Psychiatric disorders among infertile and fertile women
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- Noorbala, A.A., Ramezanzadeh, F., Abedinia, N. et al. Soc Psychiat Epidemiol (2009) 44: 587. doi:10.1007/s00127-008-0467-1
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This study was performed in order to determine the prevalence and predisposing factors of psychiatric disorders among infertile and fertile women attending Vali-e-Asr Hospital. A total of 150 fertile women from Vali-e-Asr Reproduction Health Research Center and fertile women from the Gynecology Clinic of Imam Khomeini Hospital were chosen by consecutive sampling. Data included demographic information, SCL-90-R, and a semi-structured questionnaire about stress factors. Results showed that 44% of infertile and 28.7% of fertile women had a psychiatric disorder (P < 0.001). Using the SCL-90-R test, the highest mean scores in infertile women were found to be on the paranoid ideation, depression and interpersonal sensitivity scales, and lowest scores were found on the psychoticism and phobic anxiety scales. The interpersonal sensitivity, depression, phobic anxiety, paranoid ideas and psychoticism scales were significantly different between infertile and fertile women (P < 0.05). Infertile women were at higher risk of developing psychiatric disorders if they were housewives rather than working women (P = 0.001). Considering the high prevalence of psychiatric disorders among infertile women, it seems that gynecologists, psychiatrists and psychologists should be more attentive to identify and treat these disorders. The use of psychotherapy, especially supportive methods, should be considered as part of the general therapeutic framework of infertility.
In recent years, special attention has been paid to the psychological health of infertile couples, because infertility is without a doubt a severely distressing experience for many couples. Freeman et al.  reported that 50% of couples considered infertility as the most disappointing experience in their lives . Another study carried out by Manlstedt et al.  showed that 80% of infertile couples described infertility as a stressful or very stressful experience . Other researchers have focussed on fields such as health problems, lack of self-confidence, feeling of grievance, threat, depression, sin, disappointment and marital problems, believing that the above factors are related to infertility [15, 19, 23, 28]. Recently, more research has been devoted to anxiety and depression associated with in vitro fertilization (IVF), specially during egg retrieval or embryo transfer; this includes fear of treatment failure and lack of hope of having a child, leading to psychiatric problems among these infertile women [10, 13, 20, 26]. The results of one study show that high levels of anxiety among women who conceive by IVF can lead to more complications in the newborn at the time of delivery and afterwards as compared to the control group . The overall prevalence of psychiatric problems among infertile couples has been estimated to be 25–60% [14, 24]. Furthermore, the methods used to treat infertility impose significant stress on these subjects [2, 26, 28]. Psychological difficulties of infertile patients are complex and are influenced by a number of factors, such as gender differences, causes and length of infertility, the specific stage of investigation, the treatment contexts in which couples are studied, and the coping strategies used to deal with their infertility.
Psycho-social support can bring about satisfaction with infertility treatment methods through affecting the coping potential of women with infertility . On the other hand, counseling and supportive psychotherapy are very effective in decreasing the rate of anxiety in couples undergoing infertility treatment . Since links have been suggested between anxiety, depression, the hypothalamic–pituitary–adrenal axis (e.g. anxiety-induced hyperprolactinemia) and failure to conceive, psychological interventions aimed at reducing anxiety might increase the likelihood of conception [8, 20]. Thus, the chance of pregnancy may increase by improving psychiatric problems. On the other hand, there has been some evidence that pregnancy rates were unlikely to be unaffected by psychosocial interventions .
Infertility is a social onus for women in Iran, who are expected to have children early in a marriage . Women without children often feel incomplete and this results in pressure from her family and society, thus leading to psychological problems.
This paper compares the prevalence of psychiatric disorders and potential predisposing factors in fertile and infertile women in Iran. The results of this study should help identify psychiatric disorders and organize programs for their prevention and treatment, thereby improving the mental health of infertile women.
Materials and methods
This descriptive study was performed on 150 infertile women who attended the Infertility Clinic of Vali-e-Asr Reproduction Health Research Center and 150 married, fertile women who attended the Gynecology Clinic of Imam Khomeini Hospital (Tehran, Iran) from March 2005 until June 2006. The subjects were selected by consecutive sampling. After obtaining written consent, a psychologist informed them about the aims of the study and they were then entered into the study. Data were obtained using the SCL-90-R and structured researcher questionnaires.
For each patient, age, educational level, work status, monthly family income, duration of marriage, previous psychological problems [services used and drug treatment(s)] and disease information (history, cause and duration) were assessed, using an open-ended questionnaire.
SCL-90-R is a 90-item questionnaire designed to assess psychological symptoms. It was initially used to show the psycho-cognitive aspects of psychological and somatic diseases. It was originally developed by Derogatis, Lipman and Covi in 1973 and was subsequently altered in response to clinical experience and psychoanalysis . The severity of the symptoms is measured on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extreme). The 90 items of this test assess the following nine aspects: somatization, obsessive–compulsive disorders, interpersonal sensitivity, depression, anxiety, aggression, phobic anxiety, paranoid ideation, and psychoticism. There are three suggested global indices for the SCL-90-R: the global severity index (GSI: the average score of the 90 items of the questionnaire); the positive symptom distress index (PSDI: the average score of the items scored above zero); and the positive symptoms total (PST: the number of items scored above zero). For the Tehran (Iran) population, a mean GSI greater than one was suggested as indicating psychiatric disorder .
In 1983, Derogatis showed good psychometric properties in all nine aspects of this test. An Iranian study to assess the reliability and validity of SCL-90-R reported that the validity of this test was more than 0.8 in all aspects except aggression, phobic anxiety, and paranoid ideation . The nine aspects of SCL-90-R had a Cronbach’s alpha greater than 0.7, except aggression which was 0.68.
Stress factors were assessed using a semi-constructed questionnaire carried out by a psychologist. Participants were asked to describe any stress in their lives based on the Holmes-Rahe stress scale . Stress factors were listed and categorized in 23 separate fields.
Subscales of the SCL-90-R are presented as means and SDs and were compared between the infertile and fertile group using the t test. GSI scores of more than one (GSI > 1) were considered to represent psychological problems and were compared between the two groups using the Chi-square test. Comparisons were also made between employed and housewife groups. Stress factors were compared between infertile women with and without psychological distress.
A multiple logistic regression was used to evaluate the relationship between psychological problems and potential predictor variables. The dependent variable in this analysis was psychological distress (GSI > 1). Independent variables included age (years), marriage duration (years), education level (primary school/secondary (high) school/diploma/university degree), occupation (housewife/working), economic status (low/medium/high), history of psychiatric visits (yes/no), history of taking psychotherapeutic drugs (yes/no), and fertility (infertile/fertile). A forward model was used for this analysis, and the criterion for including a variable into the model was a P value less than 0.05. Odds ratios with 95% confidence intervals (CI) of variables in the model are reported. P values less than 0.05 were considered as statistically significant. Two-tailed tests of significance were used. All computations were carried out with SPSS 11.5 (SPSS Inc., Chicago, IL).
Frequency and percentage of demographic factors in study groups
χ2 = 9.701
P = 0.021
High school diploma
χ2 = 3.931
P = 0.047
χ2 = 1.282
P = 0.527
History of visiting by psychiatrist
χ2 = 0.679
P = 0.410
History of taking psychotherapeutic drugs
χ2 = 1.281
P = 0.258
Cause of infertility
Male and female factor
History of infertility treatment
Mean and SD of the nine scales of SCL-90-R test in study groups
Comparison of psychological distress among fertile and infertile women by employment status
χ2 = 10.571
P = 0.001
χ2 = 0.053
P = 0.818
χ2 = 7.623
P = 0.006
Logistic regression showed that marital duration (P < 0.001), a history of psychiatric visits (P = 0.009), and infertility (P = 0.021) were predictors of psychological distress, with no other variables remaining in the model. Psychological disorders were more frequently in women with infertility (OR = 2.50, 95%CI = 1.26, 4.98) and in those with a history of psychiatric visits (OR = 1.88, 95%CI = 1.15, 3.07), but greater marital duration decreased the risk of psychological disorders (OR = 0.90, 95%CI = 0.86, 0.95).
Frequency and percentage of stress factors among infertile women
Intervention of family and others
Feeling of loneliness
Treatment for infertility
Women wanting a child
Lack of hope
Woman named as infertile
Feeling of inability to reproduce
Change of behavior of husband
Change in interest of husband
Husband wanting a child
Feeling of motherhood
Lack of safety and support
The results of this study show that 44% of infertile women and 28.7% of fertile women have psychological disorders, a nearly twofold difference. In the study carried out by Noorbala et al.  in Tehran, psychological disorders were found in around 27.9% of subjects. While in 1992, Bjorn et al.  reported a figure of 35.2% among infertile women. Lu et al.  reported that 83.8% of the disorders were mild, and 52% were of moderate to severe intensity in infertile women significantly more often than in fertile women. However, some reports indicate no significant difference between the nine scales of the SCL-90-R questionnaire between fertile and infertile women . Considering the results from this study and from others, the prevalence of psychological disorders among infertile women in Iran appears higher than in western countries and lower than in other eastern countries. Having a child in eastern countries is more important for cultural and social reasons and religious beliefs than in western countries. It may indeed be a factor reducing psychological problems in western countries. In Sunni-dominated countries assisted reproductive techniques (ART) are not used because of religious beliefs, while there is no problem in using ART in Shia-dominated countries . The fact that psychological disorders were more common in infertile women than in fertile women in Iran indicates the importance of conception in our country.
The results of this study also show that infertile women obtained higher scores for paranoid ideation, depression, interpersonal sensitivity and lower scores for psychoticism and phobic anxiety. Comparing fertile and infertile women, there was no significant statistical difference between somatization, obsession–compulsion, anxiety, or aggression, while there was a significant difference for interpersonal sensitivity, depression, panic phobia, paranoid ideation and psychoticism. In the 1994 study performed by Bagheri et al. , somatization, depression, and anxiety had the highest, and panic phobia and psychoticism had the lowest scores in the subjects studied. Dyer et al.  stated that there was a statistical difference in the seven subscales of the SCL-90-R questionnaire between fertile and infertile women, with the highest mean values in the groups studied being for depression and somatization. Berg and Wilson  reported an increasing in the mean scores for interpersonal sensitivity, depression and psychoticism among infertile women. Also Wischmann et al.  reported the highest scores for somatization, anxiety, depression and paranoid ideation, and the lowest scores for obsession–compulsion.
Thus, the findings in our study are in line with those of others. Our results show that the most important stress factors linked to psychological disorders in infertile women include the reaction of relatives and friends, feelings of loneliness, and the actual treatment for infertility. Financial and sexual factors are also important. We also found that the prevalence of psychiatric disorders is associated with occupational status, with psychiatric disorders being more common in housewives than in working women. Noorbala et al. also found that psychiatric disorders were more frequent in housewives than in working women [6, 7, 21]. However, Yaghoobi et al. reported that the rate of psychiatric disorders was higher among working women .
Thus, there are some differences between our results and others, which may be due to cultural differences, methods of data collection, or other factors. However, our finding of a higher prevalence of psychological disorders in infertile women suggests that specialists should be aware of the importance of psychological factors in these patients and in the treatment of infertility.
It is possible that the provision of appropriate psychological treatment (especially supportive therapy and behavioral–cognitive therapy) may be effective in the treatment of infertility itself. As a consequence, the rate of psychiatric symptoms will fall, mental health will improve, and there will be an increase in the fertility rate of infertile women.
Gynecologists should be more aware of the prevalence of psychiatric and personality disorders among infertile women and their need for referral to psychologists or psychiatrists.
Counseling methods, especially supportive psychotherapy, should be considered for infertile women in order to improve their mental health and increase their chance of conceiving.
Treatment of infertile women in all infertility treatment centers should be through the combined and close work of both gynecologists and psychologists, and psychiatric counseling centers should be set up in these centers.
The media should make the public, especially infertile women, aware of the importance of combined use of psychotherapy and routine treatment to treat infertility. This may assist in increasing the success rate of infertility treatment and in improving the quality of life of these patients.
The media should make family members of infertile women aware of the help and support they can give in order to decrease mental stress.
Where appropriate, the Social Welfare Society and other related centers should cooperate to facilitate adoption in these individuals.
We greatly thank the Deputy of Research of Tehran University of Medical Sciences who provided funding for this study. We would also like to thank all the personnel of Vali-e-Asr Reproduction Health Research Center and the Gynecology Clinic of Imam Khomeini Hospital, who helped us throughout this study.