Correlative analysis of social support with anxiety and depression in men undergoing in vitro fertilization embryo transfer for the first time

Abstract

Objective

To explore the correlation between the level of social support and the extent of anxiety and depression in Chinese men undergoing in vitro fertilization embryo transfer (IVF-ET) for the first time, in order to provide a basis for male mental health counselling.

Methods

Self-administered questionnaires covering general health status, anxiety (self-rating anxiety scale), depression (self-rating depression scale) and social support (social support rating scale) were completed by men undergoing their first round of IVF-ET.

Results

A total of 502 completed questionnaires were considered valid and were analysed. The anxiety, depression and social support scores for men undergoing their first round of IVF-ET were significantly higher than those for Chinese normative data. Social support was inversely correlated with anxiety and depression.

Conclusions

These findings suggest that health care professionals should provide specific psychological counselling to Chinese men undergoing their first round of IVF-ET, in order to improve their psychological health and to facilitate increased levels of social support.

Keywords

male anxiety depression social support

Introduction

Infertility is a global health issue that affects ∼8–10% of couples and over 80 million people worldwide.^1,2 In China, 12.5% of couples are infertile and there are over 50 million infertile individuals.³ This has promoted the rapid development of assisted reproductive technology in China. The wide application of in vitro fertilization embryo transfer (IVF-ET) allows research to be undertaken on the mental health aspects of IVF-ET in couples undergoing this assisted reproductive technique. It has been reported that infertile couples experience psychological symptoms, such as mood disorders, caused by IVF-ET.⁴ Although there may be more severe psychological reactions in infertile women,⁵ infertile men also have psychological problems.^6,7

In this current study, the extent of anxiety, depression and social support was investigated in men undergoing IVF-ET for the first time. Correlations between anxiety and depression and the extent of social support were analysed, in order to provide a basis for improving male mental health.

Subjects and methods

Subjects

This prospective study sequentially enrolled men undergoing IVF-ET at the Reproductive Medical Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China, between April and September 2011. The major inclusion criteria were: (i) undergoing the first round of IVF-ET treatment; (ii) educated to junior middle school or above; (iii) provided written informed consent. Exclusion criteria were: (i) presence of vision disorders, auditory perceptual disorders or communication disorders; (ii) artificial insemination with donor; (iii) refused to participate in this study after an explanation of the study's aims and methods was provided. A record was made of whether the men had primary infertility, which is defined as infertility in a couple who have never had a child; or secondary infertility, which is defined as a failure to conceive following a previous pregnancy.

All study methods were approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University. All study subjects provided written informed consent to participate.

Research tools

The mental health and social support of the men were evaluated using the following tools: (i) a general status questionnaire that included medical record number, age, educational background and family income (yuan/month); (ii) a self-rating anxiety scale (SAS) was used to evaluate subjective feelings of anxiety.⁸ SAS contains 20 items (15 positive items and five negative items) and the score for each item is recorded on a four-grade scale. According to the frequency of the negative (i.e. not typically associated with anxiety) or positive (i.e. typically associated with anxiety) symptoms, the four-grade scale was as follows: symptoms occur a little of the time; symptoms occur some of the time; symptoms occur a good part of the time; symptoms occur most of the time. These four grades were scored as 1, 2, 3 or 4, respectively, for the 15 positive items and 4, 3, 2 or 1, respectively, for the five negative items. The standard score was the scores from the 20 items × 1.25. A standard score ≥50 was regarded as indicative of anxiety; (iii) a self-rating depression scale (SDS) was used to evaluate depression.⁸ SDS contains 20 items (10 positively worded items and 10 negatively worded items) and the score for each item was recorded on a four-grade scale that was the same as that used for SAS. The standard score was calculated as the scores from the 20 items × 1.25. A standard score ≥53 was regarded as being indicative of depression; (iv) a social support rating scale (SSRS) containing 10 items including objective support, subjective support and social support.⁸ The scoring system for the 10 items on the SSRS was as follows: for items 1–4 (items 1, 3, and 4 represented subjective support; item 2 represented objective support) and 8–10 (represented social support), there were four choices, which gave scores of 1, 2, 3 and 4, with higher scores indicating more social support. For item 5 (which represented subjective support), there were four choices: A, no; B, very little; C, generally; D, all. These choices provided scores of 1, 2, 3 and 4, respectively. For items 6 (financial support) and 7 (psychological support), if the subject selected ‘no source’ they received a score of zero; and if they selected several sources of support from a list of possible sources, they obtained a score commensurate with the number of sources that they had selected. The higher the SSRS score, the greater the extent of social support. Test–retest total score consistency of the SSRS is 0.92.⁸

Data collection

At the beginning of IVF-ET, the purpose and methods of this study were explained to the men undergoing their first round of IVF-ET. After the men had signed the informed consent form, they were provided with the three questionnaires. The men completed the questionnaires independently; questionnaires were then collected. The questionnaires were considered valid if all items had been answered.

Statistical analyses

All statistical analyses were performed using the SPSS® statistical software package, version 17.0 (SPSS Inc., Chicago, IL, USA) for Windows® and Excel software version 2003 (Microscoft Corporation, Redmond, WA, USA). Single-sample t-test was used to compare the data collected from the men in this study and Chinese normative data.⁸ Independent sample t-test was used to compare the levels of anxiety, depression and social support between men undergoing IVF-ET, categorized according to ‘living place’ and ‘educational level’. Single-factor analysis of variance was used to compare the levels of anxiety, depression and social support between men undergoing IVF-ET categorized according to ‘age’ and ‘family income’. Least significant difference (LSD) t-test was used to compare any two means from a set of multiple means for men undergoing IVF-ET categorized according to different demographic characteristics. Pearson's correlation coefficient analysis was used to evaluate the correlations between the social support scores and the scores for anxiety and depression. A P-value < 0.05 was considered statistically significant.

Results

From a total of 510 questionnaires that were distributed to men undergoing their first round of IVF-ET, 502 questionnaires were returned and considered valid (response rate 98.4%). The mean ± SD age of the 502 men was 32.41 ± 5.05 years (range 20–53 years). Of the 502 men, the educational level was below junior college in 278 (55.4%) and at or beyond junior college in 224 (44.6%); 209 (41.6%) lived in urban and 293 (58.4%) in rural communities; family income was <1000 yuan/month in 143 (28.5%), 1000–3000 yuan/month in 286 (57.0%) and >3000 yuan/month in 73 (14.5%); primary infertility occurred in 204 (40.6%) and secondary infertility in 298 (59.4%). The mean ± SD age of their partners was 31.07 ± 4.43 years (range 21–45 years) and the median duration of infertility was 3 years (range 1–18 years). Scores for anxiety, depression and social support in the men undergoing their first round of IVF-ET were significantly higher compared with Chinese normative data (P < 0.01 for all comparisons) (Table 1).⁸

Table 1.

Comparison of anxiety, depression and social support rating scale scores between men undergoing their first round of in vitro fertilization embryo transfer (IVF-ET) and Chinese normative data (n = 502).

Rating scales	Men with IVF-ET	Chinese normative data	t	Statistical significance^a
SAS	39.75 ± 7.01	37.23 ± 12.59	8.05	P < 0.01
SDS	44.00 ± 8.58	41.88 ± 10.57	5.53	P < 0.01
SSRS	42.54 ± 6.23	34.56 ± 3.73	28.68	P < 0.01

Data presented as mean ± SD.

Single-sample t-test

SAS, self-rating anxiety scale; SDS, self-rating depression scale; SSRS, social support rating scale.

When men undergoing their first round of IVF-ET were categorized according to demographic characteristics, there were significant differences in anxiety and depression scores between the men who lived in different places or had different educational levels (P < 0.01 for all comparisons) (Table 2). There was a significant difference in the depression scores between the men who had different family income levels (P < 0.01). Further comparison of any two of the family income levels indicated that there was no significant difference in the depression scores between <1000 yuan/month and 1000–3000 yuan/month (LSD t-test), but there was a significant difference in the depression scores between <1000 yuan/month and >3000 yuan/month (LSD t-test, P < 0.001) and between 1000–3000 yuan/month and >3000 yuan/month (LSD t-test, P = 0.001). There was no significant difference in the anxiety and depression scores between the men based on age, and in anxiety between the men who had different family income levels.

Table 2.

Comparisons of anxiety, depression and social support rating scale scores between men undergoing their first round of in vitro fertilization embryo transfer, categorized according to different demographic characteristics (n = 502).

Characteristics	N	Rating scales
Characteristics	N	SAS	t/F	Statistical significance^a	SDS	t/F	Statistical significance^a	SRSS	t/F	Statistical significance^a
Age, years
<30	143	39.83 ± 6.54	2.111	NS	45.01 ± 9.04	1.794	NS	41.43 ± 6.30	5.239	0.006
30–35	229	40.28 ± 6.68	43.90 ± 8.16	42.48 ± 5.95
>35	130	38.71 ± 7.94	43.06 ± 8.74	43.85 ± 6.45
Residence
Rural	293	40.82 ± 7.25	4.128	P < 0.01	45.64 ± 8.43	5.212	P < 0.01	42.19 ± 6.09	−.1.477	NS
Urban	209	38.24 ± 6.36	41.69 ± 8.27	43.02 ± 6.41
Educational level
<Junior college	278	41.23 ± 7.03	5.426	P < 0.01	45.89 ± 8.56	5.664	P < 0.01	42.03 ± 6.07	−.2.060	0.040
≥Junior college	224	37.91 ± 6.54	41.65 ± 8.03	43.17 ± 6.39
Family income, yuan/month
<1000	143	40.04 ± 6.31	0.956	NS	45.11 ± 8.21	6.971	P < 0.01	41.31 ± 6.23	5.019	0.007
1000–3000	286	39.86 ± 6.82	44.28 ± 8.50	42.78 ± 6.24
>3000	73	38.72 ± 8.82	40.68 ± 8.91	43.99 ± 5.87

Data presented as mean ± SD.

Independent sample t-test for ‘residence’ and ‘educational level’; single-factor analysis of variance for ‘age’ and ‘family income’.

SAS, ; SDS, ; SSRS, self-rating anxiety scaleself-rating depression scalesocial support rating scale; NS, no statistically significant difference (P ≥ 0.05)

There were significant differences in the social support scores based on age, educational levels and family income levels (P < 0.05 for all comparisons) (Table 2). Further comparisons of any two of the age groups indicated that there was no significant difference between <30 years and 30–35 years (LSD t-test), but there was a significant difference between <30 years and >35 years (LSD t-test, P = 0.001) and between 30–35 years and >35 years (LSD t-test, P = 0.044). Further comparison of any two of the family income levels indicated that there was no significant difference between 1000–3000 yuan/month and >3000 yuan/month (LSD t-test), but there was a significant difference between <1000 yuan/month and 1000–3000 yuan/month (LSD t-test, P = 0.021) and between <1000 yuan/month and >3000 yuan/month (LSD t-test, P = 0.003). There was no significant difference in social support between the men who lived in different places.

Pearson's correlation coefficient analysis indicated that social support was inversely correlated with anxiety (r = −0.265, P < 0.01) and depression (r = −0.290, P < 0.01).

Discussion

Infertility, which is a serious negative life event, often causes psychological stress in couples.⁹ Those undergoing IVF-ET face considerable psychological stress, and often experience a series of negative emotions. It has been shown that the pressures placed on infertile men come mainly from the social impact of being recognized as a man who does not have any children, the influence on daily life caused by not having any children and the influence on sex life caused by infertility.¹⁰ The incidence of anxiety and depression was 4.5% and 6.9%, respectively, in men undergoing IVF-ET in Italy.¹¹ Beaurepaire et al.¹² reported that anxiety occurs in 38% of men undergoing IVF-ET for the first time, but in 34% of men undergoing repeated rounds of such treatment. Our current study demonstrated that anxiety and depression were present in men undergoing their first round of IVF-ET, which was consistent with the results of other Chinese studies.^13,14 This may be due to a longer IVF-ET treatment cycle, more clinical examinations, limited success rate and Chinese traditional beliefs. Although doctor–patient communication was undertaken before initiation of IVF-ET in our current study, more severe anxiety and depression scores were recorded for men undergoing their first round of IVF-ET compared with Chinese normative data.

This current study demonstrated that anxiety and depression were more severe in the men who lived in the countryside compared with those that lived in towns; and in those men with an educational level below junior college than in men with an educational level at or beyond junior college. These current findings were similar to the results reported by Feng et al.¹⁵ We speculate that men with lower educational levels, especially those who live in rural settings, might have more severe anxiety and depression because they are not be able to control their negative emotions and psychological stresses (because they are more likely to be deeply affected by conventional ideas about male infertility and might also have a poor understanding of IVF-ET). We also believe that men who live in urban areas, and who have a higher educational level, might be able to cope better with their negative emotions because they have easier access to social welfare and social security systems, and they possibly do not hold deeply conventional ideas about male infertility. Our current study indicated that the rate of depression was significantly lower in the group of men with a higher family income than in two lower family income groups. This might be because each cycle of IVF-ET costs 30 000–35 000 yuan (US $4800–5600) and the success rate remains low. We consider that men tend to face more financial pressure because they are the main source of family income; as men readily suppress their emotions under pressure, depression might be expected to be more severe in men who have a lower family income. Our current study demonstrated that there were no significant differences in the anxiety and depression scores between men based on age, and in the anxiety scores between the men with different family incomes, which was not consistent with the results reported by He et al.¹³ This discrepancy might be due to the fact that the men in this current study had higher levels of social support than the normative levels for the Chinese population.

Our current study demonstrated that the level of social support was significantly higher in men undergoing their first round of IVF-ET compared with Chinese normative data. This may be related to the conventional idea that Chinese people pay close attention to children,¹⁶ which might result in infertile men obtaining more social support from their friends and family. Our current study indicated that the level of social support was significantly higher in men who had an educational level at or beyond junior college and were >35 years of age than in men who had an educational level below junior college and were <30 years of age. These findings might reflect the fact that men who have an educational level above junior college and who are >35 years of age play an important role in the family and have a higher social status within society in general; consequently they might be able to obtain greater levels of social support. Our current study also showed that the level of social support was significantly higher in the two higher family income groups than in lowest family income group. We believe that this might be because those with a higher income also have a higher level of self-worth, which in turn leads to greater levels of social support. Our current study findings demonstrated that the higher the level of social support, the lower the anxiety and depression scores, which was consistent with the results reported by Van den Broeck et al.¹⁷ The ‘social support buffering model’ believes that social support can relieve the negative effects of stressful events on the physical and mental health of individuals.¹⁸ Therefore, although anxiety and depression scores were significantly higher in men undergoing their first round of IVF-ET compared with Chinese normative data in this current study, the levels were still below the diagnostic criteria for anxiety and depression, possibly as a result of the high levels of social support.

In conclusion, Chinese men undergoing their first round of IVF-ET experienced anxiety and depression at levels greater that those observed in the general population. Improvements in the level of social support might help to relieve their symptoms of anxiety and depression. In our opinion, health care professionals should provide specific psychological counselling to men undergoing IVF-ET, in order to improve their psychological health and to provide a communication platform from which to facilitate increased levels of social support.

Footnotes

Declaration of conflicting interest

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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