Psychological evaluation and support in a program of in vitro fertilization and embryo transfer*

Transcription

1 FERTILITY AND STERILITY Copyright 1985 The American Fertility Society Printed in U.SA. Psychological evaluation and support in a program of in vitro fertilization and embryo transfer* Ellen W. Freeman, Ph.D. t:j: AndreaS. Boxer, Ph.D.t Karl Rickels, M.D. t Richard Tureck, M.D. t Luigi Mastroianni, Jr., M.D. t Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania This report describes the psychological evaluation of 200 couples consecutively seen at a pretreatment consultation in an in vitro fertilization and embryo transfer program. Attitudinal and emotional characteristics of the sample are also described. Half the women and 15% of the men reported that infertility is the most upsetting experience of their lives. On the Minnesota Multiphasic Personality Inventory (MMPI), approximately 20% of the m,ales and females had one or more elevated scale scores, suggesting dysfunctional emotional distress or personality difficulties. Half the sample had high scores on the MMPI Ego Strength scale, which indicated effective. functioning and ability to withstand stress. T scores for the Taylor Manifest Anxiety Scale were in the normal range before treatment. Further longitudinal study is needed to define the emotional impact of procedures and reactions to treatment outcomes. Fertil Steril 43:48, 1985 Since the first successful intrauterine pregnancy was announced by Steptoe et al. in 1979/ in vitro fertilization and embryo transfer (IVF ET) has resulted in hundreds of pregnancies worldwide. In the United States, there are many successful IVF treatment programs in operation, with many more expected. IVF-ET has moved rapidly from an esoteric technique to an available method of infertility treatment for more than one million couples who may benefit from it. 2 Received May 29, 1984; revised and accepted September 12, *Supported in part from the Mudd Expense Fund. tdepartment of Obstetrics and Gynecology. +Reprint requests: Ellen W. Freeman, Ph.D., Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Mudd Professorship Suite, 3400 Spruce Street, Philadelphia, Pennsylvania Department of Psychiatry. Accompanying the development of IVF treatment have been questions about socialand ethical issues as reviewed by Walters 3 and Jones. 4 Thus far, there are no conclusions about the psychological.and emotional implications for the couples involved, although several programs are investigating these concerns. 5-7 While the potential benefits of IVF -ET treatment are obvious, the psychosocial costs of involvement in an IVF program are hidden because of the lack of information aboutthe emotional impact of the procedures and the couple's reactions following successful treatment outcomes. 8 This article describes the psychological evaluation of patients participating in a universitybased IVF-ET treatment program. It also presents data on the couples' perceptions of their infertility and psychological status at the initial evaluation for IVF-ET treatment. These pretreatment data describe a baseline for further 48 Freeman et al. Psychological evaluation before IVF -ET Fertility and Sterility

2 longitudinal study of emotional factors in the treatment process and couples' responses to treatment outcomes. CRITERIA MATERIALS AND METHODS Couples entering this IVF treatment program are required to meet the following criteria: (1) there is a legal marriage; (2) the wife has a uterus and at least one ovary accessible for ovum retrieval; (3) the fallopian tubes are absent or blocked, or pregnancy has failed to occur following reconstructive surgery; (4) the husband's sperm count is in the normal fertile range; and (5) the couple has exhausted all attempts to restore fertility. SAMPLE SELECTION AND PROCEDURE The sample comprised 200 couples consecutively enrolled for IVF treatment and evaluated by a clinical social worker (A. S. B., the counselor) during a 14-month period from January 1983 to March The evaluation session is required and scheduled for approximately 1 hour during the initial IVF consultation visit. The counselor discusses with the couple their experience and feelings about infertility, expectation of treatment, plans if pregnancy does or does not occur, and characteristic approaches to stressful experiences. Recommendations for treatment management are then made to both the couple and the medical team. Subsequent counseling sessions are scheduled if requested by the couple. The counselor is also available on a brief, informal basis during the treatment process. DATA Prior to the evaluation session, couples complete a brief psychosocial questionnaire constructed for the IVF program. This provides the counselor with information on the couples' attitudes, self-perceptions in relation to infertility, perceived alternatives to pregnancy, and background characteristics to guide the ensuing discussion. Following the session, the counselor completes global ratings of each individual's ego strength, coping skills, and ambivalence about treatment as observed during the session. The Minnesota Multiphasic Personality Inventory (MMPI), a standardized, widely used measure of psychological functioning, 9 is later completed at home by each partner and returned before treatment proceeds. Data in this report are analyzed with descriptive statistics using chi-square tests for significance of differences. Probability values of~ 0.05 (two-tailed) are considered significant. MMPI data, scored independently by Interpretive Scoring Systems, are presented with standardized T scores. COUNSELING FOCUS The counselor assesses the couple's emotional status and reactions to infertility before treatment begins and provides further clarifications of what is involved in IVF treatment. The following areas are explored. Attitude How realistic is the couple about the chance for success with IVF? Do they recognize the small chance of success or do they appear overinvested in believing treatment must work and that they will achieve pregnancy? It is important to discuss straightforwardly the actual chances of success and failure. The counselor looks for and encourages an attitude of "realistic optimism." Couples need to recognize the outcome statistics but at the same time retain enough hope to engage in treatment. Information Information is one of the best antidotes to anxiety, but the couples' information levels vary considerably. How much they know about the process, particularly what will be expected of them at each step of treatment, is reviewed. The counselor encourages them to ask questions and emphasizes that understanding treatment enables cooperation with the IVF team. The couple is urged to deal with treatment one step at a time, as a means of avoiding or reducing anxiety. Commitment to Treatment How realistically is the couple planning for a treatment which demands a major commitment of time, emotions, and finances? The counselor explores whether they are choosing a time when they can handle the additional stress of treatment and discusses details such as where they will stay, how they will get to the hospital, who will accompany them, how they are planning to pay, Freeman et al. Psychological evaluation before IVF -ET 49

3 and so forth. The counselor also probes whether the couple has made agreements with each other on such matters as the number of treatment cycles they will have even before they have experienced the process once. Such agreements may indicate that one partner is putting pressure on the other. Also, rigid plans about treatment length may increase emotional distress if treatment results diverge from these plans. Desire for Pregnancy Is the decision to participate mutual, or does one partner participate because it is "owed" or the other insists on it? It is rare that a couple has an equal commitment to treatment, and usually one partner does have more emotional investment in proceeding than the other. However, this needs to be recognized openly, with each partner feeling the decision is shared. Alternatives to Pregnancy It is important to look at alternatives to pregnancy and discuss what the next steps might be if treatment is not successful. This begins the process of considering life after treatment if the couple has not yet begun to do so. Most couples are extremely responsive to the idea of psychological closure. Usually, the decision to continue with IVF represents the final step in a long involvement with infertility treatment. Encouraging feelings that they have done everything possible gives couples permission to move on and develop other aspects of their lives. Other Considerations How previous stressful experiences have been handled are discussed to ascertain attitudes and coping styles. The couple's communication and interactions during the interview may show the degree of sensitivity to each other's needs and feelings or identify disagreement about infertility treatment and the importance of having a child. RESULTS CHARACTERISTICS OF THE SAMPLE The mean age of the women is 32 years ( ± 4) and of the men, 34 years ( ± 5). Ninety-six percent are Caucasian; there are four black, three Asian, and two Indian couples. The economic status is Table 1. Most Stressful Life Experiences Reported by IVF Sample Women Men (n = 200) (n = 200) % % Infertility 48 15a Death Environmental situations 11 33a (school, work, military service, moving) Illness, accident 6 11 Interpersonal stresses (divorce, childhood, adoption, interpersonal relationships) None, not answered 3 14a achi-square, p < middle to upper class. Seventy-one percent of the women and 80% of the men have education beyond high school. Typically both partners are employed (only 23% of the women are not working). Religious preferences are 40% Protestant, 36% Catholic, 14% Jewish, and 10% other or none. Sixty-six percent of the couples have no children, 21% have children from previous marriages (12% the woman, 6% the man, and 3% both partners), 7% have adopted children, and 6% have natural children from the present marriage. Half have been in infertility treatment for 4 or more years. ATTITUDES AND PERCEPTIONS RELATED TO INFERTILITY Forty-nine percent of the women and 15% of the men consider infertility the most upsetting experience in their lives. This is compared with other stressful experiences noted in Table 1. Of the women citing infertility as their most upsetting experience, 72% have no children, compared with 60% in the remaining sample (the difference is not significant). Interest in adopting a child is indicated as positive or neutral by 68% of the women; 32% state reluctance or opposition or have not considered adoption. Forty-nine percent of the women have positive or neutral views about a career, and 51% are reluctant or opposed to a career. Fifty-five percent of the women have no plans or "don't know" what they will do at the conclusion ofivf ET treatment if the outcome is negative; 32% plan to develop the possibilities of adoption, foster parenting, or surrogate pregnancy; 4% have educational plans; 9% designate "other." 50 Freeman et al. Psychological evaluation before IVF -ET Fertility and Sterility

4 Table 2. MMPI Clinical Scores for NF Sample MMPI score (T score) Hypochondriasis (Hs) Depression (D) Hysteria (Hy) Psychopathic Devi ate (Pd) Masculinity-Fernininity (Mf) Paranoia (Pa) Psychasthenia (Pt) Schizophrenia (Sc) Hypomania (Ma) Social Introversion (Si) Validity indicators Cannot Say Score (?) Lie Scale (L) Infrequency Scale (F) Defensiveness Scale (K) "Standard deviation. Women Mean SD" Men Mean SD More women (46%) than men (32%) indicate that infertility treatment has changed their sexual relationship (P < 0.01). Of those reporting a change, two-thirds report that sex has become less pleasurable, while one-third report that sex has become more pleasurable. Sixty-one percent of couples report sex frequencies of two or more times per week; 39% state once a week ol" less. Eighty-three percent of women and 85% of men rate their satisfaction with sex above the midpoint on a 9-point scale, i.e., above average to excellent. Ratings by each partner of their self-perceptions as a spouse, woman or man, sex partner, and worker are high (showing positive self-perceptions) for all factors. Ratings for the pl"esent time are slightly lower than the ratings before infertility treatment (which were rated retrospectively), but the decrease is not significant. EMOTIONAL FACTORS Standardized T scores for the clinical scales of the MMPI are shown in Table 2 for 152 couples proceeding with IVF treatment. The mean scores of all scales are well within the normal range for both men and women. The data do not include 24 couples who withdrew after the initial visit and did not complete MMPis, 15 who were in the program before the MMPI was added to the evalua- tion, 2 who did not speak English, and 7 who had invalid results because of the large numbers of omitted answers. Twenty-five women (16%) and 27 men (18%) have high scores (> 70) on one or more clinical scales that suggest psychological dysfunction. Approximately half of these persons appear to have clinical syndromes of emotional disorders, primarily depression and. somatization difficulties, while the remaining have personality disorders. Low scores are of interest on the Masculinity-Femininity (Mf) scale, where 41 women (27%) have abnormally low scores ( < 40) reflecting stereotypically feminine characteristics such as passivity and sensitivity. Ego Strength (Es) scale scores are in the normal range (Table 3). Half of both males and females have high scores (;;:. 60) which suggest effective functioning, while only two women and one man have low scores ( < 40) that suggest inadequate functioning. The Taylor Manifest Anxiety Scale (MAS) scores are near the standardized mean (Table 3), showing average anxiety levels before treatment. The MMPI results overall are consistent with global assessments recorded by the counselor after the initial evaluation session. The counselor's independent ratings of coping skills correlate significantly withes scale scores for men (x 2 = df; P < 0.02) and show a similar but not significant trend for women (x 2 = 3.6/2 df). Coping skills ratings also correlate significantly with MMPI clinical scale scores indicating psychiatric diagnoses: dysfunctionally high MMPI scores have low coping skills ratings (P < 0.01). Table 3. Ego Strength and Anxiety Measures Scale Women Mean SD" Ego Strength (MMPI Es) T score Taylor Manifest Anxiety Scale (MMPI MAS) T score Raw score Counselor ratings Coping skills (0-4 high) Ambivalence about treatment (0-4) "Standard deviation (n = 200) Men Mean SD (n = 200) Freeman et al. Psychological evaluation before IVF -ET 51

5 Counselor ratings of couples' ambivalence about IVF treatment at the outset are very low for the sample. Twenty-two couples indicated moderate to high ambivalence; 5 of these voluntarily withdrew from the program prior to treatment. The counselor evaluated four couples as having emotional problems that precluded treatment (in these cases, major depression or severe conflicts about pregnancy), and MMPI profiles for these persons were consistent with the clinical judgment. However, nearly all those having psychological diagnoses on the MMPI were accepted for treatment. The clinical evaluations of this group found that there were emotional difficulties but that they were not dysfunctional. The following example illustrates the unusual case where a couple was advised against proceeding for psychological reasons: Mr. and Mrs. Z completed all medical screening for the IVF program and presented themselves to the medical team as well-educated, successful, and positive about proceeding with treatment. However, as the counselor explored their feelings about pregnancy, Mrs. Z suddenly blurted out that she had agreed with her husband to "sit, smile, look pretty and go along with what he says." Further probing following this outburst revealed that she had deep-seated fears about pregnancy and motherhood and was sterilized many years earlier before marriage because of her strong desire to remain childless. Although Mr. Z was aware of her sterilization when they married, he subsequently decided that only having his own child would make him "feel satisfied to the fullest." He views adoption as unacceptable and has finally persuaded Mrs. Z to proceed with IVF. However, after further discussing the extent of the conflict with the counselor, the couple was able to accept the counselor's recommendation and referral to psychotherapy to resolve this issue before proceeding in the IVF program. DISCUSSION Attention given in recent years to emotional factors observed in infertility treatment has emphasized that treatment itself may result in anxiety or depression and that there is a predictable pathway from emotional crisis to its resolution. 10 An alternative interpretation is that severe emotional distress in infertility treatment is an exacerbation of preexisting psychological problems, but prospective studies that demonstrate this are 52 Freeman et al. Psychological evaluation before IVF-ET lacking. These pretreatment data from a consecutive sample of couples show normal psychological profiles for the majority before IVF-ET treatment begins. Possibly these couples, who typically have had many years of infertility treatment, are particularly well-equipped psychologically as well as economically to handle hope and disappointment. They may have resolved feelings from prior infertility experience and are not yet experiencing IVF treatment stress. These data cannot be generalized to all infertility patients, but we previously found similar MMPI results in a sample of 40 anovulatory infertile women at enrollment in a treatment study/ 1 as have several other researchers who reported normal MMPI scores for small samples of infertile women 12 and infertile couples. 13 These findings suggest support for the first hypothesis. However, it also may be that the subgroup with abnormal psychological distress before treatment ( ~ 20% in this sample) will experience greater exacerbation of symptoms than those with normal pretreatment levels. Further longitudinal study of the present sample is needed to know (1) whether respondents with pretreatment normal profiles react to treatment with increased emotional distress, (2) whether respondents with psychological problems before treatment respond with greater emotional distress, and (3) the effects of treatment outcome in the lives of these couples. Additional measures of mood and behavior as well as repeated measures of selected MMPI scales are being collected in each treatment cycle and at end points for answers to these questions. The normal anxiety levels for the majority of respondents seem surprising in view of the stress associated with IVF-ET treatment. However, it is important to emphasize again that the couples were evaluated before treatment and that anxiety (MAS) scores reflect characteristic anxiety levels rather than response to stressful experience. Continued evaluations will determine whether anxiety increases during treatment and whether it then returns to pretreatment levels. Additional emotional state measures (e.g., the Profile of Mood States, the Hopkins Symptom Checklist), as well as MAS scale items, will be used. However, it is also noteworthy that recent research shows anxiety (MAS) scale scores did significantly increase in stressful situations and decreased following the stressful time, 14 providing support for Spielberger's suggestion that this MMPI scale Fertility and Sterility

6 measures a "reactive disposition to respond with anxiety" in stressful situations. 15 Twenty-six couples (13%) did not proceed with treatment following the initial evaluation and were compared with the continuing group. Five were rated by the counselor as having high ambivalence about treatment, but this incidence of ambivalence is not significantly different in the continuing group, where 17 couples (10%) also were rated high. Two couples withdrew for financial reasons and two for medical reasons. Reasons for the remaining withdrawals are not known. Other background and attitudinal variables described in the results were not significantly different from those of the continuers. Psychological evaluation was incorporated in the IVF-ET program to provide emotional support for couples and to provide recommendations to the treatment team because of the emotional distress observed with unsuccessful treatment outcomes. Most couples respond positively to the required evaluation session, and many have stated that they would have liked to discuss their concerns and feelings when they first had infertility treatment. Few couples request ongoing counseling, but many report that the content helps them during stressful times in the course of treatment and are reassured that contact with the counselor is available if needed. The treatment team uses the evaluation as a guide in providing information and recognizing patients' responses to- stressful treatment experience. Important psychological components of treatment management include avoiding false hope ("I know you're pregnant," "It's going to work out," etc.) and allowing direct expression of disappointment and grief. Couples who seek IVF-ET treatment do so in spite of the likelihood of negative outcomes and have enabled scientific development of the procedures. It is important to provide them in turn with emotional support and to develop better understanding of the psychological components of IVF. This will further enable infertile couples to make informed choices about treatment options and may increase understanding ofivf-et treatment outcomes. REFERENCES 1. Steptoe PC, Edwards RG, Purdy JM: Clinical aspects of pregnancy established with cleaving embryos grown in vitro. Br J Obstet Gynaecol 87:757, Kolata G: In vitro fertilization goes commercial. Science 221:1160, Walters L: Human in vitro fertilization: a review of the ethical literature. Hastings Cent Rep 9:23, Jones HW Jr: The ethics of in vitro fertilization Fertil Steril 37:146, Garner CH, Kelly M, Arnold ES: Psychological profile of IVF patients. Fertil Steril (Abstr) 41:57S, Mazure CM, Greenfeld DA, De L'Aune W, Laufer N, Polan ML, DeCherney AH, Haseltine FP: Psychological interviews and assessments of couples participating in in vitro fertilization. Fertil Steril (Abstr) 41:57S, Mikesell S, Falk R: The utilization of assessment of marital satisfaction and interpersonal perceptions with in vitro fertilization couples to develop intervention strategies to reduce the psychological impact of the stress ofinfertility. Fertil Steril (Abstr) 41:58S, Aitken J, Oke M: The implications ofivf for the individual. Royal Women's Hospital, Victoria, Australia. Unpublished data 9. Hathaway SR, McKinley JC: User's Guide for the Minnesota Report. Minneapolis, MN, Interpretive Scoring Systems, Menning BE: The emotional needs of infertile couples. Fertil Steril 34:313, Freeman EW, Garcia C-R, Rickels K: Behavioral and emotional factors: comparisons of anovulatory infertile women with fertile and other infertile women. Fertil Steril 40:195, Denber HCB, Roland M: Psychologic factors and infertility. J Reprod Med 2:285, Dominici L, Coshi I, Panchiri P, Nicotra M, Aboulkhair N, Zichilla Z, Peruggini M: Psychological evaluation in couples with sterility without apparent cause. In Emotion and Reproduction 20-A, Edited by L Carenza, L Zichella. Proceedings of the Serono Symposia. New York, Academic Press, 1979, p Halbreich U, Kas D: Variations in the Taylor MAS of women with premenstrual syndrome. J Psychosom Res 21:391, Spielberger CD (Ed): Anxiety and Behavior. New York, Academic Press, 1966, p 385 Freeman et al. Psychological evaluation before IVF -ET 53