Infertility affects an estimated 10-15% of couples of reproductive age.  Several studies have indicated that patients undergoing in vitro fertilization (IVF) experience high levels of stress, depression, and anxiety.  Multiple risk factors for anxiety and depression during infertility treatment have been identified; these include being female, age over 30, lower level of education, lack of occupational activity, a male cause for infertility, and infertility for 3-6 years.

In addition, studies have indicated that higher levels of depression and anxiety are associated with lower pregnancy rates among patients undergoing IVF.  One study of 80 Turkish couples demonstrated a significant correlation between depressive symptoms (as measured using the Beck Depression Inventory) and number of retrieved oocytes.  The higher the depression score, the lower the number of oocytes.  Furthermore, sperm motility was decreased with higher levels of depression and anxiety in the male partner.  When followed longitudinally, it was shown that women with higher depression and anxiety scores had lower pregnancy rates.

Another study found that women who coped poorly with stress during infertility treatment had higher rates of first trimester miscarriage. In this study, depression in males was associated with decreased sperm concentration.

Importantly, recent data indicate that treatment of anxiety and depression in patients undergoing IVF may improve conception rates.  A recent meta-analysis including a total of 21 controlled studies found that while psychological interventions had no significant effect on the levels of depression or anxiety symptoms, they did appear to have a positive impact on pregnancy rates.

An important study compared whether therapy or antidepressant medications were more effective in treating depression and anxiety in women suffering from infertility.  In this randomized, controlled clinical trial, 89 depressed, infertile women were assigned to receive 10 sessions of cognitive behavioral therapy (CBT), 20mg of fluoxetine (Prozac) for 3 months or were enrolled in a control (no treatment) group.  Depression scores were assessed using the BDI at study onset and at the end of three months.

Women receiving fluoxetine experienced decreased levels of anxiety and depression (reduced by about 50%), but they noted no improvement in psychosomatic symptoms.  CBT decreased depression scores by 79.3% but also improved anxiety and psychosomatic symptoms.  Those in the control group experienced a 10% reduction in depression scores. While it appears that the response in the CBT group was more robust than in the medication group, it is worth noting that the fluoxetine dose was relatively low and that there was no dose titration involved in the study.

In summary, rates of depression and anxiety are high among couples undergoing infertility treatment.  Several studies have demonstrated that these symptoms may diminish the chances of conception.  Both medication and cognitive behavioral therapy can be helpful in alleviating these symptoms.  Patients should be sure to talk with their treaters and to seek a referral if they are experiencing symptoms of depression or anxiety in this setting.

Kimberly Pearson, MD

Zorn B, et al.  Psychologic factors in male partners of infertile couples:  relation with semen quality and early miscarriage. Int J Androl 2008;  31(6): 557-64.

Gurhan N, et al.  Association of depression and anxiety with oocyte and sperm number and pregnancy outcomes during In Vitro Fertilization. Psychol Rep 2009; 104(3): 796-806.

Drosdzol A., Skrzypulec V. Depression and anxiety among Polish infertile couples: an evaluative prevalence study.  J Psychosom Obstet Gynecol 2009;  30(1):11-20.

Hammerli K.  Efficacy of psychological interventions for infertile patients:  a meta-analysis examining mental health and pregnancy rates. Hum Reprod Update 2009; 15(3): 279-95.

Faramarzi M. Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women:  a randomized controlled trial. Eur J Obs Gynecol and Reprod Biol 2008;  141(1): 49-53.

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