|Year : 2019 | Volume
| Issue : 2 | Page : 74-85
A preliminary study of stress and infertility among Egyptian female sample in Benha city
Victor S Mikhael, Mohamed M El-Hamady, Shewikar T El-Bakry, Raghdaa A Abdel-Halem
Department of Psychiatry, Benha Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||17-Feb-2019|
|Date of Acceptance||11-Mar-2019|
|Date of Web Publication||11-Jul-2019|
Shewikar T El-Bakry
Department of Psychiatry, Benha University Hospital, Benha, 11543
Source of Support: None, Conflict of Interest: None
Background To study infertility-related stress among women, as the experience of infertility can be extremely stressful and associated with a range of psychiatric problems in infertile women, to examine its relationship with their coping capability to stress and marital satisfaction, and to study some of the risk factors that may lead to psychiatric disorders.
Objective In this study, we have analyzed the psychiatric problems of infertile women, their coping capability to stressful life events, and marital satisfaction among them.
Patients and methods In a cross-sectional study, 30 infertile women (15 explained and 15 unexplained infertility) were randomly selected and advised to a clinical psychiatric assessment and to fill up Stressful Life Events Coping questionnaire and Marital Satisfaction Inventory. After obtaining their consents, psychiatric problems such as depressive disorders, anxiety disorders, panic, somatoform disorders, and personality profile were assessed. Moreover, their coping capability to stressful life events and marital satisfaction was studied. Results were analyzed and compared with the results from 10 fertile women.
Results According to a clinical psychiatric assessment, Stressful Life Events Coping questionnaire, and Marital Satisfaction Inventory, major depression, anxiety disorders, comorbid anxiety and depression, and premenstrual dysphoric disorder were significantly more frequent in infertile women. Considering somatization and personality disorders, there was no significant difference between infertile and fertile women. Pathological coping capability to stress and marital dissatisfaction, on the contrary, was significantly higher among infertile women.
Conclusion Infertility may be considered as one of the major casual factor in depression and anxiety disorders, has negative coping capability to stress, and shows marital dissatisfaction.
Keywords: females, infertility, psychiatric manifestations, stress
|How to cite this article:|
Mikhael VS, El-Hamady MM, El-Bakry ST, Abdel-Halem RA. A preliminary study of stress and infertility among Egyptian female sample in Benha city. Egypt J Psychiatr 2019;40:74-85
|How to cite this URL:|
Mikhael VS, El-Hamady MM, El-Bakry ST, Abdel-Halem RA. A preliminary study of stress and infertility among Egyptian female sample in Benha city. Egypt J Psychiatr [serial online] 2019 [cited 2022 May 19];40:74-85. Available from: http://new.ejpsy.eg.net/text.asp?2019/40/2/74/262554
| Introduction|| |
Exposure to stressful stimuli can lead to a variety of secondary diseases such as anxiety, depression, cardiovascular diseases, immune suppression (McEwen, 2002), as well as reproductive dysfunction (Lynch et al., 2014).
Stress is a physical, mental, or emotional response to adverse events, which causes bodily or mental tension (Catherino, 2011). The author added that extreme stress (e.g. anorexia nervosa) can disrupt reproductive function, but determining what is stressful is complex, in that individual responses to stressful stimuli can differ dramatically.
Thus, stress is a feeling of strain and pressure. Humans experience stress, or perceive things as threatening, when they do not believe that their resources for coping with obstacles (stimuli, people, situations, etc.) are enough for what the circumstances demand. Chronic stress and a lack of coping resources available or used by an individual can often lead to the development of psychological issues such as depression and anxiety.
Ancient Egyptians were highly sensual people, and a major theme of their religion was fertility and procreation (Brewer and Teeter, 1999), and they even had gods and goddesses such as Mut and Isis for female fertility and motherhood; moreover, there were others such as Bastet who, having the shape of a cat, embodied fertility (Booth, 2015). Placing a clove of garlic in the vagina was supposed to test for fertility: if garlic could be detected on the breath of a woman then she was fertile; if not, then she was infertile (Brewer and Teeter, 1999).
Infertility is defined as the inability to conceive after 12 months of regular unprotected intercourse (American Society for Reproductive Medicine, 2008). Recently, infertility was also referred to be the biological inability of an individual to contribute to conception or to a woman who cannot carry a pregnancy to full term (Nordqvist, 2016).
Women’s trials for adjustment to infertility is exacerbated by the negative view of infertility and that infertile females have to go through many medical and psychological analysis. Women find infertility painful and feel themselves marginalized (Stodland, 2002). At time they occur with negative views of themselves as desperate or inadequate, preoccupied with their desire to become mothers and eager to grasp at any solution, however oppressive or unlikely to lead to success (Eugster et al., 2004).
Actually a crisis of infertility is a difficult emotional experience as it affects various aspects of marital and individual life such as social relations, life objectives, quality of life, and sexual relations (Spector, 2004). In fact, the psychological problems that have been most commonly investigated are anxiety and depression: anxiety because of the stressful nature of the treatment procedures and fear of treatment failure and depression because of the patients’ inability to conceive (Wischman et al., 2001). Although most studies were performed in the Western world (Chen et al., 2004; Monga et al., 2004), contemporary studies show similar findings for infertile women from Eastern world (Guz et al., 2003; Matsubayashi et al., 2004).
Several factors were held to be associated with marital satisfaction in infertile couples. A review article depicted that various factors play a role in creating marriage life satisfaction in an infertile couple that have to be taken into consideration during continuation of their protocol treatment that are highly based on culture. These can be classified into six categories: demographic factors; using fertility assisting methods; psychological health; quality of life; economic, social, and family support; and sexual function (Samadaee-Gelehkolaee et al., 2016).
Nevertheless, the problem was not fully tackled in the Middle East or in Egypt. The association of duration of infertility and depressive symptoms seems to be significant according to a study conducted at Beni-Suef city in Egypt (Hassan et al., 2013). A statistically significant association was recorded (Hassan, 2016) between psychological status among Northern Upper Egyptian women who were infertile in relation to their sociodemographic, special variables, gynecological impairments as well as reproductive tract infections and regarding depression, anxiety, and tension. As far as the present study is concerned, no records of interrelation between infertility and stress were reported in Benha city, Egypt.
| Aim of the study|| |
The study had the following aims:
- To find out the relation between stress and infertility and vice versa among infertile females in Benha city.
- To assess the possible psychiatric problems in infertile females in Benha city.
- To study whether there is a coping strategy with the current events or not?
- To assess the marital satisfaction among infertile females in Benha city.
| Patients and methods|| |
This is a cross-sectional random study conducted in Benha University Hospital and private infertility clinics in Benha city. A formal consent was obtained from all participating females and the aim of the study was thoroughly explained. An approval from the ethical committee of Banha University was also obtained. It was conducted in the period from August 2011 till February 2012. Forty women (organized into a control group and a study group) participated in the study. The study group comprised thirty infertile women who receiving treatment for infertility. Fifteen had obvious organic causes for infertility (explained infertility patients). The other 15 had no obvious organic cause for infertility (unexplained infertility patients).
The study included female patients with the following inclusion criteria:
- They fulfilled the diagnosis of infertility (Shahet al., 2003).
- Normal marital life: the couples live with each other to ensure regular intercourse.
- Age range: childbearing period.
To control the founding effects of prior medical factors, the following exclusion criteria were adopted for all cases:
- Major general medical diseases, such as possibility of a neurological disease, birth injuries, obstetrical complications, or serious renal, cardiovascular, hepatic or endocrinal disorders that may affect conception.
- Male infertility as proven by semen analysis.
All participants were screened to determine eligibility for participation in the study. Screening was conducted through an interview form, which examined demographic data, infertility history (including semen analysis), and medical history.
The control group consisted of 10 Egyptian fertile females (with neither history of infertility, abortions nor hormonal contraception), with no apparent physical illness. They were matched for age and other demographic variables as far as possible with the studied group.
A formal clear written consent was taken from every participating female in the study where the aim of the study was explained.
Females participating in the study were subjected to the following:
A semi-structured interview
A set of questions were designed in the form of yes/no, multiple choice, or closed ended format to emphasize the following:
- Demographic data, occupation, working hours per day, and holidays.
- Full psychiatric evaluation according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-ΙV).
- Past history of psychiatric illness, drugs intake, and major general medical or surgical problems.
- Family history of psychiatric problems or infertility.
- Early and late home atmosphere.
- Marital history: this included type of marriage and its duration and who is domineering in the relationship and the financial status.
- Sexual history: this included regularity of menses, attitude towards sex, and frequency of sexual relation per week, sexual satisfaction and sexual dysfunctions as painful intercourse or vaginismus among other dysfunctions.
- Infertility assessment: the duration of infertility, the investigations carried out, the cause of infertility if known, previous and current treatment, and attitude of relatives toward the patient.
- Patients of the study were interviewed by two psychiatrists to ensure consistency, to eliminate bias and decrease errors, and to assess the psychiatric symptoms.
The following psychometric measures were used:
- Stressful life events coping psychometry (Poon, 2003) translated by Ali (2008).
- Marital Satisfaction Inventory (Snyder, 1987) translated by El Beblawy (1987).
Recorded data were tabulated and analyzed using statistical package for the social science (SPSS), version 16 software (IBM Corp, Armonk, NY). Data were presented as percentages with means and SD. χ2 and analysis of variance were used as tests of significance. The accepted level of significance in this work was stated at 0.05 (P<0.05 was considered significant).
| Results|| |
[Table 1] discusses the mean and SD for age in the three studied groups. Concerning occupation and working hours per day (P=0.341), no statistical significant differences were recorded among the three groups. On the contrary, data indicated significant statistical difference (P=0.019) between explained infertility group and control, whereas nonsignificant differences between the unexplained infertility group in comparison with the control and explained infertility groups regarding the holidays.
|Table 1 Sociodemographic data of the control, explained, and unexplained infertility groups according to the age, occupation, work hours per day, and holidays|
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Evaluation of axis-1 disorders according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
- According to anxiety disorders presented in [Table 2], statistically significant differences were recorded between both explained and unexplained infertility groups and control group (P=0.028), with no significant difference between explained and unexplained infertility groups.
|Table 2 Axis-1 disorders according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. among the control, explained infertility, and unexplained infertility groups|
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- For mood disorders ([Table 2]), there was a statistically significant difference between explained and unexplained infertility groups and the control group (P=0.034), but no significant difference between explained and unexplained infertility groups.
- Contrary to that for somatization disorder ([Table 2]), there was no significant difference among the three groups, including the control (P=0.076).
Evaluation of premenstrual dysphoric disorder
There was a statistically significant difference between both the explained and unexplained infertility groups and the control group (P=0.037), but there was no significant difference between the explained and the unexplained infertility groups concerning presence of premenstrual dysphoric disorder (PMDD), as 46.7% of the unexplained infertility group and 40% of the explained infertility group fulfilled the diagnostic criteria of PMDD, whereas none of the control group had PMDD.
[Table 3] shows that the comorbidity between anxiety and depression disorders was high (35%) in explained and unexplained infertility groups. There was a statistically significant difference between both explained and unexplained infertility groups and the control group (P=0.02), but there was no significant difference between the explained infertility group and the unexplained one.
|Table 3 Psychiatric comorbidities with respect to anxiety and depression disorders among the control, explained infertility, and unexplained infertility groups|
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Evaluation of axis-II diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
[Table 4] shows that there was insignificant statistical difference regarding personality disorders (P=0.99) between the control, the explained infertility, and the unexplained infertility groups.
|Table 4 Personality disorders (axis-II diagnosis) according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. among the control, explained infertility, and unexplained infertility groups|
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The most frequently encountered categorical axis-II diagnoses were paranoid (15%), obsessive (15%), depressive (12.5%), avoidant (10%), dependent (5%), and histrionic (5%). Results signified 13.3% versus 13.3% in the explained infertility group and unexplained infertility group, respectively, and 20% in the control group for paranoid and obsessive personality.
Explained infertility group revealed that most had hormonal or ovulate factor (80%) followed by tube (6.7%) and then uterine and cervical causes (6.7%), recording highly statistical significant difference between the two experimental groups concerning the hormonal cause of infertility (P<0.001).
Overall, 73.3% of explained infertility group received conservative treatment in the form of hormonal therapy for induction of ovulation but none of the unexplained infertility group, so there was a highly statistically significant difference between the two groups (P<0.001).
None of the explained infertility group had IVF treatment but 73.3% of the unexplained infertility group underwent IVF treatment, showing highly statistically significant difference between the two groups (P<0.001).
Overall, 20% of explained infertility group and 6.7% of the unexplained infertility group underwent surgical treatment.
Moreover, 6.7% of explained infertility group had both hormonal and surgical treatment and none of the unexplained infertility group.
Although none of the explained infertility group had no treatment yet 20% of the unexplained infertility group did not receive any treatment.
The attitude of relatives toward infertile patients was sympathy in 33.3% and aggression in 66.7% of unexplained infertility group, whereas sympathy was in 46.7% and aggression in 53.3% of explained infertility group.
Evaluation of stress coping
Applying the stress life events coping psychometry data revealed that 42.5% had negative coping capability to stress ([Table 5]), so there was a statistically significant difference only between the unexplained infertility group and the control group (P=0.019).
|Table 5 Stressful life events coping psychometry among the control, explained infertility, and unexplained infertility groups|
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- Evaluation of conventionalization (CNV): 46.7% of explained infertility group, 20% of unexplained group, and 10% of control group had low CNV, which was of statistically significant difference (P=0.012).
- Evaluation of global distress: [Table 6] designates statistically significant difference (P=0.002).
|Table 6 Comparison between the control, explained infertility, and unexplained infertility groups regarding global distress|
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- Evaluation of affective communication: [Table 7] revealed statistically significant difference recording (P=0.02).
|Table 7 Comparison between the control, explained infertility, and unexplained infertility groups regarding affective communication|
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- Evaluation of problem-solving communication (PSC): 13.3% of the explained infertility group, 10% of the control group, and none of the unexplained group had bad PSC, which was of statistically insignificant difference (P=0.07).
- Evaluation of time together: 53.3% of the explained infertility group in comparison with 20% of the unexplained group and 10% of the control group had bad time together, which was of statistically significant difference (P=0.04).
- Evaluation of disagreement about finance: 53.3% of the unexplained infertility group, 6.7% of the explained group, and 20% of the control group had severe financial disagreements, which was of statistically significant difference (P=0.016).
- Evaluation of sexual dissatisfaction: data recorded that 26.7, 6.7, and 0% in the explained, unexplained, and control group, respectively, had severe sexual dissatisfaction, which was of statistically significant difference (P=0.032).
- Evaluation of role orientation: 6.7% of the unexplained infertility group and none of the explained group or control group had low role orientation, which was of statistically insignificant difference (P=0.25).
- Evaluation of family history of distress: 53.3, 13.3, and 10% of the unexplained, explained, and control group had severe family distress, which was of statistically significant difference (P=0.037).
- Psychiatric morbidity and PMDD: most infertile females with psychiatric morbidity had statistically significant difference (P=0.04) regarding the past history of PMDD (54.5%) when compared with infertile females without psychiatric morbidity (12.5%).
- Psychiatric morbidity and stress coping: correlation showed that infertile females without psychological morbidity (100%) showed healthy coping capability to stress more than infertile females with psychological morbidity (43.5%), which had significant statistical difference (P=0.027).
| Discussion|| |
The present study was designed to explore the proposed bidirectional relation between stress and infertility, to assess the possible psychiatric problems in infertile Egyptian females in Benha city, and to study their ability of coping with the stress and their marital satisfaction.
In the present study, there were no statistical significant differences between the control, explained, and unexplained infertility groups regarding sociodemographic data such as age, occupation, work hours per days, and holidays. These finding could be explained by the fact that maternity for Egyptian female is the cornerstone role expected and appreciated by her, to the extent that all other roles and goals of life seems subsidiary revolving around the major central goal.On the contrary, a study showed that patients from the female infertility group were significantly older than the control group (Sheiner et al., 2003). This shows that women in Egypt seek treatment fast as they wish to get pregnant as soon as they get married.
A similar conclusion was reached also by a study, with no significant differences between the female infertility and the control groups regarding type of occupation (Sheiner et al., 2003). In Egypt, regardless of the occupation among women, having a child comes in her higher priorities.
On the contrary, studies found inverse associations between higher workloads and conceiving (Barzilai-Pesach et al., 2006), yet this was the hallmark and focus of their study; thus, working in the past 3 months was a criterion for inclusion.
Concerning evaluation of axis-I disorders according to DSM-IV, this work demonstrates that there was a high frequency of psychiatric morbidity among the infertile women. Not only was anxiety disorder the most encountered diagnosis, as it represents 73.3% in the unexplained infertility group, 60% in the explained infertility group, and 20% of the control group, followed by depression disorder, which represents 53.3% of the unexplained infertility, 60% of the explained infertility, and 10% of the control group ([Table 2]), but also there was high comorbidity between anxiety and depression, which represents 53.3% in the unexplained infertility group, 40% in the explained infertility group, and none in the control group ([Table 3]).
Moreover, there was a high frequency of PMDD among both the explained (40%) and the unexplained infertility groups (46.7%) in comparison with none of the control group. In contrast to somatization disorder, although it represents 26.7% in the unexplained infertility group, 40% in the explained infertility group, and none of the control group, yet it was statistically insignificant ([Table 3]).
These findings reflect the major perceived identity of married Egyptian women aiming maternity, which when not achieved involuntary leads to demeaning feelings and situations that exert major stress and consequent psychiatric morbidity with high frequency. The psychiatric morbidity of infertility is immense in Egypt and is likely to be the same in all countries of the developing world because social and financial securities are lacking for women and because of the unique perception of maternity in the identity, role, and value of women. Additionally from the biological point of view, infertility is considered a chronic stress that may cause neuro-psychiatric manifestations such as anxiety and depression, as the pathogenesis of chronic stress-related disorders can also be explained by sustained, excessive secretion of the major mediators of stress such as corticotropin-releasing hormone, norepinephrine, cortisol, and other hormones, which activate the fear system producing anxiety. The same mediators cause tachyphylaxis of the reward system, which produces depression. Adversely, stress hormones and the hypothalamic-pituitary-adrenal axis interact with hormones that influence fertility directly, such as gonadotropin-releasing hormone, prolactin, luteinizing hormone, and follicular-stimulating hormone, as well as with hormones that may interfere with fertility such as cortisol, endogenous opioids, and melatonin.
Studies on Egyptian infertile women are scarce. In a previous work, high levels of state anxiety were found in infertile women (manifest anxiety score was 28) in comparison with fertile women, in addition to high levels of anxiety and depression traits as demonstrated by the high scores obtained in D-Guilford scale and N and E scores of the Eysenck Personality Questionnaire. Yet there was neither further analysis or correlations nor diagnosable psychiatric disorders in the sample (El-Fakharany, 1986).
In Arab countries, namely, Kuwait (Fido, 2004), similar high rates of tension, anxiety, depression, self-blame, and suicidal ideation were found in Kuwaiti infertile women. Similar rates were found in Nigeria (Umezulike and Efetie, 2004) as they found sadness, anger, guilt, and regrets on expressed suicidality.
The concurrent study is also supported by the findings of a work on Taiwanese women (Chen et al., 2004) as well as Japanese women in another study by Matsubayashi et al., 2004. Psychiatric morbidity was not different in Chinese infertile women (Loc et al., 2002) and in Korea infertile women (Kee et al., 2000), which showed similar findings.
However, in the Western world, some studies presented similar rates of depression and anxiety among infertile women (Epstein et al., 2002; Ismail et al., 2004).
The interpersonal sensitivity, depression, phobic anxiety, paranoid ideas, and psychoticism scales were significantly different between infertile and fertile women (Noorbala et al., 2008).
In another study in South Africa, women experiencing involuntary childlessness scored significantly higher on all subscales and the global indices of the distress of the Symptom Checklist-90-Revised when compared with controls. The highest mean values were found on the anxiety scales followed by depression and somatization (Dyer et al., 2005).
The present study is also supported by the findings of Anvar et al. (2006) who found that infertile women have higher prevalence of somatoform disorder when compared with normal women, but this difference was not significant. Another study (Noble, 2005) showed that women may develop depression as PMDD during reproductive dysfunction.
These results may be owing to that negative psychological consequences of childlessness are common and often severe. In many cultures, womanhood is defined through motherhood, and infertile women usually carry the blame for the couple’s inability to conceive. Moreover, in the absence of social security systems, older people are economically completely dependent on their children. Moreover, childless women are frequently stigmatized; thus, all of the prementioned issues result in isolation, neglect, domestic violence, anxiety, and depression.
On the contrary, some reports show that there is no statistically significant difference between depression and anxiety levels of both healthy and infertile groups, such as the study held in Turkey (Guz et al., 2003). This might be owing to the fact that being literate and without family or past history of psychiatric illness were criteria for participation.
A study (Verhaak et al., 2007) showed that female fertility-seeking patients did not differ from normal groups with respect to depression levels.
This comes in accordance with the present findings that showed no statistically significant difference between the unexplained infertility and the explained infertility groups regarding anxiety, depression, somatization disorders or comorbid anxiety, and depression. This could be owing to that both groups are under the same burden and distress of infertility.
Some studies were unable to identify any differences between the explained and the unexplained infertility groups regarding psychiatric morbidity (Cahill and Wardle, 2002), as it is impossible to say whether such emotional disorders are partly responsible for infertility or whether they are the consequence of the inability to have a child. On the contrary, others indicated that women with unexplained infertility were more anxious and dissatisfied with themselves and their lifestyle than women in the explained infertility group (Romano et al., 2012). In another study (Stauber, 2003), 39 couples with unexplained infertility were judged by the author to be ‘anxious and depressive persons.’
Comparing 16 organically infertile women and 14 women with unexplained infertility, a study found above-average neuroticism scores for the group with unexplained infertility (Morse and Dennerstein, 2002).
Such contradictions with the present results may be explained as women with explained infertility face an unambiguous and comprehensible situation, in which known physical obstacles are identified and dealt with evidence-based algorithms, which have been proved useful in similar clinical settings. On the contrary, women with unexplained infertility deal with an obscure clinical situation and have to go through wearing trial-and-error treatment attempts.
In addition, such conflicting results might be owing to cultural factors, which may play a major role in mood and anxiety of infertile women. In traditional Eastern culture, the family is usually valued more than the individual. The meaning of an individual’s life often includes the extension of the family. Infertile women in the East may experience more psychological dysfunction than those in the West.
Moreover, there are some cultural meanings in Egypt rendering infertility to be such a devastating problem for women, who attempt to rectify their socially tenuous situation by becoming pregnant. Not only are women typically blamed for the reproductive failing, but they must bear the burden of overcoming it.
A second factor ascribes these differences to variations in methodology as comorbidity studies differ in approach (epidemiological or clinical), focus of attention (broad pattern or focus on one particular disorder), diagnostic criteria (DSM-IV or ICD-10), the use of regular or structured interviews (SCID-I, SCID-II, Symptom Checklist-90-Revised, BDI, etc.), sample selection (in-patient and out-patient), type of assessment (longitudinal or cross-sectional), and infertility classification (primary vs. secondary, male factor vs. female factor, explained vs. unexplained, etc.).
Lastly, some patients with anxiety and depression may lack insight into their psychiatric condition. Consequently, it is possible that estimation based on the patients’ self-assessment of whether or not they are depressed may underestimate these psychiatric disorders.
Although our study represented that the most frequently encountered categorical axis-II diagnoses were paranoid, obsessive, depressive, avoidant, dependent, and histrionic personalities, yet there was no statistical significant difference between the control, the explained infertility, and the unexplained infertility groups, which may be attributed to the small sample size of patients in the study (Wischman et al., 2001).
Contrary to the current results, several studies (El-Fakharany, 1986; Kee et al., 2000; Lancastle and Boivin, 2005) considered that neuroticism is significantly related to infertility itself and to the biological state (peak estradiol level, number of the follicles, and number of oocytes). The importance of neuroticism as a vulnerability factor in emotional response to a severe stressor in the development of anxiety and depression after a failed fertility treatment was indicated, yet no significant correlations were found in the previously mentioned studies with the other personality factors (extraversion and optimism) (Verhaak et al., 2005).
A study in Sweden (Czemiczky et al., 2000) revealed that infertile women scored higher than the fertile controls on suspicion, guilt, and hostility but lower on indirect aggression, which could be interpreted with caution to the personality traits found in the present study. Pathways by which personality variables could affect reproductive health include indirect effects via lifestyles (e.g. smoking or obesity) or reproductive behavior (e.g. intercourse frequency and sexual hygiene). Additionally, personality exerts direct biological effects. Personality effects would need to be exerted on processes that occur before the implantation stage of reproduction, namely, follicular maturation and ovulation. It seems reasonable that personality would influence reproductive health via the pathways that mediate the effects of stress, namely, via activation of hypothalamic-pituitary-adrenal axis that regulates the stress response.
For infertility history, the present results showed that 73.3% of explained infertility group received conservative treatment in the form of hormonal therapy for induction of ovulation. The effect of hormonal therapy in developing anxiety and depression is well known and could be a contributing factor causing these disorders. Again 73.3% of the unexplained infertility group underwent IVF treatment. Similar results were reported by Van Den Akker, 2005. The financial burden, exhausting steps and procedures, and feelings of doing the last-resort treatment may contribute to such finding.
Moreover, 20% of explained infertility group and 6.7% of the unexplained infertility group underwent surgical treatment and 6.7% of explained infertility group had both hormonal and surgical treatment, which are considered additional stress factors contributing to the development of anxiety and depression.
The attitude of relatives toward infertile patients was sympathy in 33.3% and aggression in 66.7% of unexplained infertility group versus 46.7% and 53.3%, respectively, in explained infertility group. It could be observed that sympathy increases and aggression decreases as the cause of infertility is revealed, and relatives stop blaming the patient as they start to perceive that her condition is out of her hands. The relatives may also interpret that her condition is God’s will and that nobody could do anything about it. The Egyptian culture is considered a quite religious culture that accepts such a kind of interpretation.
In the present study, although the highest percentage of negative coping capability with stressful life events was among the unexplained infertility group (66.7%) followed by explained infertility group (40%), yet there was no statistical significant difference between them. On the contrary, there was a statistically significant difference between the unexplained infertility group and the control group. Pressure from family, friends, and society contributes to the escalating of distress level and therefore coping to stress in women facing infertility. Infertile individuals may have to deal with the failure of personal, family, and cultural expectations of parenthood, as well as the medical treatment itself that can be rather painful and intrusive. This renders them more prone to depression, shame, and dysfunctional coping strategies, as well as to present less protective psychological functioning characteristics. The highest percentage among the unexplained infertility group may be owing to the burden of continuous searching for the cause of the infertility on the emotion of the infertile females. Similar findings were recorded for coping strategies with infertility stress (Schmidt et al., 2005; Peterson et al., 2006a, 2006b; Lechner et al., 2007).
Higher scores were found in the infertility group when compared with normal controls in the two maladaptive coping styles measured by avoidance and emotional subscales. That is, individuals with an infertility diagnosis seem to cope with life difficulties with high emotional responses and tend to physically and psychologically avoid dealing with problems. It may be that these individuals have more difficulties in regulating their emotions and use avoidance as a defensive strategy to protect themselves from the emotional burden of the infertility experience (Galhardo et al., 2011).
In the present study, marital dissatisfaction designated high frequency among the explained and the unexplained infertility groups regarding CNV, global distress, bad late home atmosphere, affective communication, time spent together, disagreement about finance, sexual dissatisfaction, and family history of distress. This is in contrast to PSC and role orientation, which were statistically insignificant. These findings could be owing to that infertility is commonly experienced as a traumatic crisis, and not only does it have a negative effect on the individual’s sense of self but it also has a profound effect on the integrity of the couple as a healthy unit (Diamond et al., 1999; Daniluk and Trench, 2007).
This may be explained by that partners often find themselves out of synch with one another both emotionally and in their ability to communicate and make decision together effectively owing to feeling of guilt over being the cause of infertility, in addition to the conflicts between couples about high expenses of fertility treatment and hormonal medications.
In contrast, a study (Monga et al., 2004; Schmidt et al., 2005; Galhardo et al., 2011) conducted concerning intimacy showed that infertile couples scored significantly higher in ‘Intimacy Dimensions Scale’ and showed no statistically significant difference in dyadic adjustment in comparison with normal controls. Interestingly, insignificant differences were found in the scales measuring sexual functioning (sexual interest, desire, excitation, lubrication, orgasm, satisfaction, and sexual pain) between the infertile and the control groups. Results of this study suggest that the infertility condition, as well as the medical treatment procedures can function as a cohesion factor within the couple.
Similarly, no significant differences were found between the infertile and the control groups in sexual functioning variables (Ramezanzadeh et al., 2006; Read, 2007). Nonetheless, it is noteworthy that there was a nonsignificant tendency for the infertile couples to score lower in these variables. They hypothesized that these findings may be explained by social desirability.
In the present study, the presence of PMDD seems to predict − with precaution − certain vulnerability or at least sensitivity to psychiatric morbidity among infertile women, as it was statistically significant.
Regarding psychiatric morbidity and stress coping among infertile women, the present results noted that infertile women with negative coping to stressful life events showed high frequency of psychiatric morbidity. Bad coping to stress leads to more distress and therefore to the evolution of psychiatric disorders as anxiety and depression. Similarly, Lechner et al. (2007) found that the concepts of passive coping style and dissatisfaction with social support were positively associated with health complaints, depression, anxiety, and complicated grief. The concept of active coping style was negatively associated with depression, anxiety, and complicated grief (Peterson et al., 2006a, 2006b).
Conclusion and recommendations
It may be concluded that psychiatric aspects associated with infertility are increasingly considered both a determinant and a consequence of fertility problem.
Infertile women in Egypt whether of explained or unexplained cause (being more vulnerable) are at risk of developing mood and anxiety disorders, comorbidities between them, and PMDD in comparison with controls. They are also at threat of marital dissatisfaction in all its aspects including sexual dissatisfaction.
Age, occupation, work hours per day, holidays, financial state, infertility duration, infertility cause, previous treatment, family history of psychiatric disorders, and personality disorders had no relation to psychiatry morbidity among infertile females, but PMDD is a predictive factor among infertile females.
There is a positive relation between bad coping with stressful life events and psychiatric morbidity among infertile women; in contrast, marital satisfaction had no relation with psychiatric morbidity among infertile women.
It is therefore recommended that clinicians offering infertility treatment to their patient should be aware of the high prevalence of psychiatric morbidity. Providing means of psychotherapies for infertile couples such as marital therapy, cognitive behavioral, and group therapies and possible pharmacological interventions is also recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]