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Yin Y, Wang K, Xu Y, Huang X, Zheng J, Fan Y, Bai J. The Impact of Using Donor Sperm After ICSI Failure in Severe Oligozoospermia on Male Mental Health and Erectile Function. J Multidiscip Healthc 2024; 17:21-28. [PMID: 38196937 PMCID: PMC10775149 DOI: 10.2147/jmdh.s440778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/04/2023] [Indexed: 01/11/2024] Open
Abstract
Objective To analyze the mental health and erectile function status of men using sperm donor during pregnancy after ICSI failure in severe oligoasthenospermia and to provide reference for clinical implementation of more targeted psychological intervention and nursing for this group. Methods A total of 410 sterile men who received assisted pregnancy treatment in our hospital from December 2020 to December 2022 and met the inclusion and exclusion criteria were collected as the study subjects. Among them, 68 patients with severe oligoasthenospermia who used donor assisted pregnancy after ICSI failure were used as the study group. Sixty-eight patients with severe oligoasthenospermia who continued to receive ICSI assisted pregnancy were matched by propensity score 1:1 as control group. General data questionnaire, self-rating Anxiety Scale (SAS), self-rating Depression Scale (SDS), Chinese version of perceived Stress Scale (CPSS) and International Erectile Function Index Rating Scale (IIEF-5) were used to conduct a cross-sectional investigation to compare the mental health and erectile function status of the two groups. Results There were statistical differences in age and occupational status between the two groups before PSM (P < 0.05), but there was no statistical significance in social demographic data between the two groups after matching (P > 0.05). The incidence of anxiety, depression, stress and erectile dysfunction (ED) in the study group was higher than that in the control group, and there were statistical differences between the two groups (P < 0.05). Conclusion The use of donor sperm to assist pregnancy has a great impact on the mental health and erectile function of infertile men. Medical personnel should pay attention to the mental health and erectile function of these men, and formulate targeted measures to help these patients actively cope with infertility, so as to improve the life and marriage quality of this group and improve their mental health status.
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Affiliation(s)
- Ying Yin
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
| | - Ke Wang
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
- School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
| | - Yan Xu
- School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
- School of International Medical Technology, Sanda University, Shanghai, 201206, People’s Republic of China
| | - Xin Huang
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
| | - Jinxia Zheng
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
| | - Yuping Fan
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
| | - Jie Bai
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People’s Republic of China
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Kusumawaty I, Yunike Y. Investigating the experiences of family caregivers who shackle people with mental disorders. Front Psychiatry 2023; 14:1062100. [PMID: 37555001 PMCID: PMC10405514 DOI: 10.3389/fpsyt.2023.1062100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 06/12/2023] [Indexed: 08/10/2023] Open
Abstract
The mental health literacy gap has resulted in the shackling of people with mental illness by family caregivers. Although shackling violates human rights and impacts physical and psychological health, it still occurs in some countries, such as Indonesia. An in-depth study using the family function approach is needed to distinguish the components behind the application of shackling by families to find solutions to prevent shackling. Thus, this study aims to identify family functions in people with mental disorder (PWMD) care and to create a family care model for PWMD in accordance with the family function approach and recommendations for preventing shackling. This qualitative research used a phenomenological approach, involving eight participants who are family caregivers and live with their patients. Triangulation was conducted by applying interviews with four health cadres to confirm previous information. The process of in-depth interviews and observational data collection methods was carried out until reaching data saturation. The data analysis process used Collaizi's pattern to formulate three main themes, namely confinement as the final solution for the family, the specifics of confinement, and the family's purpose for confinement. The conclusion is that shackling occurs due to a lack of understanding of the impact of shackling and the various limitations experienced, so shackling becomes the last resort when dealing with patients. Peer support is very important for families to prevent the confinement of mentally ill family members. Technological advances are an inherent need in everyday life and must support family caregivers with mental disorders.
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Affiliation(s)
- Ira Kusumawaty
- Department of Mental Health Nursing, Poltekkes Kemenkes Palembang, Palembang, Indonesia
| | - Yunike Yunike
- Department of Pediatric Nursing, Poltekkes Kemenkes Palembang, Palembang, Indonesia
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Leeners B, Tschudin S, Wischmann T, Kalaitzopoulos DR. Sexual dysfunction and disorders as a consequence of infertility: a systematic review and meta-analysis. Hum Reprod Update 2023; 29:95-125. [PMID: 35900268 DOI: 10.1093/humupd/dmac030] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/06/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Sexuality has a key impact on quality of life and on reproductive health. Infertility often results in sexual dysfunction. Despite this close association, addressing sexuality is not a standard component of infertility counselling, especially since in most countries sexual medicine is not a core element of specialist training. Even today, many doctors and patients consider discussing sexuality to be more challenging than other aspects of reproductive medicine. The present review addresses the complex consequences of infertility on sexuality. OBJECTIVE AND RATIONALE Our goals were: (i) to identify the prevalence of sexual problems resulting from infertility, (ii) to evaluate characteristics of sexual difficulties and disorders resulting from infertility and (iii) to analyse factors involved in the complex association between sexual problems and infertility. SEARCH METHODS A systematic search for publications containing keywords related to sexual disorders and infertility was performed via PubMed, Web of Science and Psyndex. A total of 170 manuscripts published between January 1966 and April 2021 were identified after verification of inclusion and exclusion criteria. The reference lists in these manuscripts were searched for further relevant literature. Studies were reviewed for quality-related methodological details. OUTCOMES Couples diagnosed with infertility have an increased risk of sexual disorders. Loss of sexual desire and erectile dysfunction are among the most frequent sexual disorders resulting from infertility. Currently available literature reflects only fragmentarily the complexity of the diverse interactions. Sexuality plays out against the backdrop of interactions among personal, cultural, infertility-related and sexuality-related factors. Considering this complexity, it is crucial to evaluate individual profiles as well as partnership interactions to avoid a negative impact of infertility on a couple's sexual life. WIDER IMPLICATIONS Identifying sexual disorders as relevant considerations in the context of infertility and exploring their impact during the entire course of diagnosis and treatment constitute an important contribution to comprehensively care for the couples concerned. Counselling should focus on preventing the onset and aggravation of sexual disorders. As sexuality represents a major component of quality of life and of partnership, such support may improve not only the current overall wellbeing but also the chances of a satisfactory long-term partnership and family life.
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Affiliation(s)
- Brigitte Leeners
- Department of Reproductive Endocrinology, University Hospital Zurich, Zurich, Switzerland
| | - Sibil Tschudin
- Division of Social Medicine and Psychosomatics, University Hospital Basel, Basel, Switzerland
| | - Tewes Wischmann
- Institute for Medical Psychology, University Hospital Heidelberg, Heidelberg, Germany
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Fernandes J, Pedro J, Costa ME, Martins MV. Effect of depression and anxiety on sexual functioning in couples trying to conceive with and without an infertility diagnosis. Psychol Health 2023; 38:37-54. [PMID: 34279131 DOI: 10.1080/08870446.2021.1955115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study examined the effects of anxiety and depression on sexual functioning in couples trying to conceive, and tested the moderating role of infertility diagnosis on this association. DESIGN An online questionnaire was completed by 1453 individuals in a heterosexual relationship for more than one year. The final sample had 107 couples who were actively attempting a pregnancy (63 had an infertility diagnosis; 44 were presumably fertile). Data was analyzed with the Actor-Partner Interdependence Model (APIM). MAIN OUTCOME MEASURES Depression and anxiety symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS), and male and female sexual functioning were assessed through the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI), respectively. RESULTS Actor effects were found between depression and sexual functioning in both men (β= -.28, p= .003) and women (β= -.43, p < .001), with no significant partner effects. The moderation analysis showed that the relationship between depression and sexual functioning is stronger in infertile men than in presumably fertile men (β= -.29; p= .002). CONCLUSION Psychological interventions with couples trying to conceive should address the role of depression in sexual functioning, particularly in infertile men.
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Affiliation(s)
- Joana Fernandes
- Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Juliana Pedro
- Centre for Psychology, University of Porto, Porto, Portugal
| | - Maria Emília Costa
- Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal.,Centre for Psychology, University of Porto, Porto, Portugal
| | - Mariana Veloso Martins
- Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal.,Centre for Psychology, University of Porto, Porto, Portugal
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Nakić Radoš S, Soljačić Vraneš H, Tomić J, Kuna K. Infertility-related stress and sexual satisfaction: a dyadic approach. J Psychosom Obstet Gynaecol 2022; 43:18-25. [PMID: 32326782 DOI: 10.1080/0167482x.2020.1752658] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
PURPOSE OF THE STUDY to examine whether women's and men's infertility-related stress, and specifically its sexual concerns aspect, is related to their and their partner's sexual satisfaction. MATERIALS AND METHODS In a cross-sectional study, 94 couples experiencing infertility filled out the New Sexual Satisfaction Scale and Fertility Problem Inventory, which measures infertility-related stress with dimensions of social, sexual and relationship concerns, rejection of childfree lifestyle, and need for parenthood. Dyadic analyses were performed following the Actor-Partner Interdependence Model (APIM). RESULTS The dyadic analysis revealed that women's and men's greater infertility-related stress contributed to their lower levels of sexual satisfaction (actor effect). Moreover, women's and men's greater sexual concerns (as the aspect of infertility-related stress) contributed to their own and their partner's lower levels of sexual satisfaction (actor and partner effect). CONCLUSIONS The findings suggest that both individual and relational processes are important in the association between the specific dimension of infertility-related stress and sexual satisfaction. These findings could guide the psychosocial support for couples experiencing infertility.
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Affiliation(s)
- Sandra Nakić Radoš
- Department of Psychology, Catholic University of Croatia, Zagreb, Croatia
| | - Hrvojka Soljačić Vraneš
- Department of Obstetrics and Gynecology, University Hospital Centre Sisters of Mercy, Zagreb, Croatia
| | - Jozo Tomić
- Department of Obstetrics and Gynecology, University Hospital Centre Sisters of Mercy, Zagreb, Croatia
| | - Krunoslav Kuna
- Department of Obstetrics and Gynecology, University Hospital Centre Sisters of Mercy, Zagreb, Croatia
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Amiri SE, Brassard A, Rosen NO, Rossi MA, Beaulieu N, Bergeron S, Péloquin K. Sexual Function and Satisfaction in Couples with Infertility: A Closer Look at the Role of Personal and Relational Characteristics. J Sex Med 2021; 18:1984-1997. [PMID: 34702685 DOI: 10.1016/j.jsxm.2021.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/11/2021] [Accepted: 09/14/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Research to date suggests that couples undergoing assisted reproductive technology (ART) are at a high risk of experiencing sexual difficulties. AIM This dyadic cross-sectional study aimed to provide a better understanding of the infertility-specific personal (ie, emotional, mind-body) and relational stressors associated with the sexual desire, orgasm, arousal, and sexual satisfaction of infertile couples seeking ART. METHODS The sample included 185 mixed-sex infertile couples seeking ART. Participants completed online the Fertility Quality of Life tool and either the Female Sexual Function Index or the International Index of Erectile Function. Data were analyzed using path analyses based on the Actor-Partner Interdependence Model. OUTCOMES Individuals' own and their partners' sexual function (desire, orgasm, arousal domains) and sexual satisfaction. RESULTS For men and women, infertility-related emotional stressors were associated with their own and their partner's lower sexual desire. For women, experiencing greater infertility-related emotional stressors was also associated with their partner's lower sexual satisfaction. While experiencing greater infertility-related mind-body stressors was not associated with men and women's own sexual desire, arousal, orgasm, and satisfaction, for women, it was associated with their partner's lower sexual arousal. Lastly, for men and women, infertility-related relational stressors were associated with their own lower sexual arousal, as well as with their own and their partner's lower sexual satisfaction. For women, experiencing greater relational stressors was also associated with their own lower sexual desire and orgasm. CLINICAL IMPLICATIONS Interventions addressing the emotional, mind-body, and relational spheres of infertile couples seeking ART may help facilitate improvements in sexual function and satisfaction and better serve their needs. STRENGTHS & LIMITATIONS This study included a large sample of couples. Our sample was heterogeneous with regards to couples' cause of infertility and treatment stage. The use of an infertility-related measure allowed us to better capture personal and relational stressors specific to couples seeking ART. Given the cross-sectional design of our study, causality between infertility-related stressors and sexual function and satisfaction cannot be inferred. Our sample included predominantly White, mixed-sex individuals with a high level of education, which may reduce the generalizability of our findings. CONCLUSION Couples' subjective experience of infertility and treatment (personal and relational stressors) seems to be strongly associated with their sexual health, allowing us to identify potential targets of intervention with couples seeking ART. S.E. Amiri, A Brassard, N.O. Rosen, et al. Sexual Function and Satisfaction in Couples with Infertility: A Closer Look at the Role of Personal and Relational Characteristics. J Sex Med 2021;18:1984-1997.
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Affiliation(s)
- Sawsane El Amiri
- Departement of Psychology, Université de Montréal, Montréal, Québec, Canada
| | - Audrey Brassard
- Departement of Psychology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Natalie O Rosen
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Meghan A Rossi
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Noémie Beaulieu
- Departement of Psychology, Université de Montréal, Montréal, Québec, Canada
| | - Sophie Bergeron
- Departement of Psychology, Université de Montréal, Montréal, Québec, Canada
| | - Katherine Péloquin
- Departement of Psychology, Université de Montréal, Montréal, Québec, Canada.
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Luca G, Parrettini S, Sansone A, Calafiore R, Jannini EA. The Inferto-Sex Syndrome (ISS): sexual dysfunction in fertility care setting and assisted reproduction. J Endocrinol Invest 2021; 44:2071-2102. [PMID: 33956331 PMCID: PMC8421318 DOI: 10.1007/s40618-021-01581-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Infertility represents a peculiar social burden affecting more than 15% of couples, provoking it a real threat to the general quality of life and to the sexual health. The medicalization (diagnosis, therapy and follow up) of the lack of fertility is frequently a challenge in term of personal and couple's involvement. In particular, while the Assisted Reproductive Technology (ART) has allowed many infertile couples to achieve pregnancy, the therapeutic process faced by the couple bears a strong psychological stress that can affect the couple's quality of life, relationship and sexuality. Despite infertility affects both female and male sexual health, only recently the interest in the effects of ART on the couple's sexuality has grown, especially for women. METHODS A literature research on the sexual dysfunction in fertility care and particularly in ART setting was performed. RESULTS Literature largely found that intimacy and sexuality appear specifically impaired by intrusiveness of treatments and medical prescriptions. Moreover, there is a close relationship between emotional, psychological and sexual aspects, which can be integrated in the new concept of Inferto-Sex Syndrome (ISS) that can impair the ART treatment outcomes. Evidence demonstrates that the assessment of sexual function is necessary in couples undergoing diagnosis of infertility and ART. CONCLUSION A close relationship between infertility and sexuality, both in the female and male partners, was detected. ART treatments may heavily impact on the couple's psychosexual health. A couple-centred program for the integrated management of psychological and sexual dysfunction should be considered in the context of ART programs.
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Affiliation(s)
- G Luca
- Unit of Andrology and Endocrinology of Reproduction, Department of Experimental Medicine, University Medical School, 06129, Perugia, Italy
| | - S Parrettini
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia, University Medical School, 06129, Perugia, Italy
| | - A Sansone
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, E Tower South. Floor 4, Room E413, 00133, Rome, Italy
| | - R Calafiore
- Section of Endocrinology and Metabolism, Department of Medicine, Perugia, University Medical School, 06129, Perugia, Italy
| | - E A Jannini
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, E Tower South. Floor 4, Room E413, 00133, Rome, Italy.
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Zarif Golbar Yazdi H, Aghamohammadian Sharbaf H, Kareshki H, Amirian M. Psychosocial Consequences of Female Infertility in Iran: A Meta-Analysis. Front Psychiatry 2020; 11:518961. [PMID: 33250787 PMCID: PMC7674496 DOI: 10.3389/fpsyt.2020.518961] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 09/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Although not a life-threatening condition, infertility does influence various aspects of life. Based on a meta-analysis of the relevant literature, the aim of this study is to identify the psychosocial consequences of infertility in Iranian women. Methods: Comprehensive Portal of Human Sciences, Magiran, Scientific Information Database, Noormags, MEDLIB, ScienceDirect, Google Scholar, Medline, and ProQuest were the databases searched from inception (1999) to 2018. To maximize the comprehensiveness of the search, the reference lists of all the relevant papers identified were manually examined. The evaluation of the content was based on PRISMA guidelines, and Comprehensive Meta-Analysis software was used for data analysis. Results: Based on the analysis of 124 quantitative papers, the psychosocial consequences of infertility in women in Iran can be classified into 14 categories: psychological well-being (effect size = 3.10), adaptation to infertility (effect size = 2.71), quality of life (effect size = 1.83), depression (effect size = 1.80), anxiety (effect size = 1.72), marital relationships (effect size = 1.37), personality disorders (effect size = 1.37), violence (effect size = 1.31), social support (effect size = 0.90), self-efficacy (effect size = 0.90), coping strategies (effect size = 0.84), irrational thoughts (effect size = 0.77), somatization disorders (effect size = 0.65), and sexual dysfunction (effect size = 0.55). Conclusion: Considering the wide-ranging psychosocial consequences of infertility in women, it is necessary for treatment to account for psychological factors.
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Affiliation(s)
| | | | - Hossein Kareshki
- Department of Psychology, Ferdowsi University of Mashhad, Mashhad, Iran
| | - Malihe Amirian
- Department of Reproductive Medicine and Gynecology, Milad (Mashhad) Infertility Center, Mashhad, Iran
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Golmakani N, Ebrahimzadeh Zagami S, Esmaily H, Vatanchi A, Kabirian M. The relationship of the psychological coping and adjustment strategies of infertile women with the success of assisted reproductive technology. Int J Reprod Biomed 2019; 17. [PMID: 31435590 PMCID: PMC6693316 DOI: 10.18502/ijrm.v17i2.3989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/02/2018] [Accepted: 10/13/2018] [Indexed: 11/25/2022] Open
Abstract
Background The success of assisted reproductive techniques plays a very important role in the quality of life of infertile couples and decreases the negative behavior states of infertility. Objective This study aimed at determining the relationship between psychological coping and adjustment strategies with the success of assisted reproductive technology (ART). Materials and Methods This correlational study was conducted on 204 women visiting Milad Infertility Center in Mashhad during 2015-2016. The research instruments included Fertility Adjustment Scale and Infertility Coping Strategies Scale. The positive result of two pregnancy tests within 48 hours was considered as the success of ART. Results The mean and standard division score of adjustment in the group achieved treatment success (34.3±8.2) exceeded the group failed (33.6±8.8), the difference was not statistically significant (p= 0.381). Also, there was no significant difference between groups in the median and interquartile range of total coping strategies 81 (13) vs. 79.5 (12.25), (p= 0.369). Based on the logistic regression model for one increased transferred embryo, the chance of getting pregnant is 1.3 times, and for each unit increase in FSH level, the chance of ART success decreases 18%. Conclusion The results of this study showed that there is no relationship between psychological coping and adjustment strategies with ART success. However, the number of transferred fetus and tirthday FSH are introduced as factors that are related to the success of ART.
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Affiliation(s)
- Nahid Golmakani
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Habibollah Esmaily
- Social Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Atiyeh Vatanchi
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Kabirian
- Student Research Committee,School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
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