JIIMS final


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ORIGINAL ARTICLE

Introduction
Infertility is defined as failure to conceive

after a year of regular intercourse without

contraception. Infertility is the major life

crisis particularly in our society. It comes as

a severe shock to couples who have

probably taken their fertility for granted. It

cannot be denied that infertility is a deeply
1distressing experience for many couples.

Couples suffering from infertility have a

tough time admitting that they have a

problem as they feel that they have failed in

their basic role of reproduction. When they

are not successful in treatments they feel that
2they and their marriage is a failure. This life

crisis can lead to many emotional and

psychological reactions. It presents them

with one of their first major crises together.

It may affect the couple's inter-personal

relationships, marital, social and sexual

aspects of life.

Infertility can cause depression, anxiety,
3, 4social isolation and sexual dysfunction.

That is why the impact of infertility on the

psychological well being of couples has been

the object of increasing attention in recent

y e a r m a n y s t u d i e s h a v e r e p o r t e d

psychological symptoms and problems in

infertile couples. These psychological

symptoms can be the cause of infertility or

the consequence of it or both. A study found

that infertility has a significant effect on

psychological health of couples. They suffer

from loss of self-esteem, sadness of mood,

fear, sexual dysfunction, depression, guilt,
5anxiety, frustration, emotional distress.

A m o n g t h e p s y c h o l o g i c a l p r o b l e m

depression, anxiety and stress are most

ABSTRACT

Objective: To assess psychological morbidity amongst infertile couples.
Study Design: Cross-Sectional study.
Place and Duration of Study: This study was carried out at MAS Infertility Clinic, Rawalpindi from August 2010
to January 2011.
Materials & Methods: A total of 30 subjects (15 couples) were included in the study. After taking an informed
consent, they were asked to complete a questionnaire. Depression, Anxiety and Stress Scale (DASS)
questionnaire was used for this study. Data was analyzed using SPSS version-14 and t-test was applied to see
the significance in differences.
Results: Majority of couples were over 30 years of age and were married for more than 5 years. Vast majority
(73.3%) were living in joint family system. Psychological morbidity, particularly anxiety and depression affected
significantly (p=0.05) female partner. However no significant relationship was observed between the cause of
infertility or duration of infertility and psychological manifestations.
Conclusion: This study presents pragmatic evidence regarding the psychological health of infertile couples in
our society.  Findings suggest that high levels of stress and depression exist in these couples, which not only
affects their physical health, but also their psychological well being. It highlights the importance of providing
psychotherapeutic help along with treatment for the cause of infertility.

Key Words: Infertility, Infertile couple, Psychological morbidity, Depression, Anxiety and Stress

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Psychological Morbidity amongst Infertile Couples
Shazia Ali, Fazaila Sabih, Farah Rashid, Sarwat Jehan, Masood Anwar

Correspondence:

Dr. Shazia Ali

Department of Physiology

Islamic International Medical College, Peshawar

Road, Rawalpindi

e-mail: alishazia259@gmail.com

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commonly reported. Several studies have

demonstrated that anxiety has a detrimental
6effect on fertility. and the reduction of

7,8anxiety increases pregnancy rate. Men and

women with infertility experience poor self

esteem and loss of physical potency and

feeling of stigma in the society, which

ultimately leads to elevated distress and
9great difficulties for the couple. Different

tools used for measurement of depression,

anxiety and stress include Depression
10,11Anxiety Stress Scale (DASS). BECK

1 2D e p r e s s i o n I n v e n t o r y ( B D I ) . a n d
13Symptom Check List (SCL-90-R).

Eventually these all yield comparable
11, 12, & 13results. We have used, in this study

DASS for the reason of convenience and

simplicity. The present study focuses on the

psychological morbidity of Pakistani

couples attending an infertility clinic. The

Depression Anxiety Stress Scale (DASS) is

used to assess psychological morbidity

which is increasingly used in diverse clinical

settings.

This was a cross-sectional study of

psychological morbidity in infertile couples

attending MAS Infertility Clinic in

Rawalpindi, from August 2010 to January

2011. All infertile couples attending MAS

infertility clinic for the first time were asked

to participate in this prospective, cross

sectional study. Thirty patients (15 women,

15 men) were entered into the study. The

couples were asked, after informed consent 

to complete the questionnaire separately in

the clinic. The Depression Anxiety Stress

Scale (DASS) questionnaire was used for the
11study.

Materials and Methods

Study Measures

Results

The psychological morbidity was assessed

using the Depression Anxiety Stress Scale
11(DASS). The Depression Anxiety Stress

Scale (DASS) is a 42-item self-report

measure of anxiety, depression and stress

which is increasingly used in diverse

settings. The DASS has three sub-scales i.e.

Depression, Anxiety and Stress. Each of the 

three DASS scales contains 14 items and

scores on each subscale range from zero to 3

indicating did not apply to me at all to

applied to me very much. The alpha

reliability of the instrument for this study

was 93, which is highly significant. Patients'

demographic and clinical characteristics

were also recorded on history taking

proforma. Data were analyzed through

SPSS-14 by applying different statistical

tests. Student t- test was used to measure the

significances.

A total of 30 subjects, 15 male & 15 female (15

couples) were included in the study. Age of

the couples ranged from 25-30 years in 11,

31-35 years in 13 and more than 35 years in 6

subjects. Only 8(26.7%) were living

independently while 22(73.3%) were living

in joint family system. Eight (26.7%) couples

were married for more than 10 years, ten

(33.3%) for 6-10 years and 12 (40%) for up to

5 years. In majority (73.3%) both male and

female factors were identified as the cause of

infertility. Female factor alone was

responsible in 6(20%) females and no cause

of infertility could be determined in 2(6.7%)

couples. Majority (28/30) of the subjects

w e r e f o u n d t o h a v e p s y c h o l o g i c a l

morbidity. However, manifestations were

moderate in most (53.3%) of them. Anxiety

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and depression was observed in all affected

(93.3%) subjects where is stress was seen in

86.6%. All three were seen in 66.7%. Details 

are shown in Figure 1. Significant gender

differences were observed. DASS total score

was significantly (p=0.05) higher in females

and so, were the manifestations of anxiety

and depression. Details are shown in table-I.

No significant relationship was observed

between the cause of infertility and

psychological manifestations in either of the

gender (Table-II). There was also no

significant relationship between the

duration of infertility and psychological

morbidity in both sexes (Table-III).

This study investigated psychological

m o r b i d i t y a m o n g i n f e r t i l e c o u p l e s

attending infertility clinic. We observed that

93.3% of infertile couples suffered from

different levels of depression anxiety and

stress (Figure-1). In the present study the

psychological morbidity was assessed using

the Depression Anxiety Stress Scale
11(DASS). It is reported by Siebel and

Taymor using BECK Depression Inventory
1 2( B D I ) . t h a t o v e r a l l p e r c e n t a g e o f

psychological problems in infertile couples
12range between 25 and 60%. Another study

carried out by Downey J using Symptom

Check List (SCL-90-R) demonstrated that

74.6% patients reported changes in their
1 3m o o d . P r e v a l e n c e P s y c h o l o g i c a l

morbidity appears to be much higher in our

society. This may be the result specific

religious and cultural effects. Psychological

difficulties of infertile patients are complex

and influenced by a number of factors such

as gender differences, cause and length of

infertility. Risk factors that predispose an

Discussion

individual to anxiety and depression during

infertility are being female, age over 30,

l o w e r l e v e l o f e d u c a t i o n , l a c k o f

occupational activity, a male cause for

infertility, and infertility for 3-6 years.

Duration of infertility also affects the

psychological state of the couple as 2-3 years

infertility had more depression / anxiety

than those couples who suffer from
14, 15infertility for more than 6 years. We also

observed that it was female gender which

was affected more. In our study there was

also no significant relationship between the 

duration of infertility and psychological

morbidity in both sexes Similar results have
16,17,18also been reported by many others.

One reason for such findings is due to the

fact that usually women are more

vulnerable to psychological problems. In

our society women especially get more

stigmatized regardless of the diagnosis of

infertility and they carry more burden of

being labeled as infertile from all sections of

society. It causes more distress and decline

in health-related quality of life amongst
19,20infertile females. In various studies it is

observed that when the male partner is

responsible for infertility in the couple the

reaction of the male partner is very different

from the couple in which the diagnosis was 

female, mixed or unexplained infertility.

This was not observed in our study. This

may be because in our study in majority

there was a male as well a female cause for

infertility. Therefore, our study analysis

showed that no significant differences in the

psychological morbidity when aspects of

duration of infertility and causes of

infertility (Table II, III) were considered.

These results are in line with previous
21studies. A possible explanation might be

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that the infertility leads to similar

experiences by all men and women

although they might express themselves in

different ways. In the light of above we

recommend that more attention should be

given to health education and awareness

about reproductive health for male and

female both. Couples should be advised to

seek treatment early and should receive

proper counseling and psycho-education.

1. Guerra D, Liobra A, Veiga A, Barri PN.
Psychiatric morbidity in couples attending a
fertility service.Hum Reprod, 1998; 13:1733-36.

2. H. Holter , L. Anderheim, C. Bergh1 and A.
Möller2 The psychological influence of gender
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IVF or ICSI treatment using their own sperm.
2007; 2559-65.

3. Fassino S, Piero A, Boggio S, Piccioni V, Garzaro
L. Anxiety, depression and anger suppression in
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4. Chen TH, Chang SP, Tsai CF, Juang KD.
Prevalence of depressive and anxiety disorders
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Hum Reprod. 2004; 19:2313-18.

5. Edelmann RG, Connolly KJ. Psychological
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6. Demyttenaere K, Nijs P, Steeno O, Koninckx PR,
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11. Lovibond S H & Lovibond P F Manual for the
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References

Figure 1:  Levels of Depression, Anxiety
and Stress Amongst Infertile Couples

Table-I: Mean, SD and t-value of Infertile
Couples (Male and Female) on the total scores
of DASS and its Subscales (N = 30)

Table-II: Mean, SD and t-value of Causes of
Infertility on the Scores on the total scores of
DASS and its Subscales (N = 28)

Table-III: Mean, SD and t-value of Duration of
Infertility on the total scores of DASS
and its Subscales (N = 30)

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