By Salina Kalik
Editor’s Note: While on the FACTS elective, Salina Kalik summarized an article published by Rooney and Domar in 2018. [1] The authors reviewed the literature to date exploring the relationship between stress and infertility. Their findings highlight the importance of offering evidence-based psychological interventions early in the treatment of infertility, which may not only lower the impact of cognitive distortions and mental health conditions but possibly even improve fertility outcomes. By identifying root causes of infertility, a restorative approach using fertility awareness-based methods (FABMs) may further reduce stress while improving overall wellbeing.
Infertility and Stress
According to data from the CDC, approximately 6% of married women ages 15 to 44 years are unable to get pregnant, and 12% of women in the same age group have difficulty getting pregnant or are unable to carry a pregnancy to term. Identifying the root causes of infertility and the path to achieve pregnancy can be overwhelmingly stressful. Patients often report higher levels of anxiety and distress, and some experience feelings of shame and low self-esteem. [1] In a 2004 study that interviewed 122 women before their first appointment at an infertility clinic, 40% of them had anxiety, depression, or both. [2] The evidence suggests that infertility causes stress and has a strong psychological impact; the authors further considered whether the opposite may be true as well. [1]
Risk Factors
Multiple factors impact the level of stress associated with infertility, including type and length of treatment, repeated treatment failures, and miscarriages. In particular, patients undergoing assisted reproductive technology (ART) are at higher risk of developing anxiety and depression. In one study, more than 42,000 women were screened for depression prior to treatment with ART and 35% were found to have depression. [3] The length of treatment can be extended due to treatment failures, miscarriages, and wait time based on additional screenings. Some patients may get pregnant after one round of in vitro fertilization (IVF) or ART treatment, but many patients may need multiple rounds due to treatment failures or unknown causes of infertility. The longer a patient is in treatment with ART, the more likely they are to show symptoms of anxiety and depression.
“The longer a patient is in treatment with ART, the more likely they are to show symptoms of anxiety and depression.”
Patients who are unable to achieve pregnancy after one or two rounds of ART report significantly higher levels of anxiety and depression compared to those who have not had treatment for infertility. [4] Women who also experience pregnancy loss or miscarriages report symptoms of anxiety and depression and meet the criteria for post-traumatic stress disorder (PTSD). Some patients may consider getting Preimplantation Genetic Testing, a technology that takes a biopsy of the blastocyst to select out those with chromosomal defects prior to transplantation. This may reduce the chances of treatment failure and pregnancy loss but may increase stress, since the biopsy results take two weeks, which extends the waiting period before transplantation can occur. Furthermore, it is possible to have no normal blastocyst to transfer, which may cause considerable distress for the patient. [1]
Impact of Stress on Fertility Outcomes
Many people believe that stress, anxiety, and depression have a negative impact on fertility. [1] Many women have noticed that going through a stressful time at work or even taking an exam can throw off their menstrual cycle. Miracle stories abound of patients who decided to adopt a child after years of infertility and then were able to conceive with no treatment when they were less stressed.
It is difficult to determine the impact of stress and psychological factors on actual pregnancy rates. Medications used to treat infertility, such as clomiphene and leuprolide, have side effects that include anxiety, irritability, and depression. Therefore, it is unclear whether the impact on infertility is due to medication side effects, psychological impact of treatment, or both. [1] Furthermore, some patients are thought to report their level of stress inaccurately, especially before their initial appointment for ART and higher levels of optimism for their first round of treatment.
“It is difficult to determine the impact of stress and psychological factors on actual pregnancy rates … (as) medications used to treat infertility, such as clomiphene and leuprolide, have side effects that include anxiety, irritability, and depression.”
On the other hand, a study that examined cortisol, a biomarker of stress, from the hair of 135 patients undergoing IVF found that hair cortisol levels significantly correlated to pregnancy rates. [5] In another study, levels of α-amylase (another biomarker of stress) were measured in 501 women in the U.S. The researchers found that α-amylase levels correlated significantly with time to pregnancy, and women with very high levels were more likely to experience infertility. [6] Although there is mixed data on the impact of psychological symptoms on fertility rates in studies that relied primarily on self-reported questionnaires, studies that examined biomarkers of stress were significantly correlated with a negative impact on fertility.
Psychosocial Interventions for Women with Infertility
Evidently, women with infertility often experience significant stress and depression and should be offered psychosocial interventions early on. One such intervention is the Mind/Body (MB) Program for infertility launched in 1987. [7] The program offered sessions of cognitive behavioral therapy (CBT) as well as group therapy in which the partners must also attend some sessions. [7] CBT challenges negative thought patterns that may arise during infertility treatment, such as thinking “infertility is my fault” or “I may never have a baby.” In the 2011 study that assessed the program’s impact, involving the partners helped improve psychological outcomes and marital relations. [7] Several studies on the efficacy of the Mind/Body Program showed that patients experienced significantly lower levels of distress and higher pregnancy rates compared to those who did not attend the program. [1] Other studies showed that psychosocial interventions were impactful in decreasing stress and negative affect but did not significantly affect pregnancy rates. [1]
“Several studies on the efficacy of the mind/body program showed that patients experienced significantly lower levels of distress and higher pregnancy rates compared to those who did not attend the program.”
Self-administered cognitive coping and relaxation interventions are available that do not have to be administered by a clinician. In one study, patients who used the self-administered program reported less anxiety, improved quality of life, and lower IVF dropout rates. [1]
Conclusion
Although it is apparent that infertility causes significant stress, particularly in patients going through ART, there is mixed data on the impact of stress on fertility outcomes. Nevertheless, patients and their partners benefit significantly from early psychosocial interventions such as the Mind/Body Program for Infertility. It is possible that incorporating similar programs into routine practice in ART clinics may reduce stress, anxiety, and depression significantly and even potentially improve fertility outcomes.
References
[1] Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues Clin Neurosci. 2018;20(1):41-47. doi:10.31887/DCNS.2018.20.1/klrooney
[2] Chen TH., Chang SP., Tsai CF., Juang KD. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod. 2004;19(10):2313–2318.
[3] Sejbaek CS., Hageman I., Pinborg A., Hougaard CO., Schmidt L. Incidence of depression and influence of depression on the number of treatment cycles and births in a national cohort of 42 880 women treated with ART. Hum Reprod. 2013;28(4):1100–1109.
[4] Maroufizadeh S., Karimi E., Vesali S., Omani Samani R. Anxiety and depression after failure of assisted reproductive treatment among patients experiencing infertility. Int J Gynaecol Obstet. 2015;130:253–256.
[5] Massey AJ., Campbell BK., Raine-Fenning N., Pincott-Allen C., Perry J., Vedhara K. Relationship between hair and salivary cortisol and pregnancy in women undergoing IVF. Psychoneuroendocrinology. 2016;74:397–405.
[6] Lynch CD., Sundaram R., Maisog JM., Sweeney AM., Buck Louis GM. Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study-the LIFE study. Hum Reprod. 2014;29(5):1067–1075.
[7] Domar AD., Rooney KL., Wiegand B., et al. Impact of a group mind/body intervention on pregnancy rates in IVF patients. Fertil Steril. 2011;95(7):2269–73.
ABOUT THE AUTHOR
Salina Kalik is a fourth-year medical student at Philadelphia College of Osteopathic Medicine (PCOM) in Philadelphia, PA. She earned a Bachelor of Arts in biology from Barnard College in 2014, and then studied depression at the Greengard Lab at Rockefeller University. She is pursuing residency in internal medicine with a strong interest in women’s health.
