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Stress and Anxiety in Couples Who Conceive via In Vitro Fertilization Compared With Those Who Conceive Spontaneously
RESEARCH
Stress and Anxiety in Couples Who Conceive via In Vitro Fertilization Compared With Those Who Conceive Spontaneously Eleanor L. Stevenson, Morine Cebert, and Susan Silva
Correspondence Eleanor L. Stevenson, PhD, RN, Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710. [email protected]
ABSTRACT Objective: To determine the feasibility of recruitment and explore whether women and their partners who conceive via in vitro fertilization (IVF) experience greater levels of stress and anxiety during pregnancy compared to each other and compared to couples who conceive spontaneously. Design: Longitudinal, descriptive, pilot study. Setting: Recruitment was conducted at three sites in the United States (two fertility clinics and one well-woman clinic).
Keywords anxiety in vitro fertilization infertility pregnancy-related anxiety stress
Participants: Informed consent was obtained from 48 women and their partners (22 IVF couples and 26 spontaneous conception [SC] couples). Methods: During each trimester, participants completed the Perceived Stress Scale, the State–Trait Anxiety Inventory, and the Pregnancy-Related Anxiety Measure to assess their levels of stress and anxiety. We used hierarchical linear mixed-effects models for repeated measures adjusting for woman and partner nesting effects to conduct trajectory analyses to test for group differences in stress and anxiety levels. Results: Recruitment goals were met (31 IVF and 27 SC couples gave informed consent and 22 IVF and 26 SC couples completed questionnaires). We found no significant group main or group by time interaction effects on anxiety and stress. However, pregnant women had significantly higher mean state and pregnancy-related anxiety scores than their male partners. Of interest, the women showed a gradual reduction in state and pregnancy-related anxiety across trimesters, whereas pregnancy-related anxiety of their partners gradually increased. Conclusion: Among our participants, IVF did not increase risk for stress, state anxiety, or pregnancy-related anxiety, which provides reassurance during patient counseling. Although pregnant women overall experienced greater state and pregnancy-related anxiety than men, we found that levels in women decreased closer to birth, which may contribute to successful emotional transition to parenthood. Men’s experiences with anxiety require additional investigation given the recent attention to male postpartum depression.
JOGNN, 48, 635–644; 2019. https://doi.org/10.1016/j.jogn.2019.09.001 Accepted September 2019
Eleanor L. Stevenson, PhD, RN, is an associate professor in the School of Nursing, Duke University, Durham, NC.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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B
ecoming a parent is a significant milestone for most individuals. Despite the desire for a biological child, many heterosexual couples experience challenges with fertility and in building their desired families. Infertility, the inability to conceive after 1 year of unprotected heterosexual intercourse (Zegers-Hochschild et al., 2009), affects as many as 186 million people worldwide or approximately 15% of all couples of reproductive age (Chandra, Copen, & Stephen, 2014). The effectiveness of in vitro fertilization (IVF) to treat
fertility problems continues to increase globally (Stephen, Chandra, & King, 2016; Sunderam et al., 2014). Women who undergo infertility treatment, including IVF, experience increased emotional distress, including stress and anxiety, compared with the general population (Boivin, Griffiths, & Venetis, 2011; Matthiesen, Frederiksen, Ingerslev, & Zachariae, 2011). Stress is a dynamic process in which individuals continually
ª 2019 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Women who undergo in vitro fertilization experience increased stress compared with the general population, but it is unclear if this persists into the resultant pregnancy.
appraise their environments, and anxiety is an emotional response to stress (Lazarus & Folkman, 1984). Women with certain types of infertility experience significantly greater rates of psychological distress than fertile women (Hung et al., 2014), and some older research findings showed that the psychological effect of infertility is similar to other chronic medical conditions such as cancer and hypertension (Domar, Zuttermeister, & Friedman, 1993). It can take months to years of infertility treatment to achieve pregnancy. Researchers found a direct relationship between the time spent on fertility treatment and fertility-related stress (Wu, Elliott, Katz, & Smith, 2013), and women experienced increasing levels of anxiety after each failed cycle of IVF (Mahajan et al., 2010). Women who received treatment often perceived that their psychosocial distress negatively affected the likelihood of becoming pregnant, although evidence about the relationship of stress and fecundability is equivocal (Rooney & Domar, 2018).
experiences of distress during pregnancies achieved via IVF. For example, a history of miscarriage was associated with greater pregnancyrelated anxiety among these women (Stevenson & Silva, 2017), as was being treated unsuccessfully in previous cycles (Stevenson & Sloane, 2017). Less investigated are the experiences of partners, who are primarily men, of psychological distress during infertility treatment. Although men’s anxiety was less than women’s during infertility treatment in two studies (Casu & Gremigni, 2016; El Kissi et al., 2013), other researchers found that men had similar levels of anxiety (Chiaffarino et al., 2011) and infertilityrelated stress (Boivin & Schmidt, 2005) as women. Furthermore, men were more likely to experience increased levels of anxiety when their partners experienced greater levels of anxiety (Chiaffarino et al., 2011). Hjelmstedt et al. (2003) reported that these men had more somatic anxiety and specific anxiety about losing the pregnancy than men whose partners conceived spontaneously. Additionally, men with greater levels of infertility distress were more likely to be anxious about the infant not being healthy than men with lower infertility distress (Hjelmstedt et al., 2003). It is also important to note that much of the research on this topic has been conducted outside of the United States, and it is unclear if there may be cultural variation in certain psychological responses to stress, such as anxiety (Casu & Gremigni, 2016; Chiaffarino et al., 2011; El Kissi et al., 2013; Hjelmstedt et al., 2003).
Susan Silva, PhD, is an associate professor in the School of Nursing, Duke University, Durham, NC.
Despite the strong evidence that infertility is a distressing experience for couples, it is unclear whether stress and anxiety continue in pregnancies that result from treatment. Much of what we understand about the experience of pregnancy after infertility treatment is found in less contemporary published work. Early qualitative researchers found that women who conceived via IVF perceived their pregnancies differently and viewed them as hard-won and special (Sandelowski, Harris, & Black, 1992). Other earlier findings indicated that women who were pregnant after IVF had similar levels of anxiety between 12 and 28 weeks gestation as women who conceived naturally (Klock & Greenfeld, 2000) and that women who conceived after IVF did not experience severe fear of childbirth or pregnancy-related anxiety (Poikkeus et al., 2006). Alternatively, other early researchers found that women who became pregnant after IVF had greater levels of pregnancy-related anxiety than those who became pregnant spontaneously (Hjelmstedt, Widstrom, Wramsby, Matthiesen, & Collins, 2003). More recent research results indicate that certain variables influence women’s
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JOGNN, 48, 635–644; 2019. https://doi.org/10.1016/j.jogn.2019.09.001
Morine Cebert, MSN, FNPC, is a doctoral student in the School of Nursing, Duke University, Durham, NC.
Recognition of and response to stress and anxiety in couples who conceive via IVF are important for several reasons. Women who conceived after IVF were at increased risk of preterm birth (Helmerhorst, Perquin, Donker, & Keirse, 2004; Nkansah-Amankra, Luchok, Hussey, Watkins, & Liu, 2010), and increased anxiety increased the risk of low birth weight (Copper et al., 1996). It is unclear if stress plays a role in the increased risk of preterm birth in women who become pregnant via IVF. Furthermore, increases in psychological stress are associated with more marital conflict (Timmons, Arbel, & Margolin, 2017), which affects family functioning. This can negatively affect the long-term psychological outcomes of children (Rothenberg, Solis, Hussong, & Chassin, 2017). It is essential to better understand whether women and their partners who conceive pregnancies via IVF are at increased risk of stress and anxiety.
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Stevenson, E. L., Cebert, M., and Silva, S.
Therefore, the aims of this pilot study were to meet recruitment goals and explore whether women and their partners who conceived via IVF experience greater levels of stress and anxiety during pregnancy compared with each other and compared with couples who conceived spontaneously.
Theoretical Framework Currently, leading stress researchers conceptualize stress as a multidimensional construct that consists of various types of stress and anxiety to allow a more complete understanding of the phenomena. The theoretical framework that supports this approach is based on the works of Lazarus and Folkman and Lobel and colleagues. Lazarus and Folkman (Folkman & Lazarus, 1988; Lazarus, 1966; Lazarus & Folkman, 1984, 1987) viewed stress as a dynamic process in which individuals continually appraise their environments, and emotional responses such as anxiety are the final outcome. In the linear sequence of Lazarus and Folkman’s framework, situations such as negative life events occur to individuals in their environments. The individual appraises these situations, and the result is an emotional response such as anxiety. The degree to which an individual appraises a specific stressor influences how she or he copes with that stressor and is based on personal and contextual factors. Coping with stress is a specific part of the process of cognitive appraisal, which is influenced by whether personal resources exist with which to respond or change in the setting of a stressor (Folkman & Lazarus, 1988; Lazarus, 1966; Lazarus & Folkman, 1984, 1987). Lobel and colleagues (Lobel, 1994; Lobel & Dunkel-Schetter, 1990; Lobel, Dunkel-Schetter, & Scrimshaw, 1992) built on the work of Lazarus and Folkman. Instead of a linear model, they proposed three components of the overall stress construct that require simultaneous measurement. The stimulus/ environmental component refers to life events, the perceptual component refers to personal appraisal, and the emotional response component refers to emotions. Currently, there is no single measure with which to account for the multiple dimensions of stress; therefore, it is important to consider measuring various types of stress to understand this complex phenomenon.
Methods Design and Setting In this pilot study, we sought to determine the feasibility of a prospective cohort study to explore stress and anxiety during pregnancy in women and
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their male partners after conception via IVF compared with women and their male partners who conceived spontaneously. Our goal was to recruit pregnant women and their partners into two groups: those who conceived via IVF and those who conceived via spontaneous conception (SC). Our target was to recruit 25 to 30 couples into each group and follow them throughout pregnancy. We collected data at three time points: between 7 and 12 weeks gestation (T1), between 14 and 20 weeks gestation (T2), and between 26 and 36 weeks gestation (T3). Women and their partners were recruited from three Northeast and Southeast clinics in the United States (two fertility clinics and one wellwoman clinic). Our study was approved by the Duke Health Institutional Review Board, and we obtained informed consent from all study participants.
Participants The inclusion criteria for women in the IVF group were as follows: 25 to 40 years of age, nulliparous or multiparous, single or twin gestation, and the ability to read and write English. Women were excluded if they experienced a selective reduction of multiple pregnancies or their pregnancies were deemed medically or obstetrically high risk. For both groups, partners cohabited with the women and intended to assume parental roles after birth. Although male or female partners could have been included in this study, all partners who participated were men. The inclusion criteria for the women in the SC group were identical to the IVF group except that they could be between the ages of 28 and 40 years. The older age range for participants in the SC group was to balance the ages between groups given that women who seek IVF tend to be older than the general population of pregnant women.
Measures We designed the participant information sheet to capture information on age, marital status, educational level, household income, race/ ethnicity, parity, and number of previous miscarriages. For participants in the IVF group, we also asked the length of infertility and the number of previous IVF cycles. All participants completed the information sheet at T1 only. For the variables of interest (stress and anxiety), we used three instruments commonly used during pregnancy to measure two components of stress: perceptual and emotional response. We used the Perceived Stress Scale (PSS; Cohen, Kamarack, & Mermelstein, 1983) to measure the perceptual component and the State–Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) and the Pregnancy-Related
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Anxiety Measure (PRAM; Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999) to measure the emotional response component. We administered the instruments at the three time points to participants in both groups. PSS. The PSS is the most widely used psychological instrument to measure the perception of stress (Cohen et al., 1983), the first component in the Lobel et al. model. The PSS is a 14-item selfreport questionnaire that is used to measure the degree to which an individual appraises situations in life as stressful. Items are designed to indicate how predictable, uncontrollable, and overloaded the individual feels. The scale also includes direct queries about current levels of stress experienced during the past month (Lobel et al., 2008). Total scores on the PSS can range from 0 to 40, and a higher score indicates a greater level of perceived stress. The PSS has been used in women during pregnancy with good evidence of internal consistency reliability at 18 to 20 weeks (Cronbach’s alpha ¼ 0.88) and 32 to 34 weeks gestation (Cronbach’s alpha ¼ 0.88; Bann et al., 2017). Cronbach’s alpha coefficients for PSS T1 data in our study were good for women (0.92) and men (0.93). STAI. The STAI, a self-administered questionnaire used to measure state and trait anxiety, has been used extensively in research and clinical practice (Spielberger et al., 1983). We measured state anxiety with only the use of the state anxiety subscale (S-Anxiety scale [STAI Form Y-1]), which consists of 20 statements to evaluate how the individual feels “right now, at this moment” (Spielberger et al., 1983). Total state anxiety scores range from 20 to 80, and a higher score indicates a greater level of state anxiety. Spielberger et al. (1983) reported an average score of 36 among a nonclinical sample of women. The STAI has been used with women during pregnancy (Bann et al., 2017) with good estimates of internal consistency reliability (Cronbach’s a ¼ 0.86). In our study, Cronbach’s alpha coefficients for STAI T1 data were 0.97 for women and men. PRAM. The PRAM is used to assess maternal fears and anxiety related to the health of the fetus; the labor and birth process; and confidence in the obstetrician, birth attendant, and other health care providers (Rini et al., 1999). We used the revised 10-item version to evaluate the extent to which women worried or felt concerned about their health, the health of the fetus, labor and birth, and caring for the infant. This tool was also completed by male partners, and language was
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modified to reflect the partner’s pregnancy (i.e., change from “I am confident of having a normal childbirth” to “I am confident my partner will have a normal childbirth”). PRAM total scores can range from 10 to 40, and a higher score indicates a greater level of pregnancy-related anxiety (Rini et al., 1999). A Cronbach’s alpha coefficient of 0.78 was reported for the PRAM (Rini et al., 1999). Cronbach’s alpha coefficients for our PRAM T1 data were 0.85 for women and 0.84 for men.
Procedures Participants were recruited from two settings. The couples in the IVF group were recruited from a large infertility clinic in the Northeast of the United States during the discharge visit, which is approximately 8 to 10 weeks gestation. All couples pregnant via IVF were provided a study information/invitation sheet with instructions to contact the research nurse. Once contacted, she explained the study and, if they were interested, met with the couple in person to obtain informed consent. The couples in the SC group were recruited from a women’s clinic immediately after their first prenatal visit, which was approximately 10 to 12 weeks gestation. They were invited in person, and informed consent was obtained. After informed consent, each participant received an e-mail invitation to complete Time 1 study questionnaires (demographic form, PSS, STAI, and PRAM) via REDCap (Harris et al., 2019; Harris et al., 2009). Each participant received two reminders if the questionnaires were not completed. Time 2 and Time 3 questionnaires (PSS, STAI, and PRAM) were sent using the same process.
Data Analysis We used descriptive statistics to detail demographic characteristics and measures of perceived stress, state anxiety, and pregnancyrelated anxiety for women and men during pregnancy for each group (SC and IVF). We performed nondirectional statistical testing with the level of significance set at 0.05 for each test. For this pilot study, the significance level was not adjusted for multiple outcomes because of the small sample sizes for women and their male partners per group (n < 30). Small sample sizes often yield insufficient statistical power (< 80%) to detect differences or associations that may exist. Thus, a conservative approach was applied when testing each outcome to reduce the Type II error rate. Data were analyzed with the use of SAS Version 9.4 statistical software. We compared group differences using nonparametric Wilcoxon two-sample tests and chi-
JOGNN, 48, 635–644; 2019. https://doi.org/10.1016/j.jogn.2019.09.001
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Stevenson, E. L., Cebert, M., and Silva, S.
square/Fisher’s exact tests. We used random coefficient regression models for longitudinal data, a type of hierarchical mixed-effects models for repeated measures, to conduct trajectory analyses to test for conception group differences in stress and anxiety levels across trimesters in the women and their partners. We conducted a separate trajectory analysis on each of the three dependent measures (PSS, STAI, and PRAM). We evaluated the fixed effects of group, trimester, sex, group by trimester, sex by trimester, group by sex, and group by sex by trimester, and the random effects of individuals and individual by time in the final model. We incorporated woman and partner nesting effects as a level 3 predictor variable. The age of the woman and the age of her partner were initially included as covariates but were not retained in the final model because these variables were not statistically significant.
Results Characteristics of Participants We recruited 31 IVF and 27 SC couples who signed consent forms. Nine couples in the IVF group and one couple in the SC group did not complete any study questionnaires; therefore, they were deleted from the sample. The final participant groups included 48 women and their male partners (N ¼ 96 participants) with 22 couples (n ¼ 44 participants) in the IVF group and 26 couples (n ¼ 52 participants) in the SC group. The demographic and clinical characteristics of the participants in the SC and IVF groups (N ¼ 96 individuals, 48 female–male couples) are presented in Table 1. All participants in the SC group had singleton pregnancies, and four participants in the IVF group (16%) had twin pregnancies. Most women in the IVF group (n ¼ 13, 54%) completed one IVF cycle to conceive their current pregnancies.
Stress and Anxiety Analysis The missing rate for stress and anxiety measures assessed during the third trimester was 21% for the SC group and 20% for the IVF group. For each dependent variable, level 1 of the linear random coefficient regression model analysis estimated individual trajectories over the three trimesters for the 96 individuals included in the analysis. The model provided estimated scores at each time point for the 48 women and their male partners. The missing at random assumption of trajectory analysis was met for each of the three dependent variables (PSS, STAI, and PRAM). We calculated the adjusted means at each time point
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Pregnancy-related anxiety is a discrete anxiety type and is associated with adverse pregnancy outcomes such as low birth weight and preterm birth.
from each individual’s estimated scores based on the fixed, random, and nesting effects in the model. The unadjusted and adjusted means (M) and standard deviations (SD) for the participants by group across the trimesters are provided in Table 2. No significant main or interaction effects of group were demonstrated for any of the three dependent variables. Furthermore, other main or interaction effect terms in the model were not statistically significant for the PSS total scores. For the S-Anxiety (STAI) total scores, we found significant sex (F ¼ 8.0, p ¼ .005) and sex by trimester (F ¼ 6.17, p ¼ .014) effects on the adjusted mean anxiety scores regardless of group. When averaged across trimesters, compared with their partners, women had a significantly higher adjusted mean anxiety score (women: M ¼ 36.9, SD ¼ 10.8; men: M ¼ 33.5, SD ¼ 8.2). The interaction effect was caused by the gradual reduction in adjusted mean anxiety across trimesters for women; the anxiety levels of their partners gradually increased over time (see Figure 1). The trajectory results for the pregnancy-related anxiety (PRAM) total scores indicated significant sex (F ¼ 10.56, p ¼ .001), trimester (F ¼ 4.98, p ¼ .027), and sex by trimester (F ¼ 5.10, p ¼ 0.025) effects. When averaged across trimesters, women compared with their male partners had a significantly higher adjusted mean pregnancy-related anxiety score (women: M ¼ 20.3, SD ¼ 4.1; men: M ¼ 18.0, SD ¼ 4.4). When averaged across women and men, a significant gradual reduction in pregnancy-related anxiety across trimesters was observed (Trimester 1: M ¼ 19.7, SD ¼ 4.5; Trimester 2: M ¼ 19.2, SD ¼ 4.4; Trimester 3: M ¼ 18.7, SD ¼ 4.3). The interaction effect indicated that the women had a small but clinically meaningful reduction in pregnancy-related anxiety across trimesters, whereas the anxiety levels of their partners did not change over time (see Figure 1).
Discussion In this pilot study, we sought to determine the feasibility of recruitment of a sample of pregnant women and their partners to explore whether women and their partners who conceive via IVF experience greater levels of stress and anxiety
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Table 1: Sample Characteristics for Women and Their Male Partners by Group (N [ 96) Characteristic
SC: Women (n ¼ 22)
IVF: Women (n ¼ 26)
Age, in years
30.0 (29.0, 32.0)
33.0 (31.0, 36.0)
White
p Value .004
19 (86.4)
26 (100.0)
.089
1 (4.6)
0 (0.0)
.468
Graduate/professional degree
13 (59.1)
15 (57.7)
.922
Annual total household income
11 (50.0)
14 (53.9)
.790
22 (100.0)
22 (84.6)
.114
Hispanic
$125,000 or more Singleton pregnancy IVF cycles for current pregnancy One cycle
14 (53.9)
Two cycles
8 (30.8)
Three to five cycles
4 (15.4)
Age, in years White Hispanic Graduate/professional degree
SC: Male Partners (n ¼ 22)
IVF: Male Partners (n ¼ 26)
p Value
32.5 (30.0, 37.0)
37.0 (34.0, 41.0)
.017
20 (90.9)
26 (100.0)
.205
4 (18.2)
1 (3.9)
.165
12 (54.6)
9 (34.6)
.166
Note. Median (25th, 75th percentile) and Wilcoxon Two-Sample tests for age; n (%) and chi-square/Fisher’s Exact test for categoric measures. IVF ¼ in vitro fertilization; SC ¼ spontaneous conception.
during pregnancy compared with each other and compared with couples who conceive spontaneously. Our team successfully met the recruitment goals for both the IVF and SC groups. There were more people in the IVF group who completed consent but chose not to participate in the study, which may be because the SC group was recruited by the investigator in person at the time of their health care visit. This trend will inform recruitment strategies in future study planning. When we analyzed the data collected for those who participated, we found no significant group main or interaction effects on the anxiety and stress variables. However, pregnant women on average had significantly higher state and pregnancy-related anxiety scores than their partners. In addition, the women showed a gradual reduction in state and pregnancy-related anxiety across trimesters, whereas pregnancy-related anxiety of their partners gradually increased and state anxiety did not change over time.
Women and Their Partners We observed significant group differences between all pregnant women and their male partners. Overall, women in our study had greater levels of state and pregnancy-related anxiety at all three time points than their partners; however, we noted
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a gradual decline in anxiety among women as the pregnancy progressed. Recent evidence suggested that pregnancy-related anxiety is a discrete anxiety type (Brunton, Dryer, Saliba, & Kohlhoff, 2019) and that this type of anxiety is most associated with adverse pregnancy outcomes such as low birth weight and preterm birth (Dunkel Schetter & Tanner, 2012). Early in pregnancy, women most frequently report anxiety about the health of the fetus and about their own well-being (Deklava, Lubina, Circenis, Sudraba, & Millere, 2015). Pregnancy is a time of continual adaptation and transition, and women experience less anxiety as birth approaches. That said, it may be useful to examine the relationship between the fluctuation of anxiety throughout pregnancy and role maladaptation after birth. We also found that men experienced pregnancyrelated anxiety differently than women. Although men had overall lower state and pregnancy-related anxiety levels than women at all three time points, their anxiety levels increased as birth approached. Our findings add to the limited understanding of psychological experiences of men throughout pregnancy, especially in those who conceived via IVF, although our findings must be interpreted with caution given the small sample size. In related
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Stevenson, E. L., Cebert, M., and Silva, S.
Table 2: Descriptive Statistics for Stress and Anxiety Measures (N [ 96)
Measure Trimester
SC
IVF
Adjusted Mean (SD)
Adjusted Mean (SD)
1
2
3
1
2
3
20.3 (6.5)
20.0 (5.8)
19.6 (5.5)
21.1 (7.3)
21.1 (7.1)
21.1 (7.0)
Women
21.9 (7.2)
20.4 (6.5)
19.0 (6.0)
22.3 (8.4)
22.4 (8.0)
22.4 (7.8)
Male partners
18.7 (5.3)
19.5 (5.1)
20.2 (5.1)
19.9 (5.9)
19.8 (5.9)
19.7 (6.0)
33.7 (8.5)
33.3 (7.9)
33.0 (8.0)
37.4 (10.8)
36.8 (10.7)
36.2 (10.6)
Women
36.9 (8.5)
34.1 (8.5)
31.3 (8.5)
40.4 (11.9)
39.4 (11.9)
38.3 (11.9)
Male partners
30.5 (7.3)
32.6 (7.3)
34.8 (7.3)
34.4 (8.9)
34.2 (8.9)
34.1 (8.9)
19.0 (3.8)
18.3 (3.7)
17.7 (3.6)
20.3 (5.0)
19.9 (4.9)
19.5 (4.8)
Women
20.4 (3.1)
19.1 (3.1)
17.8 (3.1)
22.2 (4.5)
21.4 (4.5)
20.6 (4.5)
Male partners
17.6 (4.1)
17.6 (4.1)
17.6 (4.1)
18.3 (4.8)
18.4 (4.8)
18.4 (4.8)
Perceived Stress Scale
State–Trait Anxiety Inventory: S-Anxiety
Pregnancy-Related Anxiety Measure
Trimester Perceived Stress Scale
SC
IVF
Unadjusted Mean (SD)
Unadjusted Mean (SD)
1
2
3
1
2
3
20.4 (8.3)
19.9 (7.0)
20.1 (6.7)
20.9 (8.3)
21.5 (9.4)
20.7 (8.8)
Women
22.1 (9.3)
19.9 (8.4)
19.6 (6.4)
22.2 (9.7)
22.3 (10.2)
22.3 (9.6)
Male partners
18.7 (7.0)
20.0 (5.6)
20.5 (7.2)
19.5 (6.7)
20.6 (8.5)
18.9 (7.6)
34.0 (13.0)
33.1 (10.4)
33.2 (10.3)
36.9 (13.1)
37.9 (15.0)
35.6 (13.6)
Women
37.7 (14.8)
32.5 (11.2)
32.3 (9.3)
39.8 (14.8)
40.4 (16.4)
37.3 (14.6)
Male partners
30.2 (9.6)
33.6 (9.8)
34.1 (11.5)
34.0 (10.8)
35.2 (13.4)
33.7 (12.4)
19.0 (5.0)
18.9 (5.4)
17.6 (4.6)
20.2 (5.8)
20.1 (6.2)
19.2 (6.2)
Women
20.5 (4.7)
18.8 (3.8)
18.0 (4.0)
22.2 (5.1)
21.5 (5.8)
20.4 (6.5)
Male partners
17.3 (5.0)
18.9 (6.8)
17.2 (5.3)
18.2 (5.9)
18.7 (6.4)
18.0 (5.8)
State–Trait Anxiety Inventory: S-Anxiety
Pregnancy-Related Anxiety Measure
Note. SC total sample ¼ 44 (22 women and 22 male partners); IVF total sample ¼ 52 (26 women and 26 male partners). Adjusted mean (standard deviation) total score for each measure derived from fixed and random effects included in the hierarchical linear mixed-effects model. IVF ¼ conception through in vitro fertilization; SC ¼ spontaneous conception; SD ¼ standard deviation.
studies, researchers examined men’s psychological experiences with infertility in singular periods compared with their female partners. Men may experience greater levels of psychological distress during infertility diagnosis (Warchol-Biedermann, 2019), lower levels of anxiety during infertility treatment (Volgsten, Skoog Svanberg, Ekselius, Lundkvist, & Poromaa, 2010), and lower levels of anxiety in the first trimester of pregnancies that result from that treatment (Hjelmstedt et al., 2003) than their female partners. Men’s experiences of anxiety throughout pregnancy have been addressed in the literature. One group of researchers found that men had greater levels of anxiety than women throughout the
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pregnancy (Condon, Boyce, & Corkindale, 2004), and other researchers found that men’s levels of anxiety increased at the time of transition to fatherhood, particularly in first-time parents, compared with their female partners (Da Costa, Zelkowitz, Letourneau, et al., 2017). Additionally, men are at risk for postpartum depression after the birth of their infants (Da Costa, Zelkowitz, Dasgupta, et al., 2017). Attention to psychological changes during men’s early transition to fatherhood and risk for depression after birth is a relatively new area of inquiry that requires longitudinal research designs. Future researchers should examine potential factors that trigger or alleviate men’s psychosocial experiences throughout pregnancy.
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Nurses need to recognize that men have their own specific needs during pregnancy, specifically if they experience increased anxiety.
Women Who Conceive via IVF and Spontaneously Our findings contribute to the growing body of literature on emotional changes throughout pregnancy and the difference between women who conceive via IVF and those who conceive spontaneously. In a recent systematic review of the literature, Gourounti (2016) reported that women who conceive via IVF are more likely to have greater pregnancy-specific anxiety than women who conceive spontaneously. However, Gourounti (2016) found insufficient evidence to determine any differences in general or state anxiety. Evidence pertaining to state anxiety is limited and often conflicting in comparisons of pregnant women who conceived via IVF with those who conceived spontaneously. The authors of a prominent longitudinal study found no significant differences in state anxiety between the two groups of women (Hjelmstedt et al., 2003), but other researchers found that women who conceived via IVF experienced greater levels of stress and anxiety, specifically during the first trimester (Darwiche et al., 2014). Our findings suggest that a history of IVF does not increase the risk of stress and anxiety during the resultant pregnancy.
Limitations
24
40
22
38
20
Male partners
18
Pregnant women
16
14
Adjusted mean STAI S-Anxiety score
Adjusted mean PRAM score
One limitation of this initial pilot study was the small sample size for each group. The observed effect sizes for the outcomes were small, and the study lacked power to test for
Trimester 2
Trimester 3
Implications To deliver family-centered health care, our focus must be the family unit as well as the individual. It is essential that the health care team consider both women’s and men’s experiences throughout pregnancy during antepartum care. Although our findings provide some reassurance that mode of conception may not influence stress and anxiety during pregnancy, additional research with larger,
Male partners
36
Pregnant women
34
32
30
Trimester 1
differences in the effects of conception group on the stress and anxiety variables over trimesters. By the third trimester, approximately 20% of the data was missing in each conception group. Although the IVF and SC groups did not differ in rates of missing data over time for the anxiety and stress measures, future research would benefit from methods to improve the capture of data during all trimesters to ensure unbiased and more precise population estimates. Also, the lack of racial/ ethnic variability in our sample is another limitation. Most of the sample was White, and although most IVF users in the United States are White (Chandra et al., 2014), the lack of heterogeneity of the study sample limited our ability to address potential racial/ethnic differences in stress and anxiety during pregnancy for couples who conceived via IVF. One other limitation was that there were four couples in the IVF group pregnant with twins. Having twins affects the perception of stress and anxiety (Tendais, Figueiredo, Canario, & Kenny, 2018); therefore, there may have been variations in stress and anxiety levels for parents with twin pregnancies not able to be discerned given the small sample size.
Trimester 1
Trimester
Trimester 2
Trimester 3
Trimester
Figure 1. Pregnancy-related and state anxiety in women and their male partners across the trimesters of pregnancy (N ¼ 96). PRAM ¼ Pregnancy-Related Anxiety Measure; STAI ¼ State–Trait Anxiety Inventory.
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more diverse samples is needed to further understand differences in levels and mediating and moderating variables to stress and anxiety during and after pregnancy in both women and men.
assisted reproductive treatment in an Italian infertility department. European Journal of Obstetrics & Gynecology and Reproductive Biology, 158(2), 235–241. https://doi.org/10.1016/ j.ejogrb.2011.04.032 Cohen, S., Kamarack, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health Social Behavior, 24, 385–396.
Conclusions Our findings suggest that women and men who use IVF to achieve pregnancy experience similar levels of stress and anxiety as those who conceive spontaneously, although given the small sample size, our findings should be interpreted with caution. Also, although pregnant women in our study overall experienced more state and pregnancy-related anxiety than men, women seemed to approach birth with lower levels. On the other hand, men experienced increases in state and pregnancy-related anxiety, a finding that is worthy of additional investigation, particularly given the recent attention to men who experience postpartum depression during the transition to new fatherhood. Our pilot study provided data to help understand potential differences in stress and anxiety in women and their partners pregnant via IVF and compared with those who conceived spontaneously.
Condon, J. T., Boyce, P., & Corkindale, C. J. (2004). The First-Time Fathers Study: A prospective study of the mental health and wellbeing of men during the transition to parenthood. Australian and New Zealand Journal of Psychiatry, 38(1-2), 56–64. https:// doi.org/10.1177/000486740403800102 Copper, R. L., Goldenberg, R. L., Das, A., Elder, N., Swain, M., Norman, G., … Meier, A. M. (1996). The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks’ gestation. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. American Journal of Obstetrics and Gynecology, 175(5), 1286–1292. Da Costa, D., Zelkowitz, P., Dasgupta, K., Sewitch, M., Lowensteyn, I., Cruz, R., … Khalife, S. (2017). Dads get sad too: Depressive symptoms and associated factors in expectant first-time fathers. American Journal of Mens Health, 11(5), 1376–1384. https://doi.org/10.1177/1557988315606963 Da Costa, D., Zelkowitz, P., Letourneau, N., Howlett, A., Dennis, C. L., Russell, B., … Khalife, S. (2017). HealthyDads.ca: What do men want in a website designed to promote emotional wellness and healthy behaviors during the transition to parenthood? Journal of Medical Internet Research, 19(10), e325. https://doi.org/10. 2196/jmir.7415 Darwiche, J., Lawrence, C., Vial, Y., Wunder, D., Stiefel, F., Germond,
Acknowledgment Funded by the Office of Research Affairs, Duke University School of Nursing, Durham, NC.
M., … de Roten, Y. (2014). Anxiety and psychological stress before prenatal screening in first-time mothers who conceived through IVF/ICSI or spontaneously. Women and Health, 54(5), 474–485. https://doi.org/10.1080/03630242.2014.897677 Deklava, L., Lubina, K., Circenis, K., Sudraba, V., & Millere, I. (2015). Causes of anxiety during pregnancy. Procedia - Social and Behavioral Sciences, 205, 623–626. https://doi.org/10.1016/j. sbspro.2015.09.097
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Stress and Anxiety in Couples Who Conceive via In Vitro Fertilization Compared With Those Who Conceive Spontaneously Eleanor L. Stevenson, Morine Cebert, and Susan Silva
Correspondence Eleanor L. Stevenson, PhD, RN, Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710. [email protected]
ABSTRACT Objective: To determine the feasibility of recruitment and explore whether women and their partners who conceive via in vitro fertilization (IVF) experience greater levels of stress and anxiety during pregnancy compared to each other and compared to couples who conceive spontaneously. Design: Longitudinal, descriptive, pilot study. Setting: Recruitment was conducted at three sites in the United States (two fertility clinics and one well-woman clinic).
Keywords anxiety in vitro fertilization infertility pregnancy-related anxiety stress
Participants: Informed consent was obtained from 48 women and their partners (22 IVF couples and 26 spontaneous conception [SC] couples). Methods: During each trimester, participants completed the Perceived Stress Scale, the State–Trait Anxiety Inventory, and the Pregnancy-Related Anxiety Measure to assess their levels of stress and anxiety. We used hierarchical linear mixed-effects models for repeated measures adjusting for woman and partner nesting effects to conduct trajectory analyses to test for group differences in stress and anxiety levels. Results: Recruitment goals were met (31 IVF and 27 SC couples gave informed consent and 22 IVF and 26 SC couples completed questionnaires). We found no significant group main or group by time interaction effects on anxiety and stress. However, pregnant women had significantly higher mean state and pregnancy-related anxiety scores than their male partners. Of interest, the women showed a gradual reduction in state and pregnancy-related anxiety across trimesters, whereas pregnancy-related anxiety of their partners gradually increased. Conclusion: Among our participants, IVF did not increase risk for stress, state anxiety, or pregnancy-related anxiety, which provides reassurance during patient counseling. Although pregnant women overall experienced greater state and pregnancy-related anxiety than men, we found that levels in women decreased closer to birth, which may contribute to successful emotional transition to parenthood. Men’s experiences with anxiety require additional investigation given the recent attention to male postpartum depression.
JOGNN, 48, 635–644; 2019. https://doi.org/10.1016/j.jogn.2019.09.001 Accepted September 2019
Eleanor L. Stevenson, PhD, RN, is an associate professor in the School of Nursing, Duke University, Durham, NC.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
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B
ecoming a parent is a significant milestone for most individuals. Despite the desire for a biological child, many heterosexual couples experience challenges with fertility and in building their desired families. Infertility, the inability to conceive after 1 year of unprotected heterosexual intercourse (Zegers-Hochschild et al., 2009), affects as many as 186 million people worldwide or approximately 15% of all couples of reproductive age (Chandra, Copen, & Stephen, 2014). The effectiveness of in vitro fertilization (IVF) to treat
fertility problems continues to increase globally (Stephen, Chandra, & King, 2016; Sunderam et al., 2014). Women who undergo infertility treatment, including IVF, experience increased emotional distress, including stress and anxiety, compared with the general population (Boivin, Griffiths, & Venetis, 2011; Matthiesen, Frederiksen, Ingerslev, & Zachariae, 2011). Stress is a dynamic process in which individuals continually
ª 2019 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
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Women who undergo in vitro fertilization experience increased stress compared with the general population, but it is unclear if this persists into the resultant pregnancy.
appraise their environments, and anxiety is an emotional response to stress (Lazarus & Folkman, 1984). Women with certain types of infertility experience significantly greater rates of psychological distress than fertile women (Hung et al., 2014), and some older research findings showed that the psychological effect of infertility is similar to other chronic medical conditions such as cancer and hypertension (Domar, Zuttermeister, & Friedman, 1993). It can take months to years of infertility treatment to achieve pregnancy. Researchers found a direct relationship between the time spent on fertility treatment and fertility-related stress (Wu, Elliott, Katz, & Smith, 2013), and women experienced increasing levels of anxiety after each failed cycle of IVF (Mahajan et al., 2010). Women who received treatment often perceived that their psychosocial distress negatively affected the likelihood of becoming pregnant, although evidence about the relationship of stress and fecundability is equivocal (Rooney & Domar, 2018).
experiences of distress during pregnancies achieved via IVF. For example, a history of miscarriage was associated with greater pregnancyrelated anxiety among these women (Stevenson & Silva, 2017), as was being treated unsuccessfully in previous cycles (Stevenson & Sloane, 2017). Less investigated are the experiences of partners, who are primarily men, of psychological distress during infertility treatment. Although men’s anxiety was less than women’s during infertility treatment in two studies (Casu & Gremigni, 2016; El Kissi et al., 2013), other researchers found that men had similar levels of anxiety (Chiaffarino et al., 2011) and infertilityrelated stress (Boivin & Schmidt, 2005) as women. Furthermore, men were more likely to experience increased levels of anxiety when their partners experienced greater levels of anxiety (Chiaffarino et al., 2011). Hjelmstedt et al. (2003) reported that these men had more somatic anxiety and specific anxiety about losing the pregnancy than men whose partners conceived spontaneously. Additionally, men with greater levels of infertility distress were more likely to be anxious about the infant not being healthy than men with lower infertility distress (Hjelmstedt et al., 2003). It is also important to note that much of the research on this topic has been conducted outside of the United States, and it is unclear if there may be cultural variation in certain psychological responses to stress, such as anxiety (Casu & Gremigni, 2016; Chiaffarino et al., 2011; El Kissi et al., 2013; Hjelmstedt et al., 2003).
Susan Silva, PhD, is an associate professor in the School of Nursing, Duke University, Durham, NC.
Despite the strong evidence that infertility is a distressing experience for couples, it is unclear whether stress and anxiety continue in pregnancies that result from treatment. Much of what we understand about the experience of pregnancy after infertility treatment is found in less contemporary published work. Early qualitative researchers found that women who conceived via IVF perceived their pregnancies differently and viewed them as hard-won and special (Sandelowski, Harris, & Black, 1992). Other earlier findings indicated that women who were pregnant after IVF had similar levels of anxiety between 12 and 28 weeks gestation as women who conceived naturally (Klock & Greenfeld, 2000) and that women who conceived after IVF did not experience severe fear of childbirth or pregnancy-related anxiety (Poikkeus et al., 2006). Alternatively, other early researchers found that women who became pregnant after IVF had greater levels of pregnancy-related anxiety than those who became pregnant spontaneously (Hjelmstedt, Widstrom, Wramsby, Matthiesen, & Collins, 2003). More recent research results indicate that certain variables influence women’s
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Morine Cebert, MSN, FNPC, is a doctoral student in the School of Nursing, Duke University, Durham, NC.
Recognition of and response to stress and anxiety in couples who conceive via IVF are important for several reasons. Women who conceived after IVF were at increased risk of preterm birth (Helmerhorst, Perquin, Donker, & Keirse, 2004; Nkansah-Amankra, Luchok, Hussey, Watkins, & Liu, 2010), and increased anxiety increased the risk of low birth weight (Copper et al., 1996). It is unclear if stress plays a role in the increased risk of preterm birth in women who become pregnant via IVF. Furthermore, increases in psychological stress are associated with more marital conflict (Timmons, Arbel, & Margolin, 2017), which affects family functioning. This can negatively affect the long-term psychological outcomes of children (Rothenberg, Solis, Hussong, & Chassin, 2017). It is essential to better understand whether women and their partners who conceive pregnancies via IVF are at increased risk of stress and anxiety.
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Stevenson, E. L., Cebert, M., and Silva, S.
Therefore, the aims of this pilot study were to meet recruitment goals and explore whether women and their partners who conceived via IVF experience greater levels of stress and anxiety during pregnancy compared with each other and compared with couples who conceived spontaneously.
Theoretical Framework Currently, leading stress researchers conceptualize stress as a multidimensional construct that consists of various types of stress and anxiety to allow a more complete understanding of the phenomena. The theoretical framework that supports this approach is based on the works of Lazarus and Folkman and Lobel and colleagues. Lazarus and Folkman (Folkman & Lazarus, 1988; Lazarus, 1966; Lazarus & Folkman, 1984, 1987) viewed stress as a dynamic process in which individuals continually appraise their environments, and emotional responses such as anxiety are the final outcome. In the linear sequence of Lazarus and Folkman’s framework, situations such as negative life events occur to individuals in their environments. The individual appraises these situations, and the result is an emotional response such as anxiety. The degree to which an individual appraises a specific stressor influences how she or he copes with that stressor and is based on personal and contextual factors. Coping with stress is a specific part of the process of cognitive appraisal, which is influenced by whether personal resources exist with which to respond or change in the setting of a stressor (Folkman & Lazarus, 1988; Lazarus, 1966; Lazarus & Folkman, 1984, 1987). Lobel and colleagues (Lobel, 1994; Lobel & Dunkel-Schetter, 1990; Lobel, Dunkel-Schetter, & Scrimshaw, 1992) built on the work of Lazarus and Folkman. Instead of a linear model, they proposed three components of the overall stress construct that require simultaneous measurement. The stimulus/ environmental component refers to life events, the perceptual component refers to personal appraisal, and the emotional response component refers to emotions. Currently, there is no single measure with which to account for the multiple dimensions of stress; therefore, it is important to consider measuring various types of stress to understand this complex phenomenon.
Methods Design and Setting In this pilot study, we sought to determine the feasibility of a prospective cohort study to explore stress and anxiety during pregnancy in women and
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their male partners after conception via IVF compared with women and their male partners who conceived spontaneously. Our goal was to recruit pregnant women and their partners into two groups: those who conceived via IVF and those who conceived via spontaneous conception (SC). Our target was to recruit 25 to 30 couples into each group and follow them throughout pregnancy. We collected data at three time points: between 7 and 12 weeks gestation (T1), between 14 and 20 weeks gestation (T2), and between 26 and 36 weeks gestation (T3). Women and their partners were recruited from three Northeast and Southeast clinics in the United States (two fertility clinics and one wellwoman clinic). Our study was approved by the Duke Health Institutional Review Board, and we obtained informed consent from all study participants.
Participants The inclusion criteria for women in the IVF group were as follows: 25 to 40 years of age, nulliparous or multiparous, single or twin gestation, and the ability to read and write English. Women were excluded if they experienced a selective reduction of multiple pregnancies or their pregnancies were deemed medically or obstetrically high risk. For both groups, partners cohabited with the women and intended to assume parental roles after birth. Although male or female partners could have been included in this study, all partners who participated were men. The inclusion criteria for the women in the SC group were identical to the IVF group except that they could be between the ages of 28 and 40 years. The older age range for participants in the SC group was to balance the ages between groups given that women who seek IVF tend to be older than the general population of pregnant women.
Measures We designed the participant information sheet to capture information on age, marital status, educational level, household income, race/ ethnicity, parity, and number of previous miscarriages. For participants in the IVF group, we also asked the length of infertility and the number of previous IVF cycles. All participants completed the information sheet at T1 only. For the variables of interest (stress and anxiety), we used three instruments commonly used during pregnancy to measure two components of stress: perceptual and emotional response. We used the Perceived Stress Scale (PSS; Cohen, Kamarack, & Mermelstein, 1983) to measure the perceptual component and the State–Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) and the Pregnancy-Related
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Anxiety Measure (PRAM; Rini, Dunkel-Schetter, Wadhwa, & Sandman, 1999) to measure the emotional response component. We administered the instruments at the three time points to participants in both groups. PSS. The PSS is the most widely used psychological instrument to measure the perception of stress (Cohen et al., 1983), the first component in the Lobel et al. model. The PSS is a 14-item selfreport questionnaire that is used to measure the degree to which an individual appraises situations in life as stressful. Items are designed to indicate how predictable, uncontrollable, and overloaded the individual feels. The scale also includes direct queries about current levels of stress experienced during the past month (Lobel et al., 2008). Total scores on the PSS can range from 0 to 40, and a higher score indicates a greater level of perceived stress. The PSS has been used in women during pregnancy with good evidence of internal consistency reliability at 18 to 20 weeks (Cronbach’s alpha ¼ 0.88) and 32 to 34 weeks gestation (Cronbach’s alpha ¼ 0.88; Bann et al., 2017). Cronbach’s alpha coefficients for PSS T1 data in our study were good for women (0.92) and men (0.93). STAI. The STAI, a self-administered questionnaire used to measure state and trait anxiety, has been used extensively in research and clinical practice (Spielberger et al., 1983). We measured state anxiety with only the use of the state anxiety subscale (S-Anxiety scale [STAI Form Y-1]), which consists of 20 statements to evaluate how the individual feels “right now, at this moment” (Spielberger et al., 1983). Total state anxiety scores range from 20 to 80, and a higher score indicates a greater level of state anxiety. Spielberger et al. (1983) reported an average score of 36 among a nonclinical sample of women. The STAI has been used with women during pregnancy (Bann et al., 2017) with good estimates of internal consistency reliability (Cronbach’s a ¼ 0.86). In our study, Cronbach’s alpha coefficients for STAI T1 data were 0.97 for women and men. PRAM. The PRAM is used to assess maternal fears and anxiety related to the health of the fetus; the labor and birth process; and confidence in the obstetrician, birth attendant, and other health care providers (Rini et al., 1999). We used the revised 10-item version to evaluate the extent to which women worried or felt concerned about their health, the health of the fetus, labor and birth, and caring for the infant. This tool was also completed by male partners, and language was
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modified to reflect the partner’s pregnancy (i.e., change from “I am confident of having a normal childbirth” to “I am confident my partner will have a normal childbirth”). PRAM total scores can range from 10 to 40, and a higher score indicates a greater level of pregnancy-related anxiety (Rini et al., 1999). A Cronbach’s alpha coefficient of 0.78 was reported for the PRAM (Rini et al., 1999). Cronbach’s alpha coefficients for our PRAM T1 data were 0.85 for women and 0.84 for men.
Procedures Participants were recruited from two settings. The couples in the IVF group were recruited from a large infertility clinic in the Northeast of the United States during the discharge visit, which is approximately 8 to 10 weeks gestation. All couples pregnant via IVF were provided a study information/invitation sheet with instructions to contact the research nurse. Once contacted, she explained the study and, if they were interested, met with the couple in person to obtain informed consent. The couples in the SC group were recruited from a women’s clinic immediately after their first prenatal visit, which was approximately 10 to 12 weeks gestation. They were invited in person, and informed consent was obtained. After informed consent, each participant received an e-mail invitation to complete Time 1 study questionnaires (demographic form, PSS, STAI, and PRAM) via REDCap (Harris et al., 2019; Harris et al., 2009). Each participant received two reminders if the questionnaires were not completed. Time 2 and Time 3 questionnaires (PSS, STAI, and PRAM) were sent using the same process.
Data Analysis We used descriptive statistics to detail demographic characteristics and measures of perceived stress, state anxiety, and pregnancyrelated anxiety for women and men during pregnancy for each group (SC and IVF). We performed nondirectional statistical testing with the level of significance set at 0.05 for each test. For this pilot study, the significance level was not adjusted for multiple outcomes because of the small sample sizes for women and their male partners per group (n < 30). Small sample sizes often yield insufficient statistical power (< 80%) to detect differences or associations that may exist. Thus, a conservative approach was applied when testing each outcome to reduce the Type II error rate. Data were analyzed with the use of SAS Version 9.4 statistical software. We compared group differences using nonparametric Wilcoxon two-sample tests and chi-
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square/Fisher’s exact tests. We used random coefficient regression models for longitudinal data, a type of hierarchical mixed-effects models for repeated measures, to conduct trajectory analyses to test for conception group differences in stress and anxiety levels across trimesters in the women and their partners. We conducted a separate trajectory analysis on each of the three dependent measures (PSS, STAI, and PRAM). We evaluated the fixed effects of group, trimester, sex, group by trimester, sex by trimester, group by sex, and group by sex by trimester, and the random effects of individuals and individual by time in the final model. We incorporated woman and partner nesting effects as a level 3 predictor variable. The age of the woman and the age of her partner were initially included as covariates but were not retained in the final model because these variables were not statistically significant.
Results Characteristics of Participants We recruited 31 IVF and 27 SC couples who signed consent forms. Nine couples in the IVF group and one couple in the SC group did not complete any study questionnaires; therefore, they were deleted from the sample. The final participant groups included 48 women and their male partners (N ¼ 96 participants) with 22 couples (n ¼ 44 participants) in the IVF group and 26 couples (n ¼ 52 participants) in the SC group. The demographic and clinical characteristics of the participants in the SC and IVF groups (N ¼ 96 individuals, 48 female–male couples) are presented in Table 1. All participants in the SC group had singleton pregnancies, and four participants in the IVF group (16%) had twin pregnancies. Most women in the IVF group (n ¼ 13, 54%) completed one IVF cycle to conceive their current pregnancies.
Stress and Anxiety Analysis The missing rate for stress and anxiety measures assessed during the third trimester was 21% for the SC group and 20% for the IVF group. For each dependent variable, level 1 of the linear random coefficient regression model analysis estimated individual trajectories over the three trimesters for the 96 individuals included in the analysis. The model provided estimated scores at each time point for the 48 women and their male partners. The missing at random assumption of trajectory analysis was met for each of the three dependent variables (PSS, STAI, and PRAM). We calculated the adjusted means at each time point
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Pregnancy-related anxiety is a discrete anxiety type and is associated with adverse pregnancy outcomes such as low birth weight and preterm birth.
from each individual’s estimated scores based on the fixed, random, and nesting effects in the model. The unadjusted and adjusted means (M) and standard deviations (SD) for the participants by group across the trimesters are provided in Table 2. No significant main or interaction effects of group were demonstrated for any of the three dependent variables. Furthermore, other main or interaction effect terms in the model were not statistically significant for the PSS total scores. For the S-Anxiety (STAI) total scores, we found significant sex (F ¼ 8.0, p ¼ .005) and sex by trimester (F ¼ 6.17, p ¼ .014) effects on the adjusted mean anxiety scores regardless of group. When averaged across trimesters, compared with their partners, women had a significantly higher adjusted mean anxiety score (women: M ¼ 36.9, SD ¼ 10.8; men: M ¼ 33.5, SD ¼ 8.2). The interaction effect was caused by the gradual reduction in adjusted mean anxiety across trimesters for women; the anxiety levels of their partners gradually increased over time (see Figure 1). The trajectory results for the pregnancy-related anxiety (PRAM) total scores indicated significant sex (F ¼ 10.56, p ¼ .001), trimester (F ¼ 4.98, p ¼ .027), and sex by trimester (F ¼ 5.10, p ¼ 0.025) effects. When averaged across trimesters, women compared with their male partners had a significantly higher adjusted mean pregnancy-related anxiety score (women: M ¼ 20.3, SD ¼ 4.1; men: M ¼ 18.0, SD ¼ 4.4). When averaged across women and men, a significant gradual reduction in pregnancy-related anxiety across trimesters was observed (Trimester 1: M ¼ 19.7, SD ¼ 4.5; Trimester 2: M ¼ 19.2, SD ¼ 4.4; Trimester 3: M ¼ 18.7, SD ¼ 4.3). The interaction effect indicated that the women had a small but clinically meaningful reduction in pregnancy-related anxiety across trimesters, whereas the anxiety levels of their partners did not change over time (see Figure 1).
Discussion In this pilot study, we sought to determine the feasibility of recruitment of a sample of pregnant women and their partners to explore whether women and their partners who conceive via IVF experience greater levels of stress and anxiety
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Table 1: Sample Characteristics for Women and Their Male Partners by Group (N [ 96) Characteristic
SC: Women (n ¼ 22)
IVF: Women (n ¼ 26)
Age, in years
30.0 (29.0, 32.0)
33.0 (31.0, 36.0)
White
p Value .004
19 (86.4)
26 (100.0)
.089
1 (4.6)
0 (0.0)
.468
Graduate/professional degree
13 (59.1)
15 (57.7)
.922
Annual total household income
11 (50.0)
14 (53.9)
.790
22 (100.0)
22 (84.6)
.114
Hispanic
$125,000 or more Singleton pregnancy IVF cycles for current pregnancy One cycle
14 (53.9)
Two cycles
8 (30.8)
Three to five cycles
4 (15.4)
Age, in years White Hispanic Graduate/professional degree
SC: Male Partners (n ¼ 22)
IVF: Male Partners (n ¼ 26)
p Value
32.5 (30.0, 37.0)
37.0 (34.0, 41.0)
.017
20 (90.9)
26 (100.0)
.205
4 (18.2)
1 (3.9)
.165
12 (54.6)
9 (34.6)
.166
Note. Median (25th, 75th percentile) and Wilcoxon Two-Sample tests for age; n (%) and chi-square/Fisher’s Exact test for categoric measures. IVF ¼ in vitro fertilization; SC ¼ spontaneous conception.
during pregnancy compared with each other and compared with couples who conceive spontaneously. Our team successfully met the recruitment goals for both the IVF and SC groups. There were more people in the IVF group who completed consent but chose not to participate in the study, which may be because the SC group was recruited by the investigator in person at the time of their health care visit. This trend will inform recruitment strategies in future study planning. When we analyzed the data collected for those who participated, we found no significant group main or interaction effects on the anxiety and stress variables. However, pregnant women on average had significantly higher state and pregnancy-related anxiety scores than their partners. In addition, the women showed a gradual reduction in state and pregnancy-related anxiety across trimesters, whereas pregnancy-related anxiety of their partners gradually increased and state anxiety did not change over time.
Women and Their Partners We observed significant group differences between all pregnant women and their male partners. Overall, women in our study had greater levels of state and pregnancy-related anxiety at all three time points than their partners; however, we noted
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a gradual decline in anxiety among women as the pregnancy progressed. Recent evidence suggested that pregnancy-related anxiety is a discrete anxiety type (Brunton, Dryer, Saliba, & Kohlhoff, 2019) and that this type of anxiety is most associated with adverse pregnancy outcomes such as low birth weight and preterm birth (Dunkel Schetter & Tanner, 2012). Early in pregnancy, women most frequently report anxiety about the health of the fetus and about their own well-being (Deklava, Lubina, Circenis, Sudraba, & Millere, 2015). Pregnancy is a time of continual adaptation and transition, and women experience less anxiety as birth approaches. That said, it may be useful to examine the relationship between the fluctuation of anxiety throughout pregnancy and role maladaptation after birth. We also found that men experienced pregnancyrelated anxiety differently than women. Although men had overall lower state and pregnancy-related anxiety levels than women at all three time points, their anxiety levels increased as birth approached. Our findings add to the limited understanding of psychological experiences of men throughout pregnancy, especially in those who conceived via IVF, although our findings must be interpreted with caution given the small sample size. In related
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Table 2: Descriptive Statistics for Stress and Anxiety Measures (N [ 96)
Measure Trimester
SC
IVF
Adjusted Mean (SD)
Adjusted Mean (SD)
1
2
3
1
2
3
20.3 (6.5)
20.0 (5.8)
19.6 (5.5)
21.1 (7.3)
21.1 (7.1)
21.1 (7.0)
Women
21.9 (7.2)
20.4 (6.5)
19.0 (6.0)
22.3 (8.4)
22.4 (8.0)
22.4 (7.8)
Male partners
18.7 (5.3)
19.5 (5.1)
20.2 (5.1)
19.9 (5.9)
19.8 (5.9)
19.7 (6.0)
33.7 (8.5)
33.3 (7.9)
33.0 (8.0)
37.4 (10.8)
36.8 (10.7)
36.2 (10.6)
Women
36.9 (8.5)
34.1 (8.5)
31.3 (8.5)
40.4 (11.9)
39.4 (11.9)
38.3 (11.9)
Male partners
30.5 (7.3)
32.6 (7.3)
34.8 (7.3)
34.4 (8.9)
34.2 (8.9)
34.1 (8.9)
19.0 (3.8)
18.3 (3.7)
17.7 (3.6)
20.3 (5.0)
19.9 (4.9)
19.5 (4.8)
Women
20.4 (3.1)
19.1 (3.1)
17.8 (3.1)
22.2 (4.5)
21.4 (4.5)
20.6 (4.5)
Male partners
17.6 (4.1)
17.6 (4.1)
17.6 (4.1)
18.3 (4.8)
18.4 (4.8)
18.4 (4.8)
Perceived Stress Scale
State–Trait Anxiety Inventory: S-Anxiety
Pregnancy-Related Anxiety Measure
Trimester Perceived Stress Scale
SC
IVF
Unadjusted Mean (SD)
Unadjusted Mean (SD)
1
2
3
1
2
3
20.4 (8.3)
19.9 (7.0)
20.1 (6.7)
20.9 (8.3)
21.5 (9.4)
20.7 (8.8)
Women
22.1 (9.3)
19.9 (8.4)
19.6 (6.4)
22.2 (9.7)
22.3 (10.2)
22.3 (9.6)
Male partners
18.7 (7.0)
20.0 (5.6)
20.5 (7.2)
19.5 (6.7)
20.6 (8.5)
18.9 (7.6)
34.0 (13.0)
33.1 (10.4)
33.2 (10.3)
36.9 (13.1)
37.9 (15.0)
35.6 (13.6)
Women
37.7 (14.8)
32.5 (11.2)
32.3 (9.3)
39.8 (14.8)
40.4 (16.4)
37.3 (14.6)
Male partners
30.2 (9.6)
33.6 (9.8)
34.1 (11.5)
34.0 (10.8)
35.2 (13.4)
33.7 (12.4)
19.0 (5.0)
18.9 (5.4)
17.6 (4.6)
20.2 (5.8)
20.1 (6.2)
19.2 (6.2)
Women
20.5 (4.7)
18.8 (3.8)
18.0 (4.0)
22.2 (5.1)
21.5 (5.8)
20.4 (6.5)
Male partners
17.3 (5.0)
18.9 (6.8)
17.2 (5.3)
18.2 (5.9)
18.7 (6.4)
18.0 (5.8)
State–Trait Anxiety Inventory: S-Anxiety
Pregnancy-Related Anxiety Measure
Note. SC total sample ¼ 44 (22 women and 22 male partners); IVF total sample ¼ 52 (26 women and 26 male partners). Adjusted mean (standard deviation) total score for each measure derived from fixed and random effects included in the hierarchical linear mixed-effects model. IVF ¼ conception through in vitro fertilization; SC ¼ spontaneous conception; SD ¼ standard deviation.
studies, researchers examined men’s psychological experiences with infertility in singular periods compared with their female partners. Men may experience greater levels of psychological distress during infertility diagnosis (Warchol-Biedermann, 2019), lower levels of anxiety during infertility treatment (Volgsten, Skoog Svanberg, Ekselius, Lundkvist, & Poromaa, 2010), and lower levels of anxiety in the first trimester of pregnancies that result from that treatment (Hjelmstedt et al., 2003) than their female partners. Men’s experiences of anxiety throughout pregnancy have been addressed in the literature. One group of researchers found that men had greater levels of anxiety than women throughout the
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pregnancy (Condon, Boyce, & Corkindale, 2004), and other researchers found that men’s levels of anxiety increased at the time of transition to fatherhood, particularly in first-time parents, compared with their female partners (Da Costa, Zelkowitz, Letourneau, et al., 2017). Additionally, men are at risk for postpartum depression after the birth of their infants (Da Costa, Zelkowitz, Dasgupta, et al., 2017). Attention to psychological changes during men’s early transition to fatherhood and risk for depression after birth is a relatively new area of inquiry that requires longitudinal research designs. Future researchers should examine potential factors that trigger or alleviate men’s psychosocial experiences throughout pregnancy.
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Nurses need to recognize that men have their own specific needs during pregnancy, specifically if they experience increased anxiety.
Women Who Conceive via IVF and Spontaneously Our findings contribute to the growing body of literature on emotional changes throughout pregnancy and the difference between women who conceive via IVF and those who conceive spontaneously. In a recent systematic review of the literature, Gourounti (2016) reported that women who conceive via IVF are more likely to have greater pregnancy-specific anxiety than women who conceive spontaneously. However, Gourounti (2016) found insufficient evidence to determine any differences in general or state anxiety. Evidence pertaining to state anxiety is limited and often conflicting in comparisons of pregnant women who conceived via IVF with those who conceived spontaneously. The authors of a prominent longitudinal study found no significant differences in state anxiety between the two groups of women (Hjelmstedt et al., 2003), but other researchers found that women who conceived via IVF experienced greater levels of stress and anxiety, specifically during the first trimester (Darwiche et al., 2014). Our findings suggest that a history of IVF does not increase the risk of stress and anxiety during the resultant pregnancy.
Limitations
24
40
22
38
20
Male partners
18
Pregnant women
16
14
Adjusted mean STAI S-Anxiety score
Adjusted mean PRAM score
One limitation of this initial pilot study was the small sample size for each group. The observed effect sizes for the outcomes were small, and the study lacked power to test for
Trimester 2
Trimester 3
Implications To deliver family-centered health care, our focus must be the family unit as well as the individual. It is essential that the health care team consider both women’s and men’s experiences throughout pregnancy during antepartum care. Although our findings provide some reassurance that mode of conception may not influence stress and anxiety during pregnancy, additional research with larger,
Male partners
36
Pregnant women
34
32
30
Trimester 1
differences in the effects of conception group on the stress and anxiety variables over trimesters. By the third trimester, approximately 20% of the data was missing in each conception group. Although the IVF and SC groups did not differ in rates of missing data over time for the anxiety and stress measures, future research would benefit from methods to improve the capture of data during all trimesters to ensure unbiased and more precise population estimates. Also, the lack of racial/ ethnic variability in our sample is another limitation. Most of the sample was White, and although most IVF users in the United States are White (Chandra et al., 2014), the lack of heterogeneity of the study sample limited our ability to address potential racial/ethnic differences in stress and anxiety during pregnancy for couples who conceived via IVF. One other limitation was that there were four couples in the IVF group pregnant with twins. Having twins affects the perception of stress and anxiety (Tendais, Figueiredo, Canario, & Kenny, 2018); therefore, there may have been variations in stress and anxiety levels for parents with twin pregnancies not able to be discerned given the small sample size.
Trimester 1
Trimester
Trimester 2
Trimester 3
Trimester
Figure 1. Pregnancy-related and state anxiety in women and their male partners across the trimesters of pregnancy (N ¼ 96). PRAM ¼ Pregnancy-Related Anxiety Measure; STAI ¼ State–Trait Anxiety Inventory.
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more diverse samples is needed to further understand differences in levels and mediating and moderating variables to stress and anxiety during and after pregnancy in both women and men.
assisted reproductive treatment in an Italian infertility department. European Journal of Obstetrics & Gynecology and Reproductive Biology, 158(2), 235–241. https://doi.org/10.1016/ j.ejogrb.2011.04.032 Cohen, S., Kamarack, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health Social Behavior, 24, 385–396.
Conclusions Our findings suggest that women and men who use IVF to achieve pregnancy experience similar levels of stress and anxiety as those who conceive spontaneously, although given the small sample size, our findings should be interpreted with caution. Also, although pregnant women in our study overall experienced more state and pregnancy-related anxiety than men, women seemed to approach birth with lower levels. On the other hand, men experienced increases in state and pregnancy-related anxiety, a finding that is worthy of additional investigation, particularly given the recent attention to men who experience postpartum depression during the transition to new fatherhood. Our pilot study provided data to help understand potential differences in stress and anxiety in women and their partners pregnant via IVF and compared with those who conceived spontaneously.
Condon, J. T., Boyce, P., & Corkindale, C. J. (2004). The First-Time Fathers Study: A prospective study of the mental health and wellbeing of men during the transition to parenthood. Australian and New Zealand Journal of Psychiatry, 38(1-2), 56–64. https:// doi.org/10.1177/000486740403800102 Copper, R. L., Goldenberg, R. L., Das, A., Elder, N., Swain, M., Norman, G., … Meier, A. M. (1996). The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks’ gestation. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. American Journal of Obstetrics and Gynecology, 175(5), 1286–1292. Da Costa, D., Zelkowitz, P., Dasgupta, K., Sewitch, M., Lowensteyn, I., Cruz, R., … Khalife, S. (2017). Dads get sad too: Depressive symptoms and associated factors in expectant first-time fathers. American Journal of Mens Health, 11(5), 1376–1384. https://doi.org/10.1177/1557988315606963 Da Costa, D., Zelkowitz, P., Letourneau, N., Howlett, A., Dennis, C. L., Russell, B., … Khalife, S. (2017). HealthyDads.ca: What do men want in a website designed to promote emotional wellness and healthy behaviors during the transition to parenthood? Journal of Medical Internet Research, 19(10), e325. https://doi.org/10. 2196/jmir.7415 Darwiche, J., Lawrence, C., Vial, Y., Wunder, D., Stiefel, F., Germond,
Acknowledgment Funded by the Office of Research Affairs, Duke University School of Nursing, Durham, NC.
M., … de Roten, Y. (2014). Anxiety and psychological stress before prenatal screening in first-time mothers who conceived through IVF/ICSI or spontaneously. Women and Health, 54(5), 474–485. https://doi.org/10.1080/03630242.2014.897677 Deklava, L., Lubina, K., Circenis, K., Sudraba, V., & Millere, I. (2015). Causes of anxiety during pregnancy. Procedia - Social and Behavioral Sciences, 205, 623–626. https://doi.org/10.1016/j. sbspro.2015.09.097
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