This study was a case control study conducted in a tertiary care setup in a medical college of Delhi. The study subjects consisted of patients attending the family planning and infertility clinic. The patients who were married and had children were considered as controls; which were usually the ones attending the family planning OPD. An effort was made to include all the patients attending these clinics during the proposed time span; however those patients who declined participation were excluded. The study was conducted for a period of 6 months in the months of February to July 2014.

A total of 280 females were included in the study. The patients with a past history of medical illness and patients coming for medical termination of pregnancy were excluded from the study. Patient with a previous history of mental illness were also excluded. Data collection was done by a predesigned, prestructured and pretested questionnaire. Prior approval was sought from the ethical committee of the institute and written consent was obtained from the study subjects. The participants were explained the aims and utility of the study and were ensured that all information about every participant would be confidential. For this study; Infertility was defined as primary; if the conception has never occurred in the subject, and secondary; if the conception failed to occur after a previous pregnancy irrespective of the pregnancy outcome; in participants engaged in regular sexual intercourse without contraception for one year. The questionnaire included questions on socio demographic profile namely age, socioeconomic status, education status, employment status and residence. Obstetric information whether the infertility was primary or secondary, parity, history of abortions, treatment history and for how long patient has been trying to get pregnant was asked. The cost of the treatment of infertility whether borne by maternal in-laws, mother alone, or was equally borne by both was included in the questionnaire as well.

The Beck Depression Inventory [21,22] has 21 questions testing the presence of symptoms of hopelessness, irritability, lack of concentration and interest, guilt, fatigue, weight loss, and lack of interest in sex. It is meant for individuals above the age of 13 years. The standard cut-offs are 0-9, 10-18, 19-29 and 30-63 indicating minimal, mild, moderate and severe depression respectively [23].

The Hospital Anxiety and Depression Scale [24] is a standardized scale to study the prevalence of both anxiety and depression in study participants. This scale has 14 items; 7 of which belong to anxiety and 7 of them belong to depression. A score of 8 over a maximum of 21 is considered as a cut off mark for anxiety and depression.

Brief Cope Inventory assesses a wide spectrum of coping responses [25]. It contains 28 items. In total, 14 dimensions are covered by this scale; further every dimension has 2 items. The coping strategies are of two types; the problem focused strategies and the emotion focused strategies, Active planning, using instrumental support, planning are the problem focused measures and measures like self-blame, religion, positive reframing, humor, denial fall into the emotion focused ways to cope with stress [26].

To estimate depression as well as depression and anxiety; a sample size of 123 cases and 123 controls is required; assuming confidence level as 95% with level of significance 5% with effect size of 0.17. The t-test was applied to compare the cases and control groups. Chi-Square with Fischer exact-test was applied to compare the fertile and infertile females. SPSS ver 20 was used to analyse the data.

A total of 296 women were enrolled in the study. Ten women from the family planning OPD and 6 from the infertility clinic were excluded from the study. The exclusion criteria included women with age less than 18 years or greater than 45 years, those who were not available for the collection of data or who were suffering from co-morbidities including but not limited to psychiatric illnesses.

A total of 280 females were thus included in the study. These included; 140 females each from the family planning and the infertility clinic. The mean age of infertile females (cases) was 26.69±5.361. The Mean age of controls was 28.70 ±5.943. Most of the females attending the infertility clinic belonged to 26-35 years of age 45.6% (36/75). The socio demographic characteristics and gynecological and obstetric history of the cases and controls has been depicted in [Table/Fig-1].

Among the total number of infertile females 56.4% (79/140) females were found to be suffering from depression as calculated on the BDI scale. The number of females suffering from secondary infertility outnumbered as compared to females suffering from primary infertility which were 87.14% (122/140) and 12.86% (18/140) respectively. The average/mean BDI scores of the cases was found to be 14.23±7.996, thus most of the women were found to be mildly depressed based on this scale. The BDI score among the controls was found to be 7.29± 2.678. The [Table/Fig-2] shows the data comparing the depressed females on various socio demographic variables based on the BDI scale among the females suffering from infertility.

Among the infertile females depression was statistically significant among the females who had 2 or more than 2 abortions (p-0.001, df=2, Chi-Sq-50.729). Not having even one child was found to be significant factor causing depression (p-0.0001, df=2, chi-sq-35.663), and was found to be the most important risk factor independently associated with depression. The other significant factors associated with causation of depression have been shown in the [Table/Fig-2]. The risk factors which came out to be significant on univariate analysis were increasing age, lack of employment, abortion, no. of children, support from spouse, relatives support, menses, gynaecological infections, duration of infertility and previous treatment of infertility. The females were more commonly depressed if the funds for the treatment of infertility were either funneled from mother or the mother’s relative end rather than the combined cost shared by both (X²-35.902, df=2, p-0.0001). Residence and education status were reported to be insignificant factors among the respondents. The independent risk factors causing depression in the females were found to be number of abortion, number of children, cost of treatment and the duration of infertility and previous treatment of infertility.

The most important method used for coping by the infertile females was venting 72.2% (57/79), followed by behavioural disengagement 70.9% (55/79). The method least commonly used was instrumental support 55/79 (69.6%) among the respondents. [Table/Fig-3] throws light on the various coping strategies adopted by the infertile females.

The HADS scale was used to measure the Anxiety and depression. The number of infertile females suffering from anxiety and depression both; based on the HADS scale were found to be 68.6% (96/140) with a mean HADS score of 12.16±5.347. These findings have been depicted in [Table/Fig-4]. The Mean HADS score for the fertile females was 7.19±1.904. The risk factors which came out to be significant on univariate analysis were increasing age of the study subjects, lack of employment, education, abortion, number of children, support from spouse, lack of support from relatives, menstrual disturbances, gynecological infection, duration of infertility and previous treatment for infertility. The risk of anxiety and depression was higher in women in whom the cost was borne by the maternal in-laws or the mother and was found to be statistically significant as well (X²-33.74, Df-2, p-0.0001). The risk factors independently associated with anxiety and depression on binary logistic regression were lack of employment, duration of infertility, previous treatment for infertility and the cost of treatment, the adjusted odds for which have been shown in [Table/Fig-4]. The various coping strategies adopted by the depressed infertile women have been shown in [Table/Fig-3]. With reference to the infertile women suffering from both anxiety and depression; the coping strategies adopted have been mentioned in the [Table/Fig-5].

The methods adopted by the infertile females to alleviate anxiety and depression were behavioural disengagement 71.9% (69/96), use of instrumental support 70.8% (68/96) and venting 70.8% (68/96) in that order. These findings have been depicted in [Table/Fig-5].

The purpose of the present study was to determine the prevalence and severity of depression using the BDI scale and the combined anxiety and depression using the HADS scale. The percentage of depression in our study was found to be 56.4%; which is in close association with the prevalence of depression seen in developing nations like Ghana 62% [27]; A study conducted on Chinese women has reported higher percentage of depression viz 67% [28]. This study reported depression levels higher compared to study done by Ramezanzadeh et al., who reported levels of depression in the infertile women to be 40.8% [29]. However, study done in Poland found that the rates of depression were 35.44% and were lower as compared to our study [30].

The present study also depict that employed women, spousal support, support from relatives seemed to protect against the causation of depression. However, the presence of gynecological infections and prior treatment of infertility seemed to increase the existence of depression among the infertile women. Similar findings have been reported by Alhassan et al., as well [27]. Studies have shown that fertility of the females peaks at around the age of 26-35 years so depression is more common in this age group [31,32]. Education has a protective effect on depression and educated and employed infertile women are less prone to depression [Table/Fig-3]. According to one study the unemployed women were more prone to develop depression and anxiety compared to their working counterparts [23]. It was also found that the duration of infertility poses a detrimental effect on the women; as the increasing duration of infertility had an increasing association with depression [32,28,33,34]. With reference to educational status the results of our study are in close concordance with the studies done by Ramezanzadeh et al., and Domar et al., [29,35]. However, Study done in Nigeria reported a lower incidence of anxiety viz 37.5% on HADSA scale [36]. Also, study done in Poland reported 15.53% on Beck anxiety inventory which was less compared to our study [30]. In Iran the levels of anxiety were significantly higher as compared to our study and were found to be 86.8% using the cattle questionnaires for surveying anxiety and depression [29]. Primary infertility is not very common; the values from our study are less in comparison as compared to the data from other developing nations [29].

Similar studies using the Brief cope scale have been done in southern Ghana by Donkor S et al., in which the primary method of coping used by women was by keeping information about their infertility to themselves and also women tried to avoid situations that reminded them of infertility [34]. Our study found venting followed by behavioural disengagement as two important causes of coping mechanisms adopted by this set of women; thus bringing forth the India scenario. Study done by Joshi et al., found that problem solving approach, logical analysis and cognitive avoidance were lesser in infertile women as compared to the normal women [37].

The prevalence of depression and anxiety should not be underestimated in the women suffering from infertility. Apart from searching for the obstetrical causes of infertility; psychological morbidity should be considered as a serious concern affecting these women. Moreover, there are several risk factors which may increase the likelihood of psychological stress; like presence of two or more abortions, nulliparity, lack of support from spouse or relatives etc. These must be kept in kind by the clinicians, obstetricians and healthcare workers when evaluating a case of infertility.

Further it is recommended to screen prospective patients coming in for the treatment of infertility; especially if they are found to have presence of any of the above risk factors strongly associated with the prevalence of anxiety and/ or depression in these women. It would be useful if a quick and short screening instrument is developed for the benefit of the clinicians and healthcare workers to identify prospective patients in need of psychosocial assistance.