Introduction
According to the World Health Organization, infertility is a chronic disease where couples are unable to achieve pregnancy after 1-year regular sexual intercourse without using birth control methods [1]. Approximately 8% to 12% of couples in the world suffer from infertility [2]. In Iran, the overall prevalence rates of primary and secondary infertility are 5.2% and 3.2%, respectively [3]. Regardless of which one of the couple is infertile, infertility is a stressful condition [4] which imposes many psychological problems on infertile couples [5], as infertile couples develop low emotional control. Emotional control is the ability to recognize, express, and control emotions in a variety of situations [6]. 
This construct which seems essential in order to adapt to stressful life events such as infertility, consists of four components of anger, depression, anxiety, and positive emotion [7]. Empirical evidence suggests that depression is a common problem in infertile couples [8]. Also, infertile women suffer from other psychological consequences of infertility such as anger and anxiety [9]. As a result, researchers are trying to find the best treatment methods to reduce the problems of infertility in couples [10]. One of these therapeutic methods is Emotionally Focused Couples Therapy (EFCT). It is a structured and short-term approach in couple therapy focused on emotional schema processes that provide interpersonal and cognitive behavioral determinants [11]. During EFCT process, marital interactions, attachment injuries, and problematic emotions should be recognized, and appropriate therapeutic measures should be taken to remedy these issues [12].
Recent studies have provided satisfactory results and rational reasons for using EFCT in clinical practice, especially for solving the psychological problems of couples. Different studies have shown the effectiveness of EFCT as an appropriate intervention for improving marital conflicts, physical-psychological health of the infertile couples [13], and communication styles of couples [14]; reducing marital stress [15]; changing attachment styles [16]; and affecting marital satisfaction [17]. However, few studies have been conducted on the effect of this method on the control of emotions, especially in infertile couples. Thus, this study attempted to investigate the effectiveness of EFCT in control of infertile couples’ emotions.
Materials and Methods 
This is a quasi-experimental study with pre-test-post-test and a control group. The statistical population consists of all infertile couples referred to infertility centers of Isfahan in 2016. Given that in experimental and quasi-experimental studies, to increase the internal validity, at least 15 people must be included in each study group [18], samples in this study were considered 40 people (considering dropouts) selected using convenience sampling technique. Then, they were randomly assigned to EFCT (n=20) and control groups (n=20) (matched with demographic characteristics, duration of infertility, gender, education, and age) to control confounders. Afterward, the participants took part in a briefing session. In this session, couples agreed to participate in the study after knowing the research objectives. To comply with the ethical principles, they signed a written consent form and were assured of the confidentiality of their information. 
The inclusion criteria were having the first visit to the infertility centers regardless of their age or sexual restrictions, having at least a high school diploma education, taking part of both spouses in the treatment sessions, and lacking a history of receiving EFCT. The exclusion criteria were having a serious medical disorder that disrupts the study process, missing two consecutive sessions, and failing to complete the questionnaire.
The data collection tool was the Affective Control Scale developed by Williams et al. in 1997 [19]. It has 42 items and 4 subscales of anger, depressed mood, anxiety, and positive affect scored based on a 7-point Likert-type scale (from completely disagree to completely agree). Williams et al. reported a Cronbach alpha of 0.94 for overall scale, and 0.72 to 0.91 for its subscales. Moreover, they found a reliability coefficient (2-week test-retest) of 0.78 for the overall scale, and 0.66 to 0.77 for its subscales [19]. Tahmasebiyan et al. reported a Cronbach alpha for internal consistency of its Persian version as 0.782 among school students, 0.889 among school teachers, 0.818 among college students, 0.935 among college professors, and 0.909 among nurses [20]. 
In the present study, the content validity of the questionnaire was evaluated according to the viewpoints of three Psychology graduates of Islamic Azad University of Khorasgan branch and was approved after necessary corrections. Regarding its internal consistency, a Cronbach alpha of 0.75 was obtained after a preliminary study.
After approval by the Research Ethics Committee (Code: 23820701942058) and receiving permission to start data collection, an EFCT program was designed according to instructions of Johnson [12] and then conducted during eight 90-minute sessions, twice per week. The content of EFCT program is presented in Table 1.
 The collected data were analyzed using descriptive (Mean and SD) and inferential statistics (Univariate ANCOVA) in SPSS V. 20.
Results
In this study, 20 infertile couples in the two groups participated. The Mean±SD age of EFCT group was 36.79±5.67 years, and for controls, it was 37.41±5.02 years. The mean scores of anger, depressed mood, and anxiety in the EFCT group reduced after the intervention, while the mean score of positive affect increased after EFCT (Table 2). Normal distribution and homogeneity of variance were assumptions of the parametric test confirmed using the Kolmogorov-Smirnov test (P=0.284) and Levene’s test (F=1.280, P=0.556).
There was a significant difference between the two groups in controlling their emotions (F27,1=0.381, P=0.001, η2=0.62) where emotional control of the samples in EFCT group increased 62% compared to those in the control group. The obtained test power was 1, indicating the appropriate sample size for such a conclusion (Table 3).
Discussion 
The purpose of this study was to determine the effect of EFCT on improving the emotional control of infertile couples in Isfahan City, Iran. The results showed that EFCT is effective in samples’ emotional control. This finding is in line with some studies that have reported the benefits of EFCT for improving the psychological problems of infertile couples. For example, Najafi et al. in a study showed that EFCT had a significant effect on increasing marital adjustment (cohesion, agreement, and affection) as well as the quality of life (physical and psychological health) of infertile couples [14]. Aarts et al. also reported that EFCT could increase the quality of life of infertile couples and reduce their anxiety and depression [21]. In another study by Sadri Damirchi et al., the effect of EFCT on increasing intimacy, reducing marital conflict, and improving the quality of relationship in infertile couples was reported [22]. The results of Babaei Gharmkhani et al. indicate that EFCT reduces marital stress of couples in the intervention group compared to the control group [15]. Khojasteh Mehr et al. found out that EFCT reduced depression symptoms and improved emotional regulation of couples [23].

Emotional structures play an important role in adjustment to stressful life events [24]. Anger, depressed mood, anxiety, and negative affection caused by an inappropriate reaction to misunderstandings between couples with infertility deteriorate the relations. This deterioration continues due to negative emotional states, attachment injuries, lack of attention to personal needs and desires, negative interaction styles, and inappropriate emotional experience [25]. EFCT by revealing the vulnerable emotions of couples and experiencing and re-processing those emotional responses (that underlie interactive situations), helps the couples to shape emotions safely [26]. The processing of emotions in a safe context creates healthy interactive patterns, which adjusts the emotional turmoil of couples and optimizes their emotional control [25]. 

When one of the couples is uncertain about the emotional response of her or his partner to confront the infertility crisis, she or he feels insecure. EFCT identifies the negative interactive cycles representing insecure attachment and adjusts them again based on the expression of latent attachment needs. In this way, couples can express their needs easily using new cycles and accept the attachment needs of their spouse [27]. The new experiences gained in the treatment sessions challenge the active mental patterns of couples reflecting their past experiences, and makes couples to have new expectations from each other, and find new ways to control their emotions under the difficult situations caused by infertility [26].

One of the limitations of this study was the non-generalizability of the results considering the type of sampling. According to the results, it is suggested to study the effect of EFCT at multiple sessions and times, and conduct long-term follow-up studies (at least 1-year period). It is also recommended that a similar study should be conducted on infertile couples with different educational levels.


Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Khorasgan (Isfahan) Branch, Islamic Azad University, Isfahan (Code: 23820701942058).
Funding
The present paper was extracted from the master thesis of the first author, in Islamic Azad University of Khorasgan branch.
Authors' contributions
Study design, implementation, writing the manuscript: Hamid Kazemi; and Project manager, data collection, contributing in all research data analyses: Saba Faghih.
Conflict of interest
The authors declared no conflict of interest.


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