Alice D. Domar

The prevalence and predictability of depression in infertile women.

OBJECTIVE To determine the prevalence, severity, and predictability of depression in infertile women compared with a control sample of healthy women. DESIGN Subjects were assessed while waiting to see their physician: infertility patients before a visit with an infertility specialist and control subjects before seeing either a gynecologist or internist for a routine gynecological examination. Subjects completed a demographic form and two depression scales. SETTING A group infertility practice affiliated with an academic medical center, a hospital-based gynecology practice, and a health maintenance organization internal medicine clinic. PARTICIPANTS 338 infertile women and 39 healthy women. INTERVENTIONS None. MAIN OUTCOME MEASURES The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale. RESULTS The infertile women had significantly higher depression scores and twice the prevalence of depression than the controls; women with a 2- to 3-year history of infertility had significantly higher depression scores compared with women with infertility durations of < 1 year or > 6 years; women with an identified causative factor for their infertility had significantly higher depression scores than women with unexplained or undiagnosed infertility. CONCLUSIONS Depressive symptoms are common in infertile women. Psychological interventions aimed at reducing depressive symptoms need to be implemented, especially for women with a definitive diagnosis and for those with durations of 2 to 3 years of infertility.

The Mind/Body Program for Infertility: a new behavioral treatment approach for women with infertility

There is increasing evidence that a behavioral treatment approach might be efficacious in the treatment of the emotional aspects of infertility and may lead to increased conception rates. The first 54 women to complete a behavioral treatment program based on the elicitation of the relaxation response showed statistically significant decreases in anxiety, depression, and fatigue as well as increases in vigor. In addition, 34% of these women became pregnant within 6 months of completing the program. These findings established a role for stress reduction in the long-term treatment of infertility. They further suggest that behavioral treatment should be considered for couples with infertility before or in conjunction with reproductive technologies such as intrauterine insemination and gamete intrafallopian transfer.

The effects of relaxation response training on menopausal symptoms

The specific aim of this study was to investigate the efficacy of elicitation of the relaxation response for the treatment of menopausal hot flashes and concurrent psychological symptoms. The volunteer sample consisted of 33 women, between the ages of 44 and 66 years, who were in general good health, with a minimum of 6 months without a menstrual period, experiencing at least five hot flashes per 24-h, and not using hormone replacement therapy. The setting was an outpatient clinic in a tertiary care teaching hospital. The interventions used were relaxation response training and an attention-control group and a daily symptom diary measuring both the frequency and intensity of hot flashes, the Spielberger State-Trait Anxiety Inventory (STAI), and the Profile of Mood Scale (POMS) were the measures used. This was a randomized, controlled, prospective study. Subjects were randomly assigned to one of three groups (relaxation response, reading, or control) for the 10-week study. The first 3 weeks of baseline measurement of frequency and intensity of hot flash symptoms, and the preintervention psychological scores were compared with the final 3 weeks measurement of frequency and intensity and the postintervention psychological scores for symptomatic improvement. The relaxation response group demonstrated significant reductions in hot flash intensity (p < 0.05), tension-anxiety (p < 0.05) and depression (p < 0.05). The reading group demonstrated significant reductions in trait-anxiety (p < 0.05) and confusion-bewilderment (p < 0.05). There were no significant changes for the control group. Daily elicitation of the relaxation response leads to significant reductions in hot flash intensity and the concurrent psychological symptoms of tension-anxiety and depression.

The Impact of Group Psychological Interventions on Distress in Infertile Women

Infertile women express higher levels of distress than fertile women, with distress peaking between the 2nd and 3rd year. The purpose of this study was to determine whether group psychological interventions could prevent this surge. One hundred eighty-four women who had been trying to conceive between 1 and 2 years were randomized into either a cognitive-behavioral group, a support group, or a control group. All experimental participants attended a 10-session group program. Participants completed psychological questionnaires at intake and again at 6 and 12 months. Substantial attrition occurred, particularly in the control group. The cognitive-behavioral and support participants experienced significant psychological improvement at 6 and 12 months compared with the control participants, with the cognitive-behavioral participants experiencing the greatest positive change.

The impact of acupuncture on in vitro fertilization outcome.

OBJECTIVE To replicate previous research on the efficacy of acupuncture in increasing pregnancy rates (PR) in patients undergoing IVF and to determine whether such an increase was due to a placebo effect. DESIGN Prospective, randomized, controlled, single blind trial. SETTING Private, academically affiliated, infertility clinic. PATIENT(S) One hundred fifty patients scheduled to undergo embryo transfer. INTERVENTION(S) Subjects were randomized to either the acupuncture or control group. Acupuncture patients received the protocol, as first described by Paulus and his colleagues, for 25 minutes before and after embryo transfer. Control subjects laid quietly. All subjects then completed questionnaires on anxiety and optimism. The IVF staff remained blind to subject assignment. MAIN OUTCOME MEASURE(S) Clinical PRs, anxiety, optimism. RESULT(S) Before randomization both groups had similar demographic characteristics including age and psychological variables. There were no significant differences in PRs between the two groups. Acupuncture patients reported significantly less anxiety post-transfer and reported feeling more optimistic about their cycle and enjoyed their sessions more than the control subjects. CONCLUSION(S) The use of acupuncture in patients undergoing IVF was not associated with an increase in PRs but they were more relaxed and more optimistic.

Tackling burden in ART: an integrated approach for medical staff

Discontinuation is a problem in fertility clinics. Many couples discontinue assisted reproductive technologies (ART) without achieving a live birth for reasons other than poor prognosis or the cost of treatment. Discontinuation has been attributed to the burden of treatment. The causes of burden can be broadly classified according to whether they originate in the patient, clinic or treatment. Interventions to alleviate these burdens include provision of comprehensive educational material, screening to identify highly distressed patients, provision of tailored coping tools and improvements in the clinic environment and medical interventions. Practical interventions to reduce the different causes of burden in ART exist, but further development and evaluation of the efficacy of these interventions requires more precise definition of terms and theory. In this paper, we propose a general integrated approach to cover different perspectives in dealing with burden in ART clinics. We firstly describe the integrated approach and present common sources of burden. We then describe interventions that could help reduce the burden in ART. Our paper is aimed at fertility clinic staff because of their day-to-day involvement with patients. However, this discussion should also be relevant to companies that develop treatments and to psychosocial experts. Reducing the burden of treatment should lead to improved outcomes, namely better quality of life during treatment and lower discontinuation rates.

Psychological improvement in infertile women after behavioral treatment: a replication * †

OBJECTIVE To replicate previously reported psychological improvements in infertile women attending a group behavioral treatment program. DESIGN Psychological and demographic data were collected before entering and again upon completion of a behavioral medicine program on a second cohort of patients. SETTING The program was offered in the Division of Behavioral Medicine, an outpatient clinic of the Department of Medicine at New England Deaconess Hospital. All patients were receiving care from infertility specialists not affiliated with this hospital. PATIENTS Fifty two self-referred women receiving medical treatment for infertility attended the program. INTERVENTION A 10-week group behavioral treatment program. MAIN OUTCOME MEASURES Three validated psychological instruments. RESULTS Psychological improvement was statistically significant (Profile of Mood States Tension/Anxiety: P less than 0.0001; Depression/Dejection: P less than 0.0122; Vigor/Activity: P less than 0.0431; Confusion/Bewilderment: P less than 0.0057; Spielberger Anger Expression: P less than 0.0013; Spielberger State Anxiety: P less than 0.0037, and Trait Anxiety: P less than 0.0001). CONCLUSIONS Behavioral treatment is associated with significant decreases in negative psychological symptoms.

Impact of a group mind/body intervention on pregnancy rates in IVF patients

OBJECTIVE To determine if women who were randomized to a mind/body program before starting their first IVF cycle would have higher pregnancy rates than control subjects. DESIGN Randomized, controlled, prospective study. SETTING Private academically affiliated infertility center. PATIENT(S) A total of 143 women aged≤40 years who were about to begin their first IVF cycle. INTERVENTION(S) Subjects were randomized to a ten-session mind/body program (MB) or a control group and followed for two IVF cycles. MAIN OUTCOME MEASURE(S) Clinical pregnancy rate. RESULT(S) Only 9% of the MB participants had attended at least one-half of their sessions at cycle 1 start. Pregnancy rates for cycle 1 were 43% for all subjects; 76% of the MB subjects had attended at least one-half of their sessions at cycle 2 start. Pregnancy rates for cycle 2 were 52% for MB and 20% for control. CONCLUSION(S) MB participation was associated with increased pregnancy rates for cycle 2, prior to which most subjects had attended at least half of their sessions.

Preoperative Anxiety: Is It a Predictable Entity?

Most surgical and anesthesia personnel assume that certain factors lead to increased preoperative anxiety, yet the predictability of preoperative anxiety has not been extensively studied. We hypothesized that surgical and anesthesia personnel could be more effective in reducing preoperative anxiety if potential predictors of presurgical anxiety were identified. A sample of 523 patients awaiting elective surgery completed an anxiety scale, had their blood pressure and pulse measured, and had 14 different characteristics recorded. These characteristics included demographics, possibility of cancer, presence of support person, previous surgical experience, and extent of surgery. Female patients were more anxious than male patients, and individuals accompanied by a support person were more anxious than those not accompanied. However, all other factors were noncontributory to anxiety. It appears that patient anxiety does not reflect the assumptions of surgical and anesthesia personnel. This suggests that preoperative anxiety may reflect a patients personality and coping style more than medical data.

The efficacy of relaxation response interventions with adult patients: a review of the literature.

The relaxation response is an integrated psycho-physiologic response originating in the hypothalamus that leads to a generalized decrease in arousal of the central nervous system. As such it is the physiologic antithesis of the stress response. This hypometabolic state is the foundation of many nursing interventions. Relaxation interventions have been taught for centuries. They include many theoretic and philosophic traditions and an array of specific strategies. The possible outcomes using relaxation response strategies in nursing practice are numerous and enable the patient to use the bodys own innate mechanisms for health and healing. Thirty-seven studies of the efficacy of relaxation response interventions with adult patients are reviewed. Although numerous patient populations are addressed by the studies, some of which have methodologic problems, consistencies in the results suggest the effectiveness of the relaxation response in reducing hypertension, insomnia, anxiety, pain, and medication use across multiple populations, diagnostic categories, and settings. Recommendations for the use of relaxation responses in varied clinical settings are included.