Depression: an emotional obstacle to seeking medical advice for infertility

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1 SYCHOLOGICAL FACTORS Depression: an emotional obstacle to seeking medical advice for infertility Danielle L. Herbert, M.Sc., Jayne C. Lucke, h.d., and Annette J. Dobson, h.d. School of opulation Health, University of Queensland, Brisbane, Queensland, Australia Objective: To investigate the mental and general health of infertile women who had not sought medical advice for their recognized infertility and were therefore not represented in clinical populations. Design: Longitudinal cohort study. Setting: opulation based. atient(s): articipants in the Australian Longitudinal Study on Women s Health aged years in 2006 who had ever tried to conceive or had been pregnant (n ¼ 5,936). Intervention(s): None. Main Outcome Measure(s): Infertility, not seeking medical advice. Result(s): Compared with fertile women (n ¼ 4,905), infertile women (n ¼ 1,031) had higher odds of self-reported depression (odds ratio [OR] 1.20, 95% confidence interval [CI] ), endometriosis (5.43, ), polycystic ovary syndrome (9.52, ), irregular periods (1.99, ), type II diabetes (4.70, ), or gestational diabetes (1.66, ). Compared with infertile women who sought medical advice (n ¼ 728), those who had not sought medical advice (n ¼ 303) had higher odds of self-reported depression (1.67, ), other mental health problems (3.14, ), urinary tract infections (1.67, ), heavy periods (1.63, ), or a cancer diagnosis (11.33, ). Infertile women who had or had not sought medical advice had similar odds of reporting an anxiety disorder or anxiety-related symptoms. Conclusion(s): Women with self-reported depression were unlikely to have sought medical advice for infertility. Depression and depressive symptoms may be barriers to seeking medical advice for infertility. (Fertil Steril Ò 2010;94: Ó2010 by American Society for Reproductive Medicine.) Key Words: Infertility, medical advice, depression, anxiety disorder, mental health, women, obesity, chronic disease Most women of reproductive age who desire to have children are able to conceive. For the minority, however, conception is difficult and may not be achieved without the use of assisted reproductive technologies (ART). Worldwide estimates of the prevalence of infertility and the proportions of infertile couples who seek medical advice have been described (1). Earlier research on infertility prevalence in Australia at the population level has been limited to two studies: reproductive disability in metropolitan Western Australia (2) and infertility within a case-control study of ovarian cancer (3). Most recently, an infertility prevalence of 17% has been reported for Australian women aged years who had ever tried to conceive or had been pregnant (4). The mental health of infertile couples affects their ability to cope with treatment, pregnancy, and parenting after successful treatment Received August 7, 2009; revised October 2, 2009; accepted October 29, 2009; published online January 4, D.H. has nothing to disclose. J.L. has nothing to disclose. A.D. has nothing to disclose. Based on research conducted as part of the Australian Longitudinal Study on Women s Health at the University of Queensland and University of Newcastle. Reprint requests: Danielle L. Herbert, M.Sc., School of opulation Health, University of Queensland, ublic Health Building, Herston, Brisbane QLD 4006 Australia (FAX: þ ; d.herbert@sph.uq.edu.au). (5, 6). Those findings refer to infertile women and their partners recruited from clinical populations. Research is lacking, however, on the mental and general health of infertile women who have not sought medical advice for their infertility and who are therefore not represented in clinical populations. The Australian Longitudinal Study on Women s Health (ALSWH) provides a unique opportunity to explore the mental and general health status of infertile women aged %33 years who are potentially in their prime reproductive years. Among these women, those who have recognized infertility but have not sought medical advice can be identified and compared with those who have sought medical advice. The risk of infertility, however, is increased for overweight and obese women (7, 8), and studies need to account for body mass index (BMI). The present study explores the associations between seeking any type of medical advice for infertility and mental health, reproductive, metabolic, and physical factors. MATERIALS AND METHODS Study Design The present study is focused on the youngest cohort of women who participated in the ALSWH: women born in The ALSWH is a broadranging longitudinal examination of the impact of reproductive, physiologic, and social factors on women s health. In 1996, Australian women from three /$36.00 Fertility and Sterility â Vol. 94, No. 5, October doi: /j.fertnstert Copyright ª2010 American Society for Reproductive Medicine, ublished by Elsevier Inc.

2 age cohorts (born in , , and ) were selected from the national health insurance (Medicare) database, which contains names and addresses of all Australian citizens and permanent residents (9). Random sampling of the population was undertaken, with intentional oversampling of women living in rural and remote areas. articipants were recruited through a mailed invitation and have responded to mailed surveys every 3 4 years after the first survey of each cohort in 1996 (10). The methodology for the ALSWH has been described fully elsewhere, and the study has ethical approval from the Human Research Ethics Committees of the Universities of Queensland and Newcastle (9, 10). articipants At survey 1 (S1) in 1996, the participants were aged years (n ¼ 14,247), and they have been resurveyed up to three times: when they were aged years at survey 2 (S2, 2000; n ¼ 9,688), years at survey 3 (S3, 2003; n ¼ 9,081), and years at survey 4 (S4, 2006; n ¼ 9,145). Among S4 participants, 74.8% responded to all four surveys (n ¼ 6,840), 9.0% to S1, S2, and S4 (n ¼ 822), 9.9% to S1, S3, and S4 (n ¼ 906), and 6.3% to S1 and S4 (n ¼ 577) (11). The attrition of participants has been described elsewhere (12). Outcome Measures: Infertility, Not Seeking Medical Advice The term infertility throughout this study describes women who had reported difficulties conceiving at S4. The format of the survey question on infertility was consistent with the clinical definition of infertility, i.e., trying for >12 months without spontaneous conception (13). At S4, participants were asked, Have you and your partner (current or previous) ever had problems with fertility, that is, tried unsuccessfully to get pregnant for 12 months or more? articipants were asked to choose only one response from four options: a) no, never tried to get pregnant ; b) no, had no problem with fertility ; c) yes, but have not sought help/treatment ; d) yes, and have sought help/treatment. Survey 4 did not include any questions on the types of advice. For the first outcome, infertility, participants who indicated that they had experienced infertility (answered yes to question c or d) were compared with those without infertility (b: no problems) (4). For the second outcome, medical advice, infertile participants who sought help/treatment were categorized as sought medical advice and compared with those who had not sought medical advice (4). Study Variables Mental health was examined at S4. Self-reported depression was measured by the Center for Epidemiologic Studies Depression Scale (CES-D10), a shortened version of the original 20-item scale with 10 items and 4-point response options (14). A CES-D10 score of R10 is indicative of clinical depression. A further two survey questions examined conditions and symptoms related to depression or anxiety disorders. articipants were asked whether they had been diagnosed with a medical condition within the preceding 3 years in a single survey question that listed 19 conditions. These conditions were categorized as: mental health (depression [not postnatal], anxiety disorder, postnatal depression, other major mental illness); reproductive (endometriosis, polycystic ovary syndrome [COS], urinary tract infection [UTI], sexually transmitted infection [e.g., chlamydia, genital herpes]); and metabolic/physical (insulin-dependent [type I] diabetes, noninsulin-dependent [type II] diabetes, gestational diabetes [during pregnancy], heart disease, hypertension during pregnancy, hypertension other than during pregnancy, low iron, asthma, bronchitis, cancer, other major physical illness). A lifetime diagnosis (ever) of depression (not postnatal), anxiety disorder, or postnatal depression was determined by examining responses to similar questions in S2 (preceding 4 years, >4 before), S3 (preceding 3 years), and S4 (preceding 3 years). In a separate question, participants were asked about 22 symptoms experienced within the preceding 12 months. These symptoms were categorized as: mental health (difficulty sleeping, depression, episodes of intense anxiety [e.g., panic attacks], other mental health problems); reproductive (vaginal discharge or irritation, premenstrual tension, irregular periods, heavy periods, severe period pain); and metabolic/physical (allergies/hay fever/sinusitis, headaches/migraines, severe tiredness, stiff/painful joints, back pain, problems with one or both feet, urine that burns or stings, leaking urine, constipation, hemorrhoids/piles, other bowel problems, skin problems, heart palpitations). articipants were offered four response options: no, rarely, sometimes, or often. The responses sometimes or often were categorized as indicating a symptom suffered regularly. Sociodemographic factors included age at participation in the survey and highest qualification (high school only, trade/certificate/diploma, university). articipants postcodes were classified by their area of residence (major city, inner regional, outer regional/remote) (15). articipants reported their height and weight at S4; women who were pregnant at S4 reported their prepregnancy weight. Self-reported height and weight were used to calculate BMI using the formula: weight (kg)/height (m) 2. The BMI was categorized according to the World Health Organization classification (16): underweight, BMI <18.5; healthy weight, 18.5 % BMI < 25.0; overweight, 25.0 % BMI < 30.0; obese, BMI R30.0. The frequencies for these sociodemographic factors have been described elsewhere (4). Analytic Approach The selection criterion for inclusion in the analysis was that women had ever tried to conceive or had been pregnant (n ¼ 5,936). Women who met this criterion were able to report on their fertility status. To take account of the oversampling of rural and remote women, results reported as percentages were based on weighted data, and regression models included adjustment for area of residence. The odds ratios (ORs) of infertility or not seeking medical advice, adjusted for age, highest qualification, area of residence, and BMI at S4, were estimated by multivariable logistic regression models. Using backward selection at <.05 in a fully adjusted model, a parsimonious multivariable model was identified with only those factors that remained statistically significant. Data analysis was conducted using SAS software, version 9.2 (TS1M0) of the SAS System for Windows (SAS Institute, Cary, NC). RESULTS Among 5,936 women aged years who had tried to conceive or had been pregnant, 17.3% (n ¼ 1,031) had infertility, and 28.3% (n ¼ 303) of these women had not sought medical advice for their recognized infertility. The examination of the mental health of infertile women and those who had not sought medical advice included reproductive and metabolic/physical factors deemed to be potential confounders with depression, anxiety, or associated symptoms. Adjustment of the results for BMI accounted for the impact of overweight and obesity on endocrine factors affecting infertility and chronic disease. The most significant factors associated with infertility or not seeking medical advice were identified by the parsimonious multivariable logistic regression models. Comparisons were made between fertile women and infertile women and the proportions reporting the medical condition (<3 years) or symptom (<12 months), adjusted for age, highest qualification, area of residence, and BMI (Table 1). Compared with fertile women (n ¼ 4,905), infertile women (n ¼ 1,031) had higher odds of self-reported depression, i.e., CES-D10 R 10 (OR 1.27, 95% CI ), having ever had a diagnosis of depression (1.21, ), endometriosis (6.11, ), COS (12.47, ), premenstrual tension (1.19, ), irregular periods (2.74, ), heavy periods (1.67, ), severe period pain (1.77, ), type II diabetes (5.58, ), gestational diabetes (1.86, ), high blood pressure (1.65, ), another major physical illness (1.38, ), and headaches (1.16, ). In contrast, infertile women had lower odds of having hemorrhoids (0.70, ) and leaking urine (0.75, ) compared with fertile women. Fertile and infertile women had similar odds of anxiety disorders or having symptoms of anxiety Herbert et al. Depression: an obstacle to infertility advice Vol. 94, No. 5, October 2010

3 TABLE 1 Associations between infertility among women aged years and medical conditions and symptoms. Infertile (n [ 1,031), % Fertile (n [ 4,905), % Adjusted OR b value a OR (95% CI) arsimonious multivariable OR c value OR (95% CI) value Mental health Depression ( ) ( ).04 (CES-D10 R 10) Depression d ( ).2 Depression ever e ( ) ( ) ( ).02 mental illness d Depressive ( ).2 symptoms f Other mental health ( ).6 problems f Reproductive Endometriosis d < ( ) < ( ) <.0001 olycystic ovary < ( ) < ( ) <.0001 syndrome d Urinary tract ( ).3 Sexually transmitted ( ).07 remenstrual tension f ( ).02 Irregular periods f < ( ) < ( ) <.0001 Heavy periods f < ( ) <.0001 Severe period pain f < ( ) <.0001 Metabolic/physical Diabetes type I d ( ) 0.2 Diabetes type II d < ( ) < ( ).002 Gestational diabetes d ( ) ( ).01 High B d ( ) 0.02 Heart disease d ( ) ( ).01 Low iron d ( ) ( ).002 Cancer d ( ) ( ) 0.02 physical illness d Headaches f ( ) 0.04 Hemorrhoids f ( ) ( ).007 Leaking urine f ( ) ( ).02 Note: B ¼ blood pressure; CI ¼ confidence interval; OR ¼ odds ratio. a Chi-squared test to compare proportions. b Wald test from logistic regression model (adjusted for age, highest qualification, area of residence, and body mass index). Reference categories: fertile; not reporting the condition/symptom. c Wald test from parsimonious logistic regression model with backward selection at <.05; fully adjusted model. d Diagnosed <3 years preceding. e Ever had diagnosis. f Recurrent symptom <12 months preceding. Herbert. Depression: an obstacle to infertility advice. Fertil Steril From the parsimonious model comparing fertile and infertile women, the most significant factors associated with infertility were self-reported depression (OR 1.20, 95% CI ), endometriosis (5.43, ), COS (9.52, ), irregular periods (1.99, ), type II diabetes (4.70, ), and gestational diabetes (1.66, ). In contrast, the most significant factors not associated with infertility were another major mental illness (0.22, ), heart disease (0.05, ), low iron (0.73, ), hemorrhoids (0.70, ), and leaking urine (0.74, ). Comparisons were made between infertile women who had (n ¼ 728) or had not (n ¼ 303) sought medical advice (Table 2). Compared with infertile women who had sought medical advice, those who had not sought medical advice had higher odds of self-reported depression (OR 1.65, 95% CI ), depressive symptoms (1.60, ), other mental health problems (3.16, ), and being diagnosed with UTI (1.55, ). Furthermore, those who had not sought medical advice had lower odds of endometriosis (0.22, ), COS (0.22, ), and gestational diabetes (0.37, ). Infertile women who had or had not sought medical advice had similar odds of anxiety disorders or having symptoms of anxiety. From the parsimonious model comparing infertile women who sought medical advice and those who had not sought medical advice, the most significant factors associated with not seeking medical advice were self-reported depression (OR 1.67, 95% CI ), other mental health problems (3.14, ), being diagnosed with UTI (1.67, ), heavy periods (1.63, ), and Fertility and Sterility â 1819

4 TABLE 2 Associations between infertility among women aged years who had not sought medical advice and medical conditions and symptoms. No advice Sought advice (n [ 303), % (n [ 728), % Adjusted OR b value a OR (95% CI) arsimonious multivariable OR c value OR (95% CI) value Mental health Depression (CES-D10 R 10) ( ) ( ) Depression d ( ) 0.3 Depression ever e ( ) ( ) 0.05 mental illness d Depressive symptoms f ( ) Other mental < ( ) 0.01 health problems f Reproductive Endometriosis d < ( ) < ( ) < olycystic ovary < ( ) < ( ) < syndrome d Urinary tract ( ) ( ) 0.01 Sexually transmitted ( ) 0.7 remenstrual tension f ( ) 0.05 Irregular periods f ( ) 0.05 Heavy periods f ( ) ( ) Severe period pain f ( ) 0.4 Metabolic/physical Diabetes type I d ( ) 1.0 Diabetes type II d ( ) 0.3 Gestational diabetes d ( ) ( ) 0.04 High B d ( ) 0.8 Heart disease d g Low iron d ( ) 0.8 Cancer d ( ) ( ) ( ) 0.07 physical illness d Headaches f ( ) ( ) 0.01 Hemorrhoids f ( ) 0.9 Leaking urine f ( ) 0.6 Note: Abbreviations as in Table 1. a Chi-squared test to compare proportions. b Wald test from logistic regression model (adjusted for age, highest qualification, area of residence, and body mass index). Reference categories: fertile; not reporting the condition/symptom. c Wald test from parsimonious logistic regression model with backward selection at <.05; fully adjusted model. d Diagnosed <3 years preceding. e Ever had diagnosis. f Recurrent symptom <12 months preceding. g Cannot be estimated, owing to small frequencies. Herbert. Depression: an obstacle to infertility advice. Fertil Steril a cancer diagnosis (11.33, ). In contrast, for infertile women the most significant factors not associated with not seeking medical advice were endometriosis (0.15, ), COS (0.17, ), gestational diabetes (0.39, ,) and headaches (0.66, ). DISCUSSION Among women aged years in the general population, those who reported infertility were more likely to have self-reported depression and medically diagnosed chronic metabolic and reproductive conditions. Infertile women who had not sought medical advice for their recognized infertility were more likely to have reported depression or other underlying mental health issues. Depression and symptoms of other mental health problems may be barriers to seeking medical advice for infertility. The strength of the present study is the heterogeneity of women who participated in the ALSWH. The data were provided by women with a range of reproductive histories who had been surveyed longitudinally over 10 years (11); the reproductive histories and 1820 Herbert et al. Depression: an obstacle to infertility advice Vol. 94, No. 5, October 2010

5 sociodemographic factors have been described elsewhere (4). Strengths in the results include the capacity to profile the mental and general health of women who do not seek medical advice and are, therefore, not represented in clinical populations. Adjustment of the results for age and highest qualification accounted for the impact of these sociodemographic factors on access to medical advice for infertility (4). Additional adjustment for area of residence was used first to account for the sampling of initial participants. This adjustment was also important because the participants have varying geographic access to medical advice for infertility and treatment, because fertility centers are typically located in metropolitan areas of Australia. Women with infertility who reside in regional and remote areas of Australia may have sporadic access to regional fertility units and typically need to travel to a major city to access fertility specialists. The BMI was used in the logistic regression models to account for the confounding issue of overweight and obesity, because the impact of BMI on fertility is multidirectional. Chronic disease is confounded by obesity and further affects women s fertility and responses to hormonal/ivf treatments (17). The present findings indicated that medical conditions affected by high BMI, i.e., COS, diabetes, and high blood pressure, were also associated with infertility. Because the participants were aged %33 years, these findings were unlikely to be biased by the confounding effect of age. As women become older, the detrimental impact of increasing age (R35 years) on fertility is well established (18). From the present study, the associations between medical conditions and infertility can be explored before any increases in prevalence associated with increasing age. As women age beyond 35 years and experience more infertility, there may be changes to the association with depression and other mental health issues. For infertile women diagnosed with the chronic reproductive conditions of endometriosis or COS, it is unclear whether they were diagnosed with either condition before seeking medical advice for infertility or as a diagnosis consequent to infertility investigations. Furthermore, because this time order could not be identified, it is possible for any medical condition to have been diagnosed before or after seeking medical advice for infertility. In contrast, recurrent symptoms of hemorrhoids and leaking urine were associated with being fertile and suggested that many of these fertile women had undergone childbirth. The present study found that infertile women were more likely to have not sought medical advice for infertility if they also had selfreported depression or symptoms of depression or other mental health problems. However, participants who reported a medical diagnosis of depression or other major mental illnesses in <3 years were no more likely to have sought medical advice for infertility. This inconsistency suggested that women who had sought medical advice for their depression, and had been medically diagnosed, were equally likely to have or to have not sought medical advice for their infertility. In Australia, most people with mental health issues do not seek advice from health professionals (19). Similarly, the Australian National Fertility Study (in 2006) showed that fewer than half of women with recognized infertility actually sought medical advice (20). The findings from the present study showed almost three-fourths (72%) of infertile women had sought medical advice. For the remaining 28% of infertile women who had not sought medical advice, these findings supported the association between depression and infertility for those not included in clinical populations. For women in their prime reproductive years, infertility and depression appear to be comorbid conditions. Depression and depressive symptoms may be barriers to seeking medical advice for recognized infertility. Further research is needed to explore how depression manifests as a barrier to seeking medical advice for infertility. Depression may prevent infertile women from seeking medical advice at a younger age, when there is a higher chance of successful fertility treatment. Acknowledgments: The Australian Longitudinal Study on Women s Health is conducted by a research team at the Universities of Queensland and Newcastle. We are grateful to the women who participated in the study and the Australian Government Department of Health and Ageing for funding. REFERENCES 1. Boivin J, Bunting L, Collins JA, Nygren KG. Internationalestimates ofinfertilityprevalenceand treatmentseeking: potential need and demand for infertility medical care. Hum Reprod 2007;22: Webb S, Holman D. 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