1. Introduction
Infertility is a global problem that leads to physical, psychological, and social complications and is defined as the inability to conceive after one year of sex without contraception [1, 2, 3]. The prevalence of infertility is 12% to 15%, worldwide, and its prevalence is reported 20.2% in Iran [4]. Studies show that the psychological damage caused by infertility is far greater in women compared to men [5]. Infertility is one of the worst life experiences and a stressful factor for women and brings about many physical and mental effects, including depression, isolation, envy, anger, fear, a lack of confidence, self-criticism, sleep disorder, and a lack of appetite [6]. According to studies, one of the most important psychological consequences in an infertile woman is infertility stress, which is a set of symptoms in women that occur following infertility and is similar to many of the symptoms of posttraumatic stress disorder [7]. There is a correlation between stress and physical illnesses because stress causes disorders in the endocrine system, hypothalamic axis-adrenal pituitary, platelet function, and heart rate [8]. Studies show that infertility stress can lead to disruption of treatment and causes hopelessness and low confidence in infertile women, making infertility treatments ineffective [9]. Another psychological consequence of infertility in women is a decrease in psychological well-being [10]. Psychological well-being is defined as a positive evaluation of the self and an individual’s life, believing in a purposeful and meaningful life, having a high-quality relationship with others, meaning one’s personal life, overcoming the world’s problems, and accepting the self. People who are rated high in psychological well-being usually have positive emotions and are optimistic about events, while people with low psychological well-being have negative reactions, such as anxiety and depression [11]. 
The results of a study showed that the promotion of psychological well-being is associated with an increase in general health [12]. The complex interaction between psychological problems and infertility in women, as well as the importance of mental health, has led to the use of several psychological therapies, all of which have provided beneficial effects [13, 14, 15, 16]. One of the interventions that can affect the mental health of infertile women is teaching positive thinking, which is thinking differently about positive and negative events and valuing them with a new perspective [17]. Positive psychology emphasizes various concepts, such as happiness, resilience, life satisfaction, and life expectancy [18]. In a meta-analysis, Boiler showed that positive thinking has a positive and significant effect on psychological well-being [19]. Numerous studies have confirmed the effect of positive thinking on psychological well-being, hope, confidence, and happiness [20, 21, 22].
Using a variety of art therapies to many psychological problems is a method that psychology has always considered. Poetry therapy, which is a type of art therapy in which poetry is used to achieve the goals of personal growth and mental health, was first officially introduced in 1969 and in recent years has found a special position in the field of psychology [23]. In the process of poetry therapy, people find a different opportunity to define themselves by reading and writing poetry that expresses deeper emotions compared to ordinary conversations. In other words, expressing emotions and desires symbolically, relieving stress, and finding new meanings through new ideas and insights in poetry therapy effectively affect people’s spirit and ultimately lead to changing attitudes, creating a positive attitude, increasing confidence, and adapting to present conditions [24]. The effectiveness of poetry therapy in reducing psychological disorders has been reported in numerous studies with different approaches. The poems of famous Persian poets, such as Hafiz and Molavi are rich sources of gaining inner peace and cultivating the great meanings of life, such as freedom, inhibition, avoiding envy, hope, and satisfaction. Since the language of poetry is much more pleasant compared to colloquial language because of its rhythm and given that words in poetry often carry a special meaning, they can have a great impact on the direction of a person’s life and psyche and double the effect of positive thinking on the psyche of the audience [25, 26, 27, 28, 29]. Considering that, so far, no research has been conducted that uses poetry therapy as a therapeutic approach to reduce the psychological damage of infertile women, in the present study, poetry has been employed to teach positive thinking concepts. Given the high prevalence of infertility, the background on the effectiveness of positive thinking and poetry therapy in reducing psychological problems, helping to reduce the psychological damage of infertile women, and the lack of research on this issue, this research aims to determine the effectiveness of positive thinking, concentrating on poetry therapy, on the psychological well-being and infertility stress of infertile women.
2. Methods 
This was a quasi-experimental research with a pre-test, post-test design and a control group. The statistical population of this research consisted of infertile women who were referred to infertility clinics in Khorramabad City, Iran, in 2020. The statistical sample consisted of 46 infertile women who were selected via the convenience sampling method. After ensuring the similarity of the demographic characteristics and mental state of the subjects by the interview method, they were randomly assigned to experimental and control groups. Given the following measures in the present research, the sample size was sufficient: P<0.05, Eta2 >0.020, and power >0.080 [30]. The criteria for entering the research were providing consent to participate in the study, diagnosis of infertility by a gynecologist, being in the age range of 20 to 40 years, and having a degree of at least 9 classes. The exclusion criteria were unwillingness to continue participating in therapeutic sessions and pregnancy.
Study instruments
Psychological well-being questionnaire
The psychological well-being questionnaire was compiled by Ryff in 1989. It aims to evaluate the level of psychological well-being and includes 18 questions. The subscales of this instrument include autonomy, personal growth, mastery of the environment, positive relationships with others, purpose in life, and self-acceptance. These subscales make up the total score on psychological well-being. The scoring of this questionnaire is done based on a 6-point Likert scale from “Completely Agree” to “Completely Disagree”. The positive correlation of this questionnaire with the life satisfaction scale, the Oxford happiness scale, and the Rosenberg self-esteem questionnaire indicates the convergent validity of the Ryff psychological well-being questionnaire. In his studies, Ryff obtained the reliability of psychological well-being subscales ranging from 0.72 to 0.89 via the Cronbach α method [31]. Bayani et al. standardized the psychological well-being questionnaire in Iran and reported its reliability coefficient using the Cronbach α method [32]. In the present research, the face and content validity of this questionnaire was confirmed and its internal consistency was calculated via the Cronbach α method at 0.84. 
Newton infertility stress questionnaire
The Newton infertility stress questionnaire is a multidimensional questionnaire developed by Newton et al. and measures 5 components of social concern, sexual concern, relationship concern, risk of a childfree lifestyle, and the need for parenthood. This scale is scored based on a 6-point Likert scale from “Completely Agree” to “Completely Disagree”. The scores range from 46 to 276, with higher scores indicating more stress. Newton evaluated the content, face, and criterion validity of this questionnaire as appropriate and also reported the Cronbach α of social concern at 0.87, sexual concern at 0.77, relationship concern at 0.82, risk of childfree lifestyle at 0.80, and the need for parenthood at 0.84 [33]. In the present research, the face and content validity of this questionnaire was confirmed and its internal consistency was calculated using the Cronbach α method at 0.81.
The purpose and nature of the research for subjects were first explained and they were assured that the content of the treatment sessions would be confidential. The subjects from both experimental and control groups underwent the pre-test process and were asked to complete the relevant questionnaires. The experimental group received positive thinking intervention based on poetry therapy conducted by a person with a Master’s degree in psychology (the therapist specialized in spiritual therapy and positive therapy and has published articles in this field); however, during this period the control group did not receive any intervention. A total of eight 90-min psychotherapy sessions were held for each participant individually and after the treatment sessions, the Post-test was performed in both groups. The data analysis of this research was done via the SPSS software, version 22. We used Mean and Standard Deviation (SD) for descriptive statistics and multivariate and univariate covariance analysis for inferential statistics.
The summary of the positive thinking protocol based on poetry therapy, which was compiled by the researchers and then confirmed by 5 psychology experts, a psychiatrist, and Persian language and literature experts who were prominent university professors, is provided in Table 1.


3. Results 
In the present study, the mean±SD of the age of the experimental group was 28.76±7.23 years and the control group was 30±6.32 years. Also, the mean±SD of the education of the experimental group was 14±3.22 years while the control group was 15±42 years. Descriptive statistics (Mean and SD) of psychological well-being and infertility stress scales of the experimental and control groups with the pre-test, post-test separation are provided in Table 2.


The multivariate analysis of the covariance method was used to determine the effectiveness of positive thinking training based on poetry therapy. Necessary assumptions for using this analysis, such as the normality of the data distribution and the homogeneity of the variance were analyzed. The distribution of the scores on the scales of psychological well-being and infertility stress was normal and according to the Levene test, the homogeneity of the variance was established in the scores of these variables (P>0.05). 
The findings of Table 3 demonstrate a significant difference in our indicator after removing the pre-test effect.


Subsequently, to evaluate the role of positive-thinking-based poetry therapy in improving infertility stress and psychological well-being subscales, the univariate analysis of covariance was used and the results are provided in Table 4.


According to Table 4, assuming the control of the pre-test effect, positive thinking training based on poetry therapy improves the subscales of autonomy (F=11.32, P=0.002), mastery of environment (F=22.41, P=0.001), personal growth (F=22.49, P=0.001), positive relationship with others (F=12.49, P=0.001), purpose in life (F=12.68, P=0.001), self-acceptance (F=33.83, P=0.001), and total psychological well-being (F=30.80, P=0.001). It also improves all infertility stress subscales, such as social concern (F=21.27, P=0.001), sexual concern (F=13.14, P=0.001), relationship concern (F=24.60, P=0.001), risk of childfree lifestyle (F=21.62, P=0.001), the need for parenthood (F=10.18, P=0.003), and the total infertility stress (F=22.38, P=0.001) in the experimental group. The results showed that the experimental group had a significant change in the mentioned variables compared to the control group.
4. Discussion
This study aimed to determine the effectiveness of positive thinking teaching based on poetry therapy on infertility stress and the psychological well-being of infertile women. The results of the present research showed that positive thinking, concentrating on poetry therapy, has been effective in improving psychological well-being and infertility stress in infertile women. This finding is consistent with previous research. Gozashtis et al. examined the effectiveness of poetry therapy in reducing the psychological problems of women with breast cancer. To explain these findings, poetry therapy as a kind of adjunctive therapy can improve the quality of life in breast cancer patients while increasing their life expectancy [26]. In a study, Mirzaee et al. examined the effectiveness of poetry therapy for posttraumatic stress disorder in patients with heart disease and the results were in line with the findings of this research. The results showed that depression and social behaviors after poetry therapy intervention had a positive and significant difference [27]. In a meta-analysis, Boiler et al. found that positive thinking interventions were effective in increasing psychological and physical well-being and could help reduce depressive symptoms [19].
In explaining the effects of positive thinking based on poetry therapy on infertility stress, the main function of this intervention is to modify the individual‘s attitude and interpretation of life. And since Persian poems emphasize the transience of life and moral virtues, it strengthens the will to live and reduces psychological damage. Presenting positive thinking skills, such as optimism, hope, and patience in the form of poetry facilitates dealing with negative thoughts and leads a person to peace and excellence while minimizing the destructive effects of infertility stress.
In addition, in explaining the effect of positive thinking based on poetry therapy on psychological well-being, by taking advantage of the rich concepts of Persian poems, people achieve the power of transcendence and ignore worldly appearances; hence, they understand the meaning of life. In addition, a positive attitude toward life crises and trying to solve them and emphasis on the present improves metacognitive beliefs and changes the lifestyle, which brings vitality and psychological well-being. Future studies should be encouraged to allow the generalization of the results by implementing poetry therapy on other chronic patients, given that the measurement tools are self-reported and not reliable as the interview. 
5. Conclusion
The findings of this research showed that positive thinking intervention, concentrating on poetry therapy, has been effective in improving infertility stress and psychological well-being. Therefore, it is suggested that psychologists and counselors use a positive thinking approach based on poetry therapy to improve the stress of infertile women in counseling centers along with other common psychotherapies. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Lorestan University of Medical Science (Code:IR.LUMS.REC.1399.338).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.


References

1. Petre LM, Gemescu M, Bulgari D. Using artistic activities within experiential psychotherapy to alleviate the psychological consequences of female infertility. The Arts in Psychotherapy. 2021; 1(73):101758. [DOI:10.1016/j.aip.2021.101758]
2. Galhardo A, Cunha M, Monteiro B, Pinto -Gouveia j. Assessing psychological inflexibility in infertility: The development and validation study of the Psychological Inflexibility Scale-Infertility (PIS-I).Journal of Contextual Behavioral Science. 2020; 1(18):239-246. [DOI:10.1016/j.jcbs.2020.09.006]
3. Bräuner EV, Nordkap L, Priskorn L, Hansen AM, Bang AK, Holmboe SA, et al. Psychological stress, stressful life events , male factor infertility, and testicular function: a cross -sectional stud. International Journal of Fertility and Sterility. 2020; 113(4):865-875. [DOI:10.1016/j.fertnstert.2019.12.013] [PMID]
4. Hamid N. The effectiveness of stress management based on cognitive-behavior method on depression, anxiety and fertilization of infertile women. International Journal of Behavioral Sciences. 2011; 5(1):55-60. [Link]
5. Yazdi HZ, Sharbaf HA, Kareshki H, Amirian M. Infertility and psychological and social health of Iranian infertile women: a systematic review. Iranian Journal of Psychiatry. 2020; 15(1):67-9. [PMCID] [PMID]
6. Farazmand M, Ebrahimi S. Effectiveness of Quality of Life Therapy on Marital Burnout and Psychological Distress in the Infertile Women. Mashhad University of Medical Sciences. 2019; 21(61):320-329. [Link]
7. Patel A, Sharma PS, Narayan P, Binu VS, Dinesh N, Pai PJ. Prevalence and predictors of infertility-specific stress in women diagnosed with primary infertility: A clinic-based study. Journal of Human Reproductive Sciences. 2016; 9(1):28. [DOI:10.4103/0974-1208.178630] [PMID] [PMCID]
8. Pournaghash Tehrani S, Kashanaki H. [Stress in health psychology. A review study (Persian)]. Rooyesh-e-Ravanshenasi Journal. 2018; 7(9):139-52. [Link]
9. Patel A, Sharma PS, Kumar P, Binu VS. Sociocultural determinants of infertility stress in patients undergoing fertility treatments. Journal of Human Reproductive Sciences. 2018; 11(2):172. [DOI:10.4103/jhrs.JHRS_134_17] [PMID] [PMCID]
10. Afshani SA, Abooei A, Abdoli AM. Self-compassion training and psychological well-being of infertile female. International Journal of Reproductive Biomedicine. 2019; 17(10):757-62. [PMCID] [PMID]
11. Safarinia M, Aghayousefi AR, Baradaran M. The relationship between personality aspects, problem solving and psychological well-being the role of narcissism. Counsel Psychother Culture 2014. 2014; 5:89-102. [Link]
12. Salehi B, Asghari Ebrahimabad MJ. Role of Psychological Security in Predicting Psychological Well-Being of Infertile Women with Mediation of Religion. Islamic Life Journal. 2018; 2(4):195-201. [Link]
13. Nasrolahi H, Mousavimoghadam SR. The effectiveness of cognitive behavioral group therapy on the sense of well-being among infertile women of Ilam. Medical Science Journal of Islamic Azad Univesity-Tehran Medical Branch. 2018; 28(4):313-8. [DOI:10.29252/iau.28.4.313]
14. Jalili Niko S , Rezaei Z, Nejati Nejad N, Ghasemi Jobaneh R , Nourian K. [Effectiveness of existential psychotherapy in increasing the resiliency of infertile women (Persian)]. Armaghan-e- Danesh. 2015; 20(5):453-9. [Link]
15. Jamshidian-QalehShahi P, Aghaei A, Golparvar M. [Investigating the effectiveness of iranian–islamic positive therapy on depression, anxiety, and stress of infertile women (Persian)]. Journal of Isfahan Medical School. 2017; 35(418):70-6. [Link]
16. Wood AM, Joseph S. The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders. 2010; 122(3):213-7. [DOI:10.1016/j.jad.2009.06.032] [PMID]
17. Kim M, Moon SH, Kim JE. Effects of psychological intervention for Korean infertile women under in vitro fertilization on infertility stress, depression, intimacy, sexual satisfaction and fatigue. Archives of Psychiatric Nursing. 2020; 34(4):211-7. [DOI:10.1016/j.apnu.2020.05.001] [PMID]
18. Fard TR, Kalantarkousheh M, Faramarzi M. Effect of mindfulness-based cognitive infertility stress therapy on psychological well-being of women with infertility. Middle East Fertility Society Journal. 2018; 23(4):476-81. [DOI:10.1016/j.mefs.2018.06.001]
19. Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health. 2013; 13(1):1-20. [DOI:10.1186/1471-2458-13-119] [PMID] [PMCID]
20. Hariri M, Khodami N. A study of the efficacy of teaching happiness Based on the Fordyce method to elderly people on their life expectancy. Procedia-Social and Behavioral Sciences. 2011; 30:1412-5. [DOI:10.1016/j.sbspro.2011.10.275]
21. Pictet A, Coughtrey AE, Mathews A, Holmes EA. Fishing for happiness: The effects of generating positive imagery on mood and behaviour. Behaviour Research and Therapy. 2011; 49(12):885-91. [DOI:10.1016/j.brat.2011.10.003] [PMID] [PMCID]
22. Arjmandnia AA, Vatani S, Hasanzadeh S. The effect of positive thinking training on happiness and irrational beliefs in blind adolescents. Positive Psychology Research. 2017; 2(3):21-34. [Link]
23. Mazza N. Poetry therapy: Theory and practice. Routledge; 2016. [DOI:10.4324/9781315748740]
24. Hatampour S, Pourhasan K. [Analyzing the effect of poetry on decreasing depression and increasing optimism (Persian)]. Half-Yearly Persian Language and Literature. 2018; 26(84):53-71. [Link]
25. Mohammadian Y, Shahidi S, Mahaki B, Mohammadi AZ, Baghban AA, Zayeri F. Evaluating the use of poetry to reduce signs of depression, anxiety and stress in Iranian female students. The Arts in Psychotherapy. 2011; 38(1):59-63. [DOI:10.1016/j.aip.2010.12.002]
26. Gozashti MA, Daboui P, Moradi S. [Effectiveness of group poetry therapy in reducing psychological problems and improving quality of life in patients with breast cancer (Persian)]. Journal of Mazandaran University of Medical Sciences. 2017; 26(144):98-107. [Link]
27. Mirzaee MS, Hajivandi AB, Jahanpour F. The Assesment of the Effect of Poetry Therapy on the Post-Traumatic Stress Disorder (PTSD) in Myocardial Infarction Patient. Iranian Journal of Psychiatric Nursing. 2016; 4(2):11-8. [DOI:10.21859/ijpn-04022]
28. Blumenau D. Facilitating Inner-Strength Building in Adolescent Girls with Depressive Symptoms through Ego State Therapy and Creative Expressive Art in Therapy. University of Johannesburg (South Africa); 2019. [Link]
29. Asgarabad EY, Ahangi A, Feizi M, Sarmasti E, Sharifnezhad A. The effectiveness of detached mindfulness techniques-oriented poetry therapy on cognitive attentional syndrome. The Arts in Psychotherapy. 2018; 61:33-7. [DOI:10.1016/j.aip.2018.09.002]
30. Molavi H. [Apractical guide to SPSS in the behavioral sciences (Persian)]. Isfahan: Pooyesh Andishe; 2007. [Link]
31. Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology. 1989; 57(6):1069. [DOI:10.1037/0022-3514.57.6.1069]
32. Bayani AA, Koochaki A, Bayani A. Validity and reliability of the Reef psychological well-being scale. Journal of Psychiatry and Clinical Psychology. 2008; 14(2):151-46. [Link]
33. Newton CR, Sherrard W, Glavac I. The Fertility Problem Inventory: measuring perceived infertility-related stress. Fertility and Sterility. 1999; 72(1):54-62. [DOI:10.1016/S0015-0282(99)00164-8] [PMID]