Assessing the effect of subfertility and its treatment on postpartum mental health

Published 14 June 2022

Two recently published studies have examined the effect of subfertility and its treatment on postpartum mental health; the results differ slightly but are broadly reassuring, say the authors.

Two reports recently published in journals off the beaten path highlight the possible risk of postpartum mental illness in those with subfertility or following fertility treatment. The first, a large cohort study of almost 800,000 women without previously diagnosed mental disorders who gave birth in Canada between 2006 and 2014, investigated the association in four conception groups: those with subfertility without treatment, with non-invasive infertility treatment (ovulation induction, IUI), with invasive infertility treatment (ART); and without reproductive assistance (the largest group).(1) Results showed that subfertility or infertility treatment was associated with a slightly higher risk of postpartum mental illness when compared with spontaneous pregnancy and no reproductive assistance.

‘Mental illness’, defined as an ‘emergency department visit or a hospital admission with a mood, anxiety, psychotic or substance use disorder, self-harm event or other mental illness’, was diagnosed in 6.1% of those with no investigation or treatment for infertility. Against this benchmark, those with subfertility had a higher adjusted relative risk of postpartum mental illness (RR 1.14 adjusted for age, income, etc), which was similar to that found in the non-invasive and invasive treatment groups.

Most diagnoses were mood or anxiety disorders identified in an outpatient setting at a median of 5.2 months after delivery and discharge. ‘Although the association is modest and unlikely to be causal,’ said the authors, ‘it may nevertheless identify a group that warrants closer surveillance for mental health concerns.’

The authors note that results were unchanged when restricted to mothers with a live birth, but, given the small numbers, data could not be presented for those who had a stillbirth. Moreover, when those with a diagnosis of mental illness in the two years preceding the date of conception (n = 137,511), the rate of the composite mental health outcomes (’as might be expected’) was substantially higher in all exposure groups.

The authors note that their findings align with other estimates of postpartum mental problems – of about 6% - but are unable to offer a simple and clear explanation in their conception groups. Numerous studies, they write, ‘have indicated substantial psychological distress during and after infertility treatment’, although a 2011 review found no clear association of postpartum depression with IVF per se.(2)

The second study also investigated the association between postpartum mental health problems and conception history but found that women with a record of subfertility and treatment with ovulation induction or ART were not at any increased risk of postpartum depression and/or anxiety than those with no fertility problems.(3)

In this second study information was drawn from a UK medical record database of women who had had a livebirth between 1991 and 2013. Similar to the Canadian study, conception history was defined in four groups: no fertility problems, untreated subfertility, ovulation induction, and ART, with depression and/or anxiety in the 12 months postpartum identified from records of diagnoses, symptoms and prescriptions.

Results here showed an overall depression/anxiety prevalence rate of 13.6%, although mothers in the ART group had a lower risk than those in the reference fertile group (OR 0.78). There was no statistically significant association between fertility history and postpartum depression and/or anxiety for mothers in the subfertile group and ovulation induction group.

Explaining the ART finding, the authors speculate that mothers who conceive after ART ‘may perceive their pregnancies as more rewarding and satisfactory’ than those conceived naturally, or ‘are more willing to adjust to pregnancy demands and are more likely to idealize parenthood’.

The results, say the authors, are ‘broadly generalisable’ and ‘broadly reassuring’, but are unable to conclude whether they represent a true effect or indicate a group of women who are less likely to seek help when needed.

1. Dayan N, Velez MP, Vigod S, et al. Infertility treatment and postpartum mental illness: a population-based cohort study. CMAJ Open 2022; 10: E430-E438.
2. Ross LE, McQueen K, Vigod S, Dennis CL. Risk for postpartum depression associated with assisted reproductive technologies and multiple births: a systematic review. Hum Reprod Update 2011; 17: 96-106.
3. Tiany F-L, Yangmei L, Alderdice F, et al. The association between conception history and subsequent postpartum depression and/or anxiety: Evidence from the Clinical Practice Research Datalink 1991-2013. J Affect Disord 2022; 310: 266-273.

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