Effect of Anxiety and Depression on the Outcome of Infertility Treatment Among Women in Sudan: a Multi Center Cross-sectional Study

Effect of Anxiety and Depression on the Outcome of Infertility Treatment Among Women in Sudan: a Multi Center Cross-sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Anxiety and Depression on the Outcome of Infertility Treatment Among Women in Sudan: a Multi Center Cross-sectional Study Hadeel Mohamed Muaid Abdelseid, Hiba Yousif Merghani Awadallah, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3852664/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and objectives: Infertility and its treatment have been linked to psychological distress, and many couples experience significant stress throughout treatment cycles that might affect their relationship. An Ethiopian study indicated that the incidence of infertility-related stress was 92.7% in 2022, which is concerning for couples seeking therapy as they believe that stress may have an impact on the success of their treatment. The purpose of this study was to investigate the effect of the psychological burden on the treatment outcome of infertility among Sudanese women in Khartoum state. Methods: The study was performed at 4 infertility treatment centers in Khartoum State. Data were collected using an interviewer-structured Hamilton anxiety rating scale (HAM-A) for assessment of anxiety level and Beck's depression inventory (BDI) for depression, considering some demographic variables (age, occupation, duration of marriage, annual income, and pregnancy test results). Women who sought infertility treatment were recruited and consented to participate in the study. Results: One hundred fifty-eight participants were interviewed, majority aged between 31–35 years and 36–40 years of age, with a percentage of 27.2% and 22.2% respectively. Most of the participants (53.8%) were housewives and 85.4% of their annual income was from moderate socio-economical level. Primary infertility causes were found in 57.0% with 36.7% due to male factors, 24.1% due to female factors, only 13.3% due to combined causes, and 25.9% unexplained. No significant association was found between pregnancy tests and other women's demographics and social characteristics, except for the annual income (p = 0.046). According to BDI, severe depression was found in 13.3% and 8.2% of severe anxiety reported according to Hamilton. However, both anxiety and depression scales had no significant statistical association between pregnant and non-pregnant women (p = 0.462 and p = 0.059, respectively) Conclusion: Women who faced psychological stress in terms of anxiety or depression do not have a diminished chance to have a baby; however, further research must be done on a larger scale. Infertility psychological stress ART IVF depression anxiety Figures Figure 1 Background A person's ability to reproduce is impaired by infertility, which is a condition that results in disability because it negatively impacts functioning. Infertility is characterized by the failure to establish a clinical pregnancy after 12 months despite regular, unprotected sexual intercourse. Fertility is defined as the capacity to establish clinical pregnancy; its interventions can be initiated in less than 1 year according to the medical, sexual, and reproductive history, age, physical findings, and diagnostic testing( 1 ). One of these interventions is in vitro fertilization (IVF), which is defined as a series of techniques involving extracorporeal fertilization of gametes, such as traditional in vitro insemination and intra-cytoplasmic sperm injection (ICSI)( 1 )( 2 ). Ovulation induction (OI) and intrauterine insemination (IUI) are additional infertility treatment techniques. Mature eggs are removed from ovaries during IVF and fertilized in a lab by sperm. The fertilized egg (or eggs) is/are then transferred to a uterus. IVF cycles are completed in roughly three weeks. If you or your spouse have endometriosis, uterine fibroids, previous tubal sterilization or removal, decreased sperm production or function, unexplained infertility, or a genetic disease, IVF may be a possibility for treatment( 3 ). Couples may face significant difficulties after receiving the diagnosis of infertility; many patients who visit large IVF clinics develop depressive symptoms. Infertility has been linked to stress, sadness, and anxiety previously( 4 )( 5 ). Moreover, women undergoing IVF therapy frequently experience anxiety and depression due to their infertility as well as the uncertainty of the procedure( 6 ). Epidemiological evidence points to a connection between emotional issues and infertility. In addition, the influence of psychological factors on the success of IVF should be determined in order to provide the couples considering treatment with the required adjuvant psychosocial therapy. Failing infertility treatment has no doubt associated with a negative psychological impact and deterioration of emotional well-being( 7 )( 8 ). Infertility treatment-associated anxiety and depression are major stressors before and during the procedure, their effect on the outcome of IVF has been a concern for many researchers, and the true impact of these stressors on the pregnancy outcome differences between these studies, some reviews of recent literature will be discussed below: Validated psychometric questionnaires were used to measure baseline depression, infertility-related stress, anxiety state, and trait levels in the studies. The questions were designed to assess stress, depression, and anxiety symptoms, participants who experienced certain thresholds were considered at risk of clinical depression or clinical anxiety, this is what was meant to be measured as an effect on IVF outcomes. In a prospective cohort study conducted in Kazakhstani public assisted reproductive technology (ART) clinics between June 2019 and September 2020, results demonstrated that there is no significant effect of stress or depression on pregnancy outcome; however, there was a significant association between the anxiety state and the pregnancy outcome in the multivariable analysis. Furthermore, this study did not eliminate the possible confounding effect of previous unsuccessful IVF outcomes on this association ( 5 ). On the other hand, another prospective cohort study conducted in the same country and around the same period (June 2019 to February 2020) had different results. The study was conducted in 3 centers and concluded that infertility-related stress is associated with clinical pregnancy outcomes( 9 ). These results were similar to the results of the meta-analysis including 31 prospective studies, which aimed to assess the significant association, estimate the effect size, and the reason for the differences in effect sizes. The authors found a significant, but, small association between stress, trait anxiety, and reduced pregnancy chances with infertility treatment. However, the authors concluded that stress and distress relatively had limited influence on achieving a pregnancy; also, the association of distress (but not stress) and treatment of infertility seem to be affected by Sample mean age, mean duration of infertility, and percentage of first-time IVF attendees( 10 ). This goes in consistence with the results of a study conducted in Iran in 2017, they found a negative impact of age and female-only infertility on the outcome, and no impact of duration of infertility on the outcome( 11 ). Limited data is available in Low and Middle-income countries, and thus this research aimed to examine the effect of psychological distress (anxiety and depression) on the outcome of infertility treatment (including IVF-ICSI and IUI) among Sudanese women in Khartoum state, Sudan. Methods and materials Study settings and design: This was an observational cross-sectional multi-center health facility-based prospective study conducted in Khartoum state in Sudan, where the majority of infertility centers are located. The study included 4 centers; Nile Fertility center, Banoon, Ganin, and Royal Care Fertility center. These were purposely selected based on size and clients’ capacity. Additionally, they were recommended by specialists in the Obs & Gyn department. Participants: All women who came for IVF/ICSI or IUI during the study period in the specific centers were included in our study, Participation required women to agree to participate in the study and All Women who came for any other gynecological operations were excluded. A total of 158 women participated in this study, they were recruited using simple random sampling and the sample size was calculated by using Cochran's formula: with assumptions of 5% level of precision (d) = 0.05, 95% confidence level (Z) = 1.96, Population proportion (p) = 11.5%, which is the prevalence of infertility in Sudan according to a study done in 2019 ( 12 ). IVF /ICSI & IUI in Sudan: All women undergoing IVF/ICSI as a fertilization process were administered a stimulation procedure that included pituitary down-regulation either with a GnRH agonist or GnRH antagonist. Ovarian stimulation, recombinant FSH, or HMG were used, along with serum estradiol levels, and vaginal ultrasounds were used for monitoring. The procedure for fertilization was either traditional IVF or ICSI both acceptable methods in Sudan. Three or five days following oocyte retrieval, two embryos were typically transferred using an embryo transfer catheter. Luteal support was given with both oral and vaginal progesterone then additional embryos of high quality were allowed for their subsequent replacement, and extra embryos undergo cryopreservation. On day 14 after the transfer, a positive HCG urine test or serum HCG of more than 20 IU/ml was considered evidence of pregnancy. Five weeks after embryo transfer, clinical pregnancy was determined by ultrasound. Regarding IUI, All patients underwent ovulation induction with clomiphene citrate, Letrozole (Aromatase inhibitor), or HMG injections either separately or in combination. Then follicular tracking was done with trans-vaginal ultrasound till reaching one or two matured follicles. The IUI procedure was done after 36 hours from the time of the HCG trigger. All patients received oral progesterone after the procedure up to the time of pregnancy test which was done two weeks thereafter using quantitative β-hCG to confirm pregnancy. Measures: Data collection was done between January 2021 and February 2022, selected women answered questionnaires before IVF/ICSI or IUI procedures and were interviewed using the close-ended Hamilton anxiety rating scale (HAM-A), which is one of the earliest rating scales created to test the severity of anxiety symptoms and still often employed in both clinical and academic settings. The scale has 14 items, each of which is characterized by a set of symptoms, and it assesses somatic anxiety as well as psychic anxiety (mental agitation and psychological distress) and (physical complaints related to anxiety). There are no standardized probe questions offered by the HAM-A. Despite this, the scale's reported levels of inter-rater reliability seem to be satisfactory. With a total score range of 0–56, each item is rated on a scale of 0 (not present) to 4 (severe), with 17 denoting mild severity, 18–24 mild–to–moderate severity, and 25–30 moderate–to–severe severity ( 13 ). Beck's depression inventory (BDI) was also used to gauge depression; it has a very high level of validity and is one of the most often used inventories for assessing the signs and symptoms of depression. The BDI has been created in a variety of ways; consisting of the nine-item abbreviated form the nine items are social withdrawal, unsureness, irregular sleep patterns, exhaustion, excessive worrying about health ailments, being unable to work, being downbeat, unhappy, unable to enjoy life, and placing blame on oneself. Each item's response on a four-point scale was required of participants. Likert scale showing the degree of agreement (from 0 = not at all to 3 = very much) and the greater the score the more frequently depressed symptoms occur ( 14 ). Both questionnaires were validated and an Arabic-translated version was used through Google form ( 15 ). Data was presented as frequency and percentage and chi-squared (χ2) was used to compare association between categorical data. All p-values were two-tailed and a significance level of 0.05 was chosen. In order to ascertain the internal consistency of the HAM-A and BDI tools, Cronbach's coefficient alpha was calculated. The statistical program SPSS v26.0 was used to conduct the analysis (SPSS Inc., Chicago, IL, USA). Results In total, 158 women were approached and interviewed with overall response rate of 93%. The majority of the study participants were between the ages of 31–35 (27.2%) and 36–40 (22.2%). Most of the respondents were housewives account for 53.8%, while 39.9% were employees. Regarding the annual income, a moderate socioeconomic status was represented by 85.4% which was estimated to be 500$ USD. Details on participants’ demographic and socioeconomic characteristics are showed in Table 1 . And only 3.2% of women had been married for less than a year, while 58.9% of women had been married for more than four years. Table (1): Demographic and socioeconomic characteristics of the study participants. N= 158 N = 158 N (%) Age < 25–30 62 (39.2%) 31–35 43 (27.2%) 36–40 35 (22.2%) 41–45 17 (10.8%) < 45 1 (0.6%) Occupation Housewife 85 (53.8%) Worker 3 (1.9%) Employee 63 (39.9%) Student 7 (4.4%) Duration of marriage 4 years 93 (58.9%) Number of previous trials This is first time 91 (57.6%) one or two 52 (32.9%) three or four 9 (5.7%) More than four 6 (3.8%) Annual income estimation Low ( 1000$ USD) 13 (8.2%) About 57.0% had no history of previous pregnancy (primary infertility) while 43.0% of the participants had previous pregnancy trails (secondary infertility). Indications of infertility treatment are represented in Fig. 1 . In regards to the pregnancy test findings, 60.1% of study participants had negative results while 39.9% had positive pregnancy test. Variables (Demographic and social characteristics) were found to have no significant effect on women receiving treatment in fertility centers in the state of Khartoum. In contrast, this study showed that there is a slightly statistically significant association between pregnancy test and the annual income of families, with a p value of (p = 0.046), details showed in Table 2 . Table (2): Association between demographic and socioeconomic characteristics and the results of pregnancy test. N= 158 Results of pregnancy test P- Value Positive Negative Age 45 1 0 Job Housewife 33 52 0.905 Worker 1 2 Employee 27 36 Student 2 5 Duration of marriage 4 years 37 56 Indication of ART Male factor 18 40 0.167 Female factor 19 19 Both 11 10 Unexplained 15 26 Number of previous trials This is first time 40 51 0.544 One or two 19 33 Three or four 3 6 More than four 1 5 Previous history of pregnancy Yes 30 38 0.412 No 33 57 Annual income Low ( 1000$ USD) 1 12 Depression and anxiety Beck's depression inventory (BDI) was used to assess the level of depression and Hamilton anxiety rating scale (HAM-A) was used for assessment of anxiety level, details represented in Table 3 . Table (3) : Depression and anxiety between the participants N= 158 Anxiety N= 158 Mildly anxious 122 (77.2%) Moderately anxious 23 (14.6%) Severely anxious 13 (8.2%) Depression N= 158 No depression 56 (35.4%) Mild depression 25 (15.8%) Moderate depression 44 (27.8%) Severe depression 21 (13.3%) There is no statistically significant difference between women with a positive pregnancy test and the result of women with a negative test since both anxiety and depression scale score were not different between pregnant and not pregnant women (p = 0.462 and p = 0.059, respectively), as showed in Table 4 . Table (4) Anxiety and depression in relation to results of pregnancy test N= 158 Results of pregnancy test P-Value Positive Negative Anxiety N= 158 Mildly anxious 51 71 0.462 Moderately anxious 8 15 Severely anxious 4 9 Depression N= 146 No depression 27 29 0.059 Mild depression 11 14 Moderate depression 10 34 Severe depression 7 14 Discussion This study examined how psychological issues such as depression and anxiety affected the success of infertility treatment in Khartoum state, Sudan. Moreover, the statistical analysis of deferent demographic and socioeconomic characteristics showed no significant association with the success of the infertility treatment, except for a slight significance found in the annual income of families, with a p value of (p = 0.046). This was due to the possibility that low-income couples would delay their treatment and the fact that they cannot pay the high expenses of infertility therapy without health insurance. As mentioned by Dr. Bayoumi RR et al upon studying the quality of life of infertile couples in Sudan ( 16 ). Additionally, severe depression and anxiety symptoms were found in 13.3% and 8.2%, respectively. This was in consistent with a Meta-analysis by Zahra Kiani et al in 2021, using the same psychological assessment used in our study ( 17 ). Although many articles support the idea that psychological stress impairs fertility function, it has been difficult to prove this theory in the literature. This has been one of the most debatable issues in the field of assisted reproductive medicine and considerable research has looked into the connection between psychological disorders before and during infertility treatment cycles and future conception rates, with a variety of results ( 4 ). Our findings of no significant association between the state of anxiety and depression to the pregnancy outcome whether positive or negative can be considered reassuring and can minimize the fear that patients feel regarding their treatment outcome, and the results are consistent with the Meta-analysis done by J. Nicoloro-santabarbara et al in 2018 ( 18 ). In contrast to another Meta-analysis by S. Purewal et al , which showed a significant but small association between depression and state anxiety throughout infertility treatments, and its relation to poor pregnancy outcomes ( 19 ). Additionally, some of the literature in the developed world studied the impact of stress by measuring stress hormones such as cortisol ( 20 ) and a-amylase in saliva ( 21 ), and their results match the theory of stress negatively affecting the pregnancy rates. There variations in results have different causes, for example, infertile women might not adequately express how distressed they are when answering psychological questionnaires. Another cause is the presence of multiple confounding factors that can affect their mental health and the psychological assessment, for instance; social, financial and even personal or cultural factors ( 5 ). Moreover, using different psychological assessment tool might also lead to variations in results ( 9 ). Strengths and Limitations: This study is the first of its type to be conducted in Sudan, including East Africa, as far as we are aware. The fact that we believe our study is giving couples who are looking to start families a scientific reassurance regarding their concerns about treatment-related stress and if it adversely impacts the pregnancy rate is another of its most significant contributions. Additionally, our study showed that it was feasible to study infertility in Sudan using quantitative methods. The main limitation of this study is that it was conducted in a clinic, and the relative sample size may not be representative of all infertile women in Sudan. However, because of COVID-19 restrictions and lockdowns in infertility treatment institutions, raising it was not possible at the time of the study. This has been mitigated by conducting the study in 4 centers around Khartoum state, in Sudan. Additionally, the results of this study might not be easily generalized to apply to women undergoing IVF/ICSI treatment. It's also important to keep in mind that the psychological stress outcomes seen in the group of unclassified causes would have been different if they could have been put into one of the cause categories, such as female, male, combination, or unexplained. Last but not least, this study offers a framework for further research questions and inquiries and may be applied to provide psychological support during the course of treatment. Additionally, more thorough research using empirical methods is needed to quantify women's psychological functioning throughout therapy and its connection to the success rate of infertility treatment. Conclusion The results of this study provided important insights into the relationship between psychological distress and the outcome of infertility treatment in Sudan. In addition, anxiety and depression scale scores of pregnant and non-pregnant women were identical. This information can be used to inform the development of interventions to support women undergoing infertility treatment and improve their chances of successful conception. The psychological distress associated with infertility has been proven and thus, we recommend concentrating on the psychological aspect despite the fact that there is no solid link between psychological distress and outcome of infertility treatment. Further research on the impact of this distress on the treatment outcome is recommended on a larger scale. Declarations Ethics approval and consent to participate : The study was approved by the department of Community Medicine, Faculty of Medicine, University of Khartoum, as well as permission was taken from the fertility center's administration. Each participant was required to give written informed consent before participating in the study and had the right to refuse. No information that can lead to the identification of the participant will be used in the questionnaire Competing interests: Authors declare no conflict of interest. Funding: Researchers did not receive any funding to conduct the study. Authors’ roles: All authors have contributed actively to this study and they have revised and approved the manuscript. H. Abdelseid and H. Awadallah have designed the study, along with A. Ellahawi, H. Mohammed, G. Ali, T. Ahmed, and A. A. Mohamedalnour were involved in patients recruitment and data collection. R.Ali has performed the psychological evaluations and A. M. MohamedElnour carried out the statistical analysis and data management. Lastly, S. Handady and S. Osman have supervised the study, drafted and approved the manuscript. Acknowledgements: we appreciate every woman who participated in our study. We also wish to express our gratitude to all the mentors, especially, the nurse Khamisa, and the doctors Hibatalla Ahmed, Mohammed Hafiz, and Mohammed Abdelgafor for their guidance and assistance throughout this journey. References Zegers-hochschild F, Adamson GD, Dyer S, Racowsky C, Mouzon J De, Sokol R, et al. The International Glossary on Infertility and Fertility Care , 2017. Fertil Steril [Internet]. 2017;108(3):393–406. Available from: http://dx.doi.org/10.1016/j.fertnstert.2017.06.005 Wang J, Sauer M V. In vitro fertilization ( IVF ): a review of 3 decades of clinical innovation and technological advancement. 2006;2(4):355–64. In vitro fertilization (IVF). Mayo Clin Press [Internet]. Available from: https://www.mayoclinic.org/tests-procedures/in-vitro-fertilization/about/pac-20384716 Rooney KL, Domar AD. The relationship between stress and infertility. Transl Res. 2018;41–7. Bapayeva G, Aimagambetova G, Issanov A, Terzic S, Ukybassova T, Aldiyarova A, et al. The Effect of Stress , Anxiety and Depression on In Vitro Fertilization Outcome in Kazakhstani Public Clinical Setting : A Cross-Sectional Study. 2021;1–10. Teklemicheal AG, Kassa EM, Weldetensaye EK. Prevalence and correlates of infertility related psychological stress in women with infertility : a cross ‑ sectional hospital based survey. BMC Psychol [Internet]. 2022;1–8. Available from: https://doi.org/10.1186/s40359-022-00804-w de Klerk C, Macklon NS, Heijnen EMEW, Eijkemans MJC, Fauser BCJM, Passchier J, et al. The psychological impact of IVF failure after two or more cycles of IVF with a mild versus standard treatment strategy. Hum Reprod. 2007;22(9):2554–8. Milazzo A, Mnatzaganian G, Elshaug AG, Hemphill SA, Hiller JE, Health A, et al. Depression and Anxiety Outcomes Associated with Failed Assisted Reproductive Technologies : A Systematic Review and Meta- Analysis. 2016;41:1–19. Aimagambetova G, Issanov A, Terzic S, Bapayeva G, Ukybassova T, Baikoshkarova S, Aldiyarova A, Shauyen F TM. The effect of psychological distress on IVF outcomes: Reality or speculations? PLoS One. 2020; Matthiesen SMS, Frederiksen Y, Ingerslev HJ, Zachariae R. Stress , distress and outcome of assisted reproductive technology ( ART ): a meta-analysis. 2011;26(10):2763–76. Maroufizadeh S, Navid B, Samani RO, Amini P. The effects of depression , anxiety and stress symptoms on the clinical pregnancy rate in women undergoing IVF treatment. BMC Res Notes [Internet]. 2019;10–3. Available from: https://doi.org/10.1186/s13104-019-4294-0 Elhussein OG, Ahmed MA, Suliman SO, Yahya I, Adam I. Epidemiology of infertility and characteristics of infertile couples requesting assisted reproduction in a low- resource setting in Africa , Sudan. 2019;1:7–11. The HM, Psychol M. Hamilton Anxiety Rating Scale ( HAM-A ) Reference : Hamilton M . The assessment of anxiety states by rating . Br J Med Psychol 1959 ; Additional references. 1993;61(4):81–2. Beck’s Depression Inventory. :1–3. Available from: http://www.med.navy.mil/sites/NMCP2/PatientServices/SleepClinicLab/Documents/Beck_Depression_Inventory.pdf Anderheim L, Holter H, Bergh C, Möller A. Does psychological stress affect the outcome of in vitro fertilization ? 2015;(April). Bayoumi RR, Koert E, Boivin J, Viswanath K. Quality of life of Sudanese patients attending a fertility clinic : a mixed methods study. 2021;9(1):1006–30. Kiani Z, Simbar M, Hajian S, Zayeri F. The prevalence of depression symptoms among infertile women : a systematic review and meta-analysis. 2021;3:1–10. Nicoloro-santabarbara J, Busso C, Moyer A, Lobel M. Just Relax and You’ll Get Pregnant? Meta-Analysis Examining Women’s Emotional Distress and the Outcome of Assisted Reproductive Technology [Internet]. Social Science & Medicine. Elsevier Ltd; 2018. Available from: https://doi.org/10.1016/j.socscimed.2018.06.033 Purewal S, Chapman SCE, Akker OBA Van Den. Depression and state anxiety scores during assisted reproductive treatment are associated with outcome : a meta-analysis. Reprod Biomed Online [Internet]. 2018;1–12. Available from: https://doi.org/10.1016/j.rbmo.2018.03.010 Rooney KL, Domar AD. The impact of stress on fertility treatment. 2016;28(3):198–201. Lynch CD, Sundaram R, Maisog JM, Sweeney AM, Louis GMB. Preconception stress increases the risk of infertility : results from a couple-based prospective cohort study — the LIFE study. 2014;29(5):1067–75. Additional Declarations No competing interests reported. Supplementary Files Analysis.sav Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3852664","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267346512,"identity":"3c790d57-f806-4ee7-9025-88a059dc633a","order_by":0,"name":"Hadeel Mohamed Muaid Abdelseid","email":"data:image/png;base64,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","orcid":"","institution":"University of Khartoum","correspondingAuthor":true,"prefix":"","firstName":"Hadeel","middleName":"Mohamed Muaid","lastName":"Abdelseid","suffix":""},{"id":267346513,"identity":"f30f30a3-764f-4110-a525-e55a499239c5","order_by":1,"name":"Hiba Yousif Merghani Awadallah","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Hiba","middleName":"Yousif Merghani","lastName":"Awadallah","suffix":""},{"id":267346514,"identity":"3b3d3eb8-cb40-4457-951a-ddf3179be49e","order_by":2,"name":"Alaa Merghani Babiker Ellahawi","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Alaa","middleName":"Merghani Babiker","lastName":"Ellahawi","suffix":""},{"id":267346515,"identity":"4d41445a-bfb1-4786-859f-4334bb972a11","order_by":3,"name":"Hajer Abdalmonem Abdullah Mohammed","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Hajer","middleName":"Abdalmonem Abdullah","lastName":"Mohammed","suffix":""},{"id":267346516,"identity":"8066e83f-f1aa-41e8-9e2e-a2327e517a6e","order_by":4,"name":"Gadeer Khalil Osman Ali","email":"","orcid":"","institution":"National Ribat University","correspondingAuthor":false,"prefix":"","firstName":"Gadeer","middleName":"Khalil Osman","lastName":"Ali","suffix":""},{"id":267346517,"identity":"f8025195-e92a-43a1-9ec0-a269ec099af1","order_by":5,"name":"Rayan Abdo Ibrahim Adam Ali","email":"","orcid":"","institution":"Bedaya Center for Psychological Counseling","correspondingAuthor":false,"prefix":"","firstName":"Rayan","middleName":"Abdo Ibrahim Adam","lastName":"Ali","suffix":""},{"id":267346518,"identity":"32156cc9-f62b-4032-bf99-f616abcbe5d2","order_by":6,"name":"Tarteel Abdelrahim Elobeid Ahmed","email":"","orcid":"","institution":"Sudan International University","correspondingAuthor":false,"prefix":"","firstName":"Tarteel","middleName":"Abdelrahim Elobeid","lastName":"Ahmed","suffix":""},{"id":267346519,"identity":"0872a3d3-3460-4906-8a4a-4c9842fc3fa7","order_by":7,"name":"Areej Ahmed Ali Mohamedalnour","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Areej","middleName":"Ahmed Ali","lastName":"Mohamedalnour","suffix":""},{"id":267346520,"identity":"6ed38928-ff18-4c09-aa84-7e2a9b07cc89","order_by":8,"name":"Abdulhay Bushra Mohamed Mohamed Elnour","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Abdulhay","middleName":"Bushra Mohamed Mohamed","lastName":"Elnour","suffix":""},{"id":267346521,"identity":"b7b3da66-72a0-4c28-8784-5f42e9c5e7ad","order_by":9,"name":"Siddig Omer Mohammed Handady","email":"","orcid":"","institution":"Sudan Medical Specialization Board","correspondingAuthor":false,"prefix":"","firstName":"Siddig","middleName":"Omer Mohammed","lastName":"Handady","suffix":""},{"id":267346522,"identity":"426b829d-69a6-4f31-b042-6dd266871bff","order_by":10,"name":"Suliman Osman","email":"","orcid":"","institution":"University of Khartoum","correspondingAuthor":false,"prefix":"","firstName":"Suliman","middleName":"","lastName":"Osman","suffix":""}],"badges":[],"createdAt":"2024-01-11 07:29:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3852664/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3852664/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49766774,"identity":"8c5ef319-05a1-4c94-8faf-2acd7550d154","added_by":"auto","created_at":"2024-01-17 17:01:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63702,"visible":true,"origin":"","legend":"\u003cp\u003eIndications of infertility treatment\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3852664/v1/a6abfc8395eee4faf662a80c.png"},{"id":52613197,"identity":"66cee416-4825-4142-b992-c8073dce6040","added_by":"auto","created_at":"2024-03-13 15:28:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":488084,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3852664/v1/e7002a8c-a4a2-4d29-a009-4cb1a90c6847.pdf"},{"id":49766775,"identity":"0a54c23d-5d44-4351-bb67-aba7edf0ebd4","added_by":"auto","created_at":"2024-01-17 17:01:28","extension":"sav","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":17333,"visible":true,"origin":"","legend":"","description":"","filename":"Analysis.sav","url":"https://assets-eu.researchsquare.com/files/rs-3852664/v1/5959c32c9cdc34322cefc89d.sav"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffect of Anxiety and Depression on the Outcome of Infertility Treatment Among Women in Sudan: a Multi Center Cross-sectional Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eA person's ability to reproduce is impaired by infertility, which is a condition that results in disability because it negatively impacts functioning. Infertility is characterized by the failure to establish a clinical pregnancy after 12 months despite regular, unprotected sexual intercourse. Fertility is defined as the capacity to establish clinical pregnancy; its interventions can be initiated in less than 1 year according to the medical, sexual, and reproductive history, age, physical findings, and diagnostic testing(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). One of these interventions is in vitro fertilization (IVF), which is defined as a series of techniques involving extracorporeal fertilization of gametes, such as traditional in vitro insemination and intra-cytoplasmic sperm injection (ICSI)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Ovulation induction (OI) and intrauterine insemination (IUI) are additional infertility treatment techniques. Mature eggs are removed from ovaries during IVF and fertilized in a lab by sperm. The fertilized egg (or eggs) is/are then transferred to a uterus. IVF cycles are completed in roughly three weeks. If you or your spouse have endometriosis, uterine fibroids, previous tubal sterilization or removal, decreased sperm production or function, unexplained infertility, or a genetic disease, IVF may be a possibility for treatment(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Couples may face significant difficulties after receiving the diagnosis of infertility; many patients who visit large IVF clinics develop depressive symptoms. Infertility has been linked to stress, sadness, and anxiety previously(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, women undergoing IVF therapy frequently experience anxiety and depression due to their infertility as well as the uncertainty of the procedure(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Epidemiological evidence points to a connection between emotional issues and infertility. In addition, the influence of psychological factors on the success of IVF should be determined in order to provide the couples considering treatment with the required adjuvant psychosocial therapy. Failing infertility treatment has no doubt associated with a negative psychological impact and deterioration of emotional well-being(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Infertility treatment-associated anxiety and depression are major stressors before and during the procedure, their effect on the outcome of IVF has been a concern for many researchers, and the true impact of these stressors on the pregnancy outcome differences between these studies, some reviews of recent literature will be discussed below:\u003c/p\u003e \u003cp\u003eValidated psychometric questionnaires were used to measure baseline depression, infertility-related stress, anxiety state, and trait levels in the studies. The questions were designed to assess stress, depression, and anxiety symptoms, participants who experienced certain thresholds were considered at risk of clinical depression or clinical anxiety, this is what was meant to be measured as an effect on IVF outcomes. In a prospective cohort study conducted in Kazakhstani public assisted reproductive technology (ART) clinics between June 2019 and September 2020, results demonstrated that there is no significant effect of stress or depression on pregnancy outcome; however, there was a significant association between the anxiety state and the pregnancy outcome in the multivariable analysis. Furthermore, this study did not eliminate the possible confounding effect of previous unsuccessful IVF outcomes on this association (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). On the other hand, another prospective cohort study conducted in the same country and around the same period (June 2019 to February 2020) had different results. The study was conducted in 3 centers and concluded that infertility-related stress is associated with clinical pregnancy outcomes(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These results were similar to the results of the meta-analysis including 31 prospective studies, which aimed to assess the significant association, estimate the effect size, and the reason for the differences in effect sizes. The authors found a significant, but, small association between stress, trait anxiety, and reduced pregnancy chances with infertility treatment. However, the authors concluded that stress and distress relatively had limited influence on achieving a pregnancy; also, the association of distress (but not stress) and treatment of infertility seem to be affected by Sample mean age, mean duration of infertility, and percentage of first-time IVF attendees(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This goes in consistence with the results of a study conducted in Iran in 2017, they found a negative impact of age and female-only infertility on the outcome, and no impact of duration of infertility on the outcome(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimited data is available in Low and Middle-income countries, and thus this research aimed to examine the effect of psychological distress (anxiety and depression) on the outcome of infertility treatment (including IVF-ICSI and IUI) among Sudanese women in Khartoum state, Sudan.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy settings and design:\u003c/h2\u003e\n \u003cp\u003eThis was an observational cross-sectional multi-center health facility-based prospective study conducted in Khartoum state in Sudan, where the majority of infertility centers are located. The study included 4 centers; Nile Fertility center, Banoon, Ganin, and Royal Care Fertility center. These were purposely selected based on size and clients’ capacity. Additionally, they were recommended by specialists in the Obs \u0026amp; Gyn department.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants:\u003c/h2\u003e\n \u003cp\u003eAll women who came for IVF/ICSI or IUI during the study period in the specific centers were included in our study, Participation required women to agree to participate in the study and All Women who came for any other gynecological operations were excluded.\u003c/p\u003e\n \u003cp\u003eA total of 158 women participated in this study, they were recruited using simple random sampling and the sample size was calculated by using Cochran's formula:\u0026nbsp;\u003cimg src=\"data:image/png;base64,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\"\u003e with assumptions of 5% level of precision (d) = 0.05, 95% confidence level (Z) = 1.96, Population proportion (p) = 11.5%, which is the prevalence of infertility in Sudan according to a study done in 2019 (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eIVF /ICSI \u0026amp; IUI in Sudan:\u003c/h2\u003e\n \u003cp\u003eAll women undergoing IVF/ICSI as a fertilization process were administered a stimulation procedure that included pituitary down-regulation either with a GnRH agonist or GnRH antagonist. Ovarian stimulation, recombinant FSH, or HMG were used, along with serum estradiol levels, and vaginal ultrasounds were used for monitoring. The procedure for fertilization was either traditional IVF or ICSI both acceptable methods in Sudan. Three or five days following oocyte retrieval, two embryos were typically transferred using an embryo transfer catheter. Luteal support was given with both oral and vaginal progesterone then additional embryos of high quality were allowed for their subsequent replacement, and extra embryos undergo cryopreservation. On day 14 after the transfer, a positive HCG urine test or serum HCG of more than 20 IU/ml was considered evidence of pregnancy. Five weeks after embryo transfer, clinical pregnancy was determined by ultrasound.\u003c/p\u003e\n \u003cp\u003eRegarding IUI, All patients underwent ovulation induction with clomiphene citrate, Letrozole (Aromatase inhibitor), or HMG injections either separately or in combination. Then follicular tracking was done with trans-vaginal ultrasound till reaching one or two matured follicles. The IUI procedure was done after 36 hours from the time of the HCG trigger. All patients received oral progesterone after the procedure up to the time of pregnancy test which was done two weeks thereafter using quantitative β-hCG to confirm pregnancy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eMeasures:\u003c/h2\u003e\n \u003cp\u003eData collection was done between January 2021 and February 2022, selected women answered questionnaires before IVF/ICSI or IUI procedures and were interviewed using the close-ended Hamilton anxiety rating scale (HAM-A), which is one of the earliest rating scales created to test the severity of anxiety symptoms and still often employed in both clinical and academic settings. The scale has 14 items, each of which is characterized by a set of symptoms, and it assesses somatic anxiety as well as psychic anxiety (mental agitation and psychological distress) and (physical complaints related to anxiety). There are no standardized probe questions offered by the HAM-A. Despite this, the scale's reported levels of inter-rater reliability seem to be satisfactory. With a total score range of 0–56, each item is rated on a scale of 0 (not present) to 4 (severe), with 17 denoting mild severity, 18–24 mild–to–moderate severity, and 25–30 moderate–to–severe severity (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). Beck's depression inventory (BDI) was also used to gauge depression; it has a very high level of validity and is one of the most often used inventories for assessing the signs and symptoms of depression. The BDI has been created in a variety of ways; consisting of the nine-item abbreviated form the nine items are social withdrawal, unsureness, irregular sleep patterns, exhaustion, excessive worrying about health ailments, being unable to work, being downbeat, unhappy, unable to enjoy life, and placing blame on oneself. Each item's response on a four-point scale was required of participants. Likert scale showing the degree of agreement (from 0 = not at all to 3 = very much) and the greater the score the more frequently depressed symptoms occur (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). Both questionnaires were validated and an Arabic-translated version was used through Google form (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Data was presented as frequency and percentage and chi-squared (χ2) was used to compare association between categorical data. All p-values were two-tailed and a significance level of 0.05 was chosen. In order to ascertain the internal consistency of the HAM-A and BDI tools, Cronbach's coefficient alpha was calculated. The statistical program SPSS v26.0 was used to conduct the analysis (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 158 women were approached and interviewed with overall response rate of 93%. The majority of the study participants were between the ages of 31\u0026ndash;35 (27.2%) and 36\u0026ndash;40 (22.2%). Most of the respondents were housewives account for 53.8%, while 39.9% were employees. Regarding the annual income, a moderate socioeconomic status was represented by 85.4% which was estimated to be 500$ USD. Details on participants\u0026rsquo; demographic and socioeconomic characteristics are showed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. And only 3.2% of women had been married for less than a year, while 58.9% of women had been married for more than four years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (1): Demographic and socioeconomic characteristics of the study participants.\u003csup\u003e N= 158\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eN\u0026thinsp;=\u0026thinsp;158\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;25\u0026ndash;30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62 (39.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u0026ndash;35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (27.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36\u0026ndash;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (22.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41\u0026ndash;45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (10.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHousewife\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85 (53.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWorker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (1.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63 (39.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStudent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (4.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDuration of marriage\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 (22.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u0026ndash;4 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (15.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;4 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93 (58.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNumber of previous trials\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis is first time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91 (57.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eone or two\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 (32.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ethree or four\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than four\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (3.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAnnual income estimation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLow (\u0026lt;\u0026thinsp;500$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (6.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerate (500\u0026ndash;1000$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e135 (85.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh (\u0026gt;\u0026thinsp;1000$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (8.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbout 57.0% had no history of previous pregnancy (primary infertility) while 43.0% of the participants had previous pregnancy trails (secondary infertility). Indications of infertility treatment are represented in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. In regards to the pregnancy test findings, 60.1% of study participants had negative results while 39.9% had positive pregnancy test. Variables (Demographic and social characteristics) were found to have no significant effect on women receiving treatment in fertility centers in the state of Khartoum. In contrast, this study showed that there is a slightly statistically significant association between pregnancy test and the annual income of families, with a p value of (p\u0026thinsp;=\u0026thinsp;0.046), details showed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(2): Association between demographic and socioeconomic characteristics and the results of pregnancy test.\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003eN= 158\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabb\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eResults of pregnancy test\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP- Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;25\u0026ndash;30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.676\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31\u0026ndash;35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36\u0026ndash;40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41\u0026ndash;45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eJob\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHousewife\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.905\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWorker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployee\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStudent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eDuration of marriage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.787\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u0026ndash;4 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;4 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eIndication of ART\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale factor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.167\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale factor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnexplained\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eNumber of previous trials\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis is first time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.544\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOne or two\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThree or four\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than four\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrevious history of pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.412\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eAnnual income\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLow (\u0026lt;\u0026thinsp;500$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.046\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerate (500\u0026ndash;1000$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh (\u0026gt;\u0026thinsp;1000$ USD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eDepression and anxiety\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeck's depression inventory (BDI) was used to assess the level of depression and Hamilton anxiety rating scale (HAM-A) was used for assessment of anxiety level, details represented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(3)\u003c/strong\u003e: \u003cstrong\u003eDepression and anxiety between the participants\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003eN= 158\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabc\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAnxiety \u003csup\u003eN= 158\u003c/sup\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMildly anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e122 (77.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerately anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23 (14.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSeverely anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13 (8.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003eN= 158\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e56 (35.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMild depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25 (15.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerate depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44 (27.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSevere depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21 (13.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThere is no statistically significant difference between women with a positive pregnancy test and the result of women with a negative test since both anxiety and depression scale score were not different between pregnant and not pregnant women (p\u0026thinsp;=\u0026thinsp;0.462 and p\u0026thinsp;=\u0026thinsp;0.059, respectively), as showed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(4) Anxiety and depression in relation to results of pregnancy test\u003c/strong\u003e \u003csup\u003e\u003cstrong\u003eN= 158\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tabd\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eResults of pregnancy test\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eP-Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePositive\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eAnxiety \u003csup\u003e\u003cstrong\u003eN= 158\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMildly anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.462\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerately anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSeverely anxious\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eDepression \u003csup\u003e\u003cstrong\u003eN= 146\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.059\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMild depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eModerate depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSevere depression\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined how psychological issues such as depression and anxiety affected the success of infertility treatment in Khartoum state, Sudan. Moreover, the statistical analysis of deferent demographic and socioeconomic characteristics showed no significant association with the success of the infertility treatment, except for a slight significance found in the annual income of families, with a p value of (p\u0026thinsp;=\u0026thinsp;0.046). This was due to the possibility that low-income couples would delay their treatment and the fact that they cannot pay the high expenses of infertility therapy without health insurance. As mentioned by \u003cem\u003eDr. Bayoumi RR et al\u003c/em\u003e upon studying the quality of life of infertile couples in Sudan (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Additionally, severe depression and anxiety symptoms were found in 13.3% and 8.2%, respectively. This was in consistent with a Meta-analysis by \u003cem\u003eZahra Kiani et al\u003c/em\u003e in 2021, using the same psychological assessment used in our study (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Although many articles support the idea that psychological stress impairs fertility function, it has been difficult to prove this theory in the literature. This has been one of the most debatable issues in the field of assisted reproductive medicine and considerable research has looked into the connection between psychological disorders before and during infertility treatment cycles and future conception rates, with a variety of results (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Our findings of no significant association between the state of anxiety and depression to the pregnancy outcome whether positive or negative can be considered reassuring and can minimize the fear that patients feel regarding their treatment outcome, and the results are consistent with the Meta-analysis done by \u003cem\u003eJ. Nicoloro-santabarbara et al\u003c/em\u003e in 2018 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast to another Meta-analysis by \u003cem\u003eS. Purewal et al\u003c/em\u003e, which showed a significant but small association between depression and state anxiety throughout infertility treatments, and its relation to poor pregnancy outcomes (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Additionally, some of the literature in the developed world studied the impact of stress by measuring stress hormones such as cortisol (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and a-amylase in saliva (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and their results match the theory of stress negatively affecting the pregnancy rates.\u003c/p\u003e \u003cp\u003eThere variations in results have different causes, for example, infertile women might not adequately express how distressed they are when answering psychological questionnaires. Another cause is the presence of multiple confounding factors that can affect their mental health and the psychological assessment, for instance; social, financial and even personal or cultural factors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, using different psychological assessment tool might also lead to variations in results (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations:\u003c/h2\u003e \u003cp\u003eThis study is the first of its type to be conducted in Sudan, including East Africa, as far as we are aware. The fact that we believe our study is giving couples who are looking to start families a scientific reassurance regarding their concerns about treatment-related stress and if it adversely impacts the pregnancy rate is another of its most significant contributions. Additionally, our study showed that it was feasible to study infertility in Sudan using quantitative methods.\u003c/p\u003e \u003cp\u003eThe main limitation of this study is that it was conducted in a clinic, and the relative sample size may not be representative of all infertile women in Sudan. However, because of COVID-19 restrictions and lockdowns in infertility treatment institutions, raising it was not possible at the time of the study. This has been mitigated by conducting the study in 4 centers around Khartoum state, in Sudan. Additionally, the results of this study might not be easily generalized to apply to women undergoing IVF/ICSI treatment. It's also important to keep in mind that the psychological stress outcomes seen in the group of unclassified causes would have been different if they could have been put into one of the cause categories, such as female, male, combination, or unexplained.\u003c/p\u003e \u003cp\u003eLast but not least, this study offers a framework for further research questions and inquiries and may be applied to provide psychological support during the course of treatment. Additionally, more thorough research using empirical methods is needed to quantify women's psychological functioning throughout therapy and its connection to the success rate of infertility treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study provided important insights into the relationship between psychological distress and the outcome of infertility treatment in Sudan. In addition, anxiety and depression scale scores of pregnant and non-pregnant women were identical. This information can be used to inform the development of interventions to support women undergoing infertility treatment and improve their chances of successful conception. The psychological distress associated with infertility has been proven and thus, we recommend concentrating on the psychological aspect despite the fact that there is no solid link between psychological distress and outcome of infertility treatment. Further research on the impact of this distress on the treatment outcome is recommended on a larger scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study was approved by the department of Community Medicine, Faculty of Medicine, University of Khartoum, as well as permission was taken from the fertility center\u0026apos;s administration. Each participant was required to give written informed consent before participating in the study and had the right to refuse. No information that can lead to the identification of the participant will be used in the questionnaire\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eAuthors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Researchers did not receive any funding to conduct the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; roles:\u0026nbsp;\u003c/strong\u003eAll authors have contributed actively to this study and they have revised and approved the manuscript. H. Abdelseid and H. Awadallah have designed the study, along with A. Ellahawi, H. Mohammed, G. Ali, T. Ahmed, and A. A. Mohamedalnour were involved in patients recruitment and data collection. R.Ali has performed the psychological evaluations and A. M. MohamedElnour carried out the statistical analysis and data management. Lastly, S. Handady and S. Osman have supervised the study, drafted and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003ewe appreciate every woman who participated in our study. We also wish to express our gratitude to all the mentors, especially, the nurse Khamisa, and the doctors Hibatalla Ahmed, Mohammed Hafiz, and Mohammed Abdelgafor for their guidance and assistance throughout this journey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZegers-hochschild F, Adamson GD, Dyer S, Racowsky C, Mouzon J De, Sokol R, et al. The International Glossary on Infertility and Fertility Care , 2017. Fertil Steril [Internet]. 2017;108(3):393\u0026ndash;406. Available from: http://dx.doi.org/10.1016/j.fertnstert.2017.06.005\u003c/li\u003e\n\u003cli\u003eWang J, Sauer M V. In vitro fertilization ( IVF ): a review of 3 decades of clinical innovation and technological advancement. 2006;2(4):355\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eIn vitro fertilization (IVF). Mayo Clin Press [Internet]. Available from: https://www.mayoclinic.org/tests-procedures/in-vitro-fertilization/about/pac-20384716\u003c/li\u003e\n\u003cli\u003eRooney KL, Domar AD. The relationship between stress and infertility. Transl Res. 2018;41\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eBapayeva G, Aimagambetova G, Issanov A, Terzic S, Ukybassova T, Aldiyarova A, et al. The Effect of Stress , Anxiety and Depression on In Vitro Fertilization Outcome in Kazakhstani Public Clinical Setting : A Cross-Sectional Study. 2021;1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eTeklemicheal AG, Kassa EM, Weldetensaye EK. Prevalence and correlates of infertility related psychological stress in women with infertility : a cross ‑ sectional hospital based survey. BMC Psychol [Internet]. 2022;1\u0026ndash;8. Available from: https://doi.org/10.1186/s40359-022-00804-w\u003c/li\u003e\n\u003cli\u003ede Klerk C, Macklon NS, Heijnen EMEW, Eijkemans MJC, Fauser BCJM, Passchier J, et al. The psychological impact of IVF failure after two or more cycles of IVF with a mild versus standard treatment strategy. Hum Reprod. 2007;22(9):2554\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMilazzo A, Mnatzaganian G, Elshaug AG, Hemphill SA, Hiller JE, Health A, et al. Depression and Anxiety Outcomes Associated with Failed Assisted Reproductive Technologies : A Systematic Review and Meta- Analysis. 2016;41:1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eAimagambetova G, Issanov A, Terzic S, Bapayeva G, Ukybassova T, Baikoshkarova S, Aldiyarova A, Shauyen F TM. The effect of psychological distress on IVF outcomes: Reality or speculations? PLoS One. 2020; \u003c/li\u003e\n\u003cli\u003eMatthiesen SMS, Frederiksen Y, Ingerslev HJ, Zachariae R. Stress , distress and outcome of assisted reproductive technology ( ART ): a meta-analysis. 2011;26(10):2763\u0026ndash;76. \u003c/li\u003e\n\u003cli\u003eMaroufizadeh S, Navid B, Samani RO, Amini P. The effects of depression , anxiety and stress symptoms on the clinical pregnancy rate in women undergoing IVF treatment. BMC Res Notes [Internet]. 2019;10\u0026ndash;3. Available from: https://doi.org/10.1186/s13104-019-4294-0\u003c/li\u003e\n\u003cli\u003eElhussein OG, Ahmed MA, Suliman SO, Yahya I, Adam I. Epidemiology of infertility and characteristics of infertile couples requesting assisted reproduction in a low- resource setting in Africa , Sudan. 2019;1:7\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eThe HM, Psychol M. Hamilton Anxiety Rating Scale ( HAM-A ) Reference : Hamilton M . The assessment of anxiety states by rating . Br J Med Psychol 1959 ; Additional references. 1993;61(4):81\u0026ndash;2. \u003c/li\u003e\n\u003cli\u003eBeck\u0026rsquo;s Depression Inventory. :1\u0026ndash;3. Available from: http://www.med.navy.mil/sites/NMCP2/PatientServices/SleepClinicLab/Documents/Beck_Depression_Inventory.pdf\u003c/li\u003e\n\u003cli\u003eAnderheim L, Holter H, Bergh C, M\u0026ouml;ller A. Does psychological stress affect the outcome of in vitro fertilization ? 2015;(April). \u003c/li\u003e\n\u003cli\u003eBayoumi RR, Koert E, Boivin J, Viswanath K. Quality of life of Sudanese patients attending a fertility clinic : a mixed methods study. 2021;9(1):1006\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eKiani Z, Simbar M, Hajian S, Zayeri F. The prevalence of depression symptoms among infertile women : a systematic review and meta-analysis. 2021;3:1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eNicoloro-santabarbara J, Busso C, Moyer A, Lobel M. Just Relax and You\u0026rsquo;ll Get Pregnant? Meta-Analysis Examining Women\u0026rsquo;s Emotional Distress and the Outcome of Assisted Reproductive Technology [Internet]. Social Science \u0026amp; Medicine. Elsevier Ltd; 2018. Available from: https://doi.org/10.1016/j.socscimed.2018.06.033\u003c/li\u003e\n\u003cli\u003ePurewal S, Chapman SCE, Akker OBA Van Den. Depression and state anxiety scores during assisted reproductive treatment are associated with outcome : a meta-analysis. Reprod Biomed Online [Internet]. 2018;1\u0026ndash;12. Available from: https://doi.org/10.1016/j.rbmo.2018.03.010\u003c/li\u003e\n\u003cli\u003eRooney KL, Domar AD. The impact of stress on fertility treatment. 2016;28(3):198\u0026ndash;201. \u003c/li\u003e\n\u003cli\u003eLynch CD, Sundaram R, Maisog JM, Sweeney AM, Louis GMB. Preconception stress increases the risk of infertility : results from a couple-based prospective cohort study \u0026mdash; the LIFE study. 2014;29(5):1067\u0026ndash;75. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Infertility, psychological stress, ART, IVF, depression, anxiety","lastPublishedDoi":"10.21203/rs.3.rs-3852664/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3852664/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground and objectives: \u003c/strong\u003eInfertility and its treatment have been linked to psychological distress, and many couples experience significant stress throughout treatment cycles that might affect their relationship. An Ethiopian study indicated that the incidence of infertility-related stress was 92.7% in 2022, which is concerning for couples seeking therapy as they believe that stress may have an impact on the success of their treatment. The purpose of this study was to investigate the effect of the psychological burden on the treatment outcome of infertility among Sudanese women in Khartoum state.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The study was performed at 4 infertility treatment centers in Khartoum State. Data were collected using an interviewer-structured Hamilton anxiety rating scale (HAM-A) for assessment of anxiety level and Beck's depression inventory (BDI) for depression, considering some demographic variables (age, occupation, duration of marriage, annual income, and pregnancy test results). Women who sought infertility treatment were recruited and consented to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOne hundred fifty-eight participants were interviewed, majority aged between 31–35 years and 36–40 years of age, with a percentage of 27.2% and 22.2% respectively. Most of the participants (53.8%) were housewives and 85.4% of their annual income was from moderate socio-economical level. Primary infertility causes were found in 57.0% with 36.7% due to male factors, 24.1% due to female factors, only 13.3% due to combined causes, and 25.9% unexplained. No significant association was found between pregnancy tests and other women's demographics and social characteristics, except for the annual income (p = 0.046).\u003c/p\u003e\n\u003cp\u003eAccording to BDI, severe depression was found in 13.3% and 8.2% of severe anxiety reported according to Hamilton. However, both anxiety and depression scales had no significant statistical association between pregnant and non-pregnant women (p = 0.462 and p = 0.059, respectively)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eWomen who faced psychological stress in terms of anxiety or depression do not have a diminished chance to have a baby; however, further research must be done on a larger scale.\u003c/p\u003e","manuscriptTitle":"Effect of Anxiety and Depression on the Outcome of Infertility Treatment Among Women in Sudan: a Multi Center Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-17 17:01:24","doi":"10.21203/rs.3.rs-3852664/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a61e990-4ed9-450d-92e0-736d10adb918","owner":[],"postedDate":"January 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-13T15:19:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-17 17:01:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3852664","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3852664","identity":"rs-3852664","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}