Infertility is a common and
worrisome problem that encounters many couples nowadays. It has been defined
as the inability to conceive in spite of regular normal sexual intercourse
for more than one year.
Infertility could be either functional i.e. no cause identified in either
partner or organic meaning an identifiable cause is present.
Stress plays a major role in causing infertility through the physical and
psychological changes that are associated with it leading to a vicious
endless circle.
Stress is defined as any event that a person perceives as threatening or
harmful.
Stress affects brain/ hypothalamic function thereby affecting hormones
produced by the pituitary gland and ovaries (hypothalamic- pituitary-
gonadal axis ( HPG axis) leading to altered ovulatory function and delayed
follicle maturation.
Stress causes insomnia and sleep deprivation which leads to 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.
Stress hormones and the hypothalamic pituitary adrenal axis (HPA) interact
with hormones which influence fertility like GnRH, prolactin, LH, FSH and
with the hormones that may interfere with fertility like cortisol, melatonin
and endogenous opioids.
Also it has been found that similar neurotransmitters and nuclei within the
hypothalamus control both stress and reproduction.
Also through neuronal transmitters, stress leads to spasm of the fallopian
tubes and the uterus interfering with the implantation of the fertilized
ovum.
Also stress affects the immune system and as such affects 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.
Whereas the 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 inconvenience of daily injections and blood samples
- 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 and 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.
- Woman with a previous pregnancy history has a higher cumulative
probability of pregnancy.
- Woman with a full time employment has 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.
- Women who are anxious have a lower pregnancy probability during the later
treatment cycles.
Highly trait – anxious females are less likely to achieve 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 and so develop 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.
Anxiety and high anticipatory cortisol levels prior to oocyte retrieval and
embryo transfer lead to a lower pregnancy rate as do depression, high active
coping and high expression of emotion.
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 sulphydryl 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.
Reasons for stress treatment before fertility treatment:
1- Infertility causes stress in the infertile couple.
2- Infertility treatments causes stress in the couple involved.
3- Stress may be a primary or secondary cause of infertility.
Short term goals 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.
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.
