Published 10 October 2023
Fear of failure, high cost, and juggling a job with clinic visits are among many factors that make fertility treatment stressful. What is unclear is whether mental distress is worse for couples who achieve a pregnancy using ART than those who conceive spontaneously.
The psychological impact of ART in pregnancy is important because it may affect offspring health, but data has been mixed. Some studies have reported that anxiety and depression are greater with ART while others have found no difference – or even lower rates. This inconsistency in the evidence prompted a recent review (1) to call for more research.
Now a large prospective cohort study (2) suggests that differences exist in populations and may influence psychosocial wellbeing among parents-to-be.
The data from more than 180,000 women and their male partners show that ART couples report lower overall levels of anxiety/depression during pregnancy compared to expectant parents who conceive spontaneously. However, according to a sub-sample analysis of couples who conceived both with ART and spontaneously, fertility treatment was associated with increased maternal anxiety and depression in early pregnancy (17 weeks of gestation). For the reported study, there was no difference at 30 weeks of gestation between ART and spontaneous conception.
This is the first study of its kind to examine mental health difficulties in the same expectant parents, across different types of pregnancies and at two specific timepoints.
The authors say their findings on maternal and paternal mental health and relationship satisfaction help to ‘disentangle some of the mechanisms related to pregnancy-specific treatment’. They add: “Conceiving a child through ART is often a long and stressful process that can cause emotional strain’”.
Data came from the Norwegian Mother, Father and Child Cohort Study (MoBa), which includes 111,143 mothers (spontaneous conception n=108,183; ART n=2,960) and 76,594 fathers.
Of these, a sub-sample of 497 expectant parents (not all were matched couples) had two consecutive pregnancies: one resulting from ART and one spontaneous (n=286 mothers; n=211 fathers), and the majority had their ART pregnancy first.
Women self-reported their symptoms of anxiety and depression such as worrying too much, feeling constantly frightened/anxious, or feeling blue.
Female study participants completed a questionnaire at two timepoints during each pregnancy (at weeks 17 and 30); while male participants did so at one timepoint (week 17). Couples reported their relationship satisfaction at 17 weeks of gestation.
Results showed that pregnancy after ART was associated with less total anxiety and depression, and greater relationship satisfaction among both women and men, compared to spontaneous conception.
However, in the sub-sample of parents where each couple had experienced both ART and spontaneous pregnancies, ART was associated with increased levels of maternal anxiety and depression at 17 weeks of gestation, compared to spontaneous pregnancies (mean=1.19 and mean=1.15, respectively).
This association was not observed in the late stages of pregnancy: anxiety and depression at 30 weeks of gestation were similar for ART and spontaneous pregnancies.
In the sub-sample, expectant fathers reported similar levels of anxiety and depression at 17 weeks of gestation during both pregnancies (ART and spontaneous).
Among women, relationship satisfaction was higher following ART conception than spontaneous conception, a trend the authors say may be explained by the ‘shared challenge of going through infertility; which necessitates enhanced communication, intimacy and closeness between partners’.
Limitations of the study, as outlined by the authors, included the potential for bias due to the rarity of women having conceived through both ART and spontaneous conception in their first two pregnancies.
In addition, they write that important predictors of mental health in the context of the ability to conceive were not assessed e.g., previous miscarriages and long-term infertility. These warrant exploration in future research, say the authors.
They add that previous discrepancies in the literature on the impact of ART on mental health in pregnancy may be related to ‘inherent differences’ between the groups of parents receiving reproductive treatment and those who did not.
In an attempt to explain mixed findings from earlier studies, the authors say these may relate to the ‘use of cross-sectional designs that do not account for confounding factors such as differences in socioeconomic status (and) a history of mental illness’.
Variations in gestational age when anxiety and depression were assessed by previous researchers may also have been a factor.
What the study does indicate is that women’s emotional health may be influenced by the emotional strain of infertility treatment. However, on a reassuring note, the authors write that this impact on emotional wellbeing ‘seems temporary’.
1 Capuzzi E et al. Is in vitro fertilization (IVF) associated with perinatal affective disorders?. Journal of Affective Disorders 2020; vol 277; 271-278; https://doi.org/10.1016/j.jad.2020.08.006
2 Oftedal A, Tsotsi S, Kaasen A, Mayerhofer L JK, Espen Røysamb et al. Anxiety and depression in expectant parents: ART versus spontaneous conception. Hum Reprod, vol 38 (9) September 2023; 1755–1760, https://doi.org/10.1093/humrep/dead133
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