Emotional and Psychosocial Risk Associated with Fertility Treatment



Fig. 5.1
Classifications of the severity of consequences of infertility on individuals depending upon social contexts (Adapted from WHO (2002))





  • lead to physical violence, abusive emotional or verbal behaviour, intimidation resulting in fear, familial or community physical or emotional violence, and sexual abuse (including refusal of sex or rape) by the husband toward the wife.


  • result in further economic deprivation through loss of income due to loss of child labour, loss of a job as a result of social alienation, inability to operate a familial business or farm.


  • affect social avoidance, disrespectful and humiliating social treatment, social assumption that the couple or the woman only afflicted with infertility is evil or cursed, overall denigration of social status and quality of lifestyle.


In developed countries, infertility is also described as an agonising experience, publicly stigmatised and subject to bio power—the developed world’s equivalent cultural tradition [11]. Bio power refers to the practice of paternalistic political systems to regulate and control populations using the power of modern medical techniques, including public health regulation. Although the context is different from the complex harsh and devastating consequences reported in developing countries, bio power impacts upon the quality of life of those affected with similar devastation, depending on the individuals’ educational, socioeconomic, and regional status.



Economic and Demographic Factors Affecting Infertility Treatment


Where infertility treatments are available, scientific, technological, and medical options vary greatly. The widely advertised treatment developments have fuelled people’s desires to use them. These desires, coupled with perceptions of “rights” to treatment, have led to increasing demand in developed and developing countries [12]. Most treatments involve social and economic costs and require life changes for people who become patients. Changes in psychological adjustment to new types of parenthood are also required. These changes are not usually anticipated. The treatment process—regular monitoring of functions, use of medication potentially inhibiting daily tasks and affecting mood, and oocyte and sperm retrieval processes—can become intrusive and uncomfortable [13]. The psychosocial risks and consequences associated with treatment for infertility can be substantial and require taking responsibility within a Prevention, Outcomes, Consequences (POC) model [14] for the ethical, social, and political consequences of treatment. Since treatment takes place at one point in time, and consideration of the moral rights and wrongs of the consequences of some treatments takes place at another, usually much later on, there may be a discontinuity between the initial treatment and the future consequences of these treatments which needs to be addressed.


Policy and Practices

Legislation, codes of practice, and other forms of bio power determining who may or may not access fertility treatment can be discriminatory. For example, Australia restricts infertility treatment through legislation which does not always accord with the Commonwealth Sex Discrimination Act [15]. There are many ways of discrimination despite the fact that all individuals have rights to autonomy. If, for example, an individual poses a risk to public or private health, or treatment involves a scarce resource which they cannot afford, then they may not receive the treatment despite their human rights. For as long as infertility treatment has been available, there have been socioeconomic gradients of its use [16]. Those with money pay for it, while those without lose out, unless treatment is funded. In the United States, white, middle class, heterosexual couples are twice as likely as Hispanic and four times more likely than black women to have used infertility treatment [17]. The consequences of selective discrimination in treatment should not be condoned. The risks associated with ability to pay in third-party reproduction are even greater.


Employment Factors

Treatment factors may affect other aspects of quality of life. The effects of time off from work to attend clinic appointments is not always addressed in policy. The U.K. for example, does not have specific work policies for infertility treatment, although it does have excellent maternity, paternity, adoption, and—recently—surrogacy leave entitlements. Needing time off work to conceive via a clinic is not catered to. Differences in treatment protocols which could affect mood are not always described or acknowledged [7] and may result in additional requests for time off from work. The problem for employed infertility patients is compounded by several facts disadvantaging them even more. Unlike sick leave requests, time off from employment for treatment means disclosing this very private set of circumstances. Not disclosing it means using alternative routes such as taking sick leave, unpaid leave, or annual leave. The risks of unexplained leave requests may affect future career progression prospects, and these issues are heavily under-investigated [18]. Job insecurity or employment promotion and progression doubts will weigh heavily on those spending up to £15,000 for approximately three cycles of IVF (in the U.K.). Their future employment and depleting finances are stressful, particularly since only about 1 in 3 will succeed and only 1 in 10 will if they are over 40 years of age.


Psychosocial Factors

Support to those coping with infertility is a necessity. This is important because the treatment, coping with genetic or gestational distance in the baby, never succeeding in achieving a pregnancy, miscarrying, or bringing a pregnancy to a healthy conclusion are psychologically and socially difficult. For those using IVF for pre-implantation genetic diagnosis (PGD) to conceive a genetically matched sibling, the risk of stress is likely to be even greater. Figure 5.2 illustrates the possible psychosocial complexities of the infertility trajectory on the individual. These private identity factors, individual burdens, and stressors are also experienced publicly. Contact with health care professionals, employers, social networks, and family about failure to conceive turns this private experience into a public event.

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Fig. 5.2
Psychological risk factors associated with each stage of the infertility journey



Psychological Risks of Infertility Treatment


Sophisticated treatment techniques carry a risk of uncertain long-term physical, genetic, and cognitive/mental health effects on the resultant children. Treatment with donated gametes or surrogate mothers, compromise the genetic or gestational link to the offspring [19, 20]. Similarly, conventional IVF treatment and intracytoplasmic sperm injection (ICSI) are based on ovarian stimulation regimes using gonadotropin releasing hormone (GnRH) agonists. Apart from the possible risk of developing ovarian hyper-stimulation syndrome (OHSS) which can even be fatal [21], treatment with GnRH agonists is also thought to cause unpleasant side effects and stress [22]. Specific psychological distress such as anxiety and depression [23] during pituitary down-regulation following conventional IVF treatment has also been reported [24]. Stress or elevated anxiety in pregnancy has in turn been associated with adverse perinatal outcomes [25].


Effects of Uncertainties


For those persevering with treatment, some stages of the treatment journey are associated with the experience of elevated stress. Following an infertility diagnosis, commencing the IVF treatment poses a new stressor [7], and the unpredictability of its success or failure constitutes another stressor [26]. Certain segments of the IVF cycle, such as oocyte retrieval and waiting for the pregnancy test, are reported as more stressful than other stages of the treatment cycle [27, 28]. Other researchers reported that depression correlates with adrenaline concentrations pre treatment and before embryo transfer (ET) [29]. They also found lower levels of adrenaline at oocyte retrieval and ET, and lower nor-adrenaline at ET in women with a successful outcome compared to an unsuccessful outcome, showing further risks associated with treatment processes. The outcomes of many of these techniques and treatments themselves are unpredictable and pose additional psychological risks to the mental health of those undergoing them.


Individual Differences

There is some evidence showing specific subgroups of individuals may be more vulnerable to psychological distress than others during treatment. Women are reported to be more at risk of psychological distress than men [30], and younger men and women are more distressed than older couples [6]. It is further reported that individuals having irrational parenthood perceptions had a lower quality of life, showing a need for psychological interventions. The significance of a number of other risk factors such as coping, social support, and personality characteristics which are known to influence emotional responses has also been investigated [7]. Some studies did not find an effect for coping on psychological distress [31], whereas others did [32, 33]. Infertility-specific variables may therefore be less predictive of psychological distress than coping strategies [34], suggesting psychological risk factors need attention alongside future treatments.


Treatment Stress and Outcome Failure

Treatment stress can, however, contribute to treatment failure [35], although a recent prospective study reported no relationship [36]. One systematic review concluded that the literature—which suffers from methodological problems—does overall support a relationship between psychological distress and assisted conception outcomes [37]. A recent updated systematic review and meta-analysis found that depression and anxiety do not contribute to IVF success or failure [38]. A better understanding of factors contributing to psychological distress is necessary to enhance targeted counselling during treatment.


Dropout

There is some evidence showing that emotional stress mediates dropout from treatment [39]. Dropout rates are known to be affected by the type of ovarian stimulation regimes used, which can impact upon stress and emotions [40]. The burden (intensity) of the treatment strategy is an additional reason for dropout rates [41]. In one study 7.7 % of patients dropped out of one to three cycles of a mild treatment protocol versus 10 % who dropped out following conventional stimulation cycles. ET failure and severe male sub-fertility also contributed to dropping out. Refusal to continue to treat patients with a poor prognosis or the patients’ inability to pay for further treatments are additional reasons for treatment discontinuation as reported in some [37], but not all, studies [42].


Support

Support for the emotional welfare of people with infertility is important and should form part of the treatment process. Research has shown positive effects of a first cycle of treatment on the marital relationship [43] and negative effects on the marital relationship after 3 years and three cycles of treatment [5, 44], although not all studies confirm this [45]. Other studies report improved relationships [46], or no change after treatment failure [47]. Because stigma can be attached to infertility, support outside the marital relationship is not always sought or offered. Support from online forums is commonly used by people wanting to share information and support for medical conditions [48], including infertility [49]. A recent poll conducted by Infertility Network U.K. in 2013 reported 91 % of infertile people surveyed reported depression. More specifically, the symptoms reported were similar to those reported in their earlier survey as shown in Fig. 5.3.

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Fig. 5.3
Symptoms reported in a survey of INUK members

Not all treatment centres make counselling or online support freely available, despite its known benefits. Counselling pre treatment, as well as during and after treatment, is recommended in the U.K. by the British Infertility Counselling Association, Infertility Network U.K., and the Human Fertilization and Embryology Authority.


Risks Associated with Third-Party Reproduction


Historically, most donor-conceived children/adults have not been aware they were conceived with the use of donor sperm, depriving them of their right to accurate genetic information about their origins [19]. Oocyte and embryo donation requires medical and technological intervention and is therefore more invasive and more expensive than sperm donation. It also poses physical and psychological risks to the donors [50]. Recipients of donated gametes or embryos need to come to terms with the genetic difference with the child, with the constant reminder of their infertility, and with the fact that the child may wish to find his or her donor (see Fig. 5.4).

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Fig. 5.4
Psychological and social risks associated with third party reproduction

The psychosocial concerns of gamete and embryo donation have become more complex with the open market in the recruitment of donors and sale of gametes and embryos. Donor-conceived offspring now face the fact that payment was involved in their conception, their (maternal) donor risked her health to sell her gametes, and is likely to have been less well-off financially than the parents who brought them up. Legislation and codes of practice can be protective. The European Parliament’s Resolution on the Trade of Human Egg Cells (the European Resolution) 2005 responded to countries wanting to buy oocytes from abroad, that payment for oocytes should be prohibited because the harvesting of oocytes constitutes a high medical risk for the health of donors, the planned oocyte trade would exploit the economic situation of women who lived in impoverished regions and, despite the possibility of serious effects on women’s health, a high price paid for oocytes incites and encourages donation, given the relative poverty of the donors.

There are also concerns about the motivations of donors, the consequences of the realisation that the donor will not be able to protect partly genetically related child(ren), and that they may regret their decisions to donate some years into their own future [51]. Similarly, supernumerary embryos which are left over cannot remain stored forever and therefore need to be used or destroyed, which can have psychological effects on the couples who see an embryo as a baby [52].


Surrogate Motherhood


Surrogate motherhood works well for individuals unable to carry a pregnancy to term, if regulated and controlled [53]. The international brokering of fertility treatment, gamete donation, and surrogacy is increasingly openly marketed in much the same way as package holidays abroad are offered. Shopping around for international health care or health enhancement through medically assisted reproduction in countries where these services are offered cheaper and without waiting lists, has become a booming industry. The ethics of international baby buying cannot be in the interests of any child conceived for the sole purpose of meeting the specifications of the commissioning parent(s) at a negotiated price.

Similar welfare concerns exist for surrogates. Websites list items included and excluded from standard packages in international surrogacy arrangements. Caesarean sections, gender selection, and “premium” egg donors can be added to the package at additional cost. Elective caesarean sections pose an additional risk to the health of the surrogate mother and should not be available as an option of choice for the intending parent(s). Gender selection for commissioning individuals without gender-linked genetic disorders, and differentiating between premium and non-premium donors crosses ethical boundaries which are hard to justify.


Legal and Regulatory Issues


Commercial surrogacy and compensation to surrogates is illegal in many countries—although it is possible to use overseas financially motivated arrangements. Australian citizenship application statistics, which are logged on behalf of minors, have increased over recent years: with Indian surrogacy applications increasing by 24 % and Thai applications by 64 % since 2008. In the U.K. it has proved impossible to accurately predict the number of Parental Order reports made for surrogate babies born overseas [54].

Commercial surrogacy is seen under some laws to equate to the sale of children. The United Nations Convention on the Rights of the Child (CRC) does not condone any type of transaction of a child to another person for remuneration, whatever that may be. The fact that it involves a transaction is of concern and this is prohibited because it commodifies children. Although in the majority of surrogate motherhood cases the people who enter the surrogacy agreement will love and care for the child, in some cases they do not. It has opened up a previously untapped route to obtain children for trafficking and exploitation. This risk is now known to be a real risk. Australia, which has seen true cases of exploitation following an internationally brokered surrogacy arrangement, has laws that prohibit people from engaging in commercial surrogacy domestically and abroad to explicitly prohibit the sale of children, hereby meeting international (UN) legal obligations. The U.K. does not yet safeguard against such exploitation and commodification of children from domestic or international arrangements. A recent study charted the apparent decline in involvement of surrogacy agencies in international arrangements and suggests the potential for exploitation is imminent since scrutiny of arrangements and follow-up are limited. It recommends improvements to data collection and argues the need for a more integrated approach to a review of surrogacy arrangements (including birth and parental order registrations) both nationally and internationally [54] and a coordinated approach to visa entry and naturalisation of surrogate babies commissioned abroad.


Health Risks


There is some concern about the discrepancy between male and female infant births. Abortions for sex selection (for non medical reasons), is illegal in India and in some other countries. However, according to the Centre for Social Research, sex-selective abortions are prolific in fertility treatment of surrogate mothers—with 72 % of commissioning parents in Jamnagar, and 50 % of commissioning parents in Surat agreeing that sex selection was performed during surrogacy through selective foetal reduction. The survey carried out by The Centre for Social Research also reported on the exploitations of Indian surrogate mothers. It lists a number of major concerns, as shown below in Fig. 5.5. Additionally, trafficking, exploitation, and other concerning aspects of international commercial surrogacy are current concerns involving the welfare of the child.

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Fig. 5.5
A list of major known risks of exploitation of surrogates in international surrogate arrangements, and new additional concerns about the welfare of the child


Risky Psychosocial Consequences for Children Conceived after Infertility Treatment


No adverse neuro-developmental or psychological outcomes are reported for children born from third-party assisted conception if maternal factors are considered [55]. Increased congenital malformations and other perinatal morbidity and mortality even in singleton births have been attributed to couple factors rather than specifically to the treatment techniques used. Psychological research reports no differences in attachment and interactions in IVF and control mothers and their infants [56], and shows IVF children to be more regular, habitual, sensitive, and manageable than control children [57]. Numerous other studies using small samples report good short-term relationships between IVF parents and their children [58].

What is less well documented in the research looking at the welfare of children are the intrauterine risks affecting foetal development and contributing to the biological makeup and future health of the resultant children [16]. A parent contributing a genetic or gestational environment in effect contributes their pre-pregnancy makeup as well as the health behaviours of the woman during pregnancy (no stress; a good diet; and the absence of alcohol, smoking, or other drugs). There is ample evidence of the effects of maternal stress [59], smoking [60], and alcohol [61] on the long-term health of the child following spontaneous pregnancies. Any disregard for, or lack of clinical interest in, these factors could potentially place the offspring at risk. Mitigating these risks means acknowledging and considering the maternal and paternal behavioural precursors as part of the treatment process.

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Jun 23, 2017 | Posted by in OBSTETRICS | Comments Off on Emotional and Psychosocial Risk Associated with Fertility Treatment

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