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A Systematic Review of Psychosocial Factors Associated With Emotional Adjustment in in Vitro Fertilization Patients

This systematic review examines 23 studies exploring the association between psychosocial factors and emotional adjustment outcomes in in vitro fertilization (IVF) patients. The review finds that neuroticism and the use of escapist coping strategies are positively associated with distress in multiple studies, while social support is negatively associated with distress in several studies. A number of other psychosocial variables appear to be associated with distress based on one or two studies. However, two-thirds of the psychosocial variables tested have not been found to be significantly associated with emotional adjustment. The review highlights key psychosocial risk factors and notes a lack of research on positive emotional outcomes.

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0% found this document useful (0 votes)
86 views20 pages

A Systematic Review of Psychosocial Factors Associated With Emotional Adjustment in in Vitro Fertilization Patients

This systematic review examines 23 studies exploring the association between psychosocial factors and emotional adjustment outcomes in in vitro fertilization (IVF) patients. The review finds that neuroticism and the use of escapist coping strategies are positively associated with distress in multiple studies, while social support is negatively associated with distress in several studies. A number of other psychosocial variables appear to be associated with distress based on one or two studies. However, two-thirds of the psychosocial variables tested have not been found to be significantly associated with emotional adjustment. The review highlights key psychosocial risk factors and notes a lack of research on positive emotional outcomes.

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Mirjana14
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Human Reproduction Update, Vol.20, No.4 pp.

594–613, 2014
Advanced Access publication on March 27, 2014 doi:10.1093/humupd/dmu010

A systematic review of psychosocial


factors associated with emotional
adjustment in in vitro fertilization
patients

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Helen E. Rockliff 1,*, Stafford L. Lightman 1, Emily Rhidian 1,
Heather Buchanan 2, Uma Gordon 3, and Kavita Vedhara 2
1
Department of Clinical Sciences, University of Bristol, Whitson Street, Bristol BS1 3NY, UK 2School of Community Health Sciences, University of
Nottingham, Nottingham NG7 2RD, UK 3Bristol Centre for Reproductive Medicine, Southmead Hospital, Bristol BS10 5NB, UK

*Correspondence address. E-mail: mdher@bristol.ac.uk


Submitted on November 15, 2013; resubmitted on January 30, 2014; accepted on February 19, 2014

table of contents 1
...........................................................................................................................
† Introduction
Individual differences in sensitivity to stressors
Outline of previous research
Purpose of this review
† Methods
Criteria for selecting studies
Search strategy
Selection of studies
Methodological assessments
Description of included studies
† Results
Outcome variables
Psychosocial factors
Psychosocial factors associated with emotional adjustment
Psychosocial factors not significantly associated with emotional adjustment
† Discussion
Psychological risk factors
Psychosocial protective factors
Additional findings
Limitations and additional considerations
Clinical implications
† Conclusions

background: IVF treatment is usually stressful for patients, but individual differences in emotional response do exist. Differences in the
stress response may be related to reproductive outcomes as well as to the development of psychiatric problems. This review collates research
exploring which psychosocial factors (e.g. personality traits and coping strategies) are associated with the emotional adjustment of IVF patients.
The aim is to reveal what is currently known about risk and protective factors for coping with the stress of IVF treatment and where further enquiry
would be most beneficial.

& The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
The associates of IVF stress 595

methods: The databases, MEDLINE/PUBMED (US National Library of Medicine), PsycINFO (American Psychological Association), Web of
Science (Social Sciences Citation Index) and EMbase, were searched from 1978 to September 2012 using relevant key words. All published peer-
reviewed studies exploring associations between psychosocial factors and emotional adjustment outcomes were considered for inclusion.
results: There were 23 studies identified for review. One-third of the psychosocial factors explored were found to be significantly related to
emotional adjustment outcome measures. Neuroticism and the use of escapist coping strategies were positively associated with distress by mul-
tiple studies. Social support was negatively associated with distress by several studies. A number of other psychosocial variables appear to be
associated with distress, including self-criticism, dependency, situation appraisals and attachment style, but these have only been explored by
one or two studies at most. There is a paucity of research using positive emotional outcome measures (e.g. well-being, positive affect, happiness
or life satisfaction) to quantify emotional adjustment.
conclusions: Whilst some psychosocial variables appear to be consistently associated with distress for IVF patients, two-thirds of the vari-
ables tested to date do not appear to be associated with emotional adjustment. This review highlights key psychosocial factors to assist the iden-

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tification of patients at high risk of psychological distress. These findings highlight at least two psychological factors that may be amenable to
alteration with psychological or educational interventions. Future work should explore whether experimental manipulation of such psychosocial
factors can provide effective stress reduction in this clinical context.

Key words: IVF/ICSI / coping / stress / emotion / systematic review

Haemmerli et al., 2008; Greil et al., 2009; Hammerli et al., 2009; Ander-
Introduction son et al., 2010; Chachamovich et al., 2010; Morreale et al., 2010; Boivin
Since the development of in vitro fertilization (IVF) in 1978, there has been et al., 2011; Matthiesen et al., 2011). Verhaak et al. (2007) systematically
growing interest in the emotional experiences of IVF patients. Patients reviewed studies exploring the emotional adjustment of women to IVF
frequently report infertility and its treatment as one of the most stressful treatment, presenting separately studies that recorded data before,
experiences of their lives (Freeman et al., 1985; Eugster and Vingerhoets, during and after the treatment cycle(s). The authors conclude that, ‘. . .
1999; Cousineau and Domar, 2007). Among the undesirable effects of whilst most women adjust well to this multidimensional stressor, . . .a
stress on health (Lopez et al., 1999; Muscatell and Eisenberger, 2012), considerable group show subclinical emotional problems’ (p.27). This
there exists evidence that it adversely affects reproductive function finding has guided the development of the present review as Verhaak
(Buck Louis et al., 2011). The mechanisms are thought to include et al. (2007) highlight the need for a better understanding of risk and pro-
centrally controlled GnRH pulse inhibition (Ferin, 1999; Li et al., 2010) tective factors in the development of emotional problems, a need that
as well as autonomic nervous system activation leading to alterations in the present review aims to satisfy.
ovarian and uterine function (Schenker et al., 1992; Negro-Vilar, 1993; A review of psychosocial predictors of infertility-related stress was
Chachamovich et al., 2010). published 3 years ago (Gourounti et al., 2010) collating the findings of
19 empirical studies that had explored the relationship between psycho-
Individual differences in sensitivity to stressors social factors and a negative emotional outcome measure (distress,
Few of the studies exploring stress-related reductions in IVF conception stress, depression, etc.). However Gourounti et al. (2010) did not
or live birth rates have accounted for the possibility of individual differ- focus on IVF treatment patients but included a heterogeneous popula-
ences in sensitivity to stressors or in propensity to stress induced repro- tion of ‘infertile women’ who were not necessarily all in receipt of infer-
ductive malfunctions, despite evidence of such differences among tility treatment(s). They also only reviewed psychosocial risk factors, e.g.
primates (Verhaak et al., 2004; Bethea et al., 2005) and other species those associated with increased (di)stress levels, and did not include any
(Schoech, 1991). Exceptions, supporting the possibility of such individual positive emotional outcome measures of emotional adjustment such as
differences existing for humans as well, include Facchinetti et al. (1997) well-being, positive affect, happiness or life satisfaction, which are just as
who found that high cardiovascular reactivity of IVF patients to an emo- significant to health and for quality of life as the prevalence of negative
tional Stroop task was indeed related to reduced pregnancy odds. The emotions (Folkman and Moskowitz, 2000; Steptoe and Wardle, 2005;
possibility that sensitivity to stressors could be related to reproductive Rutten et al., 2013). Identifying those at risk of higher distress levels,
inhibition has been suggested (Marcus et al., 2001; Michopoulos et al., for example, through a reliance on maladaptive coping strategies is
2013), along with the possibility that individual differences in reward pro- useful, but we must also identify adaptive strategies to replace them if
cessing (i.e. perception and response to positive stimuli) could determine stress reduction interventions are to be evidence based (Coyne and
psychological and/or reproductive resilience (Rutten et al., 2013). Racioppo, 2000; Folkman and Moskowitz, 2000). Adaptive coping
However both hypotheses remain to be properly explored. mechanisms are highly context specific (Troy et al., 2013) and this task
therefore requires detailed exploration of factors associated with emo-
tional adjustment, specifically in the context of IVF treatment.
Outline of previous research
Numerous studies have been conducted exploring various aspects of
stress and emotional adjustment in infertility treatment patients. This Purpose of this review
body of literature has also been reviewed (Eugster and Vingerhoets, The present review extends the studies of both Verhaak et al. (2007) and
1999; Boivin, 2003; Klonoff-Cohen, 2005; Verhaak et al., 2007; Gaurounti et al. (2010) by reviewing psychosocial factors (both risk and
596 Rockliff et al.

protective factors) associated with psychological adjustment, including a published in a language other than English, which could not be excluded or
wide breadth of outcome measures to capture both positive and nega- included on the basis of their English titles or abstracts (n ¼ 5), were rated
tive emotional aspects of psychological adjustment. Whilst demographic by native speakers of the publication language who were informed of the
and clinical factors can also determine the emotional experiences of review inclusion criteria. However none of the foreign language articles iden-
tified in the searches were suitable for inclusion in this review, making transla-
women undergoing IVF (Templeton et al., 1996), studies which exam-
tions unnecessary.
ined these factors were considered to be outside the scope of this
There were 36 studies were identified which aimed to explore associa-
review, as they are concerned with determinants not very amenable to
tions, or predictive effects of, psychosocial factors on emotional distress.
change. The present review will focus specifically on psychosocial One additional study was found by checking reference lists of included
factors associated with psychological adjustment in IVF patients, and studies, giving a total of 37 studies relevant to this systematic review. The
will additionally include literature published in the years since previous study selection process is depicted in Fig. 1 below.
reviews (Verhaak et al., 2007; Gourounti et al., 2010).
Methodological assessments

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Methods There were 37 studies identified, which aimed to explore associations
between psychosocial variables and emotional adjustment outcome mea-
Criteria for selecting studies sures. Prior to review of their findings, the methodology of these articles
was assessed.
Papers included in this review were those reporting empirical research (cross
The methodological inclusion criteria were as follows. (i) The time of data
sectional or longitudinal in design) exploring associations between a psycho-
collection had to be specified in relation to IVF treatment (i.e. before stimu-
social variable and emotional adjustment, or the predictive effect of, at least
lation medication commenced, 30 min prior to oocyte collection, etc.). (ii)
one psychosocial variable on an emotional adjustment outcome measure.
The psychosocial factor(s) had to be assessed using a validated measure.
The study participants had to be IVF or intracytoplasmic sperm injection
(iii) The outcome measures of emotional adjustment had to be measured dir-
(ICSI) patients, either about to begin, currently undergoing or having previ-
ectly (i.e. not indirect measures such as use of counselling, admission rates to
ously undergone IVF treatment for reasons of infertility. The studies had to
parenting classes, etc.). (iv) Finally the statistical analysis needs to be detailed
be published in a peer-reviewed journal.
in the paper and had to include a test of at least one of the following: associ-
ation (correlation) between variables, predictive power (regression) of a
Search strategy hypothesized independent variable (psychosocial variable) on a hypothe-
The following databases were searched between 1978 and 1 October 2012: sized dependent variable (distress), or between groups comparison (t-test,
MEDLINE/PUBMED (US National Library of Medicine), PsycINFO (Ameri- ANOVA) using psychosocial variable or emotional adjustment as a
can Psychological Association), Web of Science (Social Sciences Citation between groups factor.
Index) and EMbase. The methodology of the studies selected was assessed. Methodological in-
The search terms comprised two groups of keywords: (i) assist* repro- clusion criteria are listed as column headings in Table I and excluded studies
duc*, (fertili#ation adj2 vitro), IVF, ICSI; and (ii) stress*, anxi*, depress*, per- are listed in the left hand column with the reason for exclusion denoted by the
sonalit*, cop*,(coping adj2 style), psychopathology, distress, well-being, position of ‘no’ under the methodological inclusion criteria that the study did
resilience, emotion, affect (psychological adj2 trait), (individual adj2 differ- not meet.
enc*), (mental adj2 health). Twelve studies were excluded from the review for methodological
The search terms within each group were combined using OR, and the two reasons. Three studies (Sonawalla et al., 2000; Cassidy and Sintrovani,
groups of terms were combined using AND. Finally, NOT embryo OR 2008; Gourounti et al., 2012) recruited IVF patients but were unable to
blastocyst was used to reduce the number of irrelevant studies. Limits confirm when, in relation to the IVF treatment, the study variables were mea-
were set for human adult studies only (ages 18 – 64). No language restrictions sured. As stress levels are known to vary considerably in relation to treatment
were set. Each database retrieved the following numbers of articles: medline/ stages (Boivin and Takefman, 1995), this information was deemed necessary
PubMed (1238 results), Web of Science (1353), psycINFO (247) and EMbase in order to contextualize study findings. Four studies (Baluch et al., 1992;
(261). All 3099 references were downloaded into endnote and 495 duplicate Collins et al., 1992; Newton et al., 1992; Bringhenti et al., 1997) did not
studies were automatically identified and removed, leaving a total of 2604 assess the psychosocial variable(s) explored with a validated measure.
articles. Baluch et al. (1992) also did not report the statistical tests used along with
(Pottinger et al., 2006) and (Bar-Hava et al., 2001). Five studies (Brinsmead
Selection of studies et al., 1986; Baluch et al., 1992; Hjelmstedt et al., 1999; Bar-Hava et al.,
2001; Fisher et al., 2012) used indirect measures of stress, such as use of
The studies retrieved from the database searches (n ¼ 2604) were reduced
counselling services, as the outcome variable. One study Edelmann et al.
by manual inspection of titles and removal of articles unrelated to humans,
(1994) was included in the review despite not stating distress as its
infertility treatment and psychosocial factors. This left 563 articles on
outcome measure. This study used a regression analysis to explore the pre-
psychosocial aspects of infertility treatment. A further 73 non-peer-reviewed
dictive effect of distress on the coping strategies IVF patients use. As
articles were removed (websites, meeting abstracts, etc.) leaving 490
regression is basically a test of association and both distress and coping strat-
peer-reviewed articles. Review articles (65) were removed leaving 425 peer-
egies were measured at the same time point (before beginning IVF), this study
reviewed empirical studies of psychosocial factors and infertility treatment.
was included on the basis of having explored associations between these two
Finally abstracts and full texts were examined to remove studies that did
variables.
not use an exclusively an IVF/ICSI treatment population or explore an asso-
ciation between variables of relevance to this review. A second researcher
(ER) blind reviewed 85 articles (20%) randomly selected from the 425 Description of included studies
studies of psychology and infertility treatment, with no resulting conflict of There were 25 studies which fulfilled all the inclusion criteria for this review.
opinion over the studies for inclusion. Where the necessary information However three pairs of the articles appeared to contain essentially the same
was not available in the paper, contact was initiated with the author. Articles information, observed in data gathered from one population (Verhaak et al.,
The associates of IVF stress 597

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Figure 1 Flow chart showing the process of article selection.

2005a, b; Peterson et al., 2006a, b; Lowyck et al., 2008, 2009). Following a outcomes were quantified using 20 different measures. With the excep-
request to the authors for clarification, Peterson et al. (2006a, b) and tion of the stress-related hormones cortisol and prolactin (Csemiczky
Lowyck et al. (2009) were treated as duplicate publications. Consequently, et al., 2000), all outcome measures were validated with self-report
further reference will only be made to the findings of Peterson et al.
scales, combined scores from several validated self-report scales
(2006a) and Lowyck et al. (2009). In contrast, Verhaak’s studies recorded
(Terry and Hynes, 1998) or a combination of self-report scale and tele-
data at three different time points, publishing analysis of the 4 weeks’
post-IVF data in Verhaak et al. (2005a) and the 6-month follow-up data in phone interview (Litt et al., 1992; Volgsten et al., 2010). The most
Verhaak (2005b). These were therefore treated as separate studies. The common outcome variable, used in eight studies, was depression. This
remaining 23 studies were published in 15 different journals between 1990 was quantified most often with the Beck Depression Inventory (BDI)
and October 2012, with over half being published since 2006, suggesting a (Beck, 1967), used in five of the eight studies. State anxiety was the
growing interest in this area of research. Participants characteristics for the second most commonly employed outcome, used by seven studies.
studies included in this review are shown in Table II.
Six of these studies used the same measure to quantify anxiety, the
State Trait Anxiety Inventory (STAI) (Spielberger, 1983). The least fre-
Results quent outcome measure used was well-being, explored by only one
study (Lowyck et al., 2009), revealing a notable lack of published research
Outcome variables that has explored positive aspects of emotional adjustment, such as life
The 23 studies reviewed (see Table III) collectively explored six indices of satisfaction, happiness, well-being or marital quality. For this reason,
psychological adjustment including: stress, depression, anxiety, distress, the negative psychological adjustment outcomes are referred to ‘distress
well-being and a specially designed ‘IVF distress’ measure. These six outcomes’ where appropriate below.
598 Rockliff et al.

Psychosocial factors

..........................................................................................................................................................................................................................................................
statistical tests
The 23 studies reviewed collectively explored 22 different psychosocial
reported? variables using 48 different measures. With the exception of attentional
Are the

bias (Verhaak et al., 2004), which was measured using an Emotional


Stroop task, all psychosocial variables were measured with self-report
Yes
Yes
Yes

Yes
Yes
Yes

Yes
Yes
Yes
No

No
No
scales. A total of 89 significant associations between psychosocial vari-
ables and psychological adjustment outcome were reported. However
between psychosocial factor
and emotional adjustment

a total of 264 associations were hypothesized and tested, meaning that


only about 33% of the associations tested by this collection of studies
Analysis of association

were significant. The numbers of associations reported as statistically sig-


nificant by each study are given in column 8 of Table III and are shown as a
fraction of the number of association the study reported exploring. The

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outcome?

most common psychosocial factors explored were personality traits and


Table I Studies that aimed to explore associations of relevance to this review but were excluded for methodological reasons.

coping strategies (nine studies each). This was followed by marital quality,
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

social support and situation appraisals (five studies), then romantic


attachment (three studies). All other psychosocial factors were explored
by only two studies at most, with the exception of baseline anxiety and/
Direct measure of

or depression which were either controlled for or used to predict subse-


quent distress by 11 of the 23 studies.
adjustment
emotional

outcome?

Psychosocial factors associated with


emotional adjustment
Yes
Yes
Yes

Yes
Yes
Yes
Yes
No

No
No
No
No

Table IV summarizes findings from the studies included in this review.


Psychosocial factors that were significantly associated with adjustment
psychosocial factor

are listed in the right hand column. References for each study have
with valid tool?

been placed in the cells corresponding to the timing of the outcome


Measures

data collection and direction of the association between variables.


With each reference, the type of emotional adjustment outcome
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
No
No
No
No

measure is stated.

Personality traits
Data collection time
specified in relation
to IVF treatment?

Nine studies explored whether personality traits were related to


emotional adjustment outcomes using six different measures of person-
ality. Eight of these studies reported significant findings. However the
most striking overall result is that of 29 different personality constructs
explored, only 5 were found to relate to emotional adjustment.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No

These were neuroticism, vulnerability, self-criticism, dependency and


optimism.
Aims to tests association or

The most common personality subscale explored was neuroticism


(five studies, all longitudinal in design). Four of these studies used the
emotional adjustment?
psychosocial factor on

Revised short form Eysenck Personality Questionnaire (EPQ-R)


predictive effect of

(Eysenck and Eysenck, 1991) and Volgsten et al. (2010) used the
Swedish university Scales of Personality (Gustavsson et al., 2000) to
measure neuroticism. All five studies found positive associations with
emotional adjustment outcomes. Neuroticism was positively associated
with trait anxiety at oocyte collection (Cooper et al., 2000), state anxiety
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

following IVF treatment failure (Verhaak et al., 2004, 2005a, b) and


Cassidy and Sintrovani (2008)

depression after IVF treatment success and failure Verhaak et al.


(2005a, b; Volgsten et al., 2010).
Hjelmstedt et al. (1999)
Brinsmead et al. (1986)
Gourounti et al. (2012)

Bringhenti et al. (1997)


Sonawalla et al. (2000)

Bar-Hava et al. (2001)


Pottinger et al. (2006)

Self-criticism and dependency, subscales of the Depressive Experiences


Newton et al. (1992)
Collins et al. (1992)
Baluch et al. (1992)

Fisher et al. (2012)

Questionnaire (Blatt et al., 1976), were explored by one study (Van den
Broeck et al., 2010) using a pre-IVF cross-sectional design. Both traits
Reference

were associated with higher distress outcome scores. Vulnerability (to


post-natal depression) (Boyce et al., 2001) was also explored by one
study (Fisher et al., 2008) using a longitudinal design and found to
predict depression in late pregnancy. However, it was not found to be
The associates of IVF stress 599

Table II Summary of participant characteristics for each article included in this review.

Study reference Country Sample Mean age of Mean Mean Mean years of First IVF Primary
size and participants period of period of marriage cycle only infertility
sex (years) infertility treatment (relationship) only
(years) (years)
.............................................................................................................................................................................................
Baor and Soskolne Israel 88f 30.4 4.7
(2012)
Cooper et al. (2000) UK 34f 31.6f 5.2 3
32m 34.2m
Edelmann et al. (1994) UK 152f 32f 5.4 3
152m 34m
Csemiczky et al. Sweden 22f 33.4 3.1

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(2000)
Donarelli et al. (2012) Italy 316f 33.97f 3.9 4.5 3 3
316m 37m
Fisher et al. (2008) Australian 170f 34.3 9.9
Gameiro et al. (2011) Portugal 35f 33.09f 7.71
35m 35.11m
Hynes et al. (1992) Australian 100f 32 9
Knoll et al. (2009) German 82f 34.5f 9 62%
88m 36.83m
Lee et al. (2011) Taiwan 60f 32.38 4.58
Litt et al. (1992) American 36f 32.4 2.8 3
Lord and Robertson UK 30f 34 5 2.5
(2005) 20m
Lowyck et al. (2009) Belgium 68f 32f 8 3
60m 35m
Moura-Ramos et al. Portugal 70f 32.51f 4.78 1.34 6.94
(2012) 70m 34.77m
Newton et al. (1990) Canadian 187f 31.4f 77%
160m 33.5m
Peterson et al. American 520f 32.7f 3.4 3
(2006a, b) 506m 33.9m
Terry and Hynes Australian 171f 32.81 6.95
(1998)
Van den Broeckand Belgium 106f 7 3 85%
Hooghe et al. (2010) 102m
Verhaak et al. (2004) Netherlands 49f 33.5
Verhaak et al. (2005b) Netherlands 148f 34.1f 50% ¼ 3 –5 3 80%
71m 36.3m
Verhaak et al. (2005a) Netherlands 187f 34.3 3.3 3 83%
Verhaak et al., 2010) Netherlands 279f 3
Volgsten et al. (2010) Sweden 413f 32.8f 3.13 78%
412m 34.5m

f, female. m, male. Empty cells, not reported in paper. 3, yes. X%, percentage of participants who can be described by the column heading.

an independent predictor of depression once early pregnancy depression Csemiczky et al. (2000) used a pre-IVF cross-sectional design but did
was controlled for. Trait optimism, explored by three studies (Litt et al., not report any significant associations between personality and hormo-
1992; Verhaak et al. 2005b) all using longitudinal designs, was the only per- nal markers of stress serum cortisol and prolactin. However this was also
sonality factor found to be associated with lower levels of distress: specif- the only study not to use a self-reported outcome measure.
ically with lower depression scores 2 weeks following a negative pregnancy
test (Litt et al., 1992) and 6 months following IVF failure (Verhaak et al., Coping strategies
2005b). Oddly though it was not found to relate to depression levels 4 Nine studies explored whether coping strategies were related to emo-
weeks following IVF treatment failure Verhaak et al. (2005a). tional adjustment outcomes. Six of these studies reported 19 significant
600
Table III All studies included in this review with a summary of findings.

Study Country Sample Mean age Psychosocial Emotional adjustment Outcome No. of Results
size and participants variable outcome measure assessment associations/
sex assessment time no. tested

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time
..........................................................................................................................................................................................................................................................
Baor and Israel 88f 30.4 Post-IVF: 6 months Maternal Stress (Parenting Post-IVF: 6 months 1/2 Social support negatively associated with
Soskolne (2012) post birth Stress Index-Short form: post birth maternal stress
Abidin, 1983)
Cooper et al. UK 34f 31.6f Pre-IVF: 1 month State and Trait Anxiety (STAI: During IVF:EC 1/8 Neuroticism positively correlated with trait
(2000) 32m 34.2m Spielberger et al., 1970) anxiety
Csemiczky et al. Sweden 22f 33.4 Pre-IVF Serum Prolactin and cortisol Pre-IVF 0/18 No significant associations
(2000)
Donarelli et al. Italy 316f 33.9f During IVF Infertility Stress (Fertility During IVF 6/9 Attachment style: avoidant and anxious
(2012) 316m 37m (pre-stimulation) Problem Inventory, Newton (pre-stimulation) positively associated with infertility stress for
et al., 1999) men and women. Partner effect for men’s
anxious attachment and women’s avoidant
attachment
Edelmann et al. UK 152f 32f Pre-IVF State Anxiety (Spielberger Pre-IVF 2/24 Coping strategies: catharsis and redefinition
(1994) 152m 34m et al., 1970) were positively and negatively associated with
anxiety respectively
Fisher et al. Australian 170f 34.3 Post-IVF success: Post-natal Depression (Cox Post-IVF success 3/5 Intimate Bonds Measure (IBM) control and
(2008) 16 and 32 weeks et al., 1987 Edinburgh 32 weeks Vulnerability were positively associated with
pregnant Post-natal Depression depression and IBM care was negatively
Scale) associated with it.
Gameiro et al. Portugal 35f 33.09f Post-IVF success: Parenting Stress (Parenting Post-IVF success: 4 0/22 No significant associations for women. Extended
(2011) 35m 35.11m 24 weeks Stress Index: Abidin, 1983) months post birth family support positively associated and friends
support negatively associated with men’s
parenting stress.
Hynes et al. Australian 100f 32 Pre-IVF Depression (Mitchel et al., Post-IVF failure 2/3 Problem-focused coping (cognitive) associated
(1992) 1983) with lower depression. Avoidance coping
associated with higher depression.
Knoll et al. German 82f 34.5f During IVF: EC Depression (German Centre Post-IVF: After PT 3/12 Women and Men: Own stress appraisals at T1
(2009) 88m 36.83m for Epidemiological Studies and T2 positively associated with own
Depression Scale, depression at T3. Men’s depression positively
Hautzinger, 1988) associated with women’s subsequent stress
appraisals.
Lee et al. (2011) Taiwan 60f 32.38 Post-IVF success Depression (Chinese BDI-II, Post-IVF success 3/4 Family function, social support and perceived
Beck et al., 1961 and Chen, stress correlated with depression. Social support
2000) only factor to significantly predict depression
Litt et al. (1992) American 36f 32.4 Pre-IVF Distress (Depression Post-IVF failure 6/19 Pre-IVF BSI, Feelings of lost control, perceived

Rockliff et al.
Adjective Checklist, Lubin, contribution to IVF failure and escape coping
1965 and self-esteem, positively associated and optimism and
The associates of IVF stress
Timko and Janoff-Bulman, perceived contribution to infertility negatively
1985) associated with distress.
Lord and UK 30f 34 Pre-IVF Anxiety (HADS, Zigmond Pre-IVF 18/18 Anxiety and depression were positively
Robertson 20m and Snaith, 1983) associated with Illness Perceptions: timeline
(2005) Depression (HADS, cynical and coping strategies: Self-distraction,
Zigmond and Snaith, 1983) denial, disengagement, venting, self-blame. The
only negative association was with Illness

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perception measure - Illness coherence.
Lowyck et al. Belgium 68f 32f Pre-IVF Psychological Well-being Post-IVF 3/6 Well-being was positively associated with secure
(2009) 60m 35m (Amsterdam Scale of attachment and negatively associated with
Well-being, Van self-criticism and dependency.
Dierendonck, 2003)
Moura-Ramos Portugal 70f 32.51f During IVF (HS) Distress (Portuguese Brief During IVF (HS) 1/1 Importance of parenthood was positively
et al. (2012) 70m 34.77m Problem Inventory, associated with distress
Derogatis, 1993;
Canavarro, 1999)
Newton et al. Canadian 187f 31.4f Pre-IVF State Anxiety (Anxiety Post-IVF failure 4/12 Post-IVF anxiety and depression were both
(1990) 160m 33.5m Inventory, Spielberger, associated with pre-IVF trait anxiety and
1983) depression.
The Life Appraisal Inventory
(Campbell et al., 1976)
Depression (Beck
Depression Inventory Beck
et al., 1988)
Peterson et al. American 520f 32.7f Pre-IVF: 2 months Depression (Beck Pre-IVF: 2 months 5/8 Depression was positively associated with
(2006a, b) 506m 33.9m Depression Inventory Beck escape/avoidance and accepting responsibility
et al., 1979) coping and negatively associated with the coping
strategies seeking social support, problem
solving and distancing.
Terry and Australian 171f 32.81 Pre-IVF Psychological Distress Post-IVF failure: 1 2/5 Post-IVF distress was positively associated with
Hynes (1998) (Standardized composite week and 6 weeks pre-IVF distress and escapism as a coping
score of Beck Depression strategy.
Inventory, Beck et al., 1961
and State Trait Anxiety
Scale, Spielberger et al.,
1970)
Van den Broeck Belgium 106f N.R. Pre-IVF Psychological Distress (Brief Pre-IVF 4/20 Psychological distress was positively associated
et al. (2010) 102m symptom Inventory, with self-criticism, dependency and use of
Derogatis and Spencer, passive coping strategies and negatively
1982) associated with seeking social support coping.
Verhaak et al. Netherlands 49f 33.5 Pre-IVF State Anxiety (Anxiety Post-IVF failure: 3/12 State anxiety was associated positively with
(2004) Inventory, Spielberger, pre-IVF trait anxiety, neuroticism and attentional
1983; Dutch: Van der Ploeg, bias for the subliminal infertility condition.
2000)
Verhaak et al. Netherlands 187f 34.1f Pre-IVF State Anxiety: Change Pre-IVF Post-IVF failure: 4 9/20 State anxiety change was positively associated
(2005a) 36.3m - Post-IVF (Anxiety Inventory, weeks post PT with neuroticism, helplessness (wrt infertility)
Spielberger, 1983 Dutch marital dissatisfaction, but negatively associated

601
Continued
602
Table III Continued

Study Country Sample Mean age Psychosocial Emotional adjustment Outcome No. of Results
size and participants variable outcome measure assessment associations/
sex assessment time no. tested
time
..........................................................................................................................................................................................................................................................

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translation Van der Ploeg, with acceptance (wrt infertility). Depression
2000) change was positively associated with
Depression: Change Score neuroticism and helplessness and negatively
Pre-IVF - 4 weeks Post-IVF associated with acceptance and perceived social
(BDI, Beck et al., 1979) support.
Verhaak et al. Netherlands 148f 34.3 Pre-IVF State Anxiety: Change Pre-IVF Post-IVF failure: 6 8/22 State anxiety change was positively associated
(2005b) 71m – Post-IVF (Anxiety months post PT with neuroticism and marital dissatisfaction, but
Inventory, Spielberger, 1983 negatively associated with optimism and
Dutch translation Van der perceived social support. Depression change
Ploeg, 2000) was positively associated with neuroticism,
Depression: Change Score helplessness (wrt infertility) and marital
Pre-IVF - 6 months Post-IVF dissatisfaction, but negatively associated with
failure (BDI, Beck et al., optimism, acceptance (wrt infertility) and
1979) perceived social support.
Verhaak et al., Netherlands 279f N.R. Pre-IVF Anxiety (short form – Post-IVF: 3– 4 2/2 Risk factors (SCREENIVF) explained 4% variance
2010) Speilberger, 1983) weeks post PT in anxiety and 10% variance in depression
Depression (Short form BD,
Beck et al., 1979)
Volgsten et al. Sweden 413f 32.8f During IVF: EC Psychiatric Status (Primary Post-IVF: 3 days 3/12 Only neuroticism significantly predicted
(2010) 412m 34.5m Care Evaluation of Mental post PT Psychiatric status for men and women after IVF
Disorders, Spitzer et al., treatment.
1984)

f, female; M, male; N.S, not reported. Participant age (years).


HS, hormonal stimulation phase; EC, egg collection; ET, embryo transfer; PT, pregnancy test.

Rockliff et al.
The associates of IVF stress
Table IV Summary of the significant findings in this review.

Psychosocial factors Pre-IVF psychological adjustment Mid-IVF psychological adjustment Post-IVF (success) psychological Post-IVF (failure) psychological adjustment
outcome outcome adjustment outcome outcome
............................................... ......................................... ........................................... ...........................................................

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Positive Negative Positive Negative Positive Negative Positive Negative association
association association association association association association association
..........................................................................................................................................................................................................................................................
a a
Personality Neuroticism Cooper et al. Verhaak et al. (2004):
(2000): anxiety anxiety
a
Verhaak et al.
(2005a): anxiety and
depression
a
Verhaak et al.
(2005b): anxiety and
depression
a
Volgsten et al. (2010):
psychiatric status
a
Optimism Litt et al. (1992): distress
a
Verhaak (2005a): depression
b a a
Self-criticism Van den Broeck Lowyck et al. Lowyck et al. (2009):
(2010): Distress (2009): well-being well-being
a
Vulnerability Fisher et al.
(2008):
depression
b a
Coping strategy Problem-focused Peterson et al. Hynes et al. (1992):
coping (2006a, b): depression
depression
b
Distancing Peterson et al.
(2006a, b):
depression
b a
Avoidance/escape Peterson et al. Hynes et al.
(2006a, b): (1992): depression
a
depression Litt et al. (1992):
distress
a
Terry and Hynes
(1998): distress
b
Accepting Peterson et al.
responsibility (2006a, b):
depression
b
Self-distraction Lord and
Robertson (2005):
depression and
anxiety
b
Self-blame Lord and
Robertson (2005):
depression and
anxiety
b
Denial Lord and
Robertson (2005):
depression and
anxiety

Continued

603
604
Table IV Continued

Psychosocial factors Pre-IVF psychological adjustment Mid-IVF psychological adjustment Post-IVF (success) psychological Post-IVF (failure) psychological adjustment
outcome outcome adjustment outcome outcome
............................................... ......................................... ........................................... ...........................................................
Positive Negative Positive Negative Positive Negative Positive Negative association
association association association association association association association

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..........................................................................................................................................................................................................................................................
b
Disengagement Lord and
Robertson (2005):
depression and
anxiety
b
Venting Lord and
Robertson (2005):
depression and
anxiety
b
Catharsis Edelmann et al.
(1994): state anxiety
b
Redefinition Edelmann et al.
(1994): state anxiety
b
Passive Coping Van den Broeck
(2010): distress
b b
Seeking social Van den Broeck Baor and Soskolne
support (2010): distress (2012): maternal
distress
a
Situation appraisal Helplessness Verhaak et al (2005b):
depression
a
Verhakka et al.
(2005a): anxiety and
depression
a
Situation Verhaak et al. (2005b): anxiety
acceptance and depression
b a
Perceived stress Lee et al. (2011): Knoll et al. (2009): Verhaak et al. (2005a):
depression depression depression should also be in
a
Knoll et al. this cell (negative association
(2009): between depression &
depression situation acceptance)
b
Fertility problems Importance of Moura-Ramos
parenthood et al. (2012):
distress
b
Illness perceptions Symptoms Lord and
Robertson (2005):
depression and
anxiety
b
Timeline Lord and
Robertson (2005):
depression and
anxiety
b
Emotional Lord and
representations Robertson (2005):
depression and
anxiety
b
Illness coherence Lord and
Robertson (2005):

Rockliff et al.
depression and
anxiety
b a a
Attachment style Dependency Van den Broeck Lowyck et al. Lowyck et al. (2009):
(2010): Distress (2009): well-being well-being
The associates of IVF stress 605

associations, 14 of which were positive associations with distress out-

Verhaak et al. (2005a): anxiety

Verhaak et al. (2005a): anxiety


comes (i.e. high use of the coping strategy was associated with high dis-
tress levels) and five were negative associations.
The most commonly explored strategy was escapist coping (or
distraction/disengagement in Lord and Robertson, 2005), which was

and depression

and depression
measured by five separate studies. Four of these studies found it to be
positively associated with their outcome measures of distress at
various different phases of treatment (Litt et al., 1992; Terry and
a

a
Hynes, 1998; Peterson et al., 2006a, b; Lord and Robertson, 2005).

Verhaak et al. (2004):


Lowyck et al. (2009):

This strongly indicates that high use of escapist strategies is associated


Verhaak (2005a):

with higher distress levels. In addition Hynes et al. (1992) reported


Anxiety and

that a similar construct ‘avoidance coping’ was related to depression.


Depression
well-being

However, Verhaak et al. (2005b) did not find significant associations

anxiety

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between escapist coping and distress despite using the same coping
a

a
scale as Terry and Hynes (1998), and employing a very similar longitudinal
Fisher et al. (2008):
Lee et al. (2011):

Lee et al. (2011):

design focused on predicting distress after IVF treatment failure.


Of the five negative associations reported, problem focused/solving
Depression

depression

depression

and social support were each associated with distress outcomes by


two studies (Hynes et al., 1992 and Peterson et al., 2006a, b; Peterson
b

et al., 2006a, b and Van den Broeck et al., 2010, respectively). All of
(2009): well-being

these studies used pre-IVF cross-sectional designs except for Hynes


Lowyck et al.

et al., 1992 which was longitudinal and collected outcomes after IVF
Fisher et al.

depression

treatment failure. The remaining negative association, between distan-


(2008):

cing and infertility stress, was reported by one study (Peterson et al.,
a

2006a, b) using a pre-IVF cross-sectional design.


Fourteen positive associations were reported between coping
strategies and distress outcomes across six different papers. Use of
avoidance coping (Hynes et al., 1992) and escapist coping (Litt et al.,
1992; Terry and Hynes, 1998) was linked to higher levels of depression
following IVF treatment failure, and was associated with infertility-specific
stress pre-IVF treatment (Peterson et al., 2006a, b). Peterson et al.
(2006a, b) also found confronting, self-control and accepting responsibil-
ity were positively associated with infertility-specific stress, whilst Terry
and Hynes (1998) identified emotional approach as positively linked to
their depression/anxiety composite outcome measure. Using a pre-IVF
cross-sectional design Lord and Robertson (2005) identified distraction,
Longitudinal study reporting predictive capacity of psychosocial variable on outcome.

denial, disengagement, venting and self-blame to be positively associated


with depression and anxiety and Van den Broeck et al. (2010) reported
that passive coping was associated with higher distress levels.
Six different coping scales were used to quantify participants’ use of
coping strategies, with the Ways of Coping – Revised (WOC-R) scale
Cross-sectional study reporting associations between variables.

(Lazarus and Folkman, 1984) and the Utrecht Coping List (Schreurs
(2012): Infertility

(2012): infertility
Donarelli et al.

Donarelli et al.

et al., 1993) each being used twice. However although the WOC-R
scale was used twice (Litt et al., 1992; Peterson et al., 2006a, b), the sub-
Stress

stress

grouping of items into separate coping strategies was done differently for
b

each study. Peterson et al. (2006a, b) using a pre-IVF cross-sectional


Secure attachment

design reported escapist coping as one of six strategies positively asso-


Perceived social

Infertility words
Family function
dissatisfaction

ciated with infertility specific distress, with the other factors studied
attachment

attachment

being problem solving, accepting responsibility, self-control, distracting


Avoidant
Anxious

Control
support
Marital

and confronting. However Litt et al. (1992) using a longitudinal design


Care

reported that only escapist coping was positively associated with depres-
sion following IVF treatment failure, with none of the other coping strat-
Social environment

Attentional bias

egies showing any significant associations with the outcome measures.


In addition to these findings, Hynes et al. (1992) reported that
problem-focused coping was positively associated with depression follow-
ing failed IVF treatment, a finding replicated by Peterson et al. (2006a,b).
b
a

Terry and Hynes (1998) also found that another active coping strategy
606 Rockliff et al.

(i.e. emotional approach coping) was also positively related to distress control of their situation to themselves, others or to chance was unre-
following IVF failure. The other coping strategies reported as positively lated to their subsequent levels of depression. In contrast, Lord and
associated with distress outcomes were venting and self-blame (Lord Robertson (2005) found that appraisals of symptoms, timeline cynical
and Robertson, 2005), confronting, self-control and accepting responsi- and emotional representations were all positively related to both
bility (Peterson et al., 2006a, b), and passive coping (Van den Broeck anxiety and depression following IVF treatment. They also found illness
et al., 2010). However, these associations were not replicated and in coherence to be negatively associated with these distress outcomes.
some cases were reported as non-significant by other studies Verhaak et al. (2005a, b) were the only studies to use the same appraisal
exploring the same construct, e.g. self-blame (Litt et al., 1992). measures. Both reported that helplessness was positively associated
with change in depression 4 weeks and 6 months following failed IVF
Social support treatment and change in anxiety 4 weeks following failed treatment.
Five studies explored the relationship between social support and dis- They also both reported that acceptance of one’s situation was negatively
tress, with all of them reporting significant associations (i.e. high social associated with changes in anxiety and depression (i.e. that acceptance
support and low distress). These studies used four different self-report was related to smaller increases (or to decreases) in distress from pre- to

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measures to quantify perceived social support, reporting similar findings post-IVF treatment).
for each measure. For the two cross-sectional studies, social support was
negatively associated with maternal distress 6 months following the birth Attachment style
of IVF conceived twins (Baor and Soskolne, 2010) and depression in Tai- Only three studies to date have explored the relationship between at-
wanese women 2 months after birth (Lee et al., 2011). Three longitu- tachment style and emotional adjustment outcomes in IVF patients.
dinal studies also reported perceived social support as a predictor of Each study used a different scale to classify attachment style, although
distress. It predicted a change in women’s depression scores 4 weeks fol- Donarelli et al. (2012) used an Italian language version of the Revised
lowing (Verhaak et al., 2005a), and depression and anxiety scores 6 Experiences in Close Relationships (ECR-R) scale (Picardi et al., 2000),
months following a failed IVF cycle Verhaak et al. (2005b). Gameiro the English language version of which was used by Van den Broek et al.
et al. (2011) used a diagrammatic measure of social support to distinguish (2010). All three studies exploring attachment used different emotional
between emotional and practical support from friends, family and adjustment outcome measures and all reported significant associations
extended family. They found that neither emotional nor practical between at least one attachment style category and their outcome
support from any group was related to parenting stress in women 4 measure. Lowyck et al. (2009) used a longitudinal design and found
months post-partum. They did however find one significant predictor secure attachment style positively predicted well-being following either
for male parenting stress as support from the extended family (but not successful or unsuccessful IVF treatment. Van den Broeck et al. (2010)
from friends) positively predicted higher stress levels. found anxious attachment style was positively associated with pre-IVF
distress, measured with the Brief Symptom Inventory (Derogatis and
Marital quality Spencer, 1982). Donarelli et al. (2012) reported finding both attachment
Six studies explored the relationship between marital satisfaction and dis- anxiety and avoidance were positively associated with infertility-specific
tress using five different measures of marital satisfaction. However only stress for both male and female patients during IVF treatment. Further-
two of these studies reported any significant associations Verhaak et al. more a male partner’s anxious attachment style (but not avoidant) was
(2005a, b). Using the Maudsley Marital Satisfaction Scale (MMQ: Arrin- positively associated with his partner’s increased infertility stress and a
dell et al. 1983), on which a high score indicates marital dissatisfaction, female partner’s avoidant attachment (but not anxious) was associated
Verhaak et al. (2005a, b) reported a positive association between with her partner’s infertility-related stress.
marital dissatisfaction and change in anxiety and depression both 4
weeks following, and 6 months following a negative pregnancy test. Pre-IVF distress
These relationships were found after controlling for pre-IVF distress Fifteen studies controlled for pre-IVF distress in some way or simply
levels. The majority of studies exploring marital quality however explored the usefulness of pre-IVF distress as a predictor for post-IVF dis-
(Newton et al., 1990; Litt et al., 1992; Fisher et al., 2008; Baor and Sos- tress (Newton et al., 1990; Hynes et al., 1992; Litt et al., 1992; Edelmann
kolne, 2010) reported no significant relationships between this psycho- et al. 1994; Terry and Hynes, 1998; Csemiczky et al., 2000; Verhaak et al.,
social factor and emotional adjustment, even after controlling for pre-IVF 2004, 2005a, b, 2010; Fisher et al., 2008; Knoll et al., 2009; Lowyck et al.,
distress levels. 2009; Van den Broeck et al., 2010; Lee et al., 2011). Pre-IVF treatment de-
pression was the most commonly used distress measure, recorded by ten
Situation appraisals studies (Newton et al., 1990; Hynes et al., 1992; Terry and Hynes, 1998;
Five studies explored whether situation appraisals were related to dis- Verhaak et al., 2004, 2005a, b; Fisher et al., 2008; Knoll et al., 2009; Lowyck
tress, hypothesizing that the way in which patients appraise their infertil- et al., 2009; Lee et al., 2011). Five of these ten studies also controlled for
ity and its treatment (i.e. as uncontrollable, manageable, threatening or pre-IVF anxiety (Newton et al., 1990; Terry and Hynes, 1998; Verhaak
damaging) would be related to emotional adjustment outcomes. Four et al., 2004, 2005a, b). All studies that explored pre-IVF distress consistent-
of these studies reported significant associations. Knoll et al. (2009) ly report it to be a significant predictor of post-IVF distress, usually account-
found a positive association between patients’ assessment of the ing for a far higher proportion of the variance in distress outcomes than any
degree of loss and threat that their infertility had inflicted and depression of the psychosocial factors investigated.
following a treatment cycle. Litt et al. (1992) were the only authors not The most robust studies are those that used longitudinal designs and
to find any associations of significance, having explored attributions of controlled for time 1 levels of distress or well-being before examining the
control and distress, meaning that the degree to which patients attribute predictive effect of time 1 psychosocial variables on time 2 psychological
The associates of IVF stress 607

adjustment. Eleven studies conformed to these criteria (Newton et al., warrant further investigation as well as those which repeatedly appear
1990; Hynes et al., 1992; Litt et al., 1992; Terry and Hynes, 1998; not to be related to distress and could reasonably be excluded from con-
Verhaak et al., 2004, 2005a,b, 2010; Fisher et al., 2008; Knoll et al., sideration in future.
2009; Lowyck et al., 2009). Three of these studies reported that none The protective psychosocial factors identified were trait optimism,
of their psychosocial variables were significant predictors of subsequent problem-focused coping, positive family/marital function, social
psychological adjustment after existing distress levels were controlled for support, situation appraisal involving acceptance and secure attachment
(Newton et al., 1990; Fisher et al., 2008; Verhaak et al., 2010). Knoll et al. style. Risk factors identified were trait neuroticism, self-criticism, vulner-
(2009) reported that in addition to pre-IVF depression, pre-IVF stress ability to depression, use of avoidance or escapist coping strategies, situ-
appraisals significantly predicted subsequent depression following IVF ation appraisals involving helplessness and marital dissatisfaction. These
treatment. These authors also identified a significant partner effect, factors will be discussed below according to their risk or protective rela-
namely that a man’s depression score at oocyte collection predicted tionship to emotional adjustment outcomes.
their partner’s stress appraisals after the embryo transfer and pregnancy With the exception of Lowyck et al. (2009) who use the Amsterdam
test. The remaining seven studies reported significant psychosocial pre- Scale of Well-being (Van Deierendonck, 2003) and Hynes et al. (1992)

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dictors of emotional adjustment, after having controlled for pre-existing who included measures of self-esteem and self-confidence as part of a
distress levels. These studies collectively found that secure attachment constellation of psychological adjustment measures, all the studies
style (Lowyck et al., 2009), social support (Verhaak et al., 2005a, b), ac- reviewed used only negative emotional measures of psychological adjust-
ceptance of the situation (Verhaak et al., 2005a, b), optimism (Litt et al., ment (e.g. depression, negative affect, distress, anxiety, etc.). Whilst
1992; Verhaak et al., 2005b) and problem-focused coping (Hynes et al., some bias is expected in this direction given the relatively recent arrival
1992; Verhaak et al., 2004) predicted better psychological adjustment of positive resilience building psychology, this highlights an area of
following IVF treatment. These studies recorded outcomes post-IVF deficit which will inevitably influence our understanding of coping and
failure, except Lowyck et al. (2009) who included both pregnant and non- intervention development accordingly. To quote Seligman (Seligman
pregnant participants following IVF treatment. In contrast to these and Csikszentmihalyi, 2000): ‘Treatment is not just fixing what is
protective factors, neuroticism (Verhaak et al., 2004; Verhaak et al., broken; it is nurturing what is best. Psychology is not just a branch of
2005a, b), Stroop interference on infertility-related words (Verhaak medicine concerned with illness or health; it is much larger. It is about
et al., 2004), marital dissatisfaction (Verhaak et al., 2005a, b), escapist work, education, insight, love, growth, and play.’ (P.7)
coping (Terry and Hynes, 1998) and avoidance coping (Hynes et al., Broadening our approach to understanding adaptive coping and man-
1992) were all found to predict poorer psychological adjustment. agement of emotional challenges may be of particular relevance to the
development of psychological support for this patient group because
Psychosocial factors not significantly of the uncertain outcome (i.e. whether resolution will ever be achieved
through parenthood) and given the evidence that some couples manage
associated with emotional adjustment
to find positive outcomes in a traditionally negative infertility experience.
The majority of psychosocial variables explored for their relationship to Outcomes such as increased intimacy and interest in other aspects of life
emotional adjustment were not found to have a significant relationship. may provide a fruitful focus for helping couples navigate the trauma of in-
Personality trait measures that were not related to any emotional adjust- fertility and IVF with increased resilience. Both resilience-building strat-
ment outcomes included all subscales of the Karolinaska Scale of Person- egies and attempting to reduce or remove the negative factor by
ality (unreferenced in Csemiczky et al., 2000), Extroversion measured by focusing on it are useful and complement one another, but it seems
the Eysenck Personality Questionnaire-Revised (Eysenck and Eysenck, timely given the apparent literature bias in this review, for future
1991) and the Swedish Universities Scales of Personality (Gustavsson studies to focus on the positive end of the human functioning spectrum.
et al., 2000). The coping strategy measures that were not found to be
related to distress outcomes were all subscales of the Coping Strategies
Questionnaire by Stone and Neale (1984) and all the adaptive coping Psychological risk factors
strategies from the COPE (Carver, 1997). Interpersonal measures that Psychosocial factors that were positively related to distress include per-
were not associated with outcomes included Marital Quality, measured sonality traits, coping strategies, social situations and cognitive appraisals
by the Israeli Marital bonds scale (Lavee, 1995), the Intimate Bonds of the situation. This means that higher levels of these traits were related
Measure (Wilhelm and Parker, 1988) and the Dyadic Adjustment Scale to higher levels of distress.
(Spanier, 1976). Additionally, all subscales of the Multidimensional The personality trait neuroticism predicted distress outcomes in all of
Locus of Control Scale (Levenson, 1972), which measures the degree the five longitudinal studies testing this association. This trait is defined as
to which people attribute control of their fertility to chance, themselves an enduring tendency to experience negative emotional states and show
or others, were not associated with the distress outcomes investigated. reactivity to stressors (McCrae and Costa, 1987; Terracciano et al.,
2008; Trevino et al., 2013). Perhaps not surprisingly, therefore, neuroti-
cism has been related to higher self-reports of distress in many other con-
Discussion texts, as well as to lower perceived health and life satisfaction (Otonari
This review collates and summarizes all good quality published empirical et al., 2012). However, as well as the psychological associations
research studies exploring associations between psychosocial factors between neuroticism and distress, neuroticism has also been implicated
and emotional adjustment in IVF patients. Viewed as a whole this litera- as a risk factor for a range of physical health outcomes, from general lon-
ture clarifies which psychosocial factors have most robustly been asso- gevity to cardiovascular disease mortality (Terracciano et al., 2008).
ciated with distress for IVF patients. It also highlights factors that Relatively little is known about how this trait actually influences
608 Rockliff et al.

physiology and health, but the data suggest it does (Lahey, 2009) and it the longer-term. This sits in line with more recent coping literature sug-
could therefore be of clinical importance to infertility patients, as well gesting simple categorization of escapist/avoidance coping as maladap-
as of psychological significance to their treatment experience. It tive is not sufficient but requires the context in order to determine its
should, however, be acknowledged that not all studies of neuroticism adaptive function (Penley et al., 2002). When it comes to dealing with
and health find a consistent relationship. Following up on this literature long-term stressors, situations that can be altered and more complex
discrepancy, a recent study (Hagger-Johnson et al., 2012) found evidence situations requiring engagement and thoughtfulness in order to
that socioeconomic status (SES) moderates the link between neuroti- problem solve effectively, it has been suggested that over reliance on
cism and health. Neuroticism may, therefore, be a risk factor, but avoidance coping causes a rebound effect or heightened distress as
other factors, such as SES, may also need to be taken into account in soon as attention is paid to the stressor again or the stressor intrudes
order to understand its relationship to physical clinical outcomes. on efforts to avoid it (Wegner, 2011).
Coping strategies involving avoidance, escape, distraction and disen- A further consideration with this literature is that most of the studies
gagement were positively associated with distress, meaning that high reporting avoidance/escape associated with distress measure the distress
use of these strategies was associated with or predicted high levels of dis- outcome after a treatment failure. Since treatment failure is the more likely

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tress. Five studies exploring coping observed a relationship between outcome, this does not negate these findings but may suggest that this
strategies involving disengagement or withdrawal and higher distress coping strategy is associated with treatment failure distress rather than
levels; however, three studies also exploring this did not report any asso- treatment process related distress. Previous work has shown that the cog-
ciation between these forms of coping and distress. A wide range of dif- nitions and coping strategies that are most adaptive for long-term well-
ferent measures were used across the studies which is likely to have being are not necessarily so good for short-term mood and vice versa
influenced findings. For example some scales measure situation-specific (Bonanno et al., 2004). The most adaptive emotional state to try and
coping strategies while others ask about general preferences for coping. create is highly dependent on the goal trying to be achieved (Kashdan
The fact that three of the longitudinal studies that controlled for pre- and Rottenberg, 2010). In the context of IVF treatment, this could be
existing distress levels reported avoidance or escapist strategy use to optimal odds of pregnancy, the least stressful treatment experience or
predict depression (Hynes et al., 1992) and other measures of distress the most optimal long-term adaption to the treatment outcome. These
(Litt et al., 1992; Terry and Hynes 1998) suggests reasonable confidence three goals may necessitate very different emotional and cognitive
in this relationship. Collectively the associative and predictive findings ground work to increase their likelihood. It would be advantageous for
strongly suggest that escapist/avoidant coping strategies can robustly future work to explore such possibilities, since it cannot be assumed
predict higher distress levels and can therefore be considered a risk that adaptive coping for short-term positive emotional experience
factor for psychological distress in this patient group. However, whilst the requires the same strategies as adaptive coping for long-term psychological
use of such coping strategies could lead to an increase in distress, patients adjustment. To understand comprehensively which psychosocial factors
experiencing high distress levels are also more inclined to use avoidance/ are most useful for achieving pregnancy, for short-term coping and for
escapist coping (Edelmann et al., 1994). Most studies assumed coping strat- long-term well-being whatever the pregnancy outcome is, would be ex-
egies influenced distress levels, but this is likely a bidirectional relationship in tremely useful for patients, clinicians, psychologists developing interven-
which coping influences distress and distress levels influence the choice of tions and for treatment planning and policy design.
coping strategy used (Aldwin and Revenson, 1987). In addition to the risk factors discussed above, several other variables
The transactional theory of coping states (Folkman et al., 1986; were found to be associated with distress, but have only been explored
Lazarus, 1987) the context in which coping strategies are employed is by one study to date. These psychosocial factors included vulnerability
as important as the strategy itself. The debate over which coping strat- (to depression), reported by Fisher et al. (2008) to predict post-natal de-
egies are adaptive or maladaptive suggests that this cannot be deter- pression, and self-criticism and dependency, both reported by Van den
mined without understanding the context of the situation that is Broeck et al. (2010) as positively associated with distress in their cross-
demanding a coping strategy be used (Buck Louis et al., 2011; Aldao sectional investigation. Consequently these factors merit further research
and Nolen-Hoeksema, 2012). Escapist and avoidant coping strategies to establish the strength of their relationship with psychological distress
such as distraction have been shown to reduce anxiety, fear and pain in and time scales over which these relationships exist.
situations such as medical procedures (Lee et al., 2012) or exposure to
feared stimuli (Johnstone and Page, 2004) and could therefore be consid-
ered highly adaptive for dealing with these particular situations. These Psychosocial protective factors
situations have in common their level of controllability: all are low Factors that were associated with lower distress levels include trait opti-
control situations. It may be that distracting oneself from ruminating or mism, seeking social support (as a coping strategy), perceived social
avoiding dwelling on anxiety-provoking thoughts while waiting to hear support, and marital satisfaction/quality. In addition to these associations
the results of a pregnancy test can be considered adaptive for psycho- (which several studies found), secure attachment style was also linked to
logical well-being, since this is a low control situation, i.e. no amount of lower distress levels by the only study to explore this relationship. All
strategizing or rumination will change the test result. Folkman and these protective factors, except perhaps optimism, are reflective of our
Lazarus (1985) demonstrated that people generally increase their use capacity to affiliate with others and collectively they highlight the import-
of distraction/avoidance coping strategies in a low control situation. ance of this affect regulation system for psychological health (Morrone-
IVF is a prolonged process requiring multiple different situations to be Strupinsky and Depue, 2004; Depue and Morrone-Strupinsky, 2005).
dealt with and decisions to be made along the way. In this context, it These findings reflect literature on the health benefits of good marriages
appears that avoidance and escape can be maladaptive and do not and secure attachment figures (Robles and Kiecolt-Glaser, 2003; Gouin
serve people as well for reducing anxiety, depression or distress over et al., 2010; Stanton and Campbell, 2013). Social support is known to
The associates of IVF stress 609

confer many psychological and physical benefits in a wide range of other for research to develop specialist psychological services and to ensure
contexts, e.g. inhibition of cardiovascular disease progression (Årestedt patients are aware of their availability (Boivin et al., 1999).
et al., 2012) adjustment to having cancer (Trevino et al., 2013) and An additional finding of note was that contrary to our expectation, the
reduced risk of depression (Khatib et al., 2013). It is even related to majority (67%) of the associations tested by the studies in this review did
overall mortality risk showing an effect size comparable to smoking not show a significant relationship to emotional adjustment at all. Given
(House et al., 1988). These beneficial effects appear linked to both the pro- that the authors of the individual studies explored the chosen factors
vision and receipt of social support, prompting suggestion that the because they were thought likely to be associated with psychological ad-
mechanisms underpinning this effect may lie with the experience of posi- justment, it could be considered surprising that most psychosocial
tive emotions elicited by affiliation with others, rather than in receipt of factors were not associated with emotional health, or apparently not
the support per say (Brown et al., 2003; Cohen et al., 2006; Steptoe in this particular clinical context. However it might also be that these
et al., 2009; Kok et al., 2013). factors are associated with some aspect of emotional adjustment, but
We suggest that these reported associations may be an especially rele- not to the outcome measures used in these particular studies.
vant finding for helping to understand the experience of IVF patients. In-

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fertility tends to be a personal journey, often not shared with one’s usual
social support network (Imeson and McMurray, 1996). Patients often Limitations and additional considerations
state social isolation as a contributory factor to the stress of infertility There are several limitations to consider regarding both the method-
(Greil et al., 2009). It may even contribute to the stressful nature of IVF ology of this review and the methodology of the empirical research
as a result of the effort involved in hiding a significant and ongoing reviewed. Every effort was made to include all relevant research, by
problem. Finamore et al. (2007) suggested this with data showing evi- searching multiple databases, using the reference lists of included
dence of higher stress levels in women who did not disclose IVF treat- studies and contacting known authors for this area of research;
ment to work colleagues than in those who did. however, it is possible that research articles were missed. A second limi-
Psychological interventions that train people on the skills and emo- tation is that only one author decided which studies fulfilled inclusion cri-
tions of affiliation (connecting with others), soothing oneself and care teria for the review. Although this does increase the risk of erroneous
giving/accepting are yielding promising results for a wide range of inclusion/exclusion, this risk was mitigated by having 20% of the
patient and non-clinical groups (Neff and Germer, 2012; Braehler studies found blind rated for inclusion by a second researcher, with no
et al., 2013; Jazaieri et al., 2013). Effects include both increased positive resulting conflict in decisions.
emotional capacities and reduced negative emotional experiences. Regarding limitations of the empirical studies, the research partici-
There is also evidence emerging that such ‘affiliative affect regulation’ pants were often couples. In some studies, the non-independent
techniques and interventions can alter physical health (Hofmann et al., nature of the data collected is acknowledged, even tested directly (e.g.
2011), which could be of special relevance to those with subfertility Knoll et al., 2009). However, the majority of these articles do not
looking to improve both their emotional experience and their physical account for the interconnected nature of their psychological measures.
health in order to try and increase the odds of conception. This is an especially important statistical consideration when exploring
Acceptance of one’s situation (i.e. infertility) was found to be protective stress and coping, since dyadic coping models differ from others, with
against distress suggesting that lower distress might be one positive an added layer of complexity involving joint appraisals (Bodenmann,
outcome resulting from adopting this particular coping strategy. Recent re- 1997). As Fisher et al. (2008) shows, the distress levels of one partner
search has documented the success of mindfulness training (Galhardo et al., influence the other partners’ distress levels and degree of threat apprais-
2013) and acceptance and commitment therapy (Peterson and Eifert, al. So, it may be that statistical assumptions have been violated for studies
2011) for infertile couples, as both are interventions to increase openness using data from both partners but treating them as unrelated participants.
to and acceptance of emotions, which in turn appears to promote psycho- Moura-Ramos et al. (2012) for example account for this in their analysis
logical flexibility and health (Kashdan and Rottenberg, 2010). There is also by considering each couple as a unit of analysis; however, other studies
evidence that acceptance of one’s infertility and ‘letting go’ coping are did not. Despite a possible limitation for the purposes of interpreting
related to higher IVF conception rates (Rapoport-Hubschman et al., this particular group of studies, this cannot be considered a limitation
2009) as well. Therefore, in addition to reducing psychological stress, it is in the wider context of stress and coping research. Indeed the fact that
possible that some psychological strategies for coping could also impact couples undergo IVF treatment together provides a convenient natural
pregnancy odds, perhaps via the reduction of stress or the induction of af- situation in which to explore and test dyadic stress and coping models.
filiative emotions and their concomitant effects on the body. Most studies included in this review measure distress outcomes
before or after IVF treatment but not during it. This raises issues regarding
the differences between anticipatory anxiety before an event, stress
levels during an event and post-event recovery following the end of ex-
Additional findings posure to a stressor. In the case of infertility, termination of the stressor
This review revealed that interest in this area appears to be increasing, (i.e. childlessness) may never be achieved; nevertheless adjustment or
with over half of the studies reviewed being published since 2006. This adaptation to accommodate the stressor occurs eventually for most
is probably because of the growing numbers of patients having IVF treat- people. People vary both in their acute stress responses and abilities
ment and thus a growing awareness of its psychological challenges. As to recover from stress-related arousal. There is evidence that stress
well as increasing the number of patients available to take part in re- response and recovery are related to health outcomes, possibly via indi-
search, there will inevitably be increased numbers of people seeking vidual differences in trait positive affect, which serves to ‘undo’ the nega-
help for the emotional aspects of treatment and a consequent pressure tive emotional arousal elicited by a stressor and consequently protects
610 Rockliff et al.

against the deleterious effects of stress (Yuan et al., 2010). Future begins and following either successful or unsuccessful IVF treatment.
research may wish to extend these studies by examining how individual Conversely escapist/avoidant coping strategies were consistently
differences in psychosocial factors impact each stage of an encounter linked to higher distress levels before treatment and at several time
with a stressor (i.e. anticipation, response and recovery). Stress recovery points following a failed cycle. These two psychological factors may be
may be especially relevant to IVF patients given the quick succession of amenable to alteration with psychological or educational interventions
acute stressors that a treatment cycle involves. Being able to capitalize to promote social engagement, feelings of connectedness and to
on positive aspects of life during treatment may also serve patients well reduce reliance on escapist coping strategies that appear detrimental
for optimizing their recovery. to psychological health. The next step is to explore whether such inter-
The deficit of studies exploring how psychosocial variables are asso- ventions, which have shown promising results for other patients groups,
ciated with distress during IVF treatment may be because of the could also provide effective ways to reduce distress for this clinical popu-
extreme variation in treatment protocols across patients. Distress lation.
levels during IVF treatment tend to fluctuate with some consistency as
a cycle progresses (Boivin and Takefman, 1995). For example there

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are trends applicable to all patients such as an increase in anxiety Conclusions
before oocyte collection and during the waiting period following Approximately one-third of the psychosocial variables explored were
embryo transfer. However, the treatment cycle for women is highly het- found to be significantly related to psychological adjustment. This
erogeneous, driven by a range of clinical factors (e.g. response to stimu- review highlights several key psychosocial factors that could be used to
lation drugs, endometrial thickness, etc.). Such variations may hinder assist in the identification of prospective IVF patients at high risk of psy-
attempts to capture the distress experienced during treatment as the chological distress. Neuroticism and the use of escapist coping strategies
medical feedback patients receive throughout their treatment cycle were linked with increased distress by multiple studies. In addition to
differs greatly between patients and impacts distress levels and feeling identifying high risk patients, there are clinical implications for the pro-
of hopefulness and optimism. Thus very different personal situations tective factors identified in this review. Social support was associated
can end up grouped as the same stage of IVF treatment (e.g. oocyte col- with low distress levels across several studies. A number of other psycho-
lection). To our knowledge there are no studies that measure distress social variables, including self-criticism, dependency, situation appraisals
during IVF treatment and take these individual differences into and attachment style, appear to be associated with distress but have only
account, perhaps because of the logistical difficulties of such a design. been explored by one or two studies at most. There is also a paucity of
Most studies in this review measured psychological outcomes after IVF research using positive emotional outcome measures (e.g. well-being,
treatment was complete. This requires consideration as two groups: positive affect, happiness or life satisfaction) to quantify psychological ad-
those including patients who have become pregnant and those for justment.
whom the treatment did not work. This is based on the assumption
that the treatment outcome will influence on the emotional status of
patients. Whilst this is highly likely, it is of interest to note that Lowyck Authors’ roles
et al. (2009) reported that pregnancy status was not significantly H.R.: protocol development, literature searches, study selection, review
related to participants well-being at all. This may be to do with the fact of literature and manuscript preparation. S.L.: supervision of research
that a global measure of well-being was used 3 and 6 months following and review of manuscript. E.R.: blind rating of studies for inclusion in
the IVF treatment, and reflected the adjustment period of the partici- review, discussion and interpretation of results. H.B.: expertise in con-
pants. It could be expected that a more acute measure of distress recorded ducting systematic reviews, protocol development, and review and crit-
immediately following the discovery of treatment outcome would more ical revision of manuscript. U.G.: expertise in clinical aspects of IVF
accurately capture women’s emotional responses. In view of the increasing treatment and review of manuscript. K.V.: supervision of research and
numbers of women seeking this type of fertility treatment, it is important to review and critical revision of manuscript.
examine whether there are long-term psychological costs associated with
the treatment, regardless of the treatment outcome.
Review of the studies that controlled for baseline distress before Funding
exploring the predictive effects of their psychosocial variables all
Funding for this work was received from The Medical Research Council
showed that a large portion of variance in psychological outcome mea-
Grant No. SD1601.
sures can be accounted for by baseline distress levels. This highlights
the importance of controlling for this in future studies. Baseline distress
needs to be measured routinely in this kind of research in order to Conflict of Interest
control for the variance it adds to outcomes, as well as the effect it
The authors declare no financial or commercial conflicts of interest in this
may have on choice of coping strategies and appraisals, etc., which in
study.
turn may also influence distress outcomes.

Clinical implications
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