The Impact of the FertiStrong Mobile Application on Anxiety and Depression in Men: A Randomised Control Pilot Study.

Background: Male factor accounts for up to half of all cases of infertility. Previously, research has focused on the psychological effects of infertility on female partners, but recent studies show negative consequences on male patients as well. Despite evidence that men are affected by infertility, there is limited studies focusing on coping methods for them. Aims: Determine if a cognitive-behavioral and relaxation mobile application, targeted at men experiencing infertility, could lead to decreases in psychological distress. Settings and Design: Randomized controlled. Materials and Methods: Thirty-nine men participated in a randomized pilot study of the FertiStrong application. Participants completed a demographic form, the Hospital Anxiety and Depression Scale (HADS) and Fertility Problem Inventory (FPI) at baseline and one month follow-up. The intervention group downloaded the FertiStrong application and used it when needed. Control participants received routine infertility care. Statistical Analysis Used: Normally distributed data is presented as mean+/- SD; Differences in proportions were tested using Chi-square test and within group comparison were performed using paired t-test. Results: One participant was excluded, resulting in 38 participants, 19 in each group. There were no baseline differences in demographic characteristics (P>0.31). For the HADS anxiety domain, the control group had a small increase between baseline and follow up, while the intervention group had a small decrease. For the HADS depression domain, there was a slight increase in the controls. For the FPI, the control group had a two-point increase, from moderately stressed to extremely high while the intervention group had a five-point decrease, from extremely high to moderately high, but was not significant. Each FPI domain-specific score in the intervention group decreased and one, Rejection of Childfree lifestyle, was significant (P=0.03). The increase in stress level was significantly greater in the control group (P<0.02). Conclusion: Recruitment was challenging due to the short recruitment phase and the sample size was smaller than planned. However, there were several significant improvements noted in the intervention group and on all testing, the intervention group trended to less distress. More research is needed on convenient interventions for men experiencing infertility.

The impact of a reminder email on the return to care behavior of infertility patients after a first office visit: A quality improvement project.

Research question: Prior research has determined that up to half of infertility patients attend one visit with an infertility specialist but do not return for a diagnostic workup or treatment. As part of a quality-of-care improvement project, patients who had not returned after one visit with an infertility specialist received an email which asked why they had not returned. The return to care behavior was then compared to a period of time when the email was not sent out, to answer the question as to whether or not the email had a significant impact on behavior. Design: From July 2017 to March 2018, 301 eligible patients who attended one visit but did not return to care received an email; 657 subsequent patients from April to December 2018 did not receive one. The email asked questions about that visit, offered support, contact information for the employee sending the email and why they had not returned. Results: All patients were followed for 11 months after their initial visit. Forty-one percent of the email group returned to care, compared to 32% who did not (P < 0.0014). For those who gave a reason why they hadn't returned, 32% of the respondents conceived on their own, 3% transferred to another infertility center, 31% were taking a break, 3% were unhappy with their care, and 31% made a return to care appointment. Thus, the email was associated with a significant increase in return to care when compared to women who did not receive an email. The most common reason why patients did not return was spontaneous conception closely followed by taking a break. Conclusions: A compassionate email sent after one visit may increase return to care behavior.

Prevention of Pregnancy Loss: Combining Progestogen Treatment and Psychological Support.

Pregnancy loss can be defined as a loss before either 20 or 24 weeks of gestation (based on the first day of the last menstrual period) or the loss of an embryo or fetus less than 400 g in weight if the gestation age is unknown. Approximately 23 million pregnancy losses occur worldwide every year, equating to 15-20% of all clinically recognized pregnancies. A pregnancy loss is usually associated with physical consequences, such as early pregnancy bleeding ranging in severity from spotting to hemorrhage. However, it can also be associated with profound psychological distress, which can be felt by both partners and may include feelings of denial, shock, anxiety, depression, post-traumatic stress disorder, and suicide. Progesterone plays a key part in the maintenance of a pregnancy, and progesterone supplementation has been assessed as a preventative measure in patients at increased risk of experiencing a pregnancy loss. The primary objective of this piece is to assess the evidence for various progestogen formulations in the treatment of threatened and recurrent pregnancy loss, postulating that an optimal treatment plan would preferably include a validated psychological support tool as an adjunct to appropriate pharmacological treatment.

Impact of empathic physician contact on patient anxiety and distress during the waiting period after embryo transfer: a randomized controlled trial.

RESEARCH QUESTION: Can an empathic physician phone call in the interval between embryo transfer and first serum human chorionic gonadotrophin measurement decrease anxiety and distress amongst patients undergoing IVF? DESIGN: This was a randomized controlled trial at a single academically-affiliated fertility centre including patients aged 18-43 undergoing their first embryo transfer with autologous fresh or euploid cryopreserved embryos following preimplantation genetic testing for aneuploidies (frozen embryo transfer, FET/PGT-A). After embryo transfer, participants were randomized to a 5-minute scripted phone call (intervention) from a single physician 3-4 days after embryo transfer or to routine care. The primary and secondary outcomes included were change in State-Trait Anxiety Inventory (STAI) and Hospital Anxiety and Depression Scale (HADS) scores from the start of IVF stimulation to 8-9 days after embryo transfer, respectively. RESULTS: A total of 231 participants (164 fresh, 67 FET/PGT-A) were randomized to intervention (n = 116) or routine care (n = 115). While mean STAI and HADS scores increased in both groups, the intervention group experienced lower mean increases than the routine care group for both the STAI (3.3 [0.97] versus 7.8 [1.10], respectively; P = 0.002) and the HADS (0.3 [0.44] versus 2.4 [0.53], respectively; P = 0.003). Most participants in the intervention group found the call helpful (91.4%) and reported that it decreased distress and anxiety (81%). CONCLUSIONS: A brief empathic phone call from a physician during the waiting period resulted in significantly lower self-reported levels of patient anxiety and distress. As the intervention in this study averaged 5 min, implementing this in clinical practice would not be onerous and may ease the distress associated with the waiting period.

Tailored support may reduce mental and relational impact of infertility on infertile patients and partners.

RESEARCH QUESTION: What is the psychological impact of infertility on infertile patients and partners of infertile patients? DESIGN: This online, international, quantitative survey assessed the impact of infertility on mental health, relationships and daily activities for 1944 respondents. Respondents were male or female infertile patients (n = 1037) or partners to infertile patients (n = 907; not necessarily partners of the patient sample) and were recruited at different stages of the treatment journey. RESULTS: The most common emotions were 'sadness' at infertility diagnosis and 'anxiety' during treatment. Emotions differed in nature and intensity throughout the journey. Envy of others who achieved pregnancy was frequently reported by women. More than half of respondents (60.4%; n = 1174) perceived the infertility journey to have impacted their mental health, and 44.1% (n = 857) of respondents sought mental health support. More patients reported mental health impacts (70.1%, n = 727) than partners (49.3%, n = 447). One in three respondents indicated that their relationship had suffered due to the infertility diagnosis. Of these respondents, 55.0% (n = 409) strongly agreed that infertility caused an emotional strain. Patients more often than partners reported a detrimental impact on daily activities. Respondents most commonly agreed with statements regarding an 'effect on work-life balance'. CONCLUSION: Treatment journey stages are defined by their impact profile, which differs between infertile patients and partners of infertile patients. Negative impacts are diverse (mental health, relational, daily activities). There was disparity between the number of respondents reporting mental health issues and the number seeking mental health support. This indicates the need for support services tailored to different treatment stages.

The psychological impact of the coronavirus disease 2019 pandemic on women who become pregnant after receiving treatment for infertility: a longitudinal study.

OBJECTIVE: To compare the impact of the coronavirus disease 2019 (COVID-19) pandemic on the psychological health of patients with infertility who have become pregnant with that of women who have not. DESIGN: Prospective cohort study conducted from April 2020 to June 2020. The participants completed three questionnaires over this period. SETTING: A single large, university-affiliated infertility practice. PATIENTS: A total of 443 pregnant women and 1,476 women still experiencing infertility who completed all three questionnaires. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Patient-reported primary stressor over three months of the first major COVID-19 surge; further data on self-reported sadness, anxiety, loneliness, and the use of personal coping strategies. RESULTS: Pregnant participants were significantly less likely to report taking an antidepressant or anxiolytic medication, were less likely to have a prior diagnosis of depression, were more likely to cite COVID-19 as a top stressor, and overall were less likely to practice stress-relieving activities during the first surge. CONCLUSIONS: Women who became pregnant after receiving treatment for infertility cited the pandemic as their top stressor and were more distressed about the pandemic than their nonpregnant counterparts but were less likely to be engaging in stress-relieving activities. Given the ongoing impact of the pandemic, patients with infertility who become pregnant after receiving treatment should be counseled and encouraged to practice specific stress-reduction strategies.

Barriers and factors associated with significant delays to initial consultation and treatment for infertile patients and partners of infertile patients.

RESEARCH QUESTION: What are the key drivers and barriers for infertile patients and their partners to see an infertility specialist and initiate treatment? DESIGN: An online, international, 30-minute quantitative survey collected data from 1944 respondents from nine countries. Respondents were infertile patients (n = 1037) or partners of infertile patients (n = 907; but not necessarily partners of the patient sample), at different stages of the treatment journey. RESULTS: The overall average times were 3.2 years to receiving a medical infertility diagnosis, 2.0 years attempting to achieve pregnancy without assistance before treatment, and 1.6 years of treatment before successful respondents achieved pregnancy. The most common driver for considering treatment after a consultation (n = 1025) was an equal desire within the couple to have a child (40.8%). Of the partners (n = 356), 29.8% reported that transparency of information from healthcare professionals about treatment expectations was important. A significantly higher proportion of respondents seeking treatment reported that healthcare professionals offered supportive services (61.2%) and mental health services (62.0%), than of the 207 respondents who did not seek treatment (32.4% and 36.7%, respectively; P < 0.001). Perceived cost was the most commonly reported barrier for respondents not seeking a consultation (37.5% of n = 352) or treatment (42.0% of n = 207). Of the 95 respondents who discontinued treatment, 34.7% discontinued due to the financial impact. CONCLUSIONS: Respondents reported significant delays to seeking treatment, probably negatively impacting the chances of achieving pregnancy. Motivational coherence within couples was a key driver and cost of treatment was the main barrier. Reported supportive service offerings by healthcare professionals were significantly associated with continuation of the treatment journey.

Research-supported mobile applications and internet-based technologies to mediate the psychological effects of infertility: a review.

Infertility is a chronic condition commonly accompanied by psychological and emotional distress. A significant contributor to the discontinuation of infertility treatment is the psychological burden of treatment. Many individuals experiencing infertility report high levels of depression and anxiety. Unfortunately, barriers to traditional individual and couples counselling include stigmatization, finances, trepidation, challenges of travel and uncertainty. New technology, such as mobile applications and internet-based programmes, may be a feasible option for reducing the emotional distress of infertility diagnoses and treatments. This review focuses on current and developing technologies designed to decrease emotional distress in individuals with infertility.

Infertility remains a top stressor despite the COVID-19 pandemic.

RESEARCH QUESTION: What is the psychological impact of the COVID-19 pandemic on infertility patients? DESIGN: An anonymous cross-sectional online survey was sent to patients who attended a large university-affiliated infertility practice in the USA between 1 January 2019 and 1 April 2020. At three different time-points respondents were asked to note their top three stressors, from a list of 10 commonly reported life stressors. RESULTS: The questionnaire was sent to 10,481 patients, with 3604 responses (response rate 34%) received. A total of 2202 non-pregnant female respondents were included in the final analysis. One-third of respondents had a prior diagnosis of an anxiety disorder, and 11% reported taking anxiolytic medications; over one-quarter had a prior diagnosis of a depressive disorder and 11% reported taking antidepressant medications. At all three time-points, infertility was noted to be the most frequent top stressor. Coronavirus was noted to be the third most common stressor among the respondents in early March but, at the time of writing, is similar to that of infertility (63% and 66%, respectively). A total of 6% of patients stated that infertility treatment, including IVF, should not be offered during the COVID-19 pandemic. CONCLUSION: Despite the unprecedented global pandemic of COVID-19, causing economic and societal uncertainty, the stress of infertility remains significant and is comparable a stressor to the pandemic itself.

An internet-based mind/body intervention to mitigate distress in women experiencing infertility: A randomized pilot trial.

OBJECTIVE: To determine if an internet-based mind/body program would lead to participants experiencing infertility (1) being willing to be recruited and randomized and (2) accepting and being ready to engage in a fertility-specific intervention. Secondary exploratory goals were to examine reduced distress over the course of the intervention and increased likelihood to conceive. METHODS: This was a pilot randomized controlled feasibility trial with a between-groups, repeated measure design. Seventy-one women self-identified as nulliparous and meeting criteria for infertility. Participants were randomized to the internet-based version of the Mind/Body Program for Fertility or wait-list control group and asked to complete pre-, mid- and post-assessments. Primary outcomes include retention rates, number of modules completed, and satisfaction with intervention. Secondary exploratory outcomes sought to provide preliminary data on the impact of the program on distress (anxiety and depression) and self-reported pregnancy rates relative to a quasi-control group. RESULTS: The retention, adherence, and satisfaction rates were comparable to those reported in other internet-based RCTs. Although time between pre- and post-assessment differed between groups, using intent-to-treat analyses, women in the intervention group (relative to the wait-list group) had significant reduction in distress (anxiety, p = .003; depression, p = .007; stress, p = .041 fertility-social, p = .018; fertility-sexual, p = .006), estimated as medium-to-large effect sizes (ds = 0.45 to 0.86). The odds of becoming pregnant was 4.47 times higher for the intervention group participants as compared to the wait-list group, OR 95% CI [1.56, 12.85], p = .005 and occurred earlier. The findings suggest that the research design and program specific to this population are feasible and acceptable. Replication efforts with an active control group are needed to verify distress reduction and conception promotion findings.

The relationship between stress and infertility.

The relationship between stress and infertility has been debated for years. Women with infertility report elevated levels of anxiety and depression, so it is clear that infertility causes stress. What is less clear, however, is whether or not stress causes infertility. The impact of distress on treatment outcome is difficult to investigate for a number of factors, including inaccurate self-report measures and feelings of increased optimism at treatment onset. However, the most recent research has documented the efficacy of psychological interventions in lowering psychological distress as well as being associated with significant increases in pregnancy rates. A cognitive-behavioral group approach may be the most efficient way to achieve both goals. Given the distress levels reported by many infertile women, it is vital to expand the availability of these programs.

Por años ha sido debatida la relación entre estrés e infertilidad. En las mujeres con infertilidad se encuentran puntuaciones elevadas de ansiedad y depresión, por lo que está claro que la infertilidad causa estrés. Sin embargo, lo que está menos claro es si el estrés causa o no infertilidad. Por numerosos factores, como las inexactas mediciones de auto-reporte y los sentimientos de aumentado optimismo al comienzo de los tratamientos es difícil investigar el impacto del distrés en el resultado terapéutico. Ahora bien, la investigación más reciente ha documentado la eficacia de las intervenciones psicológicas en la reducción del distrés psicológico, además de asociarse con aumentos significativos en la frecuencia de embarazos. Una aproximación grupal cognitivo conductual puede ser la forma más eficiente para alcanzar ambos objetivos. Es vital expandir la disponibilidad de estos programas, dado los niveles de distrés reportados por muchas mujeres infértiles.

La relation entre le stress et l'infertilité est débattue depuis des années. Les niveaux d'anxiété et de dépression des femmes infertiles sont élevés, il est donc clair que l'infertilité provoque du stress. Ce qui est néanmoins moins clair c'est de savoir si le stress entraîne, ou pas, de l'infertilité. De nombreux facteurs rendent difficile la recherche sur l'effet de l'anxiété sur les résultats thérapeutiques, comme les auto-mesures imprécises, et les sentiments d'optimisme accru au début du traitement. Cependant, d'après les recherches les plus récentes, la prise en charge psychologique est efficace pour diminuer l'anxiété et elle s'associe aussi à des taux de grossesses significativement augmentés. C'est l'approche cognitivo-comportementale de groupe qui semble la plus efficace pour atteindre ces deux buts. Il est vital d'élargir la disponibilité de ces programmes compte tenu des niveaux d'anxiété rapportés par de nombreuses femmes infertiles.

Burden of care is the primary reason why insured women terminate in vitro fertilization treatment.

OBJECTIVE: To study the reason(s) why insured patients discontinue in vitro fertilization (IVF) before achieving a live birth. DESIGN: Cross-sectional study. SETTING: Private academically affiliated infertility center. PATIENT(S): A total of 893 insured women who had completed one IVF cycle but did not return for treatment for at least 1 year and who had not achieved a live birth were identified; 312 eligible women completed the survey. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reasons for treatment termination. RESULT(S): Two-thirds of the participants (65.2%) did not seek care elsewhere and discontinued treatment. When asked why they discontinued treatment, these women indicated that further treatment was too stressful (40.2%), they could not afford out-of-pocket costs (25.1%), they had lost insurance coverage (24.6%), or they had conceived spontaneously (24.1%). Among those citing stress as a reason for discontinuing treatment (n = 80), the top sources of stress included already having given IVF their best chance (65.0%), feeling too stressed to continue (47.5%), and infertility taking too much of a toll on their relationship (36.3%). When participants were asked what could have made their experience better, the most common suggestions were evening/weekend office hours (47.4%) and easy access to a mental health professional (39.4%). Of the 34.8% of women who sought care elsewhere, the most common reason given was wanting a second opinion (55.7%). CONCLUSION(S): Psychologic burden was the most common reason why insured patients reported discontinuing IVF treatment. Stress reduction strategies are desired by patients and could affect the decision to terminate treatment.

Insights from clinical experience in treating IVF poor responders.

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

The impact of younger age on treatment discontinuation in insured IVF patients.

PURPOSE: This retrospective cohort study aimed to determine whether age influences treatment discontinuation among insured patients undergoing in vitro fertilization (IVF). We hypothesized that the youngest patients would be the least likely to discontinue treatment. METHODS: All women age 18-42 who underwent their first fresh, non-donor IVF cycle from 2002 to 2013 were followed until a live birth was achieved, until they discontinued treatment at our center (not presenting for treatment for a one-year period), or until they completed six fresh or frozen embryo transfer cycles, whichever occurred first. RESULTS: Of 11,361 women included, 4336 (38.2 %) discontinued treatment at our center before achieving a live birth or undergoing six IVF cycles. Discontinuation differed by age for cycles 2-4 (all P ≤ 0.004), with the proportion among women age 40-42 averaging 6-7 % higher than the other groups; discontinuation per cycle was similar among women <30 compared to women age 30-<35 and 35-<40. This continued in cycles 5 and 6, and in the sixth, 35.2, 32.0, 32.3, and 40.2 % of women among the four age groups discontinued treatment, respectively (P = 0.17). In cycles 2-5, women in the oldest two age groups with secondary infertility consistently discontinued treatment more frequently than those with primary infertility. CONCLUSIONS: We found that women in the oldest age group were more likely to discontinue IVF treatment than younger women. Surprisingly, we found that the youngest women discontinued treatment in a similar fashion to women age 30-<40.

Addressing the emotional barriers to access to reproductive care.

Health care professionals make the medical care of infertility patients a priority, with the goal of achieving a singleton pregnancy for each. Patients who never seek out care, who do not return for treatment after the diagnostic workup, or who drop out of treatment are rarely noticed. Yet this is the outcome for the majority of patients, and the primary reason after financial for treatment termination is the emotional aspect. Attending to the psychological needs of our patients must become a higher priority, to provide all patients true access to care.

The impact of stress on fertility treatment.

PURPOSE OF REVIEW: The goal of this review was to summarize the recent research on the relationship between stress and assisted reproductive technology treatment. RECENT FINDINGS: Women and men with infertility report high levels of distress that can impact their quality of life. There are numerous psychosocial interventions, including cognitive behavior therapy and/or self-help ones, which may decrease distress, increase patient retention and improve pregnancy rates. SUMMARY: Patient distress is an important factor to consider. Decreasing burden of care may lead to significant improvements in assisted reproductive technology outcome.

Aging and the environment affect gamete and embryo potential: can we intervene?

Optimal maturation of the oocyte depends on its environment and determines embryo competence, because the embryonic genome is not active until the cleavage stage and new mitochondria are not produced until blastulation. Adverse environmental factors include aging, andropause, oxidative stress, obesity, smoking, alcohol, and psychologic stress, whereas androgen supplementation, a prudent diet, exercise, nutritional supplements, and psychologic interventions have beneficial effects. Mitochondrial function and energy production deteriorate with age, adversely affecting ovarian reserve, chromosome segregation, and embryo competence. In aging mice, the mitochondrial cofactor coenzyme Q10 reverses most of these changes. Early human experience has been encouraging, although only a small study using a shorter duration of intervention compared with the murine model has been carried out. Mitochondrial metabolic stress can result in an abnormal compensatory increase in mitochondrial DNA, which can be assessed in biopsied blastomeres of trophectoderm as a predictive biomarker of implantation failure. Psychologic stress may reduce oocyte competence by shifting blood flow away from the ovary as part of the classic "fight or flight" physiologic response, and methods to reduce stress or the body's reaction to stress improve pregnancy success. Enhancing oocyte competence is a key intervention that promises to reduce the number of euploid embryos failing to produce viable deliveries.

Lifestyle habits of 12,800 IVF patients: Prevalence of negative lifestyle behaviors, and impact of region and insurance coverage.

Lifestyle habits of women undergoing in vitro fertilization (IVF) treatment are largely unknown. Therefore, this prospective study aimed to determine the prevalence of negative lifestyle habits in women undergoing IVF and determine if habits are related to the region in the United States and/or by mandated insurance coverage. A total of 12,811 ART patients were surveyed in infertility clinics throughout the US. They took an online questionnaire added to the patient portal of electronic medical record eIVF, a fertility-specific electronic health record. Of the women surveyed, 17-23% of patients drank alcohol, 2-7% smoked, 62-68% drank caffeine, < 1% used recreational drugs, and 47-62% exercised during their IVF treatment. There were a few statistically significant regional differences in health habits (p < 0.001) but there were no differences in health habits between women who resided in a state with mandated insurance coverage versus those without insurance coverage. This is the first prospective assessment of lifestyle habits across regions in the USA and by insurance coverage. The study concluded that women undergoing IVF engage in behaviors which may negatively impact their cycle. Women in certain parts of the US had significantly worse habits than other regions, but the availability of mandated insurance coverage did not impact health habits.