Depression, anxiety, and psychotropic medication use and fecundability

Exposure to Residential Greenness, Perceived Stress, and Depressive Symptoms in a North American Preconception Cohort

BACKGROUND

/Aims: Studies suggest that greater exposure to natural vegetation (i.e., greenness) is associated with better mental health. However, there is limited research on greenness and mental health in the preconception period, a critical window of exposure in the life course. We investigated the associations of residential greenness with perceived stress and depressive symptoms using cross-sectional data from a cohort of pregnancy planners.

METHODS

From 2013 to 2019, we enrolled female-identified participants aged 21-45 years who were trying to conceive without the use of fertility treatment into a North American preconception cohort study (Pregnancy Study Online [PRESTO]). On the baseline questionnaire, participants completed the 10-item Perceived Stress Scale (PSS) and the Major Depression Inventory (MDI). Using geocoded addresses, we estimated residential greenness exposure via satellite imagery (Normalized Difference Vegetation Index [NDVI]) in a 100m buffer. We estimated mean differences and 95% confidence intervals for the association of greenness with perceived stress and depression scores using linear regression models, adjusting for individual and neighborhood sociodemographic characteristics. We also evaluated the extent to which associations were modified by urbanicity and neighborhood socioeconomic status (SES).

RESULTS

Among 9,718 participants, mean age was 29.9 years, 81.5% identified as non-Hispanic White, 25% had household incomes <$50,000, and mean neighborhood income was $61,932. In adjusted models, higher greenness was associated with lower stress and depression scores (mean difference per interquartile range in greenness: -0.20, 95% CI: -0.39, -0.01; and -0.19, 95% CI: -0.48, 0.10, respectively). The association was stronger among residents of lower SES neighborhoods in urban areas (PSS: -0.57, 95% CI: -1.00, -0.15; MDI: -0.72, 95% CI: -1.40, -0.04).

CONCLUSIONS

Higher greenness exposure was associated with lower stress and depressive symptoms among pregnancy planners, particularly in lower-SES neighborhoods.

The relationship between cesarean delivery and fecundability: a population-based cohort study

BACKGROUND

Previous studies have found that women who undergo cesarean delivery have fewer pregnancies. Cesarean delivery is also more common among women with lower fecundability. The potential role of cesarean delivery in reduced fecundability is not known.

OBJECTIVE

This study aimed to assess the bidirectional relationship between cesarean delivery and fecundability.

STUDY DESIGN

This was a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥12 months) by mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a cesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,024 women.

RESULTS

The proportion of women with infertility was 7.3% (2707/37,226) among women with a previous vaginal delivery and 9.9% (508/5153) among women with a previous cesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval, 1.10-1.33). Women with a previous cesarean delivery also had a lower fecundability ratio (0.90; 95% confidence interval, 0.88-0.93) than women with a previous vaginal delivery. When assessing the reverse association between fecundability and cesarean delivery, we found that women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery (adjusted relative risk, 1.57; 95% confidence interval, 1.48-1.66) than women who conceived within the first 2 cycles. The associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups.

CONCLUSION

Among women with more than 1 child, those who had a previous cesarean delivery subsequently had a lower fecundability ratio and an increased infertility risk than those who had a vaginal delivery. However, women who needed a longer time to conceive were also more prone to be delivered by cesarean delivery, indicating a bidirectional relationship between cesarean delivery and fecundability. This could suggest a common underlying explanatory mechanism and that the surgical procedure itself may not or only partly directly influence fecundability.

Preconception depression reduces fertility: a couple-based prospective preconception cohort

STUDY QUESTION

Is preconception depression associated with time to pregnancy (TTP) and infertility?

SUMMARY ANSWER

Couples with preconception depression needed a longer time to become pregnant and exhibited an increased risk of infertility.

WHAT IS KNOWN ALREADY

Preconception depression in women contributes to impaired fertility in clinical populations. However, evidence from the general population-especially based on couples-is relatively scant.

STUDY DESIGN SIZE DURATION

A couple-based prospective preconception cohort study was performed in 16 premarital examination centers between April 2019 and June 2021. The final analysis included 16 521 couples who tried to conceive for ≤6 months at enrollment. Patients with infertility were defined as those with a TTP ≥12 months and those who conceived through ART.

PARTICIPANTS/MATERIALS SETTING METHODS

Couples' depression was assessed using the Patient Health Questionnaire-9 at baseline. Reproductive outcomes were obtained via telephone at 6 and 12 months after enrollment. Fertility odds ratios (FORs) and infertility risk ratios (RRs) in different preconception depression groups were analyzed using the Cox proportional-hazard models and logistic regression, respectively.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 16 521 couples analyzed, 10 834 (65.6%) and 746 (4.5%) couples achieved pregnancy within the first 6 months and between the 6th and 12th months, respectively. The median (P25, P75) TTP was 3.0 (2.0, 6.0) months. The infertility rate was 13.01%. After adjusting for potential confounders, in the individual-specific analyses, we found that preconception depression in women was significantly related to reduced odds of fertility (FOR = 0.947, 95% CI: 0.908-0.988), and preconception depression in either men or women was associated with an increased risk of infertility (women: RR = 1.212, 95% CI: 1.076-1.366; men: RR = 1.214, 95% CI: 1.068-1.381); in the couple-based analyses, we found that-compared to couples where neither partner had depression-the couples where both partners had depression exhibited reduced fertility (adjusted FOR = 0.904, 95% CI: 0.838-0.975). The risk of infertility in the group where only the woman had depression and both partners had depression increased by 17.8% (RR = 1.178, 95% CI: 1.026-1.353) and 46.9% (RR = 1.469, 95% CI: 1.203-1.793), respectively.

LIMITATIONS REASONS FOR CAUTION

Reporting and recall bias were unavoidable in this large epidemiological study. Some residual confounding factors-such as the use of anti-depressants and other medications, sexual habits, and prior depressive and anxiety symptoms-remain unaddressed. We used a cut-off score of 5 to define depression, which is lower than prior studies. Finally, we assessed depression only at baseline, therefore we could not detect effects of temporal changes in depression on fertility.

WIDER IMPLICATIONS OF THE FINDINGS

This couple-based study indicated that preconception depression in individuals and couples negatively impacts couples' fertility. Early detection and intervention of depression to improve fertility should focus on both sexes.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by grants from the National Natural Science Foundation of China (No. 82273638) and the National Key Research and Development Program of China (No. 2018YFC1004201). All authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Holistic preconception care: Providing real-time guidance via a mobile app to optimise maternal and child health

Introduction

Preconception is a critical period to optimise gamete function and early placental development, essential for successful conception and long-term maternal-child health. However, there is a lack of preconception services and consequently, global fertility rates continue to fall and mothers embark on their pregnancy journey in poor health. There is an urgent need to implement a holistic community-level preconception care programme to optimise risk factors for poor fecundability and improve long-term maternal-child health.

Method

We reviewed current evidence on fecundability lifestyle risk factors, the efficacy of existing preconception interventions and the use of digital platforms for health optimisation, to create a new digital-based preconception intervention model that will be implemented via an app. We present the theory, content and mode of delivery of this holistic model targeting couples planning for pregnancy.

Results

We propose a new model featuring a user-friendly mobile app, which enables couples to self-assess fecundability risks through a personalised risk score that drives a tailored management plan. This tiered management provides anticipatory guidance supported by evidence-based recommen-dations, and promotes ongoing engagement for behavioural optimisation and specialist referrals as required. Based on the health belief model, this new model delivered with a mobile app seeks to shift couples' perceptions about their susceptibility and severity of subfertility, benefits of making a change and barriers to change.

Conclusion

Our proposed digital-based intervention model via a mobile app stands to enhance preconcep-tion care by providing personalised risk assessments, real-time feedback and tiered management to optimise preconception reproductive health of couples. This model forms a reference content framework for future preconception care intervention delivery.

A bidirectional causal relationship study between mental disorders and male and female infertility

Background

The relation between mental disorders (MDs) and infertility can be reciprocal. But exactly which MD affects infertility remains controversial. Our aim was to use Mendelian randomization (MR) to explore bidirectional causality between 15 MDs and male infertility and female infertility.

Methods

The data of MDs, male infertility, and female infertility were derived from published genome-wide association studies (GWAS). The inverse variance weighted method was considered to be the main analytical approach. Sensitivity analysis was performed using MR-Egger, Cochran's Q, radial MR, and MR-PRESSO tests.

Results

Our results found that mood disorders (OR, 1.4497; 95% CI, 1.0093 - 2.0823; P = 0.0444) and attention deficit hyperactivity disorder (OR, 1.3921; 95% CI, 1.0943 - 1.7709; P = 0.0071) were positively correlated with male infertility, but obsessive-compulsive disorder (OR, 0.8208; 95% CI, 0.7146 - 0.9429; P = 0.0052) was negatively associated with male infertility. For females, anorexia nervosa (OR, 1.0898; 95% CI, 1.0070 - 1.1794; P = 0.0329), attention deficit hyperactivity disorder (OR, 1.1013; 95% CI, 1.0041 - 1.2079; P = 0.0406), and major depressive disorder (OR, 1.1423; 95% CI, 1.0213 - 1.2778; P = 0.0199) increased risk of infertility. In reverse relationship, female infertility increased the incidence of bipolar disorder (OR, 1.0009; 95% CI, 1.0001 - 1.0017; P = 0.0281).

Conclusion

We demonstrated the association between five MDs and male or female infertility. Female infertility was also found to be associated with an increased risk of one MD. We look forward to better designed epidemiological studies to support our results.

The effect of serum calcium on the association of depression with infertility among U.S. women

This study aimed to explored the association between depressive symptoms and infertility among U.S. women, and the effect of serum calcium on this association. We used data from the National Health and Nutrition Examination Survey (2013-2018), relating to women aged 20-45 years. Depressive symptoms were determined using the nine-item Patient Health Questionnaire (PHQ-9 scores ≥10), and interview data were used to identify self-reported infertility. Of 2708 women (mean age: 32.7 ± 7.5 years), 274 were depressed and 12.0 % self-reported being "ever-infertile." Depressive symptoms were associated with infertility in multivariable logistic regression (OR, 1.62; 95 % CI, 1.11-2.38). Depressive symptoms were associated with infertility among participants who were obese (OR, 1.68; 95 % CI, 1.03-2.74), had not received psychological counseling (OR, 1.60; 95 % CI, 1.03-2.50), were antidepressant users (OR 3.22; 95 % CI, 1.15-9.00), and had high serum calcium levels (OR, 2.05; 95 % CI, 1.25-3.35). A significant interaction between serum calcium and depression was observed for infertility (P = .038, interaction likelihood ratio test). In sensitivity analyses, the association between depressive symptoms and infertility remained after excluding women aged ≥35 years (OR, 1.87; 95 % CI, 1.08-3.23), lowering the cut-off for PHQ-9 scores (≥5) (OR, 1.48; 95 % CI, 1.12-1.96), excluding women with some gynecological diseases (OR, 1.63; 95 % CI, 1.07-2.49), and using inverse probability of treatment weighting (OR, 1.64; 95 % CI, 1.17-2.31).

Conclusion

Our findings indicate that depression is associated with infertility among U.S. women and serum calcium may have an effect on the association. Interventions such as serum calcium reduction, weight management and psychosocial counseling for infertility treatment in individuals with depression may be integrated into routine clinical practice. Additionally, more caution could be exercised when using antidepressants.

Optimizing preconception care and interventions for improved population health

There is growing literature indicating that optimal preconception health is associated with improved reproductive, perinatal, and pediatric outcomes. Given that preconception care is recommended for all individuals planning a pregnancy, medical providers and public health practitioners have a unique opportunity to optimize care and improve health outcomes for reproductive-aged individuals. Knowledge of the determinants of preconception health is important for all types of health professionals, including policy makers. Although some evidence-based recommendations have already been implemented, additional research is needed to identify factors associated with favorable health outcomes and to ensure that effective interventions are made in a timely fashion. Given the largely clinical readership of this journal, this piece is primarily focused on clinical care. However, we acknowledge that optimizing preconception health for the entire population at risk of pregnancy requires broadening our strategies to include population-health interventions that consider the larger social systems, structures, and policies that shape individual health outcomes.

Trauma and female reproductive health across the lifecourse: motivating a research agenda for the future of women's health

The aetiology behind many female reproductive disorders is poorly studied and incompletely understood despite the prevalence of such conditions and substantial burden they impose on women's lives. In light of evidence demonstrating a higher incidence of trauma exposure in women with many such disorders, we present a set of interlinked working hypotheses proposing relationships between traumatic events and reproductive and mental health that can define a research agenda to better understand reproductive outcomes from a trauma-informed perspective across the lifecourse. Additionally, we note the potential for racism to act as a traumatic experience, highlight the importance of considering the interaction between mental and reproductive health concerns, and propose several neuroendocrinological mechanisms by which traumatic experiences might increase the risk of adverse health outcomes in these domains. Finally, we emphasize the need for future primary research investigating the proposed pathways between traumatic experiences and adverse female reproductive outcomes.

Associations between Residential Greenspace and Fecundability in a North American Preconception Cohort Study

BACKGROUND

Residential green space can have positive physiological effects on human health through various mechanisms, including reducing stress and/or depression or facilitating physical activity. Although green space has been consistently associated with improved birth outcomes in several studies, there has been limited study of its effect on other reproductive outcomes, including fertility.

OBJECTIVE

We examined associations between residential green space and fecundability, the per-cycle probability of conception.

METHODS

We analyzed data from 8,563 female participants enrolled between 2013 and 2019 in Pregnancy Study Online (PRESTO), a prospective preconception cohort study of North American couples attempting conception. Participants completed a baseline questionnaire on sociodemographic, behavioral, and reproductive factors, and bimonthly follow-up questionnaires for up to 12 months to ascertain pregnancies. Using geocoded addresses, we calculated residential green space exposure using the Normalized Difference Vegetation Index (NDVI) within 50-, 100-, 250-, and 500 -m buffers across multiple temporal scales: annual maximum, seasonal maximum, and seasonal mean. We used proportional probabilities regression models to estimate fecundability ratios (FRs), adjusting for sociodemographic, behavioral, and neighborhood characteristics. We also evaluated the extent to which associations were mediated by reductions in perceived stress or depressive symptoms and increased physical activity.

RESULTS

When comparing the highest (≥ 0.8 ) with the lowest (< 0.2 ) NDVI exposures within 50 m , we observed positive associations in the annual maximum NDVI [FR: 1.33; 95% confidence interval (CI): 1.06, 1.67] and seasonal maximum NDVI (FR: 1.19; 95% CI: 1.00, 1.41) models, but little association in the seasonal mean NDVI models (FR: 0.98; 95% CI: 0.73, 1.30). Restricted cubic splines showed evidence of nonlinearity in this association. Results were similar across buffer distances. Perceived stress, depressive symptoms, and physical activity explained ≤ 5 : 0 % of mediation across all NDVI metrics.

DISCUSSION

In this cohort, greater residential green space was associated with a modest increase in fecundability. https://doi.org/10.1289/EHP10648.

Effects of Selective Serotonin Reuptake Inhibitor Treatment on Ovarian Reserves in Patients with Depression

Background and Objectives: The goal of this study was to investigate the effect of selective serotonin reuptake inhibitor treatment on the ovarian reserves of women of reproductive age with major depressive disorder. Materials and Methods: The current study is a prospective controlled trial including 48 women with major depressive disorder and 48 age-matched healthy controls. Ovarian reserve tests are performed prior to treatment and after six cycles of selective serotonin reuptake inhibitor treatment in the major depressive disorder group. Serum follicle-stimulating hormone, luteinizing hormone, estradiol, and anti-Müllerian hormone levels were evaluated from blood samples, and endometrial thickness, total antral follicle count, and volume of both ovaries were assessed using transvaginal ultrasonography. Results: When the first measurements were compared, menstrual duration and menstrual bleeding increased (p = 0.007 and 0.005, respectively) and luteinizing hormone decreased (p = 0.045) in the major depressive disorder group, while follicle-stimulating hormone, estradiol, anti-Müllerian hormone, endometrial thickness, total antral follicle count, and mean ovarian volume did not differ significantly between groups (p > 0.05). When the major depressive disorder group’s first and final measurements were compared, follicle-stimulating hormone, estradiol, and endometrial thickness increased (p = 0.05, 0.0001, and 0.005, respectively), luteinizing hormone remained constant (p = 0.541), and anti-Müllerian hormone and total antral follicle count decreased (p = 0.024 and 0.042, respectively). Conclusions: In this study, we observed that the ovarian reserve test results of patients diagnosed with major depression for the first time after 6 months of SSRI treatment were significantly different from the results of the pretreatment and control groups.

Association between depression and the likelihood of having children: a nationwide register study in Finland

BACKGROUND

Depression may be associated with a lower likelihood of having children, but the findings are inconsistent. Previous population-based studies on this topic are limited.

OBJECTIVE

We examined associations between depression and the likelihood of having children, the number of children, and the parental age at first birth. We also evaluated whether these associations differ for people with low, middle, and high educational levels.

STUDY DESIGN

We conducted a nationwide register cohort study including all individuals born in Finland from 1960 to 1980 (n=1,408,951). Depression diagnoses were identified from the Care Register for Health Care (containing records of inpatient hospital episodes for the period 1969 to 2017 and of specialist outpatient visits for the period 1996 to 2017). The main outcomes-having biological children, the number of biological children, and the parental age at first birth-were identified from the Population Register of Statistics Finland and were defined either in the last year of the follow-up in 2017 or the last year alive or living in Finland. The association between depression and the likelihood of having children was examined using a logistic regression analysis; the association between depression and the number of children was evaluated using Poisson regression analyses, and the association between depression and the age at first birth was evaluated using a linear regression analysis. All analyses were conducted separately for men and women.

RESULTS

For both men and women, secondary care-treated depression was associated with a lower likelihood of having children (odds ratio, 0.66; 95% confidence interval, 0.64-0.67 for men; odds ratio, 0.84; 95% confidence interval, 0.82-0.85 for women) and with having fewer children (incidence rate ratio, 0.86; 95% confidence interval, 0.86-0.87 for men; incidence rate ratio, 0.96; 95% confidence interval, 0.96-0.96 for women). Depression was associated with a slightly lower parental age at first birth (33.1 vs 34.0; P<.001 for men; 31.3 vs 32.1; P<.001 for women). Dose-response associations between the severity of depression and a decreased likelihood of having children, as well as having fewer children, were observed. Earlier onset of depression was related to a lower likelihood of having children and to having fewer children. Among men and women in middle- and high-level educational groups, depression was associated with a lower likelihood of having children and with having fewer children. Among men with a low level of education, no associations were observed. Among women with a low level of education, depression was associated with a higher likelihood of having children and with having more children.

CONCLUSION

Both men and women with secondary care-treated depression have a lower likelihood of having children and have fewer children. Our findings suggest that depression may be one of the factors that contribute to the likelihood of having children, which should be addressed by policy makers.

Impact of Isolation measures on pregnancy outcome during the COVID-19 pandemic

This study aims to explore the impact of isolation measures implemented during the COVID-19 pandemic on childbirth outcomes in pregnant women. The design was a retrospective cohort study. The pregnant women during the outbreak lockdown and isolation from February 1 to April 30, 2020, were defined as the exposed population, and the pregnant women in the same time frame in 2019 as the non-exposed population. All data for the study were obtained from the National Health Care Data Platform of Shandong University. Generalized linear regression models were used to analyze the differences in pregnancy outcomes between the two study groups. A total of 34,698 pregnant women from Shandong Province, China in the data platform met the criteria and were included in the study. The proportions were 11.53% and 8.93% for macrosomia in the exposed and the non-exposed groups and were 3.47% and 4.37% for low birth weight infants, respectively, which were significantly different. They were 22.55% and 25.94% attributed to average exposed effect for macrosomia and low birth weight infants. Meanwhile, the mean weight and standard deviation of full-term infants in the exposure group were 3414.80 ± 507.43 g, which were significantly higher than in the non-exposed group (3347.22 ± 502.57 g, P < 0.001). The effect of exposure was significant in the third trimester. In conclusion, the isolation during the COVID-19 pandemic increases the birth weight of infants and the probability of macrosomia, regardless of which trimester in isolation a pregnant woman was, while the third trimester is the sensitive window of exposure. Our findings provide a basis for health care and policy development during pregnancy in COVID-19, due to COVID-19 still showing a pandemic trend around the world in 2022.

Confounding by Indication in Studies of Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are used worldwide as the first-line pharmacological treatment for depression. Although SSRI use can increase the risk of suicide, fractures, and infertility, the nature of these relationships is controversial. This review reports confounding by indication and confounding by severity for SSRI side effects in previously published observational studies. The PubMed and Google Scholar databases were searched for English-language articles published from 2005 to 2022. SSRIs are often prescribed for depressive symptoms, and depression is associated with an increased risk of side effects. Therefore, confounding by indication, whereby patients are selected for a particular treatment depending on their diagnosis or severity of illness, may lead to erroneous treatment conclusions, resulting in an adverse outcome. The side effects of SSRIs that can be considered due to confounding by indication or severity include suicide, fractures, infertility, atrial fibrillation, stroke, autism spectrum disorder, and congenital malformation. When prescribing SSRIs for depression, physicians must consider confounding by indication and severity in the management of side effects. In addition, medication discontinuation should be carefully considered when side effects occur during the treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The current situation and future directions for the study on time-to-pregnancy: a scoping review

Introduction

As problems associated with infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability. Here, we present a comprehensive overview of this topic.

Methods

Relevant qualitative and quantitative studies were identified by searching the Web of science and PubMed electronic databases. We included all literature, written in English, from inception to the 10th April 2021 providing the focus was on TTP. We conducted a narrative synthesis using thematic analysis.

Results

Traditional TTP-related study protocols include prospective and retrospective cohorts that provide a wealth of data to reveal potential influences on TTP. Thus far, a variety of factors have been shown to be associated with TTP in couples preparing for pregnancy, including basic demographic characteristics, menstrual status, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, there are inevitable epidemiological bias in the existing studies, including recall bias, selection bias and measurement bias. Some methodological advances have brought new opportunities to TTP research, which make it possible to develop precision interventions for population fertility. Future TTP studies should take advantage of artificial intelligence, machine learning, and high-throughput sequencing technologies, and apply medical big data to fully consider and avoid possible bias in the design.

Conclusion

There are many opportunities and future challenges for TTP related studies which would provide a scientific basis for the “precise health management” of the population preparing for pregnancy.

As the problems of infertility and population aging increase, there is a growing interest in the factors that cause a decline in human fertility. Time-to-pregnancy (TTP) is a good indicator with which to reflect human fecundability, and a longer TTP is known to reflect a reduction in fertility. Many original studies, with different designs, have used TTP to explore the factors that might influence fertility, including basic demographic characteristics, chronic disease status, environmental endocrine disruptor exposure, and lifestyles. However, much of the existing evidence is inconsistent and limited by various types of bias. This review provides a synopsis of recent TTP studies, and highlights new opportunities and future challenges.

Effects of the pandemic on women's reproductive health protective attitudes: a Turkish sample

OBJECTIVES

This descriptive, cross-sectional study was performed to examine the effects of the COVID-19 pandemic on women's reproductive health protective attitudes.

METHODS

The study sample included 306 women and data were collected through a web-based, online questionnaire. The data were collected using the Personal Information Form, Determination of Married Women's Reproductive Health Protective Attitudes Scale. Descriptive statistics, independent samples t-test, ANOVA test were used to assess the data.

RESULTS

The mean scores for Determination of Married Women's Reproductive Health Protective Attitudes Scale significantly differed in terms of education, employment status, income, health insurance and perceived health status (p < 0.05). A total of 69.3% of women had their first pregnancy at the agerange of 21-34 years, 17.6% of the women had four or more pregnancies, 55.6% of the women gave birth 1-3 times, 13.4% of the women gave birth at home and 57.8% of the women did not use modern family planning methods. A total of 23.2% of women experienced a problem with their reproductive organs during the pandemic, 70.6% of them did not present to a health center for their problems and 74.5% of these women did not present to a health center to avoid the risk of COVID-19 transmission. A total of 40.2% of women used the methods they already know at home to relieve their problems and 16.0% of the women used them edications previously prescribed by their doctors.

CONCLUSION

The pandemic negatively affects there productive health of women. In the COVID-19 pandemic, health policies should be planned in accordance with the continuation of reproductive health and sexual health services.

Predictive models of pregnancy based on data from a preconception cohort study

STUDY QUESTION

Can we derive adequate models to predict the probability of conception among couples actively trying to conceive?

SUMMARY ANSWER

Leveraging data collected from female participants in a North American preconception cohort study, we developed models to predict pregnancy with performance of ∼70% in the area under the receiver operating characteristic curve (AUC).

WHAT IS KNOWN ALREADY

Earlier work has focused primarily on identifying individual risk factors for infertility. Several predictive models have been developed in subfertile populations, with relatively low discrimination (AUC: 59-64%).

STUDY DESIGN, SIZE, DURATION

Study participants were female, aged 21-45 years, residents of the USA or Canada, not using fertility treatment, and actively trying to conceive at enrollment (2013-2019). Participants completed a baseline questionnaire at enrollment and follow-up questionnaires every 2 months for up to 12 months or until conception. We used data from 4133 participants with no more than one menstrual cycle of pregnancy attempt at study entry.

PARTICIPANTS/MATERIALS, SETTING, METHODS

On the baseline questionnaire, participants reported data on sociodemographic factors, lifestyle and behavioral factors, diet quality, medical history and selected male partner characteristics. A total of 163 predictors were considered in this study. We implemented regularized logistic regression, support vector machines, neural networks and gradient boosted decision trees to derive models predicting the probability of pregnancy: (i) within fewer than 12 menstrual cycles of pregnancy attempt time (Model I), and (ii) within 6 menstrual cycles of pregnancy attempt time (Model II). Cox models were used to predict the probability of pregnancy within each menstrual cycle for up to 12 cycles of follow-up (Model III). We assessed model performance using the AUC and the weighted-F1 score for Models I and II, and the concordance index for Model III.

MAIN RESULTS AND THE ROLE OF CHANCE

Model I and II AUCs were 70% and 66%, respectively, in parsimonious models, and the concordance index for Model III was 63%. The predictors that were positively associated with pregnancy in all models were: having previously breastfed an infant and using multivitamins or folic acid supplements. The predictors that were inversely associated with pregnancy in all models were: female age, female BMI and history of infertility. Among nulligravid women with no history of infertility, the most important predictors were: female age, female BMI, male BMI, use of a fertility app, attempt time at study entry and perceived stress.

LIMITATIONS, REASONS FOR CAUTION

Reliance on self-reported predictor data could have introduced misclassification, which would likely be non-differential with respect to the pregnancy outcome given the prospective design. In addition, we cannot be certain that all relevant predictor variables were considered. Finally, though we validated the models using split-sample replication techniques, we did not conduct an external validation study.

WIDER IMPLICATIONS OF THE FINDINGS

Given a wide range of predictor data, machine learning algorithms can be leveraged to analyze epidemiologic data and predict the probability of conception with discrimination that exceeds earlier work.

STUDY FUNDING/COMPETING INTEREST(S)

The research was partially supported by the U.S. National Science Foundation (under grants DMS-1664644, CNS-1645681 and IIS-1914792) and the National Institutes for Health (under grants R01 GM135930 and UL54 TR004130). In the last 3 years, L.A.W. has received in-kind donations for primary data collection in PRESTO from FertilityFriend.com, Kindara.com, Sandstone Diagnostics and Swiss Precision Diagnostics. L.A.W. also serves as a fibroid consultant to AbbVie, Inc. The other authors declare no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Sulfur mustard and biological ageing: A multisystem biological health score approach as an extension of the allostatic load in Sardasht chemical veterans

BACKGROUND

Mustard gas as a chemical weapon has been used in wars and its long-term side effects are substantial in the human body. This study was aimed to apply an extension of allostatic load, known as synthetic biological health score (BHS), including the wear-and-tear of four physiological systems (endocrine, inflammatory, cardiovascular and metabolic systems) and two organs (liver and kidney) to estimate biological aging caused by sulfur mustard (SM) gas poisoning.

METHODS

The plasma samples were prepared from two following groups of people; 1) 446 individuals exposed to SM gas in 1987. 2) 115 healthy members, at the same range of age and residence, as the non-exposed group. These people were chosen from the same patients' families and have not had any exposure to SM or pulmonary dysfunction. To estimate BHS, 18 blood-derived biomarkers of the mentioned systems and organs were measured and the relative contribution of many social and body parameters across the age groups was explored.

RESULTS

It was revealed, in BHS calculation, the cardiovascular system had the most effect. Also, in the SM group, BHS was significantly higher than in the control group. This feature has a positive correlation with physical parameter (BMI) and a negative correlation with social parameters (salary and educational levels).

CONCLUSION

The multisystem BHS could be useful in the evaluation of biological aging due to SM exposure. Social (education, good-paying job) and physical (BMI) parameters could influence BHS and the higher BHS indicates the progress of biological aging due to mustard gas.

Electronic Cigarettes and Fecundability: Results From a Prospective Preconception Cohort Study

Although electronic cigarette (e-cigarette) aerosol contains similar toxicants to combustible cigarettes, few studies have examined their influence on fecundability. We assessed the association between e-cigarette use and fecundability, overall and according to combustible cigarette smoking history, in a cohort of 4,586 North American women (aged 21-45 years) enrolled during 2017-2020 in Pregnancy Study Online, a Web-based prospective preconception study. Women reported current and former e-cigarette use on baseline and follow-up questionnaires, and they completed bimonthly follow-up questionnaires until self-reported pregnancy or censoring. Fecundability ratios and 95% confidence intervals were calculated using proportional probabilities models, controlling for potential confounders. Overall, 17% of women had ever used e-cigarettes and 4% were current users. Compared with never use of e-cigarettes, current e-cigarette use was associated with slightly lower fecundability (fecundability ratio = 0.84, 95% confidence interval (CI): 0.67, 1.06). Compared with current nonusers of e-cigarettes and combustible cigarettes, fecundability ratios were 0.83 (95% CI: 0.54, 1.29) for current dual users of e-cigarettes and combustible cigarettes, 0.91 (95% CI: 0.70, 1.18) for current e-cigarette users who were nonsmokers of combustible cigarettes, and 1.01 (95% CI: 0.85, 1.20) for nonusers of e-cigarettes who were current smokers of combustible cigarettes. Current e-cigarette use was associated with slightly reduced fecundability, but estimates of its independent and joint associations with combustible cigarette smoking were inconsistent and imprecise.

Residential proximity to major roads and fecundability in a preconception cohort

Supplemental Digital Content is available in the text.

Emerging evidence from animal and human studies indicates that exposure to traffic-related air pollution may adversely affect fertility.

Urinary selective serotonin reuptake inhibitors across critical windows of pregnancy establishment: a prospective cohort study of fecundability and pregnancy loss

OBJECTIVE

To prospectively investigate the association of selective serotonin reuptake inhibitor (SSRI) exposure through critical windows of pregnancy establishment with fecundability and pregnancy loss.

DESIGN

Prospective cohort study using longitudinal urine measurements of common SSRIs while women are actively trying to conceive.

SETTING

Four clinical sites.

PATIENT(S)

A total of 1,228 women without uncontrolled depression/anxiety, attempting natural conception while participating in a randomized trial of preconception-initiated low-dose aspirin.

INTERVENTIONS(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Urinary SSRIs (fluoxetine, sertraline, escitalopram/citalopram) were measured while trying to conceive and, for women who became pregnant, at weeks 0, 4, and 8 of pregnancy. Fecundability odds ratios and incidence of pregnancy loss and live birth were estimated.

RESULT(S)

A total of 172 women (14%) were exposed to SSRIs while trying to conceive. SSRI exposure was associated with 24% reduced fecundability, and accordingly, a nonsignificant 9% lower live birth incidence, with significantly lower live birth in fluoxetine-exposed women. SSRI exposure was not associated with subsequent pregnancy loss, whether exposure was before conception or at 0, 4, or 8 weeks of gestation, although estimates varied by specific SSRI drug.

CONCLUSION(S)

Women using SSRIs may have more difficulty becoming pregnant, and although SSRI exposure overall was not associated with pregnancy loss, fluoxetine deserves caution and future study.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00467363.

Potential risks of SARS-CoV-2 infection on reproductive health

The outbreak of 2019 novel coronavirus disease (COVID-19) has become a major pandemic threat worldwide. Such a public health emergency can greatly impact various aspects of people's health and lives. This paper focuses on its potential risks for reproductive health, including the reproductive system and its functioning, as well as gamete and embryo development, which could be affected by the virus itself, drug treatments, chemical disinfectants and psychological effects related to panic during the COVID-19 outbreak.

Selective Serotonin Reuptake Inhibitors and Fertility: Considerations for Couples Trying to Conceive

BACKGROUND

Depression and anxiety are prevalent disorders and are often treated with selective serotonin reuptake inhibitors (SSRIs). Infertility is also common among couples, and rates of depression and anxiety are elevated in this population, but the impact of SSRIs on fertility has received modest attention. This review explores the literature available on SSRIs, fertility, and infertility-treatment outcomes to assist clinicians in better counseling their patients.

METHODS

A literature search was performed using the search terms infertility, fertility, antidepressants, and SSRIs to identify studies that investigated the relationship between SSRI use and fertility or infertility-treatment outcomes.

RESULTS

Twenty relevant articles were identified, 16 of which were original research studies. The studies varied in design, quality, and outcome measures, limiting meta-analysis. The prevalence of antidepressant use ranged from 3.5%-10% in reproductive-age women, with infertile populations reporting less use. The two studies examining the impact of SSRIs in fertile women had conflicting results. Six of the seven studies in infertility patients found no significant association between SSRIs and treatment outcomes; three observed a trend, however, toward reduced fecundability or negatively influenced fertility biomarkers. One study found treatment increased pregnancy rates. In males, most studies were of relatively poor quality, though six of the seven studies found SSRIs to have an adverse effect on semen parameters.

CONCLUSIONS

There is insufficient evidence at present to propose that SSRIs reduce fertility or influence infertility-treatment outcomes. SSRIs may have an adverse impact on sperm quality, but further research is warranted.

Mental and somatic comorbidity of depression: a comprehensive cross-sectional analysis of 202 diagnosis groups using German nationwide ambulatory claims data

BACKGROUND

Depression is frequently accompanied by other mental disorders and various somatic diseases; however, previous comorbidity studies often relied on self-reported data and have not simultaneously assessed the entire spectrum of mental and somatic diagnoses. The aim is to provide a complete picture of mental and somatic comorbidity of depression in routine outpatient care in a high income country with a relatively well equipped health care system.

METHODS

Using ambulatory claims data covering 87% of the German population (age 15+), we designed a cross-sectional study by identifying persons diagnosed with mild, moderate and severe depression in 2017 (N = 6.3 million) and a control group matched 4:1 on sex, 5-year age group and region of residence (N = 25.2 million). Stratified by severity, we calculated the prevalence of 202 diagnosis groups included in the ICD-10 in persons with depression as compared to matched controls using prevalence ratios (PR).

RESULTS

Nearly all mental disorders were at least twice as prevalent in persons with depression relative to controls, showing a dose-response relationship with depression severity. Irrespective of severity, the three most prevalent somatic comorbid diagnosis groups were 'other dorsopathies' (M50-M54), 'hypertensive diseases' (I10-I15) and 'metabolic disorders' (E70-E90), exhibiting PRs in moderate depression of 1.56, 1.23 and 1.33, respectively. Strong associations were revealed with diseases of the central nervous system (i.e. multiple sclerosis) and several neurological diseases, among them sleep disorders, migraine and epilepsy, most of them exhibiting at least 2- to 3-fold higher prevalences in depression relative to controls. Utilization of health care was higher among depression cases compared to controls.

CONCLUSIONS

The present study based on data from nearly the complete adolescent and adult population in Germany comprehensively illustrates the comorbidity status of persons diagnosed with depression as coded in routine health care. Our study should contribute to increasing the awareness of the strong interconnection of depression with all other mental and the vast majority of somatic diseases. Our findings underscore clinical and health-economic relevance and the necessity of systematically addressing the high comorbidity of depression and somatic as well as other mental diseases through prevention, early identification and adequate management of depressive symptoms.

Antidepressant-Like Effects and Cognitive Enhancement of Coadministration of Chaihu Shugan San and Fluoxetine: Dependent on the BDNF-ERK-CREB Signaling Pathway in the Hippocampus and Frontal Cortex

Background

Fluoxetine (FLU) is the first-line and widely used medication for depression; however, FLU treatment is almost ineffective in 30%-40% of patients with depression. In addition, there are some problems in FLU treatment, such as delayed efficacy, large side effects, and poor tolerance. Chaihu Shugan San (CSS) is a classic and effective antidepressant Chinese herbal medicine that has been used in China for thousands of years. CSS or coadministration of CSS and FLU has become one of the most recommended methods in the treatment of depression in China. However, the specific pathways of CSS and coadministration of CSS and FLU for antidepressant are still unclear.

Objective

This study was designed to evaluate the antidepressant effects of CSS and coadministration of CSS and FLU.

Methods

The chronic unpredictable mild stress (CUMS) rat model was used to simulate depression. 120 healthy adult male Sprague-Dawley (SD) rats were randomly divided into seven groups: the control group, CUMS group, low-dose CSS group, high-dose CSS group, FLU group, coadministration of low-dose CSS and FLU group, and coadministration of high-dose CSS and FLU group. The rats in different groups were given different interventions. Then, the depression-like behavior and cognitive function were evaluated by the sucrose preference test (SPT), forced swimming test (FST), open field test (OFT), and Y-maze test. What is more, the antidepressant mechanism of CSS and coadministration of CSS and FLU were studied through BDNF mRNA, ERK mRNA, CREB mRNA, BDNF, p-ERK/ERK, and p-CREB/CREB levels in the hippocampus and frontal cortex by Western blot and RT-PCR.

Results

Compared with the CUMS group, CSS and coadministration of CSS and FLU could alleviate the depressive symptoms and improve cognitive function in CUMS rats (p < 0.05); CSS and coadministration of CSS and FLU could increase the expression of BDNF, p-CREB/CREB, p-ERK/ERK, and BDNF mRNA, CREB mRNA, and ERK mRNA in the hippocampus and frontal cortex (p < 0.05); CSS and coadministration of CSS and FLU could increase the expression of BDNF, p-CREB/CREB, p-ERK/ERK, and BDNF mRNA, CREB mRNA, and ERK mRNA in the hippocampus and frontal cortex (p < 0.05); CSS and coadministration of CSS and FLU could increase the expression of BDNF, p-CREB/CREB, p-ERK/ERK, and BDNF mRNA, CREB mRNA, and ERK mRNA in the hippocampus and frontal cortex (Discussion and Conclusion. Finally, we found that both CSS and coadministration of CSS and FLU play an antidepressant role, which may be due to the regulation of the BDNF/ERK/CREB signaling pathway in the hippocampus and frontal cortex. Among them, the coadministration of CSS and FLU can enhance the antidepressant effect of CSS or FLU alone, and the underlying mechanism needs further investigation.

Infertility and mental disorders in women. Communication 1

This paper presents the definition, epidemiology, etiological factors, and approaches to classifying infertility and describes the relationship between mental health and infertility in women. The problem of idiopathic infertility is analyzed from both obstetric/gynecological and psychiatric positions. The psychological factors influencing the reproductive function of a woman are disclosed. Mental health disorders potentiating infertility are considered. Attention is paid to that mental disorders are insufficiently and untimely diagnosed in women with reproductive disorders, that certain forms of psychopathology are masked by functional gynecological disorders, and that obstetricians/gynecologists have no specialized ideas of women's mental health, which may lead to unsuccessful infertility therapy.

The Herb-Drug Pharmacokinetic Interaction of Fluoxetine and Its Metabolite Norfluoxetine with a Traditional Chinese Medicine in Rats by LC-MS/MS

Background

Fluoxetine (FLU) is the first-line and widely used medication for depression. The combination of Chaihu Shugan san (CSGS) and FLU is commonly used to enhance antidepressant effects and reduce side effects.

Objective

The primary objective of this study was to investigate the potential pharmacokinetic effect of CSGS on FLU.

Materials and Methods

Thirty-two healthy adult male Sprague-Dawley (SD) rats were randomly divided into four groups, the fluoxetine group and multiple dose groups A, B, and C. The rats in the different groups were orally administered with a combination of FLU and different doses of CSGS for 14 d. On the fifteenth day, serial blood samples were taken from the caudal vein before the administration and at 0.25, 0.5, 0.75, 1, 2, 4, 6, 8, 10, 12, 24, 36, and 48 h after the administration. A liquid-liquid extraction method was applied to extract the analytes from serum. Then, the concentrations of FLU and its metabolite, norfluoxetine (NOF), were determined using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The pharmacokinetic parameters were calculated by DAS 3.2.8 program and compared by statistic analysis.

Results

Compared with the FLU group, the FLU and NOF area under the plasma concentration-time curve (AUC) (0–∞) in multiple dose group C was significantly increased, while the NOF AUCs (0–∞) in multiple dose group A and multiple dose group B were decreased. Compared with the FLU group, the NOF clearance (CL) in multiple dose group C was decreased, while the CL in multiple dose groups A and B was increased.

Discussion and Conclusion

There were some differences in pharmacokinetic parameters between the FLU group and multiple dose groups, and CSGS can affect the pharmacokinetics of fluoxetine.

Allostatic load, a measure of chronic physiological stress, is associated with pregnancy outcomes, but not fertility, among women with unexplained infertility

STUDY QUESTION

Among infertile women undergoing ovarian stimulation, is allostatic load (AL), a measure of chronic physiological stress, associated with subsequent fertility and pregnancy outcomes?

SUMMARY ANSWER

AL at baseline was not associated with conception, spontaneous abortion or live birth, however, it was significantly associated with increased odds of pre-eclampsia and preterm birth among women who had a live birth in the study.

WHAT IS KNOWN ALREADY

Several studies have linked AL during pregnancy to adverse outcomes including preterm birth and pre-eclampsia, hypothesizing that it may contribute to well-documented disparities in pregnancy and birth outcomes. However, AL biomarkers change over the course of pregnancy, raising questions as to whether gestational AL assessment is a valid measure of cumulative physiologic stress starting long before pregnancy. To better understand how AL may impact reproductive outcomes, AL measurement in the non-pregnant state (i.e. prior to conception) is needed.

STUDY DESIGN, SIZE, DURATION

A secondary data analysis based on data from 836 women who participated in Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS), a multi-center, randomized clinical trial of ovarian stimulation conducted from 2011 to 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Ovulatory women with unexplained infertility (ages 18-40) were enrolled and at baseline, biological and anthropometric measures were collected. AL scores were calculated as a composite of the following baseline variables determined a priori: BMI, waist-to-hip ratio, systolic blood pressure, diastolic blood pressure, dehydroepiandrosterone sulfate, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, C-reactive protein and HOMA score. Participants received ovarian stimulation for up to four cycles and if they conceived, were followed throughout pregnancy. We fit multi-variable logistic regression models examining AL (one-tailed and two-tailed) in relation to the following reproductive outcomes: conception, spontaneous abortion, live birth, pre-eclampsia, preterm birth and low birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

Adjusting for covariates, a unit increase in two-tailed AL score was associated with 62% increased odds of pre-eclampsia (OR: 1.62, 95% CI: 1.14, 2.38) 44% increased odds of preterm birth (OR: 1.44, 95% CI: 1.02, 2.08), and 39% increased odds of low birthweight (OR: 1.39, 95% CI: 0.99, 1.97). The relationship between AL and preterm birth was mediated by pre-eclampsia (P = 0.0003). In one-tailed AL analyses, associations were similar, but slightly attenuated. AL was not associated with fertility outcomes (conception, spontaneous abortion, live birth).

LIMITATIONS, REASONS FOR CAUTION

Results may not be generalizable to fertile women who conceive naturally or women with other types of infertility. Comparisons to previous, related work are difficult because variables included in AL composite measures vary across studies. AL may be indicative of overall poor health, rather than being specific to chronic physiological stress.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that chronic physiological stress may not impact success of ovarian stimulation, however, they confirm and extend previous work suggesting that AL is associated with adverse pregnancy outcomes. Physiological dysregulation due to chronic stress has been proposed as a possible mechanism underlying disparities in birth outcomes, which are currently poorly understood. Assessing biomarkers of physiological dysregulation pre-conception or in early pregnancy, may help to identify women at risk of adverse pregnancy outcomes, particularly pre-eclampsia.

STUDY FUNDING/COMPETING INTEREST(S)

Support for AMIGOS was provided by: U10 HD39005, U10 HD38992, U10 HD27049, U10 HD38998, U10 HD055942, HD055944, U10 HD055936 and U10HD055925. Support for the current analysis was provided by T32ES007271, R25HD075737, P30ES001247 and P30ES005022. This research was made possible by funding by American Recovery and Reinvestment Act. The content is solely the responsibility of the authors and does not necessarily represent the official views of NICHD, NIEHS or NIH. E.B., W.V., O.M., R.A., M.R., V.B., G.W.B., C.C., E.E., S.K., R.U., P.C, H.Z., N.S. and S.T. have nothing to disclose. R.L. reported serving as a consultant to Abbvie, Bayer, Kindex, Odega, Millendo and Fractyl and serving as a site investigator and receiving grants from Ferring. K.H. reported receiving grants from Roche Diagnostics and Ferring. R.R. reported a grant from AbbVie. M.D. reported being on the Board of Directors of and a stockholder in Advanced Reproductive Care.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov number: NCT01044862.

Psychosocial Aspects of Fertility and Assisted Reproductive Technology

Psychosocial aspects of fertility, infertility, and assisted reproductive technology (ART) can significantly impact patients' sense of self-identity and personal agency, mental well-being, sexual and marital relationships, reproductive efficiency, compliance with treatment, and pregnancy outcomes. Research is needed to understand how stress, anxiety, depression, mood disorders, and psychotropic medications impact fertility and infertility treatment. The psychosocial implications of ART on our society include a shift toward older maternal age at conception, the complexities of third-party reproduction, and consideration for the psychological and socioeconomic barriers to receiving care. Clinicians must understand, screen for, and identify couples struggling with the psychological and social aspects of fertility and ART.

Case-based care for pre-existing or new-onset mood disorders in patients undergoing infertility therapy

The inability to conceive is an immensely stressful event in a woman's life. Thus, it is no surprise that women with infertility have twice the rates of depressive symptoms as women without infertility. Incidence of depression in the general female population is approximately 20% compared to almost 40% in infertile females. Based on this information, we expect many individuals with infertility to have pre-existing mood disorders requiring ongoing treatment. In addition, we expect a subset of women to develop a mood disorder during infertility treatment due to related stressors. The reproductive endocrinology team must understand the impact of stress on pregnancy outcomes, the types of treatment options, and the safety and use of various medications. The goal of this case-based commentary is to summarize information on the relationship between stress and infertility and to offer a guide for a range of treatment options that include non-pharmacologic and pharmacologic therapies.

Major depression, antidepressant use, and male and female fertility

OBJECTIVE

To determine if maternal major depression (MD), antidepressant use, or paternal MD are associated with pregnancy outcomes after non-IVF fertility treatments.

DESIGN

Cohort study.

SETTING

Clinics.

PATIENT(S)

Participants in two randomized trials: PPCOS II (clomiphene citrate versus letrozole for polycystic ovary syndrome), and AMIGOS (gonadotropins versus clomiphene citrate versus letrozole for unexplained infertility).

INTERVENTION(S)

Female and male partners completed the Patient Health Questionnaire (PHQ-9). Female medication use was collected. PHQ-9 score ≥10 was used to define currently active MD.

MAIN OUTCOME MEASURE(S)

Primary outcome: live birth.

SECONDARY OUTCOMES

pregnancy, first-trimester miscarriage. Poisson regression models were used to determine relative risks after adjusting for age, race, income, months trying to conceive, smoking, and study (PPCOS II versus AMIGOS).

RESULT(S)

Data for 1,650 women and 1,608 men were included. Among women not using an antidepressant, the presence of currently active MD was not associated with poorer fertility outcomes (live birth, miscarriage), but rather was associated with a slightly increased likelihood of pregnancy. Maternal antidepressant use (n = 90) was associated with increased risk of miscarriage, and male partners with currently active MD were less likely to achieve conception.

CONCLUSION(S)

Currently active MD in the female partner does not negatively affect non-IVF treatment outcomes; however, currently active MD in the male partner may lower the likelihood of pregnancy. Maternal antidepressant use is associated with first-trimester pregnancy loss, which may depend upon the type of antidepressant.

CLINICAL TRIAL REGISTRATION NUMBERS

NCT00719186 and NCT01044862.

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.

Selective serotonin reuptake inhibitors for depression in pregnancy

Perinatal depression is associated with a high risk of morbidity and mortality and may have long-term consequences on child development. The US Preventive Services Task Force has recently recognized the importance of identifying and treating women with depression in the perinatal period. However, screening and accessing appropriate treatment come with logistical challenges. In many areas, there may not be sufficient access to psychiatric care, and, until these resources develop, the burden may inadvertently fall on obstetricians. As a result, understanding the risks of perinatal depression in comparison with the risks of treatment is important. Many studies of selective serotonin reuptake inhibitors in pregnancy fail to control for underlying depressive illness, which can lead to misinterpretation of selective serotonin reuptake inhibitor risk by clinicians. This review discusses the risks and benefits of selective serotonin reuptake inhibitor treatment in pregnancy within the context of perinatal depression. Whereas selective serotonin reuptake inhibitors may be associated with certain risks, the absolute risks are low and may be outweighed by the risks of untreated depression for many women and their offspring.