Stress and Infertility

Prior to tackling the issue of patient retention, one needs to understand why patients drop out of treatment and which patients are the most likely to make that decision. For uninsured patients, finances are the primary reason why patients cannot initiate or continue with infertility treatment. However, for patients with financial resources and/or insurance coverage, the emotional burden of that treatment is the most commonly cited reason for dropping out[2]. Treatment termination is defined as the decision to stop receiving infertility treatment despite a favorable prognosis where payment is not an issue.

In Israel, couples are covered by national health insurance to continue ART until they have two children, yet not all couples continue care. In a recent study of women under the age of 35, where 34% discontinued treatment[2], psychological burden was the most commonly cited reason for discontinuation, followed by lost hope of success; both of which reflect the distress caused by treatment. In a larger study in the United States[3], in a state which has a six-cycle mandated insurance coverage plan, of the women who terminated treatment, 40% reported that more treatment would have been too stressful. When these participants were asked more about their stress level, the top sources of stress were the feeling that they had already given IVF their best chance of success, feeling too stressed to continue, and infertility was taking too high a toll on their relationship.

Stress is in fact a significant factor for infertility patients. It is well known that women who are depressed are the least likely to initiate treatment. And, despite the impression of 15 years ago that infertility had a benign impact on psychological status, patients in treatment actually report high levels of distress. In a large recent study of both men and women who were receiving care in clinics in California, 56% of women and 32% of men scored in the clinical range for symptoms of depression and 76% of women and 61% of men scored in the clinical range for anxiety[4].

Despite the knowledge that distress is the most commonly cited reason for treatment termination and precludes treatment initiation, obviously not every distressed patient drops out of treatment. Thus, identifying which patients are the most likely to drop out would allow for pinpointing interventions at those most at risk. Research shows that risk factors for discontinuation include female depression, poorer prognosis, longer duration of infertility, and higher parity[5]. One cannot change prognosis, infertility duration, or parity. One can, however, treat stress.

Treating Stress

There have been dozens of RCTs on various psychological interventions designed to treat the distress reported by individuals and couples experiencing infertility. Unfortunately, these trials have included almost exclusively women already being seen at an infertility clinic. Thus, women who are not seeing an infertility specialist and men are vastly underrepresented.

In the largest most recent meta-analysis on the efficacy of psychological interventions with infertile women[6], 39 eligible studies were included on a total of 2746 women and men. The results were as follows: “statistically significant and robust overall effects” for both clinical pregnancy and combined negative psychological symptoms, which included depression, anxiety, stress, and marital function. There were no significant differences between cognitive behavioral therapy (CBT), mind body interventions (MBIs), and other forms of treatment, but the authors concluded that CBT and MBIs could be particularly efficacious. Other meta-analyses have included fewer trials, but most have come to the same conclusions in terms of the impact; structured interventions that provide specific skills acquisition to increase coping and reduce stress lead to decreases in psychological symptoms, specifically anxiety and depression. CBT has been highlighted more than other forms of intervention.

Preventing Treatment Termination

If one accepts the theory that stress is the leading contributor to insured patient dropout behavior, and that psychological interventions, specifically CBT, lead to decreases in distress, then it would be logical to assume that these interventions should also be associated with increases in patient retention.

Unfortunately, there is minimal research in this area. Only one study could be located through a literature review. In this study, 166 insured women were recruited prior to commencing their first IVF cycle[7]. Participants randomized to the intervention group received a packet in the mail, which contained a cognitive-coping and relaxation intervention (CCRI). The control participants received routine control (RC). The CCRI included two components: positive reappraisal coping and relaxation. The positive reappraisal intervention was a series of ten statements, all focused on infertility and its treatment, which encouraged the reader to think more about the positive aspects of their situation and to dwell less on recurrent negative thought patterns. There was one set for the stimulation phase of the ART cycle and one set for the waiting phase. In addition, the packet included instructions on relaxation; for the stimulation phase there were instructions on how to do “mini” relaxations and for the waiting phase, the packet included a guided CD on breath focus, meditation, and autogenic training.

All participants were followed for one year. In the CCRI group, 5.5% discontinued care compared to a 15.2% rate in the RC group. In addition, the CCRI participants engaged in significantly more positive reappraisal coping, an improved quality of life, less anxiety, and positively rated the intervention for ease of use, helpfulness, and the perception of stress reduction. There were no differences in pregnancy rates between the two groups.

Communicating with Patients

Physician/patient communication is a vital aspect of patient care. Many patient satisfaction surveys reveal that patients are highly sensitive to the communication style of their physician and this may impact a patient’s decision on whether or not to initiate or continue with treatment. The ability of the physician to connect with patients is often revealed at the first visit, so connecting with patients at that visit is vital. In one study in Europe, 6% of patients did not return after that first visit[8]. In fact, half the patients dropped out before any treatment was initiated. Research has shown that unempathetic physicians are the most common complaint among infertility patients[9].

Infertility patients have a strong need to be understood and accepted by their physician, a concept called empathy. Empathic communication requires that the physician understand the patient’s point of view and effectively communicate that they understand it, as well as tuning into the emotional state of the patient to establish trust. A physician can tell a patient that their pregnancy test was negative by simply saying, “your pregnancy test was negative,” or a physician can be empathetic and say it in a different way: “I am so sorry to tell you that your pregnancy test was negative. I know this was not the outcome you were hoping for and that this may well feel incredibly disappointing. I am feeling so sad for you. When you are ready, I would love to sit down with you to talk about this cycle, and together see what we can plan for future, hopefully successful, treatment.”

An infertility center in Spain recognized the need to improve their physicians’ abilities in empathetic communication in an effort to keep patients from switching to other infertility clinics[9]. The focus was on the first patient visit: 1281 patients reported on their satisfaction with their physician after that first visit. Thirteen physicians then attended 14 hours of training over two days. The training included sessions on empathy, emotional intelligence, and verbal and nonverbal communication. Exercises included role-playing, active listening, and discovering one’s own personal behavioral style. Two months after the training, 895 new patients reported on their satisfaction with their physician after the first visit. There were statistically significant positive increases on all aspects of physician assessment: information, dynamic, time, interaction, and professionalism. In addition, all the participating physicians were highly receptive to and satisfied with the training experience. Unfortunately, the study did not follow patients, so the impact of the training on patient compliance, emotional distress, and pregnancy rates is unknown.

Patient Retention: Summary and Suggestions for the Future

Individuals and couples who are experiencing infertility report high levels of stress. Many have clinical levels of anxiety and depression. Depression in women precludes them coming in to see an infertility specialist for a first visit and is a major contributor to their decision to not initiate or to terminate treatment. In addition, the psychological burden of treatment is the most common reason given why insured patients drop out of ART. Thus, distress leads to fewer individuals coming to an infertility clinic, proceeding to treatment, and staying in treatment until a viable pregnancy is established.

Research has firmly established that psychological interventions are associated with significant decreases in distress and most studies also show increases in pregnancy rates. Interventions with a CBT or mind/body focus appear to be the most efficacious. In addition, at least one RCT has shown that women who are provided with CBT and relaxation training experience less distress and are less likely to drop out of treatment.

It seems incredibly obvious that providing patients with stress-reducing skills is an obvious solution to the retention issue, yet it is rare for an infertility clinic to provide these opportunities. Yet papers published in 2012 and 2013 carefully outlined what could be easily implemented to reduce the treatment burden[10,11]. These suggestions included:

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  screening patients for distress and referring at risk patients to an MHP prior to treatment

  
  
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  creating educational materials to prepare patients adequately

  
  
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  providing patients with easily accessible psychological counseling and coping interventions

  
  
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  ensuring that the partner is included and involved

  
  
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  simplifying treatment protocols

  
  
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  integrating psychological support into patient daily care

  
  
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  training physicians and staff on communication and interaction skills

  
  
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  promoting shared decision-making

  
  
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  changing/modifying areas that cause distress to patients

  
  
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  supporting/educating patients on changing negative lifestyle habits

  
  
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  creating ways to support patients who experience negative cycles

  
  
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  accepting that, for some patients, treatment termination is their best choice

Research shows that supporting patients to complete their covered IVF cycles would result in far higher cumulative pregnancy rates as well as increases in cycles per year for clinics. Thus, creating initiatives to decrease patient stress would be a win–win. Patients would experience less distress, they would undergo more cycles, they would be more likely to conceive, and clinics would be busier.