Mental health and fertility

a woman holding her confused thoughts in her hands, the title "mental health awareness" and MEDIPASS logo

In the US, May is designated as the mental health awareness month, and for the UK this week 9-15/05 is also mental health awareness week. What a great opportunity to shed some light on if and how our mind’s health affects fertility.

Let’s start with the most common misconception. Infertility can cause stress, but stress does not necessarily cause infertility. When you struggle with infertility, most of the time you struggle in silence, alone, and feelings of shame, guilt, fear and sadness arise. These negative feelings may lead to varying degrees of depression, anxiety, distress, and an overall poor quality of life. 

Some early studies concluded that infertile women did not report any significant differences in symptoms of anxiety and depression than fertile women. However, based on a 2004 study, a total of 122 women were interviewed prior to their first infertility clinic visit with striking results; 40% of women were diagnosed as having anxiety, depression, or both. Subsequent research has supported these findings. Volgsten and colleagues reported a 31% prevalence of psychiatric symptoms, the most common of which was major depression. In a large Danish study of 42,000 women who underwent ART treatment and were screened for depression prior to treatment, 35% screened positive. In another recent study of 174 women undergoing infertility treatment, 39% met the criteria for major depressive disorder. In one of the largest studies to date, 7,352 women and 274 men were assessed in infertility clinics in northern California. It was determined that 56% of the women and 32% of the men reported significant symptoms of depression and 76% of the women and 61% of the men reported significant symptoms of anxiety. Not surprisingly, recent research documents show that infertility patients consistently report significantly more symptoms of anxiety and depression than fertile individuals. Finally, in a recent concerning study on suicidality in 106 women with infertility, 9.4% of the women reported having suicidal thoughts or attempts.
The medications used to treat infertility -including clomiphene, leuprolide, and gonadotropins, are associated with psychological symptoms such as anxiety, depression, and irritability. Thus, when assessing symptoms of women mid-treatment, it is difficult to differentiate between the psychological impact of infertility versus the side effects of the medication. Studies which included measures of these symptoms prior to beginning medication, or after going off it, may be more accurate than those done only on women as they cycle.

What impact do psychological factors have on pregnancy rates?
It’s a question that has divided the scientific community. There have been dozens of studies which have investigated the relationship between psychological symptoms prior to and during ART cycles and subsequent pregnancy rates, with conflicting results. Some have shown that the more distressed the women prior to and during treatment, the lower the pregnancy rates, while other studies have not. There are several explanations about the variety of findings. In a study of fertility in 339 women in the UK trying to conceive, self-reported symptoms of depression, anxiety, and stress were not significantly associated with time to pregnancy. However, in a similar study on 501 women in the US, levels of salivary α-amylase, a biomarker of stress, were significantly correlated with time to pregnancy. Women in the highest quartile of α-amylase levels at baseline were twice as likely to subsequently experience infertility. Finally, in a more recent study in 135 IVF patients, cortisol was measured through samplings of hair, which measures levels from the prior 3 to 6 months and they were significantly correlated to pregnancy rates. These findings match what most infertility patients believe; that psychological symptoms have a negative impact on fertility. 

Are miscarriages caused by psychological disorders and in what percentage?
According to the American College of Obstetricians and Gynecologists (ACOG), studies reveal that anywhere from 10% to 25% of all clinically recognized pregnancies will end in miscarriage. Pregnancy loss occurs for many reasons, one of the leading being the chromosomal abnormality of the fetus. Patients who experience pregnancy loss have met the criteria for post-traumatic stress disorder; the majority of women report suffering from anxiety and depression. And that may have a negative effect on a later try naturally or via ART. That is why many patients undergoing ART are taking advantage of a relatively new scientific advancement known as preimplantation genetic screening (PGS). PGS allows scientists to identify chromosomal defects through the biopsy of a blastocyst and thus can allow the transfer of only normal blastocysts. Patients who take advantage of this testing may increase their chance of pregnancy by eliminating the embryos which would likely result in a miscarriage. PGS is gaining in popularity, with some ART centers only transferring one PGS normal blastocyst per cycle.

Side effects from medication
The synthetic estrogen clomiphene citrate (Clomid, Serophene), which is often prescribed to improve ovulation and increase sperm production, can trigger anxiety, interruptions of sleep and irritability in women. Other medications for infertility may cause issues such as depression, mania, irritability and difficulty in concentrating. For example, letrozole, which is an estrogen receptor blocker, may cause various side effects such as severe headaches, dizziness, fatigue, sleeplessness, breast pain or an abnormal cycle. Lupron, which is another drug commonly used in the treatment of infertility, has been indicated to cause mood swings, depression and anxiety symptoms, vaginal dryness, acne, joint pain and decreased sex drive in some women. 

Ways to improve your mental health
It is extremely important to acknowledge an infertility issue as quickly as possible. The emotional roller-coaster is inevitable but you can do some things in order to process it a little more smoothly. 

Talk about your feelings: The most difficult thing to do when you are struggling with infertility is to open up and share your story. It is not an easy process and you may feel weak talking about it, but imagine the emotional support people can give you when you explain what you are going through. Also, you will feel relieved sharing your journey with the people that care about you. 

Lead a healthy lifestyle: Exercise more, reduce smoking and alcohol intake and eat healthier. The 3 keys to success. 

Meditation: There are plenty of apps and YouTube videos with meditation exercises that you can add in your daily routine.  According to the National Center for Complementary and Integrative Health, meditation can help reduce stress, chronic pain (such as headaches), and blood pressure. It can also help you to quit smoking and better navigate a variety of mental health conditions. You can try apps like Headspace, Calm, Aura, and Inscape.

Do something for yourself: A short walk, a hot bath, a dance class, gardening, singing, whatever makes you calm and happy. It is your time, it is you you should care for.

Join the fertility communities: There are many women that struggle the same way you do and want to share their experience and find support. Communities like resolve.org, fertilitynetworkuk.org, modernfertility.com could make you feel much better.

Here’s also a woman’s personal story about how she dealt with mental health issues during her fertility journey, in case you want to feel inspired: https://fertilitynetworkuk.org/mental-health-fertility-and-me/

The one thing you should keep from this article is the pressing need to take better care of yourself. Improving your mental and physical health is the first step of improving your fertility levels. And if any issue arises, and you wish to try on a fertility treatment, trust us to make your fertility journey a little more safer and personalized.

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