Everything You Need to Know About Stress and Fertility

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by Jacky Boivin
Summer 2006

The stress-fertility problem

Most people think stress interferes with fertility, and there is good cause to have this belief. First, the mind and reproductive organs inhabit the same body, and that body houses a multitude of complex interconnections including those linking the hormonal systems responsible for stress and the reproductive response. First of all, we know from biological studies that stress activates a part of the brain that inhibits the hormones necessary for the development of eggs and sperm, as well as uterine receptivity. Second, many studies on non-human animals have shown that stress disrupts fertility in many species. For example, marmoset monkeys housed in isolation have lower sperm counts than those allowed to live in pairs, which is the preferred living arrangement for this species. From an evolutionary perspective, it makes sense that humans would have evolved a mechanism to stop them from reproducing in high stress conditions. If food is scarce, predators abundant or the social environment unstable then parents cannot be sure they will survive to take care of their offspring. In such circumstances it is better to switch off fertility until the situation improves. Demonstrating such an adaptive mechanism in humans, however, is more problematic. Humans have evolved incredibly powerful ways of coping with stress and the availability of such mental strategies makes them different from non-human animals, and makes it possible for people to override these basic mechanisms. The fact that every year millions of women give birth in extremely harsh conditions of poverty, famine and war shows that stress may not have the same effects in humans. 

These observations demonstrate that the dynamic between stress and fertility is incredibly complex, and explains why it is hard to get a straight answer from anyone about whether stress has a direct impact on fertility, and why fertility experts very often give contradictory answers to this question. These observations also demonstrate that it is possible to conceive in times of stress and that this happens every day with stress that is far greater than what would be experienced by the average reader of this magazine. Stress may disrupt fertility but it rarely, if ever, causes people to never conceive. Keep this in mind when reading this article.

We use the terms ‘stress’ and ‘fertility’ to refer to many variables. Stress can refer to emotional reactions (tension, worry, sadness), physical reactions (high level of stress hormones, shortness of breath) or the occurrence of particular events (high job demand, bereavement) that are considered to be taxing for the individual. In some studies, ”fertility” refers to the functioning of the ovaries or the testicles (estrogen level, number of eggs or sperm count) whereas in others it is about a positive pregnancy test or the delivery of a baby. Thus while we talk about stress and fertility, we may mean more specifically depression and a positive pregnancy test. The fact that the term “stress” means different factors to different researchers makes it even harder to give a definitive answer to whether or not stress impacts fertility. For these reasons, some prefer to talk about psychological influences on conception rather than the effects of stress on fertility.

Parenting is one of the most important and desired developmental goals in adulthood, so it is not surprising to discover that having a fertility problem can be stressful to couples. In one study, men and women were asked to rate how stressful they thought various life events would be (e.g., divorce, unemployment). Respondents rated the stress of fertility problems as second only to death of their spouse or marital break-up. Although almost all will experience stress, certain factors, called risk factors, make this experience even more demanding. People who have chronic psychological problems are at greater risk mainly because their coping resources are already being stretched in dealing with these problems. Women are also at greater risk than men because having children is more central to their identity and because invasive medical procedures are performed on them. Other factors, called buffers, are protective and make the experience of fertility problems less stressful. People with strong partnerships, where both spouses are in agreement about how to deal with the fertility problem, tend to report less stress. Finally, people who already have children either together or from a previous relationship find the experience of fertility problems less demanding than those who do not.

We do not yet have a definitive answer to this question, but there is more and more evidence pointing to an association between stress and fertility. The most common experimental model used to answer this question examines how stress levels prior to fertility treatment relate to the outcome; that is, whether or not pregnancy is achieved. Many such studies have now been conducted, especially with people undergoing IVF, and high stress scores appear to be related to lower pregnancy rates. Stress is also associated with a lower pregnancy rate in people trying to conceive naturally. Before becoming alarmed it is important to note that stress effects are small compared to the impact of other life style factors. If your chance of pregnancy is 25%, then the effect of stress might reduce your chances to 21%. This drop is in comparison to the effect of being 40 pounds overweight, which would reduce the chances to 17% or the effect of smoking which would reduce them to 18%.

Why is stress associated with a lower pregnancy rate? 

Before we make a definitive conclusion that stress reduces fertility, we need to be sure that it really and truly is stress that is causing the pregnancy failure in these studies. Unfortunately, at the moment we cannot demonstrate this with absolute certainty. First, it could be that people who are very anxious or depressed engage in behaviours that are unhealthy and bad for their fertility. People who are stressed-out tend to smoke and drink more, tend to skip meals, eat too much or eat unhealthy food and tend not to exercise. It might be these lifestyle factors that reduce fertility and not stress per se.

Second, psychological factors may cause people to compromise their efforts to conceive. In IVF studies, people who have high stress levels often drop out of treatment prematurely and as a result appear to have a lower pregnancy rate than people who are less stressed (and who stay in treatment). In work with couples trying to conceive naturally, high stress couples were more ambivalent about starting a family (e.g., not sure they wanted a child at this time, worried about how children would affect their relationship), and as a result were having sex less frequently during the fertile period. 

This is the million-dollar question for which no one has an answer. When people take medication we know at what dosage negative side effects can happen. Unfortunately, there is no such precision with stress, and there never will be because people vary too much in how they react to events and how stress affects them. Some people seem to thrive on stress whereas others become sick and run down with the slightest amount of stress. This may seem like a very unsatisfying answer, but it is very important because it explains why general results often do not match up with individual experience. In other words, knowing that there is an association between stress and fertility in the general population does not mean that your stress will reduce your fertility.

People with fertility problems constantly get advice to reduce stress levels with the idea that doing so will increase their chances of pregnancy. Common advice to relax, adopt, go on holiday or even stop thinking about fertility is easily and freely given by those who, frankly, know nothing about stress and fertility. In fact, doing any of those things is unlikely to improve fertility. Adopting does not make people pregnant and the pregnancy rate in infertile couples who adopt and those who do not is the same. Holidays do not produce babies either, though they will make you feel better. Research has shown that when it comes to thinking about the fertility problem, the reverse is actually true: those who think about it often are more likely to eventually conceive probably because they spend much more time working out their fertile period, consulting medical doctors or researching ways to stay healthy, all of which increase their chance of getting pregnant. 

People with fertility problems are often encouraged to participate in psychological therapies aimed at reducing stress and thereby increasing the chance of pregnancy. Some teach relaxation exercises or coping skills, some help people express their negative emotions, and others provide validation and group support to name but a few. In a recent review of eight studies examining the effects of psychological interventions, it was found that all reduced distress and helped women and men to feel better. However, this did not necessarily translate into a higher pregnancy rate. In three of the studies women who participated in the psychological intervention had a better pregnancy rate than those who did not, but in the other five there was no improvement.

Do something about stress to improve your quality of life and minimise the disruptions it can bring to the project of having a child. As noted previously, high stress makes people unhappy and can sometimes lead them to engage in negative health behaviours that compromise fertility. This is particularly important if stress is causing you to want to drop out of treatment prematurely. If you do not have support from your partner or close family and friends then you might want to consider participating in a support group or enrolling in a psychological programme aimed at reducing distress. These are successful in reducing distress, and may help you discover coping strategies that would make going through the infertility experience easier for you and your partner, even if they don’t increase your chance of pregnancy. Finally, keep the issue of stress in perspective. Stress rarely (and most likely never) causes a person to never reproduce, and women get pregnant even in the most demanding of life circumstances. It is impossible to judge from the general findings presented here how your body is responding to whatever stress you might be experiencing.

About the author

Jacky Boivin, PhD, is an Associate Professor at the School of Psychology, Cardiff University, Wales, UK and Honorary Fellow at the Cardiff Assisted Reproduction Unit & Department of Obstetrics and Gynaecology, University Hospital Wales, UK. She has authored and co-authored numerous articles on the psychological aspects of infertility and in particular about the connections between stress and fertility.

Counseling
Daniluk, JC. (2002). The Infertility Survival Guide. California: New Harbinger Publications.
Boivin, J. (2003). A review of psychosocial interventions in infertility. Soc Sci Med 57, 2325-41.

Stress and life style effects on fertility treatment
Klonoff-Cohen, H., Chu, E., Natarajan, L. & Sieber, W. (2001). A prospective study of stress among women undergoing in vitro fertilization and gamete intrafallopian transfer. Fertil Steril 76, 675-687.
Lancastle, D. & Boivin, J. (2005). Dispositional optimism, trait anxiety, and coping: Unique or shared effects on biological response to fertility treatment? Health Psychology, 24,171-178.

Impact of stress hormones on reproductive hormones
Ferin, M. (1999). Clinical review 105: Stress and the reproductive cycle. J Clin Endocrinol Metabol, 84, 1768-73.