Karin Hammarberg

Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: a systematic review

BACKGROUND It is known that infertility affects emotional well-being, satisfaction with life and self-esteem and that failed assisted reproductive technology (ART) treatment is associated with diminished life satisfaction, reduced self-confidence and substantial psychological distress. Investigations of whether these persist when treatment results in a pregnancy and live birth have been undertaken. METHODS A systematic search for English-language research articles on psychological and social aspects of pregnancy, childbirth and the first post-partum year after ART conception. RESULTS Of 466 retrieved papers, 46 met inclusion criteria. These reported data from 28 studies. There is consistent evidence that marital satisfaction, emotional well-being and self-regard in pregnancy, attachment to the fetus and parent-infant relationship in ART groups are similar to comparison groups. Anxiety about the survival of the fetus and early parenting difficulties appear to be higher and post-natal self-confidence lower. Evidence about adjustment to pregnancy and parenthood and the experience of childbirth is inconclusive and reports of parental perceptions of infant temperament and behaviour are contradictory. Between-study methodological differences may explain the lack of consistency in findings of the influence of infertility and ART on some aspects of the transition to parenthood. CONCLUSIONS Overall, this body of evidence is best described as emergent. It is possible that in pregnancy after ART, parenthood might be idealized and this might then hinder adjustment and the development of a confident parental identity.

Psychological and social aspects of infertility in men: an overview of the evidence and implications for psychologically informed clinical care and future research.

Research concerning the psychosocial aspects of infertility and infertility treatment focuses more often on women than men. The aim of this review was to synthesize the English-language evidence related to the psychological and social aspects of infertility in men and discuss the implications of these reports for clinical care and future research. A structured search identified 73 studies that reported data concerning the desire for fatherhood and the psychological and social aspects of diagnosis, assisted reproductive technology (ART) treatment and unsuccessful treatment among men with fertility difficulties. The studies are diverse in conceptualisation, design, setting and data collection, but the findings were reasonably consistent. These studies indicated that fertile and infertile childless men of reproductive age have desires to experience parenthood that are similar to those of their female counterparts; in addition, diagnosis and initiation of treatment are associated with elevated infertility-specific anxiety, and unsuccessful treatment can lead to a state of lasting sadness. However, rates of clinically significant mental health problems among this patient population are no higher than in the general population. Infertile men who are socially isolated, have an avoidant coping style and appraise stressful events as overwhelming, are more vulnerable to severe anxiety than men without these characteristics. Men prefer oral to written treatment information and prefer to receive emotional support from infertility clinicians rather than from mental health professionals, self-help support groups or friends. Nevertheless, structured, facilitated psycho-educational groups that are didactic but permit informal sharing of experiences might be beneficial. There are gaps in knowledge about factors governing seeking, persisting with and deciding to cease treatment; experiences of invasive procedures; parenting after assisted conception; adoption and infertility-related grief and shame among men. Few resource-constrained countries have any data concerning male experiences of infertility.

Knowledge about factors that influence fertility among Australians of reproductive age: a population-based survey.

OBJECTIVE To explore knowledge about the effects on fertility of age, obesity, smoking, and timing of intercourse among Australians of reproductive age. DESIGN Telephone survey of a representative sample of Australians. SETTING Not applicable. PATIENT(S) Australians aged 18 to 45 years who wish to have a child or another child now or in the future. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Knowledge about the effect on fertility of age, obesity, smoking, and timing of intercourse. RESULT(S) A total of 462 interviews were conducted. The majority of respondents underestimated, by about 10 years, the age at which male and female fertility starts to decline. Only one in four correctly identified that female fertility starts to decline before age 35, and one in three identified that male fertility starts to decline before age 45. Most (59%) were aware that female obesity and smoking affect fertility, but fewer recognized that male obesity (30%) and smoking (36%) also influence fertility. Almost 40% of respondents had inadequate knowledge of when in the menstrual cycle a woman is most likely to conceive. CONCLUSION(S) Considerable knowledge gaps about modifiable factors that affect fertility were identified. These are targeted in a national education campaign to promote awareness of factors that influence fertility.

Age at first birth, mode of conception and psychological wellbeing in pregnancy: findings from the parental age and transition to parenthood Australia (PATPA) study

BACKGROUND It is increasingly common for women in high-income countries to delay childbearing. We aimed to describe the context of pregnancy for first-time mothers of different ages and examine relationships among maternal age at first birth, mode of conception and psychosocial wellbeing in pregnancy. METHODS Using stratified sampling, we recruited similar numbers of women conceiving through assisted reproductive technology (ART; n = 297) or spontaneously (n = 295) across three age groups: younger, ≤ 20-30 years; middle, 31-36 years; older, ≥ 37 years. Women participated in a structured interview and completed validated questionnaires assessing socio-economic status, personality, quality of partner relationship, state and trait anxiety, pregnancy-focused (P-F) anxiety and maternal-fetal attachment. RESULTS Older maternal age was associated with lower depression and anxiety symptoms, lower maternal-fetal attachment (P< 0.05), greater psychological hardiness (resilience) (P< 0.001) and lower ratings of control in the partner relationship (P< 0.05) at a univariate level. ART conception, but not older maternal age, was associated with more P-F anxiety. Although most main effects of age and mode of conception became non-significant after controlling for contextual/reproductive history variables, a significant association between ART conception and more intense fetal attachment emerged (P< 0.05). CONCLUSIONS Women having their first baby when older appear to have some psychological advantages over their younger counterparts; they are more resilient, report their partners as less controlling and report lower symptoms of depression and anxiety during pregnancy. However, women conceiving through ART have a more complex experience of pregnancy, simultaneously experiencing more P-F anxiety and more intense emotional attachment to the fetus.

LONG-TERM HEALTH, WELL-BEING, LIFE SATISFACTION, AND ATTITUDES TOWARD PARENTHOOD IN MEN DIAGNOSED AS INFERTILE: CHALLENGES TO GENDER STEREOTYPES AND IMPLICATIONS FOR PRACTICE

OBJECTIVE To investigate attitudes toward parenthood, long-term life satisfaction, and health and well-being in men diagnosed as infertile. DESIGN A cross-sectional survey of a cohort of men 5 years after diagnosis of infertility. SETTING The andrology clinic at the Royal Womens Hospital Reproductive Services, Melbourne Australia. PATIENT(S) All men diagnosed at this center as infertile in 2001 and 2002. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Attitudes to parenthood (Meaning of Parenthood), quality of intimate relationship (Intimate Bonds Measure), personality characteristics (Vulnerable Personality Style Questionnaire), life satisfaction (Satisfaction with Life Scale), and self-rated physical health (Physical Component Summary of SF-12 [PCS-12]) and relationship with mental health (Mental Component Summary of SF12 [MCS-12]). RESULT(S) A total of 112 (41%) of 276 men completed the survey. Of these, 96% had pursued infertility treatment and 87% had become fathers. Only 10% thought that fertility confirmed by fatherhood reflected masculinity, and 84% desired parenthood as much as their partners did. When all other factors were controlled for, men who had not become fathers had poorer mental health (MCS-12 score = 43.9 +/- 9.9) than those who were fathers (MCS-12 score = 49.25 +/- 8.7). CONCLUSION(S) Clinical practice should not presume that infertile men conflate fertility and masculinity, are less distressed than women about the potential loss of parenthood, or adjust more readily to childlessness, which appear to be inaccurate but widespread stereotypes.

Looking downstream: a review of the literature on physical and psychosocial health outcomes in adolescents and young adults who were conceived by ART

BACKGROUND The use of assisted reproductive technology (ART) is now well established in many countries and the first generations of offspring are reaching maturity. We reviewed the published literature to describe the available evidence about health outcomes in ART-conceived young people who were of an adolescent age or older. METHODS The EMBASE, Medline and PsychINFO databases were searched from January 1998 to October 2010. Key inclusion criteria were that the study sample have a mean age of ≥ 12 years or a mean follow-up period of ≥ 12 years and were conceived by ART. RESULTS Seven publications reported physical health outcomes and 10 reported psychosocial health outcomes in ART offspring. Compared with control groups, some differences in physiological outcomes in relation to growth and development, chronic illness and risk of cancer have been reported. Overall, psychosocial studies of ART-conceived young people indicate that their cognitive function and psychological and social adjustment are similar to that of comparison groups. CONCLUSIONS Overall, nine ART-conceived populations of this age group have been studied. Most samples included < 300 participants and methodologies varied between studies. Health information on this age group is therefore limited and the clinical significance of the findings remains unclear. Further research focusing on ART-conceived young adults is needed, particularly in relation to neurological health outcomes where no studies have been reported to date.

Men's experiences of infertility and infertility treatment 5 years after diagnosis of male factor infertility: a retrospective cohort study

BACKGROUND The aim of this study was to describe the perceptions of infertile men regarding the impact of infertility on their intimate relationships, their experience of treatment and their sources of information and support. METHODS A cross-sectional survey of a consecutive cohort of men diagnosed 5 years earlier as infertile at Melbourne IVF and the Royal Womens Hospital Reproductive Services, Melbourne was conducted. Study-specific questions assessed the impact of male factor infertility on the intimate relationships, their perceived quality of infertility-related health care and their preferred sources of infertility-related information and personal support and the effectiveness of these. RESULTS The response rate was 41% (112/276). Male factor infertility was reported to have had a negative impact on the intimate partner relationship by 25% of men, and 32% reported a negative effect on their sexual satisfaction. Satisfaction with medical care and clinic information was high and not influenced by the outcome of the treatment. Clinic-provided information and discussion with clinic staff were the most strongly preferred sources of information, and the partner and clinic staff were the most valued sources of personal support. Very few men found support groups useful and less than half confided in friends. CONCLUSIONS The findings suggest that for a significant subgroup of men, male factor infertility affects their intimate relationship negatively. Wider sources of social support are not used by infertile men as they rely predominantly on clinic-provided information and support. This indicates that psychologically informed supportive clinical care is particularly important for men diagnosed as infertile.

Gamete donors’ and recipients’ evaluation of donor counselling: A prospective longitudinal cohort study

Background: Those considering donating or receiving gametes are required to undergo counselling to ensure that they are aware of and consider the psychosocial, emotional and ethical complexities of donor conception before proceeding.

Older first-time mothers and early postpartum depression : a prospective cohort study of women conceiving spontaneously or with assisted reproductive technologies

OBJECTIVE To evaluate whether older first-time mothers (≥37 years) have higher rates of postpartum depression compared with younger first-time mothers, controlling for mode of conception and known risk factors for postpartum depression. DESIGN Prospective cohort study. SETTING Assisted reproductive technology (ART) clinics in two large Australian cities and public and private antenatal clinics and/or classes in the vicinity of ART clinics. PATIENT(S) Nulliparous women who had conceived spontaneously (n = 295) or through ART (n = 297) in three age-groups: younger, 20 to 30 years (n = 173); middle, 31 to 36 years (n = 214); and older, ≥37 years (n = 189). INTERVENTION(S) Semistructured interviews and questionnaires. MAIN OUTCOME MEASURE(S) Major depressive disorder in the first 4 months after birth as assessed by structured diagnostic interview. RESULT(S) The study performed 592 complete pregnancy assessments and 541 postpartum assessments. The prevalence of major depressive disorder was 7.9%, at the lower end of community rates. Neither maternal age-group nor mode of conception was statistically significantly related to depression. CONCLUSION(S) Older first-time mothers, whether conceiving through ART or spontaneously, do not show increased vulnerability to postnatal depression.

Pregnancy-specific anxiety, ART conception and infant temperament at 4 months post-partum

STUDY QUESTION Is anxiety focused on the pregnancy outcome, known to be particularly salient in women conceiving through assisted reproductive technology (ART), related to difficult infant temperament? SUMMARY ANSWER While trait anxiety predicts infant temperament, pregnancy-focused anxiety is not associated with more difficult infant temperament. WHAT IS KNOWN ALREADY A large body of research has provided convincing evidence that fetal exposure to maternal anxiety and stress in pregnancy has adverse consequences for child neurodevelopmental, behavioural and cognitive development, and that pregnancy-specific anxiety (concerns related to the pregnancy outcome and birth) may be of particular significance. Women conceiving through ART are of particular interest in this regard. Research over more than 20 years has consistently demonstrated that while they do not differ from spontaneously conceiving (SC) women with respect to general (state and trait) anxiety, they typically report higher pregnancy-specific anxiety. While research suggests normal behavioural and developmental outcomes for children conceived through ART, there is some evidence of more unsettled infant behaviour during the first post-natal year. STUDY DESIGN, SIZE, DURATION The longitudinal cohort design followed 562 nulliparous women over a 7-month period, during the third trimester of pregnancy and at 4 months after birth. PARTICIPANTS/MATERIALS, SETTING, METHODS Approximately equal numbers of nulliparous women conceiving through ART (n = 250) and spontaneously (SC: n = 262) were recruited through ART clinics and nearby hospitals in Melbourne and Sydney, Australia. Participants completed three anxiety measures (state, trait, pregnancy specific) at time 1 in the third trimester of pregnancy and a measure of infant temperament at time 2, 4 months after birth. At time 1, relevant socio-demographic, pregnancy (maternal age, smoking, alcohol, medications, medical complications) information was recorded and at time 2, information regarding childbirth (gestation, infant birthweight, mode of delivery) and post-natal (concurrent mood) variables was recorded and controlled for in analyses. MAIN RESULTS AND THE ROLE OF CHANCE In the third trimester of pregnancy, women conceiving through ART reported lower state and trait anxiety, but higher pregnancy-focused anxiety than their SC counterparts (all Ps < 0.05). Hierarchical regression analyses including mode of conception, all anxiety variables and relevant covariates indicated that while trait anxiety in pregnancy predicted more difficult infant temperament (P < 0.001), pregnancy specific and state anxiety did not. Mode of conception predicted infant temperament; with ART women reporting less difficult infant temperament (P < 0.001) than their SC counterparts. LIMITATIONS, REASONS FOR CAUTION The major limitations in the study are the reliance on a self-report measure of infant temperament and the fact that the study did not assess quality of caregiving which may moderate the effect of pregnancy anxiety on infant temperament. WIDER IMPLICATIONS OF THE FINDINGS This study is the first to our knowledge to prospectively examine the impact of gestational stress (pregnancy anxiety) on infant temperament in women conceiving through ART. Findings confirm existing research indicating that trait anxiety in pregnancy is associated with difficult infant temperament and suggest that pregnancy-specific anxiety (measured in the third trimester) is not implicated. These findings are reassuring for women conceiving through ART whose pregnancies may be characterized by particularly intense concerns about the wellbeing of a long sought after baby. STUDY FUNDING/COMPETING INTEREST(S) The study was funded by a grant from the Australian Research Council (ARC) and in kind and financial contributions from IVF Australia and Melbourne. TRIAL REGISTRATION NUMBER N/A.