Behaviour Research and Therapy 77 (2016) 96e104

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

Effects of a mindfulness-based intervention on fertility quality of life

and pregnancy rates among women subjected to first in vitro
fertilization treatment
Jing Li a, Ling Long b, Yu Liu c, Wei He b, Min Li a, *
a
Department of Military Psychology, College of Psychology, Third Military Medical University, Chongqing 400038, China
b
Reproductive Medical Center, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
c
Department of Laboratory Medicine, Southwest Hospital, Third Military Medical University, Chongqing 400038, China

a r t i c l e i n f o a b s t r a c t

Article history: Generally, undergoing an in vitro fertilization (IVF) treatment is an emotional and physical burden for the
Received 20 May 2015 infertile woman, which may negatively influence the treatment outcome. We conducted a study to
Received in revised form investigate the effectiveness of a mindfulness-based intervention (MBI) among women subjected to first
15 December 2015
IVF treatment at a fertility medical center in China. Among infertile women registered for their first IVF
Accepted 16 December 2015
Available online 19 December 2015
treatment, 58 completed the intervention, and 50 were assigned to a control group using a non-
randomized controlled study. Standardized measures of mindfulness, self-compassion, emotion regula-
tion difficulties, infertility-related coping strategies and fertility quality of life (FertiQoL) were endorsed
Keywords:
IVF
pre- and post-MBI, and measure of pregnancy rates at the sixth months after the intervention. Both
Fertility quality of life groups were shown to be equivalent at baseline. By the end of the intervention, women who attended
Mindfulness-based intervention the intervention revealed a significant increase in mindfulness, self-compassion, meaning-based coping
Emotion regulation difficulties strategies and all FertiQoL domains. Inversely, they presented a significant decrease in emotion regula-
Self-compassion tion difficulties, active- and passive-avoidance coping strategies. Women in the control group did not
Infertility-related coping present significant changes in any of the psychological measures. Moreover, there were statistically
significant differences between participants in the pregnancy rates, the experiment group higher than
the control group. Being fully aware of the present moment without the lens of judgment, seems to help
women relate to their infertility and IVF treatment in new ways. This is beneficial for promoting their
self-compassion, adaptive emotion regulation and infertility-related coping strategies, which, in turn,
may influence the FertiQoL and pregnancy rates. The brief and nonpharmaceutical nature of this inter-
vention makes it a promising candidate for women' use during first IVF treatment.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction fertilization (IVF) to realize their wish to have children. However,

Rather than a medical issue, infertility is seen as a develop-
mental crisis (Sexton, Byrd, O Donohue, & Jacobs, 2010), experi-
enced by individuals and couples as a stressful and often
heartbreaking situation (Cousineau & Domar, 2007). Although both
sexes are emotionally affected by infertility, women appear to
experience greater stress and pressure (Newton, Sherrard, &
Glavac, 1999; Ramazanzadeh, Noorbala, Abedinia, & Naghizadeh,
2009) as well as lower quality of life (El Kissi et al., 2014).
Women who suffer from fertility issues often use in vitro
* Corresponding author.
E-mail address: limin52267@tmmu.edu.cn (M. Li).
IVF is a multidimensional stressor, including the treatment itself
and its unpredictable outcome (Verhaak et al., 2007), leaving the
women physically and emotionally exhausted (Kaliarnta, Nihle n-
Fahlquist, & Roeser, 2011). Despite there are inconclusive conclu-
sion regarding the association between emotional distress and
pregnancy outcome in women undergoing assisted reproductive
treatment (Greil, Slauson Blevins, & McQuillan, 2010), patients may
still want interventions to improve quality of life during treatment
(Boivin et al., 2011a,b). Given that many infertile individuals
seeking medical treatment experience the impairments in QoL for
years (Ferreira, Vicente, Duarte, & Chaves, 2015), an increased focus
on improving QoL, one of the most important issues to be
addressed in infertility counseling (Haica, 2013), may benefit many

http://dx.doi.org/10.1016/j.brat.2015.12.010
0005-7967/© 2015 Elsevier Ltd. All rights reserved.
 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104
patients. Updating knowledge concerning the improvement of the
QoL of women with fertility difficulties has become increasingly
important for health professionals (Ferreira et al., 2015).
There are many psychosocial variables that may impact the in-
dividual's perception of QoL, including mindfulness (Carlson, Speca,
Patel, & Goodey, 2004; Witek-Janusek et al., 2008), self-compassion
(Neff, 2003a,b; Shapiro, Astin, Bishop, & Cordova, 2005), emotion
regulation (Ciuluvica, Amerio, & Fulcheri, 2014) and coping stra-
tegies (Stanton, Tennen, Affleck, & Mendola, 1992).
Mindfulness is commonly and operationally defined as the
quality of consciousness or awareness that arises through inten-
tionally attending to present moment experience in a non-
judgmental and accepting way (Kabat-Zinn, 1994). It can also be
understood as a disposition, trait or stable tendency to be mindful
in everyday life (Brown & Ryan, 2003). Dispositional mindfulness
has been shown to be related to less perceived stress (Tran et al.,
2014), fewer depressive and anxiety symptoms (Campos et al.,
2015) or acceptance of pain (Cebolla, Luciano, DeMarzo, Navarro-
Gil, & Campayo, 2013). Self-compassion represents a warm and
accepting stance towards those aspects of oneself and one's life that
are disliked (Neff, 2003a,b). It is a powerful predictor of mental
health. Several studies have shown that self-compassion is nega-
tively associated with anxiety, stress, depression, rumination
(Castilho, Pinto Gouveia, & Duarte, 2015; Neff, Rude, & Kirkpatrick,
2007; Raes, 2010). On the contrary, self-compassion is strongly and
positively linked to psychological well-being, happiness, life satis-
faction, optimism, emotional intelligence, and interpersonal
connectedness (Neff et al., 2007). As for emotion regulation, it is the
activation of a goal to influence the emotion trajectory (Gross,
Sheppes, & Urry, 2011), being a mechanism underlying various
forms of psychopathology and important target of treatment (Gratz
& Tull, 2010). In addition, the literature on stress processes has
considerably focused on coping, a class of affect regulation strate-
gies that operate by altering physiological, experiential, or behav-
ioral responses to stressful situations (Larsen, 2000). A review of
psychosocial interventions in infertility (Boivin, 2003) indicates
that the more successful interventions included the acquisition of
coping techniques. Maladaptive coping styles can lead to psycho-
logical distress, unhealthy beliefs and behaviors (Karaca & Unsal,
2015), which, if fueled by the stress of continued failure to over-
come childlessness, is likely to further damage women's emotional
well-being (van den Akker, 2005). Emotion regulation overlaps
with coping, but refers to attempts to influence which emotions
one has, when one has them, and how one experiences or expresses
these emotions (Gross, 1998). On the other hand, coping may
emphasis on alleviating stress responses and its relatively long
temporal horizon (Gross, 2015).
Infertility individuals seem to struggle with being kind and
understanding towards themselves in instances of pain and failure,
and less capable of perceiving their experiences as part of the larger
human experience, as well as less aware of their unpleasant
thoughts and feelings in an open and non-judgmental way (Gilbert,
2005; Neff, 2003a,b; Pinto-Gouveia, Galhardo, Cunha, & Matos,
2012). In addition, infertile women generally respond to infertility
with deep sorrow and mourning, which can lead to the adoption of
maladaptive coping strategies such as crying, praying, and a belief
in God (Farzadi, Mohammadi-Hosseini, Seyyed-Fatemi, & Alikhah,
2007; Schmidt et al., 2005). Therefore, some researchers suggested
that interventions that target emotion-regulation, mindfulness,
self-compassion and coping strategies may improve the effective-
ness of psychotherapeutic interventions (Berking et al., 2008).
Meanwhile, a growing body of robust evidence has demon-
strated that mindfulness-based interventions (MBIs) are effective
in improving a range of clinical and non-clinical psychological
outcomes in comparison to control conditions (Gu, Strauss, Bond, &
97
Cavanagh, 2015). MBIs significantly improve the QoL in breast and
prostate cancer patients (Carlson et al., 2004, 2007; Witek-Janusek
et al., 2008), people with generalized anxiety disorder (Morgan,
Graham, Hayes-Skelton, Orsillo, & Roemer, 2014), recurrently
depressed patients (Teasdale et al., 2000), a heterogeneous patient
populations (Reibel, Greeson, Brainard, & Rosenzweig, 2001). In
addition, correlational research supports the proposed association
between mindfulness and reduced emotion regulation difficulties
(Baer, 2006; Hayes & Feldman, 2004). Meditators reported signifi-
cantly higher levels of mindfulness, self-compassion, and lower
level of difficulties with emotion regulation (Lykins & Baer, 2009).
In a study in women newly diagnosed with early stage breast
cancer, the results show that women in the midst of breast cancer
treatment, who participated in the MBSR program, reported more
improvements in coping effectiveness (Witek-Janusek et al., 2008).
Thus, given that special physical, psychological and behavioral
characteristics among women undergoing first IVF-treatment, as
well as the efficacy of MBIs, the women undergoing first IVF
treatment may also benefit from MBIs. Moreover, although there
are some studies that have applied MBIs into infertility (Galhardo,
Cunha, & Pinto-Gouveia, 2013; Peterson & Eifert, 2011) and
proved effective in decreasing psychological distress, the studies
that evaluate the effectiveness of MBIs on fertility quality of life
(FertiQoL) and treatment outcomes among women undergoing first
IVF treatment is few.
Therefore, the major goal of present study is to evaluate the
effectiveness of a MBI on FertiQoL, mindfulness, self-compassion,
emotion regulation difficulties, infertility-related coping strategies
and pregnancy outcome among infertile women undergoing first
IVF treatment in study group when compared to women in control
group. The measure outcomes include mindfulness, self-
compassion, emotion regulation difficulties, infertility-related
coping strategies, FertiQoL and pregnancy rate. Our overall hy-
pothesis is that the MBI will improve mindfulness, self-compassion,
emotion regulation, coping strategies and ultimately lead to
favorable changes in FertiQoL and pregnancy rate in women un-
dergoing first IVF treatment. This would support the integration of
MBI with conventional medical treatments to improve FertiQoL and
promote treatment outcomes in first IVF-treatment women.
2. Materials and methods
2.1. Participants
Potential candidates were women that attended to the fertility
medical center in Southwest Hospital, Chongqing, China, for their
first IVF treatment. Inclusion criteria were infertile women who had
registered for their first IVF treatment; were willing to participate
in the study; were able to read and understand the questionnaires;
had never received a mental disorder diagnosis or psychological
treatment from a mental health professional; hadn't undergone
yoga or meditation previously.
2.2. Procedures
On the every afternoon from Monday to Friday per week,
infertile women were informed about the study by the first author
at the end of their registration for IVF treatment in the following
days. The aims of the study, inclusion criteria, participants' role,
researchers' obligations, and procedure to participate were
explained to them.
During the recruitment period (from November 2013 to
November 2014), we invited 316 eligible women, and 166 of them
agreed to participate. Participants who volunteered to participate
and enrolled for the MBI program were included in the
98 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104
experimental group. Those who volunteered to participate but not
enrolled for the program mainly due to time constraints, inconve-
nient residence, were included in the routine care control group.
Participants in the test group attended a structured clinical inter-
view and signed the informed consent forms. Participants in the
control group received 6 free B ultrasonic wave examinations as the
compensation upon completion of the post-test questionnaires
packet. In the both group, the pretest assessment protocol was
completed after they agreed to participate, and the posttest
assessment protocol was sent and returned by mail at the end of
the last session. The attrition rates of the intervention and control
group were 32.55% (9: discontinued intervention due to family
reason or unknown reason; 19: absent > 2 sessions due to physical
health or treatment problem) and 37.5% (8: due to unknown
reason; 17: postponement of treatment due to medical reasons; 5:
treatment termination), respectively. The study was approved by
the Ethics Committee of Third Military Medical University prior to
participants' enrollment.
2.3. Measures
2.3.1. Demographic, clinical information and psychological
assessment
Demographic and clinical data were obtained regarding age,
education, occupation, duration of infertility, duration of infertility
treatment, causes of infertility.
Before and after the program, the following set of self-report
psychological measures was completed by all the subjects.
2.3.1.1. Self-Compassion Scale (SCS). The SCS(Neff, 2003a,b) is a 26-
item self-report questionnaire that measures six components of
self-compassion: self-kindness (five items, e.g., “I try to be under-
standing and patient toward those aspects of my personality I don't
like”); self-judgment (five items, e.g., “I'm disapproving and judg-
mental about my own flaws and inadequacies”); common hu-
manity (four items, e.g., “I try to see my failings as part of the
human condition ”); isolation (four items, e.g., “When I think about
my inadequacies, it tends to make me feel more separate and cut off
from the rest of the world ”); mindfulness (four items, e.g., “When
something painful happens, I try to take a balanced view of the
situation”); and overidentification (four items, e.g., “When I'm
feeling down, it ends to obsess and fixate on everything that's
wrong”). Mean scores on the six subscales can be averaged (after
reverse-coding negative items) to create an overall self-compassion
score. Items are rated on a 5-point Likert scale ranging from 1
(almost never) to 5 (almost always). Research indicates that the SCS
demonstrates concurrent validity, convergent validity, discriminate
validity, test-retest reliability, and good internal consistency
(a ¼ .92; Neff, 2003a,b).
SCS has been used in China and proved acceptable reliability and
validity, Cronbach's alphas of total scale .68, subscales from .60 to
.68 in Chinese adolescent population (Ping, Ling, Yongsheng, &
Ying, 2012), total above .84, subscales from .51 to .74 in Chinese
undergraduate students (Jian, Liang-shi, & Li-hua, 2011; Kai, Jing-
qun, & LiuFen, 2011). In the present study, Cronbach's alphas for the
total scale in the experimental and control group were .92 and .88,
respectively, and ranged between .68 and .78 for the subscales.
2.3.1.2. The Chinese version of Five Facet Mindfulness Questionnaire
(Ch-FFMQ). The Ch-FFMQ (Deng, Liu, Rodriguez, & Xia, 2011) is
translated from FFMQ (Baer, 2006), The FFMQ is a questionnaire for
measuring dispositional mindfulness. It consists of 39 items rated
on a Likert scale ranging from 1 (never or very rarely true) to 5 (very
often or always true). These items measure a personal disposition
to being mindful in daily life, focusing on five factors of
mindfulness: Observing, refers to the subject's capacity to pay
attention to internal and external experiences such as sensations,
thoughts, or emotions; Describing, measures the ability to describe
events and personal responses in words; Acting with awareness,
includes focusing on the activity being carried out, as opposed to
behaving automatically; Non-judging of inner experience, refers to
the ability to take a non-evaluative stance toward thoughts and
feelings; and Non-reactivity to inner experience, allowing thoughts
and feelings to come and go, without getting caught up in them or
carried away by them (Baer et al., 2008). The FFMQ has been shown
to have good internal consistency and significant relationships in
the predicted directions with a variety of constructs related to
mindfulness (Baer, 2006). Cronbach's alphas for the Ch-FFMQ are
acceptable, except for the relatively low a (.448) for the non-
reacting factor, subscales from .659 to .843 (Deng et al., 2011). In
the present study, Cronbach's alphas for the total scale in the
experimental and control group were .86 and .77, respectively, and
ranged between .62 and .81 for the subscales.
2.3.1.3. Fertility Quality of Life (FertiQoL) tool. The FertiQoL (Boivin
et al., 2011a,b) tool is specifically designed for infertile patients to
assess their QoL. Two main modules compose the FertiQoL tool:
The Core FertiQoL module and the optional Treatment module.
There are 24 items in the Core FertiQoL module and 10 items in the
Treatment FertiQoL module. The 24 items from the Core FertiQoL
are categorized into four domains, including the emotional,
cognitive and physical (marked as mind/body), relational, and so-
cial domains. The emotional domain evaluates the impact of
infertility on emotions, such as sadness, resentment, or grief. The
mind/body domain refers to the influence of infertility on physical
health, cognition, and behavior. The relational domain and the so-
cial domain are used to quantify the impact of infertility on part-
nership and on social aspects (e.g., social inclusion, expectation,
and support), respectively. The optional treatment module consists
of two domains that are used to assess the environment and
tolerability for the treatment for infertility. Items from these do-
mains are presented in the questionnaire randomly and rated on a
scale of 0e4. The subscale and total FertiQoL scores are computed
and transformed to achieve a range of 0e100, where higher scores
indicate better QoL. The FertiQoL tool has been translated into 20
different languages, including traditional Chinese, and is available
on the FertiQoL website (http://www.fertiqol.org/). The present
study used the Chinese version of FertiQoL questionnaire. In this
study, Cronbach's alphas for the total scale in the experimental and
control group were .94 and .93, respectively, and ranged between
.73 and .92, .70 and .90 for the subscales, respectively.
2.3.1.4. Difficulties in Emotion Regulation Scale (DERS). The DERS
(Gratz & Roemer, 2004) consists of 36 items that load onto six
subscales. Nonacceptance of emotional responses reflects a ten-
dency toward negative secondary responses to negative emotions,
and/or denial of distress. The difficulties engaging in goal-directed
behavior scale captures problems concentrating and accomplishing
tasks while experiencing negative emotions. The impulse control
difficulties subscale reflects struggles to control behavior when
upset. The lack of emotional awareness scale captures inattention to
emotional responses. The limited access to emotion regulation stra-
tegies scale assesses beliefs that there is little a person can do to
regulate one's emotions effectively after becoming upset. Finally,
the last subscale, labeled lack of emotional clarity, reflects the extent
to which individuals are unclear about which emotions they are
experiencing. The Chinese version of DERS (Li, Hengchao, Du, &
Zhongquan, 2007) has good overall internal consistency (.89),
subscale alphas ranged from .79 to.88 among Chinese university
students (Li et al., 2007). In this study, Cronbach's alphas for the
 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104
total scale in the experimental and control group were .90 and .86,
respectively, and ranged between .75 and .90,.78and .89 for the
subscales, respectively.
2.3.1.5. The Copenhagen Multi-Centre Psychosocial Infertility
(COMPI) coping strategy scales. The COMPI coping strategy scales
(Schmidt et al., 2005) measures infertility-related coping and was
categorized into four subscales: 1) active-avoidance strategies (e.g.,
avoiding pregnant women or children); 2) active-confronting
strategies (e.g., showing feelings, asking others for advice); 3)
passive-avoidance strategies (e.g., hoping for a miracle); and 4)
meaning-based coping (e.g., growing as a person in a positive way,
finding other goals in life). The COMPI coping strategy scales has
been shown to have acceptable internal consistency among infer-
tile women and men, Cronbach's alphas ranged between .46 and
.76, .55 and .74 for the subscales, respectively (Peterson, Pirritano,
Block, & Schmidt, 2011). In this study, Cronbach's alphas for the
subscales in the experimental and control group ranged between
.62 and .70, .56 and .67 respectively.
2.4. Pregnancy assessment
Pregnancy rate was defined as evidence of pregnancy according
to clinical or ultrasound parameters (ultrasound visualization of a
gestational sac; Zegers-Hochschild et al., 2006). The resultant
pregnancy rate was assessed according to the reports of clinicians
at the sixth months after the intervention.
2.5. Intervention
An intervention was developed to train the women undergoing
first IVF-treatment in mindfulness. We began by reviewing and
compiling intervention elements of MBSR (Kabat-Zinn, 2013; Stahl
& Goldstein, 2010) and MBCT (Segal, Williams, & Teasdale, 2002),
theoretical and clinical work on working with physical and psy-
chological distress and concerns among women undergoing ART
(Verhaak et al., 2007), Mindfulness-Based Childbirth and Parenting
(MBCP; Bardacke, 2012), and acceptance-based psychological ap-
proaches such as Acceptance and Commitment Therapy (Hayes,
Follette, & Linehan, 2004). Based on the above approaches, we
developed the Mindfulness-Based Intervention for IVF women(-
MBII), tailoring this intervention to match the population and
problem being addressed, i.e., the symptoms we hoped to alleviate
with the intervention, as well as the skills we hoped to enhance.
Participants in the MBII program engage in various exercises that
range in form from lying to sitting to walking mindfully. The goal of
these exercises is to give the participant the opportunity to practice
and develop the skill of mindful awareness, enhancing present-
moment awareness and learning to tolerate, acknowledge, label,
and embrace thoughts and feelings rather than reacting to or
avoiding them (Shapiro et al., 2005).
This intervention incorporates the following approaches to
cultivating mindfulness: (1) mindfulness of thoughts and feelings
through breath, thoughts and emotions awareness, and contem-
plative practices, (2) mindfulness of the body through guided body
scan, body awareness meditation and mindful hatha yoga, (3)
presentation of psychological concepts that incorporate mindful-
ness attitudes such as acceptance, letting go, patience and culti-
vation of an observing self, and (4) waving the mindfulness
practices into the daily life, especially during the IVF-treatment,
such as doctors' visit, medical check-up, operation. This MBII ses-
sions follow a similar structure. They begin with a first half-hour of
sharing, sharing beginning in the second session as the first one
follows a different format. After the first half hour, a formal
mindfulness practice is held, followed by sharing how participants
99
felt, what they have noticed, how the experience was for them. The
first session is mainly introductory, beginning with each person
introducing herself. The mindful pain meditation is held in the fifth
session.
Adaptations of typical mindfulness-based intervention compo-
nents included, for example, (1) inclusion of awareness of the
uterus, pelvic cavity and related thoughts and emotions during the
body scan meditation; (2) use of explanatory examples and exer-
cises having to do with IVF treatment such as pain or sleep issues
during IVF treatment, anxiety about follicular growth or embryo
implantation, or dealing with a physical discomfort, or adverse
effect caused by medicine; and (3) greater inclusion of walking and
moving mindfulness practices, and forms of mindful movement
that have been tailored for IVF women such a yoga drawing on
MBCP.
We provided a participant's manual, therapist manual and an
audio mp3 with mindfulness meditation instructions to subjects.
The participant's manual covers various topics (emotion and
fertility, definition of mindfulness, instructions for mindfulness
practice, the commitment to the program etc.). The audio mp3
presents several Chinese version instructions for mindfulness
meditation translated and adapted from “body scan” (Kabat-Zinn,
2013; Williams & Penman, 2011), “sitting meditation” (Bardacke,
2012; Kabat-Zinn, 2013), “mindfulness yoga” (Stahl & Goldstein,
2010), “walking meditation” (Kabat-Zinn, 2013), “mindful anxiety
meditation” (Forsyth & Eifert, 2007; Stahl & Goldstein, 2010), and
“loving-kindness meditation” (Bardacke, 2012; Stahl & Goldstein,
2010). The therapist manual describes content and instructions
for conducting each session. Each of these practices is held during
sessions, and participants are invited to practice it on a daily basis
during the following week and hand in the homework at the start
of the following session. After that QQ group chatting also is good
method, in which they can exchange and discuss ideas concerning
treatment and mindfulness practices.
This MBII consists of a six week course, in which up to 15 women
meet for 2e2.5 h per week for mindfulness-based meditation in-
struction and training that were held on Saturday or Sunday af-
ternoons. A total of 6 groups completed the 6-week program within
this one year study. Sessions were led by the first author who is an
experienced clinical psychologist with training in mindfulness-
based approaches, and psychological interventions for infertile
patients, held in the multipurpose rooms of the Southwest Hospital
Fitness Center. The MBII sessions were held between November
2013 and November 2014.
2.6. Statistical analyses
All quantitative data were analyzed using SPSS18.0. First, inde-
pendent samples t tests and c2-tests were conducted to explore
whether there were differences between the groups regarding
demographic, clinical and study variables. To explore mean differ-
ences between pretreatment (T1) and post-treatment (T2),
between-groups and time  group interaction effect, repeated
measures analyses of variance (ANOVAs) were conducted, consid-
ering the intervention and the control group as the between-
subjects factor. Mean differences of the study variables were also
studied in each group through paired samples t tests. We measured
the effect sizes using the partial eta squared (h2p): a partial eta
squared ES of .01 is considered small, .06 is considered medium,
and .14 is considered large (Cohen, 2013).
3. Results
Social demographic and clinical information about the experi-
mental and control group is presented in Table 1. The groups were
100 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104

equivalent in any of demographic and clinical variables. Table 2 Table 2

presents the differences between the groups concerning the Means, SDs, mean comparisons of the two groups at baseline (T1).

study variables. Both groups did not present significant differences MBII Control group
in any of the variables. T1(n ¼ 58) T1(n ¼ 50)
Table 3 shows the group comparisons based on time and group Mean SD Mean SD t (106) p h2Р
direct effect as well as on the time  group interaction effect. A
SCS 3.06 .61 3.07 .28 .11 .92 .000
significant direct effect of time was found for self-compassion and DERS 92.00 19.83 89.04 15.05 .88 .39 .007
total FertiQoL. Significant direct group effects were found for self- Active-avoidance 9.02 2.60 9.48 4.93 .62 .54 .004
compassion, mindfulness, mind-body FertiQoL. Medium effect Active-confronting 17.40 3.37 17.00 3.61 .59 .56 .003
Passive-avoidance 9.17 1.92 9.20 1.78 .08 .94 .000
sizes were found. Significant time  group interaction effects were
Meaning-based coping 13.98 3.43 13.78 2.40 .36 .73 .001
found only for self-compassion, emotion regulation difficulties, FFMQ 117.93 16.79 117.56 9.56 .14 .89 .000
mindfulness, mind-body and total FertiQoL, all of them with me- Emotional 54.60 23.66 54.58 21.68 .20 .84 .000
dium effect sizes. Mind-body 54.96 23.91 56.17 22.07 .27 .79 .001
Table 4 presents the comparison of mean scores before (T1) and Relational 68.89 18.14 72.33 15.86 1.04 .30 .010
Social 65.45 16.45 66.17 18.05 .22 .83 .000
after the program completion (T2) in the intervention group
Environment 56.68 13.13 57.83 12.33 .47 .64 .002
regarding those variables with significant time  group effect. A Tolerability 50.97 21.39 54.88 19.33 .99 .33 .009
significant increase was found in self-compassion, mindfulness Total FertiQoL 59.04 14.94 60.65 13.67 .58 .56 .003
mind-body and total FertiQoL. On the other hand, there was a Note:SCS ¼ self-compassion, DERS ¼ emotion regulation difficulties,
significant decrease in emotion regulation difficulties. Besides FFMQ ¼ mindfulness.
those variables with significant time  group effects, we have also
explored mean comparisons before (T1) and after the intervention
(T2) in the two groups separately through paired samples t tests. In
the experimental group, there was also a significant increase in In the present study, when considering the interaction
meaning-based coping, emotional, relational, social, environment time  group effect, we found that MBII increased scores on mea-
and tolerability FertiQoL domains, and a decrease in active- and sures of self-compassion, mindfulness and mind-body and total
passive-avoidance coping strategies. The same analysis was con- FertiQoL in the experimental group, and decreased scores on
ducted in the control group, and no differences were found in all emotion regulation difficulties. When considering mean compari-
variables. son within the MBII group, we also found decrease scores on active-
In addition, we also show the number and proportion of par- and passive-avoidance coping strategies and increase on meaning-
ticipants who had a viable pregnancy by virtue of IVF treatment based coping, emotional, relational, social, environment and
(Table 5). The c2 test indicated that there were significant differ- tolerability FertiQoL, not significant changes in active-confronting
ences in the number of viable pregnancies. The pregnancy rate was coping. The core skills trained during this MBII are enhancing
44.83% and 26% in the experimental group and the control group, present-moment awareness through disengaging in rumination
respectively. and intrusive self-judgment (Kabat-Zinn, 2013), and learning to
tolerate, acknowledge, label, and embrace thoughts and feelings
rather than reacting to or avoiding them (Shapiro et al., 2005),
4. Discussions which may be crucial factors for the psychological variables
changes in the MBII group.
The overall aim of this study was to examine the effectiveness of An increase in self-compassion among the women in the MBII
the MBII for infertile women undergoing first IVF treatment. group indicated that they responded in a more kind and accepting
Several psychological variables and pregnancy rate were included manner toward themselves whether things go well or badly (Leary,
in the study, and a routine care control group was used for Tate, Adams, Batts Allen, & Hancock, 2007). However, this finding is
comparison.

Table 1
Comparisons between the groups regarding demographic and clinical variables.

MBII group (n ¼ 58) Control group (n ¼ 50)

Mean SD Mean SD t (106) p value

Age (y) 30.66 4.29 30.70 4.77 .05 .96

Infertility duration(y) 4.66 3.06 5.20 3.03 .93 .36
Infertility treatment duration(y) 2.34 1.63 2.68 1.53 1.10 .28
n % n % c2a p
Education 4.60 .20
junior high school 14 24.10 15 30.00
senior high school 9 15.50 14 28.00
college 17 29.30 8 16.00
Bachelor or above 18 31.00 13 26.00
Occupation .44 .93
unemployment 19 32.80 16 32.00
enterprise employee 17 29.30 13 26.00
government institutions employee 11 19.0 9 18.00
other 11 19.0 12 24.00
Causes of infertility 2.71 .44
Male factor 11 19 4 8.00
Female factor 32 55.2 31 62.00
Both factor 14 24.1 14 28.00
Unexplained factor 1 1.7 1 2.00
 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104 101

Table 3
Means, SDs before and after the MBII, time main effect, group main effect, and time  group interaction effect.

Measure Time MBII group Control group Time Group Time  Group
(n ¼ 58) (n ¼ 50)

Mean SD Mean SD F p h2Р F p h2Р F p h2Р

SCS T1 3.06 .61 3.07 .28 20.87 <.001 .090 16.16 <.001 .071 17.40 <.001 .076
T2 3.60 .51 3.09 .29
DERS T1 92.00 19.83 89.04 15.05 3.84 .052 .018 5.99 .015 .027 13.80 <.001 .061
T2 78.76 18.65 93.14 13.32
Active-avoidance T1 9.02 2.60 9.48 4.93 .99 .322 .005 12.54 <.001 .056 6.20 .014 .028
T2 7.48 2.13 10.14 2.77
Active-confronting T1 17.40 3.37 17.00 3.61 .67 .415 .003 2.93 .088 .014 .79 .376 .004
T2 17.43 3.82 16.18 3.26
Passive-avoidance T1 9.17 1.92 9.20 1.78 1.21 .273 .011 3.57 .060 .017 3.18 .076 .015
T2 7.41 2.25 9.38 1.67
Meaning-based T1 13.98 3.43 13.78 2.40 9.41 .002 .043 9.14 .003 .041 6.23 .013 .029
T2 16.12 2.62 14.00 2.63
FFMQ T1 117.93 16.79 117.56 9.56 10.23 .002 .046 25.12 <.001 .106 23.27 <.001 .099
T2 133.83 17.04 114.34 12.46
Emotional T1 54.60 23.66 54.58 21.68 5.42 .021 .025 11.91 .001 .053 9.89 .002 .045
T2 71.12 17.38 52.25 20.36
Mind-body T1 54.96 23.91 56.17 22.07 3.66 .057 .017 13.43 <.001 .060 16.81 <.001 .073
T2 71.70 16.66 50.08 18.02
Relational T1 68.89 18.14 72.33 15.86 3.26 .072 .015 .02 .895 .000 2.99 .085 .014
T2 76.51 12.98 72.50 15.75
Social T1 65.45 16.45 66.17 18.05 5.25 .023 .024 4.50 .035 .021 5.94 .016 .027
T2 76.22 14.20 65.83 18.23
Environment T1 56.68 13.13 57.83 12.33 9.23 .003 .042 3.64 .058 .017 6.72 .010 .031
T2 66.16 12.09 58.58 11.68
Tolerability T1 50.97 21.39 54.88 19.33 8.39 .004 .038 3.76 .054 .017 12.20 .001 .054
T2 67.03 15.61 53.38 16.67
Total FertiQoL T1 59.04 14.94 60.65 13.67 9.46 .002 .043 9.29 .003 .042 15.51 <.001 .068
T2 71.72 11.43 59.09 12.67

Note: SCS ¼ self-compassion, DERS ¼ emotion regulation difficulties, FFMQ ¼ mindfulness.

Table 4
Mean comparisons at T1 and T2 in the MBII and in the control group.

MBII T1 (n ¼ 58) MBII T2 (n ¼ 58) Control group T1 Control group T2

(n ¼ 50) (n ¼ 50)

Mean SD Mean SD t(57) P h2Р Mean SD Mean SD t(49) P h2Р

SCS 3.06 .61 3.60 .51 8.10 <.001 .141 3.07 .28 3.09 .29 .84 .667 .002
DERS 92 19.83 78.76 18.65 7.49 <.001 .108 89.04 15.05 93.14 13.32 5.09 .152 .021
Active-avoidance 9.02 2.59 7.48 2.13 5.09 .001 .096 9.48 4.93 10.14 2.77 1.08 .411 .007
Active-confronting 17.4 3.37 17.43 3.82 .08 .959 .000 17.00 3.61 16.18 3.26 5.02 .236 .014
Passive-avoidance 9.17 1.91 7.41 2.25 4.23 .010 .060 9.20 1.78 9.38 1.67 1.50 .603 .003
Meaning-based 13.98 3.43 16.12 2.62 5.47 <.001 .111 13.78 2.40 14.00 2.63 1.36 .663 .002
FFMQ 117.93 16.78 133.83 17.04 7.78 <.001 .183 117.56 9.56 115.80 12.46 1.584 .416 .007
Emotional 54.60 23.66 71.12 17.38 6.56 <.001 .139 54.58 21.68 52.25 20.36 1.75 .580 .003
Mind-body 54.96 23.91 71.70 16.66 6.68 <.001 .144 56.17 22.07 50.08 18.02 5.11 .134 .023
Relational 68.89 18.14 76.51 12.98 4.31 .010 .060 72.33 15.86 72.50 15.75 .53 .958 .000
Social 65.45 16.45 76.22 14.20 5.82 <.001 .111 66.17 18.05 65.83 18.23 .70 .927 .000
Environment 56.68 13.13 66.16 12.09 6.83 <.001 .126 57.83 12.33 58.58 11.68 1.06 .756 .001
Tolerability 50.97 21.39 67.03 15.61 7.35 <.001 .158 54.88 19.33 53.38 16.67 1.00 .679 .002
Total FertiQoL 59.04 14.94 71.72 11.43 8.56 <.001 .188 60.65 13.67 59.09 12.67 2.443 .556 .004

Note: SCS ¼ self-compassion, DERS ¼ emotion regulation difficulties, FFMQ ¼ mindfulness.

Table 5 and type of participants. Additionally, a significant decrease in

Comparisons between the groups regarding pregnancy rate.
n Clinical pregnancy rate (n, %)
MBII group 58 26(44.83)
Control group 50 13(26.00)
inconsistent with the study conducted by Galhardo et al. (Galhardo
et al., 2013), which showed that women participated in the
mindfulness-based program for infertility did not present signifi-
cant change in self-compassion. The reasons for the inconsistency
may lie in the using of SCS differently, different program contents
emotion regulation difficulties was found in the MBII group.
c2 p Treatments that emphasize mindfulness and self-compassion
4.13 .04
should in theory also facilitate more adaptive emotion regulation,
because of the overlap conceptualization of emotion regulation
with self-compassion and mindfulness (Gratz & Tull, 2010).
In this study, the MBII group presented significant decrease in
active- and passive-avoidance coping, increase in meaning-based
coping. While avoidant coping (e.g. ignoring or escaping threat-
ening stimuli) can reduce distress in the short-term, it is ultimately
ineffective in supporting well-being (Davies & Clark, 1998). As a
chronic and long-term stressor, existing research assessing coping
strategies in IVF patients has demonstrated that populations using
102 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104
avoidance coping strategies report more psychological distress
(Stanton et al., 1992). In contrast, approach coping (e.g. active
coping or acceptance) is generally believed to facilitate the assim-
ilation and transcendence of stress in a way that ultimately en-
hances well-being (Weinstein, Brown, & Ryan, 2009). Mindfulness
may promote less avoidant coping (Weinstein et al., 2009), in that
trait mindfulness has been associated with lower levels of rumi-
nation, thought suppression, and other negative thinking styles
associated with poorer emotional outcomes (Baer, 2006; Shapiro,
Brown, & Biegel, 2007). Specifically, if more mindful individuals
are able or willing to objectively observe internal events, thoughts,
and emotions as they occur instead of engaging in past- or future-
oriented negative or distorted thinking patterns, they may be more
likely to cope in adaptive ways (McCullough, Orsulak, Brandon, &
Akers, 2007). However, in the present study, the scores of active-
confronting coping (e.g., finding a way to let feelings out) didn't
change in the MBII group. This finding is consistent with another
study, which suggests that under the low-control conditions such
as IVF procedure (Chan, Ng, Chan, & Chan, 2006), expression of
negative emotions is a less effective coping mechanism, at least in
terms of IVF treatment (Demyttenaere et al., 1998). On the other
hand, teaching people to “letting go”, which is one of the main
themes in this MBII program, may have a beneficial effect on the
psychological and physiological responses to stress, possibly
pertinent to IVF outcomes (Rapoport-Hubschman, Gidron, Reicher-
Atir, Sapir, & Fisch, 2009).
In this study, the scores on FertiQoL and all subscales signifi-
cantly increased after finishing the MBII sessions. These results are
consistent with some studies. For example, a group MBSR program
and conscious yoga significantly increased the QoL and its subscales
(physical and mental health) in infertile women (Hoveyda, Abadi, &
Dabaghi, 2014). The elements of mindfulness, namely awareness
and nonjudgmental acceptance of one's moment-to-moment
experience, are regarded as potentially effective antidotes against
common forms of psychological distresse rumination, anxiety,
worry, fear, anger, and so on e many of which involve the mal-
adaptive tendencies to avoid, suppress, or over-engage with one's
distressing thoughts and emotions (Keng, Smoski, & Robins, 2011).
Learning to observe and describe one's emotions, and empha-
sizing on letting go of evaluations such as “good” or “bad” and
taking a nonjudgmental and nonevaluative stance toward these
emotions are the skills trained in the MBII. These skills are expected
to facilitate emotional awareness, acceptance and willingness,
which is expected to increase emotion regulation and reduce
emotional suffering (Gratz & Tull, 2010), being beneficial to
emotional and mind-body and total FertiQoL. Besides, mindfulness
meditation also causes significant decreases in physical stress in
patients (Carlson et al., 2004) and has an effect on controlling the
body and therefore the mind, and reducing stress and anxiety
(Hoveyda et al., 2014), which is useful to mind-body FertiQoL. In
addition, it is likely that a more strong alliance is developed be-
tween the patients and the trainer, which facilitates the healing
process and better continuity of the treatment (Hoveyda et al.,
2014), thus better tolerability FertiQoL. As for the improvement in
social FertiQoL, it may be attributed to enhanced compassion, and
the factors related to group. Group therapy not only eliminates
social isolation, but also develops relief and expands the relation-
ships in these patients.
In terms of the increases on the score of relational FertiQoL, one
study showed that couples who are more mindful appear to be
more likely to enjoy greater relationship health and stability, more
satisfaction and affectionate behavior, as well as greater inter-
partner harmony on a range of life issues (Wachs & Cordova,
2007). In addition, the MBII also has increased the score on envi-
ronment FertiQoL. Participants performed a self-help role and
gained a sense of control through mindfulness practices (Chan
et al., 2006). Moreover, acquiring comprehensive knowledge
about IVF through group increased the predictability of the treat-
ment process for them. Those may help improve the women's
perception of the treatment quality and interactions with medical
staff during the IVF treatment, thus better environment FertiQoL.
Besides, the improvement in self-compassion, emotion regulation
skills and adaptive coping strategies may indirectly influence Fer-
tiQoL and its all subscales, although which is needed to examined in
the future research.
Moreover, our finding pointed to an increased pregnancy rate
due to psychological intervention that are somewhat effective in
increasing pregnancy rates (Hammerli, Znoj, & Barth, 2009). The
hypothalamic-pituitary-adrenal axis (HPA) has been shown to be
an important mediator of infertility, involved in the excretion of
some hormone e.g., cortisol that may negatively influence the
clinical pregnancy rate in IVF treatment (An, Wang, Ji, Zhang, & Wu,
2011). On the other hand, MBIs can improve the function of HPA.
For example, MBSR improved immune function for women recently
diagnosed with early stage breast cancer (Witek-Janusek et al.,
2008), and decreased cortisol level, Th1 (pro-inflammatory) cyto-
kines, systolic blood pressure and heart rate among breast and
prostate cancer outpatients (Carlson et al., 2004, 2007). In addition,
sleep disturbance may be related to infertility through HPA acti-
vation (Kloss, Perlis, Zamzow, Culnan, & Gracia, 2015). A study
demonstrated that MBSR can significantly improve the sleep
quality among breast and prostate cancer outpatients (Carlson
et al., 2004). In our study, the participants in the MBII also re-
ported better sleep quality since the start of the course. In sum-
mary, given that the role of HPA and sleep disturbance in infertility,
and efficacy of MBIs on HPA and sleep, our finding was not sur-
prising. Although the studies on the effect of this MBII on physio-
logic indicators of participants are needed, as well as many factors
influencing pregnancy rate, the MBII increased pregnancy rates in
this study.
This study has particular limitations. First, although we used a
matched control group, the current findings await replication in a
randomized design. Another main concern is the lack of a follow up
time point, follow-up assessments be needed in the future
research. The second limitation is related to measures. This study
used self-report tools that have some essential problems (e.g., lack
of self-insight). Additionally, although involving some physical
health (e.g. physical component of FertiQoL questionnaires), this
study did not examine the effect of this MBII on physiologic in-
dicators of participants. The studies on the effect of MBII on phys-
iologic indicators of participants (e.g. cortisol) are needed in the
future research. The third limitation is related to lack of individual
factors control. It is possible that participants overestimated effect
of the program because of personal willingness, optimism and
factors like that. It is recommended, to conduct pseudo-therapy
programs (placebo program) on control group in future studies to
control for expectancy effects. Lastly, the participants came from
fertility medical center in Southwest hospital, Chongqing, and un-
dergone first IVF treatment cycle. Researchers are recommended to
implement group mindfulness-based program on other patients in
other hospitals to expand the findings of this study. In addition, if a
follow up time is possible, maybe a mediation analysis would have
been more appropriate in the future research, with self-
compassion, emotion regulation and coping strategies being as
mediators between mindfulness and FertiQoL.
In conclusion, notwithstanding the above limitations, results
point to the effectiveness of the MBII for first IVF women. They
learned to related to their infertility and IVF treatment in new ways,
leading to increases in mindfulness levels, self-compassion, adap-
tive emotion regulation and coping strategies, which in turn
 J. Li et al. / Behaviour Research and Therapy 77 (2016) 96e104
improved fertility-related quality of life and pregnancy rates.
Competing interests
The authors declare that they have no competing interests.
Acknowledgments
The authors wish to especially thank all the individuals who
responded to our recruitment invitation for their interest in and
support of our research. This study was supported by the National
Natural Science Foundation of China granted to M.L. (no. 31170994).
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