Title: Impact of primary Care Posttraumatic Stress Disorder (PC-PTSD) on fertility problem of
Iranian women with infertility during the COVID#19 pandemic
Version: 0 Date: 09 Jan 2024
Reviewer's report:
Overall comments:
This is an important study that has come at a time when WHO and other global organisations
are highlighting infertility and its association with PTSD. The research team has conducted a
cross-sectional study.
Major comment:
The discussion is written superficially, and a deeper critique is needed. Practice implications are
missing in the discussion section.
There are numerous grammatical and spelling errors throughout the document. Please use editing
services to ensure the manuscript is grammatically correct.
“Infertile women or infertile couple” is a term associated with stigma. I will recommend you
use the term “women with infertility or couples with infertility” throughout the document.
Abstract
The abstract contains several results and lacks a clear introduction and discussion. I suggest
rewriting the abstract for better readability. Start by what are the gaps in previous study, aim,
then key results, brief discussion about the results and conclusion that is novel and useful for
future policymakers and practitioners in the field.
Please correct the punctuation, grammatical and spelling mistakes.
Is the phrase “related with husband” or “relationship with husband” in the sentence “After
adjusting….”? Please correct.
Background
I think the first paragraph of the background section (“Trauma….”) is emotive and generalised
personal description of trauma. Such sentences should not be included in the background section
unless referenced. The authors can directly start by describing post-traumatic stress disorder.
Millions of people lost their loved ones during the pandemic. This was the major cause for grief
and PTSD. Please include this and add reference.
The sentence “The post-traumatic effects of COVID-19 are considered to be…” needs reference.
What do you mean by “Infertile couples meet infertility as the most difficult challenge they must
control.”? Please rephrase for clarity.
What is primary care PTSD? A brief DSM explanation would help improve clarity for the
readers.
The sentence “According to the literature, COVID-19 affects the reproductive system and
fertility treatment” should be “According to the literature, COVID-19 affects the reproductive
system and response to fertility treatment”. Also, Why is it so? Some explanation warranted here.
Methods
The authors mention the study was conducted during the third to fifth waves of COVID-19. How
have you defined wave? Several working definitions are currently being proposed, but due to
the unreliability of data reported by several countries, a consistent standard definition of “wave”
is not possible. It is better to combine the previous sentence and rephrase the sentence to “the
study was conducted from September 2020 to January 2022 when the COVID-19 cases were at
their peak or upward/downward trends or when R-value was >1 or <1”.
Please add references for the sentences “The overall integrity was 0.92. Cronbach’s alpha for
all sub-scales was more than 0.7.”
Results
Please correct several grammatical and punctuation errors in this section too. Several words after
commas should not be capitalised.
Discussion
Please read my comment regarding “waves” and “infertile couple” above and make changes in
this section too.
We cannot make causal inferences. Instead, you can say that PTSD and infertility are associates
with each other. A history of PTSD can increase fertility-related stress. These initial arguments
should be clear, so please rephrase and avoid repetitive sentences in the following section:
“The present study displayed that primary care posttraumatic stress disorder was significantly
associated with total fertility problems. Based on the results, the variable of Pc-PTSD was a
predictor of fertility problems in infertile women. In other words, more Pc-PTSD symptom is
associated with more fertility problem.”
The discussion is written superficially, and a deeper critique is needed. I am providing some
questions that can be answered to help the discussion stronger. What do the overall results of
the study indicate? What are its implications for clinicians or policymakers? What are your
recommendations? What do the longitudinal studies on this topic say? What about the social
determinants such as gender equity, women’s reproductive health autonomy, or the cultural and
religious impact that exacerbates emotional distress in couples with infertility? Please add these
into your discussion.
You can get some of the insights from the following articles (list is not exhaustive):
Bagade, T., Thapaliya, K., Breuer, E. et al. Investigating the association between infertility and
psychological distress using Australian Longitudinal Study on Women's Health (ALSWH). Sci
Rep 12, 10808 (2022). https://doi.org/10.1038/s41598-022-15064-2
Bagade, T., Mersha, A.G. & Majeed, T. The social determinants of mental health disorders
among women with infertility: a systematic review. BMC Women's Health 23, 668 (2023).
https://doi.org/10.1186/s12905-023-02828-9
Schanz, S. et al. Long-term life and partnership satisfaction in infertile patients: A 5-year
longitudinal study. Fertil. Steril. 96, 416–421. https://doi.org/10.1016/j.fertnstert.2011.05.064
(2011).
Lee, C. et al. Cohort profile: The Australian Longitudinal Study on women’s health. Int. J.
Epidemiol. 34, 987–991. https://doi.org/10.1093/ije/dyi098 (2005).
Tabong, P.T.-N. & Adongo, P. B. Infertility and childlessness: a qualitative study of the
experiences of infertile couples in Northern Ghana. BMC Pregnancy Childbirth 13, 72. https://
doi.org/10.1186/1471-2393-13-72 (2013).
Bos HMW, Van Rooij FB. The influence of social and cultural factors on infertility and new
reproductive technologies. J Psychosom Obstet Gynecol. 2007;28(2):65–8.