Psychological well-being and depression among Lebanese women with infertility: influencing factors and implications for care

Psychological well-being and depression among Lebanese women with infertility: influencing factors and implications for care | 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 Psychological well-being and depression among Lebanese women with infertility: influencing factors and implications for care Reva Mosleh, Joanna Jaffal, Jana Kassir, Hiba Assi, Joseph Azoury, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8473666/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 Infertility is frequently associated with psychological distress; however, evidence remains limited on mental health outcomes among Lebanese women experiencing infertility. This study aimed to assess the psychological well-being and depression using the World Health Organization Well-Being Index (WHO-5) and the Patient Health Questionnaire-9 (PHQ-9), and to identify factors influencing each outcome. Method A cross-sectional study was conducted between June and September 2024 and included 346 Lebanese women recruited from two fertility centers in Beirut. Participants were randomly selected and completed a structured questionnaire through individual interviews. Descriptive and bivariate analyses were performed, and binary logistic regressions were used to identify the factors influencing each of the well-being and depression indices. Results Among the participants, 50.00% had poor well-being and 37.90% had major depression. Good well-being was significantly associated with exercise frequency per week (OR = 1.260), sleeping seven hours or more (OR = 1.904), being a former water-pipe smoker (OR = 4.039), having a history of previous cesarean section (OR = 2.266), living in rural areas (OR = 0.594), and attending different fertility clinics (OR = 0.564). Moreover, major depression was significantly associated with more frequent water pipe smoking (OR = 1.099), attending different fertility clinics (OR = 2.055), living in central areas (OR = 1.784), and having a past medical history of anxiety (OR = 7.278). However, no major depression was associated with exercise (OR = 0.564), nor with sleeping seven hours or more (OR = 0.399). Conclusion Lifestyle, behavioral, clinical, and demographic factors significantly influence the well-being and depression among Lebanese women experiencing infertility. Integrating psychological support and patient care services into fertility services is essential to improve outcomes. Women’s health psychological well-being mental health depression infertility reproductive health. Background The World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system, characterized by the failure to achieve a pregnancy after twelve months or more of regular unprotected sexual intercourse ( 1 ). Infertility remains a crucial public health issue, with estimates suggesting that approximately one in every six individuals of reproductive age worldwide experience it at some point in their lifetime ( 1 ). In Lebanon, based on global metrics data sets in 2025, the fertility rate was estimated at 1.99 births per woman, marking a 0.6 decline from 2024, and projections suggest this downward trend will continue until 2050 ( 2 ). The causes of infertility are equally divided between both genders, with male and female factors each contributing to around 35.00% of cases. In 20.00% of cases, a combination of both factors is involved, while 10.00% remain unexplained ( 3 ). Although infertility affects both genders at the same rates, women often bear the societal burden, particularly in societies where a woman’s identity and social value are closely tied to motherhood ( 4 ). The management of infertility has evolved over the past four decades to include assisted reproductive technology (ART), which helped infertile or sub-fertile couples to have a child. This was a revolution in the field of medicine, and with continued advancements and increased accessibility, more than 9 million babies have been born worldwide following ART procedures ( 5 ). Despite these advancements and the widespread success of ART, infertility and its treatment continue to impose a substantial negative impact on women’s quality of life (QoL) and mental well-being. Studies have shown that women undergoing infertility evaluation and medical treatment often face feelings of anxiety, depression, self-blame, lethargy, irritability, loneliness, vulnerability, financial burden, and risk of failure ( 6 – 9 ). In addition to that, infertile women are 1.6 times more likely to experience mental distress and higher levels of anxiety and depression, and exhibit lower levels of sexual self-esteem compared to fertile women ( 6 , 10 ). Disease-related stigma is also common among women experiencing infertility. The inability to conceive places substantial psychological and emotional stress on affected women, and both societal judgment and self-perceived shame can further exacerbate their distress ( 11 ). This burden is often more pronounced in traditional societies or among women adhering to traditional cultural beliefs, where infertility is perceived as one of the greatest sources of stigma, in contrast to women in more developed countries ( 11 ). In Lebanon, a population-based survey exploring public perceptions of infertility found that more than half of the respondents (52.00%) believe that women are most often blamed when a couple is unable to conceive. Additionally, 73.40% consider psychological stress to be a main cause of infertility, and 26.40% report that family pressure plays a significant role in this context. Notably, 11.30% consider that if a woman is unable to have children, it is an acceptable reason for a man to seek divorce or pursue a second marriage ( 12 ). Limited research has examined the QoL of Lebanese women experiencing difficulty conceiving. One recent study validated the FertiQoL tool and demonstrated that a longer duration of infertility, lower income, absence of children, and exposure to social and familial stigma were all significantly associated with lower QoL scores ( 13 ). Although the study also utilized the WHO-5 questionnaire, it didn’t assess the associated factors through bivariate or multivariate analysis, nor did it explore the impact of infertility on the mental well-being of Lebanese women. Thus, an important gap remains in understanding levels of well-being and depression, and the factors influencing these outcomes among women seeking fertility treatments. It is essential for guiding targeted psychosocial support, optimizing clinical care in fertility clinics, and addressing unmet mental health needs in this population. Therefore, the present study aimed to assess the well-being of the Lebanese women experiencing difficulty conceiving using the World Health Organization well-being index (WHO-5), evaluate their depression using the Patient Health Questionnaire-9 (PHQ-9) index, and identify the associated influencing factors. Methods Study design and data collection This cross-sectional study was conducted from June 1, 2024, to September 30, 2024, at Hope Clinic (Al Zahraa Hospital University Medical Center), a private university-affiliated teaching hospital, and Azoury IVF Clinic (Mount Lebanon Hospital), a private referral center—both located in Beirut. A simple random sampling method was employed; patients were selected among those seen by participating clinicians. Eligible individuals were approached and invited to participate, and those who consented were individually interviewed by three researchers—one PhD candidate and two Master’s students in Clinical Research and Pharmacoepidemiology using a structured paper questionnaire. Participation was anonymous and voluntary, with written consent obtained. To ensure anonymity, consent forms were stored separately from the completed questionnaires, which contained no personal identifiers. The three interviewers coordinated through regular team meetings throughout the data collection period to discuss any discrepancies and ensure consistency in interviewing techniques. Interviews were conducted in Arabic and took 12 to 15 minutes to complete. Inclusion and exclusion criteria Lebanese married women 18 years or older who were actively attempting to conceive, and have been diagnosed with infertility regardless of the infertility source were included. Infertility was defined as the inability to conceive after one year of unprotected intercourse for women under 35, or after six months for women 35 and older ( 1 , 14 ). Women with incomplete questionnaires (any questionnaire with missing responses in any section) were excluded. Sample size The sample size (n) was calculated using the standard formula for estimating a proportion in a finite population survey through Epi Info software ( 15 ). The formula used: $$\:n=\frac{N\times\:{Z}^{2}\times\:p\times\:(1-p)}{{d}^{2}\times\:(N-1)+{Z}^{2}\times\:p\times\:(1-p)}$$ N is the total Lebanese population size in 2024 (N = 5,800,000), z is the z-score corresponding to the desired confidence level (1.96 for 95% confidence level), d = 0.05 margin of error, and an expected infertility prevalence of 0.343, resulting in a target sample size of 346 participants ( 16 , 17 ). Study tool The questionnaire was developed following a comprehensive review of the literature and was structured into four main sections. The first section included questions addressing socio-demographic (residence, medical insurance, income, educational level, etc.) and lifestyle factors (smoking, alcohol consumption, physical exercise, etc.) ( 18 ). The second section included questions on health status, covering history of chronic conditions (hypertension, diabetes, dyslipidemia, etc.), gynecological history (menstruation, history of pregnancy, history of gynecological surgery, etc.), and infertility history (e.g., causes, family history) ( 19 – 22 ). The third section included the WHO-5 index, which consists of five positively worded questions, each rated on a 6-point Likert scale, ranging from 0 (at no time) to 5 (all of the time) ( 23 , 24 ). The fourth section included the PHQ-9, which consists of 9 questions, each rated on a 4-point Likert scale, ranging from 0 (not at all) to 9 (nearly every day) ( 24 , 25 ). The questionnaire was translated from English to Arabic and back-translated to ensure linguistic accuracy. To establish face and content validity, the tool was reviewed by two experts in the field of infertility, including an obstetrics and gynecology reproductive specialist and a maternal health researcher. It was pilot tested on 10–15 participants, which led to minor revisions. Data Analysis The data from the questionnaire were analyzed using SPSS version 26, with descriptive statistics, bivariate, and multivariate analysis. Frequencies were calculated for categorical variables, and means and standard deviations were used for continuous variables. Both the WHO-5 and PHQ-9 total scores were considered as dependent variables and were dichotomized into two groups each. For the bivariate analysis, chi-square tests were used for qualitative variables, independent samples t-tests for normally distributed quantitative variables, and Mann–Whitney U tests for non-normal distributions. Variables with p < 0.2 were included in the binary logistic regression models. Results were expressed as adjusted odds ratios (OR) with 95% confidence intervals. P-values < 0.05 were considered statistically significant. Cronbach’s alpha was used to assess the internal consistency for each of the scores. In this study, items with a Cronbach's alpha of 0.7 or above were considered to have acceptable reliability ( 26 ). The Cronbach’s alpha values for the WHO-5 and PHQ-9 were 0.899 and 0.887, respectively. Scoring For the WHO-5, participants responded to five items to describe their general emotional well-being for the past two weeks, using a six-point Likert scale: 0 (at no time), 1 (some of the time), 2 (less than half of the time), 3 (more than half of the time), 4 (most of the time), and 5 (all of the time). The item scores were summed to yield a total score ranging from 0 to 25, where 0 indicates the worst possible well-being and 25 the best. A cutoff score of 13 was used to categorize the results; scores from 0 to 12 indicated poor well-being, while scores from 13 to 25 indicated good well-being ( 27 ). For the PHQ-9, participants responded to nine items to describe the frequency of their depressive symptoms over the past two weeks using a 4-point Likert scale: 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). The item scores were summed to produce a total score ranging from 0 to 27. A cutoff score of 10 was used to classify depression severity, with scores from 0 to 9 indicating no or minimal depression, and scores from 10 to 27 indicating major depression ( 28 ). Ethical consideration This study employed a questionnaire for data collection, without invasive procedures or interventions. The study protocol, survey, and consent forms were reviewed and approved by the Institutional Review Board of the School of Pharmacy at the Lebanese University (7/24/D) which adhered to the Declaration of Helsinki. Since the participating centers are private clinics without independent IRBs, the University’s IRB approval was accepted by these clinics to cover all study sites. Data was anonymous, non-identifiable, and stored according to the University’s data protection guidelines. Written informed consent was obtained, and participants were informed that their involvement was voluntary and they could withdraw at any time without justification. Results Sociodemographic characteristics and health status of the participants The study included 346 women, with a mean age of 34 years (± 6.48 years). Of these, 53.47% were from the Azoury clinic, and 46.50% were from the Hope clinic. Half of the participants were workers, 53.47% lived in central areas, 57.51% had health insurance, and 32.40% did exercise. Additionally, 90.46% were non-cigarette smokers, 63.29% were non-water-pipe smokers, and 88.44% non-alcohol consumers. For the past medical history, 38.20% had at least one chronic disease. Among these, obesity (53.78%) and thyroid disorders (25.00%) were the most common. Among the participants, 34.39% had routine Pap smears, and 52.02% had at least one previous gynecological surgery. Among women with a history of gynecological surgery, cesarean section (38.89%) and laparoscopy (36.67%) were the most frequent. Difficulty conceiving was primarily due to female factors (41.91%), such as Polycystic Ovary Syndrome (PCOS) (36.56%), ovulatory disorders (33.10%), and endometriosis (28.97%). Among those who reported infertility due to male factors, low sperm count (93.75%) and low sperm quality (92.50%) were common issues. Also, 9.83% had a family history of infertility, predominantly on the mother's side (52.94%) (Table 1). Table 1 . Sociodemographic characteristics and health status of the participants (N=346) Variable Frequency (%) Mean ± SD Age (years) 33.82 ± 6.48 BMI (kg/m 2 ) 26.19 ± 4.77 Region Mount Lebanon 113 (32.66) Beirut 85 (24.57) Beqaa 64 (18.50) South 46 (13.29) North 30 (8.67) Nabatiyeh 8 (2.31) Family monthly income ≤ 250 USD 68 (19.65) > 250 - 500 USD 119 (34.39) > 500 - 1000 USD 64 (18.50) > 1000 - 2000 USD 35 (10.12) ≥ 2000 USD 60 (17.34) Educational level Didn’t receive any education 4 (1.16) Elementary or Intermediate 42 (12.14) High School 61 (17.63) University Degree 180 (52.02) Post-Graduate Degree 59 (17.05) Having health insurance (Y) 199 (57.50) Cigarette smoking Non-smoker 313 (90.50) Former smoker 8 (2.30) Smoker 25 (7.20) Alcohol consumption Non-alcoholic 313 (90.50) Ex-alcoholic 8 (2.30) Alcoholic 25 (7.20) Water-pipe smoking Non-smoker 194 (56.10) Former smoker 25 (7.20) Smoker 127 (36.70) Exercise (Y) 112 (32.40) Sleeping hours < 7 hrs 126 (36.40) ≥ 7 hrs 220 (63.60) Past medical history of chronic disease (Y) 132 (38.20) Infertility cause Female factors 145 (41.90) Male factors 80 (23.10) Combined factors 50 (14.50) Unexplained factors 71 (20.50) Abbreviations: BMI = Body Mass Index, N = Frequency, SD = Standard Deviation, USD = United States Dollar, Y = Yes, hrs = hours Description of the scores WHO-5 The results showed a mean score of 12.98 ± 6.39 (median = 12.50). Half of the participants (50.00 %) were classified as having a good well-being (Table 2). Table 2: Participants’ response to the WHO-5 questionnaire (N=346) At no time N (%) Some of the time N (%) Less than half of the time N (%) More than half of the time N (%) Most of the time N (%) All of the time N (%) I have felt cheerful and in good spirits 29 (8.40) 58 (16.80) 81 (23.40) 49 (14.20) 89 (25.70) 40 (11.60) I have felt calm and relaxed 33 (9.50) 68 (19.70) 77 (22.30) 51 (14.70) 82 (23.70) 35 (10.10) I have felt active and vigorous 34 (9.80) 61 (17.60) 89 (25.70) 52 (15.00) 81 (23.40) 29 (8.40) I woke up feeling fresh and rested 37 (10.70) 59 (17.10) 65 (18.80) 56 (16.20) 98 (28.30) 31 (9.00) My daily life has been filled with things that interest me 35 (10.10) 54 (15.60) 78 (22.50) 47 (13.60) 88 (24.50) 44 (12.70) PHQ-9 The results showed a mean score of 8.08 ± 6.16 (median = 7.00). Of the participants, 131 (37.90 %) were classified as having major depression, while 215 (62.10 %) were classified as not having major depression (Table 3). Table 3: Participants’ response to the PHQ-9 (N=346) Not at all N (%) several days N (%) more than half of the days N (%) nearly everyday N (%) Little interest or pleasure in doing things 116 (33.50) 129 (37.30) 62 (17.90) 39 (11.30) Feeling down, depressed, or hopeless 115 (33.20) 126 (36.40) 61 (17.60) 44 (12.70) Trouble falling or staying asleep, or sleeping too much 106 (30.60) 127 (36.70) 67 (19.40) 46 (13.30) Feeling tired or having little energy 56 (16.20) 164 (47.40) 74 (21.40) 52 (15.00) Poor appetite or overeating 140 (40.50) 113 (32.70) 58 (16.80) 35 (10.10) Feeling bad about yourself or that you are a failure or have let yourself or your family down 203 (58.70) 79 (22.80) 32 (9.20) 32 (9.20) Trouble concentrating on things, such as reading the newspaper or watching television 169 (48.80) 105 (30.30) 39 (11.30) 33 (9.50) Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 206 (59.50) 88 (25.40) 32 (9.20) 20 (5.80) Thoughts that you would be better off dead, or of hurting yourself 227 (80.10) 37 (10.70) 20 (5.80) 12 (3.50) Analysis of factors associated with well-being Good well-being was significantly associated with older age women (p = 0.039), and higher exercise frequency per week (p < 0.001). Significant associations were observed between women’s well-being status and exercise (p < 0.001), sleeping hours (p = 0.014), history of cesarean section (p = 0.016), water-pipe smoking (p = 0.035), alcohol consumption (p = 0.038), different fertility clinics (p = 0.024) (Table 4). Table 4: Bivariate analysis of the factors associated with participants’ well-being (N=346) Poor well-being Good well-being Quantitative variables Mean ± SD Mean ± SD p-value* Age (years) 33.10 ± 6.23 34.54 ± 6.66 0.039 N (Mean rank) N (Mean rank) p-value** Exercise frequency/week 173 (156.41) 173 (190.59) < 0.001 Qualitative variables N (%) N (%) p-value*** Fertility clinics 0.024 Clinic 1 82 (47.40) 103 (59.50) Clinic 2 91 (52.60) 70 (40.50) Exercise <0.001 Yes 40 (23.10) 72 (41.60) No 133 (76.90) 101 (58.40) Sleeping hours 0.014 < 7 hrs 74 (42.80) 52 (30.10) ≥ 7 hrs 99 (57.20) 121 (69.90) History of cesarean section 0.016 Yes 26 (15.00) 44 (25.40) No 147 (85.00) 129 (74.60) Water pipe smoking 0.035 Non-smoker 95 (54.90) 99 (57.20) Former smoker 7 (4.00) 18 (10.40) Smoker 71 (41.00) 56 (32.40) Alcohol consumption 0.038 Non-alcoholic 156 (90.20) 150 (86.70) Ex-alcoholic 9 (5.20) 20 (11.60) Alcoholic 8 (4.60) 3 (1.70) * Independent-samples t-test, ** Mann–Whitney U test, *** Chi-square test Analysis of factors associated with depression Women without major depression demonstrated lower water-pipe smoking frequency (p = 0.001) and higher exercise frequency (p = 0.006) compared with those with major depression. Significant associations were also observed between different fertility clinics (p = 0.001), living area (p = 0.027), consanguinity marriage (p = 0.038), exercise (p = 0.007), sleeping hours (p = 0.001), chronic medical conditions (p = 0.040), obesity as a cause of infertility (p = 0.019), and water-pipe smoking status (p = 0.006) (Table 5). Table 5: Bivariate analysis of the factors associated with participants’ depressive symptoms (N=346) No major depression Major depression Quantitative variables N (Mean rank) N (Mean rank) p-value* Water pipe smoking/week 215 (160.37) 131(195.06) 0.001 Exercise frequency/week 215 (182.99) 131 (157.92) 0.006 Qualitative variables N (%) N (%) p-value** Fertility clinics 0.001 Clinic 1 130 (60.50) 55 (42.00) Clinic 2 85 (39.50) 76 (58.00) Living area 0.027 Rural 110 (51.20) 51 (38.90) Central 105 (48.80) 80 (61.10) Consanguinity marriage 0.038 Yes 15 (7.00) 18 (13.70) No 200 (93.00) 113 (86.30) Exercise 0.007 Yes 81 (37.70) 31 (23.70) No 134 (62.30) 100 (76.30) Sleeping hours 0.001 < 7 hrs 64 (29.80) 62 (47.30) ≥ 7 hrs 151 (70.20) 69 (52.70) Chronic medical condition 0.04 Yes 73 (34.00) 59 (45.00) No 142 (66.00) 72 (55.00) Obesity as an infertility cause 0.019 Yes 35 (16.30) 35 (26.70) No 180 (83.70) 96 (73.30) Water pipe smoking 0.006 Non-smoker 133 (61.90) 61 (46.60) Former smoker 17 (7.90) 8 (6.10) Smoker 65 (30.20) 62 (47.30) * Mann–Whitney U test, **Chi-square test Influencing factors associated with well-being and depression In binary logistic regression analysis for the WHO-5, several factors were significantly associated with good well-being. Each additional weekly exercise session increased the odds of good well-being by a factor of 1.26 (OR = 1.260, p < 0.001). Women living in central areas had lower odds of good well-being compared with those living in rural areas (OR = 0.594, p = 0.028). Similarly, women attending one clinic had lower odds of good well-being compared with those attending another clinic (OR = 0.564, p = 0.021). Sleeping seven hours or more was associated with nearly double the odds of good well-being compared with sleeping less than 7 hours (OR = 1.904, p = 0.009). Being a former water pipe smoker was associated with four times higher odds of good well-being (OR = 4.039, p = 0.006). Additionally, having had a cesarean section was associated with more than double the odds of good well-being compared with not having had one (OR = 2.266, p = 0.007). Regarding depression, each additional weekly water pipe smoking session increased the odds of depression by a factor of 1.10 (OR = 1.099, p = 0.002). Women attending one clinic had 2.06 times higher odds of depression compared with those attending another clinic (OR = 2.055, p = 0.003). Living in central areas was associated with 1.78 times higher odds of depression compared with living in rural areas (OR = 1.784, p = 0.017). Conversely, engaging in exercise was associated with 0.56 times lower odds of depression (OR = 0.564, p = 0.033), and sleeping seven hours or more per night was associated with 0.40 times lower odds of depression compared with sleeping less than seven hours (OR = 0.399, p < 0.001). Additionally, women who reported to have anxiety had 7.28 times higher odds of depression compared with those without anxiety (OR = 7.278, p = 0.031) (Table 6). Table 6: Binary logistic regression Binary logistic regression for the influencing factors associated with WHO-5 well-being index OR 95% CI p-value Exercise frequency/week 1.260 [1.11, 1.42] < 0.001 Living area (central vs rural) 0.594 [0.37, 0.94] 0.028 Fertility clinics (2 vs 1) 0.564 [0.34, 0.91] 0.021 Sleeping hours (≥7 hrs vs <7 hrs) 1.904 [1.17, 3.07] 0.009 Water pipe smoking (former smoker vs non-smoker) 4.039 [1.49, 10.94] 0.006 Cesarean section (Yes vs No) 2.266 [1.245, 4.093] 0.007 Binary logistic regression for the influencing factors associated with PHQ-9 depression index Water pipe sessions per week 1.099 [1.03, 1.16] 0.002 Fertility clinics (2 vs 1) 2.055 [1.27, 3.32] 0.003 Living area (central vs rural) 1.784 [1.10, 2.87] 0.017 Exercise (yes vs no) 0.564 [0.33, 0.95] 0.033 Sleeping hours (≥7 hrs vs <7 hrs) 0.399 [0.24, 0.65] < 0.001 Anxiety (yes vs no) 7.278 [1.19, 44.23] 0.031 Vs = versus Discussion This study found that 37.9% of the women had major depression (PHQ-9 mean score: 8.08 ± 6.16), and 50.00 % had poor well-being (WHO-5 mean score: 12.98 ± 6.39). Similar findings were reported in a study from Iran, where the prevalence of anxiety and depression among infertile women was 41.70% and 29.60% respectively (29). Another study in Switzerland reported a moderate WHO-5 well-being (mean = 13.89/25) (27). These findings suggest that the emotional burden of infertility is largely universal, with profound psychological consequences. Older age was significantly associated with higher well-being, in contrast to findings from Iranian studies reporting poorer mental health and QoL among older infertile women. (30,31). The divergence from previous studies may reflect that older women in our sample demonstrate greater emotional maturity, acceptance, and psychological adaptation, whereas younger women often view infertility as a major disruption to their life plans. However, this association was not significant in the multivariate analysis. Exercise seemed to be significantly associated with increasing the odds of good well-being and reducing the odds of depression. This aligns with findings from a Hungarian study showing that infertile women who exercised had better treatment and quality of life outcomes (32). Together, these findings suggest that promoting regular, structured physical activity within fertility care can enhance well-being and improve the overall treatment outcomes. Sleeping seven hours or more has been shown to be an influencing factor in nearly doubling the odds of good well-being and significantly reducing the odds of depression among participants. Similarly, prior studies in China and Denmark found that poor sleep quality is associated with psychological distress, anxiety, depression and poor pregnancy outcomes (33,34). Therefore, good sleep helps improve mood, reduce stress, and boost energy, making it easier for infertile women to cope with treatment challenges. Living in central areas increased the odds of having major depression and reduced the odds of good well-being. Our results contrast the findings in China and Iran, where infertile women who lived in rural areas had significantly lower QoL in the economic, emotional, sexual, physical and psychological aspects (35,36). A possible explanation for our results could be that living in central areas induces urban stressors such as living costs, fast-paced lifestyles, and greater exposure to environmental stressors alongside cultural differences across settings. Being a former pipe smoker compared to a non-smoker increased the odds of well-being fourfold; in the same context, the increased frequency of water pipe smoking significantly increases the odds of major depression. These results are consistent with previous findings in Iran and Saudi Arabia showing a poorer health-related quality of life and a higher prevalence of major depression among water pipe smokers, respectively (37,38). This pattern implies that while continued smoking negatively affects psychological health, cessation may lead to recovery or improvement. These findings emphasize the importance of addressing water pipe smoking among women facing infertility. In search of predictors, different fertility clinics appeared to significantly impact WHO-5 and PHQ-9 indices in terms of lowering the odds of well-being and doubling the odds of depression, respectively. This aligns with findings from a meta-analysis and a Portuguese study, which emphasize that a lack of compassion in the healthcare environment, coupled with poor communication, negatively impacts women's infertility experiences and treatment (39,40). Such results may be explained by variations in institutional factors such as counseling approaches, privacy, staff expertise, or patient psychological support systems, which can significantly influence patients’ emotional experiences during fertility management. Women with a history of cesarean were more likely to report better well‑being. This finding may be explained by the fact that women with a history of cesarean section have previously achieved a live birth, which may provide psychological reassurance, a sense of reproductive capability, and greater optimism. Anxiety was strongly associated with the PHQ-9 depression index, with women reporting anxiety as a part of their past medical history being over seven times as likely to have major depression. This aligns with a Chinese research showing that infertile women experience elevated anxiety and depression compared with the general population (41). These findings suggest that existing anxiety amplifies the psychological burden and the depressive symptoms among women with infertility. This study aims to assess the well-being and depression among Lebanese women experiencing infertility. This study’s strengths include a robust sample size and the use of validated scales to accurately assess the psychological well-being and depression. Additionally, the application of multivariate analysis allowed for controlling potential confounders, enhancing the reliability of the findings. The study's cross-sectional design is a limitation, as it cannot establish causality, only generate hypotheses. Although participants were from various regions, the study was conducted in clinics in Beirut and among women experiencing infertility and actively seeking fertility treatment. This may have introduced selection bias, as these women could differ from infertile women not seeking or not having access to specialized care, potentially limiting the generalizability of the findings to the broader population of Lebanese women experiencing infertility. Information bias is another concern, as the sensitive nature of some questions could lead to under- or over-reporting. Conclusion A considerable psychological burden was observed among Lebanese women with infertility, with over one-third experiencing major depression and half reporting poor well-being. Physical activity and adequate sleep were consistently associated with better mental health outcomes, while water pipe smoking, anxiety, living in central areas, and clinic-related factors were linked to poorer well-being and higher depression. These findings may guide healthcare professionals in developing supportive programs that integrate psychological support, patient-centered care, and culturally sensitive interventions. Implementing mental health screening, counseling, lifestyle guidance, and stress-management programs, alongside clear communication and empathetic care, may strengthen emotional resilience and improve treatment experiences. Further research is needed to monitor changes in well-being and evaluate the effectiveness of psychosocial interventions on depression. Abbreviations WHO-5 World Health Organization Well-Being Index PHQ-9 Patient Health Questionnaire-9 OR Odds Ratio ART Assisted Reproductive Technology QoL Quality of Life PhD Doctor of Philosophy SPSS Statistical Package for the Social Sciences IRB Institutional Review Board BMI Body Mass Index N Frequency or mean rank SD Standard Deviation USD United States Dollar Y Yes Hrs hours Vs Versus Declarations Description of the scores WHO-5 The results showed a mean score of 12.98 ± 6.39 (median = 12.50). Half of the participants (50.00%) were classified as having a good well-being (Table 2). Competing interests The authors have declared that no competing interests exist. Submission declaration and verification This manuscript is not under consideration for publication elsewhere. All authors have approved the manuscript for submission, and the research has received approval from the institutional review board of the School of Pharmacy at the Lebanese University and the Clinical Research Unit at Al Zahraa Hospital University Medical Center. If accepted, this article will not be published elsewhere in the same form, in English or any other language, without written consent from the copyright-holder. Funding Source No funding was received for the conduct of this research and preparation of the article. Author Contribution Conception and study design: Amal Al-Hajje, Roula Ajrouche, Joanna Jaffal, Reva MoslehAcquisition of Data: Jana Kassir, Hiba Assi, Reva MoslehAnalysis and Interpretation of Data: Joanna Jaffal, Reva MoslehWriting original draft: Joanna Jaffal, Reva MoslehRevising & editing: Amal Al-Hajje, Roula Ajrouche, Malak Issa, Hassan Ajami, Joseph AzouryFinal approval: All authors have approved the final manuscript. Acknowledgement Thank you for considering our manuscript. Data Availability The data that support the findings of this study are available on request from the corresponding author. Due to the sensitive nature of the data and to protect patient privacy, they are not publicly available. References Infertility, World health Organization Fact Sheets [Internet]. World Health Organization. ; 2025 Nov. Available from: https://www.who.int/news-room/fact-sheets/detail/infertility Lebanon Fertility. Rate 1950–2025 [Internet]. 2025 Nov. Available from: https://www.macrotrends.net/global-metrics/countries/lbn/lebanon/fertility-rate Puscheck E. Elizabeth. Practice Essentials, Overview, Etiology of Infertility [Internet]. 2024 May. Available from: https://emedicine.medscape.com/article/274143-overview#a1 Thoma M, Fledderjohann J, Cox C, Kantum Adageba R. Biological and Social Aspects of Human Infertility: A Global Perspective. In: Oxford Research Encyclopedia of Global Public Health [Internet]. Oxford University Press; 2021 [cited 2025 Dec 10]. Available from: https://oxfordre.com/publichealth/view/ 10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-184 Kuhnt AK, Passet-Wittig J. Families formed through assisted reproductive technology: Causes, experiences, and consequences in an international context. Reprod Biomed Soc Online. 2022;14:289–96. Nik Hazlina NH, Norhayati MN, Shaiful Bahari I, Nik Muhammad Arif NA. Worldwide prevalence, risk factors and psychological impact of infertility among women: a systematic review and meta-analysis. BMJ Open. 2022;12(3):e057132. Rahimi R, Hasanpour S, Mirghafourvand Mojgan, Esmaeilpour K. Effect of Hope-oriented group counseling on mental health of infertile women with failed IVF cycles: a randomized controlled trial. BMC Psychiatry. 2021;21(1):286. Wojciechowska P, Milska-Musa KA. Quality of life and mental state of women trying to conceive using the in vitro method. Eur J Trans Clin Med. 2024 June;14(1):106–12. Berg BJ, Wilson JF. Psychiatric morbidity in the infertile population: a reconceptualization. Fertil Steril. 1990;53(4):654–61. Zayed AA, El-Hadidy MA. Sexual satisfaction and self-esteem in women with primary infertility. Middle East Fertil Soc J. 2020;25(1):13. Xie Y, Ren Y, Niu C, Zheng Y, Yu P, Li L. The impact of stigma on mental health and quality of life of infertile women: A systematic review. Front Psychol. 2022;13:1093459. Sahakian JPKK, El Helou E, Azoury J, Salameh L, Abou Jaoude I, Sleilaty G. Infertility within the Lebanese population: beliefs and realities. Middle East Fertil Soc J. 2020;25(1):27. Al Obeisat S, Hayajneh A, Hweidi I, Abujilban S, Mrayan L, Alfar R, et al. Psychometric properties of the Arabic version of the Fertility Quality of Life (FertiQoL) questionnaire tested on infertile couples in Jordan. BMC Women’s Health. 2023;23(1):283. Infertility Workup for the Women’s Health Specialist. ACOG Committee Opinion, Number 781. Obstet Gynecol. 2019 June;133(6):e377–84. Centers for Disease Control and Prevention. Epi Info ™ version 7.2.6 [Internet]. 2023 [cited 2025 Feb 11]. Available from: https://www.cdc.gov/epiinfo/pc.html Lebanon Demographics Population, Population of Lebanon. (2024) [Internet]. worldometers; 2024. Available from: http://srv1.worldometers.info/demographics/lebanon-demographics/ Dia N, Mansour S, Kharaba Z, Malaeb B, Sarray El Dine A, Kokash S et al. Factors associated with infertility among the Lebanese population: a cross-sectional study. Int J Environ Health Res. 2023;1–9. Sharma R, Biedenharn KR, Fedor JM, Agarwal A. Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol. 2013;11(1):66. Walker MH, Tobler KJ. Female Infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sept 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK556033/ Leslie SW, Soon-Sutton TL, Khan MA. Male Infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sept 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK562258/ Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al. The International Glossary on Infertility and Fertility Care, 2017. Fertil Steril. 2017 Sept;108(3):393–406. Hammarberg K, Stocker R, Romero L, Fisher J. Pregnancy planning health information and service needs of women with chronic non-communicable conditions: a systematic review and narrative synthesis. BMC Pregnancy Childbirth. 2022;22(1):236. Kassab Alshayea A. Development and Validation of an Arabic Version of the World Health Organization Well-Being Index (WHO-5). J Psychopathol Behav Assess. 2023;45(1):247–55. Doumit R, Hallit S, Sanchez-Ruiz MJ, El Khoury-Malhame M. Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese adolescents. Metzler J, editor. PLoS One. 2025 July 17;20(7):e0317644. Summaka M, Zein H, Abbas LA, Elias C, Elias E, Fares Y, et al. Validity and Reliability of the Arabic Patient Health Questionnaire-9 in Patients with Spinal Cord Injury in Lebanon. World Neurosurg. 2019;125:e1016–22. Cronbach LJ. Coefficient Alpha and the Internal Structure of Tests. Psychometrika 1951 Sept;16(3):297–334. Bernet M, Quaas AM, von Wolff M, Santi A, Streuli I, Wunder D, et al. Quality of life, spiritual needs, and well-being of people affected by infertility and its treatment: quantitative results of a mixed-methods study. J Assist Reprod Genet. 2025 June;42(6):1853–62. Levis B, Benedetti A, Thombs BD. DEPRESsion Screening Data (DEPRESSD) Collaboration. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ. 2019;365:l1476. Foroudifard F, Amini P, Navid B, Omani-Samani R, Sepidarkish M, Maroufizadeh S. Cognitive emotion regulation, anxiety, and depression in infertile women: a cross-sectional study. Middle East Fertil Soc J. 2020;25(1):24. Bakhtiyar K, Beiranvand R, Ardalan A, Changaee F, Almasian M, Badrizadeh A, et al. An investigation of the effects of infertility on Women’s quality of life: a case-control study. BMC Women’s Health. 2019;19(1):114. Ashraf DM, Ali D, Azadeh DM. Effect of infertility on the quality of life, a cross- sectional study. J Clin Diagn Res. 2014;8(10):OC13–15. Prémusz V, Makai A, Gács B, Nagy Á, Perjés B, Ács P, et al. Preliminary study on pre-treatment physical activity and quality of life in infertility. EQOL. 2019;11(2):5–17. Li QL, Wang C, Cao KX, Zhang L, Xu YS, Chang L, et al. Sleep characteristics before assisted reproductive technology treatment predict reproductive outcomes: a prospective cohort study of Chinese infertile women. Front Endocrinol. 2023;14:1178396. Philipsen MT, Knudsen UB, Zachariae R, Ingerslev HJ, Hvidt JEM, Frederiksen Y. Sleep, psychological distress, and clinical pregnancy outcome in women and their partners undergoing in vitro or intracytoplasmic sperm injection fertility treatment. Sleep Health. 2022;8(2):242–8. Ni Y, Tong C, Huang L, Zhou W, Zhang A. The analysis of fertility quality of life and the influencing factors of patients with repeated implantation failure. Health Qual Life Outcomes. 2021;19(1):32. Namdar A, Naghizadeh MM, Zamani M, Yaghmaei F, Sameni MH. Quality of life and general health of infertile women. Health Qual Life Outcomes. 2017;15(1):139. Tavafian SS, Aghamolaei T, Zare S. Water pipe smoking and health-related quality of life: a population-based study. Arch Iran Med. 2009;12(3):232–7. Alsanosy R, Prevalence. Knowledge, Attitude, and Predictors of Waterpipe Smoking among School Adolescents in Saudi Arabia. Santangelo OE, editor. Global Health. 2022 Sept 30;2022:1–9. Assaysh-Öberg S, Borneskog C, Ternström E. Women’s experience of infertility & treatment – A silent grief and failed care and support. Volume 37. Sexual & Reproductive Healthcare; 2023 Sept. p. 100879. Pedro J, Canavarro MC, Boivin J, Gameiro S. Positive experiences of patient-centred care are associated with intentions to comply with fertility treatment: findings from the validation of the Portuguese version of the PCQ-Infertility tool. Hum Reprod. 2013 Sept;28(9):2462–72. Wang L, Tang Y, Wang Y. Predictors and incidence of depression and anxiety in women undergoing infertility treatment: A cross-sectional study. PLoS ONE. 2023;18(4):e0284414. Additional Declarations No competing interests reported. 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. 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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-8473666","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587179791,"identity":"76511e99-676e-4d96-abac-ab10bf7cef69","order_by":0,"name":"Reva 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University","correspondingAuthor":false,"prefix":"","firstName":"Roula","middleName":"","lastName":"Ajrouche","suffix":""},{"id":587179806,"identity":"bd21f747-7ee2-41b9-ac45-b3a56d161702","order_by":8,"name":"Amal Al-Hajje","email":"","orcid":"","institution":"Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University","correspondingAuthor":false,"prefix":"","firstName":"Amal","middleName":"","lastName":"Al-Hajje","suffix":""}],"badges":[],"createdAt":"2025-12-29 13:53:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8473666/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8473666/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104401272,"identity":"549f5906-c2f7-4033-a559-6c1b978e67bd","added_by":"auto","created_at":"2026-03-11 12:12:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1988002,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8473666/v1/c8908165-757a-4916-b889-a9ecb3256b82.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological well-being and depression among Lebanese women with infertility: influencing factors and implications for care ","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system, characterized by the failure to achieve a pregnancy after twelve months or more of regular unprotected sexual intercourse (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Infertility remains a crucial public health issue, with estimates suggesting that approximately one in every six individuals of reproductive age worldwide experience it at some point in their lifetime (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Lebanon, based on global metrics data sets in 2025, the fertility rate was estimated at 1.99 births per woman, marking a 0.6 decline from 2024, and projections suggest this downward trend will continue until 2050 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe causes of infertility are equally divided between both genders, with male and female factors each contributing to around 35.00% of cases. In 20.00% of cases, a combination of both factors is involved, while 10.00% remain unexplained (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although infertility affects both genders at the same rates, women often bear the societal burden, particularly in societies where a woman\u0026rsquo;s identity and social value are closely tied to motherhood (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe management of infertility has evolved over the past four decades to include assisted reproductive technology (ART), which helped infertile or sub-fertile couples to have a child. This was a revolution in the field of medicine, and with continued advancements and increased accessibility, more than 9\u0026nbsp;million babies have been born worldwide following ART procedures (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Despite these advancements and the widespread success of ART, infertility and its treatment continue to impose a substantial negative impact on women\u0026rsquo;s quality of life (QoL) and mental well-being.\u003c/p\u003e \u003cp\u003eStudies have shown that women undergoing infertility evaluation and medical treatment often face feelings of anxiety, depression, self-blame, lethargy, irritability, loneliness, vulnerability, financial burden, and risk of failure (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In addition to that, infertile women are 1.6 times more likely to experience mental distress and higher levels of anxiety and depression, and exhibit lower levels of sexual self-esteem compared to fertile women (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Disease-related stigma is also common among women experiencing infertility. The inability to conceive places substantial psychological and emotional stress on affected women, and both societal judgment and self-perceived shame can further exacerbate their distress (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This burden is often more pronounced in traditional societies or among women adhering to traditional cultural beliefs, where infertility is perceived as one of the greatest sources of stigma, in contrast to women in more developed countries (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Lebanon, a population-based survey exploring public perceptions of infertility found that more than half of the respondents (52.00%) believe that women are most often blamed when a couple is unable to conceive. Additionally, 73.40% consider psychological stress to be a main cause of infertility, and 26.40% report that family pressure plays a significant role in this context. Notably, 11.30% consider that if a woman is unable to have children, it is an acceptable reason for a man to seek divorce or pursue a second marriage (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimited research has examined the QoL of Lebanese women experiencing difficulty conceiving. One recent study validated the FertiQoL tool and demonstrated that a longer duration of infertility, lower income, absence of children, and exposure to social and familial stigma were all significantly associated with lower QoL scores (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Although the study also utilized the WHO-5 questionnaire, it didn\u0026rsquo;t assess the associated factors through bivariate or multivariate analysis, nor did it explore the impact of infertility on the mental well-being of Lebanese women. Thus, an important gap remains in understanding levels of well-being and depression, and the factors influencing these outcomes among women seeking fertility treatments. It is essential for guiding targeted psychosocial support, optimizing clinical care in fertility clinics, and addressing unmet mental health needs in this population.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to assess the well-being of the Lebanese women experiencing difficulty conceiving using the World Health Organization well-being index (WHO-5), evaluate their depression using the Patient Health Questionnaire-9 (PHQ-9) index, and identify the associated influencing factors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data collection\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted from June 1, 2024, to September 30, 2024, at Hope Clinic (Al Zahraa Hospital University Medical Center), a private university-affiliated teaching hospital, and Azoury IVF Clinic (Mount Lebanon Hospital), a private referral center\u0026mdash;both located in Beirut. A simple random sampling method was employed; patients were selected among those seen by participating clinicians. Eligible individuals were approached and invited to participate, and those who consented were individually interviewed by three researchers\u0026mdash;one PhD candidate and two Master\u0026rsquo;s students in Clinical Research and Pharmacoepidemiology using a structured paper questionnaire. Participation was anonymous and voluntary, with written consent obtained. To ensure anonymity, consent forms were stored separately from the completed questionnaires, which contained no personal identifiers. The three interviewers coordinated through regular team meetings throughout the data collection period to discuss any discrepancies and ensure consistency in interviewing techniques. Interviews were conducted in Arabic and took 12 to 15 minutes to complete.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eLebanese married women 18 years or older who were actively attempting to conceive, and have been diagnosed with infertility regardless of the infertility source were included. Infertility was defined as the inability to conceive after one year of unprotected intercourse for women under 35, or after six months for women 35 and older (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Women with incomplete questionnaires (any questionnaire with missing responses in any section) were excluded.\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe sample size (n) was calculated using the standard formula for estimating a proportion in a finite population survey through Epi Info software (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The formula used:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:n=\\frac{N\\times\\:{Z}^{2}\\times\\:p\\times\\:(1-p)}{{d}^{2}\\times\\:(N-1)+{Z}^{2}\\times\\:p\\times\\:(1-p)}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eN is the total Lebanese population size in 2024 (N\u0026thinsp;=\u0026thinsp;5,800,000), \u003cem\u003ez\u003c/em\u003e is the z-score corresponding to the desired confidence level (1.96 for 95% confidence level), d\u0026thinsp;=\u0026thinsp;0.05 margin of error, and an expected infertility prevalence of 0.343, resulting in a target sample size of 346 participants (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStudy tool\u003c/h3\u003e\n\u003cp\u003eThe questionnaire was developed following a comprehensive review of the literature and was structured into four main sections. The first section included questions addressing socio-demographic (residence, medical insurance, income, educational level, etc.) and lifestyle factors (smoking, alcohol consumption, physical exercise, etc.) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The second section included questions on health status, covering history of chronic conditions (hypertension, diabetes, dyslipidemia, etc.), gynecological history (menstruation, history of pregnancy, history of gynecological surgery, etc.), and infertility history (e.g., causes, family history) (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The third section included the WHO-5 index, which consists of five positively worded questions, each rated on a 6-point Likert scale, ranging from 0 (at no time) to 5 (all of the time) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The fourth section included the PHQ-9, which consists of 9 questions, each rated on a 4-point Likert scale, ranging from 0 (not at all) to 9 (nearly every day) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The questionnaire was translated from English to Arabic and back-translated to ensure linguistic accuracy. To establish face and content validity, the tool was reviewed by two experts in the field of infertility, including an obstetrics and gynecology reproductive specialist and a maternal health researcher. It was pilot tested on 10\u0026ndash;15 participants, which led to minor revisions.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data from the questionnaire were analyzed using SPSS version 26, with descriptive statistics, bivariate, and multivariate analysis. Frequencies were calculated for categorical variables, and means and standard deviations were used for continuous variables. Both the WHO-5 and PHQ-9 total scores were considered as dependent variables and were dichotomized into two groups each. For the bivariate analysis, chi-square tests were used for qualitative variables, independent samples t-tests for normally distributed quantitative variables, and Mann\u0026ndash;Whitney U tests for non-normal distributions. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.2 were included in the binary logistic regression models. Results were expressed as adjusted odds ratios (OR) with 95% confidence intervals. P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. Cronbach\u0026rsquo;s alpha was used to assess the internal consistency for each of the scores. In this study, items with a Cronbach's alpha of 0.7 or above were considered to have acceptable reliability (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The Cronbach\u0026rsquo;s alpha values for the WHO-5 and PHQ-9 were 0.899 and 0.887, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eScoring\u003c/h2\u003e \u003cp\u003eFor the WHO-5, participants responded to five items to describe their general emotional well-being for the past two weeks, using a six-point Likert scale: 0 (at no time), 1 (some of the time), 2 (less than half of the time), 3 (more than half of the time), 4 (most of the time), and 5 (all of the time). The item scores were summed to yield a total score ranging from 0 to 25, where 0 indicates the worst possible well-being and 25 the best. A cutoff score of 13 was used to categorize the results; scores from 0 to 12 indicated poor well-being, while scores from 13 to 25 indicated good well-being (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the PHQ-9, participants responded to nine items to describe the frequency of their depressive symptoms over the past two weeks using a 4-point Likert scale: 0 (not at all), 1 (several days), 2 (more than half the days), and 3 (nearly every day). The item scores were summed to produce a total score ranging from 0 to 27. A cutoff score of 10 was used to classify depression severity, with scores from 0 to 9 indicating no or minimal depression, and scores from 10 to 27 indicating major depression (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003eThis study employed a questionnaire for data collection, without invasive procedures or interventions. The study protocol, survey, and consent forms were reviewed and approved by the Institutional Review Board of the School of Pharmacy at the Lebanese University (7/24/D) which adhered to the Declaration of Helsinki. Since the participating centers are private clinics without independent IRBs, the University\u0026rsquo;s IRB approval was accepted by these clinics to cover all study sites. Data was anonymous, non-identifiable, and stored according to the University\u0026rsquo;s data protection guidelines. Written informed consent was obtained, and participants were informed that their involvement was voluntary and they could withdraw at any time without justification.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003eSociodemographic characteristics and health status of the participants \u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study included 346 women, with a mean age of 34 years (\u0026plusmn; 6.48 years). Of these, 53.47% were from the Azoury clinic, and 46.50% were from the Hope clinic. Half of the participants were workers, 53.47% lived in central areas, 57.51% had health insurance, and 32.40% did exercise. Additionally, 90.46% were non-cigarette smokers, 63.29% were non-water-pipe smokers, and 88.44% non-alcohol consumers. For the past medical history, 38.20% had at least one chronic disease. Among these, obesity (53.78%) and thyroid disorders (25.00%) were the most common. Among the participants, 34.39% had routine Pap smears, and 52.02% had at least one previous gynecological surgery. Among women with a history of gynecological surgery, cesarean section (38.89%) and laparoscopy (36.67%) were the most frequent. Difficulty conceiving was primarily due to female factors (41.91%), such as Polycystic Ovary Syndrome (PCOS) (36.56%), ovulatory disorders (33.10%), and endometriosis (28.97%). Among those who reported infertility due to male factors, low sperm count (93.75%) and low sperm quality (92.50%) were common issues. Also, 9.83% had a family history of infertility, predominantly on the mother's side (52.94%) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable \u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e. \u003cstrong\u003eSociodemographic characteristics and health status of the participants (N=346)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"624\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e33.82 \u0026plusmn; 6.48\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e26.19 \u0026plusmn; 4.77\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eMount Lebanon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e113 (32.66)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eBeirut\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e85 (24.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eBeqaa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e64 (18.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eSouth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e46 (13.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eNorth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e30 (8.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eNabatiyeh\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e8 (2.31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eFamily monthly income\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026le; 250 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e68 (19.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026gt; 250 - 500 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e119 (34.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026gt; 500 - 1000 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e64 (18.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026gt; 1000 - 2000 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e35 (10.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026ge; 2000 USD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e60 (17.34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eDidn\u0026rsquo;t receive any education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e4 (1.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eElementary or Intermediate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e42 (12.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eHigh School\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e61 (17.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eUniversity Degree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e180 (52.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003ePost-Graduate Degree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e59 (17.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eHaving health insurance (Y)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e199 (57.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eCigarette smoking\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eNon-smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e313 (90.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e8 (2.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eSmoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e25 (7.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eAlcohol consumption\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eNon-alcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e313 (90.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eEx-alcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e8 (2.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eAlcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e25 (7.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eWater-pipe smoking \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eNon-smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e194 (56.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e25 (7.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eSmoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e127 (36.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eExercise (Y)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e112 (32.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eSleeping hours\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026lt; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e126 (36.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u0026ge; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e220 (63.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003ePast medical history of chronic disease (Y)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e132 (38.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003e\u003cstrong\u003eInfertility cause\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"252\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eFemale factors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e145 (41.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eMale factors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e80 (23.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eCombined factors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e50 (14.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"372\"\u003e\n\u003cp\u003eUnexplained factors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e71 (20.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"126\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: BMI = Body Mass Index, N = Frequency, SD = Standard Deviation, USD = United States Dollar, Y = Yes, hrs = hours\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eDescription of the scores \u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eWHO-5 \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results showed a mean score of 12.98 \u0026plusmn; 6.39 (median = 12.50). Half of the participants (50.00 %) were classified as having a good well-being (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Participants\u0026rsquo; response to the WHO-5 questionnaire (N=346)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eAt no time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eSome of the time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eLess than half of the time\u0026nbsp; \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eMore than half of the time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eMost of the time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eAll of the time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have felt cheerful and in good spirits\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003cp\u003e(8.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e58 (16.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e81 (23.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e49 (14.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e89 (25.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e40 (11.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have felt calm and relaxed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003cp\u003e(9.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e68 (19.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e77 (22.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e51 (14.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e82 (23.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e35 (10.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003eI have felt active and vigorous\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003cp\u003e(9.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e61 (17.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e89 (25.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003cp\u003e(15.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e81 (23.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003cp\u003e(8.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003eI woke up feeling fresh and rested\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e37 (10.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e59 (17.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e65 (18.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e56 (16.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e98 (28.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003cp\u003e(9.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003eMy daily life has been filled with things that interest me\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e35 (10.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e54 (15.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e78 (22.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e47 (13.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e88 (24.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e44 (12.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHQ-9\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results showed a mean score of 8.08 \u0026plusmn; 6.16 (median = 7.00). Of the participants, 131 (37.90 %) were classified as having major depression, while 215 (62.10 %) were classified as not having major depression (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Participants\u0026rsquo; response to the PHQ-9 (N=346)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"664\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eNot at all\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eseveral days\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003emore than half of the days\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003enearly everyday\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eLittle interest or pleasure in doing things\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e116 (33.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e129 (37.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e62 (17.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e39 (11.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eFeeling down, depressed, or hopeless\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e115 (33.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e126 (36.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e61 (17.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e44 (12.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eTrouble falling or staying asleep, or sleeping too much\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e106 (30.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e127 (36.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e67 (19.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e46 (13.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eFeeling tired or having little energy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e56 (16.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e164 (47.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e74 (21.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e52 (15.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003ePoor appetite or overeating\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e140 (40.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e113 (32.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e58 (16.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e35 (10.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eFeeling bad about yourself or that you are a failure or have let yourself or your family down\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e203 (58.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e79 (22.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e32 (9.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e32 (9.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eTrouble concentrating on things, such as reading the newspaper or watching television\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e169 (48.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e105 (30.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e39 (11.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e33 (9.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eMoving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e206 (59.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e88 (25.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e32 (9.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e20 (5.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"264\"\u003e\n\u003cp\u003e\u003cstrong\u003eThoughts that you would be better off dead, or of hurting yourself\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e227 (80.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e37 (10.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e20 (5.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e12 (3.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of factors associated with well-being\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGood well-being was significantly associated with older age women (p = 0.039), and higher exercise frequency per week (p \u0026lt; 0.001). Significant associations were observed between women\u0026rsquo;s well-being status and exercise (p \u0026lt; 0.001), sleeping hours (p = 0.014), history of cesarean section (p = 0.016), water-pipe smoking (p = 0.035), alcohol consumption (p = 0.038), different fertility clinics (p = 0.024) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e \u003cstrong\u003eBivariate analysis of the factors associated with participants\u0026rsquo; well-being (N=346)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u003cstrong\u003ePoor well-being\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003eGood well-being\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative variables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years) \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e33.10 \u0026plusmn; 6.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e34.54 \u0026plusmn; 6.66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.039\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (Mean rank)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (Mean rank)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eExercise frequency/week \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e173 (156.41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e173 (190.59)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative variables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value***\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eFertility clinics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.024\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eClinic 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e82 (47.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e103 (59.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eClinic 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e91 (52.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e70 (40.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eExercise \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e40 (23.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e72 (41.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e133 (76.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e101 (58.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eSleeping hours \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u0026lt; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e74 (42.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e52 (30.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u0026ge; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e99 (57.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e121 (69.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eHistory of cesarean section\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e26 (15.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e44 (25.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e147 (85.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e129 (74.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eWater pipe smoking\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.035\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eNon-smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e95 (54.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e99 (57.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e7 (4.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e18 (10.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eSmoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e71 (41.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e56 (32.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAlcohol consumption\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.038\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eNon-alcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e156 (90.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e150 (86.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eEx-alcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e9 (5.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e20 (11.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"32%\"\u003e\n\u003cp\u003eAlcoholic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"27%\"\u003e\n\u003cp\u003e8 (4.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e3 (1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; * Independent-samples t-test, ** Mann\u0026ndash;Whitney U test, *** Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of factors associated with depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen without major depression demonstrated lower water-pipe smoking frequency (p = 0.001) and higher exercise frequency (p = 0.006) compared with those with major depression. Significant associations were also observed between different fertility clinics (p = 0.001), living area (p = 0.027), consanguinity marriage (p = 0.038), exercise (p = 0.007), sleeping hours (p = 0.001), chronic medical conditions (p = 0.040), obesity as a cause of infertility (p = 0.019), and water-pipe smoking status (p = 0.006) (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e \u003cstrong\u003eBivariate analysis of the factors associated with participants\u0026rsquo; depressive symptoms (N=346)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo major depression\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajor depression\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative variables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (Mean rank)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (Mean rank)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eWater pipe smoking/week\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e215 (160.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e131(195.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eExercise frequency/week\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e215 (182.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e131 (157.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative variables\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value**\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eFertility clinics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eClinic 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e130 (60.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e55 (42.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eClinic 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e85 (39.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e76 (58.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eLiving area\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.027\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e110 (51.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e51 (38.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eCentral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e105 (48.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e80 (61.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eConsanguinity marriage\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.038\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e15 (7.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e18 (13.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e200 (93.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e113 (86.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eExercise\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e81 (37.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e31 (23.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e134 (62.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e100 (76.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eSleeping hours \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u0026lt; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e64 (29.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e62 (47.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u0026ge; 7 hrs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e151 (70.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e69 (52.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eChronic medical condition\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e73 (34.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e59 (45.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e142 (66.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e72 (55.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eObesity as an infertility cause\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e35 (16.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e35 (26.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e180 (83.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e96 (73.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e\u003cstrong\u003eWater pipe smoking\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eNon-smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e133 (61.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e61 (46.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e17 (7.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e8 (6.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003eSmoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"25%\"\u003e\n\u003cp\u003e65 (30.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e62 (47.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Mann\u0026ndash;Whitney U test, **Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluencing factors associated with well-being and depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn binary logistic regression analysis for the WHO-5, several factors were significantly associated with good well-being. Each additional weekly exercise session increased the odds of good well-being by a factor of 1.26 (OR = 1.260, p \u0026lt; 0.001). Women living in central areas had lower odds of good well-being compared with those living in rural areas (OR = 0.594, p = 0.028). Similarly, women attending one clinic had lower odds of good well-being compared with those attending another clinic (OR = 0.564, p = 0.021). Sleeping seven hours or more was associated with nearly double the odds of good well-being compared with sleeping less than 7 hours (OR = 1.904, p = 0.009). Being a former water pipe smoker was associated with four times higher odds of good well-being (OR = 4.039, p = 0.006). Additionally, having had a cesarean section was associated with more than double the odds of good well-being compared with not having had one (OR = 2.266, p = 0.007).\u003c/p\u003e\n\u003cp\u003eRegarding depression, each additional weekly water pipe smoking session increased the odds of depression by a factor of 1.10 (OR = 1.099, p = 0.002). Women attending one clinic had 2.06 times higher odds of depression compared with those attending another clinic (OR = 2.055, p = 0.003). Living in central areas was associated with 1.78 times higher odds of depression compared with living in rural areas (OR = 1.784, p = 0.017). Conversely, engaging in exercise was associated with 0.56 times lower odds of depression (OR = 0.564, p = 0.033), and sleeping seven hours or more per night was associated with 0.40 times lower odds of depression compared with sleeping less than seven hours (OR = 0.399, p \u0026lt; 0.001). Additionally, women who reported to have anxiety had 7.28 times higher odds of depression compared with those without anxiety (OR = 7.278, p = 0.031) (Table 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Binary logistic regression\u003c/strong\u003e\u003c/p\u003e\n\u003ctable width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"100%\"\u003e\n\u003cp\u003e\u003cstrong\u003eBinary logistic regression for the influencing factors associated with WHO-5 well-being index\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003e95% CI \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eExercise frequency/week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e1.260\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.11, 1.42]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eLiving area (central vs rural)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e0.594\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[0.37, 0.94]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.028\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eFertility clinics (2 vs 1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e0.564\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[0.34, 0.91]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.021\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eSleeping hours (\u0026ge;7 hrs vs \u0026lt;7 hrs)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e1.904\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.17, 3.07]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.009\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eWater pipe smoking (former smoker vs non-smoker)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e4.039\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.49, 10.94]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.006\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eCesarean section (Yes vs No)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e2.266\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.245, 4.093]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"100%\"\u003e\n\u003cp\u003e\u003cstrong\u003eBinary logistic regression for the influencing factors associated with PHQ-9 depression index\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eWater pipe sessions per week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e1.099\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.03, 1.16]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eFertility clinics (2 vs 1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e2.055\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.27, 3.32]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eLiving area (central vs rural)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e1.784\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.10, 2.87]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.017\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eExercise (yes vs no)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e0.564\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[0.33, 0.95]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.033\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eSleeping hours (\u0026ge;7 hrs vs \u0026lt;7 hrs)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e0.399\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[0.24, 0.65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"37%\"\u003e\n\u003cp\u003eAnxiety (yes vs no)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"15%\"\u003e\n\u003cp\u003e7.278\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e[1.19, 44.23]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003e0.031\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eVs = versus\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that 37.9% of the women had major depression (PHQ-9 mean score: 8.08 ± 6.16), and 50.00 % had poor well-being (WHO-5 mean score: 12.98 ± 6.39). Similar findings were reported in a study from Iran, where the prevalence of anxiety and depression among infertile women was 41.70% and 29.60% respectively (29). Another study in Switzerland reported a moderate WHO-5 well-being (mean = 13.89/25) (27). These findings suggest that the emotional burden of infertility is largely universal, with profound psychological consequences.\u003c/p\u003e\n\u003cp\u003eOlder age was significantly associated with higher well-being, in contrast to findings from Iranian studies reporting poorer mental health and QoL among older infertile women. (30,31). The divergence from previous studies may reflect that older women in our sample demonstrate greater emotional maturity, acceptance, and psychological adaptation, whereas younger women often view infertility as a major disruption to their life plans. However, this association was not significant in the multivariate analysis.\u003c/p\u003e\n\u003cp\u003eExercise seemed to be significantly associated with increasing the odds of good well-being and reducing the odds of depression. This aligns with findings from a Hungarian study showing that infertile women who exercised had better treatment and quality of life outcomes (32). Together, these findings suggest that promoting regular, structured physical activity within fertility care can enhance well-being and improve the overall treatment outcomes.\u003c/p\u003e\n\u003cp\u003eSleeping seven hours or more has been shown to be an influencing factor in nearly doubling the odds of good well-being and significantly reducing the odds of depression among participants. Similarly, prior studies in China and Denmark found that poor sleep quality is associated with psychological distress, anxiety, depression and poor pregnancy outcomes (33,34). Therefore, good sleep helps improve mood, reduce stress, and boost energy, making it easier for infertile women to cope with treatment challenges.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiving in central areas increased the odds of having major depression and reduced the odds of good well-being. Our results contrast the findings in China and Iran, where infertile women who lived in rural areas had significantly lower QoL in the economic, emotional, sexual, physical and psychological aspects (35,36). A possible explanation for our results could be that living in central areas induces urban stressors such as living costs, fast-paced lifestyles, and greater exposure to environmental stressors alongside cultural differences across settings.\u003c/p\u003e\n\u003cp\u003eBeing a former\u0026nbsp;\u003c/p\u003e\n\u003cp\u003epipe smoker compared to a non-smoker increased the odds of well-being fourfold; in the same context, the increased frequency of water pipe smoking significantly increases the odds of major depression. These results are consistent with previous findings in Iran and Saudi Arabia showing a poorer health-related quality of life and a higher prevalence of major depression among water pipe smokers, respectively (37,38). This pattern implies that while continued smoking negatively affects psychological health, cessation may lead to recovery or improvement. These findings emphasize the importance of addressing water pipe smoking among women facing infertility.\u003c/p\u003e\n\u003cp\u003eIn search of predictors, different fertility clinics appeared to significantly impact WHO-5 and PHQ-9 indices in terms of lowering the odds of well-being and doubling the odds of depression, respectively. This aligns with findings from a meta-analysis and a Portuguese study, which emphasize that a lack of compassion in the healthcare environment, coupled with poor communication, negatively impacts women's infertility experiences and treatment (39,40). Such results may be explained by variations in institutional factors such as counseling approaches, privacy, staff expertise, or patient psychological support systems, which can significantly influence patients’ emotional experiences during fertility management.\u003c/p\u003e\n\u003cp\u003eWomen with a history of cesarean were more likely to report better well‑being. This finding may be explained by the fact that women with a history of cesarean section have previously achieved a live birth, which may provide psychological reassurance, a sense of reproductive capability, and greater optimism.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnxiety was strongly associated with the PHQ-9 depression index, with women reporting anxiety as a part of their past medical history being over seven times as likely to have major depression. This aligns with a Chinese research showing that infertile women experience elevated anxiety and depression compared with the general population (41). These findings suggest that existing anxiety amplifies the psychological burden and the depressive symptoms among women with infertility.\u003c/p\u003e\n\u003cp\u003eThis study aims to assess the well-being and depression among Lebanese women experiencing infertility. This study’s strengths include a robust sample size and the use of validated scales to accurately assess the psychological well-being and depression. Additionally, the application of multivariate analysis allowed for controlling potential confounders, enhancing the reliability of the findings. The study's cross-sectional design is a limitation, as it cannot establish causality, only generate hypotheses. Although participants were from various regions, the study was conducted in clinics in Beirut and among women experiencing infertility and actively seeking fertility treatment. This may have introduced selection bias, as these women could differ from infertile women not seeking or not having access to specialized care, potentially limiting the generalizability of the findings to the broader population of Lebanese women experiencing infertility. Information bias is another concern, as the sensitive nature of some questions could lead to under- or over-reporting.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA considerable psychological burden was observed among Lebanese women with infertility, with over one-third experiencing major depression and half reporting poor well-being. Physical activity and adequate sleep were consistently associated with better mental health outcomes, while water pipe smoking, anxiety, living in central areas, and clinic-related factors were linked to poorer well-being and higher depression. These findings may guide healthcare professionals in developing supportive programs that integrate psychological support, patient-centered care, and culturally sensitive interventions. Implementing mental health screening, counseling, lifestyle guidance, and stress-management programs, alongside clear communication and empathetic care, may strengthen emotional resilience and improve treatment experiences. Further research is needed to monitor changes in well-being and evaluate the effectiveness of psychosocial interventions on depression.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO-5\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization Well-Being Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHQ-9\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Health Questionnaire-9\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAssisted Reproductive Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePhD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDoctor of Philosophy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFrequency or mean rank\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States Dollar\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eY\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHrs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehours\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVersus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003e \u003cb\u003eDescription of the scores\u003c/b\u003e \u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eWHO-5\u003c/strong\u003e \u003cp\u003eThe results showed a mean score of 12.98\u0026thinsp;\u0026plusmn;\u0026thinsp;6.39 (median\u0026thinsp;=\u0026thinsp;12.50). Half of the participants (50.00%) were classified as having a good well-being (Table\u0026nbsp;2).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have declared that no competing interests exist.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eSubmission declaration and verification\u003c/h2\u003e \u003cp\u003eThis manuscript is not under consideration for publication elsewhere.\u003c/p\u003e \u003cp\u003e All authors have approved the manuscript for submission, and the research has received approval from the institutional review board of the School of Pharmacy at the Lebanese University and the Clinical Research Unit at Al Zahraa Hospital University Medical Center. If accepted, this article will not be published elsewhere in the same form, in English or any other language, without written consent from the copyright-holder.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding Source\u003c/h2\u003e \u003cp\u003eNo funding was received for the conduct of this research and preparation of the article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and study design: Amal Al-Hajje, Roula Ajrouche, Joanna Jaffal, Reva MoslehAcquisition of Data: Jana Kassir, Hiba Assi, Reva MoslehAnalysis and Interpretation of Data: Joanna Jaffal, Reva MoslehWriting original draft: Joanna Jaffal, Reva MoslehRevising \u0026amp; editing: Amal Al-Hajje, Roula Ajrouche, Malak Issa, Hassan Ajami, Joseph AzouryFinal approval: All authors have approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThank you for considering our manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. Due to the sensitive nature of the data and to protect patient privacy, they are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInfertility, World health Organization Fact Sheets [Internet]. World Health Organization. ; 2025 Nov. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/infertility\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/infertility\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLebanon Fertility. Rate 1950\u0026ndash;2025 [Internet]. 2025 Nov. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.macrotrends.net/global-metrics/countries/lbn/lebanon/fertility-rate\u003c/span\u003e\u003cspan address=\"https://www.macrotrends.net/global-metrics/countries/lbn/lebanon/fertility-rate\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePuscheck E. Elizabeth. Practice Essentials, Overview, Etiology of Infertility [Internet]. 2024 May. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://emedicine.medscape.com/article/274143-overview#a1\u003c/span\u003e\u003cspan address=\"https://emedicine.medscape.com/article/274143-overview#a1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThoma M, Fledderjohann J, Cox C, Kantum Adageba R. Biological and Social Aspects of Human Infertility: A Global Perspective. In: Oxford Research Encyclopedia of Global Public Health [Internet]. Oxford University Press; 2021 [cited 2025 Dec 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://oxfordre.com/publichealth/view/\u003c/span\u003e\u003cspan address=\"https://oxfordre.com/publichealth/view/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-184\u003c/span\u003e\u003cspan address=\"10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuhnt AK, Passet-Wittig J. Families formed through assisted reproductive technology: Causes, experiences, and consequences in an international context. Reprod Biomed Soc Online. 2022;14:289\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNik Hazlina NH, Norhayati MN, Shaiful Bahari I, Nik Muhammad Arif NA. Worldwide prevalence, risk factors and psychological impact of infertility among women: a systematic review and meta-analysis. BMJ Open. 2022;12(3):e057132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahimi R, Hasanpour S, Mirghafourvand Mojgan, Esmaeilpour K. Effect of Hope-oriented group counseling on mental health of infertile women with failed IVF cycles: a randomized controlled trial. BMC Psychiatry. 2021;21(1):286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWojciechowska P, Milska-Musa KA. Quality of life and mental state of women trying to conceive using the in vitro method. Eur J Trans Clin Med. 2024 June;14(1):106\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerg BJ, Wilson JF. Psychiatric morbidity in the infertile population: a reconceptualization. Fertil Steril. 1990;53(4):654\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZayed AA, El-Hadidy MA. Sexual satisfaction and self-esteem in women with primary infertility. Middle East Fertil Soc J. 2020;25(1):13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie Y, Ren Y, Niu C, Zheng Y, Yu P, Li L. The impact of stigma on mental health and quality of life of infertile women: A systematic review. Front Psychol. 2022;13:1093459.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahakian JPKK, El Helou E, Azoury J, Salameh L, Abou Jaoude I, Sleilaty G. Infertility within the Lebanese population: beliefs and realities. Middle East Fertil Soc J. 2020;25(1):27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Obeisat S, Hayajneh A, Hweidi I, Abujilban S, Mrayan L, Alfar R, et al. Psychometric properties of the Arabic version of the Fertility Quality of Life (FertiQoL) questionnaire tested on infertile couples in Jordan. BMC Women\u0026rsquo;s Health. 2023;23(1):283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInfertility Workup for the Women\u0026rsquo;s Health Specialist. ACOG Committee Opinion, Number 781. Obstet Gynecol. 2019 June;133(6):e377\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenters for Disease Control and Prevention. Epi Info\u003csup\u003e\u0026trade;\u003c/sup\u003e version 7.2.6 [Internet]. 2023 [cited 2025 Feb 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/epiinfo/pc.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/epiinfo/pc.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLebanon Demographics Population, Population of Lebanon. (2024) [Internet]. worldometers; 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://srv1.worldometers.info/demographics/lebanon-demographics/\u003c/span\u003e\u003cspan address=\"http://srv1.worldometers.info/demographics/lebanon-demographics/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDia N, Mansour S, Kharaba Z, Malaeb B, Sarray El Dine A, Kokash S et al. Factors associated with infertility among the Lebanese population: a cross-sectional study. Int J Environ Health Res. 2023;1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma R, Biedenharn KR, Fedor JM, Agarwal A. Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol. 2013;11(1):66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalker MH, Tobler KJ. Female Infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sept 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK556033/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK556033/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeslie SW, Soon-Sutton TL, Khan MA. Male Infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sept 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK562258/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK562258/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al. The International Glossary on Infertility and Fertility Care, 2017. Fertil Steril. 2017 Sept;108(3):393\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammarberg K, Stocker R, Romero L, Fisher J. Pregnancy planning health information and service needs of women with chronic non-communicable conditions: a systematic review and narrative synthesis. BMC Pregnancy Childbirth. 2022;22(1):236.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKassab Alshayea A. Development and Validation of an Arabic Version of the World Health Organization Well-Being Index (WHO-5). J Psychopathol Behav Assess. 2023;45(1):247\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoumit R, Hallit S, Sanchez-Ruiz MJ, El Khoury-Malhame M. Psychometric validation of an Arabic version of the WHO-5 wellbeing index among Lebanese adolescents. Metzler J, editor. PLoS One. 2025 July 17;20(7):e0317644.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSummaka M, Zein H, Abbas LA, Elias C, Elias E, Fares Y, et al. Validity and Reliability of the Arabic Patient Health Questionnaire-9 in Patients with Spinal Cord Injury in Lebanon. World Neurosurg. 2019;125:e1016\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCronbach LJ. Coefficient Alpha and the Internal Structure of Tests. Psychometrika 1951 Sept;16(3):297\u0026ndash;334.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernet M, Quaas AM, von Wolff M, Santi A, Streuli I, Wunder D, et al. Quality of life, spiritual needs, and well-being of people affected by infertility and its treatment: quantitative results of a mixed-methods study. J Assist Reprod Genet. 2025 June;42(6):1853\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevis B, Benedetti A, Thombs BD. DEPRESsion Screening Data (DEPRESSD) Collaboration. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ. 2019;365:l1476.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForoudifard F, Amini P, Navid B, Omani-Samani R, Sepidarkish M, Maroufizadeh S. Cognitive emotion regulation, anxiety, and depression in infertile women: a cross-sectional study. Middle East Fertil Soc J. 2020;25(1):24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakhtiyar K, Beiranvand R, Ardalan A, Changaee F, Almasian M, Badrizadeh A, et al. An investigation of the effects of infertility on Women\u0026rsquo;s quality of life: a case-control study. BMC Women\u0026rsquo;s Health. 2019;19(1):114.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshraf DM, Ali D, Azadeh DM. Effect of infertility on the quality of life, a cross- sectional study. J Clin Diagn Res. 2014;8(10):OC13\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePr\u0026eacute;musz V, Makai A, G\u0026aacute;cs B, Nagy \u0026Aacute;, Perj\u0026eacute;s B, \u0026Aacute;cs P, et al. Preliminary study on pre-treatment physical activity and quality of life in infertility. EQOL. 2019;11(2):5\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi QL, Wang C, Cao KX, Zhang L, Xu YS, Chang L, et al. Sleep characteristics before assisted reproductive technology treatment predict reproductive outcomes: a prospective cohort study of Chinese infertile women. Front Endocrinol. 2023;14:1178396.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhilipsen MT, Knudsen UB, Zachariae R, Ingerslev HJ, Hvidt JEM, Frederiksen Y. Sleep, psychological distress, and clinical pregnancy outcome in women and their partners undergoing in vitro or intracytoplasmic sperm injection fertility treatment. Sleep Health. 2022;8(2):242\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNi Y, Tong C, Huang L, Zhou W, Zhang A. The analysis of fertility quality of life and the influencing factors of patients with repeated implantation failure. Health Qual Life Outcomes. 2021;19(1):32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNamdar A, Naghizadeh MM, Zamani M, Yaghmaei F, Sameni MH. Quality of life and general health of infertile women. Health Qual Life Outcomes. 2017;15(1):139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTavafian SS, Aghamolaei T, Zare S. Water pipe smoking and health-related quality of life: a population-based study. Arch Iran Med. 2009;12(3):232\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsanosy R, Prevalence. Knowledge, Attitude, and Predictors of Waterpipe Smoking among School Adolescents in Saudi Arabia. Santangelo OE, editor. Global Health. 2022 Sept 30;2022:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssaysh-\u0026Ouml;berg S, Borneskog C, Ternstr\u0026ouml;m E. Women\u0026rsquo;s experience of infertility \u0026amp; treatment \u0026ndash; A silent grief and failed care and support. Volume 37. Sexual \u0026amp; Reproductive Healthcare; 2023 Sept. p. 100879.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePedro J, Canavarro MC, Boivin J, Gameiro S. Positive experiences of patient-centred care are associated with intentions to comply with fertility treatment: findings from the validation of the Portuguese version of the PCQ-Infertility tool. Hum Reprod. 2013 Sept;28(9):2462\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang L, Tang Y, Wang Y. Predictors and incidence of depression and anxiety in women undergoing infertility treatment: A cross-sectional study. PLoS ONE. 2023;18(4):e0284414.\u003c/span\u003e\u003c/li\u003e\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":"Women’s health, psychological well-being, mental health, depression, infertility, reproductive health.","lastPublishedDoi":"10.21203/rs.3.rs-8473666/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8473666/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInfertility is frequently associated with psychological distress; however, evidence remains limited on mental health outcomes among Lebanese women experiencing infertility. This study aimed to assess the psychological well-being and depression using the World Health Organization Well-Being Index (WHO-5) and the Patient Health Questionnaire-9 (PHQ-9), and to identify factors influencing each outcome.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted between June and September 2024 and included 346 Lebanese women recruited from two fertility centers in Beirut. Participants were randomly selected and completed a structured questionnaire through individual interviews. Descriptive and bivariate analyses were performed, and binary logistic regressions were used to identify the factors influencing each of the well-being and depression indices.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the participants, 50.00% had poor well-being and 37.90% had major depression. Good well-being was significantly associated with exercise frequency per week (OR\u0026thinsp;=\u0026thinsp;1.260), sleeping seven hours or more (OR\u0026thinsp;=\u0026thinsp;1.904), being a former water-pipe smoker (OR\u0026thinsp;=\u0026thinsp;4.039), having a history of previous cesarean section (OR\u0026thinsp;=\u0026thinsp;2.266), living in rural areas (OR\u0026thinsp;=\u0026thinsp;0.594), and attending different fertility clinics (OR\u0026thinsp;=\u0026thinsp;0.564). Moreover, major depression was significantly associated with more frequent water pipe smoking (OR\u0026thinsp;=\u0026thinsp;1.099), attending different fertility clinics (OR\u0026thinsp;=\u0026thinsp;2.055), living in central areas (OR\u0026thinsp;=\u0026thinsp;1.784), and having a past medical history of anxiety (OR\u0026thinsp;=\u0026thinsp;7.278). However, no major depression was associated with exercise (OR\u0026thinsp;=\u0026thinsp;0.564), nor with sleeping seven hours or more (OR\u0026thinsp;=\u0026thinsp;0.399).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLifestyle, behavioral, clinical, and demographic factors significantly influence the well-being and depression among Lebanese women experiencing infertility. Integrating psychological support and patient care services into fertility services is essential to improve outcomes.\u003c/p\u003e","manuscriptTitle":"Psychological well-being and depression among Lebanese women with infertility: influencing factors and implications for care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 13:53:00","doi":"10.21203/rs.3.rs-8473666/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":"7880b704-f04f-4d8c-aef1-3ebe70d94ffc","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T07:58:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-09 13:53:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8473666","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8473666","identity":"rs-8473666","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}