Document Type : Original Article
Authors
1 Department of Internal Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
2 Department of Obstetrics and Gynecology, Islamic Azad University, Mashhad Branch, Mashhad, Iran
Abstract
Keywords
Infertility is defined by failure of getting pregnant after
at least one year of regular and unprotected intercourse
(
Prevalence of primary infertility in a population-based
study in an urban population in Iran was 17.3% which is
higher than global infertility rate. In Iranian couples, female
(56.1%) and male factors (29.1%) were the most common
causes of infertility, followed by unexplained infertility
(14.4%). Among female factors of infertility, ovulation
disorders (39.7%) were the most common cause (
Infertility can profoundly affect different aspects of
life in infertile couples and due to its social, cultural and
economic problems, it produces a sever crisis in infertile
couples’ life and causes severe distress and psychological
(anxiety, depression, etc.) (
Above-mentioned factors affect deeply the quality of
life (QOL) and general health in infertile couples (
Most of studies showed impaired QOL and general
health in infertile couples where QOL was affected by
factors such as the duration of infertility, age, education, income, residential place and cause of infertility (
Following successful progresses in infertility treatment
and achieving pregnancy, it is assumed that the abovementioned problems may decrease and QOL may improve
(
The main goal of this study was to evaluate QOL and general health in pregnant women conceived with assisted reproductive technology (ART).
This case-control study was conducted during 2013- 2014 in a private clinic in Mashhad, Iran and 40 pregnant women conceived with ART and 40 pregnant women who conceived spontaneously were included.
Pregnant women who conceived with one of the ART
methods including
Pregnant women with a history of chronic diseases, diabetes, cardiovascular diseases, seizure, or addiction and those with a history of psychiatric disorders as well as those who did not sign the informed consent, were excluded from the study.
To evaluate QOL, a Persian version of WHO quality of life- BREF questionnaire (WHOQOL-BREF) was used. Also, a Persian version of General Health Questionnaire-28 (GHQ-28) was used to evaluate general health in the participants. In the present study, participants completed these two questionnaires twice (once in the first and once in the second trimester of pregnancy).
WHOQOL-BREF inventory has 26 items and four
domains including physical health, psychological health,
social relationship and environment. Reliability and
validity of the Persian version of WHOQOL-BREF was
previously evaluated and approved (
GHQ-28 is a self-administered inventory with 28 items that has been developed for screening of emotional distress and possible psychiatric morbidity. GHQ-28 evaluates psychological well-being in four subscales namely, somatic symptoms, anxiety/insomnia, social dysfunction and severe depression. Each subscale has seven questions and each item has four optional responses scored 0 to 3 as follows; score 0: “not at all” score 1: “no more than usual”; score 2: “rather more than usual” and score 3: “much more than usual.” The total score of the GHQ-28 ranges from 0 to 84 and a higher score indicates a higher distress level. In each subscale, a score >6 was considered “abnormal condition”.
Validity and reliability of the Persian version of GHQ28 was previously assessed and confirmed (
Considering Nilforooshan et al. (
Sample size of 40 was considered in each group. Obtained data was analyzed using SPSS software version 22.00 for Windows (Armonk, NY: IBM Corp.) and STATISTICA Ver. 10.00. Numerical data are presented as mean ± standard deviation and categorical data as numbers/percentages. Normality of data was assessed by Kolmogorov-Smirnov test with the correction of Lilliefors.
For comparison of data with normal distribution between the two groups, Student’s t test was used and for comparison of data obtained in the first and second trimester of pregnancy, paired t test was used. For comparison of data without normal distribution, nonparametric Mann-Whitney U test was applied. To compare qualitative and categorical data such as education and job between the two groups, Chi-square test was applied. A P≤0.05 was considered significant.
Institutional Review Board at Mashhad Branch of Islamic Azad University approved the study protocol and all participants signed written informed consent before enrollment (IR.IAU.NEYSHABUR.REC.1398.008).
Eighty women in the first trimester of pregnancy
participated in this study; of them, 40 conceived with ART
and 40 conceived spontaneously (control group). Mean
age of all women was 29.5 ± 4.7 years. Demographic
characteristics of pregnant women in two study groups are
depicted in
There were no significant differences in QOL score
between ART and control group neither in the first
trimester nor in the second trimester of pregnancy.
Also, there were no significant differences between the
two groups in none of the four QOL sub-domains in the
first and second trimesters of pregnancy. In the second
trimester of pregnancy, QOL improved significantly in
both groups compared to the first trimester (P=0.006 and
P=0.03, respectively) while the differences in the four subdomains of QOL were not significantly different between
the first and second trimesters, in each group (
There was a significant difference in general health
between the women conceived with ART and the
control group in a way that general health score of
women conceived with ART was significantly higher
than those conceived spontaneously in the first as well
as the second trimester of pregnancy (P<0.001). Also,
a significant difference was observed between the two
groups in all subscales of GHQ-28 in the first trimester
of pregnancy while in the second trimester a significant
difference was only found in somatic symptoms and
anxiety (P=0.001 and 0.009, respectively,
In the second trimester of pregnancy, in the ART
group, general health score and all its subscales
except for somatic symptoms, were significantly
lower than those of the first trimester of pregnancy
while in the control group, total general health score
and all its subscales were significantly higher than
those of the first trimester of pregnancy (
Demographic characteristics of study participants in two study groups
Parameter | ART pregnancy group | Spontaneous pregnancy group | P value | ||
---|---|---|---|---|---|
Age (Y) | 29.42 ± 4.39 | 29.57 ± 5.02 | 0.47 | ||
Education | |||||
Primary | 13 (32.5) | 10 (25) | |||
High school diploma | 11 (27.5) | 13 (32.5) | |||
University education | 16 (40) | 17 (42.5) | 0.74 | ||
Job | |||||
Housewife | 30 (75) | 29 (72.5) | |||
Employed | 10 (25) | 11 (27.5) | 0.79 | ||
Income* | |||||
Below 5000 | 6 (15) | 7 (17.5) | |||
5000-10000 | 14 (35) | 16 (40) | |||
10000-15000 | 12 (30) | 12 (30) | |||
More than 15000 | 8 (20) | 5 (12.5) | 0.82 | ||
Gestational age (weeks) | 9.87 ± 1.91 | 9.55 ± 2.11 | 0.55 | ||
Data are presented as mean ± SD or n (%). *; Thousands rials and ART; Assisted reproductive technology.
Quality of life score and scores of its four domains in two study groups in the first and second trimesters of pregnancy (0-100)
WHOQOL-BREF domain | ART pregnancy group | Spontaneous pregnancy group | P value | 95% CI | |
---|---|---|---|---|---|
First trimester of pregnancy | |||||
Physical health | 50.71 ± 12.05 | 51.61 ± 11.91 | 0.74 | -4.44, 6.22 | |
Psychological health | 57.08 ± 19.29 | 60.83 ± 19.28 | 0.38 | -4.83, 12.33 | |
Social relationship | 62.08 ± 15.20 | 65.83 ± 14.71 | 0.26 | -2.91, 10.41 | |
Environment | 60.31 ± 12.40 | 63.35 ± 14.20 | 0.31 | -2.88, 8.98 | |
Overall feeling | 66.25 ± 25.50 | 68.43 ± 23.34 | 0.69 | -8.69, 13.07 | |
Second trimester of pregnancy | |||||
Physical health | 51.42 ± 11.17 | 52.58 ± 12.68 | 0.66 | -4.16, 6.48 | |
Psychological health | 59.37 ± 18.62 | 60.20 ± 20.71 | 0.85 | -7.93, 9.60 | |
Social relationship | 61.66 ± 13.96 | 64.79 ± 13.80 | 0.31 | -3.05, 9.30 | |
Environment | 60.78 ± 14.65 | 62.50 ± 14.41 | 0.59 | -4.75, 8.19 | |
Overall feeling | 73.43 ± 22.32* | 74.06 ± 19.69* | 0.89 | -8.74, 9.99 | |
Data are presented as mean ± SD or n (%). *; Thousands rials and ART; Assisted reproductive technology.
GHQ-28 and its subscales scores in two study groups in the first and second trimesters of pregnancy
GHQ-28 domain | ART pregnancy groupn=40 | Spontaneous pregnancy groupn=40 | P value | 95% CI | |
---|---|---|---|---|---|
The first trimester of pregnancy | |||||
Somatic symptoms | 8.70 ± 3.00 | 5.60 ± 3.30 | 0.001* | -4.50, -1.69 | |
Anxiety and insomnia | 9.15 ± 3.36 | 5.80 ± 2.52 | 0.001* | -4.67, -2.02 | |
Social dysfunction | 8.55 ± 3.28 | 6.22 ± 2.61 | 0.001* | -3.64, -1.00 | |
Severe depression | 6.85 ± 3.14 | 5.47 ± 2.83 | 0.04* | -2.70, -0.04 | |
Total general health | 33.25 ± 7.41 | 23.10 ± 5.68 | 0.001* | -13.09, -7.20 | |
The second trimester of pregnancy | |||||
Somatic symptoms | 9.65 ± 3.18† | 6.80 ± 3.39† | 0.001* | -4.31, -1.38 | |
Anxiety and insomnia | 7.80 ± 2.20† | 6.35 ± 2.64† | 0.009* | -2.53, -0.36 | |
Social dysfunction | 7.52 ± 2.63† | 6.60 ± 2.76† | 0.12 | -2.12, 0.27 | |
Severe depression | 6.05 ± 2.36† | 6.05 ± 3.39† | 0.99 | -1.30, 1.30 | |
Total general health | 31.02 ± 5.54† | 25.80 ± 6.18† | 0.001* | -7.83, -2.61 | |
Data are presented as mean ± SD. ART; Assisted reproductive technology, CI; Confidence interval, *; Significant difference, GHQ-28; General Health Questionnaire-28, and †; Significant changes compared to the first trimester of pregnancy in the same group.
Prevalence of psychiatric disorders based on GHQ-28 results in two study groups in the first and second trimesters of pregnancy
GHQ-28 domain | ART pregnancy groupn=40 | Spontaneous pregnancy groupn=40 | P value | |
---|---|---|---|---|
The first trimester of pregnancy | ||||
Somatic symptoms disorder | 32 (80) | 12 (30) | <0.001* | |
Anxiety and insomnia disorder | 30 (75) | 14 (35) | <0.001* | |
Social function disorder | 29 (72.5) | 20 (50) | 0.03* | |
Severe depression disorder | 22 (55) | 9 (22.5) | <0.001* | |
Total general health disorder | 38 (95) | 21 (52.5) | <0.001* | |
The second trimester of pregnancy | ||||
Somatic symptoms disorder | 33 (82.5) | 18 (45) | <0.001* | |
Anxiety and insomnia disorder | 27 (67.5) | 17 (42.5) | 0.02* | |
Social function disorder | 26 (65) | 19 (47.5) | 0.11 | |
Severe depression disorder | 18 (45) | 12 (30) | 0.16 | |
Total general health disorder | 39 (97.5) | 26 (65) | <0.001* | |
Data are presented as n (%). *; Significant difference, ART; Assisted reproductive technology, and GHQ-28; General Health Questionnaire-28
Somatic symptoms score in the ART group was
significantly higher in the second trimester of pregnancy
(P<0.001). However, the difference in GHQ-28 between
the two study groups was significant and distress in the
ART group was higher compared to the control group, in
the second trimester of pregnancy (
This study found that QOL in pregnant women conceived with ART was similar to women conceived spontaneously, in the first and second trimesters of pregnancy while general health in ART group was significantly superior to control group in the first and second trimesters. Women conceived with ART had significantly higher somatic symptoms, anxiety, social dysfunction and depression compared to the control group, in the first trimester of pregnancy. In the second trimester of pregnancy, all GHQ-28 subscales were significantly reduced compared to the first trimester in the ART group while at the same time, distress increased in the control group. In the first trimester of pregnancy, in women conceived with ART, stress, anxiety and depression increase probably due to uncertainty about the continuity of pregnancy and in the second trimester, this uncertainty about stability of pregnancy decreases which may lead to reduced distress and anxiety.
Due to infertility and probably repeated treatment
failures, couples face different problems such as financial
problems and difficulties in social relations that affect
different aspects of their life. Infertility has negative
psychological effects such as anxiety, depression (
Maroufizadeh et al. (
Previous studies showed poor QOL in infertile couples
in Iran and other countries in the world (
However, successful infertility treatment and conception
may restore reduced QOL and increased distress level
during pregnancy. In a study conducted in Canada, QOL
was evaluated in 243 women conceived with ART and
3,309 women with spontaneous conception before the
25th week of pregnancy and during the 34th-36th weeks of
gestational age as well as four months postpartum by using
SF-12 questionnaire. This study reported lower physical
and mental health for women conceived with ART during
pregnancy (before the 25th week and during the 34th-36<sup>th</sup>
weeks of pregnancy) compared to women conceived
spontaneously while these indices were equal between
the two groups four months postpartum (
Gameiro et al. (
Ahmadi et al. (
A study in Slovenia showed that women conceived with
ART had positive emotion that improved by progression
of pregnancy despite the existence of more medical
problems during pregnancy. However, they tend to social
isolation (
The main limitation of the current study was the small sample size and lack of assessment of QOL and general health in the last trimester of pregnancy and postpartum. Cross- sectional design of the study, use of self-report questionnaire and lack of evaluation of psychological factors such as depression, anxiety, stress and self-esteem, were other limitations of the current study.
Future studies with larger sample size which assess QOL and general health using other valid, approved inventories in all trimesters of pregnancy and postpartum are suggested to be conducted to identify possible changes in QOL in the third trimester of pregnancy and during postpartum.
It seems that in infertile women following treatment and after successful conception and during pregnancy, QOL is similar to women conceived spontaneously and is not different. Although during pregnancy these women have high distress levels but by progression of pregnancy and increasing certainty about pregnancy, distress level reduces.