Psychological Impact of Infertility
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC)
The psychological stress of infertility and its managements is widely acknowledged; and it actually affects pregnancy rates. The relationship between stress and infertility has been recognized since biblical times. Recent research indicates that distress may indeed influence the outcome of infertility treatments, and that psychological interventions are associated with increased pregnancy rates. Most of the women undergoing infertility treatment have some type of mental health problem, mostly anxiety and depression. Some studies show the least distressed women during in-vitro fertilization (IVF) egg retrieval are nearly twice likely to become pregnant and give birth than women who were distressed. Not becoming pregnant when you want to, coping with a diagnosis of infertility, and undergoing fertility treatments is stressful. Obtaining the support and resources to cope with this difficult situation can help you feel better and may even improve the chance of success.
The purpose of this document is to understand infertility and the mind/body connection. Infertility affects every aspect of women's lives. With infertility treatment, some women become pregnant after one or two tries, but others need many attempts before they are successful. A few never be able to become pregnant or have live and healthy baby. This chapter reviews the psychological impacts of infertility and helps to guide the various coping mechanism. Many institutions have developed mind/body program for infertility, and helps many to reduce the distress of coping with infertility. Although attending the sessions is no guarantee of pregnancy, women who have participated generally feel better.
Understanding Psychological Impact:
It is not surprising that infertility patients experience psychological symptoms after unsuccessful treatment; it is troubling that the majority of patients also report such symptoms prior to treatment. If psychological distress can interfere with the success of treatment and most patients are affected, then the impact of distress can not be overestimated. Women who experience infertility report increased levels of distress, as this condition has an impact on virtually every aspect of their lives; i.e., partner relationships, sex life, employment, relationships with fertile family members and friends, financial stability and even religious beliefs. In addition, many infertile women are blamed by others for their condition. A proliferation in assisted reproductive technologies (ARTs) has dramatically increased the number of diagnostic and therapeutic options available to patient and her partner. Healthcare costs also have increased as a byproduct of this technologic expansion. Thus, not only the physician but also the patient may face the daunting task of selecting from among myriad highly technologic and expensive healthcare choices.
The maternal-fetal relationship is unique in medicine because of the complete physiologic dependence of the fetus on the pregnant woman and because both the fetus and the woman are regarded as patients of the physician. The level of distress in infertility patients tends to increase as treatment intensifies, so it is possible that the 40% or higher patients undergoing in vitro fertilization (IVF) will have anxiety or depression (1). Because IVF is the most invasive and intensive form of infertility treatment, patient distress is extremely common. In fact, most IVF patients report that treatment is more of psychological than a physical stressor. Many IVF patients report depressive symptoms prior to initiation, which likely reflects the impact of prior unsuccessful forms of treatment. The "gold standard" in psychological evaluation is a structured personal interview with a trained mental health professional.
Psychological difficulties of infertile patients are complex and influenced by a number of factors, such as gender differences, causes and length of infertility, specific stage of investigation and treatment procedures at which couples are studied, or the coping strategies used to deal with their infertility problem. Moreover, a recent study revealed significantly higher levels of anxiety in mother who had conceived by IVF about the survival and normality of their newborn babies, about damage to their babies during childbirth and about separation from their babies after birth as compared with matched control. The most commonly investigated psychological problems at the time of infertility treatment procedures, especially at the time of retrieval and embryo transfer during IVF are anxiety and depression (2). The overall percentage of psychological problems in infertile couples ranges between 25-60%. Different factors including approach-coping strategies and stable emotional, marital and psychological relationships at the time of embarking upon IVF have been shown to play an important role in predicting adjustment to infertility and patient satisfaction with fertility treatment. On the other hand, psychological counseling and supportive psychotherapy have been very effective in reducing high levels of anxiety in couples undergoing different treatment procedures.
The degree to which psychogenic or lifestyle factors play a role in infertility is controversial. Couples should not be told their infertility is related to stress unless there is documented evidence of sperm dysfunction, ovulatory dysfunction, or sexual dysfunction. However, because lifestyle variables, such as tobacco exposure, alcohol consumption, drug use, excessive exercise, weight loss or gain and psychogenic stress, can compromise reproduction, it is worth reviewing lifestyle factors with the couple and informing them of the potential adverse consequences of these factors in a supportive manner.
Distress and Outcome:
Since a link has been suggested between anxiety-depression dynamics involving the hypothalamic-pituitary-adrenal axis (e.g., anxiety-induced hyperprolactinemia) and failure to conceive, psychological interventions aimed at reducing anxiety might increase the likelihood of conception. Psychological services in an infertility clinic help to identify at an early stage those individuals who are more likely to be vulnerable. This would enable psychological interventions to be targeted towards those in greater need. A higher prevalence of psychiatric morbidity among patients could be expected. Various studies on stress and IVF identify the theory that distress adversely affects pregnancy rates. The studies found a statistically significant relationship between distress and IVF outcome suggest, baseline depression is associated with lower pregnancy rate, marital harmony is predictive of fertilization, stress led to higher T cell activation and anxiety on day of retrieval has significant predictor of failure of implantation (3) (4). These results indicate that the baseline level of stress is significantly related to numerous biologic end-points, including number of oocytes retrieved and fertilized, pregnancy, live-birth rate, and birth weight. The stress level on the day of the procedure is significantly related to the number of oocytes retrieved and fertilized and the strength of the correlation between distress and outcome is profound. In these studies it is noted that the women who expressed the least distress were 93% more likely to give birth than those who expressed the most distress and counseling, support, and education to decrease stress levels during baseline period is strongly recommended.
A patient's psychological state prior to treatment may predict dropout behavior. Because infertility patients are highly motivated, factors affecting the voluntary dropout rate (other than cost) have been under-explored until recently. It is widely presumed that patients discontinue therapy either because the physician instructs them to do so, or because they have exhausted their funds. However, active censoring by the physician or medical team is rare. Research also suggests that cost is not the determinant of many IVF patients. The most common reasons (66%) for terminating treatment are emotional. Pretreatment levels of depression are highly predictive of patient dropout behavior after only one cycle. Thus, the majority of insurance-covered patients voluntarily terminate prior to completing the allotted cycles. Not only are anxious and depressed patients more likely to discontinue treatment after only one cycle, but patients who prematurely terminate treatment cite psychological burden as the primary reason. Prematurely discontinuing treatment severely limits a couple's chance of conception. While the potential impact of psychological intervention on treatment termination decisions is unknown, it is plausible to assume that patients who receive support services have lower discontinuation rates.
Patients undergoing ovulation induction with medications, especially with injectable gonadotropins should be informed about possible risks and benefits before receiving any medication. The risks of multiple-gestation, ovarian hyperstimulation, genetic defects, incidence of miscarriage and premature delivery are real. Before beginning ovulation induction patient and her partner should be counseled about the option of multifetal reduction to increase likelihood of delivering viable infants if a high-order multiple conception does occur. Diagnostic uncertainty and a seemingly endless array of treatment approaches can easily provoke tension, indecision, and disagreement in the couple with infertility. A sense of psychological and physical invasion is common. Infertile men and women may feel angry, damaged or guilty. The potential for husbands and wives to respond differently to the experience of infertility and its treatments, particularly any of the assisted reproductive technologies, can overwhelm customary adaptation patterns and lead to psychological decompensation.
Almost all patients who undergo infertility treatment experience a loss of privacy as they cope with physicians, nurses, insurance carriers, psychologists, hospitals, and laboratory personnel. Ultimately, infertility presents the specter of a psychological death. Thus, it is not surprising that patients with infertility report anguish and distress. Reproductive technologies have made it possible to separate biological and social parenthood. A further concern of infertile couples is whether assisted reproductive techniques increase the risk of neurodevelopmental or other abnormalities, including childhood cancers. The uncertainty as to whether there is a link between infertility treatments and poor health outcomes in the mother or child only serves to exacerbate anxiety and guilt. Infertility is a far more devastating disorder than most lay persons and physicians realize.
Mind/ Body Intervention:
A typical psychological profile for infertile couples can not identify using standard psychometric rating methods. For some couples, the infertility crisis can be seen as a cumulative trauma, which indicates that couples have a marked need for infertility counseling. The impact of infertility on psychological functions is a complex matter influenced by a number of variables, such as the investigative procedures involved, the duration of infertility, the diagnosis which is made, or the quality of the couple's relationship. Psychogenic variables can interfere with coital frequency and reduce the likelihood of conception and can suppress the central hypothalamic-pituitary drive to the gonad and compromise the quality and quantity of gametes produced. Treatments of infertility are expensive and consume much time and energy.
Ideally, psychological support services should be available for all individuals and couples undergoing active evaluation and intervention for infertility. Since 1987, mind/body infertility programs have been established throughout the United States and in other countries (5). They generally include training in relaxation, stress management, and coping skills, plus group support. Programs range from 5 to 10 sessions, and most include partners. Sessions are led by mental health professionals, nurses, or both. Participants report significant decrease in all assessed psychological and physical symptoms, including depression, anxiety, hostility, fatigue, headaches, insomnia, and abdominal pain. Approximately 45% of patients conceive within 6 months of program completion. In many studies significant differences in birth rates; 55% in the mind/body group, 54% in the support group, and 20% in the control group, has been reported. There are also significant differences in psychological status, with the mind/body patients reporting improvement, the support group reporting no change, and the control group reporting an increase in psychological symptoms.
The mechanism whereby such interventions increase pregnancy rates is unknown. However, in a randomized, prospective study that assessed natural killer cell activity in group of 74 infertile women, 50% were randomized to a five-session mind/body group and 50% served as routine care controls. Psychological distress and natural killer cell activity decreased significantly in the intervention group, while the control group had no change. In addition, 38% of the intervention subjects conceived during the 1-year follow-up (P< .03) compared with only 13.5% of the controls (6).
Dysfunctional attitudes and disharmony constantly threaten the infertile person. Prophylactic evaluation is preferred in all treatment settings, but specialized services may not always be immediately available. Stress can compromise gametogenesis and libido, and infertility treatment alone can be stressful enough to activate the central mechanisms that compromise reproductive function. Psychological support is intended to lessen the likelihood of this effect and reverse it if it is already occurring.
Perhaps it is time to consider psychologically screening all prospective infertility patients. Infertile women report elevated levels of distress, which may in turn contribute to their infertility. If a patient is found to be psychologically healthy, she could undergo therapy knowing that her psychological state should have little or no impact on the outcome. Highly distressed patients have lower pregnancy rates, and are more likely to terminate treatment. However, a patient who is determined to be highly distressed could be counseled that receiving support services is likely to facilitate treatment, and may increase the chance of pregnancy and decrease the risk of premature termination. Current psychological interventions for infertility patients include psychotherapy, support groups, and mind/body approaches. Specifically, mind/body approaches show the greatest promise in symptom improvement, and also appear to promote pregnancy. Because mind/body programs are easy to administer and utilize a group format, they are highly cost-effective as well. They generally include training in relaxation, stress management, and coping skills, plus group support. Patients can put together these programs themselves, if the mind/body programs are not available at their healthcare facilities or it is financially not feasible. Teach yourself yoga, meditation, or relaxation exercises through books or videotapes available at libraries, or through low-cost classes at hospitals, health departments, or community centers.
Professionals in the field of assisted reproductive technologies (ARTs) should be aware of the importance of psychological factors in consumers of infertility treatment, the need to make available a rapid and reliable screening instrument for identifying patients at greater demand for psychological support, and the inclusion of counseling and supportive psychotherapy in the general therapeutic framework of infertility. Psychological counseling should be offered at any stage of infertility treatment, and not only when treatment fails. It might be useful to provide written information on common emotional / psychological reactions to infertility, and information about coping with this condition. For those couples whose coping resources are inadequate and/or depleted, counselors must make efforts to contact such patients individually to discuss the potential benefits of using counseling and/or participating in support groups.
- Chen TH, Chang SP, Tsai CF et al. Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod. 2004;19(10):2313-2318
- 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(3):525-531
- Csemiczky G, Landrgren 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(2):113-118
- Lovely LP, Meyer WR, Ekstrom RD, et al. Effect of stress on pregnancy outcome among women undergoing assisted reproduction procedures. South Med J. 2003;96(6):548-551
- Lemmens GM, Vervaeke M, Enzlin P, et al. Coping with infertility: a body-mind group intervention program for infertile couples. Hum Reprod. 2004;19(8):1917-1923
- 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(5):335-356
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