Major Depressive Disorder Association with Unsuccessful In-Vitro Fertilization (IVF) of Primary Infertile Women

Background: Women who go through unsuccessful IVF treatment were at increased risk of depressive disorders. Objective: investigate the association between the unsuccessful IVF and depression among women with primary infertility. Methods: a cross-sectional study included infertile women attending fertility center. Socio-demographic and clinical variables were compiled. Self-Reporting Questionnaire (SRQ-20) to identify mental illnesses; DSM-V criteria for depression and Hamilton-17 Scale for severity of depression, were used. Results: high prevalence of depression among infertile women 80%. Unsuccessful IVF were 46%. About 26 % of infertile women with unsuccessful IVF were depressed. Depression was significantly associated with education, monthly income, duration of marriage, smoking, medication, chronic illness, and religion. Conclusion: Depressive disorders are the most frequently observed disorder among infertile women exposed to unsuccessful IVF


Introduction:
Infertility is a widespread condition known to affect more than 10% of all couples worldwide. It is regarded as psychologically stressful by most individuals and can lead to depression, social isolation and a lower quality of life 1 . The experience of having children is linked to every human life in the hope of a better, more beautiful and more productive tomorrow; and not having it is associated with a faceless state, mental confusion and frustration, especially among women 2 . The World Health Organization (WHO) defines infertility as not getting pregnant after a year of marriage without using a couple of contraception methods (quoted Mousavi et al., 2014) 3 . Reviewing several studies have shown that infertility is considered as a crisis with the potential to threaten the stability of individuals and has always been associated with a variety of psychological problems, such as anger, anxiety, stress, depression, obsession, decrease in sexual function and eventually, disappointment 2 . Most epidemiological studies report high intensity of anxiety and depression in people who participate in ART. However, due to the large methodological differences between the analyzed studies the results were very different. A number of studies identify an increased incidence of depressive symptoms in patients treated for infertility 4 . Such a conclusion was also confirmed in a critical analysis of previous studies conducted by Williams et al. who found that for women taking the therapy for infertility an increased incidence of depressive symptoms and major depression are observed 5 . Over the last years, impressive progress has been made in the development of medical technological interventions for fertility problems. Depending on the precise nature of the fertility problem, various reproductive technologies are available to help couples achieve a pregnancy. This includes in vitro fertilization (IVF), artificial insemination with the semen of a donor (AID), artificial insemination with the semen of the husband (AIH) and intracytoplasmic sperm injection (ICSI) 6 . It is reported that about 13% of women in developed countries suffer from postnatal depression (PND) 7,8 . Studies have shown that the prevalence of PND cases that require psychiatric care is 0.3% 9 and that the prevalence of hospitalizations due to PND is 0.06%-0.26% 10 . In general, women who undergo infertility treatment have fewer risk factors of PND. Ross et al. (2011) speculated that future studies controlling for these factors may in fact find the risk of PND to be increased among women who have undergone infertility treatment 11 . Since an increasing number of couples use IVF treatment to conceive 12 it is important to determine if this treatment increases the risk of PND [13][14][15] . Studies examining risk of psychiatric illness after IVF treatment have varied in their results. Baldur-Felskov et al 16 found that women who go through unsuccessful IVF treatment were at increased risk of hospitalization due to most psychiatric disorders 16 . Yli-Kuha et al 17 showed that the risk of depression was increased in those who had gone through an unsuccessful IVF treatment. Many studies focus on psychological issues within the context of in vitro fertilization (IVF), including the psychological states before, during and after the IVF treatment 17 .This study was done to investigate the association between the unsuccessful IVF and depression among women with primary infertility.

Patients and Methods:
Design and setting: This is a cross-sectional study conducted on primary infertile women attending, Imamain Kadhimain Medical City, Um Al-Baneen fertility center, Baghdad, Iraq. Data collected during the period March, 1st, 2014 to September, 1st, 2017. Study Population and Sampling Technique: The study included women attending the fertility center during the data collection time. A systematic random sampling technique was applied. Inclusion criteria: all women with primary infertility of any age who welcomed participation were included. Exclusion criteria: Women with history of inability to conceive of less than12 months, current serious or unstable medical illnesses that cannot complete the interview, not cooperative, and who did not give their consent to participate were exclude from the study. Data collection Tools: sociodemographic variables and clinical characteristics of women were compiled using a questionnaire filled through a direct interview. List contained question about exposures to in-vitro fertilization (IVF) failure. Mental status was assessed using the SRQ-20 scale (self-reporting questionnaires) that was developed by the WHO and used in many countries 18 . Women with positive results were assessed for the presence of depression using the DSM-V criteria of depression 19 . Women with "depression" were further assessed for the severity of depression using the Hamilton scale 20 . Definition of variables: The independent variables evaluated to explain depression were socio demographics (age, education, occupation, and religious status), smoking habits, and duration of marriage. Statistical Analysis: Statistical package of social sciences (SPSS) version 20 was used for data entry and analysis. Categorical variables were tested using chi square test. P<0.05 was considered statistically significant. Ethical Issue: Official approvals were granted from the officials in the study setting. Informed consent was obtained from each participant to be included in this study. Names were kept anonymous and interviews were conducted with full privacy.
Nearly half of women were of low education. Employed women about 4% and all other were house wives.
Smoker women were 7.5%. About 94% were taking different medication. Nearly half of women were mild religious ( Table 2).

Discussion:
The correlation of unsuccessful IVF of infertile women with SRQ-20 results, DSM-V criteria of depression, and the Hamilton severity of depression were strongly statistical significant results (P < 0.001). Infertile women with unsuccessful invtro fertilization were 148 (46.25%). More than half of them were depressed 84 (26.25%). This finding was statistically significant (P < 0.001). Study found 80% of infertile women were depressed. High prevalence of infertile women depression might be explained by that; in our culture, female always blamed for causes of infertility. Gynecologists are hurry to attribute couple infertility to female factors. Infertile women suffer social pressure from their relatives and friend. Unsuccessful IVF constitutes a crisis and stigma in affected women, may become isolated and neglected. The unsuccessful IVF reactions may include; frustration, shock, anger, depression, and grief, loss of self-esteem, self-confidence. Chen et al. 2004 21 found Psychiatric disorders were present in 40.2% of patients; 23.2%generalized anxiety disorder; 17%major depressive disorder; dysthymic disorder in 9.8% of patients 21 . Petersen et al. 2014 22 : Severe depressive symptoms were reported in 11.6% of women and 4.3% of men, and were significantly associated with increased infertility-related distress at the individual and partner level 22 . Current study found depression of primary infertile women was significantly associated with; education, monthly income, duration of marriage, smoking, medication, chronic illness, religion, and BMI. This association might be explained by the fact that the longer the infertility crisis continues, the more people in families and neighbors will know about it lead to more social pressure women will feel; another possible explanation is that longer infertility duration and repeated referrals would gradually change infertility to a chronic problem. Current study Findings was lower than the results of a study conducted in Pakistan 23 which showed depression was 95% in infertile women. Findings of current study were higher than many studies. The study done in Morocco 24 showed that 55% of the women had depression with positive relation to occupation. Nigerian study 25  Conclusion: In patients treated with IVF for infertility mental disorders represent very common clinical problem. Depressive disorders are the most frequently observed disorder. Unsuccessful IVF constitutes an independent risk factor for development of mental disorders. Current study found high prevalence of depression among infertile women 80%. Unsuccessful IVF were 46%. About 26 % of infertile women with unsuccessful IVF were depressed. Depression was significantly associated with education, monthly income, duration of marriage, smoking, medication, chronic illness, and religion.