Outline Objective(s) Background Methods Results Discussion Questions
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
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
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)
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
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)
Methods T1 T2 T3 T4
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
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
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%
State Trait Anxiety Index (STAI)
Results - STAI STAI 38 37 36 Average score 35 34 33 32 31 1 2 3 4 Time points P = 0.018
Beck Depression Index II
Results - BDI 10 9 BDI 8 7 Average score 6 5 4 3 2 1 0 1 2 3 4 Time points P = 0.089
Dyadic Adjustment Scale
Results - DAS DAS 120.5 120 119.5 Average score 119 118.5 118 117.5 1 2 3 4 Time points P = 0.758
Infertility Experiences Questionnaire
Results - IEQ 21.5 21 IEQ 20.5 20 Average score 19.5 19 18.5 18 17.5 17 16.5 1 2 3 4 Time points P = 0.105
Results - age subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_1 10.00 9.00 Age 37 or older (1=y; 0=n).00 1.00 42.00 40.00 Age 37 or older (1=y; 0=n).00 1.00 Estimated Marginal Means 8.00 7.00 6.00 Estimated Marginal Means 38.00 36.00 34.00 32.00 5.00 30.00 4.00 28.00 1 2 3 4 1 2 3 4
Results income subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_1 11.00 10.00 Income category <=100 K >100 K 42.00 40.00 Income category <=100 K >100 K Estimated Marginal Means 9.00 8.00 7.00 6.00 Estimated Marginal Means 38.00 36.00 34.00 5.00 32.00 4.00 30.00 1 2 3 4 1 2 3 4
Results prior IVF subgroups BDI STAI Estimated Marginal Means of MEASURE_1 Estimated Marginal Means of MEASURE_1 10.00 Previous IVF TX no yes 40.00 Previous IVF TX no yes 39.00 Estimated Marginal Means 8.00 6.00 Estimated Marginal Means 38.00 37.00 36.00 35.00 34.00 1 2 3 4 1 2 3 4
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
Conclusions Are these results clinically significant? mean STAI score from 33.8 -> 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?
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): 1467-72. Li et al. Baseline psychological stress and ovarian norepinephrine levels negatively affect the outcome of in vitro fertilisation. Gynecological Endocrinology. 2011; 27(3): 139 43 Mahajan et al. Changes in affect and state anxiety across an in vitro fertilization/intracytoplasmic sperm injection cycle. Fertility and Sterility. 2010; 93(2); 517-26. Ardenti R. et al. Anxiety and perceptive functioning of infertile women during in-vitro fertilization: exploratory survey of an Italian sample. Hum Reprod. 1999 Dec;14(12):3126-32. Merari D et al. Psychological and hormonal changes in the course of in vitro fertilization. J Assist Reprod Genet. 1992 Apr;9(2):161-9.
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?