Discussion
In this study; which compared the levels of alexithymia, somatosensory amplification, and anxiety sensitivity of the patients with unexplained infertility to those of fertile patients and the patients with infertility due to a known cause, no statistically significant differences have been detected across the groups (p>0.05). However; evaluating the awareness of feelings, the level of ability to express feelings, anxiety sensitivity, and the perception of somatosensory sensations, this is an important study that sheds light on the mental health of infertile cases; who did not have any known psychiatric disorder or who did not need to receive any medical treatment. Additionally; this study contributes to the literature significantly because it is the first study that examined infertile patients in two groups as unexplained infertility and infertility of known causes, comparing them with fertile patients.
It is known that difficulty identifying and communicating feelings, anxiety, and somatosensory amplification are associated with somatic disorders.25-27 Somatic disorders are described as diseases with no organic causes and medical explanation. A prevalence study in our country in 2009 found the prevalence of somatic disorders as 7.7% and reported that somatic disorders were more common in women, among patients suffering from chronic diseases, and in patients; whose mothers had a low level of education.28 Somatization is a coping mechanism in traditional cultures. Considering the social structure in Turkey, somatization of distress appears to be commonplace for women feeling dependent on men and suffering from difficulty communicating feelings openly. Alexithymia was found at a rate of 45.9% in individuals with somatization disorders in a study conducted in our country in 2016.29 Prior to our study, we conceptualized that unexplained infertility might be a form of somatization. Therefore, we hypothesized that the scores of the somatization-associated scales including the alexithymia, somatosensory amplification, and anxiety sensitization scales of such patients would be higher than those of participants in the control group and the ”infertility due to a known cause” group. However, our study result may lead us away from the conclusion that unexplained infertility is a form of somatization. On the other hand, such a result is likely to have come out because of the inadequacy of the sample size.
Most people associate being a woman with the ability to conceive and have children. Studies have reported that infertile women suffer from anger, sadness, shame, self-blaming, and feeling incomplete.30 The extent of their communicating and sharing such feelings is debatable. In the literature, difficulty identifying and communicating feelings and lacking imaginative capacity are defined as alexithymic characteristics.31 The severity of alexithymia has been reported to be high in depression and anxiety disorders in many studies.29,32 There are studies in the literature suggesting that a two-way relationship exists between depression and alexithymia.33 Such alexithymic characteristics may cause individuals to develop psychiatric disorders including anxiety disorders and depression. Considering the social aspects of infertility; it is possible to foresee that alexithymic characteristics of infertile women will be at the forefront, resulting in not only difficulty communicating but recognizing feelings as well. We hypothesized in our study that alexithymic characteristics would be more severe in the infertile patient group compared to the control group but no such conclusion has been reached. The total scores of alexithymia were found similar and at moderate severity in all three groups. One of the reasons for the lack of differences across the groups may result from inadequacies of women in our country in identifying their feelings in general. Another reason may be the inadequacy of the sample size. In the literature; there are no studies, in which the levels of alexithymia of infertile women have been measured. Therefore, the results of our study are important for contributing to the literature.
The decision to have a child and raising a child instigate considerable responsibility with the potential to induce anxiety. Moreover; such a decision will give rise to another concern, whether the woman will ever get pregnant. Expectations begin from the first month when people begin to monitor their menstrual cycles and even to schedule the days of sexual intercourse accordingly. Anxiety starts building up with every upcoming month when pregnancy cannot be established. Medically unexplained infertility can sometimes contribute to further rise in anxiety because known causes make the things easier to control; whereas uncertainty is perceived of as uncontrollable and threatening, building up stress.34 Studies have shown that high levels of perceived uncertainty are associated with high levels of anxiety and depression and with the quality of life.35
Anxiety sensitivity is defined as an individual difference variable arising from the individual’s conceptions that anxiety or fear experiences will lead to maladies, embarrassment, or further anxiety.23 In our study, we found out that anxiety sensitivities of infertile patients were correlated with difficulty identifying and describing feelings, difficulty communicating feelings, and somatosensory amplification regardless of the cause of infertility (p<0.05). This can be considered stemming from their inability to identify feelings, in other words from their alexithymic characteristics, resulting in the somatization of anxiety. Studies show that anxiety and depression act on the outcomes of treatment for infertility.36-37 Starting from such information, the ability to identify feelings can be worked through for improvement to reduce anxiety sensitivity and somatic complaints so that the levels of anxiety and depression can be reduced; which can make a difference in the treatment process of infertile patients. Infertile individuals may undergo psychiatric examinations before treatment to identify and treat individuals having difficulties in identifying and communicating feelings and receiving inadequate social support. Thus; the development of depression and anxiety disorders can be prevented, potentially increasing both spontaneous pregnancy rates and the success of infertility treatment indirectly. Therefore, we are of the opinion that routine psychiatric evaluation is important in patients presenting for infertility treatment even in the absence of findings in the pre-treatment medical history suggesting any mental disorders.
This study has some limitations. The cross-sectional study design does not allow for the formulation of opinions about the changes in findings to occur over time. Both undergoing treatment and the stage of treatment can induce changes in individuals, particularly in infertile patients. Regarding the study sample; the normal distribution of variables including age, educational status, employment status, and the length of marriage in the infertile patient group strengthens the results. However, the limited sample size makes it difficult to generalize the results. Because of the use of self-administered scales in the study, potential bias in responses of participants to the scale items should not be ignored.
In conclusions, it has been found out that; regardless of the knowledge of the etiology of infertility, the levels of alexithymia, somatosensory amplification, and anxiety sensitivity of infertile cases did not differ from those of fertile women. However, it has been shown that as the difficulty in identifying emotions increases in infertile cases, anxiety sensitivity, which may cause psychological infertility, also increases. These results suggest that more research is required to understand the role of psychological disorders in the etiology of unexplained infertility due to its complicated nature of human fertility.