diploma in holistic stress management with laurel alexander

 

FERTILITY AND STRESS

By Laurel Alexander

The term stress is used to describe circumstances in our environment that challenge our bodies both physically and psychologically. Stress is not always bad. In fact, some stress is a necessary part of life that helps compel us into action, increasing our alertness and awareness.

When we encounter a stress-creating stimulus, our body responds by secreting hormones that stimulate our nervous system and prepare us to move, or react. If the stimulus is mild or perceived as non-threatening, then there is little hormone release and we react in a healthy fashion. An example is, when we move to avoid an obstacle while walking.

At times however, excess stress-creating stimuli may overwhelm our abilities to respond and cause a negative effect, often called "distress". In this case, the stimuli may present either a "real" or "perceived" threat to us. The body responds immediately, pouring out hormones, which result in increased heart rate, blood pressure and breathing, as well as sweaty palms and cool, clammy skin. Stressful events can also trigger emotional feelings of anxiety, fear, insecurity and anger.

For most, brief stressful encounters are well tolerated. Prolonged stress, however, has been linked to many health problems including sleep disturbances, ulcers, high blood pressure, heart disease, stroke and depressed immune function. While the results are inconclusive, recent research suggests that excess stress may contribute to infertility and pregnancy risks.

 

Men who cannot express their emotions could find it harder to father children, according to psychological research. A study, presented at a British Psychological Society conference in Leeds, compared 25 men with fertility problems with 25 with none. It suggested that "new men", who find it easier to talk about their feelings, could be more likely to be fertile. Although the 25 fertile men reported more stress-causing incidents day to day over a two-week period, they were far more likely to talk about them. The report's author, psychologist Keith Hurst, said that bottling up stressful events was far more likely to lead to higher stress level overall. And increased stress could well lead to reductions in the body's ability to cause stress, he said. Men who are good at expressing their feelings might include someone, who, sitting in a traffic jam, would talk to their passenger about how frustrated they were feeling. "The fertile men were ‘cartharsis coping’, anything from just talking about things to getting quite upset or angry," said Keith Hurst. He is now planning more research to hopefully prove the physical link between stress and fertility. Male fertility is known to be on the decline in many Western industrialised countries, although it is not known why. It is thought that the stress hormone cortisol, or more particularly another chemical, CRH, also produced by the body, can interfere directly with sperm production. BBC NEWS

"Just relax and you'll get pregnant…."
" Take a holiday…."
" Don't think about it too much…."
" You're trying too hard…."

If you have been trying to get pregnant, chances are that you have heard some or all of this advice. Underlying the statements above is the basic assumption that infertility and stress are linked. This advice, while well meaning, is often very hard to hear because that assumption has very negative implications for you. The message is one of blame: if you were better at relaxing and not being overly concerned with your fertility, then you would be pregnant.

When you are trying to get pregnant, it is impossible not to feel stress as months pass by and diagnoses are confirmed. Hope waxes and wanes depending upon what treatment is available and how long you have been trying to get pregnant. Add to this emotional mixture the real demands of doctor's visits, medications, monitoring, and cost, and it would seem impossible for stress not to enter the picture of coping with infertility.
Stress can have a dramatic impact on one's reproductive life. Most physicians and mental health professionals who work in this field have encountered men who have experienced temporary impotence when diagnosed with azoospermia (the inability to produce sperm), or women who have temporarily lost all interest in sexual intimacy after a diagnosis of female factor infertility. Feelings about our fertility are entwined in our feelings about sexuality. Many women with infertility say they do not feel like "real women" and are not members of the club who have experienced pregnancy and childbirth. These women say that they feel like outsiders at social functions when talk inevitably turns to children related topics. Men can often feel that having normal sperm function is related to virility, when in fact impotence (male sexual dysfunction) and male infertility are not the same. Hearing phrases such as "he shoots blanks" reinforces feelings of inadequacy and complicates these feelings for men.

Think about all the factors that go into our concept of stress. Are you a Type A personality? Do you like stress and perform better under stress? Is infertility only a small part of the stress in your life compared with other stresses such as illness or family problems? Personality styles, ways of coping with stress, the amount of stress in your environment, and support systems are only some of the factors that need to be considered when we look at the relationship of stress and pregnancy. The desire to be able to directly affect your ability to become pregnant is powerful. On the other hand, acting on this desire may make you feel responsible if you are unable to get pregnant because you are "too uptight", "working too many hours," or "not relaxed enough". It is still unknown whether stress causes infertility. More research is needed in this area to prove this relationship.

Unfortunately, stress is a natural consequence of worrying about fertility, and stress can also depress fertility. Moreover, knowing that your increased stress levels can impair your fertility can bring on more feelings of anxiety, compounding the situation. That is why it's important to develop coping mechanisms to help manage stress.

Because each of us finds different situations stressful, the optimal level of stress varies from person to person. A task that one person finds enjoyable can be highly stressful to another. For example, your sister may love the thrill of speeding downhill on skis, but may panic while taking a driving exam. You, on the other hand, may feel terrified at the thought of even getting on skis, but feel very comfortable taking exams.

A person (pregnant or not) who is coping well with stress, feels relaxed and energized, and probably does not face health risks from stress. While another, who is coping poorly, may feel tired, drained, anxious and is more likely to suffer the health risks of excess stress.

Does Stress Affect Fertility and Pregnancy?
Stress and Infertility Studies on the effects of stress on fertility are limited. It appears that some women with high stress levels may have hormonal changes, irregular ovulation or on occasion, fallopian tube spasm. In men, stress may be one of many factors responsible for decreased sperm production.
Infertility and Stress It is clear that infertility is a highly stressful experience, for both men and women. Infertile couples experience chronic stress each month, first hoping that they will conceive and then dealing with the disappointment if they do not. Infertility treatments can place additional stress on couples. The medical evaluations to determine the source of infertility and the treatment interventions can create tremendous financial and emotional strain for couples. Some stress research has shown that women undergoing infertility treatment, experience an equal or higher level of "stress" of those faced with the life-threatening illnesses of cancer or heart disease.
Stress and Pregnancy

Studies also suggest that high levels of stress may pose special risks during pregnancy. Pregnancy presents a unique set of circumstances that can mean joy and bliss in some, but overwhelming anxiety and stress in others.

The physical effects of pregnancy (such as hormone-related mood swings, nausea, fatigue, frequent urination, swelling and backache) can be stressful. In addition, many have emotional stress due to concerns about the baby's health and parenting responsibilities.

Getting adequate rest and limiting activities that cause discomfort can minimize some of the physical discomforts. Support persons and health care providers can also provide help in dealing with the concerns and stresses of pregnancy.

Research also indicates that high stress levels may pose special risks during pregnancy. Several recent studies found that women, who had preterm delivery or low birth-weight infants, had high levels of stress (such as a family death, divorce, job loss) during their pregnancy. Researchers are trying to clarify exactly how stress contributes to these outcomes. It may be that women who are experiencing high stress levels, have poor health habits and may even be prone to using alcohol, drugs and cigarettes. Another recent observation is that the stress hormone 'cortisol' can cross the placental barrier when a pregnant woman is under a high degree of stress and dietary protein is low. High cortisol levels can effect foetal brain development, specifically memory.

More information is needed before proving that stress resulted in these pregnancy risks. No doubt, persistent, unrelieved stress causes damaging "wear and tear" on the body.


RESEARCH
In a study of women undergoing either IVF or GIFT procedures, researchers asked the question: Does stress affect fertility and pregnancy rates? The researchers looked at whether stress from a patient’s life situation or stress from the procedure negatively reduced the patient’s ability to achieve pregnancy or to have a live birth. The women were given questionnaires to rate their moods, feelings about infertility, expectation of achieving pregnancy, amount of social support, coping style, and overall stress levels. The questionnaires were completed at their first clinic visit, before and after hormone use and before embryo transfer.

Women who had higher expectations of achieving pregnancy and had less overall stress had a greater number of eggs retrieved and fertilized, a higher number of embryos to transfer, and a higher pregnancy rate as compared to the women who had a lower expectation of pregnancy and a higher rate of stress.

Klonoff-Cohen H, Chu E, Natarajan L, Seiber W. A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer. Fertility and Sterility 2001;76:675-687.

 

For those who have not yet achieved an ongoing pregnancy, the anguish of waiting and repetitive cycle failures engender sorrow and despair. As time goes on, the prolonged cumulative effect of this stress can actually cause physiological responses counter productive to reproduction. Blenner (1990) describes the predictable progression of infertility's emotional toll. There are eight stages as summarized below. The spiral depicted on the left illustrates the downward drift of emotional health and escalating despair:

1. Dawning of awareness: Couples plan the best time of the year to have a baby; realize it seems to be taking longer than expected, still identify with fertile population.
2. Facing a new reality: Diagnosis stimulates couples to face reality of infertility. Blaming, guilt arise. Selective perception of success rates and discounting of side effects and risks. Begin to isolate themselves.
3. Treatment: Hopeful, excited, high energy.
4. Intensifying treatment: Infertility major focus of life, financial and time sacrifices intensify. Anger or depression occurs. Increasing isolation, avoids activities with children. Loss of control.
5. Spiralling down: Tearful, overwhelmed, enraged by the injustice of infertility
6. Letting go: Usually a husband “shut down” first, then wives. Resume social life but activities without children (backpacking). Strong desire to regain control of life, quitting is gradually OK.
7. Quitting and moving out: Initial feelings of relief, followed by grief. Initiation of adoption for some.
8. Shifting focus: For childless couples, peaceful resignation. For adoptive parents, focus on the child. Reengagement with fertile worked.
Adapted from: Blenner, J. (l990) Image: Journal of Nursing Scholarship. 22(3), 153-158.

In addition to the stresses of the medical regimens, overwhelming feelings of loss of control and increasing isolation as described by Blenner, there are psychosocial pressures on couples to reproduce. Erickson's "stages of development" theory describes the tasks of human development from infancy's need to establish trust, through the adolescence's search for identity to middle adulthood, which includes the task of generativity. Generativity is the task of guiding and helping children. It is the next stage of a human's development, (according to Erickson), but infertility blocks the accomplishment of this task. The couple can't understand why this stage is thwarted when all of life's other developmental tasks occurred without conscious thought.

Compounding the couple's despair is the societal stigma that accompanies infertility. The couple may feel "defective" and the inability to fulfil the role of parenthood may be regarded as a personal failure. And while the couple grapples with these unpleasant feelings the woman's biological clock continues to tick adding time pressure to their list of stressors.

RESEARCH
Researchers have verified that infertility does cause stress. Domar ( l992) reported that infertile women experience twice the level of depression when compared to their fertile counterparts. And this elevated stress does compromise reproduction. Facchinetti (l997) documented that the higher a woman's vulnerability to stress the lower her pregnancy rates. Sharma and Sharma (l992) documented double the pregnancy rates in women who took anti-anxiety pills. Domar, a researcher who works at the Mind and Body Institute in Boston, which is associated with Harvard Medical School, proposes a model that explains the deleterious effects of stress on the reproductive functions. This model was published in The Wellness Book (1992) by Herbert Benson. Adapted from: A. Domar in The Wellness Book, by H. Benson, l992

 

To break this cycle, the emotional tension must be addressed. We intuitively know that the mind can influence physiological responses. Just think of the emotion of fear. When one feels fear, there are distinct bodily symptoms such as dry mouth, pounding heart, sweaty palms, etc. that accompany this emotional feeling. Perhaps, the techniques available for stress reduction could reverse the emotional stress of infertility.

Benson (l992) contends that stress and relaxation cannot co-exist. Several research studies have documented the positive effect of relaxation in other fields. Stuart (l987) used relaxation to help patients reduce blood pressure with out medication. Mandle (l990) documented less pain medication use and a decrease in anxiety by hospital patients who listened to a relaxation tape. Goodale (l990) was able to document decreased premenstrual symptoms in women who practiced relaxation techniques. And lastly Domar (l992) cited double the pregnancy rates for In Vitro Fertilization (IVF) patients who practiced relaxation coping techniques.

The stress of infertility can be minimized with conscious effort to honour your emotions and utilization of techniques to counteract the effects of infertility's despair. Use of a variety of relaxation methods will restore a sense of control, decrease the sense of isolation, restore optimism and may help increase the chance of pregnancy.

Infertility places a heavy burden upon people's self-esteem, and stress arises from this negative self-image. Many men and women report feeling less masculine or feminine after a diagnosis of infertility. I often hear infertile women and men tell me that they feel their bodies do not work right or are defective. Phrases such as “everyone else can get pregnant” or “I must have done something wrong to deserve this” reflect how badly individuals view themselves. Unknowingly, family or friends can reinforce this image. Hearing statements like "I just had to look at my husband to get pregnant" can be very hurtful. Some mothers have told their daughters "I don't understand - I never had a problem getting pregnant". This statement, which may have meant to reassure the daughter that there cannot be a major problem because it would have been known previously in the family, only serves to make the infertile daughter feel defective or estranged from her mother.

Research has shown that women going through infertility rated themselves as having higher levels of depression than women going through cancer treatment. How can infertile women rate greater levels of depression than cancer patients? We all know we can get sick, even with terrible diseases like cancer, but not that we may be infertile. We grow up assuming we are fertile. It feels like we should be able to control our fertility - after all we have always assumed we could control to have a baby. Infertility robs us of our control and choices, leaving us vulnerable to depression and feelings of hopelessness. For the infertile partner in a couple, feelings of guilt and responsibility can arise.

Stress may also arise from uncertainty in the future. Couples postpone holidays "in case" they are pregnant. Women will put off buying clothes with the hope that they will be pregnant and not need them. One of my clients put off changing her job “just in case”. Other women will stop all caffeine, alcohol and heavy exercise.

Infertile couples are living in limbo not knowing what the future holds. They also live in limbo because they do not always know when they need to be available to run into the doctor's offices. Men may find their work schedule impacted because they need to be available for timed intercourse or to provide a specimen.

Many couples experience a change in their sex lives while trying to battle infertility. Sexual intimacy may be replaced by scheduled sex. Men joke that they feel like a "sperm donor" during sex. Couples may also feel that sex and pregnancy are no longer related. This may be the case if the couple is going through inseminations or through assisted reproductive technologies. To this couple, sex may represent something that has failed them. Women may also feel that their bodies are changed for the worse by the medications. Certainly, if you are having an ultrasound every morning and your ovaries are enlarged, you may feel less sexy or sexual than usual.

Treating infertility takes time. Appointments, research, bloodwork, ultrasound examinations, medications and emotions all take a lot of time. For those individuals who are working, doctors' appointments, phone calls to and from the doctor's office, procedures, and conferences can take a serious toll on their work availability and productivity. During some procedures, women may be in their doctor's office for 3 to 7 mornings in a row for monitoring. Co-workers may wonder what is going on and the infertile women may be faced with losing her privacy or losing her co-workers patience and support. Certainly there are employment situations where an infertile woman's desire to be pregnant may have an impact on her promotions. Stress arises from trying to balance privacy and practical considerations and the everyday demands of treatment and work obligations.

The medications most women take during infertility treatment can have side effects. These side effects include headaches, fatigue, and pre-menstrual symptoms such as feeling irritable, sad or moody. For those women who need to take injections, the stress of mixing medication and the injections can cause a great deal of stress. Some couples find that sharing the responsibility for mixing medication and injection can prevent all of the stress from falling on the woman and can help reduce her feelings that she is going through treatment on her own.

There are many different approaches to coping with the stress associated with infertility: progressive muscle relaxation, guided imagery, yoga, exercise, reading, writing, massage therapy, psychotherapy, and relaxation techniques. The best approach to coping with stress is the most obvious: do what works best for you.

Although ultimately the relationship between stress and infertility is unknown, learning to cope effectively with stress is an important goal. There are many ways to cope with stress, and taking the time to explore the right one for you may help ease the emotional burden that infertility places upon you and your partner.