Document Type : Original Article
Authors
1 Consultation in Midwifery, Department of Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
2 Mother and Child Care Research Center, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
3 Mother and Child Care Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
4 4Modeling of Noncommunicable Diseases Research Center, Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
5 5Endometrium and Endometriosis Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
Abstract
Keywords
Primary infertility is defined as an inability to conceive
after 1 year of unprotected sex (without using contraceptives), and can be related to the male or female partner
or both (
The WHO states that inability to bear a child, either
due to the inability to become pregnant or the inability to
carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy
to a live birth. In 2010, among women 20-44 Y of age
who were exposed to the risk of pregnancy, 1.9% (95%
uncertainty interval 1.7%, 2.2%) were unable to attain a live birth (primary infertility). Out of women who had had
at least one live birth and were exposed to the risk of pregnancy, 10.5% (9.5%, 11.7%) were unable to have another
child (secondary infertility) (
Prevalence varies between countries with a global average of 12 to 15%. Infertility can be divided into two
groups; primary (no conception occurring over the past
year) and secondary infertility (conception without giving
birth to a living child). In Iran the prevalence of primary
infertility based on the WHO's clinical, epidemiological
and demographic definitions. is 20.2, 12.8 and 9.2%, respectively (
In response to the infertility rate, rapid progress in reproductive medicine has contributed to new technologies
associated with the care and treatment of infertile couples across the world (
Although most people who seek infertility treatment
seem to be emotionally stable, infertility is known to be
a life-long crisis. Most infertile people have to deal with
depression, feelings of loss and guilt, detachment, meaninglessness, and sexual and marriage problems. In addition,
physical, psychological and economic problems associated
with ART influence the psychological stability of couples
(
Studies conducted in infertile women have indicated the
positive effect of counseling and psychological interventions on improving life quality (
Given the problems of infertile women, such as depression, the prevalence of infertility and the few studies conducted in Iran, especially on the impact of group counseling on infertility and the lack of comprehensive therapeutic methods in the field of counseling, the present study aimed to evaluate the effect of mindfulness-based group counseling on depression in infertile women under IVF treatment.
Demographic characteristics were assessed using a questionnaire designed by the researchers. It included questions about the personal characteristics of infertile women and their partners (10 questions), expenditures and the existence of health insurance coverage (2 questions), duration of marriage, duration of infertility, number of infertility years, frequency of IVF use and questions regarding psychiatric history (5 questions). Personal information included: first and last name, place of residence, age, employment, and education of the women and their partners, and monthly family income. Infertility was either primary (no pregnancy) or secondary (only pregnant once). Questions related to psychiatric histories included history of admission to psychiatric hospitals, history of mental illness, and use of psychiatric drugs and narcotics.
The second Beck depression inventory (BDI-II) is a
depression inventory and a self-report index for measuring depression symptoms in different clinical and nonclinical populations. Published in 1996 the second edition of BDI-II inventory was developed in response to
the American Psychiatric Association’s publication of
the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which changed many
of the diagnostic criteria for Major Depressive Disorder
(American Psychiatric Association, 1994). This inventory is a 21-item self-reported measure of depression with
15 questions related to psychological symptoms and 6
questions related to physical symptoms. Time frame for
BDI-II is consistent with the 1-2 weeks time frame for
major depressive disorders in DSM-IV. All the questions
assess the severity of the disorder based on a Likert scale
(0-3). The total score of a participant is obtained by aggregating the scores of all questions of 0 to 63. Based
on Beck's suggested scoring, a score of 0-9 indicates the
absence of depression, 10-18 indicates mild to moderate
depression, 19-29 moderate to severe depression, and 30-63 severe depression. Since the results of many studies of the BDI-II have shown its validity and reliability
in different countries, the same questionnaire was used
in the present research. Rajabi and Karjo (
The present clinical trial (IRCT2015082013405N14) which included a pre-test, post-test, and control group was conducted in women with diagnosed primary infertility who were in the early stages of IVF. Inclusion criteria were age 25-40 years, high school education or more, residency in Hamedan, no psychiatric hospital admissions, no addiction, no neurological or other progressive diseases, and no psychiatric drug use. Level of depression [mild mood disturbances, moderate depression, and severe depression (up to 63)] were determined using cut-off points of the BDI-II. Exclusion criteria were absence from more than two counseling sessions in the test group, natural pregnancy and no use of ART during treatment, and incidence of physical or psychological illness during the study. Women meeting the inclusion criteria and who agreed to participate in the study were selected prior to IVF treatment. Based on the eligibility criteria, a convenience sampling approach was used to select the participants. Among the 120 women who met the inclusion criteria, 90 women were enrolled in the present study.
According to Khormaei et al. Study, if the first type
error is 5% and the study power is 90%, the mean score
of the first group is 12 and the second group is 10, with a
standard deviation of 3 need 41 persons in both groups
(82 persons in total). On the other hand, the sample size
is increased to 45 persons in each group in order to counter the probable loss of 10% (
It should be noted that applying the above equation is equivalent to using the following formula:
After enrollment, the women were divided into intervention and control groups by block randomization,
and group counseling was delivered to the intervention
group. We constructed 10 blocks of 4 and one block of
5 (45 women), and randomly assigned the participants
to the two study groups by assigning the next block
of participants according to the specified sequence
(
Modified CONSORT flow diagram for individual randomized controlled trials of nonpharmacologic treatments.
Before starting the study, the aim of the study was explained and verbal and written informed consent was obtained from the women. First, the 45-member intervention group was divided into three 8-member groups and
three 7-member groups to increase the efficiency of group
counseling sessions. After that, eight 90-minute group
counseling sessions were held twice a week (the IVF process can last for 4 to 6 weeks) using mindfulness training packages. Counseling axes included auto-guidance,
confrontation with obstacles, breathing with mindfulness,
staying in the moment, the untruthfulness of thoughts, and
how to take optimal care of oneself (
The participants in the intervention group were asked to practice conscious yoga exercises at home and present the principles of counseling, goals, and exercises of the previous session at the beginning of each session. Moreover, in order to resolve possible ambiguities, women in the intervention group were asked to do all exercises in class with the researcher. This resulted in more repetition and training, and helped the creation of a new mindset. During the counseling sessions, we tried to fully explain the meaning and concept of mindfulness through daily routine examples, stories, and conscious yoga exercises. This method was also employed in the infertility center while the women were undergoing their IVF treatment. The control group received routie programs of infertility center and did not recive any intervention. Due to ethical considerations at the end of the study the educational pamphlets and the CD were administered to the control group. Pre-test assessments were conducted on the 90 randomised participants prior to commencing IVF treatments, meaning all members of both groups completed the demographic information and Beck depression inventories. After the intervention the post-test was performed using the BDI-II 3-7 days before the embryo transfer stage. At this point depression is at its minimum and the effect of the intervention on intervention group can be determined better. The counseling sessions are shown in Table 1.
Mindfulness training taken from Crane R. Mindfulness-based cognitive therapy (
Session | Goals | Practical exercise per session | Each session’s program | Homework |
---|---|---|---|---|
1 | Automated guidance | Eating a raisin with mindfulness meditation on body checking | Making a group, presenting the moral code of the method and group boundary, introducing participants, providing explanations about infertility and the resulting depression and the necessity of mindfulness training, explaining the automated guidance system | 1. Concentration on body checking for 45 min |
2. Attention to daily routines such as daily showers | ||||
3. Eating a meal once a week with mindfulness | ||||
2 | Facing obstacles | Body checking meditation, 10-minute breathing with meditation and mindfulness | Thinking about practices and the exact feeling of each | 1. Reviewing the previous session |
2. 4-minute body checking meditation | ||||
3. 10-minute breathing with mindfulness | ||||
4. Focusing on continuous activity to experience a pleasant day or event | ||||
3 | Breathing with mindfulness | Conscious breathing and stretching practice, breathing and stretching with mindfulness | 3-minute breathing, Identifying and recording pleasant experiences or unpleasant ones to be studied in the fourth session | 1. Reviewing the previous session |
2. Continuity and breathing exercises on days 1, 3 and 5 of a week | ||||
3. Practicing movements consciously on days 2, 4 and 6 in a week | ||||
4. Daily recording of pleasant experiences | ||||
5. Three minutes of breathing over three periods of time | ||||
4 | Staying in the moment | 5-Minute seeing or listening with mindfulness 3-minute breathing space, and walking with mindfulness | Discovering unpleasant experiences, detecting and defining depression problems or alternate group focus. | 1. Revewing the previous session |
2. Creating relaxation and meditation | ||||
3. 3-minute normal breathing (3 times a day) | ||||
4. 3-minute patterning breathing ( as a meditative strategy while experiencing unpleasant feelings) | ||||
5 | Acceptance and authorization of presence | Awareness of breathing and body, emphasizing the perception of how to react to thoughts, feelings and body sensations. 3-minute breathing | Reading Guest House poems by Rumi's works and identifying them in the group, practicing the discovery of reactions to normal patterns and the application of the potential talents of mindfulness skills to facilitate the response to the present-day experiences. | 1. Reviewing previous session’s assignments. |
2. Thinking in sitting position. | ||||
3. 3-minute normal breathing (three times a day) | ||||
4. Four minutes of patterned breathing (as a meditative strategy in the experience of unpleasant feelings) | ||||
5. Reopening (body doors) and entering the outside realm of the body (in the body) | ||||
6 | Thoughts do not have a real origin | Meditation sessions, awareness of breathing and body, highlighting the patient's problems during exercise and detecting their effects on the body and mind. | Training in changing behaviors, thoughts, and attitudes, start the development of personal rehabilitation and activity plans, and preparing the participants for the end of the course | 1. Reviewing the previous session’s assignments |
2. 40 minutes of daily practice, with different combinations of the three main exercises | ||||
3. Exploring the use of short-term exercises | ||||
4. 3-minute normal breathing (three times a day) | ||||
5. 3-minute patterned breathing (as a meditative strategy when experiencing unpleasant feelings) | ||||
6. Reflection and work on the plan to prevent personal recurrence | ||||
7 | How can we look after ourselves? | -Meditation sessions- Awareness of breathing, organs, sounds, thoughts, and emotions.-3 minutes of breathing- Highlighting a problem during exercise and detecting its effect on the body and mind. | Discovering the relationship between activity and mood, a general list of daily activities and considerations (emotional drainage) that empowers the body, exploring ways to increase activity (useful), recognizing relapses and activities that cause recurrence. | 1. Reviewing previous session’s assignments |
2. The breathing space in accordance with the routine as a coping strategy | ||||
3. Discovering a wa to do dexterous work after practice | ||||
4. Developing an early warning system for recurrence detection | ||||
5. Developing a practical plan that can be used in depressed moods | ||||
8 | How to use these factors in future decision making | End course body checking meditation | Reviewing early warning system and practical plans (to use in high-risk relapsing time), reviewing all previous sessions, discussing the way of preserving motor power, developed in formal and informal exercises. End of course and acknowledgments. | 1. Reviewing previous session’s assignments |
2. Making questions to answer the personal reflections during the day | ||||
3. Doing homework(Mindfulness exercise with booklet study) and practice at home alone ( | ||||
The Kolmogorov-Smirnov test was used to confirm the normal distribution of all the variables. Data were analyzed includes independent t test and using IBM SPSS V.21, (http://www.meta-analysis.com), to provide descriptive statistics, such as mean and standard deviation, for the quantitative data. Independent tests and Chi-square tests were employed to compare the variables before and after the intervention; paired t tests were employed to compare variations between the groups. The significance level was assumed to be P<0.050.
This study code IR.UMSHA.REC.1395.336 was approved by the Ethics Committee and Research Council of Hamedan University of Medical Sciences. For ethical considerations, at the end of the study, educational notes and CDs were given to the control group.
In the present study, 90 women meeting the inclusion
criteria were divided into two groups of intervention (45
women) and control (45 women); and the effect of mindfulness-based group counseling on depression in infertile women undergoing IVF treatment was evaluated.
The mean age of the infertile women in the intervention
and control groups was 30.28 ± 5.39 and 29.64 ± 4.71
years, respectively and the mean age of their partners
was 34.82 ± 4.97 and 34.37 ± 5.39 years, respectively.
Mean marriage duration in the intervention and control
group was 8.28 and 8.16 years, and the mean infertile
period was 5.26 and 4.39 years, respectively. The majority of infertile women in the intervention (84.4%) and
control (71.1%) group were unemployed and most of
their partners were employed, 97.8% in the intervention
group and 95.6% in the control group. The majority of
infertile women in the intervention (57.8%) and control group (57.8%) had a high school diploma. Others
had a license and master’s degree; intervention group
(40.0-2.2%) and control group (35.6-6.7%) (P=0.08).
Most of their partners, 66.7% in the intervention group
and 44.4% in the control group, had high school diploma. Others had a license and master’s degree; intervention group (24.4-8.9%) and control group (33.3-
22.2) (P=0.63). Most of the patients in the intervention
(86.7%) and control group (62.2%) had health insurance,
although most of the treatment costs in both groups were
not paid by their health insurance [intervention group
(73.3%) and control group (84.4%)]. The frequency of
IVF was divided into five categories (0-1, 2, 3, 4 or 5
times): the majority of women in the intervention group
had used 0 and 1 times (37.8%) and the majority of subjects in the control group had used 0 times (35.6%) of
the IVF treatment. The mean number of previous IVF
treatments in the intervention and control groups was
1.11 and 1.24 respectively (
Comparison of the mean and standard deviation of certain demographic characteristics (age of men and women, male income, duration of marriage and duration of infertility) in the two groups
Group | Intervention group | Control group | P value |
---|---|---|---|
Infertile women’s age (Y) | 30.28 ± 4.41 | 29.64 ± 4.71 | 0.500 |
Partners’ age (Y) | 34.82 ± 4.97 | 34.37 ± 5.39 | 0.680 |
Partner’s income (Toman) | 10681707 ± 2215337.3 | 1617777 ± 669222.3 | 0.850 |
Marriage duration (Y) | 8.28 ± 3.45 | 8.16 ± 4.12 | 0.870 |
Infertility duration (Y) | 5.26 ± 3.20 | 4.93 ± 3.38 | 0.620 |
Data are presented as mean ± SD.
Comparison of average depression scores in infertile women before and after intervention in the experimental and control groups
Group | Depression(Before) | Depression(After) | P value for test of difference |
---|---|---|---|
Experimental | 20.77 ± 6.35 | 10.82 ± 7.16 | <0.001 |
Control | 17.95 ± 6.85 | 21.33 ± 6.48 | <0.001 |
P value for test of difference | 0.0460 | <0.001 | |
Data are presented as mean ± SD.
The aim of the present study was to evaluate the effect
of mindfulness-based group counseling on depression in
infertile women undergoing IVF treatment. Our results
showed that mindfulness-based group counseling reduced
depression scores in infertile women. This findings is in
line with Hoveyda et al. (
Galhardo et al. (
Panahi and Faramarzi (
One of the limitations of this study was the inadequate completion of the questionnaires (due to their anxiety) by the study sample. In an attempt minimize the error rate in this case, the investigators talked to the participants in the study to resolve this problem and inspire confidence that information would remain confidential. Finally, it was explained to infertile women that reducing anxiety may have the effect of speeding up their pregnancy. Also, due to the length of the counseling sessions (8 sessions), some of the women in the study were not able to attend all the scheduled sessions. To minimize this problem, meeting times were adjusted based on the participants’ suggested time.
The findings of the present study point to the effectiveness of mindfulness-based cognitive group therapy on depression in infertile women undergoing IVF treatment. Mindfulness counseling reduced depression in the intervention group. In the control group, where no intervention was performed, the depression score increased. As mindfulness-based cognitive group therapy results in a significant decrease in depression symptoms in infertile women under IVF treatment, it is suggested that it should be available to all depressed women undergoing IVF treatment.