Chapter 32
Stress And Infertility

from the book How to Have a Baby: Overcoming Infertility
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, it’s 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 " runner’s 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 fertility.

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 – 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 today’s "urban myths".

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 – 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 doctor’s clinic. Waiting can be stressful, so do carry a book to read – 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 the case!

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.

Don’t 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, it’s 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 even worse.

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 overall outcome.

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 "stressed out".

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.

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