The Real Relationship between Stress and IVF Outcome by Alice D. Domar, PhD (Fall 2011)

THE REAL RELATIONSHIP BETWEEN STRESS AND IVF OUTCOME
Alice D. Domar, PhD

If you have paid attention to recent media coverage on stress and IVF outcome, you may well have observed some conflicting reports. A study published in February in the British Medical Journal reported that stress in IVF patients does not have an impact on pregnancy rates,1 yet a study released in early May found that stress reduction was associated with significantly higher pregnancy rates in IVF patients. How can both of these studies be right? Or are they?

The study published in the British Medical Journal was a meta-analysis undertaken by Jacky Boivin, Ph.D., a Canadian researcher currently at Cardiff University in Wales. She looked at the data from 14 different studies which had all assessed the distress levels of women who underwent an IVF cycle. When she pooled the data, she did not observe a significant relationship between distress and outcome. This conclusion went against a number of other studies, not included in the meta-analysis, which did find a relationship. So what does this mean?

The relationship between distress and IVF outcome is likely a highly complex one, and observed results may well depend on when you assess distress. Boivin mainly looked at the scores from a psychological questionnaire called State Anxiety, which focuses on how anxious one feels at a particular moment. However, in the 14 studies included in the meta-analysis, State Anxiety was assessed at different points. In one study it was assessed three months prior to beginning the IVF cycle, in a number of others it was assessed weeks prior to the cycle, while in still others it was assessed during the cycle. Further research has also shown that women tend to feel optimistic prior to beginning their first IVF cycle; then stress levels rise during the cycle, peaking in the days prior to the pregnancy test. Clearly, it is unrealistic to measure one facet of distress (i.e. how anxious you feel right at this very moment) and assume that there will be a relationship to an outcome weeks or months from now.

The theory that timing in measuring stress is important was reinforced by a recent study which was presented at the last meeting of the American Society for Reproductive Medicine.2 In that study, we recruited 143 women who were about to undergo their first IVF cycle, collected baseline psychological data at that point, and again daily throughout their cycle. In addition, half the women were randomly assigned to participate in a mind/body group. What we found was that women who had the highest distress scores at baseline actually had the highest pregnancy rates. But when we looked more carefully at the data, pregnancies were far more likely to occur in women who had high baseline levels of distress, but whose distress came down as they cycled. The women with the highest pregnancy rates were those who had high baseline levels of distress and participated in a mind/body group. This suggests that anticipatory distress is actually good, but only if one is able to learn how to cope better and thus feel less anxious and depressed during the cycle.

If one combines the results of these two papers, they do make sense. The key here is to understand that distress fluctuates, and that it may be beneficial prior to cycling whereas distress while cycling may well be detrimental.

This hypothesis is reinforced by the most recent study, published June 1st in the journal Fertility and Sterility.3 This study included the pregnancy rates of the study described above, where women were randomized to attend a mind/body (MB) group and undergo IVF, or to receive IVF treatment alone. Unfortunately, most of the MB patients began their first IVF cycle before they attended most or all of their sessions. In fact, only nine percent had attended at least half of the program before they began their first IVF cycle. For cycle 1, both groups had a pregnancy rate of 43%. For their second IVF cycle, 76% of the MB patients had attended at least half the program and the pregnancy rates were 52% for the MB patients compared to only 20% for the control patients.

So what is the take home message from all of this recent research? The most important thing to remember, I would suggest, is that we are talking about relationships here, namely the relationship between stress and IVF outcome. We are not talking absolutes; I have had patients who were so mellow, who had wonderful IVF cycles, but who didn’t achieve a pregnancy. Conversely, I have had patients who were total wrecks throughout their cycle and conceived a healthy baby. Thus, please know that I am not saying that if you are relaxed during your cycle you will get pregnant, and if you are stressed you will not. What I am saying is this: feelings of distress prior to cycling do not seem detrimental to pregnancy rates (and in fact, the opposite might be true), but distress during a cycle might well be associated with lower pregnancy rates. In addition, several studies have shown that learning relaxation and stress management strategies prior to and during infertility treatment is associated with significantly higher pregnancy rates, as well as far lower levels of anxiety and depression.

What should this mean to you? During a treatment cycle, think carefully about your needs, your wants, your stress triggers, and what in the past has helped you feel calmer and more in control. Take good care of yourself, distance yourself from the toxic people in your life, and implement all the coping skills you have. Learn and practice a relaxation technique or two, get support from those in your life you trust, and go ahead and pamper yourself. There are many health care professionals in Canada who are trained in mind/body strategies for infertility patients. To find one, or to enroll in a local mind/body program, ask your doctor or go to www.domarcenter.com for more information on this topic.

References

1 Boivin J, Griffiths E, Venetis CA. Emotional distress in infertile women and
failure of assisted reproductive technologies: meta-analysis of prospective
psychosocial studies. Br Med J 2011 epub.

2 Lynch CD, Domar AD. Meta-analysis is not the final word on the effect of
emotional distress on fertility treatment outcomes. BMJ 2011 epub

3 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 epub.

About the author
Alice D. Domar, PhD, is the executive director of the Domar Center for Mind/Body Health, the director of mind/body services at Boston IVF, an assistant professor at Harvard Medical School, and the author of Conquering Infertility.