CHAPTER V RESULTS AND DISCUSSION

Transcription

1 CHAPTER V RESULTS AND DISCUSSION In this chapter the results are presented and discussed systematically under the following sections keeping in view the objectives and hypotheses of the study. 5.1 This section deals with the frequency and per cent distribution of the demographic variables of infertile women such as age, educational status, religion, occupation, type of family, type of marriage, and years of infertility. 5. This section deals with the frequency and per cent distribution of the biological variables of infertile women such as menstrual cycle pattern, sexual Pattern, ovulation, causes, investigations, treatment for female infertility and semen characteristics of husband. 5.3 The mean and standard deviation including the frequency and per cent of the level of psychological variables of quality of life, self-concept, anxiety, depression, and stress in infertile women are presented under this section. 5. The mean and standard deviation including the frequency and per cent of the social variables in terms of the marital adjustment between the husband and wife and the family support of infertile women. 5.5 The mean and standard deviation including the frequency and per cent of the health behaviour of infertile women through their attitude towards treatment options and treatment seeking behaviour sequential tracking, back tracking, paralleling, taking a break and withdrawal. 5. This section presents the association between demographic variables and psycho-social and health behavioural variables of infertile women. 5.7 This section presents the association between biological variables and psychosocial and health behavioural variables of infertile women. 5. The inter correlation between the psycho-social variables and health behavioural variables of infertile women are presented in this section. 99

2 5.9. The prediction of variance between the psycho-social and health behavioural variables are reported in this section. 5.. The prediction of the variance of demographic, biological, psycho-social and health behavioural variables upon the self-concept in infertile women is presented in this section Demographic Variables of Infertile Women This section deals with the frequency and per cent distribution of the demographic variables of infertile women such as age, educational status, religion, occupation, type of family, type of marriage, and years of infertility. 0

3 Table. Frequency and Percentage Distribution of Demographic Variables of Infertile Women. (N=00) Variables Frequency Per cent 1. Age (in years) < > Educational status High school Higher Secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage Non consanguineous Consanguineous 19 9 The data presented in Table. shows that 3 per cent of infertile women were in the age group of -30 years and 30 per cent were between years and only.5 per cent of infertile 1

4 women were above 1 years of age. It is well documented that there is diminished fertility with increasing age. A woman reaches her maximum fertility potential at age when there is per cent of chances to conceive within 1 months. By the time age fertility potential begins to decline to 3 per cent and by age the decline accelerates to 5 per cent. Pregnancy is almost impossible after age 5. (Carcio 1999). This is due to variety of factors. Oocyte factors are mainly responsible. There is a decline in ovarian reserve accompanied by unresponsiveness of the follicles to gonadotropic stimulation. There is little ageing effect on the uterus and with hormonal supplementation the uterus can support a pregnancy even in fifties. (Scott & Hoffman 1995). In the present study only.5 per cent of infertile women were above 1 years and others have better chances to conceive. The age related fertility potential facts can be used during counseling to strengthen the hope in infertile women to conceive. The educational status of infertile women in this study was almost equally distributed at high school (7%), higher secondary (35%) and graduate (3%) levels. None of them were illiterate. As the women are educated it is easy to disseminate the information related to infertility through self instructional modules and their doubts can be cleared especially when there is shortage of nurses and lack of time availability for the healthcare team to educate the women. A majority of the infertile women were Hindu (%). The country itself is a Hindu predominant country and it is natural to have more participants from Hindu religion. At the same time the cultural view of infertility must be best understood by the healthcare team members involved in the care of infertile women to render them culturally sensitive care. Especially in a Hindu society the blame on infertility is squarely laid on women. In this study a majority of the infertile women were housewives (3%). Being majority of them as housewives will be helpful to attend the infertility clinics regularly as recommended by the physician. Whereas the employed women will find it difficult to sequentially track the

5 treatment regimens as most of the regimens need them to come daily for monitoring the follicular growth during the first 1 1 days of the menstrual cycle. The infertile women in the present study were living in nuclear families (75%).The change in societal living resulted in most of the women living in nuclear families now than ever before. Education and employment opportunities outside the home town often results in nuclear families. Living in nuclear families may facilitate better privacy for the couples and avoid pressure from family members to conceive. It was found that 9 per cent of them were married non-consanguineously. To notice that a majority of the infertile women are married non-consanguineously it shows that the public are aware of the harmful effects of consanguineous marriage. Figure depicts that most of the infertile women were suffering for years of infertility. The number of women attending the infertility clinic with longer duration of infertility may be less because of the failure rates of treatment taken might have demotivated the women to continuously attend the infertility clinic. 3

6 Fig. Frequency and Percentage Distribution of Years of Infertility 5.. Biological Variables of Infertile Women This section deals with the frequency and percentage distribution of the biological variables of infertile women such as menstrual cycle pattern, sexual Pattern, ovulation, semen characteristics of husband, causes, investigations, and treatment for female infertility.

7 Table. 3 Frequency and Percentage Distribution of Biological Variables of Infertile Women. (N=00) Variables Frequency Percentage 1. Menstrual cycle Pattern Regular Irregular Sexual pattern Adequate Inadequate Ovulation Ovulatory Anovulatory Causes Ovulatory Tubal Uterine Any other Ovulatory & Tubal Ovulatory & Uterine Ovulatory & Any other Tubal & Uterine Tubal & Any other Ovulation, Tubal & Uterine Investigations Hormonal studies Follicular studies Laparoscopy Hormonal studies & Follicular studies Hormonal studies &Laparoscopy Hormonal studies & Endometrial biopsy Follicular studies & Laparoscopy Endometrial Biopsy & Laparoscopy

8 Hormonal studies, Follicular studies & Laparoscopy Follicular studies, Endometrial Biopsy & Laparoscopy Hormonal studies, Follicular studies, Endometrial Biopsy & Laparoscopy.Treatment Ovulation induction IUI Donor IVF ICSI Husband Any other 7. Semen characteristics Normal Oligozoospermia Asthenozoospermia Azoospermia Any other Not done The data in table 3 shows that a majority (71%) of the infertile women had regular menstrual cycles. In a regular menstrual cycle it is easy for the infertile women to calculate the day of ovulation and plan their pregnancy. Whereas in a irregular menstrual cycle it is difficult to predict the day of ovulation which may cause the infertile women a confusion to plan their contacts. The present study also identified that only 50 per cent of the infertile couples practice adequate sexual patterns. During the fertile days it is necessary that the couple have sexual

9 contact on alternative days because the life cycle of the ovum is hours and the sperm is 7 hours. Coital frequency may also be a factor. With daily coitus, the sperm count is somewhat lower. Decreased frequency (abstinence for - 1 days or more) may save up sperm but their motility may be lowered due to the increased concentration of sperm. Thus it is imperative to teach the above facts to the infertile couple and help them plan their contacts during the period of ovulation. It was also noted that per cent of the infertile women had anovulatory menstrual cycles. In anovulatory cycles the ovum does not mature and it is often due to hormonal irregularities, polycystic ovaries resulting in infertility. Obesity can also play a significant role in anovulation because obesity is associated with hormonal abnormalities and elevated levels of estrogen. Increased prolactin levels, hypothyroidism, hypopituitarism may also cause anovulation. The causes of infertility in the present study were observed to be per cent of ovulation problems, 1 per cent of tubal problems and 1 per cent of uterine problems and 19 per cent of any other problems. The combined causes of infertility like ovulatory & tubal ( %), ovulatory & uterine ( %), ovulatory &any other (3 %), tubal & uterine ( %), tubal & any other (1%), ovulatory, tubal &uterine (%) were also present. Infertility in women has many causes, including hormonal problems and factors that can affect the uterus and tubes. Hormonal factors of infertility causing anovulation are seen in polycystic ovarian syndrome, obesity, and strenuous physical exercise, systemic diseases of liver and kidney, and kallmann s syndrome. Hyper prolactinemia, hypothyroidism, Sheehan s syndrome also cause anovulation. Cervical causes may be related to poor quality or quantity of cervical mucus, cervical stenosis, and varicosities of the endo cervical canal, all of which may inhibit the migration of the sperm through the cervical mucus. Endo cervical polyps and cervical fibroids can obstruct the cervical os. Premature ovarian failure, luteal phase defect and luteinized unruptured follicle are the ovarian causes of infertility. 7

10 Infertility related to tubal pathology is most often the result of infection. Obstruction of the fallopian tube can be caused by infections. This can lead to intra luminal damage, destroying epithelial elements necessary for normal gamete transport and interaction. Hydro salphinx may develop which results in the mechanical closure of the distal end of the tubes. The tubal obstruction may also be caused by endometriosis. Endometriosis is the presence of tissue that closely resembles endometrium in an area outside the uterus. It occurs approximately in 7 per cent of women in their child bearing years. Endometriosis may cause infertility by anatomic alteration of the reproductive organs. Tubal adhesions, fimbrial agglutination or altered tubal proximity to the ovaries limit the probability of fertilization. Periovarian adhesions may restrict the available surface area for oozyte release. Uterine factors are found in per cent of infertile women. Polyps and fibroids may distort the cavity and interfere with implantation of the zygote. Uterine fibroids are solids benign lumps, ranging in size from small peas to large grapefruits and can weigh many pounds. Fibroids are usually multiple and often near the top of the uterus. Fibroids may cause a woman to have difficulty becoming pregnant or interfere with a pregnancy because of the space they occupy within the uterus. Fibroids are not a major cause of infertility. They are a cause of infertility in only per cent to 3 per cent of women. Fibroids may alter the contour of the endometrium, making implantation impossible The cause of infertility is diagnosed in the majority of couples. However, in per cent to 0 per cent of couples a cause is never identified. This reflects continuing gaps in knowledge and treatment modalities. A couple is diagnosed with unexplained infertility when no cause for the infertility has been identified. The diagnosis is often emotionally difficult for the couple because, if the cause is unknown, then how can it be treated? It causes a feeling of hopelessness. In the present study majority of the infertile women have undergone hormonal and follicular studies (7%). A significant number of infertile women had undergone combined investigations like Hormonal studies, follicular studies & laparoscopy (1%), follicular studies

11 & laparoscopy (9%). The data in above table reveals that they have also undergone many combinations of investigations as required by the medical team to identify the cause of infertility. The subject of what should be considered for routine testing in the initial investigation of the infertile couple, and who should care for the infertile couple, is controversial. Many clinicians still order an extensive number of tests during the workup. It seems, however, that a more conservative approach is emerging in the face of recent research related to the predictability of the specific tests, cost effectiveness, and convenience for the couple. The couple needs to be actively involved in the decision-making process regarding testing. It must first be determined whether or not a woman is ovulating before moving on to more aggressive testing because per cent to 15 per cent of infertile women have a problem related to ovulation. Assessment of ovulation is fairly simple to determine. A thorough history will document the existence of the classic determinant of ovulatory cycles regular, cyclic menses varying within to days each month. This is indicative of ovulation in 95 per cent to 9 per cent of cycles. A woman who has a history of amenorrhea or long periods of oligoamenorhea or irregular cycles (< 1 days or > 35 days) is probably not ovulating regularly and, therefore, no further assessment of ovulation is necessary. If anovulation is found, it should be treated for a few months before looking into other areas, excluding the semen analysis, unless clinically indicated. Sonography, if readily available, may be a useful tool as an adjunct to the PCTs to measure follicular sizing and the quality of ovulation. Pelvic ultrasound, the day after the LH surge, can visualize the development of the ovarian follicle and the release of the mature ovum. The mature ovum is not seen on ultrasound; the correlation between follicle size and maturity of the ovum is a good indicator. 9

12 Cyclic, predictable menstrual cycles within 5 to 3 days almost always ensure ovulation on a regular basis. (Regular 3-day cycles may indicate an elevated Follicle Stimulating Hormone [FSH] level). It probably also assumes normalcy of several hormones that are commonly ordered in infertility evaluation such as the FSH, LH, prolactin, and androgens. Therefore, hormonal testing is usually not indicated in a normally ovulating woman except if clinically indicated. The purpose of the endometrial biopsy is to assess the synchrony between the endometrium and the day of the menstrual cycle. An endometrial biopsy is not recommended as a routine part of the initial evaluation of the infertile woman. It may be included if an luteal phase defect is suspected. The level of suspicion rises when the woman gives a history of a shortened luteal phase or of recurrent early pregnancy loss. The prevalence of luteal phase defect ranges from 3 per cent to 30 per cent for infertility patients and 5 per cent to 0 per cent in women with habitual abortion. The hystero salphingo gram demonstrates tubal patency as well as normalcy of the internal uterine cavity contour. It is important to perform because the tubes must be patent for conception to occur because they act as a conduct for the passage of sperm to the ovum and for the transit of the fertilized ovum to reach the prepared endometrium at a time optimal for implantation. Laparoscopy is the gold standard for assessing pathology in the peritoneal cavity, including tubal status. Laparoscopy is the direct visualization of the peritoneal cavity and reproductive organs (uterus, tubes and ovaries) for diagnostic purposes with the added therapeutic ability to treat certain abnormalities such as adhesions from tubal disease and endometriosis. In view of treatment of infertile women it was noted in the study that 5 per cent of the women were induced for ovulation, per cent underwent Intra Uterine Insemination and 1 per cent have undergone IVF. 1

13 The induction of ovulation is a critical component in the clinical management of the infertile women. The ovulation induction medications should not be used without first attempting to explain the etiology of couples infertility. The infertile couple with a normal workup may require more extensive evaluatory studies before empirically prescribing ovarian stimulants. During normal sexual intercourse only a few thousand, of the many millions of sperm, actually reach the site of potential fertilization. Almost 300 million sperm may be deposited into the vagina, but only 1 per cent of the sperm survive the migration to the distal portion of the fallopian tube. Many sperm are simply lost in the semen fluid that escapes out from the vagina. The sperm may not be able to successfully navigate the cervical mucus either due to the character of the sperm itself or the inhibitory factors in the mucus. Intra Uterine Insemination (IUI) overcomes some of these barriers. Washing the specimen before IUI, using a gradient technique, refines and concentrates sperm, thus enhancing the fertility potential of the ejaculate. IUI is the direct placement of processed, highly motile, concentrated sperm, washed free of semen plasma and other cells, into the uterus. This procedure greatly reduces the distance that the sperm must travel and increases the amount of spermatozoa available to the Oocytes. The performance of IVF is demanding in terms of clinical expertise and patient dedications for the maintenance of impeccable laboratory standards, for patient education, and for cycle coordination to achieve multiple high-quality Oocytes. Thus, IVF is relatively expensive financially. It should be selected as the treatment of choice only after careful consideration is given to the etiology of a couple s infertility. The semen characteristics of the husbands of the study participants revealed that 57 per cent of them had normal findings, where as 37 per cent of them had abnormal semen characteristics. 111

14 The semen analysis of the man is an important first step in the initial workup of the infertile couple and is concurrently assessed with the woman s ovulatory status. It is usually performed after the initial visit. Definitive information can be obtained from the ejaculate. It is an accurate quantitative test of sperm concentration, motility and morphology. Fig. 3 Percentage Distribution of Causes of Infertility 11

15 5.3. Psychological variables of infertile women The mean and standard deviation including the frequency and per cent of the level of Psychological variables of quality of life, self-concept, anxiety, depression, and stress in Infertile women are presented under this section. Table. Mean and Standard Deviation of the Psychological Variables of Infertile Women. (N=00) Variables Minimum Maximum Mean Standard Deviation Quality of life Self-concept Anxiety Depression Stress Dimensions of depression Pervasive affective disturbances Physiological disturbances Psychomotor disturbances Psychological disturbances Dimensions of stress Physical Emotional Social Sexual Relationship concern Rejection of childfree life style Need for parenthood

16 The data in the above table revealed that the quality of life in infertile women had a mean score of (SD = 3.7), the self-concept mean was 7.3 (SD =13.7), mean anxiety was.9 (SD=1.07), depression mean score was 9. (SD =9.03) and their stress mean score was (SD =.33). Further analysis on the dimensions of depression revealed that the infertile women had more psychological disturbances (M = 3.90, SD = 3.) in comparison with physiological disturbances (M = 15.5, SD = 3.0). Similarly the psychomotor disturbances were higher than (M = 5.17, SD = 1.19) pervasive affective disturbances (M =.7, SD = 1.). The dimensions of stress in infertile women were analyzed and it was found the need for parenthood dimension had higher mean score (M =.0, SD =.3) in comparison with social dimension of stress (M = 3., SD =.33) and relationship concern dimension of stress (M = 3.0, SD =.7). The stress dimension of rejection of child free life style scored higher than (M = 33.3, SD = 3.3) sexual dimension of stress (M = 3.57, SD = 3.7). The emotional dimension of stress (M = 5.1, SD =.55) was also found to be more than the physical dimension of stress (M =.9, SD =.7). The consequences of infertility are manifold and can include societal repercussions and personal suffering. Advances in assisted reproductive technologies, such as IVF, can offer hope to many couples where treatment is available, although barriers exist in terms of medical coverage and affordability. The medicalization of infertility has unwittingly led to a disregard for the emotional responses that couples experience, which include distress, loss of control, stigmatization, and a disruption in the developmental trajectory of adulthood. Infertility may have profound psychological effects. Partners may become more anxious to conceive, ironically increasing sexual dysfunction. Marital discord often develops in infertile couples, especially when they are under pressure to make medical decisions. Women trying to conceive often have clinical depression rates similar to women who have heart disease or cancer. Even couples undertaking IVF face considerable stress. 11

17 To evaluate the hypothesis that infertility may result in a decrease in quality of life and an increase in marital discord and sexual dysfunction a study was conducted by Monga et al (00). A trend toward lower quality of life scores was noted in women (P=0.09) but not in the men of infertile couples. No statistically significant impact on sexual functioning in women was noted; however, the men in the infertile couples had lower total International Index of Erectile Function scores (P<0.05) and intercourse satisfaction scores (P<0.03). Women in infertile couples reported poor marital adjustment and quality of life compared with controls. Table. 5 Frequency and Percentage Distribution of Psychological Variables in Infertile Women. (N=00) Variables Frequency Percentage 1. Level of Quality of life Low Moderate High 1. Self-concept Low Moderate High Anxiety Normal Anxious Depression Normal Mild Moderate Stress Low Average Moderate High

18 The data from table 5 identified that only 1 per cent of them had low quality of life and the remaining per cent had moderate quality of life and per cent of them had high quality of life. Fifty two per cent of them had moderate level of self-concept while 7 per cent of them had low self-concept and 1 per cent had high level of self-concept. Sixty one per cent of them were anxious to conceive whereas 39 per cent of them were found to be normal. While 55 per cent of infertile women were normal, 1 per cent of them had moderate level of depression and 9 per cent had mild depression. Twenty four per cent of them experienced high level of stress at the same time 0 per cent experienced moderate level of stress and 1 per cent experienced average level of stress and 0 per cent of them had only low level of stress. The aim of the study by Ardent et al (1999) was to study the emotional impact of In Vitro Fertilization (IVF) and any possible influence due to the type of diagnosis, duration of infertility, number of cycles and type of responses to treatment. The study was carried out on 00 patients admitted to hospital for the final stages of IVF (oocyte retrieval and embryo transfer). The psychological measures taken into consideration were: state and trait anxiety levels (State Trait Anxiety), unconscious and symptomatic anxiety, perception of self and of others. Monitoring of anxiety levels during hospitalization highlighted significant differences with respect to the state anxiety values (P< 0.01) and general anxiety (P<0.05), but not with respect to trait anxiety. Women who have experienced infertility of medium to long duration presented a significantly lower state anxiety value (P<0.01). The failure of oocytes fertilization determines a significant increase in state anxiety level (P<0.01) There were no significant differences in anxiety values with respect to the cycle number. Perceptive functioning was normal. In another study the psychology of infertile women was investigated with a battery of psychological tests consisting of a semi structured interview, State Trait Anxiety Inventory (STAI), Center for Epidemiologic Studies Depression Scale (CES-D), and Cornell Medical Index (CMI). The subjects were 7 infertile women being treated for infertility. The semi structured interviews revealed that the stress factor for infertile women changes with the length 11

19 of infertility. In the early states, the main stress is related to a physical inferiority complex, while later it changes into stress about what others outside the family say. According to STAI, CES-D and CMI, infertile women are considered to become more depressive the longer treatment persists. Therefore, counseling for infertile women should be adapted to long term treatment. (Chiba et al 1997). Fig. Frequency Polygon showing Scores of Quality Of Life 117

20 Fig. 5 Frequency Polygon showing Scores of Self-concept Fig. Frequency Polygon showing Scores of Anxiety in Infertile Women 11

21 Fig. 7 Frequency Polygon showing Scores of Depression in Infertile Women Fig. Frequency Polygon showing Scores of Stress Reactions in Infertile Women 119

22 5. The Social Variables of Infertile Women The Mean and standard deviation including the frequency and per cent of the social variables in terms of the marital adjustment between the husband and wife and the family support of infertile women are presented in this section. Table. Mean and Standard Deviation of Social Variables in Infertile Women (N=00) Variables Minimum Maximum Mean Standard Deviation Marital adjustment Family support Dimensions of family support Informational Emotional Economical Table.7 Frequency and Percentage Distribution of Social Variables in Infertile Women. Variables Frequency Per cent (N=00) 1. Level of marital adjustment Marital distress Marital adjustment. Level of family support Low Moderate High

23 The mean marital adjustment score in infertile women was 93. with a standard deviation of The marital distress was present in per cent of infertile women and only 3 per cent of them had marital adjustment. The mean score of family support to infertile women was 5.35 with a standard deviation of 9.1. Most of the infertile women had moderate (%) to high level (%) of family support. Infertility treatment and marital relationships among successfully treated ART couples and their controls were evaluated (Repokari et al 007) and found no between-group differences were found in marital satisfaction and dyadic cohesion. Dyadic consensus deteriorated among control group women. The shared responsibility of infertility may even stabilize the marital relationships was the conclusion of the study. Monga et al (00) also reported that the Marital Adjustment Test scores for the women of the infertile couples were significantly lower than the scores of the controls (P< 0.01); however no difference was noted in the men. Using path analysis and hierarchical linear modeling, the authors evaluated the associations between both partners level of depression and anxiety, as measured by Minnesota Multiphasic Personality Inventory- (MMPE-) content scales, and both partners level of marital satisfaction among married couples (N = 77) that participated in the MMPI Re-standardization study. Results indicated that marital satisfaction was predicted by the person s own level of anxiety and depression (i.e., actor effects) and by his or her spouse s level of depression only (i.e., partner effects). Findings also indicated that (a) there were no significant gender differences in the magnitude of effects, (b) depression effects were significantly stronger than anxiety effects, (c) actor effects were significantly stronger than partner effects, and (d) there were interactions between actor and partner effects for depression only. (Whisman,Uebelacker and Weinstock 00). 11

24 Fig.9 Frequency Polygon showing Scores of Marital Adjustment in Infertile Women. Fig. Frequency Polygon showing Scores of Family Support in Infertile Women 1

25 5.5 The Health Behaviour Variables of Infertile Women The mean and standard deviation including the frequency and per cent of the health behaviour of infertile women through their attitude towards treatment options and treatment seeking behaviour sequential tracking, back tracking, paralleling, taking a break and withdrawal are discussed in this section. Table. Mean and Standard Deviation of Health Behaviour Variables in Infertile Women. (N=00) Variables Minimum Maximum Mean Standard Deviation Attitude towards treatment options Treatment seeking behaviour Attitude towards treatment options Ovulation induction Artificial insemination Tubal surgery IVF Surrogacy Adoption Treatment seeking behaviour Sequential tracking Back tracking.5.51 Paralleling.7.3 Taking a break..3 Withdrawal The infertile women had a mean score of.01 with a standard deviation of 7.3 in their attitude towards treatment options. None of them had low positive attitude and 7 per cent of them had moderately positive attitude towards treatment options. 13

26 The treatment seeking behaviour had a mean score of. with a standard deviation of 9.0.The regular treatment seeking behaviour was found among per cent of infertile women and 9 per cent of them had highly irregular treatment seeking behaviour. Table.9 Frequency Infertile Women. and Percentage Distribution of Health Behaviour Variables in (N=00) Variables Frequency Per cent 1. Level of attitude towards treatment options Moderately positive High positive. Level of treatment seeking behaviour Regular Moderately Irregular Highly irregular It can be noted from Table 9 that the infertile women had high (%) and moderately positive (7%) attitude towards the treatment options available for infertility. Whereas only percent of the infertile women were undergoing treatment regularly and 5 percent of them had moderately irregular treatment seeking behaviour and 9 percent of them had highly irregular behaviour. The cost of the treatment and the failure rates could have been the demotivating factors for the infertile women to continue the treatment regularly. Most of the treatment also require them to go continuously for at least weeks during the follicular phase of the menstrual cycle for monitoring the follicular growth, which is essential for the medical team to decide upon the dosage of follicular stimulating drugs. 1

27 To investigate reasons for discontinuation of IVF treatment a prospective, cohort study was conducted at Centre for Reproductive Medicine at a Large University hospital. The 50 couples of a cohort of 97 couples who started IVF treatment between January 199 and December 1997and did not achieve childbirth participated in the study. The reasons for ceasing treatment were evaluated by scrutinizing the medical records for all couples (n=) who did not achieve live birth and who did not complete three stimulated IVF cycles. A questionnaire was sent to all patients for whom the reason for discontinuation was not obvious from the medical records (n = 11).Result(s): of 50 couples not achieving live birth, 0 completed their subsidized cycles, whereas, discontinued IVF. In 19 (79%) of the cases, the reasons for ceasing treatment could be identified from records or questionnaires. The reason for discontinuation was psychological burden in per cent, poor prognoses in 5 per cent, spontaneous pregnancy in 19 per cent, physical burden in per cent, serious disease in per cent, and other reasons in 7 per cent. An unexpectedly high per cent of couples who performed IVF discontinued the treatment before the three cycles that were offered to a majority of the couples. A majority of these discontinuations were due to psychological stress. This information is of importance when counseling patients during treatment. (Olivius et al 00). This study by Chiliaoutakis, KouKouli and Papadakaki (00) aimed to investigate attitudinal indicators and their potential relationship with the public s intention to have recourse to gamete donation and surrogacy. A total of 35 individuals of reproductive age (9.3% men and 50.7% women) completed a questionnaire referring to their intention to receive or donate sperm/oocytes and their acceptance of becoming a commissioning couple or surrogate mother, and also to explore their attitudes towards gamete donation and surrogacy. Two attitudinal indicators emerged from the principal component analysis identifying (i) recipients and donors choice for anonymity, donors renunciation of parental obligations and refusal of children s rights to know their Biological parents and (ii) favorable attitudes towards legislative and financial measures to be adopted by the government for the promotion of reproductive technologies. It was found that the indicator of Donors Anonymity and Refusal of Children s Right (DARCR) and the Legislative and Financial Support (LFS) scale were positively associated with intention to have recourse to Gamete Donation and Surrogacy (GDS). 15

28 Moreover, among the other variables used recourse to GDS (p=0.09), suggesting that the more religious respondents are less willing to use GDS. Social, legislative and financial implications provide a convenient rationale for adopting a favorable intention towards reproductive technologies. The findings of the present research should be given close consideration by policy makers and health education campaigns. Infertility is a major reproductive health problem in Africa. The paper by Dyer. Abrahams, Hoffman and Spuy (00) presents the findings of new studies which focus on the knowledge that infertile woman have about fertility and the causes of infertility, their treatmentseeking behaviour and their expectations of an infertility clinic. A total of 150 infertile women from a culturally diverse, urban community in South Africa participated in the two studies. Both qualitative and quantitative research methods were applied using in-depth, semi-structured interviews and structured questionnaires. Results showed that the women who participated had little knowledge about human reproduction and modern treatment options for infertility. They were highly motivated to find treatment and accessed both traditional and modern health care. Treatment barriers within the modern health care were identified. The importance of health education and counseling is recognized and both need to be integrated into infertility management, particularly in the developing world. The introduction of clinical guidelines is recommended in order to overcome treatment barriers and improve the delivery of health services. 1

29 Fig. 11 Frequency Polygon showing Scores of Attitude towards Treatment Options in Infertile Women. Fig. 1 Frequency Polygon showing Scores of Treatment Seeking Behaviour in Infertile Women 17

30 5. Association between demographic variables, psycho-social and health behavioural variables of infertile women. This section presents the association between demographic variables, psycho-social and health behavioural variables of infertile women, using chi square as the inferential statistics. Table Association between Quality of Life and Demographic Variables in Infertile Women. (N=00) Quality of Life Variables Low Moderate High X Age (in years) < >1 Education High school Higher Secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage NC C *** 0. ***.590 NS 7.77 NS.355 *** 5.37 NS 1

31 Years of infertility 1 yrs. yrs. yrs. yrs. yrs. > yrs *** There was a significant association between quality of life and the demographic variables of age, education, type of family and years of infertility at a statistically significant level of p<.001 level. Hence the null hypothesis H 1 that there will be no significant association between quality of life and the demographic variables such as age, educational status, and type of family, type of marriage and years of infertility is partially retained. Quality of life was better in young women (below 30 yrs) than their counterpartswomen above 30 years. It reflects the fact that as the age advances their quality of life is compromised. Quality of life is also poor when the duration of infertility is increased. In fact age of the women and duration of infertility are interrelated factors, which tend to have positive correlation. Thus the same factors causing stress and anxiety in advanced age may also influence their quality of life with regard to duration of infertility. It may due to the fact that, younger women with shorter duration of infertility might have more scope of becoming mother in the near future. As the years goes on, with many negative experiences such as treatment failure, fear of facing and responding others regarding their queries about child, fear of unsuccessful treatment and financial burden, women become more anxious and frustrated which is reflected through their low quality of life. There is also evidence in this study that quality of life is higher in the women who have higher education. It may be associated with the fact that education prepares the individual to deal the problems rationally, appropriately considering many alternatives. Whereas women with less education may not be much aware of alternative approaches to deal with problems for finding the solution, thus the future without child may threaten the women s ego which may 19

32 lead to poor quality of life. Even though there is no association between quality of life and occupation in this study, educated women tend to be employed which facilitates the better economic status by which it become affordable for the couple for the infertility treatment which is usually very high depending on the nature problem. It may indirectly influence the better quality of life, as the financial burden is one of the major factor affecting the quality of life of the individual. In this study it is also interesting to note that quality of life is better in the women who live in joint family. It may be due to the fact that there may be more social support in joint family by the elders, in laws or parents turnout to be the contributing factor for better quality of life of joint family infertile women. In joint family there is also better chances and opportunities for the women to ventilate their problems and concerns with significant family members other than the spouse. Having someone to listen to one s problem with love and concern it is a single most important factor that can enhance the quality of life of an individual. There was no association between quality of life and the demographic factors such as religion, occupation and type of marriage. It indicates the reality, that quality of life may be influenced by the quality of marital life and understanding among the couple rather than the type of marriage, and overall economic status of the family irrespective of the employment status of the women influence the quality of life. Findings underscore the need for the health professionals to focus on the infertile women with less education, advanced age and longer duration of infertility particularly in the nuclear family so as to reduce their stress by which their quality of life can be improved. 130

33 Table. 11 Association between Self-concept and Demographic Variables in Infertile Women. (N=00) Self-concept Variables Low Moderate High X Age (in Years) < >1 Education High school Higher secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage Non Consanguineous Consanguineous Years of infertility 1 yrs. yrs. yrs. yrs. yrs. > yrs *** NS 3.57 NS.3 NS 39.3 ***.70 NS *** 131

34 The self-concept was found to have significant association with age, type of family and years of infertility (P<.001). Hence the null hypothesis H that there will be no significant association between self-concept and the demographic variables such as age, educational status, type of family, type of marriage and years of infertility is partially retained. Proportion of Infertile women with high self esteem was significantly higher in younger women, with shorter duration of infertility and from joint family. Many psychological variables analyzed in this study such as quality of life, self-concept, anxiety, stress and depression are interrelated factors which may influence each other. Thus the selected demographic variables such as age, years of infertility, and type of family are consistently associated with many of these psychological variables. Self-concept is the way one sees on self. It is formed as a result of experiences one acquires in wide variety of situation. It is influenced by various factors such as childhood experiences, life satisfaction, values acquire in one s life etc. Self-concept in women is particularly associated with becoming mother and motherhood is viewed as a ultimate achievement in women s life. When it is not possible for the women due to numerous factors she becomes frustrated in the life and views herself as lower than others. This becomes more complicated as the age and duration of the infertility increases. There is also evidence in this study that low self-concept is further confounded with nuclear family as there may not be much support from the elders which otherwise must be encouraging to the couple to cope with the problem more realistically which can be reflected through high self-concept. 13

35 Table. 1 Association between Anxiety and Demographic Variables in Infertile Women. Level of Anxiety Variables Normal Anxious Age (in Years) < >1 Education High school Higher secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage Non Consanguineous Consanguineous Years of infertility 1 yrs. yrs. yrs. yrs. yrs. > yrs (N=00) *** 5.1 NS.3 NS 0. NS 3.57 *** 0.0 NS.55 ** 133

36 The anxiety in infertile women was found to have significant association with age and type of family (p<.001). Hence the null hypothesis H 3 that there will be no significant association between anxiety and the demographic variables such as age, educational status, and type of family, type of marriage and years of infertility is partially accepted. Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. Anxiety is considered to be a normal reaction to a stressor. It may help someone to deal with a difficult situation by prompting them to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder. Physical effects of anxiety may include heart palpitations, muscle weakness and tension, fatigue, nausea, chest pain, shortness of breath, stomach aches, or headaches..emotional effects may include, feelings of apprehension or dread, trouble concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching (and waiting) for signs (and occurrences) of danger, as well as nightmares/bad dreams, and feeling like everything is scary. Infertile Woman becomes more anxious as the age increases which may be due to loss of hope in conceiving. However a woman living in the joint family is less anxious than the women living in nuclear family. This supports the common belief that joint family is great strength in Indian families which supports the individual in stress to cope with the problems rather becoming distressed. The beauty about the Indian culture still lies in its age-long prevailing tradition of the joint family system. The reason why infertile women feel more comfortable in joint family is because of the significance they attach to the joint family system. All working cohesively to solve a problem faced by any one or more members of the joint family, is what works magic in keeping one tension-free, happy and contended even when the couple is childless. 13

37 Table. 13 Association between Depression and Demographic Variables in Infertile Women. Level of Depression Variables Normal Mild Moderate Age (in Years) < >1 Education High school Higher secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage Non Consanguineous Consanguineous ***.31 NS.35 NS 3.9 NS 30.5 *** 3.30 NS (N=00) Years of infertility 1 yrs. yrs. yrs. yrs. yrs. > yrs *** 135

38 The psychological variable of depression was found to have significant association with age, type of family and years of infertility (p<.001). Hence the null hypothesis H that there will be no significant association between depression and the demographic variables such as age, educational status, and type of family, type of marriage and years of infertility is partially retained. Depression is more severe and common among women in women above 5 years of age, and living in the nuclear family. It is a known fact that, in recent days women get married at late age than earlier days due to various reasons such as higher education, higher aspiration, desire to achieve something significantly before marriage and having children. As age increases the fertility potential decreases and depression comes because of this reason. Many couple also voluntarily postpones the conception as the feel that they cannot enjoy the life and experience freedom when they have child. However after 5 years women comes out of the excitement of marriage and new life and realizes the importance and need for having child which is considered as ultimate aim of marriage and living together. Even though many are successful in their attempt to conceive, for some women it is not possible to conceive naturally which leads to depression. However it is encouraging to note that women from joint family reported less depressive symptoms while comparing to their counterparts from nuclear families. As discussed earlier joint family in Indian context is still meaningful, encouraging, motivating, and helps the individuals in need and stress. It is true that when there are people to share the views, and ventilate the feelings that becomes a tonic for the people to approach the situation from the various angles rather than contemning to depression. This also supports the common belief that joy becomes double and sorrow becomes half when it is shared with concerned, loving and significant family members. The duration of years of infertility and the level of depression was also significant (P<.001). It is evident that as age increases the fertility potential declines in a women and it may lead to depression. 13

39 Table. 1 Association between Stress and Demographic Variables in Infertile Women. Level of Stress (N=00) Variables Low Average Moderate High Age (in Years) < >1 Education High school Higher secondary Graduate Post graduate Religion Hindu Muslim Christian Occupation Housewife Employed Type of family Nuclear Joint Type of marriage Non Consanguineous Consanguineous Years of infertility 1 yrs. yrs. yrs. yrs. yrs. > yrs ***.1 ** NS 7. NS.17 ***.7 NS.593 *** 137

40 There was a significant association between stress and the demographic variables of age, education, type of family and years of infertility at a statistically significant level of p<.001 level. Hence the null hypothesis H 5 that there will be no significant association between stress and the demographic variables such as age, educational status, and type of family, type of marriage and years of infertility is partially retained. Younger women with shorter duration of infertility and graduate level of education, reported low level of stress. Since the depression and stress are closely related to each other same factors causing depression may also influence stress. It is also not known that whether the depression is cause or consequence of infertility and stress. Thus findings of these study highlights the need for health care professionals to focus on psychological impact of infertility, keeping in mind the factors influencing the psychological morbidity which include advanced age with longer duration of the infertility, women from nuclear families and lower educational status. The diagnosis of infertility and concurrent medical treatment may inflict an array of negative emotional symptoms in infertile persons. Evidence for the positive effects of psychotherapy on negative affect and also possible influence on conception rates has been discussed in several studies. Meta analyses were conducted in order to evaluate the efficacy of group and individual / couple therapies on (i) the reduction of negative emotional symptoms, and (ii) the possible promotion of pregnancy. Group and individual / couple psychotherapy led to a decrease in feelings of anxiety. Psychotherapy accompanying IVF treatment yielded similar conception success rates to psychological interventions administered to patients not in specific medical care. Results are suggestive of positive effects of psychotherapy for infertile patients. (De Liz and Strauss 005). Thus there is a need for health professionals to plan and implement psycho-social interventions including stress management, counseling, behavioural modification etc which might positively influence the possibility and scope for conception and also to enhance the coping ability of the couple particularly infertile women. 13