Stress and Infertility

Helpful Advice From Alice Domar, Ph.D.

Dr. Alice Domar, Ph.D. ~ the Executive Director of the Domar Center for Mind/Body Health and the Director of Mind/Body Services at Boston IVF, she established the first ever Mind/Body Center for Women’s Health ~ as well as the very first Mind/Body Program for Fertility.

Alice D. Domar, PhD

Because the drive to reproduce is one of our most basic instincts, unanticipated difficulties conceiving can have a negative impact on everything from your outlook on life to your closest relationships. Couples may find that by the time they are diagnosed with infertility and are initiating treatment, an array of emotions, often contradictory, are coming to bear on the decisions that they make and their outlook on treatment.

Research has shown that the stress associated with fertility treatment can be at a level comparable to the stress associated with serious illness. Patients who seek emotional support early in treatment are often better prepared for their experiences and find it significantly less stressful than patients who do not.”

We don’t know for sure whether or not stress causes infertility. There has been some recent evidence that depressive symptoms are linked to some forms of infertility and that the more distressed the woman is at the beginning of her IVF cycle, the less likely she is to conceive during that cycle. But the evidence is not conclusive and until there is some solid research, don’t assume that your level of distress is an issue in terms of treatment success.

‘Stressing’ Over Stress?

Stress is one of the top concerns of most infertility patients, leading to a number of questions. Is your stress level contributing to or causing your infertility? Are you too stressed to be able to handle complex treatment cycles? Will your old “pre-infertility” personality ever return? Many consider IVF to be the ultimate in terms of cost, both financially and emotionally.

So, what is the relationship between stress and IVF? Is IVF more stressful than other infertility treatments? Does stress have any impact on the outcome? Are there ways to reduce IVF-induced stress? The answers are probably, probably, and yes.

How Stressful is IVF?

Female in the sunlightThe answer actually depends on the path you took to IVF. For couples who basically start with IVF, either because of blocked tubes or a severe male factor, IVF can seem pretty overwhelming.

The thought of daily injections, frequent visits for blood tests and ultrasounds, and a surgical procedure to extract eggs may feel extreme for a couple who just finished their infertility work-up. However, there may be some excitement about proceeding with a treatment which can compensate for the diagnosed problem.

Conversely, for a couple who has not conceived despite numerous medicated cycles, with and/or without IUI’s, IVF may seem scary. Often it is perceived as the treatment of last resort with the accompanying thought that if IVF doesn’t work, you may have to say goodbye to the dream of producing a genetic child. However, these couples may also approach IVF with renewed hope and optimism since it has the highest per cycle success rates of any infertility treatment.

The Research Says….

The research on the psychological impact of IVF indicates that prior to beginning treatment, many patients report increased levels of stress, but a significant portion also report excitement and hope. In addition, couples report that the stressful part of IVF is not the physical aspect, but rather the emotional. I have had many patients tell me that proceeding to IVF feels completely overwhelming. However, if you have undergone a cycle of gonadotropin therapy (the shots) with IUI, you actually may find that IVF doesn’t feel all that different. The shots, the blood work, and the ultrasounds will feel familiar. You may be on additional medication, such as Lupron, and the egg retrieval is new (but hopefully you will be asleep for it), but the embryo transfer feels a lot like an IUI. Unfortunately, the horrible two weeks of waiting will feel too familiar.

Stress and Infertility and $$$

Another stressor associated with IVF is the financial cost. Many patients can find the money needed for preliminary treatment but IVF brings with it a much bigger price-tag. Although some people have insurance or the financial means to effortlessly pay for treatment, they are the exception. When considering the various contributors to the stress of treatment, paying for it usually ranks up in the top one or two.

There are several things to do, including making sure (as in not necessarily believing your HR rep) than your insurance policy covers none of IVF before assuming you are responsible for the cost yourself. If you are indeed on your own financially, make some noise. Tell your doctor that this will be difficult for you since some programs have sliding scale fees, many patients donate medications they no longer need, and some of the pharmaceutical companies offer medication support. Consider asking family members to contribute to the cause but be aware that if, for example, your parents do contribute but his parents don’t, your parents may feel that they are entitled to more time with any resultant baby.

So, to answer the question about the stress of IVF, yes, it is stressful but most of that stress comes from the intense desire to have a baby and the fear that it may not work, rather from the stress of the medical aspects of the cycle itself. Recent research on why insurance-covered patients drop out of treatment prior to completing all of their covered cycles has shown that it is the stress of the treatment, not the physical demands.

So, Does Stress Have any Impact on Outcome?

This is a controversial question because the research has been somewhat contradictory. I just did a literature review on the subject and found 20 research studies from around the world; all looked at whether or not psychological distress had an impact on IVF success rates. Fifteen of these found that increased levels of psychological distress before or during the IVF cycle were associated with decreased pregnancy rates, three found no relationship, and two were inconclusive. Several of the studies found strong relationships between distress and outcome- in one study, depressed women were only half as likely to conceive as nondepressed women. One of the problems in interpreting these studies is that a patient’s distress may be related to her prognosis. Thus, if a patient is told by her doctor before she starts an IVF cycle that he is pessimistic about her chances (due to age, FSH level, past response to treatment, etc), she would likely be more anxious before and during her cycle than a patient told that her chances were exceptionally good. If the “poor prognosis” patient reports significant amounts of distress during her cycle and then finds out she is not pregnant, how can one be certain that the distress caused the cycle to fail? In addition, even if a patient does not receive any sort of prognosis from her physician beforehand but hears from the technicians and nurses during her cycle that the cycle is not going well, she is understandably going to experience a lot of distress. So, if she doesn’t get pregnant, how can one blame the distress caused by the IVF cycle? It could well be that the distress was the result, not the cause, of the cycle not going well.

Recent research from the University of California, San Diego, controlled for the factors which are related to poor prognosis, such as age and FSH level. They surveyed women prior to starting an ART cycle and found a very strong relationship between pre-cycle psychological state and birth rates. In fact, the women who expressed the most negative emotions prior to starting their cycle were 93% less likely to have a baby than the women who were the most positive.

Are There Ways to Reduce IVF-Induced Stress?

The answer is yes, lots! One of the first things you can do when planning your upcoming IVF cycle is to look carefully at your work schedule. If you have some massive work deadline May 1, don’t do an April cycle. Conversely, if you are committed to doing a April cycle and your boss asks if you would be willing to do a new project, which is due May 1, take a pass. Also, think carefully about who you tell about your plans to do an IVF cycle. If you tell 20 people that you are cycling, expect 20 calls per day to inquire about your progress. And if you get a negative pregnancy test on Day 28, receiving those 20 hopeful calls may be very difficult. You need to think about achieving a balance between receiving support from loved ones, and communicating to your best advantage. Perhaps appoint a spokesperson (sister, best friends, etc) who you will keep posted and anyone who wants to know how you are doing will call her. You are then free to call any one you want. If you decide not to tell anyone, don’t expect to get effortless support if the cycle doesn’t work because you will be catching them off guard.

Consider adding some relaxation techniques to your routine to do on a daily basis to keep your baseline level of stress down and learn some “mini” relaxation techniques to use during blood tests, ultrasounds, etc. Think about all the ways you can nurture yourself during your treatment. Since alcohol is out, indulge in hot chocolate, old family muffin recipes, or other comfort foods. Since you are saving time from your routine by not exercising, buy some juicy novels and revel in the indulgence of reading. And you can now consider yourself under doctor’s orders to skip all baby showers because of the stress they can cause (and don’t, as one of my patients just did and regretted it enormously, make the huge mistake of actually giving a baby shower). Plan some couple time for the day of your pregnancy test so you ensure time to talk- to either mourn privately together or to celebrate. And always go into each cycle with a “Plan B” which may be time off, another cycle, obtaining a second opinion, getting information about donor egg, etc. You don’t have to stick to Plan B when the time comes, but it makes it easier to go into a cycle knowing there is another plan.

Think seriously about obtaining some more formal structured stress-reduction training. Mind/body programs are group or individual programs which provide you with the skills to reduce stress at every stage of the cycle. You will learn numerous relaxation strategies, stress management skills, and get the support from others who “get it”. The data shows that participants experience significant decreases in infertility distress as well as decreases in stress-related physical symptoms (insomnia, abdominal pain, shortness of breath, back/neck pain, etc) and preliminary research shows increased pregnancy rates as well.

Undergoing an IVF cycle can be a very stressful experience but planning ahead can give you a much greater sense of control. Going into a cycle feeling calm and prepared not only makes the treatment more bearable, but may well increase the chance of success.

I wish you the very best of luck.