Women's emotional adjustment to IVF: a systematic review of 25 years of research

© The Author 2006. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For

Permissions, please email: [email protected] 27

Human Reproduction Update, Vol.13, No.1 pp. 27–36, 2007 doi:10.1093/humupd/dml040

Advance Access publication August 29, 2006

Women’s emotional adjustment to IVF: a systematic review of 25 years of research

C.M.Verhaak1,3, J.M.J.Smeenk2, A.W.M.Evers1, J.A.M.Kremer2, F.W.Kraaimaat1

and D.D.M.Braat2

1Department of Medical Psychology and 2Department of Obstetrics and Gynaecology, Radboud University Nijmegen, Medical Centre, Nijmegen, The Netherlands

3To whom correspondence should be addressed at: Radboud University Nijmegen, Medical Centre, 818 Department of Medical Psychology, PO Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail: [email protected]

This review provides an overview of how women adjust emotionally to the various phases of IVF treatment in termsof anxiety, depression or general distress before, during and after different treatment cycles. A systematic scrutiny ofthe literature yielded 706 articles that paid attention to emotional aspects of IVF treatment of which 27 investigatedthe women’s emotional adjustment with standardized measures in relation to norm or control groups. Most studiesinvolved concurrent comparisons between women in different treatment phases and different types of control groups.The findings indicated that women starting IVF were only slightly different emotionally from the norm groups.Unsuccessful treatment raised the women’s levels of negative emotions, which continued after consecutive unsuccess-ful cycles. In general, most women proved to adjust well to unsuccessful IVF, although a considerable group showedsubclinical emotional problems. When IVF resulted in pregnancy, the negative emotions disappeared, indicating thattreatment-induced stress is considerably related to threats of failure. The concurrent research reviewed, should nowbe underpinned by longitudinal studies to provide more information about women’s long-term emotional adjustmentto unsuccessful IVF and about indicators of risk factors for problematic emotional adjustment after unsuccessfultreatment, to foster focused psychological support for women at risk.

Key words: anxiety/depression/emotional response/fertility treatment/IVF

Introduction

From the treatment’s launch, the emotional adjustment to IVF hasreceived ample attention in clinical, descriptive and empiricalstudies (Menning, 1980; Greenfeld et al., 1984; Freeman et al.,1985; Mahlstedt, 1985; Hearn et al., 1987; Callan and Hennessey,1988; Dennerstein and Morse, 1988; Kemeter, 1988; Kentenich,1989; Mazure and Greenfeld, 1989; Edelmann, 1990). Thedescriptive studies have predominantly addressed the stressfulconsequences of infertility and its treatment, thus solely focusingon a selective sample of help seekers. Using representative sam-ples and standardized measures, empirical research conducted inthe 1980s, however, demonstrated that, in general, infertilewomen do not differ significantly from control or norm groups onemotional aspects (Dunkel-Schetter and Lobel, 1991). This reviewconcluded that longitudinal and prospective studies were neededto support these results and to uncover information about groups atrisk of emotional problems as a result of unsuccessful fertilitytreatment. Recent years have seen a substantial expansion ofresearch efforts into women’s emotional adjustment to IVF.

With this review, we provide a systematic and comprehensiveoverview of the empirical research into women’s emotional

adjustment to IVF over the last 25 years with a special emphasison directions for future research. Because our review specificallytargets the process and the multidimensional character of emo-tional adjustment to unsuccessful treatment, it extends earlierreviews (Wright et al., 1989; Dunkel-Schetter and Lobel, 1991;Eugster and Vingerhoets, 1999; Pasch, 2001). We consider thepsychological adjustment process in relation to the various charac-teristics and stages of the medical procedure by differentiatingbetween the different cycles of an IVF treatment because, in linewith Beaurepaire et al. (1994), we assume that the number oftreatment options left could easily determine the emotionalresponse to the treatment and its outcome. For the same reason,this review exclusively focuses on IVF as it is nearly always thelast treatment option for couples with fertility problems. Accord-ingly, we do not consider studies on emotional adjustment to lessinvasive treatment options such as intrauterine insemination.

IVF is a multidimensional stressor; the treatment itself consti-tutes the primary stressor and is most likely to evoke anxiety. Theunpredictable outcome of the treatment is another major stress-inducing agent, more likely to evoke feelings of depression (Dunkel-Schetter and Lobel, 1991). To do justice to the course and varying

at Rice U

niversity on September 27, 2014

http://humupd.oxfordjournals.org/

Dow

nloaded from


C.M.Verhaak et al.

28

impact of consecutive IVF cycles and its multidimensional characteras a stressor, we have looked at how women tend to emotionallyadjust to their infertility problems and treatment in relation to thefollowing four phases of treatment: before the start of the treat-ment, within one treatment cycle, before and after treatment cycles(comparing differences) and after abandoning treatment.

Following stress-coping models on adjustment to a chronicstressor, our review regards the emotional response to IVF interms of anxiety, depression and general distress. Aspects of cop-ing skills, social support and personality characteristics are consid-ered determinants of the emotional response and are thus takeninto account as risk and protective factors to explain individualdifferences in emotional response to unsuccessful IVF based onstress-coping models (Abramson et al., 1978; Beck et al., 1979;Eysenck, 1981; Lazarus and Folkman, 1984; Leventhal et al.,1984; Cohen and Wills, 1985; Holahan and Moos, 1985; Ormeland Wohlfart, 1991; Edelmann, 1992; Clark et al., 1994; Costaet al., 1996; Holahan et al., 1996; Alloy et al., 1999). A soundinsight into such risk and protective factors would facilitate theidentification of women at risk of experiencing emotional problemsand foster the development of preventative and tailored support.

In summary, this paper reviews empirical research on the emo-tional adjustment of women to IVF treatment published in the past25 years with special emphasis on (i) the different phases in thetreatment process and the various aspects of the emotionalresponse in terms of anxiety, depression or general distress and (ii)specific risk and protective factors that are assumed to contributeto the emotional adjustment to IVF, i.e. the role of personalitycharacteristics, coping skills, cognitions with respect to fertilityproblems and social support.

The four treatment phases that were taken into account are sche-matically represented in Figure 1. The status and course of thepatients’ emotional adjustment was assessed (i) pretreatment, i.e.before the start of the treatment, (ii) within cycle, i.e. during onetreatment cycle, (iii) before and after treatment, i.e. from the pre-treatment phase up to and including one or more treatment cyclesand (iv) post-treatment, i.e. after treatment was abandoned.

Methodology

Selection of eligible studies

This review comprises studies published between 1978 (the intro-duction of IVF) and December 2005 in peer reviewed journals in

English, German, Dutch and French. The electronic databases ofMedline, PubMed and PsychInfo and the snowball method wereused to identify relevant articles. To identify those articles thatspecifically paid attention to issues relating to emotional aspectsof IVF (including ICSI treatment) in women, we used the searchterms IVF, ICSI and infertility treatment in combination with theterms anxiety, depression, emotional, distress, stress, psychoso-cial, psychological and psychology. The selection criteria thusexcluded studies focusing on the emotional aspects of assistedreproductive treatment (ART) in general, i.e. those which did notdifferentiate between IVF (including ICSI) and other ARTs suchas intrauterine sperm inseminiation.

Assessment of study quality

Study quality was determined by using criteria based on the proto-cols of the Cochrane Database of Systematic Reviews. Weadjusted the criteria to fit the research questions of this review:

(i) Database: studies should be published in English, Dutch,French or German with an abstract presented in an electronicdatabase.

(ii) Selection of subjects: the participants invited to take part inthe study should be selected randomly or consecutively.(iii) Outcome measures: the studies should make use of outcome

measures defined in terms of anxiety or depression or in terms ofgeneral distress indicative of emotional adjustment, with provenreliability and validity, and compared with norm groups.

(iv) Sample size: the sample size should be sufficient to indicatemedium effect sizes (d = 0.50) with a power of 0.80 (Cohen,1977).

(v) Statistical analyses: preferably, effects should be expressedin significance levels or t- or F-values.

The additional criteria for prospective studies were as follows:(i) Sample sizes of prospective studies needed to be sufficient

and in relation to the number of predictors (at least 10 subjects foreach predictor, see Cohen, 1977).

(ii) Studies should be of longitudinal design predicting changesin emotional factors out of predictive factors assessed at baseline.

Presentation of the results

The results are presented per treatment phase investigated, andprospective studies are discussed at the end. Information about sta-tistics (t- or F-values) and mean scores on the instruments used,

Figure 1. Different phases in the process of the IVF treatment.

IVF-1 IVF-2 IVF-x

within one cycle

Pre- and post treatment post treatment pre treatment

at Rice U



Dow

nloaded from


Women’s emotional adjustment to IVF

29

e.g. Spielberger State in Trait Anxiety Inventory (STAI) scores areonly presented when studies performed comparable analyses andused comparable assessment tools.

Results

The search of the literature yielded 706 articles that paid attentionto a broad range of topics related to psychology and IVF. Twoindependent raters subsequently conducted a further selection toidentify those studies that fit the contents and methodological cri-teria for this review (interrater agreement was 92%). The focalpoints of the studies are summarized in Table I.

Thirty-one articles did not provide an abstract and 27 were notpublished in the target languages. A considerable proportion of theremaining studies focused on ethical, legal or sociological issues(24%), on medical aspects (16%), on the effects for the childrenconceived by IVF (11%), on relationships between psychologicalfactors and treatment outcome (5%) or on the effects of psychoso-cial interventions, e.g. counselling (3%). Of the studies, 4%focused on a special group (e.g. women recovering from a severedisease), 5% addressed aspects of new reproductive technologies(e.g. surrogacy) and 1% of the studies dealt with treatment satis-faction or alternative treatments or concerned animal studies. Ofthe remaining 87 studies, 27 met the contents and methodologicalcriteria for this review, presenting data on anxiety, depression orgeneral distress of women before, during or after IVF treatmentbased on standardized measures. Thus, studies on women with fer-tility problems in general were not taken into account, nor were

studies focusing on specific groups like distinctive causes of fertil-ity problems, nor studies limited to a comparison between menand women, to the development of assessment instruments orexplanation of treatment dropout.

Emotional response to IVF

Pretreatment emotional adjustment

Nine studies investigated emotional adjustment before the start offertility treatment (Table II). Six studies provided informationabout pretreatment depression levels using different inventories:three used the Beck Depression Inventory (BDI) (Beck et al.,1961), one the Symptom Checklist (SCL-90) (Derogatis et al.,1973), one the Centre for Epidemiologic Studies Depression Scale(CES-D) (Radloff, 1977) and two the Profile of Mood States(POMS) (McNair et al., 1971). None of the studies reported differ-ences in depression between the IVF patients and norm groups.

All studies also assessed anxiety, most frequently by use of theSTAI (Spielberger, 1983) or SCL-90. With respect to state anxi-ety, four studies did not report differences with norm groups(Hearn et al., 1987; Edelmann et al., 1994; Verhaak et al., 2001;Fekkes et al., 2003), whereas five showed enhanced pretreatmentlevels of state anxiety (Beaurepaire et al., 1994; Visser et al.,1994; Mori et al., 1997; Slade et al., 1997; Salvatore et al., 2001).Pretreatment anxiety scores on the STAI differed considerably,ranging from 50 to 33. This is partly explained by the differencesin norms over countries. In Japan, the norm score for state anxietywas 42, whereas in other countries norms varied between 34 and38; the differences may be because of cultural aspects and the typeof norm group. As anxiety scores differ per age and sex, normativedata should match these variables. However, most studies failed toprovide information about the characteristics of the norm groups.Still, the differences in norm groups could not explain the consid-erable differences in pretreatment state anxiety levels even withinone country (Visser et al., 1994; Verhaak et al., 2001).

The time in which the study was conducted (i.e. just after theintroduction of IVF or more recently) could not explain the dispar-ity in the state anxiety findings nor were there differences relatedto type of sample (only inductees versus inductees and veterans).In addition, the variations were also present in studies assessingstate anxiety at more or less the same moment: immediately beforethe start of the medication. Nor could age differences explain thevariations: the mean age of the women participating in the studiesvaried from 32 to 34 years. It is known that ways of communi-cating fertility problems and treatment possibilities, just as themethod of delivering information, tend to influence the patients’emotional responses before the start of IVF. The differences inpretreatment emotional adjustment may hence have been attributableto the different patient approaches the studies adhered to, but,unfortunately, the studies presented did not provide any details onthese aspects of their procedures. Future studies should pay atten-tion to these different treatment protocols.

All but one study assessed anxiety with general inventories thatwere unrelated to the fertility problem. Of special interest is thestudy by Fekkes et al. (2003) that took both general and fertility-related emotional problems into account. The authors found nodeviations from the norm groups on the general instruments butdid report higher levels of emotional complaints for the fertility-related measures (Fekkes et al., 2003).

Table I. Subject of studies revealed by search and snowball method (n = 706)

Studies with focus of attention in italics met the criteria for the first selectionfor this review, based on content.Twenty-seven studies were not published in English, German, French orDutch: Spanish (5), Swedish (4), Japanese (3), Chinese (3), Norge (4), Czech(2), Hebrew, Danish, Portugese, Hungarian, Polish and Italian (all 1).

Focus of attention Total Percentage

Focus on ethical or legal aspects 125 18Medical aspects of IVF 110 16Characteristics of parents and or children after IVF 80 11Emotional adjustment before IVF 56 8Qualitative/case studies 50 7Focus on sociological aspects of IVF 44 6New technology 39 5Relationship between psychological factors and outcome 35 5Special groups 32 4Focus on counselling 20 3Reviews 14 2Course of the emotional response 14 2Long-term response 11 2Genetics 7 1Prospective studies 6 1Studies with animals 5 1Satisfaction with treatment 4 1Dropout 4 1Alternative treatment 3 0Lifestyle 2 0Other 14 2No abstracts available 31 4Total 706 100

at Rice U



Dow

nloaded from


C.M.Verhaak et al.

30

In summary, it may be concluded that before the start of thetreatment, in general, IVF patients did not differ from norm groupswith respect to depression levels, whereas the results on state anx-iety were equivocal: some studies showed elevated levels in thepatients, other studies found no difference compared to normgroups.

Within-cycle emotional adjustment

Five studies (Table III) assessed women’s anxiety and general dis-tress during the course of one treatment cycle (Merari et al., 1992;Boivin and Takefman, 1995; Ardenti et al., 1999; Yong et al.,2000; Kolonoff-Cohen et al., 2001). None of these studies pre-sented statistics; all descriptions of the results were restricted to anindication whether differences were significant or not. The designsvaried regarding the times of the assessments: from the start of thecycle to immediately before oocyte retrieval (OPU), shortly beforeembryo transfer and following the pregnancy test.

The study of Boivin and Takefman (1995) warrants specialmention because they monitored the entire course of the IVF treat-ment cycle by having the women keep a daily record of subjectivegeneral distress, starting at day 1 of the cycle and ending after theresult of the pregnancy test had been obtained. Distress levels didnot show remarkable changes in the first segment of the treatmentcycle, despite a slight increase at OPU. A more significant

increase of distress was reported at the end of the cycle, just beforethe pregnancy test (Boivin and Takefman, 1995). Other studies,too, indicated a similar increase in distress during the course of thecycle. Overall, OPU and pregnancy test proved to constitute themost stressful stages of the IVF cycle (Merari et al., 1992; Ardentiet al., 1999; Yong et al., 2000; Kolonoff-Cohen et al., 2001).

Pre- and post-treatment emotional adjustment

Six studies repeated their assessments of women’s emotionalresponse before and after one or more treatment cycles (Table IV).Three are of special interest because they discussed the results ofwomen after both successful and unsuccessful treatments (Visseret al., 1994; Slade et al., 1997; Verhaak et al. 2001, 2005a). How-ever, the subsamples of pregnant and non-pregnant women in twostudies (Visser et al., 1994; Slade et al., 1997) were not sufficientto draw any firm conclusions. Three studies (Newton et al., 1990;Hynes et al., 1992; Lok et al., 2002) investigated the emotionalresponse to unsuccessful treatment only.

Four studies used ANOVAs or MANOVAs to analyse thecourse of emotional adjustment between the various times ofassessment and treatment outcomes. The most consistent findingreported by three studies was an increase in depression after one ormore unsuccessful treatment cycles showing significant interactioneffects between time and treatment outcome (Verhaak et al., 2005b:

Table II. Studies investigating pretreatment emotional adjustment to IVF

BDI, Beck Depression Inventory (Beck et al., 1961); CES-D, Centre for Epidemiologic Studies Depression Scale (Radloff, 1977); GHQ, General Health Question-naire (Goldberg, 1972); HSCL, Hopkins Symptom Checklist (Derogatis et al., 1974); POMS, Profile of Mood States (McNair et al., 1971); SCL-90, SymptomChecklist (Derogatis et al., 1973); SIP, Sickness Impact Profile (Bergner et al., 1981); STAI, Spielberger State in Trait Anxiety Inventory (Spielberger, 1983).

References Sample size Measurement point Measures Reference group Results

Fekkes et al. (2003), The Netherlands

n = 447, inductees Before start of treatment, not clear how much

HSCL: general emotional complaints; SIP: infertility-related emotional complaints

Norms HSCL: no differences with norms; SIP: more emotional complaints compared with norms (t = 7.17, P < 0.01)

Salvatore et al. (2001), Italy

n = 176, inductees and veterans

Not defined Anxiety, depression: SCL-90; general distress: GHQ-30

IVF versus matched controls

Anxiety: IVF > controls (t = –2.01); depression: IVF = controls (t = –0.65); general distress: IVF = controls, no statistics given

Verhaak et al. (2001), The Netherlands

n = 207, inductees only, primary and secondary infertility

Just before starting medication of first treatment cycle

State anxiety: STAI (36–38); depression: BDI

Norm groups State anxiety: IVF = norms; depression: IVF = norms, no statistics given

Mori et al. (1997), Japan

n = 102, inductees Just before starting medication of first treatment cycle

State anxiety: STAI (50) Norm groups State anxiety: IVF > norms

Slade et al. (1997), UK

n = 144, inductees only


State anxiety: STAI (44); depression: BDI; anxiety and depression: POMS

Norm groups State anxiety: IVF > norms; depression: IVF = norms; POMS: no comparisons with norms

Beaurepaire et al. (1994), Australia

n = 230, inductees versus veterans, primary and secondary infertility

Just before starting medication of treatment cycle

State anxiety: STAI (39); depression: CES-D

Norm groups State anxiety: IVF > norms; depression: IVF = norms

Edelmann et al. (1994), UK

n = 155, inductees, primary and second-ary infertility


State anxiety: STAI (43); anx-iety and depression: POMS

Norm groups State anxiety: IVF = norms; depression: IVF = norms, no statistics given

Visser et al. (1994), The Netherlands

n = 150, inductees Not defined State anxiety: STAI (44) Norm groups State anxiety: IVF > norms

Hearn et al. (1987), Canada

n = 300, primary and secondary infertility

3 months before starting treatment

State anxiety: STAI (33); depression: BDI Norm groups

State anxiety: IVF = norms; depression: IVF = norms

at Rice U



Dow

nloaded from



31

F = 12.9; P < 0.01; Hynes et al., 1992; Lok et al., 2002: F =12.0; P < 0.01). Newton et al. (1990) only presented results afterunsuccessful treatment and showed a significant effect of time (F =11.1; P < 0.01). The results with respect to anxiety after unsuc-cessful treatment were less consistent: of the three studies thatassessed anxiety, two showed an increase in anxiety levels relativeto baseline after unsuccessful treatment (Verhaak et al., 2005b:time × outcome: F = 6.5; P < 0.01; Newton et al., 1990: time: F =25.2; P < 0.01). Visser et al. (1994) did not find any pre-post-treat-ment differences. However, the results of the latter study are diffi-cult to interpret because the researchers differentiated betweensubgroups based on the number of treatment cycles before preg-nancy. This resulted in small sample sizes thus rendering too littlepower.

Only one study evaluated the course of anxiety and depressionseveral months after treatment conclusion and reported no recov-ery from enhanced anxiety and depression levels in this periodafter unsuccessful treatment (Verhaak et al., 2005b). The resultswith respect to the emotional adjustment to successful treatmentconsistently showed equally low or decreased pre-to-post-treat-ment anxiety and depression levels, reflecting that negative emo-tions regarding IVF disappear after successful treatment.

In general, unsuccessful treatment tends to evoke an increase ofat least depressive symptoms, which are not liable to diminishshortly after treatment. Successful treatment, on the contrary,tends to alleviate negative emotional responses.

The pre–post results are based on averages of the emotionaladjustment observed in women after successful and unsuccessful

Table III. Studies investigating emotional response during one treatment cycle

DACL, Depression Adjective Checklist (Lubin, 1981); MAACL, Mean Affect Adjective Checklist (Zuckerman and Lubin, 1965); PANAS, Positive and NegativeAffect Scale (Watson et al., 1988); POMS, Profile of Mood States (McNair et al., 1971); STAI, Spielberger State in Trait Anxiety Inventory (Spielberger, 1983).

References Sample size Moments of measurement Measures Results

Kolonoff-Cohen et al. (2001), USA


T1: at first visit; T2: before embryo transfer Anxiety: POMS positive and negative affect: PANAS

Anxiety: T1 < T2; positive affect: T1 > T2; negative affect: T1 < T2

Yong et al. (2000), UK


T1: at first visit; T2: before embryo transfer; T3: before pregnancy test

Anxiety and depression: MAACL

Anxiety: T1<T2 = T3; depression: T1 = T2 < T3

Ardenti et al. (1999), Italy


T1: before oocyte pick-up; T2: between oocyte pick-up and embryo transfer; T3: at embryo transfer.

Anxiety: STAI Anxiety: T1 > T2 < T3

Boivin and Takefman (1995), Canada

n = 40, inductees Daily during cycle Daily record Highest distress at oocyte pick-up and pregnancy test

Merari et al. (1992), Israel

n = 113, inductees T1: oocyte pick-up; T2: embryo transfer; T3: before pregnancy test

Anxiety: STAI; depression: DACL

Anxiety: T1 > T2 < T3; depression: T1 > T2 < T3

Table IV. Studies investigating emotional response pre- and post-IVF

BDI, Beck Depression Inventory (Beck et al., 1961); GHQ, General Health Questionnaire (Goldberg, 1972); HSC, Hopkins Symptom Checklist (Derogatis et al.,1974); POMS, Profile of Mood States (McNair et al., 1971); STAI, Spielberger State in Trait Anxiety Inventory (Spielberger, 1983).aSample too small to draw firm conclusions.

References Sample size Moments of measurement Measures Results

Verhaak et al. (2001, 2005b), The Netherlands

n = 65 unsuccessful treatment, n = 83 successful treatment, inductees

T1: before cycle 1; T2: 4 weeks after last cycle; T3: 6 months after last cycle

Anxiety: STAI; depression: BDI

Unsuccessful treatment—anxiety: T1 < T2 = T3; depression: T1 < T2 = T3 ; successful treatment—anxiety: T1 > T2 = T3 ; depression: T1 > T2 = T3 ; MANOVA

Lok et al. (2002), China

n = 372 unsuccessful treatment, inductees and veterans

T1: before IVF; T2: 4 weeks after IVF

General health: GHQ; depression: BDI

Unsuccessful treatment:—depression: T1 < T2; general health: T1 > T2; ANOVA

Slade et al. (1997), UK

n = 14 unsuccessful treatment)a, n = 42 successful treatment, inductees

T1: before cycle 1; T2: 6 months after last cycle

Anxiety: STAI; depression: BDI; mood: POMS

No test on repeated measures, only cross-sectional Mann Whitney U-test

Visser et al. (1994), The Netherlands

n = 53 unsuccessful treatment, n = 12 successful treatmenta inductees

T1: before first cycle; T2: 4 weeks after first cycle

Anxiety: STAI; general health: HSC

Unsuccessful treatment—anxiety: T1 = T2; depression: T1 < T2; successful treatment—anxiety and depression: T1 = T2; Wilcoxon matched pairs test

Hynes et al. (1992), Australia

n = 100 unsuccessful treatment, n = 73 controls, inductees and veterans

T1: before treatment cycle; T2: 4 weeks after treatment cycle

Depression: Mitchell, Cronkite and Moos Depression Scale

Unsuccessful treatment—depression: T1 < T2; ANOVA

Newton et al. (1990), Canada

n = 187 unsuccessful treatment, n = 26 successful treatment, inductees

T1: 3 months before cycle 1; T2: 4 weeks after cycle 1


Unsuccessful treatment: increase anxiety and depression; successful treatment: no informa-tion; MANOVA

at Rice U



Dow

nloaded from


C.M.Verhaak et al.

32

IVF. Women who may have clinical levels of emotional problemsconstitute a group that may also need additional psychologicalsupport during fertility treatment. Three studies reported propor-tions varying from 10 (Lok et al., 2002) to 25% (Verhaak et al.,2005b; Newton et al., 1990) of women with clinically relevantlevels of depression after one or more unsuccessful treatmentcycles. Although most of the women therefore seem to adjust wellto unsuccessful treatment, a considerable number of patients mightbe eligible for supplemental counselling.

Long-term post-treatment emotional adjustment

The six studies we found on long-term emotional adjustment toIVF that met the criteria for review are summarized in Table V.There were no longitudinal studies on the emotional response ofwomen after IVF treatment had been abandoned. There were twocross-sectional studies that compared the emotional adjustment ofwomen after unsuccessful treatment with that of women after suc-cessful IVF (Freeman et al., 1987; Hammarberg et al., 2001).Remarkably, Hammarberg et al. (2001) did not report any differ-ences in emotional status between these two contrasting groupsseveral years after treatment cessation. In contrast, the earlierstudy by Freeman et al. (1987) did find higher levels of depressionin the women who had not conceived following IVF comparedwith the controls (women with children). The discrepancy in find-ings may be because of the variations in the time elapsed since thefinal treatment cycle. In Hammerberg et al.?s (2001) sample thiswas 2.5–3.5 years, whereas, in the sample of Freeman et al.(1987), this was 6 months to 2.5 years. It is reasonable to suggestthat the longer the time since the end of the treatment, the betterthe emotional adjustment will be. In addition, the comparisongroups the studies used differed: pregnant and non-pregnantwomen after IVF (Hammarberg et al., 2001) and non-pregnantwomen after IVF versus spontaneously pregnant women andwomen having conceived after IVF (Freeman et al., 1987).

Van Balen and Trimbos-Kemper (1993) did not use a comparisongroup but reported more general distress in women 2 years orlonger after unsuccessful fertility treatment compared with norms.In addition, the study by Hammarberg et al. (2001) indicated low-ered life satisfaction in women after unsuccessful IVF relative towomen after successful IVF, whereas no differences in emotionaldistress measures were reported. This seems to imply that, withrespect to negative effects after unsuccessful IVF, women may notdiffer from their peers who have undergone successful IVF butthat they do show less positive effects as indicated by their lowerlevels of life satisfaction (Hammarberg et al., 2001). This supportsresults of earlier explorative studies with smaller samples (Weaveret al., 1997; Leiblum et al., 1998).

Three studies presented longitudinal data on the emotionalresponse of pregnant women or young mothers after successfulIVF: no differences were reported between the women havingconceived through IVF and the women who had conceived spon-taneously, indicating that the stress of the treatment disappearedwhen a pregnancy was achieved (Klock and Greenfeld, 2000;Sydsjo et al., 2002; Hjelmstedt et al., 2004).

In sum, longitudinal research into women’s emotionalresponse after unsuccessful IVF is lacking, and cross-sectionalstudies showed women after unsuccessful fertility treatment tohave a less positive affect than women with successful IVF butare inconsistent about the group’s differences in negativeaffect. Studies into emotional adjustment after successful IVFshowed no differences compared with women who conceivednaturally.

Prediction of emotional response

Three studies explored potential predictors for emotional adjust-ment to unsuccessful treatment based on psychological parametersin a longitudinal design (Table VI).

Table V. Studies investigating long-term emotional response post-treatment

BDI, Beck Depression Inventory (Beck et al., 1961); CES-D, Centre for Epidemiologic Studies Depression Scale (Radloff, 1977); GHQ, General Health Question-naire (Goldberg, 1972); HSC, Hopkins Symptom Checklist (Derogatis et al., 1974); SCL-90, Symptom Checklist (Derogatis et al., 1973); STAI, Spielberger Stateen Trait Anxiety Inventory (Spielberger, 1983).

References Sample size Moment of measurement Measures Results

Hjelmstedt et al. (2004), Sweden

n = 55 IVF mothers, n = 40 non–IVF mothers

T1: early pregnancy; T2: 2 months post-partum; T3: 6 months post-partum

Parental stress: Swedish Parental Stress Questionnaire

No differences in parental stress between both groups

Sydsjo et al. (2002), Sweden

n = 110 pregnant women after IVF, n = 108 women after spontaneous pregnancy

T1: week 15–20 in pregnancy; T2: 12 months post-partum

Parental stress and life satisfaction

More favourable outcome in IVF women compared with women after spontaneous pregnancy

Hammarberg et al. (2001), Australia

n = 108 women after unsuccessful treatment, n = 121 women after successful treatment

T1: 2.5–3.5 years post-IVF General Health: GHQ; life satisfaction: satis-faction with life scale

More life satisfaction after successful IVF compared with unsuccessful. No difference on GHQ

Klock and Greenfeld (2000), USA

n = 74 pregnant women after IVF, n = 40 pregnant women after spontaneous pregnancy

T1: 12 weeks pregnant; T2: 28 weeks pregnancy


Both at week 12 and week 28, no differences in anxiety and depression between both groups

Van Balen and Trimbos-Kemper (1993), The Netherlands

n = 108 long-term infertile women

Last treatment at least 2 years ago

General health: SCL-90

Descriptive analysis: anxiety and depression above norms, 50% of women will continue treatment

Freeman et al. (1987), USA

n = 87 women after unsuccessful IVF, n = 37 women who got spontaneously pregnant, n = 37 women pregnant after IVF

Last treatment at 6–32 months ago

General health: HSC Most depression in unsuccessful group

at Rice U



Dow

nloaded from



33

The determinants of psychological factors assessed at baselinewere compared to the course of the emotional adjustment tounsuccessful treatment. One study limited its predictors to copingfactors (Terry and Hynes, 1998), whereas the other two studiesused a more comprehensive model (Lukse and Vacc, 1999;Verhaak et al., 2005a), but all the three models were based onstress-coping theory. Verhaak et al. (2005a) and Lukse and Vacc(1999) compared pretreatment outcomes to outcomes after unsuc-cessful treatment, but the former group did so by controlling foremotional adjustment at baseline which the latter group omitted.Terry and Hynes studied adjustment patterns for many weeksstarting some weeks after treatment by controlling for pretreat-ment emotional adjustment. Because of these different studydesigns, the statistical data do not allow any firm conclusions. Thesignificance of cognitive strategies in the adjustment to unsuccess-ful IVF was consistently underlined (Terry and Hynes, 1998;Verhaak et al., 2005a). Furthermore, evidence was found for thecontribution of social factors and personality characteristics. Onlya comprehensive model would allow a proper assessment of therelative importance of the various predictors of emotional adjust-ment to unsuccessful IVF, but none of the studies reviewed wassufficiently extensive.

Discussion

Emotional adjustment to fertility treatment

Apart from individual differences, 25 years of research into thepsychological aspects of IVF has not yielded compelling evidencefor significant negative emotional consequences of unsuccessfultreatment. Most women seem to be able to deal effectively withthe burden of the successive cycles. Most women seem to adjustwell, even to unsuccessful treatment, but still a considerablenumber develops clinical relevant emotional problems as a resultof ineffective IVF. These findings imply that psychological sup-port should target on those women who are at risk of developingadjustment problems following failed cycles. However, prospec-tive studies that have tried to delineate risk factors are scarce, leav-ing the identification of women at risk in an early treatment phaseflawed. Accordingly, in addition to standardized assessments ofemotional adjustment before the start of IVF, research into earlyrisk factors is warranted because this will open new avenues for

timely and tailored psychological support for those women likelyto experience problems in an early phase of the treatment.

When IVF results in a pregnancy, negative emotions tend todisappear immediately, indicating that the stress of the treatment ispredominantly determined by the threat of failure. It also justifiesthe conclusion that the IVF treatment itself evokes no long-termemotional problems. Comparisons of parental stress in IVF moth-ers and controls did not reveal any differences in emotional adjust-ment, precluding negative emotional consequences of IVFtreatment in parenthood. However, any conclusion about the emo-tional impact of unsuccessful IVF should be interpreted with cau-tion. Despite the ample number of studies into the psychologicalaspects of IVF, comprehensive, consistent knowledge about thecourse of the emotional response through the various stages andcycles of the treatment is scarce, as is univocal information aboutthe factors that determine that course, which underscores theimportance of longitudinal and prospective studies.

The lack of enhanced anxiety and depression levels in womenstarting fertility treatment was unexpected, as women’s history ofseveral years of fertility problems represents a relatively chronicstressor (Stanton et al., 1992; Domar et al., 1993). Possibly,women embarking on IVF may see the treatment as a first steptowards a solution of their fertility problems, a possibility toregain control over the fulfilment of an important life goal, whichis likely to positively affect their emotional disposition. Prelimi-nary support for this assumption can be found in longitudinal stud-ies that investigated the course of the adaptation process startingbefore the actual IVF intervention (i.e. from the first consultationwith a fertility specialist; Berg and Wilson, 1991; Boivin et al.,1995). This yielded a curvilinear course starting and ending withlow distress scores after several years of infertility with a peak inbetween, which course may be explained by adaptation to theinfertility (Boivin et al., 1995) or as the perceived regaining ofcontrol because of the focus on a new treatment option.

Regarding long-term emotional adjustment, a potentially com-plicating factor is the availability (at least in theory) of endlesstreatment options that may only be curbed by financial or medicaltreatment barriers (Smeenk et al., 2004). In the adaptation processto unsuccessful IVF and definitive childlessness, women willeventually have to shift from an active, treatment-focused copingstyle to a cognitive coping style (by adjusting important life goals).When the possibility to resolve the infertility through treatment is

Table VI. Studies investigating prediction of emotional response after unsuccessful IVF

Sample size and design Predictors Emotional responsein terms of

Results

Verhaak et al. (2005a)

n = 187 after unsuccessful treatment; T1: before cycle 1; T2: after cycle 1

Personality characteristics, infertility-related cognitions, coping, social support

Change in anxiety and depression

Personality characteristics, infertility-related cognitions and social support predicted change in anxiety and depression

Lukse and Vacc (1999)

n = 100 after unsuccessful treatment; T1: before cycle 1; T2: some weeks after cycle 1

Coping (general), demographic factors, life events

Depression, grief No prediction of coping variables on depression and grief. No control for baseline levels of depression and grief

Terry and Hynes (1998)

n = 171 after unsuccessful treatment; T1: before cycle 1; T2: after cycle 1; T3: 6 weeks after T2

Post-treatment coping (at T2, specific)

Composite of anxiety and depression T3 controlled for T1 levels

Problem appraisal, emotional approach and less avoidance coping predicted distress at T3 (controlled for distress at T1)

at Rice U



Dow

nloaded from


C.M.Verhaak et al.

34

abandoned, woman has to adjust the meaning of her infertility(Folkman, 1984), for instance, by looking for other life goals, byacknowledging certain benefits of childlessness or by concentrat-ing on other ways to care for one or more children, e.g. adoptionor fostering. These shifts in coping efforts have been found to bebeneficial to people dealing with different kinds of uncontrollablehealth-related stressors and to particularly induce positive mood(Evers et al., 2001). Similarly, on average, childless women arenot characterized by an enhanced negative mood, but they doshow lower positive mood and lower levels of life satisfaction(Weaver et al., 1997; Leiblum et al., 1998; Hammarberg et al.,2001) which may be because of a lack of cognitive coping efforts(see Predictors of adjustment to infertility). For women undergo-ing IVF treatment, the apparently unlimited treatment possibilitiescan prevent them from adopting more cognitive coping efforts:they may be more likely to persist in considering or trying differ-ent treatment options thus preventing themselves from truly facingthe loss of their main life goal and making a start to accepting ulti-mate childlessness. This lack of a well-marked end of treatmentmay be an important aggravating aspect in women’s adaptationprocess to definitive childlessness.

Predictors of adjustment to infertility

Compared with studies in the emotional adjustment to IVF, studiesin the prediction of the emotional response to unsuccessful treat-ment are relatively scarce. This does not tally with the relevanceof this type of research for the psychological support for IVFpatients as it can provide essential information about protectiveand risk factors for adaptation problems facilitating the identifica-tion of women at risk at an early stage. Few studies with solid pro-spective designs showed that cognitive processes play animportant role in the adjustment to unsuccessful treatment. To dealeffectively with the uncontrollable stressor of infertility, womenneed to exert considerable effort to change or to adjust the meaningof their childlessness. This is in line with adjustment studies exam-ining other uncontrollable health problems (Rothbaum et al., 1982;Taylor, 1983; Folkman, 1984; Carver et al., 1993; Osowiecki andCompass, 1999; Pakenham, 1999) and, more specifically, studiesdelineating the process of having to reconstruct one’s life afterunsuccessful fertility treatment (Daniluk, 2001) and adjustment toART in general (Schmidt et al., 2005). Based on a qualitative inter-view assessment, the latter study describes an adaptive process fromthe first acknowledgement that the fertility problems will under nocircumstances be solved, through grief about the unsuccessful treat-ment attempts, to turning towards the future and giving meaning tochildlessness. Schmidt et al. (2005) also stressed the importance ofcognitive processes in terms of changing the meaning of infertility.It would be interesting to see whether prospective, longitudinalstudies would support these findings.

Recommendations for future research

This review provides several starting points for future research.First, there is a clear need for further longitudinal studies that fol-low women in the last phase of their IVF treatment through 2–3years after abandoning treatment to shed more light on the finaladaptation process, i.e. a cognitive shift from trying to get preg-nant to trying to give meaning to one’s life without a child that isgenetically one’s own.

Furthermore, future studies into the emotional response withinone treatment cycle should differentiate between the stress of thetreatment itself and the stress caused by the threat of infertility. Isthe emotional response to the treatment itself related to that of thelooming childlessness? Are the women who have difficulties indealing with the fertility treatment the same as those that havedifficulties in dealing with its failure?

It is also desirable to know more about how the adaptation proc-ess evolves in less invasive infertility treatments before IVF. Whatis the effect of the prospect of another treatment option (IVF) onthe adaptation process to the fertility problems? Is the adjustmentto unsuccessful IVF facilitated by the ability to shift coping effortsfrom more behavioural control (seeking treatment) to cognitivecontrol (changing goals)?

Finally, the decision-making processes in connection with start-ing and abandoning IVF and the emotional consequences of thesedecisions should be addressed, possibly accompanied by researchinto how women could best be counselled in these stages of thetreatment.

As to potential predictive factors, a crucial point in psychologicalresearch into the emotional impact of IVF is the identification ofwomen who are at risk of developing severe emotional problemsas a result of failed treatment. To date, very few studies have beendedicated to this group and even fewer to their long-term adjust-ment. As the reviewed research demonstrated, ∼25% of womenexperience clinical or subclinical complaints (Verhaak et al.,2005b). Prospective, longitudinal studies testing the predictivevalue of a comprehensive set of risk and protective factors arewarranted to foster the timely identification of at-risk women,preferably before they start treatment. The study focus should beon personality characteristics, on coping and cognitive factors andon social support.

Clinical implications

The conclusion that the vast majority of women adjust well to thetreatment itself is of considerable clinical relevance. Negativeemotional responses proved to be strongly related to the outcomeof the treatment, i.e. to the threat of definitive childlessness.Accordingly, psychological support should be specifically tar-geted to help the woman adjust to the possibility of treatment fail-ure and eventual childlessness rather than to help her to cope withthe impact of the treatment itself. As prospective studies showed,especially the pretreatment cognitions of helplessness and accept-ance with respect to possible childlessness are the factors that playa prominent role in determining the emotional response to treat-ment failure. From the start, additional psychosocial care shouldbe dedicated to change the meaning of childlessness. Fertility pro-fessionals can advance the process of acceptance by discussing theinfertility problems with the couples and by improving their com-munications about the issue, i.e. by asking about possible plans inthe event of unsuccessful treatment and by gauging possible dif-ferences in motivation for treatment between the spouses (Boivinet al., 2001; Kentenich et al., 2002). Clinicians should also pre-pare their patients for possible emotional reactions to unsuccessfultreatment. Indeed, Hammarberg et al. (2001) reported that the cou-ples themselves indicated a need for information on the emotionalaspects of their fertility problems. Such psychosocial education,e.g. explaining to the couple in advance that enhanced distress is a

at Rice U



Dow

nloaded from



35

natural reaction to unsuccessful treatment, might enhance theircontrol over their emotional response to treatment failure. In mostcases, the knowledge will reassure the couple that what they areexperiencing is part of a normal reaction and not an indication ofdysfunctional adjustment.

As the majority of women and their partners seem to adjust wellto the considerable stress of successive unsuccessful treatmentcycles, standard psychological interventions for all patients are notindicated. However, as mentioned above, the early identificationof women who might benefit from psychological intervention, i.e.those at risk of developing emotional problems as the result ofunsuccessful treatment, merits close attention. Again, because per-manent infertility and eventual childlessness constitute the mostimportant stressor in IVF treatment, any psychological interven-tion should be aimed at the couple’s acceptance of their fertilityproblems and adjustment to the likelihood of childlessness.

To summarize, most women adjust well to unsuccessful IVFcycles, but there is a lack of knowledge about the process ofadjustment to definitive unsuccessful treatment and childlessnessas well as about the factors that contribute to the process. Beyondthe considerable negative emotional response, most women expe-rience after abandoning treatment, which represents a normal griefreaction that is expected to diminish over time, there is a sizeablenumber of women who develop or are at risk of developing severeemotional problems after IVF cessation. To date, the larger part ofpsychological research has focused on the emotional aspects of thetreatment itself aimed at facilitating the treatment process. Thetime has come to allocate more attention to those women forwhom the treatment does not lead to offspring and to address thequestion of how to support these women in their attempts to acceptthe treatment failure and to adjust to definitive childlessness.

ReferencesAbramson L, Seligman MEP and Teasdale J (1978) Learned helplessness in

humans: critique and reformulation. J Abnorm Psychol 87,49–74.Alloy LB, Abramson LY, Whitehouse WG, Hogan ME, Tashman NA, Steinberg

DL, Rose DT and Donovan P (1999) Depressogenic cognitive styles: pre-dictive validity, information processing and personality characteristics,and developmental origins. Behav Res Ther 37,503–531.

Ardenti R, Campari C, Agazzi L and La-Sala GB (1999) Anxiety and perceptivefunctioning of infertile women during in-vitro fertilization: exploratorysurvey of an Italian sample. Hum Reprod 14,3126–3132.

Beaurepaire J, Jones M, Thiering P, Saunders D and Tennant C (1994) Psycho-social adjustment to infertility and its treatment: male and femaleresponses at different stages of IVF/ET treatment. J Psychosom Res38,229–240.

Beck AT, Rush AJ, Shaw BF and Emery G (1979) Cognitive Therapy andDepression. Guilford Press, New York.

Beck AT, Ward CH, Mendelson M, Mock JE and Erbaugh JK (1961) Aninventory for measuring depression. Arch Gen Psychiatry 4,561–571.

Berg BJ and Wilson JF (1991) Psychological functioning across stages oftreatment for infertility. J Behav Med 14,11–26.

Bergner M, Bobbitt RA, Carter WB and Gilson BS (1981) The Sicknessimpact profile: development and final reversion of a health status measure.Med Care 19,787.

Boivin J and Takefman JE (1995) Stress levels across stages of in vitro fertili-zation in subsequently pregnant and non-pregnant women. Fertil Steril64,802–810.

Boivin J, Takefman J, Tulandi T and Brender W (1995) Reactions to infertilitybased on extent of treatment failure. Fertil Steril 63,801–807.

Boivin J, Appleton TC, Baetens P, Baron J, Bitzer J, Corrigan E, Daniels KR,Darwish J, Guerra-Diaz D, Hammar M et al. (2001) Guidelines for coun-selling in infertility. Hum Reprod 16,1301–1304.

Callan VJ and Hennessey JF (1988) Emotional aspects and support in in vitrofertilization and embryo transfer programs. J In Vitro Fert Embryo Transf5,290–295.

Carver CS, Pozo CP, Harris SD, Noriega V, Scheier MF, Robinson DS,Ketchman AS, Moffat FL and Kimberley CC (1993) How coping medi-ates the effect of optimism on distress: a study of women with early stagebreast cancer. J Pers Soc Psychol 65,375–390.

Clark LA, Watson D and Mineka S (1994) Temperament, personality, and themood and anxiety disorders. J Abnorm Psychol 103,103–116.

Cohen J (1977) Statistical Power Analysis for Behavioral Sciences. AcademicPress, New York.

Cohen S and Wills TA (1985) Stress, social support of the buffering hypothe-sis. Psychol Bull 98,310–357.

Costa PT, Somerfield MR and McCrae RR (1996) Personality and coping, areconceptualization. In Zeidner M and Endler NS (eds) Handbook of Cop-ing: Theory, Research, Applications. Wiley, New York, pp. 44–61.

Daniluk JC (2001) Reconstructing their lives: a longitudinal, qualitative analy-sis of the transition to biological childlessness for infertile couples. JCouns Dev 79,439–449.

Dennerstein L and Morse C (1988) A review of psychological and socialaspects of in vitro fertilization. J Psychosom Obstet Gynaecol 9,159–170.

Derogatis LR, Lipman RS and Covi L (1973) SCL-90: an outpatient psychiat-ric rating scale preliminary report. Psychopharmacol Bull 9,13–25.

Derogatis LR, Lipman RS, Richels K, Uhlenbluth EH and Covi L (1974) TheHopkins Symptom Checklist (HSCL): a self report symptom inventory.Behav Sci 19,1–15.

Domar AD, Zuttermeister PC and Friedman R (1993) The psychologicalimpact of infertility, a comparison with patients with other medical condi-tions. J Psychosom Obstet Gyn 14,45–52.

Dunkel-Schetter C and Lobel M (1991) Psychological reactions to infertility.In Stanton AL and Dunkel-Schetter C (eds) Infertility; Perspectives fromStress and Coping Research. Plenum, New York, pp. 29–60.

Edelmann RJ (1990) Emotional aspects of in vitro fertilization procedures: areview. J Reprod Infertil Psychol 8,161–173.

Edelmann RJ (1992) Anxiety, Theory, Research and Intervention in Clinicaland Health Psychology. John Wiley, Chichester.

Edelmann RJ, Connolly KJ and Bartlett H (1994) Coping strategies and psy-chological adjustment of couples presenting for IVF. J Psychosom Res38,355–364.

Eugster A and Vingerhoets AJJM (1999) Psychological aspects of in vitro fer-tilisation. Soc Sci Med 48,575–589.

Evers AWM, Kraaimaat FW, van Lankveld W, Jongen PJH and Bijlsma JWJ(2001) Beyond unfavorable thinking: the illness cognition questionnairefor chronic diseases. J Consult Clin Psychol 69,1026–1036.

Eysenck HJ (1981) A Model for Personality. Springer-Verlag, New York.Fekkes M, Buitendijk SE, Verrios GHW, Braat DDM, Brewaeys AMA,

Dolfing JG, Kortman M, Leerentveld RA and Macklon NS (2003) Health-releated quality of life in relation to gender and age in couples planningIVF treatment. Hum Reprod 18,1536–1543.

Folkman S (1984) Personal control and stress coping processes: a theoreticalanalysis. J Pers Soc Psychol 46,839–852.

Freeman EW, Boxer AS, Rickels K, Tureck R and Mastrionni L (1985) Psy-chological evaluation and support in a program of in vitro fertilization andembryo transfer. Fertil Steril 43,48–53.

Freeman EW, Rickels K, Tausig J, Boxer A, Mastrionni L and Tureck R(1987) Emotional and psychosocial factors in follow-up of women afterIVF-ET treatment, a pilot investigation. Acta Obstet Gynecol Scand66,517–521.

Goldberg D (1972) G.H.Q. (General Health Questionnaire): The Detection ofPsychiatric Illness by Questionnaire. Oxford University Press, London, GB.

Greenfeld D, Mazure C, Haseltine F and DeCherney A (1984) The role of thesocial worker in the in-vitro fertilization program. Soc Work Health Care10,71–79.

Hammarberg K, Astbury J and Baker HWG (2001) Women’s experience ofIVF: a follow-up study. Hum Reprod 16,374–383.

Hearn MT, Yuzpe AA, Brown SE and Casper RF (1987) Psychological char-acteristics of in vitro fertilization participants. Am J Obstet Gynecol156,269–274.

Hjelmstedt A, Widstrom AM, Wramsby H and Collins A (2004) Emotionaladaptation following successful in vitro fertilization. Fertil Steril81,1254–1264.

Holahan CJ and Moos RH (1985) Life stress and health: personality, copingand family support in stress resistance. J Pers Soc Psychol 49,739–747.

Holahan CJ, Moos RH and Schaeffer JA (1996) Coping, stress resistance andgrowth: conceptualizing adaptive functioning. In Zeidner M and Endler

at Rice U



Dow

nloaded from


C.M.Verhaak et al.

36

NS (eds) Handbook of Coping: Theory, Research, Applications. Wiley,New York, pp. 24–43.

Hynes GJ, Callan VJ, Terry DJ and Gallois C (1992) The psychological well-being of infertile women after an unsuccessful IVF attempt: the effects ofcoping. Br J Med Psychol 65,269–278.

Kemeter P (1988) Studies on psychosomatic implications of infertility –effects of emotional stress on fertilization and implantation in in-vitrofertilization. Hum Reprod 3,341–352.

Kentenich H (1989) Results of concomitant psychosomatic studies of IVFpatients. Arch Gynecol Obstet 245,1052–1055.

Kentenich H, Henning K, Himmel W, Ittner E, Kochen MM, Krause W,Ningel K, Stammer H, Strauss B and Wischmann T (2002) Practical ther-apy in infertility, a manual for gynaecologists from a psychosomatic pointof view. In Strauss B (ed.) Involuntary Childlessness PsychologicalAssessment, Counselling and Psychotherapy. Hogrefe & Huber Publishers,Seattle, pp. 175–188

Klock SC and Greenfeld DA (2000) Psychological status of in vitro fertilizationpatients during pregnancy: a longitudinal study. Fertil Steril 73,1159–1164.

Kolonoff-Cohen H, Chu E, Natarajan L and Sieber W (2001) A prospectivestudy of stress among women undergoing in vitro fertilization or gameteintrafallopian transfer. Fertil Steril 76,675–687.

Lazarus RS and Folkman S (1984) Stress, Appraisal and Coping. Springer,New York.

Leiblum SR, Aviv A and Hamer R (1998) Life after infertility treatment: along-term investigation of marital and sexual function. Hum Reprod13,3569–3574.

Leventhal H, Nerenz DR and Steele DJ (1984) Illness representations and cop-ing with health threats. In Baum A, Taylor SE and Singer SE (eds) Hand-book of Psychology and Health, Vol. 4. Lawrence Erlbaum Associates,Hillsdale, New York, pp. 219–252.

Lok IH, Lee DT, Cheung LP, Chung WS, Lo WK and Haines CJ (2002) Psy-chiatric morbidity amongst infertile Chinese women undergoing treatmentwith assisted reproductive technology and the impact of treatment failure.Gynecol Obstet Invest 53,195–199.

Lubin B (1981) Additional data on the reliability and validity of the brief listsof the Depression Adjective Check Lists. J Clin Psychol 37,809–811.

Lukse MP and Vacc NA (1999) Grief, depression, and coping in womenundergoing infertility treatment. Obstet Gynecol 93,245–251.

Mahlstedt PP (1985) The psychological component of infertility. Fertil Steril43,335–346.

Mazure CM and Greenfeld DA (1989) Psychological studies of in vitro fertiliza-tion/embryo transfer participants. J In Vitro Fert Embryo Transf 6,242–256.

McNair DM, Lorr M and Droppleman LF (1971) Edits Manual for the Profileof Mood States. Educational and Industrial Testing Service, San Diego.

Menning B (1980) The emotional needs of infertile couples. Fertil Steril34,313.

Merari D, Feldberg D, Elizur A, Goldman J and Modan B (1992) Psychologi-cal and hormonal changes in the course of in vitro fertilization. J AssistReprod Genet 9,161–169.

Mori E, Nadaoka T, Morioka Y and Saito H (1997) Anxiety of infertile womenundergoing IVF-ET: relation to the grief process. Gynecol Obstet Invest44,157–162.

Newton CR, Hearn MT and Yuzpe AA (1990) Psychological assessment andfollow-up after in vitro fertilization: assessing the impact of failure. FertilSteril 54,879–886.

Ormel J and Wohlfart T (1991) How neuroticism, long-term difficulties, andchanges in quality of life affect psychological distress: a longitudinalapproach. J Pers Soc Psychol 60,744–755.

Osowiecki DM and Compass BE (1999) A prospective study of coping, per-ceived control, and psychological adaptation to breast cancer. Cogn TherRes 23,169–180.

Pakenham KI (1999) Adjustment to multiple sclerosis: application of a stressand coping model. Health Psychol 18,383–392.

Pasch LA (2001) Confronting fertility problems: current research and future chal-lenges. In Baum A, Revenson TA and Singer JE (eds) Handbook of HealthPsychology. Lawrence Erlbaum Associates, New Jersey, pp. 559–570.

Radloff LS (1977) The CES-D scale: a self-report depression scale for researchin the general population. Appl Psychol Meas 1,385–401.

Rothbaum F, Snyder SS and Weisz JR (1982) Changing the world andchanging the self: a two-process model of perceived control. J Pers SocPsychol 42,5–37.

Salvatore P, Gariboldi S, Offidani A, Coppola F, Amore M and Maggini C(2001) Psychopathology, personality, and marital relationship inpatients undergoing in vitro fertilization procedures. Fertil Steril75,1119–1125.

Schmidt L, Holstein BE, Christensen U and Boivin J (2005) Communicationand coping as predictors of fertility problem stress: cohort study of 816participants who did not achieve a delivery after 12 months of fertilitytreatment. Hum Reprod 20,3248–3256.

Slade P, Emery J and Lieberman BA (1997) A prospective, longitudinal studyof emotions and relationships in in-vitro fertilization treatment. HumReprod 12,183–190.

Smeenk JM, Verhaak CM, Stolwijk AM, Kremer JA and Braat DD (2004)Reasons for dropout in an in vitro fertilization/intracytoplasmic sperminjection program. Fertil Steril 81,262–268.

Spielberger CD (1983) Manual for The State-Trait Anxiety Scale. ConsultingPsychologists, Palo Alto.

Stanton A and Dunkel-Schetter C (1991) Infertility; Perspectives from Stressand Coping Research. Plenum, New York.

Stanton AL, Tennen H, Affleck G and Mendola R (1992) Coping and adjust-ment to infertility. J Soc Clin Psychol 11,1–13.

Sydsjo G, Wadsby M, Kjellberg S and Sydsjo A (2002) Relationships and par-enthood in couples after assisted reproduction and in spontaneous primi-parous couples: a prospective long-term follow-up study. Hum Reprod17,3242–3250.

Taylor SE (1983) Adjustment to threatening events, a theory of cognitive adap-tation. Am Psychol 38,1161–1173.

Terry DJ and Hynes GJ (1998) Adjustment to a low-control situation: reexam-ining the role of coping responses. J Pers Soc Psychol 74,1078–1092.

Van Balen F and Trimbos-Kemper TCM (1993) Long-term infertile couples: astudy of their well-being. J Psychosom Obstet Gynaecol 14,53–60.

Verhaak CM, Smeenk JMJ, Eugster A, van Minnen A, Kremer JAM andKraaimaat FW (2001) Stress and marital satisfaction among womenbefore and after their first cycle of in vitro fertilization and intracyto-plasmic sperm injection. Fertil Steril 76,525–531.

Verhaak CM, Smeenk JMJ, Evers AWM, van Minnen A, Kremer JAM andKraaimaat FW (2005a) Predicting emotional response to unsuccessfulfertility treatment, a prospective study. J Behav Med 28,181–190.

Verhaak CM, Smeenk JMJ, van Minnen A, Kremer JAM and Kraaimaat FW(2005b) A longitudinal, prospective study on emotional adjustmentbefore, during and after consecutive fertility treatment cycles. HumReprod 20,2253–2260.

Visser AP, Haan G, Zalmstra H and Wouters I (1994) Psychological aspects ofin vitro fertilization. J Psychosom Obstet Gynaecol 15,35–43.

Watson D, Clark LA and Tellegen A (1988) Development and validation ofbrief measures of positive and negative affect: the PANAS scales. J PersSoc Psychol 54,1063–1070.

Weaver SM, Clifford E, Hay DM and Robinson J (1997) Psychosocialadjustment to unsuccessful IVF and GIFT treatment. Patient EducCouns 31,7–18.

Wright J, Allard M, Lecours A and Sabourin S (1989) Psychological distressand infertility: a review of controlled research. Int J Fertil 34,126–142.

Yong P, Martin C and Thong J (2000) A comparison of psychological func-tioning in women at different stages of in vitro fertilization treatmentusing the mean affect adjective checklist. J Assist Reprod Genet17,553–556.

Zuckerman M and Lubin B (1965) Manual for the Multiple Affect AdjectiveChecklist Measure of Anxiety. Educational and Industrial Testing Service,San Diego.

Submitted on February 15, 2006; resubmitted on June 25, 2006; accepted onJuly 27, 2006

at Rice U



Dow

nloaded from


Women's emotional adjustment to IVF: a systematic review of 25 years of research

Documents

Transcript of Women's emotional adjustment to IVF: a systematic review of 25 years of research