Does Stress Cause Infertility?

The claim that stress causes infertility has long been controversial—and sometimes spurious. Hawkers of meditation, massage, acupuncture, yoga, foot reflexology, and chiropractic have tried to convince despondent women that they need to chill out to become pregnant. Doctors acknowledge that such relaxation techniques make women feel calmer, but they’ve largely dismissed their efficacy in increasing the chances of bringing home a baby.

But two exceptions to that rule are gaining scientific credibility: acupuncture and a popular mind-body program [2], which holds that a woman’s emotions affect her physical health. In the case of the latter, a randomized controlled study presented last month at the annual conference of the American Society for Reproductive Medicine found that about half of the 21 women who attended multi-week mind-body sessions [3], consisting of stress management exercises and cognitive behavioral therapy, became pregnant through in vitro fertilization—compared with about one-fifth of the 20 women who didn’t participate. It’s not exactly clear why the comforting mix of group support, nature imagery, and focus on changing negative thought patterns (from “I’ll never have a baby” to “I’m doing everything I can to have a baby,” for example) helped women conceive. But here’s a clue: The patients who were the most depressed at the beginning of the study—and had the most opportunity to improve—emerged with the highest pregnancy rates.

The author of the study, psychologist Alice Domar, who started the mind-body program for infertility patients in 1987 and has since trained hundreds of practitioners around the world, wanted to see if she could replicate promising results from a study she conducted in the ’90s. This latest trial supports Domar’s original finding, published in Fertility and Sterility in 2000, that the mind-body program participants have a higher rate of conception.

Domar’s conclusions were based on a small sample size. Still, her study is a welcome addition to a field that desperately needs more randomized rigorous research, says James Smith, assistant professor of urology at the University of California-San Francisco.

Scientists have suspected for decades that depression might play a role in infertility, but the connection has been understudied and hard to establish. For starters, plenty of depressed women have no problem getting pregnant, and many infertile women feel fine. And although some 40 percent to 50 percent of infertility cases are unexplained, the majority have a physical cause. A mind-body program won’t fix blocked fallopian tubes or rehabilitate old eggs. In fact, several studies have shown that a woman’s psychological well-being has little effect on IVF outcomes.

But mental health specialists are increasingly recognizing that a subgroup of depressed women may also have trouble conceiving. It makes sense from an evolutionary perspective, explained Domar, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School. A severely depressed woman might have trouble taking care of herself and wouldn’t be in good shape to deal with the demands of a new baby. Another theory holds that depression increases the levels of the stress hormone cortisol, which leads to higher blood pressure, blood sugar, and the likelihood of getting sick. Researchers have speculated that cortisol might affect fertility but don’t know how. Perhaps the hormone changes the timing of ovulation, when the egg is released for fertilization, or messes with pregnancy hormones, or prevents embryos from implanting into the uterine lining. No one knows. (Domar’s group next will analyze cortisol and blood samples from her subjects.)

What experts do know is that infertility is often emotionally debilitating. Unsurprisingly, studies have shown that even the most resilient couples can suffer from depression, anger, anxiety, low self-esteem, sexual dysfunction, and marital strain. Infertility treatment—with its dashed hopes and roller coasters—can deal a double blow. Even women who showed good mental health during their first IVF consultations had a greater chance of becoming depressed the more failed cycles they endured and the longer treatment took. It’s hard to separate out the chicken or the egg puzzle of whether the infertility diagnosis or treatment led to depression or vice versa, but doctors have good reason to try. Not only will addressing depression help women cope better and potentially improve pregnancy rates, but it may prevent them from developing post-partum depression later, explains Samantha Meltzer-Brody, a psychiatrist at the University of North Carolina-Chapel Hill. Some evidence suggests that women who experience high levels of stress, depression, and anxiety during IVF treatment have a higher risk of the mood disorder.

Yet few infertility patients or doctors bring up the subject of depression in the course of treatment. Doctors might not regard mental health as a priority or know how to counsel a woman. They also don’t want to wrongly imply that her depression caused her infertility. “How do you broach it without suggesting to the woman that it’s all in her head?” asks Julianne Zweifel, an infertility counselor and assistant professor of obstetrics and gynecology at the University of Wisconsin-Madison. The problem, she says, is that in trying not to be insensitive, doctors “are actually being less sensitive by not inquiring how a women is doing emotionally.” Patients, for their part, may not want to bother their doctors or divulge that they’re having a hard time. As a result, two reproductive professional groups, the American Society for Reproductive Medicine [3] and the European Society of Human Reproductive and Embryology [4], along with the pharmaceutical company Merck-Serono [5], have developed a questionnaire [6] that measures patients’ psychological well-being during treatment. A growing number of clinics are using the tool—a sign of taking the problem more seriously.

For now, women told to “just relax” shouldn’t worry that if they can’t, they won’t get pregnant. But if a woman can’t stop ruminating about having a child and persistently feels downhearted, counseling could help. It might not help her have a baby, but it might make her feel better.