According to the result, infertile women are 21 times more likely to develop depression compared to the fertile ones. After adjusting for confounding variables such as marital duration, history of underlying illnesses, and family marriage, the chances of contracting depression still remains higher in infertile than fertile women by number of times. Since an infertile person is not able to go through the process of reproduction, she turns this failure into a social psychological crisis. A previous study in Iran measured psychological symptoms among infertile women using a similar tool to the one was used in the present study and found infertility has been a source of anxiety and depression among Iranian infertile women(11).
Cultural and social factors may play a critical role in the psychological status of Iranian infertile women as well(8, 11, 30). Infertile women experience various forms of ignorance in the family and society, thus; let them avoid the community which does not appropriate for their social health while may even exacerbate their psychological symptoms(8, 31, 32). Based on a qualitative study that examined the experiences of infertile Nigerian women, most women expressed anxiety and depression as a result of their inability to get pregnant. They also suffered from social self-isolation and marital problems(33). Likewise, a study measured mood distress in infertile couples again which used similar tools used in our study. That showed about 10% of the sample experience clinical symptoms of anxiety and depression(14).The results of our study are consistent with previous studies which shows anxiety and depression are common manifestations among infertile women.
According to the results of our study, the chance of insufficient sexual satisfaction is higher by 15 times among infertile women compared to fertile ones. Based on a few Iranian studies, the infertile couples' welfare and relationships are more likely to be affected by infertility in countries where a daughter has been trained and expected to be a mother later on(11, 30, 34–38). Various studies have already measured the levels of sexual satisfaction among infertile women using different tools. For example a previous study conducted in Iran, measured the levels of sexual satisfaction using the Female Sexual Function Index Questionnaire which showed the levels of satisfaction is significantly lower in infertile group compared to the opposite cluster(37). These findings show that the results of sexual satisfaction assessment in Iranian infertile women are similar by different questionnaires. Likewise, a meta-analysis without language restriction on 11 comparative studies showed that infertility was associated with an increased sexual dysfunction(39).
According to the results of previous studies in Iran the prevalence of sexual dissatisfaction was significantly higher in infertile women compared to their husbands, which indicates infertile women were more affected by psychological complications of infertility than their spouses(40). In addition, Men and women may differ in their perceptions of sexual satisfaction. For example, a study of 113 infertile couples who attended an infertility clinic showed a higher proportion of women believe their partner do not understand how infertility issues have impacted their marital life. This can be an origin of concern about longevity of their relationships. In contrast, men reported having significant lower quality of sex compared to the women(41).
Our study demonstrated the severity of depression in infertile women who received IVF treatment increased over time. A systematic review reported multiple failed IVF treatment attempts may increase the likelihood of developing unfavorable mood conditions, especially depression. For instance, Infertility treatment affects changes in perception, marital relationship, and personality of an infertile woman(42).
Previous studies have also shown that treatment of infertility are sometimes predictive of stressful conditions related to infertility rather than getting them fertile(43, 44). It may be thought that seeking fertility may take the form of obsessive-compulsive behavior that may affect couples' self-esteem and identity. Couples may feel they are responsible for the outcome of the pregnancy, which raises concerns. This causes couples to neglect other aspects of life, making them susceptible to depressive traits such as declined social and physical activity as well as the interest in daily life(45).There is a mutual relationship between depression and infertility treatment. During a study conducted in North Carolina, U.S. infertile women who already started receiving treatment were given the NIH PROMIS screening tool questionnaire which screens people for mental disorders. Infertile women who suffered from depression were less likely to follow oral or IVF treatments than infertile women who were not depressed(46).
Our study demonstrated low sexual satisfaction is commonly seen in women undergoing infertility treatment through surgery and IVF. Couples' focus on pregnancy may diminish their interest in sexual activity. In addition, sexual problems in the treatment of infertility may be attributed to hormonal changes produced as a result of medical treatments such as surgery or IVF(47). A previous study in Iran showed that poor general health, stress, and marital dissatisfaction were associated with IVF treatment in infertile women(48).In a study of three target groups, including successful IVF treatment group, unsuccessful IVF treatment group with a step kid, and unsuccessful IVF treatment group with no step kin at all, there were no significant differences between them in terms of sexual satisfaction. They did not have sexual satisfaction and indicated(49).This may indicate the negative impact of IVF treatment on having sexual satisfaction. Studies show that people who find fertility through medical treatment experience symptoms of anxiety, stress, depression, and sexual concerns related to infertility. When infertile group got pregnant by means of reproductive medical assistance, if the women of previously infertile group were exposed to stressors, they showed a greater decline in sexual satisfaction(50).
In addition our study demonstrated, relatively high level of depression and low level of sexual satisfaction are seen among infertile women, while the cost of treating them has been at least 5 million Tomans. In a study of 85 Iranian infertile women referred to a public clinic in order to assess sexual satisfaction, the cost of treatment was significantly associated with sexual function. Women who are positive for depression screening are more prone to long-term infertility. In contrast, infertile women who are not depressed they are less likely to start and continue infertility treatment(51)
Our study has many strong points and we are absolutely confident in the validity of the results. The fact that it was a case-control study within a cohort of Lorestan, Iran enabled us to minimize the risk of selection bias. Likewise, the confounding factors were well identified. Data of confounding variables was available and the effects of them were controlled over the multivariate marginal model. Nonetheless, our study was not without limitations. Due to the fact that marital issues are considered extremely a private topic and that there are cultural and religious restrictions at this point in Iran, people may not be able to open up and tell the truth. Therefore, the inability of most individuals to express themselves explicitly was beyond the reach of the researchers, so the present study only includes psychological assessment of women. For future studies, it is suggested that both data of woman and her spouse to be examined simultaneously. In addition, considering that this is a non-longitudinal case-control study; we have had difficulty controlling it for some confounding variables. Therefore, prospective longitudinal studies are recommended for future studies on this link.