The Role of Mental Health in Infertility

Table of Content

Abstract

Introduction

Problem statement

Aim of study

Research Questions (RQ)

Research Design

Literature review

Overview of Infertility

Etiology/Contributory factors of Infertility
Male and Female Infertility
Male-Factor Infertility
Female-factor Infertility
Idiopathic Factor:
Diagnosis of Infertility
Medical Interventions (Assisted Reproduction Technologies)

Mental Health and Psychological Trends of Infertility
Stress, Distress, and Infertility
Coping Strategies with Infertility: Women
Coping Strategies with Infertility: Men
The Impact of Infertility on the Couple
Overview of Psychological Interventions
Psychotherapy and Infertility treatment: Evidence-Based Review
Cognitive and Behavioral Therapies (CBT)
Acceptance and Commitment Therapy
Psychoeducational Interventions
Online Interventions
Empirical Studies Relating to Mental and Reproductive Health

Conclusion/Future Directions

Reference

Appendix

Abstract

Background: The subject of reproduction has, since recent history been gaining a lot of attention as there has been reports of decline in successful pregnancy rate by the World Health Organisation and other global health organisations. Healthcare professionals and researchers have attributed the root causes of the declining reproduction success to a myriad of factors including untreated mental health challenges. Globally, there has been anecdotal and empirical evidences that individuals diagnosed as infertile may also be faced by co-morbidity of mental health disorders. This arguably has been the basis of a hypothesis on a ‘dyadic’ nature of mental health and reproductive health.

Rationale/Objectives: The theory of untreated psychological stress leading to obstetric complications and treatment failure is quite alarming. It is therefore imperative to investigate the extent to which patients exposed to mental health ailments (or psychological disturbances) are threatened by obstetric complications and reduced chances of pregnancy – a subject which is yet to be well-explored. Hence, the present study. Alternatively, the present review seeks to evaluate the evidences on a possible association between mental health and reproduction success. Reproduction success in the context of this review, is defined by improvement in fertility treatment outcomes including pregnancy.

Outcomes: The review employed the use of psychological and medical research databases such as Google Scholar, PsycINFO, PubMed, Human Reproduction Update, Web of Science, EBSCO and the Cochrane Library. The systematic search considered open-access published papers (in English language) based on keywords such as infertility, mental health and reproductive health, infertility treatment, reproduction success rate, assisted reproduction technologies, psychological traits, psychological intervention, coping strategies among others.

The study found evidences of possible association between variables of mental health (or psychotherapy) and infertility treatment outcomes including significant increases in pregnancy rate, reduction in obstetric complications among others. The researchers concluded on the need for psychotherapy as complementary or support care in infertility treatment. In spite of this, there were also evidences of no or little effect following psychological intervention and coping strategies.

Wider implications: The present review also found certain limitations owing to the high level of non-homogeneity and variability across the study designs of many studies. This inevitably therefore served as a barrier to ascertaining the significant role of mental health in achieving the goals of infertility treatment programs, one of which include increasing the chances of conception while catering for the psychological burden of infertility. It is important that subsequent research incorporate the research capacities of various healthcare professionals and researchers in order to improve the quality of research on this subject.

Keywords: infertility, mental health and reproductive health, infertility treatment, reproduction success rate, assisted reproduction technologies, psychological traits, psychological intervention, coping strategies.

Introduction

Infertility (or subfertility as designated in various literature [Verkuijlen et al., 2016]) is a global phenomenon. It has been described as a medical condition of the reproductive system characterized by the inability to achieve pregnancy when couples have regular ‘unprotected’ intercourse (World Health Organization (WHO), 2016).

In a bid to evaluate infertility, various scholarly works have further categorized the ability to achieve pregnancy in terms of whether (i) the couple is attempting to achieve pregnancy for the first time (primary infertility) (ii) the couple is unable achieve pregnancy despite previous success or is unable to carry a pregnancy to a ‘live birth’ despite previous success (secondary infertility) (RESOLVE, 2012; Mansour, 2014; Musa, 2014). Esselstrom (2014) replaced secondary infertility with the term ‘Impaired fecundity.’

It is important to critically consider also how scholars and healthcare professionals perceived infertility by various criteria. For instance, some healthcare professionals may diagnose infertility in women over 35 years of age after six months of unsuccessful attempts to achieve pregnancy. Such diagnosis may be partly aimed to encourage early commencement of fertility treatment (CDC, 2012). Bell (2013) however among those researchers that argue against such under-1-year diagnosis in favor of allowing couples longer period to achieve conception.

Researches have highlighted that the reproduction health deficiency in fact affects millions of couples across the world regardless of their demography. In one study, variables such as age was implicated as predisposing couples to infertility (and/or infertility treatment outcomes). Couples attempting to achieve pregnancy for the first time had been investigated where it was found that infertility was ‘[…] higher among women aged 20 to 24 years in comparison with women aged 25 to 29 years’ (Mascarenhas, 2012). The study further concluded that a degree of secondary infertility amongst aged 40 to 44 years compared to women aged between 20 and 24 years.

Problem statement

Across the world, there has been anecdotal and empirical evidence that many couples that are diagnosed as infertile were subject to immense psychology stress and distress. This has also led researchers to a hypothesis on a ‘dyadic’ nature of mental health and reproductive health. In other words, certain scholars believe that there might be a possible link between the psychological state of infertility patients and their ability to achieve pregnancy.

In a review by Thornton et al. (2010); it was highlighted that there were increasing reports that pregnant women were experiencing increasing rate of serious obstetric complications during labor and delivery ‘many of which are preventable through optimal obstetric care’ (Danel et al., 2003; Guendelman et al., 2006; Remy et al., 2008). This is also consistent with a few previous research works that have attempted to investigate the subject of supportive care (via psychotherapy) during the period of infertility or infertility treatment (Van den Broeck et al., 2009; Turner et al., 2013). The consequences of untreated psychological stress leading to obstetric complications and treatment failure is quite alarming. It is therefore imperative to investigate the extent to which women exposed to mental health ailments (or psychological disturbances) are threatened by obstetric complications and reduced chances of pregnancy – a subject which is yet to be well-explored. Hence, the present study.

Aim of study

To investigate the effectiveness of psychological interventions on fertility treatment outcomes.

The subject of the review will contribute knowledge on the psychological needs of individuals and couples seeking fertility services for various healthcare professionals.

Research Questions (RQ)

This narrative review seeks to explore the extant literature that addresses the following questions:

RQ1: Do psychological interventions affect infertility treatment?

RQ2: Do psychological traits, coping strategies and psychological interventions affect infertility treatment outcomes?

Research Design

The present review adopted the modified methods of Boivin (2003), Hammerli et al. (2009) and Verkuijlen et al. (2016) in a systematic search that identified all open-access published papers written only in English language. Such search was based on literature that included words, phrases and sentences on the topic of ‘(a) psychosocial interventions (b) psychological traits and coping strategies in infertility (c) assisted reproduction technologies and other infertility treatments (d) the effect of any of the treatment outcomes in infertility programs.’

Additionally, the review employed the use of psychological and medical research databases such as Google Scholar, PsycINFO, PubMed, Human Reproduction Update, Web of Science, EBSCO and the Cochrane Library.

Literature review

Overview of Infertility

According to the 2010 World Health Organization’s (WHO) report, it was estimated that approximately 45 million couples across the world were affected by fertility-related problems (Mascarenhas et al., 2012). Interestingly, there has also been an increase in scientific innovations in the field of reproduction medicine that has seen the introduction of assisted reproductive technologies. Accordingly, a number of these reproductive technological innovations have been applied in the management of infertility including (but not limited to): ‘in-vitro fertilization’ (IVF), ‘intracytoplasmatic sperm injection’ (ICSI) or ‘intrauterine insemination’ (IUI) (Dunn et al., 2014).

Etiology/Contributory factors of Infertility

Several biological, psychological and environmental variables have been implicated for their role in infertility. According to a Center for Disease Control and Prevention (CDC) report, age has been found to be one of the strongest predictors in the ability to achieve pregnancy (and/or fertility treatment outcomes) (CDC, 2005).

The National Fertility Association, RESOLVE in their 2012 report estimated that female fertility has reduced from 90% to 15% by age 50. Their research suggested that this may be as a result of the combinations of age-related health complications and potential chromosomal aberrations in the female sex cell as they age. Hence, the increased cases of miscarriage in older woman (RESOLVE, 2012).

Male and female fertility have also been reported to be adversely affected by certain personal, social and environmental factors such as ‘[…] smoking, excessive alcohol use, poor diet, engaging in unprotected sexual intercourse, athletic training, obesity or anorexia, and environmental exposure (CDC, 2012; 2013; Lynch et al., 2014).’ This is in addition to research papers on environmental changes such as exposure to toxic chemical, radiation, and high temperatures which has been associated with reduced fertility in men and women (RESOLVE, 2012).

Interestingly, other studies have reported a link between the body mass index (BMI) and the likelihood of pregnancy in relation to hormone regulation in the female reproductive system (Khaskheli et al., 2013; Kort et al., 2014).

Male and Female Infertility

As highlighted in Esselstrom (2014), the causes of infertility are multiparous. However, in this section; infertility was discussed with respect to biological factors.

Male-Factor Infertility

Unlike the female reproductive system; male infertility has been linked to disturbances in the hypothalamic-pituitary-testicular axis (CDC, 2011). The hypothalamic-pituitary-testicular system controls the processes of steroidogenesis and spermatogenesis. Steroidogenesis is concerned with male hormonal imbalances while spermatogenesis deals with the production of morphologically and functionally-normal sperm cells (Choy and Ellsworth, 2012).

Female-factor Infertility

Based on the suggestions from various research findings, biological factors that have been studied to be the sources of female infertility include age; endometriosis ; tubal disturbance which is a blockage or damage in fallopian tube leading to difficulty in fertilization and travel of an embryo to the uterus; ovulatory disorders ‘any condition that impacts ovulation’ and uterine disorders, which could ‘[…] impact a woman’s ability to conceive and carry a pregnancy to term’ (CDC, 2011; RESOLVE, 2012)

With women undergoing assisted reproduction; fertility treatment can be impaired as a result of insufficient eggs in spite of large doses of ovulation stimulating medications. Such condition for instance may also be due to premature ovarian failure (RESOLVE, 2012).

It is also important to consider the presence of other biological/medical variables such as presence of chromosomal aberrations, cancer chemotherapy, immune system, and other serious medical conditions (CDC, 2011; RESOLVE, 2012).

Idiopathic Factor:

In the absence of the male- and female-factor source of infertility as mentioned such as ‘[…] ovulatory function, sufficient ovarian reserve, a normal uterine cavity, unobstructed fallopian tubes, and normal semen quality’, a diagnosis of idiopathic infertility may be provided (Fritz, 2012). To this end, other possible sources of infertility have been hypothesized including the presence of psychogenic elements (Lykeridou et al., 2009; Romano et al., 2012).

There is a myriad of scholarly works whose findings suggests an interaction between psychogenic factors (such as psychotropic drugs, mental ailments) and infertility among couples (Ramezanzadeh et al., 2004; Chiaffarino et al., 2011).

Hajela et al. (2016) for instance; reported that psychological stress induced by inability to achieve pregnancy; coupled with the exposure to psychological traits (such as anorexia and depressive disorders) may significantly alter the hypothalamic-pituitary-ovarian (HPO) axis of the woman. Consequently, such imbalances within the HPO axis could negatively impact a woman’s reproductive health function. Hence, the cause of infertility.

Hajela et al. (2016) also reported the link between psychological stress in men and coital dysfunction, which has been implicated in male infertility.

Diagnosis of Infertility

The root cause of infertility amongst couples could said to be definitive or non-specific as highlighted above. For the specific or definitive root causes, investigations of a normal functioning male and female reproductive system are typically carried out.

Esselstrom (2014) stressed that couples who resolve to talk to a professional at a fertility clinic have to pass through different stages before treatment is administered – beginning with a diagnostic interview.

The aim of the diagnostic interview is to collect relevant information on the patient (s) including ‘[…] data on drug use, marital status, stability of relationship with spouse or partner, mental and physical health of existing children, sexual orientation, reasons for wanting a child, and financial stability, HIV status, race, mental health, data on previous pregnancies and associated complications, sexual history, duration of infertility, and assessment of physical symptoms’ (Gurmankin et al., 2003; Fritz, 2012).

Esselstrom noted that sequel to the data collection phase, couples commence the process of diagnostic testing, which may be followed sessions to discuss results and more testing until a final diagnosis is attained (Fritz, 2012). Accordingly, to assess male fertility, the males are required to provide a semen sample which will be used to assess certain sperm parameters such as sperm motility and morphology. A urologic and endocrinology screening is also done. Women on the other hand, are subjected a battery of test to assess their potential for fecundity. A few of them include ‘[…] basal body temperature, a transvaginal ultrasound, serum hormonal levels such as progesterone, antimullerian hormone’ (Esselstrom, 2014).

Quite visibly, the infertility treatment journey requires several tasks in a bid to assess the primary and secondary causes of infertility such as the physiological state of the couple in addition to other data as required in the diagnostic procedures. Therefore, one might understand why the success or failure of the treatment has in recent times been discussed in relation to mental health.

Medical Interventions (Assisted Reproduction Technologies)

The recent advancements of reproductive medicine may be translated to the availability of multiple treatment options for couples seeking infertility treatment.

The Assisted Reproduction Technologies (ART) as defined by the “1992 Fertility Clinic Success Rate and Certification Act’ comprise includes all fertility treatments where both eggs and sperm are handled” (CDC, 2011).

Summarily, some of the common ART approaches to treating infertility include in-vitro fertilization (IVF); intracytoplasmic sperm injection (ICSI); gamete intrafallopian transfer (GIFT); zygote intrafallopian transfer (ZIFT) amongst others – with varying success rates (CDC, 2011; RESOLVE, 2012).

Other non-ART approaches have also been highlighted including intrauterine insemination and procedures that involve medication use to stimulate egg production without intended retrieval of the eggs (CDC, 2011).

Mental Health and Psychological Trends of Infertility

The psychological intervention approach to infertility treatment arguably stem from advocacy work of Barbara Eck Menning in 1980 and has since been supported by various organisations (such as RESOLVE) and healthcare professionals in reproductive medicine (Boivin and Kentenich, 2002).

As mentioned earlier on the origin of infertility, Verkuijlen et al., (2016) in their report mentioned that 20% of all unfertile couples seeking fertility treatment show clinically relevant levels of anxiety, depression, or distress. For this reason, there has been strong recommendations on the need for psychotherapeutic measures amongst other medical care. Its effectiveness however has been subjected a lot of debates on how psychological intervention actually do have impact infertility treatments whether primary or secondary.

Studies have suggested that fertility treatment may result in tremendous psychological burden, particularly in the event of failure to achieve in a clinical pregnancy or a live birth (Gameiro, 2012). This was revealed in the research works such as Verhaak (2005) , Chiaffarino (2011) where the incidence of depressive or anxious symptoms, measured between the first visit to a fertility clinic and the start of treatment, were reported to higher in both women and men seeking fertility treatment following the commencement of the treatment cycle.

Various literature also estimated that in many cases during the fertility treatment cycle, one-fifth of all infertile couples receiving reproductive medical care would need some form of psychotherapy (Verhaak, 2007; Gameiro, 2015), and, according to Gameiro (2015), may even cease fertility treatment due to ‘psychological burden or relational and personal problems across any stage of fertility treatment.’

To this end, some scholars have opined on the need to provide supportive care for families diagnosed to be under psychological stress owing to the fertility treatment. This has been agreed to lead to ‘[…] better functioning in daily life and reduce discontinuation of fertility treatment (De Liz 2005; Gameiro 2012).’ This is consistent with the position of some scholars that believe that psychological interventions increase the chances of pregnancy following treatment programs (De Liz, 2005; Hämmerli, 2009).

The proceeding sections are included to highlight important aspects of psychotherapy on assisted reproduction.

Stress, Distress, and Infertility

Podolska and Bidzan (2011) (cited in Gdańska et al., 2017) mentioned that often times, infertility treatment was often a long term process which has been found to elicit psychological stress within affected individuals. Anxiety and depression are a few commonly reported examples of mental health disturbance. This was reiterated in a review by Hajela et al. (2016) on the relationship between stress and infertility which favored the argument that imbalances in mental health could interfere fertility and success in infertility treatment procedure.

The role of the mental health as an integral component of total well-being is increasing receiving attention in recent times. In the case of fertility, the role of mental health in relation to the likelihood of achieving pregnancy is currently being considered among researchers (Holka-Pokorska et al., 2015) in spite of mixed findings on the psychogenic roots of male and female infertility (Pook et al., 2004; Lynch et al., 2014).

As mentioned earlier, the long-term psychological burden of infertility treatment has been linked to the risk of anxiety and depression which in turn complicates the goal of achieving pregnancy.

According to Oxford Handbook of Psychiatry (2013); anxiety is a normal ‘adaptive response’ to an exposure to stressful events. However, this could become pathological if not controlled. Depression on the other hand; marked by ‘[…] lowered mood, lowered activity, loss of interest and an inability to experience pleasure from joyful activities’ is another subject gaining significant public health concern. It is important to note here that, both anxiety and depression are broad terms that defined a myriad of psychological disorders according to the Diagnostic and Statistical Manual of mental Disoders (DSM).

In the context of fertility, anxiety and depressive disorders and other psychogenic ailments have been suggested from various works to affect outcomes of infertility treatment (Chiaffarino et al., 2011; Baghianimoghadam et al., 2013; Reis et al., 2013; Schaller et al., 2016). However, as discussed below, this argument has generated conflicting findings (Gdańska et al., 2017).

This was also the concern of Esselstrom (2014) in a doctoral research that was based on the fact that: ‘(i) stress decrease fertility in men and women, and may also impact fertility treatment outcomes. (ii) psychological burden was linked to treatment discontinuation, due to the physical and emotional stress associated with the personal, social, and medical aspects of infertility.’

Various works have documented the psychological experience of couples affected by infertility medical care; to which Esselstrom stressed that the theory of such experience should also be extended to couples desiring pregnancy via natural means (Esselstrom, 2014).

Coping Strategies with Infertility: Women

It is not uncommon that most literature search often lead to results on the impact of infertility on mental health. However, the focus of this review is on the effect of psychological intervention and / or psychological coping strategies on chances of achieving pregnancy.

Scholars have ranked infertility as the ‘fourth most distressing experience’ in a woman’s life (Lykeridou et al., 2009). Accompanied by elevated stress levels, infertility was found to be associated with feelings of grief, depression, guilt, and anxiety. This is consistent with the work of McQuillan et al. (2003). More so, there are studies that reveal that when matched to women who can achieve pregnancy via natural means, ‘distress in infertile women was reported to be significantly higher (Lewis et al., 2013).

Interestingly, Johnson and Fledderjohann (2012) work on women in the United States aimed at determining ‘[…] the relationship between infertility diagnosis, treatment type, distress levels, and self-identification as infertile.’ Found that women who were medically diagnosed as infertile were more likely to self-identify as infertile. Women seeking treatment for male factor infertility were less likely to identify as infertile. Women who identified as infertile endorsed higher levels of distress.

The researchers concluded that ‘self-identification-as-infertile, as opposed to type of infertility diagnosis was directly related to distress levels.’ (Johnson and Fledderjohann, 2012).

In the context of the present study, asides highlighting the tremendous psychological burden experienced by women desiring pregnancy; it is also important to highlight how affected individuals are able to cope with the burden of infertility during treatment courses.

Several researchers in a study developed a “[…] fifty-one-item measure, ‘Coping with Infertility Questionnaire’ to assess styles of coping related to the infertility experience (Benyamini et al. 2008).” Three main coping areas were revealed from their study and each is composed of more specific coping styles as mentioned in Esselstrom (2014): The approach-avoidance coping strategy which includes aspects of social withdrawal, denial, self-blame, self-neglect, disclosure, acceptance, and positive re-interpretation. Relationship coping strategy which includes seeking spousal support. Practical management coping strategy which includes self-nurturing, seeking social support, planning and information-seeking, and faith.

Benyamini and colleagues also compared ‘[…] coping with psychological adjustment, which was assessed through measures of well-being, distress, life satisfaction, and somatic symptoms. They found that emotional approach coping such as self-nurturing, and problem appraisal strategies such as positive reinterpretation were associated with better psychological adjustment. On the other hand, emotional avoidance, and problem-management strategies such as seeking social support and information-seeking were associated with worse adjustment.’ This however conflicted with the work of La Joie (2003) that suggested that ‘[…] strong social support, including marital support, was associated with lower distress levels.’

The study by Benyamini and colleagues was further corroborated by Adams (2002) (cited in Esselstrom, 2014) that found that women experiencing primary or secondary infertility typically used social support, problem solving, and positive reappraisal in coping with distress. They were less likely to use avoidance, self-controlling, distancing, accepting responsibility, and confrontational coping to resolve the situation. For those experiencing primary infertility, accepting responsibility and avoidance were associated with increased levels of distress.

Another interesting investigation has been on the interaction of various coping strategies across various phases of the infertility treatment. In one study by Gerrity, as noted in Esselstrom (2014): ‘[…] the affected women were most likely to use seeking social support and escape avoidance across all treatment stages (Gerrity, 2001). Self-control was also commonly used, though women no longer undergoing treatment were less likely to use this coping technique. More so, those with five or more years of unsuccessful medical interventions) were more likely to use accepting responsibility than those who had concluded infertility treatment.’

A study by Sexton and colleagues revealed that women experiencing infertility demonstrated lower resilience than normal populations and that lower resilience was associated with higher levels of infertility-related and general distress (Sexton et al., 2009).

Lastly, as indicated in the aforementioned scholarly works, there is a need to investigate the psychological dimensions to female infertility. This is also based on the position by some scholars that claim ‘women experience peak prevalence of psychiatric disorders occurs during the childbearing years’ (Burke et al., 1991).

Coping Strategies with Infertility: Men

Similar to women, there exists scholarly works that reveal that male fertility could be impacted by psychogenic stress (Pook et al., 2004: Culley et al., 2013). Although as Esselstrom (2014) aptly observed there exists a disproportionately low body of work on the male experience during infertility treatment including their support needs, or their decisions to end treatment. Bell (2013) and Herrera (2013) argued that the paucity of research may be due to the fact that infertility treatments may mainly and unconsciously target the female partner in the relationship.

Meanwhile, considering the psychological coping strategies favored by men undergoing fertility treatment; a study by Schmidt and other researchers carried out in the Netherland found that men of higher social class, as determined by ‘education, vocational training, and occupation, were more likely to use active-avoidance coping than men of middle or lower social class (Schmidt et al., 2005).’ The use of ‘avoidance coping and self-blame’ techniques have been linked to increased psychological stress levels (Esselstrom, 2014).

Furthermore, Stanton and colleagues (1992) studied the differences in coping with infertility between men and women. Their findings pointed to the fact that the male partner was more likely to employ “[…] distancing, more organised problem-solving, and self-control strategies to cope with infertility compared to their female partners.’ They added that the male partners were more like to adopt social support in response to the psychological stress that comes with infertility and infertility treatment compared to the women (Stanton et al., 1992).

Interestingly, the likelihood for affected individuals to adopt ‘social support, distancing and organised problem solving approach has been reported to correlate with lower infertility-related distress. On the other hand, adopting self-control has associated with increased infertility-related distress (Esselstrom, 2014).

From other researchers; it was concluded that the (i) male partners diagnosed to be infertile used fewer coping strategies unlike their female partners (Stanton et al., 1992; Esselstrom, 2014). Although when compared with fertile men; ‘greater utilization of coping strategies’ among sub-fertile males (Hurst et al., 1999). (ii) men were more likely to adopt coping a strategy of withholding information on their psychological stress, which has further been correlated with higher fertility and general distress levels (Dooley et al., 2011). (iii) self-control, relaxation, search for self-affirmation, intrusive thoughts, disparagement, avoidance, and escape are among several commonly employed coping mechanisms for managing male infertility psychological stress as reported in a doctoral research by Esselstrom (2014).

The Impact of Infertility on the Couple

Fundamentally, as observed in various literature; the level of stress induced by infertility in the lives of couples can quite overwhelming. Therefore, the role played by the partners towards themselves cannot be downplayed. Hammarberg et al. (2010) in their report noted that couple undergoing infertility treatment programs typically serve as ‘primary source of support’ for each other.

Regardless of the source of the infertility, research has shown that the success or failure of achieving pregnancy following the diagnosis of infertility may depend on the effectiveness of the coping strategies adopted by the couple.

Various studies in varying degrees have been able to link more ‘negative affect’ or the inability to control psychological distress (resulting in psychological traits such as anxiety disorders, depression) during the ‘infertility journey’ to the potential for success in achieving pregnancy and ‘marital satisfaction’ (Pasch et al., 2002; Peterson et al., 2006; Benyamini et al., 2009; Martins et al., 2014).

In similar manner, other studies have investigated the beneficial effect of infertility including sexual performance and other marital advantages (Pasch et al., 2002; Schmidt et al., 2005; Smith et al., 2009; Hammarberg et al., 2010; Wischmann, 2010; Ferraresi et al., 2013). This was underscored in a study where negative psychological traits and coping strategies was associated with lower sexual performance (Nelson et al., 2008). Similarly, there are reports that suggest the positive outcomes in the marital lives of couples undergoing assisted reproduction technologies (Onat and Beji, 2012).

On the other hand, other researchers have held opposing views in support of the negative consequences of infertility over long period and failure of infertility treatment with reduced marital benefits (Peronance et al., 2007; Drosdzol and Shrzypulec, 2009; Sina et al., 2010).

Considering these studies, it is important to note how they highlight the ‘dyadic potential of the infertility experience how ‘understanding the potential benefits of infertility may assist couples to adopting more effective stress-coping mechanisms (Sina et al., 2010; Esselstrom, 2014).

Overview of Psychological Interventions

Various literature on mental health have continued to advocate on standard routines for stress management such as psychological interventions (Hajela et al. (2016). In the context of reproductive medicine and infertility, psychological interventions are specific therapies designed to assist couples affected by infertility, in meeting their psychological needs in the period of infertility and infertility treatment.

Since recent history, researchers and healthcare professionals have gained new perspectives on the role of psychotherapy in relation to achieving pregnancy. Verkuijlen and other researchers highlighted common interventions employed in the course of the infertility treatments including psychological and educational interventions (van Peperstraten, 2010; Verkuijlen et al., 2016). Fundamentally, psychological treatment is targeted towards behavioral changes while educational interventions is aimed at providing vital medical or procedural information on infertility including “[…] its causes, treatment, and techniques on ‘self-management and self-efficacy’ such as skills training, psycho-education.” (Verkuijlen et al., 2016).

In the context of this review; the goals of psychological interventions in providing support for individuals affected by infertility and its treatment has been categorized in the following dimensions designated as cognitive, behavioural, and psychodynamic therapies (Verkuijlen et al., 2016). In another way, the aim of the interventions for infertility patients is ‘[…] to improve their mental health and increase their pregnancy rate.’

Briefly, cognitive therapeutic interventions encompass ‘[…] changing dysfunctional cognitions and beliefs about infertility and its consequences.’ Studies have shown that holding certain negative beliefs about stressful situations often pre-dispose individuals to psychological stress and distress. Therefore, an effective approach at managing detect such dysfunctional beliefs have been theorized to alleviating psychological stress (Cuijpers, 2013).

The cognitive therapeutic interventions are often joined with behavioural interventions (Verkuijlen et al., 2016). The behavioural interventions are designed toward a shift in negative behavior associated with infertility.

Lastly, psychodynamic interventions are developed in a bid to ‘[…] alleviating internal conflicts that are believed to involve strong negative emotion about pregnancy for instance’ (Verkuijlen et al., 2016). Such emotions often originate from childhood experiences in women (Boivin, 2003).

Psychotherapy and Infertility treatment: Evidence-Based Review

There appears to be an ongoing debate on exploring the possible psychogenic source of infertility in a quest to providing effective and optimum healthcare service delivery for infertility patients. The subject of efficacy of psychological interventions are being addressed by various researchers.

As highlighted earlier, psychotherapy in infertility treatment comprise of several dimensions, some of which include (but not limited to): ‘[…] psycho-analysis, psychodynamic, cognitive-behavioral therapy, psycho-education therapies amongst others.’ (Boivin, 2003).

The purpose of this section is to present some of the scholarly works that have investigated the role of psychotherapy in infertility.

Cognitive and Behavioral Therapies (CBT)

Findings from various studies revealed that the coping strategies ‘(such as self-blame, rumination, and catastrophizing’ that people use in managing infertility-related distress may be a predictor of a tendency towards depressive symptoms (Kraaij et al., 2008; Kraaij et al., 2010). Hence, the goal of the healthcare professional should be focused on fostering positive coping strategies in management of infertility-related distress (Esselstrom, 2014).

Accordingly, one study by Domar et al. (2000) found that the recruitment of CBT in a 10-session group therapy program facilitated significant improvement in psychological outcomes in the support group compared to the control group. Significant improvements were also seen in the support group.

Faramarzi and colleagues studied the benefits of psychotropic substances (such as antidepressant) compared to CBT in women experiencing infertility and depression. The study found significant improvement in depressive symptoms in 79.3% of CBT group participants compared to 50% in patients administered the psychotropic drug, and 10% of controls.’ (Faramarzi et al., 2008). Furthermore, the study also showed similar pattern with infertile patients diagnosed with anxiety disorder: the CBT group showed a significant reduction in anxiety following treatment which was better than groups for the psychotropic drugs and control group. This was consistent in the study by Faramarzi et al. (2013).

Furthermore, based on available literature, Cognitive behavioral therapy was associated with several benefits in infertility treatment including ‘[…] optimizing likelihood of pregnancy, improved sexual performance, better couple relationship, reduction in depressive symptoms’ (Tuschen-Caffier et al., 1999).

Acceptance and Commitment Therapy

This intervention is designed to reinforce ‘[…] non-judgmental self-awareness, acceptance, and living out one’s values’ in place of avoidance as a coping strategies to dealing with psychological stress (Peterson and Eifert, 2011; Esselstrom, 2014). Esselstrom (2014) reported that this therapy was associated with lowered psychological distress in women and reduced sexual infertility-related stress in men over a period of one year, amongst other benefits (Van Rooij et al., 2007; Lykeridou et al., 2009).

Another instance where the acceptance and commitment therapy can be used is the subject of body mass index (BMI). As earlier explained, excessive weight gain or loss could interfere with the female reproductive system (RESOLVE, 2012). Esselstrom (2014) highlighted the result of a 24-week group treatment program for obese, infertile women. It is found that sequel to the intervention program, the women achieved lower weight and improvements in self-esteem, anxiety, depression, and general health (Galletly et al., 1996). It was also reported that at ‘follow-up, the majority of participants achieved pregnancy.’ (Galletly et al., 1996).

Psychoeducational Interventions

Educational interventions are designed to provide vital medical or procedural information on infertility. It addresses the subject of effective communication which as Schmidt et al. mentioned leads to an increased adoption of social support as a coping strategies for stress management (Schmidt et al., 2005).

Schimdt and other researchers (cited in Esselstrom, 2014) reported that ‘[…] couples who underwent a stress management and communication skills building program spoke more often with each other and others regarding their infertility, and were more likely to contact support groups or other psychological services.’ (Schmidt et al., 2005).

There are also reports of benefits in terms of improved spousal relationship and well-being which was evident following a study designed to assess the impact of ‘a problem-focused versus emotion-focused coping skills treatment program for 6 weeks’ (McQueeney et al., 1997). Esselstrom further noted that both problem-solving and emotion-focus coping skills are integral components of the program. ‘[…] Emotion-focused treatment was developed to assist in regulating mood-related disorders whereas the problem-solving skills was focused on increased perceived control over the infertility which is reinforced by building assertive communication skills […].’ (Esselstrom, 2014)

Online Interventions

The world wide web has in many aspects of life revolutionalised the way healthcare services are being delivered. It has also been able to create greater opportunities to the ease of accessibility particularly in providing psychological support for (Esselstrom, 2014). Couples undergoing infertility programs (in online support group) reported several benefits due to online intervention, such as ‘[…] improved relationship with their partner, reduced sense of isolation, and gaining information and empowerment (Malik and Coulson, 2008). There are research works that highlighted the demographic pattern of internet use. For instance; Haagen and colleagues study highlighted the fact that more than 50% of couples with fertility-related problems accessed the internet for consultative services including providing psychological support for infertility treatment (Haagen et al., al., 2003; Slauson-Blevins et al., 2013).

Due to its ability to provide anonymity, internet-based forums may provide a platform for couple to express the mental and psychological burden associated with infertility more openly (Malik and Coulson, 2008).

On the other hand, some researchers have also highlighted the drawbacks of online intervention including the risk of ‘[…] misunderstandings between members of the support group, feeling overwhelmed by the stories of others, and ineffectively managing involvement with the online group.’ (Malik and Coulson, 2010). This may also be consistent with studies such as one conducted by Sexton et al. (2010) that concluded that ‘[…] psychological distress among infertile couples was not significantly reduced through this intervention.

Consequently, the efficacy of these interventions have been questioned among scholars. For instance; in a review conducted by Boivin (2003) to provide evidence on whether the interventions provided better treatment outcomes than usual care; the paper reported mixed results. Boivin reported that the psychological interventions did indeed provide better results particularly among infertile patients diagnosed with anxiety disorder (8 of 13 analyses, 61.5%) compared to infertile patients suffering from depressive disorders (5 of 13 analyses, 38.4%). There was also reduction in infertility-specific stress following the psychological interventions (6 of 6 analyses, 100%) and changes in sexual behaviour in 10 of 10 analyses (100%). As noted by the researcher (Boivin, 2003); there was however, no clear indications on the efficacy for interventions on pregnancy rates after completion of infertility treatment. Of the 8 analyses conducted, only three (3) recorded increase in pregnancy rate with 18 months following psychological intervention.

In similar manner, a meta-analysis by de Liz and Strauss (2005) was conducted to investigate how efficacious the psychological interventions were across several studies (anxiety, N = 10), depressive symptoms, N = 10 and pregnancy rate, N = 16). Their effect size (pre and post) was assessed via psychometric scales for anxiety and depressive disorders while pregnancy was compared by successful pregnancy rate. The results showed similar pattern with Boivin’s (2003) for the effect of the psychological interventions on anxiety and depression. For instance; the effect sizes for pre-post analyses for anxiety disorders following the interventions were higher than those for the depressive disorders. However, the study indicated an increased successful pregnancy rate among the patients sequel to the psychological interventions.

As in both review, researchers undertaking quantitative and qualitative systematic reviews have highlighted that regardless of the findings of treatment outcomes following various psychological interventions; these analyses were often replete with varying levels of heterogeneity in the study design and methodologies (Chan et al., 2006; Domar et al., 2011; Koszycki et al., 2012; Matthiesen et al., 2012). This has been highlighted as a barrier to relying on evidence on whether psychological interventions do indeed have a significant effect on treatment outcomes.

Empirical Studies Relating to Mental and Reproductive Health

As mentioned earlier, the root causes of fertility disorders are quite multifactorial. However, in the context of the present review, more evidence on the phenomenon of “psychogenic infertility” is presented.

Available literature has for instance; highlighted the interaction between anomalies of mental health and infertility. For instance; Gdańska et al. (2017) reviewed the dyadic relationships between anxiety and depression; and how they may interfere with the success of infertility treatment.

A popular hypothesis on the root causes of infertility has been on the psychogenic model which postulates that the chances of fertility is reduced in the presence of psychogenic factors such as ‘personality traces, family relations, sexual disorders, feeling of guilt, an urge need to possess a baby or even the fear of parturition […]’ (Podolska and Bidzan, 2011).

This model arguably further produced another model that was based on a possible complex interaction between psychological and social factors and the success of achieving pregnancy (Holka-Pokorska et al., 2015). The models as Gdańska et al. (2017) noted puts into consideration the modulation of the reproductive system by the action of the hypothalamus-pituitary-adrenal (HPA) axis which is believe to juxtapose the mechanism of stress and physiological functions of reproductive system.

Interestingly, there are several studies that supports this argument. An et al. (2011) for example; worked on evaluating the relationship between HPA axis, the level of anxiety and the efficacy of IVF treatment. The sample size of the study comprised of 264 women undergoing IVF treatment. Findings from the study revealed a significant elevation in the level of norepinephrine and cortisol on the oocyte-retrieval day’ compared to the levels prior to the ART procedure. The researchers also found a relationship between the ‘concentration of serum cortisol and the intensity of state anxiety in the psychometric questionnaires.’ as reported in Gdańska et al. (2017). Additionally, it was also reported women who became pregnant recorded reduced levels of norepinephrine and cortisol in the serum and intracellular fluid.

Meanwhile, another study conducted by Turner et al. (2013) using a lower sample size (n = 44) documented an increase in anxiety levels throughout the infertility treatment course (measured by psychometric scales) in women undergoing IVF treatment. Furthermore, the study noted that women who had a lower level of anxiety before the oocyte retrieval procedure, recorded a greater success rate of pregnancy.

On the other hand, several other scholarly works did not find a relationship between anxiety and the likely of success during the infertility treatment (Hashemi et al., 2012; Pasch et al., 2016). This was also reflected in a quantitative systematic review of 31 prospective studies in Denmark where the researchers could not find anxiety disorders to be a predictor of the success of infertility treatment (Matthiesen et al., 2011).

Alternatively, depressive disorders have also been assessed as a predictor of infertility or success of the ART treatments (Gdańska et al., 2017). Some studies agree that depressive disorders actually do lead to infertility treatment failures. One of these studies – cohort study revealed that women diagnosed with depressive disorders and receiving ART treatment recorded a ‘[…] lower rate of commenced ART cycles compared to women without diagnosed depression. women with a prior diagnosis of depression had a lower mean number of live births after ART procedures compared to women without depression (Sejbaek et al., 2013).’

As Gdańska and colleagues noted several other researchers had opposing views to the fact that depression actually reduces chances of a successful infertility treatment (Pasch et al., 2002). This was consistent with the study conducted by Mathiessen et al. (2011).

Hajela et al. (2016) mentioned the negative consequences of anxiety. This was addressed in a study done in Europe (Bergner et al., 2008) that found that women diagnosed with anxiety disorders ‘[…] took longer to conceive and were more likely to miscarry, compared to women who have lower levels of anxiety. This was similar to another study that associated an history of depression to infertility. This was in fact related to ‘elevated level of luteinizing hormone in depressed woman.’

As Hammerli and other researchers stressed, there exist several evidence-based scholarly works that suggest that high levels of depressive symptoms, anxiety and psychological distress negatively impacted the success rate of achieving pregnancy during infertility program such as ART (Klonoff-Cohen et al., 2001; Smeenk et al., 2001; Hammerli et al., 2009).

It is also important to highlight the similarity of this claim with the results of various systematic reviews that eventually concluded that ‘[…] psychosocial variables such as psychosocial distress, ineffective coping strategies, anxiety and depression may possibly increase likelihood of the failure of infertility treatment.’ (Klonoff-Cohen, 2005; Homan et al., 2007; Hammerli et al., 2009).

Based on various reviews; in addition to the effect of psychotherapy on the mental well-being of patients; table 1 (in appendix section) below purposively categorised several research works that indicate an association between psychological variables and various treatment outcomes of infertility treatment programs.

Conclusion/Future Directions

The present review has addressed the fact that infertility undeniably impacts huge psychological burden to individuals and couples desiring to achieve pregnancy (Bell, 2013). More so, it addressed the subject of the root causes of infertility which have been traced to the combined effect of physiological and psychosocial factors (Peronace et al., 2007; Ferland & Caron, 2013). Lastly, the question on whether psychological traits, coping strategies and psychological interventions do in fact affect infertility treatment outcomes?

Meanwhile, stress particularly psychological stress has been implicated in the etiology of infertility and has been associated with the success rates of pregnancy following treatments (Read et al., 2013; Turner et al., 2013; Lynch et al., 2014). Hence, the importance of the review.

To this end, it is important to highlight the fact that several scholars are actually in favor of the use of psychological intervention as complementary, adjunct or supportive care (Emery et al., 2003; Wischmann et al., 2009; Funderburk et al., 2012; Vickers et al., 2013).

As observed in the current review; based on the several stand-alone studies and systemic reviews, there are findings that indicate that addressing the psychological needs of infertility patients was integral to the success rate of infertility programs. On the other hand, there are still a myriad of studies that had opposing views.

Lastly, as advanced in similar researches to investigate possible linkages, there is need for more homogeneity (a hallmark of systemic reviews) across the currently available studies. Specifically, there were a lot of concerns on the reliability and validity of these studies (in the reviews of Boivin, 2003; Thornton et al., 2010; Matthiesen et al., 2011; Esselstrom, 2014; Gdańska et al., 2017). This inevitably therefore served as a barrier to ascertaining the significant role of mental health in achieving the goals of infertility treatment programs, one of which include increasing the chances of conception while catering for the psychological burden of infertility.

It is thus important, that subsequent research effort incorporate the research capacities of various healthcare professionals and researchers in order to improve the quality of research on this subject.

Reference

Adams, E. Adjustment to infertility: The role of coping strategies, time in treatment, and infertility category. Dissertation Abstracts International 2002, 62.

An Y, Wang Z, Ji H., Zhang Y, Wu K. Pituitary-adrenal and sympathetic nervous system responses to psychiatric disorders in women undergoing in vitro fertilization treatment. Fertil Steril. 2011; 96(2): 404–408, doi: 10.1016/j. fertnstert.2011.05.092, indexed in Pubmed: 21722893.

Andersson, L., I. Sundstrom-Poromaa, M. Wulff, M. Astrom, and M. Bixo. ‘‘Implications of Antenatal Depression and Anxiety for Obstetric Outcome.’’ Obstetrics and Gynecology 2004. 104 (3): 467–76.

Baghianimoghadam MH, Aminian AH, Baghianimoghadam B, et al. Mental health status of infertile couples based on treatment outcome. Iran J Reprod Med. 2013; 11(6): 503–510, indexed in Pubmed: 24639785.

Banhidy, F., A. Nandor, P. Erzsebet, and A. E. Czeizel. ‘‘Association between Maternal Panic Disorders and Pregnancy Complications and Delivery Outcomes.’’ European Journal of Obstetrics, Gynecology and Reproductive Biology 2006. 124 (1): 47–52.

Beaurepaire J, Jones M, Thiering P, Saunders D, Tennant C. Psychosocial adjustment to infertility and its treatment: male and female responses at different stages of IVF/ET treatment. Journal of Psychosomatic Research 1994;38:229-40.

Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry 1961;4:561-71.

Bell, K. Constructions of “infertility” and some lived experiences of involuntary childlessness. Affilia: Journal of Women & Social Work 2013, 28(3): 284-295. doi:10.1177/0886109913495726.

Bennedsen, B. E., P. B. Mortensen, A. V. Olesen, and T. B. Henriksen. ‘‘Con- genital Malformations, Stillbirths, and Infant Deaths among Children ofWomen with Schizophrenia.’’ Archives ofGeneral Psychiatry 2001. 58 (7): 674–9.

Benyamini, Y., Gefen-Bardarian, Y., Gozlan, M., Tabiv, G., Shiloh, S., Kokia, E. Coping specificity: The case of women coping with infertility treatments. Psychology & Health 2008, 23(2): 221-241. doi:10.1080/14768320601154706.

Benyamini, Y., Gozlan, M., Kokia, E. Women’s and men’s perceptions of infertility and their associations with psychological adjustment: A dyadic approach. British Journal of Health Psychology 2009, 14(1): 1-16. doi:10.1348/135910708X279288.

Bergner A, Beyer R, Klapp BF, Rauchfuss M. Pregnancy after early pregnancy loss: A prospective study of anxiety, depressive symptomatology and coping. Journal of psychosomatic obstetrics and gynaecology. 2008;29,2:105-13.

Boivin J, Kentenich H: Guidelines for Counselling in Infertility. Oxford, Oxford University Press, 2002.

Boivin J, Scanlan L, Walker S. Why are infertile patients not using psychosocial counselling?. Human Reproduction 1999;14(5):1384-91.

Boivin J. A review of psychosocial interventions in infertility. Soc Sci Med 2003 ; 57:2325–2341.

Boivin, J. J. A review of psychosocial interventions in infertility. Social Science & Medicine 2003, 57(12), 2325-2341. doi:10.1016/S0277-9536(03)00138-2.

Boivin, J., Kentenich, H. ESHRE monographs: Guidelines for counselling in infertility. London: Oxford University Press 2002.

Bouwmans C, Lintsen B, Al M, Verhaak C, Eijkemans R, Habbema J, et al. Absence from work and emotional stress in women undergoing IVF or ICSI: an analysis of IVF-related absence from work in women and the contribution of general and emotional factors. Acta Obstetricia et Gynecologica Scandinavica 2008;87:1169-75.

Burke, K. C., J. D. Burke, D. S. Rae, D. A. Regier. ‘‘Comparing Age at Onset of Major Depression and Other Psychiatric Disorders by Birth Cohorts in Five US Community Populations.’’ Archives ofGeneral Psychiatry 1991. 48 (9): 789–95.

Catoire P, Delaunay L, Dannappel T, Baracchini D, Marcadet- Fredet S, Moreau O, et al. Hypnosis versus diazepam for embryo transfer: a randomized controlled study. American Journal of Clinical Hypnosis 2013; 55:378-86.

Center for Disease Control and Prevention (CDC). 2009 assisted reproductive technology success rates: National summary and fertility clinic reports. Atlanta, Georgia: National Center for Disease Prevention and Health Promotion, 2011.

Center for Disease Control and Prevention. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 national survey of family growth. Vital and Health Statistics 2005, 23(25).

Center for Disease Control and Prevention. Infertility FAQs 2012. Retrieved from http://www.cdc.gov/reproductivehealth/Infertility/#6 (accessed on 15/1/2021).

Center for Disease Control and Prevention. STDs & infertility 2013. Retrieved from http://www.cdc.gov/STD/infertility/default.htm. (accessed on 15/1/2021).

Chan C, Chan C, Ng E, Ho P, Chan T, Lee G, et al. Incorporating spirituality in psychosocial group intervention for women undergoing in vitro fertilization: a prospective randomized controlled study. Psychology & Psychotherapy: Theory, Research & Practice 2012;85:356-73.

Chan C, Ng E, Chan C, Ho, Chan T. Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study. Fertility and Sterility 2006;85:339-46.

Chan CHY, Ng EHY, Chan CLW, Ho PC, Chan THY. Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study. Fertil Steril 2006; 85:339–346.

Chiaffarino F, Baldini MP, Scarduelli C, et al. Prevalence and incidence of depressive and anxious symptoms in couples undergoing as- sisted reproductive treatment in an Italian infertility department. Eur J Obstet Gynecol Reprod Biol. 2011; 158(2): 235–241, doi: 10.1016/j. ejogrb.2011.04.032, indexed in Pubmed: 21641108.

Choobforoushzade A, Kalantari M, Molavi H. The effectiveness of cognitive behavioral stress management therapy on quality of life in infertile women. Iranian Journal of Obstetrics, Gynecology and Infertility 2011;14.

Choy, J. T., Ellsworth, P. Overview of current approaches to the evaluation and management of male infertility. Urologic Nursing 2012, 32(6), 286-304. Retrieved from: http://www.medscape.com/viewarticle/778652.

Chung T. K., Lau T. K. Yip A. S., Chiu H. F., Lee D. T. ‘‘Antepartum Depressive Symptomatology Is Associated with Adverse Obstetric and Neonatal Outcomes.’’ Psychosomatic Medicine 2001. 63 (5): 830–4.

Connolly K, Edelmann R, Bartlett H, Cooke I, Lenton E, Pike S. An evaluation of counselling for couples undergoing treatment for in-vitro fertilization. Human Reproduction 1993;8:1332-8.

Conrad R, Karpawitz-Godt A, Allam J, Geiser F, Van Der Ven H, Haidl G. Expressive writing in male infertility - a randomized controlled trial. Psychotherapy and Psychosomatics 2013;82:21.

Cousineau T, Green T, Corsini E, Seibring A, Showstack M, Applegarth L, et al. Online psychoeducational support for infertile women: a randomized controlled trial. Human Reproduction 2008;23:554-66.

Cuijpers P, Berking M, Andersson G, Quigley L, Kleiboer A, Dobson K. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry 2013; 58(7):376-85.

Culley, L., Hudson, N., Lohan, M. Where are all the men? The marginalization of men in social scientific research on infertility. Reproductive BioMedicine Online 2013, 27(3): 225-235. doi:10.1016/j.rbmo.2013.06.009.

Czamanski-Cohen J, Sarid O, Cwikel J, Zeadna A, Levitas E, Har-Vardi I. Practicing cognitive behavioral interventions (CBI) increases pregnancy rates in women undergoing IVF. Fertility and Sterility 2012;98 Suppl 1:S45 Abstract no:O-147.

Danel, I., Berg C. J, Atrash H. ‘‘Magnitude of Maternal Morbidity during Labour and Delivery: United States, 1993–1997.’’ American Journal of Public Health 2003. 93 (4): 631–4.

Daya S. Life table (survival) analysis to generate cumulative pregnancy rates in assisted reproduction: are we overestimating our success rates?. Human Reproduction 2005;20(5):1135-43.

de Klerk C, Hunfeld J, Duivenvoorden H, den Outer M, Fauser B, Passchier J, et al. Effectiveness of a psychosocial counselling intervention for first-time IVF couples: a randomized controlled trial. Human Reproduction 2005;20:1333-8.

de Klerk C, Hunfeld J, Macklon N, Passchier J. Little effect of one psychosocial counselling session on emotional distress experienced by couples undergoing infertility treatment. Human Reproduction 2003;18:47-8, Abstract no: O-136.

De Liz TM, Strauss B. Differential efficacy of group and individual/couple psychotherapy with infertile patients. Hum Reprod 2005; 20:1324–1332.

Dhaliwal L, Gupta K, Gopalan S, Kulhara P. Psychological aspects of infertility due to various causes - prospective study. International Journal of Fertility and Women's Medicine 2004;49:44-8.

Dooley, M., Nolan, A., Sarma, K. M. The psychological impact of male factor infertility and fertility treatment on men: A qualitative study. The Irish Journal of Psychology 2011, 32(1-2): 14-24. doi:10.1080/03033910.2011.611253.

Drosdzol, A., Skrzypulec, V. Evaluation of marital and sexual interactions of Polish infertile couples. Journal of Sexual Medicine 2009, 6(12): 3335-3346. doi:10.1111/j.1743-6109.2009.01355.x.

Dunn AL, Stafinski T, Menon D. An international survey of assisted reproductive technologies (ARTs) policies and the effects of these policies on costs, utilization, and health outcomes. Health Policy. 2014; 116(2-3): 238–263, doi: 10.1016/j.healthpol.2014.03.006, indexed in Pubmed: 24698476.

Emery M, Be´ran M-D, Darwiche J, Oppizzi L, Joris V, Capel R, Guex P, Germond M. Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routine pre-IVF counselling. Hum Reprod 2003; 18:2647–2653.

Emery M, Beran M, Darwiche J, Oppizzi L, Joris V, Capel R, et al. Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routine pre-IVF counselling. Human Reproduction 2003;18:2647-53.

Emery M, Beran M, Darwiche J, Oppizzi L, Joris V, Capel R, et al. What do couples expect and what do they receive through systematic pre-IVF counselling? Results from a randomized controlled study. Human Reproduction 2002;17:192.

Esselstrom, Linnea, "A Guide for the Psychosocial Treatment of Infertility". Loma Linda University Electronic Theses, Dissertations & Projects 2014. 304.

EuroQol Group. EuroQol - a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199-208.

Faramarzi M, Pasha H, Esmailzadeh S, Kheirkhah F, Heidary S, Afshar Z. The effect of the cognitive behavioral therapy and pharmacotherapy on infertility stress: A randomized controlled trial. International Journal of Fertility and Sterility 2013; 7:199-206.

Faramarzi, M., Alipor, A., Esmaelzadeh, S., Kheirkhah, F., Poladi, K., Pash, H. Treatment of depression and anxiety in infertile women: Cognitive behavioral therapy versus fluoxetine. Journal of Affective Disorders 2008, 108(1-2), 159-164. doi:10.1016/j.jad.2007.09.002.

Faramarzi, M., Pasha, J., Esmailzadeh, S., Kheirkhah, F., Heidary, S., Afshar, Z. The effect of the cognitive behavior therapy and pharmacotherapy on infertility stress: A randomized controlled trial. International Journal of Fertility and Sterility 2013, 7(3): 199-206. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914487/.

Feili A, Borjali A, Sohrabi F, Farrokhi N. The comparative efficacy of cognitive-behavior therapy and Teasdale mindfulness-based cognitive therapy of infertile depressed women's rumination. Armaghane Danesh 2012;17(1):14-21.

Ferland, P., Caron, S. L. Exploring the long-term impact of female infertility: A qualitative analysis of interviews with postmenopausal women who remained childless. The Family Journal 2013, 21(2), 180-188. doi:10.1177/1066480712466813.

Ferraresi, S. R., Lara, L. S., de Sá, M. S., Reis, R. M., Silva, A. Current Research on How Infertility Affects the Sexuality of Men and Women. Recent Patents on Endocrine, Metabolic & Immune Drug Discovery 2013, 7(3), 198-202.

Folkman S, Lazarus R, Dunkel-Schetter C. Dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology 1986;50:992-1003.

Fritz, M. A. The modern infertility evaluation. Clinical Obstetrics & Gynecology 2012, 55(3), 692-705. Retrieved from: http://www.clinicalobgyn.com/.

Funderburk, J. S., Fielder, R. L., DeMartini, K. S., & Flynn, C. A. Integrating behavioral health services into a university health center: Patient and provider satisfaction. Families, Systems & Health: The Journal of Collaborative Family Healthcare 2012, 30(2), 130-140. doi:10.1037/a0028378.

Galletly C, Clark A, Tomlinson L, Blaney F. Improved pregnancy rates for obese, infertile women following a group treatment program: an open pilot study. Gen Hosp Psychiatry 1996; 18:192–195.

Gameiro S, Boivin J, Dancet E, de Klerk C, Emery M, Lewis- Jones C, et al. ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction - a guide for fertility staff. Human Reproduction 2015;30(11):2476-85.

Gameiro S, Boivin J, Dancet E, de Klerk C, Emery M, Lewis- Jones C, et al. ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction - a guide for fertility staff. Human Reproduction 2015;30(11):2476-85.

Gameiro S, Boivin J, Peronace L, Verhaak C. Why do patients discontinue fertility treatment? A systematic review of reasons and predictors of discontinuation in fertility treatment. Human Reproduction update 2012;18:652-69.

Garcia R, Sala M, Lafuente R, Brassesco A, Cairo O, Villanueva D, et al. Role of the relaxation therapies in IVF treatments. Human Reproduction 2003;18:206.

Gdańska P., Drozdowicz-jastrzębska E., Grzechocińska B. Anxiety and depression in women undergoing infertility treatment. Ginekologia Polska 2017; 88, 2: 109–112.

Gerrity, D. A. Five medical treatment stages of infertility: Implications for counselors. The Family Journal 2001, 9(2), 140-150. doi:10.1177/1066480701092008.

Gorayeb R, Borsari A, Rosa-e-Silva A, Ferriani R. Brief cognitive behavioral intervention in groups in a Brazilian assisted reproduction program. Behavioral Medicine 2012;38:29-35.

Guendelman, S., D. Thornton, J. Gould, N. Hosang. ‘‘Obstetric Complications during Labor and Delivery: Assessing Ethnic Differences in California.’’ Women’s Health Issues 2006. 16 (4): 189–97.

Gurmankin, A. D., Caplan, A. L., & Braverman, A. M. Screening practices and beliefs of assisted reproductive technology programs. Fertility and Sterility 2005, 83(1): 61-67. doi:10.1016/j.fertnstert.2004.06.048

Haagen, E. C., Tuil, W., Hendriks, J., de Bruijn, R. P., Braat, D. D., & Kremer, J. A. Current internet use and preferences for IVF and ICSI patients. Human Reproduction 2003, 18: 2073-2078.

Hajela S, Prasad S, Kumaran A, Kumar Y. Stress and infertility: a review. Int J Reprod Contracept Obstet Gynecol 2016; 5:940-3.

Hammarberg, K., Baker, H. W. G., Fisher, J. R. W. Men’s experiences of infertility and infertility treatment 5 years after diagnosis of male factor infertility: A retrospective cohort study. Human Reproduction 2010, 25(11): 2815-2820. doi:10.1093/humrep/deq259,

Hammerli K., Znoj H., Barth J. (2009). The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Human Reproduction Update 2009, 15, 3: 279–295.

Hashemi S, Simbar M, Ramezani-Tehrani F, et al. Anxiety and success of in vitro fertilization. Eur J Obstet Gynecol Reprod Biol. 2012; 164(1): 60–64, doi: 10.1016/j.ejogrb.2012.05.032, indexed in Pubmed: 22727918.

Heidari P, Latif N, Sahebi A, Jahaniyan M, Mazloum S. Impact of cognitive behaviour therapy on anxiety level of primary infertile women undergoing IUI. Medical Journal of Reproduction & Infertility 2002.

Herrera, F. “Men always adopt”: Infertility and reproduction from a male perspective. Journal of Family Issues 2013, 34(8), 1059-1080. doi:10.1177/0192513X13484278.

Higgins J, Thompson S, Deeks J, Altman D. Measuring inconsistency in meta-analyses. BMJ 2003;327:557–60.

Holka-Pokorska J, Jarema M, Wichniak A. Clinical determinants of mental disorders occurring during the infertility treatment. Psychiatr Pol. 2015; 49(5): 965–982, doi: 10.12740/PP/35958, indexed in Pubmed: 26688847.

Homan AC, Davies M, Norman R. The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review. Hum Reprod Update 2007; 11:1–15.

Hope N, Rombauts L. Can an educational DVD improve the acceptability of elective single embryo transfer? A randomized controlled study. Fertility and Sterility 2010;94:489-95.

Hosaka T, Matsubayashi H, Sugiyama Y, Izumi S, Makino T. Effect of psychiatric group intervention on natural-killer cell activity and pregnancy rate. General Hospital Psychiatry 2002;24:353-6.

Huppelschoten A, van Duijnhoven N, Hermens R, Verhaak C, Kremer J, Nelen W. Improving patient-centeredness of fertility care using a multifaceted approach: study protocol for a randomized controlled trial. Trials [Electronic Resource] 2012;13:175.

Hurst KM, Dye L, Rutherford AJ, Oodit R: Differential coping in fertile and sub-fertile males attending an assisted conception unit: A pilot study. J Reprod Infant Psychol 1999; 17:189–198

Jablensky, A. V., V. Morgan, S. R. Zubrick, C. Bower, L. A. Yellachich. ‘‘Pregnancy, Delivery, and Neonatal Complications in a Population Cohort of Women with Schizophrenia and Major Affective Disorders.’’ American Journal of Psychiatry 162 (1): 79–91.

Johnson, K. M., Fledderjohann, J. Revisiting “her” infertility: Medicalized embodiment, self-identification and distress. Social Science & Medicine 2012, 75(5), 883-891. doi:10.1016/j.socscimed.2012.04.020.

Kelly, R. H., B. H. Danielson, D. F. Zatzick, M. N. Haan, T. F. Anders, W. M. Gilbert, and V. K. Burt. ‘‘Chart-Recorded Psychiatric Diagnoses in Women Giving Birth in California in 1992.’’ American Journal of Psychiatry 1999. 156 (6): 955–7.

Khalatbari J, Ghorbanshirodi S, Akhshabi M, Hamzehpour T, Esmaeilpour M. The effectiveness of the behavioral-cognitive therapy on the reduction of the rate of the depression and anxiety of the infertile women of the Rasht city. Indian Journal of Science and Technology 2011;4:1578-82.

Kharde S, Pattad S, Bhogale G. Effectiveness of a therapeutic counseling intervention for depression, anxiety, self esteem and marital adjustment among infertile women. International Journal of Nursing Education 2012;4:151-4.

Khaskheli, M. N., Baloch, S., Baloch. A. S. Infertility and weight reduction: Influence and outcome. Journal of the College of Physicians and Surgeons Pakistan 2013, 23(10), 798-801. doi: 11.2013/jcpsp.798801.

Klonoff-Cohen H, Chu E, Natarajan L, Sieber W. A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer. Fertil Steril 2001; 76:675–687.

Klonoff-Cohen H. Female and male lifestyle habits and IVF: what is known and unknown. Hum Reprod Update 2005; 11:179–203.

Kort, J. D., Winget, C., Kim, S. H., Lathi, R. B. A retrospective cohort study to evaluate the impact of meaningful weight loss on fertility outcomes in an overweight population with infertility. Fertility and Sterility 2014. doi:10.1016/j.fertnstert.2014.01.036.

Koszycki D, Bisserbe J, Blier P, Bradwejn J, Markowitz J. Interpersonal psychotherapy versus brief supportive therapy for depressed infertile women: First pilot randomized controlled trial. Archives of Women's Mental Health 2012;15:193-201.

Koszycki, D., Bisserbe, J., Blier, P., Bradwejn, J., & Markowitz, J. Interpersonal psychotherapy versus brief supportive therapy for depressed infertile women: First pilot randomized controlled trial. Archives of Women's Mental Health 2012, 15(3), 193-201. doi:10.1007/s00737-012-0277-z.

Kraaij, V., Garnefski, N., Schroevers, M. J., Weijmer, J., & Helmerhorst, F. Cognitive coping, goal adjustment, and depressive and anxiety symptoms in people undergoing infertility treatment: A prospective study. Journal of Health Psychology 2010, 15(6): 876-886. doi:10.1177/1359105309357251

Kraaij, V., Garnefski, N., Vlietstra, A. Cognitive coping and depressive symptoms in definitive infertility: A prospective study. Journal of Psychosomatic Obstetrics & Gynecology 2008, 29(1), 9-16. doi:10.1080/01674820701505889.

Kurki, T., V. Hiilesmaa, R. Raitasalo, H.Mattila, and O. Ylikorkala. ‘‘Depression and Anxiety in Early Pregnancy and Risk for Preeclampsia.’’ Obstetrics and Gynecology 2000. 95 (4): 487–90.

La Fianza A, Dellafiore C, Travaini D, Broglia D, Gambini F, Scudeller L, et al. Effectiveness of a single education and counseling intervention in reducing anxiety in women undergoing hysterosalpingography: a randomized controlled trial. The Scientific World Journal 2014;ID 598293:1-7.

La Joie, M. Psychological adjustment of women experiencing secondary infertility. Dissertation Abstracts International Section A, 2003, 64.

Lancastle D, Boivin J. A feasibility study of a brief coping intervention (PRCI) for the waiting period before a pregnancy test during fertility treatment. Human Reproduction 2008;23:2299-307.

Lewis, A. M., Liu, D., Stuart, S. P., Ryan, G. Less depressed or less forthcoming? Self-report of depression symptoms in women preparing for in vitro fertilization. Archives of Women's Mental Health 2013, 16(2), 87-92. doi:10.1007/s00737-012-0317-8

Liswood M. Treating the crisis of infertility: A cognitive- behavioral approach. Dissertation Abstracts International Section A: Humanities and Social Sciences 1995;55:4006.

Luke B, Brown M, Wantman E, Lederman A, Gibbons W, Schattman G, et al. Cumulative birth rates with linked assisted reproductive technology cycles. The New England Journal of Medicine 2013;366:2483-91.

Lykeridou, K., Gourounti, K., Deltsidou, A., Loutradis, D. & Vaslamatzis, G. The impact of infertility diagnosis on psychological status of women undergoing fertility treatment. Journal of Reproductive and Infant Psychology 2009, 27(3): 223- 237.

Lynch, C. D., Sundaram, R., Maisog, J. M., Sweeney, A. M., & Buck Louis, G. M. Preconception stress increases the risk of infertility: Results from a couple-based prospective cohort study—the LIFE study. Human Reproduction 2014, 0(0), 1-9. doi:10.1093/humrep/deu032.

Malik, S. H., & Coulson, N. S. Computer-mediated infertility support groups: An exploratory study of online experiences. Patient Education and Counseling 2008, 73(1): 105-113. doi:10.1016/j.pec.2008.05.024.

Malik, S., Coulson, N. S. ‘They all supported me but I felt like I suddenly didn't belong anymore’: An exploration of perceived disadvantages to online support seeking. Journal of Psychosomatic Obstetrics & Gynecology 2010, 31(3): 140- 149. doi:10.3109/0167482X.2010.504870.

Mansour R, Ishihara O, Adamson G, Dyer S, de Mouzon J, Nygren K, et al. International Committee for Monitoring Assisted Reproductive Technologies world report: Assisted Reproductive Technology 2006. Human Reproduction 2014;29(7):1536-51.

Martins, M. V., Peterson, B. D., Almeida, V., Mesquita-Guimarães, J., Costa. M. E. Dyadic dynamics of perceived social support in couples facing infertility Human Reproduction 2014, 29(2): 84-89. doi:10.1093/humrep/det403.

Mascarenhas MN, Flaxman SR, Boerma T, [et al.]. National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med. 2012;9(12):1-12. doi:10.1371/journal. pmed.1001356.

Matthiesen S, Klonoff-Cohen H, Zachariae R, Jensen- Johansen M, Nielsen B, Frederiksen Y, et al. The effect of an expressive writing intervention (EWI) on stress in infertile couples undergoing assisted reproductive technology (ART) treatment: a randomized controlled pilot study. British Journal of Health Psychology 2012;17:362-78.

Matthiesen SMS, Frederiksen Y, Ingerslev HJ, et al. Stress, distress and out- come of assisted reproductive technology (ART): a meta-analysis. Hum. Reprod. 2011; 26(10): 2763–2776, doi: 10.1093/humrep/der246, indexed in Pubmed: 21807816.

Matthiesen, S. S., Frederiksen, Y. Y., Ingerslev, H. J., Zachariae, R. R. Stress, distress and outcome of assisted reproductive technology (ART): a meta-analysis. Human Reproduction 2011, 26(10): 2763-2776. doi:10.1093/humrep/der246.

Matthiesen, S., Klonoff‐Cohen, H., Zachariae, R., Jensen‐Johansen, M. B., Nielsen, B. K., Frederiksen, Y., Ingerslev H. The effect of an expressive writing intervention (EWI) on stress in infertile couples undergoing assisted reproductive technology (ART) treatment: A randomized controlled pilot study. British Journal of Health Psychology 2012, 17(2): 362-378. doi:10.1111/j.2044-8287.2011.02042.x.

McCarthy-Keith, D. M., Schisterman, E. F., Robinson, R. D., O’Leary, K., Lucidi, R. S., & Armstrong, A. Y. Will decreasing assisted reproduction technology costs improve utilization and outcomes among minority women?. Fertility and Sterility 2010, 94(7). doi:10.1016/j.fertnstert.2010.02.021.

McQueeney DA, Stanton AL, Sigmon S. Efficacy of emotion-focused and problem-focused group therapies for women with fertility problems. J Behav Med 1997; 20:313–331.

McQuillan, J., Greil, A. L., White, L., Jacob, M. Frustrated Fertility: Infertility and Psychological Distress Among Women. Journal of Marriage and Family 2003, 65(4), 1007-1018. doi:10.1111/j.1741-3737.2003.01007.x.

Mori A, Shimizu K, Kawamoto M, Momoi M, Nagamori K. Partnerships between fertility nurses and self-help groups in Britain to support coping with infertility [Japanese]. Bulletin of St Luke's College of Nursing 2008;9.

Mosalanejad L, Koolaee A, Behbahani B. Looking out for the secret wound: The effect of E-cognitive group therapy with emotional disclosure on the status of mental health in infertile women. International Journal of Fertility and Sterility 2012;6:87-94.

Mosalanejad L, Koolee A. Looking at infertility treatment through the lens of the meaning of life: The effect of group logotherapy on psychological distress in infertile women. International Journal of Fertility and Sterility 2013;6:224-31.

Mousavinik M. Effect of rational emotive behavior therapy on depression in infertile women. ZENITH International Journal of Multidisciplinary Research 2012;2:77-84.

Musa R, Ramli R, Yazmie A, Khadijah M, Hayati M, Midin M, et al. A preliminary study of the psychological differences in infertile couples and their relation to the coping styles. Comprehensive Psychiatry 2014;55 (Supp 1):S65-9.

Nagaoka Y. The effect of guided imagery to reduce pain at the time of in vitro fertilization egg retrieval: A randomized controlled trial. Fertility and Sterility 2012;1:S114.

Nelen W, Huppelschoten A, Verkerk E, Adang E, Kremer J. Towards more patient-centred fertility care: What does it cost. Human reproduction: 29th Annual Meeting of the European Society of Human Reproduction and Embryology. July 2013; Vol. 28:i284-5.

Nelson, C. J., Shindel, A. W., Naughton, C. K., Ohebshalom, M., Mulhall, J. P. Prevalence and predictors of sexual problems, relationship stress, and depression in female partners of infertile couples. Journal of Sexual Medicine 2008, 5(8), 1907- 1914. doi:10.1111/j.1743-6109.2008.00880.x.

Nieschlag E, Behre H, Fischedick A, Hertle L. Treatment of varicocele in the age of "evidence-based medicine". Medical counseling is as successful as interventional treatment (ligation or embolization). Urologe (Ausg. A) 1998;37:265-9.

Nilforooshan P, Ahmadi A, Abedi M, Ahmadi M. Counseling based on interacting cognitive subsystems and its effect on anxiety of infertile couples. Pakistan Journal of Psychological Research 2006;21:95-103.

Nilforooshan P, Ahmadi A, Abedi M, Ahmadi M. Counseling based on interacting cognitive subsystems and its effect on anxiety of infertile couples. Pakistan Journal of Psychological Research 2006;21:95-103.

Ockhuijsen H, van den Hoogen A, Eijkemans M, Macklon N, Boivin J. The impact of a self-administered coping intervention on emotional well-being in women awaiting the outcome of IVF treatment: a randomized controlled trial. Human Reproduction 2014. [DOI: 10.1093/humrep/deu093]

Onat, G., Beji, N. Marital relationship and quality of life among couples with infertility. Sexuality and Disability 2012, 30(1), 39-52. doi:10.1007/s11195-011-9233-5.

Oxford Handbook of Psychiatry. Oxford Medicine Online. 2013, doi: 10.1093/med/9780199693887.001.0001.

Pakgohar M, Vizheh M, Babaee G, Ramezanzadeh F, Abedininia N. Effect of counseling on sexual satisfaction among infertile women referred to Tehran Fertility Center [Farsi]. Hayat 2008;14:79.

Panagopoulou E, Montgomery A, Tarlatzis B. Experimental emotional disclosure in women undergoing infertility treatment: Are drop outs better off?. Social Science & Medicine 2009;69:678-81.

Pasch, L. A., Dunkel-Schetter, C., & Christensen, A. Differences between husbands’ and wives’ approach to infertility affect marital communication and adjustment. Fertility & Sterility 2002,77(6): 1241-1247.

Perkin, M. R., J. L. Peacock, and H. R. Anderson. ‘‘The Effect of Anxiety and Depression during Pregnancy on Obstetric Complications.’’ British Journal of Obstetrics and Gynecology 1993. 100 (7): 629–34.

Peronace, L. A., Boivin, J., & Schmidt, L. Patterns of suffering and social interactions in infertile men: 12 months after unsuccessful treatment. Journal of Psychosomatic Obstetrics & Gynecology 2007, 28(2), 105-114. doi:10.1080/01674820701410049.

Peterson, B. D., Eifert, G. H. Using Acceptance and Commitment Therapy to treat infertility stress. Cognitive and Behavioral Practice 2011, 18(4), 577-587. doi:10.1016/j.cbpra.2010.03.004.

Peterson, B. D., Newton, C. R., Rosen, K. H., & Schulman, R. S. Coping processes of couples experiencing infertility. Family Relations: An Interdisciplinary Journal of Applied Family Studies 2006, 55(2), 227-239. doi:10.1111/j.1741-3729.2006.00372.x.

Podolska MZ, Bidzan M. Infertility as a psychological problem. Ginekol Pol. 2011; 82(1): 44–49, indexed in Pubmed: 21469521.

Pook M, Krause W. Stress reduction in male infertility patients: a randomized, controlled trial. Fertility and Sterility 2005;83:68-73.

Pook, M., Tuschen-Caffier, B., Krause, W. (2004). Is infertility a risk factor for impaired male fertility? Human Reproduction, 19(4), 954-959.

Ramezanzadeh F, Aghssa MM, Abedinia N, et al. A survey of relationship be- tween anxiety, depression and duration of infertility. BMC Womens Health. 2004; 4(1): 9, doi: 10.1186/1472-6874-4-9, indexed in Pubmed: 15530170.

Ramezanzadeh F, Noorbala A, Abedinia N, Rahimi A, Naghizadeh M. Psychiatric intervention improved pregnancy rates in infertile couples. The Malaysian Journal of Medical Science 2011;18:16-24.

Rasoulzadeh BM, Latifinejad RR. Adopting problem-focused coping strategies following implementation of a collaborative counseling program in infertile women undergoing IVF. Conference: 14th Royan Congress on Reproductive Biomedicine and 8th Royan Nursing and Midwifery Seminar Tehran Islamic Republic of Iran. International Journal of Fertility and Sterility: http://ovidsp.ovid.com/ovidweb.cgi? T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=emed13&AN=71791030. 2013; Vol. 7:46.

Read, S. C., Carrier, M., Boucher, M., Whitley, R., Bond, S., Zelkowitz, P. Psychosocial services for couples in infertility treatment: What do couples really want? Patient Education and Counseling, 2013. doi:10.1016/j.pec.2013.10.025.

Reis S, Xavier MR, Coelho R, et al. Psychological impact of single and multiple courses of assisted reproductive treatments in couples: a comparative study. Eur J Obstet Gynecol Reprod Biol. 2013; 171(1): 61–66, doi: 10.1016/j.ejogrb.2013.07.034, indexed in Pubmed: 23928476.

Remy, L., G. Oliva, T. Clay. Maternal Morbidity and Outcomes Including Mortality, California 2001–2006. Family Health Outcomes Project 2008. University of California, San Francisco.

RESOLVE. (2012). Infertility overview. Retrieved from http://www.resolve.org/diagnosis-management/infertility-diagnosis/. (accessed on 15/1/2021)

Rezabek K, Vichova V, Pavelkova J, Zivny J. Hypnosis during embryo transfer does not ameliorate IVF results. In: Abstracts of the 19th Annual Meeting ofESHRE, Madrid, Spain, 2003. Abstract P-403. Hum Repro.

Roberts C, Roberts S. Design and analysis of clinical trials with clustering effects due to treatment. Clinical Trials 2005;2(2):152-62.

Romano, G., Ravid, H., Zaig, I., Schreiber, S., Azem, F., Shachar, I., & Bloch, M. The psychological profile and affective response of women diagnosed with unexplained infertility undergoing in vitro fertilization. Archives of Women's Mental Health 2012, 15(6), 403-411. doi:10.1007/s00737-012-0299-6.

Rossi BV, Chang C, Berry KF, Hornstein MD, Missmer SA. In vitro fertilization outcomes and alcohol consumption in at-risk drinkers: the effects of a randomized intervention. American Journal on Addictions 2013;22(5):481-5.

Rubin D. Causal inference through potential outcomes and principal stratification: application to studies with “censoring” due to death. Statistical Science 2006;21(3):299-309.

Sarrel P, DeCherney A. Psychotherapeutic intervention for treatment of couples with secondary infertility. Fertility and Sterility 1985;43:897-900.

Sarrel, P. M., DeCherney, A. H. Psychotherapeutic intervention for treatment of couples with secondary infertility. Fertility and Sterility 1985, 43, 897–900.

Schaller MA, Griesinger G, Banz-Jansen C. Women show a higher level of anxiety during IVF treatment than men and hold different concerns: a cohort study. Arch Gynecol Obstet. 2016; 293(5): 1137–1145, doi: 10.1007/s00404-016-4033-x, indexed in Pubmed: 26884350.

Schmidt, L., Christensen, U., Holstein, B. E. The social epidemiology of coping with infertility. Human Reproduction 2005, 20(4), 1044-1052. doi:10.1093/humrep/deh687.

Sejbaek CS, Hageman I, Pinborg A, et al. Incidence of depression and influence of depression on the number of treatment cycles and births in a national cohort of 42,880 women treated with ART. Hum. Reprod. 2013; 28(4): 1100–1109, doi: 10.1093/humrep/des442, indexed in Pubmed: 23300199.

Seuc A, Peregoudov A, Pilar Betran A, Metin Gulmezoglu A. Intermediate outcomes in randomized clinical trials: an introduction. Trials March 2013;14(78).

Sexton, M. B., Byrd, M. R., Kluge, S. V. Measuring resilience in women experiencing infertility using the CD-RISC: Examining infertility-related stress, general distress, and coping styles. Journal of Psychiatric Research 2009, 44, 236-241.

Sexton, M. B., Byrd, M. R., O’Donohue, W. T., & Jacobs, N. Web-based treatment for infertility-related psychological distress. Archives of Women's Mental Health, 13(4), 347-358. doi:10.1007/s00737-009-0142-x

Shahrestani M, Qanbari B, Nemati S, Rahbardar H. The effectiveness of mindfulness based cognitive group therapy (MBCT) on improving perceived infertility-related stress and irrational parenthood cognitions among infertile women undergoing IVF treatment. Iranian Journal of Obstetrics, Gynecology and Infertility 2012;15:28-38.

Shahrestani M, Qanbari B, Nemati S, Rahbardar H. The effectiveness of mindfulness based cognitive group therapy (MBCT) on improving perceived infertility-related stress and irrational parenthood cognitions among infertile women undergoing IVF treatment. Iranian Journal of Obstetrics, Gynecology and Infertility 2012;15:28-38.

Sina, M., ter Meulen, R., & de Paula, I. Human infertility: Is medical treatment enough? A cross-sectional study of a sample of Italian couples. Journal Of Psychosomatic Obstetrics & Gynecology 2010, 31(3), 158-167. doi:10.3109/0167482X.2010.487952.

Skiadas C, Terry K, De Pari M, Geoghegan A, Lubetsky L, Levy S, et al. Does emotional support during the luteal phase decrease the stress of in vitro fertilization?. Fertility and Sterility 2011;96:1467-72.

Slauson-Blevins, K. S., McQuillan, J., & Greil, A. L. Online and in-person health-seeking for infertility. Social Science & Medicine 2013, 99: 110-115. doi:10.1016/j.socscimed.2013.10.019

Smeenk JM, Verhaak CM, Eugster A, van Minnen A, Zielhuis GA, Braat DD. The effect of anxiety and depression on the outcome of in-vitro fertilization. Hum Reprod 2001; 16:1420–1423.

Smith, J. F., Walsh, T. J., Shindel, A. W., Turek, P. J., Wing, H., Pasch, L., & Katz, P. P. Sexual, marital, and social impact of a man's perceived infertility diagnosis. Journal of Sexual Medicine 2009, 6(9), 2505-2515. doi:10.1111/j.1743- 6109.2009.01383.x.

Soltani M, Shairi MR, Roshan R, Rahimi C. The impact of emotionally focused therapy on emotional distress in infertile couples. International Journal of Fertility and Sterility 2014;7(4):337-44.

Spielberger C. State-trait Anxiety Inventory: Bibliography. 2nd Edition. Palo Alto, CA: Consulting Psychologists Press, 1989.

Stanton, A. L., Tennen, H., Affleck, G., Mendola, R. Coping and adjustment to infertility. Journal of Social and Clinical Psychology 1992, 11(1), 1-13. doi:10.1521/jscp.1992.11.1.1

Sterne J, White I, Carlin J, Spratt M, Royston P, Kenward M, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ (Clinical research ed.) 2009;338.

Stewart, D. E., Boydell, K. M., McCarthy, K., Swerdlyk, S., Redmond, C., Cohrs, W. A prospective study of the effectiveness of brief professionally led support groups for infertility patients. International Journal ofPsychiatry in Medicine 1992, 22, 173–182.

Strauss B, Hepp U, Stading G, Mettler L. Focal counseling for women and couples with an unfulfilled desire for a child: a three-step model. In: Strauss B (ed). Involuntary Childlessness: Psychological Assessment, Counseling, and Psychotherapy. Ashland, OH: Hogrefe and Huber Publishers, 2002, 79–103.

Sue D, Sue D, Sue S. Understanding abnormal behaviour (4th edition). Houghton Mifflin, Boston 1994.

Takefman, J. E., Brender, W., Boivin, J., Tulandi, T. Sexual and emotional adjustment of couples undergoing infertility investigation and the effectiveness of preparatory information. Journal of Psychosomatic Obstetrics and Gynaecology 1990, 11, 275–290.

Tang WH, Jiang H, Ma LL, Hong K, Zhao LM, Liu DF, et al. Tadalafil combined with behavior therapy for semen collection from infertile males in whom masturbation fails. Zhonghua Nan Ke Xue 2013;19(5):439-42.

Tarlov A, Ware J Jr, Greenfield S, Nelson E, Perrin E, Zubkoff M. The Medical Outcomes Study. An application of methods for monitoring the results of medical care. JAMA 1989;262:925-30.

Terzioglu F. Anxiety of infertile men who undergo genetic testing for assisted reproductive treatment. Journal of Psychosomatic Obstetrics and Gynaecology 2007;28:147-53.

Terzioglu F. Investigation into effectiveness of counseling on assisted reproductive techniques in Turkey. Journal of Psychosomatic Obstetrics & Gynecology 2001;22:133-41.

Thornton D., Guendelman S., Hosang N. Obstetric Complications in Women with Diagnosed Mental Illness: The Relative Success of California ’ s County Mental Health System. Health Research and Educational Trust. HSR: Health Services Research 2010. 45:1 (246-264). DOI: 10.1111/j.1475-6773. 2009.01058.x

Troude P, Guibert J, Bouyer J, de La Rochebrochard E. Medical factors associated with early IVF discontinuation. Reproductive Biomedicine Online 2014;28(3):321-9.

Turner K, Reynolds-May MF, Zitek EM, et al. Stress and anxiety scores in first and repeat IVF cycles: a pilot study. PLoS ONE. 2013; 8(5): e63743, doi: 10.1371/journal.pone.0063743, indexed in Pubmed: 23717472.

Turner, K., Reynolds-May, M. F., Zitek, E. M., Tisdale, R. L., Carlisle, A. B., Westphal, L. M. Stress and anxiety scores in first and repeat IVF cycles: A pilot study. PLOS One 2013, 8(5). doi: 10.1371/journal.pone.0063743

Tuschen-Caffier B, Florin I, Krause W, Pook M: Cognitive- behavioral therapy for idiopathic infertile couples. Psychother Psychosom 1999; 68:15–21.

Tuschen-Caffier, B., Florin, I., Krause, W., & Pook, M. Cognitive-behavioral therapy for idiopathic infertile couples. Psychotherapy and Psychosomatics 1999, 68(1), 15-21. doi:10.1159/000012305.

Valiani M, Abediyan S, Ahmadi S, Pahlavanzadeh S, Hassanzadeh A. The effect of relaxation techniques to ease the stress in infertile women. Iranian Journal of Nursing and Midwifery Research 2010;15:259-64.

Van den Broeck, U., Holvoet, L., Enzlin, P., Bakelants, E., Demyttenaere, K., D’Hooghe, T. Reasons for dropout in infertility treatment. Gynecologic and Obstetric Investigation 2009, 68(1): 58-64. doi:10.1159/000214839.

van Peperstraten A, Hermens R, Nelen W, Stalmeier P, Wetzels A, Maas P, et al. Deciding how many embryos to transfer aſter in vitro fertilisation: development and pilot test of a decision aid. Patient Education and Counseling 2010; 78(1):124-9.

Van Rooij, F. B., Van Balen, F., & Hermanns, J. A. Emotional distress and infertility: Turkish migrant couples compared to Dutch couples and couples in Western Turkey. Journal of Psychosomatic Obstetrics & Gynecology 2007, 28(2), 87- 95. doi:10.1080/01674820701410015.

Vause T, Evans M, Vause T, Min J. Comparison of an interactive web-based teaching tool and traditional didactic learning for IVF patients: A randomized controlled trial. Fertility and Sterility 2011;1:S179.

Verhaak C, Smeenk J, Nahuis M, Kremer J, Braat D. Long-term psychological adjustment to IVF/ICSI treatment in women. Human Reproduction 2007;22(1):305-8.

Verhaak, C. M., Smeenk, J. M., Evers, A. W., van Minnen, A., Kremer, J. A., & Kraaimaat, F. W. Predicting emotional response to unsuccessful fertility treatment: A prospective study. Journal of Behavioral Medicine 2005, 28(2), 181-190. doi:10.1007/s10865-005-3667-0.

Verkuijlen J, Verhaak C, Nelen WLDM, Wilkinson J, Farquhar C. Psychological and educational interventions for sub-fertile men and women. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD011034. DOI: 10.1002/14651858.CD011034.pub2.

Vickers, K. S., Ridgeway, J. L., Hathaway, J. C., Egginton, J. S., Kaderlik, A. B., & Katzelnick, D. J. Integration of mental health resources in a primary care setting leads to increased provider satisfaction and patient access. General Hospital Psychiatry 2013, 35(5), 461-467. doi:10.1016/j.genhosppsych.2013.06.011.

Vizheh M, Pakgohar M, Babaei G, Ramezanzadeh F. Effect of counseling on quality of marital relationship of infertile couples: a randomized, controlled trial (RCT) study. Archives of Gynecology & Obstetrics 2013;287:583-9.

Wiener-Megnazi Z, Adin Zinman M, Zeidner M, Dirnfeld M. Study of a novel progressive muscular relaxation technique and state- anxiety in IVF patients during ET and luteal phase. Human Reproduction 2006;21:i64.

Wischmann T, Stammer H, Scherg H, Gerhard I, Strowitzki T, Verres R. Evaluation of the psychological effects of counselling and couple-therapy with infertile couples. Paper presented at the 17th Annual Meeting of the European Society for Human Reproduction and Embryology. Hum Reprod 2001a; 16:198.

Wischmann T, Stammer H, Scherg H, Gerhard I, Verres R. Couple counselling and therapy for the unfulfilled desire for a child: the two-step approach of the “Heidelberg Infertility Consultation”. In: Strauss B (ed). Involuntary Childlessness: Psychological Assessment, Counseling, and Psychotherapy. Ashland, OH: Hogrefe and Huber Publishers, 2002, 127–150.

Wischmann T, Stammer H, Scherg H, Gerhard I, Verres R. Psychological characteristics of infertile couples: a study of the “Heidelberg Fertility Consultation Service”. Hum Reprod 2001b; 16:1753–1761.

Wischmann, T. H. Sexual disorders in infertile couples. Journal of Sexual Medicine 2010, 7(5), 1868-1876. doi:10.1111/j.1743-6109.2010.01717.x.

Wischmann, T., Scherg, H., Strowitzki, T., Verres, R. Psychosocial characteristics of men and women attending infertility counselling. Human Reproduction 2009, 24(2), 378-385. doi:10.1093/humrep/den401.

World Health Organization (WHO). International Regulatory Co-operation. 2016: 198–199, doi: 10.1787/9789264244047-59-en.

Wu, J., A. Viguera, L. Riley, L. Cohen, and J. Ecker. 2002. ‘‘Mood Disturbances in Pregnancy and the Mode of Delivery.’’ American Journal of Obstetrics and Gynecology 187 (4): 864–7.

Zegers-Hochschild F, Adamson G, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al. International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertility and Sterility 2009;92:1520-4.

Zhu H, Hu P, Qiao J. Effects of group psychotherapy on mood in patients undergoing in vitro fertilization and embryo transfer. Chinese Mental Health Journal 2010;24:912-6.

Appendix

Table 1: Impact of psychological variables and Treatment Outcomes (adopted from Boivin (2003) and Thornton et al., 2010)

Abbildung in dieser Leseprobe nicht enthalten

Note: The study designs comprised of longitudinal and cross-sectional studies (randomized and non-randomized) with varying sample sizes and treatment outcomes (pregnancy, disorders of male and female reproductive system; obstetrics complications).

[...]