Document Type : Original Article
Authors
1 Infertility and Health Reproductive Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2 Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
Abstract
Keywords
Polycystic ovarian syndrome (PCOS) is one of the
most common etiological factors of infertility which is
identified in up to 20% of infertile females (
Many females experience infertility as a feeling of
distress and stigma (
Alexithymia is a personality construct with inability
in normal affect regulation that is comprised of five
characteristics including difficulty to identify and distinguish
emotions from bodily sensations, difficulty to
describe and verbalize emotions, externally oriented
thinking style, poverty of fantasy life, and poor empathy
(
Although many previous studies indicated that psychiatric
disorders are common in patients with PCOS
(
The current case-control study was conducted in Fatemeh Azahra Infertility and Reproductive Health Research Center (Babol, Iran) from May 2016 to December 2017 on 240 infertile females selected through census sampling method. The case group was composed of 120 females with a definite diagnosis of PCOS. The control group was comprised of 120 infertile females without PCOS based on Rotterdam diagnostic criteria. Besides, the control group was matched with the case group in terms of age, level of education, and duration of infertility.
Inclusion criteria for infertile females with and without
PCOS were being 15-45 years old, completion of
primary school as the minimum level of education, being
married and having an active sex life, and lacking
any problems in speaking or understanding the Persian
language; also, a definite diagnosis of PCOS was an
additional criterion for PCOS group. Definite diagnosis
of PCOS was done based on two of the following Rotterdam
diagnostic criteria: ultrasound scan of PCOS
(presence of .12 follicles in one or both ovaries and/
or increased ovarian volume >10 mL), clinical signs of
hyperandrogenism (hirsutism or obvious acne), and/or
an elevated plasma testosterone level, and/or irregular
menstrual periods (interval between menstrual periods
>35 days, amenorrhea defined as the absence of vaginal
bleeding for .6 months, and/or variable menstruation)
(
Exclusion criteria for all participants (females with and without PCOS) were diagnosis of the husband with azoospermia or oligospermia, presence of other disorders that could mimic PCOS syndrome such as congenital adrenal hyperplasia, thyroid disease, or hyperprolactinemia.
Four staff of the infertility center explained the study’s objectives to the participants and accordingly, the subjects were required to sign the written informed consent forms. The staff interviewed the subjects and recorded their demographic characteristics, as well as their medical and gynecological history. Furthermore, the subjects were asked to complete five questionnaires of the study including the fertility problem inventory (FPI), the female sexual function index (FSFI), the Beck depression inventory-II (BDI-II), and the Toronto alexithymia scale (TAS-20). First, 258 females (129 with and 129 without PCOS) were enrolled of which 240 females with infertility (120 with and 120 without PCOS) completed the questionnaires.
The current study was approved by the Ethics Committee of Babol University of Medical Sciences (No.4834).
Demographic characteristics including age, educational level, infertility history, clinical information of PCOS, and assisted reproductive technology (ART) history were obtained from the subjects. In addition, weight and height were measured in order to obtain body mass index (BMI).
Infertility stress was assessed using FPI developed by
Newton in 1999. It is a multi-dimensional tool to detect
stress and infertility problems. The FPI is comprised
of 46 questions divided in five subscales: social concern,
sexual concern, relationship concern, rejection of
parenthood, and the need for parenthood. Each item is
scored based on a six-point Likert scale, ranging from 1
(strongly disagree) to 6 (strongly agree). The total score
ranges from 46 to 276 with higher scores representing
higher levels of stress (
The FSFI was used to assess sexual function in subjects.
The FSFI assesses sexual function over the past four
weeks. It covers six domains: desire, arousal, lubrication,
orgasm, satisfaction, and pain. The score for each domain
ranges from 0 or 1 to 5 with higher scores representing
better sexual function (
Depression was measured by the BDI-II. It is a self-
reported scale and a screening instrument for depression
with 21 items, most of which assess depressive symptoms
on a four-point Likert scale ranging from 0 to 3. Total
scores range from 0 to 63. In clinical settings, the severity
of depression based on BDI-II, is classified as follows:
0-13: minimal depression; 14-19: mild depression; 20-
28: moderate depression; and 29-63: severe depression
(
In the current study, alexithymia was assessed using
TAS-20. It is one of the most common instruments to
measure alexithymia that has 20 items in three subscales:
difficulty to describe emotions, difficulty to
identify feelings (DIF), and externally-oriented thinking.
Items are scored based on a five-point Likert
scale, ranging from 1 (strongly disagree) to 5 (strongly
agree). The total alexithymia score ranges from 20 to
100 (
All data were analyzed using SPSS for Windows, version 18.0 (SPSS Inc., Chicago, IL, USA). To present characteristics of females with and without PCOS, continuous variables are expressed as mean ± SD and categorical variables as numbers (%). Chi-square test was employed to compare categorical variables such as educational attainment level, duration of infertility, regularity of menstruation, and BMI between the two groups. Also, independent samples t test was employed to compare the means of age and duration of marriage between the two groups. In addition, comparisons of the mean scores between females with PCOS and those without PCOS in all four questionnaires and their subscales including FPI, FSFI, TAS-20, and BDI-II, were done using independent t test. A P<0.0.5 was considered statistically significant.
Table 1 provides the summarized demographic information of subjects in the two groups. There were no significant differences between the two groups regarding the subjects’ age, husbands’ age, educational level of the subjects, educational level of their husbands, and duration of infertility (P>0.05 in all cases). The frequency of irregular menstruation was significantly higher in females with PCOS than the ones without PCOS (P<0.001).
Demographic characteristics of women with and without polycystic ovary syndrome (PCOS)
Variable | Yes (n=120) | No (n=120) | P value |
---|---|---|---|
Age (Y) | 29.55 ± 5.17 | 29.33 ± 6.23 | 0.771 |
Education | 0.278 | ||
≤12 years | 51 (56.7) | 39 (43.3) | |
>12 years | 63 (49.2) | 65 (50.8) | |
BMI | 0.218 | ||
<25 | 41 (34.2) | 29 (24.2) | |
25-29.99 | 45 (37.5) | 52 (43.3) | |
≥30 | 34 (28.3) | 39 (32.5) | |
Duration of infertility (Y) | 0.159 | ||
<5 | 66 (74.2) | 56 (64.4) | |
≥5 | 23 (25.8) | 31 (35.64) | |
Regular menstruation | <0.001 | ||
Regular | 64 (53.3) | 93 (77.5) | |
Irregular | 56 (47.7) | 27 (22.5) | |
Duration of marriage (Y) | 5.9 ± 3.99(5) | 6.04 ± 3.88(5) | 0.587 |
Husband’ age (Y) | 33.06 ± 5.43 | 32.66 ± 4.82 | 0.554 |
Husbands’ education* | 0.504 | ||
≤12 years | 54 (47.8) | 45 (43.3) | |
>12 years | 59 (52.2) | 59 (56.7) | |
Data are presented as mean ± SD or n (%). BMI; Body mass index, *; There were some missing data; therefore, the sum of the frequencies for qualitative variables is not equal to 120.
Table 2 a comparison in the mean scores of FPI, FSFI, BDI-II, and TAS-20 between the two groups. The results of the t-test revealed that females with PCOS had higher total mean scores of infertility stress (FPI) than the ones without PCOS (120.68 ± 29.42 vs. 112.83 ± 30.94, P=0.046).
Comparison of psychological profile of women with and without polycystic ovary syndrome (PCOS)
Variable | PCOS | P value | |
---|---|---|---|
Yes (n=120) | No (n=120) | ||
Infertility stress (FPI) | |||
Social concerns | 24.20 ± 8.31 | 21.74 ± 8.39 | 0.024 |
Sexual concerns | 17.53 ± 7.98 | 16.75 ± 7.81 | 0.455 |
Marital concerns | 25.15 ± 7.25 | 24.30 ± 7.34 | 0.371 |
Acceptance of life without child | 18.57 ± 7.28 | 16.27 ± 7.87 | 0.021 |
Need for parenthood | 36.06 ± 9.56 | 35.15 ± 9.67 | 0.467 |
Total scores | 120.68 ± 29.42 | 112.83 ± 30.94 | 0.046 |
Alexithymia (TAS-20) | |||
Difficulty in describing feelings | 15.17 ± 4.08 | 13.94 ± 3.62 | 0.015 |
Difficulty in identifying feelings | 22.62 ± 6.06 | 19.74 ± 6.03 | <0.001 |
Externally-oriented thinking | 22.04 ± 4.26 | 22.38 ± 4.03 | 0.532 |
Total scores | 59.83 ± 11.36 | 55.69 ± 11.52 | 0.005 |
Sexual dysfunction (FSFI) | |||
Desire | 3.94 ± 0.85 | 3.92 ± 0.84 | 0.835 |
Orgasm | 3.5 ± 0.8 | 3.49 ± 0.84 | 0.975 |
Satisfaction | 4.78 ± 1.19 | 4.92 ± 1.05 | 0.364 |
Pain | 4.64 ± 1.13 | 4.80 ± 1.16 | 0.279 |
Arousal | 3.92 ± 0.92 | 3.88 ± 0.91 | 0.752 |
Lubrication | 4.41 ± 0.85 | 4.49 ± 0.73 | 0.476 |
Total scores | 25.13 ± 3.95 | 25.35 ± 3.87 | 0.660 |
Depression symptoms (BDI-II) | 18.06 ± 12.03 | 15.65±11.76 | 0.121 |
Severity of depression | 0.114 | ||
Minimum | 31 (26.1) | 46 (39.0) | |
Mild | 35 (29.4) | 27 (22.9) | |
Moderate | 33 (27.7) | 33 (28.0) | |
Severe | 20 (16.8) | 12 (10.1) | |
Ranges scores; social concern (1-60), sexual concern (1-48), relationship concern (1-60), rejection of life without child (1-48), need for parenthood (1-60), total scores of infertility stress (46-276). Difficulty in describing emotions (1-25), Difficulty in identifying feeling (1-35), Externally-oriented thinking (1-40), total scores of alexithymia (20-100). Desire (6-0), arousal (6-0), lubrication (6-0), orgasm (6-0), satisfaction (6-0), pain (6-0), total scores of sexual dysfunction (36-0). Depression symptoms (0-63), Minimum (0-13), mild (14-19), moderate (20-28), severe (29-63). Data are presented as mean ± SD or n (%).
Of the subscales of infertility stress, the mean scores of social stress and rejection of life without child were higher in females with PCOS than those of the other group (P=0.024 and P=0.021, respectively). There were no significant differences in the mean scores of subscales of sexual stress, marital stress, and parental stress between the two groups. Also, females with PCOS had higher total mean scores of alexithymia symptoms (TAS-20) than the ones without PCOS (59.83 ± 11.36 vs. 55.69 ± 11.52, P=0.005). Of the subscales of TAS-20, DIF and difficulty to describe feeling were significantly higher in females with PCOS than the ones in the other group (P<0.001 and P=0.015, respectively). There was no significant difference between the two groups in the mean scores of depression symptoms. In addition, severity of depressive symptoms did not significantly differ between the two groups (18.06 ± 12.03 vs. 15.65 ± 11.76, P=0.121). Total scores of FSFI and all its six subscales did not significantly differ between the two groups (25.13 ± 3.95 vs. 25.35 ± 3.87, P=0.660).
The current study aimed at comparing the psychological
profiles of infertile females with PCOS with those of
women without PCOS. The results showed that females
with PCOS had higher total mean scores of infertility
stress (FPI) than the ones without PCOS. Infertile females
with PCOS had more social concerns than the ones
in the other group. Also, infertile females with PCOS had
more stress of rejection of life without child than the other
group. To the authors' best knowledge, no published study
has examined various aspects of infertility stress in infertile
females with and without PCOS. However, some studies
evaluated social relationships in patients with PCOS
compared to the controls. Such studies reported that the
social relationships of patients with PCOS was more impaired
compared to the normal population (
Now, higher intensity of infertility stress observed in infertile
females with PCOS compared to the ones without
PCOS, should be explained. There are some hypotheses
to explain this finding. First, the secondary analysis of the
data showed that symptoms of PCOS such as obesity and
hirsutism were related to infertility stress. Second, some
previous studies confirmed that females with PCOS experienced
social pressure due to hirsutism, especially excessive
facial hair (
In contrast with the current study’s expectation, the total
scores of FSFI and all of its six subscales did not significantly
differ between females with PCOS and those without
PCOS. Results of some previous studies were consistent
with the findings of the present study reporting that
females with PCOS did not have more depression symptoms
than the ones without PCOS (
The current study also aimed at comparing the alexithymia
between infertile females with and those without
PCOS. The results of the current study indicated that infertile
females with PCOS had higher alexithymia scores
than the ones without PCOS. Infertile females with PCOS
had more difficulty to identify their feelings and describe
their emotions compared to the ones without PCOS. To
the authors’ best knowledge, no previous study assessed
the alexithymia in infertile females with PCOS. Although
the current study did not have enough information about
the reasons for higher alexithymia in females with PCOS
compared to the ones without PCOS, several hypotheses
could be proposed. First, there are associations between
alexithymia and maladaptation to stress. A study investigated
the association between alexithymia and fertility-
related stress in females with infertility demonstrated that
alexithymia was related to fertility-related stress. The
authors concluded that alexithymia acted as a secondary
coping strategy in females with infertility (
Due to some limitations of the current study, data should be interpreted with caution. First, the case-control nature of the current study prevents drawing any conclusions concerning possible relationships. Prospective cohort studies in the area using reliable approaches are required to describe the casual relationship between infertile females with PCOS and those without PCOS. Second, data was collected using self-report scales that may result in underreporting of the conditions. Future studies using more reliable methods such as interviewing, might give a better picture of the psychological profile of infertile females with PCOS. Third, all of the patients included in the current study were recruited from one hospital, rather than multiple centers, that could be a limitation of the current study. Fourth, the study sample was small and cannot be generalized to numerous phenotypes of PCOS. Further, multi-centered studies with larger sample sizes are recommended. Finally, since the study was the first work that showed higher alexithymia in infertile females with PCOS, more studies in the area should investigate the extent of the associations between alexithymia and PCOS in females with infertility. Additionally, future studies are required to clarify how alexithymia arises in infertile females with PCOS.
The current study results showed that infertile females with PCOS experience more infertility stress than the ones without PCOS. Also, infertile females with PCOS had higher means of alexithymia, especially with respect to the ability to distinguish and describe, compared to the ones without PCOS. The results of the current study indicated that infertility care providers should provide more psychosocial support for infertile females with PCOS. The current study was a step to present the profiles of infertile females with PCOS; thus, further longitudinal studies are required to follow the changes in psychological profiles of females with and without PCOS during infertility treatment.