Minnesota Multiphasic Personality Inventory (MMPI-2) profiles in the assessment of ovum donors

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1 Minnesota Multiphasic Personality Inventory (MMPI-2) profiles in the assessment of ovum donors Susan C. Klock, Ph.D. a and Sharon N. Covington, M.S.W. b a Northwestern University Feinberg School of Medicine, Section of Reproductive Endocrinology and Infertility, Chicago, Illinois; and b Shady Grove Fertility Reproductive Science Center, Rockville, Maryland Objective: To examine the relationship between MMPI-2 scores and oocyte donation outcome. Design: Descriptive chart review. Setting: Two oocyte donation programs. Subject(s): Five hundred anonymous oocyte donor applicants. Intervention(s): None. Main Outcome Measure(s): Demographics, MMPI-2 scores and donation outcome. Result(s): The mean age was 26.6 years, 54% were Caucasian, 37% were high school graduates with some college, 55% were single, and 49% were nulliparous. Fifty-nine percent of donors completed at least one donation cycle, 10% were ruled out because of medical concerns, 12% dropped out, 11% were ruled-out because of psychologic concerns, and 8% had not been selected by a recipient. On the MMPI-2, the mean profile was in the normal range. Significant differences were found between groups on subscales F, F(p), L, S, S1, 2, 4, 8, and 9. The largest differences in scores between donors who completed a cycle and those who were psychologically excluded were on L (8 points) and 9 (6 points). Use of the non-k corrected scores replicated group differences. Conclusion(s): MMPI-2 scores differed between donors who completed a donation cycle and those who were psychologically excluded. Attention should be paid to validity scale L when considering donor selection. (Fertil Steril Ò 2010;94: Ó2010 by American Society for Reproductive Medicine.) Key Words: Oocyte donation, psychologic, psychologic testing, MMPI-2 Donated oocytes enable women with primary ovarian insufficiency, diminished ovarian functioning, or ovarian absence to become pregnant. The use of donor oocytes is growing, but often demand for donated oocytes exceeds supply (1, 2). One factor that may account for the limited availability of donors is the complex screening process, which includes comprehensive medical and psychologic evaluation (3). Gorrill et al. (4) demonstrated that of 315 phone inquiries from prospective donors, only 38 women (12%) entered the active donor pool. Levy et al. (5) found the most frequent reason for rejection of a donor is for mental health concerns, which accounted for denial of 24% of their donor applicants. Based on these data, it is crucial to screen potential donors efficiently and effectively. It is common clinical practice to administer psychologic testing as one part of the counseling and assessment of women applying to be ovum donors. Personality testing, similar to medical testing conducted during evaluation, can provide objective information about how the donor approaches the process as well as psychologic strengths and vulnerabilities, which may impact donation. Based on current Medline and PsychINFO searches, the Minnesota Multiphasic Personality Inventory (MMPI) is the only personality test found in the literature that has been researched in oocyte donation. The MMPI is the most widely used and researched personality inventory in the world (6). It has been used to assess suitability for egg donation in several studies (7 12). Schover et al. (7) studied 45 prospective anonymous donors and found that 35% of the sample had at Received April 10, 2009; revised July 15, 2009; accepted August 29, 2009; published online October 12, S.C.K. has nothing to disclose. S.N.C. has nothing to disclose. Reprint requests: Susan Klock, Ph.D., Northwestern University Feinberg School of Medicine, Section of Reproductive Endocrinology and Infertility, 676 N. St. Clair, Suite 1845, Chicago, IL (FAX: ; sck318@northwestern.edu). least one elevated T score on a clinical scale. Lessor et al. (8) studied the MMPIs of 95 donor applicants and found relative elevations on scales 6 and 9. They described the donor profiles as being consistent with persons who are socially conventional, outgoing, and free from psychopathology. Riddle et al. (9) reported on 90 MMPI-2 profiles of sister s serving as egg donors for their sister. They found a significant portion of their donors had elevations above 65 on scales 5 (masculinity femininity) and 6 (paranoia). Klock et al. (10) studied 150 prospective oocyte donors MMPI-2 scores based on donation outcome. They found significant differences in MMPI-2 validity and clinical subscale scores between women who donated and those who were excluded because of psychologic concerns. Those who were accepted to donate reported fewer psychologic symptoms and were more defensive in their test taking attitude. On the clinical scales, women who were not accepted to donate reported more depressive symptoms, obsessive compulsive features, idiosyncratic thinking, and social introversion than women who completed a donation cycle. These studies are limited by small samples and, with one exception, an absence in relating MMPI-2 scores to donation outcome. Furthermore, there have been no published studies on the use of the MMPI-2 in donor assessment in the last 10 years despite the growth in ovum donation. The purpose of this study is to examine demographic information, outcome, and the relationship between scores on the MMPI-2 among a large sample of anonymous egg donor applicants to provide information on the clinical utility of the test as a screening tool. MATERIALS AND METHODS The MMPI-2 consists of 567 true false self-report items, requires a sixthgrade reading level, and takes about 1.5 hours to complete. The test consists 1684 Fertility and Sterility â Vol. 94, No. 5, October /$36.00 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 of four validity scales to assess whether a respondent is open and honest in his or her responses: the L (Lie), F (Infrequency), and K (Correction) and S (Superlative Self-Presentation), and 10 clinical scales: 1 hypochondraisis, 2 depression, 3 hysteria, 4 psychopathic deviant, 5 masculinity/femininity, 6 paranoia, 7 psychasthenia, 8 schizophrenia, 9 hypomania, 0 social introversion. Clinical scales of the original MMPI were used to describe a cluster of clinical symptoms of psychiatric patients and were revised to numbers with the MMPI-2 to reflect the broader use in a variety of settings. When analyzing the responses, higher scores on the F scales (F, F[b], F[p]) relate to overreporting of symptoms and problems, while higher scores on the L, K, and S relate to defensive responses or underreporting of symptoms (13). In addition, S scores are highly correlated with K scores as measures of defensiveness (14). The validity scales are important as they indicate test-taking attitudes and whether the information obtained on the clinical and content scales can be trusted to accurately reflect the individual. K scores are also used to weight 5 of the 10 clinical scales [1, 4, 7, 8, and 9] to correct for defensiveness in these clinical scale scores. Applicant charts of 500 donors from two donor recruitment programs were reviewed. Of the donors, 80 were from a large Midwestern egg donor program and 420 were from a large mid-atlantic program. The charts included applicants who volunteered to be donors from 2002 through Study participants were made up of prospective donors who passed initial medical screening of profile review and preliminary laboratory work, before comprehensive medical evaluation. Donor applicants were given the MMPI-2, which was administered by a qualified health professional using standard instructions. After review of all test results, the prospective donor was interviewed for psychologic assessment by a staff social worker or psychologist. If approved after medical and psychologic evaluation, the donor was accepted into the egg donation program. The data collected included age, marital status, education level, religion, number of children, and whether the donor was accepted to donate or not and if not, the reason for not donating, for example, medical issue, psychologic concern, dropped out, or no appropriate recipient match. MMPI-2 T scores for the validity and clinical scales (both K and non-k corrected) were compared between outcome groups. The data were analyzed using the chi-square tests for demographic characteristics. Analysis of variance and Tukey s test for post hoc group comparisons were used for the MMPI- 2 data between outcome groups. A level of P<.05 was used to indicate significant differences between groups. The study was approved by the institutional human subjects review board. RESULTS The average donor was Caucasian, single, 26 years old, nulliparous, high school graduate with some college education (Table 1). Fiftynine percent of donors were selected to donate and completed at least one donation cycle; 10% were ruled out because of medical concerns, 12% dropped out of consideration, 11% were ruled-out because of psychologic concerns, and 8% had not yet been picked by a recipient couple. African American donors were significantly over represented in the not selected group, making up 42% of the not selected group while comprising 10% of the total sample (c 2 ¼ 5.4, P<.000). Additionally, parity, education level, and age were significantly related to donor outcome with women who had at least one child, making up the 71% of the medically ruled-out group (c 2 ¼ 2.1, P<.000). Women with lower educational attainment were overrepresented in the psychologically ruled out group (c 2 ¼ 2.7, P<.007) and women with younger age were over represented in the donated group (c 2 ¼ 3.46, P<.02). No relationship was found between donation outcome and marital status or religious affiliation. On the MMPI-2, the mean validity profile for the entire sample of prospective donors was in the normal range, indicating appropriate levels of psychologic difficulties and defensiveness. Mean scale scores for all validity and clinical scales were below 65. The two highest clinical scale score means were on scales 5 (masculinity/ femininity: X ¼ 56) and 9 (hypomania: X ¼ 51) indicating that the group did not endorse traditional feminine role behaviors. They reported being somewhat unconventional and inclined to take risks. They were socially outgoing and had a relatively high degree of energy. We compared the MMPI-2 scores for four donation outcome groups (group 1 ¼ completed; group 2 ¼ medically excluded; group 3 ¼ dropped out and; group 4 ¼ psychologically excluded) using analysis of variance and Tukey s test of post hoc group comparisons (Fig. 1). The mean T scores for the validity and clinical scales are given in Table 2. Statistically significant differences were found between groups on subscales F (F ¼ 16.52, P<.001), F(p) (F ¼ 12.88, P<.001), L (F ¼ 8.35, P<.001), S (F ¼ 4.11, P<.007), S1 (F ¼ 6.75, P<.001), 2 (f ¼ 4.61, P<.003),4 (F ¼ 6.12, P<.001), 8(F ¼ 4.75, P<.003), and 9 (F ¼ 9.38, P<.001). There was a high level of similarity in profiles, which is not surprising because the MMPI-2 was administered to a nonpsychiatric, nonclinical group of women. The pool of donor applicants is generally within normal clinical range of functioning, and therefore this type of homogenous clustering of scores was expected. There were, however, significant differences between groups. Post hoc analyses indicated significant differences on subscale F (infrequency) between Group 4 (psychologically excluded) and all other groups, with mean subscale score differences between 4 and 7 T score points higher on F for Group 4 compared with the other groups. A similar result was found for the F(p) (infrequency psychopathology) subscale, with Group 4 having significantly higher scores, by 5 to 7 T scores points, than the other three groups. Post hoc analyses of subscale L (lie) demonstrated that Group 4 had a significantly higher mean score than the other three groups by over eight points. On this subscale the closest clustering of the mean scores of Groups 1, 2, and 3 and the largest divergence of Group 4 s mean score are evident. The relatively higher mean score on L indicates overly positive presentation of oneself, with possible minimization of psychologic or behavioral problems. Significant differences were also found between groups on scale S (superlative self-presentation) and S1 (belief in human goodness). On S, significant differences were found between Groups 1 and 4 (X 1 ¼ 60.0, X 4 ¼ 56.48, P<.05) and Group 3 and 4 (X 3 ¼ 62.05, X 4 ¼ 56.48, P<.009). Scale S1 also significantly differentiated between Groups 1 and 4 (X 1 ¼ 54.28, X 4 ¼ 50.02, P<.005) and Groups 3 and 4 (X 3 ¼ 56.49, X 4 ¼ 50.02, P<.000). Donors who were psychologically ruled out had mean scores significantly lower on the scales assessing superlative self presentation and belief in human goodness. On the clinical scales, post hoc analyses indicated that Group 4 had significantly higher scores than Groups 1 and 3, but not Group 2, on scale 2 (depression). On scale 4 (psychopathic deviant) Group 4 scored significantly higher than Groups 1 and 3. Similarly Group 4 scores were significantly higher than Groups 1 and 2 on scale 8 (schizophrenia) and Groups 1 and 3 on scale 9 (hypomania). We then compared the scale scores between groups using the non- K corrected scores for scales 1, 4, 7, 8, and 9. Significant differences between groups were found on all these scales when the non-k corrected scores were used. Of particular relevance is that Group 4 was significantly different from only Group 1 on scales 1 (hypochondriasis) (P<.002), 7 (psychasthenia) (P<.05) and 8 (schizophrenia) (P<.000). Group 4 was significantly different from all other outcome groups on scale 4 (psychopathic deviant) and scale 9 (hypomania). See Table 3 for a summary of mean scores differences for the non-k-corrected scales. Fertility and Sterility â 1685

3 TABLE 1 Demographic characteristics and donation outcome for oocyte donor applicants. FIGURE 1 Mean group profiles of the MMPI-2. Characteristic n % Age, y Mean SD Range Ethnicity Caucasian African American Hispanic 27 5 Asian 15 3 Other 8 2 No data available Education High school grad High school þ some college College grad Postgrad No data available Marital Status Single Married Divorced/separated 37 8 Widowed 11 2 No data available Number of Children No data available Religion Christian/non-Catholic No religious affiliation Catholic Jewish 6 1 Muslim 2 <0.4 Other 15 3 No data available Donation outcome Donated Medically ruled out Dropped out Psychologically ruled-out Not selected by recipient 38 8 DISCUSSION This study examined MMPI-2 scores, demographic characteristics, and the relationship to outcome of 500 women who volunteered to be anonymous oocyte donors. It is the largest study of donors to date describing how MMPI-2 scores relate to donation outcome. In our sample, the average donor applicant was Caucasian, 26 years old, single, nulliparous, had some college education and identified herself with some religious affiliation. These demographic characteristics are largely in keeping with earlier studies (8, 10). An unexpected finding in our study was the overrepresentation of African American donors who were accepted as donors but not selected by recipients. Although African American women made up 10% of our total sample, and 8% of donors accepted had not been selected by a recipient at the time our study closed, 42% of those not selected were African American. Studies have found that African Americans are significantly underrepresented in infertility clinics and when accessing reproductive health services, waiting longer time periods before seeking treatment (15, 16). In this regard, it may be that African American donor egg recipients were underrepresented and so these donors were less likely to be selected by recipients of another race. In this study, significant differences in mean MMPI-2 scores between donors who were psychologically excluded and all other groups were found on the F, F(p), and L validity scales. In keeping with an earlier study (10), the higher F and F(p) indicated that testtakers were acknowledging a higher index of psychopathologic behavior, although still within normal limits of adequate functioning. The greatest difference in F was between Group 3 (drop-outs) and Group 4, and may indicate that Group 3 was underreporting responses to fake good. Group 4 had significantly lower S scores than Group 3 who had the highest T scores of all groups. It is notable that Group 3 reported the highest responses on all of the five S subscales, indicating they were presenting themselves as more highly virtuous, responsible individuals with fewer moral flaws than most people (13). This group ended up dropping out before donation, and it may be speculated that they were invested in appearing admirable and well adjusted, but were not being particularly forthright in their responses. Unlike earlier studies, Group 4 had significantly higher scores on scale L than the other three groups by over eight T score points, although the mean was within normal limits. This is understandable as the MMPI-2 is used as a screening tool, and this defensiveness is a factor in deciding if the donor will be accepted or rejected. Higher L scores also indicate an unsophisticated attempt to deny small personal deficiencies (14), and because Group 4 had significantly lower education this may have contributed to a na ıve effort to look good. K scores for Group 1 and 3 were moderately high, reflecting some defensiveness. As noted in an earlier study (10), the moderate elevation in Group 1 can be seen in a positive light as successful donors have sufficient ego strength to carry them through the process. In contrast, the elevations in Group 3 when taken into consideration 1686 Klock and Covington Oocyte donors MMPI-2 Vol. 94, No. 5, October 2010

4 TABLE 2 MMPI-2 subscale mean T scores by outcome group. Subscale Group 1 Group 2 Group 3 Group 4 vrin trin F a F(b) F(p) a L a K S a S a S S S S a a a a Note: Scale names: vrin ¼ variable response inconsistency; trin ¼ true response inconsistency; F ¼ infrequency; F(b) ¼ back infrequency; F(p) ¼ infrequency psychopathology; L ¼ lie; K ¼ correction deny; psychopathology S ¼ superlative self-presentation; S1 ¼ belief in human goodness; S2 ¼ serenity; S3 ¼ contentment with life; S4 ¼ patience; S5 ¼ denial of moral flaws; 1 ¼ hypochondriasis; 2 ¼ depression; 3 ¼ hysteria; 4 ¼ psychopathic deviate; 5 ¼ masculinity-femininity; 6 ¼ paranoia; 7 ¼ psychasthenia; 8 ¼ schizophrenia; 9 ¼ hypomania; 0 ¼ social introversion. a Significant differences (P<.05 or greater) between group 4 and other groups. with other elevations in the S scales and low F, indicate that this group s level of defensiveness and reflects an inability to be honest as well as fully commit to the process. Clinical scales of the MMPI-2 are used to describe a cluster of certain personality attributes, with generally higher elevations reflecting more psychologic distress and lower scores less. Regarding the clinical scales, Group 4 had significantly higher scores on scale 2 (depression), 4 (psychopathic deviate), 8 (schizophrenia), and 9 (hypomania) than Group 1, the donors who completed a cycle. These scores indicate that Group 4 displayed higher depressive symptoms, amoral behavior, unusual thoughts and attitudes, and excessive energy or activity than Group 1. Nonetheless, these levels were still within normal limits with T scores <60. By combining the two or three highest clinical scales, a personality code type for donors can be identified (13). We found an aggregate profile of 5 to 9 among all donor applicants, indicating that they were nontraditional women with a moderate amount of physical and psychologic energy. This profile was also demonstrated as a code type for Group 1, successful donors. These results are anticipated as ovum donors are women participating in an unconventional process and so would be somewhat unconventional in nature. They also need physical and emotional energy to go through the process. TABLE 3 Group differences on non-k corrected scales. Subscale Group 1 Group 2 Group 3 Group 4 NonK1 a NonK4 b NonK7 a NonK8 a NonK9 b a Significant difference between groups 1 and 4 (P< ). b Significant differences between group 4 and all other groups (P< ). Fertility and Sterility â 1687

5 Group 4 donors displayed a code type, which has not been documented in earlier studies. The elevation in scale 4 indicates that the donor is somewhat rebellious, impulsive, antisocial, and nonconformist, in addition to the 5 to 9 attributes. Although some of the characteristics may prompt women to want to be oocyte donors, they may also reflect more difficulty in working with the process. In contrast, we found that Group 3 had no defined code type, as there must be at least 5 T-score points between the lowest clinical scale and the next highest scale in the profile. Without a defined code type, interpretation focuses on individual scales (13). The lack of definition in Group 3 s scales was likely because of the level of defensiveness on the validity scales and thus little reliable information could be gleaned from the clinical scales. In conclusion, this study has demonstrated that MMPI-2 scores differ between outcome groups in a large sample of anonymous donor applicants. Strengths of the study include the large sample size and collection of outcome data. The study is limited by the use of only two donor programs, which may reduce the ability to generalize the findings. In addition, because of the complex nature of donor screening many sources of information are used and the analysis of group differences may be confounded because MMPI- 2 scores were taken into consideration in making some donor inclusion/exclusion decisions. Additional research is needed to determine the predictive validity of MMPI-2 scores in donor screening and to compare other standardized psychologic tests with the MMPI-2 to determine which is best suited for use in the donor assessment. Acknowledgments: The authors thank Nazca Fontes of Conceivabilities, and Kara Weaver and LeAnne Tran of Shady Grove Fertility Reproductive Science Center for their assistance in data collection. REFERENCES 1. Assisted Reproductive Technology in the United States: 1995 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry. Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine. Fertil Steril 1998;69: Society for Assisted Reproductive Technology, National Summary, All SART member clinics. results. 3. Practice Committee of the American Society for Reproductive Medicine, and the Practice Committee of the Society for Assisted Reproductive Technology Guidelines for gamete and embryo donation: a Practice Committee report. Fertil Steril 2008;90: S Gorrill M, Johnson L, Patton P, Burry K. Oocyte donor screening: the selction process and cost analysis. Fertil Steril 2001;75: Levy D, Minjarez D, Weaver T, Keller J, Surrey E, Schoolcraft W. Oocyte donor screening: a retrospective analysis of selection process and prospective donor exclusions. Fertil Steril 2007;88(Suppl 1):S Butcher JN. MMPI-2: A Practitioner s Guide. Washington, DC: American Psychological Association, Schover LR, Collins RL, Quigley MM, Blankstein J, Kanoti G. Psychological follow-up of women evaluated as oocyte donors. Hum Reprod 1991;6: Lessor R, Cervantes N, O Connor N, Balmaceda J, Asch RH. An analysis of social and psychological characteristics of women volunteering to become oocyte donors. Fertil Steril 1993;59: Riddle MP, Applegarth L, Josephs L, Grill E, Cholst I, Rosenwaks Z. Psychological characteristics of sister oocyte donor candidates: a comparison against anonymous donor candidates using the MMPI-2. Fertil Steril 2004;82:S Klock S, Stout JE, Davidson M. Analysis of Minnesota Multiphasic Personality Inventory-2 profiles of prospective anonymous oocyte donors in relation to the outcome of the donor selection process. Fertil Steril 1999;72: Klock S, Covington S. Minnesota Multiphasic Personality Inventory, 2nd ed. (MMPI-2) scores of recruited oocyte donors based on donation outcome. Fertil Steril 2007;88(Suppl 1):S Lee SS, Cho M, Berkeley AS, Licciardi FL, Noyes N, Grifo J. Analysis of abnormal MMPI-2 profiles of prospective donor gamete recipient and partners. Fertil Steril 2008;90(Suppl 1):S Graham JR. MMPI-2: Assessing Personality and Psychopathology. 4th ed. Oxford: Oxford University Press, Butcher JN, Graham JR, Ben-Porath YS, Tellegen A, Dahlstrom WG, Kaemmer B. Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manualfor Administration, Scoring, and Interpretation (rev. ed.). Minneapolis, MN: University of Minnesota Press, Jain T. Hornstein Disparities in access to infertility services in a state with mandated insurance coverage. Fertil Steril 2005;84: Jain T. Socioeconomic and racial disparities among infertility patients seeking care. Fertil Steril 2006;85: Klock and Covington Oocyte donors MMPI-2 Vol. 94, No. 5, October 2010