April 19, 2021
FACTS Infertility Awareness Series
Stress and its Impact on Fertility: A Research Review
By Michal Dusza
Editor’s Note: Last week, we published a broad overview of the impact of lifestyle factors and medical conditions on fertility. This month’s series continues by examining in more depth the impact of stress on infertility. While on the FACTS online elective, Michal Dusza summarized a research[i] article published in 2018 in Dialogues in Clinical Neuroscience by Rooney and Domar titled, “The relationship between stress and infertility.” Dusza’s synopsis of their research focuses on the article’s review of psychiatric disorders associated with infertility treatment involving assisted reproductive technology (ART), and whether the symptoms impact the outcome of treatment.
Infertility is generally defined as the inability to conceive after 1 year of unprotected intercourse. More specifically, physicians define it as the inability to conceive after 6 months for women over 35 years of age, and after more than 1 year for women under 35 years of age. The prevalence of infertility has gradually risen in the United States. The reasons for this trend are multi-factorial, and include the decision to delay having children due to personal, financial or educational reasons, among others. Infertility can be a silent struggle for women and couples trying to conceive. The article summarized below stresses that patients who decide to undergo assisted reproductive treatment have a higher risk of developing psychiatric disorders; thus, it is vital for physicians to recognize infertility as a risk factor for other conditions.
It is essential for physicians to recognize that a patient who is infertile may undergo a life crisis that places a significant amount of stress on them. The consequences are real, ranging from mental health manifestations such as depression, anxiety, and psychological distress to physical consequences such as weight changes, loss of sex drive, and more frequent infections. A question can be posed to consider whether stress lowers a woman’s chances of conceiving or whether stress results purely from the inability to conceive. Which one comes first?
Unfortunately, there does not appear to be a definitive answer to this question. But what is known is that infertility is distressing, and that psychological interventions are associated with decreased rates of depression.
The Psychological Impact of Infertility: Depression, Anxiety, and Distress
It is difficult to accurately assess the distress level in women with infertility, as this is largely based on self-reporting. Often these measurements are taken before patients start their fertility treatment; thus, data can be skewed by initial optimism. A 2004 study[ii] on the subject found that 40% of women were diagnosed as having anxiety, depression, or both. A 2008 study[iii] by Volgsten et al found that 31% had psychiatric symptoms, most commonly depression. Much of the recent research done on the subject supports the claim that psychiatric disorders are common among both women and men as they undertake ART.
Medications used in the treatment of infertility, including clomiphene, leuprolide, and gonadotropins, have been found to cause psychological symptoms. This adds a layer of complexity that, in many instances, makes it difficult to ascertain whether these symptoms reflect the impact of infertility or a medication side effect. A 2015 study[iv] in patients who underwent unsuccessful ART demonstrated that the further the patient is into their treatment, the higher the risk of them displaying signs of depression and/or anxiety. Patients with one failed treatment are more likely to have significant levels of anxiety than those without a history of treatment, and those with more than one failed treatment have higher levels than patients with just one.
The Impact of Stress on Treatment Outcome
According to the authors, various “old wives’ tales” would support the notion that stress has a negative impact on reproductive function, but this proves to be difficult to study and confirm. Many studies have shown conflicting results. Some show that women who feel distressed before and during ART treatment have lower pregnancy rates, while others have demonstrated no difference. Authors offer several explanations for this discrepancy. For instance, research supports that individuals may not be accurately self-reporting their level of distress when completing questionnaires. A 2012 study by Lynch et al[v] in the United Kingdom found that surveys of self-reported psychological symptoms by women trying to conceive were unreliable to establish an association between fecundity and these symptoms. Yet, a similar study[vi] published two years later that measured α-amylase, a bio-marker for stress, was the first study to demonstrate a significant correlation between stress and time-to-pregnancy. The authors further concluded that women with high α-amylase were twice as likely to experience infertility.
ART offers many patients hope. Some may see quick results, even in the first cycle. Yet, for many women, it can take years to conceive, and possibly never at all. Causes of infertility can range from underlying health conditions such as PCOS or endometriosis to a frustrating designation of “unexplained infertility.” Knowing the exact cause behind infertility reduces a patient’s distress and emotional burden, while patients with an unidentified cause may obsess over the diagnosis.
Patients will alter their lifestyle by changing their diet, decreasing alcohol, tobacco, and caffeine intake in hopes of altering the diagnosis of infertility. These changes, when combined with ART treatment, may result in a desired pregnancy, but not for all.
Psychosocial Interventions for Women with Infertility
A meta-analysis [vii] of twenty-five studies demonstrated that psychological interventions did not improve pregnancy rates. However, psychological interventions have been found to be effective in reducing negative affect. Men and women benefit equally, and group interventions appear to be more effective than counseling sessions.
Many more meta-analyses have been performed, and most reach similar conclusions: while these interventions are proven to lower psychological distress and improve marital satisfaction, data shows that pregnancy rates demonstrate insignificant improvement at best.
The Mind/Body Program for Infertility
The Mind/Body Program for Infertility was launched in 1987 with hopes of improving psychological outcomes and marital relationships for infertile couples. The program consists of ten group sessions in which the participants’ partners attend at least three of the sessions. Patients are taught relaxation techniques and other cognitive-behavioral skills. The Mind/Body therapy has been shown to reduce stress and increase pregnancy rates.[viii]
Interventions do not need to be administered by a clinician. Self-administered cognitive coping and relaxation intervention (CCRI) has been shown to be effective. It enables patients to take control of their mental wellbeing and improve their coping skills when dealing with stressful situations. Positive Reappraisal Coping Intervention (PRCI) has been shown to specifically aid patients during the 2-week period between embryo transfer and the pregnancy test.[ix]
Patients experience tremendous stress when faced with the diagnosis of infertility and while battling it. Clinicians should be aware of the pain and stress patients experience so they may support them more effectively throughout their treatment and provide them with better psychological care. It has become a regular practice for ART clinics to incorporate psychological interventions for their patients.
Editor’s note: Physicians trained in fertility awareness-based methods commonly seek to find the root cause of infertility and focus on a restorative and comprehensive approach to care. This includes addressing the emotional as well as physical aspects of health and fertility. At FACTS, we strongly believe it is important for students to learn about this aspect of care, so this year we added a presentation to our elective focused on addressing the psychosocial and emotional aspects of fertility and infertility. We are grateful to our colleagues at Organic Conceptions for sharing their expertise and research with our students.
[i] 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.
[ii] Chen TH, Chang SP, Tsai CF, Juang KD. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod. 2004 Oct; 19(10):2313-8.
[iii] Volgsten H, Skoog Svanberg A, Ekselius L, Lundkvist O, Sundström Poromaa I. Prevalence of psychiatric disorders in infertile women and men undergoing in vitro fertilization treatment. Hum Reprod. 2008 Sep; 23(9):2056-63.
[iv] 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 Sep; 130(3):253-6.
[v] Lynch CD, Sundaram R, Buck Louis GM, Lum KJ, Pyper C. Are increased levels of self-reported psychosocial stress, anxiety, and depression associated with fecundity? Fertil Steril. 2012 Aug; 98(2):453-8.
[vi] 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 May;29(5):1067-75. doi: 10.1093/humrep/deu032. Epub 2014 Mar 23. PMID: 24664130; PMCID: PMC3984126.
[vii] Boivin J. A review of psychosocial interventions in infertility. Soc Sci Med. 2003 Dec; 57(12):2325-41.
[viii] Domar AD, Rooney KL, Wiegand B, Orav EJ, Alper MM, Berger BM, Nikolovski J. Impact of a group mind/body intervention on pregnancy rates in IVF patients. Fertil Steril. 2011 Jun; 95(7):2269-73.
[ix] Lancastle D, Boivin J. A feasibility study of a brief coping intervention (PRCI) for the waiting period before a pregnancy test during fertility treatment. Hum Reprod. 2008 Oct; 23(10):2299-307.
About the Author
Author Bio: Michal Dusza is a fourth-year medical student at Jagiellonian University Medical College in Poland. He will soon begin residency in family medicine at Central Michigan University (CMU) in Saginaw, Michigan. He participated in the FACTS elective to gain greater insight and experience in diagnosing women’s health issues. In his spare time, he enjoys reading short stories and taking architecture and landscape photographs.
WHAT’S IN YOUR TOOLBOX?
The FACTS 2021 CME Conference
Fertility Awareness – Expanding Care for Women’s Health
On the heels of the success of our fall 2020 two-day CME virtual conference, we are excited to announce the details for our 2021 event. We are looking forward to this year’s virtual conference as an opportunity to connect with one another, to learn more about fertility awareness, and to explore timely topics in women’s reproductive health together. Expand your toolbox and join us in May! Click here for more details and registration information.We hope to “see” you there!
• FABM overview and their applications for:
– Hypothalamic Amenorrhea
– Thyroid Dysfunction
– Recurrent Pregnancy Loss
– Adolescence and Body Literacy
– Polycystic Ovarian Syndrome (PCOS)
• Fem Tech – NeoFertility and FEMM
• Functional Medicine in Women’s Health and FABMs
• Extensive Q&A with our expert panels
• Bonus Pre-conference Presentations!
• CME Credit*
*AAFP (American Academy of Family Physicians) CME credit is pending.
Can’t make it on these days?! Not to worry – Your registration will also allow access to these presentations through the end of 2021!