The Risk of Psychiatric Morbidity and Course of Distress in Males Undergoing Infertility Evaluation Is Affected by Their Factor of Infertility

Depression, anxiety, quality of life, and infertility: a global lens on the last decade of research

We aimed to review the global literature in the past 10 years regarding the impact of infertility on depression, anxiety, stress, and quality of life while exploring the potential clinical utility of psychosocial fertility questionnaires. PubMed, Scopus, and CINAHL were searched for English-published articles since 2013 on key search terms related to infertility, assisted reproductive technologies, and psychological terms such as depression, anxiety, mood disorders, and quality of life. The search yielded 7,947 articles, of which 366 articles were independently deemed relevant by the 3 reviewers. Anxiety, depression, and diminished quality of life are prevalent in the infertility experience of both men and women. Studies from around the world show similar experiences independent of culture.

Psychological consequences of a diagnosis of infertility in men: a systematic analysis

Almost half of infertility cases involve male infertility. Understanding the consequence of a diagnosis of male infertility, as a sole or partial contributor to the couples' infertility, to the mental health of men is required to ensure clinical care meets their psychological needs. The aim of this systematic analysis was to synthesize the evidence regarding whether men diagnosed with male factor infertility experience greater psychological distress than (1) men described as fertile and (2) men in couples with other infertility diagnoses. Online databases were searched using a combination of Medical Subject Headings (MeSH) headings and keywords relating to male infertility and psychological distress. The search yielded 1016 unique publications, of which 23 were included: 8 case-control, 14 prospective cohort, and 1 data linkage studies. Seven aspects of psychological distress were identified depression, anxiety, self-esteem, quality of life, fertility-related stress, general psychological stress or well-being, and psychiatric conditions. Case-control studies reported that men with male factor infertility have more symptoms of depression, anxiety and general psychological distress, worse quality of some aspects of life, and lower self-esteem than controls. When men with male factor infertility were compared to men in couples with other causes of infertility, there were few differences in the assessed aspects of psychological distress. Despite methodological limitations within the studies, this systematic analysis suggests that the experience of infertility, irrespective of its cause, negatively affects men's mental health and demonstrates the need for assisted reproduction technology (ART) providers to consider men undergoing assisted reproduction as individuals with their own unique support needs.

Global Research Trends on Infertility and Psychology From the Past Two Decades: A Bibliometric and Visualized Study

Objectives

The aim of this study was to evaluate the global scientific output of research on infertility and psychology; explore the current status and trends in this field through the cooperation of authors, countries, and institutions; shed light on the direction of clinical infertility research in the future, and provide inspiration for targeted diagnosis and treatment of infertility.

Methods

Research publications on infertility and psychology from the past two decades were retrieved from the Web of Science Core Collection (WoSCC). Bibliometric analyses were performed using VOSviewer software and the bibliometrix R package. Network maps were generated to evaluate the collaborations between different authors, countries, institutions, and keywords.

Results

A total of 151 articles related to the study of infertility and psychology were identified. We observed a gradual increase in the number of publications from 2001 to 2021, and the trend has been relatively stable in the past eight years. Human Reproduction (England), as the leading journal publishing the most papers (29 articles), was cited in the most journals (1208 times). Boivin J was the most prolific author (16 articles), with the largest number of citations (890 times) and the highest h-index (14) during the past decades. Boivin J was also the leader with the highest publication frequency and more active cooperation with other top authors. The United Kingdom (34 papers) and Cardiff University (25 articles) contributed the most publications and were the leading contributors in this field. Active cooperation between countries and between institutions was observed, and analyses of articles and references were also shown. The main hot topics included matters related to women (39 times), in-vitro salt (31 times), infertility (30 times), couples (25 times), and impact (24 times).

Conclusion

Our study results provide a comprehensive overview of the development of scientific literature, allowing relevant authors and research teams to recognize the current research status in this field. At the same time, infertility and psychology may soon become hotspots and should be closely monitored.

Depression Among Infertile Men in the Gaza Strip, Palestine: The Neglected Aspect of Fertility Care

Background:

Infertility is a worldwide public health problem and affects psychological aspects of males’ and females’ life. However, the problem has not been well investigated in Palestine. Therefore, the purpose of this study was to determine prevalence and predictors of depression among infertile men in the Gaza strip.

Methods:

A cross-sectional study was carried out among three hundred eighty five infertile males from January to December 2019. Participants were selected from three main in-vitro fertilization (IVF) centers following simple random sampling. The Arabic version of Beck Depression Inventory was used. Descriptive and inferential analyses were performed using the SPSS V22. Binary analysis was done to determine independent variables and t-test and one-way ANOVA were conducted afterwards. Logistic regression was performed to determine independent factors associated with depression symptoms. The p-value of 0.05 or less was considered statistically significant.

Results:

Findings showed that 42.6% (164/385) of infertile men had at least one type of depression. Severe depression was presented in 16.6% (64/164) of participants, while 13.2% (51/164) and 12.7% (49/164) showed moderate and mild depression, respectively. Predictors for depression were duration of marriage (>8 years) (CI 95%: 1.099–2.615) and at least one IVF attempt (CI 95%: 0.373–0.873).

Conclusion:

It has been revealed that depression is prevalent among infertile men. Marriage of long duration and several failures in IVF attempts are predictors for depressions. Psychological counseling besides medical interventions seems to be an optimal strategy to alleviate psychological distress associated with infertility.

KNOWLEDGE AND PERCEPTION OF INFERTILITY AMONG ADULT MALES IN IBADAN, NIGERIA

BACKGROUND

Infertility is a public health problem with significant social and psychological distress of the affected men due to the inability to achieve the desired social role of fatherhood. Men with infertility may experience lower life satisfaction, heightened distress and anxiety. This study assessed the knowledge, perception and factors influencing knowledge and perception of infertility among adult males in Ibadan, Nigeria.

METHODS

Cross-sectional descriptive survey was conducted among 388 adult males between April and November 2019 in the selected communities. Respondents were interviewed using a pretested structured questionnaire. Data was analysed with SPSS version 22. Descriptive and bivariate analyses were conducted. Level of significance was set at p≤5%.

RESULTS

The mean age of the respondents was 45.74±10.76 years. Majority were married 310(80%) and had tertiary education 234(60%). Less than half (48.7%) understood the correct meaning of infertility, 170(44%) agreed that witchcraft could cause infertility while 230(59%) disagreed that infertility could be prevented. Two hundred and sixty (67%) and 283 (73%) of the respondents had good knowledge and perception towards infertility respectively. Religion, education and income were statistically significant with knowledge of infertility (p<0.05). In addition, knowledge and perception of infertility showed statistically significant association (p<0.001).

CONCLUSION

Knowledge and perception of respondents towards infertility was suboptimal in this study. Some cultural beliefs persist despite the high level of education of respondents. Community-based education on infertility to increase the knowledge and perception of men towards infertility is recommended.

Common mental disorders, quality of life and explanatory models in men undergoing infertility treatment in a tertiary care hospital: A cross-sectional study

BACKGROUND

Men with infertility experience significant distress, however research on psychiatric morbidity among this group is limited. Literature on explanatory models of infertility, which influence help seeking behaviour is also scarce.

OBJECTIVES

The aim of this cross-sectional study was to assess the prevalence and factors associated with psychiatric morbidity among men with infertility, their quality of life, and explanatory models regarding infertility.

MATERIALS AND METHODS

One hundred and thirty-five consecutive males who attended the reproductive medicine outpatient clinic in a tertiary care hospital were recruited after obtaining informed consent. Psychiatric morbidity, quality of life and explanatory models were assessed using the Clinical Interview Schedule - Revised, Fertility Quality of Life scale and modified Short Explanatory Model Interview respectively. Socio-demographic and clinical details were recorded using a structured proforma.

RESULTS

Common mental disorder (CMD), observed in one third of the sample, was associated with longer duration of infertility and treatment, family history of psychiatric illness, sexual dysfunction, and past psychiatric illness in spouse. Presence of CMD was associated with lower quality of life scores. Participants held simultaneous and multiple explanatory models for infertility.

CONCLUSION

Men with infertility experience psychological distress that can further impair their quality of life. They should be offered support and psychosocial interventions as they undergo infertility treatment.

The Etiology of Infertility Affects Fertility Quality of Life of Males Undergoing Fertility Workup and Treatment

This panel study explored the effects of male, female, mixed, or idiopathic factor of infertility on the fertility quality of life (FertiQoL) in involuntarily childless males undergoing fertility workup for the first time. A convenience sample of 255 married males (age range = 22–51 years, mean = 30.24 years), 254 (99.6%) of whom suffered from primary infertility were assessed (1) at the baseline, before their initial fertility evaluation (T1); (2) before their second andrological appointment, 2–3 months after diagnostic disclosure (T2); and (3) before subsequent treatment-related/ follow-up appointments (T3, T4). The timing of psychological assessment was strictly related to andrological appointments and routine medical procedures. Respondents completed Emotional, Mind–Body, Relational, and Social subscales of the Polish version of FertiQoL and a baseline demographic survey. The research demonstrated that the FertiQoL scores across the Emotional, Mind–Body, and Relational subscales markedly decreased after the diagnostic disclosure, particularly in the subgroups with male and concurrent male and female factor. Social subscale scores in all subgroups remained stable after the diagnostic disclosure (at T2) but significantly decreased in the follow-up (at T3 and T4). Significant differences in FertiQoL scores associated with respondents’ infertility factor could be demonstrated at each time point. The study identifies the FertiQoL in unintentionally childless males is significantly affected by their factor of infertility and evolves across the pathway of treatment-related/follow-up appointments.

Supportive care: men's expectations who undergoing in vitro fertilization treatment

Objective

Infertile couples perceive some needs and expectations during treatment. Most studies have focused on infertile women’s needs. The study was done to explore the expectations of men who undergoing in in vitro fertilization (IVF) treatment. Participants were men whose wives undergo IVF treatment in the IVF clinic of Shahid Motahhri hospital in Urmia. Purposive sampling was performed and data collection was done through in-depth semi-structured interviews until data saturation.

Results

“Supportive care” was emerged as the main theme consisted of two categories. The first category was “to be treated with attention in healthcare setting” which included three subcategories: Receiving couple based care, establishing counseling centers, and continuous care. The second category was “to be welcomed in the society” which included two subcategories: Financial support from community and close family, and changing community views about IVF treatment. Expectations of men undergoing IVF focuses on supportive care. They seek to receive the kind of care from health care setting and society. A deep understanding of the needs could help practitioners to consider men’s expectations, and assist policy makers and researchers to design and implement interventions and programs in infertility clinics which enhance the partnership of infertile men and fulfill their expectations.

Individual and Relational Well-Being at the Start of an ART Treatment: A Focus on Partners' Gender Differences

Infertility and ART treatments represent stressful experiences for the couples, impacting on the overall psychological well-being of partners as well as on their couple adjustment. Several variables were analyzed as risk factors for infertility-related distress. The impact of these experiences has been well-documented in both women and men, reporting important gender differences. The aim of this study was to assess gender differences in individual and relational well-being in infertile couples. Gender differences for psychological and medical variables predicting psychological distress were investigated. Two hundred and thirty couples who entered an ART program at a public hospital in Milan were recruited. Each partner completed the following scales: ScreenIVF, Dyadic Adjustment Scale, and Experience in Close Relationship Questionnaire. Findings revealed several gender differences with women reporting higher levels of both anxiety and depressive symptoms, anxiety and avoidance attachment, and helplessness, but lower levels of acceptance than men. Differences emerged also in factors predicting well-being: poor support predicted anxiety in men and depression in women. Furthermore, individual well-being was predicted only for men by attachment anxiety and previous treatment. Finally, in the women subsample, couple's adjustment was predicted by anxiety attachment, while in men predictors were helplessness and type of diagnosis. These results suggest the importance of implementing support interventions for couples which take into consideration the specific needs and fragility of each partner as well as focusing on enhancing a sense of partnership.

Depression among men in ART treatment: a register-based national cohort study

STUDY QUESTION

Are male factor infertility or remaining childless risk factors for unipolar depression among men in assisted reproductive technology (ART) treatment?

SUMMARY ANSWER

Male factor infertility was not associated with a significantly increased risk of unipolar depression and men remaining childless did not have a significantly increased risk of developing unipolar depression compared to men in ART treatment who became fathers.

WHAT IS KNOWN ALREADY

Men in medically assisted reproduction due to male factor infertility are more distressed and have more negative emotions such as feelings of loss, stigma and low self-esteem compared to men in fertility treatment due to other infertility diagnosis. Stress is in general a risk factor for depression. However, previous studies show conflicting results whether male factor infertility is a risk factor for depression.

STUDY DESIGN, SIZE, DURATION

This national, register-based cohort study consisted of 37 913 cohabitant male partners of women in ART treatment recorded in the Danish IVF register (1994–2009). Via a national register, the men’s personal identification number data were linked to the Danish Psychiatric Central Research Register (PCRR) (1969–2009) which records psychiatric diagnoses including unipolar depression, based on the ICD-8 and ICD-10 classification system.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The full cohort of male partners (n = 37 913) was included in the initial analysis on prevalence of unipolar depression before or after ART treatment initiation. The association between male factor infertility and unipolar depression diagnosis after initiating ART treatment was analysed with Cox regression analysis in a sub-study population of men with the exclusion of men having a depression prior to ART treatment or not having full data on educational level and infertility diagnosis (n = 34 817).

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 1.2% (n = 446) of the men were diagnosed with unipolar depression either before initiating ART treatment (n = 146) or during follow-up (n = 300). In all, 76.0% of men with depression prior to or after ART treatment achieved fatherhood compared to 82.3% of men without depression (P < 0.001). In the sub-study population (n = 34 817, which included 266 men with a unipolar depression diagnosis), male factor infertility was not associated a significantly increased risk of depression (adjusted hazard ratio (aHR) = 1.04, 95% CI: 0.79–1.36, P = 0.804), and ART-treated men who remained childless did not have a significantly increased risk of developing depression compared to ART treated men who became fathers (aHR = 1.13, 95% CI: 0.87–1.48, P = 0.355).

LIMITATIONS, REASONS FOR CAUTIONS

Only severe cases of depression are recorded and included in this national register-based study given that only men with clinically diagnosed unipolar depression recorded in a psychiatric hospital (in-patient and out-patient) are included in the Danish PCRR. It is difficult to completely rule out an association between the exposures and depression as this outcome is so rare, and therefore the results are still statistically uncertain despite a large cohort. Furthermore, only men in ART treatment were included in this study, and caution should be taken in generalising findings to the total population of men in all areas of medically assisted reproduction or infertile men who have not sought treatment.

WIDER IMPLICATIONS OT THE FINDINGS

This large national cohort study suggests that despite evidence showing that male factor infertility is a potential severe stressor for men, which can increase psychological distress and negative emotions, infertile men in ART treatment and men remaining childless after ART are not at a significantly increased risk of developing clinically diagnosed unipolar depression.

STUDY FUNDING/COMPETING INTERESTS

C.S.S. was funded by unrestricted research grants received by Lone Schmidt from The Danish Health Insurance Foundation (J.nr. 2008B105) and Merck Sharp & Dohme (MSD). The sponsors had no influence on how data were retrieved and analysed or on the conclusions of the study. C.S.S. and L.S. have declared conflicts of interests; the remaining co-authors have no conflicts of interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Stress and Anxiety in Couples Who Conceive via In Vitro Fertilization Compared With Those Who Conceive Spontaneously

OBJECTIVE

To determine the feasibility of recruitment and explore whether women and their partners who conceive via in vitro fertilization (IVF) experience greater levels of stress and anxiety during pregnancy compared to each other and compared to couples who conceive spontaneously.

DESIGN

Longitudinal, descriptive, pilot study.

SETTING

Recruitment was conducted at three sites in the United States (two fertility clinics and one well-woman clinic).

PARTICIPANTS

Informed consent was obtained from 48 women and their partners (22 IVF couples and 26 spontaneous conception [SC] couples).

METHODS

During each trimester, participants completed the Perceived Stress Scale, the State-Trait Anxiety Inventory, and the Pregnancy-Related Anxiety Measure to assess their levels of stress and anxiety. We used hierarchical linear mixed-effects models for repeated measures adjusting for woman and partner nesting effects to conduct trajectory analyses to test for group differences in stress and anxiety levels.

RESULTS

Recruitment goals were met (31 IVF and 27 SC couples gave informed consent and 22 IVF and 26 SC couples completed questionnaires). We found no significant group main or group by time interaction effects on anxiety and stress. However, pregnant women had significantly higher mean state and pregnancy-related anxiety scores than their male partners. Of interest, the women showed a gradual reduction in state and pregnancy-related anxiety across trimesters, whereas pregnancy-related anxiety of their partners gradually increased.

CONCLUSION

Among our participants, IVF did not increase risk for stress, state anxiety, or pregnancy-related anxiety, which provides reassurance during patient counseling. Although pregnant women overall experienced greater state and pregnancy-related anxiety than men, we found that levels in women decreased closer to birth, which may contribute to successful emotional transition to parenthood. Men's experiences with anxiety require additional investigation given the recent attention to male postpartum depression.