Psychological stress and infertility
- Alice D Domar, PhD
Alice D Domar, PhD
- Associate Professor of Obstetrics, Gynecology and Reproductive Biology (part-time)
- Harvard Medical School
The belief that psychologic factors play a role in infertility is long-standing, and there is evidence that stress levels may influence the outcome of infertility treatment, as well as contribute to patients' decisions to continue treatment [1,2]. Stress also affects patients' reactions to pregnancy loss during infertility treatment and pregnancy complications. Moreover, psychological distress is associated with infertility treatment failure, and interventions to relieve stress are associated with increased pregnancy rates .
In addition, preconception stress may increase the risk of infertility. In a 12-month, prospective observational study of women starting to attempt pregnancy naturally, salivary alpha-amylase (an index of stress) was measured at baseline . After adjusting for potential confounding factors (eg, age of the woman, consuming alcohol, and smoking cigarettes), the baseline level of alpha-amylase predicted subsequent infertility, such that infertility was more than twice as likely to occur in women with the highest tertile levels of alpha-amylase, compared with women in the lowest tertile.
Many patients with infertility and psychological stress (eg, anxiety and/or depressive symptoms) do not receive mental health services .
PREVALENCE OF STRESS
Psychological distress (eg, anxiety and/or depressive symptoms) is common in couples with infertility, and appears to be more common in the partner with the fertility problem :
●A prospective study followed women (n = 352) who presented for treatment at an infertility clinic for up to 18 months, along with their male partners (n = 274), using self-report instruments to assess clinically significant symptoms of anxiety and/or depression . The primary findings included the following:
- Campagne DM. Should fertilization treatment start with reducing stress? Hum Reprod 2006; 21:1651.
- Brandes M, van der Steen JO, Bokdam SB, et al. When and why do subfertile couples discontinue their fertility care? A longitudinal cohort study in a secondary care subfertility population. Hum Reprod 2009; 24:3127.
- Frederiksen Y, Farver-Vestergaard I, Skovgård NG, et al. Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. BMJ Open 2015; 5:e006592.
- Lynch CD, Sundaram R, Maisog JM, et al. Preconception stress increases the risk of infertility: results from a couple-based prospective cohort study--the LIFE study. Hum Reprod 2014; 29:1067.
- Pasch LA, Holley SR, Bleil ME, et al. Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services? Fertil Steril 2016; 106:209.
- Dhaliwal LK, Gupta KR, Gopalan S, Kulhara P. Psychological aspects of infertility due to various causes--prospective study. Int J Fertil Womens Med 2004; 49:44.
- Chen TH, Chang SP, Tsai CF, Juang KD. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod 2004; 19:2313.
- Lapane KL, Zierler S, Lasater TM, et al. Is a history of depressive symptoms associated with an increased risk of infertility in women? Psychosom Med 1995; 57:509.
- Domar AD, Broome A, Zuttermeister PC, et al. The prevalence and predictability of depression in infertile women. Fertil Steril 1992; 58:1158.
- Warnock JK, Bundren JC, Morris DW. Depressive mood symptoms associated with ovarian suppression. Fertil Steril 2000; 74:984.
- Steingold KA, Cedars M, Lu JK, et al. Treatment of endometriosis with a long-acting gonadotropin-releasing hormone agonist. Obstet Gynecol 1987; 69:403.
- Demyttenaere K, Bonte L, Gheldof M, et al. Coping style and depression level influence outcome in in vitro fertilization. Fertil Steril 1998; 69:1026.
- Eugster A, Vingerhoets AJ. Psychological aspects of in vitro fertilization: a review. Soc Sci Med 1999; 48:575.
- Freeman EW, Boxer AS, Rickels K, et al. Psychological evaluation and support in a program of in vitro fertilization and embryo transfer. Fertil Steril 1985; 43:48.
- Rockliff HE, Lightman SL, Rhidian E, et al. A systematic review of psychosocial factors associated with emotional adjustment in in vitro fertilization patients. Hum Reprod Update 2014; 20:594.
- Baram, D, Tourtelot, E, Muechler, E, Huang, K. Psychological adjustment following unsuccessful in vitro fertilization. J Psychosom Obstet Gynecol 1988; 8:181.
- Land JA, Courtar DA, Evers JL. Patient dropout in an assisted reproductive technology program: implications for pregnancy rates. Fertil Steril 1997; 68:278.
- Olivius K, Friden B, Lundin K, Bergh C. Cumulative probability of live birth after three in vitro fertilization/intracytoplasmic sperm injection cycles. Fertil Steril 2002; 77:505.
- Hammarberg K, Astbury J, Baker H. Women's experience of IVF: a follow-up study. Hum Reprod 2001; 16:374.
- Olivius C, Friden B, Borg G, Bergh C. Why do couples discontinue in vitro fertilization treatment? A cohort study. Fertil Steril 2004; 81:258.
- Rajkhowa M, McConnell A, Thomas GE. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Reprod 2006; 21:358.
- Schröder AK, Katalinic A, Diedrich K, Ludwig M. Cumulative pregnancy rates and drop-out rates in a German IVF programme: 4102 cycles in 2130 patients. Reprod Biomed Online 2004; 8:600.
- Gameiro S, Boivin J, Peronace L, Verhaak CM. Why do patients discontinue fertility treatment? A systematic review of reasons and predictors of discontinuation in fertility treatment. Hum Reprod Update 2012; 18:652.
- Smeenk JM, Verhaak CM, Stolwijk AM, et al. Reasons for dropout in an in vitro fertilization/intracytoplasmic sperm injection program. Fertil Steril 2004; 81:262.
- Boivin J, Schmidt L. Infertility-related stress in men and women predicts treatment outcome 1 year later. Fertil Steril 2005; 83:1745.
- Boivin J, Takefman JE. Stress level across stages of in vitro fertilization in subsequently pregnant and nonpregnant women. Fertil Steril 1995; 64:802.
- Creac'h-Le Mer, M, Stoleru, S, Cornet, D, Zerah, S, Fermanian, J, Bimbard, S, Spira, A. Women's anxiety is a predictor of the implantation step of in vitro fertilization. Psychosom Med 1999; 61:92.
- Facchinetti F, Matteo ML, Artini GP, et al. An increased vulnerability to stress is associated with a poor outcome of in vitro fertilization-embryo transfer treatment. Fertil Steril 1997; 67:309.
- Gallinelli A, Roncaglia R, Matteo ML, et al. Immunological changes and stress are associated with different implantation rates in patients undergoing in vitro fertilization-embryo transfer. Fertil Steril 2001; 76:85.
- Kee BS, Jung BJ, Lee SH. A study on psychological strain in IVF patients. J Assist Reprod Genet 2000; 17:445.
- Kemeter P. Studies on psychosomatic implications of infertility--effects of emotional stress on fertilization and implantation in in-vitro fertilization. Hum Reprod 1988; 3:341.
- Klonoff-Cohen H, Chu E, Natarajan L, Sieber W. A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer. Fertil Steril 2001; 76:675.
- Klonoff-Cohen H, Natarajan L. The concerns during assisted reproductive technologies (CART) scale and pregnancy outcomes. Fertil Steril 2004; 81:982.
- Merari, D, Feldberg, D, Shitrit, A, Elizur, A, Modan, B. Psychological characteristics of women undergoing in vitro fertilization: a study of treatment outcome. Israel J Obstet Gynecol 1996; 7:65.
- Sanders KA, Bruce NW. Psychosocial stress and treatment outcome following assisted reproductive technology. Hum Reprod 1999; 14:1656.
- Smeenk JM, Verhaak CM, Eugster A, et al. The effect of anxiety and depression on the outcome of in-vitro fertilization. Hum Reprod 2001; 16:1420.
- Stoléru S, Cornet D, Vaugeois P, et al. The influence of psychological factors on the outcome of the fertilization step of in vitro fertilization. J Psychosom Obstet Gynaecol 1997; 18:189.
- Thiering P, Beaurepaire J, Jones M, et al. Mood state as a predictor of treatment outcome after in vitro fertilization/embryo transfer technology (IVF/ET). J Psychosom Res 1993; 37:481.
- Verhaak CM, Smeenk JM, Eugster A, et al. Stress and marital satisfaction among women before and after their first cycle of in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril 2001; 76:525.
- Harlow CR, Fahy UM, Talbot WM, et al. Stress and stress-related hormones during in-vitro fertilization treatment. Hum Reprod 1996; 11:274.
- Csemiczky G, Landgren BM, Collins A. The influence of stress and state anxiety on the outcome of IVF-treatment: psychological and endocrinological assessment of Swedish women entering IVF-treatment. Acta Obstet Gynecol Scand 2000; 79:113.
- Lovely LP, Meyer WR, Ekstrom RD, Golden RN. Effect of stress on pregnancy outcome among women undergoing assisted reproduction procedures. South Med J 2003; 96:548.
- Slade P, Emery J, Lieberman BA. A prospective, longitudinal study of emotions and relationships in in-vitro fertilization treatment. Hum Reprod 1997; 12:183.
- Merari D, Feldberg D, Elizur A, et al. Psychological and hormonal changes in the course of in vitro fertilization. J Assist Reprod Genet 1992; 9:161.
- Salvatore P, Gariboldi S, Offidani A, et al. Psychopathology, personality, and marital relationship in patients undergoing in vitro fertilization procedures. Fertil Steril 2001; 75:1119.
- Boivin J, Griffiths E, Venetis CA. Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies. BMJ 2011; 342:d223.
- Lynch CD, Domar AD. Meta-analysis is not the final word on the effect of emotional distress on fertility treatment outcomes. BMJ 2011.
- Domar AD, Backman KL, Friscia D, Alper MM, Berger BM, Nikolovski J. The relationship between stress and IVF outcome. Presented at the annual meeting of the American Society of Reproductive Medicine, Denver CO, October 2010.
- Boivin J. A review of psychosocial interventions in infertility. Soc Sci Med 2003; 57:2325.
- de Liz TM, Strauss B. Differential efficacy of group and individual/couple psychotherapy with infertile patients. Hum Reprod 2005; 20:1324.
- Domar AD, Seibel MM, Benson H. The mind/body program for infertility: a new behavioral treatment approach for women with infertility. Fertil Steril 1990; 53:246.
- Lemmens GM, Vervaeke M, Enzlin P, et al. Coping with infertility: a body-mind group intervention programme for infertile couples. Hum Reprod 2004; 19:1917.
- Domar AD, Gross J, Rooney K, Boivin J. Exploratory randomized trial on the effect of a brief psychological intervention on emotions, quality of life, discontinuation, and pregnancy rates in in vitro fertilization patients. Fertil Steril 2015; 104:440.
- Hosaka T, Matsubayashi H, Sugiyama Y, et al. Effect of psychiatric group intervention on natural-killer cell activity and pregnancy rate. Gen Hosp Psychiatry 2002; 24:353.
- Domar AD, Moragianni VA, Ryley DA, Urato AC. The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Hum Reprod 2013; 28:160.
- Boivin J, Domar AD, Shapiro DB, et al. Tackling burden in ART: an integrated approach for medical staff. Hum Reprod 2012; 27:941.
- Gameiro S, Boivin J, Domar A. Optimal in vitro fertilization in 2020 should reduce treatment burden and enhance care delivery for patients and staff. Fertil Steril 2013; 100:302.