Well-being and relationship satisfaction of couples dealing with an in vitro fertilization/ intracytoplasmic sperm injection procedure: a multilevel approach on the role of self-criticism,

Well-being and relationship satisfaction of couplesdealing with an in vitro fertilization/ intracytoplasmicsperm injection procedure: a multilevel approach onthe role of self-criticism, dependency, and romanticattachmentBenedicte Lowyck, Ph.D.,a Patrick Luyten, Ph.D.,a Jozef Corveleyn, Ph.D.,a

Thomas D’Hooghe, M.D., Ph.D.,b Evelien Buyse, Ph.D.,a and Koen Demyttenaere, M.D., Ph.D.a,b,c

Departments of aPsychology and c Psychiatry, University of Leuven, and b University Hospital Gasthuisberg, Leuven University

Fertility Centre, Leuven, Belgium

Objective: To extend existing research on the psychological impact of IVF by studying the association betweenthe psychosocial factors of self-criticism and dependency, and romantic attachment, with the well-being andrelationship satisfaction of couples across the different phases of IVF/intracytoplasmic sperm injection (ICSI)treatment.Design: Prospective, three-wave study (i.e., from start of IVF/ICSI treatment, to 3- and 6-month follow-up).Setting: University hospital.Patient(s): Seventy couples in IVF/ICSI treatment.Intervention(s): Psychometric tests were administered at first visit of IVF/ICSI treatment, and at 3- and 6-monthfollow-up.Main Outcome Measure(s): Psychological well-being, relationship satisfaction.Result(s): Results demonstrated that preexisting psychosocial factors such as self-criticism, dependency, andromantic attachment are more important factors for psychological well-being and relationship satisfaction duringIVF/ICSI than gender and treatment-related factors such as duration of fertility problems. In addition, multilevelanalysis, a statistical method that is required for the analysis of longitudinal couple data and decomposes var-iation in three levels (i.e., time, individuals, and couples), showed more variation in psychological well-beingand relationship satisfaction between couples, than between individuals and different time measurements.Conclusion(s): Preexisting personality factors and being embedded within a certain couple relationship are impor-tant factors for the psychological well-being and relationship satisfaction during IVF/ICSI. (Fertil Steril� 2009;91:387–94. �2009 by American Society for Reproductive Medicine.)

Key Words: IVF, couples, well-being, relationship satisfaction, romantic attachment, self-criticism, dependency

A considerable body of research has shown that dealing withfertility problems and their medical treatment, such as IVF orintracytoplasmic sperm injection (ICSI), has negative effectson both intrapersonal and interpersonal functioning for manyindividuals (1–6). However, there are many differences be-tween individuals in this respect, and studies have suggestedthat various psychosocial factors such as coping styles andsocial support influence these differences (7–11).

The purpose of this study is to extend this research on thepsychosocial aspects of IVF/ICSI treatment in three impor-tant ways.

First, from a theoretical point of view, most studies on psy-chosocial factors involved in IVF/ICSI treatment originatedfrom stress and coping theories (12, 13) and therefore, havehad relatively little attention for developmental issuesinvolved in fertility problems. It can be argued that an impor-tant aspect of dealing with fertility problems is that theypotentially jeopardize a central developmental task of adult-hood (i.e., biological and parental generativity) (14, 15). Inthis context Blatt and Blass (16) have argued that the abilityto negotiate problems concerning generativity may dependon the synthesis or balance individuals have achievedbetween relatedness and self-definition, that is, between thecapacity to form mature and complex interpersonal relation-ships and an essentially positive definition of the self. Ac-cording to Blatt and Blass, vulnerability occurs when thereis an imbalance in this development (i.e., when there is toomuch emphasis on the development of one capacity at theneglect of the other). Blatt and Blass have coined the notionsof dependency and self-criticism to refer to these two types ofimbalance. Dependency refers to putting too much emphasison the development of interpersonal relatedness at the neglect

Received September 14, 2007; revised November 14, 2007; accepted No-

vember 16, 2007.

B.L. has nothing to disclose. P.L.has nothing to disclose. J.C. has nothing to

disclose. T.D. has received research funding from Merck-Serono, Pfizer,

Ferring, and Organon. E.B. has nothing to disclose. K.D. has received

honoraria from Boehringer Ingleheim, Eli Lilly, Lundbeck, and Wyeth.

Reprint requests: Benedicte Lowyck, Ph.D., Department of Psychology,

University of Leuven, Tiensestraat 102, 3000 Leuven, Belgium

(FAX: þ32-16-325920; E-mail: [email protected]).

0015-0282/09/$36.00 Fertility and Sterility� Vol. 91, No. 2, February 2009 387doi:10.1016/j.fertnstert.2007.11.052 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.

of developing one’s self-definition, whereas self-criticismrefers to putting too much emphasis on the development ofa positive self-definition at the neglect of interpersonalrelatedness (17–19).

A large number of studies in clinical and nonclinical pop-ulations have shown that self-criticism has a negative impacton both intrapersonal and interpersonal functioning (20, 21),whereas dependency negatively influences intrapersonalfunctioning (20, 21), but is unrelated to interpersonal func-tioning, and to relationship satisfaction in particular (22,23). In addition, studies have shown that these effectsremained significant even after taking into account individualdifferences in levels of depression (20, 24).

Furthermore, a considerable body of research has investi-gated the role of these personality dimensions within thecontext of the transition to parenthood, demonstrating thatself-criticism is associated with higher levels of both intraper-sonal and interpersonal distress in this period, whereasdependency seems to incorporate both aspects of vulnerabil-ity and resilience (25–27). Interestingly, a recent study byBesser and colleagues (28) suggests that vulnerability associ-ated with self-criticism and dependency during the transitionto parenthood may be even more outspoken under highlystressful conditions, such as in high risk pregnancies (29).Therefore, it may be interesting to study the role of bothself-criticism and dependency for the intrapersonal and inter-personal functioning of couples dealing with the stressful lifeevent of fertility problems (30).

In addition to research investigating the role of self-criticism and dependency, studies have shown that romanticattachment to the partner may also play an important rolefor intrapersonal and interpersonal functioning of adults dur-ing the transition to parenthood (31, 32).

One of the original premises of John Bowlby’s attach-ment theory is that human beings are born with an innateattachment behavioral system that motivates them to seekproximity to attachment figures in times of stress andneed (33, 34). Although primary care givers, most oftenthe parents, are the main attachment figures during infancy,romantic partners have been found to be the most importantattachment figures during adulthood (35–37). Therefore, ro-mantic attachment involves the fact whether individuals canuse their couple relationship as a supportive context or ‘‘safehaven.’’

Studies have identified four types of romantic attachment(38). Individuals with a secure romantic attachment to theirpartner see themselves as worthy of care and evaluate theirpartner as being responsive. Individuals with an insecure,preoccupied romantic attachment style think of themselvesas unworthy of care, but evaluate their partner as beingresponsive. Furthermore, individuals with an insecure fear-ful–avoidant attachment style, believe themselves unworthyof care and expect their partner to be rejecting, whereas inse-cure dismissive individuals have a positive sense of self, butsee their partner as being unresponsive (38).

388 Lowyck et al. IVF, couples, personality, attachment

Interestingly, studies have also shown that self-criticismand dependency on the one hand, and attachment on theother, are related theoretically and empirically. Dependencyhas been shown to be most closely related to preoccupiedattachment, whereas self-criticism is most closely related tofearful–avoidant attachment, and inversely related to preoc-cupied attachment (39). However, despite this overlap, recentstudies have found that dependency and self-criticism, andromantic attachment grasp unique aspects of both intraper-sonal (25) and interpersonal functioning (24). Hence, inthis study we wanted to investigate both factors concurrentlyto determine whether, and to which extent, they may contrib-ute to the understanding of vulnerability and resilience incouples dealing with fertility problems.

Second, from a methodological point of view, it is clearthat both partners of a couple are affected by fertility prob-lems (13). Yet, existing research on psychosocial aspects ofinfertility has mainly concentrated on women or has investi-gated men and women separately (2, 6, 10). In addition, mostresearch in this area has adopted cross-sectional designs (2,11), or studies have focused on only one treatment cycle ofIVF/ICSI using a two-wave design (6, 8). Therefore, in thisstudy, we used a three-wave, multilevel approach, investigat-ing well-being and relationship satisfaction across IVF/ICSItreatment from the start of IVF/ICSI treatment to 3 and 6months of follow-up (5, 40). Longitudinal multilevel model-ing is suited for the analysis of couple data (41, 42), as it takesinto account the dependent character of this kind of data, thatis, the fact that different time measures are nested within eachindividual, as well as the fact that each individual or partner isnested or embedded within a specific couple relationship.

Finally and third, we wanted to explore whether thepsychosocial factors related to self-criticism, dependency,and romantic attachment were uniquely associated withwell-being and relationship satisfaction over and abovemore objective factors that have been shown to influenceIVF/ICSI treatment, such as gender (5), duration of fertilityproblems and number of prior treatments (2), and pregnancystatus (6, 43, 44).

The hypotheses of this study were threefold:

1. Self-criticism, dependency, and insecure (fearful–avoidant, preoccupied, dismissive) romantic attach-ments are negatively, and secure romantic attachmentto the partner is positively associated with well-being.

2. Self-criticism and insecure romantic attachments arenegatively, and secure romantic attachment is posi-tively associated with relationship satisfaction, whereasdependency is not significantly associated with rela-tionship satisfaction.

3. The effects of self-criticism, dependency, and romanticattachments on well-being and relationship satisfactionremain significant even when controlling for gender,and treatment-related factors such as duration of fertil-ity treatment, number of previous treatments, andwhether or not the woman became pregnant.

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MATERIALS AND METHODS

Procedures

Participation in the study was voluntarily and anonymity wasguaranteed. This study was approved by the ethical commit-tee of the University of Leuven (Belgium). Before the start oftheir first IVF or ICSI treatment all prospective couples weresent a letter with information about the study. Once in thehospital to start the treatment, participants met with themain researcher and were provided more detailed informa-tion about the study. After signing the informed consent,they were each given a set of questionnaires measuring de-mographic and fertility-related variables, personality, roman-tic attachment, psychological well-being, and relationshipsatisfaction. Each partner was asked to separately fill in thesequestionnaires and return them to the main researcher (Time1). Follow-up questionnaires, measuring pregnancy status(i.e., whether the woman became pregnant), psychologicalwell-being, and relationship satisfaction, were administeredat 3 (Time 2) and 6 (Time 3) months of follow-up. Datacollection schedules were fixed (i.e., all variables were mea-sured at the same time intervals for all participants) and theywere all collected in a 2-year time period (2004–2006).

Participants

Participants were eligible for the study if [1] they weremarried or living together with their partner for at least 2years, [2] there was no oocyte or sperm donation involved,and [3] they started their first cycle of IVF or ICSI. Seventyof the 123 couples who met inclusion criteria agreed to par-ticipate (57%). When both partners agreed to participatebut one of them was not fluent in Dutch, or was not presentin the hospital at the time of the study, only one partnerwas included in the study. Therefore, at Time 1, the sampleconsisted of 68 women and 60 men, and 58 of these partici-pants were partners. Women were on average 32 years old(SD¼ 3.98); 20% of them had obtained a high school degree,and 76% had obtained a degree of higher education or univer-sity. Almost all women were working at the time of the study(96%). Seventy-one percent were married, and on averagehad been together with their partner for 8 years (mean ¼8.15 years; SD ¼ 4.13). Before starting their first IVF/ICSItreatment, 31% had undergone one previous medical treat-ment for their fertility problems (e.g., artificial insemination),16% had undergone two, and 7% had undergone three priortreatments. For approximately half of the women (46%),this IVF or ICSI procedure was their first medical treatmentfor their fertility problems. On average women had been deal-ing with fertility problems for 2 years (mean ¼ 2.07 years;SD ¼ 1.10). The mean age of the men was 35 years (SD ¼5.44); 43% of them had obtained a high school degree, and52% had a degree of higher education or a university degree.Almost all men (97%) were professionally active at the timeof the study. Most men (i.e., 68%) were married, 7% wereremarried after a divorce, and 25% were living togetherwith their partner without being married. On average, menhad been together with their partners for 8 years (SD ¼ 4.1).

Fertility and Sterility�

Of the 68 women participating at Time 1, 50 (73%) partic-ipated at Time 2, and 37 (54%) at Time 3. One woman drop-ped out of IVF/ICSI treatment between Time 1 and Time 2,and one woman conceived naturally, therefore they were ex-cluded from analyses at follow-up. Furthermore, 26% of thewomen (n¼ 9) became pregnant between Time 1 and Time 2,and 28% (n¼ 10) between Time 2 and Time 3. Of the 60 menparticipating at Time 1, 42 (70%) also participated at Time 2,and 27 (45%) participated at Time 3. A multivariate analysisof variance (MANOVA) showed no significant differencesbetween any of the study variables and drop-out from thestudy. Likewise, a logistic regression analysis showed no sig-nificant association between gender and drop-out (c2 (1) ¼1.09, P¼not significant [NS]).

Measurements

1. Depressive Experiences Questionnaire (DEQ; 45). TheDEQ consists of 66 items, scored on a 7-point Likert-type scale, ranging from 1 (‘‘I don’t agree’’) to 7 (‘‘Itotally agree’’) and measures self-criticism and depen-dency. The Dutch version of the DEQ has good internalconsistency and validity, similar to the original DEQ(46, 47). The DEQ was scored using the original factorscores of Blatt et al. (45).

2. Relationship Questionnaire (RQ; 38). The RQ was usedto assess adult romantic attachment to one’s partner.Participants had to indicate on a 7-point Likert-typescale how well each of the romantic attachment styles(secure, fearful–avoidant, preoccupied, dismissive)represented the relationship with their partner. TheRQ has demonstrated convergent validity with struc-tured interviews and observer ratings (38), and showsmoderate test–retest stability (48). The RQ was trans-lated to Dutch according to guidelines of the Interna-tional Test Commission (49). Although in the pastsome studies have criticized the use of the RQ, a recentstudy by Sibley and colleagues (50) has shown that theuse of the RQ is appropriate for measuring adult roman-tic attachment to one’s current partner, when [1] the RQis administered concurrently with other variables ofinterest, [2] one expects moderate to large effect sizes,and [3] the relationship domain being assessed matchesthe outcome domain of interest, such as in our study therelationship satisfaction with current partner. All threeconditions are met in this study, and hence we decidedto use the RQ.

3. Amsterdam Scale of Well-Being (ASWB [51]) consistsof 55 items and 8 subscales. All items are scored on6-point Likert scale, ranging from 1 (‘‘I don’t agree’’)to 6 (‘‘I totally agree’’). In this study, only 6 subscales(39 items) were included—self-acceptance, positive re-lations, autonomy, environmental mastery, purpose inlife, and personal growth. The total scale consists ofthe sum of the subscales. The internal consistency(Cronbach’s alpha) for this total scale was 0.97 atTime 1.

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4. Dyadic Adjustment Scale (DAS [52]). The DAS is a 32-item scale and produces a total score reflecting a generalsense of relationship satisfaction, as well as foursubscales: cohesion, consensus, satisfaction, and affec-tional expression. Because of the high association be-tween the subscales and the total scale (r’s between0.64 and 0.90), only the total scale was used in thisstudy. The internal consistency (Cronbach’s alpha) ofthe total scale was 0.90 at Time 1.

Statistical Analyses

Multilevel modeling was used including three levels: differ-ent measures of time (level 1) nested within individuals(level 2), and nested within couples (level 3). Two typesof three-level models were tested in this study (53): an un-conditional model (null model), and a fixed effects model.The unconditional model provides estimations of the pro-portion of variance found at all three levels investigated.Next, to test the hypothesis that self-criticism, dependency,and romantic attachment predicted psychological well-beingand relationship satisfaction, fixed effects models weretested, using hierarchical linear modeling. The purpose ofhierarchical linear modeling is similar to traditional hierar-chical regression analysis, but in contrast to hierarchical re-gression analysis, the variance is decomposed at differentlevels. First, in the initial model, all investigated predictorswere included. Next, in a final model, only the significantpredictors of the initial model were included. The improve-ment in fit of this final model was compared with the uncon-ditional model by computing differences in model fit, usingc2 statistics (53). Next, more objective factors, such as gen-der, duration of the fertility problems, and number of previ-ous treatments were added to the final model and it wastested whether they significantly contributed to well-beingand relationship satisfaction. Finally, to investigate the pos-sible influence of pregnancy status (i.e., whether or not thewoman became pregnant through IVF/ICSI), we re-ran all

analyses, but only included the data of Time 2 and Time3, controlling for pregnancy status at Time 2. Using theFull Information Maximum Likelihood, multilevel analysisallows for missing data, and thus we also included datafor couples where only one partner completed assessments(41, 54). All analyses were conducted using MLwiN 2.02(54).

RESULTS

Unconditional Models

As presented in Table 1, results showed a significant propor-tion of variance in psychological well-being and relationshipsatisfaction at the time, the individual, and the couple level.Hence, because there was a significant proportion of varianceat all three levels, multilevel modeling was justified.

Fixed Models: Self-Criticism, Dependency, and RomanticAttachment

As presented in Table 2, for well-being results showed thatadding self-criticism, dependency, and secure romantic at-tachment to the unconditional model explained 34% of thetotal variance (i.e., 266.50 � 176.50/266.50). Self-criticismand dependency were negatively associated, and secure ro-mantic attachment was positively associated with well-beingacross times.

For relationship satisfaction, adding predictors to the un-conditional model explained 42% of the total variance. Asshown in Table 2, self-criticism, preoccupied, and dismissiveromantic attachments were negatively associated, whereassecure romantic attachment was positively associated withrelationship satisfaction across times.

Comparing the fit of the final fixed models with the uncon-ditional model showed that adding self-criticism, dependency,and secure romantic attachments significantly improvedmodel fit for well-being (c2 ¼ 46; Ddf ¼ 3; n ¼ 243;

TABLE 1The unconditional model with partitioning of variance of well-being and relationship satisfaction.

Well-being (n [ 243) Relationship satisfaction (n [ 248)

Estimate (SE) % Variance Estimate (SE) % Variance

FixedConstant 177.54 (1.71) 121.18 (1.41)

RandomBetween couples 124.682 (36.30)a 47% 113.77 (23.31)a 73%Between individuals 84.67 (23.34)a 32% 20.02 (6.32)a 13%Between times 57.15 (7.15)a 21% 21.73 (2.72)a 14%

Total 266.50 155.52Deviance 1,899.85 1,721.65

a P< .001.

Lowyck. IVF, couples, personality, attachment. Fertil Steril 2009.

390 Lowyck et al. IVF, couples, personality, attachment Vol. 91, No. 2, February 2009

TABLE 2Fixed model and final fixed model for well-being and relationship satisfaction.

Well-being (n [ 243) Relationship satisfaction (n [ 248)

Parameters Fixed model Final model Fixed model Final model

FixedConstant 166.41 166.43 119.66 119.16Self-criticism �6.63 (1.45)a �6.63 (1.38)a �2.65 (1.01)b �2.33 (0.95)b

Dependency �5.32 (1.26)a �5.18 (1.21)a 1.21 (0.80)Secure 2.99 (1.29)c 3.40 (1.24)b 2.32 (0.76)a 2.26 (0.76)b

Fearful–avoidant 0.40 (1.21) 0.70 (0.77)Preoccupied �0.73 (0.91) �2.44 (0.60)a �2.34 (0.61)a

Dismissive �0.67 (0.91) �1.06 (0.50)c �1.15 (0.49)b

RandomBetween couples 48.73c (28%) 44.47a (49%)Between individuals 71.67a (40%) 24.56a (27%)Between times 56.07a (32%) 21.77a (24%)Total 176.50 90.79Deviance 1,853.58 1,682.41

% Explained varianceCouple level 61% 61%Individual level 15% 0%Time level 2% 0%Total 34% 42%

a P< .001.b P< .01.c P< .05.

Lowyck. IVF, couples, personality, attachment. Fertil Steril 2009.

P<.001). Likewise, adding self-criticism, secure, preoccu-pied, and dismissive romantic attachments significantly addedto the model fit for relationship satisfaction (c2¼ 39; Ddf¼ 4;n ¼ 248; P<.001).

Gender and Treatment-Related Factors

Gender (B ¼ 0.29; SE ¼ 2.20; P¼NS), duration of fertilityproblems at the start of treatment (B ¼ 0.37; SE ¼ 1.50,P¼NS), and number of previous treatments (B ¼ �0.40;SE ¼ 1.50, P¼NS) were not significantly associated withwell-being, whereas self-criticism (B ¼ �4.76; SE ¼ 1.38,P<.001), dependency (B ¼ �3.85; SE ¼ 1.36; P<.001),and secure romantic attachment (B ¼ 2.69; SE ¼ 1.25;P<.01) remained significantly related to well-being.

Furthermore, neither gender (B¼ 0.35; SE¼ 1.20; P¼NS)nor duration of fertility problems (B ¼ 0.72; SE ¼ 0.90,P¼NS) were significantly associated with relationship satis-faction, whereas the number of previous treatments was a neg-ative predictor of relationship satisfaction (B ¼ �2.31; SE ¼1.03; P<.05). Furthermore, self-criticism (B ¼ �2.33; SE ¼0.94, P<.05) and secure (B ¼ 2.27; SE ¼ 0.76; P<.01),preoccupied (B¼�2.52; SE¼ 0.60; P<.001), and dismissive(B ¼ �1.13; SE ¼ 0.48; P<.05) romantic attachments re-mained significantly associated with relationship satisfaction.

Fertility and Sterility�

Pregnancy Status

Pregnancy status was not significantly associated withpsychological well-being (B ¼ �1.71; SE ¼ 2.88, P¼NS),whereas dependency (B ¼ �4.35; SE ¼ 1.33 P<.001),self-criticism (B¼�3.94; SE¼ 1.52; P<.01), and secure ro-mantic attachments (B ¼ 2.50; SE ¼ 1.42, P<.08) remainedsignificantly associated with psychological well-being.

Furthermore, pregnancy status was not significantly relatedto relationship satisfaction (B ¼ �1.20; SE ¼ 3.0, P¼NS),whereas self-criticism (B ¼ �1.83; SE ¼ 1.07; P<.08),preoccupied (B¼�2.80; SE¼ 0.73, P<.001), and dismissive(B ¼ �1.99; SE ¼ 0.61; P<.001), but not secure romanticattachment (B ¼ 0.60; SE ¼ 1.05, P¼NS), remained signifi-cantly associated with relationship satisfaction.

DISCUSSION

In general results were in line with expectations showing thatself-criticism, dependency, and romantic attachment were as-sociated with well-being and relationship satisfaction of menand women dealing with IVF/ICSI.

First, results demonstrated that self-criticism and depen-dency were negatively associated, and romantic attachmentto the partner was positively associated with the well-being

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of men and women undergoing IVF/ICSI. Hence, congruentwith theoretical expectations (17, 18, 21), results suggest thatthe ability to deal with IVF/ICSI, and thus with problemsconcerning adult generativity (14), may depend on the bal-ance individual partners have achieved in their developmentof self-definition and relatedness. Furthermore, in line withexpectations (55), results showed that adults who are securelyattached to their partner (i.e., who represent their partner asbeing emotional available and responsive) report a higherdegree of well-being during IVF/ICSI than individuals withan insecure romantic attachment style.

Next, results showed a negative association between self-criticism and preoccupied and dismissive romantic attach-ments on the one hand, and relationship satisfaction on theother. These results suggest that self-critical adults (i.e.,adults showing excessive self-evaluative concerns, highpersonal standards, and a high need for recognition andachievement) report a lower degree of relationship satisfac-tion dealing with an event that may jeopardize adult genera-tivity (14, 16) compared to adults who have obtained a betterbalance between the development of their self-definition andrelatedness. In addition, perceiving one’s partner as beingemotionally available and responsive during IVF/ICSI mayalso lead to greater relationship satisfaction, whereas beingeither overly preoccupied with the availability of one’s part-ner, or dismissing the need for his/her presence may nega-tively impact relationship satisfaction across IVF/ICSIprocedures. Furthermore, most of the variation in relationshipsatisfaction was situated between couples, suggesting that thefact that partners are embedded within a certain couple rela-tionship may play an important role for their relationshipsatisfaction during IVF/ICSI.

In contrast to most previous studies (2, 5), but in line withothers (56), results showed no significant differences inwell-being between men and women. Furthermore, as foundin previous studies (2, 57), results showed no significantassociation between gender and relationship satisfaction.In addition, in accord with previous findings (43, 44, 58),results suggest that during the early stages of pregnancy,whether or not the woman became pregnant was not relatedto their psychological well-being and relationship satis-faction.

In general our findings suggest that preexisting personalityfactors related to self-criticism and dependency, and romanticattachment to the partner, may be important and complemen-tary factors associated with well-being and relationship satis-faction during IVF/ICSI. Although more research in largersamples is needed, this study suggests that these relativelystable psychosocial dimensions may be more important fac-tors determining the psychological functioning of individualsand couples that receive IVF/ICSI than gender, treatment-related factors, and even whether or not the woman becomespregnant.

In addition, this study may have important implications forprevention and counseling. First, results suggest that taking

392 Lowyck et al. IVF, couples, personality, attachment

into account preexisting personality factors such as self-criticism, dependency, and romantic attachment may helpclinicians to detect individuals and couples whose well-beingand relationship satisfaction during IVF/ICSI may be mostvulnerable and provide them with the necessary guidanceand support. Second, results suggest that counselors mayalso need to situate fertility problems within a broad develop-mental context of adult generativity. In addition, when IVF/ICSI fails, counselors may assist the couple in finding alter-native ways to be generative (e.g., adoption, mentorship)(59). Third, counselors may need to discuss romantic attach-ment with the couple and help insecure couples developa more secure partner relationship in which they can overtlytalk about their thoughts and emotions associated with thisdifficult experience of IVF/ICSI (60). Working towarda more secure partner relationship may be especially impor-tant for two reasons: [1] research has shown that the partneris a primary source of support during IVF/ICSI treatment(56), and [2] difficulties in partner communication predicthigh fertility problem stress when couples fail to get pregnant(61).

Furthermore, because a significant amount of variation inwell-being and relationship satisfaction is situated betweencouples, even when preexisting factors of the partners suchas self-criticism, dependency, and romantic attachmentwere accounted for, the interaction between both partnersof a couple may be a crucial factor in determining psycholog-ical well-being and relationship satisfaction during IVF/ICSItreatment. Therefore, in counseling, sufficient attentionshould be directed toward exploring the role of the couplerelationship (5, 62).

Finally, despite its clear strengths, including the assess-ment of both partners in a three-wave prospective design,and the use of multilevel modeling, this study has a numberof limitations.

First, although the use of the RQ as an assessment ofadult romantic attachment with single items for each attach-ment style was appropriate in this study, future researchshould include a multi-item self-report scale of romantic at-tachment, such as the Relationship Scales Questionnaire(63).

Second, although multilevel modeling, a statistical methodthat takes into account the dependence of couple data, wasused to analyze our data, future research should extend thisstudy by investigating cross-partner effects, that is, the effectof psychological variables of one partner (e.g., self-criticism)on the outcome of the other partner (e.g., well-being).

Finally, although self-criticism and dependency, as well asromantic attachment, are relatively stable personality char-acteristics (21), the stress of fertility problems may haveled to an increased activation of these personality dimen-sions (28). Hence, an important question is whether naturalpregnancy also leads to the activation of these personalitydimensions, and thus to similar effects. Therefore, future re-search should adopt a case-control design, comparing

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couples in IVF/ICSI treatment with couples going througha natural pregnancy.

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