This study was conducted to determine the distribution of depression among infertile females. According to our society’s norms and culture, having a child is an important issue in marital life and inability to have it would create challenges for infertile couples, particularly females. Infertile females are deprived of their important maternal role and are ultimately threatened by psychological disorders. To the best of our knowledge, this is the first study addresses a psychological disorder, depression, in infertile women. A growing body of evidence emphasized on psychological aspect of infertility in women (1, 6, 10, 17–23). Infertility is a source of stress for couples who are unable to conceive and depression was most commonly reported and its incidence varied among societies and countries. However, a study found occurrence of depression in infertile individuals is no more common than in entire population (24). The Depression Beck Inventory is a screening tool characterized by good sensitivity but low specificity.
In our study, 50.6% of infertile women had some form of depression. This finding is similar to reports from Nigeria and Saudi Arabia (6, 22) which was 52.7% and 53.8%, respectively. Other studies found lower prevalence (25, 26). Differences in prevalence rate could be attributed to using various instruments to assess depression. Some have used the Patient Health Questionnaire, the Beck's Depression Inventory (BDI), the General Health Questionnaire (GHQ) or the Hospital Anxiety and Depression Scale (HADS).
Husband infertility was a significant predictor for depression in women. This is in line to previous studies(18, 27–29). Men in Middle Eastern countries practice their family role as powerful virile by means of reproduction, thus infertility is challenging and threatening problem which may result in psychological distress to their counterparts women. These psychological distresses are displacing to women because they are the submissive and dependent on males. Males' infertility may also result in low sexual self-esteem and performance and if emotional connection, in terms of sexual intercourse, is failed to achieve its purpose, couples might be divided or isolated. Thus, women remain under stress for prolong duration. Savadzadeh and Madadzadeh (29) stated if males' capabilities failed to get their partners pregnant, a devastating emotional sequence, including depression, is expected for couples however is much more among wives. By and large, male infertility factors lead to psychological burden for both men and women; however, it is much more in women(30) .
Duration of infertility was not a predictor for depression. This is in line with findings from Iran (19, 27), Nigeria(26) and Japan (31). In return, infertility duration showed to have effect on occurrence of depression in first three years of infertility, however, depression subsequently decreased with time (32). Possible explanation could be attributed to adjustment of infertile women to infertility, sharing problem with medical professionals and the hope for successful trials in accordance with new technologies and techniques which give hope for pregnancy. Moreover, the desensitization model presented by Kopitzke et al.,(33) could also be applied. The model describes individual's stress response to initial diagnosis and his/her coping with prolong exposure to stressful situations and become desensitized.
In our study, we found no significant relationship between age and depression. In line to studies' findings (21), female age was not a predictor for occurrence of depression. This is in contrast to Alhassan, Ziblim and Muntaka(17), Al-Homaidan (6) and Awoyinka and Ohaeri (34) reports from Ghana, Saudi Arabia and Nigeria, respectively. We do speculate that young females expose to psychological and social pressure similar to their older counterparts which hide age related symptoms of depression.
Duration of marriage was a significant predictor for depression similar to previous studies (24, 25). However, this is not in line with Oladeji and OlaOlorun,(21). Possible explanation could be attributed to different geographical locations and societies that held different beliefs and norms and to social or partner support.
Abortion was found to be a significant predictor for depression among infertile women. This result is in agreement with findings of Kolte et al., (35), Zamani et al., (36) and Adib-Rad et al., (37). Similarly, Kagami et al., (38) used the Beck Depression index and found significant higher levels of depression among women as compared with men. Recurrent abortion is a serious point for infertile women and it is not easy to cope or recover spontaneously. For sure, they require kind of support, care and interventions to help them to adjust after pregnancy loss. Moreover, we think that infertile women after spontaneous abortion lose hope to become mothers and thus may produce source of internal psychological pressure and guilty feeling.
Type of infertility is another predictor of depression in our present study. This result is similar to the previous publishes result from survey about depression among infertile women in Ghana (17), Saudi Arabia(39) and in Iraq (40). Having a child is very important to the Palestinian community. Childbearing women have higher marital satisfaction and social value among her family members. Being unable to conceive add psychosocial burden over the infertile woman life. Infertility affects the infertile women marriage stability and psychological well-being as it proven in our research result.
The study has many limitations; firstly, the study approached only infertile females who seek IVF treatment, however, there were still infertile women who are economically unaffordable to seek treatment and we belief that depression could be much higher. We do recommend further studies on this part of population. Secondly, the conservative culture of Palestinian community makes it hard sometimes to ask questions about infertility and sexual function. Thirdly, the nature of cross-sectional design limits establishment of causal inferences with study variables. Fourthly, using of self-rating questionnaire limited the in-depth exploration of psychological distresses, depression. The advantage of the study is that findings reflect the characteristics of general population in infertile women because most famous infertility treatment clinics, including the selected center in our study, are located in Gaza city.