European Journal of Cardiovascular Medicine

Infertility is a growing public health concern, affecting approximately one in six couples worldwide1. It is defined as the inability to conceive after 12 months or more of regular, unprotected sexual intercourse. Infertility can be classified as primary, where a woman has never conceived, or secondary, where conception occurred previously but has not recurred2,3. The increasing prevalence of infertility is attributed to multiple factors, including delayed childbearing, lifestyle changes, and comorbid conditions such as obesity and metabolic disorders4.

Obesity, a significant health problem globally, is strongly linked to reproductive dysfunction in women. Body mass index (BMI) and waist circumference are widely used anthropometric measures to assess obesity. Elevated BMI has been associated with adverse reproductive outcomes, including anovulation, polycystic ovary syndrome (PCOS), and decreased fertility5. Central obesity, characterized by increased waist circumference, has a particularly detrimental impact on fertility due to its role in hormonal imbalances, insulin resistance, and chronic inflammation5.

In addition to physiological challenges, infertility often leads to profound psychological disturbances, including depression, anxiety, sexual dysfunction, and reduced quality of life6. These psychological effects are more pronounced in women with obesity and comorbidities, creating a complex interplay between physical and mental health7.

This study aims to explore the associations between obesity, infertility, and psychological disturbances in women seeking infertility treatment. Understanding these interrelationships will help inform clinical interventions that address both the physiological and psychological aspects of infertility, thereby improving reproductive outcomes and overall well-being in affected women

Study Design:

This qualitative content analysis study was conducted from October 2023 to March 2024 to explore the associations between obesity, infertility, and psychological disturbances among women seeking infertility treatment.

Study Setting and Participants:

The study was carried out in the obstetrics and gynecology outpatient department of Konaseema Institute of Medical Sciences, Amalapuram. A purposive sampling method was used to recruit 40 infertile women attending the infertility clinic.

Inclusion Criteria:

• Women with a history of infertility for more than one year
• Married women cohabitating with their partners
• Women not using any contraceptive methods
• Participants willing to provide informed consent

Exclusion Criteria:

• Women unwilling to participate
• Women with pre-existing mood disorders

Data Collection:

Data were collected through in-depth, semi-structured, face-to-face interviews, lasting 10-15 minutes each, conducted in private settings to ensure confidentiality. Interviews focused on infertility-related challenges, psychological disturbances, comorbidities, and demographic details. Field notes were also taken during interviews to supplement the data.

Data Recorded:

The study recorded demographic information (age, socioeconomic status, and education level), type of infertility (primary or secondary), BMI, waist circumference, comorbidities (PCOS, hypothyroidism, diabetes, and hypertension), and psychological symptoms (depression, anxiety, and sexual dysfunction).

Ethical Considerations:

Ethical approval was obtained from the institutional ethics committee, Konaseema Institute of Medical Sciences, Amalapuram and written informed consent was secured from all participants. Confidentiality of personal data was maintained throughout the study.

Data Analysis:

The qualitative data were thematically analyzed using content analysis techniques to identify patterns and associations. Data were categorized under key themes related to obesity, infertility type, comorbidities, and psychological outcomes

The study analyzed the impact of infertility on women, considering age, socioeconomic background, comorbidities, obesity, and psychological disturbances. The results highlight key associations between these factors and infertility, providing insights into primary and secondary infertility cases.

Infertility and Age Group Distribution

The distribution of infertility cases by age revealed a higher prevalence of secondary infertility in women aged 31-35 years (40%) and primary infertility being more common among women aged 25-30 years (35%) (Table 1). As age advances, the incidence of infertility tends to shift towards secondary infertility.

Table 1: Distribution of Infertility Cases by Type and Age Group

Figure No:1. Distribution of Infertility Cases by Type and Age Group

Socioeconomic and Educational Background

Primary infertility was predominantly observed among women from upper socioeconomic status (50%) and those with a graduate-level education (60%) (Table 2). This trend suggests a possible link between lifestyle factors associated with higher education and socioeconomic status and infertility.

Table 2: Socioeconomic and Educational Background of Women with Primary Infertility

Figure No:2.Socioeconomic and Educational Background of Women with Primary Infertility

Comorbidities and Infertility

The study found that PCOS and hypothyroidism were the most common comorbidities associated with primary infertility, present in 60% and 50% of cases, respectively. In contrast, secondary infertility cases were marked by higher occurrences of diabetes (35%) and hypertension (25%) (Table 3). These findings emphasize the role of metabolic and endocrine disorders in infertility.

Table 3: Comorbidities in Women with Primary and Secondary Infertility

Figure No:3.Comorbidities in Women with Primary and Secondary Infertility

Psychological Disturbances in Obese Women

Obese women with infertility experienced a range of psychological disturbances, with 55% of obese women with primary infertility reporting depression, and 50% reporting sexual dysfunction. Similar trends were observed in secondary infertility, although the prevalence was slightly lower (Table 4). Anxiety was another notable concern, affecting 30% of obese women with primary infertility and 35% with secondary infertility. This underscores the need for psychological support as part of infertility management.

Table 4: Psychological Disturbances in Obese Women with Infertility

Figure No:4.Psychological Disturbances in Obese Women with Infertility

Impact of Obesity on Infertility and Previous Abortions

Central obesity was identified as a major contributor to secondary infertility, affecting 65% of the cases. Additionally, a history of previous abortions was associated with secondary infertility in 45% of the cases (Table 5). These findings highlight the role of central adiposity and previous reproductive events in the development of secondary infertility.

Table 5: Impact of Obesity (Central Adiposity) on Infertility and Previous Abortions

Figure No:5.Impact of Obesity (Central Adiposity) on Infertility and Previous Abortions

This study highlights the multifactorial nature of infertility, emphasizing the critical roles of obesity, comorbidities, and psychological disturbances in infertile women. The findings align with previous research indicating that infertility is not only a physical condition but also a significant psychological burden, particularly in women of reproductive age.

Obesity and Infertility:

The results demonstrated that central obesity is prevalent among women with secondary infertility (65%), consistent with studies that link abdominal adiposity to impaired reproductive outcomes (Kocełak et al¹⁰., 2012). Obesity contributes to infertility through mechanisms such as hormonal imbalances, insulin resistance, and anovulation (Li et al¹²., 2022). Women with primary infertility exhibited high rates of comorbidities, particularly polycystic ovary syndrome (PCOS) (60%) and hypothyroidism (50%). These findings are in line with previous studies, which highlight the role of metabolic and endocrine disorders in disrupting normal ovulatory functions and conception rates (Li et al¹²., 2022). As reported in earlier studies, obesity exacerbates PCOS by worsening insulin resistance, leading to anovulatory cycles and poor reproductive outcomes (Kocełak et al¹⁰., 2012).

Psychological Disturbances and Infertility:

The psychological burden of infertility was evident in this study, with high rates of depression (55%) and sexual dysfunction (50%) observed among obese women with primary infertility. This aligns with findings by Bahadur et al¹¹. (2024) and Dyer et al⁹. (2005), which show that infertility is a major psychological stressor, increasing the risk of mood disorders due to feelings of inadequacy, social pressure, and failed fertility treatments. Anxiety was also prevalent, particularly in secondary infertility cases (35%), supporting studies that highlight psychological distress as a key factor affecting the overall quality of life in infertile women (Aduloju et al⁸., 2018; Bakhtiyar et al¹⁴., 2019). Emotional eating and physical inactivity, often seen in response to stress, may further exacerbate obesity, creating a vicious cycle between psychological distress and infertility (Kocełak et al¹⁰., 2012).

Comorbidities and Secondary Infertility:

Secondary infertility cases were associated with higher rates of diabetes (35%) and hypertension (25%), indicating that metabolic disorders play a significant role in women who have experienced previous pregnancies. This finding is consistent with studies highlighting the impact of metabolic dysfunctions on secondary infertility (Kocełak et al¹⁰., 2012; Maroufizadeh et al¹³., 2018). Additionally, a history of previous abortions was present in 45% of secondary infertility cases, underscoring the influence of previous adverse reproductive events on current fertility. This observation emphasizes the need for a comprehensive evaluation of metabolic and reproductive history when managing secondary infertility.

Socioeconomic and Educational Factors:

Primary infertility was more common among women from higher socioeconomic backgrounds and those with a graduate-level education. This trend reflects findings by Dyer et al⁹. (2005) and Bakhtiyar et al¹⁴. (2019), which suggest that lifestyle factors, including delayed childbearing and work-related stress, contribute to infertility in women of higher socioeconomic status. Similar associations have been reported in studies showing that lifestyle changes, such as late marriages and professional commitments, can negatively affect reproductive health (Aduloju et al⁸., 2018; Bahadur et al¹¹., 2024).

Clinical Implications:

The findings suggest that effective infertility management requires a multidisciplinary approach involving gynecologists, endocrinologists, and mental health professionals. Weight loss interventions, particularly targeting central obesity, could improve ovulation, reproductive outcomes, and psychological well-being. Counseling and psychological support should be integrated into infertility treatment plans to help women cope with the emotional burden of infertility and avoid maladaptive behaviors, such as emotional eating and physical inactivity.

Limitations:
This study is limited by its small sample size and qualitative design, which restricts the generalizability of the findings. Further studies involving larger, more diverse populations are needed to validate the observed associations and establish causal relationships.

This study highlights the significant role of obesity, particularly central obesity, in secondary infertility, affecting 65% of cases. Primary infertility was more prevalent among women with PCOS (60%) and hypothyroidism (50%), underscoring the importance of addressing metabolic and endocrine disorders. Psychological disturbances, including depression (55%) and sexual dysfunction (50%), were notably higher in obese women, emphasizing the need for mental health support during infertility treatment. Secondary infertility was associated with prior reproductive events, with 45% of cases having a history of previous abortions. These findings advocate for a multidisciplinary approach combining weight management, comorbidity control, and psychological support to improve reproductive outcomes and quality of life in infertile women.

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