Department of Community Medicine

HCM&D
Community Medicine Research
Synopsis Group: United
Supervisor: Dr.Shahid Ahsan
Group Members:
Inam ullah Bukhari Azeem Altaf
Naseebullah Khan khalil khan
Usman Khan Anita iqbal
Nimra Tariq Nusrat
Ramsha
Title:Depression and its Factors
among primary infertile women in
Karachi Background:
Infertility
There is no unanimous definition of female infertility, because the definition
depends on social and physical characteristics which may vary by culture and
situation. According to the World Health Organization (WHO), infertility can be
described as the inability to become pregnant, maintain a pregnancy, or carry a
pregnancy to live birth(1).

Prevalence:
Female infertility varies widely by geographic location around the world. In 2010,
there was an estimated 48.5 million infertile couples worldwide, The highest rate
regions included Eastern Europe, North Africa, the Middle East, Oceania, and Sub-
Saharan Africa(2).

Types
Infertility can further be broken down into primary and secondary infertility. Primary
infertility refers to the inability to give birth either because of not being able to
become pregnant, or carry a child to live birth, which may include miscarriage or a
stillborn child. [5][6] Secondary infertility refers to the inability to conceive or give
birth when there was a previous pregnancy or live birth

Causes and factors Causes or factors of female infertility can

basically be classified regarding whether they are acquired or genetic, or strictly by
location.
 Although factors of female infertility can be classified as either acquired or genetic,
female infertility is usually more or less a combination of nature and nurture. Also, the
presence of any single risk factor of female
infertility

Acquired According to the American Society for Reproductive Medicine Age,

Smoking, Sexually Transmitted Infections, and Being Overweight or Underweight
can all affect fertility.

Age A woman's fertility is affected by her age. The average age of a girl's first
period (menarche) is 12-
13 A woman's fertility peaks in the early and mid 20s, after which it starts to
decline, with this decline being accelerated after age 35. However, the exact
estimates of the chances of a woman to conceive after a certain age are not clear,
with research giving differing results.(14)

Tobacco smoking Is injrous to the ovaries, and the degree of damage is

dependent upon the amount and length of time a woman smokes or is exposed to a
smoke-filled environment. Nicotine and other harmful chemicals in cigarettes
interfere with the bodys ability to create estrogen, a hormone that regulates
folliculogenesis and ovulation. Also, cigarette smoking interferes with
folliculogenesis, embryo transport, endometrial receptivity, endometrial
angiogenesis, uterine blood flow and the uterine myometriumAlso, female smokers
have an earlier onset of menopause by approximately 14 years.

Sexually transmitted infections leading cause of infertility. They

often display few, if
any visible symptoms, with the risk of failing to seek proper treatment in time to
prevent decreased
fertility

Body weight and eating disorders Twelve percent of all infertility cases are a
result of a woman either being underweight or overweight. Fat cells produce
estrogen,[18] in addition to the primary sex organs. Too much body fat causes
production of too much estrogen and the body begins to react as if it is on birth
control, limiting the odds of getting pregnant.Too little body fat causes insufficient
production of estrogen and disruption of the menstrual cycle.] Both under and
overweight women have irregular cycles in which ovulation does not occur or is
inadequate.[14] Proper nutrition in early life is also a major factor for later fertility
 Chemotherapy Chemotherapy poses a high risk of infertility.
Chemotherapies with high risk of infertility include procarbazine and other
alkylating drugs such as cyclophosphamide, ifosfamide, busulfan, melphalan,
chlorambucil and chlormethine.Drugs with medium risk include doxorubicin and
platinum analogs such as cisplatin and carboplatin]

Adhesions secondary to surgery in the peritoneal cavity is the leading cause of

acquired infertility.[27] A meta-analysis in 2012 came to the conclusion that there
is only little evidence for the surgical principle that using less invasive
Diabetes mellitus. A review of type 1 diabetes came to the result that,
despite modern treatment, women with diabetes are at increased risk of female
infertility, such as reflected by delayed puberty and menarche, menstrual
irregularities,Coeliac disease . Non-gastrointestinal symptoms of coeliac
disease may include disorders of fertility, such as delayed menarche, amenorrea,
infertility or early menopause; and pregnancy complications, such as intrauterine
growth restriction (IUGR), small for gestational age (SGA) babies, recurrent
abortions, preterm deliveries or low birth weight (LBW) babies. Nevertheless,
gluten-free diet reduces the risk. Some authors suggest that physicians should
investigate the presence of undiagnosed coeliac disease in women with
unexplained infertility, recurrent miscarriage or IUGR Significant liver or kidney
disease Thrombophilia

Genetic factors There are many genes wherein mutation causes female
infertility, as shown
in table below. Also, there are additional conditions involving female infertility which
are believed to be genetic but where no single gene has been found to be
responsible, notably Mayer-Rokitansky-KstnerHauser Syndrome (MRKH).

By location Hypothalamic-pituitary factors Hypothalamic dysfunction

Hyperprolactinemia
Ovarian factors Chemotherapy also disturb ovarian function. Polycystic ovary
syndrome )
Anovulation. Female infertility caused by anovulation is called "anovulatory
infertility", as opposed to
"ovulatory infertility" in which ovulation is present Diminished ovarian reserve, also
see Poor Ovarian Reserve Premature menopause
Menopause Luteal dysfunction[45] Gonadal dysgenesis (Turner syndrome)
Ovarian cancer
Tubal (ectopic)/peritoneal factors[edit] Further information: Tubal factor infertility
Endometriosis (also see endometriosis and infertility) Pelvic adhesions Pelvic
inflammatory diseaseTubal dysfunction
Previous ectopic pregnancy. Uterine factor Uterine malformation Uterine fibroids
Asherman's Syndrome Implantation failure
Cervical factors Cervical stenosis Antisperm antibodies Non-receptive cervical
mucus Vaginal factors Vaginismus Vaginal obstruction

Diagnosis of infertility begins with a medical history and physical exam.

The healthcare provider may order tests, including the following: Lab tests o
hormone testing measure of FSH and estrogen, to assess ovarian reserve o
measurements of thyroid function o measurement of progesterone in the second
half of the cycle to help confirm ovulation Examination and imaging o an
endometrial biopsy, o laparoscopy, o fertiloscopy, o Pap smear, o pelvic exam, o
a postcoital test, which is done soon after intercourse to check for problems with
sperm surviving in cervical mucous (not commonly used now because of test
unreliability) o Hysterosalpingography Sonohysterography

There are genetic testing techniques under development to detect any mutation in
genes associated with female infertility.

Prevention: Acquired female infertility may be prevented through identified

interventions: Maintaining a healthy lifestyle. Not delaying parenthood. Egg
freezing.

Mental Impact:
Women who suffer from infertility might deal with psychological stressors such as
denial, anger, grief, guilt, and depression. There can be considerable social shaming
that can lead to intense feelings of sadness and frustration that potentially
contribute to depression and suicide. The implications behind infertility bear huge
consequences for the mental health of an infertile woman because of the social
pressures and personal grief behind being unable to bear children.
Depression
Depression is a common mental disorder, characterized by sadness, loss of interest
or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings
of tiredness, and poor concentration. prevalence
Depression is a common illness worldwide, with more than 300 million people
affected. Depression is different from usual mood fluctuations and short-lived
emotional responses to challenges in everyday life. Especially when long-lasting
and with moderate or severe intensity, depression may become a serious health
condition. It can cause the affected person to suffer greatly and function poorly at
work, at school and in the family. At its worst, depression can lead to suicide. Close
to 800 000 people die due to suicide every year. Suicide is the second leading
cause of death in 15-29-year-olds.
Although there are known, effective treatments for depression, fewer than half of
those affected in the world (in many countries, fewer than 10%) receive such
treatments. Barriers to effective care include a lack of resources, lack of trained
health-care providers, and social stigma associated with mental disorders. Another
barrier to effective care is inaccurate assessment. In countries of all income levels,
people who are depressed are often not correctly diagnosed, and others who do not
have the disorder are too often misdiagnosed and prescribed antidepressants.
The burden of depression and other mental health conditions is on the rise globally.
A World Health Assembly resolution passed in May 2013 has called for a
comprehensive, coordinated response to mental disorders at country level. Types
and symptoms Depending on the number and severity of symptoms, a depressive
episode can be categorized as mild, moderate, or severe.
A key distinction is also made between depression in people who have or do not
have a history of manic episodes. Both types of depression can be chronic (i.e. over
an extended period of time) with relapses, especially if they go untreated.
Recurrent depressive disorder: this disorder involves repeated depressive episodes.
During these episodes, the person experiences depressed mood, loss of interest
and enjoyment, and reduced energy leading to diminished activity for at least two
weeks. Many people with depression also suffer from anxiety symptoms, disturbed
sleep and appetite and may have feelings of guilt or low self-worth, poor
concentration and even medically unexplained symptoms.
Depending on the number and severity of symptoms, a depressive episode can be
categorized as mild, moderate, or severe. An individual with a mild depressive
episode will have some difficulty in continuing with ordinary work and social
activities, but will probably not cease to function completely. During a severe
depressive episode, it is very unlikely that the sufferer will be able to continue with
social, work, or domestic activities, except to a very limited extent. Bipolar affective
disorder: this type of depression typically consists of both manic and depressive
episodes separated by periods of normal mood. Manic episodes involve elevated or
irritable mood, over-activity, pressure of speech, inflated self-esteem and a
decreased need for sleep. Contributing factors and prevention Depression results
from a complex interaction of social, psychological and biological factors. People
who have gone through adverse life events (unemployment, bereavement,
psychological trauma) are more likely to develop depression.
Depression can, in turn, lead to more stress and dysfunction and worsen the
affected persons life situation and depression itself.
There are interrelationships between depression and physical health. For example,
cardiovascular disease can lead to depression and vice versa.
Prevention programmes have been shown to reduce depression. Effective
community approaches to prevent depression include school-based programmes to
enhance a pattern of positive thinking in children and adolescents. Interventions for
parents of children with behavioural problems may reduce parental depressive
symptoms and improve outcomes for their children. Exercise programmes for the
elderly can also be effective in depression prevention. Diagnosis and treatment
There are effective treatments for moderate and severe depression. Health-care
providers may offer psychological treatments (such as behavioural activation,
cognitive behavioural therapy [CBT], and interpersonal psychotherapy [IPT]) or
antidepressant medication (such as selective serotonin reuptake inhibitors [SSRIs]
and tricyclic antidepressants.
 Litreature review
1)In a study conducted in 2015 in Basrah Iraq had aim to examine
prevalence and risk factors of depression among infertile women this was an
cross sectional study which included 251 women attending infertility clinic
they were interviewd using questionnaire and the prevalence of depression
in infertile women was found to be 68.9% it was significantly related to
primary type pf infertility duration treatment and threat of husband(1)

2) a study conducted by Baqai university karachi in 2015 was objected to

identify frequency of depression in infertile women this was an cross
sectional study 100 women were interviewed using depression questionnaire

70% of women were found to have depression and anxiety.(2) 3)

a study
conducted in 2012 in Ghana the study had aim to check depression in
infertile women this was an cross sectional study 100 women were
interviewed using questionnaires the results showed that 62% of women had
depression.(3)

4)individuals experiencing infertility says that it is the most stressful period

of time.a research showed that women with infertility have same levels of
anxiety and depression as do women with cancer,heart diseases and hiv+
status have.(4)

5) a study conducted in greek had aim to check depression and

psychological distress in infertile women it was an cross sectional study
included 404 women the study showed incidence of depressive diorders
were higher in infertile women as compared to infertile

women(5)

6) a study was conducted in Riyadh ,Saudi Arabia in 2011 which was

objected to determine the prevalence of depressive disorders among infertile
women this was an cross sectional stdy which included 91 women result
showed 53% of infertile women had depression at any stage.(6)
7) a study conducted in Korea had aim to investigate the psychological
distress in infertile women it was an cross sectional study which included
141 infertile women and 65 fertile women the incidence of depression was
found to be be significantly higher in infertile women as compare to the
fertile women than(7)

8) A sutdy conduted in turkey from 2004 to 2007 had aim to examine the
status of depression in infertile couples it was an cross sectional study which
included 248 infertile women the results showed that depression occurred
more frequently in infertile women as compare to fertile women'(8)
Objective The objective of the study was to determining the prevalence and
predisposing factors of depressive disorders among the infertile compared to fertile
women.

Methodology :
Study Design:Cross Sectional study
Target Population:Females attendig Infertility Clinic.
Study Setting:the Research will be conducted inPrivate
infertility clinics Karachi.
Duration of study:6 months.
Sampling Technique: Participants will be selected by
simple random sampling from the patient list.
Sample Size:200 infertile patients will be included.
Inclusion Criteria:people selected would be aged
between 20 35years,with infertility duration of > 1
year and diagnosed with primary infertility.
Exclusion criteria:Patients will be excluded from the
study if age would be > 35 years,Or diagnosed as
having any other psychiatric disorder or having
secondary infertility.
Description:The Beck Depression Inventory (BDI)
Scale,urduversion, with some additional variables will
be used.
Validity:Test-retest reliability and validity of Beck
questionnaire has been proven by several studies and
researches.
 variable list:A full 21-items BDI would administered. Each
item describes a specific behavioral, emotional and
somatic manifestation of depression. The 21 items cover
sadness, pessimism, sense of failure, dissatisfaction,
guilt, expectation of punishment, self-dislike, self-
accusations, suicidal ideas, crying, irritability, social
withdrawal, indecisiveness, body image change, work
retardation, insomnia, fatigability, anorexia, weight loss,
somatic preoccupation and loss of libido.
Scores on each item range from 0 indicating no depressive
symptoms to a maximum of 3 indicating severe
symptoms.
Total scale scores can thus range from 0 to 63: a score of
0 9 indicates no depression, 10 15 suggests mild
depression, 16 29 is for moderate severe depression
and 30 or more indicates severe depression.

Demographic Variables:Information about certain

variables including age, duration of marriage, educational
level, occupation, primary cause of infertility, duration of
infertility, number of miscarriages, pressure from family
members to conceive,threats of husband for second
marriage and support from husband will be collected.
Consent:The Data will be collected from those Study
subjects who will give a written or verbal consent.
The Anonymity and confidentiality of subjects will be
strictly maintained.
The participants will have right to withdraw from study at
any point of time.
Data Anlysis:
Statistical analysis will be performed using the (Statistical Package
for Social Sciences Software Version 18) (SPSS). Descriptive
analysis was carried out, estimating mean, standard deviation (SD),
for Beck Depression Inventory scores. Frequencies and percentages
were calculated for the categorical variables. Chisquare was
performed for comparing the level of depression of the infertile and
fertile women. T-test was carried out to explore relationship
between variables.

Rationale:
Inferility being an importantpublic health measuremotivated the conductance of
study in karachi
Being a part of community medicine course in 4th year m.b.b.s
Infertility Bear an social stigma in our society for women one of the aim of study is
spread of awareness for infertile women to cope with deression.

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