Impact of Infertility Duration on Mental Health of Infertile Women

Abstract

Objectives: The objective of this study was to measure the impact of infertility duration on the mental health of infertile women. Study Design: Cross sectional study. Place and duration of Study: The data for this study were taken from DHQ hospital Mansehra,DHQ hospital Abbottabad, DHQ hospital Haripur, Ayub medical complex Abbottabad, Saad Maternity hospital Mansehra, Afshan fertility hospital Mansehra, Similia fertility treatment center Abbottabad, Sher Khan hospital Ghazi Haripur, Al Ishaq hospital and American hospital Haripur, Jinnah maternity clinic Haripur. This study was conducted during the month of October 2015 to April 2016. Methodology: A sample of 200 infertile women, with the age of 25-50 years and infertility duration from 5-33 years were taken. To measure the mental health of infertile women, Mental Health Inventory(MHI-38) was used. Results: The results indicate that infertile women have high levels of depression, anxiety and loss of behavioral/ emotional control (psychological distress). The results of the study also indicate that as infertility period prolong the infertile women tend to have higher levels of anxiety, depression and loss of behavioral/ emotional control (psychological distress). Conclusion: Infertility is the risk factor for women for anxiety, depression and loss of behavioral/ emotional control (psychological distress).

Full text

Impact of Infertility Duration on Mental Health of Infertile Women
J. Soc. Obstet. Gynaecol. Pak. 2016; Vol 6. No.2 83
Original Article
Impact of Infertility Duration on Mental Health of
Infertile Women
Syeda Farhana Kazmi1, Annum Jadoon2, Atiq ur Rehman3
1Chairperson, Department of Psychology, Hazara University, Mansehra, Khyber Pakhtunkhwa, Pakistan.
2Department of Psychology, Hazara University, Mansehra, Khyber Pakhtunkhwa, Pakistan.
3Lecturer, Department of Psychology, Govt. Post Graduate College Jaranwala, District Faisalabad, Punjab, Pakistan.
Address of Correspondence: Atiq ur Rehman, Lecturer, Department of Psychology, Govt. Post Graduate College Jaranwala,
District Faisalabad, Punjab, Pakistan.
Email: atiq0004@yahoo.com
Abstract
Objectives: The objective of this study was to measure the impact of infertility duration on the mental health
of infertile women.
Study Design: Cross sectional study.
Place and duration of Study: The data for this study were taken from DHQ hospital Mansehra,DHQ hospital
Abbottabad, DHQ hospital Haripur, Ayub medical complex Abbottabad, Saad Maternity hospital Mansehra,
Afshan fertility hospital Mansehra, Similia fertility treatment center Abbottabad, Sher Khan hospital Ghazi
Haripur, Al Ishaq hospital and American hospital Haripur, Jinnah maternity clinic Haripur. This study was
conducted during the month of October 2015 to April 2016.
Methodology: A sample of 200 infertile women, with the age of 25-50 years and infertility duration from 5-33
years were taken. To measure the mental health of infertile women, Mental Health Inventory(MHI-38) was
used.
Results: The results indicate that infertile women have high levels of depression, anxiety and loss of
behavioral/ emotional control (psychological distress). The results of the study also indicate that as infertility
period prolong the infertile women tend to have higher levels of anxiety, depression and loss of behavioral/
emotional control (psychological distress).
Conclusion: Infertility is the risk factor for women for anxiety, depression and loss of behavioral/ emotional
control (psychological distress).
Key words: Mental health, Infertility, Anxiety, Depression, Loss of Behavioral/ Emotional Control,
Psychological Distress.
Cite this article as: Kazmi SF,Jadoon A, Rehman A. Impact of Infertility Duration on Mental Health of Infertile Women J. Soc. Obstet. Gynaecol. Pak. 2016;
Vol 6(2):83-88.
Introduction
Infertility distresses around 80 million persons over the
world and it has been expected that psychological
problems in infertile couples are contained in the range
of 25-60%.1 Infertility is clinically characterized as a
disorder of the reproductive system described by the
failure to attain the pregnancy after twelve months or
more of a consistent sexual interaction. Infertility can be
classified into two types of infertility primary and
secondary. If a couple have never had children or have
been incapable to attain pregnancy after one year of
undergoing unprotected sexual intercourse is said to be
primary infertility and if a couple have had children or
attained pregnancy in the past, but is incapable to
conceive at this time, yet after one year of undergoing
Authorship Contribution
:
All authors contributed in designing, literature review, data collection, data interpretation,
manuscript writing and proof reading.
Funding Source:
none
Conflict of Interest: none
Received:
June 19, 2016
Revised :
July 11, 2016
Accepted: July 15, 2016

Syeda Farhana Kazmi, Annum Jadoon, Atiq ur Rehman
84 J. Soc. Obstet. Gynaecol. Pak. 2016; Vol 6. No.2
unprotected sexual intercourse is said to be secondary
infertility. The rate of secondary infertility is more than
primary infertility, particularly in developing countries
where sexually transmitted diseases are frequent. In
numerous countries induced (deliberately) abortion
causes much of secondary infertility. By and large, it
reports for 60% of the overall number of infertility
cases.2
Infertility is increasing progressively all over the world,
10-15% of couples overall experience infertility.3
Approximately 1/3 of infertility complications are
attributed to women, 1/3 of infertility complications are
caused by men and the other 1/3 of cases are due to
by a mixture of both women and men complications or
by unspecified reasons.4Regardless of either male or
female is infertile, infertility is a severe psychological
trauma as well as an unpleasant emotional stress for
infertile couples.5
Prevalence of infertility is highest in Sub-Saharan
Africa, North Africa/Middle East, South/Central Asia
and Central/Eastern Europe.6 Prevalence of infertility
among young females was approximately 12.6% in
India 7, 10% in the United State, 1.72% in China 8,
11.5% to 15.7% in Canada.9 The prevalence of
infertility in Pakistan is 21.9%, while primary infertility
rate is 3.9%, but secondary infertility rate is 18.0%.10,11
There may be various reasons which can cause
infertility among women, i.e. obstruction in fallopian
tube. There are various diseases among women, which
produce infection in the reproductive tract. In the
absence of treatment gonorrhea and chlamydia can
infect the fallopian tubes, ovaries and uterus which can
produce pelvic inflammatory disease (PID) that has
usually no symptoms and obstructing the egg from
moving downward in the tubes to contact the sperm. An
episode of pelvic inflammatory disease, there may be a
15% probability of infertility, whereas afterward two
episodes it may be to 35%, and after three episodes it
may be a nearly 75% chance of infertility. Post abortion
and postpartum infection may be the cause of pelvic
inflammatory disease, which can produce infertility.
Moreover, non sexually transmitted diseases like
schistosomiasis, genital tuberculosis and endometriosis
may be lead to infertility. Ovulation disorders can cause
infertility among women and these disorders are related
to an absence of ovulation, i.e. while there is an
elevated level of the prolactin hormone it restrains
ovulation (hyperprolactinaemia) and further factors
which can cause infertility are ovarian tumours, stress,
thyroid gland disorder and malnutrition. Uterine factors
can cause infertility among women while there is an
abnormal development of the uterus such as any
congenital malformation, or fibroids in the uterus.
Cervical factors can cause infertility among women.
There are cases where the cervical canal is excessively
narrow and obstructs the route of sperm into the uterus.
Vaginal factors in very rare cases, conditions like a
vaginal septum which obstructs sperm transportation
can be causes of infertility and unexplained infertility
which appears in 5% to 10% of couples may be
happening and it is more usual in males than females
for unidentified reasons but sexually transmitted
infections (STIs) are the main causes of infertility.12
Shaheen et al. reported in their study, which was
conducted at the Government Services Hospital,
Islamabad, Pakistan that the causes of infertility among
534 couples were as normal pelvis 26.40%, ovulatory
failure 22.09%, male factor 21.91%, tubal blockage
14.41%, endometriosis 6.55%, sexual dysfunction
5.61%, mucus hostility 1.68%, tubal blockage and tubo-
ovarian masses 1.31%.13
Tension is a usual effect of infertility which can be seen
in the form of stress, impatience, trouble thinking and
fatigue.14The most problematic emotional effects of
infertility is the loss of control in life when infertility
freeze out other essential aspects of life.15 This may be
due to the actuality that in childhood and adolescence,
social implications about the consequence of parenting
are always propagated, particularly in regard to women.
As a result infertile women frequently encounter a
feeling of loss of identity, sense of hopelessness and
uselessness.16
Anxiety, depression and stress are common effects of
infertility. It has been seen that the prevalence of
depression in infertile women reporting for infertility
treatment is substantially higher in the range of 15 to
54% as compared to fertile women.17 It has also been
seen that the existence of depressive symptoms is
related with length of infertility treatment.18 Anxiety has
also been reported to be much high in infertile women
in the range of 8 to 28% as compared to normal women
and is mostly the generalized anxiety disorder.19
Depression is a mental disorder distressing almost 121
million persons internationally. This disorder is mostly
diagnosed by a number of symptoms as loss of
pleasure and interest, sad mood, low self-worth, sense
of guilt, upset in sleep, inadequate appetite, loss
concentration and poor energy. Depression is expected
to became the second foremost cause of disability in
the world by the year 2020.20
It is believed that depression can directly influence
infertility, contain the physiology of the depressed

Impact of Infertility Duration on Mental Health of Infertile Women
J. Soc. Obstet. Gynaecol. Pak. 2016; Vol 6. No.2 85
condition, i.e. higher prolactin levels, disorder of the
hypothalamic pituitary adrenal (HPA) axis and thyroid
malfunction. The findings of a study of depressed and
non-depressed women indicated that depression is
seen with abnormal adjustment of luteinizing hormone
which regulates ovulation.21 Variations in immune
function related with depression and stress can also
negatively have an effect on reproductive function.22
Living place and socioeconomic status can also affect
emotional distress. Family background indirectly affects
emotional distress among infertile women.23
Every person usually encounter some stress in daily
life that is caused by stressor which stimulate a
response in the brain called as stress perception that
provokes nervous, immune and endocrine in the body
to get a stress response. The pathophysiological
variations related to stress response change the
regular process of the super systems and produce the
discrepancies that cause the impairment in fertility. 24
Lynch states when a stimulus is noticed as stressful,
communications are referred to
the hypothalamus, which subsequently get under way
the sympathetic adrenomedullary (SAM) pathway and if
stress is prolonged, the sympathetic adrenomedullary
remains overactive and the hypothalamic pituitary
adrenal axis (HPA) become to be stimulated also.
The norepinephrine is released into the blood flow,
which final outcomes in a surge in salivary alpha
amylase production thru the parotid gland. The level of
stress can be easily measured from the α-
amylase and cortisol hormone levels, which is secreted
in saliva and urine.25
Louis investigated stress, salivary cortisol and α-
amylase during the fertile period of a woman's
menstrual cycle, proving that stress significantly
reduced the possibilities of conception by effecting the
sympathetic medullary pathway for women exhibiting
elevated levels of cortisol. It has been proved by the
evidences about the relationship between stress and
the activation of the hypothalamic pituitary adrenal axis
and, that the bodily stress can interrupt the woman's
menstrual cycle. Stress activates the HPA, which
controls adrenocorticotropic hormone, corticotropin
releasing hormone, and glucocorticoids and these
hormones are essential to remain stable for the female
reproductive system to perform best possible while
raised levels of these stress hormones can intervene
with the control of ovulation and decrease the
opportunity of implantation or cause a miscarriage.26
Infertility can lead to emotional outcomes such as
depression, anxiety, anger, feelings of inadequacy,
setbacks with sex life and marital harms.16 Significantly
worse fertility consequences are attained in couples
take excessive psychological stress.27 Meta- analysis
inspecting psychological health and pregnancy rate
confirmed that psychological mediations enhanced
fertility conceive pregnancies. These mediations
suggest an attractive treatment opportunity for infertile
couple who are not taking medical treatment.28
A couple can confront several levels of infertility
concerned stress determined upon individual or couple
communication, links earlier to infertility and spirituality
or religiosity.29 Forgoing studies have realized that
infertile women who encounter pressures of negative
response from their husbands and relatives, suffer in
higher levels of stress.30 A couple who feel difficulty in
communicating about infertility can experience stress,
which emphasizes the requirement for psychological
intervention.31
Depression can produce infertility as the physiological
affects raised prolactin levels, the consequence of
the HPA axis thyroid malfunction with ovulation.
Depression and stress have been recognized to harm
reproductive function which cause infertility. Infertile
women almost reveal the depression at an equal rate of
depression as with heart disease or cancer.16 It has
been observed in the studies of infertility and
depression that there is a significant association
between negative self-judgment and high internal and
external level of disgrace, especially when a person on
medical treatment.32 Studies observed that 81.3%
infertile depressed couple explained that the major
cause of their depression was negative remarks from
their families about their infertility.33
Methodology
A sample of 200 infertile women, with the age range
25-50 years and infertility duration range 5-33 years
were taken. The data for this study were taken from
DHQ hospital Mansehra, DHQ hospital Abbottabad,
DHQ hospital Haripur, Ayub medical complex
Abbottabad, Saad Maternity hospital Mansehra, Afshan
fertility hospital Mansehra, Similia fertility treatment
center Abbottabad, Sher Khan hospital Ghazi Haripur,
Al Ishaq hospital and American hospital Haripur, Jinnah
maternity clinic Haripur. This study was conducted
during the month of October 2015 to April 2016.The
current study is based on cross sectional research
design.
Urdu translation of MHI-38 developed by Viet and Ware
in 1983 was exercised in the current study. The
inventory possesses 38 items having 6 points scale. It

Syeda Farhana Kazmi, Annum Jadoon, Atiq ur Rehman
86 J. Soc. Obstet. Gynaecol. Pak. 2016; Vol 6. No.2
has six measurements, i.e. depression, anxiety, loss of
behavioral/emotional control, emotional ties, life
satisfaction and general positive affect. The inventory
also yields the universal mental health index.
Results
The analysis has been incorporated about the
demographic information of infertile women who were
the part of sample as shown in table I. As presented in
the table I, infertile women with the age 25-50 years
and infertility duration 5-33 years have been split
among three subgroups as per age and as per infertility
duration.
Table I: Demographic descriptions of infertile women.
Variables
Subgroups
Infertile
women(N=200)
%
Age 25-35 65 32.5
36-25 69 34.5
56-50 66 33.0
Infertility
Duration
5-10
11-20
94
70
47
35
21-33 36 18
As presented in the table II, it has been observed that
the anxiety scores among infertile women were 10- 49
with a mean of 32.5 and SD=8.4, depression scores
were 4-23 with a mean of 15.0 and SD=4.7, loss of
behavioral /emotional control scores were 11-51 with a
mean of 32.5 and SD=8.5 and psychological distress
scores among infertile women were 42-122 with a
mean of 86.5 and SD = 18.1.
As presented in the table III, it has been observed that
anxiety among infertile women were significantly
variable among three groups with duration 5 - 10 years,
11- 20 years and 21 -33 years F(2,197 ) = 27.21,
p<.05, depression were significantly variable among
three groups with duration 5 -10 years, 11 - 20 years
and 21- 33 years F(2,197 ) = 24.79, p<.05,loss of
behavioral/ emotional control were significantly variable
among three groups with duration 5 - 10 years, 11 - 20
years and 21 - 33 years women, F(2 ,197 ) = 29.32,
p<.05 and psychological distress among infertile
women were significantly variable among three groups,
with duration 5-10 years, 11- 20 years and 21- 33 years
F(2 ,197 ) = 10.28, p < .05,
Discussion
The objective of the study is to find out the impact of
duration of infertility on anxiety, depression and loss of
behavioral/ emotional control (psychological distress) in
infertile women.
In the current research it was detected that the level of
psychological distress among infertile women were
significantly variable among three groups with duration
5 - 10 years, 11 - 20 years and 21 - 33 years F (2 ,197)
= 10.28, p<.05 which shows the level of psychological
distress boost up as the infertility duration enlarges.
The infertility has a serious distress to a couple self
respect and further psychological distress is added as
the infertility duration increases.34
The findings of the current study reveal that the level
among three groups with duration 5 - 10 years, 11 - 20
years and 21 - 33 years F(2 ,197 ) = 27.21, p<.05. Our
results show that as the infertility period increases the
level of anxiety among infertile women also rises up.
The fact is well-known from different studies that
infertile women have excessive discomfort,
nervousness and miserable life.35,36,which escalate with
Table III: Difference in the level of anxiety, depression, loss of behavioral/ emotional control and psychological
distress, as per duration of Infertility among infertile women on MHI-38
Infertility
Duration
Infertility
Duration
Infertility
Duration
(5
-
10 Year)
(11
-
20Year)
(21
-
33 Year)
M
SD
M
SD
M
SD
F
P
Anxiety
27 8.29 35.20 6.34 38.38 7.31 27.21 .000
Depression
13.9 4.27 16.6 3.89 17.96 3.44 24.79 .000
Loss of Behavioral/Em
otional Control
28.75 8.16 34.9 7.15 39.0 6.25 29.32 .000
Psychological
Distress
126.4 14.01 131.48 12.82 137.92 12.54 10.28 .000
df=197, p<.05
Table II: The obtained
range, mean and SD of anxiety,
depression, loss of behavioral/emotional control and
psychological distress among infertile women on MHI-
38,(N=200)
M
SD
Possible
Range
Obtained
Range
Anxiety
32.5 8.4 9-54 10-49
Depression
15.0 4.7 4-23 4- 23
Loss of
Behavioral/
Emotional Control
32.5
8.5
9-53 11-51
Psychological
Distress
86.5 18.1 24-142 42-122

Impact of Infertility Duration on Mental Health of Infertile Women
J. Soc. Obstet. Gynaecol. Pak. 2016; Vol 6. No.2 87
the infertility duration and the lack of treatment.37,38,39
Zamani, Ghasemi, Jokar and Khazri Moghadam
reported in their study, which was conducted to
evaluate the level of depression among those women
who were experiencing infertility, repeated abortions
and subfertility. The results of their study revealed that
women suffering from repeated abortions and having
infertility have higher levels of depression as compared
to fertile women.40 Infertile women suspect fault,
disgrace, embarrassment, low self-esteem, irritation,
loneliness, loss of emotions as infertility duration
increased.15
Conclusion
It is concluded from the current study that mental p
health roblems such as anxiety, depression, loss of
behavioral/ emotional control and psychological
distress are rampant among infertile women. The
current study provided an insight into psychological
adjustments that may take place among infertile
women after being exposed to the problem of infertility.
The verdict has been confirmed that as the infertility
duration increases anxiety, depression, loss of
behavioral/ emotional control and psychological
distress is also exaggerated.
Limitation: The demographic factors such as economic status,
education and cultural perspective were not the part of study while
these factors have the significant effect on the mental health of
infertile women with regard to infertility.
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