Infertility experience and health differentials - a population-based comparative study on infertile and non-infertile women (the HUNT Study)

A phenomenological exploration of the mental health experiences of young women with diminished ovarian reserve

Infertility is a reproductive disease affecting one in six individuals that renders an individual unable to conceive. One cause of infertility is diminished ovarian reserve (DOR), which reduces the quantity and/or quality of a female's oocyte pool. Although typically indicating normal ovarian aging during the late 30s and early 40s, DOR can also impact younger women, increasing their risk for psychological distress from an unexpected diagnosis of infertility. A phenomenological approach examined the mental health experiences and perceptions of infertility-related mental health care of young women with DOR. Women diagnosed with DOR by age 35 in the United States who experienced emotional distress during infertility were recruited from infertility-specific social media and via snowball sampling. Participants completed a demographic survey and semi-structured individual interview that was audio-recorded, transcribed verbatim, and analyzed using a phenomenological approach. Ten women ages 27-41 completed the study. On average, participants were 30 years of age at the time of DOR diagnosis (age range 25-35), primarily Caucasian (90%), and married (90%). Two main themes were found: (1) Young women with DOR feel like a "forgotten community" coping with an invisible disease; and (2) Not all fertility clinics are created equal. Participants perceived their diagnosis as devastating and hopeless and urged others to find a provider with ample experience treating patients with DOR. This study helped to understand how young women with DOR perceive their mental health and identified a significant need for advancing towards more holistic infertility healthcare that encompasses both physical and mental health.

The association between time-to-pregnancy and postpartum depressive symptoms in a North American prospective cohort study

PURPOSE

To prospectively examine the association between time-to-pregnancy (TTP) and postpartum depression (PPD) and determine whether perceived stress during early pregnancy mediated this association.

METHODS

In Pregnancy Study Online, an internet-based preconception cohort study of pregnancy planners, participants completed questionnaires every 8 weeks for up to 12 months or conception, during pregnancy, and at postpartum. A total of 2643 women provided information on sociodemographic factors, reproductive history, and stress (i.e., Perceived Stress Scale [PSS]) during preconception and early pregnancy (completed at ∼4-12 weeks' gestation) and on postpartum depressive symptoms (i.e., Edinburgh Postnatal Depression Scale [EPDS]) at ∼6 months postpartum. We used multivariable modified Poisson regression models to estimate risk ratios and 95% confidence intervals (CIs) for the association between TTP (<3, 3-5, 6-11, ≥12 menstrual cycles) and PPD (EPDS score ≥13). Causal mediation analyses assessed the mediating role of early pregnancy PSS scores.

RESULTS

10.6% of women had EPDS scores indicating possible PPD (≥13). Compared with women who took less than 3 cycles to conceive, risk ratios for those who took 3-5, 6-11, and greater than or equal to 12 were 1.06 (95% CI: 0.77, 1.45), 1.24 (95% CI: 0.90, 1.70), and 1.31 (95% CI: 0.87, 1.99), respectively. Approximately 30% of the association between infertility (TTP ≥ 12) and PPD was mediated by early pregnancy PSS.

CONCLUSIONS

There was a modest positive dose-response association between delayed conception and PPD. Perceived stress in early pregnancy explained a small proportion of this association. However, given the width of the CIs, chance cannot be ruled out as an explanation for the observed association.

Healthcare Use in the Five Years Before a First Infertility Diagnosis: A Danish Register-Based Case–Control Study in the CROSS-TRACKS Cohort

Purpose

Infertility may affect somatic and mental health later in life. Nevertheless, health status before diagnosed infertility is sparsely studied in women. We aimed to describe healthcare use in primary and secondary care before a first infertility diagnosis and compare use between cases and controls.

Materials and Methods

The case–control study was based on register data and used incidence density sampling. From the CROSS-TRACKS Cohort, we included women residing in the Horsens area in Denmark in 2012–2018 (n = 54,175). Eligible women were aged 18–40 years, nulliparous, and living in heterosexual relationships. Cases were women with a first infertility diagnosis in the Danish National Patient Registry (index date). Five controls were matched on age, birth year, and calendar time. Through linkage to Danish national health registries, we identified general practitioner (GP) attendance, paraclinical examinations, hospital contacts, diagnoses, and redeemed prescriptions. Healthcare use from one year to five years before index date was compared with conditional logistic regression.

Results

We identified 711 cases and 3555 controls. At one year before index date, cases consulted their GP (odds ratio (OR) = 5.2, 95% confidence interval (CI): 3.2, 8.3) and visited hospital (OR = 1.2, 95% CI: 1.0, 1.4) and redeemed prescriptions (OR = 2.3 95% CI: 1.9, 2.7) more often compared to controls. Cases more often had blood and hemoglobin tests performed, redeemed more drugs related to genitourinary and hormonal diseases, and were more often diagnosed with endocrine and genitourinary diseases in the year before a first infertility diagnosis compared to controls. Cases and controls had comparable healthcare use from five years to one year before a first infertility diagnosis.

Conclusion

Cases and controls had similar healthcare use from five years to one year before a first infertility diagnosis. However, cases had a higher healthcare use in the year preceding a first infertility diagnosis compared to controls.

Infertility-related stress: A concept analysis

AIM

To develop a clear definition of infertility-related stress using Rodgers' method of concept analysis.

BACKGROUND

Infertility affects approximately 13% of women in the United States. Though poorly defined in the literature, previous studies suggest infertility-related stressors contribute to psychological distress.

DESIGN

Rodgers' method of concept analysis guided the review, including sample and setting, literature search, and data analysis.

DATA SOURCE

PubMed, CINAHL, and PsycINFO were searched for relevant literature.

REVIEW METHODS

Following abstract, title, and text screenings, 21 articles were included and reported using the PRISMA-S checklist. Texts were analyzed and results informed the proposed definition of infertility-related stress.

RESULTS

Antecedents included infertility, desire for children, and fear of the unknown. Attributes were identity crisis, social isolation and stigma, sexual stress, and financial strain. Consequences included treatment dropout and marital strain. Anxiety, depression, and decreased quality of life were identified as both attributes and consequences.

CONCLUSIONS

Synthesized results informed a proposed definition of infertility-related stress. Improved understanding of infertility-related stress allows for measurement development and facilitates recognition of patients in need of additional support, while potentially reducing the impact on the health and well-being of infertile women.

Comparison of anxiety scores between unexplained primary and secondary infertile couples

OBJECTIVE

To investigate the anxiety levels among infertile women and their partners also factors that may affect the anxiety status.

STUDY DESIGN

A total of 403 infertile couples who applied to Infertility Outpatient Clinics of a University-affiliated Teaching and Research Hospital were included in the study. The infertile group was divided into two groups as primary and secondary infertile. One hundred and thirty-two fertile couples who applied to Gynecology Outpatient Clinics composed the control group. Hamilton Anxiety Rating Scale (HAM-A) form was filled by the infertile couples to evaluate the anxiety status before they started their treatment.

RESULTS

Three hundred and twenty infertile and 84 fertile couples completed the study. The mean total scores of HAM-A of women were similar between the groups. So were the scores of their husbands. In all groups, women had significantly higher mean total HAM-A scores than their husbands. There was no association between the mean HAM-A score of women and age, BMI, AFC, duration of marriage, duration of infertility, number of previous treatment cycles. Education status, working status and family structure of women did not correlate with the mean HAM-A score.

CONCLUSION

Unexplained primary and secondary infertile couples had similar anxiety scores before the commencement of fertility treatments. However, the scores were higher in women than their male partners. Since the burden of treatment and the likelihood of treatment failure might increase the level of anxiety the women could be offered proper cognitive coping and relaxation interventions.

The prevalence of depression symptoms among infertile women: a systematic review and meta-analysis

BACKGROUND

Infertile women's mental health problems, including depression, are key fertility health issues that affect infertile women more severely than infertile men. Depression may threaten the health of individuals and reduce the quality of their lives. Considering the role and impact of depression on responses to infertility treatments, a systematic review and meta-analysis were conducted to investigate the prevalence of depression symptoms among infertile women.

METHODS

International databases (PubMed, Cochrane Library, Web of Sciences, Scopus, Embase, and PsycINFO), national databases (SID and Magiran), and Google Scholar were searched by two independent reviewers for articles published from 2000 to April 5, 2020. The search procedure was performed in both Persian and English using keywords such as "depression," "disorders," "infertility," "prevalence," and "epidemiology." The articles were evaluated in terms of their titles, abstracts, and full texts. The reviewers evaluated the quality of the articles using the Newcastle-Ottawa Scale, after which they analyzed the findings using STATA version 14. The I2 and Egger's tests were performed to examine heterogeneity and publication bias, respectively.

RESULTS

Thirty-two articles were subjected to the meta-analysis, and a random effects model was used in the examination given the heterogeneity of the articles. The samples in the reviewed studies encompassed a total of 9679 infertile women. The lowest and highest pooled prevalence rates were 21.01% (95% confidence interval [CI]: 15.61-34.42), as determined using the Hospital Anxiety and Depression Scale, and 52.21% (95% CI: 43.51-60.91), as ascertained using the Beck Depression Inventory, respectively. The pooled prevalence values of depression among infertile women were 44.32% (95% CI: 35.65-52.99) in low- and middle-income countries and 28.03% (95% CI: 19.61-36.44) in high-income countries.

CONCLUSION

The prevalence of depression among infertile women was higher than that among the general population of a given country. Especially in low- and middle-income countries, appropriate measures, planning, and policy that target the negative effects of depression on infertile women's lives should be established to reduce related problems.

Comparison of depression between primary and secondary infertile couples

OBJECTIVE

We aimed to compare the depression levels between primary and secondary infertile couples and to investigate the related factors that may affect depression.

STUDY DESIGN

Two hundred and fifty primary and secondary infertile couples, who admitted to Gynecology and Infertility Clinics of Pendik Teaching and Research Hospital affiliated with Marmara University were enrolled in this study. Sixty-four BMI-matched fertile female patients who applied to the General Gynecology Clinic and their husbands were taken as the control group. Beck Depression Inventory (BDI) form was filled by the infertile couples to evaluate the depression status before they started their cycles.

RESULTS

The mean total BDI scores were alike between groups among women. Mild depression was found to be higher in the primary infertile women and moderate depression was higher in women of the control group. Women had statistically higher depression scores than male partners. Primary infertile, secondary infertile, and fertile women had higher depression scores than their male partners in the corresponding groups. There was no significant difference in mean total BDI scores among males between the groups. The percentage of distribution of male partners in each level of depression was similar between the groups.

CONCLUSIONS

Only a weak positive correlation between the mean total BDI score and the number of previous treatment cycles was found. Psychiatric support before and during the upcoming fertility treatment might reduce the perception of the probable treatment failure.

Mini-Review on the Possible Interconnections between the Gut-Brain Axis and the Infertility-Related Neuropsychiatric Comorbidities

Both the gut-brain axis (GBA) and the hypothalamic–pituitary–adrenal (HPA) axis remain an intriguing yet obscure network with a strong influence over other systems of organs. Recent reports have sought to describe the multitude of harmful stressors that may impact the HPA axis along with the interconnections between these. This has improved our knowledge of how the underlying mechanisms working to establish homeostasis are affected. A disruption to the HPA axis can amplify the chances of gastrointestinal deficiencies, whilst also increasing the risk of a wide spectrum of neuropsychiatric disorders. Thus, the influence of microorganisms found throughout the digestive tract possess the ability to affect both physiology and behaviour by triggering responses, which may be unfavourable. This is sometimes the case in of infertility. Numerous supplements have been formulated with the intention of rebalancing the gut microflora. Accordingly, the gut flora may alter the pharmacokinetics of drugs used as part of fertility treatments, potentially exacerbating the predisposition for various neurological disorders, regardless of the age and gender.

The prevalence of anxiety symptoms in infertile women: a systematic review and meta-analysis

BACKGROUND

Infertile women are exposed more frequently to anxiety risk than are infertile men, thereby adversely affecting the procedures with which they are treated and the quality of their lives. Yet, this problem is often disregarded. This study accordingly determined the prevalence of anxiety symptoms among infertile women.

METHODS

All Persian and English studies published from the early 2000s to May 2019 were searched in international (i.e., PubMed, the Cochrane Library, Web of Science, Scopus, Embase, and PsycINFO) and national (i.e., SID, Magiran) databases as well as through Google Scholar. After the titles and abstracts of the articles were reviewed, their quality was evaluated, and relevant works for examination were selected in consideration of established inclusion and exclusion criteria. The risk of biases of individual studies according to Newcastle - Ottawa Scale was assessed. The heterogeneity of the studies was assessed using the I2 statistic, and indicators of publication bias were ascertained using Egger's test. Stata (version 14) was employed in analyzing the findings.

RESULTS

Thirteen studies having a collective sample size of 5055 infertile women were subjected to meta-analysis, with study heterogeneity incorporated into a random effects model. The findings indicated that 36% of the infertile women involved in the evaluated studies self-reported their experience with anxiety. The pooled prevalence of the condition among the subjects was 36.17% [95% confidence interval (CI): 22.47-49.87]. The pooled prevalence levels in low- and middle-income countries and high-income countries were 54.24% (95% CI: 31.86-78.62) and 25.05% (95% CI: 15.76-34.34), respectively. The results revealed no evidence of publication bias (P Egger's test = 0.406).

CONCLUSION

Considering the prevalence of anxiety in infertile women and its effects on health processes and quality of life, this problem requires serious consideration and planning for effective intervention, especially in low- and middle-income nations.

Association Between the Frequency of Eating Non-home-prepared Meals and Women Infertility in the United States

OBJECTIVES

The purpose of this study was to determine whether eating non-home-prepared meals (NHPM), including fast food, ready-to-eat foods, and frozen foods, was associated with self-reported infertility in the United States women.

METHODS

Data on diet and infertility from women aged 20-49 years who participated in the 2013-2014 and 2015-2016 National Health and Nutrition Examination Surveys were analyzed (n=2143). Dietary information, including the number and types of NHPM consumed, was obtained from a self-reported questionnaire, and infertility status was analyzed using the following question, "Have you ever attempted to become pregnant over a period of at least a year without becoming pregnant?"

RESULTS

The frequency of NHPM consumption was positively associated with self-reported infertility after adjusting for confounding effects (odds ratio [OR], 2.82; 95% confidence interval [CI], 1.48 to 5.38 of >1 vs. 0 NHPM/d). The odds of infertility were 2-3 times higher in women who consumed fast food than in those who did not consume fast food (OR, 2.73; 95% CI, 1.15 to 6.48 of >1 vs. 0 times/d).

CONCLUSIONS

The frequency and types of NHPM may be a factor contributing to infertility. Although our findings require confirmation, they suggest that eating out may be deleterious to women fecundity.

Epigenetically regulated imprinted gene expression associated with IVF and infertility: possible influence of prenatal stress and depression

PURPOSE

Despite the growing body of research implying an impact of in vitro fertilization (IVF) on imprinted genes and epigenetics, few studies have examined the effects of underlying subfertility or prenatal stress on epigenetics, particularly in terms of their role in determining infant birthweights. Both subfertility and prenatal stressors have been found to impact epigenetics and may be confounding the effect of IVF on epigenetics and imprinted genes. Like IVF, both of these exposures-infertility and prenatal stressors-have been associated with lower infant birthweights. The placenta, and specifically epigenetically regulated placental imprinted genes, provides an ideal but understudied mechanism for evaluating the relationship between underlying genetics, environmental exposures, and birthweight.

METHODS AND RESULTS

In this review, we discuss the impacts of IVF and infertility on birthweight, epigenetic mechanisms and genomic imprinting, and the role of these mechanisms in the IVF population and discuss the role and importance of the placenta in infant development. We then highlight recent work on the relationships between infertility, IVF, and prenatal stressors in terms of placental imprinting.

CONCLUSIONS

In combination, the studies discussed, as well as two recent projects of our own on placental imprinted gene expression, suggest that lower birthweights in IVF infants are secondary to a combination of exposures including the infertility and prenatal stress that couples undergoing IVF are experiencing. The work highlighted herein emphasizes the need for appropriate control populations that take infertility into account and also for consideration of prenatal psychosocial stressors as confounders and causes of variation in IVF infant outcomes.

Health-Related Quality of Life for Women Ever Experiencing Infertility or Difficulty Staying Pregnant

INTRODUCTION

Information on the health-related quality of life (HRQOL) for women with infertility is limited and does not account for the co-occurrence of chronic conditions or emotional distress.

METHODS

We used data from state-added questions on reproductive health included in the 2013 Behavioral Risk Factor Surveillance System in seven states. HRQOL indicators included: self-reported health status; number of days in the past 30 days when physical and mental health was not good; number of days in the past 30 days that poor physical or mental health limited activities. We computed rate ratios for HRQOL for women ever experiencing infertility or difficulty staying pregnant compared with women never reporting these conditions; interactions with chronic conditions and depressive disorders were assessed.

RESULTS

Of 7,526 respondents aged 18-50 years, 387 (4.9%) reported infertility only and 339 (4.3%) reported difficulty staying pregnant only. Infertility was associated with an increase in average number of days with poor physical health for women with chronic conditions [rate ratio (RR) 1.85, 95% confidence interval (CI) 1.04-3.29] but was protective for women without chronic conditions (RR 0.47, 95% CI 0.29-0.75). Difficulty staying pregnant was associated with an increase in average number of days of limited activity among both women with chronic conditions (RR 2.14, 95% CI 1.32-3.45) and women with depressive disorders (RR 1.72 95% CI 1.14-2.62).

DISCUSSION

Many HRQOL measures were poorer for women who had infertility or difficulty staying pregnant compared to their counterparts; the association was modified by presence of chronic conditions and depressive disorders.

Outcome of assisted reproductive technology (ART) and subsequent self-reported life satisfaction

OBJECTIVE

To compare life satisfaction between women with successful or unsuccessful outcome after assisted reproductive treatment (ART) by taking into account the time since the last ART.

DESIGN

Cohort study.

SETTING

Tertiary hospital.

PATIENTS

A total of 987 consecutive women who had undergone ART during 1996-2007 were invited and altogether 505 women participated in the study.

INTERVENTIONS

A postal enquiry with a life satisfaction scale.

MAIN OUTCOME MEASURE

Self-reported life satisfaction in respect to the time since the last ART.

RESULTS

In general, women who achieved a live birth after ART had a significantly higher life satisfaction than those who had unsuccessful ART, especially when compared in the first three years. The difference disappeared in the time period of 6-9 years after ART. The unsuccessfully treated women who had a child by some other means before or after the unsuccessful ART had comparable life satisfaction with successfully treated women even earlier.

CONCLUSIONS

Even if unsuccessful ART outcome is associated with subsequent lower level of life satisfaction, it does not seem to threaten the long-term wellbeing.