Comparing the Effectiveness of Expressive Writing and Relaxation on Mental Health and Treatment Success in Women Undergoing Assisted Reproductive Technology: A Randomized Controlled Trial
,
Abstract
Objective: Infertility and its treatments can lead to mood disorders such as depression, anxiety, stress. This study aimed to compare the effects of relaxation and expressive writing on depression, anxiety, stress, and treatment success in women utilizing assisted reproductive technology methods.
Materials and methods: In this parallel randomized clinical controlled trial, 90 infertile women undergoing assisted reproductive technology were involved. Participants were randomly assigned to three groups: writing (n=30), relaxation (n=30), and control (n=30). The writing and relaxation groups received either expressive writing or relaxation interventions, while the control group only received routine treatment. The primary outcomes measured in the study were depression, anxiety, and stress, with treatment success as the secondary outcome. All participants completed the Depression, Anxiety, and Stress Scale at the beginning of the treatment cycle and again before ovarian puncture. Statistical analysis was performed using the Chi-squared, Kruskal-Wallis, and Wilcoxon tests. A p-value<0.05 was considered statistically significant.
Results: The results showed that mean differences in depression (P=0.001) and stress scores (P=0.011) before and after intervention in the writing group were significantly higher than in the control group. Additionally, only the writing group experienced a significant decrease in depression (P=0.016). However, there was no significant difference in other measured outcomes among the three groups.
Conclusion: It is recommended to conduct more well-designed studies to further investigate the effects of expressive writing and relaxation techniques.
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7. Benyamini Y, Gozlan M, Kokia E. Women's and men's perceptions of infertility and their associations with psychological adjustment: a dyadic approach. Br
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8. Navid B, Mohammadi M, Vesali S, Mohajeri M,
Omani Samani R. Correlation of The Etiology of Infertility with Life Satisfaction and Mood Disorders in Couples who Undergo Assisted Reproductive Technologies. Int J Fertil Steril. 2017;11(3):205-210.
9. Peterson BD, Newton CR, Feingold T. Anxiety and sexual stress in men and women undergoing infertility treatment. Fertil Steril. 2007;88(4):911-4.
10. Torres-Arce E, Vizmanos B, Babio N, Márquez-Sandoval F, Salas-Huetos A. Dietary Antioxidants in the Treatment of Male Infertility: Counteracting Oxidative Stress. Biology (Basel). 2021;10(3):241.
11. Greil AL, McQuillan J, Lowry M, Shreffler KM. Infertility treatment and fertility-specific distress: A longitudinal analysis of a population-based sample of U.S. women. Soc Sci Med. 2011;73(1):87-94.
12. Lee YH, Park JS. Factors affecting the infertility-related quality of life among the infertility women. Journal of the Korean Society of Maternal and Child Health. 2019;23(3):191-201.
13. Lawson AK, Klock SC, Pavone ME, Hirshfeld-Cytron J, Smith KN, Kazer RR. Prospective study of depression and anxiety in female fertility preservation and infertility patients. Fertil Steril. 2014;102(5):1377-84.
14. Rooney KL, Domar AD. The impact of stress on fertility treatment. Curr Opin Obstet Gynecol. 2016;28(3):198-201.
15. Malmir M, Teimouri F, Pishgooie SAH, Dabaghi P. The Role of Benson´ s relaxation on reducing state anxiety on candidate of open heart surgery patient’s. Military Caring Sciences Journal. 2015;2(3):182-90.
16. Vieskarami H, bavazin f. Effectiveness of Benson Therapeutic Therapy and Bioresonance on Isfurs Reduction and Increasing Ovulation in Infertile Women Compared to Drug Therapy. Studies in Medical Sciences. 2018;28(10):620-8.
17. Frederiksen Y, Farver-Vestergaard I, Skovgård NG, Ingerslev HJ, Zachariae R. Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ open. 2015;5(1):e006592.
18. Pennebaker JW. Expressive Writing in Psychological Science. Perspect Psychol Sci. 2018;13(2):226-9.
19. Stanton AL, Low CA. Expressing emotions in stressful contexts: Benefits, moderators, and mechanisms. Current directions in psychological science. 2012;21(2):124-8.
20. Afshar B, Amini L, Hasani M, Jahanfar S, Massood Nabavi S. The most effective sexual function and dysfunction interventions in individuals with multiple sclerosis: A systematic review and meta-analysis. Int
J Reprod Biomed. 2022;20(4):241-254.
21. Halpert A, Rybin D, Doros G. Expressive writing is a promising therapeutic modality for the management of IBS: a pilot study. Am J Gastroenterol. 2010;105(11):2440-8.
22. Afshar B, Amini L, Nabavi SM, Hasani M, Mohammadnoori M, Jahanfar S, et al. What Effects Can Expressive Writing Have on Sexual Dysfunction in Women with Multiple Sclerosis? A Randomized Controlled Trial. Acta Neurologica Scandinavica. 2023;2023(1):6754178.
23. Smeltzer S, Bare B, Hinkle J, Cheever K. Biophysical and pychological concepts in nursing practice, Brunner & suddarths text book of medical surgical nursing. Philadelphia: Woltres, 2010.
24. Torabi M, Salavati M, GHahri Sarabi A, Pouresmaeil Z. Foot reflex massage and relaxation on anxiety and physiological parameters in hospitalized patients undergoing coronary angiography. J Nurs Midwifery Hamedan. 2012;20(1):63-71.
25. Nereu Bjorn M, Neves de Jesus S, Casado Morales M. Estrategias de relajación durante el período de gestación: beneficios para la salud. Clínica y Salud. 2013;24(2):77-83.
26. Karami J, Mokari Z, Shalani B. The effectiveness of relaxation training on depression, anxiety, and stress in infertile women. 2018;6(4(21)):241-255.
27. Cameron J. The Artist's Way: A Spiritual Path to Higher Creativity. Los Angeles: J.P.Tarcher/Putnam, 2002.
28. Frederiksen Y, O'Toole MS, Mehlsen MY, Hauge B, Elbaek HO, Zachariae R, et al. The effect of expressive writing intervention for infertile couples: a randomized controlled trial. Hum Reprod. 2017;32(2):391-402.
29. Matthiesen S, Klonoff‐Cohen H, Zachariae R, Jensen‐Johansen MB, Nielsen BK, Frederiksen Y, et al. The effect of an expressive writing intervention (EWI) on stress in infertile couples undergoing assisted reproductive technology (ART) treatment: a randomized controlled pilot study. Br J Health Psychol. 2012;17(2):362-78.
30. Renzi A, Solano L, Di Trani M, Ginobbi F, Minutolo E, Tambelli R. The effects of an expressive writing intervention on pregnancy rates, alexithymia and psychophysical health during an assisted reproductive treatment. Psychol Health. 2020;35(6):718-33.
31. Vieskarami H. Effectiveness of Benson Therapeutic Therapy and Bioresonance on Isfurs Reduction and Increasing Ovulation in Infertile Women Compared to Drug Therapy. Studies in Medical Sciences. 2018;28(10):620-8.
32. Lovibond SH. Manual for the depression anxiety stress scales. Sydney Psychology Foundation.
1995;33(3):335-343.
33. Pooravari M, Dehghani M, Salehi S, Habibi M. Confirmatory Factor Analysis of Persian Version of Depression, Anxiety and Stress (DASS-42): Non-Clinical Sample. Razavi International Journal of Medicine. 2017;5(4): ):e12021.
34. Hamzehgardeshi Z, Yazdani F, Elyasi F, Moosazadeh M, Peyvandi S, Gelehkolaee KS, et al. The efficacy of group counselling on perceived stress among infertile women undergoing in vitro fertilization treatment: An RCT. Int J Reprod Biomed. 2019;17(1):57.
35. Reinhold M, Bürkner PC, Holling H. Effects of expressive writing on depressive symptoms—A meta‐analysis. Clinical Psychology: Science and Practice. 2018;25(1):e12224.
36. Niles AN, Haltom KEB, Mulvenna CM, Lieberman MD, Stanton AL. Randomized controlled trial of expressive writing for psychological and physical health: the moderating role of emotional expressivity. Anxiety Stress Coping. 2014;27(1):1-17.
37. Panagopoulou E, Montgomery A, Tarlatzis B. Experimental emotional disclosure in women undergoing infertility treatment: Are drop outs better off? Soc Sci Med. 2009;69(5):678-81.
38. Akbari A, Ahmadi F, Jalili E, Khazaei S. The effect of relaxation technique (Jacobsen and Benson) on depression, anxiety, and stress in patients with multiple sclerosis. Current Psychiatry Research and Reviews Formerly: Current Psychiatry Reviews. 2020;16(3):213-9.
39. Renzi A, Mariani R, Di Trani M, Gorman B, Tambelli R. Expressive writing and linguistic analysis in women undergoing fertility treatment: an exploratory study on the possible association with medical outcome. Revista Argentina de Clínica Psicológica. 2021;30(2):406-19.
40. Abbasi M, Bavazin F, Mansouri L. Effectiveness of benson relaxation method on reduction of stress and
increase of the number and motility of sperms among infertile males. Iranian journal of psychiatric nursing. 2017;5(3):22-8.
41. Srinivasan R, Donnagayathri K J, M T, Kumar A. Effectiveness of Benson’s Relaxation Technique In Stressed PCOD Women. International Journal of Physiotherapy and Research. 2024;12:4664-9.
42. Vieskarami H. The Effect of Relaxation Techniques on the Reduction of Stress, Sexual Anxiety, Communication Concerns, and Social Concerns in Females with Infertility. Iranian Journal of Nursing Research. 2018;13(2):10-6.
43. Valiani M, Abediyan S, Ahmadi SM, Pahlavanzadeh S, Hassanzadeh A. The effect of relaxation techniques to ease the stress in infertile women. Iran J Nurs Midwifery Res. 2010;15(4):259.
44. Amini L, Ghorbani B, Afshar B. The comparison of infertility stress and perceived social support in infertile women and spouses of infertile men. Iran J Nurs. 2020;32(122):74-85.
45. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The Social Consequences of Infertility among Iranian Women: A Qualitative Study. Int J Fertil Steril. 2015;8(4):409-20.
46. Bogović A, Potkonjak AM, Djaković I, Vraneš HS. Depression, anxiety, and stress in infertile couples during the COVID-19 pandemic: the consequences we face. JBRA Assist Reprod. 2024;28(1):9-12.
2. Valiani M, Abedian S, Pahlavanzade S. The effects of relaxation on outcome treatment in infertile women. Complementary Medicine Journal. 2014;4(2):845-53.
3. Rouchou B. Consequences of infertility in developing countries. Perspect Public Health. 2013;133(3):174-9.
4. World Health Organization, Infertility. https://www.who.int/health-topics/infertility#tab=tab_1/, 2023.
5. Imannezhad S, Mirzaei M, Khodadadi B, Heydari O, Dehghani N. Prevalence of Infertility among Iranian Women: An Overview of Systematic Reviews and Meta-Analyses. Health Providers. 2024;4(1):1-8.
6. Hasanpoor-Azghady SB, Simbar M, Vedadhir AA, Azin SA, Amiri-Farahani L. The Social Construction of Infertility Among Iranian Infertile Women: A Qualitative Study. J Reprod Infertil. 2019;20(3):178-190.
7. Benyamini Y, Gozlan M, Kokia E. Women's and men's perceptions of infertility and their associations with psychological adjustment: a dyadic approach. Br
J Health Psychol. 2009;14(Pt 1):1-16.
8. Navid B, Mohammadi M, Vesali S, Mohajeri M,
Omani Samani R. Correlation of The Etiology of Infertility with Life Satisfaction and Mood Disorders in Couples who Undergo Assisted Reproductive Technologies. Int J Fertil Steril. 2017;11(3):205-210.
9. Peterson BD, Newton CR, Feingold T. Anxiety and sexual stress in men and women undergoing infertility treatment. Fertil Steril. 2007;88(4):911-4.
10. Torres-Arce E, Vizmanos B, Babio N, Márquez-Sandoval F, Salas-Huetos A. Dietary Antioxidants in the Treatment of Male Infertility: Counteracting Oxidative Stress. Biology (Basel). 2021;10(3):241.
11. Greil AL, McQuillan J, Lowry M, Shreffler KM. Infertility treatment and fertility-specific distress: A longitudinal analysis of a population-based sample of U.S. women. Soc Sci Med. 2011;73(1):87-94.
12. Lee YH, Park JS. Factors affecting the infertility-related quality of life among the infertility women. Journal of the Korean Society of Maternal and Child Health. 2019;23(3):191-201.
13. Lawson AK, Klock SC, Pavone ME, Hirshfeld-Cytron J, Smith KN, Kazer RR. Prospective study of depression and anxiety in female fertility preservation and infertility patients. Fertil Steril. 2014;102(5):1377-84.
14. Rooney KL, Domar AD. The impact of stress on fertility treatment. Curr Opin Obstet Gynecol. 2016;28(3):198-201.
15. Malmir M, Teimouri F, Pishgooie SAH, Dabaghi P. The Role of Benson´ s relaxation on reducing state anxiety on candidate of open heart surgery patient’s. Military Caring Sciences Journal. 2015;2(3):182-90.
16. Vieskarami H, bavazin f. Effectiveness of Benson Therapeutic Therapy and Bioresonance on Isfurs Reduction and Increasing Ovulation in Infertile Women Compared to Drug Therapy. Studies in Medical Sciences. 2018;28(10):620-8.
17. Frederiksen Y, Farver-Vestergaard I, Skovgård NG, Ingerslev HJ, Zachariae R. Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ open. 2015;5(1):e006592.
18. Pennebaker JW. Expressive Writing in Psychological Science. Perspect Psychol Sci. 2018;13(2):226-9.
19. Stanton AL, Low CA. Expressing emotions in stressful contexts: Benefits, moderators, and mechanisms. Current directions in psychological science. 2012;21(2):124-8.
20. Afshar B, Amini L, Hasani M, Jahanfar S, Massood Nabavi S. The most effective sexual function and dysfunction interventions in individuals with multiple sclerosis: A systematic review and meta-analysis. Int
J Reprod Biomed. 2022;20(4):241-254.
21. Halpert A, Rybin D, Doros G. Expressive writing is a promising therapeutic modality for the management of IBS: a pilot study. Am J Gastroenterol. 2010;105(11):2440-8.
22. Afshar B, Amini L, Nabavi SM, Hasani M, Mohammadnoori M, Jahanfar S, et al. What Effects Can Expressive Writing Have on Sexual Dysfunction in Women with Multiple Sclerosis? A Randomized Controlled Trial. Acta Neurologica Scandinavica. 2023;2023(1):6754178.
23. Smeltzer S, Bare B, Hinkle J, Cheever K. Biophysical and pychological concepts in nursing practice, Brunner & suddarths text book of medical surgical nursing. Philadelphia: Woltres, 2010.
24. Torabi M, Salavati M, GHahri Sarabi A, Pouresmaeil Z. Foot reflex massage and relaxation on anxiety and physiological parameters in hospitalized patients undergoing coronary angiography. J Nurs Midwifery Hamedan. 2012;20(1):63-71.
25. Nereu Bjorn M, Neves de Jesus S, Casado Morales M. Estrategias de relajación durante el período de gestación: beneficios para la salud. Clínica y Salud. 2013;24(2):77-83.
26. Karami J, Mokari Z, Shalani B. The effectiveness of relaxation training on depression, anxiety, and stress in infertile women. 2018;6(4(21)):241-255.
27. Cameron J. The Artist's Way: A Spiritual Path to Higher Creativity. Los Angeles: J.P.Tarcher/Putnam, 2002.
28. Frederiksen Y, O'Toole MS, Mehlsen MY, Hauge B, Elbaek HO, Zachariae R, et al. The effect of expressive writing intervention for infertile couples: a randomized controlled trial. Hum Reprod. 2017;32(2):391-402.
29. Matthiesen S, Klonoff‐Cohen H, Zachariae R, Jensen‐Johansen MB, Nielsen BK, Frederiksen Y, et al. The effect of an expressive writing intervention (EWI) on stress in infertile couples undergoing assisted reproductive technology (ART) treatment: a randomized controlled pilot study. Br J Health Psychol. 2012;17(2):362-78.
30. Renzi A, Solano L, Di Trani M, Ginobbi F, Minutolo E, Tambelli R. The effects of an expressive writing intervention on pregnancy rates, alexithymia and psychophysical health during an assisted reproductive treatment. Psychol Health. 2020;35(6):718-33.
31. Vieskarami H. Effectiveness of Benson Therapeutic Therapy and Bioresonance on Isfurs Reduction and Increasing Ovulation in Infertile Women Compared to Drug Therapy. Studies in Medical Sciences. 2018;28(10):620-8.
32. Lovibond SH. Manual for the depression anxiety stress scales. Sydney Psychology Foundation.
1995;33(3):335-343.
33. Pooravari M, Dehghani M, Salehi S, Habibi M. Confirmatory Factor Analysis of Persian Version of Depression, Anxiety and Stress (DASS-42): Non-Clinical Sample. Razavi International Journal of Medicine. 2017;5(4): ):e12021.
34. Hamzehgardeshi Z, Yazdani F, Elyasi F, Moosazadeh M, Peyvandi S, Gelehkolaee KS, et al. The efficacy of group counselling on perceived stress among infertile women undergoing in vitro fertilization treatment: An RCT. Int J Reprod Biomed. 2019;17(1):57.
35. Reinhold M, Bürkner PC, Holling H. Effects of expressive writing on depressive symptoms—A meta‐analysis. Clinical Psychology: Science and Practice. 2018;25(1):e12224.
36. Niles AN, Haltom KEB, Mulvenna CM, Lieberman MD, Stanton AL. Randomized controlled trial of expressive writing for psychological and physical health: the moderating role of emotional expressivity. Anxiety Stress Coping. 2014;27(1):1-17.
37. Panagopoulou E, Montgomery A, Tarlatzis B. Experimental emotional disclosure in women undergoing infertility treatment: Are drop outs better off? Soc Sci Med. 2009;69(5):678-81.
38. Akbari A, Ahmadi F, Jalili E, Khazaei S. The effect of relaxation technique (Jacobsen and Benson) on depression, anxiety, and stress in patients with multiple sclerosis. Current Psychiatry Research and Reviews Formerly: Current Psychiatry Reviews. 2020;16(3):213-9.
39. Renzi A, Mariani R, Di Trani M, Gorman B, Tambelli R. Expressive writing and linguistic analysis in women undergoing fertility treatment: an exploratory study on the possible association with medical outcome. Revista Argentina de Clínica Psicológica. 2021;30(2):406-19.
40. Abbasi M, Bavazin F, Mansouri L. Effectiveness of benson relaxation method on reduction of stress and
increase of the number and motility of sperms among infertile males. Iranian journal of psychiatric nursing. 2017;5(3):22-8.
41. Srinivasan R, Donnagayathri K J, M T, Kumar A. Effectiveness of Benson’s Relaxation Technique In Stressed PCOD Women. International Journal of Physiotherapy and Research. 2024;12:4664-9.
42. Vieskarami H. The Effect of Relaxation Techniques on the Reduction of Stress, Sexual Anxiety, Communication Concerns, and Social Concerns in Females with Infertility. Iranian Journal of Nursing Research. 2018;13(2):10-6.
43. Valiani M, Abediyan S, Ahmadi SM, Pahlavanzadeh S, Hassanzadeh A. The effect of relaxation techniques to ease the stress in infertile women. Iran J Nurs Midwifery Res. 2010;15(4):259.
44. Amini L, Ghorbani B, Afshar B. The comparison of infertility stress and perceived social support in infertile women and spouses of infertile men. Iran J Nurs. 2020;32(122):74-85.
45. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The Social Consequences of Infertility among Iranian Women: A Qualitative Study. Int J Fertil Steril. 2015;8(4):409-20.
46. Bogović A, Potkonjak AM, Djaković I, Vraneš HS. Depression, anxiety, and stress in infertile couples during the COVID-19 pandemic: the consequences we face. JBRA Assist Reprod. 2024;28(1):9-12.
| Files | ||
| Issue | Vol 19, No 2 (June 2025) | |
| Section | Original Articles | |
| DOI | https://doi.org/10.18502/jfrh.v19i2.19301 | |
| Keywords | ||
| Anxiety Depression Infertility Relaxation Stress Writing | ||
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How to Cite
1.
Najdgholami Z, Amini L, Montazeri A, Mohammadnoori M. Comparing the Effectiveness of Expressive Writing and Relaxation on Mental Health and Treatment Success in Women Undergoing Assisted Reproductive Technology: A Randomized Controlled Trial. J Family Reprod Health. 2025;19(2):128-135.
