Men who find it stressful in the days and weeks before their first visit with an infertility specialist to begin testing often decide to cancel their appointment, says a team of German doctors. However, they explain that providing a leaflet that contains procedural information may help allay these fears and help men keep their appointment.¹

Abolishing Pre-Appointment Jitters
"One might ask whether efforts are needed to reduce these worries because empirical research suggests that infertility patients are seldom distressed in a clinically significant way," wrote Martin Pook, PhD, and Walter Krause, PhD, psychologists at the University of Siegen in Siegen, Germany. "However, a study in an outpatient diabetes clinic revealed that procedural information sent 2 weeks before the scheduled appointments reduced the nonattendance rate."²

Some ART programs offer psychological counseling for patients. But in an interview with Priority Healthcare, Pook said there's a distinction between the stress associated with treatment failure, and the stress associated with a pending infertility workup. That's why an informational leaflet prior to a first doctor's appointment might be more valuable to these patients than professional counseling, he explained. "Different studies indicate that anticipatory worries represent the biggest stressor related to fertility workup, whereas experiencing treatment failure is worst when undergoing an ART program."

Does a Mailout Help?
To answer questions about this, Pook and Krause randomly enrolled 250 male patients who were planning to undergo a fertility workup in an andrology clinic. Before undergoing their tests to find the cause of their infertility, all patients filled out a questionnaire about the level of their stress. As part of their workup,  patients discussed their medical history with a physician, and also underwent a routine physical, which included an ultrasound examination of the testes and a semen analysis.

For the study, the men were divided into a "treatment" group, and a group that received no intervention. The intervention was a leaflet outlining the contents and sequence of the different procedures that would be performed in the fertility workup. It also included typical questions that the physician may ask during the examination, as well as certain sensory information.

"Combined sensory and procedural information have been found to be most beneficial for reducing stress," the two study investigators wrote. "For example, the leaflet mentioned that a gel would be applied for sonography, which is at room temperature, is odorless, and can easily be removed with a dry tissue."

Fears that men might have in providing a semen sample were also addressed in the leaflet. It described the privacy and seclusion of the room for delivering the semen sample, explained that this type of uneasiness is "very common and natural", and outlined the subsequent procedure in the event a patient could not provide such a sample.

Finally, the leaflet underscored that no invasive test would be performed other than a blood test. Each patient had also been given a small survey asking if they were aware of and had visited the andrology clinic's website. This was done to determine how well each patient had read the leaflet since the website information was used in it repeatedly.

At the end of the study, the two psychologists measured each man's stress level as assessed using a special test. For various reasons, 204 of the original patients were evaluated at the end of the study.

Positive Effects Found
Pook and Krause learned that stress levels were significantly lower in the group of men who had received the leaflet compared to the group that had not received it. The investigators then wanted to find out if the leaflet had been valuable in helping the patients keep their doctors' appointments. Of 16 men who initially canceled their appointments, 4 had received the leaflet, and the rest had not. (The study defined "nonattendees" as those who canceled their initial appointment and had not returned within 6 months).

The doctors found that those who received the informational leaflet tended to keep their appointment compared to the others. However, Pook and Krause write that it's unknown why the leaflet helped reduce these cancellations. While no appointment reminders were specifically included in the information, it's not known whether the leaflet helped the patients remember their appointments, or whether it actually reduced their pre-workup stress. But they noted that sending any type of mail may help reduce nonattendance for whatever reason, based on these results.

The investigators finally analyzed the results of the survey on the andrology clinic's website. "In the treatment group, awareness of the existence of the clinic's website was much greater," they wrote. "Nevertheless, more than half of the patients receiving the leaflet were unaware of its existence" suggesting that they hadn’t read the leaflet in-depth.

A First Focusing on Infertility Stress
In conclusion, the psychologists wrote: "The present study is the first to deliver evidence of a stress-relieving effect of preparatory information for infertility patients. To the best of our knowledge, it is even the first randomized controlled trial to show that infertility-related distress can be reduced effectively."

It is hoped these findings "will encourage the development and evaluation of alternative forms of support for infertility patients," they wrote.

In the meantime, Pook says, "the low uptake rates of psychological services for infertility patients represent a challenge for future research. It is striking that no study meeting the common standards of therapy research has delivered evidence that patients benefit from those services."

1. Pook M, Krause W. Stress reduction in male infertility patients: A randomized, controlled trial. Fertil Steril 2005 Jan;83(1):68-73.
2. Hardy KJ, O'Brien SV, Furlong NJ. Information given to patients before appointments and its effect on non-attendance rate. BMJ 2001 Dec 1;323(7324):1298-300

John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.