Psychological distress and in vitro fertilization outcome.

OBJECTIVE: To examine whether psychological distress predicts IVF treatment outcome as well as whether IVF treatment outcome predicts subsequent psychological distress. DESIGN: Prospective cohort study over an 18-month period. SETTING: Five community and academic fertility practices. PATIENT(S): Two hundred two women who initiated their first IVF cycle. INTERVENTION(S): Women completed interviews and questionnaires at baseline and at 4, 10, and 18 months' follow-up. MAIN OUTCOME MEASURE(S): IVF cycle outcome and psychological distress. RESULT(S): In a binary logistic model including covariates (woman's age, ethnicity, income, education, parity, duration of infertility, and time interval), pretreatment depression and anxiety were not significant predictors of the outcome of the first IVF cycle. In linear regression models including covariates (woman's age, income, education, parity, duration of infertility, assessment point, time since last treatment cycle, and pre-IVF depression or anxiety), experiencing failed IVF was associated with higher post-IVF depression and anxiety. CONCLUSION(S): IVF failure predicts subsequent psychological distress, but pre-IVF psychological distress does not predict IVF failure. Instead of focusing efforts on psychological interventions specifically aimed at improving the chance of pregnancy, these findings suggest that attention be paid to helping patients prepare for and cope with treatment and treatment failure.

The role of feelings of intimacy on perceptions of risk for a sexually transmitted disease and condom use in the sexual relationships of adolescent African-American females.

OBJECTIVES: A core construct targeted by behavioural interventions is the perception that one is at risk for acquiring a sexually transmitted disease (STD). The objective of this analysis was to examine the role of intimacy on perceptions of risk for an STD (PRSTD) and condom use within late adolescent females' main relationships. METHODS: A clinical sample of African-American women aged 14-19 years at enrolment were followed prospectively for 3 years. At each semiannual interview, participants reported their partner-specific PRSTD, feelings of intimacy, perceptions of partner's concurrency and condom use at last sex for each of their main sex partners. RESULTS: A total of 285 individuals reported 724 main relationships. Using generalised estimating equations, intimacy was negatively associated with risk perception, after adjusting for perceptions of partner concurrency (OR: 0.68; 95% CI 0.60 to 0.76). PRSTD was no longer associated with condom use after adjusting for intimacy (OR: 1.30; 95% CI 0.83 to 2.02. CONCLUSIONS: Intimacy was found to be associated with risk perception and condom use within adolescent main relationships. Adolescents may not view their intimate partners as sources of infection. The success of individual-level STD prevention efforts, such as condom promotion, might be limited as condoms may be in conflict with adolescents' expectations about intimate relationships.

Fertility treatment response: is it better to be more optimistic or less pessimistic?

OBJECTIVE: To evaluate the prospective relation between dispositional traits of optimism and pessimism and in vitro fertilization (IVF) treatment failure among women seeking medical intervention for infertility. METHODS: Among 198 women (aged 24-45 years, mean [standard deviation] = 35.1 [4.1] years; white, 77%), the outcome of each participant's first IVF treatment cycle was examined. Treatment outcome was classified as being successful (versus failed) if the woman either delivered a baby or was pregnant because of the cycle by the end of the 18-month study period. At baseline, optimism and pessimism were measured as a single bipolar dimension and as separate unipolar dimensions according to the Life Orientation Test total score and the optimism and pessimism subscale scores, respectively. RESULTS: Optimism/pessimism, measured as a single bipolar dimension, predicted IVF treatment failure initially (B = -0.09, p = .02, odds ratio [OR] = 0.917, 95% confidence interval [CI] = 0.851-0.988), but this association attenuated after statistical control for trait negative affect (B = -0.06, p = .13, OR = 0.938, 95% CI = 0.863-1.020). When examined as separate unipolar dimensions, pessimism (B = 0.14, p = .04, OR = 1.146, 95% CI = 1.008-1.303), not optimism (B = -0.09, p = .12, OR = 0.912, 95% CI = 0.813-1.023), predicted IVF treatment failure independently of risk factors for poor IVF treatment response and trait negative affect. CONCLUSIONS: Being pessimistic may be a risk factor for IVF treatment failure. Future research should attempt to delineate the biological and behavioral mechanisms by which pessimism may negatively affect treatment outcomes.

Does delivering preventive services in primary care reduce adolescent risky behavior?

PURPOSE: To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits. METHODS: The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14-15 years. RESULTS: The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS). CONCLUSIONS: The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.

Socioeconomic disparities in the use and success of fertility treatments: analysis of data from a prospective cohort in the United States.

OBJECTIVE: To determine the effect of income, education, and race on the use and outcomes of infertility care. DESIGN: Prospective cohort. SETTING: Eight community and academic infertility practices. PATIENT(S): Three hundred ninety-one women presenting for an infertility evaluation. INTERVENTION(S): Face-to-face and telephone interviews and questionnaires. MAIN OUTCOME MEASURE(S): Use of infertility services and odds of pregnancy. Linear and logistic regression used to assess relationship between racial and socioeconomic characteristics, use of infertility services, and infertility outcomes. RESULT(S): After adjustment for age and demographic and fertility characteristics, college-educated couples (ß = $5,786) and households earning $100,000-$150,000 (ß = $6,465) and ≥$150,000 (ß = $8,602) spent significantly more on infertility care than their non-college-educated, lower-income counterparts. Higher income and college-educated couples were much more likely to use more cycles of higher-intensity fertility treatment. The increased cost of infertility care was primarily explained by these differences in number and type of infertility treatment. Even after adjustment for these factors and total amount spent on fertility care, having a college degree was associated with persistently higher odds of achieving a pregnancy (OR = 1.9). CONCLUSION(S): Education and household income were independently associated with the amount of money spent on fertility care. This relationship was primarily explained by types and intensity of infertility treatments used. Having at least a college degree was independently associated with improved odds of pregnancy.

Developmental changes in condom use among urban adolescent females: influence of partner context.

PURPOSE: National surveys have found that the percentage of female adolescents who report condom use at last sex differs by age group. Using longitudinal data, the authors examined whether there are longitudinal changes in condom use and whether these changes are due in part to developmental changes in the types of sexual relationships in which young women are involved. METHOD: A clinic sample of 298 African American female adolescents aged 14-19 years at enrollment were interviewed every 6 months for a period of 36 months. At each interview, participants were asked to name all their recent sex partners, to classify each partner as main or casual, and to report whether a condom was used at last sex with each of these partners. Hierarchical generalized linear modeling was used to analyze repeated measures within individuals. RESULTS: On average, there was no statistically significant change in condom use over time. The odds of having a single main partner increased by 4% for each 6 months spent in the study (odds ratio: 1.04%, 95% confidence interval: 1.02-1.05). Stratifying females by longitudinal relationship patterns resulted in three distinct condom use trajectories. CONCLUSION: Data suggest that longitudinal changes in condom use are a function of developmental changes in relationships, whereby young women trend toward monogamous relationships. As condoms are abandoned within these monogamous relationships, lowering infection rates in sex partners through broader sexually transmitted infections screening or through community-level interventions aimed at sex networks might prove to be a more effective approach to reduce sexually transmitted infections risk in young women.

Costs of infertility treatment: results from an 18-month prospective cohort study.

OBJECTIVE: To examine resource use (costs) by women presenting for infertility evaluation and treatment over 18 months, regardless of treatment pursued. DESIGN: Prospective cohort study in which women were followed for 18 months. SETTING: Eight infertility practices. PATIENT(S): Three hundred ninety-eight women recruited from infertility practices. INTERVENTION(S): Women completed interviews and questionnaires at baseline and after 4, 10, and 18 months of follow-up. Medical records were abstracted after 18 months to obtain details of services used. MAIN OUTCOME MEASURE(S): Per-person and per-successful-outcome costs. RESULT(S): Treatment groups were defined as highest intensity treatment use. Twenty percent of women did not pursue cycle-based treatment; approximately half pursued IVF. Median per-person costs ranged from $1,182 for medications only to $24,373 and $38,015 for IVF and IVF-donor egg groups, respectively. Estimates of costs of successful outcomes (delivery or ongoing pregnancy by 18 months) were higher--$61,377 for IVF, for example--reflecting treatment success rates. Within the time frame of the study, costs were not significantly different for women whose outcomes were successful and women whose outcomes were not. CONCLUSION(S): Although individual patient costs vary, these cost estimates developed from actual patient treatment experiences may provide patients with realistic estimates to consider when initiating infertility treatment.

Fertility treatments and outcomes among couples seeking fertility care: data from a prospective fertility cohort in the United States.

OBJECTIVE: To determine the relationship between number of fertility treatment cycles and pregnancy rates. DESIGN: Prospective cohort study. SETTING: Eight community and academic infertility practices. PATIENT(S): Four hundred eight (408) couples presenting for an infertility evaluation. INTERVENTION(S): Face-to-face and telephone interviews and questionnaires. MAIN OUTCOME MEASURE(S): Incidence of pregnancy. Cox regression analysis compared the efficacy of cycle-based fertility treatments with no cycle-based fertility treatment after multivariable adjustment. RESULT(S): Couples using one to two medications-only cycles had a significantly higher pregnancy rate (hazard ratio [HR] 4.7 [95% confidence interval 1.3-16.6]), a benefit that did not persist after three or more cycles (HR 0.6 [0.1-3.2]). Couples using IUI for one (HR 2.9 [1.4-5.8]), two (HR 2.0 [0.9-4.5]), and three cycles (HR 4.5 [1.8-10.9]) were more likely to achieve a pregnancy. No additional benefit was seen for couples using four or more IUI cycles (HR 1.0 [0.4-2.6]). In vitro fertilization was associated with significant benefit for couples using one (HR 2.8 [1.5-5.2]) and two cycles (HR 2.2 [1.2-4.1]). Couples using three or more IVF cycles had a non-statistically significant higher likelihood of pregnancy (HR 1.3 [0.7-2.4]). CONCLUSION(S): Cycle-based fertility treatments may offer a point of diminishing returns for infertile couples: two cycles of medications only, three cycles of IUI, and two cycles of IVF.

Predictors of not pursuing infertility treatment after an infertility diagnosis: examination of a prospective U.S. cohort.

We studied a prospective cohort of 434 couples in Northern California and found that 13% did not pursue any form of infertility treatment after their initial consultation. Although age, education, and financial concerns remain important for patients in choosing whether to pursue infertility treatment, depressive symptoms may also be a barrier to achieving reproductive goals.

The use of complementary and alternative fertility treatment in couples seeking fertility care: data from a prospective cohort in the United States.

OBJECTIVE: To determine the prevalence of complementary and alternative medicine (CAM) use among couples seeking fertility care and to identify the predictors of CAM use in this population. DESIGN: Prospective cohort study. SETTING: Eight community and academic infertility practices. PATIENT(S): A total of 428 couples presenting for an infertility evaluation. INTERVENTION(S): Interviews and questionnaires. MAIN OUTCOME MEASURE(S): Prevalence of complementary and alternative medicine therapy. RESULT(S): After 18 months of observation, 29% of the couples had utilized a CAM modality for treatment of infertility; 22% had tried acupuncture, 17% herbal therapy, 5% a form of body work, and 1% meditation. An annual household income of > or = $200,000 (odds ratio 2.8, relative to couples earning <$100,000), not achieving a pregnancy (odds ratio 2.3), and a positive attitude toward CAM use at baseline were independently associated with CAM use. CONCLUSION(S): A substantial minority of infertile couples use CAM treatments. CAM was chosen most commonly by wealthier couples, those not achieving a pregnancy, and those with a baseline belief in the effectiveness of CAM treatments.

Adolescents' perceived risk of dying.

PURPOSE: Although adolescents' expectations are accurate or moderately optimistic for many significant life events, they greatly overestimate their chances of dying soon. We examine here whether adolescents' mortality judgments are correlated with their perceptions of direct threats to their survival. Such sensitivity would indicate the importance of ensuring that adolescents have accurate information about those threats, as well as the psychological support needed to deal with them. METHODS: Data from two separate studies were used: a national sample of 3,436 14-18-year-old adolescents and a regional sample of 124 seventh graders and 132 ninth graders, 12-16 years old. Participants were asked about their chance of dying in the next year and before age 20, and about the extent of various threats to their physical well-being. RESULTS: Adolescents in both samples greatly overestimated their chance of dying. Those mortality estimates were higher for adolescents who reported direct threats (e.g., an unsafe neighborhood). Thus, adolescents were sensitive to the relative size of threats to their survival, but not to the implications for absolute risk levels. CONCLUSIONS: Contrary to the folk wisdom that adolescents have a unique sense of invulnerability, the individuals studied here reported an exaggerated sense of mortality, which was highest among those reporting greater threats in their lives. Such fears could affect adolescents' short-term well-being and future planning.

Perceived negative consequences of donor gametes from male and female members of infertile couples.

OBJECTIVE: To determine the views toward donor sperm and eggs of both men and women. The use of donor sperm or ova becomes an option for some infertile couples. DESIGN: Prospective cohort of infertile couples. SETTING: Eight California reproductive endocrinology practices. PATIENT(S): Infertile couples (n=377) were recruited after an initial infertility clinic visit. MAIN OUTCOME MEASURE(S): From questionnaires administered at recruitment, ratings concerning the impact of the use of donor gametes were assessed. Differences between men and women in attitudes toward donor gametes were compared with analysis of variance (ANOVA). Linear regression was used to identify independent predictors of attitudes toward gametes. RESULT(S): Women's attitudes toward donor sperm were significantly more negative than their attitudes toward donor eggs (5.1+/-1.4 vs. 4.7+/-1.6). Similarly, male donor gamete attitude scores were higher for donor sperm compared with donor eggs (4.9+/-1.6 vs. 4.1+/-1.6). Both men and women agreed that the use of donor sperm was more likely to have negative effects on their relationship and negative societal ramifications. Female donor gamete attitude scores were predicted by marital status, race, and education, whereas men's scores were independent of all measured factors. CONCLUSION(S): Both men and women view the use of donor sperm with more skepticism compared with the use of donor eggs, suggesting a unique underlying perception regarding the use of male donor gametes.

Developing an acceptability assessment of preventive dental treatments.

OBJECTIVES: Early childhood caries (ECC) is very prevalent among young Hispanic children. ECC is amenable to a variety of preventive procedures, yet many Hispanic families underutilize dental services. Acceptability research may assist in health care planning and resource allocation by identifying patient preferences among efficacious treatments with the goal of improving their utilization. The purposes of this study were (a) to develop a culturally competent acceptability assessment instrument, directed toward the caregivers of young Hispanic children, for five preventive dental treatments for ECC and (b) to test the instrument's reliability and validity. METHODS: An instrument of five standard treatments known to prevent ECC was developed, translated, reviewed by focus groups, and pilot tested, then tested for reliability The instrument included illustrated cards, brief video clips, and samples of the treatments and was culturally appropriate for low-income Hispanic caregivers. In addition to determining the acceptability of the five treatments individually, the treatments were also presented as paired comparisons. RESULTS: Focus groups and debriefing interviews following the pilot tests established that the instrument has good face validity. The illustrated cards, product samples, and video demonstrations of the five treatments resulted in an instrument possessing good content validity. The instrument has good to excellent test-retest reliability, with identical time 1-time 2 responses for each of the five treatments 92 percent of the time (range 87 to 97 percent), and the same treatment of the paired comparisons preferred 75 percent of the time (range 61 to 90 percent). CONCLUSIONS: The acceptability instrument described is reliable and valid and may be useful in program planning efforts to identify and increase the utilization of preferred ECC preventive treatments for target populations.

The measurement of childbearing motivation in couples considering the use of assisted reproductive technology.

Relatively little is known about the motivational antecedents to the use of assisted reproductive technology (ART). In this paper we measure the fertility motivations of infertile couples who are considering the use of ART, using an established instrument, the Childbearing Questionnaire (CBQ). Our sample consists of 214 men and 216 women who were interviewed at home after an initial screening for ART but before making a final decision. We conducted two sets of analyses with the obtained data. In one set, we compared the scores on scales and subscales of the CBQ for the males and females in our sample with the scores for males and females from a comparable normative sample. For these analyses we first examined sample and gender differences with a four-group analysis of variance. We then conducted a series of linear models that included background characteristics as covariates and interactions between sample, gender, and age and between those three variables and the background characteristics. The results showed the expected higher positive and lower negative motivations in the ART sample and a significant effect on positive motivations of the interaction between sample and age. In the second set of analyses, we developed several new subscales relevant to facets of the desire for a child that appear to be important in ART decision-making. These facets include the desire to be genetically related to the child and the desire to experience pregnancy and childbirth. A third facet, the desire for parenthood, is already well covered by the existing subscales. The results showed the new subscales to have satisfactory reliability and validity. The results also showed that the original and new subscales predicted the three facets of the desire for a child in a multivariate context. We conclude with a general discussion of the way our findings relate both to ART decision-making and to further research on the motivations that drive it.

Greater expectations: adolescents' positive motivations for sex.

CONTEXT: Effective STD and pregnancy prevention efforts should benefit from knowledge of what motivates adolescents to have sex. Positive motivations, and how they differ by gender and sexual experience, are poorly understood. METHODS: A sample of 637 ninth graders were asked about their relationship goals, expectations of the degree to which sex would satisfy these goals and sexual experience. Three scales measured adolescents' goals for intimacy, sexual pleasure and social status within a romantic relationship. Another three scales measured expectations that sex would lead to these goals. Data were examined in analyses of variance and mixed models. RESULTS: Participants valued intimacy the most, then social status and, finally, sexual pleasure. These relationship goals differed significantly by gender and sexual experience. Females valued intimacy significantly more and sexual pleasure less than males. Sexually experienced adolescents valued both intimacy and pleasure more than sexually inexperienced adolescents. Among females, but not males, sexually experienced adolescents valued the goal of social status less than those with no sexual experience did. Adolescents expected that sex would most likely lead to sexual pleasure, then intimacy and, finally, social status. Females and sexually inexperienced adolescents reported lower expectations that sex would meet goals than did males and sexually experienced participants. CONCLUSIONS: Adolescents view intimacy, sexual pleasure and social status as important goals in a relationship. Many have strong positive expectations that sex would satisfy these goals. Prevention programs and providers should address the risks of sex in the context of expected benefits.

Service utilization and the life cycle of youth homelessness.

The study sought to describe service utilization patterns of homeless youth based on their life cycle stage. Ninety-nine percent of participants accessed services. Medical service utilization was highest among youth who were attempting to leave the street. Drug-related service utilization was lowest among youth most entrenched in street life.

Gender-based differences in fertility beliefs and knowledge among adolescents from high sexually transmitted disease-prevalence communities.

PURPOSE: Limited information is available about adolescents' beliefs about fertility in women and its link to sexually transmitted disease (STD) and whether men and women differ in their beliefs. This information may be useful for developing messages intended to motivate youth to seek STD screening while they are asymptomatic. The purpose of this study was to examine gender-based differences in fertility beliefs and knowledge. METHODS: Data were derived from the Adolescent Health Study, a population-based telephone survey study in which urban household adolescents from a high STD-prevalence community were queried about their sexual experience, fertility-related knowledge, beliefs related to timing of childbearing, and risk assessment of future fertility problems. Chi2 and regression analyses were used to evaluate group differences. RESULTS: The majority of adolescents reported that having children was somewhat or very important, but that the 15- to 19-year-old age group was not the optimal time for a woman to have a child. Regression analyses indicated that female adolescents were more likely than male adolescents to identify chlamydia and pelvic inflammatory disease as causes of fertility problems. Seventy-two percent of adolescent girls thought there was some chance they would have future fertility problems and 58% thought they had little or no control over developing fertility problems in the future. CONCLUSION: Additional health education is needed if we are to motivate adolescents to participate in asymptomatic STD screening programs. Involving male adolescents may be a more significant challenge given that fewer male adolescents understand the link between female fertility and common STD-related conditions. Given our findings, fertility preservation may be a valuable teaching tool and social marketing agent for STD prevention in adolescents.

Does parental involvement predict new sexually transmitted diseases in female adolescents?

BACKGROUND: African American female adolescents living in low-income urban areas are at increased risk for sexually transmitted diseases. OBJECTIVE: To determine if high levels of perceived parental supervision and communication were associated with reduced gonorrhea (GC) and chlamydia (CT) incidence in low-income, African American, sexually experienced female adolescents, aged 14 to 19 years, attending urban health clinics. DESIGN: A prospective cohort study was used to determine the predictive value for high levels of parental supervision and communication on GC and CT infection in 158 adolescent females. Multiple logistic regression analysis explored the association between incident infection and perceived parental supervision and perceived parental communication while controlling for relevant demographic and behavioral factors (age, religious involvement, school enrollment, a 2-parent household, having a main sex partner, and having concurrent sex partners). RESULTS: When adjusted for age and baseline GC and CT infection, high levels of perceived parental supervision were associated with reduced GC and CT incidence (adjusted odds ratio, 0.06; 95% confidence interval, 0.01-0.31). High levels of perceived parental communication were not associated with reduced GC and CT incidence (adjusted odds ratio, 0.55; 95% confidence interval, 0.21-1.42). CONCLUSIONS: The link between parental supervision and disease acquisition is particularly valuable because it provides evidence that parental supervision can result in lower sexually transmitted disease rates in urban high-prevalence populations. This is important for interventions designed to increase parental involvement as a strategy for promoting protective sexual behaviors in female adolescents because it indicates that increased parental involvement can also influence subsequent disease acquisition.

Young adults' attitudes, beliefs, and feelings about testing for curable STDs outside of clinic settings.

The purpose of this paper was to elicit attitudes, beliefs, and feelings about testing for curable STDs outside of clinic settings. Telephone interviews were conducted with 120 black, Latino, and white young adults aged 18 to 25 years. Data were analyzed with descriptive frequencies and content analyses. Most (73%) reported people their age would use self-test urine STD kits if available. Perceived advantages were privacy and convenience. Disadvantages included not having an immediate "face-to-face" discussion with a medical professional about positive tests. Young adults report a range of attitudes, beliefs, and feelings that may influence the success of efforts to screen for curable STDs in nonclinic settings.

Perceived risk of chlamydial and gonococcal infection among sexually experienced young adults in the United States.

CONTEXT: Understanding young adults' perceived risk of chlamydial and gonococcal infection can inform interventions to reduce the prevalence of these sexually transmitted diseases. METHODS: Bivariate and multivariate analyses, using data from Wave 3 of the National Longitudinal Study of Adolescent Health (2001-2002), were conducted to examine relationships between perceived risk and selected characteristics in two groups: a nationally representative sample of sexually experienced 18-26-year-olds and a subsample of those who tested positive for chlamydia or gonorrhea. The relationship between current infection and perceived risk was also evaluated. RESULTS: Only 14% of all respondents and 33% of infected participants reported some perceived risk of chlamydial or gonococcal infection. In the overall sample, the odds of perceiving risk were significantly elevated among blacks, Hispanics, unmarried respondents, inconsistent condom users and nonusers, respondents who reported multiple partners in the past year, those who had received a diagnosis of chlamydia or gonorrhea in the past year, and those reporting current symptoms (odds ratios, 1.5-3.3). Currently infected participants were significantly more likely than those who were not infected to perceive some risk of infection (2.4). Among infected respondents, the factors positively associated with perceived risk were being black or Hispanic, using condoms inconsistently or not using them, having exchanged money for sex, having been tested in the past year but with no diagnosis, having received a diagnosis, and reporting current symptoms (2.5-5.2). CONCLUSIONS: Interventions to increase the accuracy of young adults' risk perceptions may influence sexual and health care-seeking behaviors in a way that will reduce rates of chlamydia and gonorrhea.