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Human Reproduction Vol.20, No.10 pp. 29692975, 2005 doi:10.

1093/humrep/dei219
Advance Access publication August 25, 2005.

Does psychological stress affect the outcome of in vitro


fertilization?

L.Anderheim1,3, H.Holter1, C.Bergh1 and A.Mller2


1
Reproductive Medicine, Department of Obstetrics and Gynaecology, Institution of Womens and Childrens Health,
Sahlgrenska University Hospital, Gteborg University, SE-413 45 Gteborg, and 2Nordic School of Public Health, Box 12133,
SE-402 42 Gteborg, Sweden
3
To whom correspondence should be addressed. E-mail: lisbeth.anderheim-soderqvist@vgregion.se

BACKGROUND: The aim of the study was to investigate the effect of psychological stress before and during IVF
treatment on the outcome of IVF, controlling for known physiological predictors. METHODS: This is a prospective,
longitudinal study. A total of 166 women were studied during their first IVF treatment. They answered question-
naires concerning psychological and social factors on two occasions. Psychological well-being was measured by the
Psychological General Well-Being (PGWB) index and psychological effects of infertility were assessed by 14 items.
RESULTS: In the analysis of the psychological variables, no differences were found between pregnant and non-
pregnant women. The total number of good quality embryos, the number of good quality embryos transferred, and
the number of embryos transferred were significantly higher in the pregnant than in the non-pregnant group. In a
multivariate analysis, the number of good quality embryos transferred was the only variable that was independently
associated with pregnancy. CONCLUSIONS: We found no evidence that psychological stress had any influence on
the outcome of IVF treatment. When counselling infertile couples, it might be possible to reduce the stress they
experience during the treatment procedure by informing them of these findings.

Key words: counselling/in vitro fertilization/outcome/psychology/stress/well-being

Introduction secretion of gonadotropin; (ii) by local effects of catecho-


For most couples unable to conceive, childlessness is a source lamines on the uterus and on the functions of the fallopian
of stress. Both the condition of infertility and its treatment tubes; (iii) by immunological processes that can disturb
cause stress, and it is well known that infertility can induce implantation; and (iv) by influencing behaviour, e.g. drug
psychological disturbances (Mller and Fllstrm, 1991; addiction and sexual problems. In addition, an association
Lalos, 1999). Infertility has been ranked as one of the greatest between psychological stress and sperm quality has been
sources of stress in a persons life, comparable to a somatic observed in some studies (Harrison et al., 1987; Ragni and
disease such as cancer (Domar et al., 1993). The stress of infer- Caccamo, 1992), while others have found that the effect of
tility treatment was ranked second to that involving the death psychological stress on sperm quality is small or non-existent
of a family member or divorce by couples undergoing this (Hjollund et al., 2004). The stress caused by infertility itself
treatment (Freeman et al., 1985; Baram et al., 1988). might also further diminish the chances of having a child irre-
The concept of stress can be defined and described in differ- spective of the primary cause of the infertility.
ent ways. In the present study, stress refers to reactions (psycho- However, whether psychological factors have any independ-
logical or physiological) to the differences between the ent influence on the outcome of in vitro fertilization is still
womans experience of demands, both internal and external, under discussion. Several researchers have demonstrated that
and how she perceives her capacity to cope with these demands. the treatment procedure can cause women to experience great
Several authors have discussed the concept of stress as an psychological stress (Newton et al., 1990; Litt et al., 1992;
aetiological factor related to infertility (Seibel and Taymor, Mahlstedt, 1994), but whether psychological stress has any
1982; Harrison, 1983; Harrison et al., 1986, 1987; Edelman effect on treatment outcome is unclear. It seems, however, that
and Golombok, 1989; Reading et al., 1989; Domar et al., 1990; variables such as age of the woman, embryo quality, infertility
Strauss et al., 1992; Wasser et al., 1993; Christie, 1994; Vartiainen diagnosis, IVF technique and number of earlier trials do not
et al., 1994; Domar, 1996). The mechanisms in this interaction totally explain the variation in the results of IVF treatment.
are not yet known, but different ways in which psychological Harlow and co-workers (Harlow et al., 1996) found no evid-
stress reactions might influence reproduction have been sug- ence that psychological stress has any influence on the out-
gested (Reading et al., 1989). These are: (i) by disturbing the come of IVF. The groups conceiving and not conceiving had

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L.Anderheim et al.

similar levels of state and trait anxiety. In another study, high Subjects
levels of anxiety and stress did not predict an adverse preg- Two hundred women planning to start their first IVF/ICSI treatment
nancy outcome (Milad et al., 1998). were invited to participate in the study. Before their first visit to the
In contrast, other studies found an association between psy- clinic, the women received a letter with information about the study.
chological stress and the results of in vitro fertilization. In Following an information meeting at the clinic, the women were
these studies, the dependent variable was the outcome of IVF, asked if they were interested in participating. The exclusion criteria
were inadequate knowledge of the Swedish language and participation
either as pregnancies or births. The independent variables were
in other studies. A total of 166 women agreed to participate in the
anxiety (Demyttenaere et al., 1989, 1992, 1994; Merari et al.,
study. The main reasons for not participating in the study were lack of
1992, 1996; Boivin and Takefman, 1995; Csemiczky et al., interest, considering the treatment too demanding, and not wanting
2000; Smeenk et al., 2001; Lancastle and Boivin, 2005), any more obligations. The mean age of those who declined to particip-
depression (Reading, 1992; Merari et al., 1992, 1996; Smeenk ate in the study was 32.3 years and did not differ significantly from
et al., 2001), coping patterns or coping resources (Demyttenaere that of participants. The pregnancy rate per started cycle among
et al., 1992; Merari et al., 1992, 1996; Boivin and Takefman, women not participating in the study was 38.2%, which did not differ
1995), psychosocial interventions ( Boivin, 2003), baseline and significantly from the rate of those who participated (34.9%).
procedural stress (Klonoff-Cohen et al., 2001), marital satis- The demographic data for all women who received embryo transfer,
faction (Boivin and Takefman, 1995; Merari et al., 1996), per- obtained from the womens medical records, are presented in Table I.
sonality (Kemeter, 1988), intensity of the child-wish (Stoleru The mean age of the women was 32.1 years. The majority (89.9%)
et al., 1996), sperm quality related to psychological stress were working, 37.4% had a university/college level education, and
(Harrison et al., 1987; Ragni and Caccamo, 1992), participa- 68.3% lived in urban areas. Among the women, 13% were smokers.
The cause of infertility was male factors in 41.7%, while the remain-
tion in psychotherapy (Brandt and Zech, 1991), and vulnerabil-
ing cases involved female factors, unknown factors and mixed factors.
ity to psychological stress (Facchinetti et al., 1997).
Five women had a psychiatric history such as earlier depression, psy-
However, support for a causal relationship between psycho- chosis, anxiety or anorexia. Somatic diseases such as diabetes,
logical stress and results of IVF is often weak. Few studies asthma, epilepsy, gastro-intestinal disorders and gynaecological dis-
indicating an association between psychological stress and IVF eases such as endometriosis were observed frequently.
outcome have tried to control for known confounders. In addi-
tion, the number of women included has often been low. IVF treatment
Thus, several studies have shown certain physiological All women were treated using a stimulation procedure including down-
markers such as age, duration of infertility, number of earlier regulation with a GnRH agonist according to a long protocol starting
failed IVF cycles, tubal indication for infertility, previous preg- either in the follicular phase or the luteal phase (1.2 mg/day nasally or
nancies, number of good quality embryos transferred and 1.0 mg/day as a subcutaneous injection; Suprecur or Suprefact;
number of oocytes to be independent predictors of IVF out- Hoechst, Frankfurt, Germany). Down-regulation was followed by stim-
come (Stolwijk et al., 1996; Templeton et al., 1996; Strandell ulation with recombinant FSH (Gonal-F, Serono, Geneva, Switzerland
or Puregon, Organon, Oss, Netherlands). Monitoring was carried out by
et al., 2000).
vaginal ultrasound scans and serum estradiol measurements. When ade-
The aim of the present study was to investigate the effect
quate stimulation was achieved (3 follicles of 18 mm diameter),
of psychological stress before and during IVF treatment on 10,000 IU HCG (Profasi, Serono) was administered.
the outcome of IVF, controlling for known physiological Fertilization was performed by conventional IVF or by ICSI follow-
predictors. The hypothesis was that psychological stress ing standard techniques. In general, two embryos were transferred two
may have a negative influence on the results of IVF. Psy- or three days after oocyte retrieval using a Wallace or a Frydman cathe-
chological stress is expressed here as a low level of general ter. Luteal support was given either with s.c. HCG or with progesterone
psychological well-being including experienced negative (i.m. or vaginally). Additional embryos of good quality were cryopre-
psychological effects of infertility, negative effects of infer- served and replaced later. Pregnancy was defined as a positive HCG test
tility on the womans relationship with her partner, high in urine on day 19 post-transfer. Clinical pregnancy was defined as
intensity of the child-wish, experiencing infertility as a threat ultrasound verified pregnancy 5 weeks after embryo transfer.
to a positive self-picture, experiencing life as meaningless
and feeling little affinity with others, and a major difference Measures
between an ideal life situation and the way the woman experi-
The women answered extensive questionnaires concerning psy-
ences the life she is living.
chological factors. The first questionnaire was filled in directly
after the information meeting one month before onset of down-
regulation, and the second questionnaire one hour before
Materials and methods
oocyte retrieval. The questionnaires included the following.
Design
This is a prospective, longitudinal study of women during their first First occasion of measurement
IVF cycle at Sahlgrenska University Hospital, Gteborg, Sweden. The Psychological well-being
women were recruited between March 1999 and June 2002 from the
Reproductive Unit, Department of Obstetrics and Gynaecology. They General psychological well-being during recent weeks was
answered questionnaires concerning psychological and social factors measured by the Psychological General Well-Being (PGWB)
on two occasions during the IVF treatment. The study was approved index (Dupuy, 1984). PGWB contains 22 items with six response
by the ethics committee at Gteborg University. alternatives (16). The higher the value, the better the well-being.
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Psychological stress of in vitro fertilization

Table I. Background variables for pregnant and non-pregnant women in patients receiving embryo transfer

Pregnant (n = 58) Non-pregnant (n = 81) P

Age (years), mean (SD) (range) 32.2 (3.4) (25.038.0) 31.9 (3.7) (24.043.0) 0.66
Duration of infertility (years), mean (SD) (range) 4.7 (2.6) (1.517.0) 4.2 (2.1) (1.512.0) 0.20
Waiting period for IVF-treatment (months), mean (SD) (range) 18.6 (9.0) (2.048.0) 17.6 (8.2) (2.036.0) 0.70
No. of previous IVF cycles,* mean (SD) (range) 0.02 (0.13) (0.01.0) 0.17 (0.54) (0.03.0) 0.04
Cause of infertility, n (%)
Male 24 (41.4) 34 (42.0) 1.0
Female 34 (58.6) 47 (58.0)
No. of women with previous pregnancies, n (%) 22 (37.9) 31 (38.3) 1.0
No. of women with children in earlier relationship, n (%) 6 (10.3) 10 (12.4) 0.79
No. of women with current somatic disease, n (%) 12 (20.7) 31 (38.3) 0.04
No. of women with previous somatic disease, n (%) 5 (8.6) 12 (14.8) 0.31
No. of women with current psychiatric disorder, n (%) 3 (5.3) 2 (2.5) 0.40
Smoking, n (%) 5 (8.6) 13 (16.0) 0.31
College/university, n (%) 19 (32.8) 33 (40.7) 0.37
Urban residence, n (%) 41 (70.7) 54 (66.7) 0.71
Rural residence, n (%) 17 (29.3) 27 (33.3) 0.71
Working, n (%) 53 (91.4) 72 (88.9) 0.78
Studying, n (%) 2 (3.5) 6 (7.4) 0.47
Unemployed, n (%) 3 (5.2) 2 (2.5) 0.65

*One woman in the pregnant group and nine women in the non-pregnant group had previously undergone 13 IVF-cycles at a private IVF clinic.

In addition to a total score for the index, there are sub-scores for Difference between the ideal and the real-life situation
anxiety, depressed mood, positive well-being, self-control, gen- Seven items were formulated concerning the womans percep-
eral health and vitality. In the current study, we focused on the tions of the correspondence between how she wanted her life to
total score and two sub-scoresdepressed mood and anxiety. be and how she thought it was. The answers were given on a
The scale has been translated into Swedish and tested on VAS. The items covered work, leisure time, social contacts
Swedish patients (Dimens et al., 1996). PGWB has shown with friends and relatives, relation with her partner, sexual life,
satisfactory reliability and validity (Dupuy, 1984; Naughton and life in general.
and Wiklund, 1993).
In addition to the well-evaluated PGWB, psychological Optimism versus pessimism
effects of infertility were measured by 14 items (guilt, success, Optimism/pessimism was captured by two questions: (i) what
anger, contentment, frustration, happiness, isolation, confid- do you think about the results of the treatment you are about to
ence, anxiety, satisfaction, depression, powerlessness, compe- start? And (ii) how do you describe yourself, as an optimist or
tence and control). These items were devised for the present a pessimist? The answers were given on a VAS.
study and seek to capture aspects of experiences often
expressed by infertility patients. The items were formulated as Second occasion of measurement
questions like How much of the following feelings do you
The same 14 items regarding psychological effects of infertil-
experience during the present days: guilt, success, etc?. The
ity were assessed as at the first measurement occasion. The
items were analysed separately.
same two questions regarding the relationship were asked as at
Each item was graded from 1 to 5. Low figures indicate
the first measurement occasion.
well-being.
Relationship with her partner Subgroups
The effects of infertility on the womans relationship with her The following subgroups were analysed in relation to pregnant
partner were estimated by two questions: (i) do you feel that versus non-pregnant:
infertility has caused problems in your marriage? and (ii) do you (i) those with scores on the PGWB in the lowest quartile,
find it harder to talk to each other now than before? These items i.e. those who experienced the poorest psychological well-
were also graded from 1 to 5 (1 = not at all, 5 = very much). being (n = 39);
(ii) those with scores for psychological effects of infertility in
Intensity of the child-wish the highest quartile at the second measurement occasion, i.e. those
The strength of the child-wish was estimated by seven ques- who experienced the most negative effects of infertility (n = 35);
tions [visual analogue scale (VAS)] covering perceptions of (iii) those who answered no to the question as to whether
the womans own wishes (six questions) and of the expecta- they could consider an alternative to IVF (n = 36);
tions of others (one question). (iv) a combination of groups 13 (n = 8).
Meaning of reproduction
The meaning of reproduction was estimated by six items (VAS) Statistics
covering aspects of self-picture, meaningfulness and affinity Means, standard deviations, medians and ranges are descriptive
(Mller and Fllstrm, 1991). statistics. Continuous and ordered variables were compared by
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L.Anderheim et al.

the MannWhitney U-test, dichotomous variables by Fishers poor ovarian response. Embryo transfer was performed in 139
exact test and the MantelHaenszel 2 test for the variable (83.7%) out of 166 patients. Reasons for not reaching embryo
number of previous IVF cycles. A stepwise forward logistic transfer were: risk of ovarian stimulation syndrome (n = 3);
regression analysis was performed for the dependent variable fertilization failure (n = 3); bad quality embryos (n = 12); and
clinical pregnancy. Variables with P < 0.1 in the univariate freezing of all embryos due to myoma uteri or intrauterine pol-
analysis were included in the model. All significance tests yps that had not been detected earlier (n = 2).
were two-sided and performed at a significance level of 0.05.
First measurement occasion
Results Psychological well-being
Demographic and treatment variables for the pregnant and PGWB results did not differ between pregnant and non-pregnant
non-pregnant groups are shown in Tables I and II. No differ- women. In general, PGWB values were comparable with
ences between pregnant and non-pregnant women were found Swedish reference values (Dimens et al., 1996) reflecting that
regarding age, length of infertility or number of previous preg- the women starting IVF treatment were in good psychological
nancies/previous births. The total number of good quality health.
embryos, the number of good quality embryos transferred, and When analysing each of the 14 items in the questionnaire
the number of embryos transferred were significantly higher in concerning the psychological effects of infertility, no signific-
the pregnant than in the non-pregnant group (Table II). ant difference was found. The mean scores for each of the 14
All 166 women answered the first questionnaire and 151 items were mainly in the middle of the scale (Table III). How-
women answered the second questionnaire. In seven patients, ever, there was considerable variation between individual
the IVF cycle was cancelled before oocyte aspiration due to women.

Table II. Treatment variables for pregnant and non-pregnant women in patients receiving embryo transfer

Pregnant (n = 58) Non-pregnant (n = 81) P

IVF, n (%) 26 (44.8) 33 (40.7) 0.73


ICSI, n (%) 32 (55.2) 48 (59.3) 0.60
No. of oocytes aspirated
mean (SD) 12.7 (5.3) 12.6 (6.9) 0.48
median (range) 12.0 (2.028.0) 12.0 (235.0)
No. of good quality embryos total
mean (SD) 4.4 (2.9) 3.6 (3.0) 0.04
median (range) 4.0 (1.0 12.0) 3.0(0.012.0)
No. of good quality embryos transferred
mean (SD) 1.9 (0.3) 1.6 (0.7) 0.001
median (range) 2.0 (1.02.0) 2.0 (0.02.0)
No. of embryos transferred
mean (SD) 1.9 (0.3) 1.8 (0.4) 0.05
median (range) 2.0 (1.02.0) 2.0 (1.02.0)

Table III. Psychological variables for pregnant and non-pregnant women in patients receiving embryo transfer

Pregnant (n = 58) Non-pregnant (n =81) P

Mean (SD) (range)

PGWB
Total for items 122 100.9 (14.0) (62120) 100.3 (15.9) (53127) 0.89
Depressed mood 15.4 (2.2) (9.018.0) 15.5 (2.5) (4.018.0) 0.53
Anxiety 21.0 (4.7) (9.029.0) 21.8 (4.8) (8.030.0) 0.32
Effect of infertility, the first measurement
Guilt 1.5 (0.7) (1.04.0) 1.4 (0.6) (1.03.0) 0.35
Success 3.1 (0.8) (2.05.0) 3.0 (1.0) (1.05.0) 0.32
Anger 2.1 (1.0) (1.04.0) 2.2 (1.1) (1.05.0) 0.79
Contentment 3.1 (0.9) (1.05.0) 3.0 (1.0) (2.05.0) 0.44
Frustration 3.0 (1.1) (1.05.0) 2.8 (1.2) (1.05.0) 0.24
Happiness 2.5 (0.8) (1.04.0) 2.6 (1.0) (1.05.0) 0.98
Isolation 1.5 (0.9) (1.04.0) 1.5 (0.9) (1.05.0) 0.67
Confidence 2.4 (0.8) (1.05.0) 2.2 (0.9) (1.05.0) 0.15
Anxiety 2.9 (3.0) (1.05.0) 2.7 (1.1) (1.05.0) 0.48
Satisfaction 2.8 (0.8) (1.05.0) 2.9 (0.9) (1.05.0) 0.62
Depression 1.8 (0.9) (1.04.0) 1.8 (1.0) (1.05.0) 0.84
Powerlessness 2.9 (1.2) (1.05.0) 2.8 (1.3) (1.05.0) 0.76
Competence 2.9 (1.0) (1.05.0) 2.8(1.1) (1.05.0) 0.68
Control 2.9 (0.9) (1.05.0) 3.0 (0.9) (1.05.0) 0.34

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There were no differences between women who got preg- the highest quartile for the questions on psychological effects
nant and those who did not with regard to the relationship with of infertility. A recent study from the Netherlands (Smeenk
her partner, intensity of the child-wish, meaning of reproduc- et al., 2001) showed that psychological factors were independ-
tion, difference between ideal and real-life situations, and opti- ently related to treatment outcome. Differences in population
mism versus pessimism. For problems in the marriage, we and choice of questionnaires may explain these differences. In
found a mean of 1.5 (SD 0.8) (range 14) in the pregnant group our study, a relatively large number of patients were included,
versus a mean of 1.6 (SD 0.8) (range 14 ) in the non-pregnant several different psychological measurements were used, and
group. Regarding intensity of the child-wish (the sum of six the design was prospective. Even when analysing the subgroup
items), the pregnant women scored a mean of 35.7 (SD 10.0) of patients with very high scores for stress, the results changed
(range 14.654.9) compared with 34.9 (SD 10.2) (range only marginally and no significant differences between preg-
13.658.3) in the non-pregnant group. nant and non-pregnant women were noted.

Second measurement occasion


Analysing all data including those patients not achieving
The results of the 14 items covering psychological effects of
embryo transfer did not change the overall results
infertility and the two questions covering the womans rela-
tionship with her partner did not differ between the women According to the PGWB results and those for other questions,
who got pregnant and those who did not. In the pregnant group, the women in this study, as a group, expressed surprisingly
frustration measured a mean of 2.5 (SD 1.2) (range 1.05.0) good psychological well-being prior to the IVF treatment,
versus 2.8 (SD 1.4) (range 1.05.0) in the non-pregnant group. although there were large inter-individual differences. This
The item anxiety scored a mean of 2.8 (SD 1.1) (range 1.05.0) finding was somewhat unexpected and did not correspond with
by the pregnant women and a mean of 2.9 (SD 1.2) (range our earlier clinical impression. One possible reason for this
1.05.0) by the non-pregnant. could be that patients answers were more positive than what
When analysing the subgroups, scores on the PGWB in the they actually experienced, and that they kept their worries and
lowest quartile (n = 39), scores for psychological effects of anxiety to themselves because they had great expectations
infertility in the highest quartile (n = 35), those who could not regarding both themselves and the anticipated treatment. Per-
consider an alternative to IVF (n = 36) and a combination of haps they also wanted to show how well they felt and that they
these groups (n = 8), no statistically significant differences could handle the treatment. It has been reported that infertility
were found between the women who got pregnant and those patients suppress their feelings of stress because they want to
who did not [PGWB group (P = 0.70), effects of infertility (P = show the clinic that they are functioning well both socially and
0.32), those who could not consider an alternative (P = 0.85) psychologically (Demyttenaere et al., 1998).
and a combination of the three subgroups (P = 0.46)]. Time points for questionnaires could, of course, always be
Selected psychological variables in the univariate analysis discussed. The choice of the first measurement was because we
are presented in Table III. wished to study the psychological status before any appoint-
A stepwise forward logistic regression analysis was per- ments at the clinic apart from the information meeting. The
formed for variables that showed a difference at P < 0.1 in the second measurement was chosen based on our clinical experi-
univariate analysis (number of good quality embryos trans- ence that patients often express feelings of anxiety and stress
ferred, total number of good quality embryos, number of just before the oocyte retrieval. The day of embryo transfer is
embryos transferred, number of previous IVF cycles, number certainly also a distressing moment for the patients and perhaps
of women with current somatic disease). The only variable that it could have been valuable to measure on that occasion.
was significantly associated with pregnancy was the number of One of the chosen instruments, PGWB, has proven good
good quality embryos transferred. reliability and validity. It is also sensitive to changes (Dimens
et al., 1996). The other instruments have been devised for the
present study and have not been psychometrically evaluated.
Discussion The instruments were chosen in order to capture aspects of
During IVF treatment, patients frequently ask about the rela- stress seen in the literature and expressed by infertility patients.
tionship between psychological stress and IVF outcome. They One cannot exclude, however, that the failure to find an associ-
often express worries that their own stress might have a nega- ation between psychological stress and outcome of IVF is due
tive influence on the outcome. The results of the present pro- to a lack of sensitivity of the instruments used.
spective study do not indicate any relationship between Another aspect, at least in Sweden, is the observation that
perceived psychological stress or perceived psychological patients tend to express negative emotions and psychological
well-being before or during the first IVF treatment and out- strain in verbal interviews rather than in questionnaires (Sjgren,
come of IVF. These results can be regarded as reassuring and 1989; Forsberg-Wrleby et al., 2002). It could be regarded as
can help to decrease the stress experienced by patients. more definitive and dangerous to put experiences of negative
Our findings are in accordance with some earlier studies feelings in writing rather than expressing these feelings verbally
(Harlow et al., 1996; Slade et al., 1997, Ardenti et al., 1999). in an interview. The tendency to level out ones responses is
However, we had expected to find such a relationship regard- more pronounced when filling in questionnaires.
ing at least some of the variables or for the group of women However, it is also true that when IVF treatment is immi-
who scored in the lowest quartile on the PGWB index and in nent, women have great hope for success. Couples have waited
2973
L.Anderheim et al.

for this possibility for years and their view is that at last Forsberg-Wrleby G, Mller A and Blomstrand C (2004) Psychological well-
being of spouses of stroke patients during the first year after stroke. Clin
something concrete and hopeful is going to happen. If this Rehabil 18,430437.
study had been performed after failed IVF treatments, the Freeman EW, Boxer AS, Rickels K, et al. (1985) Psychological evaluation and
results might have been different. support in a program of in vitro fertilization and embryo transfer. Fertil
In conclusion, this study could not demonstrate an associa- Steril 43,4853.
Harlow CR, Fahy UM, Wardle PG and Hull MGR (1996) Stress and stress-
tion between psychological stress and IVF outcome. This related hormones during in vitro fertilization treatment Hum Reprod
information should be reassuring and should help to reduce 11,274279.
womens stress and worry during infertility treatment. Harrison RF (1983) Stress in infertile couples. Proceedings 7th International
Congress on Psychosomatic Obstetrics and Gynaecology, Dublin.
Harrison RF, OMoore RR and OMoore AM (1986) Stress and fertility. Some
modalities of investigation and treatment in couples with unexplained infer-
Acknowledgements tility in Dublin. Int J Fert 32,153159.
We would like to thank Nils-Gunnar Pehrsson and Mattias Molin for Harrison KL, Callan VJ and Hennesey JF (1987) Stress and semen quality in
statistical assistance. The study was supported by grants from the an in vitro fertilization program. Fertil Steril 48,633636.
Vardal Foundation and Sahlgrenska Academy. Hjollund NH, Bonde JP, Brink Henriksen T, Giwercman A, Olsen J and the
Danish First Planner Study Team (2004) Reproductive effects of male psy-
chologic stress. Epidemiology 15,2127.
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