Hum. Reprod. Advance Access originally published online on August 24, 2006
Human Reproduction 2006 21(12):3295-3302; doi:10.1093/humrep/del288
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First IVF treatment—short-term impact on psychological well-being and the marital relationship
1 Reproductive Medicine, Department of Obstetrics and Gynaecology, Institution of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital/Sahlgrenska, Göteborg University and 2 Nordic School of Public Health, Göteborg, Sweden
3 To whom correspondence should be addressed at: Reproductive Medicine, Department of Obstetrics and Gynaecology, Institution of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital/Sahlgrenska, Göteborg University, SE-413 45 Göteborg, Sweden. E-mail: herborg.holter{at}vgregion.se
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Abstract |
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BACKGROUND: The aim of this study was to assess infertile couples’ short-term emotional responses to their first IVF treatment (the women’s and men’s emotional reactions and their experiences of the marital relationship at different stages of the first treatment) and to relate these responses to the outcome of the IVF treatment. METHODS: The study was part of a prospective, longitudinal study where 117 couples participated. The women and men answered questionnaires separately concerning psychological and social factors at three occasions: before, during and 1 month after treatment. RESULTS: Women’s and men’s emotional reactions related to first IVF treatment were dependent on whether they achieved a pregnancy or not. Those who failed to become pregnant rated their emotional well-being worse, whereas those who became pregnant rated their emotional well-being better than before treatment started. The women reported stronger emotional reactions about their infertility than their husbands. However, the men reacted in the same emotional pattern as their wives when pregnancy was not achieved. A majority reported that the marital relationship improved during treatment. CONCLUSION: Couples undergoing their first IVF treatment are as a group well adjusted and manage to handle the short-term emotional strain under treatment. The determining factor for short-term emotional response of treatment was whether pregnancy was achieved.
Key words: emotional reactions/IVF/marital relationship/psychological well-being
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionAcknowledgementsReferences |
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Psychological factors associated with infertility are well documented. Infertility is ranked as one of the greatest stressors in life, comparable to divorce and death in the family (Baram et al., 1988
) and to somatic diseases such as cancer and HIV (Domar et al., 1993). It threatens the individual’s identity (Möller and Fällström, 1991) and affects every facet of a couple’s life (Mahlstedt, 1994). Infertility is regarded as a prolonged life crisis (Lalos, 1999), associated with risk for depression, feelings of loss, guilt, isolation and meaninglessness, as well as sexual and marital problems (Baram et al., 1988; Möller and Fällström, 1991; Wirtberg, 1992; Mahlstedt, 1994; Lalos, 1999). Domar et al. (1992) found that infertile women were significantly more depressed than a control group of fertile women. These authors also found that women who had been infertile for a moderate length of time were significantly more depressed than women with infertility <1 year or >6 years.
Despite this, most people seeking IVF treatment seem to be well adjusted (Connolly et al., 1993; Edelmann et al., 1994; Wischman et al., 2001; Anderheim et al., 2005).
Several studies investigating the psychological profile of IVF treatment found that the couples were well adjusted compared with normal groups with no psychological maladjustment (Edelmann et al., 1994; Wischman et al., 2001). Bringhenti et al. (1997) did not find any psychological maladjustment in infertile women compared with a control group of mothers but suggested that the infertile women’s higher level of state-anxiety was a situational response to the stress of treatment. However, Salvatore et al. (2001) found a particular psychological profile among women in an IVF group with higher, although not abnormal, levels of anxiety and emotional tension, passivity, dependency and sensitivity, and a different marital relationship pattern where the women were more symbiotic and prone to idealize their partners yet felt unsatisfied with their emotional and sexual relationships, when compared with a control group of gynaecological patients without any infertility problems.
Several studies present results concerning the patients’ experience of different treatment cycles. Slade et al. (1997) found that first and last treatment cycles were associated with greater anxiety among women, whereas Boivin et al. (1995) found highest levels of distress in women with moderate experience of treatment failure and no relationship between distress and years of infertility. Greenfeld et al. (1988) found the intensity of grief reactions among women to be greatest after a failed first cycle of treatment. Berg and Wilson (1991) found increased emotional strain after the third year of infertility treatment, which they labelled a chronic strain response to long-term treatment. Beaurepaire et al. (1994) found that women with repeated cycles faced further risk of developing severe depressive symptoms. Verhaak et al. (2001) concluded in their study that high levels of distress in women after the first failed treatment are associated with a high level of emotional strain before the start of the second treatment and represent a risk for developing depression, a risk that increases with repeated cycles.
Most women seem to manage the long-term reactions following infertility treatment. However, Verhaak et al. (2005) found subclinical forms of depression and anxiety in >20% of women 6 months after unsuccessful treatment but also that most women adjusted well. Leiblum et al. (1998) found by long-term investigation that women who became biological mothers through IVF were significantly more satisfied with life than those who were unsuccessful in IVF and remained childless, but the majority adjusted to infertility treatment and its aftermath. Hammarberg et al. (2001) found in a follow-up study, 2–3 years after treatment, that unsuccessful women tended to be more critical about the experience of treatment, but general health was not different compared with those who were successful.
Most studies in this field focus on women’s reactions during treatment, but there are also studies that investigate the reactions of both spouses. Women have been found to react more strongly than men to infertility and treatment (Beaurepaire et al., 1994; Hjelmstedt et al., 1999; Newton et al., 1999; Lee and Sun, 2001). Beutel et al. (1999) noticed more treatment-related stress and depression among women than men. A recent longitudinal study by Verhaak et al. (2005) showed that women reacted with increased anxiety and depression after IVF failure, whereas no change was observed among men. Boivin et al. (1998) found the same pattern in men and women concerning psychological reactions during the first IVF treatment, although women had stronger reactions. Baram et al. (1988) also found the same pattern but stronger feelings of depression, sadness, helplessness, loss, guilt and loss of control in women. On the contrary, Edelmann and Connolly (2000) found no evidence for a differential increase in infertility attributable to distress scores for women over time but that the gender differences were comparable to normative gender differences. They report in their study of gender differences in response to infertility and treatment: ‘Differences of this kind may be primarily a function of the methodology adopted, the findings reflecting simply a tendency for women to express their feelings more readily to a stranger than are their partners.’(p. 372).
Earlier studies also reported different findings and results concerning experiences of the marital relationship related to infertility and treatment. Slade et al. (1997) found women initially to be less positive than men about their marital and sexual relationship. After treatment at follow-ups, those who were pregnant were less depressed and more positive about their relationship. Beaurepaire et al. (1994) found men to feel that fertility problems had much greater negative impact on their sexual relationship than their wives. According to Boivin et al. (1995), moderate amount of treatment failure resulted in most marital distress among women, whereas Berg and Wilson (1991) found that marital adjustment deteriorated after the third year of treatment.
Hammarberg et al. (2001) found no difference in marital satisfaction between successful and unsuccessful women at a follow-up study 2–3 years after treatment, and 37% reported that IVF treatment had had a positive impact on their marriage. Also other studies found that infertility and treatment may improve and strengthen the relationship (Baram et al., 1988; Hjelmstedt et al., 1999).
Some authors mention the problem that infertility-related stress is mostly measured by standardized psychiatric measurements, which may limit the expression of the specific problems represented by infertility and its treatment (Berg and Wilson, 1990; Newton et al., 1999; Edelmann and Connolly, 2000; Yong et al., 2000).
In this study, we concentrate on the first IVF treatment and short-term emotional reactions and experiences of the marital relationship. The first treatment is the foundation for further treatments, and investigating the couples’ emotional reactions during this period may give valuable information that may help improve support during and after treatment.
There is a lack of information from prospective studies about emotional reactions of both women and men concerning experiences of the marital relationship before, during and after IVF treatment and emotional reactions related to the outcome of the first IVF treatment. The aim of this study was to assess infertile couples’ emotional short-term responses to their first IVF treatment and their experiences of the marital relationship at different stages of the first treatment. The results were related to whether a pregnancy was achieved.
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Materials and methods |
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Design
This study is part of a larger, prospective, longitudinal study in which couples (both men and women) were followed during their first IVF treatment by means of questionnaires administered on three occasions, before, during and after treatment. The patients were recruited between March 1999 and June 2002 at the Reproductive Unit, Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Sweden.
The study was approved by the Ethics Committee in Göteborg.
Procedure
All patients planning to start their first IVF/ICSI treatment received written information about the study a week before the information group meeting that was held 2–4 weeks before the first treatment. Exclusion criteria were inadequate fluency in the Swedish language and participation in other studies. At the information meeting, those who felt interested in participating in the study were asked to remain after the meeting to answer the first questionnaire. Of the 151 couples invited, 117 agreed to participate in the study (71% participation rate). Reasons for not participating were lack of time or interest.
Each spouse was asked to answer the questionnaire separately without communicating with his or her partner.
The second questionnaire was given to the couples to fill in about 1 h before oocyte retrieval, and the third questionnaire was sent by mail in a stamped, pre-addressed envelope 2 weeks after menstruation or result of pregnancy test or 2 weeks after the cancellation of treatment for those who did not receive embryo transfer.
Patients
A total of 117 couples participated in the study. Demographics are presented in Table I. Of the 117 couples who agreed to participate in the study and who answered the first questionnaire, 100 couples (200 men and women) answered all three questionnaires. Of the 17 couples who did not answer the third questionnaire, three couples discontinued ovarian stimulation, one couple separated during the time period, one couple reported psychological distress and, for the remaining 12 couples, the reasons for not answering the third questionnaire are unknown.
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IVF treatment
All women were treated using a stimulation protocol including down-regulation with GnRH agonist in a long protocol starting either in the follicular phase or in the luteal phase (1.2 mg per day administered nasally or 1.0 mg per day as an s.c. injection; Suprecur or Suprefact; Hoechst, Frankfurt, Germany). Down-regulation was followed by stimulation with recombinant FSH (Gonal-F, Serono, Geneva, Switzerland or Puregon, Organon, Oss, the Netherlands). Monitoring was performed by vaginal ultrasound scans and serum estradiol measurements. When adequate stimulation was achieved (
3 follicles of 18 mm), 10 000 IU hCG (Profasi, Serono) was administered. Fertilization was performed by conventional IVF or by ICSI, following standard techniques. In general, two embryos were transferred 2 or 3 days after oocyte retrieval using a Wallace or a Frydman catheter. Luteal support was given either with s.c. hCG or with progesterone (administered i.m. or vaginallly). Additional embryos of good quality were cryopreserved and replaced later. Clinical pregnancy was defined as ultrasound-verified pregnancy 5 weeks after embryo transfer.
Measurements
First measurement occasion
Background factors, such as age, living conditions, occupation and duration of infertility, are given in Table I.
Psychological well-being among the participants during recent weeks before the study was measured when entering the study by the Psychological General Well-Being index (PGWB) (Dupuy, 1984). The PGWB contains 22 items divided into 6 subscales: anxiety, depressed mood, positive well-being, self-control, general health and vitality. The index scores can be totalled to form a global overall score, and the scores can be divided into these six dimensions. Each item is graded 1–6. The higher the value, the better is the well-being. Norm values from the Swedish population matched for age and gender are available (Dimenäs et al., 1996). The PGWB has shown satisactory reliability and validity (Dupuy, 1984; Wiklund et al., 1995).
The strength of the child-wish was evaluated by means of four questions covering the respondents’ perceptions of the importance of having a child and effects of childlessness. Visual analogue scale 0–10 was used, where 0 = not at all and 10 = very much.
Psychological effects of infertility were measured by 14-item ‘the effects of infertility’ (guilt, success, anger, contentment, frustration, happiness, isolation, confidence, anxiety, satisfaction, depression, powerlessness, competence and control) (Anderheim et al., 2005). These items seek to capture the aspects of experiences often expressed by infertility patients. The items were formulated as questions such as ‘How much of the following feelings do you experience during the present days: guilt, success, etc.’. These items were summarized and also analysed separately. Each item was graded 1–5. Low values indicate better well-being.
The respondent’s relationship with his or her partner was evaluated by means of two questions: ‘Do you feel that childlessness has caused problems in your marriage?’ and ‘Is talking to each other more difficult now than it was before infertility became an issue?’ These items were also graded 1–5 (1 = not at all and 5 = very much).
Second measurement occasion
The same 14 items regarding psychological effects of infertility were used as at the first measurement occasion.
The same two questions regarding the relationship were used as at the first measurement occasion.
Third measurement occasion
The same 14 items regarding psychological effects of infertility were used as at the first measurement occasion.
The same two questions regarding the relationship were used as at the first measurement occasion.
The effects of treatment on the respondent’s relationship with his or her partner were evaluated by means of questions concerning affection, understanding, support and time spent talking with the partner about the treatment.
Statistical analysis
Means, standard deviations, medians and ranges were used for descriptive statistics. Mann–Whitney U-test was used for group comparisons of continuous and ordinal scale variables and Wilcoxon’s signed rank test for paired comparisons of continuous and ordinal scale variables. A multiple linear regression was performed for each gender on the dependent variable ‘the effects on infertility’ total score, third measurement. The variables, PGWB, ‘strength of child-wish’, ‘the effects of infertility’ first and second measurement, age, duration of infertility, waiting time for treatment, previous children, employment, college/university education, IVF/ICSI, embryo transfer and clinical pregnancy were tested for independent correlation. All tests were two sided, and a P-value <0.05 was considered significant. SPSS software (version 12.0) and SAS software (version 8.2) were used.
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Results |
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Individual responses before treatment (first measurement occasion)
Before starting the treatment, the participants as a group had high scores on the PGWB, indicating a high level of general well-being in the group. Considered together with the demographic factors (Table I), this suggests quite a homogeneous and well-adjusted group of people. In total, men scored significantly higher than women (P = 0.0054), felt less depressed (P = 0.0002), showed less anxiety (P = 0.0042) and had better self-control (P < 0.0001). There were no significant differences between men and women concerning positive well-being, general health or vitality (Table II).
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Concerning questions related to the strength of the child-wish, women expressed stronger reactions than men (Table III). It was significantly more important for the women to have children (P = 0.0055), they felt significantly more emotionally affected by their childlessness (P < 0.0001) and thought significantly more about their difficulty in having children (P < 0.0001).
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On their first visit to the clinic, before starting the treatment, the participants answered the ‘the effects of infertility’ questionnaire. Women scored significantly higher than men on total score, [33.5 (9.1) versus 30.8 (7.8), P = 0.005] and on several items: anger, frustration, anxiety, depression, powerlessness and control (Table IV).
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Individual responses during the treatment (second measurement occasion)
One hour before oocyte retrieval, both men and women again answered ‘the effects of infertility’ questionnaire. Women scored significantly higher than men on feelings of anger, frustration, anxiety, depression and powerlessness. However, the mean figures were low, indicating that most of the men and women had few uncomfortable feelings (Table IV).
Individual responses 2 weeks after the pregnancy test (third measurement occasion)
Two weeks after the pregnancy test, all participants answered ‘the effects of infertility’ questionnaire for the third time. Here, the results are presented separately for those who achieved or did not achieve a clinical pregnancy.
Women and men in the pregnant group reported a significantly higher degree of success, contentment, happiness and satisfaction than women and men in the not pregnant group. Women and men in the not pregnant group reported significantly stronger feelings of powerlessness. Women in the not pregnant group felt significantly more guilt, anger, frustration, isolation and depression compared with women in the pregnant group (Table IV).
Gender differences were also found at the third measurement. Women scored significantly higher than men in the not pregnant group concerning frustration, anxiety, depression, powerlessness and anger and lower on feeling of success. In the pregnant group, women scored significantly higher than men concerning anxiety and powerlessness (Table IV).
Figure 1 shows the development of the women’s and men’s reactions over the 
8 weeks covered by the study.
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The women in the not pregnant group felt significantly more guilt, isolation, depression and powerlessness and significantly less success, contentment, happiness, confidence and satisfaction after than before treatment. The men in the not pregnant group felt significantly more anger, anxiety, powerlessness and significantly less contentment, happiness, satisfaction and control after treatment. Pregnant women felt significantly more success and significantly less anger and frustration after treatment, and men in the pregnant group felt significantly less frustration after than before treatment (Table V).
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View of the marital relationship before, during and after treatment
Men felt to a higher degree than women that childlessness had caused problems in the marriage both before treatment (P < 0.0001) and during treatment (borderline significant P = 0.0507), but there was no difference after treatment in either the pregnant group or the not pregnant group.
A great majority (90%) answered ‘not at all’ to the question ‘Do you find it more difficult to talk to each other now than before childlessness became an important issue?’
There were no significant differences (P-values between 0.14 and 1.00) between men and women in either the pregnant group or the not pregnant group in answers to the questions ‘Do you believe that your spouse understood your feelings and provided emotional support?’ and ‘Do you think you understood your spouse’s feelings and provided emotional support?’ The majority felt that they understood and could support each other, but in 20% of the couples, either the woman or the man or both answered ‘no’ to these questions, and more women in the pregnant group than in the not pregnant group gave a negative answer. There were no significant differences between the pregnant and not pregnant groups in answers to the question ‘How did the infertility treatment process affect your relationship with your spouse?’ (Table VI). The majority answered that the treatment had affected the relationship with their spouse to the better during the treatment in both the pregnant and the not pregnant group. More persons in the not pregnant group answered negatively.
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In most couples, the spouses gave the same answers. However, in nine couples in the pregnant group and in 18 couples in the not pregnant group, the spouses answered differently. There were no differences between men and women.
Two men in the pregnant group and two couples in the not pregnant group gave the answer ‘worse’. Seven persons in the not pregnant group gave double answers (both to the worse and to the better).
In response to the question ‘How much time have you and your spouse spent talking about the treatment?’ Seventy-four couples gave the same answer, and 18 couples gave different answers. The majority had spent a good deal of time talking to each other (71.3% women, 71.6% men), and only two women and two men answered that they had not talked about it at all.
In the multiple linear regression analysis concerning the men, the variables pregnancy (P = 0.0006), ‘the effects of infertility’, second measurement (P = 0.0022) and PGWB (P = 0.0055) significantly correlated with the dependent variable ‘the effects of infertility’ third measurement. For the women, the variables pregnancy (P < 0.0001), ‘the effects of infertility’ first measurement (P = 0.0158) and second measurement (P = 0.0033) significantly correlated with ‘the effects of infertility’ third measurement.
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Discussion |
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Not surprisingly, the results of the present study focusing on the first IVF cycle clearly illustrate that the women’s and men’s emotional reactions after their first IVF cycle are dependent on whether they achieved a pregnancy. Those who failed to become pregnant rated their emotions worse, whereas those who became pregnant rated their emotions better than before treatment started. The women seemed to have stronger emotional reactions about their infertility than their husbands. This was true on all three measurement occasions. However, the pattern of reaction was similar for both spouses. The men reacted as strongly as their wives did when pregnancy was not achieved, in the sense that they reported their emotions worse on the third measurement occasion as compared with the first occasion in a similar pattern as their wives.
The results also show that for most couples, IVF treatment did not have any negative impact on their relationship during the period of time studied, independent of the outcome of the IVF. Instead, it seemed as if most of the spouses tried to be close to and support each other during and immediately after IVF. There was more variation between men and women before than after treatment. At the time of treatment, the relationships were strengthened because of the treatment process. However, further IVF failures might cause more problems, both individually and within the relationships. Verhaak et al. (2005) found depression and/or anxiety in >20% of women 6 months after unsuccessful treatment.
The differences between women and men regarding the intensity of feelings related to infertility have been discussed in the literature. The explanation that reproduction, and thereby also infertility, is more closely associated with women than with men from the perspective of evolution may hold. Alternative explanations have been suggested, such as the insensitivity of the questionnaires used (Newton et al., 1999), and that differences in expressing emotional reactions are related more to differences in the language used by women and men, respectively, and in coping styles than in differences in the intensity of the feelings experienced (Edelmann and Connolly, 2000). It is also clear that the kinds of stress symptoms usually focused on in studies in this field are more prevalent in women in general. In the present study, it was clear that men reacted at least as strongly as their partners when IVF failed.
Lalos (1999) wrote in the article ‘Bringing bad news concerning fertility’ that ‘to exaggerate a little, one could say that there is, in this respect, only one form of good news for the couple – that of a successful pregnancy’. This is of course true in one respect. However, many couples reported that they experienced more closeness even after the failure of IVF, something that they regarded as positive. Nevertheless, it is worth noting that there were also couples who reported that their relationship had deteriorated during treatment. Furthermore, there was also a group of persons who felt very bad after realizing that they had not become pregnant. This group may be in need of support and counselling.
Both women and men in the group that did not receive embryo transfer (n = 15) scored higher on the effect of infertility scale, although not significantly.
When studying couples with infertility problems, it is of value to use specific methods of measurement related to the problem at issue, and not only generic instruments. It is easier to express emotions related to the problem being focused on than in general terms. The disadvantage is that comparison with studies of other conditions will be more difficult. A risk with using a design with repeated measurements is that respondents may remember how they answered each question the previous time and then give the same answers. Our impression was that most of the subjects were serious about answering the questions and wanted to give as many true answers as possible in a situation that was of greatest importance to them. On the contrary, they probably also wanted to give a ‘balanced impression’ as good future parents and as good patients, at least when starting the treatment, which might have influenced the answers in a non-problem direction.
Several comparisons have been performed in the present study, and therefore, it is possible that some of the significant differences we have found are chance findings. We have however chosen not to adjust for multiple comparisons, only to point out that they exist, and leave to the reader to judge and evaluate the risk of chance findings.
The generalization of a study is an important issue. During the study period, 20% of all patients treated at the clinic participated in the study. The reason for not achieving a higher participating rate was mainly other parallel running studies. Of those who refused to participate, the reason for refusal was the lack of time and emotional strain in the present situation. The results presented here may thus show less of the strong emotional reactions that may have been seen if these couples had also participated. Despite this limitation, it is good news not finding damaging reactions because of treatment. We had expected stronger short-term reactions after IVF failure. Even 1 h before oocyte retrieval, a time that we know is demanding for most patients and even frightening for some, the mean figures at ‘the effects of infertility’ were low indicating relative psychological well-being. We regarded this as good evaluation of care and support given by the staff during treatment, but it could of course also indicate the lack of sensitivity of the measurement scales. It is also possible that it is easier now than it was some years ago to cope with infertility and infertility treatment. An early study by Baram et al. (1988) reported that 94% of women and 64% of men had symptoms of depression and anxiety after the failure of IVF treatment, and Domar et al. (1992) found depressive symptoms common in infertile women. The success rate after IVF has increased. Possibly infertility is more accepted today, and there is more openness in society towards infertility and its treatment. Gender roles have also changed.
In reproductive medicine, the development of new methods and technique are rapid, and it is important that studies dealing with emotions and psychological reactions go in parallel with other scientific studies in this field.
In conclusion, the present study shows that infertile couples undergoing their first IVF treatment in general are well adjusted and can cope with the strain of treatment. Most couples who failed to achieve a pregnancy after IVF and thus experienced emotional suffering could at a short-term level manage the crises.
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Acknowledgements |
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We thank Nils-Gunnar Pehrsson and Mattias Mohlin for statistical assistance. The study was supported by grants from the Vardal Foundation and Sahlgrenska Academy. We also thank Organon Sweden for economical support.
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References |
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Submitted on January 20, 2006; resubmitted on April 21, 2006; resubmitted on June 16, 2006; accepted on June 26, 2006.
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