Effect of Health Education Interventions on Knowledge, Attitudes and Behaviour of Women Experiencing Infertility

Dewi Puspitaningrum1*, Mohammad Zen Rahfiludin2, Zahroh Shaluhiyah2, Sri Winarni3

1Universitas Muhammadiyah Semarang (UNIMUS), 50273 Jawa Tengah, Indonesia

2Faculty of Public Health, Diponegoro University, 50275 Semarang, Indonesia

3Department Biostatistics and Population, Diponegoro University, 50275 Semarang, Indonesia

*Corresponding Author’s Email: dewipuspita@unimus.ac.id

ABSTRACT

Background: Prevention and management of infertility are important issues in reproductive health services. The purpose of this study was to measure the effect of an educational model for primary infertile women. Methods: A quasi-experimental design and General Linear Model Repeated Measures (GLM- RM) test were used in a population of 80 couples at KRMT Wongsonegoro Hospital and 50 couples at Tugurejo Semarang Regional Hospital. The minimum sample size was 25 individuals, determined using the Lameshow formula and inclusion criteria. An additional 20% was added, resulting in 30 people in the intervention group, who participated in a module and direct practice for six weeks, and 30 individuals in the control group, who received general health information through a WhatsApp group for six weeks. Results: A significant increase in knowledge, attitude, and healthy behaviour was observed in post-test 2. Respondents’ knowledge in the intervention group increased by 2 points, attitude by 3 points, and healthy behaviour by 5 points with the health education programme carried out by healthcare professionals. Conclusion: There is an increase in knowledge, attitudes, and behaviour variables through this educational model, which is conducted effectively and in an engaging manner. The study suggested that providing this educational model for primary infertile women over an extended period strengthens its effectiveness.

Keywords: Healthcare Services; Healthy Behaviour; Primary Infertility; Reproductive Health

INTRODUCTION

Infertility is the inability of a couple to conceive, defined as failure to achieve a pregnancy after 12 months or more of regular, 2–3 times per week, unprotected sexual intercourse (Boedt et al., 2021). Data from the WHO, (2021) stated that 50–80 million couples, or one in seven couples, have fertility problems (Carson & Kallen, 2021). The improvement of primary infertile women's quality of life requires special treatment (BKKBN, 2020). In Indonesia, more than 20% of married couples experience infertility problems. Infertility affects 15% of couples aged between 30–34 years, 30% of couples aged between 35–39 years, and 55% of couples aged between 40–44 years. Based on data from the Indonesian Association for In Vitro Fertilisation (Perfitri), the total number of IVF cycles in Indonesia during 2021 reached 10,000. This is categorised as a large number of infertility interventions (All Indonesian Hospital Association, 2021).

The infertility problem affects 66% of couples of reproductive ages in Semarang, and based on 2020 data, there were 227 cases of primary infertility in women after more than a year of marriage and 100 cases up to October 2021 (Jateng, 2022). Data from KRMT Wongsonegoro Semarang Hospital stated that 213 cases of primary infertility and reproductive diseases were recorded from January 2022 to February 2023 (Wongsonegoro, 2022). Couple fertility may be affected by reproductive organ disorders such as endometriosis, PCOS (Polycystic Ovarian Syndrome), age, stress levels, under- or over-Body Mass Index (BMI), occupation, miscalculation of fertile days, hormones, and anatomical abnormalities (Younis et al., 2020). Infertility could also be influenced by external factors such as the environment and lifestyle (Mena, Mielke & Brown, 2019). An unhealthy lifestyle and the use of excessive oestrogen- containing medicines could lead to implantation and tube function disorders, reducing fertility. Additionally, excessive caffeine consumption can inhibit fertility (Asazawa et al., 2019; Chazan & Kushnir, 2019). The significant or dominant factors of infertility include alcohol consumption, smoking habits, an unhealthy diet, genital organ care, age, body weight, and genetics (Boedt et al., 2021).

Infertility is related to physical, psychological, and social problems that require social support to achieve better quality of life (Tripathy, Nayak & Khosla, 2020). Infertility is also a significant stressor in a woman's life (Omani-Samani et al., 2018). Studies have proven that poor psychological states can reduce the number of IVF-ET pregnancies and negatively affect pregnancy outcomes. During fertility treatment, it is essential to understand and integrate information about healthy behaviour (Zurlo et al., 2019). The preliminary analysis of 10 primary infertile women revealed that they had not properly understood the correlation between infertility and behaviour following clinical assessment, as well as health behaviour in response to infertility problems. Additionally, hospitals have not provided educational media for primary infertile couples. The only available service is direct counselling after clinical assessment, without the use of any media. Five nurses and midwives reported difficulties in observing patients with primary infertility, particularly women, as there is no existing model for primary infertile patients. The gap in research is the absence of a comprehensive educational model that addresses the specific needs of women experiencing infertility in healthcare services. Therefore, the purpose of this study is to support women experiencing infertility by increasing their knowledge, attitudes, and behaviours, ultimately improving their quality of life.

METHODOLOGY

Study Design and Setting

A quasi-experiment was conducted using pre-tests, post-test 1, and post-test 2 with a control group design, allowing the intervention to be carried out without harming the participants. Quasi-experiments are also easier to apply in real practice as they are conducted in conditions that more closely resemble everyday life. The study was carried out from March to June 2023 at KRMT Hospital and Tugurejo Hospital, Semarang, Central Java, Indonesia. Women with primary infertility were divided into two groups: the intervention group and the control group. The intervention group was based at KRMT Hospital, while the control group was located at Tugurejo Hospital. These two hospitals had the same hospital type characteristics and provided infertility services in accordance with Type B hospital standards. In the intervention group, a module and education card were provided to women with primary infertility. Meanwhile, in the control group, participants received a leaflet once a week for two months without any monitoring from nurses or midwives.

Respondents and Criteria

The study was conducted on 80 couples at KRMT Wongsonegoro Hospital in Semarang and 50 couples at Tugurejo Semarang Regional Hospital that population 130 couples. The determination of the sample size of this study used a sample formula for hypothesis testing of 2 or more proportions, so that the hypothesis testing depends on the combined proportion of P1 and P2 according to Lameshow. In case- control studied, the calculation of the sample size is carried out with the aim of finding a minimum for each, both the case group (intervention) and the control group), with the number of case and control group sample comparisons of 1: 1. Calculating the minimum sample size of this study, the calculation of the delta value (∆) on the P1 and P2 values as per the Lameshow formula, is based on the test results of a similar study conducted by Park and Shin (2021), the title "How satisfaction about web-based online information for infertile women". The results of the study showed a significant difference in the intervention group of 74.2% (0.742) compared to the proportion of the control group of 25.8% (0.258). Furthermore, calculations were carried out to determine the minimum sample size of the study.

Based on calculations, it was determined that the minimum sample size for each group was 25 individuals using the Lameshow formula. To avoid dropout risks in the sample, 20% of 25 (±5 individuals) were added, resulting in 30 individuals in the intervention group at KRMT Wongsonegoro Hospital and 30 individuals in the control group at Tugurejo Semarang Regional Hospital from April to August 2023. The sampling technique used was purposive sampling, with inclusion criteria being primary infertile women with infertility duration > five years, marriage duration > 5 years, and no previous history of in vitro fertilisation. Exclusion criteria included direct infertile women who had successfully become pregnant and those who refused to participate as respondents.

Health Education Intervention

In the intervention group, participants were provided with educational materials in the form of modules and educational cards containing an understanding of infertility from spiritual, psychological, physical, and social aspects commonly faced by primary infertile women over six weeks (material and practice sessions were conducted every week for 70 minutes) at the hospital. The pretest was conducted before the intervention, the post-test 1 evaluation was done in the 6th week after the intervention, and the post- test 2 evaluation was conducted in the 7th week, one week after post-test 1. The control group received general education via WhatsApp through leaflets over six weeks. WhatsApp was chosen because it was a very popular instant messaging application and was widely used by various groups of people. This means they were likely familiar with and had access to this application, making it easier to distributed materials with leaflets.

Study Variables and Study Instrument

The variables included statements on knowledge about the definition of infertility, understanding the link between causes and management of infertility, attitudes towards coping with infertility, perceived support and coping strategies for infertility, and behaviours related to maintaining health during infertility, regularity of healthy behaviours during infertility, and adherence to fertility care in health services. The questionnaire was validated and tested for reliability among primary infertile women at infertility clinics in Semarang. Validity and reliability test on the knowledge questionnaire of 15 infertility women with 20 questions, on the attitude questionnaire of 15 infertility women with 30 questions and on the behaviour questionnaire of 15 infertility women with 15 questions on infertile women. The knowledge questionnaire had a correlation coefficient (r calculated) > critical correlation coefficient (r table = 0.254), indicating validity, and Cronbach's Alpha value greater than 0.6 (0.633 > 0.6), indicating reliability. The attitude questionnaire had a correlation coefficient (r calculated) > critical correlation coefficient (r table = 0.254), validity, and Cronbach's Alpha value greater than 0.6 (0.787 > 0.6). The behaviour questionnaire also showed validity with a correlation coefficient (r calculated) > critical correlation coefficient (r table = 0.254) and Cronbach's Alpha value greater than 0.6 (0.649 > 0.6).

Data Analysis

In this study, there were eight confounding (age, education, occupation, living arrangement, income, duration of infertility, history of reproductive diseases and frequency of fertility treatment. Variables in this study by controlling the confounding variables, so a homogeneity test is needed so that the confounding variables can be minimised. There were eight confounding equated with the relationship between knowledge, attitudes and healthy behaviour. The Levene’s test was used to check the homogeneity of the intervention group and the control group with a p>0.05. Normality tests using skewness kurtosis with Z-score ±3.29 (Mishra et al., 2019). And the results of all normality tests. So, analysis was then conducted through descriptive characteristics of the two groups and a paired t-test within-group. Effect size was measured to determine the intervention and the control group used General Linear Model Repeated Measures (GLM-RM) test, because the health education program measured repeated pretests-post-test 1-post-tests 2 and had met the requirements for all data to be tested normally.

Ethics Consideration

The researchers obtained ethical clearance from the ethics committee at KRMT Wongsonegoro Hospital, in Semarang, Indonesia with reference number B/3229/010/V/2023 on 4th May 2023.

RESULTS

Respondents’ Characteristics

The respondents in this study are primarily infertile women. The intervention is provided for six weeks. The characteristics of the respondents for intervention group and control group are presented in Table 1.

Table 1: Frequency Distribution of Characteristics of Respondents in the Intervention and Control Groups

Differences in Knowledge, Attitude and Health Behaviour Pretest, Post-Test 1 and Post-Test 2 in the Intervention Group and Control Group

In the difference test between the two groups, namely the intervention group and the control group, with normality results indicating that all variables are normally distributed, the difference test results are as follows: Table 2, Table 3 and Table 4.

Table 2: Results of Difference Test for Variables Knowledge, Attitude, and Healthy Behaviour in the Intervention and Control Groups at Pretest

a Analysed using Independent t test

Table 3: Results of Difference Test for Variables Knowledge, Attitude, and Healthy Behaviour in the Intervention and Control Groups at Post-Test 1

a Analysed using Independent t test

*Statistically significant at p=0.05

Table 4: Results of Difference Test for Variables Knowledge, Attitude, and Healthy Behaviour in the Intervention and Control Groups at Post-Test 2

a Analysed using Independent t test

* Statistically significant at p=0.05

In the difference test for the variable of knowledge among primary infertile women in the intervention and control groups, significant differences were observed. In post-test 1, the p-value was 0.044, and in post-test 2, the p-value was 0.000 (p-value < 0.05), indicating a strong increase in knowledge after utilising this model. Many respondents showed a better understanding of the definition of primary infertility and the health history factors that significantly affect couples' fertility, as well as an understanding of the causes of infertility in couples with fertility disorders. The increase in knowledge among primary infertile women in post-test 2 demonstrates that this educational model significantly influences respondents' knowledge greater than post-test 1.

Regarding the difference test for the variable of attitude among primary infertile women in the intervention and control groups, significant differences were found. In post-test 1, the p-value was 0.024, and in post-test 2, the p-value was 0.000. Thus, there was a substantial increase in respondents' attitudes after the intervention, most notably in post-test 2, with an increase compared to post-test 1. In the difference test for the variable of healthy behaviour among primary infertile women in the intervention and control groups, significant differences were observed in post-test 2 with a p-value of 0.000. This indicates a fivefold increase in healthy behaviour among wives after receiving the intervention in post-test 2.

Eight confounding factors were identified among primary infertile women. Therefore, a multivariate analysis was conducted using General Linear Model Repeated Measures (GLM-RM) due to repeated testing and normal distribution. The results are as follows Table 5.

Table 5: GLM-RM Multivariate Test on Education Model for Primary Infertile Women Intervention Group and Control Group

Based on Table 5, the multivariate analysis conducted for the knowledge variable of primary infertile women showed that there were several potential eight confounding variables. These variables were tested for their relationship with the knowledge score of primary infertile women using the General Linear Model Repeated Measures (GLM-RM) test. The statistical analysis showed that none of the potential confounding variables had a significant impact. In the first week after the intervention, knowledge increased by 1.533 points, and by the fourth week, the increase reached 3.834 points. Therefore, it can be concluded that the intervention resulted in a knowledge improvement approximately 2 points higher than the control group.

The multivariate analysis results for the attitude variable of primary infertile women also showed several potential confounding variables. However, none of these variables proved to be confounding. There was a significant increase in attitude scores for the intervention group in post-test 1 and an even higher increase in post-test 2. In the first week after the intervention, there was an effect in the attitude by 6.167 points; after the fourth week, there was an increase of 9.7 points. Thus, it can be concluded that the intervention resulted in a 3-point higher effect in compared to the control group. The multivariate analysis results for the healthy behaviour variable of primary infertile women showed several potential confounding variables. However, none of these variables proved to be confounding. A significant increase in healthy behaviour scores in post-test 2. In the first week after the intervention, there was an effect in the healthy behaviour by 2.733 points; after the fourth week, there was an increase of 8.634 points. Thus, the intervention resulted in a 5-point higher effect in compared to the control group.

DISCUSSION

The results of the analysis show that there are significant differences between knowledge, attitudes and health behaviour between the intervention group and the control group. The intervention group is provided with midwife who have been trained in the health education program concept, so that these nurse and midwives provide intensive to women primary infertile. The knowledge, there was an increase in all indicators of the knowledge variable. There was a significant increase in knowledge on the importance about definition of primary infertility and the health history factors that significantly affect couples' fertility, as well as an understanding of the causes of infertility. There was also a significant increase in attitude values for all indicators of the attitude variable in the intervention group. The highest improvement in the attitudes about fertility needs to be considered through the menstrual cycle and agrees that the problem of infertility is caused by infrequent sexual intercourse. There was also significant increase in health behaviour variable in the intervention group. The highest improvement in the health behaviour about often like foods that can increase fertility every day.

Enhanced understanding of infertility correlates with improved quality of life for primary infertile couples, reduced anxiety, and increased adoption of healthy lifestyle habits during fertility treatment, particularly among primary infertile women (Massarotti et al., 2019; Ikemoto et al., 2021). The knowledge aspect can be further improved by education, which in turn might also improve practice among women of childbearing age (Yuan et al., 2024). Respondents' attitudes improved after using this model, adhering to healthcare provider advice. Over time, the increased involvement in self- improvement efforts, particularly in addressing spiritual, psychological, physical, and social aspects during infertility, is evident by the seventh week of the intervention. Additionally, other studies have shown that attitudes of infertile women regarding fertility and treatment become more realistic with the duration of treatment, alongside emotional, physical, and financial demands, leading to increased anxiety while awaiting fertility outcomes (Chu et al., 2021; Ni et al., 2021).

Awareness of beneficial lifestyle factors, such as reducing obesity, could positively impact the adoption of healthy living habits among primary infertile women. Supported from nurse and midwife could influence behavioural changes toward a healthier lifestyle, including nutrition, to enhance fertility (Bayoumi et al., 2021; van Dammen et al., 2021; Lam, Linh & Thuy, 2021). The implementation of the multivariate analysis showed that education influenced the effectiveness of the educational intervention. There was a significant increase in knowledge during post-test 2, conducted one week after post-test 1 in the seventh week, indicating an improvement in respondents' understanding of the importance of various aspects, such as spiritual, psychological, physical, and social aspects during infertility. This finding highlights the necessity for improved patient education and enhanced care coordination in low-resource settings. More data is needed as this program continues to improve the delivery of fertility care (Ruderman et al., 2020). After the intervention, there was an increase in knowledge about fertility information, and the effectiveness of health education interventions models (Golshani et al., 2021). Consistent with research that the positive impact and emphasise the importance of continuous educational programs like regarding IVF to improve knowledge, decrease stress levels, and increase their overall satisfaction with the treatment (Mohamed et al., 2024).

The nursing approach in supporting primary infertile women should be holistic, taking into account physical, psychological, social and spiritual aspects so that patients can develop more adaptive coping mechanisms and improve their quality of life. Consistent with other studies, attitudes towards fertility are highly recommended during fertility treatment at hospitals, allowing effective intervals for attitude changes that can provide strong motivation for primary infertile women (Iordăchescu et al., 2021; Skvirsky et al., 2018; Massarotti et al., 2019). Indicated a substantial increase in healthy behaviour after the intervention. The repeated implementation of the educational model with regular intervals significantly improved respondents' healthy behaviour, focusing on adopting healthy lifestyle changes without considering other burdens (Tripathy, Nayak & Khosla, 2020). Consistent with further research, regular healthy behaviour during primary infertility treatment and adherence to recommended by healthcare, along with support from surrounding individuals, contribute to improving the quality of life for primary infertile women. Additionally, it increases primary infertile women's efforts and endeavours in coping with clinical management (Güneri, Kavlak & Göker, 2019; Ni et al., 2021). Another research that the main support system of participants was family, husband, and friends. Prayer and getting busy and adoption were the most common coping strategies (Mpono et al., 2024). Based on the findings of this study, policymakers can develop, or updated policies related to education for infertility women.

Limitation

The study has some limitation that it exclusively focused on primary infertile women receiving care within hospital health services, without including participants from outside the hospital community. As a result, the findings may not be generalisable to women seeking infertility care in non-hospital settings. Future research could address this limitation by developing a model applicable to community-based healthcare environments.

CONCLUSION

Research in reproductive health and infertility management has had broad and profound impacts. These impacts include increasing knowledge and quality of services, improving access and equity, and strengthening spiritual, physical, and psychosocial support. The implementation of research findings can enhance patient experience and outcomes and support the development of more effective and inclusive policies.

The implementation of this educational model, using a nursing and midwifery approach, led to increased knowledge, improved attitudes, and healthier behaviours among participants, particularly evident by the seventh week of the intervention. The use of modules, educational cards, regular monitoring, and repeated evaluations contributed to this positive change. Respondents demonstrated a better understanding of infertility definitions and causes, and their attitudes toward fertility showed significant improvement. This model is recommended for women with primary infertility undergoing fertility treatment. Future research could explore how this model enhances care quality and outcomes, integrate technology to assess the influence of family and friends on primary infertile women, and identify knowledge gaps to inspire new innovations.

Conflict of Interest

All the authors declare that there are no conflicts of interest.

ACKNOWLEDGEMENT

The authors expressed their gratitude to KRMT Wongsonegoro Hospital and Tugurejo Hospital Semarang, Indonesia, as well as all respondents for providing accurate information with willingness.

REFERENCES

All Indonesian Hospital Association (2021). Program In Vitro pada infertilitas Pasangan Usia Subur [In Vitro Program on infertility of Childbearing Couples]. Retrieved from: https://validnews.id/kultura/peminat-bayi-tabung-di-indonesia-terus-meningkat. Accessed on 10th February, 2023.

Asazawa, K., Jitsuzaki, M., Mori, A., Ichikawa, T., Shinozaki, K., & Porter, S. E. (2019). Quality-of- life predictors for men undergoing infertility treatment in Japan. Japan Journal of Nursing Science, 16(3), 329–341. https://doi.org/10.1111/jjns.12248

Bayoumi, R. R., Koert, E., Van der Poel, S., & Boivin, J. (2021). Determining the need for fertility care and the acceptability and feasibility of administering a fertility awareness tool from the user’s perspective in a sample of Sudanese infertility patients. Reproductive Biomedicine & Society Online, 13, 85-97. https://doi.org/10.1016/j.rbms.2021.06.004

BKKBN.(2020). Menepis Infertilitas, Mendapatkan Anak Permata Hati Keluarga [Eliminate Infertility, Get a Child, the Jewel of the Family's Heart]. Retrieved from: https://digilib.bkkbnjateng.com/index.php?p=show_detail&id=15&keywords=. Accessed on 10th August, 2023.

Boedt, T.,Vanhove, A. C. Vercoe, M. A.,Matthys, C., Dancet, E., & Lie Fong, S. (2021). Preconception lifestyle advice for people with infertility. In Cochrane Database of Systematic Reviews, 4. https://doi.org/10.1002/14651858.CD008189.pub3

Carson, S. A., & Kallen, A. N. (2021). Diagnosis and Management of Infertility: A Review. JAMA - Journal of the American Medical Association, 326(1), 65–76. https://doi.org/10.1001/jama.2021.4788

Chazan, L., & Kushnir, T. (2019). Losses and gains of psychosocial resources: effects on stress among women undergoing infertility treatments and participating in social network systems. Psychiatric Quarterly, 90(4), 717-732. https://doi.org/10.1007/s11126-019-09661-0

Chu, X., Geng, Y., Zhang, R., & Guo, W. (2021). Perceived social support and life satisfaction in infertile women undergoing treatment: A moderated mediation model. Frontiers in Psychology, 12(May), 1–8. https://doi.org/10.3389/fpsyg.2021.651612

Golshani, F., Hasanpour, S., Mirghafourvand, M., & Esmaeilpour, K. (2021). Effect of cognitive behavioral therapy-based counseling on perceived stress in pregnant women with history of primary infertility: A controlled randomized clinical trial. BMC Psychiatry, 21, 1-11. https://doi.org/10.1186/s12888-021-03283-2

Güneri, S. E., Kavlak, O., & Göker, E. N. T. (2019). Hope and hopelessness in infertile women: Phenomenological study. Current Approaches in Psychiatry/Psikiyatride Guncel Yaklasimlar, 11. https://doi.org/10.18863/pgy.530714

Ikemoto, Y., Kuroda, K., Endo, M., Tanaka, A., Sugiyama, R., Nakagawa, K., ... & Takeda, S. (2021). Analysis of severe psychological stressors in women during fertility treatment: Japan-Female Employment and Mental health in Assisted reproductive technology (J-FEMA) study. Archives of Gynecology and Obstetrics, 304, 253-261. https://doi.org/10.1007/s00404-020-05923-6

Iordăchescu, D. A., Paica, C. I., Boca, A. E., Gică, C., Panaitescu, A. M., Peltecu, G., Veduță, A., & Gică, N. (2021). Anxiety, difficulties, and coping of infertile women. Healthcare (Switzerland), 9(4), 1–13. https://doi.org/10.3390/healthcare9040466

Jateng. (2022). Profil Kesehatan Jawa Tengah [Central Java Health Profile]. Retrieved from: https://jateng.bps.go.id/id/publication/2023/05/30/be07aa22ae941fcedfa8aeca/profil-kesehatan- provinsi-jawa-tengah-2022.html . Accessed on 18th August, 2023.

Lam, T. Q., Linh, T. T., & Thuy, L. B. (2021). The impact of social support on infertility-related stress: A study in the vietnamese context. Open Journal of Social Sciences, 9(12), 259-273. https://doi.org/10.4236/jss.2021.912017

Massarotti, C., Gentile, G., Ferreccio, C., Scaruffi, P., Remorgida, V., & Anserini, P. (2019). Impact of infertility and infertility treatments on quality of life and levels of anxiety and depression in women undergoing in vitro fertilization. Gynecological Endocrinology, 35(6). https://doi.org/10.1080/09513590.2018.1540575

Mena, G. P., Mielke, G. I., & Brown, W. J. (2019). The effect of physical activity on reproductive health outcomes in young women: A systematic review and meta-analysis. Human Reproduction Update, 25(5), 542–564. https://doi.org/10.1093/humupd/dmz013

Mishra, P., Pandey, C. M., Singh, U., Gupta, A., Sahu, C., & Keshri, A. (2019). Descriptive statistics and normality tests for statistical data. Annals of Cardiac Anaesthesia, 22(1), 67–72. https://doi.org/10.4103/aca.ACA_157_18

Mohamed, H. M., Badia, T. S., Khalaf, S. A., Abdullah, S. O., Farghaly, T. A., Fetih, A. N., & Aly, S. E. (2024). Effect of health education program on knowledge, stress, and satisfaction among infertile women undergoing in vitro fertilization injection. Middle East Fertility Society Journal, 29(1), 1–12. https://doi.org/10.1186/s43043-023-00160-8

Mpono, E. P., Kobenge, F. M., Mengne, G. L., Belinga, E., Kasia, J. M., & Egbe, T. O. (2024). The support systems and coping strategies of infertile women attending the out-patient consultation unit of Chracerh Yaoundé, Cameroon: A cross-sectional study. Open Journal of Obstetrics and Gynecology, 14(6), 869-887. https://doi.org/10.4236/ojog.2024.146070

Ni, Y., Tong, C., Huang, L., Zhou, W., & Zhang, A. (2021). The analysis of fertility quality of life and the influencing factors of patients with repeated implantation failure. Health and Quality of Life Outcomes, 19, 1-10. https://doi.org/10.1186/s12955-021-01666-3

Omani-Samani, R., Ghaheri, A., Navid, B., Sepidarkish, M., & Maroufizadeh, S. (2018). Prevalence of generalized anxiety disorder and its related factors among infertile patients in Iran: A cross-sectional study. Health and Quality of Life Outcomes, 16(1), 129. https://doi.org/10.1186/s12955-018-0956-1

Park, J., & Shin, N. (2021). Effect of an infertility counseling education program on education satisfaction and counseling competency of nurses. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 58. https://doi.org/10.1177/00469580211059997

Ruderman, R., Tate, M., Lin, E., Lee, J., Cai, S., Kassi, L. A., Yilmaz, B. D., & Boots, C. E. (2020). Resident perceptions of fertility care in the low resource setting: Preliminary data from the fertility passport program. Fertility and Sterility, 114(3), e196. https://doi.org/10.1016/j.fertnstert.2020.08.556

Skvirsky, V., Taubman–Ben-Ari, O., Shlomo, S., Ben, Azuri, J., & Horowitz, E. (2018). Are mothers a source of support for women entering fertility treatment? Health Care for Women International, 39(7), 719–733. https://doi.org/10.1080/07399332.2018.1424170

Tripathy, D., Nayak, D., & Khosla, P. (2020). Psychosocial wellbeing among primary infertile women attending infertility clinic. European Journal of Molecular & Clinical Medicine, 7(11), 2020. Retrieved from:https://www.ejmcm.com/archives/volume-7/issue-11/7393. Accessed on 18th March, 2023.

van Dammen, L., Bush, N. R., de Rooij, S., Mol, B. W., Mutsaerts, M., van Oers, A., ... & Roseboom, T. (2021). A lifestyle intervention randomized controlled trial in obese women with infertility improved body composition among those who experienced childhood adversity. Stress and Health, 37(1), 93-102. https://doi.org/10.1002/smi.2976

Wongsonegoro, R. K. (2022). Rekam Medik RS KRMT Wongsonegoro [KRMT Wongsonegoro Hospital Medical Records]. Retrieved from: https://sirs.kemkes.go.id/fo/home/profile_rs/3374342. Accessed on 20th August, 2023.

World Health Organization. (2021). Infertility prevalence estimates. Retrieved from: https://www.who.int/publications/i/item/978920068315. Accessed on 12th August, 2023.

Younis, J. S., Iskander, R., Fauser, B. C. J. M., & Izhaki, I. (2020). Does an association exist between menstrual cycle length within the normal range and ovarian reserve biomarkers during the reproductive years? A systematic review and meta-analysis. Human Reproduction Update, 26(6), 904-928. https://doi.org/10.1093/humupd/dmaa013

Yuan, Y., Yang, L., Hu, J., Deng, Y., & Zhang, H. (2024). Knowledge, attitude and practice on ovarian reserve function among women of childbearing age: a prospective cross-sectional study in chongqing and surrounding regions. BMJ Open, 14(3), 1–7. https://doi.org/10.1136/bmjopen-2023-080890

Zurlo, M. C., Cattaneo Della Volta, M. F., & Vallone, F. (2019). The association between stressful life events and perceived quality of life among women attending infertility treatments: The moderating role of coping strategies and perceived couple’s dyadic adjustment. BMC Public Health, 19, 1-8. https://doi.org/10.1186/s12889-019-7925-4