More women are delaying pregnancy to pursue education, develop their careers, choose a partner, or decide to become a single parent by choice. Likely both because of delaying fertility and because pregnancy by that time is so strongly desired, the process of trying to conceive can be both exciting and stressful for many individuals and couples. When we experience delayed fertility, infertility, and pregnancy loss, the stress can become overwhelming. Pursuing fertility treatment can help us feel empowered that we are actively doing everything we can to achieve our dreams, however going through infertility treatment can also be stressful for people. Women go through the most during infertility treatment, and so often experience the most stress with treatment as well.

Your Fertility Specialists at Reproductive Partners Fertility Center San Diego understand how stressful the journey through infertility can be.

One of our fertility specialists, Dr. Jamie Stanhiser, has particularly studied stress in fertility and infertility.  One of her many publications is a chapter entitled, “Psychosocial Aspects of Fertility and Assisted Reproductive Technology,” with a focus on the relationships between stress, anxiety, and depression, and fertility published in the Perinatal Mental Health issue of Obstetrics & Gynecology Clinics of North America.1

In this chapter, Dr. Stanhiser shares that infertility occurs in 12% of reproductive-aged couples, and it is nearly universally perceived as distressing.2  A study of 200 infertile couples reported that 50% of the women and 15% of the men felt that infertility was the most upsetting experience of their lives.3  Another study of 488 women concluded that women with infertility felt as stressed, anxious or depressed as women who had been diagnosed with cancer, human immunodeficiency virus (HIV), or a heart attack.4  Studies consistently show that many women with infertility have a perceived loss of control over their lives, and experience a sense of loss of identity, feelings of defectiveness, shame, and self-blame.5  Depression and anxiety occur in 39 – 41% and 47% of women with infertility, respectively, which are twice the rates observed in women without infertility.6

The stress and its associated anxiety and depression within infertility can be overwhelming for many people, and it can make it more difficult for women to initiate and persevere in fertility treatment.  Women with infertility who screened positive for depression were less likely to initiate fertility treatment after their initial consultation, and another study found that a diagnosis of depression in women undergoing infertility treatment was associated with a significantly lower number of treatment cycles and therefore a lower mean number of live births compared to women undergoing infertility treatment without a diagnosis of depression.7

Some of the most common questions from our patients are those regarding stress and fertility, essentially asking, “Does stress reduce my chances of getting pregnant?”

A recent study found that 69% of women seeking fertility care believed that stress could reduce their success with fertility treatment, 29% believed stress could cause their overall infertility, and 31% believed that stress could cause a miscarriage.  Less than a quarter of the women believed that stress had no impact on fertility.8  Dr. Angela Lawson is a psychologist at Northwestern’s Center for Fertility and Reproductive Medicine and shares how women for generations have been told that being too stressed can cause infertility and miscarriage, which further contributes to the shame and self-blame that women experience with reproductive loss.9  The truth is that it is difficult to study stress and fertility for many reasons, including that psychological stress is subjective with individual variability and that there are many confounders (other contributing variables difficult to account for in studies).  While on the surface it may seem biologically plausible that psychological distress can be a cause of infertility, it is important to remember that historically we have lived as a species in famine-ravaged, poverty-stricken, war-torn regions with omnipresent threat, surviving through exhaustive daily physical labor, and yet continued to reproduce.  Dr. Lawson writes:

“If being too stressed affected the survival and reproduction of our species, we would have likely died out long ago.”9

While studies suggest that psychosocial stress affects the sympathetic and parasympathetic nervous systems, research also finds that neither system is ever completely shut down, and very rarely impact the hypothalamic pituitary ovarian axis of ovulation.10  Studies on biomarkers of stress, including corticotrophin-releasing hormone, cortisol, and alpha-amylase have either shown no association with pregnancy chances or suffer from flawed study design such as failure to assess for infertility history, exposure to other factors associated with infertility, and single time point assessments in a large study time period.  It is also important to know that research does not show a strong biologic link between reducing stress (through psychotherapy and acupuncture) and improved fertility.  In 2016 a Cochrane review of all available randomized control trials on pregnancy and managing stress through psychotherapy judged the quality of the evidence to be very low due to serious inconsistency in study findings.11

The unsolicited advice, “Just relax and it will happen,” is a hurtful falsity.

No rigorous research to date has shown a causal and biological role of emotional stress and infertility.

While we cannot conclude that stress and relieving stress biologically impacts fertility and infertility, nevertheless learning skills to understand and manage stress can significantly improve your experience of wellbeing and perseverance with treatment on the fertility journey.  With this goal, our Fertility Doctors at Reproductive Partners Fertility Center San Diego want to empower you with understanding the difference between stressors and stress, and the power of resilience to stressors that we can build intentionally during hard times.  Stressors are situations or things that are a possible threat to one’s wellbeing or position in life, especially if the challenge of dealing with it exceeds a person’s available resources.12  When one encounters stressors, the body’s stress response is triggered, and a series of physiological and psychological changes take place that shift us away from our sturdy baseline into a stress response.  Resilience is the practice of narrowing the window between the stress response and returning to your sturdy baseline.

It is helpful to think of resilience as a muscle we can strengthen through intentional practice and exercise of stress management techniques and strategies.

In a study by Facchinetti et al., women undergoing fertility treatment were all exposed to the same stressor.  Women who had an attenuated response to the stressor experienced higher success in their treatment cycle.13  While the weight of this study is limited by its small cohort size and more studies are needed, this study remains interesting because it showed that it wasn’t the stressor that impacted the success rate – all the women were exposed to the same stressor. Instead, it was the individual stress response and resilience to that stressor that predicted success (albeit with several confounders likely contributing in this study).  Nevertheless, this is a powerful idea, because we can’t always control the stressors in our lives, but we can build and practice the skills to improve our stress response and meet life’s challenges with resilience.  We want to give you this hope and personal agency within your fertility journey, because studies have suggested that they are important in building resilience and improving psychological adjustment (one’s wellbeing) during infertility.14    It is also important to understand that there are several different types of stress, and not all are harmful.  Eustress for example refers to stress that leads to a positive response that often feels exciting and motivating.

While stressors are an inescapable part of life and the infertility journey is one of the most powerful stressors people may experience in their lives, your fertility Specialists at Reproductive Partners Fertility Center San Diego see this time as an opportunity to empower you to cultivate tools for stress management that benefit your fertility journey and the entire rest of your life.

Tools for Stress Management

Develop Stress Relieving Habits

Exercise

  • Regular physical movement is one of the most important things you can do for your health and wellbeing according to the Centers for Disease Control (CDC).15
  • Immediate benefits of physical movement include improved energy, thinking, learning, and judgement skills and reduced stress.15
  • Exercise reduces your risk of depression and anxiety and is first line treatment for these as well.15
  • Exercise also helps you sleep better.15
  • Stay tuned for a future blog post on fertility and exercise!

Go for a Walk in Nature

  • Walking is a wonderful form of physical movement, with the exercise benefits above.
  • Studies show that being in nature for a 40 minute walk significantly reduces stress by lowering cortisol levels (a stress hormone) and blood pressure, as well as supporting your immune system.16  Nature serves as a refuge to reflect, heal, and inspire.

Get Enough Sleep

  • Sleep reduces stress and improves your mood.  It also helps improve energy, cognitive function, your immune system, blood sugar regulation and your ability to maintain a healthy weight.  We recommend eight hours of sleep each night.17

Be Creative; Learn Something New

  • Being creative and learning something new can shift your focus from stressors in your life to your power as a creative being to bring beauty and joy into your life no matter what the day brings.

Mindfulness, Meditation and Self-Compassion

  • Mindfulness, meditation, and self-compassion have been found to significantly reduce stress.18  There are many resources for developing a mindfulness, meditation, and self-compassion routine.  Some free resources include:
  1. The Plum Village App for guided meditations
  2. Tara Brach’s podcast also includes free guided meditations
  3. The Omega Institute’s YouTube channel offers a wide variety of meditations

Nourish your Body with Healthy Food and Hydration

  • We recommend a Mediterranean Diet with a foundation of plant-based foods (such as whole grains, vegetables, legumes, fruits, nuts, seeds, herbs and spices), fish if one is not vegetarian (while avoiding red meats), and using olive oil instead of butter in preparing food.  The Mediterranean diet may improve fertility and also has been found to reduce stress biomarkers including cortisol.19

Journal

  • Studies consistently show that journaling reduces stress.  Burton and King published a study entitled, “Effects of (Very) Brief Writing on Health: The Two Minute Miracle,” finding that taking just two minutes each day for two days to write about life experiences may garner significant health benefits including reduced stress.20

Therapy

  • Your fertility doctors at Reproductive Partners Fertility Center San Diego recommend connecting with a therapist on your fertility journey.  Speaking with a therapist can improve wellbeing and mitigate the effects of stress from infertility.

Social Support through friendships and playing with a pet

  • Studies have found that social support through friendships and playing with a pet can significantly reduce stress and improve wellbeing.21

Three Ways to Calm Down Quickly When You Feel Overwhelmed

Practice Breathing Exercises

  • Our breathing is a powerful way to regulate our stress response.  Practice deep, calming breaths, and notice your in-breath and your out-breath.

Grounding in the Present Moment with your Five Senses (5-4-3-2-1):

  • Notice 5 things you see around you
  • Notice 4 things you can touch around you
  • Notice 3 things you can hear around you
  • Notice 2 things you can smell around you
  • Notice 1 thing you can taste

A Mantra to Remind Yourself of Your Resilience

  • Mantras can help reframe the stress you experience into a powerful reminder of your own resilience.  Dr. Stanhiser recommends a simple mantra that validates the stress of the current moment and your ability to cope with it, like:  “This is stressful.  I can cope with this.”

Eliminate Stressors When You Can

We recommend mindfully assessing the stressors in your life, and eliminating or at least minimizing the ones you can, in order to give more of your energy and resiliency to the unavoidable stressors of life and the fertility journey.

Your fertility doctors at Reproductive Partners Fertility Center San Diego are here for you to answer any questions about stress and your fertility journey.

We care about your wellbeing and want to help reduce your stress on your fertility journey.  We look forward to continuing to empower you while helping you achieve your fertility dreams.

References:

1.  Stanhiser J, Steiner AZ.  Psychosocial aspects of fertility and assisted reproductive technology. Obstetrics & Gynecology Clinics of North America, 2018; 45(3):563-574.

2.   Boivin J, Bunting L, Collins JA, et al. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod 2007;22(6):1506–12.

3.  Potter-Efron P. The Psychological impact of infertility and its treatment. Harv Ment

Health Lett 2009;24(11):1–3.

4.  Domar AD, Zuttermeister PC, Friedman R. The psychological impact of infertility: a comparison with patients with other medical conditions. J Psychosom Obstet Gynaecol 1993;14(Suppl):45–52.

5.  Deka P, Sarma S. Psychological aspects of infertility. Br J Med Pract 2010;3:a336.

6.  Hoff HS, Crawford NM, Mersereau JE. Mental health disorders in infertile women: prevalence, perceived effect on fertility, and willingness for treatment for anxiety and depression. Fertil Steril 2017;104(3):e357.

7.  Cesta CE, Viktorin A, Olsson H, et al. Depression, anxiety, and antidepressant treatment in women: association with in vitro fertilization outcome. Fertil Steril 2016;105(6):1594–602.e3.

8.  Negris O, Lawson A, Brown D, Warren C, Galic I, Bozen A, Swanson A, Jain T. Emotional stress and reproduction: what do fertility patients believe? J Assist Reprod Genet. 2021 Apr;38(4):877-887.

9.  Lawson, A.  What Research Says about Stress as a Cause of Infertility. Fertility Smarts, 2020.  https://www.fertilitysmarts.com/what-research-says-about-stress-as-a-cause-of-infertility/2/2253

10.  McCorry, Laurie Kelly. “Physiology of the autonomic nervous system.” American journal of pharmaceutical education vol. 71,4 (2007): 78. doi:10.5688/aj710478

11.  Verkuijlen J, Verhaak C, Nelen WLDM, Wilkinson J, Farquhar C. Psychological and educational interventions for subfertile men and women. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD011034. DOI: 10.1002/14651858.CD011034.pub2

12.   Oken BS, Chamine I, Wakeland W. A systems approach to stress, stressors and resilience in humans. Behav Brain Res. 2015;282:144-54. PMID:25549855

13.  Facchinetti F, Volpe A, Matteo ML, Genazzani AR, Artini GP, An increased vulnerability to stress is associated with a poor outcome of in vitro fertilization-embryo transfer treatment. Fertility and Sterility, 1997; 67 (2): 309-314.

14.  Omani Samani R, Vesali S, Navid B, et al. Evaluation on hope and psychological symptoms in infertile couples undergoing assisted reproduction treatment. Int J Fertil Steril 2017;11(2):123–9.

15.  https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm

16.  Park, B.J., Tsunetsugu, Y., Kasetani, T. et al. The physiological effects of Shinrin-yoku (taking in the forest atmosphere or forest bathing): evidence from field experiments in 24 forests across Japan. Environ Health Prev Med 15, 18 (2010).

17.  Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N., Herman, J., Adams Hillard, P. J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N., O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Sachdeva, R. C., Setters, B., Vitiello, M. V., & Ware, J. C. (2015). National Sleep Foundation’s updated sleep duration recommendations: Final report. Sleep health, 1(4), 233–243.

18.  Astin JA. Stress reduction through mindfulness meditation. Psychotherapy and psychosomatics. 1997;66(2):97-106.

19.  Shively CA, Appt SE, Chen H, Day SM, Frye BM, Shaltout HA, Silverstein-Metzler MG, Snyder-Mackler N, Uberseder B, Vitolins MZ, Register TC.  Mediterranean diet, stress resilience, and aging in nonhuman primates. Neurobiology of Stress, 2020; 13: 2354-2895.

20.  Burton CM, King LA.  The health benefits of writing about intensely positive experiences, Journal of Research in Personality, 2004; 38 (2): 150-163.

21.  Blascovich, Tomaka J, Kelsey J. Presence of human friends and pet dogs as moderators of autonomic responses to stress in women. Journal of Personality and Social Psychology, 1991; 61(4): 582-589.