1 Department of Obstetrics and Gynecology and 2 Department of Psychiatry and Behavioral Science, Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa, 259-1193, Japan
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: distress/emotion/infertility/Japan
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In Japan, historically, women have been frequently asked such questions as `Are you married? Do you have a child?' without hesitation, because these are forms of greeting. Old people sometimes criticize women without children, because they think women should have heirs bearing their family name, and because they still believe that infertility is caused by the female. Moreover, the media sometimes criticize the new technology of fertilization [e.g. IVF, intracytoplasmic sperm injection (ICSI)], which might result in patients being ashamed of infertility. However, little attention has been paid to the psychological aspects of infertility in Japan. For instance, the Japan Society of Obstetrics and Gynecology has not had a discussion of psychological aspects of infertility at the annual meeting for over a decade. Only one study has been published in English (Chiba et al., 1996) concerning psychological issues among patients with infertility in Japan. Their results indicated that the stress factor for infertile women changed with the length of the infertility period, but they did not compare infertile women to any other group. We postulated that Japanese infertile women had increased stress, resulting in high levels of anxiety and depression. Therefore this study was conducted to clarify whether Japanese infertile women are psychologically disturbed.
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
As a control population, we asked 105 women who visited our obstetric clinic in Tokai University Hospital to fill in the same questionnaire. The subjects filled in the questionnaires during waiting periods at the outpatient clinic, as the infertile women did. All women returned the questionnaires (return rate: 100%). In our hospital, both the obstetrics and gynaecology outpatient clinics are located in the same section, divided in two parts (right obstetrics, left gynaecology), so that patients have to enter the same entrance and to wait in the same room. About half of pregnant women achieved pregnancy after infertility treatment given in our hospital. Therefore, the condition of two groups was quite similar, and the only difference was whether they were pregnant or not. In this study, the women whose current pregnancy had any problems (e.g. growth retardation, macrosomia, placenta previa, threatened abortion, or preterm labour) as well as women with a history of any psychiatric disorder, intrauterine fetal death in the second or third trimester of a previous pregnancy, or hereditary disease, were completely excluded. Finally, as a control population, we recruited 81 healthy pregnant women (30.5 ± 4.2 years, range 2341) at 1139 weeks of gestation (26.6 ± 8.4 weeks).
In order to detect emotional states, we used two questionnaires which have been used commonly for screening psychological distress. The Hospital Anxiety and Depression Scale (HADS) was relatively newly developed for detecting depression and anxiety (Zigmond and Snaith, 1983). HADS is well known to be useful for screening emotional disorders (e.g. adjustment disorders, major depression, anxiety disorder, or dysthymia) regardless of benign or malignant diseases (Andrews et al., 1987
; Barczak et al., 1988
; Wilkinson and Barczak, 1988
; Hamer et al., 1991
; Moorey et al., 1991
). The Japanese version of HADS was introduced by Kitamura (1993); he translated the inventory of the original HADS into Japanese (Kitamura, 1993
), followed by retranslation into English by someone who did not know HADS. The retranslation was checked and accepted by the original authors, Zigmond and Snaith. Although we do not have any standardized scores in HADS, there are appropriate threshold points as a screening test in the Japanese version. Kugaya et al. (1998) first reported that the optimal threshold score of total HADS in Japanese was 10/11 for emotional disorders (e.g. adjustment disorder, major depressive disorder) in cancer patients with 92% sensitivity and 65% specificity (Kugaya et al., 1998
). Our previous report also revealed that the appropriate threshold score of total HADS in Japanese was 12/13 for emotional disorders in otolaryngology patients with 92% sensitivity and 90% specificity (Hosaka et al., 1999
).
The profile of mood states (POMS) has been widely used for measuring emotional disturbances (McNair et al., 1971). The POMS can produce scores for depression/dejection, aggression/hostility, lack of vigour, fatigue, tension anxiety, confusion, and total mood disturbances. The validation study of the Japanese version of the POMS was reported (Yokoyama et al., 1990
) and standardized with 5557 normal controls, both male and female, between the ages of 10 and 60 (Yokoyama et al., 1994).
Statistical analysis
Unpaired Student's t-test was used to compare two groups. The 2 test was performed for 2x2 tables. Correlation coefficient (r) between two parameters was calculated as linear correlation. A P value less than 0.05 was considered statistically significant.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Although we did not perform a psychiatric structured interview to all women in this study, our results showed that significantly more infertile women (38.6%) showed positive HADS scores (i.e. emotional disorders) compared to pregnant women (16.0%) when the threshold was set at 12/13. Our previous report revealed that positive HADS scores were observed in 30% of benign otolaryngology patients and in 46% of those with malignancies (Hosaka et al., 1999). Therefore, we should emphasize that the 38.6% in healthy infertile women is high and the 16.0% in healthy pregnant women is quite low. Since Japanese people think all women who are pregnant will have an intact baby, to be pregnant seems to be a goal. This may explain why the healthy pregnant women had low HADS scores in Japan.
The HADS score of the current study (depression 4.6 ± 2.9, anxiety 6.9 ± 3.1) was similar to the results in a UK population using HADS (depression 4.0 ± 3.6, anxiety 7.9 ± 4.0) (Glover et al., 1999) in spite of the language difference of the inventory, suggesting that not only the Japanese population but also Caucasians have high HADS scores. However, it may not be possible to compare each score directly, because the UK study included both men and women and because the HADS questionnaire used in our study was translated into Japanese.
Since half of pregnant women in the current study group are from our infertility clinic after appropriate treatment, successful pregnancy may reduce those scores or reduced scores may lead to successful pregnancy. Similar results have been reported, indicating that the POMS scores improved during pregnancy compared to the same women before pregnancy (Sanders and Bruce, 1997). If the hypothesis that decreasing HADS/POMS might lead to successful pregnancy is true, the mechanism whereby increased depression and anxiety may lead to infertility may be explained by a link between hormonal changes and the psychological states. There is some evidence showing that anxiety-induced hyperprolactinaemia is associated with failure to conceive (Harrison et al., 1986
; Edelmann et al., 1989), and there is other evidence showing that changes in prolactin, cortisol and testosterone provoked by emotional stress vary with anxiety and depression (Demyttenare et al., 1989; Merari et al., 1992
).
In this population of Japanese women, duration of infertility, experience of previous conception, routine tests and work did not contribute to the HADS scores. Since some papers have reported that the length of treatment changed emotional stress (Berg and Wilson, 1991; Chiba et al., 1996
) or some of the routine tests were stressful (Eimers et al., 1997
), emotional states detected by the HADS may not be influenced by these factors.
It may not be suitable to compare infertile women with pregnant women, because the entity is completely different and because both may have special psychological problems. A good comparison group would be a healthy population, such as those female patients who come for a general investigation or a PAP smear. Unfortunately, we have few such patients in our institution. Although we matched the other conditions of the two groups as much as possible, the results from this study are limited by the comparison group of pregnant women. As to the pregnant women whose gestational weeks were different between 11 and 39 weeks, their psychological situations may be different in themselves, but gestational week was not related to the HADS scores in the current study, suggesting that there might be little concern on this point.
To date, gynaecologists are eager to recognize the need to provide psychological care for women with infertility in the western world. Although results from this study are limited by the cross-sectional design and by the comparison group, we conclude that some of the Japanese infertile women are psychologically disturbed. Further research is necessary for detection of the cause of these high scores of the HADS and the POMS and for seeking beneficial treatment for these infertile women.
![]() |
Acknowledgements |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Barczak, P., Kane, N., Andrews, H. et al. (1988) Patterns of psychiatric morbidity in a genito-urinary clinic. A validation of the hospital anxiety depression scale (HAD). Br. J. Psychiatr., 152, 698700.[Abstract]
Berg, B.J. and Wilson, J.F. (1991) Psychological functioning across stages of treatment for infertility. J. Behavioral Med, 14, 1126.
Bernstein, J., Mattox, J.H. and Kellner, R. (1988) Psychological status of previously infertile couples after a successful pregnancy. J. Obstet. Gynecol. Neonatal Nurs., 17, 404408.[Abstract]
Chiba, H., Mori, E., Morioka, Y. et al. (1996) Stress of female infertility: relations to length of treatment. Gynecol. Obstet. Invest., 43, 171177.[ISI]
Cook, R., Parsons, J., Mason, B. et al. (1989) Emotional, marital and sexual functioning in patients embarking upon IVF and AID treatment for infertility. J. Reprod. Infant. Psychol, 7, 8793.
Demyttenaere, K., Nijs, P., Evers-Kiebooms, G. et al. (1989) The effect of specific emotional stress on prolactine, cortisol and testosterone concentrations in women varies with their trait anxiety. Fertil. Steril, 52, 942948.[ISI][Medline]
Domar, A.D., Zuttermeister, P.C., Seibel, M. et al. (1992) Psychological improvement in infertile women after behavioral treatment: a replication. Fertil. Steril., 58, 144147.[ISI][Medline]
Downey, J. and McKinney, M. (1992) The psychiatric status of women presenting for infertility evaluation. Am. J. Orthopsychiat., 62, 196205.[ISI][Medline]
Edelmann, R.J. and Golombok, S. (1989) Stress and reproductive failure. J. Reprod. Infant. Psychol., 7, 7986.
Eimers, J.M., Omtzigt, A.M., Vogelzang, E.T. et al. (1997) Physical complaints and emotional stress related to routine diagnostic procedures of the fertility investigation. J. Psychosom. Obstet. Gynecol., 18, 3135.[ISI][Medline]
Glover, L., Hunter, M., Richards, J-M. et al. (1999) Development of the fertility adjustment scale. Fertil. Steril., 72, 623628.[ISI][Medline]
Golombok, S. (1992) Psychological functioning in infertility patients. Hum. Reprod., 7, 208212.[Abstract]
Greil, A.L. (1997) Infertility and psychological distress: a critical review of the literature. Soc. Sci. Med, 45, 16791704.[ISI][Medline]
Hamer, D., Sanjeev, E., Butterworth, E. et al. (1991) Using the hospital anxiety and depression scale to screen for psychiatric disorders in people presenting with deliberate self-harm. Br. J. Psychiatr, 158, 782784.[Abstract]
Hosaka, T., Awazu, H., Aoki, T. et al. (1999) Screening for adjustment disorders and major depression in otolaryngology patients using the hospital anxiety and depression scale. Intl. J. Psychiatr. Clin. Prac, 3, 4348.
Harrison, R.F., O'Moore, R.R. and O'Moore, A.M. (1986) Stress and fertility: some modalities of investigation and treatment in couples with unexplained infertility in Dublin. Int. J. Fertil., 31, 153159.[ISI][Medline]
Kitamura, T. (1993) Hospital anxiety and depression scale. Seishinka. Shindangaku (Diagnostic Psychiatry), 4, 371372 (in Japanese).
Kugaya, A., Akechi, T., Okuyama, T. et al. (1998) Screening for psychological distress in Japanese cancer patients. Jpn J. Clin. Oncol., 28, 333338.
McNair, D.M., Lorr, M. and Droppleman, L.F. (eds) (1971) Manual for the Profile of Mood States. Educational and Industrial Testing Service, San Diego.
Merari, D., Feldberg, D., Elizur, A. et al. (1992) Psychological and hormonal changes in the course of in vitro fertilization. J. Assist. Reprod. Genet., 9, 161169.[ISI][Medline]
Moorey, S., Greer, S., Watson, M. et al. (1991) The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br. J. Psychiatr, 158, 255259.[Abstract]
Sanders, K.A. and Bruce, N.W. (1997) A prospective study of psychosocial stress and fertility in women. Hum. Reprod, 12, 23242329.[Abstract]
Wilkinson, M.J.B. and Barczak, P. (1988) Psychiatric screening in general practice: comparison of general health questionnaire and the hospital anxiety depression scale. J. Roy. Coll. Gen. Pract, 38, 311313.[ISI]
Yokoyama, K. and Araki, S. (1994) Japanese edition of profile of mood states (POMS). Kaneko Shobou (in Japanese).
Yokoyama, K., Araki, S., Kawakami, N. et al. (1990) Production of the Japanese edition of profile of mood states (POMS): assessment of reliability and validity. Koushueiseigaku Zasshi (Jpn. J. Epidemiol.), 37, 913918 (in Japanese).
Zigmond, A.S. and Snaith, R.P. (1983) The hospital anxiety and depression scale. Acta Psychiatr. Scand, 67, 361370.[ISI][Medline]
Submitted on October 24, 2000; accepted on January 31, 2001.