| A qualitative analysis of women who have undergone a multi-stage psychotherapy and hypnotherapy intervention to manage psychological stress while undergoing in-vitro fertilisation: What were their experiences and outcomes? | ||
| Professor Alan Francis Patching Bath Spa University, United Kingdom & Bond University, Australia |
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| For presentation at the 8th International Conference of the World Council for Psychotherapy, Asia, Malaysia 2015, held in conjunction with The 2nd International Conference of Psychotherapy, Counseling and Psychiatry: Theories, Research and Clinical Practice | ||
Abstract The literature is rich with studies addressing stress effects on In Vitro Fertilisation (IVF) outcomes. Debate continues regarding whether there is a cause-and-effect relationship, or merely a correlation, between stress and IVF failure. While several studies have addressed coping mechanisms used by couples undergoing IVF, and the effects of coping mechanisms used at three points within an IVF cycle, the author found no study that presented a programme for women to deal with stress before, during and after IVF cycles. Based on evidence from practice, the author devised a five-phased psychotherapy and hypnotherapy protocol (“IVF-Assist”). This qualitative study provides insights from the narratives of eight ‘difficult case’ women who underwent that programme, including one who found she would never be able to carry to term. The narratives of both the seven participants who fell pregnant and the one who was unable to carry to term inform future psychotherapy interventions to assist women better address stress effects that could affect IVF outcomes. 1.00 Introduction and Research Aims 1.01 Introduction Stress affects people in different ways, contributing to changes in emotional and other responses that can lead to disease (Cohen et al., 2007). In (financial) 2011/2012, stress was prevalent in 428,000 (40 per cent) cases of work-related illness in Britain, with females affected totalled 253,000, and women in the 35-44 age bracket were most affected (HSE, 2013). Across this age range, IVF success rates reduce from 27.7% to 5% in Britain (www.hfea.gov.uk). An Australian study noted physical injury claims were decreasing, but mental stress related claims increased 83% between 1996-97 and 2003-04 (Keegel et al., 2009). The author’s previous workplace stress study findings (Patching and Best, 2013) prompted the question, ‘Does the stress often experienced by women undergoing IVF derive from the IVF process itself, or from factors external to that process; and does the origin of stress make any difference to IVF process outcomes?’ Studies focusing on women’s experience of IVF treatment tend to concur that the practical aspects of IVF process and emotional responses to treatment are interwoven (Redshaw et al., 2007; Berg and Wilson, 1988; Berg and Wilson, 1990; Munoz et al., 2009; Turner et al., 2013). Those works focused on emotional experience of IVF, and paid scant attention to how pre-existing stress might contribute to perceptions of IVF stress. Studies that addressed pre-existing stress concluded that couples commencing IVF were psychologically well-adjusted, with little deviation between their data and the normative (Hearn et al., 1987; Shaw et al., 1988; Newton et al., 1990; Edelmann et al., 1994; in Eugster and Vingerhoets 1999; Lord and Robertson, 2005). This researcher found no evidence to conclude ‘psychologically well-adjusted’ means free of a level of stress that could impact IVF outcomes, or even at a level within normative data ranges that might easily exceed normative ranges during IVF treatment. Research supports this view, concluding that average scores used in many tests could mask participants with high distress levels (Lord and Robertson, 2005). Conflicting opinion exists regarding levels of psychological stress in women about to undertake IVF. Eugster and Vingerhoets (1999) report a study by Visser et al., in 1994, that women about to begin their first IVF cycle scored higher on state anxiety than the normative group. Several studies identify elevated stress levels in women at specific times of the IVF cycle. For example, waiting for pregnancy test results, and hearing that treatment failed (Beaurepaire et al., 1994; Boivin and Takefman, 1995; Eugster and Vingerhoets, 1999; Turner et al., 2013). Some researchers found the stage of treatment, especially for women who have experienced IVF failure, exerts major influence on psychological functioning (Berg and Wilson, 1990) while one controlled study found no significant difference between first versus subsequent cycles (Turner et al., 2013). Turner et al., also found that, while anxiety did not significantly change across three separate points in the cycle, resilience decreased over time, opening the possibility that perception of the ability to cope with stress might reduce, and contribute to IVF failure. Despite a solid body of literature addressing stress at particular stages of the IVF cycle, and coping strategies used by couples during IVF (Berg and Wilson, 1990; Eugster and Vingerhoets, 1999; Schmidt et al., 2005;) the author found no recommendation for a stress management intervention with components specific to particular stages of the IVF process. An Israeli study investigated having women hypnotised during embryo transfer to reduce the impact of mini-uterine contractions triggered by insertion of the embryo transfer cannula. Women in hypnosis experienced double the successful implantation rate of those not in hypnosis, and the pregnancy rate of the hypnosis group was 53.1% compared with 30.2% for the control group (Levitas et al., 2006). The author formulated IVF-Assist, based on proven therapeutic techniques, to assist women undergoing IVF. The programme is outlined in Appendix A. Smoking affects female fertility and pregnancy (Bolumar et al., 1996; Augood et al., 1998, Klonoff and Cohen, 2005) as does alcohol consumption (Klonoff-Cohen et al.,2003) which is also associated with still birth rate (Kesmodel et al., 2001) and post birth problems (Feldman, 2012) including future fertility of the foetus (Sharpe and Franks, 2002) so the author decided to include smoking cessation and alcohol consumption reduction work as a part of Phase 1 of the intervention. Based on number of successful pregnancies in a high risk-of-failure group, IVF-Assist could be regarded as successful. However, it is important that any (new) intervention be evaluated not only on outcomes, but also on the basis of the experiences of those involved. The purpose of this research was to gain insights into the experiences of those who have undertaken IVF-Assist. 1.02 Research Aim This research aims to gain insight into perceived effects of psychological stress before, during and after IVF, from the perspective of women who have experienced the process. The study seeks insights from participants into factors associated with psychological stress in relation to IVF that might assist formulation of a better therapeutic intervention to alleviate psychological stress before, during and after IVF, and enhance prospects of pregnancy. 2.00 Literature Review 2.01 Introduction This research aims to investigate the effects of IVF-Assist in alleviating stress for women undergoing IVF. Some participants experienced several IVF failures before undertaking the subject protocol and so an understanding of stress effects on IVF outcomes is necessary. 2.02 Stress and reproduction Stress is largely governed by the limbic hypothalamic system (LHS), which regulates vitally important body functions and regulates the pain and pleasure centres of the brain, which are very important in an individual’s perception of stress (Flynn and Patching, 2006). A number of reproductive disorders in women are proven to be associated with inhibited Gonadotropin-Releasing-Hormone (GnRH) pulsatility (Tsutsumi and Webster, 2009). GnRH is responsible for releasing Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH) from the anterior pituitary gland during the follicular phase of the female fertility cycle. In turn, GnRH pulsatility is linked to the LHS (Brkovich and Fisher, 1998). Glucocorticoids (GCs), the adrenal steroid hormones secreted in response to stress, suppress and otherwise influence reproductive ability (Sapolski, 2003). The definition that stress is comprised of psychological factors that can affect general medical conditions (DSM-IV-TR, 2000) aligns with this thinking. 2.03 Workplace stress These biological-physiological connections imply that stress management would be a step towards achieving better outcomes from IVF, especially where workplace-generated stress effects are in play. All study participants were working women, and most held senior positions in demanding work environments. Some researchers conclude that factors other than work are involved in the formation and manifestation of stress (Lingard, 2003; Lingard and Francis, 2004). Others agree that non-work factors contribute to an individual’s stress, but conclude the most frequent stressors are work-related problems (Nakao, 2010; Sparks et al., 2001; Cox et al., 2006; Albertsen et al., 2010; Waite, 2012). These factors suggest that focusing attention on stress generated by sources other than IVF-related processes, is prudent. 2.04 Defining Stress Psychological stress is ‘a condition’ likely to be experienced when individuals perceive they face demands and responsibilities beyond their capacity. The perceived lack of control during IVF can be stress-inducing. To effectively review the literature regarding stress, it is important to maintain awareness of how the LHS governs stress. The LHS categorises our feelings about a situation into a sense of being either safe or threatened. It operates by emotions associated with situations, not by reasoned logic. If the LHS notices that one survives a perceived threat by being stressed, it replays that survival programme whenever the individual faces similar circumstances. (Flynn and Patching, 2006). Stress can broadly be divided into eustress such as that experienced when first seeing a new-born, or winning a competition, and distress, requiring no elaboration (Colligan and Higgins, 2008). Whether an individual experiences eustress or distress, she (or he) will experience a cognitive, behavioural-emotional and physical response directly related to the individual’s capacity to cope (Colligan and Higgins, 2008). This study addresses distress. There are three levels of distress, acute, episodic and chronic, in ascending order. Women undergoing IVF are more likely to suffer episodic or chronic stress. The works studied, except one, employed a variety of subjective stress assessment protocols. All literature relied upon in this study asserted acceptable levels of validity and reliability for the assessment tools applied. 2.05 Defining Infertility The World Health Organisation (WHO) provides three definitions of infertility, Most experts use WHO’s clinical definition: A disease of the reproductive system defined by the failure to achieve clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (www.who.int/reproductivehealth/infertility/definition/en/). The Mayo Clinic (www.mayoclinic.org) John Hopkins Medicine (www.hopkinsmedicine.org) and The Victorian Assisted Reproductive Treatment Authority (www.varta.org.au) agree that frequent unprotected sex for 12 months not resulting in pregnancy constitutes infertility. Infertility affects 10-15% of couples of reproductive age (Deka and Sarma, 2010; www.hopkinsmedicine.org; www.asrm.org). Approximately 15-30% of women who present for infertility treatment will receive a diagnosis of “unexplained infertility” (Quass and Dokras, 2008; Templeton and Penny, 1982, in Pandian et al., 2001; Omland et al., 2004; Bearepaire et al., 1994). Male issues also contribute to infertility. A 1992 report revealed a 25% decrease in sperm count since 1970 in Scotland compared with the 11 years prior to 1970 (Brake and Krause, 1992, in Miyamoto et al., 2012). Environmental factors prevented any conclusive connection between stress increase and sperm count decrease. Despite one clinical trial finding very low percentages of IVF problems attributable to men (Peterson et al., 2006), male infertility are regarded as in the order of 40 to 50 per cent (Quaas and Dokras, 2008; www.mayoclinic.org; www.hopkinsmedicine.org). Some 50% of male infertility is classified idiopathic (Olooto, 2012). Males are the sole cause of couples’ infertility in approximately 30% of cases (Quaas and Dokras, 2008). Treatment of male infertility has been revolutionised by Intra-Cytoplasmic Sperm Injection (ICSI) which involves injecting a single healthy male sperm into the ovum (Quaas and Dokras, 2008). Because of the extensive interference with the female necessitated by IVF, research must centre around women’s experience of the process (Throsby, 2004). All study participants were women. Assisted Reproductive Techniques (ART) cover all human reproductive technologies apart from natural intercourse (www.cdc.gov). WHO stipulates that ART includes all procedures for in-vitro handling of human oocytes and sperm for establishing pregnancy, not including artificial insemination (www.who.int). IVF-Assist was developed for women undergoing IVF, and most participants underwent IVF (albeit one did have three cycles of Intra Uterine Insemination (IUI) prior to commencing IVF) so IVF has been used throughout. 2.07 Stress and IVF Prolific literature highlights that psychological stress can be caused by IVF processes, Thee is also a strong focus on coping strategies. Some research has focused on both the psychological impact of infertility and of prolonged exposure to infertility treatment. While significant data is lacking concerning psychiatric intervention, some data does support psychotherapeutic interventions (Deka and Sarma, 2010). Stress arising from lack of fulfilment of the desire to reproduce can produce feelings of anger, failure and worthlessness, anxiety and depression (Deka and Sarma, 2010; Dunkel-Schetter and Lobel 1991; Munoz et al., 2009; Eugster and Vingerhoets,1999). Evidence exists that women experience higher levels of distress than their male partners (Beaurepaire et al., 1993; Munoz et al., 2009; Verhaak et al., 2005; Eugster and Vingerhoets; 1999). This is not surprising, given the highly intrusive nature of IVF on women’s lives. Some women feel they lose control over their body function (Munoz et al., 2009, Eugster and Vingerhoets, 1999). The most impactful intrusions include initial medical tests, regular injections, oocyte collection, and embryo transfer (Klonoff-Cohen, 2005; Gaasbeek and Leerentveld, 1993; Redshaw et al., 2007). Some studies posit that IVF failure can increase symptoms of depression (Thiering et al., 1993) while others conclude that IVF process or failure is of insignificant effect (Boivin and Takefman, 1996; Boivin et al., 1995). Clinical depression can produce elevated prolactin levels and disrupt hypothalamic-pituitary-adrenal (HPA) axis function, suggesting caution in dismissing the impact of anxiety and depression on IVF outcome (Deka and Sarma, 2010). One study concludes that depression can disrupt normal functioning of ovulation-regulating LH (Meller et al., 1997, in Deka and Sarma 2010) and another found ovulatory defects present in 40% of infertile women (PCASRM, 2006, cited in Quaas and Dokras, 2008). The literature contains strongly conflicting findings regarding the effect of number of IVF cycles undertaken on psychological variables. Some researchers found no significant association between number of IVF cycles and psychological variables, including anxiety (Beaurepaire et al., 1994), others concluded that stress may contribute to infertility (Eugster and Vingerhoets, 1999). Beaurepaire et al., (1994) found repeat-cycle women more depressed than IVF inductees, and other research found repeat patients showed greater drops in resilience than inductees, which may indicate cumulative stress from multiple cycles (Turner et al., 2013). Beaurepaire et al. (1994) also reported significantly higher anxiety in those undergoing IVF than for same-sexed community controls. Another study found similar results for infertile women on three out of four anxiety measures (O’Moore et al., 1983, in Dunkel-Schether and Lobel, 1991). Other studies found no significant differences between those undergoing IVF and control groups on several measures of anxiety, depression and loss of control (Paulson et al., 1988 in Dunkel-Schetter and Lobel 1991). 2.08 Causal Relationship? The most controversial area of the literature concerns whether or not a causal relationship exists between psychological stress and IVF outcome. One Swedish study concluded there was no evidence that psychological stress had any influence (Anderheim et al., 2005) while a contradicting Dutch study found that psychological factors were related to treatment outcomes (Smeenk et al., 2001). Klonoff-Cohen’s extensive literature study concluded the evidence that psychological stress was associated with IVF failure was suggestive but inconclusive (Klonoff-Cohen, 2005). Anderheim et al., (2005) reference Smeenk’s study in their work, citing differences in population and choice of questionnaires as possible explanations for the different findings. Despite different survey instruments having been found to have reliability and validity, lack of consistency of approach appears to explain differences in many studies’ conclusions. This gives rise to the question, ‘Why not use more objective measurement tools in research design?’ The answer probably lies in the absence of an accepted and convenient bio-marker for stress (Turner et al., 2013) and in the longitudinal nature and large, geographically dispersed sampling of much research. Earlier studies would have required blood testing for biological analysis and this might not appeal to IVF patients who cited medical testing, and needles in particular, as stressors. Csemicsky et al., (2000) used radio-immunoassay to measure the stress markers serum prolactin and cortisol and proved elevated levels for infertile women compared with fertile controls, and concludeded that psychological stress may affect the outcome of IVF treatment. Recently, less intrusive objective tests, including saliva analysis, have facilitated conclusive research based on objective data. A breakthrough United States study concluded that higher levels of stress are associated with longer time-to-pregnancy and increased risk of infertility (Lynch et al., 2014). This study was the first in the United States to use salivary bio-markers to associate psychological stress with time-to-pregnancy. Moreover, it was the first study in the world to prove an association between psychological stress and infertility. The authors of the Lynch study stated that repeat saliva sampling was logistically and fiscally impossible. Professor Ray Isles, a British researcher into bio-marking technology for a number of stress related diseases, believes that cortisol is a stress bio-marker of choice in objective quantitative research, but lacks ultimate reliability unless multiple saliva samples are collected over time and cortisol fluctuations within individuals noted in response to various stressors (Isles interview, 2014). 2.09 Stress Levels at IVF stages Some research addressed stress across the time during which women underwent IVF, but little addressed specific cycle-related stressors. In addition, a body of research addresses coping strategies’ effects, but there is scant literature concerning management interventions designed to assist with specific stressors within each IVF cycle. One study investigated 104 couples in different stages of medical interventions for infertility over a number of years, concluding that length of time into treatment and number of failed IVF cycles may exert a major influence on psychological functioning (Berg and Wilson, 1990). Few studies focused on stress level variations across each cycle. One study had 40 women record subjective stress ratings daily for one complete cycle, and answer a questionnaire regarding the stress of IVF. Women who did not become pregnant reported more stress during specific stages of IVF and that stress was higher during the wait for pregnancy test results than generally during the cycle. The study concluded that stress is related to IVF outcome, but not that a causal relationship exists (Boiven and Takefman, 1995). Turner et al. (2013) also conducted a study across individual cycles without collecting subjective stress ratings daily. Participants completed a survey instrument prior to ovarian stimulation, prior to oocyte retrieval and 5-7 days after embryo transfer. They found relatively consistent anxiety levels across the cycle and no significant collective difference between IVF groups and controls, despite considerable difference in scores on survey questionnaires between women (Turner et al., 2013) a finding the author considers significant. Importantly, Turner’s study emphasised the need to investigate stress reduction modalities throughout IVF, because women with lower stress the day before oocyte retrieval achieved higher pregnancy rates (Turner et al., 2013). The literature is consistent in recognising strong correlation between psychological stress and IVF results. 2.10 IVF Service British researchers approached 460 women who had received infertility treatment and received 230 responses. They found participants wished to be treated with respect and dignity, have their distress recognised and be given appropriate information and support. Participants emphasised the need for better communication from health professionals and adequate follow up and support during and after service provision (Redshaw et al., 2007) The study concluded that IVF treatment was an “emotional and physically difficult process” (Redshaw et al., 2007:304) and that almost all participants desired improvements in “psychological impact of the problem and of the treatment process” (Redshaw et al., 2007:304). The majority of studies in the literature were quantitative and virtually all focused on the stress of undergoing infertility treatment. Few investigated effects of pre-existing psychological stress from causes other than infertility. The few studies that addressed stress from both pre-existing factors and those caused by the IVF process paid scant attention to the first of these two distinct and separate concerns. 2.11 Coping Strategies Coping is a person’s constantly changing cognitive and behavioural efforts to manage specific internal and external demands appraised as taxing or exceeding the person’s resources (Lazarus and Folkman 1984, in Folkman et al., 1986). The literature regarding coping appears more weighted towards assessment of strategies used by research participants of their own volition than towards the effect of strategies proposed by researchers or clinicians. Earlier coping strategies were common-sense based, with maintaining a positive attitude towards success, keeping busy and seeking support among the most popular (Berg and Wilson, 1988). Berg and Wilson also reported staying calm to be a commonly used coping strategy. (Cue visualising a British greeting card emblazoned with “Keep Calm and Get Pregnant” in circa-World War II font styling – See Figure 2.1). Figure 2.1 – Keep Calm and Get Pregnant - greeting card
A study covering 25years research (706 literature articles) concluded that women starting IVF were only slightly different emotionally from the normative group, but that IVF failure triggered higher levels of negative emotions which increased with consecutive unsuccessful cycles (Verhaak et al., 2007). This highlights the potential value of effective coping strategies. Coping skills, personality and social support are, to an extent, determinants of emotional response and can explain differences in response to IVF failure (Abraham et al., 1978, in Verhaak et al., 2007). Coping during treatment is important, and coping after ceasing treatment following failures should not be ignored, and counselling is recommended (Newton et al., 1990, in Verhaak et al., 2006). One study found that women suffering IVF failure may not experience more negative effects than those who had success, but they do express less positive effects, and lower levels of life satisfaction (Hammarberg et al., 2001). This informs counselling intervention approaches for women who cease IVF after failure. Some women who cease IVF after failure cope well by being forced to accept their unresolved infertility (Peddle et al., 2005). Generally, post-treatment adjustment and coping following failure have not been widely studied (Verhaak et al., 2006) but the importance of cognitive strategies to successful adjustment after IVF failure is consistently stressed (Terry and Hynes 1998, in Verhaak et al., 2006; Verhaak et al., 2005). In summary, the literature reveals less need for coping strategies at commencement of IVF than during the IVF process and after cessation following unsuccessful treatment. But what of coping with IVF procedures, the emotional demands of which were highlighted earlier? A longitudinal cohort study involving 2,250 people at the beginning of treatment with a 12-month follow-up indicated no significant difference in coping strategies and communication between those who became pregnant and those who did not (Schmidt et al., 2005). However, another study concluded that not all coping strategies are equal, and emphasis on use of those shown to be more effective is to be encouraged (Peterson et al., 2006). Difficult marital communication is a significant predictor of high fertility problem-related stress for both men and women (Schmidt et al., 2005). Broader communication is important as a coping mechanism, provided that appropriate decisions are made about to whom one should talk and what one should disclose (Schmidt et al., 2005b, in Schmidt et al., 2005a). The Schmidt study indicated that secretive communication and high use of active-avoidance coping were significant predictors of high fertility problem stress, while meaning-based coping and passive-avoidance coping are not associated with fertility problem stress. This seems to contradict what an informed person might reasonably expect to be the case. Appropriately, the study authors noted that their findings regarding passive-avoidance coping did contradict the findings of three other studies between 1992 and 2002 which reported that escapism or avoidance, similar in nature and definition to passive-avoidance coping, were associated with poor adaption in women after a failed IVF cycle (Schmidt et al., 2005a. Others have emphasised that infertility stress was positively related to escape-avoidance coping approaches (Peterson et al., 2006). The literature does not appear to test coping strategies beyond derivatives of the emotion-focused coping strategies (adjusting emotional response to the perceived problem) and problem-focused coping strategies (managing or altering the problem causing the stress) developed by Lazarus and Folkman (1984). 2.12 Medical Aspects Cannulisation during embryo transfer causes uterine contractions (similar to but less intense than those of child birth) which can hinder successful implantation (Fanchin et al., 1998). Evidence from ultrasound examination prior to transfer suggests pregnancy rates are related to the frequency of those uterine contractions (Kovaks, 1999). A 2006 study by Israel’s Soroka University Medical Centre indicated that women in hypnosis during embryo transfer achieved higher embryo implantation and clinical pregnancy rates (Levitas et al., 2006). 52 of 98 patients in the hypnosis group became pregnant compared with 29 of 96 in the control group. Another study reported that 8.7% of routine embryo transfers found embryos in the cervix, or on the speculum, the probable cause being expulsion from the uterus by the contractions that the Levitas research sought to control (Poindexter et al., 1986; in Levitas et al., 2006). 2.13 Knowledge Gap Much of the literature has been driven by the dictates of research (as science) more than by the needs of women suffering the impacts of psychological stress on IVF outcomes. The literature covers several aspects of stress effects on IVF outcome. Studies that do explore stress within individual IVF cycles investigate reactions at three points of the cycle. The author found no study that focused on five phases of the IVF process, including prior to beginning IVF and the period following a successful IVF cycle, or of women’s experience of an intervention designed to address stress at each of those five stage 3.00 Methodology This work follows the Braun and Clarke (2013:3) statement that qualitative research, “…uses words as data collected and analysed in all sorts of ways”, and was sustained by concurrence with the assertion it is absurd to insist that interpretive research should conform to inappropriate definitions of scientific research from the quantitative domain (Atkinson and Delamont, 2006, in Denzin, 2009). Quantitative and qualitative data are at some level, inseparable, and neither can be considered devoid of the other (Trochim, 2006). 3.02 Research Paradigm Quantitative and qualitative data are at some level, inseparable, and neither can be considered totally devoid of the other (Trochim, 2006). The research needed to gain valuable insights into meanings, experiences and views of the participants (Pope and Mays, 1995) and to interpret and understand the manner in which participants constructed their perception of the subject protocol experience (Schwandt, 1994; Frost, 2011). The literature review revealed little consistency regarding a causal relationship between stress and IVF failure. It seemed pointless attempting to establish such a link, and more appropriate to focus on participants’ experience of the intervention and outcome. The aim of science is not to discover order where order simply does not or might not exist (Runeson and Skitmore, 1999). This study follows a qualitative research paradigm, ethnographic to an extent, employing an interpretive hermeneutic approach to analysis following data collection using semi-structured interviews. Observation of participants’ expressions, choice of words and the “…emotional tone of participants’ talk and of the researcher’s reactions” was important (Willig and Stainton-Rogers, 2013:16). Furthermore, the approach allowed adjusting methodological emphasis to embrace individual participants’ needs while maintaining process rigour. (Smith, 2007). Interviews were conducted with participants who had undergone IVF-Assist. The researcher used prepared questions in a less-structured open approach to encourage a more comfortable flow of narrative (Kelley et al., 2003; Smith, 2007). 3.03 Important Aspects of Methodology It has been argued that qualitative research methods execution must often be negotiated within time and context (Johnson et al., 2008) and this study accepts this proposition. The study is ethnographic, providing a portrait of the ‘world view’ of women who had undergone IVF-Assist. The researcher (and recording equipment) were embedded in the research environment, so the author recognises the possibility of “reciprocal impact of the researcher on the researched” (Lyons and Coyle, 2007:232; Willig, 2013). The ethnographic aspect of the study provides basis for extending the intervention within the community (Ebrahim and Sullivan, 1995) based on insights from the experience and narratives of the participants (Madison,2005, in Denzin 2009). The study employed phenomenology in studying each participant’s lived experience of the IVF-Assist (Ebrahim and Sullivan 1995). 3.04 Sampling Quantitative approaches emphasise the need for the sample to be representative in order to assert that what is true for the sample is also true for the whole population (Runeson and Skitmore, 1999). Applying these words to the whole population which interests people (Maxfield and Barbie, 2012) opens the possibility that even a small sample might constitute a firm basis for interest in the subject matter. Purposive sampling identified women regarded as difficult clients, either because of age or number of previous unsuccessful IVF cycles, or both. The possible sample was 14 women including three who became pregnant naturally using the subject intervention prior to commencing IVF. In addition, three women withdrew from the programme for personal reasons. The final sample comprised eight women, and all accepted the invitation to participate in the research. Participants’ demographics and outcomes are presented in Appendix “B” 3.05 Subjectivity and Rigour As data gathering interviews progressed following the noticing, collecting and thinking model (Seidel 1998) the author reflected that the study might be seen to lack rigour and therefore, validity and reliability – even credibility because the researcher had been therapist to the participants. To obviate this issue, the author employed peer debriefings of process, triangulation, a deviant case study (one of the women who became pregnant prior to commencing IVF) and a reflexive journal. An interview was conducted with an informed medical professional, for a different perspective (onlineqda.hud.ac.uk/into_QDA/qualitative_analysis.php). Despite attempts to minimise researcher effects, these cannot be neutralised. These steps provide a sense of transparency of process to ensure this report can be trusted (AERA, 2006, in Denzin, 2009). The information gleaned from interview responses can be regarded as representing typical examples of interaction and therefore give credibility to the likelihood of these perspectives prevailing in a similar but broader sampling of the community (Sandall, 2013). Peer debriefings were undertaken with a respected therapist colleague. Triangulation was via discourse with a study supervisor, with a researcher colleague, with a respected London-based stress bio-marker researcher, and with a prominent IVF medical practitioner in Australia who is familiar with the researcher’s work but presumably might not agree with all aspects of it. The reflexive journal (Frost, 2011) was a practice found helpful after commencing data analysis. As well as seeking to achieve credibility and dependability, the qualitative research equivalents of internal validity and reliability respectively (NCDDR, 2007, in Denzin, 2009) the author used referential adequacy to achieve transferability, the qualitative research equivalent of external validity (http://online.hud.ac.uk/Intro_QDA/qualitative_analysis.php). With this approach, the author contends the research meets acceptable standards for qualitative research accountability (Onwiegbuzie and Daniels, 2003). 3.06 Ethics Ethics approval for this study was given by Bath Spa University and the research complies with the BSU ethics policy. It also has been conducted within the ethics guidelines of the United Kingdom Council for Psychotherapy, the researcher’s professional institution. 3.07 Data Analysis Data analysis was complex, challenging, and immensely interesting, and began with transcribing then reading each interview (Etherington, 2004). Re-reading followed, while simultaneously listening to the recording and marking up the transcript with pauses, emotional responses and para-lingual and neuro-semantic characteristics. Text coding, and theme identification and categorisation followed prior to generating results (Bradley et al., 2007; Willig and Stainton-Rogers, 2013). 4.00 Findings Appendix “D” presents the main themes and categories that emerged from analysis of the eight participants’ narratives. The author will now address each theme individually. 4.02 Category – Intensely Personal Aspects of Experience All eight participants mentioned intensely personal aspects of IVF experience. Key themes within this category were maternal drive and the sense of loss of control. For two participants decision-making regarding embryos remaining after becoming pregnant was stressful. 4.02.01 Maternal drive All eight participants addressed their strength of maternal drive. Several connected their perceived stress with failure to satisfy that drive. One participant, already the mother and/or stepmother of five children, expressed the feelings of most participants: - The drive for a woman to have a baby is just inordinately strong. It’s clear and absolute…women will do absolutely anything to get that child. A woman not yet pregnant said: A comment from one woman indicated how her maternal drive was not extinguished by having babies: Even reflecting on the failure to conceive from the perspective of having had her baby raised particularly strong emotion in one participant:
4.02.02 Loss of, or need to regain control Six participants indicated that lack of control gave rise to stress between embryo transfer and pregnancy test. The issue was of more concern for four multiple-cycle participants. This is apparent in the comments presented in 4.06. The following comment exemplifies participants’ feelings regarding control: - All of this is happening TO me (emphasised) and I don’t get any part of it; I’m just the body they’re putting the embryo into. They’re telling you ‘This is what you’ve got to take; this is when you’ve got to take it; I am someone who likes to have a little bit of control (laughs) in my life, so I found that stressful.
4.02.03 Remaining embryos This issue was significant for the two participants who’d undergone the most IVF cycles. The following provides insight into their emotional conflict: - I wanted to have all those embryos. They are my children and I want them. It’s complete and utter insanity! None of them thawed properly and I was…absolutely devastated. I cried for 3 days Another participant, with no remaining embryos after transferring two, faced a moral dilemma:
4.03 Stress Psychological stress and its impact on infertility have been controversial issues. This research is concerned with participants’ experience of stress prior to, during and after IVF. 4.03.01 Life and work stress Seven participants experienced high-level stress. One experienced no stress from factors other than efforts to become pregnant. The following comments provide a flavour of participants’ stress: - I was stressed with my fertility situation, but I was working with a lady who was mentally unstable - that was also stressful. - It’s more the back stabbing, talking behind people’s backs – that I cannot stand. I stress myself out for days (laughs) thinking, ‘What have I done wrong? Why are they being mean
4.03.02 Personality and attitude-related stress Two participants referred to aspects of their personality in relation to IVF experience. All gave overt or implied insight into their attitude during IVF. The following comments provide a sense of the effect of those characteristics: - There are people I know who’ve had failed cycles – and you have a pity party, which usually involves chocolate and wine. Then you say, ‘OK, you just have to stand up, just get tough, and start again. Yeah!’ - I was like – I’m over it, sick of the mood swings. Every step things go wrong. I’m always waiting. My life is ruled by it! My husband was like, ‘do something with her; fix her!’ (laughs). While narrating something of emotional significance, participants often changed from using associated language (‘I’ language, narrating as if from within the scene) to dissociated (speaking other than from a personal perspective). Para-lingual characteristics often changed as this occurred. It was subtle and initially not identified, but a thorough review of data revealed it was broadly prevalent. Following are examples: - It was the change in my moods I didn’t expect. What happens to your moods is you are up and down. - All I want is a baby, and my body is not delivering it. What is wrong with me? (Voice change). Desperation! Am I ever going to have this child with this man I love.….. And you go again next month, but you don’t win. Someone’s just going, ‘oh sorry, it’s not positive’. It’s just so easy to become….suicidal. 4.03.03 IVF process-related stress All participants reported this as very high at various stages of IVF. Extracts from narratives provide insight into the participants’ emotions: - The whole IVF process is quite a sin … you can really go to the absolute upper limit of irrationality. - I see women in the street with babies and I hate them and I want to go and slap them – just really angry.….depressive. Extremely stressful! 4.03.04 Finance-related stress Finance-related stress was high for all participants. One woman underwent three cycles without anaesthetic for painful oocyte retrieval to secure a fee reduction. The following comment offers insight to the intensity of this stress : - I’ve heard of couples that have mortgaged their house. We spent $60,000, maybe $70,000, on IVF, which is ridiculous….a huge amount of money.
4.03.05 Miscarriage-related stress This was a very high level experience for six participants who experienced miscarriage or stillbirth. The following comment provides insight into these women’s stress and emotions: - It was only two cycles for the (stillborn) twins. I didn’t want to tell anyone I was pregnant this time - I was really scared something would happen. It was just a way of dealing with it. I can’t explain it.
4.03.06 Age-related stress This factor was a concern for four participants. All but two participants regarded age as of some concern and the following comment gives insight into the dimension of those concerns: - My age was always on my mind. I was 37 for the first round and 38 when I worked with you. Getting older was always on my mind.
4.04 Social Social stress involved perceived pressure from friends to become pregnant. A second source was participants’ tendency to not want to discuss fertility challenges at work or with friends, often leading to withdrawal from social circumstances. 4.04.01 Family and culture-related This was a significant stressor for four participants. Except for one participant, it did not have the same affect as other stressors. The following provides a sense of the effect of family and culture pressures
4.04.02 Friends and work-related This factor was regarded of quite high significance for four participants. The following comment gives a sense of how this theme affected them: -Nobody knew I was doing IVF. I had a transfer that ended in a miscarriage - I had to juggle transfer with the school concert day, and so I’m at the school concert thinking, ‘I’ve got to get out of here because they’re implanting my embryo tomorrow’ – which was strongly stressful. 4.05 Major Life Experience Four participants had experienced significant life events that might have contributed to their infertility. All who fitted this category became pregnant in the cycle following identification of and dealing with their imprinted life experience. 4.05.01 Primarily relating to self The comments in this category had profound impact on the researcher. Following is an example: - It definitely helped me with the grieving over the boys. I kept a lot of it to myself and allowing myself to talk to you - helped to let go the pain in a way where I could focus on trying again to have another baby. Before I was more focused on what happened with the twins than I was with the new baby. The 20-week mark was such a big thing for me ... That’s why I couldn’t tell anybody. 4.05.02 Primarily relating to others, but with significant effect on self This was of high impact for three participants. The following is typical from those affected: - My dad is a big stressor for me….he’s attempted suicide twice. I‘m very close to him and…I react badly. It’s very hard to deal with (abreaction). I’m concerned he’ll try suicide again…or that he’ll hurt mum. He admitted he wanted no longer to be here, he didn’t see a point in his life…. 4.06 IVF-Assist All participants offered comments about their experience of IVF-Assist, and differentiated between the hypnotherapy-creative visualisation and psychotherapy-counselling components. All participants reported a significant depth of impact on their experience of IVF. 4.06.01 IVF-Assist - sychotherapy and counselling One participant recalled pre-commencement doubts about the programme. The following comments typify participants’ narrations of benefits: - It stopped me having a breakdown, I was a bit of a mess – emotional and shaky – and that’s how I felt all the time…I just didn’t feel like I was able to cope; but I would do a session and feel like a weight was lifted for a while. - It would sometimes bring up things that I didn’t even realise were issues. I would love the feeling after. Even doctors and nurses noticed a change in my personality. Women who had been referred by doctors or trusted friends expressed a stronger sense of acceptance earlier than others: - You gave me this different way of thinking. I was completely stressed before, but you gave me a way of dealing with it, and of changing my thought patterns. 4.06.02 IVF–Assist: hypnotherapy and visualisation One part of IVF-Assist involves visualisation in hypnosis of correct levels of cycle hormones, endometrial lining thickness and successful pregnancy and delivery. Participants’ reactions to this visualisation was positive, as the following comments exemplify: - The whole process saying, ‘you’re in more and more control’ helps you to get yourself together. You start to believe it, and that starts to change your brain. It’s moving back into the light. 4.06.03 IVF-Assist: other aspects This section presents more comments addressing aspects other than hypnotherapy or psychotherapy related: - … it’s going to touch on a few things that have been buried- that you didn’t even know were issues. You could become emotional. Be open to it. - I would have gone to the clinic for three hours a day if I had to. You put my mindset at the right place…I could allow myself to fall pregnant. - Knowing you were always available was a big plus. It was amazing for that - just having someone walk through with you – to get the feeling they were supporting you. I can’t say how important that was.
4.06.04 IVF-Assist – medical/clinical issues One participant’s comment regarding medical experiences is significant:
5.00 Discussion This section explores the extent to which participants’ experience aligns with or contradicts the findings of previous research, and attempts to explain any differences. It acknowledges the limitations and weaknesses of the study as a means of reinforcing the validity of the work and ensuring it can withstand any challenges regarding rigour. Finally, it addresses triangulation for the study. 5.02 Discussion of Identified Categories Limiting discussion to the theme categories identified in the data analysis constitutes the most efficient approach to this task. 5.02.01 Maternal drive The literature review failed to prepare the researcher for what reflection on interview recordings and transcriptions revealed to be a significant aspect of participants’ experience. One participant had previously delivered stillborn twins mid-way through pregnancy. The author (as therapist) opined that unresolved grief was a major concern after the participant reported disappointment at her husband not understanding her nightly pre-retirement ritual of kissing her babies’ urns. Phase 1 therapy addressed that unresolved grief. The author realised that loss of the twins was devastating for this participant, but her failure to achieve pregnancy and satisfy her maternal drive was the major stress-inducing factor. Having a child provides a sense of “being complete” for some women (Redshaw et al., 2006:303). Some women who cannot have a child experience a sense of inadequacy or being less fulfilled (Callan and Hennessey, 1988; Leiblum et al., 1998). The author initially found no references to failure to satisfy maternal drive being a major stressor, despite it emerging strongly as such from participants’ narratives. One could argue it is evident from increased propensity to suffer depression among women experiencing multiple IVF failures and nearing the end of treatment (Beaurepaire et al., 1993) and from statements like “women regarded infertility problems as the major problem in their lives.” (Andrews et al.,1992, in Beaurepaire et al.,1993:236). The insight concerning maternal drive was one of the most impactful from the study. It is ironic that failure to satisfy maternal drive could trigger stress at a level that might contribute to failure to become pregnant. 5.02.02 Loss of control Redshaw et al., 2007:298 summarised women’s feelings while undergoing IVF: This aligns with participants’ narratives. Having to follow rigid medical protocols within disciplined timings, often feeling like numbers within a busy system, and being unable to get detailed information quickly on medical issues such as unexpected spotting, were major triggers of feeling out of control. Participants credited IVF-Assist with returning the feeling of being more in control. The full time availability of the researcher (as therapist) to provide counselling was regarded positively by all participants despite there being very few incidences of that being exploited. 5.02.03 Remaining embryos This was a major concern for two participants, and it triggered extensive reflection before their decision-making. It also initiated author reflection and critical thinking regarding ethical-religious-scientific questions that this finding triggered within him. The strength of the moral dilemma for some is summarised by Lo and Parhem (2009:4): As a matter of religious faith and moral conviction, (some) believe that “human life begins at conception” and that an embryo is therefore a person….From this perspective, taking a blastocyst and removing the inner cell mass to derive an embryonic stem cell line is tantamount to murder. While resolution of the concerns raised is not a matter for this report, this issue is one to be carefully considered by therapists who might offer IVF-Assist in future. 5.02.04 Impact of stress on IVF outcome The causes of stress for participants generally aligned with the major stressors of IVF cycles identified in the literature. Most reported high levels of pre-IVF stress from various causal factors, with stress levels increasing in response to the rigour and intrusiveness of IVF, especially over repeated cycles. Participants who had given birth also reported stress during the first pregnancy trimester. This was of higher significance for participants who had experienced stillbirth or miscarriage. The literature highlights times during IVF when women are likely to experience increased stress. Several studies reviewed coping strategies employed by women undergoing IVF. Some studies recommend coping skills education for those undergoing IVF (Munoz et al., 2009) and counselling prior to IVF commencement (Van den Broeck et al., 2010). Most studies addressed dealing with stress after it occurred. There was no evidence of studies that proposed a multi-phased and IVF-specific approach to psychological stress management for women undergoing IVF, despite strong evidence of the need for such a structured intervention. This study’s finding that the wait for pregnancy testing represented the biggest IVF stressor aligns with other studies’ conclusions (Boivin and Takefman, 1995; Eugster and Vingerhoets, 1999; Verhaak et al. 2007) and with triangulation input from a respected medical professional, endorsing the need to address this important aspect of IVF impact. The debate regarding the impact of psychological stress on IVF outcomes continues, with some research recognising a correlation, but no causal relationship (Munoz et al., 2009; Czemiczky et al., 2000) and others concluding that stress has no effect on IVF outcome (Anderheim et al., 2005). The debate is almost certain to escalate following recent work using objective stress bio-markers (rather than subjective testing) to prove that higher stress levels are associated with longer time to pregnancy and increased risk of infertility (Lynch et al., 2014). This researcher was surprised the recognised correlation had not previously prompted formulation of purpose-specific multi-phased IVF stress intervention protocols, a point concurred with by two medical professors in triangulation of this study. Most studies focussed on overall effect of stress arising from repeated cycles over several years, and of the effects of recognised non IVF stress-specific coping strategies (Berg and Wilson, 1990; Schmidt et al., 2005; Van den Broeck et al., 2010). Very few investigated stress effects at various stages throughout individual cycles (Eugster and Vingerhoets (1999) were an early exception) and none explored stress before, at several stages during and after IVF (first trimester). For most studies, women who failed to become pregnant may have experienced stress effects in excess of the median for the study, and in excess of the control group in several studies (Eugster and Vingerhoets, 1999; Beaurepaire et al., 1994). Studies using average scores from respondents may have masked important percentages of patients with high levels of distress (Munoz et al., 2009). This study confirmed that virtually all women experience stress at five clearly identifiable stages before, during and after each cycle. Participants reported significant reduction in stress effects using IVF-Assist. Most studies were quantitative, but relied upon survey instruments that seek subjective responses. These instruments are largely heterogenous, introducing risk of inconsistency of results (Anderheim et al., 2005). The lack of homogeneity in survey instruments makes it difficult to compare and interpret results effectively. In contrast, participants in this study were notably consistent in their narratives of IVF experience, and of the impact of IVF-Assist. The author recognises limits on clinics needing to achieve specified patients to doctor ratios. Nonetheless, the findings are suggestive of a need for clinics to remain aware of the single-minded focus of women undergoing IVF, to explore with each woman her specific service expectations, and to negotiate satisfactory arrangements in that regard, rather than offer only a ‘one-size-fits-all’ service. The literature highlights need for supportive counselling of those who cease IVF treatment after unsuccessful attempts (Verhaak et al., 2007). The one study participant who ceased IVF having failed to become pregnant initially reported no significant negatives: I really didn’t want to look at donor eggs. I want a baby with my own eggs or I don’t want a baby. The tools you taught me when we were trying to get pregnant have been so helpful as coping mechanisms. This participant’s coping strategies to that time aligned with those the literature recognises to be most effective (Van den Broeck et al., 2010Schmidt et al., 2005; Verhaak et al., 2005; Beaurepaire et al., 1994). This participant later underwent donor egg cycle and was unsuccessful. This time her reaction was quite different: We are devastated. I feel utterly defeated, sad and angry and I think it will take a while for the wounds to heal this time. This reaction highlights the need for psychotherapy to support couples who learn they will never give birth to a child. Participants found compelling the positive effect of hypnotherapy during embryo transfer (Levitas et al., 2006). Participants reported that listening to the audio programme designed for use immediately prior to, during and after transfer provided an enhanced sense of control during the procedure. Triangulation input from an IVF practitioner confirmed the effectiveness of this programme in calming patients during transfer. 5.02.05 Social aspects Data analysis indicated two separate themes in findings from this category and the author will briefly address them together. Women in Australia generally do not reveal their pregnancy to anyone except their partner, and perhaps a trusted friend until the end of the first trimester. The reasons include difficulty to physically hide pregnancy after that time. However, most woman explained it would be difficult to discuss losing the pregnancy with several people and they considered this less of a risk after the first trimester. If this is reality for people who easily fall pregnant, one can imagine this social pressure impact for those who have difficulty conceiving. The social pressure of avoiding having to explain failure is exacerbated by covertly managing medical appointments, often difficult-to-disguise mood changes, and other effects of IVF process. The end result of is often increased stress. The author concurs with the advice of Schmidt et al. (2005) that one should choose carefully with whom one discusses the issue and what one would discuss. In addition, the observation of Peterson et al. (2006) that different approaches to coping could lead to marital problems hints at the importance of couples counselling to deal with conflict arising from the joint endeavour to have a child. A minor point that fits this ‘social aspects’ section was identified from one woman who had a child several years ago using IVF and who mentioned feeling guilty when disciplining her child after going through so much to conceive him, and this suggests the need for inclusion of counselling on this matter during Phase 5 of IVF-Assist in future. 5.02.06 Major life experience The data analysis identified two separate strong themes in this category, but it is appropriate to address them together in this discussion. The literature contains little on this topic. Ebbesen et al. (2009) addressed significant life events occurring in the year previous to commencing IVF, finding a small but significant lower pregnancy rate in those suffering significant life events was linked to higher levels of stress. The author’s clinical observations suggest that major negative life experience can impact IVF outcomes. Furthermore, the affecting life event does not need to be significant in a logical sense. The limbic system of the brain is often at work in these situations, processing with emotion rather than reason. Evidence in support of this theory lies in four participants falling pregnant in the cycle during which mental imprints (Flynn and Patching, 2006) were identified and addressed. Other major life experiences of the participant or of others (for example, close family members) but nonetheless affecting the participant, were more likely to affect IVF outcome in the manner described by Ebbesen et al., by giving rise to major distress, which in turn affected their fertility system (Ebbesen et al., 2009). 5.02.07 IVF-Assist, and medical – clinical aspects Participants’ experience of IVF-Assist was consistently positive. Six became pregnant on their first full cycle using IVF-Assist and one on her third after failing on between one and 12 previous IVF cycles (average=5.2). The rate experienced by participants is well in excess of that one would reasonably expect from formal statistics (VARTA, 2014; CDCP(US), 2014). IVF-Assist addresses major stress triggers experienced by patients before, during and after IVF identified by the collective literature and from clinical observations and experience. All participants responded positively to the intervention and reported noticeable reductions in anxiety within a very short time of commencing the programme. All who conceived believed IVF-Assist was a significant factor in their becoming pregnant. The participant who failed to conceive also reported positives from using IVF-Assist. The woman who fell pregnant using the programme before commencing IVF (deviant case) credits it for helping her fall pregnant on her first cycle using it. 5.03 General – weaknesses in the study The interview process provided information about participants’ experience of IVF-Assist. Repeated review of transcripts and audio recordings, and the process of coding and cross coding of themes revealed a rich complexity of emotional layers and behavioural facets to that experience. Initially, emerging themes seemed to conveniently fit categories aligned with the stages of IVF-Assist. Reflective and critical thinking, and triangulation discussion, revealed that researcher bias was at play. The author decided to leave seven days between conducting any interview and revisiting the audio recording or transcription, and to code themes soon after completing transcription, but to delay final thematic analysis until all coding was completed for all transcripts. The author is satisfied the early tendency to sub-consciously fit themes to the research topic was rigorously replaced with allowing themes to emerge from repeated reading and critical review of the transcripts. This approach produced a matrix of often over-lapping and inter-related themes which, while not wed to the IVF-Assist structure, informed improvements for its ongoing use. 5.04 Triangulation A much-published university professor described this work as “easy to read, which is important, and rigorous in methodology and execution”. The study supervisor concurred with the study approach and findings. The respected IVF practitioner aware of the author’s work concurred with the author’s identification of the most significant stressors associated with IVF from literature and practice and concurred that the protocol success rate confirms its value. He commented that the five women he referred were a sub-category of patients selected based on his opinion they would respond positively to the protocol because of their level and type of stress, the stressors involved, and their personality, openness to psychotherapy and hypnotherapy and commitment to using complementary as well as allopathic approaches to becoming pregnant. This might have skewed the results somewhat and perhaps a lower success rate should reasonably be expected from application to a broader sample of patients chosen using a less structured approach. Finally, asked to comment on the study’s assumptions and findings regarding stress being a factor in IVF that is best reduced rather than simply coped with, Professor Ray Isles, former Dean of Research at King’s College, London University, stated as follows: I completely agree with your approach. I agree these stress effects are accumulative so you can’t just switch it off once you are already at a high stress level – it’s exactly as you posit – it takes time (without stress reduction techniques). It’s undeniable; I would stand in front of any scientific meeting and say this. Asked to comment on the study conclusion that it is a combination of past life stress, current life stress and stress from IVF processes and failures that collectively affect fertility, despite much research looking at only one or two of these factors, Professor Isles responded: You’re absolutely right. We are coming back to the concept of systems psycho-biology (a term coined during the interview). What’s involved with high stress? The limbic system and pituitary gland. What controls whether an egg is going to mature? The pituitary gland. Where is that gland located? Off the limbic system. To me it’s simply very obvious.
Statistically, the live birth rate from IVF decreases significantly as women’s age increases, particularly for women approaching and over 40. While the birth rate for women undergoing infertility treatment has remained relatively stable since 1965, that rate is relatively low at some 20-25% live births per cycle (Peddle et al., 2005). An independent government-commissioned review reported that two cycles of IVF cost the Australian tax payer $30,000 (per live birth) for patients between 30-35 years of age and $187,000 between 42 and 45, so this author anticipates increasing pressure in Australia for higher IVF success rates. This could involve steps similar to those taken by New Zealand, whose public medical system covers only two cycles of IVF, only for women under 40 who are not clinically obese and do not smoke. Some consider that policy harsh, but its results are compelling. Whereas Australians under-35s success rate is 26%, the New Zealand result is 31.6%. For women between 35 and 39 the Australian to New Zealand comparison is 17.6% to 26.1%. (www.som.uq.edu.au). In Australia during 2010, 57,000 IVF cycles were undertaken with 10,500 live births resulting, at a cost per cycle in 2010 between $4,420 and $4,930 to the tax payer. Given economic pressures from an aging population, government subsidisation of IVF is likely come under closer scrutiny. That possibility adds a great weight of importance to this work. This work occasionally had strong emotional impact on the researcher. It was only when the researcher remained in empathy with the participant that the narrative flowed into deeper and more meaningful revelations. This approach to dealing with researcher emotions is recognised in the literature (Mitchell and Irvine, 2008; Beale et al., 2004). Undertaking this research at a time the researcher’s wife was undergoing breast cancer-tests and surgery had positive implications for the research. He could better empathise and remain aware of the strong emotional impact of women’s issues on women than he otherwise might have. This led to more insightful consideration of participants’ narratives than might otherwise have occurred. This experience somewhat aligns with the findings of Bahn and Weatherill (2012) regarding the affects on researchers of collecting sensitive data. 6.00 Conclusions In this section the researcher draws conclusions from the data analysis and discussion, and explores the degree to which the study aims were achieved and the knowledge gap closed. 6.02 Study Methodology Feuer et al., 2002, in Denzin, 2009:145, writing about qualitative research in teaching, stated, “when problems are poorly understood, and plausible hypotheses are scant – qualitative methods such as ethnographies….are necessary to describe complex phenomena, generate theoretical models and reframe questions.” The author contends that same principle applies to research into stress effects on IVF, and that an ethnographic methodology was the most appropriate to adopt. 6.03 Knowledge Gap, and IVF-Assist Effectiveness Debate regarding causal relationship between stress and IVF outcomes continues, but doctors appear to increasingly be paying attention to practice evidence as much as structured research. Many agree distress is associated with lower pregnancy rates among women pursuing fertility treatment (Deka and Sarma, 2010). The ground-breaking research by Lynch et al., (2014)in the United States can be expected to divert medical science to a focus on solving an obvious problem rather than further debating its theoretical construction. The medical community adopts trial and error approaches in the treatment of numerous idiopathic disorders and has a clear precedent for acting on the Lynch study without delay. These factors, and pressures to achieve better value for investment in IVF, can be expected to soften attitudes towards complementary therapies shown to be effective from practice evidence. This research sought to explore perceived effects of psychological stress before, during and after IVF, from the perspective of women who experienced the process in concert with IVF–Assist. Participants all reported significantly reduced stress at all stages of IVF. All seven participants who became pregnant prior to research completion credited IVF-Assist with contributing significantly to that outcome. It is reasonable to conclude that IVF-Assist can be regarded as an effective multi-phased intervention to manage stress approaching, during and following undergoing IVF. Two non-participant clients of the researcher also became pregnant on their first IVF cycle with IVF-Assist since completion of data collection for this study, and these cases stand as further anecdotal support for the conclusion drawn in this paragraph. Appendices A IVF-Assist Phases description B Participants’ overview C Identified themes and categories
Appendix A – Programme Stages Please refer to the document following. IVF-Assist Phases PHASE 1 Pre-Cycle Psychotherapy and Counselling Administered: Preferably prior to IVF cycle commencement but it is possible up until two days prior to oocyte retrieval Objectives:
Comments/Explanation: The third bullet point above relates to any life event that might contribute to the women failing to become pregnant. For example (from the author’s clinical experience) sexual or physical abuse, particularly by a parent, during childhood or teen years; negative self-image/self esteem concerns and the like.
PHASE 2 Pre-Oocyte Collection Primarily hypnotherapy, but all sessions involve some psychotherapeutic counselling. Administered: Preferably from start of IVF cycle, but in any case, no later then one week before scheduled Trans Vaginal Oocyte Retrieval (TVOR) Objectives: To engage subconscious resources and enhance the body chemistry and biological/psychological aspects for a successful conception and early pregnancy. Comments/Explanation: The hypnotherapy for this stage involves deep relaxation and strong visualisation, using the “Control Room” technique, of appropriate levels of:
It also involves strong visualisation of a healthy endometrium, and creative visualisation of the uterus as a metaphoric nursery into which the ‘baby’ is received, comfortably nestled into a safety capsule and securely attached to the nursery (uterus) wall
PHASE 3 Embryo Transfer Protocol Hypnotherapy Administered:
Objectives: To reduce, and ideally eliminate the embryo expulsion effect of the rapid mini-uterine contractions that can occur in response to the intrusion of the instruments used in the embryo transfer protocol. Comments/Explanation:
Where possible, these sessions are done face-to-face. However, they can be conducted using pre-recorded audio (and most often are conducted this way). In addition, the audio recording is used for the induction of hypnosis during the embryo transfer procedure. NOTE: The author has produced audio for all stages of the process but often prefers to record in-clinic sessions to better personalise the material for individual clients. PHASE 4 Between Transfer and Pregnancy test Psychotherapeutic Counselling and Hypnotherapy Administered: Daily, and often twice daily listening to hypnotherapy recordings and/or face-to-face or phone sessions as required by client. At least two in-clinic sessions during the wait period for most clients. Objectives: To reduce, and ideally eliminate the psychological stress/anxiety caused by waiting for Comments/Explanation:
The author agrees with the literature that the stress during this period can be the most severe of all stress experienced during IVF cycles. The author’s clinical experience influences him to believe that high levels of stress experienced during this period is usually generated by thinking about the unwanted outcome of cycle failure. Ironically, the anxiety generated by this type of thinking might very well contribute to the very unwanted outcome the woman wishes to avoid. PHASE 5 First Trimester of Pregnancy Psychotherapeutic Counselling and Hypnotherapy Daily - listening to relaxation hypnotherapy-recordings. Psychotherapeutic Counselling is used as required. Objectives: To maintain calmness during the period often perceived by clients as high risk of miscarriage, and therefore can be stress-inducing. Comments/Explanation: If clients have had previous miscarriage or still birth, face-to-face sessions are held weekly during this period and until after the time in the cycle the miscarriage took place. Appendix B Participants overview - click here to view / download
APPENDIX “C” - Main Themes and Categories - click here to view / download
References
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