Efficacy of Psychological Intervention for Infertility Patients
copyright 2010 by Melissa Libby
PLEASE DO NOT REPUBLISH, PRINT, OR COPY WITHOUT EXPRESS PERMISSION FROM THE AUTHOR (ME). THANK YOU.
Introduction
Infertility in women and men is a growing problem in the United States and worldwide. Many theories surround the reason behind this growing trend, but most people agree that the high amount of chemicals in everything that people put on and in their bodies and expose themselves to is a highly likely culprit behind infertility (Mayo Foundation for Medical Education and Research, 2010). In this research study, the efficacy of psychological intervention on overall well-being and pregnancy success in infertility patients receiving assisted reproduction treatment will be examined. For the purpose of this research study, infertility will be defined as at least one year of unprotected sexual intercourse (Hämmerli, Znoj, & Barth, 2009), and only infertile patients as determined by medical diagnosis who are receiving assisted reproduction treatment at Libby Fertility Center* will be selected for this study. Psychological intervention will be defined as psychotherapy, psychoeducation, and fertility counseling.
Women’s infertility is much more complicated than men’s. Women can have conditions that cause infertility; such as endometriosis, polycystic ovarian syndrome (PCOS), pelvic inflammatory disease (PID), or any number of sexually transmitted diseases (STDs). Men can have any number of STDs, trauma to the penis and/or testes, low sperm motility and/or count, or abnormal sperm. Both women and men can also have unexplained infertility or secondary infertility. Unexplained infertility simply means that your health care providers cannot find any medical explanation for why you are having fertility issues. There are two groups of people who usually get diagnosed with this frustrating problem: those couples who are simply unlucky, and don’t have any biological problems interfering with pregnancy; and those couples who do have a medical reason for infertility, but this reason cannot be found due to insufficient medical knowledge or technology. Secondary infertility is defined as the inability to conceive or carry a pregnancy to term after you have already successfully given birth to one or more children. (Shared Journey, 2010).
The purpose of this research is to examine the efficacy of psychological intervention; most notably psychotherapy, psychoeducation, and fertility counseling, on overall well-being and successful pregnancy during assisted reproduction treatment. This study proposes that infertility patients who enter assisted reproduction treatment under any level of stress will benefit from psychological intervention, and that some patients may experience a heightened degree of overall well-being and pregnancy success during assisted reproduction treatment due to decreased stress levels as a result of such psychological intervention (Hämmerli, et al., 2009; De Liz & Strauss, 2005; Wischmann, 2008; De Klerk, Hunfeld, Duivenvoorden, den Outer, Fauser, Passchier, & Macklon, 2005).
The connection between mind and body in the scope of infertility and pregnancy is important research because the number of women and men with infertility is increasing, thus pushing more women and couples to receive assisted reproduction treatment in order to have the family they want. Infertility is a difficult issue both physically and emotionally, for both women and men. This research examines whether infertility patients who receive psychological intervention during their assisted reproduction treatment will have more positive outcomes in terms of emotional well-being and pregnancy success than infertility patients who do not receive psychological intervention during their assisted reproduction treatment. While there have been a number of studies that look at this issue, there needs to be more current research in this area, to reflect the growing number of infertile people. Existing research has been insufficient due to poor response and retention rates of participants and lack of further research conducted on male infertility (De Klerk, et al., 2005) as well as the medical complexity of infertility in general.
The research question that will be examined is whether infertility patients who utilize psychological intervention during their assisted reproduction treatment have higher overall well-being and successful pregnancy rates than patients who utilize assisted reproduction treatment with no psychological intervention. This question addresses the knowledge that stress will affect the rate of conception in women, as well as the stress of difficult conception when an infertility condition has been medically diagnosed (American Pregnancy Association, 2007). The hypothesis is that infertility patients who utilize psychological intervention during their assisted reproduction treatment will have higher overall well-being and successful pregnancy rates than patients who utilize assisted reproduction treatment with no psychological intervention.
This research study will be conducted by a Principal Investigator as well as qualified Key Study Personnel, who have Doctor of Philosophy degrees from prestigious research institutions in the United States and abroad. Each of the Key Study Personnel at Libby Fertility Center is trained in interrater reliability, or consistency among different observers in their judgments (Rubin & Babbie, 2008) over the course of sixteen weeks.
Literature Analysis, Synthesis, and Critique
Prior research on the efficacy of psychological intervention for infertility patients needs to be examined in order to gain a better perspective on infertility and assisted reproduction. According to Hämmerli, Znoj, and Barth (2009), psychological intervention appears to increase the chances of a couple without an infertility condition conceiving naturally, more so than an assisted reproduction patient. Not surprisingly, infertility patients who receive psychological interventions for longer periods of time may benefit from the interventions. This analysis would impact other professional services sought as many infertile patients feel anxious or depressed about assisted reproduction treatment and potential negative outcomes. Overall, it is helpful for infertility patients and pregnancy outcomes using psychological interventions.
Similarly, according to De Liz and Strauss (2005), psychological intervention is practical for infertility patients who are receiving assisted reproduction treatment; however, pregnancy rates are affected by psychological intervention only when a considerable amount of time has lapsed. De Liz and Strauss noticed that social desirability results may occur from the self-report questionnaire. Social desirability (also known as social desirability bias), is a source of systematic measurement error involving the tendency of people to say or do things that will make them or their reference group look good (Rubin & Babbie, 2008). Individual counseling as well as couples counseling (if appropriate) and support groups all may help the infertility patient feel better about their issues and treatments, and even diminish the difficult decision to terminate unsuccessful assisted reproduction treatments. This analysis would impact other professional services sought as it is imperative to consider all aspects of the infertility patient’s treatment, from individual to couples counseling and support group work. De Liz and Strauss’ study relates to the study by Hämmerli, Znoj, and Barth (2009) due to necessary time lapse for the greatest benefit of psychological intervention for infertility patients.
A study conducted by Thomas and Rausch (2002) evaluated marital cohesion, pregnancy outcome, and the differences between genders and stress levels while pursuing assisted reproduction treatment. The study included a Likert Scale, which is a type of composite measure developed in an attempt to improve the levels of measurement in social research through the use of standardized response categories in survey questionnaires. Likert items use such responses as strongly agree, agree, disagree, and strongly disagree (Rubin & Babbie, 2008). The conclusion that Thomas and Rausch reached is that women experience more stress and depression than men while undergoing assisted reproduction treatment. Thus, pregnancy rates were affected by stress and depression levels of the female. Interestingly, for men, pre-treatment depression and pregnancy outcome were significant predictors of post-treatment depression. This analysis would impact other professional services sought as it is essential that men also seek psychological intervention when experiencing stress or depression during assisted reproduction treatment. This study contained associated scales for assessing patients and contained sections on variables and feedback, which are vital aspects of research. It is important to evaluate how men handle assisted reproduction treatment when they are actively involved in the treatment process, and within the scope of psychological interventions.
Males differ from females biopsychosocially in regards to fertility. Gerrity (2001) found that women employ escape-avoidance tactics more frequently than men in order to cope with their infertility and that therapists need to assess both coping styles of the infertility patient and whether the complexity of their diagnosis is leading the patient to a healthy or detrimental coping pattern. Coping mechanisms are important to the biopsychosocial aspects of life. Overall, men and women possess different coping styles, and it is important to be able to compare and contrast the two. Gerrity’s study relates to the study conducted by Thomas and Rausch (2002) in that women experience more stress in infertility and assisted reproduction treatment than men and thus may cope by escape-avoidance tactics related to their stress level.
Conversely, Daniluk and Tench (2007) assessed the transition of infertile people to the acceptance of biological childlessness following unsuccessful assisted reproduction treatments. They concluded that many people react the same, over time, to accepting biological childlessness; and there were few differences between the reactions of men and women and older and younger participants. Another noteworthy aspect of this study is that the inability to cope with infertility is compounded by the insensitivity of fertile people. Psychological interventions should focus on support and adjustment to childlessness. The majority of assisted reproduction treatments do not work unless tried multiple times, further aggravating the infertile patient’s coping and adjustment abilities, thus increasing the need for psychological interventions.
According to Wischmann (2008), psychological interventions and infertility support groups are constructive for infertility patients who are receiving assisted reproduction treatment, but only on a psychological level. Pregnancy rates seem to be impervious to psychological intervention. Wischmann also found that most infertility patients utilize the Internet for research and self-help concerning infertility. Psychological interventions should be available to infertility patients who are receiving assisted reproduction treatment. Overall, the basic principle of providing psychosocial support for patients receiving assisted reproduction would be case-by-case, but an important intervention for those with little or no support elsewhere.
In a similar study; De Klerk, Hunfeld, Duivenvoorden, den Outer, Fauser, Passchier, and Macklon (2005) realized that not all women who utilize in vitro fertilization, or IVF, treatment are necessitate of psychological interventions; but couples who start IVF under high stress may benefit the most from psychological intervention. In their research, almost half of the couples dropped out of the study and others either discontinued IVF or did not want counseling.
Overall, there were many variables which caused divergent and confounding data. For example, De Klerk, et al., said that there were poor response rates from and poor retention rates of participants. An overall synthesis of the research articles used for this literature analysis, synthesis, and critique support the research hypothesis that psychological intervention would have a positive impact on assisted reproduction outcomes (Wischmann, 2008; De Klerk, et al., 2005; Thomas & Rausch, 2002). Thomas and Rausch’s study (2002) as well as De Liz and Strauss’ study (2005) also supported the research hypothesis that psychological intervention did improve pregnancy success. This study is important in that the desire to have children is a driving force for many women and men, and the impact of infertility can be particularly traumatic.
The meta-analysis (Hämmerli, Znoj, & Barth, 2009) states that psychological intervention had more of an impact on naturally-occurring pregnancies rather than assisted reproduction pregnancies. The study conducted by De Liz and Strauss (2005) states that psychological intervention does impact assisted reproduction pregnancy outcomes, although it adds that a considerable amount of time had lapsed before the benefit was seen. More research showing psychological interventions on people who were attempting to conceive naturally should be examined in order to be able to fully compare with assisted reproduction cycles, as well as the lack of use of psychological interventions, would be interesting.
The literature analysis, synthesis, and critique related to the topic revealed that as long as infertility patients have a strong support network, they fared well in assisted reproduction with or without psychological intervention (De Klerk, Hunfeld, Duivenvoorden, den Outer, Fauser, Passchier, & Macklon, 2005; Wischmann, 2008). The research considers that the increase in infertility patients and the effectiveness of psychological intervention is key in a social work setting, because being familiar with what infertility patients feel would benefit them psychologically as well as medically is important to providing the best quality care and outcomes for the infertile populace.
For example, in the study conducted by Gerrity (2001); women had different ways of coping with the stress of infertility than men. This finding reveals a need for more research to be conducted with both women and men for accurate findings regarding both genders. Gerrity recognized that men react differently to stress, depression, and emotional conflict than women; and therefore realized that more research needs to be conducted using male participants who have a strong desire to be fathers.
The conclusion that can be inferred from the literature synthesis, analysis, and critique is that further research conducted by Libby Fertility Center will provide further examination of the proposal that psychological intervention received during assisted reproduction treatment will improve overall well-being and pregnancy success in infertility patients.
Methodology
The efficacy of psychological intervention on overall well-being and pregnancy success in assisted reproduction will be examined by a general questionnaire and instruments that involve levels of stress, anxiety, and depression and perceived infertility problems. The Libby Fertility Questionnaire (Appendix C) will gather statistical data and data that are relevant to the course of assisted reproduction treatment. The Libby Fertility Questionnaire has been created for this study and is an important tool to assess the way infertility patients feel about the manner in which their lifestyle choices affect them. For example, a poor diet will affect fertility and conception as well as the use of alcohol and tobacco (Mayo Foundation for Medical Education and Research, 2010). The Beck Depression Inventory (BDI; Appendix D) will assess stress, anxiety, and depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The Fertility Problem Inventory (FPI; Appendix E) will assess the patients’ perceived infertility problems and their surrounding environment as it relates to fertility (Newton, Sherrard, & Glavac, 1999).
The Libby Fertility Questionnaire asks questions about pelvic pain, which is indicative of a fertility condition (Mayo Foundation for Medical Education and Research, 2010); as well as substance use, sexually transmitted diseases, and previous births or pregnancy losses. By knowing the lifestyle and current mental health status of the infertility patient, clinicians can tailor their psychological intervention specifically to the patient. Other similar questionnaires include the FertiQol Online Survey by Cardiff University (Cardiff University, n. d.), and an Online Survey by The Fertility Center of Las Vegas (2008). Using the BDI is important for gauging crucial physiological responses experienced by infertility patients; such as stress, anxiety, and depression.
The FPI, on the other hand, delves into the emotions experienced by infertility patients; such as how they feel around people who have children, how infertility affects an intimate relationship, and how to possibly come to terms with a child-free life. Each of these instruments are important tools to use for research into assisted reproduction treatment because of the emotional impact of infertility on people who desire to have children. Strong amounts of stress, anxiety, and depression can also impact physical areas such as conception (American Pregnancy Association, 2007). These instruments will allow the Principal Investigator as well as Key Study Personnel to determine how to best provide care and a successful pregnancy for infertile patients.
Sample
The efficacy of psychological intervention on overall well-being and pregnancy success in assisted reproduction will be examined by the random sample for the study accessed at Libby Fertility Center in Concord, New Hampshire. A random sample means that each element has an equal chance of selection that is independent of any other event in the selection process (Rubin & Babbie, 2008). The population that will be used consist of medically diagnosed infertile single and coupled women within the United States, aged 18 to 40 years, who are currently not pregnant and are in the beginning phases of assisted reproduction treatment in order to achieve pregnancy. These women and couples will be accessed by those choosing to receive a flyer advertising the need for research study participants at Libby Fertility Center as they arrive for assisted reproduction treatment. Participants will be randomly selected upon the flyer deadline date. The total number of respondents will be divided in half, with one group being randomly selected as the research study group and the other group being randomly selected as the control group.
This study includes single women without male partners and also includes married heterosexual and homosexual women. This study does not recognize homosexual male singles or couples due to their inability to utilize assisted reproduction to achieve physical pregnancy. This study is not limited by race, ethnic origin, socioeconomic class, religion, or location within the United States in that any woman or man from any walk of life can struggle with infertility.
Measures
The efficacy of psychological intervention on overall well-being and pregnancy success in assisted reproduction will be examined by the key variables that will be explored in the study: infertility, mental health, well-being, and pregnancy success. According to Rubin and Babbie (2008), independent variables are those whose value is not problematic, but are simply taken as a given. In this study; independent variables include demographic data such as city and state of residence, age, gender, race, ethnicity, and so on. Independent variables help to cause or explain a dependent variable and are generally things that are taken as a given or those things that cannot be altered.
Dependent variables, according to Rubin and Babbie, are variables that are assumed to depend on or be caused by another (such as the independent variable). In other words, the independent and dependent variables are a cause-and-effect on each other. In this research, dependent variables include levels of stress, anxiety, and depression; lack of children, poor overall well-being, and so on. Dependent variables can be altered.
Operationalizing these variables will be determined using overall well-being and pregnancy success. For this research study, overall well-being will be defined as positive physical or mental health during assisted reproduction treatment. Pregnancy success will be defined as a live birth which resulted from the successful conception and full-term (approximately 40 weeks) gestation of the implanted embryo.
Data in this research study may be defined as nominal and interval. A nominal measure is a level of measurement that describes a variable whose different attributes differ only categorically and not metrically, such as gender. An interval measure describes variables whose attributes are rank-ordered and have equal distances between adjacent attributes. For example, the age group 18 to 40 has an equal distance of one year between each number; such as age 18, 19, 20, and so on up until the age of 40 (Rubin & Babbie, 2008).
Data collection methods
Examining the efficacy of psychological intervention on overall well-being and pregnancy success in assisted reproduction will be conducted by self-administered paper-and-pencil questionnaires and inventories that will gather many forms of data; such as demographic information, medical history, gynecological history, male history, and one-to-ten and other Likert scales that indicate how much certain areas of their life impact their mental health. All questionnaires and inventories will be administered at the Libby Fertility Clinic inside a conference room with all participants using conference tables and partitions for privacy and confidentiality. Questionnaires and inventories will be administered by qualified Key Study Personnel, who have Doctor of Philosophy degrees from prestigious research institutions in the United States and abroad. Each of the Key Study Personnel at Libby Fertility Center are trained in interrater reliability, or consistency among different observers in their judgments (Rubin & Babbie, 2008) over the course of sixteen weeks.
The instruments that will be used are the Libby Fertility Questionnaire (Appendix C), which will gather statistical data and data that is relevant to the course of assisted reproduction treatment. The Libby Fertility Questionnaire has been created for this research study and is an important tool to assess the way infertility patients feel about the manner in which their lifestyle choices affect them. The Beck Depression Inventory (BDI; Appendix D) will assess stress, anxiety, and depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). The Fertility Problem Inventory (FPI; Appendix E) will assess the patients’ perceived infertility problems and their surrounding environment as it relates to fertility (Newton, Sherrard, & Glavac, 1999).
Data analysis
As this research study seeks to assess the efficacy of psychological intervention on overall well-being and pregnancy success in assisted reproduction, the study will contain mixed qualitative (non-numerical) and quantitative (numerical) data. These will be treated different in analysis in that the qualitative data will come from the Libby Fertility Questionnaire (Appendix C) and will be analyzed using NUD*IST, a computer program for researchers to analyze qualitative data (Rubin & Babbie, 2008). The Libby Fertility Questionnaire is a source of statistical and demographic data and is not scored using a numerical range of scores.
The quantitative data will come from the Beck Depression Inventory (Appendix D) and the Fertility Problem Inventory (Appendix E) and will be analyzed using SPSS. SPSS is Statistical Package for the Social Sciences, and is a statistical software program which helps researchers analyze numerical and other data. SPSS can also categorize variables of this research study; using demographic data such as age, test scores, geographical regions, and other data.
The Libby Fertility Questionnaire (Appendix C) has numerous questions about fertility, testing, sexual and other histories, and a ten-point and other Likert scales determining how much various issues affect their life.
The Beck Depression Inventory (Appendix D) contains twenty-nine questions and gives four response choices, numbered zero (0) to three (3), with some also having 3a, 3b, and so on. The participant may choose only one choice that best describes their situation. Scoring the BDI is as follows: a score of 0–9 indicates that a person is not depressed, 10–18 indicates mild-moderate depression, 19–29 indicates moderate-severe depression and 30–63 indicates severe depression (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961).
The Fertility Problem Inventory (Appendix E) contains four categories with eight to ten statements in each category. On a six-point Likert Scale using responses such as strongly disagree, disagree, strongly agree, agree, etc., the respondent marks their best response (Newton, Sherrard, & Glavac, 1999).
A null hypothesis postulates that the relationship being statistically tested is explained by chance—that it does not really exist in a population or in a theoretical sense—even though it may seem to be related in our particular findings (Rubin & Babbie, 2008). Rejection of the null hypothesis supports plausibility of the research hypothesis, that the use of psychological intervention on assisted reproduction patients will increase the overall well-being and pregnancy success of the group that receives the psychological intervention.
The literature analysis, synthesis, and critique contains research literature supporting the research hypothesis that psychological intervention increases overall well-being in assisted reproduction patients, but not necessarily the pregnancy success (Wischmann, 2008). Therefore, due to findings of this study, there will be a risk of a Type I error, because the null hypothesis will be rejected. The clinical significance will determine the importance of psychological intervention on assisted reproduction patients from a practical standpoint.
A two-sample independent t-test will be utilized in order to compare the scores of the Beck Depression Inventory of the two groups: the study group (women receiving psychological intervention while receiving assisted reproduction treatment) and the control group (women receiving assisted reproduction treatment with no use of psychological intervention). A t-test is a test of the statistical significance of the difference between the means of two groups (Rubin & Babbie, 2008). An ANOVA, or Analysis Of Variance, could be used to further separate females and males with assisted reproduction counseling and no assisted reproduction counseling. An Analysis Of Variance is a variance of a dependent variable examined for the whole sample and separate subgroups created on the basis of one or more independent variables (Rubin & Babbie, 2008).
Discussion
Much of the research on the use of psychological intervention to determine the overall well-being and pregnancy success rates on assisted reproduction patients points to the fact that, yes, psychological intervention does promote overall well-being in infertility patients receiving assisted reproduction treatment, but that psychological intervention does not necessarily increase the rate of pregnancy success (Wischmann, 2008). Some cases are the exception, rather than the rule, such as in the study conducted by Thomas and Rausch (2002). This research study expects to find that the research hypothesis will be shown to be true, also correlating to data in the literature synthesis that points to the use of psychological intervention improving overall well-being but not necessarily pregnancy success, although with some exceptions. Literature from De Liz and Strauss (2005); Wischmann (2008); and De Klerk, Hunfeld, Duivenvoorden, den Outer, Fauser, Passchier, and Macklon (2005) help correlate and support the research hypothesis in this research study.
Some limitations in this research study might be considered. Were the data collection methods comprehensive enough to determine an accurate research hypothesis? Research participants may also have provided data that they felt the research team would rather see (social desirability bias). Other races have a higher likelihood of infertility than others. For example, in 1997, African-American women were the most likely group to have an infertility condition (Minnesota Public Radio, 1997). More limitations may include errors or flaws in the study method and/or design, as well as from Type I or Type II errors.
Implications of this research study indicate that good mental health and well-being may not be enough for an infertile woman to have a successful pregnancy via assisted reproduction. Underdeveloped laboratory techniques, poor quality and/or quantity of eggs and sperm, or the inability of the uterus to perform correctly and allow the implantation of a fertilized egg may be to blame. Perhaps the diets of the mother and/or father have been poor, or perhaps one or both prospective parents have been substance abusers. Further research into the reasons behind failed assisted reproduction cycles, rather than just labeling them as failed attempts and proceeding to the next cycle, may help clarify why many infertile patients may experience a number of failed assisted reproduction cycles before a successful pregnancy occurs.
The research results on the efficacy of psychological intervention for infertility patients could imply for the social work practice that fertility counseling may be a more crucial component for assisted reproduction treatment than previously thought. Because of the growing trend of infertility cases in the United States and abroad, further research is necessary to determine how to best provide assisted reproduction care to infertile patients. Assisted reproduction as a science has far to go to improve and develop its already amazing achievements. However, because many in vitro fertilization cycles do not produce a live birth; it is recommended that particular research is conducted to determine whether the overall well-being and mental health of the parents, in particular the mother, is a component to a successful live birth; or whether other avenues such as improved laboratory technology need to be investigated. Infertility is one of the more confounding human issues, and can afflict any woman or any man from any walk of life.
References
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* Not a real fertility clinic.
PLEASE DO NOT REPUBLISH, PRINT, OR COPY WITHOUT EXPRESS PERMISSION FROM THE AUTHOR (ME). THANK YOU.
