ORIGINAL PAPER
Psychological Burden in Couples with Infertility and Its Association with Sexual Dysfunction
Thanh Tam Thi Ho1,2 · Minh Tam Le1,2 · Quang Vinh Truong1 · Vu Quoc Huy Nguyen1 · Ngoc Thanh Cao1,2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
This study aimed to assess the rate and level of depression, anxiety, and stress among peo- ple with infertility and the association between psychological disorders and sexual dysfunc- tion. In this cross-sectional study, we investigated 255 couples with infertility undergoing examination at a university hospital between January and December 2017. The assessment tools included the Depression, Anxiety and Stress Scale-21, Female Sexual Function Index (FSFI), Premature Ejaculation Diagnostic Tool (PEDT), and International Index of Erectile Function-15 (IIEF-15). The rates and mean scores of depression, anxiety, and stress among wives were statistically significantly higher than among husbands. Additionally, there was a slight negative correlation between all these scores and FSFI score among wives. Simi- larly, these scores among husbands were slightly negatively correlated with IIEF-15 score and positively correlated with PEDT score. Development of a holistic approach to infertil- ity management is necessary and psychological issues should be addressed together with sexual problems.
Keywords Infertility · Depression · Anxiety · Stress · Sexual dysfunction · Vietnam
Introduction
Infertility is a common health problem, with prevalence rates ranging from 15 to 20% [6]
and it is supposed to be associated with an increased prevalence of psychological disorders such as depression, anxiety, and stress [7]. These disorders destabilize individuals, inter- personal relationships, and marital life. In particular, they can interfere with fertility and increase the probability of quitting infertility treatment [13, 18]. Recently, Belevska [5]
reported that psychological support in infertility treatment protocols increased the success rate of in vitro fertilization.
* Minh Tam Le
1 Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, 06 Ngo Quyen St, Hue City, Vietnam
2 Center for Reproductive Endocrinology and Infertility, Hue University Hospital, Hue University, 06 Ngo Quyen St, Hue City, Vietnam
A perusal of the current medical literature reveals that the rates of psychological disorders in people with infertility vary widely. In previous studies, the rates of depres- sion and anxiety among wives ranged from 2.7 to 79% and 14 to 70%, respectively, and from 1.8 to 36.7% and 4.5 to 48.3%, respectively, among husbands [3, 8, 12, 15, 24, 30]. Studies in Iran and Pakistan have reported stress rates ranging from 48.3 to 69% among wives, with the figure among husbands standing at 33.3% [24, 30]. In a study conducted in Saudi Arabia, among couples with infertility, depression and anxi- ety rates were reported to be 21.7% and 21.2%, respectively [2].
The psychological pressure associated with infertility can be responsible for the prevalence of sexual dysfunction among couples with infertility, as opposed to sexual dysfunction leading to increased psychosocial burden [17, 21]. There have been vary- ing reports regarding theassociation between psychological disorders and sexual dys- function. For example, Gao et al. [12] concluded that both erectile dysfunction and premature ejaculation were moderately correlated with depression and anxiety. Lotti et al. [16] reported a mild correlation between erectile dysfunction and depression and between premature ejaculation and anxiety. Female sexual function was demonstrated to display a trend toward a negative correlation with depression [19].
Providing data on psychological burden and its correlation with sexual dysfunc- tion can contribute to the development of a step-by-step strategy toward psychologi- cal interventions in infertility management programs, as recommended by the WHO.
However, so far, there has been no study on this issue in Vietnam. Therefore, the pre- sent study aimed to (1) assess the rates and levels of depression, anxiety, and stress among wives, husbands, and couples with infertility and (2) investigate the association between psychological disorders and sexual dysfunction.
Methods
This study employed a cross-sectional design. We studied a cohort of 255 couples with infertility who were being examined at the Center for Reproductive Endocrinology and Infertility, Hue University Hospital from January to December 2017.
The exclusion criteria were ethnic minorities, illiteracy, psychiatric disorders, known drug or alcohol dependence, treatment with antihypertensive medications or hormones, penile anatomic defects, and no sexual activity over the past 4 weeks. As the primary outcome, the Depression, Anxiety and Stress Scales-21 (DASS-21) was used to measure psychological disorders.
Couples with infertility who visited our clinic during the study period were pro- vided with a letter explaining the study’s purpose and method. Informed consent was obtained from all individual participants included in the study. The couples who agreed to participate were asked to provide information on sociodemographics and his- tory of infertility. The husbands and wives were then individually asked to complete the DASS-21 and sexual function questionnaires in private (i.e., without the presence of their partners). Each individual respondent was assigned an identification code, but no personal information was recorded.
Instruments DASS‑21
In this study, we used a shortened 21-item Vietnamese version of the DASS-42. The DASS-21 has previously been validated by Tran et al. [26]. The depression subscale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest/
involvement, anhedonia, and inertia. The anxiety subscale assesses autonomic arousal, skeletal muscle effects, situation anxiety, and subjective experience of anxious affect.
The stress subscale assesses difficulty in relaxing, nervous arousal, being easily upset/
agitated, irritable/overreactive, and impatient. Each subscale has seven items. The score of each item can range from 0 (no symptomatology) to 3 (severe symptomatology). The total depression, anxiety and stress scores are calculated by summing the scores of all items from each subscale; these scores are then doubled to match the diagnostic thresh- old of the DASS-42.
Sexual Function Questionnaires
These instruments were translated back and forth between Vietnamese and English to con- firm their accuracy.
Female Sexual Function Index [22]
The Female Sexual Function Index (FSFI) is a multiple choice, self-reported instrument including 19 items across six domains of female sexual function (desire, arousal, lubrica- tion, orgasm, satisfaction, and pain). Individual domain scores are obtained by summing up the scores of the corresponding items and multiplying them by the domain factor. The total score is obtained by summing up six domain scores, with a higher score indicating a better level of sexual functioning.
Premature Ejaculation Diagnostic Tool [25]
The Premature Ejaculation Diagnostic Tool (PEDT) is a multiple choice, self-reported questionnaire for diagnosing premature ejaculation, including five items related to control, frequency, minimal stimulation, distress, and interpersonal difficulty. The PEDT total score is calculated by summing up the scores of these items, with a lower score indicating a bet- ter level of sexual functioning.
International Index of Erectile Function [23]
The International Index of Erectile Dysfunction-15 (IIEF-15) is a multiple choice, self- reported questionnaire for assessment of erectile dysfunction that includes 15 items across five domains (erectile function, orgasmic function, sexual desire, intercourse satisfaction,
and overall satisfaction). The IIEF-15 total score is calculated by summing up the scores of these domains, with a higher score indicating a better level of sexual functioning.
Statistical Analysis
Descriptive statistics were calculated for all variables. The Chi square (χ2) test with a sig- nificance level of α = 0.05 was used to compare the difference between two or more pro- portions. A linear regression analysis was conducted to determine the association between psychological disorders and sexual dysfunction. Statistical significance was defined as p < 0.05.
The data were analyzed with the Statistical Package for the Social Sciences version 20.0 (SPSS Inc, Chicago, USA).All data were encrypted and confidential.
Results
A total of 255 couples completed all the relevant surveys. The general characteristics of the sample are presented in Table 1.
Prevalence of Depression, Anxiety, and Stress
The prevalence rates of psychological disorders in participants with infertility are presented in Table 2. The rates of depression, anxiety, stress and at least one of the three disorders among wives were 16.1%, 27.5%, 12.9%, and 33.3%, respectively; the rates among hus- bands were 6.3%, 15.3%, 5.1%, and 18.4%, respectively; among couples, these rates were 20.0%, 36.5%; 16.9%, and 40.8%, respectively. Regarding severity, about half of these dis- orders were moderate to very severe. Especially, the rates and mean scores of depression, anxiety and stress among wives were statistically significantly higher than among husbands (Table 2, Fig. 1). The mean scores of depression, anxiety, and stress were 2.27 ± 2.64, 2.38 ± 2.53, and 3.95 ± 3.09 in wives and 1.34 ± 2.23, 1.69 ± 1.91, and 3.12 ± 2.76 in hus- bands, respectively.
Association Between Psychological Disorders and Sexual Dysfunction
As reported in Table 3, among wives, there was a slight negative correlation between the scores of depression, anxiety, and stress and FSFI score (coefficient |r|: 0.238–0.276, p < 0.001). Similarly, the depression, anxiety, and stress scores among husbands were slightly negatively correlated with IIEF score and positively correlated with PEDT score (coefficient |r|: 0.200–0.285, p < 0.001).
Discussion
The results showed that among participants with infertility, there was a high prevalence of psychological disorders: nearly half of the couples, about a third of wives, and one-fifth of husbands experienced them. The severity of about half of these disorders ranged from moderate to very severe. Especially, wives experienced more severe psychological pressure
than husbands. Furthermore, psychological disorders in both husbands and wives were associated with sexual dysfunction.
Psychological disorders among the participants of our study were more severe than reported in the general population. The rates of depression, anxiety, stress and at least one mental disorder in our study were higher than those previously reported among married men [27] and Northern rural women [26] in Vietnam. In studies from various regions, among couples with infertility, psychological pressure in both wives and husbands was higher than in the control groups [1, 7, 9–11, 30].
Among couples with infertility, psychological burden was associated with a common reason for marriage—having children. This is considered a necessary criterion not only for achieving personal satisfaction but also social acceptance. When facing infertility, Table 1 General characteristics of the infertile couples
Factors Mean ± SD (range) n (%)
Wives Husbands Wives Husbands
Age (years) 31.29 ± 5.06 (20–46) 34.33 ± 6.08 (22–59) Education
Primary school 6 (2.4%) 7 (2.8%)
Secondary school 43 (16.9%) 49 (19.2%)
Secondary high school 58 (22.7%) 75 (29.4%)
University 148 (58.0) 124 (48.6%)
Employment status
Employed 227 (89.0%) 253 (99.2%)
Unemployed 28 (11.0%) 2 (0.8%)
Religion
Yes 62 (24.3%) 51 (20.0%)
No 193 (75.7%) 204 (80.0%)
Couples (255) Socioeconomic status (self-
reported)
Low 15 (5.9%)
Medium 229 (89.8%)
High 11 (4.3%)
Duration of marriage (years) 4.98 ± 3.98 (1–18) Duration of infertility (years) 3.77 ± 3.05 (1–17.7) Infertility type
Primary 179 (70.2%)
Secondary 76 (29.8%)
Infertility cause
Female 84 (32.9%)
Male 79 (31.0%)
Combined 57(22.4%)
Unexplained 35(13.7%)
Duration of infertility treatment
(months) 13.10 ± 12.36 (1–62)
In vitro fertilization 18 (7.1%)
couples are likely to have negative emotional responses, such as feelings of defective- ness, incompetence, loss, and disappointment. They also may experience stigma and pressure from family members and the people around them and worry about old age without children. In addition, the process of diagnosis and infertility treatment increases psychological pressure [13, 18, 21].
Table 2 Percentage of psychological disorders in wives, husbands, and couples with infertility
Depression Anxiety Stress At least one of the three Wives
Disorder 16.1 27.5 12.9 33.3
Mild 6.7 9.8 7.5
Moderate 8.2 11.8 3.9
Severe 0.8 4.3 1.6
Very severe 0.4 1.6 0.0
Husbands
Disorder 6.3 15.3 5.1 18.4
Mild 3.5 6.3 2.0
Moderate 1.6 7.5 2.0
Severe 0.4 0.8 0.8
Very severe 0.8 0.8 0.4
Couples
Disorder 20.0 36.5 16.9 40.8
Abnormal wives–normal husbands 13.7 21.2 11.8
Normal wives–abnormal husbands 3.9 9.0 3.9
Abnormal wives–abnormal husbands 2.4 6.3 1.2
p (disorder of wives–husbands) 0.0008 0.0012 0.0035 0.0002
Fig. 1 Comparison of the mean Depression, Anxiety and Stress Scales-21 scores between wives and husbands of infertile couples
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Depresion Anxiety Stress
Husband Wife
Previous studies have reported widely varying rates and levels of depression, anxiety, and stress in participants with infertility; such variations are related to differences in the standardized psychometric self-reported instruments used, dissimilar cultural and geo- graphical regions, and varying infertility characteristics of study groups. Such differences are presented in Table 4.
Although previous studies used widely varying diagnostic instruments, they showed a consistent pattern: the rates and/or levels of depression in both wives and husbands were comparable with the anxiety rates in those same studies. This suggests the high reliabil- ity of instruments. However, the diagnostic thresholds of the instruments were unlikely to result in consistent discriminant validity between clinical and nonclinical populations.
Table 3 Correlation of mean DASS-21 scores with FSFI, IIEF-15 and PEDT scores
DASS-21, Depression, Anxiety and Stress Scales-21; FSFI, Female Sexual Function Index; IIEF 15, International Index of Erectile Func- tion-15; PEDT, Premature Ejaculation Diagnostic Tool
FSFI IIEF-15 PEDT
p r p r p r
Depression < 0.000 − 0.274 < 0.000 − 0.276 < 0.000 0.285 Anxiety < 0.000 − 0.238 < 0.000 − 0.255 < 0.000 0.261 Stress < 0.000 − 0.276 < 0.001 − 0.200 < 0.000 0.233
Table 4 Studies on depression, anxiety, and stress in people with infertility
W, Wives; H, Husbands; DASS, Depression, Anxiety and Stress Scales; CES-D, Center for Epidemiologic Studies-Depression; STAI, State Trait Anxiety Inventory; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; HADS, Hospital Anxiety and Depression Scale; ZAS, Zung Anxiety Scale; ZDS, Zung Depression Scale; PCEMD, Primary Care Evaluation of Mental Disorders; SAS, Self-rating Anxiety Scale;
SDS, Self-rating Depression Scale; SCL-90-R, Symptom Checklist-90-R
Country/region Depression Anxiety Stress Instrument
W H W H W H
South Korea [7] 13.7 (8.4) 10.7 (6.4) 18.0 (8.3) DASS-42
Iran [24] 48.3% 36.7% 66.7% 48.3% 48.3% 33.3% DASS-21
Pakistan [30] 79%
16.1 (8.3) 70%
14.6 (8.1) 69%
19.7 (9.2) DASS-42
China [12] 15.74% 38.01% SAS, SDS
Turkey [1] 49.5% STAI
South Africa [11] 58.7 (10.3) 56.2 (11.9) SCL-90-R
South Africa [10] 63.6 (5.6) 62.1 (7.9) SCL-90-R
Poland [9] 35.44%
8.5 (8.3) 15.60%
5.2 (6.6) 15.53%
10.9 (8.9) 4.70%
6.16 (7.7) BDI, BAI
Scotland [3] 2.7% 1.8% 26% 9% HADS
Sweden [28] 10.9% 5.1% 14.8% 4.9% PCEMD
Italy [8] 17.9% 6.9% 14.7% 4.5% ZDS, ZAS
Australia [4] 9.2 (7.9) 6.4 (5.7) 38.8 (11.8) 34.7 (8.1) CES-D, STAI
United States [29] 5.6% 3.8% 14.4% 8.8% BDI, STAI
As depicted in Table 4, among past studies, the highest prevalence of psychologi- cal disorders was in Muslim countries. The prevalence of disorders in our study, which fell in the moderate group, was just higher than in European countries and the United States. Compared with other Asian studies using the DASS, the double mean scores of the DASS-21 in our study were lower than the mean scores of the DASS-42 in Chi et al.’s study [7] in South Korea and Yusuf’s study [30] in Pakistan. The rates of dis- orders were also much lower than those in Muslim nations such as Iran [24] and Paki- stan [30]. When compared with Asian research that did not use the DASS, such as Gao et al.’s study [12] in China and Albayrak and Gunay’s study [1] in Turkey, the rates of psychological disorders in our study were also lower. The sociocultural factors may affect the emotional impact of infertility, as well as the emotional response of patients with infertility.
There have been a few studies on stress disorder in people with infertility (Table 4). The two studies using the DASS in Pakistan and Iran showed a higher prevalence of stress than ours [24].
In our study, the prevalence of at least one of the psychological disorders was 33.3%, 18.4%, and 40.8% among wives, husbands, and couples, respectively; these figures are relatively high in the context of people with infertility. Our findings are consistent with those previously reported using divergent assessment means; in couples with infertility, the prevalence has ranged from 26.2 to 66% among wives and from 9.2 to 50.3% among hus- bands [2, 14, 20, 28, 29].
Our finding regarding the higher level of psychological pressure in wives than husbands is in line with previous studies [3, 4, 8–11, 24, 28, 29] (Table 4). Wives might face greater threats, stigma, and loss owing to infertility than husbands in a wide range of cultural con- texts and geographic locations.
In most cultures, conception and childbirth are perceived as an important part of women’s responsibilities. Infertility, therefore, is regarded as a failure to fulfill the role of a woman. In a culture of persistent social prejudices, a woman with infertility is often viewed as a “tree without fruit” or “barren land.” In some communities, women are held responsible for their inability to conceive. Furthermore, women themselves often feel that the responsibility of carrying on their husbands’ family line falls on them. More severely, infertility may give men a reason to get married again. In addition, the procedures for diag- nosis and treatment of infertility are more invasive and painful in women.
Regarding the association between psychological disorders and sexual dysfunction, our finding only partially conformed to previous studies. While we found that both erectile dysfunction and premature ejaculation were associated with mild depression, anxiety, and stress among male partners, in their study in China, Gao et al. [12] reported a moderate association between both erectile dysfunction and premature ejaculation and depression and anxiety. In Italy, Lotti et al. [16] found mild associations between erectile dysfunction and only depression and premature ejaculation and only anxiety. Among female partners, our study showed that sexual dysfunction had a negative correlation with depression, anxi- ety, and stress, but in Nelson et al.’s study [19], sexual dysfunction had a negative correla- tion with just depression. Infertility, sexual health, and mental health problems are related in many ways. People with infertility are more likely than others to experience negative emotions and their sexual intimacy may be seriously compromised because of modifica- tions in sexual behavior for the primary goal of getting pregnant or interference with sexual privacy in the process of infertility diagnosis and treatment. Therefore, sexual dysfunc- tion may be the consequence of the psychological implications of infertility, which can, in turn, worsen psychological problems [17, 21]. Some of the discordance with the above
mentioned studies may have been due to sociocultural influences as well as the instruments used.
Our findings showed that the psychological burden is a real challenge and support needs among couples with infertility, especially wives, is very important because psychological counseling has been believed to reduce the probability of quitting and increasing of success rate of infertility treatment. At the same time, psychological and sexual problems should not be separated; there is a need for a comprehensive approach to this issue.
Our study had some limitations. First, we assessed psychological disorders based on the self-reported DASS-21, which is more suitable for screening than diagnostic purposes.
Second, as the participants were recruited from a single infertility center, caution must be exercised in attempts to generalize the results to people with infertility vising other centers and undergoing different treatments. Finally, owing to the cross-sectional design, we were unable to determine the causal relationship between psychological disorders and sexual dysfunction.
However, our study had the following strengths. The DASS-21 is a standardized instru- ment that has displayed high validity and reliability in both its original and Vietnamese formats. Second, our study is the first in Vietnam to consider not only the level of psy- chological burden but also its association with sexual dysfunction in people with infertil- ity. Finally, our data add to the literature on psychological disorders among couples with infertility.
Conclusion
Our study shows that there is a need to develop a psychological strategy that takes a holis- tic approach to infertility management. In addition, psychological issues and sexual prob- lems should be addressed simultaneously.
Acknowledgements We would like to thank Editage (www.edita ge.com) for English language editing.
Authors’ Contribution HTTT, LMT and TQV participated in the study design, data collection, data analysis, manuscript drafting and critical discussion. NVQH and CNT participated in data analysis, manuscript draft- ing and critical discussion. All authors were involved in drafting the work or revising it critically for impor- tant intellectual content of the final manuscript.
Funding This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Compliance with Ethical Standards
Conflict of interest The authors have no competing financial or other interests to declare in relation to this manuscript.
Availability of Data and Materials The dataset used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Consent for Publication All authors have provided consent for publication.
Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethics Committee of Hue University of Medicine and Pharmacy and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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