Prevalence of Anxiety and Associated Factor Among Infertile Couples in Eastern India: A Cross-Sectional Study

INTRODUCTION

Infertility affects millions of people and has an impact on their families and communities. Estimates suggest that approximately one in every six people of reproductive age worldwide experience infertility in their lifetime.^[1] In males, infertility is most commonly caused by problems due to the absence or low levels of sperm, abnormal shape (morphology), movement (motility), and the ejaculation of semen. In females, infertility may be caused by a range of abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine system. Infertility is subdivided into primary and secondary. Primary infertility denotes those patients who have never conceived; however, secondary infertility indicates previous pregnancy but failure to conceive subsequently. Out of 60–80 million couples suffering from infertility globally, 15–20 million (25%) are in India.^[2,3] According to a World Health Organisation (WHO) report, more than 10% of women are affected by infertility.^[4] Infertility is increasing primarily in urban areas due to late marriages.

Childbirth is considered a valued role in our society.^[5] As a result, infertile couples often experience feelings of anxiety, loss of self-esteem, and depression.^[6] WHO identifies infertility as a major healthcare and social problem that leads to mental health issues like depression and anxiety, marital conflict, social isolation, and sexual dysfunction.^[7] Although both women and men can suffer from infertility, women are often perceived to suffer from infertility, regardless of whether they are infertile or not. Infertility has significant negative social impacts on the lives of infertile couples and, particularly, women who frequently experience domestic violence, divorce, and social stigma.^[8] Evaluation and treatment of infertility are not available and accessible in many countries. There are not many government schemes which focus on the reproductive and fertility health of couples.

Despite the importance of psychiatric disorders in infertile couples, there has been little research on anxiety and depression assessment in infertile couples in recent years. The objective of our study was to assess the prevalence of anxiety and its association with fertility and demographic characteristics in infertile couples attending the outpatient department (OPD) in a tertiary care hospital.

MATERIAL AND METHODS

This was a cross-sectional study done on 109 infertility patients attending OPD in a tertiary care hospital in West Bengal from Dec 2023 to June 2024. Informed verbal consent was taken before including the participant in the study. The operational definition of infertility by the WHO states that infertility is a disease of the male or female reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.^[9]

RESULTS

The mean age of the respondents was 36.23 ± 4.64 years. Most patients in the study had primary infertility (88.99%). Most of the respondents were female (96.33%). Around 1/3 of patients had attained education up to graduation and above (36.70%). More than half of the couples (57.29%) received mental health services. Only 12.84% of patients had a prior abortion history. Duration of infertility was 5.80 ± 4.62 years. The prevalence of anxiety among infertility patients was 56.88% [Table 1].

A cutoff value of 10 or more was used to categorise it into anxious and non-anxious. After doing logistic regression, according to adjusted analysis, women aged more than 35 years were 2.52 times more likely to develop anxiety compared to women below 35 years of age (OR 2.522, p-value 0.042). Women with primary education compared with secondary education were 3.47 times more likely to develop GAD (OR 0.288, p-value 0.002). Participants from lower socio-economic classes were 1.91 times more likely to have anxiety compared to infertile patients from higher socio-economic classes (OR 1.910, p-value 0.001). Participants who didn’t receive MHS during their treatment had 3.74 times higher chances of developing anxiety (OR 0.267, p-value −0.003) [Table 2].

Among anxious infertile patients, 29.16% fall into the mild category, 65.28% into the moderate category, and the rest 5.56% into the severe category [Figure 1].

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Figure 1:

Prevalence and severity of anxiety among infertile individuals (n = 109).

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DISCUSSION

The present study shows that the majority (44.95%) of the infertile patients were in the age group of 26–35 years, which was similar to the findings of a study conducted by Verma P et al., which found that most of the infertile women were in the age group of 26–35 years.^[11] The majority of the patients (88.99%) who participated in our study were having primary infertility, while 11.01% were suffering from secondary infertility, which is consistent with the findings done by Abdelhafid Benksim et al.^[12] and Kalpana Singh et al.,^[13] which can be explained by the fact that having a single child prevents them from being tagged as a childless couple. The majority of the participants were female, which can be due to the patriarchal nature of society and the false belief that men can’t be the reason for infertility.

Our study reported that nearly 46.8% of infertile couples were anxious, as measured by the GAD scale. The findings are consistent with several studies done in India and abroad.^{[14, 15, 16]} This can be explained by the fact that infertility predisposes social exclusion, deprivation, broken marriages, loss of self-esteem, feelings of shame, self-blame, and hence anxiety in infertile couples. This study also proposes that older women aged more than 35 years are more anxious, which could be understood by the fact that infertility treatment has poor outcomes with increasing age. Older age women are also more prone to delivering babies with congenital anomalies, thereby increasing anxiety among couples. Our study also found that the likelihood of anxiety increases with lower education levels, as has been reported by several studies.^[17,18] Higher education enlightens people about the biological basis for infertility and, hence, believes in the treatment. They are open-minded to issues of childbirth and have a better mindset to accept the consequences of being infertile in comparison to low-educated people who have traditional thinking and beliefs that childbirth is the primary task of marriage. This study found that GAD is more prevalent in lower socio-economic status couples and has been reported the same by Dijkstra-Kersten et al.^[19] It can be due to the higher cost of treatment of infertility, including ART.

We want to propose that mental health services can significantly reduce the prevalence of anxiety among infertile couples. Counsellors or doctors sitting in the hospital should educate patients about the pathology of the disease, possible treatment alternatives, and possible prognosis in a positive way. It reduces the negative psychological impact of infertility.

Our study didn’t find any association between OCP usage and anxiety among infertile couples. However, a study done by Poroma ISM et al.^[20] reported an association between OCP use and anxiety. Usually, increasing duration of marriage increases anxiety among couples; however, our study didn’t find any association. Maroufizadeh et al.^[21] and Ogawa et al.^[22] also reported no relationship between anxiety and duration of infertility. This might be due to delays in family planning in urban areas these days. The type of family, whether joint or nuclear, doesn’t affect the prevalence of anxiety in infertile couples.

CONCLUSION

The prevalence of GAD among infertile couples is high, particularly in patients aged more than 35 years and with low education levels and lower socioeconomic class. The study suggests that appropriate GAD screening should be done for all infertile individuals, and mental health services should be provided to all couples taking treatment for infertility.