Introduction
According to the World Health Organization (WHO), infertility refers to the failure to achieve a pregnancy after one year of regular sexual intercourse without the use of contraceptives. In general, infertility affects about 10-12% of couples worldwide [1]. Based on studies conducted in Iran, the average prevalence of infertility in Iranian women is 13.2% [2] and the prevalence rate of primary infertility is estimated at 17.3% [3], both of which are higher than the global average. Infertility has been declared as a serious concern by the WHO; neglecting this issue can leave wide-ranging problems at the individual and social levels [1]. Infertility is one of the unfortunate events of life. Evidence shows that infertile women are exposed to significantly more pressures that infertile men [4]. Usually, due to social prejudices, infertility is considered a female problem [5], or in many developing and developed countries, a woman is considered a complete person only when she becomes a mother. In many traditional cultures, the husbands of infertile women are more likely to remarry than those of fertile women [6]. In addition, the treatments used for infertility are often performed on women, which increases the pressure on them. Therefore, infertility can put women at high risk of various psychological disorders including depression [7]. Depression, on the other hand, can affect the health status, quality of life, and the response to infertility treatments [6]. Considering the high prevalence of psychological disorders in infertile women, as well as the significant role of psychological interventions in increasing the probability of successful treatment and fertility of infertile women [8], this study aims to investigate the prevalence of depression and the factors related to it in infertile women referring to the infertility centers in Ardabil, Iran.

Materials and Methods
This descriptive cross-sectional study was conducted from September 2022 to March 2023. The study population consisted of infertile women referring to an infertility treatment center in Ardabil, Iran. The sample size, taking into account the prevalence of 48.7% reported for depression in infertile women in a previous study in Iran [9] was calculated 96 using the Equation 1:
1.
n‌=‌{Z² (p×q)}/d^2‌=95
Z‌=‌1.96, P‌=‌0.487, q‌=‌0.513, d=‌0.1

The sampling was done by a convenience sampling method. Inclusion criteria were consent to participate in the study, being infertile, age 18-40 years, and being literate. The diagnosis of infertility was based on the evaluations made by an expert in obstetrics/gynecology. Exclusion criteria were neurological and psychiatric diseases, alcohol consumption, smoking or drug use, and not completing the questionnaires.
For all participants, the required information including age, educational level, place of residence, employment status, family income level, duration of marriage, duration of infertility, type of infertility, history of abortion, and history of taking antidepressants, were collected and recorded by an expert in obstetrics/gynecology and the author. Women were then asked to complete the Beck Depression Inventory (BDI), which has 21 items rated on a 4-point Likert scale from 0 to 3. It can measure the severity of depression, with a total score of 0-63; a score of 0-13 indicates no depression or minimal depression, a score of 14-19 shows mild depression, a score of 20-28 shows moderate depression, and a score of 29-63 indicates severe depression. The validity and reliability of the Persian BDI have been confirmed by a study in Iran [10]. The data was analyzed in SPSS v.25. The chi-square test was used to determine the difference in depression based on sociodemographic factors. The significance level was set at P≤0.05.

Results
The mean age of the participants was 30.6±0.5 years, ranging 20-40 years; 42 (42%) had <30 years of age, and 58 (58%) had ≥30 years of age. The education level of 35 women (35%) was lower than high school; 40 (40%) had a high school diploma, and 25 (25%) had a university degree; 81 (81%) were living in urban areas and 19 (19%) were in rural areas. In total, 72 women (72%) were housekeepers, and 28 (28%) were employed (13 were office employees and 15 were non-office employees). The family income level was unfavorable in 14 cases (14%), moderate in 74 cases (74%), and favorable in 12 cases (12%). The mean duration of marriage in women was 7.9 ± 4.6 years, ranging from 2 to 22 years; for 36 women, it was 2-5 years (36%), and for 64 women, it was more than 5 years (64%). The mean period of infertility was 6.1±4.2 years, ranging from 1 to 16 years; for 50 people (50%), it was 1 to 5 years, and for 50 people (50%), it was more than 5 years. The type of infertility was primary in 72 women (72%) and secondary in 28 women (28%). There was a history of abortion in 20 women (20%) and a history of taking antidepressants in 10 women (10%). The mean score of BDI was 15.6±11.2. Based on the cut-off point of this scale, 52 (52%) had depression, of whom 22 (22%) had mild depression, 19 (19%) had moderate depression, and 11 (11%) had severe depression. 
The results of the chi-square test are shown in Table 1. The results showed a significant difference in depression level based on age (P=0.006, 95%CI: 1.4-7.3, OR‌= 3.2), occupation (P=0.042, 95%CI: 1-6.2, OR‌=‌2.5), duration of marriage (P=0.001, 95%CI: 1.7-9.7, OR=‌4.1), infertility period (‌P<‌0.001, 95%CI: 1.9-10.5, OR = 4.5), infertility type (P=0.013, 95%CI: 1.2-7.9, OR‌=‌3.1), and history of abortion (P‌=‌0.021, 95%CI: 1.2-10.5, OR=3.5). Those with 30 years of age or older, housewives, married for more than 5 years, having infertility for more than 5 years, having primary infertility, and having a history of abortion were at higher risk of depression.



Discussion
The prevalence of depression among infertile women in Ardabil was 52%, which is similar to the prevalence reported in the study by Mohammadi et al. [9] in Iran, Al-Homaidan et al. [11] in Saudi Arabia, Benbella et al. [12] in Morocco, and Verma et al. [13] in India, who reported the prevalence of depression in infertile women as 48.7%, 53.8%, 55%, and 56.4%, respectively. However, some studies reported higher levels of depression in infertile women, including a prevalence of 65% in the study by Pinar et al. in Turkey [14], 62% in the study by Alhassan et al. in Ghana [15], and 58.4% in the study by Lata et al. in India [16]. On the other hand, the prevalence of depression among infertile women in the study by Ramzanzadeh et al. in Tehran [17] was 40.8%. Elsous et al. [18]reported a prevalence of 40.1% in Gaza. Vo et al. [19] reported a prevalence of 12.2% in Vietnam, and Yousefi et al. [20] reported 15% in Semnan, Iran. These prevalence rates are lower than our findings. The discrepancies in the results can be attributed to the difference in the study populations in terms of infertility characteristics (the probability of success is higher in some cases of infertility), the ruling culture of the society (attitudes towards women with infertility, or the amount their support), and in the instruments used to measure depression (BDI vs. the General Health Questionnaire, the Hospital Anxiety and Depression Scale, or the Patient Health Questionnaire). In addition, having a child is considered a value in Iranian culture, and therefore infertility is mainly associated with a negative attitude towards childless women and creates challenges for them. Behaviors such as isolation, stigmatization, verbal and physical abuse, or instability in marital relationships such as divorce or polygamy, can all lead to psychological problems in infertile women and a high prevalence of depression in them.
In terms of severity, depression was mild in 22% of infertile women, moderate in 19%, and severe in 11%. In Elsous et al.’s study, the prevalence of mild, moderate, and severe depression in infertile women was reported as 22.3%, 8.6%, and 10.6%, respectively, [18]. In the study by Lata et al. [16], depression was mild in 16.8%, moderate in 32.7%, and severe in 8.9% of infertile women. In our study, the depression of infertile women aged ≥30 years was significantly higher than in younger infertile women. Contrary to our finding, the results of Elsous et al. [18], Lata et al. [16], and Benbella et al. [12] did not show a relationship between the age of infertile women and depression, while the results of Alhassan et al. [15]showed that that the risk of depression in infertile women increases with their aging, which is in line with our finding. Considering that increasing age even in fertile women is associated with a decrease in reproductive ability [21], awareness of this negative effect of age on fertility may put more pressure on infertile women and thus lead to more psychological disorders in them.
In the present study, there was no significant difference in depression among infertile women based on their level of education. Consistent with this finding, Elsous et al. [18], Lata et al. [16], Vo et al. [19], Benbella et al. [12], and Yousefi et al. [20] also did not show a relationship between the level of education and depression in infertile women, but Verma et al.[13] reported the power of educational level in predicting the risk of depression, which is not consistent with our findings. In our study, depression in employed women was significantly lower than in housekeeper women. However, Elsous et al. [18] and Lata et al. [16] did not show a relationship between the occupation of infertile women and their depression, but in Benbella et al.’s study [12], depression scores in working women were significantly lower than non-working women, which is consistent with our findings. Having a job and income may bring goals other than childbearing in women and be a way to experience other goals other than having children [15, 22]. This may explain why employed women in the present study had lower depression than non-employed women.
In this study, there was no significant difference in depression among infertile women living in a city or a village, which is in agreement with the findings of previous studies [18، 19]. Also, there was no significant difference in depression based on the family income level, which is consistent with the results of Lata et al. [16]. The infertile women with a duration of marriage >5 years and an infertility period >5 years had significantly higher depression. In Elsous et al.’s study [18], it was found that marriage duration of more than 6 years and infertility duration of more than 5 years significantly increased the risk of depression in infertile women, which is consistent with our findings. Contrary to our findings, Lata et al. [16] and Benbella et al. [12] did not report the significant relationship of depression with the duration of marriage and infertility in infertile women. The psychological burden of infertile women increases with the duration of infertility, maybe because expectations and hope for a positive outcome after treatment may fade over time, while social pressure remains or even increases.
In this study, the difference in depression was also significant in terms of infertility type, where the depression of infertile women with primary infertility was higher than that with secondary infertility. Elsous et al. [18] and Alhassan et al. [15] also reported that depression was significantly higher in women with primary infertility than in women with secondary infertility. However, in studies by Lata et al. [16] and Benbella et al. [12], depression was not significantly related to the type of infertility, which is not consistent with our findings. Considering that women with secondary infertility have already given birth and mostly have children, their psychological burden is lower compared to women with primary infertility who have no history of pregnancy or childbearing.
In this study, the difference in depression among infertile women was also significant in terms of the history of abortion. The results of Elsous et al. [18] showed that the history of abortion increases the risk of depression in infertile women by 2.9 times, which is in line with our findings. Abortion is a serious concern in infertile women and is not easy to cope with [23]. Evidence shows that women with infertility lose their hope of becoming a mother after abortion more than before. As a result, they face a lot of internal psychological pressure and guilt, all of which can lead to an increased risk of depression. In this study, there was no significant difference in depression among infertile women in terms of antidepressant use. This is not consistent with the results of Vo et al.’s study [19] in which the history of taking antidepressants was a significant risk factor for depression in infertile women. In our study, the prevalence of depression in women with a history pf antidepressant use was higher (80% vs. 48.9%), but the difference was not statistically significant. It seems that the small number of women with a history of taking antidepressants in our study was involved.
The present study was conducted on infertile women referred to a center in Ardabil, therefore, caution should be exercised in generalizing its results to all infertile women in Iran. In addition, the cross-sectional design of the study limits the establishment of causal relationships between the study variables. Moreover, considering that the data was collected using a self-report questionnaire, there may be a response bias.

Conclusion
In conclusion, more than half of the infertile women in Ardabil have different degrees of depression. The depression is significantly higher in those older than 30 years, housewives, those with marriage duration and infertility more than 5 years, those with primary infertility, and those with a history of abortion. Based on these findings, screening for depression among women seeking infertility treatment, particularly those at higher risk for depression, and referral of positive cases to a psychiatrist is recommended. This may improve the mental health of women and even have a positive effect on their treatment outcomes. It is recommended to conduct larger studies in a multi-centered manner by considering more factors related to depression in infertile women.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Islamic Azad University, Ardabil, Iran (Code: IR.IAU.ARDABIL.REC.1401.093). 

Funding
This article was extracted from the professional doctorate thesis of Mandana Rajabi approved by University of Islamic Azad University, Ardabil. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization, methodology, and supervision: Narges Salehi; Investigation, writing the initial draft, review & editing, data collection, and data analysis: All authors.

Conflict of interest
The authors declared no conflict of interest.


 

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