1 Reproductive Medicine Unit, Dept. Obstet.-Gynaecol., Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, 2 Consultation/Liaison Psychiatry Service, CHUV and 3 Institute of Psychology, Lausanne University, 1015 Lausanne, Switzerland
4 To whom correspondence should be addressed. e-mail: marysa.emery{at}chuv.hospvd.ch
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Abstract |
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Key words: assisted reproduction/counselling/emotional factors/infertility/IVF
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Introduction |
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A preventive counselling concept was developed in the Reproductive Medicine Unit (RMU) in collaboration with the Consultation/Liaison Psychiatry Service. A qualitative study evaluating videotaped interviews with infertile couples was carried out (Darwiche et al., 2002) and defined the offer of psychological support in relation to the narrative capacity of each couple. This narrative capacity indicates the way in which the partners share their personal and family histories as perceived by the interviewer. The hypothesis was that the couples abilities to stand back from their own stories and to share them with a third party is linked to their capacities to handle emotional stress, to act as partners to the medical team and to prepare themselves for future parenthood. In practice, this model of counselling requires couples to participate in an initial 6090 min interview in which they share the history of their infertility. The personal and family histories of both partners are also narrated and summarized on a genogram. This illustration includes family members and friends, strong ties and support as well as difficulties, conflicts, deaths, accidents, illnesses or other events which could have generated emotional distress. In conclusion, possible offers of further psychological support or investigation are discussed.
A retrospective study evaluating this model was carried out (Béran and Germond, 2000) and showed that the majority of participants felt reassured and had gained knowledge of their personal resources through counselling. Results indicated that routine counselling is more acceptable to couples than the selection of fragile couples by the treating physician. Selection reinforces the couples feelings of inadequacy: not only can we not have a baby naturally, but the doctor thinks we have a mental problem as well! As a routine procedure it specifies clearly to all patients that taking care of their emotional state is important.
Various types of psychological assistance in the field of assisted reproduction technologies have undergone evaluation. Domar et al. (2000) carried out a prospective controlled clinical trial comparing a cognitivebehavioural therapy group and a psychological support group with a control group. Results showed that the participants in the intervention groups experienced psychological improvement compared with the control group, especially in the cognitivebehavioural group. A controlled study by Stewart et al. (1992
) also showed that participants in their professionally led support groups lowered their anxiety and depression scores compared with controls. It must be noted that both these studies concern patients motivated for psychological support and therefore the results cannot be generalized to an IVF population. One study supporting the implementation of routine nurse counselling (Terzioglu, 2001
) shows that couples who receive daily information and support during treatment lower their anxiety and depression scores and indicate higher life satisfaction than controls. Connolly et al. (1993
) evaluated the effects of systematic psychosocial counselling through a randomized, controlled study. Couples having participated in counselling and in an information session were compared with those participating in the information session alone. The results showed no differences between groups in terms of anxiety and depression scores. However, only 82 of 152 couples completed the evaluation and the study concludes that these may represent the more robust couples, as those with psychological difficulties may have quit the programme. Furthermore, half of the IVF treatments were natural cycles, which are less invasive and thereby less stressful than those requiring pituitary down-regulation and ovarian stimulation. In conclusion it was mentioned that information alone may be sufficient to act as a protecting factor against anxiety and depression.
The aim of the present study was to evaluate the RMUs model of routine pre-IVF counselling which focuses on the narrative capacities of couples. The population was selected to be homogeneous for known factors that increase anxiety: only childless couples awaiting their first cycle of IVF treatment involving pituitary down-regulation and ovarian stimulation were included. The hypotheses were that routine pre-IVF counselling is acceptable to most couples, that it can contribute to lessening anxiety and depressive symptoms during and after the first cycle of IVF, and that couples feel they are helped through this form of psychological assistance. A prospective, randomized, controlled design was applied, using standardized measures. The two assessment points were before counselling and IVF, and 6 weeks after IVF.
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Materials and methods |
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Participant flow
Of the 288 patients (144 couples) approached for the study, six (three couples) declined participation because of lack of time or interest concerning the questionnaires. The remaining 282 were included as follows: 200 signed their consent for randomization and filling out questionnaires, giving 100 in group A (counselling) and 100 in group B (no counselling), another 24 wanted counselling and agreed to fill out questionnaires (group C) and 58 refused counselling but agreed to fill out questionnaires (group D). Thereafter, six participants (three couples) in group B requested counselling before IVF and passed into group C. Finally, the total of 282 participants were distributed as follows: 100 in group A, 94 in group B, 30 in group C and 58 in group D. There were 268/282 participants who returned the questionnaires at T1 (before commencement of IVF treatment) and T2 (6 weeks after embryo transfer). Two subjects in group A dropped out as they decided not to begin treatment. Others did not return questionnaires and were lost to follow-up (four in group A, three in group B, seven in group D). The variations of participant numbers in the analyses are due to missing data in questionnaires for each measure.
Study design
Data were obtained through self-administered questionnaires which were sent to the participants homes with a stamped envelope for their return. First they were mailed to all subjects at T1, after the nurses IVF information session, but before the counselling intervention for groups A and C and before the initiation of IVF treatment. Partners were asked to fill out the questionnaires separately. The second mailing occurred at T2, 6 weeks following embryo transfer and therefore 4 weeks after the outcome of treatment was known. If a participant had not sent back the questionnaire after 4 weeks, a replacement copy was sent. If there was still no response after 2 weeks, the subject was noted as lost to follow-up.
Measures
The State-Trait Anxiety Inventory (STAI)
The STAI is a widely used instrument composed of two 20-item scales. Each item has a four-point evaluation of how participants feel. The first 20 items evaluate how they feel right now (state anxiety), the second how they generally feel (trait anxiety). The French translation (STAI-Y) (Spielberger et al., 1993) was used, which includes scores of French populations in different situations of stress.
The Becks Depressive Inventory (BDI)
The BDI is widely used for detecting depression in normal populations and for evaluating severity of depression in clinical situations (Beck et al., 1988). It comprises 21 items, each with five possible indications of the severity of the symptom. The BDI is sensitive to change and exists in a validated French translation which was used for this study (Cottraux et al., 1985
).
Assessments of counselling
Participants were asked to rate the help they expected to receive through counselling at T1, and the help they had received at T2. The ratings were: no help (1), little help (2), moderate help (3), much help (4), or dont know.
They were also asked in which areas they had received help: by receiving technical explanations (body functioning, aspects of treatment); by receiving psychological support; by reinforcing the solidarity within the couple; by discussing family relationships; by other means; dont know. More than one answer was possible.
Statistical analyses
Mean trait anxiety (STAI-T), state anxiety (STAI-S) and depression (BDI) scores were computed using analyses of variance (ANOVA). The within-subjects variable was time. The between-subjects variables for simple and interaction effects were: group, gender and outcome.
The differences between ratings of expected help at T1 were analysed with the non-parametric KruskalWallis test. The Wilcoxon signed rank test was applied to differences at T2 between groups A and C who had received counselling. For the various types of expected help, differences between groups at T1 were analysed with 2-tests. Cochrans Q-test was applied to differences between T1 and T2. A confidence interval of 95% was used for interpreting the significance of differences.
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Results |
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Acceptability of counselling
The initial distribution of the sample in the four groups shows that pre-IVF counselling was acceptable to 224/282 (79%) of all participants: 200 agreed to be randomly attributed to the counselled or non-counselled groups, and another 24 requested a counselling session. The 24 subjects (8.5%) who requested counselling before treatment put forward their need to better understand what they were going through, to feel less alone and to receive support. Of the 58 (20.5%) refusing counselling, 28 indicated being interested but not wanting to take more time off work, 18 felt strong enough and had no interest, 12 felt they already had enough support in their environment. The 200 participants (70%) accepting randomization had no strong feelings either way but were open to the idea of counselling. All subjects knew that psychological support would be available in case of need and six participants in the randomized no-counselling group B did request it before their treatment.
In the groups A and B accepting randomization, the percentage of higher education was 40% (40/95 and 36/91 respectively) while it was 20% (10/51) in group D who refused counselling and 70% (21/30) in group C who requested counselling. The differences were statistically significant between the four groups (
2 = 20.26, P < 0.001), and between group D and C (
2 = 20.30, P < 0.0001).
Trait anxiety
Higher scores indicate a higher level of trait anxiety. Norms for French-speaking adults (Spielberger et al., 1993) in non-stressful situations are: 41.9 ± 9.5 for men, and 45.1 ± 11.1 for women. In this sample, mean scores for both genders are within the normal range for all groups at T1 and T2 (Table I). There are no differences between the counselled and non-counselled groups. The outcome of treatment influences the evolution of scores between T1 and T2 (Table II). Contrast analyses show that for participants with a pregnancy, scores decrease (P < 0.01) between T1 and T2. Furthermore, scores are lower at T2 (P < 0.01) for participants with a pregnancy than for those with a negative outcome.
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Depression
Higher scores on the BDI indicate more depressive symptoms. The cut-off score (Beck et al., 1988) for minimal depression is 10.9 ± 8.1 and for mild depression it is 18.7 ± 10.2. Results from this sample show mean BDI scores under the limit for minor depression for all groups at T1 and T2 (Table I). There are no differences between counselled and non-counselled groups. Mean scores are significantly higher (F = 6.48, P = 0.012) at T2 (4.6 ± 5.1) than at T1 (3.6 ± 4.0) in the total sample, indicating a general rise in depressive symptoms. The womens mean scores (5.1 ± 4.4) are overall higher (F = 7.24, P = 0.008) than the mens (3.1 ± 3.6). Furthermore, as shown in Table II, participants with a pregnancy have lower scores at T2 (P < 0.001) and lower total scores (P < 0.05) than those with a negative outcome.
Assessments of counselling
At T1, 65% (174/267) of participants noted that they expected to be helped through counselling. The ratings were significantly higher (2 = 31.1, P < 0.001) in groups A (3.2 ± 0.8) and C (3.4 ± 0.6), who were to receive counselling, than for groups B (2.6 ± 0.9) and D (2.5 ± 0.9), who were proceeding without counselling. At T2, the majority of subjects who had participated in counselling noted that they had received help: 86% (75/87) in randomized group A and 96% (25/26) in group C who had requested counselling from the start. There were no differences between the ratings of help received and expected, which remained moderate in both groups.
The types of help participants expected at T1 are summarized in Table III. Most help was expected through technical explanations and psychological support. In group D, where participants refused counselling, fewer subjects expected help than in other groups (P < 0.01). However, 37% (19/51) did expect that help could be provided through technical explanations and 29% (15/51) through psychological support. In group C, where counselling was requested, 70% (21/39) of participants expected help through psychological support and this was significantly more (P < 0.01) than in the other groups.
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Discussion |
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Concerning the effects of counselling on the patients emotional states, this study revealed mean anxiety and depression scores in the normal no stress range for all groups before and after IVF. As observed in other studies, women presented higher state anxiety and depression scores than men (Beaurepaire et al., 1994; Slade et al., 1997
; Boivin et al., 1998
), as did participants with a negative outcome compared with those with a pregnancy (Beaurepaire et al., 1994
; Bryson et al., 2000
; Kee et al., 2000
; Hammarberg et al., 2001
). However, there were no significant differences between counselled and non-counselled groups and the second hypothesis that pre-IVF counselling could positively influence anxiety and depression scores was not verified. The previously mentioned controlled study (Connolly et al., 1993
) also resulted in no measurable effects of counselling on emotional factors. Higher levels of anxiety were expected in the present study because it included only first IVF attempts for childless couples, because the financial aspects were consequential (there is no insurance policy covering IVF in Switzerland) and because of the more intrusive nature of the treatment (all cycles with pituitary down-regulation and ovarian stimulation). The relatively low scores indicated that subjects were emotionally well prepared for coping with their IVF treatment and outcome. However, the questionnaires employed may have been insufficient to specifically evaluate emotional components related to infertility and assisted reprodutive technologies. An extensive review of psychosocial interventions in infertility (Boivin, 2003
) has recently demonstrated that studies using non-validated outcome measures of infertility-specific distress showed more positive effects of psychosocial interventions than those using non-specific or global measures. Future research recommendations therefore aim toward the further development and validation of measures with higher specificity (Glover et al., 1999
; Newton et al., 1999
).
Over half of the participants expected counselling to be helpful, including those who had refused to take part in a session. Individuals who knew they were to participate in counselling expected to receive more help than those who were to proceed without counselling. For those having requested counselling this seems evident, and for the randomized group it may indicate a positive but also resigned attitude: since we are going to do it, we might as well be positive, which is often heard in the consultations. The great majority of participants report having been helped by counselling, whether they were initially motivated (96%) or not (86%). They rated the help received as slightly above moderate which corresponded to the rate of help they had expected. This signifies that the objectives of counselling were initially well defined and understood by the participants and it confirms the third hypothesis that participants receive help through this form of psychological assistance. Help was mostly expected in the areas of technical explanations and psychological support, over reinforcing the solidarity in the couple and discussing family relationships. Fewer participants received help through technical explanations than initially expected help in that area. Technical questions evidently have their place in assisted reproductive treatment counselling as clarifications give reassurance and furthermore provide openings to explore certain fears or doubts that couples are burdened with. However, this model of counselling focusing on the narrative is clearly oriented toward psychological support. This is confirmed by further results which showed that more participants had received help through psychological support (65%) and discussing relationships (33%) than had initially expected help in these areas. These assessments support former observations that pre-IVF counselling is perceived as globally reassuring and helpful (Connolly et al., 1993; Béran and Germond, 2000
).
The psychological reactions related to the unfulfilled desire to have a child and the fear of treatment failure are the unchanging issues which must be recognized and addressed for every couple (Beaurepaire et al., 1994; Syme, 1997
; Wischmann et al., 2002
). Moreover, as assisted reproduction technologies advance and ethical limits are challenged, other issues arise which bring about new doubts and concerns. During the early years of IVF, anxiety levels were higher because the procedures were new, considered with suspicion and were often kept secret (Golombok, 1992
). Ten years later, technical advances have made procedures more comfortable and outcome studies concerning the physical and mental health of IVF offspring are generally reassuring (Golombok, 2000
; Sutcliffe et al., 2001
; Bonduelle et al., 2002
). However, a recent study of ICSI offspring showed that the risk of a major birth defect was twice as high than in naturally conceived children (Hansen et al., 2002
) and concerns about the safety of ICSI have been reactivated. Disquiet also emerges when the media expand on excesses of scientific power as in reproductive cloning, treatment of elderly women or errors occurring in assisted reproduction technologies. These aspects have not been taken into account in this study but arise from the practice of routine counselling where couples concerns are voiced and worked through. To measure this function of counselling may be difficult but it may also be necessary in order to widen the accepted scope of its helpfulness. The omnipresent issue of cost-effectiveness and the limited resources for psychological interventions make it difficult to favour of routine counselling as hard data do not show enough distress to justify psychological assistance for all (Boivin et al., 1999
). This was confirmed in the present study, but it also showed that even non-demanding participants feel helped and reassured through counselling. Creating a supportive relationship in which couples confronted with assisted reproduction technologies can work through their ethical deliberations and their emotional reactions represents the basis for recommending routine pre-IVF counselling.
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Acknowledgements |
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References |
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Submitted on April 10, 2003; resubmitted on July 1, 2003; accepted on September 8, 2003.