|ORIGINAL RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 6 | Page : 685-690
Does infertility affect the quality of life of infertile women? A study in a gynecology outpatient department of a tertiary care hospital of Kolkata
Deepta Dutta1, Aparajita Dasgupta1, Soumit Roy1, Chandra Shekhar Taklikar2, Debdatta Ghosh3, Bobby Paul1
1 Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
2 Department of Health Promotion and Education, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
3 Department of Obstetrics and Gynaecology, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Submission||08-Jan-2020|
|Date of Decision||29-Jul-2020|
|Date of Acceptance||30-Jul-2020|
|Date of Web Publication||14-Jul-2021|
Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Infertility, which is an inability to conceive after a prolonged time period, is a neglected domain of reproductive health. Infertility affects couples physically and psychologically and leads to discrimination and stigma in society, especially to women. Various sociodemographic, physiological, and environmental attributes and access to health care may interplay with the quality of life (QoL) of the women afflicted with infertility. Objectives: The aim of this study was to assess the QoL and its predictors among women diagnosed with infertility. Materials and Methods: A cross-sectional study was conducted among 247 women diagnosed with infertility and receiving treatment for at least 6 months at a gynecology outpatient department in a tertiary care hospital of Kolkata. Results: The mean (±standard deviation) score of total ferti-QoL was 65.76 (±11.15). Differential mean scores were observed in domains of ferti-QoL such as emotional (58.49 ± 12.75), body/mind (47.67 ± 16.14), relational (78.36 ± 15.51), social (60.71 ± 12.43), core (61.31 ± 12.71), environment (80.09 ± 10.77), tolerability (70.95 ± 11.97), and treatment (76.44 ± 10.36). Nearly half of them also reported abuse in terms of verbal (50.6%) and physical (6.9%). On multivariable analysis, unsatisfactory QoL was significantly associated with age above 32 years (adjusted odds ratio [AOR] = 2.76, confidence interval [CI] = 1.07–7.12), increasing duration of infertility (AOR = 1.46, CI = 1.17–1.82), and presence of chronic diseases (AOR = 2.21, CI = 1.01–4.83). Conclusion: There is, till date, no provision of management for women suffering from infertility in the Reproductive and Child Health Programme. The problem of infertility must be considered as a public health problem, and all policymakers, health administrators, and other stakeholders should come forward with exemplary guidelines specially targeted for providing relief to these affected women in every stratum of the health-care system.
Keywords: Abuse, ferti-quality of life, infertility, quality of life
|How to cite this article:|
Dutta D, Dasgupta A, Roy S, Taklikar CS, Ghosh D, Paul B. Does infertility affect the quality of life of infertile women? A study in a gynecology outpatient department of a tertiary care hospital of Kolkata. Med J DY Patil Vidyapeeth 2021;14:685-90
|How to cite this URL:|
Dutta D, Dasgupta A, Roy S, Taklikar CS, Ghosh D, Paul B. Does infertility affect the quality of life of infertile women? A study in a gynecology outpatient department of a tertiary care hospital of Kolkata. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Dec 6];14:685-90. Available from: https://www.mjdrdypv.org/text.asp?2021/14/6/685/321279
| Introduction|| |
Infertility is defined as an inability to conceive within 1 or more years even after a regular unprotected sexual intercourse. There are two types of infertility: primary and secondary. Primary infertility refers to the patients who never conceive or continue a pregnancy to a live birth, whereas secondary infertility stands for infertility with a past history of successful pregnancy outcome.
A systematic analysis of demographic and reproductive health surveys from 190 countries showed that the global prevalence of primary and secondary infertility in 2010 was 1.9% and 10.5% among women aged between 20 and 44 years. Primary infertility was more common among younger women (20–24 years), whereas reverse pattern was observed for secondary infertility. In spite of some regional variations, there was no change in patterns of primary and secondary infertility in developed and developing countries. Another review showed that in the second decade of the new millennium, the global infertility ranged from 8% to 30%. This variation can be attributed to heterogeneity in sampling techniques and operational definition of infertility used in those studies.
In 1952, India launched the world's first-ever family planning program to fight against the population explosion through an array of national health programs as and when necessary. However, different studies have shown that of late, infertility has emerged as a source of concern in India. According to the National Family Health Survey 4 (2015–2016), the prevalence of primary and secondary infertility in India was 8.5% and 4.9%. In West Bengal, this prevalence was slightly lower (7.9% and 2.2%). However, these data should be assessed cautiously as there may be a chance of underreporting and socially desirable response during population-based survey due to stigma associated with it.
Infertility is a neglected domain of reproductive health. Each couple feels the need and has the right to maintain their bloodline by reproduction. Literature has shown that both primary infertility and secondary infertility affects the mental health of the patient in a vicious cycle and often result in bad interpersonal relationships with family members. Thus, it affects the quality of life (QoL) of couples physically and psychologically as well as leads to discrimination and stigma in the society, especially among women. Various sociodemographic, physiological, and environmental attributes and health-care-seeking behavior pattern may interplay with the QoL of the women afflicted with infertility.,,,
An extensive literature review on infertility showed that there are limited studies on QoL in women suffering from infertility. With this background, this study was undertaken to assess the QoL and its predictors among women suffering from infertility in a tertiary health-care facility of West Bengal.
| Materials and Methods|| |
A cross-sectional study was conducted in the Gynecology Outpatient Department (OPD) of R. G. Kar Medical College and Hospital, Kolkata, from July 2017 to August 2019 (period of data collection was June 2018–February 2019). All women diagnosed with infertility for at least 1 year and treated for the same at least for 6 months were included in the study and women who declined to give informed written consent were excluded from the study.
Based on the work of Dillu et al., the sample size for this study was calculated. Considering 95% confidence interval (CI), 2.5% relative error and estimated mean score (standard deviation) of fertiQoL as 83.97 (11.82) and using formula sample size (N) = (Z2 × [SD] 2)/ (relative error/100 × mean) 2 where Z = standard normal variate at 95% CI.
N = ([1.96]2 × [11.82]2)/(2.5 × 0.8397)2 = 121.79 ≈ 122
Applying a design effect of 2, the final sample size was n = 122 × 2 = 244.
The OPD runs for 6 days a week, of which the researcher attended for 2 days per week for 9 months from June 2018 to February 2019 for data collection from 9 a.m. to 3 p.m. During this period, 247 infertile women were included in the study. All efforts were taken to avoid duplication of data collection.
Method of data collection
Face-to-face interviews were conducted with the help of a predesigned pretested schedule which included ferti-QoL Questionnaire., The schedule was constructed in the local language with inputs from the experts of the faculty member of All India Institute of Hygiene and Public Health, Kolkata. The schedule consisted of the following domains: sociodemographic, reproductive, and biological characteristics and QoL using ferti-QoL. Their past medical records were also reviewed.
QoL: QoL was assessed with the help of Ferti-QoL Questionnaire containing 34 items under the two domains (core and treatment). Each item was scored from 0 to 4 (Likert's scale). Higher the score better was the QoL., QoL was considered unsatisfactory if the total ferti-QoL score and all its domains were below the 75th percentile of the attained score.
Statistical Package for the Social Sciences (SPSS)acquired in 2009 by IBM, headquarters in Chicago version 16 was used to analyze the data. Univariate logistic regression and multivariable logistic regression were conducted to determine the factors associated with the QoL of women suffering from infertility. P < 0.05 was considered for statistical significance.
Approval was obtained from the Institutional Ethics Committees of All India Institute of Hygiene and Public Health (15.11.17) and R. G. Kar Medical College and Hospital, Kolkata (RKC/Ethics/38 dated 05.12.17). Informed written consent was obtained from participants prior to interview. Privacy and confidentiality was ensured during data collection.
| Results|| |
Most of the women were aged up to 32 years of age (80.2%) and received education below a higher secondary level (86.6%). Majority were Hindus (60.3%) and lived in rural Bengal (56.7%). Nearly three-fourth of them were suffering from primary infertility, with a median (interquartile range) duration of infertility being 3 (2, 5) years. Dysmenorrhea was the most common symptom (60.3%) followed by menorrhagia (12.1%) and irregular cycle (8.1%). Almost one-third (34.8%) had chronic comorbidities. Nearly half of them reported abuse due to infertility in terms of verbal (50.6%) and physical (6.9%) [Table 1].
|Table 1: Distribution of the study population according to sociodemographic and biological characteristics (n=247)|
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Quality of life
Under core domain, in emotional subscale, 79.8% the study participants scored unsatisfactorily <66.67; in body/mind subscale, unsatisfactory scores <54.17 were found in 76.9% subjects; in relational subscale, 78.1% of the women had unsatisfactory score <91.67; in social subscale, 77.3% showed unsatisfactory score of <66.67, while under treatment domain, in environmental subscale, 61.5% were seen to have unsatisfactory score <87.5 and in tolerability subscale, 50.6% depicted unsatisfactory score <75. The total ferti-QoL score which is the average QoL (for all core and treatment domains) was unsatisfactory, i.e., <72.79 score in 74.1% of the study subjects suffering from infertility [Table 2].
|Table 2: Distribution of study population according to the quality of life (n=247)|
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Predictors of quality of life
On univariate logistic regression, unsatisfactory QoL was significantly associated with age (above 32 years) odds ratio (OR) CI = 4.04 (1.65–9.94), education below higher secondary OR (CI) = 2.81 (1.32–5.97), increased duration of infertility OR (CI) = 1.58 (1.28–1.96), and presence of chronic diseases OR (CI) = 2.63 (1.25–5.53).
On adjusted model, age (above 32 years) OR (CI) = 2.76 (1.07–7.12), increased duration of infertility = 1.46 (1.17–1.82), and presence of chronic disease = 2.21 (1.01–4.83) retained their significance. However, educational attainment below higher secondary = 2.07 (0.91–4.69) lost its significance. Model fit was good which was evident from Hosmer and Lemeshow Test (P = 0.42), Cox and Snell R2 was 0.147, and Nagelkerke R2 was 0.22. Thus, 14.7% to 22% of the variance of dependent variable was explained by the model [Table 3].
|Table 3: Distribution of the study population according to the predictors of unsatisfactory quality of life: Univariate and multivariable logistic regression (n=247)*|
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| Discussion|| |
The relation between infertility and QoL among infertile couple is important to design policies for prevention and treatment efforts and to curb the social stigma associated with it. In the present study, the mean of total ferti-QoL score was 65.76 ± 11.15. The total ferti-QoL score was found to be unsatisfactory, i.e., <72.79 in 74.1% of the study participants. The unsatisfactory score was associated significantly with age above 32 years, increased duration of infertility, and presence of chronic diseases. It was also associated with education below the higher secondary level. Different domains of ferti-QoL showed different mean scores such as emotional (58.49 ± 12.75), body/mind (47.67 ± 16.14), relational (78.36 ± 15.51), social (60.71 ± 12.43), environment (80.09 ± 10.77), and tolerability (70.95 ± 11.97). This result corroborated with many of the studies mentioned below.
In a study by Zeren et al., in west. Turkey in 2019, the mean ferti-QoL score was 79.74 ± 15.94 (general), 62.56 ± 22.05 (emotional), 72.57 ± 23.36 (body/mind), 44.6 ± 11.01 (relational), 70.13 ± 17.02 (social), 37.56 ± 9.7 (environment), and 67.43 ± 22.14 (tolerability). In a study by Li et al. in China in 2019, ferti-QoL was found to be 64.54 ± 16.90. Ismail and Moussa conducted a study in Egypt in 2017 and showed mean scores of total ferti-QoL – 59.38 ± 15.79, emotional – 58.83 ± 23.21, body/mind – 61.80 ± 20.90, relational – 69.78 ± 20.99, social – 66.71 ± 18.84, environment – 41.21 ± 15.09, and tolerability – 56.49 ± 25.04.
In a study by Hsu et al., in 2013, in Taiwan, the means of different component areas of QoL were calculated as emotional = 54.81 ± 19.40, body/mind = 51.58 ± 24.29, relational = 54.80 ± 11.10, social = 59.32 ± 11.05, environment = 54.63 ± 9.19, and burden = 59.04 ± 18.99. In study by Sexty et al. in 2018, in Germany, ferti-QoL scores were global – 72.6 ± 12.8, emotional – 61.3 ± 18.7, body/mind – 74.3 ± 14.5, relational – 79.3 ± 14.1, and social – 75.6 ± 15.6.
Predictors of unsatisfactory quality of life
Unsatisfactory QoL was found to be significantly associated with increased duration of infertility and presence of chronic diseases, namely diabetes mellitus, hypertension, and hypothyroidism after adjustment for increasing age, decreasing level of education, less Per capita income, nuclear type of family, and secondary type of infertility. Similar findings were observed in the studies mentioned below. Royani Z et al. in 2019 in Iran observed that QoL was associated significantly with increasing age (P = 0.03), poor educational level (P = 0.04), and also with increased duration of infertility, though not significantly (P < 0.07). Cheng et al., in 2017, in Taiwan found that low QoL was associated with advancing age. Ferreiraa et al., in 2015 in Portugal found that QoL was associated with years of schooling (P < 0.05). Keramat et al., in 2014, in Iran, found that QoL in most components was positively associated with urbanization, level of education, and monthly income, while it was negatively related to the duration of infertility. Karabulut et al., in 2013, concluded that higher level of education and secondary infertility had positive impact on QoL, while QoL was affected negatively by prolonged duration of infertility. Namdar et al., in 2017, in Iran, observed that QoL was positively associated with university education (P = 0.02) and higher income per month (P = 0.01). Direkvand-Moghadam et al., in 2016, in Iran, observed that the association of QoL with the educational level was not found to be statistically significant (P = 0.42). Li et al. in China, in 2019, showed that QoL was significantly associated with decreased monthly income, infective causes, and resilience. The association of QoL with education was not found to be significant (P = 0.40). In a review by Palomba et al., in 2018, no precise cause effect association could be found between QoL and its covariates. Similarly, Desai and Gundabattula et al. could not find any associates of poor QoL among women diagnosed with infertility in Telangana. Subsequent subscale analysis showed secondary infertility and higher education had a significantly positive association with emotional subscale, while obese women and women receiving ovulation induction treatment had significant poor mind–body and relational scores. Women with associated comorbidities had significantly worse QoL on the treatment and environment scale. These findings were concordant with the present study.
Abuse due to infertility
A substantial amount of verbal (50.6%) and physical abuse (6.9%) was reported by participants. However, the current study could not find any significant relationship between unsatisfactory QoL and abuse. This finding might be attributed to the uniform presence of abuse across the levels of QoL. Due to patriachial psychosocial structure, women might cope up with such abuse or feel themselves guilty for infertility. A similar pattern of verbal (44.5%) and physical (14.5%) abuse was noted by Dyer et al. in South African women with infertility. Higher prevalence of physical (68%), sexual (60%), and psychological (70%) abuse was noted in Iranian women with infertility by Rahebi et al. Bondade et al. found in a study that infertile women in Bengaluru faced psychological (34%), physical (11%), and sexual (5%) violence.
The present study was conducted in the gynecology OPD at a tertiary care hospital. Thus, the definitive diagnosis of infertility and comorbidities was obtained. Interview of subjects was conducted in a separate room near the OPD to maintain privacy and confidentiality. This allowed the researchers to inquire and elicit responses for sensitive questions like abuse faced by the women in the society as well as in their family. Robust sampling technique and use of inferential statistics were also key strengths of this study. QoL was assessed using a validated questionnaire (ferti-QoL) specifically designed for women with infertility and that imparts accurate and reliable assessment of QoL among these women.
| Conclusion|| |
Unsatisfactory QoL was observed in majority of subjects (74.1%). QoL was associated significantly with higher age, increased duration of infertility, and presence of chronic diseases. A substantial amount of verbal (50.6%) and physical abuse (6.9%) was also reported.
Infertility plays a very significant toll on the mental health of these unfortunate women who are pining to bear children. The nation has worked and is still working on family planning and all measures to restrict the family size. Unfortunately, little attention has been given to those large number of couples who are childless but are unable to start a family due to some known and unknown pathology.
The problem of infertility must be considered as a grave problem, and all policymakers, health administrators, and other stakeholders should come forward with exemplary guidelines for the specific investigations and treatment of these couples as an intregrated approach under umbrella of existing reproductive and child health package at different tiers of the health-care system in India and other developing countries so that they are available, accessible, acceptable, and affordable in a platter to those in dire need of them. There should be strict guidelines for legal and ethical issues and quality of care by health professionals, and the society, as a whole, should be educated to fight the stigma related to infertility, which, in turn, may improve the QoL among couples with infertility. Indeed, prevention and treatment of infertility now claim to be one of the agendas in the priority list of maternal health in the developing nations. Researchers can try to improve the situation by innovative techniques like qualitative studies to explore further into the mines of undetermined causes and their subsequent outcomes associated with them so that necessary and appropriate interventions can be imparted.
We are thankful to Director, All India Institute of Hygiene and Public Health, Kolkata, and Principal, R.G. Kar Medical College and Hospital, for providing permission to conduct the study. We would like to thank Boivin, J, Takefman, J, and Braverman, A for Ferti-QoL questionnaire. We are thankful to faculties and staff of the Department of Gynecology and Obstetrics, R.G. Kar Medical College and Hospital, for their immense cooperation during data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]