Abstract
Background:
PCOS is associated with substantial psychological morbidity related to its clinical features and associated infertility.
Aim:
To compare psychological morbidity and fertility quality of life (FertiQoL) amongst infertile women with and without PCOS and to correlate the psychological parameters with clinical, socio-demographic, endocrine and metabolic parameters.
Settings and Design:
Analytical cross-sectional study.
Materials and Methods:
Psychological assessment was done using validated questionnaires for Stress (Perceived Stress Scale); Anxiety (Hamilton Anxiety Rating Scale); depression (Patient Health Questionnaire-9) and quality of life (FertiQoL tool [core]). The main outcome measure was psychological morbidity and FertiQoL scores and correlation of these with clinical, socio-demographic, endocrine and metabolic parameters.
Statistical Analysis Used:
The categorical data were analysed using the Chi-square or Fisher’s exact test. Shapiro–Wilk test/t-test was used to assess the normality and Spearman’s rank correlation was applied for correlation analysis. A two-tailed P < 0.05 was considered statistically significant.
Results:
Stress and anxiety were significantly higher in non-PCOS women. Depression and FertiQoL scores were comparable between the two groups. Amongst PCOS women, longer infertility duration and obesity were associated with the lower quality of life based on FertiQ_E, FertiQ_MB and total FertiQoL scores. In non-PCOS women, obese women were more likely to have depression and lower quality of life. Longer duration of infertility led to depression and poor FertiQ_E scores. On regression analysis in PCOS women, BMI was independent factor having positive association with depression, anxiety and negative association with individual and total FertiQoL scores.
Conclusions:
PCOS women had comparable depression and FertiQoL scores and lower levels of anxiety and stress when compared to non-PCOS women. Longer duration of infertility and obesity were associated with depression and lower quality of life irrespective of cause.
KEYWORDS: Fertility quality of life scale, infertility, polycystic ovary syndrome, psychological morbidity, quality of life
INTRODUCTION
Infertility, defined as the inability to conceive after 1 year of unprotected intercourse, is an emerging health concern. The global prevalence of infertility has risen by 14.9% in 2017 compared to 1990, now affecting more than 10% of the world’s population.[1] Inability to conceive along with time and cost involved in the treatments, often leads to distress and psychological morbidity in the affected couples and especially women.[2] The need for early detection, with comprehensive support systems to effectively address the mental health needs of infertile women has been emphasised by many authors.[3]
Polycystic ovary syndrome (PCOS) is one of the most common endocrinological disorders worldwide, affecting around 12%–21% of reproductive age women.[4] In India, the reported prevalence of PCOS ranges from 3.7% to 22.5%.[5] Being the most prevalent cause of anovulatory infertility, PCOS contributes substantially to the overall burden of infertility and its consequences. Along with anovulatory infertility, PCOS women often suffer from other symptoms including infrequent menses, obesity, hirsutism, acne, sleep and sexual disturbances which precipitate their psychological ill-health.[6,7] Along with symptomatic treatments, it is imperative to address the mental health issues along with symptomatic treatments for all women with the diagnosis of PCOS.[8] Few authors have reported that PCOS women to have poorer psychological health as compared to non-PCOS infertile counter parts,[9] although data are inconclusive.[10]
In addition to standard scales for assessing psychological morbidity (stress, anxiety and depression), Fertility Quality of Life (FertiQoL) Scale has been developed to assess FertiQoL amongst men and women experiencing fertility problems.[11] Although some specific scales have been developed for assessing psychological morbidity amongst PCOS women, these cannot be used for assessing and comparing psychological morbidity in non-PCOS infertile women.[12,13]
The present study was planned to evaluate and compare the psychological morbidity (stress, anxiety and depression) and FertiQoL between PCOS and non-PCOS infertile Indian women and to correlate these psychological parameters with clinical, socio-demographic, endocrine and metabolic parameters.
MATERIALS AND METHODS
Study design and setting
This was an analytical cross-sectional study, conducted at the Outpatient Department and Infertility Clinic in the Department of Obstetrics and Gynaecology at All India Institute of Medical Sciences, New Delhi (India). The study was conducted from March 2019 to December 2021 and was commenced after receiving ethical clearance from the institute’s review board (Institute Ethics committee) (IECPG-712/19.12.2019) and with Helsinki declaration.
Subjects and methods
The study included infertile women (aged 21–38 years) either with the diagnosis of PCOS (as per Rotterdam criteria 2003) or those visiting clinic for other causes of infertility (tubal, male factor and unexplained infertility [UI]). Patients visiting with complaints of infertility (those trying for pregnancy with unprotected sexual intercourse at least for 1 year or those >35 years and trying for >6 months) were screened and recruited as per the inclusion and exclusion criteria.
The primary objective was to assess the psychological morbidity amongst infertile women with and without PCOS. The secondary objectives were to correlate the psychological morbidity with various clinical, socio-demographic, endocrine and metabolic parameters.
A sample size of convenience was decided to take at least 125 women in each group.
Screening was done among all infertile women attending Obstetrics and Gynaecology Out-patient department. Eligible women were explained about the type, purpose and duration of study in a language understood by them and were enrolled after informed written consent. Clinical history, including demographic details, anthropometric measurements; height (cm), weight (kg), hip circumference (widest part of hip), waist circumference (horizontal to umbilicus) and BMI were documented.
On day 2–3 of spontaneous or induced menses, blood sample (5–6 mL) was taken for hormonal analysis (serum LH, follicle-stimulating hormone [FSH], total testosterone, TSH, prolactin and ANti-mullerian Hormone (AMH) [Beckman Coulter; Chemiluminescence Immunoassay]), serum fasting insulin levels, blood sugar fasting and post-prandial and lipid profile. In early follicular phase of menstrual cycle, ovarian volume and follicle number per ovary were measured using transvaginal ultrasound. On the basis of symptoms, clinical examination and investigations, patients were classified into PCOS and non-PCOS women. PCOS women were further classified into phenotypes based on the NIH 2012 extension of ESHRE/ASRM 2003 criteria: Phenotype A: Hyperandrogenism (HA) + Oligo/anovulation (OA) + Polycystic ovarian morphology (PCOM); Phenotype B: HA + OA; Phenotype C: HA + PCOM and Phenotype D: OA + PCOM.
Criteria: HA (clinical – modified FG score ≥5 or biochemical – serum testosterone ≥0.56 ng/mL), OA) and PCOM (antral follicle count ≥12 or ovarian volume >10 cc).
Instruments to assess psychological health morbidity
Stress was measured using the Perceived Stress Scale (PSS), anxiety using the Hamilton Anxiety Rating Scale (HAM-A) and depression using the Patient Health Questionnaire-9 (PHQ-9).[14,15,16] FertiQoL was assessed using the core module of FertiQoL tool, which included the Emotional (E), Mind/Body (MB), Relational (RR) and Social (RS) domains of the instrument.[17] The FertiQoL_TR (total) is scored from 0 to 100, with higher scores indicating better QOL. All participants were informed about the nature of the questionnaires and a designated resident was responsible for explaining how to complete them. Participants were offered the choice of Hindi or English versions of all scales and were provided with a peaceful environment and sufficient time as needed to complete the questionnaires. The PSS, PHQ-9 and FertiQoL were filled out by the patients themselves and Hamilton Anxiety Scale (HAM-A) was scored by clinicians.
Statistical analysis
Data were entered and managed in Microsoft Excel and statistical analysis was carried out using Stata 18.0 (StataCorp LLC, College Station, TX, USA). Data were presented as mean ± standard deviation or median (p25–p75) for the continuous variables and as number or percentage for the categorical variables. Categorical socio-demographic parameters were compared between PCOS and non-PCOS infertile women using the Chi-square/Fisher’s exact test. All the continuous parameters were assessed for the normality assumption using Shapiro–Wilk test and parameters that followed normal distribution were compared between PCOS and non-PCOS infertile women using unpaired t-test and parameters that did not follow normal distribution were compared using Wilcoxon rank-sum test. Correlation of clinical, endocrine and metabolic parameters of participants with stress, anxiety, depression and FertiQoL variables was assessed using Spearman rank correlation coefficient. Furthermore, linear regression analysis and univariate and multivariate analyses were carried out to find the relationship of clinical, endocrine and metabolic parameters with psychological morbidity. A two-tailed P < 0.05 was considered statistically significant.
RESULTS
A total of 399 infertile women were screened during the study period according to the inclusion and exclusion criteria. After excluding drop-outs, lost to follow up and incomplete data, 126 women with PCOS and 126 non-PCOS infertile women were included in the final analysis [Supplemetary Figure 1 (1.7MB, tif) ]. Table 1 describes the demographic, clinical endocrine and metabolic parameters of the study groups. The mean age and duration of infertility were comparable between the two groups, whereas weight and BMI were significantly higher in the PCOS group. More than half of the women with PCOS had already undergone some form of fertility treatment, while the majority of the non-PCOS cohort (57.1%) had not received any treatment at the time of assessment.
Table 1.
Baseline clinical, demographic and biochemical characteristics of the study groups
| Variable | PCOS (n=126) | Non-PCOS (n=126) | P |
|---|---|---|---|
| Age (years)* | 28.5±3.3 | 29.4±4.4 | 0.058 |
| SES@ | |||
| Upper class | 19 (15.1) | 2 (1.5) | 0.001s |
| Upper middle | 52 (41.3) | 57 (45.2) | |
| Lower middle | 39 (30.9) | 55 (43.6) | |
| Upper lower | 16 (12.7) | 12 (9.5) | |
| Patient education@ | |||
| Post-school | 75 (59.5) | 101 (80.1) | <0.001s |
| School | 50 (39.6) | 16 (12.7) | |
| Illiterate | 1 (0.79) | 9 (7.14) | |
| Patient profession@ | |||
| Employed | 32 (25.4) | 13 (10.3) | 0.002s |
| Homemakers | 94 (74.6) | 113 (89.6) | |
| Family@ | |||
| Joint | 54 (42.9) | 75 (59.5) | 0.006s |
| Nuclear | 72 (57.1) | 51 (40.5) | |
| Weight (kg)* | 62.12±9.9 | 56.3±8.0 | <0.0001s |
| BMI (kg/m2)* | 26.10±3.9 | 24.24±3.2 | 0.0001s |
| Type of infertility@ | |||
| Primary | 92 (73.0) | 103 (81.7) | 0.098 |
| Secondary | 34 (26.9) | 23 (18.2) | |
| Duration of infertility (years)# | 4 (2–6) | 4.75 (3–6) | 0.124 |
| Treatment received@ | |||
| None | 47 (37.3) | 72 (57.1) | 0.004s |
| OVI±IUI | 64 (50.7) | 36 (28.6) | |
| IVF | 7 (5.5) | 8 (6.3) | |
| Waiting for IVF | 8 (6.3) | 10 (7.9) | |
| Biochemical parameters | |||
| FSH (mIU/mL)# | 5.2 (4.2–5.8) | 5.7 (4.8–7) | 0.14 |
| LH (mIU/mL)# | 6.8 (4.6–9.9) | 4.2 (2.9–5.8) | <0.001s |
| LH/FSH ratio# | 1.2 (0.94–1.9) | 0.71 (0.5–0.9) | <0.001s |
| TSH (uIU/mL)# | 2.5 (1.88–3.6) | 2.4 (1.7–3.5) | 0.287 |
| PRL (ng/mL)* | 14.4±5.1 | 15.1±6.8 | 0.395 |
| AMH# | 10.9 (6.8–15.2) | 3.2 (1.9–4.3) | <0.001s |
| FBS (mg/dL)* | 91.0±9.7 | 92.1±8.7 | 0.336 |
| Fasting insulin (uIU/mL)# | n=126 | n=53 | |
| 9.4 (6.5–11.8) | 6.2 (4.8–7.5) | <0.0001s | |
| HOMA-IR# | 2.1 (1.5–2.6) | 1.3 (1.0–1.8) | <0.0001s |
*Mean±SD, #Median (p25–p75), @n (%), sP<0.05. PCOS: Polycystic ovary syndrome, SES=Socio-economic status, FSH=Follicle-stimulating hormone, LH=Luteinizing Hormone, TSH=Thyroid-stimulating Hormone, PRL=Prolactin, AMH=Anti-Müllerian Hormone, FBS=Fasting blood sugar, HOMA-IR=Homeostatic model assessment of insulin resistance, OVI=Ovulation induction, IUI=Intrauterine insemination, IVF=in vitro fertilization, SD=Standard deviation, BMI=Body mass index
Psychological morbidity and fertility quality of life scores amongst PCOS versus non-PCOS women
The distribution of psychological morbidity parameters (stress, anxiety and depression) and FertiQoL scores in PCOS and non-PCOS groups are shown in Figure 1a and b, respectively. As shown in Table 2, both stress (P < 0.001) and anxiety (P = 0.033) were significantly higher in non-PCOS women compared to PCOS women. There were no significant differences in depression and FertiQoL scores (individual and total scores) between PCOS and non-PCOS infertile women.
Figure 1.
Distribution of psychological morbidities and fertility-related quality of life between women with and without PCOS. (a) Stress, anxiety, and depression; (b) Raw Emotional, Raw Mind and Body, Raw Relational, Raw Social and Raw Total FertiQol
Table 2.
Comparison of psychological morbidity markers in polycystic ovary syndrome and non-polycystic ovary syndrome groups
| Variables | PCOS group (n=126) | Non-PCOS group (n=126) | P |
|---|---|---|---|
| Depression# | |||
| A | 5 (2–12) | 8 (2–12) | 0.206 |
| B | 1 (1–2) | 1.5 (1–2) | 0.811 |
| Anxiety# | 5 (2–10) | 8 (4–13) | 0.033s |
| Stress* | 17.3±7.4 | 20.8±8.7 | <0.001s |
| FertiQoL* | |||
| A | 2.2±0.8 | 2.3±0.9 | 0.33 |
| B | 2.4±0.8 | 2.2±0.9 | 0.134 |
| Raw emotional* | 10.2±3.1 | 10.3±3.7 | 0.81 |
| Raw mind body* | 12.2±5 | 12.7±5.7 | 0.492 |
| Raw relational* | 16.3±4.2 | 15.7±4.2 | 0.271 |
| Raw social* | 13.8±5.2 | 12.7±5.3 | 0.11 |
| Total raw* | 52.6±13.1 | 51.5±15.4 | 0.548 |
*Mean±SD, #Median (p25–p75), sP<0.05. PCOS=Polycystic ovary syndrome, FertiQol=Fertility quality of life
Correlation of psychological morbidity and fertility quality of life with clinical, socio-demographic, endocrine and metabolic parameters
The relationship of psychological morbidity parameters (stress, anxiety and depression) with clinical, socio-demographic and endocrine parameters in PCOS and non-PCOS women is shown in Figure 2a and b, respectively.
Figure 2.
Correlation of demographic and clinical variables with psychological morbidity parameters and fertility-related quality of life (FertiQoL) scores among (a) PCOS women; (b) non-PCOS women. *P<0.05
In the PCOS group [Figure 2a], there was no correlation of clinical and endocrine parameters with stress, anxiety and depression. There was a significant negative correlation between duration of infertility and FertiQ_E (r = −0.176, P = 0.049). There was a significant negative correlation between BMI and FertiQ_MB (r = −0.213, P = 0.016) and total FertiQoL (r = −0.216, P = 0.015). AMH was negatively correlated with FertiQ_RR. In the non-PCOS group [Figure 2b], there was a positive correlation of BMI with depression (r = 0.282, P = 0.043) and negative correlation of BMI with FertiQ_E (r = −0.295, P = 0.034) and total FertiQoL scores (r = −0.281, P = 0.044). Duration of infertility was positively correlated with depression (r = 0.339, P = 0.014) and negatively correlated with FertiQ_E (r = −0.371, P = 0.007).
Regression analyses in PCOS women: Factors of psychological morbidity
The factors associated with psychological morbidity and QoL were assessed using both univariate [Table 3a and b] and multiple linear regression analyses [Figure 3a and b]. BMI was an independent factor associated with depression, anxiety indicating a positive association and it affected all the domains and total FertiQoL scores indicating a negative association. PCOS women belonging to nuclear family had a significantly better relational FertiQoL (RR) scores. Women with higher FG score had a poor FertiQoL _MB scores. The stress score was significantly higher in women with schooling or less educated women as compared to graduated and above women (P − 0.038).
Table 3a.
Relationship of demographic, anthropometric and laboratory parameters with Perceived Stress Scale, Hamilton Anxiety Scale, Patient Health Questionnaire using simple linear regression analysis
| Variables | Stress |
Anxiety |
Depression |
|||
|---|---|---|---|---|---|---|
| β (SE) | P | β (SE) | P | β (SE) | P | |
| Age | −0.31 (0.19) | 0.122 | −0.01 (0.17) | 0.940 | −0.19 (0.16) | 0.216 |
| BMI | 0.10 (0.17) | 0.555 | 0.25 (0.14) | 0.065 | 0.25 (0.13) | 0.051 |
| FG score | −0.003 (0.12) | 0.980 | 0.05 (0.10) | 0.620 | −0.10 (0.09) | 0.311 |
| Cycle length | 1.03 (0.89) | 0.248 | 0.50 (0.73) | 0.496 | 1.13 (0.69) | 0.103 |
| Infertility duration | 0.20 (0.22) | 0.380 | 0.07 (0.19) | 0.717 | 0.13 (0.18) | 0.472 |
| AMH | 0.06 (0.13) | 0.655 | 0.06 (0.10) | 0.567 | 0.03 (0.10) | 0.790 |
| Testosterone | −1.10 (2.82) | 0.696 | 0.91 (2.32) | 0.694 | −1.54 (2.21) | 0.488 |
| HOMA-IR | −0.31 (0.40) | 0.443 | −0.17 (0.33) | 0.595 | −0.23 (0.31) | 0.471 |
| Triglyceride | 0.0009 (0.02) | 0.953 | 0.004 (0.01) | 0.773 | 0.01 (0.01) | 0.281 |
| Educations | ||||||
| Schooling and below | 2.79 (1.33) | 0.038* | 1.32 (1.11) | 0.236 | 1.16 (1.06) | 0.272 |
| SESs | ||||||
| Middle | −1.32 (1.88) | 0.482 | −0.82 (1.55) | 0.600 | −0.64 (1.46) | 0.663 |
| Lower | −1.96 (2.53) | 0.440 | −0.74 (2.09) | 0.721 | −2.95 (1.97) | 0.137 |
| Family types | ||||||
| Nuclear versus joint | 0.43 (1.34) | 0.751 | 0.26 (1.10) | 0.815 | −0.23 (1.05) | 0.830 |
| Phenotype | ||||||
| D versus A | 1.22 (1.39) | 0.383 | 0.15 (1.12) | 0.891 | 2.04 (1.08) | 0.060 |
sReference category for Education is ‘Graduation and above’; for SES is ‘upper SES’ and for family type is ‘joint family’. BMI=Body mass index, HOMA-IR=Homeostatic model assessment of insulin resistance, SES=Socio-economic status, SE=Standard error, AMH=Anti-Müllerian hormone
Table 3b.
Relationship of demographic, anthropometric and laboratory parameters with fertility quality of life score using the simple linear regression analysis
| Variables | Emotional |
Mind body |
Relational |
Social |
Total FertiQol |
|||||
|---|---|---|---|---|---|---|---|---|---|---|
| β (SE) | P | β (SE) | P | β (SE) | P | β (SE) | P | β (SE) | P | |
| Age | 0.02 (0.08) | 0.769 | 0.01 (0.13) | 0.919 | 0.15 (0.11) | 0.185 | 0.23 (0.14) | 0.107 | 0.42 (0.35) | 0.236 |
| BMI | −0.11 (0.07) | 0.100 | −0.27 (0.11) | 0.016* | −0.16 (0.09) | 0.082 | −0.16 (0.12) | 0.179 | −0.71 (0.29) | 0.015* |
| FG score | 0.02 (0.05) | 0.639 | −0.07 (0.08) | 0.421 | 0.04 (0.07) | 0.597 | 0.07 (0.09) | 0.430 | 0.06 (0.21) | 0.772 |
| Cycle length | −0.24 (0.37) | 0.521 | −0.74 (0.60) | 0.219 | −0.73 (0.50) | 0.150 | −0.18 (0.63) | 0.783 | −1.88 (1.56) | 0.230 |
| Duration of infertility | −0.18 (0.09) | 0.049* | −0.24 (0.15) | 0.122 | −0.20 (0.13) | 0.123 | −0.07 (0.16) | 0.649 | −0.69 (0.39) | 0.082 |
| AMH | −0.07 (0.05) | 0.193 | −0.01 (0.09) | 0.864 | −0.15 (0.07) | 0.036* | −0.11 (0.09) | 0.235 | −0.34 (0.22) | 0.127 |
| Testosterone | −0.82 (1.16) | 0.480 | −2.64 (1.90) | 0.167 | −0.39 (1.61) | 0.807 | 0.58 (2.01) | 0.774 | −3.28 (4.97) | 0.510 |
| HOMA-IR | 0.20 (0.16) | 0.215 | 0.35 (0.27) | 0.202 | −0.31 (0.23) | 0.169 | −0.07 (0.28) | 0.794 | 0.16 (0.70) | 0.817 |
| Triglyceride | −0.01 (0.01) | 0.089 | −0.02 (0.01) | 0.095 | −0.004 (0.01) | 0.666 | −0.01 (0.01) | 0.597 | −0.04 (0.03) | 0.163 |
| Educations | ||||||||||
| Schooling and below | −0.66 (0.56) | 0.239 | −0.47 (0.92) | 0.612 | −1.92 (0.75) | 0.012* | −1.39 (0.96) | 0.150 | −4.43 (2.36) | 0.063 |
| SESs | ||||||||||
| Middle | 0.03 (0.78) | 0.966 | 0.45 (1.28) | 0.724 | −0.98 (1.06) | 0.360 | 0.77 (1.34) | 0.565 | 0.28 (3.33) | 0.932 |
| Lower | −0.26 (1.05) | 0.802 | 1.27 (1.72) | 0.461 | −2.63 (1.43) | 0.068 | −0.69 (1.80) | 0.702 | −2.31 (4.47) | 0.607 |
| Family types | ||||||||||
| Nuclear | 0.06 (0.55) | 0.920 | 0.00 (0.91) | 1.000 | 2.53 (0.73) | 0.001* | 0.21 (0.96) | 0.828 | 2.79 (2.36) | 0.238 |
| Phenotype | ||||||||||
| D versus A | −0.26 (0.56) | 0.641 | −0.50 (0.94) | 0.594 | −0.65 (0.79) | 0.415 | −0.66 (0.98) | 0.499 | −2.07 (2.45) | 0.399 |
sReference category for Education is ‘Graduation and above’; for SES is ‘upper SES’ and for family type is ‘joint family’. BMI=Body mass index, HOMA-IR=Homeostatic model assessment of insulin resistance, SES=Socio-economic status, SE=Standard error, AMH=Anti-müllerian hormone, FertiQol=Fertility Quality of Life
Figure 3.
Forest plot showing multivariable regression analysis showing the association of demographic and clinical variables with psychological outcomes and fertility-related quality of life (FertiQoL). (a) Stress, anxiety, and depression; (b) Emotional, Mind Body, Relational, Social and Total FertiQol Score. *P<0.05
DISCUSSION
The findings of the present study indicate that infertility itself is an independent stressor and PCOS status does not add to psychological morbidity and FertiQoL deterioration amongst infertile women. The study concluded a significant effect of longer duration of infertility and high BMI on psychological morbidity amongst both PCOS and non-PCOS infertile women.
Recently, there have been studies evaluating the psychological morbidity amongst PCOS women, but the results are inconclusive as multiple factors interplay thus making it difficult to draw the uniform conclusions. The presence of hirsutism in PCOS women has been shown to be associated with higher prescriptions of anti-depression medications.[18] Our study also revealed poor FertiQoL_MB scores amongst PCOS women with higher mFG scores, although no correlation was found between biochemical hyperandrogenemia with any of the psychological parameters. This may be explained by the negative perception of physical appearance (higher mFG scores) leading to low self-esteem and quality of life.
Santoro et al. studied the fertility-related quality of life using FertiQoL scale and reported that PCOS women had significantly lower scores in all the domains (P < 0.001) than women in UI except relational domain.[10] However, on multivariate analysis after adjustment of age, BMI, hirsutism score, education, annual household income and race on FertiQoL scores, FertiQoL total or domain scores became comparable between women with PCOS and those with UI. The present study also failed to show any causal relation between PCOS status and psychological morbidity and FertiQoL scores were comparable between PCOS and non-PCOS infertile women.
Similar to Santoro et al., our study reported lesser scores of depression, stress and anxiety with increasing age and improvement in the emotional domain of FertiQoL with increasing age. The exact explanation for this observation may be difficult but may be explained by negative effect of duration of infertility on psychological health more than age of women.
Obesity has been reported to be an independent stressor amongst infertile women where it considerably affects the mental health, quality of life and sexual function of infertile women.[19,20] BMI remained an independent variable affecting anxiety, depression and all individual and total scores of FertiQoL in the present study.
Similar to the study by Mínguez-Alarcón et al. which reported higher perceived stress scores amongst PCOS women with higher AMH levels,[21] our study reported poor FertiQol scores amongst PCOS women with higher AMH levels.
The main strength of this study is being the first and largest study of its kind to compare the psychological health of infertile women with and without PCOS in the Indian Asian population, with a good sample size. The main limitation of the study was COVID pandemic during the study period which led to the suspension of routine OPD services for many months. The study did not assess male partners for psychological assessment. The impact of sleep and sexual dysfunction on psychological health and FertiQoL scales amongst PCOS women were also not studied. As the study commenced before updated PCOM criterion, the cutoff for PCOM was taken as 12. Difference in baseline parameters and previous fertility treatments may have affected the final results of the study which need to be studied further.
CONCLUSION
Women with PCOS had lower levels of anxiety and stress and similar levels of depression compared to non-PCOS women. Both PCOS and non-PCOS infertile women had comparable FertiQoL scores. Longer duration of infertility and obesity were associated with depression and lower quality of life irrespective of cause. The study emphasises the need of psychological health screening as a part of initial assessment of all infertile women, so that those with poor scores may be referred for psychological interventions. Further prospective data are needed to assess the impact of PCOS on psychological health, sleep and sexual health.
Author contribution
RM: Conceptualization, methodology, draft writing; DP-conceptualisation, methodology, data collection, investigations; MK-methodology, formal analysis; CH-methodology, formal analysis; RP-conceptualisation, methodology; AKJ-data analysis, data curation; RB-writing and editing; AS-writing and editing. All the authors have read the final draft of manuscript and approved.
Conflicts of interest
There are no conflicts of interest.
Data availability statement
Data will be made available with reasonable request to the corresponding author.
Disclosure on use of Artificial Intelligence
None.
Flow diagram showing the progression of patients from screening to inclusion. LFTU-Loss to follow-up, OPD-Outpatient Department, PCOS-Polycystic Ovary Syndrome
Acknowledgements
The authors express their sincere gratitude to all the study participants for their invaluable contribution.
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Flow diagram showing the progression of patients from screening to inclusion. LFTU-Loss to follow-up, OPD-Outpatient Department, PCOS-Polycystic Ovary Syndrome
Data Availability Statement
Data will be made available with reasonable request to the corresponding author.