Stress and Infertility | How does stress affect fertility | Dr N Layyous

Stress and Infertility, Interaction between stress and fertility And Stress reduction strategies

Infertility is a common and worrisome problem faced by many couples nowadays. Infertility is the inability to conceive in spite of regular normal sexual intercourse for more than one year.

Infertility could be present without any cause identified in the female or the male (functional infertility), or organic meaning an identifiable cause is present.

Stress has an important role in infertility through the physical and psychological changes that are associated with it leading to a vicious endless circle.

Any condition that a person considers as threatening or harmful is known as Stress.

Stress affects pituitary gland hormones and ovaries (hypothalamic- pituitary- gonadal axis / HPG axis) through affecting brain/ hypothalamic function leading to altered ovulatory function and delayed follicle maturation.

Stress leads to sleep on deprivation (Insomnia) causing changes in the daily rhythm of many hormones connected to reproduction.

Stress elevates prolactin level and cortisol and interferes with the regulation of LH thereby affecting ovulation.

The interaction between stress hormones (cortisol, melatonin and endogenous opioids) and the hypothalamic pituitary adrenal axis (HPA) hormones (GnRH, prolactin, LH, FSH) will affect the fertility.

It has been found that similar neurotransmitters and nuclei within the hypothalamus control both stress and reproduction.

Through neuronal transmitters, stress leads to spasm of the fallopian tubes and the uterus interfering with the implantation of the fertilized ovum.

Stress affects the immune system and implantation. Activated T-cells in peripheral blood are associated with reduced implantation rate in IVF cycles.

Infertile couples have greater susceptibility to depression and anxiety.

Anxiety is either trait or state:

• Trait anxiety is the tendency to respond to stressful situations with elevated exaggerated responses.
• State anxiety is the anxiety related to a specific cause, mainly the procedures and drugs used to treat infertility.

Females with functional infertility have a greater tendency towards anger repression and anxiety, while females with organic infertility have a tendency towards depression.

It was found that women trying to achieve pregnancy have stress levels similar to those having cancer or HIV and heart disease.

Infertile couples have to deal with many stressors related to the IVF program, mainly:

• Their infertility
• The daily injections and blood samples that may be inconvenient.
• The perception of low success rates
• Waiting for the results
• The financial pressures

Stress factors related to low cumulative pregnancy rates in IVF cycles:

• Previous pregnancy history.
• Trait anxiety and hostile mood state.
• Full time employment.

Factors affecting ART outcome include:

• Patient’s age
• Infertility category (male factor/ female factor/ combined factor or idiopathic infertility)
• Infertility duration
• Response to ovarian stimulation, stimulation protocol used and number of ova retrieved and embryos transferred.

An individuals’ ability to deal with stress is conditioned by past experience and current social status.

Life style factors could influence the woman’s ability to cope with infertility treatment.

Women with previous pregnancy history have a higher cumulative probability of pregnancy.

Those with a full-time employment have a lower pregnancy probability for the first five treatment cycles.

Such women have the stress of difficulty arranging leave from work, the financial burden, added time pressure, the worry and embarrassment over work colleagues’ knowledge of her personal issues and the added discomfort of stimulatory drugs.

Women who are hostile have a lower success rate for all treatment cycles.

Hostile mood is associated with decreased pregnancy probability after successive treatment cycles, and it could be that these females are less responsive to treatment or that the treatment itself is compromised by the hostile attitude.

Anxious women have less chance to get pregnant during the later treatment cycles.

They fail achieving pregnancy through ART because they are less able to cope with stressors of treatment; this is observed only in the initial treatment cycles but later cycles showed increased pregnancy rates. This could be explained by the fact that such females deal with their anxiety by defense mechanisms like repression and denial developing a different psycho endocrine stress response which positively affects treatment outcome.

Female reproductive tract has catecholamine receptors thus catecholamine in stress affects fertility by interfering with the transport of gametes through the tubes and by altering uterine blood flow.

In addition to depression, high active coping and high expression of emotion, being anxious with high cortisol levels prior to oocyte retrieval and embryo transfer lead to a lower pregnancy rate.

Treatment of chronic /trait stress anxiety is much more important than treatment of procedural/state anxiety related to fertility treatment.

Stress affects semen quality and sperm motility by the loss of glutathione and free sulfhydryl content of seminal plasma or through the inhibition of conversion of androstendione to testosterone in Leydig cells on account of higher adrenocorticotrophic hormone and cortisol levels.

Why stress should be treated before fertility treatment:

1. Infertility causes stress in the infertile couple.
2. Infertility treatments cause stress in the couple involved.
3. Stress could be a cause on infertility (either primary or secondary) .

Helpful advices for male and female fertility patients:

1. Reduction of feelings of helplessness through coping with infertility.
2. Changes in sexual behavior.
3. Modifications of negative cognitions as to infertility
4. Overcoming deficiencies in knowledge about infertility.
5. Improving marital communication skills.

Relation between stress and fertility could be through:

1. Stressful event
2. Psychological factors (coping, habituation)
3. Stress
4. Autonomic system
5. Behavioral activation
6. Para ventricular nucleus
7. CRH
8. Sympathetic system
9. Adrenal medulla
10. Adrenaline
11. Metabolic cardiovascular activation
12. ACTH
13. Adrenal cortex
14. Cortisol
15. Hypothalamic pituitary adrenal activation
16. Para ventricular nucleus
17. Vasopressin
18. B-endorphin
19. GnRH Pulse
20. LH, FSH
21. Ovary
22. Oestraodiol/ progesterone
23. Hypothalamic pituitary gonadotrophic inhibition.

Stress reduction strategies:

1. Regular physical exercises to release physical and emotional tension.
2. Avoid excessive intake of caffeine and other stimulants.
3. Learn stress reduction techniques like yoga, massage therapy.
4. Get emotional support.
5. Psychotherapy

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist