An investigation of the relationship between emotional maladjustment and infertility

Infertility and Social Issue Have the Most Significant Impact on Health-related Quality of Life among Polycystic Ovarian Syndrome Women in South India

Background

Infertility can have a significant impact on the identity of women. Individual women, who are infertile, experience tragic emotions, as well as those who are sad for great losses, like the death of a loved one. In this case, the woman is experiencing the loss of the ability to procreate.

Aim

In the present study, our major concern was to implement the health-related quality of life (HRQOL) Questionnaire on South Indian polycystic ovarian syndrome (PCOS) women to assess the impact of various clinical features of polycystic ovary syndrome on the HRQOL of South Indian women diagnosed.

Settings and Design

A total of 126 females in the first phase and 356 females in the second phase between the age group of 18-40 years characterised under the Rotterdam criteria were selected for the study.

Materials and Methods

The study was carried out in three different phases which included a one-to-one interview, group discussion and questionnaire session. In our study, we found that all the females who attend the study showed positivity for all the domains developed in the previous study and suggested that further domain can be developed.

Statistical Analysis Used

Suitable statistical methods were used with Graph pad PRISM (version 6).

Results

Hence, in our study, we developed a further new sixth domain called as 'social impact domain'. Among South Indian PCOS women, we found that infertility and social issue have the most significant impact on HRQOL.

Conclusion

The revised questionnaire by including the sixth domain called 'Social issue' is likely to be useful in measuring the quality of health of female having PCOS in regard to South Indian population.

Impact of polycystic ovary syndrome on eating behavior, depression and health related quality of life: A cross-sectional study in Riyadh

Background & objectives

Polycystic ovary syndrome (PCOS) is the most common endocrinal disorder, and the greatest cause of infertility in women. Despite availability of individual data on impact of multiple endocrinal, reproductive and even metabolic factors in PCOS individuals, the data on the co-existence of BED and depression in PCOS patients with its relationship on the quality of life in Saudi Arabian females is not found. Hence this study is aimed to elucidate the implication of PCOS on eating behaviour, induction of depression and general health quality in Saudi Arabian population of Riyadh.

Materials and methods

This is a cross-sectional study carried out in multiple health facilities of Riyadh from January to March 2019. The study samples (494) were recruited by convenience sampling and administered validated questionnaire by trained research participants. The data obtained was analysed by binary logistic regression using SPSS-IBM 25.

Results

Of the total 494 women participated in the study, 23.48% (116) were PCOS individuals. The odds of developing abnormal health related quality of (HRQ) in patients with PCOS was significantly (P = 0.000, OR = 3.472) high when compared to non-PCOS participants. The odds of showing high binge eating disorder (BED, P = 0.007, OR = 2.856) and depression (P = 0.000, OR = 2.497) scores in PCOS participants were significantly more than patients who were not having PCOS. Out of the three parameters studied, abnormal health related quality of life possessed a higher influence of PCOS compared to depression and abnormal eating behavior.

Interpretation & conclusion

In conclusion, the present study shows that women with PCOS are at a significant risk for depressive disorders, disorganized eating behavior and impaired quality of life. Therefore, necessary care and screening is required to minimize the impact of PCOS on already burdened individuals.

Stress in couples undergoing assisted reproductive technology

PURPOSE

To determine the associations between pre-treatment self-reported stress level, salivary cortisol levels, and clinical pregnancy outcome in couples undergoing assisted reproductive technology treatment (ART).

STUDY DESIGN

Seventy-five couples (150 patients) undergoing ART treatment were enrolled in this study. Psychological variables were assessed using the Perceived Stress Scale, Beck Anxiety Inventory, State-Trait Anxiety Inventory, and Beck Depression Inventory. Salivary cortisol levels were obtained from each couple prior to commencing gonadotropin treatment at several times (upon waking and at 15, 30, and 60 min after waking).

RESULTS

There was no statistically significant association between the self-reported stress levels and the ART treatment outcome in couples. Women with a successful outcome after ART treatment had higher median salivary cortisol levels than women who had an unsuccessful result [24.7 (19.9-63.1) vs. 20.7 (10.4-30.4), respectively]. There was no statistically significant difference in the median salivary cortisol levels of men in relation to ART treatment outcome. Salivary cortisol levels of the couples were not correlated.

CONCLUSIONS

Women who had higher median salivary cortisol levels in the pre-treatment period had a higher clinical pregnancy rate. This result suggests that moderately increased activity of the hypothalamic-pituitary-adrenal axis during ART treatment might be associated with successful conception.

The impact of depression, self-esteem, and body image on sleep quality in patients with PCOS: a cross-sectional study

BACKGROUND

To date, some factors associated with quality of sleep in patients with PCOS have been identified. Previous studies have mainly focused on limited psychological variables related to sleep disorder without evaluating them in a comprehensive framework.

OBJECTIVE

The aim of the present study was to evaluate the impact of predictive factors on the sleep quality of PCOS patients using structural equation modeling (SEM).

MATERIAL AND METHODS

The present study is a case control that is done in an infertility clinic in Hormozgan, Iran. The case group (n = 201) consisted of women with PCOS and the control group (n = 199) was healthy women whose partners had male infertility. All the women recruited to the study completed the Hospital Anxiety and Depression Scale, the Body Image Concern Investigation, the Rosenberg Self-esteem Scale, and the Pittsburgh Sleep Quality Index on attendance at the Hormozgan Infertility Clinic. Direct and indirect relationship between clinical signs, psychological situation, self-esteem, and body image was studied as independent predictors of sleep quality using structural equation modeling.

RESULTS

Compared with the control group, there was a lower sleep quality in women with PCOS in all fields, especially subjective sleep quality (P < 0.05), daytime function (P = 0.001), and use of sleep medication (P = 0.003). The strongest effect from a psychological variable on sleep quality was body image which had negative impact on sleep quality of patients with PCOS.

CONCLUSION

Our study showed that body image plays an important role in the sleep quality of women with PCOS.

Infertility and mental health

The World Health Organization (WHO) has indicated that 8–12% of couples worldwide experience infertility, and in recent years the number seeking treatment has dramatically increased. The diagnosis and therapy put a heavy psychological and physical burden on most patients, female and male. The incidence of depression in couples presenting for infertility treatment is significantly higher than in comparable fertile couples. Anxiety is significantly higher in infertile couples than in the general population. Professionals have become aware of the importance of providing educational interventions to address patients' fears and concerns, and to better prepare patients for the demands of treatment. Health professionals should follow a patient-centred approach to provide for the specific needs of the couple. Women in general have a positive attitude to seeking psychological help in the form of cognitive-behavioural therapy, couples counselling and infertility counselling.

Learning Objectives

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Quality of life in overweight (obese) and normal-weight women with polycystic ovary syndrome

OBJECTIVE

Polycystic ovary syndrome (PCOS) is characterized by phenotypic heterogeneity and has a wide variety of consequences. Approximately half of women with PCOS are overweight or obese, and their obesity may be a contributing factor to PCOS pathogenesis through different mechanisms. The aim of this study was to evaluate if PCOS alone affects the patients' quality of life and to what extent obesity contributes to worsen this disease.

DESIGN

To evaluate the impact of PCOS on health-related quality-of-life (HRQoL), 100 Mediterranean women with PCOS (group A), 50 with a body mass index (BMI) >25 kg/m² (group A₁) and 50 with BMI <25 kg/m² (group A₂), were recruited. They were evaluated with a specific combination of standardized psychometric questionnaires: the Symptom Checklist-90 Revised, the 36-Item Short-Form Health Survey, and the Polycystic Ovary Syndrome Questionnaire. The patients were compared with a normal-weight healthy control group of 40 subjects (group B). Another control group of 40 obese healthy women (group C) was used to make a comparison with PCOS obese patients (A₁).

RESULTS

Our results showed a considerable worsening of HRQoL in PCOS patients (A) compared with controls (B). In addition, patients with PCOS and BMI >25 (A₁) showed a significant and more marked reduction in scores, suggesting a lower quality of life, compared with controls (B) and with normal-weight PCOS patients (A₂).

CONCLUSION

PCOS is a complex disease that alone determines a deterioration of HRQoL. The innovative use of these psychometric questionnaires in this study, in particular the PCOS questionnaire, has highlighted that obesity has a negative effect on HRQoL. It follows that a weight decrease is associated to phenotypic spectrum improvement and relative decrement in psychological distress.

Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycystic ovarian syndrome: A randomized control trial

Context:

Yoga techniques practiced for varying durations have been shown to reduce state anxiety. This was never assessed in adolescents with polycystic ovarian syndrome (PCOS).

Aims:

To compare the effect of a holistic yoga program with the conventional exercise program on anxiety level in adolescents with PCOS.

Settings and Design:

Ninety adolescent (15-18 years) girls from a residential college in Andhra Pradesh, who satisfied the Rotterdam criteria, were randomized into two groups.

Materials and Methods:

Anxiety levels were assessed at inclusion and after 12 weeks of intervention wherein yoga group practiced a holistic yoga module while the control group practiced a matching set of physical exercises (1 h/day, for 12 weeks).

Statistical Analysis Used:

Mann-Whitney U test was used to compare difference scores (delta change) between the two groups

Results:

Changes in state anxiety after the intervention were nonsignificantly different between the two groups (P=0.243), while changes after the intervention were significantly different between the two groups (P=0.002) for trait anxiety.

Conclusions:

Twelve weeks of a holistic yoga program in adolescents with PCOS is significantly better than physical exercise program in reducing anxiety symptoms.

Psychological disturbances and quality of life in obese and infertile women and men

Anovulatory cycles and endometriosis are the main causes of female infertility. The most frequently anovulatory cycles are related to polycystic ovary syndrome (PCOS) commonly associated with obesity and hormonal disturbances in the course of obesity. Recently published studies revealed that infertility affects about one in six couples during their lifetime and is more frequent in obese. Obesity is also associated with male infertility related to erectile dysfunction, hormonal disturbances and lower semen quality. Any of these above mentioned disorder is the important risk factor of psychological disturbances and poor quality of life among women and men in the reproductive age. On the other hand the mood disorders may exacerbate the hormonal disturbances and worsen the effectiveness of infertility management. Infertility, its therapy with accompanying psychological disturbances may also significantly affect the partners relationships. The review summarize the results described in the current literature on the association between obesity and infertility and psychological disturbances as well as their impact on quality of life and sexual functioning in women and men. Moreover, the impact of infertility and psychological disturbances on partners relationships is discussed.

Web-based treatment for infertility-related psychological distress

Infertility has been associated with stigma and negative psychosocial functioning. However, only a small proportion of this population actually receives care. Fertility patients predominantly use the Internet for information gathering, social support, and assistance with decision-making; yet, available web resources are unreliable sources of mental health care. Web-based alternatives also have the potential to assist with intervention access difficulties and may be of significant lower cost. This study evaluated the efficacy of a web-based approach to providing a cognitive behavioral intervention with 31 infertile women seeking medical reproductive technologies. Following randomized assignment, participants using the web-based intervention were compared with those in a wait-list control condition on general and infertility-related psychological stress measures. Results were mixed regarding intervention efficacy. Significant declines in general stress were evidenced in the experimental group compared with a wait-list control group. However, website access did not result in statistically significant improvements on a measure of infertility-specific stress. These findings add to the literature on psychological interventions for women experiencing fertility problems. Moreover, despite the widespread use of the Internet by this population, the present study is one of the first to investigate the usefulness of the Internet to attenuate stress in this population. Preliminary results suggest general stress may be significantly reduced in infertile women using an online cognitive behavioral approach.

Depressive symptoms related to infertility and infertility treatments

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

Polycystic ovary syndrome and its impact on women's quality of life: More than just an endocrine disorder

In the past, polycystic ovary syndrome has been looked at primarily as an endocrine disorder. Studies now show that polycystic ovary syndrome is a metabolic, hormonal, and psychosocial disorder that impacts a patient’s quality of life. It is extremely important to holistically treat these patients early on to help them deal with the emotional stress that is often overlooked with polycystic ovary syndrome. Early diagnosis and long term management can help control polycystic ovary syndrome so that women can still live a healthy active life and avoid long-term complications such as metabolic syndrome and cardiovascular diseases.

Psychosocial characteristics of women and men attending infertility counselling

BACKGROUND

Little is known about the psychosocial characteristics of infertile couples seeking psychological help. This study describes couples attending infertility counselling.

METHODS

Questionnaires pertaining to socio-demographic factors, motives for wanting a child, lay aetiology of their infertility, dimensions of life and partnership satisfaction, and a complaints list were completed by 974 women and 906 men. Of those who indicated an openness to counselling, almost half actually attended infertility counselling, and two groups, 'no counselling' (358 women and 292 male partners) and 'taking up counselling' (275 women and 243 male partners), were therefore compared.

RESULTS

More couples with stressful life events were found in the counselling group. For women taking up counselling, psychological distress, in the form of suffering from childlessness and depression as well as subjective excessive demand (as a potential cause for infertility), was higher in comparison to women not counselled. The higher distress for men in the counselling group was indicated by relative dissatisfaction with partnership and sexuality and by accentuating the women's depression.

CONCLUSIONS

Infertile couples seeking psychological help are characterized by high levels of psychological distress, primarily in women. The women's distress seems to be more important for attending infertility counselling than that of the men.

Percutaneous vesiculodeferentography in the diagnosis of male infertility: A review of our results and the data reported in the literature

Vesiculodeferentography was used in the past to evaluate suspected cases of obstruction of the seminal ducts. Over the years, numerous attempts have been made to improve the technique used to perform this examination and to render it less invasive. Its use is currently indicated in selected cases, where it is combined with functional studies like seminal tract washout and followed by immediate interventions to correct the alterations revealed. Vesiculodeferentography includes collection of the contents of the seminal vesicles, which can later be used in vitro assisted fertilization procedures.

Mood disorders and fertility in women: a critical review of the literature and implications for future research

A medline literature review of fertility and mood disorder articles published since 1980 was performed in order to critically review the literature regarding a relationship between mood disorders, fertility and infertility treatment. Previous studies suggests that mood disorders, both in the bipolar and unipolar spectrum, may be associated with decreased fertility rates. Most studies report that women seeking treatment for infertility have an increased rate of depressive symptoms and possibly major depression (none showed evaluated mood elevations). Many, but not all, studies found that depressive symptoms may decrease the success rate of fertility treatment. Treatments for infertility may independently influence mood through their effects on estrogen and progesterone, which have been shown to influence mood through their actions on serotonin. Studies are limited in scope and confounding variables are many, limiting the strength of the results. In conclusion, a range of existing studies suggests that fertility and mood disorders are related in a complex way. Future studies should use clinical interviews and standardized and validated measures to confirm the diagnosis of mood disorders and control for the variables of medication treatment, desire for children, frequency of sexual intercourse, age, FSH levels, menstrual cycle regularity in assessing an interrelationship between mood disorders and fertility.

Psychological distress by type of fertility barrier

BACKGROUND

We examined fertility-specific distress (FSD) and general distress by type of fertility barrier (FB).

METHODS

In a random sample telephone survey, 580 US women reported their fertility intentions and histories. Six groups of women were identified: (i) no FBs, (ii) infertile with intent, (iii) infertile without intent, (iv) other fertility problems, (v) miscarriages and (vi) situational barriers. Multiple regression analyses were used to compare groups with FBs.

RESULTS

Sixty-one percent reported FBs and 28% reported an inability to conceive for at least 12 months. The infertile with intent group had the highest FSD, which was largely explained by (a) self-identification as infertile and (b) seeking medical help for fertility. The no FB group had a mean Center for Epidemiological Studies Depression scale score above the commonly used cut-off of 16, although 23% of the women with FBs did score above 16.

CONCLUSIONS

FBs are common. Self-identification as infertile is the largest source of FSD. More women with FBs had elevated general distress than women without FBs; mean general distress was below 16 for all FB groups. It may be that, for some women (even those with children), FBs can have lasting emotional consequences, but many women do heal from the emotional distress that may accompany fertility difficulties.

The social implications of embryo cryopreservation

OBJECTIVE

To summarize the existing literature regarding the social implications of embryo cryopreservation and outline areas in need of further study.

RESULT(S)

The potential social impact of oocyte cryopreservation has not been investigated. Embryo cryopreservation has been increasingly used to improve the cost-effectiveness of in vitro fertilization (IVF) and expand the options available to infertile couples, yet its widespread adoption has occurred more rapidly than our ability to study the social consequences for the couples and health professionals involved. For maintaining cryopreserved embryos, the existing literature is fragmented and incompletely explores the effects on an infertile couple's psychosocial health and personal relationships, their family planning strategies, or their preferences for the disposition of the embryos. Managing unclaimed embryos continues to create challenges for assisted reproduction professionals.

CONCLUSION(S)

We currently lack a thorough understanding of the numerous social implications of cryopreservation. Major areas for future research include the impact of stored embryos on couples' fertility intentions and psychosocial health, factors that affect couples' decisions about embryo disposition, strategies to minimize unclaimed embryos, and the consequences of oocyte/ovarian cryopreservation.

Health-related quality of life in women with polycystic ovary syndrome, a self-administered questionnaire, was validated

OBJECTIVE

We examined the measurement properties of a questionnaire (PCOSQ) measuring health-related quality of life (HRQOL) in women with the polycystic ovary syndrome (PCOS).

STUDY DESIGN

This multicenter prospective randomized placebo-controlled blinded study enrolled 393 patients with PCOS at tertiary care sites. Participants were randomized to placebo or troglitazone (150 mg/d, 300 mg/d, or 600 mg/d). At baseline (n=393) and after 44 weeks of treatment (n=284) the proportion of normal menstrual cycles, the free testosterone (T) level, four objective measures of facial hair growth (hair density and hair growth rate by photography, and hair diameter and hair growth rate using plucked hairs), and a subjective assessment of the degree of hirsutism, the modified Ferriman-Gallwey (F-G) score, were determined. At both visits, patients also completed the PCOSQ. Since the trial was conducted, troglitazone has been removed from the market because of toxic effects. The PCOSQ includes 26 questions (items) that address five areas of concern (domains), including emotions, body hair, body weight, fertility, and menstruation rated on a seven-point scales in which lower scores denote higher degrees of patient concern and a lower HRQOL.

RESULTS

Cronbach's alpha was >0.7 for four of five domains. Factor analysis provided moderate to strong support for the five-domain structure of the PCOSQ. Cross-sectional correlations were weak with all measures but the F-G score and hair growth (r=-.46, P < .01). The change in the F-G score showed a statistically significant (P < .01) correlation with changes in PCOSQ hair growth (r=-.22), weight (r=-.17), infertility (r=-.20), and menstruation (r=-.20). Changes in the proportion of normal menstrual cycles correlated with change in the infertility domain (r=.14, P < .03) and with the change in the menstruation domain (r=.31, P < .001). The PCOSQ proved as responsive as the F-G, and more responsive than the objective measures of hair growth, to effects of troglitazone.

CONCLUSIONS

Our data provides some support for the discriminative and longitudinal validity, and appreciable support for the responsiveness, of the PCOSQ.

L'impact de l'infertilité et de ses traitements sur la vie sexuelle et la relation de couple : revue de la littérature

This paper reviews the literature on the psychosocial impact of infertility and its treatments by the ART on the marital sexuality, by paying special attention to the relationship between gender and the infertility experience. It is convenient to divide this literature into articles that explore the sexual life of the infertile couples on the one hand, and those focusing on the couple relationship - marital satisfaction and marital adjustment-, on the other hand. The literature on the infertile couples' sexuality and sexual satisfaction, mostly descriptive, presents infertility as a deleterious experience for both women and men even if the repercussion differ according to gender, with correlative dynamic effects within the couple. The contributions to the investigation of the couple relationship, mostly quantitative Anglo-Saxon studies, have produced equivocal or contradictory results concerning the satisfaction with the relationship, the closeness between the two partners so that it is difficult to assume a trend in this field. This situation is largely due to the problems of sampling. In this view, future research should perform its methodological apparatus to take into account the processual nature of the infertility experience, at both levels of couple history and its involvement in the ART process.

Psychogenic infertility--myths and facts

PURPOSE

The hypothesis of this review is that the role of psychological factors as the sole cause of infertility is generally overrated.

METHODS

A review is given of studies concerning the influence of psychological factors on the development of infertility.

RESULT

A prevalence of psychogenic infertility of 10-15 per cent must be discussed critically. A value of approximately 5 per cent is more realistic. Equating unexplained infertility with psychogenic infertility is not justified. A definition of psychogenic infertility according to the German guidelines Psychosomatics in Reproductive Medicine is presented. Spontaneous pregnancies following adoption or the decision to remain childless are the absolute exception. The association of stress and infertility in humans is still unclear. For many women the effect of infertility and notably of medical therapy is a considerable emotional stress. This may make psychosocial counseling necessary in certain cases.

CONCLUSIONS

An exclusive psychological/psychodynamical point of view on the complexity of infertility is as inadequate as a strictly somatic point of view. Infertility should always be treated as a psychosomatic entirety.

Quality of life, psychosocial well-being, and sexual satisfaction in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by chronic anovulation and hyperandrogenism. PCOS is one of the leading causes of infertility and manifests with hirsutism, acne, and obesity. To investigate its impact on health-related quality of life and sexuality, 50 women with PCOS and 50 controls were evaluated with standardized questionnaires (36-item short-form health survey, symptom checklist revised, and life satisfaction questionnaire). The impact of hirsutism, obesity, and infertility was assessed using five-point rating scales, and sexual satisfaction was analyzed with visual analog scales. Patients showed greater psychological disturbances on the symptom checklist revised dimensions, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, aggression, and psychoticism, along with a lower degree of life satisfaction in the life satisfaction questionnaire scales health, self, and sex. Health-related quality of life measured with the 36-item short-form health survey revealed significantly decreased scores for physical role function, bodily pain, vitality, social function, emotional role function, and mental health in patients with PCOS. Although patients had the same partner status and frequency of sexual intercourse, they were significantly less satisfied with their sex life and found themselves less attractive. Most of the differences were not affected by correction for body weight. In conclusion, PCOS causes a major reduction in the quality of life and severely limits sexual satisfaction.

Psychiatric symptoms in Turkish infertile women

The aims of this study were to determine the psychiatric symptoms which may develop because of infertility in Turkish women and to find out the precipitating factors. Fifty women with primary infertility and 50 health controls were evaluated using the Beck Depression Inventory, Spielberger Stait-Trait Anxiety Inventory, Rosenberg self-esteem scale and Symptom Checklist scale. They were also asked to describe the reactions received from their husband, husbands' families and social group because of infertility. Psychiatric symptoms were not significantly different between the two groups. However, within the infertile group, depression and anxiety were more frequent in the women who received negative reactions from their husband, their husbands' families and social group. Depression, anxiety and self-esteem were improved in the infertile women as age and the duration of infertility increased. In conclusion, our findings indicate that the reactions the infertile women are faced with play an important role in the development of certain psychiatric symptoms.

Ultrasound diagnosis of polycystic ovaries in women who have no symptoms of polycystic ovary syndrome is not associated with subfecundity or subfertility

OBJECTIVE

To evaluate the effect on fertility of the appearance of polycystic ovaries in women who have no symptoms of polycystic ovary syndrome.

DESIGN

Case-control study.

SETTING

Teaching hospitals in Hull, United Kingdom.

PATIENT(S)

Women with the appearance of polycystic ovaries on ultrasound and women with normal ovaries.

INTERVENTION(S)

A questionnaire about previous subfertility, pregnancies, menstrual pattern, features of polycystic ovary syndrome, gynecological history, and individual lifestyle factors.

MAIN OUTCOME MEASURE(S)

Time to pregnancy (TTP) and relative risk (RR) of subfertility in symptomatic and asymptomatic subgroups of both groups.

RESULT(S)

Women with PCOs took longer TTP and were significantly less fertile if they were obese (RR = 2.6), had menstrual disturbances (RR = 4.6), hirsutism (RR = 2.5), and/or acne (RR = 2.7). Further reductions in fecundity occurred with an increasing number of symptoms (threefold, sevenfold, and 10-fold longer TTP with two, three, and four symptoms, respectively). The TTP of women with no symptoms was not significantly longer and they were not more likely to be subfertile than women with normal ovaries. These symptoms were not associated with significantly reduced fecundity in women with normal ovaries.

CONCLUSION(S)

The appearance of polycystic ovaries has been shown to have no significant impact on fertility in women with no symptoms. Appearances alone do not reflect the pathological features of polycystic ovary syndrome, and additional diagnostic criteria should be considered. Obesity, menstrual disturbances, and/or hyperandrogenism are factors associated with subfertility in women with polycystic ovaries.

Distress and concerns in couples referred to a specialist infertility clinic

OBJECTIVES

The aims of this study were to examine emotional distress and infertility-related concerns in male and female members of couples referred to a specialist infertility clinic and to determine changes in these over time.

METHODS

A prospective cohort study with a 6-month follow-up. Emotional distress was measured using the Hospital Anxiety and Depression Scale, and concerns by a specially designed questionnaire.

RESULTS

The response rate achieved was 38%. At baseline, 25.7% of women and 8.9% of men had scores of greater than 10 on the Hospital Anxiety and Depression Scale (HADS) Anxiety subscale, and 2.7% of women and 1.8% of men had scores of greater than 10 on the HADS Depression subscale. At 6-month follow-up the HADS scores were substantially unchanged. Females reported a significantly greater infertility-related concerns regarding life satisfaction, sexuality, self-blame, self-esteem and avoidance of friends compared with males.

CONCLUSIONS

The prevalence of emotional disorder identified was low. There were gender differences in the nature of the specific concerns reported. The degree of distress and concerns did not change significantly over time. There are a minority of patients, mainly females, with clinically significant distress and infertility-related concerns amongst patients attending infertility clinics who deserve psychological attention.

Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life

OBJECTIVE

To examine the fertility concerns and sexual behavior of adolescent girls with polycystic ovary syndrome (PCOS) as compared to healthy adolescent girls and the effect of these concerns on health-related quality of life.

DESIGN AND SETTING

A cross-sectional study of adolescent girls with PCOS (n = 97) and healthy comparisons (n = 186) was conducted at an urban, hospital-based adolescent medicine practice. Participants completed the Child Health Questionnaire Version CF-87 as a measure of health-related quality of life and a general health history questionnaire that included items regarding sexual activity, contraception, fertility concerns, and severity of illness. Findings were evaluated using multivariate logistic and linear regression models.

RESULTS

Healthy subjects were 2.8 times more likely to have had sexual intercourse than PCOS participants, though the mean age at initiation of sexual intercourse among sexually active girls was not significantly different between the two groups. Severity of illness and the worry about fertility were not associated with odds of being sexually active. Girls with PCOS were 3.4 times more likely to be worried about their ability to become pregnant than comparisons and concern about future fertility was associated with significant reductions in quality of life.

CONCLUSION

Adolescents with PCOS are more concerned about fertility than their healthy peers and this concern may affect their overall quality of life. The finding that more than a third of the adolescents with PCOS in this study were sexually active underscores the importance of providing ongoing counseling on fertility issues, contraception, and STD prevention in the care of adolescent girls with PCOS.

A review of the literature relating caffeine consumption by women to their risk of reproductive hazards

From this detailed review of the literature, several conclusions can be drawn: (a) An association between caffeine consumption and a reproductive hazard is more likely to be seen in lower-quality studies than in studies that come closer to approximating the ideal. This is especially evident for "lower" birthweight and congenital anomalies. (b) The association between caffeine consumption and spontaneous abortion may well reflect the Stein-Susser epiphenomenon (women with prominent nausea tend to reduce caffeine consumption and nausea appears to be a marker of good implantation, perhaps reflecting a favorable balance of hormones produced by a healthy placenta). (c) The claim that caffeine consumption by women delays conception has not been followed by convincing support. (d) Reproductive hazards associated with cigarette smoking tend to be associated with caffeine/coffee consumption. Sometimes this appears to be a consequence of residual confounding associated with inadequate adjustment for cigarette smoking, which is over-represented among those who drink the most coffee/caffeine. Sometimes this reflects the tendency of women to underreport socially undesirable behaviors (e.g. smoking) while accurately reporting socially neutral behaviors (e.g. coffee and caffeine consumption). Thus, it seems reasonable to conclude that no convincing evidence has been presented to show that caffeine consumption increases the risk of any reproductive adversity.

Psychopathology, personality, and marital relationship in patients undergoing in vitro fertilization procedures

OBJECTIVE

To compare the psychopathology, personality features, and marital relationships of women undergoing in vitro fertilization (IVF) with those of control patients, and to compare IVF inductees with program veterans.

DESIGN

Cross-sectional clinical study.

SETTING

A university hospital.

PATIENT(S)

One hundred and one women undergoing IVF treatment.

INTERVENTION(S)

Psychometric tests were administered at first visit (baseline) of index treatment cycle.

MAIN OUTCOME MEASURE(S)

Achievement of pregnancy.

RESULT(S)

Women undergoing IVF show higher levels of anxiety and emotional tension than do controls. Although the infertile women showed no abnormal personality dimensions, the IVF group did have a particular psychological profile and a different marital relationship pattern when compared with the control participants. Between IVF veterans and inductees, there are significant differences with respect to psychopathology, psychological dimensions, and couple dynamics. The achievement of pregnancy is not associated with any special psychopathological, personality, or marital characteristics among the IVF women.

CONCLUSION(S)

The most crucial period in IVF procedures may immediately follow the end of the first cycle because of the high risk of patients dropping out of the program. To determine the most effective supporting therapies for women undergoing fertilization procedures it could be useful to consider the psychological and relational differences between veterans and inductees.

Stress and reproductive failure: an evolutionary approach with applications to premature labor

This article takes an evolutionary approach to the study of reproductive failure, drawing attention to the importance of reproductive failure among mammals as a means of timing reproduction in response to a variable environment. These concepts also apply to the diagnosis and treatment of prematurity, because before the advent of modern medicine most premature births probably constituted failed reproduction. Problems in the diagnosis and treatment of reproductive failure are described, with specific parallels drawn between the diagnoses and treatments of infertility and prematurity.

Psychological distress and infertility: forty years of research

A critical review is provided of the literature of psychosomatic infertility, including research on the relation of psychological distress and infertility, interventional studies in which efforts to treat underlying psychopathology are related to success or failure in conceiving, and proposed neurophysiological mechanisms that relate psychological status and fertility. Directions for future research to address the issue of psychological distress and infertility are also outlined.

Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS)

OBJECTIVE

To develop a self-administered questionnaire for measuring health-related quality of life (HRQL) in women with polycystic ovary syndrome (PCOS).

METHODS

We identified a pool of 182 items potentially relevant to women with PCOS through semistructured interviews with PCOS patients, a survey of health professionals who worked closely with PCOS women, and a literature review. One hundred women with PCOS completed a questionnaire in which they told us whether the 182 items were relevant to them and, if so, how important the issue was in their daily lives. We included items endorsed by at least 50% of women in the analysis plus additional items considered crucial by clinicians and an important subgroup of patients in a factor analysis. We chose items for the final questionnaire taking into account both item impact (the frequency and importance of the items) and the results of the factor analysis.

RESULTS

Over 50% of the women with PCOS labelled 47 items as important to them. Clinicians chose 5 additional items from the infertility domain, 4 of which were identified as important by women who were younger, less educated, married, and African-American. The Cattell's Scree plot from a factor analysis of these 51 items suggested 5 factors that made intuitive sense: emotions, body hair, weight, infertility, and menstrual problems. We chose the highest impact items from these 5 domains to construct a final questionnaire, the Polycystic Ovary Syndrome Questionnaire (PCOSQ), which includes a total of 26 items and takes 10-15 minutes to complete.

CONCLUSIONS

We have used established principles to construct a questionnaire that promises to be useful in measuring health-related quality of life. The questionnaire should be tested prior to, or concurrent with, its use in randomized trials of new treatment approaches.

Infertility and psychological distress: a critical review of the literature

This essay reviews the literature on the social psychological impact of infertility, paying special attention to the relationship between gender and the infertility experience. It is convenient to divide the literature into articles which explore the possibility that infertility may have psychological causes (Psychogenic Hypothesis) and those which examine the psychological consequences of infertility (Psychological Consequences Hypothesis). The psychogenic hypothesis is now rejected by most researchers, but a related hypothesis, which states that stress may be a causal factor in infertility, is worthy of exploration. The descriptive literature on the psychological consequences of infertility presents infertility as a devastating experience, especially for women. Attempts to test the psychological consequences hypothesis have produced more equivocal results. In general, studies which look for psychopathology have not found significant differences between the infertile and others. Studies which employ measures of stress and self-esteem have found significant differences. The psychological consequences literature is characterized by a number of flaws, including over sampling of women, small sample size, non-representative samples, failure to study those who have not sought treatment, primitive statistical techniques, and an over-reliance on self-reports. Studies on infertility and psychological distress need to take into consideration both the duration of infertility and the duration of treatment. Finding an appropriate set of "controls" is a particularly intractable problem for this area of research. In general, the psychological distress literature shows little regard for the social construction of infertility. By taking what should be understood as a characteristic of a social situation and transforming it into an individual trait, the literature presents what is essentially a medical model of the psycho-social impact of infertility. Most researchers conclude that infertility is a more stressful experience for women than it is for men. Most studies have found that the relationship between gender and infertility distress is not affected by which partner has the reproductive impairment. Future research needs to be better informed by theoretical considerations. Scholars need to pay more attention to the way the experience of infertility is conditioned by social structural realities. New ways need to be developed for better taking into account the processual nature of the infertility experience. Efforts need to be make to include under-studied portions of the infertile population. Finally, more effort needs to be made to better integrate the empirical study of the experience of infertility with important social policy questions.

Choices and motivations of infertile couples

When couples are confronted with infertility they may choose among several options: medical help, adoption, fostering, alternative medicine and focusing on other life goals. The frequency of choices and motivations for these options were investigated among 131 infertile couples. Husbands and wives answered a structured questionnaire. The medical option was chosen in more than 80% of the cases. Also, this choice is made very quickly. Other options were considered at a later time, and chosen much later than the medical option. The most frequently mentioned motive for seeking help is the desire to have a child. This motive is reported in all forms of help seeking Motives for medical consultation are often seeking information, understanding the cause of infertility and physical complaints. Altruistic motives are rather important when considering adoption, and very important when considering foster-care.

Is there too much emphasis on psychosocial counseling for infertile patients?

Clinical papers strongly recommend psychosocial counseling for patients attending infertility clinics. These recommendations are at odds with studies showing that very few patients actually take-up such services. The disparity between recommendation and actual use would seem to be due to the lack of distinction between the needs of the few highly distressed patients who feel overwhelmed by their infertility and those of the average infertile couple who experience distress but cope well with it. In the former case, psychosocial counseling is likely to be beneficial, while in the latter case informal sources of help, for example, that provided through documentation, are likely to be sufficient. Unfortunately, the emphasis on psychosocial counseling for highly distressed patients in the area of infertility has left the needs of less distressed patients neglected and the potential usefulness of alternative methods of intervening with these patients unexplored.

Perceived support and counselling needs in relation to in vitro fertilization

This paper reports findings from a study investigating perceived support and desire for support in a sample of 101 men and 117 women who were consecutive referrals to an in vitro fertilization (IVF) clinic. Both men and women perceived their partners as providing the most support and there were only small gender differences in the extent to which other people were perceived as supportive. There were also only modest gender differences in the types of support participants felt to be desirable and both men and women felt that support would be most desirable after a failed IVF cycle. Both men and women also felt that a routinely provided information booklet about the practical aspects of IVF would improve knowledge of and passage through an IVF cycle. There was a tendency for women who expressed a desire for some form of counselling or support to obtain higher General Health Questionnaire scores. Implications of the results for counselling provision are discussed.

A researcher's guide to investigating the psychological sequelae of infertility: methodological considerations

Research into the psychological sequelae of infertility has been plagued by a number of methodological problems. The most common methodological concerns involve conceptual confusion regarding the measurement and existence of psychiatric morbidity among the infertile, selection of convenience samples which limit generalizability, and failure to analyze the influence of important variables like diagnosis, treatment length, dyadic concordance and dyadic patterns. These methodological limitations are detailed and recommendations are made for future research.

Coping strategies and psychological adjustment of couples presenting for IVF

The study was designed to examine the extent to which the psychological profiles of couples entering an IVF programme were influenced by evidence of previous fertility, the history of fertility investigations, the diagnosis made, and the coping strategies adopted. A sample of 152 couples was administered a number of standardized psychological instruments and a coping strategies questionnaire. They showed little variation from the normative range on the standardized measures. There was little evidence of differences between couples referred for primary or secondary infertility, between those with some evidence of fertility and those with none, or between different diagnostic groups. In relation to coping strategy, for women at least, taking direct action appears to be effective if it is associated with some degree of acceptance of one's position. For males, the picture is less clear, though direct action and acceptance again appear to be effective coping strategies.

Psychosocial adjustment to infertility and its treatment: male and female responses at different stages of IVF/ET treatment

Gender differences in psychosocial adjustment to infertility and its treatment were evaluated amongst a cross-sectional sample of 330 couples, of whom 113 were first time participants and 217 were repeat cycle couples. Whilst 30% of both husbands and wives experienced clinically elevated anxiety regardless of stage of treatment; repeat cycle women (25%) faced the further risk of developing clinically severe depressive symptoms. Significant differences in the amount of care and control received from their spouse and in the degree they suppressed their emotions were reported amongst repeat cycle couples. Any clinical implications of differences in male-female caring styles are discussed within the IVF context. Our results suggest that interventions intended not only to reduce anxiety and depressive symptoms, but also to facilitate ongoing psychosocial functioning, should be implemented for couples at different stages of IVF/ET treatment.

The impact of infertility on psychological functioning

To explore the impact of infertility on psychological functioning 130 couples presenting with primary infertility were assessed at their initial visit to an infertility clinic. Of these, 116 couples were assessed on a second occasion some 7-9 months later when in most cases the medical tests were complete. Measures of personality, psychopathology, perceived social support, sex role identity and marital state were obtained from both partners. The set was subsequently divided into five subgroups on the basis of the diagnosis made or the outcome (female cause, male cause, female and male cause, unexplained and pregnant). The results show little evidence of psychopathology in the sample, depression scores remained low throughout the period of investigation. The results also indicated stable marital relationships. Scores on tests of anxiety and psychiatric morbidity declined between the first and second assessment except in the case of men who were diagnosed with a fertility problem. The implications of these findings are discussed in the increased use of donor insemination which circumvents rather than treats the problem of male infertility.

Stress and human reproduction

The interaction between emotional stress and infertility has been investigated for many years. Many infertile couples show marked stress during infertility evaluation and treatment. Most of the investigations that were performed during the last two decades show that in the majority of cases stress is the result and not the cause of infertility. The biological interaction between stress and infertility is the result of the action of stress hormones at the brain level, especially on the hypothalamus-pituitary and on the female reproductive organs. Stress hormones such as catecholamines (adrenalin, nonadrenaline and dopamine) and the hypothalamic-pituitary-adrenal axis interact with hormones which are responsible for normal ovulatory cycles: i.e., gonadotropin releasing hormone (GnRH), prolactin, LH and FSH. Endogenous opiates and melatonin secretion are altered by stress and interfere with ovulation. Sympathetic innervation of the female reproductive system provides routes by which stress can influence fertility at the of the sex organs level. Infertility causes stress which is aggravated as time passes and the couple remains infertile. Among the causes of stress are the couple's isolation, life with unrealized potential and unborn child, disruption of day-to-day life during infertility evaluation and treatment, and the couple's feeling that they do not have control of their own lives. The IVF program is considered by many as the final step for the evaluation of the couples fertility potential, hence, couples participating in an IVF program are highly stressed, especially after a failed IVF cycle.

Motives for parenthood and response to failed in vitro fertilization: implications for counseling

The purpose of this investigation was to identify in vitro fertilization (IVF) candidates' motives for parenthood and hence for seeking treatment. The relationship among identified motives, pretreatment emotional adjustment, and reaction to treatment failure was then examined. Women as a group placed greatest emphasis on fulfilling gender-role requirements, and those strongly endorsing such motives showed the poorest adjustment before IVF and the most negative reaction to first-cycle failure. In contrast, men in general were more likely to stress a desire for marital completion, although this motive was not predictive of emotional status before or after IVF. However, men experiencing social pressures to have children were at greater risk when treatment failed. The results indicate that greater consideration of cognitive factors may enhance understanding of emotional reactions to IVF failure and provide important insights for therapeutic intervention.