To be included in the review, the selected articles had to meet the following criteria: (1) Peer-reviewed articles published in English between 1990 and 2011; (2) The primary or secondary objective was to assess marital relationship in the context of infertility; (3) The study participants comprised of infertile individuals, or infertile couples comprised infertile subjects and their partners. All participants were not in marital separation; (4) A relevant, validated instrument was used to assess marital relationship. Furthermore, studies needed to report original data. Thus, reviews, editorials, debates, letters, case reports, non-peer-reviewed articles, meeting abstracts and brief communications were excluded.

In this study, a systematic literature review was conducted using the following electronic databases as the most appropriate resources to identify published studies: MedLine (Ovid), PsycInfo (Ovid) and Scopus. The search was compiled using keywords and phrases separated by the Boolean word “OR”: Marital Relationship “OR” Marital Quality “OR” Marital Satisfaction “OR” Marital Adjustment “OR” Marital Distress in combination with Infert* “OR” Childless* in the title, abstract, or keywords. Since some studies linked with marital relationship are explored in the context of clinical treatment, we included the following terms too: In-vitro Fertilization (IVF) “OR” Intra-cytoplasmic Sperm Injection (ICSI) “OR” Assisted Reproduction (AR). In addition, citations from these articles which appeared particularly relevant were also sought. Many of the searches generated duplicate articles, or articles which were unrelated to the study, these were not considered in the review. In the process of extraction, one of the investigators reviewed both the tile of the citation and the abstract to determine its suitability for inclusion.

Firstly, the titles and abstracts following with the search strategy were evaluated for the selection of eligible studies. Some studies were excluded at this stage as they were scarce of evidence with regard to the inclusion criteria. Secondly, the full-text of selected studies were further evaluated to decide whether they fulfilled the inclusion criteria.

The quality of the included studies was assessed using the criteria checklist (Table 1), which was derived from some systematic review studies (33–38), and adjusted to fit the research questions. The criteria for evaluating the quality of studies included in our study were: the quality of the measure instrument, the profile of study participants, study design and main results. The criteria checklist comprised 16 items; each item was scored with one point if the study met a criterion, and a score of zero if the study had an insufficient or no description of the item. The total maximum score was sixteen. Studies scoring 75% or more of the maximum attainable score (≥12 points) were considered to be of “high quality”. Studies scoring between 50 and 75% (between 8 and 12 points) were rated as “moderate quality”, and scores lower than 50% (≤7 points) were considered as “low-quality” studies.

As can be seen in Figure 1, the initial search in the online databases identified 910 citations, comprising 65 articles from Med-Line (Ovid), 329 from PsycInfo (Ovid) and 516 from Scopus. 116 articles were excluded due to the extraction of duplicates. After applying the study inclusion criteria, the final number of articles eligible for inclusion was 18. The flowchart of study selection is shown in Figure 1.

Table 2 provided a summary of the 18 published studies that met the inclusion criteria. They included studies that investigated the status of marital relationship and its influence across different infertility types. The main results related to marital relationship were indicated. All studies had been conducted in a clinical setting, of which, thirteen studies (39–51) were cross-sectional, and five (52–56) were longitudinal. The sample sizes differed due to variations in research protocols. In the studies on infertile couples, the sample sizes ranged from 20 (43) to 525 (46); and in studies on infertile individuals, the sample sizes ranged from 18 (47) to 520 (48). Participants included those who sought medical attention and/or treatment for assisted reproduction. The instruments were reliable and valid for the assessment of marital relationship in all of the reviewed studies.

In total, all studies described at least two demographic variables and most described at least two clinical variables of interest. The most reported demographic variables were age, ethnicity, economical status, education and duration of the marital relationship. Frequently represented clinical variables were type of infertility, type of treatment, time interval since diagnosis and time of medical attention.

Quality scores ranged from 8 (low quality) (47) to 15 (high quality) (56). Six studies (33%) were graded as high and twelve (67%) as moderate. Among these 18 studies, over half had some limitations in methodological quality, 12 (66%) studies could not meet the criteria H “Participation rates for the infertile groups and/or their spouses were described (defined as the percentage of eligible patients who gave informed consent) and they exceeded 70%”, 13 (72%) studies could not meet the criteria I “Information was given about the ratio of non-responders versus responders”, 13 (72%) studies could not meet the criteria K “The collection of data was prospectively gathered”, 13 (72%) studies could not meet the criteria L “The design was longitudinal (more than 1 year)”, 13 (72%) studies could not meet the criteria N “The follow-up period was at least 6 months”, 17 (94%) studies could not meet the criteria O “The loss to follow-up was described and was less than <20%”.

Three studies were on infertile males’ marital relationship among the 18 studies, using a cross-sectional design.

One study demonstrated that male factor infertility did not have a negative marital impact after controlling for male age, partner's age, race, religion, educational level, employment status, prior pregnancy, duration of infertility, and prior paternity (51). Another study presented the incidence of partnership disorders within marriage was not different between infertile and fertile males, but the marital dysfunction of infertile males should be given more attention in males over 30, lower education and infertility lasting 3–6 years (50).

Findings of a third study on the effects of infertility diagnosis on martial relationship in Chinese society, indicated no significant differences between infertile males and their spouse regarding infertility stress, but infertile males expressed more marital satisfaction than their partners (45).

Studies on marital relationship of infertile females are reported either in specific studies (five papers) (41, 49, 50, 53, 55) or as part of investigations in couples (one paper) (45).

Among infertile females referred for ART, the findings indicated infertile females had less stable relationships than fertile females, and the condition was negatively correlated with advanced age, increased duration of infertility, and failed IVF-ICSI attempts in the past (49). Moreover, more partnership disorders seen within marriage in infertile females appeared to be due to age over 30, lower education and infertility lasting 3–6 years (50). However, those women who became biological mothers through IVF were significantly more satisfied with their marital lives than women who were unsuccessful in IVF and remained childless (53), even though marital satisfaction changed in both pregnant and non-pregnant women after the first treatment cycle due to an increase in sexual dissatisfaction (55). As for the inferile female's marital satisfaction in different treatment periods, one study demonstrated that marital satisfaction during treatment was significantly lower compared with the periods before and after the treatment. In addition, the study found female initiation of treatment, partner's embarrassment for treatment termination, female's age and length of treatment period were negatively correlated with marital satisfaction in infertile females for all the three aforesaid periods, but no significant relationship was found between type of infertility (primary vs. secondary) and marital satisfaction (41).

Apart from the above studies, which directly selected infertile females as research subjects, another study selected infertile females from infertile couples as research subjects to explore marital relationship. The findings indicated that infertile females experienced significantly more distress than their husbands, and were less satisfied with their marriage than their husbands (45).

Amongst the studies on marital relationship in infertile couples, one study (45) examined marital relationship affected by a gender-specific infertility diagnosis in Chinese society, and made comparison between husbands and wives. The findings indicated when both partners were infertile women expressed less marital satisfaction than their husbands. No differences in marital satisfaction between wives and husbands with unexplained infertility were seen, and only wives with a diagnosed female infertility expressed higher distress than their husbands.

In other studies, the data on marital relationship were mixed without differentiating gender-specific infertility diagnosis. One study suggested marital adjustment of the wives of infertile couples were significantly lower than the scores of controls, but no differences were noted in husbands of infertile couples (47). However, some studies further demonstrated various factors contributing to marital dissatisfaction in infertile couples, e.g., age of partners above 30 years, individuals with greater stress, higher emotional distress, lower education, lower income, lengthier treatment, and unsuccessful treatment (39, 43, 44, 56). In addition, the level of sexual satisfaction in female partners was positively correlated to their marital satisfaction, but the level of infertility-related stress did not contribute significantly to fluctuations in their marital satisfaction. By contrast, marital satisfaction of male partners was influenced by the level of infertility stress, and not by their own degree of sexual satisfaction, nor by their wives becoming pregnant (52). Furthermore, coping strategies were emphasized to be correlated with marital relationship and coping strategies such as self-blame, were emphasized to be correlated with marital difficulties in both male and female partners (54). Both escape/avoidance and accepting responsibility coping strategies could diminish marital adjustment in both males and females, but seeking social support and planful problem-solving coping strategies could enhance or did not diminish their marital satisfaction (48).

Considering that infertility is a condition shared by both couples, other studies have suggested the intra-couple coping concordance might have different effects on marital relationship. One study demonstrated couples with high levels of congruence concerning infertility stress reported significantly higher levels of marital adjustment when compared to couples with different infertility-related stress (46). Another study showed that marital satisfaction was highest in couples where the males were using low levels of emotion-oriented coping, specifically the least satisfaction for women was evident when the woman was using less emotion-oriented coping than her partner or than when both partners were using more emotion-oriented coping strategies (42).