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Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 34-38

To assess prevalence of anxiety, depression and its association with coping in females suffering from infertility

Department of Psychiatry, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission14-Mar-2022
Date of Decision23-Apr-2022
Date of Acceptance25-Apr-2022
Date of Web Publication30-May-2022

Correspondence Address:
Dr. Shubhangi Sambhaji Dere
H: 6/27, Parijat Society, Spaghetti Complex, Sector 15, Kharghar, Navi Mumbai - 410 210, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_11_22

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Background: Infertility is a major psychosocial problem having an impact on their emotional and marital life. Among infertile couples, females show higher levels of distress than their male partners.
Aim: The aim of this study is to assess the prevalence of anxiety and depression in female patients with infertility and to assess its association with various coping strategies used by them.
Methods: A total of 85 females in the reproductive age group, having primary infertility, drug-naive, and willing to participate in the study were included in the study after obtaining informed consent and institutional ethics committee approval. Those with preexisting psychiatric or medical illnesses which can add to psychological distress were excluded from the study. The patients were assessed for anxiety, depression, and stress coping behavior using the Hamilton Anxiety, the Center for Epidemiologic Studies Depression, and Stress Coping Behavior scales, respectively.
Results: The prevalence of anxiety and depression was observed to be 27.1% and 55.3%, respectively. Common coping styles used included “active coping” (94.1%), “religion” (91.8%), “acceptance” (90.5%), and “planning” (88.3%) whereas “substance use” and “humor” were rarely used. Females with anxiety significantly used “self blame” and among females with depression, significant association was observed with “positive reframing” (P = 0.001) and “behavioral disengagement” (P = 0.004).
Conclusions: Anxiety and depression are common and are influenced by coping strategies used by female with infertility. Structured psychological support is essential to improve their emotional well-being and coping with infertility.

Keywords: Anxiety, coping strategy, depression, females, infertility

How to cite this article:
Gupta A, Dere SS, Ghildiyal P R. To assess prevalence of anxiety, depression and its association with coping in females suffering from infertility. Telangana J Psychiatry 2022;8:34-8

How to cite this URL:
Gupta A, Dere SS, Ghildiyal P R. To assess prevalence of anxiety, depression and its association with coping in females suffering from infertility. Telangana J Psychiatry [serial online] 2022 [cited 2022 Jun 30];8:34-8. Available from: https://tjpipstsb.org/text.asp?2022/8/1/34/346233

  Introduction Top

Infertility is defined as “failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse” in a reproductive age being between 14 and 49 years.[1]

Infertility can lead to severe negative impacts on one's physical, emotional, financial, social, and psychological well-being.[2],[3] It is observed in the existing literature that the patients with infertility experience more stress and emotional tension than those who are fertile.[4] Research on gender differences in infertility and psychological distress highlights that the female partners tend to be more adversely affected than the males.[5] The experience of psychological distress can further cause the development of various psychiatric morbidities, including anxiety, guilt, somatization, and depression.[6],[7],[8]

Coping toward the physical, psychological, and social stressors associated with infertility can influence the development of various psychological problems. Healthy or positive coping can help woman with infertility to accept the problem and seek appropriate support rather than internalizing the problem, resulting in psychological morbidity. Gourounti et al. mention that understanding the mechanism of coping in case of infertility can help to understand the vulnerability and risk of an individual toward the development of psychological distress and needing support.[9]

The current study aimed at assessing psychological distress, including depression, anxiety, and its association with the pattern of coping strategies used in females suffering from infertility.

  Methods Top

  1. Self-designed, semi-structured pro forma was used for collecting various sociodemographic details.
  2. Hamilton's Anxiety (HAM-A) Scale: A 14-item clinician-rated instrument designed to assess and quantify the severity of anxiety. Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where <17 indicates mild severity, 18–24 mild-to-moderate severity, and 25–30 moderate to severe. This instrument is well-researched and widely used to assess anxiety symptoms. Internal consistency was observed to be good (Cronbach's alpha = 0.893)[10]
  3. Center for Epidemiologic Studies Depression Scale (CES-D): A 10-item Likert scale questionnaire used to assess depressive symptoms. The scale includes items on depressed affect, somatic symptoms, and positive affect. Options for each item range from “rarely or none of the time” scored as “0” to “all of the time” scored as “3.” Reversed scoring exists for items which are positive affect statements. Total scores range from 0 to 30. Any score of above 10 indicates depression. Internal consistency reliability was observed to be good[11]
  4. Stress Coping Behavior Scale (SCBS): It is a Hindi version of “BRIEF COPE” scale designed to measure the stress-coping behavior of the Indian adult population. The scale consists of 28 items divided into 14 domains such as self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. These domains can be further divided into adaptive (active coping, planning, use of emotional support, positive reframing, use of instrumental support, acceptance, and religion) and maladaptive coping such as self-distraction, denial, venting, substance use, behavioral disengagement, and self-blaming. The research on assessing the psychometric property of SCBS observed good reliability and subscale internal consistency in adaptive and maladaptive coping.[12]

This was an open-label cross-sectional study conducted at outpatient department of psychiatry at tertiary care teaching hospital in Navi Mumbai, Maharashtra, after obtaining ethics committee approval. Females in reproductive age group, diagnosed with primary infertility were enrolled using a simple random sampling technique after taking written informed consent. The sample size was estimated using OpenEpi Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. www.OpenEpi.com, updated 2013/04/06 software with a 95% confidence interval. The reported prevalence of anxiety disorders in patients suffering from infertility is 45.60%.[13] The estimated sample size calculated after considering nonresponse rate of 10% was 85. The data collection was done for 6 months.

Sociodemographic profile of the study population was recorded using predesigned study pro forma. Anxiety symptoms were evaluated using HAM-A scale and CES-D Scale was used for the assessment of depressive symptoms. Coping strategies used were evaluated using SCBS. Data thus obtained were tabulated and analyzed using Microsoft Excel version 15.30 with descriptive tests, Chi-square, and t-test.

  Results Top

Sociodemographic profile

A total of 85 females diagnosed with primary infertility participated in our study. The mean age of the females was 26.28 years (standard deviation = 4.156). More than half (61.2%) had received higher secondary education, were homemakers (62.4%) and belonged to nuclear families (61.2%) [Table 1].
Table 1: Sociodemographic profile

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Prevalence of anxiety symptoms based on Hamilton's Anxiety Scale

In the current study, anxiety symptoms were reported by 23 (27.1%) females. Out of those who were screened positive for anxiety, 9 (39.13%) females reported to have mild anxiety and moderate-to-severe anxiety was observed in 14 (60.87%) females.

Prevalence of depressive symptoms based on Center for Epidemiologic Studies Depression Scale

On CES-D, 47 (55.3%) females reported to have depressive symptoms.

Coping strategies used by females with infertility

As assessed on SCBS, “Adaptive” coping strategies were predominantly used by the current study sample. These coping styles included “religion” (91.8%), “active coping” (94.1%), “acceptance” (90.5%) and “planning” (88.3%). The coping strategies which were rarely used included “substance use” (9.4%) and “humor” (22.4%), as shown in [Table 2].
Table 2: Coping strategies used by females with infertility

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Association of coping strategies with depression

All the coping styles were used comparably by females who had depressive symptoms and those without them, except for “positive reframing” (P = 0.001) and “behavioral disengagement” (P = 0.004), which were significantly used by those with depression as compared to females without depression, as shown in [Chart 1] and [Table 3].

Table 3: Significantly associated coping strategies found in depressive patients

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Association of pattern of coping with anxiety

When coping strategies were compared to the presence of anxiety symptoms on HAMA, it was observed that “self-blame” was the most used coping strategy by anxious females as compared to those without anxiety. The rest of the other coping styles were used comparably by both the groups [Chart 2].

  Discussion Top

The most common emotional response to infertility is usually either anxiety (perceived threat, tension, and worry) or depression (a sense of loss, sadness, and lack of control).[14]

In the current study, the prevalence of anxiety was observed to be 27.1% and the prevalence of depression was observed to be 55.3%. The reported prevalence of anxiety in infertility ranges from 14.8% to 62%.[15],[16],[17],[18] Available literature observes a wide prevalence of depression in infertility ranging from 17.9% to 79%.[18],[19],[20],[21],[22],[23] One Indian study observed the prevalence of stress in infertility to be as high as 80% in females.[24] This wide range of prevalence of anxiety and depression in infertility can be explained due to the use of a variety of rating scales used to screen anxiety and depression, sociocultural influences, perceived social support, and stigma by female partners diagnosed with infertility.

Various gender-specific biological, psychological, and social factors can be attributed to the occurrence of anxiety and depression in infertility. Females are usually the ones who have to face extensive investigations and treatment regimens, including hormonal treatment and interventions for infertility. Females may internalize stress of infertility to feel “inadequate,” “incomplete,” “guilty,” “lack of self-confidence” and “unfortunate,” and “worthless as a spouse” for not being able to enjoy motherhood. Furthermore, there could be a lot of relationship difficulties, fear of abandonment, and sexual problems arising due to the stress of infertility. In a country like India, females usually face the social pressure to conceive and blame for the infertility.[25],[26],[27] Moreover, the stress in females can lead to further difficulty to conceive, resulting in a vicious cycle.[28]

There has been a wide amount of literature on coping strategies in infertility majorly studying healthy versus unhealthy, adaptive versus maladaptive, or problem-based versus emotion-based coping strategies. The scales used are variable, and the observations are influenced by sociocultural factors. There is, however, scarce Indian literature on the same. The current study reflects that the participating females with infertility used “adaptive” coping strategies more frequently as compared to the “maladaptive” coping styles.

In India, religious beliefs and religious practices play an important role in handling any stressful life events, which even applies to infertility.[29] Another study by Singh. mentions that active coping was the most prevalent coping pattern, followed by religion and self-distraction.[30] An African study observed that the females with infertility undertook instrumental support (seeking professional help), trying to be economically independent, talking to their husbands, and religious beliefs as their predominant coping.[31]

The pattern of coping style and stress can correlate. About 22% of the infertility stress variance was explained by coping strategies and personality trait. The author concluded that social and psychological factors play an important role in females who experience infertility stress.[32] An Iranian study reports that personal coping methods are important factors influencing the infertility stress and needs attention.[33]

”Self-blame” as a coping was significantly frequently used by female participants sharing anxiety. Females can take the blame of infertility on themselves even if they are not the cause of infertility. Furthermore, the social criticism faced by females is way more than their male partners. The “motherhood” is appealed by most of the infertility treatment advertisements than “fatherhood.” Hence, the self-blame of being the reason of infertility can lead to guilt, health-seeking behavior, uncertainty of waiting for outcomes of infertility treatment, and financial burden which can further pose a female at high risk to develop anxiety disorder. Similar findings were reflected in a research by Erica.[34]

In the current study, the females who had depression, used behavioral disengagement significantly more frequently as compared to nondepressed female participants. Behavioral engagement means getting engaged in activities to distract and reduce the sense of isolations and hence stress of infertility. In accordance with our findings, Hess et al. observed that the ones who practiced behavioral disengagement or isolation experienced sadness, loneliness, and social deprivation.[35]

In our study, it was observed that females having depression used “positive reframing” more frequently than those without depression. Positive reframing, a type of adaptive coping strategy, helps a person to look beyond the stressful situation in a positive light, thus reducing the stress arising from it. In our study, it may be hypothesized that the use of positive reframing by female participants with infertility was influenced by the duration of infertility or perceived social support, both of which was not assessed as it was not part of the study. It has been discussed that the duration and nature of the stressful situation are related to the effectiveness of a coping strategy.[36] Peterson et al. concluded that the use of more passive and less active coping strategies has been found to be related to psychological distress in patients with chronic illnesses.[37]

  Conclusions Top

The prevalence of anxiety and depression among infertile females was high and was associated with the use of maladaptive coping strategies. Understanding coping styles can hint toward a female's psychological health and they could be aided to build on effective coping strategies through psychological interventions.


This was hospital-based study with a small sample size. A community-based study with a larger sample size can help generate results which can be generalized. A comparison group for studying the psychological distress and coping strategies in male partners can throw light on gender-based difference in the parameters. Furthermore, other factors influencing psychological health and coping in infertility, such as duration of infertility, cause of infertility, and perceived social support, were not part of the current study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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