Current status of fertility QoL in RIF patients
Karabulut et al.[25] used the FertiQoL scale to study the fertility QoL of women with IVF. The results showed that the average fertility QoL score of women with infertility was 66. This study used the FertiQoL scale to investigate RIF patients in our centre. The average fertility QoL score was 60.44 ± 11.60, and the average score range of each dimension was 54.29-66.88. Compared with the Karabulut study, the fertility QoL and scores of each dimension of RIF patients in this study were reduced to varying degrees. Ying L Y et al. [26] reported that the fertility QoL is significantly lower than that of women of childbearing age without infertility. Factors including the specific Chinese cultural background, traditional concepts, heavy financial burden and social public opinion lead to low QoL on infertile women. RIF patients, as part of infertile women, may suffer more economic pressure, physical pain, psychological distress, and disappointment caused by repeated failure during treatment.
In this study, among the dimensions of fertility QoL, the scores of physical-mental relationship and treatment tolerance were lower in RIF patients. The long-term, complicated treatment process, continuous drug use, surgical treatment and other invasive treatments cause physical pain, financial pressure, and psychological shock to RIF patients, which result in a sharp decline of their QoL. In addition, RIF patients are under pressure from their spouses and family members. As couples are daunted by repeated treatment failure, their emotional communication worsens; the resultant marriage crisis may cause them to fail to obtain sufficient family and social support, which damages the fertility QoL. Among the dimensions, the treatment environment ranked the highest. By optimizing the treatment environment and process, formulating a proper set of treatment and nursing measures, increasing patients' trust in medical institutions and professionals and reducing the negative emotions and psychological pressure of RIF patients, we can enhance the therapeutic effects and improve their fertility QoL.
Analysis of influencing factors of fertility QoL
Residence
This study found that RIF patients in urban areas exhibit higher fertility QoL than patients in rural areas (Table 3). Patients in rural areas maintain relatively old-fashioned ideas and are more influenced by the traditional Chinese saying, "There are three forms of unfilial conduct, of which the worst is to have no descendants". In China's rural areas, children are the link to family. It is an important task for most rural families to have a child and carry on the family line. They tend to attribute infertility to women and place a greater mental burden on infertile women with RIF, whose QoL is consequently severely impaired. Moreover, rural patients with RIF must travel to urban areas far from home for examinations and treatments, which causes them hardships, such as additional transportation and accommodation costs. In contrast, despite the rapid pace of life, high pressure and irregular routine, women in urban cities are relatively more independent and well paid and generally have a later childbearing age. Furthermore, urban society is more tolerant and open to women with infertility. All of these factors may be responsible for the high fertility QoL scores in urban RIF patients.
Attribution of infertility
Infertility is often considered to be a decrease or loss of fertility. Therefore, patients with male infertility may suspect their masculinity, especially men with sexual dysfunction or azoospermia who may have strong feelings of inferiority and guilt[27]. This study found that male infertility is one of the factors that affects the QoL of infertile women with RIF (Table 5). It is likely that the negative emotions and personality changes related to male infertility lead to a lack of timely support, encouragement and comfort to RIF patients. Due to the lack of care from their husbands, the fertility QoL of women with RIF is low. As health care professionals, we should evaluate couples systematically to fully understand their emotional states. In addition, joint treatment and positive intervention for the couple are necessary to solve couples’ psychological problems and improve the state of communication in couples. The ultimate goal is to enhance the marriage satisfaction of the couple. On the one hand, men are encouraged to support and accompany their wives. On the other hand, the couple should fully understand that reproduction is the responsibility of both parties, which requires mutual understanding and support as well as joint efforts.
Financial difficulties
Chachamovich et al.[28] reviewed the literature published in 1980-2009 on the factors that influence the QoL of patients with infertility and found that low income of women with infertility is a predictor of lower QoL. Keramat et al.[29] used the World Health Organization Quality of Life Brief (WHOQoL-BREF) and FertiQol to investigate 385 infertile couples and found that body section of the WHOQoL-BREF was significantly correlated with economic income. In the emotion/body part of the FertiQol subscale, the low-income group scored 49.82 points while the high-income group scored 56.08 points, with significant differences. In this study, monthly household income and financial difficulties were influencing factors of QoL (Table 5), which was consistent with the results of Chachamovich and other studies. The lower the family income, the lower the fertility QoL score. Moreover, there is a significant difference in the QOL scores of patients with high or low monthly family income (Table 3). In addition, failures in repeated implanting and enormous medical expenses exacerbate the financial burden, resulting in a decrease in QoL. Patients with low income must consider the basic needs of the family before the cost of assisted reproductive treatment, which affects QoL, while patients with high income can obtain more medical resources and receive better treatment. For families with financial difficulties, medical institutions can seek charity sponsorship and other means to realize patients’ dreams of assisted pregnancy, thereby improving the QoL of these patients.
BMI Index
The body mass index (BMI) is a relative reference standard recommended by the WHO to assess the weight status of the body and is one of the important indicators for evaluating the fertility of women of childbearing age. Some scholars believe that overweight and obesity affect the quality of embryos and lead to many problems in the process of in vitro fertilization, such as high gonadotropin consumption, a decreased number of ova, a lower rate of high-quality embryos and clinical pregnancy, and an increased rate of abortion[30-32]. However, other researchers believe that overweight and obesity have no negative impact on the outcome of in vitro fertilization-embryo transfer therapy and do not affect the pregnancy outcome of in vitro fertilization[33-34]. The results from our study revealed that RIF patients with a BMI≥24 kg/m2 had lower QoL scores than those with a BMI in the normal range of 18.5-23.9 kg/m2 (Table 3). Similar to the study of Nanette Santoro, who compared 733 patients with polycystic ovary infertility and 865 patients with unexplained infertility[35], the higher the BMI of women with polycystic ovary is, the lower their fertility QoL scores are. It has been found that overweight is an important factor in anxiety and depression[36-37], which is caused not only by external appearance characteristics but also by pathological changes. These patients exhibit abnormal emotions and behaviours due to altered hormone levels and neurotransmitter conduction in the body.
Depression and anxiety
The diagnosis and treatment of infertility can cause emotional and psychological stress in patients, of which anxiety and depression are the most common mental disorders[38]. Aarts et al.[39] used the HADS and FertiQol to study 472 infertile women in the Netherlands. They found that the quality of life of the patients was low, and there was a negative correlation between anxiety and depression with quality of life. Kahyaoglu et al.[40] conducted a cross-sectional study of 85 infertile women with FertiQol and HADS and found that the quality of life of patients with anxiety and depression scores over 8 was significantly impaired. A study by Wishmann et al.[41] showed that the self-esteem of women with infertility decreased significantly, which led to a decrease in their sexual quality of life. Their overall quality of life was also significantly affected. In this study, the anxiety score was 54.84 ± 9.79 and the incidence was 69.34%, and the depression score was 58.22 ± 9.99, and the incidence was 83.21% (Table 2), indicating that the psychological state of RIF patients is not optimistic; furthermore, the findings of our study are worse than those of Lakatos et al. (anxiety rate 39.6%/depression rate 44.8%)[42]. The scores for the fertility QoL of RIF patients with anxiety and depression were significantly lower (57.13 ± 9.08 and 58.18 ± 8.68, respectively) (Table 2). We hypothesize that in China, the traditional ideology and societal gender orientation cause infertile women with RIF to experience pressure from family housework and working tasks, which increases their psychological and mental burden and seriously affects their fertility QoL. It has been reported in the literature[43] that during IVF-ET assisted pregnancy treatment, positive psychological support and counselling can effectively alleviate or eliminate psychological problems such as anxiety and depression, thus improving the health and QoL of patients with infertility and enhancing the treatment effects of infertility. It is suggested that when developing clinical technology, medical institutions should strengthen psychological counselling to provide RIF patients with appropriate opportunities to vent and alleviate their negative emotions. Similarly, health care professionals should strengthen health education, provide details of precautions and success rates during assisted pregnancy periods, and share successful cases of assisted pregnancy, thereby enhancing RIF patients’ confidence in assisted pregnancy and reducing their psychological distress. Furthermore, for medical centres with sufficient resources to effectively address psychological problems and improve the fertility QoL of RIF patients, psychological counselling clinics, hotlines, public WeChat, QQ groups, WeChat groups and other platforms can be established to help patients understand fertility and medical information.
Family Support
Martins et al.[44] investigated 252 infertile women under treatment and found that perceived family support directly or indirectly affected all aspects of stress related to fertility. The research of Yazdani et al.[45] showed that the quality of the relationship with their husband affects the marital satisfaction and marital quality of infertile women. This finding suggests that understanding and care from family members, the most intimate contact persons for patients, can help patients actively accept treatment, enhance their confidence to overcome the disease, improve their quality of life and promote rehabilitation. In this study, the total score of the social support scale was 60.92 ± 12.02, and the scores for family support and social support were most closely correlated with the scores of fertility QoL (Table 4) with a positive correlation (R = 0.745, R = 0.768). This finding indicates that the more family support and social support that patients experience, the better their fertility QoL. According to the results of multivariate regression analysis (Table 5), the standardized coefficient beta of family support was the highest, suggesting that family support had the greatest impact on fertility QoL. A study by Ching-Yu Cheng et al. noted that the relationship between infertile women and their spouses and family members can have a positive or negative impact on women's psychological stress and QoL during assisted pregnancy treatment [46]. Takaki and Hibino et al. also noted in their research in 2014 that a lack of family support can create stressful situations and increase psychological pressure on infertile women[47]. Sufficient family support can enable patients to obtain more care and emotional support and can improve their QoL and their ability to deal with psychological stress. Therefore, for infertile women undergoing assisted reproductive therapies, health care professionals should 1) comprehensively evaluate family function, 2) help to establish a better family support system, 3) encourage family members to participate actively in various health education activities, 4) create a good family atmosphere, and 5) give patients more support and care to improve the patient’s fertility QoL. It is also recommended that reproductive clinics can distribute missionary handbooks or play educational videos about assisted pregnancy and encourage couples to watch them together and discuss their feelings to reach mutual understanding and joint efforts in infertility treatment and the enhancement of family support, thereby improving their QoL and pregnancy rate.
Limitations
In this study, we mainly focused on the external influencing factors of the fertility QoL of infertile women with RIF. However, some internal positive factors, such as resilience, may also affect the fertility QoL of RIF patients. This area of research and clinical implications deserves to be further explored. What’s more, further studies need to be conducted to examine whether the results of the present study are suitable to the different cultural context.