Outline. Objective(s) Background. Methods. Results. Discussion. Questions

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2 Outline Objective(s) Background Methods Results Discussion Questions

3 Objectives To evaluate if psychological stress varies with the phase of in vitro fertilization treatment To determine if socio-demographic factors influence the amount of psychological stress or variance in stress levels during an IVF cycle age income prior IVF treatment

4 Background 1 in 10 couples experience infertility prevalence of psychological distress in infertility patients ranges from 48-96% 49% of females described infertility as most stressful event in their lives during consultation for in vitro fertilization (IVF) 15-20% of couples require psychological counseling for emotional distress during or after IVF treatment

5 Background Correlation with outcomes association between anxiety and depression and IVF outcome described in some studies but not others biological theories altered gonadotropin release effects of catecholamines on uterine function immunological processes affect implantation influence on destructive behaviours Targeted support some evidence that emotional support after ET decreases stress of IVF (Skiadas et al, 2011)

6 Background Few studies of psychological stress during IVF Mahajan et al. (2008) 85 Indian women with serial assessments x 3 (prior to starting IVF, 24hrs prior to OPU and ET) STAI (anxiety) score at time of OPU and ET vs baseline (p = 0.02) Yong et al (2000) 37 UK women, serial assessments x 3 (baseline, prior to ET, and HPT) with MAACL Depression at visit 2 and 3 vs baseline, anxiety at visit 3 vs baseline Merari et al. (1992) 113 Israeli women, serial assessments x 4 (baseline, OPU, ET, and HPT) with 3 different questionnaires significant in stress score between baseline and all 3 phases of IVF cycle

7 Methods Prospective cohort study Psychological stress measured at 4 time points during IVF cycle T1 start of GnRH agonist T2 day 8-10 of gonadotropin stimulation T3 day of embryo transfer (ET) T4 day of home pregnancy test (HPT) 4 questionnaires self-administered at each time point State Trait Anxiety Inventory (STAI) state anxiety subscale Beck Depression Index (BDI) Dyadic Adjustment Scale (DAS) Infertility experiences questionnaire (IEQ)

8 Methods T1 T2 T3 T4

9 Methods 28 patients wishing to proceed with IVF recruited, consented during AART clinic visit 2 lost to follow-up 5 returned incomplete questionnaires 21 patients for analysis Inclusion criteria: Patients planning to start 1 st cycle of new IVF treatment All ultrasounds and bloodwork to be completed in Halifax Exclusion criteria: Non-fluent in English given information packet with 4 sets of 4 questionnaires, SASE phone calls during cycle to ensure completion of questionnaires

10 Methods Statistics repeated measures analysis of variance (one-way ANOVA) was used to test for difference in means at four different time points (T1, T2, T3, T4) heterogeneity of variance checked with Mauchly s sphericity test t-tests were performed where appropriate for paired comparisons when repeated measured ANOVAs showed statistically significant results

11 Patient Demographics Variable Mean (range) age 34.4 (28-39) years of infertility 4.2 (1.3 10) prior pregnancy 35.2% (0-2) marital status 88% married, 12% common-law household income 0% <$50,000 47% $50-$100,000 53% >$100,000 IVF outcome (clinical PR rate) 64.7%

12 State Trait Anxiety Index (STAI)

13 Results - STAI STAI Average score Time points P = 0.018

14 Beck Depression Index II

15 Results - BDI 10 9 BDI 8 7 Average score Time points P = 0.089

16 Dyadic Adjustment Scale

17 Results - DAS DAS Average score Time points P = 0.758

18 Infertility Experiences Questionnaire

19 Results - IEQ IEQ Average score Time points P = 0.105

20 Results - age subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_ Age 37 or older (1=y; 0=n) Age 37 or older (1=y; 0=n) Estimated Marginal Means Estimated Marginal Means

21 Results income subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_ Income category <=100 K >100 K Income category <=100 K >100 K Estimated Marginal Means Estimated Marginal Means

22 Results prior IVF subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_ Previous IVF TX no yes Previous IVF TX no yes Estimated Marginal Means Estimated Marginal Means

23 Conclusions Summary of results: only STAI (anxiety) showed significant increase during IVF cycle no change in BDI (depressive symptoms), DAS (martial relationships), IEQ (injustice) over time trend toward less psychological stress in patients > 36 yo, and income > $100K no effect based on prior IVF treatment

24 Conclusions Are these results clinically significant? mean STAI score from > 37.6 mean BDI score from 6.4 -> 8.9 Implications for IVF physicians target counseling toward later phases of IVF treatment if sociodemographic subgroups are more likely to experience stress during IVF cycle, can we make treatment less stressful for these subgroups?

25 Thank-you! Acknowledgements Dr. Renda Bouzayen, Colleen O Connell, Dr. Desiree Fofie, Kate Lively References: Skiadas et al. Does emotional support during the luteal phase decrease the stress of in vitro fertilization? Fertil Steril 2011; 96(6): Li et al. Baseline psychological stress and ovarian norepinephrine levels negatively affect the outcome of in vitro fertilisation. Gynecological Endocrinology. 2011; 27(3): Mahajan et al. Changes in affect and state anxiety across an in vitro fertilization/intracytoplasmic sperm injection cycle. Fertility and Sterility. 2010; 93(2); Ardenti R. et al. Anxiety and perceptive functioning of infertile women during in-vitro fertilization: exploratory survey of an Italian sample. Hum Reprod Dec;14(12): Merari D et al. Psychological and hormonal changes in the course of in vitro fertilization. J Assist Reprod Genet Apr;9(2):161-9.

26 Discussion Strengths prospective unique design serial measurements standardized questionnaires Limitations low participation rate of those consented small sample size inconsistent timing of responses? assumes honesty Modifications baseline testing (prior to any medications/teaching)? have patients fill out questionnaires at AART?

Christianne Verhaak PhD Clinical psychologist. Department medical psychology University Medical Center Radboud, Nijmegen, the Netherlands

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