Preferences Toward Psychological Interventions Among Women Experiencing Infertility

Abstract

Introduction:

Psychological distress among women experiencing infertility is high. The purpose of this study was to assess women's preferences toward various psychological intervention formats to manage stress during infertility treatment, and to gauge interest in an online mindfulness-based intervention in particular.

Materials and Methods:

Participant (N = 272) recruitment included in-person and online methods: (1) patients completed surveys in a fertility clinic waiting room and (2) an electronic link to the survey was shared on social media platforms relevant to individuals experiencing infertility.

Results:

Participants were highly interested in receiving psychological support in multiple formats. Participants showed a clear preference for behavioral interventions over pharmacotherapy. Ninety percent of participants reported they were willing to practice a designated coping skill two to three times per week or daily. On average, participants rated their interest in using a mindfulness app to help manage uncertainty and stress during fertility treatment as 7.78 on a scale of 0–10.

Conclusion:

Women experiencing infertility are highly interested in receiving psychological support, and are open to a variety of intervention formats.

Introduction

The Centers for Disease Control defines infertility as the inability to conceive after 12 months of timed unprotected intercourse. A broader characterization of infertility includes individuals who may be able to get pregnant but have difficulty carrying a pregnancy to term, and same sex couples who have difficulty conceiving despite the use of medical treatment. Infertility is an emerging priority and public health issue. Recent estimates indicate that infertility affects ∼12.5% of women of ages 20–44 years in the United States.¹ The World Health Organization recognizes infertility as a disease, and the use of assisted reproductive technology for the treatment of infertility has doubled in the past decade.²

The experience of infertility is often accompanied by notable psychological distress. Women presenting for care at fertility clinics report significant psychological symptoms, with ∼75% scoring at or above clinical cutoff scores for anxiety and ∼56% scoring at or above clinical cutoff scores for depression at some point during treatment, assessed using standardized self-report measures.³ Longitudinal reports suggest negative emotions increase as women endure consecutive unsuccessful treatment cycles.⁴

In particular, the experience of infertility is characterized by a high degree of uncertainty, which predicts increased distress.⁵ Although fertility treatment involves significant financial investment and can be physically taxing, psychological burden is a primary reason patients discontinue treatment.⁶ However, only 21% of female patients report that they received mental health services during their fertility treatment.³

A number of reviews and meta-analyses have assessed the effects of psychological interventions on the mental health of individuals experiencing infertility, with mixed findings. Some have reported significant effects of psychological interventions on mental health outcomes,^7–9 whereas others have not.^10,11 Of note, these reviews vary in their inclusion of controlled versus uncontrolled and randomized versus unrandomized studies. Cognitive-behavioral therapy (CBT) and mindfulness-based intervention (MBI) are two of the most commonly studied types of psychological interventions with fertility patients.^9–11

One review that conducted subgroup analysis by intervention type concluded that there were no significant differences in effect sizes on mental health outcomes between CBT and MBIs.⁹ Intervention formats have included individual, couples, and group counseling and psychoeducation sessions, as well as self-guided interventions (e.g., educational handouts, listening to music, and expressive writing). Frederiksen et al. reported that group interventions, which were the most commonly studied intervention format (22 of the 39 studies included), produced the largest effects.

There is also some evidence that interventions of a longer duration (six sessions or more) may be more impactful than shorter interventions.^7,10 Many reviews point to significant methodological limitations of existing studies, which limit the ability to draw meaningful conclusions about true intervention effects. These limitations include lack of randomized study design, attention-matched control groups, and intention-to-treat analyses. Studies also vary in terms of sample characteristics, assessment measures used, and assessment time points.

Given these limitations, the authors of a Cochrane systematic review published in 2016 concluded that it is not possible to form conclusions about the efficacy of psychological interventions on mental health outcomes in infertility at present.¹¹ Finally, a discussion about acceptability, willingness to engage, and patient preferences toward various intervention formats is notably missing from existing reviews of psychological interventions. This information may help to inform what kinds of interventions may be most successful for infertility patients.

There is reason to believe that an online mindfulness intervention might be particularly well suited to the needs of infertility patients. The experience of infertility is characterized by managing the uncertainty that comes with repeated waiting periods, and feeling out of control.¹² Fertility patients often spend significant time ruminating about possible future outcomes of treatment. Mindfulness offers an antidote to rumination, through the cultivation of present moment focused attention. MBIs further offer a promising approach to addressing psychological well-being in the context of infertility because they target experiential avoidance and intolerance of uncertainty.

Avoidance and higher levels of dispositional intolerance of uncertainty are associated with heightened distress in the context of infertility.^5,13 Mindfulness meditation promotes nonjudgmental and nonreactive acceptance of one's cognitive and emotional experience,¹⁴ and a previous pilot study has demonstrated that MBIs have the potential to decrease anxiety and uncertainty intolerance among patients with cancer.¹⁵ There is an ample body of research demonstrating that MBIs are effective in reducing the types of psychological symptoms fertility patients commonly experience, including anxiety and depression.¹⁶

Several unique aspects of fertility treatment make the feasibility and accessibility of psychological interventions important. Specifically, infertility treatment is a highly demanding process involving multiple medical appointments. These appointments require women to take time off work and time away from other priorities. Online delivery of a psychological intervention may be appealing to women undergoing fertilitytreatment given its autonomous and flexible nature. Mindfulness training has been widely used in online intervention delivery.^17,18

Thus far, very few existing psychological interventions for infertile patients have utilized an online format,⁹ making this mode of delivery an important area for investigation. Furthermore, fewer than 20% of mental health professionals specializing in reproductive medicine report being embedded in a fertility center.¹⁹ Consequently, a self-guided intervention may provide the best way to meet the psychological needs of fertility patients, as opposed to relying on in-person individual or group counseling.

Given the need to develop empirically supported psychological interventions for individuals experiencing infertility and the suitability of MBIs, we conducted a brief survey of women experiencing infertility to determine their preferences toward various intervention formats, and to assess their willingness to participate in an online MBI in particular. The results of this study have the potential to inform the development of future psychological interventions for infertility.

Materials and Methods

Participants

This study was approved by an institutional review board (Pro00104762). This study consisted of an anonymous survey and, therefore, the IRB determined it was exempt from collecting consent. Participants self-selected to enter the study if they identified as someone pursuing fertility treatment. Individuals <18 years of age were excluded.

Methods

Participants were recruited during the spring of 2020 through a combination of in-person and online methods: (1) patients completed surveys in the waiting room of a fertility clinic in the southeast and (2) an electronic link to the survey was shared on social media platforms relevant to infertility patients (e.g., Instagram, Twitter).

Measures

The survey consisted of questions designed by the authors to assess participants' (1) preferences toward psychological intervention formats, (2) willingness to practice skills learned through an intervention, (3) perceptions of how helpful an intervention would be in managing stress and uncertainty during fertility treatment, (4) experience with meditation, and (5) preferences toward various types of meditation content. See Appendix A1 for a full copy of the survey.

Analysis

SPSS v26 was used to calculate frequencies and descriptive statistics for all variables and for nonparametric tests. Means were calculated based on the total number of participants who responded to each item.

Results

Demographics

Five participants stopped completing the survey after the first question and were excluded from analyses. A summary of demographic characteristics is given in Table 1. Participants (N = 272) were on average 31.95 years old (SD = 4.40), predominantly white (87.9%), married (94.5%), and had been pursuing infertility treatment for an average of 32.20 months (SD = 24.94). Though the survey was open to all genders, all participants identified as female.

Table 1.

Demographics

	N (272)	% Yes
Race
White	239	87.87
Black	6	2.21
American Indian or Alaska Native	6	2.21
Asian	5	1.84
Native Hawaiian or Pacific Islander	1	0.37
Other	11	4.04
Missing or no choice selected	11	4.04
Ethnicity
LatinX	22	8.09
Missing or no choice selected	8	2.94
Marital status
Single, never married	7	2.57
Married or in a domestic partnership	257	94.49
Widowed	0	0.00
Separated	0	0.00
Divorced	0	0.00
Missing or no choice selected	8	2.94
Education
Some high school, no diploma	2	0.74
High school diploma or general education development	12	4.41
Some college, no degree	24	8.82
Associates degree	17	6.25
Bachelor's degree	105	38.60
Master's degree	76	27.94
Doctorate/professional degree	28	10.29
Missing or no choice selected	8	2.94
Income
Less than $25,000	3	1.10
$25,000–$49,999	17	6.25
$50,000–$74,999	42	15.44
$75,000–$99,999	55	20.22
$100,000–$149,999	80	29.41
$150,000–$199,999	29	10.66
$200,000–$249,999	13	4.78
$250,000 or more	16	5.88
Missing or no choice selected	17	6.25

Participants had the option to select more than on racial group, consequently percentages do not add up to 100.

Intervention format

Participants rated their interest in various intervention formats on a scale of 0–10 (0, not at all interested—10, extremely interested). Overall, participants rated their interest in individual interventions (M = 8.42, SD = 2.18) higher than group-based interventions (M = 6.12, SD = 2.77). Because data were left skewed, a Wilcoxon signed ranks test was used to compare median rankings, indicating this difference was statistically significant, z = 9.81, p < 0.001. Participants showed no significant difference in preference between in-person (M = 7.06, SD = 2.82) and online interventions (M = 7.41, SD = 2.69), z = 1.71, p = 0.087.

Most participants (87.9%) were interested in receiving individual psychological counseling, followed by support groups (80.1%), couples counseling (76.8%), and take-home materials and online exercises (67.3%). Far fewer participants (30.9%) were interested in receiving psychotropic medication. Participants had the option to write in additional suggestions, and four mentioned an interest in acupuncture. One participant explicitly expressed interest in support groups offered for male partners.

Perceived helpfulness and willingness to practice

On average, participants rated their interest in using a mindfulness meditation app to manage stress and uncertainty during fertility treatment as a 7.78 (SD = 2.60) on a scale of 1—10 (1, not at all interested—10, extremely interested). Participants further rated their belief that a mindfulness meditation mobile app could help manage stress during fertility treatment as 6.55 (SD = 2.46) on a scale of 1—10 (1, not helpful at all—10, extremely helpful). The majority of participants (57%) said they were willing to practice a coping skill two to three times per week; 32.7% reported once a day, 8.5% reported once a week, and 1.1% reported not at all.

Meditation experience and preferences

Participants ranged in their experience with meditation: 23.9% reported no experience, 39.3% indicted they had practiced once or twice before, 21.7% practiced regularly in the past but not currently, and 15.1% reported that they currently practiced regularly. We asked participants to select the types of meditation content they would be interested in. The most frequently selected topics were fertility-specific content, acceptance and letting go, and tolerating uncertainty, with ∼80% of participants expressing interest in each of these, respectively. In total, 50% to 60% of participants were interested in self-compassion, breathing, and body-focused meditations; 3.7% had no preference.

Limitations

One limitation of this study is its lack of racial diversity. Similarly to other infertility research studies,²⁰ the majority of participants identified as white. Despite experiencing similar to higher prevalence rates of infertility, non-Latina black and Mexican/American women are less likely to seek fertility care than non-Latina Asian and white women.¹ Disparities in income and insurance coverage partially mediate differences in rates of received care for white and nonwhite groups, but social factors also play a role.^21,22 Future studies should utilize directed recruitment methods to include women of color experiencing infertility, to ensure their preferences and needs are represented.

Discussion

Overall, women are highly interested in receiving psychological support during fertility treatment. Responses indicate that women are open to a variety of intervention formats, with a preference toward individual over group interventions, and equal interest in online and in-person modalities. Of note, these data were collected during the spring of 2020 just as the COVID-19 pandemic was taking hold, and we hypothesize that openness to online interventions may have increased given the national transition to telehealth that has occurred since.

Although we did not specify gender-based inclusion criteria for this study, 100% of the participants who completed our survey identified as female. Previous studies examining coping strategies of men and women experiencing infertility have shown that women are more likely to seek social support and use confrontative coping, whereas men are more likely to use distancing.²³ Men are also less likely than women to seek help for psychological issues.²⁴ For these reasons, it is not surprising that women would be more likely to show interest in this research study. Women experiencing infertility also tend to report higher depression and anxiety than their partners,²⁵ and effect sizes of psychological interventions on mental health outcomes tend to be larger in women than in men.^9,10 Further research is necessary to determine men's preferences for psychological support in the context of fertility.

Participants in our study showed a clear preference for behavioral interventions over pharmacotherapy. Women experiencing infertility may have concerns about the effects of psychotropic medication on fertility and pregnancy. This further underscores the importance of developing effective behavioral interventions. Quite notably, the vast majority (87.9%) of participants expressed interest in individual psychological counseling.

These data provide a sharp contrast to the 21% of female fertility patients who report that they received mental health services.³ We believe that these findings support the integration of mental health specialists into fertility clinic care to support patient's psychological needs throughout treatment. Until that becomes the standard of care, an online MBI may be a desirable alternative.

A majority of women indicated that they were willing to practice coping skills regularly (i.e., several times a week). Women expressed interest in using an online mindfulness intervention and believed that such a program would be helpful in managing the stress and uncertainty associated with fertility treatment. Our findings suggest that an MBI would be well received among women receiving fertility treatment. Women showed a preference for meditation content specific to the experience of infertility, suggesting the importance of tailoring existing interventions to suit the needs of this population.

Conclusions

This study demonstrates that women undergoing fertility treatment are highly interested in receiving psychological intervention, and they are open to a range of modalities. In particular, the study indicates that an online MBI would be well received in this population. Further research is necessary to develop empirically supported behavioral interventions to support the psychological needs of women experiencing infertility.

Footnotes

Authors' Contributions

S.A.S. contributed to the study design, data collection, data analysis, and writing of this article. J.T.W. contributed to the study design, data collection, and editing. M.J.S. contributed to the study design and editing. All coauthors have reviewed and approved of the article before submission.

Data Availability Statement

The data for this article will be made available upon reasonable request.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

Appendix

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