Journal of Psychosomatic Obstetrics & Gynecology

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The association of type D personality and

depression with infertility in women

Esra Nur Tola, Serenat Eris Yalcin, Nadiye Dugan & Baha Oral

To cite this article: Esra Nur Tola, Serenat Eris Yalcin, Nadiye Dugan & Baha Oral (2019): The
association of type D personality and depression with infertility in women, Journal of Psychosomatic
Obstetrics & Gynecology, DOI: 10.1080/0167482X.2019.1573224

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Published online: 20 Feb 2019.

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JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY
https://doi.org/10.1080/0167482X.2019.1573224

ORIGINAL ARTICLE

The association of type D personality and depression with infertility

in women
Esra Nur Tolaa, Serenat Eris Yalcinb, Nadiye Duganc and Baha Orala
a
Department of Obstetrics and Gynecology, In vitro Fertilization Unit, Suleyman Demirel University Faculty of Medicine, Isparta,
Turkey; bDepartment of Obstetrics and Gynecology, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey; cDepartment of
Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey

ABSTRACT ARTICLE HISTORY

Purpose: Type D personality—defined as the presence of two personality characters, namely Received 18 May 2018
negative affectivity (NA) and social inhibition (SI)—is associated with various disorders. The 14- Revised 5 January 2019
item Type D Scale (DS14), which consists of NA and SI subscales, can be used for the detection Accepted 15 January 2019
of the presence of Type D personality. The aim of our study was to investigate the association
KEYWORDS
of Type D personality and depression with infertility in women. Type D personality;
Method: A total of 324 women, 168 primary unexplained infertile women (92 patients under- depression; infertility
going in vitro fertilization (IVF) treatment and 76 undergoing intrauterine insemination (IUI)
treatment) and 156 fertile controls were recruited. The 21-item Beck Depression Inventory (BDI-
21) and DS14 were completed by all participants. The study was approved by Local Ethics
Committee with the protocol number 72867572-050-218.
Results: Depression and Type D personality were found to be significantly more prevalent in
the infertile group than the fertile group. Type D was positively associated with infertility (OR ¼
2.34, 95% CI ¼ 1.45–3.78, p < .0001), especially in the younger-aged (<35 years) population (OR
¼ 2.59, 95% CI ¼ 1.48–4.5, p ¼ .001). After adjusting for the duration of marriage, age, obesity,
educational level, and the same characteristics of the partner, the association between Type D
personality and infertility persisted (OR ¼ 2.56, 95% CI ¼ 1.52–4.29, p < .001). The scores of the
BDI-21 and NA subscale were found to be negatively correlated with age and partner’s age. The
BDI and SI scores, and the NA, SI, and Type D personality rates were similar between the IUI
and the IVF groups; however, the NA score was higher, and depression was found to be more
prevalent and severe in the IUI group than the IVF group.
Conclusions: Type D personality could be positively associated with infertility, especially in
younger-aged women.

Introduction having a child is very important for religious, sociocul-

Infertility is defined as the failure to achieve a clinical
pregnancy after 12 months despite having regular
unprotected sexual intercourse [1]. The prevalence of
primary and secondary infertility varies according to
the developmental stage of the countries, with the
average being 10% globally [2]. In addition to the clas-
sical risk factors, psychological factors such as emo-
tional distress, depression, and personality traits have
seemed to be potential risk factors for infertility [3].
Therefore, in recent years, studies have focused on the
psychological health of infertile couples.
Although infertility is considered a stressful condition
for couples, women bear more stress than men [4].
Because, they are commonly considered to be the cause
of infertility, particularly in developing countries where
tural, and economic reasons [4]. Therefore, infertility
could affect their social, physical, and psychological well-
being and cause them to become neglected and socially
inhibited [5]. Infertility causes distress that develops into
major depression, and depression has been found to be
more common and severe among infertile than fertile
couples [6]. The role of depression in the pathogenesis
of infertility has been also reported [7]. Several theories
have been reported regarding infertility such as “Grief
and Bereavement theory” [8] and “chronic infertility spe-
cific grief model” [9]. The first one reveals a causal rela-
tion between infertility and feeling disturbances such as
sadness, disappointment, helplessness and loss of phys-
ical and mental well-being, life goals, position, reputa-
tion, regard, and self-confidence [10]. Depressive

CONTACT Esra Nur Tola perinatalog@hotmail.com Department of Obstetrics and Gynecology, In vitro Fertilization Unit, Suleyman Demirel
University Faculty of Medicine, Isparta, Turkey
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 E. N. TOLA ET AL.
symptoms are more frequent in infertile women. The
second theory which is named as “chronic infertility spe-
cific grief model” acknowledges infertility as a chronic
sorrow lasting for a longer period of time.
Type D (distressed) personality, a broad personality
type, is defined as the presence of two personality charac-
ters—namely, negative affectivity (NA) and social inhib-
ition (SI) as described by Denollet et al. [11]. It is a general
tendency to experience emotional distress characterized
by the inhibition of the expression of emotions/behav-
iours in social relations (SI) and the predisposition to a
negative mood (NA). Individuals with NA commonly have
feelings of discomfort, depression, and worry. Socially
inhibited individuals are vulnerable to feeling inhibited
and unsafe in interactions with others because of fears of
disapproval and rejection [12]. These feelings related to
Type D personality make the individual vulnerable to gen-
eral psychological distress/disorders (e.g. depression),
decreased quality of life, and various diseases [12,13].
Type D personality is associated with the presence of
chronic disorders and clinical manifestations of various
disorders such as cardiovascular disease (CVD) and anky-
losing spondylitis [14,15]. Neuroendocrine and immuno-
logic pathways have been investigated to explain the
negative clinical outcomes for patients with Type D per-
sonality [16] and increased pro-inflammatory immune
activation [17], oxidative stress [16], and cortisol levels
[18] in cardiac patients found to be related to Type D per-
sonality. There is also a relationship between Type D per-
sonality and negative psychological effects negative
psychological effects such as depression, anxiety and
emotional stress [19]. However, the role of Type D person-
ality and its association with infertility have not been
studied. The 14-item Type D Scale (DS14) is a simple and
easy-to-use scale that could routinely be performed for
the detection of Type D personality. It allows for the rapid
screening of chronic emotional distress so that patients
could be referred for examination and treatment by a
psychiatrist [20].
The importance and increasing prevalence of infertil-
ity for the society and its effect on physiological well-
being, as well as the paucity of studies on personality
type in infertile patients, motivated us to investigate the
relationships among depression, Type D personality and
infertility. It is the first study to investigate the relation-
ship between Type D personality and infertility.
Methods
Study design
This was a cross-sectional study conducted at the
infertility unit of a tertiary center over a 1-year period
from January 2016 to March 2017. All participants pro-
vided written informed consent before enrolling in
this study.
Sampling methods and sample size
A total of 324 reproductive-age (18–44 years) women,
168 diagnosed as primary unexplained infertile com-
prising the infertile group and 156 age- and body mass
index (BMI)-matched women diagnosed as fertile com-
prising the fertile group (the control group), were
recruited to the study. Infertility is defined as the fail-
ure to achieve a clinical pregnancy after 12 months
despite having regular sexual intercourse without
using any type of contraceptive [1]. The infertile group
had not used any contraceptive method since the
beginning of their marriages, so the duration of infer-
tility was equal to the duration of marriage. They com-
prised two subgroups: the in vitro fertilization (IVF)
group consisting of 92 participants undergoing IVF
treatment and the intrauterine insemination (IUI) group
consisting of 76 participants undergoing an IUI cycle.
The patients enrolled as being in regular gynecological
health in our outpatient clinic were recruited as fertile
controls. Everyone in the fertile group had a normal
regular cycle and normal basal hormone levels on the
third day of the cycle, and each had at least one child.
The women in the fertile group had not experienced
infertility at any time of their lives. The controls
included healthy women that were compatible with
inclusion/exclusion criteria throughout the 1-year
study period.
The exclusion criteria for all participants were a his-
tory of any psychiatric disorder (depressive disorder,
generalized anxiety disorders, etc.), chronic diseases,
endocrinopathies, chronic depression secondary to
any organic disorder apart from infertility, declined
participation in the study and secondary infertility. All
participants were also free from chronic medication
use. Patients were also excluded if the duration of
unprotected sexual intercourse was less than 1 year.
Data collection
The personal data of all the participants, including
age, educational level, weight, height, smoking, and
alcohol use (the same data as their partners’) and also
the duration of the marriage/infertility were noted at
their enrollment. BMI was calculated as the ratio of
weight (kg) to height (m) squared (kg/m2). The partici-
pants were divided into two groups according to their
BMI: normoweight (BMI  25 kg/m2) and overweight

(BMI > 25 kg/m2). With respect to education, the par-
ticipants were divided into three subgroups: primary
education, high school (lyc
ee) education
and university.
The Turkish versions of the DS14 and the 21-item
Beck Depression Inventory (BDI-21) were administered
to all participants at their enrollment, and the scores
were noted. The BDI-21 Scale is a self-report inventory
that measures the severity of depression [21]. Each
item describes a specific behavioral, emotional and
somatic manifestation of depression. The scores range
from 0 to 3. The Turkish version was validated by Hisli
N [22]. Having more than 17 points was considered
depression. Mild depression was considered for a total
of 17–20 points, moderate depression was considered
for 21–30 points and severe depression was accepted
as having more than 30 points. The DS14, which is a
brief, valid and worthwhile scale, consists of two sub-
scales—the NA and SI. Each subscale consists of seven
items that are scored 0 (false) to 4 (true). A score
equal to 10 points and above on both scales is used
to classify patients as Type D personality (NA  10 and
SI  10) [23].
Statistical analyses
Data were analyzed using the SPSS version 20
(SPSS Inc, Chicago, IL). A p values < .05 was
accepted as significant. The Kolmogorov–Smirnov
test was used to test the normality of distribution
of the continuous variables. While mean ± SD was
used to present normally distributed continuous var-
iables, median and interquartile ranges (IQR; the
range of values lying between the 25th and 75th
percentiles) were used to represent non-normally
distributed variables. Categorical variables were com-
pared using the v2 or Fischer’s exact test which
were shown as frequencies. We used the Student’s
t-test and Mann-Whitney U test for parametric and
nonparametric data, respectively. The Spearman’s or
Pearson’s rank correlation tests were performed to
determine the relationships between continuous var-
iables for parametric and nonparametric datas,
respectively. Logistic regression analysis was per-
formed to clarify the impacts of Type D personality
and depression on infertility.
Ethical approval
The study was approved by Local Ethics Committee
with the protocol number 72867572-050-218.
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 3
Results
A total of 324 participants, 168 diagnosed as primary
infertile (76 undergoing IUI treatment and 92 under-
going IVF treatment) and 156 age- and BMI-matched
fertile controls who fulfilled the inclusion criteria and
two scales were recruited to our study.
Demographic features and depression and type D
personality rates for the fertile and the
infertile groups
The age of the infertile group ranged between 20 and
44 years (31.55 ± 5.24 years). The mean marriage dur-
ation of infertile group was 6.16 years (±4.42 years).
There were no significant differences in terms of wom-
an’s age, partner’s age, BMI, hormone profile on the
third day of cycle between the fertile and the infertile
groups. However, the partner’s BMI was significantly
higher in the infertile group (27.5 ± 3.49 kg/m2) than
the fertile group (26.63 ± 3.57 kg/m2, p ¼ .02). The dur-
ation of marriage was significantly lower in the infer-
tile group (6.16 ± 4.42 years) than the fertile group
(9.06 ± 5.16 years, p < .0001). The infertile group had
lower educational levels than the fertile group
(p ¼ .026); however, the partner’s educational level was
similar for the two groups. The characteristics of smok-
ing, alcohol use were also similar for the groups.
The scores for the BDI, NA and SI subscales were
higher in the infertile than in the fertile population
(p ¼ .005, p ¼ .01, and p < .0001, respectively).
Depression was found to be significantly prevalent in
26.2% of the infertile group, whereas it was 16.7% in
the fertile group (p ¼ .037). Of the depressed women,
50% had mild depression, 43.2% had moderate
depression and 6.8% had severe depression in the
infertile group. However, the severity of depression
was distributed homogeneously between two groups.
In the infertile group, 51.2% had Type D personality,
whereas 29.5% of the fertile group had Type D per-
sonality. Type D personality, NA and SI were also sig-
nificantly more prevalent in the infertile than the
fertile group (p < .0001, p ¼ .011, and p < .0001,
respectively). Demographic features, depression, NA,
SI, and Type D scores and rates for the groups are
summarized in Table 1.
The association between type D personality,
depression, and infertility
We also evaluated the association between type D
personality, depression and infertility using regression
4 E. N. TOLA ET AL.

Table 1. Demographic features and depression, NA, SI, and Type D scores and rates for the fertile and infer-
tile groups.
Fertile group (n ¼ 156), mean ± SD, %a Infertile group (n ¼ 168), mean ± SD, %a p Value
Age (year) 31.76 ± 5.41 31.55 ± 5.24 .7
Partner’s age (year) 35.44 ± 5.63 34.37 ± 5.82 .051
BMI (kg/m2) 25.51 ± 4.7 25.92 ± 4.55 .3
Obesity 85/156 (54.5%) 86/168 (51.2%) .55
Partner’s BMI (kg/m2) 26.63 ± 3.57 27.5 ± 3.49 .02
Partner’s obesity 61/56 (39.1%) 45/168 (27.1%) .22
Duration of marriage (year) 9.06 ± 5.16 6.16 ± 4.42 <.0001
TSH (uıU/mL) 1.78 ± 1.16 2 ± 0.89 .059
E2 (pg/mL) 39.93 ± 23.06 43.63 ± 17.89 .1
FSH (mlU/mL) 7.49 ± 3.1 8.2 ± 5.03 .1
LH (mlU/mL) 4.79 ± 1.99 4.6 ± 2.15 .4
PRL (ng/mL) 9.92 ± 5.31 10.61 ± 5.02 0.2
BDI score (points) 9.28 ± 8.55 11.26 ± 8.02 .005
NA score (points) 11.57 ± 7.38 13.75 ± 7.96 .01
SI score (points) 9.91 ± 5.26 12.35 ± 5.52 <.0001
Depression, present(%) 26/156 (16.7%) 44/168 (26.2%) .037
Depression severity
Mild 10/26 (40%) 22/44 (50%)
Moderate 11/26 /44%) 19/44 (43.2%) .43
Severe 4/26 (16%) 3/44 (6.8%)
NA, present (%) 88/156 (56.4%) 117/168 (% 69.6) .011
SI, present (%) 64/156 (41%) 114/168 (% 67.9) <.0001
Type D personality, present (%) 46/156 (29.5%) 86/168 (% 51.2) <.0001
Educational level
Primary 50/156 (32.1%) 78/168 (46.4%)
High 49/156 (31.4%) 38/168 (22.5%) .026
University 57/156 (36.5%) 52/168 (31%)
Partner’s education
Primary 44/156 (28.2%) 50/168 (29.8%) .51
High 46/156 (29.5%) 57/168 (33.9%)
University 66/156 (42.3%) 61/168 (36.3%)
Smoking 30/156 (19.4%) 22/168 (13.1%) .126
Partner’s smoking 66/156 (41.9%) 70/168 (41.6%) .94
Alcohol 1/156 (0.6%) 1/168 (0.6%) .95
Partner’s alcohol use 8/156 (4.5%) 7/168 (4.2%) .86
The italic values represent significantly different values between the groups.
v test for categorical comparisons.
a 2

BMI: body mass index; TSH: thyroid stimulan hormone; E2: estradiol; FSH: follicle stimulating hormone; LH: luteinizing hormone;
PRL: prolactin; BDI: beck depression inventory; NA: negative affectivity; SI: social inhibition.

analysis. The univariate analysis showed that having

Table 2. The association between Type D personality and
type D personality was positively associated with infer-
infertility.
tility (OR ¼ 2.34, 95% CI ¼ 1.45–3.78, p < .0001); how-
95% CI for OR
ever, having depression was not associated with
B p OR Lower Upper
infertility (p > .05). When we divided the participants
Type D personality 0.94 <.0001 2.56 1.52 4.29
according to their ages as being younger (<35 years) Duration of marriage –0.19 <.0001 0.82 0.77 0.87
and older (35 years), the association between type D Educational level (university) .01
Educational level (primary) 0.83 .008 2.29 1.24 4.24
personality and infertility persisted only in the younger Educational level (high) 0.03 .9 1.03 0.55 1.93
population (OR ¼ 2.59, 95% CI ¼ 1.48–4.5, p ¼ .001) but Age 0.08 .003 1.08 1.02 1.15
Partner’s obesity 0.63 .01 0.53 0.31 0.89
not in the older population (p > .05) (Data not shown). Constant –1.62 .06 0.19
After adjusting for the variables that were significantly The italic values represent significantly different values between
different between the two groups and could affect fertil- the groups.
Covariates: Age, obesity, educational level, partner’s age, partner’s obes-
ity (e.g., age, obesity, educational level, partner’s age, ity, partner’s educational level, duration of marriage.
partner’s obesity, partner’s educational level, and dur-
ation of marriage), the positive predictive effect of Type
D personality on infertility persisted (OR ¼ 2.56, 95% CI ¼ 0.31–0.89, p ¼ .01), and primary education (OR ¼ 2.29,
1.52–4.29, p < .0001). We also found a positive associ- 95% CI ¼ 1.2–4.2, p ¼ .008) and infertility. The duration of
ation between age (OR ¼ 1.08, 95% CI ¼ 1.02–1.15, marriage (OR ¼ 0.82, 95% CI ¼ 0.77–0.87, p < .0001) was
p ¼ .003), partner’s obesity (OR ¼ 0.53, 95% CI ¼ negatively associated with infertility. Related data
 JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 5

Table 3. Comparison of characteristics of IUI and IVF groups.

IVF group (n ¼ 92), mean ± SD, %a IUI group (n ¼ 76), mean ± SD, %a p Value
Age (year) 33.43 ± 4.95 29.27 ± 4.69 <.0001
Partner’s age (year) 35.84 ± 5.95 32.59 ± 5.17 .001
BMI (kg/m2) 26.01 ± 4.44 25.8 ± 4.7 .62
Obesitya 43/92(46.7%) 43/76 (56.6%) .2
Partner’s BMI (kg/m2) 27.33 ± 3.27 27.7 ± 3.75 .47
Partner’s obesitya 24/92 (26.4%) 22/76 (28%) .81
Duration of infertility (year) 7.38 ± 4.88 4.68 ± 3.25 <.0001
BDI score (points) 10.22 ± 7.23 12.51 ± 8.776 .09
NA score (points) 12.26 ± 7.47 15.55 ± 8.21 .008
SI score (points) 11.93 ± 5.64 12.86 ± 5.35 .275
Depression. present (%)a 16/92 (17.4%) 28/76 (36.8%) .004
Depression severitya
Mild 11/26 (68.8%) 11/28 (39.3%) .04
Moderate 3/26 (18.8%) 16/28 (57.12%)
Severe 2/16 (12.5%) 1/28 (3.6%)
NA, present (%)a 60/92 (65.2%) 57/76 (75%) .17
SI, present (%)a 61/92 (66.3%) 53/76 (69.7%) .63
Type D, present (%)a 43/92 (46.7%) 43/76 (56.6%) .2
Educational levela
Primary (n, %) 43/92 (46.7%) 35/76 (46.1%) .13
High (n, %) 16/92 (17.4%) 22/76 (28.9%)
University (n, %) 33/92 (35.9%) 19/76 (25%)
Partner’s educational levela
Primary (n, %) 26/92 (28.3%) 24/76 (31.6%) .08
High (n, %) 26/92 (28.3%) 31/76 (40.7%)
University (n, %) 40/92 (43.5%) 21/76 (27.6%)
Smokinga 8/92 (8.7%) 14/76 (18.4%) .06
Partner’s smokinga 32/92 (35.2%) 37/76 (49.3%) .06
Alcohol usea 0/92 (0%) 1/76 (1.3%) .28
Partner’s alcohol usea 4/92 (4.3%) 3/76 (3.9%) .89
The bold/italic values represent significantly different values between the groups.
v test for categorical comparison.
a 2

IVF: In vitro fertilization; IUI: Intrauterine insemination; BMI: Body mass index; BDI: Beck Depression Inventory; NA: Negative affect-
ivity; SI: Social inhibition.

associated with the relationships between Type D per- and type D personality rates were similar for the two
sonality, depression and infertility are shown in Table 2. groups. The data are shown in Table 3.

Comparison of characteristics of IUI and IVF groups
We also compared demographic characteristics,
depression and type D personality rates of the IVF and
IUI groups (Table 3). The mean age in the IVF group
was higher than that of the IUI group (p < .0001); this
was also true for the partner’s mean age (p ¼ .001).
BMI and partner’s BMI were distributed homoge-
neously between the groups. The duration of infertility
was longer in the IVF group (7.38 ± 4.88 years) than in
the IUI group (4.68 ± 3.25, p < .0001), as was expected.
Educational level, smoking, alcohol use were distrib-
uted homogeneously between the IUI and the
IVF groups.
The BDI and SI scores were distributed homoge-
neously between the IUI and IVF groups; however, the
NA score was higher in the IUI group than in the IVF
group (p ¼ .008). Depression was found to be preva-
lent in 17.4% of the IVF group, whereas it was 36.8%
in the IUI group (p ¼ .004). Depression was more
severe in the IUI group (mild: 39.3%; moderate: 57.1%;
severe: 3.6%) than in the IVF group (mild: 68.8%; mod-
erate: 18.8%; severe: 12.5%, p ¼ .04). However, NA, SI,
Correlations between BDI, NA, SI scores and
demographic and clinical characteristics for
infertile group
We also evaluated the correlations of the BDI, NA,
and SI scores with the demographic and clinical char-
acteristics of the infertile patients. The BDI, NA, and SI
scores of the infertile patients were not correlated
with the day 3 hormone levels, BMI, duration of infer-
tility and cycle count. All of the aforementioned scores
were strongly correlated with one another. The scores
of the BDI-21 and NA subscale of the DS14 were
found to have a weak negative correlation with age
and partner’s age. The correlations among the scores
of the scales and the demographic and clinical charac-
teristics for the infertile patients are shown in Table 4.
Discussion
Studies have evaluated the relationship between
depression and infertility; however, the present study
is the first to investigate the relationship between
type D personality and infertility. Our results suggest
6 E. N. TOLA ET AL.
Table 4. Correlations between BDI, NA, and SI scores and demographic and clinic characteristics for infertile group.
BDI-21 score NA score SI score Age
BDI-21 score r 1 0.59 0.27 –0.22
NA score r 0.59 1 0.4 –0.24
SI score r 0.27 0.4 1 –0.03
BDI: beck depression inventory; NA: negative affectivity; SI: social inhibition; BMI: body mass index.
that type D personality may affect the fertility status
of women.
We found significantly higher rates of type D per-
sonality, NA, SI, and depression in the infertile popula-
tion than in the fertile controls. Type D personality
was positively associated with infertility. After adjust-
ing for the variables that were significantly different
for the two groups and that could affect fertility, the
positive association between type D personality and
infertility persisted in our study. An association
between type D personality and the presence of
chronic disorders and clinical outcomes of various dis-
orders such as CVD, ankylosing spondylitis and dia-
betes was found [14,15]. Several investigations have
focused on neuroendocrine and immunologic path-
ways to explain the negative clinical outcomes for
patients with type D personality [16]. Type D personal-
ity has been found to be associated with increased
proinflammatory immune activation [17], oxidative
stress [16], cortisol levels [18], autonomic imbalance
[24], and higher macrophage activity [25] in cardiac
patients. We could not find any correlations among
the scores of the NA, SI, BDI-21 scales and BMI, part-
ner’s BMI, duration of infertility, day-3 hormone levels,
and cycle count for infertile patients.
The lack of association between the scores of the
scales and basal hormones in this study was also an
expected result. It may indicate the relevance of the
study population because basal hormone levels are an
objective measurement regardless of the patient’s per-
sonality or emotions. Biological pathways, particularly
oxidative stress and immune activation, could support
the biological plausibility of type D as a risk factor for
infertility. The biological pathways that can lead to
infertility in type D should be investigated in further
studies. The main problem with our results is the
bidirectional relationship between personality trait and
infertility. Because type D personality could be a risk
factor for infertility or infertility could create Type D
personality, further investigation is warranted.
When we divided the participants into two groups
according to age, the association between type D per-
sonality and infertility persisted in the younger popu-
lation (<35 years) but not in the older population
(>35 years). The BDI-21 and NA scores were also found
to be negatively correlated with age and partner’s age
Partner’s age BMI Infertilty duration Cycle count TSH E2 FSH LH PRL
–0.19 –0.08 –0.02 0.026 0.01 0.06 0.07 0.06 –0.007
–0.17 –0.0 –0.08 0.02 –0.01 0.12 –0.01 0.09 –0.04
–0.02 0.07 0.03 0.01 –0.14 0.12 0.01 0.02 –0.04
in our study. A previous study had found a predictive
effect of type D personality on the outcome of CVD in
a younger but not an older population [14,26]. This is
consistent with our findings. Kupper et al. also sug-
gested that type D personality could change with age
[14]. It has been suggested that the adverse effect of
type D personality was more efficient on the outcome
of disease in younger than in older patients with CVD
[27]. Therefore, it is possible that younger patients
may have a greater tendency to experience psycho-
logical and social stress because of infertility. It is also
possible that aging may be accompanied by changes
in personality [28]; nevertheless, aging might play a
more prominent role than personality in explaining
increased infertility. The prognostic role of type D may
become less pronounced in older people due to the
mitigating or neutraulizing effects of fatalism, deep
convictions, shift of life perspectives from childbearing
to another aspects of life. To better understand the
interactive networks of the risk factors for infertility,
the prevalence of infertility in subgroups and ethnic-
ities should be examined.
We also found a positive association between pri-
mary education and infertility. Applying to hospital
with infertility problems could be more prevelant in
women with low educational levels because having a
child is more important for this population than for
women with higher education levels.
We could not find any differences in the BDI and SI
scores for the IUI and the IVF groups; however, the NA
score was higher for the IUI group than for the IVF
group. Depression was found to be significantly more
common and severe in the IUI group than in the IVF
group. However, NA, SI, and type D personality rates
were similar for the two groups. The duration of infer-
tility and the mean age were lower in the IUI group
than IVF group, as was expected. The longer duration
of infertility in the IVF group could have caused lower
depression rates because of the adaptation to the
infertility condition, as was found in previous studies
[6,29]. In contrast, some studies have found a positive
association between the duration of infertility and the
rates of depression [6,30]. The higher NA score, but
not Type D personality rates in the IUI group, could
have been a result of the small sample size.
Depression is thought to be a common reaction to

infertility. The severity and rates of depression have
been found to be higher for infertile women than for
fertile women [6], with an overall percentage of
24%–36% [31]. This rate is higher in some Islamic or
developing countries than in some Western countries
[30]. In Eastern cultures, especially those that are
Islamic, having a child is a very important and valu-
able factor in family stabilization and marital and psy-
chological satisfaction. Therefore, childlessness could
lead to negative social consequences that are psycho-
logically upsetting for infertile women [32]. Turkey is a
country having both Asian and European cultural fea-
tures. The relatively higher rates of depression in infer-
tile population in our study could be due to the
Eastern and Islamic properties of Turkey where it is
still lower than reported as 56% from the middle East
countries [33]. Infertility could cause guilt feelings and
self-blame that leads to depression [10]. In our study,
depression was found to be prevalent in 26.2% for the
infertile group, whereas it was 16.7% for the fertile
group. In contrast, we found the severity to be similar
for the fertile and the infertile groups. The low dur-
ation of marriage in the infertile group or the various
tests performed for the assessment of depression,
such as the BDI [33] and the Epidemiological Studies
Depression Scale (CES-D) [34], in different studies
could be reasons for different results regarding the
severity of depression.
We also demonstrated a strong correlation between
Type D personality and depression. The scores for the
NA and SI were also strongly correlated with the
scores for the BDI-21, consistent with the results of
previous studies [19]. Type D personality has also
been found to be associated with the tendency of
patients with CVD to experience chronic emotional
stress [13] and a decrease in their quality of life [12].
Furthermore, Type D personality was found to be
negatively linked to lower mental and physical health
status and self-management of disease [35].
The underlying cause for the pathogenetic mechan-
ism of the relationship between infertility and Type D
personality in our study needs to be studied with
larger samples. Our study has a number of limitations
that must be taken into account in our discussion of
the results. One of them is the cross-sectional design.
A longitudinal study would better explain associations.
Another limitation is that the infertile women were
patients at a tertiary center for IUI or IVF. Therefore,
the results may not be representative of infertile
women in the general population. In addition, this
may have introduced selection bias. The association
with the clinic might have decreased the patient’s
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 7
negative emotions, and this might have influenced
their answers to the questionnaires. Our study group
included infertile patients who were receiving rela-
tively good medical treatment because our unit was a
tertiary center with doctors with specialties in repro-
ductive health, and this might have improved the psy-
chological status of the patients. Another limitation is
noninclusion of male partner in our design. The dis-
crepancies between educational level and duration of
marriage for the two groups are additional potential
effect modifiers that might have influenced the per-
sonality type and psychological status of the partici-
pants. We hypothesized that personality might affect
fertility. Despite these limitations, an association
between infertility and Type D personality was shown
for the first time.
Conclusion
We concluded that Type D personality could affect the
fertility status of patients. Knowing the patient’s per-
sonality may lead clinicians to be alert when identify-
ing patients for psychological therapies. Our study
also raises questions of whether psychological inter-
ventions might have a beneficial role in infertility
treatment, especially for targeted patient subgroups.
The underlying mechanisms of increased infertility in
Type Ds should be investigated with large samples.
Acknowledgement
Special thanks to the nurse and personnel of IVF depart-
ment. Thanks to participants for their patience and kindness.
Disclosure statement
The authors report no declarations of interest.
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