Mental Health Across the Conception Journey: Trying To Conceive Without Treatment, Considering Treatment, and with Treatment.

This retrospective cohort study included 3458 US-based individuals trying to conceive while using Maven (Maven Clinic), a comprehensive digital health platform for reproductive, women’s and family health. Maven offers continuous access to virtual health care providers, allied health professionals and care coordinators via messaging and telehealth appointments, as well as patient educational materials (e.g. articles, virtual classes), and community forums. Individuals receive access to Maven as a benefit through their or their partners’ employer or health plan (i.e., all users have private health insurance). Descriptive statistics and bivariate tests were used to determine differences in prevalence of depression, generalized anxiety, conception-specific anxiety, and interest in receiving mental health support on a digital platform at various stages of the trying to conceive pathway from trying to conceive without treatment, to considering fertility treatment, to undergoing fertility treatment. Identification of users’ stage on the trying to conceive pathway, mental health, and interest in mental health support were all based on responses from a survey completed upon enrolment into Maven. To determine a user’s stage, each user indicated where they are on their journey towards pregnancy by selecting if they were trying to conceive without any treatment, trying to conceive and considering or planning to start treatment, or trying to conceive with treatment (including fertility medications, intrauterine insemination (IUI), or in vitro fertilization (IVF)). Time trying to conceive was collected by asking the user to indicate the number of months they have been trying to conceive, which was then divided into categories: less than 6 months, 6–12 months, and more than 12 months. User age was derived from date of birth. The experience of depression and generalized anxiety were based on users’ responses to 1-item modified versions of the Patient Health Questionnaire 2-Item (PHQ-2) (Kroenke et al. 2003 ) and Generalized Anxiety Disorder 2-Item (GAD-2) (Kroenke et al. 2022 ; Sapra et al. 2020 ) questions, respectively: “Over the past two weeks, how often did you feel down, depressed, hopeless, or have little interest or pleasure in doing things?” and “Over the past two weeks, how often did you feel nervous, anxious, on edge, or like you were not able to stop or control worrying?” To measure conception-specific anxiety, users were asked: “Over the past two weeks, how often have you felt anxious specifically about trying to conceive?” For all three questions, users selected from the responses not at all, several days, more than half the days, or nearly every day. Based on guidance provided in personal communication with the developer of PHQ-2 and GAD-2, who approved our use of the 1-item scales, a person was considered to have screened positive for generalized anxiety or depression if they selected “nearly every day” or “more than half the days” on the respective screener. Similarly, a person was considered to have screened positive for conception-specific anxiety if they selected “nearly every day” or “more than half the days” on that scale. For all three types of emotional distress (depression, generalized anxiety, conception-specific anxiety), users were considered to have any presence of the distress if they selected any response option other than “not at all.” Users were considered interested in receiving mental health support if they selected that they wanted help with “mental and emotional well being” in response to the statement “I would like Maven to help me with.” This study used de-identified data only, and the protocol was designated as exempt by WCG Institutional Review Board, an independent ethical review board.

User characteristics, mental health outcomes and support interests are presented in Table  1 . Users’ race did not differ by stage of trying, but there were differences in users’ age, gravidity, history of miscarriage, reproductive health conditions, and time trying. Users trying to conceive with treatment were more likely to be parous, older, have a history of miscarriage, and report reproductive health conditions including polycystic ovary syndrome (PCOS), endometriosis, and thyroid disease. Users who were trying to conceive without treatment were significantly more likely to have been trying for less than 6 months (31.1%) and 6 to 12 months (24.5%) compared to users who were considering treatment (14.1%, 19.9%) or using treatment (15.4%, 9.9%), respectively ( p  < 0.001). Users who were trying to conceive without treatment, considering treatment, and using treatment screened positive (i.e., response of “nearly every day” or “more than half the days”) at comparable rates for depression (4.1%, 4.2%, 4.6%; p  = 0.82), generalized anxiety (7.5%, 8.9%, 8.8%; p  = 0.77), and conception-specific anxiety (22.0%, 23.5%, 20.4%; p  = 0.13), respectively. For any presence of generalized anxiety or depression (i.e., response other than “not at all”), users who were trying to conceive without treatment, considering treatment, and using treatment reported comparable levels of depression (34.4%, 34.4%, 33.2%; p  = 0.78) and generalized anxiety (46.9%, 50.4%, 50.6%; p  = 0.55), respectively. Users who were considering treatment or trying to conceive without treatment had higher rates of any presence of conception-specific anxiety (73.3% and 73.0%, respectively) compared to users who were using treatment (68.7%) ( p  = 0.02). Interest in receiving support for mental and emotional well being was lowest among people trying to conceive without treatment, higher among people considering treatment, and highest among people using treatment (32.0%, 34.6%, 39.5%; p  = 0.005), respectively. Table 1 Prevalence of mental health outcomes and interest in mental health support by stage of trying to conceive Trying to conceive without treatment ( n  = 241) Trying to conceive and considering treatment ( n  = 1032) Trying to conceive with fertility treatment (medications, IUI, IVF) ( n  = 2185) Overall ( n  = 3458) P -value User characteristics Age (years), Mean (SD) 1,2 33.7 (4.64) 34.6 (5.04) 35.6 (4.88) 35.2 (4.94) < 0.001 Race 0.07 Non-Hispanic White 129 (53.5%) 520 (50.4%) 1224 (56.0%) 1873 (54.2%) Non-Hispanic Asian 30 (12.4%) 147 (14.2%) 310 (14.2%) 487 (14.1%) Hispanic 42 (17.4%) 151 (14.6%) 261 (11.9%) 454 (13.1%) Non-Hispanic Black 24 (10.0%) 132 (12.8%) 224 (10.3%) 380 (11.0%) Non-Hispanic Other 1 (0.4%) 6 (0.6%) 10 (0.5%) 17 (0.5%) Multiracial 7 (2.9%) 30 (2.9%) 49 (2.2%) 86 (2.5%) I prefer not to say 8 (3.3%) 46 (4.5%) 107 (4.9%) 161 (4.7%) Gravidity, nulliparous 132 (54.8%) 555 (53.8%) 1054 (48.2%) 1741 (50.3%) 0.005 History of miscarriage 48 (19.9%) 245 (23.7%) 585 (26.8%) 878 (25.4%) 0.02 Reproductive health conditions Polycystic ovary syndrome (PCOS) 35 (14.5%) 211 (20.4%) 488 (22.3%) 734 (21.2%) 0.01 Endometriosis 9 (3.7%) 80 (7.8%) 240 (11.0%) 329 (9.5%) < 0.001 Thyroid disease 27 (11.2%) 86 (8.3%) 285 (13.0%) 398 (11.5%) < 0.001 Trying time 1 < 6 months 75 (31.1%) 146 (14.1%) 337 (15.4%) 558 (16.1%) < 0.001 6–12 months 59 (24.5%) 205 (19.9%) 217 (9.9%) 481 (13.9%) ≥ 12 months 106 (44.0%) 635 (61.5%) 1567 (71.7%) 2308 (66.7%) Mental health screeners Depression Nearly every day 2 (0.8%) 7 (0.7%) 28 (1.3%) 37 (1.1%) 0.76 More than half the days 8 (3.3%) 36 (3.5%) 73 (3.3%) 117 (3.4%) Several days 73 (30.3%) 312 (30.2%) 625 (28.6%) 1010 (29.2%) Not at all 158 (65.6%) 677 (65.6%) 1459 (66.8%) 2294 (66.3%) Screened positive for depressions (nearly every day, more than half the days) 10 (4.1%) 43 (4.2%) 101 (4.6%) 154 (4.5%) 0.82 Any depression (nearly every day, more than half the days, several days) 83 (34.4%) 355 (34.4%) 726 (33.2%) 1164 (33.7%) 0.78 Generalized anxiety Nearly every day 5 (2.1%) 32 (3.1%) 54 (2.5%) 91 (2.6%) 0.84 More than half the days 13 (5.4%) 60 (5.8%) 138 (6.3%) 211 (6.1%) Several days 95 (39.4%) 428 (41.5%) 913 (41.8%) 1436 (41.5%) Not at all 128 (53.1%) 512 (49.6%) 1080 (49.4%) 1720 (49.7%) Screened positive for generalized anxiety (nearly every day, more than half the days) 18 (7.5%) 92 (8.9%) 192 (8.8%) 302 (8.7%) 0.77 Any anxiety (nearly every day, more than half the days, several days) 113 (46.9%) 520 (50.4%) 1105 (50.6%) 1738 (50.3%) 0.55 Conception-specific anxiety Nearly every day 23 (9.5%) 112 (10.9%) 200 (9.2%) 335 (9.7%) 0.15 More than half the days 30 (12.4%) 131 (12.7%) 246 (11.3%) 407 (11.8%) Several days 123 (51.0%) 513 (49.7%) 1056 (48.3%) 1692 (48.9%) Not at all 65 (27.0%) 276 (26.7%) 683 (31.3%) 1024 (29.6%) Screened positive for conception-specific anxiety (nearly every day, more than half the days) 53 (22.0%) 243 (23.5%) 446 (20.4%) 742 (21.5%) 0.13 Any conception-specific anxiety (nearly every day, more than half the days, several days) 176 (73.0%) 756 (73.3%) 1502 (68.7%) 2434 (70.4%) 0.02 Support interests Mental and emotional well being support 77 (32.0%) 357 (34.6%) 864 (39.5%) 1298 (37.5%) 0.005 1 0.2% missing data for age; 3.2% missing data for trying time 2 SD = standard deviation Prevalence of mental health outcomes and interest in mental health support by stage of trying to conceive 1 0.2% missing data for age; 3.2% missing data for trying time 2 SD = standard deviation

Starting or growing a family should be an exciting and joyous time but it can also be fraught with stress, even when trying to conceive without fertility treatment. Early identification of people who are struggling with their mental health and provision of support can improve well being (Nik Hazlina et al., 2022 ) and may decrease the time to conception (Byun et al., 2013 ; Sharma & Shrivastava, 2022 ). Primary care, including gynecology, and digital health platforms may be an effective mechanism by which screening and support are provided.

Research and mental health support while trying to conceive has typically focused on people undergoing fertility treatment but our study found that people in earlier phases of their conception journey experience anxiety and depression at comparable rates to those undergoing treatment. The high prevalence of mental health struggles while trying to conceive naturally is unexpected given that people in this stage possessed characteristics that one may assume would reduce the risk of anxiety and depression; compared to people who were considering or undergoing treatment, people trying to conceive without treatment tended to have fewer known reproductive health conditions, have been trying to get pregnant for fewer months, and were less likely to have a prior miscarriage. The distress experienced in this stage may be a consequence of the uncertainty of trying to conceive as they wait each month to find out if they will receive the good news of being pregnant or the disappointment of menstruation may contribute to anxiety (Boivin et al., 2011 ; Sweeny et al., 2015 ), and anxiety may be further exacerbated by the emotional strain of tracking ovulation and having timed intercourse (Byun et al., 2013 ; Balsom & Gordon, 2021 ). In contrast to people who are undergoing fertility treatment, people who are trying to conceive without treatment are unlikely to be interacting with healthcare professionals who are supporting their efforts to conceive (Frayne 2017 ; AAFP 2022 ; Bello et al. 2015 ). Consequently, this population is neither screened nor supported for their mental health challenges (Balsom & Gordon, 2021 ) and the high rates of anxiety and interest in receiving emotional support may reflect unmet needs in resources and services. Since their contact with the healthcare system is likely to be largely through primary care, including routine gynecology appointments, these venues provide an opportunity to inquire if patients are trying to conceive and to proactively use mental health screeners. Similarly, these healthcare touchpoints can be a place where support or referrals are provided. Digital health platforms also provide an effective way to screen for mental health issues. It is already exceedingly common for people who are trying to conceive to turn to the Internet and apps for information and advice and to use trackers that support conception (Jacobs et al., 2019 ; Skouteris & Savaglio, 2021 ). Upon identification of people experiencing mental health issues, digital health platforms can effectively provide support (Rubin-Miller et al., 2023 ; Bae et al., 2023 ) or can refer users to in-person care. Strengths of this analysis are the large sample size, which includes users from across the US with a distribution by region (Northeast, Midwest, South, and West) that is representative of the country, and collection of data from a population (i.e., those trying to conceive without fertility treatment) who are often overlooked in research. Our analysis has several limitations. The scoring for our modified versions of the PHQ-2 and GAD-2 screeners, per the guidance of the developer, used a higher threshold for scoring positive, which may underestimate the prevalence of generalized anxiety and depression in our sample. As well, the 1-item version of these screeners has not been validated. Users who are choosing to use a digital health resource while trying to conceive may have higher rates of emotional distress about conceiving than people who are not seeking information and support at this stage in their fertility journey, although this may be true of users across all stages. Since people access the digital resource as an employee benefit or through a private health insurance provider and have access to internet enabled devices, the users in our sample are not representative of the socio-economic status of the US population.

While it is well established that trying to conceive while experiencing infertility and undergoing fertility treatment is associated with anxiety (Kiani et al., 2020 ; Nik Hazlina et al., 2022 ; Sharma & Shrivastava, 2022 ), less is known about the mental health toll of trying to conceive without fertility treatment. There are signals in prior research that anxiety may be experienced early in a person’s journey to pregnancy before they have been trying to conceive for long enough that they are considered to have infertility (defined as trying for more than 12 months for people under age 35 years and trying for more than 6 months for people over age 35 (World Health Organization (WHO), 2018 ). It is known that tracking one’s ovulation and engaging in timed intercourse are associated with increased anxiety (Byun et al., 2013 ; Balsom & Gordon, 2021 ). For people using fertility treatment, sex on demand, and the disappointment of menstruating after an attempt cycle both contribute to anxiety (Sharma & Shrivastava, 2022 ). These may also be similar sources of anxiety for people who are trying to conceive without infertility or conception challenges. There is a dearth of information on people’s emotional needs while trying to conceive without treatment, most of whom lack the robust contact with the healthcare system that is experienced during fertility treatment and pregnancy and this population is consequently less likely to have their needs identified and supported. The aim of this research is to provide formative insights into the prevalence of mental health distress (depression, generalized anxiety (i.e., general feelings of anxiousness, worry or overwhelm), and conception-specific anxiety (i.e., anxiety specifically about trying to conceive) among people trying to conceive without treatment, their interest in receiving mental and emotional support, and how this compares to mental health distress and support needs at later phases of the journey to conception.