Key words
infertility - assisted reproductive technology (ART) - positive and negative affectivity
- depression - anxiety
Schlüsselwörter
Infertilität - assistierte Reproduktion - positive und negative Affektivität - Depression
- Angst
Introduction
Infertility is clinically defined as “the failure to achieve a clinical pregnancy
after 12 months or more of regular unprotected sexual intercourse” [1]. Infertility has become a worldwide public health problem due to that fact that
it affects up to 15% of reproductive-aged couples worldwide [2]. According to the epidemiological data, one in every six couple struggles against
infertility in Hungary [3].
Infertility can be caused by a female, male factor, a combination of female and male
factor, or an idiopathic factor. Approximately 40% of infertility is due to a female
factor (e.g. anovulation, endometriosis) and 40% to a male factor (e.g. ejaculatory
dysfunction), and about 15% of couples do not display any objective alteration leading
to a definite diagnosis [4], [5].
In fact, there is a continuing expansion of the number of assisted reproductive technologies
(ART) treatment cycles including In Vitro Fertilization and Embryo Transfer (IVF-ET)
in Europe [6]. The in vitro fertilization and embryo transfer can be divided into four steps:
-
hormonal stimulation, monitoring, ultrasound,
-
oocyte retrieval,
-
fertilization, cleavage,
-
embryo transfer.
The goal of hormonal stimulation is to create numerous oocytes for manipulation for
IVF and transfer by stimulating the womanʼs ovulatory process. Monitoring of oocyte
development and endometrial thickness and patterns is also included. Transvaginal
ultrasound-guided oocyte aspiration occurs after terminating of the ovarian stimulation.
After which the egg and sperm are prepared for fertilization (IVF or ICSI), embryos
are transferred into the uterus [7]. As a matter of fact, five IVF cycles are funded by the National Health Insurance
Fund of Hungary. Nowadays, the results of such treatment show that approximately 35%
of IVF treatments are successful in Hungary [8].
In spite of the fact that, there are infertile couples that show resilience throughout
their infertility and treatment experience, infertility is often associated with considerable
psychological distress and emotional problems [9], [10], [11]. With regard to comparison of emotional state in infertile and control population,
findings are contradictory [12], [13], [14], [15]. Most studies suggest that IVF couples show more negative emotional state than the
community controls. In fact, the majority of the research results are attributed by
studies and investigations conducted outside Hungary, with comparatively little data
from Hungarian populations.
There is increasing evidence that emotional factors (e.g. anxiety, depression) are
related to IVF treatment outcome. Higher levels of anxiety and depression have been
associated with lower pregnancy rates in several studies [16], [17], [18]. In contrast, a meta-analysis of 14 prospective studies has found no statistically
significant difference between women who achieved a pregnancy after a cycle of ART
and those who did not in pretreatment emotional distress (e.g. anxiety, feelings of
tension, depression) [19]. Furthermore, according to a meta-analysis including 31 prospective studies, a negative
association has been found between both trait and state anxiety and the outcome of
ART, whereas there has been no significant association between depression and clinical
pregnancy [20].
As regards couplesʼ emotional state changes during the treatment, few studies have
compared the emotional status of infertile couples at different stages of the IVF
cycle, particularly the association between changes in psychological factors and the
IVF success. Yong et al. [21] have reported similar anxiety scores in women undergoing IVF treatment before embryo
transfer and before pregnancy test; furthermore, they tend to be most vulnerable to
psychological distress at the stage of pregnancy test. Turner et al. [22] have found that lower level of state anxiety of IVF women one day prior to oocyte
retrieval is associated with higher pregnancy rate, while Lintsen et al. [23] suggest that the anxiety gain score from pretreatment to oocyte retrieval does not
affect the pregnancy rate after IVF.
Despite the large number of studies conducted to examine the effect of psychological
factors on the IVF success, still little is known about changes in emotional reactions
of both partners over the course of the cycle and experience of couples who achieved
pregnancy and those who did not. Investigating the couplesʼ emotional reactions during
the treatment may provide valuable information that may help improve support before
and during the treatment. Thus, the present study aimed to explore to what extent
the positive and negative affectivity, the predisposition for depression and anxiety
appear among infertile couples during the IVF treatment and how the results relate
to the emotional state of the general and patient populations. Moreover, we aim to
test the differences between the emotional states of infertile couples at determinant
stages of the treatment in association with the outcome of it.
Materials and Methods
Participants
Altogether 174 people (87 couples) took part in our research. 87 women and 87 men
entering IVF treatment completed self-report questionnaires.
The participants were recruited using simple random sampling at an Assisted Reproductive
Centre in Hungary, which was a private center at the time of the research, but since
1st of January 2018, it has become again a university institution.
Participation required couples
-
to be at least 18 years of age,
-
to be about to begin an IVF cycle during the time of data collection,
-
and to have the ability to read and write in Hungarian language and to be able to
complete the questionnaires.
Couples were excluded from the study if
-
one or both of the partners had a psychiatric diagnosis,
-
or were currently receiving psychological care.
The study was approved by the Human Reproduction Committee of the Medical Research
Council in Hungary, and informed consent was obtained from all participants.
Procedure
The study is a prospective, longitudinal study in which couples (both men and women)
were followed by means of questionnaires at the following significant stages of the
IVF treatment: at the beginning of the treatment (T1), before embryo transfer (T2),
and before pregnancy test (T3). GnRH-a (gonadotropin-releasing hormone agonists) short
or long protocols were used for ovarian stimulation in IVF cycles in accordance with
age and previous history. The long protocol was applied in patients under the age
of 35 years, while the short protocol was applied in patients aged 35 years or over.
In 90% of cases, we used recombinant follicle-stimulating hormone (rFSH) and recombinant
luteinizing hormone (rLH) as well as recombinant human chorionic gonadotropin (hCG).
Only in 10% of cases, we used urinary human menopausal gonadotropin (uhMG). Patients
were invited to participate in the study personally with written information about
the study.
Of the 105 couples invited, 104 agreed to participate in the study (99% participation
rate). We have elected participants in our study who were about to begin their first
(62 couples) or second (25 couples) IVF treatment, as we had assumed that each failed
treatment may increase levels of depression, anxiety and psychological distress among
infertile couples, thereby not allowing us to compare couples with no or a short history
of infertility treatment and couples with a longer one.
Couples were given the first questionnaire set before the hormonal treatment started,
and asked to complete it at home, and then bring back by the time of the next visit.
The second questionnaire set was given to the couples at the stage of oocyte retrieval
to fill in on the day before embryo transfer. Finally, the third questionnaire set
was given to the couples at the stage of embryo transfer to complete on the day before
the pregnancy test. At the second measurement occasion one man, while at the third
measurement occasion three men and two women did not complete the questionnaire set.
Subsequently, we divided the study group into two subgroups depending on the IVF treatment
outcome. Couples who achieved pregnancy after treatment were included in the successful
group (n = 82), whereas couples who did not achieve pregnancy after IVF were included
in the unsuccessful group (n = 92). Pregnancy status was defined by a positive serum
β-hCG test result two weeks after embryo transfer.
Measurements
First measurement occasion (T1)
The participants completed a demographic and infertility-specific questionnaire and
three psychological questionnaires described in detail below.
Demographic and infertility-specific questionnaire
This questionnaire included questions concerning gender, age, marital status, duration
of marriage or cohabitation, residence, qualification, current employment, subjective
evaluation of financial status, duration and cause of infertility, and number of previous
IVF treatments.
Positive and Negative Affect Schedule
Positive and negative emotional states of couples were assessed using the Positive
and Negative Affect Schedule (PANAS). The original questionnaire was developed by
Watson et al. [24]. This measurement contains twenty items, ten describing positive (e.g. enthusiastic,
attentive) and ten describing negative (e.g. upset, irritable) personality traits,
which the individuals should judge on a five-point Likert scale how they feel with
regard to each statement (from 1 = very slightly, or not at all, to 5 = very much)
[25]. It can be used with both long-term (e.g. past year or general) and short-term instructions
(e.g. right now or today) [24]. In the present study, participants were asked to rate how they felt at the present
moment. The higher the positive affectivity score, the more positive the current emotional
state is. The higher the negative affectivity score, the more negative the current
emotional state is. The Cronbach alpha coefficient of the negative affectivity subscale
was 0.88, while 0.8 for the positive affectivity subscale, suggesting that both subscales
have high internal consistency.
Beck Depression Inventory
Depression was measured by the short form of the Beck Depression Inventory (BDI-R).
The original version of the instrument is one of the most widely used inventories
for measuring characteristic attitudes and symptoms of depression with very good validity
and reliability [26]. The BDI has been developed in different forms, including the 9-item short form.
The nine items refer to social withdrawal, indecisiveness, sleep disorders, fatigue,
excessive worrying of physical symptoms, inability to work, pessimism, dissatisfaction,
inability to feel pleasure, and self-blame [27]. The participants were asked to respond to each item on a four-point Likert scale
(from 1 = not at all, to 4 = very much), indicating the extent to which the statement
describes them. The higher the score, the higher the occurrence of depressive symptoms
is. Although this inventory is not suitable for diagnosing depression, it can be applied
to monitor mood state changes in both research and therapy [28]. The Cronbach alpha coefficient of 0.77 demonstrates good internal consistency.
Spielberger State-Trait Anxiety Inventory
The couplesʼ state and trait anxiety were assessed using the Spielberger State-Trait
Anxiety Inventory (STAI). The widely used 40-item self-report questionnaire with two
subscales was developed for measuring the severity of anxiety, which is a reliable
indicator of two types of anxiety, the state and trait anxiety. The state anxiety
scale (A-State) evaluates the current state of anxiety, asking how the individual
feels “right now”, whereas the trait anxiety scale (A-Trait) evaluates relatively
stable “personality dependent” anxiety, namely the predisposition to anxiety. It contains
20 items for assessing trait anxiety and 20 items for state anxiety. The participants
were asked to respond to each item on a four-point Likert scale (from 1 = not at all,
to 4 = very much), indicating the extent to which the statement describes them. Higher
scores indicate greater anxiety [29]. The Cronbach alpha coefficient of the state anxiety scale was 0.94, while 0.7 for
the trait anxiety scale, suggesting that the subscales have acceptable internal consistency.
Second measurement occasion (T2)
The participants completed the questionnaires detailed above measuring transient psychological
variables, namely PANAS, BDI-R, and A-State.
Third measurement occasion (T3)
The same questionnaires were applied as at the second measurement occasion.
Data analysis
In order to explore the differences in the demographic and reproductive characteristics
between the successful and unsuccessful IVF groups, we performed an independence test.
The following research questions were examined:
-
whether IVF couples do differ from the general adult and patient populations with
regard to emotional state (positive and negative affectivity, depression, anxiety)
during the treatment, and how specific the negative change in emotional state and
depression is to them;
-
how the emotional states of infertile couples change over the course of the IVF cycle
in association with the treatment outcome, and what emotional process is associated
with it.
In comparison with the general adult population, we compared our findings with the
published results of Hungarostudy 2013 survey [30], a cross-sectional survey enrolling a large nationally representative sample of
the Hungarian population aged > 18 years (n = 2000) (mean age = 46.9 years; SD = 18.24;
46.6% male). The survey aimed to examine the biopsychosocial status and potential
risk factors of the general Hungarian population.
In comparison with the patient population, we compared our findings with the published
results of Gyollai and his colleagues [25], who examined Hungarian patients (n = 466) visiting their General Practitioners
for various somatic complaints (mean age = 44.76 years; SD = 15.04; 36.9% male). The
study aimed to investigate the psychometric properties of the Hungarian version of
the original and the short form of the Positive and Negative Affect Schedule (PANAS).
Comparisons of our study participants and reference groups could act as confounding
factors in the interpretation of results, due to their different study design.
Before the detailed examination of research questions, we used the Kolmogorov-Smirnov
test for testing normality. In the case of normal distribution, we used parametric
tests, while if the data were not normal, we used non-parametric tests.
One-sample t-tests were applied in order to compare mean scores of our sample and
the mean scores found in the samples of the reference groups (general adult and patient
populations) after examining the assumptions of the one-sample t-test. Repeated measures
ANOVA was performed to test the emotional state changes during the treatment in respect
of the success of the treatment after examining the assumptions of the repeated measures
ANOVA. Our between-subjects factor (treatment outcome) only had two groups (successful
and unsuccessful), thus we did not perform post hoc tests.
Statistical significance was defined as p < 0.05. The statistical analyses were conducted
with the Statistical Package for the Social Sciences (SPSS) version 22.0.
Results
Descriptive statistics
The study sample consisted of 87 couples who were about to begin a trial of IVF. [Table 1] summarizes the demographic and reproductive characteristics of the 174 participants
in the sample.
Table 1 Demographic and reproductive characteristics of participants (n = 174).
|
Variable
|
Successful IVF group (n = 82)
|
Unsuccessful IVF group (n = 92)
|
|
Age (years)
|
|
|
|
|
34.05 (0.73)
|
36.51 (1.23)
|
|
|
34.50
|
36
|
|
|
24 – 49
|
26 – 58
|
|
Marital status (%)
|
|
|
|
|
85.37
|
76.09
|
|
|
14.63
|
23.91
|
|
Duration of marriage/
cohabitation (%)
|
|
|
|
|
14.63
|
23.91
|
|
|
29.27
|
10.87
|
|
|
12.20
|
10.87
|
|
|
43.90
|
54.35
|
|
Residence (%)
|
|
|
|
|
87.80
|
84.78
|
|
|
12.20
|
15.22
|
|
Education (%)
|
|
|
|
|
2.44
|
1.09
|
|
|
50
|
54.34
|
|
|
47.56
|
44.57
|
|
Current employment (%)
|
|
|
|
|
86.90
|
84.78
|
|
|
2.38
|
4.35
|
|
|
0
|
0
|
|
|
1.19
|
1.09
|
|
|
0
|
0
|
|
|
4.76
|
6.52
|
|
|
2.38
|
3.26
|
|
Subjective evaluation of financial status (%)
|
|
|
|
|
2.44
|
1.09
|
|
|
23.17
|
25
|
|
|
46.34
|
42.39
|
|
|
28.05
|
25
|
|
|
0
|
6.52
|
|
Duration of infertility (years)
|
|
|
|
|
3.99 (2.85)
|
4.21 (2.75)
|
|
Cause of infertility (%)
|
|
|
|
|
34.15
|
30.43
|
|
|
26.83
|
19.57
|
|
|
29.27
|
26.09
|
|
|
9.76
|
23.91
|
We found no remarkable difference between the successful and unsuccessful IVF groups,
except for the cause of infertility. It can be seen from the [Table 1] that compared to the successful IVF group, idiopathic infertility was observed in
the unsuccessful IVF group to a greater extent (9.76 vs. 23.91%). Due to the fact
that there was no remarkable difference between the successful and unsuccessful IVF
women in respect of age either (successful group: mean age = 32.39 years, SD = 3.78;
unsuccessful group: mean age = 34.85 years, SD = 4.89), the proportions of patients
treated with short or long GnRH-a protocol were comparable in both groups, just as
in the case of the applied stimulation drugs. Consequently, the type of the applied
protocols and stimulation drugs does not act as a confounding factor in the comparison
of successful and unsuccessful IVF groups regarding emotional state changes during
the treatment.
Comparison of IVF couples and reference groups regarding emotional state
Firstly, we examined the characteristics of the emotional state in infertile couples
with regard to IVF treatment compared to the general adult and patient populations.
First of all, with regard to negative and positive emotional states, we compared the
IVF couplesʼ negative and positive affectivity with the mean scores of a Hungarian
patient sample (n = 466) in which patients visited their General Practitioners for
a variety of somatic complaints [25]. According to the results, the negative affectivity scores of both IVF men and women
were significantly lower than male and female patientsʼ scores at every stage of the
treatment (for details see [Table 2]). As regards the differences in positive emotional state, IVF men and women showed
significantly higher level of positive affectivity than their male and female controls
from the patient population during the whole cycle.
Table 2 Comparison of IVF couples (n = 174) with comparative norms.
|
Variable
|
IVF couples
|
Reference group
|
Significance
|
|
Time
|
Mean (SD)
|
Mean (SD)
|
p value
|
|
* Reference group is a Hungarian patient sample (n = 466).
** Reference group is the general adult Hungarian population.
IVF: In vitro fertilization; SD: Standard deviation; NS: Not significant
|
|
Positive affectivity*
|
|
|
|
|
|
Men
|
T1
|
37.51 (5.43)
|
32.06 (6.31)
|
< 0.001
|
|
T2
|
38.53 (5.41)
|
< 0.001
|
|
T3
|
37.84 (5.71)
|
< 0.001
|
|
Women
|
T1
|
36.67 (6.32)
|
33.93 (6.84)
|
< 0.001
|
|
T2
|
35.67 (7.93)
|
< 0.05
|
|
T3
|
36.75 (7.60)
|
< 0.01
|
|
Negative affectivity*
|
|
|
|
|
|
Men
|
T1
|
16.02 (6.25)
|
18.71 (6.22)
|
< 0.001
|
|
T2
|
15.30 (5.33)
|
< 0.001
|
|
T3
|
15.22 (5.96)
|
< 0.001
|
|
Women
|
T1
|
16.28 (4.5)
|
19.36 (6.40)
|
< 0.001
|
|
T2
|
16.80 (5.37)
|
< 0.001
|
|
T3
|
16.80 (5.43)
|
< 0.001
|
|
Depression**
|
|
|
|
|
|
Men
|
T1
|
5.21 (6.45)
|
6.63 (10.46)
|
< 0.05
|
|
T2
|
4.39 (6.37)
|
< 0.01
|
|
T3
|
4.39 (6.97)
|
< 0.01
|
|
Women
|
T1
|
6.41 (7.16)
|
8.62 (11.74)
|
< 0.01
|
|
T2
|
5.62 (6.19)
|
< 0.001
|
|
T3
|
6.67 (6.54)
|
< 0.01
|
|
Anxiety-State**
|
|
|
|
|
|
Men
|
T1
|
39.30 (10.71)
|
38.40 (10.66)
|
NS
|
|
T2
|
38.58 (10.08)
|
NS
|
|
T3
|
39.33 (10.78)
|
NS
|
|
Women
|
T1
|
39.39 (10.55)
|
42.64 (10.79)
|
< 0.01
|
|
T2
|
40.53 (11.01)
|
NS
|
|
T3
|
40.41 (8.96)
|
< 0.05
|
|
Anxiety-Trait**
|
|
|
|
|
|
Men
|
T1
|
35.06 (8.35)
|
40.96 (7.78)
|
< 0.001
|
|
Women
|
T1
|
37.3 (9.96)
|
45.37 (7.97)
|
< 0.001
|
With regard to depression and anxiety, we compared the IVF couplesʼ depression and
anxiety scores with the mean scores of the general adult Hungarian population (n = 2000)
[30]. It can be seen from the [Table 2] that compared to the comparative norms, IVF menʼs depression scores were significantly
lower than those of the general adult population at T1, T2 and T3, just as among women.
Surprisingly, the trait anxiety level of IVF couples was significantly lower than
the scores of the general adult Hungarian population. We found no remarkable difference
in state anxiety between the infertile men and the representative sample. As for womenʼs
state anxiety, IVF women experienced significantly lower level of state anxiety than
the female controls at T1 (T1: t[51] = − 3.858, p < 0.01) and T3 (T3: t[48] = − 3.655,
p < 0.05).
In summary, more positive results were observed among the IVF couples than the reference
groups. The positive and negative affectivity of the IVF couples are better compared
to the patient population; they feel less depressed and show a lower level of trait
anxiety than the average population. Furthermore, their state anxiety level is on
average.
Comparison of successful and unsuccessful IVF groups regarding emotional state changes
during the treatment
Secondly, we examined if there are significant differences between the successful
and unsuccessful IVF groups in the emotional state including positive and negative
affectivity and depression over the course of the IVF cycle.
[Fig. 1] and [Fig. 2] illustrate changes in the positive and negative emotional states of the successful
and unsuccessful IVF couples. It is clearly depicted that the positive emotions are
remarkably higher than the negative ones during the entire duration of the treatment.
With regard to womenʼs comparison ([Fig. 1]), a decrease in positive emotions can be observable in both successful and unsuccessful
IVF women between T1 and T2. Interestingly, negative emotions tend to increase in
the successful group, but decrease in the unsuccessful group. We found a tendentious
difference in negative affectivity between the successful and unsuccessful groups
at the time of embryo transfer (F[1,77] = 3.65, p = 0.06). Furthermore, there is a
tendentious increase in positive emotions of the successful group between T2 and T3,
compared to an inconsiderable change in the unsuccessful group. In addition, the negative
emotions remarkably decrease in the successful group, while increase in the unsuccessful
group.
Fig. 1 Changes of positive and negative affectivity on the Positive and Negative Affect
Schedule in women undergoing successful (n = 38) and unsuccessful (n = 41) IVF treatment
(* p = 0.06) (T1: at the beginning of the treatment; T2: before embryo transfer; T3:
before pregnancy test).
With respect to menʼs comparison ([Fig. 2]), we found an increase in positive emotions and hopefulness in both groups at T2,
which is just in contrast to the trend described in women. In the successful group,
the opposite trend can also be seen in terms of negative emotions, since the negative
emotions of men decrease, which is inconsiderable in case of the unsuccessful group.
Between T2 and T3, the positive feelings of men do not change, but decrease in the
unsuccessful group. We found a significant difference in positive affectivity between
the successful and unsuccessful groups at T3 (F[1,77] = 4.94, p < 0.05). By the time
of pregnancy test, the negative emotions of men in the successful group do not change
in contrast to men in the unsuccessful group, where the negative emotions decrease.
Fig. 2 Changes of positive and negative affectivity on the Positive and Negative Affect
Schedule in men undergoing successful (n = 37) and unsuccessful (n = 42) IVF treatment
(* p < 0.05) (T1: at the beginning of the treatment; T2: before embryo transfer; T3:
before pregnancy test).
With regard to depression, [Fig. 3] indicates that the depression level of male and female member of unsuccessful couples
is higher than that of either member of successful couples. For successful couples,
womenʼs depression score is higher than that of men. At the same time, the two curves
run almost completely parallel to each other and show a downward trend between T1
and T3.
Fig. 3 Changes of depression on the short form of Beck Depression Inventory in men and women
undergoing successful and unsuccessful IVF treatment (* p < 0.05) (T1: at the beginning
of the treatment; T2: before embryo transfer; T3: before pregnancy test).
For male and female members of unsuccessful couples, we found almost the same level
of depression at the beginning of the treatment, which is considerably higher than
that of successful couples. Moreover, for men, the difference is proved to be significant
(F[1,78] = 6.65, p < 0.05). Between T1 and T2, the level of depression of men in the
unsuccessful group significantly decreases (p < 0.05), reaching depression score of
women in the successful group, but remains considerably higher than that of men in
the successful group. By the time of pregnancy test, depression score of the male
member of unsuccessful couples continues to decrease. In contrast, depression score
of the female member of unsuccessful couples significantly increases (p < 0.05) between
T2 and T3 and exceeds baseline level.
Discussion
Our study was carried out in order to clarify whether the negative change in emotional
state and depression is specific to IVF couples compared to the general adult and
patient populations. We also wanted to explore emotional state changes in couples
undergoing successful and unsuccessful IVF treatment across stages of the cycle (T1:
at the beginning of the treatment, T2: before embryo transfer, T3: before pregnancy
test). Furthermore, we wanted to explore if there is an association between the treatment
success and the emotional state of IVF couples, and the emotional relationship between
men and women.
The positive and negative affectivity of infertile couples (both men and women) were
found to be significantly better compared to the patient population, which suggests
that no awareness of disease relates to infertility among infertile couples. It appears
that the awareness of disease would reduce motive for childbearing or increase fear
of risk of having a child with a birth defect. According to our research, the infertility
problem does not imply disease-related conditions, in spite of the fact that infertility
is a medically treated disease in a health care facility. Our study participants evaluate
their status as a special situation rather than a disease. Compared to the general
adult population, they show significantly lower levels of depression and trait anxiety.
The more favorable results of infertile couples compared to the average population
suggest that indicators of their emotional status are within the normal range. Similar
findings were reported by Beaurepaire et al. [12], who found significantly lower depression scores among female and male inductees
and repeat cycle men than the community norms. On the other hand, they showed that
infertile couples undergoing IVF experience higher level of state anxiety irrespectively
of the stage of treatment than the same-sexed community controls [12]. Our results contradict results of a German study, in which women were found to
be more depressed than their female controls from the general population. However,
men only showed marginally elevated depression scores compared to their age-matched
controls [13]. Similar results were found in the study of Galhardo et al. [14], in which couples with an infertility diagnosis pursuing medical treatment scored
higher than normal control couples in depression. Interestingly, a cross-sectional
Hungarian study [15] found that infertile women were more depressed than the normative adult population,
while infertile men did not differ significantly from their male controls regarding
depression. No significant difference was observed in men and women in terms of anxiety.
Our results are in accordance with some previous results in which most infertile couples
show resilience throughout fertility treatment [31]. IVF patients presumably have more effective coping strategies and manage to handle
emotional strain during the treatment in comparison to those who do not even undertake
the treatment. Our results indicate that the desire to have a child and all the commitments
and life goals related to it may mobilize positive energies and favorable coping mechanisms
among these people, which may preclude the appearance of anxious and depressive feelings.
This is in line with findings by Volmer et al. [32], which show that active-avoidance coping might increase the risk of developing depression
or anxiety, while meaning-based coping might have a protective effect on infertile
couples. It may be that anxiety and depression occur in couples who experience resignation.
At the same time, the history of infertility treatment may also have an effect on
psychological well-being of couples. Our study participants were undergoing their
first or second IVF treatment. Resilience of couples with longer history of infertility
treatment and recurrent IVF failures may decrease [33], while their levels of psychological distress may increase.
With regard to comparison of successful and unsuccessful IVF groups, it appears that
the predominance of the positive emotions and keeping distance from the negative emotions
in both successful and unsuccessful IVF groups during the whole IVF cycle reflect
a healthy attitude, since it may only enable couples to even undertake burdens of
the treatment. However, idiopathic infertility was observed in the unsuccessful IVF
group to a greater extent, which suggests that the unexplained infertility diagnosis
may be associated with greater uncertainty leading to higher stress level in the relationship
of couples. The unrecognized cause of infertility and individual responsibility may
not mobilize sufficient coping resources in the unsuccessful group.
The decrease in positive emotions in both successful and unsuccessful IVF women between
T1 and T2 suggests that women have to experience an unpleasant procedure at T2, when
the embryo transfer takes place. In addition, our results are aligned with studies
that found a significant decrease in positive affect after hormone use compared to
before hormone use [16]. Interestingly, negative emotions increased in the successful group but decreased
in the unsuccessful group, which may indicate an increased concern for success in
the subsequently pregnant group. A slight change in negative emotions can mobilize
limited coping resources in the unsuccessful group. We found a tendentious difference
in negative affectivity between the successful and unsuccessful IVF women at the time
of embryo transfer, thus women in the successful group presumably face and cope with
the unpleasant experience of the expected procedure, which may be the “price of success”.
The higher level of negative affectivity may lead women in the successful group to
pay more attention to developing their lifestyle, complying with medical instructions,
proposing that it becomes a protective factor. The awareness of negative emotions
seems to mobilize their coping potential. This is in line with findings by Moreno-Rosset
et al. [34], which show that a non-clinical level of state-anxiety may be beneficial for achieving
pregnancy. In contrast, some studies do not confirm the positive association between
negative emotions, anxiety and IVF pregnancy, although they included different measurement
occasions. Turner et al. [22] observed in a sample of women undergoing IVF that there is no association between
state anxiety level prior to ovarian stimulation and pregnancy rate, but a lower level
of state anxiety one day prior to oocyte retrieval is associated with higher pregnancy
rate. According to the study of Lintsen et al. [23], the anxiety gain score from pretreatment to oocyte retrieval does not affect the
pregnancy rate after IVF.
Our interpretation is also confirmed by the fact that there was a tendentious increase
in positive emotions of the successful group between T2 and T3, compared to an inconsiderable
change in the unsuccessful group. Additionally, the negative emotions remarkably decreased
in the successful group, while increased in the unsuccessful group. For women in the
successful group, anxiety may not disorganize behavior, but may facilitate it and
become the basis of the positive emotions towards success. In contrast, women in the
unsuccessful group may be debilitated by their anxiety; therefore, they may be unable
to work for success, their emotions change in a negative direction.
Thus, the decisive role of emotions is reflected by the tendentious difference in
negative affectivity between the two groups at the time of embryo transfer and the
increase of positive emotions in the successful group contrary to the unsuccessful
group before the pregnancy test, when couples are not aware of the successful or unsuccessful
outcome of the treatment yet, indicating that the subsequently pregnant women trust
in success. At the same time, the negative emotions decrease considerably in the successful
group and increase in the unsuccessful group. Overall, emotional attitudes towards
childbearing change in a positive direction among women in the successful group, in
contrast to a negative direction among women in the unsuccessful group, which can
lead to depression. These findings add to the existing literature by suggesting that
it is the emotional attitude that psychologically differentiates between the successful
and unsuccessful IVF women. The successful group seems to reflect emotional dynamics
being consistent with the situation, while women in the unsuccessful group tend to
show indifference, accordingly they may be less emotionally involved in the situation.
It may be the result of emotional exhaustion due to infertility treatment, which presumably
affects childbearing motives and the success of treatment. Consequently, it appears
that emotional attitudes of couples towards childbearing need to be more consciously
shaped, since they can be associated with the treatment outcome.
With regard to menʼs comparison, we found an increase in positive emotions and hopefulness
in both groups at T2, which is just in contrast to the trend described in women, where
the physical discomfort and risk of the treatment were accompanied by a decrease of
the positive emotions. In the successful group, the opposite trend was also seen in
terms of negative emotions, since the negative emotions of men decreased. In the relationship
of couples, it suggests that the female partner of successful couples experiencing
the unpleasant treatment expects and emerges more emotional support from the male
partner. The decrease in menʼs negative affectivity may convey encouragement, but
in the case of unsuccessful couples, it is inconsiderable. Between T2 and T3, the
positive feelings of men did not change but definitely decreased in unsuccessful couples.
We hypothesize that this result implies that, in case of successful couples, men may
provide emotional support to their partner steadily until the end of treatment, while
it remarkably decreases in the unsuccessful group by the time of pregnancy test; accordingly
the female partner of couples may be left alone. Between T2 and T3, the negative emotions
of men in the successful group did not change, thus besides emotional support they
may express their concerns, in contrast to men in the unsuccessful group, where the
negative emotions decreased, which also suggests a reduction in concern, as the burden
of childbearing may cease due to assuming unsuccessful outcome of treatment. Consequently,
the combination of these results suggests a change toward a more indifferent emotional
attitude in the unsuccessful group.
Comparison of emotional state changes of women and men in connection with successful
and unsuccessful IVF treatment shows that the emotional attitude of the male partner
of the couple is crucial. In successful IVF couples, decrease in positive affectivity
and increase in negative affectivity for women by the time of embryo transfer is accompanied
by an increase in positive affectivity for men, which remains until the time of pregnancy
test, thereby presumably providing emotional support to their partner for the purpose
of having a child. For unsuccessful couples, this is contrary to the pattern described
in the successful group. The negative feelings of women in the unsuccessful group
are remarkably less intense, which can imply a lower degree of emotional involvement.
Women in the successful and unsuccessful group almost significantly differ from each
other in negative affectivity at the time of embryo transfer; accordingly, subsequently
pregnant women may experience the physical discomfort and risk of the treatment to
a greater extent, which presumably mobilizes coping potential. Men in the successful
and unsuccessful group do significantly differ from each other in positive affectivity
at the time of pregnancy test, which reflects higher emotional support among men in
the successful group. In the unsuccessful group, menʼs negative emotions are less
intense, suggesting a lower degree of emotional involvement. They may lose hope and
faith and experience inability, thereby weakening their emotional support provided
to their partner. The study of Chen et al. [35] supports the relationship between marital satisfaction and the success of treatment.
The direction of change in positive and negative emotions is confirmed by direction
of change in depression. Compared to successful couples, the higher level of depression
may not enable unsuccessful couples to experience the positive feeling of having a
child; it can reduce the strength of childbearing motives and the coping potential
related to it. The higher level of depression among women compared to men can be derived
from the greater physical burden of the treatment imposed on women. The significant
decrease in depression of men in the unsuccessful group between T1 and T3 may indicate
relief as anticipating the final outcome, since they may not experience failure as
women in the unsuccessful group whose depression scores significantly increase. The
anticipation of failure may lead to an increase in depression for women, while a decrease
for men. Our results raise further research questions about childbearing and other
motivations of the male partner of unsuccessful couples. Perhaps, they might not be
motivated enough in having children or they might have conflicting motives that need
to be further investigated. There may be an inadequate emotional synchrony in unsuccessful
couples in terms of decision to have a child, the lack of emotional rapport and the
emotional distance between the partners may hinder the purpose of conception. Not
only conscious, but unconscious fears or rejection can affect changes in emotional
state. Our results are in line with the results of previous studies that showed that
a higher level of depression is associated with lower pregnancy rates in women [18]. In addition, Slade et al. [36] observed an increase within the IVF cycle in the degree of depressive symptoms of
women 4 – 6 weeks after embryo replacement, compared to the beginning of the treatment.
According to the study of Yong et al. [21], women undergoing IVF treatment are most vulnerable to psychological distress at
the stage of pregnancy test. In contrast, some studies found no statistically significant
differences between women undergoing a successful and unsuccessful cycle of assisted
reproductive technology in pretreatment emotional distress (e.g. anxiety, depression)
[19]. Similar findings were reported by Matthiesen et al. [20], who found no significant association between depression and clinical pregnancy.
Moreover, there is no data concerning the association between depression in men and
the treatment outcome.
The novelty of our study is that we examine infertility not only along with the biological
process of IVF treatment, but also changes in the emotional state of both partners
at the same stages of the treatment, from which we can conclude emotional relationship
of infertile couples determining intentions towards having a child.
One limitation of our study might be that we have not followed the couples after the
pregnancy test; therefore, data are not available concerning further development of
the pregnancy and live birth. Although our study does not control for all possible
negative prognostic factors, every couple who participated in our research and decided
to undergo the treatment was assessed for age, AMH (Anti-Mullerian Hormone), AFC (Antral
Follicle Count), and BMI (Body Mass Index) and made their informed decision being
aware of these prognostic factors. In spite of the fact that both partners were emphatically
asked to answer the questionnaires separately without communicating with his or her
partner, and most participants reported at the next visit that they followed our instructions,
they were allowed to complete the questionnaires at home, which is a potential confounder.
Another limitation might be that we have no information if couples took a pregnancy
test at home between the time of the embryo transfer and the pregnancy blood test,
which could influence their emotional state and act as a confounding factor. Furthermore,
pregnancy is accompanied by multiple hormonal changes [37], possibly influencing emotional state in successful IVF women before the pregnancy
test, and acting as a confounding factor as well. Nevertheless, according to a systematic
review, the occurrence of depressive symptoms during the first trimester of pregnancy
is comparable to that of the general female population [38].
Our results suggest the importance of couplesʼ emotional dynamics in childbearing.
The lack of emotional synchrony between partners is a possible explanation for an
unsuccessful IVF attempt. Participation of men in the IVF treatment is at least as
determinant psychologically as the role of women in undergoing the biological process
of the treatment. The emotional attitude and support of men become a determining factor
in the biological success of women. Our findings suggest that it is worth exploring
feelings and aspirations of couples related to childbearing and parenthood, as this
may increase the efficiency of assisted reproduction. Moreover, adaptive coping with
infertility and stressful, overwhelming fertility procedures may offer an opportunity
for posttraumatic growth [39].
Conclusions
Our study suggests the importance of couplesʼ emotional dynamics in having a child
and an association between couplesʼ emotional reactions during the IVF cycle and the
treatment success, which is also confirmed by the higher proportion of couples with
unexplained infertility in the unsuccessful group. Therapeutic counseling including
couple therapy should aim to reduce the sense of helplessness of men so that they
can get emotionally involved to a greater extent and provide emotional support to
their partner. Moreover, treatment of depression from the onset of the treatment and
giving hope to couples in the most crucial period between the time of embryo transfer
and pregnancy test could further increase the success of treatment.
