Quality of Life among Infertile Couples in Gaza City, Palestine

Background: Infertility is an important health problem affecting the quality of life accompanied by significant emotional and psychological consequences. Infertile couples living with emotional disturbances face challenges with less success of infertility treatment. Purposes: This study aimed to investigate the quality of life of infertile couples who seek In-Vitro Fertilizations (IVFs) by gender in Gaza city, Palestinian. Methods and materials: A cross sectional study was conducted, from Feb 2018 to Nov 2018, among 383 infertile couples selected through convenient sampling. A valid and reliable Arabic version of the fertility quality of life questionnaire (FertiQoL) was used in data collection. One way ANOVA and independent t-test was applied to compare between males and females. P value less than 0.05% was considered statistical significance. Results: The mean age of males and females was 34.54±8.54 and 29.28±6.71 years respectively. More than half of them had university degree (64% and 60% respectively). The mean duration of infertility of couples was 5.66±3.54 years. The mean males' scores of FertiQoL and its subscales (emotion, mind/body, social, core, tolerability and treatment) were significantly higher than females' scores (p<0.05). Conclusion: The males' total scores of FertiQoL and its subscales were higher than females' scores. The mean total of FertiQoL increased with better education, however, decreased with increase of age, duration of marriage, duration of infertility and number of IVF attempts. Psychological assessment and Counseling are necessary for infertile women taking into considerations factors affecting their QoL. were very and very satisfied) respectively. For females, 20% and 65.4% dissatisfied and satisfied with quality of their life respectively.


Introduction
Quality of life is one of the most important components of health. The concept of quality of life is defined in different ways and can be interpreted in three ways. The first definition of the welfare aspects of a person's life; the second definition is related to the economic, social and physical abilities and the third definition is dealing with symptoms or specific disease. Measurement of quality of life makes it possible to understand the needs of the clients and thus improve the quality of the services (1,2). Different factors affect the quality of life of individuals. Infertility is one of the most difficult and effective conditions for quality of life and one of the most common problems in today's world (3).
According to the World health Organization (WHO), infertility is as an important problem in reproductive health, which is not a disease but it can cause significant emotional disturbances and cause social and psychological consequences (4). In a study 12% of infertile women had low quality of life, while more than half of them had a decent quality of life. Family and community pressure on the quality of life of infertile women had a significant negative impact (5). Infertile women are more vulnerable to undesirable quality of life than men, and support measures for both sexes, especially women, are essential (6). The prevalence of infertility varies among ethnic groups and races, and is about 10-15%, and its incidence has increased by about 50% over the past decade (7)(8)(9).
In dealing with spiritual issues, couples' participation can be a good solution because there is a positive result in each issue of common life between couples (10). According to the results of the research conducted in comparison with the stressful events of life, infertility after the death of the mother, the death of the father and betrayal of the spouse is in the fourth place (11). One cause of infertility can be physical disease such as the Polycystic Ovary Syndrome, which accounts for 5-10% (12).
Infertility predisposes individuals to depression and anxiety. The emotional disturbances of infertile couples and secondary symptoms of infertility create a defective cycle that reduces the likelihood of treatment of infertility (13). On the other hand, infertility treatments cause harmful effects on the physical, economic, and psychosocial aspects reducing self-confidence and disrupting masculinity in men and femininity in women (14).
That is why, infertility is considered as defeat in the view point of couples and having a baby is one of the best events that happen for a couple. Also, in the reverse condition, infertility affects the same amount of a couple lives (15). Infertility can be one of the reasons for divorce (16). Also, nearly half of infertile women do not have marital adjustment and experienced problems in their relationship with their spouses. Lower sexual satisfaction in infertile couples than fertile couples was reported. As the treatment progresses, the stress level increases significantly and marital satisfaction decreases (17).
In general, different researchers have different opinions about the effect of infertility on couples' relationships. Some researchers believe that tolerating diagnosis and treatment of infertility causes couples to be more intimate, and they will feel closer to each other (18). While many researchers reported declining marital couples' performance as a result of infertility. They have emphasized the increase in marital conflicts among infertile couples (19). As mentioned, quality of life of infertile couples can be varied by ethic, culture and geographical aspects. In this regard, this study aimed to investigate the quality of life (QoL) of infertile couples who seek IVF in Gaza city, Palestinian.

Study design and setting
This study is a cross sectional survey, was conducted on 383 infertile couples who seek IVFs services in Alhello, Al Bassma and Al-Hindawy infertility clinics in Gaza city.

Data collection and measurement
Data were collected for nine months from February 19th, 2019 to November 2019 by three trained midwifes worked in the selected infertility clinics. Eligible couples met the inclusion criteria: primary or secondary infertility, over 18 years of age and willingness for participation in the study. The couples were asked to fill the fertility quality of life questionnaire (FertiQoL) while waiting for medical appointment following face to face interviewing. FertiQoL questionnaire consists of 34 questions and measured QoL on two sections, core (24 questions) and treatment (10 questions) (20). In addition to two questions asked about personal health and satisfaction with QoL in general. Average time to fill the questionnaire was 25 minutes.

Sample and sampling
A convenience sample of 390 couples were approached however three women and two males refused to participate and two women provided incomplete questionnaire and the missing value was more than 5%. Thus, 383 couples involved and participated. Sample size was calculated according to traditional formula of cross-sectional design (21).

Ethical issues
The couples were provided with explanation about the purpose of the study and confidentiality of information was assured. Participation was voluntary-based and women were asked to give consent prior starting the study. Permission was obtained from administration of the involved infertility clinics in Gaza city and from Ministry of health, department of research. Data are kept in the first author closet and will be discarded once publication is made.

Statistical analysis
Prior analysis, data were checked for completeness, outliers and errors. Data were analyzed using the IBM SPSS 22 (SPSS Inc., Chicago, Ill). Continuous variables (age, marital years, no of deliveries,..) were presented as mean and standard deviation. Categorical variables (gender, level of education, menstruation pattern, ..) were presented as frequency and percentage. Mean score of FertiQoL and its subscales, with regard to independent variables, were compared between males and females using one way ANOVA and independent t-test. Analysis used p value less than 0.05% as statistical significance.

Characteristics of respondent couples
The mean age (SD) of females and males was 29.28 (6.71) and 34.54 (8.54) years old respectively. More than half of them had university degree and more (60% and 64% respectively. Majority of females were housewives (77.2%), whereas, 75.7% of males had job. The mean duration of marriage was 7.94 (2.32) years. More than one third of women had been previously delivered a baby and 40% of them had at least delivered one child.
The mean duration of fertility of couples was 5.66 (3.54) years and 71.1% had experiences IVF at most twice (Table 1). Comparison of mean scales of FertiQoL subscales between males and females The mean males' scores of FertiQoL and its subscales (emotion, mind/body, social, core, tolerability and treatment) were significantly higher than females' scores (p < 0.05). The quality of infertile men is better than in women (Table 2). Relationship between couples' characteristics and FertiQoL subscales A significant differences was achieved between women' duration of marriage, number of deliveries, menstrual pattern, number of IVFs performed and emotion score. For men, husband polygamy received highest emotion score. Females achieved lower scores (> 50%) than males for emotion subscale.
Younger males (below 30 years had significant higher mind/boby and social score (p < 0.01). Males scored higher than females for mind/body and significant differences is seen with regard to age groups, education level and duration of marriage (P < 0.05). Whereas, differences of females' scores were achieved in the duration of fertility, number of previous deliveries and IFVs. There was a significant difference between age and women's relational, social and core scores.
The females who experienced IVF at least three times had lower score for its core dimensions and its subscales. However, differences are significant in core subscale and FertiQoL as a whole. The males and females below 30 years old reported higher scores for the treatment subscales and significance is achieved in treatment, its subscales and FertiQoL domain. Similar findings are reported for duration of marriage and number of previous deliveries (p < 0.05) ( Table 3).

Discussion
The current study aimed to explore QoL and associated factors of infertile couples, who seek IVF, from a dyadic or two perspectives. The results of our study showed that husbands' QoL (in terms of emotion, mind/body, social, core, tolerability and treatment) was more positively affected than was their counterparts women, similar to a conclusion drawn by Goker and his colleagues (22). Infertility is a stressful status affects individual's health including emotions especially in women. The traditional social pressure in Palestinian society enhances husbands to have a large number of children especially when infertility is women factor. Infertile Women feel inferior and disappointed (23,24).
Infertility could be life-long and interventions including medical treatments are subjected to failure, thus, psychological, social and economic effect is expected. Emotional, support, therapeutic and psychological counseling are vital contributing features for improving quality of life for infertile women (25)(26)(27).
Our findings indicated differences in the relation between QoL and age. Youngers have better QoL than infertile individuals above 30 years old similar to Khayata et al. (28).
Significant differences were seen in the score between infertile men and women in the Core QoL, treatment QoL and overall FertiQoL. This is against findings of Goker and his colleagues study (22) A significant relationship was found between the quality of life and the duration of infertility among men, infertile men for less than 3 years have a significant better QoL (35). Previous studies reported decrease in the QoL as the infertility duration increases (22,35,37). As a source of speculation, infertile men who live in a society, like in the Gaza strip, are in hurry to have children very earlier to satisfy themselves and their families and to overcome social pressure and stigma. However, as the infertility duration increases, men accept and accommodate to situation over time. We found females QoL depends on duration of infertility (38). This is inconsistent with findings of Baghiani Moghadam et al. (39).

Availability of data
Original data from the study is available with the first author up on request

Funding
None