Mood disorders and fertility in women: a critical review of the literature and implications for future research

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.

Circulating C19 steroids and progesterone metabolites in women with acute depression and anxiety disorders

Depression and anxiety disorders are highly prevalent in women. Although several studies have reported altered circulating steroids accompanying various mental disturbances, knowledge about alterations in the peripheral steroid pattern in such pathologies is incomplete. Therefore, we attempted to add to this knowledge using the simultaneous quantification of circulating steroids by gas chromatography mass spectrometry (GC-MS) in groups of premenopausal women in the follicular phase of the menstrual cycle (22 women with depression, 17 with anxiety disorders, 17 healthy controls). In addition to age-adjusted analysis of covariance (ANCOVA) followed by multiple comparisons, we developed models to successfully discriminate these groups from each other on the basis of steroid levels. Women with depression showed a reduced sulfoconjugation of steroids as well as lower levels of 7α-, 7β- and 16α-hydroxy-metabolites of C19 Δ5 steroids. Women with depression have significantly lower circulating levels of 5α/β-reduced pregnane steroids (with exception of free isopregnanolone) than women with anxiety or controls. Finally, our data indicate higher levels of estrogens in women with anxiety disorders when compared to women with depression.

The Genetic Architecture of Major Depressive Disorder in Han Chinese Women

IMPORTANCE

Despite the moderate, well-demonstrated heritability of major depressive disorder (MDD), there has been limited success in identifying replicable genetic risk loci, suggesting a complex genetic architecture. Research is needed to quantify the relative contribution of classes of genetic variation across the genome to inform future genetic studies of MDD.

OBJECTIVES

To apply aggregate genetic risk methods to clarify the genetic architecture of MDD by estimating and partitioning heritability by chromosome, minor allele frequency, and functional annotations and to test for enrichment of rare deleterious variants.

DESIGN, SETTING, AND PARTICIPANTS

The CONVERGE (China, Oxford, and Virginia Commonwealth University Experimental Research on Genetic Epidemiology) study collected data on 5278 patients with recurrent MDD from 58 provincial mental health centers and psychiatric departments of general medical hospitals in 45 cities and 23 provinces of China. Screened controls (n = 5196) were recruited from a range of locations, including general hospitals and local community centers. Data were collected from August 1, 2008, to October 31, 2012.

MAIN OUTCOMES AND MEASURES

Genetic risk for liability to recurrent MDD was partitioned using sparse whole-genome sequencing.

RESULTS

In aggregate, common single-nucleotide polymorphisms (SNPs) explained between 20% and 29% of the variance in MDD risk, and the heritability in MDD explained by each chromosome was proportional to its length (r = 0.680; P = .0003), supporting a common polygenic etiology. Partitioning heritability by minor allele frequency indicated that the variance explained was distributed across the allelic frequency spectrum, although relatively common SNPs accounted for a disproportionate fraction of risk. Partitioning by genic annotation indicated a greater contribution of SNPs in protein-coding regions and within 3'-UTR regions of genes. Enrichment of SNPs associated with DNase I-hypersensitive sites was also found in many tissue types, including brain tissue. Examining burden scores from singleton exonic SNPs predicted to be deleterious indicated that cases had significantly more mutations than controls (odds ratio, 1.009; 95% CI, 1.003-1.014; P = .003), including those occurring in genes expressed in the brain (odds ratio, 1.011; 95% CI, 1.003-1.018; P = .004) and within nuclear-encoded genes with mitochondrial gene products (odds ratio, 1.075; 95% CI, 1.018-1.135; P = .009).

CONCLUSIONS AND RELEVANCE

Results support a complex etiology for MDD and highlight the value of analyzing components of heritability to clarify genetic architecture.

Pathogen-Host Defense in the Evolution of Depression: Insights into Epidemiology, Genetics, Bioregional Differences and Female Preponderance

Significant attention has been paid to the potential adaptive value of depression as it relates to interactions with people in the social world. However, in this review, we outline the rationale of why certain features of depression including its environmental and genetic risk factors, its association with the acute phase response and its age of onset and female preponderance appear to have evolved from human interactions with pathogens in the microbial world. Approaching the relationship between inflammation and depression from this evolutionary perspective yields a number of insights that may reveal important clues regarding the origin and epidemiology of the disorder as well as the persistence of its risk alleles in the modern human genome.

Women's Preferred Sources for Primary and Mental Health Care: Implications for Reproductive Health Providers

PURPOSE

To describe women's preferences for reproductive health providers as sources of primary and mental health care.

METHODS

This is secondary data analysis of the Women's Health Care Experiences and Preferences Study, an Internet survey conducted in September 2013 of 1,078 women aged 18 to 55 randomly sampled from a U.S. national probability panel. We estimated women's preferred and usual sources of care (reproductive health providers, generalists, other) for various primary care and mental health care services using weighted statistics and multiple logistic regression.

MAIN FINDINGS

Among women using health care in the past 5 years (n = 981), 88% received primary and/or mental health care, including a routine medical checkup (78%), urgent/acute (48%), chronic disease (27%), depression/anxiety (21%), stress (16%), and intimate partner violence (2%) visits. Of those, reproductive health providers were the source of checkup (14%), urgent/acute (3%), chronic disease (6%), depression/anxiety (6%), stress (11%), and intimate partner violence (3%) services. Preference for specific reproductive health-provided primary/mental health care services ranged from 7% to 20%. Among women having used primary/mental health care services (N = 894), more women (1%-17%) preferred than had received primary/mental health care from reproductive health providers. Nearly one-quarter (22%) identified reproductive health providers as their single most preferred source of care. Contraceptive use was the strongest predictor of preference for reproductive health-provided primary/mental health care (odds ratios range, 2.11-3.30).

CONCLUSIONS

Reproductive health providers are the sole source of health care for a substantial proportion of reproductive-aged women-the same groups at risk for unmet primary and mental health care needs. Findings have implications for reproductive health providers' role in comprehensive women's health care provision and potentially for informing patient-centered, integrated models of care in current health systems.

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.

Depression, anxiety, and psychotropic medication use and fecundability

BACKGROUND

The literature regarding the associations between depression, anxiety, and fecundity is inconsistent. While cross-sectional studies suggest that depression and/or anxiety may adversely affect fecundity, the sole cohort study showed only a small association.

OBJECTIVE

We sought to evaluate the association of self-reported depressive symptoms, self-reported diagnoses of depression and anxiety, and psychotropic medication use with fecundability in a prospective cohort study.

STUDY DESIGN

Data were derived from Pregnancy Study Online (PRESTO), an Internet-based preconception cohort study of couples attempting to conceive in the United States and Canada. At baseline, female participants completed a survey that assessed demographic information, history of physician-diagnosed depression and anxiety, self-reported depressive symptoms (assessed by the Major Depression Inventory), and use of psychotropic medications. Women completed follow-up surveys every 8 weeks for up to 12 months or until reported conception to assess changes in exposures and pregnancy status. We estimated fecundability ratios and 95% confidence intervals using proportional probabilities regression models. The analysis was restricted to 2146 women who had been attempting to conceive for ≤6 cycles at study entry.

RESULTS

Severe depressive symptoms at baseline, regardless of treatment, were associated with decreased fecundability compared with no or low depressive symptoms (fecundability ratio, 0.62; 95% confidence interval, 0.43-0.91). The fecundability ratio associated with a 10-unit increase in Major Depression Inventory score was 0.90 (95% confidence interval, 0.83-0.97). Women who reported moderate to severe depressive symptoms and had never received psychotropic medications (fecundability ratio, 0.69; 95% confidence interval, 0.48-0.99) or who were currently being treated with psychotropic medications (fecundability ratio, 0.72; 95% confidence interval, 0.44-1.20) had decreased fecundability relative to women who had no/mild depressive symptoms and had never used psychotropic medications. Former users of psychotropic medications had increased fecundability regardless of the presence of no/mild depressive symptoms (fecundability ratio, 1.22; 95% confidence interval, 1.06-1.39) or moderate to severe depressive symptoms (fecundability ratio, 1.18; 95% confidence interval, 0.80-1.76).

CONCLUSION

We found an inverse association between depressive symptoms and fecundability, independent of psychotropic medication use. Use of psychotropic medications did not appear to harm fecundability.

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 Effect of Stress Management Based on Group Cognitive-Behavioural Therapy on Marital Satisfaction in Infertile Women

INTRODUCTION

In the developed world, infertility is on rise and has become a social concern. This is considered as a serious stress in life and exerts a severe psychological impact on the couple.

AIM

This study was conducted to study the efficacy of stress management based on group cognitive-behavioural therapy on marital satisfaction in infertile women.

MATERIALS AND METHODS

This was a quasi-experimental study with a pretest-post-test design and control group. The study sample consisted of 40 infertile women enrolled based on convenience sampling and randomly assigned to two groups: experimental and control, of 20 each. Then, the experimental group underwent 10 two-hour stress management sessions per cognitive-behavioural therapy. The instruments used in this study were marital satisfaction inventory ENRICH and a checklist of demographic characteristics. Immediately and three months after completion of the intervention, the instruments were administered to the participants. The data was analysed by analysis of covariance in SPSS 18.

RESULTS

There was a significant difference in marital satisfaction between the experimental and control groups in both post-test (p=0.001) and follow-up (p=0.001).

CONCLUSION

The stress management based on cognitive-behavioural therapy could contribute to increasing marital satisfaction in infertile women. The effect could remain stable three months after the last interventions (follow-up).

Is infertility really associated with higher levels of mental distress in the female population? Results from the North-Trøndelag Health Study and the Medical Birth Registry of Norway

OBJECTIVE

To explore the effect of ever having tried to conceive for more than 12 months on levels of anxiety and depressive symptoms and to investigate if symptom levels of anxiety and depression in infertile women who remain childless, or go on to have children, respectively, differ from symptom levels in mothers without reports of infertility.

METHODS

Analyses were based on information from 12 584 Norwegian women aged 19-45 years who participated in the North-Trøndelag Health Study from 1995 to 1997 and data from the Medical Birth Registry of Norway. Anxiety and depressive symptoms were measured by the Hospital Anxiety and Depression Scale.

RESULTS

Having tried to conceive for more than 12 months (ever) was weakly associated with higher levels of depressive symptoms. In the categorical analyses, women with resolved infertility had higher levels of anxiety symptoms (B = 0.25 (95% confidence interval (CI) = 0.04-0.47)) and voluntarily childfree had lower levels of depressive symptoms (B = -0.05 (95% CI = -0.50 to -0.21)) than mothers without infertility. However, women with current primary or current secondary infertility had levels of anxiety and depression not significantly different from mothers without infertility.

CONCLUSION

At the population level, and from a longitudinal perspective, unresolved infertility is less burdensome than findings from studies on women seeking help for infertility would suggest.

Maternal psychosocial consequences of twins and multiple births following assisted and natural conception: a meta-analysis

The aim of this meta-analysis is to provide new evidence on the effects on maternal health of multiple births due to assisted reproductive technology (ART). A bibliographic search was undertaken using PubMed, PsycINFO, CINAHL and Science Direct. Data extraction was completed using Cochrane Review recommendations, and the review was performed following PRISMA and MOOSE guidelines. Meta-analytic data were analysed using random effects models. Eight papers (2993 mothers) were included. Mothers of ART multiple births were significantly more likely to experience depression (standardized mean difference [SMD] d = 0.198, 95% CI 0.050 - 0.345, z = 2.623, P = 0.009; heterogeneity I(2) = 36.47%), and stress (SMD d = 0.177, 95% CI 0.049 - 0.305, P = 0.007; heterogeneity I(2) = 0.01%) than mothers of ART singletons. No difference in psychosocial distress (combined stress and depression) (SMD d = 0.371, 95% CI -0.153 - 0.895; I(2) = 86.962%, P = 0.001) or depression (d = 0.152, 95% CI -0.179 - 0.483: z = 0.901; I(2) = 36.918%) were found between mothers of ART and naturally conceived multiple births. In conclusion, mothers of ART multiple births were significantly more likely to have depression and stress than mothers of ART singletons, but were no different from mothers of naturally conceived multiples.

Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services?

OBJECTIVE

To determine the extent to which fertility patients and partners received mental health services (MHS) and were provided with information about MHS by their fertility clinics, and whether the use of MHS, or the provision of information about MHS by fertility clinics, was targeted to the most distressed individuals.

DESIGN

Prospective longitudinal cohort study.

SETTING

Five fertility practices.

PATIENT(S)

A total of 352 women and 274 men seeking treatment for infertility.

INTERVENTION(S)

No interventions administered.

MAIN OUTCOME MEASURE(S)

Depression, anxiety, and MHS information provision and use.

RESULT(S)

We found that 56.5% of women and 32.1% of men scored in the clinical range for depressive symptomatology at one or more assessments and that 75.9% of women and 60.6% of men scored in the clinical range for anxiety symptomatology at one or more assessments. Depression and anxiety were higher for women and men who remained infertile compared with those who were successful. Overall, 21% of women and 11.3% of men reported that they had received MHS, and 26.7% of women and 24.1% of men reported that a fertility clinic made information available to them about MHS. Women and men who reported significant depressive or anxiety symptoms, even those with prolonged symptoms, were no more likely than other patients to have received information about MHS.

CONCLUSION(S)

Psychological distress is common during fertility treatment, but most patients and partners do not receive and are not referred for MHS. Furthermore, MHS use and referral is not targeted to those at high risk for serious psychological distress. More attention needs to be given to the mental health needs of our patients and their partners.

Men report good mental health 20 to 23 years after in vitro fertilisation treatment

BACKGROUND

Infertility and infertility treatment are known to have negative short-term psychological consequences for men and women, with more long-term consequences for women. The long-term wellbeing and mental health of men who have experienced in vitro fertilisation (IVF) treatment has not been extensively described in the literature. Therefore, the aim of this study was to analyse the mental health of men 20 to 23 years after IVF treatment.

METHOD

The Symptom Checklist 90 tool was used to assess the self-perceived mental health of men who were part of a couple that underwent IVF treatment at Linköping University Hospital, Sweden, 20 to 23 years earlier. We enrolled 292 out of the 490 men who took part in the hospital's IVF programme from 1986 to 1989 and compared them to an aged-matched control group. In addition, the men who had remained childless were compared to those who had fathered biological children and those who had adopted children.

RESULTS

The overall mental health of the men who had received IVF was good. We found that 54% of the men had fathered their own biological children, 21% were childless and the remainder were part of a couple that had gone on to adopt. The childless men displayed more mental health problems than the other men in the study, as did men who were unemployed, single or divorced.

CONCLUSION

This study carried out 20 to 23 years after IVF treatment showed that the majority of the men who took part were in good mental health. Those who remained childless faced an increased risk of negative psychological symptoms and men who were single showed more symptoms of depression and anxiety disorders.

Investigating the Relationships among Stressors, Stress Level, and Mental Symptoms for Infertile Patients: A Structural Equation Modeling Approach

Objective

Patients with infertility are a high risk group in depression and anxiety. However, an existing theoretically and empirically validated model of stressors, stress, and mental symptoms specific for infertile patients is still a void. This study aimed to determine the related factors and their relational structures that affect the level of depressive and anxiety symptoms among infertile patients.

Methods

A cross-sectional sample of 400 infertility outpatients seeking reproduction treatments in three teaching hospitals across Taiwan participated in the structured questionnaire survey in 2011. The hypothesized model comprising 10 latent variables was tested by Structural Equation Modeling using AMOS 17.

Results

Goodness-of-fit indexes, including χ²/DF = 1.871, PGFI = 0.746, PNFI = 0.764, and others, confirmed the modified model fit the data well. Marital stressor, importance of children, guilt-and-blame, and social stressor showed a direct effect on perceived stress. Instead of being a factor of stress, social support was directly and positively related to self-esteem. Perceived stress and self-esteem were the two major mediators for the relationships between stressors and mental symptoms. Increase in social support and self-esteem led to decrease in mental symptoms among the infertile patients.

Conclusions

The relational structures were identified and named as the Stressors Stress Symptoms Model, clinically applied to predict anxiety and depression from various stressors. Assessing sources and level of infertility-related stress and implementing culturally-sensitive counseling with an emphasis on positive personal value may assist in preventing the severity of depression and anxiety.

Evolution of psychology and counseling in infertility

Five key paradigm shifts are described to illustrate the evolution of psychology and counseling in infertility. The first paradigm shift was in the 1930s when psychosomatic concepts were introduced in obstetrics and gynecology as causal factors to explain why some couples could not conceive despite the absence of organic pathology. In the second shift, the nurse advocacy movement of the 1970s stimulated the investigation of the psychosocial consequences of infertility and promoted counseling to help couples grieve childlessness when medical treatments often could not help them conceive. The third shift occurred with the advent of IVF, which created a demand for mental health professionals in fertility clinics. Mental health professionals assessed the ability of couples to withstand the demands of this new high technology treatment as well as their suitability as potential parents. The fourth shift, in the 1990s, saw reproductive medicine embrace the principles of evidence-based medicine, which introduced a much more rigorous approach to medical practice (effectiveness and safety) that extended to psychosocial interventions. The most recent paradigm shift, in the new millennium, occurred with the realization that compliance with protracted fertility treatment depended on the adoption of an integrated approach to fertility care. An integrated approach could reduce treatment burden arising from multiple sources (i.e., patient, clinic, and treatment). This review describes these paradigm shifts and reflects on future clinical and research directions for mental health professionals.

Prevalence and predictors of major depressive disorder for fertility treatment patients and their partners

OBJECTIVE

To examine the prevalence and predictors of major depressive disorder (MDD) for women and their partners during the course of fertility treatment.

DESIGN

Prospective cohort study during an 18-month period. Participants completed interviews and questionnaires at baseline and at 4, 10, and 18 months of follow-up.

SETTING

Five community and academic fertility practices.

PATIENT(S)

A total of 174 women and 144 of their male partners who did not have a successful child-related outcome during the time frame of the study.

INTERVENTION(S)

No interventions administered.

MAIN OUTCOME MEASURE(S)

The MDD was assessed using the Composite International Diagnostic Interview Major Depression module, a structured diagnostic interview. Additional variables were assessed with self-report questionnaire measures.

RESULT(S)

Of the women 39.1% and of the men 15.3% met the criteria for MDD during the 18-month course of the study. A binary logistic covariate-adjusted model showed that, for both women and men, past MDD was a significant predictor of MDD during treatment. Past MDD further predicted significant risk for MDD during treatment after controlling for other well-established risk factors (i.e., baseline levels of depression, anxiety, and partner support).

CONCLUSION(S)

The MDD was highly prevalent for fertility treatment patients and their partners. Past MDD predicted risk for MDD during treatment, and it contributed to MDD risk more than other commonly assessed risk factors. This suggests that patients and their partners would benefit from being routinely assessed for a history of MDD before the start of treatment to best direct psychosocial support and interventions to those most in need.

Perceived stress, reproductive hormones, and ovulatory function: a prospective cohort study

BACKGROUND

Stress has been shown to suppress ovulation in experimental models, but its effect on human reproduction at the population level is unclear.

METHODS

Healthy women (n = 259), aged 18-44 years from Western New York, were followed for 2 menstrual cycles (2005-2007). Women completed daily perceived stress assessments, a 4-item Perceived Stress Scale (PSS-4) up to 4 times each cycle, and a 14-item PSS at baseline. Mixed model analyses were used to assess effects of stress on log reproductive hormone concentrations and sporadic anovulation.

RESULTS

High versus low daily stress was associated with lower estradiol (-9.5% [95% confidence interval (CI) = -15.6% to -3.0%]), free estradiol (-10.4% [-16.5% to -3.9%]), and luteinizing hormone (-14.8% [-21.3% to -7.7%]) and higher follicle-stimulating hormone (6.2% [95% CI = 2.0% to 10.5%]) after adjusting for age, race, percent body fat, depression score, and time-varying hormones and vigorous exercise. High versus low daily stress was also associated with lower luteal progesterone (-10.4% [95% CI = -19.7% to -0.10%]) and higher odds of anovulation (adjusted odds ratio = 2.2 [95% CI = 1.0 to 4.7]). For each unit increase in daily stress level, women had a 70% higher odds of an anovulatory episode (odds ratio = 1.7 [1.1 to 2.4]). Similar but attenuated results were found for the association between the PSS-4 and reproductive hormones, while null findings were found for the baseline PSS.

CONCLUSION

Daily perceived stress does appear to interfere with menstrual cycle function among women with no known reproductive disorders, warranting further research to explore potential population-level impacts and causal biologic mechanisms.

Sex differences in the stress response in SD rats

Sex differences play an important role in depression, the basis of which is an excessive stress response. We aimed at revealing the neurobiological sex differences in the same study in acute- and chronically-stressed rats. Female Sprague-Dawley (SD) rats were randomly divided into 6 groups: chronic unpredictable mild stress (CUMS), acute foot shock (FS) and controls, animals in all 3 groups were sacrificed in proestrus or diestrus. Male SD rats were randomly divided into 3 groups: CUMS, FS and controls. Comparisons were made of behavioral changes in CUMS and control rats, plasma levels of corticosterone (CORT), testosterone (T) and estradiol (E2), and of the hypothalamic mRNA-expression of stress-related molecules, i.e. estrogen receptor α and β, androgen receptor, aromatase, mineralocorticoid receptor, glucocorticoid receptor, corticotropin-releasing hormone, arginine vasopressin and oxytocin. CUMS resulted in disordered estrus cycles, more behavioral and hypothalamic stress-related molecules changes and a stronger CORT response in female rats compared with male rats. Female rats also showed decreased E2 and T levels after FS and CUMS, while male FS rats showed increased E2 and male CUMS rats showed decreased T levels. Stress affects the behavioral, endocrine and the molecular response of the stress systems in the hypothalamus of SD rats in a clear sexual dimorphic way, which has parallels in human data on stress and depression.

[Characteristics of infertility-specific quality of life in Hungarian couples]

INTRODUCTION

Experiencing involuntary childlessness has a great impact on couples' quality of life.

AIM

The aim of the authors was to examine the correlations among infertility-specific quality of life and depression on the level of individuals and couples.

METHOD

126 couples in five fertility centers in Hungary filled out the FertiQoL and Beck Depression Inventory and answered some sociodemographic questions.

RESULTS

In gender comparison, women reported about more depressive symptoms and poorer quality of life than men. Both in men and women, the higher depression level correlated with lower level of quality of life. Moreover, the presence of more depressive symptoms in women was related to men's poorer quality of life.

CONCLUSIONS

The results show that differences may exist in affective responses to infertility between women and men and that female affective problems take effects on the level of the couple relationship. These findings may be useful in psychosocial support of the couples facing infertility, especially in couple counselling or couple therapy.

Stress symptoms and frequency of sexual intercourse among young women

INTRODUCTION

We have previously documented the relationships between stress and depression symptoms and adolescent women's nonuse and misuse of condoms and other contraceptive methods and on their unintended pregnancy rates.

AIM

Here, we examine relationships between mental health symptoms and another understudied adolescent reproductive health behavior-frequency of sexual intercourse.

MAIN OUTCOME MEASURE

Our outcome was weekly sexual intercourse activity.

METHODS

We used panel data from a longitudinal, population-based cohort study of 992 women ages 18-20. Weekly journals measured sociodemographic, relationship, reproductive, and mental health characteristics, sexual and contraceptive behaviors, and pregnancy history. We examined 27,130 surveys from 952 women during the first study year. Predictors of weekly sexual intercourse were moderate to severe stress (Perceived Stress Scale-4) and depression (Center for Epidemiologic Studies Depression Scale-5) symptoms measured at baseline. Multilevel, mixed-effects logistic regression models estimated the relationships between stress and depression symptoms and the weekly odds of sexual intercourse while adjusting for covariate fixed effects and random woman effects.

RESULTS

Nearly a quarter of the sample had moderate to severe stress (23%) and depression (24%) symptoms at baseline. Women reported sexual intercourse in 36% of weeks. Proportions of sexually active weeks were higher among women with stress (43%) and depression (40%) compared with those without symptoms (35% and 35%, respectively; P values<0.001). Controlling for covariates, women with baseline stress symptoms had 1.6 times higher weekly odds of sexual intercourse compared with women without stress (adjusted odds ratio 1.6, confidence interval [1.1, 2.5]; P=0.04). Depression symptoms were not associated with sexual intercourse frequency in adjusted models.

CONCLUSIONS

Stress symptoms were positively associated with sexual intercourse frequency among these young women. Research and practice efforts are needed to identify effective sexual health promotion and risk-reduction strategies, including contraceptive education and counseling, in the context of mental health symptoms and unintended pregnancy.

A comparative analysis of postpartum maternal mental health in women following spontaneous or ART conception

OBJECTIVE

To determine whether conception following assisted reproductive technology (ART) predisposes women to increased risk of postnatal depression (PND), compared to women who conceived naturally, when controlling for such factors as: multiple birth, previous maternal psychiatric history and sociodemographic status.

PARTICIPANTS

A total of 200 women who attended the private antenatal and fertility clinics of a fertility specialist in a large Australian city between January 2009 and December 2011 were contacted via telephone.

RESULTS

There was no difference in the rate of PND between the two groups (7.5% versus 7.4%, p = ns). Aside from the slightly older maternal age in the ART group (35.4 versus 33, p < 0.05), baseline socio-demographics were similar. There was a significantly higher rate of previous maternal clinical depression in the ART group compared to the controls (17% versus 5%, p < 0.05); however, other known risk factors for PND, including previous PND (10.6% versus 13.7%, p = ns), multiple births (2.1% versus 4.2%, p = ns) and low infant birth weight (3.3 kg versus 3.4 kg, p = ns), were not different in the two cohorts. Women who conceived naturally were also more likely to breastfeed for a longer duration (78% versus 89%, p < 0.05).

CONCLUSION

Our study demonstrates that when accounting for well-known risk and protective factors for postpartum depression, women who conceive using ART are not at an increased risk PND. In addition, the low rate of multiple births in the ART group further validates the practice of single embryo transfer.

First manic episode associated with use of human chorionic gonadotropin for obesity: a case report

BACKGROUND

Although highly controversial, the treatment of obesity with exogenous human chorionic gonadotropin (HCG) remains popular in the USA. We report the case of a patient whose first manic episode was associated with the use of HCG for weight loss.

CASE REPORT

A 32-year-old female patient was admitted to our psychiatric inpatient unit due to a two-week history of manic symptoms. She had no previous history of manic or hypomanic episodes and had completed a 45-day course of sublingual HCG for weight loss immediately prior to the onset of the manic episode. The patient was treated with lithium carbonate and aripiprazole, and progressed with improvement in the symptoms.

CONCLUSION

While it is not possible to definitively link the HCG use to the development of mania, available evidence suggests that HCG may have a contributing role in triggering manic symptomatology.

The risk of unintended pregnancy among young women with mental health symptoms

Depression and stress have been linked with poor contraceptive behavior, but whether existing mental health symptoms influence women's subsequent risk of unintended pregnancy is unclear. We prospectively examined the effect of depression and stress symptoms on young women's pregnancy risk over one year. We used panel data from a longitudinal study of 992 U.S. women ages 18-20 years who reported a strong desire to avoid pregnancy. Weekly journal surveys measured relationship, contraceptive use and pregnancy outcomes. We examined 27,572 journal surveys from 940 women over the first study year. Our outcome was self-reported pregnancy. At baseline, we assessed moderate/severe depression (CESD-5) and stress (PSS-4) symptoms. We estimated the effect of baseline mental health symptoms on pregnancy risk with discrete-time, mixed-effects, proportional hazard models using logistic regression. At baseline, 24% and 23% of women reported moderate/severe depression and stress symptoms, respectively. Ten percent of young women not intending pregnancy became pregnant during the study. Rates of pregnancy were higher among women with baseline depression (14% versus 9%, p = 0.04) and stress (15% versus 9%, p = 0.03) compared to women without symptoms. In multivariable models, the risk of pregnancy was 1.6 times higher among women with stress symptoms compared to those without stress (aRR 1.6, CI 1.1,2.7). Women with co-occurring stress and depression symptoms had over twice the risk of pregnancy (aRR 2.1, CI 1.1,3.8) compared to those without symptoms. Among women without a prior pregnancy, having co-occurring stress and depression symptoms was the strongest predictor of subsequent pregnancy (aRR 2.3, CI 1.2,4.3), while stress alone was the strongest predictor among women with a prior pregnancy (aRR 3.0, CI 1.1,8.8). Depression symptoms were not independently associated with young women's pregnancy risk. In conclusion, stress, and especially co-occurring stress and depression symptoms, consistently and adversely influenced these young women's risk of unintended pregnancy over one year.

Fertility treatment and risk of childhood and adolescent mental disorders: register based cohort study

OBJECTIVE

To assess the mental health of children born after fertility treatment by comparing their risk of mental disorders with that of spontaneously conceived children.

DESIGN

Prospective register based cohort study.

SETTING

Nationwide register based information from Danish National Health Registers cross linked by a unique personal identification number assigned to all citizens in Denmark.

PARTICIPANTS

All children born in Denmark in 1995-2003 with follow-up in 2012 when the children were aged 8-17; 33,139 children were conceived after fertility treatment and 555,828 children were born after spontaneous conception.

MAIN OUTCOME MEASURES

Absolute risks and hazard ratios for overall and specific mental disorders estimated with adjustment for potential confounding variables. Estimated association between the risk of mental disorders and subtypes of procedures, hormone treatments, gamete types, and cause of infertility.

RESULTS

The risk of mental disorders in children born after in vitro fertilisation or intracytoplasmic sperm injection was low, and was no higher than in spontaneously conceived children, except for a borderline significant increased risk of tic disorders (hazard ratio 1.40, 95% confidence interval 1.01 to 1.95; absolute risk 0.3%). In contrast, children born after ovulation induction with or without insemination had low but significantly increased risks of any mental disorder (1.20, 1.11 to 1.31; absolute risk 4.1%), autism spectrum disorders (1.20, 1.05 to 1.37; 1.5%), hyperkinetic disorders (1.23, 1.08 to 1.40; 1.7%), conduct, emotional, or social disorder (1.21, 1.02 to 1.45; 0.8%), and tic disorders (1.51, 1.16 to 1.96; 0.4%). There was no risk systematically related to any specific type of hormone drug treatment.

CONCLUSIONS

There was a small increase in the incidence of mental disorders in children born after ovulation induction/intrauterine insemination. Children born after in vitro fertilisation/intracytoplasmic sperm injection were found to have overall risk comparable with children conceived spontaneously.

Depression as an evolutionary strategy for defense against infection

Recent discoveries relating depression to inflammation and immune function may help to solve an important evolutionary puzzle: If depression carries with it so many negative consequences, including notable costs to survival and reproduction, then why is it common and heritable? What countervailing force or compensatory advantage has allowed susceptibility genes for depression to persist in the population at such high rates? A priori, compensatory advantages in combating infection are a promising candidate, given that infection has been the major cause of mortality throughout human history. Emerging evidence on deeply rooted bidirectional pathways of communication between the nervous and immune systems further supports this notion. Here we present an updated review of the "infection-defense hypothesis" of depression, which proposes that moods-with their ability to orchestrate a wide array of physical and behavioral responses-have played an adaptive role throughout human history by helping individuals fight existing infections, as well as helping both individuals and their kin avoid new ones. We discuss new evidence that supports several key predictions derived from the hypothesis, and compare it with other major evolutionary theories of depression. Specifically, we discuss how the infection-defense hypothesis helps to explain emerging data on psychoimmunological features of depression, as well as depression's associations with a diverse array of conditions and illnesses-including nutritional deficiencies, seasonal changes, hormonal fluctuations, and chronic diseases-that previous evolutionary theories of depression have not accounted for. Finally, we note the potential implications of the hypothesis for the treatment and prevention of depression.

Endocrinology and physiology of pseudocyesis

This literature review on pseudocyesis or false pregnancy aims to find epidemiological, psychiatric/psychologic, gynecological and endocrine traits associated with this condition in order to propose neuroendocrine/endocrine mechanisms leading to the emergence of pseudocyetic traits. Ten women from 5 selected studies were analyzed after applying stringent criteria to discriminate between cases of true pseudocyesis (pseudocyesis vera) versus delusional, simulated or erroneous pseudocyesis. The analysis of the reviewed studies evidenced that pseudocyesis shares many endocrine traits with both polycystic ovarian syndrome and major depressive disorder, although the endocrine traits are more akin to polycystic ovarian syndrome than to major depressive disorder. Data support the notion that pseudocyetic women may have increased sympathetic nervous system activity, dysfunction of central nervous system catecholaminergic pathways and decreased steroid feedback inhibition of gonadotropin-releasing hormone. Although other neuroendocrine/endocrine pathways may be involved, the neuroendocrine/endocrine mechanisms proposed in this review may lead to the development of pseudocyetic traits including hypomenorrhea or amenorrhea, galactorrhea, diurnal and/or nocturnal hyperprolactinemia, abdominal distension and apparent fetal movements and labor pains at the expected date of delivery.

The ending of treatment: the ending of hope?

Assisted reproductive technology (ART) offers patients the hope that they may have a child and provides the primary motivation for treatment. Despite the treatment failure, for many, the hope of conception remains. The decision to abandon treatment is momentous, especially for those couples with a diagnosis of unexplained infertility. The urgency for individuals to pre-empt future regrets and to know they have done enough to do so contributes to a significant amount of pressure. This pressure is further exacerbated by external pressures to conceive. A significant factor intrinsic to the decision-making process is the role of 'hope'. Hope allows women, in particular, to avoid the reality of potential childlessness. Thus, the necessity for psychological support to be offered at the point of ending treatment is crucial. This paper draws on the author's research completed in 2005 and includes a more recent literature search which finds the original evidence still pertinent.

Cross border treatment for infertility: the counselling perspective in the UK

There is increasing evidence that people with infertility problems are seeking treatment in a wide range of countries. While many make an independent choice about their destination clinic, others are referred under shared-care arrangements based in the UK. In response to cross border reproductive care, concerns have been raised and recommendations for best practice have begun to emerge. The involvement of counsellors appears to be limited. This paper considers the issues raised by cross-border reproductive care with a particular focus on those who travel abroad for treatment for gamete/embryo donation or surrogacy. It describes the part that counselling can play in both supporting patients and providing a service that will enable them to prepare for the additional challenges that may arise in the future. It concludes with a recommendation for further research, for UK clinics routinely to refer patients to a counsellor prior to travel arrangements being made and for collaboration between countries in developing and implementing best practice guidelines.

Psychiatric disorders among women and men in assisted reproductive technology (ART) treatment. The Danish National ART-Couple (DANAC) cohort: protocol for a longitudinal, national register-based cohort study

INTRODUCTION

There are complex causal associations between mental disorders, fertility treatment, fertility treatment outcome and infertility per se. Eating disorders cause endocrine disturbances, anovulation and thereby infertility, and research has shown that infertility as well as unsuccessful assisted reproductive technology (ART) treatment are potential risk factors for developing a depression on a long-term basis. Despite the fact that worldwide more than 400 000 ART treatment cycles are performed every year, the causal associations between mental disorders, use of medication for mental disorders and ART treatment in both sexes have only been sparsely explored.

METHOD AND ANALYSIS

The main objective of this national register-based cohort study is to assess women's and men's mental health before, during, and after ART treatment in comparison with the mental health in an age-matched population-based cohort of couples with no history of ART treatment. Furthermore, the objective is to study the reproductive outcome of ART treatment among women who have a registered diagnosis of a mental disorder or have used medication for mental disorders prior to ART treatment compared with women in ART treatment without a mental disorder. We will establish the Danish National ART-Couple (DANAC) cohort including all women registered with ART treatment in the Danish in vitro fertilisation Register during 1994-2009 (N=42 915) and their partners. An age-matched population-based comparison cohort of women without ART treatment (n=215 290) and their partners will be established. Data will be cross-linked with data from national registers on psychiatric disorders, medical prescriptions for mental disorders, births, causes of deaths and sociodemographic data. Survival analyses and other statistical analyses will be conducted on the development of mental disorders and use of medication for mental disorders for women and men both prior to and after ART treatment.

The evolutionary paradox and the missing heritability of schizophrenia

Schizophrenia is one of the most detrimental common psychiatric disorders, occurring at a prevalence of approximately 1%, and characterized by increased mortality and reduced reproduction, especially in men. The heritability has been estimated around 70% and the genome-wide association meta-analyses conducted by the Psychiatric Genomics Consortium have been successful at identifying an increasing number of risk loci. Various theories have been proposed to explain why genetic variants that predispose to schizophrenia persist in the population, despite the fitness reduction in affected individuals, a question known as the evolutionary paradox. In this review, we consider evolutionary perspectives of schizophrenia and of the empirical evidence that may support these perspectives. Proposed evolutionary explanations include balancing selection, fitness trade-offs, fluctuating environments, sexual selection, mutation-selection balance and genomic conflicts. We address the expectations about the genetic architecture of schizophrenia that are predicted by different evolutionary scenarios and discuss the implications for genetic studies. Several potential sources of "missing" heritability, including gene-environment interactions, epigenetic variation, and rare genetic variation are examined from an evolutionary perspective. A better understanding of evolutionary history may provide valuable clues to the genetic architecture of schizophrenia and other psychiatric disorders, which is highly relevant to genetic studies that aim to detect genetic risk variants.

Monoamine oxidases in development

Monoamine oxidases (MAOs) are flavoproteins of the outer mitochondrial membrane that catalyze the oxidative deamination of biogenic and xenobiotic amines. In mammals there are two isoforms (MAO-A and MAO-B) that can be distinguished on the basis of their substrate specificity and their sensitivity towards specific inhibitors. Both isoforms are expressed in most tissues, but their expression in the central nervous system and their ability to metabolize monoaminergic neurotransmitters have focused MAO research on the functionality of the mature brain. MAO activities have been related to neurodegenerative diseases as well as to neurological and psychiatric disorders. More recently evidence has been accumulating indicating that MAO isoforms are expressed not only in adult mammals, but also before birth, and that defective MAO expression induces developmental abnormalities in particular of the brain. This review is aimed at summarizing and critically evaluating the new findings on the developmental functions of MAO isoforms during embryogenesis.

Incidence of depression and influence of depression on the number of treatment cycles and births in a national cohort of 42,880 women treated with ART

STUDY QUESTION

Does prior depression in women treated with assisted reproduction technology (ART) influence the number of treatment cycles and ART live births?

SUMMARY ANSWER

Women with a depression diagnosis prior to ART treatment initiated statistically significantly fewer ART treatment cycles and had a lower mean number of ART live births compared with women with no history of depression.

WHAT IS KNOWN ALREADY

Previous studies have shown an increased prevalence of depressive symptoms in fertility patients than in the comparison groups.

STUDY DESIGN, SIZE, DURATION

A register-based national cohort study, including all women (n = 42,915) treated with IVF, ICSI, frozen embryo transfer and oocyte recipient cycle in Denmark from 1 January 1994 to 30 September 2009 extracted from the IVF register (ART cohort). Data on births and depression diagnoses were obtained by linking to the Danish Medical Birth Register (1994-2010) and the Danish Psychiatric Central Research Register (1969-2010).

PARTICIPANTS/MATERIALS, SETTING, METHODS

For each woman in the ART cohort, we included five age-matched women from the female background population not having received ART treatment. This comparison group was cross-linked with identical register data as the ART cohort. Women with incomplete ART information or a depression diagnosis before 18 years of age were excluded; remaining n = 42,880. The ART cohort was grouped into (i) women with a depression diagnosis and (ii) women never diagnosed with depression. In the ART group with depression, analyses were specified on women with their first depression prior to ART treatment. In total, 2.6% of the women in the ART cohort had a depression diagnosis. For the incidence rate ratio (IRR) 39,194 women from the ART cohort (3686 women were excluded due to migration) were compared with 206,005 women from the age-matched comparison group who did not receive ART treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the women in the ART cohort with a depression diagnosis, 34.7% had their first depression diagnosis prior to ART treatment, 4.7% during ART treatment and 60.7% after ART treatment. The mean number of initiated ART cycles was significantly lower in the ART group of women having a depression diagnosis prior to ART treatment [2.55 (±1.78)] compared with the ART group of women without a depression diagnosis [3.22 (±2.31); P < 0.001; P < 0.001]. Women having a depression diagnosis prior to ART treatment had a lower mean number of ART live births [0.82 (±0.73)] compared with women without a depression diagnosis [1.03 (±0.81); P < 0.001]. The incidence rate of first and recurrent depression diagnoses in the ART cohort was significantly lower compared with the age-matched background population group; IRR = 0.80 (P < 0.001) and IRR = 0.77 (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Only clinical depression diagnoses treated in a psychiatric hospital setting are included. The age-matched comparison group from the background population is heterogeneous as it consists of women differing in fertility status (both mothers and childless women).

WIDER IMPLICATIONS OF THE FINDINGS

Fewer women in the ART cohort developed depression over time compared with the age-matched background population, which might reflect a healthy patient effect of the women seeking ART treatment. Women with a depression diagnosis before ART treatment receive fewer ART treatments and are less likely to achieve an ART live birth. These women might be more vulnerable and we recommend that they be offered more psychiatric attention before starting, as well as during and after ART treatment.

STUDY FUNDING/COMPETING INTEREST(S)

Research grants are funded by the Danish Health Insurance Foundation and Merck Sharp & Dohme. The funders had no influence on the data collection, analyses or conclusions of the study. No conflict of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Burden of maternal bipolar disorder on at-risk offspring: a controlled study on family planning and maternal care

INTRODUCTION

Bipolar disorder (BD) is a highly incapacitating disease typically associated with high rates of familial dysfunction. Despite recent literature suggesting that maternal care is an important environmental factor in the development of behavioral disorders, it is unclear how much maternal care is dysfunctional in BD subjects.

OBJECTIVE

The objective of this study was to characterize maternal care in DSM-IV/SCID diagnosed BD type I subjects compared to healthy controls with (PD) and without (NPD) other psychiatric diagnoses.

MATERIALS AND METHODS

Thirty-four BD mothers and 106 controls underwent an interview about family planning and maternal care, obstetrical complications, and mother-child interactions. K-SADS-PL questions about violence exposure were used to ascertain domestic violence and physical/sexual abuse.

RESULTS

BD mothers were less likely to have stable unions (45.5%; p<0.01) or to live with the biological father of their children (33.3%; p<0.01), but had higher educational level and higher rates of social security use/retirement. They also had fewer children and used less contraceptive methods than controls. Children of BD women had higher rates of neonatal anoxia, and reported more physical abuse (16.1%; p=0.02) than offspring of NPD mothers. Due to BD mothers' symptoms, 33.3% of offspring suffered physical and/or psychological abuse.

LIMITATIONS

Post hoc analysis, and the use of questions as a surrogate of symptoms as opposed to validated instruments.

CONCLUSION

This is one of few reports confirming that maternal care given by BD women is dysfunctional. BD psychopathology can lead to poor maternal care and both should be considered important environmental risk factors in BD, suggesting that BD psychoeducation should include maternal care orientation.

The transition of care from fertility specialists to obstetricians: maternal adjustment and postpartum depressive symptoms

AIM

This study examines the transition from fertility to obstetrical care of women who conceived through IVF.

MATERIALS & METHODS

33 women filled out questionnaires before IVF, during pregnancy and after birth on infertility stress, maternal adjustment and depressive symptoms. During pregnancy, they participated in an interview about their emotional experiences regarding the transition. Responses were sorted into three categories: Autonomy, Dependence and Avoidance.

RESULTS

Exploratory results show that 51.5% of women had no difficulties making the transition (Autonomy), 21.2% had become dependent (Dependence) and 27.3% had distanced themselves from the specialists (Avoidance). Women who became dependent had more trouble adjusting to motherhood and more depressive symptoms.

CONCLUSION

Difficulty making the transition may be linked to decreased ability to adjust to motherhood and more postpartum depressive symptoms.

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.

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.

Psychological disturbances and quality of life in obese and infertile women and men

Anovulatory cycles and endometriosis are the main causes of female infertility. The most frequently anovulatory cycles are related to polycystic ovary syndrome (PCOS) commonly associated with obesity and hormonal disturbances in the course of obesity. Recently published studies revealed that infertility affects about one in six couples during their lifetime and is more frequent in obese. Obesity is also associated with male infertility related to erectile dysfunction, hormonal disturbances and lower semen quality. Any of these above mentioned disorder is the important risk factor of psychological disturbances and poor quality of life among women and men in the reproductive age. On the other hand the mood disorders may exacerbate the hormonal disturbances and worsen the effectiveness of infertility management. Infertility, its therapy with accompanying psychological disturbances may also significantly affect the partners relationships. The review summarize the results described in the current literature on the association between obesity and infertility and psychological disturbances as well as their impact on quality of life and sexual functioning in women and men. Moreover, the impact of infertility and psychological disturbances on partners relationships is discussed.

Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009

BACKGROUND

Depression is often undiagnosed and untreated. It is not clear if differences exist in the diagnosis and treatment of depression among pregnant and nonpregnant women. We sought to estimate the prevalence of undiagnosed depression, treatment by modality, and treatment barriers by pregnancy status among U.S. reproductive-aged women.

METHODS

We identified 375 pregnant and 8,657 nonpregnant women 18-44 years of age who met criteria for past-year major depressive episode (MDE) from 2005-2009 nationally representative data. Chi-square statistics and adjusted prevalence ratios (aPR) were calculated.

RESULTS

MDE in pregnant women (65.9%) went undiagnosed more often than in nonpregnant women (58.6%) (aPR 1.1, 95% confidence interval [CI] 1.0-1.3). Half of depressed pregnant (49.6%) and nonpregnant (53.7%) women received treatment (aPR 1.0, 95% CI 0.90-1.1), with prescription medication the most common form for both pregnant (39.6%) and nonpregnant (47.4%) women. Treatment barriers did not differ by pregnancy status and were cost (54.8%), opposition to treatment (41.7%), and stigma (26.3%).

CONCLUSIONS

Pregnant women with MDE were no more likely than nonpregnant women to be diagnosed with or treated for their depression.

Interpersonal psychotherapy versus brief supportive therapy for depressed infertile women: first pilot randomized controlled trial

Infertility is strongly associated with depression, yet treatment research for depressed infertile women is sparse. This study tested for the first time the feasibility and preliminary efficacy of interpersonal psychotherapy (IPT), the evidence-based antidepressant intervention with the greatest peripartum research support, as treatment for depressed women facing fertility problems. Patients who met DSM-IV criteria for major depressive disorder of at least moderate severity were randomized to either 12 sessions of IPT (n = 15) or brief supportive psychotherapy (BSP; n = 16), our control intervention. Eighty percent of IPT and 63 % of BSP patients completed the 12 sessions of therapy. Patients in both treatments improved. IPT produced a greater response rate than BSP, with more than two-thirds of women achieving a >50 % reduction in scores on the Montgomery-Åsberg Depression Rating Scale (MADRS). IPT also tended to have lower posttreatment scores on the Beck Depression Inventory, Clinical Global Impression-Severity Scale, and anxiety subscale of the Hamilton Depression Rating Scale, with between-group effect sizes ranging from 0.61 to 0.76. Gains persisted at 6-month follow-up. This pilot trial suggests that IPT is a promising treatment for depression in the context of infertility and that it may fare better than a rigorous active control condition. Should subsequent randomized controlled trials support these findings, this will inform clinical practice and take an important step in assuring optimal care for depressed women struggling with infertility.

A brief report of depressive symptoms and health promoting behaviors among women with infertility attending a clinical mind-body program

Diagnosis of infertility or treatment for infertility can result in distress, including for some women, depressive symptoms. Integrative infertility treatment programs are gaining recognition and popularity, and many women may seek this kind of care. However, depressive symptoms may be a barrier to fully engaging in and benefiting from mind-body infertility programs. The aim of this retrospective, cross-sectional chart review, was to describe the baseline level of depressive symptoms and differences in baseline health promoting behaviors by level of depressive symptoms among women (n=104) presenting to a mind-body infertility program in the clinical setting. Depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II), and health promoting behaviors were assessed using the Health Promoting Lifestyle Profile-II (HPLP-II). The mean BDI-II score for the sample was 16.3 (± 8.5). Participants scoring in the moderate-severe range on the BDI-II had significantly lower scores on Spiritual Growth, Interpersonal Relations, Stress Management and Nutrition subscales of the HPLP-II. There were no significant differences on the Physical Activity or Health Responsibility subscales. These findings may have implications for the treatment of women with infertility, particularly those who seek an integrative approach to treatment.

Demographic and medical consequences of the postponement of parenthood

BACKGROUND Across the developed world couples are postponing parenthood. This review assesses the consequences of delayed family formation from a demographic and medical perspective. One main focus is on the quantitative importance of pregnancy postponement. METHODS Medical and social science databases were searched for publications on relevant subjects such as delayed parenthood, female and male age, fertility, infertility, time to pregnancy (TTP), fetal death, outcome of medically assisted reproduction (MAR) and mental well-being. RESULTS Postponement of parenthood is linked to a higher rate of involuntary childlessness and smaller families than desired due to increased infertility and fetal death with higher female and male age. For women, the increased risk of prolonged TTP, infertility, spontaneous abortions, ectopic pregnancies and trisomy 21 starts at around 30 years of age with a more pronounced effects >35 years, whereas the increasing risk of preterm births and stillbirths starts at around 35 years with a more pronounced effect >40 years. Advanced male age has an important but less pronounced effect on infertility and adverse outcomes. MAR treatment cannot overcome the age-related decline in fecundity. CONCLUSIONS In general, women have partners who are several years older than themselves and it is important to focus more on the combined effect of higher female and male age on infertility and reproductive outcome. Increasing public awareness of the impact of advanced female and male age on the reproductive outcome is essential for people to make well-informed decisions on when to start family formation.

Reduced Fertility and Fecundity among Patients with Bipolar I Disorder and Schizophrenia in Egypt

OBJECTIVE

To evaluate reproduction among patients with bipolar I disorder (BP1) or schizophrenia (SZ) in Egypt.

METHODS

BP1 patients (n=113) were compared with community based, demographically balanced controls (n=124) and SZ patients (n=79, DSM-IV). All participants were evaluated using structured interviews and corroborative data were obtained from relatives. Standard indices of procreation were included in multivariate analyses that incorporated key demographic variables.

RESULTS

Control individuals were significantly more likely to have children than BP1 or SZ patients (controls 46.8%, BP1 15.9%, SZ 17.7%), but the BP1-SZ differences were non-significant. The average number of children for BP1 patients (0.37±0.9) and SZ patients (0.38±0.9) was significantly lower than for controls (1.04±1.48) (BP1 vs controls, p<0.001; SZ vs controls, p<0.001). The frequency of marriages among BP1 patients was nominally higher than the SZ group, but was significantly lower than controls (BP1: 31.9% SZ: 27.8% control: 57.3%). Even among married individuals, BP1 (but not SZ) patients were childless more often than controls (p=0.001). The marital fertility, i.e., the average number of children among patients with conjugal relationships for controls (1.8±1.57) was significantly higher than BP1 patients (1.14±1.31, p=0.02), but not significantly different from SZ patients (1.36±1.32, p=0.2).

CONCLUSION

Selected reproductive measures are significantly and substantially reduced among Egyptian BP1 patients. The reproductive indices are similar among BP1 and SZ patients, suggesting a role for general illness related variables. Regardless of the cause/s, the impairment constitutes important, under-investigated disability.

Support through patient internet-communities: Lived experience of Russian in vitro fertilization patients

The article is concerned with the life experiences of infertile women going through infertility treatment and their need for social and psychological support, which they try to find in their immediate social environment. The Internet has become one place where everyone can find “people like oneself.” The best support is received from these people who are in the same life situation and are able and willing to share their lived experiences with each other. Communication via the Internet and the formation of a virtual community of patients has both positive and negative aspects, all of which are examined in the article. On the one hand, it creates a psychologically favorable atmosphere and might potentially increase the success rate of IVF treatment. On the other, this leads to the seclusion of patients within the circle of “similar people” and sometimes to negative attitudes towards people outside the circle. The article is based on the author's “netnography” research of a virtual community of Russian In-Vitro Fertilization (IVF)¹ patients.