Coping strategies and psychological adjustment of couples presenting for IVF

Progression of depression and anxiety symptoms in pregnancies conceived by assisted reproductive technology in the United States

PURPOSE

Women who utilize assisted-reproductive technology (ART) to achieve pregnancy experience unique circumstances before and during their pregnancy. This study aims to examine the progression of mental health in pregnant women who conceived via various methods of ART to understand gestational time periods of emotional stability or risk specific to these populations.

METHODS

Secondary analysis of the Yale Pink and Blue Study - a prospective cohort involving women from 137 obstetrical practices in the northeastern United States between 2005-2009. Depressive and anxiety symptoms among spontaneous, planned pregnancies were compared to ART pregnancies using the Edinburgh Postnatal Depression Scale (EPDS) and its anxiety subscale (EPDS-3A), respectively. Generalized Estimating Equations were used to compare group changes (EPDS and EPDS-3A score threshold ≥10) at timepoints of <17 weeks (T1), 28(±2) weeks (T2), and 8(±4) weeks postpartum (T3).

RESULTS

1,466 spontaneous, planned pregnancies were compared to 191 pregnancies conceived via ART. Prevalence of depressive symptoms were similar between conception groups. Change in prevalence over time differed significantly between those groups (from T1 to T3 (β 0.59), as well as between spontaneous pregnancies compared to autologous gamete ART pregnancies (from T1 to T2 (β 0.48) and T1 to T3 (β 0.65). Course of anxiety did not differ between conception groups.

CONCLUSIONS

Women who conceive via ART have different rates of change in depressive symptoms throughout gestation compared to women with spontaneous pregnancies.

Perinatal Mood and Anxiety Disorders in Women Undergoing Medically Assisted Reproduction

Background: Women taking advantage of medically assisted reproduction (MAR) techniques may differ from spontaneously conceiving women (nonMAR) in risk of depression and/or anxiety. We aimed to investigate possible differences between MAR and nonMAR through the use of the Edinburgh Postnatal Depression Scale in a sample of Italian-speaking women at their third trimester of pregnancy. Methods: We administered the Edinburgh Postnatal Depression Scale (EPDS) to two groups of pregnant women, MAR and nonMAR, at the third trimester of pregnancy (T0), one month after delivery (T1), and three months after delivery (T2) from February 2013 to December 2019. EPDS total scores cutoffs were ≥9 for risk of depression, 9–11 mild depression, ≥12 major depression, and the EPDS-3A cluster ≥4 was a proxy for anxiety. Results: Included were 1303 nonMAR women and 92 MAR, an expected disproportion. NonMAR and MAR women did not differ on depression or anxiety at any assessment timepoint. MAR women were older than nonMAR, consumed more alcohol and medical drugs, and displayed more complications during pregnancy. Scoring over the threshold on depression risk was associated with foreign nationality, unemployment, psychiatric history of the patient, family or partner, psychiatric problems in past pregnancies, hyperemesis, premenstrual syndrome (PMS), and stressful life events in the last year at baseline, and, for some of them, at other timepoints. In contrast, MAR past or current was associated with having suprathreshold depression at the first-month postpartum follow-up. Conclusions: Taken together, our data show that women opting for MAR do not differ from spontaneously conceiving women regarding psychiatric outcomes but do differ on some sociodemographic and clinical variables.

Analyses of medical coping styles and related factors among female patients undergoing in vitro fertilization and embryonic transfer

OBJECTIVE

This study investigated the medical coping styles of female patients treated with in vitro fertilization and embryonic transfer (IVF-ET), and analyzed the effects of alexithymia and social support on their choice of coping style.

METHODS

A survey was conducted with 285 female patients undergoing IVF-ET in a reproductive medical center of a third-grade class-A hospital in China using the Medical Coping Modes Questionnaire, the Social Support Rating Scale, and the Toronto Alexithymia scale.

RESULTS

Patients who underwent IVF-ET treatment had a higher score for avoidance as a coping mode than did normal controls. Utilization of social support predicted the use of confrontation as a coping style. Difficulty identifying feelings, objective support, and utilization of social support were factors in the choice of avoidance as a coping style, and length of infertility treatment, difficulty identifying feelings, and subjective support predicted patients' use of the acceptance-resignation as a coping style.

CONCLUSION

Patients who undergo IVF-ET generally select the coping style of avoidance, which is not conducive to treatment. Targeted intervention strategies should be developed based on the factors influencing patients' choice of coping style(s) to guide them in choosing positive coping methods, improve compliance, and achieve successful pregnancy outcomes.

The perspective of women with an increased risk of OHSS regarding the safety and burden of IVF: a discrete choice experiment

STUDY QUESTION

What are the preferences of women with an increased risk of ovarian hyperstimulation syndrome (OHSS) for characteristics of IVF treatments?

SUMMARY ANSWER

In women with increased risk of OHSS, the chance of OHSS is a strong attribute in determining women's preference for IVF treatment and women are willing to trade off burden (side effects), costs and chance of pregnancy for lower risks of OHSS.

WHAT IS KNOWN ALREADY

OHSS is the most serious iatrogenic complication of ovarian stimulation. Polycystic ovaries, high antral follicle count (AFC) and previous OHSS increase the risk of developing OHSS. IVM of oocytes offers great potential for patients with high AFC, since there is no risk of OHSS. With regard to patients' perspectives on fertility treatments, it has been shown that women undergoing IVF place different values on treatment characteristics, such as effectiveness (pregnancy rate), cancellation risk, safety (OHSS risk) and burden (side effects). To our knowledge, the preferences for different IVF treatments in women with increased risk of OHSS have not been studied yet.

STUDY DESIGN SIZE DURATION

A multicentre discrete choice experiment (DCE) was performed between 2012 and 2016. The selected attributes offered were chance of OHSS, which represents safety; number of injections; chance of cycle cancellation (the latter two represent burden); chance of pregnancy; and out-of-pocket costs/willingness to pay. A target sample size was calculated by including 20 patients for five attributes resulting in the aim to include 100 women.

PARTICIPANTS/MATERIALS SETTING METHODS

We invited subfertile women who were diagnosed with normogonadotrophic ovulation disorder and were undergoing treatment with gonadotrophins and/or had experienced (imminent) OHSS in a previous IVF treatment in the fertility clinic of four hospitals (three teaching and one academic). Women received a printed questionnaire with fictional scenarios and were asked, for each scenario, to choose their preferred treatment. We used a multinominal logit model to determine the preferences of women and investigated heterogeneity in preferences through latent class analysis. The decrease in OHSS risk required for women to accept an increased level of an undesirable attribute, i.e. their willingness to trade off, was calculated.

MAIN RESULTS AND THE ROLE OF CHANCE

We distributed 120 questionnaires with a response rate of 79% (95/120). There were 91 questionnaires included in the analysis. All five attributes influenced women's treatment preference. About half of the women considered chance of pregnancy to be more important, while the other half considered prevention of OHSS and lower costs to be more important. Women were willing to trade off cancellation rate, number of injections, chance of pregnancy and costs for lower OHSS chances. We found that women were willing to accept 5% more chance on cycle cancellation if the OHSS rate dropped with 2%. Women were willing to accept one extra treatment for a reduction of 3.9% in OHSS risk. With respect to costs, women were willing to pay €1000 instead of no costs for a decrease in OHSS rate of 5.4%.

LIMITATIONS REASONS FOR CAUTION

The sample size of our study is relatively small which may limit the generalizability and sensitivity of the study.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this DCE help us to understand the trade-off that women at risk of OHSS make in their preference for characteristics on IVF treatments. This knowledge may be used during the counselling of couples about their treatment options.

STUDY FUNDING/COMPETING INTERESTS

B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. J.P.d.B. reports personal fees from the Ferring Medical Advisory Board and grants from Ferring B. V and Merck Serono B. V outside the submitted work. There are no other conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

None.

Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis

OBJECTIVE

To evaluate the evidence on the efficacy of psychosocial interventions for improving pregnancy rates and reducing distress for couples in treatment with assisted reproductive technology (ART).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PsycINFO, PubMed, EMBASE, CINAHL, Web of Science and The Cochrane Library between 1978 and April 2014.

STUDY SELECTION

Studies were considered eligible if they evaluated the effect of any psychosocial intervention on clinical pregnancy and/or distress in infertile participants, used a quantitative approach and were published in English.

DATA EXTRACTION

Study characteristics and results were extracted and the methodological quality was assessed. Effect sizes (ES; Hedges g) were pooled using a random effects model. Heterogeneity was assessed using the Q statistic and I(2), and publication bias was evaluated using Egger's method. Possible moderators and mediators were explored with meta-analyses of variances (ANOVAs) and meta-regression.

RESULTS

We identified 39 eligible studies (total N=2746 men and women) assessing the effects of psychological treatment on pregnancy rates and/or adverse psychological outcomes, including depressive symptoms, anxiety, infertility stress and marital function. Statistically significant and robust overall effects of psychosocial intervention were found for both clinical pregnancy (risk ratio=2.01; CI 1.48 to 2.73; p<0.001) and combined psychological outcomes (Hedges g=0.59; CI 0.38 to 0.80; p=0.001). The pooled ES for psychological outcomes were generally larger for women (g: 0.51 to 0.73) than men (0.13 to 0.34), but the difference only reached statistical significance for depressive symptoms (p=0.004). Meta-regression indicated that larger reductions in anxiety were associated with greater improvement in pregnancy rates (Slope 0.19; p=0.004). No clear-cut differences were found between effects of cognitive-behavioural therapy (CBT; g=0.84), mind-body interventions (0.61) and other intervention types (0.50).

CONCLUSIONS

The present meta-analysis suggests that psychosocial interventions for couples in treatment for infertility, in particular CBT, could be efficacious, both in reducing psychological distress and in improving clinical pregnancy rates.

Coping with infertility: Comparison of coping mechanisms and psychological immune competence in fertile and infertile couples

This study compared coping strategies and psychological immunity of parents with a child conceived with assisted reproductive technology (n = 84) and parents with a naturally conceived child (n = 84) in a Hungarian fertility-age population. Results showed that in vitro fertilization parents are able to control their emotions in a better way than comparison couples. They interpret trials as challenges and consider themselves more worthy than the members of the control group. Our research confirms that consideration and management of psychological factors in treating infertility have an important preventive role to play.

A systematic review of psychosocial factors associated with emotional adjustment in in vitro fertilization patients

BACKGROUND

IVF treatment is usually stressful for patients, but individual differences in emotional response do exist. Differences in the stress response may be related to reproductive outcomes as well as to the development of psychiatric problems. This review collates research exploring which psychosocial factors (e.g. personality traits and coping strategies) are associated with the emotional adjustment of IVF patients. The aim is to reveal what is currently known about risk and protective factors for coping with the stress of IVF treatment and where further enquiry would be most beneficial.

METHODS

The databases, MEDLINE/PUBMED (US National Library of Medicine), PsycINFO (American Psychological Association), Web of Science (Social Sciences Citation Index) and EMbase, were searched from 1978 to September 2012 using relevant key words. All published peer-reviewed studies exploring associations between psychosocial factors and emotional adjustment outcomes were considered for inclusion.

RESULTS

There were 23 studies identified for review. One-third of the psychosocial factors explored were found to be significantly related to emotional adjustment outcome measures. Neuroticism and the use of escapist coping strategies were positively associated with distress by multiple studies. Social support was negatively associated with distress by several studies. A number of other psychosocial variables appear to be associated with distress, including self-criticism, dependency, situation appraisals and attachment style, but these have only been explored by one or two studies at most. There is a paucity of research using positive emotional outcome measures (e.g. well-being, positive affect, happiness or life satisfaction) to quantify emotional adjustment.

CONCLUSIONS

Whilst some psychosocial variables appear to be consistently associated with distress for IVF patients, two-thirds of the variables tested to date do not appear to be associated with emotional adjustment. This review highlights key psychosocial factors to assist the identification of patients at high risk of psychological distress. These findings highlight at least two psychological factors that may be amenable to alteration with psychological or educational interventions. Future work should explore whether experimental manipulation of such psychosocial factors can provide effective stress reduction in this clinical context.

Recovery after unsuccessful in vitro fertilization: the complex role of resilience and marital relationships

The failure rate of in vitro fertilization (IVF) is around 75% per cycle. These unsuccessful attempts can provoke acute clinical depression and other problems. Although practitioners often recommend cognitive reappraisal, rather than avoidance, to cope with these difficulties, previous research has not established the psychosocial determinants of adaptive coping strategies. Arguably, resilience could encourage cognitive reappraisal, because resilient individuals feel confident they can overcome their emotions, whereas marital quality could prevent avoidance, because individuals feel secure enough to reflect upon their distress. Consequently, resilience and marital quality could facilitate recovery over time. To explore these possibilities, 184 women, all of whom had unsuccessfully completed IVF treatment, completed a questionnaire that gauged their levels of self-reported depression since their last IVF attempt as well as resilience and marital quality. Immediately after the unsuccessful attempt, resilience was inversely, whereas marital quality was positively, related to depression. However, within this cross-sectional sample after greater time had elapsed, marital quality became increasingly beneficial and was negatively associated with depression. These findings imply that resilience can curb the initial distress; in contrast, marital quality may enable individuals to reflect upon their trauma, initially amplifying distress but eventually facilitating recovery. Future research would benefit from longitudinal studies, illustrating whether resilience and marital quality at one time predict changes in distress at subsequent times.

Psychological impact of single and multiple courses of assisted reproductive treatments in couples: a comparative study

OBJECTIVE

To analyze the psychological impact on levels of anxiety and depression in couples who, confronted with the diagnosis of infertility, propose to carry out ART; to evaluate and compare state-trait anxiety and depression levels in couples undergoing ART treatments for the first time and repeatedly, and to verify gender differences.

STUDY DESIGN

In this prospective study in the Medically Assisted Reproduction Unit of the Centro Hospitalar de São João, Porto, Portugal, 89 couples diagnosed with infertility were divided into two groups: (1) couples starting ART for the first time (43), and (2) couples pursuing ART repeatedly (46). Participants completed the Beck Depression Inventory-II (BDI-II) and the State-Trait Anxiety Inventory-Form Y (STAI-Y), prior to their first or subsequent treatment cycle.

RESULTS

Couples pursuing ART for the first time show higher levels of state-anxiety compared to couples who repeatedly carry out ART (p < 0.05). Levels of depression are higher in couples who repeatedly carry out ART (p < 0.05). In both study groups, women and men have higher levels of state-anxiety compared to trait-anxiety (p < 0.05). With respect to depression, there are significant differences between genders in both groups, showing higher values in women compared to men (p < 0.01).

CONCLUSIONS

The results show that there is room to tailor psychological interventions for the specific story of each couple, but we emphasize the importance and need for more studies to support these findings.

Less depressed or less forthcoming? Self-report of depression symptoms in women preparing for in vitro fertilization

While depression has been associated with infertility treatments, it is not routinely assessed in women prior to undergoing in vitro fertilization (IVF) treatment. Findings are mixed regarding the degree to which women report depression prior to IVF. The purpose of this study was to (1) examine response profiles in women preparing for IVF and (2) compare responses to those of postpartum, primary care, and general population groups. Female IVF patients (n = 321; 19-45 years) completed the Patient Health Questionnaire-9 (PHQ-9) at their first visit. Clinical and demographic characteristics and incidence of major depressive disorder (MDD) and other depressive disorders (ODD) were examined. Overall score distributions of the IVF group were compared to those of local postpartum patients and published primary care and general populations. Demographic or clinical characteristics did not account for response differences within the IVF group. The IVF group had lower incidences of MDD and ODD than a PHQ-9 normative group. Women in the IVF group reported no depressive symptoms significantly more than postpartum, primary care, and general population groups. Women preparing to undergo IVF report fewer symptoms of depression than multiple comparison groups. Specific quality of life measures may be needed to assess distress in this population.

Incidence of depression and influence of depression on the number of treatment cycles and births in a national cohort of 42,880 women treated with ART

STUDY QUESTION

Does prior depression in women treated with assisted reproduction technology (ART) influence the number of treatment cycles and ART live births?

SUMMARY ANSWER

Women with a depression diagnosis prior to ART treatment initiated statistically significantly fewer ART treatment cycles and had a lower mean number of ART live births compared with women with no history of depression.

WHAT IS KNOWN ALREADY

Previous studies have shown an increased prevalence of depressive symptoms in fertility patients than in the comparison groups.

STUDY DESIGN, SIZE, DURATION

A register-based national cohort study, including all women (n = 42,915) treated with IVF, ICSI, frozen embryo transfer and oocyte recipient cycle in Denmark from 1 January 1994 to 30 September 2009 extracted from the IVF register (ART cohort). Data on births and depression diagnoses were obtained by linking to the Danish Medical Birth Register (1994-2010) and the Danish Psychiatric Central Research Register (1969-2010).

PARTICIPANTS/MATERIALS, SETTING, METHODS

For each woman in the ART cohort, we included five age-matched women from the female background population not having received ART treatment. This comparison group was cross-linked with identical register data as the ART cohort. Women with incomplete ART information or a depression diagnosis before 18 years of age were excluded; remaining n = 42,880. The ART cohort was grouped into (i) women with a depression diagnosis and (ii) women never diagnosed with depression. In the ART group with depression, analyses were specified on women with their first depression prior to ART treatment. In total, 2.6% of the women in the ART cohort had a depression diagnosis. For the incidence rate ratio (IRR) 39,194 women from the ART cohort (3686 women were excluded due to migration) were compared with 206,005 women from the age-matched comparison group who did not receive ART treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the women in the ART cohort with a depression diagnosis, 34.7% had their first depression diagnosis prior to ART treatment, 4.7% during ART treatment and 60.7% after ART treatment. The mean number of initiated ART cycles was significantly lower in the ART group of women having a depression diagnosis prior to ART treatment [2.55 (±1.78)] compared with the ART group of women without a depression diagnosis [3.22 (±2.31); P < 0.001; P < 0.001]. Women having a depression diagnosis prior to ART treatment had a lower mean number of ART live births [0.82 (±0.73)] compared with women without a depression diagnosis [1.03 (±0.81); P < 0.001]. The incidence rate of first and recurrent depression diagnoses in the ART cohort was significantly lower compared with the age-matched background population group; IRR = 0.80 (P < 0.001) and IRR = 0.77 (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Only clinical depression diagnoses treated in a psychiatric hospital setting are included. The age-matched comparison group from the background population is heterogeneous as it consists of women differing in fertility status (both mothers and childless women).

WIDER IMPLICATIONS OF THE FINDINGS

Fewer women in the ART cohort developed depression over time compared with the age-matched background population, which might reflect a healthy patient effect of the women seeking ART treatment. Women with a depression diagnosis before ART treatment receive fewer ART treatments and are less likely to achieve an ART live birth. These women might be more vulnerable and we recommend that they be offered more psychiatric attention before starting, as well as during and after ART treatment.

STUDY FUNDING/COMPETING INTEREST(S)

Research grants are funded by the Danish Health Insurance Foundation and Merck Sharp & Dohme. The funders had no influence on the data collection, analyses or conclusions of the study. No conflict of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Patients' and professionals' barriers and facilitators of tailored expectant management in subfertile couples with a good prognosis of a natural conception

BACKGROUND

European guidelines on fertility care emphasize that subfertile couples should receive information about their chances of a natural conception and should not be exposed to unnecessary treatments and risks. Prognostic models can help to estimate their chances and select couples with a good prognosis for tailored expectant management (TEM). Nevertheless, TEM is not always practiced. The aim of this study was to identify any barriers or facilitators for TEM among professionals and subfertile couples.

METHODS

A qualitative study was performed with semi-structured in-depth interviews of 21 subfertile patients who were counselled for TEM and three focus-group interviews of 21 professionals in the field of reproductive medicine. Two theoretical models were used to guide the interviews and the analyses. The primary outcome was the set of identified barriers and facilitators which influence implementation of TEM.

RESULTS

Among the subfertile couples, main barriers were a lack of confidence in natural conception, a perception that expectant management is a waste of time, inappropriate expectations prior to the first consultation, misunderstanding the reason for expectant management and overestimation of the success rates of treatment. Both couples and professionals saw the lack of patient information materials as a barrier. Among professionals, limited knowledge about prognostic models leading to a decision in favour of treatment was recognized as a main barrier. A main facilitator mentioned by the professionals was better management of patients' expectations.

CONCLUSIONS

We identified several barriers and facilitators which can be addressed to improve the implementation of TEM. These should be taken into account when designing future implementation strategies.

Variation in distress among women with infertility: evidence from a population-based sample

BACKGROUND

We examine variation in fertility-specific distress (FSD) and general distress according to different experiences of infertility among 1027 US women who have experienced infertility within the previous 10 years.

METHODS

General distress was measured by a short form of the Center for Epidemiological Studies-Depression. Multiple regression analysis was conducted on self-report data (based on a telephone interview) from a probability-based sample of US women aged 25-45 years. We compare women with infertility who have had a prior pregnancy (secondary infertility, n = 628) to women with infertility with no prior pregnancies (primary infertility, n = 399). We further distinguish between women with infertility who were actually 'trying' to become pregnant (the infertile with intent) with those who met the medical definition of infertile but did not describe themselves as trying to become pregnant (infertile without intent).

RESULTS

Both types of infertility (primary versus secondary) (β = 0.31*) and intentionality (infertile with and without intent) (β = 0.08*) are associated with FSD. These associations persist when we control for resource and demographic variables, life course variables, social support and social pressure variables. General distress does not vary by infertility type or intentionality.

CONCLUSIONS

Results reveal variation in women's recalled experiences of infertility and that FSD is more sensitive to effects of different experiences than general distress. Women with primary infertility who were explicitly trying to become pregnant at the time of the infertility episode stand out as a particularly distressed group. Caregivers should be aware that the emotional needs of women with primary infertility may differ from those with secondary infertility.

The relationship between autobiographical memory specificity and depressed mood following a stressful life event: A prospective study

OBJECTIVES

In the present prospective study, the relationship between autobiographical memory specificity and the emotional reactions to a stressful event was investigated.

DESIGN AND METHODS

The Autobiographical Memory Test (AMT) was administered to 74 women before they underwent an in vitro fertilization (IVF) treatment, which subsequently failed. Symptoms of emotional reactions - depression and anxiety - were measured both before and after the (failed) IVF treatment.

RESULTS

It was found that the number of reported specific memories at baseline was negatively related to depressive and anxiety symptoms after the treatment, even when initial depressive and anxiety symptoms and verbal fluency were controlled for.

CONCLUSIONS

Taken together, the findings indicate that a lack of autobiographical memory specificity predicts changes in depressive mood after a stressful event.

Comparison of multiple psychological distress measures between men and women preparing for in vitro fertilization

OBJECTIVE

To compare multiple measures of psychological distress between men and women preparing for IVF.

DESIGN

Retrospective cohort study.

SETTING

Outpatient, academic infertility clinic.

PATIENT(S)

One hundred sixty-two consecutive couples presenting for infertility treatment with IVF.

INTERVENTION(S)

Measures were completed as part of a routine, infertility-focused psychological evaluation, including the Beck Depression Inventory, State-Trait Anxiety Inventory, State-Trait Anger Inventory, and Impact of Events Scale.

MAIN OUTCOME MEASURE(S)

Scores of above psychological questionnaires.

RESULT(S)

Psychological distress scores were statistically significantly higher among women than men for symptoms of depression, state anxiety, infertility specific distress, and general perceived stress. However, aside from infertility-specific distress (d = .43), effect sizes for the paired differences between females and males ranged from d = .18 to .23.

CONCLUSION(S)

Women consistently scored higher on multiple measures of psychological distress than their male partners in the context of preparing for IVF. Comparison of infertility-specific distress scores yielded the largest statistically and clinically significant difference compared with traditional measures of general depression and anxiety symptoms.

Estados emocionais de casais submetidos à fertilização in vitro

A infertilidade interrompe um projeto de vida pessoal e do casal, produzindo sofrimento psíquico. O desenvolvimento das técnicas de reprodução assistida possibilitou a solução para casais que anteriormente não teriam alternativas de tratamento. Assim, a fertilização in vitro constitui uma nova fonte de esperança para ter um filho, mas, ao mesmo tempo, pode ser acompanhada de muitas dificuldades. O objetivo deste estudo foi comparar os estados emocionais de homens e mulheres submetidos à fertilização in vitro e verificar a relação entre estado emocional das mulheres e ocorrência de gravidez. Foram avaliados vinte casais submetidos ao primeiro ciclo de fertilização in vitro, entre o 5º e o 10º dia após a transferência dos pré-embriões. A avaliação foi realizada por meio de testes psicológicos e entrevistas. As mulheres apresentaram níveis mais altos de ansiedade e depressão que os homens. A autoestima delas mostrou-se mais baixa. Um quarto das mulheres que apresentaram sintomas psicoemocionais não engravidou, porém esta relação não foi significativa. Concluiu-se que as mulheres apresentaram mais ansiedade e sintomas depressivos que os homens e autoestima mais baixa. O grupo de mulheres com sintomas psicoemocionais apresentou tendência a não engravidar.

The dilemma faced by patients who undergo single embryo transfer

Purpose

The aim of this study was to identify the factors that contribute to the decision to choose single embryo transfer (SET).

Methods

Two hundred and nine patients who underwent ART treatment in our clinics between April 2006 and May 2007 were enrolled in this study. All patients had elected to undergo SET before the start of each treatment cycle; a questionnaire was administered to all patients prior to the SET procedure.

Results

The mean age of the patients was 34.6 years old (range: 24-45 years). The mean number of redundant embryos was 3.7 (range: 1-17), and the pregnancy rate per embryo transfer was 25.7%. A total of 121 patients (57.9%) who underwent SET returned their questionnaires. Based on the results of questionnaire, 56.2% of patients who received SET waived their right to choose between single and double embryo transfer. Among patients who selected SET, 67.6% believed that the pregnancy rate resulting from double embryo transfer (DET) is significantly greater than that associated with SET, and 25% of patients wanted to have twins. The majority of patients (80.9%) who underwent SET understood that multi-fetal pregnancy increases the risk of complications during gestation and delivery. Among all patients who completed the questionnaire, 72.8% believed that the number of transferred embryos should not be controlled by law.

Conclusions

The results of the present study show that greater than one-half of patients who underwent SET were faced with a dilemma--the difficult choice between their own desires and their clinician's recommendation.

Differences in female and male perception of information and decision-making in single-embryo transfer in in vitro fertilization in Sweden

PURPOSE

The aim of this study was to evaluate the information and the factors that contribute to the decision to accept and choose single embryo transfer (SET) in females and males.

MATERIALS AND METHODS

Fifty-four females and males undergoing SET were interviewed separately using a structured questionnaire.

RESULTS

The women were significantly more satisfied with the information than the men (odds ratio 3.3), but the decision to accept SET was nevertheless more difficult for women (OR 3.1). Only one-third of both female and males were aware of the increased maternal risks with twin pregnancies. There was a tendency that the women who accepted SET had previous children, shorter duration of infertility, and were younger. Cryopreservation of embryos and a good pregnancy chance were important irrespective of gender.

CONCLUSION

The female needs more support to choose SET. The male needs better information and further involvement in decision-making. The females were more aware of the fetal risks, but the awareness of the increased maternal risks with twin pregnancies was low.

Extended encounters with midwives at the first IVF cycle: a controlled trial

The aim of this prospective, controlled study was to investigate the impact of participation in extended encounters with midwives on the psychological well-being of women undergoing IVF treatment and on their experience of treatment procedures. A total of 166 couples were studied during their first IVF treatment at the authors' IVF unit, of which 49 underwent intervention via extended midwife encounters. Participants answered questionnaires on three occasions. Psychological effects of infertility and questions regarding the relationship with the partner were considered. On the third occasion, two open-ended questions regarding perception of the treatment and the support by the staff were assessed. Regarding the psychological effects of infertility and the relationship with the partner, no significant differences were found between the intervention group versus the control group. Analysis of the open-ended questions resulted in the finding that significantly (P = 0.01) more women in the intervention group expressed satisfaction with the care. No impact of the intervention on psychological well-being was noted. However, the intervention seemed to be an effective method to give couples a feeling of security, continuity and an opportunity to be seen as individuals and as couples, for which the women expressed their appreciation.

Women's emotional adjustment to IVF: a systematic review of 25 years of research

This review provides an overview of how women adjust emotionally to the various phases of IVF treatment in terms of anxiety, depression or general distress before, during and after different treatment cycles. A systematic scrutiny of the literature yielded 706 articles that paid attention to emotional aspects of IVF treatment of which 27 investigated the women's emotional adjustment with standardized measures in relation to norm or control groups. Most studies involved concurrent comparisons between women in different treatment phases and different types of control groups. The findings indicated that women starting IVF were only slightly different emotionally from the norm groups. Unsuccessful treatment raised the women's levels of negative emotions, which continued after consecutive unsuccessful cycles. In general, most women proved to adjust well to unsuccessful IVF, although a considerable group showed subclinical emotional problems. When IVF resulted in pregnancy, the negative emotions disappeared, indicating that treatment-induced stress is considerably related to threats of failure. The concurrent research reviewed, should now be underpinned by longitudinal studies to provide more information about women's long-term emotional adjustment to unsuccessful IVF and about indicators of risk factors for problematic emotional adjustment after unsuccessful treatment, to foster focused psychological support for women at risk.

First IVF treatment--short-term impact on psychological well-being and the marital relationship

BACKGROUND

The aim of this study was to assess infertile couples' short-term emotional responses to their first IVF treatment (the women's and men's emotional reactions and their experiences of the marital relationship at different stages of the first treatment) and to relate these responses to the outcome of the IVF treatment.

METHODS

The study was part of a prospective, longitudinal study where 117 couples participated. The women and men answered questionnaires separately concerning psychological and social factors at three occasions: before, during and 1 month after treatment.

RESULTS

Women's and men's emotional reactions related to first IVF treatment were dependent on whether they achieved a pregnancy or not. Those who failed to become pregnant rated their emotional well-being worse, whereas those who became pregnant rated their emotional well-being better than before treatment started. The women reported stronger emotional reactions about their infertility than their husbands. However, the men reacted in the same emotional pattern as their wives when pregnancy was not achieved. A majority reported that the marital relationship improved during treatment.

CONCLUSION

Couples undergoing their first IVF treatment are as a group well adjusted and manage to handle the short-term emotional strain under treatment. The determining factor for short-term emotional response of treatment was whether pregnancy was achieved.

Coping, quality of life and psychological symptoms in three groups of sub-fertile women

The process of assisted reproductive technology (ART), surrogacy and adoption pose different physical and psychological burdens on sub-fertile populations. Sub-fertile women (n = 176) were assessed retrospectively by questionnaire to determine if process (undergoing ART, surrogacy or adoption) or outcome (having a successful versus unsuccessful outcome) affected quality of life, coping style and psychological symptoms. The ART group was significantly younger, had a shorter period of sub-fertility, and was least likely to have a child than the adoptive and surrogate groups. Quality of life and psychological symptoms were not significantly different between groups, although significantly higher Mental Disengagement and Denial coping strategy scores were obtained for the ART group. Social, psychological, health and functioning quality of life, and Denial coping strategies were good predictors of outcome group. Treatment specific counselling of individuals use of coping strategies early on in their in/subfertility career to cope with the reality of prolonged childlessness is indicated.

The embryologist as counsellor during assisted reproduction procedures

This study aimed to establish whether patients who receive support counselling by the embryologist as counsellor during assisted reproduction procedures would be better equipped with efficient coping mechanisms than patients who were not counselled. Sixty patients were randomly assigned to either the support counselling or the control groups. Questionnaires, measuring pre- and post-treatment levels of anxiety, depression and ways of coping, were presented to both groups. The support counselling group received emotional support and counselling from the embryologist. The control group were treated routinely, received no counselling or emotional support and were asked to phone the gynaecologist daily concerning embryo development. Despite reliable internal consistency, the hypothesis was not accepted due to non-significant differences between the groups. However, t-tests indicated a changed pattern of behaviour within the support counselling group, who experienced a statistically significant (P < 0.017) reduction in anxiety levels after the counselling intervention, as well as increased use of problem-focused coping strategies, such as instrumental action, in dealing with the demands of the treatment programme.

L'impact de l'infertilité et de ses traitements sur la vie sexuelle et la relation de couple : revue de la littérature

This paper reviews the literature on the psychosocial impact of infertility and its treatments by the ART on the marital sexuality, by paying special attention to the relationship between gender and the infertility experience. It is convenient to divide this literature into articles that explore the sexual life of the infertile couples on the one hand, and those focusing on the couple relationship - marital satisfaction and marital adjustment-, on the other hand. The literature on the infertile couples' sexuality and sexual satisfaction, mostly descriptive, presents infertility as a deleterious experience for both women and men even if the repercussion differ according to gender, with correlative dynamic effects within the couple. The contributions to the investigation of the couple relationship, mostly quantitative Anglo-Saxon studies, have produced equivocal or contradictory results concerning the satisfaction with the relationship, the closeness between the two partners so that it is difficult to assume a trend in this field. This situation is largely due to the problems of sampling. In this view, future research should perform its methodological apparatus to take into account the processual nature of the infertility experience, at both levels of couple history and its involvement in the ART process.

The effect of episodic anxiety on an in vitro fertilization and intracytoplasmic sperm injection treatment outcome: a pilot study

This study examines whether the inconsistent and contradictory findings from prospective studies on the effect of psychosocial factors on treatment outcome of in vitro fertilization (IVF) can be explained by the fact that no clear distinction has been made between acute and chronic emotional stress responses. Because chronicity is difficult to measure within the context of an IVF-procedure, the focus of the present study was on episodic anxiety. We compared its predictive value on treatment outcome after the second IVF and intracytoplasmic sperm injection (ICSI) with the predictive value of trait anxiety and acute anxiety. In a prospective study with 47 women who failed to conceive after the first IVF, state anxiety was measured both before and after the first IVF treatment. Episodic anxiety was operationalized as high state anxiety both before and after the first IVF treatment Student's t-test and logistic regression analysis were used to determine the predictive value of episodic anxiety compared with acute or trait anxiety. Women with episodic anxiety, but not those with high levels of trait or acute anxiety, were less likely to become pregnant after the second IVF/ICSI. The results suggest that future studies should differentiate between acute and chronic stress, when examining the effects of psychosocial factors on treatment outcome after a fertility treatment

Counselling--its role in the infertility team

Counselling was made a statutory requirement for clinics providing assisted reproduction services as a result of the concern raised that these treatments would raise uniquely challenging emotional and ethical problems for patients. Before the Human Fertilisation and Embryology Act 1990, few counsellors specialized in this field and there were no standards for their training or experience. In the intervening years considerable progress has been made in these areas. The research evidence, which informs their practice concerning the impact of infertility and its treatment, has also grown very substantially. There is now a reasonable consensus about the broad nature of the emotional and psychological sequelae, although many unexplored questions remain. In addition, the literature providing evidence for the efficacy and effectiveness of counselling in other areas has developed in both quantity and sophistication. Counsellors are often well-placed to work with patient groups and also with the multidisciplinary assisted conception team itself on the very difficult psychosocial and ethical issues faced in practice. The sophisticated research in these fields has not yet been done in the context of infertility; it is therefore necessary to extrapolate from other fields, especially in mental health practice. This article will argue that there is now ample evidence to support the decisions made by legislators in requiring counselling to be available to patients in assisted conception units. The infertility counselling profession is in a position to begin contributing to the generation of research relevant to this field.

Subfecundity and anxiety in a nationally representative sample

Research thus far on the psychological consequences of impaired fecundity in developed countries has relied heavily on clinic-based samples. This study uses a nationally representative sample of American women regardless of fecundity status or treatment status. I analyze reports of fecundity status and anxiety from a 1995 sample of almost 11,000 respondents. The results show consistent positive effects of subfecundity on the odds of fulfilling the diagnostic criteria for Generalized Anxiety Disorder and the incidence rate of symptoms among those who would be so diagnosed, even when controlling for potential confounding factors. Whether a subfecund respondent currently desires to have a child does not moderate the likelihood of being anxious, but does moderate the number of symptoms reported. The lack of a moderating effect of seeking treatment suggests that past research on clinic-based samples is generalizable to all subfecund women.

In vitro fertilization: a long-term follow-up after treatment failure

There is a considerable body of psychological research on women presenting for in vitro fertilization (IVF), but relatively little on the long-term adjustment of such women after unsuccessful treatment. This study examined the adjustment (4--9 years after treatment) of a sample (n = 76) of women whose treatment had failed. At follow-up, it was found that eight (10.53%) of the women had conceived naturally and 16 (21.05%) had become adoptive parents. In comparison with population norms, the women who had not subsequently conceived or adopted (n = 52) were found to rate themselves as more highly stressed (P < 0.001), but rated themselves as higher in self-esteem (P < 0.001). However, when women who remained childless after unsuccessful IVF were compared with those who subsequently conceived or adopted, the former group rated themselves as more stressed (P < 0.05), more depressed (P < 0.001) and with a lower satisfaction with life (P < 0.005) and lower self-esteem (P < 0.05). Women who wished to adopt but were unable to do so made a major contribution to this negative pattern. The study indicates that infertility long after failed IVF treatment contributes to psychological dysfunction. It highlights the need to prepare women better for treatment failure and to ensure appropriate counselling is available when further IVF treatment is no longer appropriate.

The impact of frozen embryos on emotional reactions during in vitro fertilization

BACKGROUND

Emotional reactions of couples were investigated during in vitro fertilization (IVF) at a private clinic in Sweden. The purpose was to compare such reactions between couples who obtained supernumerary embryos that could be cryopreserved and couples without such embryos.

METHODS

Forty women and men undergoing IVF treatment monitored individually their emotional reactions daily for one complete treatment cycle from the first day of down-regulation until the outcome of treatment was known. Ratings were extracted and analyzed from two separate days; the very first day of treatment and the day of embryo transfer.

RESULTS

The group of women (n=16; 40%) with supernumerary embryos suitable for cryopreservation reported a greater increase in optimism than the group (n=24; 60%) without such embryos (p=0.024). Correspondingly, women with supernumerary embryos reported less pessimism than women without such embryos (p=0.014). Among men there was no difference in optimism or pessimism between the groups. The women and men with supernumerary embryos did not differ in distress reactions compared to those women and men without such embryos. There was no correlation between optimism and distress on the day of embryo transfer in women; r=-0.167 and men; r=-0.135 respectively.

CONCLUSION

The presence of frozen embryos increased optimistic and reduced pessimistic feelings about pregnancy among women undergoing IVF treatment. However, the couples' increased optimism on the day of embryo transfer did not seem to reduce their experience of distress.

The interrelationship between coping strategies and sexual functioning in in vitro fertilization patients

This study examined the correlation between various coping strategies and sexual functioning and the likelihood of conception from in vitro fertilization (IVF). Self-reported questionnaires were distributed randomly among the 102 women enrolled in an IVF program, 96 of whom were recruited. Of the studied parameters, positive reinterpretation, and growth, and active coping strategies were found to be positively associated with sexual functioning, while there was a significantly (p < .05) adverse influence of planning and self-restraint. Being sexually active during the IVF-treatment period was found to be positively associated (p < .05) with the likelihood of conception and with adaptive coping strategies.