ORIGINAL ARTICLE: MENTAL HEALTH

Psychological and emotional

concomitants of infertility diagnosis
in women with diminished ovarian
reserve or anatomical cause
of infertility
Jennifer M. Nicoloro-SantaBarbara, M.A.,a Marci Lobel, Ph.D.,a Silvina Bocca, M.D., Ph.D.,b
James R. Stelling, M.D.,c and Lisa M. Pastore, Ph.D.c
a
Department of Psychology, Stony Brook University, Stony Brook, New York; b Jones Institute for Reproductive Medicine,
Eastern Virginia Medical School, Norfolk, Virginia; and c Department of Obstetrics/Gynecology and Reproductive Medicine,
Stony Brook Medicine, Stony Brook, New York

Objective: To examine the magnitude and predictors of emotional reactions to an infertility diagnosis in two groups of women: those
with diminished ovarian reserve (DOR), and those clinically diagnosed with an anatomical cause of infertility (ACI).
Design: Cross-sectional study.
Setting: Academic and private fertility clinics.
Patient(s): Women diagnosed with DOR (n ¼ 51) and women diagnosed with ACI (n ¼ 51).
Intervention(s): Not applicable.
Main Outcome Measure(s): Fertility Problem Inventory (infertility distress), Rosenberg Self-Esteem Scale, Health Orientation Scale
(emotional reactions to receiving a diagnosis).
Result(s): Women with DOR had statistically significantly higher infertility distress scores than women with ACI and higher scores on
subscales assessing distress from social concerns, sexual concerns, and a need for parenthood. In both groups, higher self-esteem was
associated with lower infertility distress. Hierarchical multiple regression analyses revealed that for women with DOR and those with
ACI lower infertility distress but not self-esteem predicted a more positive emotional reaction toward receiving a fertility diagnosis.
Conclusion(s): Women diagnosed with DOR have greater infertility distress but similar self-esteem and emotional reactions to their
diagnosis compared with women who have an anatomical cause of infertility. These results suggest that for both groups distress
surrounding infertility itself may influence the way women respond to learning the cause of their infertility. (Fertil SterilÒ
2017;108:161–7. Ó2017 by American Society for Reproductive Medicine.)
Key Words: Diminished ovarian reserve, distress, female infertility, health psychology, self-esteem, tubal infertility, tubal obstruction

Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/
16110-fertility-and-sterility/posts/16306-23662

B
eing female is associated by women often report feeling guilt over investigators (1, 4–6), there has been
many with the ability to conceive lifestyle choices that they believe caused little research examining whether the
and bear a child. Thus, a diag- their infertility, including waiting to experience of infertility differs as a
nosis of infertility can leave a woman have children (3). Although the psycho- function of the underlying cause.
feeling defective, out of step with her logical impact of infertility has received Infertility attributed to advanced age
peers, or stigmatized (1) as well as angry, increasing attention over the past or diminished ovarian reserve (DOR),
shameful, and sad (2). Also, infertile two decades as reviewed by various for example, may elicit different
emotional and psychological reactions
Received January 3, 2017; revised April 28, 2017; accepted May 3, 2017; published online June 1, 2017.
J.M.N.-S. has nothing to disclose. M.L. has nothing to disclose. S.B. has nothing to disclose. J.R.S. has
than infertility resulting from
nothing to disclose. L.M.P. has nothing to disclose. anatomical or physiologic causes,
Supported by National Institutes of Health, grant R01HD068440 (to L.M.P.). especially unpreventable conditions. A
Reprint requests: Marci Lobel, Ph.D., Department of Psychology, Stony Brook University, Stony Brook,
New York 11794-2500 (E-mail: marci.lobel@stonybrook.edu). study by Cizmeli et al. (7) investigated
emotional distress in women with
Fertility and Sterility® Vol. 108, No. 1, July 2017 0015-0282/$36.00
Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc.
DOR, which is a reduction in oocyte
http://dx.doi.org/10.1016/j.fertnstert.2017.05.008 quantity and quality associated with

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ORIGINAL ARTICLE: MENTAL HEALTH
advanced age or with other causes (8). Cizmeli et al. (7) found
that 24% of study participants were experiencing high distress
related to their infertility but having an explanation for their
condition was associated with better emotional status.
Women who receive a diagnosis of DOR may have similar
emotional responses as women who receive a diagnosis of
primary ovarian insufficiency (POI) because their fertility
challenges have ovarian origins. It should be noted, however,
that these two diagnoses differ (9, 10); most notably, women
with DOR have regular menstrual periods whereas those with
POI have four or more months of secondary amenorrhea
before the age of 40 plus postmenopausal levels of follicle-
stimulating hormone (FSH) (11). The cessation of menses in
POI may lead to greater distress among those patients.
Research on the psychological state of women with POI has
found that they experience elevated shyness, anxiety, and
depression, as well as diminished self-esteem, social support,
and positive affect (12–14). Statistical modeling of
approximately 100 women with POI has indicated that
distress (composite measure of depression, anxiety, and
general negative affect) at study enrollment predicted
distress 12 months later and that psychosocial vulnerability
(composite measure of neuroticism, stigma, and illness
uncertainty) also predicted distress 12 months later with
mediation by avoidant coping 4 months after study
enrollment.
The primary aims of our study were to describe and
compare levels of distress and identify predictors of emotional
reactions to diagnosis in two groups of women: those with
DOR and those whose infertility has been clinically attributed
to an anatomical cause (anatomical cause of infertility, ACI),
such as tubal occlusion or damage, intrauterine adhesions, or
other uterine anomalies. In women seeking fertility assis-
tance, DOR is diagnosed in approximately 10%, and tubal
and peritoneal pathology is the primary diagnosis in 30% to
35% of infertile couples (15). Because they have regular men-
strual periods, women with DOR may not be aware of their
infertility problems until they try to conceive, which leads
some to experience the diagnosis as a ‘‘rude awakening’’
(16). Women with DOR often report feeling angry and resent-
ful while trying to conceive (17).
There has been little research examining the psychologi-
cal impact of ACI. The research that does exist suggests that
women with chronic pelvic pain due to pelvic inflammatory
disease (18), endometriosis (19), or ectopic pregnancy (20,
21) report heightened levels of psychological distress. Pelvic
inflammatory disease is known to cause tubal damage and
ectopic pregnancy, and a history of ectopic pregnancy even
without a known history of pelvic inflammatory disease is
suggestive of tubal damage (22).
We examined whether the magnitude of infertility
distress would differ between women with DOR and those
with ACI. There was no a priori expectation of difference
because of a lack of prior investigation of this possibility.
We also examined whether lower emotional distress and
higher self-esteem would be protective against negative
reactions to an infertility diagnosis in both groups of women.
Prior studies of infertile women (7, 23) suggest that
self-esteem can ameliorate a woman's distress and her
162
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reaction toward receiving an infertility diagnosis. To our
knowledge, this possibility has not been examined among
women with ACI.
MATERIALS AND METHODS
Participants and Methods
Participants were enrolled from April 2012 through June 2014
at academic and private reproductive endocrinology and infer-
tility clinics in Virginia (39% of DOR participants, 100% of ACI
participants), California (35% of DOR participants), and North
Carolina (24% of DOR participants), plus 1 DOR patient who
self-referred from the Internet (2%). All had received a diag-
nosis of DOR or ACI, and all were participants in a larger study
on the prevalence of fragile X trinucleotide repeat levels in
women with DOR (23, 24). The average length of time
between diagnosis and study enrollment was 1.03 years
(median: 0.71 years) for DOR participants; 33% (n ¼ 17)
enrolled within 6 months of their diagnosis. The time since
diagnosis was not recorded for the ACI group.
For the DOR group (n ¼ 51), eligible women were those who
received a clinical diagnosis of unexplained DOR based on [1]
elevated but not postmenopausal-level FSH levels timed to their
menstrual cycle, [2] low antim€ ullerian hormone (AMH) levels for
their age, or [3] fewer than six antral follicles sized 2–10 mm on
an ovarian ultrasound (antral follicle count, AFC). Additionally,
the DOR participants were required to be %41 year old at time of
diagnosis and to have had regular menstrual cycles for the pre-
vious 6 months. Only the Stanford University site, where the
high patient volume provided confidence in the consistency of
the AFC measurement, used AFC as an entrance criterion. The
day 2–5 FSH enrollment criterion was adjusted for the different
laboratory machines at each site to ensure consistency in the
enrollment criteria across sites, as described elsewhere (24–26).
The DOR diagnosis was based on elevated FSH in
approximately 50% of the participants, on low AMH in 43%,
and on low AFC in 9%, with a subset meeting more than one
of those criteria. Women were excluded from the DOR group
if there was a known cause of elevated FSH for their age
unrelated to fragile X syndrome (e.g., surgical removal of one
or both ovaries, chemotherapy or radiation therapy, Turner
syndrome, or autoimmune disease) or a family history of
fragile X syndrome or premutation.
For the ACI group (n ¼ 51), women were eligible if they
were determined to have ACI, defined as bilateral tubal occlu-
sion or damage, unilateral tubal occlusion or damage if
deemed likely to have affected both tubes (e.g., hydrosalpinx),
or intrauterine adhesions (e.g., Asherman syndrome), or if
their fallopian tubes had been surgically closed for contracep-
tive purposes previously and the woman now desired chil-
dren. The ACI group was aged 18–50 years at enrollment,
had regular menstrual cycles at the time of ACI diagnosis,
and were deemed ovulatory at the time of diagnosis by the
physician. Women were excluded from the ACI group if their
hormone levels (FSH or AMH) suggested they might also have
DOR (by the enrollment criteria) or if they had a family history
of fragile X syndrome or premutation.
The study was approved by the human ethics board at all
academic sites (#11448 in Virginia, #11-1535 in North
VOL. 108 NO. 1 / JULY 2017
 Fertility and Sterility®

Carolina, and #16182 in California). After providing informed
consent, the women completed a study questionnaire that
included the evaluation instruments.
Self-esteem. Self-esteem was assessed with the well-
validated 10-item Rosenberg Self-Esteem Scale (RSE) (27,
28), which uses a 9-point response scale (1 ¼ strongly
disagree to 9 ¼ strongly agree). Self-esteem is calculated after
reverse scoring five items so that higher scores indicate
greater self-esteem. The RSE has strong internal consistency
as evidenced in the current study (Cronbach's a ¼ .87).
Infertility distress. The Fertility Problem Inventory (FPI) is a
well-validated 46-item self-report measure of infertility-
related distress (29). Respondents indicate their extent of
agreement with each item from 1 (strongly disagree) to 6
(strongly agree). The FPI comprises five subscales.
Social Concern (10 items): Sensitivity to comments, re-
minders of infertility, feelings of social isolation (e.g., ‘‘I
can't help comparing myself with friends who have
children’’).
Sexual Concern (8 items): Diminished sexual enjoyment
or sexual self-esteem, difficulty with scheduled sexual re-
lations (e.g., ‘‘I find I've lost my enjoyment of sex because
of the fertility problem’’).
analysis to examine the prediction that lower total distress
and higher self-esteem would be protective against negative
reactions to an infertility diagnosis in both groups of women.
A conservative approach, listwise deletion, was used because
of missing values for some participants. Analyses reported
below were rerun using mean value imputation for missing
data. These analyses yielded the same pattern of findings;
statistical significance was unchanged.
RESULTS
Sample Description
As shown in Table 1, the majority of participants were white,
non-Hispanic, married, seeking treatment with a partner, and
college-educated. Women with DOR were older at the time of
diagnosis than women with ACI by an average of 2.5 years
(P< .01) and were more likely to be nulliparous (P< .05) The
most common (self-reported) causes of ACI were endometri-
osis (21.6%), surgery to the fallopian tubes or uterus
TABLE 1
Characteristics of study population stratified by diminished ovarian
reserve versus anatomical cause of infertility.

Relationship Concern (10 items): Difficulties in talking DOR (n [ 51) ACI (n [ 51)
about infertility, concerns about impact on relationship Characteristics n % n %
(e.g., ‘‘My partner doesn't understand the way the fertility
Age at diagnosis 34.27  3.70 31.74  4.88
problem affects me’’). (mean  SD)a
Need for Parenthood (10 items): Parenthood perceived as Marital status
Married 34 66.67 36 70.60
essential goal in life (e.g., ‘‘I will do just about anything to Not married but living 0 0.00 1 2.00
have a child’’). with partner
Single 5 9.80 1 2.00
Rejection of Child-Free Lifestyle (8 items): Negative view Missing 12 23.53 13 25.50
of child-free lifestyle or status quo, future happiness Seeking treatment with
dependent on having a child (e.g., ‘‘Couples without a a partner
child are just as happy as those with children’’). Seeking treatment with 34 66.67 32 62.70
a partner
Appropriate items are reverse scored so that higher scores Not seeking treatment 12 23.53 4 7.80
with a partner
indicate greater infertility distress. In addition to creating Not seeking to become 2 3.90 2 3.90
subscale scores, a total FPI score was calculated. Internal con- pregnantb
sistency was high (Cronbach's a ¼ .92). Missing 3 5.90 13 25.50
Race
Emotional reactions to diagnosis. Emotional reactions to White 37 72.55 38 74.51
receiving a diagnosis of DOR or ACI ‘‘How would you describe Black 2 3.92 6 11.76
your feelings at this moment regarding your diagnosis of. . Asian 10 19.61 3 5.88
Hawaiian/Pacific Islander 0 0.00 0 0.00
.?’’) were assessed with the 11-item Health Orientation Scale Native American 0 0.00 1 1.96
(HOS) (7, 30). The 11 semantic differential items are Other or mixed 2 3.92 1 1.96
anchored with a negative and a positive adjective (e.g., Missing 0 0.00 2 3.92
Hispanic or Latina ethnicity 6 11.80 3 5.90
‘‘bad’’ and ‘‘good’’). The anchored adjectives correspond to a Highest education
score of 1 or 9, respectively, on a numbered scale (30). The High school diploma 5 9.80 5 9.80
original version of this measure included an additional item or less
(‘‘inactive’’ vs. ‘‘active’’) that was not used in our study. The Some college 3 5.90 4 7.80
College graduate 18 35.30 12 23.50
HOS had strong internal consistency (Cronbach's a ¼ .92). Postgraduate degree 13 25.50 17 33.30
Missing 12 23.50 13 25.50
Parousa 16 31.37 28 54.90
Data Analytic Strategy Nulligravid 16 35.29 10 19.60
Analyses were performed using IBM's SPSS version 19. Levels Note: ACI ¼ anatomical cause of infertility; DOR ¼ diminished ovarian reserve; SD ¼ standard
deviation.
of self-esteem, infertility distress, and emotional reactions to a
P< .05.
b
Includes egg donors.
an infertility diagnosis were compared across groups using t
Nicoloro-SantaBarbara. Reactions to infertility diagnosis. Fertil Steril 2017.
tests. We conducted a hierarchical multiple regression

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ORIGINAL ARTICLE: MENTAL HEALTH

(19.6%), sexually transmitted infection and/or pelvic inflam-
matory disease (13.7%), and ectopic pregnancy (11.8%), with
some women reporting more than one cause.
The descriptive statistics (mean, standard deviation) for
study variables are displayed in Table 2. On average, the par-
ticipants reported high levels of self-esteem, with 84.3% of
the sample scoring higher than U.S. norms for adults (31).
Using published cutoffs for the infertility distress instrument
(31), 20% of participants reported low infertility distress (total
score %97), 66.25% reported average infertility distress (total
score 98–167), and 13.75% reported high infertility distress
(total score R168). Regarding emotional reactions to
receiving their infertility diagnosis, using suggested guide-
lines for the HOS (30), 2.70% had a very favorable response,
24.32% had a favorable response, 47.30% had an ambivalent
response, 21.62% had an unfavorable response, and 4.05%
had a very unfavorable response.
We conducted hierarchical multiple regression analysis to
jointly examine the predictors (infertility distress and
self-esteem) of emotional reactions to receiving an infertility
diagnosis. Although as noted earlier, bivariate associations
indicated that emotional reactions did not differ by infertility
diagnosis (DOR vs. ACI), the diagnosis group variable was
included as a predictor in the first step of the regression model
to offer the strongest test of the psychological predictors.
Infertility diagnosis was not a statistically significant
predictor of emotional reactions in the regression model
(b ¼ 8.98, SE ¼ 5.06, B ¼ .23, t ¼ 1.78, P¼ .08). In the
second step, greater infertility distress (b ¼ .186, SE ¼ .08,
B ¼ .31, t ¼ 2.26, P< .05) but not lower self-esteem
(b ¼ .109, SE ¼ .22, B ¼ .07, t ¼ .50, P¼ .62) independently
predicted more negative emotional reactions to receiving a
diagnosis. The final model predicted 13% of variance in
emotional reactions, F (3, 57) ¼ 2.86, P< .05.

Comparing Distress in Women with DOR or ACI DISCUSSION

For clarity of interpretation, item responses on the HOS mea-
sure of emotional reactions to diagnosis were reversed so that
lower scores would represent the most positive reactions and
higher scores the most negative reactions. As shown in
Figure 1, women with DOR had statistically significantly
higher infertility distress scores than women with ACI
(P< .01). Additionally, women with DOR had higher scores
on three of the infertility distress subscales: Social Concern,
Sexual Concern, and Need for Parenthood (P values of
< .05). There were no statistically significant group differ-
ences in self-esteem or in emotional reactions to diagnosis
(P values of >.05).
Prediction of Emotional Reactions to Diagnosis
Bivariate correlations indicated that infertility distress was
associated with more negative emotional reactions to
receiving a diagnosis (r ¼ .327, P< .01) but that self-esteem
was unrelated to emotional reactions (r ¼ .096, P¼ .42).
Self-esteem and distress were inversely related (r ¼ .342,
P< .01).
Our study findings reveal a higher level of total infertility
distress among women with a DOR diagnosis, and higher
distress from social concerns, sexual concerns, and a need
for parenthood compared with women with ACI. Irrespective
of the cause of their infertility, women with greater self-
esteem experienced less infertility distress. Using hierarchical
multiple regression analyses, we found that lower infertility
distress predicted a more positive emotional reaction toward
receiving an infertility diagnosis. Self-esteem was not a
unique predictor of emotional reactions to learning the cause
of one's infertility in the full model. Instead, self-esteem was
indirectly associated with more positive emotional reactions
to diagnosis, through its association with lower infertility-
related distress.
It is instructive to evaluate the magnitude of psycholog-
ical variables among study participants relative to other
groups. For example, compared with a prior study of women
diagnosed with DOR (7), participants in the present study
experienced distress of similar magnitude and had similar
levels of self-esteem. Two prior studies of women who
received a POI diagnosis found that they also possessed

TABLE 2

Comparison of participants with diminished ovarian reserve or anatomical cause of infertility on major study variables.
Total sample (n [ 102) DOR (n [ 51) ACI (n [ 51)
Variables Mean SD Mean SD Mean SD n t
Reactions to diagnosis 52.83 19.92 56.58 15.58 50.02 22.40 77 1.44
Self-esteem 78.29 19.92 78.52 10.70 78.10 15.68 92 0.15
Infertility distress 127.67 33.26 137.05 32.21 118.05 31.90 79 2.63a
Social concern – – 30.57 11.97 24.49 12.42 89 2.35b
Sexual concern – – 21.71 8.97 18.04 8.41 87 1.96b
Relationship concern – – 23.55 7.30 20.95 7.02 86 1.68
Rejection of child-free life – – 27.20 6.79 25.40 5.49 88 1.38
Need for parenthood – – 31.86 5.83 28.67 6.89 85 2.30b
Note: ACI ¼ anatomical cause of infertility; DOR ¼ diminished ovarian reserve; n ¼ number of participants in each statistical test; SD ¼ standard deviation; t ¼ t test.
a
P< .01.
b
P< .05.
Nicoloro-SantaBarbara. Reactions to infertility diagnosis. Fertil Steril 2017.

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FIGURE 1
Fertility Problem Inventory Total Score and subscales by diagnosis group. ACI ¼ anatomical cause of infertility; DOR ¼ diminished ovarian reserve.
Nicoloro-SantaBarbara. Reactions to infertility diagnosis. Fertil Steril 2017.
similar levels of self-esteem (32, 33). Such high levels of self-
esteem are often thought to reflect the participants' high level
of education. Nevertheless, infertility distress among women
in this study with a diagnosis of DOR was lower than reported
in a sample of women with recurrent implantation failure af-
ter IVF (34), lower than women with recurrent pregnancy loss
(34), and lower than a cohort of PCOS patients (35).
Although the two groups of women in the current study
were similar in their level of self-esteem and in their
emotional reactions to receiving a specific infertility diag-
nosis, those with a diagnosis of DOR reported statistically
significantly greater infertility-related distress than women
with a diagnosis of ACI. As indicated by their scores on sub-
scales of the FPI, a well-validated measure of infertility-
related distress, the greater distress among women with
DOR was primarily attributable to their experiencing stronger
feelings of social isolation, a diminished sexual relationship,
and feeling that parenthood is an essential life goal. It is valu-
able to consider that a diagnosis of DOR may have been a
recent, unexpected realization for some of these women
(17). In comparison, women with ACI may have had long-
standing awareness of circumstances that increased their
risk of later infertility (e.g., having had a sexually transmitted
infection or an ectopic pregnancy), allowing them time to
accommodate emotionally to this possibility. Additionally,
women with ACI may feel that they have a ‘‘reason’’ for their
infertility (tubal occlusion or uterine adhesions) whereas
women with DOR have no clear explanation as to ‘‘why’’ their
body has not functioned sufficiently. The ability to identify a
reason for a stressful life event is a well-demonstrated
contributor to better emotional adjustment and resilience
(36, 37). Although childlessness might also be a plausible
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Fertility and Sterility®
explanation for the group difference in infertility-related
distress observed in this study, given that 55% of the ACI
participants had given birth versus only 31% of the DOR par-
ticipants, parity was not associated with self-esteem,
emotional reactions to a diagnosis, or infertility distress.
From our clinical experience, DOR patients also tend to be
older than ACI patients (this was true only to a small degree
in our study sample), and the low chance of success with
IVF among DOR patients might particularly elevate distress
in older women. In contrast, ACI patients have a good chance
of becoming pregnant although they may need IVF, which
may help to explain their relatively lower distress.
Confidence in conclusions from the current study is
tempered by its reliance on a small, homogeneous sample
which prevented us from testing more extensive models of
reactions to diagnosis and which may have limited our statis-
tical power to observe associations of small magnitude.
Participants were predominantly white and well-educated,
which while not representative of the population at large, is
representative of women who receive reproductive endocri-
nology and infertility services in the United States (38).
Recruitment occurred in states without mandated insurance
coverage for infertility treatment services; thus, participants
would have needed sufficient financial resources to obtain
diagnostic testing. Although not systematically assessed for
all participants in this study, future research should also
examine time since diagnosis as adjustment to one's diag-
nosis may improve or otherwise change over time. Despite
these limitations, the present study is one of the first investi-
gations to examine levels and associations among
self-esteem, infertility distress, and emotional reactions to
diagnosis in two well-defined and distinct infertility cohorts.
165
ORIGINAL ARTICLE: MENTAL HEALTH
Although prior reports of self-esteem and infertility distress in
patients diagnosed with DOR have been published (7), no such
reports using a sample of women with ACI were located. A
related study (39), however, reported higher suspicion, guilt,
and hostility in 22 women with tubal infertility than in 22
fertile controls, all of whom were entering IVF treatment.
The stress experienced by women with fertility challenges
may vary in response to how and when they learn about their
chances for natural conception, the support they receive from
others including members of the clinical team, the particular
diagnostic and interventional medical procedures they un-
dergo, and the success or failure of the interventions them-
selves. In a review of 22 studies that examined reasons for
discontinuing fertility treatment among 21,453 patients from
eight countries, 14% reported psychological burden, and
16.67% reported relational and personal problems (40). Under-
standing the factors that influence fertility distress is of value
to fertility clinic professionals and mental health professionals
to identify women who may need greater support. Counseling
from mental health professionals with training in infertility
may be especially beneficial. A small randomized control trial
of interventions for fertility clinic patients recently found that
cognitive behavioral therapy reduced fertility distress
(measured with the FPI) more than did pharmacotherapy (41).
Similarly, online psychoeducational interventions have been
found to be effective in this population (42).
Study results offer a foundation for further investigation
of infertile women using more diverse samples and a wider
range of psychosocial variables, such as coping and social
support, that may influence reactions to receiving a diagnosis.
This knowledge can be used by reproductive health care pro-
viders and mental health professionals to identify women at
risk, to develop effective interventions, and to inform patient
care. Understanding the psychological and emotional con-
comitants of infertility will enable fertility clinic professionals
and mental health service providers to provide more effective
support to individuals in need.
Acknowledgments: The authors thank the participants in
this study and the clinical research coordinators at all partici-
pating clinics: Parchayi Dalal, Hannah Spencer, Amy Brown,
Amanda DeSmit, Angie Morey, Rebecca Briggs, and Janetta
Phillips. We thank the study co-investigators who are not
authors of this article: Dr. Lawrence Silverman and Dr. Ani
Manichaikhul, University of Virginia; Dr. Steven Young,
University of North Carolina at Chapel Hill; Dr. Valerie Baker,
Stanford University; and Dr. Joel Finkelstein, Massachusetts
General Hospital.
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