Stress and Infertility: How Stress Can Affect Your Fertility Journey

In short: Stress affects fertility because it raises cortisol and prolactin, which can disturb ovulation and affect sperm quality and implantation. Couples with delayed conception are more prone to anxiety and depression, creating a vicious circle. Exercise, less caffeine, relaxation and yoga, and psychological support when needed help to break it.

Infertility is a common and worrisome problem faced by many couples nowadays. Infertility is the inability to conceive despite regular, unprotected intercourse for more than one year.

Infertility can be present without any identifiable cause in the female or the male (functional infertility), or it can be organic, meaning a specific cause has been found.

Stress plays an important role in infertility through the physical and psychological changes associated with it, often creating a vicious, ongoing cycle.

Any condition that a person perceives as threatening or harmful is known as stress.

Stress affects pituitary gland hormones and the ovaries (the hypothalamic-pituitary-gonadal axis, or HPG axis) by influencing brain and hypothalamic function, which can alter ovulatory function and delay follicle maturation.

Stress can also lead to sleep deprivation (insomnia), causing changes in the daily rhythm of many hormones connected to reproduction.

Stress raises prolactin and cortisol levels and interferes with the regulation of LH, thereby affecting ovulation.

The interaction between stress hormones (cortisol, melatonin and endogenous opioids) and reproductive hormones of the hypothalamic-pituitary-gonadal (HPG) axis (GnRH, prolactin, LH, FSH) can affect fertility.

Research suggests that similar neurotransmitters and nuclei within the hypothalamus control both stress and reproduction.

Some researchers have suggested that stress-related nerve signals might affect the movement of the fallopian tubes and uterus, although this has not been proven to affect implantation in humans.

Stress can also affect the immune system and implantation. Activated T-cells in peripheral blood have been associated with reduced implantation rates in IVF cycles.

Infertile couples often have a 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 anxiety related to a specific cause, mainly the procedures and medications used to treat infertility.

Women with functional infertility tend to have a greater tendency towards anger repression and anxiety, while women with organic infertility tend to have a tendency towards depression.

Some studies have found that women trying to achieve pregnancy report stress levels similar to those with cancer, HIV, or heart disease.

Infertile couples often 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 lower 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.

A person’s ability to deal with stress is shaped by past experience and current social circumstances.

Lifestyle factors can influence a woman’s ability to cope with infertility treatment.

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

Those in full-time employment may have a somewhat lower pregnancy probability during the first five treatment cycles.

Such women often carry the added stress of arranging leave from work, financial burden, extra time pressure, worry or embarrassment over colleagues knowing about their personal situation, and the discomfort of stimulation medications.

Women experiencing hostile mood states have shown a lower success rate across treatment cycles.

Hostile mood is associated with decreased pregnancy probability after successive treatment cycles — this may relate to reduced responsiveness to treatment, or to how the treatment itself is affected by a hostile emotional state.

Anxious women may have less chance of becoming pregnant during later treatment cycles.

They may find it harder to achieve pregnancy through ART because they are less able to cope with the stressors of treatment; interestingly, this pattern is mostly seen in the initial treatment cycles, while later cycles show increased pregnancy rates. This may be explained by the fact that such women adapt over time using defense mechanisms like repression and denial, developing a different psycho-endocrine stress response that can positively affect treatment outcomes.

The female reproductive tract has catecholamine receptors, so catecholamines released during stress can affect fertility by interfering with the transport of eggs through the tubes and by altering uterine blood flow.

Along with depression, high active coping, and high emotional expression, being anxious with high cortisol levels prior to egg retrieval and embryo transfer has been linked to a lower pregnancy rate.

However, it is reassuring to know that large reviews of many studies have found that ordinary stress and anxiety during treatment do not reduce the chance of IVF success; couples should not blame themselves if a cycle fails, and emotional support is offered mainly to make the journey easier and help couples continue treatment.

Treating chronic or trait-related stress and anxiety is generally considered more important than addressing procedural or state anxiety linked specifically to fertility treatment.

Stress can also affect semen quality and sperm motility, through the loss of glutathione and free sulfhydryl content in seminal plasma, or through inhibition of the conversion of androstenedione to testosterone in Leydig cells due to higher adrenocorticotrophic hormone and cortisol levels.

Why stress should be addressed before fertility treatment:

• Infertility causes stress in the infertile couple.
• Infertility treatments cause stress in the couple involved.
• Stress could be a contributing cause of infertility (either primary or secondary).

Helpful advice for male and female fertility patients:

• Reduction of feelings of helplessness through coping with infertility.
• Changes in sexual behavior.
• Modifications of negative thoughts about infertility.
• Overcoming gaps in knowledge about infertility.
• Improving marital communication skills.

The relationship between stress and fertility can be understood through this pathway:

• Stressful event
• Psychological factors (coping, habituation)
• Stress
• Autonomic system
• Behavioral activation
• Para ventricular nucleus
• CRH
• Sympathetic system
• Adrenal medulla
• Adrenaline
• Metabolic cardiovascular activation
• ACTH
• Adrenal cortex
• Cortisol
• Hypothalamic pituitary adrenal activation
• Para ventricular nucleus
• Vasopressin
• B-endorphin
• GnRH Pulse
• LH, FSH
• Ovary
• Oestraodiol/ progesterone
• Hypothalamic pituitary gonadotrophic inhibition.

Stress reduction strategies that may help:

• Regular physical exercise to release physical and emotional tension.
• Limiting excessive intake of caffeine and other stimulants.
• Learning stress reduction techniques like yoga or massage therapy.
• Seeking emotional support from loved ones or support groups.
• Psychotherapy, when needed.

If you and your partner are navigating the stress of infertility, know that you are not alone — support and guidance are available. Dr Najeeb Layyous and his clinical team welcome the opportunity to discuss your individual situation and answer any questions you may have about your fertility journey.

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

Consultant Obstetrician, Gynecologist and Infertility Specialist