A Systematic Review of Psychosocial Factors Associated With Emotional Adjustment in in Vitro Fertilization Patients
A Systematic Review of Psychosocial Factors Associated With Emotional Adjustment in in Vitro Fertilization Patients
594–613, 2014
Advanced Access publication on March 27, 2014 doi:10.1093/humupd/dmu010
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.
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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-
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
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
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
coping strategies (nine studies each). This was followed by marital quality,
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
outcome?
Yes
Yes
Yes
Yes
No
No
No
No
No
are listed in the right hand column. References for each study have
with valid tool?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
measure is stated.
Personality traits
Data collection time
specified in relation
to IVF treatment?
(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
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
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
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
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
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
..........................................................................................................................................................................................................................................................
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
............................................... ......................................... ........................................... ...........................................................
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
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
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).
anxiety
a
scale as Terry and Hynes (1998), and employing a very similar longitudinal
Fisher et al. (2008):
Lee et al. (2011):
depression
depression
et al., 2006a, b and Van den Broeck et al., 2010, respectively). All of
(2009): well-being
et al., 1992 which was longitudinal and collected outcomes after IVF
Fisher et al.
depression
cing and infertility stress, was reported by one study (Peterson et al.,
a
(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
Infertility words
Family function
dissatisfaction
ciated with infertility specific distress, with the other factors studied
attachment
attachment
Control
support
Marital
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
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
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)
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
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-
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
Clinical implications
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