Prognostic factors of depression and anxiety in infertile women with cesarean scar defects

Table 1 Baseline characteristics of study participants by assisted reproductive technology outcome (pregnant vs non-pregnant), n (%)/mean ± SD

Variable	Pregnant (n = 51)	Non-pregnant (n = 49)	All (n = 100)	P value
Demographic characteristics
Age (years)	33.8 ± 4.1	35.3 ± 4.6	34.5 ± 4.4	0.079
BMI (kg/m²)	23.3 ± 2.6	23.9 ± 3.1	23.6 ± 2.9	0.290
Years of education	13.8 ± 2.4	13.2 ± 2.7	13.5 ± 2.6	0.248
Employed	38 (74.5)	34 (69.4)	72 (72.0)	0.556
Infertility characteristics
Infertility duration (years)	2.8 ± 1.5	3.7 ± 2.0	3.2 ± 1.8	0.012
Type: Primary	18 (35.3)	22 (44.9)	40 (40.0)	0.317
Prior ART attempts, mean	1.4 ± 0.9	1.9 ± 1.1	1.6 ± 1.0	0.017
CSD characteristics
CSD diameter (mm)	8.1 ± 2.0	9.0 ± 2.5	8.5 ± 2.3	0.046
Residual myometrium (mm)	3.6 ± 1.0	2.8 ± 1.1	3.2 ± 1.1	< 0.001
CSD severity-mild	26 (51.0)	9 (18.4)	35 (35.0)	< 0.001
CSD severity-moderate	19 (37.3)	18 (36.7)	37 (37.0)	0.954
CSD severity-severe	6 (11.8)	22 (44.9)	28 (28.0)	< 0.001
Baseline psychological scores
SAS score	54.2 ± 9.6	62.7 ± 10.3	58.3 ± 10.5	< 0.001
SDS score	52.1 ± 9.1	61.4 ± 10.0	56.6 ± 10.2	< 0.001
FertiQoL score	56.8 ± 8.4	47.9 ± 8.8	52.5 ± 9.3	< 0.001
Spousal support score	78.4 ± 9.2	68.3 ± 11.4	73.5 ± 11.2	< 0.001
ART laboratory parameters
AFC	11.4 ± 3.8	10.8 ± 4.1	11.1 ± 3.9	0.434
AMH (ng/mL)	2.8 ± 1.4	2.5 ± 1.6	2.7 ± 1.5	0.321
Oocytes retrieved (n)	12.1 ± 3.2	11.4 ± 3.7	11.8 ± 3.4	0.297
High-quality embryos (n)	5.6 ± 1.9	5.0 ± 2.2	5.3 ± 2.1	0.145

P < 0.05. BMI: Body mass index; CSD: Cesarean scar defect; ART: Assisted reproductive technology; SAS: Self-Rating Anxiety Scale (≥ 50 = anxiety); SDS: Self-Rating Depression Scale (≥ 53 = depression); FertiQoL: Fertility Quality of Life scale; AFC: Antral follicle count; AMH: Anti-Müllerian hormone.

Table 2 Prevalence and severity distribution of anxiety and depression by assisted reproductive technology outcome, n (%)

Category	All (n = 100)	Pregnant (n = 51)	Non-pregnant (n = 49)	P value
SAS
Normal (< 50)	26 (26.0)	19 (37.3)	7 (14.3)	0.008
Mild anxiety (50-59)	32 (32.0)	20 (39.2)	12 (24.5)	0.107
Moderate anxiety (60-69)	28 (28.0)	10 (19.6)	18 (36.7)	0.054
Severe anxiety (≥ 70)	14 (14.0)	2 (3.9)	12 (24.5)	0.003
Any anxiety (≥ 50)	74 (74.0)	32 (62.7)	42 (85.7)	0.007
SDS
Normal (< 53)	32 (32.0)	24 (47.1)	8 (16.3)	0.001
Mild depression (53-62)	35 (35.0)	19 (37.3)	16 (32.7)	0.624
Moderate depression (63-72)	24 (24.0)	7 (13.7)	17 (34.7)	0.012
Severe depression (≥ 73)	9 (9.0)	1 (2.0)	8 (16.3)	0.013
Any depression (≥ 53)	68 (68.0)	27 (52.9)	41 (83.7)	< 0.001
Co-morbid anxiety + depression
Both SAS ≥ 50 and SDS ≥ 53	56 (56.0)	19 (37.3)	37 (75.5)	< 0.001

P values from χ² test (pregnant vs non-pregnant). Cut-offs: Self-Rating Anxiety Scale (SAS) score ≥ 50 = any anxiety; Self-Rating Depression Scale (SDS) score ≥ 53 = any depression. Co-morbid anxiety + depression = both SAS score ≥ 50 and SDS score ≥ 53 simultaneously. SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale.

Table 3 Assisted reproductive technology outcomes stratified by cesarean scar defect severity

CSD severity	n	Clinical pregnancy rate (%)	Live birth rate (%)	Miscarriage rate (%)	P value1
Mild (RMT ≥ 3.5 mm)	35	26/35 (74.3)	22/35 (62.9)	4/26 (15.4)	Ref
Moderate (RMT 2.5-3.4 mm)	37	20/37 (54.1)	15/37 (40.5)	5/20 (25.0)	0.046
Severe (RMT < 2.5 mm)	28	5/28 (17.9)	3/28 (10.7)	2/5 (40.0)	< 0.001
Overall	100	51/100 (51.0)	40/100 (40.0)	11/51 (21.6)	-

¹P value vs mild cesarean scar defect group (χ² test).

Clinical pregnancy: Gestational sac confirmed by transvaginal ultrasound at 5-6 weeks. RMT: Residual myometrial thickness; CSD: Cesarean scar defect.

Table 4 Univariate logistic regression analysis of candidate prognostic factors for clinical pregnancy

Variable	β	OR (95%CI)	SE	Wald (df = 1)	P value
Psychological variables
SAS score (per 1 point)	-0.067	0.935 (0.904-0.967)	0.016	17.24	< 0.001
SDS score (per 1 point)	-0.071	0.932 (0.901-0.963)	0.016	19.89	< 0.001
FertiQoL score (per 1 point)	0.083	1.087 (1.047-1.128)	0.020	17.61	< 0.001
Spousal support score	0.072	1.075 (1.037-1.114)	0.019	14.23	< 0.001
Co-morbid anxiety & depression	-1.601	0.202 (0.088-0.462)	0.421	14.47	< 0.001
CSD characteristics
Residual myometrium (mm)	0.621	1.861 (1.382-2.506)	0.152	16.73	< 0.001
CSD diameter (mm)	-0.158	0.854 (0.744-0.980)	0.070	5.09	0.024
CSD severity: Mild vs severe	2.417	11.21 (3.72-33.79)	0.565	18.27	< 0.001
Infertility & ART variables
Infertility duration (years)	-0.225	0.799 (0.665-0.959)	0.094	5.74	0.017
Prior ART attempts (n)	-0.378	0.685 (0.494-0.949)	0.167	5.12	0.024
High-quality embryos (n)	0.189	1.208 (1.017-1.435)	0.088	4.62	0.032
Demographic variables
Age (years)	-0.071	0.932 (0.858-1.012)	0.042	2.86	0.091
BMI (kg/m²)	-0.039	0.962 (0.871-1.062)	0.050	0.60	0.438
Nursing intervention (comprehensive vs none)	1.005	2.732 (1.188-6.282)	0.427	5.54	0.019

All variables with P < 0.10 were entered into multivariate analysis. Dependent variable: Clinical pregnancy (1 = pregnant, 0 = non-pregnant). Reference for cesarean scar defect severity: Severe group. BMI: Body mass index; OR: Odds ratio; CI: Confidence interval; CSD: Cesarean scar defect; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; FertiQoL: Fertility Quality of Life scale; ART: Assisted reproductive technology.

Table 5 Multivariate binary logistic regression: Independent prognostic factors for clinical pregnancy

Variable	β	aOR (95%CI)	SE	Wald (df = 1)	P value
Model AUC = 0.821 (95%CI: 0.744-0.899); Hosmer-Lemeshow P = 0.612
SAS score (per 1 point)	-0.052	0.949 (0.913-0.987)	0.020	6.76	0.009
FertiQoL score (per 1 point)	0.058	1.060 (1.016-1.106)	0.022	7.00	0.008
Residual myometrium (mm)	0.488	1.629 (1.192-2.225)	0.160	9.30	0.002
CSD severity: Mild vs severe	1.642	5.167 (1.628-16.40)	0.589	7.77	0.005
Co-morbid anxiety & depression	-1.183	0.306 (0.106-0.886)	0.541	4.78	0.029
Spousal support score	0.043	1.044 (1.003-1.086)	0.021	4.20	0.040

Method: Multivariate binary logistic regression with backward stepwise elimination (retention threshold P < 0.05); only variables retained in the final model are shown. Model area under the curve = 0.821 (95% confidence interval: 0.744-0.899); Hosmer-Lemeshow P = 0.612. Reference for cesarean scar defect severity: Severe group. Variables entering multivariate analysis but eliminated by backward selection (P ≥ 0.05): Age, body mass index, infertility duration (P = 0.067), prior assisted reproductive technology attempts, high-quality embryos (P = 0.097), and nursing intervention type (P = 0.214). AUC: Area under the curve; FertiQoL: Fertility Quality of Life scale; aOR: Adjusted odds ratio; CI: Confidence interval; SAS: Self-Rating Anxiety Scale; CSD: Cesarean scar defect.

Table 6 Subgroup analysis: Psychological scores and assisted reproductive technology outcomes stratified by cesarean scar defect severity and pregnancy outcome, mean ± SD

Subgroup	SAS	SDS	FertiQoL	Pregnancy rate (%)	P (SAS/SDS)
Mild CSD (RMT ≥ 3.5 mm, n = 35)
Pregnant (n = 26)	52.8 ± 9.0	50.4 ± 8.6	58.9 ± 7.9	74.3	-
Non-pregnant (n = 9)	61.2 ± 9.8	59.1 ± 9.2	49.6 ± 8.4	25.7	0.028
Moderate CSD (RMT 2.5-3.4 mm, n = 37)
Pregnant (n = 20)	55.3 ± 9.8	52.8 ± 9.3	56.4 ± 8.8	54.1	-
Non-pregnant (n = 17)	64.1 ± 10.4	62.3 ± 10.1	46.8 ± 9.1	45.9	0.009
Severe CSD (RMT < 2.5 mm, n = 28)
Pregnant (n = 5)	58.0 ± 11.2	55.6 ± 10.4	53.2 ± 9.0	17.9	-
Non-pregnant (n = 23)	65.4 ± 10.8	65.0 ± 9.8	44.2 ± 9.6	82.1	0.018
P value (across CSD severity groups, non-pregnant only)
Between-group (non-pregnant)	0.048	0.039	0.044	-	One-way ANOVA

Values shown are the mean ± SD (psychological scores) or percentage (pregnancy rates). P values from independent-samples t-test [pregnant vs non-pregnant within each cesarean scar defect (CSD) stratum]. P values for between-group comparison across CSD severity strata (non-pregnant only) by one-way ANOVA. RMT: Residual myometrial thickness; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression Scale; FertiQoL: Fertility Quality of Life; CSD: Cesarean scar defect.