Women who have difficulty accepting the fact that they can't have children following unsuccessful fertility treatment have worse long-term mental health than women who are able to let go of their desire for children, according to new research.
The study published online today (Wednesday) in Human Reproduction , one of the world's leading reproductive medicine journals, is the first to look at a large group of women (over 7,000) to try to disentangle the different factors that may affect women's mental health over a decade after unsuccessful fertility treatment. These factors include whether or not they have children, whether they still want children, their diagnosis and their medical treatment.
Dr Sofia Gameiro, the lead author, said: "It was already known that people who have infertility treatment and remain childless have worse mental health than those who do manage to conceive with treatment. However, most previous research assumed that this was due exclusively to having children or not, and did not consider the role of other factors."
The researchers say that their findings show only that there is a link between an unfulfilled wish for children and worse mental health, and not that the unfulfilled wish is causing the mental health problems. This is due to the nature of the study, in which the women's mental health was measured at only one point in time rather than continuously since the end of fertility treatment.
Dr Gameiro, a lecturer at the School of Psychology at Cardiff University (Cardiff, UK), and colleagues from The Netherlands analysed answers to questionnaires completed by 7,148 women who started fertility treatment at any of 12 IVF hospitals in The Netherlands between 1995-2000. The questionnaires were sent out to the women between January 2011 and 2012, meaning that for most women their last fertility treatment would have been between 11-17 years ago.
The women were asked about their age, marital status, education and menopausal status, whether the infertility was due to them, their partners, both or of unknown cause, and what treatment they had received, including ovarian stimulation, intrauterine insemination and in vitro fertilisation / intra-cytoplasmic sperm injection (IVF/ICSI). In addition, they completed a mental health questionnaire, which asked them how they felt during the past four weeks.
The researchers asked the women whether or not they had children, and, if they did, whether they were their biological children or adopted (or both). They also asked them whether they still wished for children.
The majority of women in the study had come to terms with the failure of their fertility treatment. However, six percent (419) still wanted children at the time of answering the study's questionnaire and this was connected with worse mental health.
"We found that women who still wished to have children were up to 2.8 times more likely to develop clinically significant mental health problems than women who did not sustain a child-wish," said Dr Gameiro. "The strength of this association varied according to whether women had children or not. For women with no children, those with a child-wish were 2.8 times more likely to have worse mental health than women without a child-wish. For women with children, those who sustained a child-wish were 1.5 times more likely to have worse mental health than those without a child-wish. This link between a sustained wish for children and worse mental health was irrespective of the women's fertility diagnosis and treatment history."
The researchers found that women had better mental health if the infertility was due to male factors or had an unknown cause. Women who started fertility treatment at an older age had better mental health than women who started younger, and those who were married or cohabiting with their partner reported better mental health than women who were single, divorced or widowed. Better educated women also had better mental health than the less well educated.
"Our study improves our understanding of why childless people have poorer adjustment. It shows that it is more strongly associated with their inability to let go of their desire to have children. It is quite striking to see that women who do have children but still wish for more children report poorer mental health than those who have no children but have come to accept it," said Dr Gameiro.
The authors say that their findings underline the importance of psychological care of infertility patients and, in particular, more attention should be paid to their long-term adjustment, whatever the outcome of the fertility treatment.
"The possibility of treatment failure should not be avoided during treatment and a consultation at the end of treatment should always happen, whether the treatment is successful or unsuccessful, to discuss future implications," said Dr Gameiro. "This would enable fertility staff to identify patients more likely to have difficulties adjusting to the long term, by assessing the women's possibilities to come to terms with their unfulfilled child-wish. These patients could be advised to seek additional support from mental health professionals and patient support networks.
"It is not known why some women may find it more difficult to let go of their child-wish than others. Psychological theories would claim that how important the goal is for the person would be a relevant factor. The availability of other meaningful life goals is another relevant factor. It is easier to let go of a child-wish if women find other things in life that are fulfilling, like a career.
"We live in societies that embrace determination and persistence. However, there is a moment when letting go of unachievable goals (be it parenthood or other important life goals) is a necessary and adaptive process for well-being. We need to consider if societies nowadays actually allow people to let go of their goals and provide them with the necessary mechanisms to realistically assess when is the right moment to let go," she concluded.
 "Do children make you happier? Sustained child-wish and mental health in women 11-17 years after fertility treatment", by Sofia Gameiro et al. Human Reproduction journal. doi:10.1093/humrep/deu178