Physical and emotional stress associated with components of the infertility investigation: perspectives of professionals and patients

Timed intercourse for couples trying to conceive

BACKGROUND

Many factors influence fertility, one being the timing of intercourse. The 'fertile window' describes a stage in the cycle when conception can occur and is approximately five days before to several hours after ovulation. 'Timed intercourse' is the practice of prospectively identifying ovulation and, thus, the fertile window to increase the likelihood of conception. Methods of predicting ovulation include urinary hormone measurement (luteinising hormone (LH) and oestrogen), fertility awareness-based methods (FABM) (including tracking basal body temperatures, cervical mucus monitoring, calendar charting/tracking apps), and ultrasonography. However, there are potentially negative aspects associated with ovulation prediction, including stress, time consumption, and cost implications of purchasing ovulation kits and app subscriptions. This review considered the evidence from randomised controlled trials (RCTs) evaluating the use of timed intercourse (using ovulation prediction) on pregnancy outcomes.

OBJECTIVES

To evaluate the benefits and risks of ovulation prediction methods for timing intercourse on conception in couples trying to conceive.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register, CENTRAL, MEDLINE, and Embase in January 2023. We also checked the reference lists of relevant studies and searched trial registries for any additional trials.

SELECTION CRITERIA

We included RCTs that compared methods of timed intercourse using ovulation prediction to other forms of ovulation prediction or intercourse without ovulation prediction in couples trying to conceive.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane to select and analyse studies in this review. The primary review outcomes were live birth and adverse events (such as depression and stress). Secondary outcomes were clinical pregnancy, pregnancy (clinical or positive urinary pregnancy test not yet confirmed by ultrasound), time to pregnancy, and quality of life. We assessed the overall quality of the evidence for the main comparisons using GRADE methods.

MAIN RESULTS

This review update included seven RCTs involving 2464 women or couples. Four of the five studies from the previous review were included in this update, and three new studies were added. We assessed the quality of the evidence as moderate to very low, the main limitations being imprecision, indirectness, and risk of bias. Urinary ovulation tests versus intercourse without ovulation prediction Compared to intercourse without ovulation prediction, urinary ovulation detection probably increases the chance of live birth in couples trying to conceive (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.02 to 1.81, 1 RCT, n = 844, moderate-quality evidence). This suggests that if the chance of a live birth without urine ovulation prediction is 16%, the chance of a live birth with urine ovulation prediction is 16% to 28%. However, we are uncertain whether timed intercourse using urinary ovulation detection resulted in a difference in stress (mean difference (MD) 1.98, 95% CI -0.87 to 4.83, I² = 0%, P = 0.17, 1 RCT, n = 77, very low-quality evidence) or clinical pregnancy (RR 1.09, 95% CI 0.51 to 2.31, I² = 0%, 1 RCT, n = 148, low-quality evidence). Similar to the live birth result, timed intercourse using urinary ovulation detection probably increases the chances of clinical pregnancy or positive urine pregnancy test (RR 1.28, 95% CI 1.09 to 1.50, I² = 0, 4 RCTs, n = 2202, moderate-quality evidence). This suggests that if the chance of a clinical pregnancy or positive urine pregnancy test without ovulation prediction is assumed to be 18%, the chance following timed intercourse with urinary ovulation detection would be 20% to 28%. Evidence was insufficient to determine the effect of urine ovulation tests on time to pregnancy or quality of life. Fertility awareness-based methods (FABM) versus intercourse without ovulation prediction Due to insufficient evidence, we are uncertain whether timed intercourse using FABM resulted in a difference in live birth rate compared to intercourse without ovulation prediction (RR 0.95, 95% CI 0.76 to 1.20, I² = 0%, 2 RCTs, n = 157, low-quality evidence). We are also uncertain whether FABM affects stress (MD -1.10, 95% CI -3.88 to 1.68, 1 RCT, n = 183, very low-quality evidence). Similarly, we are uncertain of the effect of timed intercourse using FABM on anxiety (MD 0.5, 95% CI -0.52 to 1.52, P = 0.33, 1 RCT, n = 183, very low-quality evidence); depression (MD 0.4, 95% CI -0.28 to 1.08, P = 0.25, 1 RCT, n = 183, very low-quality evidence); or erectile dysfunction (MD 1.2, 95% CI -0.38 to 2.78, P = 0.14, 1 RCT, n = 183, very low-quality evidence). Evidence was insufficient to detect a benefit of timed intercourse using FABM on clinical pregnancy (RR 1.13, 95% CI 0.31 to 4.07, 1 RCT, n = 17, very low-quality evidence) or clinical or positive pregnancy test rates (RR 1.08, 95% CI 0.89 to 1.30, 3 RCTs, n = 262, very low-quality evidence). Finally, we are uncertain whether timed intercourse using FABM affects the time to pregnancy (hazard ratio 0.86, 95% CI 0.53 to 1.38, 1 RCT, n = 140, low-quality evidence) or quality of life. No studies assessed the use of timed intercourse with pelvic ultrasonography.

AUTHORS' CONCLUSIONS

The new evidence presented in this review update shows that timed intercourse using urine ovulation tests probably improves live birth and pregnancy rates (clinical or positive urine pregnancy tests but not yet confirmed by ultrasound) in women under 40, trying to conceive for less than 12 months, compared to intercourse without ovulation prediction. However, there are insufficient data to determine the effects of urine ovulation tests on adverse events, clinical pregnancy, time to pregnancy, and quality of life. Similarly, due to limited data, we are uncertain of the effect of FABM on pregnancy outcomes, adverse effects, and quality of life. Further research is therefore required to fully understand the safety and effectiveness of timed intercourse for couples trying to conceive. This research should include studies reporting clinically relevant outcomes such as live birth and adverse effects in fertile and infertile couples and utilise various methods to determine ovulation. Only with a comprehensive understanding of the risks and benefits of timed intercourse can recommendations be made for all couples trying to conceive.

The Impact of Ovulation Calculators on the Stress Levels of Fertility-Seeking Couples: An Evaluation Study

Introduction Infertility affects a significant portion of couples seeking pregnancy, leading to stress and emotional strain. Ovulation calculators, widely used as a tool to predict fertile days, may play a role in the stress experienced by couples undergoing fertility treatments. The aim of this study was to evaluate the impact of ovulation calculators on the stress levels of couples seeking fertility. Methods Participants were recruited from the University of Miami Health System Clinics. Fifty couples consulting for infertility were asked to participate in the study and complete anonymous self-reported surveys. The surveys consisted of validated questions related to stress levels and the use of ovulation calculators. The completed surveys were collected and analyzed using descriptive statistics. The data collected included age, number of years trying to conceive, and answers to questions related to stress levels and the use of ovulation calculators. Responses from 50 couples who met the inclusion criteria were included in the final analysis. Results A total of 50 couples who were attempting conception and who completed all the questionnaires were included in the study. Whether or not they were using ovulation calculators, females scored similarly in the four variables of the Female Sexual Function Index (FSFI), including arousal, orgasm, satisfaction, and lubrication. When evaluating International Index of Erectile Function (IIEF) scores for male erectile function, the average score of males tracking ovulation was 12.0 ± 4.8, compared to 11.5 ± 5.4 in male patients who were not (P = 0.81). The results showed no statistically significant difference in stress levels between couples who used ovulation calculators and those who did not. However, in couples experiencing higher stress levels due to infertility, both male and female participants reported higher levels of sexual dysfunction. Fertility-related stress was also found to be significantly associated with mental health implications, with increased anxiety and depression reported by couples undergoing fertility treatments. Conclusion The findings suggest that the use of ovulation calculators did not significantly influence the stress experienced by couples seeking fertility treatment. However, the study highlights the significant impact of infertility-related stress on sexual function and mental health in both male and female partners. These results emphasize the importance of addressing the psychological aspects of infertility and providing comprehensive support to couples undergoing fertility treatments. Further research is warranted to explore the complex interplay between ovulation calculator usage, infertility-related stress, sexual dysfunction, and mental health implications in couples seeking to conceive. Healthcare providers should consider incorporating mental health support into fertility treatment programs to optimize patient outcomes and overall well-being.

Effects of trying to conceive using an every-other-day strategy versus fertile window monitoring on stress: a 12-month randomized controlled trial

STUDY QUESTION

Can animation videos on how to optimize the chances of pregnancy influence stress, anxiety, depression and sexual functioning of individuals trying to conceive (TTC)?

SUMMARY ANSWER

There were no differences between those educated to have intercourse every other day, on the fertile window and a control group (CG), and depression and sexual dysfunction significantly increased over time for all arms.

WHAT IS KNOWN ALREADY

Recent findings indicate that time to pregnancy can be significantly shortened by targeting the fertile period, but some reproductive care guidelines recommend instead the practice of intercourse every other day on the basis that it is less stressful to the couple. Evidence to support guidelines on how to preserve well-being and psychosocial adjustment and optimize pregnancy chances is lacking.

STUDY DESIGN, SIZE, DURATION

We conducted a prospective, double-blinded, three-arm randomized controlled trial between July 2016 and November 2019. Participants were randomized to either not having any stimulus (CG) or visualizing a short animated video explaining how to improve chances of pregnancy by having intercourse every other day (EOD group), or by monitoring the fertile window (FWM group). Assessments were made before the intervention (T0), and 6 weeks (T1), 6 months (T2) and 12 months after (T3), with follow-ups censored in case of pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were childless individuals of reproductive age actively TTC and not diagnosed or unaware of a condition that could prevent spontaneous pregnancy. Individuals were excluded from recruitment if they had previous children or had a condition preventing spontaneous pregnancy. Our primary outcome was stress and secondary outcomes included anxiety, depression, sexual functioning and pregnancy. Primary analyses were performed according to intention-to-treat principle.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 450 randomized participants 127 were educated to use an every-other-day strategy, 135 to monitor the fertile window, and 134 received no intervention. Groups were similar regarding demographics and months TTC. Repeated measures analysis revealed that there were no significant interaction effects of psychological and sexual well-being between groups over time (P > 0.05). Significant time effects were revealed for stress (F(3,855) = 4.94, P < 0.01), depression (F(3,855) = 14.22, P < 0.01) and sexual functioning (time effects P values <0.001 for female sexual functioning dimensions and <0.002 for male dimensions), but not for anxiety (F(2,299) = 0.51, P > 0.05). Stress levels lowered after 6 months (P < 0.001) and returned to baseline levels at the 1-year follow-up. Depressive symptomatology significantly increased at 6 weeks (P = 0.023), and again 1 year after (P = 0.001). There were also significant decreases in all female sexual functioning dimensions (desire, satisfaction, arousal, pain, orgasm and lubrication). In men, there were significant variations in orgasm, intercourse satisfaction and erectile function, but not desire and sexual satisfaction. Revealed pregnancy rates were 16% for participants in the EOD group, 30% for the FWM group and 20% for the CG. Pregnancies were not significantly different between arms: EOD vs FWM (odds ratio (OR) 2.32; 95% CI 0.92-5.83); EOD vs CG (OR 0.74; 95% CI 0.30-1.87); and FWM vs CG (OR 1.71; 95% CI 0.70-4.18).

LIMITATIONS, REASONS FOR CAUTION

Participants were recruited after transitioning to procreative sex. The study might be prone to bias as almost 30% of our sample fulfilled the chronological criterion for infertility, and other reproductive strategies could have been tried over time before recruitment.

WIDER IMPLICATIONS OF THE FINDINGS

Our data suggest that stress does not arise from feeling pressured on the fertile period and that advice on timing of intercourse might have to be personalized. The increasing levels of depression and sexual dysfunction over a year emphasize the crucial role of preconception care and fertility counseling in promoting psychological and sexual well-being.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by European Union Funds (FEDER/COMPETE-Operational Competitiveness Programme) and by national funds (FCT-Portuguese Foundation for Science and Technology) under the projects PTDC/MHC-PSC/4195/2012 and SFRH/BPD/85789/2012.

TRIAL REGISTRATION NUMBER

NCT02814006.

TRIAL REGISTRATION DATE

27 June 2016.

DATE OF FIRST PATIENT’S ENROLLMENT

19 July 2016.

Depression among Infertile Women in Gaza Strip: Symptom Severity and Predictors

BACKGROUND

Mental disorders are expected for women suffering from infertility. Depression is a predictable consequence but requires more investigations and considerations. This study is aimed at determining the severity of depression symptoms and its predictors among infertile women in the Gaza Strip, Palestine.

MATERIALS AND METHODS

A cross-sectional study was conducted. Three hundred eighty-five infertile women participated and were selected by convenience sampling. The participated women were selected from three large and major in vitro fertilization treatment centers (Al Helo, Al Basma, and Hindawi). A validated Arabic version of the Beck Depression Inventory-II was used. Univariate and multivariate logistic regression was applied to determine potential predictors for depression symptoms, and p ≤ .05 was statistically significant.

RESULTS

The mean age of participated women was 29 ± 6.58 years, and the mean duration of marriage and infertility was 7.76 ± 5.31 and 5.43 ± 3.50 years, respectively. Half of the women had some form of depression symptoms (22.3%, 8.6%, and 10.6% showed to have mild depression, moderate, and severe depression symptoms, respectively). Predictors of depression symptoms were as follows: duration of marriage (Wald test: 10.493; CI95%: 0.248-0.774), at least one abortion (Wald test: 21.233; CI95%: 1.863-4.528), primary infertility (Wald test: 6.666; CI95%: 1.148-2.742), and husband cause of infertility (Wald test: 10.878; CI95%: 0.800-0.982).

CONCLUSION

Infertility affects the various aspect of women's life. Psychological intervention including counselling, support, and therapy would be necessary to limit the consequences of infertility. Such interventions could be implemented in infertility treatment clinics.

The perspective of women with an increased risk of OHSS regarding the safety and burden of IVF: a discrete choice experiment

STUDY QUESTION

What are the preferences of women with an increased risk of ovarian hyperstimulation syndrome (OHSS) for characteristics of IVF treatments?

SUMMARY ANSWER

In women with increased risk of OHSS, the chance of OHSS is a strong attribute in determining women's preference for IVF treatment and women are willing to trade off burden (side effects), costs and chance of pregnancy for lower risks of OHSS.

WHAT IS KNOWN ALREADY

OHSS is the most serious iatrogenic complication of ovarian stimulation. Polycystic ovaries, high antral follicle count (AFC) and previous OHSS increase the risk of developing OHSS. IVM of oocytes offers great potential for patients with high AFC, since there is no risk of OHSS. With regard to patients' perspectives on fertility treatments, it has been shown that women undergoing IVF place different values on treatment characteristics, such as effectiveness (pregnancy rate), cancellation risk, safety (OHSS risk) and burden (side effects). To our knowledge, the preferences for different IVF treatments in women with increased risk of OHSS have not been studied yet.

STUDY DESIGN SIZE DURATION

A multicentre discrete choice experiment (DCE) was performed between 2012 and 2016. The selected attributes offered were chance of OHSS, which represents safety; number of injections; chance of cycle cancellation (the latter two represent burden); chance of pregnancy; and out-of-pocket costs/willingness to pay. A target sample size was calculated by including 20 patients for five attributes resulting in the aim to include 100 women.

PARTICIPANTS/MATERIALS SETTING METHODS

We invited subfertile women who were diagnosed with normogonadotrophic ovulation disorder and were undergoing treatment with gonadotrophins and/or had experienced (imminent) OHSS in a previous IVF treatment in the fertility clinic of four hospitals (three teaching and one academic). Women received a printed questionnaire with fictional scenarios and were asked, for each scenario, to choose their preferred treatment. We used a multinominal logit model to determine the preferences of women and investigated heterogeneity in preferences through latent class analysis. The decrease in OHSS risk required for women to accept an increased level of an undesirable attribute, i.e. their willingness to trade off, was calculated.

MAIN RESULTS AND THE ROLE OF CHANCE

We distributed 120 questionnaires with a response rate of 79% (95/120). There were 91 questionnaires included in the analysis. All five attributes influenced women's treatment preference. About half of the women considered chance of pregnancy to be more important, while the other half considered prevention of OHSS and lower costs to be more important. Women were willing to trade off cancellation rate, number of injections, chance of pregnancy and costs for lower OHSS chances. We found that women were willing to accept 5% more chance on cycle cancellation if the OHSS rate dropped with 2%. Women were willing to accept one extra treatment for a reduction of 3.9% in OHSS risk. With respect to costs, women were willing to pay €1000 instead of no costs for a decrease in OHSS rate of 5.4%.

LIMITATIONS REASONS FOR CAUTION

The sample size of our study is relatively small which may limit the generalizability and sensitivity of the study.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this DCE help us to understand the trade-off that women at risk of OHSS make in their preference for characteristics on IVF treatments. This knowledge may be used during the counselling of couples about their treatment options.

STUDY FUNDING/COMPETING INTERESTS

B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for Merck, ObsEva and Guerbet. J.P.d.B. reports personal fees from the Ferring Medical Advisory Board and grants from Ferring B. V and Merck Serono B. V outside the submitted work. There are no other conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

None.

Investigation and management of subfertility

Subfertility affects one in seven couples and is defined as the inability to conceive after 1 year of regular unprotected intercourse. This article describes the initial clinical evaluation and investigation to guide diagnosis and management. The primary assessment of subfertility is to establish the presence of ovulation, normal uterine cavity and patent fallopian tubes in women, and normal semen parameters in men. Ovulation is supported by a history of regular menstrual cycles (21-35 days) and confirmed by a serum progesterone >30 nmol/L during the luteal phase of the menstrual cycle. Common causes of anovulation include polycystic ovary syndrome (PCOS), hypothalamic amenorrhoea (HA) and premature ovarian insufficiency (POI). Tubal patency is assessed by hysterosalpingography, hystero-contrast sonography, or more invasively by laparoscopy and dye test. The presence of clinical or biochemical hyperandrogenism, serum gonadotrophins (luteinising hormone/follicle stimulating hormone) / oestradiol, pelvic ultrasound to assess ovarian morphology / antral follicle count, can help establish the cause of anovulation. Ovulation can be restored in women with PCOS using letrozole (an aromatase inhibitor), clomifene citrate (an oestrogen antagonist) or exogenous gonadotrophin administration. If available, pulsatile gonadotrophin releasing hormone therapy is the preferred option for restoring ovulation in HA. Spermatogenesis can be induced in men with hypogonadotrophic hypogonadism with exogenous gonadotrophins. Unexplained subfertility can be treated with in vitro fertilisation after 2 years of trying to conceive. Involuntary childlessness is associated with significant psychological morbidity; hence, expert assessment and prompt treatment are necessary to support such couples.

Should home-based ovulation predictor kits be offered as an additional approach for fertility management for women and couples desiring pregnancy? A systematic review and meta-analysis

Introduction

To inform the WHO Guideline on self-care interventions, we conducted a systematic review of the impact of ovulation predictor kits (OPKs) on time-to-pregnancy, pregnancy, live birth, stress/anxiety, social harms/adverse events and values/preferences.

Methods

Included studies had to compare women desiring pregnancy who managed their fertility with and without OPKs, measure an outcome of interest and be published in a peer-reviewed journal. We searched for studies on PubMed, CINAHL, LILACS and EMBASE through November 2018. We assessed risk of bias assessed using the Cochrane tool for randomised controlled trials (RCTs) and the Evidence Project tool for observational studies, and conducted meta-analysis using random effects models to generate pooled estimates of relative risk (RR).

Results

Four studies (three RCTs and one observational study) including 1487 participants, all in high-income countries, were included. Quality of evidence was low. Two RCTs found no difference in time-to-pregnancy. All studies reported pregnancy rate, with mixed results: one RCT from the 1990s among couples with unexplained or male-factor infertility found no difference in clinical pregnancy rate (RR: 1.09, 95% CI 0.51 to 2.32); two more recent RCTs found higher self-reported pregnancy rates among OPK users (pooled RR: 1.40, 95% CI 1.08 to 1.80). A small observational study found higher rates of pregnancy with lab testing versus OPKs among women using donor insemination services. One RCT found no increase in stress/anxiety after two menstrual cycles using OPKs, besides a decline in positive affect. No studies measured live birth or social harms/adverse events. Six studies presented end-users’ values/preferences, with almost all women reporting feeling satisfied, comfortable and confident using OPKs.

Conclusion

A small evidence base, from high-income countries and with high risk of bias, suggests that home-based use of OPKs may improve fertility management when attempting to become pregnant with no meaningful increase in stress/anxiety and with high user acceptability.

Systematic review registration number

PROSPERO registration number CRD42019119402.

Home ovulation test use and stress during subfertility evaluation: Subarm of a randomized controlled trial

Objectives:

A prospective, randomized controlled trial in women seeking to conceive examined the impact of using ovulation tests on self-reported levels of stress, psychological well-being, and quality of life in women with unexplained infertility.

Method:

The test group used a home ovulation test to detect the day of ovulation, whereas the control group were provided with a predicted day of ovulation based on the average length of menstrual cycle reported during study recruitment. Volunteers collected their first morning urine samples to evaluate biochemical levels of stress (urinary cortisol and estrone-3-glucouronide) and completed questionnaires over two complete menstrual cycles.

Results:

Overall, the use of digital ovulation tests by sub-fertile women under medical care had negligible negative effects and no detectable positive benefit on psychological well-being, according to multiple measurements of stress by questionnaire and biochemical markers. No significant differences were found between groups for all stress measures at the various study time points, except in relation to “couple concordance” where the test group scored much higher than the control group (mean difference at end of study was 21.25 (95% confidence interval: 9.25, 33.25; P = 0.0015)). The maximum difference in log cortisol: creatinine ratio between the test and control groups was −0.28 (95% confidence interval: −0.69, 0.13).

Conclusions:

These results do not support propositions that using digital ovulation tests can cause stress in women trying to conceive.

Women's experiences of ovulation testing: a qualitative analysis

Background

The introduction of home digital ovulation tests (OTs) has provided a simple solution for women wishing to optimise the timing of intercourse when trying to conceive. However, despite this, very little is understood about women’s experiences of using these tests.

Methods

We carried out qualitative, semi-structured telephone interviews with women who were seeking to conceive (not actively undergoing clinical investigation/fertility treatment) from the general UK population. The interviews were conducted following participation in a randomised controlled trial (RCT) in which participants were either provided with digital home OTs to assist in timing intercourse (n = 18) or advised to have intercourse every 2–3 days (n = 18). The interviews were digitally recorded, transcribed and then analysed using Framework analysis to identify the themes.

Results

Data saturation was reached after 36 interviews. The use of the OT appeared to elicit 10 key themes, which could be described within the context of three overarching issues: 1) a positive impact (understanding the menstrual cycle, confirming when ovulating, emotional support, improving the relationship), 2) a negative impact (changing sex life and relationship with their partner, the emotional consequences of prolonged use, questions and uncertainty about what their results mean for them) and 3) the experiences of trying to conceive in general (use of clinical guidance and emotional experience).

Conclusions

Overall, the use of home OTs were found to affect women’s thoughts and feelings in multiple ways during attempts to conceive. Although some women reported a range of negative experiences when using OTs, they also reported similar negative experiences when trying to conceive without using the tests. However, there were many positive themes associated with OT use, including an increased understanding of the menstrual cycle, confirmation of ovulation timing and providing a source of help and support when trying to conceive. Overall, when women are trying to conceive, ensuring they have access to high-quality information, including use of OT, may be of benefit to help address some of the questions and uncertainties that were raised by the participants in this study.

Trial registration number

NCT01084304

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0103-y) contains supplementary material, which is available to authorized users.

Sexual satisfaction of infertile couples assessed using the Golombok-Rust Inventory of Sexual Satisfaction (GRISS)

Recently, infertility treatment-related psychological effects are receiving increased attention. However, whether sexual satisfaction is reduced amongst infertile couples remains to be elucidated. In this study, sexual satisfaction of Japanese infertile couples was assessed using a validated questionnaire designed to assess the male and female partner individually, and the couple as a whole for the first time. This study randomly included 170 infertile couples seen at the outpatient clinic and 170 couples that had recently achieved spontaneous pregnancy. All couples were given the Japanese version of the Golombok-Rust Inventory of Sexual Satisfaction (GRISS). In couples aged 35 years or older, the male partners showed significantly worse sexual satisfaction scores than the female partners. Sexual satisfaction also deteriorated with therapeutic interventions, with mental factors affected more than physical factors. Therapeutic interventions such as timed sexual intercourse and assisted reproductive technology were considered emotionally stressful for infertile couples, with sexual satisfaction accordingly lower in this group than in couples achieving spontaneous pregnancy. GRISS successfully evaluated lower sexual satisfaction associated with infertility, and hence is a useful tool for identifying couples whose sexual satisfaction could be enhanced by counselling or other stress-reduction modalities.

Home ovulation tests and stress in women trying to conceive: a randomized controlled trial

STUDY QUESTION

Does the use of a digital home ovulation test have any effect on the level of stress in women seeking to conceive?

SUMMARY ANSWER

No difference was found in levels of stress between women using digital ovulation tests to time intercourse compared with women who were trying to conceive without any additional aids: in addition, their use did not negatively impact time to conception in users but may provide additional benefits, including an increased understanding of the menstrual cycle, reassurance and confidence in focusing conception attempts to the correct time in the cycle.

WHAT IS KNOWN ALREADY

It has been suggested that timing of intercourse in such a way that it coincides with ovulation by using ovulation tests can lead to emotional distress; however, no study has been conducted to investigate this hypothesis specifically, until now.

STUDY DESIGN, SIZE AND DURATION

The study was performed over two complete menstrual cycles as a prospective, randomized, controlled trial including quantitative and qualitative methods. The intervention (test) group were given digital ovulation tests to time intercourse to the most fertile time of the cycle and the control group were provided with the current National Institute for Health and Clinical Excellence guidelines for increasing the chances of conception (intercourse every 2-3 days) and asked not to use any additional methods to time when ovulation occurs.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

A total of 210 women who were seeking to conceive were recruited from the general UK population. A total of 115 women were randomized to the test group and 95 to the control group through block randomization. The positive and negative affect schedule (PANAS) and the Perceived Stress Scale (PSS) were used to measure subjective stress levels, the Short-Form 12 health survey was used as a measure of general health and well-being and urine samples were measured for biochemical markers of stress including urinary cortisol. Qualitative data were collected in the form of a telephone interview upon study completion.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no evidence for a difference either in total stress as measured using the PSS or in total positive or negative affect using the PANAS questionnaire between the test and control groups at any time point for the duration of the study. During cycle 1, for example, on Day 6, the difference in total stress score (test-control) was -0.62 [95% confidence interval (CI) -2.47 to 1.24] and on the day of the LH surge, it was 0.53 (95% CI -1.38 to 2.44). In addition, no correlation was observed between time trying to conceive and levels of stress, or between age and levels of stress, and no evidence was found to show that stress affected whether or not a pregnancy was achieved. There is also no evidence that the biochemistry measurements are related to whether a pregnancy was achieved or of a difference in biochemistry between the treatment groups. The use of digital ovulation tests did not negatively affect time to conception and with an adequately sized study, could potentially show improvement. To ensure that the results of this study were not affected by chance, we used a number of different methods for measuring stress, each of which had been independently validated.

LIMITATIONS AND REASONS FOR CAUTION

Randomization occurred before the start of the study because of the need to provide the ovulation tests in readiness for Day 6 of the first cycle. As a consequence, a number of women fell pregnant during this period (22 and 13 in the test and control groups, respectively). A further 15 women were either lost to follow-up or withdrew consent prior to study start. Pregnancy rate was higher overall in the test group, so to ensure that there were sufficient data from women who failed to become pregnant in the test group, we implemented an additional biased recruitment. This second cohort may have been different from the first, although no significant differences were observed between the two phases of recruitment for any of the information collected upon admission to the study.

WIDER IMPLICATIONS OF THE FINDINGS

Women who seek medical advice while trying to conceive should not be discouraged by health care professionals from using digital ovulation tests in order to time intercourse. The cohort of women recruited to this study initially had no evidence of infertility and were looking to conceive in a non-medical setting. A separate study to assess the impact of home ovulation tests in a subfertile population would be of interest and complementary to the present study.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by SPD Swiss Precision Diagnostics, GmbH, manufacturer of Clearblue(®) pregnancy and ovulation tests. SPD Development Company Ltd is a wholly owned subsidiary of SPD Swiss Precision Diagnostics GmbH; together referred to as SPD.

TRIAL REGISTRATION NUMBER

NCT01084304 (www.clinicaltrials.gov).

Tackling burden in ART: an integrated approach for medical staff

Discontinuation is a problem in fertility clinics. Many couples discontinue assisted reproductive technologies (ART) without achieving a live birth for reasons other than poor prognosis or the cost of treatment. Discontinuation has been attributed to the burden of treatment. The causes of burden can be broadly classified according to whether they originate in the patient, clinic or treatment. Interventions to alleviate these burdens include provision of comprehensive educational material, screening to identify highly distressed patients, provision of tailored coping tools and improvements in the clinic environment and medical interventions. Practical interventions to reduce the different causes of burden in ART exist, but further development and evaluation of the efficacy of these interventions requires more precise definition of terms and theory. In this paper, we propose a general integrated approach to cover different perspectives in dealing with burden in ART clinics. We firstly describe the integrated approach and present common sources of burden. We then describe interventions that could help reduce the burden in ART. Our paper is aimed at fertility clinic staff because of their day-to-day involvement with patients. However, this discussion should also be relevant to companies that develop treatments and to psychosocial experts. Reducing the burden of treatment should lead to improved outcomes, namely better quality of life during treatment and lower discontinuation rates.

Comparison of a digital ovulation test with three popular line ovulation tests to investigate user accuracy and certainty

OBJECTIVES

To determine the accuracy and certainty with which volunteers interpreted results of a digital ovulation test, Clearblue digital ovulation test (CB-DOT), compared with three home use non-digital visual ovulation tests: Clearblue ovulation test (CB-OT), First Response (FR) and Answer (AN).

METHODS

A total of 72 female volunteers aged 18 - 45 years interpreted test results from each of the four ovulation tests to determine the day of the luteinising hormone surge in 40 individual menstrual cycles. We used urine previously collected from 25 volunteers. The accuracy with which volunteers interpreted the test results was calculated by comparing their results with results obtained by trained technicians using a blinded test regime. For each of the four tests, volunteers were also asked to rate seven attributes of certainty and eight attributes of preference. The primary objective was to compare the accuracy with which volunteers read results from CB-DOT when compared to three visual-based line ovulation tests.

RESULTS

A significantly higher percentage of volunteers/technicians agreed on the interpretation of the results from CB-DOT (97.3%) than for CB-OT (83.5%; p = 0.0153), AN (73%; p = 0.0011) or FR (64.3%; p = 0.0001). CB-DOT was also found to have significantly better Likert scores than CB-OT, FR and AN for all seven attributes of certainty and was the test that 97.2% of volunteers preferred.

CONCLUSIONS

Women can misread the results of line ovulation tests. Over 97% of volunteers correctly read the result of CB-DOT. CB-DOT was also the test that women read with most certainty and the test that most users preferred.

Women's views on Friendly IVF: a qualitative preliminary study

OBJECTIVE

To study in the French Context women's experiences with a low-stimulation regimen of in vitro fertilisation (Friendly IVF) and to compare them with those of women undergoing standard IVF (S-IVF).

POPULATION AND METHODS

Two assisted reproduction technology centers participated in this preliminary study. Patients'views were explored qualitatively. In-depth interviews were conducted at the end of the second monitored cycle. Twelve friendly IVF patients and 13 S-IVF patients participated in the study.

RESULTS

The respondents indicated that the most positive aspect of Friendly IVF was the low doses of hormones used. Cancellation of cycles and failure of oocyte retrieval were perceived the most negatively. Women in the Friendly IVF group reported fewer side effects and expressed emotional distress less acutely than women in the S-IVF group. The Friendly IVF treatment was percieved as a first step, sustaining the hope of success with a standard treatment.

CONCLUSION

Friendly IVF, as practiced in the center studied, represents a valuable alternative for most respondents as a first step in IVF treatment.

Anxiety symptoms during late pregnancy and early parenthood following assisted reproductive technology

OBJECTIVE

To evaluate the relationship between assisted reproduction technology (ART) and anxiety symptoms during late pregnancy and early parenthood.

METHOD

Women with ART pregnancies were prospectively compared to their partners and to women with spontaneous pregnancies. The sample of 87 subjects, 48 ART (25 mothers and 23 fathers) and 39 non-ART mothers were given the ASQ-IPAT Anxiety Scale at 30-32 weeks of gestation, and at one week and three months after delivery.

RESULTS

The main socio-demographic and obstetrical characteristics were similar between groups. ART women showed higher scores for latent anxiety than non-ART women at three months after birth and showed no difference from ART men in all assessments. Manifest anxiety scores in ART women were higher, compared to non-ART women during the third trimester of pregnancy and one week after birth and were higher in all assessments when compared to ART men. Overall level of anxiety was higher in ART women in all assessments when compared to non-ART women and higher than in ART men during the two postnatal assessments.

CONCLUSION

We confirm the higher level of anxiety that characterizes the pregnancy-birth process in ART pregnancies. In addition, the higher manifest anxiety present before delivery and one week post-partum can be explained by the special nature of these pregnancies. Psychological support should be offered to ART patients because anxiety is an important risk factor for maternal post-partum depression and can lead to negative effects on the neonate and on child emotional and behavioral development.

Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study

OBJECTIVE

To evaluate the effect of the Eastern Body-Mind-Spirit (EBMS) group intervention on anxiety-reduction of Chinese women undergoing IVF.

DESIGN

Randomized controlled study.

SETTING

Tertiary assisted reproduction unit.

PARTICIPANT(S)

Two hundred twenty-seven women undergoing their first cycle of IVF treatment.

INTERVENTION(S)

The intervention group (n = 69) received four sessions of EBMS group counseling, while the control group (n = 115) did not receive any intervention.

MAIN OUTCOME MEASURE(S)

State-Trait Anxiety Inventory.

RESULT(S)

Compared with the control group, the intervention group had a significant drop in State Anxiety mean score following intervention. A comparable number of embryos were transferred for each group, but there was a nonsignificant trend of a higher pregnancy rate in the intervention group.

CONCLUSION(S)

The Eastern Body-Mind-Spirit group intervention approach effectively reduces the anxiety level of women undergoing IVF treatment.

Comparison of conscious sedation for oocyte retrieval between low-anxiety and high-anxiety patients

STUDY OBJECTIVE

To investigate the correlation among the level of anxiety, the intravenous propofol requirement for conscious sedation, and recovery profile in in vitro fertilization patients.

DESIGN

Prospective, randomized, double-blinded study.

SETTING

Operating room of tertiary-care university hospital.

PATIENTS

One hundred fifty consecutive women scheduled for oocyte retrieval under conscious sedation.

INTERVENTIONS

Anxiety scores were separately measured by an anesthesiologist who was not involved in sedation. The patients were divided into 2 groups, high-anxiety and low-anxiety, as determined by using the median of anxiety VAS scoring for assessment of preoperative anxiety (4.0 cm). The subjects were collected, 76 in high-anxiety group and 74 in low-anxiety group.

MEASUREMENTS

An infusion of propofol with a preset target concentration of 2.5 microg/mL(-1) was started until the patient had reached and maintained a sedation level of 3 on a 5-point sedation scale. Hemodynamic variables were recorded by using standard monitors. The scorings of sedation, operability, and satisfaction were assessed by one of the investigator-anesthesiologists. Data of induction quality and concentration of propofol were obtained from Target-Controlled Infusion system that runs on a microcomputer connected to an infusion pump (Becton-Dickinson infusion system, Le Grande chemin, France). Recovery data were measured in the recovery room.

MAIN RESULTS

The high-anxiety group required more for the induction of sedation and a larger amount of total dosage of propofol for sedation, as compared with the low-anxiety group. The concentrations of propofol on the Target-Controlled Infusion at sedation level 3 of the high-anxiety group were significantly higher than those of the low-anxiety group. Context-sensitive half time of high-anxiety group was also longer than that of the low-anxiety group. The postoperative pain score of the high-anxiety group was higher than that of the low-anxiety group. Increased preoperative anxiety was significantly correlated with postoperative wound pain (r = 0.240, P = 0.009) and previously experienced pain on same procedure (r = 0.252, P = 0.031), but not with pain on propofol injection (r = -0.05, P = 0.58).

CONCLUSIONS

The high-anxiety group needs more sedative requirement of propofol for conscious sedation than the low-anxiety group. Thus, we suggest that propofol dose for such sedation must take into account the individual patient's anxiety level when propofol is administered by an anesthesiologist for oocyte retrieval.

Body-mind-spirit intervention for IVF women

BACKGROUND

Literature supports the efficacy of psychosocial intervention for infertile women. An eastern body-mind-spirit group intervention has been developed to help infertile women in the Chinese population cope with the distress arising from IVF treatment.

METHODS

The eastern body-mind-spirit group intervention adopts a bio-psycho-social-spiritual health model, recognizing the strong association between mind, body, and spirit. Chinese philosophies and concepts of health will be integrated into the intervention, helping participants to regain balance and harmony both within themselves and between them and the environment. In this paper, a revisiting of assumptions, therapeutic goals, and the therapeutic process underlying this model are outlined. Program evaluation in terms of descriptive literary sketch done by the participants will be listed so as to illustrate the clinical process.

CONCLUSIONS

It was shown and reflected that the eastern Body-Mind-Spirit approach could enhance the holistic health of IVF women. Further investigation on the program efficacy is then suggested.

Psychological side-effects of clomiphene citrate and human menopausal gonadotrophin

OBJECTIVE

This study evaluated the psychological side-effects of clomiphene citrate (CC) and hMG in women undergoing fertility treatment.

METHOD

This study was a cross-sectional, self-report survey of 454 women at various stages of treatment for infertility. At the time of study, 139 women had not taken fertility drugs and 315 women had taken one or more cycles of CC or hMG. All subjects were asked to complete the State-Trait Anxiety Inventory (STAI). Women taking CC or hMG were also asked to complete a self-administered questionnaire on the side-effects of their medications.

RESULT(S)

In the CC group (n = 162) and hMG group (n = 153), 77.8% (126 of 162) and 94.8% (145 of 153) reported at least one side-effect, respectively. Irritability, mood swings, feeling down, and bloating had high frequencies in both CC and hMG groups, with a higher mean number of side effects reported in the hMG group (4.4 +/- 3.7 for the CC group and 6.8 +/- 3.7 for the hMG group, p < 0.001). There was no significant difference among the CC, hMG and no medication groups for mean state and trait anxiety scores. However, there were significant differences among the three side-effect groups (those who reported 1 to 4, 5 to 7, and more than 7 side-effects) for the mean scores of state (df = 2, F = 8.7, p < 0.001) and trait (df = 2, F = 11.9, p < 0.001) anxiety in women taking fertility drugs.

CONCLUSION(S)

Women taking CC or hMG reported high frequencies of psychological side-effects, and should be advised of these before treatment.

A longitudinal, prospective study on emotional adjustment before, during and after consecutive fertility treatment cycles

BACKGROUND

A longitudinal study into the course of the emotional response to IVF from pre-treatment to 6 months post-treatment and factors that contributed to that course.

METHODS

A total of 148 IVF patients and 71 partners completed self-report questionnaires on anxiety, depression, personality characteristics, meaning of fertility problems, coping, marital relationship and social support at pre-treatment. Assessments of anxiety and depression were repeated immediately following the final treatment cycle and again 6 months later (follow-up).

RESULTS

Women showed an increase of both anxiety and depression after unsuccessful treatment and a decrease after successful treatment. Men showed no change in anxiety and depression either after successful or after unsuccessful treatment. In the 6 months after unsuccessful treatment, women showed no recovery. At follow-up, >20% of the women showed subclinical forms of anxiety and/or depression. Personality characteristics, meaning of the fertility problems, and social support determined the course of the emotional response.

CONCLUSIONS

Most women adjusted well to unsuccessful treatment, but at follow-up, a considerable proportion still showed substantial emotional problems. Personality characteristics, pre-treatment meaning of the fertility problems and social support have demonstrated the adjustment to unsuccessful IVF in women. This allows early identification of women at risk as well as tailored interventions.

Variability in the difficulties experienced by women undergoing infertility treatments

OBJECTIVE

To identify the variety and extent of difficulties experienced by infertile women.

DESIGN

A cross-sectional survey study.

SETTING

A regional infertility clinic.

PATIENT(S)

Two hundred forty-two women undergoing evaluation and treatment of fertility problems, mostly at the initial stages of treatment.

INTERVENTION(S)

List of difficulties administered along with infertility distress and well-being scales.

MAIN OUTCOME MEASURES

Infertility distress and well-being measures.

RESULT(S)

Twenty-two difficulties resulting from infertility and its treatment were identified. Findings show great variability among women in the extent to which they experience these difficulties. Greater experience of difficulties was related to more distress and lower well-being. Some difficulties were lower for mothers of two or more children, yet even mothers of one child experienced difficulties that were mostly at similar levels to those reported by childless women.

CONCLUSION(S)

It is important to be aware of the great variability among women in their experience of infertility. The list of difficulties identified here, or similar lists identified using this procedure, could assist health care providers and psychosocial counselors in identifying misperceptions of difficulties that result in communication gaps between patients and providers and between patients and spouses.

A comparison of psychological functioning in couples undergoing frozen-thawed embryo replacement in various stages of treatment using the Mean Affect Adjective Check List (MAACL)

PURPOSE

The objectives were to identify the stage(s) of frozen embryo replacement cycle where the couples are most vulnerable to psychological dysfunction. Assessment was performed by using the Mean Affect Adjective Check-List (MAACL).

METHODS

Thirty couples completed the MAACL questionnaire at the following stages: (a) pretreatment (visit 1), (b) before embryo transfer (visit 2), and (c) before pregnancy test (visit 3). Each partner had to complete a separate questionnaire set.

RESULTS

For both partners, the depression score for visit 3 was significantly higher and the sensation seeking and positive affect scores were significantly lower than the corresponding scores for earlier visits. Anxiety scores were similar for all visits. For men, the hostility scores were significantly higher between visits 1 and 2 while in women the same was reported between visits 3 and 2.

CONCLUSIONS

Psychological counselling should be targeted at couples especially after embryo transfer. MAACL is a useful method for measuring psychological dysfunction in these couples.

Cohesion and Adaptability among Individuals under Treatment for Infertility

The objective of this study was to evaluate cohesion and adaptability as relationship patterns of individuals in the presence or absence of infertility. Infertile subjects (20 men and 26 women, age 29.9 yr., SD = 3.8), and 100 fertile individuals (52 men and 48 women, age 29.5 yr., SD = 3.6) were included in this cross-sectional study conducted in Brazil. Subjects were married for the first time and had no children. The pattern of relationship (cohesion and adaptability) was assessed on the Family Adaptability and Cohesion Evaluation Scale (FACES III). Subjects were also interviewed and the interviews tape-recorded and analyzed by independent and blinded senior psychiatrists. The concepts of cohesion and adaptability did not differentiate infertile couples from fertile ones. Further, the recorded interviews also resulted in heterogeneous, nonconcordant judgments. These results lead to two conclusions: that awareness of infertility is not present in the population studied or that it is present but the magnitude of its effect is quite small and that FACES III and the interview focus on adaptability and cohesion are not sensitive enough to measure the difficulties in these couples' relationships. This leads us to reflect on the type of psychiatric support available to infertile couples.

Survey of psychological health in women with infertility

The aims of this study were to assess mental well-being in women undergoing investigation and initial management of infertility and to determine any specific factors, such as the duration or type of infertility, that might be associated with an increased risk of psychological morbidity. A postal survey was sent to 1080 women with infertility attending gynecology outpatient departments in 12 Scottish centres. The survey included the Twelve-Item General Health Questionnaire (GHQ-12) and three multi-item scales from the Short Form Health Survey Questionnaire (SF-36). The response rate was 47.4% (512/1080) of which 507 completed the GHQ-12. Of the 507 GHQ-12 responders, 32.5% had a GHQ-12 score of > or = 8/12 suggesting they were at risk of clinically significant psychological disturbance. There were no significant associations between GHQ-12 scores and duration of infertility, the presence of existing children, or the cause of infertility. GHQ-12 scores significantly increased with the number of clinic attendances and decreased as the patient's age increased. Responders scored significantly lower on all aspects of the selected SF-36 questions as compared to published population data, suggesting poorer mental health. These standardized psychological instruments suggest that approximately 32% of women in the early stages of infertility management may be at risk of developing clinically relevant mental health problems. Psychological aspects of infertility should be addressed as part of a more holistic approach to management of these patients.

A study on psychological strain in IVF patients

PURPOSE

The objectives of this study were to compare average stress levels in infertile women to fertile women, to determine the stress levels whether the patients was pregnant or not pregnant, and to examine for a cross-section of infertile patients in different stages of medical investigation for the infertility.

METHODS

One hundred thirty-eight women receiving medical treatment for infertility attended the program. The State Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI) of perceived stress associated with the infertility was the outcome measure.

RESULTS

Infertile women showed significant increases in trait anxiety and depressive symptoms than the fertile women. Anxiety and depression in the in vitro fertilization (IVF)-failed women were significantly higher than the IVF-success women. According to the duration of infertility, STAI and BDI were moderately elevated in the first stage (< 3 year). There was a trend of a decreasing psychological stress with an advanced infertility duration. On depression scales, the intermediate and final duration of infertility patients showed less symptomatology than the first-stage patients. Contrary to the expectation, demographic factors such as religion and husband cooperation were not related to the experience of stress.

CONCLUSIONS

We must pay an attention to the infertile patient, especially from the initial infertility workup. We recommend psychological counselling for IVF-failed patients.

Anxiety and perceptive functioning of infertile women during in-vitro fertilization: exploratory survey of an Italian sample

The aim of this study was to study the emotional impact of in-vitro fertilization (IVF) and any possible influence due to the type of diagnosis, duration of infertility, number of cycles and type of responses to treatment. The study was carried out on 200 patients admitted to hospital for the final stages of IVF (oocyte retrieval and embryo transfer). The psychological measures taken into consideration were: state and trait anxiety levels (Stait-Trait Anxiety), unconscious and symptomatic anxiety, perception of self and of others (EWI). Monitoring of anxiety levels during hospitalization highlighted significant differences with respect to the state anxiety values (P < 0.01) and general anxiety (P < 0.05), but not with respect to trait anxiety. The level of state anxiety of women with a diagnosis of infertility was significantly lower (P < 0. 05). Women who have experienced infertility of medium to long duration presented a significantly lower state anxiety value (P < 0. 01). The failure of oocyte fertilization determines a significant increase in state anxiety level (P < 0.01) There were no significant differences in anxiety values with respect to the cycle number. Perceptive functioning was normal.

Culture, conceptive technology, and nursing

Technology is a form of cultural expression, formed of and forming culture. A paradox about technological innovation is that, in addition to creating new human arrangements and possibilities, it often serves only to reinforce existing sociocultural practices, norms, and values. The technologically radical is often the culturally conservative. Conceptive technology has contributed toward the redefinition of patienthood, the multiplication of models of infertility, and the reinforcement of existing cultural norms. Nurses are well-positioned to conduct a kind of technology assessment that places culture and ethics at the center of inquiry. They are also well-positioned to assist women and their partners seeking technological assistance to reproduce to understand the controversies concerning conceptive technology that may account for their own ambivalence toward continuing or terminating medical treatment, societal ambivalence toward supporting expensive fertility treatments, and cultural ambivalence toward technological development.

Physical complaints and emotional stress related to routine diagnostic procedures of the fertility investigation

The aim of this study was to map out the extent of the physical complaints and emotional stress due to diagnostic routines of the infertility work-up. To this end a questionnaire was sent to 96 consecutive couples visiting an infertility clinic of a university hospital. The results indicate that women often have physical complaints as a result of the hysterosalpingography (59%) and the diagnostic laparoscopy (47%) and mostly experience these diagnostic procedures as very stressful. Both the postcoital test and the semen analysis caused a moderate amount of stress. The other diagnostic procedures, including physical examination of both sexes, recording of the basal temperature and taking blood for hormonal determinations, were accompanied by fewer complaints and much less stress. It is concluded that the role of the hysterosalpingography and the diagnostic laparoscopy in the routine infertility work-up needs to be reconsidered in view of the burden they pose to the women involved.

Is a history of depressive symptoms associated with an increased risk of infertility in women?

Researchers have reported an association between self-reported antidepressant use and increased risk of ovulatory infertility but could not control for confounding by the drug indication. We evaluated the role of depressive symptoms in the development of infertility. We recontacted a population-based sample of Pawtucket Heart Health Program (PHHP) health survey respondents to perform this case-control study. Self-reported infertility was defined as an inability to conceive after 12 months of unprotected intercourse. Controls were women who reported at least one pregnancy. The index age for infertile women was the age at which they first experienced fertility problems, and for the fertile women it was the age of their first pregnancy. History of depressive symptoms was based on self-report before the index age. Women with a history of depressive symptoms were nearly twice as likely to report infertility relative to women without a history of depressive symptoms before the index age after controlling for potential confounders (90% confidence interval: 0.9-3.2). Our data suggest that depressive symptoms as well as the drugs used to treat these conditions may play an important role in the pathogenesis of infertility. The association between depressive symptoms and infertility should be explored further.

Quality of care for infertility patients. An evaluation of a plan for a hospital investigation

AIM OF STUDY

In this study we assessed the quality of health care for infertile patients as expressed by the patients themselves. The implementation of the existing structured plan for infertility investigation and treatment was also reviewed. DESIGN AND DATA: The sample consisted of all 361 women registered with an infertility diagnosis during 1982 at Rikshospitalet. Their medical records were reviewed in 1988. The process and outcome of the investigation as it appeared was analyzed for each individual patient. A structured questionnaire was distributed to the patients in 1988 and 72.6% responded. The questions included several items on outcome and personal experience of the treatment in the hospital.

RESULTS

Data from the medical records show that the medical investigation lasted three years on average. The records often showed evidence of discontinuity of the process. The mean number of consultations was eight (range 1-28). An average of one new doctor for each consultation was involved in the investigation. One third of the patients left the investigation without a noted definite termination of the treatment process. According to the questionnaire around 40% had delivered at least one child, while 30% had adopted. Of those who got a biological child, two thirds were satisfied with the clinical treatment efforts of the medical staff. Less than half of those who did not become pregnant were satisfied. Independent of outcome, 70% were dissatisfied with the emotional support during the investigations, and nearly 90% felt that waiting lists were too long. More than half expressed a need for professional psychological counselling.

CONCLUSIONS

The study shows that medical records and service organizations do not meet the need for continuity in treatment nor research and evaluation requirements. We suggest that more emphasis should be devoted to planning of the services. They should be improved with regard to quality in medical handling as well as emotional counselling.

Influence of perceived psychological stress and distress on antibody response to low dose rDNA hepatitis B vaccine

The present study focused on the relationship between psychological stress and immune reaction to a novel antigen. Participants completed questionnaires on daily hassles, psychoneurotic complaints, coping style, and loneliness, 2 and 6 months after the first of a series injections with a low dose recombinant DNA hepatitis B vaccine. Antibody response was determined 7 months after the first vaccination. Based on the psychological questionnaires two different stress measures were calculated: a Stress Index score-month-2 and a Stress Index score-month-6 indicating stress levels experienced at the beginning and at the end of the study respectively. Antibody levels were found to be negatively related with the Stress Index score-month-2. Although the influence of psychological stress reported on month 6 tended to be in the same direction, this effect was not significant. Coping styles and loneliness were not associated with antibody formation. These results suggest that antibody formation to rDNA hepatitis B vaccine is negatively influenced by psychological stress.