Relationship Between Sleep Disorder and the Outcome of Infertility Treatment with Intrauterine Insemination

⁶ Bent-Alhoda Hospital, North Khorasan University of Medical Sciences, Bojnurd, Iran

*Corresponding author: Maryam Hassanzadeh Bashtian, Department of Midwifery, School of Medicine, Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran. Email: m.h.bashtian@gmail.com

EXTENDED ABSTRACT

Background

Infertility is a major health and social challenge and can become a substantial source of psychological stress for affected couples [1–3]. Intrauterine insemination (IUI) is commonly used as a first-line treatment for unexplained infertility and mild male-factor infertility; in these settings it is generally combined with ovarian stimulation because IUI alone does not improve pregnancy rates in unexplained infertility [5–7]. Women undergoing infertility treatment may experience marked hormonal changes, somatic complaints, psychological distress, and sleep disturbance [8]. Sleep is essential for normal cognitive and physiological function, and women report difficulties with sleep initiation, light sleep, and recurrent nocturnal awakening more often than men [9–11]. Sleep disturbance has also been associated with hypertension, impaired glucose regulation, cardiovascular disease, anxiety, and several female reproductive outcomes [12, 13]. Proposed pathways linking sleep and fertility include activation of the hypothalamic-pituitary-adrenal axis, altered sleep duration or continuity, and abnormal circadian rhythms [14]. In a previous study of women receiving IUI, 35% had poor sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) [8]. However, the relationship between sleep disturbance across the IUI treatment period and treatment outcome had not been clearly characterized. This study therefore investigated sleep quality longitudinally in women undergoing IUI and examined whether sleep disturbance was associated with a positive or negative treatment result.

Methods

This prospective cohort study included infertile women referred to the infertility clinic of Bent-Alhoda Hospital and a private infertility clinic in Bojnurd, Iran, between 2020 and 2023. The investigators initially enrolled 290 women who were candidates for IUI; 131 women aged 18-45 years successfully completed all three study assessments and comprised the analytic cohort. Eligibility required literacy and Iranian nationality. Withdrawal criteria included unwillingness to continue, development of a severe physical illness during follow-up, or a major emotional shock capable of affecting psychological status. Data were collected at three time points relative to IUI: day 0, day 14, and day 30. Pregnancy was determined approximately two weeks after IUI using beta-hCG testing. Demographic and clinical information included age, education, employment, duration of marriage and infertility, cause and type of infertility, gynecologic or obstetric history, and use of traditional or herbal medications. Sleep was assessed with the PSQI, which evaluates subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, sleep-medication use, and daytime dysfunction; the global score ranges from 0 to 21, and a score above 5 indicates sleep disturbance. The questionnaire had previously demonstrated acceptable validity and reliability [16, 17]. Quantitative and qualitative variables were compared between groups using independent t tests or Mann-Whitney tests and chi-square tests as appropriate. Repeated-measures analysis of variance was used to examine associations of demographic and clinical factors with sleep disturbance across the three assessments. Analyses were performed in SPSS version 23 with a significance threshold of 0.05. The study was approved by North Khorasan University of Medical Sciences (project No. 980216; ethics code IR.NKUMS.REC.1399.051), and informed consent was obtained from participants.

Results

Among the 131 women who completed all three assessments, 18 became pregnant during the IUI cycle and 113 did not. Mean age was 29.85±5.75 years and mean infertility duration was 4.85±3.39 years. Most women had non-university education (54.2%) and were not employed (83.1%). Ovulatory disorders were the most frequent identified cause of infertility (37.3%), and primary infertility was the most common infertility type (72.9%). Baseline demographic and infertility characteristics did not differ significantly between women with positive and negative IUI outcomes. At the first assessment, 40 women (30.5%) met the criterion for impaired global sleep quality. Subjective sleep quality was most often mildly impaired (62.6%); sleep latency was commonly mildly or moderately impaired (35.7% and 38.1%, respectively). Most participants had no impairment in sleep duration (60.5%), sleep efficiency (81.4%), sleep-medication use (94.7%), or daytime dysfunction (55.8%). Sleep disturbances themselves were usually mild (74.8%).

Table 2. Overall prevalence of sleep-quality disorder and prevalence across the seven PSQI domains at the first assessment.

Longitudinally, sleep-quality scores changed significantly within both IUI outcome groups. In women with a positive IUI result, the score increased across the three assessments (within-group P=0.042). In women with a negative IUI result, the score initially increased and subsequently decreased, and the within-group change was also significant (P=0.001). Despite these different within-group trajectories, there was no statistically significant between-group difference in sleep-quality score at any of the three assessment points. Analysis of demographic and clinical correlates showed that women whose husbands were farmers had significantly higher sleep-disturbance scores than those whose husbands were employees at all three assessments (beta=7.576, P=0.002; beta=7.04, P=0.007; and beta=8.303, P=0.001, respectively). Infertility cause was also associated with sleep score at selected time points: compared with unexplained infertility, ovulatory disorders, tubal factor, male factor, or combined factors were associated with higher scores in several assessments, whereas the pattern was not uniform across all three time points. Overall, the principal finding was that sleep quality varied over time during the IUI process, but sleep disturbance did not distinguish women who achieved pregnancy from those who did not.

Conclusion

Sleep-quality disturbance was common in women undergoing IUI, affecting approximately one-third of participants at baseline. Sleep scores changed significantly over time within both the positive- and negative-IUI groups, but the study found no significant difference in sleep quality between the two outcome groups at any assessment. These findings indicate that sleep disturbance accompanied the IUI treatment period but, in this cohort, was not associated with the success or failure of the IUI cycle. The observed time-related changes and the associations with selected social and infertility characteristics support attention to sleep and psychological well-being during infertility care without interpreting sleep quality as a demonstrated predictor of IUI outcome in this study.

Keywords: Infertility, Intrauterine Insemination (IUI), Sleep Disorders

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