Relationships in couples after failed IVF treatment: a prospective follow-up study

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1 Human Reproduction Page 1 of 6 Hum. Reprod. Advance Access published March 24, 2005 doi: /humrep/deh882 Relationships in couples after failed IVF treatment: a prospective follow-up study Gunilla Sydsjö 1,3, Katarina Ekholm 1, Marie Wadsby 2, Svante Kjellberg 1 and Adam Sydsjö 1 1 Division of Obstetrics and Gynaecology and 2 Division of Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Linköping, Sweden 3 To whom correspondence should be addressed at: Division of Obstetrics and Gynaecology, University Hospital, S Linköping, Sweden. Gunilla.sydsjo@lio.se BACKGROUND: There are few studies of couples that analyse satisfaction with treatment, adoption plans and relationships in couples after unsuccessful IVF. METHODS: ENRICH marital inventory was used to describe marital dynamics and to gain information about treatment and adoption plans. A specially designed questionnaire was used. Of the 51 couples without previous children who were asked to participate after their first failed IVF cycle, 45 participated. The next stage of the study was carried out when the couples had reached the 6 months point after the first IVF cycle, and the last stage after the couples had been through one to three treatments, years after the last treatment. RESULTS: The couples displayed a stable relationship from the start as well as 1 year after the last IVF cycle. The vast majority of the couples had decided to go through with an adoption. Seventy-three per cent of the women were interested in more IVF treatment compared to 33% of the men. CONCLUSION: The stresses associated with IVF treatment did not have a negative impact on the couples appreciation of their relationships during and after the treatment period. After treatment had been completed, the couples seemed to have reoriented themselves toward other solutions to childlessness. Key words: couples relationship/failed assisted reproduction treatment/infertility Introduction Recent studies show that infertile couples are generally well adjusted and stable in their relationships and psychological well-being (Connolly et al., 1992; Sydsjö et al., 2002). Long-term infertility is stressful in itself and IVF treatment is demanding for both the women and the men, although in different ways. Women show a greater tendency toward depression, anxiety and feelings of stress (Collins et al., 1992) during treatment periods but also in between (van Balen and Trimbos-Kemper, 1993; Slade et al., 1997; Verhaak et al., 2001). If the treatment is unsuccessful the couple faces new decisions such as whether or not to undertake a second or third IVF treatment. In those decisions there are economic, emotional and physical considerations to be discussed and considered this demands skill in communicating and in decision-making within the relationship and could cause stress and strain on the couple s relationship. There is only one study, as far as we know, that has followed up couples after failed IVF treatment where the focus has been on both the men and the women using welldocumented scales for measuring different aspects of, for example, sexuality and quality of the relationship. That is the study by Slade et al. (1997) that followed 144 couples before treatment, after identified pregnancy and after three unsuccessful treatment cycles. They found that the women who did not become pregnant showed higher levels of anxiety than their spouses, and that these women also were less positive than the men about their marital and sexual relationships. Other studies such as Leiblum et al. (1998) focus only on the women, not the couple. They studied 38 women who had completed at least three IVF cycles between the years 1983 and These women were retrospectively followed up concerning their opinions about marital and sexual satisfaction. The results showed that there were no differences on standardized measures of marital and sexual satisfaction between the women who had conceived through IVF treatment and those who remained childless. The childless women reported that infertility had had a greater negative impact on their perceived relationship with their partners (Leiblum et al., 1998). Service evaluation and expectations studies on couples using assisted reproduction and other fertility treatment are sparse and the available studies show mixed findings (Hammerberg et al., 2001; Malin et al., 2001; Schmidt et al., 2003). For couples who are unsuccessful in becoming pregnant and having a baby, the demands on counselling and information might be regarded as more important than for couples who achieve a pregnancy and have a child. Schmidt et al. (2003) found that the majority of new couples seeking q The Author Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please journals.permissions@oupjournals.org Page 1 of 6

2 G.Sydsjö et al. infertility treatment considered medical information important but fewer considered psychosocial services important and fewer had any intention to use psychosocial services. Infertility investigation and treatment have improved over the years; for example, pregnancy rate per transfer has increased from 26.1% in 1997 to 28.4% in 2000 (Nygren and Nyboe Andersen, 2002; National Board of Health and Welfare, 2004; Nyboe Andersen et al., 2004). Therefore one can assume that couples obtain their diagnoses and treatment more rapidly and have more success in becoming pregnant and having a child. Also there is now available ample information about the importance of counselling, preparation, and the provision of high-quality information to the couples, so one can presume that the infertile men and women are better prepared, both regarding the treatment process and the impact the treatment might have on their well-being and on their relationship. They are also better informed about success rates and adoption as an alternative. Since there are so few studies that have studied the relationship in an unselected sample of couples who have not succeeded in becoming the woman pregnant from IVF treatment, the aim of this study was to follow couples who were treated during the late 1990s and follow them using marital scales that are validated and that measure different dimensions of a relationship such as sexuality, communication, conflict resolutions, etc. A second aim was to study the couple s satisfaction with the IVF treatment and their plans for further treatment and adoption plans. Materials and methods Sample and procedure The initial sample comprised all the couples with no previous children, who, during September 1997 and until December 1998, were treated at the Reproductive Centre at Linköping University Hospital (n ¼ 320). From that sample, 51 couples were included in this study because their IVF treatment was not successful. Three couples were unable to communicate in the Swedish language and were therefore not included in the study. Three couples declined participation and gave as a reason that they did not want anybody to know that they had been through infertility treatment. The other reasons for declining were the nature of the questions, which were considered to be concerned with matters that should remain private. The study group thus comprised 45 couples. These couples were sent an introductory letter that explained the purpose of the study and a request from the author G.S. to contact them by phone to obtain a more complete explanation of the study and to ask for permission to send the ENRICH inventory. This was done in connection with the couples first treatment cycle. The next stage of the study was carried out when the couples had reached the 6 months point after the first IVF cycle, and the last stage was carried out after the couples had been through one to three treatments years after the last treatment. Both the men and women in the 45 couples answered the ENRICH inventory at the three study occasions. None of these couples was identified as having psychosocial problems such drug/alcohol problems, psychiatric problems, and/or social problems according to defined criteria of relevance for pregnancy and parenthood (Sydsjö, 1992). All couples see the IVF doctor for min sessions to discuss psychosocial and medical matters before acceptance for IVF treatment. The couples in need of Page 2 of 6 counselling are given an opportunity to obtain both brief and extended counselling by a psychotherapist who belongs to the IVF team. All couples attending the IVF clinic are screened on a routine basis for psychosocial problems such as drug addiction, mental retardation and psychiatric illness and, if evident, excluded from treatment. No IVF treatment with donated gametes was performed, as this was not legal in Sweden at that time. The mean age of the men was 33.6 years (SD 2.57, range 27 40) and of the women 32 years (SD 2.5, range 27 38). These couples had lived together for an average of 7.4 years (range ). Of the men, five were born outside Sweden (11%). The corresponding number for the women was three (7%). The group represented well the socio-economic distribution and employment status in the study area with the exception of couples with obvious and identified psychosocial problems (Sydsjö et al., 2002). Measures Questionnaire The Swedish version of ENRICH marital inventory, originally created by Olson and co-workers (Fournier et al., 1983), was used in order to describe marital dynamics. The instrument provides scores of the wives and husbands evaluation of their relationship in 10 categories comprising 10 items each. The scales are briefly described as follows:. Personality issues: Examines an individual s satisfaction with his or her partner s behaviours.. Communication: Is concerned with an individual s feelings and attitudes toward communication in the marriage. Items focus on the level of comfort felt by the respondent sharing and receiving emotional and cognitive information from the partner.. Conflict resolution: Assesses the partner s perception of the existence and resolution of conflict in the relationship. Items focus on how openly issues are recognized and resolved, as well as the strategies used to end arguments.. Financial management: Focuses on attitudes and concerns about the way economic issues are managed within the marriage. Items assess spending patterns and the manner in which financial decisions are made.. Leisure activities: Assesses preferences for spending free time. Items reflect social versus personal activities, shared versus individual preferences, and expectations about spending leisure time as a couple.. Sexual relationship: Examines the partner s feelings about the affectional and sexual relationship. Items reflect attitudes about sexual issues, sexual behaviour, and sexual fidelity.. Children and parenting: Assesses attitudes and feelings about having and raising children. Items focus on decisions regarding discipline, goals for the children, and the supposed impact of children on the couple s relationship.. Family and friends: Assesses feelings and concerns about relationships with relatives, in-laws, and friends. Items reflect expectations for and comfort with spending time with family and friends.. Egalitarian roles: Focuses on an individual s feelings and attitudes about various marital and family roles. Items reflect occupational, household, sex, and parental roles. High scores indicate a preference for more egalitarian roles.. Conception of life: Examines the meaning of values, religious beliefs and practice, and conception of life within the marriage. Each category scale can vary between 10 and 50 points, 50 points being the most positive outcome. There are six alternatives for each item ranging from in total agreement to do not agree at all.

3 Relationships in unsuccessful IVF couples Summed, the category scale scores provide a global assessment of marital satisfaction varying between 100 and 500 points. The ENRICH also includes a Positive Couples Agreement (PCA) score which is a measure of the couple s consensus for each of the 10 relationship areas. Husband and wife responses are combined and the items that they agree on (within 1 point on a 1 5 scale) are summed and converted to a percentage score, which could range from 0 to 100%. PCA includes only those items where they both see the issues as positive. ENRICH scales have shown good internal consistency (a, range: ) and test retest reliability (r tt, range: ) as well as content and construct validity (Fournier et al., 1983). The discriminant and concurrent validity of these scales have been established (Fowers and Olson, 1989). The Swedish version of the inventory has been evaluated (Wadsby, 1998), whereby the reliability and the validity of the instrument have been established to be satisfactory. Experience of the infertility procedure and future plans on treatment and/or adoption plans Four questions were added to the relationship inventory at the final assessment and they were: experience of infertility investigations, experience of IVF treatment, intentions on having further treatment and adoption plans. Ethics The study was approved by the Human Research Ethics Committee, Faculty of Health Sciences, Linköping University. Statistics The ENRICH scores (i.e. the 10 factors as well as the total scores on each occasion) were tested for normality by use of the Kolmogorov Smirnov test. The data were also examined visually by scatter-plots to identify possible extreme values. As the assumption of normality could not be met in all of the studied variables, we chose to use a non-parametric approach when analysing the data. The Friedman test of related samples was used to determine whether the scores on the factors as well as the total scores changed over time for the studied men and women respectively, as well as for the couples PCA. In addition, we also used the Spearman rank correlation coefficient and the Mann Whitney test. Results Reproductive history and duration of infertility, and number of IVF cycles The couples stated that they had been infertile for an average of 4 years (range 2 8) at the first assessment. The average number of IVF treatments was 3 (range 1 4). There were 17 (38%) couples that had experienced spontaneous abortions. The average number of completed IVF cycles was 3 (range 1 3) for the couples, and 25% of the couples had one or two counselling sessions during the treatment period. Experience of infertility investigations and treatment and plans for the future Table I shows men s and women s experiences of infertility investigations and treatment at the third assessment. There is a difference between men and women concerning future plans for further IVF treatment. No differences were found between men and women concerning adoption plans. Table I. Men s and women s experience of investigation, treatment and adoption plans measured years after the last IVF cycle Women (n ¼ 45) Men (n ¼ 45) Experience of infertility investigation Very positive 0 0 Positive 8 30 Negative Very negative 2 4 Experience of IVF treatment NS Very positive Positive 5 20 Negative 4 0 Very negative 0 0 Wish to have more IVF treatments cycles or other alternative treatment (AID, oocyte donation) Yes Undecided 2 6 No Have decided to adopt a child/children NS Yes No 7 10 a x 2 -Test for the difference between men and women. Relationships The men s and women s average individual scores on the ENRICH inventory for the three study occasions are shown in Tables II and III. In Figure 1 the total scores on the ENRICH scale for the men and women are displayed. Overall the couples showed good and stable relationships over time. The men did show some tendencies towards a more satisfied relationship after they had finished their last treatment. A significant increase in the average scores could be seen for the factors communication, family and friends, egalitarian roles and total score for both men and women (Tables II and III). The women experienced a stable relationship over the treatment time and a significant increase in the scores was found in the same factors as for the men but also for the factors sexual relationship, conception of life and leisure activities (Table III). Concerning the differences between men and women, there is a tendency for the men throughout the study period to make a lower assessment on their opinion about their relationship and score significantly lower on the factors for all three assessment times (P ¼ 0.002, and 0.003). In Table IV the PCA between the men and women shows an overall highly positive agreement between the couples. On the factor communication there is a significantly lower positive agreement between the second and third assessments compared to the first. On the factors egalitarian roles and conception of life, the agreement is more sound between the couples at the assessments two and three. Discussion In this study we found that couples going through IVF treatment that does not lead to pregnancy have a solid and stable relationship at their beginning of treatment and after termination of treatment. In one earlier study with the same P a Page 3 of 6

4 G.Sydsjö et al. Table II. Mean and SD scores for men at three different times: (1) the beginning of IVF treatment, (2) 6 months after the first treatment and (3) years after the last treatment (n ¼ 45) Mean SD x 2a P a Personality issues Communication , Conflict resolution Financial management Leisure activities Sexual relationship Children and parenting Family and friends , Egalitarian roles Conception of life Total score , a x 2 -Value and corresponding P-value for Friedman test of related samples. method (Sydsjö et al., 2002) the IVF couples were very satisfied with their relationship directly after the successful IVF treatment and continued to be so when the child/children reached 1 year of age. When compared to spontaneously pregnant couples expecting their first child, the IVF couples were stable in their opinion about their relationship when the child reached 1 year of age whereas the spontaneous couples experienced a decrease in the quality of their relationship. The IVF group had a total score on the ENRICH Inventory of 438 at pregnancy and 437 when the child reached 12 months. In the control group of spontaneous pregnant couples the total scores were 424 and 409 respectively. The men and women in the present study had a total score at the last assessment times of 422 and 439 respectively. Normative data for the ENRICH Inventory in a Swedish population in fertile ages are for men 422 and for women 420 (Wadsby, 1998). Page 4 of 6 Table III. Mean and SD scores for women at three different times: (1) the beginning of IVF treatment, (2) 6 months after the first treatment and (3) years after the last treatment (n ¼ 45) Mean SD x 2a P a Personality issues Communication , Conflict resolution Financial management Leisure activities Sexual relationship Children and parenting Family and friends , Egalitarian roles , Conception of life Total score , a x 2 -Value and corresponding P-value for Friedman test of related samples. Figure 1. Average total score on relationship satisfaction for the men and the women assessed at three different times.

5 Relationships in unsuccessful IVF couples Table IV. Positive Couples Agreement (PCA) at three different times: (1) the beginning of IVF treatment, (2) 6 months after the first treatment and (3) years after the last treatment (n ¼ 45) Mean SD x 2a P a Personality issues Communication , Conflict resolution Financial management Leisure activities Sexual relationship Children and parenting Family and friends Egalitarian roles Conception of life a x 2 -Value and corresponding P-value for the Friedman test of related samples. The reason for the stable development in IVF couples might be that there are some rules at the Reproduction Medical Centre that must be met before the couples can be accepted for treatment. The couples should have had a stable relationship for 2 years, and none of the men and women could have an ongoing psychiatric illness or have psychosocial problems, for example drug addiction. As a rule both men and women are informed about the treatment and the consequences and are also given opportunities to have counselling or therapy before during and after treatment by a psychotherapist who is a member of the IVF team. The waiting time from acceptance to treatment was,6 months at the centre at the time of the study. A number of studies have found that what is most stressful about infertility and treatment is not the medical procedures per se but the fact of trying to become pregnant and not succeeding (Leiblum et al., 1987; Baram et al., 1988; Callan and Hennessey, 1988; Connolly et al., 1993; Boivin et al., 1995). In this study the stress of not achieving pregnancy did not affect the couples relationships. Slade et al. (1997) and Leiblum et al. (1998) found that women were more dissatisfied with their marriage and sexuality but we were not able to confirm this result. One can speculate that going through a treatment process is in itself beneficial for the couples they have a clear goal and must be in agreement taking the next step if not successful. When a couple has tried and then failed, the challenge for the couple is to make new decisions such as whether they should adopt, take foster children or remain childless. Marital strain is associated with the active phase of treatment and is greater for couples that are unsuccessful in their parenthood quest (Connolly et al., 1992). The couples in our study were stable over time and the relationship was not affected by the treatment and disappointment of the unsuccessful result of not becoming pregnant. This might be due to the assessment times and the fact that we assessed relationships, not wellbeing or depressiveness. The majority of both the women and men stated that they wanted to adopt or had applied for adoption, a rather surprising result since it has been found that women are more prone to plan for adoption of a child than are men (Leiblum et al., 1998). One explanation for this is that the department works extensively with counselling and information, so the couples obtain adoption information at their first appointment with the doctor in charge of the medical treatment. Clearly there are difficulties for the couples and especially for the women to terminate the wish for treatment to cure their childlessness. New options and new assisted reproductive technologies give the childless couples opportunities and/or wishes to start new treatment. Both men and women stated that the IVF treatment was a positive experience but the majority of the women experience the infertility investigation as a negative experience. Whether this was due to lack of information, waiting time or lack of psychosocial support could not be answered in this study. The limitation of this study is the small number of participants and the few questions about treatment service and expectations. The optimal study would have been to interview the men and women separately about their experience of the treatment and fertility investigations and their plans for the future. The strength of the study is the longitudinal approach and the low drop-out rate, only 12%, and that both the men and women answered all the questions. ENRICH is a welldocumented and broad instrument that measures different aspects of a relationship. This, together with the repeated measures, leads us to believe that we have captured the couple s view of their relationship in a correct and satisfactory way. The vast majority of both men and women had decided to adopt a child and this is perhaps another indication of the stable relationship that we see over time in this study these couples really have a good and secure relationship and are therefore taking decisions on adoption. The majority of the women, 73%, stated that they had wishes to undergo more IVF treatment or have alternative treatment to become pregnant whereas the majority of the men stated that they did not intend to go through with more treatments. Page 5 of 6

6 G.Sydsjö et al. To minimize stress on couples in their future plans, both physicians and counsellors must inform and educate the couples on success rates for different treatment options including the effect of the couple s background such as diagnosis and age, time of treatment, and termination of treatment. In conclusion, infertile couples who have had a stable relationship 2 years prior to infertility treatment report that they have good and stable relationships during IVF treatment and even after failed IVF treatment. Acknowledgements This investigation was supported by grants from The Research Fund of County Council in the South East Sweden. References Baram D, Tourtelot E, Muechler E and Huang K (1988) Psychosocial adjustment following unsuccessful in vitro fertilisation. J Psychosom Obstest Gynaecol 9, Boivin J, Takefman JE, Tulandi T and Brender W (1995) Reactions to infertility based on extent of treatment failure. Fertil Steril 63, Callan VJ and Hennessey JF (1988) Emotional aspects and support in in vitro fertilisation and embryo transfer program. J In Vitro Fertil Embryo Transfer 5, Collins A, Freeman EW, Boxer AS and Tureck R (1992) Perceptions of infertility and treatment stress in females as compared with males entering in vitro fertilizations treatment. Fertil Steril 57, Connolly KJ, Edelman RJ, Cooke ID and Robson J (1992) The impact of infertility on psychological functioning. J Psychosom Res 36, Connolly KJ, Edelmann RJ, Bartlett H, Cook ID, Lenton E and Pike S (1993) An evaluation of counselling for couples undergoing treatment for in vitro fertilization. Hum Reprod 8, Fournier DG, Olson DH and Druckman JM (1983) Assessing marital and premarital relationships: The PREPAE/ENRICH Inventories. In Filsing EE (ed) Marriage and Family Assessment. Sage Publications, Newsbury, CA, pp Fowers BJ and Olson DH (1989) ENRICH marital inventory: a discriminant validity and cross-validation assessment. J Marital Fam Ther 15, Hammerberg K, Astbury J and Baker HWG (2001) Women s experience of IVF: a follow-up study. Hum Reprod 16, Leiblum SR, Kemman E and Lane MK (1987) The psychosocial concomitants of in vitro fertilization. J Psychosom Obstest Gynaecol 6, Leiblum SR, Aviv A and Hamer R (1998) Life after infertility treatment: a long-term investigation of marital and sexual function. Hum Reprod 13, Malin M, Hemminiki E, Räikkönen O, Sihvo S and Perälä M-L (2001) What do women want? Women s experiences of infertility treatment. Soc Sci Med 53, National Board of Health and Welfare (2004) Assisted Reproduction Stockholm, Sweden. Nyboe Andersen A, Gianaroli L and Nygren KG (2004) Assisted reproductive technology in Europe, Results generated from European registers by ESHRE. Hum Reprod 19, Nygren KG and Nyboe Andersen A (2002) Assisted reproductive technology in Europe, Results generated from European registers by ESHRE. Hum Reprod 17, Schmidt L, Holstein BE, Boivin J, Tjornhoj-Thomsen T, Blaabjerg J, Hald F, Rasmussen PE and Nyboe Andersen A (2003) Patients attitudes to medical and psychosocial aspects of care in fertility clinics: findings from the Copenhagen Multi-centre Psychosocial Infertility (COPI) Research Programme. Hum Reprod 18, Slade P, Emery J and Lieberman BA (1997) A prospective, longitudinal study of emotions and relationship in in-vitro fertilization treatment. Hum Reprod 12, Sydsjö G (1992) Prevalence and significance of social and psychological risk factors during pregnancy. Int J Technol Assess Health Care 8 (Suppl 1), Sydsjö G, Wadsby M, Kjellberg S and Sydsjö A (2002) Relationship and parenthood in couples after assisted reproduction and in spontaneous primiparous couples: a prospective long-term follow-up study. Hum Reprod 17, Van Balen F and Trimbos-Kemper TCM (1993) Long-term infertile couples: a study on their well-being. J Psychosom Obstet Gynaecol 14, Verhaak CM, Smeek JM, Eugster A, van Minnen A, Kremer JA and Kraaimaat W (2001) Stress and marital satisfaction among women before and after their first cycle of in vitro fertilization and intracytoplasmic injection. Fertil Steril 76, Wadsby M (1998) Evaluation of the Swedish version of ENRICH marital inventory. Nord J Psychiat 52, Submitted on July 30, 2004; resubmitted on February 15, 2005; accepted on February 24, 2005 Page 6 of 6