Low negative affect prior to treatment is associated with a decreased chance of live birth from a first IVF cycle

Reproductive history does not compromise subsequent live birth and perinatal outcome following in-vitro fertilization: analysis of 25 329 first frozen-thawed embryo transfer cycles without preimplantation genetic testing for aneuploidy

OBJECTIVE

To investigate the effect of women's reproductive history on live-birth rate and perinatal outcome after first frozen-thawed embryo transfer (FET) without preimplantation genetic testing for aneuploidy.

METHODS

This was a retrospective cohort study of women who had undergone their first FET cycle between January 2014 and December 2020 at a university-affiliated fertility center. No transferred embryo underwent preimplantation genetic testing for aneuploidy. The women were categorized into five groups based on their reproductive history: no previous pregnancy; previous termination of pregnancy (TOP); previous pregnancy loss; previous ectopic pregnancy (EP); and previous live birth. The women with no previous pregnancy were considered as the reference group. The primary outcome was the live-birth rate and secondary endpoints included rates of positive pregnancy test, clinical pregnancy, pregnancy loss and EP as well as perinatal outcomes such as birth weight and preterm birth. Multivariable logistic regression analyses were used to control for a number of potential confounders, including age, body mass index, education level, duration and cause of infertility, insemination method, type of endometrial preparation, number of embryos transferred, embryo developmental stage, quality of the embryos transferred, year of treatment and endometrial thickness. Additionally, propensity score matching (PSM) was used to check the robustness of the main findings.

RESULTS

In total, 25 329 women were included in the final analysis. On univariate analysis, each reproductive-history type except for previous EP was significantly associated with worse pregnancy outcome following in-vitro fertilization (IVF), including rates of positive pregnancy test, clinical pregnancy, pregnancy loss and live birth, when compared with the group of women with no previous pregnancy. However, after correcting for several potential confounders, the differences in rates of live birth, pregnancy loss, positive pregnancy test and clinical pregnancy were no longer significant between the study and control groups on multivariable regression models, while the risk of EP after embryo transfer was elevated among women with a previous TOP or EP. There was no increased risk of adverse perinatal outcome associated with reproductive history compared with the control group. Notably, similar results were obtained from the PSM models, confirming the robustness of the main findings.

CONCLUSION

Relative to women without a previous pregnancy, those with a prior TOP, pregnancy loss, EP or live birth did not have compromised live-birth rate or perinatal outcomes following FET without preimplantation genetic testing for aneuploidy, with the exception of an increased risk of EP in those with prior TOP or EP. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Global Research Trends on Infertility and Psychology From the Past Two Decades: A Bibliometric and Visualized Study

Objectives

The aim of this study was to evaluate the global scientific output of research on infertility and psychology; explore the current status and trends in this field through the cooperation of authors, countries, and institutions; shed light on the direction of clinical infertility research in the future, and provide inspiration for targeted diagnosis and treatment of infertility.

Methods

Research publications on infertility and psychology from the past two decades were retrieved from the Web of Science Core Collection (WoSCC). Bibliometric analyses were performed using VOSviewer software and the bibliometrix R package. Network maps were generated to evaluate the collaborations between different authors, countries, institutions, and keywords.

Results

A total of 151 articles related to the study of infertility and psychology were identified. We observed a gradual increase in the number of publications from 2001 to 2021, and the trend has been relatively stable in the past eight years. Human Reproduction (England), as the leading journal publishing the most papers (29 articles), was cited in the most journals (1208 times). Boivin J was the most prolific author (16 articles), with the largest number of citations (890 times) and the highest h-index (14) during the past decades. Boivin J was also the leader with the highest publication frequency and more active cooperation with other top authors. The United Kingdom (34 papers) and Cardiff University (25 articles) contributed the most publications and were the leading contributors in this field. Active cooperation between countries and between institutions was observed, and analyses of articles and references were also shown. The main hot topics included matters related to women (39 times), in-vitro salt (31 times), infertility (30 times), couples (25 times), and impact (24 times).

Conclusion

Our study results provide a comprehensive overview of the development of scientific literature, allowing relevant authors and research teams to recognize the current research status in this field. At the same time, infertility and psychology may soon become hotspots and should be closely monitored.

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.

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.

Just relax and you'll get pregnant? Meta-analysis examining women's emotional distress and the outcome of assisted reproductive technology

RATIONALE

Couples worldwide are seeking treatment for infertility in growing numbers. Both infertility and its treatment are stressful experiences that generate considerable emotional distress. There is speculation that women's distress is associated with poorer likelihood of pregnancy via assisted reproductive technology (ART) and plausible psychobiological mechanisms bolster this association, although prior reviews of existing evidence find little support. A rigorous, comprehensive, and up to date analysis of research on the association of women's distress with ART outcomes is imperative.

OBJECTIVE

We systematically searched for and analyzed evidence regarding the association of women's distress before and during treatment with the likelihood of treatment success via ART.

METHOD

Meta-analysis using a random-effects model was conducted on prospective studies (k = 20) that compared levels of anxiety, depressive symptoms, or perceived stress before or during ART treatment in women who achieved successful pregnancy outcomes versus those who did not (total N = 4308).

RESULTS

Anxiety, depressive symptoms, or perceived stress pre-treatment, and anxiety or depressive symptoms during treatment, were not associated with less favorable ART outcomes. Prior treatment experience, age, and duration of infertility were not significant moderators of these associations. No eligible studies examined perceived stress during treatment.

CONCLUSION

Results cast doubt on the belief that distress impedes the success of infertility treatment, offering hope and optimism to the many women who feel emotionally responsible for the outcome of ART and informing the evidence-based practices of their health-care providers. We also identify specific areas and research methods needed to corroborate and extend study conclusions, including study of factors that elevate or attenuate distress in women undergoing infertility treatment.

A systematic review and meta-analysis of psychological predictors of successful assisted reproductive technologies

Objectives

The aim of this systematic review and meta-analysis was to perform an updated investigation of the effects of depression and anxiety on pregnancy outcomes following assisted reproductive technologies. A bibliographic search was performed using PubMed, PsycINFO, Embase, Science Direct databases. Data retrieved were analysed using a random effects model to estimate standardised mean differences.

Results

Of the 22 included studies, 18 investigated depression, 15 state anxiety, and seven trait anxiety. Data from 4018 patients were included in the meta-analysis. Results indicated that women who achieved pregnancy or a live birth reported lower levels of depression pre-treatment than those who did not, although the effects were small d = − 0.177 (95% CI − 0.327 to − 0.027, z = 2.309, p = 0.021). These results were consistent under different methodological conditions and the quality of these observational were graded as satisfactory. A similar pattern was seen for state (d = − 0.096, 95% CI − 0.180 to − 0.012: z = 2.241, p = 0.025) and trait anxiety (d = −  0.188, 95% CI − 0.007 to 0.356, z = 2.181, p = 0.029). More research is needed to investigate the impact of psychological variables on assisted reproductive technologies outcomes and moderator influences during assisted reproductive technologies processes.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-3049-z) contains supplementary material, which is available to authorized users.

Linking Stress and Infertility: A Novel Role for Ghrelin

Infertility affects a remarkable one in four couples in developing countries. Psychological stress is a ubiquitous facet of life, and although stress affects us all at some point, prolonged or unmanageable stress may become harmful for some individuals, negatively impacting on their health, including fertility. For instance, women who struggle to conceive are twice as likely to suffer from emotional distress than fertile women. Assisted reproductive technology treatments place an additional physical, emotional, and financial burden of stress, particularly on women, who are often exposed to invasive techniques associated with treatment. Stress-reduction interventions can reduce negative affect and in some cases to improve in vitro fertilization outcomes. Although it has been well-established that stress negatively affects fertility in animal models, human research remains inconsistent due to individual differences and methodological flaws. Attempts to isolate single causal links between stress and infertility have not yet been successful due to their multifaceted etiologies. In this review, we will discuss the current literature in the field of stress-induced reproductive dysfunction based on animal and human models, and introduce a recently unexplored link between stress and infertility, the gut-derived hormone, ghrelin. We also present evidence from recent seminal studies demonstrating that ghrelin has a principal role in the stress response and reward processing, as well as in regulating reproductive function, and that these roles are tightly interlinked. Collectively, these data support the hypothesis that stress may negatively impact upon fertility at least in part by stimulating a dysregulation in ghrelin signaling.

Lifestyle and in vitro fertilization: what do patients believe?

Background

Patients have many beliefs regarding lifestyle factors and IVF outcomes.

Methods

Observational study of 208 IVF patients at an academic infertility center. Main outcome measures were perceived influence of various lifestyle factors assessed by multivariable logistic regression and p-value tests for linear trend (P_t).

Results

A majority of participants believed that there were many women’s lifestyle choices that were influential, compared to fewer male factors (cessation of tobacco (72 %), alcohol (69 %), caffeine (62 %), and use of vitamins (88 %)). Compared to participants with less education, participants with a higher education level were less likely to believe vitamins were helpful and some alcohol use was not harmful. As income decreased, participants were less likely to consider dietary factors contributory to IVF success, such as women (p-trend, p = 0.02) and men (p-trend, p = 0.009) consuming a full-fat dairy diet. Participants’ beliefs were most commonly influenced by physicians (84 %) and the internet (71 %).

Conclusions

Patients believed many lifestyle factors are associated with IVF success. Understanding patients’ assumptions regarding the effect of lifestyle factors on IVF success may better allow physicians to counsel patients about IVF outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s40738-016-0026-5) contains supplementary material, which is available to authorized users.

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.

The effects of anxiety and depression on in vitro fertilisation outcomes of infertile Chinese women

The object was to assess anxiety and depression during in vitro fertilisation (IVF) treatment and determine IVF-related psychological factors in infertile Chinese women. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate anxiety and depression among 842 patients, respectively. A univariate analysis was used to compare variables among three SAS groups and three SDS groups. Anxiety and depression were both represented in 21.3% of the cases. Patients <35 years tended to be more anxious. In women <35 years, the SDS scores were higher with lower educational backgrounds and female or couple's infertility, while the SAS scores were higher in female or couple's infertility. In older ones, the SDS scores were higher in those with lower educational backgrounds and longer time for infertility, while the SAS scores were higher in those with lower educational backgrounds. In SAS groups 1-3, the embryo availability was 5.0 (3.0-8.0), 5.0 (3.0-8.0), and 3.0 (2.0-4.5) (p = .013); and the fertilisation rate was 91.9, 90.4, and 81.8% (p < .001), respectively. We concluded that infertile women experience anxiety and depression during IVF treatment, especially in women <35 years. Younger women with female infertility would be more anxious and depressive while higher education can protect them from depression. In older ones, they would experience more depressive with longer time for infertility and be less anxious and depressive with higher education. Anxiety affects the fertilisation rate and embryo availability.

Differences in psychophysical well-being and signs of depression in couples undergoing their first consultation for assisted reproduction technology (ART): an Italian pilot study

OBJECTIVE

The data we refer to belong to a longitudinal research project starting at the first contact of individual couples with the Infertility Unity; they were then followed-up till pregnancy or failure of treatments. The study aims at investigating in depth the emotional state of patients admitted for first consultation. Specifically, we investigated the emotional state of the two members of an infertile couple, considering also their biomedical and socio-demographic characteristics.

STUDY DESIGN

This is a cross-sectional study evaluating a consecutive series of 309 couples, consulting for the first time our Infertility Unit for a multidisciplinary diagnostic evaluation in relation to their infertility. The multidisciplinary equip is composed of a gynaecologist, an andrologist and a clinical psychologist. Two standardized instruments were administered by the clinical psychologist to the two members of the couple: the Edinburgh Depression Scale (EDS) and the General Health Questionnaire-form 12 (GHQ-12), for screening of non-somatic signs of depression and psychophysical well-being, respectively. Couples were eligible for the study if they had not received any prior ART treatment in our Unit and were able to read and understand Italian. In addition, they had to agree to provide informed consent for the study.

RESULTS

We obtained a response in 62% of all eligible couples. There were two major unexpected findings:

CONCLUSION

Psychological and counselling services dedicated to ART should consider also socio-demographic data and always specifically consider gender differences, not only a couple's psychology and its dynamics.

Modifiable Risk Factors and Infertility: What are the Connections?

Infertility is a relatively common condition, greatly affecting couples medically and psychologically. Although infertility treatment is safe, it can be time-intensive, expensive and increase the risk of multiple gestations. Thus, to reduce costs and risks, couples may initially consider lifestyle change to increase their fertility and chances of pregnancy. For many of the diet factors studied (for example: caffeine, soy, protein, iron), there are conflicting data. However, there are some items men and women consume that are detrimental to fertility, such as alcohol and tobacco. The data on exercise are varied but may have an effect on ovulation and fertility - positive or negative. Body mass index appears to impact fertility also, with obesity in both men and women negatively affecting pregnancy rates. In addition, there remains concern and a growing body of research on environmental toxin exposures and reproductive health. Finally, supporting patients through infertility diagnosis and treatment is critical, as psychological stress may impact conception. It is imperative that the relationship between lifestyle factors and fertility continue to be explored as to lessen the morbidity associated with infertility.

Depression and coping strategies of Chinese women undergoing in-vitro fertilization

OBJECTIVES

To explore the relationship between coping strategies and depression, and the risk factors of depression among Chinese women in infertile couples undergoing in-vitro fertilization (IVF).

STUDY DESIGN

Two hundred and eighty-eight women undergoing IVF completed the Center for Epidemiologic Studies Short Depression Scale and the Brief COPE Inventory. Demographic data were collected, hormone levels were tested and oocyte numbers were counted.

RESULTS

The incidence of depression was 22.6%. The prevalence of depression was higher among women who had been married for >8 years, women who had been infertile for >6 years and women with a family income ≤3000 CNY/month. High basal follicle-stimulating hormone, oocyte number and denial score were associated with greater risk of depression. High oestradiol (basal and peak), and substance use and humour scores were associated with lower risk of depression.

CONCLUSION

Many women in infertile couples undergoing IVF have depression. Preventive interventions should be provided for women with risk factors of depression, such as long duration of marriage, long duration of infertility, low monthly family income, high basal follicle-stimulating hormone, low serum oestradiol, high oocyte number, and use of denial as a coping strategy.

Auricular acupressure reduces anxiety levels and improves outcomes of in vitro fertilization: a prospective, randomized and controlled study

The study was to explore whether auricular acupressure (AA) can relieve anxiety during the period from trans-vaginal oocyte retrieval to the embryo transfer in IVF treatment and whether AA can improve the outcomes of IVF. 305 infertile patients with tubal blockage who were referred for IVF were included. The women were randomized into a control group with 102 cases, a Sham-AA group with 102 cases and an AA group with 101 cases. The anxiety levels were rated with Spielberger's State Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale. Data of clinical pregnancy rate (CPR), implantation rate (IR) and live birth rate (LBR) were obtained. The levels of neuropeptide Y (NPY) and transforming growth factor alpha (TGF-alpha) in the follicular fluids were detected with ELISA. After treatment, in AA group, the levels of state anxiety, preoperative anxiety and need-for-information were significantly lower, whereas CPR, IR, LBR and NPY levels in the follicular fluids were markedly higher than Sham-AA group and control group. We concluded that AA could help to reduce anxiety levels associated with IVF and improves the outcomes of IVF partly through increasing the levels of NPY in the follicular fluids.

The impact of a self-administered coping intervention on emotional well-being in women awaiting the outcome of IVF treatment: a randomized controlled trial

STUDY QUESTION

What is the effect of the positive reappraisal coping intervention (PRCI) on anxiety in women awaiting the outcome of an IVF/ICSI cycle?

SUMMARY ANSWER

Women reported significantly more anxiety during the waiting period than before treatment, but the use of the PRCI did not significantly reduce anxiety during the waiting period.

WHAT IS KNOWN ALREADY

Waiting for the outcome of IVF/ICSI treatment after embryo transfer is one of the most stressful periods of fertility treatments. At present, no evidence-based coping interventions are available to assist women though this waiting period. The PRCI has been designed to address this unmet need by promoting positive reappraisal coping.

STUDY DESIGN, SIZE, DURATION

A three-armed randomized controlled trail (RCT) was designed to evaluate the PRCI in women undergoing IVF/ICSI. Data were collected between October 2010 and June 2012. A total of 377 participants were randomized to receive either the PRCI and emotional monitoring, emotional monitoring only, or routine care. Only the PRCI-monitoring group received the coping intervention, comprising an explanatory leaflet and ten statements to be read at least once in the morning and once in the evening.

PARTICIPANT, MATERIALS, SETTING, METHODS

To capture the general impact of the PRCI, all three groups completed questionnaires at three time points: just before the waiting period (time 1: stimulation phase), on Day 10 of the 14-day waiting period (time 2: waiting period) and 6 weeks after the start of the waiting period (time 3: 6-week follow-up). In addition, to capture the specific impacts of the PRCI on the days of the waiting period, the PRCI-monitoring group and the monitoring-control group also rated their emotions and reactions daily, for the 14-day waiting period.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the women who agreed to participate and who met eligibility criteria, 377 were randomized. All study participants reported significantly more anxiety and depression during the waiting period than before treatment (P < 0.001). The mean difference in anxiety between time 1 versus time 2 was 1.465 (95% CI 1.098–1.832). The mean difference in depression between time 1 versus time 2 was 0.514 (95% CI 0.215–0.813). Use of the PRCI did not significantly reduce anxiety or depression, or daily negative emotions during the waiting period. However, patients randomized to the PRCI reported significantly more positive emotions during the waiting period (P < 0.001) than the monitoring-control group, and reported the intervention to be easy to use, and as having a positive psychological effect. No significant differences were found between the groups in treatment outcome.

LIMITATIONS, REASONS FOR CAUTION

The lack of difference observed in the present study for anxiety levels between the PRCI and the monitoring-control group could have been due to the effects of monitoring itself or its ability to attenuate or obscure the effects of the PRCI intervention in unknown ways. A randomized group of women who used only the PRCI without daily monitoring would provide more insight.

WIDER IMPLICATIONS OF THE FINDINGS

The PRCI was shown to help women reinterpret the demands of the waiting period in a more positive way. These results are consistent with previous studies showing that positive reappraisal coping is a useful strategy for unpredictable and uncontrollable situations represented by a medical waiting period. This simple low cost self-help coping intervention increases positive affect during the waiting period in an IVF/ICSI treatment. STUDY FUNDING/COMPETENT INTEREST(S): The Women and Baby Division of the University Medical Centre Utrecht funded the study. The authors have no conflicting interest(s).

TRIAL REGISTRATION NUMBER

The study is registered at the Clinical Tials.gov (NCT01701011).

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.

Relationship between psychological stress and reproductive outcome in women undergoing in vitro fertilization treatment: psychological and neurohormonal assessment

PURPOSE

To evaluate whether psychological stress, as well as changes in hypothalamus-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) at different time points during a first in vitro fertilization (IVF) cycle, correlates with the reproductive outcome.

METHODS

A prospective study was conducted in 264 women undergoing IVF or intracytoplasmic sperm injection (ICSI) treatment between January 2009 and March 2010. Standardized psychological questionnaires were used to assess anxiety and depression. Norepinephrine and cortisol in serum were measured with specific assays.

RESULTS

The non-pregnant women reported higher anxiety and depression scores at the pregnancy detection day compared with the pregnant group. Lower levels of norepinephrine and cortisol at the time of oocyte retrieval and lower levels of cortisol at the time of pregnancy test were found in women with successful treatment. Significant increases in serum norepinephrine and cortisol values were observed during ovarian stimulation. State Anxiety scores were negatively correlated with live birth rate, and positively associated with serum norepinephrine and cortisol values.

CONCLUSIONS

State anxiety is associated with both pregnancy rate and live birth rate in IVF patients, an effect that is partly mediated by activities in the HPA and SNS.

Brief cognitive behavioral intervention in groups in a Brazilian assisted reproduction program

The study's objective was to assess the effect of a cognitive behavioral group intervention on the pregnancy rates of patients submitted to in vitro fertilization (IVF) techniques or to intracytoplasmic sperm injection (ICSI). The study was conducted on 188 patients, 93 who participated in a group of psychological intervention before the IVF and ICSI procedures and 95 patients submitted to IVF and ICSI during the same period of time, who did not participate in the intervention (control group). Clinical pregnancy was the outcome measure. Demographic and clinical variables were compared between groups in order to assess the group's homogeneity. Participants in the psychological intervention obtained a pregnancy rate of 39.8%, significantly higher than the 23.2% rate of nonparticipants (χ(2) = 6.03, p = .01, odds ratio of 22 (CI: 1.16-4.13). The data suggest that group psychological intervention before IVF and ICSI in order to control stress seems to increase the rate of success of these procedures.

Women's psychological profile and psychiatric diagnoses and the outcome of in vitro fertilization: is there an association?

The influence of psychological processes and psychiatric syndromes on the outcome of fertility treatments is not well understood. In this prospective study, we investigated the effect of baseline psychiatric diagnosis and situational psychiatric symptoms on several biological outcome factors of in vitro fertilization treatments (IVF). Women undergoing their first IVF treatment (n = 108) were interviewed before treatment for the presence of a lifetime DSM-IV-TR disorder. Questionnaires measuring state depression (Center for Epidemiologic Studies Depression scale), anxiety (State Trait Anxiety Inventory), and psychiatric symptomatology (Brief Symptom Inventory) were administered at ovulation induction. Outcome variables were number of retrieved and fertilized oocytes, chemical pregnancy, and a take home baby. Situational anxiety, depression, or other psychiatric symptoms had no effect on any of the outcome measures. Women diagnosed with mood or anxiety disorder prior to the onset of the IVF treatment showed a higher, though not statistically significant, pregnancy success rate compared to women without a diagnosis (57 % compared to 38 %). We speculate that in women with such psychopathology, chronic stress results in biological effects that impede successful implantation, thus impairing fertility. Fertility treatment using the IVF paradigm may bypass this negative effect, resulting in high success rates. This hypothesis should be further explored.

Physical symptoms throughout IVF cycles

The physical impact of in vitro fertilisation (IVF) is not well explored. The aim of this prospective controlled longitudinal study was to examine the impact of 11 symptoms during an entire long down regulation (LDR) cycle and to determine the effect of the mean recombinant follicle stimulating hormone (RecFSH) dose and ovarian responsiveness of patients and outcome had on reported symptoms. The severity of symptoms was measured using a daily questionnaire to determine a total summary score (TSS) for each symptom, a summary symptom score (SSS) based on all TSS and a mean daily severity for each symptom. Outcome was determined by beta human chorionic gonadotrophin (β-hCG) test result. 79.1% of women undertaking LDR IVF cycles had significant physical symptoms. Treatment symptom severity peaked at oocyte retrieval, with prominent symptoms including bloating, abdominal pain/cramps and fatigue. No relationship was found between outcome, RecFSH dose and ovarian responsiveness with reported symptoms. In conclusion, IVF places a real physical burden on women should be encouraged to reduce undertaking LDR cycles. The impact of the symptoms, particularly the increase in severity leading up to day of oocyte retrieval suggests that women may be warned to reduce stress and activities during this time.

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.

Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies

OBJECTIVE

To examine whether pretreatment emotional distress in women is associated with achievement of pregnancy after a cycle of assisted reproductive technology.

DESIGN

Meta-analysis of prospective psychosocial studies.

DATA SOURCES

PubMed, Medline, Embase, PsycINFO, PsychNET, ISI Web of Knowledge, and ISI Web of Science were searched for articles published from 1985 to March 2010 (inclusive). We also undertook a hand search of reference lists and contacted 29 authors. Eligible studies were prospective studies reporting a test of the association between pretreatment emotional distress (anxiety or depression) and pregnancy in women undergoing a single cycle of assisted reproductive technology. Review methods Two authors independently assessed the studies for eligibility and quality (using criteria adapted from the Newcastle-Ottawa quality scale) and extracted data. Authors contributed additional data not included in original publication.

RESULTS

Fourteen studies with 3583 infertile women undergoing a cycle of fertility treatment were included in the meta-analysis. The effect size used was the standardised mean difference (adjusted for small sample size) in pretreatment anxiety or depression (priority on anxiety where both measured) between women who achieved a pregnancy (defined as a positive pregnancy test, positive fetal heart scan, or live birth) and those who did not. Pretreatment emotional distress was not associated with treatment outcome after a cycle of assisted reproductive technology (standardised mean difference -0.04, 95% confidence interval -0.11 to 0.03 (fixed effects model); heterogeneity I²=14%, P=0.30). Subgroup analyses according to previous experience of assisted reproductive technology, composition of the not pregnant group, and timing of the emotional assessment were not significant. The effect size did not vary according to study quality, but a significant subgroup analysis on timing of the pregnancy test, a contour enhanced funnel plot, and Egger's test indicated the presence of moderate publication bias.

CONCLUSIONS

The findings of this meta-analysis should reassure women and doctors that emotional distress caused by fertility problems or other life events co-occurring with treatment will not compromise the chance of becoming pregnant.

Physical and mental health correlates of pregnancy following breast cancer

INTRODUCTION

The safety of pregnancy after breast cancer is an important issue for many younger breast cancer survivors and their health care providers. Current research does not indicate that pregnancy negatively affects survival, but the 'healthy mother bias,' suggesting that survivors who go on to become pregnant are a self-selected healthier group based on their prognosis, has led to cautious interpretation of these findings. No studies have systematically evaluated the potential for this bias.

METHODS

This nested case-control study includes 81 younger participants from the Women's Healthy Eating and Living (WHEL) study (N=3088). Our sample includes 27 cases who had children after breast cancer and 54 controls, matched on age and stage at diagnosis. We used hierarchical linear modeling to accommodate longitudinal data with individuals nested within matched sets (cases and controls). The primary aim was to evaluate the association between summary scores of health and childbearing after breast cancer. Covariates were added for adjustment and to improve model precision.

RESULTS

Controlling for other variables in the model, physical health scores were not different between cases and controls (B=0.14, p=0.96). Mental health scores were marginally higher among cases (B=6.40, p=0.08), as compared with controls, a difference considered clinically significant.

CONCLUSION

This preliminary study did not find evidence of a healthy mother bias based on physical health. However, mental health was 6 points higher (p=0.08) among those who had children, indicating that the role of mental health needs evaluation in future research. Larger studies are needed to verify these findings.

Cognitive coping, goal adjustment, and depressive and anxiety symptoms in people undergoing infertility treatment: a prospective study

The relationships between cognitive coping strategies, goal adjustment, and symptoms of depression and anxiety were studied in people with fertility problems. Both cross-sectional and prospective relationships were studied in a sample of 313 patients attending an infertility clinic. Self-report questionnaires were filled out at home. Positive refocusing, rumination and catastrophizing, and goal reengagement were related to symptoms of depression and anxiety. When looking at the long-term effects, rumination and catastrophizing were also related to emotional problems nine months later. These findings suggest that intervention programs should focus on cognitive coping strategies and goal-based processes.

Pre-treatment preferences and characteristics among patients seeking in vitro fertilisation

Background

This study sought to describe patient features before beginning fertility treatment, and to ascertain their perceptions relative to risk of twin pregnancy outcomes associated with such therapy.

Methods

Data on readiness for twin pregnancy outcome from in vitro fertilisation (IVF) was gathered from men and women before initiating fertility treatment by anonymous questionnaire.

Results

A total of 206 women and 204 men were sampled. Mean (± SD) age for women and men being 35.5 ± 5 and 37.3 ± 7 yrs, respectively. At least one IVF cycle had been attempted by 27.2% of patients and 33.9% of this subgroup had initiated ≥3 cycles, reflecting an increase in previous failed cycles over five years. Good agreement was noted between husbands and wives with respect to readiness for twins from IVF (77% agreement; Cohen's K = 0.61; 95% CI 0.53 to 0.70).

Conclusion

Most patients contemplating IVF already have ideas about particular outcomes even before treatment begins, and suggests that husbands & wives are in general agreement on their readiness for twin pregnancy from IVF. However, fertility patients now may represent a more refractory population and therefore carry a more guarded prognosis. Patient preferences identified before IVF remain important, but further studies comparing pre- and post-treatment perceptions are needed.

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.

Stimulation day-six serum estradiol: a predictive indicator for the probability of embryo cryopreservation in IVF/ICSI cycles

OBJECTIVE

To evaluate the predictive value of stimulation day six serum estradiol (E2) for the probability of embryo cryopreservation after fresh embryo transfer in intracytoplasmic sperm injection (ICSI) cycles.

SUBJECTS AND METHODS

The study included 282 ICSI cycles for different causes of infertility, provided that the age of the female partner was <40 years and her basal follicle stimulating hormone <10 IU/L.

SETTING

Alexandria IVF/ICSI center.

MAIN OUTCOME MEASURES

Primary outcome measures are stimulation day-six serum E2, and rate of embryo cryopreservation, after transfer of three good-quality embryos. Secondary outcome measures are pregnancy rate per fresh embryo transfer, and other intermediate variables of the ICSI cycle.

RESULTS

Patients were stratified into three groups according to day-six serum E2 levels: Group I with values <400 pg/mL; Group II, between 400 and 900; and Group III with values >900. The mean number of oocytes retrieved was 6.3, 8.9, and 12.4; the mean number of obtained embryos was 3.3, 4.8, and 6.7; and pregnancy rates were 18.1, 36.2, and 44.7% in the three groups, respectively. Rate of embryo cryopreservation, after transfer of three good-quality embryos was 70.7% in Group III, and 26.5% in Group I. (P = 0.01). The negative predictive value of day-six E2 <400 pg/mL for freezing was 83% while day-six serum E2 >900 pg/mL has a sensitivity of 55%, specificity of 72% and positive predictive value of 50% for embryo freezing.

CONCLUSION

Higher stimulation day-six estradiol was associated with a higher probability of cryopreservation, and a higher pregnancy rate.

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.

Risk factors for psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment

OBJECTIVE

To identify risk factors associated with depression and anxiety in infertile women and men undergoing in vitro fertilization (IVF).

DESIGN

Prospective study.

SETTING

A university hospital in Sweden during a 2-year period.

PATIENT(S)

825 participants (413 women and 412 men).

INTERVENTION(S)

Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), as the diagnostic tool for evaluating mood and anxiety disorders, and fertility history and outcome of IVF treatment collected from the patients' medical records.

MAIN OUTCOME MEASURE(S)

Risk factors associated with depression and anxiety disorders.

RESULT(S)

A negative pregnancy test and obesity were the independent risk factors for any mood disorders in women. Among men, the only independent risk factor for depression was unexplained infertility. No IVF-related risk factors could be identified for any anxiety disorder.

CONCLUSION(S)

A negative pregnancy test is associated with an increased risk for depression in women undergoing IVF, but no risk of developing anxiety disorders is associated with the pregnancy test result after IVF. Pregnancy test results were not a risk factor for depression or anxiety among men.