Our study revealed significantly worse psychological status in infertile women in terms of both depression and trait anxiety compared with either a group of fertile women or the normative population. Almost half (44.8%) of our infertile sample displayed moderate to severe depressive symptoms. This result lends further support to previous Hungarian evidence of considerable depression (moderate to severe depression levels up to 27% [37] and 32% [38] among infertile women). More than a third (39.6%) of our infertile sample returned results indicative of clinical-level trait anxiety. The rate of infertile women with high trait-anxiety was 20% in an earlier Hungarian survey [38]. In addition, more than a third (37.3%) of our infertile sample, whereas less than a fifth of the fertile subjects (17.6%) displayed comorbid depression and trait anxiety. Our results are also in line with previous findings in other cultures reporting an increased level of trait anxiety [39, 40] and depressive symptoms [9, 41] associated with infertility.
As for the differences between infertile women undergoing assisted reproduction and those not, we found a higher level of depressive symptoms in ART patients. However, there was no difference in terms of either trait anxiety or infertility-related distress between the two groups. Previous review articles reported that (mostly unsuccessful) IVF treatments increased the probability of negative emotions [12], especially depression [9]. Repeated fertility treatments have sometimes been found to be even more predictive of infertility-related stress [13] and depression [42] than infertility itself. Our own results indicate that the effect of fertility treatments on psychological health may be the strongest in the case of depressive symptoms, possibly due to an increased sense of powerlessness [42].
In our study, infertile women were on average older than mothers at the time of their first delivery. Like in previous studies [35], older age was associated with higher level of depression in the infertile women. Compared with a few decades ago, in Europe (including Hungary) women tend to postpone childbearing, and advanced age is associated with impaired fertility [43, 44]. Depression could be the reaction to the potential shattering of a wish postponed until its fulfillment is doubtful.
Infertility-specific social concern was one of the strongest factors related to psychological status, and we assume that this association is possibly amplified by cultural factors, e.g. fertility expectations. Women’s motivations to have children include conformity to social norms and expectations [45], also depending on the original family background [46]. Social concern may express the individual’s reaction to social pressure for motherhood, which has been shown to be positively associated with infertility-related stress [20] and severe depressive symptoms [47]. Since the Hungarian society is one in which traditional values of mothering and child-orientedness still prevail [48], social concern about childlessness may well lead to higher levels of distress.
We found sexual concern to be another key variable connected to both trait anxiety and depression. Infertile women report more sexual problems, which is associated with an increased level of depressive symptoms [18]. Previous studies have shown that vegetative and subjective symptoms of general anxiety (nervousness, perspiration, abdominal discomfort) [19] or depression [37] are associated with more infertility-specific sexual concern. Thus, sexual concern might be a core manifestation of the severity of infertility-related psychological problems.
Interestingly, while partner support was elsewhere often found to be crucial in dealing with infertility-related psychological issues [30], relationship concern in our study did not correlate with psychological status. This suggests that loss of sexual self-esteem and of enjoyment, and feelings of pressure to schedule sexual intercourse are perceived by women as more disturbing than problems in communicating openly or constructively about infertility with the partner, difficulty accepting infertility-specific gender differences or concerns about the future of the relationship.
A result we find remarkable is that stress resulting from the relationship to their own mother of women with reproductive problems appeared to connect significantly with both depression and trait anxiety. While previous literature demonstrates the stress-relieving effect of perceived social support from the family in general, the attitude of the infertile woman’s mother and its effect on her coping with infertility have not been largely studied. In the few works on this topic, mothers proved to have a more supportive role for infertile women than fathers and siblings [49]; however, mothers’ rejection or ambivalence predicted the depression of less socially skilled women with fertility problems [31]. Our result corroborates that, if support from the mother, an essential element of the family network, is insufficient, especially when the woman herself is struggling with maternal role attainment, this may well increase the distress level of the infertile woman.
Despite the fact that a higher income was more frequent among infertile women than among their fertile counterparts, financial stress was another important entity associated with the trait anxiety of infertile women. This result is somewhat ambiguous because, while increased presence of financial problems put an additional strain on couples struggling with infertility [32], in Hungary up to 5 IVF cycles are covered by mandatory social health insurance plans [50]. However, we hypothesize that financial problems are still significant because infertility entails several additional expenses beyond the cost of IVF treatments (expenditure of medications, travelling to fertility centers and lost work time).
We did not find illness stress to be related to either depression or trait anxiety among our infertile subjects. Since reproductive problems are often dealt with from a medical perspective [1], the question about illness stress was intended to detect emotional distress resulting from a chronic illness, which in the case of infertility often reaches the severity found in sufferers from cancer or heart disease [33]. The fact that illness stress lacked connection to depression and anxiety in our study is possibly due to two factors: 1) that the Fertility Problem Inventory captures infertility stress in a more comprehensive manner and, indeed, two of its subscales were associated with distress in our study, and 2) we measured illness stress with only one question formulated in a much too general way.
One of the strengths of our survey is that we used common, well-validated questionnaires and an analytical design to assess trait anxiety and depression (STAI-T and BDI, respectively), while also measuring infertility-related stress (FPI). Additionally, we investigated a wide array of stress sources as potential psychological background factors behind distress. Our study also has the advantage of including subjects never having received fertility treatment (23.1% of our infertile sample). A novelty of our study stands in examining the effect of social support on psychological well-being, thus being able to point at the crucial importance of maternal support. Finally, our respondents were reached not only personally but also through the internet, thus mounting to a broader sample of women with or without fertility impairments.
However, our study has some shortcomings and it does leave some questions open for future research. First, our study included a relatively small sample, especially for the infertile group with no assisted reproduction, and all subsamples consisted only of women. Second, despite having exact data on present fertility intentions of the fertile group as well, thus being able to rule out secondary infertile women, there is a possibility of including in the fertile group women with children who are in fact secondary infertile, but have no knowledge about this (because of using contraception or trying to conceive for less than a year). Similarly, fertility intention could be a potential source of misclassification of the infertile group: theoretically a woman (despite an active sexual life without contraception, even in the absence of a “willingness to have a baby”) can be biologically infertile. However, we aimed to study “involuntary childlessness”, therefore, we considered “willingness to have a child” a relevant criterion for infertility. Then again, the classification criteria of our sample (infertile vs. fertile) correspond to categorization methods used in previous studies [39,40,41]. Third, sources of stress were measured with only one question each, formulated in a much too general way.
The generalization of our results is also limited by self-selection in the case of online respondents, whose meeting of the inclusion criteria cannot be determined clearly. We did not verify the identity of online respondents (no phone calls or clinic follow-ups), which may have influenced the results through selection bias. Also, the groups from clinical settings and online were not examined separately, due to the low number of cases from clinical settings. However, recent studies have proved results based on online data to be as authentic as those obtained through clinical data [17, 30]. Further, women with a high level of education are overrepresented in both samples. Therefore, while this rules out the possibility of educational stage being a confounding variable behind our results, it is uncertain whether our findings can be generalized for women of a lower education level. Finally, since our study had a cross-sectional design, it is impossible to draw meaningful conclusions about the routes of causation between correlated variables.
For future studies we suggest backing up the quantitative analyses with qualitative methods including in-depth interviews with a strategically selected sample (e.g. infertile women with their partners and/or other family members such as mothers). We also suggest using a longitudinal design in order to clarify the potentially circular causation between infertility-related distress and impaired reproductive potential.