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Abstract:

Background: Tonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding.

Objectives: The aim of the study was to compare the tonsillectomy in adults: indications and complications in a tertiary care hospital.

Methods: This cross-sectional study was carried out in the Department of Medicine, Mymensingh medical college hospital, Mymensingh, during January 2023 to December 2023. A total of 200 patients were participated in the study. Statistical analyses of the results were be obtained by using window-based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-24).

Results: In this study, the population consisted of (56.5%) children under the age of 15 and (43.5%) adults over the age of 15. In terms of gender distribution, (54%) of the sample population was male, while (46%) was female. And 9(4.5%) of the patients suffered trauma, 5(2.5%) had difficult intubation, 3(1.5%) had anesthesia difficulty, and 183(0.91) had no complications. In terms of the study population's symptoms, 113 (56.5%) had recurrent or chronic tonsillitis with obstructive symptoms and 34 (22%) had adenotonsillar hypertrophy with obstructive symptoms.

Conclusion: The most common surgical indication was recurrent tonsillitis and bleeding the most common and important complication. Regarding the risk of post-tonsillectomy hemorrhage, no statistically significant differences were detected in patients in whom tonsillar pillars were sutured comparing to those that were not, nor related to surgical indication. Tonsillectomy was not set as outpatient surgery at the time.

Keywords: Tonsillectomy; Otolaryngologists; Hemorrhage; Bleeding

Description:

The fiscal policy had been a useful tool for an effective smoking control. During the two first decades from the present century, several countries had adopted several fiscal measures showing an effective smoking control. [1- 4]^. Health professionals related with the smoking control need research the fiscal policy incidence over the smoking behavior. For that it is important that these professionals understand:    

1. The cigarettes and tobacco domestic market behavior´s. [5]
2. The self importance from the cigarettes and tobaccos consumption for each smoker.[6]
3. The smoking incidence over the fiscal account. [7]
4. The best fiscal authority’s role in the smoking control. [8]
5. The useful from the fiscal policies agree to the smoking epidemiologic step. [9]
6. Experiences from others societies where were applied effective fiscal policies in the smoking control. [10-12].

These subjects have a strong supporting in the Health Economy. However, much health professional related with the smoking control haven´t sufficient academic formation in economic subjects, especially in the fiscal policy useful for the smoking control. [13]. the postgraduate education may contribute to solve these capacitating needs. The available from a postgraduate course about the fiscal policy for the smoking control should be an opportune capacitating form for health professionals related with the smoking control.

Objective

To design a postgraduate course about the fiscal policy useful in the smoking control for health professionals.
Materials and methods

Were used the inductive – deductive and the comparative as theorical methods. As empiric method was used the bibliographic research

Results

According to the previous elements identified the suggested course related subjects as shows the following table.

 

Course conteiner	Hours
	Class	Self research	Total
Domestic market for cigarettes and tobaccos	4	12	16
Personal spends on cigarettes and tobaccos	4	12	16
The smoking fiscal space	4	12	16
The fiscal authorities role in the smoking control	4	12	16
Tributary policy vs. no tributary policy in the smoking control	4	12	16
Examples of tributary policy for the smoking control	4	12	16
TOTAL	24	72	96

 

The first subject is about the behavior of the domestic market for cigarettes and tobaccos. In this case the professor must emphasize in the detailed description of consumption and price behavior and the relation between cigarettes and tobacco from different trade market. 14 .The second subject is supported by the previous. In this case the professor must focus the attention in the relevance from the personal spends on cigarettes and tobaccos respect to others products. The subject must appoint to describe how much important is the tobacco products for smokers. 6

The third subject is about the smoking fiscal space in the national economy. This subject must focus the attention of the smoking impact over the fiscal account. In this subject the professor must appoint to the smoking behavior given a particular fiscal policy. 15

The fourth subject focuses the attention in the fiscal authorities role in the smoking control. In this case the professor must describe in general terms the best taking decision process from the fiscal authorities for a better smoking control. 16

The fifth subject introduce a discussion about the better use from tributaries and no – tributaries policies for the smoking control. In this subject the professor must raise the relation between the smoking epidemiologic step and the use of fiscal policies for the best smoking control. 17

The sixth and last subject shows several examples of tributary policy for the smoking control. In this subject the professor must raise the good and bad results from each fiscal policy analyzed.

The suggested course has the particularity of be contextualized agree to general learning needs from health professionals related to the smoking economic control. The course has the characteristic that each subject is supported by the previous. Thus the course carries by a logic sequence to straight the learning process.

Conclusion

Was designed a postgraduate course about the fiscal policy useful in the smoking control for health professionals related with the smoking economic control. The course is agreed to general learning needs from health professionals related to the smoking economic control.

 

Variable	Frequency	Percent
Why did you visit the pharmacy?
To collect a prescription (for myself, someone else or both)	98	23.2
For consultation	17	4.1
Cosmetics	112	26.5
Baby’s product (milk, food)	97	22.9
Supplements	41	9.8
Woman’s products	53	12.6
Others	4	0.9
Was the pharmacists’ help to get other items satisfactory?
Yes	173	41
No	249	59
Was there a language barrier in communication with the pharmacist?
Yes	166	39.3
No	256	60.7
What amount of time the pharmacist spends with you?
Enough	161	38.2
Not enough	261	61.8
How much time on average?
<5 minute	203	48.1
5 minute	162	38.4
10 minute	23	5.5
15 minute	23	5.5
>30 minute	11	2.6
How do you rate your usual pharmacist?
Experienced	10	25.1
Trustworthy	115	27.3
Confident	65	15.4
Helpful	70	16.6
Others	66	15.6
Have you ever been given an advice about any of the following by the pharmacist?
Yes	151	35.8
No	271	64.2

 

Table 4: Client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422) Client’s satisfaction with the services provided by the community pharmacist.  

 

Variable	Frequency (%)
	I agree	Neutral	I disagree
Is the pharmacist delivers your medicines in a polite way?	115(27.3)	138(32.7)	169(40.0)
Is the instructions were clearly labeled by the pharmacist on each medication?	146(34.6)	140(33.2)	136(32.2)
Could the pharmacist clearly explains to you all possible side effects?	138(32.7)	178(42.2)	106(25.1)
Would the pharmacist provides you with written  information about drug therapy and/or diseases?	150(35.5)	154(36.5)	118(28.0)
Is the pharmacist uses information about your previous drugs when assessing your drug therapy?	148(35.1)	140(33.2)	134(31.8)
Could the pharmacist provides you with information about the proper storage of  your medication?	164(38.9)	123(29.1)	135(32.0)
Would the place of pharmaceutical counseling respects your privacy?	145(34.4)	85(20.1)	192(45.5)
Is any recommendations you think will improve the performance of the pharmacist?	120(28.4)	110(26.1)	192(45.5)

 

 

Table 5: Logistic regression for client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422).

 

Variable	Category	N (%)	AOR (95% C. I)	p-value
Age	19-30	132(31.3)	Reference
	31-40	118(28.0)	5.13(0.415-63.464)	0.003
	41-50	107(25.4)	1.790(0.096-33.489)	0.697
	51-60	35(8.3)	0.937(1.098-7.890)	0.269
	≥ 61	30(7.1)	5.444(0.697-42.504)	0.106
Sex	Male	180(42.7)	Reference
	Female	242(57.3)	2.447(0.130-1.538)	0.007
Residency	Rural	208(49.3)	Reference
	Urban	214(50.7)	0.620(0.705-5.152)	0.658
Income	<500	168(39.8)	Reference
	501-2500	138(32.7)	1.54(0.013-4183)	0.004
	2501-5000	85(20.1)	0.107(0.005-1669)	0.09 5
	>5000	31(7.3)	1.932(1.853-2.341)	0.08
Marital status	Single	173(41.0)	Reference
	Married	161(38.2)	2.93(2.013-4183)	0.007
	Divorced	66(15.6)	0.107(0.005-1669)	0.095
	Widowed	22(5.2)	1.342(0.927-1.736)	0.429
Spoken language	Oromic+Amharic	253(60.0)	Reference
	Oromic only	104(24.4)	4.016(1.065-5.739)	0.000
	Amharic only	65(5.6)	0.154(0.20-1.190)	0.73
Educational status	Illiterate	142(33.6)	Reference
	Grade 1-8	110(26.1)	4.063(2.970-9.341)	0.000
	Grade 9-10	77(18.2)	0.294(1.174-1.943)	0.927
	Grade 11-12	47(11.1)	1.873(0.056-3.618)	0.037
	Diploma	27(6.4)	2.032(1.109-1.856)	0.187
	Degree and above	19(4.5)	0.094(0.216-1.927)	0.749
How much time on average?	<5 minute	203(48.1)	Reference
	5 minute	162(38.4)	1.431(1.937-3.831)	0.97
	10 minute	23(5.5)	2.501(0.927-4.876)	0.001
	15 minute	23(5.5)	0.984(0.386-1.439)	0.074
	> 30 minute	11(2.6)	0.219(0.037-1.148)	0.587
Have you ever been advised?	Yes	151(35.8)	Reference
	No	271(64.2)	1.596(1.25-2.851)	0.095

Discussion

Generally, the society’s perception to the community pharmacists as health care services professionals in charge of the utilization of pharmaceuticals in the avoidance and treatment of diseases is limited [16]. An analysis of the available literature has been conducted and studies measuring patient satisfaction with pharmacy services delivered by pharmacists in a community setting were identified and evaluated. In the present study the overall prevalence of client’s satisfaction regarding the Pharmaceutical care services delivered in community pharmacies was 41.5%. This is finding on the present study was found to be lower than that of a study conducted in Mozambique 55%, JUSH 61.9% Brazilian 58.4% , Malaysia 74.6%, South Wollo 59.4%, Valencia 76.0%, Black lion Specialized Referral Hospital 51.6%[17-23] which assessed clients’ satisfaction with pharmacy services as part of overall health services and reported a high level of satisfaction. This difference was due to the majority of community pharmacy in our study where not give advice accordingly on the items purchased by the customers, and not communicate with the clients enough times about what they were bought, and there is different time in study period. In our study 35.8%clients were satisfied to counselling given by pharmacists was showed a slightly consistent with the degree of satisfaction with the medication counselling service compared to the survey employed in South Korea 34.0% [24]. This similarity was due to the community pharmacies in our study and South Korea were independently owned and are more business-oriented than oriented towards patient- centered care, and also they gave priority for their profit rather than customers satisfactions. In our current study 31.3% clients age were between 19-30 were consistent with the study conducted in United Arab Emirates revealed that majority of respondents were from the younger population sector with their ages ranging between 20 and 34 years and with good educational level [25]. This is due to younger females visit the community pharmacy mostly to purchased contraceptives, and clients age between 19-30 where visit community to also bought beauty commodities. And also 48.1% customers spent <5 minutes in pharmacy were slightly less than the study conducted in Emirates which revealed the most respondents feel that the time spent in the pharmacy was enough, the average time spent with a patient in this study varied from <5 min up to 10 min [22]. This was due to most community pharmacy workers where had unwillingness to conservative with clients to keep their self-dignity, and some where non-health related workers (cleaners, and cashiers) works in some community pharmacy as assistant. So they know now about medication except some drug name. The current study revealed only few of client were acquired educational information 2.8%use of anabolic steroids and 4.9% Smoking cessation were consistent with the study conducted in Arab the number of respondents who received health educational information in the community pharmacy was rather low with regard to smoking and use of anabolic steroids [25]. This was due to clients were reluctant to accept the counselling given about tobacco, khat, and alcohol because few customers uses those social substance as incentive, and also pharmacists fear to brought them advice due to their profit they got from those customers. The present study showed the preponderance 27.3% and 34.6%of participants were agree that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively, were contrary to the study carried out in United Arab Emirates which displayed the majority (74.1%) and (43.7%) of the respondents agreed that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively. Present study was “the information the pharmacist [22]. In our survey the pharmacists very few clients were acquire their medication in polite way and clearly labelled instructions due to the prescription where ineligible and made pharmacists higgledy-piggledy, then pharmacists prescribed carelessly for profit rather than send back to the physicians. The current study showed the pharmacist clearly explains to you all possible side effects, provides you with written/printed information about drug therapy and/or disease, uses information about your previous condition/drugs when assessing your drug therapy, and provides you with information about the proper method of storage of your medication were less than half of satisfaction were consistent with the study done in Gondar which showed that how well the pharmacist explains about the proper storage of your medication, possible side effects, storage, expected results from the medications and other were responsible for the lower level of satisfaction [26]. The difference is due to the community pharmacies in our survey were no adequate place to consul, no enough time to brought the clients written form about medication, and no much knowledge about unique medications storage, drug interaction, and side effects, so they not brought education to the clients accordingly. In our current study age between 19-30 were 5 times more likely satisfied(AOR: 5.13; 95%CI: 0.415-63.464; P=0.003) than others age category contrary to some previous studies, however, have found that older patients were more likely to report satisfaction compared with younger patients. This was due to most age between 19-30 bought familiar commodities, and then pharmacists bought them adequate consul. In our survey female were 2 times more likely satisfied (AOR: 2.447; 95%CI: 0.130-1.538; P=0.007) than males was consistent to some studies revealed, females were more likely to express satisfaction than males while in others no relationship was found between gender and satisfaction [27]. The majority of clients perceived that they spent 5 min counselling from pharmacists, were 2 times more likely satisfied (AOR: 2.501; 95%CI: 0.927-4.876; P=0.001) inconsistent with the study conducted with South Korea which were showed the majority of pharmacists perceived that they spent 1–5 min counselling patients, whereas the majority of clients reported that the length of time taken for medication counselling was less than 1 min[24]. Present study displayed customers who speaking Oromic language were 4 times more likely satisfied (AOR: 4.016; 95%CI: 1.065 -5.739; P=0.000) than those who speaking Oromic+Amharic and Amharic only were inconsistent with the study done in Saudi Arabia which showed mostly Arabs who can speak a second language may have significantly contributed to the high response rate obtained in the present study [25].  Due to they had got what they want and they comprehend each other accordingly due to they use their mother tongue language.

Overview of Azoospermia and Its Prevalence Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2]. Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertilityrelated stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals. While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7]. Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life. While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being. Objectives of the Study • To assess the quality of life among infertile males with azoospermia attending infertility clinics. • To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals. • To identify specific domains of QoL most affected by azoospermia.

 

Objectives: This study aims to describe the lived experiences of a patient in a coronavirus disease 2019 intensive care unit. Design: This study employed an interpretive phenomenological analysis. Methods: This study was conducted in the coronavirus intensive care unit of a tertiary university hospital in Japan. Data were collected from June 5, 2020 to March 30, 2021, via field observations and unstructured interviews. Informal interviews were conducted with five patients, and an in-depth interview was conducted with a male patient in his 70s—the only patient who survived throughout the research period and could communicate verbally. A phenomenological approach was adopted, which focused on describing the patient’s experience thoroughly from his perspective and analyzing the internal logic of his story while avoiding the introduction of external elements. Results: The patient described feeling alienated and stuck between this world and the afterlife. His experiences revealed five themes: “Disconnected from reality,” “Could I return to my former self?” “The doctors did not enter my room,” “Identifying people by voice and smell,” and “Going back and forth between this world and the afterlife.” Although he experienced death anxiety, he hoped to live in a shared world with others. The patient struggled to form relationships with healthcare personnel because he did not know the people around him. Conclusions: Individualized care must be provided to instill hope in patients. Understanding patients’ experiences can help in implementing measures to retain patients’ sense of identity and belongingness, thereby enhancing their well-being.

Conclusion and Recommendations

Our current study found that the overall prevalence of clients satisfaction regarding the pharmaceutical care services delivered in community pharmacies was meagre. This due to preponderance of community pharmacy was profit oriented rather than patient centered. Majority of clients were visit community pharmacy to purchase cosmetics and to collect a prescription (for myself, someone else or both). Greater than one-third of customers were obtained regarding oral contraceptives due to majority of the respondents was female. The level of satisfaction was found to be significantly affected by clients’ age category, sex, customers monthly income, marital status, educational status, spoken language, Andon average time pharmacist spent with clients. Pharmacists should have to work best to improve health education, communication, and understanding between the clients friendly. Government should have construct community pharmacy to improve level of customers’ satisfaction. Pharmacists should have to work well to improve health education, communication and understanding between the clients friendly.

 

Acknowledgments

We had extended our grateful thanks to all our study participants, and those encourage us to conduct this research through everything.

Conflict of Interests

We have no conflict of interest in this article.

Funding

None

Overview of Azoospermia and Its Prevalence

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2].

Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertility-related stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals.

While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7].

Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life.

While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being.

Objectives of the Study

• To assess the quality of life among infertile males with azoospermia attending infertility clinics.
• To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals.
• To identify specific domains of QoL most affected by azoospermia and its implications for clinical practice and intervention strategies

Methods

Study Design

This study is designed as a prospective observational study aimed at assessing the outcomes of infertile males undergoing in-vitro fertilization (IVF) treatment at Indira IVF centers across India.

Study Population

The study population will consist of infertile males attending Indira IVF centers for their treatment.

Study Setting

The study was conducted across all 103 Indira IVF centers in India, leveraging state-of-the-art infrastructure and advanced equipment available at these centers.

Subjects Selection

Inclusion Criteria

• Male attending in-vitro fertilization centers and giving informed consent.
• Male infertility cause identified as azoospermia.
• The male patient is between 18-45 years of age.

Exclusion Criteria

• Male partners older than 45 years of age.
• Male patient if in the terminal stage of an illness such as cancer, HIV-AIDS, transplant patients, etc.
• Male patient affected by COVID-19 disease.

Instruments/Tools Used

Fertility Quality of Life (FertiQoL) Questionnaire:

• Purpose: Assess the quality of life specifically about fertility issues.
• Structure: Consists of core and treatment sections, encompassing various domains such as mind/body, relational, social, emotional, and treatment-related aspects.
• Scoring: Comprises 36 items scored according to 5 response categories, with a response scale ranging from 0 to 4. Higher scores indicate a higher quality of life. Ferti QoL yields six subscales and three total scales with a range of 0 to 100.

WHO Quality of Life-BREF (WHOQOL-BREF)

• Purpose: Measure the general quality of life across four domains.
• Structure: Contains 26 items divided into four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), along with two items for overall quality of life and general health.
• Scoring: Each item is scored from 1 to 5. Domain scores are transformed to a 0-to-100-point scale using the WHO-QoL transformation table. Higher scores indicate a better quality of life.

Socio-demographic and Medical History Questionnaire

• Purpose: Collect data on general characteristics, socio-demographic information, medical history, and personal history.
• Structure: Developed specifically for this study to gather comprehensive background information relevant to the study population.

Reliability: We obtained acceptable reliability for both the tools examined by Cronbach's alpha coefficient analysis. (WHO physical domain, 0.70; WHO psychiatric domain, 0.76; WHO social domain, 0.75; WHO environment domain, 0.91; WHO Overall, 0.78; Core (FertiQoL), 0.84) Table 1.

Table 1: Socio-demographical characteristics of the study population (N=719).

Statistical Analysis Plan

The results were reported as Mean (SD) for quantitative variables and number (percentages) for categorical variables. The quantitative variables were compared using the Whitney U test and Kruskal Wallis test after testing for normal distribution. Multiple linear regression analysis was used with dependence on the Ferti (QoL) and WHOQOL-BREF subscales. The regression equation included terms for the participant’s demographics and information from his medical history. Adjusted regression coefficient (β) with the standard error (SE) were computed from the results of the linear regression analysis. All statistical analyses were performed at the 95% significance level (P<0.05) using the statistical software SPSS 28.0 statistical software (SPSS, Inc., Chicago, IL, USA).

Results

Study Population and Characteristics

In this cross-sectional study, 719 patients undergoing IVF treatment were invited to participate; 719 agreed, resulting in a response rate of 100.0%. The age of the respondents ranged from 18 to 45 years, with a majority falling between 26-35 years (57.6%) and a mean age of 34.52 years (SD =5.03 years). Most respondents completed academic education, with 80.1% having ten or more years of education, and 61.1% lived in urban areas.

A significant proportion of respondents had an annual family income between 5 lakhs and 2.5 lakhs INR, which is near the average yearly income. The most prevalent duration of infertility among the respondents was 5-10 years (44.4%), followed by less than 5 years (33.7%), and more than 10 years (22.0%).

Most participants were gainfully employed (90.5%) and resided in nuclear families (54.1%). The majority had five or fewer family members (73.0%). Regarding BMI, 55.1% of the respondents had a BMI of 25 or higher, 22.7% had a BMI between 18.5-22.9, 20.7% had a BMI of 23-24.9, and 1.5% had a BMI less than 18.5.

Tobacco use was reported by 27.4% of the participants, while 72.6% did not use tobacco. Alcohol consumption was noted in 24.1% of the population, with 75.9% reporting no alcohol consumption history. Only 10.2% of respondents reported suffering from any chronic disease.

A significant number of participants (60.5%) had undergone treatment for infertility, while 39.5% had not. Most participants (94.6%) had fewer than five medical consultations for infertility before coming to the center, with only 5.4% having more than five consultations. Lastly, 84.8% of participants reported no failures after IVF treatment, 9.0% had fewer than two failures, and 6.1% experienced two or more failures.

The WHOQOL Questionnaire demonstrates good reliability (Table 2) across all its subscales, with particularly high reliability in the WHO Environment Domain [22]. The mean scores suggest that respondents perceive their quality of life most positively in terms of overall quality (WHOQOL BREF) and environmental factors, while physical health is perceived less positively. The variability in responses is highest in the Social Relationship Domain, indicating differing perceptions of social relationships among the population. Overall, the WHOQOL Questionnaire is a reliable tool for assessing various aspects of quality of life in this population. Similarly, the Core (FertiQoL) Questionnaire demonstrates acceptable reliability across (Table 3) its subscales, with Cronbach's alpha values ranging from 0.64 to 0.84. The highest reliability is in the overall Core (FertiQoL) score (α = 0.84), while the Social Domain shows the lowest reliability (α=0.64). Mean scores indicate that respondents perceive their quality of life most positively in the Social Domain (77.60) and least positively in the Relationship Domain (65.61).

Table 2: Reliability analysis for WHOQOL Questionnaire.

Table 3: Reliability analysis for Core (FertiQoL) Questionnaire.

WHOQOL Tool

Our analysis of 719 participants revealed several significant trends in WHOQOL domain scores across various demographic characteristics (Table 4).

• Age: Younger participants (18-25 years) reported higher overall WHOQOL scores (Mean=83.33, P=0.030) and significantly higher psychological scores (P=0.010) compared to older age groups.
• Religion: Hindu participants generally reported higher scores across all domains compared to Muslim participants. This was particularly significant in the Physical Health (P<0.001), Psychological (P=0.003), Social Relationship (P < 0.001), and Environment (P<0.001) domains.
• Residential Status: Urban residents scored significantly higher in the Physical Health (P < 0.001), Social Relationship (P < 0.001), and Environment (P = 0.030) domains compared to rural residents.
• Education Level: Participants with less than 10 years of education had higher overall WHOQOL scores (P = 0.001) and scored significantly higher in the Physical Health (P=0.004) and Psychological (P=0.003) domains.
• Annual Family Income: Individuals with an annual family income greater than 5 lakhs INR reported better scores in the Physical Health (P < 0.001) and Social Relationship (P<0.001) domains.
• Body Mass Index (BMI): Those with a BMI <18.5 had lower scores in the Physical Health (P=0.004), Psychological (P=0.010), Social Relationship (P = 0.004), and Environment (P=0.007) domains compared to individuals with a higher BMI.
• Current Use of Tobacco: Tobacco users scored significantly lower in the Physical Health (P<0.001) and Social Relationship (P<0.001) domains compared to non-users.
• Years of Infertility: Participants experiencing infertility for less than 5 years had higher scores across all domains, particularly in the Psychological (P<0.001), Social Relationship (P=0.001), and Environment (P<0.001) domains.

These significant findings indicate the profound impact that demographic factors such as age, religion, residential status, education level, income, BMI, tobacco use, and duration of infertility have on the quality of life among individuals undergoing infertility treatment.

In this study, the multiple linear regression analysis shown in Table 5 reveals several key factors influencing the total WHOQOL score among infertile males with azoospermia. The results indicate that education level, religion, and years of infertility are significant predictors of WHOQOL scores. Specifically, lower education levels and longer durations of infertility are associated with poorer quality of life, while religious affiliation plays a role in the overall quality of life. Conversely, variables such as age, residential status, number of children, number of family members, suffering from chronic diseases, and history of infertility treatment do not significantly affect the WHOQOL scores. These findings highlight the critical importance of educational and religious factors, along with the impact of prolonged infertility, in shaping the quality of life for individuals facing azoospermia. Addressing these factors may be essential for improving support and interventions for this population.

Characteristics (n=719)	Categories	Total WHOQOL			Physical Health			Psychological			Social Relationship			Environment
		Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value
Age	18-25 years	83.33	12.07	0.03	60.24	11.14	0.478	81.24	13.94	0.01	78.24	15.63	0.073	82.05	16.55	0.058
	26-35 years	72.71	20.45		56.32	12.97		71.54	16.57		68.95	20.38		72.31	18.45
	36-45 years	71.74	19.61		57.32	12.22		69.56	16.95		67.23	20.52		71.43	18.13
Religion	Hindu	73.41	19.35	0.028	57.59	12.35	<0.001	71.93	16.23	0.003	69.91	19.74	<0.001	73.65	17.55	<0.001
	Muslim	68.16	23.02		52.42	13.4		65.87	18.8		60.62	22.25		64.16	20.63
Residential status	Urban	73.35	20.17	0.153	58.17	12.53	<0.001	71.99	16.26	0.101	71.44	18.99	<0.001	73.63	17.49	0.03
	Rural	71.6	19.73		54.88	12.56		69.67	17.38		64.36	21.6		70.26	19.34
Education Level	<10 years of education	77.1	20.44	0.001	60.01	15.7	0.004	74.23	16.5	0.003	70.28	20.92	0.142	73.9	17.87	0.124
	>=10 years of education	71.53	19.75		56.04	11.63		70.25	16.74		68.11	20.24		71.84	18.44
Occupation	Gainfully Employed	72.54	19.75	0.57	57.09	12.69	0.215	70.83	16.53	0.259	68.84	20.17	0.293	72.11	17.82	0.249
	Unemployed	73.53	22.39		54.31	11.92		73.04	18.76		65.69	22.26		73.6	22.78
Annual Family Income (INR)	<=5 lakhs (INR)	73.07	20.57	0.283	55.04	12.31	<0.001	70.92	17.66	0.979	65.89	21.36	<0.001	71.6	19.36	0.25
	>5 lakhs (INR)	71.68	18.71		60.72	12.47		71.3	14.62		74.33	16.69		73.67	15.81
Any Living Children	Yes	78.13	16.99	0.209	56.21	9.46	0.974	73.75	17.06	0.497	67.42	20.68	0.639	75.25	16.91	0.61
	No	72.45	20.08		56.85	12.73		70.95	16.75		68.58	20.38		72.15	18.38
Number of Children	None	72.45	20.08	0.209	56.85	12.73	0.974	70.95	16.75	0.497	68.58	20.38	0.639	72.15	18.38	0.61
	One or More	78.13	16.99		56.21	9.46		73.75	17.06		67.42	20.68		75.25	16.91
Type of Family	Nuclear	72.17	20.26	0.686	58.34	12.84	<0.001	71.4	17.14	0.242	69.58	20.56	0.062	72.6	18.59	0.351
	Joint	73.18	19.69		55.04	12.17		70.62	16.3		67.33	20.13		71.84	18.04
Number of Family Members	<=5 members	71.9	20.22	0.143	57.47	13.26	0.037	70.64	16.81	0.543	68.19	20.59	0.701	71.73	18.45	0.369
	>5 members	74.61	19.29		55.1	10.59		72.11	16.6		69.49	19.82		73.66	17.98
Body Mass Index (BMI)	<18.5	68.18	29.72	0.516	56.91	18.6	0.004	65.09	22.35	0.01	62.82	25.45	0.004	63.18	25.7	0.007
	18.5-22.9	70.86	18.89		55.54	12.9		68.2	16.82		64.88	19.63		68.65	18.55
	23-24.9	73.15	19.94		60.22	12.03		74.01	16.35		72.41	18.53		74.09	16.78
	>=25	73.3	20.17		56.08	12.38		71.26	16.54		68.76	20.97		73.29	18.38
Current use of Tobacco	Yes	71.7	21.91	0.526	53.41	12.22	<0.001	69.98	18.94	0.57	62.83	23.17	<0.001	70.2	20.88	0.204
	No	72.99	19.24		58.12	12.56		71.44	15.85		70.7	18.8		73.02	17.23
Current Alcohol Consumption History	Yes	73.55	19.75	0.495	55.99	12.33	0.234	72.29	15.26	0.302	68.06	19.77	0.573	73.2	17.44	0.396
	No	72.34	20.08		57.09	12.73		70.64	17.2		68.7	20.58		71.95	18.61
Suffering From Any Chronic Disease	Yes	69.18	22.63	0.231	56.86	11.7	0.982	70.9	18.45	0.986	69.9	22.01	0.402	72.92	19.02	0.668
	No	73.03	19.66		56.82	12.47		71.05	16.57		68.39	20.2		72.17	18.27
Years of Infertility	<5 years	74.9	18.84	0.034	57.34	11.5	0.131	74.65	16.73	<0.001	72.4	19.93	0.001	76.55	17.74	<0.001
	5-10 years	72.73	19.74		57.21	13.17		70.15	14.96		67.16	19.79		71.39	17.33
	>10 years	68.99	21.75		55.27	13.37		67.3	19.12		65.42	21.43		67.4	19.81
Cause of Infertility	Male factor	72.29	19.62	0.28	57.04	13.36	0.754	70.71	16.35	0.014	68.47	20.36	0.901	71.55	17.93	0.112
	Both	74.12	21.16		56.23	11.03		73.02	18.61		68.32	21.33		74.23	20.27
	Unknown	70.16	19.81		56.55	7.58		65.68	10.41		70.97	15.06		73	12.37
History of treatment for Infertility	Yes	71.78	20.39	0.13	57.35	13.84	0.34	70.79	17.4	0.933	68.1	21.4	0.95	71.91	19.03	0.9
	No	73.94	19.34		56.03	10.5		71.42	15.73		69.22	69.22		72.77	17.23
Number of medical consultations for infertility before coming to this center	<=5 Consultations	72.83	19.65	0.434	56.92	12.52	0.272	71.11	16.39	0.979	68.76	20.29	0.346	72.34	18.16	0.929
	>5 Consultations	69.23	25.3		55.15	14.5		69.77	22.38		64.77	21.85		70.64	21.28
Number of failures to conceive after IVF treatment	None	73.07	19.88	0.294	57.06	12.71	0.157	71.25	16.91	0.22	68.59	20.81	0.257	72.24	18.52	0.488
	<2	71.15	20.83		56.71	12.31		72.09	15.08		70.65	17.76		74.12	17.18
	>=2	68.75	20.26		53.84	12		66.57	16.65		64.8	17.66		69.61	69.61

Table 4: Comparison of WHO domains mean score across demographic characteristics (n=719).

Table 5: Multiple Linear Regression for Total WHOQOL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

FertiQoL score across Socio-demographic

The comparison of FertiQoL domain scores across various demographic characteristics reveals several significant patterns shown in Table 6. History of treatment and the number of failures to conceive after IVF treatment also show significant variations in the emotional and relationship domains. These findings highlight the complex interplay between demographic and clinical factors in influencing the quality of life among infertile azoospermic males.

Table 6: Comparison of FertiQoL domains mean score across demographic characteristics using t-test or ANOVA (n=719).

Table 7 illustrates the multiple linear regression analysis of the total FertiQoL score among infertile males with azoospermia reveals that education level, religion, BMI, and the duration of infertility are significant determinants of fertility-specific quality of life. Specifically, lower education levels and longer infertility durations are associated with a poorer quality of life, while higher BMI is linked to better quality of life. Religion also plays a significant role, with certain religious backgrounds correlating with lower quality of life scores. In contrast, factors such as age, residential status, occupation, number of children, alcohol consumption, cause of infertility, and the number of IVF failures do not significantly impact fertility-specific quality of life. These findings underscore the importance of considering educational background, religious context, BMI, and the length of infertility when assessing and addressing the quality of life in infertile azoospermic males.

Table 7: Multiple Linear Regression for Total FertiQoL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

Discussion

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. The psychological impact of this condition on patients' Quality of Life (QOL) is well-documented. Li-Yan Luo et al. [12] emphasize that infertility-related psychological stress negatively impacts the QOL of azoospermia patients. Their study reveals a correlation between higher stress levels and poorer QOL outcomes, underscoring the importance of addressing psychological factors in the management of azoospermia [12].

Core FertiQoL Domains

The key findings from our study, based on this tool, are as follows

• Physical Health: Scores in this domain were lower for males with infertility. Factors such as age, body mass index (BMI), and chronic health conditions significantly influenced the scores. Older age and higher BMI were associated with poorer physical health, while the presence of chronic diseases also negatively impacted this domain.
• Psychological: Psychological well-being was significantly affected by age, and duration of infertility. Older individuals and reported lower scores, indicating greater psychological distress. Prolonged infertility duration exacerbated psychological stress.
• Social Relationships: Social well-being was influenced by age, gender, education level, and residential status. Older individuals, and those with higher education levels reported poorer social relationships. Rural residents also experienced lower sco res, likely due to limited access to support and stigma associated with infertility [13].
• Environment: This domain was affected by factors such as income, occupation, and residential status. Lower-income and unemployment were associated with poorer environmental scores, reflecting financial and living conditions' impact on overall well-being [14].

FertiQoL Results

The key findings from our study using the FertiQoL tool are

• Emotional Well-being: Significant factors included age, gender, annual family income, tobacco use, unexplained infertility, and duration of infertility., and those with lower incomes or tobacco use reported greater emotional distress. Unexplained infertility and longer disease duration also negatively impacted emotional well-being [15].
• Mind/Body Health: Influencing factors were age, annual family income, BMI, cause of infertility, years of infertility, and history of infertility treatment. Older age, lower income, and normal BMI were associated with poorer scores. Unexplained infertility and longer infertility duration also resulted in lower scores, highlighting the physical and psychological toll of prolonged infertility [16].
• Relational: This domain was affected by relationship duration and previous treatment history.Males with longer marriages and those with unsuccessful treatment attempts reported poorer relational well-being, indicating the strain infertility places on relationships.
• Social: Social well-being was influenced by age, rural residence, education level, employment status, income, duration of infertility, and number of failed IVF treatments [17]. Older age, rural residence, higher education, unemployment, lower income, longer infertility duration, and failed treatments all contributed to poorer social well-being [18].

Hypothesis 1

• Null Hypothesis (H0): There exists no correlation (there is no linear relation) between Azoospermia and Quality of Life.
• Alternate Hypothesis (H1): There is a significant correlation (there is an inverse linear relation) between Azoospermia and Quality of Life.

Findings

The multiple linear regression analysis showed that several factors related to azoospermia, such as years of infertility and education level, significantly impacted the Quality of Life (QoL). Specifically, longer years of infertility and lower education levels were associated with poorer QoL scores, indicating an inverse relationship. In comparison, the Polish study by Makara SM et al. reported lower social domain scores, whereas the current study showed relatively higher scores in this domain, suggesting better social integration among the study participants. Therefore, we reject the null hypothesis and accept the alternate hypothesis, concluding that there is a significant correlation between azoospermia and quality of life.

Hypothesis 2

• Null Hypothesis (H0): Azoospermic males get adequate societal acceptance and support towards their infertility.
• Alternate Hypothesis (H1): Society plays little to no role in supporting or accepting the Azoospermic male’s battle with infertility.

Findings

Social well-being scores from the FertiQoL indicate that societal support is lacking for azoospermic males. Factors such as rural residence, male gender, and lack of education were associated with lower social well-being, suggesting inadequate societal acceptance and support. Thus, we reject the null hypothesis and accept the alternate hypothesis that society plays little to no role in supporting azoospermic males [16].

Hypothesis 3

• Null Hypothesis (H0): Azoospermic males with higher income will have a better quality of life than Azoospermic males with lower income.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across income groups.

Findings

The multiple regression analysis indicated that lower annual family income significantly impacted Mind/Body Health and Emotional Well-being, suggesting that income level does influence QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across income groups. Further supporting this, Bahadır Topuz et al. [4] report that patients with Non-Obstructive Azoospermia (NOA) experience reduced QOL across physical, psychological, and social domains. The study highlights the necessity for routine assessments of mental health and QOL, advocating for integrated care approaches that include psychological support alongside medical treatments [4].

Hypothesis 4

• Null Hypothesis (H0): Azoospermic males in a higher age bracket will have a poorer quality of life than Azoospermic males in a lower age bracket.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across differing age brackets.

Findings

Age was found to negatively impact the QoL scores, but it was not statistically significant in the regression analysis (β =-2.00, p=0.164). This suggests age might not significantly affect QoL, leading us to accept the alternate hypothesis that there is no significant difference in QoL across different age brackets [19].

Hypothesis 5

• Null Hypothesis (H0): The higher the years of infertility, the poorer quality of life the Azoospermic male will have.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across years of infertility endured.

Findings

Years of infertility was a significant negative predictor of QoL (β=-3.96, p < 0.001), indicating that longer infertility duration is associated with poorer QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across years of infertility. This aligns with previous findings by Dourou P et al., who reported lower mind/body scores in females and those with higher education. However, these factors did not significantly impact mind/body scores in the present study [20].

Hypothesis 6

• Null Hypothesis (H0): The higher the history of failures using ART, the poorer the quality of life of the Azoospermic male.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across the number of ART failures incurred by the Azoospermic male.

Findings

The number of failed IVF treatments was not a significant predictor of QoL (β=-1.21, p=0.362). This indicates that ART failure history does not significantly affect QoL. Therefore, we accept the alternate hypothesis that there is no significant difference in QoL across the number of ART failures [21].

Limitation

The study population was specific to males with azoospermia, which may not reflect the experiences of the overall infertile population, with other reasons for infertility. The cross-sectional nature of the study limits the ability to infer causality between azoospermia and QoL. Longitudinal studies would be beneficial to understand the temporal relationship and causal pathways.

Given the significant impact of social well-being on QoL, integrating psychosocial support into infertility treatment protocols is crucial. Counseling services and support groups could help address the emotional and social challenges faced by azoospermic males. Increasing awareness and education about azoospermia and its impact on QoL can help reduce stigma and improve societal acceptance. Educational campaigns targeting both urban and rural populations could promote understanding and support for infertile males.

Studies involving larger and more diverse populations, as well as those incorporating qualitative methods, could provide deeper insights into the experiences of azoospermic males. The partners of azoospermic males could be studied separately to understand coping mechanisms employed as a couple to deal with Azoospermia.

Conclusion

Overall, this study reveals that several socio-demographic and medical factors significantly influence the quality of life of azoospermic males. Factors such as education level, years of infertility, and income levels were particularly impactful. The WHOQoL-BREF and FertiQoL tools both provide valuable insights, though they emphasize different aspects of quality of life. Comprehensive support strategies, including psychosocial interventions, are essential to improve the overall well-being of these individuals.

Funding

There is external funding for the study.

Conflict of Interest

There is no conflict of interest among authors.

Declaration

Consent has been taken from each participant. All the data will be shared on request.

 

The fiscal policy had been a useful tool for an effective smoking control. During the two first decades from the present century, several countries had adopted several fiscal measures showing an effective smoking control. [1- 4]^. Health professionals related with the smoking control need research the fiscal policy incidence over the smoking behavior. For that it is important that these professionals understand:    

1. The cigarettes and tobacco domestic market behavior´s. [5]
2. The self importance from the cigarettes and tobaccos consumption for each smoker.[6]
3. The smoking incidence over the fiscal account. [7]
4. The best fiscal authority’s role in the smoking control. [8]
5. The useful from the fiscal policies agree to the smoking epidemiologic step. [9]
6. Experiences from others societies where were applied effective fiscal policies in the smoking control. [10-12].

These subjects have a strong supporting in the Health Economy. However, much health professional related with the smoking control haven´t sufficient academic formation in economic subjects, especially in the fiscal policy useful for the smoking control. [13]. the postgraduate education may contribute to solve these capacitating needs. The available from a postgraduate course about the fiscal policy for the smoking control should be an opportune capacitating form for health professionals related with the smoking control.

Objective

To design a postgraduate course about the fiscal policy useful in the smoking control for health professionals.
Materials and methods

Were used the inductive – deductive and the comparative as theorical methods. As empiric method was used the bibliographic research

Results

According to the previous elements identified the suggested course related subjects as shows the following table.

 

Course conteiner	Hours
	Class	Self research	Total
Domestic market for cigarettes and tobaccos	4	12	16
Personal spends on cigarettes and tobaccos	4	12	16
The smoking fiscal space	4	12	16
The fiscal authorities role in the smoking control	4	12	16
Tributary policy vs. no tributary policy in the smoking control	4	12	16
Examples of tributary policy for the smoking control	4	12	16
TOTAL	24	72	96

 

The first subject is about the behavior of the domestic market for cigarettes and tobaccos. In this case the professor must emphasize in the detailed description of consumption and price behavior and the relation between cigarettes and tobacco from different trade market. 14 .The second subject is supported by the previous. In this case the professor must focus the attention in the relevance from the personal spends on cigarettes and tobaccos respect to others products. The subject must appoint to describe how much important is the tobacco products for smokers. 6

The third subject is about the smoking fiscal space in the national economy. This subject must focus the attention of the smoking impact over the fiscal account. In this subject the professor must appoint to the smoking behavior given a particular fiscal policy. 15

The fourth subject focuses the attention in the fiscal authorities role in the smoking control. In this case the professor must describe in general terms the best taking decision process from the fiscal authorities for a better smoking control. 16

The fifth subject introduce a discussion about the better use from tributaries and no – tributaries policies for the smoking control. In this subject the professor must raise the relation between the smoking epidemiologic step and the use of fiscal policies for the best smoking control. 17

The sixth and last subject shows several examples of tributary policy for the smoking control. In this subject the professor must raise the good and bad results from each fiscal policy analyzed.

The suggested course has the particularity of be contextualized agree to general learning needs from health professionals related to the smoking economic control. The course has the characteristic that each subject is supported by the previous. Thus the course carries by a logic sequence to straight the learning process.

Conclusion

Was designed a postgraduate course about the fiscal policy useful in the smoking control for health professionals related with the smoking economic control. The course is agreed to general learning needs from health professionals related to the smoking economic control.

 

Variable	Frequency	Percent
Why did you visit the pharmacy?
To collect a prescription (for myself, someone else or both)	98	23.2
For consultation	17	4.1
Cosmetics	112	26.5
Baby’s product (milk, food)	97	22.9
Supplements	41	9.8
Woman’s products	53	12.6
Others	4	0.9
Was the pharmacists’ help to get other items satisfactory?
Yes	173	41
No	249	59
Was there a language barrier in communication with the pharmacist?
Yes	166	39.3
No	256	60.7
What amount of time the pharmacist spends with you?
Enough	161	38.2
Not enough	261	61.8
How much time on average?
<5 minute	203	48.1
5 minute	162	38.4
10 minute	23	5.5
15 minute	23	5.5
>30 minute	11	2.6
How do you rate your usual pharmacist?
Experienced	10	25.1
Trustworthy	115	27.3
Confident	65	15.4
Helpful	70	16.6
Others	66	15.6
Have you ever been given an advice about any of the following by the pharmacist?
Yes	151	35.8
No	271	64.2

 

Table 4: Client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422) Client’s satisfaction with the services provided by the community pharmacist.  

Variable	Frequency (%)
	I agree	Neutral	I disagree
Is the pharmacist delivers your medicines in a polite way?	115(27.3)	138(32.7)	169(40.0)
Is the instructions were clearly labeled by the pharmacist on each medication?	146(34.6)	140(33.2)	136(32.2)
Could the pharmacist clearly explains to you all possible side effects?	138(32.7)	178(42.2)	106(25.1)
Would the pharmacist provides you with written  information about drug therapy and/or diseases?	150(35.5)	154(36.5)	118(28.0)
Is the pharmacist uses information about your previous drugs when assessing your drug therapy?	148(35.1)	140(33.2)	134(31.8)
Could the pharmacist provides you with information about the proper storage of  your medication?	164(38.9)	123(29.1)	135(32.0)
Would the place of pharmaceutical counseling respects your privacy?	145(34.4)	85(20.1)	192(45.5)
Is any recommendations you think will improve the performance of the pharmacist?	120(28.4)	110(26.1)	192(45.5)

 

 

Table 5: Logistic regression for client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422).

 

Variable	Category	N (%)	AOR (95% C. I)	p-value
Age	19-30	132(31.3)	Reference
	31-40	118(28.0)	5.13(0.415-63.464)	0.003
	41-50	107(25.4)	1.790(0.096-33.489)	0.697
	51-60	35(8.3)	0.937(1.098-7.890)	0.269
	≥ 61	30(7.1)	5.444(0.697-42.504)	0.106
Sex	Male	180(42.7)	Reference
	Female	242(57.3)	2.447(0.130-1.538)	0.007
Residency	Rural	208(49.3)	Reference
	Urban	214(50.7)	0.620(0.705-5.152)	0.658
Income	<500	168(39.8)	Reference
	501-2500	138(32.7)	1.54(0.013-4183)	0.004
	2501-5000	85(20.1)	0.107(0.005-1669)	0.09 5
	>5000	31(7.3)	1.932(1.853-2.341)	0.08
Marital status	Single	173(41.0)	Reference
	Married	161(38.2)	2.93(2.013-4183)	0.007
	Divorced	66(15.6)	0.107(0.005-1669)	0.095
	Widowed	22(5.2)	1.342(0.927-1.736)	0.429
Spoken language	Oromic+Amharic	253(60.0)	Reference
	Oromic only	104(24.4)	4.016(1.065-5.739)	0.000
	Amharic only	65(5.6)	0.154(0.20-1.190)	0.73
Educational status	Illiterate	142(33.6)	Reference
	Grade 1-8	110(26.1)	4.063(2.970-9.341)	0.000
	Grade 9-10	77(18.2)	0.294(1.174-1.943)	0.927
	Grade 11-12	47(11.1)	1.873(0.056-3.618)	0.037
	Diploma	27(6.4)	2.032(1.109-1.856)	0.187
	Degree and above	19(4.5)	0.094(0.216-1.927)	0.749
How much time on average?	<5 minute	203(48.1)	Reference
	5 minute	162(38.4)	1.431(1.937-3.831)	0.97
	10 minute	23(5.5)	2.501(0.927-4.876)	0.001
	15 minute	23(5.5)	0.984(0.386-1.439)	0.074
	> 30 minute	11(2.6)	0.219(0.037-1.148)	0.587
Have you ever been advised?	Yes	151(35.8)	Reference
	No	271(64.2)	1.596(1.25-2.851)	0.095

Discussion

Generally, the society’s perception to the community pharmacists as health care services professionals in charge of the utilization of pharmaceuticals in the avoidance and treatment of diseases is limited [16]. An analysis of the available literature has been conducted and studies measuring patient satisfaction with pharmacy services delivered by pharmacists in a community setting were identified and evaluated. In the present study the overall prevalence of client’s satisfaction regarding the Pharmaceutical care services delivered in community pharmacies was 41.5%. This is finding on the present study was found to be lower than that of a study conducted in Mozambique 55%, JUSH 61.9% Brazilian 58.4% , Malaysia 74.6%, South Wollo 59.4%, Valencia 76.0%, Black lion Specialized Referral Hospital 51.6%[17-23] which assessed clients’ satisfaction with pharmacy services as part of overall health services and reported a high level of satisfaction. This difference was due to the majority of community pharmacy in our study where not give advice accordingly on the items purchased by the customers, and not communicate with the clients enough times about what they were bought, and there is different time in study period. In our study 35.8%clients were satisfied to counselling given by pharmacists was showed a slightly consistent with the degree of satisfaction with the medication counselling service compared to the survey employed in South Korea 34.0% [24]. This similarity was due to the community pharmacies in our study and South Korea were independently owned and are more business-oriented than oriented towards patient- centered care, and also they gave priority for their profit rather than customers satisfactions. In our current study 31.3% clients age were between 19-30 were consistent with the study conducted in United Arab Emirates revealed that majority of respondents were from the younger population sector with their ages ranging between 20 and 34 years and with good educational level [25]. This is due to younger females visit the community pharmacy mostly to purchased contraceptives, and clients age between 19-30 where visit community to also bought beauty commodities. And also 48.1% customers spent <5 minutes in pharmacy were slightly less than the study conducted in Emirates which revealed the most respondents feel that the time spent in the pharmacy was enough, the average time spent with a patient in this study varied from <5 min up to 10 min [22]. This was due to most community pharmacy workers where had unwillingness to conservative with clients to keep their self-dignity, and some where non-health related workers (cleaners, and cashiers) works in some community pharmacy as assistant. So they know now about medication except some drug name. The current study revealed only few of client were acquired educational information 2.8%use of anabolic steroids and 4.9% Smoking cessation were consistent with the study conducted in Arab the number of respondents who received health educational information in the community pharmacy was rather low with regard to smoking and use of anabolic steroids [25]. This was due to clients were reluctant to accept the counselling given about tobacco, khat, and alcohol because few customers uses those social substance as incentive, and also pharmacists fear to brought them advice due to their profit they got from those customers. The present study showed the preponderance 27.3% and 34.6%of participants were agree that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively, were contrary to the study carried out in United Arab Emirates which displayed the majority (74.1%) and (43.7%) of the respondents agreed that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively. Present study was “the information the pharmacist [22]. In our survey the pharmacists very few clients were acquire their medication in polite way and clearly labelled instructions due to the prescription where ineligible and made pharmacists higgledy-piggledy, then pharmacists prescribed carelessly for profit rather than send back to the physicians. The current study showed the pharmacist clearly explains to you all possible side effects, provides you with written/printed information about drug therapy and/or disease, uses information about your previous condition/drugs when assessing your drug therapy, and provides you with information about the proper method of storage of your medication were less than half of satisfaction were consistent with the study done in Gondar which showed that how well the pharmacist explains about the proper storage of your medication, possible side effects, storage, expected results from the medications and other were responsible for the lower level of satisfaction [26]. The difference is due to the community pharmacies in our survey were no adequate place to consul, no enough time to brought the clients written form about medication, and no much knowledge about unique medications storage, drug interaction, and side effects, so they not brought education to the clients accordingly. In our current study age between 19-30 were 5 times more likely satisfied(AOR: 5.13; 95%CI: 0.415-63.464; P=0.003) than others age category contrary to some previous studies, however, have found that older patients were more likely to report satisfaction compared with younger patients. This was due to most age between 19-30 bought familiar commodities, and then pharmacists bought them adequate consul. In our survey female were 2 times more likely satisfied (AOR: 2.447; 95%CI: 0.130-1.538; P=0.007) than males was consistent to some studies revealed, females were more likely to express satisfaction than males while in others no relationship was found between gender and satisfaction [27]. The majority of clients perceived that they spent 5 min counselling from pharmacists, were 2 times more likely satisfied (AOR: 2.501; 95%CI: 0.927-4.876; P=0.001) inconsistent with the study conducted with South Korea which were showed the majority of pharmacists perceived that they spent 1–5 min counselling patients, whereas the majority of clients reported that the length of time taken for medication counselling was less than 1 min[24]. Present study displayed customers who speaking Oromic language were 4 times more likely satisfied (AOR: 4.016; 95%CI: 1.065 -5.739; P=0.000) than those who speaking Oromic+Amharic and Amharic only were inconsistent with the study done in Saudi Arabia which showed mostly Arabs who can speak a second language may have significantly contributed to the high response rate obtained in the present study [25].  Due to they had got what they want and they comprehend each other accordingly due to they use their mother tongue language.

Overview of Azoospermia and Its Prevalence Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2]. Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertilityrelated stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals. While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7]. Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life. While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being. Objectives of the Study • To assess the quality of life among infertile males with azoospermia attending infertility clinics. • To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals. • To identify specific domains of QoL most affected by azoospermia.

 

Objectives: This study aims to describe the lived experiences of a patient in a coronavirus disease 2019 intensive care unit. Design: This study employed an interpretive phenomenological analysis. Methods: This study was conducted in the coronavirus intensive care unit of a tertiary university hospital in Japan. Data were collected from June 5, 2020 to March 30, 2021, via field observations and unstructured interviews. Informal interviews were conducted with five patients, and an in-depth interview was conducted with a male patient in his 70s—the only patient who survived throughout the research period and could communicate verbally. A phenomenological approach was adopted, which focused on describing the patient’s experience thoroughly from his perspective and analyzing the internal logic of his story while avoiding the introduction of external elements. Results: The patient described feeling alienated and stuck between this world and the afterlife. His experiences revealed five themes: “Disconnected from reality,” “Could I return to my former self?” “The doctors did not enter my room,” “Identifying people by voice and smell,” and “Going back and forth between this world and the afterlife.” Although he experienced death anxiety, he hoped to live in a shared world with others. The patient struggled to form relationships with healthcare personnel because he did not know the people around him. Conclusions: Individualized care must be provided to instill hope in patients. Understanding patients’ experiences can help in implementing measures to retain patients’ sense of identity and belongingness, thereby enhancing their well-being.

Conclusion and Recommendations

Our current study found that the overall prevalence of clients satisfaction regarding the pharmaceutical care services delivered in community pharmacies was meagre. This due to preponderance of community pharmacy was profit oriented rather than patient centered. Majority of clients were visit community pharmacy to purchase cosmetics and to collect a prescription (for myself, someone else or both). Greater than one-third of customers were obtained regarding oral contraceptives due to majority of the respondents was female. The level of satisfaction was found to be significantly affected by clients’ age category, sex, customers monthly income, marital status, educational status, spoken language, Andon average time pharmacist spent with clients. Pharmacists should have to work best to improve health education, communication, and understanding between the clients friendly. Government should have construct community pharmacy to improve level of customers’ satisfaction. Pharmacists should have to work well to improve health education, communication and understanding between the clients friendly.

 

Acknowledgments

We had extended our grateful thanks to all our study participants, and those encourage us to conduct this research through everything.

Conflict of Interests

We have no conflict of interest in this article.

Funding

None

Overview of Azoospermia and Its Prevalence

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2].

Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertility-related stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals.

While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7].

Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life.

While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being.

Objectives of the Study

• To assess the quality of life among infertile males with azoospermia attending infertility clinics.
• To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals.
• To identify specific domains of QoL most affected by azoospermia and its implications for clinical practice and intervention strategies

Methods

Study Design

This study is designed as a prospective observational study aimed at assessing the outcomes of infertile males undergoing in-vitro fertilization (IVF) treatment at Indira IVF centers across India.

Study Population

The study population will consist of infertile males attending Indira IVF centers for their treatment.

Study Setting

The study was conducted across all 103 Indira IVF centers in India, leveraging state-of-the-art infrastructure and advanced equipment available at these centers.

Subjects Selection

Inclusion Criteria

• Male attending in-vitro fertilization centers and giving informed consent.
• Male infertility cause identified as azoospermia.
• The male patient is between 18-45 years of age.

Exclusion Criteria

• Male partners older than 45 years of age.
• Male patient if in the terminal stage of an illness such as cancer, HIV-AIDS, transplant patients, etc.
• Male patient affected by COVID-19 disease.

Instruments/Tools Used

Fertility Quality of Life (FertiQoL) Questionnaire:

• Purpose: Assess the quality of life specifically about fertility issues.
• Structure: Consists of core and treatment sections, encompassing various domains such as mind/body, relational, social, emotional, and treatment-related aspects.
• Scoring: Comprises 36 items scored according to 5 response categories, with a response scale ranging from 0 to 4. Higher scores indicate a higher quality of life. Ferti QoL yields six subscales and three total scales with a range of 0 to 100.

WHO Quality of Life-BREF (WHOQOL-BREF)

• Purpose: Measure the general quality of life across four domains.
• Structure: Contains 26 items divided into four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), along with two items for overall quality of life and general health.
• Scoring: Each item is scored from 1 to 5. Domain scores are transformed to a 0-to-100-point scale using the WHO-QoL transformation table. Higher scores indicate a better quality of life.

Socio-demographic and Medical History Questionnaire

• Purpose: Collect data on general characteristics, socio-demographic information, medical history, and personal history.
• Structure: Developed specifically for this study to gather comprehensive background information relevant to the study population.

Reliability: We obtained acceptable reliability for both the tools examined by Cronbach's alpha coefficient analysis. (WHO physical domain, 0.70; WHO psychiatric domain, 0.76; WHO social domain, 0.75; WHO environment domain, 0.91; WHO Overall, 0.78; Core (FertiQoL), 0.84) Table 1.

Table 1: Socio-demographical characteristics of the study population (N=719).

Statistical Analysis Plan

The results were reported as Mean (SD) for quantitative variables and number (percentages) for categorical variables. The quantitative variables were compared using the Whitney U test and Kruskal Wallis test after testing for normal distribution. Multiple linear regression analysis was used with dependence on the Ferti (QoL) and WHOQOL-BREF subscales. The regression equation included terms for the participant’s demographics and information from his medical history. Adjusted regression coefficient (β) with the standard error (SE) were computed from the results of the linear regression analysis. All statistical analyses were performed at the 95% significance level (P<0.05) using the statistical software SPSS 28.0 statistical software (SPSS, Inc., Chicago, IL, USA).

Results

Study Population and Characteristics

In this cross-sectional study, 719 patients undergoing IVF treatment were invited to participate; 719 agreed, resulting in a response rate of 100.0%. The age of the respondents ranged from 18 to 45 years, with a majority falling between 26-35 years (57.6%) and a mean age of 34.52 years (SD =5.03 years). Most respondents completed academic education, with 80.1% having ten or more years of education, and 61.1% lived in urban areas.

A significant proportion of respondents had an annual family income between 5 lakhs and 2.5 lakhs INR, which is near the average yearly income. The most prevalent duration of infertility among the respondents was 5-10 years (44.4%), followed by less than 5 years (33.7%), and more than 10 years (22.0%).

Most participants were gainfully employed (90.5%) and resided in nuclear families (54.1%). The majority had five or fewer family members (73.0%). Regarding BMI, 55.1% of the respondents had a BMI of 25 or higher, 22.7% had a BMI between 18.5-22.9, 20.7% had a BMI of 23-24.9, and 1.5% had a BMI less than 18.5.

Tobacco use was reported by 27.4% of the participants, while 72.6% did not use tobacco. Alcohol consumption was noted in 24.1% of the population, with 75.9% reporting no alcohol consumption history. Only 10.2% of respondents reported suffering from any chronic disease.

A significant number of participants (60.5%) had undergone treatment for infertility, while 39.5% had not. Most participants (94.6%) had fewer than five medical consultations for infertility before coming to the center, with only 5.4% having more than five consultations. Lastly, 84.8% of participants reported no failures after IVF treatment, 9.0% had fewer than two failures, and 6.1% experienced two or more failures.

The WHOQOL Questionnaire demonstrates good reliability (Table 2) across all its subscales, with particularly high reliability in the WHO Environment Domain [22]. The mean scores suggest that respondents perceive their quality of life most positively in terms of overall quality (WHOQOL BREF) and environmental factors, while physical health is perceived less positively. The variability in responses is highest in the Social Relationship Domain, indicating differing perceptions of social relationships among the population. Overall, the WHOQOL Questionnaire is a reliable tool for assessing various aspects of quality of life in this population. Similarly, the Core (FertiQoL) Questionnaire demonstrates acceptable reliability across (Table 3) its subscales, with Cronbach's alpha values ranging from 0.64 to 0.84. The highest reliability is in the overall Core (FertiQoL) score (α = 0.84), while the Social Domain shows the lowest reliability (α=0.64). Mean scores indicate that respondents perceive their quality of life most positively in the Social Domain (77.60) and least positively in the Relationship Domain (65.61).

Table 2: Reliability analysis for WHOQOL Questionnaire.

Table 3: Reliability analysis for Core (FertiQoL) Questionnaire.

WHOQOL Tool

Our analysis of 719 participants revealed several significant trends in WHOQOL domain scores across various demographic characteristics (Table 4).

• Age: Younger participants (18-25 years) reported higher overall WHOQOL scores (Mean=83.33, P=0.030) and significantly higher psychological scores (P=0.010) compared to older age groups.
• Religion: Hindu participants generally reported higher scores across all domains compared to Muslim participants. This was particularly significant in the Physical Health (P<0.001), Psychological (P=0.003), Social Relationship (P < 0.001), and Environment (P<0.001) domains.
• Residential Status: Urban residents scored significantly higher in the Physical Health (P < 0.001), Social Relationship (P < 0.001), and Environment (P = 0.030) domains compared to rural residents.
• Education Level: Participants with less than 10 years of education had higher overall WHOQOL scores (P = 0.001) and scored significantly higher in the Physical Health (P=0.004) and Psychological (P=0.003) domains.
• Annual Family Income: Individuals with an annual family income greater than 5 lakhs INR reported better scores in the Physical Health (P < 0.001) and Social Relationship (P<0.001) domains.
• Body Mass Index (BMI): Those with a BMI <18.5 had lower scores in the Physical Health (P=0.004), Psychological (P=0.010), Social Relationship (P = 0.004), and Environment (P=0.007) domains compared to individuals with a higher BMI.
• Current Use of Tobacco: Tobacco users scored significantly lower in the Physical Health (P<0.001) and Social Relationship (P<0.001) domains compared to non-users.
• Years of Infertility: Participants experiencing infertility for less than 5 years had higher scores across all domains, particularly in the Psychological (P<0.001), Social Relationship (P=0.001), and Environment (P<0.001) domains.

These significant findings indicate the profound impact that demographic factors such as age, religion, residential status, education level, income, BMI, tobacco use, and duration of infertility have on the quality of life among individuals undergoing infertility treatment.

In this study, the multiple linear regression analysis shown in Table 5 reveals several key factors influencing the total WHOQOL score among infertile males with azoospermia. The results indicate that education level, religion, and years of infertility are significant predictors of WHOQOL scores. Specifically, lower education levels and longer durations of infertility are associated with poorer quality of life, while religious affiliation plays a role in the overall quality of life. Conversely, variables such as age, residential status, number of children, number of family members, suffering from chronic diseases, and history of infertility treatment do not significantly affect the WHOQOL scores. These findings highlight the critical importance of educational and religious factors, along with the impact of prolonged infertility, in shaping the quality of life for individuals facing azoospermia. Addressing these factors may be essential for improving support and interventions for this population.

Characteristics (n=719)	Categories	Total WHOQOL			Physical Health			Psychological			Social Relationship			Environment
		Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value
Age	18-25 years	83.33	12.07	0.03	60.24	11.14	0.478	81.24	13.94	0.01	78.24	15.63	0.073	82.05	16.55	0.058
	26-35 years	72.71	20.45		56.32	12.97		71.54	16.57		68.95	20.38		72.31	18.45
	36-45 years	71.74	19.61		57.32	12.22		69.56	16.95		67.23	20.52		71.43	18.13
Religion	Hindu	73.41	19.35	0.028	57.59	12.35	<0.001	71.93	16.23	0.003	69.91	19.74	<0.001	73.65	17.55	<0.001
	Muslim	68.16	23.02		52.42	13.4		65.87	18.8		60.62	22.25		64.16	20.63
Residential status	Urban	73.35	20.17	0.153	58.17	12.53	<0.001	71.99	16.26	0.101	71.44	18.99	<0.001	73.63	17.49	0.03
	Rural	71.6	19.73		54.88	12.56		69.67	17.38		64.36	21.6		70.26	19.34
Education Level	<10 years of education	77.1	20.44	0.001	60.01	15.7	0.004	74.23	16.5	0.003	70.28	20.92	0.142	73.9	17.87	0.124
	>=10 years of education	71.53	19.75		56.04	11.63		70.25	16.74		68.11	20.24		71.84	18.44
Occupation	Gainfully Employed	72.54	19.75	0.57	57.09	12.69	0.215	70.83	16.53	0.259	68.84	20.17	0.293	72.11	17.82	0.249
	Unemployed	73.53	22.39		54.31	11.92		73.04	18.76		65.69	22.26		73.6	22.78
Annual Family Income (INR)	<=5 lakhs (INR)	73.07	20.57	0.283	55.04	12.31	<0.001	70.92	17.66	0.979	65.89	21.36	<0.001	71.6	19.36	0.25
	>5 lakhs (INR)	71.68	18.71		60.72	12.47		71.3	14.62		74.33	16.69		73.67	15.81
Any Living Children	Yes	78.13	16.99	0.209	56.21	9.46	0.974	73.75	17.06	0.497	67.42	20.68	0.639	75.25	16.91	0.61
	No	72.45	20.08		56.85	12.73		70.95	16.75		68.58	20.38		72.15	18.38
Number of Children	None	72.45	20.08	0.209	56.85	12.73	0.974	70.95	16.75	0.497	68.58	20.38	0.639	72.15	18.38	0.61
	One or More	78.13	16.99		56.21	9.46		73.75	17.06		67.42	20.68		75.25	16.91
Type of Family	Nuclear	72.17	20.26	0.686	58.34	12.84	<0.001	71.4	17.14	0.242	69.58	20.56	0.062	72.6	18.59	0.351
	Joint	73.18	19.69		55.04	12.17		70.62	16.3		67.33	20.13		71.84	18.04
Number of Family Members	<=5 members	71.9	20.22	0.143	57.47	13.26	0.037	70.64	16.81	0.543	68.19	20.59	0.701	71.73	18.45	0.369
	>5 members	74.61	19.29		55.1	10.59		72.11	16.6		69.49	19.82		73.66	17.98
Body Mass Index (BMI)	<18.5	68.18	29.72	0.516	56.91	18.6	0.004	65.09	22.35	0.01	62.82	25.45	0.004	63.18	25.7	0.007
	18.5-22.9	70.86	18.89		55.54	12.9		68.2	16.82		64.88	19.63		68.65	18.55
	23-24.9	73.15	19.94		60.22	12.03		74.01	16.35		72.41	18.53		74.09	16.78
	>=25	73.3	20.17		56.08	12.38		71.26	16.54		68.76	20.97		73.29	18.38
Current use of Tobacco	Yes	71.7	21.91	0.526	53.41	12.22	<0.001	69.98	18.94	0.57	62.83	23.17	<0.001	70.2	20.88	0.204
	No	72.99	19.24		58.12	12.56		71.44	15.85		70.7	18.8		73.02	17.23
Current Alcohol Consumption History	Yes	73.55	19.75	0.495	55.99	12.33	0.234	72.29	15.26	0.302	68.06	19.77	0.573	73.2	17.44	0.396
	No	72.34	20.08		57.09	12.73		70.64	17.2		68.7	20.58		71.95	18.61
Suffering From Any Chronic Disease	Yes	69.18	22.63	0.231	56.86	11.7	0.982	70.9	18.45	0.986	69.9	22.01	0.402	72.92	19.02	0.668
	No	73.03	19.66		56.82	12.47		71.05	16.57		68.39	20.2		72.17	18.27
Years of Infertility	<5 years	74.9	18.84	0.034	57.34	11.5	0.131	74.65	16.73	<0.001	72.4	19.93	0.001	76.55	17.74	<0.001
	5-10 years	72.73	19.74		57.21	13.17		70.15	14.96		67.16	19.79		71.39	17.33
	>10 years	68.99	21.75		55.27	13.37		67.3	19.12		65.42	21.43		67.4	19.81
Cause of Infertility	Male factor	72.29	19.62	0.28	57.04	13.36	0.754	70.71	16.35	0.014	68.47	20.36	0.901	71.55	17.93	0.112
	Both	74.12	21.16		56.23	11.03		73.02	18.61		68.32	21.33		74.23	20.27
	Unknown	70.16	19.81		56.55	7.58		65.68	10.41		70.97	15.06		73	12.37
History of treatment for Infertility	Yes	71.78	20.39	0.13	57.35	13.84	0.34	70.79	17.4	0.933	68.1	21.4	0.95	71.91	19.03	0.9
	No	73.94	19.34		56.03	10.5		71.42	15.73		69.22	69.22		72.77	17.23
Number of medical consultations for infertility before coming to this center	<=5 Consultations	72.83	19.65	0.434	56.92	12.52	0.272	71.11	16.39	0.979	68.76	20.29	0.346	72.34	18.16	0.929
	>5 Consultations	69.23	25.3		55.15	14.5		69.77	22.38		64.77	21.85		70.64	21.28
Number of failures to conceive after IVF treatment	None	73.07	19.88	0.294	57.06	12.71	0.157	71.25	16.91	0.22	68.59	20.81	0.257	72.24	18.52	0.488
	<2	71.15	20.83		56.71	12.31		72.09	15.08		70.65	17.76		74.12	17.18
	>=2	68.75	20.26		53.84	12		66.57	16.65		64.8	17.66		69.61	69.61

Table 4: Comparison of WHO domains mean score across demographic characteristics (n=719).

Table 5: Multiple Linear Regression for Total WHOQOL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

FertiQoL score across Socio-demographic

The comparison of FertiQoL domain scores across various demographic characteristics reveals several significant patterns shown in Table 6. History of treatment and the number of failures to conceive after IVF treatment also show significant variations in the emotional and relationship domains. These findings highlight the complex interplay between demographic and clinical factors in influencing the quality of life among infertile azoospermic males.

Table 6: Comparison of FertiQoL domains mean score across demographic characteristics using t-test or ANOVA (n=719).

Table 7 illustrates the multiple linear regression analysis of the total FertiQoL score among infertile males with azoospermia reveals that education level, religion, BMI, and the duration of infertility are significant determinants of fertility-specific quality of life. Specifically, lower education levels and longer infertility durations are associated with a poorer quality of life, while higher BMI is linked to better quality of life. Religion also plays a significant role, with certain religious backgrounds correlating with lower quality of life scores. In contrast, factors such as age, residential status, occupation, number of children, alcohol consumption, cause of infertility, and the number of IVF failures do not significantly impact fertility-specific quality of life. These findings underscore the importance of considering educational background, religious context, BMI, and the length of infertility when assessing and addressing the quality of life in infertile azoospermic males.

Table 7: Multiple Linear Regression for Total FertiQoL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

Discussion

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. The psychological impact of this condition on patients' Quality of Life (QOL) is well-documented. Li-Yan Luo et al. [12] emphasize that infertility-related psychological stress negatively impacts the QOL of azoospermia patients. Their study reveals a correlation between higher stress levels and poorer QOL outcomes, underscoring the importance of addressing psychological factors in the management of azoospermia [12].

Core FertiQoL Domains

The key findings from our study, based on this tool, are as follows

• Physical Health: Scores in this domain were lower for males with infertility. Factors such as age, body mass index (BMI), and chronic health conditions significantly influenced the scores. Older age and higher BMI were associated with poorer physical health, while the presence of chronic diseases also negatively impacted this domain.
• Psychological: Psychological well-being was significantly affected by age, and duration of infertility. Older individuals and reported lower scores, indicating greater psychological distress. Prolonged infertility duration exacerbated psychological stress.
• Social Relationships: Social well-being was influenced by age, gender, education level, and residential status. Older individuals, and those with higher education levels reported poorer social relationships. Rural residents also experienced lower sco res, likely due to limited access to support and stigma associated with infertility [13].
• Environment: This domain was affected by factors such as income, occupation, and residential status. Lower-income and unemployment were associated with poorer environmental scores, reflecting financial and living conditions' impact on overall well-being [14].

FertiQoL Results

The key findings from our study using the FertiQoL tool are

• Emotional Well-being: Significant factors included age, gender, annual family income, tobacco use, unexplained infertility, and duration of infertility., and those with lower incomes or tobacco use reported greater emotional distress. Unexplained infertility and longer disease duration also negatively impacted emotional well-being [15].
• Mind/Body Health: Influencing factors were age, annual family income, BMI, cause of infertility, years of infertility, and history of infertility treatment. Older age, lower income, and normal BMI were associated with poorer scores. Unexplained infertility and longer infertility duration also resulted in lower scores, highlighting the physical and psychological toll of prolonged infertility [16].
• Relational: This domain was affected by relationship duration and previous treatment history.Males with longer marriages and those with unsuccessful treatment attempts reported poorer relational well-being, indicating the strain infertility places on relationships.
• Social: Social well-being was influenced by age, rural residence, education level, employment status, income, duration of infertility, and number of failed IVF treatments [17]. Older age, rural residence, higher education, unemployment, lower income, longer infertility duration, and failed treatments all contributed to poorer social well-being [18].

Hypothesis 1

• Null Hypothesis (H0): There exists no correlation (there is no linear relation) between Azoospermia and Quality of Life.
• Alternate Hypothesis (H1): There is a significant correlation (there is an inverse linear relation) between Azoospermia and Quality of Life.

Findings

The multiple linear regression analysis showed that several factors related to azoospermia, such as years of infertility and education level, significantly impacted the Quality of Life (QoL). Specifically, longer years of infertility and lower education levels were associated with poorer QoL scores, indicating an inverse relationship. In comparison, the Polish study by Makara SM et al. reported lower social domain scores, whereas the current study showed relatively higher scores in this domain, suggesting better social integration among the study participants. Therefore, we reject the null hypothesis and accept the alternate hypothesis, concluding that there is a significant correlation between azoospermia and quality of life.

Hypothesis 2

• Null Hypothesis (H0): Azoospermic males get adequate societal acceptance and support towards their infertility.
• Alternate Hypothesis (H1): Society plays little to no role in supporting or accepting the Azoospermic male’s battle with infertility.

Findings

Social well-being scores from the FertiQoL indicate that societal support is lacking for azoospermic males. Factors such as rural residence, male gender, and lack of education were associated with lower social well-being, suggesting inadequate societal acceptance and support. Thus, we reject the null hypothesis and accept the alternate hypothesis that society plays little to no role in supporting azoospermic males [16].

Hypothesis 3

• Null Hypothesis (H0): Azoospermic males with higher income will have a better quality of life than Azoospermic males with lower income.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across income groups.

Findings

The multiple regression analysis indicated that lower annual family income significantly impacted Mind/Body Health and Emotional Well-being, suggesting that income level does influence QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across income groups. Further supporting this, Bahadır Topuz et al. [4] report that patients with Non-Obstructive Azoospermia (NOA) experience reduced QOL across physical, psychological, and social domains. The study highlights the necessity for routine assessments of mental health and QOL, advocating for integrated care approaches that include psychological support alongside medical treatments [4].

Hypothesis 4

• Null Hypothesis (H0): Azoospermic males in a higher age bracket will have a poorer quality of life than Azoospermic males in a lower age bracket.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across differing age brackets.

Findings

Age was found to negatively impact the QoL scores, but it was not statistically significant in the regression analysis (β =-2.00, p=0.164). This suggests age might not significantly affect QoL, leading us to accept the alternate hypothesis that there is no significant difference in QoL across different age brackets [19].

Hypothesis 5

• Null Hypothesis (H0): The higher the years of infertility, the poorer quality of life the Azoospermic male will have.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across years of infertility endured.

Findings

Years of infertility was a significant negative predictor of QoL (β=-3.96, p < 0.001), indicating that longer infertility duration is associated with poorer QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across years of infertility. This aligns with previous findings by Dourou P et al., who reported lower mind/body scores in females and those with higher education. However, these factors did not significantly impact mind/body scores in the present study [20].

Hypothesis 6

• Null Hypothesis (H0): The higher the history of failures using ART, the poorer the quality of life of the Azoospermic male.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across the number of ART failures incurred by the Azoospermic male.

Findings

The number of failed IVF treatments was not a significant predictor of QoL (β=-1.21, p=0.362). This indicates that ART failure history does not significantly affect QoL. Therefore, we accept the alternate hypothesis that there is no significant difference in QoL across the number of ART failures [21].

Limitation

The study population was specific to males with azoospermia, which may not reflect the experiences of the overall infertile population, with other reasons for infertility. The cross-sectional nature of the study limits the ability to infer causality between azoospermia and QoL. Longitudinal studies would be beneficial to understand the temporal relationship and causal pathways.

Given the significant impact of social well-being on QoL, integrating psychosocial support into infertility treatment protocols is crucial. Counseling services and support groups could help address the emotional and social challenges faced by azoospermic males. Increasing awareness and education about azoospermia and its impact on QoL can help reduce stigma and improve societal acceptance. Educational campaigns targeting both urban and rural populations could promote understanding and support for infertile males.

Studies involving larger and more diverse populations, as well as those incorporating qualitative methods, could provide deeper insights into the experiences of azoospermic males. The partners of azoospermic males could be studied separately to understand coping mechanisms employed as a couple to deal with Azoospermia.

Conclusion

Overall, this study reveals that several socio-demographic and medical factors significantly influence the quality of life of azoospermic males. Factors such as education level, years of infertility, and income levels were particularly impactful. The WHOQoL-BREF and FertiQoL tools both provide valuable insights, though they emphasize different aspects of quality of life. Comprehensive support strategies, including psychosocial interventions, are essential to improve the overall well-being of these individuals.

Funding

There is external funding for the study.

Conflict of Interest

There is no conflict of interest among authors.

Declaration

Consent has been taken from each participant. All the data will be shared on request.

The fiscal policy had been a useful tool for an effective smoking control. During the two first decades from the present century, several countries had adopted several fiscal measures showing an effective smoking control. [1- 4]^. Health professionals related with the smoking control need research the fiscal policy incidence over the smoking behavior. For that it is important that these professionals understand:    

1. The cigarettes and tobacco domestic market behavior´s. [5]
2. The self importance from the cigarettes and tobaccos consumption for each smoker.[6]
3. The smoking incidence over the fiscal account. [7]
4. The best fiscal authority’s role in the smoking control. [8]
5. The useful from the fiscal policies agree to the smoking epidemiologic step. [9]
6. Experiences from others societies where were applied effective fiscal policies in the smoking control. [10-12].

These subjects have a strong supporting in the Health Economy. However, much health professional related with the smoking control haven´t sufficient academic formation in economic subjects, especially in the fiscal policy useful for the smoking control. [13]. the postgraduate education may contribute to solve these capacitating needs. The available from a postgraduate course about the fiscal policy for the smoking control should be an opportune capacitating form for health professionals related with the smoking control.

Objective

To design a postgraduate course about the fiscal policy useful in the smoking control for health professionals.
Materials and methods

Were used the inductive – deductive and the comparative as theorical methods. As empiric method was used the bibliographic research

Results

According to the previous elements identified the suggested course related subjects as shows the following table.

 

Course conteiner	Hours
	Class	Self research	Total
Domestic market for cigarettes and tobaccos	4	12	16
Personal spends on cigarettes and tobaccos	4	12	16
The smoking fiscal space	4	12	16
The fiscal authorities role in the smoking control	4	12	16
Tributary policy vs. no tributary policy in the smoking control	4	12	16
Examples of tributary policy for the smoking control	4	12	16
TOTAL	24	72	96

 

The first subject is about the behavior of the domestic market for cigarettes and tobaccos. In this case the professor must emphasize in the detailed description of consumption and price behavior and the relation between cigarettes and tobacco from different trade market. 14 .The second subject is supported by the previous. In this case the professor must focus the attention in the relevance from the personal spends on cigarettes and tobaccos respect to others products. The subject must appoint to describe how much important is the tobacco products for smokers. 6

The third subject is about the smoking fiscal space in the national economy. This subject must focus the attention of the smoking impact over the fiscal account. In this subject the professor must appoint to the smoking behavior given a particular fiscal policy. 15

The fourth subject focuses the attention in the fiscal authorities role in the smoking control. In this case the professor must describe in general terms the best taking decision process from the fiscal authorities for a better smoking control. 16

The fifth subject introduce a discussion about the better use from tributaries and no – tributaries policies for the smoking control. In this subject the professor must raise the relation between the smoking epidemiologic step and the use of fiscal policies for the best smoking control. 17

The sixth and last subject shows several examples of tributary policy for the smoking control. In this subject the professor must raise the good and bad results from each fiscal policy analyzed.

The suggested course has the particularity of be contextualized agree to general learning needs from health professionals related to the smoking economic control. The course has the characteristic that each subject is supported by the previous. Thus the course carries by a logic sequence to straight the learning process.

Conclusion

Was designed a postgraduate course about the fiscal policy useful in the smoking control for health professionals related with the smoking economic control. The course is agreed to general learning needs from health professionals related to the smoking economic control.

 

Variable	Frequency	Percent
Why did you visit the pharmacy?
To collect a prescription (for myself, someone else or both)	98	23.2
For consultation	17	4.1
Cosmetics	112	26.5
Baby’s product (milk, food)	97	22.9
Supplements	41	9.8
Woman’s products	53	12.6
Others	4	0.9
Was the pharmacists’ help to get other items satisfactory?
Yes	173	41
No	249	59
Was there a language barrier in communication with the pharmacist?
Yes	166	39.3
No	256	60.7
What amount of time the pharmacist spends with you?
Enough	161	38.2
Not enough	261	61.8
How much time on average?
<5 minute	203	48.1
5 minute	162	38.4
10 minute	23	5.5
15 minute	23	5.5
>30 minute	11	2.6
How do you rate your usual pharmacist?
Experienced	10	25.1
Trustworthy	115	27.3
Confident	65	15.4
Helpful	70	16.6
Others	66	15.6
Have you ever been given an advice about any of the following by the pharmacist?
Yes	151	35.8
No	271	64.2

 

Table 4: Client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422) Client’s satisfaction with the services provided by the community pharmacist.  

 

 

Variable	Frequency (%)
	I agree	Neutral	I disagree
Is the pharmacist delivers your medicines in a polite way?	115(27.3)	138(32.7)	169(40.0)
Is the instructions were clearly labeled by the pharmacist on each medication?	146(34.6)	140(33.2)	136(32.2)
Could the pharmacist clearly explains to you all possible side effects?	138(32.7)	178(42.2)	106(25.1)
Would the pharmacist provides you with written  information about drug therapy and/or diseases?	150(35.5)	154(36.5)	118(28.0)
Is the pharmacist uses information about your previous drugs when assessing your drug therapy?	148(35.1)	140(33.2)	134(31.8)
Could the pharmacist provides you with information about the proper storage of  your medication?	164(38.9)	123(29.1)	135(32.0)
Would the place of pharmaceutical counseling respects your privacy?	145(34.4)	85(20.1)	192(45.5)
Is any recommendations you think will improve the performance of the pharmacist?	120(28.4)	110(26.1)	192(45.5)

 

Table 5: Logistic regression for client’s satisfaction with the services provided by the community pharmacist, Mettu, Ethiopia (n=422).

 

Variable	Category	N (%)	AOR (95% C. I)	p-value
Age	19-30	132(31.3)	Reference
	31-40	118(28.0)	5.13(0.415-63.464)	0.003
	41-50	107(25.4)	1.790(0.096-33.489)	0.697
	51-60	35(8.3)	0.937(1.098-7.890)	0.269
	≥ 61	30(7.1)	5.444(0.697-42.504)	0.106
Sex	Male	180(42.7)	Reference
	Female	242(57.3)	2.447(0.130-1.538)	0.007
Residency	Rural	208(49.3)	Reference
	Urban	214(50.7)	0.620(0.705-5.152)	0.658
Income	<500	168(39.8)	Reference
	501-2500	138(32.7)	1.54(0.013-4183)	0.004
	2501-5000	85(20.1)	0.107(0.005-1669)	0.09 5
	>5000	31(7.3)	1.932(1.853-2.341)	0.08
Marital status	Single	173(41.0)	Reference
	Married	161(38.2)	2.93(2.013-4183)	0.007
	Divorced	66(15.6)	0.107(0.005-1669)	0.095
	Widowed	22(5.2)	1.342(0.927-1.736)	0.429
Spoken language	Oromic+Amharic	253(60.0)	Reference
	Oromic only	104(24.4)	4.016(1.065-5.739)	0.000
	Amharic only	65(5.6)	0.154(0.20-1.190)	0.73
Educational status	Illiterate	142(33.6)	Reference
	Grade 1-8	110(26.1)	4.063(2.970-9.341)	0.000
	Grade 9-10	77(18.2)	0.294(1.174-1.943)	0.927
	Grade 11-12	47(11.1)	1.873(0.056-3.618)	0.037
	Diploma	27(6.4)	2.032(1.109-1.856)	0.187
	Degree and above	19(4.5)	0.094(0.216-1.927)	0.749
How much time on average?	<5 minute	203(48.1)	Reference
	5 minute	162(38.4)	1.431(1.937-3.831)	0.97
	10 minute	23(5.5)	2.501(0.927-4.876)	0.001
	15 minute	23(5.5)	0.984(0.386-1.439)	0.074
	> 30 minute	11(2.6)	0.219(0.037-1.148)	0.587
Have you ever been advised?	Yes	151(35.8)	Reference
	No	271(64.2)	1.596(1.25-2.851)	0.095

Discussion

Generally, the society’s perception to the community pharmacists as health care services professionals in charge of the utilization of pharmaceuticals in the avoidance and treatment of diseases is limited [16]. An analysis of the available literature has been conducted and studies measuring patient satisfaction with pharmacy services delivered by pharmacists in a community setting were identified and evaluated. In the present study the overall prevalence of client’s satisfaction regarding the Pharmaceutical care services delivered in community pharmacies was 41.5%. This is finding on the present study was found to be lower than that of a study conducted in Mozambique 55%, JUSH 61.9% Brazilian 58.4% , Malaysia 74.6%, South Wollo 59.4%, Valencia 76.0%, Black lion Specialized Referral Hospital 51.6%[17-23] which assessed clients’ satisfaction with pharmacy services as part of overall health services and reported a high level of satisfaction. This difference was due to the majority of community pharmacy in our study where not give advice accordingly on the items purchased by the customers, and not communicate with the clients enough times about what they were bought, and there is different time in study period. In our study 35.8%clients were satisfied to counselling given by pharmacists was showed a slightly consistent with the degree of satisfaction with the medication counselling service compared to the survey employed in South Korea 34.0% [24]. This similarity was due to the community pharmacies in our study and South Korea were independently owned and are more business-oriented than oriented towards patient- centered care, and also they gave priority for their profit rather than customers satisfactions. In our current study 31.3% clients age were between 19-30 were consistent with the study conducted in United Arab Emirates revealed that majority of respondents were from the younger population sector with their ages ranging between 20 and 34 years and with good educational level [25]. This is due to younger females visit the community pharmacy mostly to purchased contraceptives, and clients age between 19-30 where visit community to also bought beauty commodities. And also 48.1% customers spent <5 minutes in pharmacy were slightly less than the study conducted in Emirates which revealed the most respondents feel that the time spent in the pharmacy was enough, the average time spent with a patient in this study varied from <5 min up to 10 min [22]. This was due to most community pharmacy workers where had unwillingness to conservative with clients to keep their self-dignity, and some where non-health related workers (cleaners, and cashiers) works in some community pharmacy as assistant. So they know now about medication except some drug name. The current study revealed only few of client were acquired educational information 2.8%use of anabolic steroids and 4.9% Smoking cessation were consistent with the study conducted in Arab the number of respondents who received health educational information in the community pharmacy was rather low with regard to smoking and use of anabolic steroids [25]. This was due to clients were reluctant to accept the counselling given about tobacco, khat, and alcohol because few customers uses those social substance as incentive, and also pharmacists fear to brought them advice due to their profit they got from those customers. The present study showed the preponderance 27.3% and 34.6%of participants were agree that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively, were contrary to the study carried out in United Arab Emirates which displayed the majority (74.1%) and (43.7%) of the respondents agreed that the pharmacist delivers their medicines in a polite way, and instructions were clearly labelled on each medicine respectively. Present study was “the information the pharmacist [22]. In our survey the pharmacists very few clients were acquire their medication in polite way and clearly labelled instructions due to the prescription where ineligible and made pharmacists higgledy-piggledy, then pharmacists prescribed carelessly for profit rather than send back to the physicians. The current study showed the pharmacist clearly explains to you all possible side effects, provides you with written/printed information about drug therapy and/or disease, uses information about your previous condition/drugs when assessing your drug therapy, and provides you with information about the proper method of storage of your medication were less than half of satisfaction were consistent with the study done in Gondar which showed that how well the pharmacist explains about the proper storage of your medication, possible side effects, storage, expected results from the medications and other were responsible for the lower level of satisfaction [26]. The difference is due to the community pharmacies in our survey were no adequate place to consul, no enough time to brought the clients written form about medication, and no much knowledge about unique medications storage, drug interaction, and side effects, so they not brought education to the clients accordingly. In our current study age between 19-30 were 5 times more likely satisfied(AOR: 5.13; 95%CI: 0.415-63.464; P=0.003) than others age category contrary to some previous studies, however, have found that older patients were more likely to report satisfaction compared with younger patients. This was due to most age between 19-30 bought familiar commodities, and then pharmacists bought them adequate consul. In our survey female were 2 times more likely satisfied (AOR: 2.447; 95%CI: 0.130-1.538; P=0.007) than males was consistent to some studies revealed, females were more likely to express satisfaction than males while in others no relationship was found between gender and satisfaction [27]. The majority of clients perceived that they spent 5 min counselling from pharmacists, were 2 times more likely satisfied (AOR: 2.501; 95%CI: 0.927-4.876; P=0.001) inconsistent with the study conducted with South Korea which were showed the majority of pharmacists perceived that they spent 1–5 min counselling patients, whereas the majority of clients reported that the length of time taken for medication counselling was less than 1 min[24]. Present study displayed customers who speaking Oromic language were 4 times more likely satisfied (AOR: 4.016; 95%CI: 1.065 -5.739; P=0.000) than those who speaking Oromic+Amharic and Amharic only were inconsistent with the study done in Saudi Arabia which showed mostly Arabs who can speak a second language may have significantly contributed to the high response rate obtained in the present study [25].  Due to they had got what they want and they comprehend each other accordingly due to they use their mother tongue language.

Overview of Azoospermia and Its Prevalence Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2]. Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertilityrelated stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals. While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7]. Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life. While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being. Objectives of the Study • To assess the quality of life among infertile males with azoospermia attending infertility clinics. • To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals. • To identify specific domains of QoL most affected by azoospermia.

 

Objectives: This study aims to describe the lived experiences of a patient in a coronavirus disease 2019 intensive care unit. Design: This study employed an interpretive phenomenological analysis. Methods: This study was conducted in the coronavirus intensive care unit of a tertiary university hospital in Japan. Data were collected from June 5, 2020 to March 30, 2021, via field observations and unstructured interviews. Informal interviews were conducted with five patients, and an in-depth interview was conducted with a male patient in his 70s—the only patient who survived throughout the research period and could communicate verbally. A phenomenological approach was adopted, which focused on describing the patient’s experience thoroughly from his perspective and analyzing the internal logic of his story while avoiding the introduction of external elements. Results: The patient described feeling alienated and stuck between this world and the afterlife. His experiences revealed five themes: “Disconnected from reality,” “Could I return to my former self?” “The doctors did not enter my room,” “Identifying people by voice and smell,” and “Going back and forth between this world and the afterlife.” Although he experienced death anxiety, he hoped to live in a shared world with others. The patient struggled to form relationships with healthcare personnel because he did not know the people around him. Conclusions: Individualized care must be provided to instill hope in patients. Understanding patients’ experiences can help in implementing measures to retain patients’ sense of identity and belongingness, thereby enhancing their well-being.

Conclusion and Recommendations

Our current study found that the overall prevalence of clients satisfaction regarding the pharmaceutical care services delivered in community pharmacies was meagre. This due to preponderance of community pharmacy was profit oriented rather than patient centered. Majority of clients were visit community pharmacy to purchase cosmetics and to collect a prescription (for myself, someone else or both). Greater than one-third of customers were obtained regarding oral contraceptives due to majority of the respondents was female. The level of satisfaction was found to be significantly affected by clients’ age category, sex, customers monthly income, marital status, educational status, spoken language, Andon average time pharmacist spent with clients. Pharmacists should have to work best to improve health education, communication, and understanding between the clients friendly. Government should have construct community pharmacy to improve level of customers’ satisfaction. Pharmacists should have to work well to improve health education, communication and understanding between the clients friendly.

 

Acknowledgments

We had extended our grateful thanks to all our study participants, and those encourage us to conduct this research through everything.

Conflict of Interests

We have no conflict of interest in this article.

Funding

None

Overview of Azoospermia and Its Prevalence

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. It can be classified into obstructive and non-obstructive types, each with distinct etiologies and treatment approaches [1]. The prevalence of azoospermia varies across populations, with estimates ranging from 1% to 15% of infertile men. Understanding the prevalence and subtypes of azoospermia is crucial for diagnosing and managing infertility in affected individuals [2].

Infertility, including azoospermia, has been shown to have a profound impact on the Quality of Life (QoL) of affected individuals and couples [2]. The inability to conceive can lead to feelings of inadequacy, stress, anxiety, and depression, affecting various aspects of daily life, including relationships, self-esteem, and social interactions. Research [1,2] indicates that infertility-related stress can significantly impair QoL and psychological well-being, highlighting the need for comprehensive support and interventions for affected individuals.

While numerous studies have investigated the QoL of infertile couples, relatively few have specifically focused on males affected by azoospermia. Existing research [3] in this area has primarily explored the psychological and emotional impact of azoospermia on individuals and relationships. Studies [2,4] have reported decreased QoL scores among infertile men with azoospermia, with factors such as treatment outcomes, coping strategies, and social support influencing QoL outcomes. However, there remains a need for more comprehensive research specifically examining the QoL of males affected by azoospermia, including the impact on marital satisfaction, sexual function, and overall well-being [5-7].

Despite the growing recognition of the psychological burden of infertility, there are notable gaps in the literature regarding the QoL of infertile males with azoospermia. Existing research often lacks a comprehensive assessment of QoL domains specific to azoospermia and specifically male infertility. It may overlook the unique challenges such males face. Therefore, there is a pressing need for empirical studies that explore the QoL of infertile males with azoospermia in-depth, identifying key determinants and interventions to improve well-being. The current study aims to address these gaps by providing valuable insights into the QoL of males affected by azoospermia and informing targeted interventions to enhance their overall quality of life.

While previous research [8-11] has examined the impact of infertility on QoL, limited attention has been paid to the specific challenges faced by males affected by azoospermia. Given the emotional distress and social stigma associated with infertility, investigating QoL in this population is imperative. By identifying factors influencing QoL, healthcare providers can develop tailored interventions to address the unique needs of infertile males with azoospermia, thereby enhancing their overall well-being.

Objectives of the Study

• To assess the quality of life among infertile males with azoospermia attending infertility clinics.
• To explore the association of poor quality of life with different socio-demographic, medical, and personal characteristics of infertile individuals.
• To identify specific domains of QoL most affected by azoospermia and its implications for clinical practice and intervention strategies

Methods

Study Design

This study is designed as a prospective observational study aimed at assessing the outcomes of infertile males undergoing in-vitro fertilization (IVF) treatment at Indira IVF centers across India.

Study Population

The study population will consist of infertile males attending Indira IVF centers for their treatment.

Study Setting

The study was conducted across all 103 Indira IVF centers in India, leveraging state-of-the-art infrastructure and advanced equipment available at these centers.

Subjects Selection

Inclusion Criteria

• Male attending in-vitro fertilization centers and giving informed consent.
• Male infertility cause identified as azoospermia.
• The male patient is between 18-45 years of age.

Exclusion Criteria

• Male partners older than 45 years of age.
• Male patient if in the terminal stage of an illness such as cancer, HIV-AIDS, transplant patients, etc.
• Male patient affected by COVID-19 disease.

Instruments/Tools Used

Fertility Quality of Life (FertiQoL) Questionnaire:

• Purpose: Assess the quality of life specifically about fertility issues.
• Structure: Consists of core and treatment sections, encompassing various domains such as mind/body, relational, social, emotional, and treatment-related aspects.
• Scoring: Comprises 36 items scored according to 5 response categories, with a response scale ranging from 0 to 4. Higher scores indicate a higher quality of life. Ferti QoL yields six subscales and three total scales with a range of 0 to 100.

WHO Quality of Life-BREF (WHOQOL-BREF)

• Purpose: Measure the general quality of life across four domains.
• Structure: Contains 26 items divided into four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), along with two items for overall quality of life and general health.
• Scoring: Each item is scored from 1 to 5. Domain scores are transformed to a 0-to-100-point scale using the WHO-QoL transformation table. Higher scores indicate a better quality of life.

Socio-demographic and Medical History Questionnaire

• Purpose: Collect data on general characteristics, socio-demographic information, medical history, and personal history.
• Structure: Developed specifically for this study to gather comprehensive background information relevant to the study population.

Reliability: We obtained acceptable reliability for both the tools examined by Cronbach's alpha coefficient analysis. (WHO physical domain, 0.70; WHO psychiatric domain, 0.76; WHO social domain, 0.75; WHO environment domain, 0.91; WHO Overall, 0.78; Core (FertiQoL), 0.84) Table 1.

Table 1: Socio-demographical characteristics of the study population (N=719).

Statistical Analysis Plan

The results were reported as Mean (SD) for quantitative variables and number (percentages) for categorical variables. The quantitative variables were compared using the Whitney U test and Kruskal Wallis test after testing for normal distribution. Multiple linear regression analysis was used with dependence on the Ferti (QoL) and WHOQOL-BREF subscales. The regression equation included terms for the participant’s demographics and information from his medical history. Adjusted regression coefficient (β) with the standard error (SE) were computed from the results of the linear regression analysis. All statistical analyses were performed at the 95% significance level (P<0.05) using the statistical software SPSS 28.0 statistical software (SPSS, Inc., Chicago, IL, USA).

Results

Study Population and Characteristics

In this cross-sectional study, 719 patients undergoing IVF treatment were invited to participate; 719 agreed, resulting in a response rate of 100.0%. The age of the respondents ranged from 18 to 45 years, with a majority falling between 26-35 years (57.6%) and a mean age of 34.52 years (SD =5.03 years). Most respondents completed academic education, with 80.1% having ten or more years of education, and 61.1% lived in urban areas.

A significant proportion of respondents had an annual family income between 5 lakhs and 2.5 lakhs INR, which is near the average yearly income. The most prevalent duration of infertility among the respondents was 5-10 years (44.4%), followed by less than 5 years (33.7%), and more than 10 years (22.0%).

Most participants were gainfully employed (90.5%) and resided in nuclear families (54.1%). The majority had five or fewer family members (73.0%). Regarding BMI, 55.1% of the respondents had a BMI of 25 or higher, 22.7% had a BMI between 18.5-22.9, 20.7% had a BMI of 23-24.9, and 1.5% had a BMI less than 18.5.

Tobacco use was reported by 27.4% of the participants, while 72.6% did not use tobacco. Alcohol consumption was noted in 24.1% of the population, with 75.9% reporting no alcohol consumption history. Only 10.2% of respondents reported suffering from any chronic disease.

A significant number of participants (60.5%) had undergone treatment for infertility, while 39.5% had not. Most participants (94.6%) had fewer than five medical consultations for infertility before coming to the center, with only 5.4% having more than five consultations. Lastly, 84.8% of participants reported no failures after IVF treatment, 9.0% had fewer than two failures, and 6.1% experienced two or more failures.

The WHOQOL Questionnaire demonstrates good reliability (Table 2) across all its subscales, with particularly high reliability in the WHO Environment Domain [22]. The mean scores suggest that respondents perceive their quality of life most positively in terms of overall quality (WHOQOL BREF) and environmental factors, while physical health is perceived less positively. The variability in responses is highest in the Social Relationship Domain, indicating differing perceptions of social relationships among the population. Overall, the WHOQOL Questionnaire is a reliable tool for assessing various aspects of quality of life in this population. Similarly, the Core (FertiQoL) Questionnaire demonstrates acceptable reliability across (Table 3) its subscales, with Cronbach's alpha values ranging from 0.64 to 0.84. The highest reliability is in the overall Core (FertiQoL) score (α = 0.84), while the Social Domain shows the lowest reliability (α=0.64). Mean scores indicate that respondents perceive their quality of life most positively in the Social Domain (77.60) and least positively in the Relationship Domain (65.61).

Table 2: Reliability analysis for WHOQOL Questionnaire.

Table 3: Reliability analysis for Core (FertiQoL) Questionnaire.

WHOQOL Tool

Our analysis of 719 participants revealed several significant trends in WHOQOL domain scores across various demographic characteristics (Table 4).

• Age: Younger participants (18-25 years) reported higher overall WHOQOL scores (Mean=83.33, P=0.030) and significantly higher psychological scores (P=0.010) compared to older age groups.
• Religion: Hindu participants generally reported higher scores across all domains compared to Muslim participants. This was particularly significant in the Physical Health (P<0.001), Psychological (P=0.003), Social Relationship (P < 0.001), and Environment (P<0.001) domains.
• Residential Status: Urban residents scored significantly higher in the Physical Health (P < 0.001), Social Relationship (P < 0.001), and Environment (P = 0.030) domains compared to rural residents.
• Education Level: Participants with less than 10 years of education had higher overall WHOQOL scores (P = 0.001) and scored significantly higher in the Physical Health (P=0.004) and Psychological (P=0.003) domains.
• Annual Family Income: Individuals with an annual family income greater than 5 lakhs INR reported better scores in the Physical Health (P < 0.001) and Social Relationship (P<0.001) domains.
• Body Mass Index (BMI): Those with a BMI <18.5 had lower scores in the Physical Health (P=0.004), Psychological (P=0.010), Social Relationship (P = 0.004), and Environment (P=0.007) domains compared to individuals with a higher BMI.
• Current Use of Tobacco: Tobacco users scored significantly lower in the Physical Health (P<0.001) and Social Relationship (P<0.001) domains compared to non-users.
• Years of Infertility: Participants experiencing infertility for less than 5 years had higher scores across all domains, particularly in the Psychological (P<0.001), Social Relationship (P=0.001), and Environment (P<0.001) domains.

These significant findings indicate the profound impact that demographic factors such as age, religion, residential status, education level, income, BMI, tobacco use, and duration of infertility have on the quality of life among individuals undergoing infertility treatment.

In this study, the multiple linear regression analysis shown in Table 5 reveals several key factors influencing the total WHOQOL score among infertile males with azoospermia. The results indicate that education level, religion, and years of infertility are significant predictors of WHOQOL scores. Specifically, lower education levels and longer durations of infertility are associated with poorer quality of life, while religious affiliation plays a role in the overall quality of life. Conversely, variables such as age, residential status, number of children, number of family members, suffering from chronic diseases, and history of infertility treatment do not significantly affect the WHOQOL scores. These findings highlight the critical importance of educational and religious factors, along with the impact of prolonged infertility, in shaping the quality of life for individuals facing azoospermia. Addressing these factors may be essential for improving support and interventions for this population.

Characteristics (n=719)	Categories	Total WHOQOL			Physical Health			Psychological			Social Relationship			Environment
		Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value	Mean	SD	P value
Age	18-25 years	83.33	12.07	0.03	60.24	11.14	0.478	81.24	13.94	0.01	78.24	15.63	0.073	82.05	16.55	0.058
	26-35 years	72.71	20.45		56.32	12.97		71.54	16.57		68.95	20.38		72.31	18.45
	36-45 years	71.74	19.61		57.32	12.22		69.56	16.95		67.23	20.52		71.43	18.13
Religion	Hindu	73.41	19.35	0.028	57.59	12.35	<0.001	71.93	16.23	0.003	69.91	19.74	<0.001	73.65	17.55	<0.001
	Muslim	68.16	23.02		52.42	13.4		65.87	18.8		60.62	22.25		64.16	20.63
Residential status	Urban	73.35	20.17	0.153	58.17	12.53	<0.001	71.99	16.26	0.101	71.44	18.99	<0.001	73.63	17.49	0.03
	Rural	71.6	19.73		54.88	12.56		69.67	17.38		64.36	21.6		70.26	19.34
Education Level	<10 years of education	77.1	20.44	0.001	60.01	15.7	0.004	74.23	16.5	0.003	70.28	20.92	0.142	73.9	17.87	0.124
	>=10 years of education	71.53	19.75		56.04	11.63		70.25	16.74		68.11	20.24		71.84	18.44
Occupation	Gainfully Employed	72.54	19.75	0.57	57.09	12.69	0.215	70.83	16.53	0.259	68.84	20.17	0.293	72.11	17.82	0.249
	Unemployed	73.53	22.39		54.31	11.92		73.04	18.76		65.69	22.26		73.6	22.78
Annual Family Income (INR)	<=5 lakhs (INR)	73.07	20.57	0.283	55.04	12.31	<0.001	70.92	17.66	0.979	65.89	21.36	<0.001	71.6	19.36	0.25
	>5 lakhs (INR)	71.68	18.71		60.72	12.47		71.3	14.62		74.33	16.69		73.67	15.81
Any Living Children	Yes	78.13	16.99	0.209	56.21	9.46	0.974	73.75	17.06	0.497	67.42	20.68	0.639	75.25	16.91	0.61
	No	72.45	20.08		56.85	12.73		70.95	16.75		68.58	20.38		72.15	18.38
Number of Children	None	72.45	20.08	0.209	56.85	12.73	0.974	70.95	16.75	0.497	68.58	20.38	0.639	72.15	18.38	0.61
	One or More	78.13	16.99		56.21	9.46		73.75	17.06		67.42	20.68		75.25	16.91
Type of Family	Nuclear	72.17	20.26	0.686	58.34	12.84	<0.001	71.4	17.14	0.242	69.58	20.56	0.062	72.6	18.59	0.351
	Joint	73.18	19.69		55.04	12.17		70.62	16.3		67.33	20.13		71.84	18.04
Number of Family Members	<=5 members	71.9	20.22	0.143	57.47	13.26	0.037	70.64	16.81	0.543	68.19	20.59	0.701	71.73	18.45	0.369
	>5 members	74.61	19.29		55.1	10.59		72.11	16.6		69.49	19.82		73.66	17.98
Body Mass Index (BMI)	<18.5	68.18	29.72	0.516	56.91	18.6	0.004	65.09	22.35	0.01	62.82	25.45	0.004	63.18	25.7	0.007
	18.5-22.9	70.86	18.89		55.54	12.9		68.2	16.82		64.88	19.63		68.65	18.55
	23-24.9	73.15	19.94		60.22	12.03		74.01	16.35		72.41	18.53		74.09	16.78
	>=25	73.3	20.17		56.08	12.38		71.26	16.54		68.76	20.97		73.29	18.38
Current use of Tobacco	Yes	71.7	21.91	0.526	53.41	12.22	<0.001	69.98	18.94	0.57	62.83	23.17	<0.001	70.2	20.88	0.204
	No	72.99	19.24		58.12	12.56		71.44	15.85		70.7	18.8		73.02	17.23
Current Alcohol Consumption History	Yes	73.55	19.75	0.495	55.99	12.33	0.234	72.29	15.26	0.302	68.06	19.77	0.573	73.2	17.44	0.396
	No	72.34	20.08		57.09	12.73		70.64	17.2		68.7	20.58		71.95	18.61
Suffering From Any Chronic Disease	Yes	69.18	22.63	0.231	56.86	11.7	0.982	70.9	18.45	0.986	69.9	22.01	0.402	72.92	19.02	0.668
	No	73.03	19.66		56.82	12.47		71.05	16.57		68.39	20.2		72.17	18.27
Years of Infertility	<5 years	74.9	18.84	0.034	57.34	11.5	0.131	74.65	16.73	<0.001	72.4	19.93	0.001	76.55	17.74	<0.001
	5-10 years	72.73	19.74		57.21	13.17		70.15	14.96		67.16	19.79		71.39	17.33
	>10 years	68.99	21.75		55.27	13.37		67.3	19.12		65.42	21.43		67.4	19.81
Cause of Infertility	Male factor	72.29	19.62	0.28	57.04	13.36	0.754	70.71	16.35	0.014	68.47	20.36	0.901	71.55	17.93	0.112
	Both	74.12	21.16		56.23	11.03		73.02	18.61		68.32	21.33		74.23	20.27
	Unknown	70.16	19.81		56.55	7.58		65.68	10.41		70.97	15.06		73	12.37
History of treatment for Infertility	Yes	71.78	20.39	0.13	57.35	13.84	0.34	70.79	17.4	0.933	68.1	21.4	0.95	71.91	19.03	0.9
	No	73.94	19.34		56.03	10.5		71.42	15.73		69.22	69.22		72.77	17.23
Number of medical consultations for infertility before coming to this center	<=5 Consultations	72.83	19.65	0.434	56.92	12.52	0.272	71.11	16.39	0.979	68.76	20.29	0.346	72.34	18.16	0.929
	>5 Consultations	69.23	25.3		55.15	14.5		69.77	22.38		64.77	21.85		70.64	21.28
Number of failures to conceive after IVF treatment	None	73.07	19.88	0.294	57.06	12.71	0.157	71.25	16.91	0.22	68.59	20.81	0.257	72.24	18.52	0.488
	<2	71.15	20.83		56.71	12.31		72.09	15.08		70.65	17.76		74.12	17.18
	>=2	68.75	20.26		53.84	12		66.57	16.65		64.8	17.66		69.61	69.61

Table 4: Comparison of WHO domains mean score across demographic characteristics (n=719).

Table 5: Multiple Linear Regression for Total WHOQOL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

FertiQoL score across Socio-demographic

The comparison of FertiQoL domain scores across various demographic characteristics reveals several significant patterns shown in Table 6. History of treatment and the number of failures to conceive after IVF treatment also show significant variations in the emotional and relationship domains. These findings highlight the complex interplay between demographic and clinical factors in influencing the quality of life among infertile azoospermic males.

Table 6: Comparison of FertiQoL domains mean score across demographic characteristics using t-test or ANOVA (n=719).

Table 7 illustrates the multiple linear regression analysis of the total FertiQoL score among infertile males with azoospermia reveals that education level, religion, BMI, and the duration of infertility are significant determinants of fertility-specific quality of life. Specifically, lower education levels and longer infertility durations are associated with a poorer quality of life, while higher BMI is linked to better quality of life. Religion also plays a significant role, with certain religious backgrounds correlating with lower quality of life scores. In contrast, factors such as age, residential status, occupation, number of children, alcohol consumption, cause of infertility, and the number of IVF failures do not significantly impact fertility-specific quality of life. These findings underscore the importance of considering educational background, religious context, BMI, and the length of infertility when assessing and addressing the quality of life in infertile azoospermic males.

Table 7: Multiple Linear Regression for Total FertiQoL Score to find out Factors influencing the poor quality of life among infertile couples with Azoospermia.

Discussion

Azoospermia, characterized by the absence of sperm in semen, is a significant cause of male infertility. The psychological impact of this condition on patients' Quality of Life (QOL) is well-documented. Li-Yan Luo et al. [12] emphasize that infertility-related psychological stress negatively impacts the QOL of azoospermia patients. Their study reveals a correlation between higher stress levels and poorer QOL outcomes, underscoring the importance of addressing psychological factors in the management of azoospermia [12].

Core FertiQoL Domains

The key findings from our study, based on this tool, are as follows

• Physical Health: Scores in this domain were lower for males with infertility. Factors such as age, body mass index (BMI), and chronic health conditions significantly influenced the scores. Older age and higher BMI were associated with poorer physical health, while the presence of chronic diseases also negatively impacted this domain.
• Psychological: Psychological well-being was significantly affected by age, and duration of infertility. Older individuals and reported lower scores, indicating greater psychological distress. Prolonged infertility duration exacerbated psychological stress.
• Social Relationships: Social well-being was influenced by age, gender, education level, and residential status. Older individuals, and those with higher education levels reported poorer social relationships. Rural residents also experienced lower sco res, likely due to limited access to support and stigma associated with infertility [13].
• Environment: This domain was affected by factors such as income, occupation, and residential status. Lower-income and unemployment were associated with poorer environmental scores, reflecting financial and living conditions' impact on overall well-being [14].

FertiQoL Results

The key findings from our study using the FertiQoL tool are

• Emotional Well-being: Significant factors included age, gender, annual family income, tobacco use, unexplained infertility, and duration of infertility., and those with lower incomes or tobacco use reported greater emotional distress. Unexplained infertility and longer disease duration also negatively impacted emotional well-being [15].
• Mind/Body Health: Influencing factors were age, annual family income, BMI, cause of infertility, years of infertility, and history of infertility treatment. Older age, lower income, and normal BMI were associated with poorer scores. Unexplained infertility and longer infertility duration also resulted in lower scores, highlighting the physical and psychological toll of prolonged infertility [16].
• Relational: This domain was affected by relationship duration and previous treatment history.Males with longer marriages and those with unsuccessful treatment attempts reported poorer relational well-being, indicating the strain infertility places on relationships.
• Social: Social well-being was influenced by age, rural residence, education level, employment status, income, duration of infertility, and number of failed IVF treatments [17]. Older age, rural residence, higher education, unemployment, lower income, longer infertility duration, and failed treatments all contributed to poorer social well-being [18].

Hypothesis 1

• Null Hypothesis (H0): There exists no correlation (there is no linear relation) between Azoospermia and Quality of Life.
• Alternate Hypothesis (H1): There is a significant correlation (there is an inverse linear relation) between Azoospermia and Quality of Life.

Findings

The multiple linear regression analysis showed that several factors related to azoospermia, such as years of infertility and education level, significantly impacted the Quality of Life (QoL). Specifically, longer years of infertility and lower education levels were associated with poorer QoL scores, indicating an inverse relationship. In comparison, the Polish study by Makara SM et al. reported lower social domain scores, whereas the current study showed relatively higher scores in this domain, suggesting better social integration among the study participants. Therefore, we reject the null hypothesis and accept the alternate hypothesis, concluding that there is a significant correlation between azoospermia and quality of life.

Hypothesis 2

• Null Hypothesis (H0): Azoospermic males get adequate societal acceptance and support towards their infertility.
• Alternate Hypothesis (H1): Society plays little to no role in supporting or accepting the Azoospermic male’s battle with infertility.

Findings

Social well-being scores from the FertiQoL indicate that societal support is lacking for azoospermic males. Factors such as rural residence, male gender, and lack of education were associated with lower social well-being, suggesting inadequate societal acceptance and support. Thus, we reject the null hypothesis and accept the alternate hypothesis that society plays little to no role in supporting azoospermic males [16].

Hypothesis 3

• Null Hypothesis (H0): Azoospermic males with higher income will have a better quality of life than Azoospermic males with lower income.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across income groups.

Findings

The multiple regression analysis indicated that lower annual family income significantly impacted Mind/Body Health and Emotional Well-being, suggesting that income level does influence QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across income groups. Further supporting this, Bahadır Topuz et al. [4] report that patients with Non-Obstructive Azoospermia (NOA) experience reduced QOL across physical, psychological, and social domains. The study highlights the necessity for routine assessments of mental health and QOL, advocating for integrated care approaches that include psychological support alongside medical treatments [4].

Hypothesis 4

• Null Hypothesis (H0): Azoospermic males in a higher age bracket will have a poorer quality of life than Azoospermic males in a lower age bracket.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across differing age brackets.

Findings

Age was found to negatively impact the QoL scores, but it was not statistically significant in the regression analysis (β =-2.00, p=0.164). This suggests age might not significantly affect QoL, leading us to accept the alternate hypothesis that there is no significant difference in QoL across different age brackets [19].

Hypothesis 5

• Null Hypothesis (H0): The higher the years of infertility, the poorer quality of life the Azoospermic male will have.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across years of infertility endured.

Findings

Years of infertility was a significant negative predictor of QoL (β=-3.96, p < 0.001), indicating that longer infertility duration is associated with poorer QoL. Thus, we reject the null hypothesis and accept the alternate hypothesis that there is a significant difference in QoL across years of infertility. This aligns with previous findings by Dourou P et al., who reported lower mind/body scores in females and those with higher education. However, these factors did not significantly impact mind/body scores in the present study [20].

Hypothesis 6

• Null Hypothesis (H0): The higher the history of failures using ART, the poorer the quality of life of the Azoospermic male.
• Alternate Hypothesis (H1): There is no significant difference in the quality of life of Azoospermic males across the number of ART failures incurred by the Azoospermic male.

Findings

The number of failed IVF treatments was not a significant predictor of QoL (β=-1.21, p=0.362). This indicates that ART failure history does not significantly affect QoL. Therefore, we accept the alternate hypothesis that there is no significant difference in QoL across the number of ART failures [21].

Limitation

The study population was specific to males with azoospermia, which may not reflect the experiences of the overall infertile population, with other reasons for infertility. The cross-sectional nature of the study limits the ability to infer causality between azoospermia and QoL. Longitudinal studies would be beneficial to understand the temporal relationship and causal pathways.

Given the significant impact of social well-being on QoL, integrating psychosocial support into infertility treatment protocols is crucial. Counseling services and support groups could help address the emotional and social challenges faced by azoospermic males. Increasing awareness and education about azoospermia and its impact on QoL can help reduce stigma and improve societal acceptance. Educational campaigns targeting both urban and rural populations could promote understanding and support for infertile males.

Studies involving larger and more diverse populations, as well as those incorporating qualitative methods, could provide deeper insights into the experiences of azoospermic males. The partners of azoospermic males could be studied separately to understand coping mechanisms employed as a couple to deal with Azoospermia.

Conclusion

Overall, this study reveals that several socio-demographic and medical factors significantly influence the quality of life of azoospermic males. Factors such as education level, years of infertility, and income levels were particularly impactful. The WHOQoL-BREF and FertiQoL tools both provide valuable insights, though they emphasize different aspects of quality of life. Comprehensive support strategies, including psychosocial interventions, are essential to improve the overall well-being of these individuals.

Funding

There is external funding for the study.

Conflict of Interest

There is no conflict of interest among authors.

Declaration

Consent has been taken from each participant. All the data will be shared on request.