Depression, anxiety, and antidepressant treatment in women: association with in vitro fertilization outcome

Psychological distress, vaccine, and booster acceptance in women considering or undergoing fertility treatments during the Omicron surge of the COVID-19 pandemic

OBJECTIVE

Follow-up study to evaluate perceptions of COVID-19 vaccination and booster with psychological distress during the COVID-19 pandemic and Omicron surge in women considering or undergoing fertility treatment.

MATERIALS AND METHODS

Cross-sectional anonymous survey (N = 2558) from a single academic fertility center. Five hundred forty patients completed the survey (response rate = 21.1%). Participants were randomized 1:1 to a one-page evidence-based graphic with information and benefits regarding COVID-19 vaccination. Mental health and vaccine hesitancy were assessed via the Patient Health Questionnaire Depression (PHQ-8), the Generalized Anxiety Disorder (GAD-7) scales, and the Medical Mistrust Index (MMI).

RESULTS

Majority of participants were nulliparous, fully vaccinated with a booster dose, with > 1 year of infertility and mild to moderate distress. Patients with vaccine hesitancy had higher medical mistrust scores (r = .21,  p < .001). Higher MMI scores were not associated with vaccination during pregnancy. Participants that had higher PHQ-8 and GAD-7 scores were more likely to believe the omicron variant would cause delay in fertility treatments, would have impact on fertility outcome, and were more likely exhibiting medical system distrust (p < .001). Participants who received educational material were more likely to know pregnant women with COVID-19 had increased risk of death, stillbirth, and preterm birth (p < .05).

CONCLUSION

The majority of women in this study were vaccinated and had received their booster dose but also with clinically significant levels of depression. Patients with higher levels of distress and greatest medical mistrust demonstrated a concern that the Omicron variant would delay treatment, lead to suboptimal fertility outcomes, and COVID-19 vaccination would impact risk of miscarriages.

The Inflammatory State of Follicular Fluid Combined with Negative Emotion Indicators can Predict Pregnancy Outcomes in Patients with PCOS

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder syndrome with an incidence of 6% to 10% in women of reproductive age. Women with PCOS not only exhibit abnormal follicular development and fertility disorders, but also have a greater tendency to develop anxiety and depression. Our aim was to evaluate the ability of inflammatory factors in follicular fluid to predict embryonic developmental potential and pregnancy outcome and to construct a machine learning model that can predict IVF pregnancy outcomes based on indicators such as basic sex hormones, embryonic morphology, the follicular microenvironment, and negative emotion. In this study, inflammatory factors (CRP, IL-6, and TNF-α) in follicular fluid samples obtained from 225 PCOS and 225 non-PCOS women were detected via ELISA. For patients with PCOS, the levels of CRP and IL-6 in the follicular fluid in the pregnant group were significantly lower than those in the nonpregnant group. For non-patients with PCOS, only the level of IL-6 in the follicular fluid was significantly lower in the pregnant group than in the nonpregnant group. In addition, for both PCOS and non-patients with PCOS, compared with those in the pregnant group, patients in the nonpregnant group showed more pronounced signs of anxiety and depression. Finally, the factors that were significantly different between the two subgroups (pregnancy and nonpregnancy) of patients with or without PCOS were identified by an independent sample t test first and further analysed by multilayer perceptron (MLP) and random forest (RF) models to distinguish the two clinical pregnancy outcomes according to the classification function. The accuracy of the RF model in predicting pregnancy outcomes in patients with or without PCOS was 95.6% and 91.1%, respectively. The RF model is more suitable than the MLP model for predicting pregnancy outcomes in IVF patients. This study not only identified inflammatory factors that can affect embryonic development and assessed the anxiety and depression tendencies of PCOS patients, but also constructed an AI model that predict pregnancy outcomes through machine learning methods, which is a beneficial clinical tool.

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.

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.

Medically assisted reproduction and mental health: a 24-year longitudinal analysis using Finnish register data

BACKGROUND

Medically assisted reproduction can negatively affect women's mental health, particularly when the treatments do not result in a live birth. Although the number of women relying on medically assisted reproduction to conceive has grown rapidly, our knowledge about the mental health effects before, during, and after treatment is limited.

OBJECTIVE

This study aimed to understand the long-term association between medically assisted reproduction and mental health outcomes for women before, during, and after their treatments, and according to whether the treatment resulted in a live birth.

STUDY DESIGN

Using Finnish register data for the period from 1995 to 2018, we estimated the probability of psychotropic purchases (antidepressants, anxiolytics, hypnotics, and sedatives) for 3 groups of women who: (1) gave birth after natural conception, (2) gave birth after medically assisted reproduction treatments, or (3) underwent medically assisted reproduction but remained childless. We followed up women for up to 12 years before and 12 years after the reference date, which corresponded to the conception date for women who had a first live birth either after a natural or a medically assisted conception, or the date of the last medically assisted reproduction treatment for women with no live birth by the end of 2017. We estimated linear probability models before and after adjustment for sociodemographic characteristics.

RESULTS

The results show that women who did not have a live birth after undergoing medically assisted reproduction treatments purchased more psychotropics than women who gave birth after conceiving naturally or through medically assisted reproduction, and that these differences did not attenuate over time. Twelve years after the reference date, 17.73% (95% confidence interval, 16.82-18.63) of women who underwent medically assisted reproduction but remained childless purchased psychotropics vs 11.11% of women who gave birth after natural conception (95% confidence interval, 10.98-11.26) and 12.17% (95% confidence interval, 11.65-12.69) of women who gave birth after medically assisted reproduction treatments. In addition, women who conceived naturally and through medically assisted reproduction had very similar psychotropic use patterns from 3 years before conception to 4 years after, and over the long term. Adjustment for women's sociodemographic characteristics did not change the results.

CONCLUSION

The similarities in psychotropic purchases of women who had a live birth, whether naturally or through medically assisted reproduction, suggest that the higher psychotropic use among women who remained childless after undergoing medically assisted reproduction were likely driven more by involuntary childlessness than by treatment-related stress. The results highlight the importance of counseling for women undergoing medically assisted reproduction treatments, especially if their attempts to conceive are unsuccessful.

Research progress on the impact of anxiety and depression on embryo transfer outcomes of in vitro fertilization

Infertile women who receive in vitro fertilization-embryo transfer (IVF-ET) often present psychological distress such as anxiety, depression and perceived stress. This adverse psychological state can affect the immune homeostasis at the mother-fetus interface, the incubation of blastula and the receptivity of the maternal endometrium through the psycho-neuro-immuno-endocrine network, which in turns affect the proliferation, invasion and vascular remodeling of the embryo trophoblast, and reduces the success rate of embryo transfer. This adverse outcome of embryo transfer will further aggravate the psychological pain of patients, forming a vicious circle. The positive partner effect between husband and wife or the use of cognitive behavioral therapy, acupuncture, yoga and other measures for psychological intervention before and after IVF-ET, may break the vicious cycle and improve clinical pregnancy rate, continuous pregnancy rate and live birth rate after IVF-ET by alleviating anxiety and depression. This article reviews the research progress on anxiety and depression states in women receiving IVF-ET and the impact on outcome of IVF-ET and related mechanisms, as well as the application of psychological intervention for alleviating anxiety and depression, so as to provide insights in improving the outcome of IVF-ET.

Association between Pet Ownership and Threatened Abortion in Pregnant Women: The China Birth Cohort Study

Background: The aim of this study was to assess the association between pet ownership and threatened abortion (TA) in pregnant Chinese women. Materials and Methods: We enrolled pregnant women from 18 provinces and autonomous regions across China between November 2017 and December 2020. Participants were grouped based on the presence or absence of pet ownership. Pet owners were further sub-grouped based on the presence or absence of close contact with their pets. Pet species included cats, dogs, and both. Generalised linear mixed models, with province as a random effect, were used to estimate the associations between pet ownership and TA. Results: Pet ownership, whether or not one had close contact with pets, was associated with greater odds of TA (OR: 1.30, 95% CI: 1.21, 1.40). Keeping pet cats (OR: 1.24, 95% CI: 1.11, 1.40), dogs (OR: 1.29, 95% CI: 1.18, 1.41), or both cats and dogs (OR: 1.36, 95% CI: 1.04, 1.68) during pregnancy were all risk factors for TA. We observed significant group differences (p for difference < 0.05) in pre-pregnancy body mass index, education levels, and annual household income. Conclusions: Cat or dog ownership during pregnancy was associated with an increased risk of TA, especially among overweight, less educated, or lower-income participants.

Psychological status of infertile patients who had in vitro fertilization treatment interrupted or postponed due to COVID-19 pandemic: a cross-sectional study

PURPOSE

To explore the psychological status of infertile women and men who had in-vitro fertilization (IVF) treatment interrupted or postponed because of the COVID-19 emergency.

MATERIALS AND METHODS

An electronic survey (NCT04395755) was e-mailed between April and June 2020 to couples whose IVF treatments have been interrupted or postponed due to the COVID-19 pandemic. The presence and severity of symptoms suggestive of anxiety and/or depression were assessed using the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Subjects with preexisting psychiatric disorders were excluded.

RESULTS

Overall, 524 out of 646 patients completed the survey. The prevalence of anxiety and/or depression feelings was significantly higher in women, mainly if aged more than 35 years and with a previous IVF attempt. The occurrence of these psychological symptoms was significantly associated with the time spent on COVID-19 related news per day and partner with evidence of psychological disorder and, in females, with a diagnosis of poor ovarian reserve, diagnosis of endometriosis or uterine fibroids.

CONCLUSIONS

The psychological impact of the COVID-19 pandemic on the infertile couples who should have undergone IVF treatment has been significant. IVF centers should systematically offer these couples adequate psychological counseling to improve mental health.

Psychological domain of quality of life, depression and anxiety levels in in vitro fertilization/intracytoplasmic sperm injection cycles of women with endometriosis: a prospective study

OBJECTIVE

To evaluate the psychological domain of quality of life (PDQoL), anxiety and depression levels of infertile women with endometriosis versus non endometriosis who applied for Assisted Reproductive Technologies (ART).

METHOD

This prospective case-control study compromised a total of 105 women who applied for IVF/ICSI program. Ninety-three women were divided into two groups as endometriosis (n = 37) and non-endometriosis (n = 56) after 12 patients who refused to participate in the study were excluded. The WHOQOL-BREF questionnaire, Beck Depression and Anxiety Inventory scales were used to determine the psychological stress levels.

RESULTS

A significant difference was found between the endometriosis and non-endometriosis groups regarding depression scores, while no significant difference was reported with respect to PDQoL and anxiety (p < 0.01, p = 0.897 and p = 0.058, respectively). A weak but significant correlation was observed between depression and endometriosis (CC: 0.435, p < 0.01). Though anxiety scores were found to be higher in endometriosis group this can not reach statistical significance (p = 0.058). Impact of PDQoL, depression and anxiety scores on pregnancy outcomes were found to be insignificant.

CONCLUSION

Women with endometriosis seem to be more susceptible to depression and anxiety than women without endometriosis. Although infertility treatment outcomes are not found to be significantly affected, the impact of depression and anxiety over ART treatment success merit further research.

Preconception Dietary Patterns and Associations With IVF Outcomes: An Ongoing Prospective Cohort Study

There is a lack of research on preconception diet and reproductive outcomes conducted in the Chinese population using individual assessment. Between April 2017 and April 2020, 2,796 couples undergoing in vitro fertilization treatment were recruited in this ongoing prospective cohort, and 1,500 eligible couples were included in the final analysis. A validated semi-quantitative food frequency questionnaire was used to evaluate the maternal preconception diet. Other lifestyle factors, including smoking status, psycho-mental status, sleep quality, and physical activity, were also assessed. Five dietary patterns were identified using principal component analysis, namely "Fruits-Vegetables-Dairy-Eggs," "Fish/Seafood-Animal blood," "Tubers-Beans-Cereals," "Puffed food-Candy-Bakery," and "Dried Fruits-Organs-Rice." After adjusting for multiple confounders, we detected that the women who are more inclined to the "Fruits-Vegetables-Dairy-Eggs" pattern and less adherent to the "Tubers-Beans-Cereals" were more likely to achieve normally fertilized eggs and transferable embryos. Regarding pregnancy outcomes, we observed that a lower "Puffed food-Candy-Bakery" score and a higher "Dried fruits-Organs-Rice" score were related to a higher likelihood to achieve biochemical pregnancy. In terms of pregnancy complications, an inverse association between "Fish/Seafood-Animal blood" and hypertensive disorders was observed. We further clustered the dietary patterns based on the proportion of food groups consumed and found that dairy intake was beneficial to embryo quality, while frequent rice consumption was associated with a higher risk of macrosomia. Notably, in the stratified analysis, we observed that the positive relationship between the "Fruit-Dairy-Vegetables-Eggs" score and normal fertilization and the inverse association of the "Fish/Seafood-Animal blood" score with hypertensive disorders during pregnancy were exhibited only among women with body mass index ≥25 kg/m2. In conclusion, pre-treatment diets might be an important target for intervention to achieve a better reproductive outcome.

Long-term Follow-up of Psychiatric Disorders in Children and Adolescents Conceived by Assisted Reproductive Techniques in Sweden

Importance

Individuals conceived with assisted reproductive techniques (ARTs) could be at elevated risk of psychiatric disorders owing to potential adverse effects of the procedures themselves, or because such traits or their risk factors may be more common in couples with infertility.

Objective

To investigate the risk of psychiatric disorders in adolescents and young adults conceived with ARTs and to evaluate the role of treatment-related parental characteristics.

Design, Setting, and Participants

This prospective follow-up of a nationwide birth cohort used linkage of Swedish population registers with coverage through 2018. All children born in Sweden from January 1, 1994, to December 31, 2006, were included in the analysis. Follow-up was completed on December 31, 2018, when participants were 12 to 25 years of age, and data was analyzed from March 17, 2020, to September 10, 2021.

Exposures

In vitro fertilization with or without intracytoplasmic sperm injection and transfer of fresh or frozen-thawed embryos.

Main Outcomes and Measures

Clinical diagnoses of mood disorder, including major depression, anxiety, obsessive-compulsive disorder (OCD), or suicidal behavior, were identified from hospital records and outpatient specialist care. Suicide was additionally identified from death certificates. Antidepressant use was identified from dispensations of prescribed medications.

Results

A total of 1 221 812 children (48.6% female, 51.4% male) born between 1994 and 2006 were followed up to a median age of 18 (IQR, 15-21) years. Among these participants, 31 565 (2.6%) were conceived with ART. Compared with all others, adolescents conceived with ART had an elevated risk of OCD (hazard ratio [HR], 1.35 [95% CI, 1.20-1.51]), but the association was attenuated and no longer statistically significant after adjustment for parental characteristics (adjusted HR [aHR], 1.10 [95% CI, 0.98-1.24]) and was no longer present when restricted to individuals born to couples with known infertility (aHR, 1.02 [95% CI, 0.89-1.17]). Adolescents conceived with ARTs were not at elevated risk of depression or suicidal behavior compared with other adolescents (irrespective of parental infertility). Type of fertilization (standard in vitro fertilization or intracytoplasmic sperm injection) had no association with outcomes. Compared with non-ART-conceived children of couples with infertility, fresh, but not frozen, embryo transfer was associated with a lower risk of mood disorders (aHR, 0.90 [95% CI, 0.83-0.97]), making frozen embryo transfer appear less advantageous when directly contrasted with fresh embryo transfer.

Conclusions and Relevance

These findings suggest that adolescents conceived with ARTs around the millennium are not at risk of poor psychiatric health compared with the general population, except for an elevated risk of OCD that may be explained by differences in parental characteristics.

Stress, anxiety, and depression in infertile couples are not associated with a first IVF or ICSI treatment outcome

BACKGROUND

Psychological distress may exert a negative influence on reproductive function of couples at reproductive age. Couples seeking assisted reproductive technology (ART) treatment may have a higher prevalence of psychological distress than fertile couples. However, whether psychological distress is associated with the outcome of ART treatment remains unknown. We aimed to investigate the association of pre-treatment psychological distress and clinical pregnancy rate among infertility couples undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment.

METHODS

This nested case-control study was conducted based on women who underwent their first fresh IVF or ICSI cycle in the Jiangsu Birth Cohort Study (JBC) between November 2015 and January 2019. A total of 150 women who did not obtain clinical pregnancy after first IVF or ICSI fresh embryo transfer were identified as cases, and a total of 300 age matched women who obtained clinical pregnancy were identified as controls. Conditional logistic regression analyses were used to investigate the association between psychological distress and the outcome of first IVF or ICSI treatment, adjusting for multiple potential confounders.

RESULTS

No statistically significant association was observed between score of maternal symptoms of psychological distress and clinical pregnancy. Adjusted ORs of logistic regression were 1.00 (95% CI 0.97-1.03) for anxiety, 0.98 (95% CI 0.95-1.02) for depression, and 0.98 (95% CI 0.95-1.01) for perceived stress, respectively. When treat depression and anxiety as categorical variables, 62 (13.8%) were classified as clinical depression, 11 (2.4%) were classified as clinical anxiety, among 450 women in the present study. Psychological distress symptoms were also not associated with clinical pregnancy rate. Adjusted ORs of logistic regression were 0.27 (95% CI 0.03-2.33) for anxiety, 0.88 (95% CI 0.46-1.68) for depression, respectively.

CONCLUSIONS

Our findings firstly indicated that psychological distress experienced prior to IVF/ICSI treatment was not associated with clinical pregnancy.

Resilience, Perceived Stress, and Depressed Mood in Women Under in Vitro Fertilization Treatment

It has been suggested that women who display higher resilience levels may have less psychological distress during IVF. The aim of this study was to evaluate how infertile women deal with perceived stress, depressed mood, and sleep disturbances at the first IVF attempt and after one or more negative IVF outcomes depending on their level of resilience. An observational, cross-sectional study was carried out in a sample of 207 infertile women undergoing IVF procedures. The participants completed the short version of the Connor-Davidson Resilience Scale (CD-RISC), the short version of the European Spanish Version of Perceived Stress Scale (PSS-10), the Center of Epidemiologic Studies Depression Scale (CESD-10), and the Jenkins Sleep Scale (JSS). The relationship between CD-RISC scores ranked according to percentiles and mean PSS-10 scores revealed that women with strong resilience had lower perceived stress. After splitting the sample according to CD-RISC percentiles, differences were observed only at the first IVF attempt and the observed protective effect of high resilience scores appears to disappear following a negative IVF outcome. Women with high resilience are less likely to suffer from perceived stress or depressed mood during their first IVF attempt, this protective effect appears to be lost after a negative outcome.

Psychotropic medication use among women seeking assisted reproductive technology (ART) therapy: A cross-sectional study

Background Infertility is associated with increased anxiety, depressive symptoms and mood disorders. Unfortunately, mental health is not often addressed in infertility treatment and infertile patients could be at higher risk of self-administration of not prescribed drugs or/and be exposed to alternative emotional treatments. Therefore, the aim of the present study is to investigate the use of psychotropic medication and to evaluate the frequency of psychiatric diagnosis among infertile women seeking assisted reproductive technology (ART) therapy. Methods All infertile women starting treatment at an ART clinic who agreed to participate in the study were included. Patients were submitted to a structured psychiatric interview, the Mini International Neuropsychiatric Interview (M.I.N.I.). Current and lifetime use of psychotropic medication were assessed. Results Ninety patients who agreed to participate completed the research protocol.  A total of 12/90  were on current use of psychotropic medication.Thirty-six out of ninety patients  had at least one psychiatric disorder. Mood disorders were detected in 19 of the 90. Anxiety disorders were highly frequent, reaching 27/90 of the patients, as agoraphobia the most common diagnosis (12/90). Limitations The study has several limitations, such as the absence of a control group of fertile patients and strict inclusion criteria, in which only subjects that spontaneously agreed to participate were enrolled. Conclusion Women suffering from infertility seeking ART treatment are at high risk for depression and anxiety disorders and a considerable number of them are in use of medication. Its implications on infertility treatments and offspring are uncertain.

The association between antidepressant use and assisted reproductive technology (ART) treatment in Danish women: A national registry-based cohort study

OBJECTIVE

To investigate (1) if antidepressant use among women in assisted reproductive technology (ART) treatment and among women without ART treatment influences cumulative live birth rates (CLBR) and number of initiated treatment cycles per woman, (2) whether women undergoing ART treatment are at higher risk of initiating use of antidepressants compared to women not having undergone ART, (3) if mothers after ART treatment have higher risk for postpartum use of antidepressants after ART treatment compared to mothers not having used ART treatment.

STUDY DESIGN

A Danish nation-wide register-based cohort study including all women in ART treatment between 1995 through 2009 and an age-matched comparison group of women not having initiated ART treatment. In both groups, women had no previous children before study entry. The women were followed from time of initiating first ART treatment until time of permanent emigration (> 6 months), date of death, or end of follow-up by 31st of December 2009. Chi-square test was used to assess whether observed differences in CLBR between groups were significant. Adjusted incidence rates (IR) and incidence rate ratio (IRR) with 95 % confidence interval (CI) were calculated using Poisson regression analysis. The main outcome measures were: CLBR, number of initiated ART treatment cycles and IRR of initiating antidepressant use.

RESULTS

Women using antidepressants before, during or after ART treatment were significantly older, had a lower CLBR and a lower mean number of initiated ART treatment cycles compared to women in ART treatment with no use of antidepressants. No significant difference was found in the incidence of initiating antidepressant use between women in ART treatment and the comparison group. However, when comparing only women with a live birth, significantly more women in ART treatment initiated antidepressant use in the postpartum period (adjusted incidence rate ratio (IRR) = 2.56 (95 % CI 1.98-3.30; p < 0.001)).

CONCLUSION

Generally, women undergoing ART treatment are not at higher risk of initiating use of antidepressants compared with an age-matched comparison group not treated with ART. However, women with antidepressant medication use prior to ART initiate fewer ART treatments and have lower CLBR. Even though it has not been possible to adjust for all relevant confounders and our follow-up period only runs until the end of 2009, we still believe the results of this study to be highly relevant. According to our study, clinicians should be aware that women conceiving after ART treatment might experience an increased level of psychological strain during the postpartum period compared to mothers who conceived without ART.

Perinatal Mood and Anxiety Disorders in Women Undergoing Medically Assisted Reproduction

Background: Women taking advantage of medically assisted reproduction (MAR) techniques may differ from spontaneously conceiving women (nonMAR) in risk of depression and/or anxiety. We aimed to investigate possible differences between MAR and nonMAR through the use of the Edinburgh Postnatal Depression Scale in a sample of Italian-speaking women at their third trimester of pregnancy. Methods: We administered the Edinburgh Postnatal Depression Scale (EPDS) to two groups of pregnant women, MAR and nonMAR, at the third trimester of pregnancy (T0), one month after delivery (T1), and three months after delivery (T2) from February 2013 to December 2019. EPDS total scores cutoffs were ≥9 for risk of depression, 9–11 mild depression, ≥12 major depression, and the EPDS-3A cluster ≥4 was a proxy for anxiety. Results: Included were 1303 nonMAR women and 92 MAR, an expected disproportion. NonMAR and MAR women did not differ on depression or anxiety at any assessment timepoint. MAR women were older than nonMAR, consumed more alcohol and medical drugs, and displayed more complications during pregnancy. Scoring over the threshold on depression risk was associated with foreign nationality, unemployment, psychiatric history of the patient, family or partner, psychiatric problems in past pregnancies, hyperemesis, premenstrual syndrome (PMS), and stressful life events in the last year at baseline, and, for some of them, at other timepoints. In contrast, MAR past or current was associated with having suprathreshold depression at the first-month postpartum follow-up. Conclusions: Taken together, our data show that women opting for MAR do not differ from spontaneously conceiving women regarding psychiatric outcomes but do differ on some sociodemographic and clinical variables.

Delayed versus immediate frozen embryo transfer after oocyte retrieval: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to compare pregnancy outcomes between immediate frozen embryo transfer (FET) performed within the first menstrual cycle after oocyte retrieval and delayed FET following subsequent cycles.

METHODS

PubMed, EMBASE, and Web of Science were searched for eligible studies through January 2020. The main outcome measures were clinical pregnancy rate (CPR), live birth rate (LBR), and pregnancy loss rate (PLR). The effect size was estimated as risk ratio (RR) with 95% confidence interval (CI) using a random effects model. Inter-study heterogeneity was assessed by the I² statistic.

RESULTS

Twelve retrospective cohort studies involving 18,230 cycles were included. The pooled results revealed no significant differences between delayed and immediate FET in CPR (RR 0.94, 95% CI 0.87-1.03; I² = 67.9%), LBR (RR 0.94, 95% CI 0.85-1.03; I² = 67.5%), and PLR (RR 1.05, 95% CI 0.87-1.26; I² = 42.7%). Subgroup analyses of freeze-all cycles showed a marginal decrease of CPR in delayed FET (RR 0.93, 95% CI 0.86-1.00; I² = 53.6%), but no significant changes were observed regarding LBR (RR 0.93, 95% CI 0.85-1.02; I² = 65.2%) and PLR (RR 1.09, 95% CI 0.84-1.41; I² = 59.1%). No statistical differences were found in effect estimates among other subgroup analyses by ovarian stimulation protocol, trigger agent, endometrial preparation regimen, and embryo stage.

CONCLUSION

Timing of the first FET after oocyte retrieval was not significantly associated with pregnancy outcomes. This finding refutes the current common practice to delay FET after oocyte retrieval and reassures patients who wish to proceed with FET at their earliest convenience. Due to the high heterogeneity and observational nature of included studies, further randomized controlled trials are needed to confirm the results.

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.

Timing of frozen-thawed embryo transfer after controlled ovarian stimulation in a non-elective freeze-all policy

Background

Non-elective freeze-all policy has been increasingly utilized in assisted reproductive treatment, but the optimal timing of frozen-thawed embryo transfer (FET) after controlled ovarian stimulation (COS) remains to be investigated.

Methods

This retrospective cohort study included 2,998 patients who underwent their first FETs after the first COS cycles using the non-elective freeze-all strategy from Jan 2013 to Dec 2016 at a tertiary-care academic medical center. Patients were divided into the "immediate" group in which FET took place within the first menstrual cycle after oocyte retrieval, and the "delayed" group where FET started after one or more menstrual cycles following COS.

Results

The mean interval between oocyte retrieval and FET was 33.3±5.8 days in the immediate group (n=280; 9.3%) and 91.3±19.4 days in the delayed group (n=2,718; 90.7%). Cycles with delayed FET had a significantly lower live birth rate than those with immediate FET before [1,246/2,718 (45.8%) vs. 156/280 (55.7%); P=0.002] and after propensity score matching (PSM) [123/280 (43.9%) vs. 156/280 (55.7%); P=0.005]. When controlling for a number of confounding factors by multivariable logistic regression analysis, the risk remained significant with the adjusted odds ratio (aOR) [95% confidence interval (CI)] of 0.69 (0.53-0.90) and 0.60 (0.42-0.85) before and after matching, respectively.

Conclusions

Performing FET immediately within the first menstrual cycle following COS was associated with a higher chance to achieve live birth compared with delaying FET to subsequent cycles in a non-elective freeze-all policy. However, further randomized controlled trials are still needed to confirm this conclusion.

Infertility-related stress and the risk of antidepressants prescription in women: a 10-year register study

STUDY QUESTION

Is the first-time redeemed prescription of antidepressants predicted by the level of infertility-related stress in women seeking ART treatment?

SUMMARY ANSWER

Infertility-related stress in the personal and marital domains and general physical stress reactions were significant predictors of a first redeemed prescription of antidepressants after ART treatment in this 10-year follow-up cohort study.

WHAT IS KNOWN ALREADY

The literature has found inconsistent findings regarding the association between infertility-related stress and later psychological adjustment in fertility patients. The association between infertility-related stress and later prescription of antidepressants had never been explored in long-term cohort studies.

STUDY DESIGN, SIZE, DURATION

All women (n = 1169) who participated in the Copenhagen Cohort Multi-centre Psychosocial Infertility (COMPI) cohort study in the year 2000 (questionnaire data) were linked with the register-based Danish National ART-Couple (DANAC) I cohort, which includes women and their partners having received ART treatment from 1 January 1994 to 30 September 2009. The study population were among other national health and sociodemographic registers further linked with the Danish National Prescription Registry.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women initiating ART treatment were followed until they had redeemed the first prescription of antidepressants or until 31 December 2009. Logistic regression analyses were conducted to test the association between general physical stress reactions and infertility-related stress in the personal, marital and social domains, respectively, and a future redeemed prescription of antidepressants. Age, education level, marital status, number of fertility treatments prior to study inclusion and female infertility diagnosis were included as covariates in the adjusted analyses. Further, the analysis was stratified according to childbirth or no childbirth during follow-up.

MAIN RESULTS AND THE ROLE OF CHANCE

The final sample consisted of 1009 women with a mean age of 31.8 years. At study inclusion, women had tried to conceive for an average of 3.45 years. At 10-year follow-up, a total of 13.7% of women had a first redeemed prescription of antidepressant medication. The adjusted odds ratio (OR) showed that high general physical stress predicted the later prescription of antidepressants (adjusted (adj) OR = 2.85, 95% confidence interval (CI) 1.96–4.16). Regarding infertility-related stress domains, high personal stress (adj OR = 2.14, 95% CI 1.46–3.13) and high marital stress (adj OR = 1.80, 95% CI 1.23–2.64) were significantly associated with the later prescription of antidepressants. Social stress was not significantly associated with the future redeemed prescription of antidepressants (adj OR = 1.10, 95% CI 0.76–1.61). Among women not having achieved childbirth during follow-up, the risk of a first-time prescription of antidepressants associated with infertility-specific stress was higher compared to the risk among women having childbirth during follow-up.

LIMITATIONS, REASONS FOR CAUTION

This study did not account for potential mediating factors, such as negative life events, which could be associated with the prescription of antidepressants. Second, we are not able to know if these women had sought psychological support during follow-up. Additionally, antidepressants might be prescribed for other health conditions than depressive disorders.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that women presenting high infertility-related stress in the personal and marital domains were at higher risk of redeemed first-time prescription of antidepressants after ART, independently of having delivered a child or not after initiation of ART treatment. Women would benefit from an initial screening specifically for high infertility-related stress. The COMPI Fertility Problem Stress Scales can be used by clinical staff in order to identify women in need of psychological support before starting ART treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Portuguese Foundation for Science and Technology (FCT) under an individual doctoral grant attributed to the first author (SFRH/BD/103234/2014). The establishment of the DANAC I cohort was funded by Rosa Ebba Hansen’s Fund. The COMPI Infertility Cohort project was supported by The Danish Health Insurance Fund (J.nr. 11/097–97), the Else and Mogens Wedell-Wedellsborgs Fund, the manager E. Danielsens and Wife’s Fund, the merchant L.F. Foghts Fund, the Jacob Madsen and Wife Olga Madsens Fund. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

NA

The effects of depression, anxiety and stress symptoms on the clinical pregnancy rate in women undergoing IVF treatment

OBJECTIVE

Women undergoing assisted reproductive technology treatment, are often anxious and depressed because of their fertility problem and the uncertainties of the treatment with which they have to deal. On the other hand, recent studies have shown that the effects of psychological distress on the IVF treatment outcome is unclear. This study aimed to examine the effects of anxiety, depression, and stress symptoms before IVF treatment on the clinical pregnancy rate, controlling for known confounders.

RESULTS

In total, 142 women undergoing IVF treatment participated in this prospective study. The clinical pregnancy rate was 26.8% in this study. Controlling for age, infertility duration, and cause of infertility, there were no relationship between IVF outcome and anxiety (relative risk (RR) = 1.00; 95% CI 0.91-1.09), depression (RR = 0.96; 95% CI 0.88-1.05), and stress (RR = 1.01; 95% CI 0.96-1.07) symptoms. High woman's age and women with both cause of infertility were independent predictors of IVF clinical pregnancy rate. In sum, we found that anxiety, depression, and stress symptoms were not associated with the IVF clinical pregnancy rate.

Depressive symptoms among women with endometriosis: a systematic review and meta-analysis

OBJECTIVE

To evaluate whether endometriosis is associated with depressive symptoms, and whether the association is modulated by pelvic pain.

DATA SOURCES

PubMed, Embase, PsychINFO, and the Cochrane Library, were systematically searched through September 2017.

STUDY ELIGIBILITY CRITERIA

The following eligibility criteria applied: full-text original article; quantitative data about depressive symptoms or depression; comparison of women with and without endometriosis, or women with endometriosis with and without pelvic pain. Articles reporting duplicated data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers selected and reviewed the studies. Disagreements were resolved through discussion or a third opinion. Qualitative synthesis was performed through tabulation and assessment using a modified version of the Newcastle-Ottawa Scale. Effect sizes were pooled through meta-analysis, and moderator analyses were performed to identify potential confounders with several variables: region of the sample, method of ascertainment of endometriosis, method of measurement of depression, year of publication, and quality score.

RESULTS

A meta-analysis of 24 studies (99,614 women) showed higher levels of depression among women with endometriosis compared to controls (standardized mean difference [SMD], 0.22, 95% confidence interval [CI], 0.13-0.32). The heterogeneity in this analysis (I² = 68%) was not explained by any of the moderating variables. When only healthy controls were considered, a larger endometriosis-depression effect was found (11 studies, SMD, 0.49; 95% CI, 0.24-0.73; I² = 69%). Endometriosis patients reporting pelvic pain had significantly higher levels of depression compared to those without pain (4 studies; SMD, 1.01; 95% CI, 0.71-1.31; I² = 0%). No significant difference was found between women with pelvic pain and endometriosis and those with pelvic pain but without endometriosis (11 studies, SMD, -0.11; 95% CI, -0.25 to 0.04; I² = 0%).

CONCLUSION

The association between endometriosis and depressive symptoms is largely determined by chronic pain but may also be modulated by individual and context vulnerabilities. Awareness of the complex relationship between endometriosis and depressive symptoms informs tailored care and patient-centered research outcomes.

Women's morbid conditions are associated with decreased odds of live birth in the first IVF/ICSI treatment: a retrospective single-center study

PURPOSE

The present study aims to ascertain whether there is a causal relationship between women's disease conditions present at the starting time of the first intended oocyte retrieval cycle and IVF/ICSI outcomes, primarily odds of live birth in the first IVF/ICSI treatment.

METHODS

This is a retrospective study of infertile healthy and diseased women that had a live birth and/or exhibited a complete first oocyte retrieval cycle. Generalized Estimating Equations (GEE) models were applied to adjust standard errors for the potential correlation among women exhibiting the same infertility etiology. Confounders to be controlled for in these GEE models were previously selected following a strict stepwise methodology.

RESULTS

Compared to healthy women, diseased women exhibited lower odds of live birth (OR (95% CI) 0.704 (0.576-0.860)). Further screening analyses indicated that subclinical iodine-deficiency hypothyroidism together with autoimmune thyroiditis contributed significantly to decrease odds of live birth (OR (95% CI) 0.720 (0.608-0.853)). Another important contribution arose from practically all the remaining morbid conditions analyzed. These diseases were individually associated with lower odds of live birth, although differences were non-significant. Notwithstanding, differences became significant after merging these diseases in a single group (OR (95% CI) 0.605 (0.394-0.930)).

CONCLUSION

There is a significant causal association between most diseases present at the starting time of the first intended oocyte retrieval cycle and lower odds of live birth in the first IVF/ICSI treatment.

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.

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.

Effects of assisted reproductive technologies in neonates with indications for surgery (2007-2016)

PURPOSE

Recently, the number of births using assisted reproductive technologies (ART) has increased. An associated increase in the incidence of congenital malformations in babies conceived using this technology has also been reported. Therefore, we aimed to investigate the rate of malformations in babies with neonatal surgical diseases, who were conceived using ART.

MATERIALS AND METHODS

Between January 2007 and December 2016, 1737 patients were admitted to our hospital. We analyzed the incidence of congenital cardiac diseases, genetic anomalies, and congenital anomalies of the kidney and urinary tract (CAKUT) in neonates conceived by ART. The χ2 test and logistic regression analysis were used to assess the odds ratios (ORs) for congenital malformations. A P-value < 0.05 indicated statistical significance.

RESULTS

The OR for CAKUT was 16.94 for the first-birth neonates conceived using ART, [P < 0.05, AUC (area under the curve) = 0.86]. However, for non-surgery neonates, the OR for CAKUT was 5.99 (P = 0.15, AUC = 0.87), compared to 32.27 (P < 0.05, AUC = 0.93) for parallel conditions in surgery-neonates.

CONCLUSION

Neonates conceived using ART are prone to develop CAKUT, which will need surgical treatment. Therefore, more management is necessary for associated malformations in these babies, particularly in cases with CAKUT.

Anxiety and depression symptoms among sub-fertile women, women pregnant after infertility treatment, and naturally pregnant women

BACKGROUND

Infertility has been associated with psychological distress, but whether these symptoms persist after achieving pregnancy via assisted reproductive technology (ART) remains unclear. We compared the prevalence of anxiety and depressive symptoms between women seeking for infertility treatment and women who conceived after ART or naturally.

METHODS

Four hundred and sixty-eight sub-fertile non-pregnant women, 2972 naturally pregnant women and 143 women pregnant after ART completed a questionnaire in this cross-sectional study. The Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A≥8) and Edinburgh Postnatal Depression Scale (EPDS≥12) were used for assessing anxiety and depressive symptoms, respectively. Multivariate Poisson regression models with robust variance were applied to explore associations with anxiety and depressive symptoms.

RESULTS

The prevalence of anxiety and depressive symptoms among sub-fertile, non-pregnant women (57.6% and 15.7%, respectively) were significantly higher compared to women pregnant after ART (21.1% and 8.5%, respectively) and naturally pregnant women (18.8% and 10.3%, respectively). History of psychiatric diagnosis was identified as an independent risk factor for both anxiety and depressive symptoms. The presence of at least one unhealthy lifestyle behavior (daily tobacco smoking, weekly alcohol consumption, BMI≥25, and regular physical exercise<2h/week) was also associated with anxiety (Prevalence Ratio, PR: 1.24; 95%CI: 1.09-1.40) and depressive symptoms (PR: 1.25; 95%CI: 1.04-1.49).

CONCLUSIONS

Women pregnant after ART showed no difference in anxiety and depressive symptoms compared to naturally pregnant women. However, early psychological counseling and management of unhealthy lifestyle behaviors for sub-fertile women may be advisable, particularly for women with a previous history of psychiatric diagnosis.

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.

Effects of depression pharmacotherapy in fertility treatment on conception, birth, and neonatal health: A systematic review

OBJECTIVES

While antidepressant medications are currently used during conception, gestation and post-partum, considerable uncertainty exists regarding the benefits and harms conferred to mothers and their offspring. A significant body of evidence has focused on antidepressant use during pregnancy and post-partum. However, it is difficult to know if this translates to specific populations. Women receiving treatment for infertility are especially vulnerable to symptoms of depression and adverse perinatal outcomes. This systematic review aimed to determine the effects of antidepressants taken during the perinatal period by women receiving fertility treatment on conception, birth, and long-term maternal and child health outcomes.

METHODS

We searched MEDLINE, EMBASE, CINAHL, the Cochrane Library, PsycINFO, ProQuest Dissertation & Theses, and Pubmed databases from January 1950 to November 2015. Articles were screened for inclusion independently by two reviewers. Studies were included if they enrolled women of reproductive age exposed to pharmacotherapy for depression and infertility at any point during the perinatal period.

RESULTS

A total of 8587 unique citations, and 83 full-text articles were reviewed. Of these, two randomized controlled trials and two retrospective chart reviews were included in the narrative synthesis. While most studies reported on assisted reproduction processes and birth outcomes, none examined long-term impacts on maternal-child health. The few included studies did not find that antidepressant use by women receiving fertility therapy impacted gamete quality or pregnancy success.

CONCLUSIONS

Currently, no studies address whether pharmacotherapy for the treatment of depression in women undergoing assisted reproduction affects their health or that of their offspring long-term. It appears that much like antidepressant use in fertile women, there are risks associated with both antidepressant use and untreated depression. Decisions regarding the treatment of depression should be made taking into account clinical presentation and illness severity. Given the complexities of conducting research in this population, future research should attempt to leverage health registry data, to increase sample sizes and follow mothers and children longitudinally.