Psychological functioning across stages of treatment for infertility

The effect of an educational animation on knowledge of testicular health and fertility of adolescents

STUDY QUESTION

Does the provision of an educational animation, developed with young people, about testicular health and fertility impact the knowledge of these topics among adolescents?

SUMMARY ANSWER

The development and provision of education on testicular health and fertility were welcomed by adolescents and associated with a significant increase in knowledge.

WHAT IS KNOWN ALREADY

Young people may know less than they should about testicular health and male fertility topics. Lack of knowledge can have implications for health including late medical help-seeking for signs and symptoms of scrotal disorders, such as torsion, for which late presentation frequently results in testicular damage.

STUDY DESIGN, SIZE, DURATION

A mixed methods experimental pre- and post-design was used with embedded qualitative data collection. High school students completed a pre-animation questionnaire, watched four animations on testicular health and fertility, and completed a post-animation questionnaire. Data were collected during Personal Social and Health Education lessons across a 2-week period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Four animations on testicular health and fertility, informed by andrologists, academics, designers, boys, and young men, were developed. Eligible participants were boys and girls in the UK school years 8 and 9 (age 13-14 years). Participants completed a Time 1 (T1) survey (fertility knowledge, demographics) prior to watching the animations and a Time 2 (T2) survey (fertility knowledge, perceptions of the animations) immediately after the animations. Perceptions were rated on 10-point response scales (higher scores better). Participants additionally expressed in their own words positive and negative aspects of the animations. ANOVA was used to examine the effects of the animations using a 2 (time: T1, T2)×2 (gender: male, female) design on topic knowledge, perceived importance, usefulness, and style of the animations according to gender. Regression analysis examined the associations between gender, disability, class year, and knowledge at T2 while controlling for knowledge at T1. Qualitative data on perceptions of the animations were analyzed using inductive thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Results showed that the animations significantly increased testicular health and fertility-related knowledge from T1 (x̄=41.84 ± 24.72) to T2 (x̄=79.15, ±15.04). Boys had significantly higher levels of knowledge compared to girls at T1 (x̄=44.74, SD = 25.16 versus x̄=37.79 ± 23.49, respectively) and T2 (x̄=80.07, SD = 15.68 versus x̄=77.89 ± 14.30, respectively) but knowledge gain from T1 to T2 was not significantly different according to gender (P = 0.11) as shown by non-significant gender×time interaction. There were no significant gender differences in the perceived usefulness and importance of the animations or liking of the style of the animations, with both genders considering the animations as useful, important, and likable. Regression analysis showed only knowledge at T1 to be significantly associated with knowledge at T2. Qualitative data showed three main themes: accessibility of important and useful information; information engagement and help-seeking behaviour; and inclusivity of information.

LIMITATIONS, REASONS FOR CAUTION

This was a pre- and post-study with a sample of young people from a selected educational institution without a control group. Only short-term effects of the animations were recorded.

WIDER IMPLICATIONS OF THE FINDINGS

Adolescents are interested in and learn from the provision of engaging fertility-related information. Boys and men should be considered as being a relevant target population for fertility education, not just girls and women.

STUDY FUNDING/COMPETING INTEREST(S)

This research was carried out in partnership with the British Fertility Society, was financially supported by an Economic and Social Research Council Impact Acceleration Award (520792) and commercial sponsorship from iMediCare Ltd, Bayer AG, Merck Group, Cryos International given to the British Fertility Society, and a financial contribution from Orchid Cancer Appeal. The authors are fully responsible for the content of the animations and this manuscript, and the views and opinions described in the publication reflect solely those of the authors. J.B. reports a grant from Merck Serono Ltd outside the submitted work. C.H., G.G., A.D., E.B., U.G., M.L, B.W., and M.H. declare no conflict of interest. K.M. reports honoraria from Bayer and Merck. A.P. reports paid consultancy for Cryos International, Cytoswim Ltd, Exceed Health, and Merck Serono in the last 2 years, but all monies have been paid to the University of Sheffield.

TRIAL REGISTRATION NUMBER

N/A.

Psychometric evaluation and validation of Urdu Social Rank Scale for women with infertility in Pakistan

Background

Infertility negatively affects nearly all aspects of women's life and is a source of demotion in the rank/status of women that they have achieved after marriage. This social rank/status demotion due to infertility may result in depression and several other psychopathologies. No extant instrument is available to measure the phenomenon of social rank in women with infertility in Pakistan.

Objective

The aim of the current study was to evaluate the psychometric properties and validate the Social Rank Scale for women experiencing infertility in Pakistan.

Methodology

This study was conducted in four phases. The data were collected from women with primary infertility who visited hospitals all over Pakistan from 2016 to 2018. Social Rank Scale for Women with Infertility (SRS-WI) comprising of two scales, the Social Comparison Scale for Women with Infertility (SCS-WI) and the Submissive Behavior Scale for Women with Infertility (SBS-WI), was developed.

Results

The factor structure of 37 items of SCS-WI and of 21 items of SBS-WI was determined through exploratory factor analysis (EFA) on a sample of 215 women with primary infertility with an age range of 20-45 years (Mage = 31.03; SD = 6.18). Principal component analysis with varimax rotation method yielded a three-factor solution for SCS-WI, and 32 items were retained for SCS-WI that accounted for 62.38% variance. For SBS-WI, a uni-factor solution was obtained, and 20 items were retained for SBS-WI, which collectively accounted for 42.01% variance. The factor structure for both scales was confirmed via confirmatory factor analysis among a sample of 210 participants with good model fit indices.

Conclusion

The study provides acceptable psychometric properties of the SRS-WI in Pakistan. Testing of psychometric properties in different groups of samples would justify the generalized use of the instrument.

Effect of depression and anxiety on sexual functioning in couples trying to conceive with and without an infertility diagnosis

OBJECTIVE

This study examined the effects of anxiety and depression on sexual functioning in couples trying to conceive, and tested the moderating role of infertility diagnosis on this association.

DESIGN

An online questionnaire was completed by 1453 individuals in a heterosexual relationship for more than one year. The final sample had 107 couples who were actively attempting a pregnancy (63 had an infertility diagnosis; 44 were presumably fertile). Data was analyzed with the Actor-Partner Interdependence Model (APIM).

MAIN OUTCOME MEASURES

Depression and anxiety symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS), and male and female sexual functioning were assessed through the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI), respectively.

RESULTS

Actor effects were found between depression and sexual functioning in both men (β= -.28, p= .003) and women (β= -.43, p < .001), with no significant partner effects. The moderation analysis showed that the relationship between depression and sexual functioning is stronger in infertile men than in presumably fertile men (β= -.29; p= .002).

CONCLUSION

Psychological interventions with couples trying to conceive should address the role of depression in sexual functioning, particularly in infertile men.

The association between pregnancy intention, fertility treatment use, and postpartum depression

RATIONALE

Understanding whether postpartum depressive (PPD) symptoms vary by pregnancy intention and use of fertility treatments has implications for reproductive health policies and practices.

OBJECTIVE

The first aim of this study was to determine whether PPD symptoms differ between women who had unintended pregnancies, women who conceived spontaneously and were unsure about their pregnancy intention, women who used fertility treatments to conceive, and women who conceived spontaneously and intentionally. The second aim was to determine whether PPD symptoms differed based on the fertility treatment used to conceive (fertility drugs only, medicated insemination, or assisted reproductive technology [ART]).

METHODS

Data from the Pregnancy Risk Assessment Monitoring System (2012-2019), a cross-sectional survey administered to women throughout the U.S. who have recently given birth, was used to carry out our aims.

RESULTS

For the first aim (unweighted N = 243,677), compared to women who had spontaneous, intended pregnancies, women who had unintended pregnancies (OR: 1.32, 95% CI: 1.26-1.39, p < 0.01) and those with spontaneous pregnancies who were unsure about their intention (OR: 1.30, 95% CI: 1.23-1.38, p < 0.01) had higher odds of elevated PPD symptoms, adjusting for a range of covariates. Women who conceived with fertility treatments did not have higher odds of elevated PPD symptoms (OR: 0.97, 95% CI: 0.84-1.10, p = 0.61). For the second aim (unweighted N = 2,210), compared to those in the ART group, those who conceived using only fertility enhancing drugs had greater odds of developing elevated PPD symptoms (OR: 2.00, 95% CI: 1.24-3.24, p < 0.01).

CONCLUSIONS

These findings suggest that giving birth to an unintended pregnancy in the U.S. increases risk of elevated PPD symptoms. While overall women who conceive with the use of fertility treatments are not at increased risk of experiencing elevated PPD symptoms, there may be variability in risk based on the specific fertility treatments used.

The Infertility-Related Stress Scale: Validation of a Brazilian-Portuguese Version and Measurement Invariance Across Brazil and Italy

Infertility constitutes an essential source of stress in the individual and couple’s life. The Infertility-Related Stress Scale (IRSS) is of clinical interest for exploring infertility-related stress affecting the intrapersonal and interpersonal domains of infertile individuals’ lives. In the present study, the IRSS was translated into Brazilian–Portuguese, and its factor structure, reliability, and relations to sociodemographic and infertility-related characteristics and depression were examined. A sample of 553 Brazilian infertile individuals (54.2% female, mean aged 36 ± 6 years) completed the Brazilian–Portuguese IRSS (IRSS-BP), and a subsample of 222 participants also completed the BDI-II. A sample of 526 Italian infertile individuals (54.2% female, mean aged 38 ± 6 years) was used to test for the IRSS measurement invariance across Brazil and Italy. Results of exploratory structural equation modeling (ESEM) indicated that a bifactor solution best represented the structure underlying the IRSS-BP. Both the general and the two specific intrapersonal and interpersonal IRSS-BP factors showed satisfactory levels of composite reliability. The bifactor ESEM solution replicated well across countries. As evidence of relations to other variables, female gender, a longer duration of infertility, and higher depression were associated with higher scores in global and domain-specific infertility-related stress. The findings offer initial evidence of validity and reliability of the IRSS-BP, which could be used by fertility clinic staff to rapidly identify patients who need support to deal with the stressful impact of infertility in the intrapersonal and interpersonal life domains, as recommended by international guidelines for routine psychosocial care in infertility settings.

Psychological Impact of Infertility. Directions for the Development of Interventions

Introduction: Infertility represents a major health problem that oftentimes is experienced as a crisis situation. Because it interposes with achieving an important life goal, that of having children, its implications on the psycho-emotional level are robust. Purpose: The present article aimed at exploring the multidimensional effects of infertility on mental health, as well as suitable psychological intervention strategies for patients both at an individual and couple level. Methodology: An extensive literature review was conducted to select the most relevant information. Articles included were searched in PubMed, Google Scholar and other similar databases within a seven years interval (2014-2021) to assure the up-to-date quality of the paper. The main criteria of inclusion were: studies about the consequences of infertility on mental health, epidemiology, risk and protective factors, psychological models for infertility, psychological evaluation, established instruments, psycho-social and therapeutic interventions, intervention protocols used in public health for infertility patients. Results and Discussion: Infertility is often experienced as a crisis situation, in which the most common consequences are visible at the level of mood disorders (e.g. anxiety, depression, marked distress) and at the social level (stigma, divorce, social isolation, financial difficulties). Psychological counseling is needed throughout medical treatment and therapeutic interventions (e.g. cognitive-behavioral therapy) have shown favorable results in managing the emotional balance of the individual/couple and reducing the risk of psychopathology. Conclusions: Research highlights the beneficial effects of psychological interventions on reducing levels of stress related to infertility, anxiety and depressive symptoms and on improving the quality of life and couple dynamics

The efficacy of cognitive behavioural therapy on stress, anxiety and depression of infertile couples: a systematic review and meta-analysis

Infertility is considered globally to be a stressful and hard experience that affects the couples psychologically, socially and individually. The aim of this study was to systematically review the effectiveness of cognitive behavioural therapy (CBT) on depression, stress and anxiety in infertile couples. In this systematic review and meta-analysis, databases were searched up to August 2019. Twelve articles were included in the meta-analysis and analysed with Comprehensive Meta-Analysis (CMA) v2. The results of pooled studies showed that the mean scores for depression and anxiety decreased in patients receiving CBT as compared to the control group. The results of three pooled studies showed no significant difference on stress in patients receiving CBT as compared to the control group. The findings of this study provides valuable suggestions for improving mental health status through applying CBT to manage anxiety and depression in infertile couples.

[Effects of First Assisted Reproductive Technologies on Anxiety and Depression among Infertile Women: A Systematic Review and Meta-Analysis]

PURPOSE

The purpose of this study was to analyze anxiety and depression among infertile women at different time points during the first In Vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) treatment through a systematic review and meta-analysis.

METHODS

Seven out of 3,011 studies were included for meta-analysis. To estimate the effect size, a meta-analysis of the studies was performed using the RevMan 5.3 program. We compared the measurement outcomes at three time points: before the start of treatment (T0), cancellation of treatment after pregnancy detection (T2), one to six months after treatment (T3). The effect size used was the standardized mean difference (SMD).

RESULTS

In comparing the different time points of the pregnant women from their cycle, significantly lower levels of depression were found at T2 than at T0. In non-pregnant women, anxiety at T2 and depression at T2 and T3 were significantly higher than those at T0. At T2 and T3, the non-pregnant women reported higher levels of anxiety and depression compared with the pregnant women.

CONCLUSION

Anxiety and depression in infertile women undergoing the first IVF or ICSI are associated with the time points and pregnancy status after treatment. These findings suggest that attention should be paid to helping infertile women prepare for and cope with treatment and treatment failure.

The complex relationship between infertility and psychological distress (Review)

Infertility is defined as the inability to procreate, or carry or deliver a baby naturally. The majority of specialists describe infertility as being unable to get pregnant after having tried for at least one year. The relationship between infertility and psychological stress is complex. On the one hand, infertile couples are subject to greater stress and have a greater risk of developing psychological disorders compared with normal, healthy couples. On the other hand, high levels of psychological distress have been indicated to increase infertility. Therefore, in the present review, the main factors that may lead to increased stress in couples who try to conceive, psychological stress as the reason for infertility, and the therapies that can help decrease psychological distress and increase chances of pregnancy are underlined. In addition to the psychological side effects that may occur from infertility itself, a range of other side effects can be caused by hormones and drugs used to treat infertility. Additionally, problem during erection and ejaculation can cause of psychological distress, which can lead to infertility among men. Psychotherapy is the main intervention recommended for couples who suffer from any form of infertility. Ideally, counselling should begin before patients start any medical intervention to help with their infertility.

An internet-based mind/body intervention to mitigate distress in women experiencing infertility: A randomized pilot trial

OBJECTIVE

To determine if an internet-based mind/body program would lead to participants experiencing infertility (1) being willing to be recruited and randomized and (2) accepting and being ready to engage in a fertility-specific intervention. Secondary exploratory goals were to examine reduced distress over the course of the intervention and increased likelihood to conceive.

METHODS

This was a pilot randomized controlled feasibility trial with a between-groups, repeated measure design. Seventy-one women self-identified as nulliparous and meeting criteria for infertility. Participants were randomized to the internet-based version of the Mind/Body Program for Fertility or wait-list control group and asked to complete pre-, mid- and post-assessments. Primary outcomes include retention rates, number of modules completed, and satisfaction with intervention. Secondary exploratory outcomes sought to provide preliminary data on the impact of the program on distress (anxiety and depression) and self-reported pregnancy rates relative to a quasi-control group.

RESULTS

The retention, adherence, and satisfaction rates were comparable to those reported in other internet-based RCTs. Although time between pre- and post-assessment differed between groups, using intent-to-treat analyses, women in the intervention group (relative to the wait-list group) had significant reduction in distress (anxiety, p = .003; depression, p = .007; stress, p = .041 fertility-social, p = .018; fertility-sexual, p = .006), estimated as medium-to-large effect sizes (ds = 0.45 to 0.86). The odds of becoming pregnant was 4.47 times higher for the intervention group participants as compared to the wait-list group, OR 95% CI [1.56, 12.85], p = .005 and occurred earlier. The findings suggest that the research design and program specific to this population are feasible and acceptable. Replication efforts with an active control group are needed to verify distress reduction and conception promotion findings.

Supportive Social Interactions in Infertility Treatment Decrease Cortisol Levels: Experimental Study Report

PURPOSE

The aim of the research project was to analyze the importance of supportive social interactions in the process of infertility treatment. The acceptance rates of ART (Assisted Reproductive Technology) in Poland are lower than in western European countries and the social stigma of infertility exists. The research project draws attention to the issue of disclosure of fertility problems and the ability to seek support in Polish couples.

METHODS

An experimental study was conducted with 51 heterosexual couples who qualified for IVF. The participants were randomly divided into an experimental and control group. The first stage of the research procedure, with all the couples, was to extract a saliva (cortisol) sample as a biomarker for stress. In the second stage the control group viewed an informational (non-emotional) video about human embryology. The experimental group took part in a supportive social interaction process. In the supportive social interaction process, a maximum of five couples, were led through a broad general understanding of their IVF experience by an experienced group psychologist. The third stage of the research involved the second extraction of a saliva (cortisol) sample form all participants. In addition, demographic and medical history related to fertility was collected.

RESULTS

The statistical analysis indicates a significant decrease in the level of stress experienced after the supportive social interaction. The reported differences between the experimental group and the control group indicated a larger decrease of cortisol level for women and men.

CONCLUSION

In the current study, the hypothesis that taking part in supportive social interaction significantly lowers stress levels (measured via cortisol) of infertile couples (men and women) was supported. Further the project indicates that a supportive social interaction has a beneficial effect on infertile couple's health and well-being. The results of the study clearly point to the benefits of couples involved in infertility treatment to express and share their experience, and in doing so, provides measurable physiological and psychological benefits.

"In Cycles of Dreams, Despair, and Desperation:" Research Perspectives on Infertility Specific Distress in Patients Undergoing Fertility Treatments

"Emotional distress in infertility" is a broad expression that loosely denotes anxiety, depression, grief, crisis, depleting psychological well-being, and all forms of affective and interpersonal disturbances faced by individuals with infertility. The distress is usually associated with involuntary childlessness as it is an unwelcoming event. The developmental crisis associated with childlessness poses a threat to one's sense of self at all levels (individual, family and social). Distress may begin before or during treatments as a person experiences the loss of control over attaining parenthood, anxiety or dejection after the diagnosis, treatments, its complications particularly its limited success rates. This paper reviews the basic concepts, theoretical models related to infertility specific distress (ISD). It elaborates on the effects of individual and treatment-specific variables on ISD with special highlights gathered from the national and international research.

Fertility patients demonstrate an unmet need for the provision of psychological information: A cross sectional study

OBJECTIVES

To examine the provision of information by health care providers (HCPs) to fertility patients about accessing psychological resources.

METHODS

This study utilized data from a cross-sectional survey of 659 male and female patients seeking fertility treatment at clinics in Toronto and Montreal. Regression analyses were used to assess if sociodemographic and treatment variables were associated with the receipt of information, the desire for information, the helpfulness of the information, and the likelihood that participants had sought counselling.

RESULTS

The majority of respondents (79.8%) said that their HCP had not given them information about accessing psychological resources. Of the patients who did not receive this information, most (60%) said that they wanted it. Regression analysis revealed that immigrants, women, and patients with higher perceived stress scores were significantly more likely to desire this information. Furthermore, having received this information was associated with increased odds of counselling seeking (odds ratio = 3.31, p = 0.013).

CONCLUSION

Fertility patients demonstrated an unmet need for information about accessing psychological resources, and HCPs may play an integral role in bridging this information gap.

PRACTICE IMPLICATIONS

To improve the patient-centeredness of fertility care, HCPs should be proactive in informing all patients about how to access psychological resources.

What makes people ready to conceive? Findings from the International Fertility Decision-Making Study

This study investigated fertility decision-making in people currently trying to conceive, and examined whether factors that make people ready to conceive differ by gender and country. The study used data from the International Fertility Decision-Making Study, a cross-sectional study of 10,045 participants (1690 men and 8355 women) from 79 countries. Respondents were aged 18-50 years (mean 31.8 years), partnered and had been trying to conceive for > 6 months (mean 2.8 years). Respondents indicated their need for parenthood; their own/partner's desire for a child; and the influence of certain preconditions, motivational forces and subjective norms in relation to readiness to conceive. Factor analysis of preconditions and motivational forces revealed four decisional factors: social status of parents, economic preconditions, personal and relational readiness, and physical health and child costs. Significant gender differences were found for desire for a child, decisional factors and subjective norms. Compared with men, women had higher personal desire for a child, and rated economic and personal and relational readiness as more influential. Men were more likely to rate subjective norms and social status of parents as more influential. Country comparisons found significant differences in personal desire for a child, partner's desire for a child, need for parenthood, preconditions, motivational forces and subjective norms. The results demonstrate that some decisional factors have a universal association with starting families (e.g. desire for a child), whilst the influence of others (e.g. personal and relational readiness) is dependent on contextual factors. These findings support the need for contemporary, prospective and international research on reproductive decision-making, and emphasize the need for effective fertility policies to take contextual factors into account.

Infertility Centrality in the Woman's Identity and Goal Adjustment Predict Psychological Adjustment Among Women in Ongoing Fertility Treatments

PURPOSE

Some of the women that go through repeated fertility treatments will not adjust well to the treatments and will experience increased distress. The present study examined how centrality of the fertility problem in the woman's identity and dispositional goal adjustment (disengagement and reengagement) are associated with the woman's psychological adjustment. These issues are examined in a context of a pro-natal society (Israel) where parenthood is a major life goal.

METHODS

One hundred ninety-three women in ongoing fertility treatments filled out questionnaires, and follow-up on their psychological well-being was carried out after 3 months (N = 130).

RESULTS

Women who perceived their fertility problem as more central to their identity experienced greater distress (β = 0.34, p < 0.01) and less well-being (β = - 0.31, p < 0.01). Concurrently, high ability for goal disengagement was a resource that protected women from these feelings. Women high on goal disengagement who were low on goal reengagement experienced greater distress (β of interaction = - 0.24, p < 0.01), probably because they remained with feelings of emptiness and lack of purpose. These findings were found in both cross-sectional and longitudinal analyses. Finally, the models predicting well-being and distress at T2 using centrality, goal adjustment, and T1 well-being/distress explained 42 and 47.5% of the variance, respectively.

CONCLUSIONS

Much research and therapeutic attention has been invested in coping with fertility treatments, while the options of reducing investment in treatments and finding alternative goals did not receive adequate attention. This study discusses these issues and their possible clinical implications especially in a pro-natal context.

Illness Cognitions, Anxiety, and Depression in Men and Women Undergoing Fertility Treatments: A Dyadic Approach

Background

Emotional response to infertility is mediated by numerous interrelated psychological variables such as personality, health perceptions, cognitive appraisals, coping, and social support. While men and women respond to infertility differently, illness cognitions are a vital component of their emotional adjustment. The aim of this study is to compare the infertile men and women undergoing fertility treatments on perceived distress, helplessness, acceptance, benefits, anxiety, and depression.

Materials and Methods

Eighty-one infertile couples, undergoing intrauterine insemination participated in the study. They were assessed on the presence of infertility distress using the fertility problem inventory, for psychiatric morbidity using the Mini International Neuropsychiatric Interview, for affective disturbances using the Hamilton Anxiety and Depression scales, and for illness cognitions using the Illness Cognition Questionnaire.

Statistical Analysis

Data are analyzed using SPSS version 15. The paired sample t-test is performed for assessing differences on normally distributed data. The Wilcoxon Signed-Rank test is performed for assessing differences in medians obtained on data that was skewed.

Results and Discussion

Infertile women (wives) were more emotionally distressed, anxious, and depressed than men (husbands). Gender-wise differences were found for perceptions of helplessness and acceptance of infertility. Infertility was perceived to be a nonbeneficial event for both partners investigated.

Conclusion

Negative cognitions and affective disturbances may contribute to higher treatment burden in couples seeking-assisted conception. The present study suggests that psychosocial intervention for couples plays a central role and should be integrated within the conventional treatments for infertility.

Psychosocial effects of infertility among couples attending St. Michael's Hospital, Jachie-Pramso in the Ashanti Region of Ghana

Objective

Infertility is a life crisis with a wide range of socio-cultural, emotional, physical and financial problems. This study sought to determine the psychosocial effects of infertility among couples attending St. Michael’s hospital, Jachie-Pramso. A descriptive study design was adopted using a quantitative approach. A simple random technique was used to select 100 respondents and a structured closed ended questionnaire was administered to couples who visited the St. Michaels Hospital at Jachie-Pramso.

Results

The study has revealed that the social effects of infertility on couples included exclusion, verbal and physical abuse, divorce as well as stigma. There is high level of despondence among couples who are considered infertile. Reliance on family members for emotional support as well as avoidance of sensitive conversations was the main coping strategies adopted by the couples to cope with their conditions. Infertility has psychological, emotional and social consequences on individuals as well as couples. Families should support infertile individuals in every way that they can so that they will not be isolated.

Effect of Marital Relationship Enrichment Program on Marital Satisfaction, Marital Intimacy, and Sexual Satisfaction of Infertile Couples

Background

Infertile couples only think of having children during their sexual intercourse, and their constant concern about this issue increases their stress level. Psychosocial and social stress leads to decreased life satisfaction, increased marital problems, and reduced sexual confidence. This study aims to determine the effect of enrichment program on marital and sexual satisfaction as well as marital intimacy among infertile couples.

Materials and Methods

This randomized controlled clinical trial was conducted on 50 infertile couples in 2013 in Hamedan. The marital relationship enrichment program was taught to the experimental group during seven 90 minutes sessions. Enrich marital satisfaction, Linda Berg sexual satisfaction, and marital intimacy questionnaires were completed by both groups in 3 pretest steps immediately after the end of training sessions, and 8 weeks later. The results were analyzed in STATA11 software using t test, Chi-square, ANCOVA, RM-ANOVA, and Bonferroni post-hoc test. To check the data normality, Kolmogorov-Smirnov test was used. P<0.05 was considered significant.

Results

Comparison of mean scores related to pretest on the one hand and immediately after the test in 8 week later on the other hand showed marital relationship enrichment program significantly increased marital and sexual satisfaction (P<0.001). Also, mean score of marital intimacy immediately after the test (P=0.04) and 8 weeks after the test (P<0.001) significantly increased in comparison with the pretest under the influence of the program.

Conclusion

Enrichment training can increase marital intimacy and also marital and sexual satisfaction in infertile couples (Registration Number: IRCT201604299014N97).

Depression and Anxiety Outcomes Associated with Failed Assisted Reproductive Technologies: A Systematic Review and Meta-Analysis

Objective

Our study examined the psychological outcomes associated with failed ART treatment outcomes in men and women.

Search Strategy

A systematic search for studies published between January 1980 and August 2015 was performed across seven electronic databases.

Inclusion Criteria

Studies were included if they contained data on psychosocial outcomes taken pre and post ART treatment.

Data Extraction and Synthesis

A standardised form was used to extract data and was verified by two independent reviewers. Studies were meta-analysed to determine the association of depression and anxiety with ART treatment outcomes. Narrative synthesis identified factors to explain variations in the size and directions of effects and relationships explored within and between the studies.

Main Results

Both depression and anxiety increased after a ART treatment failure with an overall pooled standardised mean difference (SMD) of 0.41 (95% CI: 0.27, 0.55) for depression and 0.21 (95% CI: 0.13, 0.29) for anxiety. In contrast, depression decreased after a successful treatment, SMD of -0.24 (95% CI: -0.37,-0.11). Both depression and anxiety decreased as time passed from ART procedure. Nonetheless, these remained higher than baseline measures in the group with the failed outcome even six months after the procedure. Studies included in the narrative synthesis also confirmed an association with negative psychological outcomes in relation to marital satisfaction and general well-being following treatment failure.

Conclusion

Linking ART failure and psychosocial outcomes may elucidate the experience of treatment subgroups, influence deliberations around recommendations for resource allocation and health policy and guide patient and clinician decision making.

Prevalence and predictors of infertility-specific stress in women diagnosed with primary infertility: A clinic-based study

BACKGROUND

According to the existing literature on infertility, stress appears to be inevitably associated with infertility diagnosis and treatment in sub-fertile individuals. The epidemiological data on the prevalence and predictors of infertility-specific stress in cultural specific scenario are scarce. The objective of the present study was to estimate the prevalence of infertility-specific stress and identify predictors of infertility-specific stress in women diagnosed with primary infertility.

MATERIALS AND METHODS

This cross-sectional study was conducted on 300 infertile married women, diagnosed with primary infertility. The tools used for the assessment were "semi-structured questionnaire" compiled by the authors, "ICD-10 Classification of Mental and Behavioral Disorders (Clinical Descriptions and Diagnostic Guidelines)," and "Psychological Evaluation Test for infertility."

STATISTICAL ANALYSIS

Data were analyzed using SPSS (version 15). Chi-square test was used for univariate analysis followed by multiple logistic regressions between stress and the predictor variables.

RESULTS AND DISCUSSION

The prevalence of stress among women was 80%. Univariate analysis revealed that predictors of stress were years of marital life, duration of infertility, infertility type, history of gynecological surgery, cycles of ovulation induction with timed intercourse and intra-uterine inseminations, present and past psychiatric morbidity, coping difficulties, gynecological diagnosis, and severity of premenstrual dysphoria. Multivariate analysis showed leading associations of stress with infertility type and coping difficulties.

Does infertility history affect the emotional adjustment of couples undergoing assisted reproduction? the mediating role of the importance of parenthood

Objectives

The emotional adjustment of couples undergoing assisted reproductive technology (ART) treatments has been widely studied; however, it remains unclear whether infertility history contributes to couples' adjustment. This study examined the impact of infertility history (duration of infertility and number of previous ART treatment cycles) on the emotional adjustment of couples undergoing an ART cycle and the mediating effect of importance of parenthood on that association.

Methods

In this cross‐sectional study, 70 infertile couples (70 women and 70 men) completed self‐report questionnaires assessing emotional adjustment and infertility stress during the hormonal stimulation phase of an ART cycle. Path models accounting for the dyadic nature of the data examined the direct and indirect effects (by affecting representations about parenthood and childlessness) of infertility history on emotional adjustment.

Results

The number of previous cycles affected men's, but not women's, emotional adjustment by affecting the representations on the importance of parenthood and of childlessness. Duration of infertility had the opposite effect, as couples with longer infertility reported heightened importance of parenthood, which negatively affected their emotional adjustment.

Conclusions

Infertility history was associated with emotional adjustment in men and women, although these associations were complex. The results suggest that progression through treatment is harder for those men and women who attribute higher importance to being parents, which is aggravated by longer infertility.

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.

Effects of a partnership support program for couples undergoing fertility treatment

AIM

The study's purpose was to examine the effects of providing a partnership support program. It was designed to improve Japanese couples' partnership, maintain quality of life, decrease psychological distress, and improve marital relationship satisfaction while they underwent infertility treatment that included the possibility of using assisted reproductive technology.

METHODS

This quasi-experimental study with a two-group pretest-post-test design used purposive sampling and non-random assignment of 318 consenting Japanese patients from previous phases of assisted reproductive technology fertility treatment who were patients from a fertility clinic in Tokyo, Japan. The intervention group of 152 patients (76 couples) participated in the partnership support program. The comparison group of 166 patients (83 couples) received usual care. Recruitment was age matched. The program provided information and used a participatory-interactive approach to enhance understanding and cooperation in couples undergoing fertility treatment. The main outcome measures were: "partnership", FertiQoL, Quality Marriage Index, and "psychological distress".

RESULTS

There were 311 participants (intervention group n = 148; comparison group, n = 163). The intervention group showed significant improvement in the couples' partnerships and a significant decrease in women's psychological distress using subgroup analysis.

CONCLUSION

The partnership support program provided effective improvement in partnership for the couples, and reduced psychological distress for the women; however, it had less impact for the men. The program was not effective in improving couples' overall quality of life (QOL); however, it was effective in improving the "mind-body" aspects of the QOL subscale.

Development of a partnership causal model for couples undergoing fertility treatment

AIM

The goals of this study were to develop a partnership causal model and verify the model's fitness for couples undergoing fertility treatment.

METHODS

A purposive sample of 1004 consenting participants (502 couples) undergoing fertility treatment was selected from five fertility clinics across Japan. A mailed self-administered questionnaire was used to collect data. The partnership causal model was examined with structural equation modeling.

RESULTS

A total of 565 questionnaires were returned (56.3%) and the number of valid responses was 466 (46.4%). The factor "medical professionals' support (nurses and physicians)" influenced the couples' "partnership" (β = 0.16) and had a direct effect on the men's quality of life (QOL) and an indirect effect on the women's QOL (β = 0.20). Couples' partnership had a significant impact on couples' QOL (β = 0.20) and on "satisfaction in their relationship with their partner" (β = 0.48). The multi-population path analysis revealed that married couples influenced each other's perceptions of their partnership (men, β = 0.84; women, β = 0.88). Additionally, the spouse's partnership influenced both individual's QOL (men, β = 0.77; women, β = 0.77) and the satisfaction with the relationship (men, β = 0.46; women, β = 0.59). The participants' "distress" significantly and negatively affected the participants' QOL.

CONCLUSION

The results revealed that for a couple undergoing fertility treatments, a strong partnership maintains their QOL, and this could decrease the couples' distress (particularly in women). Partnership was also related to the variability of "medical professionals' support".

Family-related opinions and stressful situations associated with psychological distress in women undergoing infertility treatment

The purpose of this study is to investigate how family-related opinions and stressful situations are related to psychological distress in women undergoing infertility treatment. The subjects in this cross-sectional study were recruited from female patients undergoing infertility treatment (n = 2540) at 70 infertility treatment institutions in Japan. Because of non-participation or missing data, the number of subjects included in the analysis was 635 (response rate, 25.0%). The family-related opinions and stressful situations were evaluated using the original questions. Psychological distress was assessed using a self-report measure, the Kessler Six-question Psychological Distress Scale (K6). The K6 scores of the following participants were significantly (p < 0.05) and independently high: those with more frequent miscarriage/stillbirth/abortions, those with repeated miscarriages as the cause of infertility, those with infertility of unknown causes, those living with no child, those having a low joint income with their partner, those with the opinion that “women should devote themselves to their household duties” those who had considered stopping treatment, those without the opinion that “married life without children is favorable” and those who had experienced stressful situations such as inadequate explanation by doctors, frustration of multiple failed attempts, differences of opinion with the partner, and lack of knowledge regarding when to stop treatment. Family-related opinions and stressful situations associated with psychological distress in women undergoing infertility treatment are outlined. The results of this study may contribute to the prevention of and care for psychological distress in female patients undergoing infertility treatment.

Recovery after unsuccessful in vitro fertilization: the complex role of resilience and marital relationships

The failure rate of in vitro fertilization (IVF) is around 75% per cycle. These unsuccessful attempts can provoke acute clinical depression and other problems. Although practitioners often recommend cognitive reappraisal, rather than avoidance, to cope with these difficulties, previous research has not established the psychosocial determinants of adaptive coping strategies. Arguably, resilience could encourage cognitive reappraisal, because resilient individuals feel confident they can overcome their emotions, whereas marital quality could prevent avoidance, because individuals feel secure enough to reflect upon their distress. Consequently, resilience and marital quality could facilitate recovery over time. To explore these possibilities, 184 women, all of whom had unsuccessfully completed IVF treatment, completed a questionnaire that gauged their levels of self-reported depression since their last IVF attempt as well as resilience and marital quality. Immediately after the unsuccessful attempt, resilience was inversely, whereas marital quality was positively, related to depression. However, within this cross-sectional sample after greater time had elapsed, marital quality became increasingly beneficial and was negatively associated with depression. These findings imply that resilience can curb the initial distress; in contrast, marital quality may enable individuals to reflect upon their trauma, initially amplifying distress but eventually facilitating recovery. Future research would benefit from longitudinal studies, illustrating whether resilience and marital quality at one time predict changes in distress at subsequent times.

Couples’ Resolution of an Infertility Diagnosis Before Undergoing in Vitro Fertilization

Although the use of assisted reproductive technology has today become more familiar, the suffering associated with the experience of infertility remains. This study assesses the emotional resolution of couples faced with an infertility diagnosis by examining their narratives. Fifty-seven couples were recruited from fertility clinics to participate in a semistructured interview prior to in vitro fertilization. Two aspects of the couples’ reactions to the infertility diagnosis were assessed: (1) each individual’s capacity to acknowledge the emotional reality of the diagnosis (diagnosis resolution) and (2) the couple’s ability to construct a shared meaning of the infertility diagnosis experience (narrative co-construction). Associations between these aspects and self-reported marital satisfaction, infertility-related stress, and diagnosis-related variables were analyzed. 73.7% of women and 61.4% of men had acknowledged the emotional reality of the diagnosis, and their scores for narrative co-construction were comparable to reference samples. Marital satisfaction, but not infertility-related stress, was associated with diagnosis resolution and narrative co-construction. The results indicate the importance of detecting couples with fewer individual and marital resources needed to face the reality of the diagnosis. A couple’s capacity to perceive the infertility diagnosis as a shared problem is also essential for dealing with this common life event.

Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study

STUDY QUESTION

How good is fertility knowledge and what are treatment beliefs in an international sample of men and women currently trying to conceive?

SUMMARY ANSWER

The study population had a modest level of fertility knowledge and held positive and negative views of treatment.

WHAT IS KNOWN ALREADY

Few studies have examined general fertility treatment attitudes but studies of specific interventions show that attitudes are related to characteristics of the patient, doctor and context. Further, research shows that fertility knowledge is poor. However, the majority of these studies have examined the prevalence of infertility, the optimal fertile period and/or age-related infertility in women, in university students and/or people from high-resource countries making it difficult to generalize findings.

STUDY DESIGN, SIZE, DURATION

A cross-sectional sample completed the International Fertility Decision-making Study (IFDMS) over a 9-month period, online or via social research panels and in fertility clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were 10 045 people (8355 women, 1690 men) who were on average 31.8 years old, had been trying to conceive for 2.8 years with 53.9% university educated. From a total of 79 countries, sample size was >100 in 18 countries. All 79 countries were assigned to either a very high Human Development Index (VH HDI) or a not very high HDI (NVH HDI). The IFDMS was a 45-min, 64-item English survey translated into 12 languages. The inclusion criteria were the age between 18 and 50 years and currently trying to conceive for at least 6 months. Fertility knowledge was assessed using a 13-item correct/incorrect scale concerned with risk factors, misconceptions and basic fertility facts (range: 0-100% correct). Treatment beliefs were assessed with positive and negative statements about fertility treatment rated on a five-point agree/disagree response scale.

MAIN RESULTS AND THE ROLE OF CHANCE

Average correct score for Fertility Knowledge was 56.9%, with greater knowledge significantly related to female gender, university education, paid employment, VH HDI and prior medical consultation for infertility (all P < 0.001). The mean agreement scores for treatment beliefs showed that agreement for positive items (safety, efficacy) was correlated with agreement for negative items (short/long-term physical/emotional effects) (P > 0.001). People who had given birth/fathered a child, been trying to conceive for less than 12 months, who had never consulted for a fertility problem and who lived in a country with an NVH HDI agreed less with negative beliefs. HDI, duration of trying to conceive and help-seeking were also correlates of higher positive beliefs, alongside younger age, living in an urban area and having stepchildren. Greater fertility knowledge was associated with stronger agreement on negative treatment beliefs items (P < 0.001) but was unrelated to positive treatment beliefs items.

LIMITATIONS, REASONS FOR CAUTION

There was volunteer bias insofar as more women, people of higher education and people with fertility problems (i.e. met criteria for infertility, had consulted a medical doctor, had conceived with fertility treatment) participated and this was true in VH and NVH HDI countries. The bias may mean that people in this sample had better fertility knowledge and less favourable treatment beliefs than is the case in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Educational interventions should be directed at improving knowledge of fertility health. Future prospective research should be aimed at investigating how fertility knowledge and treatment beliefs affect childbearing and help-seeking decision-making.

Assessing infertility stress: re-examining the factor structure of the Fertility Problem Inventory

BACKGROUND

Research has documented that fertility problems can negatively affect the life of infertile patients, by imposing an obstacle to one important life goal: the achievement of parenthood. The Fertility Problem Inventory (FPI) proposes a comprehensive approach in assessing infertility stress, by measuring the impact on social, marital and sexual life dimensions and the importance of parenthood in infertile patients' life. This study examined the factor structure of the FPI, testing two alternative models using confirmatory factor analysis.

METHODS

A sample of 209 infertile patients was recruited in two public hospital departments of assisted reproduction technology. Measures included the FPI, the Brief Symptom Inventory and the ENRICH Marital Inventory.

RESULTS

Results confirmed the original measurement model of the instrument but suggested that the inclusion of an intermediate conceptual level resulted in a better fit to the model (χ²₈₄= 147.89, P< 0.001) i.e. the instrument assesses infertility stress by assessing two main conceptual domains: the impact of infertility in infertile patients' life and representations about the importance of parenthood. The instrument revealed measurement and structure invariance and construct validity by correlating with other measures assessing similar constructs.

CONCLUSIONS

This approach to the FPI has important contributions for research and clinical practice by distinguishing between the impact of infertility on different dimensions of a couple's' life and representations about the importance of parenthood, therefore extending the utility of the FPI in research and clinical practice.

Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis

BACKGROUND

A number of studies have investigated the relationship between psychological factors such as stress and distress (measured as anxiety and depression) and outcomes of assisted reproductive technology (ART). The results, however, are inconsistent, and the strength of any associations remains to be clarified. We conducted a systematic review and meta-analysis of the results of studies reporting on the associations between stress, anxiety, and depression and ART outcomes.

METHODS

Prospective studies reporting data on associations between stress or distress in female patients and ART outcome were identified and evaluated by two independent researchers according to an a priori developed codebook. Authors were contacted in cases of insufficient data reporting. Stress was defined as perceived stress, work-related stress, minor life events or major life events, and distress was defined as anxiety or depression.

RESULTS

A total of 31 prospective studies were included. Small, statistically significant, pooled effect sizes were found for stress [ESr, effect size correlation) = -0.08; P = 0.02, 95% confidence interval (CI): -0.15, -0.01], trait anxiety (ESr = -0.14; P = 0.02, 95% CI: -0.25, -0.03) and state anxiety (ESr = -0.10, P = 0.03, 95% CI: -0.19, -0.01), indicating negative associations with clinical pregnancy rates. A non-significant trend (Esr = -0.11, P = 0.06) was found for an association between depression and clinical pregnancy. For serum pregnancy tests and live birth rates, associations between trait anxiety or state anxiety were not significant. The fail safe number did not exceed the suggested criterion in any analyses, between-study heterogeneity was considerable and the mean age, mean duration of infertility and percentage of first time ART attenders in the study samples were found to moderate several of the associations.

CONCLUSIONS

Small but significant associations were found between stress and distress and reduced pregnancy chances with ART. However, there were a limited number of studies and considerable between-study heterogeneity. Taken together, the influence of stress and distress on ART outcome may appear somewhat limited.

Depressive symptoms related to infertility and infertility treatments

This article reviews depressive symptoms in women as they relate to infertility and infertility treatments. Common causes of infertility in women are discussed and the literature on depressive symptoms before and during various infertility treatments is presented. Recommendations are made from a psychiatric perspective regarding how to manage depressive symptoms in women in the context of infertility.