Reviewer ’s report  
 
Title: Anxiety and depression among infertile women: a cross -sectional survey from Hungary  
 
Version: 0 Date: 28 Jan 2017  
 
Reviewer: Andrew Edmonds  
 
Reviewer's report:  
 
Abstract: I think it is overstatement to say so definitively that "infertility is a permanent, chronic 
state of stress." First, infertility is not necessarily permane nt - for example, it can be caused by 
female/male tube blockages that can be corrected surgically, polycystic ovary syndrome that can 
be corrected by lifestyle changes or drugs, ovulation problems that can be corrected by drugs, 
endometriosis that can be c orrected by surgery or drugs, poor sperm count that can be corrected 
by drugs, etc.  Second, is not necessarily associated with stress or chronic stress - many 
individuals with infertility are not stressed either psychologically or in a biological sense; i f the 
reason for infertility is simple tube blockage, for example, how is this chronic stress? Especially 
if a person doesn't even realize there is an issue? I would significantly soften this statement. 
Also, I would remove "apparently" from the sentence a nd say that it may be associated with 
anxiety -related and depressive symptoms, rather than characterized by. Again, there are many 
examples of infertile individuals without these symptoms, so to say that infertility is 
characterized by depression is too st rong of a claim.  
 
 
Abstract: In the methods section of the abstract you should say where the study took place (i.e., 
where the women were from), in in the results section you should say how old the women were).  
 
 
Abstract: Need to add the word "and" after "(BD I)." 
 
 
Abstract: "Mapped" sociodemographic and fertility -specific characteristics? Is "mapped" the 
right word? This implies mapping in a geographical sense; perhaps say "described" instead?  
 
 
Abstract: Is the p -value associated with BDI or STAI -T? It is not cl ear. Also, I am surprised that 
the difference(s) are statistically different given the large standard deviations (?)… is this 
correct? What does the +/ - represent? It would be good to say what this means. Is it a standard 
deviation, or something else? Ther e does not appear to be an explanation anywhere in the paper. 
What is "trait anxiety"? Is it different than anxiety?  
 
 
Background: It may be overstated to say that infertility is a disease of the reproductive system 
because there are so many causes of infertility, and some may not be characterized as diseases of 
the reproductive system (e.g., sperm allergy). It may be good  to soften this statement.  
Background: What does "about 9% through 10 -15%" mean? Do you mean "about 9 -15%"?  
 
 
Background: Infertility many not be associated with significant psychological strain. The strain 
may not be significant, and infertility may not bot her some women/couples at all (e.g., if the 
couple is indifferent to whether or not they have a child).  
 
 
Background: What does "ART treatments" mean? Antiretroviral therapy? This term is never 
defined in the paper and therefore it is not clear what you mean  here. Can you provide references 
in this sentence to substantiate the responses to infertility and ART treatments?  
 
 
Background: "Years'" should not have an apostrophe, just say "of 10 years of research."  
 
 
Background: Spell out all acronyms before using them  the first time (e.g., ART, IVF). Most 
readers will know the meaning of IVF but some will not.  
 
 
Background: What is "the norm groups"? Women not starting IVF? Why does "IVF patients" 
have a hyphen here and later in the section?  
 
 
Background: Two consecutive p aragraphs have the same last sentence ("most of what is known 
about infertility psychology is based on IVF -patients…"); I suggest to correct this.  
 
 
Background: Supported the consistent finding? How can a finding be consistent if there is only 
one study cite d? 
 
 
Background: The background section does not say at all what THIS study is about. It is 
recommended to move some of the information from the "aims of the present study" section into 
the last paragraph of the background in order to set up the methods sect ion. After reading the 
background, it is ideal to have introduced at least a few specifics of what the study is about (e.g., 
"we compared the mental wellbeing of fertile and infertile women in Hungary.").  
 
 
Methods: "The goal of this study is to examine…"  
 
 
Methods: "…using questionnaires designed to assess the general population (BDI, STAI) and 
infertile women (FPI)." This sentence could be written more succinctly.  
Methods: Recommend to say "was included" and "was examined" rather than "have also been 
included " and "has also been examined." This study was done in the past and is not ongoing. 
Same comment below where it says "sources of stress have been assessed."  
 
 
Methods: The sentence "Moreover, the questionnaires…" seems out of place. What does this 
have to wi th selection of participants? Moreover, what? The availability of questionnaires online 
doesn't seem to have relevance to participant selection.  
 
 
Methods:  What about consent and IRB approval? There is nothing in the paper about this.  
 
 
Methods: So, a woman c ould be in the fertile group even if she was 42 years old and had a 25 or 
15-year-old child, and no children since the first child? How do we know that she is still fertile? 
It seems like this is a major potential source of bias (not all fertile women were  actually known 
to be fertile at the present time) and this should be acknowledged and discussed in the discussion 
section.  
 
 
Methods: What does "despite their willingness" mean? Willingness to conceive? So, if a woman 
is sexually active and could not concei ve for a year, but she doesn't want to have a baby (perhaps 
her husband is pressuring to have a baby but she doesn't want to), she wasn't considered infertile? 
This seems like another source of potential bias and should be discussed.  
 
 
Methods: No need to sa y "with the help of." Just say "was assessed with."  
 
 
Methods: Here, you spell out the meaning of STAI, but you have already used the acronym 
above without giving the meaning. I recommend giving the meaning of the acronym the first 
time you use it, rather th an defining it later in the paper. Same recommendation for BDI and FPI.  
 
 
Methods: Above the mean, rather than "above the mean of the norm"?  
 
 
Methods: What is STAI -T when you have only described the meaning of STAI?  
 
 
Methods: Say "the level of depressive sympt oms" rather than "the prevalence." Prevalence is a 
proportion, bounded by 0 and 1, but you are using a scale that goes from 0 -27. Prevalence is not 
the right word.  
 
 
Methods: Misplaced quotation marks after "(hereafter, illness stress)" - the quotation mark 
should come after item 8, not item 6.  
 
 
Methods: Following the principle of multicollinearity? Do you mean "because of concerns of 
multicollinearity"?  
 
 
Methods: Still have no idea what ART treatments means.  
 
 
Methods: The sentence about how many women participa ted in the study should be in the results 
section, not in the methods section.  
 
 
Methods: You say that fertile women had to have attended checkups at one clinic in order to 
participate, yet they could also have been recruited online. OK, somehow you recruite d them 
online but verified that they were attending outpatient checkups at a specific clinic? What about 
infertile women? Did they have to be attending one of the three clinics listed? This is not stated. 
Also, if you recruited women online, did you verify  that they attended one of the three listed 
clinics? This seems unlikely if the questionnaires were available on a general website for 
reproductive problems in the Hungarian language. This all should be clarified. Also, if you are 
recruiting women online, did you indeed not consent them, and you have no way to know 
whether the questionnaires are even being completed by women? (with online data collection 
from someone you have never met/consented, you have no way to know who is completing the 
surveys - the d ata could have come from anyone!) I recommend that you discuss this potential 
limitation; there is no way to know who is filling out the surveys online.  
 
 
Or, were the women simply recruited online and then asked to come to the clinic for data 
collection in person? This is not described anywhere in the paper. I assume not, since you say 
questionnaires were available online. This should be clarified.  
 
 
Results: Is the multivariable analysis only done in the infertile women, or in both the infertile 
women and fer tile women? This is not stated. Without this vital information, the results (in the 
results section and tables) are hard to understand.  
 
 
Methods: In multivariable modeling, did you use some sort of forward/backward/stepwise 
procedure with variables included only if they had a significant p -value? It is not clear what the 
"enter" method of SPSS is. I recommend that you give more details on t he model -building 
process for readers who do not use SPSS.  
 
 
Results: As noted above, it would be helpful to say what the +/ - means (standard deviation, or 
something else)?  
 
 
Results: Use the past tense (The rate was higher, not the rate is higher). Also, it's  not a rate… it's 
a proportion. Rate is a number of events per unit of time, which is different than a proportion. No 
difference was detectable in education, not is. A large income was more frequent, not is. Can you 
give p -values for education and income c omparisons?  
 
 
Results: It's not the prevalence of depressive symptoms, it's the level of depressive symptoms. As 
noted above, prevalence is a proportion bounded by 0 and 1, while this is a scale. If you wanted 
to compare odds (which is a concept related to b ut not exactly the same as prevalence/risk), you 
could dichotomize women into depressed or not and then calculate odds ratios and confidence 
intervals.  
 
 
Results: What is the normative Hungarian female population of the same age? Do you mean 
"than the fertil e group"? The female population of Hungary would include both infertile and 
fertile women, but you have no such sample of the general population in your paper. Also, there 
is no mention of matching by age in the methods section. How did you compare to wome n of the 
same age? This is not clear.  
 
 
Results: In the second paragraph of the "psychological well -being of fertile and infertile women" 
section, the comparison of proportions (and their significance) would be more meaningful if you 
could present prevalence  odds ratios and 95% confidence intervals rather than just stating the 
proportions.  
 
 
Results: What is an ART patient? Same question in discussion.  
 
 
Results: It would be helpful to say in the methods section how the variables in the multivariable 
models were specified. Was age continuous, categorical? Were the Likert scale items entered in 
their original forms, or dichotomized, or ordinal, categorical? It is difficult to interpret the betas 
without this information. Also, in the tables, there are no footnotes with this information. From 
the tables, it looks like factors that were non -significant were retained in the multivariable 
models… so, was the strategy just to put in all factors a -priori and not remove any? There was no 
model -building strategy (including forward, stepwise, backward, looking at bivariate models first 
and including in multivariable models factors that were statistically significant, etc.)? As stated, 
more detail on the methods would be helpful. It is not typical simply to include a bunch of 
variables in a multivariable model and leave it at that.  
 
 
Discussion: "or the normative population." In the methods section, there is no mention of how 
you had data from a "normative population" (only infertile and fertile samples were described). 
What is n ormative? General population?  
 
 
Discussion: The comparison of proportions is not very meaningful/informative without measures 
and confidence intervals (e.g., prevalence odds ratios). Not sure if these differences are 
substantial…  
 
 
Discussion: Depression, rath er than depressivity? Not sure the latter is a word.  
 
 
Discussion: Why is there a paragraph with only one sentence? You introduce the concept of 
predictors but do not say anything about it here.  
 
 
Discussion: I don't follow the logic that because women are hav ing children at older ages, it is no 
surprise that advanced age is associated with depression. Please clarify.  
 
 
Discussion: What is a background variable? A variable associated with the outcome? How does 
the lack of an association between partner support an d outcomes point to the role played by 
sexual health and outcomes? This argument is not clear.  
 
 
Discussion: You argue that illness stress is physical and not psychological? How is this possible? 
It seems that illness stress is in large part psychological.  
 
 
Discussion: Again, you talk about women recruited from the internet. It is not clear how these 
women match up to the inclusion criteria outlined earlier (e.g., attending one of the three clinics).  
 
 
Discussion: Other limitations that I described should be con sidered here.  
 
 
Declarations: Now I see the ethical approval and meaning of ART. Would be good to say the 
meaning of ART in the paper itself (the first time the acronym is used). Also, why include WHO 
when you have never used this term? I still think it woul d be good to talk about the apparent lack 
of consent for participation.  
 
 
References: Recommend to edit for formatting and consistency. Font size is not consistent (see 
reference 26, 38 , etc.). Why do some journal articles have PMID and PMCID but others don 't? 
Why does 40 have "epub" and "eng" while others don't have this information?  
Tables: Recommend to remove "test -statistics" from tables (won't be meaningful to readers) and 
also you didn't talk about chi -square testing in the methods although this testin g was apparently 
done. Also, give acronyms (SD, HUF, EUR, BDI, ART, etc.) in footnotes. What is the unit for 
duration of infertility (months, years)? What does "No participated in ART" mean? Not 
participated in ART? What does "number of assistant reproduct ive technology" mean? Number 
of technologies used, number of procedures? A footnote to describe how variables were specified 
would be helpful, but if not, it would be great to put this in the methods.  
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments t o the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review ? 
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manus cript:  
 
Acceptable  
 
 
 
 
 
 
 
 
 
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