Results from this study showed that the mean perceived stress and anxiety scores were significantly lower in the counseling group than the control four weeks after intervention. The mean depression score was lower in the control group four weeks after intervention with adjusted baseline values; however, this between-group difference was not significant. Moreover, the mean quality of life score was significantly higher in the counseling group than the control.
In a review and meta-analytical study, Hopkinson et al. (2018) showed that CBT significantly reduced depression (p < 0.001) and stress (p < 0.001) among caregivers of patients with dementia; whereas, their anxiety level did not reduce (p = 0.47) (34). Their findings were consistent with our findings in terms of the effect of counseling on stress. The present study was similar to the above study in terms of holding in-person and telephone CBT sessions; whereas, they differed in the target population(that comprised of people aged 57–73 years old), and there was no limitation regarding the number and duration of intervention sessions.
In a review study, Ying et al. (2016) investigated the effect of psychological interventions on mental health, pregnancy rate, and marital function of infertile couples undergoing IVF. In 20 trials under investigation, 14 interventions, such as CBT, mindfulness, counseling, coping with stress, and positive reassessment used at different IVF stages were studied. The authors concluded that none of these interventions were effective in soothing stress and depression of patients undergoing IVF (35). Results from the above study were inconsistent with the present study, which could be attributed to the following reasons. The present study investigated the use of CBT on pregnant women with successful IVF; whereas, Ying et al. implemented interventions during the course of treatment. Moreover, none of the reviews investigated the psychological outcomes of intervention in the two-week wait period, despite the fact that this period is one of the most difficult times in the life of infertile couples.
Given that stress perception and responding to it are affected by previous experiences, the present situation and learned behaviors(36), it could be concluded that the CBT counseling in which new thinking and behavior techniques are taught to replace negative thoughts of patients about self, world, and future(37, 38), are helpful in identifying stressful situations and using coping strategies. The correction of cognitive assessments, improvement of coping skills, and combination of practices to integrate learned techniques with real-life situations can reduce the level of stress (26).
Hamzeh Poor (2013) showed that anxiety in infertile women was significantly lower in the CBT group than the control (39). Findings of the present study were consistent with those of the above study. However, Hamzeh Poor investigated the participants from the initial treatment to the IUI stage, i.e. before getting positive pregnancy result. In a quasi-experimental study, Salehi (2016) compared the effectiveness of group CBT and interactive lecturing in reducing anxiety in pregnancy. Results showed a significant reduction in the state and trait anxiety in CBT and IL groups after four weeks (p < 0.001). In addition, group CBT was more effective than interactive lectures in reducing participants anxiety; however, this between-group difference was not significant (p > 0.05) (40). Results from the above study were consistent with the findings of the present study; however, there was a difference between two studies in the number of counseling sessions and participants.
Iman-Parast et al. (2013) showed that CBT can significantly reduce anxiety in nulliparous women (41). Chatwin et al, (2016) investigated the effectiveness of CBT and EFT in reducing depression and anxiety in adults and showed that both methods significantly reduced depression symptoms in adults with major depression. However, the post-intervention anxiety score was not significantly diffident from the pretest score (p = 0.104). Moreover, anxiety score in the CBT group was significantly lower than that of EFT group (p = 0.032) (42). In a study on patients with major depression disorder, Rosso et al. (2017) showed that depression symptoms were significantly lower in the Internet-based CBT group than the control group (d=-0.80)(43). In a controlled randomized clinical trial, Fann et al. (2015) investigated the effect of in-person and telephone CBT on reducing major depression in patients with traumatic brain damage. Results showed no significant difference between the CBT and control groups (p = 0.37) (44). This inconsistency may be due to the difference in the target population and intervention type.
According to the cognitive-behavioral theory, anxiety disorders are caused by mistaken beliefs, which affect the interpretation of events and induce a disproportionate emotional response (45). As a result, holding counseling sessions for muscle relaxation, and identification of challenging thoughts and beliefs can replace the wrong attitudes of pregnant women with rational ones, indicating the effectiveness of CBT in anxiety management (33, 46). Studies have shown that infertility treatment failure may cause permanent emotional burden in 20% of infertile women (47, 48). To explain the results, in many participants, negative experiences, such as infertility treatment costs, continuous worries about treatment outcomes, fatigue from frequent visits to medical centers, curiosity of relatives, fear of family breakdown, and fear of losing husband interest before and during mental and social stress assessment resulted in a sense of helplessness, conflict, frustration, sharp decline in self-esteem and self-confidence, and isolation (49). These severe mental stressors play a significant role in depression. As a result, our intervention may be insufficient for addressing many of the participants' psychosocial needs.
In this study, cognitive-behavior counseling improved the quality of life of pregnant women with a history of primary infertility. In the review of literature, the author found no relevant study on pregnant women. In a controlled randomized clinical trial, Cooney et al. (2018) investigated the effect of CBT on weight and quality of life of women with polycystic ovary syndrome (PCOS). Results showed that weekly CBT + LS (lifestyle) for eight weeks was more effective than LS alone in reducing weight and improving the quality of life in women with PCOS (50). In a quasi-experimental study, 'Isa-Zadegan et al. (2013) showed that CBT in patients with hypertension can significantly increase the mean quality of life score in the counseling and control groups (p < 0.01) (51). In a clinical trial, Jalilian et al. (2018) showed that the CBT can affect and enhance the psychological and physical components of the quality of life in women with PCOS (p < 0.05)(52). Results from the above study were consistent with the present study; however, there were between-study differences in the target population, CBT type, and the number of follow-up sessions.
The financial burden from infertility treatment, lengthy treatment period, irrational thoughts about having a child, psychological pressures from relatives, and low educational level are among factors having adverse effects on the quality of life of infertile women (53). Women impregnated after these difficult stages experience a very stressful and challenging pregnancy (54). The researchers believe that although infertility, as a source of psychological pressure, can endanger mental health of infertile people, its effect depends on the psychological assessment and coping skills of those people. Therefore, teaching these skills to control emotions plays a significant role in reducing psychological pressures caused by infertility-induced stress (55). It could be concluded that CBT can cause some changes in the psychological dimensions of pregnant women. When these women use CBT skills in stressful situations, they feel capable of making decisions, controlling their life events, and taking effective measures to achieve desirable results. They internally feel satisfaction which, in turn, increases happiness, mental well-being, and self-efficiency, as the quality of life factors. (51).