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Robin J. Roberts, LCSW, PhD

what came first? We've all heard the parable of the chicken or the egg: which came first? In the case of infertility, women and their partners want to know: does stress cause infertility or does infertility cause stress?

Let me be clear from the outset: In the beginning was the egg, called infertility. Infertility causes stress. In a reproductively normal population, stress does not cause infertility. Think about it: if stress caused infertility, work stress would be an effective form of birth control!

The diagnosis of infertility does not occur until a woman 35 years old or younger has been trying to conceive for a year without success. For women over 35 years old, this period is only 6 months, not because they are expected to conceive in less time than younger women, but because they need to seek help sooner. At this point, you should save yourself more frustration by seeing a Reproductive Endocrinologist for a diagnostic evaluation.

No matter what the cause of infertility is for any individual, ongoing infertility (the egg) develops into stress (the chicken), which further impairs fertility (more bad eggs). Women who have been trying to conceive not just for months but for one or more years, and who are engaged in medical treatment for infertility, should be concerned about the effects of infertility-related stress on their treatment, as overcoming these effects can improve their treatment outcomes.

My husband and I have been trying to start our family for almost a year now. I know my mother is well meaning when she tells me, "Relax and you'll get pregnant," but she's driving me crazy already. Could it be that stress is making me infertile?

Probably not. For a healthy population, there is only a 25% conception rate in any cycle of unprotected intercourse. Therefore, even a reproductively healthy couple may take several months of unprotected intercourse to get pregnant. Normal life stressors can delay ovulation or cause an episode of erectile dysfunction at just the wrong time of month, making it hard to conceive during that cycle. A weekend getaway can be helpful under those circumstances. But in a healthy couple, stress does not cause infertility. If you are not depressed and your attitude is positive, it is unlikely that stress is delaying conception for you.

This may sound simple, but what is stress?

It isn't simple at all. The psychological definition of stress is the perception of a threat to one's physical or psychological well-being and the perception that one's resources are inadequate to deal with it. You can see that this is a highly subjective definition, as what is stressful to one person is not necessarily stressful to another. When facing infertility, however, most women and men feel emotionally threatened by the situation and often helpless. Also, adapting to the life changes entailed in infertility treatment, such as managing schedules and finances, is emotionally stressful and sets off "internal alarms" in many people.

The biological definition of stress is any impetus that requires adaptation or change in an organism. Artificially manipulating hormones, either by shutting them down with Lupron or other agents, and then hyperstimulating them, creates wide deficits and surges for the body to adapt to.

Is psychological stress really different from physical stress?

No. The human body reacts the same way to both psychological stress (thinking about, remembering, or anticipating painful events) and a physical threat: our heart rate increases, breathing quickens, and muscles tense for action whether we are fighting a physical, imaginary, or emotional enemy. Unchecked, repeated Stress Responses contribute to stress syndromes and depression.

What is "The Stress Response"?

The "Stress Response" is the innate "Fight or Flight" reaction to alarming situations, whether these situations are an immediate physical danger or an imagined one. The body responds to the alarm with basic physiological changes that ready us for defensive action: either by fighting or fleeing to get us out of danger. In response to the stress hormones of adrenalin and corticosteroids, these changes include:

  • Increased heart rate
  • Rapid shallow breathing
  • Increased muscle tension
  • Increased stomach acids (to immediately digest any food in the gut for energy)
  • Increased blood sugar (for energy)
You can see that these changes are very useful if you have to suddenly stop your car to avoid an accident, but they are not useful if your primary stressors are psychological. They certainly aren't helpful when we are trying to relax for an IUI or IVF procedure!

What are stress syndromes?

When Stress Responses are repeated over time, without sufficient opportunity to relax, rest the body and recover normal baseline function, the undischarged energy/tension creates syndromes in the body. Each physical system has associated stress syndromes. These become our weak points or sore spots: areas of the body where we feel the breakdown first. Unfortunately, we often ignore these signals, and adapt to them as normal aspects of modern life. You might recognize some of these syndromes for yourself:

  • Increased heart rate over time can be associated with higher blood pressure.
  • Changes in respiration patterns can be associated with allergies, asthma, and panic attacks, etc.
  • Increased muscle tension is associated with neck aches, head aches, back problems, TMJ, etc.
  • Disregulated digestion is associated with overeating, undereating, constipation/diarrhea, GERD, Irritable Bowel Syndrome, etc.
  • Increased blood sugar is associated with insulin resistance and diabetes, etc.
  • Reduced sex drive and reproductive hormones.

So, how does stress contribute to infertility?

There are many ways that stress might influence infertility. Though stress usually does not start out as the primary cause of infertility, the stress of dealing with infertility can become a compounding factor in successful treatment. Foremost, the stress of infertility is psychological, and the body reacts to this with the same Stress Response as to physical danger. Without adequate release or care, we internalize this tension in a depressive state.

It's easy to understand that the emotional losses of infertility lead to depression in many women and couples. Also, the medications involved in infertility treatment contribute to mood instability and depression: enough estrogen and you feel good; too much or too little, and you feel awful. Estrogen is a precursor of serotonin, a mood elevating neurotransmitter in the brain. Artificially spiking estrogen may cause the brain to shut down estrogen receptors to maintain biochemical equilibrium. Overtime, brain chemistry may become exhausted by the game of catch-up, leading to depression.

An often cited study by the Harvard School of Mind/Body Medicine showed that women in infertility treatment for an average of two years have depression levels equal to patients with chronic or terminal illness, such as cardiac disease or cancer. Depression affects the same centers in the brain (the hypothalamus and pituitary gland) that control our reproductive hormones. Studies also show that when depression is effectively treated with either a support group or mind/body group, conception rates more than double. These results surprised some doctors who assumed that infertility medications alone were sufficient to produce positive outcomes.

I know I'm unhappy, but how do I know if I'm depressed?

Depression is more than feeling unhappy. Many of the symptoms of depression are physical in nature, such as negative changes in appetite and weight, energy, sleep, concentration, sex drive, and motivation. Tearfulness, irritability, anxiety, overwhelming feelings of guilt, worthlessness, helplessness and hopelessness are more consistent and hard to shake when they are part of depression. Cycles of negative thinking are also hard to break. Social withdrawal is especially common for women dealing with infertility who do not want to be around pregnant women, families, or young children.

Many people mask the signs of depression with negative coping behaviors, such as drinking, smoking, overeating, over working, or over exercising. If you think you may be depressed, you should contact a mental health provider experienced in dealing with infertility. Resolve and ASRM have many good referrals.

What can I do about the level of stress I am experiencing?

There are three basic strategies for reducing stress: eliminate or reduce the stressors; slow down your reactions and change them to less harmful ones; allow an adequate period of recovery with the Relaxation Response. A good Mind/Body Group can teach you all three strategies.

What is the "Relaxation Response?"

There is good news! The human body has an innate Relaxation Response that heals the negative effects of the Stress Response. The physiological changes elicited by this response are:

  • Slower heart rate and decreased blood pressure
  • Slow, deep breathing
  • Relaxed muscles
  • Smooth digestion and elimination
  • Reliable energy with regular sleep patterns

There are many techniques for eliciting this response. Some of them are:

  • Deep Breathing
  • Progressive Muscle Relaxation
  • Meditation
  • Guided imagery
  • Hypnosis
  • Massage
  • Yoga & Yai Chi

I really freaked out during my first IVF cycle. I was so nervous before the retrieval I asked for a sedative. Then the two weeks of waiting were unbearable. I was devastated when my HCG test was negative. Now I'm wondering if my anxiety caused my cycle to fail.

You might be relieved to know that even women with high levels of situational anxiety caused by treatment procedures are not ruining their chances of conception. Studies show that situational anxiety does not negatively impact treatment outcomes.

However, women with high levels of depression and accompanying anxiety at the start of a treatment cycle do have poorer treatment outcomes in general. They may produce fewer follicles over all, which limits success in any given cycle.

Either way, rather than being miserable during procedures you should seek relief for your anxiety ahead of time. Try writing about the procedure going well; create a script for a tape to listen to during the procedure. You might consider learning more ways to elicit the Relaxation Response in yourself, such as progressive muscle relaxation and meditation.

I am so depressed that I don't believe my next IVF cycle will work. But I'm going to turn 39 in a couple of months, and I want to get this cycle done before I'm any older. I'm supposed to start now but my heart isn't in it. Will my attitude influence my cycle?

Possibly. Research shows that a woman's attitude at the start of a treatment cycle correlates with treatment outcomes: women with more pessimistic attitudes have poorer outcomes than women with optimistic attitudes. This doesn't mean that every negative thought is harmful. Most likely it indicates that women who feel pessimistic are suffering from depression and need to address their mental health.

If you find yourself having a preponderance of negative thoughts that you cannot escape, you should try journaling and asking yourself what proof you have for them. Most negative thoughts are cognitive distortions and are not true

When is the best time for me to start preparing for a treatment cycle and practicing Mind/Body techniques?

Research shows that baseline stress and outlook at the start of a treatment cycle correlates with treatment outcomes. Therefore, the best time to address depression, anxiety, or other effects of stress is about two months before a treatment cycle. Women who participate in either Mind/Body Groups or Support groups show improvement within five to ten weeks. The benefits of Mind/Body Groups appear to last up to six months longer. Women in both groups have double the conception rates within one year as women who do not receive group support.

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