Of 1930 infertile women who were given questionnaires, 1727 women responded (a response rate: 89.5%) from August to December 2018 at four ART facilities in Tokyo, Japan (Sugiyama Clinic Shinjuku, Sugiyama Clinic Marunouchi, Saint Mother Obstetrics and Gynecology Clinic, and Takasaki ART Clinic). Of these, we analyzed 1672 subjects excluding 55 subjects, 36 of whom were undergoing mental health treatment and 19 with missing Kessler Six-question Psychological Distress Scale (K6) data. Regarding stress in workplace, we focused on 1335 women who reported working at the time of starting their fertility treatment.

Various questions were employed in the questionnaire including patient age, education background, marital status, living with a partner, life and habits, pregnancy history, fertility treatment, and adjuvant treatment for infertility. Furthermore, work-related questions included annual family income; work environment including employment status, unexpected leave for fertility treatment, infertility-related harassment experience, ability to consult with one`s employer about fertility treatment, and difficulty of balancing fertility treatment and work. To evaluate non-specific psychological distress, we used the K6 score [16] in, which estimates how frequently respondents have experienced symptoms of psychological distress during the previous 30 days. Responses are recorded using a five-category scale (4 = all of the time, 3 = most of the time, 2 = some of the time, 1 = a little of the time, and 0 = none of the time), yielding a score range of 0–24. The K6 scores between 0 and 7, 8 and 12, and 13 and 24 indicate a very low possibility, a moderate probability, and high likelihood of the respondents to develop a psychological disorder, respectively. The K6 score has been translated into Japanese, and has been shown to have acceptable reliability and validity for measuring levels of psychological distress in a Japanese population with a high value of the areas under receiver operating characteristic curves [17]. We defined a K6 cut-off score of ≥ 13 (high K6) as indicative of a high probability of severe psychological distress as per previous reports [18].

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