https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Anxiety and Depression among Infertile Couples Undergoing Invitro Fertilization Treatment in Erbil City ABSTRACT Background and objectives: Infertility affects millions of couples worldwide and is a ma- jor public health problem. It is identified as a significant psychosocial crisis and a patho- logical state. The most prevalent psychological responses in infertile couples are anxiety and depression. This study aimed to assess the status of anxiety and depression symp- toms in infertile couples attending IVF centers in Erbil City. Methods: A quantitative cross-sectional study was conducted in two private IVF centers for infertility diagnosis and treatment at Sardam and Hawler Private Hospitals in Erbil City, Kurdistan Region, from 1st September 2021 to 1st November 2022. A non- probability (convenience) sampling technique was used on 150 infertile couples. Data were collected through the interview method by using data collection tools including a socio-demographic part and the Hospital Anxiety and Depression (HADS). Results: The results of the present study revealed that 58% of the participants were be- tween the ages of 29-39 years old, and 23.7% of husbands had self- Jobs, whereas wives, (26 %) were housewives, and the highest percentage of husbands and wives (14%) and (15%) graduated from university. The family income of the majority of couples was ≥1000,000IQD per month. The highest proportion 35.7% were married between 6-10 years. Levels of anxiety in wives were (13.3% mild, 16% moderate, and 7.3% severe) compared with (11%, 11%, and 6%) levels of anxiety among husbands. Wives had 17.7% mild,6.3% moderate, and 3.7% severe depression compared with 18%,3%, and 3 % de- pression levels in husbands. Anxiety levels were higher in wives than in husbands but no significant difference was shown for depression. Conclusion: The study found that infertile couples receiving IVF treatment had a higher proportion of anxiety and depression symptoms, which could have negative effects on treatment for couples seeking assisted conception. According to the study, couples' psy- chosocial intervention should be a key component of standard infertility treatments. Keywords: Infertility couples; Anxiety; Depression; In-vitro fertilization. Zhyan Hussein Khdhir; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: zhianhussen859@gmail.com) Abdulqader Hussein Hamad; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 169 Received: 31/08/2022 Accepted: 20/09/2022 Published: 30/11/2023 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:zhianhussen859@gmail.com?subject=zhianhussen859@gmail.com mailto:yousif.omar@hmu.edu.krd?subject=yousif.omar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Infertility is a common and big health prob- lem globally. In 2010, it was assessed that there are 48.5 million infertile couples worldwide. defined by (WHO) as a disease of the reproductive system by the failure to achieve a clinical pregnancy after one year or more of consistent unprotected sexual intercourse [1,2], and it has been found to affect about 10–12% of spouses overall in the world [3]. An organism's natural adap- tive response to stressful or dangerous events is anxiety. The most prevalent men- tal disorders are anxiety disorders, which are equally prevalent across all peoples and cultural groups. When anxiety is more intense or doesn't respond as well to the cause, it is considered pathological and needs to be treated by medical care [8]. Anxiety disorders affect more than 260 mil- lion individuals worldwide (3.6%) of the global population. Between 2005 and 2015, the prevalence of anxiety disorders - in- cluding generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder— increased globally by 14.9%, with the Americas accounting for the majority of this rise. Anxiety disorders are currently the sixth-leading cause of disability. Addi- tionally, more women than men are affect- ed [41].Depression is a widely recognized and serious mental health problem with no current effective treatment, and about one out of every ten individuals globally suffers from depression. Depression may need long-term therapy. They are currently the fourth-leading cause of disability world- wide, and the WHO has determined that in 2020, they will be ranked second after car- diovascular disease. The most severe signs of depression include a depressed mood, decreased activity, loss of interest, and an inability to experience pleasure from joyful events (World Health Organization, 1992). About 5–10% of people experience clinical depression, and today as much as 30% of people experience depressive symptoms at varying intensities throughout their lives [10,42].Infertility can be initiated by a man, a woman, or both of the causes of infertility, 40% can be attributed to men, 40% to women, 10% to both couples and 10% to unknown causes [4]. The inability to conceive a child naturally can lead to feelings of guilt, and shame. These negative feelings may be associated with varying grades of depression, anxiety, distress, and a poor. quality of life, although they dramatically affect the self- esteem and body image of infertile couples, social life, and marriage relationships [5,6]. The use of artificial reproductive technology (ART), including in vitro fertilization (IVF) is one option for people with infertility who wish to become pregnant. Pregnancy loss can cause post- traumatic stress disorder and increased levels of anxiety in women, as well as an increased risk of the spousal relationship dissolving. Studies have also shown that the use of IVF itself has associated physical, psychological, emotional, and financial effects. The prevalence of infertility, as well as the subsequent rates of treatment failure and spontaneous abortion, are widespread problems [7].The first negative emotional reaction to both infertility and assisted reproductive treatment (ART) is frequently either anxiety (a sense of threat, tension, or worry) or depression (a sense of loss, sadness, or lack of control) [10]. The risk of distress, depression, and anxiety is high for infertile couples. Despite the prevalence of infertility, the majority of infertile men and women do not share their stories with people around them (family or friends), thus increasing the susceptibility of their psychological disorders [9]. In our region, most married couples wish to become parents because they believe that 170 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article interviews using data collection tools in- cluding a socio-demographic part, and the Hospital Anxiety and Depression Scale (HADS) by the investigator. The researcher distributed an interview questionnaire among the infertile couples in the centers. During the process of completing the ques- tionnaire, the researcher interviewed illit- erate candidates who had difficulty under- standing the questionnaires. The interview with each client lasted around 25-30 minutes. The questionnaire was composed of two parts. The first part was on the so- cio-demographic characteristics of the study sample. This part was composed of 8 questions regarding (age, gender, occupa- tion and education for both genders, and family income per month. duration of mar- riage, religion, and nationality). The second part was related to assessing infertile cou- ples’ anxiety and depression levels, which were measured through the Hospital Anxi- ety and Depression Scale (HADS) which was used as a scale that was modified by the researcher to organize it according to infertility cases. HADS is a self- administered rating scale composed of 14 items: seven for anxiety and seven for de- pression. Items are rated on a 4-point se- verity scale ranging from 0 to 3. Both anxi- ety and depression can be scored sepa- rately, with each subscale scored from 0 to 21. Higher scores on each subscale indicate a higher level of anxiety and depression [12]. Scores of 0-7 are normal, 8-10 are mild,11-14 are moderate,15-21is severe for both anxiety and depression scales [13].The questionnaires have been validat- ed by a panel of eleven experts to investi- gate the content of the questionnaire for clarity, relevancy, and adequacy. The ex- perts’ responses were evaluated based on their agreements or disagreements. The results showed that the majority of the experts agreed with the items of the ques- tionnaire for the study. Some small childbearing is important for the stability of any couple. Some Kurdish people still be- lieve that infertility is exclusively limited to female causes. Kurdish women often come face to face with questions such as, “Are you married? Do you have a child? Howev- er, if the cause of infertility is diagnosed as due to male factors, marital conflict can increase and couples may become more separated. Psychologically, women lose their motherhood and sense of gender dis- tinctiveness when they cannot conceive, and men are not measured “to be a man” if they do not have a child [11]. A cross-sectional descriptive study was car- ried out in Erbil city of Kurdistan/Iraq. from 1st September 2021 to 1st November 2022. A convenience (non-probability) sample (of 300 infertile husbands and their wives) of either of those diagnosed with infertility and undergoing treatment for infertility at an IVF center was included in the study; they were taken from two pri- vate hospitals; (Sardam and Hawler Private Hospitals). The investigator used a conven- ient sampling method for recruiting the patients and included all infertile couples attending IVF centers (Primary and Second- ary infertile couples), those infertile cou- ples who did not have a history of mental disorders, and the duration of infertility of more than one year. While those couples who were not willing to participate in the study and who suffered from chronic ill- nesses were excluded. A pilot study was carried out on (12) infertile couples. Statis- tical analysis has been done by using relia- bility-testing methods to measure internal consistency and detect the concordance among the items of the scale using the al- pha Cronbach. The reliability coefficient was high (r=0.97) for anxiety and (r=0.68) for depression, such items were statistically adequate. Data was collected through 171 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article changes have been made to the study in- strument according to their recommenda- tion.Before data collection, formal approv- al was obtained from the Ethical Com- mittee at the College of Nursing, Hawler Medical University. Formal permission was also obtained from IVF centers in Hawler and Sardam private hospitals. Further- more, informed oral consent was obtained from the candidate’s participation in the study after confirmation of confidentiality, and anonymity, and participants were withdrawn from the study's self- determination by the researcher. Partici- pants have withdrawn from the study. The statistical package for social science (SPSS, Version 28) was used for data processing and statistical analysis. The statistical anal- ysis included descriptive statistical analysis such as frequency and percentage to de- scribe the basic features of the data in a study and provide simple summaries about the sample and the measures. Inferential statistical analyses such as the Chi-square test and Fisher-Exact test were applied to make a judgment about inferences from our data to more general conditions. The confidence interval was 95%. The P-value of each test of ˂ 0.05 is considered statisti- cally significant. Table 1: shows the socio demographic characteristics of the study sample. This table also shows that 58% of couples were between the age groups of 29-39 years old and ranging from 18 to 50 years old. Re- garding the occupation of the husbands, 23.7% of husbands were self- employed Whereas wives, (26 %) were housewives. 14% of husbands graduated from universi- ty and only 2.3% of them were illiterate. The same trend existed in the wife’s educa- tion as most of them 15% graduated from university and 3% were illiterate. The fami- ly income of the majority of study samples was ≥1000,000IQD per month [44], The highest proportion of couples (35.7%) were married between 6-10 years. 172 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT Table 1: Basic characteristics of the infer- tility couples (n=300) Variables Categories F (%) Gender Male 150(50) Female 150 (50) Age 18 – 28 74 (24.7) 29 – 39 174 (58) ≥40 52 (17.3) Occupation (husbands) Governmental Employed 58 (19.3) Non- Governmental Employed 10 (3.3) Unemployed 6 (2) Self-Job 71(23.7) Student 2 (0.7) No Work 3 (1) Occupation (Wives) Governmental Employed 34(11.3) Non- Governmental Employed 12(4) Unemployed 12(4) Self-Job 7(2.3) Student 7(2.3) Housewife 78(26) Educational level (husbands) Illiterate 7(2.3) Able to read and write 18 (6) Primary school 31(10.3) High School 24 (8) Institution Graduate 16(5.3) University Graduate 42(14) Post Graduate 12(4) Total 300(100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 173 depression levels among husbands and wives,48.3% of total infertile couples were normal. While wives had (mild=17.7%, moderate =6.3%, se- vere=3.7%) depression compared with (mild=18%, moderate=3%, severe=3%) levels of depression of husbands (P- val- ue 0.200). Table 2: Illustrates the comparison of anxi- ety, and depression levels among husbands and wives, 35.3% of the study sample were normal. Wives had (Mild=13.3%, moder- ate=16%, severe=7.3%) levels of anxiety compared with (11%,11%, 6%) of their hus- bands; a significant difference was detect- ed (P- value 0.016). No significant 0.200).association was detected between Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Cont. Table Variables Categories F (%) Educational level (Wives) Illiterate 9(3) Able to read and write 13(4.3) Primary school 35(11.7) High School 27 (9) Institution Graduate 14(4.7) University Graduate 45(15) Post Graduate 7(2.3) The family income per month < 500.000IQD 55(18.3) 500.000 – 749.000IQD 82(27.3) 750.000 – 999.000IQD 28(9.3) ≥1000.000IQD 135(45) Years of marriage 1 – 5 100(33.3) 6 – 10 107(35.7) 11 – 15 75(25) ≥16 18(6) Religion Islam 300(100) Nationality Kurdish 182(60) Arab 118(39.3) Total 300(100) F= Frequency; %= Percentage Table 2: Comparison of the overall level of anxiety, and depression between husbands and wives HADS calcification (score) Male Female Total P-Value No. (%) No. (%) No. (%) Anxiety Normal (0-7) 66 (22) 40 (13.3) 106 (35.3) 0.016 (S) Mild (8-10) 33 (11) 40 (13.3) 73 (24.3) Moderate (11-14) 33 (11) 48 (16) 81 (27) Severe (15-21) 18 (6) 22 (7.3) 40 (13.3) Depression Normal (0-7) 78 (26) 67 (22.3) 145 (48.3) 0.200 (NS) Mild (8-10) 54 (18) 53 (17.7) 107 (35.7) Moderate (11-14) 9 (3) 19 (6.3) 28 (9.3) Severe (15-21) 9 (3) 11 (3.7) 20 (6.7) Total 150 (50) 150 (50) 300 (100) S= Significant levels; NS= non-significant levels; by Chi-Square test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article association betweenthe educational level of both spouses and anxiety level was de- tected (P- value 0.001), Those who gradu- ated from university had a higher level of anxiety. A very highly significant associa- tion was detected between family income and anxiety (P- value 0.001). No significant association was found between anxiety and years of marriage (P- value 0.150). 174 Table 3: Demonstrates the association be- tween Socio-demographic characteristics and level of anxiety. This table showed that no significant association was detect- ed between age (P- value 0.532) and anxi- ety. A significant association was detected between working status and anxiety for both couples(P-0.003), and the highest level of anxiety was shown among house- wife females. And A very highly significant Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3: Association between Socio-demographic characteristics and level of anxiety Anxiety P-Value Variables Categories Normal Mild Moderate Severe No. (%) No. (%) No. (%) No. (%) Age (years) 18 – 28 31 (10.3) 17 (5.7) 17 (5.7) 9 (3) 0.532 (NS) 29 – 39 53 (17.7) 47 (15.7) 50 (16.7) 24 (8) ≥ 40 22 (7.3) 9 (3) 14 (4.7) 7 (2.3) Occupation Governmental Employed 37 (12.3) 21 (7) 22 (7.3) 12 (4) 0.003 (HS) Non- Governmental Employed 13 (4.3) 7 (2.3) 2 (0.7) 0 (0) Unemployed 4 (1.3) 6 (2) 4 (1.3) 4 (1.3) Self-Job 29 (9.7) 18 (6) 20 (6.7) 11 (3.7) Student 4 (1.3) 4 (1.3) 1 (0.3) 0 (0) Housewife 16 (5.3) 17 (5.7) 32 (10.7) 13 (4.3) Non-Workers 3 (1) 0 (0) 0 (0) 0 (0) Educational level Illiterate 0 (0) 1 (0.3) 11 (3.7) 4 (1.3) 0.001 (VHS) Able to read and write 7 (2.3) 6 (2) 11 (3.7) 7 (2.3) Primary school 17 (5.7) 14 (4.7) 25 (8.3) 10 (3.3) High School 22 (7.3) 15 (5) 11 (3.7) 3 (1) Institution Graduate 13 (4.3) 8 (2.7) 2 (0.7) 7 (2.3) University Graduate 36 (12) 24 (8) 19 (6.3) 8 (2.7) Post Graduate 11 (3.7) 5 (1.7) 2 (0.7) 1 (0.3) The family income per month <500,000IQD 9 (3) 10 (3.3) 26 (8.7) 10 (3.3) 0.001 (VHS) 500,000 – 749,000IQD 28 (9.3) 24 (8) 17 (5.7) 13 (4.3) 750,000 – 999,000IQD 7 (2.3) 6 (2) 11 (3.7) 4 (1.3) ≥1000,000 IQD 62 (20.7) 33 (11) 27 (9) 13 (4.3) Years of marriage 1-5 37 (12.3) 28 (9.3) 24 (8) 11 (3.7) 0.150 (NS) 6-10 45 (15) 26 (8.7) 25 (8.3) 11 (3.7) 11-15 19 (6.3) 14 (4.7) 28 (9.3) 14 (4.7) ≥16 5 (1.7) 5 (1.7) 4 (1.3) 4 (1.3) NS= Non significant; HS= Highly significant; VHS= Very Highly Significant. by Chi-Square test and Fisher’s Exact Test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article The majority of infertile couples' family income per month was 1000,000 IQD or more and they had (mild =14.7%, moder- ate = 3.7%, severe =1.3%) levels of depres- sion and levels of depression (mild =8.3%, moderate = 3%, severe =2%) when family income 500,000IQD or less with a lower study sample (P- value 0.015). A significant association was found between depression and the duration of the marriage. The pro- portion was (mild depression =11.3%, moderate depression = 2.7%, and severe depression =3%) when the duration of marriage was between 11-15 years (P- val- ue 0.042). Table 4: Indicates the relationship be- tween the socio demographic characteris- tics of infertile couples and their level of depression. The result shows that a signifi- cant association was detected between depression and the age group 29-39 (P- value 0.004). The level of depression of both spouses with the jobs was significant- ly associated (P- value 0.028). A very highly significant association between depression and the educational level of both couples was detected (P- value 0.001), and levels of depression were higher among primary school and university graduates. The result showed that (mild = 10%, moderate =2.3 %, severe =1.3%) and (mild=12%, moder- ate=1.3%, severe=0.3%). 175 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: Association between Socio-demographic characteristics and level of depression Depression P-Value Variables Categories Normal Mild Moderate Severe No. (%) No. (%) No. (%) No. (%) Age 18 – 28 47 (15.7) 17 (5.7) 9 (3) 1 (0.3) 0.004 (HS) ⸸ 29 – 39 75 (25) 70 (23.3) 17 (5.7) 12 (4) ≥ 40 23 (7.7) 20 (6.7) 2 (0.7) 7 (2.3) Occupation Governmental Employed 44 (14.7) 37 (12.3) 7 (2.3) 4 (1.3) 0.028 (S) ⸸ Non- Governmental Employed 18 (6) 4 (1.3) 0 (0) 0 (0) Unemployed 7 (2.3) 7 (2.3) 3 (1) 1 (0.3) Self-Job 36 (12) 31 (10.3) 4 (1.3) 7 (2.3) Student 5 (1.7) 3 (1) 1 (0.3) 0 (0) Housewife 32 (10.7) 25 (8.3) 13 (4.3) 8 (2.7) Non-Workers 3 (1) 0 (0) 0 (0) 0 (0) Educational level Illiterate 0 (0) 5 (1.7) 5 (1.7) 6 (2) 0.001 (VHS) ⸸ Able to read and write 12 (4) 9 (3) 4 (1.3) 6 (2) Primary school 25 (8.3) 30 (10) 7 (2.3) 4 (1.3) High School 33 (11) 11 (3.7) 6 (2) 1 (0.3) Institution Gradu- ate 14 (4.7) 12 (4) 2 (0.7) 2 (0.7) University Gradu- ate 46 (15.3) 36 (12) 4 (1.3) 1 (0.3) Post Graduate 15 (5) 4 (1.3) 0 (0) 0 (0) The family income per month < 500,000 15 (5) 25 (8.3) 9 (3) 6 (2) 0.015 (S) ⸸ 500,000 – 749,000 43 (14.3) 25 (8.3) 7 (2.3) 7 (2.3) 750,000 – 999,000 11 (3.7) 13 (4.3) 1 (0.3) 3 (1) ≥1000,000 76 (25.3) 44 (14.7) 11 (3.7) 4 (1.3) Years of marriage 1-5 54 (18) 33 (11) 10 (3.3) 3 (1) 0.042 (S) ⸸ 6-10 61 (20.3) 32 (10.7) 8 (2.7) 6 (2) 11-15 24 (8) 34 (11.3) 8 (2.7) 9 (3) ≥16 6 (2) 8 (2.7) 2 (0.7) 2 (0.7) S= Significant level; HS= Highly significant. ⸸ by Chi-Square test.⸸ by Fisher Exact Test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article depression was significantly higher among females as compared to males in contrast with our result [38]. Another study con- ducted on infertile Italian couples refused our result because the level of anxiety and depression among women was significant- ly higher than in men (P- value ˂ 0.0001) [40]. Faramarzi et al. showed that women reported statistically significantly higher levels of anxiety and depression when compared with men, in contrast to the present study [43]. Socio-demographic characteristics of both couples and their association with anxiety and depression levels Age and gender The result of this study revealed that the highest percentage (58%) of the present study samples were between the ages of 29-39 years old, and the lower proportion of the study was between the ages of 40 and more (17.3%). A similar study in Bangladesh on the psychological state of infertile couples revealed that (75.9%) of the study samples were between the ages of 29-38 years old and only (3.9%) of couples aged ≤ 39 years old [15]. It means that people in the age group 29- 39, who are of reproductive age had a higher desire and ability to be preg- nant and to have a child, especially wom- en. Regarding gender, 150 husbands and their wives participated in our study at the same time to assess and compare the rates of anxiety and depression among couples Regarding the association of study sam- ples' age with anxiety and depression lev- els (Table 3), the current study illustrated no significant association between anxiety and age. A similar study was conducted in Iran and found no significant association between anxiety and age [16]. Our result refused by this study conducted on infer- tile women in China demonstrated that the psychopathological symptoms of the infer- tile women were aggravated by advanced age [17].Regarding the relationship be- tween age and depression levels, Compression level of anxiety and depres- sion in Husbands and WivesThe present study found that husbands and their wives had higher anxiety levels; the levels were significantly higher among infertile women compared with men. Anxiety among infertile women: the percentage of those with mild, moderate, and severe anxiety was (13.3%, 16%,7.3%) compared to their husbands, and the percentage of those with mild, moderate, and severe anxiety was (11%, 11%, 6%). Regarding the depression levels among couples, our result shows that depression was higher among women than men but not statisti- cally significant. Among infertile women, the percentages of those with mild, mod- erate, and severe depression were (17.7%,6.3%, and 3.7%) compared with (18%= mild,3% =moderate,3%= severe) levels of depression among men. This study was conducted in China on infertile couples under IVF treatment. Regarding anxiety in women it was demonstrated that women significantly had a higher lev- el of anxiety compared to men (p-value ˂ 0.05), and also about the level of depres- sion, women had more depression than men but it was not statistically signifi- cant;it was similar to our study results [39]. Another supportive study shows that the prevalence rates of anxiety and de- pression were (49.6%) and (33%), respec- tively, and women were 2.26 times more likely to have anxiety symptoms than men, but it disagreed with our results re- garding depression because it revealed that depression was not related to sex [16]. Also, another study conducted in In- dia supports our finding regarding anxiety and found that among 270 consecutive couples’, the prevalence of anxiety was observed in 49.6% of females and 45.6% of males. The difference was statistical- lysignificant. Also, the prevalence of 176 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article occupation among study samples. High lev- els of anxiety and depression were detect- ed among the housewives’ group. An indi- vidual's working status affects both their social and economic lives Women with economic power have much more self- confidence and a sense of control over their lives. However, this study in Turkey carried out on infertile couples discovered that depression ratios in infertile house- wives were higher.It was similar to our re- sult, but anxiety did not have relationship with working status. It was demonstrated that. There were no statistically significant differences between occupation and anxie- ty and depression levels among infertile men, this disagreed with our study results [24]. However, this study in Turkey on in- fertile this women also shows that the ma- jority of the participants were unem- ployed, and found a positive relationship between the employment status of partici- pants receiving infertility treatment with anxiety and depression. Participants who did not have wage-earning employment had higher anxiety and depression than those who had jobs. It was similar to our results [25]. Educational level The highest percent- age of the study participants in this current study graduated from university and only a few of them were illiterate. A descriptive- analytical study conducted in Iran revealed that the majority of the participants had a high level of education (university) (63.92%) which was similar to our result [26]. Although this study carried out in Vi- etnam had the same results as the highest study sample graduated from university [27].Regarding the association between the educational level of couples and the level of anxiety and depression (Table 3,4), a higher percentage of the study sample graduated from university, so the level of anxiety and depression was higher among those groups. Maybe it is related to the our result in (Table 4) demonstrated a highly significant association between de- pression and age, the age group 29-39 years had a higher level of depression be- cause they were closer to menopause in this age group or they also may have been receiving treatment for infertility for a long time, especially in cases of long-term marriage. This supported study in Japan shows a significant association between depression and age; higher depression was detected among patients in their twenties and those in the 35-39, 40, and over age groups. As age increased, partici- pants exhibited a greater tendency toward depression [18]. Another study in Nigeria reported that the age of the respondents is associated with increased psychological distress [19]. Equally, Drosdzol et al re- ported that there is an increased risk of psychiatric disorders (anxiety and depres- sion) in infertile women older than 30 years [20]. On the contrary, Gameiro et al reported that older age was a protective factor against developing mental health problems in individuals undergoing fertility treatment [21]. Occupation Regarding the occupation of the husband, the majority (23.7%) of hus- bands were self-employed and only 1% were non-workers. Whereas the wives (26%) were housewives, and, only 2.3% had self-employed. Similar results were shown in a study conducted in Turkey on infertile couples, in which the researcher revealed that all of the men worked. Meanwhile, the highest percent of the wives were housewives [22]. In contrast, another cross-sectional study conducted on infertile Turkish couples showed that a higher percentage of husbands and wives were self-employed [23].Regarding the relationship between occupation with anx- iety and depression levels (Table 3,4). The finding in this study indicated that anxiety was significantly associated with 177 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article participants had a high level of income [35]. Another supportive study found that infertile females and males’ monthly in- come was significantly associated with a psychiatric disorder [37]. The result of this study in Egypt opposed to our result re- veals that there is a highly significant cor- relation was found between family income and depression, but depression was more observed in low family incomes compared with high ones [45]. Duration of mar- riage, n this study, we demonstrated that the highest percentage of couples (35.7%) were married between (6-10) years. It is similar to a cross-sectional study done by Singh et al in India, (43.3%) of the couples were married between (6-10) years [38]. In contrast to our study, in this study in Nige- ria, the highest percentage of couples’ marriages is equal to or less than 5 years [19].Regarding the relationship between anxiety and depression with the duration of marriage (Table 3,4), in the present study, a significant association was not found between anxiety and the duration of married couples, but according to the rela- tionship between depression and the dura- tion of marriage, we found a significant association. The finding was different from the result of this study conducted by Chen et al. established that there was no signifi- cant association between anxiety, depres- sion, and duration of marriage [14]. Anoth- er study also shows that there was no sta- tistically significant correlation between marriage span, and depression as well be- tween marriage span and anxiety [36]. Religion and nationality A recent study found that all candidates who participated in the study were Muslims. Regarding na- tionality, the highest proportion of them were Kurdish people because the study was carried out in a city in the Kurdistan region of Iraq. Only (39.3%) of the cases were Arabic people. fact that they had graduated from univer- sity but had not been employed or had job opportunities, in public institutions or the private sector. Our result was rejected by this study in Iran. The results demonstrat- ed that the level of educational back- ground had an input on the psychological strains of patients. In general, illiterate couples compared with educated couples, were shown to have the highest rates of both depression and anxiety. Also, severe depression and anxiety were observed in 27% and 22% of illiterate women, respec- tively. These levels were reduced to 4.5% and 0% in women with university educa- tions, respectively [28]. Although numer- ous studies have shown that education levels have a protective impact on depres- sion and anxiety, they revealed that the level of anxiety and depression tends to decrease when the level of education in- creases [29,30,31,32]. The family income per month In the pre- sent study, the highest percentage of in- fertile couples (45%) had one million IQD or more per month, which means that they had high economic status. The results were similar to the study in Iran, (48.3%) of the couples had a high level of income (20.000.000IRRs or more) [34]. In this study in Turkey, the finding in disagree- ment with the present study was that (33.3%) of the study samples had lower categories (equal to or less than 1000TL) [33]. Regarding family income per month (Table 3,4), the current study demonstrat- ed that there was a highly significant asso- ciation between family income and anxiety level and a significant association between family income and depression. The highest percentage 45% of the study sample had a higher level of income. Findings of this study in Pakistan reported by Razzaque et al. similar to the present study stated that monthly income was associated with anxi- ety and depression and most of the 178 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 2021; 15:161. [8] DeMartini J, Patel G, Fancher TL. Generalized anxiety disorder. Annals of internal medi- cine. 2019;2;170(7): ITC49-64. [9] Zaidouni A, Fatima O, Amal B, Siham A, Houyam H, Jalal K, “et al”. Predictors of in- fertility stress among couples diagnosed in a public center for assisted reproductive tech- nology. Journal of Human Reproductive Sci- ences. 2018 ;11(4):376 [10] Gdańska P, Drozdowicz-Jastrzębska E, Grzechocińska B, Radziwon-Zaleska M, Węgrzyn P, Wielgoś M. Anxiety and depres- sion in women undergoing infertility treat- ment. Ginekologia polska. 2017;88(2):109- 12. [11] Mahadeen A, Mansour A, Al Halabi J, Al Ha- bashneh S, Bani Kenana A. Psychosocial well- being of infertile couples in Jordan. EMHJ- Eastern Mediterranean Health Journal. 2018;24(02):169-76. [12] Zigmond, A.S. and Snaith, R.P. The Hospital and Anxiety Scale. Acta Psychiatric Scandina- vica.1983;67(6):361-370. [13] Stern AF. The hospital anxiety and depres- sion scale. Occupational medicine. 2014 ;1;64(5):393-4. [14] Chen TH, Chang SP, Tsai CF, Juang KD. Prev- alence of depressive and anxiety disorders in an assisted reproductive technique clinic. Human reproduction. 2004; 1;19(10):2313-8. [15] Irfan SN, Rahman MM, Mithun S, Arafat SY, Zafreen F. Psychological State of Selected Infertile Couples of Bangladesh. Journal of Armed Forces Medical College, Bangladesh. 2018;14(1):41-5. [16] Maroufizadeh S, Ghaheri A, Almasi-Hashiani A, Mohammadi M, Navid B, Ezabadi Z,” et al”. The prevalence of anxiety and depres- sion among people with infertility referring to Royan Institute in Tehran, Iran: A cross- sectional questionnaire study. Middle East Fertility Society Journal. 2018; 1;23(2):103-6. [17] Wang K, Li J, Zhang JX, Zhang L, Yu J, Jiang P. Psychological characteristics and marital quality of infertile women registered for in vitro fertilization-intracytoplasmic sperm injection in China. Fertility and. Fertility and sterility.2007;87(4), pp.792-798. [18] Ogawa M, Takamatsu K, Horiguchi F. Evalua- tion of factors associated with the anxiety and depression of female infertility patients. BioPsychoSocial medicine. 2011 ;5(1):1-5. [19] Omoaregba JO, James BO, Lawani AO, Mo- rakinyo O. Psychosocial characteristics of The study found that infertile couples re- ceiving IVF therapy had greater rates of anxiety and depression, which could in- crease the treatment burden for couples seeking assisted conception. According to the study, couples' psychosocial interven- tion should be a key component of stand- ard infertility treatments and play a signifi- cant part in them. There are no conflicts of interest or sources of financial support for any of the authors. [1] Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, region- al, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS medicine. 2012;18;9 (12): e1001356. [2] Elhussein OG, Ahmed MA, Suliman SO, Ad- am I. Epidemiology of infertility and charac- teristics of infertile couples requesting as- sisted reproduction in a low-resource setting in Africa, Sudan. Fertility research and prac- tice. 2019 ;5(1):1-5. [3] Cui C, Wang L, Wang X. Effects of self- esteem on the associations between infertil- ity-related stress and psychological distress among infertile chinese women: a cross- sectional study. Psychology Research and Behavior Management. 2021; 14:1245. [4] Luk BH, Loke AY. The impact of infertility on the psychological well-being, marital rela- tionships, sexual relationships, and quality of life of couples: A systematic review. Jour- nal of sex & marital therapy. 2015; 2;41 (6):610-25. [5] Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues in clinical neuroscience. 2022; 1. [6] Çavdar NK, Coskun AM. The effect of infer- tility upon quality of life and self-esteem. MedCrave Online Journal of Women's Health. 2018;7(3):89-94. [7] Forgie M. Exploring Women's Experiences of Infertility, Reproductive Loss, and Grief (Doctoral dissertation, Université d'Ottawa/University of Ottawa). 179 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION CONFLICT OF INTEREST REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article [30] Benbella A, Ktiri F, Kasouati J, Aboulmakarim S, Hardizi H, Zaidouni A. Depression and Anx- iety Among Infertile Moroccan Women: A Cross-Sectional Study in the Reproductive Health Center in Rabat. Journal of Depres- sion and Anxiety. 2018;7(312):2167-1044. [31] Verma P, Rastogi R, Sachdeva S, Gandhi R, Kapoor R, Sachdeva S. Psychiatric morbidity in infertility patients in a tertiary care setup. Journal of clinical and diagnostic research: JCDR. 2015;9(9):VC01. [32] Maroufizadeh S, Karimi E, Vesali S, Samani RO. Anxiety and depression after failure of assisted reproductive treatment among pa- tients experiencing infertility. International Journal of Gynecology & Obstetrics. 2015;1;130(3):253-6. [33] Güleç G, Hassa H, YALÇIN EG, Yenilmez C. The effects of infertility on sexual functions and dyadic adjustment in couples that pre- sent for infertility treatment. Turk Psikiyatri Dergisi. 2011; 1;22(3):166. [34] Bakhtiar K, Ardalan A, Ebrahimzadeh F, Al- masian M, Bastami F. Depression Severity and Sexual Satisfaction in Fertile and Infer- tile Women in Iran: A Population-Based Case -Control Study. Jundishapur Journal of Health Sciences. 2022; 31;14(1). [35] Razzaque MA, Ali A, Ahmed W, Hussain S, Wahid A, Razzaque A. Assessment of the Level of Depression, Anxiety, Stress among Infertile Women (20-45 Years Age) in Ter- tiary Care Hospital. Journal of Liaquat Uni- versity of Medical & Health Sciences. 2021;20(5):358-62. [36] Yassa M, Arslan E, GULBAHAR DS. Effects of infertility treatment on anxiety and depres- sion levels. Cukurova Medical Journal. 2019;44(2):410-5. [37] Alosaimi FD, Altuwirqi MH, Bukhari M, Abo- talib Z, BinSaleh S. Psychiatric disorders among infertile men and women attending three infertility clinics in Riyadh, Saudi Ara- bia. Annals of Saudi medicine. 2015;35 (5):359-67. [38] Singh V, Bhirud YR, Lele P, Bhagasra S. A study to screen infertile couples for psycho- logical problems by using the perceived stress scale, brief COPE scale and hospital anxiety and depression scale. International Journal of Research in Medical Sciences. 2021 ;9(3):750. [39] Liu YF, Fu Z, Chen SW, He XP, Fan LY. The analysis of anxiety and depression in differ- ent stages of in vitro fertilization-embryo female infertility in a tertiary health institu- tion in Nigeria. Annals of African Medicine. 2011;10(1). [20] Drosdzol A, Skrzypulec V. Depression and anxiety among Polish infertile couples–an evaluative prevalence study. Journal of Psy- chosomatic Obstetrics & Gynecology. 2009; 1;30(1):11-20. [21] Gameiro, S., van den Belt-Dusebout, A.W., Bleiker, E., Braat, D., van Leeuwen, F.E. and Verhaak, C.M. Do children make you happi- er? Sustained child-wish and mental health in women 11–17 years after fertility treat- ment. Human Reproduction. 2014; 29(10), pp.2238-2246. [22] Yilmaz T, Oskay UY. The Evaluation of Meth- ods Used to Cope with Infertility Stress of Infertile Couples in Turkey. International Journal of Caring Sciences. 2017 Sep 1;10(3). [23] Erdem K, Apay SE. A sectional study: the relationship between perceived social sup- port and depression in Turkish infertile women. International journal of fertility & sterility. 2014 ;8(3):303. [24] Kazandi M, Gunday O, Mermer TK, Erturk N, Ozkınay E. The status of depression and anx- iety in infertile Turkish couples. Iranian jour- nal of reproductive medicine. 2011;9(2):99. [25] Kamışlı S, Terzioğlu C, Bozdağ G. The psy- chological health of women with infertility: Hopelessness, anxiety and depression levels. Journal of Psychiatric Nursing. 2021;12(1):43 -9. [26] Karimzadeh M, Salsabili N, Asbagh FA, Teymouri R, Pourmand G, Naeini TS. Psycho- logical disorders among Iranian infertile cou- ples undergoing assisted reproductive tech- nology (ART). Iranian Journal of Public Health. 2017;46(3):333. [27] Ho TT, Le MT, Truong QV, Nguyen VQ, Cao NT. Psychological burden in couples with infertility and its association with sexual dysfunction. Sexuality and Disability. 2020 ;38(1):123-33. [28] YASINI M, Khalili MA, Hashemian Z. The lev- el of anxiety and depression among Iranian infertile couples undergoing in vitro fertiliza- tion or intra cytoplasmic sperm injection cycles. Journal of Research in Medical Sci- ences .2005;10(6):358-62 [29] Pinar G, Zeyneloglu HB. Quality of life, anxi- ety and depression in turkish women prior to receiving assisted reproductive tech- niques. International journal of fertility & sterility. 2012 ;6(1):1. 180 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article transfer in couples in China. Neuropsychiat- ric Disease and Treatment. 2021; 17:649. [40] Chiaffarino F, Baldini MP, Scarduelli C, Bom- marito F, Ambrosio S, D’Orsi C, “et al”. Prev- alence and incidence of depressive and anx- ious symptoms in couples undergoing assist- ed reproductive treatment in an Italian in- fertility department. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2011;1;158(2):235-41. [41] Friedrich MJ. Depression is the leading cause of disability around the world. Journal of American Medical Association. 2017; 18;317(15):1517-. [42] Vaioleti T. Talanoa: Differentiating the ta- lanoa research methodology from phenom- enology, narrative, Kaupapa Maori and fem- inist methodologies. Reo, Te. 2013 ; 56:191- 212. [43] Faramarzi M, Pasha H, Esmaelzadeh S, Jor- sarai G, Mir MRA, Abedi S. Is coping strate- gies predictor of anxiety and depression in couple infertile? Health;2013; 5(3): pp. 643– 9. [44] KRSO, IOM, UNFPA. The Demographic Sur- vey of the Kurdistan Region of Iraq .2018. Available from: https://krso.gov.krd/en/ pressreleases/demographic-survey-of-the- kurdistan-region-of-iraq-press-release. [45] Hassan HE, Hassan SE, Mohammed A, Baraka MA. A survey of relationship be- tween duration of infertility and depression among infertile women in BeniSuef Gover- norate. IJSR. 2013;4:1169-77. 181 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/