PRACA ORYGINALNA

ORIGINAL ARTICLE

CHANGES OF PSYCHO-EMOTIONAL STATE IN THE INFERTILE PREGNANT FEMALES DUE TO THE ANAMNESIS AND IVF

Volodymyr K. Likhachov, Yanina V. Shymanska, Yulia S. Savelieva, Viktoriya L. Vashchenko, Ludmyla М. Dobrovolska

Ukrainian Medical Stomatologycal Academy, Poltava, Ukraine

ABSTRACT

Introduction: During pregnancy in the body of a healthy woman there are physiological and psychological changes that contribute to the bearing a child and prepare the female for future labour and motherhood. In women who experience failure at the stage of fertilization or during pregnancy, as a result of prolonged negative emotional states, psycho-emotional stress develops.

The aim of the research was to study the psycho-emotional state of women with infertility in history, whose pregnancy resulted from extracorporal fertilization (IVF), and to develop methods for reducing their anxiety.

Materials and methods: At the first stage, the initial psycho-emotional state of 60 women in the second trimester, whose pregnancy resulted from IVF (Group I), was studied; the control group consisted of 20 healthy women with a physiological course of pregnancy (Group II). At the second stage, 10 art therapy exercises with a requestioning of pregnant women from Group I were conducted for improving their psycho-emotional state.

Results: Women of Group I had a high level of both situational anxiety (SA) and the personal one (PA). The prevalent type of the psychological component of gestational dominant was anxiety and euphoric types (58.3%). In one third of women with burdened gynecological history examined mild or masked depression was diagnosed. 43 pregnant women from Group I used a method of psychocorrection – art therapy, which included colouring antistress pictures of perinatal topic, making flowers from paper and creating a collage of dreams.

Conclusions: After the art therapy course, a high level of SA (from 46.5% to 7.0%) and OA (from 48.8% to 32.6%) decreased, the index of the optimal type of the psychological component of gestational dominant increased from 25.6% to 53.5%. The number of women without depression increased from 62.8% to 93%.

KEY WORDS: infertility, preterm delivery risk depression, anxiety disorder, art-therapy

Wiad Lek 2019, 72, 4, 562-567

Introduction

The issue of infertility and miscarriage is the significant social and medical problem. Today in Ukraine there are about 20% infertile couples, i.e. every fifth family in the country [1]. A large number of couples apply to the clinics of assisted reproductive technologies for the procedure of extracorporal fertilization (IVF) with embryo transfer [2, 3].

During pregnancy in the body of a healthy woman there are psychological and physiological changes that contribute to the bearing a child and prepare the female for future labour and motherhood. The dominant component of pregnancy transforms the character, behavior, emotional background of a future mother, defining her mental condition [4]. Women who become pregnant as a result of IVF with embryo transfer are at high risk for stress. Psychoemotional stress, as a holistic reaction of the organism, is a cerebro-visceral syndrome, which is formed as a result of prolonged negative emotional states [5], leading to changes in neuroendocrine parameters. The implementation of this mechanism occurs through the cortex of the brain, subcortical nuclei, particularly the thalamic one, involving the autonomic nervous system and hormonal mechanisms; hormones of stress activating the metabolism are of particular importance as well [3, 5]. Chronic stress and associated disorder of adaptation significantly worsens the prognosis of pregnancy [5, 6].

The aim

The purpose of the research: to study the psycho-emotional state of women with infertility in history, whose pregnancy resulted from IVF, and to reduce their level of anxiety by art-therapeutic methods.

Materials and methods

The ethics commission of Ukrainian Medical Stomatologycal Academy, Poltava, Ukraine (protocoil №170) decided: the materials of the scientific work in the form as scientific article “Changes of psycho-emotional state in the infertile pregnant females due to the anamnesis and IVF” editer by Volodymyr K. Likhachov can be published in free print.

At the first stage of the research, the initial psychoemotional state of 60 females in the second trimester of pregnancy resulting from IVF with a history of infertility and the threat of interruption of this pregnancy (Group I) was studied. As a control group, 20 healthy females with a physiological course of pregnancy were examined (Group II).

Quantitative expression of the influence of stress factors and their perceptions in pregnant women were assessed by the level of personal anxiety (PA) and situational one (SA), and the degree of depressive disorders, which were determined using the following questionnaires [5]:

State-Trait Anxiety Inventory (STAI);

“Pregnant woman relationship test” by V. I. Dobryakov;

Zung Self-Rating Depression Scale.

Initial testing of women from Group I was conducted in a hospital setting, at the beginning of hospitalization, in the presence of a threat of premature birth. Healthy pregnant women from Group II (control group) were tested in women’s consultation clinic.

At the second stage of the research, 10 art therapy classes (drawing with paints and pencils, making flowers from paper, creating a collage of dreams) were carried out in the hospital for the improving psychoemotional condition of pregnant women from Group I. This technique is based on the mobilization of human creative potential, internal mechanisms of self-regulation and healing [7]. In the process of creative activity, there is a feeling of emotional fullness, a deeper understanding of oneself and of the inner world of your own takes place, the relationships of a future mother and the child are harmonized [8]. Among pregnant women from Group I, 43 women from 60 pre-screened persons agreed on art therapy.

At the third stage of the research, a requestioning was completed by 43 pregnant women after the art therapy course.

State-Trait Anxiety Inventory (STAI) consists of individual statements allowing to assess situational anxiety (anxiety levels at the moment) and personal anxiety (anxiety as a stable personality trait). SA is characterized by tension, frustration, nervousness, PA is directly correlated with the presence of a neurotic conflict, emotional breakdowns and psychosomatic illnesses [6].

The result of this inventory is evaluated as follows: 30 points – low anxiety; 31-45 points – moderate anxiety; 46 or more points – a high level of anxiety.

“Pregnant woman relationship test” by V. I. Dobryakov helps to determine the psychological component of gestational dominant (PCGD) – a set of mechanisms of psychic self-regulation, which are included into the development of pregnancy and form behaviour stereotypes in pregnant women aimed at preserving pregnancy and creating conditions for the development of the child [9].

Zung Self-Rating Depression Scale is designed and adapted to examine pregnant women for the diagnosing depression in them. The rate of depression (RD) is not more than 50 points means a state without depression; RD in the range of 50-59 points shows a slight degree of depression; RD from 60 to 69 points – sub-depressive state or disguised depression; RD more than 69 points demonstrates depressed state.

The obtained data were analyzed by methods of mathematical statistics. The statistical significance of the differences in the results obtained for the distribution of the indices of various groups was determined using the non-parametric Mann-Whitney criterion. The statistical significance of the differences between the distribution of indices before and after treatment was determined using the Wilcoxon method for bound choices.

Results

The results of STAI are presented in Table I.

The high level of situational anxiety was registered in 32 pregnant women (53.3%) from Group I with the score of 47.4±0.5 points, whereas in Group 2 any woman showed high SA level. The mean SA level was found in 22 women (36.7%) from Group I with 38.9±0.8 points and in the vast majority of women from the control group (85%) with the score of 35.9±0.9 points. Low SA levels were found in 10% of women from Group I (28.3±1.3 points) and in 15% of pregnant women from Group ІІ (25.0±1.2 points).

High personal anxiety is characteristic for the majority of surveyed pregnant women from Group I (56.8%) and is 48.4±0.6 points, whereas in the control group high level of PA was detected in only 1 woman (5%) and was 47 points. The mean level of PA was found in 31.7% of pregnant women from Group I and in the vast majority of pregnant women from the control group (90%), with a mean PA score higher in Group I (39.0±1.0 points vs 35.7±0.7 points in Group ІІ, p<0.001). Low PA levels were found in 11.7% of women from Group I and 5.0% in pregnant women from the control group.

The mean level of anxiety is considered by most authors as normal (adaptive) during pregnancy, while a high level of anxiety is often accompanied by complicated pregnancy [4, 8]. According to the data obtained, there are some features indicating serious psychological discomfort in women with reproductive problems. So, in pregnant from Group I high level of both personal and situational anxiety predominates. A high level of PA suggests that the women examined are more likely to be exposed to stress of strong emotions and frustration, they associate negative events entirely with their own personality. PA directly correlates with the presence of neurotic conflict and psychosomatic illness. SA indicates emotional discomfort of women at the time of the research, associated with the expectations of discomfort, it is characterized by tension, anxiety and cause attention disorder.

Women with a high level of anxiety cannot be set categorical tasks and encouraged to promptly perform certain actions, as this can lead to a conflict or nervous excitation of the pregnant [10].

In women from Group ІІ, who has had no history of infertility, has physiological pregnancy and are not in a hospital with the threat of premature birth, the adaptive (mean) level of anxiety (85%-90% of pregnant women) predominates, which is favorable for carrying pregnancy.

Table II presents the results of our research on the psychological component of gestational dominant (PCGD) in the women examined.

According to the results of this research, pregnant women can be related to one of the main subgroups, each of which requires different tactics of prenatal care. 15 women (25%) from Group I included pregnant women with the best type of PCGD, and they are in a state of psychological comfort.

In 3 of the women under study from Group I (5%) the hypogestognostic type of PCGD predominates. It indicates lack of awareness of their own pregnancy, unwillingness to abandon the lifestyle that was before pregnancy (studying, career). This psychological type is characterized by emotional alienation, undeveloped parental feelings.

The “risk group” should include women with euphoric, depressive and anxiety type of PCGD. In Group I anxiety (20 women, 33.3%) and euphoric (15 women, 25%) types of PCGD predominates, and depressive type was in 7 pregnant women (11.7%). The condition of women in these groups is characterized by a high level of anxiety, which affects their somatic status. A pregnant woman either overestimates existing problems or cannot explain what the anxiety she is constantly experiensing is associated with; anxiety is often accompanied by hypochondria. Any actions of the medical staff (laboratory research, doctor’s examination) promote anxiety in pregnant women [9, 11].

In Group 2 (the control group) the optimal type of gestational dominant (18 women, 90%) predominates, indicating the pregnant women treat their pregnancy responsibly, but without particular anxiety. The pregnant woman continues to lead an active lifestyle, follows the recommendations of physicians, takes care of her health, and is engaged into prenatal care courses [12].

Zung Self-Rating Depression Scale allowed to conduct diagnostics of depressive states in pregnant women surveyed. The results are presented in Table III.

The mean score according to Zung Self-Rating Depression Scale when calculating the rates in all 60 women from Group I was 44.8±1.0 points, which falls into the category “state without depression”. However, in a detailed analysis it was found that 66.7% of women (40 persons) actually showed no depression, but 30% (18 women) demonstrated a state of mild depression, and two pregnant women (3.3%) were diagnosed with masked depression. In the control group all women were without depression.

Found in 20 women from Group I (33.3%) states of mild and masked depression may be explained by a history of infertility and a fear of failure of this pregnancy. Such women mark permanent irritability, mood swings, tearfulness, periodic headaches and sleep disturbances. They have an extremely developed feeling of inferiority due to women’s subconscious persistent perceptions of their physical, mental and/or moral inferiority (often fictitious one).

After conducting 10 art therapy classes, a re-questioning was held among 43 women from Group I who agreed to the art therapy course (Table IV-VI).

According to State-Trait Anxiety Inventory, in pregnant women the mean (23 cases, 53.5%) and low (17 women, 39.5%) situational anxiety became predominant, and only 3 persons (7%) had a high level of SA. Such a change in the structure of levels of anxiety occurred due to a sharp decline in the number of pregnant women with high level of SA – from 46.5% to 7.0%. The mean score of SA was 35.6±1.05 points, while before the art therapy course it was 42.4±0.88 points (in the control group – 34.3±1.2 points).

The level of PA also became predominantly moderate and low – respectively, 13 women (30.2%) and 16 women (37.2%). High PA level was kept only in 14 women (32.6%). The mean score of PA after art therapy classes was 38.0±1.3, in comparison with the beginning of the course – 43.2±1.0 points (in the control group it was 35.7±1.2 points). Such results in women from Group I indicate the effectiveness of the applied method.

In the analysis of the PCGD indicator by V. I. Dobryakov (Table V), you could see the number of women of the optimal type increased from 25.6% before the art therapy course to 53.5% after it. The indicator of “risk group” after art therapy classes decreased from 30 to 17 pregnant women: euphoric type – 10 women (23.3%); anxiety one – 5 women (11.6%); depressive type – 2 women (4.6%). That is, in the groups of the surveyed the number of women with a predominantly anxiety (by almost three times) and depressive (twice) types decreased. There remains an almost constant number of women with hypogestogenic PCGD, since this indicator is a permanent personality trait [9].

When re-evaluating the state of depression in pregnant women from Group I by Zung Self-Rating Depression Scale after the art therapy course (Table VI), the overwhelming number of women were without depression (40 women, 93%); in mild depression – 2 women (4.7%) and only 1 woman (2.3%) was diagnosed with masked depression. The mean score by Zung after art therapy classes was 40.5±1.05 points, compared with the state before – 44.8±1.0 points. The given data indicate the efficiency of the applied method.

Discussion

In women with reproductive loss, infertility in the history and IVF pregnancy changes of the psychoemotional and psychosomatic character have been revealed: the pregnant have showed a high prevalence of situational and personal anxiety. It indicates the emotional discomfort of women at the time of the research, associated with the expectations of ill-being. The tendency of the women surveyed to the influence of stress, strong feelings and anxiety has been revealed. The dominant type of psychological component of the gestational dominant is the anxiety and euphoric types (58.3%) that are characterized by high levels of anxiety in the pregnant woman, which affects her somatic state. This is due to the presence of infertility in history, multiple unsuccessful attempts at pregnancy, acute or chronic illness, disharmonious family relationships, dissatisfaction with material needs, and so on. In one third of the women with aggravated history examined mild or masked depression was diagnosed.

After the initial testing of patients, the method of psycho-correction – art therapy, which consisted in painting “I and my baby” picture, colouring “antistress” pages with perinatal themes, making flowers from paper, creating a collage of dreams, was applied. With repeated testing, we received the following results: the level of SA decreased from 46.5% to 7.0%, and PA level – from 48.8% to 32.6%, the indicator of the optimal type of the psychological component of the gestational dominant increased from 25.6% to 53.5%. The number of women without depression increased from 62.8% to 93%. The given data indicate the effectiveness of the applied method of psychocorrection. One of the indicators was the fact that, in the course of medical treatment of the threat of preterm birth and art therapy classes in women who agreed to work with a psychologist, pregnancy lasted for up to 35 weeks. And in women who refused the art therapy course, childbirth occurred in 32-33 weeks of pregnancy.

Conclusions

1. In women with reproductive loss, infertility in the history and IVF pregnancy violations of the psycho-emotional state with a high level of situational and personal anxiety were revealed.

2. In 70% of women with aggravated obstetric history the euphoric, anxiety and depressive type of the psychological component of gestational dominant are prevalent, and only the fourth of the surveyed has the optimal type.

3. The state of mild and masked depression was found in 33.3% of the examined pregnant women with infertility in history, extracorporal fertilization and the threat of preterm labour.

4. After 10 art therapy classes the number of women with high level of situational anxiety decreased by 7 times and by 1.5 – with high level of personal anxiety; the number of pregnant women with the optimal type of psychological component of gestational dominant doubled with a significant reduction in the number of women with anxiety type; the majority of the surveyed (93%) showed no depression.

5. In the group of women undergoing the art therapy course (with the course of appropriate medical treatment of the threat of preterm labour) pregnancy was prolonged on average up to 35 weeks. And in women who refused this psychocorrection childbirth occurred in 32-33 weeks of pregnancy.

References

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The theme of the scientific and research work of the Department of Obstetrics and Gynaecology 2 of Ukrainian Medical Stomatological Academy “The role of chronic infection of the uterus and lower sections of the genital tract in the formation of obstetric and gynaecological pathology” (number of state registration is 0117U005276, 2017-2022).

Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Volodymyr K. Likhachov

42 Stritenska Str., app. 19, Poltava 36011, Ukraine.

tel: +380952212112.

e-mail: vladimir.lihachov@gmail.com

Received: 10.12.2018

Accepted: 05.03.2019

Table I. Results of questioning pregnant women by State-Trait Anxiety Inventory for determining personal and situational anxiety

Indicators of anxiety

Group І n=60

Group ІІ n=20

Situational anxiety

High level (≥46 points)

Number of people (%)

32 (53.3%)

Scores (М ± м)

47.4 ± 0.5

Mean level (31-45 points)

Number of people (%)

22 (36.7%)

17 (85.0%)*

Scores (М ± м)

38.9 ± 0.8

35.9 ± 0.9*

Low level (1-30)

Number of people (%)

6 (10.0%)

3 (15.0%)

Scores (М ± м)

28.3 ± 1.3

25.0 ± 1.2*

Personal anxiety

High level (≥46 points)

Number of people (%)

34 (56.8%)

1 (5%)*

Scores (М ± м)

48.4 ± 0.6

47,0

Mean level (31-45 points)

Number of people (%)

19 (31.7%)

18 (90.0%)*

Scores (М ± м)

39.0 ± 1.0

35.7 ± 0.7*

Low level (1-30)

Number of people (%)

7 (11.7%)

1 (5.0%)*

Scores (М ± м)

29.6 ± 0.7

25*

Note: * – an indicator of the statistical significance of the distribution difference by Mann-Whitney method (p<0.001).

Table II. Analysis of assessing the psychological component of gestational dominant by V. I. Dobryakov’s method

Indicators

Predominating the optimal type

Predominating the euphoric type

Predominating the anxiety type

Predominating the depressive type

Predominating the hypogestognostic type

Group І

15 (25%)

15(25%)

20(33/3%)

7(11.7%)

3(5%)

n=60

Group ІІ

18(90%)

2(10%)

n=20

p

<0.001

Note: p – an indicator of the statistical significance of the distribution difference between the indices of the groups I and II surveyed by Mann-Whitney method (p<0.001).