a reading report by Marion Delaboudinière and Nathalie Madiot
Cwikel, J., Gidron, Y., & Sheiner, E. (2004). Psychological interactions with infertility among women. European Journal of Obstetrics & Gynecology and Reproductive Biology, 117(2), 126-131.
Summary
I. Introduction
This article was published in 2004 by Cwikel, Gidron and Sheiner on European Journal of Obstetrics & Gynecology and Reproductive Biology. This literature review deals with the interactions between psychosocial and biological aspects of infertility, in a course of Medically Assisted Procreation (MAP). The target audience is medical teams who take care of infertil couples in order to achieve a viable pregnancy.
The text is clearly organized in three parts. The first one tries to examine the psychological factors as predictor or consequence of infertility, and it concludes that there is a reciprocal relation between psychological distress and infertility. The second part points out that psychological interventions during a MAP pathway can reduce stress, anxiety and depression for women and infertile couples. However, these interventions do not have a statistically significant impact on the probability of achieving a viable pregnancy. The third part investigates the field of psychoneuroimmunology that attempts to make the link between physical and mental health in the context of infertility, which requires further research.
II. Psychological aspects
II.1. Psychological factors as predictors of infertility
Infertile couples who embark on a procreation process go through many psychological upheavals. In this literature review, the authors first question the predictive power of psychological factors on these couples’ infertility. They present the following results: Lapane et al. (1995) found that women with a history of depression reported later infertility issues, however, the authors indicate that those results are not statistically significant. Storelu & al. (1993) found, in a sample of people in demand of infertility treatment, that women with positive expectations about motherhood, and men who combined a desire to have a child with sexual activity, were more likely to see their wish come true. Some other studies mentioned contradictory results. On one hand, according to Vartiainen et al. (1994) low scores of psychosomatic symptoms, few negative life events, having no phobic traits, …, predicted high fertility rates for women without infertility history. On another hand, no relation was found between measures of stress-hormones (adrenaline, noradrenaline, and cortisol) and conception in the case of assisted procreation program (Sanders & Bruce, 1999), or between job-strain and pregnancy for Danish women (Hjollund et al., 1998). This last factor was predictive of unsuccessful pregnancy, only in the case of idiopathic infertility. Another research team (Facchinetti et al., 1997) suggested that a strong physiological response to stress could impair fertility. Thus, job-strain, distress and psychosomatic symptoms could predict infertility.
II.2. Psychological consequences of infertility
Infertility and fertility treatments have many psychological consequences, especially for women. Oddens, den Tonkelaar et Nieuwenhuyse (1999) compared women awaiting In Vitro Fertilization (IVF) treatment with a control group. Women awaiting IVF treatment had higher levels of depressive symptoms and unfavourable scores on self-assessed attractiveness, anxiety, memory and concentration. Studies have sought to understand the relationship between the duration of infertility and the level of depression (Domar, Broome, Zuttenmeister, Seibel & Friedman, 1992 ; Lok et al., 2002). They did not obtain similar results, however the three studies cited above showed a higher level of depression in women awaiting IVF treatment than in the control groups. This level of depression would have been as high as in women with serious or chronic pathologies such as cancer, HIV or CHD (Domar, Zuttermeister & Friedman, 1993). Men could also report distress over infertility.
For all these reasons, Hjelmstedt et al. (2003) recommended emotional support in early pregnancy and Schmidt et al. (2003) advocated access to psychological services for infertile couples.
II.3. Reciprocal relations between psychological distress and infertility
In this paragraph, the literature review concerns studies carried out on patients who have undergone IVF treatment. The first study, by Thiering et al. (1993), highlighted an increase in depressive symptoms as IVF tentatives are carried out. To the authors, depressive symptoms are a sign of the psychological strain of infertility. In addition, women in the sample with depressive symptoms on the first attempt were less likely to carry their pregnancy to term, compared to the women in the control group. Newton et al. (1999) showed similar results: predisposition to anxiety, pre-IVF depressive symptoms, and nulliparity were predictive factors of adverse psychological reactions to IVF failure. Sheiner et al. (2002, 2003) investigated the link between occupational stress and infertility in both women and men.
The results of these studies suggested that the link between infertility and psychological factors exists and is reciprocal.
III. Effects of psychological interventions on fertility-outcomes
Several studies have attempted to observe the impact of cognitive-behavioural therapies on psychological distress and on the outcome of a viable pregnancy in infertile women or couples (Domar, Seibel & Benson, 1990 ; Tuschen-Caffier, Florin, Krause & Pook, 1999 ; Domar et al., 2000 ; Hosaka, Matsubayashi, Sugiyama, Izumi & Makino, 2002). The results showed that the interventions had beneficial effects on psychological distress, however the impact on infertility was not demonstrated. In addition, some of these studies had recruitment or statistical processing biases.
Nevertheless, the authors agreed on the usefulness of treatment for infertile subjects, in conjunction with medical treatment, in order to reduce the psychological distress caused by infertility.
IV. Neuro-immuno-endocrinological pathways linking psychological factors with infertility
In the scientific literature, in the field of neurobiology, the authors underlined the potential effects of different biological factors on the psychological aspects of infertility. Firstly, they pointed that chronic stress leaded to cortisol secretion via the hypothalamo-pituitary-adrenal (HPA) axis. Cortisol had an inhibitory action on the hypothalamo-pituitary-gonadal (HPG) axis. This resulted in a decrease in the secretion of the sex hormones responsible for gametes’ production. It also had a negative impact on sexual behaviour, thus reducing fertility. Furthermore, coping with infertility could be considered as a lasting stress. In this case, the effects of cortisol on the HPG axis in turn activated the neuroendocrine response to stress conducted on the HPA axis. The two neuroendocrinological pathways mediated the effects of psychological factors (like chronic stress) on the reproductive system in a reciprocal manner. A synthesis of these interactions is shown in Figure1. We note that while the Sympathetic-Adrenal-Medullary axis was described in the article, no research finding referring to it was mentioned by the authors.
Figure 1. Interactions between neuroendocrinological pathways and psychological factors.
In addition, the authors illustrated them with the results of two studies (Csemiczky et al., 2000; Demyttenaere et al., 1992) on the link between cortisol level and IVF treatment outcomes. They concluded that it was the stress-induced cortisol-reactivity (measured just before undergoing oocyte retrieval and embryo transfer) that was important for predicting fertility outcomes, versus resting cortisol.
Secondly, according to the authors, oxytocin also had effects on fertility. This other hypothalamic-pituitary hormone, whose levels increased after positive mood and also physical contacts, like massages, promoted the progression of sperm in the female genital tract (Wildt et al., 1998). Cwikel et al. suggest to experiment the effectiveness of massages between partners on both stress reduction and oxytocin increase, in order to increase fertility.
Lastly, the authors question the effects of the immune system on fertility. On the one hand, TNF (Tumor Necrosis Factor) might induce apoptosis in ovarian cells (Morrison and Marcinkiewicz, 2002) and its serum concentration increased with stress and anxiety (Maes et al., 1998; Matthews et al., 1995). Therefore, Cwikel et al. recommend investigating effects of stress-induced ovarian apoptosis on fertility. On the other hand, stress and anxiety also increased the serological rate of NK activity (Natural Killer cell, a specific lymphocyte). High levels of NK were found in cases of miscarriage and feminine idiopathic infertility. Furthermore, in therapeutic treatment aimed at reducing stress for women with idiopathic infertility, a link was found between pregnancy and NK activity reduction (Hosaka et al., 2002).
Cwikel et al., through this review of literature, enable us to observe the powerful interactions between stress, hormonal mechanisms related to fertility, and fertility outcomes.
V. Conclusion
In conclusion, Cwikel et al. suggest that screening for markers of psychological and physiological stress should be included in future clinical trials about women infertility. This would increase the strength of such research, and make it possible to learn how to modify these psychological and physiological parameters through therapeutic interventions such as those mentioned in this literature review: according to the authors, the chances of a successful pregnancy would be increased by treatments combining psychological and physiological measures with biofeedback techniques and cognitive-behavioural therapies.
Critical evaluation
We have encountered difficulties in summarising this article, due to the unequal treatment of the studies by the authors and a lack of precision in the transmission of the results which weakens their purpose. This has made the understanding of this article sometimes confusing. For example, the interactions between psychology and biology in infertility requires precise knowledge of neurobiology, endocrinology and immunology. Not being specialised in physiology slows down the reading of this article. We would have appreciated some definitions in footnotes.
Despite this, we find it interesting to propose a multidisciplinary approach for the care of women entering a MAP programme. It is indeed certainly essential to take care of both body and mind in a pregnancy project, by proposing a global assistance.
Words we have learned
a burden : une charge, un fardeau
a miscarriage : une fausse couche
a cognitive weariness : la fatigue cognitive
an occupational stress: le stress professionnel
a pathway: une voie, un parcours
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