Infertility is an important health problem prevalent
throughout the world. There are approximately 80
million infertile couples in the world and it is suggested
that this number corresponds approximately
to 15% of all couples at reproductive age (18-45) in
the world (
Infertility is defined as the inability to conceive a
child after 12 months of regular unprotected sexual
While being mainly a medical condition, the diagnosis of infertility still has multi-dimensional effects on couples including biological, psycho-social, economical, ethical, and cultural dimensions (
Drawing attention to this fact, Monga et al. referred to infertility as a developmental crisis that can threaten a couple’s future goals (
This comparative study suggests that childbearing is a vital means of stability and satisfaction in married life in Islamic societies such as Iran while negative social attitudes to infertility may reach detrimental levels and result in the end of the marriage (divorce) or a second marriage for men. Thus, the study also reveals a strong belief in infertility as a female factor phenomenon in such societies (
Another important point concerning these psychological and sociological impacts of infertility is the fact that although they are common among cases of infertility, certain socio-demographical and medical characteristics such as age, educational background, family type, working status, income level, and environmental pressures play important roles in determining the level of anxiety-depression experienced by the infertile group (
It is also known that all the psychosocial effects of infertility become stronger as the duration of diagnosis and treatment increases (
Taking into consideration the aforementioned facts about infertility and its psycho-social impacts as well as the importance of timely consultancy services, this study aims, on one hand, to make a comparative analysis of fertile and infertile groups in terms of anxiety-depression levels and the quality of life, and on the other, to reveal whether meaningful differences exist within the infertile group depending on the various socio-demographical characteristics they exhibit. More specifically the following two hypotheses were tested throughout this study:
a. Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) scores in the infertile group are higher than in the fertile group while quality of life scores are higher in the fertile group.
b. Within the infertile group certain independent socio-demographic variables determine the anxiety-depression levels as well as quality of life.
This study was planned as a cross-sectional study. Research was conducted in a private University Faculty of a Medical Department of Obstetrics and Gynecology in Ankara. Required permissions were received from Baskent University Research and Ethics Committee in order to conduct the research. The patients who agreed to participate in the study and who met the research criteria were included in the study.
The population of the study consisted of 214 infertile patients who were referred to the aforementioned medical center between January 20 and May 20, 2009. Of these, 160 patients complying to the study criteria and willing to volunteer in the study were taken as the sample for the infertile group. In addition, 160 fertile people referred to the Maternity-Child Welfare Centre of the same institution, complying with the criteria, and willing to participate in the study were included in the study. Thus, a convenience sample total number of 320 people made up the complete sample of the study.
Infertility cases associated with male factors were included in the study (male=80, female=80). Study participants in the infertile group were at least elementary school graduates, above 18 years old and married, diagnosed with primary or secondary infertility (not having a living child) with planned programs of infertility treatment, receiving infertility treatment for the first time, not diagnosed with psychiatric illness before infertility diagnosis, and did not have a severe illness or receive treatment for such an illness. Those with a history of miscarriage were not excluded from study.
Volunteer fertile women and their husbands agreed to participate in the study and formed the fertile group. These women had at least one child older than one year of age, were married, did not have any difficulty conceiving without assistive reproduction techniques, were not treated for any gynecological illness, were not pregnant, and were literate.
Three instruments were used for data collection purposes. These were the following: "Patient Identification Form", "BAI", "BDI" and the "World Health Organization Quality of Life (WHOQOL)- Brief life Quality Scale". These were used in identifying socio-demographical characteristics and obtaining the infertility history (
The "Patient Identification Form" was prepared by the researchers in order to determine socio-demographical characteristics (age, sex, educational background, spouse’s educational background, working status, income, family type, marriage type, smoking and alcohol use), as well as the participants’ feelings and opinions about treatment. Form items were determined from review of the literature on the experiences of individuals with infertility (
The BDI is a likert-type scale consisting of 21 items. The total scores range between 0 and 63. It is used in clinical applications in order to determine the severity of depression. Interpretation of the depression score is as follows: 0-10 points show that there is no depression, 11-17 points indicate a mild level of depression, 18-29 points indicate a medium level depression, and 30-63 points indicate severe depression Hisli conducted a validity reliability study in 1988 for Turkish application of the BDI, with Cronbach Alfa internal consistency values of 0.74 (
BAI is a likert-type clinical scale consisting of 21 articles, which was developed by Beck, Epstein, Brown, and Steer in 1988 in order to measure anxiety levels. The patient is asked to evaluate symptoms for "the last one week including today". Total scores range between 0 and 63. Ulusoy et al. determined that there is internal consistency in the use of the BAI scale with Turkish patients (Cronbach Alfa=0.81). Anxiety levels of patients were classified according to the scores received in BAI: 0-17 points indicates mild level, 18-24 points indicates medium level, and 25 and above indicates severe anxiety (
The WHOQOL has 27 questions and consists of four sub-groups, which are physical, emotional, environmental, and social areas. Questions are answered by taking into account the experience of the patient over the last 15 days. A Turkish version of the scale was translated in 1997 and is available, and can be used both for healthy individuals and patients with the method stipulated by WHO. The internal consistency of the WHOQOL scale is 0.92 as established by the WHOQOL Turkey Group (
Pearson correlation analysis, Student’s t test and Chi-Square were used in the evaluation of data. Means and standard deviations of BDI, BAI, and Quality of Life (QOL) scores were given in descriptive statistics. Student’s t test was applied to evaluate the relationships between socio-demographic variables and BDI, BAI, QOL scores. The same relationships were also examined through the application of the Pearson correlation analysis. Assumptions of the Multiple Regression Analysis were assessed by focusing on the BDI, BAI, QOL scores and the socio-demographic and clinical characteristics of the infertile group. P ≤ 0.05 was considered as the statistical significance level.
Findings on characteristics of patients
|Socio demographical||Groups||Total||Statistical analysis*|
|Infertile (n=160)||Fertile (n=160)|
|High school and above||84||52.5||76||47.5||160||50.0|
|Core family||112||70.0||92||57.5||204||63.7||x2=0.131 p=0.718|
* Chi- Square test was used.
As can be seen from
All participants were comfortable with their social status. Couples stated that they knew and understood each other before marriage and were living in an urban area. The percentage of university (or above) graduates in spouses was 66.7% in the infertile group and 63.3% in the fertile group. Considering both groups, 36.7% were married for 1-3 years, 43.3% were married for 4-6 years, and 20% were married for ≥7 years. Participants described their incomes as "medium" (46.7%) or "good" (53.3%). There was no significant statistical difference between the groups in respect to the educational background of spouses (x<sup>2</sup>=1.815, p =0.464), period of marriage (x<sup>2</sup>=1.116, p=0.553), type of marriage (x<sup>2</sup>=0.156, p=0.381), and income status (x<sup>2</sup>=0.213, p=0.305).
As can be seen from
Findings on medical characteristics of the infertile group
|≥ 5 Years||40||25.0|
|Infusion and hormone||52||32.5|
|IVF, hormone, tubal operation||64||40.0|
Infertile group participants were asked the question "what do you think about the meaning of having a child". Seventy-six expressed that this was "my biggest dream in my life". In addition, in response to the question "whose wish for a child is stronger, yours or your spouse’s?" 20% answered as "me", 23.3% answered as "my spouse", and 56.7% answered as "both of us". All of the individuals in the infertile group participating in the study had expected health personnel to support them during treatment process and to be interested in and receptive to their questions and concerns.
This study describes the experiences or possible difficulties with the treatment process. Accordingly, it was reported that difficulties such as failure (66.7%), psychological problems and stress (50%), fear of the operations (36.7%), necessity of frequent examinations (33.3%), and having trouble in leaving work (30%) have been or may be experienced. One hundred percent (100%) of the patients in the infertile group stated that they had the support of their spouses during the treatment process. This support was also found with "health personnel"(56.7%), family-relatives (26.7%), and friends (20%), respectively. It was determined that none of the participants in the infertile group had received support from psychiatric-mental health care providers to date.
As can be seen from
Distribution of BDI, BAI, and QOL score averages of infertile and fertile groups
|Infertile mean ± SD||Fertile mean ± SD|
|8.43 ± 4.16||5.25 ± 3.26||9.135||0.003|
|25.00± 11.58||19.87 ± 9.78||11.026||0.006|
|74.8 ± 5.78||99.2 ± 5.83||-4.400||0.004**|
|64.70± 4.72||85.50 ± 6.85||-10.800||0.001**|
|66.45± 8.17||87.57 ± 8.64||-6.112||0.002**|
|69.77± 5.25||89.93 ± 6.26||3.000||0.007**|
*Student (independent sample) t test was used.
BDI and BAI percentage distributions of infertile and fertile groups
|Infertile n (%)||Fertile n (%)|
|1-10- doesn’t exist||56 (35.0)||108 (67.5)|
|11-17-mild||40 (25.0)||35 (22.0)||44.093||0.000**|
|18-29-medium||64 (40.0)||17 (10.5)|
|0-17-mild||100 (62.5)||112 (70.0)|
|18-24-medium||40 (25.0)||29 (18.0)||2.459||0.293|
|≥ 25-severe||20 (12.5)||19 (12.0)|
*Student (independent sample) t test was used.
High positive correlation (r=0.308, p= 0.017) was found between depression (r=0.390, p=0.017) and anxiety scores of the infertile group while, for the same group, there was a strong negative correlation between these values and quality of life (r=-0.367, p=0.041).
The distribution of the average BDI and BAI scores of the infertile group according to certain socio-demographic characteristics (age, sex, education level, family type, and environmental pressure) is shown in
Distributions of socio-demographical characteristics of infertile group with BDI and BAI score averages
|Score||Min||Max||Mean ± SD|
|≥ 34||6||20||9.60± 3,95|
|≥ 34||10||41||30.14± 11.00|
|Elementary school||6||11||9.57± 5.442|
|High school||3||20||8.25± 2.217|
|Elementary school||20||41||34.50± 9.74|
|High school||7||24||26.79± 10.90|
|Immediate family||1||20||8.42± 4.30|
|Extended family||5||13||9.50± 3.6|
|Immediate family||7||44||24.35± 11.47|
|Extended family||10||39||29.25± 13.15|
Multiple regression analysis of socio-demographical characteristics of infertile group with BDI-BAI and QOL score averages
|Pressure of Eenvironment||0.19||2.64||0.008**|
|Having knowledge on infertility treatment||-0.22||-2.20||0.002**|
|Pressure of environment||0.28||2.10||0.001**|
|Having knowledge on infertility treatment||-0.27||-2.11||0.002**|
|Pressure of environment||-0.23||-3.46||0.001**|
|Having knowledge on infertility treatment||0.16||2.13||0.004**|
R=0.51, R2=0.50, F=35.75, p=0.000.
*Multiple regression analysis was used.
In the study, the mean BAI and BDI scores were 8.43 ± 4.16 and 25.00 ± 11.58 for the infertile group, respectively. For the fertile group, BAI and BDI scores were 5.25 ± 3.26 and 19.87 ± 9.78, respectively. Most of the infertile subjects suffered from depression and anxiety as higher depression and anxiety scores suggest. At the same time, quality of life scores were lower in the infertile group (p<0.05).
In another study on the psychological experiences of infertile patients, conducted on a 51-person infertile and a 30-person fertile group in the Infertility Policlinics of Istanbul University Cerrahpasa School of Medicine and Marmara University School of Medicine, the average BDI was found to be 6.10 ± 6.29 in the infertile group and 7.66 ± 6.70 in the control group. In the same study the BAI average was found to be 11.6 ± 11.17 in the infertile group and 10.15 ± 9.14 in the fertile group. Thus, Gulseren et al. did not find any significant difference between infertile and fertile groups with respect to anxiety and depression (
In this study, the effects of socio-demographical and medical characteristics such as age, educational background, husband’s educational background, family type, working status, income level, environmental pressures, psychological response to infertility, and quality of life were examined. The percentage of those stating that they felt environmental pressure was high in the infertile group (65%). We found that environmental pressure increased anxiety-depression scores and decreased quality of life (p<0.05). Significant differences were found in BAI-BDI and QOL scores depending on the educational background of infertile patients. Accordingly, anxiety-depression scores of those having at least a university education were low and quality of life scores were high (p<0.05). Chachamovich et al. examined the relationship between education and quality of life and found a decrease in environmental and mental health scores in the group with lower educational status (
In this study, anxiety-depression scores increased in direct proportion to the increase in age in the infertile group (p< 0.05). Accordingly, it can be said that anxiety-depression is dependent on age. This finding is in agreement with the findings of other studies on the issue (
Support from partner is a crucial factor in the positive effects of infertility treatment (
In our study, we determined that the psychological effects of infertility become stronger as the duration of infertility increases (p< 0.05). Previous studies on this subject matter support our findings (
Coping strategies of women and men in the infertility period differ significantly according to social role theory (
In our study significant correlations were found between marriage type and levels of anxiety-depression (p< 0.05). Infertile women who had arranged marriages experienced anxiety more than those who were not in arranged marriages. Literature states that an increase in the period of marriage affects one’s psychological situation adversely (
We found that infertile individuals had some treatment-specific needs and difficulties. The feelings of failure, psychological problems, fear about operations, need to have frequent examinations, and troubles leaving the workplace for appointments were found to be difficulties. In another study it was found that some patients had isolation, social problems, insomnia, and stress problems (
In this study it was determined that the infertile group had anxiety and depression related symptoms and their quality of life was affected adversely. They stated that they had faced difficulties at the beginning of their treatment process. In conclusion, our study found that individuals who are infertile need psychological support in order to overcome the difficulties they experience. This study proposes that physicians and nurses be aware about anxiety-depression disorders among infertile groups and the necessity of referring patients to psychosocial counsellors who provide professional infertility counselling. Moreover, health teams may provide a routine counselling model to understand the factors contributing to anxiety-depression and quality of life in the infertile couples. Thus, counselling may help them to cope with the negative feelings especially when their treatment duration is prolonged. Finally, comprehensive qualitative and prospective studies should be conducted in order to examine further the effects of infertility on mental health and quality of life for infertile groups.