility treatment remain stressed
and suffers from depression. Alongside, it is evaluated that anxiety is major cause for women of
infertility. It leads to fear among them. Due to this, their behaviour is influenced. They feel highly
stressed during treatment. It has been evaluated that women or couple undergoing infertility
treatment faces many issues.
What does this review add?
The review will summarise areas related to factors that lead to difficulties among women. Also, it
will show psychological impact leads to distress. Besides that, study will show how needs of
women can be identified and what type of strategies can be used.
Key Words: Infertility , Psychological, Conception, IVF
treatment, Treatment ,Wellbeing , Mental health , Distress
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Chapter 1 INTRODUCTION
Title: How does patient undergoing infertility treatment, nurses can provide support with
conception challenges which can address the psychosocial needs of the patient or couple?
Infertility is a disease which is affecting life style of people (Jodar et al., 2017). Married couples
are facing the problems of infertility because that women are not able to achieve the clinical
pregnancy. Treatment for infertility is complex and time-consuming. There are certain infertility
couples which are dealing with stress and trauma because of these diseases. As per
Bisht et.al (2017), infertility is affecting the 10 to 15 % couples. In case in which there is
unexpected loss for couples after infertility treatment, couples are only left with option of
adapting. Due to these, couples are dealing with stress and these stresses will affect the life style
of people. In many cases woman is undergoing treatment of infertility and in case of it fails,
women are facing many problems regarding their health. Childless women are undergoing stress
and trauma which will affect the psychosocial condition of women. The life of women is
affected, and they will face problems in life (Mehta et al., 2016). Women with infertility will
deal with the negative emotional pressure which will include shock, anger, and isolation. Many
women are using treatment of In Vitro Fertilization (IVF) even when treatment is complicated
and it will include many uncomfortable procedures for them. In many cases treatment of IVF
fails and these will affect health of women. In case of infertility among couples’ women are
affect but men are also affected and so, they will also face stress and trauma.
Infertility is affecting life of people because people are not able to expand their family which will
affect life of couples. Couple are opting for treatment related measures which will not affect the
life of people but in this case several treatments have been started. In order to fee from these
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problems people are using treatment, and they are not aware about the severe health problems
which will be faced by women so, these research project will provide knowledge regarding
treatment and the effect of treatment on health of people. Due to these conditions’ women are not
able to do work, and they are dealing with mental pressure and psychological conditions are
affected (Okafor Joe-Ikechebelu and Ikechebelu, 2017).
This dissertation will identify psychosocial needs of patient and couples undergoing infertility
treatment and challenges. Infertility is affecting life style of people and couples are dealing with
stress and trauma. People are dealing with stress and the physiological condition of couple are
affected. In case of treatment is not successful women will deal with problems of health.
Research have included research related method and strategies. It includes critical evaluation of
influence of infertility among married couples. In these type of case women needs support form
family which will help them to overcome these problems. The research has discussed the
treatment of infertility and the effect of the treatment on health of women.
These all have affected the health of women because women are not to handle stress and manage
the health conditions. Effects, factors and consequences are being discussed in report. It will
include certain condition is which woman are not able to survive because of failure in treatment
of infertility. These will not only affect the health of women but it will affect the health of male
as well. The aim this of study is to identify the psychosocial needs of patients or couples who are
undergoing infertility treatment and challenges faced by them.
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Chapter 2 METHODOLOGY
2.1 Search Strategy
Before the search was started, an area of interest was identified and PICOT (P--Patient/Problem,
I—Intervention, C—Comparison, O—Outcome) was created with the help of the supervisor. The
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PICOT approach can help in the definition and clarification of research questions and having the
question right increases the probability of a solution to the issue ( Thabane, Thomas, and Paul,
2010). The PICOT question identified as “How does patient undergoing infertility treatment,
nurses can provide support with conception challenges which can address the psychosocial needs
of the patient or couple?” A broad range of primary literatures have been explored utilizing
computer through UWE library initially and medical databases such as, British Nursing
Database, Cochrane Reviews, PubMed, MEDLINE and CINAHL. The key literature terms used
can be found in the Appendix……There are certain key terms, including some suffixes which
helps is relevant literature search (Pan et.al, 2019).
The initial search provided some undesirable results, therefore Boolean Operators and
trunctation were used. Strategies for optimizing searches are also suggested by using truncation,
Boolean operators and search limits using these methods may assist in more successful literature
reviews and may help with decision-making on evidence-based practice (Robb and Shellbarger,
2014). The basic Boolean search method ' ' and '' and ' ' or '' were used to broaden and specify the
content of the search. it results to further narrowed down the search results.
2.2 Critiquing Tool
The research critiquing is a structured method for the evaluation of research studies and the
reported results (Lee, 2016). CASP (Critical Appraisal Skills Program) helps to consistently
determine the reliability, validity and outcomes of published research (Knowles and Gray, 2011).
Different CASP checklists were established to review eight types of research. While there are
many critical evaluation methods that can be used as guidelines, the CASP tools are concise and
clearly cover the areas needed for critical evaluation of proof (Nadelson and Nadelson, 2014).
This tool will therefore be used for the methodological examination of the articles selected for
Chapter 03. Using the framework for reviewing a research article can be beneficial, more general
and specific questions will be asked when implemented within a critical evaluation system
(Baker, 2014).
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2.3 Limitations
This research study also has got some potential limitations on it. At first, non-English
publications were excluded due to a lack of understanding other languages. In addition, in order
to effectively complete the research, abstract and peer reviewed were included which narrowed
down the search. Additionally, access to the literature was a barrier because of the nonexistence
of full text in many research articles. Moreover, it was difficult to accept 8 articles from the
supervisor, as initially, the articles were not fit in the PICOT question which was formed.
Primary research is included in this study and will have negative impact on research in the event
of a lack of discussion (Zhuoran Wanpeng, Tao and Coates, 2018). The research was also limited
to 10 years (2009-2019) in order to obtain the latest research papers. Furthermore, a research like
this was not carried out in the local context. Infertility is an issue here in Maldives and if a
research was carried out on, it could have been a benchmark for this dissertation.
2.4 Decision on Articles
2.5 Main themes
Main themes identified from the 8 articles are, to provide psychological and counselling support
to cope with infertility, Watson’s theory of human caring is recommended as a guide to nursing
patients with infertility treatment and health education and awareness before IVF treatment.
Theme Description
1 To provide psychological and counselling support to cope with infertility
2 Watsons theory of human caring is recommended as a guide to nursing patients with
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infertility treatment
3 Health education and awareness before IVF treatment
.
Chapter 3 CRITICAL REVIEW OF DATA
This chapter shows requirements of psychological and counselling support to cope up
with infertility and satisfy all needs of couples with infertility (Lawson, 2016). It will also show
importance of using different ways of satisfying psychological needs which can help couples
with infertility in understanding their behaviour and providing them support which they seek for.
Further, this literature review will analyse both impacts positive and negative and also will show
that whether physiological needs is beneficial or counselling support to cope with infertility.
Lastly it will analyse different types of counselling support which can be used to support couples
with infertility.
Theme 1: Providing psychological and counselling support to cope with infertility
Zagami. et.al., (2019) stated importance of some requirements which infertile couples
seek after unsuccessful fertility treatment. The main aim of this study and articles is to gain
direct knowledge of the experiences of all involved patients about infertility topic and provide all
those information for clinical interventions in order to cope with infertility. This study was
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conducted in an Iranian infertility centre. It is stated that in Iran prevalence of infertility is
about 21.1%. For this study, researcher has conducted descriptive qualitative methodology in
an Iranian infertility centre. It is stated that this method is useful for this study because with its
help, researcher can gain a deep information about all relevant questions like the need for
physiological support as well as counselling by third party (Logan and et.al., 2019). Total 29
individual are being selected in this study as a sample which includes 9 couples, 9 women, 2
men by using purposive sampling. All relevant information regarding needs after failure of
infertility treatment collected by conducting semi-structured interviews. In Iran approximate,
29000 IUI and almost 35000 IVF and ICI cycle were performed in the year of 2011. From the
systematic review of this study, it is identified that infertile women as well as couples with
infertility who experienced a failure treatment has high level of stress, low self-esteem and low
morale. The main cause of infertility which is being identified in this study is male factor such as
abnormal sperm production, some female factors such as: fallopian tube damages and both male
and female factors include mixed and some are unexplained (Crawshaw and Daniels, 2019). All
participants in this study were the age group of 21-46 years and duration of infertility was also
identified which was 10 months-18 months. Some physiological needs which women see is care
given by their partner as well as society. Some participants were sad due to lack of support and
stated that it decreases mental health. The need of empathy was found the most important need
which couples with infertility seek after failure and at the time of infertility treatment (Pasch and
et.al.,2016).
Vinitha, Judith and Shobha (2015) stated importance of some physiological needs and
coping strategies which infertile women seek for after and at the time of infertility treatment.
They stated that infertility and failure of treatment have several negative impacts on their health
and their well-being. The main aim of this study is to identify coping strategies and psychosocial
well-being of women with infertility (Mahadeen and et.al., 2018). For this study, researcher has
conducted qualitative methodology in the US in which they identify that women who use
coping strategies like avoidance of reminders of infertility have the best as well as regaining
control, share their burden and deal with the problem of infertility in an efficient manner. For
collecting more relevant information about the psychological well-being and coping strategies,
researcher conducted a cross-sectional survey and for that they took 180 participants as a
sample. All participants were infertile women with the age group of 20-40. This study and
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survey were conducted in infertility clinics of Udupi district Karnataka. In the data collection
process, it is stated that the majority of the study population was 146 (81.1%) which was
moderate level, good psychological well-being was 33 (18.3%) and only 1 (0.6%) had poor
psychological well-being. All selected women were those who were seeking for treatment from
infertility clinic of Udupi district. The main reason of selecting this clinic is it has all
infrastructure facilities. Researcher also developed a validated questionnaire on psychological
well-being (Rooney and Domar, 2018). In the questionnaire, they also focused on demographic
which includes: biological characteristics of women such as: education, age, causes etc. In the
result of this study, relationship between psychological well-being and coping strategies were
identified (Moudi and et.al., 2019). It is identified in this study that lower the psychological well-
being higher the coping strategies which involve: Self-controlling, social support etc. Total scale
of psychosocial well-being and WOC questionnaire were negatively correlated. The correlation
was (R=-0.42, p<0.01). In the discussion part it can be said that severe psychological problems
have impact on their everyday life. For discussing results, researcher made an effective use of
exploitative study. In the psychological problems some major problems which women with
infertility face include: feelings of stress (35%), anger (20%) as well as guilt of infertility was
8%. So, it can be said that quality of life of women can be influenced by instrumental as well as
emotional support. All selected women were seeking social support in order to improve their
quality of life and making their treatment successful. They can also use varieties of coping
strategies in order to cope with infertility.
Read at. al. (2013) stated that psychological well-being and coping strategies plays an
important role. The main aim of this study and article is to identify psychological support that
infertile women seek in order to cope with infertility. Researcher selected total 32 women with
the age of 20-40 years as a sample. They were heterosexual infertile couples who were seeking
and desire to cope with problems of infertile couples. One of the main problem which they face
is distress. For this research they conducted variation sampling and study was conducted in
Montreal fertility clinic in Canada. They conducted demographic survey in which they mainly
focused on demographic factors like their age etc. Qualitative interview survey and research
methodology was conducted in order to get in depth information about feelings which infertile
couples experience (Szatmári and et.al., 2020). For analysing all gathered information from
survey, researcher used thematic analysis model. In the whole study, it is identified that most
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couples have desire to get psychosocial support. This study also shows the gendered nature of the
reaction to IVF failure. It is also identified that women more than men and as compare to men,
women are more likely to have desire of being happy and seek societal support. Psychological
counselling also plays an important role as it can lead a healthy treatment. It is recommended
that this type of counselling should be concerned with support as well as clarification of life
purpose. In the results and findings of this study, it is identified that those women who enjoyed
their family and husband's support in both emotional and physical form said that they do not
require any type of psychological support and counselling. They also do not face any critical and
severe stress after failure (Volmer and et.al., 2017.). This finding is congruent as men as
compare to women were not able to describe their needs openly as they were not comfortable.
Some other factors by which they were not feeling comfortable was cultural constraints. So, it
can be said that from the discussion and finding part that it is important for multi-disciplinary
team which include: nurses, doctors, counsellors and mid wives to satisfy psychological needs of
women with infertility and give prioritize them in order to cope with infertility in an efficient
manner.
Yael(2005) stated women with infertility face several problems as there are variability in
difficulties which are experienced by women undergoing infertility treatments. The main aim of
conducting this study and using this article is to identify the degree to which women with
infertility face problems. For this study, researcher used quantitative research type or
methodology in order to get mean and all numbers as well as extent to which women with
infertility undergoes infertility treatment (McLaughlin and Cassidy, 2019). In this research
methodology, researcher identified that they mainly experience stress, impacts on their married
life, sense of self. For getting more information regarding psychological needs and difficulties
which women with infertility face, researcher conducted a cross-sectional survey in a regional
infertility clinic. For this, they selected 242 women as a sample who are undergoing in treatment
of fertility problems. In the data collection and data analysis, it is analysed that one of the main
difficulty which women with infertility face is distress and lower well-being. Women which took
as a sample were with the age group of 25-50. This study also shows that infertility is mostly
accompanied by increased psychological distress. This stress level impacts on their treatment as
well because it affects hormone secretion and interfere with ovulation. In the results, it is also
identified that women feel strong pressure from their society in order to fulfil the societal norm
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of motherhood (Zurlo and et.al., 2019). Failure to conceive impact on their mental health to the
great extent and it also affects their relation with their partners. Quantitative research and its
main aim is to understand needs of specific people population. In this whole study, scholar
focused on main three areas of stress such as: sexual concern, social concern, relationship
concern, rejection of child free style and need of parenthood. Those couples who reported more
stress in all these aspects were reported anxiety and depression. From the findings and results it
can be said that most of the women faced several emotional distress and problems which include:
disappointment, anger, loneliness, sad, frustrated, impatient etc. They all were seeking for being
happy, cure, proud, confident, optimistic, capable and pleased. The mean age of women was 30.8
in which the most, about 93% were married, 66% were childless. The overall aim was to focus
on their overall emotional status rather focusing on only feelings which attributes their infertility.
Descriptive informative method used for discussion part. Correlation al were also identified
(.Gameiro and Boivin, 2017).
So, from the above it can be said that qualitative and quantitative study in all articles
were conducted in order to identify as well as explain needs of infertile couples of selected
country. Some needs which were identified the most include: respect, societal support care, stress
management from their partners. They think that by getting all these types of support they can
reduce stress and can improve their well-being.
Theme 2 Watsons theory of human caring is recommended as a guide to nursing patients with
infertility treatment
Yeter stated about the social problems such as individual, family, etc. that lead to failure
of infertility treatment. thus, the main aim of study was to evaluate effectiveness of Watson
theory of human caring on anxiety and distress that is caused by coping up with failure of
treatment. Also, the methodology used in study was quantitative and data was gathered through
questionnaire. So, it enabled scholar to gather data about different social problems and how it led
to infertility treatment. here, single blind randomized controlled trail method was used in study.
Also, each stage of study was based on CONSORT. In addition, in Diyarbakir Veni Vidi IVF
center study was conducted from April to November. the center conducts 400 IVF cycle per
year. also, in study respondent selected were those women who have received IVF treatment in
this center. Furthermore, researcher followed inclusion and exclusion criteria as well. In
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inclusion elements included were primary infertility, age of above 18, ability to write and speak
in Turkish and last is application of assisted reproduction technique like IVF, sperm injection,
etc. also women whose treatment was failed were also included within study. In exclusion
criteria only one factor was excluded that is diagnosed with chronic disease. apart from it, block
randomization method was applied to divide groups into two categories. In this sample size taken
was 86 Turkish women with fertility. In this they were further divided into two groups that is
control and intervention that were 32 infertile women who failed infertility treatment from
intervention group and 35 fertile women from control group. However, the data was
gathered via Spiel Berger state anxiety inventory, distress scale and ways of coping
questionnaire. Besides, the data was analyzed using SPSS tool version 13.
By interpreting outcomes, it is stated that there is no significant different between
intervention and control group P value is 0.59, but difference was observed after ET and one
moth follow up P = 0.00. alongside, there was difference in P value 0.00 in intervention group
and no different P= 0.07 in control group. Likewise, there was no difference found between
intervention and control group pre treatment P= 0.89 in infertility distress. similarly, in coping
with stress self approach there was no different between control and intervention group as P
value is 0.24. likewise, in optimistic approach there was no difference found between
intervention and control group pre treatment P value is 0.80. Moreover, in social support seeking
approach there is no difference between control and intervention group with P value of 0.07. in
unconfident approach there is no difference between control and intervention group with P value
of 0.71. at last in submissive approach was no difference between control and intervention group
as P= 0.10.
thus, the results show that there is increase in anxiety during process of infertility. so,
there is difference in anxiety levels. Furthermore, anxiety occurs after 12 days in case of failure
of treatment. However, Watson theory highly influences on decreasing anxiety level. if first
treatment fails then in second there is high risk of depression due to higher anxiety levels. also, it
is analyzed that in infertility process, infertility distress increases. Expression of emotions,
problem solving, teaching learning, and help confidence relationship found in the improvement
processes of the theory of human caring could be influential on women’s positive coping.
besides that, prevention programs, relaxation exercise, etc. is highly useful in creating positive
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impact on women behavior. The Watson theory of human caring provides a holistic viewpoint
for the nursing care in infertility treatment.
Ilkay conducted a study to find out effect of infertility on women distress. the main aim
is to identify the effects of nursing care on Theory of human caring on distress causes by
infertility, self efficacy and adjustment levels. Moreover, study provided a framework of
nursing care in infertility. also, with help of it care results can be improved as well. Here, the
methodology used is randomized controlled trail method. However, quantitative research
design was used. the study was conducted at university hospital in Antalya, Turkey. Also,
inclusion and exclusion criteria were followed where inclusion factors were primary infertility,
age between 18- 45 and ability to speak Turkish. exclusion factors include secondary infertility,
under age 18 and over 45. The sample size was 120 women in which 52 was in experiment
group and 53 in control group. The simple randomization was done using SAS version 8.2. in
this 60 were randomly selected in intervention group and 60 in control. furthermore, the data was
gathered via interview. It is because interview allowed researcher to gather in depth data so that
effective outcomes are achieved. In order to gather data the researcher used different instruments
such as infertility distress scale, fertility adjustment scale an self efficacy scale. Besides this, data
was analyzed with help of SPSS and various tests were conducted such as t test, chi square, etc.
Therefore, by analyzing outcomes it is identified that there is no different between
intervention and control group in term of attrition. the intervention and control groups differed in
infertility distress, self efficacy and adjustment level. In this intervention group mean of self
efficacy was more than 7 point and adjustment score were less than 7 points. Along with it, in
infertility distress there was reduction in intervention group and not in control group. In
infertility distress there was decrease in IDS score between pre and post test within intervention
group. but in control group there was no difference in IDS. However, the intervention group
exhibited a statistically significant difference t= 8.9, P=0.01) in the mean TISE-SF scores
between pre-test and posttest. In the control group, the difference between mean TISE-SF pre-
test and posttest scores was not significant t = 0.4, P = 0.89). in adjustment group the mean T-
FAS scores in the intervention group decreased from pre-test to posttest t = 9.7, P = 0.01). In the
control group, the difference between mean T-FAS pre test and posttest scores was not
statistically significant (t = 1.0, P = 0.32.
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Hence, it can be discussed that infertile women faces many difficulties during treatment.
but in this study women were relaxed and relieved. however, intervention group showed increase
in their self efficacy. the women who were availing Watson theory of human care perceived
higher self efficacy than who did not. but in both groups it was same before study. Furthermore,
for maintaining coping behavior will enable in boosting confidence and generating more
effective outcomes. it has been identified that theory of human caring increases adjustment of
infertility in intervention group rather than control one. the factors that adjust to infertility are
loss, isolation, anxiety, etc. With help of Watson theory, it was easy for women to communicate
their emotions. moreover, in intervention directed in accepting emotion and feelings. in addition,
infertile women have to face may problems during treatment process. in order to express feeling
it is important to provide care to women. in present study, women expressed their emotion as
they feel relaxed. thus, it is summarized that to mitigate effect of infertility Watson theory is
useful in it. The nursing care theory helps in reducing negative impact of infertility in women
who receive treatment. It increases their self efficacy and adjustment. the theory is useful in
reducing distress and increasing self efficacy.
So, from above it is analyzed that Watson theory of nursing care is useful in reducing the
negative impact during infertility. Also, it allows in sharing women emotions, feelings, etc. and
decreasing their anxiety level. besides that, strong relationship is developed between nurse and
women. there are certain social factors due to which infertility treatment fails. The Watson
theory of human caring provides a holistic viewpoint for the nursing care in infertility treatment.
The Watson theory of human caring provides a holistic viewpoint for the nursing care in
infertility treatment. The nursing care theory helps in reducing negative impact of infertility in
women who receive treatment. the theory is useful in reducing distress and increasing self
efficacy.
Theme 3: Health education and awareness before IVF treatment
Shu-Hsin Lee and et.al., (2010) had focused on strategies that can be used by infertile
women for coping up after the failure of vitro fertilization treatment. The main aim of this study
and articles is also same i.e. to identify grief responses and associated coping strategies of
women who have undergone failed IVF treatment may assist nurses and other health care
professionals in their efforts to provide appropriate information, care and psychological support.
As per the Technology Act in Taiwan, couples who are infertile can receive ART on the basis of
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self-paid basis. In 2006 approximately 7281 treatments were done and approximately 70 to 80
percent of treatment failed. Most of the Chinese infertile women try to conceive their best by
traditional childbearing attitude. For this study, researcher has conducted a quantitative
methodology. In this study, data analysis was done by descriptive statistics and inferential
statistics using SPSS 12.0. this methodology was quite suitable for the researcher as it helped
them to understand grief response of all the participants as well as coping strategy chosen by
them in a much better manner. For this quantitative study non-probability sampling method
was chosen. In this sampling all the members of population selected does not have a known
chance of participating in the study. Even in this study out of 95 participants only 90 were
selected and even in those 90 only 66 of them responded to the questionnaire. This study had
focused on target population of total 95 women who experienced a failed IVF treatment at an
IVF treatment center in central Taiwan between January and December 2003. Out of all the 95
women, 90 of them were accessible during the period of the study. It is cross-sectional study in
which self-administrated structured questionnaire was sent to all the selected participants through
mail within 1 week after knowing outcome of their IVF treatment. Out of all the 90 selected
participants only 66 participants returned the questionnaire. Infertility history of the
respondents and total participants was same i.e. there was no difference in face demography of
all the respondents was also same. Out of all the 66 respondents most of the respondents were of
approximately 33 years of age, approximately 50 percent of respondents had university
education and 57.6% of the participants had family income more than more than $22 500 (USD).
In this study researcher could have used a large population to be studies so that analysis results
could have been much better. Data collected from the questionnaire had its own pros and cos as
the questionnaire was send through mail. One of the main advantage of this was that it was quite
convenient for the researcher but one of the main disadvantage it has was that only 66
participants readily participated in this study. And researcher was not able to convince rest of the
respondents to participated in the study. From this study it was observed that grief response of all
the 66 respondents were different and their responded in five different manners that are:
Bargaining, acceptance, depression, anger and denial or isolation. More than 64 percent of
women’s grievance response was bargaining. This structure questionnaire survey helps the
researcher to evaluate responses of 66 respondents in a better manner which further help them to
understand grief responses after a failed IVF treatment and coping strategies and self-perceived
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effectiveness in infertile women. It was clearly derived from the researcher that approximately
40 to 80 percent of women who failed IVF treatment will be repeating the treatment. They will
continue thinking, bargaining with themselves, medical providers, family members and will
proceed to next treatment in order to achieve conception. As per the analysis results of this study
most of the infertile women in cycle of failure have much expectations for future success of the
treatment. The methods chosen by researcher for analysis was absolutely correct as most of the
respondents chosen for this study were suffering from same issue and had same infertility issue.
Demographic background and history of all the respondents was also same. This helped the
researcher to appropriately conduct a data analysis and interpreted correct and accurate results.
This research study has been smoothly conducted by an experience research team which further
helped them to enhance overall reliability and accuracy of the research.
According to Karaca and Unsal, (2015) Aim of the study is to determine the various
factors that affect psychosocial problems of infertile Turkish Women and various strategies that
may help in dealing with these issues. Researcher has used qualitative method to conduct this
investigation, use of descriptive approach has helped investigator in gaining in-depth
information about subject matter. Purposive sampling method was used to select participants.
Researcher has involved such sample of women those who have visited gynecology polyclinic.
Purposive sampling method has helped scholar in in selecting such people those who are
suffering from the illness and have knowledge about it. For this study 24 women were randomly
selected and contacted by phone. Most of the participants were between age group of 20e41
years who were married for 2 to19 years.
By this way scholar has become able to gain right information related to factors affecting
psychosocial problems of infertile Turkish Women. Researches used fertility problem
inventory (FPI) to measure stress level of women that are in stage of infertility. Scholar has used
interview method to measure the factors that affect psychosocial problems. No one was forced
to give answers and scholar has ensured that women feel safe while participating in this
investigation. Data collection is most important aspect of research, in order to gain in-depth
detail researcher used interview technique. Scholar used SPSS software to analyses data.
Qualitative data analyses method was suitable for this investigation as t has helped individual
in identifying various themes and analyses details on the bases of these themes. Content analyses
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was great tool for the present research as it aids researcher in doing analyses ion detail bases. In
the first reading of transcription codes were established and accordingly data was analyzed in
second reading. Researcher has used most relevant articles and themes or codes that has helped
to reach to desired end results and answering research questions in most significant manner. This
research method was appropriate for the present investigation as it was reliable to give
appropriate answer. Scholar has involved right sort of participants because women those who are
suffering from infertility issues have adequate detail about it and can explain factors that are
affecting them. Interview is the simple process and maintain privacy as well. Face to face
interview was really comfortable for women and they were in condition to express their views
freely. At the end of study scholar was able to find coping strategies of infertile Turkish women.
It is found that giving birth to child is very emotional moment for the women. Due to social
pressure they feel psychological stress. Many times, family of men pressurize women to have
baby otherwise they pressure to take divorce. Themes prepared by researcher were perfectly
suitable for this research are and has helped in searching more insight about the topic. It is found
that support of spouse develops confidence of people and make them able to deal with these
issues effectively. Researcher has involved that women who have infertility issue from more
than 10 years and they are taking treatment for the same. Hence this samples are perfectly
suitable and scholar become able to find out actual issues of them.
So, from the above critical review of the articles it was found that both qualitative and
quantitative research methods can help in identifying Health education and awareness of IVF
treatment. Both the articles represented different health education and awareness results. First
article laid emphasis on after effects of failed IVF treatment on infertile women their grief
response and coping strategies chosen by them to overcome the failure grief. However, the other
study focused on psychological problems encountered by the women’s and methods used by
them to overcome the problem or issue. This article focused on ways in which infertility
negatively affect participant’s self-perception and view towards life. Both the articles were quite
appropriate for the theme as both of them focused on negative impact of infertility on infertile
women, ways it affect their perception but first article was much more appropriate for the theme
as it also focuses on coping strategies that were used by infertile women to cope up with the
infertility issue.
19

Chapter 4 DISCUSSION AND SERVICE IMPROVEMENT PLAN
Service improvement plan can be identified as a map or a plan that helps in bringing
improvement within service level. This chapter will focus on all the improvement areas of
Chapter 3 where improvement is required to be brought. In this chapter development of a service
improvement plan will be done. In this chapter Psychological and counselling support which is
required to be provided to couple in order to cope up with infertility will be explained.
4.1 key findings from chapter 3:
There are various things that have been identified in Chapter 3: Critical review of data. In
Chapter 3, 8 research articles had been reviewed that focused on infertility. Ways in which
women or couple reacted to success or failure of infertility treatment and ways in which support
or education can be provided to those women or couples. Based on critical review of 8 articles 8
these were generated: First theme was Providing psychological and counselling support to cope
with infertility. Second theme was: Watsons theory of human caring is recommended as a guide
to nursing patients with infertility treatment. Third theme was Health education and awareness
before IVF treatment. From all the above these it was identified that most of the women who had
experienced a failure treatment had extremely lower level of self-esteem, higher level of stress
and lower morale. It was also identified that there were various kinds of issues because of which
females or couples faced infertility some of the most common factors were: damage to fallopian
tube, abnormal production of sperm and many more factors that cannot be explained. It was also
found that there are various ways that can help infertile women to overcome from failed or
unsuccessful infertility treatment. It is important to boost morale or confidence of infertile
women or couples so that they do not fee demotivated. Out of all the three identified theme one
of the best theme chosen on the basis of which service improvement plan can be made is ‘To
provide psychological and counselling support to cope with infertility’.
20

4.2 Aim:
Service improvement plan Aim: Development of Service improvement plan will help in bring
improvement within the identified service level. The main aim of this service improvement plan
is “To provide psychological and counselling support to cope with infertility before and after the
infertility treatment”. For this service improvement plan PDSA method will be used.
Rationale: The main research topic of this study is ways in which patient undergoing infertility
treatment and ways in which support can be provided to fulfil psychosocial needs of infertile
patients of couples. This research topic has been chosen be the researcher because according to a
statistic more than 18 percent couples face infertility issue or problem and face fertility issues. It
has also been observed that different types of patients of coupes react in a different manner and
each of them have variety of needs and requirement that are required to be completed. This topic
has a strong significance as most of the infertile patients that undergo failed infertility treatment
require psychological support. This research topic is quite important and is quite interesting area
of research as it will help in addressing main needs of infertile patients of couples. Main research
objective of this study is “How does patient undergoing infertility treatment, nurses can provide
support with conception challenges which can address the psychosocial needs of the patient or
couple?”. With the help of this research study, researcher will explain in an elaborated manner
way in which needs of infertile women or couple can be addressed or ways in which
psychological and counselling provides a support to infertile women or couples to cope with
infertility.
4.3 Service Improvement Plan:
Service improvement plan can be referred as a kind of plan or steps that can be used to
bring improvement within service level which is provided to the target audience. With the help
of this plan current service level can be reviewed so that on the basis of this review improvement
plan can be made and suggestions can be provided. The main thing on this service improvement
plan focuses on is: if there is gap within current expected service delivery quality and actual
delivery quality then it can be reduced in an appropriate and effective manner. There are various
kinds of service improvement methods that can be used by the researcher for bringing
improvement within current quality of service and can provide better service to them. One of the
most commonly used method or model that can be used for this service improvement plan is
21

PSDA model. PDSA or Plan-Do-Study-Act is an iterative problem solving model that can be
used for bringing improvement within the services or bring any kind of changes within the
current services. While using this model there is one thing which is required to be focused on is
that in this both internal and external audience or customers should be included so that they can
provide their feedback about things that works and things that won’t work while bring changes
or improvement within the services. It model is quite appropriate to be used because it is
completely based upon experiments and can also help in understanding ways in which
improvement can be brought in an appropriate manner.
Plan, Do, Study, Act or PDSA model
Four stages of PDSA model are: Plan: In this phase objectives of service improvement plan are
decided. Do: in this phase plan is carried out and data is collected. Study: In this phase analysis of test
cycle is done that helps in reflecting upon what researcher have learned. Act: At this phase team decides
whether there are many kind of treatments required to be done or not.
4.4 Plan (PDSA):
The main aim of carrying out the planning stage is to provide the psychological as well as
counselling assistance to females and couples for coping up with the issue of infertility. Besides
this, the main aim is to change the overall services of the hospital in order to provide the
effective and quality treatment and services to the couples for overcoming infertility.
Firstly the change will mainly involve providing the effective training to the fertility
nurse and incorporate the required experience within them. The second change and improvement
22

will be bought in the working patterns of counsellors (Tamrakar and Bastakoti, 2019). The
psychological counsellors who currently works in the hospital will be provided proper guidance
in order to give effective counselling to couples. Another major improvement as well as change
will include providing fertility specialist to visit the different infertility couples from country to
country. Basically the couples which needs prior treatment and assistance will be the target
population. One of the major modification which will be incorporated and will help to fight with
the problem of infertility is beginning a new fertility OPD within hospital in order to provide
proper cure and treatment to the infertility couples.
This planning will be carried out by initially seeking the help at ministry level. Planning
will basically start by soliciting help from the high governmental organizations and by
communicating with the to provide the fund for the improvement within the services. These
governmental organizations as well as local authorities will help to effectively manage the plan
by providing advice and needed support. Along with this, the another authority which will be
considered in the improvement plan is hospital management. Communication with the hospital
management will be done in order to explain them the main reason of bringing changes, its
advantages, objectives, purpose for seeking their support and assistance (Eliza and et.al.,2019).
Currently the situation is that nurses are not well-trained to provide the effective
treatment to infertility couples thus the major change will involve providing the proper training
and mentoring to the nurses for providing accurate and efficient treatment to the infertility
couples. Besides this, a separate OPD fertility room will be added within the hospital in order to
provide special attention to the infertility couples.
Objectives
 To provide psychological counsellors for giving counselling to couples in next 3 months
 Training the fertility nurses for providing effective treatment to couples within one and
half years
 To have women group discussion with infertile patients on monthly basis for helping
them with infertility
 To offer visiting fertility specialist for clearing queries of infertile couples within next 1
month
23

 To begin fertility OPD in hospital for providing effective treatment to patient within 1
month.
Improvement
goals
Target
population
rational frequency Target
period
location
To involve
psychologists
/ counsellors
who are
currently
working in
the hospital
Couples with
Preconception
Period
post treatment
period
To give pre
conception
counselling to couples
Monthly
basis
Should
achieve
In next 3
months
Meeting hall
Training
fertility
nurses for
hospital
Infertility
couples
Fertility Nurses care
for a variety of
individuals, couples,
and families who seek
counselling or
treatment options
related to reproductive
health
Weekly
basis or on
demand
Should
achieve
in next 1
and half
years
Fertility
OPD
Peer support
women
group
sessions
Post
infertility
treatment
failed patients
Helps in coping when
they express their
feelings as the women
is the one who go
through it physically
more than the men
Monthly
basis
Should
achieve
in next
one
month
Meeting hall
Offering
management
to arrange a
Visiting
Couples who
are in need to
know more
about the
Helps in clearing the
queries of infertility
couples
Monthly
basis visit
to country
Should
achieve
in In next
one
Gynecology
department
24

fertility
specialist
from another
country
treatment
opportunities
month
Start a
Fertility
OPD in
hospital
(a doctor
from our
own
hospital)
Couples who
want to take
infertility
treatment
locally
Weekly
basis
Should
achieve
in In
next one
month
Gynaecology
OPD
The major activities and improvements which will be included in plan are as follows
Psychological counsellors will be provided to couples for providing effective counselling in
meeting hall. Nurses will be given training to properly treat the infertility couples in Fertility
OPD. Besides this, plan will include peer support women group discussion to provide proper
understanding of infertility in Meeting hall. Along with this, hospital will have separate fertility
department and Gynaecology OPD within one month for treating infertility couples. Fertility
specialist will be provided who will visit infertile couples for helping them within one month
(Pasch and Sullivan, 2017).
4.5 Do (PDSA):
In this a fixed plan will be made and specific time period in which these goals will be achieved are
explained. Plan which is required to be achieved within a fix period of time is as follows:
Goals Target Period
Involve psychologists / counsellors
who are currently working in hospital
Should achieve In next 3 months
Training fertility nurses for hospital Should achieve in next 1 and half years
25

Peer support women group sessions Should achieve in next one month
Offering management to arrange a Visiting
fertility specialist from another country
Should achieve in In next one month
Fertility OPD
(a doctor from our own hospital)
Should achieve in In next one month
In order to carry out this plan a time period of 6 months to 1 year will be required. In order
to achieve these objective a survey will be conducted in which a questionnaire will be formed.
Most of the patients who are suffering from this infertility problem will be asked to participate in
this survey and will be asked to fill the questionnaire in order to gather required data or
information which will further help in analyzing challenges of consequences that will be
required to be checked.
Questionnaire for patients:
 What Are the infertility problems that are being faced by you?
 Damage to fallopian tube
 Abnormal production of sperm
 Others
 What according to you are the main reasons because of which proper treatment
is not provided to patients?
 Lack of required knowledge of the nurses
 Lack of required equipment’s
 Shortage or unavailability of nurses
 others
 Do you think there are any kind of improvements that can help in bringing
improvement within the current services?
 Recruiting more staff members
26

 Providing training to the staff members
 No idea
From the above questionnaire following challenges that can be faced have
been identified such as: lack of funds required for training, shortage of staff
members and many more. But there are many other ways that can be used for
overcoming these challenges such as: focus on getting volunteer workers or try to
organize funds from other organizations.
4.6 Study (PDSA):
From the analysis of above plan it was identified that due to the challenges that can occur
within this study it would be difficult to complete one or two goals on time such as: due to lack
of funds fertility OPD goal is difficult to be achieved within a month. Data collected from
questionnaire will be analysed or measured using thematic analysis in which a graph will be
plotted for each identified theme in order to be evaluated or analysed. Other than this in order to
identify any other kinds of required changes feedback from the participants of the survey will be
asked. On the basis of this analysis and evaluation of results and questionnaire challenges that
can faced in future are identified.
4.7 Act (PDSA):
On the basis of above steps it can be identified that one of the most important and
demanding service which is required to be focused on more is Training fertility nurses for
hospital. Training current nurses will also help the hospital to reduce requirement of recruiting
additional staff members. Training fertility nurses can also help in enhancing overall infertility
treatment results in a much enhanced and elaborated manner.
27

REFERENCES
Books and journals
Acharya, S. and Gowda, C.R., 2017. Lifestyle factors associated with infertility in a rural area: A
cross-sectional study. Int J Med Sci Public Health. 6. p.502.
Arif, T., 2018. Hepatitis Service Provision at HMP Birmingham: Progressing a Previous Service
Improvement Plan. BMJ Open Qual, 7(4), p.e000192.
Baker, K. (2014) How to Make Critiquing Easy. Midwives [online]. 17 (2), p. 34.
Bennett, L. and Pangestu, M., 2017. Regional reproductive quests: Cross‐border reproductive
travel among infertile Indonesian couples. Asia Pacific Viewpoint. 58(2). pp.162-174.
[Accessed 31 January 2020]
Bisht, S and et.al., 2017. Oxidative stress and male infertility. Nature Reviews Urology.14(8).
p.470. [Accessed 31 January 2020]
Choudhary, M. and Halder, S., 2019. Cognitive Behavior Therapy in Management of
Psychosocial Factors in Female Infertility. Journal of Psychosocial Research. 14(1).
pp.53-62.
Crawshaw, M. and Daniels, K., 2019. Revisiting the use of ‘counselling’as a means of preparing
prospective parents to meet the emerging psychosocial needs of families that have used
gamete donation. Families, Relationships and Societies. 8(3). pp.395-409.
Duffy, J., and et.al., 2018. Quality Improvement Plan to Widen the Involvement of Service Users
and Carers in the Northern Ireland Degree in Social Work.
Eliza, C.A., and et.al., 2019. MASCULINE INFERTILITY, A REAL PROBLEM IN A
COUPLE'S LIFE. Acta Medica Marisiensis.65.
Fuller, F. and Gadsby, R., 2019. G566 (P) Improving transition for patients with type 1 diabetes:
a service improvement project.
Gameiro, S. and Boivin, J., 2017. The Psychology of Infertility in Reproductive Medicine and
Healthcare, c. 1940s–2000s. In The Palgrave Handbook of Infertility in History (pp. 393-
413). Palgrave Macmillan, London.
Ghelich-Khani, S. and et.al., 2020. A mental health program for infertile couples undergoing
oocyte donation: protocol for a mixed methods study. Reproductive Health. 17(1). pp.1-
5.
Hesari, Z.H.N.A. And et.al., 2019. The need for a training software among iranian infertile
couples: A qualitative study. International journal of fertility & sterility. 13(2). p.118.
Hyland, A. and et.al., 2016. Associations between lifetime tobacco exposure with infertility and
age at natural menopause: the Women's Health Initiative Observational Study. Tobacco
control. 25(6). pp.706-714.
Jodar, M and et.al., 2017. Semen proteomics and male infertility. Journal of proteomics.162.
pp.125-134. [Accessed 31 January 2020]
Jones, S., 2018. Watson’s Theory of Human Caring: Effect on Nurse Perception of Care
Environment.
28

Karaca, A. and Unsal, G., 2015. Psychosocial problems and coping strategies among Turkish
women with infertility. Asian nursing research. 9(3). pp.243-250.
Knowles, J.M. and Gray, M.A. (2011) The Experience of Critiquing Published Research:
Learning from the Student and Researcher Perspective. Nurse Education in Practice,
11(6), pp.390-94. [Accessed 2020 February 2020].
Lawson, A.K., 2016. Psychological stress and fertility. Fertility and Assisted Reproductive
Technology (ART): Theory, Research, Policy and Practice for Health Care Practitioners,
p.65.
Logan, S. and et.al., 2019. Systematic review of fertility‐related psychological distress in
cancer patients: informing on an improved model of care. Psycho‐oncology. 28(1). pp.22-30.
Mahadeen, A. and et.al., 2018. Psychosocial wellbeing of infertile couples in Jordan. EMHJ-
Eastern Mediterranean Health Journal. 24(02). pp.169-176.
Lee, J.Y. and Hwang, R.I., 2018. Comparison of Perceptions of Local Residents and Public
Health Center Staffs on the Performance of Medical Service Improvement Plan in Rural
Areas. J Agric Med Community Health, 43(2), p.74.
Lee, P. (2016) Understanding and Critiquing Quantitative Research Papers. Nursing Times,
102(28), pp.28-30. [Accessed 03 February 2020].
Lee, S.H., and et.al., 2010. Grief responses and coping strategies among infertile women after
failed in vitro fertilization treatment. Scandinavian journal of caring sciences. 24(3).
pp.507-513.
Li and et.al., 2019. Infertility-Related stress and life satisfaction among chinese infertile women:
a moderated mediation model of marital satisfaction and resilience. Sex Roles. pp.1-9.
[Accessed 31 January 2020]
Lloyd-Evans, B., and et.al., 2019. The CORE service improvement programme for mental health
crisis resolution teams: results from a cluster-randomised trial. The British Journal of
Psychiatry, pp.1-9.
Mathur, S., 2018. Relationship between age and infertility in female population undergoing
infertility treatments.
McLaughlin, M. and Cassidy, T., 2019. Psychosocial predictors of IVF success after one year: a
follow-up study. Journal of reproductive and infant psychology. 37(3). pp.311-321.
Mehta and et.al., 2016. Limitations and barriers in access to care for male factor infertility.
Fertility and sterility. 105(5). pp.1128-1137. [Accessed 31 January 2020]
Milne, D., 2018. An Organizational Improvement Plan: Implementing Service Learning into the
Curriculum at an International School to Meet an Organization’s Strategic Aims.
Moudi, Z. and et.al., 2019. Effect of an infertility counseling program on perceived stigma
among infertile female candidates for intra-uterine insemination. Journal of Midwifery
and Reproductive Health. 7(4). pp.1870-1879.
Mourad, S.M. And et.al., 2019. Measuring patient‐centredness in publicly funded fertility care: A
New Zealand validation and international comparison of the Patient‐Centred
Questionnaire‐Infertility. Australian and New Zealand Journal of Obstetrics and
Gynaecology. 59(2). pp.265-271.
Mukherjee, B., Chakrabarti, S. and Dasgupta, P., 2018. Psychological Impact of Infertility and
Role of Counseling. Practical Guide in Infertility. 78.
29

Nadelson, S. and Nadelson, L.S. (2014) Evidence-Based Practice Article Reviews Using CASP
Tools : A Method for Teaching EPB. Worldviews on Evidence-Based Nursing, 11(5),
pp.344-46. [Accessed 01 February 2020].
Okafor, N.I., Joe-Ikechebelu, N.N. and Ikechebelu, J.I., 2017. perceptions of infertility and in
vitro fertilization treatment among married couples in Anambra State, Nigeria. African
journal of reproductive health. 21(4). pp.55-66. [Accessed 31 January 2020]
Ozan, Y.D. and Okumuş, H., 2017. Effects of nursing care based on watson’s theory of human
caring on anxiety, distress, and coping, when infertility treatment fails: A randomized
controlled trial. Journal of caring sciences. 6(2). p.95.
Pan and et.al., 2019. Factors that influence infertile couples’ selection of reproductive medicine
centers---A cross-sectional questionnaire study. Taiwanese Journal of Obstetrics and
Gynecology. 58(5). pp.633-639. [Accessed 31 January 2020]
Park, S. and Choi, Y., 2019. Improvement Plan of Welfare Service for Adults with
Developmental Disabilities.
Pasch, L.A. and Sullivan, K.T., 2017. Stress and coping in couples facing infertility. Current
opinion in psychology.13. pp.131-135.
Pasch, L.A., and et.al.,2016. Addressing the needs of fertility treatment patients and their
partners: are they informed of and do they receive mental health services?. dddFertility and
sterility. 106(1). pp.209-215.
Patel, A., Sharma, P.S.V.N. and Kumar, P., 2018. Role of mental health practitioner in
infertility clinics: A review on past, present and future directions. Journal of
human reproductive sciences. 11(3). p.219.
Peterson, B. and Place, J.M.S., 2019. The Experience of Infertility: An Unexpected Barrier in the
Transition to Parenthood. In Pathways and Barriers to Parenthood (pp. 19-37). Springer,
Cham.
Robb, M. and Shellenbarger, T. (2014) Strategies for Searching and Managing Evidence-based
Practice Resources. The Journal of Continuing Education in Nursing [online]. 45 (10),
pp. 461-466. [Accessed 05 February 2020]
Rooney, K.L. and Domar, A.D., 2018. The relationship between stress and infertility. Dialogues
in clinical neuroscience. 20(1), p.41.
Szatmári, A. and et.al., 2020. Adaptive coping strategies in male infertility, paramedical
counselling as a way of support. Journal of Reproductive and Infant Psychology, pp.1-18.
Tamrakar, S.R. and Bastakoti, R., 2019. Determinants of Infertility in Couples. Journal of Nepal
Health Research Council.17(1). pp.85-89.
Thabane, L., Thomas, T. and Paul, J. (2010) Posing the Research Question: Not so Simple.
Canadian Journal of Anesthesia, pp.56-71.
Thenmozhi, S., Bhaskar, S. and Gautham, K.K., 2018. Stress and Depression during Assisted
Reproductive Technology Treatment-Need for Infertility Counselling.
30

Tong, Y.J. And et.al., 2017. Features of Professor Ma Kun's medication in treating ovulatory
infertility. Zhongguo Zhong yao za zhi= Zhongguo zhongyao zazhi= China journal of
Chinese materia medica. 42(23). pp.4459-4463.
Tsevat, D.G and et.al., 2017. Sexually transmitted diseases and infertility. American journal of
obstetrics and gynecology.216(1). pp.1-9. [Accessed 31 January 2020]
Vitale, S.G. And et.al., 2017. Psychology of infertility and assisted reproductive treatment: the
Italian situation. Journal of Psychosomatic Obstetrics & Gynecology. 38(1). pp.1-3.
Volmer, L. and et.al., 2017. Infertile Partnersʼ coping strategies are interrelated–
implications for targeted psychological counseling. Geburtshilfe und
Frauenheilkunde. 77(01). pp.52-58.
Wan, J.W.Y., and et.al., 2017. G189 (P) Development of an annual endoscopy audit plan using
measures in the P-GRS (paediatric global rating scale for endoscopy) in a tertiary
paediatric endoscopy service to facilitate quality improvement.
Wei, H., Fazzone, P.A., Sitzman, K. and Hardin, S.R., 2019. The Current Intervention Studies
Based on Watson's Theory of Human Caring: A Systematic Review. International
Journal for Human Caring. 23(1).
Zagami, S.E. And et.al., 2019. Infertile couples' needs after unsuccessful fertility treatment: a
qualitative study. Journal of caring sciences. 8(2). p.95.
Zegers-Hochschild, F and et.al., 2017. The international glossary on infertility and fertility care,
2017. Human reproduction.32(9). pp.1786-1801. [Accessed 31 January 2020]
Zhuoran, W., Wanpeng, L., Tao, P. and Coates, R., 2018. Qualitative research on infertile
Chinese couples’ understanding of sexuality. Family practice. 35(1). pp.88-92.
[Accessed 31 January 2020]
Zhuoran, W., Wanpeng, L., Tao, P. and Coates, R., 2018. Qualitative research on infertile
Chinese couples’ understanding of sexuality. Family practice. 35(1). pp.88-92.
[Accessed 31 January 2020]
Zurlo, M.C. and et.al., 2019. Infertility-related stress and psychological health outcomes in
infertile couples undergoing medical treatments: testing a multi-dimensional model.
Journal of clinical psychology in medical settings, pp.1-15.
31

Appendix 1
PICO QUESTION
P patient undergoing infertility treatment
I supporting with conception challenges
C nil
O address the psychosocial needs of the patient or couple
Key Search words
1 Infertility
2 Psychological
3 Conception
4 IVF treatment
...
32