- Email: [email protected]
Assessing the quality of life of infertile Chinese women: a cross-sectional study
Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Original Article
Assessing the quality of life of infertile Chinese women: a cross-sectional study Su Xiaoli a, 1, Li Mei a, 1, Bao Junjun a, *, 1, Ding Shu b, 1, Wei Zhaolian c, Wang Jin a, Quan Ju a, Sun Wanli a, Zhao Huali a, Jin Li a, Li Dong a, Pan Li a, He Xiaojin c a b c
Endoscopy Center, The First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China Department of Economics, Hefei University of Technology, Hefei, Anhui, China Department of Obstetrics and Gynecology, the First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 5 June 2015
Objective: To assess QoL of infertile Chinese women and determine the specific factors adversely affecting QoL for improving the care and treatment compliance of infertile women. Materials and methods: We conducted a cross-sectional study on a randomized, demographically matched, controlled population of infertile married Chinese women to determine their demographic, menstrual, family stress, and infertility characteristics and then applied the World Health Organization QoL Instrument (WHOQOL-100) to determine which factors would be associated with significant QoL differences between infertile women and their demographically matched fertile controls. Results: Infertile women showed lower QoL scores in the facets of spirituality/religion/personal beliefs, self-esteem, financial resources, and accessibility to and quality of health and social care, as well as increased pain and discomfort, while also experiencing positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety, security, and transport. Conclusion: Married infertile Chinese women had significantly lower overall and comprehensive QoL scores, as well as higher anxiety scores, compared with fertile controls. Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
Keywords: infertility quality of life WHOQOL-100 Chinese
Introduction Infertility, which is defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination [1], remains a global public health issue. Since 2007, 72.4 million women were estimated to be infertile with the 12-month prevalence rate ranging from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less developed nations, with an estimated overall median prevalence of 9% [2]. The inability to conceive children is experienced as highly stressful by infertile women. Although quantitative psychological assessments of infertile women have shown equivocal results with respect to depression and anxiety, the qualitative descriptive
* Corresponding author. Endoscopy Center, The First Affiliated Hospital, Anhui Medical University, Hefei 230022, Anhui Province, China. E-mail address: [email protected] (B. Junjun). 1 These authors contributed equally to this work.
literature on female infertility demonstrates that infertile women are more likely to experience higher levels of psychological distress than fertile comparators [3]. Moreover, although this psychological distress has not been shown to affect the success of fertility treatment [4], previous reports do suggest higher levels of emotional distress in infertile women that underwent unsuccessful fertility treatment [5,6]. Therefore, female infertility and an unsuccessful fertility treatment process likely have a negative impact on quality of life (QoL), defined by the World Health Organization (WHO) as “an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns” [7]. Thus, assessing QoL and determining the specific factors adversely affecting QoL should improve the care and treatment compliance of infertile women. To that end, the fertility problem inventory has been the traditionally used measure of psychological distress in infertile women [8]. Although the fertility problem inventory is a useful psychometric tool, it merely assesses psychological stress levels in infertile
http://dx.doi.org/10.1016/j.tjog.2015.06.014 1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
women as opposed to the broader WHO construct of QoL, and has only been validated by samples primarily consisting of Caucasian patients from a homogeneous socioeconomic category with access to assisted reproductive techniques, which may not be directly translatable to a broader demographic of Chinese patients. Although several QoL measures for infertile women have also been developed, they have been designed for specific disease subpopulations [e.g., polycystic ovary syndrome (PCOS), endometriosis] [9,10], or for Caucasian populations in developed countries [11]; therefore, they cannot be directly applied as a QoL measure in a general population of Chinese infertile women. In contrast to these disease-specific and culturally-specific QoL measurement tools, the WHO QoL Instrument (WHOQOL-100) was specifically developed to be a cross-cultural QoL measurement tool by simultaneous development across 15 global centers through a process of item creation, focus groups, pilot tests, and field tests [12,13]. From 236 select items in pilot studies, a final set of 100 items scored on a 5-point Likert scale, with only the anchor points being specified (neverealways, etc.), were grouped into 25 facetsdone facet examining overall QoL and general health perceptions, and 24 QoL facets grouped into six larger domains (i.e., physical, psychological, level of independence, social relationships, environment, and spirituality). The universality of the WHOQOL100 has been globally examined in various respects across several countries (e.g., USA, several European countries, Russia, India, China, Japan, Australia, Panama, and Zimbabwe) and has been found to be remarkably adept at identifying QoL facets that are cross-culturally relevant [14]. Based on this cross-cultural success of the WHOQOL-100, the objective of this study was to assess the QoL of infertile Chinese women through the WHOQOL-100. We conducted a cross-sectional study on a randomized, demographically-matched controlled population of infertile Chinese women to first determine their demographic, menstrual, family stress, and infertility characteristics and then applied the WHOQOL-100 to determine which factors are associated with significant QoL differences between infertile women and their demographically matched fertile controls. This QoL assessment can help identify specific aspects of the infertility experience associated with poor QoL in order to improve health service evaluation, patient satisfaction, and policy making [14]. Methods Ethics statement This study was conducted according to the principles expressed in the Declaration of Helsinki. The study was approved by the Institutional Review Board (Ethics Committee) of the First Affiliated Hospital of Anhui Medical University (Hefei, Anhui Province, China; approval no. 2014009). All research participants provided written informed consent for the collection of data and subsequent analysis.
245
secondary), menarche, four levels of dysmenorrhea (no, light, moderate, and serious), two types of infertility (primary infertility defined as having never gestated and no contraception after marriage, and secondary infertility defined as infertility 2 years after gestation), three reasons for infertility (female, male, and both), and two diagnosis for infertility (male and female). The inclusion criteria for infertile participants were as follows: women, of fertile age and seeking fertility treatment, who met the diagnostic criteria for infertility with no utilization of any contraception method, a normal sex life, and cohabitation with a male marriage partner for at least 2 years. The inclusion criteria for fertile controls were as follows: healthy women with a positive birthing history who presented with an unremarkable annual health examination. The exclusion criteria for all participants were as follows: candidates who had difficulty understanding the content of the questionnaire, found it impossible to complete the questionnaire, or candidates possessing another disease adversely affecting their QoL. Participants From February 2014 to April 2014, a randomly selected sample of 81 female infertile women and 81 demographically matched (aged 22e57 years, female, Han Chinese, married) fertile controls from inpatient and outpatient treatment facilities of the First Affiliated Hospital at Anhui Medical University meeting the aforementioned inclusion and exclusion criteria were finally recruited. All women were examined by standard hormonal testing to exclude the presence of endocrine disease and by hysteroscopy to examine the uterine cavity. Both infertile women and fertile controls received detailed instructions on the WHOQOL-100 questionnaire from trained staff and then independently completed the WHOQOL-100 questionnaire. Any questions concerning the process were immediately explained by the staff. Statistical analysis All questionnaire data were blindly analyzed by a qualified statistician (Table 1). As a measure of the scale's internal consistency, Cronbach a was calculated for the total population and each domain and facet (Table 1). For the entire sample, Cronbach a values were acceptable (> 0.7) for the six domains and 25 facets. Because the probability of Bartlett's test for sphericity was < 0.001 and the Kaiser-Meyer-Olkin sample accuracy was 0.8857, the scale and construct validity were both deemed suitable for factor analysis. Chisquare testing was performed to discriminate the frequency rate of item response. Student t test was used to compare infertile and fertile control individuals in each domain and facet. All p values < 0.05 were deemed significant. All data analysis was conducted on Stata 12.0 software (StataCorp, College Station, TX, USA). Results Demographic characteristics of infertile women
Study design and recruitment WHOQOL-100 data was collected using a cross-sectional design. Data collection methods followed the internationally agreed protocols designed during the development of the WHOQOL-100 [12,13]. Using a common and consensually agreed protocol, quota sampling was used to structure the sample such that equal numbers of infertile and fertile candidates would be recruited spanning the adult age range of 22e57 years of age, six educational levels (primary, middle, senior, technical education, college/university, and above), three levels of occupational intensity (low, moderate, and high), two types of marriage status (primary and
The demographic characteristics of the 81 infertile women are detailed in Table 2. The age of infertile women ranged from 23 years to 41 years of age with a mean ± standard deviation (SD) of 30.34 ± 4.07 years. Age of menarche for the infertile participants ranged from 12 years to 18 years of age with a mean ± SD of 14.28 ± 1.37 years. All infertile women were married with 97.53% in their first marriage. As for appetite, most infertile women reported a Level 3 (so-so; 40.72%) or Level 4 (good; 48.12%) appetite. By means of Chi-square testing, there were no significant differences in the distribution of appetite levels across the various levels of occupational intensity or education (Table 2).
246
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Table 1 Quality of life comparison between infertile women and fertile controls. Domains and facets
Cronbach a
Mean
SD
Mean
SD
t
p
Physical health Pain and discomfort Energy and fatigue Sleep and rest Psychological Positive feelings Thinking, learning, memory, and concentration Self esteem Bodily image and appearance Negative feelings Level of independence Mobility Activities of daily living Dependence on medicinal substances and medical aids Work capacity Social relations Personal relationships Social support Sexual activity Environment Freedom, physical safety, and security Home environment Financial resources Health and social care: accessibility and quality Opportunities for acquiring new information and skills Participation in and opportunities for recreation/leisure Physical environment Transport Spirituality/religion/personal beliefs Spirituality/religion/personal beliefs Overall Comprehensive score Anxiety score
0.8234 0.9342 0.9306 0.9313 0.7817 0.9316 0.9300 0.9302 0.9317 0.9331 0.8194 0.9331 0.9298 0.9333 0.9306 0.7748 0.9287 0.9292 0.9303 0.7760 0.9295 0.9297 0.9299 0.9313 0.9298 0.9291 0.9320 0.9303 0.8763 0.9349 0.9276 0.9722 0.9729
62.81 41.28 60.34 69.37 61.11 54.86 56.94 59.10 70.76 36.11 76.50 70.60 75.08 9.80 70.14 67.70 71.68 62.27 69.14 217.16 66.74 62.50 58.18 53.55 1312.04 57.02 57.87 69.37 47.92 47.92 61.50 79.88 38.57
13.45 16.76 15.57 18.64 10.79 13.44 16.39 13.80 14.35 16.18 11.24 18.53 12.98 11.94 17.87 13.08 15.41 17.24 13.71 12.49 16.44 16.00 20.00 16.91 13.36 18.89 14.68 16.14 21.79 21.79 17.47 11.65 8.57
65.68 34.61 62.73 68.91 63.13 56.09 59.45 63.83 68.98 32.73 67.29 60.78 68.20 19.69 59.84 65.77 71.02 63.05 63.29 217.04 62.89 60.31 65.08 59.06 1312.03 57.81 55.16 63.98 56.56 56.56 65.63 88.09 31.96
12.94 17.05 12.67 17.17 8.96 14.55 13.23 12.13 13.58 14.89 11.79 14.55 12.23 17.82 16.36 8.84 10.54 10.30 13.70 9.26 10.68 16.37 16.48 10.89 10.13 13.10 11.59 14.38 13.49 13.49 12.34 7.41 5.33
1.3787 2.5037 1.0697 0.1632 1.2873 0.5585 1.0680 2.3057 0.8045 1.3775 5.0794 3.7379 3.4580 4.1411 3.8110 1.0882 0.3200 0.3472 2.6975 0.0678 1.7610 0.8575 2.3869 2.4558 0.0031 0.3084 1.3009 2.2334 3.0233 3.0233 1.7299 5.3265 5.8719
0.085 0.0066 0.1432 0.4353 0.0999 0.2886 0.1436 0.0112 0.7889 0.0851 0.0000 0.0001 0.0003 0.0000 0.0001 0.8609 0.6253 0.6356 0.0039 0.4730 0.0401 0.8038 0.0091 0.0076 0.5012 0.6209 0.0976 0.0135 0.0015 0.0015 0.0428 0.0000 0.0000
*
*
* * * * *
* * * *
* * * * * *
SD ¼ standard deviation. *p < 0.05.
Table 2 Demographic characteristics of infertile women (n ¼ 81). Ocpa
Edub
n
2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
2 5 6 3 4 2 5 3 4 1 2 5 6 3
21 11 4 6 2 15 2 3 1 2 1 4 8 1 81
Age (y)
Marriage historyc
Menarche age (y)
Appetited
Mean
SD
Mean
SD
1
%
2
%
2
%
3
%
4
%
5
%
29.14 29.27 31.50 32.00 33.50 30.93 34.00 28.00 31.00 32.00 27.00 34.00 29.25 31.00 30.34
4.05 3.41 0.58 3.22 6.36 5.16 2.83 1.00
14.81 14.27 13.25 14.17 13.50 14.33 12.50 15.00 14.00 13.50 16.00 14.00 14.00 14.00 14.28
1.33 1.01 0.96 2.04 2.12 1.45 0.71 1.00
19 11 4 6 2 15 2 3 1 2 1 4 8 1 79
23.46 13.58 4.94 7.41 2.47 18.52 2.47 3.7 1.23 2.47 1.23 4.94 9.88 1.23 97.53
2 0 0 0 0 0 0 0 0 0 0 0 0 0 2
2.47 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.47
1 0 0 0 0 1 0 0 0 0 0 0 0 0 2
1.23 0.0 0.0 0.0 0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.00 2.46
14 3 2 1 1 6 0 2 0 0 1 1 2 0 33
17.28 3.7 2.47 1.23 1.23 7.41 0.0 2.47 0.00 0.0 1.23 1.23 2.47 0.00 40.72
6 8 1 5 1 7 1 1 1 2 0 2 3 1 39
7.41 9.88 1.23 6.17 1.23 8.64 1.23 1.23 1.23 2.47 0.00 2.47 3.7 1.23 48.12
0 0 1 0 0 1 1 0 0 0 0 1 3 0 7
0.00 0.00 1.23 0.0 0.0 1.23 1.23 0.00 0.00 0.00 0.00 1.23 3.7 0.00 8.62
5.66 6.98 1.28 4.07
0.71 1.41 1.41 1.37
SD ¼ standard deviation. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Marriage history: 1 ¼ first marriage and 2 ¼ second marriage. d Appetite: 2 ¼ worse, 3 ¼ so-so, 4 ¼ good, and 5 ¼ excellent.
Menstrual characteristics of infertile women We investigated four menstrual factors in the infertile participants, including menstrual cycle, menstruation duration, menstruation volume, and dysmenorrhea (Table 3). As for the menstrual cycle, 83.95% of infertile women reported a regular menstrual cycle. Regarding menstruation duration, 97.51% of
infertile women reported completion of menstruation within a 7day period. For menstrual volume, 60.48% of infertile women reported a moderate menstruation volume. As for dysmenorrhea, 53.09% of infertile women reported no dysmenorrhea. Chi-square testing showed no significant differences in the distribution of these four physiological factors across the different levels of occupational intensity or education (Table 3).
f
e
d
Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). Menstrual cycle: 1 ¼ regular and 2 ¼ irregular. Menstruation duration: 1 ¼ < 5 days; 2 ¼ 5e7 days, and 3 ¼ > 7 days. Menstruation amount: 1 ¼ less, 2 ¼ moderate, and 3 ¼ more. Dysmenorrhea; 0 ¼ none, 1 ¼ light, 2 ¼ moderate, and 3 ¼ serious. c
a
b
% 3
0 0 0 0 0 1 0 1 0 0 0 0 1 0 3 9.87 3.70 0.00 2.46 2.46 1.23 0.00 0.00 0.00 0.00 0.00 1.23 2.46 1.23 24.69
% 2
8 3 0 2 2 1 0 0 0 0 0 1 2 1 20 6.17 3.7 1.23 1.23 0.0 4.94 0.0 0.0 0.0 0.0 0.0 0.0 1.23 0.0 18.5
% 1
5 3 1 1 0 4 0 0 0 0 0 0 1 0 15 9.877 6.173 3.704 3.704 0.0 11.11 2.469 2.469 1.235 2.469 1.235 3.704 4.938 0.0 53.09
% 0
8 5 3 3 0 9 2 2 1 2 1 3 4 0 43 3.7 3.7 1.23 1.23 0.0 2.47 0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 13.56
% 3
3 3 1 1 0 2 0 1 0 0 0 0 0 0 11 14.81 7.41 3.7 2.47 2.47 12.35 1.23 2.47 1.23 2.47 1.23 2.47 6.17 0.0 60.48
% 2
12 6 3 2 2 10 1 2 1 2 1 2 5 0 49 7.41 2.47 0.0 3.7 0.0 3.7 1.23 0.0 0.0 0.0 0.0 2.47 3.7 1.23 25.91
% 1
6 2 0 3 0 3 1 0 0 0 0 2 3 1 21 0 0 1.20 1.20 0 0 0 0 0 0 0 0 0 0 2.4
% 3
0 0 1 1 0 0 0 0 0 0 0 0 0 0 2 16.05 12.35 2.47 4.94 1.23 13.58 2.47 1.23 0.0 2.47 1.23 2.47 7.41 0.0 67.90
% 2
13 10 2 4 1 11 2 1 0 2 1 2 6 0 55 9.88 1.23 1.23 1.23 1.23 4.94 0.0 2.47 1.23 0.0 0.0 2.47 2.47 1.23 29.61 2 5 6 3 4 2 5 3 4 1 2 5 6 3 2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
1
%
2
%
1
%
Menstruation durationd Menstrual cyclec Edub
In this study, we conducted a cross-sectional study on 81 infertile women (age range: 23e41 years, mean age: 30.34 years) and 81
Ocpa
Discussion
Table 3 Menstrual characteristics of infertile women (n ¼ 81).
In order to compare QoL between infertile and fertile individuals, we collected data from the infertile women and their demographically matched fertile controls, all of whom were married and had given birth (Table 1). Overall, infertile women had significantly lower overall and comprehensive QoL scores, and a significantly higher anxiety score, compared with fertile controls. Moreover, infertile women showed a significantly higher score in the “level of independence” domain. Within this domain, infertile participants showed significantly higher scores in the “mobility”, “activities of daily living”, and “work capacity” facets, but a significantly lower score in the “dependence on medicinal substances and medical aids” facet. In addition, infertile participants showed a significantly lower score in the “spirituality/religion/personal beliefs” domain/facet. Infertile participants also showed significant differences from fertile controls in the following individual QoL facets ([ indicating a significant increase and Y indicating a significant decrease): [“pain and discomfort”, Y“self-esteem”, [“sexual activity”, [“freedom, physical safety and security”, Y“financial resources”, Y“health and social care: accessibility and quality”, and [“transport”.
8 1 1 1 1 4 0 2 1 0 0 2 2 1 24
Menstruation amounte
QoL comparison between infertile participants and fertile controls
4.90 2.50 0.00 1.20 0.00 2.50 0.00 1.20 1.20 0.00 1.20 0.00 1.20 0.00 15.9
Infertility was classified by type, reported reason, and diagnosis (Table 5). By type, 61.71% of infertile women reported primary infertility, while 38.26% reported secondary fertility. By reported reason, 81.47% of infertile women reported female infertility as the underlying reason for infertility. However, by diagnosis, 93.82% of infertile women held a female diagnosis of infertility. Chi-square testing showed a significant difference in infertility type across different levels of occupational intensity (p ¼ 0.012; Table 5), and the Kendall's tau-b (correlation coefficient) of 0.2450 showed a negative correlation between these two variables. Therefore, a higher reported occupational intensity was significantly correlated with a higher incidence of secondary infertility. Moreover, Chisquare testing showed a significant difference in the reported infertility reason across different levels of occupational intensity (p ¼ 0.017; Table 5), and the Kendall's tau-b (correlation coefficient) of 0.2163 showed a positive correlation between these two variables. Therefore, a higher reported occupational intensity was significantly correlated with a lower tendency to report female infertility as the underlying reason for infertility.
4 2 0 1 0 2 0 1 1 0 1 0 1 0 13
Dysmenorrheaf
Infertility characteristics of infertile women
20.99 11.11 4.94 6.17 2.47 16.05 2.47 2.47 0.0 2.47 0.0 4.94 8.64 1.23 83.95
Family stress in infertile participants was also assessed (Table 4). Approximately 53.06% of infertile women reported feeling stress from family life. In addition, 41.95% of infertile women reported that family stress had an effect on work, 28.37% of infertile participants reported that family stress had a lesser effect on work, and 13.56% of infertile participants reported a large impact on work. Chi-square testing showed a significant difference in the degree of family stress effect on work across different levels of education (p ¼ 0.026; Table 4), while the Kendall's tau-b (correlation coefficient) of 0.0294 showed a very low negative correlation between these two variables. Therefore, higher education levels in Chinese infertile women were significantly, but only marginally, correlated with a lower degree of effect of family stress upon work.
17 9 4 5 2 13 2 2 0 2 0 4 7 1 68
Family stress characteristics of infertile women
247
0.0 0.0 0.0 0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 0.0 1.23 0.0 3.69
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
248
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Table 4 Family stress characteristics of infertile women (n ¼ 81). Ocpa
2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
Edub
2 5 6 3 4 2 5 3 4 1 2 5 6 3
Family stressc
Family stress effects on workd,*
0
%
1
%
1
%
2
%
3
%
4
%
5
%
8 3 3 3 2 7 0 2 1 1 0 3 5 0 38
9.88 3.7 3.7 3.7 2.47 8.64 0.0 2.47 1.23 1.23 0.0 3.7 6.17 0.0 46.89
13 8 1 3 0 8 2 1 0 1 1 1 3 1 43
16.05 9.88 1.23 3.7 0.0 9.88 2.47 1.23 0.0 1.23 1.23 1.23 3.7 1.23 53.06
5 0 0 1 0 3 0 0 0 0 0 1 2 0 12
6.17 0.0 0.0 1.23 0.0 3.70 0.0 0.0 0.0 0.0 0.0 1.23 2.47 0.0 14.8
3 5 2 2 2 2 1 1 1 0 0 1 3 0 23
3.7 6.17 2.47 2.47 2.47 2.47 1.23 1.23 1.23 0.0 0.0 1.23 3.7 0.0 28.37
11 0 2 3 0 9 1 1 0 2 1 1 2 1 34
13.58 0.0 2.47 3.7 0.0 11.11 1.23 1.23 0.0 2.47 1.23 1.23 2.47 1.23 41.95
2 5 0 0 0 1 0 1 0 0 0 1 1 0 11
2.47 6.17 0.0 0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 1.23 1.23 0.0 13.56
0 1 0 0 0 0 0 0 0 0 0 0 0 0 1
0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.23
* Chi-square ¼ 33.9520, degrees of freedom ¼ 20, p ¼ 0.026; a significant difference in the degree of family stress effect on work across different levels of education. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Family stress: 0 ¼ no and 1 ¼ yes. d Family stress effects on work: 1 ¼ no effect, 2 ¼ less effect, 3 ¼ moderate effect, 4 ¼ large impact, and 5 ¼ extremely significant impact.
Table 5 Infertility characteristics of infertile women (n ¼ 81). Ocpa
Edub
1 1 1 1 2 2 2 2 2 3 3 3 3 3 Totals
2 3 5 6 2 3 4 5 6 1 2 3 4 5
Infertility type c,*
Reported infertility reasond,**
Infertility diagnosise
1
%
2
%
1
%
2
%
3
%
1
%
2
%
1 0 2 5 11 2 1 6 2 2 13 3 1 1 50
1.23 0.0 2.47 6.17 13.58 2.47 1.23 7.41 2.47 2.47 16.05 3.7 1.23 1.23 61.71
0 1 2 3 10 4 1 5 2 0 2 0 0 1 31
0.0 1.23 2.47 3.7 12.35 4.94 1.23 6.17 2.47 0.0 2.47 0.0 0.0 1.23 38.26
1 1 2 7 18 6 2 11 4 1 10 2 1 0 66
1.23 1.23 2.47 8.64 22.22 7.41 2.47 13.58 4.94 1.23 12.35 2.47 1.23 0.0 81.47
0 0 1 0 1 0 0 0 0 0 1 0 0 0 3
0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 0.0 0.0 1.23 0.0 0.0 0.0 3.69
0 0 1 1 2 0 0 0 0 1 4 1 0 2 12
0.0 0.0 1.23 1.23 2.47 0.0 0.0 0.0 0.0 1.23 4.94 1.23 0.0 2.47 14.8
0 0 0 0 2 0 0 0 0 1 2 0 0 0 5
0.0 0.0 0.0 0.0 2.47 0.0 0.0 0.0 0.0 1.23 2.47 0.0 0.0 0.0 6.17
1 1 4 8 19 6 2 11 4 1 13 3 1 2 76
1.23 1.23 4.94 9.88 23.46 7.41 2.47 13.58 4.94 1.23 16.05 3.7 1.23 2.47 93.82
* Chi-square ¼ 8.8829, degrees of freedom ¼ 2, p ¼ 0.012; a significant difference in infertility type across different levels of occupational intensity. ** Chi-square ¼ 11.994, degrees of freedom ¼ 4, p ¼ 0.017; a significant difference in the reported infertility reason across different levels of occupational intensity. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Infertility type: 1 ¼ primary and 2 ¼ secondary. d Infertility reason: 1 ¼ female, 2 ¼ male, and 3 ¼ both. e Infertility diagnosis: 1 ¼ male and 2 ¼ female.
demographically matched fertile controls to first determine their demographic, menstrual, family stress, and infertility characteristics and then applied the WHOQOL-100 to determine which factors are associated with significant QoL differences between these two cohorts. All infertile participants were married, with the vast majority (> 97%) in their first marriage. The majority of infertile participants reported relatively normal levels of appetite and a regular menstrual cycle of moderate volume, with menstruation completed within a 7day period and no dysmenorrhea. Approximately 50% of infertile participants reported stress from family life, with higher education levels significantly, but only marginally, correlating with a lower degree of the effect of family stress upon work. There was an approximately 60/40 split in primary and secondary infertility, with a higher occupational intensity significantly correlating with a
higher incidence of secondary infertility. Although 94% of infertile participants held a female diagnosis of infertility, only 81% of infertile participants reported female infertility as the underlying reason for infertility with a higher occupational intensity significantly correlating with a lower tendency to report female infertility as the underlying reason for infertility. Infertility and QoL Comparing QoL between infertile participants and fertile controls, infertile participants had significantly lower overall and comprehensive QoL scores compared with fertile controls. Moreover, infertile women showed a significantly higher score in the “level of independence” domain. Within this domain, infertile
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
participants showed significantly higher scores in the “mobility”, “activities of daily living”, and “work capacity” facets, but a significantly lower score in the “dependence on medicinal substances and medical aids” facet. In addition, infertile participants showed a significantly lower score in the “spirituality/religion/personal beliefs” domain/facet. Infertile participants also showed significantly higher “pain and discomfort”, significantly lower “self-esteem”, significantly higher “sexual activity”, significantly higher “freedom, physical safety and security”, significantly lower “financial resources”, significantly lower “health and social care: accessibility and quality”, and significantly higher “transport”. In agreement with the current findings, mounting research across a host of countries that applied various QoL instruments indicates that non-PCOS-, nonendometriosis-based female infertility is associated with lower measures of QoL. For example, in a caseecontrol study administering the 36-item Short-Form Health Survey (SF-36), 100 primary infertile Tunisian women undergoing reproductive technology displayed lower mental and physical dimension scores and lower vitality, social functioning, roleemotional, and mental health scores than fertile female controls [15]. Moreover, in another study using the Tuebingen QoL and the COPE questionnaires, infertile Australian women seeking traditional Chinese medicine fertility therapy reported a lower QoL due to high levels of distress, guilt, grief, and frustration caused by infertility [16]. In addition, WHOQOL-100 data derived from 199 infertile German couples showed that high scores on “suffering from childlessness” went along with lower satisfaction on “physical” and “psychological” QoL domains for the infertile women [17]. Additionally, a meta-analysis of 14 studies showed that infertile women had significantly lower QoL scores on mental health, social functioning, and emotional behavior compared with fertile controls [18]. Although our current findings of lower QoL scores in spirituality/religion/personal beliefs, self-esteem, financial resources, and accessibility and quality to health and social care, as well as increased pain and discomfort QoL scores concord with the previously cited findings of lower psychological, mental health, emotional, social functioning, and physical QoL scores in infertile women, our WHOQOL-100-based analysis reveals that Chinese infertile women also experience positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety and security, and transport. We infer that the positive QoL adjustments in mobility, daily living activities, work capacity, sexual activity, and freedom may be caused by the state of childlessness (which allows for a more independent mode of living), personality changes in reaction to infertility, and/or changes to internal motivation to compensate for the infertile state. Moreover, we infer that the positive QoL adjustments in physical safety and security and transport may be due to the higher disposable income available from being childless, which would allow for increased spending on safer neighborhoods and superior transportation methods. Further research is needed to address these hypotheses. Infertility and anxiety In addition, this study revealed that infertile participants also had a significantly higher anxiety score compared with fertile controls. The prevalence of anxiety and/or depression symptoms in infertile patients has been assessed across several countries. In China, analysis of anxiety and depression in 130 infertile mainland Chinese women revealed the presence of such symptoms in 83.8% of infertile women with moderate-to-severe symptoms in 52% of infertile women; moreover, in a similar Hong Kong-based study, 33% of infertile women showed anxiety or depression symptoms [19,20]. In Iran, a cross-sectional showed 40.8% depression and
249
86.8% anxiety in infertile women [21]. In Europe, a Spanish study showed that 67% of infertile women suffered from anxiety [22], and a multicenter study in The Netherlands, Belgium, and France revealed that infertile women showed higher scores on scales for depressed mood, memory/concentration, anxiety, and fears, with 24.9% of these infertile patients meeting the diagnostic criteria for a depressive disorder [23]. These increased anxiety and depression symptoms in infertile women may have a relationship with their lower QoL scores. For instance, a Dutch study examining the relationship between emotional distress as measured by the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL) questionnaire statistically demonstrated a negative relationship between QoL and anxiety and depression in infertile women [24]. Study limitations There are several limitations to the current study. First, the present study was limited by a relatively small sample size (n ¼ 81 in each group) and was limited to one center in central China; a larger sample size derived from multiple centers across China would have been preferable for a cross-sectional study. However, our sample size was sufficient to reach thematic saturation, and our findings are consistent with other QoL studies. Second, as all infertile participants in this study were seeking fertility treatment, self-selection bias limits the generalizability of our findings; those infertile women who were not seeking or had quit pursuing fertility therapy are not represented here. Third, the mean duration of infertility was not assessed in the present study. Fourth, WHOQOL100 questionnaire responses were not validated by follow-up interviews. Conclusion Married infertile Chinese women had significantly lower overall and comprehensive QoL scores, as well as higher anxiety scores, compared with fertile controls. Infertile women showed lower QoL scores in the facets of spirituality/religion/personal beliefs, selfesteem, financial resources, and accessibility and quality to health and social care, as well as increased pain and discomfort while also experiencing positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety and security, and transport. We infer that the positive QoL adjustments in mobility, daily living activities, work capacity, sexual activity, and freedom may be caused by the state of childlessness (which allows for a more independent mode of living), personality changes in reaction to infertility, and/or changes to internal motivation to compensate for the infertile state. Moreover, we infer that the positive QoL adjustments in physical safety and security and transport may be due to the higher disposable income available from being childless, which would allow for increased spending on safer neighborhoods and superior transportation methods. Further research is needed to address these hypotheses. Conflicts of interest The authors have no conflicts of interest relevant to this article. Acknowledgments Su Xiaoli, Bao Junjun, Wei Zhaoli, and He Xiaojin conceived and designed the experiments. Li Mei, Quan Ju, Sun Wanli, Wang Jin, Zhao Huali, Jin Li, Li Dong, and Pan Li carried out data collection. Ding Shu analyzed the data. Su Xiaoli wrote the manuscript. Bao
250
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Junjun critically revised the manuscript. Su Xiaoli and Bao Junjun supervised the study.
Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.tjog.2015.06.014.
References [1] Practice Committee of American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril 2013;99:63. http://dx.doi.org/10.1016/j.fertnstert.2012.09.023. [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;22:1506e12. [3] Greil AL, Slauson-Blevins K, McQuillan J. The experience of infertility: a review of recent literature. Sociol Health Illn 2010;32:140e62. [4] Boivin J, Griffiths E, Venetis CA. Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies. BMJ 2011;342:d223. http://dx.doi.org/10.1136/ bmj.d223. [5] Chochovski J, Moss SA, Charman DP. Recovery after unsuccessful in vitro fertilization: the complex role of resilience and marital relationships. J Psychosom Obstet Gynaecol 2013;34:122e8. [6] Verhaak CM, Smeenk JM, Evers AW, Kremer JA, Kraaimaat FW, Braat DD. Women's emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update 2007;13:27e36. [7] Skevington SM, Lotfy M, O'Connell KA. The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res 2004;13:299e310. [8] Newton CR, Sherrard W, Glavac I. The Fertility Problem Inventory: measuring perceived infertility-related stress. Fertil Steril 1999;72:54e62. [9] Colwell HH, Mathias SD, Pasta DJ, Henning JM, Steege JF. A health-related quality-of-life instrument for symptomatic patients with endometriosis: a validation study. Am J Obstet Gynecol 1998;179:47e55. [10] Malik-Aslam A, Reaney MD, Speight J. The suitability of polycystic ovary syndrome-specific questionnaires for measuring the impact of PCOS on quality of life in clinical trials. Value Health 2010;13:440e6.
[11] Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Hum Reprod 2011;26: 2084e91. [12] The WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL). Position paper from the World Health Organization. Soc Sci Med 1995;41:1403e9. [13] The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998;46:1569e85. [14] Power M, Harper A, Bullinger M. The World Health Organization WHOQOL100: tests of the universality of quality of life in 15 different cultural groups worldwide. Health Psychol 1999;18:495e505. [15] El Kissi Y, Amamou B, Hidar S, Ayoubi Idrissi K, Khairi H, Ali BB. Quality of life of infertile Tunisian couples and differences according to gender. Int J Gynaecol Obstet 2014;125:134e7. [16] Ried K, Alfred A. Quality of life, coping strategies and support needs of women seeking Traditional Chinese Medicine for infertility and viable pregnancy in Australia: a mixed methods approach. BMC Womens Health 2013;13:17. http://dx.doi.org/10.1186/1472-6874-13-17. [17] Herrmann D, Scherg H, Verres R, von Hagens C, Strowitzki T, Wischmann T. Resilience in infertile couples acts as a protective factor against infertilityspecific distress and impaired quality of life. J Assist Reprod Genet 2011;28: 1111e7. [18] 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;31:101e10. [19] Lok IH, Lee DT, Cheung LP, Chung WS, Lo WK, Haines CJ. Psychiatric morbidity amongst infertile Chinese women undergoing treatment with assisted reproductive technology and the impact of treatment failure. Gynecol Obstet Invest 2002;53:195e9. [20] Lu Y, Yang L, Lu G. Mental status and personality of infertile women. Zhonghua Fu Chan Ke Za Zhi 1995;30:34e7 [In Chinese]. [21] Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M, et al. A survey of relationship between anxiety, depression and duration of infertility. BMC Womens Health 2004;4:9. http://dx.doi.org/10.1186/14726874-4-9. [22] Guerra D, Llobera A, Veiga A, Barri PN. Psychiatric morbidity in couples attending a fertility service. Hum Reprod 1998;13:1733e6. [23] Oddens BJ, den Tonkelaar I, Nieuwenhuyse H. Psychosocial experiences in women facing fertility problemsea comparative survey. Hum Reprod 1999;14:255e61. [24] Aarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod 2011;26:1112e8.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Original Article
Assessing the quality of life of infertile Chinese women: a cross-sectional study Su Xiaoli a, 1, Li Mei a, 1, Bao Junjun a, *, 1, Ding Shu b, 1, Wei Zhaolian c, Wang Jin a, Quan Ju a, Sun Wanli a, Zhao Huali a, Jin Li a, Li Dong a, Pan Li a, He Xiaojin c a b c
Endoscopy Center, The First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China Department of Economics, Hefei University of Technology, Hefei, Anhui, China Department of Obstetrics and Gynecology, the First Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 5 June 2015
Objective: To assess QoL of infertile Chinese women and determine the specific factors adversely affecting QoL for improving the care and treatment compliance of infertile women. Materials and methods: We conducted a cross-sectional study on a randomized, demographically matched, controlled population of infertile married Chinese women to determine their demographic, menstrual, family stress, and infertility characteristics and then applied the World Health Organization QoL Instrument (WHOQOL-100) to determine which factors would be associated with significant QoL differences between infertile women and their demographically matched fertile controls. Results: Infertile women showed lower QoL scores in the facets of spirituality/religion/personal beliefs, self-esteem, financial resources, and accessibility to and quality of health and social care, as well as increased pain and discomfort, while also experiencing positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety, security, and transport. Conclusion: Married infertile Chinese women had significantly lower overall and comprehensive QoL scores, as well as higher anxiety scores, compared with fertile controls. Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
Keywords: infertility quality of life WHOQOL-100 Chinese
Introduction Infertility, which is defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination [1], remains a global public health issue. Since 2007, 72.4 million women were estimated to be infertile with the 12-month prevalence rate ranging from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less developed nations, with an estimated overall median prevalence of 9% [2]. The inability to conceive children is experienced as highly stressful by infertile women. Although quantitative psychological assessments of infertile women have shown equivocal results with respect to depression and anxiety, the qualitative descriptive
* Corresponding author. Endoscopy Center, The First Affiliated Hospital, Anhui Medical University, Hefei 230022, Anhui Province, China. E-mail address: [email protected] (B. Junjun). 1 These authors contributed equally to this work.
literature on female infertility demonstrates that infertile women are more likely to experience higher levels of psychological distress than fertile comparators [3]. Moreover, although this psychological distress has not been shown to affect the success of fertility treatment [4], previous reports do suggest higher levels of emotional distress in infertile women that underwent unsuccessful fertility treatment [5,6]. Therefore, female infertility and an unsuccessful fertility treatment process likely have a negative impact on quality of life (QoL), defined by the World Health Organization (WHO) as “an individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns” [7]. Thus, assessing QoL and determining the specific factors adversely affecting QoL should improve the care and treatment compliance of infertile women. To that end, the fertility problem inventory has been the traditionally used measure of psychological distress in infertile women [8]. Although the fertility problem inventory is a useful psychometric tool, it merely assesses psychological stress levels in infertile
http://dx.doi.org/10.1016/j.tjog.2015.06.014 1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
women as opposed to the broader WHO construct of QoL, and has only been validated by samples primarily consisting of Caucasian patients from a homogeneous socioeconomic category with access to assisted reproductive techniques, which may not be directly translatable to a broader demographic of Chinese patients. Although several QoL measures for infertile women have also been developed, they have been designed for specific disease subpopulations [e.g., polycystic ovary syndrome (PCOS), endometriosis] [9,10], or for Caucasian populations in developed countries [11]; therefore, they cannot be directly applied as a QoL measure in a general population of Chinese infertile women. In contrast to these disease-specific and culturally-specific QoL measurement tools, the WHO QoL Instrument (WHOQOL-100) was specifically developed to be a cross-cultural QoL measurement tool by simultaneous development across 15 global centers through a process of item creation, focus groups, pilot tests, and field tests [12,13]. From 236 select items in pilot studies, a final set of 100 items scored on a 5-point Likert scale, with only the anchor points being specified (neverealways, etc.), were grouped into 25 facetsdone facet examining overall QoL and general health perceptions, and 24 QoL facets grouped into six larger domains (i.e., physical, psychological, level of independence, social relationships, environment, and spirituality). The universality of the WHOQOL100 has been globally examined in various respects across several countries (e.g., USA, several European countries, Russia, India, China, Japan, Australia, Panama, and Zimbabwe) and has been found to be remarkably adept at identifying QoL facets that are cross-culturally relevant [14]. Based on this cross-cultural success of the WHOQOL-100, the objective of this study was to assess the QoL of infertile Chinese women through the WHOQOL-100. We conducted a cross-sectional study on a randomized, demographically-matched controlled population of infertile Chinese women to first determine their demographic, menstrual, family stress, and infertility characteristics and then applied the WHOQOL-100 to determine which factors are associated with significant QoL differences between infertile women and their demographically matched fertile controls. This QoL assessment can help identify specific aspects of the infertility experience associated with poor QoL in order to improve health service evaluation, patient satisfaction, and policy making [14]. Methods Ethics statement This study was conducted according to the principles expressed in the Declaration of Helsinki. The study was approved by the Institutional Review Board (Ethics Committee) of the First Affiliated Hospital of Anhui Medical University (Hefei, Anhui Province, China; approval no. 2014009). All research participants provided written informed consent for the collection of data and subsequent analysis.
245
secondary), menarche, four levels of dysmenorrhea (no, light, moderate, and serious), two types of infertility (primary infertility defined as having never gestated and no contraception after marriage, and secondary infertility defined as infertility 2 years after gestation), three reasons for infertility (female, male, and both), and two diagnosis for infertility (male and female). The inclusion criteria for infertile participants were as follows: women, of fertile age and seeking fertility treatment, who met the diagnostic criteria for infertility with no utilization of any contraception method, a normal sex life, and cohabitation with a male marriage partner for at least 2 years. The inclusion criteria for fertile controls were as follows: healthy women with a positive birthing history who presented with an unremarkable annual health examination. The exclusion criteria for all participants were as follows: candidates who had difficulty understanding the content of the questionnaire, found it impossible to complete the questionnaire, or candidates possessing another disease adversely affecting their QoL. Participants From February 2014 to April 2014, a randomly selected sample of 81 female infertile women and 81 demographically matched (aged 22e57 years, female, Han Chinese, married) fertile controls from inpatient and outpatient treatment facilities of the First Affiliated Hospital at Anhui Medical University meeting the aforementioned inclusion and exclusion criteria were finally recruited. All women were examined by standard hormonal testing to exclude the presence of endocrine disease and by hysteroscopy to examine the uterine cavity. Both infertile women and fertile controls received detailed instructions on the WHOQOL-100 questionnaire from trained staff and then independently completed the WHOQOL-100 questionnaire. Any questions concerning the process were immediately explained by the staff. Statistical analysis All questionnaire data were blindly analyzed by a qualified statistician (Table 1). As a measure of the scale's internal consistency, Cronbach a was calculated for the total population and each domain and facet (Table 1). For the entire sample, Cronbach a values were acceptable (> 0.7) for the six domains and 25 facets. Because the probability of Bartlett's test for sphericity was < 0.001 and the Kaiser-Meyer-Olkin sample accuracy was 0.8857, the scale and construct validity were both deemed suitable for factor analysis. Chisquare testing was performed to discriminate the frequency rate of item response. Student t test was used to compare infertile and fertile control individuals in each domain and facet. All p values < 0.05 were deemed significant. All data analysis was conducted on Stata 12.0 software (StataCorp, College Station, TX, USA). Results Demographic characteristics of infertile women
Study design and recruitment WHOQOL-100 data was collected using a cross-sectional design. Data collection methods followed the internationally agreed protocols designed during the development of the WHOQOL-100 [12,13]. Using a common and consensually agreed protocol, quota sampling was used to structure the sample such that equal numbers of infertile and fertile candidates would be recruited spanning the adult age range of 22e57 years of age, six educational levels (primary, middle, senior, technical education, college/university, and above), three levels of occupational intensity (low, moderate, and high), two types of marriage status (primary and
The demographic characteristics of the 81 infertile women are detailed in Table 2. The age of infertile women ranged from 23 years to 41 years of age with a mean ± standard deviation (SD) of 30.34 ± 4.07 years. Age of menarche for the infertile participants ranged from 12 years to 18 years of age with a mean ± SD of 14.28 ± 1.37 years. All infertile women were married with 97.53% in their first marriage. As for appetite, most infertile women reported a Level 3 (so-so; 40.72%) or Level 4 (good; 48.12%) appetite. By means of Chi-square testing, there were no significant differences in the distribution of appetite levels across the various levels of occupational intensity or education (Table 2).
246
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Table 1 Quality of life comparison between infertile women and fertile controls. Domains and facets
Cronbach a
Mean
SD
Mean
SD
t
p
Physical health Pain and discomfort Energy and fatigue Sleep and rest Psychological Positive feelings Thinking, learning, memory, and concentration Self esteem Bodily image and appearance Negative feelings Level of independence Mobility Activities of daily living Dependence on medicinal substances and medical aids Work capacity Social relations Personal relationships Social support Sexual activity Environment Freedom, physical safety, and security Home environment Financial resources Health and social care: accessibility and quality Opportunities for acquiring new information and skills Participation in and opportunities for recreation/leisure Physical environment Transport Spirituality/religion/personal beliefs Spirituality/religion/personal beliefs Overall Comprehensive score Anxiety score
0.8234 0.9342 0.9306 0.9313 0.7817 0.9316 0.9300 0.9302 0.9317 0.9331 0.8194 0.9331 0.9298 0.9333 0.9306 0.7748 0.9287 0.9292 0.9303 0.7760 0.9295 0.9297 0.9299 0.9313 0.9298 0.9291 0.9320 0.9303 0.8763 0.9349 0.9276 0.9722 0.9729
62.81 41.28 60.34 69.37 61.11 54.86 56.94 59.10 70.76 36.11 76.50 70.60 75.08 9.80 70.14 67.70 71.68 62.27 69.14 217.16 66.74 62.50 58.18 53.55 1312.04 57.02 57.87 69.37 47.92 47.92 61.50 79.88 38.57
13.45 16.76 15.57 18.64 10.79 13.44 16.39 13.80 14.35 16.18 11.24 18.53 12.98 11.94 17.87 13.08 15.41 17.24 13.71 12.49 16.44 16.00 20.00 16.91 13.36 18.89 14.68 16.14 21.79 21.79 17.47 11.65 8.57
65.68 34.61 62.73 68.91 63.13 56.09 59.45 63.83 68.98 32.73 67.29 60.78 68.20 19.69 59.84 65.77 71.02 63.05 63.29 217.04 62.89 60.31 65.08 59.06 1312.03 57.81 55.16 63.98 56.56 56.56 65.63 88.09 31.96
12.94 17.05 12.67 17.17 8.96 14.55 13.23 12.13 13.58 14.89 11.79 14.55 12.23 17.82 16.36 8.84 10.54 10.30 13.70 9.26 10.68 16.37 16.48 10.89 10.13 13.10 11.59 14.38 13.49 13.49 12.34 7.41 5.33
1.3787 2.5037 1.0697 0.1632 1.2873 0.5585 1.0680 2.3057 0.8045 1.3775 5.0794 3.7379 3.4580 4.1411 3.8110 1.0882 0.3200 0.3472 2.6975 0.0678 1.7610 0.8575 2.3869 2.4558 0.0031 0.3084 1.3009 2.2334 3.0233 3.0233 1.7299 5.3265 5.8719
0.085 0.0066 0.1432 0.4353 0.0999 0.2886 0.1436 0.0112 0.7889 0.0851 0.0000 0.0001 0.0003 0.0000 0.0001 0.8609 0.6253 0.6356 0.0039 0.4730 0.0401 0.8038 0.0091 0.0076 0.5012 0.6209 0.0976 0.0135 0.0015 0.0015 0.0428 0.0000 0.0000
*
*
* * * * *
* * * *
* * * * * *
SD ¼ standard deviation. *p < 0.05.
Table 2 Demographic characteristics of infertile women (n ¼ 81). Ocpa
Edub
n
2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
2 5 6 3 4 2 5 3 4 1 2 5 6 3
21 11 4 6 2 15 2 3 1 2 1 4 8 1 81
Age (y)
Marriage historyc
Menarche age (y)
Appetited
Mean
SD
Mean
SD
1
%
2
%
2
%
3
%
4
%
5
%
29.14 29.27 31.50 32.00 33.50 30.93 34.00 28.00 31.00 32.00 27.00 34.00 29.25 31.00 30.34
4.05 3.41 0.58 3.22 6.36 5.16 2.83 1.00
14.81 14.27 13.25 14.17 13.50 14.33 12.50 15.00 14.00 13.50 16.00 14.00 14.00 14.00 14.28
1.33 1.01 0.96 2.04 2.12 1.45 0.71 1.00
19 11 4 6 2 15 2 3 1 2 1 4 8 1 79
23.46 13.58 4.94 7.41 2.47 18.52 2.47 3.7 1.23 2.47 1.23 4.94 9.88 1.23 97.53
2 0 0 0 0 0 0 0 0 0 0 0 0 0 2
2.47 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.47
1 0 0 0 0 1 0 0 0 0 0 0 0 0 2
1.23 0.0 0.0 0.0 0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.00 2.46
14 3 2 1 1 6 0 2 0 0 1 1 2 0 33
17.28 3.7 2.47 1.23 1.23 7.41 0.0 2.47 0.00 0.0 1.23 1.23 2.47 0.00 40.72
6 8 1 5 1 7 1 1 1 2 0 2 3 1 39
7.41 9.88 1.23 6.17 1.23 8.64 1.23 1.23 1.23 2.47 0.00 2.47 3.7 1.23 48.12
0 0 1 0 0 1 1 0 0 0 0 1 3 0 7
0.00 0.00 1.23 0.0 0.0 1.23 1.23 0.00 0.00 0.00 0.00 1.23 3.7 0.00 8.62
5.66 6.98 1.28 4.07
0.71 1.41 1.41 1.37
SD ¼ standard deviation. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Marriage history: 1 ¼ first marriage and 2 ¼ second marriage. d Appetite: 2 ¼ worse, 3 ¼ so-so, 4 ¼ good, and 5 ¼ excellent.
Menstrual characteristics of infertile women We investigated four menstrual factors in the infertile participants, including menstrual cycle, menstruation duration, menstruation volume, and dysmenorrhea (Table 3). As for the menstrual cycle, 83.95% of infertile women reported a regular menstrual cycle. Regarding menstruation duration, 97.51% of
infertile women reported completion of menstruation within a 7day period. For menstrual volume, 60.48% of infertile women reported a moderate menstruation volume. As for dysmenorrhea, 53.09% of infertile women reported no dysmenorrhea. Chi-square testing showed no significant differences in the distribution of these four physiological factors across the different levels of occupational intensity or education (Table 3).
f
e
d
Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). Menstrual cycle: 1 ¼ regular and 2 ¼ irregular. Menstruation duration: 1 ¼ < 5 days; 2 ¼ 5e7 days, and 3 ¼ > 7 days. Menstruation amount: 1 ¼ less, 2 ¼ moderate, and 3 ¼ more. Dysmenorrhea; 0 ¼ none, 1 ¼ light, 2 ¼ moderate, and 3 ¼ serious. c
a
b
% 3
0 0 0 0 0 1 0 1 0 0 0 0 1 0 3 9.87 3.70 0.00 2.46 2.46 1.23 0.00 0.00 0.00 0.00 0.00 1.23 2.46 1.23 24.69
% 2
8 3 0 2 2 1 0 0 0 0 0 1 2 1 20 6.17 3.7 1.23 1.23 0.0 4.94 0.0 0.0 0.0 0.0 0.0 0.0 1.23 0.0 18.5
% 1
5 3 1 1 0 4 0 0 0 0 0 0 1 0 15 9.877 6.173 3.704 3.704 0.0 11.11 2.469 2.469 1.235 2.469 1.235 3.704 4.938 0.0 53.09
% 0
8 5 3 3 0 9 2 2 1 2 1 3 4 0 43 3.7 3.7 1.23 1.23 0.0 2.47 0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 13.56
% 3
3 3 1 1 0 2 0 1 0 0 0 0 0 0 11 14.81 7.41 3.7 2.47 2.47 12.35 1.23 2.47 1.23 2.47 1.23 2.47 6.17 0.0 60.48
% 2
12 6 3 2 2 10 1 2 1 2 1 2 5 0 49 7.41 2.47 0.0 3.7 0.0 3.7 1.23 0.0 0.0 0.0 0.0 2.47 3.7 1.23 25.91
% 1
6 2 0 3 0 3 1 0 0 0 0 2 3 1 21 0 0 1.20 1.20 0 0 0 0 0 0 0 0 0 0 2.4
% 3
0 0 1 1 0 0 0 0 0 0 0 0 0 0 2 16.05 12.35 2.47 4.94 1.23 13.58 2.47 1.23 0.0 2.47 1.23 2.47 7.41 0.0 67.90
% 2
13 10 2 4 1 11 2 1 0 2 1 2 6 0 55 9.88 1.23 1.23 1.23 1.23 4.94 0.0 2.47 1.23 0.0 0.0 2.47 2.47 1.23 29.61 2 5 6 3 4 2 5 3 4 1 2 5 6 3 2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
1
%
2
%
1
%
Menstruation durationd Menstrual cyclec Edub
In this study, we conducted a cross-sectional study on 81 infertile women (age range: 23e41 years, mean age: 30.34 years) and 81
Ocpa
Discussion
Table 3 Menstrual characteristics of infertile women (n ¼ 81).
In order to compare QoL between infertile and fertile individuals, we collected data from the infertile women and their demographically matched fertile controls, all of whom were married and had given birth (Table 1). Overall, infertile women had significantly lower overall and comprehensive QoL scores, and a significantly higher anxiety score, compared with fertile controls. Moreover, infertile women showed a significantly higher score in the “level of independence” domain. Within this domain, infertile participants showed significantly higher scores in the “mobility”, “activities of daily living”, and “work capacity” facets, but a significantly lower score in the “dependence on medicinal substances and medical aids” facet. In addition, infertile participants showed a significantly lower score in the “spirituality/religion/personal beliefs” domain/facet. Infertile participants also showed significant differences from fertile controls in the following individual QoL facets ([ indicating a significant increase and Y indicating a significant decrease): [“pain and discomfort”, Y“self-esteem”, [“sexual activity”, [“freedom, physical safety and security”, Y“financial resources”, Y“health and social care: accessibility and quality”, and [“transport”.
8 1 1 1 1 4 0 2 1 0 0 2 2 1 24
Menstruation amounte
QoL comparison between infertile participants and fertile controls
4.90 2.50 0.00 1.20 0.00 2.50 0.00 1.20 1.20 0.00 1.20 0.00 1.20 0.00 15.9
Infertility was classified by type, reported reason, and diagnosis (Table 5). By type, 61.71% of infertile women reported primary infertility, while 38.26% reported secondary fertility. By reported reason, 81.47% of infertile women reported female infertility as the underlying reason for infertility. However, by diagnosis, 93.82% of infertile women held a female diagnosis of infertility. Chi-square testing showed a significant difference in infertility type across different levels of occupational intensity (p ¼ 0.012; Table 5), and the Kendall's tau-b (correlation coefficient) of 0.2450 showed a negative correlation between these two variables. Therefore, a higher reported occupational intensity was significantly correlated with a higher incidence of secondary infertility. Moreover, Chisquare testing showed a significant difference in the reported infertility reason across different levels of occupational intensity (p ¼ 0.017; Table 5), and the Kendall's tau-b (correlation coefficient) of 0.2163 showed a positive correlation between these two variables. Therefore, a higher reported occupational intensity was significantly correlated with a lower tendency to report female infertility as the underlying reason for infertility.
4 2 0 1 0 2 0 1 1 0 1 0 1 0 13
Dysmenorrheaf
Infertility characteristics of infertile women
20.99 11.11 4.94 6.17 2.47 16.05 2.47 2.47 0.0 2.47 0.0 4.94 8.64 1.23 83.95
Family stress in infertile participants was also assessed (Table 4). Approximately 53.06% of infertile women reported feeling stress from family life. In addition, 41.95% of infertile women reported that family stress had an effect on work, 28.37% of infertile participants reported that family stress had a lesser effect on work, and 13.56% of infertile participants reported a large impact on work. Chi-square testing showed a significant difference in the degree of family stress effect on work across different levels of education (p ¼ 0.026; Table 4), while the Kendall's tau-b (correlation coefficient) of 0.0294 showed a very low negative correlation between these two variables. Therefore, higher education levels in Chinese infertile women were significantly, but only marginally, correlated with a lower degree of effect of family stress upon work.
17 9 4 5 2 13 2 2 0 2 0 4 7 1 68
Family stress characteristics of infertile women
247
0.0 0.0 0.0 0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 0.0 1.23 0.0 3.69
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
248
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Table 4 Family stress characteristics of infertile women (n ¼ 81). Ocpa
2 2 2 2 2 3 3 3 3 3 1 1 1 1 Totals
Edub
2 5 6 3 4 2 5 3 4 1 2 5 6 3
Family stressc
Family stress effects on workd,*
0
%
1
%
1
%
2
%
3
%
4
%
5
%
8 3 3 3 2 7 0 2 1 1 0 3 5 0 38
9.88 3.7 3.7 3.7 2.47 8.64 0.0 2.47 1.23 1.23 0.0 3.7 6.17 0.0 46.89
13 8 1 3 0 8 2 1 0 1 1 1 3 1 43
16.05 9.88 1.23 3.7 0.0 9.88 2.47 1.23 0.0 1.23 1.23 1.23 3.7 1.23 53.06
5 0 0 1 0 3 0 0 0 0 0 1 2 0 12
6.17 0.0 0.0 1.23 0.0 3.70 0.0 0.0 0.0 0.0 0.0 1.23 2.47 0.0 14.8
3 5 2 2 2 2 1 1 1 0 0 1 3 0 23
3.7 6.17 2.47 2.47 2.47 2.47 1.23 1.23 1.23 0.0 0.0 1.23 3.7 0.0 28.37
11 0 2 3 0 9 1 1 0 2 1 1 2 1 34
13.58 0.0 2.47 3.7 0.0 11.11 1.23 1.23 0.0 2.47 1.23 1.23 2.47 1.23 41.95
2 5 0 0 0 1 0 1 0 0 0 1 1 0 11
2.47 6.17 0.0 0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 1.23 1.23 0.0 13.56
0 1 0 0 0 0 0 0 0 0 0 0 0 0 1
0.0 1.23 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.23
* Chi-square ¼ 33.9520, degrees of freedom ¼ 20, p ¼ 0.026; a significant difference in the degree of family stress effect on work across different levels of education. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Family stress: 0 ¼ no and 1 ¼ yes. d Family stress effects on work: 1 ¼ no effect, 2 ¼ less effect, 3 ¼ moderate effect, 4 ¼ large impact, and 5 ¼ extremely significant impact.
Table 5 Infertility characteristics of infertile women (n ¼ 81). Ocpa
Edub
1 1 1 1 2 2 2 2 2 3 3 3 3 3 Totals
2 3 5 6 2 3 4 5 6 1 2 3 4 5
Infertility type c,*
Reported infertility reasond,**
Infertility diagnosise
1
%
2
%
1
%
2
%
3
%
1
%
2
%
1 0 2 5 11 2 1 6 2 2 13 3 1 1 50
1.23 0.0 2.47 6.17 13.58 2.47 1.23 7.41 2.47 2.47 16.05 3.7 1.23 1.23 61.71
0 1 2 3 10 4 1 5 2 0 2 0 0 1 31
0.0 1.23 2.47 3.7 12.35 4.94 1.23 6.17 2.47 0.0 2.47 0.0 0.0 1.23 38.26
1 1 2 7 18 6 2 11 4 1 10 2 1 0 66
1.23 1.23 2.47 8.64 22.22 7.41 2.47 13.58 4.94 1.23 12.35 2.47 1.23 0.0 81.47
0 0 1 0 1 0 0 0 0 0 1 0 0 0 3
0.0 0.0 1.23 0.0 1.23 0.0 0.0 0.0 0.0 0.0 1.23 0.0 0.0 0.0 3.69
0 0 1 1 2 0 0 0 0 1 4 1 0 2 12
0.0 0.0 1.23 1.23 2.47 0.0 0.0 0.0 0.0 1.23 4.94 1.23 0.0 2.47 14.8
0 0 0 0 2 0 0 0 0 1 2 0 0 0 5
0.0 0.0 0.0 0.0 2.47 0.0 0.0 0.0 0.0 1.23 2.47 0.0 0.0 0.0 6.17
1 1 4 8 19 6 2 11 4 1 13 3 1 2 76
1.23 1.23 4.94 9.88 23.46 7.41 2.47 13.58 4.94 1.23 16.05 3.7 1.23 2.47 93.82
* Chi-square ¼ 8.8829, degrees of freedom ¼ 2, p ¼ 0.012; a significant difference in infertility type across different levels of occupational intensity. ** Chi-square ¼ 11.994, degrees of freedom ¼ 4, p ¼ 0.017; a significant difference in the reported infertility reason across different levels of occupational intensity. a Ocp: Occupational intensity (1 ¼ low, 2 ¼ moderate, and 3 ¼ high). b Edu: Educational level (1 ¼ primary, 2 ¼ middle, 3 ¼ senior, 4 ¼ technical school, 5 ¼ college/university, and 6 ¼ above university). c Infertility type: 1 ¼ primary and 2 ¼ secondary. d Infertility reason: 1 ¼ female, 2 ¼ male, and 3 ¼ both. e Infertility diagnosis: 1 ¼ male and 2 ¼ female.
demographically matched fertile controls to first determine their demographic, menstrual, family stress, and infertility characteristics and then applied the WHOQOL-100 to determine which factors are associated with significant QoL differences between these two cohorts. All infertile participants were married, with the vast majority (> 97%) in their first marriage. The majority of infertile participants reported relatively normal levels of appetite and a regular menstrual cycle of moderate volume, with menstruation completed within a 7day period and no dysmenorrhea. Approximately 50% of infertile participants reported stress from family life, with higher education levels significantly, but only marginally, correlating with a lower degree of the effect of family stress upon work. There was an approximately 60/40 split in primary and secondary infertility, with a higher occupational intensity significantly correlating with a
higher incidence of secondary infertility. Although 94% of infertile participants held a female diagnosis of infertility, only 81% of infertile participants reported female infertility as the underlying reason for infertility with a higher occupational intensity significantly correlating with a lower tendency to report female infertility as the underlying reason for infertility. Infertility and QoL Comparing QoL between infertile participants and fertile controls, infertile participants had significantly lower overall and comprehensive QoL scores compared with fertile controls. Moreover, infertile women showed a significantly higher score in the “level of independence” domain. Within this domain, infertile
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
participants showed significantly higher scores in the “mobility”, “activities of daily living”, and “work capacity” facets, but a significantly lower score in the “dependence on medicinal substances and medical aids” facet. In addition, infertile participants showed a significantly lower score in the “spirituality/religion/personal beliefs” domain/facet. Infertile participants also showed significantly higher “pain and discomfort”, significantly lower “self-esteem”, significantly higher “sexual activity”, significantly higher “freedom, physical safety and security”, significantly lower “financial resources”, significantly lower “health and social care: accessibility and quality”, and significantly higher “transport”. In agreement with the current findings, mounting research across a host of countries that applied various QoL instruments indicates that non-PCOS-, nonendometriosis-based female infertility is associated with lower measures of QoL. For example, in a caseecontrol study administering the 36-item Short-Form Health Survey (SF-36), 100 primary infertile Tunisian women undergoing reproductive technology displayed lower mental and physical dimension scores and lower vitality, social functioning, roleemotional, and mental health scores than fertile female controls [15]. Moreover, in another study using the Tuebingen QoL and the COPE questionnaires, infertile Australian women seeking traditional Chinese medicine fertility therapy reported a lower QoL due to high levels of distress, guilt, grief, and frustration caused by infertility [16]. In addition, WHOQOL-100 data derived from 199 infertile German couples showed that high scores on “suffering from childlessness” went along with lower satisfaction on “physical” and “psychological” QoL domains for the infertile women [17]. Additionally, a meta-analysis of 14 studies showed that infertile women had significantly lower QoL scores on mental health, social functioning, and emotional behavior compared with fertile controls [18]. Although our current findings of lower QoL scores in spirituality/religion/personal beliefs, self-esteem, financial resources, and accessibility and quality to health and social care, as well as increased pain and discomfort QoL scores concord with the previously cited findings of lower psychological, mental health, emotional, social functioning, and physical QoL scores in infertile women, our WHOQOL-100-based analysis reveals that Chinese infertile women also experience positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety and security, and transport. We infer that the positive QoL adjustments in mobility, daily living activities, work capacity, sexual activity, and freedom may be caused by the state of childlessness (which allows for a more independent mode of living), personality changes in reaction to infertility, and/or changes to internal motivation to compensate for the infertile state. Moreover, we infer that the positive QoL adjustments in physical safety and security and transport may be due to the higher disposable income available from being childless, which would allow for increased spending on safer neighborhoods and superior transportation methods. Further research is needed to address these hypotheses. Infertility and anxiety In addition, this study revealed that infertile participants also had a significantly higher anxiety score compared with fertile controls. The prevalence of anxiety and/or depression symptoms in infertile patients has been assessed across several countries. In China, analysis of anxiety and depression in 130 infertile mainland Chinese women revealed the presence of such symptoms in 83.8% of infertile women with moderate-to-severe symptoms in 52% of infertile women; moreover, in a similar Hong Kong-based study, 33% of infertile women showed anxiety or depression symptoms [19,20]. In Iran, a cross-sectional showed 40.8% depression and
249
86.8% anxiety in infertile women [21]. In Europe, a Spanish study showed that 67% of infertile women suffered from anxiety [22], and a multicenter study in The Netherlands, Belgium, and France revealed that infertile women showed higher scores on scales for depressed mood, memory/concentration, anxiety, and fears, with 24.9% of these infertile patients meeting the diagnostic criteria for a depressive disorder [23]. These increased anxiety and depression symptoms in infertile women may have a relationship with their lower QoL scores. For instance, a Dutch study examining the relationship between emotional distress as measured by the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL) questionnaire statistically demonstrated a negative relationship between QoL and anxiety and depression in infertile women [24]. Study limitations There are several limitations to the current study. First, the present study was limited by a relatively small sample size (n ¼ 81 in each group) and was limited to one center in central China; a larger sample size derived from multiple centers across China would have been preferable for a cross-sectional study. However, our sample size was sufficient to reach thematic saturation, and our findings are consistent with other QoL studies. Second, as all infertile participants in this study were seeking fertility treatment, self-selection bias limits the generalizability of our findings; those infertile women who were not seeking or had quit pursuing fertility therapy are not represented here. Third, the mean duration of infertility was not assessed in the present study. Fourth, WHOQOL100 questionnaire responses were not validated by follow-up interviews. Conclusion Married infertile Chinese women had significantly lower overall and comprehensive QoL scores, as well as higher anxiety scores, compared with fertile controls. Infertile women showed lower QoL scores in the facets of spirituality/religion/personal beliefs, selfesteem, financial resources, and accessibility and quality to health and social care, as well as increased pain and discomfort while also experiencing positive QoL adjustments in terms of mobility, daily living activities, work capacity, sexual activity, freedom, physical safety and security, and transport. We infer that the positive QoL adjustments in mobility, daily living activities, work capacity, sexual activity, and freedom may be caused by the state of childlessness (which allows for a more independent mode of living), personality changes in reaction to infertility, and/or changes to internal motivation to compensate for the infertile state. Moreover, we infer that the positive QoL adjustments in physical safety and security and transport may be due to the higher disposable income available from being childless, which would allow for increased spending on safer neighborhoods and superior transportation methods. Further research is needed to address these hypotheses. Conflicts of interest The authors have no conflicts of interest relevant to this article. Acknowledgments Su Xiaoli, Bao Junjun, Wei Zhaoli, and He Xiaojin conceived and designed the experiments. Li Mei, Quan Ju, Sun Wanli, Wang Jin, Zhao Huali, Jin Li, Li Dong, and Pan Li carried out data collection. Ding Shu analyzed the data. Su Xiaoli wrote the manuscript. Bao
250
S. Xiaoli et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 244e250
Junjun critically revised the manuscript. Su Xiaoli and Bao Junjun supervised the study.
Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.tjog.2015.06.014.
References [1] Practice Committee of American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril 2013;99:63. http://dx.doi.org/10.1016/j.fertnstert.2012.09.023. [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;22:1506e12. [3] Greil AL, Slauson-Blevins K, McQuillan J. The experience of infertility: a review of recent literature. Sociol Health Illn 2010;32:140e62. [4] Boivin J, Griffiths E, Venetis CA. Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies. BMJ 2011;342:d223. http://dx.doi.org/10.1136/ bmj.d223. [5] Chochovski J, Moss SA, Charman DP. Recovery after unsuccessful in vitro fertilization: the complex role of resilience and marital relationships. J Psychosom Obstet Gynaecol 2013;34:122e8. [6] Verhaak CM, Smeenk JM, Evers AW, Kremer JA, Kraaimaat FW, Braat DD. Women's emotional adjustment to IVF: a systematic review of 25 years of research. Hum Reprod Update 2007;13:27e36. [7] Skevington SM, Lotfy M, O'Connell KA. The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res 2004;13:299e310. [8] Newton CR, Sherrard W, Glavac I. The Fertility Problem Inventory: measuring perceived infertility-related stress. Fertil Steril 1999;72:54e62. [9] Colwell HH, Mathias SD, Pasta DJ, Henning JM, Steege JF. A health-related quality-of-life instrument for symptomatic patients with endometriosis: a validation study. Am J Obstet Gynecol 1998;179:47e55. [10] Malik-Aslam A, Reaney MD, Speight J. The suitability of polycystic ovary syndrome-specific questionnaires for measuring the impact of PCOS on quality of life in clinical trials. Value Health 2010;13:440e6.
[11] Boivin J, Takefman J, Braverman A. The fertility quality of life (FertiQoL) tool: development and general psychometric properties. Hum Reprod 2011;26: 2084e91. [12] The WHOQOL Group. The World Health Organization Quality of Life assessment (WHOQOL). Position paper from the World Health Organization. Soc Sci Med 1995;41:1403e9. [13] The WHOQOL Group. The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998;46:1569e85. [14] Power M, Harper A, Bullinger M. The World Health Organization WHOQOL100: tests of the universality of quality of life in 15 different cultural groups worldwide. Health Psychol 1999;18:495e505. [15] El Kissi Y, Amamou B, Hidar S, Ayoubi Idrissi K, Khairi H, Ali BB. Quality of life of infertile Tunisian couples and differences according to gender. Int J Gynaecol Obstet 2014;125:134e7. [16] Ried K, Alfred A. Quality of life, coping strategies and support needs of women seeking Traditional Chinese Medicine for infertility and viable pregnancy in Australia: a mixed methods approach. BMC Womens Health 2013;13:17. http://dx.doi.org/10.1186/1472-6874-13-17. [17] Herrmann D, Scherg H, Verres R, von Hagens C, Strowitzki T, Wischmann T. Resilience in infertile couples acts as a protective factor against infertilityspecific distress and impaired quality of life. J Assist Reprod Genet 2011;28: 1111e7. [18] 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;31:101e10. [19] Lok IH, Lee DT, Cheung LP, Chung WS, Lo WK, Haines CJ. Psychiatric morbidity amongst infertile Chinese women undergoing treatment with assisted reproductive technology and the impact of treatment failure. Gynecol Obstet Invest 2002;53:195e9. [20] Lu Y, Yang L, Lu G. Mental status and personality of infertile women. Zhonghua Fu Chan Ke Za Zhi 1995;30:34e7 [In Chinese]. [21] Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M, et al. A survey of relationship between anxiety, depression and duration of infertility. BMC Womens Health 2004;4:9. http://dx.doi.org/10.1186/14726874-4-9. [22] Guerra D, Llobera A, Veiga A, Barri PN. Psychiatric morbidity in couples attending a fertility service. Hum Reprod 1998;13:1733e6. [23] Oddens BJ, den Tonkelaar I, Nieuwenhuyse H. Psychosocial experiences in women facing fertility problemsea comparative survey. Hum Reprod 1999;14:255e61. [24] Aarts JW, van Empel IW, Boivin J, Nelen WL, Kremer JA, Verhaak CM. Relationship between quality of life and distress in infertility: a validation study of the Dutch FertiQoL. Hum Reprod 2011;26:1112e8.