CRD summary

This review concluded that despite the absence of clinical effects on mental health measures, psychological interventions were found to improve some patients' chances of becoming pregnant, but more randomised controlled trials were needed. The authors' cautious conclusions reflected the data presented, but the potential for various biases in the review means that their reliability is unclear.

Authors' objectives

To determine the effectiveness of psychological interventions for the improvement of mental health and pregnancy rates in infertile patients.

Searching

MEDLINE, PsycINFO, PSYNDEX, Web of Science, and the Cochrane Library were searched without language restriction for articles from 1978 to 2007; search terms were reported. Reference lists of reviews and conference abstracts of the European Society of Human Reproduction (2002 to 2006) and the American Society for Reproductive Medicine (2002 to 2006) were scanned for additional articles.

Study selection

Prospective studies of infertile patients receiving psychological interventions independent of actual medical treatment were eligible for inclusion. Eligible control group participants were those not receiving a psychological intervention and on waiting lists or receiving routine care. To be included studies had to report at least one of the following outcome measures: mental health, interpersonal functioning, infertility-specific stress, or pregnancy rates.

The interventions in the included studies were undertaken in a range of settings and included counselling, cognitive-behavioural therapy, mind or body orientated relaxation, education, psychodynamic or psychoanalytic therapy, or mixed interventions. Duration of interventions varied between studies. Control groups included routine care and waiting list or participants who refused the intervention. Ten studies reported participants receiving in vitro fertilisation (IVF) or intra cytoplasmic sperm injection (ICSI); eight studies reported other interventions, such as intra-uterine sperm insemination; and three studies reported mixed treatments. The mean duration of infertility was 3.8 years (range 1.5 to 5.9 years). The mean age of participants ranged from 27 to 38.5 years. Some studies included women only, some included men and women and some studies only included treated couples. The following psychosocial outcomes as well as pregnancy rates were reported: depression, anxiety, state anxiety, mental distress, interpersonal functioning, and infertility-specific stress. Measurement of these outcomes varied between studies. The majority of studies measured outcomes between four weeks and six months after the psychological intervention. Studies were conducted in Europe, USA, China, and Canada.

Two reviewers independently assessed studies for inclusion and the authors did not report how disagreements were resolved.

Assessment of study quality

Validity was assessed using the following criteria: use of standardised measures of psychological outcomes, randomisation, blinding, comparable intervention and control groups, comparable care, dropouts (before allocation, during the study, and difference between intervention and control groups), and reporting of inclusion criteria.

The authors did not state how many reviewers performed the validity assessment.

Data extraction

Data were extracted for each outcome at baseline, at post-intervention, or at follow-up. The mean and standard deviation were used to calculate the effect sizes (ESs) and their corresponding 99% confidence intervals (CIs) for psychological outcomes. Where only median data were reported, the ES was calculated using methods described by Hozo et al. (2005, see Other Publications of Related Interest). For studies with more than two groups, one ES was calculated for the entire study through a collective comparison of effects registered by treatment groups, compared with control conditions. ESs were defined as: low (0.2 to 0.5), medium (0.5 to 0.8) and large (more than 0.8). Data on the number of pregnancies following the intervention were compared with control groups and used to calculate the relative risk (RR) and 99% CI. An intention-to-treat analysis was used.

Two reviewers independently extracted data and disagreements were resolved through discussion.

Methods of synthesis

Pooled RRs and ESs together with 99% CIs were calculated using a random-effects model. Heterogeneity was assessed using the χ² and I² statistics. Heterogeneity for the I² statistic was defined as low at 25%, moderate at 50%, or high at 75%. Subgroup analyses were conducted for sex (men versus women), duration of intervention (short interventions of five or fewer sessions versus longer ones of six or more sessions), treatment (IVF or ICSI versus no IVF or ICSI), and randomisation (versus no randomisation). Publication bias was assessed through a visual inspection of funnel plots.

Results of the review

Forty-one studies were included in the review and 21 controlled studies (n=4,762 patients) were included in the meta-analysis. Twelve studies reported random allocation; 10 studies reported standardised measures of psychological outcomes; three studies reported blinded assessment of outcomes and group membership; in 19 studies the groups were comparable at baseline; 20 studies provided comparable care for intervention and control groups; and 13 studies reported 20% or fewer dropouts during the course of their study.

Psychological measures (12 controlled studies): There were no statistically significant differences between intervention and control groups in depression (12 studies), anxiety (12 studies), mental distress (eight studies), interpersonal functioning (five studies), nor infertility-specific stress (five studies). Significant statistical heterogeneity was found for depression (I²=88%) and for anxiety (I²=81%). Heterogeneity was reduced when one study was removed from the analyses, but the overall differences remained non significant.

Pregnancy rate (13 controlled studies): Psychological interventions had a significant positive impact on pregnancy rates (RR 1.42, 99% CI 1.02 to 1.96, 13 studies) and heterogeneity was moderate (I²=43%). For the intention-to-treat analysis the pooled pregnancy relative risk was 1.48 (99% CI 0.98 to 2.21) with moderate heterogeneity (I²=58%).

There was evidence of potential publication bias for some analyses. The results of subgroup analyses were reported.

Authors' conclusions

Despite the absence of clinical effects on mental health measures, psychological interventions were found to improve some patients' chances of becoming pregnant, but more randomised controlled trials were needed.

CRD commentary

The review question was clear and the inclusion criteria were defined. Several relevant sources were searched and efforts were made to reduce language and publication biases, but the authors reported evidence of possible publication bias. Appropriate methods were used to reduce reviewer error and bias for study selection and data extraction, but it is unclear whether similar steps were taken for validity assessment. Validity was assessed using appropriate criteria, but it is unclear whether the results of the assessment were used to inform the analysis. Studies were appropriately combined in a meta-analysis and the reasons for heterogeneity were explored. The authors reported combining the outcomes of multiple intervention groups in one study and the potential impact of combining these arms on the pooled results is unclear.

The authors' cautious conclusions reflected the data presented, but the potential for various biases in the review means that their reliability is unclear.

Implications of the review for practice and research

Practice: The authors stated that psychological interventions should be integrated in the treatment of infertility as there was some evidence of their effectiveness in increasing pregnancy rates, particularly for patients not receiving IVF or ICSI. The efficacy of psychological interventions on the mental health of infertile patients could not be verified.

Research: The authors stated that further randomised controlled trials using robust methodology were required. These trials should consider different types of psychological interventions (psychotherapy, counselling, or education), different settings (single, couple, or group), and different intensities of therapy. Further research should examine the effects of gender on outcomes and analyse the results for men and women separately. The patients' phase of infertility should be taken into account and adequate measures of infertility-specific mental distress need to be established.

Funding

Swiss National Science Foundation (325100-11375411).

Bibliographic details

Hammerli K, Znoj H, Barth J. The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Human Reproduction Update 2009; 15(3): 279-295. [PubMed: 19196795]

Original Paper URL

http://humupd.oxfordjournals.org/cgi/content/abstract/15/3/279

Other publications of related interest

Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of sample. BMC Medical Research Methods 2005; 5: 1-10.

Indexing Status

Subject indexing assigned by NLM

MeSH

Adult; Controlled Clinical Trials as Topic; Female; Humans; Infertility /psychology; Male; Mental Health; Pregnancy; Pregnancy Rate; Reproductive Techniques, Assisted /psychology; Treatment Outcome

AccessionNumber

12009104793

Database entry date

31/03/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.