Stress And Infertility
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Stress has become a buzzword today. It is one of the most over used words in
our vocabulary - and one of the most poorly understood ones as well. Stress is
defined as any event that a person perceives as threatening, and in order to
protect itself, the body responds to stressors with a classic "fight or
flight" response, which nature designed to allow survival. In response to
stress, the hypothalamus produces a hormone called corticotropin releasing
factor ( CRF) which activates the hypothalamic-pituitary-adrenal (HPA) system,
causing it to releases neurotransmitters (chemical messengers) called
catecholamines, as well as cortisol, the primary stress hormone.
The relationship between stress and infertility is still poorly understood
today. While there is little doubt that infertility causes considerable stress,
the question whether stress can cause infertility, and whether stress reduction
can enhance pregnancy rates in infertile couples, is still very controversial.
Can Stress Cause Infertility?
Historically, infertility, particularly "functional" infertility,
was attributed to abnormal psychological functioning on the part of one or both
members of the couple. Preliminary works in the 1940s and 1950s considered
"psychogenic infertility" as the major cause of failure to conceive in
as many as 50% of cases. As recently as the late 1960s, it was commonly believed
that reproductive failure was the result of psychological and emotional factors.
Psychogenic infertility was supposed to occur because of unconscious anxiety
about sexual feelings, ambivalence toward motherhood, unresolved Oedipal
conflict, or conflicts of gender identity. Fortunately, advances in reproductive
endocrinology and medical technology as well as in psychological research have
de-emphasized the significance of psychopathology as the basis of infertility,
and modern research shows that there is little evidence to support a role for
personality factors or conflicts as a cause of infertility. This perspective
unburdens the couple by relieving them of the additional guilt of thinking that
it is their mental stress that may be responsible for their infertility.
Biologically, since the hypothalamus regulates both stress responses as well
as the sex hormones, itís easy to see how stress could cause infertility in
some women. Excessive stress may even lead to complete suppression of the
menstrual cycle, and this is often seen in female marathon runners, who develop
" runnerís amenorrhea". In less severe cases, it could cause
anovulation or irregular menstrual cycles. When activated by stress, the
pituitary gland also produces increased amounts of prolactin, and elevated
levels of prolactin could cause irregular ovulation. Since the female
reproductive tract contains catecholamine receptors catecholamines produced in
response to stress may potentially affect fertility, for example, by interfering
with the transport of gametes through the Fallopian tube or by altering uterine
blood flow. However, more complex mechanisms may be at play, and researchers
still don't completely understand how stress interacts with the reproductive
system. This is a story which is still unfolding, and during the last 20 years,
the new field of pychoneuroimmunology has emerged, which focuses on how your
mind can affect your body. Research has shown that the brain produces special
molecules called neuropeptides, in response to emotions, and these peptides can
interact with every cell of the body, including those of the immune system. In
this view, the mind and the body are not only connected, but inseparable, so
that it is hardly surprising that stress can have a negative influence on
Stress can reduce sperm counts as well. Thus, testicular biopsies obtained
from prisoners awaiting execution, who were obviously under extreme stress,
revealed complete spermatogenetic arrest in all cases. Researchers have also
showed significantly lower semen volume and sperm concentration in a group of
chronically stressed marmoset monkey, and these changes were attributed to lower
concentrations of LH and testosterone (which were reduced in the stressed
group). However, how relevant these research findings are in clinical practise
is still to be determined.
In addition to these direct effects, stress can also suppress libido, cause
erectile dysfunction, and result in a reduction in the frequency of intercourse,
which in turn could also reduce fertility. Also, many women start overeating in
response to the stress of infertility. The increased fat cells then disrupt the
hormonal balance, making a bad situation even worse.
While studies have shown that infertile couples do show psychologic
dysfunction and even psychiatric abnormalities ( such as depression or anxiety),
this is actually a chicken and egg problem, and in reality the response of the
infertile couple is a perfectly "normal" response to their abnormal
situation, which is designed to help them to cope with the difficult
circumstances they find themselves in. However, many people start blaming the
couple, and many couples themselves start believing that it is the stress which
they are under which is causing them to be infertile. Victim blaming is popular
Ė especially where fertility and women are concerned, and instead of providing
them with support, couples receive completely gratuitous and unwanted advise.
Ironically, victim blaming has become more prevalent today because of the
fashionable "holistic health" belief about the influence of the mind
on the body, which holds that even patients with cancer can cure themselves by
the power of positive thinking. Many IVF couples too may subscribe to the belief
that success is practically guaranteed if the patient remain optimistic and
relaxed. Thus, if the attempt fails, it was because the patient was "too
tense" or " too stressed out".
This myth has been perpetuated by anecdotes of friends or relatives who have
conceived while on holiday, and stories of couples conceiving after many years
of infertility after they have adopted a baby are a part of todayís
Stress and infertility often have a circular relationship, and they can
aggravate each other, setting up a vicious cycle. Infertile couples, who are
under stress because of their infertility, start blaming themselves for their
infertility. This increases their stress levels and further aggravates the
problem! As one mind-body expert has said, "Stress causes illness causes
more stress causes more illness."
Infertility Causing Stress
Research has shown that women undergoing treatment for infertility have a
similar, and often higher, level of "stress" as women dealing with
life-threatening illnesses such as cancer and heart disease. Infertile couples
experience chronic ( long-term) stress each month, first hoping that they will
conceive and then dealing with the disappointment if they do not.
It is helpful to differentiate between external stress and internal stress;
as well as stressors you can control and those which you cannot. Internal stress
arises when you are not able to achieve the goals you set yourself while
external stress is created by relatives, friends, and work pressures. Some
stressors you can do nothing about Ė for example, the frustration you feel
when your period starts. However, there are many others which you can control.
As an example, many patients get upset when they are forced to wait in the
doctorís clinic. Waiting can be stressful, so do carry a book to read Ė
while you cannot control the stressor, you can modify your response to it, and
this helps to decrease your distress.
Why Infertility is Stressful
When diagnosed with infertility, many couples feel helpless and no longer in
control of their bodies or their life plan. Infertility can be a major crisis
because the important life goal of parenthood is threatened. Most couples are
accustomed to planning their lives and experience has shown them that if they
work hard at something, they can achieve it. With infertility, this may not be
However, not all stress faced by infertile couples is emotional or
psychological - infertility treatment can be physically stressful as well! Blood
tests; injections; hysterosalpingograms, inseminations and surgery can be
painful, awkward, and embarrassing.
There is considerable financial stress too and this is especially acute for
poor patients. Infertility treatment is expensive, and this represents a major
hurdle. Many patients drop out of treatment because they cannot afford it, and
this can be very hard to come to terms with, especially when they know they
could have got pregnant, if only they could have afforded the treatment.
Some of the hormonal medications you may need to take can also cause mood
swings and emotional upsets, making it harder for you to cope with the stress.
Donít forget the impact of being stressed on your personal relations. Being
stressed out can add to marital distress and disrupt sexual intimacy as well,
making a bad situation even worse. It can also alienate you from your friends,
cutting off sources of support. Also, if you are always irritable, tense, and
angry, itís going to be hard to build a rapport with your doctor or his clinic
staff. You may get a reputation as being a " difficult " patient, and
this may make it harder for you to get good medical care.
There are certain times which are especially stressful:
- Having to time sex when trying at home
- Waiting for the menses. The suspense can be killing each month - and is
even worse when the period is delayed for any reason
- Having to answer questions from family-members and friends. Many of these
questions are insensitive and hurtful.
- Having to juggle infertility treatment with work pressures
- Making a decision to see the doctor
- Deciding which medical treatment to take
- Waiting for results -Is the sperm count normal? have the eggs fertilized?
Many of these stresses are amplified considerably during IVF treatment. Many
couples start IVF focused anxiously on one primary concern: failure of the
procedure. To compound this anxiety, couples are aware that they have little
control over the final outcome - and this helplessness can make the situation
The inconvenience of daily injections and blood tests, the perception of low
success rates, the wait for results, and financial pressures only add to the
travails. Often, IVF is their last hope after many years of trying, and they
feel that their entire future rides on the outcome of the cycle.
While it is true that couples cannot control the outcome, they can be helped
to control their responses to the various phrases of the process and to the
It has been suggested that patients who are better able to cope with stress
have higher pregnancy rates, although there have been relatively few studies in
this area. Interestingly, we find that patients coming for the second IVF
treatment cycle are much more relaxed and in control, so that they are less
What are Some Methods for Reducing Stress?
Perhaps the best general approach for treating stress can be found in the
Serenity Prayer by Reinhold Niebuhr, " God, Grant me the serenity to accept
the things I cannot change, the courage to change the things I can change, and
the wisdom to know the difference." Remember that no single method is
uniformly successful: a combination of approaches is generally most effective.
Also, what works for one person does not necessarily work for someone else.
There are a number of very useful books which deal with stress management
techniques in great detail. A special bonus is that these tools will help you
cope with stress for the rest of your life as well! Some of these tools, which
you need to learn how to use, so that you can deal better with the ups and downs
of your infertility include: imagery, visualization, hypnosis, auto-suggestion,
meditation, positive thinking, progressive muscular relaxation, deep breathing,
biofeedback, and massage.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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