RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10016-1340 |
Effects of 8-week Structured Yoga Program on Anxiety and Depression among Women Undergoing In Vitro Fertilization Treatment: A Randomized Controlled Trial
1,2Department of Community Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India
Corresponding Author: Neha G Khandekar, Department of Community Physiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India, Phone: +91 7769881345, e-mail: nehakhandekar1596@gmail.com
Received on: 09 November 2022; Accepted: 01 December 2024; Published on: 28 October 2024
ABSTRACT
Introduction: The approximate 33% likelihood of conception in vitro fertilization (IVF) therapy often leads to feelings of anxiety, distress, and depression for many women undergoing IVF treatment. Furthermore, most women’s chances of conceiving after IVF treatment decrease due to various factors like late age and associated fertility factors. Yoga is a holistic strategy that could provide a platform for women to manage their emotional reactions during and after the IVF treatment process. This research study aimed to investigate the effects of an 8-week structured yoga program (SYP) on the level of anxiety and depression in women undergoing IVF treatment.
Materials and methods: A total of 102 women undergoing IVF treatment were randomized into two groups—a structured yoga group (SYG) and a home-based walking group (HWG). SYG participants received yoga therapy for a period of 8 weeks, performing 3 days per week lasting for 60 minutes. The Spielberger State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory-II (BDI-II) were used to evaluate anxiety and depression. Data was analyzed using paired and unpaired t-tests.
Results: Women who participated in the summer youth program demonstrated significantly reduced levels of anxiety and depression compared to the control group (p < 0.001).
Conclusion: Participation in a SYP can lead to a significant reduction in perceived levels of anxiety and depression in women who are undergoing IVF treatment.
Clinical significance: Yoga can be considered an inexpensive and safe therapy that can help women to cater through psychological disturbances faced during and after the IVF procedures.
How to cite this article: Khandekar NG, Sundarajan DP. Effects of 8-week Structured Yoga Program on Anxiety and Depression among Women Undergoing In Vitro Fertilization Treatment: A Randomized Controlled Trial. Int J Infertil Fetal Med 2024;15(2):77-82.
Source of support: Nil
Conflict of interest: None
Keywords: Anxiety, Depression, In vitro fertilization, Yoga therapy.
INTRODUCTION
The failure to achieve a clinical pregnancy after engaging in regular, unprotected sexual activity for a period of 12 months is referred to as infertility.1 Inability to possess children may be a sad reality for several reproductive-aged women, causing psychological strain. Infertility affects 48.5 million couples globally.2 Women are often subjected to stress, beginning with the diagnosis of infertility and continuing during treatment.3 In the context of infertility, women experiencing this condition commonly express emotions of despair, stress, a sense of helplessness, social isolation, and stigma. Invasive medical techniques used in the in vitro fertilization (IVF) include follicular aspiration, transvaginal ultrasonography, and injection of drugs. The impact of ovulation-promoting medications, pain, the number of oocytes collected before ovulation, and whether the embryo can be implanted following transplantation are additional concerns for patients in the ovulation induction stage.4
Women frequently avoid taking psychotropic medications in favor of nonpharmacological treatments. Effective psychological modalities include cognitive behavioral interventions and mindbody therapies, which are becoming increasingly popular nonpharmacological treatments for common mental illnesses.
Another psychological intervention is yoga, which emphasizes the regulation of lifestyle through mindbody exercises. Yoga is a useful technique for controlling or lowering stress, and many studies have demonstrated its efficacy in treating diseases linked to stress. Women who are having trouble conceiving can benefit from yoga and meditation. Meditation and relaxation techniques may improve mental clarity, support women going through infertility therapy, and maintain the equilibrium of parasympathetic and sympathetic function in regulating healthy body chemicals. A woman starts to feel better about herself and starts to treat herself with more respect when she learns how to physically relax.12 Oron et al. conducted a prospective cohort study in women awaiting IVF treatment.13
Dumbala et al. from India conducted a review that revealed no study had compared physical exercise with yoga intervention among individuals dealing with infertility.14 To the best of our knowledge, no randomized controlled trial (RCT) has explored the effects of yoga before and during IVF procedures using an active control group. Therefore, the primary objective of this study was to assess the influence of an 8-week structured yoga program (SYP) on anxiety and depression levels in women undergoing IVF treatment. Additionally, the secondary goal was to compare the effects of the 8-week yoga program with a home-based walking intervention.
MATERIALS AND METHODS
A randomized controlled clinical trial was undertaken for this investigation between July 2021 and 2022. Women with primary infertility reading and writing abilities undergoing IVF treatment were included in the study with age-groups between 25 and 45. The study excluded women who had confirmed pregnancies, severe mental illnesses requiring medication, those with significant absenteeism during the intervention program (more than twice), women undergoing IVF treatment with donor sperm or surrogate, individuals facing sexual problems (such as erectile dysfunction, vaginismus, and premature ejaculation), and those with comorbid conditions like diabetes or cardiovascular disease. The Ethical Committee at the MGM Institute of Physiotherapy, Aurangabad, accepted the study’s protocol (MGM/IOP/IEC/PG/2021/12).
Participants were told of the study’s goals and given assurances about its confidentiality. All participants also provided oral and written informed permission. Additionally, this research study was registered in the India Clinical Trial Registry (registration number: CTRI/2022/01/039515).
The estimation of sample size was determined using sources from similar studies in the literature. It is statistically calculated by using the following formula:
Z1 = associated with confidence = 0.824.
M = population M = 14.94.
S = standard deviation of M = 12.90.
D = absolute precision = 105.
N = sample size = 102 (51 in each group).
Outcome Measures
Spielberger State-Trait Anxiety Inventory
It is a self-reported tool developed to measure levels of both trait and state anxiety. It has two versions (Y1 and Y2), each of which has 20 items that are scored on a four-point scale. In the present investigation, which measured trait anxiety, Form Y2—a reasonably stable individual propensity to react to events viewed as threatening was given. The questionnaire will be assessed for trait anxiety (20 questions), ranging from 20 to 80 when favorably worded item values are reversed. As “no or low anxiety (20–37),” “moderate anxiety (38–44),” and “high anxiety (45–80),” respectively.
Beck Depression Inventory-II
This validated 21-item tool measures self-reported depression symptoms. It includes things like pessimism, sadness, loss of pleasure, past failure, punishment, guilty feelings, self-criticalness, self-dislike, crying, suicidal thoughts, agitation, being unsure what to do, loss of interest, losing energy, feeling worthless, irritability, changing one’s sleeping habits, changing one’s appetite, difficulty concentrating, and losing interest in sex. A total Beck Depression Inventory (BDI) score ranging between 0 and 63 is calculated by adding the individual item scores. From 0 to 13 on the BDI scale, depressed symptoms are absent or minimal, 14–19 are mild, 20–28 are moderate, and 29–63 are severe.
Randomization
Women who met the requirements and provided their agreement were assigned at random to either a home-based walking or a structured yoga group (SYG). For our convenience, the randomization process and sampling method were carried out on a computer using https://www.randomizer.org/website. This website provided a list of random numbers which divided participants into two groups. The sequentially numbered opaque sealed envelopes were kept in the reception area. The study participants were asked to pickup the envelope, and according to the envelope picked, either the intervention group or the control group was allotted.
The therapist was blinded until the randomization process.
Intervention
Structured Yoga Group
The women in this group followed a structured yoga protocol for a duration of 8 weeks, engaging in yoga sessions 3 days per week. The duration of each session was approximately 60 minutes, and participants had the option to attend either a morning or evening session. The 60-minute session started with a warm-up followed by 30 minutes of structured yoga exercises, 10 minutes of breathing technique, 10 minutes of meditation, and 10 minutes of relaxation. The detailed SYP protocol for the different stages of IVF treatment is given in Table 1. In total, there were 24 sessions. The first three sessions were orientation sessions about infertility and a SYP.
| Serial number | Sequence | Intervention | Frequency |
|---|---|---|---|
| 1 | Warm-up | Sukshma vyayama, (starting from legs, hands, neck, and eyes) | 10 repetition each |
| 2 | Structured yoga asanas | Initial visit to stimulation—setu bandhasana (bridge pose), viparita karani (legs up the wall pose) Janu sirsasana (head to knee pose), baddha konasana (bound angle pose), adho mukha svanasana (downward facing dog) Stimulation to egg retrieval—no yoga pose Egg retrieval—embryo transfer (including vitrification process)—setu bandhasana (bridge pose), baddha konasana (bound angle pose) Adha mukha svanasana (downward facing dog), virabhadrasana II (warrior pose) |
Yoga poses—start with holding the pose for 6–8 seconds; further progress by increasing the holding time Initially, start with two repetitions and further progress it |
| 3 | Breathing technique | Anulom vilom Bhastrika |
12 inhales and exhales |
| 4 | Meditation | To be practiced in a comfortable position, with eyes closed | 10 minutes |
| 5 | Relaxation | Shavasana (corpse pose) | 10 minutes |
During the first session, the women in the study group received information regarding infertility, the potential negative effects of psychological disturbances during their treatment procedure, and the role of yoga in alleviating anxiety and depression symptoms. They were also provided with preintervention instructions. The session concluded with an interactive segment to address any doubts. In the second session, the participants were taught how to perform various asanas (yoga poses) and breathing patterns. Additionally, they received instructions on how to engage in meditation and relaxation techniques. From the third session onward, the subjects were given a scheduled plan for yoga practice, which included breathing techniques, meditation, and relaxation exercises.
Home-based Walking Group
The participants in the other group were provided with a home-based walking program, which involved walking for approximately 45 minutes per day, 3 days in 1 week, at a moderate intensity. Before and after each walk, they performed muscle stretching for 10 minutes, and a 5-minute rest break was given between the walks. Both groups completed the two questionnaires at the beginning of the study (baseline) and again after 8 weeks.17
Statistical Analysis
Statistical Package for the Social Sciences version 27.0 was used to evaluate the data once it was input into Microsoft Excel. To verify that all of the variables had a normal distribution, the Kolmogorov–Smirnov test was utilized. For quantitative variables, the standard deviation (SD) and mean were computed, while proportions were determined for categorical variables. To evaluate the outcome variable data within the groups, a paired “t-test” was utilized. To compare the outcome variable data between the groups, an unpaired “t-test” was utilized. Statistical significance was defined as a p-value < 0.05.
RESULTS
In the initial screening of 150 individuals, 30 were excluded from the study for various reasons—20 did not meet the inclusion criteria, five declined to participate, and five had other reasons. This left a total of 120 participants who agreed to take part in the research. At the conclusion of the 8-week study period, 102 participants [51 in the SYG—experimental group and 51 in the home-based walking group (HWG)—control group] successfully completed the study. The final statistical analysis was based on the data collected from these 102 participants. Details of the retention and recruitment of women can be found in Flowchart 1.
Flowchart 1: Flowchart of recruitment and retention of women in the study
Table 2 presents the demographic characteristics of the 102 participants. Among them, 48% (n = 49) of the women fell into the age range of 25–30 years, while 54% (n = 57) were above 31 years old. Regarding employment status, 76% (n = 78) of the participants identified as homemakers. For the majority of the women participating in the study (N = 54), the duration of their marriage ranged from 6 to 10 years. Regarding infertility treatment, 78% of the women had been undergoing treatment for 10 years, while 20% had been receiving treatment for 11–20 years. The analysis did not reveal any statistically significant differences in the demographic data among the participants.
| Characteristics | SYG (n = 51) |
Home-based walking (n = 51) |
Total n (%) (n = 102) |
|---|---|---|---|
| Age (years) | |||
| 25–30 | 24 | 25 | 49 (48) |
| 31–35 | 18 | 14 | 32 (31) |
| 36–40 | 11 | 10 | 21 (20) |
| 41–45 | 02 | 02 | 04 (3) |
| Occupation of patient | |||
| Homemaker | 39 | 39 | 78 (76) |
| Employed | 07 | 06 | 13 (12) |
| Self-employed | 05 | 06 | 11 (10) |
| Years of marriage | |||
| 1–5 | 12 | 12 | 24 (23) |
| 6–10 | 25 | 29 | 54 (52) |
| 11–15 | 10 | 07 | 17 (16) |
| 16–20 | 03 | 01 | 04 (3) |
| 21–25 | 01 | 01 | 02 (1) |
| Years of infertility treatment | |||
| 01–10 | 39 | 41 | 80 (78) |
| 11–20 | 11 | 10 | 21 (20) |
| 21–30 | 01 | 00 | 01 (0.9) |
The women in the (SYG) experimental group’s mean pre- and posttest results from the BDI-II and State-Trait Anxiety Inventory (STAI) demonstrate that the score improved in the posttest, and the difference was statistically significant (p < 0.05) (Table 3). The depression as well as anxiety scores improved in the SYG after the intervention compared to the HWG (p < 001) (Table 4).
| Group I | |||
|---|---|---|---|
| Outcome | At baseline mean ± SD | At 8-week mean ± SD | p-valuea |
| BDI-II | 27.43 ± 9.34 | 12.39 ± 6.19 | <0.0001 |
| STAI | 43.31 ± 6.77 | 28.17 ± 7.56 | <0.0001 |
BDI-II, Beck Depression Inventory-II, ap-value was calculated using the Wilcoxon test; SD, standard deviation; STAI, Spielberger State-Trait Anxiety Inventory
| Outcome | SYG (n = 51) | Home-based walking (n = 51) | p-valueb |
|---|---|---|---|
| BDI-II At 8th week | 12.39 ± 6.19 | 28.07 ± 10.17 | <0.0001 |
| STAI At 8th week | 28.17 ± 7.56 | 41.07 ± 5.62 | <0.0001 |
BDI-II, Beck Depression Inventory-II, bp-value was calculated using the Mann–Whitney U test; SD, standard deviation; STAI, Spielberger State-Trait Anxiety Inventory
There were no adverse events registered during the entire study period, and henceforth, the positive outcomes and reviews were discussed by the participants with the principal investigator.
DISCUSSION
The main objective of this research was to determine if an 8-week SYP could help alleviate depression and anxiety in women undergoing IVF therapy. The study’s findings indicated that the SYP was effective in improving symptoms of anxiety and depression compared to a group engaged in home-based walking. There were no statistically significant differences when comparing the mean prescores obtained from both scales.
The participants in the study exhibited mild to moderate anxiety and depression scores, which were similar to the findings of a study conducted by Valoriani et al.18 Anxiety is more prevalent among infertile couples, particularly among females, compared to the general population, but anxiety issues are prevalent worldwide among various populations.19
Infertility could negatively impact a woman’s social and psychological health and the treatment process. The stress, depression, and anxiety that come with infertility are made worse by a variety of issues, such as health issues, sexual discomfort, annoyance, emotional pain, and marital difficulties. According to research by Terzioglu et al., there is a substantial correlation between a woman’s depression score and the success of her pregnancy.20 Another study by Hajela has shown that women with anxiety or depression during the IVF treatment are less likely to conceive.21 This is in contrast to another research that found no correlation between stress, anxiety, or depressive symptoms with the outcomes of IVF when considering age, the length of infertility, or the reason for infertility.22
The positive results of our study could be due to the SYP, which included yoga poses, pranayama, meditation, and relaxation techniques. We also started the intervention before the stimulation phase, which prepared the women for the further treatment process. Our results are consistent with research by Oron et al. on yoga-practicing infertile women awaiting IVF treatment, which indicated that the practice enhanced infertility-related quality of life and decreased anxiety, depression, and particularly negative sentiments and thoughts related to infertility.13 Another report presented by Kirca and Pasinlioglu found that practicing yoga for 6 weeks while receiving IVF therapy helped infertile women feel less stressed.23
People experience a considerable degree of stress as a result of assisted reproductive approaches and treatment procedures, which lowers their ability to cope. With the help of professionals, safe methods like yoga may be used to stimulate the ovaries.24 Yoga is a holistic approach that encourages people to become aware of their bodies by bringing attention to body tension and teaching techniques for reducing tension. It orchestrates neuroendocrine axis modulation and fine-tuning, leading to positive improvements by lowering stress and thereby enhancing reproductive functioning.25 According to research by Dalgas et al., yoga’s nature is controlling the mind and central nervous system, and unlike other sports, it has a moderating effect on the hormone emissions, nervous system, physiological factors, and regulation of nerve impulses. As a result, it can be useful in treating depression and other mental disorders.26
Yoga activities have been proven by researchers to have a significant impact on both physical and mental health. According to a review by Darbandi et al., yoga may help couples overcome infertility and raise the success rate of assisted reproductive technology by enhancing the physical and mental well-being of both men and women.27 Before the first IVF treatment, Valoriani et al. ran a 3-month yoga session and discovered that anxiety, depression, and stress levels were considerably lower in the yoga group than in the control group.18
In the current study, home-based walking was provided to the control group, and the outcomes were not statistically significant. Patients demonstrated considerable reductions in their levels of anxiety and depression, according to a study by Chen et al.28 However, our findings are consistent with another study done by Streeter et al., which concluded that the mood and anxiety of yoga participants improved more than those of the walking group.29 Techniques for reducing stress may have a significant impact on patient and clinical results. Future research is required to assess how yoga affects secondary infertility. The depression and anxiety scores should be evaluated after the embryo transfer, as Awtani et al. reported that the anxiety and stress scores were higher after the embryo transfer.30
The depression and anxiety caused by infertility and its treatments can be effectively treated with yoga. Meditation and relaxation techniques improve focus, safeguard healthy body chemistry, and aid people in overcoming the difficulties of infertility therapy. In light of this, it is reasonable to conclude that yoga exercises involving bodily postures, breathing, and relaxation techniques can help to reduce the psychological symptoms among infertile women, thereby facilitating fertility. Yoga has been discovered to be a fantastic approach to balancing the body and can easily be incorporated into daily practice.31
The limitations of the study include the measurements used in the study were self-reported, individual perceptions, and the margin of error must be considered. Since the study included female patients who received IVF treatment in a private medical facility with primary infertility, the findings are solely applicable to these individuals and cannot be generalized to other infertile women.
CONCLUSION
The 8-week SYP, including pranayama, meditation, and relaxation techniques, resulted in a significant reduction in anxiety and depression levels among women undergoing IVF treatment. Yoga, being a low-cost and natural form of exercise, proves to be safe and effective in alleviating depression and anxiety. It offers a viable option for patients who are reluctant to consider pharmacological therapy for their mental health concerns.
Clinical Implications
Yoga is known to be an effective stress-reduction technique. IVF treatment can be emotionally taxing, and stress can negatively impact the success of the procedure. Implementing a SYP as part of the treatment can help patients manage stress levels, leading to a more relaxed and conducive environment for the procedure. Yoga provides a supportive environment and encourages mindfulness, helping patients cope with the emotional challenges and anxieties associated with the treatment process. Yoga practices, such as specific postures and breathing exercises, can positively influence hormonal balance, which may have potential benefits for fertility and implantation success during IVF. In the event of treatment failure, yoga can provide valuable coping mechanisms to deal with disappointment and foster resilience, preparing patients for future treatment cycles or alternative options. It is essential for healthcare providers to recognize the potential benefits of integrating yoga into IVF treatment and offer it as an adjunct therapy to support patients throughout their fertility journey.
ORCID
Neha G Khandekar https://orcid.org/0000-0002-4840-0332
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