Impact of a group mind/body intervention on pregnancy rates in IVF patients

The clinical effectiveness of the Mind/Body Program for Infertility on wellbeing and assisted reproduction outcomes: a randomized controlled trial in search for active ingredients

STUDY QUESTION

Does the Mind/Body Program for Infertility (MBPI) perform better, due to certain distinctive elements, than a partly matched support group in improving the wellbeing and medically assisted reproduction (MAR) outcomes of women with elevated distress levels in a clinical setting?

SUMMARY ANSWER

While robust enhancements occurred in the wellbeing overall, the cognitive behavioural and formalized stress management elements of the MBPI allowed a significantly stronger improvement in trait anxiety, but not in other mental health and MAR outcomes, compared with a support group.

WHAT IS KNOWN ALREADY

Mind-body psychological programmes adjacent to MAR have been found to improve women's mental states and possibly increase chances of pregnancy. However, not enough is known about the programme's effectiveness among patients with elevated distress levels in routine clinical settings, nor is it clear which of its particular ingredients are specifically effective.

STUDY DESIGN, SIZE, DURATION

A pre-post design, single-centre, randomized controlled trial was performed between December 2019 and October 2022 (start and end of recruitment, respectively). The sample size (n = 168) was calculated to detect superiority of the MBPI in improving fertility-related quality of life. Randomization was computer-based, with random numbers concealing identities of patients until after allocation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The trial was conducted at a large university teaching hospital. A total of 168 patients were randomly assigned to the mind-body (MBPI) group (n = 84) and the fertility support (FS) control group (n = 84). Patients received a 10-week, 135-min/week group intervention, with the FS group following the same format as the MBPI group, but with a less restricted and systematic content, and without the presumed effective factors. The number of patients analysed was n = 74 (MBPI) and n = 68 (FS) for post-intervention psychological outcomes, and n = 54 (MBPI) and n = 56 (FS) for pregnancy outcomes at a 30-month follow-up.

MAIN RESULTS AND THE ROLE OF CHANCE

Significant improvements occurred in both groups in all psychological domains (adjusted P < 0.001), except for treatment-related quality of life. Linear mixed-model regression analysis did not reveal significantly greater pre-post improvements in the MBPI group than in the FS group in fertility-related quality of life (difference in differences (DD) = 4.11 [0.42, 7.80], d = 0.32, adjusted P = 0.124), treatment-related quality of life (DD = -3.08 [-7.72, 1.55], d = -0.20, adjusted P = 0.582), infertility-specific stress (DD = -2.54 [-4.68, 0.41], d = -0.36, adjusted P = 0.105), depression (DD = -1.16 [3.61, 1.29], d = -0.13, adjusted P = 0.708), and general stress (DD = -0.62 [-1.91, 0.68], d = -0.13, adjusted P = 0.708), but it did show a significantly larger improvement in trait anxiety (DD = -3.60 [-6.16, -1.04], d = -0.32, adjusted P = 0.042). Logistic regression showed no group effect on MAR pregnancies, spontaneous pregnancies, or live births.

LIMITATIONS, REASONS FOR CAUTION

The follow-up only covered MAR-related medical outcomes and no psychological variables, and their rates were not equal in the two groups. Biological factors other than age, aetiology, and duration of infertility may have confounded the study results. Loss to follow-up was between 5% and 10%, which may have led to some bias.

WIDER IMPLICATIONS OF THE FINDINGS

The psychologically and medically heterogeneous sample, the normal clinical setting and the low attrition rate all raise the external validity and generalizability of our study. The MBPI works not only in controlled conditions, but also in routine MAR practice, where it can be introduced as a cost-effective, low-intensity psychological intervention, within the framework of stepped care. More studies are needed to further identify its active ingredients.

STUDY FUNDING/COMPETING INTEREST(S)

The authors received no financial support for the research, authorship, and/or publication of this article. The authors have no conflict of interest to disclose.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04151485.

TRIAL REGISTRATION DATE

5 November 2019.

DATE OF FIRST PATIENT’S ENROLMENT

15 December 2019.

The effect of supportive counseling on self-esteem of infertile women after in vitro fertilization (IVF) failure: a randomized controlled trial study

BACKGROUND

The unsuccessful treatment of infertility can lead to heightened levels of negative emotions, which are often associated with various psychological consequences. These consequences may include a decrease in self-confidence, feelings of loneliness, reduced self-esteem, and even discontinuation of treatment. Therefore, it is crucial to implement interventions that can help improve these consequences for women who have experienced IVF failure. The present study aimed to examine the effect of supportive counseling on self-esteem of infertile women after IVF failure.

METHODS

this randomized clinical trial study was conducted on 63 infertile women after IVF failure, referred to Milad Infertility Center in Mashhad in 2021. In the intervention group, the researcher provided individual supportive counseling sessions. These sessions took place over a span of four weeks, with each session lasting 60 min (One session every week). Data collection was conducted both before and one month after the study using Eysenck self-esteem Questionnaire. Data were analyzed using SPSS25, as well as statistical tests such as chi-square, independent t-test, Paired t-test and Mann-Whitney tests. A significance level of less than 5% was considered.

RESULTS

The study found no significant difference in mean scores of self-esteem between the two groups before the study (p = 0.823). However, after one month, the intervention group had significantly higher self-esteem scores (24.3 ± 18.55) compared to the control group (21.74 ± 5.62) (p = 0.043) Moreover, Based on the Within-group comparison, there was a 2.43 ± 3.24 point increase in self-esteem scores of the intervention group after one month, while the control group showed a -0.33 ± 3.72 point decrease.

CONCLUSION

Supportive counseling was found to be effective in improving self-esteem following IVF failure. As a result, it can be recommended as an effective, affordable, and low-risk counseling approach for women who have experienced IVF failure. By offering supportive counseling, it is possible to help prevent and alleviate the psychological consequences associated with IVF failure.

TRIAL REGISTRATION

This research project was registered at the Iranian Registry of Clinical Trials with code IRCT20210407050883N1- Date of registration 2021-05-25.

The effect of hypnofertility on fertility preparedness, stress, and coping with stress in women having in vitro fertilization: A randomized controlled trial

BACKGROUND

In vitro fertilisation is a stressful process for women. Hypnofertility is a method that can be used to relieve stress during in vitro fertilisation. It is based on an effective and strong body-mind interaction, as well as balancing the brain and body via positive words and thoughts.

OBJECTIVE

This study aimed to investigate the effects of hypnofertility on fertility preparedness, stress, and coping with stress in women undergoing in vitro fertilisation.

METHODS

This study was conducted with a randomised controlled trial design. Hypnofertility-based relaxation, visualisation, imagination, and affirmation techniques were applied to the intervention group at four stages, and no initiative was applied to the women in the control group. The Clinical Trial Registration number of the study is NCT04755270.

RESULTS

After the hypnofertility method, the mean score of the intervention group in the positive feelings and thoughts subscale of the Fertility Preparedness Scale was higher than that of the control group (p < 0.05). The hypnofertility method caused a significant decrease in the level of infertility stress in the intervention group, and the intervention group used the active-confronting and passive-avoidance methods more than control group did (p < 0.05).

CONCLUSION

The hypnofertility method increased the levels of preparedness for fertility, reduced stress levels and provided effective strategies to cope with stress.

Yoga and Lifestyle Changes: A Path to Improved Fertility - A Narrative Review

Infertility, a widespread medical condition affecting numerous couples globally, persists as a challenge despite advances in assisted reproductive technologies (ARTs), often burdened by financial, physical, and emotional strains. Complementary and alternative approaches, notably yoga, have garnered attention for potentially enhancing fertility outcomes. Studies reveal yoga's influence on factors contributing to infertility, including reduced oxidative stress (OS) and oxidative DNA damage (ODD). OS, linked to mutagenic base formation, higher malondialdehyde levels, abnormal methylation, and altered gene expression, can impair sperm genome integrity. Yoga's efficacy is evident in lowering OS, positively affecting signal transmission, gene expression, and physiological systems. Furthermore, yoga has a positive impact on addressing the dysregulation of apoptosis, resulting in improved processes such as spermatogenesis, sperm maturation, and motility, while also reducing DNA fragmentation. OS correlates with genome-wide hypomethylation, telomere shortening, and mitochondrial dysfunction, contributing to genome instability. Yoga and meditation significantly reduce OS and ODD, ensuring proper reactive oxygen levels and preserving physiological systems. The review explores potential mechanisms underlying yoga's positive impact on infertility, including enhanced blood flow, reduced inflammation, relaxation response, and modulation of the hypothalamic-pituitary-adrenal axis. Furthermore, a comprehensive review of the literature reveals substantial evidence supporting the positive effects of yoga on infertility factors. These include oxidative stress (OS), oxidative DNA damage (ODD), epigenetic changes, hormonal balance, ovarian function, menstrual irregularities, and stress reduction. In summary, yoga emerges as a promising adjunctive therapy for infertility, demonstrating the potential to mitigate key factors influencing reproductive success. Although preliminary evidence indicates the positive effects of yoga on infertility, further clinical research is imperative to define specific benefits, molecular mechanisms associated, optimal protocols, and long-term effects in infertility treatment plans.

Consulting patients and providers of assisted reproductive technologies to inform the development of a group psychological intervention for women with infertility

Objective

To consult providers and women patients of Assisted Reproductive Technologies regarding their preferences for the format, duration and content in the development of a group psychological intervention.

Methods

Providers and current and past women patients of Assisted Reproductive Technologies completed an online cross-sectional survey comprising items about session content, number, frequency, timing, format, delivery mode and inclusion of experiential practice of psychological strategies to promote well-being.

Results

Eight providers, 51 current women patients and 51 women who previously underwent Assisted Reproductive Technologies participated. Sixty-two percent of participants indicated a group psychological program would be helpful; and 34% thought it may be helpful. Face-to-face was the preferred delivery mode (42%). Seventy-one percent preferred 60-min sessions held fortnightly (64%), with six sessions most acceptable (24%). Most respondents (74%) felt group participants would likely complete at-home practice. Detailed thematic content from participants highlighted a complex range of consumer challenges. Relevant behaviour change techniques were verified, with those to be included identified as: feedback and monitoring, regulation, self belief, reward and threat, natural consequences, identity, support, shaping knowledge, and comparison of outcomes.

Conclusion

Providers and patients were supportive of the development of a group psychological intervention to provide support for women undergoing Assisted Reproductive Technologies.

Innovation

The results of this study provide insight informing the co-design of a group psychological program for women with infertility.

Efficacy of psychosocial interventions for pregnancy rates of infertile women undergoing in vitro fertilization: a systematic review and meta-analysis

PURPOSE

This study aimed to analyze the efficacy of psychosocial interventions for improving pregnancy rates in infertile women undergoing in vitro fertilization (IVF) treatment through a systematic review and meta-analysis.

METHODS

Twelve studies were included in the meta-analysis. To estimate the effect size, a meta-analysis of the studies was performed using RevMan 5.3. The possibility of publication bias was evaluated using funnel plots and Egger's method.

RESULTS

A statistically significant effect size (standardized mean difference [SMD] = 1.39; 95% confidence interval [CI] = 1.11-1.71; p = 0.004; I² = 19%) was found for the 12 studies that investigated the effects of psychosocial interventions on clinical pregnancy rates. The psychosocial interventions that had a significant effect on pregnancy rates were mind-body interventions (SMD = 1.37; 95% CI = 1.01-1.85; p = 0.040; I² = 0%) and cognitive behavioral therapy (SMD = 2.19; 95% CI = 1.17-4.13; p = 0.010).

CONCLUSIONS

The results suggest that psychosocial interventions affect pregnancy rates. Moreover, they indicate that mind-body interventions and cognitive behavioral therapy are beneficial for improving the pregnancy outcome in infertile women undergoing IVF.

Evaluating group psychological interventions for mental health in women with infertility undertaking fertility treatment: A systematic review and meta-Analysis

ABSTRACTWe conducted a systematic review and meta-analysis of the published literature concerning the effectiveness of group psychological interventions in improving anxiety, depression, marital dissatisfaction, fertility quality of life and stress, and pregnancy outcomes of women with infertility, participating in fertility treatment. A search of five databases yielded 1603 studies; 30 articles met inclusion criteria, and computations of effect sizes ensued (Hedges' g and Odds Ratios (OR)). The total sample comprised 2752 participants, with 1279 participants receiving group intervention and 1473 participants in the comparison group. Group psychological interventions reduced depression (Hgw =  -1.277; 95% CI = [-1.739- -0.815]; p =  0.000), anxiety (Hgw = -1.136, 95% CI [-1.527- -0.744]; p =  0.000), fertility stress (Hgw = -0.250, 95% CI [-0.388- -0.122]; p =  0.000), and marital dissatisfaction (Hgw = -0.938; 95% [CI -1.455- -0.421]; p =  0.000), and pregnancy rates improved (OR = 2.422 95% CI [2.037-2.879]; p = 0.000). No improvement was observed regarding fertility quality of life (Hgw = 0. 144; 95% CI [-0.176- 0.463]; p =  0.379). Our findings highlight that participation in group psychological intervention improved the mental health, fertility stress and pregnancy rates of women with infertility.

Integrative medicine utilization among infertility patients

BACKGROUND

Previous research suggests that some women are using integrative and complementary holistic approaches to optimize their own health and treat infertility. We aimed to determine patterns of integrative medicine use among those seeking fertility optimization by 1) Characterizing patterns of integrative medicine use to increase fertility; 2) Identifying demographic predictors associated with such integrative medicine use; and 3) Exploring cultural and religious influences on use of integrative medicine.

METHODS

Cross-sectional self-reported survey data were collected from 1460 patients presenting to an academic fertility center in Chicago, Illinois. Variables were described with univariate frequencies and proportions, unadjusted bivariate comparisons were made between patient-level factors and reported integrative modality use, and multivariable logistic regression evaluated the strength of covariate-adjusted predictors of reported integrative medicine utilization.

RESULTS

80.4% of respondents reported using at least one integrative medicine modality to treat infertility (Acupuncture: 38.5%, Yoga: 27.6%, Massage: 25.8%, Meditation: 16.7%, and Herbal supplements: 18.5%). Diet therapy was the most frequently utilized modality (74.0%) followed by body therapy (45.2%), traditional alternative medicine (42.0%), mind therapy (32.1%), and senses therapy (23.0%). Any integrative medicine modality use was 4.03 times more likely among Hindu respondents compared to participants that identified as not religious (95% CI 1.2-13.7, p < 0.026). Significant differences in specific modality use were observed by race, religious affiliation, age, income, and insurance coverage.

CONCLUSION

Most infertility patients in our study reported using at least one integrative medicine modality to help them conceive. Utilization was associated with age of participant, religious affiliation, annual income, and insurance coverage. Further research is needed to assess the impact of integrative medicine utilization on patient quality of life and outcomes.

Perceived stress and markers of ovarian reserve among subfertile women

RESEARCH QUESTION

Is self-reported psychological stress associated with markers of ovarian reserve among subfertile women?

DESIGN

Observational study of women (n = 520) seeking fertility care at the Massachusetts General Hospital who enrolled in the Environment and Reproductive Health study between 2005 and 2019. Women completed the short version of the validated PSS4, which assesses psychological stress. Ovarian reserve markers included AFC and circulating serum levels of day-3 FSH, with AMH assessed in a subset of participants (n = 185).

RESULTS

Higher total PSS4 scores were negatively associated with AFC and serum AMH levels. Analyses adjusted for age, BMI, race, smoking, education, physical activity and type of infertility diagnosis. Women in the second and third tertiles of stress had lower AFC (13.3, 95% CI 12.7 to 13.8; and 13.5, 95% CI 13.0 to 14.1) compared with women in the lowest tertile of psychological stress score (14.3, 95% CI 13.8 to 14.9, both P < 0.05). Women in the second and third tertiles of total PSS4 scores also had lower mean serum AMH compared with women in the lowest tertile (2.99, 95% CI 2.24 to 3.74), and (2.99 95% CI 2.22 to 3.76) versus (3.94 95% CI 3.23 to 4.64). These associations varied by several socioeconomic factors, and were observed among women who were younger, belonging to minority races, with a college degree or with annual household income less than $100,000.

CONCLUSIONS

Higher perceived stress was negatively associated with AFC and serum AMH levels. These associations varied by several socioeconomic factors.

Effectiveness of psychological interventions on pregnancy rates in infertile women undergoing assisted reproductive technologies: a meta-analysis of randomised controlled trials

The purpose of this study was to assess the effects of psychological interventions on the pregnancy rates of infertile women undergoing assisted reproductive technology (ART). Using the electronic databases PubMed, EM Base, Cochrane Library, WOS, CNKI, WanFang Data, CSTJ, and CBM, a systematic literature search was conducted in the second week of August 2019. Randomized controlled trials (RCTs) on the effect of psychological interventions on the pregnancy rate of infertile women undergoing assisted reproductive technology were collected. There is no time limit for this search setting. The language is limited to Chinese or English. Two investigators independently screened the literature, extracted data, and assessed the risk of bias of the included studies, and then used Revman5.3 and STATA16.0 software for meta-analysis. A total of 25 randomized controlled trials were included in this meta-analysis, including 2098 patients in the experimental group and 2075 patients in the control group. There was a significant difference in the pregnancy rate between the two groups [RR=1.31, 95%CI(1.22,1.40)]. Subgroup analysis showed that this is also true of infertile women of different nationalities, different intervention timing and format. However, different psychological interventions may indeed have different effects. Current evidence suggests that psychological interventions may improve pregnancy rates in infertile women undergoing assisted reproductive technology. Limited by the quantity and quality of included studies, the above conclusions need to be verified by more high-quality studies. Our PROSPERO registration number is: CRD42019140666.

The effect of self-compassion-based programs for infertility (SCPI) on anxiety and depression among women pursuing fertility treatment: a three-armed, randomised controlled trial

PURPOSE

To examine the effects of self-compassion training using videos (SCV) versus self-compassion training using digital stories (SC-DS) as compared to a control group (CG) on reducing anxiety and depression symptoms among women pursuing fertility treatment.

METHODS

A three-armed, randomised controlled trial randomly assigned 200 eligible women to SCV(n = 65), SC-DS (n = 67), and CG (n = 68). All three randomised groups completed questionnaires immediately after randomisation (T1), after completing the interventions (T2), and 10 weeks after the interventions (T3). A generalised estimation equation was used with the intention-to-treat analysis. The primary outcomes were anxiety and depression, and secondary outcomes were self-compassion, infertility self-efficacy, and pregnancy rates.

RESULTS

SCV and SC-DS participants experienced a significant reduction in anxiety and depression from T1 to T2 and from T1 to T3 (p < 0.001; d > 0.8). SCV and SC-DS participants experienced a significant increase in self-compassion and infertility self-efficacy from T1 to T2 and from T1 to T3 (p < 0.001; d > 0.8). SC-DS seemed to be superior to SCV and CG. No significant differences were found among the three groups in pregnancy rates. SCV and SC-DS participants rated self-compassion training programs positively and said they would highly recommend them to others.

CONCLUSION

These findings suggest that SCV and SC-DS were effective in reducing anxiety and depression and increasing self-compassion and infertility self-efficacy. Online flexible self-compassion interventions could make psychological support more accessible for women undergoing fertility treatment in resource-poor settings.

TRIAL REGISTRATION

(ChiCTR2100046065) [12/04/2021].

The effect of the approach based on the Neuman Systems Model on stress and coping in women receiving intrauterine insemination treatment: A randomized controlled trial

This randomized controlled study was conducted to determine the effect of the approach based on the Neuman Systems Model (NSM) on stress and coping in women receiving intrauterine insemination (IUI) treatment. The study participants consisted of 62 women. Data was collected using a personal information form, the COMPI Fertility Problem Stress Scale, and the COMPI Coping Strategy Scale. Women in the intervention group had lower stress levels in their personal and marital domain post-test median scores than those in the control group. Women in the intervention group also had lower active-avoidance coping method and higher meaning-based coping method post-test mean scores. The NSM-based approach is beneficial in decreasing stress and positively affects women to cope with stress. Both infertility and its treatments are stressful. Health care professionals have important responsibilities for reducing the stress of infertile women and strengthening infertile women's ability to cope. The NSM-based approach is considered to have positive effects on stress and the ability of women to cope who receive IUI treatments. In addition, IUI is a widely applied method which is used before switching to assisted reproductive techniques. If this treatment fails, the stress coping techniques learned during this treatment can be used in later treatment processes. We conducted this study to investigate the effects of the NSM-based approach on stress and coping strategies in women receiving IUI treatment.

Efficacy of psychological interventions for mental health and pregnancy rates among individuals with infertility: a systematic review and meta-analysis

BACKGROUND

Depression and anxiety are highly prevalent among individuals struggling with infertility. Thus, numerous psychological interventions have been adapted to infertility, with the aim of relieving distress as well as increasing pregnancy rates.

OBJECTIVE AND RATIONALE

This systematic review and meta-analysis aimed to identify all randomized controlled trials (RCTs) evaluating the effect of psychological interventions on infertility-related distress and pregnancy rates among individuals and/or couples with infertility and to analyse their overall effect. It also sought to examine potential treatment moderators, including intervention length, format and therapeutic approach.

SEARCH METHODS

An electronic search of 11 databases, including MEDLINE, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials, was performed for studies published until January 2022. The inclusion criteria were RCTs conducted on humans and published in English. Psychological outcomes of interest included anxiety, depression, infertility-related distress, wellbeing and marital satisfaction. The Cochrane Risk of Bias tool was used to assess study quality, and the Grading of Recommendations Assessment, Development and Evaluation was used to assess the overall quality of the research evidence.

OUTCOMES

There were 58 RCTs in total, including 54 which included psychological outcomes and 21 which assessed pregnancy rates. Studies originated from all regions of the world, but nearly half of the studies were from the Middle East. Although a beneficial effect on combined psychological outcomes was found (Hedge's g = 0.82, P < 0.0001), it was moderated by region (P < 0.00001) such that studies from the Middle East exhibited large effects (g = 1.40, P < 0.0001), while the effects were small among studies conducted elsewhere (g = 0.23, P < 0.0001). Statistically adjusting for study region in a meta-regression, neither intervention length, therapeutic approach, therapy format, nor participant gender (P > 0.05) moderated the effect of treatment. A beneficial treatment effect on pregnancy (RR (95% CI) = 1.25 (1.07-1.47), P = 0.005) was not moderated by region, treatment length, approach or format (P > 0.05). Largely due to the lack of high quality RCTs, the quality of the available evidence was rated as low to moderate.

WIDER IMPLICATIONS

This is the first meta-analysis of RCTs testing the effect of psychological interventions on infertility-related distress and pregnancy rates. These findings suggest that in most regions of the world, psychological interventions are associated with small reductions in distress and modest effects on conception, suggesting the need for more effective interventions. These findings must be considered in light of the fact that the majority of the included RCTs were deemed to be at high risk of bias. Rigorously conducted trials are needed.

Doing today’s work today: real-time data recording and rolling audit in an IVF clinic

The assisted conception unit at Sheffield Teaching Hospital NHS Foundation Trust provides in vitro fertilisation treatment. A team of seven embryologists provides a routine clinical laboratory service, involving culture and storage of embryos. This requires a series of management and statutory data administration and communication tasks.

We were aware that these were often done many days after clinical tasks, resulting in delays sending patient correspondence and unavailability of clinical notes for multidisciplinary team (MDT) cycle-review meetings. Embryologists also complained that transcribing data were time-consuming and duplicated across our IDEAS software, spreadsheets and paper.

We process-mapped our processes and gathered staff views on problems and potential solutions. The baseline average total cycle time (TCT) for completion of all administrative steps was around 17 days; data administration time (DAT, data ‘touch time’) was around 30 min per patient.

We embarked on this Quality Improvemen (QI) project to reduce waste in TCT and DAT, and to have data available for patient communication and MDT deadlines. Exploration of IDEAS’ capabilities led to progressive realisation of how much could be transferred to this single data system, removing a lot of off-putting redundancy. Through this we developed a ‘to-be’ vision of all data entry being real time, as part of the clinical ‘jobs’. We conducted five Plan–Do–Study–Act cycles plus two more to test performance and sustainability as changes bedded-in and an external constraint disappeared.

We have cut TCT to 0 or 1 days and DAT to around 18 min. All project metrics are reliably within our targets, and data are now always available for timely patient letters and the MDT. Other benefits include easy access for all staff to patient records and removal of paper and spreadsheets. A further, unanticipated, benefit was a switch from a tedious 2 yearly storage tank audit to a more-agreeable and safer rolling audit.

The Use of Integrative Medical Services to Address Psychological Concerns around Infertility in an Indian Academic Medical Centre

Background

Alternative and complementary therapies have been gaining popularity as ways to reduce anxiety in patients.

Aim:

This study aimed to assess whether yoga and meditation could decrease the severity of anxiety in Indian women diagnosed with infertility Study.

Study Setting and Design:

This was a retrospective data analysis of anxiety score of 354 women undergoing treatment at a tertiary infertility hospital between January 2016 and December 2018.

Materials and Method:

Women participated in group yoga, meditation and counselling therapy intervention during their treatment period. A self-reported questionnaire that used the Generalised Anxiety Disorder-7 criteria measured the participants’ severity of anxiety at the start of and again at the end of the intervention.

Statistical Analysis:

Demographic analysis and a two-tailed paired t-test were applied between groups.

Results:

The results indicated that there was a statistically significant mean reduction (7.3 ± 2.7) in the anxiety scores of the participants between entry (12.94 ± 2.65) and following exposure (5.39 ± 1.99) to the intervention (P < 0.0001). The mean reduction in scores remained similar between participants who received ≤6 sessions (7.50 ± 2.68) and participants who received >6 sessions (7.10 ± 2.64) (P > 0.05). Among the participants that experienced mild anxiety at baseline (n = 43), 72.1% (n = 31) reported experiencing minimal anxiety following the intervention (P < 0.0001). Among those that experienced moderate anxiety at baseline (n = 213), 32.4% (n = 69) reported experiencing minimal anxiety post-intervention (P < 0.0001). Participants who expressed severe anxiety at baseline (n = 94, 26.6%), reported experiencing minimal anxiety (13.8% [n = 13)], mild anxiety (81.9% [n = 77]) and moderate anxiety (4.3% [n = 4]) after exposure to the intervention (P < 0.0001). None of the participants reported experiencing severe anxiety post-intervention.

Conclusion:

The benefits of alternative anxiety-reduction therapies for women diagnosed with infertility have been demonstrated in this study. These therapies can be used to complement the routine treatment of such patients.

Emotional Support for Infertility Patients: Integrating Mental Health Professionals in the Fertility Care Team

Patients seeking fertility treatment are at risk of experiencing psychological distress, with both women and men reporting higher levels of depression and anxiety during infertility treatment than patients in the general population. Multiple professional societies, fertility care providers, and patients have advocated for integrating mental health providers in the treatment of infertile patients in order to provide comprehensive patient-centered care. Research with other patient populations shows that embedding mental health professionals into clinics provides the greatest benefit to patients. Despite acknowledging the importance of mental health in infertility care, professional societies, such as ASRM and ESHRE, have not universally standardized recommendations or methods for imbedding mental health providers in the fertility team. This review article aims to serve as a resource for providers and patients to appraise the available literature on the importance of embedding mental health providers into the fertility treatment team and discusses feasible methods to develop this comprehensive care team.

Acupuncture as Treatment for Female Infertility: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

The effects of acupuncture on female infertility remain controversial. Also, the variation in the participant, interventions, outcomes studied, and trial design may relate to the efficacy of adjuvant acupuncture. The aim of the study is to systematically evaluate the efficacy and safety of acupuncture for female with infertility and hopefully provide reliable guidance for clinicians and patients.

Methods

We searched digital databases for relevant studies, including EMBASE, PubMed, Cochrane Library, and Web of Science, and the Cochrane Library up to April 2021, for randomized controlled trials (RCTs) evaluating the effects of acupuncture on women undergoing IVF and other treatment. We included studies with intervention groups using acupuncture and control groups consisting of no acupuncture or sham (placebo) acupuncture. Primary outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR). Meta-regression and subgroup analysis were conducted on the basis of ten prespecified covariates to investigate the variances of the effects of adjuvant acupuncture on pregnancy rates and the sources of heterogeneity. Results: Twenty-seven studies with 7676 participants were included. The results showed that the intervention group contributes more in outcomes including live birth rate (RR = 1.34; 95% CI (1.07, 1.67); P < 0.05), clinical pregnancy rate (RR = 1.43; 95% CI (1.21, 1.69); P < 0.05), biochemical pregnancy rate (RR = 1.42; 95% CI (1.05, 1.91); P < 0.05), ongoing pregnancy rate (RR = 1.25; 95% CI (0.88, 1.79); P < 0.05), adverse events (RR = 1.65; 95% CI (1.15, 2.36); P < 0.05), and implantation rate (MD = 1.19; 95% CI (1.07, 1.33); P < 0.05) when compared with the control group, and the difference is statistically significant. In terms of the number of oocytes retrieved, good-quality embryo rate, miscarriages, and ectopic pregnancy rate, the difference between the acupuncture group and the control group was not statistically significant. Conclusions: Our analysis finds a benefit of acupuncture for outcomes in women with infertility, and the number of acupuncture treatments is a potential influential factor. Given the poor reporting and methodological flaws of existing studies, studies with larger scales and better methodologies are needed to verify these findings. More double-blind RCTs equipped with high quality and large samples are expected for the improvement of the level of evidence.

A Systematic Review of Interventions Targeting Infertility-Related Distress: A Search for Active Ingredients

Various psychological interventions have been developed to combat negative mental and physical health effects of infertility. However, it is unknown if there are common elements, or "active ingredients," between interventions. This review examined which active ingredients were present among psychological interventions targeting the impacts of infertility. Using a predetermined search strategy, 72 articles and 22 active ingredients were identified. Relaxation/stress management was found to be the most common treatment element. Future research should investigate which active ingredients are most effective for reducing infertility-related stressors so clinicians and researchers can create and implement treatments that contain essential and effective components.

Preconception lifestyle advice for people with infertility

BACKGROUND

Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of people with infertility having a baby. However, no guideline is available about what preconception advice should be offered. It is important to determine what preconception advice should be given to people with infertility and to evaluate whether this advice helps them make positive behavioural changes to improve their lifestyle and their chances of conceiving.

OBJECTIVES

To assess the safety and effectiveness of preconception lifestyle advice on fertility outcomes and lifestyle behavioural changes for people with infertility.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, trial registers, Google Scholar, and Epistemonikos in January 2021; we checked references and contacted field experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), randomised cross-over studies, and cluster-randomised studies that compared at least one form of preconception lifestyle advice with routine care or attention control for people with infertility.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary effectiveness outcomes were live birth and ongoing pregnancy. Primary safety outcomes were adverse events and miscarriage. Secondary outcomes included reported behavioural changes in lifestyle, birth weight, gestational age, clinical pregnancy, time to pregnancy, quality of life, and male factor infertility outcomes. We assessed the overall quality of evidence using GRADE criteria.

MAIN RESULTS

We included in the review seven RCTs involving 2130 participants. Only one RCT included male partners. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care for women with infertility and specific lifestyle characteristics. The evidence was of low to very low-quality. The main limitations of the included studies were serious risk of bias due to lack of blinding, serious imprecision, and poor reporting of outcome measures. Preconception lifestyle advice on a combination of topics versus routine care or attention control Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.79 to 1.10; 1 RCT, 626 participants), but the quality of evidence was low. No studies reported on adverse events or miscarriage. Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behavioural changes: body mass index (BMI) (mean difference (MD) -1.06 kg/m², 95% CI -2.33 to 0.21; 1 RCT, 180 participants), vegetable intake (MD 12.50 grams/d, 95% CI -8.43 to 33.43; 1 RCT, 264 participants), alcohol abstinence in men (RR 1.08, 95% CI 0.74 to 1.58; 1 RCT, 210 participants), or smoking cessation in men (RR 1.01, 95% CI 0.91 to 1.12; 1 RCT, 212 participants). Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of women with adequate folic acid supplement use (RR 0.98, 95% CI 0.95 to 1.01; 2 RCTs, 850 participants; I² = 4%), alcohol abstinence (RR 1.07, 95% CI 0.99 to 1.17; 1 RCT, 607 participants), and smoking cessation (RR 1.01, 95% CI 0.98 to 1.04; 1 RCT, 606 participants), on low quality evidence. No studies reported on other behavioural changes. Preconception lifestyle advice on weight versus routine care Studies on preconception lifestyle advice on weight were identified only in women with infertility and obesity. Compared to routine care, we are uncertain whether preconception lifestyle advice on weight affects the number of live births (RR 0.94, 95% CI 0.62 to 1.43; 2 RCTs, 707 participants; I² = 68%; very low-quality evidence), adverse events including gestational diabetes (RR 0.78, 95% CI 0.48 to 1.26; 1 RCT, 317 participants; very low-quality evidence), hypertension (RR 1.07, 95% CI 0.66 to 1.75; 1 RCT, 317 participants; very low-quality evidence), or miscarriage (RR 1.50, 95% CI 0.95 to 2.37; 1 RCT, 577 participants; very low-quality evidence). Regarding lifestyle behavioural changes for women with infertility and obesity, preconception lifestyle advice on weight may slightly reduce BMI (MD -1.30 kg/m², 95% CI -1.58 to -1.02; 1 RCT, 574 participants; low-quality evidence). Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice affects the percentage of weight loss, vegetable and fruit intake, alcohol abstinence, or physical activity. No studies reported on other behavioural changes. Preconception lifestyle advice on alcohol intake versus routine care Studies on preconception lifestyle advice on alcohol intake were identified only in at-risk drinking women with infertility. We are uncertain whether preconception lifestyle advice on alcohol intake affects the number of live births (RR 1.15, 95% CI 0.53 to 2.50; 1 RCT, 37 participants; very low-quality evidence) or miscarriages (RR 1.31, 95% CI 0.21 to 8.34; 1 RCT, 37 participants; very low-quality evidence). One study reported on behavioural changes for alcohol consumption but not as defined in the review methods. No studies reported on adverse events or other behavioural changes. Preconception lifestyle advice on smoking versus routine care Studies on preconception lifestyle advice on smoking were identified only in smoking women with infertility. No studies reported on live birth, ongoing pregnancy, adverse events, or miscarriage. One study reported on behavioural changes for smoking but not as defined in the review methods.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.

The association between psychosocial interventions and fertility treatment outcome: A systematic review and meta-analysis

OBJECTIVE

Does psychosocial intervention affect pregnancy outcomes in women and couples undergoing assisted reproductive technology (ART) treatment?.

DESIGN

A systematic review and meta-analysis of Randomized Controlled Trials (RCTs) evaluating the efficacy of psychosocial intervention on pregnancy outcomes in women and couples undergoing ART treatment. The primary outcome was Pregnancy Rates. Secondary outcomes were Live Birth Rate (LBR) and Abortion Rate (AR).

MATERIALS AND METHODS

Databases searched were Pubmed, PsycINFO, Embase, CINAHL and The Cochrane Library. 1439 records were screened, 15 were eligible and included in the meta-analyses (N = 2434). Data was extracted using the Covidence software. Effect sizes were reported as relative risks with 95% confidence-intervals and p-values.

RESULTS

A positive association was found between psychosocial intervention and pregnancy rates (RR = 1.12 CI=(1.01;1.24), p = 0.033). Long-duration interventions and mind-body intervention types were found to be associated with increased pregnancy rates (RR 1.21, CI= (1.04;1.43), p = 0.017) and (RR = 1.25, CI= (1.00;1.55), p = 0.046) respectively. Q and I²tests suggested no to low heterogeneity. Funnel plots, Trim and Fill analyses and Fail-safe numbers were applied to adjust for possible publication bias.

CONCLUSIONS

Our findings suggest a positive association between psychosocial interventions, particularly long-duration interventions, and pregnancy rate in infertile women and couples in ART treatment. The findings are in line with findings from other reviews and meta-analyses exploring the same topic. More good quality RCTs need to be performed to increase the quality of guidance for infertile women and couples. The effect of psychosocial interventions on LBR and AR remain to be examined.

Clinical Applications of Telemedicine in Gynecology and Women's Health

Telemedicine and telehealth (TM/TH) are the 2 terms used interchangeably focusing on the delivery of health care services at a long distance using telecommunication technology. TM/TH has several gynecologic applications, including the well-woman visits, preventive care, preconception counseling, family planning including contraception and medical abortion, infertility workup, teleradiology, cervical cancer screening and colposcopy, mental health, and telesurgery. The goals of TM/TH are not only improving quality of health care in patients and building a virtual community of physicians but also increasing convenience, efficacy, and decreasing medical cost. In gynecology, TM/TH plays an important role, especially in well-woman care.

Research-supported mobile applications and internet-based technologies to mediate the psychological effects of infertility: a review

Infertility is a chronic condition commonly accompanied by psychological and emotional distress. A significant contributor to the discontinuation of infertility treatment is the psychological burden of treatment. Many individuals experiencing infertility report high levels of depression and anxiety. Unfortunately, barriers to traditional individual and couples counselling include stigmatization, finances, trepidation, challenges of travel and uncertainty. New technology, such as mobile applications and internet-based programmes, may be a feasible option for reducing the emotional distress of infertility diagnoses and treatments. This review focuses on current and developing technologies designed to decrease emotional distress in individuals with infertility.

Does Hypnofertility-Based Nursing Care Affect Cortisol Levels, Fertility Preparedness, and Pregnancy Outcomes in Women Undergoing In Vitro Fertilization? A Randomized Controlled Trial

This study used Hypnofertility-based interventions to determine whether these interventions would lead to increased fertility preparedness and pregnancy outcomes and decreased cortisol levels in women undergoing In Vitro Fertilization (IVF) treatment. This randomized, controlled, prospective study was conducted from November 2017 through March 2019 in 61 Turkish women with unexplained infertility (intervention group: 30, control group: 31). Hypnofertility-based nursing care included affirmations, visualization, imagination, and relaxation from the first day of treatment until the day of the pregnancy test. The Fertility Preparedness Scale, a saliva sample for cortisol level, and the pregnancy test results were used for data collection. Hypnofertility-based nursing care decreased the cortisol levels of women in the intervention group compared to that in the control group (p = 0.00). Though fertility preparedness was higher in the intervention group, the difference was not statistically significant (p = 0.13). Although interventions relieved the women during the treatment process, there was no anticipated effect on pregnancy outcomes (p = 0.75). Hypnofertility-based nursing care significantly reduce the cortisol levels, suggesting that the intervention helped women relax.

The effect of mind-body interventions on psychological and pregnancy outcomes in infertile women: a systematic review

Preliminary evidence suggests that mind-body interventions, including mindfulness-based interventions and yoga, may be effective in reducing mental health difficulties and psychological distress in infertile patients undergoing fertility treatments. We systematically reviewed and synthesized current medical literature of the effectiveness of mind-body interventions in reducing the severity of psychological distress and improving marital function and pregnancy outcomes in infertile women/couple. Databases including PsychINFO, PubMed, EMBASE, and the Cochrane Library were searched for relevant studies. Manual searches were conducted in relevant articles. We included 12 studies that met the inclusion criteria. Four studies were randomized controlled trials (RCT), 4 non-randomized controlled trial (NRCT), and 4 uncontrolled studies (UCT). Participation in a mind-body intervention was associated with reduced anxiety trait and depression scores. The reduction was of low or moderate amplitude in most studies. Our review offers evidence for the effectiveness of mind-body interventions in reducing anxiety state and depression in infertile women and a possible improvement in pregnancy rate. Further RCTs with a precise timing of intervention are needed.

Human immunodeficiency: Extragonadal comorbidities of infertility in women

Introduction

Infertility is mediated by several changes system‐wide. These changes are likely to cause other systems‐related pathologies, such as changes in systemic immune response, particularly inflammatory response can lead to cardiovascular diseases and breast cancer.

Methods

These morbidities can exist immediately or years after the diagnosis of infertility. Therefore, understanding the mechanism is important to move toward therapeutic interventions.

Results

Several extragonadal pathologies are reported due to infertility, as well as, how these might also contribute to reproductive disabilities. Detailed evidence are still not present that can give stronger result.

Conclusion

This review highlights some of the most frequent comorbidities that are seen in infertile women, hence requiring a need for complete clinical screening and care, as well as diagnosis and treatment in early stages.

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.

Effectiveness of two guided self-administered interventions for psychological distress among women with infertility: a three-armed, randomized controlled trial

STUDY QUESTION

What is the effect of two guided self-administered interventions on psychological distress in women undergoing IVF or ICSI?

SUMMARY ANSWER

A brief mindfulness intervention significantly reduced depression and improved sleep quality, while the gratitude journal intervention showed no significant effect on any outcome variables.

WHAT IS KNOWN ALREADY

Mindfulness and gratitude journal interventions have been found to be beneficial in reducing negative affect and improving well-being. However, there are very few mental health professionals who implement such interventions in low- and middle-income countries. Therefore, two guided self-administered interventions for women with infertility were designed to help them cope with their psychological distress.

STUDY DESIGN, SIZE, DURATION

A three-armed, randomized controlled trial was designed to evaluate the mindfulness and gratitude journal interventions for women undergoing IVF/ICSI. Between May 2016 and November 2017, at the reproductive center in a public hospital, 234 women were randomly assigned to the brief mindfulness group (BMG, n = 78), gratitude journal group (GJG, n = 78) or control group (CG, n = 78). The inclusion criteria were being a woman undergoing her first cycle of IVF, having at least junior middle school education and having no biological or adopted children.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Female infertility patients (n = 346) were approached, and 112 did not meet the inclusion criteria. All three randomized groups completed questionnaires on the day of down-regulation (T1), the day before embryo(s) transfer (T2), and 3 days before the pregnancy test (T3). The BMG completed four sessions and listened to a 20-minute audio daily, including guided mindfulness breathing and body scan. The GJG completed four sessions and wrote three gratitude journals daily. The CG received routine care. A generalized estimating equation was used in an intention-to-treat analysis. The primary outcome was depression. Secondary outcomes were anxiety, sleep quality, infertility-related stress, mindfulness and gratitude.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants of the BMG showed decreased depression (mean difference (MD) = −1.69, [−3.01, −0.37], d = 0.44) and improved sleep quality (MD = −1.24, [−1.95, −0.39], d = 0.43) compared to the CG, but the effect was not significant for anxiety, Fertility Problem Inventory totals, mindfulness, gratitude scores or pregnancy rates. The BMG showed a significant reduction in depression and improvement in sleep quality between T1 and T2, a continuous significant reduction between T1 and T3 and no reduction between T2 and T3. There were no significant effects on any of the variables for the GJG.

LIMITATIONS, REASONS FOR CAUTION

The inclusion criteria may result in bias because some participants with low education were excluded and only women with infertility were included. A low compliance rate occurred in the gratitude journals group. Moreover, men were not included in this study. Further research should consider including spouses of the target population.

WIDER IMPLICATIONS OF THE FINDINGS

The brief mindfulness intervention was beneficial in decreasing depression and improving sleep quality. Implementation of guided self-administered mindfulness could make the psychological counseling service more accessible for patients with infertility in resource-poor settings. The efficiency and feasibility of the gratitude journal intervention needs to be investigated further.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the National Social Science Foundation (17BSH054). The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-16008452.

TRIAL REGISTRATION DATE

9 May 2016

DATE OF FIRST PATIENT’S ENROLMENT

15 May 2016.

The effect of yoga on stress level in infertile women

PURPOSE

The aim of the present study was to examine the effects of planned yoga practices on stress levels in infertile women.

DESIGN AND METHODS

This randomized controlled study included 128 volunteer women who were registered at a private in vitro fertilization (IVF) clinic and received infertility treatment. The patients in the experimental group took part in the yoga program twice a week for 6 weeks. A personal information form and The Copenhagen Multi-center Psychosocial Infertility (COMPI) Fertility Problem Stress Scale were used to collect data.

FINDINGS

The differences between the mean scores of the control and experimental groups on the COMPI Fertility Problem Stress Scale at pre- and posttests were statistically significant (P < 0.05).

PRACTICE IMPLICATIONS

Because yoga practices may be effective in reducing stress in infertile women, these applications can be performed before treatment. It may reduce patients' stress and increase the success of the treatment. These findings indicate that yoga could reduce stress levels in infertile women.

Mindfulness-based program for stress reduction in infertile women: Randomized controlled trial

Infertile women often experience chronic stress, which may have a negative impact on general well-being and may increase the burden of infertility. In this open-label, parallel, randomized controlled trial, infertile women aged 18-50 years (median 37 years) were assigned to an 8-week mindfulness-based program (MBP) or no intervention. The primary outcome was stress severity measured by the Lipp's Stress Symptoms Inventory (ISSL). Data were analyzed by modified intent-to-treat principle, which included all cases available to follow-up regardless of adherence to the intervention (62 participants from the MBP group and 37 from the control group). The median number of symptoms of chronic stress recorded in the past month decreased from six (interquartile range 2 to 9) before the MBP to two (interquartile range 1 to 4) after the intervention (p < 0.001, repeated measures analysis of variance with Time × Group interaction). Depressive symptoms also decreased after MBP, whereas general well-being improved (p < 0.01 for both outcomes). Hair cortisol and serum brain-derived neurotrophic factor (BDNF) did not change significantly between preintervention and postintervention. None of the outcomes changed significantly in the control group. MBP was effective in reducing stress and depressive symptoms while increasing general well-being in infertile women.

Perceived Stress and Fecundability: A Preconception Cohort Study of North American Couples

While some epidemiologic studies support the hypothesis that stress can adversely affect fertility, few prospective studies have assessed the association in couples from the general population. We used data from Pregnancy Study Online, a web-based preconception cohort study of pregnancy planners from the United States and Canada (2013-2018), to examine the association between women's and men's perceived stress levels prior to conception and fecundability. Women (aged 21-45 years) and their male partners (aged ≥21 years) who were attempting conception without fertility treatment were eligible. We measured perceived stress using the 10-item Perceived Stress Scale (PSS). We ascertained pregnancy information using bimonthly follow-up questionnaires of female participants. We followed 4,769 couples until self-reported pregnancy, initiation of fertility treatment, loss to follow-up, or 12 menstrual cycles of attempt time, whichever came first. We used proportional probabilities regression models to estimate fecundability ratios and 95% confidence intervals, adjusting for potential confounders. Higher PSS scores among the women were associated with slight reductions in fecundability (comparing PSS scores of ≥25 vs. <10, fecundability ratio = 0.87, 95% confidence interval: 0.74, 1.02). PSS scores among the men were not substantially associated with fecundability.

The relationship between stress and infertility

The relationship between stress and infertility has been debated for years. Women with infertility report elevated levels of anxiety and depression, so it is clear that infertility causes stress. What is less clear, however, is whether or not stress causes infertility. The impact of distress on treatment outcome is difficult to investigate for a number of factors, including inaccurate self-report measures and feelings of increased optimism at treatment onset. However, the most recent research has documented the efficacy of psychological interventions in lowering psychological distress as well as being associated with significant increases in pregnancy rates. A cognitive-behavioral group approach may be the most efficient way to achieve both goals. Given the distress levels reported by many infertile women, it is vital to expand the availability of these programs.

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.

Stress has a direct and indirect effect on eating pathology in infertile women: avoidant coping style as a mediator

Patient-perceived stress and avoidance-oriented coping strategies are mental health risk factors well documented within the infertility literature. Relatedly, these factors are associated with maladaptive eating behaviours known to influence reproductive functioning. This study aims to investigate the interconnection between perceived stress, avoidant coping style and eating pathology in infertile women, and to determine whether avoidant coping style mediates the relationship between stress and eating pathology. A multicentre cross-sectional study of 416 women (aged 20-47 years) was completed. Women were assessed on the Eating Disorder Examination Questionnaire, the Perceived Stress Scale and the Brief COPE. Correlational matrices, principal components analysis and structural equation modelling were used to develop a measurement model to test the avoidant coping style mediation hypothesis. Results showed that perceived stress had a direct effect on maladaptive eating behaviours [β = 0.21; 95% confidence interval (CI) 0.065-0.346; P = 0.005]. Furthermore, a statistically significant indirect effect between perceived stress and maladaptive eating via avoidant coping style was also observed (β = 0.14; 95% CI = 0.017-0.267; P = 0.018), indicating partial mediation. These findings highlight that both perceived stress and avoidant coping style are important psychotherapy targets to consider in infertile women presenting with eating pathology.

A Partnership and Coping Enhancement Program for Couples Undergoing In Vitro Fertilization Treatment: An Intervention Study

This is a feasibility study to examine the effects of a partnership and coping enhancement program (PCEP) on improving the psychological well-being and marital functions of couples undergoing in vitro fertilization treatment. A total of 100 couples were recruited consecutively and assigned to a PCEP intervention group or a routine care control group. The couples in the PCEP group received an additional face-to-face, couple-based, 90-minute session on enhancing partnership and coping on the day of the embryo transfer (ET). The outcome measures were assessed at baseline (T0), 10 days after the ET (T1), and one month after the ET (T2). The level of anxiety of the women was lower in the intervention than in the control group at T1. Significant improvements in partnership and dyadic coping were seen in women at T2. The men of infertile couples reported a significant improvement in the scores for partnership at T2. The PCEP had no significant effects on marital satisfaction and marital adjustment for both the females and males of the infertile couples. The findings indicated that the PCEP is feasible and acceptable. Before a larger simple-size randomized controlled trial with participants drawn from multiple reproductive medical centers is conducted to further confirm its effectiveness.

Role of Mental Health Practitioner in Infertility Clinics: A Review on Past, Present and Future Directions

A large body of literature has emerged over the past four decades which highlights the need to address emotional needs in infertility and integrates psychological services within routine fertility care. Evidenced-based guidelines in most countries propagate that the mental health expert (MHP) plays a vital role as a team member in reducing the impact of infertility on the lives of patients, across all stages of treatment. In accordance with these global developments, inclusion of psychosocial care in fertility treatments is an upcoming trend in our nation. This review article brings forth the traditional role of MHP in infertility, compares patient-centered care with counseling, and elaborates on the guidelines on determinants of patient needs and suitability for structured psychological interventions. It also highlights the evidence-based studies on the application of psychotherapy in infertility.

Association of ß-hCG Surveillance with Emotional, Reproductive, and Sexual Health in Women Treated for Gestational Trophoblastic Neoplasia

BACKGROUND

To assess the emotional, reproductive, sexual health, and relationship concerns of women treated for gestational trophoblastic neoplasia (GTN) and examine associations with ß-hCG surveillance.

METHODS

This institutional review board approved study surveyed GTN survivors (n = 51) who received treatment from 1996 to 2008. Fifty-one women, including those actively followed or formerly treated, were surveyed. The survey consisted of background/medical information, the Reproductive Concerns Scale, the Female Sexual Function Index, an item from the Abbreviated Dyadic Adjustment Scale, the Center for Epidemiologic Studies-Depression scale, the Menopausal Symptom Checklist, the Impact of Life Events Scale, and exploratory items.

RESULTS

Mean age at diagnosis was 37.1 years; 41.6 years at study enrollment. Twenty-seven patients (56%) expressed worry about treatment harm and 30 (60%) about recurrence. Twenty percent reported significant depressive symptomatology. Mild cancer-related distress, reproductive concerns, sexual dysfunction, and bothersome menopausal symptoms were noted. Nineteen patients (40%) rated their ß-hCG surveillance worry as "high." Among patients who attempted conception after treatment, 3 of 12 (25%) succeeded in the ß-hCG high-worry group versus 13 of 19 (68%) in the ß-hCG low-worry group. Survivors with high ß-hCG worry had greater reproductive concerns than those with low worry (p = 0.002) and reported less sexual desire (p = 0.025). There was no difference in the number of low-worry versus high-worry participants in active surveillance (p = 0.09).

CONCLUSION

Our study suggests that cancer-specific distress, sexual health, and reproductive concerns continue to impact women years after treatment. High worry about ß-hCG surveillance is negatively associated with the emotional well-being of GTN survivors and possibly influences reproductive attempts and success.

Insights from clinical experience in treating IVF poor responders

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

The Partnership and Coping Enhancement Programme for couples undergoing in vitro fertilization treatment: the development of a complex intervention in China

PURPOSE

Couples as dyads suffer from the diagnosis of infertility and related treatment. These couples commonly experience emotional and physical pain and tension in their marital lives. The purpose of this study is to report on the process of developing a potentially feasible and effective complex intervention for couples undergoing in vitro fertilization treatment in China.

METHODS

The Medical Research Council (MRC) framework for developing and evaluating the complex intervention was adopted to guide the development of the Partnership and Coping Enhancement Programme (PCEP). In developing the PCEP, three steps were taken, namely, (1) identifying evidence by conducting literature reviews, a concept analysis and a qualitative study; (2) identifying/developing a theory-in this case, a preliminary Endurance with Partnership Conceptual Framework (P-EPCF) was proposed; and (3) modelling the process and outcomes of the PCEP.

RESULTS

The PCEP that was developed is targeted mainly at the domains of the partnership mediators of stress in the P-EPCF. It consists of two sections-partnership and coping-and will be delivered to infertile couples on the day of embryo transfer. The main focuses of the programme are to facilitate mutual sharing and support in infertile couples, and to improve their individual and dyadic coping strategies while undergoing IVF treatment, especially in the period when they are waiting for the results of a pregnancy test and after the disclosure of a negative treatment outcome. The programme is couple-based, consisting of experience sharing, psychoeducation, meditation exercise, skill practise and supplemental written materials.

CONCLUSIONS

The Partnership and Coping Enhancement Programme (PCEP) for couples undergoing in vitro fertilization treatment was developed according to the guideline of the MRC framework. It is recommended that a pilot study be conducted to evaluate its feasibility and to model the process and outcomes of the programme.

Psychological and educational interventions for subfertile men and women

BACKGROUND

Approximately one-fifth of all subfertile couples seeking fertility treatment show clinically relevant levels of anxiety, depression, or distress. Psychological and educational interventions are frequently offered to subfertile couples, but their effectiveness, both in improving mental health and pregnancy rates, is unclear.

OBJECTIVES

To assess the effectiveness of psychological and educational interventions for subfertile couples on psychological and fertility treatment outcomes.

SEARCH METHODS

We searched (from inception to 2 April 2015) the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 2, 2015), MEDLINE, EMBASE, PsycINFO, EBSCO CINAHL, DARE, Web of Science, OpenGrey, LILACS, PubMed, and ongoing trials registers. We handsearched reference lists and contacted experts in the field.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs), cluster randomised trials, and cross-over trials (first phase) evaluating the effectiveness of psychological and educational interventions on psychological and fertility treatment outcomes in subfertile couples.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial risk of bias and extracted data. We contacted study authors for additional information. Our primary outcomes were psychological measures (anxiety and depression) and fertility rates (live birth or ongoing pregnancy). We assessed the overall quality of the evidence using GRADE criteria.As we did not consider the included studies to be sufficiently similar to permit meaningful pooling, we summarised the results of the individual studies by presenting the median and interquartile range (IQR) of effects as well as the minimum and maximum values. We calculated standardised mean differences (SMDs) for continuous variables and odds ratios (ORs) for dichotomous outcomes.

MAIN RESULTS

We included 39 studies involving 4925 participants undergoing assisted reproductive technology. Studies were heterogeneous with respect to a number of factors, including nature and duration of interventions, participants, and comparator groups. As a result, we judged that pooling results would not result in a clinically meaningful estimate of a treatment effect. There were substantial methodological weaknesses in the studies, all of which were judged to be at high risk of bias for one or more quality assessment domains. There was concern about attrition bias (24 studies), performance bias for psychological outcomes (27 studies) and fertility outcomes (18 studies), and detection bias for psychological outcomes (26 studies). We therefore considered study-specific estimates of intervention effects to be unreliable. Thirty-three studies reported the outcome mental health. Only two studies reported the outcome live birth, and both of these had substantial attrition. One study reported ongoing pregnancy, again with substantial attrition. We have combined live birth and ongoing pregnancy in one outcome. Psychological outcomesStudies utilised a variety of measures of anxiety and depression. In all cases a low score denoted benefit from the intervention.SMDs for anxiety were as follows: psychological interventions versus attentional control or usual care: median (IQR) = -0.30 (-0.84 to 0.00), minimum value -5.13; maximum value 0.84, 17 RCTs, 2042 participants; educational interventions versus attentional control or usual care: median = 0.03, minimum value -0.38; maximum value 0.23, 4 RCTs, 330 participants.SMDs for depression were as follows: psychological interventions versus attentional control or usual care: median (IQR) = -0.45 (-0.68 to -0.08), minimum value -3.01; maximum value 1.23, 12 RCTs, 1160 participants; educational interventions versus attentional control or usual care: median = -0.33, minimum value -0.46; maximum value 0.17, 3 RCTs, 304 participants. Fertility outcomesWhen psychological interventions were compared with attentional control or usual care, ORs for live birth or ongoing pregnancy ranged from minimum value 1.13 to maximum value 10.05. No studies of educational interventions reported this outcome.

AUTHORS' CONCLUSIONS

The effects of psychological and educational interventions on mental health including distress, and live birth or ongoing pregnancy rates is uncertain due to the very low quality of the evidence. Existing trials of psychological and educational interventions for subfertility were generally poorly designed and executed, resulting in very serious risk of bias and serious inconsistency in study findings. There is a need for studies employing appropriate methodological techniques to investigate the benefits of these treatments for this population. In particular, attentional control groups should be employed, that is groups receiving a treatment that mimics the amount of time and attention received by the treatment group but is not thought to have a specific effect upon the participants, in order to distinguish between therapeutic and non-specific effects of interventions. Where attrition cannot be minimised, appropriate statistical techniques for handling drop-out must be applied. Failure to address these issues in study design has resulted in studies that do not provide a valid basis for answering questions about the effectiveness of these interventions.

Addressing the emotional barriers to access to reproductive care

Health care professionals make the medical care of infertility patients a priority, with the goal of achieving a singleton pregnancy for each. Patients who never seek out care, who do not return for treatment after the diagnostic workup, or who drop out of treatment are rarely noticed. Yet this is the outcome for the majority of patients, and the primary reason after financial for treatment termination is the emotional aspect. Attending to the psychological needs of our patients must become a higher priority, to provide all patients true access to care.

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

OBJECTIVE

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

DESIGN

Prospective longitudinal cohort study.

SETTING

Five fertility practices.

PATIENT(S)

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

INTERVENTION(S)

No interventions administered.

MAIN OUTCOME MEASURE(S)

Depression, anxiety, and MHS information provision and use.

RESULT(S)

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

CONCLUSION(S)

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

The effects of psychosocial interventions on the mental health, pregnancy rates, and marital function of infertile couples undergoing in vitro fertilization: a systematic review

PURPOSE

The purpose of this study was to examine the effects of psychosocial interventions on the mental health, pregnancy rates, and marital function of infertile couples undergoing in vitro fertilization (IVF), as determined through RCT studies.

METHODS

Using the electronic databases PubMed, EMBase, Cochrane Library, CINAHL, PsycInfo, and CAJ, a systematic literature search was conducted in July 2015. MeSH terms, key words, and free words such as "infertility," "fertilization in vitro," "psychotherapy," "intervention," "anxiety," "depression," and "marital satisfaction" were used to identify all potential studies. The quality of the studies that were included was assessed using the risk of bias assessment tool developed by the Cochrane Back Review Group. Descriptive analysis was adopted to synthesize the results.

RESULTS

A total of 20 randomized controlled trials were included in this review. There were reports of positive effects on the anxiety levels, pregnancy rates, or marital function of infertile couples in six studies that adopted different psychosocial approaches, including mind body intervention (Eastern body-mind-spirit, Integrative body-mind-spirit, and Mind/body intervention), cognitive behavioral therapy, group psychotherapy, and harp therapy. However, there were methodological or practical issues related to measurement points and attrition rates in these studies. None of these interventions were found to be efficacious in relieving the depression or stress of individuals or couples undergoing IVF treatment. None of the included studies tackled or measured the mental health status of the couples during the most stressful time of waiting for the pregnancy results of their treatment.

CONCLUSIONS

A complex intervention, based on sound evidence, should be developed targeting both females and males of infertile couples undergoing IVF treatment, particularly during the stressful period of waiting for the results of the pregnancy test result and after failed cycles.

Aging and the environment affect gamete and embryo potential: can we intervene?

Optimal maturation of the oocyte depends on its environment and determines embryo competence, because the embryonic genome is not active until the cleavage stage and new mitochondria are not produced until blastulation. Adverse environmental factors include aging, andropause, oxidative stress, obesity, smoking, alcohol, and psychologic stress, whereas androgen supplementation, a prudent diet, exercise, nutritional supplements, and psychologic interventions have beneficial effects. Mitochondrial function and energy production deteriorate with age, adversely affecting ovarian reserve, chromosome segregation, and embryo competence. In aging mice, the mitochondrial cofactor coenzyme Q10 reverses most of these changes. Early human experience has been encouraging, although only a small study using a shorter duration of intervention compared with the murine model has been carried out. Mitochondrial metabolic stress can result in an abnormal compensatory increase in mitochondrial DNA, which can be assessed in biopsied blastomeres of trophectoderm as a predictive biomarker of implantation failure. Psychologic stress may reduce oocyte competence by shifting blood flow away from the ovary as part of the classic "fight or flight" physiologic response, and methods to reduce stress or the body's reaction to stress improve pregnancy success. Enhancing oocyte competence is a key intervention that promises to reduce the number of euploid embryos failing to produce viable deliveries.

Impact of A Short-Term, Mindfulness-Based Stress Reduction Program on the Well-Being of Infertile Women: A Mixed-Method Study

Background

Mind-body skills groups represent an experiential approach to teaching antistress techniques that can enable a person to achieve mindfulness, self-awareness and self-reflection, to engage in self-care. This study examined whether a short-term mindfulness-based stress reduction (MBSR) program improved the well-being of infertile women.

Methods

A cohort of 25 women was enrolled at a public academic center of reproductive medicine, while on the waiting list for in vitro fertilization (IVF). The MBSR intervention consisted of 12 weekly sessions of mindfulness meditation, relaxation, autogenic training, biofeedback and guided imagery. The participants completed a qualitative, open-ended questionnaire and the Psychological General Well-Being Index (PGWBI) questionnaire to assess anxiety, depressed mood, positive well-being, self-control, general health and vitality, before and after the intervention period. Data were analyzed by paired t-test and by 95% confidence interval.

Results

The qualitative analysis revealed 5 central themes in patients’ responses to the questionnaires: connections, self-discovery, stress relief, learning and consciousness. Total PGWBI score increased by 17% (mean difference 14.1 ± 3.9 points, p<0.01), and all subscales improved after the intervention course compared with the preintervention values.

Conclusions

Both qualitative and quantitative assessment suggest that a 12-week MBSR program may improve the general well-being of infertile women awaiting IVF.