Human Reproduction Vol.16, No.5 pp. 966–969, 2001

Emotional distress of infertile women in Japan

Hidehiko Matsubayashi1,3, Takashi Hosaka2, Shun-ichiro Izumi1, Takahiro Suzuki1 andTsunehisa Makino1

1Department of Obstetrics and Gynecology and 2Department of Psychiatry and Behavioral Science, Tokai University School ofMedicine, Bohseidai, Isehara, Kanagawa, 259-1193, Japan

3To whom correspondence should be addressed. E-mail: hide-m@is.icc.u-tokai.ac.jp

Although recent papers have suggested that psychological factors are implicated in the experience of infertility, fewstudies have assessed this relationship in a sample of Japanese infertile women. This study was carried out in orderto clarify whether Japanese infertile women experience emotional distress. A cross-sectional questionnaire studywas performed to assess the psychological states of 101 infertile women compared to 81 healthy pregnant women.The hospital anxiety and depression scale (HADS) and the profile of mood states (POMS) were administered. Thesequestionnaires produced scores for depression/dejection, anxiety, aggression/hostility, lack of vigour, fatigue, tensionanxiety, and confusion. The HADS and the POMS scores of infertile women were significantly higher than those ofpregnant women, except for fatigue score. Infertile women with positive HADS indicating emotional disorders(39/101, 38.6%) were significantly (P � 0.0008, χ2 test) more than those of pregnant women (13/81, 16.0%) whenthe threshold was set at 12/13 of total HADS scores. The HADS scores were not affected by the women’s age,duration of infertility, experience of conception, routine tests, and work states. In this Japanese population, infertilewomen reported higher levels of emotional distress than pregnant women, suggesting psychological support isneeded for infertile women.

Key words: distress/emotion/infertility/Japan

Introduction people sometimes criticize women without children, becausethey think women should have heirs bearing their family name,Recent papers have suggested that psychological factors areand because they still believe that infertility is caused by theimplicated in the experience of infertility; however whetherfemale. Moreover, the media sometimes criticize the newstress and infertility are linked as cause or consequence is stilltechnology of fertilization [e.g. IVF, intracytoplasmic spermuncertain (Greil, 1997). The psychological problems whichinjection (ICSI)], which might result in patients being ashamedhave been most commonly investigated are anxiety and depres-of infertility. However, little attention has been paid to thesion; anxiety because of the stressful nature of the treatmentpsychological aspects of infertility in Japan. For instance, theprocedures and because of the fear that treatment will fail,Japan Society of Obstetrics and Gynecology has not had aand depression because of the inability to conceive (Golombok,discussion of psychological aspects of infertility at the annual1992). From recent studies, it appears that the major difficultymeeting for over a decade. Only one study has been publishedfacing patients during infertility is anxiety (Cook et al., 1989),in English (Chiba et al., 1996) concerning psychological issueswhile couples whose treatment was unsuccessful are insteadamong patients with infertility in Japan. Their results indicatedat risk of depression (Golombok, 1992). High levels of anxietythat the stress factor for infertile women changed with thehave been suggested possibly to have a direct effect in reducinglength of the infertility period, but they did not compareconception rates. In particular, a link has been suggestedinfertile women to any other group. We postulated that Japanesebetween anxiety-induced hyperprolactinaemia and failure toinfertile women had increased stress, resulting in high levelsconceive (Harrison et al., 1986; Edelmann and Golombok,of anxiety and depression. Therefore this study was conducted1989). Domar et al. (1992) have shown that psychologicalto clarify whether Japanese infertile women are psychologicallyinterventions were successful at decreasing anxiety and atdisturbed.improving conception (Domar et al., 1992). However, there is

no clear evidence to show that psychological factors contributetowards female infertility. Materials and methods

In Japan, historically, women have been frequently asked We asked 137 women who visited our infertility clinic in Tokaisuch questions as ‘Are you married? Do you have a child?’ University Hospital to fill in questionnaires. The subjects filled in the

questionnaires during waiting periods at the outpatient clinic. Allwithout hesitation, because these are forms of greeting. Old

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Distress in Japanese infertile women

women returned the questionnaires (return rate: 100%). In this study,Table I. Comparison of the HADS and the POMS scores of infertile andthe women with history of any live birth, psychiatric disorders andpregnant womenwith other physical diseases concomitantly were excluded. Finally,

the subjects were 101 patients (32.9 � 4.3 years; mean � SD, rangeScores Infertile Pregnant P valuea

24–43) who had been infertile for more than 1 year (58.9 � 40.0months, range 1–18 years).

HADS depression 4.6 � 2.9 3.5 � 2.1 0.003As a control population, we asked 105 women who visited our HADS anxiety 6.9 � 3.1 5.3 � 3.0 0.0007

obstetric clinic in Tokai University Hospital to fill in the same HADS (total) 11.6 � 5.2 8.8 � 4.2 0.0002Depression/dejection 10.9 � 8.7 5.0 � 4.9 �0.0001questionnaire. The subjects filled in the questionnaires during waitingAggression/hostility 9.4 � 7.3 7.2 � 5.5 0.02periods at the outpatient clinic, as the infertile women did. All womenLack of vigour 29.4 � 5.8 26.2 � 5.0 0.0001

returned the questionnaires (return rate: 100%). In our hospital, both Fatigue 8.3 � 5.9 8.2 � 5.0 NSthe obstetrics and gynaecology outpatient clinics are located in the Tension anxiety 10.4 � 6.1 7.6 � 5.4 0.001

Confusion 7.9 � 4.2 6.3 � 3.0 0.005same section, divided in two parts (right obstetrics, left gynaecology),Total mood disturbances 76.3 � 28.8 60.4 � 19.3 �0.0001so that patients have to enter the same entrance and to wait in the

same room. About half of pregnant women achieved pregnancy afterData are shown as mean values � SD.infertility treatment given in our hospital. Therefore, the condition of aUnpaired Student’s t-test was used between groups.

two groups was quite similar, and the only difference was whether NS � not significant; HADS � hospital anxiety and depression scale;they were pregnant or not. In this study, the women whose current POMS � profile of mood states.pregnancy had any problems (e.g. growth retardation, macrosomia,placenta previa, threatened abortion, or preterm labour) as well aswomen with a history of any psychiatric disorder, intrauterine fetal Table II. Positive percentage of total HADS scores in infertile and pregnant

womendeath in the second or third trimester of a previous pregnancy, orhereditary disease, were completely excluded. Finally, as a control

Threshold Thresholdpopulation, we recruited 81 healthy pregnant women (30.5 � 4.2years, range 23–41) at 11–39 weeks of gestation (26.6 � 8.4 weeks). 12/13 P valuea 10/11 P valuea

In order to detect emotional states, we used two questionnaireswhich have been used commonly for screening psychological distress. Infertile 38.6% (39/101) 0.0008 59.4% (60/101) 0.0005The Hospital Anxiety and Depression Scale (HADS) was relatively Pregnant 16.0% (13/81) – 33.3% (27/81) –newly developed for detecting depression and anxiety (Zigmond and

aχ2 test compared to pregnant women.Snaith, 1983). HADS is well known to be useful for screeningemotional disorders (e.g. adjustment disorders, major depression,anxiety disorder, or dysthymia) regardless of benign or malignant Resultsdiseases (Andrews et al., 1987; Barczak et al., 1988; Wilkinson and In this Japanese population, all parameters of both the HADSBarczak, 1988; Hamer et al., 1991; Moorey et al., 1991). The Japanese and the POMS except for fatigue score from infertile womenversion of HADS was introduced by Kitamura (1993); he translated

were significantly greater than those of pregnant women usingthe inventory of the original HADS into Japanese (Kitamura, 1993),

unpaired Student’s t-test (Table I). The depression/dejectionfollowed by retranslation into English by someone who did not knowscore of infertile women (10.9 � 8.7) was twice as much asHADS. The retranslation was checked and accepted by the originalthat of pregnant women (5.0 � 4.9). The scores of the HADSauthors, Zigmond and Snaith. Although we do not have any standard-and the POMS between pregnant women with (n � 40) andized scores in HADS, there are appropriate threshold points as awithout (n � 41) infertility treatment were not statisticallyscreening test in the Japanese version. Kugaya et al. (1998) firstsignificant using unpaired Student’s t-test (data not shown).reported that the optimal threshold score of total HADS in Japanese

was 10/11 for emotional disorders (e.g. adjustment disorder, major The total HADS scores and the subscales of the POMSdepressive disorder) in cancer patients with 92% sensitivity and 65% were well correlated using linear correlation; depression/specificity (Kugaya et al., 1998). Our previous report also revealed dejection (P � 0.0001, r � 0.714), aggression/hostilitythat the appropriate threshold score of total HADS in Japanese was (P � 0.0001, r � 0.630), lack of vigour (P � 0.0004,12/13 for emotional disorders in otolaryngology patients with 92% r � 0.350), fatigue (P � 0.0001, r � 0.525), tension anxietysensitivity and 90% specificity (Hosaka et al., 1999). (P � 0.0001, r � 0.726), confusion (P � 0.0001, r � 0.595),

The profile of mood states (POMS) has been widely used fortotal mood disturbances (P � 0.0001, r � 0.793). Since the

measuring emotional disturbances (McNair et al., 1971). The POMSHADS and the POMS scores were well correlated, and sincecan produce scores for depression/dejection, aggression/hostility,the HADS is well known to be useful for screening emotionallack of vigour, fatigue, tension anxiety, confusion, and total mooddisorders, we focused on the total score of the HADS. Whendisturbances. The validation study of the Japanese version of thethe threshold point of the total score of the HADS was set atPOMS was reported (Yokoyama et al., 1990) and standardized with12/13, positive HADS (i.e. indicating emotional disorders) was5557 normal controls, both male and female, between the ages of 10observed in 38.6% (39/101) of infertile women compared toand 60 (Yokoyama et al., 1994).16.0% (13/81) of pregnant women (Table II, P � 0.0008, χ2

test). Similar significance was observed with the threshold atStatistical analysis10/11 (Table II, 50.9% versus 33.3%, P � 0.0005, χ2 test).Unpaired Student’s t-test was used to compare two groups. The χ2

Ages between infertile and pregnant groups were statisticallytest was performed for 2�2 tables. Correlation coefficient (r) betweendifferent (P � 0.0002, unpaired Student’s t-test), but the agetwo parameters was calculated as linear correlation. A P value less

than 0.05 was considered statistically significant. did not contribute to the HADS scores in both groups using

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linear correlation (P � NS, r � 0.054 for infertile women; are from our infertility clinic after appropriate treatment,successful pregnancy may reduce those scores or reducedP �NS, r � 0.124 for pregnant women), indicating that these

two groups were comparable without concern with ages. scores may lead to successful pregnancy. Similar results havebeen reported, indicating that the POMS scores improvedDuration of infertility of the infertile women or gestational

week of the pregnant women was not related to the HADS during pregnancy compared to the same women before preg-nancy (Sanders and Bruce, 1997). If the hypothesis thatscores using linear correlation (P � NS, r � 0.072 for infertile

women; P � NS, r � –0.090 for pregnant women). In these decreasing HADS/POMS might lead to successful pregnancyis true, the mechanism whereby increased depression andJapanese infertile women, experience of conception (primary

or secondary infertility, P � NS), routine tests (ongoing or anxiety may lead to infertility may be explained by a linkbetween hormonal changes and the psychological states. Theredone, P �NS), and work (with or without, P �NS) did not

influence the HADS scores using unpaired Student’s t-test. is some evidence showing that anxiety-induced hyper-prolactinaemia is associated with failure to conceive (Harrisonet al., 1986; Edelmann et al., 1989), and there is other evidence

Discussion showing that changes in prolactin, cortisol and testosteroneprovoked by emotional stress vary with anxiety and depressionIn this population of Japanese women, all parameters of both

the HADS and the POMS except for fatigue score from (Demyttenare et al., 1989; Merari et al., 1992).In this population of Japanese women, duration of infertility,infertile women were significantly greater than those of healthy

pregnant women. In other words, these results suggested that experience of previous conception, routine tests and work didnot contribute to the HADS scores. Since some papers haveinfertile women were more likely to have higher level of

depression, dejection, anxiety, aggression, hostility, lack of reported that the length of treatment changed emotional stress(Berg and Wilson, 1991; Chiba et al., 1996) or some of thevigour, tension anxiety, and confusion. Since anxiety and

depression are the psychological problems which have been routine tests were stressful (Eimers et al., 1997), emotionalstates detected by the HADS may not be influenced bymost commonly investigated, many studies showed that anxiety

and depression were frequently observed in infertile women these factors.It may not be suitable to compare infertile women withcompared to controls (Greil, 1997). Subscales related to

interpersonal sensitivity such as aggression or hostility have pregnant women, because the entity is completely differentand because both may have special psychological problems.sometimes been reported in infertile women (Bernstein et al.,

1988; Downey and McKinney, 1992), but there were no A good comparison group would be a healthy population, suchas those female patients who come for a general investigationsignificant differences between infertile and non-infertile

women with regard to personality (Greil, 1997). Our results or a PAP smear. Unfortunately, we have few such patients inour institution. Although we matched the other conditions ofare consistent with these previous studies in the western world,

and we speculate that infertile women with anxiety and the two groups as much as possible, the results from this studyare limited by the comparison group of pregnant women. Asdepression may induce interpersonal sensitivity and may

reduce vigour. to the pregnant women whose gestational weeks were differentbetween 11 and 39 weeks, their psychological situations mayAlthough we did not perform a psychiatric structured inter-

view to all women in this study, our results showed that be different in themselves, but gestational week was not relatedto the HADS scores in the current study, suggesting that theresignificantly more infertile women (38.6%) showed positive

HADS scores (i.e. emotional disorders) compared to pregnant might be little concern on this point.To date, gynaecologists are eager to recognize the need towomen (16.0%) when the threshold was set at 12/13. Our

previous report revealed that positive HADS scores were provide psychological care for women with infertility in thewestern world. Although results from this study are limitedobserved in 30% of benign otolaryngology patients and in 46%

of those with malignancies (Hosaka et al., 1999). Therefore, we by the cross-sectional design and by the comparison group,we conclude that some of the Japanese infertile women areshould emphasize that the 38.6% in healthy infertile women

is high and the 16.0% in healthy pregnant women is quite low. psychologically disturbed. Further research is necessary fordetection of the cause of these high scores of the HADS andSince Japanese people think all women who are pregnant will

have an intact baby, to be pregnant seems to be a goal. This the POMS and for seeking beneficial treatment for theseinfertile women.may explain why the healthy pregnant women had low HADS

scores in Japan.The HADS score of the current study (depression 4.6 � 2.9,

Acknowledgementanxiety 6.9 � 3.1) was similar to the results in a UK populationThis work was supported partly by a Project Research Grant, Tokaiusing HADS (depression 4.0 � 3.6, anxiety 7.9 � 4.0) (GloverUniversity School of Medicine, Japan.

et al., 1999) in spite of the language difference of the inventory,suggesting that not only the Japanese population but also

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