Depression, anxiety and stress among female patients of infertility; A case control study

Objectives: Infertility, in many ways, is a very distressing condition that can have its impact on social and marital life of a couple. Depression, anxiety and stress associated with infertility may affect treatment and outcomes for such couples. The purpose of this study was to find out prevalence of depression, anxiety and stress among females suffering from infertility. Methods: One hundred females suffering from infertility as study subjects and 100 females accompanying them as controls were randomly selected from infertility clinic at Arif Memorial Teaching Hospital, Lahore, Pakistan. Females with diagnosed mental health issues and those from couples having male factor infertility were not included. Validated Urdu version of Depression, anxiety, stress scale (DASS) was used for assessment of depression, anxiety and stress scores. Results from both groups were compared and independent sample t-test was used to analyze the results. Results: There was high prevalence of depression, anxiety and stress among females suffering from infertility compared to females in control group (p < 0.05). Level of education did not appear to have any positive effect on these scores. Similarly, results did not appear to change when occupations of infertile females were used for stratified analysis. Conclusion: Depression, anxiety and stress are very common among females suffering from infertility. Healthcare professionals should consider psychological counseling, and psychiatric help if required, when they offer fertility treatment for such females.


INTRODUCTION
Having children is one of the most likely wishes any couple can have and being unable to bear one despite having regular and unprotected intercourse for a year, is defined as infertility.
Prevalence of infertility varies all over the world, largely depending upon the cultural and familial values. 1 It is estimated that about 10% of the couples suffer from infertility, due to one or the other reason and in many of these couples cause remains unidentified. 2 It is not uncommon for an infertile couple to develop mental health problems. The estimated prevalence of mental health problems ranges from 30% to 80% as reported in different studies and is linked to the cause and duration of infertility and number of attempts at different treatment options. [3][4][5] Psychological impact of infertility may range from inferiority complex and stress to interpersonal relationships to major depression and anxiety. 6,7 Females are more likely to suffer from psychological disturbances, especially in societies where females are mostly accused to be the reason for couple's inability to conceive and cultural and social pressures and norms are one of the most important contributing factors in the development of these psychological issues. In addition, education and employment status of the female partner are among the influencing factors. 1,6,8,9 In some societies e.g. Muslim societies, childlessness can especially be very distressing for infertile females because their religion and culture allow men to have more than one wives at the same time and female's inability to conceive gives them a pretty good excuse to remarry. 10 Pakistan has a culture where having children is considered of utmost importance for any couple. Expectations from society, family and friends put the couple, especially the female, in a very awkward situation. Men are often pressurized to for a second or multiple marriage and this adds to the psychological problem for the females.
Prevalence of psychological ailments among infertile Pakistani females has not been studied so far. So, this study was designed to assess the magnitude of depression, anxiety and stress among infertile females.

METHODS
This case control study was conducted at Arif Memorial Teaching Hospital Lahore from February 2015 and August 2015. After approval from the hospital's Ethics Committee, 100 female patients, with diagnosed female factor infertility, attending infertility clinic were included in the study and 100 fertile females who were accompanying the infertile patients were recruited in the study as controls. Females from couples who had male factor infertility and those with diagnosed mental health issues were not included in the study. A written and informed consent was obtained from all the patients after explaining the purpose and method of the study.
Socio-demographic information including age, occupation, educational level and presence or absence of pressure from family were obtained from the respondents. Depression, Anxiety Stress Scale (DASS) was used to collect data regarding psychological impact of infertility.

Depression Anxiety Stress Scales (DASS):
To measure negative emotional states of depression, anxiety and stress, a validated Urdu version of 42-item DASS was used. Scores on each item can range from 0, indicating no symptomatology, to 3, indicating a severe level of symptomatology. Total score for each of the negative emotional states were calculated separately. 11 DASS scoring was classified using the following classification.

DISCUSSION
This study was conducted to find the magnitude of depression, anxiety and stress among females suffering from infertility, at a tertiary care hospital, in suburbs of Lahore Pakistan.
Infertility, for a Pakistani couple, is considered to be a havoc due to cultural and familial issues. Having children is every couple's dream and for some families, this is of highest importance. For a married female, being childless can be disastrous especially because this gives males a reason to go for second (or more) marriage which is not very uncommon in this society and is a nightmare for a female. This socio-cultural pressure may lead to development of psychiatric symptoms in childless females.
Alhassan A et al. reported 62% infertile females having depression 1 in Ghana. Similarly, Guerra D et al. found prevalence of depression to be 69% among infertile women 12 in China. The prevalence of depression has been found to be 79% in our study, which is a bit higher compared to the two above mentioned studies. This higher prevalence of depression may have been contributed by the sociocultural and religious norms that allow husbands for multiple marriages and the wife being infertile Lamia Yusuf  One interesting finding from our study was that among infertile females, depression, anxiety and stress scores were higher no matter what their level of education was (p < 0.05). This differs from the results from Alhassan A et al., 1 who showed higher rates of psychological symptoms among infertile women with no or very little formal education.
Our study was not a prospective study (which was a limitation of this study) and we did not compare the depression, anxiety and stress score with those of patients suffering from other chronic illnesses. So, due to these limitations, results of the current study may not be generalized.

CONCLUSION
The results from current study suggest very high rates of depression anxiety and stress among patients suffering from infertility. Further prospective studies comparing psychological stress of infertile females with females suffering from other chronic diseases and those exploring other factors that may be responsible for stress symptoms are suggested to confirm these results.