Nowadays, infertility is one of the medical problems, which its rate has increased by 50% since 1955, and now 10-15% of couples suffer from this problem (1, 2). The mean global prevalence of infertility is 9%, which has a range of 3.5-16.7% in developed countries. The prevalence of lifelong infertility in Iran is 10.9% (3). According to the World Health Organization, infertility is one of the global public health problems that can threaten individual, marital and social balance (4). Physiological and pathological factors cause infertility; however, its psychosocial aspects should not be neglected. Infertility can affect various aspects of the life of infertile women. It may lead to depression, despair, feelings of guilt and worthlessness (5), a crisis in marital relationships, increased marital tension, the disintegration of sexual life (6), decreased sexual desire, sexual pain, and the inability to reach the peak of sexual pleasure (7). Sexual satisfaction and marital relations may decrease even after infertility diagnosis and during infertility treatment (8). In the study conducted by Abdul Qadir (2014), 15.7% of the infertile people examined complained of a lack of marital satisfaction (9). Studies have shown that marital problems are one of the main reasons for termination of treatment among infertile patients, although they still have a chance of pregnancy. The reason is that infertility can cause a decrease in intimacy in marital relationships and disrupt the quality of the relationship, termination of the marital relationship, and eventually separation and divorce (10). Anderson et al. (2003) also showed in their research that the marital satisfaction and expression of the passion of infertile couples is significantly less than that of fertile couples (11). Not paying attention to the marital issues and emotional disorders of infertile couples creates a vicious cycle that reduces the possibility of infertility treatment (12). Consequently, a key component of the success of infertility treatment is paying attention to the sexual needs that are influenced by psychological issues; because it can affect the couple's relationship during the treatment; particularly when they require their partner's compassion and support. According to the results of the studies, poor communication support, particularly from the spouse, disintegrates sexual activity and raises marital conflict (13, 14). There are numerous counseling techniques available to address the psychological and sexual effects of infertility, including group counseling on infertility adaptation (15), a mindfulness-based program for infertility (16), and cognitive behavioral counseling on sexual performance (17). Psychotherapists have suggested various approaches, such as individual, couple, and family approaches, to address the issues brought on by infertility. To help couples cope with the stressful event of infertility, infertility counselors should try to use holistic approaches (13, 18-20). However, experts contend that when a whole family or a two-person unit is looking for the treatment of family life issues, the family or couple therapy approach is more effective than individual therapy (21).
One of the approaches that are important for improving marital issues in couples is emotion-oriented therapy. Recent pioneers in the field of couple therapy, Greenman and Johnson, introduced this approach. This treatment identifies the emotional experiences of individuals and, through processing and reorganization, the interaction patterns that lead to troubles in marital relationships eliminates and improves (22). Additionally, in this therapeutic approach, couples' compatibility, intimacy, and satisfaction are increased by identifying safe attachment patterns and engaging in constructive interactions with one another. This approach also emphasizes changing attachment behaviors to repair troubled relationships (23). Due to its structure and step-by-step treatment plan for couples, emotion-focused couple therapy is more effective than other approaches. As a result, the likelihood of marital issues recurrence is extremely low, and its effect is more significant (24). Focused couple therapy identifies the suppressed and hidden emotions that feed this destructive communication cycle. Using interventions whose efficacy has been supported by numerous studies, this cycle will stop, and the relationships of couples will improve (25, 26). Tracy et al. (2013), while expressing the multifaceted problems associated with infertility, including emotional, physical, and social problems, stated that emotion-focused couple therapy, along with medical treatments, is one of the most necessary things in the treatment of infertility, and the related biological, physical and psychological problems (27). The outcomes of the study by Alavi et al. (2019) also revealed that emotion-focused couple therapy boosts marital trust and intimacy (28). Given that infertility has a detrimental impact on marital satisfaction, it is advised that infertility clinics offer the necessary training to minimize marital conflicts. Teaching marital relations to infertile couples can help them avoid divorce and instead strengthen their family foundation (10).
Several studies have been conducted on the effect of emotion-focused couple therapy on various aspects of the marital problems of infertile couples in iran. Therefore, the present study was conducted to analyze, summarize, and synthesize the findings of clinical trials conducted in Iran regarding the effect of emotion-focused couple counseling on infertile couples' marital issues.
Materials and Methods
This systematic review was written based on the latest version of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, 2020). English language databases including PubMed, ProQuest, Scopus, Web of Science, Cochrane Library, Embase, and Persian language databases of Magiran, SID, and IranDoc were used to search the published articles. In the English language databases, we looked for the keywords "infertility," "subfertility," "subfecundity," "sterility," "infecundity," "childlessness," "unresolved infertility," and "Emotionally Focused Therapy," "Emotion Focused Couples Therapy," "Emotionally Focused Couples Therapy," "Emotionally Focused Therapy for Couples," "Emotionally Focused Therapy for Couples," "EFT". In thr Persian language databases Persian equivalents of the mentioned keywords were used. " Also, their combinations were evaluated by two independent researchers using Boolean operators ("and," "or") without any time limit until Feb. 2023. The cases of contradiction were then discussed with the third author and looked into manually using references from related articles. Table 1 displays the search strategy for databases in English and Persian.
As a search tool in this study, the PICOS model was applied as follows: Population: infertile couples; Intervention: emotion-focused treatment; Comparison group: infertile couples with no intervention; Outcome: marital issues including marital compatibility, commitment, boredom and conflict, as well as sexual satisfaction; Study type: experimental and quasi-experimental studies.
This systematic review included all experimental and semi-experimental clinical
trials that looked at how emotional-focused treatment affected marital issues of infertile couples in Iran. The exclusion criteria, on the other hand, included observational and descriptive studies, case reports, case series, editorials, abstracts presented at the conferences, unpublished data, national and local reports, as well as the article with no full text.
In the process of selecting articles, at first, the retrieved studies searched from English and Farsi databases were entered into the Endnote version 7 software, and then duplicates were removed. After their titles and abstracts were reviewed, the articles that had no relationship to the objectives of the study were removed. Following a full-text review of the relevant articles considering the inclusion and exclusion criteria, the eligible studies were included in the systematic review. The aforementioned procedure was carried out by two independent researchers (NS and SM) to increase the validity of the study.
Two independent researchers extracted data using a self-structured checklist. This checklist was divided into four sections: general information about the article (names of the authors, year in which the study was conducted, location of the study), participants’ characteristics (age, duration of infertility), data about the intervention and control groups (type of study, number of participants, number of groups, percentage of dropout, type of intervention, type of control, and data collection tool), the outcomes under investigation (marital issues including marital compatibility, commitment, marital boredom and conflict as well as sexual satisfaction) (Table 2).
In this study, two researchers (NS and SM) independently assessed the quality of studies. In instances of disagreement, a third researcher (RLR) participated in the assessment to reach a consensus. The Risk of Bias tool developed by the Cochrane Collaboration was used to evaluate the quality of studies. The results of quality assessment were presented graphically using the Review Manager program (RevMan 5.3). This tool evaluates the quality of articles in terms of 1) selection bias (random sequence generation and allocation concealment), 2) implementation bias (blinding of participants and personnel), 3) detection bias (blinding of outcome assessment), 4) attrition bias (incomplete outcome data, 5) reporting bias (selective reporting and 6) other biases. Each item examined by this tool has a particular level of bias including low, medium, or ambiguous. No studies were excluded based on their quality score. The achieved coefficient of inter rater of the quality of articles was 0.80. Synthesis of the data carried out qualitatively.
The research team followed all ethical guidelines, including honesty and trustworthiness in text analysis, when conducting this study and presenting its findings.
3.1. Characteristics of studies
Figure 1 shows the flowchart of the study selection process. In the initial stage of the search, 88 articles were identified. Then, 10 duplicate articles, 72 irrelevant articles, and two articles that did not meet the inclusion criteria were removed, and finally, six articles were included in the study. The total sample size was 456 people. Four studies were published in English (29-32) and two in Persian language (33-34).
3.2. Risk of bias of included studies
Figures 2 and 3 show the quality of the articles included in the study using the Cochrane Collaboration’s tool for assessing risk of bias (35).
In ters of selection bias, in contrast to one study (29), where the randomization process was poorly described, the risk of bias was low in other studies (30-34). There were incomplete explanations in all of the studies about the random allocation method of concealment (29-34). Regarding mplementation bias, all studies had a high level of bias regarding participant and evaluator blindness (29-34). In relation to detection bias, in some studies, the blinding of statistical analyst was not adequately explained. With respect to attrition bias, in two studies, explanations (33, 34) were ambiguous, but other studies showed a low risk of sample attrition bias (29-32). Respecting reporting bias, in all studies, the risk of this bias was low (29-34). Finally, the risk of bias was low in terms of other items (29-34).
3.3. The effectiveness of emotion-focused therapy on couples’ compatibility, commitment, boredom, conflicts, and marital satisfaction
Three studies on marital compatibility (30-32), one on marital commitment and boredom(34), one on marital conflicts (33), and one on marital satisfaction (29) were examined in this systematic review. The treatment lasted 10 sessions in 6 studies. In two studies, each session lasted 90 minutes, and in four, it lasted 120 minutes.
Emotion-focused couple therapy increased marital compatibility, intimacy, and the quality of relationships between couples, according to the research findings of Maryam Najafi et al. (2013) (30), Soltani et al. (2013) (32) and Soleimani et al. (2015) (31). The intervention group received treatment weekly for 120 minutes over 10 sessions. Spanier's Marital Compatibility Questionnaire was employed in these three studies on a semi-experimental basis. Couple therapy improved marital adjustment, satisfaction, solidarity, agreement, expression of affection, quality of life, and psychological health of couples in these three studies. Teaching the skills of paying attention to the cycle of each other's daily interactions, identifying excitement, emotions, and pure feelings, focusing on oneself, and identifying the underlying fears of couples gave them a clearer and deeper view of their emotions and relationships with their spouses. As a result, they gained more peace, and their mental health improved.
In the research of Sayadi et al. (2017) (34), the couples of the intervention group were treated for 10 sessions and each lasted for 120 minutes per week. In this study the Marital Commitment Questionnaire was used. In the intervention group, emotion-focused couple therapy significantly raised the mean post-test scores of the marital commitment variable and its subscales (personal commitment, moral commitment, and structural commitment).
In the study conducted by Sayadi et al. (2017) (34), the couples of the intervention group were treated for 10 sessions and each lasted for 120 minutes per week. In this study the marital boredom Questionnaire was used. The results showed that emotion-focused couple therapy could decrease couples’ burnout in the intervention group.
According to the results of study by Sadri et al. (2017) (33), intervention group were treated for 10 sessions with duration of 90 minutes per week. The Harris and Bozorgi Marital Conflict Questionnaire was used in this study. The emotion-focused couple therapy was effective in marital conflict and improving the quality of couples' relationships. This therapy aims to reveal vulnerable emotions and facilitate the ability of couples to create these emotions safely and lovingly. Processing emotions in a safe environment results in a healthier and more innovative interaction pattern, which lowers the level of confusion, boosts affection between partners, and ultimately improves compatibility and marital satisfaction.
According to Hassani et al. (2010) (29), couples in the intervention group were treated for 10 sessions of 90-minutes duration per week. Enrich Marital Satisfaction Questionnaire was used in this research. The Mann-Whitney U test results revealed no significant difference in the ability of emotion-focused couple therapy to improve marital satisfaction in couples.
This study aimed to examine how emotion-focused therapy could affect marital issues in Iranian infertile couples. .. Six articles were ultimately included in the systematic review. According to these studies, marital compatibility and commitment increased significantly in the group receiving emotion-focused therapy, while marital boredom and conflicts decreased significantly. Regarding marital satisfaction, however, there was no discernible effect.
The findings of this study demonstrated that emotion-focused therapy in couples experiencing infertility resulted in enhanced compatibility. In this regard, Woolley and Girard (36), Rathgeber et al. (37), and Wiebe et al. (38) also demonstrated the benefits of emotion-focused couple therapy. They indicated that finding unspoken emotions and resolving them in a relationship can increase a couple's marital compatibility, lower interpersonal tensions, and increase their level of agreement (24) According to they study conducted by Ramezanzadeh et al., in the study of emotional compatibility concluded that due to the high prevalence of psychiatric disorders (especially anxiety and depression) in infertile people, marital dissatisfaction and marital incompatibility are more than fertile women. (39). On the other hand, Hosseinabadi et al. (40), in the study of the effectiveness of emotion-focused therapy on marital compatibility and positive emotions of couples, concluded that emotion-focused couple therapy has favorable results in the subscale of satisfaction, solidarity, and expression of marital affection. However, in the scale of agreement and compatibility, they observed no effect.
Another finding of this study was the effect of the emotion-focused therapy approach on reducing marital conflicts. according to Johnson (41) and Mirzadeh (42). The result is similarly consistent with the findings of the study of Forouzanfar et al. (2019)(43). In their most recent meta-analysis, they concluded that emotion-focused couple therapy was more effective than other couple therapy approaches at treating psychological issues related to communication style and minimizing conflicts(24).
The findings of Torkan (2019) (44) revealed that couples who tended to resolve conflicts were experiencing higher levels of positive emotions. This suggests that emotion-focused therapy has contributed to the development of a sense of responsibility in the couple's conflict. Ardehaee et al. (45), found that emotion-focused couple therapy improved negative interactive cycles, rebuilt interactive patterns, and encouraged novel approaches to address long-standing communication issues. As a result, marriage performance and the psychological well-being of women with marital conflicts improved, which is congruent with the findings of our study.
This study also found that emotion-focused therapy had a favorable effect on boosting marital commitment. According to Cohen's research in 2014, emotion-focused couple therapy can increase marital commitment and honesty (46). Onat et al. (2012), similarly, reported that couple training with an emotion-focused approach has a significant impact on enhancing sexual intimacy and commitment in relationships (47).
The findings of the current studyalso suggested that this therapy approach may successfully lower marital boredom. According to Johnson (48), Ellen (49), and Denton (50), an emotion-focused approach can assist couples in rebuilding their relationship with their spouse and lessen marital dissatisfaction. This process can take place by growing emotional awareness, emotional symbolization, awareness of the role of experience and changing processes, emphasis on caring for the spouse, and identification and removal of negative interactive cycles in marital life. While the research findings of Addis and Jacobson (51) showed that not considering the underlying issues of the relationship and the emotional injuries of the spouses will lead to the recurrence of turmoil shortly after couple therapy, Barrett et al. (52) in their research made it clear that mere changes in the couple's behavior do not lead to the improvement of marital quality, but it is the perceived positive and negative emotions of the couple that plays an important role.
In this review no significant effect was observed in marital satisfaction, which is congruent with the findings reported by Hassani (2008), who found couples' marital satisfaction does not significantly increase as a result of emotion-focused couple therapy (29). However, Merzadeh et al. (2016) found that emotion-focused couple therapy successfully modified avoidant and anxious attachment styles and improved marital satisfaction (53). Similarly, Dalgleish (2015) (54), reported that emotional control, relationship trust, and attachment security all improve before and after treatment, which leads to more changes in marital satisfaction. According to Rostami (2014), couples who participated in emotion-focused couple therapy sessions expressed greater satisfaction in the quality of their communication than couples in the control group (55), which was inconsistent with the findings of our study. Couples endure a lot of pressure during infertility treatment, while emotinally focused therapy is effective in reducing mild to moderate problems of couples, in order to create marital satisfaction, couples need to receive more education and try to spend more time together (29).
Therefore, the findings of the present studies demonstrated that it is possible to highlight the crucial role of emotions in all couples' communication when attempting to explain the effectiveness of emotion-focused couple therapy in enhancing and increasing communication. Therefore, the emotion-focused couple therapy approach can be used because it is a subset of couple therapy and puts emotions at the center of its therapeutic work.
One of the strengths of this study was its summary of the benefits of emotion-focused couple therapy for various marital problems. On the other hand, one of the research weaknesses was that all studies, regardless of quality score, were included in this study due to the small number of articles. The most significant limitation of this study was the small number of articles were included in the review, due to the limited number of studies conducted in Iran. Also publication bias could be a possible threat for the validity of the results like previous studies in the field of infertility (56, 57), therefore the findings should be interpreted with caution.
It is suggested that researchers use and compare this therapy method with other methods. Regarding the effectiveness of emotion-focused couple therapy on marital satisfaction, we recommend researchers conduct further studies with more advanced design. In general, future research should consider studies with stronger designs, larger sample size and more attention to confounding variables.
The findings of this study demonstrated that emotion-focused therapy could increase marital compatibility and commitment, while lowering marital boredom and conflicts. However, it was ineffective in raising marital satisfaction. As a result, it can be said that emotional couple therapy is one of the most effective types of counseling for helping infertile couples with their various marital issues. The results of this study, while creating a clear and practical outlook for counselors and psychotherapists, especially family therapists. can be an effective guide for improving the relationships of infertile couples and subsequently reducing marital conflicts. It can be used as a practical guide for boosting marital relationships, revealing and correcting inconsistencies in couples' communications and behavioural patterns.
This study was supported financially (grant number: 4011074) and approved ethically at Mashhad University of Medical Sciences (ethical code: IR.MUMS.NURSE.REC.1401.120). We would like to thank the university and all the authors whose articles were included in this review.
Conflicts of interest
The authors declared no conflicts of interest.