Disordered eating and distress in the in vitro fertilization population: preliminary results of a pilot study

Transcription

1 Disordered eating and distress in the in vitro fertilization population: preliminary results of a pilot study Christie Urquhart, MD Child and Adolescent Psychiatry Fellow, PGY-IV

2 Content Background Infertility, IVF & mental health Project aims & hypotheses Methods Results Participant demographics, questionnaire scores Discussion & limitations Clinical implications References

3 Infertility An umbrella term for the inability to conceive within 12 months of regular unprotected sex Thought to occur in about 15% of couples 12-17% of women yrs have sought infertility assistance ~1/3 male factor, 1/3 female factor and 1/3 combined or unexplained Most common in females is polycystic ovarian syndrome (PCOS) Following diagnostic testing to determine the etiology, treatments may include: hormonal modulation, lifestyle interventions, intrauterine insemination or in-vitro fertilization (IVF)

4 Infertility and mental health Rates of depression and anxiety in infertile women have been found to be elevated and similar to other chronic medical conditions (e.g., cancer) One study found up to 20% of patients had a past or current eating disorder (ED), but none disclosed this to providers and the majority of infertility specialists do not assess for eating disorder history or symptoms Many patients with an ED or mental illness are infertile it is 2/2 functional hypothalamic amenorrhea (FHA) and can conceive with hormonal and/or psychological treatment PCOS patients with similar rates of mental health problems

5 IVF subpopulation Within the assistive reproductive technology (ART) subgroup (>99% IVF) etiologies are differ from general infertility population Diagnosis % ART Diagnoses %ART Tubal factor 13% Uterine factor 6% Male factor 33% Multiple female factors 12% Ovulatory 15% Male and female factors 17% Diminished ovarian reserve 32% Unknown factor 13% Endometriosis 9% Other factor 16%

6 IVF outcome factors IVF outcomes have been shown to be negatively correlated with increasing age, smoking, lower parity and BMI >35. Etiology of infertility also impacts success rates Some studies indicate psychosocial stress and depression may negatively impact success but the literature is mixed There is a relative paucity of research on how disordered eating symptoms affect IVF outcomes. Some studies show diet may play a role and extreme ends of BMI Most literature has not shown a significant correlation with SSRIs and IVF outcomes

7 Project aims 1. Determine the prevalence of disordered eating using the Eating Disorder Examination Questionnaire (EDE-Q) and depression/anxiety using the 4 item Patient Health Questionnaire (PHQ-4) among the IVF population 2. Explore if scores differ between the various etiologies of infertility in the IVF population 3. Examine if a relationship exists between disordered eating and stress scores and IVF outcomes (conception, clinical pregnancy, live births) Collect secondary measures to control for variables that may impact outcomes

8 Hypotheses 1. EDE-Q scores will be higher in the IVF population than community and ovulatory disorders will have higher rates than other factors 2. EDE-Q scores will increase with increasing weight (BMI), except in those who are clinically underweight 3. PHQ-4 scores will be higher in the IVF population than community and ovulatory disorders will have higher rates than other factors 4. Higher scores on the EDE-Q and PHQ-4 will correlate with a lower success rate of the subsequent IVF trial

9 Methods Obtained IRB approval for study Participants recruited: female patients between yrs seen at Magee Women s Hospital infertility clinic about to have an IVF cycle Patients approached by clinical staff and then a member of the research team obtained informed consent and assigned a randomized numeric code EDE-Q, PHQ-4 completed in a private office Primary investigator collected demographic information and diagnosis from chart review Questionnaires scored and analyzed

10 Results: Demographics Participants: 72 female patients consented 83 patients approached (87% recruitment rate) Age: 34.4 years (3.8) Parity: 0.6 (0.8) BMI: 26.7 (5.2) 78% never smokers, 15% former smokers 26% with documented history of a mental illness, none endorsed having a current ED, 1 reported past ED 14% taking psychiatric medication(s) 9.7% reported taking SSRIs

11 Results: Infertility etiologies Diagnoses % Diagnoses % Tubal factor 7% Uterine 1% Male factor 18% Multiple female factors 3% Ovulatory 8% Male and female factors 14% Diminished ovarian 10% Unknown factor 20% reserve Endometriosis 0% Other factor 18%

12 Results: Infertility etiologies Expected % IVF Study %

13 Results: EDE-Q scores Community norm 1.5 Clinical cut-off 4 Study mean 1.1 (46 th percentile) Community women (1994) Women ages (2006) Study mean 0 Total score Restraint Eating concern Shape concern Weight concern

14 Results: Scores by infertility etiology EDE-Q total score

15 Results: EDE-Q score by BMI 4 Mean score BMI <30 (n=57): 0.8 Mean score BMI 30 (n=15): BMI kg/m 2

16 Results: PHQ-4 scores Mean score: 2.65 (2.96) 17% of patients with moderate-severe symptoms Community norm 1.61 (1.97) GAD-2: 1.90 (1.84)- 25% 3 PHQ-2: 0.72 (1.31)- 10% 3 Interpretation: PHQ-4 severity: 3-5=mild, 6-8=moderate, 9-12 severe Each subscale 3 positive screen

17 Results: Scores by infertility etiology 5 PHQ-4 total score

18 Discussion Our study sample had more patients with unknown or other factor infertility than expected Over 1/4th of patients with history of mental health dx 10% currently on an SSRI which is higher than expected for IVF population Results revealed lower than expected scores for disordered eating in the infertility population, however, the IVF subpopulation may differ EDE-Q scores increased with BMI, as expected

19 Discussion The PHQ-4 average score was higher than the established norm which is not surprising, however, it still falls short of the clinical cut-off 25% of patients rated anxiety in the clinical range and 17% reported moderate-severe anxiety/depression Limited number of patients in each category to determine if scores differed by infertility etiology In process of determining whether disordered eating and anxiety symptoms correlated with IVF outcomes

20 Limitations Patients may be prone to social desirability bias and misor under report symptoms Patients may change eating habits as a result of pending IVF Many patients with unknown or multiple causes of infertility Limited number of patients in study and findings should be replicated in a larger patient population

21 Clinical implications Many women and couples seek infertility treatment IVF is an invasive, expensive and time intensive process and mental health screening is crucial: Some causes of infertility if identified, such as FHA, may be addressed and treated allowing natural conception Identifying mental health concerns at the start of IVF allows an opportunity to refer the patient (or couple) to therapy, support groups or a mental health professional for further evaluation and treatment

22 References 1.Brugo-Olmedo S, Chillik C & Kopelman S. (2001). Definition and causes of infertility. Reprod Biomed Online. 2(1): Chandra A, Copen C & Hervey Stephen E. (2013b). Infertility service use in the United States: Data from the national survey of family growth, Jan 22; 73: Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology Assisted Reproductive Technology National Summary Report. Atlanta (GA): US Dept of Health and Human Services; Freizinger M, Franko DL, Dacey M, Okun B & Domar AD. (2010). The prevalence of eating disorders in infertile women. Fertil Steril. Dec; 90(6): Rodino I, Byrne S & Sanders K. (2016). Disordered eating attitudes and exercise in women undergoing fertility treatment. Australian and New Zealand Journal of Obstetrics and Gynaecology. 56: Marcus M, Loucks T & Berga S. (2001). Psychological correlates of functional hypothalamic amenorrhea. Fertil Steril. 76: Rodino I, Byrne S & Sanders K. (2016). Eating disorders in the context of preconception care: fertility specialists knowledge, attitudes, and clinical practices. Fertil Steril. In press. 8.Becker A, Thomas J, Franko D and Herzog D. (2005). Disclosure patterns of eating and weight concerns to clinicians, educational professionals, family and peers. Int J Eat Disord. 38: Mond J, Hay P, Rodgers B & Owen C. (2006). Eating disorder examination questionnaire (EDE-Q): norms for young adult women. Behav Res and Therapy. 44: Lӧwe B et al. (2010). A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affective Disord. 122: Friborg O, Reas D, Rosenvinge J & Ro O. (2013). Core pathology of eating disorders as measured by the Eating Disorder Examination Questionnaire (EDE-Q): the predictive role of a nested general (g) and primary factors. Int J Methods in Psychiatric Research. 22(3):

23 Acknowledgments Mentors: Marie Menke, Priya Gopalan Medical students: Annika Shearer, Ellen Ribar