Differences in perceived stress during ovarian stimulation between women with infertility and those pursing oocyte cryopreservation.

OBJECTIVE: To determine whether the purpose of ovarian stimulation (oocyte cryopreservation [OC] versus in vitro fertilization (IVF) is associated with perceived stress before or after ovarian stimulation; and whether perceived stress is associated with ovarian stimulation outcomes. DESIGN: Prospective cohort study. SETTING: Academic practice. PATIENTS: Women undergoing their first ovarian stimulation cycle as part of a randomized clinical trial, the Learning from Online Video Education (LOVE) study (NCT02979990). INTERVENTIONS: Questionnaire before and after ovarian stimulation. MAIN OUTCOME MEASURES(S): Perceived stress scale (PSS) scores before and after stimulation. The number of oocytes collected was a secondary measure. RESULTS: After adjustment for age, income, race, education, financial assistance, and fertility diagnosis, the indication for treatment (IVF vs. OC) was a significant predictor of pretreatment PSS scores. IVF participants had higher pretreatment scores (18.01 ± 6.43) than did OC participants (15.62 ± 5.61). Posttreatment PSS scores did not differ between the two groups. IVF participants experienced a decrease of 0.85 ± 2.34 points in PSS scores after treatment, whereas OC participant scores were stable over time. The trajectory of PSS scores differed between the two groups and neared significance. Financial support was a significant predictor of pretreatment and posttreatment PSS scores for the entire cohort. Neither pretreatment nor posttreatment PSS was predictive of the number oocytes collected. CONCLUSION: Compared with OC patients, IVF patients have higher stress levels, which decrease after ovarian stimulation. Perceived stress does not affect oocyte yield.

Impact of infertility and infertility treatments on quality of life and levels of anxiety and depression in women undergoing in vitro fertilization.

This study aims to evaluate levels of anxiety and depression in women, correlated with infertility per se and with infertility treatments, highlighting predictors of higher levels of distress. Two validated standardized questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Fertility Quality of Life (FertiQoL), were administered to 89 women both before their first cycle of infertility treatment and again at the end of the ovarian stimulation for in vitro fertilization (IVF). Women's levels of anxiety were significantly higher before the treatment than during the treatment itself. Stratifying the women in three groups based on principal cause of infertility (male infertility, female infertility, or both male and female), we found significantly higher levels of anxiety and general distress in patients under treatment for female infertility. Higher anxiety levels in our sample before the treatment are probably an effect of not knowing what they are expected to do to solve their problem. Moreover, when the cause of infertility is exclusively female, women experience higher levels of anxiety and general distress both before and during the treatment, probably correlated to a sense of guilt. These data help the treating physician to better counsel patients and to provide a more focused psychological support.

Using the EngagedMD multimedia platform to improve informed consent for ovulation induction, intrauterine insemination, and in vitro fertilization.

OBJECTIVE: To study patient and provider feedback on how a multimedia platform (EngagedMD) helps patients to understand the risks and consequences of in vitro fertilization (IVF), ovulation induction (OI), and intrauterine insemination (IUI) treatments and the impact of the informed consent process. DESIGN: Prospective survey study. SETTING: IVF units in the United States. PATIENT(S): Six-thousand three-hundred and thirty-three patients who viewed the multimedia platform before IVF or OI-IUI treatment at 13 U.S. IVF centers and 128 providers. INTERVENTION(S): Quantitative survey with 17 questions. MAIN OUTCOME MEASURE(S): Assessment of the impact of a multimedia platform on patient anxiety, comprehension, and satisfaction and provider/nurse feedback related to the informed consent process. RESULT(S): The survey was completed by 3,097 respondents (66% IVF treatment; 34% OI-IUI treatment) and 44 providers. Overall, 93% felt the media platform was intuitive, and 90% and 95% felt it had appropriate duration and detail, respectively. Most agreed/strongly agreed it better prepared them to consent (88%), increased their comfort in pursuing treatment (77%) and increased their satisfaction with their care (83%). Compared with the OI-IUI group, statistically significantly more participants who viewed the IVF media platform strongly agreed that the comprehension questions reinforced key concepts (47% vs. 40%), educated them about treatment risks (55% vs. 44%), helped them ask providers informed questions (45% vs. 36%), and better prepared them to sign consent forms (46% vs. 37%). Overall, 63% of providers felt that the media platform improved patient learning, made patients more accountable, and standardized information dissemination. CONCLUSION(S): The EngagedMD media platform improves patient knowledge, satisfaction, and control over medical decision making and better prepares patients to give informed consent. Furthermore, it is well-liked by providers and is easily implemented.

Insights from clinical experience in treating IVF poor responders.

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

Treatment-related psychological stress in different in vitro fertilization therapies with and without gonadotropin stimulation.

INTRODUCTION: Infertility treatments such as in vitro fertilization (IVF) impose substantial distress. However, the specific role of individual contributory factors remains unclear. We therefore compared treatment-related psychological stress in IVF treatments with (cIVF) and without (NC-IVF) gonadotropin stimulation, as cIVF includes potentially stressful factors such as ovarian stimulation, anesthesia, embryo selection and cryopreservation, whereas NC-IVF does not. MATERIAL AND METHODS: Women were offered to have cIVF or NC-IVF. Validated psychological questionnaires filled in online before, during and after completed treatment cycle(s) at home were used to analyze psychological distress and treatment-related satisfaction and quality of life. To avoid different pregnancy rates in the two treatment groups, one cIVF was compared with three NC-IVF therapies, resulting in the same cumulative pregnancy rate. RESULTS: Data from 57 NC-IVF and 62 cIVF patients were evaluated. NC-IVF resulted in a similar overall clinical pregnancy rate than one cIVF. NC-IVF patients had a significantly lower level of depression (CES-D, 13.4 vs. 15.7, p < 0.05) and a higher satisfaction with the treatment (Treatment FertiQoL, 67.9 vs. 62.9, p < 0.05) compared with cIVF patients. The level of psychological distress increased during c-IVF treatment and decreased during NC-IVF treatment. In contrast, during NC-IVF treatment there was a significant increase in satisfaction with the treatment, whereas satisfaction with treatment in the cIVF patients decreased. CONCLUSIONS: Factors other than just pregnancy rate seem to have an impact on psychological stress in IVF treatment. Due to reduced psychological stress in NC-IVF, this treatment could be especially considered in psychologically stressed women.

Psychiatric Symptoms Associated with Oocyte-Donation.

Oocyte-donation is generally safe but may exacerbate psychiatric symptoms in some women. In this prospective study 63 oocyte-donating women and, as a control group, 63 women providing their own oocytes for in vitro fertilization (in couples with male infertility) were evaluated pre- and post-ovulation-induction in regard to hypochondriasis, anxiety, social impairment, and depression. The mean hypochondriasis score for oocyte-donators was significantly lower than for women providing their own oocytes, prior to ovulation-induction (5.03 vs. 6.59). However, after ovulation-induction and oocyte retrieval this score rose to 6.66 among oocyte-donators, whereas it remained essentially unchanged among women providing their own oocytes (6.66). The mean anxiety score for oocyte-donating women also rose following this procedure, from 5.87 to 7.65. Depression scores for both groups remained similar, before and after the procedure. Results showed that at the beginning of the ARP donating women have the same conditions as own oocyte women regarding depression and anxiety but after the egg harvesting they would suffer more damages regarding hypochondriasis and anxiety aspects.

Does oocyte banking for anticipated gamete exhaustion influence future relational and reproductive choices? A follow-up of bankers and non-bankers.

STUDY QUESTION: What is the nature of the relational status, reproductive choices and possible regret of a pioneer cohort of women that either considered or actually performed oocyte banking for anticipated gamete exhaustion (AGE)? SUMMARY ANSWER: Only half of the women who banked oocytes anticipate using them in the future but the experience with oocyte banking is overwhelmingly positive, with the majority of AGE bankers preferring to have it performed at a younger age. WHAT IS KNOWN ALREADY: Most women who choose to cryopreserve oocytes for the prevention of age-related fertility decline are single and are hoping to buy time in their search for a suitable partner. The question of why some candidates actually embark on such treatment while others eventually prefer not to freeze remains unclear. There are no follow-up data available either on post-freezing changes in relational status, or on attitude towards the undergone treatment and the reproductive outcome. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study was performed with 140 women who visited the outpatient clinic between 2009 and 2011. All women (mean age 36.7 ± SD 2.62) considered oocyte preservation for age-related infertility. At least 1 year after their initial visit (range 12-45 months), women were contacted by phone to participate in a standardized questionnaire developed to evaluate their actual relational and reproductive situation, their attitude towards banking and future reproductive plan. PARTICIPANTS/MATERIALS, SETTING, METHODS: Eighty-six women (61.4%) completed at least one cryopreservation cycle. The non-bankers included 54 women who either preferred no treatment (n = 51) or attempted stimulation but cancelled because of poor response (n = 3). The response rate among bankers was 75.4% (65/86) while 55.8% (29/52) of the non-bankers were reached for interview. MAIN RESULTS AND THE ROLE OF CHANCE: Among bankers, 50.8% of women think they will use the oocytes at some point, while 29.2% indicated that they currently consider the use of frozen oocytes less likely than anticipated at time of oocyte retrieval. However, although 95.4% would decide to do it again, the majority (76.0%) would prefer to do it at a younger age. Among bankers, 96.1% would recommend the treatment to others. Women who banked accept a higher maximum age for motherhood when compared with non-bankers (43.6 versus 42.5 years; P < 0.05). Almost all bankers and 89.6% of the non-bankers still have a desire for a child. Bankers and non-bankers did not differ in terms of experiencing steady relations (47.7 versus 55.2%), attempting conception (35.4 versus 44.8%) and not conceiving within 1 year (17.4 versus 15.4%). LIMITATIONS, REASONS FOR CAUTION: The study has a limited follow-up of 1-3 years and therefore does not provide information on the reproductive outcome of the cryopreserved oocytes. Although most women appear to be realistic about their chances of pregnancy, the outcome of such treatment could affect the attitude of women towards the treatment. Furthermore, the findings of non-bankers cannot be generalized to the general population because the control group of non-bankers in this study actually visited a centre as a potential candidate for banking. WIDER IMPLICATIONS OF THE FINDINGS: Bankers and non-bankers have a surprising congruent relational status and reproductive choices, indicating that freezing oocytes does not appear to influence the life choices of the women. The study provides insights into the important psychological aspect of reassurance associated with preventive oocyte banking, expressed by high satisfaction after banking in combination with a decreased intention of ever using the eggs.

Validation of the controlled ovarian stimulation impact measure (COSI): assessing the patient perspective.

BACKGROUND: Controlled Ovarian Stimulation (COS) is the first step for in vitro fertilization (IVF) treatment, a treatment often described and experienced as stressful to patients and their partners. COS also requires concerted efforts by the patients in administering medication and general compliance to treatment protocols. Little is known about the impacts on patients that may be specific to this important first step in treatment. The absence of a conceptually sound and well-validated measure assessing patient experience and functioning during ovarian stimulation has been an obstacle to understanding the impacts of ovarian stimulation on women pursuing IVF. To address this gap, the Controlled Ovarian Stimulation Impact Measure (COSI) was developed based upon accepted methods for designing patient reported outcome (PRO) measures. The purpose of this study was to psychometrically validate the COSI. METHODS: 267 patients from three countries (Ireland, United Kingdom, United States) were administered the COSI. Psychometric validation was conducted according to an a priori statistical analysis plan. RESULTS: The final 28-item COSI was found to have robust scale structure with four domains: Interference in Daily Life (Work and Home), Injection Burden, Psychological Health and Compliance Worry. Internal consistency of all domains was adequate (between 0.80 to 0.87) as was test-retest reliability (between 0.72-0.87). All a-priori hypotheses for convergent and known-groups validity tests were met. CONCLUSIONS: There is a measurable impact of COS on patient functioning and well-being. The COSI is a well-developed and validated PRO measure of this impact. Future work should include examination of responsiveness and confirmation of concepts in non-western countries.

Are attachment dimensions associated with infertility-related stress in couples undergoing their first IVF treatment? A study on the individual and cross-partner effect.

STUDY QUESTION: Are attachment anxiety and avoidance dimensions in female and male partners in couples seeking infertility treatment associated with her and his infertility-related stress? SUMMARY ANSWER: Attachment dimensions are significantly associated with several aspects of infertility stress in couples undergoing IVF treatment. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Attachment dimensions of anxiety and avoidance (where highly anxious individuals fear rejection and are preoccupied with maintaining proximity to their partner and highly avoidant individuals are uncomfortable with intimacy and prefer to maintain distance from their partner) may influence the well being of individuals undergoing IVF/ICSI treatment. This study showed that one partner's attachment dimensions had a direct effect on the infertility-related stress of the other partner. DESIGN: Cross-sectional study of consecutive couples before starting their first IVF/ICSI treatment in 2009-2011 at the ANDROS clinic in Palermo, Italy. PARTICIPANTS AND SETTING: Three hundred and fifty-nine couples undergoing fertility treatments were invited to participate in the research. The final sample comprised 316 females and 316 males who filled out the psychological questionnaires (Experiences in Close Relationships; Fertility Problem Inventory; State scale of State-Trait Anxiety Inventory). The participants included patients who had a primary infertility diagnosis and were about to undergo their first IVF or ICSI treatment. DATA ANALYSIS METHOD: Paired t-tests were used to examine gender differences on the study variables (attachment anxiety, attachment avoidance, infertility stress, state anxiety, etc.). Associations between infertility-related stress and the study variables were explored using hierarchical stepwise multivariate linear regression analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Attachment anxiety and attachment avoidance were significantly associated with global infertility stress in both women (ß = 0.24, P < 0.01 and ß = 0.27, P < 0.01) and men (ß = 0.23, P < 0.01 and ß = 0.37, P < 0.01). Regarding the cross-partner effects, men's infertility stress and relationship concerns were associated with their partners' attachment avoidance (ß = 0.10 P < 0.05 and ß = 0.12, P < 0.05); and the infertility stress of women and the scores for need of parenthood were associated with their partners' attachment anxiety (ß = 0.14 P < 0.05 and ß = 0.16, P < 0.05). BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION: The study data are cross sectional, and specifically focus on associations between adult attachment style and infertility stress. Treating the data from couples as independent observations may be a limitation of the analysis. Potential moderators of such relationships (e.g. coping strategies, stress appraisal) are not included in this study. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by funds provided by Centro Andros S.r.l., Palermo, Italy. The authors declare no financial or commercial conflicts of interest in this study.

Physicians should be more open-minded about performing in vitro fertilization-embryo transfer in women with diminished oocyte reserve and consider the couple's wishes and desires.

PURPOSE: By presenting anecdotal cases of women who conceived with IVF-ET despite very poor odds, this editorial hopes to make some of the infertility specialists to be more optimistic about the prognosis for pregnancy in women with diminished oocyte reserve. METHODS: Description of case reports where despite poor odds the couples elected to still attempt IVF-ET which appeared to be needed for conception to be possible. RESULTS: Five cases are presented where the couple was willing to deplete their financial resources to achieve a pregnancy with IVF-ET using their own gametes and were eventually successful. CONCLUSIONS: Physicians should restrain from being dogmatic and present all options to patients not merely the physicians' preference. It is embarrassing for a physician to insist that successful pregnancy is impossible only for the patient to prove that physician wrong. After receiving proper data patients should be allowed greater input into their treatment decision.

Understanding the perceptions of and emotional barriers to infertility treatment: a survey in four European countries.

BACKGROUND: Infertility can significantly impact women's lives and personal relationships. Despite the negative impact of infertility, a significant number of women who are struggling to conceive do not consult a physician. This cross-sectional survey was conducted to determine the emotional impact of infertility on women to identify which aspects of fertility treatment contribute to the psychological stress experienced by so many patients and to identify barriers to seeking treatment. METHODS: Women (n = 445; 18-44 years) who had received fertility treatment within the past 2 years or were having trouble conceiving but had not received treatment, completed a 15-min survey online. RESULTS: Participants were from France (n = 108), Germany (n = 111), Italy (n = 112) and Spain (n = 114). Responses indicated that infertility causes a range of emotions and can strain relationships. Women who had received treatment were more likely to feel hopeful (26 versus 21%) and closer to their partner than women not in treatment (33 versus 19%, P < 0.05). Most women delayed starting treatment because of a desire to conceive naturally, and on the advice of physicians. Women aged ≥35 years took longer to seek help with their fertility issues. Injection-related anxiety was the second greatest barrier to treatment. CONCLUSIONS: This study has provided insight into the physical and psychological challenges of infertility treatments and permitted a better understanding of the factors that impact patient lives. A treatment protocol with minimal injections and provision of additional information may lessen the emotional impact and challenges of infertility and contribute to patient satisfaction with fertility treatment protocols.

Pituitary-adrenal and sympathetic nervous system responses to psychiatric disorders in women undergoing in vitro fertilization treatment.

OBJECTIVE: To evaluate whether psychological variables as well as changes in hypothalamus-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) at baseline and in response to a psychosocial stressor affect the chance of achieving pregnancy in women undergoing a first in vitro fertilization (IVF) cycle. DESIGN: Prospective study. SETTING: Private IVF center. PATIENT(S): 264 women undergoing IVF or intracytoplasmic sperm injection (ICSI) treatment. INTERVENTION(S): Oocyte retrieval after ovarian stimulation. MAIN OUTCOME MEASURE(S): Standardized psychological questionnaires to assess anxiety and depression, and norepinephrine and cortisol in serum or follicular fluid measured by specific assays. RESULT(S): Only a trend increase was found in psychological scores during treatment, which did not affect the ongoing pregnancy rates. On the oocyte retrieval day, a statistically significant increase in norepinephrine and cortisol concentrations was found. Lower concentrations of norepinephrine and cortisol, both in serum and follicular fluid, were found in women whose treatments were successful. Concentrations of steroid in serum before treatment and in follicular fluid were positively associated with the State Anxiety scores. CONCLUSION(S): Norepinephrine and cortisol concentrations may negatively influence the clinical pregnancy rate in IVF treatment. These biological stress markers could be one of the links in the complex relationship between psychosocial stress and outcome after IVF-ICSI.

Willingness to pay and conjoint analysis to determine women's preferences for ovarian stimulating hormones in the treatment of infertility in Spain.

BACKGROUND: Despite many advances in assisted reproductive techniques (ART), little is known about preferences for technological developments of women undergoing fertility treatments. The aims of this study were to investigate the preferences of infertile women undergoing ART for controlled ovarian stimulation (COS) treatments; to determine the utility values ascribed to different attributes of COS treatments; and to estimate women's willingness to pay (WTP) for COS. METHODS: A representative sample of ambulatory patients ready to receive, or receiving, COS therapies for infertility were recruited from seven specialized private centres in six autonomous communities in Spain. Descriptive, inferential and conjoint analyses (CA) were used to elicit preferences and WTP. Attributes and levels of COS treatments were identified by literature review and two focus groups with experts and patients. WTP valuations were derived by a combination of double-bounded (closed-ended) and open questions and contingent ranking methods. RESULTS: In total, 160 patients [mean (standard deviation; SD) age: 35.8 (4.2) years] were interviewed. Over half of the participants (55.0%) had a high level of education (university degree), most (78.8%) were married and half (50.0%) had an estimated net income of >€1502 per month and had paid a mean (SD) €1194.17 (€778.29) for their most recent hormonal treatment. The most frequent causes of infertility were related to sperm abnormalities (50.3%). In 30.6% of cases, there were two causes of infertility. The maximum WTP for COS treatment was €800 (median) per cycle; 35.5% were willing to pay an additional €101-€300 for a 1-2% effectiveness gain in the treatment. Utility values (CA) showed that effectiveness was the most valued attribute (39.82), followed by costs (18.74), safety (17.75) and information sharing with physicians (14.93). CONCLUSIONS: WTP for COS therapies exceeds current cost. Additional WTP exists for 1-2% effectiveness improvement. Effectiveness and costs were the most important determinants of preferences, followed by safety and information sharing with physicians.

GnRH-agonist induced depressive and anxiety symptoms during in vitro fertilization-embryo transfer cycles.

To determine whether the use of a GnRH agonist inducing a hypogonadic state during IVF-ET cycles induces negative mood symptoms, we conducted a prospective randomized study in 108 women comparing two different controlled ovarian stimulation protocols. A significant phase effect was observed for depression and anxiety symptoms during IVF-ET cycles reflecting an increase in symptoms between the hypogonadal phase and the peak in gonadotropin stimulation; however, the hypogonadal phase induced by the GnRH agonist was not associated with a significant increase in any of the studied mood parameters.

Heterosexual couples' uses and meanings of ovarian stimulation: Relatedness, embodiment and emotions.

This article is about how ovarian stimulation is understood within the context of heterosexual couples' relationships. The empirical research involves 15 semi-structured interviews with patients in Portugal who have undergone IVF programmes performed with eggs collected in stimulated cycles. We argue that the uses and meanings of ovarian stimulation expressed in the patients' narratives represent situated values and knowledges conveyed by existing emotional resources within multiple gendered relations and identities. We discuss how empirical reconfigurations work in a mode of conversion of physical and emotional pain so that the application of subcutaneous injections to women's bodies makes sense within IVF couples' daily routine and in their conjugal relationship. The different practices of men's involvement in the injection of hormones into women's bodies are perceived as emotional moments, and men's cooperation and/ or protection seems to be essential in this domain. The cultural assumptions underlying women's duties regarding maternity reinforce a moral framework in which the pain and the complications associated with the ovarian stimulation are naturalized, normalized and accepted.

Understanding the burden of ovarian stimulation: fertility expert and patient perceptions.

This multinational, interview-based study was conducted to provide insights into participants' experiences, behaviour, attitudes and emotions towards fertility treatments. One study group comprised 185 patients who were undergoing ovarian stimulation for IVF while the other comprised 170 physician and nurse fertility experts. A key study objective was to identify which aspects of ovarian-stimulation treatment contribute to the physical and psychological burden on patients. Ovarian-stimulation treatment was considered by 55% (n = 102) of patients to impact upon daily life, while 31% (n = 57) felt that daily injections limited their everyday activities. The most frequent questions from patients to physicians and nurses concerned fertility drug-related side effects, followed by concerns about how to perform their injections. More than half of patients (57%, n = 106) had concerns about the injection process. Within the fertility expert group, almost half (47%, n = 80) expressed concern about whether their patients injected themselves correctly, with 26% (n = 44) raising concerns about patient compliance. This study adds to the growing body of literature on the impact of ovarian stimulation on patients' lives and highlights areas in which improved patient education could help to reduce the psychological burden of IVF treatment.

Women's views on Friendly IVF: a qualitative preliminary study.

OBJECTIVE: To study in the French Context women's experiences with a low-stimulation regimen of in vitro fertilisation (Friendly IVF) and to compare them with those of women undergoing standard IVF (S-IVF). POPULATION AND METHODS: Two assisted reproduction technology centers participated in this preliminary study. Patients'views were explored qualitatively. In-depth interviews were conducted at the end of the second monitored cycle. Twelve friendly IVF patients and 13 S-IVF patients participated in the study. RESULTS: The respondents indicated that the most positive aspect of Friendly IVF was the low doses of hormones used. Cancellation of cycles and failure of oocyte retrieval were perceived the most negatively. Women in the Friendly IVF group reported fewer side effects and expressed emotional distress less acutely than women in the S-IVF group. The Friendly IVF treatment was percieved as a first step, sustaining the hope of success with a standard treatment. CONCLUSION: Friendly IVF, as practiced in the center studied, represents a valuable alternative for most respondents as a first step in IVF treatment.

Patient satisfaction and clinical outcome after injecting gonadotropins with use of a needle-free carbon dioxide injection system for controlled ovarian hyperstimulation for in vitro fertilization.

In this prospective, randomized clinical trial, we tested the hypothesis that a needle-free CO(2) injection system (Biojector 2000) would be better tolerated by patients when compared with traditional sharp needles used for gonadotropin injections during stimulation for IVF. As measured by our questionnaire, the needle-free CO(2) injection system was not better tolerated by patients, even though it was equally effective clinically.

Trial development of the Cognitive Appraisal Scale for Infertility (CASI) (version 1).

OBJECTIVE: To develop the Cognitive Appraisal Scale for Infertility (CASI) and assess it for reliability and validity. DESIGN: Cross-sectional and longitudinal study. SETTING: A private fertility institute in Japan. PATIENT(S): 223 infertile women being treated at the institute. INTERVENTION(S): Administration of questionnaire at initial consultation and 6 months later. MAIN OUTCOME MEASURE(S): A self-rating questionnaire of perceptions and feelings about infertility on a four-point Likert scale, the State-Trait Anxiety Inventory (STAI), and the Self-rating Depression Scale (SDS). Internal consistency (Cronbach's alpha), test-retest reliability coefficients, and concurrent validity correlations. RESULT(S): Factor analysis identified eight factors with 35 items: difficulty accepting infertility, decrease in self-esteem, acceptance/coming to terms with new self-identity, despair, loss of libido and erosion of marital relationship, guilt, denial, and self-imposed isolation. Internal consistency for factors 1 and 2 was 0.88 and 0.82, for factors 3 to 8 was from 0.68 to 0.58. Test-retest reliability coefficients were 0.90 to 0.72. Concurrent validity correlations between CASI and STAI, and SDS ranged from 0.54 to 0.29. CONCLUSION(S): The CASI, a new and potentially useful scale to assess emotional responses to infertility, is still in development. Further refined CASI and standardized scores of each subscale could be efficient for clinical practice.