Psychological Reports, 1992, 71, 1187-1190. O Psychological Reports 1992
WHAT IS STRESSFUL ABOUT IN VITRO FERTILIZATION? ' BAHMAN BALUCH
Thames Valley University IAN CRAFT AND TALHA ALSHAWAF
London Fertilify and Gynaecology Centre Summary.-The present work was designed to explore whether psychological stress is more related to concerns about the actual physical pain or fear of treatment during in vitro fertilization. Analysis of data for 12 middle-class women from Iran showed that the greatest psychological stress during treatment was associated with worries about the outcome of Uferent stages of treatment rather than fear and pain of the actual procedure.
The number of individuals experiencing some form of subinfertility is relatively high. Statistics suggest that at least 1 out of 6 (Daniluk, 1991) or as many as 1 out of 4 (Morse & Van-Hall, 1987; Greenhall & Vessey, 1990) of the population of reproductive age in the developed Western countries who attempt to conceive experience an episode of subinfertility at some stage in their lives. There is now agreement that infertility for a very large proportion of these individuals is a most significant lifetime crisis which leads to psychologically stressful experiences (see Morse & Van-Hall, 1987; Golombok, 1992, for a review). Although medical science has made huge advances in the treatment of infertility in the last decade, especially with the development of in vitro fertilization (IVF) (Steptoe, Edwards, & Purdy, 1980), the success rate for this and other infertility treatments is relatively low; for example, for IVF Hartz (1992) reports a pregnancy rate of 21% and delivery rate of 14% in the USA. Consequently, most patients who are unsuccessful with a first attempt tend to repeat the treatment on more than one occasion. Moreover, some researchers (Menning, 1980; Van-Hall, 1983; Saltzer, 1986; Greenfeld & Haseltine, 1986; Dennerstein & Morse, 1988; Edelmann, 1990) have argued that the IVF treatment itself could produce considerable psychological distress which may influence the course and result of treatment. These studies, although of interest, are not conclusive. Unclear is what aspect of IVF treatment is stressful, for example, daily hormone injections, egg retrieval, undergoing anaesthetic, or the main stressful episodes related to concerns such as the growth and number of follicles, the quality and number of eggs retrieved, the quality and number of embryos, or waiting at home for results 'Address correspondence to Bahman Baluch, Ph.D., Thames Valley University, St. Mary's Road, Ealing, London W5 5RF, United Kingdom.
1188
B. BALUCH. ETAL
of pregnancy? I n other words, is the psychological distress of IVF participants more in relation to the actual procedure or the biological outcome? To clarify the distinction, stress associated with visits to the dentist is possibly heightened because of fear of procedural routines such as drilling, hitting nerves, and painful injections rather than serious worries about the outcome, e.g., quality or number of the fdhngs. We make a clear distinction between two possible stress-provoking aspects of IVF, namely, procedural aspects versus those that relate to the outcome. A clear distinction between procedure and outcome should be most useful to counsellors in helping patients during and after infertility treatment.
Materials and Procedure We have devised an eight-item questionnaire that takes into account all possible procedural and outcome aspects of IVF treatment. The patient is simply asked to make a judgement between two episodes, one relating to a particular procedural aspect and the other to the outcome. All questions were asked in Persian as all participants were Iranian. Each item was asked at its appropriate stage rather than days after the treatment. This strategy enabled one to have a reflection of the psychological state of the patients during actual involvement with the treatment. An English translation of the questions appears in the Appendix (p. 1190). Subjects We concentrated on a particular patient group, namely, Iranians, so the sample is homogeneous. All 12 subjects were women of middle class from Iran, whose mean age was 34 years and who had recently arrived in the United Kingdom. All patients undergoing IVF treatment were briefed by the gynaecologists on the actual procedures and given handouts explaining in simple medical terms various fertility treatments. All patients were informed of the chances of success and of possible follow-up complications after pregnancy, such as ectopic pregnancy or miscarriage. Thus all patients in our study shared similar levels of medical knowledge about the actual procedures involved and what outcomes to expect. We calculated the number of responses given on items for which either the outcome or the procedural aspects of the treatment were considered more anxiety-provoking. The mean score for the outcome was 10.3 and for the procedure was only 1.6. A t test for independent group comparisons showed that the difference between the two means was significant (t,, = 10.9, SE = .80, p < .00001). One can conclude that perhaps the psychological stress of IVF was more related to the patients' worries about the outcome of each
STRESS: IN VITRO FERTILIZATION
1189
particular episode rather than to the procedures. Indeed, the nature of the treatment is such that successful outcome of a particular stage is crucial to whether the treatment should proceed further. For example, egg collection would depend on successful outcome of the phase of follicle growth. Embryo transfer could proceed approximately 52 hours after the operation only if there was fertilization. Throughout the sequence the patient is constantly anxious about the outcome of each particular phase of treatment. I t is true that procedural aspects place psychological stress on patients; indeed, there could be occasions at which patients may be concerned primarily about the procedural aspects. One item concerned whether the patients were more anxious about the pain and side effects of a nasal spray (procedural) rather than missing the exact timing of its use (thereby affecting the outcome). Half of the subjects were concerned with the side effects rather than missing the timing. I n short, we believe that, unlike most other operational procedures, the psychological aspects of infertility are so great (cf. Golombok, 1992) that worries about outcome overshadow concerns about the procedural aspects of treatment. I t would be of interest to explore whether similar conclusions may be reached with patients in Western societies. Perhaps some psychological aspects of infertility and its treatment may vary across different cultural groups (e.g., Baluch, 1992; Baluch, Al-Shawaf, & Craft, 1992). REFERENCES
BALUCH,B. (1992) [Infertility and its psychological consequences in Iran.] Baranoosh Scientijic Quarterly, 5(1), 34-35. [Persian] BALUCH,B., AL-SHAWAF, T., & CRAFT,1 (1992) Prime factors for seeking infertility treatment amongst Iranian patients. Psycholog~t:alReports, 71, 265-266. DANILIJK, J. C. (1991) Strategies for ccunselling infertile couples. Journal of Counselling and Developmenl, 69, 317-320. DENNERSTEIN, L., & MORSE,C. (1988) A review of psychological and social aspects of in uiho fertilisation. Journal of Psychosomatic Obstetrics and Gynaecology, 9, 159-170. EDELMANN, R. J. (1990) Emotional aspects of in uitro fertilization procedure: review. Journal of Reproductiue and Infant Psychology, 8 , 161-173. GOLOMBOK, S. (1992) Review: psychological functioning in infertility patients. Human Reproduction, 7, 208-212. GREENFELD, D., & HASELTINE, F. (1986) Candidate selection and psychological considerations of in uitro fertilization procedures. Clinical Obstetrics and Gynaecology, 29, 119-126. GREENHALL, E., & VESSEY,M. (1990) The prevalence of subfertility: a review of the current conhsion and a report of two new studies. Fertility and Sterility, 54, 978-983. HARTZ,S. C. (1992) In uitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF-ET Registry. Fertilily and Sterilily, 57, 15-24. H O P K ~ES. , (1992) Behind the IVF hype: a shocking failure rate. Medical Economics, 1, 152163. MENNTNG, B. E. (1980) The emotional needs of infertile couples. Fertility and Sterility, 34, 313319. MORSE,C. A., & VAN-HALL,E. V. (1987) Psychological as ects of infertility: a review of current concepts. Journal of Psychosomatic Obstetrics anB~ynaecology,6, 157-164. SALTZER, L. P. (1986) Infertility: how couples can cope. Boston, M A : Hall.
1190
B. BALUCH, ET AL.
STEPTOE,P C., EDWARDS, R. C., & PURDY,J. M. (1980) Clinical aspects of pregnancy established with cleaving embryos grown in vitro. British Jor,mal of Obstetrics and Gynaecology, 87, 757-781. VAN-HALL, E. V. (1783) Ps chological and emotional aspects of infertility. Journal of Psycho2, 251.255. somatic Obstetrics an%~~naecology, Accepted October 23, 1992
APPENDIX
1. Are you more anxious about being examined internally (procedure) or about what the diagnosis might be (outcome)? (Administered on the day of initial consultation) 2. Are you more anxious about what the results of the blood test might indicate (outcome) or the act of your blood being taken (procedure)? (Administered on the day of initial consultation) 3 . Are you more anxious about the pain and side effects of the superfact nasal spray (procedure) or missing on the actual time of using the spray (outcome)? (Administered two days after the use of nasal spray) 4. Are you mote anxious about daily injections of hormones and their side effects (procedure) or the effects they might have on the gowth of follicles (outcome)? (Administered two days after injection of hormones) 5. Are you more anxious about what the ultrasound scan might indicate by way of growth of follicles (outcome) or the act of being scanned (procedure)? (Administered a day prior to ultrasound scan) 6 . Are you more anxious about being under full or partial anaesthetic (procedure) or the number of eggs retrieved (outcome)? (Administered 24 hours prior to operation) 7. Are you more anxious about possible pain in egg retrieval (procedure) or the quality of eggs retrieved (outcome)? (Administered 24 hours prior to operation) 8. Are you more anxious about the process of embryo transfer (procedure) or the number and quality of fertilized embryos (outcome)? (Administered 24 hours prior to embryo transfer)
WHAT IS STRESSFUL ABOUT IN VITRO FERTILIZATION? ' BAHMAN BALUCH
Thames Valley University IAN CRAFT AND TALHA ALSHAWAF
London Fertilify and Gynaecology Centre Summary.-The present work was designed to explore whether psychological stress is more related to concerns about the actual physical pain or fear of treatment during in vitro fertilization. Analysis of data for 12 middle-class women from Iran showed that the greatest psychological stress during treatment was associated with worries about the outcome of Uferent stages of treatment rather than fear and pain of the actual procedure.
The number of individuals experiencing some form of subinfertility is relatively high. Statistics suggest that at least 1 out of 6 (Daniluk, 1991) or as many as 1 out of 4 (Morse & Van-Hall, 1987; Greenhall & Vessey, 1990) of the population of reproductive age in the developed Western countries who attempt to conceive experience an episode of subinfertility at some stage in their lives. There is now agreement that infertility for a very large proportion of these individuals is a most significant lifetime crisis which leads to psychologically stressful experiences (see Morse & Van-Hall, 1987; Golombok, 1992, for a review). Although medical science has made huge advances in the treatment of infertility in the last decade, especially with the development of in vitro fertilization (IVF) (Steptoe, Edwards, & Purdy, 1980), the success rate for this and other infertility treatments is relatively low; for example, for IVF Hartz (1992) reports a pregnancy rate of 21% and delivery rate of 14% in the USA. Consequently, most patients who are unsuccessful with a first attempt tend to repeat the treatment on more than one occasion. Moreover, some researchers (Menning, 1980; Van-Hall, 1983; Saltzer, 1986; Greenfeld & Haseltine, 1986; Dennerstein & Morse, 1988; Edelmann, 1990) have argued that the IVF treatment itself could produce considerable psychological distress which may influence the course and result of treatment. These studies, although of interest, are not conclusive. Unclear is what aspect of IVF treatment is stressful, for example, daily hormone injections, egg retrieval, undergoing anaesthetic, or the main stressful episodes related to concerns such as the growth and number of follicles, the quality and number of eggs retrieved, the quality and number of embryos, or waiting at home for results 'Address correspondence to Bahman Baluch, Ph.D., Thames Valley University, St. Mary's Road, Ealing, London W5 5RF, United Kingdom.
1188
B. BALUCH. ETAL
of pregnancy? I n other words, is the psychological distress of IVF participants more in relation to the actual procedure or the biological outcome? To clarify the distinction, stress associated with visits to the dentist is possibly heightened because of fear of procedural routines such as drilling, hitting nerves, and painful injections rather than serious worries about the outcome, e.g., quality or number of the fdhngs. We make a clear distinction between two possible stress-provoking aspects of IVF, namely, procedural aspects versus those that relate to the outcome. A clear distinction between procedure and outcome should be most useful to counsellors in helping patients during and after infertility treatment.
Materials and Procedure We have devised an eight-item questionnaire that takes into account all possible procedural and outcome aspects of IVF treatment. The patient is simply asked to make a judgement between two episodes, one relating to a particular procedural aspect and the other to the outcome. All questions were asked in Persian as all participants were Iranian. Each item was asked at its appropriate stage rather than days after the treatment. This strategy enabled one to have a reflection of the psychological state of the patients during actual involvement with the treatment. An English translation of the questions appears in the Appendix (p. 1190). Subjects We concentrated on a particular patient group, namely, Iranians, so the sample is homogeneous. All 12 subjects were women of middle class from Iran, whose mean age was 34 years and who had recently arrived in the United Kingdom. All patients undergoing IVF treatment were briefed by the gynaecologists on the actual procedures and given handouts explaining in simple medical terms various fertility treatments. All patients were informed of the chances of success and of possible follow-up complications after pregnancy, such as ectopic pregnancy or miscarriage. Thus all patients in our study shared similar levels of medical knowledge about the actual procedures involved and what outcomes to expect. We calculated the number of responses given on items for which either the outcome or the procedural aspects of the treatment were considered more anxiety-provoking. The mean score for the outcome was 10.3 and for the procedure was only 1.6. A t test for independent group comparisons showed that the difference between the two means was significant (t,, = 10.9, SE = .80, p < .00001). One can conclude that perhaps the psychological stress of IVF was more related to the patients' worries about the outcome of each
STRESS: IN VITRO FERTILIZATION
1189
particular episode rather than to the procedures. Indeed, the nature of the treatment is such that successful outcome of a particular stage is crucial to whether the treatment should proceed further. For example, egg collection would depend on successful outcome of the phase of follicle growth. Embryo transfer could proceed approximately 52 hours after the operation only if there was fertilization. Throughout the sequence the patient is constantly anxious about the outcome of each particular phase of treatment. I t is true that procedural aspects place psychological stress on patients; indeed, there could be occasions at which patients may be concerned primarily about the procedural aspects. One item concerned whether the patients were more anxious about the pain and side effects of a nasal spray (procedural) rather than missing the exact timing of its use (thereby affecting the outcome). Half of the subjects were concerned with the side effects rather than missing the timing. I n short, we believe that, unlike most other operational procedures, the psychological aspects of infertility are so great (cf. Golombok, 1992) that worries about outcome overshadow concerns about the procedural aspects of treatment. I t would be of interest to explore whether similar conclusions may be reached with patients in Western societies. Perhaps some psychological aspects of infertility and its treatment may vary across different cultural groups (e.g., Baluch, 1992; Baluch, Al-Shawaf, & Craft, 1992). REFERENCES
BALUCH,B. (1992) [Infertility and its psychological consequences in Iran.] Baranoosh Scientijic Quarterly, 5(1), 34-35. [Persian] BALUCH,B., AL-SHAWAF, T., & CRAFT,1 (1992) Prime factors for seeking infertility treatment amongst Iranian patients. Psycholog~t:alReports, 71, 265-266. DANILIJK, J. C. (1991) Strategies for ccunselling infertile couples. Journal of Counselling and Developmenl, 69, 317-320. DENNERSTEIN, L., & MORSE,C. (1988) A review of psychological and social aspects of in uiho fertilisation. Journal of Psychosomatic Obstetrics and Gynaecology, 9, 159-170. EDELMANN, R. J. (1990) Emotional aspects of in uitro fertilization procedure: review. Journal of Reproductiue and Infant Psychology, 8 , 161-173. GOLOMBOK, S. (1992) Review: psychological functioning in infertility patients. Human Reproduction, 7, 208-212. GREENFELD, D., & HASELTINE, F. (1986) Candidate selection and psychological considerations of in uitro fertilization procedures. Clinical Obstetrics and Gynaecology, 29, 119-126. GREENHALL, E., & VESSEY,M. (1990) The prevalence of subfertility: a review of the current conhsion and a report of two new studies. Fertility and Sterility, 54, 978-983. HARTZ,S. C. (1992) In uitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF-ET Registry. Fertilily and Sterilily, 57, 15-24. H O P K ~ES. , (1992) Behind the IVF hype: a shocking failure rate. Medical Economics, 1, 152163. MENNTNG, B. E. (1980) The emotional needs of infertile couples. Fertility and Sterility, 34, 313319. MORSE,C. A., & VAN-HALL,E. V. (1987) Psychological as ects of infertility: a review of current concepts. Journal of Psychosomatic Obstetrics anB~ynaecology,6, 157-164. SALTZER, L. P. (1986) Infertility: how couples can cope. Boston, M A : Hall.
1190
B. BALUCH, ET AL.
STEPTOE,P C., EDWARDS, R. C., & PURDY,J. M. (1980) Clinical aspects of pregnancy established with cleaving embryos grown in vitro. British Jor,mal of Obstetrics and Gynaecology, 87, 757-781. VAN-HALL, E. V. (1783) Ps chological and emotional aspects of infertility. Journal of Psycho2, 251.255. somatic Obstetrics an%~~naecology, Accepted October 23, 1992
APPENDIX
1. Are you more anxious about being examined internally (procedure) or about what the diagnosis might be (outcome)? (Administered on the day of initial consultation) 2. Are you more anxious about what the results of the blood test might indicate (outcome) or the act of your blood being taken (procedure)? (Administered on the day of initial consultation) 3 . Are you more anxious about the pain and side effects of the superfact nasal spray (procedure) or missing on the actual time of using the spray (outcome)? (Administered two days after the use of nasal spray) 4. Are you mote anxious about daily injections of hormones and their side effects (procedure) or the effects they might have on the gowth of follicles (outcome)? (Administered two days after injection of hormones) 5. Are you more anxious about what the ultrasound scan might indicate by way of growth of follicles (outcome) or the act of being scanned (procedure)? (Administered a day prior to ultrasound scan) 6 . Are you more anxious about being under full or partial anaesthetic (procedure) or the number of eggs retrieved (outcome)? (Administered 24 hours prior to operation) 7. Are you more anxious about possible pain in egg retrieval (procedure) or the quality of eggs retrieved (outcome)? (Administered 24 hours prior to operation) 8. Are you more anxious about the process of embryo transfer (procedure) or the number and quality of fertilized embryos (outcome)? (Administered 24 hours prior to embryo transfer)
