Title: The influence of Assisted Reproductive Technologies-related stressors and social support
on perceived stress and depression
Version: 2 Date: 19 Sep 2023
Reviewer:  Mala Ramanathan
Reviewer's report:
1. The authors state in hypothesis 2 that a specific instrument based on qualitative studies to
evaluate the stress due to the following ART related factors:
i. Their financial situation
ii. Uncertainty about ART success
iii. Shame about their infertility
iv. The physical demands of ART procedures (such as hormonal injections, egg
retrieval, embryo transfer, etc.)
v. The time commitment for ART procedures (such as doctor appointments and travel)
A Likert scale of 1- 5 for each was developed and used for analysis. A scale development
process of this kind needs some sort of validation process to say the least. The authors have not
established the reliability and validity of the self-reported stress using this scale. Given this is
an important input for the study, the reliability and validity of each input needs to be stated.
2. Similarly, the authors say in hypothesis 3 that they examined the ‘helpfulness of different
sources of support’ and the different sources of support were self-identified. This helpfulness
was also evaluated using a likert scale of 1- 5 of ‘not helpful’ to ‘very helpful’. Developing such
scales is a useful tool. However, these scales need to be validated and their reliability checked.
The authors need to discuss the process used by them to at least validate this likert scale or justify
its use and also state its limitations.
3. The authors have used the EPDS to evaluate the depression among women with infertility or
undergoing IVF or those who had children in the last year through IVF treatments. The EDPS is
usually used among post partum women. Some of the women in the study are seeking treatment
for infertility and others have obtained a baby through IVF, some others are considering ART but
have not started treatment.  The EPDS is a screening tool and its use for PP women after 6 weeks
has been established. Some literature indicates its efficacy after 2 weeks PP. It has also been
used (with or without validity being established) during pregnancy for screening and its utility
has been debated.(1) There is a need to justify the use of EPDS across this heterogenous group of
women seeking treatment, women who had a child through IVF and those contemplating IVF.(2)
The authors have cited Levis’s paper, but ignored its implications. Therefore, the authors need
to discuss the applicability of EPDS across this heterogenous group of women and not ignore it.
4. The authors have some narrative responses from the participants which they have used to
explain the different aspects of stress. However, they have also claimed that qualitative analysis
was not attempted. Therefore, the use of these quotes to explain the specific aspects of stress
need to be preceded by explaining exactly how these quotes were selected. If there were 8 quotes
on the issue, which one did they select because women could have marked anything from 1-5
on the scale. Is this a quote from a woman who scored 5 on this aspect of the scale or 4 or 3?
If there were more than one woman who scored 5, then which or whose quote was selected and
why? This is important to demonstrate lack of bias in selection of quotes.
1. Levis B, Negeri Z, Sun Y, Benedetti A, Thombs B D. Accuracy of the Edinburgh Postnatal
Depression Scale (EPDS) for screening to detect major depression among pregnant and
postpartum women: systematic review and meta-analysis of individual participant data BMJ
2020; 371 :m4022 doi:10.1136/bmj.m4022
2. Cox, J. Use and misuse of the Edinburgh Postnatal Depression Scale (EPDS): a ten point
‘survival analysis’. Arch Womens Ment Health 20, 789–790 (2017). https://doi.org/10.1007/
s00737-017-0789-7