NEW ORLEANS — The majority of women who are at risk for anxiety and depression following a failed in vitro fertilization cycle can be identified by a one-page screening questionnaire administered before treatment, Christianne M. Verhaak, Ph.D., reported at the annual meeting of the American Society for Reproductive Medicine.
“If you can identify who is at risk before the start of treatment, you can offer them tailored intervention in time to prevent future emotional problems,” said Dr. Verhaak, a clinical psychologist at Radboud University Nijmegen Medical Center in the Netherlands.
She suggested that simply informing patients about the emotional impact of unsuccessful treatment can help them prepare appropriately. “For most patients and their families, the emotional impact of infertility is unknown because it is still not easy for people to talk about,” she said in an interview. “But it is comparable to grief. With grief, people expect an emotional reaction, they understand that is not something that passes after 1 or 2 months—it's something that takes a lot of time and often involves a reconsideration of one's life.”
Her study, which was awarded the Mental Health Professional Group prize paper at the meeting, followed 400 women who were starting in vitro fertilization (IVF) cycles at eight different fertility clinics in the Netherlands. Psychological questionnaires were administered before treatment, after each IVF cycle, and 6 months after the last IVF cycle. The questionnaires included the short version Spielberger State Trait Anxiety Inventory (STAI) to assess state anxiety, the Beck Depression Inventory (BDI) to assess depression, the Illness cognition questionnaire to assess cognitions of helplessness and acceptance regarding infertility, and a social support inventory.
Six months after the end of all IVF treatment, 20% of the women who had failed to become pregnant showed clinically relevant levels of anxiety and 25% showed clinically relevant levels of depression, reported Dr. Verhaak. “What is important is that in these women no recovery had taken place since the end of treatment. A negative response to treatment failure is normal, but in grief studies, recovery is apparent by 6 months, and if it is absent this is considered abnormal.” She added that emotional problems that interfere with daily life are almost always associated with failed, rather than successful, IVF cycles.
“The emotional impact is mostly influenced by the stress of possible childlessness. So if the treatment succeeds, in most cases the stress diminishes considerably,” Dr. Verhaak said.
The study found five pretreatment risk factors that were associated with persistent emotional problems after treatment: anxiety, depression, cognitions of helplessness, reduced cognitions of acceptance, and lack of social support. Patients with at least one of these risk factors had a fourfold chance of developing posttreatment emotional problems compared with patients who had no risk factors, she said.
The researchers then developed a one-page screening tool to identify these risk factors before treatment and validated the tool in a separate group of 512 patients. They found the screening tool identified 74% of the overall cohort correctly as either at risk or not, with a sensitivity of 69% and a specificity of 79%. The sensitivity increased to 70% and the specificity to 87% in the subgroup of women who did not get pregnant.
Dr. Verhaak said the findings suggest that screening all patients is worthwhile before they start IVF; this would include both those with primary and those with secondary infertility. “The longing for a second child is the same as the longing for a first child, and the emotional impact of not getting pregnant is the same in both cases,” she said.