Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study

A randomized controlled trial of the effects of nursing care based on Watson's Theory of Human Caring on distress, self-efficacy and adjustment in infertile women

AIMS

To investigate the effects of nursing care based on the Theory of Human Caring on distress caused by infertility, perceived self-efficacy and adjustment levels.

BACKGROUND

Infertility leads to individual, familial and social problems. Nursing care standards for women affected by infertility have yet to emerge.

DESIGN

A randomized controlled trial.

METHODS

This study was conducted from May 2010-February 2011, with 105 Turkish women with infertility (intervention group: 52, control group: 53). We collected data using the Infertility Distress Scale, the Turkish-Infertility Self Efficacy Scale Short Form and the Turkish-Fertility Adjustment Scale. The intervention group received nursing care based on the Theory of Human Caring. Data were analysed using t-tests, chi-square tests and intention-to-treat analyses.

RESULTS

The intervention and control groups significantly differed with regard to infertility distress, self-efficacy and adjustment levels. The intervention group's mean self-efficacy score increased by seven points and adjustment score decreased by seven points (in a positive direction). In addition, there was a significant reduction in infertility distress scores in the intervention group, but there was no change in the control group.

CONCLUSION

Nursing care based on the Theory of Human Caring decreased the negative impact of infertility in women receiving infertility treatment and increased self-efficacy and adjustment.

A systematic review of the evidence for complementary and alternative medicine in infertility

BACKGROUND

The use of complementary and alternative medicine (CAM) by patients and physicians has increased markedly in recent years. Many case reports, case series, and uncontrolled trials of varying quality have been completed; however, there is now a slowly increasing number of randomized controlled trials (RCTs) examining the use of CAM.

OBJECTIVES

To identify, survey, and review RCTs investigating the use of CAM for infertility treatment.

SEARCH STRATEGY

The MEDLINE and Cochrane databases were electronically searched.

SELECTION CRITERIA

RCTs examining modalities for treatment or improvement of health status were reviewed.

DATA COLLECTION AND ANALYSIS

RCTs were included based on use of objective measures, articles written in English, availability through the University of Michigan database, and clear published clinical outcomes.

MAIN RESULTS

Thirty-seven articles assessing a variety of CAM modalities met inclusion criteria. Acupuncture, selenium supplementation, weight loss, and psychotherapeutic intervention had 3 or more studies demonstrating beneficial effect. Other interventions had been studied less and evidence for them was limited.

CONCLUSIONS

Although there is preliminary evidence of the effectiveness of some CAM interventions among infertile patients, many of these interventions require further investigation before they can be considered for routine clinical use.

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.

Incorporating spirituality in psychosocial group intervention for women undergoing in vitro fertilization: a prospective randomized controlled study

OBJECTIVES

This study examined the efficacy of a group intervention, the Integrative Body-Mind-Spirit (I-BMS) intervention, which aims at improving the psychosocial and spiritual well-being of Chinese women undergoing their first IVF treatment cycle.

DESIGN

The I-BMS intervention facilitates the search of meaning of life in the context of family and childbearing, as well as the letting go of high IVF expectations. A randomized controlled study of 339 women undergoing first IVF treatment cycle in a local Hong Kong hospital was conducted (intervention: n= 172; no-intervention control: n= 167).

METHODS

Assessments of anxiety, perceived importance of childbearing, and spiritual well-being were made at randomization (T(0) ), on the day starting ovarian stimulations (T(1)), and on the day undertaking embryo transfer (T(2)).

RESULTS

Comparing T(0) and T(2), interaction analyses showed women who had received the intervention reported lower levels of physical distress, anxiety, and disorientation. They reported being more tranquil and satisfied with their marriage, and saw childbearing as less important compared to women in the control group.

CONCLUSIONS

These findings suggest that I-BMS intervention was successful at improving the psychosocial and spiritual well-being of women undergoing their first IVF treatment cycle. This study highlights the importance of providing integrative fertility treatment that incorporates psychosocial and spiritual dimensions.

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.

Does emotional support during the luteal phase decrease the stress of in vitro fertilization?

OBJECTIVE

To determine if phone calls between ET and pregnancy test, decrease stress levels as determined by the Perceived Stress Scale (PSS).

DESIGN

Randomized controlled trial.

SETTING

Academic medical center.

PATIENT(S)

Women undergoing a first fresh cycle of assisted reproductive technology using autologous oocytes with a day 2 or 3 ET.

INTERVENTION(S)

Phone calls from specialized social workers or standard of care.

MAIN OUTCOME MEASURE(S)

Primary outcome was the change in PSS score from day of ET compared with 10 days after ET; secondary outcome was perceived patient benefit.

RESULT(S)

A total of 131 patients were randomized to the intervention (n = 66) or control (n = 65) group. No differences were seen in the final PSS score or the change in PSS score between groups. At the completion of the study, the intervention group was more likely to report that participating in this study was helpful (65.9% vs. 21.4%), as well as to recommend emotional support during an IVF cycle (95.4% vs. 78.6%).

CONCLUSION(S)

Although we observed no significant change in PSS score, first-cycle IVF patients felt that increased emotional support was needed during the waiting period between ET and pregnancy test. Additional research should be conducted to determine the best interventions for this time period.

Life after unsuccessful IVF treatment in an assisted reproduction unit: a qualitative analysis of gains through loss among Chinese persons in Hong Kong

BACKGROUND

Previous studies examining experiences of infertility focused mainly on the aspect of loss but neglected the possible gains realized through surviving the experience of infertility. The success rate of IVF remains relatively low, and we used the strengths perspective to examine adjustment after unsuccessful treatment. This study aims to provide an in-depth description of the gains perceived by Chinese men and women and how they re-constructed their lives after unsuccessful IVF treatment.

METHODS

Four couples and another six women who experienced unsuccessful IVF treatment were recruited from an assisted reproduction clinic. Data were collected through in-depth interviews, using a grounded theory constructivist approach.

RESULTS

Of the 10 women and 4 men interviewed, 9 remained childless, 3 had adopted a child and 2 had conceived naturally. They reported gains on a personal level, interpersonal level and transpersonal level through surviving the experience of infertility. All, regardless of the eventual outcome, reported at least one form of personal gain: in personality or knowledge gain. Interpersonal gains were perceived in relationships with their spouses, children, parents, friends, colleagues and fellow IVF service users. More than half of them reported spiritual growth and a change in identity through integrating their experiences and offering help to others.

CONCLUSION

Despite the small sample size, this study makes a significant contribution by suggesting that while negative feelings provoked by the failure to conceive should be acknowledged, people in this situation should also be enabled to consolidate their negative experiences of IVF constructively, helping them to move on with their lives.

The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate

BACKGROUND

Psychological interventions for infertile patients seek to improve mental health and increase pregnancy rates. The aim of the present meta-analysis was to examine if psychological interventions improve mental health and pregnancy rate among infertile patients. Thus, controlled studies were pooled investigating psychological interventions following the introduction of assisted reproductive treatments (ART).

METHODS

The databases of Medline, PsycINFO, PSYNDEX, Web of Science and the Cochrane Library were searched to identify relevant articles published between 1978 and 2007 (384 articles). Included were prospective intervention studies on infertile patients (women and men) receiving psychological interventions independent of actual medical treatment. The outcome measures were mental health and pregnancy rate. A total of 21 controlled studies were ultimately included in a meta-analysis comparing the efficacy of psychological interventions. Effect sizes (ES) were calculated for psychological measures and risk ratios (RR) for pregnancy rate.

RESULTS

The findings from controlled studies indicated no significant effect for psychological interventions regarding mental health (depression: ES 0.02, 99% CI: -0.19, 0.24; anxiety: ES 0.16, 99% CI: -0.10, 0.42; mental distress: ES 0.08, 99% CI: -0.10, 0.51). Nevertheless, there was evidence for the positive impact of psychological interventions on pregnancy rates (RR 1.42, 99% CI: 1.02, 1.96). Concerning pregnancy rates, significant effects for psychological interventions were only found for couples not receiving ART.

CONCLUSIONS

Despite the absence of clinical effects on mental health measures, psychological interventions were found to improve some patients' chances of becoming pregnant. Psychological interventions represent an attractive treatment option, in particular, for infertile patients who are not receiving medical treatment.

Benefits of combining massage therapy with group interpersonal psychotherapy in prenatally depressed women

One hundred and twelve pregnant women who were diagnosed depressed were randomly assigned to a group who received group Interpersonal Psychotherapy or to a group who received both group Interpersonal Psychotherapy and massage therapy. The group Interpersonal Psychotherapy (1h sessions) and massage therapy (20 min sessions) were held once per week for 6 weeks. The data suggested that the group who received psychotherapy plus massage attended more sessions on average, and a greater percentage of that group completed the 6-week program. The group who received both therapies also showed a greater decrease in depression, depressed affect and somatic-vegetative symptom scores on the Center for Epidemiological Studies-Depression Scale (CES-D), a greater decrease in anxiety scale (STAI) scores and a greater decrease in cortisol levels. The group therapy process appeared to be effective for both groups as suggested by the increased expression of both positive and negative affect and relatedness during the group therapy sessions. Thus, the data highlight the effectiveness of group Interpersonal Psychotherapy and particularly when combined with massage therapy for reducing prenatal depression.

A randomized double blind comparison of real and placebo acupuncture in IVF treatment

BACKGROUND

Acupuncture has been used during IVF treatment as it may improve outcome, however, there are concerns about the true efficacy of this approach. This randomized double blind study aimed to compare real acupuncture with placebo acupuncture in patients undergoing IVF treatment.

METHODS

On the day of embryo transfer (ET), 370 patients were randomly allocated to either real or placebo acupuncture according to a computer-generated randomization list in sealed opaque envelopes. They received 25 min of real or placebo acupuncture before and after ET. The endometrial and subendometrial vascularity, serum cortisol concentration and the anxiety level were evaluated before and after real and placebo acupuncture.

RESULTS

The overall pregnancy rate was significantly higher in the placebo acupuncture group than that in the real acupuncture group (55.1 versus 43.8%, respectively, P = 0.038; Common odds ratio 1.578 95% confidence interval 1.047-2.378). No significant differences were found in rates of ongoing pregnancy and live birth between the two groups. Reduction of endometrial and subendometrial vascularity, serum cortisol concentration and the anxiety level were observed following both real and placebo acupuncture, although there were no significant differences in the changes in all these indices between the two groups.

CONCLUSIONS

Placebo acupuncture was associated with a significantly higher overall pregnancy rate when compared with real acupuncture. Placebo acupuncture may not be inert. Trial registered with HKClinicalTrials.com: number HKCTR-236.

Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping

Miscarriages can have lasting psychological effects on those concerned. In a prospective longitudinal study, 342 women were questioned about the way in which they coped after an early miscarriage (up to the 16th week of gestation), a few weeks after the pregnancy loss. There are data available from the first trimester of a subsequent pregnancy for 108 of these women. Standardized symptom scales were used to explore the pregnancy-specific anxiety, state and trait anxiety (STAI) and depressive symptoms in pregnant women and these were compared with the symptoms of 69 pregnant women with no history of miscarriages. Women with a history of miscarriages suffer more from pregnancy-specific anxieties in the first trimester of a new pregnancy than pregnant women with no history of miscarriages. Patterns of "depressive coping" and "anxious grieving" after the losses are predictive of more marked anxiety and depression symptoms in the first trimester of a subsequent pregnancy. These results suggest that women who have had an early miscarriage are particularly at risk of disturbances in their psychological adaptation in a new pregnancy. It is possible to determine risk factors which can be used to recognize those women who are particularly at risk directly after the miscarriage.

Implications of psychosocial support in infertility--a critical appraisal

OBJECTIVE

Various psychosocial interventions have been recommended for infertile persons, but it remains unclear what their implications are, and if some of them might even be harmful under certain circumstances.

METHODS

A survey is given of papers concerning the usefulness of psychosocial support in infertility.

RESULTS

Providing procedural information concerning the technical aspects of infertility investigation probably facilitates coping with infertility and with assisted reproductive techniques. This information can be given in the form of booklets or educational films. Using the Internet is a fast and easy way to obtain information on infertility and its treatment, but with the risk of getting wrong or misleading information. Telephone counseling can be helpful in providing specific information about the infertility workup but it cannot replace face-to-face counseling on distressing psychosocial issues. Attendance at support groups can be recommended to strengthen coping abilities. Psychosocial counseling and psychotherapy are definitely effective in reducing negative affect, mostly within a short period of time (less than 10 sessions). Pregnancy rates are unlikely to be affected by psychosocial interventions.

CONCLUSION

Infertility counseling and support groups seem to be the most efficient psychosocial interventions in infertility. Therefore, infertility counseling should be available at all stages of medical therapy, and it should be free of charge for the persons attending it. Course, content and goals of the infertility counseling should be made transparent. The efficacy of support groups has to be evaluated more systematically. Several methodological questions have to be solved yet, and the generalizability of these results is still restricted.

The role of acupuncture in the management of subfertility

OBJECTIVE

To review systematically the use of acupuncture in the management of subfertility.

DESIGN

A computer search was performed via several English and Chinese databases to identify journals relevant to the subject.

RESULT(S)

The positive effect of acupuncture in the treatment of subfertility may be related to the central sympathetic inhibition by the endorphin system, the change in uterine blood flow and motility, and stress reduction. Acupuncture may help restore ovulation in patients with polycystic ovary syndrome, although there are not enough randomized studies to validate this. There is also no sufficient evidence supporting the role of acupuncture in male subfertility, as most of the studies are uncontrolled case reports or case series in which the sample sizes were small. Despite these deficiencies, acupuncture can be considered as an effective alternative for pain relief during oocyte retrieval in patients who cannot tolerate side effects of conscious sedation. The pregnancy rate of IVF treatment is significantly increased, especially when acupuncture is administered on the day of embryo transfer.

CONCLUSION(S)

Although acupuncture has gained increasing popularity in the management of subfertility, its effectiveness has remained controversial.

East meets West: applying Eastern spirituality in clinical practice

AIMS AND OBJECTIVES

The paper discusses the application of the Eastern body-mind-spirit approach in healthcare practice.

BACKGROUND

Traumas, sufferings and losses may induce immense distress in patients and their families, as well as apathy and exhaustion in healthcare workers. Over-specialization and compartmentalization of services may provide a convenient shelter for healthcare workers to be detached and to simply focus on a narrowly defined scope of intervention. However, the existential problems are still there. Based upon eastern philosophies and holistic health practices, we propose the body-mind-spirit approach in healthcare settings.

METHODS

This is a review paper summarizing the application of the approach on various clinical populations.

RESULTS

The approach has been trialled with promising results in a number of health conditions and psychosocial predicaments. Spirituality is not restricted to any religious practices, nor is it narrowed to the pursuit of knowledge at a high level of abstraction. The interconnectedness of the body, mind and spirit presupposes that the practice of spirituality is multidimensional and multi-levelled.

CONCLUSIONS

Using the body-mind-spirit framework flexibly we can engage more clients while facilitating the important process of exploration and change. The key components include getting in touch with the inner self, coming back to our senses, connecting our body and mind and rebalancing our relationship with the natural and social environment. The ultimate goal is to move out of meaninglessness and to reach a state of mature spirituality of tranquillity and transcendence.

RELEVANCE TO CLINICAL PRACTICE

The practice of spirituality can be easily applied to daily life.