1 Divisions of Obstetrics and Gynaecology and 2 Child and Adolescent Psychiatry, Faculty of Health Sciences, University of Linköping, Sweden
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Abstract |
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Key words: child behaviour/couples relationships/infertility/parental health
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Introduction |
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Couples seeking assisted reproductive treatment (ART) undergo prolonged investigations and treatment. Most studies have focused on the stress associated with IVF treatment, and physical and psychological circumstances around the treatment procedures. Less attention has been paid to how infertility and infertility treatments affect marital relationships in the long-term. However, studies by Connolly et al., Abbey et al. and Golombok et al. have shown that couples who have experienced infertility are in general well adjusted and stable in their relationship and psychological well-being (Connolly et al., 1993; Abbey et al., 1994
; Golombok et al., 2002
).
In short-term studies on donor and IVF families, parenthood and child development have been reported to be good (Golombok et al., 1993; van Balen, 1996
; Cook et al., 1997
; Gibson et al., 2000
; Hahn and Di Pietro, 2001
). Most of these studies have approached the IVF families when the children are 28 years old and compared them with families who have adopted or donor-conceived children, and with couples with spontaneously conceived children. The interpretation of these results is somewhat limited since the sample sizes have been small and the response rates in some studies are low. However, one exception is Golombok et al.s longitudinal European study based on 102 IVF families and an equally large group of families with spontaneously conceived children (Golombok et al., 1993
, 2002
).
Studies on physical health in the infertility-treated mother and her child during pregnancy, delivery and the neonatal period show high rates of Caesarean section, prematurity and children small for gestational age, and an increased risk of congenital malformations (Tan et al., 1992; Gissler et al., 1995
; Von Düring et al., 1995
; Bergh et al., 1999
). The interpretation of these results was that the high frequency of multiple births and the high maternal age were contributing factors, not the IVF technique itself. In a study with an age-matched control group of singleton IVF pregnancies, Reubinoff and colleagues did not find any increased risk for prematurity, low birth weight, or maternal or fetal complications, but a still high rate of Caesarean section (Reubinoff et al., 1997
) in IVF mothers. Their explanation for this outcome was the correction for the maternal factors.
The health of IVF children has been investigated and no statistically significant negative effects have been found on their mental and physical development (Cederblad et al., 1996). While IVF children and their mothers might differ from others in the quality of the parentchild relationship, little research has yet been done in this field. Weaver et al. reported that IVF parents expressed more positive feelings towards their children compared with those who spontaneously conceived, and are more protective towards their children (Weaver et al., 1993
). Golombok et al. reported a strong motherly warmth and high emotional involvement with the child among mothers who conceived by assisted conception (Golombok et al., 1995
). Furthermore, superior parentchild interactions and lower levels of parental stress were found.
There are many stress factors associated with the transition to parenthood for all couples, regardless of their previous fertility status (Belsky and Rovine, 1990; Osofsky and Culp, 1992
; Wadsby and Sydsjö, 2001
). The adjustment to parenthood and marital relationship after the first child is born might be different between men and women who have experienced infertility, as the woman in an infertile couple will have been through more investigations and will perhaps perceive the infertility investigations and treatments as more negative than the man (Van Balen and Trimbos-Kemper, 1993
).
The fact that infertility has been a deeply distressing experience can perhaps be overlooked by most women when they finally become pregnant. But for some couples or individuals there may be an idealization about parenthood and a wishful positive impact on their relationship. To our knowledge, the effects of becoming a parent on the relationship of previously infertile couples (with the experience of a variety of infertility treatments and investigations behind them) have not been prospectively studied using an age-matched control group. Many aspects of the marital relationship might be affected by efforts to have a child or to come to terms with involuntary childlessness, including sexuality, self-esteem, communication patterns and future life choices.
As there is obviously still a lack of knowledge in the field of IVF couples and their children, the aim of the present study was to compare the experience of relationships and parenthood in primiparous IVF couples with the experience of couples who had become spontaneously pregnant with their first child.
A second aim was to study obstetrical and neonatal data, and the childrens temperament and behaviour in relation to the parents relationship.
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Methods |
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None of these couples was identified as having psychosocial problems, such drug/alcohol, psychiatric and/or social problems, according to defined criteria of relevance for pregnancy and parenthood (Sydsjö, 1992). No IVF treatment with donated gametes was performed, as this is not legal in Sweden.
The mean age for the women was 31.8 ± 3.3 years (range 2439), and for the men 33.1 ± 3.3 years (range 2540). The couples had lived together for an average of 76.4 ± 27.1 months (range 29168). They had experienced infertility for an average of 5 years (range 215) before treatment. Fifty percent of the couples became pregnant at the first IVF treatment cycle and 50% went through 24 cycles before obtaining pregnancy.
The group was representative of the socio-economic distribution and employment status in the study area.
Control group
A total of 108 spontaneously pregnant women and their spouses, recruited from a parallel ongoing prospective longitudinal study of a population-based sample, also at Linköping University Hospital, formed the control group. They were matched to the study group on the womens age, and were all first time parents-to-be. At the follow-up, three couples did not take part, so that the control group comprised 105 couples.
The mean age of the women in the control group was the same as in the study group because they were matched. The mean age of the men in the control group was 32.3 ± 5.8 years (range 2450). The couples in this group had lived together for an average of 33.0 ± 27.5 months (range 1132). This was a significantly shorter time than that of the couples in the study group (P = 0.0001).
In addition, this group had a socio-economic and employment status equivalent to the study group and the population in the study area. For further details about the study from which the control group was recruited, see the study by Wadsby and Sydsjö (Wadsby and Sydsjö, 2001).
Procedure
The couples were sent an introductory letter, which explained the purpose of the study and contained a request from G.S. to contact the authors by phone so that they could explain more about the study and ask for participation. This was done around gestational week 1520.
The second phase of the study was carried out when the children had reached 12 months of age. The couples were again approached by mail and asked to take part in the study. One couple in the IVF group whose child died shortly after partus was not approached again for participation.
Measures
Questionnaire
The Swedish version of the ENRICH marital inventory, originally compiled by Olson and co-workers (Fournier et al., 1983; Olson et al., 1987
), was used to describe marital dynamics. The inventory provides scores of the wives and husbands evaluation of their relationship in 10 categories, each comprising 10 items. The scales are briefly described as follows.
Each category scale can vary between 10 and 50 points, 50 being the most positive outcome. Totalled, the category scale scores provide a global assessment of marital satisfaction varying between 100 and 500 points.
The ENRICH scale also includes a positive couples agreement (PCA) score which is a measure of the couples consensus for each of the 10 relationship areas. Husband and wife responses are combined and the items that they agree on (within 1 point on a 15 scale) are totalled and converted to a percentage score, which could range from 0 to 100%. The PCA includes only those items where they both see the issues as positive.
ENRICH scales have shown good internal consistency (alpha, range = 0.690.97) and testretest reliability (rtt, range = 0.650.94), as well as content and construct validity (Fournier et al., 1983). The discriminant and concurrent validity of these scales have been established (Fowers and Olson, 1989
). The Swedish version of the inventory has been evaluated (Wadsby, 1998
), whereby the reliability and the validity of the instrument has been established to be satisfactory.
Interview
A telephone interview was carried out with every second couple in each group, i.e. 50% of each group was interviewed. The questions had predefined answers, and the interviewers were careful to capture the answers correctly before being noted in the protocol. This interview was designed to complement the questionnaires in order to gain a deeper picture of the couples apprehension of being parents together. All the interviews were conducted by two experienced interviewers trained together for the purpose of this study. Men and woman were interviewed separately.
Medical records
Every woman who was included in the present investigation attended the public antenatal care units operating in the south-east region of Sweden, and the obstetrical findings were registered in standardized antenatal and delivery records. All information concerning the progress and outcome of the pregnancies was manually extracted from the records by the authors.
Toddler behaviour questionnaire
In order to investigate temperament and behaviour in the infants, the toddler behaviour questionnaire was used (Hagekull et al., 1980; Bohlin et al., 1981
). The questionnaire is filled in by the parents, and is suitable for children 1115 months old. The inventory is designed to yield information about specific behaviours in the everyday situations that most infants encounter (e.g. sleeping, feeding, response to caring, playing, meeting new situations and new people). It measures six behavioural dimensions: intensity/activity, regularity, approach/withdrawal, sensory/sensitivity, attentiveness and manageability. The questionnaire comprises 37 items which are coded on a 5-point scale. Reliability and stability estimates have been known to be satisfactory (rtt range = 0.630.93, alpha range = 0.510.77) (Hagekull and Bohlin, 1981
). Direct observations of infant behaviour, together with the scale, have shown satisfactory results as regards concurrent validity (Hagekull et al., 1984
).
Ethical considerations
The Human Research Ethics Committee at the Faculty of Health Sciences, Linköping University, approved this study.
Statistical methods
Repeated measures analysis of variance with group as the between-subjects factor and duration of relationship as co-variate was carried out on each of the marital scales (Tables I and II). The results of these analyses are presented as means and 95% confidence intervals (CI), adjusted for false significance with the method of Bonferroni.
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Results |
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In comparison between the assessments at the two study occasions, the IVF group was found to be less satisfied with conflict resolution. On the other hand, they turned out to be more satisfied with equalitarian roles. However, the control group showed a decline in satisfaction on all scales, although the changes were significantly lowered only in communication, sexual relationship, and children and parenting.
When comparing the PCA scores, it was found that the IVF group scored higher than the control group on five of 10 scales during pregnancy, and that the control group scored significantly higher than the IVF group on perception of life (Table II). At follow-up, the control group showed a lower agreement score than the IVF group on all scales, except for conflict resolution.
The PCA scores remained similar on the two study occasions, although the score on equalitarian roles was significantly higher for the IVF group. The control group had a lower agreement score on sexual relationship and conception of life.
Obstetrical and neonatal data
The majority of the women in the IVF group had a normal pregnancy, as shown in Table III. There were 14 twin pregnancies (12%) in the IVF group and two in the control group. There were no triplets or quadruplets in any of the groups.
The number of visits to the midwife at the antenatal care clinics during pregnancy was 9.6 and 10.1 for the IVF and control groups respectively. In both groups, the women had an equal number of visits to the obstetrician at the antenatal care clinics: 2.6 (range 18) in the IVF group and 2.1 (range 111) in the control group.
Sick leave during pregnancy was more frequent among the IVF women: 60 women (54%) compared with 40 (44%) in the control group (P < 0.01) The major reason for sick-listing in both groups was complicated multiple pregnancy and premature contractions. If the twin pregnancy women were subtracted, no difference in sick leave could be found.
Ten women in the IVF group had been referred to hospital for an average of 5.3 days (range 130) during their pregnancies; five women in the control group had been hospitalized for an average of 11 days (range 130). The reasons were premature contraction, abdominal pain and twin pregnancies for both groups.
Table III shows the pregnancy outcome in both groups. The majority of women in both groups had normal vaginal deliveries, and the distribution of instrumental deliveries was the same in the groups.
The number of days spent in the maternity ward was 4.0 ± 1.1 (range 28) for mothers in the IVF group and 4.5 ± 2.1 (range 218) for those in the control group. This difference was due to one child in the control group having a serious heart condition, and one child being born prematurely in gestational week 34.
The childrens somatic health
The childrens neonatal health data is shown in Table III. Of the 122 children born in the IVF group, all were healthy except for the child who died and one who was diagnosed with Downs syndrome. None of the IVF twin children had any malformations. Of the 110 children in the control group, one hadas previously mentioneda heart condition and one child had a clubfoot.
One mother in the IVF group and two mothers in the control group did not breastfeed when discharged from the maternity ward.
Interview with the parents
The interviews revealed an overall positive experience of becoming parents according to both men and women (Table IV). One difference between the sexes was noted: the men in both groups perceived that the child took more time and energy from being husband and wife than did the women.
The childrens behaviour and temperament
Table V shows the means and SDs for the six scales in the two groups. Significant differences were present for four of the six scales, i.e. the IVF parents scored their children as more regular/habitual, more sensitive to strong stimuli, more attentive, and more manageable than the children in the control group.
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Discussion |
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The investigation and treatment for infertility had no negative impact on the couples relationship when they were finally successful. On the contrary, the relationships seemed to be strengthened by the fact that the couple had been through a physically and psychologically demanding time before conception. This is in accordance with a number of studies that have studied couples psychological well-being and found that what is most stressful about infertility and treatment is not the medical procedures per se, but the fact of trying to conceive and not succeeding (Lieblum et al., 1987; Baram et al., 1988
; Callan and Hennessey, 1988
; Connolly et al., 1993
).
The strength of this study was that the women were age-matched, both men and women participated, and there was a very low drop-out rate (2%). In addition, the instruments used are well tested and used in other studies. The outcome that the IVF couples had a more positive view of their relationship over time might be explained by their preceding struggle to become parents and the strengthening effect this can be assumed to have on a relationship.
It is possible that the IVF couples spent more time discussing questions of relationships and parenthood and thereby are more in agreement on these questions. Inversely, couples who are not in relative agreement probably separate at an earlier stage of the infertility investigation.
We were unable to demonstrate that the significantly longer duration of the relationship per se was an explanation for the more stable results in the IVF group.
It should be taken into consideration that in this study, all couples were screened for psychosocial problems and risk behaviour before being accepted to the treatment programme, and therefore no couples with drug addiction, severe mental handicap or an ongoing psychiatric illness were included. Also, as a general rule for this kind of treatment in Sweden, no couples with a relationship shorter than 2 years are accepted for IVF treatment (National Board of Health and Welfare, 1998). As a consequence of this, it can be assumed that the IVF couples have a more stable relationship and are also more oriented towards formation of a family.
The clinical and scientific experience is that IVF women more often deliver by Caesarean section and that the children are more often hospitalized during the neonatal period because of preterm deliveries and growth retardation (Wennerholm et al., 1997; Bergh et al., 1999
; Koudstaal et al., 2000a
,b
). The reason we could not confirm this in our study could be that the women were age-matched and had no previous children. This is in agreement with the results of the study by Reubinoff et al. who also studied an age-matched sample of women (Reubinoff et al., 1997
).
The median age for IVF patients in Sweden is 4 years higher than the child-bearing population as a whole (Bergh et al., 1999). It is well known that the risk of complications during pregnancy and delivery is positively correlated with the age of the woman (Cnattingius et al., 1992
; Prysak et al., 1995
). By age-matching between the IVF and control groups, we have avoided this bias in our study.
The twin pregnancy rate in the IVF group was 14%, somewhat lower than international and national registers, which show a rate of 2025% (Derom et al., 1995; Wennerholm et al., 1997
). However, the twin frequency was still high compared with the control group, though no negative outcome for the children, parenthood or the couple's relationship was noted. This ought to be more thoroughly investigated when the children are older.
All children in this study were healthy and able to be assessed in their temperament and behaviour. The results showed no deviance from normality in either of the groups. However, the IVF children were perceived by their parents to be more regular/habitual, sensitive, attentive and easier to manage than the control children. After finally being successful in becoming parents and with the experience of the infertility crisis, these parents are probably even more focused and sensitive about their children than the couples who spontaneously conceived.
An unrealistic and too positive picture of parenthood could lead to disappointment when that goal is finally achieved. It does not seem that the risk for such a disappointment is greater after a long period of infertility. On the contrary, couples who have managed to maintain a functioning relationship despite infertility and infertility investigation might be more prepared for the difficult task of raising a child.
In conclusion, the IVF couples and their children were not in any way deviant from normality with regards to relationships, health and parenthood. In fact, the IVF families turned out to be more stable and harmonious than the control families. Whether these results will persist or change over time will be the focus of the next follow-up, planned for when the children reach 4 years of age.
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Acknowledgements |
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Notes |
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References |
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Submitted on May 10, 2002; accepted on September 2, 2002.