Antenatal mood and fetal attachment after assisted conception

Assisted reproductive technologies and postpartum depressive symptoms: A meta-analysis

BACKGROUND

Assisted reproductive technologies (ARTs) have become the main treatment for infertility. ART treatment can be a stressful life event for infertile females. Whether there is an association between ARTs and postpartum depressive symptoms (PDS) has not been established.

METHODS

PubMed, MEDLINE, EMBASE, PsycINFO, and CNKI were searched. The pooled outcome was the difference in incidence of PDS within 1 year postpartum between ARTs and the spontaneous pregnancy group.

RESULTS

A total of 12 cohort studies, which were conducted in eight developed countries and two developing countries, were involved. In total, 106,338 pregnant women, including 4990 infertile females with ARTs treatment and 101,348 women with spontaneous pregnancy, were enrolled in our final analysis. ARTs women had a lower incidence of PDS compared to the spontaneous pregnancy group according to a random effect model (OR = 0.83, 95 % CI: 0.71-0.97, p = 0.022, I2 = 62.0 %). Subgroup analyses indicated that studies on late PDS (follow-up: 3-12 months postpartum) were more heterogeneous than those on early PDS (follow-up: <3 months postpartum) (I2 = 24.3 % vs. I2 = 0 %, interaction p-value < 0.001). There was a strong relationship between ARTs and late PDS (OR = 0.65, 95 % CI: 0.55-0.77, p < 0.001). Therefore, the possible source of heterogeneity was the postpartum evaluation time, which was confirmed by post-hoc meta-regression.

LIMITATIONS

Some underlying confounders, such as previous psychiatric illness, the limited availability of ARTs, and ethnic disparities, cannot be ignored and may have biased interpretation of the results.

CONCLUSION

The available data suggested that ARTs were associated with lower incidence of PDS, especially when follow-up lasted over 3 months. However, these findings should be interpreted with caution. Better-designed trials are needed to confirm this association.

Impact of a private sector residential early parenting program on clinically significant postnatal depressive symptoms experienced by women: Audit of routinely collected data

INTRODUCTION

Early parenting services in Australia offer brief structured residential programs to address moderate to severe non-psychotic mental health problems among women and unsettled infant/toddler behaviours. The aims were to (1) estimate the immediate and medium-term impact of a five-night psychoeducational residential early parenting program on postpartum depressive symptoms and (2) identify the factors associated with improvement or worsening of postpartum depressive symptoms after completing the program and six weeks post-discharge.

METHODS

Audit of routinely collected medical record data from pre-admission, pre-discharge and post-discharge assessments of a consecutive cohort of women admitted, with their infants/toddlers in a 15-month period to Masada Private Hospital Early Parenting Centre. Data included structured questions assessing: demographic characteristics, access to family and social support, past and current mental health problems, reproductive and obstetric health, chronic health conditions, breastfeeding problems, coincidental major life events, health risk behaviours and infant/toddler feeding, sleeping and crying behaviours. Standardised instruments included the Partner Interaction after Birth Scale (PIBS), the MacLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Modified Fatigue Assessment Scale (FAS) and selected items from the Karitane Parenting Confidence Scale. The primary outcomes were Edinburgh Postnatal Depression Scale scores at pre-discharge and follow up assessments. Data were analysed using multinomial logistic regression models in which individual and psychosocial characteristics at pre-admission were included as predictors of the likelihood of the changes of the outcomes from pre-admission to pre-discharge and follow up.

RESULTS

Complete data from 1220 of 1290 (95%) eligible women were available to assess pre-admission to pre-discharge and from 559 (45.8%) to assess pre-discharge to six-week follow-up changes. The mean pre-admission EPDS score was 11.7 (95% CI: 11.5; 12.0), pre-discharge it was 7.1 (95% CI: 6.9; 7.4) and at six-week follow up it was 5.7 (95% CI: 5.3; 6.1). We found that almost all women experienced a clinically meaningful and rapid improvement in depressive symptoms of at least this magnitude (reduction in mean EPDS scores of 4.6 points from pre-admission to pre-discharge (five nights) and a further reduction of 1.2 points pre-discharge to follow up) (six weeks) and we identified an interpretable set of risk factors for symptoms that did not improve or worsened. The adverse outcomes were associated with having symptoms of borderline personality disorder, a partner experienced as lacking kindness and care, coincidental adverse events and having a child younger than six months.

CONCLUSION

Residential early parenting programs, which take a psycho-educational approach to strengthening caregiving skills, maximising agency, and reducing helplessness, have a rapid beneficial effect on women's postpartum depressive symptoms. These programs provide a valuable and effective component of comprehensive mental health services. Long-term dialectical behaviour therapy is indicated for women with borderline personality disorder traits for whom early parenting programs alone are insufficient to improve depressive symptoms.

Antenatal predictors of postnatal maternal attachment and competence after assisted conception-a prospective cohort study in South India

The aim of this study is to examine the influence of antenatal factors such as anxiety, depression, perceived stress, marital satisfaction, maternal antenatal attachment, and social support on postnatal maternal attachment and competence in women who received assisted reproductive treatment. A prospective longitudinal cohort design was adopted with two groups-50 women who received assisted reproductive treatment and 50 women who had natural conception. Both the groups were assessed using self-report measures over three time points: T1, 7th month of pregnancy; T2, 2 weeks postpartum; and T3, 3 months postpartum. A final sample of 44 women who had assisted conception and 47 women who had natural conception completed assessments across all three time points. Descriptive, bivariate analyses, and stepwise multiple linear regression analyses were carried out. In the assisted conception group, maternal antenatal attachment, depression, and marital satisfaction significantly predicted postnatal maternal-infant attachment. Perceived social support, depression, and duration of marriage significantly predicted postnatal maternal competence. In the naturally conceived group, maternal antenatal attachment and social support significantly predicted postnatal maternal-infant attachment; perceived stress significantly predicted postnatal maternal competence. Antenatal depressive symptoms and relational factors significantly influenced postnatal maternal attachment and competence highlighting the need for screening and targeted psychological interventions during pregnancy.

(De)Bonding with embryos: The emotional choreographies of Portuguese IVF patients

In this article we develop the new concept of emotional choreography to describe how patients bond, debond and/or rebond with their embryos created in vitro using assisted reproductive technologies (ART). Using this concept, we explore how the patients' management of their own emotions intertwines with political, scientific, and religious factors. Our analysis relies on and further advances Thompson's concepts of ethical and ontological "choreography". It is through these forms of choreography that complex contemporary biomedical issues with high political, ethical, and scientific stakes are negotiated, and through which different actors, entities, practices, roles, and norms undergo mutual constitution, reinforcement and (re)definition. Our article draws on the analysis of 69 in-depth interviews and the results of an online survey with 85 respondents.

Couples' experiences of pregnancy resulting from assisted reproductive technologies: A qualitative meta-synthesis

Background

Across the world, a growing number of couples are directly or indirectly affected by infertility. Advances in assisted reproductive technologies are now enabling many of them to plan to have a child. As pregnancies resulting from assisted reproductive technologies are being experienced by a growing number of couples, it is important to better understand their experiences and the difficulties they encounter during the prenatal period.

Objective

This literature review aims to synthesize the qualitative results of primary studies in order to better understand couples' experiences of pregnancy resulting from assisted reproductive technologies, after having experienced infertility.

Design

A meta-synthesis was conducted in accordance with the guidelines put forth by Sandelowski and Barroso in order to carry out an integrative analysis of the knowledge resulting from qualitative studies on this phenomenon.

Data sources

The literature search was carried out between October and November 2020. Seven electronic databases were searched (CINAHL, Medline, PsycNet, SCOPUS, ScienceDirect, CAIRN, ERUDIT) and 14 eligible articles were selected.

Review methods

The data from the "results" and "findings" sections of each of the articles were synthesized through thematic analysis to examine and summarize the topics found in the articles selected and develop the main themes.

Results

The thematic analysis is structured around four themes to describe and interpret different aspects of the experience of pregnancy resulting from ART, namely: 1) travelling a long and complex journey; 2) moving on with paradoxical emotions; 3) struggling with an emerging identity; and 4) reorganizing relationships. These results shed light on the complex issues faced by couples previously affected by infertility during a pregnancy resulting from assisted reproductive technologies.

Conclusion

The journey of a pregnancy resulting from assisted reproductive technologies must be recognized in order to offer support in line with the challenges faced by couples. This research will allow for a deeper understanding of women's experience, as well as that of their partner's, in a more specific way, and to better understand the impact on family and loved ones.

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.

The relationship between quality of life, perceived stress, marital satisfaction in women conceived through ART

BACKGROUND

The stress experienced during pregnancy and the decrease in marital satisfaction affects the quality of life of the woman negatively.

OBJECTIVE

This study conducted to determine the quality of life and the relationship with perceived stress and marital satisfaction in pregnant women with ART.

METHODS

This study is a descriptive and corelational study. The study sample consisted of 120 pregnant women with ART. The patient descriptive form, the Married Life Scale (SWML), The Perceived Stress Scale (PSS) and The Fertility Quality of Life (FertiQoL) were used for data collection in this study.

RESULTS

The mean of the total score of PSS was 16.38 ± 4,721, the mean score of SWML was 23.03 ± 4.42 and the mean of the total score of FertiQoL was 81,25 ± 17,56. There was a moderate negative correlation (r = -0,551, p = 0,001) between the total score of the FertiQol and the total score of PSS and there was a moderate positive correlation (r = 0,452, p = 0,001) between FertiQol total score and SWML.

CONCLUSION

This study found that the rate of perceived stress affected the quality of life negatively and marital satisfaction affected the quality of life positively in pregnant women with ART.

Prenatal attachment in pregnancy following assisted reproductive technology: a literature review

Objective: To summarise the literature on prenatal attachment in pregnancies following Assisted Reproductive Technology (ART).Background: Prenatal attachment can predict the quality of the postpartum parent-infant relationship and is linked to perinatal mental health of the parents and their adjustment to the parental role. It might be expected prenatal attachment will be influenced by fertility treatment such as ART, but there are contradictory results.Methods: In this review, studies with a cross-sectional and longitudinal design, published in 1990-2019 were included. A search was conducted in MEDLINE/PubMed, EMbase, Web of Science and Scopus, and using the Google Scholar search engine. A total of 17 articles were found which met the inclusion criteria and after these articles were reviewed using the STROBE-checklist, 15 articles were included in the study.Results: In most couples who conceived following ART, the level of prenatal attachment was either similar to or higher than in couples who conceive without ART.Conclusions: The findings challenge the idea that infertility problems affect attachment in pregnancies following ART. However, ART- couples may be more susceptible to anxiety due to pregnancy loss and support may be better focused on the pregnancy-related anxiety in these couples rather than any attachment intervention.

A systemic review of maternal wellbeing and its relationship with maternal fetal attachment and early postpartum bonding

Background

An emerging body of literature suggests there is a relationship between a pregnant woman’s psychological wellbeing and the development of maternal-fetal attachment (MFA) and early postpartum bonding. The nature of this relationship is not well understood because of the limited theoretical framework surrounding the construct of MFA and variations in study methods and data collection points. In this systematic review, we synthesize the published literature to determine the nature of the relationship from the antenatal to early postnatal period and to provide recommendations for future research and clinical practice.

Method

Using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach, four electronic databases were searched for peer-reviewed empirical studies, published in English. Articles were considered for inclusion if data was collected on at least one domain of maternal wellbeing/mental health and MFA during pregnancy or MFA during pregnancy and the mother-infant relationship during the early postpartum period (up to 12 weeks). No date parameters were applied to the search strategy. The review was registered with PROPSERO (registration number: CRD42018096174).

Results

25 studies examining maternal mental health and MFA/postpartum bonding were selected for inclusion in this review. Key findings identified from the review were: a need to validate existing mental health measures or develop new measures specific for use in antenatal populations; inconsistencies in data collection points throughout pregnancy and postpartum; a lack of consensus about the construct of MFA and the way it is assessed; and a continued focus on postpartum outcomes.

Conclusion

Scientific gaps remain in our understanding of the relationship between maternal mental health and both MFA and postpartum bonding which limit our theoretical understanding of the MFA construct. Recommendations for future research are to employ prospective longitudinal designs that span the full pregnancy and postpartum period, and for consistency in the terminology and methodology used when considering MFA. A re-focus of research attention on the theory behind MFA will allow a richer and more holistic account of the emerging relationship between mother and baby.

Anxiety and depressive symptoms, and stress biomarkers in pregnant women after in vitro fertilization: a prospective cohort study

STUDY QUESTION

Does in vitro fertilization (IVF) affect the course of anxiety and depressive symptoms as well as physiological stress from pregnancy to postpartum period?

SUMMARY ANSWER

IVF mothers have more anxiety symptoms and higher stress biomarker levels but fewer depression symptoms than natural conception mothers at the third trimester of pregnancy, but these differences are negligible during postpartum period.

WHAT IS KNOWN ALREADY

Cross-sectional studies have found an association between IVF and high stress levels during the prenatal period. There is, however, no follow-up study about the IVF effect on the mental health status from pregnancy to postpartum, adopting simultaneous measurement of self-reported symptoms and stress biomarkers.

STUDY DESIGN, SIZE, DURATION

This is a prospective cohort study. A total of 243 eligible women were recruited during the third trimester of pregnancy (60 women after successful IVF and 183 who conceived naturally). The recruitment was performed during a 12-month period, and the follow-up was carried out until 3 months after delivery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study was performed in the Division of Obstetrics in a regional referral center. The State scale of the State-Trait Anxiety Inventory (STAI-S) and the Beck Depression Inventory-Sort Form (BDI/SF) were used as anxiety and depression indicators, respectively; salivary cortisol and α-amylase levels as stress biomarkers. Anxiety, depression and stress biomarkers were measured at the third trimester of pregnancy (T1), at 48 h after birth (T2) and at 3 months after birth (T3). Associations with IVF were assessed using ordinal mixed models for anxiety and depressive symptoms and linear quantile models for stress biomarkers.

MAIN RESULTS AND THE ROLE OF CHANCE

Relative to natural conception mothers, IVF mothers had higher STAI-S scores at T1 (P = 0.016, odds ratio (OR) = 2.46), and this difference remained steady from T1 to T2 (P = 0.37, OR = 0.70) and from T2 to T3 (P = 0.36, OR = 0.69). In the case of depressive symptoms, the IVF group obtained lower BDI/SF scores at T1 (P < 0.001, OR = 0.192). This difference was apparently reduced from T1 to T2 (P = 0.072, OR = 2.21) and remained constant from T2 to T3 (P = 0.107, OR = 2.09). It is important to note that whereas the mean BDI/SF score was not clinically significant for any group (it was lower than the cut-off 4), the mean STAI-S score of the IVF group at T1 was so (it was higher than the cut-off 19). As for stress biomarkers, IVF mothers had higher cortisol levels at T1 (P = 0.043, Δlog(cortisol) = 0.88) compared to natural conceptions. From T1 to T2 cortisol levels of both groups increased at the relatively same rate (P = 0.81, Δlog(cortisol) = -0.16). However, the progressions tended to be different from T2 to T3, with IVF mothers exhibiting a sharp decrease in cortisol levels (P = 0.059, Δlog(cortisol) = -0.94), while natural conceptions value remained steady. In the case of α-amylase, there were no statistically significant differences between both groups at T1 (P = 0.7, Δlog(α-amylase) = -0.095). On the contrary, while IVF mothers showed sustained α-amylase levels across the time, the progression was different in the natural conception group, who showed a decrease in α-amylase levels from T1 to T2 (P = 0.049, Δlog(α-amylase) = 0.596) and a non-significant increase from T2 to T3 (P = 0.53, Δlog(α-amylase) = -0.283).

LIMITATIONS REASON FOR CAUTION

Since this follow-up study has been carried out from the third trimester of pregnancy, the findings cannot be generalized to extremely preterm births.

WIDER IMPLICATIONS OF THE FINDINGS

IVF women may have lower depressive symptoms for being pregnant. However, due to the potential pregnancy complications associated with IVF, they may have higher physiological stress and clinically significant anxiety at the third trimester of pregnancy but not during postpartum. Taking into account that both prenatal high maternal cortisol levels and prenatal clinically significant anxiety increase the risk of disturbance in the fetal neurodevelopment, psychological therapy should be extended during pregnancy in IVF women.

STUDY FUNDING/COMPETING INTEREST(S)

MV funded by FIS PI17/0131 grant from the Instituto de Salud Carlos III (ISCIII) and RETICS funded by the PN 2018-2011, and the European Regional Development Fund, reference RD16/0022/0001; AG-B funded by a 'Juan Rodés' Grant (JR17/00003) from the ISCIII. CC-P funded by a 'Miguel Servet I' Grant (CP16/00082) from the ISCIII. Authors declare no competing interests.

Lack of association between receiving ART treatment and parental psychological distress during pregnancy: Preliminary findings of the Japan Environment and Children's Study

In a nationwide population-based birth cohort study in Japan, pregnant women and their partners were evaluated for psychological distress as part of the first and second/third trimester health checks. Participants were divided into three groups: an infertility group receiving assisted reproductive technology (ART) treatment (239 mothers and 151 fathers); an infertility group receiving non-ART treatment (350 mothers and 215 fathers); and a spontaneous pregnancy group (8514 mothers and 5110 fathers). Data on maternal and child health as well as basic characteristics were collected via medical records and self-administered questionnaires. The Kessler Six-item Psychological Distress Scale was employed for eligible women and their partners. Multivariate logistic regression analysis was used to evaluate the association between psychological distress experienced during pregnancy and ART treatment, with adjustment for potential confounders such as basic health status and socio-economic status. The mothers who received ART treatment suffered less psychological distress than the mothers in the other two groups. In multivariate analysis adjusted for background characteristics, no significant association was observed between persistent maternal distress and ART treatment (adjusted odds ratio 0.79, 95% confidence interval 0.49-1.26). Higher socio-economic status among couples receiving ART treatment may explain, in part, the lack of association between ART treatment and parental distress during pregnancy.

Antenatal needs of couples following fertility treatment: a qualitative study in primary care

BACKGROUND

It is known that couples may experience emotional distress while undergoing infertility treatment, but less is known about their experience of pregnancy following successful conception. Typically, couples are discharged from the fertility clinic to receive standard antenatal care. Recent research has raised questions about whether this care adequately meets their needs.

AIM

To explore the antenatal experiences of females and males who have successfully conceived through infertility treatment.

DESIGN AND SETTING

An exploratory qualitative approach was undertaken, using individual, in-depth interviews with females and males who had successfully undergone infertility treatment in one of three fertility clinics in the south of England.

METHOD

Twenty participants were interviewed (12 females and eight male partners) when their pregnancy had reached 28 weeks' gestation. Participants were asked about their experiences of infertility treatment, pregnancy, and antenatal care. Interviews were audiorecorded, transcribed, and analysed thematically.

RESULTS

Analysis of the interviews suggested females and males experienced a 'gap' in their care, in terms of time and intensity, when discharged from the fertility clinic to standard antenatal care. This gap, combined with their previous experience of infertility treatment, heightened their fear of pregnancy loss and increased their need for support from their health professionals. Participants' previous experience of infertility treatment also appeared to deter them from preparing for the birth and parenthood, and disclosing negative feelings to others about the pregnancy.

CONCLUSION

Females and males who have successfully undergone infertility treatment may require additional support in primary care to address anxiety during pregnancy, enable disclosure of negative feelings, and to help them prepare for childbirth and parenthood.

Psychosocial needs of women and their partners after successful assisted reproduction treatment in Barcelona

It is assumed that pregnancy and parenthood after a period of infertility are unproblematic and gratifying. However, a review of the literature highlights the complexity of the psychological and social consequences of pregnancy, childbirth and parenting after successful treatment with assisted reproductive technology. These experiences, including those following the creation of new forms of non-genetic and/or social parenthood, require investigation in order to understand how women and their partners integrate their journey from infertility to pregnancy and parenthood after successful assisted reproductive treatment. This paper presents results derived from qualitative interviews with 30 pregnant women and 21 couples after assisted reproductive treatment (repeated rounds of individual interviews with the study participants) conducted from July 2010 to April 2014 as part of a larger ethnographic study exploring the psychosocial needs of women and partners following assisted reproductive treatment in Barcelona's. The transcribed text was coded into categories of either predetermined or emergent topics. Prior studies have found that couples who achieve pregnancy after infertility may experience higher levels of anxiety in relation to pregnancy. This anxiety can be linked with a higher risk of complications during pregnancy after assisted reproductive treatment compared with spontaneous conception. However, the evidence concerning adjustment to pregnancy and parenthood is inconclusive. This study highlights the necessity for participants to give meaning to these treatments, given the variability that exists in perceptions of infertility and pregnancy after successful assisted reproductive treatment.

The Quality of Life in Pregnant Women Conceiving Through in Vitro Fertilization

Objective

The aim was to determine whether pregnant women conceiving through in vitro fertilization (IVF) differ from those conceiving spontaneously in terms of psychological well-being and the quality of life.

Methods

In a prospective study we included 75 women conceived after IVF and 78 who conceived spontaneously in the same time period (control group). All the women were sent a self-report questionnaire about demographic and reproductive history, health, pregnancy concerns, containing Subjective Quality of Life Scale (QLS), Positive and Negative Affect Schedule (PANAS), the Psychological Well-Being Scale (PWB), Beck Depression Inventory (BDI), and Zung Self-Assessment Anxiety Scale (SAS); obstetric and newborn’s data were obtained from medical records. Response rate was 66.6% in the IVF and 83.3% in control group.

Results

The mean women’s age was 33.8 years in the IVF, and 32.5 years in the control group (NS). There were no significant differences between groups on the most of the outcome measures assessing psychological status. IVF mothers were just less satisfied in “friend/acquaintances” (P=0.03), a higher percentage had sexual problems prior to conception (P=0.03); the length of hospitalization during pregnancy was longer (P=0.02), and the preterm delivery rate was higher (P=0.01). Withingroup changes over gestation time indicated that IVF women, not controls, showed an increase in positive affect (P=0.04) and purpose in life (P=0.05).

Conclusions

IVF women are inclined to social isolation. Despite more medical problems during pregnancy, they reported improved positive emotions and purpose in life as the pregnancy progressed.

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review

Objective. The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF). Methods. Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines. Results. Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss. Conclusions. This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

Stress, Depression, and Fetal Attachment in Pregnant Women having Infertility Treatments

PURPOSE

The purpose of this study was to determine the stress, depression, and fetal attachment of pregnant women who underwent infertility treatment, and to identify factors associated with fetal attachment.

METHODS

As a correlation survey design, data were collected from 136 pregnant women who underwent infertility treatment. Data were analyzed using chi2-test, t-test, ANOVA, Pearson correlation coefficients, and stepwise multiple regression.

RESULTS

Stress, depression, and fetal attachment averaged 3.01+/-0.60 (range of scale 1~5), 10.02+/-6.51 (out of a possible 63), and 3.64+/-0.55 (range of scale 1~5), respectively. Level of fetal attachment was higher when mother's age was less than 35, having other children, and having prenatal education experience. Lower score of depression and client's age less than 35 were significant factors affecting fetal attachment.

CONCLUSION

Infertility is a life-affecting trauma for the individual, and personal and social changes due to infertility cause physical and psychological difficulties even after a successful pregnancy with infertility treatment. Therefore, prenatal management programs need to be developed giving consideration to the emotional and physical changes in order to promote physical and psychological stability in the women pregnant following infertility treatment.

A comparative analysis of postpartum maternal mental health in women following spontaneous or ART conception

OBJECTIVE

To determine whether conception following assisted reproductive technology (ART) predisposes women to increased risk of postnatal depression (PND), compared to women who conceived naturally, when controlling for such factors as: multiple birth, previous maternal psychiatric history and sociodemographic status.

PARTICIPANTS

A total of 200 women who attended the private antenatal and fertility clinics of a fertility specialist in a large Australian city between January 2009 and December 2011 were contacted via telephone.

RESULTS

There was no difference in the rate of PND between the two groups (7.5% versus 7.4%, p = ns). Aside from the slightly older maternal age in the ART group (35.4 versus 33, p < 0.05), baseline socio-demographics were similar. There was a significantly higher rate of previous maternal clinical depression in the ART group compared to the controls (17% versus 5%, p < 0.05); however, other known risk factors for PND, including previous PND (10.6% versus 13.7%, p = ns), multiple births (2.1% versus 4.2%, p = ns) and low infant birth weight (3.3 kg versus 3.4 kg, p = ns), were not different in the two cohorts. Women who conceived naturally were also more likely to breastfeed for a longer duration (78% versus 89%, p < 0.05).

CONCLUSION

Our study demonstrates that when accounting for well-known risk and protective factors for postpartum depression, women who conceive using ART are not at an increased risk PND. In addition, the low rate of multiple births in the ART group further validates the practice of single embryo transfer.

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.

A repeated measures study of changes in health-related quality of life during pregnancy and the relationship with obstetric factors

AIMS

To examine changes in health-related quality of life throughout the course of pregnancy and among three pairs of consecutive periods (pre-pregnancy to early pregnancy, early to middle pregnancy and middle to late pregnancy), as well as to identify associated obstetric factors during the entire period of pregnancy.

BACKGROUND

Only sparse data are available concerning the profiles of health-related quality of life throughout pregnancy.

DESIGN

A within-subject comparison was undertaken.

METHODS

In total, 358 women completed the Taiwanese version of the Medical Outcomes Study Short Form-36 Health Questionnaire and a demographic-obstetric questionnaire at three stages of pregnancy at a medical centre. The participants were recruited between 2009-2010. A generalized estimating equation regression model was employed for the repeated measures.

RESULTS

The scores for physical component summary decreased significantly throughout early, middle and late pregnancy. The scores for mental component summary increased. The scores for physical, mental component summary and the eight domains of health-related quality of life decreased significantly from pre-pregnancy to early pregnancy. After adjusting for demographic and clinical factors, significant factors predicting physical component summary during pregnancy included stage of pregnancy and previous infertility. The factors predicting mental component summary included stage of pregnancy, parity and medical condition.

CONCLUSIONS

The results revealed the dynamic pattern of perceived health status by the Taiwanese pregnant women in their surrounding socio-cultural context and identified the stage of pregnancy and obstetric factors predicting health-related quality of life.

Mental health outcomes of mothers who conceived using fertility treatment

OBJECTIVE

To compare the proportion of women with self-reported depression and anxiety symptoms at four months postpartum between mothers of singletons who conceived spontaneously and mothers who conceived with the aid of fertility treatment.

METHODS

The sample used for this study was drawn from The "All Our Babies Study", a community-based prospective cohort of 1654 pregnant women who received prenatal care in Calgary, Alberta. This analysis included women utilizing fertility treatment and a randomly selected 1:2 comparison group. The data was collected via three questionnaires, two of which were mailed to the participants during pregnancy and one at four months postpartum. Symptoms of depression and anxiety at four months postpartum were measured using the Edinburg Postnatal Depression Scale and the Spielberger State Anxiety Inventory. Secondary outcomes of parenting morale and perceived stress were also evaluated. Descriptive statistics were used to characterize the population. Chi square tests and in cases of small cell sizes, Fisher Exact Tests were used to assess differences in postpartum mental health symptomatology between groups.

RESULTS

Seventy-six participants (5.9%) conceived using a form of fertility treatment. At four months postpartum, no significant differences were observed in the proportions reporting excessive depression symptoms (2.6% vs. 5.3%, p = 0.50), anxiety (8.1% vs. 16.9%, p = 0.08) or high perceived stress scores (7.9% vs. 13.3%, p = 0.23). Women who conceived with fertility treatment were less likely to score low on parenting morale compared to women who conceived spontaneously and this was particularly evident in primiparous women (12.5% vs. 33.8%, p = 0.01). There were no group differences in proportions reporting low parenting morale in multiparous women.

CONCLUSION

This study suggests that at four months postpartum, the proportion of women who experience elevated symptoms of depression, anxiety or perceived stress do not differ between mothers who conceive using fertility treatment and those who conceive spontaneously. Parenting morale at four months postpartum is significantly lower in primiparous mothers conceiving spontaneously compared to those who conceive with fertility treatment.

Assisted conception, maternal age and breastfeeding: an Australian cohort study

AIM

To establish the relationships between age, mode of conception and breastfeeding.

METHOD

Consecutive cohorts of nulliparous women >25 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age groups ≤30, 31-36 and ≥37 years were recruited. Data were obtained via telephone interviews and postal questionnaires in late pregnancy and 4 months postpartum. Sociodemographic characteristics, reproductive health, birth and breastfeeding experiences were assessed by study-specific questions. Self-rated general health and symptoms of depression and anxiety were assessed with standardized psychometric instruments. Main outcomes were exclusive breastfeeding at discharge from maternity hospital and 4 months postpartum.

RESULTS

Of 1179 eligible women, 791 (67%) participated; 549 (93%) had singleton infants, provided complete data and were included in analyses. Overall, 37.2% of participants aged ≤30, 33% aged 31-36 and 55.1% aged ≥37 years experienced Caesarean births. Regardless of age, compared with the SC group, ARTC women had twice the rate of Caesareans prior to labour. Controlling for other factors, exclusive breastfeeding rates at hospital discharge and 4 months postpartum were lowest amongst ARTC women who experienced Caesarean prior to labour (p < .001).

CONCLUSION

Independent of age, assisted conception increases the risk conferred by Caesarean birth to breastfeeding initiation and maintenance.

Age, mode of conception, health service use and pregnancy health: a prospective cohort study of Australian women

BACKGROUND

There is limited evidence about the ways in which maternal age and mode of conception interact with psychological, sociodemographic, health and health service factors in governing pregnancy health. The aim of this study was to establish in what ways maternal age and mode of conception are associated with, health behaviours, health service use and self-rated physical and mental health during pregnancy.

METHOD

A prospective cohort study was conducted in a collaboration between universities, infertility treatment services and public and private obstetric hospitals in Melbourne and Sydney, Australia,. Consecutive cohorts of nulliparous English-literate women at least 28 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age-groups: 20-30; 31-36 and at least 37 years were recruited. Data were obtained via structured individual telephone interviews and self-report postal questionnaires at recruitment and four months postpartum. Study-specific questions assessed: sociodemographic characteristics; reproductive health; health behaviours and health service use. Standardized instruments assessed physical health: SF 12 Physical Component Score (PCS) and mental health: SF12 Mental Component Score (MCS); State Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale. The main outcome measures were the SF 12 PCS, SF12 MCS scores and pregnancy-related hospital admissions.

RESULTS

Of 1179 eligible women 791 (67%) participated, 27 had fertility treatment without oocyte retrieval and were excluded and 592/764 (78%) completed all pregnancy assessments. When other factors were controlled speaking a language other than English, having private health insurance and multiple gestation were associated with worse physical health and having private health insurance and better physical health were associated with better mental health. Pregnancy-related hospital admissions were associated with worse physical health and multiple gestation.

CONCLUSIONS

Maternal age and mode of conception are not associated with pregnancy health and health service use when sociodemographic factors are considered.

Medical successes and couples' psychological problems in assisted reproduction treatment: a narrative based medicine approach

OBJECTIVE

1) To explore the psychological processes that develop in women and men during their first pregnancy obtained with assisted reproduction treatment; 2) to individuate the main plot that women and men use to recount their transition to parenthood.

METHODS

A face-to-face semi-structured autobiographical interview was administered. The interview was aimed to investigate the story of pregnancy. Interviews were transcribed verbatim and analyzed in order to merge principal themes.

PARTICIPANTS

15 Italian couples waiting for the first child after a conception with assisted reproductive technologies.

RESULTS

Medically assisted pregnancy constitutes an extremely stressful, highly medicalised experience, that the couple, however, narrated according to a basic plot consisting in four phases: doubt, final sentence, victory, monitoring.

CONCLUSIONS

Results suggest that physicians can benefit from knowing the phases that infertile couples experience during pregnancy because these can serve as a framework to use in monitoring their transition to parenthood and in planning psychological support and health interventions for them.

Será que eu consigo levar essa gestação até o fim? A experiência materna da gestação no contexto da reprodução assistida

Quando o projeto parental não pode ser realizado em decorrência de infertilidade no casal, é possível recorrer às técnicas de reprodução assistida para a realização desse projeto. Entretanto, o desgaste físico e emocional decorrente desses procedimentos pode conferir à gestação e à parentalidade um caráter específico, com repercussões ainda pouco conhecidas. Por meio deste estudo qualitativo, com três mulheres que engravidaram por diferentes técnicas de reprodução assistida, buscou-se conhecer o processo de tornar-se mãe nesse contexto, com entrevistas no terceiro trimestre de gestação. A discussão dos resultados deuse a partir da Constelação da Maternidade, da compreensão da vivência materna na gestação e da noção de estágios da concepção em casais inférteis. Os resultados apontaram que a experiência da gestação caracterizou-se pelo predomínio do medo de perder o bebê e sentimentos de incapacidade de levar a gestação a termo, conferindo singularidade a esse momento.

Relação conjugal no contexto de reprodução assistida: o tratamento e a gravidez

Neste estudo de caso coletivo, investigou-se a relação conjugal de três casais que conceberam com o auxílio das Técnicas de Reprodução Assistida (TRA). Os dados, obtidos a partir de entrevistas individuais semiestruturadas, foram submetidos à análise de conteúdo qualitativa, embasada em três categorias: coesão, sexualidade e comunicação, durante o tratamento e a gravidez. O tratamento mostrou-se fonte potencial de dificuldades nas três dimensões. Durante a gravidez, permaneceram algumas dificuldades, especialmente na sexualidade, mas relataram-se aumento na coesão e redução de conflitos. Identificou-se a interação das três dimensões, de forma que uma pode tanto compensar dificuldades nas demais como contribuir para o funcionamento destas. Destaca-se, assim, a importância de considerar as diferentes dimensões da relação conjugal, em estudos com casais.

Perinatal attachment in naturally pregnant and infertility-treated pregnant women in Taiwan

AIM

This article is a report of a study of the differences in maternal-foetal attachment and maternal-infant attachment among naturally pregnant and infertility-treated pregnant women in Taiwan.

BACKGROUND

Studies have shown that infertility treatment is likely to make up an increasing proportion in the coming years. As these experiences are unique, the attachment relationship may be affected.

METHOD

The research data were collected from two obstetrics clinics which were located in central Taiwan. In 2008, all participants (n = 125) were asked to fill out the prenatal questionnaires at the beginning of the study and were followed up with postnatal questionnaires that were mailed to them 1-2 months after labour (n = 110). We used chi-square tests for categorical and t- tests for continuous variables. Multivariate analysis of variances was then performed, and changes in the maternal-foetal attachment and maternal-infant attachment Scales were assessed.

FINDINGS

Women who became pregnant after fertility treatment had higher maternal-foetus and maternal-infant attachment scores, and this result was statistically significant; pregnancy mode and level of education are the main factors that have a significant effect on maternal-foetus attachment; and pregnancy mode and participation in prenatal education have a main effect on maternal-infant attachment.

CONCLUSION

Development of a specific support group for mothers, such as a group for prenatal education, and providing useful resources for pregnant women with a lower level of education are involved in the future research studies for therapeutic intervention.

Breastfeeding after assisted conception: a prospective cohort study

AIM

The aims were to investigate the prevalence of breastfeeding after conception with assisted reproductive technology (ART) and identify risk factors for breastfeeding duration <6 weeks and cessation of breastfeeding before the baby is 8 months old.

METHODS

A consecutive cohort of women who had conceived at one of two ART centres in Melbourne, Australia, was recruited in early pregnancy. The women completed telephone interviews and postal questionnaires in pregnancy and 3, 8 and 18 months after the birth.

RESULTS

Of 239 eligible women, 183 (77%) agreed to take part. Participants were more likely than the general population of childbearing Australian women to initiate breastfeeding (89% vs 83.3%, p=0.05) but by 3 months, a smaller proportion was breastfeeding exclusively (46% vs 57.3%, p=0.004). The proportions not providing any breast milk at 6 weeks and 8 months were 23% and 57%, respectively. More anxiety in late pregnancy and sub-optimal breastfeeding advice predicted breastfeeding duration <6 weeks and breastfeeding cessation before 8 months.

CONCLUSION

The predictors of less favourable breastfeeding outcomes after ART identified may be modifiable. Antenatal strategies to reduce anxiety in pregnancy and postnatal strategies to ensure consistent breastfeeding advice may improve breastfeeding outcomes among women who give birth after ART.

Quick, simple measures of family relationships for use in clinical practice and research. A systematic review

BACKGROUND

Family functioning has been implicated in the onset of child and adult psychopathology. Various measures exist for assessing constructs in the areas of parent-child relationships, parental practices and discipline, parental beliefs, marital quality, global family functioning and situation-specific measures.

OBJECTIVES

To identify systematically all questionnaire measures of family functioning appropriate for use in primary care and research.

METHODS

A systematic literature review was conducted, following PRISMA guidelines and searching 14 bibliographic databases using pre-determined filters, to identify family functioning measures suitable for use in families with children from 0 to 3 years old.

RESULTS

One hundred and seven measures of family functioning were reported and tabulated and the most commonly used measures were identified.

CONCLUSIONS

There are numerous measures available demonstrating characteristics, which make them suitable for continued use. Future research is needed to examine the more holistic measurement of family functioning using integration of multi-informant data.

Age at first birth, mode of conception and psychological wellbeing in pregnancy: findings from the parental age and transition to parenthood Australia (PATPA) study

BACKGROUND

It is increasingly common for women in high-income countries to delay childbearing. We aimed to describe the context of pregnancy for first-time mothers of different ages and examine relationships among maternal age at first birth, mode of conception and psychosocial wellbeing in pregnancy.

METHODS

Using stratified sampling, we recruited similar numbers of women conceiving through assisted reproductive technology (ART; n = 297) or spontaneously (n = 295) across three age groups: younger, ≤ 20-30 years; middle, 31-36 years; older, ≥ 37 years. Women participated in a structured interview and completed validated questionnaires assessing socio-economic status, personality, quality of partner relationship, state and trait anxiety, pregnancy-focused (P-F) anxiety and maternal-fetal attachment.

RESULTS

Older maternal age was associated with lower depression and anxiety symptoms, lower maternal-fetal attachment (P< 0.05), greater psychological hardiness (resilience) (P< 0.001) and lower ratings of control in the partner relationship (P< 0.05) at a univariate level. ART conception, but not older maternal age, was associated with more P-F anxiety. Although most main effects of age and mode of conception became non-significant after controlling for contextual/reproductive history variables, a significant association between ART conception and more intense fetal attachment emerged (P< 0.05).

CONCLUSIONS

Women having their first baby when older appear to have some psychological advantages over their younger counterparts; they are more resilient, report their partners as less controlling and report lower symptoms of depression and anxiety during pregnancy. However, women conceiving through ART have a more complex experience of pregnancy, simultaneously experiencing more P-F anxiety and more intense emotional attachment to the fetus.

A prospective study assessing anxiety, depression and maternal-fetal attachment in women using PGD

BACKGROUND

PGD has been described in previous cross-sectional and retrospective studies as a stressful experience. No prospective studies of the psychological impact of PGD are currently available.

METHODS

Using a prospective study design, validated measures exploring anxiety and depression were used to assess women using PGD prior to treatment, following embryo transfer, following the pregnancy test result and at 24 weeks of pregnancy. Maternal-fetal attachment was also assessed during pregnancy.

RESULTS

The prospective design revealed the cyclical pathway through PGD for many women, often comprising repeated cycles of ovarian stimulations and IVF and frozen embryo transfers. As predicted, there were significant fluctuations in women's anxiety scores, with increases observed following embryo transfer and pregnancy testing. Women's anxiety scores returned to baseline levels during pregnancy as assessed at 24 weeks gestation. Depression scores did not significantly fluctuate during PGD. Maternal-fetal attachment scores in this sample did not differ from the normative Australian data.

CONCLUSIONS

For some women, the PGD pathway is convoluted and requires multiple IVF cycles and embryo transfers to achieve pregnancy. A subset of women experience significant emotional burden during PGD treatment, and it is these women who require closer attention and support. In this sample, emotional adjustment in pregnancy following PGD appears to be sound.

Infertility history: is it a risk factor for postpartum depression in Turkish women?

PURPOSE

The aim of this cohort study was to assess postpartum depressive symptoms in women who had been successfully treated for primary infertility at 2 teaching hospitals in Turkey in 2008.

METHODS

The study groups comprised 51 fertile and 105 infertile women. The number of participants lost to follow-up was 28 fertile and 8 infertile women. "Descriptive Information Questionnaire" developed by the authors, the adapted "Beck Depression Inventory," and the adapted "Postpartum Depression Scanning Scale" were used to collect data.

RESULTS

The probability of developing postpartum depression in the infertile group is 1.352 times higher than that in the fertile group. However, this result cannot be considered to be statistically meaningful. A similar correlation was present between the level of depressive symptoms during pregnancy and in the postpartum period in both the infertile and fertile groups. Additional risk factors such as health issues during pregnancy, the notion that pregnancy causes a decrease in libido and negative body image, the infant's gender, pain from incision or infection, and dyspareunia were manifest in the fertile women, but not in the infertile women.

CONCLUSION

A history of infertility is not a major factor in postpartum depression. However, a history of depression may contribute to its development during pregnancy and in the postpartum period. Infertile women who experience severe anxiety and stress could be more prone to depression and should therefore be monitored closely.

Reprodução assistida e relação conjugal durante a gravidez e após o nascimento do bebê: uma revisão da literatura

A chegada de um bebê inicia um período de desafios e mudanças para o casal. Quando a gravidez é alcançada a partir da reprodução assistida, soma-se aos desafios já característicos desse período o impacto das experiências próprias a esse contexto. Neste trabalho, são revisadas e discutidas pesquisas que investigaram a relação de casais que recorreram à reprodução assistida, durante a gravidez e os dois primeiros anos do bebê. A revisão da literatura indica semelhanças entre esses casais e aqueles que conceberam naturalmente. No entanto, essas pesquisas tendem a basear-se na avaliação de variáveis específicas, como as relacionadas à satisfação conjugal e a características sociodemográficas, bem como pela ausência de um enfoque desenvolvimental que investigue a história prévia desse casal e suas famílias de origem. Esse enfoque, aliado a uma abordagem que privilegie a descrição das experiências desses casais, poderia contribuir para a compreensão desse contexto.

Psychological impact of preimplantation genetic diagnosis: a review of the literature

Preimplantation genetic diagnosis (PGD) was first reported as successful in humans in the early 1990s and nearly two decades later the psychological impact of PGD has not yet been clearly defined. As PGD requires the use of IVF, this paper provides a brief summary of literature related to the various psychological aspects of IVF followed by a review of the literature related to the psychological and broader psychosocial impact of PGD. The current literature includes attitudinal studies of couples for whom PGD may be beneficial and results suggest that those with traumatic reproductive and genetic histories are more likely to find PGD an acceptable treatment option. A small number of studies have used samples of women and couples who have used PGD. Due to a general lack of homogeneity in scope, method and results, these studies have not provided a uniform understanding of the PGD experience. Promisingly, however, two studies on parents of children born after PGD that explored parental stress show no differences between PGD, IVF and natural conception couples. The paper concludes that the missing link in the literature is a prospective study of PGD using validated psychological scales. Suggestions for future research are provided.