Exploring the Impact of In Vitro Fertilization (IVF) on the Quality of Life of Lebanese Women andUnraveling the Determinants: A FertiQoL Questionnaire Validation

doi:10.21203/rs.3.rs-3772340/v1

BACKGROUND AND AIMS: Infertility is a growing global concern, and In Vitro Fertilization (IVF) has emerged as a popular solution. Women receiving treatment for infertility deal with a range of physical and psychological challenges. However, there is limited understanding of the specific factors that impact their quality of life. This study looked at the current state of fertility quality of life among Lebanese women undergoing IVF and analyzed the factors that influence it.

METHODS: A cross-sectional survey was conducted from June to September 2020 among women undergoing IVF all over Lebanon. The survey collected demographic characteristics and treatment data and included the fertility quality of life scale (FertiQoL), The couple’s satisfaction Index (CSI-4), the wellbeing index (WHO-5), and the patient-doctor relationship questionnaire (PDRQ-9). General Linear Model was used to explore the predictors of fertility quality of life.

RESULTS: In total, 403 women completed the survey. Participants had a mean of total FertiQoL score of 61.98 (SD = 21.15). The mean CSI-4 and WHO-5 scores were 10.15 (SD = 5.76) and 11.15 (SD = 6.56), respectively. The mean PDRQ-9 score was 29.33 (SD = 8.5). The General Linear Model showed that conceiving duration failure, no children status, facing a stigma, being underweight, and having no income were risk factors for diminished fertility quality of life. While male factor infertility, being a sedentary office worker and having religious or cultural beliefs that influence the perspective on IVF positively influenced the total score. CSI-4 and WHO-5 score had also a positive significant association with FertiQol.

CONCLUSION: Lebanese women undergoing IVF have relatively acceptable quality of life. This study in Lebanon revealed that women's quality of life depends on various factors, and the validated FertiQoL measurement tool has demonstrated its reliability, with Cronbach’s alpha ranging from 0.949. Further studies with a larger sample size are necessary to validate our results and gain deeper insights.

IVF

infertility

FertiQol score

Not all couples are fortunate enough to achieve one of life's most cherished landmarks - parenthood. Infertility, or the inability to conceive naturally, is a common stumbling block on the path to starting a family. This condition is medically diagnosed when a sexually active woman under 35 remains unpregnant after a year or after six months for women older than 35, despite unprotected intercourse or therapeutic donor insemination ^[1].

An investigation revealed that the likelihood of infertility was 17.8% in high-income countries and 16.5% in low- and middle-income countries ^[2]. In Lebanon, a significantly higher rate of 34.3% of women had infertility^[3]. A study in the area discovered that several factors increased the chance for women to develop infertility. Advanced age, polycystic ovarian syndrome, and endometriosis were the main culprits ^[4]. A reduction in infertility risk can be associated with obtaining a college degree instead of just a high school diploma. Interestingly, Lebanon has a high occurrence of infertility caused by several socio-demographic and medical conditions ^[3].

In Lebanon, the fertility rate has plummeted from 4.84 children per woman in 1971 to 2.06 children per woman in 2020 due to various factors^[5]. These factors are likely to have impacted fertility rates. Economic downturns can play a significant role in influencing the fertility rates. When there is a lack of financial stability, individuals and families struggle to manage the expenses that come along with raising a child, such as housing, education, and healthcare costs. As a result, fertility rates in Lebanon, as well as other countries, may have experienced a decline due to the financial stress created by economic instability ^[6].

Particularly in Lebanon, where there is no explicit legislation or regulation-governing reproductive practices, infertility is frequently overlooked ^[7]. The quality of a person's life is profoundly impacted by infertility and its treatment. According to studies, infertility issues rank among the saddest occurrences in people's lives ^[8]. Women undergoing IVF treatments deal with a range of psychological challenges, including stress, worry, and sadness ^{[9] [10]}. Another study revealed that in Lebanese society, there is a notable gender difference in attitudes towards infertility within a partnership. It found that men are more inclined than women to consider infertility as a valid reason for divorce or pursuing a new marriage. Furthermore, a significant proportion of men expressed a preference for seeking assistance from a gynecologist in cases of couple infertility, implying a prevailing belief that women bear the sole responsibility for infertility, despite its potential impact on both sexes.

Interestingly, the study also observed that individuals with higher levels of education displayed greater awareness and acceptance of alternative options such as adoption or in vitro fertilization. It is noteworthy that men were twice as likely as women to express reluctance in establishing a life with an infertile partner ^[11].

The societal pressure on women in Lebanon to have children, coupled with expectations from their spouse, family, friends, and the wider community, adds difficulty to the journey towards parenthood. Furthermore, couples undergoing evaluation and therapy for infertility also experience financial hardship and mental exhaustion ^[12]. These challenges are further exacerbated by the negative societal connotations, scarcity and the high costs making it inaccessible for many people ^[2]. This study holds significance as it aims to investigate the quality of life experienced by Lebanese women undergoing IVF treatment. Infertility is a growing global concern, and IVF has emerged as a popular solution. However, there is limited understanding of the specific factors that impact the quality of life of IVF patients in Lebanon. By identifying these factors, healthcare providers can develop tailored interventions to enhance the well-being of IVF patients and optimize treatment outcomes. Moreover, this study seeks to validate the FertiQoL questionnaire in the Lebanese context, thereby contributing to the existing knowledge on IVF and improving the assessment of patients' quality of life during their IVF journey.

Building upon existing research, it's evident that women undergoing IVF treatments face a spectrum of psychological challenges, including stress, worry, and sadness [9] [10]. This established vulnerability emphasizes the necessity to delve deeper into the specific experiences of IVF patients, shedding light on the nuanced psychological impact they endure. While acknowledging the profound challenges faced by all infertile women, the focus on IVF patients in this study stems from the unique and intricate nature of the IVF process. The extended duration, potential side effects, and emotional toll associated with IVF create a distinctive set of circumstances that warrant specific attention. By honing in on this subgroup, the study aims to provide targeted insights into the quality of life of women undergoing IVF, recognizing the complexity of their journey and offering a rationale for the exclusive focus on this particular aspect of infertility. This approach underscores the importance of understanding and addressing the mental well-being of those undergoing IVF treatments, contributing valuable insights into their unique challenges.

Research question: What is the impact of undergoing IVF treatment on the quality of life of Lebanese women, and how can the FertiQoL questionnaire be adapted and validated for use in Lebanon to assess the impact of IVF treatment on their quality of life?

Hypothesis: Lebanese women undergoing IVF treatment experience a decrease in their quality of life, as measured by the FertiQoL questionnaire.

The main objective of this research work is to explore the quality of life of Lebanese women undergoing IVF treatment.

Specific objectives:

To identify factors that may affect the quality of life of Lebanese women undergoing IVF treatment.
To validate the FertiQoL questionnaire for use in Lebanon.
To compare the quality of life of Lebanese women undergoing IVF treatment with the quality of life of women in other countries who have undergone IVF treatment, as measured by the FertiQoL questionnaire.

2.1 Study design

A cross-sectional survey was conducted among women who are undergoing in vitro fertilization (IVF) treatment, from June 15, 2023 until September 8, 2023 in Lebanon. The questionnaire was completed by the women themselves after receiving it via WhatsApp from their treating doctor.

To ensure clarity, the questionnaire was pilot-tested on ten women, and the resulting data were incorporated into the final database. Participation was entirely anonymous and voluntary, and participants did not receive any compensation for their involvement in the study.

2.2 Inclusion and exclusion criteria

The inclusion criteria were as follows: Lebanese woman of reproductive age (18 years and above) diagnosed with infertility, regardless of whether she is the source of infertility, currently residing in Lebanon, and undergoing in vitro fertilization (IVF) treatment.

The exclusion criteria were as follows: individuals with cognitive impairment that may hinder their ability to understand and respond accurately to the study questionnaire, as well as those diagnosed with severe psychological illnesses including anxiety and depression.

2.3 Sample size calculation

The minimum sample size was calculated using the G-Power software, version 3.0.10. Anticipating a squared multiple correlation of 0.05 (R2 deviation from 0) in regard to the Omnibus test of multiple regression, the computed effect size was 0.0526. The minimum necessary sample was n=371, considering an alpha error of 5%, a power of 80%, and allowing 15 predictors to be included in the model. An overall sample of 400 participants would be collected to take potential missing values into account.

2.4 Selection procedure

The recruitment strategy involved collaboration with fertility clinics in Lebanon to draw participants from their patient pool. Additionally, the study was shared by 23 fertility doctors from various regions in Lebanon, all practicing in certified IVF centers approved by the Lebanese Medical Syndicate. Among these doctors, three had ceased IVF practice, three were unavailable during the study period, and eight were working abroad. However, nine doctors agreed to distribute the survey to their patients, ensuring coverage across all Lebanese regions, including Beirut, Mount Lebanon, North, South, and Beqaa.

Woman who participated in the study are those who filled in a link received, by their doctor, on their mobile phone through the "WhatsApp" application. The distribution was expanded through the "sharing" option, to reach 403 participants. Initially, doctors were first contacted via a phone call, and subsequently, researchers visited their clinics to facilitate their involvement in the study.

2.5 Data collection procedure

The online survey consisted of closed- ended questions in English and Arabic. The questionnaire was developed on Google Forms, and the link was distributed through WhatsApp.

First, a questionnaire was developed to meet the objectives of the study. Standardized questionnaires that measured quality of life, couple’s satisfaction, patient-doctor relationship and well-being were used. This questionnaire was transformed into a form on "Google form" in accordance with the required conditions, and this after a double translation from English to Arabic according to the WHO translation guidelines. Subsequently, the form including the questions necessary for data collection was saved as a link (https://docs.google.com/forms/d/e/1FAIpQLSeuNUcOiGUuJyDTR6xKDal1b0qbXBp6uQUzjLfeFx1sB7kxXA/viewform?usp=sf_link ) to be distributed as described in the previous paragraph. The construction of the questionnaire requires participants to answer all the questions in order to be able to proceed and this to avoid missing data. Once the form was completed and submitted, the results were recorded spontaneously on an answer sheet for further statistical analysis.

2.6 Questionnaire and variables

Primary variable: Quality of life of Lebanese women undergoing IVF, which can be measured using a standardized questionnaire: FertiQoL.

Secondary variables:

Socio-Demographic variables: Age, education level, occupation, and geographic location, hobby, type of work and income, physical activity (sport), living near family members, quality of the marital relationship, access to support from family and friends (social support), access to infertility counseling and support groups, religious or cultural beliefs related to fertility and IVF, Household income, relationship with the health care provider.

Infertility-related variables: Duration of infertility, cause of infertility, and number of IVF cycles, type of infertility (male factor, female factor, combined, unexplained), use of additional fertility treatments or medications (such as IUI, ovarian stimulation drugs), pregnancy outcome (successful or unsuccessful), adverse effects experienced during IVF treatment, success rate of IVF (pregnancy and live birth rates), number of embryos transferred, time since last IVF cycle, use of donor gametes (egg or sperm), previous history of pregnancy or miscarriage, treatment protocol, access to information about IVF.

Health-related variables: Presence of comorbidities, pregnancy complications, mode of delivery of previous pregnancy if applicable, alcohol consumption, smoking, medical history (e.g. PCOS, endometriosis, thyroid disorders) and surgical history, weight, height, alimentation, medication, Mental health status (such as anxiety and depression), presence of children.

2.7 Questionnaire

This questionnaire was constructed after reviewing the prior literature. It includes 5 sections with duration of completion: 10-15 minutes. The content is displayed in appendix 1.

Section 1: Consent: In the preamble, a brief explanation of the objective of the study with identification of the researchers, a clarification of ethical rights, respect for anonymity and confidentiality, and the right to withdraw before submitting the answers. The form was constructed so that informed consent was a mandatory statement to be clicked in order to continue browsing and answering questions.

Section 2: Including demographic variables, infertility-related variables, health-related variables and others. In addition, the WHO-5 well-being index: a multiple-choice grid including five questions.

Section 3: FertiQoL questionnaire including 34 items (Likert scale).

Section 4: CSI-4 couple’s satisfaction index: four questions (Likert scale).

Section 5: PDRQ-9 the patient-doctor relationship questionnaire: nine questions (Likert scale).

The standardized questionnaires, which measured, couple’s satisfaction, patient-doctor relationship, underwent a meticulous process of double translation. Initially, they were translated from English to Arabic following the WHO translation guidelines. Subsequently, to ensure linguistic accuracy and cultural relevance, the translated questionnaire was then back translated from Arabic to English.

2.7.1 Description of CSI-4 score

The Couples Satisfaction Index (CSI-4) is a brief self-report questionnaire designed to assess relationship satisfaction within a couple. It's a shorter version of the more comprehensive CSI (Couples Satisfaction Index). Participants were asked to provide their perceptions of their relationships using multiple scales. First, they were asked to rate the level of reward in their relationship and their general satisfaction, using a scale from 0 (indicating no reward or satisfaction) to 5 (indicating complete reward or satisfaction). Additionally, participants assessed their overall happiness in the relationship on a scale ranging from 0 (Extremely Unhappy) to 6 (Perfect). Furthermore, they evaluated the truthfulness of a statement about their relationship on a scale from 'Not at all TRUE' to 'Completely TRUE.' This statement was: 'I have a warm and comfortable relationship with my partner.' The combination of these scales allowed participants to express various aspects of their relationship perceptions, including reward, satisfaction, happiness, and truthfulness. For scoring the CSI-4, respondents' answers to all items are summed. In terms of interpretation, CSI-4 scores have a range of 0 to 21. Higher scores on this scale are indicative of greater relationship satisfaction. On the other hand, CSI-4 scores below 13.5 suggest significant levels of dissatisfaction within the relationship ^[14].

The research article by Funk and Rogge (2007) validated this scale in English and authorized its use ^[7]. The Cronbach’s alpha in this study was 0.974. Calculation: Variables were recoded and computed into total score according to the CSI-4 scoring method (attached in appendix 2). The calculation syntax is attached in appendix 6.

2.7.2 Description of WHO-5 score

The WHO-5 Well-Being Index consists of the following five questions:

(1) I have felt cheerful and in good spirits;

(2) I have felt calm and relaxed;

(3) I have felt active and vigorous;

(4) I woke up feeling fresh and rested;

(5) My daily life has been filled with things that interest me.

Considering the score, each of the five questions in the WHO-5 scale is rated on a 6-point Likert scale, ranging from 0 (at no time) to 5 (all of the time). Participants select the response that best reflects their well-being during the last two weeks. The total score on the WHO-5 Well-Being Index is calculated by summing the scores for each of the five questions. The overall score can range from 0 to 25, with higher scores indicating better well-being. In other words, a higher score suggests that the individual has experienced more positive emotions, vitality, and overall well-being in the past two weeks. Conversely, a lower score may indicate a lower level of well-being or potential mental health concerns [15]. A study validated the WHO5 questionnaire within an infertile population and found a Cronbach's alpha of 0.858, indicating good reliability [16]. It has consistently demonstrated strong reliability, with Cronbach's alpha values ranging from 0.991.

Calculation: Variables were recoded and computed into total score according to the WHO-5 scoring method (attached in appendix 3). The calculation syntax is attached in appendix 6.

1.7.3 Description of PDRQ-9 score:

The Patient-Doctor Relationship Questionnaire (PDRQ-9) is composed of nine items, each assessed using a 5-point Likert-type scale, with ratings ranging from 1 (indicating 'not at all appropriate') to 5 (representing 'totally appropriate’) ^[17]. These items have been thoughtfully designed to evaluate various facets of the doctor-patient relationship, encompassing vital elements such as trust, communication, and satisfaction. The total score is derived by summing the responses to each item. Elevated total scores denote a more positive perception of the doctor-patient relationship, falling within the range of 9 to 45 ^[18]. It is noteworthy that the reliability of this instrument, as assessed through Cronbach's alpha, demonstrated remarkable internal consistency, with a calculated value of approximately 0.969, signifying a high degree of reliability. Previous research has consistently reported substantial internal consistency, with a Cronbach's alpha of .94, reaffirming its reliability ^[19]. The PDRQ scale has been effectively utilized for the evaluation of doctor-patient relationships in diverse contexts, spanning patients with physical ailments ^[20] and those with mental health conditions ^[21]. It has consistently exhibited exceptional reliability and validity across various cultural settings ^{[21] [22]}. Calculation [18] : Variables were recoded and computed into total score according to the calculation syntax attached in appendix 6.

1.7.4 Description of FERTIQOL INTERNATIONAL 2008: scores and subscales

The FertiQoL serves as a valid instrument for evaluating the well-being of individuals facing infertility challenges. It's a self-administered questionnaire created through collaborative efforts by researchers and clinicians from the European Society of Human Reproduction and the American Society of Reproductive Medicine (ASRM). This questionnaire comprises two key components: The Core FertiQoL module and an Optional Treatment Module, as shown in appendix 4. The Core FertiQoL is composed of 24 items, divided into four domains: emotional (measuring the emotional impact of infertility, including feelings of sadness, resentment, and grief), cognitive and physical (exploring how infertility affects physical health, cognitive function, and behavior), relational (evaluating its influence on partnerships), and social (examining its impact on social inclusion, expectations, and support). The Optional Treatment Module of FertiQoL consists of two domains, aimed at assessing the treatment environment and the tolerability of infertility treatment. All items in the FertiQoL questionnaire, whether in the core or optional sections, are rated on a scale from 0 to 4. The scores are then calculated and transformed into a range between 0 and 100. While subscales are computed / 100, fertiQoL score can range from 0 to 120. A higher FertiQoL score indicates a better quality of life, while lower scores suggest a poorer quality of life among individuals experiencing infertility. Importantly, the FertiQoL tool has been translated into over 20 languages, including ARABIC and English. In this particular study, the researchers utilized the officially printed ARABIC/ English translation of FertiQoL, which can be accessed on the FertiQoL website (http://www.fertiqol.org) ^[23]. It has demonstrated good reliability, with Cronbach’s alpha ranging from 0.949. Calculation: Variables were reversed, recoded and computed into total score according to the FertiQoL scoring method (attached in appendix 5). The calculation syntax is attached in appendix 6.

We conducted the analysis on SPSS software version 25. No-missing values were detected in the database. Cronbach’s alpha values were recorded for the reliability analysis of all scales. For the descriptive analysis, we used the absolute frequencies and percentages for categorical variables and means and standard deviations (SD) for quantitative measures. The total FertiQoL score was the dependent variable. The sample was considered normally distributed as by the visual inspection of the histogram, with skewness and kurtosis lower than one. These conditions are considered compatible with normality in a sample size greater than 300, as by Mishra et al., 2019 ^[24].

The bivariate analysis was conducted using the Student’s independent T-test to compare the FertiQoL score (continuous variable) to dichotomous variables, and the ANOVA test (and Independent samples Kruscal-Wallis) to compare three or more means, after checking for assumptions of normality, when appropriate. After ANOVA and Kruskal wallis significant testing, post hoc analysis were conducted using Bonferroni adjustment. A Pearson correlation was used for linear correlation between continuous variables.

As for the multivariable analysis, three linear regressions were performed, taking FertiQOL as the dependent variable in order to check the residues normality, the absence of multi-collinearity, and the homoscedasticity assumptions; a forward method was used.

Finally, A General Linear Model was conducted on the same dependent variable (FERTIQOL); the Enter method was used to come up with the appropriate model with appropriate assumptions. Independent variables introduced in the model were those that had a p value lower than 0.2 in the bivariate analysis to decrease confounding, taking into account the maximum number allowed of variables in the sample size. A p-value of less than 0.05 was deemed significant in all cases.

4.1 Participants

In total, 403 women were included in this study. These women are those who completed the surveys they received from their treating doctors, as shown in the flow diagram in figure1

4.2 Socio-demographic characteristics of participants

We received a total of 403 questionnaires to women undergoing or have undergone IVF with negative pregnancy. The average age of the participants was 35.2 (SD = 5.451), and the average BMI was 23.21 (SD = 3.366) Kg/m². More than half of the women have a high education level, and are employed full-time, with mostly light and moderate physical work demands. The sample was distributed between eight Governates in Lebanon, with higher provenance from Beirut and Mount Lebanon. Most of the studied women are living in a city, with their partner, and have no children. The specific results are shown in Table 1.

Table 1. Socio-demographic characteristics of the studied population .

Socio-demographic characteristics of the studied population (N=403)
Variables	Mean (SD) or N (%)
Age, years(N=403)	35.20 ±5.451
BMI, kg/m²(N=403)	23.21 ±3.366
Educational level
Bachelor and more	230(57.1%)
Below high school	22(5.5%)
High school	150(37.2%)
None	1(0.2%)
Physical work demands
Heavy physical work	7(1.7%)
Light physical work	194(48.1%)
Moderate physical work	141(35.0%)
Sedentary/Office work	60(14.9%)
Not working	1(0.2%)
Employment status
Unemployed	34(8.4%)
Employed part-time	66(16.4%)
Employed full-time	255(63.3%)
Self-employed	48(11.9%)
Monthly Income
None	27(6.7%)
Less than $600	56(13.9%)
$600 - $1000	157(39.0%)
$1000 - $3000	129(32.0%)
$3000 - $6000	25(6.2%)
More than $6000	9(2.2%)
Governate
Beirut	119(29.5%)
Mount Lebanon	96(23.8%)
Nabatiyeh	20(5.0%)
North Lebanon	93(23.1%)
South Lebanon	22(5.5%)
Akkar	18(4.5%)
Baalbek-Hermel	18(4.5%)
Bekaa	17(4.2%)
Place of residence
Urban	315(79.1%)
Rural	83(20.9%)
Household arrangement
Living with partner	307(76.2%)
Living alone	27(6.7%)
Living with my partner and his family	49(12.2%)
Living with my partner and my family	15 (3.7%)
Living with my partner, his family, and my family in one house.	5(1.2%)
Children status
Yes, I have one or more children	86 (21.3%)
No, I do not have any children	317(78.7%)
Hobby
No	190(47.1%)
Yes	213(52.9%)

4.3 Medical history of participants

Half of the participants have no medical problems, and half of them have not undergone any surgery. All the studied women have no mental health therapy, and most of them don’t smoke. 45.7% of women consume alcohol. The specific results are shown in Table 2.

Table 2. Medical history of the studied population

Medical history of the studied population (N=403)
Variables	Mean (SD) or N (%)
Medical history
None of the above	201(49.9%)
Respiratory conditions	40(9.9%)
Heart disease	2(0.5%)
Blood clotting disorders	20(5.0%)
Cancer	1(0.2%)
Stroke or other cerebrovascular diseases	2(0.5%)
Endocrine diseases	16(4.0%)
Gynecological diseases	15(3.7%)
Autoimmune disease	21(5.2%)
Infectious diseases	14(3.5%)
More than one disease	71(17.6%)
Surgical history
None	210(52.1%)
Tubal ligation or sterilization	9(2.2%)
Cesarean section	16(4.0%)
Polyp removal	3(0.7%)
Endometrial ablation	3(0.7%)
Laparoscopy or laparotomy for reproductive conditions	37(9.2%)
Ovary removal	1(0.2%)
Operation due to abortion	74(18.4%)
More than one surgery	50(12.4%)
Mental Health Therapy
No	403(100%)
Yes	0(0%)
Smoking status
No	307(76.2%)
Yes	96(23.8%)
Alcohol consumption
No	219(54.3%)
Yes	184(45.7%)

4.4 Infertility related data of participants

Among the surveyed women, the conceiving duration failure was mostly more than one year. The treatment duration was less than one year for 37.2% of women, and more than one year for 41.2% of them. The causes of infertility were mainly either female factor (48.6%), either combined (32.3%), and approximately half of the women had never been pregnant. The number of IVF cycles varied from one cycle to more than four cycles. Most of the participants did not use donor gametes, and had more than one adverse effect. For the majority of women, the IVF treatment protocol was either a long protocol, either frozen embryo transfer protocol. 63% of them did not report any stigma, but also they do not receive a support from their surroundings. Most of the studied population have not yet disclosed the IVF journey, and don’t have any beliefs that influence their perspective on fertility and IVF. Further infertility related information is shown in Table 3.

Table 3. Infertility related variable of the studied population.

Infertility related variable of the studied population (N=403)
Variables	Mean (SD) or N (%)
Conceiving duration failure
Not applicable	13(3.2%)
Less than six months	49(12.2%)
Six month to one year	79(19.6%)
More than one year	262(65.0%)
Infertility treatment duration
Not applicable	87(21.6%)
Less than one year	150(37.2%)
More than one year	166(41.2%)
Infertility Type
Not diagnosed with infertility	14(3.5%)
Female factor infertility	196(48.6%)
Male factor infertility	35(8.7%)
Combined	130(32.3%)
Unexplained infertility	28(6.9%)
Previous pregnancies-miscarriages
Only successful pregnancies	32(7.9%)
Experienced abortion and successful pregnancies	156(38.7%)
Never been pregnant	215(53.3%)
IVF success rate
More than 50%	19(4.7%)
Lower than 50%	164(40.7%)
Not sure	220(54.6%)
Number of IVF cycles
One cycle	101(25.1%)
Two cycles	99(24.6%)
Three cycles	42(10.4%)
More than four cycles	63(15.6%)
None	91(22.6%)
Not sure	7(1.7%)
Donor gametes
Preferred not to answer	17(4.2%)
No donor gametes usage	364(90.3%)
Yes donor gametes usage	9(2.2%)
Don’t know	13(3.2%)
IVF treatment protocol
Don’t know	11(2.7%)
Long protocol	121(30.0%)
Short protocol	2(0.5%)
Mild stimulation protocol	91(22.6%)
Natural cycle protocol	26(6.5%)
Frozen embryo transfer protocol	152(37.7%)
IVF Adverse effects
None	18(4.5%)
Abdominal discomfort or bloating	5(1.2%)
Nausea or vomiting	10(2.5%)
Mood swings or emotional changes	11(2.7%)
Headaches	12(3.0%)
Fatigue or tiredness	2(0.5%)
Injection site reactions	2(0.5%)
More than one symptom	343(85.1%)
Stigma
No	254(63.0%)
Yes from both family and friends	104(25.8%)
Yes from friends	11(2.7%)
Yes from family members	34(8.4%)
Disclosed IVF journey
No	267(66.3%)
Yes	136 (33.7%)
Environment support
No	270(67.0%)
Yes	133(33.0)
Infertility counselling
No	403(100%)
Yes	0(0%)
IVF beliefs
Yes, religious and/or cultural beliefs that influence negatively the perspective on IVF.	9(2.2%)
Yes, religious and/or cultural beliefs that positively influence the perspective on IVF.	98(24.3%)
No, I do not have any religious or cultural beliefs that influence my perspective on fertility and IVF.	296(73.4%)

4.5 Tools

In this study, the mean CSI-4 and WHO-5 scores were 10.15 (SD = 5.76) and 11.15 (SD = 6.56), respectively. The mean PDRQ-9 score was 29.33 (SD = 8.5). The specific scores are shown in table 4.

Table 4. Scores of the studied population

Scores of the studied population (N=403)
Variables	Mean (SD)
Fertiqol scale	61.98±21.15
PDRQ9-scale	29.33±8.50
CSI- 4 scale	10.15±5.76
WHO-5 scale	11.15±6.56

According to the scoring standard of the FertiQoL, the total FertiQoL score, the Core FertiQoL score and the Treatment FertiQoL score were calculated. The mean of total FertiQoL score was 61.98 (SD = 21.15). The mean treatment FertiQoL score was 19.47 (SD = 6.93). The mean core FertiQoL score was 42.51 (SD = 15.08). The mean emotional subscale score was 38.86 (SD = 16.74). The mean Mind-Body subscale score was 38.17 (SD = 25.28). The mean relational subscale score was 55.47 (SD = 11.09), and the mean social subscale score was 44.62 (SD = 18.57). The mean environment subscale score was 56.05 (SD = 16.8) and the mean tolerability subscale score was 37.62 (SD = 24.56). The specific scores are shown in table 5.

Table 5. FertiQoL score of the studied population

FertiQoL score of the studied population (N=403)
	Core_ FertiQol	TREATMENT_fertiqol	Total_ FertiQol_score	Emotional_subscale	MindBody_subscale	Relational_subscale	Social subscale	Environmentsubscale	Tolerability subscale
Mean	42.5112	19.4715	61.9826	38.8648	38.1720	55.4694	44.6237	56.0484	37.6241
Median	39.0000	20.0000	59.0000	33.3333	29.1667	54.1667	41.6667	54.1667	31.2500
Mode	34.00	14.00	48.00	33.33	25.00	50.00	33.33	41.67	25.00
Std. Deviation	15.08522	6.92936	21.15713	16.74005	25.28216	11.09154	18.57474	16.79805	24.56446
Minimum	19.00	8.00	28.00	12.50	.00	8.33	12.50	20.83	.00
Maximum	84.00	40.00	120.00	95.83	100.00	91.67	100.00	100.00	100.00

4.6 Bivariate analysis: variables associated with total Fertiqol score

According to the bivariate analysis for dichotomous variables results, the environmental support, the smoking status, the presence of a hobby, the IVF journey status and the children status are significantly associated with total FertiQoL score, as shown in table 6.

Table 6 Association of total FertiQoL scale with dichotomous variables

Association of total FertiQoL scale with dichotomous variables
FertiQoL Variable	P value	Mean difference	Lower CI	Upper CI	Test
Place of residence 0 Urban 1 Rural	0.596	-1.39	-6.55	3.76	Independent samples T-test
Environment support 0 Yes 1 No	0.007*	5.98	1.61	10.36	Independent samples T-test
Smoking status 0 No 1 Yes	<0.001*	-16.62	-21.21	-12.03	Independent samples T-test
Alcohol consumption 0 No 1 Yes	0.056	4.12	-0.97	8.33	Adjusted T-test
Hobby 0 No 1 Yes	<0.001*	9.44	5.39	13.49	Independent samples T-test
Disclosed IVF journey 0 Yes 1 No	0.01*	5.72	1.37	10.07	Independent samples T-test
Children status 0 Yes children 1 No children	<0.001*	26.98	22.67	31.3	Independent samples T-test
Surgical history 0 one surgery 1 More than one surgery	0.191	-2.99	-7.47	1.5	Adjusted T-test
Mental health therapy No Yes	the variable is constant				All answers are “no” so there is no 2 groups to compare
Infertility counselling No Yes	the variable is constant				All answers are “no” so there is no 2 groups to compare

*indicates the presence of significant association

Concerning the remaining categorical variables, the bivariate analysis showed that the variables that are significantly associated with total FertiQoL score are the following: Physical work demands, Employment status, Monthly income, Governate, Household arrangement, Conceiving duration, Infertility treatment duration, Infertility type, IVF success rate , Stigma, IVF beliefs , IVF adverse effect, Treatment protocol, BMI , Educational Level, Previous pregnancy miscarriage , Number of IVF cycles and the IVF success rate. Results are shown in table 7.

Table 7. Association of categorical variables with total FertiQoL score

Association of categorical variables with total FertiQoL score
	ANOVA (Kruskal-Wallis)		Post hoc test (bonferroni / adjusted)
FertiQoL Variable Categories	P value	Test	Significant associations and levels (descending order)	P value	Mean difference + [CI]
Physical work demands Not working Sedentary/ office work Light work Moderate work Heavy work	<0.001*	NPT Independent samples Kruskal-Wallis	Light work > Moderate work	<0.001*
	<0.001*	NPT Independent samples Kruskal-Wallis	Office work > Moderate work	<0.001*
Employment status Unemployed Employed part-time Employed full-time Self-employed	0.001*	One way ANOVA	Self-employed & Employed full time	0.001*	12.3 [3.64 ; 20.97]
Monthly income None Less than $600 $600 - $1000 $1000 - $3000 $3000 - $6000 More than $6000	<0.001*	NPT Independent samples Kruskal-Wallis	None > less than 600$	0.047*
			less than 600$ >1000$-3000$	<0.001*
			Less than 600$ > 600$-1000$	0.001*
			1000$-3000$ > 600$-1000$	0.033*
			1000$-3000$ > 3000-6000$	0.005*
Governate Beirut Mount Lebanon Nabatiyeh North Lebanon South Lebanon Akkar Baalbek-Hermel Bekaa	<0.001*	NPT Independent samples Kruskal-Wallis	Baalbek Hermel > North Lebanon	0.009*
			Baalbek-hermel > Beirut	0.009*
			Akkar > Bekaa	0.017*
			Nabatiyeh > North Lebanon	0.002*
			Nabatiyeh > Beirut	0.002*
			Mount Lebanon > Bekaa	0.004*
			North Lebanon > Bekaa	<0.001*
			Bekaa > Beirut	<0.001*
Household arrangement Living with partner. Living alone. Living with my husband and his family. Living with my husband and my family. Living with my partner, his family, my family in one house.	<0.001*	NPT Independent samples Kruskal-Wallis	Living with partner > living with partner and his family	0.004*
	<0.001*	NPT Independent samples Kruskal-Wallis	Living with partner > Living with my husband and my family	0.021*
Conceiving duration Not applicable. Less than 6 month. Six month to one year. More than one year.	<0.001*	NPT Independent samples Kruskal-Wallis	Less than six month > not applicable	0.001*
			less than six months > More than one year	<0.001*
			not applicable > More than one year	<0.001*
			not applicable > Six month to one year	0.004*
			More than one year > six month to one year	<0.001*
Infertility treatment duration Not applicable. Less than one year. More than one year.	<0.001*	NPT Independent samples Kruskal-Wallis	Not applicable > Less than one year	0.023*
			Not applicable > More than one year	<0.001*
			Less than one year > More than one year	<0.001*
Infertility type Not diagnosed with infertility. Female factor. Male factor. Combined. Unexplained.	<0.001*	NPT Independent samples Kruskal-Wallis	Male factor > Female factor	<0.001*
			Not diagnosed with infertility > Female factor	<0.001*
			Not diagnosed with infertility > Combined	<0.001*
			Female factor > unexplained	<0.001*
			Female factor & Combined	0.014*
IVF success rate More than 50%. Lower than 50%. Not sure.	<0.001*	NPT Independent samples Kruskal-Wallis	Lower than 50% > more than 50%	0.007*
	<0.001*	NPT Independent samples Kruskal-Wallis	Lower than 50% > Not sure	<0.001*
Donor Gametes I prefer not to answer. No use for donor gametes. Yes, use for donor gametes. I do not know.	0.455	NPT Independent samples Kruskal-Wallis
Stigma -No, I have not experienced any stigma from family or friends -Yes, from both family members and friends -Yes, from family members only -Yes, from friends only.	<0.001*	NPT Independent samples Kruskal-Wallis	No stigma from family and friends > yes stigma from both family members and friends.	<0.001*
			No stigma from family members or friends > yes from family members	<0.001*
			No stigma from family members or friends > yes from friends.	0.001*
IVF beliefs Yes cultural and/or religious beliefs that positively influence my perspective on fertility and IVF Yes cultural and/or religious beliefs that negatively influence my perspective on fertility and IVF No beliefs	<0.001*	One Way ANOVA	Yes cultural and/or religious beliefs that positively influence my perspective on fertility and IVF & No beliefs	<0.001*	20.32 [14.83; 25.81]
Medical History Gynecologic disease. Others than gynecological disease. None.	0.509	One Way ANOVA
IVF adverse effect None. One symptom. More than one symptom.	<0.001*	NPT Independent samples Kruskal-Wallis	None > More than one symptom	<0.001*
	<0.001*	NPT Independent samples Kruskal-Wallis	More than one symptom > one symptom	<0.001*
Treatment protocol I do not know. Long protocol. Short protocol. Mild stimulation protocol. Natural cycle protocol. Frozen embryo transfer (FET) protocol.	<0.001*	NPT Independent samples Kruskal-Wallis	Mild stimulation protocol & frozen embryo transfer protocol	<0.001*
BMI category Normal weight underweight overweight obesity	<0.001*	NPT Independent samples Kruskal-Wallis	Normal weight > Overweight	<0.001*
	<0.001*	NPT Independent samples Kruskal-Wallis	Overweight > underweight	0.001*
Educational Level Bachelor and more Below high school High School None	0.004*	NPT Independent samples Kruskal-Wallis	High school > Bachelor or more	0.008*
Previous pregnancy miscarriage -Only successful pregnancies. -Experienced abortion and successful pregnancies. -Never been pregnant.	<0.001*	One way ANOVA	Only successful pregnancies & abortion + successful pregnancy Only successful pregnancies & never been pregnant	<0.001* <0.001*	28.93 [19.73; 38.13] 28.54 [19.55;37.53]
Number of IVF cycles None one cycle Two cycle Three cycles Four cycles or more Not sure	<0.001*	NPT Independent samples Kruskal-Wallis	Four cycles or more > None 1	0.019*
			four cycles or more > Two cycles	<0.001*
			None > Two cycles	<0.001*
			Two cycles > Three cycles 3	0.018 *
			four cycles or more > One cycle 4	0.001*
			none > One cycle 4	<0.001*
			None > Three cycles 5	0.001*
Age categories 18-25 years 26-30 years 31-35 years 36-40 years 41 or above	0.619	One way ANOVA

*indicates the presence of significant association

> indicates a higher level of association

As a matter of fact, the post Hoc tests showed the following: The light work seemed to have the highest level of association with the FertiQoL score, compared to sedentary work, and the moderate work have the lowest level of association. Self-employed women have an increased FertiQoL compared to full time employed women (mean = 12.3), as for the income, women who are not paid seemed to have the highest association compared to those paid less than 600 $ and those paid 1000- 3000 $. Participants living in Baalbek-Hermel are having the highest level of association with fertiqol compared to those living in other governates. The results also revealed that living with the husband only has a higher level of association with FertiQoL than living with his or her family. Conceiving failure duration of less than 6 has the highest association with the studied score compared to all other conceiving durations, as well as the fact that the infertility treatment duration is not applicable.

In addition, the male factor infertility has the highest level of association with our primary variable, compared to other infertility types, and knowing that the IVF success rate is lower than 50% has shown the highest association between its groups. Not facing a stigma has the highest association with the FertiQoL score, as well as not having any adverse effect on the IVF treatment. Having beliefs about IVF has the highest level of association with the score, compared to not having any beliefs about IVF (mean = 20.32). The unknown/short treatment protocol has a higher level of association with our score than the Mild stimulation protocol and the Frozen Embryo Transfer one.

Surprisingly, a normal BMI has the highest level of association with FertiQol, higher than an overweight BMI category. The overweight category, on its turn, is having a higher level of association than the underweight category. A high school education level has a higher association level with the studied score than the bachelor degree or more. Having only successful pregnancies is the most associated with the score, compared to experiencing successful pregnancies and abortions (mean = 28.93) and to none pregnancies (mean = 28.54). Lastly, having undergone 4 or more IVF cycles has shown having the highest level of association with FertiQoL compared to a lower number of cycles. Results are shown in table7.

As for the association between total FertiQoL score and the other studied scores, the correlation showed a high positive linear association between FertiQoL and CSI-4 score, and a weak positive linear association between FertiQoL and both PDRQ-9 and WHO-5 scores. Specific results are shown in table 8.

Table 8. Correlation between total FertiQoL scores and CSI-4 score, PDRQ-9 score and WHO-5 score

FertiQoL Variable	P value	r coefficient	Test
CSI4 score	<0.001*	0.825	Pearson correlation
PDRQ9 score	<0.001*	0.661	Pearson correlation
WHO5 score	<0.001*	0.697	Pearson correlation

*indicates the presence of significant association

4.7 Multivariable analysis: Fertiqol score predictors

The general linear model results are shown in table 9 and they are as following:

There is a negative significant association (p< 0.001) between the FertiQoL score and the conceiving duration failure, in fact, having a conceiving duration less than 6 month decreases the total score by B= -21.850 compared to none, and durations between 6 months to one year and more than one year also decrease total score by B= -18.892 and B= -21.024 respectively, compared to none.
There is a positive significant association (p<0.001) between total FertiQoL score and male factor infertility, as having a male factor infertility increases the total score by B= 11.268 compared to unexplained infertility.
Not having a child significantly decreases total score by B= -11.781 compared to having a child or more (p<0.001), and having IVF adverse effect with multiple symptoms decreases total FertiQoL by B= -7.229 compared to not having any adverse effect.
Total FertiQoL score is significantly associated (negative association) with the fact of facing a stigma from both family members and friends (p<0.001; B=-5.494) compared to the group who is not facing any stigma.
There is a positive significant association between the total score and physical work demands, the total score is increased by B= 4.543 when being a sedentary office worker compared to light physical workers (p=0.001).
Having religious or cultural beliefs that positively influence the perspective on IVF significantly increases total fertiqol by B= 8.413 compared to not having any beliefs (p=0.17).
Being underweight significantly decreases FertiQoL by B=-6.206, compared to having normal weight (p=0.005).
Having no income decreases FertiQoL score by B= -5.547, compared to having an income between 600$ to 1000$, p= 0.13.
WHO-5 score and CSI-4 score are significantly associated with the Fertiqol score (p< 0.001). They increase the total score by B= 0.630 and B= 1.968 respectively.
The FertiQoL total score was not found to be significantly associated with the following variables: previous pregnancy miscarriage, IVF success rate, environment support and educational level.

Table 9 : Results of the general linear model conducted to study FertiQol predictors

Parameter		B	Std. Error	Sig.	95% Confidence Interval
Parameter		B	Std. Error	Sig.	Lower Bound	Upper Bound
conceiving duration failure	1 = less than 6 month	-21.850	3.440	.000*	-28.615	-15.085
	2 = 6 months - one year	-18.892	3.528	.000*	-25.829	-11.954
	3 = More than 1 year	-21.024	3.409	.000*	-27.727	-14.321
	4 = none	0^a	.	.	.	.
Infertility Type	1 = female factor	.651	1.999	.745	-3.280	4.582
	2 = male factor infertility	11.268	2.391	.000*	6.567	15.969
	3 = combined	1.549	1.907	.417	-2.201	5.298
	4 = Unexplained	0^a	.	.	.	.
Previous pregnancy miscarriages	1 = Experienced abortions and successful pregnancies	-2.289	2.139	.285	-6.495	1.916
	2 = Never been pregnant	1.202	2.362	.611	-3.442	5.846
	3 = only successful pregnancies	0^a	.	.	.	.
IVF success rate	1 = lower than 50%	4.350	2.395	.070	-.359	9.059
	2 = not sure	3.333	2.306	.149	-1.201	7.867
	3 = more than 50 %	0^a	.	.	.	.
Children status	1 = no children	-11.781	1.734	.000*	-15.190	-8.372
Children status	2 = One or more children	0^a	.	.	.	.
IVF Adverse effects	1 = one symptom	-.967	2.852	.735	-6.575	4.642
	2 = more than one symptom	-7.229	2.557	.005*	-12.257	-2.200
	3 = none	0^a	.	.	.	.
Stigma	1 = From family members and friends	-5.494	1.372	.000*	-8.192	-2.796
	2 = from family or friends	2.282	1.672	.173	-1.006	5.571
	3 = none	0^a	.	.	.	.
Physical work demands	0 = not working	2.211	9.592	.818	-16.651	21.072
	1 = sedentary office work	4.543	1.407	.001*	1.776	7.311
	3 = moderate work	.263	1.112	.813	-1.923	2.449
	4 = heavy work	1.769	3.609	.624	-5.328	8.866
	5 = light physical work	0^a	.	.	.	.
Environment support	1 = no	-1.379	1.067	.197	-3.478	.720
Environment support	2 = yes	0^a	.	.	.	.
Educational Level	1 = below high school	-2.059	2.391	.390	-6.760	2.643
	2 = high school	.475	1.054	.652	-1.597	2.547
	4 = bachelor and more	0^a	.	.	.	.
IVF beliefs	1 = religious or cultural beliefs that positively influence the perspective on IVF	8.413	3.519	.017*	1.493	15.333
	2 = religious or cultural beliefs that negatively influence my perspective on IVF	.604	1.323	.648	-1.998	3.206
	3 = no beliefs	0^a	.	.	.	.
BMI	1 = underweight	-6.206	2.183	.005*	-10.499	-1.912
	2 = overweight	-1.405	1.226	.253	-3.815	1.006
	3 = obesity	-6.266	3.334	.061	-12.822	.290
	4 = Normal weight	0^a	.	.	.	.
Monthly income	0 = none	-5.547	2.222	.013*	-9.917	-1.177
	1 = less than 600$	-.405	1.626	.803	-3.602	2.792
	3 = 1000$-3000$	1.773	1.157	.126	-.502	4.047
	4 = 3000$-6000$	1.260	2.048	.539	-2.768	5.288
	5 = more than 6000$	-6.578	3.357	.051	-13.181	.024
	6 = 600$ to 1000$	0^a	.	.	.	.
WHO-5 SCORE		.630	.124	.000*	.387	.874
CSI-4 Score		1.968	.140	.000*	1.692	2.244

To our knowledge, this study is the first in Lebanon related to the quality of life of Lebanese women undergoing IVF, and its associated factors.

This study underscores the significant impact of fertility treatments on the quality of life of women who have undergone IVF. The majority of participants reported experiencing multiple adverse effects during their fertility treatments, particularly reflected in the Treatment FertiQoL subscale, which had the lowest score in this study (19.47 ± 6.93) when compared to Taiwan (56.03 ± 10.7) ^[25]. These findings highlight the substantial challenges faced by the participants, many of whom endured multiple cycles of IVF, which took a toll on their overall well-being, both emotionally and physically. This toll was also confirmed by a study from Turkey, which found that with an increase in the number of IVF treatment cycles, women's FertiQoL gradually decreased, while the risk of anxiety and depression gradually increased ^[26]. Similar results were found in a study from

Kazakhstan ^[27]. These effects can significantly impact their emotional well-being, as indicated by the very low emotional subscale score (38.86 ± 16.740) and the Mind-Body Subscale score (38.17 ± 25.28) in this study, in contrast to a Taiwanese study where the Emotional subscale scored 53.60 ± 18.95 and the Mind/Body subscale scored 49.84 ± 24.01. This suggests that infertile women in Lebanon may experience greater emotional stress and have poorer physical health status. This finding aligns with a prior study conducted in Iran, which found a higher rate of depression in women suffering from infertility compared to infertile men ^[28]. It has been reported in Japan that infertile women may experience increased depression and anxiety due to a lack of support from their spouses and feelings of stress ^[29]. These findings emphasize the need for comprehensive support during fertility treatments. In our reports, the scores in the relational and social domains were 55.46 ± 11.09 and 44.62 ± 18.57, respectively, compared to another Taiwanese study where relational scores were 54.80 ± 10.98 and social scores were 59.31 ± 11.15 ^[25]. This suggests that poorer family support might be the primary reason for the lower emotional and mind/body scores in Lebanese infertile women.

Moreover, extended treatment duration of more than one year exacerbated these challenges, leading to a lower score on the Treatment FertiQoL subscale. This aligns with the findings of another Chinese study, where the Treatment FertiQoL score was the lowest (59.9 ± 13.3), with an average tolerability score of 57.9 ± 19.8 and an environment subscale score of 64.9 ± 13.0 ^[30]. In contrast, a Taiwanese study reported a higher environment subscale score of 54.28 ± 8.87 ^[25], which is in contrast to the Lebanese results, where the tolerability score was 37.62 ± 24.56, and the Environment Subscale yielded the highest score (56.05 ± 16.80).

The scores for women undergoing IVF in Lebanon were notably lower when compared to the findings for the IVF population in China and Taiwan. This discrepancy may be attributed to the current study being conducted in renowned reproductive medicine facilities in Lebanon, where many patients often face long wait times for treatment. Additionally, the extended waiting periods at home for IVF patients could contribute to these issues. Women may feel that the medical staff doesn't provide them with sufficient attention or psychological support, potentially impacting their quality of life and psychological well-being. The lower tolerability score could be a result of women undergoing IVF having a history of unsuccessful treatments or being more susceptible to stress, making them less tolerant of the procedure.

When comparing the quality of life of Lebanese women undergoing IVF with that of women in various other countries, it becomes evident that the female respondents from Lebanon tend to exhibit low FertiQoL scores. Our study reports a mean FertiQoL score of 61.98 ± 21.16 for the Lebanese female participants. These variations in FertiQoL scores across countries may be attributed to several factors, including cultural norms, access to healthcare, affordability of IVF treatments, availability of psychological support, and societal attitudes toward infertility.

Furthermore, in a sample of female participants from Serbia, the mean FertiQoL score was 48.88 ± 12.02. In Kazakhstan, it was 59.6 ± 11.5 ^[31], while in Tehran, Iran, it was 62.57 ± 16.89 ^[32]. In China, the mean score was 64.54 ± 16.90; in Turkey, 66.97 ± 14.35. Comparatively, in Western countries such as the Netherlands, the United States, and Germany, the mean scores were notably higher, with values of 70.80 ± 13.90, 72.30 ± 14.80, and 73.00 ± 12.00, respectively ^[33]. These discrepancies in FertiQoL scores worldwide highlight the influence of various factors on the well-being of women undergoing IVF, when differences in healthcare systems and psychological support playing a significant role. For example, the relatively low FertiQoL scores in Serbia might reflect the absence of comprehensive psychological counseling as a part of the IVF process, which differs from the practices in Western countries.

The study results indicate that several factors have an impact on the total FertiQoL score. Male factor infertility, sedentary office work, and adherence to religious or cultural beliefs have a positive influence on the total FertiQoL score. On the other hand, factors such as prolonged duration of infertility, childlessness, facing social stigma, being underweight, and having no income have a negative effect on the score. Interestingly, factors like previous pregnancy miscarriage, IVF success rate, level of environmental support, and educational level do not appear to significantly affect FertiQoL. This finding is in contrast to a study in Turkey titled "Predictors of fertility quality of life (FertiQoL) in infertile women: analysis of confounding factors," which reported that education level and secondary infertility had a positive impact, while a prolonged duration of infertility and a desire for psychological support had a negative impact on total quality of life scores ^[34]. These variations in research findings may be attributed to differences in cultural contexts.

The duration of infertility failure demonstrates an inverse relationship with fertility quality of life, suggesting that as the duration of infertility failure increases, the quality of life of patients tends to decline. Prolonged periods of infertility failure can result in heightened disappointment and dissatisfaction, leading to self-doubt and increased pressure among women, all of which can adversely affect their quality of life. Furthermore, the absence of children can pose a threat to personal values, social security, social status, gender identity, and family heritage, particularly in Middle Eastern countries. Women may face increased social prejudice, as society often assigns blame for infertility and even stigmatizes them.

Consistent with our findings, two studies conducted by Jing X. et al. and Song, D., Li, X. ^{[35] [30]} demonstrated that stigma and social concerns have a significant impact on the FertiQoL of infertile women. Stigma exacerbates their psychological burden, ultimately having a negative impact on their FertiQoL. Interventions based on psychological theories could be employed for women receiving IVF services to enhance their quality of life, as stigma negatively affects it. Considering that infertility treatment is often a protracted and costly process, involving various examinations and medications, and couples frequently have to finance it themselves, the lack of income when in dire need can significantly reduce their quality of life, given the substantial financial pressures that accumulate during treatment.

It's worth noting that being underweight can impact a woman's fertility and increase the risk of health problems during pregnancy. Our study also revealed a negative impact of low BMI on a woman's FertiQoL. On the other hand, overweight/obesity is a significant global public health issue, as it not only negatively affects the quality of life but also has severe implications for health ^[36]. The self-perception of being overweight or underweight can both lead to concerns about social rejection and the internalization of weight stigma.

Furthermore, the fact that male factor infertility positively influences the quality of life clearly suggests that women may be less susceptible to the subjective burden of experiencing infertility when the issue is attributed to male factors. Additionally, when the IVF journey aligns with religious or cultural beliefs, it tends to be easier, less stressful, and less likely to result in feelings of guilt and shame.

Regarding sedentary office work, it has a positive impact, as it can be explained by the initial weeks of IVF treatment when doctors often recommend rest to women to avoid strenuous physical activities that might reduce the chances of IVF success. Jobs that involve sedentary work and minimal physical exertion can provide greater comfort and reassurance, similar to other types of work that do not demand heavy physical labor.

The positive impact of the CSI-4 and WHO-5 on FertiQoL underscores the importance of marital support during the IVF journey. This study confirms that well-being during the IVF journey is influenced by social support. Adequate social support empowers infertile women to receive emotional care and support, which enhances their quality of life and their ability to cope with psychological stress ^[37].

5.1 Public health implications

Addressing the public health implications of infertility treatments, including IVF, involves a multi-faceted approach. Firstly, fostering supportive communities and networks for women undergoing IVF is crucial, as it can significantly contribute to better mental health outcomes and overall well-being. Concurrently, focusing on psychological well-being through tools like FertiQoL assessments is imperative, as it helps identify and address the emotional impact of these treatments. Equally important is the need to consider long-term health outcomes for both women and children born through IVF. Encouraging research in this area can provide valuable insights to inform comprehensive public health strategies.

5.2 Strengths and limitations

The strengths of this study included, first of all, its use of assessment tools validated and used in many countries. In addition, this study was the first to take Lebanese women undergoing IVF, and the quality of life status and predictors in this group were investigated. Finally, this study was diverse between many Lebanese districts.

However, this study still has some limitations. First, its cross sectional design cannot show causality but only generated hypothesis. Second, a selection bias is suspected, given that only educated women with internet access could answer the online survey. Furthermore, the fact that the survey was shared by Doctors based on their assessment could also introduce potential selection bias, which leads to the underestimation of our results. Accordingly, the representativeness and generalizability of our study are limited.

As our study concentrates specifically on exploring the quality of life of women undergoing IVF treatments, it's essential to acknowledge its inherent limitation in not encompassing the broader spectrum of all infertile women. While our research delves into the intricate experiences of IVF patients, we recognize the necessity for complementary studies to thoroughly investigate the quality of life among other segments of the infertile population. This deliberate scope allows for a more comprehensive understanding of the diverse challenges faced by different subsets of individuals grappling with infertility, paving the way for a holistic perspective on the multifaceted impact of infertility on women's lives.

Finally, while our study incorporated rich demographic measures, it is possible that some factors associated with the quality of life of Lebanese women undergoing IVF were overlooked. Nonetheless, a notable strength of our research lies in the inclusion of numerous novel predictors that had not been previously studied.

Our findings emphasize the intricate and multifaceted nature of the fertility journey, where emotional, physical, and environmental factors all play significant roles. Recognizing and addressing these challenges is crucial for healthcare providers and support systems to provide tailored care and assistance to individuals navigating various aspects of fertility issues.

This study, conducted in Lebanon, has demonstrated good reliability for the FertiQoL, an internationally validated measurement tool, with Cronbach’s alpha ranging from 0.949.

Women's quality of life is low in Lebanon compared to western countries and it is influenced by a multitude of factors. The results indicate that male factor infertility, engagement in sedentary office work, and adherence to specific religious or cultural beliefs positively impact the total FertiQoL score. Conversely, factors such as experiencing difficulties in conceiving, not having children, facing societal stigma, being underweight, and lacking income have a negative effect on the score.

Evaluating an infertile patient should encompass a comprehensive assessment, including their medical and psychological issues, social background, and their ability to cope with the treatment.

Further studies with a larger sample size are necessary to validate our results and gain deeper insights into the underlying reasons for the lower quality of life experienced by women undergoing IVF in the Lebanese population.

7.1 Ethics approval and consent to participate

The free consent of the participants was obtained from each participant at the beginning of the questionnaire, participation is voluntary and taking part in the study has no harmful effect. No monetary reward was granted for their participation. In addition, confidentiality and anonymity were guaranteed. All procedures were performed in accordance with relevant guidelines.

Ethical approval was taken from the Lebanese INSPECT-LB committee, under the number: 2023REC-008-INSPECT-06-09. In addition, the procedure of this article followed the STROBE statement checklist ^[13].

7.2 Consent to publication:

Not applicable.

7.3 Availability of data and materials

All data generated or analyzed during this study are not publicly available to maintain the privacy of the individual’s identities. The dataset supporting the conclusions is available upon request to the corresponding author on reasonable request.

7.4 Acknowledgment

We would like to thank Dr Pascale Salameh for her help throughout the study and all those who participated in this study.

7.5 Competing interests

No competing interests.

7.6 Funding

None.

7.7 Author contribution

SS and SMS designed the study, drafted the manuscript, collected data and carried out the analysis with interpretation of the results. PS guided and reviewed all sections of the study. All authors reviewed the final manuscript and gave their consent.

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No competing interests reported.

Exploring the Impact of In Vitro Fertilization (IVF) on the Quality of Life of Lebanese Women andUnraveling the Determinants: A FertiQoL Questionnaire Validation

Status:

Version 1

Abstract

Figures

1. INTRODUCTION

2. MATERIALS AND METHODS

2.1 Study design

2.2 Inclusion and exclusion criteria

2.3 Sample size calculation

2.4 Selection procedure

2.5 Data collection procedure

2.6 Questionnaire and variables

2.7 Questionnaire

2.7.1 Description of CSI-4 score

2.7.2 Description of WHO-5 score

1.7.3 Description of PDRQ-9 score:

1.7.4 Description of FERTIQOL INTERNATIONAL 2008: scores and subscales

3. STATISTICAL ANALYSIS

4. RESULTS

4.1 Participants

4.2 Socio-demographic characteristics of participants

4.3 Medical history of participants

4.4 Infertility related data of participants

4.5 Tools

4.6 Bivariate analysis: variables associated with total Fertiqol score

4.7 Multivariable analysis: Fertiqol score predictors

5. DISCUSSION

5.1 Public health implications

5.2 Strengths and limitations

6. CONCLUSION

7. DECLARATIONS

7.1 Ethics approval and consent to participate

7.2 Consent to publication:

7.3 Availability of data and materials

7.4 Acknowledgment

7.5 Competing interests

7.6 Funding

7.7 Author contribution

References

Additional Declarations

Status:

Version 1