The Stress / Infertility Connection

Alice D. Domar, Ph.D.

If I had a dollar for every patient who came to me in tears because her mother-in-law (or colleague, or aunt, or well-meaning friend) told her to “just relax” and she would get pregnant, I would be able to be cheerful in these challenging economic times. The fact is that there is a widely held belief that tension causes infertility and that relaxation cures it. But like most old wives’ tales, it is just not true. Of course it would also never occur to these intrusive individuals (especially not the mother-in-law!) that half of all cases of infertility are caused by male factors. But if a man does not produce normal sperm, then how can making his wife relax cure his problem?

The answer is straightforward. Simply relaxing does not cure infertility. You can establish permanent residence in the fanciest spa, and if you have blocked tubes or severe endometriosis or a high FSH or a male factor, all the relaxation in the world is not going to increase your chances of a spontaneous pregnancy. There is in fact a relationship between stress and infertility but it is not as simple as relaxation equals pregnancy.

The relationship between stress and infertility is a two-way street – infertility causes stress and stress contributes to infertility. In order to use this connection to your advantage, you need to understand the complexity of the relationship.

There is no doubt in anyone’s mind that infertility is an acutely difficult experience. (Let me amend that – just last night one of my favorite patients told her mind/body group that her best friend told her that she was selfish because she didn’t want to go to a baby shower the rest of the group offered to hunt the friend down). In reality, there is no doubt in the minds of those who have been through it and those who work with infertility patients, that the infertility experience can be brutal. It impacts virtually every aspect in your life – your relationship with your partner, your sex life, your relationships with family and friends, your job, your financial security and even your religious or spiritual beliefs (as in, “why won’t god answer my prayers?”). So it should come as no surprise that many women struggling to have a baby report symptoms of anxiety and/or depression. What might be surprising to some is that the prevalence is so high (nearly half are symptomatic by the time they go see an infertility doctor) and that the symptoms are so intense. In two studies, the level of distress expressed by women with infertility was equivalent to women with cancer (Domar et al, 1993; Applegarth, 2008). This is why the following should be obvious: infertility causes a lot of stress.

But what about the reverse? Does stress cause infertility? This is a far harder question to answer. The answer isn’t definite. We know that women who are under great stress are able to conceive after all, women who are raped get pregnant, and so did women in concentration camps. It looks as if some women are more reproductively sensitive to stress than others, although it is difficult to know for sure,[NL1] since no study has been done to date measuring the specific effect of stress on pregnancy rates in the general population.

We do know that women with a history of depression are more likely to experience infertility than women who have no history of depression. We also know that distress is the number one reason why women drop out of infertility treatment. This can even be predicted: the more depressed the woman is before she begins high tech treatment, the more likely she is to drop out after only one cycle. And there have been numerous studies showing that the more stressed the woman is when she begins a treatment cycle, the less likely she is to get pregnant (Klonoff-Cohen et al, 2001). In one study, women under stress needed to undergo an extra IVF cycle to get pregnant; non-stressed women needed on average two cycles to conceive, while for the women under stress it took three cycles (Boivin and Schmidt, 2005).

But the real way to determine if stress can indeed contribute to infertility is to examine what happens if you decrease the stress levels of infertile women. There have been a number of studies to date, but the most recent consensus is that in fact, pregnancy rates are significantly higher in women who are able to lower their stress levels. We performed a large study on a group of about 185 women who had been trying to conceive for one to two years. We randomized the women so that 1/3 participated in a mind/body group, 1/3 attended a support group, and 1/3 received routine care only. We found big differences in live birth rates 55% for the mind/body patients, 54% for the support group patients, but only 20% for the routine care patients. And when we looked at the psychological state of the patients, the mind/body patients showed improvements during the year we followed them and the support patients stayed the same, but the control subjects got worse (Domar et al, 2000).

So to summarize all the information presented thus far, stress is a problem in a couple of ways it makes it harder to stay in treatment and it seems to decrease the efficacy of the treatment. But when patients learn skills designed to lower their stress levels, not only do they feel healthier psychologically, they are also more likely to get pregnant.

We don’t yet know exactly which skills are the most effective in terms of lowering stress levels, nor do we know if they are equally effective for all women. In the mind/body program, we teach a variety of different techniques, ranging from numerous relaxation techniques to cognitive ways to look at situations in healthier ways. For example, in an approach called cognitive restructuring, we teach women how to challenge and then reframe automatic negative thoughts (“I will never have a baby”) to positive or neutral truthful ones (“I am doing everything I can to try to get pregnant”). We also discuss how health habits can reduce fertility, and recommend some basic lifestyle changes, such as decreasing caffeine and alcohol consumption, eliminating all nicotine exposure, sticking with moderate low-intensity exercise routines, and making sure one’s BMI (body mass index) is neither in the underweight or obese range.

The fact that these sessions are taught in a group format is no accident. The power of being with women who “get it” cannot be underestimated. The group is the one place where participants feel understood, not isolated, and can speak freely. This is where, for example, a participant can get unlimited support for the grief caused by a sibling’s pregnancy.

Another important topic is the need for self-nurturance, which includes the ability to say no. For many women going through infertility, other women’s pregnancies and newborn babies can cause feelings of envy. Forcing yourself to attend baby showers, christenings, and toddlers’ birthday parties might feel like it is the right thing to do, but in fact if you don’t feel comfortable at events like these, don’t go. Make up a valid excuse, go online and order a lovely gift (I actually recommend ordering picture books you enjoyed as a child, such as Harold and the Purple Crayon and Blueberries for Sal), and when the party is being held, go have a massage or pedicure. If you don’t feel comfortable calling to say you won’t be able to come, then on the day of the event, tragically come down with a highly contagious stomach flu. No one, least of all the new mom, will want you anywhere nearby.

You also need to keep in mind that infertility is a temporary crisis. You won’t be trying for the rest of your life, and most people who go through this experience come out of it parents. There was a fascinating study conducted by a Canadian researcher Judith Daniluk, who interviewed women in their sixties and seventies who had gone through infertility years earlier. Some of the women had gotten pregnant, some had adopted, and some had remained childfree. But decades later, their psychological profiles were the same. The message to keep in mind for now is that however this turns out, you are going to be OK regardless of the outcome.

Infertility brings with it the ultimate stressor feeling out of control. You feel out of control of your body, your relationships, even your future. I have had patients tell me that it would be easier if they just knew the outcome, even if it meant no genetic child, since going through the monthly hope and then crash was excruciating.

I have counseled thousands of individuals and couples who are going through the crisis of infertility. The most important things I can do for them are to help them recognize the areas in their lives where they do have some control, give them permission to meet their own needs, teach them skills and strategies which decrease their stress level, and promise them that the human psyche is so strong that they will in fact someday become the same person they were before infertility. You too will get your old personality back.

I wish you the very best of luck in having your dreams come true.

Alice D. Domar, Ph.D is the Executive Director of the Domar Center for Mind/Body Health at Boston IVF. She is an assistant professor at Harvard Medical School and the author of Conquering Infertility.

References:

1.Domar et al. J Psychosom Obs Gyn 1993;14:45-52.

2. Applegarth, L. Presented at ESHRE, Barcelona, 2008

3. Klonoff-Cohen, H et al, Fertility and Sterility, 2001;76:675-87

4. Boivin & Schmidt, Fertility and Sterility, 2005; 83:1745-52

5. Domar et al, Fertility and Sterility 2000; 73:805-11

6. Domar et al, Health Psychology 2000; 19:568-75