SART Fertility Experts: Can IVF make people happy?

On this episode of SART Fertility Experts, host Dr. Mark Trolice is joined by Dr. Mariana Sousa-Leite and Dr. Angela Lawson to explore the emotional and psychological experiences of patients undergoing IVF. Drawing from recent research, they discuss how individuals may find meaning, hope, and even personal growth through fertility treatment—regardless of outcome. The conversation delves into the importance of early mental health support, and how clinics can better serve patients. Whether you’re a provider or a patient, this episode offers valuable insights into the nuanced emotional journey of infertility and assisted reproductive treatment.

Hi everyone, and welcome to another SART podcast. I'm Dr. Mark Trolice, a reproductive endocrinology and infertility specialist in Orlando, Florida, and am I excited about this podcast today. With me are two experts in the psychological world with infertility.

We have Dr. Angela Lawson. She was former full professor of OB-GYN and psychiatry at Northwestern University's Feinberg School of Medicine. She's a forensic psychologist specializing in reproductive mental health, as well as sexual and other traumas.

Her research is on the psychological aspects of infertility and trauma, and she lectures nationally and internationally, and I was just thrilled that she took the time out of her busy schedule to join us today. Thank you so much, Angela, for being with us today. Thank you.

Also with us from across the pond in the UK, we have the author of the reason for this podcast today. She wrote, Does IVF Make People Happy?, and I'm referring to Dr. Marianna Sousa-Leite, who is a psychologist that specialized focus on health psychology and reproductive research. She is an associate at the School of Psychology, Cardiff University in the UK, and her research involves supporting patients throughout their infertility journey, particularly, and unfortunately, if it is not successful.

She co-authored this paper in Reproductive Biomedicine Online with Dr. Jackie Borvin, and so I wanted to start by and welcome, Marianna, as well. Thank you so much to coordinate our schedules because I know the timing of you being in the UK, but thank you for being available. To just get to the crux of this, it seems as though the key message that we're taking from this is the psychological value of an IVF cycle, even without a live birth, and we're looking at happiness and positive emotions that may occur before, during, and after IVF.

So, I want to start with you, Marianna. Were you aware, and in your practice, do you see the effect of a positive coming from patients who have gone through an IVF cycle, particularly since you said that you support patients through their journey that didn't even get pregnant? What prompted the evaluation of this paper and concept, and do you see this in clinical practice? Thank you, and thank you for inviting me to be here. Pleasure.

This was very challenging to write, especially because most of my research is about the devastating experience of IVF, and particularly when it is unsuccessful. To be fair, it is documented, and the paper shows that there are positive emotions before and during and after, or patients can feel these emotions. But these are unintended emotions, of course, and people don't go through IVF to have positive emotions.

But I think we can, and Dr. Angela can speak as well about that, but we can see that, particularly in specific moments of treatment, so when this treatment is offered and patients feel excited to start this treatment, or when the treatment actually starts, or, for example, after the embryo transfer, when they have a lot of hope and these positive effects, and then these emotions, positive emotions, co-occur with these negative emotions. Of course, during the cycle, and I think the article says this, or tries to say this, these are emotions that co-occur with the negative ones. So I don't know if Angela wants to comment.

Well, you mentioned that it may fulfill other needs that the patient has, and it sounds like if they're focusing on the journey, they may miss the intrinsic value of going through IVF. I'll switch over to Angela. Angela, in your clinical practice, because I would tell you that I have not seen much of this, but are you seeing or would you agree that the actual journey, enduring fertility, seems to impress upon the individual as a positive that they went through that experience irrespective of outcome? Are you seeing that in your experience? I do think that that is possible, and I have seen that.

I think the difference for me in the way that I think about happiness, and I think certainly the title of the article is a bit provocative, right? So not all feelings, not all positive feelings mean happiness, and the article, I think, clarifies that pretty well. But I think the thing that helps me think about the positive feelings that we might see in patients either during or after treatment really is the difference between what we call hedonic or this transient state of happiness or joy. It's a temporary emotion versus eudaimonic happiness, which is really more aligned with the PERMA model that is discussed in the article, which is a deep sense of well-being in which you feel your life has meaning and purpose.

And so there's not a whole lot of this temporary hedonic happiness that occurs in fertility treatment. There's a lot of anxiety, a lot of sorrow, a lot of anger. Certainly there's positive feelings like hope or appreciation or relief that may occur during IVF, but we're most likely to see, I think, the eudaimonic happiness or this deeper sense of well-being at the end of treatment, whether treatment works or not.

It's certainly possible to achieve that. Excellent points, Angela. Mariana talked about that in the article, even those without conception express no regret for trying.

And that really just astounded me because of the impact. And I'll also interject the fact that I'm not just a professional in the infertility world. I was a patient for 10 years, and I will tell you that I did not get that feeling of gratitude or fulfillment or any sense of well-being going through this.

It was a lot of despair, as Mariana mentioned, devastation. Are there signs, do you think, of a patient who would be more prone to have that sense of value prior to going to an IVF cycle? Or is it that it was such an unknown process that they are seeing what they endure, and it is somewhat inspiring their observation of themselves to have emerged from that process and felt proud of what they had gone through, irrespective of outcome? What do you think, Mariana? I think that's totally true. And I think the patient's experience varies.

So when I speak, we speak how most patients feel. And literature shows that many patients feel relief because I try everything what I could to have to fulfill these parenthood goals. So even when treatment is unsuccessful, this feeling, this peace of mind, sometimes we see in articles this peace of mind and this relief, at least.

And even the opposite. For example, finally, even if it's negative, I'm finally out of this road. I know I did not get the outcome I wanted, but this was so difficult for me that I'm relieved that it finally ended.

And of course, how patients feel will depend on, for example, the care received, the number of treatments they underwent, even personal characteristics, such as a coping style, if it's a heterosexual couple or not, and culture as well. So I think how patients will experience these emotions, it depends also on many other factors that I try to, that we try to acknowledge. Do we have any literature, Angela, to support the pursuit of additional IVF cycles based on the attitude of the patient as they went through their first IVF cycle? In other words, that first cycle, they're experiencing what Mariana is describing in this paper, and if it is not successful, are they more prone to do another cycle as opposed to the individual that is despondent and did not have a good experience going through that? Over time, is there any evidence to support which one goes through? And if not, what is your experience? So what I would say is that we have research that shows there's a fairly high dropout from treatment for patients who could otherwise likely conceive, who are experiencing high levels of psychological distress.

That being said, I think that this general sense of well-being that we might see in some people, and I don't think it has to be the goal that we have a sort of a reflection backwards and see IVF as having been a good thing for us. It doesn't have to be something that we have positive feelings about. I don't know that that's necessarily the goal, but one of the goals I do think we could have is better supporting patients while they're going through IVF where positive feelings are often at an all-time low.

And patients, whether they stop fertility treatment before having a baby or whether they continue treatment, it's a very difficult emotional time for most patients going through treatment. And so focusing both during treatment on the support during those generally low positive feeling times and at the end of treatment, particularly for those who don't wind up with a baby, again, providing support to those patients where, you know, I mean, all of us know working in fertility clinics that once patients get pregnant and they graduate from care from the fertility treatment, they have little, if any, further contact from the clinic. And if they don't get pregnant, the same thing occurs.

If they stop treatment, we need to do better at supporting patients regardless of whether they look back and have positive feelings about their experience or not. Absolutely. And a spot on, you know, Dr. Ali Delmar's paper that looked at the emotional impact of the diagnosis of infertility and compared that to other major medical morbidities.

And it was, she showed that being told you had infertility was equivalent to the emotional impact of being told you had cancer as well as heart disease and other major morbidities. So we, as specialty physicians, I question whether we are doing enough to support the patient during their journey. We have a psychologist on staff.

I have always felt that the challenge is extremely burdensome to patients. It's not like going through other types of, well, it is like going through chemo, right? To experience that kind of thing. But what do you think that a fertility clinic, and of course you mentioned the issues of the burden, the stress is also financial, particularly in the U.S. I mean, when patients are not in a mandated state that would cover fertility, it's not just a medical problem and it's not just the burden of going through the treatment.

It's the financial expenditure that they have to go through. And it may only be there one time. They may not be able to afford another cycle, which is really sad.

And our prayers, of course, are that we get legislation to mandate it. But what do we think that we can do as clinicians to be able to help patients endure this journey in addition to their own exploration of how they're going to experience gratitude and that sense of well-being? Can we influence that, do you think? Well, I definitely think we can. So, you know, I coauthored a study when I was at Northwestern where we saw this change in mood and worsening of mood symptoms within patients' first cycle of IVF.

We compared cancer patients who were going to be engaging in gamete cryopreservation to first-time IVF patients. And within one cycle, we saw the rates of depression and anxiety for IVF patients become equivalent to that of newly diagnosed cancer patients. And so what we need to think about is starting early.

And I would say even earlier than IVF. If we're starting at supporting patients at IVF, I would argue we're starting too late. The research shows that depressed mood and anxiety begin before and often well before patients begin fertility treatment.

And so as a society, we could start there and continue the efforts to destigmatize IVF to help patients be able to get the support they need from friends and family, co-workers, whoever it might be. Certainly from a financial level, I'm fortunate to live and work in Illinois, which is a fertility insurance mandated state, but not every state has insurance coverage. Not every country can you easily access treatment.

But at the individual and clinic level, I firmly believe, and I know I'm biased because I'm a psychologist, I firmly believe that we should have multiple mental health professionals integrated into each clinic. And given the financial pressures, regardless of the country that anyone is in, I think clinics really should find a way to cover that emotional support for patients who don't have mandated insurance that would cover those sessions. And include it in the global fee for the IVF cycle, but without hiking up the fee, of course.

Correct. Correct. Mariana, are the clinics in the UK using mental health counselors on a regular basis, or are you seeing an increase, or is it just, let's get going to an IVF cycle and we're here if you need us? So there is some signposting and mental health professionals working, but research shows that patients are not using them as they should be.

And you were talking about starting this even before treatment. I fully support that. And to be fair, my PhD focused on that, on preparing patients, and preparing patients in advance, in this case for potential failure.

But I totally agree that this support, even for, for example, financial issues, if patients and patients need to know that, are not aware of that, and even what they are going through, will go through emotionally. And this supports about what are the financial burdens, what are the psychosocial burdens, even starting, even when they start the journey, this is, this is extremely important. And it's not, of course, the psychologists are more, are well trained for, to support patients with emotional issues.

But this can be mentioned by other professionals, and that are in place to signpost patients for us. So I, I totally think this is a multidisciplinary thing. And then the team needs to be together in the signposting and mentioned these as a preparatory thing.

And yeah, and the cancer literature, and I base that in the cancer literature, because it's the most, it's the disease that these diagnoses that is most related to the fertility diagnosis, and the experience that patients feel, and they, it's fully supports this approach. Well, and I think too, the thing that can be helpful, because you're right, Mariana, that a lot of patients don't know that the supports exist when they are entering fertility treatment. And so one of the things that we did at Northwestern is when patients, new patients had their registration appointments at IVF, you know, they meet with the pharmacist, they meet with their physician, they meet with the nurses, they might meet with a genetic counselor, they also met with one of the psychologists.

And we were truly integrated into that intake or registration appointments so that they had even greater awareness that we existed and that there was support that was available. And I think even in thinking about, you know, something you were talking about earlier with regard to some of your research is providing that emotional support also when treatment ends. And for some time after that, right, that's that grief that patients often feel when they don't have the outcome that they want.

They're then left to grieve that often without the emotional support of mental health professionals who truly understand how this can affect people. You both are hitting all the major, major points. And in the last few minutes that we have, I wanted to summarize this in a way of infusing hope.

You know, in my practice, I came up with the acronym that hope is to have only positive energy. And so I share that with my patients. And I was really surprised, pleasantly, that you quoted a study, Mariana, that patients who go through IVF have a lower risk of divorce.

So because, you know, it really is a deep wound. And I know that personally. But I talked about the PERMA model of happiness.

And if you could share with our listeners what that is and how we want to infuse that energy, if you will, of manifesting those feelings during an IVF cycle. So very briefly, I think when we talk about happiness and well-being and how to promote hope and this happiness in patients, we always talk about positive emotions. But it's not only that.

And the PERMA model is within positive psychology and tries to say, it's a framework that tries to say, how can we do this more substantially? And it says that we need to promote a sense of being engaged, promote a sense of better relationships, a sense of meaning, a direction, a purpose. So patients need to have these as well. We need to promote these as well.

And the sense of accomplishment as well. So mastery, achievement. And most of the literature focus on these positive emotions.

And I think these psychosocial interventions that we have for doing a lot, to be fair, during treatment, not so much after treatment, but can start to trying to target these components of the PERMA model to help patients have a better sense of well-being and in this way, happiness. Although I agree that, and I acknowledge that, that happiness is, we can have a better word for that. Angela, I'm going to give you the last word.

How do clinics better serve our patients? Do you think that it should be very, very, very, very encouraged that patients get involved with a mental health counselor from the get-go? Do we make it really more of a ask prior to the IVF cycle or when prior to the IVF cycle? Where do you see, I think it's hand in hand, of course, but where do you see clinics, what can we do better to support our patients going through this? So I do think certainly at least by the IVF stage, we should encourage or strongly recommend or even require, as long as it's financially supported, that patients be given emotional support opportunities, whether they're in clinic or outside of the clinic. I do think that we really would benefit from starting this education about the psychological burden of fertility treatment as patients walk through our doors. But I also think that we need to do what we can rather than to encourage, not that we're saying this, but we don't want to encourage people to try and chase happiness as a temporary emotion because we can't have pleasant feelings all the time.

If we want to have pleasant feelings all the time, we're going to fail at that. But I think what we can do in clinics is rather than certainly trying to encourage patients to pursue that temporary state of happiness, which is unlikely to occur in the course of IVF, we can speak to patients and support patients in a way that can help them create meaningful lives based on the values that are important to them, whether they do or don't have a child. And particularly in the case where they don't, that I think probably all of us in the field would benefit from becoming a little more comfortable with grief and being able to sit with people in their emotional pain and sorrow to be able to support them as they figure out what they want to do next.

Excellent, excellent point. And, you know, going into a type of cycle, really, you know, Mary and I talked about over-optimism, which we don't want to have because that could be more stressful. So cautious optimism, realistic expectations.

But I want to send a shout out to all of our listeners right now who have endured IVF or considering IVF or just going through your fertility journey. Kudos to you for experiencing this. You know, when you're trying to conceive, the whole world looks pregnant.

It is a very lonely, isolating, vulnerable time. And you really want to empower yourselves by getting a clinic that owns your problem. It really takes ownership in what you're enduring.

And this was, if you have the opportunity, it's a fantastic paper called Does IVF Make People Happy in the Journal of Rehabilitative Biomedicine Online. I think we probably would be safe to say we could talk about this for quite some time. But I want to thank my guests today who are just experts in the field and have gave us tremendous insights.

The first author of the paper is Dr. Mariana Sousa-Leite. Mariana, thank you so much for helping us present your paper and hopefully inspiring our audience. We also have Dr. Angela Lawson.

And both of these people, we are very appreciative of their contributions. So thank you. Thank you so much for joining me today.

Thank you so much for having us. And this is Dr. Mark Trolice for the SART podcast. Until next time, take care and good luck.