Psychiatry & Infertility

Double impact
Jamal Khatib MD
Consultant Psychiatrist
 Pubmed hits
• Infertility 41665
• Infertility& psychological 1016 Jul /57-- Dec/04
• Infertility& depression 277 Jul /66-- Dec/04
• Infertility& anxiety 199 Sep/54—Dec/04
• Infertility& stress 744 Apri/58 -- Dec/04
• Infertility quality of life 152 Feb/74 -- Oct/04
• Infertility emotions 305 Jun/56 -- May/04
Impact Of infertility
on
Psychiatric Wellbeing
 BMC Womens Health. 2004 Nov 06;4(1):9.
A survey of relationship between anxiety, depression and duration of infertility.
Ramezanzadeh F, Aghssa MM, Abedinia N, Zayeri F, Khanafshar N, Shariat M, Jafarabadi M.
Vali-e-Asr Reproductive Health Research Center, Gynecology and Obstetrics department, Tehran University of
Medical Sciences, Imam Khomeini Hospital Complex, Keshavarz BLVD, Tehran 14194, Iran.

• This survey showed that 151 women (40.8%)

had depression and 321 women (86.8%) had
anxiety. Depression had a significant relation
with cause of infertility, duration of infertility,
educational level, and job of women. Anxiety
had a significant relationship with duration of
infertility and educational level, but not with
cause of infertility, or job. Findings showed that
anxiety and depression were most common
after 4-6 years of infertility and especially
severe depression could be found in those who
had infertility for 7-9 years
 Hum Reprod. 2004 Oct;19(10):2313-8. Epub 2004 Jul 08
Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic.
Chen TH, Chang SP, Tsai CF, Juang KD.
Department of Psychiatry, Taipei Veterans General Hospital National Yang-Ming University
School of Medicine, Taipei, Taiwan

Of a total of 112 participants, 40.2% had a

psychiatric disorder. The most common
diagnosis was generalized anxiety disorder
(23.2%), followed by major depressive disorder
(17.0%), and dysthymic disorder (9.8%).
Participants with a psychiatric morbidity did not
differ from those without in terms of age,
education, income, or years of infertility. Women
with a history of previous assisted reproduction
treatment did not differ from those without in
depression or anxiety
 Int J Fertil Womens Med. 2004 Jan-Feb;49(1):24-8.
Department of Psychiatry, Faculty of Medicine, Kuwait University, Safat,
Kuwait

• Compared with an age-matched pregnant control sample,

the infertile women exhibited significantly higher
psychopathology in all HADS parameters in the form
of tension, hostility, anxiety, depression, self-blame
and suicidal ideation. The illiterate group attributed the
causes of their infertility to supernatural causes, such as evil
spirits, witchcraft and God's retribution, while the educated
group blamed nutritional, marital and psychosexual factors
for their infertility. Faith and traditional healers were the first
treatment choice among illiterate women, while the
educated women opted for an infertility clinic for treatment.
Childlessness resulted in social stigmatization for infertile
women and placed them at risk of serious social and
emotional consequences
 Int J Fertil Womens Med. 2004 Jan-Feb;49(1):44-8.
Department of Obstetrics and Gynecology, Postgraduate Institute of Medical
Education and Research, Chandigarh, India

• Psychological components were found to

play a significant role in infertility of
unknown etiology, especially in the male
partner. They affected the personality and
social behavior of the male partner and
caused anxiety, but led to depression in the
female partner. In cases of organically
caused infertility, partners were worried
about the other's reaction
 Ceska Gynekol. 2004 Jan;69(1):42-7
[Personality and characteristics of couples in infertile marriage]
Weiss P, Mateju L, Urbanek V.
Sexuologicky ustav 1. LF UK, Praha..

• Men and women from infertile couples displayed

moderate abnormal behavioral characteristics,
men from these couples are more neurotic than
general population, women display more anxiety
and social desirability. The relations in these
marriages are not substantially disturbed and
are even less conflictuous and the consistency
of the male and female roles is even better than
in general population. Men from infertile couples
are perceived by themselves as well as by their
wives as less masculine.
 Gynecol Obstet Invest. 2002;53(4):195-9.
Department of Obstetrics and Gynecology, Prince of Wales Hospital,

Chinese University of Hong Kong, People's Republic of China

• Our results show that one third of the women

who sought infertility treatment had an impaired
psychological well-being. Following failed
treatment, there was a further
deterioration in mental health, and about
10% of the participants were moderately to
severely depressed. Proper psychological care
and counseling should be an integral part of
infertility management among the Chinese
population
 Urology. 2004 Jan;63(1):126-30.
Impact of infertility on quality of life, marital adjustment, and sexual function.
Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T.
Department of Urology, University of Minnesota, Minneapolis, Minnesota 55455, USA

• A trend toward lower quality-of-life scores was noted in

women (P = 0.09) but not in the men of infertile couples.
No statistically significant impact on sexual functioning in
women was noted; however, the men in the infertile
couples had lower total International Index of Erectile
Function scores (P = 0.05) and intercourse satisfaction
scores (P = 0.03). CONCLUSIONS: Women in infertile
couples reported poor marital adjustment and quality of
life compared with controls. Men may experience less
intercourse satisfaction, perhaps because of the
psychological pressure to try to conceive or because of
the forced timing of intercourse around the woman's
ovulatory cycle
Impact of Psychiatry
On
Infertility
Psychiatric impact mainly through effect on
sexuality
Male – impotence ,sperm quality
Female-hormonal, vaganismus
The vicious circle
 Hum Reprod. 2004 Apr;19(4):954-9. Epub 2004 Feb 12.
Is infertility a risk factor for impaired male fertility?
Pook M, Tuschen-Caffier B, Krause W.
. Department of Psychology, University of Siegen, Germany

• Analyses revealed that the level of infertility distress at

follow-up has a negative impact on the change in sperm
quality from baseline to follow-up assessment. Distress
scores were highly stable. As a consequence, the level
of distress at baseline assessment provided only little
additional information for the changes in sperm
concentration. Further analysis suggested that the
fertility status had no impact on infertility distress. The
present study delivers the strongest evidence to date
that distress due to infertility is a significant risk factor for
a decrease in sperm quality.
 . Psychother Psychosom. 1999 Mar-Apr;68(2):95-101

•Results indicate that distress

caused by infertility is a risk
factor for a decrease in
sperm quality.
 W.H. Meller, K.M. Zander, R.D. Crosby and G.E. Tagatz, Luteinizing hormone
pulse characteristics in depressed women. Am J Psychiatry 154 (1997), pp.
1454–1455
• A study of 10 depressed and 13 normal women
indicated that depression is associated with abnormal
regulation of luteinizing hormone . Activation of the
hypothalamic-pituitary-adrenal axis can profoundly
inhibit reproductive function. This inhibition of
reproductive function can be at many levels, ranging
from inhibition of hypothalamic GnRH to possible
direct actions on the ovary and endometrium in a
manner that could prevent pregnancy. Furthermore,
stress and depression alters immune function and
specific cytokines , which in turn could adversely
affect reproductive function.
 Acta Obstet Gynecol Scand. 2000 Feb;79(2):113-
Department of Woman and Child Health, Karolinska Hospital,

Stockholm, Sweden .

• The main findings suggest that infertile women

have a different personality profile in terms of
more suspicion, guilt and hostility as compared
to the fertile controls, perhaps as a response
to their infertility. Their stress levels in terms
of circulating prolactin and cortisol levels were
elevated compared to the fertile controls.
Psychological stress may affect the outcome of
IVF treatment since state anxiety levels among
those who did not achieve pregnancy were
slightly higher than among those who became
pregnant.
Impact
On
Therapy
 Gen Hosp Psychiatry. 2002 Sep-Oct;24(5):353-6.
Department of Psychiatry and Behavioral Science, Tokai University

School of Medicine Japan

• We investigated the effects of psychiatric group
intervention on the emotions, natural-killer (NK) cell
activity and pregnancy rate in Japanese infertile
women by a randomized study. Thirty-seven women
completed a 5-session intervention program and were
compared with 37 controls. Psychological discomfort and
NK-cell activity (47.7% to 34.1%, P<.0001) significantly
decreased after the intervention, whereas no significant
changes were observed in controls. According to a 1-
year follow-up of both groups, the pregnancy rate in
the intervention group was significantly higher than
that of controls (37.8% vs. 13.5%, P=.03). Psychological
group intervention was therefore effective in Japanese
infertile women.
 Why do couples discontinue in vitro
fertilization treatment? A cohort study
Catharina Olivius, B.Sc.,a Barbro Friden, M.D., Ph.D.,b Gunilla Borg, R.N., B.S.,a and
Christina Bergh, M.D., Ph.D.a
Sahlgrenska University Hospital, Go¨ teborg, and Varberg Hospital, Varberg, Sweden
FERTILITY AND STERILITY_
VOL. 81, NO. 2, FEBRUARY 2004

A majority of the couples (54%) who did not achieve a live birth in our
study chose not to proceed through the full treatment program
consisting of three completed IVF cycles. This was an unexpected
finding. The reasons for discontinuing efficient treatment for infertility,
free of charge, have not previously been studied in detail. In a recent
publication from the Netherlands , where the cost of treatment for up
to three cycles is also covered by society, the dropout rate was
approximately 60% after three cycles, and those investigators
concluded that economic reasons were of major importance. In our
study, in which economic reasons for discontinuing treatment could
be ruled out, we found that the main reason for ceasing treatment
was psychological stress, followed by a poor prognosis.
 Fertility and Sterility
Volume 73, Issue 4 , April 2000, Pages 805-811
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,
Massachusetts, USA

• Women who participated in a group

psychological intervention had significantly
increased viable pregnancy rates compared
to women who did not participate in any
psychological intervention. This difference
was not due to any group demographic
differences, including age and duration of
infertility, nor was it because of group
differences in medical interventions.
 Boston IVF, Waltham, Massachusetts, and Beth Israel Deaconess Medical
Center and Harvard Medical School, Boston, Massachusetts, USA
Fertility and Sterility
Volume 81, Issue 2 , February 2004, Pages 271-273

• There have been periodic notations in the

literature since the 1980s about reasons for
patient dropouts, with the most commonly
noted reason for dropout being financial,
followed by "emotional stress
• However, the reasons for voluntary withdrawal
have only recently been investigated in a more
extensive fashion.
• In fact, the number of patients who terminate
infertility treatment is significant, even when
financial reasons can be discounted because of
insurance coverage
 …….So
?Should we interfere
 Department of Obstetrics and Gynaecology, University Medical Center Radboud, Nijmegen,
The Netherlands
Department of Medical Psychology, University Medical Center Radboud, Nijmegen,
The Netherlands

• Intervention of the mental health team could be seen as a

way to lower dropout rates, but also as interference in this
possibly self-protective process. The patient's mental health
should indeed be considered an integral component of
infertility care. Whether this leads to higher rates of
treatment success, prevention of long-term depression, or
lower dropout rates needs and deserves further exploration.
• More attention to the psychological repercussions of
infertility treatment could lead to a more personalized
approach to optimize patient satisfaction. The availability of
a multidisciplinary team that holistically integrates medical
and mental health during the treatment period, which
extends the period of regular appearances in the clinic,
would be the first step
When to
Interfere
 Obstet Gynecol. 1999 Feb;93(2):245-51
Randolph Child and Family Counseling Center, Charlotte, North
.Carolina, USA

• Because of moderate to high levels of grief and

depression, therapeutic counseling may be more
effective if initiated before the infertility
treatment. Women's present levels of distress
and coping strategies should be assessed prior to
initiating infertility treatment to provide the
patients with opportunities to learn and practice
new adaptive behaviors that could enhance their
ability to cope with infertility and the associated
medical procedures.
Thank you