Women infertility and common mental disorders: A cross-sectional study from North India.

According to the World Health Organisation “Infertility is a condition of the male or female reproductive system described by the inability to conceive after 12 months or more of unprotected sexual activity” [ 1 ]. Infertility is a chronic struggle for couples and it affects about 10 to 12% of couples worldwide [ 2 ]. Infertility in women can be caused by many different factors such as a damaged or blocked fallopian tube, endometriosis, PCOS, and hormonal imbalance [ 3 ]. It may work as a painful emotional experience and cause a lot of psychological issues or mental disorders such as stress, anxiety, depression, diminished self-esteem, and reduced quality of life [ 4 ]. Studies revealed that most infertile women were found to have higher levels of stress, anxiety, and depression [ 5 , 6 ], and these disorders were found to be more associated with infertility as compared to other mental disorders [ 7 ]. Stress is a physical and emotional reaction that people have when they are confronted with life upheavals. Long time stress can cause a variety of health concerns including depression, anxiety, and other mental illnesses [ 8 ]. The association between stress and infertility has been debated for years [ 4 ]. Stress can affect fertility in women by suppressing luteinizing hormone, increasing serum cortisol levels preventing implantation of a fertilized egg, and reducing egg quality [ 9 ]. If the stress is continued and prolonged it can result in anxiety and depression [ 6 ]. Anxiety and depressive disorders are bidirectional risk factors for one another [ 10 ]. Various studies concluded that anxiety leads to depression and thus it is a unidirectional phenomenon [ 11 – 13 ], whereas others reported that depression also led to anxiety suggesting its bidirectional mechanism [ 14 , 15 ]. A Study by Magalhaes et al. (2010) has revealed that the corticotropin-releasing factor receptor 1(CRFR1) and serotonin receptor (5-HTR) are related to anxiety and depression respectively. CRFR1 works to increase the number of 5-HTRs on the cell surface in the brain, which can cause abnormal brain signaling [ 16 ]. Since CRFR1 activation leads to anxiety in response to stress and 5-HTRs leads to depression. hence, one can assume that biological stress leads to anxiety which in turn leads to depression. The relationship between psychological factors (stress, anxiety, and depression) and infertility is rather complex, multifactorial, and bidirectional [ 17 ]. Thus, the present study aims to capture the prevalence of stress, depression, and anxiety among infertile and fertile women and to understand the relationship of psychological variables with each other. Attempt was also made to understand the effect of socio-demographic variables, reproductive trajectories, and lifestyle variables on stress, depression, and anxiety.

The median scores compared between the fertile and infertile women revealed that the median levels of stress and anxiety were significantly higher among infertile women as compared to that of fertile women (p0.05) ( Table 1 ). IQR- Interquartile range, Level of significance p<0.0.05 The infertile and fertile women were compared in terms of stress, anxiety, and depression with reference to distribution of frequency, which revealed that the individuals with high stress, anxiety, and depression were found to be significantly higher among the infertile women as compared to fertile women (p<0.05) ( Table 2 ). N is the sample size, Level of significance p<0.05 Further, the difference between non-stressed (low stress) and stressed (medium and high stress), anxious (moderately severe and severe anxiety) and non-anxious (mild and moderate anxiety), and depressed (mild, moderate, moderately severe, and severe depression) and non-depressed (normal) women were compared with respect to demographic, lifestyle variables, and reproductive trajectories, independently in both infertile and fertile women. The duration of infertility and possible causes of infertility in low versus highly stressed, anxious, and depressed infertile women were also compared (Tables 3 – 5 ). N = number of individuals, Level of significance p < 0.05. * Uterine infection, Salpingectomy and Tubal surgery N = number of individuals, Level of significance p < 0.05. * Uterine infection, Salpingectomy and Tubal surgery. N = number of individuals, Level of significance p < 0.05. * Uterine infection, Salpingectomy and Tubal surgery. The results indicate that infertile women whose husbands were having private jobs or were daily wage earners were found to be more stressed as compared to those who were unemployed or were either having government jobs or their own business (p = 0.001). The infertile women who rarely exercised were observed to be more stressed as compared to those who exercised frequently (p = 0.006). The women who had infrequent intercourse during the fertile period were found to be more stressed in comparison to those who had frequent intercourse during the fertile period among the infertile as well as fertile women category (p = 0.01). In the case of fertile women, those who were extremely active were found to be more stressed as compared to those who were less active or not active at all (p = 0.003). Among the infertile women, those who were illiterate or were having primary education were found to be more anxious as compared to those who had higher education (p = 0.03). The infertile women who were slightly active or not active were more anxious as compared to those who were extremely or moderately active (p = 0.003). The infertile women who got married before the age of 18 years were found to be more anxious as compared to those who got married after 18 years of age (p = 0.02). The women who were infertile for more than 5 years were found to be more anxious in comparison to those who were infertile for less than 5 years (p = 0.02). Among the fertile women, those women who were below 25 years of age were found to be more anxious in comparison to those who were older than 25 years (p = 0.007). The women who were having disturbed menstruation were found to be more anxious as compared to those having regular menses (p = 0.000). The fertile women who were having heavy bleeding during menstruation were found to be more anxious compared to those who were either having less bleeding or were having normal bleeding during menstruation (p = 0.04). Among the infertile women, those who never exercised were found to be more depressed as compared to those who sometimes or often exercised (p = 0.008). The infertile women who were taking more than 8 hours of sleep were more depressed as compared to those who were taking less than 8 hours of sleep (p = 0.009). The women having less bleeding during menstruation were found to be more depressed as compared to those who were having heavy bleeding during menstruation in the infertile category (p = 0.00). In the case of fertile women, those who were living in a joint family were more depressed as compared to those living in a nuclear family (p = 0.009). The fertile women who sometimes exercised were more depressed as compared to those who never exercised or exercised regularly (p = 0.01). Those fertile women who were taking more than 7 hours of sleep daily were more depressed as compared to those taking below 7 hours of sleep (p = 0.001). Among the fertile women, those who got married early i.e., before 18 years of age were observed to be more depressed as compared to those who got married after 18 years of age (p = 0.005). Lastly, the fertile women who were having normal bleeding during menstruation were found to be more depressed as compared to those having less or heavy bleeding (p = 0.03). Further, many other variables were similarly distributed among depressed and non-depressed women in both infertile and fertile category i.e., among the infertile women, those who were below 25 years of age, those who were illiterate, those who were living in a joint family, those husbands were having private jobs, those belonging to upper lower socioeconomic status, those who were slightly active or were not active at all, women whose age at menarche was 13–16 years, those who had disturbed menstruation, those who got married before 18 years of age, those who took birth control pills in the past and those having irregular menstruation and other reasons as their possible causes of infertility were more depressed as compared to other subgroups of the respective variables (p> 0.05). Linear regression was performed to understand the association between various demographic variables, lifestyle variables, and reproductive trajectories which were significantly different between stress and non-stressed, anxious and non-anxious, and depressed and non-depressed fertile and infertile women. The results revealed that the infertile women who had intercourse infrequent (sometimes) during the fertile period had significantly increased stress by 2.14 times (p = 0.01) whereas the stress is significantly increased by 0.49 times among fertile women due to extreme physical activity(p = 0.01). Regarding anxiety, women who are infertile for 6–10 years showed a significant increase in anxiety by 2.10 times (p = 0.003). Heavy bleeding during menstruation increased anxiety by 0.60 times among fertile women (p = 0.04) whereas, less bleeding during menstruation significantly increased depression by 1.21 times among infertile women (p = 0.005). Infrequent (sometimes) intercourse during the fertile period showed a mild decrease in depression among fertile women (p = 0.04) ( Table 6 ). Finally, linear regression was performed to understand the association between stress and other psychological variables, i.e., Depression and Anxiety, which revealed that among the infertile women, a unit change in stress significantly increased depression by 0.14 times (p = 0.001) and anxiety by 0.10 times (p = 0.02). Whereas, among the fertile women, a unit change in stress significantly increases depression by 0.15 times.(0.001) ( Table 7 ).

The infertile women attending gynecology OPD for treatment need to be counseled regarding reproductive trajectories mainly in terms of less bleeding during menstruation and infrequent intercourse during the fertile period. There is a need to strengthen the infrastructure to educate and eradicate the myths around infertility by providing necessary guidance and counseling to both husbands and wives and incorporating mental health screening and treatment in the routine care of infertile women in India. We should try to build an ecosystem where women are encouraged to start discussing infertility-related issues and concerns openly without any apprehensions.

The present study is a part of a Project titled “Infertility and its psychological impact: A case-control study from North India” funded by the National Commission for Women of India, Government of India. Data was collected from 500 females, including 250 infertile and 250 age-matched fertile married women with the age group of 22–35 years from August 2020 to February 2021 after obtaining the ethical clearance from the Department of Anthropology and Lady Hardinge Medical college & its associated Hospital, New Delhi. After taking a written informed consent the data of infertile women was collected from the Gynaecology Outpatient Department (OPD) of Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, and data of fertile women was collected using a household survey in Delhi. The inclusion criteria for infertile women were women seeking infertility treatment and belonging to North India. The inclusion criteria for fertile women were women of the same reproductive age, with successful pregnancy outcomes having children older than one year and also belonging to North India. A pretested modified interview schedule was used to collect data pertaining to demographic variables (age, educational status, occupational status, social-economic status [ 18 ] and family structure), lifestyle variables (sleep pattern, physical activity, exercise), and reproductive trajectories (age at menarche, age at marriage, bleeding during menstruation duration of infertility, adoption of birth control pills, intercourse during fertile period, possible causes of infertility). The psychological tools like Perceived Stress Scale (PSS), Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) were used to collect the data pertaining to stress, anxiety, and depression, respectively. In the present study, as the distribution of data was found to be skewed, so median scores of all psychological variables were considered and Mann- Whitney test was performed to compare the groups. Further, Pearson’s chi-square test was used to compare the distribution of stress, anxiety, and depression among infertile and fertile women. In order to identify the causes of stress, anxiety, and depression among infertile and fertile women linear regression analysis was done. Data analysis was performed with the statistical software SPSS, IBM version 24, and the significance level for all the data was <0.05.