A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer

The impact of sociocultural and psychological stress on the outcome of assisted reproductive technology in remarried families

OBJECTIVE

In China, there is a unique type of second marriage (SM) family where the woman is remarried, and the man is experiencing his first marriage. Additionally, the woman is older than the man. Therefore, these families experience many challenges: psychological, emotional, and societal pressure. Such family is a typical sample for studying sociocultural and psychological stress influencing on outcome of assisted reproductive technology (ART). This study aimed to investigate the impact of social psychological stress on the live birth outcomes AR.

METHODS

In this retrospective cohort, second marriage (SM) families who visited the Second Hospital of Hebei Medical University reproductive center between January 2012 to December 2022 were screened, and 561s marriage families (the SM group) with 5600 first marriage (FM) families (the FM group) were included undergoing their first ART cycles. The primary outcome of this study was the live birth rate (LBR).

RESULTS

The live birth rate (LBR) of SM group (30.7%) is lower than that of the FM group (43.6%) (p < 0.01). After adjustment by logistic regression, the second marriage group (OR = 1.269, 95%CI 1.031-1.562, p = 0.025) were independent factors associated with the outcome of live birth. After propensity score matching (PSM), the live birth rate of SM group (28.7%) is lower than the FM group (35.9%) (0 = 0.011).

CONCLUSION

The SM family experience higher levels of social and psychological pressure, which lead to lower level of LBR than FM family.

Effect of Stress on Each of the Stages of the IVF Procedure: A Systematic Review

The aim of this systematic review was to examine if chronic or acute stress, measured by questionnaires or physiological biomarkers, has a separate impact on each different stage in the IVF process. A systematic search of peer-reviewed literature was performed in three databases with keywords. Preselection included 46 articles, and in all, 36 articles were included. Most studies concluded that stress has a negative effect on IVF treatment. The egg retrieval time point was most affected by chronic and acute stress. Through this research, there may be an association between chronic stress and the fertilization stage. Only chronic stress impacted the embryo transfer stage and further evidence suggested that stress decreased during this stage. The pregnancy rate stage was weakly associated with stress. Follicular cortisol was found to affect three stages. Chronic and acute stress significantly and negatively affected the egg retrieval time point. Chronic stress was associated with a lesser extent with the fertilization point, and no significant relationship between acute stress and the embryo transfer and pregnancy rate stages were found. Follicular cortisol was found to affect the process. This review contributes to the research of the relationship between stress and IVF success.

Emotional Distress Caused by the Measures Taken in Assisted Reproductive Treatments during the COVID-19 Confinement in Spain

During the pandemic, assisted reproductive treatments suffered from major disruptions in their terms due to the restrictions imposed. The objective of this study is to evaluate the level of anxiety of women whose treatments were either suspended or delayed.

METHODS

Descriptive cross-sectional study conducted between April and May 2020. The State-Trait Anxiety Inventory was applied by telephone in a Spanish adapted version. The research also included social, personal, and work aspects which may be involved in the challenging situation.

RESULTS

A total of 115 patients participated in the study (73.7%). Women showed a mean in trait anxiety of 17.79 (SD = 8.80) and a mean in state anxiety of 19.95 (SD = 9.08). Neither the type of treatment nor the time of infertility were predictors of trait anxiety or state anxiety. Greater age pressure and more worry were associated to greater trait and state anxiety (p < 0.001). The most common emotional reactions to discontinuation of fertility treatments were sadness and anxiety.

CONCLUSIONS

Discontinuation of fertility treatments due to confinement restrictions had a negative impact on the mental health of women who were following a process of assisted reproduction treatment, increasing their levels of emotional distress and anxiety.

Examining Veterans' Experiences With In Vitro Fertilization Provided Under P.L. 114-223

BACKGROUND

Until recently, the Department of Veterans Affairs (VA) medical benefits package has expressly excluded in vitro fertilization (IVF) services for Veterans experiencing fertility problems. However, P.L. 114-223 (2016) allows VHA to provide Assisted Reproductive Technology, including IVF, to certain eligible Veterans. Little is known regarding Veterans' experiences accessing IVF through VA Community Care contracts with IVF providers.

OBJECTIVE

To examine Veterans' experiences with IVF services provided under the auspices of P.L. 114-223.

RESEARCH DESIGN

Telephone or video interviews were conducted with male and female Veterans and opposite-sex spouses of Veterans who had been approved for IVF. Interviews were recorded, transcribed, and analyzed using content analysis techniques. Major themes and representative quotes were derived from the analyses.

RESULTS

Ninety-six Veterans and 14 spouses participated in our interviews. Six major themes arose from these interviews, including (1) the need for improved communication regarding IVF benefits, (2) the need for expanded IVF benefits, (3) the lack of a comprehensive care coordination program, (4) poor access to IVF providers in some areas of the country, (5) special services needed for Veterans with spinal cord injuries, and (6) the IVF policy may be discriminatory in nature to single and LGBTQ Veterans.

CONCLUSIONS

Many Veterans with service-connected conditions related to reproductive health have taken advantage of the IVF benefit, though limitations on these benefits have prevented other Veterans from taking advantage of the IVF benefit. Further attention needs to be paid to improving communication and coordination of IVF services with ongoing VA care and ensuring special populations, including those living in rural areas and Veterans with spinal cord injuries, have access to IVF services as needed.

Effectiveness of psychosocial interventions for infertile women: A systematic review and meta-analysis with a focus on a method-critical evaluation

BACKGROUND

Approximately seven to nine percent of couples of reproductive age do not get pregnant despite regular and unprotected sexual intercourse. Various psychosocial interventions for women and men with fertility disorders are repeatedly found in the literature. The effects of these interventions on outcomes such as anxiety and depression, as well as on the probability of pregnancy, do not currently allow for reliable generalisable statements. This review includes studies published since 2015 performing a method-critical evaluation of the studies. Furthermore, we suggest how interventions could be implemented in the future to improve anxiety, depression, and pregnancy rates.

METHOD

The project was registered with Prospero (CRD42021242683 13 April 2021). The literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six databases were searched and 479 potential studies were discovered. After reviewing the full texts, ten studies were included for the synthesis. Not all studies reported the three outcomes: four studies each for depression, three for anxiety and nine studies for pregnancy rates were included in the meta-analysis, which was conducted using the Comprehensive meta-analysis (CMA) software.

RESULTS

Psychosocial interventions do not significantly change women's anxiety (Hedges' g -0,006; CI: -0,667 to 0,655; p = 0,985), but they have a significant impact on depression in infertile women (Hedges' g -0,893; CI: -1,644 to -0,145; p = 0,026). Implementations of psychosocial interventions during assisted reproductive technology (ART) treatment do not increase pregnancy rates (odds ratio 1,337; 95% CI 0,983 to 1,820; p = 0,064). The methodological critical evaluation indicates heterogeneous study design and samples. The results of the studies were determined with different methods and make comparability difficult. All these factors do not allow for a uniform conclusion.

METHODOLOGICAL CRITICAL EVALUATION

Study design (duration and timing of intervention, type of intervention, type of data collection) and samples (age of women, reason for infertility, duration of infertility) are very heterogeneous. The results of the studies were determined with different methods and make comparability difficult. All these factors do not allow for a uniform conclusion.

CONCLUSION

In order to be able to better compare psychosocial interventions and their influence on ART treatment and thus also to achieve valid results, a standardised procedure to the mentioned factors is necessary.

The Relationship between Attachment, Dyadic Adjustment, and Sexuality: A Comparison between Infertile Men and Women

Infertility impacts several life dimensions. Among them, sexuality is particularly affected; yet studies have mainly focused on infertile women. We aimed to explore infertile men's and women's experiences in sexual satisfaction, internal control, and anxiety, and the relationship between attachment, dyadic adjustment, and sexuality. The sample consisted of 129 infertile people (47.3% females, 52.7% males, Mage = 39 years) who fulfilled an ad hoc questionnaire, the Multidimensional Sexuality Questionnaire (MSQ), the Experiences in Close Relationship-Revised (ECR-R), and the Dyadic Adjustment Scale (DAS). We found a significant effect of type of infertility and infertility factors on sexual anxiety only in infertile men. As regards infertile women, dyadic adjustment predicted sexual satisfaction, anxious attachment decreased sexual internal control, and avoidant attachment reduced sexual anxiety. As regards infertile men, high dyadic adjustment increased sexual satisfaction and a high avoidant attachment predicted high levels of sexual internal control. There was no relationship between attachment, dyadic adjustment, and sexual anxiety for infertile men. From the results, it emerges how important is to consider both dyadic adjustment and attachment in studying how infertility impacts women's and men's lives.

İnfertil kadınlarda kişilik özelliklerinin anksiyete ve depresyon gelişimi üzerine olan etkileri

Amaç: Bu çalışmada infertil kadınların kişilik özelliklerinin anksiyete ve depresyon gelişimi üzerine olan etkilerinin araştırılması amaçlandı. Gereç ve yöntemler: Çalışmaya, Ocak 2015-Agustos 2016 tarihleri arasında tüp bebek merkezine ve kadın doğum polikliniğine başvurmuş olan sırası ile 67 infertil ve 61 fertil kadın olmak üzere toplam 128 kişi dahil edildi. İnfertil grubu primer veya sekonder infertilitesi olup infertilite tedavisi planlanan veya başlanan kadınlar oluşturdu. Kontrol grubunu ise birden fazla sayıda çocuğu olan fertil kadınlar oluşturdu. Her iki gruba Beck Anksiyete Ölçeği (BAÖ), Beck Depresyon Ölçeği (BDÖ), Eysenck Kişilik Anketi (EKA) ve Çift Uyum Ölçeği (ÇUÖ) uygulandı. Bulgular: İnfertil ve fertil gruplar arasında yaş gruplarının dağılımı açısından anlamlı bir fark tespit edilmedi. Bununla birlikte BAÖ, BDÖ ve ÇUÖ toplam ortalama puanları infertil grupta anlamlı olarak daha yüksek tespit edildi. Kişilik ve çift uyum ölçeklerinde nörotizm, yalan, çift doyumu, çift uyumu ve sevgi alt ölçekleri ortalama puanları infertil grupta anlamlı olarak daha yüksek bulunurken; dışa-dönüklük, psikotizm ve çiftlerin bağlılığı alt ölçekleri ortalama puanları açısından iki grup arasında anlamlı bir fark izlenmedi. Korelasyon analizinde nörotizm ile anksiyete ve depresyon arasında pozitif yönde; dışa-dönüklük ile anksiyete ve depresyon arasında negatif yönde zayıf bir ilişki bulundu. Sonuç: Bu çalışmaya göre infertil kadınlarda nörotizm kişilik özelliğine sahip olanların anksiyete ve depresyon gelişimine daha yatkın olabileceği düşünülebilir.

Restraint stress of female mice during oocyte development facilitates oocyte postovulatory aging

Studies suggest that psychological stress on women can impair their reproduction and that postovulatory oocyte aging (POA) might increase the risk of early pregnancy loss and affect offspring's reproductive fitness and longevity. However, whether psychological stress during oocyte development would facilitate POA is unknown but worth exploring to understand the mechanisms by which psychological stress and POA damage oocytes. This study observed effects of female restraint stress during oocyte development (FRSOD) on oocyte resistance to POA. Female mice were restrained for 48 h before superovulation, and they were sacrificed at different intervals after ovulation to recover aging oocytes for analyzing their early and late aged characteristics. The effects of FRSOD on aging oocytes included: (1) increasing their susceptibility to activation stimulus with elevated cytoplasmic calcium; (2) impairing their developmental potential with downregulated expression of development-beneficial genes; (3) facilitating degeneration, cytoplasmic fragmentation and apoptosis; (4) worsening the disorganization of cortical granules and spindle/chromosomes; and (5) impairing redox potential with increased oxidative stress. In conclusion, FRSOD impairs oocyte resistance to POA, so that stressed oocytes become aged significantly quicker than unstressed controls. Thus, couples wishing to achieve pregnancy should take steps to avoid not only fertilization of aged oocytes but also pregestational stressful life events.

Chronic unpredictable mild stress-induced mouse ovarian insufficiency by interrupting lipid homeostasis in the ovary

Ovarian insufficiency results from a number of disorders, and a certain causal relationship between psychological stress and ovarian insufficiency has been reported, but the underlying mechanism remains unclear. In our study, C57BL/6J female mice were subjected to chronic unpredictable mild stress (CUMS), and depression-like mice were selected and identified according to the behavioral tests. The defective ovarian follicle development, low 17 β-estradiol (E₂), and anti-Mullerian hormone (AMH) levels, which were consistent with the clinical characteristics of ovarian insufficiency, indicated that depression-like mice may be used to assess the effects of psychological stress on female reproductive function. To investigate a possible mechanism, lipid homeostasis of the ovary was detected by liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis, and the decreased abundance of cholesteryl ester (CE 24:4) was supported to be associated with the downregulated E₂. Moreover, granulosa cells did undergo more apoptosis in response to psychological stress, which was caused by downregulated Bcl2 and Bcl2/Bax in granulosa cells. Additionally, the disorder of cell death and growth-related pathways in depression-like mouse ovaries was confirmed by RNA-seq analysis. Taken together, this study will provide a better understanding of the female reproductive problem under psychological stress.

Psycho-emotional stress, folliculogenesis, and reproductive technologies: clinical and experimental data

Modern life, especially in large cities, exposes people to a high level of noise, high density of population, disrupted sleeping, large amount of excessive and controversial information as well as to other negative factors; all this may cause chronic psycho-emotional stress. The latest publications often use the term “Syndrome of megalopolis”, which means disruption of sleeping, high anxiety, and altered reproductive function. Medical treatment of infertility may also be considered as a stress factor, especially when infertility lasts for years and is aggravated with emotional frustration. Long-lasting distress may worsen health in general and suppress reproductive function, in particular. The review presents the data on the effects of maternal stress on folliculogenesis, especially when assisted reproductive technologies (ARTs) are used. Clinical data are presented alongside data from laboratory animal experiments. Different maternal stress models are taken into account in respect of their inf luence on oocyte maturation and embryo development. The interfering of psycho-emotional stress and reproductive function is the focus of the review. In these situations, exogenous hormones compensate for the stress-related disruption of the hypothalamic-pituitary-gonadal axis. When ARTs are implemented, stress-induced disruption of oogenesis is realized not via a decrease in hypothalamic and pituitary hormones, but by other ways, which involve paracrine mechanisms described in this review. Based on the literature analysis, one may conclude that stress negatively affects oocyte maturation in the ovary and suppresses subsequent embryo development. The role of some ovarian paracrine factors, such as BDNF, GDF-9, HB-EGF, TNF-α, and some others has been elucidated

Impact of prolonged one or more natural menstrual cycles on the outcomes of ovulation induction intrauterine artificial insemination pregnancy: a single-centre, retrospective study in China

OBJECTIVES

We determined if the time interval between two ovulation induction intrauterine artificial insemination (IUI) treatment cycles should be extended by one or more natural menstrual cycles in patients undergoing successive cycles of ovulation stimulation, and whether this affects clinical pregnancy rate (CPR).

DESIGN

This study was conducted on infertility patients treated under the ovulation induction programme IUI in a large reproductive centre in China. Study participants were assigned into continuous and discontinuous groups. Differences in baseline clinical pregnancy and abortion rates were compared between the groups. A multivariate logistic model was used to evaluate the effects of time interval on clinical pregnancy outcomes.

SETTING

Reproductive Centre of Maternal and Child Health Hospital of Lianyungang city.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was CPR, the secondary outcome measure was the abortion rate.

RESULTS

A total of 550 IUI treatment cycles involving 275 couples were included in this study. Differences in CPR and abortion rate between the groups were not significant (20.5% vs 21.9% and 27.8% vs 22.0%, p≥0.05). Stratified analyses based on infertility factors did not reveal any significant differences in pregnancy and abortion rates between the groups (p≥0.05). Multivariate analysis showed that increased endometrial thickness correlates with CPR (OR 1.205, 95% CI 1.05 to 1.384, p=0.008). Compared with primary infertility, secondary infertility significantly correlated with improved CPR (OR 2.637, 95% CI 1.313 to 5.298, p=0.006). The effects of time interval between the first two ovulation induction IUI treatment cycles on clinical pregnancy were not significant (OR 1.007, 95% CI 0.513 to 1.974, p=0.985).

CONCLUSIONS

Longer time intervals between the first two ovulation induction IUI treatment cycles did not significantly improve CPR. Therefore, in the absence of clear clinical indications, it may not be necessary to deliberately prolong the interval between two ovulation induction IUI treatment cycles.

Emotions, Stress and Coping among Healthcare Workers in a Reproductive Medicine Unit during the First and Second COVID-19 Lockdowns

The impact of the COVID-19 pandemic on global healthcare workers’ (HCWs) mental health has been well documented in the last two years; however, little is known regarding HCWs working in specific healthcare fields. During two subsequent periods of national lockdown in Italy (June–July 2020, T1, and November–December 2020, T2), a total sample of 47 HCWs working in a reproductive medicine hospital unit completed an ad hoc questionnaire for assessing emotional reactions to the pandemic, stress symptoms, and ways of coping. Moderate–high levels of anger and sadness were experienced by 65.9% and 68.1% of the HCWs, respectively, while moderate–high levels of anxiety and fear were experienced by 51.1% and 56.8%, respectively. Higher stress symptoms experienced by HCWs were hypervigilance, avoidance of thoughts and memories, and tiredness/low energy. At T2, levels of hypervigilance, irritability, intrusive thoughts, and detachment were higher than at T1, while avoidance of external triggers decreased. Moderate–high levels of anxiety resulted significantly associated with several symptoms of stress: irritability/fearfulness, depression/hopelessness, tiredness/low energy, problems with concentration, and intrusive thoughts. Regarding coping strategies, HCWs tended to adopt more problem-focused coping (e.g., contributing to improving a situation) and this tendency was higher at T2. Overall findings suggest a risk for the persistence of stress symptoms and, therefore, a risk for a chronic course, which might interfere with the global quality of mental health at work and the care provided to patients. Clinical implications highlight the relevance of implementing support programs for this category of HCWs focused on the elaboration of negative emotions and on fostering adaptive coping strategies.

Sociodemographic differences in utilization of fertility services among reproductive age women diagnosed with cancer in the USA

PURPOSE

To determine whether sociodemographic differences exist among female patients accessing fertility services post-cancer diagnosis in a representative sample of the United States population.

METHODS

All women ages 15-45 with a history of cancer who responded to the National Survey for Family Growth (NSFG) from 2011 to 2017 were included. The population was then stratified into 2 groups, defined as those who did and did not seek infertility services. The demographic characteristics of age, legal marital status, education, race, religion, insurance status, access to healthcare, and self-perceived health were compared between the two groups. The primary outcome measure was the utilization of fertility services. The complex sample analysis using the provided sample weights required by the NSFG survey design was used.

RESULTS

Five hundred forty-five women reported a history of cancer and were included in this study. Forty-three (7.89%) pursued fertility services after their cancer diagnosis. Using the NSFG sample weights, this equates to a population of 161,500.7 female cancer survivors in the USA who did utilize fertility services and 1,811,955.3 women who did not. Using multivariable analysis, household income, marital status, and race were significantly associated with women utilizing fertility services following a cancer diagnosis.

CONCLUSIONS

In this nationally representative cohort of reproductive age women diagnosed with cancer, there are marital, socioeconomic, and racial differences between those who utilized fertility services and those who did not. This difference did not appear to be due to insurance coverage, access to healthcare, or perceived health status.

Effectiveness of music therapy as an adjuvant to conscious sedation in women undergoing transvaginal oocyte retrieval: A randomized controlled trial

AIM

Assisted reproductive technique (ART) has emerged as the highest form of treatment for infertile couples. Transvaginal oocyte retrieval is currently performed under conscious sedation in most centers. Since it is a relatively painful procedure, a number of adjuvant therapies have been tried to improve pain relief during the procedure. Music therapy is a nonpharmacological technique that has been successfully used for pain relief in perioperative and chronic pain of malignancy. However, studies evaluating its usefulness in ART-related procedures are limited. We evaluated the effectiveness of music therapy as an adjuvant for pain relief during oocyte retrieval.

METHODS

This was a randomized controlled trial conducted at a tertiary level teaching hospital in South India from September 2020 to March 2021. All women undergoing transvaginal oocyte retrieval were randomized to receive either music therapy along with conscious sedation (Group A) or conscious sedation alone (Group B). The primary outcome was postprocedure pain score assessed by the visual analog scale. Secondary outcomes included anxiety score.

RESULTS

A total of 109 women were randomized into Group A (54 women) and Group B (55 women). The postprocedure pain score was comparable between the two study groups (6.0, interquartile range [IQR] 4 to 6 vs. 6.0, IQR 4 to 6; p = 0.69). However, anxiety levels were found to be significantly lower in women who were offered music therapy (3.0, IQR 1 to 5 vs. 4.0, IQR 3 to 6; p = 0.004).

CONCLUSION

The use of music therapy as an adjuvant to conscious sedation was found to have no significant benefit in pain relief during oocyte retrieval.

Impact of sleep patterns upon female neuroendocrinology and reproductive outcomes: a comprehensive review

Sleep is vital to human bodily function. Growing evidence indicates that sleep deprivation, disruption, dysrhythmia, and disorders are associated with impaired reproductive function and poor clinical outcomes in women. These associations are largely mediated by molecular-genetic and hormonal pathways, which are crucial for the complex and time sensitive processes of hormone synthesis/secretion, folliculogenesis, ovulation, fertilization, implantation, and menstruation. Pathologic sleep patterns are closely linked to menstrual irregularity, polycystic ovarian syndrome, premature ovarian insufficiency, sub/infertility, and early pregnancy loss. Measures of success with assisted reproductive technology are also lower among women who engage in shift work, or experience sleep disruption or short sleep duration. Extremes of sleep duration, poor sleep quality, sleep disordered breathing, and shift work are also associated with several harmful conditions in pregnancy, including gestational diabetes and hypertensive disorders. While accumulating evidence implicates pathologic sleep patterns in impaired reproductive function and poor reproductive outcomes, additional research is needed to determine causality and propose therapeutic interventions.

Immersive virtual reality as tool to reduce anxiety during embryo transfer

The use of Virtual Reality (VR) has gained wide acceptance in several scientific fields. It represents an innovative technological tool providing the experience to be immersed in a non-physical world putting on head-mounted displays that surround the users with images and sounds. To date, VR has been mainly employed in the healthcare sector for educational aims, in order to provide the learners with a new method of delivering simulations. However, its application to real clinical practice has recently generated beneficial effects for patients, especially for those who experience symptoms of psychological burden. Infertile couples often struggle with anxiety and depression which have a strong impact on life quality. Furthermore, the perspective to undergo long treatments with uncertain results and an history of failed attempts may contribute to enhance patients' negative feelings during In Vitro Fertilization (IVF) cycles until Embryo Transfer (ET). The role of VR in reducing pain and anxiety during outpatient hysteroscopy, hysterosalpingography and oocytes retrieval, has been recently investigated with satisfactory results in terms of reducing pain and anxiety levels. However, to date, inconclusive outcomes have been reported on pregnancy rate. Our study would discuss the existent literature on VR applied to current medical practice and infertility, proposing its beneficial impact on women anxiety during IVF cycle with ET.

Understanding the cross-talk between mediators of infertility and COVID-19

COVID-19 is the ongoing health emergency affecting individuals of all ages around the globe. Initially, the infection was reported to affect pulmonary structures. However, recent studies have delineated the impacts of COVID-19 on the reproductive system of both men and women. Hence, the present review aims to shed light on the distribution of SARS-CoV-2 entry factors in various reproductive organs. In addition, impacts of COVID-19 mediators like disrupted renin angiotensin system, oxidative stress, cytokine storm, fever, and the mental stress on reproductive physiology have also been discussed. For the present study, various keywords were used to search literature on PubMed, ScienceDirect, and Google Scholar databases. Articles were screened for relevancy and were studied in detail for qualitative synthesis of the review. Through our literature review, we found a multitude of effects of COVID-19 mediators on reproductive systems. Studies reported expression of receptors like ACE-2, TMPRSS2, and CD147 in the testes, epididymis, prostrate, seminal vesicles, and ovarian follicles. These proteins are known to serve as major SARS-CoV-2 entry factors. The expression of lysosomal cathepsins (CTSB/CTSL) and/ neuropilin-1 (NRP-1) are also evident in the testes, epididymis, seminal vesicles, fallopian tube, cervix, and endometrium. The binding of viral spike protein with ACE-2 was found to alter the renin-angiotensin cascade, which could invite additional infertility problems. Furthermore, COVID-19 mediated cytokine storm, oxidative stress, and elevated body temperature could be detrimental to gametogenesis, steroidogenesis, and reproductive cycles in patients. Finally, social isolation, confinement, and job insecurities have fueled mental stress and frustration that might promote glucocorticoid-mediated subnormal sperm quality in men and higher risk of miscarriage in women. Hence, the influence of COVID-19 on the alteration of reproductive health and fertility is quite apparent.

Levels of anxiety sensitivity, somatosensory amplification and alexithymia in patients with unexplained infertility

OBJECTIVE

In this study, we aimed to focus on the psychological aspect of unexplained infertility by comparing their psychological features to those of infertile patients with a known causes and fertile patients.

PATIENTS AND METHODS

Sixty unexplained infertility patients, 50 infertile patients with a known cause and 56 fertile patients were included in the study. Patients were evaluated using socio-demographic data form, Toronto Alexithymia Scale (TAS-20), Somatosensory Amplification Scale (SAS) and Anxiety Sensitivity Index (ASI-3).

RESULTS

No significant differences in the levels of alexithymia, somatosensory amplification and anxiety sensitivity were detected between the groups (P > .05). When the correlation of clinical scale scores with each other was analysed in the whole group of infertile patients regardless of the cause, a weak positive correlation was found between anxiety sensitivity and difficulty in identifying feelings.

CONCLUSION

In our study, it has been found out that; regardless of the knowledge of the aetiology of infertility, the levels of alexithymia, somatosensory amplification and anxiety sensitivity of infertile cases did not differ from those of fertile women. However, it has been shown that as the difficulty in identifying emotions increases in infertile cases, anxiety sensitivity, which may cause psychological infertility, also increases.

Stress, anxiety, and depression in infertile couples are not associated with a first IVF or ICSI treatment outcome

BACKGROUND

Psychological distress may exert a negative influence on reproductive function of couples at reproductive age. Couples seeking assisted reproductive technology (ART) treatment may have a higher prevalence of psychological distress than fertile couples. However, whether psychological distress is associated with the outcome of ART treatment remains unknown. We aimed to investigate the association of pre-treatment psychological distress and clinical pregnancy rate among infertility couples undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment.

METHODS

This nested case-control study was conducted based on women who underwent their first fresh IVF or ICSI cycle in the Jiangsu Birth Cohort Study (JBC) between November 2015 and January 2019. A total of 150 women who did not obtain clinical pregnancy after first IVF or ICSI fresh embryo transfer were identified as cases, and a total of 300 age matched women who obtained clinical pregnancy were identified as controls. Conditional logistic regression analyses were used to investigate the association between psychological distress and the outcome of first IVF or ICSI treatment, adjusting for multiple potential confounders.

RESULTS

No statistically significant association was observed between score of maternal symptoms of psychological distress and clinical pregnancy. Adjusted ORs of logistic regression were 1.00 (95% CI 0.97-1.03) for anxiety, 0.98 (95% CI 0.95-1.02) for depression, and 0.98 (95% CI 0.95-1.01) for perceived stress, respectively. When treat depression and anxiety as categorical variables, 62 (13.8%) were classified as clinical depression, 11 (2.4%) were classified as clinical anxiety, among 450 women in the present study. Psychological distress symptoms were also not associated with clinical pregnancy rate. Adjusted ORs of logistic regression were 0.27 (95% CI 0.03-2.33) for anxiety, 0.88 (95% CI 0.46-1.68) for depression, respectively.

CONCLUSIONS

Our findings firstly indicated that psychological distress experienced prior to IVF/ICSI treatment was not associated with clinical pregnancy.

d-Leucine protects oocytes from chronic psychological stress in mice

PURPOSE

Psychological stress could negatively influence female reproductive ability. d-Leucine (d-Leu) is a d-type amino acid found in foods and mammalian tissues. We have examined the protective effects of d-Leu on oocyte abnormality induced by psychological stress.

METHODS

Female mice (6-week-old) were divided into three groups: control, restraint stress (RS), and RS/d-Leu. The RS and RS/d-Leu mice were holed for 3 hours daily during 14 days. RS/d-Leu mice were fed 0.3% d-Leu diet. The oocyte maturation failure was analyzed by shapes of spindles and chromosomes. In addition, levels of heme-oxygenase-1 (HO-1) and superoxide dismutase (SOD) expression in the ovaries were also examined. Whether d-Leu reduces the generation of reactive oxygen species (ROS) in cultured cells, K562 cells were treated with d-Leu, and then ROS in K562 were analyzed.

RESULTS

Oocyte maturation failure was increased in RS mice. d-Leu reduced abnormal oocytes to control level. The expression levels of HO-1 and SOD2 increased in RS/d-Leu mice compared to those of RS mice. ROS levels were decreased in K562 cells with d-Leu in a dose-dependent manner.

CONCLUSIONS

We concluded that d-Leu protects oocytes from psychological stress through the induction of HO-1 and SOD2 expression then by reducing oxidative stress.

An Antagonistic Peptide of Gpr1 Ameliorates LPS-Induced Depression through the Hypothalamic-Pituitary-Ovarian Axis

Depression affects the reproductive axis at the hypothalamus and pituitary levels, which has a significant impact on female fertility. It has been reported that G protein-coupled receptor 1 (Gpr1) mRNA is expressed in both the hypothalamus and ovaries. However, it is unclear whether there is a relationship between Gpr1 and depression, and its role in ovarian function is unknown. Here, the expression of Gpr1 was recorded in the hypothalamus of normal female mice, and co-localized with gonadotrophin-releasing hormone (GnRH) and corticotropin-releasing factor (CRF). We established a depression mouse model to evaluate the antidepressant effect of G5, an antagonistic peptide of Gpr1. The results show that an intraperitoneal injection of G5 improves depressant–like behaviors remarkably, including increased sucrose intake in the sucrose preference test and decreased immobility time in the forced swimming tests. Moreover, G5 treatment increased the release of reproductive hormone and the expression of ovarian gene caused by depression. Together, our findings reveal a link between depression and reproductive diseases through Gpr1 signaling, and suggest antagonistic peptide of Gpr1 as a potential therapeutic application for hormone-modulated depression in women.

An Antagonistic Peptide of Gpr1 Ameliorates LPS-Induced Depression through the Hypothalamic-Pituitary-Ovarian Axis

Depression affects the reproductive axis at the hypothalamus and pituitary levels, which has a significant impact on female fertility. It has been reported that G protein-coupled receptor 1 (Gpr1) mRNA is expressed in both the hypothalamus and ovaries. However, it is unclear whether there is a relationship between Gpr1 and depression, and its role in ovarian function is unknown. Here, the expression of Gpr1 was recorded in the hypothalamus of normal female mice, and co-localized with gonadotrophin-releasing hormone (GnRH) and corticotropin-releasing factor (CRF). We established a depression mouse model to evaluate the antidepressant effect of G5, an antagonistic peptide of Gpr1. The results show that an intraperitoneal injection of G5 improves depressant–like behaviors remarkably, including increased sucrose intake in the sucrose preference test and decreased immobility time in the forced swimming tests. Moreover, G5 treatment increased the release of reproductive hormone and the expression of ovarian gene caused by depression. Together, our findings reveal a link between depression and reproductive diseases through Gpr1 signaling, and suggest antagonistic peptide of Gpr1 as a potential therapeutic application for hormone-modulated depression in women.

The relationship between psychological coping and mood across the menstrual cycle among distressed women struggling to conceive

OBJECTIVES

Infertility is disproportionately associated with distress in women yet there has been limited research focusing on the relationship between coping strategies and fertility-monitoring techniques on distress in women struggling to conceive naturally.

METHODS

Fifty-eight distressed women with infertility were recruited via social media. Every second day women's depressive and anxious mood was assessed in the morning and again in the evening along with their psychological coping strategies, the use of fertility monitoring techniques, and Fertility Quality of Life emotion subscale, over the course of one full menstrual cycle.

RESULTS

During menstruation and statistically adjusting for morning depressive mood, active coping (β(SE) = -1.35 (0.36), p < .001) and behavioural engagement (β(SE) = -0.98 (0.35), p = .006) were associated with less depressive mood in the evening. Across all phases, social support seeking was associated with greater anxiety (β(SE) = 0.50 (0.20), p = .013) and lower emotional quality of life (β(SE) = -0.82 (0.32), p = .011). Use of fertility monitoring techniques was associated with heightened anxiety (M(SE) = 6.7 (0.2) vs. 5.9 (0.2), p < .001). The use of avoidance strategies (β(SE) = 3.22 (1.29), p = .016), endorsement of optimism (β(SE) = -4.72 (1.78), p = .011) and social support seeking (β(SE) = 3.09 (1.18), p = .012) throughout the cycle were significantly predictive of depression ratings following a negative pregnancy test, despite statistically adjusting for mean depression ratings throughout the menstrual cycle.

CONCLUSION

These findings highlight a number of cognitive and behavioural strategies that could be manipulated via psychological interventions to improve distress among women struggling to conceive.

Does exercise during pregnancy impact organs or structures of the maternal-fetal interface?

Exercise during pregnancy has been shown to be associated with improved health outcomes both during and after pregnancy for mother and fetus across the lifespan. Increasing physical activity and reducing sedentary behaviour during pregnancy have been recommended by many researchers and clinicians-alike. It is thought that the placenta plays a central role in mediating any positive or negative pregnancy outcomes. The positive outcomes obtained through prenatal exercise are postulated to result from exercise-induced regulation of maternal physiology and placental development. Considerable research has been performed to understand the placenta's role in pregnancy-related diseases, such as preeclampsia, fetal growth restriction, and gestational diabetes mellitus. However, little research has examined the potential for healthy lifestyle and behavioural changes to improve placental growth, development, and function. While the placenta represents the critical maternal-fetal interface responsible for all gas, nutrient, and waste exchange between the mother and fetus, the impact of exercise during pregnancy on placental biology and function is not well known. This review will focus on prenatal exercise and its promising influence on the structures of the maternal-fetal interface, with particular emphasis on the placenta. Potential molecular mechanistic hypotheses are presented to aid future investigations of prenatal exercise and placental health.

Restraint stress and elevation of corticotrophin-releasing hormone in female mice impair oocyte competence through activation of the tumour necrosis factor α (TNF-α) system

Studies have observed that restraint stress (RS) and the associated elevation in corticotrophin-releasing hormone (CRH) impair oocyte competence by triggering apoptosis of ovarian cells but the underlying mechanisms are largely unclear. Although one study demonstrated that RS and CRH elevation triggered apoptosis in ovarian cells and oocytes via activating Fas/FasL signalling, other studies suggested that RS might damage cells by activating other pathways as well as Fas signalling. The objective of this study was to test whether RS and CRH elevation impairs oocytes by activating tumour necrosis factor α (TNF-α) signalling. Our invivo experiments showed that RS applied during oocyte prematuration significantly increased expression of TNF-α and its receptor (TNFR1) while inducing apoptosis in both oocytes and mural granulosa cells (MGCs). Invitro treatment of MGCs with CRH significantly increased their apoptotic percentages and levels of TNF-α and TNFR1 expression. Invitro knockdown by interfering RNA, invivo knockout of the TNF-α gene or injection of TNF-α antagonist etanercept significantly relieved the adverse effects of RS and CRH on apoptosis of MGCs and/or the developmental potential and apoptosis of oocytes. The results suggest that RS and CRH elevation in females impair oocyte competence through activating TNF-α signalling and that a TNF-α antagonist might be adopted to ameliorate the adverse effects of psychological stress on oocytes.

Pregnancy or Psychological Outcomes of Psychotherapy Interventions for Infertility: A Meta-Analysis

Background: The pregnancy and psychological status of infertile couples has always been a concern, but there is no clear evidence for the efficacy of psychotherapy for infertile couples. This study aimed to summarize the current evidence of the effects of psychotherapy on psychological and pregnancy outcomes for infertile couples.

Method: We searched Ovid MEDLINE, Ovid EMbase, The Cochrane Library, and Web of Science (ISI) for articles published from 1946 to June 26, 2020. The pregnancy outcomes, psychological outcomes, and acceptability were involved in the study.

Results: Overall, 29 studies with a combined total of 3,522 adult participants were included in the meta-analysis. Compared with a placebo, psychotherapy was associated with the pregnancy rate [risk ratio (RR) = 1.43, 95% CI [1.07, 1.93]], total psychological scales associated with infertility [standardized mean difference (SMD) = −0.33 95% CI [−0.63, −0.02]], subsymptoms of psychological scores using the 28-item version of GHQ (including social function [MD = −3.10, 95% CI [−4.30, −1.90]] and depression [MD = −3.90, 95% CI [−5.36, −2.44]], and depression [MD = 3.60, 95% CI [2.25, 4.95]] using the 14-item version of Hospital Anxiety and Depression Scale, but it had no statistically significant association with the other outcomes. In the stratified analyses, the pregnancy rate using assisted reproduction, cognitive behavioral therapy (CBT), and the integrative body–mind–spirit (BMS); total psychological scales associated with infertility using other treatments and more than a month; and anxiety using BMS had significant statistical significance. The funnel plots of all outcomes were approximately symmetrical, and no significant publication bias was found.

Conclusions: The study showed that psychotherapy can lead to improvements in the pregnancy rate for infertile patients, especially for patients receiving assisted fertility. In addition, it may help improve total psychological scales associated with infertility and depression. CBT and BMS play an important role in improving rate of pregnancy, and BMS is associated with reducing anxiety. Although psychological interventions had limited effects on the pregnancy outcomes of infertility, our study still recommended that psychotherapies, in particular CBT and BMS, were applied to the therapeutic regimen for infertility, especially for patients receiving assisted fertility.

Does a Career in Orthopaedic Surgery Affect a Woman's Fertility?

BACKGROUND

Orthopaedic surgery lags behind other specialties in the recruitment of women. Concerns about fertility, pregnancy, and childbearing may be a deterrent to women when considering orthopaedic surgery as a specialty.

METHODS

An anonymous 168-item survey was distributed to the members of Ruth Jackson Orthopedic Society and the Women in Orthopaedics, an online group exclusive to female orthopaedic surgeons. Respondents were queried regarding family planning, contraceptive length of use, fertility, perinatal work habits, age and stage at each pregnancy, pregnancy complications, and miscarriages.

RESULTS

Eight hundred one surveys were collected. Seven hundred fifty (94%) expressed interest in having children of their own, with 60% having at least one child at the time of the survey. The average maternal age at birth of the first child was 33.6 ± 3.6 years. Voluntary childlessness was reported by 6% (49/801) of survey respondents. Eighteen percent of this group stated that their choice as an orthopaedic surgeon served as a barrier to having children. Among those with children, childbearing was intentionally delayed by 53% because of their career choice (425/801). Fifty-two percent did not conceive their first child until the end of their training. Complications during pregnancy were reported among 24%. A total of 853 children were conceived by this cohort with assisted reproductive technology being used 106 times. Miscarriages were reported by 38% (304/801). Of those who miscarried, only 28% informed their employer and 8% took time off during or immediately after their miscarriage.

CONCLUSION

Most respondents desire to have children but two-thirds delay doing so because of their career choice and its demands. Having a family is an important part of life for many orthopaedic surgeons, and our study provides an updated description of the fertility and pregnancy characteristics of female orthopaedic surgeons to help guide present and future surgeons in their family planning.

Oxidative Stress Reduction by Midazolam Premedication during Oocyte Retrieval Procedure: Pilot Study

Infertility is one of the major medical problems nowadays. Couples who opt for In Vitro Fertilization (IVF) face a great deal of stress which certainly affects the outcome of the procedure. Therefore, we aimed to reduce the stress during the oocyte retrieval procedure by applying midazolam. Total oxidant (TOC) and antioxidant (TAC) capacities of serum, as well as glutathione (GSH) content and catalase activity, were measured in both control and midazolam groups. Follicular fluid was also tested for oxidant capacity and IL1β. Results implied that the midazolam group increased TAC at the end of the procedure. At the same time, the control group decreased GSH at the beginning of the procedure, and both groups decreased catalase activity at the end of the procedure. The results imply that stress during the procedure affects oxidative and antioxidative parameters of the patients, but did not affect the frequency of the pregnancy at the end of this pilot study. Yet, the results imply that oxidative and antioxidative mechanisms during IVF should be investigated in detail as they could affect the outcome of IVF.

Psychological coping strategies associated with improved mental health in the context of infertility

To examine the use of psychological coping strategies across the menstrual cycle in relation to within-person changes in depressed mood, anxious mood, and infertility-related distress, in a sample of women struggling to conceive. Sixty-five women from Canada and the USA (aged 19-43 years) trying to conceive naturally for ≥ 12 months were recruited via social media. On the first day of each participant's menstrual period, and every 3 days until the end of their cycle, participants completed questionnaires assessing depressed and anxious mood, and infertility-related distress. In addition, participants completed a 13-item coping questionnaire assessing four general coping strategies: emotional suppression, active coping, engagement in activities unrelated to trying to conceive, and downplaying the importance of biological children. The within-person effect of daily coping strategies on person-centred mood and infertility-related distress was examined. Day-to-day use of behavioural engagement was associated with lower person-centred depression scores, β(SEM) = - 3.25(.51), p < .0001, anxiety scores, β(SEM) = - 2.07(.36), p < .0001, and infertility-related daily distress, β(SEM) = - .64(.22), p = .005. Downplaying the importance of biological children was also associated with person-centred depression scores, β(SEM) = 1.14(.47), p = .016. Neither active coping nor emotional suppression was related to depression, anxiety, or distress (ps > .0125). These findings point to promising targets of future intervention studies, including promoting increased engagement in behaviours unrelated to conceiving and promoting acceptance, rather than denial and resistance, of feelings throughout the infertility journey.

The association between level of physical activity and pregnancy rate after embryo transfer: a prospective study

RESEARCH QUESTION

Is physical activity after embryo transfer, as assessed by a smart band activity tracker, associated with decreased pregnancy rates?

DESIGN

Prospective observational cohort study comprising infertile women aged < 38 years, who had undergone fewer than three previous embryo transfers, achieved a good ovarian response and were undergoing frozen-thawed embryo transfer in a tertiary-referral centre. A validated smart band activity tracker was used to assess physical activity level immediately after the embryo transfer and until the pregnancy test. No specific recommendations were given to participants on level or intensity of physical activity. Physicians and patients were blinded to the data stored in the pedometer. Primary outcome was ongoing pregnancy rate.

RESULTS

Fifty women met the inclusion criteria. Ongoing pregnancy rate was 30%. In a pooled analysis, participants walked significantly fewer steps per day on the day of embryo transfer compared with the first 2 days after embryo transfer (4075, interquatile range [IQR] 2932-5592 versus 5204, IQR4203-8584, P = 0.01). No significant difference was observed between pregnant women and non-pregnant women in the median steps per day after embryo transfer until serum beta-HCG was measured (7569, IQR 6008-10884 versus 6572.5, IQR 5299-8786, P = 0.43). No significant difference was observed in the median number of steps on the day of embryo transfer or the first 2 days after embryo transfer between pregnant and non-pregnant women.

CONCLUSIONS

A quantitative objective assessment of the association between physical activity and pregnancy rates after frozen-thawed embryo transfer was conducted. Ambulation after embryo transfer has no adverse effect on pregnancy rates and, therefore, women should resume regular activity immediately after embryo transfer.

Suspension of fertility treatment during the COVID-19 pandemic: views, emotional reactions and psychological distress among women undergoing fertility treatment

RESEARCH QUESTION

What are the views and emotional reactions of patients towards the suspension of fertility treatment during the COVID-19 pandemic, and what are the factors affecting their psychological distress?

DESIGN

A cross-sectional study conducted in an academic fertility centre. Online questionnaires were distributed between 18 April 2020 and 23 April 2020 to patients whose treatment cycle had been postponed or discontinued. The outcome measures included agreement with the reproductive society guidelines to postpone treatments; willingness to resume treatments, given the choice; patients' emotional reactions; and psychological distress level, measured by the Mental Health Inventory validated scale. A multivariate linear regression was conducted to identify factors associated with psychological distress.

RESULTS

Because of the small number of male respondents, only women were included in the analysis (n = 181). Forty-three per cent expressed disagreement with the guidelines and 82% were willing to resume treatments, given the choice. Sadness and anxiety were the most common emotional reactions expressed towards the guidelines. In the multivariate analysis, COVID-19-related anxiety (B = 0.145, P = 0.04) and disagreement with treatment suspension (B = -0.44, P = 0.001) were found to be significantly associated with patients' psychological distress. Background characteristics of patients did not contribute significantly to their distress.

CONCLUSIONS

Suspension of fertility treatment during the initial phase of the COVID-19 pandemic was associated with patients' negative emotional reactions. Anxiety related to COVID-19 and disagreement with treatment suspension were found to be significantly associated with psychological distress among women undergoing fertility treatment, regardless of their background characteristics. Our findings suggest the need to monitor the mental health of patients and provide psychological support should a shutdown of fertility care re-occur.

Anxiety Level During the Second Localized COVID-19 Pandemic Among Quarantined Infertile Women: A Cross-Sectional Survey in China

Infertility usually causes mental health problems for patients and unfavorable emotions such as anxiety and depression can have an adverse effect on women's normal pregnancy. We aimed to compare the anxiety level between infertile female patients in quarantined and non-quarantined areas during the second wave of COVID-19 epidemic. A total of 759 infertile women were included in this cross-sectional study conducted through an online survey. Anxiety was measured by the State-Trait Anxiety Inventory (STAI) tool. Participants were divided into the quarantined group (QG) and non-quarantined group (Non-QG). Independent sample T-test and chi-square test were performed to examine the difference between the two groups. There was no significant difference in the average STAI score of the two groups of infertile women, but responses to the emotional state showed that women in the QG had a higher tendency to be anxious. Participants in QG spent more time paying attention to the dynamics of the epidemic every day, and their sleep (p < 0.01) and mood conditions were worse (p < 0.01) than in the Non-QG. The family relationship of QG is more tense than non-QG. Through the research on the infertility treatment information of the overall research population, it is found the average STAI-State (STAI-S) (p = 0.031) score and STAI-Trait (STAI-T) (p = 0.005) score of women who were infertile for more than 3 years were significantly higher than those of women with <2 years. The STAI-T score of infertile women who underwent in vitro fertilization (IVF) was higher than that of non-IVF women (p = 0.007), but no significant difference was observed with the STAI-S score. To conclude, although the second wave of quarantine during COVID-19 epidemic did not significantly increase anxiety in infertile women, it did lead to an increase in other negative emotions and worse family relationships. Patients with long-term infertility treatment and those who have had IVF are more anxious subgroups.

The effect of psychological distress on IVF outcomes: Reality or speculations?

Introduction

Infertility is a problem that affects millions of people worldwide. The aim of this study was to assess the effect of stress, depression and anxiety on the IVF outcomes in Kazakhstan.

Methods

The prospective cohort study was performed using questionnaires to assess psychological distress in 304 infertile female in three different cities in Kazakhstan.

Results

The average age of participants was 33.7 years with infertility duration of 5.9 years. Regarding stress, depression and anxiety we found that more than 80% of all respondents had CES-D score higher than 16, indicating that they are at risk of developing clinical depression. On average, FPI subscales’ scores, global stress score and anxiety scale (STAI-S and STAI-T) scores were statistically significantly higher among not pregnant women than pregnant women. Similarly, in simple logistic regression analysis all FPI subscales scores, global stress scale score and anxiety scales’ scores were negatively associated with clinical pregnancy.

Conclusion

Rates of stress, anxiety and depression among IVF patients are higher than in general population. If the level of infertility-related stress is higher, IVF success rate is lower. Findings of our study indicate the need for the specific psychological interventions for all infertility women, to improve IVF success rate.

RFamide-Related Peptide Neurons Modulate Reproductive Function and Stress Responses

RF-amide related peptide 3 (RFRP-3) is a neuropeptide thought to inhibit central regulation of fertility. We investigated whether alterations in RFRP neuronal activity led to changes in puberty onset, fertility, and stress responses, including stress and glucocorticoid-induced suppression of pulsatile luteinizing hormone secretion. We first validated a novel RFRP-Cre mouse line, which we then used in combination with Cre-dependent neuronal ablation and DREADD technology to selectively ablate, stimulate, and inhibit RFRP neurons to interrogate their physiological roles in the regulation of fertility and stress responses. Chronic RFRP neuronal activation delayed male puberty onset and female reproductive cycle progression, but RFRP-activated and ablated mice exhibited apparently normal fertility. When subjected to either restraint- or glucocorticoid-induced stress paradigms. However, we observed a critical sex-specific role for RFRP neurons in mediating acute and chronic stress-induced reproductive suppression. Female mice exhibiting RFRP neuron ablation or silencing did not exhibit the stress-induced suppression in pulsatile luteinizing hormone secretion observed in control mice. Furthermore, RFRP neuronal activation markedly stimulated glucocorticoid secretion, demonstrating a feedback loop whereby stressful stimuli activate RFRP neurons, which in turn further activate the stress axis. These data provide evidence for a neuronal link between the stress and reproductive axes.

The impact of emotional health on assisted reproductive technology outcomes: a systematic review and meta-analysis

This systematic review and meta-analysis has addressed ongoing controversy surrounding the association between pre-treatment anxiety, stress and depression and assisted reproductive technology (ART) outcomes. Medline, Embase and PsycINFO were searched up to November 2019. The eligibility criterion was observational studies reporting the association between pre-treatment anxiety, stress or depression and ART outcomes in men, women or couples undergoing ART. The association between pre-treatment anxiety, stress and depression and ART outcomes were extracted, and meta-analyses carried out if ≥3 studies assessed the same outcome over the same number of cycles and reported results homogeneously. The review reports a potential association between decreased sperm motility and increased male state anxiety, but no significant association between women's pre-treatment emotional health and ART outcomes in terms of live birth, clinical pregnancy, chemical pregnancy, oocyte retrieval, embryos transferred or fertilization. Meta-analyses showed no significant standardized mean difference (SMD) for anxiety/stress and clinical or chemical pregnancy, or depression and clinical or chemical pregnancy.

Review of psychological stress on oocyte and early embryonic development in female mice

Psychological stress can cause adverse health effects in animals and humans. Accumulating evidence suggests that psychological stress in female mice is associated with ovarian developmental abnormalities accompanied by follicle and oocyte defects. Oocyte and early embryonic development are impaired in mice facing psychological stress, likely resulting from hormone signalling disorders, reactive oxygen species (ROS) accumulation and alterations in epigenetic modifications, which are primarily mediated by the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-ovarian (HPO) axes. The present evidence suggests that psychological stress is increasingly becoming the most common causative factor for female subfertility. Here, we review recent progress on the impact of psychological stress on female reproduction, particularly for oocyte and early embryonic development in female mice. This review highlights the connection between psychological stress and reproductive health and provides novel insight on human subfertility.

Differences in perceived stress during ovarian stimulation between women with infertility and those pursing oocyte cryopreservation

OBJECTIVE

To determine whether the purpose of ovarian stimulation (oocyte cryopreservation [OC] versus in vitro fertilization (IVF) is associated with perceived stress before or after ovarian stimulation; and whether perceived stress is associated with ovarian stimulation outcomes.

DESIGN

Prospective cohort study.

SETTING

Academic practice.

PATIENTS

Women undergoing their first ovarian stimulation cycle as part of a randomized clinical trial, the Learning from Online Video Education (LOVE) study (NCT02979990).

INTERVENTIONS

Questionnaire before and after ovarian stimulation.

MAIN OUTCOME MEASURES(S)

Perceived stress scale (PSS) scores before and after stimulation. The number of oocytes collected was a secondary measure.

RESULTS

After adjustment for age, income, race, education, financial assistance, and fertility diagnosis, the indication for treatment (IVF vs. OC) was a significant predictor of pretreatment PSS scores. IVF participants had higher pretreatment scores (18.01 ± 6.43) than did OC participants (15.62 ± 5.61). Posttreatment PSS scores did not differ between the two groups. IVF participants experienced a decrease of 0.85 ± 2.34 points in PSS scores after treatment, whereas OC participant scores were stable over time. The trajectory of PSS scores differed between the two groups and neared significance. Financial support was a significant predictor of pretreatment and posttreatment PSS scores for the entire cohort. Neither pretreatment nor posttreatment PSS was predictive of the number oocytes collected.

CONCLUSION

Compared with OC patients, IVF patients have higher stress levels, which decrease after ovarian stimulation. Perceived stress does not affect oocyte yield.

Self-reported quality of life scales in women undergoing oocyte freezing versus in vitro fertilization

PURPOSE

The objective of this study was to investigate stress levels among women undergoing elective oocyte cryopreservation by comparing their self-reported quality of life measures with women undergoing in vitro fertilization during the fertility treatment cycle.

METHODS

Patients undergoing oocyte retrieval at a single institution were offered a voluntary, anonymous, and written questionnaire. The survey was adapted and validated from the Fertility Quality of Life tool to assess self-reported fertility treatment-related problems and was tested for construct validity and reliability. Based on exploratory factor analyses, three subscales were created as follows: fertility treatment-related stress, tolerability, and environment. Relationships between patient characteristics and fertility treatment-related measures were examined with Fisher's exact test, ANOVA, and multivariate regression with significance p < 0.05.

RESULTS

A total of 461 patients (331 IVF, 130 egg freeze) were included in the analysis. Medically indicated egg freezing patients were excluded. Overall, both IVF and egg freeze patients reported stress during the current fertility cycle and there were no significant differences between IVF and egg freeze patients for any subscale scores. Three sets of generalized linear models were run and found age to be associated with fertility treatment-related stress and tolerability scores, with younger patients experiencing greater difficulties. Additionally, patients who underwent repeat cycles reported more fertility treatment-related stress.

CONCLUSIONS

Patients undergoing egg freezing have similar responses to quality of life questions as patients undergoing IVF. Repeat cycles and younger age contribute to perceptions of stress. This information supports developing stress reduction strategies for all women undergoing egg freezing.

The effect of mind-body interventions on psychological and pregnancy outcomes in infertile women: a systematic review

Preliminary evidence suggests that mind-body interventions, including mindfulness-based interventions and yoga, may be effective in reducing mental health difficulties and psychological distress in infertile patients undergoing fertility treatments. We systematically reviewed and synthesized current medical literature of the effectiveness of mind-body interventions in reducing the severity of psychological distress and improving marital function and pregnancy outcomes in infertile women/couple. Databases including PsychINFO, PubMed, EMBASE, and the Cochrane Library were searched for relevant studies. Manual searches were conducted in relevant articles. We included 12 studies that met the inclusion criteria. Four studies were randomized controlled trials (RCT), 4 non-randomized controlled trial (NRCT), and 4 uncontrolled studies (UCT). Participation in a mind-body intervention was associated with reduced anxiety trait and depression scores. The reduction was of low or moderate amplitude in most studies. Our review offers evidence for the effectiveness of mind-body interventions in reducing anxiety state and depression in infertile women and a possible improvement in pregnancy rate. Further RCTs with a precise timing of intervention are needed.

Melatonin protects against chronic stress-induced oxidative meiotic defects in mice MII oocytes by regulating SIRT1

Chronic stress which is common in the current society can be harmful to female reproduction and is associated with oocyte defects. However, the underlying mechanisms remain largely unknown. Herein, by using a mouse model of chronic restraint stress, we demonstrated that chronic stress could induce meiotic spindle abnormalities, chromatin misalignment, mitochondrial dysfunction and elevated ROS levels in oocytes in vivo, all of which were normalized by the administration of melatonin. Consistently, melatonin treatment during in vitro maturation also attenuated the meiotic defects induced by H₂O₂ by regulating autophagy and SIRT1, which could be abolished by SIRT1 inhibitor, Ex527 and autophagy inhibitor Bafilomycin A1 (Baf A1). These data indicate that melatonin can mitigate chronic stress-induced oxidative meiotic defects in mice MII oocytes by regulating SIRT1 and autophagy, providing new understanding for stress-related meiotic errors in MII oocytes and suggesting melatonin and SIRT1 could be new targets for optimizing culture system of oocytes as well as fertility management.

Stress, stigma, violence experiences and social support of US infertile women

Objectives: Previous studies investigated the physical, psychological and sociological effects of infertility; however, stigma and violence experiences of infertile women haven't yet been studied in the US. The objective of the study is to examine the perceived stress, stigma, violence experiences, and social support of US infertile women and to compare with fertile women in order to understand the effects of infertility on stress levels, violence exposures, and support. Methods: The descriptive, cross-sectional study was conducted with fertile and infertile women who use social media for an online support group. A convenience sample of 786 women completed an online survey. Results: In the study, 41.6% of participants were fertile and 58.4% were infertile. We found infertile women experienced high levels of stigma and moderate stress. One in five infertile women has been exposed to emotional or physical violence. Compared to fertile women, infertile women had significantly higher perceived stress levels and were less likely to experience emotional or physical violence. Conclusion: These findings highlight that infertile women have experienced stigma and high levels of stress in a developed country. They are also exposed to emotional or physical violence, but surprisingly infertile women are less likely to report violence than fertile women.

Hair Cortisol Concentrations as a Biomarker to Predict a Clinical Pregnancy Outcome after an IVF Cycle: A Pilot Feasibility Study

Our objective was to examine the feasibility of hair cortisol concentrations (HCC) as a biomarker to predict clinical pregnancy outcomes and investigate its potential associations with perceived anxiety, resilience, and depressive symptoms. A total of 43 participants were assessed using HCC, the state trait anxiety inventory (STAI), resilience scale (RS), and the depression subscale of the symptom checklist 90-R (SCL-90-R). Participants were approached at their second consultation with the reproductive endocrinologist (T1), before scheduling their IVF cycle, and then 12 weeks after (T2), at their post-transfer visit with the study coordinators, before the human chorionic gonadotropin (HCG) pregnancy test. The logistic regression model revealed that HCC at T2 predicted 46% of a positive pregnancy test [R2 = 0.46, (ß = 0.11, p < 0.05)]. Pregnant women had higher levels of resilience at T2 (M = 149.29; SD = 17.56) when compared with non-pregnant women at T2 (M = 119.96; SD = 21.71). Significant differences were found between both groups in depression at T2 (t = 3.13, p = 0.01) and resilience at T2 (t = -4.89, p = 0.01). HCC might be a promising biomarker to calculate the probability of pregnancy in women using assisted reproductive technologies (ART).

The association between reproductive health smartphone applications and fertility knowledge of Australian women

Background

Previous studies have identified that women living in developed countries have insufficient knowledge of factors which may be contributing to the increasingly high global infertility rates such as maternal age and assisted reproductive technologies. There is a large market of reproductive health smartphone applications, yet little is known about the advantages these apps may confer to users in regards to reproductive health knowledge.

Methods

An anonymous, online survey of women living in Australia aged 18 and above was open March–June 2018, until ≥200 responses were acquired for statistical power. Respondents answered questions regarding knowledge about general fertility and related factors (age, cyclic fertility, smoking, obesity, miscarriage rate, and success of assisted reproductive technologies). Fertility knowledge was compared in respondents who did or did not use apps relating to female reproductive health. Additionally the functions preferred in reproductive health apps was described by app using respondents. Sociodemographic information was also collected, and relevant data within the dataset was subject to multivariable modelling for the outcome of the fertility knowledge questions.

Results

Of the 673 respondents that completed the survey, 43.09% reported using mobile phone applications relating to female reproductive health. On average, respondents answered only three of the six fertility knowledge questions correctly. App using respondents were more likely to score better on one question, related to fertility during the menstrual cycle (p < 0.001). App users most commonly reported using the menstrual tracking function in apps (82.4%), which may account for the increased knowledge of cyclic fertility.

Conclusions

This data provides preliminary evidence toward the usefulness of smartphone applications as a medium for providing information about fertility to women. A limited understanding of one’s own fertility was demonstrated despite being essential for the decision-making of women throughout their reproductive years.

Association between Emotional State Changes in Infertile Couples and Outcome of Fertility Treatment

Aims Infertility and its treatment are associated with considerable psychological distress for infertile couples. The aim of our study was to explore to what extent positive and negative affectivity and a predisposition to depression and anxiety appear in infertile couples during in vitro fertilization (IVF) treatment. We also aimed to explore how the emotional state of couples changed during IVF in relation to treatment outcomes. Method In our longitudinal study, 174 people (87 couples) were followed up during treatment by means of questionnaires. Their emotional state was assessed with PANAS, BDI-R, and STAI at the beginning of treatment, before embryo transfer, and before taking a pregnancy test. Couples who achieved pregnancy after treatment were included in the successful group (n = 82), while those who did not were included in the unsuccessful group (n = 92). Results We found more favorable emotional states in IVF couples compared to patient populations and the average population. In successful IVF couples, positive affectivity decreased, and negative affectivity increased in women until the time of embryo transfer. This was accompanied by an increase in positive affectivity in men, which remained until the time of the pregnancy test and provided emotional support to their partner. These results were confirmed by changes in the levels of depression. Conclusion Our study suggests the importance of couples' emotional dynamics for having a child and an association between couples' emotional reactions during IVF cycles and treatment success.

Momentary mood response to natural outdoor environments in four European cities

Exposure to natural outdoor environments (NOE) has been shown in population-level studies to reduce anxiety and psychological distress. This study investigated how exposure to one's everyday natural outdoor environments over one week influenced mood among residents of four European cities including Barcelona (Spain), Stoke-on-Trent (United Kingdom), Doetinchem (The Netherlands) and Kaunas (Lithuania). Participants (n = 368) wore a smartphone equipped with software applications to track location and mood (using mobile ecological momentary assessment (EMA) software), for seven consecutive days. We estimated random-effects ordered logistic regression models to examine the association between mood (positive and negative affect), and exposure to green space, represented by two binary variables indicating exposure versus no exposure to NOE using GPS tracking and satellite and aerial imagery, 10 and 30 min prior to participants' completing the EMA. Models were adjusted for home city, day of the week, hour of the day, EMA survey type, residential NOE exposure, and sex, age, education level, mental health status and neighbourhood socioeconomic status. In addition, we tested for heterogeneity of effect by city, sex, age, residential NOE exposure and mental health status. Within 10 min of NOE exposure, compared to non-exposure, we found that overall there was a positive relationship with positive affect (OR: 1.39, 95% CI: 1.06, 1.81) of EMA surveys, and non-significant negative association with negative affect (OR: 0.80, 95% CI: 0.58, 1.10). When stratifying, associations were consistently found for Stoke-on-Trent inhabitants and men, while findings by age group were inconsistent. Weaker and less consistent associations were found for exposure 30 min prior to EMA. Our findings support increasing evidence of psychological and mental health benefits of exposure to natural outdoor environments, especially among urban populations such as those included in our study.

Acupuncture and Laser Acupuncture as Treatments for Emotional Distress in Infertile Women in Japan

Objectives: Needle and laser acupuncture are often used to improve the success rate of assisted reproductive technology (ART). This study examined whether needle or laser acupuncture ameliorated the emotional distress experienced by infertile women undergoing in vitro fertilization and embryo transfer (IVF-ET) or intracytoplasmic sperm injection (ICSI). Materials and Methods: Fifty-one infertile women who were undergoing IVF-ET or ICSI received needle acupuncture (needle-acupuncture group; n = 32) or laser acupuncture treatment (laser-acupuncture group; n = 19). The emotional distress experienced by the infertile women was evaluated using 2 questionnaires-the Profile of Mood States (POMS) and the State-Trait Anxiety Inventory (STAI)-both before and after 3 months of treatment. Results: In the needle-acupuncture group, the POMS detected significant post-treatment reductions in tension/anxiety (P < 0.001), depression/dejection (P < 0.001), anger/hostility (P < 0.001), confusion (P < 0.05), and total mood disturbance (TMD; p < 0.001). However, the POMS scores for vigor/activity and fatigue were not altered significantly after the treatment. In the STAI, both State and Trait scores had significantly decreased after the acupuncture (P < 0.001 and P < 0.05, respectively). In the laser-acupuncture group, the POMS detected significantly lower tension/anxiety (P < 0.05) and vigor/activity (P < 0.05) scores after the treatment. However, the POMS did not detect significant changes in depression/dejection, anger/hostility, fatigue, confusion, or TMD after the treatment. Furthermore, neither the STAI-State nor the STAI-Trait score had significantly decreased after the laser acupuncture treatment. Conclusions: These results indicate that needle and laser acupuncture ameliorate the emotional distress experienced by women who are undergoing IVF-ET or ICSI.

Restraint-induced corticotrophin-releasing hormone elevation triggers apoptosis of ovarian cells and impairs oocyte competence via activation of the Fas/FasL system

Mechanisms by which psychological stress damages oocytes are largely undetermined. Although a previous study showed that the stress-induced corticotrophin-releasing hormone (CRH) elevation impaired oocyte competence by triggering apoptosis of ovarian cells, how CRH causes apoptosis in ovarian cells and oocytes is unknown. In this study, we have examined the hypothesis that restraint stress (RS)-induced CRH elevation triggers apoptosis of ovarian cells and impairs oocyte competence through activating the Fas/FasL system. The results showed that RS of female mice impaired oocyte competence, enhanced expression of CRH and CRH receptor (CRH-R) in the ovary, and induced apoptosis while activating the Fas/FasL system in mural granulosa cells (MGCs) and oocytes. Injecting mice with CRH-R1 antagonist antalarmin significantly alleviated the adverse effect of RS on oocyte developmental potential. Treatment of cultured MGCs recapitulated the effects of CRH and antalarmin on apoptosis and Fas/FasL expression in MGCs. Silencing FasL gene by RNA interference in cultured MGCs further confirmed the involvement of the Fas/FasL system in the CRH triggered apoptosis of ovarian cells. It is concluded that the RS-induced CRH elevation triggers apoptosis of ovarian cells and impairs oocyte competence via activation of the Fas/FasL system.

The effects of an expressive writing intervention on pregnancy rates, alexithymia and psychophysical health during an assisted reproductive treatment

Objective: World Health Organization reported that in developed countries one in four couples experience infertility with serious implications for the psychophysical well-being. Aim of this study was to evaluate the effects of Pennebaker's writing technique on pregnancy rates, alexithymia and psychophysical health during an assisted reproductive treatment (ART).Method: 91 women admitted for an ART were randomly divided into two groups: an experimental one (n = 46), where women wrote about their thoughts and emotions concerning the infertility experience, and a control group (n = 45) where women did not write. All subjects completed a socio-demographic questionnaire, the 20-item Toronto Alexithymia Scale and the Symptoms Checklist-90-R before and after the writing sessions.Results: A significant difference in pregnancy rates between the experimental group (n = 13) and the control group (n = 5) was found (χ² = 4.216; p < .04). A significant difference was also found between women who participated in the study (experimental + control= 91) and women who declined to participate, in the direction of more ART successes (n = 18 vs. n = 0) in the group of women who participated (χ² = 10.17; p < .01).Conclusions: The findings support the usefulness of the writing technique during ART in promoting treatment success.