Virtually all women in this study spent time searching for infertility information on the Internet, suggesting that a high-quality psychosocial program could be a viable resource for women struggling with fertility issues. With respect to the first hypothesis, we found that women exposed to Infertility Source significantly reduced their social concerns, an aspect of infertility problem distress related to how women negotiate relations with family and friends around their fertility problems. We attribute this to the program content which emphasized strategies and skills to help patients manage relationships, particularly in dealing with pregnant family and friends. Trends for a reduction in global fertility related distress, sexual concerns and negative perceptions about childfree living were also observed. Similarly, women exposed to Infertility Source exhibited a trend for improvement in self-efficacy related to the management of infertility treatment. Effect sizes for the primary and secondary outcomes ranged from small (d = 0.24) to moderate (d = 0.47). Even a small effect size of an intervention that reduces a prevalent problem in a patient population (i.e. fertility-related stress) can have a meaningful public health impact.
Importantly, Infertility Source facilitated aspects of decision-making, our second hypotheses. The findings suggest that participants exposed to Infertility Source perceived they were more informed and clear about the costs and benefits surrounding the decision they were grappling with compared with control participants. Given that patients are not likely to seek mental health services in spite of high levels of anxiety and infertility-related distress, this finding is highly relevant. A fairly non-threatening online program may be beneficial for patients contending with treatment-related distress and may help them persist in treatment or decide to end treatment sooner. Such a question would be of interest for future research. The program did not appear to have an effect on the dyadic marital measure. It may be that couples view their marriages as cohesive despite the current medical challenge.
It also appears that participant characteristics had moderating effects on the intervention. There were subgroups of women for whom Infertility Source was more advantageous. These were women who were more anxious, further along in their treatment experience, had higher incomes, and had an explained infertility diagnosis. It may be that the program was beneficial in helping the more anxious participants put in perspective the role of treatment and the burden on sexual relations (e.g. viewing treatment as a temporary disruption, having a sense of humor and empathy for spouse). The relationship between socioeconomic status and anxiety in this medical population warrants further inquiry, including how interventions may support these couples around their fertility treatment and financial burden. That the program was more effective for women with explained fertility problems suggests that a next version of the program more pointedly address the distress common to people with idiopathic infertility whose course of treatment is less clear (Covington and Burns, 2006
). Infertility Source also had positive effects for participants who had completed four or more fertility treatment cycles and were thus farther along in their fertility treatment experience. In particular, the program reduced sexual concerns and negative perceptions related to living a childfree lifestyle.
Coping style also moderated the intervention effects. We know from prior infertility studies that women tend to use more coping styles relative to men (Klonoff-Cohen et al., 2001
; Peterson et al., 2006
) and that some coping styles are more health promoting than others depending on the circumstances. The program was beneficial for those women who tended to use escape-avoidance coping often or who did not frequently employ planful problem solving. For women who often employed distancing, the program heightened their infertility-related distress levels. We suggest that for those engaged in strategies to put the infertility experience out of their minds, the program essentially forced them to face various issues, raising their infertility distress. Further refinement of computer-tailored approaches can target these subgroups of women with individualized messaging and direct them to various skills building and ameliorating activities. Use of Infertility Source in conjunction with counseling and stress management may enhance positive effects in these domains and suggests a future avenue of study.
This study has several methodologically relevant findings. Sawilowsky and Kelley (1994)
recommended a more nuanced application of Braver and Braver’s approach in analyzing Solomon-four designs. This study provides illustration of their recommendations, as different outcomes required interpretation of different statistical tests to maximize power. The pre-post assessment decisional conflict scale scores did not correlate >0.7, hence, the meta-analytic findings are more powerful. However, the FPI and ISE scale had higher pre-post assessment correlations, larger effect sizes (i.e. large Cohen’s d
) or both, supporting the interpretation of the more statistically powerful classic parametric findings.
We also explored if the study was underpowered. Post hoc power calculations on the outcomes of marginal significance revealed that, under the tests that used half of the sample (Tests 5 and 6), power ranged from 0.053 to 0.57. Sample sizes would need to have at least doubled for outcomes of marginal significance and small effect size to be detected at the P < .05 level. Informed by these findings, analyses of intervention effects in two hypothetical scenarios were conducted: (i) doubling the Solomon four’s sample size and 2) a pre-post test design (simulations available upon request). As expected, a larger sample size reduced the standard errors of the means, making it easier to detect a true difference if one existed, and a hypothetical full pre-post test design returned significant results for those scales with high pre-post correlations. In both cases, the findings reported in this study would have exhibited greater statistical significance, indicating that the design was underpowered. Finally, because confidence intervals are a function of the standard error and influenced by sample size employed in the specific test, a larger sample size or a full pre-post design would have rendered tighter confidence intervals around the parametric test’s effect sizes and smaller P-values in general. Given that Infertility Source is a web-based intervention and could potentially reach a large constituency of patients or persons struggling with infertility in a relatively short time, we are hopeful that this intervention will prove beneficial in the practical and naturalistic environment of online help-seeking.
There are both strengths and limitations to this study. This study is limited to infertility patients actively seeking medical care, and does not attend to a large cohort of subfertile women who do not seek treatment (White et al., 2006
), thereby limiting the generalizability of our findings. However, this program was specifically designed for treatment seekers as an adjunct psychoeducational support program in medical settings. In fact, this cohort likely reflects those who will eventually be users of an online program like Infertility Source. The participants also reported a range of fertility issues over time, and we do not know if the program may have different outcomes for individuals with specific diagnoses, e.g. first-time IVF patients and patients with complicating medical conditions. Various program elements may be more relevant at different points in fertility treatment. Although we used no-treatment comparison groups to control for the effect of the online intervention, it does not rule out demand characteristics (e.g. help-seeking).
Additional limitations include the study incentive, the self-report nature of the data and the relatively short follow-up duration period that limited the use of biological outcomes such as pregnancy attainment. The study was likely underpowered to test several of the outcomes, though simulations support interpretation of the findings. The study was likely also under-powered to test moderators other than those variables used in the stratified randomization (i.e. explained/unexplained fertility and income). Nevertheless, such analyses were undertaken and presented to explore intervention effects among subgroups of clinical relevance: women employing different coping styles, with high anxiety, and of varied treatment experience. Replication of these exploratory subgroup findings in a study adequately powered to test them is preferable. Since participants could use the program at home or work to approximate natural day-to-day settings in which one may use the Internet, (versus a controlled environment), we cannot be certain the intervention dosage was in fact accurate (e.g. participant may have left their computers to do other things).
There was a high participation rate in this study. This may be in part due to the short duration of the study and/or the incentive. However, the program evaluation findings suggest women were highly motivated and enjoyed the site in spite of any distress that such focused attention on the program may have engendered. An additional strength was that participants came from demographically and geographically diverse groups. That the entire sample had an equal proportion of participants residing in states with and without health insurance mandates for fertility treatment is also a strength, diminishing the likelihood that treatment effects were influenced by this variable. Notably, the 15% minority sample is one of the largest in infertility-related intervention studies to date and may be more representative of the diversity of women who seek infertility services and treatments (Chandra et al., 2005
). Thus, the study results are likely externally valid.
The positive effects on women who used Infertility Source are promising. This study appears to be the first randomized, controlled online eHealth study for women experiencing infertility. Previous work in the area of infertility support interventions has focused primarily on group and couple interventions. Comparatively, as a self-guided program, Infertility Source is less resource intensive and potentially more cost-effective than face-to-face interventions. Given the literature that infertility patients are not apt to seek supportive services until prolonged and failed treatment cycles ensue, Infertility Source may be of interest to patients not yet ready to seek counseling or to those uncomfortable with group or couple formats. Psychological interventions can produce beneficial outcomes including reduction of distress (Boivin, 2003
), and it appears that Infertility Source represents one such viable intervention. Future analyses will address the effects of the program on male partners, couple interactions, and personal belief systems, and will contribute to further refinement of Infertility Source.