Immunological changes and stress are associated with different implantation rates in patients undergoing in vitro fertilization-embryo transfer

The effect of COVID-19 vaccination during IVF stimulation on cycle outcomes- a retrospective cohort study

The effect of the mRNA-BNT162b2 vaccine administered prior to fertility treatments has been addressed in several studies, presenting reassuring results. Cycle outcomes of patients receiving the vaccine during the stimulation itself have not been previously described. This retrospective cohort study included patients who received mRNA-BNT162b2-vaccine during the stimulation of fresh IVF cycles, between January-September 2021, age matched to pre-stimulation vaccinated patients and to non-vaccinated patients. Demographics, cycle characteristics and cycle outcomes were compared between groups. A total of 132 in-treatment vaccinated patients (study group), 132 pre-treatment vaccinated and 132 non-vaccinated patients that underwent fresh IVF cycles were included. Mean time from vaccination to retrieval in the study group was 6.68 days (SD 3.74; range 0-12). Oocyte yield was similar between groups (9.35 versus10.22 and 10.05 respectively; p=0.491). A linear regression model demonstrated no effect of vaccination before or during the stimulation, on oocyte yield (p>0.999). Clinical pregnancy rates (30 % versus 30 % versus 28 %) and ongoing pregnancy rates (25 % for all groups) did not differ between groups. In a logistic regression model for clinical pregnancy rates, vaccine administration and timing of vaccination were not a significant factor. This is the first study reporting the outcome of the mRNA BNT162b2 vaccine administration during the IVF stimulation itself. The vaccine administration had no impact on fresh IVF treatment outcomes compared to pre-treatment vaccinated or non-vaccinated patients. This adds to the growing evidence of COVID-19 vaccine safety in relation to fertility treatments and enables more flexibility regarding timing of vaccine administration.

Effect of SARS-CoV-2 infection and vaccine on ovarian reserve: A systematic review

OBJECTIVE

To evaluate the effect of SARS-CoV-2 infection and vaccination on ovarian reserve.

METHODS

Relevant articles were identified in the EMBASE, PubMed, and Web of Science databases from January 2020 to May 2023. Available clinical indicators of ovarian reserve, such as anti-Müllerian hormone (AMH), antral follicle count (AFC), follicle-stimulating hormone (FSH), and estradiol (E2), as well as the time interval from infection or vaccination to measurements, were assessed.

RESULTS

Only 2 studies provided evidence that SARS-CoV-2 infection could damage ovarian function. In a comparison of the vaccinated and unvaccinated groups, although 1 prospective cohort study observed the transient statistically significant decrease on serum AMH levels at 3 or 6 months of follow-up, serum AMH levels remained within the normal reserve range (>1.1 ng/dl) throughout the study period.

CONCLUSION

Overall, whether ovarian reserve may be affected by SARS-CoV-2 infection remains controversial and further investigations are warranted to clarify this issue. Based on the current evidence, it is safe to assume that COVID-19 vaccination does not exert any adverse effect on ovarian reserve parameters such as AMH, AFC, FSH, and E2, which will provide reassurance for women attempting to fall pregnant.

Perceived stress reduction through an infertility coaching program: a randomized controlled clinical trial

Infertility has been recognized as a distressing experience among couples worldwide, cutting across various cultures. This present study was conducted to assess the impact of a supportive stress management program led by an infertility coach for women undergoing fertility treatment. This randomized controlled clinical trial study was performed on 60 infertile women undergoing assisted reproductive techniques at Maryam Infertility Center located in Sari in 2018. After random allocation in two groups, 30 individuals were in the intervention group and 30 in the control group. The intervention program was implemented according to the infertility coach's counseling protocol in six stages. The control group received only routine ward counseling. In order to measure stress, the Newton Infertility Stress Questionnaire was used firstly before intervention and then after oocyte puncture, embryo transfer, and pregnancy testing. Data analysis was performed using SPSS statistical software version 18 and Shapiro-Wilk, Chi-square, Mann-Whitney, independent t-test, Friedman test, Wilcoxon test, GEE test, and Cohen's effect size. Our analysis approach has also been based on the analysis of (ITT). The significance level was 0.05. The mean ± SD scores of infertility perceived stress before the intervention in the control was 146.16 ± 16.90 and the intervention group was 156.53 ± 9.31, after intervention at the time of oocyte puncture in the controls was 165.36 ± 8.98 and the intervention group was 155.83 ± 10.70, at the day of embryo transfer in the control group was 156.35 ± 14.45 and in the intervention group was 123.58 ± 22.9 and in the pregnancy test day in the control group was 185.76 ± 26.56 and in the intervention group was 127.61 ± 21.57 (P < 0.001). According to Friedman test, the mean of stress in three situations after the intervention showed a significant difference in reduction of the mean of stress (P < 0.001). In the control group, the stress score of the samples had an increasing trend, which was significant during the measurement steps based on Friedman test results (P < 0.001). In the intervention group, paired t-test results showed no significant comparing mean score of Newton's infertility stress before and after oocyte puncture day (P = 0.711), comparing the mean of stress before and after pregnancy test day (P = 0.003) and also comparing of mean stress before and after pregnancy on the day of embryo transfer according to Wilcoxon test (P < 0.001). And comparing mean stress before and after pregnancy test day, paired t-test (P = 0.001) showed significant statistical differences. According to the results of the GEE test, changes in stress scores over time were significant between the two groups (P < 0.001), as well as the effect of stress on oocyte puncture day (0.41), embryo transfer day (1.69), pregnancy test day (P < 0.001) (2.46) had a significant effect on the day of embryo transfer and pregnancy test day. Based on the results of this study, the infertility coach program demonstrated the ability to decrease the perceived stress related to infertility. Additionally, it showed potential in enhancing treatment outcomes, such as oocyte count and positive pregnancy results, among infertile women undergoing assisted reproductive techniques.Trial registration: Iranian Registry for Clinical Trial (the link to trial: https://www.irct.ir/trial/33357 ). Registered 11-11-2018.

Effectiveness of psychological interventions on pregnancy rates in infertile women undergoing assisted reproductive technologies: a meta-analysis of randomised controlled trials

The purpose of this study was to assess the effects of psychological interventions on the pregnancy rates of infertile women undergoing assisted reproductive technology (ART). Using the electronic databases PubMed, EM Base, Cochrane Library, WOS, CNKI, WanFang Data, CSTJ, and CBM, a systematic literature search was conducted in the second week of August 2019. Randomized controlled trials (RCTs) on the effect of psychological interventions on the pregnancy rate of infertile women undergoing assisted reproductive technology were collected. There is no time limit for this search setting. The language is limited to Chinese or English. Two investigators independently screened the literature, extracted data, and assessed the risk of bias of the included studies, and then used Revman5.3 and STATA16.0 software for meta-analysis. A total of 25 randomized controlled trials were included in this meta-analysis, including 2098 patients in the experimental group and 2075 patients in the control group. There was a significant difference in the pregnancy rate between the two groups [RR=1.31, 95%CI(1.22,1.40)]. Subgroup analysis showed that this is also true of infertile women of different nationalities, different intervention timing and format. However, different psychological interventions may indeed have different effects. Current evidence suggests that psychological interventions may improve pregnancy rates in infertile women undergoing assisted reproductive technology. Limited by the quantity and quality of included studies, the above conclusions need to be verified by more high-quality studies. Our PROSPERO registration number is: CRD42019140666.

Effect of female coronavirus disease 2019 vaccination on assisted reproductive outcomes: a systematic review and meta-analysis

IMPORTANCE

The effect of coronavirus disease 2019 (COVID-19) vaccination on fertility warrants clarification in women undergoing assisted reproductive treatment.

OBJECTIVE

To study the association between female COVID-19 vaccination and outcomes of assisted reproductive treatment.

DATA SOURCES

PubMed, Embase, the Web of Science, Cochrane Library, and medRxiv and bioRxiv were searched for eligible studies from December 1, 2019, to November 30, 2022, with no language restrictions.

STUDY SELECTION AND SYNTHESIS

Observational studies comparing assisted reproductive outcomes between women with and without COVID-19 vaccination were included. The pooled estimates were calculated using the random-effects models as mean differences (MDs), standardized MDs, or odds ratios with 95% confidence intervals (CIs). Heterogeneity was evaluated using the I² statistic.

MAIN OUTCOMES

The number of oocytes retrieved and clinical pregnancy rate.

RESULTS

Twenty-one cohort studies involving a total of 19,687 treatment cycles were included. In a comparison of the vaccinated vs. unvaccinated groups, the pooled MD for oocyte number was -0.06 (95% CI, -0.51 to 0.39; I² = 0), and the pooled odds ratio for clinical pregnancy was 0.95 (95% CI, 0.85-1.05; I² = 0). Similarly, there were no statistically significant adverse effects identified in other outcomes determined a priori, including 4 cycle characteristics, 6 laboratory parameters, and 3 pregnancy indicators. Most results were consistently unchanged in subgroup and sensitivity analyses, with no evidence of publication bias according to Egger's test.

CONCLUSION AND RELEVANCE

Our work did not find significant differences in assisted reproductive outcomes between vaccinated and unvaccinated women. However, more data are warranted to confirm the safety of COVID-19 vaccination for assisted reproductive treatment and in female fertility in general.

No Effect of Inactivated SARS-CoV-2 Vaccination on in vitro Fertilization Outcomes: A Propensity Score-Matched Study

Purpose

Patients and Methods

Results

Conclusion

Expression of natural cytotoxicity receptors and cytokine production on endometrial natural killer cells in women with recurrent pregnancy loss or implantation failure, and the expression of natural cytotoxicity receptors on peripheral blood natural killer cells in pregnant women with a history of recurrent pregnancy loss

AIM

Natural cytotoxicity receptors (NCR) are unique markers that regulate natural killer (NK) cell cytotoxicity and cytokine production. In this study, we investigated the expression of NCR (NKp46, NKp44, and NKp30) and cytokine production in NK cells derived from the uterine endometrium of women with recurrent pregnancy loss (RPL). We also investigated the expression of NCR in peripheral blood NK cells in pregnant women with and without a history of RPL.

METHODS

The expression of NCR (NKp46, NKp44, and NKp30) in NK cells (CD56^dim and CD56^bright ) in the uterine endometrium was analyzed using 3-color flow cytometry. Cytokine (tumor necrosis factor-α and interferon-γ) production was also analyzed. NK cells from the mid-secretory endometrium of 28 women with RPL, 34 women with implantation failure, and 74 controls were collected and mechanically dispersed using a tissue grinder. The expression of NCR in peripheral blood NK cells from pregnant women with (n = 17) and without (n = 91) a history of RPL was analyzed.

RESULTS

The percentages of NKp46⁺ NK cells were significantly lower in both women with RPL and pregnant women with a history of RPL. The percentages of tumor necrosis factor-α- and/or interferon-γ-producing uterine endometrial NK cells were significantly lower in women with RPL compared with controls.

CONCLUSION

The changes in NCR expression and cytokine production, especially decreased NKp46 expression in endometrial NK cells, suggests the presence of abnormal NK cell regulation in women with reproductive failures.

Psychological distress and fertility quality of life (FertiQoL) in infertile Korean women: The first validation study of Korean FertiQoL

OBJECTIVE

To investigate psychological distress and fertility quality of life (FertiQoL) in infertile Korean women, and to investigate whether a correlation exists between psychological distress and FertiQoL.

METHODS

Participants in this study were made up of 141 infertile women and 65 fertile women. We conducted a survey on psychological distress (using the Depression Anxiety Stress Scales [DASS]-42 questionnaire) and administered a FertiQoL questionnaire. The levels of stress hormones (adrenocorticotropic hormone [ACTH] and cortisol) in serum were assessed.

RESULTS

The scores for depression (13.7±8.4), anxiety (10.7±6.4), and stress (18.0±8.3) among the infertile women were significantly higher than the scores for depression (9.4±7.5), anxiety (6.6±6.0), and stress (12.2±8.3, p<0.001) among the fertile women. There was no difference in the scores for depression (13.5±8.2, 13.8±8.6), anxiety (10.0±6.2, 11.5±6.6) and stress (17.7±8.4, 18.4±8.1) between younger (≤34) and older (≥35) participants. The mind-body (r =-0.495) and emotional (r =-0.590) subscales showed a higher negative correlation with stress compared with other scales of psychological distress. At the same time, the social (r =-0.537) and relational (r =-0.385) subscales showed a higher negative correlation with depression. Levels of cortisol and ACTH in infertile women were 9.1 µg/mL and 11.9 pg/mL, respectively, which are within normal ranges.

CONCLUSION

The levels of psychological distress and quality of life in infertile Korean women seem to require psychological intervention. This study provides a baseline measurement of psychological distress and FertiQoL in infertile women in Korea, which will be available for developing psychological interventions for infertile Korean women.

Psychological distress and fertility quality of life (FertiQoL) in infertile Korean women: The first validation study of Korean FertiQoL

OBJECTIVE

To investigate psychological distress and fertility quality of life (FertiQoL) in infertile Korean women, and to investigate whether a correlation exists between psychological distress and FertiQoL.

METHODS

Participants in this study were made up of 141 infertile women and 65 fertile women. We conducted a survey on psychological distress (using the Depression Anxiety Stress Scales [DASS]-42 questionnaire) and administered a FertiQoL questionnaire. The levels of stress hormones (adrenocorticotropic hormone [ACTH] and cortisol) in serum were assessed.

RESULTS

The scores for depression (13.7±8.4), anxiety (10.7±6.4), and stress (18.0±8.3) among the infertile women were significantly higher than the scores for depression (9.4±7.5), anxiety (6.6±6.0), and stress (12.2±8.3, p<0.001) among the fertile women. There was no difference in the scores for depression (13.5±8.2, 13.8±8.6), anxiety (10.0±6.2, 11.5±6.6) and stress (17.7±8.4, 18.4±8.1) between younger (≤34) and older (≥35) participants. The mind-body (r =-0.495) and emotional (r =-0.590) subscales showed a higher negative correlation with stress compared with other scales of psychological distress. At the same time, the social (r =-0.537) and relational (r =-0.385) subscales showed a higher negative correlation with depression. Levels of cortisol and ACTH in infertile women were 9.1 µg/mL and 11.9 pg/mL, respectively, which are within normal ranges.

CONCLUSION

The levels of psychological distress and quality of life in infertile Korean women seem to require psychological intervention. This study provides a baseline measurement of psychological distress and FertiQoL in infertile women in Korea, which will be available for developing psychological interventions for infertile Korean women.

Immunocytogenetic effects of gonadotropin releasing hormone analogue: Triptorelin Pamoate (Decapeptyl ®) during in vitro fertilization treatment

In this study, the immunocytogenetic effects of Decapeptyl ® (Triptorelin Pamoate) were assessed in the peripheral blood lymphocytes of females undergoing in vitro fertilization (IVF) treatment. Blood samples were taken from 34 females (23 treated and 11 controls), cultured and examined for sister chromatid exchanges (SCE) and cell replication index (CRI). The SCE frequency increased around ovulation time in the controls, and around the time of human chorionic gonadotropin administration in the IVF group. However, the SCE rate was significantly higher in the latter group. Furthermore, the white blood cells (WBC) count was significantly higher on the day of ovum pick up compared to the day preceding luteinizing hormone (LH) and follicle stimulating hormone (FSH) treatment. Similar observations were recorded with respect to phagocytic activity tested by nitroblue tetrazolium (NBT) assay. The nitric oxide production abilities of macrophages were not significantly changed in the LH, FSH-treated group relative to its control. Finally, the 50% complement hemolytic activity (CH50) assay results indicated that Decapeptyl lacks a significant potential to affect the complement system.

Reproductive outcomes of retransferring retained embryos in blastocyst transfer cycles

Objective

To determine the incidence of embryo retention (ER) in the transfer catheter following embryo transfer (ET) in blastocyst transfer and investigate whether retransferring retained embryos has an impact on reproductive outcomes in patients undergoing in vitro fertilization-ET.

Methods

We retrospectively analyzed the records of 1,131 blastocyst transfers, which comprised 223 single blastocyst transfer (SBT) and 908 double blastocyst transfer (DBT) cycles. Each SBT and DBT group was classified depending on whether ET was performed without retained embryos in the catheter during the first attempt (without-ER group) or whether any retained embryos were found following ET (ER group) for the purpose of comparing reproductive outcomes in a homogenous population.

Results

The overall incidence of finding retained embryos was 2.8% (32/1,131). There were no retained embryos in SBT cycles. In DBT cycles, implantation rates (30.0% vs. 26.6%), positive β-hCG rates (57.2% vs. 56.2%), clinical pregnancy rates (45.3% vs. 46.9%), and live birth rates (38.9% vs. 43.8%) were not significantly different between the without-ER and ER groups. There were no significant differences in the mean birth weight (g) 2,928.4±631.8 vs. 2,948.7±497.8 and the mean gestational age at birth (269.3±17.2 days vs. 264.2±25.7 days). A total of nine cases of congenital birth defects were found in this study population. Eight were observed in the without-ER group and one in the ER group.

Conclusion

Our results suggest that retransfer of retained embryos does not have any adverse impact on reproductive outcomes in blastocyst transfer cycles. Furthermore, our results support finding that SBT might be advantageous for decreasing the incidence of retained embryos in catheters.

Effects of Infertility Etiology and Depression on Female Sexual Function

Sexual dysfunction is common in women with infertility and interferes with the marital relationship. The study aims to compare sexual function among women with different infertility causes. The authors used a cross-sectional study design with 142 infertile women. Sexual functions and depression prevalence of infertile women were assessed using the Female Sexual Function Index and the Beck Depression Inventory. The prevalence of female sexual dysfunction was 43.3% (n = 13) in the female infertility group (Group A), 54.8% (n = 17) in the male infertility group (Group B), and 51.9% (n = 42) in the unexplained infertility group (Group C). There was no statistically significant difference in the prevalence of sexual dysfunction between the groups (p =.635). There was no significant difference in mean Beck Depression Inventory scores between the groups (p =.832). However, Beck Depression Inventory scores and depression prevalence were significantly higher in women with sexual dysfunction (p <.001). The total Female Sexual Function Index score and all subgroup scores were inversely correlated with the Beck Depression Inventory score (p <.01). Infertile women with sexual dysfunction were more likely to have depressive symptoms. Psychiatric assessment should be introduced in the management of infertility.

Effects of Coculture With Immune Cells on the Developmental Competence of Mouse Preimplantation Embryos in Vitro and in Utero

The aim of this study was to establish a coculture system using immune cells as well as an in vitro model for inflammatory conditioning using RAW 264.7 mouse macrophages activated by lipopolysaccharide. The direct and indirect coculture systems were applied to evaluate the influence of embryo-to-cell direct or indirect secretory molecules from the cocultured cells. Blastulation rate in vitro (94.6% vs 76.9%, P < .05) and implantation rate in utero (43.3% vs 17.6%, P < .01) were significantly increased in direct coculture with activated RAW 264.7 cells compared to control. We also found the embryotrophic effects in vitro in the indirect coculture system. Our results indicate that coculture of mouse preimplantation embryos with immune cells could improve the developmental competence in vitro and in utero. Taken together, RAW 264.7 cells secret embryotrophic molecules, and it suggests the valuable insights that immune cells could improve in vitro culture conditions of preimplantation embryos.

Estrogen-progesterone balance in the context of blastocyst implantation failure induced by predator stress

Diverse stressors can disrupt blastocyst implantation in inseminated female mammals. Stress-induced implantation failure can be mimicked by minute doses of exogenous estradiol, and some evidence indicates that it may be mitigated by exogenous progesterone. In Experiment 1, we showed that acute exposure to a rat across a wire-mesh grid caused elevation of corticosterone and progesterone. In Experiment 2, we showed that exposure of inseminated mice to rats across a grid during gestation days 1-5 was associated with avoidance of proximity to the grid and a significantly reduced number of implantation sites on gestation day 6. Rat-exposure also resulted in elevated progesterone levels in females that maintained their pregnancies, and elevated estradiol levels in females that lost their pregnancies. In Experiment 3, we investigated whether exogenous progesterone, estradiol, or a combination of both could influence implantation failure induced by rat-exposure stress. Treatment with 100 ng estradiol per day on gestation days 1-5 induced a complete absence of implantation sites on gestation day 6, regardless of the presence or absence of the stressor. Administration of 500 μg progesterone per day was insufficient to prevent the stress-induced pregnancy loss. However, 500 μg progesterone plus 10 ng estradiol per day did prevent implantation failure in rat-exposed females. These findings are consistent with the hypothesis that estradiol elevations contribute to stress-induced pregnancy loss, but show paradoxically that low doses of estradiol can act together with progesterone to mitigate stress-induced pregnancy loss.

Stress and anxiety scores in first and repeat IVF cycles: a pilot study

Background

The role of stress in reproduction, particularly during treatment for infertility, has been of considerable interest; however, few studies have objectively measured stress and anxiety over the course of the IVF cycle or compared the experience of first-time and repeat patients.

Methods

This prospective cohort pilot study enrolled 44 women undergoing IVF at a university-based clinic to complete the State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS) and Infertility Self-Efficacy Scale (ISES) at three time points prior to ovarian stimulation (T1), one day prior to oocyte retrieval (T2), and 5–7 days post embryo transfer (T3).

Results

Mean STAI State scores were significantly elevated at all three time points (p<0.01). STAI State and PSS mean values did not change over time and did not differ in first-time vs. repeat patients. Self-efficacy (ISES) scores declined over time, with a greater decline for repeat patients. Of the 36 women who completed a cycle, 15 achieved clinical pregnancy. Using logistic regression modeling, all scores at T2 were correlated with pregnancy outcome with lower scores on the STAI State and PSS and higher scores on the ISES associated with higher pregnancy rates.

Conclusions

Stress and anxiety levels remained elevated across all cycles. Women with lower stress and anxiety levels on the day prior to oocyte retrieval had a higher pregnancy rate. These results emphasize the need to investigate stress reduction modalities throughout the IVF cycle.

Stress relief to augment fertility: the pressure mounts

Current studies have not conclusively demonstrated an objective and consistent marker of an aberrant stress response; an effect of such a stress response on reproductive outcome; or a benefit of counseling on reproductive outcome in such patients.

Gene expression profiling of mouse aborted uterus induced by lipopolysac charide

To identify genes that participate in the abortion process, normal pregnant uteri were compared to lipopolysaccharide (LPS)-induced abortion uteri. At day 6 of pregnancy, mice were treated with LPS at various time points to induce an abortion. Total RNAs were applied to a cDNA microarray to analyze genes with altered expression. At the early stage (2 hours) of LPS-induced abortion, upregulated genes were mainly composed of immune responsive genes, including Ccl4, Ccl2, Cxcl13, Gbp3, Gbp2, Mx2, H2-Eb1, Irf1 and Ifi203. Genes related to toll-like receptor signaling were also overexpressed. At late stages of abortion (12-24 hours), many genes were suppressed rather than activated, and these were mainly related to the extracellular matrix, cytoskeleton, and anti-apoptosis. Altered expression of several selected genes was confirmed by real time reverse transcription-polymerase chain reaction. The results demonstrated that many known genes were altered in the LPS-treated pregnant uterus, implying that the molecular mechanisms of the genes involved in LPS-induced abortion are complicated. Further analysis of this expression profile will help our understanding of the pathophysiological basis for abortion.

Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis

BACKGROUND

A number of studies have investigated the relationship between psychological factors such as stress and distress (measured as anxiety and depression) and outcomes of assisted reproductive technology (ART). The results, however, are inconsistent, and the strength of any associations remains to be clarified. We conducted a systematic review and meta-analysis of the results of studies reporting on the associations between stress, anxiety, and depression and ART outcomes.

METHODS

Prospective studies reporting data on associations between stress or distress in female patients and ART outcome were identified and evaluated by two independent researchers according to an a priori developed codebook. Authors were contacted in cases of insufficient data reporting. Stress was defined as perceived stress, work-related stress, minor life events or major life events, and distress was defined as anxiety or depression.

RESULTS

A total of 31 prospective studies were included. Small, statistically significant, pooled effect sizes were found for stress [ESr, effect size correlation) = -0.08; P = 0.02, 95% confidence interval (CI): -0.15, -0.01], trait anxiety (ESr = -0.14; P = 0.02, 95% CI: -0.25, -0.03) and state anxiety (ESr = -0.10, P = 0.03, 95% CI: -0.19, -0.01), indicating negative associations with clinical pregnancy rates. A non-significant trend (Esr = -0.11, P = 0.06) was found for an association between depression and clinical pregnancy. For serum pregnancy tests and live birth rates, associations between trait anxiety or state anxiety were not significant. The fail safe number did not exceed the suggested criterion in any analyses, between-study heterogeneity was considerable and the mean age, mean duration of infertility and percentage of first time ART attenders in the study samples were found to moderate several of the associations.

CONCLUSIONS

Small but significant associations were found between stress and distress and reduced pregnancy chances with ART. However, there were a limited number of studies and considerable between-study heterogeneity. Taken together, the influence of stress and distress on ART outcome may appear somewhat limited.

The effect of medical clowning on pregnancy rates after in vitro fertilization and embryo transfer

This experimental prospective quasi-randomized study examining the impact of a medical clowning encounter after embryo transfer (ET) after in vitro fertilization (IVF) found that the pregnancy rate in the intervention group was 36.4%, compared with 20.2% in the control group (adjusted odds ratio, 2.67; 95% confidence interval, 1.36-5.24). Medical clowning as an adjunct to IVF-ET may have a beneficial effect on pregnancy rates and deserves further investigation.

Fetal rejection: infertility and immunity

Defective reaction toward fetal alloantigens could result in both recurrent spontaneous abortions (RSAs) and recurrent early pregnancy failures (REPFs), the latter existing in couples with unexplained infertility and multiple failures of implantation after in vitro fertilization embryo transfer. Immunological mechanisms leading to RSA and REPF seem to be different, although both syndromes probably have a genetic background that has not been identified so far. Despite the fact that antiphospholipid syndrome is a well-established cause of repeated pregnancy loss, the role of different autoantibodies existing in RSA and REPF patients needs to be elucidated. Immunotherapy is believed to correct the detrimental immune reactions; however, its real effectiveness and safety for the treatment of distinct forms of pregnancy loss need to be reconsidered.

Stressful life events are associated with a poor in-vitro fertilization (IVF) outcome: a prospective study

BACKGROUND

There is preliminary evidence to suggest an impact of stress on chances of achieving a pregnancy with in-vitro fertilization (IVF). The majority of the available research has focused on stress related to infertility and going through IVF-treatment, and it is still unclear whether non-fertility-related, naturally occurring stressors may influence IVF pregnancy chances. Our aim was to explore the association between IVF-outcome and negative, i.e. stressful, life-events during the previous 12 months.

METHODS

Prior to IVF, 809 women (mean age: 31.2 years) completed the List of Recent Events (LRE) and questionnaires measuring perceived stress and depressive symptoms.

RESULTS

Women who became pregnant reported fewer non-fertility-related negative life-events prior to IVF (Mean: 2.5; SD: 2.5) than women who did not obtain a pregnancy (Mean: 3.0; SD: 3.0) (t(465.28) = 2.390, P = 0.017). Logistic regression analyses revealed that the number of negative life-events remained a significant predictor of pregnancy (OR: 0.889; P = 0.02), when controlling for age, total number of life-events, perceived stress within the previous month, depressive symptoms, and relevant medical factors related to the patient or treatment procedure, including duration of infertility, number of oocytes retrieved and infertility etiology. Mediation analyses indicated that the association between negative life events and IVF pregnancy was partly mediated by the number of oocytes harvested during oocyte retrieval.

CONCLUSION

A large number of life-events perceived as having a negative impact on quality of life may indicate chronic stress, and the results of our study indicate that stress may reduce the chances of a successful outcome following IVF, possibly through psychobiological mechanisms affecting medical end-points such as oocyte retrieval outcome.

Anxiety and depression have no influence on the cancellation and pregnancy rates of a first IVF or ICSI treatment

BACKGROUND

After many years of research, the impact of psychological distress on the IVF treatment outcome is still unclear. This study aimed to determine the influences of anxiety and depression before and during IVF or ICSI treatment on the cancellation and pregnancy rates of inductees.

METHODS

In a multicentre prospective cohort study, we assessed anxiety and depression at baseline and the procedural anxiety level one day before oocyte retrieval, with the short versions of the State Anxiety Inventory (STAI) and the Beck Depression Inventory-Primary Care (BDI-PC). The effect of baseline anxiety and depression on the cancellation and pregnancy rates of 783 women in their first IVF or ICSI treatment was evaluated. We also determined if a change in anxiety from the start of treatment until just before oocyte retrieval affects the pregnancy rate. The predictive value of distress was assessed while controlling for several factors in subfertility treatment.

RESULTS

Neither baseline nor procedural anxiety, nor depression affected the ongoing pregnancy rates, with odds ratios (ORs) of 1.04 (95% CI 0.82-1.33), 0.96 (95% CI 0.77-1.20) and 0.85 (95% CI 0.65-1.10), respectively. Neither did the anxiety gain score affect the pregnancy rate, OR 1.08 (95% CI 0.83-1.41). A cancellation of treatment could not be predicted by either anxiety or depression, OR 1.16 (95% CI 0.83-1.63) and 0.85 (95% CI 0.59-1.22), respectively.

CONCLUSIONS

Inductees in IVF treatment can be reassured that anxiety and depression levels before and during treatment have no significant influence on the cancellation and pregnancy rates.

Limited importance of pre-embryo pronuclear morphology (zygote score) in assisted reproduction outcome in the absence of embryo cryopreservation

OBJECTIVE

To investigate the hypothesis that Z-score criteria represent a reliable predictor of implantation rate and pregnancy outcome in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles, excluding the possibility of embryo selection before the embryo transfer.

DESIGN

Retrospective clinical study.

SETTING

Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Arcispedale S. Maria Nuova (ASMN), Reggio Emilia, Italy.

PATIENT(S)

We analyzed 393 pregnancies obtained by IVF or ICSI cycles.

INTERVENTION(S)

Morphologic evaluations of Z-score in pre-embryos obtained from IVF or ICSI cycles.

MAIN OUTCOME MEASURE(S)

Evaluations of Z-scores, implantation rate, and clinical pregnancy outcome.

RESULT(S)

We did not find any statistically significant correlation between the Z-score of 1032 embryos transferred in 393 embryo transfers and the implantation rate or the pregnancy outcome. In particular, the best Z-score identified (Z1, 7.2%) did not seem to correlate with embryo implantation rate or pregnancy outcomes any better than those with worse scores (Z2, 6.9% and Z3, 85.9%).

CONCLUSION(S)

Our results seem to confirm that Z-score alone cannot be considered a better tool than standard morphologic criteria for identifying, controlling, or selecting embryos with a better chance of successful ongoing pregnancy.

Intracellular cytokine expression of peripheral blood natural killer cell subsets in women with recurrent spontaneous abortions and implantation failures

OBJECTIVE

To investigate the cytokine expression by peripheral blood natural killer (NK) cells of women with recurrent spontaneous abortion (SAB) or implantation failures.

DESIGN

Prospective cohort study.

SETTING

University clinic.

PATIENT(S)

Twenty-five women with recurrent SAB, 20 women with implantation failures, and 15 healthy controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cytokine expression (interferon-gamma, tumor necrosis factor [TNF]-alpha, interleukin [IL]-4, IL-5, IL-10, IL-13, granulocyte-macrophage colony-stimulating factor [GM-CSF]) in NK cells and their subsets (CD56(dim) and CD56(bright)).

RESULT(S)

Proportion (percentage) of CD56(bright)/interferon-gamma(+)/TNF-alpha(+) cells was significantly higher in women with recurrent SAB and implantation failures as compared with that of healthy controls. Proportion of CD56(bright)/IL-4(+)/IL-10(+) cells was very low (<2%) in all groups but was significantly lower in women with recurrent SAB than that of controls. The TNF-alpha/GM-CSF expressing CD56(bright) cell ratio was significantly higher in women with recurrent SAB and implantation failures than in controls.

CONCLUSION(S)

Natural killer-1 shift in peripheral blood NK cells was identified in nonpregnant women with recurrent SAB and implantation failures. Tumor necrosis factor-alpha/GM-CSF expressing CD56(bright) cell ratio can be applicable for the diagnosis of recurrent SAB or implantation failures. Further studies are needed as to whether cytokine expression of NK cells during pregnancy can affect pregnancy outcome.

Social concerns of women undergoing infertility treatment

OBJECTIVE

Our study was undertaken to determine [1] what women are disclosing to their employer with regard to their infertility, [2] what demographic characteristics are associated with women who are more likely to disclose, and [3] if there is an association between disclosure and lowering one's stress. We hypothesize that, in certain women, disclosure may lower stress, and therefore increase success rate of in vitro fertilization.

DESIGN

Cross-sectional questionnaire.

SETTING

University Infertility Treatment Center.

PATIENT(S)

We handed out a questionnaire to patients being evaluated and treated for infertility over a 6-month period. A total of 267 questionnaires were handed out and all were collected.

MAIN OUTCOME MEASURE(S)

We collected demographic data as well as information regarding privacy, disclosure, and stress. We then compared women who disclose to their employer that they are being seen by an infertility specialist to those women who do not disclose. We also measured stress and determined if higher stress level was associated with disclosure or nondisclosure.

RESULT(S)

Most women who did disclose did so because they needed a reason to leave work for frequent doctor visits. Among women who did not disclose, the main reason for nondisclosure was to protect their privacy. Women with a high school education were more likely to disclose compared with those with a college and postgraduate education. African American/Caribbean American women were least likely to disclose. Those who were out of work more often because of their infertility were more likely to disclose. There was not an association with disclosure and decreasing stress level.

CONCLUSION(S)

Women who did or did not disclose their infertility status to their employer were different with regard to level of education, race/ethnicity, and number of visits per month to the doctor. The decision to disclose does not seem to have a significant impact on stress.

Emotionally expressive coping reduces pregnancy rates in patients undergoing in vitro fertilization

OBJECTIVE

To examine the effects of coping and of infertility-specific and nonspecific stress on pregnancy outcomes after IVF treatment.

DESIGN

Cross-sectional design controlling for potential confounding variables. Psychosocial measures were assessed on the day of embryo transfer.

SETTING

Fertility clinic in Greece.

PATIENT(S)

Three hundred forty-two women.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A clinically recognized pregnancy or a biochemical pregnancy.

RESULT(S)

Of 342 women participating in the study, 79 became pregnant, representing a success rate of 23.3%. There were no statistically significant differences between women who became pregnant and those who did not in terms of duration of infertility, causes of infertility, previous IVF cycles, and infertility-specific or nonspecific stress. The only factor that was significantly associated with pregnancy outcome was emotionally expressive coping (adjusted odds ratio, 1.272; 95% confidence interval, 1.06-1.52). Women who coped by expressing their emotions were less likely to get pregnant than were women who did not.

CONCLUSION(S)

The link between psychological processes and reproductive outcomes of IVF treatment is less likely to be identified through the assessment of stress but rather is likely to be identified through the assessment of the strategies that people use to deal with stress. Emotionally expressive coping may be a risk factor for reduced pregnancy rates in women undergoing IVF.

Development and validation of the Infertility Self-Efficacy scale

OBJECTIVE

To develop and validate a scale of perceived self-efficacy for people coping with infertility treatment.

DESIGN

Self-efficacy scale development involved: [1] item generation with medical experts in reproductive health; [2] a principal components analysis with varimax rotation to identify underlying item components; [3] test-retest reliability and construct (convergent and discriminant) validity with infertility patients, who were administered the Infertility Self-Efficacy (ISE) scale with other measures; and [4] expert acceptability, as determined by reproductive health professionals.

SETTING

Recruitment at a fertility center, a national infertility organization, and medical trials web pages.

PATIENT(S)

A total of 213 participants (159 women; 54 men) with a diagnosis of infertility in the past 2 years were recruited for the various study phases.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Participants' infertility self-efficacy was assessed with an online assessment battery using the ISE scale; comparison mental health measures assessed current levels of fertility problem distress, perceived stress, and coping style. Reliability, validity, and component structure of the ISE was assessed.

RESULT(S)

Measurement development yielded a brief 16-item ISE scale that taps an infertility patient's perception about his or her ability to engage in a set of cognitive, emotional, and behavioral skills related to the medical treatment of infertility. The single component of "cognitive/affect regulation" suggests this core set of skills is relevant to successfully managing the experience of infertility. The ISE correlations with comparison mental health measures were as expected, suggesting good convergent and discriminant validity.

CONCLUSION(S)

The ISE scale appears to be a reliable and valid measure of an individual's self confidence in areas related to health promotion during infertility treatment. Assessing an infertility patients' self-efficacy with the ISE may be useful in clinical research and as a counseling tool to help guide patients in actively managing their fertility treatment.

Should fertilization treatment start with reducing stress?

In the past few decades, new and more efficient techniques to help solve fertility problems have become widely available throughout the developed world. These techniques include hormonal stimulation, ICSI, gamete intra-Fallopian transfer (GIFT) and IVF, and their cost is, on average, considerable. There is substantial initial evidence that the psychological disposition of the parents-to-be influences their fertility and thus the outcome of fertilization techniques. Many fertility treatments include consultation with a psychologist and do try to keep the stress produced by the treatment itself to a minimum, using concurrent therapy. However, the accumulating evidence points to the need to program medical fertility treatment, bearing in mind both chronic and acute stress levels, and to treat for their reduction before commencing the (actual) fertility treatment. There is ample evidence that lower stress levels mean better female and male natural fertility, though there is as yet no conclusive experimental evidence that lower stress levels result in better fertility treatment outcome. However, first reducing stress may diminish the number of treatment cycles needed before pregnancy is obtained, may prepare the couple for an initial failure of treatment or even make the more invasive techniques unnecessary. Primary psychological treatment for trait and state stress, being a less invasive method than IVF, ICSI or GIFT, is to be applied whenever indicated. Also, treatment and therapy to reduce stress, and in so doing enhance fertility, do not provoke the ethical and religious objections raised by infertility treatments.

Infertility-related stress in men and women predicts treatment outcome 1 year later

OBJECTIVE

To examine the separate and joint effects of male and female fertility problem (FP) stress and the source of stress (e.g., personal, social, marital) on treatment outcome.

DESIGN

Prospective, epidemiological cohort design.

SETTING

Fertility clinics in Denmark.

PATIENT(S)

Eight hundred eighteen couples who were about to begin a new course of treatment.

INTERVENTION(S)

An FP stress inventory was administered at the start of treatment, and the treatment outcome was evaluated 12 months later.

MAIN OUTCOME MEASURE(S)

Number of treatment cycles in 12-month study period and treatment outcome (i.e., success, no success).

RESULT(S)

Fertility problem stress was associated with a poorer treatment outcome in women (pooled within-groups [WGr] correlation,WGr = .517) and men (WGr = .392) with the effect significantly more pronounced for women (z = 3.19, P<.001). Fertility problem stress arising in the personal and marital domain showed greater associations with treatment outcome than did FP stress from the social domain. Logistic regression indicated that women who reported more marital distress required more treatment cycles to conceive (median 3) than women reporting less marital distress (median 2) (odds ratio [OR] = 1.20: Model chi2(3) = 77.21, P<.001).

CONCLUSION(S)

The findings provide evidence that infertility-related stress has direct and indirect effects on treatment outcome.

Communication and coping as predictors of fertility problem stress: cohort study of 816 participants who did not achieve a delivery after 12 months of fertility treatment

BACKGROUND

We investigated coping strategies and communication strategies as predictors of fertility problem stress 12 months after start of fertility treatment.

METHODS

We used a prospective, longitudinal cohort design including 2250 people beginning fertility treatment with a 12-month follow-up. Data were based on self-administered questionnaires measuring communication with partner and with other people, coping strategies: active-avoidance coping, active-confronting coping, passive-avoidance coping, meaning-based coping, and fertility problem stress. The study population included those participants (n = 816, men and women) who had not achieved pregnancy by assisted reproduction or delivery at follow-up.

RESULTS

Among both men and women, difficulties in partner communication predicted high fertility problem stress (odds ratio for women, 3.47, 95% confidence interval 2.09-5.76; odds ratio for men, 3.69, 95% confidence interval 2.09-6.43). Active-avoidance coping (e.g. avoiding being with pregnant women or children, turning to work to take their mind off things) was a significant predictor of high fertility problem stress. Among men, high use of active-confronting coping (e.g. letting feelings out, asking other people for advice, seeking social support) predicted low fertility problem stress in the marital domain (odds ratio 0.53, 95% confidence interval 0.28-1.00). Among women, medium or high use of meaning-based coping significantly predicted low fertility problem stress in the personal and marital domain.

CONCLUSION

The study provides information about where to intervene with fertility patients in order to reduce their stress after medically unsuccessful treatment.

Stress and outcome success in IVF: the role of self-reports and endocrine variables

BACKGROUND

The aim of this study was to examine the associations between urinary levels of the stress hormones adrenaline, noradrenaline and cortisol during treatment with self reported stress, in order to investigate the mechanism for the previously observed negative association of anxiety and depression with the outcome of IVF/ICSI.

METHODS

In a multicentre prospective cohort study, women entering their first cycle of IVF/ICSI treatment were asked to participate. From each participant nocturnal urine samples were collected; pre-treatment, before oocyte retrieval and before embryo-transfer (ET), to assess hormonal concentrations. Additionally, two questionnaires were administered before the start of the treatment to measure anxiety and depression.

RESULTS

168 women completed the questionnaires and collected at least two urine specimens. A significant positive correlation between urinary adrenaline concentrations at baseline and ET and the scores on depression at baseline were found. In women with successful treatment, lower concentrations of adrenaline at oocyte retrieval and lower concentrations of adrenaline and noradrenaline at ET, compared with unsuccessful women, were found.

CONCLUSIONS

The significant positive association of adrenaline concentration with pregnancy and with depression suggested that this adrenal hormone could be one of the links in the complex relationship between psychosocial stress and outcome after IVF/ICSI.

Estresse e função reprodutiva feminina

Este artigo discute a relação do estresse sobre a função reprodutiva, considerando que a infertilidade pode ter causas psicológicas (hipótese da psicogênese) ou pode ser a origem do estresse psicológico. A presença do estresse tem o potencial de ativar o eixo hipotálamo-hipófise-adrenal, o qual, inibe o eixo hipotálamo-hipófise-ovariano, levando à paralisação temporária das menstruações. Esse processo pode resultar em infertilidade transitória para as mulheres. Os autores enfatizam a necessidade de uma abordagem psicológica nos serviços de reprodução, objetivando trabalhar as tensões e frustrações advindas da infertilidade e do seu tratamento.

Female and male lifestyle habits and IVF: what is known and unknown

There is no greater tribute to the importance and efficacy of IVF than the fact that >1 x 10(6) babies have been born to infertile couples since its clinical introduction in 1978. Despite enormous advances regarding the technical aspects of the IVF procedure, the parents' contribution has virtually been ignored when considering aspects that influence success rates. This systematic review focuses on the effects of female and male lifestyle habits (specifically: smoking, alcohol and caffeine use, and psychological stress) on the reproductive endpoints of IVF (i.e. oocyte aspiration, fertilization, embryo transfer, achievement of a pregnancy, live birth delivery, and perinatal outcomes, e.g. low birthweight, multiple gestations). What is currently known in the field of lifestyle habits and IVF? There is compelling evidence that smoking has a negative influence on IVF outcomes, whereas for stress, the evidence is suggestive but insufficient due to the heterogeneity of studies. The evidence for the effects of alcohol and caffeine on IVF is inadequate, and therefore unknown, due to the scarcity of studies.

Environmental and occupational factors affecting fertility and IVF success

Reproductive function has been shown to be sensitive to changes in the physical, psychosocial and chemical environments. Although reproductive effects of occupational exposure to hazardous chemicals have been well documented in the literature, the potential effects of chemical contaminants at levels representative of contemporary exposures in the general population are much less certain. Evidence for adverse effects of exposure to environmental contaminants is more conclusive among the lower animals than for humans where considerable controversy remains. In addition to potential reproductive hazards of exposure to environmental contaminants, there is also evidence for adverse reproductive effects of the physical and psychosocial environments. In this review we focus on the difficulties involved in linking exposure to putative hazardous substances in environmental and occupational settings to adverse reproductive outcomes, especially success of IVF procedures. We highlight the plausibility of adverse events through animal and cell studies and the application of these results to the interpretation of human data. We consider both the male and female partners since it is essentially their combined contributions of gametes which may be affected by chemicals, which lead to successful outcomes.

Electro-acupuncture versus conventional analgesia: a comparison of pain levels during oocyte aspiration and patients' experiences of well-being after surgery

BACKGROUND

The primary aims were to compare the pain-relieving effect and post-operative well-being between electro-acupuncture analgesia (EA) and conventional analgesia (CA) comprising opiates. Further aims were to compare time for mobilization, and costs for time and drug consumption.

METHODS

In all, 160 women undergoing IVF were randomized, according to a computer-generated list, to EA or CA. Well-being was evaluated with the State Trait Anxiety Inventory (STAI). Pain and subjective expectations and experiences were recorded on a visual analogue scale (VAS). Time and drug consumption were recorded.

RESULTS

Although VAS pain ratings were significantly higher at oocyte aspiration (P < 0.0001) and after retrieval (P < 0.01) in the EA than in the CA group, they were similar 60 min after surgery. Both groups had similar STAI well-being scores. The EA group was significantly less tired and confused than the CA group after oocyte aspiration. No significant differences in time and costs for drug consumption were noted.

CONCLUSION

EA cannot generally be recommended as a pain-relieving method at oocyte aspiration but might be an alternative for women desiring a non-pharmacological method. An advantage of EA is less post-operative tiredness and confusion compared with CA.

Bed rest versus free mobilisation following embryo transfer: a prospective randomised study

OBJECTIVE

To evaluate the efficacy of two clinical methods of post-embryo transfer protocols in patients undergoing in vitro fertilisation.

DESIGN

Prospective, randomised clinical trial.

SETTING

Hospital-based clinic for reproductive medicine.

SAMPLE

Women under 40 years of age who were undergoing in vitro fertilisation with GnRH pituitary down-regulation and controlled ovarian hyperstimulation.

METHODS

Patients were randomised to rest for either 1 or 24 hours after embryo transfer.

MAIN OUTCOME MEASURE

Clinical pregnancy per cycle rate (the percentage of cycles started that demonstrated a live fetus on ultrasound examination performed at six or seven weeks of gestation).

RESULTS

The clinical pregnancy rates were 21.5% for the 1-hour and 18.2% for the 24-hour post-embryo transfer groups. The implantation rate per embryo was significantly higher in the 1-hour group (14.4%) than in the 24-hour group (9%).

CONCLUSION

One-hour and 24-hour rest post-embryo transfer result in comparable rates of clinical pregnancy. However, 24-hour rest results in reduced implantation rate per embryo.

Increased depression and anxiety in infertile Japanese women resulting from lack of husband's support and feelings of stress

We report that infertile women in Japan as well as in the Western world have high levels of emotional distress, anxiety, and depression. The reasons for anxiety and depression in infertile women are easy to presume but remain unclear. We conducted the present study to assess the relationship between the anxiety and depression of infertile Japanese women and their thought processes and emotional well-being with regard to their infertility. A cross-sectional questionnaire was administered to 101 infertile Japanese women who visited the infertility clinic at Tokai University. Inventories included the Hospital Anxiety and Depression Scale (HADS) and our original infertility questionnaire, which is composed of 22 questions to assess attitudes and emotional status in facing the stigma of infertility. After factor analysis, comparison between the HADS and the infertility questionnaire was made with simultaneous multiple regression analyses. Anxiety and depression in childless Japanese women were significantly associated with lack of husband's support and feeling stress. Our findings should prove useful in designing and implementing psychological support programs for infertile Japanese women. Psychological interventions to relieve or diminish these conditions might have significant therapeutic benefits for women attending infertility clinics in Japan.

Psychological group support attenuates distress of waiting in couples scheduled for assisted reproduction

The aim of the study is to determine whether a cognitive-behavioral group treatment could lead to a decrease of psychological distress in couples waiting for assisted reproduction. Fifty consecutive couples included in the waiting list for IVF-ET or ICSI were randomly allocated either to receive Cognitive-Behavioral Treatment (CBT Group) or just waiting (Observation Group). The group is formed by 8-10 couples; 12 meetings are provided for a period of 4 months. Two psychometric test have been administered (Symptom Rating Test and Westbrook Coping Scales) at baseline and after 4 months. At baseline, females showed a higher level of SRT than males (F= 16.6+/-14.1; M = 10.2+/-9.0; p=0.01). This became evident for anxiety (F= 5.6+/-4.9; M =3.3+/-3.0, p = 0.004), somatization (F= 3.0+/-2.5; M = 1.8+/-2.1, p = 0.01) and feelings of inadequacy (F = 3.9+/-3.7; M = 2.3+/-2.7, p = 0.01). After 4 months in the males of Observation Group (from 2.3+/-2.0 to 4.0+/-2.8, p=0.01) there was an increase of the level of anxiety. No other meaningful differences in other variables were found. In females of CBT Group a trend towards a significant decrease in the total value of psychological uneasiness (the SRT) (from 17.7+/-13.7 to 14.1+/-14.0, p = 0.07) was found. A long wait before the scheduled intervention of assisted reproduction increased anxiety levels, namely in male partners. CBT avoids such a 'waiting stress' and could be useful for stimulating discussion and awareness inside the couple. Shortening the waiting list and psychological support would be provided by infertility centres

Increasing circulating T-cell activation markers are linked to subsequent implantation failure after transfer of in vitro fertilized embryos

PROBLEM

Implantation determines success of in vitro fertilization (IVF) and embryo transfer (ET) cycles. Data are accumulating to support a role of the immune system in implantation. Most of the literature addresses the importance of natural killer (NK) cells in this process. The purpose of the current study is to examine the role of circulating T cells in implantation failure.

METHOD OF STUDY

Blood from 22 women undergoing IVF/ET during November, 2001, was drawn on cycle day 9 and analyzed for the percentage of circulating T cells expressing the activation markers CD69+ and human leukocyte antigen (HLA)-DR and the suppressor marker CD11b using immunofluorescence and flow cytometry. These results were compared with total percentage circulating CD3, CD4 and CD8 cells as well as NK cells and pregnancy outcome that cycle.

RESULTS

Infertile women had significantly greater expression of the activation marker of CD69+ among CD8+ and CD4+ T cells and HLA-DR among CD4 cells than fertile women. No difference in expression of T cell suppressor marker of CD11b was noted when infertile and fertile women were compared. No correlations were observed when activated T cells were compared with circulating CD3+, CD4+, CD8+, activated NK cells and NK cytotoxicity. CD3+ 4+ HLA-DR+ was expressed significantly less among successfully pregnant compared with unsuccessfully pregnant women.

CONCLUSION

T-cell activation markers CD 69+ and HLA-DR+ are associated with increased implantation failure after IVF/ET.

Psychogenic infertility--myths and facts

PURPOSE

The hypothesis of this review is that the role of psychological factors as the sole cause of infertility is generally overrated.

METHODS

A review is given of studies concerning the influence of psychological factors on the development of infertility.

RESULT

A prevalence of psychogenic infertility of 10-15 per cent must be discussed critically. A value of approximately 5 per cent is more realistic. Equating unexplained infertility with psychogenic infertility is not justified. A definition of psychogenic infertility according to the German guidelines Psychosomatics in Reproductive Medicine is presented. Spontaneous pregnancies following adoption or the decision to remain childless are the absolute exception. The association of stress and infertility in humans is still unclear. For many women the effect of infertility and notably of medical therapy is a considerable emotional stress. This may make psychosocial counseling necessary in certain cases.

CONCLUSIONS

An exclusive psychological/psychodynamical point of view on the complexity of infertility is as inadequate as a strictly somatic point of view. Infertility should always be treated as a psychosomatic entirety.

L’impact du stress dans le dialogue materno-fœtal : une approche immunologique

Pregnancy is controlled primarily, though not exclusively, by a delicate equilibrium between locally acting growth factors and cytokines, some under steroid control. The hypothesis considered here is that stress is able to influence the equilibrium between cytokines and thus lead to abortions or implantation failure. We thus detailed the studies on that topic in order to explore the psycho-neuro-immunological mechanisms concerned. The duration of stress, the patient's strategy for coping with this and the social context might be able to produce some opposite immunological effects. Thus, the link between stress and the immunological events induced is complex, and much care is needed for such patients.

Is there any evidence for immunologically mediated or immunologically modifiable early pregnancy failure?

PURPOSE

Human reproduction is an inefficient process. There is a high rate of loss of early pregnancies, often before the mother (or physician) knows she is pregnant. Genetic abnormalities can explain much of the wastage, but can it explain all of the failures? As embryos bear paternal and embryonic antigens foreign to the maternal immune system, could some otherwise normal embryos be "rejected"?

METHODS

Critical review of existing data.

RESULTS AND CONCLUSIONS

Otherwise normal embryos can fail prior to implantation, at implantation, in the periimplantation period as occult/chemical pregnancies, and as clinically evident miscarriages. The maternal immune system and its products (e.g., cytokines) can have innocent bystander effects, and a good case for direct recognition and "rejection" can also be made. The tools needed for accurate clinical diagnosis of such situations require further development and validation. Deliberate modification of the maternal host defence system can improve the chance of success, but the best evidence for efficacy of immunotherapeutic interventions is the situation of recurrent spontaneous abortions, which constitutes only a small percentage of losses. There is also evidence of clinical efficacy for several types of treatment to improve implantation and early pregnancy success.