|Year : 2021 | Volume
| Issue : 1 | Page : 3-10
Assessment of impact of infertility & its treatment on quality of life of infertile couples using fertility quality of life questionnaire
Geeta Shripad Wadadekar, Dattaprasad Balasaheb Inamdar, Vandana Ravindra Nimbargi
Department of Reproductive Medicine and Surgery, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
|Date of Submission||20-Aug-2020|
|Date of Decision||11-Feb-2021|
|Date of Acceptance||16-Feb-2021|
|Date of Web Publication||30-Mar-2021|
Dr. Geeta Shripad Wadadekar
Department of Reproductive Medicine and Surgery, Bharati Vidyapeeth Deemed University Medical College, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: With rising trends of infertility in India, it is no longer just a medical concern, but is rapidly becoming a public health issue due to its social and interpersonal ramifications. Limited data is available regarding quality of life of the infertile couples. Aim: The aim of this study was to understand the quality of life (QOL) of Indian infertile couples using the fertility QOL (FertiQoL) tool and to find the correlation between the values of the core and treatment FertiQoL and various sociodemographic and clinical factors. Study Setting and Design: This cross-sectional study was conducted at fertility clinic at an urban tertiary care center. Materials and Methods: Over a period of 12 months, 274 completed questionnaires obtained from 137 couples were selected for the analysis. Demographic and clinical characteristics of all the patients were recorded. Data analysis was performed using the Statistical Package for the Social Sciences software version 25:0. IBM Chicago, USA. Results: Women had worse QOL than their male partners. They scored lower than men on emotional and mind body subscales. Women showed positive and uniform trend in mean scores of all core FertiQoL subscales with age and education. Rural population had poorer QOL. Patients with primary infertility had poorer QOL except in the relational domain. Couples, in whom both partners had some pathology, had the worse QOL compared to female factor, male factor or unexplained infertility. Conclusion: Our study is a step in the direction to establish the baseline QOL objectively in Indian couples with infertility.
Keywords: Assessment, infertility, psychological stress, quality of life, questionnaire
|How to cite this article:|
Wadadekar GS, Inamdar DB, Nimbargi VR. Assessment of impact of infertility & its treatment on quality of life of infertile couples using fertility quality of life questionnaire. J Hum Reprod Sci 2021;14:3-10
|How to cite this URL:|
Wadadekar GS, Inamdar DB, Nimbargi VR. Assessment of impact of infertility & its treatment on quality of life of infertile couples using fertility quality of life questionnaire. J Hum Reprod Sci [serial online] 2021 [cited 2022 May 23];14:3-10. Available from: https://www.jhrsonline.org/text.asp?2021/14/1/3/312422
| Introduction|| |
Infertility is the inability of a sexually active couple to achieve pregnancy within a year or more of regular unprotected intercourse.
Although not a fatal medical condition, infertility does have negative ramifications on various psychological, emotional, social, and financial aspects of life of an individual suffering from it, as shown by ample studies conducted worldwide.
Numerous studies have found an adverse association between infertility-induced stress and subsequent fertility, and treatment outcome.,
Treatment of infertility in itself is a complex, time-consuming affair, involving multiple visits to the specialist, running a gamut of investigations and procedures. The best prognosis of achieving a pregnancy, even after using a costly technology like in vitro fertilization (IVF)- intracytoplasmic sperm injection (ICSI), is very much variable, depending upon patient specific and treatment-specific factors.
Going through the process can be quite overwhelming. Patients tend to stop treatment prematurely as they find it too much to handle, as shown by Shinoda et al., using the Cornel Medical Index to assess the stress levels in infertility patients. In a prospective cohort study, Olivius et al. found that psychological stress was a major reason for poor treatment compliance.
Thus, infertility, its treatment, and treatment outcome are all intricately interlinked.
Eventually, some couples may need to deal with failure of medical treatment and biological childlessness. How they approach and adapt to it over a period of time determines their long term satisfaction and quality of life (QOL).
The clinicians and health-care professionals need to be aware of these very real challenges faced by the patients and be able to assess the effect of infertility and its treatment on the quality of their life, in order to provide appropriate care.
QOL is a multifaceted concept pertaining to an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. The fertility QOL (FertiQoL) is a sensitive and reliable instrument to evaluate the FertiQoL parameters in individuals with infertility. It was developed by a multidisciplinary team and was internationally validated by expert teams from the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine in collaboration with Merck Sereno.
It consists of a Core QOL set of questions which covers four specific domains.
The emotional domain reveals the impact of negative emotions arising due to infertility, for example, (sadness, depression jealousy, and resentment) on QOL. The mind-body domain conveys the impact on physical health (e.g., fatigue and pain), cognition (e.g., concentration) and behavior (e.g., disrupted daily activities, delayed life plans), while the relational domain expresses effect on partnership (sexuality, communication, and commitment issues). The social domain evaluates that how infertility interferes with social interactions of the individual (social inclusion, expectations, stigma, and support).
There is an optional additional treatment module which is formulated to know thoughts and feelings toward treatment quality and tolerability, in those undergoing treatment for infertility.
The goal of this study was to understand the QoL of Indian infertile couples, serving as a tool for patient counseling and reference for future research.
The study also intended to find the correlation between the values of the core FertiQoL and treatment FertiQoL with various sociodemographic and clinical factors in Indian couples with infertility.
| Materials and Methods|| |
This was a cross-sectional study conducted at the department of reproductive medicine and surgery at a tertiary care institute over a period of 12 months (February 1, 2019–January 31, 2020).
Ethics committee clearance was obtained from the Institutional Ethics Committee (Approval Number: BVDUMC/IEC/2 dated 25/01/2019).
Considering 20.38% incidence of infertility in Asia, using 95% confidence interval, and estimated sample size was 249.
Couples attending the outpatient department of reproductive medicine, from February 1, 2019, to January 31, 2020, who were willing to participate, who had at least two consultations by the specialist and in whom at least a provisional diagnosis of the causative factor was reached, were included.
Patients who had already undergone IVF/ICSI cycle at the center or at any other facility were excluded.
FertiQoL questionnaire was made available in three languages – the vernacular/local language, national language, and English.
Couples were explained about the study and nature of the questionnaire. All queries about it were answered by the investigator. It was then administered to the consenting patients. They were specifically asked to fill it directly and independently, without any communication with their partner.
Partners were provided with a separate, comfortable sitting arrangement so that they could respond without any interference or influence. Any doubts or comprehension difficulties about the questions or the responses were cleared personally by the investigator.
One hundred and fifty-two couples fulfilled the criteria and were asked to fill the questionnaire. We did not come across anyone who could not read. Fifteen couples had incomplete or incorrect responses (e.g., ticking two responses for the same question/leaving few items unanswered). Completed questionnaires of 137 couples (274 patients) were analyzed.
Data analysis was performed using the Statistical Package for Social Sciences Version 25.0 IBM Chicago, USA. Qualitative data variables expressed by using frequency and percentage (%). Quantitative data variables expressed by using mean ± standard deviation (SD). Analysis of variance test used for the comparison of percentile score of domains (emotional, mind body, relational, social, environmental, and tolerability) with education and age, etc., Unpaired t-test was used for the comparison of percentile score for domains (emotional, mind body, relational, social, environmental, and tolerability) with type of infertility, gender, and diagnosis. P < 0.05 considered statistically significant.
| Results|| |
Sociodemographic and clinical profile of the study population is summarized in [Table 1]. The study included 137 couples, i.e., equal number of females and males.
There was a significant difference in the distribution of age and education of females and males, which is likely due to sociocultural structure of Indian society.
The core FertiQoL score was found to be lower in women, the difference was statistically significant (P = 0.017) [Table 2].
FertiQoL subscale analysis revealed lower scores across all domains in women. The difference reached statistical significance (P < 0.05) in emotional and mind-body subscales [Table 3].
Treatment environment and tolerability scores show that are both women and men are affected similarly [Table 3].
Overall, among various age groups, there was a significant difference between the groups in three domains, i.e., emotional, mind-body, and social subscales of the core Ferti-QOL and environmental subscale of treatment QOL [Table 4].
When men and women were analyzed separately, it was revealed that the younger age in women was associated with significantly lower values on mind body domain of core FertiQoL and environmental domain of treatment FertiQoL. In women, emotional and social subscales improved, while relational scores went down slightly with increasing age, although the difference was not statistically significant. Treatment tolerability did not change with age.
In case of men, the effect of age on core subscales or the treatment subscales did not reach statistical significance [Table 4].
Women fared better across the domains of QOL parameters with improvement in education, although the difference across education groups was not statistically significant. Treatment tolerability was similar across different levels of education in women [Table 5].
Although all scores showed lower values for the rural population, the difference in relational subscale reached statistical significance [Table 6].
Patients with secondary infertility consistently fared better across all domains, except on relational subscale [Table 7].
Patients with male factor infertility had lower scores across all domains compared to unexplained infertility and female factor infertility [Table 8].
Patients in whom both the partners had some factors contributing to infertility, had overall lowest scores in the emotional, mind-body, and social domains, but fared best on relational subscale [Table 8].
With increasing duration of infertility, emotional, mind body, and social domains suffered albeit not reaching statistical significance [Table 9].
Patients scored worse on emotional, mind-body, and social domain when they started treatment, i.e., up to six cycles of ovulation induction with or without intrauterine insemination than those receiving no treatment. The scores improved after six cycles [Table 10].
| Discussion|| |
In our study, the core FertiQoL score was significantly lower in women compared to men [Table 2].
Previous studies from India and other countries, have shown similar results with significantly lower values of core FertiQoL scores in women.
Both Indian women and men had mean core FertiQoL scores similar to the German study by Sexty et al. (72.6/SD 12.8) in women (77.8/SD 10.8) in men, and the Dutch study by Aarts et al. (70.8/SD 13.9).
The scores were better than the values from a Taiwanese study which had mean score of (60.63/SD 14.07) in men and (54.39/SD 13.52) in women.
Despite variable mean values in different studies across different countries, the difference in females and males was persistent, and in agreement to our study, that women with infertility had a worse QOL compared to their male counterparts.
On subscale analysis of core FertiQoL, women had significantly lower values on emotional and mind-body subscales [Table 3]. This finding was in agreement with many studies done worldwide, including the original developmental study of FertiQoL by Boivin et al.
Women face serious emotional turmoil and physical manifestations due to infertility. Emotions can range from confusion, anger, hopelessness, feeling of unworthiness and frustration, to denial, withdrawal, social isolation and depression, only added by anxiety of extensive treatment.
All other domain scores of core (social and relational) and treatment (environment and tolerability) FertiQoL were not significantly different in women and men. This indicates that poor support from spouse, friends, or family may not be the only reason for poor emotional and mind-body scores in Indian women, and other contributing factors need further exploration.
In our study, women showed positive trend in the mean scores of core FertiQoL subscales with age and education [Table 4 and 5]. The positive effect of age was statistically significant on the mind-body subscale of core FertiQoL and environment subscale of treatment FertiQoL. It indicates that with maturity, women were better equipped to tackle the infertility experience.
Many studies in the past have shown that younger age and low education levels are prognosticating factors for lower QOL., Less education may mean lesser opportunities for work or jobs. Women are dependent on the spouse and family. In such a situation, motherhood as an identity becomes crucial to them, both at personal and social level.
Rural population fared poorly across all subscales of core FertiQoL compared to the urban population; significantly so on relational subscale [Table 6]. This finding should be viewed in the Indian context, where sociocultural norms are more stringent in the rural area.
Patients with secondary infertility had better QOL compared to those with primary infertility, [Table 7] findings compatible with Karabulut et al. and Turkish study by Dural et al.
In our study, out of 42 couples with secondary infertility, only 13 had a live healthy child. Rest had conceived, but lost the pregnancy (missed abortion/spontaneous miscarriage/ectopic).
Even if conception did not result in birth of a live healthy baby, just getting pregnant had a positive impact on all the domains of the QOL, except relational aspect. This was akin to the findings in original developmental study by Boivin et al. in which couples with secondary infertility did worse on relational subscale.
Couples, in whom both partners had some pathology, had the worst core QOL scores, understandably so, as this group of patients has the least probability of conceiving their own child naturally or with treatment. This group of patients scored best on relational subscale, although the difference was not statistically significant. They had worst treatment tolerability. This may be explained by the fact that in this group, both partners will require go through plethora of investigations and procedures and eventually need help of advanced assisted reproductive technologies [Table 8].
Couples with male factor infertility and those in whom both partners had some pathology tend to suffer emotionally and physically. In couples with female factor infertility, the overall QOL was much better. This shows that the female being the cause of infertility was a better accepted fact by both partners [Table 8].
Patients with unexplained infertility had better core QOL scores than the other groups in emotional and social aspects. Similar findings were obtained by Heredia et al. but not by others. [Table 8]
The data from our study showed that patients with longer duration of infertility performed slightly better on relational subscale. Treatment tolerability also improved with increasing duration of treatment. None of these differences, although were statistically significant.[Table 9]
Infertility is a situational life crisis faced by couples. Although actual medical problem may be diagnosed in either of the partner, both of them, or none of them, the emotional stress, financial burden and social hardships are faced by both. Hence, it is essential that they are not only evaluated and treated as individuals but also as partners.
This study includes 137 couples. Hence, it offers a better chance at insight into how both the individuals in the relationship can affect their own and their partners' QOL.
Patients' knowledge about their own medical diagnosis was not objectively tested.
This is a cross-sectional study conducted at a single urban tertiary center. Similar studies are required across different regions of the country with diverse geography, ethnicity, social, cultural values, and accessibility of health care.
Further research is required to test the correlation of FertiQoL scores with other standardized scales for psychometric analysis in patients of infertility.
Different treatment modalities may have different tolerability which may depend upon their duration, painful nature or invasiveness. There is a scope of research in patients undergoing different forms of ART, i.e., IVF-ICSI cycles.
| Conclusion|| |
The sociodemographic background as well as clinical factors of patients should be taken into account at all the steps of management, as these are associated with how they handle the plight of infertility and its treatment.
The use of standardized disease-specific tool such as FertiQoL is helpful
- In objective assessment of baseline QoL parameters in infertile couples
- In directing interventions to the most affected subgroup of patients, thereby allowing rational use of resources.
Patients can be offered focused counseling or treatment protocols can be modified, keeping in mind the particularly affected QoL domains.
Hence, psychological assessment of the infertile couples using standardized disease-specific tool like FertiQoL should become an integral part of infertility management.
The authors are grateful to the patients for participation and providing their consent to conduct this study. Assistance form the staff of department of Reproductive Medicine & Surgery is also acknowledged. We are grateful to Dr Leena Patankar, Patankar Hospital Pvt. Ltd for valuable inputs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al
. The International Glossary on Infertility and Fertility Care, 2017. Hum Reprod 2017;32:1786-801.
Greil AL. Infertility and psychological distress: A critical review of the literature. Soc Sci Med 1997;45:1679-704.
Verhaak CM, Smeenk JM, Evers AW, Kremer JA, Kraaimaat FW, Braat DD. Women's emotional adjustment to IVF: A systematic review of 25 years of research. Hum Reprod Update 2007;13:27-36.
Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The social consequences of infertility among Iranian women: A qualitative study. Int J Fertil Steril 2015;8:409-20.
Dyer SJ, Patel M. The economic impact of infertility on women in developing countries A systematic review. Facts Views Vis Obgyn 2012;4:102-9.
Louis GM, Lum KJ, Sundaram R, Chen Z, Kim S, Lynch CD, et al
. Stress reduces conception probabilities across the fertile window: Evidence in support of relaxation. Fertil Steril 2011;95:2184-9.
Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues Clin Neurosci 2018;20:41-7.
Boivin J, Schmidt L. Infertility-related stress in men and women predicts treatment outcome 1 year later. Fertil Steril 2005;83:1745-52.
Kousalya K, Sanjeeva R, UmaMaheswara R. Depression, anxiety and stress among infertile women and the impact of counseling on these levels. Innov J Med Health Sci 2013;3:110-2.
McLernon DJ, Steyerberg EW, Te Velde ER, Lee AJ, Bhattacharya S. Predicting the chances of a live birth after one or more complete cycles of in vitro
fertilisation: Population based study of linked cycle data from 113≥873 women. BMJ 2016;355:i5735.
Shinoda T, Sashiyama M, Ueno K, Utsunomiya T. Infertility patient's mental health condition using the Cornel Medical Index [CMI]. Fertil Steril 2009;92:133-4.
Olivius C, Friden B, Borg G, Bergh C. Why do couples discontinue in vitro
fertilization treatment? A cohort study. Fertil Steril 2004;81:258-61.
Daniluk JC. Reconstructing their lives: A longitudinal, qualitative analysis of the transition to biological childlessness for infertile couples. J Couns Dev 2001;79:439-49.
The WHOQOL Group. World Health Organization Quality of Life Assessment [WHOQOL]: Position paper from the World Health Organization. Soc Sci Med 1995;41:1403-09.
Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: Development and general psychometric properties. Hum Reprod 2011;26:2084-91.
Rutstein SO, Iqbal HS. Infecundity, Infertility and Childlessness in Developing Countries. DHS Comparative Reports No. 9. Calverton, Maryland, USA: ORC Macro and the World Health Organization; 2004.
Desai HJ, Gundabattula SR. Quality of life in Indian women with fertility problems as assessed by the FertiQoL questionnaire: A single center cross sectional study. J Psychosom Obstet Gynaecol 2019;40:82-7.
Huppelschoten AG, van Dongen AJ, Philipse IC, Hamilton CJ, Verhaak CM, Nelen WL, et al
. Predicting dropout in fertility care: A longitudinal study on patient-centredness. Hum Reprod 2013;28:2177-86.
Huppelschoten AG, van Dongen AJ, Verhaak CM, Smeenk JM, Kremer JA, Nelen WL. Differences in quality of life and emotional status between infertile women and their partners. Hum Reprod 2013;28:2168-76.
Sexty RE, Griesinger G, Kayser J, Lallinger M, Rösner S, Strowitzki T, et al
. Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples. Health Qual Life Outcomes 2018;16:233.
Aarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: A validation study of the Dutch FertiQoL. Hum Reprod 2011;26:1112-8.
Hsu PY, Lin MW, Hwang JL, Lee MS, Wu MH. The fertility quality of life (FertiQoL) questionnaire in Taiwanese infertile couples. Taiwan J Obstet Gynecol 2013;52:204-9.
Peterson BD, Newton CR, Rosen KH, Skaggs GE. Gender differences in how men and women who are referred for IVF cope with infertility stress. Hum Reprod 2006;21:2443-9.
Peterson BD, Newton CR, Feingold T. Anxiety and sexual stress in men and women undergoing infertility treatment. Fertil Steril 2007;88:911-4.
Chachamovich JR, Chachamovich E, Zachia S, Knauth D, Passos EP. What variables predict generic and health-related quality of life in a sample of Brazilian women experiencing infertility? Hum Reprod 2007;22:1946-52.
Rashidi B, Montazeri A, Ramezanzadeh F, Shariat M, Abedinia N, Ashrafi M. Health-related quality of life in infertile couples receiving IVF or ICSI treatment. BMC Health Serv Res 2008;8:186.
Dong Y, Zhou F. Comparison of fertility quality of life between urban and rural infertile couples. Int J Clin Exp Med 2016;9:8664-70.
Karabulut A, Özkan S, Oğuz N. Predictors of fertility quality of life (FertiQoL) in infertile women: Analysis of confounding factors. Eur J Obstet Gynecol Reprod Biol 2013;170:193-7.
Dural O, Yasa C, Keyif B, Celiksoy H, Demiral I, Yuksel Ozgor B, et al
. Effect of infertility on quality of life of women: A validation study of the Turkish FertiQoL. Hum Fertil (Camb) 2016;19:186-91.
Lee TY, Sun GH, Chao SC. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod 2001;16:1762-7.
Heredia M, Tenías JM, Rocio R, Amparo F, Calleja MA, Valenzuela JC. Quality of life and predictive factors in patients undergoing assisted reproduction techniques. Eur J Obstet Gynecol Reprod Biol 2013;167:176-80.
Sexty RE, Hamadneh J, Rösner S, Strowitzki T, Ditzen B, Toth B, et al
. Cross-cultural comparison of fertility specific quality of life in German, Hungarian and Jordanian couples attending a fertility center. Health Qual Life Outcomes 2016;14:27.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]
|This article has been cited by|
||Assessment of Quality of Life in Men Treated for Infertility in Poland
| ||Marta Makara-Studzinska, Agnieszka Limanin, Agnieszka Anusiewicz, Paula Janczyk, Dorota Raczkiewicz, Anita Wdowiak-Filip, Michal Filip, Iwona Bojar, Krzysztof Lukaszuk, Artur Wdowiak |
| ||International Journal of Environmental Research and Public Health. 2022; 19(5): 2950 |
|[Pubmed] | [DOI]|