Psychosocial adjustment to unsuccessful IVF and GIFT treatment

Unmet Parenthood Goals, Health-Related Quality of Life and Apparent Irrationality: Understanding the Value of Treatments for Infertility

An increasing number of prospective parents are experiencing infertility along with associated negative impacts on mental health and life satisfaction that can extend across a network of individuals and family members. Assistive reproductive technologies (ART) can help prospective parents achieve their parenthood goals but, like any health technology, they must demonstrate acceptable 'value for money' to qualify for public funding. We argue that current approaches to understanding the value of ART, including quality-adjusted life-year (QALY) gains based on changes in health-related quality of life (HRQOL) and, more often, cost per live birth, are too narrow to capture the full impact of unmet parenthood goals and ART. We see a fundamental disconnect between measures of HRQOL and broader measures of wellbeing associated with met and unmet parenthood goals. We also suggest that simple concepts such as 'patient' and 'carer' are of limited applicability in the context of ART, where 'spillovers' extend across a wide network of individuals, and the person receiving treatment is often not the infertile individual. Consideration of individual and societal wellbeing beyond HRQOL is necessary to understand the full range of negative impacts associated with unmet parenthood goals and the corresponding positive impacts of successful ART. We suggest moving towards a wellbeing perspective on value to achieve a fuller understanding of value and promote cross-sector allocative efficiency.

Fertility patients demonstrate an unmet need for the provision of psychological information: A cross sectional study

OBJECTIVES

To examine the provision of information by health care providers (HCPs) to fertility patients about accessing psychological resources.

METHODS

This study utilized data from a cross-sectional survey of 659 male and female patients seeking fertility treatment at clinics in Toronto and Montreal. Regression analyses were used to assess if sociodemographic and treatment variables were associated with the receipt of information, the desire for information, the helpfulness of the information, and the likelihood that participants had sought counselling.

RESULTS

The majority of respondents (79.8%) said that their HCP had not given them information about accessing psychological resources. Of the patients who did not receive this information, most (60%) said that they wanted it. Regression analysis revealed that immigrants, women, and patients with higher perceived stress scores were significantly more likely to desire this information. Furthermore, having received this information was associated with increased odds of counselling seeking (odds ratio = 3.31, p = 0.013).

CONCLUSION

Fertility patients demonstrated an unmet need for information about accessing psychological resources, and HCPs may play an integral role in bridging this information gap.

PRACTICE IMPLICATIONS

To improve the patient-centeredness of fertility care, HCPs should be proactive in informing all patients about how to access psychological resources.

Quality of life in women of reproductive age: a comparative study of infertile and fertile women in a Nigerian tertiary centre

The study examined the quality of life in women of reproductive age and the aim was to evaluate and compare the quality of life (QoL) scores among fertile and infertile women. A cross-sectional study was carried out among women attending the Gynaecology and Postnatal Clinics of Ekiti State University Teaching Hospital comparing their QoL using the World Health Organisation Quality of Life-BREF (WHOQOL-BREF) questionnaire. The age of fertile women was significantly higher than the age of infertile women (p < .05), while a significantly higher proportion of the infertile and fertile women and their spouses were civil servants (p < .05). Infertile women obtained significantly higher scores than fertile women in the physical domain (QoL) and significantly lower scores than fertile women in the social domain (QoL), (p < .05). Among the infertile women, those with secondary infertility had significantly better overall QoL scores, (p < .05). Logistic regression showed that infertility and unemployment in women were associated with significantly lower QoL scores in psychological and social domains (p < .05). The quality of life is significantly lower among infertile women compared to fertile ones and this should be borne in mind when attending to these women. Impact statement What is already known on this subject: Infertility has been shown to be associated with poor quality of life. Most of these studies were conducted in developed countries. What the results of this study add: The findings of this study revealed that women who were infertile had low quality of life scores compared to the fertile ones in physical, social and psychological domains. What the implications are of these findings for clinical practice and/or further research: A community-based and multicultural study involving more participants may shed more light on this topic in future research. Counselling sessions should be incorporated as part of the holistic approach in the day-to-day management of the infertile women.

Disability, psychiatric symptoms, and quality of life in infertile women: a cross-sectional study in Turkey

Background

Infertility is a major life crisis which can lead to the development of psychiatric symptoms and negative effects on the quality of life of affected couples, but the magnitude of the effects may vary depending on cultural expectations.

Aim

We compare the level of psychiatric symptoms, disability, and quality of life in fertile and infertile women in urban Turkey.

Methods

This cross-sectional study enrolled 100 married women being treated for infertility at the outpatient department of the Obstetrics and Gynecology Department of the Rize Education and Research Hospital and a control group of 100 fertile married women. All study participants were evaluated with a socio-demographic data screening form, the Hospital Anxiety and Depression Scale (HADS), the Brief Disability Questionnaire (BDQ), and the Short Form Health Survey (SF-36).

Results

The mean anxiety subscale score and depression subscale score of HADS were slightly higher in the infertile group than in controls, but the differences were not statistically significant. The proportion of subjects with clinically significant anxiety (i.e., anxiety subscale score of HADS ≥11) was significantly higher in infertile women than in fertile women (31% v. 17%, χ²=5.37, p=0.020), but the proportion with clinically significant depressive symptoms (i.e., depression subscale score of HADS >8) was not significantly different (43% v. 33%, χ²=2.12, p=0.145). Self-reported disability over the prior month was significantly worse in the infertile group than in the controls, and 4 of the 8 subscales of the SF-36 - general health, vitality, social functioning, and mental health - were significantly worse in the infertile group. Compared to infertile women who were currently working, infertile women who were not currently working reported less severe depression and anxiety and better general health, vitality, and mental health.

Conclusions

Married women from urban Turkey seeking treatment for infertility do not have significantly more severe depressive symptoms than fertile married controls, but they do report greater physical and psychological disability and a poorer quality of life. The negative effects of infertility were more severe in infertile women who were employed than in those who were not employed. Larger follow-up studies are needed to assess the reasons for the differences between these results and those reported in western countries which usually report a higher prevalence of depression and anxiety in infertile patients.

Comparison of Quality of Life, Sexual Satisfaction and Marital Satisfaction between Fertile and Infertile Couples

Background:

Fertility plays an important role in sexual and psychological function in families. Infertility can result in major emotional, social, and mental disorders, including a reduction in satisfaction with marital life and quality of life. The present study aimed to compare the quality of life and marital satisfaction and sexual satisfaction between fertile and infertile couples.

Materials and Methods:

This analytical cross-sectional study was conducted on 250 couples at the Fatemiyeh Educational Research Center affiliated to Hamadan University of Medical Sciences, Hamadan, Iran, from May to August in 2014. The subjects were randomly selected from the patients referred to this center using a table of random numbers. They were then allocated into two groups of infertile group (n=125) and fertile group (n=125). The study participants completed World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, Linda Berg’s Sexual Satisfaction Scale, and Enrich Marital Satisfaction Scale. Then, the data were entered into the SPSS version16 for statistical analysis. The Chi-square and Mann-Whitney tests were also applied to compare the data between the groups.

Results:

The results revealed no significant difference between the two groups regarding demographic and general health variables. The mean scores of sexual satisfaction were 63.67 ± 13.13 and 46.37 ± 7.72 in the fertile and infertile couples, respectively. Furthermore, the mean scores of marital satisfaction were also 44.03 ± 9.36 and 36.20 ± 4.03 in the fertile and infertile groups, respectively. Our finding demonstrated that the fertile couples obtained significantly higher mean scores of quality of life as well as lower mean scores of sexual satisfaction and marital satisfaction as compared to the infertile ones (P<0.001).

Conclusion:

According to the results, the fertile couples obtained significantly higher quality of life and lower sexual satisfaction and marital satisfaction as compared to the infertile ones. Therefore, holding consultation programs and conducting more studies are necessary for improving the quality of life and promoting sexual and marital satisfaction in infertile couples.

Social Consequences of Infertility on Families in Iran

Background and Objective:

Social reactions to infertility are one of the concerns infertile people. This study aimed to investigate the social consequences of infertility among urban and rural population of Shahroud in northeast of Iran.

Method:

This study is a comparative study that was conducted in 2013. In this study, 1,528 women (511 infertile and 1017 fertile ones) were randomly selected. The 36-item questionnaire included 18 items about women’s attitude towards infertility and 18 questions about the consequences of infertility was used. Data were analyzed using chi-square test, one-way analysis of variance and t test.

Findings:

The prevalence of infertility in rural areas was estimated to be 2.23 percent. 42.2% of the participants were living the city (n= 645) and 57.8 % were living in the village (n=883). 49.2% of the participants had education below high school diploma (n=751), 31.7% had high school diploma (n=484) and 19.2% had university degrees (n=293). 51.9% of the people referred to the infertility problem among distant relatives, 24.9% referred to infertility among the close relatives and 9% reported the infertility among their family members. The mean score of attitude of the fertile was 56.6±7.0 and that of the infertile was 56.8± 6.6 and there was no statistically significant difference between the two groups (P>0.05). There was a significant association between fertility status and encouraging divorce, encouraging remarriage and encouraging adoption (P=0.001).

Conclusion:

Infertility causes a negative attitude toward infertile people. But the interference of others leads to further encouragement of divorce and remarriage among the infertile people.

Outcome of assisted reproductive technology (ART) and subsequent self-reported life satisfaction

OBJECTIVE

To compare life satisfaction between women with successful or unsuccessful outcome after assisted reproductive treatment (ART) by taking into account the time since the last ART.

DESIGN

Cohort study.

SETTING

Tertiary hospital.

PATIENTS

A total of 987 consecutive women who had undergone ART during 1996-2007 were invited and altogether 505 women participated in the study.

INTERVENTIONS

A postal enquiry with a life satisfaction scale.

MAIN OUTCOME MEASURE

Self-reported life satisfaction in respect to the time since the last ART.

RESULTS

In general, women who achieved a live birth after ART had a significantly higher life satisfaction than those who had unsuccessful ART, especially when compared in the first three years. The difference disappeared in the time period of 6-9 years after ART. The unsuccessfully treated women who had a child by some other means before or after the unsuccessful ART had comparable life satisfaction with successfully treated women even earlier.

CONCLUSIONS

Even if unsuccessful ART outcome is associated with subsequent lower level of life satisfaction, it does not seem to threaten the long-term wellbeing.

Effect of infertility on the quality of life, a cross- sectional study

INTRODUCTION

Infertility is a major life crisis which causes serious mental problems and stressful experience of infertile couples. Therefore, the aim of the present study was to compare the quality of life in fertile and infertile women.

MATERIALS AND METHODS

In a cross - sectional study compared the quality of life in 450 women attending both public and private health centers in Ilam, western of Iran, in 2013. Participants were divided in two groups' fertilities and infertilities women. Data was collected by trained research midwives using demographic and SF-36 questionnaires. SPSS software Package 16 was used to analyze the data of this project. Differences were regarded statistically significant with an alpha error of 0.05.

RESULTS

Significant difference was reported in mean age between fertile and infertile women (p=0.003). Mean scores of all Mental dimensions of quality of life were higher in fertile women in comparison with infertile women. This difference was statistically significant (58.35±19.43 vs 56.56±13.18 respectively) (p= 0.000).The mean score of all physical dimensions have not statistically significant difference in fertile and infertile women (79.77± 23.19 vs 74.96±23.45 respectively) (p= 0.441).

CONCLUSION

In most infertile women, the mean score of Mental dimensions of quality of life is lower in comparison with fertile women, therefore, it is necessary the used of counseling and treatment programs in infertile women.

Quality of life and predictive factors in patients undergoing assisted reproduction techniques

OBJECTIVES

To evaluate the quality of life (QOL) of a cohort of women undergoing assisted reproduction techniques (ART), to compare two QOL questionnaires [Short Form 36 (SF36) and FertiQoL], and to identify the predictive factors related to QOL.

STUDY DESIGN

Women who received infertility medication from a hospital pharmacist during a one-year period were included in this study. Two standardized validated questionnaires - FertiQoL and SF36 - were used. Multivariate analyses were used to assess predictive factors for QOL.

RESULTS

Sixty-one women participated in this study. Median QOL scores ranged from 58 to 100. Comparisons between the two questionnaires revealed lower QOL scores when using FertiQoL. Most correlations between the questionnaires were positive, and significant for the majority of SF36 mental dimensions. The major predictors of QOL were: accompanied to the pharmacist's visit by partner, nationality, ART (in vitro fertilization or artificial insemination), employment status (employed or unemployed), tobacco consumption, age, number of cycles, infertility factor and treatment results (pregnancy, no pregnancy or treatment cancellation).

CONCLUSIONS

FertiQoL examines dimensions such as partner and social relationships. As such, it is recommended that FertiQoL should be used together with a short version of SF36 to investigate QOL among patients undergoing ART.

Development of an Uncertainty Scale for Infertile Women

PURPOSE

The purpose of this study was to develop an uncertainty scale for infertile women.

METHODS

The process included construction of a conceptual framework, generation of 12items, verification of content validity, selection of secondary items, verification of construct validity and extraction of final items. In order to verify the reliability and validity of the preliminary instrument, data were collected from 50 infertile women in an In Vitro Fertilization (IVF) clinic. Data were analyzed by item analysis, Varimax factor analysis and Cronbach's alpha.

RESULTS

There were 10 items in the final instrument categorized into 2 factors labeled as "personal (6 items)" and "relational (4 items)" The total variance explained was 73.36%. The instrument was shown to have good reliability with a Cronbach's alpha of .899.

CONCLUSION

Validity and reliability of the scale were confirmed in this study showing its utility to measure uncertainty for infertile women. The instrument can help understand sterility and accurately measure uncertainty for infertile women. The instrument can also be used to evaluate nursing interventions designed for mitigating uncertainty for infertile women.

Family planning and psychosocial support for infertile couples

AIMS

The study was set up to analyze the psychological/emotional needs of women who undergo treatment for in vitro fertilization (IVF) and to emphasize the importance of the psychosocial support that family planning centers can provide to them.

METHOD

This was a cohort study with closed questions. A total of 235 infertile women participating in an IVF program were studied. The statistical analysis of the findings was conducted by the Statistical Package for Social Sciences.

RESULTS

The psychosocial support and the scientific information provided to those women who participate in IVF programs are insufficient. In order to succeed in an IVF program, the women must be assisted by a doctor with much medical experience. The study shows that 59.3% of the women studied sought more medical information and another 32.5% sought emotional support. These percentages varied with reference to education, age and origin. These kinds of services must be provided by family planning centers.

Attitudes of Israeli gynecologists towards the levonorgestrel-releasing intrauterine system: a questionnaire survey

OBJECTIVES

The aim of the study was to examine the current attitudes and practices of gynecologists regarding the use of the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena, Schering AG, Germany) as a contraceptive device and for the treatment of menorrhagia in the premenopausal period. In addition, physician knowledge of patient satisfaction with the device was evaluated.

METHODS

A written, self-administered questionnaire was given to 300 gynecologists actively employed in gynecological departments and outpatient clinics in urban centers in Israel. The items covered the indications for which the LNG-IUS was prescribed, the estimated rate of use of the LNG-IUS compared to copper intrauterine devices (IUDs), patient satisfaction with the LNG-IUS and previous knowledge about it, and demographic characteristics of the population using IUDs. All forms were completed on an anonymous basis.

RESULTS

The questionnaire was returned, properly completed, by 298 physicians, yielding a response rate of 99.3%. Almost one-half of the physicians (n = 147, 49.3%) used the LNG-IUS only as a contraceptive device, 17.4% only as treatment for menorrhagia, and 33.2% for both indications. The vast majority of gynecologists (82.2%) reported a patient satisfaction rate of 70% or more. Among the gynecologists using the LNG-IUS as treatment for menorrhagia, the estimated overall patient satisfaction rate was more than 50%. Although most physicians expressed greater patient satisfaction with the LNG-IUS than with copper-releasing IUDs (p < 0.004), the majority of gynecologists still used the copper-releasing IUDs more frequently. Most considered the LNG-IUS as an appropriate method for endometrial protection in postmenopausal women using estrogen replacement therapy.

CONCLUSIONS

Physicians should be made aware of the beneficial health effects of the LNG-IUS, particularly in premenopausal women with menorrhagia and for endometrial protection during hormone replacement.

Multinational development of a questionnaire assessing patient satisfaction with anticoagulant treatment: the 'Perception of Anticoagulant Treatment Questionnaire' (PACT-Q)

Background

The side effects and burden of anticoagulant treatments may contribute to poor compliance and consequently to treatment failure. A specific questionnaire is necessary to assess patients' needs and their perceptions of anticoagulant treatment.

Methods

A conceptual model of expectation and satisfaction with anticoagulant treatment was designed by an advisory board and used to guide patient (n = 31) and clinician (n = 17) interviews in French, US English and Dutch. Patients had either atrial fibrillation (AF), deep venous thrombosis (DVT), or pulmonary embolism (PE). Following interviews, three PACT-Q language versions were developed simultaneously and further pilot-tested by 19 patients. Linguistic validations were performed for additional language versions.

Results

Initial concepts were developed to cover three areas of interest: 'Treatment', 'Disease and Complications' and 'Information about disease and anticoagulant treatment'. After clinician and patient interviews, concepts were further refined into four domains and 17 concepts; test versions of the PACT-Q were then created simultaneously in three languages, each containing 27 items grouped into four domains: "Treatment Expectations" (7 items), "Convenience" (11 items), "Burden of Disease and Treatment" (2 items) and "Anticoagulant Treatment Satisfaction" (7 items). No item was deleted or added after pilot testing as patients found the PACT-Q easy to understand and appropriate in length in all languages. The PACT-Q was divided into two parts: the first part to measure the expectations and the second to measure the convenience, burden and treatment satisfaction, for evaluation prior to and after anticoagulant treatment, respectively. Eleven additional language versions were linguistically validated.

Conclusion

The PACT-Q has been rigorously developed and linguistically validated. It is available in 14 languages for use with thromboembolic patients, including AF, PE and DVT patients. Its validation and psychometric properties have been tested and are presented in a separate manuscript.

Cost-effectiveness analysis of different embryo transfer strategies in England

OBJECTIVE

The objective of this study was to assess the cost-effectiveness of different embryo transfer strategies for a single cycle when two embryos are available, and taking the NHS cost perspective.

DESIGN

Cost-effectiveness model.

SETTING

Five in vitro fertilisation (IVF) centres in England between 2003/04 and 2004/05.

POPULATION

Women with two embryos available for transfer in three age groups (<30, 30-35 and 36-39 years).

METHODS

A decision analytic model was constructed using observational data collected from a sample of fertility centres in England. Costs and adverse outcomes are estimated up to 5 years after the birth. Incremental cost per live birth was calculated for different embryo transfer strategies and for three separate age groups: less than 30, 30-35 and 36-39 years.

MAIN OUTCOME MEASURES

Premature birth, neonatal intensive care unit admissions and days, cerebral palsy and incremental cost-effectiveness ratios.

RESULTS

Single fresh embryo transfer (SET) plus frozen single embryo transfer (fzSET) is the more costly in terms of IVF costs, but the lower rates of multiple births mean that in terms of total costs, it is less costly than double embryo transfer (DET). Adverse events increase when moving from SET to SET+fzSET to DET. The probability of SET+fzSET being cost-effective decreases with age. When SET is included in the analysis, SET+fzSET no longer becomes a cost-effective option at any threshold value for all age groups studied.

CONCLUSIONS

The analyses show that the choice of embryo transfer strategy is a function of four factors: the age of the mother, the relevance of the SET option, the value placed on a live birth and the relative importance placed on adverse outcomes. For each patient group, the choice of strategy is a trade-off between the value placed on a live birth and cost.

Long-term psychological adjustment to IVF/ICSI treatment in women

BACKGROUND

The aim of this study was to gain more insight into long-term psychological adjustment to IVF in women.

METHODS

In a prospective cohort study, 298 women entering their first IVF treatment cycle (including ICSI) completed standardized psychological questionnaires before the start of the treatment, just after the last treatment cycle, and 6 months and 3-5 years after the last treatment cycle. The main outcome measures were state anxiety, depression and mode of adaptation to unsuccessful IVF.

RESULTS

Anxiety and depression were found at follow-up to return to baseline levels following treatment not resulting in a live birth, after an initial increase during treatment. On the contrary, treatment resulting in a live birth was found to lead to a more positive long-term emotional status. Women who focused on new life goals as a mode of adaptation 3-5 years after IVF without a live birth showed lower levels of anxiety and depression compared with those who persisted in their attempts to get pregnant.

CONCLUSIONS

Treatment that resulted in a live birth led to more positive emotional adjustment. In addition, most women who did not give birth to a child after treatment adjusted well psychologically. Positive adjustment was related to developing new life goals rather than persisting in attempts to get pregnant. Helping women to change life goals after abandoning treatment might have beneficial effects on the adaptation process.

Women's emotional adjustment to IVF: a systematic review of 25 years of research

This review provides an overview of how women adjust emotionally to the various phases of IVF treatment in terms of anxiety, depression or general distress before, during and after different treatment cycles. A systematic scrutiny of the literature yielded 706 articles that paid attention to emotional aspects of IVF treatment of which 27 investigated the women's emotional adjustment with standardized measures in relation to norm or control groups. Most studies involved concurrent comparisons between women in different treatment phases and different types of control groups. The findings indicated that women starting IVF were only slightly different emotionally from the norm groups. Unsuccessful treatment raised the women's levels of negative emotions, which continued after consecutive unsuccessful cycles. In general, most women proved to adjust well to unsuccessful IVF, although a considerable group showed subclinical emotional problems. When IVF resulted in pregnancy, the negative emotions disappeared, indicating that treatment-induced stress is considerably related to threats of failure. The concurrent research reviewed, should now be underpinned by longitudinal studies to provide more information about women's long-term emotional adjustment to unsuccessful IVF and about indicators of risk factors for problematic emotional adjustment after unsuccessful treatment, to foster focused psychological support for women at risk.

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.

Women's experiences of childlessness 2 years after the end of in vitro fertilization treatment

Approximately 15% of all couples in the reproductive age are involuntarily childless. Many of these couples consult medical experts for diagnosis and treatment but not all of them achieve the results. This paper describes a study of women's experiences of childlessness 2 years after the end of in vitro fertilization (IVF) treatment, which represents the end of infertility treatment in Swedish society. Giorgi's method, based on Husserl's phenomenology with the lifeworld theory, was used. The participants were eight women treated at the Clinic of Reproductive Medicine, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Sweden. Data were generated from transcriptions of taped interviews. Five constituents emerged from the analysis: (i) childlessness is a central issue in life, (ii) IVF is a positive and important part of life, (iii) contact with other people is not an important issue, (iv) the hope of achieving pregnancy still exists and (v) attempts to identify other central issues in life. The essence of all constituents is 'life-grief' and expresses the grief of being childless, of not reproducing, and being unable to confirm one's relationship through parenthood. The result is important in professional caring and presents a challenge to all midwives, nurses, physicians and other staff who are involved in the care of involuntarily childless women.

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.

Long-term follow-up of women and men after unsuccessful IVF

The experience of 92 couples, who had unsuccessfully undergone one or more IVF cycles at a university clinic, was evaluated 3-8 years following their last failed attempt. One member of each couple completed a telephone questionnaire regarding life events during their last IVF cycle performed at the clinic and at the time of the interview. Some couples had continued further treatment and some had not. Multivariate correspondence analysis was used to analyse the data. Regarding the long-term experience of couples who had undergone further treatment, for men the main experiences were psychological problems and having adopted a child. For women, the main experiences were related to problems of self-image, psychological problems, loss of hope, and having adopted a child. These women also presented a strong association with problems in their marital relationship and with adoption. For the group that did not undergo further treatment, the women showed a strong association with considering adoption, and a less intense association with psychological problems and loss of hope. The men presented psychological problems and having adopted a child as associated variables. Comparison between men and women showed that recognizing the impossibility of conceiving a child and giving up treatment were strongly associated. Men and women who had not continued with further treatment were more affected in the long term than those who had undergone further treatment after IVF failure.

Impact of infertility on quality of life, marital adjustment, and sexual function

OBJECTIVES

To evaluate the hypothesis that infertility may result in a decrease in quality of life and an increase in marital discord and sexual dysfunction. The burden of infertility is physical, psychological, emotional, and financial.

METHODS

Couples seeking treatment for infertility were asked to complete standardized validated questionnaires assessing quality of life (Quality of Well-Being Scale-Self Administered, version 1.04), marital adjustment (Locke-Wallace Marital Adjustment Test), and sexual function (Brief Index of Sexual Functioning for Women and International Index of Erectile Function for men). Couples seeking elective sterilization served as the control subjects.

RESULTS

Eighteen infertile couples and 12 couples seeking elective sterilization participated in the study. The mean age, years together, and household income were comparable. Infertile couples had made a mean of 14.5 office visits for infertility, and 83% of couples reported feeling societal pressures to conceive. The Marital Adjustment Test scores for the women of the infertile couples were significantly lower than the scores of the controls (P = 0.01); however no difference was noted in the men. A trend toward lower quality-of-life scores was noted in women (P = 0.09) but not in the men of infertile couples. No statistically significant impact on sexual functioning in women was noted; however, the men in the infertile couples had lower total International Index of Erectile Function scores (P = 0.05) and intercourse satisfaction scores (P = 0.03).

CONCLUSIONS

Women in infertile couples reported poor marital adjustment and quality of life compared with controls. Men may experience less intercourse satisfaction, perhaps because of the psychological pressure to try to conceive or because of the forced timing of intercourse around the woman's ovulatory cycle.

Parents of 5-year-old in vitro fertilization children: psychological adjustment, parenting stress, and the influence of subsequent in vitro fertilization treatment

Sixty-six parents who had conceived by in vitro fertilization (IVF) were compared with 46 matched naturally conceiving control parents regarding psychosocial adjustment and parenting stress 5 years after the birth of their first child. IVF mothers reported a more external locus of control than did control mothers but did not differ on other measures. Within the IVF group, higher levels of treatment predicted lower parenting stress and more defensive responding on the Parenting Stress Index (R. Abidin, 1990). The more positive reporting of high-treatment IVF parents may be attributable to either defensive responding or the fact that they are particularly highly motivated and competent parents. The study findings confirm a growing body of research regarding overall positive adjustment in IVF parents but also highlight the importance of considering individual differences among IVF mothers with respect to treatment experience.

Stress in assisted reproductive technology: implications for nursing practice

In a follow-up study about women's experience of assisted reproductive technology (ART) some events were identified as particularly stressful, including making the decision to try ART, starting treatment, waiting for results after a scan, having oocyte collection, the 2 week wait after embryo transfer and finding out that the treatment was unsuccessful. On the basis of these findings, a review of the literature and extensive clinical practice as a nurse co-ordinator in an ART programme, implications for nursing practice are discussed and strategies to use that may help reduce stress and improve the well-being of ART participants are suggested.

[What kind of support do couples expect when undergoing IVF treatment? Study and perspectives]

OBJECTIVES

To assess the management of the supportive aspects of treatment for couples having attempted an in vitro fertilization treatment.

MATERIAL AND METHODS

Three groups of couples were contacted by questionnaire (successful treatment, unsuccessful treatment treatment, outcome still unknown).

RESULTS

48% considered it necessary to offer psychological support after the diagnosis. 80% considered it difficult to have a thorough representation of the physical aspects of an In Vitro Fertilization treatment but mostly they were surprised by their lack of an accurate emotional representation. All couples expected an availability and receptiveness from the infertility team but the unsuccessful treatment group was less satisfied and felt significantly (P < 0.001) less well supported. The most difficult moments mentioned were the numerous moments of waiting and the announcement of the final result. Emotional support was regularly provided by the nurses but 20% wanted psychological counselling. Two thirds of all couples considered that a psychological follow-up should be proposed to couples for whom the treatment remain unsuccessful.

CONCLUSIONS

Results show the need for better emotional preparation of couples. As for the emotional support during treatment, the need for psychological counselling appears after the diagnosis of infertility as well as a constant demand of availability and empathy on behalf of the team. Post-treatment counselling may be particularly important also. Failure as well as lack of support at that time seemed to colour the way couples regard the whole support provided during treatments.

In vitro fertilization: a long-term follow-up after treatment failure

There is a considerable body of psychological research on women presenting for in vitro fertilization (IVF), but relatively little on the long-term adjustment of such women after unsuccessful treatment. This study examined the adjustment (4--9 years after treatment) of a sample (n = 76) of women whose treatment had failed. At follow-up, it was found that eight (10.53%) of the women had conceived naturally and 16 (21.05%) had become adoptive parents. In comparison with population norms, the women who had not subsequently conceived or adopted (n = 52) were found to rate themselves as more highly stressed (P < 0.001), but rated themselves as higher in self-esteem (P < 0.001). However, when women who remained childless after unsuccessful IVF were compared with those who subsequently conceived or adopted, the former group rated themselves as more stressed (P < 0.05), more depressed (P < 0.001) and with a lower satisfaction with life (P < 0.005) and lower self-esteem (P < 0.05). Women who wished to adopt but were unable to do so made a major contribution to this negative pattern. The study indicates that infertility long after failed IVF treatment contributes to psychological dysfunction. It highlights the need to prepare women better for treatment failure and to ensure appropriate counselling is available when further IVF treatment is no longer appropriate.

Use of in-vitro fertilisation embryos cryopreserved for 5 years or more

Human embryos cryopreserved after in-vitro fertilisation can be stored initially for 5 years, and the storage period may be extended to a maximum of 10 years. Of 1344 embryos cryopreserved between 1988 and 1994 at two centres in Manchester, 67% (904 embryos) have had to be destroyed at the end of the first 5-year interval, even if the couples involved remain childless.

Preimplantation genetic diagnosis as an alternative to amniocentesis and chorionic villus sampling: psychosocial and ethical aspects

Social and ethical considerations play an increasing role in decisions about the use of diagnostic technologies. In this article expert opinions of a medical-biological and a social-ethical panel on psychosocial, ethical and social aspects of preimplantation genetic diagnosis (PGD) are discussed. PGD is a new diagnostic technology for identifying chromosomal or single gene defects, which is now available as a medical treatment in several western countries. In contrast to traditional technologies like amniocentesis and chorionic villus sampling PGD offers the possibility for diagnosis before pregnancy. The panels expected PGD to be chosen only in serious situations. IVF was considered to be a barrier for PGD but less so in more serious situations. Destruction of pre-embryos was thought more acceptable than selective abortion, but only marginally. Finally a substantial decrease was expected in the acceptance of handicapped people in society as a consequence of the possibilities of technologies like PGD. Although PGD offers new possibilities for couples at risk of having a child with a genetic defect, it is important that couples are counseled in a way that emphasizes both the advantages and disadvantages of the technology. The general public should be informed about possibilities and impossibilities of preventive diagnosis and the right of future parents not to use genetic diagnosis.