Psychological assessment and follow-up after in vitro fertilization: assessing the impact of failure

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1 FERTILITY AND STERILITY Copyright 1990 The American Fertility Society Printed on acid4ree paper in U.S.A. Psychological assessment and follow-up after in vitro fertilization: assessing the impact of failure Christopher R. Newton, Ph.D.*t Margaret T. Hearn, Ph.D.* Albert A. Yuzpe, M.D.:j: University Hospital, London, Ontario, Canada The present study was conducted to assess the immediate psychological impact of failed in vitro fertilization (IVF). Emotional status and marital functioning were also examined pre-ivf, and both demographic information and psychological test scores were evaluated as predictors of reaction to treatment failure. After a failed first cycle, both males and females showed significant increases in anxiety and depressive symptoms. Although group means were not clinically elevated and most participants were coping adequately, the prevalence of both mild and moderate depression increased substantially, particularly among women. In addition, women without children were a subgroup particularly vulnerable to the stress of failure. Predisposition towards anxiety, pre IVF depressive symptoms, and fertility history were the most important predictors of emotional response. Treatment implications of these findings were discussed. Fertil Steril54:879, 1990 In recent years much evidence has been presented to suggest that long-standing infertility is a significant source of stress that produces a host of psychosocial consequences.1 2 Infertility is viewed as encompassing a series of losses including loss of children, social role, and self esteem. 3 The emotional response to infertility has been characterized as a grief reaction, 4 and includes feelings of anxiety, anger, alienation, guilt, and depression. Accordingly, concerns about the social and psychological adjustment of infertile couples entering in vitro fertilization (IVF) programs have been raised, and it has been suggested that major efforts be directed toward preparatory work dealing with the real possibility of IVF failure. 5 Unfortunately, much of the data concerning the psychological adjustment of infertile couples is based either on anecdotal evidence or derived from Received January 15, 1990; revised and accepted July 11, *Department of Psychology. t Reprint requests: Christopher R. Newton, Ph.D., Department of Psychology, University Hospital, Box 5339, London, Ontario, Canada N6A 5A5. :j: Department of Gynaecology. nonstandardized measures. Assessment of infertile couples with standardized tests has produced mixed results. Personality assessment has indicated that infertility group means are within the normal range, although 20% of men and women had elevated scores suggestive of psychological dysfunction. 6 Similarly, both elevated 7 8 and normal9 10 levels of anxiety have been observed in participants before IVF involvement. In contrast, marital adjustment scores for infertile couples have been consistently found to be average or above However, this finding has been met with skepticism and suggestions that prospective IVF couples might be motivated to conceal marital strife Despite valid concerns regarding the psychological impact of IVF failure, there have been few follow-up studies and findings have been contradictory. For example, studies using standard test measures in long-term follow-up (6 to 32 months) have observed anxiety, depression, and marital adjustment scores to be in the normal rangey In contrast, other couples assessed 1 to 36 months after IVF failure reported IVF participation to be highly stressful, as having had a significantly negative im- Newton et al. Psychological evaluation after IVF 879

2 pact on lifestyle, and that IVF failure produced both depression and diminished marital satisfaction Unfortunately, the length of time between IVF failure and subsequent assessment has often been highly variable even within studies. Often subjects are asked to make retrospective ratings of emotional distress and conclusions are based on responses to single item scales of unknown reliability and validity. In the only study to assess the immediate impact of IVF failure in a standardized fashion, elevated levels of depression and anger were observed in both partners. 11 Emotional distress was significantly greater in wives than in husbands, except in women with previous biological/ adopted children who appeared to cope more effectively. However, the level of clinical depression experienced by these couples remains unclear due to the nature of the mood scales employed. Since emotional distress and the need for intervention are likely to be higher immediately after a failed IVF attempt, more information concerning this period is needed. Equally important is the need to identify those individuals or couples most at risk. The present study addresses three related issues. First, psychological and marital functioning of infertile couples was assessed before IVF involvement to determine whether factors such as gender or fertility history had any impact on adjustment. Second, emotional status was examined through standardized testing immediately after a first IVF attempt to assess the impact of IVF failure and to identify those at greater risk. Finally, it was investigated whether reaction to failure could be predicted from information obtained before IVF. Sample Selection MATERIALS AND METHODS The initial sample for this study consisted of 94 7 women and 899 male partners, consecutively admitted to an IVF program in a university teaching hospital from January 1984 to January Couples entering the program were required to meet the following criteria: (1) stable marital relationship, (2) less than two children living at home, and (3) referral by their gynecologist or infertility specialist, typically after several years of unsuccessful treatment to overcome infertility. Measures The following psychological self-report measures were used to measure different aspects of marital and personal functioning. The Family Environment Scale (FES)16 was employed to measure the social-environmental characteristics of couples on ten subscales. Scores on the subscales indicated perception of the conjugal environment in terms of such characteristics as cohesion, expressiveness, and conflict. The State-Trait Anxiety Inventory17 was used to measure two aspects of anxiety. State anxiety provides a measure of transient emotional arousal or situational distress at a particular point in time, whereas trait anxiety assesses relatively stable differences in anxiety proneness. This measure has been shown to have high reliability (internal consistency) and good construct validity. The Beck Depression Inventory (BDI) was chosen to measure depression, as it is one of the most widely used instruments for assessing both intensity of depression and for detecting depression in normal populations. Both the reliability and validity of this scale have been substantiated through a large body of research.18 The Life Appraisal Inventory19 consists of 10 seven-point semantic differential scales on which respondents rate how they feel about life. The ratings tapped dimensions such as discouraging-hopeful, useless-worthwhile, and friendly-lonely. The Life Satisfaction Questionnaire19 assesses degree of satisfaction with various aspects of lifestyle including family life, marriage, job, and spare time. Pre-IVF Procedure On meeting medical criteria, and approximately 3 months before their first IVF attempt, prospective participants were mailed all test instruments described. Husbands and wives were requested to complete the tests independently and to return these by mail to the program. Questionnaire responses were used as a source of information for a clinical interview. On assessment day, couples participated in a structured interview designed to assess their attitudes to and preparation for the IVF program. In a few isolated cases, failure to complete a questionnaire invalidated the total score, and this data was omitted. Due to gradual refinement of the assessment package over a period of years, Life Appraisal Inventory and Life Satisfaction Questionnaire measures were only available for a reduced sample size of 995. Post-IVF Procedure Three weeks after their first IVF attempt, wives and husbands were each asked to complete a fol- 880 Newton et al. Psychological evaluation after IVF Fertility and Sterility

3 Table 1 Comparison of Male and Female Test Scores Before IVF Women" Emotional factors 6 State anxiety 32.4 ± 9.7 Trait anxiety 34.6 ± 8.2 Depression 4.4 ± 4.8 Marital 6 Expressiveness 6.8 ± 1.7 Achievement 5.0 ± 1.6 Social/ cultural 5.2 ± 2.1 Active/recreational 5.9 ± 2.1 Life appraisal d Hard-easy 4.8 ± 1.4 Tied down-free 5.4 ± 1.4 Miserable-enjoyable 6.0 ± 1.1 Empty-full 5.6 ± 1.3 Life satisfaction d Health 5.7 ± 1.5 Standard living 6.0 ± 1.1 a Values are means ± SD. b n = 1,846 (94 7 women, 899 men). 'p < d n = 995 (497 women, 498 men). Men" 31.2 ± ± ± ± ± ± ± ± ± ± ± ± ± 1.1 p.003.oooc.000'.000'.000' low-up package provided during their final hospital visit. The package comprised a questionnaire detailing the outcome of the IVF attempt, the State Anxiety Scale, the BDI, and the Life Appraisal Inventory. Follow-up assessment was phased in gradually and revised after the program began. In its final version, the post-ivf test package returned by 213 women and 184 men. Sample Characteristics RESULTS Male participants tended to be slightly older than their female partners (men, 33.5 ± 4.9; women, 31.4 ± 3.8 [mean ± SD]). Educational achievement was similar with 50% of both males and females reporting education beyond high school. Mean socioeconomic status of the group was 5.2 on the Hollingshead AB four factor index of social status. 20 Seventeen percent of all participants had been previously divorced and 1% widowed. Twenty-three percent of couples reported at least one child in their present relationship, and 12% of females and 11% of males had one or more children from a prior relationship. Pre-IVF Evaluation,A multivariate approach to analysis was adopted to avoid alpha slippage, which can occur if a large number of univariate tests are performed. To allow comparison of men and women before IVF and to examine whether fertility history affected current adjustment, a series offour two-factor (male versus female, child versus no child) multivariate analyses were performed. Thus, measures of emotional status were grouped and analyzed simultaneously, followed in turn by analysis of scales of marital adjustment, scales of life appraisal, and scales of life satisfaction. Analysis of measures of emotional status indicated a significant multivariate effect for sex (F = 13.49, P < 0.001), but no effect for child nor any sex by child interaction. Table 1 presents separate univariate test results on scales where men and women differed, and Table 2 delineates significant differences between those with and without children. As Table 1 shows, women were experiencing significantly higher levels of transitory (state) anxiety, trait anxiety, and higher levels of depression before IVF in comparison to their male partners. Examination of marital relationship scores indicated multivariate main effects for both sex (F = 4.03, P < 0.001) and child factors (F = 20.10, P < 0.001), but no significant interaction. Thus, females described their marital relationships more positively, crediting the relationship with greater expressiveness and more opportunities for social and recreational activities than did their male partners. In contrast, men scored higher on achievement orientation indicating that they placed greater weight on this aspect of the relationship. Table 2 Comparison of Participants With and Without Children Before IVF Emotional factors 6 Marital 6 Expressiveness Conflict Social/Cultural Independence Moral-Religious Control Life appraisal e Tied down-free Useless-worthwhile Discouraging-hopeful Empty-full Disappointing-rewarding Life satisfaction e Children" No Children" 6.4 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 1.2 a Values are means± SD. 6 n = 1,846 (591 with children, 1,255 no children). ' NS, not significant. d p < en = 995 (353 with children, 642 no children). P NS' NS Newton et al. Psychological evaluation after IVF 881

4 Not only did men and women differ in their appraisal of the marriage, but irrespective of sex, childless individuals portrayed the relationship quite differently than participants with children. As Table 2 shows, childless individuals reported greater expressiveness, lower levels of conflict, more individual independence, lesser moral religious emphasis, and fewer controls in their relationship, but less interest in social and/or cultural activities. Examination of current life appraisal scales revealed similar multivariate sex (F = 4. 72, P < 0.001) and child (F = 5.86, P < 0.001) main effects but no significant interaction. As shown in Table 1, women described their lives as easier, more free, more enjoyable, but more empty than did their male counterparts. Similarly, childless individuals reported feeling more free, but also less worthwhile, less hopeful, more empty, and more disappointed with life than those with children (Table 2). Scores for life satisfaction scales showed a multivariate main effect for sex but no child or interaction effects. Women reported greater dissatisfaction with personal health and men less satisfaction with current standards of living (Table 1). Post-IVF Evaluation Although follow-up information was obtained from a total of 213 female and 184 male respondents, of this group, 26 women (12.2%) and 24 men (13.0%) reported IVF success. To explore the impact of IVF failure, successful participants were omitted from further analyses. Follow-up was conducted over a period of several years and although most IVF participants were included, it was not possible to determine the exact number of questionnaires distributed. As a result, the actual questionnaire return rate could not be calculated precisely and this represents a weakness in the study. However, comparison of the unsuccessful group with other IVF participants on the basis of information obtained before IVF suggested that participants in follow-up were quite representative of the IVF population seen at the clinic. The follow-up group did not differ significantly from other IVF patients on the basis of age, educational status, number of children from past or present relationsl}ips, pre-ivf state and trait anxiety scores, or pre-ivf levels of depression. Furthermore, the pregnancy rate among follow-up respondents was quite comparable with the observed pregnancy rate for all first cycle patients (10%). Thus, it does not appear that either cases of IVF success or failure are over represented among follow-up respondents. To examine changes after IVF failure, a series of three three-factor (sex by child by time) analyses of variance were conducted on measures of state anxiety, depression, and a single composite life appraisal score. Although a total of 34 7 participants had reported IVF failure, actual pre- and/or postcomparisons are based on a slightly reduced sample size as any cases with either missing pretreatment or post-treatment information were omitted. Exact sample sizes for each comparison are noted in Table 3. Analysis of state anxiety scores revealed significant time (F = 25.2, P < 0.001), child by time (F = 6.9, P = 0.009), and child by sex by time interaction (F = 7.1, P = 0.008) effects. As Figure 1 illustrates, IVF failure had a differential impact on participants depending on gender and fertility history. A simple effects analysis of the three-way interaction revealed that fertility history was a significant predictive factor among women (F = 4.53, P = 0.034) but not among men. Women without children reported significantly greater anxiety after failure than women with children (F = 4.56, P = 0.034). In contrast, men reported a significant increase in anxiety after failed IVF regardless of fertility history (F = 12.91, P < 0.001). Examination of the actual distribution of state anxiety scores after treatment indicated that 14.2% of childless women were experiencing what might be considered clinically elevated levels of anxiety (1 to 2 SD above population mean). An additional15% of those women were experiencing quite intense emotional arousal (>2 SD above population mean). In contrast, the comparable figures before treatment were 10.6% and 0.9%, respectively. In terms of depression, the analysis of variance revealed a significant sex effect (F = 5.9, P = 0.016) and a significant time effect (F = 11.1, P = 0.001). In other words, women reported significantly higher levels of depression than did men, both before IVF and after treatment failure (Table 3). As well, both men and women experienced a significant overall increase in depressive symptomatology in the weeks after IVF. An examination of the proportion of participants experiencing clinically meaningful depressive symptoms is also shown in Table 3. After IVF failure, 25.4% of women could be characterized as experiencing some form of depression compared 882 Newton et al. Psychological evaluation after IVF Fertility and Sterility

5 Table 3 Mean Anxiety, Life Appraisal, and Depression Scores Before and After Failed IVF Pre-IVF Post-IVF Men Women Men Women State anxietya,b Life appraisal a,c Depression a,d Percent depressed d Mild Moderate Total 31.5 ± ± ± ± ± ± ± ± ± ± ± ± a Values are means± SD. b n = 272 (123 men, 149 women). c n = 164 (75 men, 89 women). d n = 273 (122 men, 151 women). with 11.6% before treatment. Among these women, 17.9% were experiencing "mild" depression (BDI score 10 to 18) and a further subgroup (7.5%) were dealing with more serious or "moderate" levels of depression (BDI score> 18). Although the percentage of men experiencing depression almost tripled after IVF failure, the actual rate of occurrence was considerably lower than among women. Furthermore, comparatively few men were found to be experiencing more than mild depression. Analysis of the composite life appraisal measure showed a main effect of time (F = 14.8, P < 0.001) but no differences in terms of sex or fertility history. All participants appraised their life situation significantly more negatively after IVF failure (Table 3). A stepwise multiple regression analysis was performed to determine whether patient information obtained before treatment would be predictive of reaction to IVF failure. Eleven possible predictors were examined (sex, age, fertility history, educa- tion, occupational status, marital cohesion, expressiveness, conflict, pre-ivf state/trait anxiety, and depression). Post-treatment levels of state anxiety and depression were selected as criteria of post IVF adjustment. A significant overall multiple correlation (R = 0.54) indicated that 29% of the variance in post-ivf anxiety could be accounted for by three variables (Table 4). Simple bivariate correlations showed that higher levels of trait anxiety and depression pre-ivf were associated with elevated anxiety after IVF failure. Similarly, fertility history was associated with adjustment; those with children experienced lower levels of anxiety after IVF failure. Inspection of partial correlation coefficients suggested that the three variables were relatively equal in explanatory power. In contrast, neither demographic nor marital variables proved useful in the prediction of adjustment. Regression results using post-ivf depression scores as the criterion are also displayed in Table 4. A significant multiple R (0.55) indicated that 30% of variance in post-ivf depression was ac- s x z <I w ~ / --Q- FEMALES NO CHILDREN --.- FEMALES WITH CHILDREN --/:r- MALES NO CHILDREN _., MALES WITH CHILDREN PRE POST PRE POST Table 4 Predictors of Adjustment After IVF Failure From Stepwise Multiple Regression Bivariate Partial Regression Predictor variables correlations correlation coefficient Post-IVF criterion: state anxiety Trait anxiety History Depression Post-IVF criterion: depression Depression Trait anxiety History 0.44a -0.20a 0.43a 0.5oa 0.45a -0.10b 0.28a -0.25a 0.23a 0.32a 0.23a -0.14b 0.312a a 0.246a 0.353a 0.244a b Figure 1 Mean state anxiety scores before and after IVF failure for men and women with and without children. a P < b P< Newton et al. Psychological evaluation after IVF 883

6 r I counted for by pre-ivf trait anxiety, depression, and fertility history. Again, heightened depression after IVF failure was associated with high trait anxiety, greater depressive symptoms, and childlessness before treatment. Inspection of partial correlations suggested that pretreatment depression level is the most important predictor of depression after IVF. DISCUSSION The results indicated wide variation in both the psychosocial effects of infertility and the impact of IVF failure. Although the majority of IVF participants seemed to be coping adequately both before and after treatment, a significant subgroup appeared to be vulnerable and attempts to understand risk factors need to take into account gender and fertility history. Assessment before IVF suggested that women were at greater emotional risk than men, both in terms of higher levels of anxiety and greater depressive symptomatology. Despite this, the results need to be interpreted with caution. Although group differences for men and women were statistically significant and therefore reliable, the size of these differences on some measures were small. Moreover, actual group means for both sexes were in the clinically normal range. Therefore, average male/female differences before IVF do not appear to be clinically meaningful. Nevertheless, inspection of score standard deviations suggested a more variable reaction among women in terms of both anxiety and depression. In this sense, the findings are consistent with the notion that societal attitudes and values can create greater pressure (at least for some women) to fulfill a parenting role. 21 At the same time, the results underscore the fact that more intense emotional disturbance is found in only a subgroup of prospective IVF participants. Marital assessment data provided objective evidence in support of the frequent clinical observation, that men and women cope rather differently with infertility. Again, statistically significant differences were in certain instances slight, and their clinical meaning should be weighed carefully. However, the pattern of results are consistent with hypothesized male/female coping strategies. Womens' reports of more open expression of feelings and greater involvement in social and/or recreational activities are congruent with suggestions that women are more likely than men to seek emotional and social support. Similarly, men's greater orientation towards achievement is consistent with suggestions that they often cope with infertility through greater involvement in work-related activities. Not only were there gender differences, but fertility history also influenced appraisal of the marital situation before IVF. In comparison with those with children, childless individuals portrayed the marriage more positively on dimensions of communication, conflict, control, and opportunities for independence. Although it has been proposed that IVF candidates may hide marital difficulties to ensure IVF participation, this argument cannot account for the observed differences. At the same time, the results are quite consistent with studies reporting closer marital relationships in voluntarily childless couples and in fertile couples who have yet to have children. 24 Although infertility undoubtedly can lead to marital strain, the absence of children may provide opportunities for greater autonomy, yet foster greater emotional intimacy. It is interesting to speculate that the apparent advantages of a relationship without children might mesh in particular with the needs of women. Despite enhanced marital satisfaction, those who were childless experienced considerably less satisfaction with their life situation than those with children. Diminished personal happiness appeared to be linked to a lack of social role as a parent. The failure of IVF had quite a differential impact on participants. For example, both sexes exhibited a significant increase in situational anxiety after failed treatment, but women without children showed a most dramatic change in this regard. The observation that childless women are a more vulnerable group is also consistent with the findings of Leiblum et al. 11 Although not surprising, it warrants careful consideration since it is precisely this group who represent the majority of IVF patients. From a possible treatment perspective, more than one quarter of childless women were reporting clinically significant elevations in anxiety and about 15% were in acute distress. These results suggest that a substantial number of women might benefit from some form of anxiety management training, not only to manage the stress of IVF procedures, but also to assist in coping with treatment failure. In contrast, women with children showed little change in anxiety level after IVF failure, suggesting perhaps that success is less crucial for this group and that levels of stress are consequently lower. Alternatively, these women may approach 884 Newton et al. Psychological evaluation after IVF Fertility and Sterility

7 the treatment cycle with a more realistic view of the likelihood of success, and this difference deserves further investigation. By comparison, already having children did not appear to ameliorate the stress of IVF failure for men. The reason for this is unclear, but one third of these men had children only from past relationships. Since males are often not the custodial parent, many of these men were functionally without children although not actually childless. Alternatively, the level of stress experienced by men after failure may be more a product of lifestyle disruption created by IVF involvement and/or the emotional impact treatment is having for their partner. Failure of IVF also seemed to precipitate a significant increase in depressive symptomatology for both sexes. However, mean depression scores remained within the normal range. Thus, the majority of participants appeared to be coping effectively and their reactions were characterized by expected feelings of sadness and disappointment but not depression per se. Nevertheless, the prevalence of actual depression rose sharply in both sexes after treatment failure. The percentage of women experiencing mild depression approximately doubled (18%) and the comparable figure for men, although lower overall, rose almost three-fold (8%). Perhaps of greater concern, 7.5% of women reported more serious difficulties characteristic of moderate levels of depression. Persons experiencing what is termed mild depression on the BDI often seek assistance for diffuse, maladaptive functioning in a variety of community or hospital settings. In the case of IVF patients, intervention in the form of emotional support, education about grief, and assistance in mobilizing coping resources might be required. Where moderate depression is identified, a mood disturbance is usually accompanied by a number of behavioral, cognitive, and vegetative symptoms and likely represents more than a grief reaction. From a cognitive behavioral perspective, 25 depression arises partly due to unrealistic negative expectations about oneself, the current situation, and the future. Patients experiencing more intense depression may require assistance to examine beliefs about IVF failure, its personal meaning, its perceived impact on their relationship, and attitudes towards a possible future without children. Alternatively, perhaps these results underscore the need to continue to improve patient preparation for IVF and to identify and deal with unrealistic expectations of success. Of course the current study does not address the question of duration of anxious and depressive symptomatology after failed IVF. Similar reassessment after 6 months or 1 year would also be of interest. However, regardless of long-term prognosis, a substantial number of patients might benefit from more immediate assistance. Given the considerable variability in reaction to IVF failure, efforts to establish accurate predictors of emotional response become even more important. The results of the present study were somewhat mixed. Anxiety proneness, pre-existing depressive symptoms and the presence or absence of children proved the best predictors of both post IVF anxiety and depression. Although the findings provide encouraging preliminary support for the use of psychological test measures before IVF, only a moderate proportion of variability in post-ivf response was actually accounted for. In contrast, neither demographic data nor information about marriage quality appeared to offer additional predictive utility. However, the FES may either lack sensitivity or fail to tap relevant aspects of marital adjustment. Other marital instruments might demonstrate greater predictive validity and this possibility deserves investigation. At this point in time, efforts need also be directed towards identifying other possible predictors. In particular, cognitive factors including attitudes towards infertility and expectancies about IVF could prove important. Finally, conclusions of the present study concerning the impact of IVF failure are limited by the fact that only first cycle patients were examined. It has been argued that participants become more realistic about IVF with subsequent cycles and presumably less distressed when treatment fails. However, each additional failure also brings couples closer to the end of what often constitutes a final treatment option. Therefore, repeated failure might be expected to trigger even greater emotional distress. The present study represents the first phase in a longitudinal study to examine this issue. REFERENCES 1. 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