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  • Research
  • Open Access

Prevalence of generalized anxiety disorder and its related factors among infertile patients in Iran: a cross-sectional study

Health and Quality of Life Outcomes201816:129

https://doi.org/10.1186/s12955-018-0956-1

  • Received: 19 February 2018
  • Accepted: 12 June 2018
  • Published:

Abstract

Background

Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders among infertile patients. This study aimed to determine the prevalence of GAD and its associated factors among infertile patients in Tehran, Iran.

Methods

This cross-sectional study included 1146 infertile patients in a referral fertility center in Tehran, Iran between May and October 2017. GAD was measured using the Generalized Anxiety Disorder-7 (GAD-7) scale. The associations between GAD and demographic/fertility characteristics were estimated using simple and multiple logistic regression with odds ratio (OR) and 95% confidence interval (CI).

Results

The mean total GAD-7 score was 6.61 (SD = 5.32). Using a cut-off value of 10, the prevalence of GAD was 28.3%. In adjusted analysis, female sex (OR = 2.54, 95% CI = 1.88–3.42, P < 0.001), low educational level (OR = 1.45, 95% CI = 1.08–1.94, P = 0.012), high infertility duration (OR = 1.05, 95% CI = 1.01–1.09, P = 0.013), and treatment failure (OR = 1.52, 95% CI = 1.13–2.04, P = 0.006) were associated with GAD.

Conclusions

The prevalence of GAD is relatively high in infertile patients. We conclude that all infertile patients should be screened for symptoms of GAD and treated for this disorder as need arises.

Keywords

  • Generalized anxiety disorder
  • Infertility
  • Prevalence
  • Iran

Background

Infertility is characterized by “the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner.” [1], and it is a disease, which generates disability as an impairment of function [1]. It is also a public health problem affecting 9% of reproductive-aged couples worldwide [2], and can lead to negative psychological consequences and diminished quality of life and well-being [3, 4]. Among psychological disorders, anxiety disorder including generalized anxiety disorder (GAD) is one of the most prevalent disorder in infertile patients. GAD is characterized by “excessive and persistent worrying that is hard to control, causes significant distress or impairment, and occurs on more days than not for at least six months” [5], and epidemiological surveys show that this disorder is more prevalent among clinical sample compared with general population. Despite the importance of GAD and its negative consequences, we still know little about the prevalence of GAD and its associated factors in people with infertility problem.

General-population studies in the US show that GAD have a lifetime prevalence of 5.7%, and 1-year prevalence of 3.1% [6, 7]. A review of epidemiological studies in Europe also find similar prevalence [8]. Epidemiologic surveys in general population show that GAD is more common in women, adults, unemployed people, people of low socioeconomic status, those who are widowed, separated, or divorced [9, 10].

In recent years, the study of GAD has received growing attention in both community and clinical sample. Yet, in the fertility context, there are few published studies on the GAD among people with infertility problem and most of the studies have been performed with relatively small sample size or only in infertile women. On the other hand, some recent studies have shown that psychological distress have negative effect on the infertility treatment outcome. Also, there are few studies in the Middle East area using GAD as a useful instrument for measuring anxiety. Thus, we aimed to determine the prevalence of GAD and associated demographic/infertility factors in a relatively large sample of infertile patients.

Methods

Participants and study design

This cross-sectional study was conducted at the Infertility Treatment Center of Royan Institute in Tehran, Iran. This center is one of the largest clinics for infertility treatment in Iran [11]. Infertile couples come to this center, not only from the capital of Iran but also from all around the country.

The data were collected using the convenience sampling method between May and October 2017.

After the evaluation phase of treatment, patients were asked to participate in the study. To be eligible for the study the participants had to meet the following criteria: (a) willingness to participate; (b) age over 18 years; (c) men or women with couple infertility; (d) ability to read, write, and comprehend Persian. In total, 1146 patients (from 1400 patients) agreed to take part and filled out the questionnaires completely (response rate: 81.9%).

Ethical consideration

Approval to perform the current study was obtained from the Ethics Committee of Royan Institute, Tehran, Iran. All infertile patients were fully informed about the objective of the study, and the confidentiality of the data. Patients were also assured that the data would be used only for the purpose of the research and refusal to participate in the study would not affect their current and future treatments in any way. Each patient gave written informed consent prior to participating in the study.

Questionnaires

Demographic/infertility data

Demographic/clinical data including age, gender, educational level, duration of infertility, cause of infertility, failure of previous treatment, and history of abortion were collected. We selected these variables according to the literature review including high-quality studies in the infertility context [1215].

The 7-item generalized anxiety disorder scale (GAD-7)

The GAD-7 is a brief, 7-item self-administrated scale designed to screen for the presence of GAD and to assess the severity of symptoms based on DSM-IV criteria [16]. This scale asks how often respondents have been affected by anxiety symptoms in the last 2 weeks. Each item is scored on a 4-point Likert scale indicating symptom frequency, ranging from 0 (not at all) to 3 (nearly every day). Total score can range from 0 to 21, with higher scores indicating more severe symptoms of GAD. According to the original validation studies, the total score can then be interpreted as suggesting no/minimal anxiety (0–4), mild (5–9), moderate (10–14), or severe (15–21). A cut off score of 10 is suggested as reflecting a possible diagnosis of GAD. The Persian version of GAD-7 has been shown to have satisfactory psychometric properties in infertile people [17]. The GAD-7 showed high internal consistency in this study (α = 0.882).

Statistical analysis

Data analyses were done using by IBM SPSS Statistics for Windows, Version 22.0 (IBM Crop., Armonk, NY, USA). Continuous variables were presented as mean ± standard deviation (SD) and categorical variables as numbers (percentage). In this study, GAD-7 score was analyzed as a dichotomous variable (GAD absent and GAD present) based on cut-off value of 10. Simple and multiple logistic regression analysis were applied to examine the association between GAD and demographic/fertility variables. The odds ratio (OR) and 95% confidence interval (CI) were calculated. All statistical tests were two-tailed and level of significance was set at 0.05.

Results

Description of participants

Demographic and fertility information of the participants are summarized in Table 1. The mean (SD) age and infertility duration of the participants were 32.76 (5.54) and 5.40 (4.04) years, respectively. Half (51.2%) were female, 38.1% had male factor infertility, 46.9% were university-educated, 49.7% had at least one failure in previous treatments, and 28.4% had history of abortion. In addition, the distribution of age is shown in Fig. 1.
Table 1

Demographic and fertility characteristics of the participants (n = 1146)

Variables

Mean ± SD or n (%)

Age (years)

32.76 ± 5.54

Sex

 

 Male

559 (48.8)

 Female

587 (51.2)

Educational level

 

 Primary

238 (20.8)

 Secondary

370 (32.3)

 University

538 (46.9)

Duration of infertility (years)

5.40 ± 4.04

Cause of infertility

 

 Male factor

437 (38.1)

 Female factor

219 (19.1)

 Both

208 (18.2)

 Unexplained

282 (24.6)

Failure of previous treatment

 

 No (first treatment)

576 (50.3)

 Yes

570 (49.7)

History of abortion

 

 No

820 (71.6)

 Yes

326 (28.4)

SD: Standard deviation

Fig. 1
Fig. 1

The distribution of age in both men and women

Distribution of GAD-7 score

The mean (SD) total score of GAD-7 was 6.61 (5.32). Distribution of scores falling within GAD-7 severity cut-offs were as follows: no anxiety 43.1%; mild 28.6%; moderate 19.1%; and severe 9.2%. Based on a cut-off value of 10, the prevalence of GAD was 28.3% (n = 324).

Factor associated with GAD

A cut-off value of 10 was used to categorize patients into anxious and non-anxious. Then, simple and multiple logistic regression analysis were used to examine the association between GAD and demographic/fertility variables (Table 2). A cut-off value of 10 was used to categorize patients into anxious and non-anxious. According to adjusted analysis, women were 2.54 times more likely to have GAD than men (OR = 2.54, 95% CI: 1.88–3.42, P < 0.001). Primary/secondary-educated individuals were 1.45 times more likely to have GAD than university-educated individual (OR = 1.45, 95% CI: 1.08–1.94, P = 0.012). Results showed that each one-year increase in infertility duration increases the odds of being anxious by 5% (OR = 1.05, 95% CI: 1.01–1.09, P = 0.013). Participants with partner cause of infertility were less likely to have GAD than those who had self-cause of infertility (OR = 0.76, 95% CI: 0.53–1.09, P = 0.134), although this difference was not statistically significant. Finally, logistic regression model showed that patients with at least one failure in their previous treatment were 1.52-fold more likely than others to have GAD (OR = 1.52, 95% CI: 1.13–2.04, P = 0.006).
Table 2

Association between GAD and demographic/fertility variables among infertile patients

Variables

Simple logistic regression

Multiple logistic regression

OR Crude (95% CI)

P

OR Adjusted (95% CI)

P

Age (years)

0.98 (0.96–1.00)

0.063

0.99 (0.96–1.01)

0.340

Sex

 Male

1

 

1

 

 Female

2.39 (1.82–3.12)

< 0.001

2.54 (1.88–3.42)

< 0.001

Education

 Primary/Secondary

1.47 (1.13–1.91)

0.004

1.45 (1.08–1.94)

0.012

 University

1

 

1

 

Infertility duration (years)

1.07 (1.03–1.10)

< 0.001

1.05 (1.01–1.09)

0.013

Cause of infertility

 Self

1

 

1

 

 Partner

1.04 (0.74–1.45)

0.832

0.76 (0.53–1.09)

0.134

 Both/Unknown

0.96 (0.70–1.30)

0.779

0.84 (0.61–1.17)

0.312

Treatment failure

 No (first treatment)

1

 

1

 

 Yes

1.62 (1.25–2.10)

< 0.001

1.52 (1.13–2.04)

0.006

Previous abortion

 No

1

 

1

 

 Yes

1.02 (0.77–1.35)

0.904

0.86 (0.63–1.18)

0.351

CI: Confidence Interval; OR: Odds Ratio

Discussion

The primary aim of the present study was to determine the prevalence and demographic determinants of GAD among infertile patients in Tehran, Iran using a relatively large data. In this study the prevalence of GAD was 28.3%, which is higher than what was reported in general population [9, 18] and among infertile women in Taiwan (23.2%) [19]. In a study conducted by Maroufizadeh et al. [20] among infertile patients in Iran, the prevalence of overall anxiety using the Hospital Anxiety Depression Scale was 49.6%.

As anticipated, the current study shows that women were 2.54 times more likely to have GAD than man. This finding is consistent with the studies from the general population in which GAD is more common in women than in men [8, 10, 21, 22]. Also, epidemiologic studies in infertile population indicate that anxiety is more prevalent among women than men [13, 23]. Similar results were obtained in previous studies on quality of life and depression among infertile patients [2325]. These findings suggest that women were more affected by infertility than men in health and psychological status.

Consistent with a study conducted among infertile patients [13], the likelihood of GAD was also increased for infertile patients with low educational level. It seems that higher education brings more information and awareness about the possible negative consequences of infertility, resulting in increased anxiety. In addition, epidemiologic studies indicate that GAD is more prevalent among people of low socioeconomic status (SES) than those of middle or high SES [21].

We found that the odds of GAD increased with rising duration of infertility, which is in line with a great deal of other previous works [20, 23, 26, 27]. In addition, similar trend was reported in other studies on measures of quality of life, marital satisfaction and depression [23, 28, 29]. However, in two studies conducted by Ogawa et al. [30] and Maroufizadeh et al. [13], there was no relationship found between anxiety and duration of infertility.

This study has several limitations that should be mentioned. First, all data are based on self-reports. Second, our measure of GAD may be less valid and reliable than a diagnostic interview.

Third, this study was conducted in one fertility clinic in Tehran; therefore, our results may not be generalizable to other populations. Fourth, the cross-sectional design of the study limits inferences about the causal relationships between GAD and the demographic/fertility variables. Fifth, psychological factors (e.g. social and family support) and some demographic information (e.g. socioeconomic status and type of infertility) that affect GAD were not investigated in this study. Despite these limitations, this study is the first to evaluate the association between GAD and demographic/fertility characteristics among infertile patients in Iran using a relatively large sample size.

Conclusion

In summary, the prevalence of GAD is relatively high in infertile patients, particularly in women, patients with low educational level and high infertility duration and patients who had failures in the previous infertility treatment. This study suggests that all infertile patients should be screened for symptoms of GAD and treated for this disorder as need arises.

Abbreviations

CI: 

Confidence Interval

GAD: 

Generalized Anxiety Disorder

OR: 

Odds Ratio

SD: 

Standard Deviation

SES: 

Socioeconomic Status

Declarations

Acknowledgements

The authors express their gratitude to the infertile patients who participated in this study and to the Royan Institute, Tehran, Iran for its kind cooperation in data collection.

Funding

This research did not receive any specific grant from any agency in the public, commercial, or not-for-profit sector.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Authors’ contributions

ROS: Study design and conception, data interpretation, and manuscript writing; AG: Study design and conception, data interpretation, manuscript editing; BN: Study design and conception, data acquisition, and manuscript editing; MS: Study design and conception, data interpretation, and manuscript editing; SM: Study design and conception, data analysis and interpretation, and manuscript writing. All authors approved the final version of the manuscript for submission.

Ethics approval and consent to participate

The Ethics Committee of Royan Institute, Tehran, Iran, approved this study. Agreement to participate and a signed consent form were obtained from all infertile couples before data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Epidemiology and Reproductive Health, Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

References

  1. Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, Rienzi L, Sunde A, Schmidt L, Cooke ID: The international glossary on infertility and fertility care, 2017. In: Oxford University Press; 2017.Google Scholar
  2. Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007;22(6):1506–12.View ArticlePubMedGoogle Scholar
  3. Maroufizadeh S, Ghaheri A, Amini P, Samani RO. Psychometric properties of the fertility quality of life instrument in infertile Iranian women. Int J Fertil Steril. 2017;10(4):371–9.PubMedGoogle Scholar
  4. Maroufizadeh S, Ghaheri A, Samani RO, Ezabadi Z. Psychometric properties of the satisfaction with life scale (SWLS) in Iranian infertile women. Int J Reprod Biomed. 2016;14(1):57–62.View ArticleGoogle Scholar
  5. Association AP: Diagnostic and statistical manual of mental disorders (DSM-5®): American psychiatric pub; 2013.Google Scholar
  6. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.View ArticlePubMedGoogle Scholar
  8. Lieb R, Becker E, Altamura C. The epidemiology of generalized anxiety disorder in Europe. Eur Neuropsychopharmacol. 2005;15(4):445–52.View ArticlePubMedGoogle Scholar
  9. Weisberg RB. Overview of generalized anxiety disorder: epidemiology, presentation, and course. J Clin Psychiatry. 2009;70(Suppl 2):4–9.View ArticlePubMedGoogle Scholar
  10. Watterson RA, Williams JV, Lavorato DH, Patten SB. Descriptive epidemiology of generalized anxiety disorder in Canada. Can J Psychiatr. 2017;62(1):24–9.View ArticleGoogle Scholar
  11. Abedini M, Ghaheri A, Omani Samani R. Assisted reproductive technology in Iran: the first national report on centers, 2011. Int J Fertil Steril. 2016;10(3):283–9.PubMedPubMed CentralGoogle Scholar
  12. Maroufizadeh S, Omani Samani R, Amini P, Navid B: Factor structure, reliability, and validity of the Levenson’s locus of control scale in Iranian infertile people. J Health Psychol 2016:1359105316666659.Google Scholar
  13. Maroufizadeh S, Karimi E, Vesali S, Samani RO. Anxiety and depression after failure of assisted reproductive treatment among patients experiencing infertility. Int J Gynaecol Obstet. 2015;130(3):253–6.View ArticlePubMedGoogle Scholar
  14. 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(1):193–7.View ArticlePubMedGoogle Scholar
  15. Hsu P-Y, Lin M-W, Hwang J-L, Lee M-S, Wu M-H. The fertility quality of life (FertiQoL) questionnaire in Taiwanese infertile couples. Taiwan J Obstet Gynecol. 2013;52(2):204–9.View ArticlePubMedGoogle Scholar
  16. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.View ArticlePubMedGoogle Scholar
  17. Omani-Samani R, Maroufizadeh S, Ghaheri A, Navid B. Generalized anxiety Disorder-7 (GAD-7) in people with infertility: a reliability and validity study. Middle East Fertil Soc J. 2018; https://doi.org/10.1016/j.mefs.2018.01.013.
  18. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychol Med. 2008;38(3):365–74.View ArticlePubMedGoogle Scholar
  19. Chen T-H, Chang S-P, Tsai C-F, Juang K-D. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod. 2004;19(10):2313–8.View ArticlePubMedGoogle Scholar
  20. Maroufizadeh S, Ghaheri A, Almasi-Hashiani A, Mohammadi M, Navid B, Ezabadi Z, Samani RO. The prevalence of anxiety and depression among people with infertility referring to Royan Institute in Tehran, Iran: a cross-sectional questionnaire study. Middle East Fertil Soc J. 2017;23(2):103–6.View ArticleGoogle Scholar
  21. Kessler RC, Keller MB, Wittchen H-U. The epidemiology of generalized anxiety disorder. Psychiatr Clin North Am. 2001;24(1):19–39.View ArticlePubMedGoogle Scholar
  22. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, Herzberg PY. Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Med Care. 2008;46(3):266–74.View ArticlePubMedGoogle Scholar
  23. Omani Samani R, Maroufizadeh S, Navid B, Amini P. Locus of control, anxiety, and depression in infertile patients. Psychol Health Med. 2017;22(1):44–50.View ArticlePubMedGoogle Scholar
  24. Maroufizadeh S, Hosseini M, Foroushani AR, Omani-Samani R, Amini P. The effect of depression on quality of life in infertile couples: an actor-partner interdependence model approach. Health Qual Life Outcomes. 2018;16(1):73.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Chachamovich JR, Chachamovich E, Ezer H, Fleck MP, Knauth D, Passos EP. Investigating quality of life and health-related quality of life in infertility: a systematic review. J Psychosom Obstet Gynaecol. 2010;31(2):101–10.View ArticlePubMedGoogle Scholar
  26. Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M, Jafarabadi M. A survey of relationship between anxiety, depression and duration of infertility. BMC Womens Health. 2004;4(1):9.View ArticlePubMedPubMed CentralGoogle Scholar
  27. Drosdzol A, Skrzypulec V. Depression and anxiety among polish infertile couples–an evaluative prevalence study. J Psychosom Obstet Gynaecol. 2009;30(1):11–20.View ArticlePubMedGoogle Scholar
  28. Omani-Samani R, Maroufizadeh S, Ghaheri A, Amini P, Navid B. Reliability and validity of the Kansas marital satisfaction scale (KMSS) in infertile people. Middle East Fertil Soc J. 2017;23(2):154–7.View ArticleGoogle Scholar
  29. Maroufizadeh S, Omani-Samani R, Almasi-Hashiani A, Navid B, Sobati B, Amini P. The relationship assessment scale (RAS) in infertile patients: a reliability and validity study. Middle East Fertil Soc J. 2018; https://doi.org/10.1016/j.mefs.2018.04.001.
  30. Ogawa M, Takamatsu K, Horiguchi F. Evaluation of factors associated with the anxiety and depression of female infertility patients. Biopsychosoc Med. 2011;5(1):15.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© The Author(s). 2018

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