According to the demographic information we collected, our research revealed that the prevalence of anxiety is comparatively high. The prevalence of anxiety in infertile patients have been assessed in several countries. Enikő Lakato reported the prevalence of anxiety among infertile patients was 39.6% in Hungary . In Sweden, one study revealed that anxiety was detected in 14.8% of infertile patients in 2008 . A study from the infertility clinics in northern California determined that 76% of the infertile women reported significant symptoms of anxiety . The data from Iran was 56.9% . In China, anxiety was represented in 21.3% of infertile patients . In Japan, researchers used the Japanese version of the State–Trait Anxiety Inventory (STAI) scale and found that infertility patients have a higher incidence of anxiety . Indeed, the incidence of anxiety can vary depending on culture, ethnicity, lifestyle, and religion. However, compared to the data used in our study, the overall incidence of anxiety in infertile patients is still relatively high.
After the full liberalization of the "second child policy", factors such as age, social roles and intricate family problems all contributed to more complex re-fertility nature in patients, thus prompting us to compare these patients. We discovered that the incidence of anxiety in "one-child" infertility patients and "Second-child" infertility patients are high, but there is no significant difference between the two groups. For patients with "second child" infertility, the general public often holds the opinion that they should not be anxious, as the "second child" should be an easier step after “one child”. However, the results of this study found that the incidence of anxiety in patients with "second child" infertility is still high, and there is no statistical difference compared with "one-child" infertility patients. This suggests that whether the infertility patient is from a "one-child" or "second child" background, council and assistance should be offered to examine their psychological status and to provide psychological intervention if necessary.
In our study, among the whole infertile patients, the likelihood of anxiety was increased with lower educational levels, which is in accordance with some previous studies [26, 27]. It is estimated that higher educational patients can have more and easier access to information. They are more open-minded to ‘child issue’, and with a better mindset to accept the negative consequence of being infertile. Patients with high education level are generally higher in social status with multiple hobbies that can alleviate the negative emotions caused by infertility. Patients with low levels of education are more susceptible to traditional thinking and believe that having children is the primary task of life. As such, they do not fully comprehend their condition and situation, which make them even more susceptible to anxiety.
Usually, patients with lower incomes are more likely to suffer from anxiety because of the long treatment period of infertility, high cost, and not within the scope of medical insurance . Dijkstra-Kersten and colleagues’ research proposed that financial strain was related to depressive and/or anxiety disorder, above the effect of income . Interestingly, our study showed that patients with middle salary incomes are more likely to have anxiety than those with high or low incomes. A possible explanation might be due to the small sample size used in the study, which requires further research. Another possible explanation for this occurrence relates to the social status and lifestyle differences between income levels. In China, most patients with low incomes still live at the countryside where the living cost is comparatively low, and their awareness and expectation about life is also low. On the other hand, middle incomes patients live in the city, where the living cost is higher and they are more likely to have financial strain. In addition, the process of diagnosis and treatment of infertility takes long periods, the treatment effect has uncertain factors, and patients often need to take time off to arrange work-time to see a doctor, affecting income.
Oral contraception (OC) history has been found to be associated with the prevalence of anxiety according to our study. Taking OC will cause a higher risk of anxiety. One study including 202 women revealed the relationship between OC and mood , which is OC use was related to a small, but statistically significant increases in mean anxiety, and mood swings scores among inter-menstrual phase women (from day 5 of the menstrual cycle to day 21). Another study reported that approximately 4–10% of combined oral contraceptive users made complain of adverse mood symptoms including increased anxiety . One possible explanation for this phenomenon is OC can cause lower endogenous estradiol levels, and estradiol is suggested to be associated with mood improvement . A higher continued vigilance for negative emotional stimuli and a biased attention towards negative stimuli in OC-users, possibly explaining adverse effects on mood . However, it is yet unknown if there is any difference in terms of mental health between the infertile and the general OC users, nonetheless infertility itself is a very stressful condition. If possible, for infertile patients, choosing other contraceptive methods could be more beneficial to their physiological situation.
The logistic regression also suggested that patients with a history of allergy are 2.098 times more likely to have anxiety than those patients without it. Patients with a history of allergies are often associated with abnormalities in the immune system, and immune factors are considered to be one of the causes of infertility. There are some studies have found certain levels of anxiety in patients with drug hypersensitive or intolerance and food allergy [34,35,36,37,38]. People with history of allergy could suffer more than the general population. The stress of managing allergy can be associated with impairments in managing anxiety and mood symptoms . One study suggested that patients with a food allergy, their quality of life improves in some but deteriorates in others during oral immunotherapy . At present, there are few studies on the history of allergies and mental health in infertile patients. The effect infertility has on the mental state of the patient still requires further studies. According to the results of our study, the history of allergies and anxiety do occur in infertile patients. The positive correlation indicates a relevant risk factor for concern.
Our study does contain some degrees of limitations around the collection, relationships and quality of data such as reliance on self-report, geographical bias, and missing data respectively. In addition, there is a selection bias in this study. First, since infertility patients were selected in this study, this part of the population may be more sensitive, leading to more serious anxiety rate; Secondly, the location of this survey did not include infertile patients in other hospitals, which may be influenced by location, economy and other aspects, and there may be selection bias. Therefore, in the follow-up study, we need to add infertile patients in other regional hospitals for comparison, to expand the sample size and reduce the bias. Despite these limitations, our study employed a large sample size to reduce bias and variances. In addition, this study is the first to evaluate the prevalence and associated factors of anxiety among infertile patients in Chongqing, China after the enforcement of ‘two-child’ policy.