The impact of treatment experiences on the course of infertility distress in male patients

M. Pook1,3 and W. Krause2

1 Department of Psychology, University of Siegen and 2 Clinic of Andrology, Philipps-University of Marburg, Germany

3 To whom correspondence should be addressed at: Staatsinstitut für Schulqualität und Bildungsforschung, Schellingstrasse 155, D-80797 Munich, Germany. Email: martin.pook{at}isb.bayern.de


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: Previous research on infertile males has delivered equivocal findings on the course of infertility distress in males. The present longitudinal study examines whether there are differentials associated with specific treatment experiences (i.e. duration of treatment, the diagnosis received, and treatment failure of assisted reproductive technologies). METHODS: The sample consisted of 118 patients who twice visited an andrology clinic on their own initiative for fertility work-ups. Baseline and follow-up examinations were ≥6 months apart. Prior to each fertility work-up, patients completed a questionnaire assessing distress due to infertility. RESULTS: No uniform course of distress could be detected. A significant interaction between treatment experiences indicated that distress rises significantly only in those patients who were in treatment ≥17 months and experienced treatment failure between the first and the second psychological evaluation. For the diagnosis of male infertility, however, neither a direct nor an indirect impact was identified. CONCLUSION: The present study indicates that the interaction of specific treatment experiences is associated with changes in distress of infertile males.

Key words: counselling/IVF/male infertility/psychological stress


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A great deal of psychological research on infertility has focused on the question, ‘Are infertiles distressed?’ rather than on the question, ‘Is infertility distressing?’ (Greil, 1997Go). As a consequence, little is known about the determinants of distress in infertile males. Neither cross-sectional nor longitudinal research has resolved whether the level of distress changes over time. Cross-sectional studies have revealed positive (Kedem et al., 1990Go), negative (Sabatelli et al., 1988Go) and insignificant (Band et al., 1998Go) correlations between distress and the duration of infertility or of infertility treatment. One study even suggested a U-shaped curve of distress over time (Berg and Wilson, 1991Go). Longitudinal research produced a similar diversity of findings. Some studies identified a decrease of distress (Connolly et al., 1992Go; Pook et al., 2002Go), whereas the majority found no significant change (Möller and Fällström, 1991Go; Benazon et al., 1992Go; Slade et al., 1992Go; Glover et al., 1996Go).

In the face of this diversity, one might speculate about aspects interacting with the length of time. The cause of infertility has been analysed as such a determinant. Unfortunately, research has once again led to different conclusions. To the best of our knowledge, no prospective study has up to now delivered statistically supported evidence that the progress of distress depends on the diagnosis received. Even without reporting a significant interaction between time and diagnosis, however, some authors in their studies saw some indication for a particular increase of distress after receiving the diagnosis of male infertility (Connolly et al., 1992Go; Slade et al., 1992Go).

Not only the diagnostic status, but also treatment failure of assisted reproductive technologies have been studied as potential determinants of the course of infertility distress. Here, prospective studies clearly indicate that distress in males sharply rises subsequent to failure of IVF (Newton et al., 1990Go; Slade et al., 1997Go) and of intrauterine insemination (Bergius and Stanton, 2002Go). Since this is sound and longitudinal research, one might tend to ignore the result of a sound, cross-sectional study indicating that the distress in male patients undergoing IVF does not depend on the experience of former treatment failure (Beaurepaire et al., 1994Go). Yet, it seems unwise to neglect the disparity induced by the latter study, as it sheds light on a shortcoming of prospective research on infertile males: little attention has been paid to whether the participants are still using fertility services at the time of follow-up. Thus, one reason for the diversity of findings with respect to the course of distress in infertile males might simply be heterogeneity in the behaviour of the study samples.

Therefore, in the present longitudinal study, a homogeneous sample of male infertility patients still seeking treatment at the time of follow-up assessment was included. Furthermore, the duration of treatment, the diagnosis received and the experience of treatment failure were analysed simultaneously as potential determinants of the course of infertility distress. Thus, interactions between these aspects could be studied.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Sample
The sample consisted of patients who visited an andrology clinic for two fertility work-ups ≥6 months apart. For the present analysis, some data from a previous study (Pook et al., 2004Go) were used. Of the 120 participants from the previous study, eight patients were excluded. Those patients had already had relevant treatment experiences (e.g. undergoing a complete fertility work-up or even having experienced treatment failure) prior to their first visit to our clinic, bearing the risk of inconclusive findings for the present study. Including a subgroup of six patients who had dropped out of the previous study partially compensated for the excluded group. Their data had been insufficient for the previous study because the patients had delivered no semen specimen on the day they filled out the questionnaire. Since concurrent assessment of psychological variables and seminal parameters is not necessary for the present study, these patients could be included in the analysis. Thus, a total of 118 patients was available for the present study. None of these patients were azoospermic.

Mean age of the patients at the former fertility work-up was 32.7 years (range 20.6–42.3). Mean duration of infertility at the former fertility work-up was 30.2 months (range 2.0–120.0) according to the patients' estimates of the length of time of unprotected intercourse. Mean interval between the former and the latter fertility work-up was 21.4 months (range 6.0–73.5).

Variables
The Infertility Distress Scale (IDS) was employed to assess the stress resulting from infertility as perceived by the participants. It consisted of eight items on 5-point Likert scales. The items ask for ratings of: (1) the distress due to the spouse's last menstruation; (2) the distress due to infertility as a whole; (3) the importance of a child; (4) the appraisal that infertility represents a challenge; (5) the appraisal that infertility represents a threat; (6) feelings of helplessness due to infertility; (7) the frequency of thoughts about infertility; and (8) the desire for a child. The IDS has been evaluated extensively (cf. Pook and Krause, 2002Go, for a review). Factor analyses revealed and confirmed that there is a single dimension underlying the eight items. Internal consistency ({alpha}=0.89) and retest reliability (e.g. r=0.74 for a follow-up of 4 months) were found to be good. The scale correlated highly with the KINT-Questionnaire (Pook et al., 1999aGo), which is a validated measure of infertility distress. Correlations with widely used measures of depressiveness are in the small-to-medium range. Additional findings indicate that the IDS is sensitive to change. There are also norms available for the IDS based on a sample of >750 patients. Even in the large normative sample, the scores were distributed approximately normally.

Information about the independent variables (usage of assisted reproductive technologies, the diagnosis received and the interval between the first and the later clinic attendance) was taken from the patients' files. These variables were used in binary form for dividing the sample into subgroups. While treatment failure of assisted reproduction treatment and the diagnosis of male infertility can easily be coded dichotomously, there were different options for dichotomizing the time between the first and second clinic visit. To achieve maximum confidence in the findings, data had been analysed with various thresholds for dividing the groups (located between 15 and 24 months). The same pattern of results emerged regardless of the strategy for dichotomization. For the present analysis, median split was chosen in order to avoid extremely unequal cell sizes in the analysis of variances. Furthermore, median split allowed the final group assignment to take place after data collection had been finished.

Procedure
The present study is the second and final part of a larger research project. Over a period of 3 years, prospective data were collected from consecutive repeat consulters of an andrology clinic. All appointments for fertility work-up were made on the participants' initiative. Upon arriving at the andrology clinic, every patient filled out the IDS prior to the medical examination at every visit as a matter of routine. The medical examination was the same for every patient. It consisted of a medical history, a physical investigation including sonography of the testes, and a semen analysis. After all laboratory tests had been performed, the patients received the reports of the fertility work-up in written form by mail. The local Ethics Committee confirmed that patient consent was not necessary for the present study because the (anonymized) data were obtained during routine clinical investigation.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
First, the variables needed to divide the sample into subgroups were analysed. For the whole sample, mean interval between the former and the latter fertility work-up was 21.4 months. After median split, patients with an interval of <17 months were assigned to the first group. Patients with an interval of ≥17 months were assigned to the second group. Mean interval between the former and the latter fertility work-up was 11.7 months in the first group (SD=2.6) and 31.1 months in the second (SD=13.7, including an extreme outlier of 73.5 months). On request of an anonymous reviewer, the outlier was excluded from the analysis reported below. However, once again it became obvious that the results of the present study do not depend on any detail of the data analysis.

Of the remaining 117 patients included in the analysis, 41 (35.0%) had experienced treatment failure with assisted reproduction technology between the first and the later clinic visit (the remaining patients did not undergo assisted reproduction treatment). In addition, 58 patients (49.6%) had been diagnosed in the first fertility work-up as having impaired fertility. After these sample characteristics had been analysed, each participant could be assigned to one of eight groups, depending on the interval between the former and the latter fertility work-up (length of follow-up: short versus long), the diagnosis received (male factor: yes versus no), and treatment failure with assisted reproduction technology (assisted reproduction treatment: yes versus no). Afterward, the course of distress could be analysed in more detail. To do so, a four-way analysis of variance was conducted with three between-subject factors (length of follow-up, male factor, and assisted reproduction treatment) and one within-subject factor (time: baseline versus follow-up assessment). The dependent variable was infertility distress.

The analysis of the course of distress is summarized in Table I. The main effect ‘time’ was insignificant, with a rather small effect size {eta}2. This indicates that there is no general change in distress over time. Furthermore, most of the interactions between time and the other independent variables were also insignificant. Two of the results led to further examinations. First, since there was a marginal four-way interaction (timexlength of follow-upxmale factorxassisted reproduction treatment), data of the eight groups were inspected (Table II). Male factor patients who experienced treatment failure showed a large decrease in distress when the length of follow-up was short, but a large increase when the length of follow-up was long. However, the only group with a critical sample size (i.e. n<10) was involved here. Moreover, the large decrease in this group was associated with increased within-group variability (i.e. a larger SD) at the follow-up assessment. These two aspects raise serious doubts concerning the reliability of the suggestive four-way interaction. Thus, this effect was no longer considered relevant.


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Table I. Changes in infertility distress over time

 

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Table II. Analysis of the four-way interaction time x length of follow-up x male factor x ART

 
The second finding presented in Table I leading to further analyses was the significant three-way interaction timexlength of follow-upxassisted reproduction treatment. This effect indicates that a change in distress could be related to a specific experience of treatment failure and the time in treatment. Before arriving at such a conclusion, however, groups were checked for baseline differences. One-way analysis revealed that there was no significant difference between any of the four groups at the initial assessment with respect to the distress scores (F<1; df=3,113). Two-way analysis (length of follow-upxassisted reproduction treatment) of distress scores at baseline assessment revealed the same result. The final analysis of the change scores (Table III) indicated that the change in distress is related to a specific experience of treatment failure and the time in treatment. Although no significant changes of distress could be detected for three of the groups, one group showed a significant increase in distress. This group consisted of patients who were in treatment ≥17 months and experienced treatment failure between the first and the second psychological evaluation. Moreover, the significant three-way interaction timexlength of follow-upxassisted reproduction treatment indicates that this course of distress is different from those of the other groups. Thus, obviously neither a long time in infertility treatment, nor the experience of treatment failure, is sufficient to induce distress in males seeking repeat andrological consultation.


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Table III. Analysis of the three-way interaction time x length of follow-up x ART

 

    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
In prospective psychological research on male fertility patients up to now, researchers have sought contact to participants for the follow-up assessment. In the present study, the patients themselves sought contact to fertility services at the follow-up. This change in study design represents an improvement in both internal and external validity in the prospective psychological research on infertility. Internal validity is improved because loss and refusal of patients represent no problems. For years now, the IDS has been employed as matter of routine at the clinic where the present study was conducted. Only a small proportion of the attendees (~3–4%) fill out the questionnaire too incompletely for the calculation of the sum score; the majority of these patients are immigrants who have difficulty reading the items. More importantly, the rate of patients refusing the questionnaire is extremely low (<1%), even when asked to fill it out again at their second or third clinic attendance. Therefore, the problem of attrition between baseline and follow-up assessment is practically irrelevant in the present study.

Compared to previous research, external validity is also improved in the present study, because it provides information about re-attending infertile males, who represent those who are seen by infertility specialists. Up to now, practitioners could only rely on longitudinal research, which does not differentiate between patients who are still seeking treatment and those who terminated treatment, although it is uncertain whether or not there are differences between ‘continuers’ and ‘discontinuers’. It must be noted, however, that the present study was not designed to identify such differences. Therefore, any reliance on the present results to explain the care-seeking behaviour of infertile males should be cautious. In other words, it is uncertain whether the long-time ‘continuers’ are particularly those males who experienced treatment failure and feel highly distressed. Nevertheless, the present findings might suggest a hypothesis that is worthy of future evaluation.

Focusing solely on those patients who continue treatment, the present study identified an interaction between different treatment experiences, which was followed by raised distress. This interaction could also represent a starting point for the integration of the diverse findings on the course of infertility distress in males outlined in the Introduction. Upon closer examination, it becomes obvious that the diversity of results corresponded to different treatment experiences of the study participants.

The diagnosis of male infertility also represents, at least in a broader sense, a treatment experience. An analysis of a patient sample having a strong overlap with the present one had already revealed that the results of a former fertility work-up have no direct impact on distress, neither as a categorical variable (i.e. impaired versus unimpaired fertility) nor as a continuous variable (i.e. value of sperm concentration) (Pook et al., 2004Go). The present study goes far beyond those analyses, because here indirect effects were considered. Yet, even when various possible interactions between the diagnosis received and other treatment experiences were examined, no effect could be detected. Thus, the present study provided further evidence for the limited impact of the received diagnosis on the patient's well-being. Nevertheless, it would seem a worthy object for future research to consider interactions between the diagnoses received by both members of an infertile couple.

Independent of this future research, the present study suggests complex interactions between different treatment experiences. In addition, previous research has already indicated that marital (e.g. Andrews et al., 1991Go) and cognitive factors (e.g. Pook et al., 1999bGo) have to be considered for modulating the infertility distress in males. Given this complexity, there is little reason to assume a ‘universal’ course of infertility-related concerns. There are, however, various stage models that propose uniformity in the reaction to infertility over time (e.g. Menning, 1980Go). Not surprisingly, this kind of model has been criticized as empirically unsupported (e.g. Stanton and Dunkel-Schetter, 1991Go). Findings like the present suggest that it makes little sense to await this support in future.

Although it seems more promising for future research to focus on the interaction of treatment experiences, eventually expanded for covariations with marital and cognitive factors, there are serious limitations: the more complex the interactions, the more patients will have to be recruited for a study. Therefore, there is little hope that the determinants of distress in infertile males will ever be fully understood. Nevertheless, improved understanding—even if incomplete—provides the chance for tailoring psychological services to better meet patient needs. For example, if counselling offers emphasize the burden of the diagnosis of male infertility, the patients' needs are not being met according to the present findings. The currently low uptake of counselling services by infertility patients should therefore motivate further research to better understand the sources of infertility distress in male patients.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
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Submitted on June 23, 2004; resubmitted on September 27, 2004; accepted on November 11, 2004.





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