Infertility is a profoundly stressful experience, physically and psychologically, write Dr Alice Domar and Lauren Prince in their recent study in Sexuality, Reproduction and Menopause. The study sheds light on the impact of stress reduction on IVF outcomes for women who are having trouble getting pregnant.
Dr Domar is the Executive Director of the Domar Center for Mind/Body Health. She works with Boston IVF, one of the biggest IVF Centers in the U.S. and is affiliated with Harvard Medical School.
The desire to procreate is one of our species’ most basic instinctual drives, and the inability to do so often brings about intense feelings of grief and emptiness. Both men and women report psychological distress when they are having trouble getting pregnant and receive a diagnosis of infertility.
The modern woman coping with an infertility diagnosis faces numerous stressors, including the difficulty of balancing a career, marriage, and highly invasive and time-consuming infertility treatments; the financial burden of treatment; the struggle to maintain romance in a relationship characterized by timed intercourse; highly personal questioning by health care providers; the general medicalization of sexual intercourse; and the recurring cycle of hope, anxiety, and disappointment that accompanies each attempt to conceive. Some women describe the infertility experience as a mourning process; others are plagued by feelings of anxiety and depression.
What types of psychological intervention have been used to address infertility stress? And do these interventions help?
Infertility is frequently associated with high levels of stress, depression, and anxiety. 40% of patients in an ART clinic will have a diagnosable psychiatric disorder. The most common condition was generalized anxiety disorder, with 23.2% of women meeting the diagnostic criteria, followed by major depression (17%) and dysthymic disorder (9.8%), a form of low-grade, chronic depression.
Research indicates that an intervention consisting of at least 5 sessions of counseling, education, and group support results in decreased depression and anxiety and increased life satisfaction; no such improvements were found in the control groups undergoing infertility care without psychosocial treatment. In another study, cognitive behavioral therapy (CBT) was found to be more effective in reducing depression in infertile women than antidepressant drug therapy.
Psychosocial treatments for infertile women generally have 2 main purposes:
To decrease distress
To increase the pregnancy rate.
While studies have repeatedly shown that psychosocial interventions can reduce distress, there is less agreement on whether they can increase pregnancy rates.
Types of psychological treatments available
The major types of interventions that have been investigated include the following:
Counseling/support. Counseling interventions can occur in a group setting or one-on-one. They usually focus on emotional expression and the discussion of thoughts and feelings. These are not as effective as participating in a mind/body group.
Cognitive behavioral, educational, and skills-based therapy. In CBT, a trained counselor works with the patient to reshape negative thoughts that tend to perpetuate feelings of depression and anxiety. Educational programs teach patients specific skills, such as preparatory information about all aspects of the IVF cycle. Mind/body programs, usually offered in a group setting, combine approaches and include relaxation training, cognitive restructuring, and information about infertility-relevant topics, such as healthy diet and exercise habits.
Domar and colleagues found that patients receiving some kind of intervention fared better than those receiving none. However, women participating in a mind/body group, which focused on relaxation-response training, cognitive restructuring, and fertility-relevant nutrition and exercise information, had significantly better scores on psychological outcome measures than women who were in a support group that focused only on discussion and emotional support.
Other interventions. A number of unorthodox psychosocial methods have also been investigated. These include “medical clowning” after embryo transfer where women were visited by a clown in the recovery room after embryo transfer had a 36.4% pregnancy rate, while women who did not receive a clown visit had a pregnancy rate of 20.2%.
How can psychological treatments increase pregnancy rates in ART and IVF patients?
Increased sex behavior. As their stress levels drop, there is decreased marital distress and increased frequency of sex.
Decreased drop out rates. Women whose coping skills are improved will tend to continue with the treatment. Providing women with more written information on how to deal with infertility-related stress and easy access to a psychologist or social worker increase patient support and decrease drop out rates.
Psychosocial interventions aimed at teaching patients skills to reduce and cope with stress may restore brain centers and hormones and, thus, reproductive functioning to their optimal state, potentially rendering IVF treatment more effective.
Does a mind/body program improve IVF pregnancy rates?
Domar and colleagues recently randomized 97 women undergoing their first IVF cycle to a mind/body group or a control group. Participants underwent 2 cycles of IVF during the study period. The mind/body group met once a week for 10 weeks and focused on stress management, CBT, relaxation training, health behavior modification, and social support.
At the end of the first IVF cycle, no significant differences in pregnancy rates were observed between the 2 groups: 43% of women in each group achieved pregnancy. At that point, however, only half of the mind/body participants had attended any sessions at all, and only 9% had attended 6 to 10 sessions. After the second IVF cycle, when 76% of mind/body participants had attended 6 to 10 sessions, significant differences in pregnancy rates emerged: 52% of the mind/body participants experienced a clinical pregnancy, while only 20% of the controls did.
This study was unique in that it rules out a placebo effect. All women knew of their group assignment at the first cycle, but pregnancy rates did not differ until the majority had actually attended at least 6 mind/body group sessions—the point at which participants begin to report psychological symptom improvements.
In conclusion, the authors believe that
Psychosocial interventions focused on skills-training, information provision, and education, rather than on emotional expression or discussion, are most effective at increasing the likelihood of IVF success.
At least 5 sessions of the intervention are needed to produce physical and psychological improvement.
Dr. Karande is Board Certified in the specialty of Obstetrics and Gynecology as well as the subspecialty of Reproductive Endocrinology and Infertility. He is a Fellow of the American College of Obstetricians and Gynecologists and Member of the American Society for Reproductive Medicine.