by: B Baldur-Felskov, SK Kjaer, V Albieri, M Steding-Jessen, T Kjaer, C Johansen, SO Dalton and A Jensen
Published in Human Reproduction, Vol 28, No 3, pp. 690-693, 2013.
Reviewed by: Courtney D. Lynch, Ph.D., MPH
Most of the studies that have examined the association between fertility treatment and psychological distress have been done in small clinic-based samples in which the outcome (psychological distress) was assessed using a variety of self-administered questionnaires. As a result, the findings of these studies are heterogeneous, limiting practitioners’ ability to make causal inferences and to design appropriate interventions, if needed.
For the purposes of this study, the authors linked the Danish Infertility Cohort with the Psychiatric Central Research Registry to examine the association between delivery following infertility evaluation and subsequent hospitalization with a psychiatric disorder. The authors examined the records from a cohort of 98,320 women who had an infertility evaluation in Denmark from 1973-2008. This analytic cohort excluded women for whom reproductive outcome could not be obtained, as well as women who had been hospitalized with a psychiatric diagnosis prior to their infertility evaluation (to avoid contaminating first-time hospitalizations with recurrence). To identify hospitalizations with a psychiatric diagnosis, the authors searched hospital discharge diagnoses for ICD-8 (<1995) and ICD-10 (1995+) codes indicating psychiatric diagnoses in one of six categories: alcohol and toxicant abuse, schizophrenia and psychoses, affective disorders, anxiety and adjustment and OCD, eating disorders, and other mental disorders. Only hospitalizations after the infertility evaluation were examined.
Among the 98,320 women, 54.5% gave birth after the evaluation. A minority of the women in the cohort (23.6%) had delivered at least one child prior to the infertility evaluation. The median length of follow-up after infertility evaluation was 11.3 years (range: 0-36). A total of 4,633 women were hospitalized with a psychiatric disorder during the follow-up period, 53.7% of those occurred among women who did not give birth after the evaluation. After adjustment for age, year of entry into the cohort, and parity status at the infertility evaluation, the authors found a statistically significant increase in hospitalizations with psychiatric diagnoses among women who did not give birth after the evaluation [HR=1.17; 95% CI=(1.11, 1.25)]. The most profound increase was seen among the subcategory of alcohol and intoxicant abuse [HR=2.02; 95% CI=(1.69, 2.41)]. The authors performed a sensitivity analysis that restricted the population to only women who gave birth to singletons, and the results remained unchanged. They also found no suggestion of a time trend related to length of follow-up.
Among the largest cohort of potentially infertile women assembled to date, the authors found a 17% increased risk of hospitalizations with psychiatric diagnoses among women who did not give birth after fertility treatment. It is very notable that this risk was unaffected by women’s parity status at the infertility evaluation, thereby suggesting that being unsuccessful in giving birth after infertility evaluation is an independent risk factor for hospitalization with a psychiatric diagnosis.
The study had several important limitations that should be noted. First, the authors only examined psychiatric diagnoses associated with hospitalization. This obviously precluded identification of women with less severe psychiatric problems. This would have led to non-differential misclassification, however, and would therefore have likely biased risk estimates towards the null. Further, the authors did not have complete information on the fertility treatment status of women in the cohort. So, they were unable to look at the effect of treatment itself. Further, since the authors could not exclude women with prior psychiatric problems not requiring hospitalizations, it is possible that some of the women were not new cases, but rather women who experienced a worsening of their condition after the infertility evaluation.
This study is unique in that it examines the effect of birth after infertility treatment evaluation on subsequent psychiatric problems, whereas most similar studies have examined the risk of psychiatric disturbance in women who were treated versus those who were not treated. While the authors were unable to tease out the effect of treatment itself, the authors identified an increased risk of problems in women for whom a subsequent birth did not occur regardless of treatment status. This is important, as it is likely that most of the women in this group experienced fertility treatment failure. Given that the authors only examined psychiatric diagnoses involving hospitalization, it is likely that the true prevalence of psychiatric disorders in this population is much higher. This is not surprising, as it is well known that women seeking infertility treatment have a higher prevalence of psychiatric disorders than women in the general population.
So, what does this mean for practice? Clearly, many infertility clinics have already established support programs for women who fail treatment. Frequent characteristics of these programs include adoption information sessions and support groups. While these resources are certainly needed and helpful, the current study suggests that such programs also should potentially consider including substance abuse prevention programs, as well as screening for new or worsening psychological symptoms. In the absence of empirical data to suggest which interventions are likely to be the most effective, after-care teams should consider borrowing from modalities that have been found to be helpful in other highly-stressed populations of women.
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