ASSESSMENT OF PSYCHOLOGICAL DISTRESS AMONG INFERTILE WOMEN:

FINDINGS FROM A CROSS-SECTIONAL STUDY

1
 LIST OF ABBREVIATIONS

PETS psychological evaluation test scale

ART Assisted Reproductive Technology

MDD premorbid major depressive disorder

IVF in vitro fertilization

ICSI intracytoplasmic sperm injection

2
 Table of Contents
LIST OF ABBREVIATIONS.....................................................................................................2

LIST OF TABLES......................................................................................................................5

LIST OF APPENDICES.............................................................................................................6

CHAPTER I................................................................................................................................7

1.0 Introduction, Background, and Research Context................................................................7

1.1 Introduction.......................................................................................................................7

1.2 Background of the study...................................................................................................8

1.3 Statement of the Problem..................................................................................................9

1.4 Definition of Terms.........................................................................................................10

CHAPTER II.............................................................................................................................11

2.0 LITERATURE REVIEW...................................................................................................11

2.1 Search Strategy...............................................................................................................11

2.2 Empirical Literature Review...........................................................................................11

2.3 Significance of the Study................................................................................................15

2.4 Study Purpose.................................................................................................................15

2.5 Research Questions.........................................................................................................15

2.6 Theoretical Framework of the Study..............................................................................16

3
 Table 2.0 Summary Of Reviewed Studies........................................................................17

CHAPTER III...........................................................................................................................22

3.0 METHODS.........................................................................................................................22

3.1 Study Design...................................................................................................................22

3.2 Settings............................................................................................................................22

3.3 Sampling Design and Sample Size.................................................................................23

3.4 Data Collection Procedures.............................................................................................23

3.5 Research Tools................................................................................................................23

3.6 Ethical Consideration......................................................................................................24

3.7 Data Analysis..................................................................................................................24

3.8 Scope and Limitations of the Study................................................................................24

References.................................................................................................................................25

Appendix A: Consent Form..............................................................................................29

Appendix B: Research Tools............................................................................................31

4
 LIST OF TABLES

Table 2.0 Summary Of Reviewed Studies................................................................................17

5
 LIST OF APPENDICES

Appendix A: Consent Form.

Appendix B: Research Tools

6
 CHAPTER I

1.0 Introduction, Background, and Research Context.

The chapter discusses the introduction to the research topic, background of the study,

statement of the problem, and definition of terms as used in the study.

1.1 Introduction

(Vander Borght & Wyns, 2018), defined infertility lack of procreation abilities, carrying or

child delivery naturally. Infertility is considered the inability of getting pregnant after a trial of

more than one year. In women, the inability of getting pregnant, and experiences of miscarriages

after being pregnant are also signs of infertility.(Petraglia et al., 2013), ascertains that infertility

is a serious global issue with increasing rates in high and low-income nations. The causes of

infertility are many but they are different across various parts globally, for instance sexually

transmitted infections, infections arising from serious pandemics, and factors about nutritional

patterns are associated with increasing infertility rates. The World Health Organization defines

the term infertility as a period of 24 months of trying to conceive without success. The

prevalence of infertility rates in the global population is approximated to be 10-15% of

Individuals of reproductive years globally (Vander Borght & Wyns, 2018).

There is a rise in the number of women looking for treatments concerning infertility problems

globally. This is associated with the rise in methods of treating infertility successfully and

medical therapies for infertility problems. According to (Zuraida, 2010) 12 % of couples globally

have difficulties with childbearing. It is estimated that in every five married individuals, there are
7
incidences of inability ty of getting pregnant after having sexual relations for a period of more

than one year. Depression, anxiety, isolation feelings, and individual loss of self-control are

observable among people with infertility problems. The prevalence of psychological distress

among infertile women is contributed to not opening up about the condition to other family

members. Infertility in women increases shame, feelings of guilt, and reduced self-esteem among

women. Infertility negatively impacts the social, physical, social, and marital status of

individuals facing the problem.

The prevalence of psychological distress signs and symptoms including depression, anxiety,

and stress in infertile women is high compared to women of active reproductive ages (Hudepohl

& Smith, 2022a). (Pasch et al., 2016) established from a study of infertility among couples that

56% of women and 32% of men experienced depression due to infertility problems.

1.2 Background of the study

Infertility is described as a condition of inability to get pregnant after more than one year of

sexual relations among couples. Infertility affects a significant number of individuals (Clifton &

Domar, 2022). According to WHO, Infertility is a condition of the human reproductive system

characterized by failure of achieving pregnancy after having unprotected sexual relations for a

period of more than one year (Zegers-Hochschild et al., 2009). Infertility is associated with

psychological distress and emotional distress in women. Women with infertility problems

experience depression, sad feelings, anger, low self-esteem, and lack of self-confidence.

Even though the problem of infertility is not among the conditions posing significant threats

to human life, the condition is associated with a lot of stress in the lives of those who experience
8
it. Infertility is perceived as a stressful condition because of the social significance attached to

having childbearing abilities in our societies, both in modern times and traditionally. The issue of

psychological distress in women with infertility has shown to have sophisticated relationships.

Past studies have identified that women with infertility problems are subjected to high rates of

psychological distress and are at risk of developing depression, anxiety, and stress disorders.

1.3 Statement of the Problem.

Infertility continues to be a major health problem affecting a significant number of women

and men globally. Infertility poses a great psychological health threat to women and their quality

of life.(Tavousi et al., 2022). Among the psychological health problems associated with

infertility are depression, anxiety, and infertility-related stress. Since the expectations of

childbearing lie on interpersonal, personal and social-cultural levels, the inability of getting

pregnant exposes women to psychological distress thus affecting their personal quality of life.

This study therefore is aimed at assessing the psychological distress among women with

infertility problems.

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 1.4 Definition of Terms.

Infertility Refers to the inability of not conceive after more than one year of unprotected sex among

couples

Depression Depression is a mental condition characterized by chronic sorrow as well as decrease of

interest.

Anxiety Refers to the type of mental disorder with symptoms of fear, tension and feeling nervous

Neuroticism Refers to traits inclination to feel unpleasant emotions such as anger, anxiety, stiffening,

impatience, psychological instabilities, and sadness.

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 CHAPTER II

2.0 LITERATURE REVIEW

This chapter presents the literature search strategy, empirical literature review, study purpose,

research questions, theoretical framework, and summary of the literature review.

2.1 Search Strategy

Relevant studies for the study were search using the term “ psychological distress”,

“infertility”, “infertile women” and “emotional distress”. The researcher search in databases such

as PubMed, Medline, ScienceDirect and Open Access Journals.

2.2 Empirical Literature Review

Patients with infertility problems are said to experience equivalent rates of psychological

distress symptoms including depression, stress, and anxiety to patients with other chronic

illnesses such as cancer (Rooney & Domar, 2022; Yokota et al.). (Yokota et al.) conducted a

study in japan intending to determine psychological distress in women placed under infertility

treatments. The study identified levels of depression, stress, stigma, and anxiety among women

with infertility problems. According to the study findings stigma was associated with high levels

of depression, anxiety, and general psychological distress among infertile women. The infertility

condition makes women considered perverts from childbearing thus leaving no room of

distancing themselves from the stigma resulting from the prevalence of the problem. Due to the

stigmatization of infertile women, the women feel threatened in terms of personal identities

11
which contributes to anxiety and depression symptoms. However, the study by (Yokota et

al.)showed that measures of reducing stigmatization due to infertility such as the use of cognitive

therapy sessions could play a significant role in handling psychological distress in infertile

women.

In a cross-sectional and descriptive correlational study, (Teklemicheal et al., 2022),

established that there were high prevalence rates of psychological stress in infertile women.

According to the study results, 93 % of the respondents indicated to be facing psychological

stress due to infertility problems. The high-stress levels were associated with personal factors

rather than marital and social factors among the respondents of the study. The results showed

that psychological stress levels were high in women 35 years of age and above in comparison to

infertile women of young age (Teklemicheal et al., 2022). Psychological stress in infertile

women was also linked to the duration of infertility (yılmaz et al., 2020). The study indicated

that women with more than 5 years of infertility problems have high-stress levels compared to

those with less than 5 years of health condition (Teklemicheal et al., 2022; yılmaz et al., 2020).

(Cao et al., 2022), employed network analysis in determining psychological distress in

infertile patients. The results identified certain psychological distress symptoms had a

correlational relationship compared to others while induvial stress levels related to infertility,

anxiety, and depression symptoms did not exhibit equal connections imperatively. The study

indicates that when infertility treatment commences, sexual relations are termed as regular and

more important tasks concerning therapy on pregnancy outcomes. Failures occurring in the

bedroom kill the sensual frames of couples leading to the loss of satisfactory sexual relationships

among the couples. Sexual stress in infertile women leads to thoughts of killing themselves due
12
to depression (Cao et al., 2022). The study also identified feelings of being restless among

infertile women, issues of relaxation, and high levels of guilt and of being worried.

The condition of infertility has been a societal issue for a long period. The cost involved in

determining the cause of the problem, and the time invested in determining possible solutions

contributed to psychosocial distress in women with fertility problems (Tripathy et al.). The most

psychological distress symptoms experienced by infertile women include anxiety, depression,

and low self-esteem (Tripathy et al.). according to the study results, psychological distress is

high in infertile women with lower levels of educational attainment. Low levels of psychological

distress in infertile women were associated with age and also determined by employment status.

Employed women had low rates of psychological distress compared to unemployed ones. The

results of the study by (Rooney & Domar, 2022; Tripathy et al.) show similarities with other

studies by indicating that infertility causes distress to women and affects psychological and

emotional well-being.

Results of a cross-sectional study done by (Cui et al., 2021), indicated that the prevalence rate

of depression was 27.9% and anxiety was 42.2%. This showed that depression and anxiety rates

were high in infertile women who participated in the study. Higher education was linked to a

decreased frequency of depression since women with high learning potentially have alternative

multiple responsibilities or other socioeconomic options than solely being moms and needing to

dwell on one life aim. Such possibilities may help individuals accept impotence as well as cope

with it more effectively (Cui et al., 2021; Maroufizadeh et al., 2018).

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 Infertile women face the threat of high depression rates compared to fertile women (Hudepohl

& Smith, 2022a, 2022b). in infertile women, the major risk factor associated with depression is

premorbid major depressive disorder (MDD). The disorder is linked to depression relapse in

infertile women during Assisted Reproductive Technology (ART). Depression symptoms are

also associated with personal characteristics such as neuroticism. (Rooney & Domar, 2022)

ascertains that psychological distress symptoms such as anxiety, depression, and stress are linked

to the typed of prescribed medication for infertility treatment. Infertility medications include

clomiphene, leuprolide, and gonadotropins, they contribute to psychological distress because,

during the assessment of psychological distress in infertile women taking medications, side

effects of the treatment received are also shown (Rooney & Domar, 2022).

According to (Lakatos et al., 2017; Patel et al., 2018), and (Tavousi et al., 2022), Infertile

women had considerably lower mental quality concerning anxiety and depression symptoms than

fertile women. Age, interpersonal and sexuality concerns, mother connection strain, and financial

burdens were all associated with anxiety in infertile women(Yang et al.). Anxiety and depression

are present in infertile individuals. infertile people experience the characteristics of fertility

problems, such as sadness as well as a sense of lack of their own body, the severity of such

characteristics there is high psychological distress in such individuals (Tavousi et al., 2022).

According to (Alam et al., 2018) and (Elsous et al., 2021), the problem of infertility is

associated with numerous effects on infertile women. Infertility leads to stress thus raising levels

of anxiety, depression, and physiological distress. The findings of (Elsous et al., 2021) concur

with previous research studies that stress, depression, and anxiety are the most psychological

problems present in women with infertility.

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2.3 Significance of the Study

Since infertility has been considered a global problem affecting a significant number of

women and men today (Elsous et al., 2021). The results of this study will be beneficial by

helping identify of causes of infertility and associated risk factors of psychological distress.

Previous research studies have shown that infertile women suffer from psychological distress

symptoms including anxiety, depression, and stress.

Therefore the study will aid healthcare providers, especially gynecologists to consider the

effects of psychological distress on women with infertility. Through the study findings, the

quality of life of infertile women could be enhanced through medications and measures taken

toward infertility problem management. The study will also help to come up with psychological

measures such as scheduling counseling sessions with infertile women, and providing social

support and therapy sessions towards the prevention and overcoming of the effects of infertility

in women.

2.4 Study Purpose

The purpose of the study will be to assess psychological distress symptoms such as

depression, anxiety, and stress among women with infertility.

2.5 Research Questions

i. What are the levels of depression symptoms among women with infertility?

15
 ii. What are the levels of anxiety symptoms among women with infertility?

iii. What are the levels of stress symptoms among women with infertility?

2.6 Theoretical Framework of the Study

The study utilizes the Cognitive-Behavioral Theory of Personality Disorders (Hoermann et

al., 2019). According to the theory individual living with personal disorders always act in a

dysfunctional manner because of the beliefs they have. The theory ascertains that core beliefs are

the representation of one’s assumptions and other people around us. The theory of personality

disorders is based on various personal characteristics (Merrill & Strauman, 2004).

The theory is utilized in the study because it lays importance on personality context. The

theory ascertains that the cognitive view of personality is centered on cognitive behavioral

therapies that show personal behavior in various circumstances dependent on certain

psychological processes, mental states, and sensory circumstances. A cognitive behavioral theory

of personality disorders holds that patients have irrational opinions regarding various people.

Patients believe that other people may criticize them, disregard and hurt them both emotionally

and physically therefore this makes them develop measures of living along with their problems

in society.

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Table 2.0 Summary Of Reviewed Studies.

Author Research title Purpose Design Sample size Research Findings

instrument
(Yokota et al.) Association between To examine the A cross- The sample The Japanese According to the study findings
Stigma and Anxiety, relationship between sectional was made version of the stigma was associated with high
Depression, and infertility stigma and study of 254 Infertility levels of depression, anxiety, and
Psychological Distress anxiety, depression, participants Stigma Scale general psychological distress
among Japanese and psychological undertaking among infertile women.
Women Undergoing distress among infertility
Infertility Treatment women undergoing treatment
infertility treatment
(Teklemicheal Prevalence and To determine the A cross- 96 women Questionnaires The findings showed that there was
et al., 2022) correlates of infertility prevalence of sectional undergoing high psychological stress among
related psychological psychological stress descriptive a non-IVF women with infertility problems.
stress in women with in women suffering correlation treatment The results showed that infertility
infertility: a from infertility. study for stress was linked to age, marital
cross-sectional infertility status, and period of infertility.
hospital-based survey
(Cao et al., Psychological Distress To identify patterns of A cross- 740 Questionnaires Certain psychological distress
2022) Among Infertility psychological distress sectional infertility symptoms were shown to have a
Patients: A Network experienced by study. patients correlational link when compared to
Analysis infertility patients and others, however induvial stress
to identify the most levels connected to infertility,
central symptoms of anxiety, and depression symptoms
anxiety, depression, did not.
and stress.
(Tripathy et Psychosocial well- To explore the Exploratory 150 infertile psychological Psychological stress is associated
17
al.) 2020 being among primary psychosocial well- study women evaluation test with the age of women, duration and
Infertile women being among primary scale cause of infertility, infertility tests,
attending infertility infertile women medication failures, lack of social
clinic support, stigma, and psychological
measures received.
(Cui et al., Effects of Self-Esteem To evaluate the A Cross- women who Questionnaire There was high psychological
2021) on the Associations prevalence of Sectional are distress in infertile women. The
Between Infertility- depression and Study diagnosed study proved that depression and
Related Stress and anxiety and with anxiety were the common infertility-
Psychological Distress investigate the effects infertility, related stress.
Among Infertile of self-esteem on the
Chinese Women: A association of
Cross-Sectional Study infertility-related
stress with

depression and
anxiety among
infertile women.
(Hudepohl & Infertility and Its A Current Infertility is a complicated,
Smith, 2022b) Association with Review unidirectional interaction, and
Depression, Anxiety, psychological pain in individuals
and Emotional receiving infertility assessment and
Distress: A Current ART can have a significant
Review influence.

18
(Rooney & The relationship A cognitive- The study showed that clearly
Domar, 2022) between stress and behavioral infertility is associated with high
infertility group rates of psychological distress in
approach infertile women.

(Lakatos et al., Anxiety and To assess the A cross- 225 (134 Questionnaires Infertile women exhibit greater
2017) depression among psychological state of sectional infertile and depressive and anxiety-related
infertile women: a women with and survey 91 fertile) symptoms than fertile ones. The
cross-sectional survey without fertility women assessment of these markers, as well
from Hungary problems, and to as the reduction of fundamental
investigate the distress through appropriate
background factors of psychological therapies, must be
anxiety-related and promoted.
depressive symptoms
in women struggling
with infertility.
(Patel et al., Sociocultural To investigate the cross-sectional 300 men Questionnaires The results showed that limited
2018) Determinants of less-known research and women partner assistance, financial burdens,
Infertility Stress in sociocultural with and societal compulsion in the initial
Patients Undergoing determinants of primary stages of marriage anticipate
Fertility Treatments infertility stress in infertility infertility discomfort in both men as
patients undergoing well as women.
assisted conception
and reproductive
treatments

19
(Tavousi et Psychological A systematic 32 studies Random-effect The study showed that infertile
al., 2022) assessment in review and from the model women experience anxiety and
infertility: A meta-analysis systematic depression. The characteristics of
systematic review and review infertility are only experienced by
meta-analysis those with the problem.
(yılmaz et al., Factors associated To determine factors A cross- 368 women Questionnaire The study findings indicated that the
2020) with infertility distress associated with sectional with desire of having children increased
of infertile women: a infertility distress in study infertility during the marriage period, and an
cross-sectional study women with problems increase in the infertility period also
infertility problems lead to high rates of psychological
distress.
(Yang et Factors Associated To investigate factors An analytical Infertile Questionnaires Anxiety and depression are
al.)2022 with Anxiety and related to anxiety and cross-sectional couples in connected with interpersonal factors,
Depression in Infertile depression among survey Thailand marital satisfaction, and adequate
Couples—Study infertile couples economy in childless couples.
Protocol
(Maroufizadeh Factors associated To determine the This cross- 539 people Questionnaires Infertile persons have a somewhat
et al., 2018) with poor well-being prevalence of poor sectional with high frequency of poor health,
of infertile people: awell-being and study included infertility particularly females, those with little
cross-sectional study associated factors education, those who have had
among infertile therapeutic failures, and those who
people, in Tehran, have causes of infertility.
Iran.
(Alam et al., Psychological Impacts To determine the Cross- 112 infertile Questionnaires The results showed that
2018) of Infertility Among psychological impacts sectional married psychological distress in infertile
Married Women of infertility among descriptive women women had different levels from
Attending a Tertiary married women study high to low levels.
Hospital, Dhaka suffering from
20
 infertility.
(Elsous et al., Depression among To determine the A descriptive- 385 Questionnaires The study findings of the study
2021) Infertile Women in severity of depression analytic cross- participants showed that psychological distress
Gaza Strip: Symptom symptoms and its sectional symptoms were present in the study
Severity and predictors among study participants.
Predictors infertile women in the
Gaza Strip, Palestine

21
 CHAPTER III

3.0 METHODS

The chapter presents the study design, sample design, settings, sample size, data collection

procedures, ethical considerations, data analysis procedures, and the scope and limitations of the

study.

3.1 Study Design

The study will employ a cross-sectional research design to assess the prevalence of

psychological distress in women with infertility. According to (Kesmodel, 2018), cross-sectional

research design utilizes data collection of important research information at one given point in

time. in using the design there are no time dimensions to be utilized since the information is

collected at the same time.

3.2 Settings

The study will be conducted at HealthPlus Fertility & Women's Health Center in Jeddah,

Kingdom of Saudi Arabia. The setting was chosen because it’s a wide network of fertility and

IVF centers in Saudi Arabia. The center provides services such as full range of services for

diagnosing and treating infertility problems, the services mainly comprise IVF, ICSI, and IUI

Infertile treatment services such as Preimplantation Genetic Testing, Andrology,

Reproductive Surgery, and Fertility Preservation are also provided in the center.

22
3.3 Sampling Design and Sample Size

The sample characteristics of the study will comprise infertile women attending fertility

clinics at HealthPlus Fertility & Women's Health Center in Jeddah, Kingdom of Saudi Arabia. A

simple random Sampling design will be used to allow each individual attending fertility clinics

in the center to have an equal chance of inclusion in the study. From a target population of 500

respondents, 200 respondents will be randomly selected for inclusion in the study.

3.4 Data Collection Procedures

The data collection process by the researcher will begin after the researcher obtains relevant

approvals from the Institutional Review Board of the university and the HealthPlus Fertility &

Women's Health Center. The researcher will visit the study setting for familiarization purposes

and to explain the purpose of the study to the study participants after meeting them. The research

participants will be educated on their rights and privileges before they agree on whether to

participate in the study or not.

3.5 Research Tools.

The searcher will use questionnaires in the data-gathering process. First, a demographic

questionnaire will be used in the collection of basic information about the respondents including

age, marital status, educational level, period of infertility employment status, and duration of

medication. To determine the prevalence of anxiety, Generalized Anxiety Disorder-7 will be

used. Patients Health Questionnaire-9 (PHQ-9) for depression and Fertility Problem Inventory

for measuring fertility-related stress.

23
3.6 Ethical Consideration

Ethical approval for the research will be obtained from the Institutional Review Board of the

university and the HealthPlus Fertility & Women's Health Center. The study participants will be

informed about the research purpose and thereafter invited to sign a consent form before

participation in the research study. Voluntary participation and research anonymity of

participants will also be considered.

3.7 Data Analysis

After data collection, the researcher will impact on data analysis with the help of the

Statistical package for social science (SPSS). Basic variables will be analyzed using percentages

and frequencies.

3.8 Scope and Limitations of the Study

The researcher will conduct the study at HealthPlus Fertility & Women's Health Center. The

participants will include infertile women attending treatment at the center. The study intends to

achieve its purpose of assessing psychological distress among women with infertility by focusing

on a limited size of respondents for an easy data collection process.

24
 References

Alam, M. J., Rahman, M. M., & Afsana, N. E. (2018). Psychological impacts of infertility

among married women attending a tertiary hospital, Dhaka. Anwer Khan Modern

Medical College Journal, 9(1), 10-14.

Cao, D., Bai, C., & Zhang, G. (2022). Psychological Distress Among Infertility Patients: A

Network Analysis. Frontiers in Psychology, 13.

Clifton, J., & Domar, A. D. (2022). Chapter 10 - Psychological distress and infertility:

prevalence, impact, and interventions. In D. Vaamonde, A. C. Hackney, & J. M. Garcia-

Manso (Eds.), Fertility, Pregnancy, and Wellness (pp. 163-181). Elsevier.

https://doi.org/https://doi.org/10.1016/B978-0-12-818309-0.00013-7

Cui, C., Wang, L., & Wang, X. (2021). Effects of self-esteem on the associations between

infertility-related stress and psychological distress among infertile chinese women: a

cross-sectional study. Psychology Research and Behavior Management, 14, 1245.

Elsous, A., El-Kass, S. d. A., Salama, A., Radwan, M., Abo-Eid, S., & Baloushah, S. (2021).

Depression among Infertile Women in Gaza Strip: Symptom Severity and Predictors.

Depression Research and Treatment, 2021, 6616489.

https://doi.org/10.1155/2021/6616489

Hoermann, S., Zupanick, C. E., & Dombeck, M. (2019). Cognitive-behavioral theory of

personality disorders. In.

25
Hudepohl, N. S., & Smith, K. (2022a). Infertility and Its Association with Depression, Anxiety,

and Emotional Distress: A Current Review. Advances in Psychiatry and Behavioral

Health, 2(1), 119-132. https://doi.org/https://doi.org/10.1016/j.ypsc.2022.05.005

Hudepohl, N. S., & Smith, K. (2022b). Infertility and Its Association with Depression, Anxiety,

and Emotional Distress: A Current Review. Advances in Psychiatry and Behavioral

Health.

Kesmodel, U. S. (2018). Cross-sectional studies – what are they good for? Acta Obstetricia et

Gynecologica Scandinavica, 97(4), 388-393.

https://doi.org/https://doi.org/10.1111/aogs.13331

Lakatos, E., Szigeti, J. F., Ujma, P. P., Sexty, R., & Balog, P. (2017). Anxiety and depression

among infertile women: a cross-sectional survey from Hungary. BMC women's health,

17(1), 1-9.

Maroufizadeh, S., Omani-Samani, R., Bagheri-Lankarani, N., Almasi-Hashiani, A., & Amini, P.

(2018). Factors associated with poor well-being of infertile people: a cross-sectional

study. Middle East Fertility Society Journal, 23(4), 468-470.

https://doi.org/https://doi.org/10.1016/j.mefs.2018.03.006

Merrill, K. A., & Strauman, T. J. (2004). The role of personality in cognitive-behavioral

therapies. Behavior Therapy, 35(1), 131-146.

https://doi.org/https://doi.org/10.1016/S0005-7894(04)80008-X

26
Pasch, L. A., Holley, S. R., Bleil, M. E., Shehab, D., Katz, P. P., & Adler, N. E. (2016).

Addressing the needs of fertility treatment patients and their partners: are they informed

of and do they receive mental health services? Fertility and sterility, 106(1), 209-215.

Patel, A., Sharma, P., Kumar, P., & Binu, V. S. (2018). Sociocultural Determinants of Infertility

Stress in Patients Undergoing Fertility Treatments. J Hum Reprod Sci, 11(2), 172-179.

https://doi.org/10.4103/jhrs.JHRS_134_17

Petraglia, F., Serour, G. I., & Chapron, C. (2013). The changing prevalence of infertility.

International Journal of Gynecology & Obstetrics, 123, S4-S8.

https://doi.org/https://doi.org/10.1016/j.ijgo.2013.09.005

Rooney, K. L., & Domar, A. D. (2022). The relationship between stress and infertility.

Dialogues in clinical neuroscience.

Tavousi, S. A., Behjati, M., Milajerdi, A., & Mohammadi, A. H. (2022). Psychological

assessment in infertility: A systematic review and meta-analysis. Front Psychol, 13,

961722. https://doi.org/10.3389/fpsyg.2022.961722

Teklemicheal, A. G., Kassa, E. M., & Weldetensaye, E. K. (2022). Prevalence and correlates of

infertility related psychological stress in women with infertility: a cross-sectional hospital

based survey. BMC Psychology, 10(1), 91. https://doi.org/10.1186/s40359-022-00804-w

Tripathy, P., Nayak, D., & Khosla, P. PSYCHOSOCIAL WELLBEING AMONG PRIMARY

INFERTILE WOMENATTENDING INFERTILITY CLINIC. European Journal of

Molecular & Clinical Medicine, 7(11), 2020.

27
Vander Borght, M., & Wyns, C. (2018). Fertility and infertility: Definition and epidemiology.

Clinical biochemistry, 62, 2-10.

Yang, T., Wongpakaran, N., Wongpakaran, T., Saeng-Anan, U., Singhapreecha, C., Jenraumjit,

R., & Peisah, C. (2022). Factors Associated with Anxiety and Depression in Infertile

Couples—Study Protocol.

yılmaz, T., Yazici, S., & Benli, T. (2020). Factors associated with infertility distress of infertile

women: a cross-sectional study. Journal of psychosomatic obstetrics and gynaecology,

41, 1-7. https://doi.org/10.1080/0167482X.2019.1708318

Yokota, R., Okuhara, T., Okada, H., Goto, E., Sakakibara, K., & Kiuchi, T. (2022). Association

between stigma and anxiety, depression, and psychological distress among Japanese

women undergoing infertility treatment.

Zegers-Hochschild, F., Adamson, G. D., de Mouzon, J., Ishihara, O., Mansour, R., Nygren, K.,

Sullivan, E., & Vanderpoel, S. (2009). International Committee for Monitoring Assisted

Reproductive Technology (ICMART) and the World Health Organization (WHO)

revised glossary of ART terminology, 2009. Fertil Steril, 92(5), 1520-1524.

https://doi.org/10.1016/j.fertnstert.2009.09.009

Zuraida, A. S. (2010). Psychological distress among infertile women: Exploring biopsychosocial

response to infertility. Malaysian Journal of Psychiatry, 19(2), 82-92.

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29
 Appendix A: Consent Form.

ASSESSMENT OF PSYCHOLOGICAL DISTRESS AMONG INFERTILE WOMEN:

FINDINGS FROM A CROSS-SECTIONAL STUDY

Principal Investigator

Dear Participants

You have been invited to participate in the study, but it is critical that you understand its aims

before committing to do so. Please read the following information carefully. If you have any

questions or need more information, please contact the researcher.

Purpose of the Study

Assessment of psychological distress among infertile women

Confidentiality

Your responses to this survey will be kept strictly confidential. Please avoid writing any

identifying information on the questionnaire. For the sake of this research project, your replies

will not be anonymized. The investigator will do all possible to preserve your privacy and

reputation.

Contact Information

If you have any questions about this study, please contact the researcher by using the information

provided above. If you have any questions concerning your rights as participants or encounter

30
difficulties that you do not feel at ease addressing with the primary researcher, please contact the

Ethical Review Board.

Voluntary Participation

It is totally up to you whether or not you choose to take part in this study. If you wish to take part

in this study, you will be required to sign a permission form. You may withdraw from the

authorization form at any time and without justification after signing it.

CONSENT

I read and comprehended the material presented. I understand that my participation is voluntary

and that I have the right to quit at any time, for any reason, and at no cost. I understand that I will

be given a copy of this permission form. I fully agree to take part in this investigation.

Respondent’s Signature: ………………………………………..Date: ……………………

Researcher’s Signature: ……………………………………… Date: ……………………

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 Appendix B: Research Tools

Part I: Demographic questionnaire.

No Items Please tick appropriately

1 Gender Male
Female

2 Between 20 to 25 years
Between 26 to 30 years
Age
Greater than 30 years

3 Less than one year

From 1 to 5 years
Years of Experience From 6 to 10 years
More than 10 years

4 Diploma
Degree
Education Qualification
Master’s Degree

Other………………………………………………….

5 Marital status Married

Single

Divorced

6 Period of infertility Less than 5 years

More than 5 years

7 Occupation Employed

Unemployed

8 Medication period 1-5 years

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5-10 years

Over 10 years

33
 Part II: Generalized Anxiety Disorder-7 scale

Generalized Anxiety Disorder 7-item (GAD-7) scale

Over the last 2 weeks, how often have you been Not at all Several Over half Nearly
bothered by the following problems? sure days the days every day

1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it's hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might 0 1 2 3

happen
Add the score for each column + + +

Total Score (add your column scores) =

If you checked off any problems, how difficult have these made it for you to do your work, take
care of things at home, or get along with other people?

Not difficult at all __________

Somewhat difficult _________
Very difficult _____________
Extremely difficult _________

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant
from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

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 Part III: PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

PATIENT HEALTH QUESTIONNAIRE-9

(PHQ-9)

More

Over the last 2 weeks, how often have you been than Nearly

bothered by any of the following problems? (Use Not at Several half the every

“✔” to indicate your answer) all days days day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too

0 1 2 3
much

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a

0 1 2 3
failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the

0 1 2 3
newspaper or watching television

8. Moving or speaking so slowly that other people 0 1 2 3

could have noticed? Or the opposite — being so

fidgety or restless that you have been moving around a

35
 lot more than usual

9. Thoughts that you would be better off dead or of

0 1 2 3
hurting yourself in some way

FOR OFFICE CODING

0 + ______ + ______ + ______

=Total Score: ______

If you checked off any problems, how difficult have these problems made it for you to do

your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely

   difficult

36
 Part Iv: Fertility Problem Inventory.

Fertility Problem Inventory (FPI)

Patient Information

Name

Today’s Date

Present age:
Relationship status:
Years with partner:

Education:
Occupation:
Years in occupation:

Infertility history (diagnoses, length of treatment, number of cycles, results of cycles, testing
completed)

Religious, cultural, familial factors that have influenced your infertility journey:

37
 Fertility Problem Inventory (FPI) Questionnaire

The following statements express different opinions about a fertility problem. Please indicate the
degree to which you agree or disagree with each statement. If you have a child, please answer the
way you feel right now, after having a child.

Strongl Moderate Slightly Slightly Moderate Strongly

y agree ly agree agree disagre ly disagree
e disagree
1. Couples without a child are just as happy as those with
children.
2. Pregnancy and childbirth are the two most important
events in a couple’s relationship.
3. I find I’ve lost my enjoyment of sex because of the
fertility problem.
4. I feel just as attractive to my partner as before.
5. For me, being a parent is a more important goal than
having a satisfying career
6. My marriage needs a child (or another child).
8. It’s hard to feel like a true adult until you have a child.

9. It doesn’t bother me when I’m asked questions about

children.
10. A future without a child (or another child) would frighten
me.
11. I can’t show my partner how I feel because it will make
him/her feel upset.
12. Family don’t seem to treat us any differently.
13. I feel like I’ve failed at sex.
14. The holidays are especially difficult for me.
15. I could see a number of advantages if we didn’t have a
child (or another child).
16. My partner doesn’t understand the way the fertility
problem affects me.

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17. During sex, all I can think about is wanting a child (or
another child).
18. My partner and I work well together handling questions
about our infertility.
19. I feel empty because of our fertility problem.
20. I could visualize a happy life together, without a child (or
another child).
21. It bothers me that my partner reacts differently to the
problem.
22. Having sex is difficult because I don’t want another
disappointment.
23. Having a child (or another child) is not the major focus of
my life.
24. My partner is quite disappointed with me.
25. At times, I seriously wonder if I want a child (or another
child).
26. My partner and I could talk more openly with each other
about our fertility problem.
27. Family get-togethers are especially difficult for me.
28. Not having a child (or another child) would allow me time
to do other satisfying things.
29. I have often felt that I was born to be a parent.
30. I can’t help comparing myself with friends who have
children.
31. Having a child (or another child) is not necessary for
my happiness.
32. If we miss a critical day to have sex, I can feel quite
angry.
33. I can’t imagine us ever separating because of this.
34. As long as I can remember, I’ve wanted to be a parent.

35. I still have lots in common with friends who have

children.
36. When we try to talk about our fertility problems, it
seems to lead to an argument.

39
37. Sometimes I feel so much pressure, that having sex
becomes difficult.
38. We could have a long, happy relationship without a
child (or another child).
39. I find it hard to spent time with friends who have
young children.
40. When I see families with children I feel left out.
41. There is a certain freedom without children that
appeals to me.
42. I will do just about anything to have a child (or
another child).
43. I feel like friends or family are leaving us behind.
44. It doesn’t bother me when others talk about their
children.
45. Because of infertility, I worry that my partner and I
are drifting apart.
46. When we talk about our fertility problem, my partner
seems comforted by my comments.

40