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
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Abstract |
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Key words: counselling/IVF/male infertility/psychological stress
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Introduction |
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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., 1992; Slade et al., 1992
).
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., 1990; Slade et al., 1997
) and of intrauterine insemination (Bergius and Stanton, 2002
). 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., 1994
). 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.
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Materials and methods |
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Mean age of the patients at the former fertility work-up was 32.7 years (range 20.642.3). Mean duration of infertility at the former fertility work-up was 30.2 months (range 2.0120.0) 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 6.073.5).
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, 2002, for a review). Factor analyses revealed and confirmed that there is a single dimension underlying the eight items. Internal consistency (
=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., 1999a
), 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.
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Results |
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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 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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Discussion |
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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., 2004). 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., 1991) and cognitive factors (e.g. Pook et al., 1999b
) 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, 1980
). Not surprisingly, this kind of model has been criticized as empirically unsupported (e.g. Stanton and Dunkel-Schetter, 1991
). 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 understandingeven if incompleteprovides 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.
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Submitted on June 23, 2004; resubmitted on September 27, 2004; accepted on November 11, 2004.
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