FACTS Mental Health Awareness Series
The Trials and Tribulations of Infertility
By Dr. Revati Narawane
Editor’s Note: To continue our series related to Mental Health Awareness month, we are featuring research that explored the connection between infertility, fertility treatments and emotional and psychological distress. Revati Narawane, a former FACTS elective student and pediatrics resident, summarized Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services? This 2016 article, published in Fertility and Sterility, found that unsuccessful treatment outcomes were associated with higher rates of women seeking mental health services. Since we strongly support caring for patients in a more comprehensive and cooperative manner, our FACTS elective and CME course both include lessons on addressing the Psychosocial Aspects of Infertility. Learn more about these educational opportunities here.
In the modern-day United States, infertility has been a growing concern. With new techniques and advances in medicine, we have been able to provide many different options to couples seeking parenthood. This grueling physical process, however, can negatively affect the well-being of many couples. Several studies over the years have shown significantly higher rates of emotional and psychological distress among patients seeking infertility treatments. Some found that infertile women who sought fertility treatments were more likely to present with depressive symptoms. Though when mental health services were offered during treatment, there appeared to be improved outcomes.
In a 2016 study published in Fertility and Sterility, Pasch et al aimed to examine the extent to which couples seeking infertility treatment experienced clinical levels of psychological distress, sought mental health services, and were provided with information about mental health services at their fertility treatment clinics. It also examined the association between being offered and utilizing mental health services and positive fertility outcomes.
A prospective longitudinal study was performed with both men and women partners of heterosexual couples from the Fertility Experiences Project. Eligibility requirements included 1) first visit to fertility clinic 2) no previous IVF treatment cycles 3) no history of hysterectomy or sterilization 4) no history of recurrent miscarriage 5) currently trying to get pregnant with a male partner and 6) English speaking. Of the eligible participants, 416 women and 378 men completed a baseline interview within three months of their first appointment. Three other follow-up assessments were conducted at four, 10, and 18 months of fertility treatment.
The study assessed distress experienced by couples as either depression or anxiety. These measures were quantified using the Study of Depression Scale and the State-Trait Anxiety Inventory. At-risk and high-risk patients were determined based on these scales. Additionally, the study assessed the provision and use of mental health services by asking two questions at the 18-month follow up: (1) “Did any clinic where you were receiving fertility treatment make information available to you about professional mental health services?” and (2) “Did you see a mental health professional for help with personal or relationship issues related to your difficulty having a baby?” They were also asked to indicate the number of sessions attended, if any, during this time.
A chi-square analysis was conducted to compare the provision and use of mental health services in at-risk and high-risk patients. Further, another subgroup division was made to distinguish participants who had a positive fertility outcome and those who did not.
The study confirmed previous findings that a majority of men and women experience significant distress during fertility treatment, and they also underutilize mental health services at that time. Specifically, the study found that at-risk and high-risk participants were no more likely to receive information about mental health services than other participants. However, at-risk and high-risk participants were also more likely to see a mental health professional during treatment.
“a majority of men and women experience significant distress during fertility treatment”
The study concluded that women whose fertility treatments were unsuccessful were significantly more likely to have clinical depressive symptoms and more likely to be in the high-risk group when compared to women who were successful. This finding also held true for the male participants. Unsuccessful treatment outcomes were also associated with significantly higher rates of women seeking mental health services, though it was only marginally higher in men seeking mental health services. Among the subgroup of those who did not have a positive fertility outcome, there was a marginal difference when receiving information about mental health services: Participants not at risk were more likely to receive this information than those at risk of the distress parameters.
This was one of the first studies to assess not only the provision but also the use of mental health services directly from fertility clinics. This study supported many previous studies and concluded there is an increased risk of distress (anxiety and depression) among those seeking fertility treatments. It also verified previous conclusions that the use of mental health services remains low among both men and women during fertility treatments. Despite previous recommendations for fertility clinics to target mental health services towards patients at higher risk of distress, the provision of these services remained low, according to this study.
“The use of mental health services remains low among both men and women during fertility treatments.”
The strength of this study is that a large number of participants’ responses were studied over 18 months, a significant period of time. The clinics were chosen to represent the demographics of the area in which they were located; however, these results may not be able to be extrapolated to the whole United States due to regional factors. Some weaknesses of this study included the inherent voluntary decision for patients to opt out of participating if there was distress already present before visiting the fertility clinic, and they chose to avoid invoking other negative emotions during this process. Furthermore, patients who were already experiencing these highly-distressed states may have been more likely to participate to ensure that their mental health concerns were being heard.
This study has once again highlighted the need for the improvement and accessibility of robust mental health services for couples going through fertility treatments. While it might be difficult to provide these mental health services at specific fertility clinics, it is important to encourage patients to utilize these services. This can be done by having open conversations, fostering a supportive environment and engaging patients in practicing self-care. Many strategies can be implemented in order to achieve these goals, providing information about mental health services at multiple times and multiple places during the fertility treatment journey or having multiple medical professionals encourage participants to engage with these services. While modern science has made many advances in providing couples with multiple paths to achieve their family planning goals, it is important to recognize that couples need support during this journey. If fertility clinics were to provide mental health services directly, this could be a useful solution for at-risk and high-risk patients to access much-needed care.
 Pasch LA, Holley SR, Bleil ME, Shehab D, Katz PP, Adler NE. Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services? Fertil Steril. 2016 Jul;106(1):209-215.e2. doi: 10.1016/j.fertnstert.2016.03.006. Epub 2016 Mar 24. PMID: 27018159.
ABOUT THE AUTHOR
Dr. Revati Narawane
Revati Narawane is a graduate of Kansas City University of Medicine and Biosciences. Currently, she is a resident in pediatrics at St. Louis University. She participated in the FACTS elective during the spring of her 4th year because of her limited experience in women’s health and a desire to learn more. Her current interests for pediatrics include adolescent health, public health, and critical care. She hopes to use the knowledge and training she was given during this elective to empower young girls and women in sexual and reproductive health.