Work Stress and Fertility

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The relationship between occupational

psychological stress and female fertility

E. Sheiner1, E. K. Sheiner2, G. Potashnik3, R. Carel2 and I. Shoham-Vardi4

Objective To investigate the association between occupational psychological stress and female

fertility.

Methods This was a case–control study including consecutive working female patients

attending fertility and in vitro fertilization clinics in the Soroka University Medical

Center. We compared occupational stress between 64 working patients who had

attended the clinics due to female infertility (case group) and 106 working patients

who had attended the clinics due to their partner’s reproductive impairment (control

group).

Results Patients from the female infertility group were older (31.9 ± 6.2 versus 30.2 ± 4.6,

P = 0.047) and tended to participate more in sporting activity [23.4 versus 10.4%,

odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.05–6.73, P = 0.022] as

compared with patients from the male infertility group.Patients from the case group

tended to work more weekly hours as compared with the controls (33.6 ± 16.8

versus 26.9 ± 17.4, P = 0.028). High reliability was found, as demonstrated by

Cronbach’s α of 0.81–0.90 for the four burnout parameters. Patients from

the female infertility group had significantly lower listlessness scores as compared

with the control group , using the Mann–Whitney test (2.6 ± 1.1 versus 3.1 ± 1.2,

P = 0.013).

Conclusions Patients admitted due to female infertility tended to have lower listlessness scores as

compared with patients admitted due to their partner’s infertility problem. No

significant association was found between other burnout, job strain and job

satisfaction scores and women’s fertility status.

Key words Female infertility; listlessness; occupational psychological stress; physical activity.

Received 30 April 2002

Revised 3 February 2003

Accepted 19 March 2003

Introduction

Psychological distress has long been suspected as having

an important impact on infertility [1–6]. In both sexes,

psychological factors were found to be predictors of the

couple’s fertility status [3–6]. However, it is still notcompletely understood whether psychological stress is

part of the aetiology of infertility as a causal factor or

whether it appears as a consequence of the overall

infertility problem.

While other aspects of work, mainly exposures to

substances, radiation, etc., have been investigated, an

important but less investigated aspect of infertility is

the influence of working conditions and psychological

distress in the workplace on female infertility. Indeed,

Occupational Medicine, Vol. 53 No. 4,

© Society of Occupational Medicine; all rights reserved 265

1Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka

University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva,

Israel.

2Department of Occupational Medicine,Faculty of Health Sciences,

Ben-Gurion University of the Negev, Beer-Sheva, Israel.

3Fertility and In-Vitro Fertilization Unit, Faculty of Health Sciences, Soroka

University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva,

Israel.

4Epidemiology and Health Services Evaluation, Faculty of Health Sciences,

Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Correspondence to: Eyal Sheiner, Department of Obstetrics and Gynecology,

Soroka Medical Center, Ben Gurion University, PO Box 151, Beer Sheva

84101, Israel. Tel: +972 8 640 3524; fax: +972 8 627 5338;e-mail:

[email protected]

Occupational Medicine 2003;53:265–269

DOI: 10.1093/occmed/kqg069



working outside the home was found to result in an

increased vulnerability to stress, which was found to be

associated with a poor outcome of in vitro fertilization and

embryo transfer treatment [7]. Likewise, Brett et al. [8]

suggested that chronic exposure to high stress at work

during pregnancy might lead to preterm delivery.

The present study aimed to investigate the influence of

occupational stress on female fertility.

Materials and methods

Setting and patients

The study included all female working patients who

attended the Fertility and In-Vitro Fertilization clinics

in the Soroka University Medical Center, a regional

teaching hospital, between October 1999 and August

2000. We compared occupational stress between patients

with female infertility (case group) and patients who had

attended the clinics due to their partner’s reproductiveimpairment, i.e. male infertility (control group). The

design of the study, including only couples with infertility,

enabled us to control for recall bias, explained by a

tendency of individuals experiencing adverse repro-

ductive outcome to over-report exposures [9–11]. The

patients were asked to complete a questionnaire, after

receiving an exact explanation concerning the purpose of

the study. Likewise, the attending physician responded to

another questionnaire, which included detailed medical

history and laboratory tests. The study was approved by

the local ethical committee and the Ministry of Health.

The inclusion criteria were working patients who spoke

fluent Hebrew and who had previously given theirinformed consent. Only one patient chose not to par-

ticipate and was excluded from the study. An additional

two patients were excluded due to unknown reason for

infertility. This high participation rate reduces the risk of

selection bias [9,12].

Data

The following were assessed or evaluated.

· Infertility parameters: type of infertility (primary or

secondary), aetiology (male, female, combined, or

unexplained), number of treatment cycles, medical

history and laboratory work-up.

· Socio-demographic parameters: age, ethnicity, level of

education, economic status and parity.

· Lifestyle parameters: smoking, alcohol consumption,

drug use, physical and sexual activities and duration of

infertility.

· Work conditions and classifications: hours of work,

shifts, occupational exposures to potential repro-

ductive toxic agents (chemical and physical) and

psychological stress; occupational classification was

standardized according to the Central Bureau of

Statistics criteria [13].

Stress questionnaire

Occupational stress was measured in three ways: burn-

out, job strain (including job demands and decision

latitude) and job satisfaction.

Burnout

Shirom [14] defined burnout as a combination of

emotional exhaustion, physical fatigue and cognitive

weariness. The questionnaire included three scales

measuring burnout, tension and listlessness, according

to Melamed et al. [15]. This questionnaire was used

among Israeli workers with high reliability coeffici-

ents—Cronbach’s α of 0.73–0.90 [15]. Another scale

investigating cognitive weariness was added, according to

Kushnir and Melamed [16], with reliability coefficients—

Cronbach’s α of 0.70.

The burnout questionnaire had eight parameters

investigating physical fatigue and emotional exhaustion

on a scale of from 1 (never) to 7 (almost always), such as

‘I feel physically exhausted’ or ‘I feel tired’.

The tension and listlessness questionnaires had four

parameters, using the same scale.Examples of parameters

inquiring about tension included ‘I feel restless’and ‘I feel

intense inner tension’. Items measuring listlessness

included ‘I feel sleepy’ and ‘I feel alert’ (reversed score),

etc.

Cognitive weariness was assessed using six parameters,

with the same scale. Sample items included ‘my head

is not clear’ and ‘I feel I am disorganized lately’. The

total score was averaged by dividing by the number of

items.

Job strain

The job-strain model of Karasek et al. [17,18] was

developed specifically to assess occupational stress

[17–19]. The two components of the model are job

demands and decisional latitude, the former being a

measure of the workload and the latter investigating

job control or autonomy, including personal schedule

freedom and intellectual discretion. The model is con-

ceptualized as four cells, corresponding to high and low

demands and high and low decision latitude. We chose

the original questionnaire, as was introduced in a

Swedish study [17] reporting an association between job

strain and the risk of a heart attack. The model was

previously examined with regard to fertility, demon-

strating significant correlation between high strain and

preterm deliveries [8] and testosterone fluctuations [20].

266 OCCUPATIONAL MEDICINE



Job satisfaction

Job satisfaction was evaluated by a simple question ‘How

satisfied are you with your job?’. The answers were on a

scale from 1 (unsatisfied) to 5 (extremely satisfied).

Statistical analysis

Statistical analysis was performed with the SPSS package(SPSS, Chicago, IL). To test the statistical significance of

the results, the χ2 test or Fisher’s exact test was used as

appropriate, when qualitative data were compared. For

continuous variables, the t -test was used. Odds ratios

(OR) and their 95% confidence intervals (CI) were

computed. P < 0.05 was considered statistically signifi-

cant. Reliability coefficients using Cronbach’s α were

assessed in the burnout and job strainquestionnaires. The

a-parametric Mann–Whitney test was used to investigate

differences in psychological tests.

Results

During the study period, 200 consecutive couples had

started a cycle of treatment in our clinics. Of those, 64

working patients had attended the clinics due to a female

fertility problem (case group), 106 working patients had

attended the clinics due to male infertility (control group)

and 30 patients had a combined fertility problem (male

and female). Since the study aimed to compare occu-

pational and stress exposures among patients with female

versus male infertility and due to the small number of

patients with a combined cause for infertility, we

excluded these last 30 patients from the analysis.

Table 1 compares the socio-demographic and healthcharacteristics of the two groups. Patients from the female

infertility group were significantly older (31.9 ± 6.2

versus 30.2 ± 4.6 years, P = 0.047) and tended to

participate more in sporting activity as compared with

the controls (23.4 versus 10.4%, OR = 2.6, 95%

CI = 1.05–6.73, P = 0.022). In addition, these patients

had higher rates of secondary infertility as compared

with the control group (OR = 2.5, 95% CI = 1.3–4.9,

P = 0.005), although there were no significant differences

regarding the number of deliveries and previous children

between the groups.

Table 2 shows the types of occupation according to the

cause of infertility (female versus male). Most patients

worked in clerical jobs and as teachers. No significant

differences were noted between the groups regarding any

type of occupation. However, a non-significant trend

towards a higher number of caretakers was found in

the female infertility as compared to the control group

(OR = 2.2, 95% CI = 0.8–6.8, P = 0.092).

Several occupational characteristics and exposures

to potential reproductive toxic agents are presented in

Table 3.Patients admitted due to female infertility did not

report higher levels of exposures as compared with the

controls. However, these patients worked significantly

more weekly hours as compared with the controls (33.6 ±

16.8 versus 26.9 ± 17.4, P = 0.028).

Table 4 compares burnout, job strain and job satis-

faction for the two groups. High reliability was found,

as demonstrated by Cronbach’s α for the four burnout

parameters: 0.90 for burnout, 0.81 for tension, 0.88 for

listlessness and 0.86 for cognitive weariness. Patients

from the female infertility group had significantly lower

listlessness scores as compared with the controls, using

the Mann–Whitney test (2.6 ± 1.1 versus 3.1 ± 1.2,

P = 0.013). No significant differences were noted

between the groups with regard to the job strain (Cron-

bach’s α of 0.44–0.55 for the items investigated) or job

satisfaction results.

Table 1. Socio-demographic and health characteristics of patients

with female versus male infertility

Characteristics

Female infertility

(n = 64)

Controls

(n = 106) P

Age (years) 31.9 ± 6.2 30.2 ± 4.6 0.047

Ethnic origin

Jewish 61 (95.3%) 95 (89.6%)

Bedouin 3 (4.7%) 11 (10.4%) 0.191Education (years) 13.1 ± 2.7 13.1 ± 3.0 0.946

Subjective economic status

Very good 8 (12.5%) 14 (13.2%)

Good 43 (67.2%) 66 (62.3%)

Not good 13 (20.5%) 26 (24.5%) 0.788

Smoking 16 (25.04%) 27 (25.5%) 0.900

Alcohol 3 (4.7%) 6 (5.7%) 0.773Physical activity 14 (21.9%) 11 (10.4%) 0.040

Type of infertility

Primary 25 (39.1%) 65 (61.3%)

Secondary 39 (60.9%) 41 (38.7%) 0.005

Sterility duration (years) 4.1 ± 2.6 3.9 ± 2.7 0.500

Sterility treatment (months) 19.9 ± 16.9 18.7 ± 21.0 0.696

Number of cycles 2.3 ± 2.7 2.1 ± 2.6 0.599

Previous children (yes) 20 (31.3%) 33 (31.1%) 0.932

Number of children 0.4 ± 0.8 0.4 ± 0.7 0.893

Data are presented as means ± standard deviation or numbers and

percentages.

Table 2. Occupational characteristics of patients with female versus

male infertility: type of occupation

Type of occupation

Female infertility

(n = 64)

Controls

(n = 106) P

Academic 5 (7.8%) 11 (10.4%) 0.578

Technicians 6 (9.4%) 7 (6.6%) 0.510

Clerical 27 (42.2%) 39 (36.8%) 0.484

Sales and service agents 2 (3.1%) 3 (2.8%) 0.912

Teachers 8 (12.5%) 20 (18.9%) 0.278

Non-professional 2 (3.1%) 8 (7.5%) 0.235Caretakers 10 (15.6%) 8 (7.5%) 0.092

Others 4 (6.3%) 10 (9.4%) 0.464

Data are presented as numbers and percentages.

E. SHEINER ET AL.: OCCUPATION STRESS AND FEMALE FERTILITY 267



Discussion

The present study found patients admitted on account of

female infertility to have lower listlessness scores than

patients admitted due to their partner’s reproductive

dysfunction. Our first hypothesis was that patients feeling

‘guilty’ for the infertility status would have higher

burnout scores. Indeed, a previous analysis performed by

our group compared male patients admitted due to theirinfertility and male patients admitted due to female

infertility in order to investigate the influence of working

conditions and psychological stress on male reproduction

[21]. Male infertility was acknowledged to be related to

higher burnout as compared with patients admitted due

to their partner’s reproductive impairment. In this study,

the opposite was found to be true, as demonstrated by the

trend of female patients towards lower marks in the

burnout scores. It may be that the burden of reproductive

failure falls most heavily on the female, whatever the

reason for that failure.

Several studies have investigated gender differences in

psychosocial responses of couples in treatment for

infertility. In general,men were found to be less motivated

than their partners towards fertility treatments [4,9].

Stoleru et al. [4] concluded that in women, stress factors

reflected reactive changes to infertility, whereas in men,stress and sexual problems represented aetiological

factors. It is possible that among the male population,

occupational stress serves as an aetiological factor, while

in women it might be a consequence of their infertility

status.

It is unclear whether the impact of sporting activity

and prolonged working hours on female infertility is ‘the

chicken or the egg’, that is to say that women who feel

‘guilty’ regarding their infertility status may tend to search

for some type of personal compensation such as increased

involvement in physical and working activities. It may be

suggested that the social responsibility for the conception

and care rests much more upon the shoulders of women

than men and, hence, it is possible that as a defence

mechanism they tend to participate more in sporting and

work activities. On the other hand, it is possible that

choosing a career delays conception and therefore recog-

nition of their infertility only occurs at a more advanced

age.

Within the past few decades, a new and far-reaching

phenomenon has been observed in which an increasing

number of women start a family relatively late in their

reproductive lives. Today, this delay in childbearing is

socially accepted and relates primarily to increased

opportunities for education, career choices and effectivebirth control measures [22–24]. However, advanced age

is a well-known risk factor for infertility [24,25]. More-

over, the success rates of elderly women in programmes

of assisted reproductive techniques are relatively low in

comparison with their younger counterparts [26]. Thus,

our finding of significantly advanced maternal age in the

study group is not surprising.

Kushnir and Melamed [16] examined the impact of the

Gulf War on burnout and well-being of working civilians

and concluded that the estimation of work stress cannot

be completely separated from other life events. Accord-

ingly, the reduced listlessness scores of patients admitted

due to female infertility might be a consequence of their

physical activity. It is noteworthy that the ability of

patients with female infertility problems to participate in

sport and prolonged working hours is not because they

did not have children at home, since there were no

significant differences between the groups regarding

previous children. In addition, although participation

in strenuous endurance sports is a well-known risk factor

for reproductive dysfunction [27], none of our patients

were recognized as professional athletes. Thus, active

Table 3. Occupational characteristics of patients with female versus

male infertility: exposure to potential reproductive toxic agents

Characteristics

Female infertility

(n = 64)

Controls

(n = 106) P

Chemical agents

Metals 2 (3.1%) 2 (1.9%) 0.605

Pesticides 1 (1.6%) 3 (2.8%) 0.485

Solvents 3 (4.6%) 4 (3.8%) 0.936Physical agents

Noise 9 (14.14%) 10 (9.4%) 0.353

Radiation 2 (3.1%) 3 (2.8%) 0.912

Solar radiation 5 (7.8%) 10 (9.4%) 0.522

Heat 2 (3.1%) 3 (2.8%) 0.912

Physical effort during work

Difficult 13 (20.3%) 18 (17.0%)

Moderate 32 (50.0%) 55 (51.2%)

Mild 19 (29.7%) 33 (31.1%) 0.782

Work experience (years) 4.0 ± 3.5 4.4 ± 3.7 0.579

Weekly hours 33.6 ± 16.8 26.9 ± 17.4 0.028Shift work 7 (11.0%) 9 (8.5%) 0.596

Data are presented as means ± standard deviation or numbers and

percentages.

Table 4. Burnout, job strain and job satisfaction of patients with

female versus male infertility

Characteristics

Female

infertility

(n = 64)

Controls

(n = 106) P

Burnout

Burnout 3.3 ± 1.0 3.4 ± 0.9 0.528

Tension 3.3 ± 1.4 3.7 ± 1.4 0.241

Listlessness 2.6 ± 1.1 3.1 ± 1.2 0.013

Cogni tive weariness 2.6 ± 1.3 2.7 ± 1.2 0.679

Job strain

Job demands 1.1 ± 0.8 1.2 ± 0.7 0.371

Personal schedule freedom 1.7 ± 1.0 1.7 ± 1.0 0.981

Intellectual discretion 16.9 ± 5.0 17.5 ± 4.8 0.552 Job satisfaction 3.9 ± 0.9 3.8 ± 1.1 0.656

268 OCCUPATIONAL MEDICINE



participation in sport activity may not be counted as a

factor for inducing infertility.

A major limitation of our study is its small size and the

homogeneity of occupations. One major drawback was

our inability to assess the effect of occupational exposures

to reproductive toxic agents on female infertility. It is

possible that in a larger cohort, the non-significant trend

we found between patients working as caretakers wouldhave been found to be statistically significant. This issue

should be evaluated in larger prospective studies, while in

addition investigating the possible influence of antibodies

from infectious diseases, which might be indigenous in

preschool populations.

In conclusion, patients admitted due to female

infertility tended to have lower listlessness scores as

compared with patients admitted due to their partner’s

infertility. No significant association was found between

other burnout, job strain and job satisfaction scores and

female fertility status. Our findings suggest gender differ-

ences in dealing with infertility. Further prospective

studies, including a higher number of participants, shouldinvestigate the effect of occupational stress on female

infertility as well as gender differences.

Acknowledgements

Presented in part at the First Congress of Women’s Mental

Health, Beer-Sheva, Israel, 16 October 2002. Supported in

part by a grant from The Whitman family, Ben-Gurion Uni-

versity Center for Women’s Health Studies and Promotion.

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Work Stress and Fertility