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.