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Abstract

This study compared responses to an in-person clown visit and a humorous film following in vitro fertilization and embryo transfer. Intervention was a 10-minute clown visit (n = 101) or 10-minute humorous video clip (n = 99). Demographic and fertility-related data and preintervention anxiety scores were collected. Participants completed an Evaluation of Intervention form postintervention. There were no group differences on demographic or fertility-related data or anxiety scores. Findings indicate while participants viewed the intervention positively, the clown visit offered a higher degree of satisfaction in more patients than did the film. Median evaluation scores were significantly higher for the clown visit, specifically reducing anxiety level and being more distracting. Both groups reported that the exposure made the clinic experience more pleasant and did not bother them, and most would recommend incorporating the intervention in routine treatment. However, free-text comments clearly expressed greater enthusiasm to the in-person clown intervention than to the film.

Keywords

in vitro fertilization medical clown psychological distress

Humor and laughter are believed to act as stress-relieving coping mechanisms that reduce psychological symptoms related to negative life events and improve quality of life and immune function. Humorous intervention in the medical setting may include clowning, viewing a humorous film, or self-induced laughter therapy. The use of clown and musician troupes to enhance healing dates back to the time of Hippocrates.¹ The contemporary concept of using medical clowns gained fame at the 1986 initiative of the Big Apple Circus Clown Care Unit in New York.² Medical clowns use pleasurable and playful techniques to promote patient well-being. Their individualized, improvisational, often humorous interactions with the patient alter the perception of the hospital milieu, and support expressions of control and emotion, enhancing the physical and mental well-being of patients and care providers.^3

–7 While medical intervention, such as drugs, begins to act by virtue of administration, based on pharmacokinetics, humorous intervention may be effective only if it is acceptable to the patient.

Infertility and treatment by in vitro fertilization and embryo transfer have been associated with stress. Since humor is considered beneficial in stressful situations, it may affect the embryo-uterine interplay through neuroendocrine pathways or nonovarian stress reduction, augmenting uterine receptivity. A study aimed to evaluate the impact of medical clowning on pregnancy rates after in vitro fertilization⁸ reported encouraging results. While a major advantage of the medical clown’s intervention is that it is based on personal interaction between the artist and the patient, it is relatively costly and time-consuming. Thus the use of a humorous film might be a reasonable alternative.

The aim of the present study was to compare patients’ evaluation of exposure to an in-person clown visit and to a humorous film intervention immediately following in vitro fertilization and embryo transfer.

Methods

Study Population

All women treated with in vitro fertilization or intracytoplasmic sperm injection in the In Vitro Fertilization Unit at Barzilai Medical Center from December, 2013 through March, 2015 who underwent embryo transfer with fresh or frozen embryos were included in the study. There were no exclusion criteria; however, each participant was included only once during the study period.

Procedure

Assignment to study groups was done by randomizing days on a weekly basis, for which 2 days (Sunday through Friday) were allocated to each group. Prior to undergoing embryo transfer, women were approached and asked to participate in the study. Those who consented completed structured questionnaires, including the Spielberg State Anxiety Inventory. Participants were assigned (according to the predetermined days) to 1 of 3 study groups:

Clown Group: live “personalized” medical clown intervention

Film Group: filmed medical clown intervention

Control Group: treatment as usual, that is, no intervention.

Intervention was offered immediately following embryo transfer, while the subject rested in the recovery room.

Intervention With a Medical Clown

Each patient included in the Clown Group had an encounter with a professional medical clown immediately following embryo transfer, while sitting in an armchair in the recovery room. The visit, which lasted for about 10 minutes, included a routine that was suitable for adults and developed especially for this study. The routine included jokes and magic tricks, performed on a personalized, interactive basis by the clown dressed as a “chef de cuisine” personage, without a red nose. During the study, the same clown performed the routine at all encounters.

Intervention With a Humorous Film

A 10-minute film was produced specifically for this study. The film was of the same clown visiting a woman (a nurse who played the part) in the recovery room. The camera was focused on the clown, filmed from the vantage point of the patient sitting in the armchair. The routine filmed was basically identical to that used by the clown for the Clown Group. The film was shown on a 29-inch flat-screen television mounted on a hospital cart (slightly above eye-level to the woman sitting in the armchair), and was rolled out for use on Film Group days.

Instruments

Demographic and fertility-related medical information, including details of the current in vitro fertilization procedure and pregnancy were abstracted from the In Vitro Fertilization Unit’s medical records onto a prepared data-entry form.

The “state” subscale of the Spielberger State-Trait Anxiety Inventory (STAI),⁹ a widely used and extensively validated measure of anxiety symptoms. The state portion of the STAI includes 20 items designed to measure the presence of current anxiety symptoms, with scores ranging from 20 to 80, with higher scores indicating more severe symptoms. The STAI was completed before intervention, as a possible confounding variable. Permission to use the translation of the STAI was granted by the publishers.

An Evaluation of Intervention form included a questionnaire regarding the specific intervention to which the participant was exposed: the clown visit or film. Five items were scored on a Likert scale, with a score of 1 indicating “not at all” and 10 indicating “very much.” The items were prefaced by the statement: “The clown’s visit/humorous film while I rested following embryo transfer…” and included the following: (1) served to reduce my level of anxiety; (2) bothered me; (3) helped to distract me; (4) made the time more pleasant for me. The final item asked “In your opinion would it be a good idea to include the clown’s visit/humorous film as part of the fertility treatment?” for which the response options were “yes” or “no.” In addition, the form had a section on which the woman could note comments that she wished to mention. The evaluation forms were of different colors for each group and were completed anonymously and deposited into a closed “mailbox.” Control group participants were not exposed to intervention, thus were not requested to complete an Evaluation of Intervention form and are not included in the present analysis.

Statistical Analysis

Data were analyzed using SAS version 9.4. Comparison of group characteristics was conducted by chi-square analysis for categorical variables and t test for continuous variables. Since the responses of the Clown and Film Group participants to the Evaluation of Intervention questions were nonparametric, the data were analyzed by median scores and interquartile ranges, using Wilcoxon 2-sample test. STAI scores were dichotomized, with scores of ≤40 indicating no or minimal symptoms and >40 indicating moderate or severe symptoms. The difference between groups was considered significant at P < .05.

Ethics

The study was approved by the Institutional Review Board of the Barzilai Medical Center (0091-13-BRZ; November 8, 2013) and informed consent was obtained from all participants.

Results

Participants

During the study period, 316 women were requested to participate. Twenty-three refused, and the remaining 295 (93.4%) were assigned randomly to the study groups as follows: Clown Group, n = 101; Film Group, n = 99; Control Group, n = 95.

There were no significant differences between the groups with respect to maternal age, educational level or family status (Table 1). Regarding fertility history and treatment, there was no significant difference with respect to years of infertility, infertility type or cause, or number of previous in vitro fertilization cycles.

Table 1.

Demographic and Obstetric Characteristics by Study Group.

	Total N = 200; n (%)^a	Clown N = 101; n (%)^a	Film N = 99; n (%)^a	P Value^b
Maternal age group (years)				.91
19-29	53 (26.5)	29 (28.7)	24 (24.2)
30-34	57 (28.5)	28 (27.7)	29 (29.3)
35-40	60 (30.0)	29 (28.7)	31 (10.3)
41+	30 (15.0)	15 (14.9)	15 (13.2)
Maternal age (years)				.61
Mean (SD)	33.8 (5.9)	33.6 (5.8)	34.0 (5.9
Level of education (years)				.66
≤12	68 (35.6)	32 (34.0)	36 (37.1)
>12	123 (64.4)	62 (66.0)	61 (62.9)
Family status				.96
Single	12 (6.1)	6 (6.0)	6 (6.2)
Married/steady partner	185 (93.9)	94 (94.0)	91 (93.8)
Infertility years				.18
Mean (SD)	3.8 (3.2)	3.5 (2.2)	4.2 (3.9)
Infertility type				.94
Primary	106 (53.8)	53 (53.5)	53 (54.1)
Secondary	91 (46.2)	46 (46.5)	45 (45.9)
Infertility cause				.47
Hormonal	35 (18.0)	21 (21.2)	14 (14.7)
Male	96 (49.5)	45 (45.5)	51 (53.7)
Mechanical	26 (13.4)	12 (12.1)	14 (14.7)
Unexplained	37 (19.1)	21 (21.2)	16 (16.8)
No. of past IVF cycles
Mean (SD)	2.5 (3.2)	2.6 (3.5)	2.3 (3.0)	.41
STAI state anxiety score >40	94 (48.7)	44 (45.8)	50 (51.5)	.43

Abbreviations: IVF, in vitro fertilization; STAI, State Trait Anxiety Inventory.

^aNot including missing values.

^bChi-square test for categorical variables and t test for continuous variables.

Anxiety

No significant difference was noted between the groups in the rate of high scores (>40) on the STAI State subscale prior to intervention

Participants’ Subjective Evaluation

Responding to the question of whether the intervention reduced their level of anxiety, the median scores were significantly higher among the Clown Group than the Film Group (10 vs 8, respectively; P = .01). It is notable that over half of the respondents in the Clown Group gave that item the highest possible score of 10, indicating “to a great extent,” while only 17 of the Film Group respondents assigned that score (Table 2).

Table 2.

Participants’ Evaluation of the Humorous Intervention.

Question: “The intervention…”	Group	Median (Interquartile Range)	P Value^a
… served to reduce my level of anxiety	Clown	10 (6, 10)	.01
	Film	8 (4, 9)
… bothered me	Clown	1 (1, 1)	.08
	Film	1 (1, 1)
… helped to distract me	Clown	10 (8, 10)	.04
	Film	9 (6, 10)
… made the time more pleasant for me	Clown	10 (8, 10)	.07
	Film	10 (7, 10)

^aWilcoxon 2-sample test; not including missing values.

There was also a significant scoring distinction regarding the extent to which the intervention served as a distraction. In general, the time was made more pleasant for all respondents, and no difference between the groups when asked if the intervention bothered them, with the majority of both signifying “not at all.”

Most participants in both groups responded in the affirmative regarding whether they would recommend incorporating the respective intervention in the routine clinic care (Clown Group, n = 67; Film Group, n = 62; P = .35).

The evaluation form offered the option for the respondent to add comments in free-text, and 29 of those in the Clown Group and 26 of those in the Film Group did so. The difference in the comments between the 2 groups was apparent and interesting.

The complete list of comments is presented in Appendixes A and B. In the Clown Group, more than half of the comments were extremely enthusiastic. Some examples include “Amazing,” “I really enjoyed the medical clown!!! It distracted me for a few minutes and I laughed a lot,” “Thank you for helping pass the time with laughter and not with tension and pressure; I was very glad and it really gave me a good feeling,” “Great! Releasing! Fun!” “It really helps me get through the procedure and also imparts a good, positive feeling,” “For the few minutes with him (the clown) I didn’t even think for a moment about the pain or the treatment, “Definitely distracting, especially for women for whom the ordeal is difficult and stressful,” “Very pleasant; I hadn’t expected this type of relaxation. Thank you.” Some were more moderate (eg, “Thanks for the idea,” “It surprised me pleasantly”), and only 2 women noted that the experience was not positive (“Thank you for the good intentions, but I don’t connect,” “Since I feel uncomfortable in such situations, it is difficult for me to express any opinion. Thank you”).

In contrast, only 6 of the comments of women in the Film Group related positively and specifically to the intervention, for example: “A great idea and initiative--we’re for it!” “Anything that might reduce the stress and anxiety can help promote the success of the treatment, or at least the psychological aspect of the procedure.” While only 2 expressed negative thoughts (“Personally I don’t feel the need … [for me this is] a time to rest,” “The film disturbed me and isn’t necessary”), some had suggestions for improvement, such as translation into other languages or adding relaxing music. However, half of the comments were very general, not relating to the film but only to the in vitro fertilization unit itself, albeit in a very positive manner. For example: “The care and attitude in the Unit are excellent,” “I like all of the medical staff very much …” “You are wonderful. We love you,” “Thank you for everything!!! You are amazing!”

Discussion

The present study compared patients’ responses to exposure following in vitro fertilization and embryo transfer to an in-person medical clown intervention with exposure to a filmed routine of the medical clown, similar to the live encounter. The results indicate that responses to the in-person clown intervention were more enthusiastic than those to the film, which were general with only a few relating directly to the film itself.

Medical clowning is increasingly perceived as a valuable complementary therapy by patients, families, and care providers^5,10,11 based on studies showing that it facilitates verbal and nonverbal communication⁶; improves mood and attitude^4,12,13; increases expressions of emotion such as laughter, joy, and humor^6,11,14,15; supports empowerment and active role-reversal.¹⁵ However most studies are qualitative and descriptive in nature with only a few prospective comparative studies, and are mainly in the domain of pediatric wards focusing on stress reduction and pain relief in acute care settings.⁷ Clowning has been less frequently utilized for adults receiving nonacute medical services in palliative care,¹⁶ rehabilitation,¹⁷ and assisted reproduction.⁸ Clowns have also participated in crisis projects for adult and child refugees in various countries.¹⁸ Studies involving health-related benefits of self-induced humor/laughter are few and mainly observational, as reviewed by Mora-Ripoll.¹⁹

Cousins,²⁰ who drew public attention to the link between humor and pain relief, used comic films, such as Candid Camera and the Marx Brothers. Weisenberg et al²¹ investigated the effect of film type (humorous, holocaust, and neutral) and length on pain perception, and found a significant advantage for the humorous film. Recent neuroimaging studies have revealed physiological evidence for a relationship between mental states and experiencing humor while watching a film.²² Their results on predicting upcoming humor, or anticipating humorous events, suggest that to induce laughter efficiently it is important that the viewer expect a humorous event and then to give him or her a punch line within a few seconds. The authors recommended further investigation to determine whether or not the findings are valid for various types of humor.

Many studies comparing medical clowning to other exposures related to nonhumorous reference groups: no-intervention control group,^23,24 sedation,²⁵ or watching a television program.²⁶ Aiming to reduce anxiety and preoperative fear in children, Messina et al²⁷ compared medical clown with handheld video games. They found an inverse relationship between clown therapy and anxiety levels. The authors concluded that the clown’s activity, along with validated nonpharmacological therapeutic methodologies, such as the presence of parents during anesthesia induction, may contribute to improving pediatric patient hospital care. Nevertheless, medical and paramedical staff’s objections might adversely affect the inclusion of such a program among the operating room activities. In the current study, the clown intervention occurred following in vitro fertilization and embryo transfer and there was no objection at all from the medical or paramedical staff.

One limitation of the present study was the fact that the clown and the film were offered only in Hebrew. While all subjects had at least a minimal knowledge of the language, some were Arabic or Russian speakers. In the case of films, it might be feasible to offer them in the patient’s mother tongue, thereby enhancing the beneficial effect of the film in comparison with the clown visit, for which offering multiple languages is less likely to be available. Another limitation was that the STAI was not administered following intervention. This might have added another aspect of the value of one or both of the interventions. It is recommended that future research include this in the methodology.

The finding of a relative preference for the in-person clown intervention over the humorous film confirms that of Kingsnorth et al²⁶ who found that both physiological and emotional responses were more favorable to a clown than to humorous television exposure. This may be explained by the fact that during the encounter with the medical clown the patient is active, responding spontaneously to the ongoing interaction. Also the clown can modify his or her approach on the spot in light of the patient’s response or attitude. Although the film used in this study was produced to be as similar as possible to the live-clown intervention, nevertheless the patient was passive. Thus, it seems that the in-person clown visit offered a higher degree of satisfaction to more patients than did viewing the humorous film.

Footnotes

Appendix A

Free-Text Comments by Group Exposed to Clown Visit

Subject	Comment
1A	Amazing.
2A	A welcome initiative.
3A	The clown is nice; he should come to birthday parties.
4A	Thank you.
5A	Thanks for the idea.
6A	It was very entertaining and is recommended.
7A	Surprised me pleasantly.
8A	The questionnaire could be completed both before and after the clown visit.
9A	It was wonderful.
10A	Great!^a Relieving! Fun!
11A	Thank you for helping pass the time with laughter and not with stress and tension; I was very glad and it really gave me a good feeling.
12A	It really helps to get through the procedure and also imparts a good, positive feeling. Thank you.
13A	The clown was funny and in my opinion there is a direct association between humor, and pregnancy and general health.
14A	Since I feel uncomfortable in these situations it is difficult for me to express an opinion--thank you.
15A	Thanks for the good intention, but I don’t connect.
16A	Thank you very, very much for the wonderful experience! I am sure that it will help--it has already had an effect.
17A	I really enjoyed the medical clown!! It distracted me for a few minutes and I laughed a lot!!
18A	I suggest waiting 5 to 10 minutes, so that the couple can have some time to share their feelings, and then have the clown arrive. It (the clown’s visit) definitely added a pleasant and fun atmosphere and made us laugh. Well done!
19A	For the few minutes with him (the clown) I didn’t think for even a moment about the pain or the treatment! It was really relieving and gave a good feeling!! Recommended!!
20A	The clown was very funny and friendly
21A	It was wonderful! Thank you ⌣
22A	We liked it and we laughed, but I suggest that the clown should come at the beginning of the treatment, to reduce the tension. Regarding Question 4 (“It didn’t bother me but it wasn’t necessary”), at this stage of the treatment (embryo transfer), we feel more relaxed. So thanks a lot; it was very funny.
23A	The experience was incredible, surprising, and exciting. I would be happy if all the women could experience it. Well done!.
24A	Definitely distracting, especially for women for whom the procedure is difficult and stressful.
25A	For me personally it was not necessary to have it (the clown’s visit) as part of the treatment, but I think that most of the patients are to some degree anxious, and it could help to reduce the pressure
26A	To the IVF staff, thank you.
27A	He was simply wonderful. I think that it (the clown’s visit) should also be done before embryo aspiration and also afterwards.
28A	Really nice and surprising. I liked it.
29A	Very pleasant; I hadn’t expected this type of relaxation. Thank you.

^aExclamation marks throughout were written in the participants’ comments.

Appendix B

Free-Text Comments by Group Exposed to Humorous Film

Subject	Comment
1B	Personally I didn’t feel the need for it (the film), but in general maybe there is a need. Thank G-d the atmosphere in the Unit gives a very good feeling, and the quiet here is relaxing to me and a time to rest.
2B	Thank G-d the care and the attitude in the Unit are excellent. Thank you.
3B	I like all of the medical staff very much. Bravo for your work.
4B	A great idea and initiative, we’re for it!!^a
5B	You are wonderful.
6B	It was wonderful. The last time that we had the treatment I waited a few minutes before going home; it was very nice today to have 20 minutes seeing the entertaining film. A great idea.
7B	What is most relaxing is the amazing staff here who gives a feeling of comfort, relaxation and security. Thank you, you are amazing.
8B	You are wonderful and amazing. We love you.
9B	The Unit staff is wonderful and that creates much calm.
10B	The clown (in the film) is wonderful and his ‘assistant.’
11B	I thank this whole winning staff.
12B	(I would prefer it) in Russian
13B	The film disturbed me and isn’t necessary.
14B	I suggest that it (the film) be offered in a few translations.
15B	You could add pictures of relaxing music.
16B	Thank you for everything !!!! You are amazing!!
17B	Anything that might reduce the stress and anxiety can help promote the success of the treatment, or at least the psychological aspect of the procedure.
18B	To some extent, even seeing a humorous program, will make me laugh, and can be very helpful in general. The idea of resting after (embryo transfer) is very good.
19B	Very nice and distracting in a positive, relieving way. Thank you.
20B	(It could be) routine to help while waiting after embryo transfer.
21B	Maybe (the film should be included as part of the fertility treatment).
22B	Everything is perfect--the attitude, the acceptance, the many improvements in the Unit. I love you.
23B	It depends on the patients (whether the film should be included as part of the fertility treatment).
24B	I love the staff, especially S and B.
25B	Humor is good to relieve the tension during the treatment. This particular film wasn’t so funny to me.
26B	Thank you.

^aExclamation marks throughout were written in the participants’ comments.

Author Contributions

The work presented here was carried out through collaboration among the authors. SF, SG, and LL-G defined the research concept, design and methodology. In addition they interpreted the data, and drafted and critically revised the manuscript for important intellectual content. SG, GL, and BS were responsible for data collection and carrying out the experimental work. LL-G, SG, GL, and DH were responsible for data processing and analysis, and interpretation and drafting the Results and Discussion. All authors read and approved the final version to be published.

Acknowledgments

The authors would like to express their sincere appreciation to Mr Shlomi Algusi, the study’s medical clown and “star” of the humorous film, for his valued participation and contribution to conducting this research. The authors also wish to express their gratitude to the staff of the IVF Unit at Barzilai Medical Center for their assistance and cooperation throughout the research.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Magi Foundation Grant (22052013).

Ethical Approval

This research was approved by the Barzilai Medical Center Ethics Committee.

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Patients’ Evaluation of Intervention by a Medical Clown Visit or by Viewing a Humorous Film Following In Vitro Fertilization and Embryo Transfer

Abstract

Keywords

Methods

Study Population

Procedure

Intervention With a Medical Clown

Intervention With a Humorous Film

Instruments

Statistical Analysis

Ethics

Results

Participants

Anxiety

Participants’ Subjective Evaluation

Discussion

Footnotes

Appendix A

Appendix B

Author Contributions

Acknowledgments

Declaration of Conflicting Interests

Funding

Ethical Approval

References