| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Randolph Child and Family Counseling Center, Charlotte, and the University of North Carolina at Greensboro, Greensboro, North Carolina.
Address reprint requests to: Nicholas A. Vacc, EdD, LPC The University of North Carolina at Greensboro 228 Curry Building, UNCG, PO Box 26171 Greensboro, NC 27402-6171 E-mail: navacc{at}uncg.edu
 |
Abstract |
|---|
Top
 Abstract MethodResultsDiscussionReferences |
|---|
Methods: Pretest and post-test data were obtained from 50 IVF and 50 ovulation-induction medication patients receiving treatment at two urban infertility centers.
Results: Both groups of women experienced measurable levels of grief and depression before, during, and after treatment. Higher scores on the Grief Experience Inventory were found for both groups of women when pregnancy did not occur. Age, reproductive problems, years infertile, financial impact, and number of past IVF cycles were not found to influence the reported grief or depression levels. Women in the IVF and ovulation-induction medication groups used isolation coping behaviors such as self-talk and sleep.
Conclusion: Because of moderate to high levels of grief and depression, therapeutic counseling may be more effective if initiated before the infertility treatment. Women’s present levels of distress and coping strategies should be assessed prior to initiating infertility treatment to provide the patients with opportunities to learn and practice new adaptive behaviors that could enhance their ability to cope with infertility and the associated medical procedures.
Women who have participated in an in vitro fertilization (IVF) program indicate that the treatment is one of the most stressful experiences of their lives.1 Also, they often grieve prior to IVF treatment and following a negative pregnancy report after IVF treatment, as if they had lost a child.2 These findings are further compounded by the high and nonreimbursable cost of IVF and the perception that IVF is a last attempt for infertility treatment. Yet, research that examines women’s psychological experiences during the infertility treatment process is limited. The current study was undertaken to address this void in the literature.
It was hypothesized that women who undergo IVF and ovulation-induction medication treatment without successfully achieving pregnancy would exhibit higher levels of grief and depression than that experienced prior to infertility treatment, and that women who fail to become pregnant following IVF treatment would experience more depression and grief than would women who completed a medication regimen as treatment. Therefore, the specific variables investigated were the coping mechanisms used most frequently by women who participate in IVF treatment or an ovulation-induction medication program, emotional reactions and spectrum of coping behaviors within the group of IVF participants, relationship between the levels of grief and depression of women who do not become pregnant following IVF treatment, IVF expense, and number of previous IVF treatments.
|
Method |
|---|
|
Top
AbstractMethodResultsDiscussionReferences |
|---|
The original IVF subject pool consisted of 61 IVF patients who responded to the first and second mailings of the pretest questionnaires. However, four subjects were dropped from the sample due to pregnancy following the IVF treatment, and eight subjects were eliminated because the post-test questionnaires were not returned after two follow-up mailings. The resulting 50 IVF subjects included 46 whites, two blacks, and two Asian women. Twenty-two percent of the IVF treatment group were high school graduates, 46% completed college, 26% completed graduate school, and 6% finished postgraduate school. The IVF subjects, on average, had been married 7.4 years, and their annual incomes ranged between $60,000 and $70,000.
The initial pool of ovulation-treatment subjects consisted of 71 women who had responded to the pretest questionnaires. However, nine were dropped from the study because their post-test questionnaires were not returned within 6 weeks from the date of mailing of the first set of post-test questionnaires, two were eliminated because they achieved pregnancy during the treatment cycle, four reported that their treatment cycle was canceled due to insufficient ovarian response to the fertility medications, and six were not included because of missing demographic data or incomplete protocols. The resulting 50 ovulation-induction medication subjects had been unsuccessful at achieving pregnancy after 1 year of unprotected intercourse and were receiving clomiphene citrate or menotropins treatment. They were between 25 and 43 years of age and consisted of 49 white patients and 1 black patient. Fourteen percent graduated from high school, 54% graduated from college, 26% completed graduate school, 6% completed postgraduate school, and one person attended a technical school. On average, the ovulation-induction medication subjects had been married for 7.8 years, and their annual incomes ranged from $40,000 to $50,000.
All subjects had to volunteer as participants in the study and agree to complete the entire pretest and post-test research packet containing a consent form, demographic information form, and the test materials, which are described below. In vitro fertilization subjects completed the pretest research packet 4–6 weeks prior to IVF treatment and the post-test packet within 4 weeks from the date of their anticipated pregnancy or from the date when the IVF cycles were canceled if they discontinued IVF before embryo transfer. Subjects receiving ovulation-induction medication completed the pretest research packet at the beginning of the treatment cycle and the post-test packet within 4 weeks from the date of onset of their next menstrual cycle.
Five instruments were used to collect data: a demographic form, Schedule of Recent Experience,3 Grief Experience Inventory,4 Depression Adjective Checklist,5,6 and Ways of Coping Checklist.7 A demographic form was completed by the subjects to obtain background information concerning age, years of infertility, reproductive diagnosis, length of time attempting pregnancy, formal education, income, impact of financial investment, and number of previous IVF treatment cycles.
The Schedule of Recent Experience (1-year version)3 was designed for collecting information about people’s lifestyle and sociologic processes in relation to health and disease. It was used in the present study to obtain information about subjects’ perceptions of their recent life experiences. The Schedule of Recent Experience is a 42-item self-report inventory that describes a life event that is either indicative of or requires a significant change in the life of the individual. The life events of the Schedule of Recent Experience were selected for their observed occurrence prior to the onset of clinical symptoms or illness. For this instrument, respondents record the number of times each event has occurred within the previous 12 months. Each life-event statement is assigned a specific numerical value, and the score is the total number of points. The life-change score is calculated as a weighted item frequency. When the life-change score is more than 300, there is an 80% chance of illness in the individual’s future. Life-change scores between 150 and 299 reflect a 50% chance of illness in the future, and life-change scores less than 150 reflect a 30% chance of illness. A reliability coefficient between .74 and .83 (n = 219 men and women ranging in age from 25 to 55 years) was reported for the Schedule of Recent Experience.8 A reliability coefficient 
value of .80 or above indicates that the instrument has a significantly high level of reliability.
The shortened version of the Grief Experience Inventory4 was used in this study to determine whether subjects were reporting changes in grief after completing infertility treatment. The Grief Experience Inventory consists of 135 statements associated with grief and bereavement. The clinical scales include anger, despair, low self-esteem, social isolation, loss of control, and somatization. The reliability of the Grief Experience Inventory is obtained by a coefficient value for each individual scale. The respective values for each of the scales measuring grief are as follows: despair, .84; anger, .69; social isolation, .54; loss of control, .68; and somatization, .81. This instrument’s validity is made evident by the similarities of subjects’ responses on the Grief Experience Inventory4 and the responses of bereaved persons on the Minnesota Multiphasic Personality Inventory.
The Depression Adjective Checklist5,6 was developed to provide a brief, reliable, and valid measure of depressive mood. It was used in the present study to determine whether subjects were reporting changes in depression after completing infertility treatment. The Depression Adjective Checklist is a self-report instrument that requires the respondent to check words that describe the feelings experienced during a specific period of time. There are seven Depression Adjective Checklists each containing 32–34 adjectives. Reliability intercorrelations of the seven lists range from .83 to .92 for males and from .80 to .93 for females, indicating that each checklist measures the same construct. A correlation of .87 was reported between the Depression Adjective Checklist and the Multiple Affect Adjective Checklist—Depression Scale. The validity of this instrument is indicated by a correlation of .47 with the Beck Depression Inventory and the Zung Depression Scale. Validity coefficients are considered significant at .30 and above.
The Ways of Coping Checklist7 was designed as a process measure to obtain information about strategies a person uses to cope with a stressful event. Thirty questions from the 68-item Ways of Coping Checklist7 were used in this study: ten questions from the problem-focused coping scale and 20 items from the emotional-focused coping scale. In completing the Ways of Coping Checklist,7 the stressful event is described by the subject, and the checklist is completed by responding "yes" or "no" to each question. The score on the Ways of Coping Checklist7 is the total number of "yes" responses for each scale.
Problem-focused coping (P scale) is measured by 21 items of the Ways of Coping Checklist7 with a reported internal consistency reliability of .80 (n = 100 men and women, age 45–64 years). Emotional-focused coping (E scale) is measured by the 40 items of the Ways of Coping Checklist7 with a reported internal consistency reliability of .81.9 The correlation between the two scales is .45, indicating a measure of two separate but related concepts. A reliability coefficient of .63 was obtained for the Ways of Coping Checklist7; women who use a problem-focused coping style to deal with stress will respond "yes" to more of the identified problem-focused coping statements than will women who respond to stress with emotion-focused coping styles.
Statistical procedures used in this study include descriptive analysis of means and standard deviations, t tests, and stepwise multiple regression. These procedures are appropriate when quantification of variables, investigation of correlations, and distinction between random and significant findings are desired.
|
Results |
|---|
|
Top
AbstractMethodResultsDiscussionReferences |
|---|
. The pretest and post-test scores on the Depression Adjective Checklist5,6 and Grief Experience Inventory4 scales were compared within and between the IVF and ovulation-induction medication treatment groups for women who received a negative pregnancy test or did not achieve successful pregnancy.
|
summarizes the pretest and post-test means and standard deviations of the IVF and ovulation-induction medication groups for the two measures of Depression Adjective Checklist5,6 and Grief Experience Inventory.4 Lubin reported a raw score of seven as the mean on the Depression Adjective Checklist5,6 and indicated that scores above 13 are rare for adults.6 Eighteen (36%) of the IVF and 17 (34%) of the ovulation-induction medication subjects scored above 13 on the Depression Adjective Checklist5,6 pretest. Twenty (40%) of the IVF group and 24 (48%) of the ovulation-induction medication group reported scores above 13 on the Depression Adjective Checklist5,6 post-test. A majority of women reported feelings of depression before and after the pregnancy test, and their scores were above the mean of seven for the normal population of adult women. Additionally, means for the subcategories of grief (denial, anger, despair, social isolation, social desirability, loss of control, and dependency) on the Grief Experience Inventory are reported in Table 3.
|
|
, pretest and post-test means and standard deviations on the Depression Adjective Checklist5,6 were not statistically significant for the IVF group (t [49] = 1.29). All other tests yielded significant results indicating partial support for the hypothesis. The pretest and post-test means for the Grief Experience Inventory4 were significantly different for the IVF group at the .01 level (t [49] = 3.14, P < .01). For the ovulation-induction medication group, a significant difference was found on pretest and post-test scores for the Depression Adjective Checklist5,6 (t [49] = 2.56, P < .05) and the Grief Experience Inventory4 (t [49] = 3.80, P < .001) (Table 2). The hypothesis that failure to become pregnant following IVF treatment would result in more depression and grief than that exhibited by ovulation-induction medication subjects was not supported. An independent t test revealed that the difference in post-test scores for the two groups was not statistically significant on the Depression Adjective Checklist5,6 (t [98] = 1.40) and the Grief Experience Inventory4 (t [98] = .51). Also, the groups did not differ significantly on the pretest scores for the Depression Adjective Checklist (t [20] = .09).
Coping strategies used most frequently by the IVF and ovulation-induction medication groups were examined by determining the frequency distribution of responses from the Ways of Coping Checklist6 and responses to three open-ended questions. The scores on the Ways of Coping Checklist6 revealed that the subjects used emotional-focused coping strategies less frequently than problem-focused coping strategies. The coping strategies identified in the Ways of Coping Checklist6 that were reported most frequently by IVF and ovulation-induction medication subjects are identified in Table 4.
|
The third open-ended question specifically sought information about how the IVF subjects’ emotional experience of treatment compared with their expectations. The most frequent response was that they had been well informed as to what to expect during IVF treatment from the IVF staff nurses, from friends who had participated in IVF treatment, and from articles describing the IVF experience. Some women expressed feelings of disbelief, anger, and conflict about whether they should attempt another IVF treatment cycle because the emotional turmoil experienced during IVF treatment was much greater than anticipated.
The demographic variables of age, diagnosis of reproductive fertility problem, number of years of infertility, impact of financial investment in the IVF program, and number of past IVF treatments were examined as they related to the post-test scores on the Grief Experience Inventory4 and Depression Adjective Checklist.5,6 A stepwise multiple-regression analysis was performed to determine the amount of variance in scores on the Depression Adjective Checklist5,6 and Grief Experience Inventory4 that could be accounted for by each of the six independent variables. Because the number of variables was fairly large, given the number of subjects, a stringent significance level of .01 was used to protect against the increased probability of a type I error. None of the six variables by themselves accounted for more than 2.5% of the variance in the Depression Adjective Checklist5,6 or 5.9% of the variance in the Grief Experience Inventory.4 However, the financial impact of the IVF treatment program on grief and depression did reach significance at the .05 level. Women who reported the expense of the IVF program to be a significant or very significant burden yielded higher scores on the Grief Experience Inventory4 (R2 = .0588, P < .05) (see Table 5).
|
|
Discussion |
|---|
|
Top
AbstractMethodResultsDiscussionReferences |
|---|
In general, all subjects experienced measurable levels of grief and depression before, during, and after treatment. Both the IVF and ovulation-induction medication subjects experienced similar levels of grief prior to treatment and again after a negative pregnancy report, and both groups reported comparable levels of depression, despair, anger, and loss of control as the hope of pregnancy faded. Overall, these findings and the higher scores on the Grief Experience Inventory4 support the results of previous research.10–13
As reported in Table 2, the pretest and post-test scores on the Depression Adjective Checklist5,6 and Grief Experience Inventory4 were not significantly different within each group. This could be attributed to the higher than average level of reported pretest depression and the subsequent result of limited sample variance. It has been reported that 38% of the women initiating IVF treatment began their IVF procedure with a measurable level of distress that increased if pregnancy was not achieved.2 Similar results were found in this study for all subjects. Fifty-six percent of the IVF and 58% of ovulation-induction medication subjects reported feelings of depression prior to initiating treatment. Sixty-two percent of IVF and 68% of the ovulation-induction medication subjects reported feelings of depression 4 weeks after the negative pregnancy test. These results indicate that therapeutic assessment and counseling may be more effective for the treatment of depression if initiated before the commencement of infertility treatment.
In comparing the two groups, depression scores for the IVF subjects were lower than those of the ovulation-induction medication subjects. This may be attributed to the possibility that many IVF subjects have had previous unsuccessful pregnancy attempts with other fertility treatments and therefore are more accepting of the possibility that they may never be able to become pregnant. Additionally, they may have been using denial as a coping strategy to survive this difficult news, or they may have desensitized some of their feelings related to pregnancy failure. Also, this may have contributed to the lack of significance in the depression scores for the IVF subjects.
The significant change in feelings of depression experienced by the ovulation-induction medication women after an unsuccessful pregnancy treatment cycle was expected. The literature has reported that many infertile women experience feelings of depression.14–16 Women initiate each treatment cycle with high expectations and a high level of hope and, therefore, are emotionally set up for disappointment.
Effective coping behaviors were found to prevent the prolonged sense of threat and reduce emotional stress. One positive intervention conducted to cope with stress is to strengthen the family’s use of their social network.17 Participants in this study used isolation behaviors such as self-talk and sleep as strategies to cope with this situational crisis. Isolation from talking to their relatives and friends or seeking professional counseling are not effective coping mechanisms because they reduce the availability of a supportive network that could assist the subjects to cope more effectively with the stress and despair of an unsuccessful pregnancy attempt.
Age, reproductive problems, years infertile, financial impact, and number of past IVF cycles were not found to influence the levels of grief and depression reported by the IVF subjects. These results contradict those of previous research18,19 that has reported that length of time of infertility, complexity of infertility treatment, female reproductive problems, and age are significantly related to the levels of grief and depression experienced by infertile women. Women who reported the expense of the IVF program to be a significant or very significant burden scored higher on the Grief Experience Inventory4 than did IVF participants who reported the expense as minimal or no burden. This relationship was not statistically significant, but it appears to have had some impact.
Based on the findings of this study, infertility programs should offer and encourage patients to participate in professional counseling services for preventive and remedial purposes. Counseling services should include but not be limited to instruction on new adaptive behaviors for coping with infertility and medical procedures, encouragement to explore and understand emotions associated with the crisis of infertility, and teaching more assertive communication styles. Also to be addressed are the influence of marital stability, financial security, psychological stability, social support, and realistic expectations on the emotional integrity of the patient. Consideration of these issues by the infertile couple with the help of a counselor or nurse could lead to the identification of more effective coping strategies.
An examination of whether to provide counseling within the context of individual, group, or family settings is an important next step in needed research concerning the psychological treatment of infertile women. Also it would be helpful to conduct research with a nonvolunteer sample because volunteers may be predisposed to grief and depression and may not be representative of all infertile women who have not achieved pregnancy. On the basis of these findings and previous research, it is evident that the inclusion of counseling in infertility programs could benefit all participants involved and result in increased satisfaction with infertility treatment procedures.
|
Footnotes |
|---|
Received April 22, 1998. Received in revised form August 6, 1998. Accepted August 20, 1998.
|
References |
|---|
|
Top
AbstractMethodResultsDiscussionReferences |
|---|
2. Garner CH, Arnold EW, Gray H. The psychological impact of in vitro fertilization. Fertil Steril 1984;41:575–8.[Medline]
3. Amundson B, Hart B, Holmes T. Manual of the schedule of recent experience. Seattle: University of Washington Press, 1981.
4. Sanders C, Mauger P, Strong P. The grief experience inventory manual. Palo Alto, California. Consulting Psychological Press, 1978.
5. Lubin B. Adjective checklists for the measurement of depression. Arch Gen Psychiatry 1965;12:57–62.
6. Lubin B. Manual of depression adjective checklist. San Diego, California: Educational and Industrial Testing Service, 1981.
7. Brenner P, Cohen J, Folkman S, Kanner A, Lazarus R, Schaefer C, et al. The ways of coping checklist. J Health Soc Behav 1977;21: 219–39.
8. Casey R, Masuda M, Holmes T. Quantitative study of recall of life events. J Psychosom Res 1967;11:239–47.[Medline]
9. Folkman S, Lazarus R. Coping in a middle-aged community sample. J Health Soc Behav 1980;21:219–39.[Medline]
10. Bresnick E, Taymor M. The role of counseling in infertility. Fertil Steril 1979;43:154–6.
11. Lukse M. The effect of group counseling on the frequency of grief reported by infertile couples. J Obstet Gynecol Neonatal Nurs 1985;14:67s–70s.[Medline]
12. Menning B. The emotional needs of infertile couples. Fertil Steril 1980;34:313–9.[Medline]
13. Seibel M, Taymor M. In vitro fertilization. In: Mazer M, Simons H, eds. Infertility: Medical, emotional, and social considerations. New York: Human Sciences Press, 1984.
14. Abbey A, Andrews FM, Halman LJ. Infertility and parenthood: Does becoming a parent increase well-being? J Consult Clin Psychol 1994;62:398–403.[Medline]
15. Bresnick E. A holistic approach to the treatment of the crisis of infertility. J Marital Fam Ther 1981;7:181–88.
16. Shapiro C. The impact of infertility on the marital relationship. Soc Casework: J Contemp Soc Work 1982;7:387–93.
17. Unger D, Powell D. Supporting families under stress: The role of social networks. Fam Relation 1980;29:566–74.
18. Edelman RJ, Connolly KJ. Psychological aspects of infertility. Br J Med Psychol 1986;59:209–19.
19. McEwan K, Costello C, Taylor P. Adjustment to infertility. J Abnorm Psychol 1987;96:108–16.[Medline]
This article has been cited by other articles:
|
|
 |
|
  K. E. Williams, W. K. Marsh, and N. L. Rasgon Mood disorders and fertility in women: a critical review of the literature and implications for future research Hum. Reprod. Update, November 1, 2007; 13(6): 607 - 616. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.M. Verhaak, J.M.J. Smeenk, A.W.M. Evers, J.A.M. Kremer, F.W. Kraaimaat, and D.D.M. Braat Women's emotional adjustment to IVF: a systematic review of 25 years of research Hum. Reprod. Update, January 1, 2007; 13(1): 27 - 36. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Poikkeus, T. Saisto, L. Unkila-Kallio, R.-L. Punamaki, L. Repokari, S. Vilska, A. Tiitinen, and M. Tulppala Fear of Childbirth and Pregnancy-Related Anxiety in Women Conceiving With Assisted Reproduction. Obstet. Gynecol., July 1, 2006; 108(1): 70 - 76. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Ragni, P. Mosconi, M. P. Baldini, E. Somigliana, W. Vegetti, I. Caliari, and A. E. Nicolosi Health-related quality of life and need for IVF in 1000 Italian infertile couples Hum. Reprod., May 1, 2005; 20(5): 1286 - 1291. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Schmidt, U. Christensen, and B.E. Holstein The social epidemiology of coping with infertility Hum. Reprod., April 1, 2005; 20(4): 1044 - 1052. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T.-H. Chen, S.-P. Chang, C.-F. Tsai, and K.-D. Juang Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic Hum. Reprod., October 1, 2004; 19(10): 2313 - 2318. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Savitz-Smith Couples Undergoing Infertility Treatment: Implications for Counselors The Family Journal, October 1, 2003; 11(4): 383 - 387. [Abstract] [PDF]
|
|
|
|
|
|
M. Fekkes, S.E. Buitendijk, G.H.W. Verrips, D.D.M. Braat, A.M.A. Brewaeys, J.G. Dolfing, M. Kortman, R.A. Leerentveld, and N.S. Macklon Health-related quality of life in relation to gender and age in couples planning IVF treatment Hum. Reprod., July 1, 2003; 18(7): 1536 - 1543. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Rosene-Montella, E. Keely, S. A. Laifer, and R. V. Lee Evaluation and Management of Infertility in Women: The Internists' Role Ann Intern Med, June 20, 2000; 132(12): 973 - 981. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
