Motivation and emotion/Book/2015/Stress and infertility

Overview

Don’t ignore infertility. Infertility affects so[how?] many people and this page will describe how stress can interfere with a couples ability to become parents. It is a condition that makes something that should be very private something very public. This page will give you some insight at how stress negatively impacts the reproductive organs and leads to a merry-go-round of grief, stigma, marital and financial strain with no pregnancy leaving the couple consumed by a psychological roller coaster of emotions that acts as a silent barrier to fertility. There is evidence to suggest that stress reduction is an effective therapy for infertile couples.

How does human reproduction work?

Figure 1 - female reproductive system

The Human reproductive system is a complex system in both sexes which involves developing and regulating hormones for sexual reproduction to occour[spelling?] in the human species. For males this involves producing sperm which fertilises an egg and for females this involves an efficient menstrual cycle which produces an egg which is fertilised by the sperm, to create a healthy pregnancy (Esteves et al., 2011).

What is infertility?

Figure 2 - Infertility causes

Infertility is the inability to conceive after twelve months of unprotected sex, a problem recognized in all cultures and societies (Lykeridou, Gourounti, Deltsidou, Loutradis & Vaslamatzis, 2009). Recurrent - miscarriage or inability to carry a baby full-term also can be classed as infertility (Dekea & Sarma, 2010). The presence of infertility is suggested not by a pathological symptoms but by the lacking of a wanted state (Griel, Slauson-Blevins & McQuillan, 2010). Statistics in 2010 show that 10% to 15% of couples experience infertility worldwide (Deka & Samara), with a further 20% experiencing unexplained infertility (Anderson, Nisenblant & Norman, 2010), declining from 25% in 2009 (see Figure 2). Medical testing and intervention is a common path travelled by couples who are unable to conceive naturally which in some cases explain and treat infertility (Lynch, Sundaram, Maisog, Sweeney & Louis, 2014). Even if there is a medical reason which involves one of the partners being treated, it is still a condition which impacts both individuals (Greil, et al., 2010).

What is stress?

Figure 3 - brain (red=hypothalamus)

Stress is an everyday occurrence in life, caused by a stimulus (stressor), stimulating a response in the brain (stress perception), which ignites the supersystems (immune, endocrine, nervous) in the body to reach a (stress response) (Nakamura, Sheps & Clara, 2008). The pathophysiological changes linked with stress response modify the consistent operation of the supersystems and cause the imbalance leading to the impairment of reproduction (Nakamura et al., 2008).

Lynch and colleagues (2014),[grammar?] claim when a stimulus is perceived as stressful, signals are sent to the hypothalamus (see red part figure 3), which then starts the sympathetic adrenomedullary (SAM) pathway; if stress is chronic the SAM stays hyperactive and the Hypothalamic–pituitary–adrenal axis (HPA) becomes activated as well. The hormone and neurotransmitter called nonepinephrine, is discharged into the bloodstream, which ultimately results in an surge in salivary alpha-amylase production by the paratoid gland. Both α-amaylase and cortisol are hormone levels that can be picked up in saliva and urine (Nakamura et al., 2008) making it easy to check stress levels in people (Lynch et al). There are various components of stress such as social stress, infertility related stress, regulation theories, and stigma which will be discussed in relation to infertility.

How does stress impact female fertility?

Figure 4 - HPA Axis Diagram (Brian M Sweis 2012)

Up until now in cross-sectional studies investigating psychological and social reasons are unclear if stress causes infertility or infertility causes stress (Greil et al., 2010). Lynch and colleagues found no significant link between salivary cortisol and the ability to get pregnant. Contrarily, research by Louis and colleagues (2011) analyzing stress biomarkers (salivatory cortisol and α-amylase measurements), during the fertility window of a woman's menstrual cycle demonstrating stress significantly decreased chances of conception, by impacting the sympathetic medullar pathway for women showing higher levels of cortisol. Science has recognised and accepted links between stress and the activation of the HPA, proving the concept that bodily stressors can disturb a woman's menstrual cycle, however it is not as clear if the same applies for psychological stress (Nakamura, Sheps, & Arck, 2008). Stress triggers the hypothalamic-pituitaryadrenal axis, which upregulates corticotrophin-releasing hormone, adrenocorticotrophic hormone, and glucocorticoids (see figure 4). These hormones need to remain balanced in order for the female reproductive system to function optimally, as increased levels of these stress hormones can interfere with the timing of ovulation, shorten the luteal phase, lessen the chance of implantation, or lead to miscarriage (Nakamura et al., 2008). Stress significantly decreases the chances of conception during the fertile period, which affects the sympathetic medullar pathway (Lous et al., 2011).

Click here to watch a video
by Dr Max Gomez
on Stress and Infertility?]

How does stress impact male fertility?

Male infertility could be the cause for 40-60% of cases where a couple is unable to conceive and should be investigated (Esteves et al., 2011). The major causes of male infertility are genetic, varicocele (enlargement of the scrotom), cryptorchidism undescended testicles, testicular failure, infections, genital, immunological disorders and unknown causes (Esteves et al). In the United States studies have found that infertile males experience greater sexual stress, lower satisfaction and greater erectile dysfunction (Smith et al., 2009). Inferior semen quality has been identified in males under stress (Smith et al.), which is known to result in infertility or pregnancy resulting in miscarriage. According to the psychodynamic theory, women that use a sperm doner due to their partners incompetent sperm can cause significant emotional irritation (Lykeridou et al., 2009).

The fleeting periods of impotence and sexual performance anxiety could possibly contribute to the reason for infertility (Anderson et al., 2010; Smith et al., 2008). Studies demonstrate men who are solely to blame for infertility in partnership feel less powerful in their lives, in their ability to meet aspirations (Smith et al). They hold themselves personally accountable for their fertility problems, and negative sexual consequences and emotions (Smith et al). This highlights that because a man is stressed that he can not impregnate his partner, decrementing his fertility. Oxidative Stress can impact both sexes and is a fairly recent discovery in the infertility field, emphasizing that factors such as smoking and alcohol, toxins, poor diet, obesity and importantly stress all contribute to the cause. In males however, this leads to impairment of cells and deoxyribonucleic acid (DNA), causing decreased sperm count and motility along with a surge of abnormal sperm (Anderson et al., 2010).

Stress and assisted reproduction techniques (ART)

Figure 5 - InVitroFertilization

Couples who find they are unable to conceive are often sent for diagnostic testing to find if there is a specific medical reason (Lynch et al., 2014). Medical treatment for infertility however has great medical and psychosocial costs (Anderson et al., 2010). Studies find not only psychological distress related to infertility but also the assisted reproductive technology (ART) (Deka & Sarma, 2010) demonstrating negative short-term effects on mental distress levels. High levels of anxiety and distress have been linked with reduced odds of achieving a successful pregnancy based on ART. In vitro fertilization (IVF) ,[grammar?] has become a popular technique for women who are unable to obtain natural pregnancies. However previous research has found that IVF women do not display greatly more distress than fertile women (Griel, Slauson-Belvins & McQuillan, 2010). Research has found that stress has been found to be harmful for achieving successful human reproduction, and found that couples who enrolled in stress reduction techniques, demonstrated improved IVF or had spontaneous conceptions after adopting a child (Louis et.al., 2011).

Psychological stress has been the most common reason for people to give up on IVF (Anderson et al., 2010). Demanding schedules requiring drugs and invasive procedures cause mood instability (Karajji et al., 2010), which leaders to further relationship stress and conflict. Recent studies in Israel find women exposed to a clown during implantation of an embryo during the IVF process, who were found to be laughing during this process have better success rates, regardless of the limitations such as cross-cultural effects, it initiates further interest in the field of stress and infertility (Friedler et al., 2011). Research also demonstrates that there is a greater chance of miscarriage and lower birth rate for women with greater workloads (Anderson et. al). However, women who achieve a successful IVF pregnancy demonstrate that all negative emotions disappear, proving that stress is linked with fears of failure (Karajji et al., 2010). Reproductive care providers should asses their male patients for sexual, relationship, and further psychosocial problems and suggest appropriate treatment or referral if evident. This mediation may reduce psychosocial stress experienced by men with an infertility diagnosis (Smith et al., 2010).

Psychological stress theories

Infertility related stress

Figure 6 - pregnancy wish

Becoming a parent is a major social role in life and the stress of not being able to achieve this can lead to emotional consequences such as anger, depression, anxiety, feelings of inadequacy, problems with sex life and marital problems (Deka & Sarma, 2010). Significantly poorer fertility outcomes are found in couples who exhibit high psychological stress (Smith et al.,2010). Meta-analyisis examining mental health and pregnancy rate demonstrated psychological interventions improved some patients’ likelihood of becoming pregnant. These interventions signify an appealing treatment possibility, for infertile patients who are not receiving medical treatment. (Hammerili, Znoj & Barth, 2009).

Couples may experience different levels of infertility related stress dependent upon couple and individual resources such as communication, relationship strength prior to infertility and religiosity/spirituality (Ridenour, Yorgason & Peterson, 2009). In the infertile partnership, women often exhibit greater levels of distress than men (Deka & Sarma, 2010). Previous research has found that infertile women who experience pressure of rejection from husbands and family experience greater levels of distress (Greil, Slauson-Blevins & McQuillan, 2009). A couples difficulty in communicating can contribute to infertility related stress, which reinforces the need for cognitive behavioral therapy (CBT) (Martins et al., 2011).

Transactional theory of stress

Lazarus & Folkman (1984) Transactional model of Stress and Coping Pardigm claim social support from a given context, among other factors, can affect a persons thought process of a stressful confrontation and, together with a coping strategy, producing a stress response. Limited studies have investigated this theory, however results by Martin and colleagues found that support from friends and family rather than ones[grammar?] partner specifically can alleviate social stress (2011).

**Stress & coping model by Lazarus & Folkman**
appraisals	factors	infertility
primary appraisals	to determine if something is a harm, loss, threat or challenge to a person	it's important for me to have a babies
secondary appraisals	self-assessment with coping with the possible benefit, harm or threat	what can I do to have babies? Should I get treatment? Should I talk about infertility?
coping	coping and behavioural efforts to manage the benefit, harm or threat	social support will help me come to terms with infertility

For people who believe becoming a parent is a primary appraisal (goal), they are highly likely to experience infertility related stress as opposed to those do not consider it as important, with the secondary appraisal acting as a buffer for psychological distress, however the more upsetting a person is towards not achieving fertility, the coping resources are ineffective dealing with the stressor emphasizing the negative perspective towards infertility (Van der buck et al.,2010). The most widely studied phenomenon is coping strategies applied for patients seeking fertility treatment. A large study with participants undergoing IVF found that men and women who have the greatest level of avoidance coping display a high level of infertility related stress compared to those who adopted a confrontational, compliant manner and sought social support (Smith et al.,2009). |}

Self-regulation theory

Kraaji and colleagues (2010), suggested the stress-coping model should be combined with the self-regulation theory in order to create a more comprehensible framework as factors from these models demonstrate to be significant predictors of depressive and anxiety symptoms.

**Four components of self-regulation by Baumeister and colleagues, 2007**
Standards	of desirable behaviour
Motivation	to meet standards
Monitoring	of situations and thoughts that precede breaking standards.
Willpower	internal strength to control urges

This [which?] theory suggests that people aim to achieve personal goals but constantly focus on what they do not have. By readjusting goals in life, it can help improve well-being, so people can live a happy life without focusing on infertility (Kraaji et al). By targeting negative emotions, support systems can be put in place to decrease stress levels for infertile couples and improve chances of a successful pregnancy. How a person copes to infertility can determine if they remain stressed or can adapt these multiple components to achieve stress reduction.

Self-discrepancy theory

The Self-discrepancy theory which verifies the difficulty of couple and self perceptions, highlighting that self-perceptions can be affected by diverse hopes by one’s self and partner, including when couples do not feel the same about infertility (Ridenour et al., 2009). The discrepancy between the selves causes negative emotions, and causes stress which leads to the issue that stress decreases fertility, (Ridenour et al.), which CBT may help fix.

**Self-discrepancy theory (Higgins 1987)**
actual self	ideal self	ought self
persons[grammar?] own attributes	presence or absence of positive outcomes	presence or absence of negative outcomes
I am not a parent	I want to be a parent	Society wants me to be a parent
we are not parents	my partner wants to be a parent	I have let my partner down
sad	disappointed/sad	fear, anxiety, depression we are stigmatized and judged for not being parents

It is imperative that when person is to blame for infertility, the counsellor should examine and change attribution errors, such as "I'm a failure" (internal attribution) to "this shock of fate is our challenge" (external attribution), and the blame in the partnership should be amended to "recognizing my part of responsibility in this common problem" (Van den Broecka et al., 2010), along with goal readjustment, creating coping strategies if children do not become a reality.

Social aspects of infertility

Social roles

Figure 7 - ideal family

Women say they want a baby more than men do, and the female role and social pressure is evident that women are supposed to have babies (Deka & Sarma, 2010). In keeping with masculine gender types, husbands tend to hide their emotions, to comply with societies expectations of being strong males supporting their partners and hiding their grief, often withdrawing to protect their partner from seeing their pain (Van de Broecka et al., 2010). Not having babies can create feelings of generativity, the loss of a potential family to contribute to the world (Ridenour et al., 2009). If a couples siblings and friends are all participating in the developmental stage in life of having children, social support can be a double edged sword and rather than be helpful, this also creates conflict and causes stress (Ridenour et al). The socio-cultural context of an individual also impacts on how fertility is handled, factors also depend on how traditional and male dominated a society is, with men often feeling as though they are being mocked and their masculinity diminished due to their infertility (Greil et al., 2010).

Stigma

"My maternal instinct is being denied. It's a slap in the face. I feel like I'm isolated in a prison; I have no one who understands how horrible this is. People don't know what to say to you . . . I think I'm alternatively dealt with as either someone who has died or that I have a handicap. And I think people approach it like that because they don't understand death; they don't understand handicaps; and they don't understand infertility." – Cathy stigma - the hidden burden of infertility Whiteford & Gonzalez, 1995.

Expanding on Goffman's theory of Stigma, in the case of infertility, this refers to people not being considered normal for having a baby (Goffman, 1963). For women who don't know what the cause of the partnerships infertility it, prevents people from being placed in a specific medical category (Whiteford & Gonzalez, 1995). This generates feelings of guilt, shame, failure, and negative feelings causing disturbance to individual. Stigma is also variable based on socio-cultural context of women from low developed countries, for example India where fertility is integral to marriage and stigmatisation is encountered to a much greater degree than in developed countries where infertility can be considered voluntary (Griel et al., 2010). Infertile males demonstrate poor self-esteem and greater feelings of stigma and loss compared to males of infertile couples who are not the cause of the problem (Smith et al., 2009).

Figure 8 - depressed

Stress and Depression

Depression may directly cause infertility as the physiology causes elevated prolactin levels, the upset of the HPA axis thyroid dysfunction and problems with ovulation (Deka & Sarma, 2010). Stress and depression have been proven to impair reproductive function which questions which of the two contributes to infertility (Deka & Sarma). Women often show symptoms of depression at the same rate of people with cancer or heart disease (Deka & Sarma). Studies looking into depression and infertility found a significant link between negative self-judgment and high external and internal levels of shame, especially when embarking on medical treatment (Galhardo, Pinto-Gouveia, Cunha &. Matos, 2011), suggesting the need for intervention makes people feel more depressed.

Studies found that 81.3% infertile participants who were depressed claimed the main reason was due to negative comments from family members regarding their infertility (Ramezanzadeh et al., 2011). Furthermore women may think their partner is not affected by infertility, but this is not the case, males may often be just as depressed and simply withdraw rather than want to talk about it like females (Van de Broecka et al).

How to manage stress

Cognitive behavioural therapy (CBT)

"Ellen and Tom, a 38-year-old couple, were never much interested in having children until the day, 2 years ago, that Tom had a vasectomy. Though they had made this decision together after careful consideration of their future together and their wish for a child, Ellen described ‘feeling’ that it was the wrong decision, moments after the procedure had been finalized. They consulted the fertility centre in distress and wanted to explore if assisted conception was still a possibility. The fertility team suggested an ICSI-treatment and though Ellen was relieved to find out that there was still an option available to them, she was left confused and immobilized by fear to make any kind of decision regarding fertility treatment. After weeks of agonizing, a careful exploration in infertility counselling of their motives for wanting children, of their coping resources and communication, the couple finally decided to go ahead with ICSI-treatment. Ellen described feelings of hope, sometimes still layered with strong feelings of guilt on the decision to sterilize her husband while Tom calmly accepted their situation. After four unsuccessful ICSI-treatments, Ellen asked to speak with the infertility counsellor of the fertility centre to deal with the overwhelming feelings of ending treatment and making sense of all her doubts and efforts to conceive in the last few years. Furthermore, she wanted help in making decisions about her future, possibly without children." Van den Broecka et al., 2010.

Simply by talking about infertility with a psychologist, especially the cause is unknown, can surface emotions such as guilt, stress, psychosomatic complaints, or even incompatibility in the partnership (Van den Broecka et al., 2010; Ramezanzadeh et al., 2011). It can also help combat self-regulation and self-discrepancy issues as previously discussed. Ramezanzadeh and colleagues found from randomised clinical trials that psychological and psychiatric intervention for infertile patients increased pregnancy rate for couples experiencing intervention by 47.1% compared to 7.1% in control group who did not have therapy (2011), emphasising that when stress levels drop pregnancy rates can rise.

Stress management for infertility

Talk about it - get social support or CBT
Don't play the blame game
Do an activity to take your mind off things
Think positive thoughts
Laugh out loud
Have sex for fun
Do relaxation exercises or calming activities like yoga or meditation

Conclusions

References

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