For couples struggling with infertility, "just relax" may be the most aggravating two-word phrase in the English language. "Those are fighting words," says infertility expert Sandra Berga, MD, chair of the Department of Gynecology and Obstetrics at Emory University in Atlanta.
Couples don't need or appreciate any suggestion that infertility is "all in their head," she says. They also don't need to hear another story about a couple who finally conceived on a cruise ship or had three babies after they "stopped trying."
Links to infertility
Such advice may be maddening, but it also contains a seed of truth, Berga says. Studies conducted over the years strongly suggest that emotional stress can actually impair fertility in men and women. For many couples suffering from infertility of unknown origin, this apparent obstacle is also an opportunity. Berga and other researchers have found that some couples can dramatically increase their chances of conceiving simply by learning how to cope with stress.
Instead of intrusive advice from well-meaning friends, infertile couples need professional help, Berga says. An infertility specialist can check each partner for underlying illnesses or anatomical problems that can make it hard to conceive. Learning how to cope with stress will not help all infertile couples, of course, particularly if the infertility is caused by a biological problem such as a lack of viable eggs. In such cases, those seeking a pregnancy would probably be advised to consider advanced reproductive technologies, such as using donor eggs.
But if there's no other obvious explanation, psychological stress just might be the culprit. In such cases, Berga says, a professional counselor or therapist may be able to help couples handle stress and put them on the path to parenthood.
Cycles of stress
It's well known that physical stress, such as over-exercising or not getting enough calories, can wreak havoc on a woman's menstrual cycle and, consequently, her fertility. For example, female athletes who push their bodies to extremes often have irregular periods, and some stop menstruating completely. Heavy exercise can occasionally cause infertility in men, too. Berga worked with one "sterile" man who suddenly achieved a normal sperm count when an injury forced him to take a break from his grueling running routine.
But there's another kind of stress, the kind that comes from deadlines, financial problems, marital conflict, and, in some cases, trying to conceive. The link between this emotional type of stress and infertility isn't well understood, but scattered studies over the years paint an intriguing picture.
As Berga and her colleague Tammy Loucks report in an issue of the Italian journal Minerva Ginecologica, several studies have found that seemingly healthy women with fertility trouble tend to have high levels of the stress hormone cortisol in their blood. Interestingly, this is the same hormone that seems to shut down ovulation in female athletes.
Berga estimates that about 5 percent of all women at any given time have stopped menstruating because of stress. "But that's just the tip of the iceberg," she says. Many other stressed-out women may have irregular periods or may go for months without menstruating. But even if a woman could set her calendar by her periods, stress might still keep her from conceiving, Berga says. Cortisol and other hormones can prevent implantation of fertilized eggs. Stress can also mess up the timing of a woman's cycles. She may end up ovulating a few days before menstruating -- bad timing if she's aiming for pregnancy.
Emotional stress also seems to reduce sperm counts in men. A study of 500 men published in the journal Fertility and Sterility found that sperm counts dropped when the men's partners were going through in vitro fertilization, a difficult and anxiety-producing procedure. Another study published in the Journal of Reproduction and Infant Psychology found that couples were less likely to achieve pregnancy if the man was depressed or had low self-esteem.
Despite the evidence to the contrary, prominent organizations such as RESOLVE (an advocacy group for people with fertility issues) and the American Society of Reproductive Medicine publicly downplay any connection between psychological strain and fertility troubles. One report from RESOLVE flatly states "stress does not cause infertility." A fact sheet published by the ASRM is only slightly less emphatic: "There isn't any proof that stress causes infertility."
As a spokesperson for RESOLVE, Berga says she understands the sentiment behind these statements. "They want to be politically correct," she says. "They don't want to be guilty of perpetuating a patronizing attitude. As a result, patients aren't getting correct information about how they can help themselves."
Learning to cope
In an ideal world, couples struggling to conceive could find a way to magically banish stress from their lives. In reality, a little turmoil is unavoidable. The whole process of overcoming infertility is stressful in itself, especially if it involves expensive, high-tech interventions such as in vitro fertilization. Even in the best-case scenario -- the one where a couple finally has a successful pregnancy -- they'll have to eventually face the stress of raising a child.
Infertile couples can't eradicate stress, but they can learn to change their approach to stressful situations. As Berga explains it, women or men suffering from infertility whose cause is unknown often have, quite understandably, a negative outlook on life. "They have a script going on in their head that makes them apprehensive and fearful," she says. If they can step back and look at their lives in a more positive light, they may be able to convince their mind and body that it's a good time to start a family.
Cognitive behavioral therapy (CBT), a type of therapy that specifically addresses negative thinking, may be especially helpful for couples hoping to conceive. Berga and colleagues recently put this therapy to the test in a group of women who had stopped ovulating for no apparent reason. Nearly 90 percent of women who underwent five month's worth of CBT ovulated in the following two months. For comparison, only 25 percent of women who didn't receive the therapy were able to ovulate.
Power of positive thinking
The study echoes findings described in a report in Fertility and Sterility, in which researchers studied 184 women who tried unsuccessfully to get pregnant over a period of one to two years. They divided the women into three groups: one that learned mind-body techniques (such as meditation, cognitive "restructuring," and deep breathing) to help them reduce symptoms of depression; a support group that met once a week to discuss the effects of infertility; and a control group, which received no intervention.
Within a year, 55 percent of the women in the mind-body group and 54 percent in the support group had pregnancies that resulted in a baby, compared with only 20 percent of the control group.
"The bottom line? Alleviating depression and other psychological distress in infertile women appears to make it easier for them to become pregnant," wrote lead researcher and Harvard psychologist Alice Domar, PhD, in a subsequent book on infertility.
Stress-related infertility, it appears, is as real as any other ailment caused by an imbalance of hormones. But unlike patients with diabetes or under-active thyroids, couples suffering from the condition don't necessarily need pills and shots. They need support from their friends and family, and they may benefit from some sessions of cognitive behavioral therapy or mind-body techniques designed to enhance fertility. With luck, it won't be long before they need a good babysitter, too.
Interview with Sandra Berga, MD, chair of the Department of Gynecology and Obstetrics at Emory University in Atlanta.
RESOLVE. Managing infertility stress.
American Society for Reproductive Medicine. Fact sheet: Stress and infertility. 2008.
Slade P et al. A 3-year follow-up of emotional, marital, and psychological functioning in couples who were infertile. Journal of Reproductive and Infant Psychology. 1992. 10: 233-243.
Harrison KL et al. Stress and semen quality in an in vitro fertilization program. Fertility and Sterility. 1987. 48: 633-636.
Berga SL et al. Recovery in ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavioral therapy. Fertility and Sterility. October 2003. 80(4): 976-981.
Schnied-Kofman N and E Sheiner. Does stress effect male sterility. Medical Science Monitor. 2005. 11(8): SR11-13.
Domar, Alice D, PhD. Conquering Infertility. Penguin, 2002.
American Society for Reproductive Medicine. Fact sheet: Stress and infertility. Revised 2008.