Psychiatr Q DOI 10.1007/s11126-016-9424-4 ORIGINAL PAPER
Psychiatric Symptoms Associated with Oocyte-Donation Ashraf Kazemi1 • Maryam Zivari Delavar2 • Gholamreza Kheirabadi3
Ó Springer Science+Business Media New York 2016
Abstract Oocyte-donation is generally safe but may exacerbate psychiatric symptoms in some women. In this prospective study 63 oocyte-donating women and, as a control group, 63 women providing their own oocytes for in vitro fertilization (in couples with male infertility) were evaluated pre- and post-ovulation-induction in regard to hypochondriasis, anxiety, social impairment, and depression. The mean hypochondriasis score for oocyte-donators was significantly lower than for women providing their own oocytes, prior to ovulation-induction (5.03 vs. 6.59). However, after ovulation-induction and oocyte retrieval this score rose to 6.66 among oocyte-donators, whereas it remained essentially unchanged among women providing their own oocytes (6.66). The mean anxiety score for oocyte-donating women also rose following this procedure, from 5.87 to 7.65. Depression scores for both groups remained similar, before and after the procedure. Results showed that at the beginning of the ARP donating women have the same conditions as own oocyte women regarding depression and anxiety but after the egg harvesting they would suffer more damages regarding hypochondriasis and anxiety aspects. Keywords
Mental health Oocyte-donor Assisted Reproduction Program (ARP)
Introduction Oocyte-donation is a common procedure for treating infertility in couples where the woman’s oocytes are unhealthy [1]. This procedure is commonly and legally employed in Iran, though there is a cultural bias against it [2]. To harvest a sufficient number of
& Ashraf Kazemi [email protected] 1
Reproductive Health Department, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Hezarjerib Av., Isfahan, Iran
2
Reproductive Health Department, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3
Behavioral Sciences Research Center, Department of psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
123
Psychiatr Q
oocytes for in vitro fertilization (IVF), donors undergo ovulation-induction and retrieval. Sperm from the husbands are then mixed with the retrieved oocytes and the resulting embryos implanted in the infertile women’s uteruses [3]. Although ovulationinduction is generally safe, it can be stressful for the donors. Repeated injection of ovulation-inducing drugs and ovarian hyper-stimulation [4], ovarian monitoring by serial trans-vaginal ultra-sound, and the side-effects of anesthesia and oocyte-retrieval over a protracted period [5] are all sources of pain and stress. Moreover, undergoing these procedures multiple times, as some donors choose to do, can predispose them to ovarian hyper-stimulation syndrome [6], ovarian torsion [4], and ovarian cancer [7], and may reduce their likelihood of becoming pregnant themselves because of depletion of ovarian reserve [8]. In cases where women provide their own oocytes for IVF, necessitated by their male partners’ infertility, such induction and retrieval may also produce harmful psychological and systemic harm, but these women’s motivation to undergo these procedures is quite different. Furthermore, oocyte-donation, in contrast to providing one’s own oocytes, is not socially or culturally approved in Iran and is thus likely to add to the donor’s stress [9]. Therefore in this study by comparing the mental health of oocyte donors and women undergoing infertility treatments due to male factor, we have tried to assess the effect of this process on the donors.
Materials This is a prospective study conducted on 63 oocyte-donating women and 63 fertile women with infertile husbands who donated their own oocytes for the purpose of IVF, all of whom were treated at the Fertility and Infertility Center of Isfahan, Iran, between September 2013 and March 2014. Inclusion criteria were the absence of any known psychological or general systemic disorders, of substance abuse disorders (assessed by self-report), or of severe stress during the month prior to the study (assessed by the Holmes–Rahe stress test). Exclusion criteria were the presence of external stress during the study and failure to follow through with study procedures, such as withdrawing from oocyte retrieval because of systemic complications. Mental health was assessed by the 28-item General Health Questionnaire (GHQ-28), which scores for hypochondriasis, anxiety, social impairment, and depression [10]. The sampling method was simple. Inclusion/exclusion criteria were assessed after consents were obtained from all 126 subjects. Ovarian down-regulation was achieved using the GnRH-long protocol [11] on the second day of each woman’s menstrual cycle. The GHQ-28 was completed by each subject prior to the induction of ovulation, which was achieved by the administration of follicle-stimulating hormone and/or human menopausal gonadotropin. Following the induction of ovulation, all subjects were assessed both for ovarian response and for occurrence of stress. Three hours after oocyte retrieval, each participant was asked to complete the GHQ-28 again. One hour’s delay was allowed if the subject was experiencing systemic effects from the procedure. The number of oocytes retrieved was recorded. Data were analyzed using SPSS-16, as well as T test, paired T test, Mann– Whitney test, Chi squared test, and multiple linear regression test. The acceptable level for all tests to be statistically significant was set at .05.
123
Psychiatr Q Table 1 Comparison of subjects’ profiles
Mean (SD) and number (%)
Sig
Group
Own oocyte
Donor
Age
29.17 (4.11)
28.36 (3.28)
Educational level (%) Illiterate
.007 1 (1.6)
2 (3.2)
High school
13 (20.6)
16 (25.2)
Diploma
27 (42.9)
1 (1.6)
Academic degree
17 (27)
3 (4.8) \.0001
Economic status (%) Low
8 (12.7)
23 (36.5)
Middle
36 (57.1)
37 (58.7)
High
19 (30.2)
Number of retrieved oocytes
Table 2 Comparison of mental health dimensions between two groups before ovarian induction and after retrieving oocytes
NS
9.76 (5.84)
3 (4.8) 10.21 (6.80)
NS
Mean (SD) Number Group
63 Own oocyte
63 Donor
Sig
Anxiety
7.17 (4.2)
5.87 (4.3)
NS
Depression
4.05 (3.9)
5.05 (5.1)
NS
Social impairment
7.05 (2.6)
6.84 (2.6)
NS
Hypochondriasis
6.59 (4.1)
5.03 (4.1)
.03
Anxiety
7.03 (4.6)
7.65 (4.7)
NS
Depression
3.57 (3.8)
4.03 (5.1)
NS
Social impairment
7.09 (2.5)
7.41 (3.4)
NS
Hypochondriasis
6.60 (4.3)
6.66 (4.4)
NS
Before ovarian induction Mental health
After retrieving oocyte Mental health
Results Demographic data for both groups of participants are presented in Table 1. There was no significant difference between the average ages in the two groups; however, there was a significant difference in financial status and in educational level, both favoring the women providing their own oocytes. Results of scores for psychological symptoms are presented in Table 2. Hypochondriasis was initially lower in oocyte donors than in women providing their own oocytes, but this difference disappeared following the procedure of oocyte retrieval. Anxiety and depression were not significantly different between groups prior to the induction of ovulation. Following the induction of ovulation and oocyte retrieval, hypochondriasis and anxiety increased significantly (p = .007) in the oocyte donors, but there were no changes in symptom intensity in the women who provided their own oocytes.
123
Psychiatr Q Table 3 Regression model of independent variables before ovarian induction Mental Health Anxiety
Depression
2
R = .01 Beta Age
Social impairment
2
R = .04 Sig
Beta
Hypochondriasis
2
R2 = .01
R = .02 Sig
Beta
Sig
Beta
Sig NS
.04
NS
-.10
NS
-.002
NS
.01
Education
-.01
NS
-.08
NS
.01
NS
.02
NS
Economic status
-.08
NS
-.20
.04
-.13
NS
-.07
NS
-1.55
NS
.01
NS
-.09
NS
-.21
.03
Donor group 2
R Adjusted R square
Table 4 Regression model of independent variables after retrieving oocytes Mental health
Age Education Economic status Donor group
Anxiety
Depression
Social impairment
Hypochondriasis
R2 = .24
R2 = .16
R2 = .12
R2 = .30
Beta
Beta
sig
Beta
sig
-.04
NS
.01
NS
.07 -.26 .07
NS
-.08
sig
Beta
sig
NS
-.04
NS
.02
NS
.06
NS
.004
-.18
.04
-1.03
.02
-.22
.01
NS
-.02
NS
NS
.08
NS
.009
-.08
-.004
.120
NS
Mental health (before ovarian induction) Anxiety Depression
.35 -.04
NS
.38
NS
.03
NS
.18
NS
.003
.05
NS
-.16
NS
Social impairment
.001
NS
-.06
NS
.26
.02
.03
NS
Hypochondriasis
.15
NS
.18
NS
.002
NS
.47
\.0001
Number of oocytes
.12
NS
.11
NS
.13
NS
.105
NS
2
R Adjusted R square
Results of regression-model testing of the relationship between demographic factors and psychological symptoms prior to the procedures are shown in Table 3, where financial status independently predicted level of depression. Results of regression-model testing of the relationship between demographic factors and psychological symptoms following the procedures are shown in Table 4, where economic status predicted the levels of all four psychological symptoms.
Discussion The main finding of this study is that the procedures involved in oocyte donation cause significant increases in both anxiety and hypochondriasis for the donors. These women are likely to be of lower economic status than women who provide their own oocytes for
123
Psychiatr Q
fertility treatment when their husbands are infertile, and thus, their principal motivation for oocyte donation appears to be financial [8]. In infertile couples anxiety and depression, along with fear of treatment failure, are common [9, 12, 13] and easily understood. For the donors the causes of psychological symptoms are quite different, appearing to arise from the effects of the procedures themselves. These effects may be exacerbated by the climate of sociocultural disapproval of oocyte donation in Iran. Furthermore, oocyte donation may have negative health effects in the future, including reduced fertility [14]. Indeed, it is possible that the increase in hypochondriasis in oocyte donors may be associated with these negative health effects [15]. Although the control group of women providing their own oocytes for IVF with donor sperm had good reproductive potential, their higher financial status than the oocyte-donating women is a possible limitation to the validity of these results. Small sample size is another potential limitation.
Conclusion Since the demand for oocyte donation is likely to persist, it is essential that further studies document the potential for negative consequences to the donors, in terms of both mental and general systemic health. Acknowledgments The authors’ appreciate Isfahan University of Medical Sciences for funding the survey and Isfahan fertility (Grant Number: 392401) and infertility assistants for their cooperation. Compliance with Ethical Standards Conflict of interest The author declares that he has no conflict of interest. Human Rights and Informed Consent The study was approved by the ethical committee of Isfahan University of Medical Sciences. This article does not contain any studies with animals performed by any of the authors and all the participants filled written consent form.
References 1. Practice Committee of American Society for Reproductive Medicine; Practice Committee of Society for Assisted Reproductive Technology.: Recommendations for gamete and embryo donation: A committee opinion. Fertility and Sterility. 99:47–62, 2013 2. Inhorn MC, Patrizio P, Serour G.: Third-party reproductive assistance around the Mediterranean: Comparing Sunni Egypt, Catholic Italy and multisectarian Lebanon. Reproductive BioMedicine Online. 21:848–853, 2010 3. Zegers-Hochschild F, Adamson GD, Demouzon J, Ishihar Mansour R, Negron K, Sullivan E, et al.: The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary on ART terminology, 2009. Human Reproduction 24:2683–2687, 2009. 4. Maxwell KN, Cholst IN, Rosenwaks Z.: The incidence of both serious and minor complications in young women undergoing oocyte donation. Fertility and Sterility. 90:2165–2171, 2008. 5. Sharpe K, Karovitch AJ, Claman P, Suh, KN.: Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy. Fertility and Sterility 6:219.e11–219.e213, 2006. 6. Isikoglu M, Senol Y, Berkkanoglu M, Ozgur K, Donmez L, Stones-Abbasi A.: Public opinion regarding oocyte donation in Turkey: First data from a secular population among the Islamic world. Human Reproduction 21:318–323, 2006 7. Mahdavi A, Pejovic T, Nezhat F.: Induction of ovulation and ovarian cancer: A critical review of the literature. Fertility and Sterility 85:819–826, 2006.
123
Psychiatr Q 8. Kenney NJ, McGowan ML.: Looking back: Egg donors’ retrospective evaluations of their motivations, expectations, and experiences during their first donation cycle. Fertility and Sterility 93:455–466, 2010. 9. Ramezanzadeh F, Haghollahi F, Bagheri M, Masoomi M, Abedi-Nia N, Jafar-Abadi M.: Attitudes of donors and recipients toward ethical issues in oocyte donation. Medical Journal of Reproduction and Infertility 10:71–80, 2009. 10. Craig J.: The General Health Questionnaire. Occupational Medicine 57:79, 2007. 11. Fritz MA, Speroff L.: Assisted reproductive technologies. Clinical Gynecologic Endocrinology and Infertility, 8rd edn., Philadelphia, Wolters Kluwer Health, pp. 1331–1382, 2011. 12. Skoog Svanberg A, Lampic C, Gejerwall AL, Gudmundsson J, Karlstro¨m PO, Solensten NG, Sydsjo G.: Gamete donors’ satisfaction; gender differences and similarities among oocyte and sperm donors in a national sample. Acta Obstetricia et Gynecologica Scandinavica 92:1049–1056, 2013. 13. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A.: The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian Journal of Reproductive Medicine. 12:131–138, 2014. 14. Van Katwijk C, Peeters LL.: Clinical aspects of pregnancy after the age of 35 years: A review of the literature. Human Reproduction Update. 4:185–194, 1998. 15. Nakao M, Shinozaki Y, Ahern DK, Barsky AJ.: Anxiety as a predictor of improvements in somatic symptoms and health anxiety associated with cognitive-behavioral intervention in hypochondriasis. Psychotherapy and Psychosomatics 80:151–158, 2011.
Ashraf Kazemi, PhD is an academic member since 2002 at Isfahan University of Medical Sciences and a member of Iran Scientific Society for Reproductive Medicine. Her discipline is reproductive health and her research Interests is infertility. In 2002, she graduated from the Tehran University of Medical Sciences. Maryam Zivari Delavar, MSc is MS holder in reproductive health. Her research Interests is infertility. Gholamreza Kheirabadi, MD is psychiatrist and academic member at Isfahan University of Medical Sciences and his research Interests is depression.
123
Psychiatric Symptoms Associated with Oocyte-Donation Ashraf Kazemi1 • Maryam Zivari Delavar2 • Gholamreza Kheirabadi3
Ó Springer Science+Business Media New York 2016
Abstract Oocyte-donation is generally safe but may exacerbate psychiatric symptoms in some women. In this prospective study 63 oocyte-donating women and, as a control group, 63 women providing their own oocytes for in vitro fertilization (in couples with male infertility) were evaluated pre- and post-ovulation-induction in regard to hypochondriasis, anxiety, social impairment, and depression. The mean hypochondriasis score for oocyte-donators was significantly lower than for women providing their own oocytes, prior to ovulation-induction (5.03 vs. 6.59). However, after ovulation-induction and oocyte retrieval this score rose to 6.66 among oocyte-donators, whereas it remained essentially unchanged among women providing their own oocytes (6.66). The mean anxiety score for oocyte-donating women also rose following this procedure, from 5.87 to 7.65. Depression scores for both groups remained similar, before and after the procedure. Results showed that at the beginning of the ARP donating women have the same conditions as own oocyte women regarding depression and anxiety but after the egg harvesting they would suffer more damages regarding hypochondriasis and anxiety aspects. Keywords
Mental health Oocyte-donor Assisted Reproduction Program (ARP)
Introduction Oocyte-donation is a common procedure for treating infertility in couples where the woman’s oocytes are unhealthy [1]. This procedure is commonly and legally employed in Iran, though there is a cultural bias against it [2]. To harvest a sufficient number of
& Ashraf Kazemi [email protected] 1
Reproductive Health Department, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Hezarjerib Av., Isfahan, Iran
2
Reproductive Health Department, Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3
Behavioral Sciences Research Center, Department of psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
123
Psychiatr Q
oocytes for in vitro fertilization (IVF), donors undergo ovulation-induction and retrieval. Sperm from the husbands are then mixed with the retrieved oocytes and the resulting embryos implanted in the infertile women’s uteruses [3]. Although ovulationinduction is generally safe, it can be stressful for the donors. Repeated injection of ovulation-inducing drugs and ovarian hyper-stimulation [4], ovarian monitoring by serial trans-vaginal ultra-sound, and the side-effects of anesthesia and oocyte-retrieval over a protracted period [5] are all sources of pain and stress. Moreover, undergoing these procedures multiple times, as some donors choose to do, can predispose them to ovarian hyper-stimulation syndrome [6], ovarian torsion [4], and ovarian cancer [7], and may reduce their likelihood of becoming pregnant themselves because of depletion of ovarian reserve [8]. In cases where women provide their own oocytes for IVF, necessitated by their male partners’ infertility, such induction and retrieval may also produce harmful psychological and systemic harm, but these women’s motivation to undergo these procedures is quite different. Furthermore, oocyte-donation, in contrast to providing one’s own oocytes, is not socially or culturally approved in Iran and is thus likely to add to the donor’s stress [9]. Therefore in this study by comparing the mental health of oocyte donors and women undergoing infertility treatments due to male factor, we have tried to assess the effect of this process on the donors.
Materials This is a prospective study conducted on 63 oocyte-donating women and 63 fertile women with infertile husbands who donated their own oocytes for the purpose of IVF, all of whom were treated at the Fertility and Infertility Center of Isfahan, Iran, between September 2013 and March 2014. Inclusion criteria were the absence of any known psychological or general systemic disorders, of substance abuse disorders (assessed by self-report), or of severe stress during the month prior to the study (assessed by the Holmes–Rahe stress test). Exclusion criteria were the presence of external stress during the study and failure to follow through with study procedures, such as withdrawing from oocyte retrieval because of systemic complications. Mental health was assessed by the 28-item General Health Questionnaire (GHQ-28), which scores for hypochondriasis, anxiety, social impairment, and depression [10]. The sampling method was simple. Inclusion/exclusion criteria were assessed after consents were obtained from all 126 subjects. Ovarian down-regulation was achieved using the GnRH-long protocol [11] on the second day of each woman’s menstrual cycle. The GHQ-28 was completed by each subject prior to the induction of ovulation, which was achieved by the administration of follicle-stimulating hormone and/or human menopausal gonadotropin. Following the induction of ovulation, all subjects were assessed both for ovarian response and for occurrence of stress. Three hours after oocyte retrieval, each participant was asked to complete the GHQ-28 again. One hour’s delay was allowed if the subject was experiencing systemic effects from the procedure. The number of oocytes retrieved was recorded. Data were analyzed using SPSS-16, as well as T test, paired T test, Mann– Whitney test, Chi squared test, and multiple linear regression test. The acceptable level for all tests to be statistically significant was set at .05.
123
Psychiatr Q Table 1 Comparison of subjects’ profiles
Mean (SD) and number (%)
Sig
Group
Own oocyte
Donor
Age
29.17 (4.11)
28.36 (3.28)
Educational level (%) Illiterate
.007 1 (1.6)
2 (3.2)
High school
13 (20.6)
16 (25.2)
Diploma
27 (42.9)
1 (1.6)
Academic degree
17 (27)
3 (4.8) \.0001
Economic status (%) Low
8 (12.7)
23 (36.5)
Middle
36 (57.1)
37 (58.7)
High
19 (30.2)
Number of retrieved oocytes
Table 2 Comparison of mental health dimensions between two groups before ovarian induction and after retrieving oocytes
NS
9.76 (5.84)
3 (4.8) 10.21 (6.80)
NS
Mean (SD) Number Group
63 Own oocyte
63 Donor
Sig
Anxiety
7.17 (4.2)
5.87 (4.3)
NS
Depression
4.05 (3.9)
5.05 (5.1)
NS
Social impairment
7.05 (2.6)
6.84 (2.6)
NS
Hypochondriasis
6.59 (4.1)
5.03 (4.1)
.03
Anxiety
7.03 (4.6)
7.65 (4.7)
NS
Depression
3.57 (3.8)
4.03 (5.1)
NS
Social impairment
7.09 (2.5)
7.41 (3.4)
NS
Hypochondriasis
6.60 (4.3)
6.66 (4.4)
NS
Before ovarian induction Mental health
After retrieving oocyte Mental health
Results Demographic data for both groups of participants are presented in Table 1. There was no significant difference between the average ages in the two groups; however, there was a significant difference in financial status and in educational level, both favoring the women providing their own oocytes. Results of scores for psychological symptoms are presented in Table 2. Hypochondriasis was initially lower in oocyte donors than in women providing their own oocytes, but this difference disappeared following the procedure of oocyte retrieval. Anxiety and depression were not significantly different between groups prior to the induction of ovulation. Following the induction of ovulation and oocyte retrieval, hypochondriasis and anxiety increased significantly (p = .007) in the oocyte donors, but there were no changes in symptom intensity in the women who provided their own oocytes.
123
Psychiatr Q Table 3 Regression model of independent variables before ovarian induction Mental Health Anxiety
Depression
2
R = .01 Beta Age
Social impairment
2
R = .04 Sig
Beta
Hypochondriasis
2
R2 = .01
R = .02 Sig
Beta
Sig
Beta
Sig NS
.04
NS
-.10
NS
-.002
NS
.01
Education
-.01
NS
-.08
NS
.01
NS
.02
NS
Economic status
-.08
NS
-.20
.04
-.13
NS
-.07
NS
-1.55
NS
.01
NS
-.09
NS
-.21
.03
Donor group 2
R Adjusted R square
Table 4 Regression model of independent variables after retrieving oocytes Mental health
Age Education Economic status Donor group
Anxiety
Depression
Social impairment
Hypochondriasis
R2 = .24
R2 = .16
R2 = .12
R2 = .30
Beta
Beta
sig
Beta
sig
-.04
NS
.01
NS
.07 -.26 .07
NS
-.08
sig
Beta
sig
NS
-.04
NS
.02
NS
.06
NS
.004
-.18
.04
-1.03
.02
-.22
.01
NS
-.02
NS
NS
.08
NS
.009
-.08
-.004
.120
NS
Mental health (before ovarian induction) Anxiety Depression
.35 -.04
NS
.38
NS
.03
NS
.18
NS
.003
.05
NS
-.16
NS
Social impairment
.001
NS
-.06
NS
.26
.02
.03
NS
Hypochondriasis
.15
NS
.18
NS
.002
NS
.47
\.0001
Number of oocytes
.12
NS
.11
NS
.13
NS
.105
NS
2
R Adjusted R square
Results of regression-model testing of the relationship between demographic factors and psychological symptoms prior to the procedures are shown in Table 3, where financial status independently predicted level of depression. Results of regression-model testing of the relationship between demographic factors and psychological symptoms following the procedures are shown in Table 4, where economic status predicted the levels of all four psychological symptoms.
Discussion The main finding of this study is that the procedures involved in oocyte donation cause significant increases in both anxiety and hypochondriasis for the donors. These women are likely to be of lower economic status than women who provide their own oocytes for
123
Psychiatr Q
fertility treatment when their husbands are infertile, and thus, their principal motivation for oocyte donation appears to be financial [8]. In infertile couples anxiety and depression, along with fear of treatment failure, are common [9, 12, 13] and easily understood. For the donors the causes of psychological symptoms are quite different, appearing to arise from the effects of the procedures themselves. These effects may be exacerbated by the climate of sociocultural disapproval of oocyte donation in Iran. Furthermore, oocyte donation may have negative health effects in the future, including reduced fertility [14]. Indeed, it is possible that the increase in hypochondriasis in oocyte donors may be associated with these negative health effects [15]. Although the control group of women providing their own oocytes for IVF with donor sperm had good reproductive potential, their higher financial status than the oocyte-donating women is a possible limitation to the validity of these results. Small sample size is another potential limitation.
Conclusion Since the demand for oocyte donation is likely to persist, it is essential that further studies document the potential for negative consequences to the donors, in terms of both mental and general systemic health. Acknowledgments The authors’ appreciate Isfahan University of Medical Sciences for funding the survey and Isfahan fertility (Grant Number: 392401) and infertility assistants for their cooperation. Compliance with Ethical Standards Conflict of interest The author declares that he has no conflict of interest. Human Rights and Informed Consent The study was approved by the ethical committee of Isfahan University of Medical Sciences. This article does not contain any studies with animals performed by any of the authors and all the participants filled written consent form.
References 1. Practice Committee of American Society for Reproductive Medicine; Practice Committee of Society for Assisted Reproductive Technology.: Recommendations for gamete and embryo donation: A committee opinion. Fertility and Sterility. 99:47–62, 2013 2. Inhorn MC, Patrizio P, Serour G.: Third-party reproductive assistance around the Mediterranean: Comparing Sunni Egypt, Catholic Italy and multisectarian Lebanon. Reproductive BioMedicine Online. 21:848–853, 2010 3. Zegers-Hochschild F, Adamson GD, Demouzon J, Ishihar Mansour R, Negron K, Sullivan E, et al.: The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary on ART terminology, 2009. Human Reproduction 24:2683–2687, 2009. 4. Maxwell KN, Cholst IN, Rosenwaks Z.: The incidence of both serious and minor complications in young women undergoing oocyte donation. Fertility and Sterility. 90:2165–2171, 2008. 5. Sharpe K, Karovitch AJ, Claman P, Suh, KN.: Transvaginal oocyte retrieval for in vitro fertilization complicated by ovarian abscess during pregnancy. Fertility and Sterility 6:219.e11–219.e213, 2006. 6. Isikoglu M, Senol Y, Berkkanoglu M, Ozgur K, Donmez L, Stones-Abbasi A.: Public opinion regarding oocyte donation in Turkey: First data from a secular population among the Islamic world. Human Reproduction 21:318–323, 2006 7. Mahdavi A, Pejovic T, Nezhat F.: Induction of ovulation and ovarian cancer: A critical review of the literature. Fertility and Sterility 85:819–826, 2006.
123
Psychiatr Q 8. Kenney NJ, McGowan ML.: Looking back: Egg donors’ retrospective evaluations of their motivations, expectations, and experiences during their first donation cycle. Fertility and Sterility 93:455–466, 2010. 9. Ramezanzadeh F, Haghollahi F, Bagheri M, Masoomi M, Abedi-Nia N, Jafar-Abadi M.: Attitudes of donors and recipients toward ethical issues in oocyte donation. Medical Journal of Reproduction and Infertility 10:71–80, 2009. 10. Craig J.: The General Health Questionnaire. Occupational Medicine 57:79, 2007. 11. Fritz MA, Speroff L.: Assisted reproductive technologies. Clinical Gynecologic Endocrinology and Infertility, 8rd edn., Philadelphia, Wolters Kluwer Health, pp. 1331–1382, 2011. 12. Skoog Svanberg A, Lampic C, Gejerwall AL, Gudmundsson J, Karlstro¨m PO, Solensten NG, Sydsjo G.: Gamete donors’ satisfaction; gender differences and similarities among oocyte and sperm donors in a national sample. Acta Obstetricia et Gynecologica Scandinavica 92:1049–1056, 2013. 13. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A.: The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian Journal of Reproductive Medicine. 12:131–138, 2014. 14. Van Katwijk C, Peeters LL.: Clinical aspects of pregnancy after the age of 35 years: A review of the literature. Human Reproduction Update. 4:185–194, 1998. 15. Nakao M, Shinozaki Y, Ahern DK, Barsky AJ.: Anxiety as a predictor of improvements in somatic symptoms and health anxiety associated with cognitive-behavioral intervention in hypochondriasis. Psychotherapy and Psychosomatics 80:151–158, 2011.
Ashraf Kazemi, PhD is an academic member since 2002 at Isfahan University of Medical Sciences and a member of Iran Scientific Society for Reproductive Medicine. Her discipline is reproductive health and her research Interests is infertility. In 2002, she graduated from the Tehran University of Medical Sciences. Maryam Zivari Delavar, MSc is MS holder in reproductive health. Her research Interests is infertility. Gholamreza Kheirabadi, MD is psychiatrist and academic member at Isfahan University of Medical Sciences and his research Interests is depression.
123
