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Journal of Psychotherapy Integration
The Elusive Connection Between Stress and Infertility: A
Research Review With Clinical Implications
Joann Paley Galst
Online First Publication, March 20, 2017. http://dx.doi.org/10.1037/int0000081
CITATION
Galst, J. P. (2017, March 20). The Elusive Connection Between Stress and Infertility: A Research
Review With Clinical Implications. Journal of Psychotherapy Integration. Advance online
publication. http://dx.doi.org/10.1037/int0000081
The Elusive Connection Between Stress and Infertility: A Research
Review With Clinical Implications
Joann Paley Galst
New York, New York
This article reviews research exploring the interface of stress and infertility, attempting
to answer the following questions: Does infertility cause stress? Does stress impact
fertility? Does infertility treatment cause stress? Does stress impact treatment out-
comes? Can stress reduction effect treatment distress and outcomes? Is there residual
stress after treatment? Recommendations are made to mental health professionals to
help their infertile patients cope more effectively with infertility stress, and suggestions
are offered for future research directions.
Keywords: infertility, stress, IVF, depression, couples
Infertility is a reproductive disease defined by
the failure to achieve or sustain a clinical preg-
nancy after 12 months or more of regular un-
protected sexual intercourse. For many, the de-
sire to have children is fundamental, and
receiving an infertility diagnosis can be an emo-
tional experience. Infertility affects over 12%,
or 7.5 million, American women ages 15– 44, or
one in six couples. Of these cases, 40% are due
to female factors, 40% to male factors, and 20%
to a combination or unexplained etiology (Cen-
ters for Disease Control & Prevention, 2015).
Infertility presents both a chronic stressor
resulting from the threat of loss of plans to have
children, and an acute stressor resulting from
the infertility treatment itself. Difficulty in con-
ceiving challenges belief systems, trust in one’s
body, hopes for future parenting, and expecta-
tions of one’s anticipated adult life. Treatment
protocols are invasive, lasting from months to
years, and can involve early morning monitor-
ing, appointments at the doctor, daily injections
and blood samples, and laparoscopic surgery.
The costs are high and failure can occur at any
phase. Infertility has been found to create as
much emotional distress as having a diagnosis
of cancer, heart disease, or HIV (Domar, Zut-
termeister, & Friedman, 1993). Certain phases
of treatment are found to be more stressful than
others, such as waiting to hear about fertiliza-
tion, results of the embryo transfer, or an un-
successful outcome (Demyttenaere, Nijs, Evers-
Kiebooms, & Konnickx, 1991). Myriad
treatment options make it difficult to know
when to stop. Even after a baby is conceived,
anxiety often remains (Hjelmstedt, Widström,
Wramsby, Matthiesen, & Collins, 2003), as in-
dividuals may be conditioned to expect loss.
Although often a long-lasting struggle, infertil-
ity is not readily understood by others. The
stigma associated with it may result in limited
sharing with others and isolation.
Two contrasting theoretical models of infer-
tility have respectively considered psychopa-
thology as cause or consequence. Psychody-
namically oriented approaches originally posed
psychogenic elements, such as a woman’s un-
conscious conflict regarding adulthood, sex,
pregnancy, labor, or motherhood, as the cause
of infertility (Deutsch, 1945). This has been
rejected by most authors, as research has con-
firmed that biomedical causes (e.g., blocked fal-
lopian tubes, sperm abnormalities, anovulation)
account for most fertility problems. The more
recent psychological consequences hypothesis
proposes that psychological distress is second-
ary to infertility, citing research on the impact
of emotional states and the ability to cope with
stress on the neuroendocrinological state of in-
fertile women and men (Demyttenaere, Nijs,
Evers-Kieboom, & Konnickx, 1992), and on
Correspondence concerning this article should be ad-
dressed to Joann Paley Galst, Independent Practice, 30 East
60th Street, Suite 1100, New York, NY 10022. E-mail:
jgalst@aol.com
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Journal of Psychotherapy Integration © 2017 American Psychological Association
2017, Vol. 0, No. 999, 000 1053-0479/17/$12.00 http://dx.doi.org/10.1037/int0000081
1
treatment outcomes (Boivin & Takefman,
1995).
For this article, stress is defined as a physio-
logical or psychological response to an external
stimulus that exceeds the individual’s coping
capacity (Lazarus & Folkman, 1984). A review
of recent research on how infertility and stress
intersect and impact reproductive function is
provided.
Does Infertility Cause Stress?
Whereas most infertility patients function
within normal limits on measures of depression
and anxiety (Verhaak, Smeenk, van Minnen,
Kremer, & Kraaimaat, 2005), there can be a
substantial subgroup in need of psychological
help as they navigate their infertility. Stress can
arise as a reaction to the diagnosis, in response
to treatment, or be premorbid. Estimates of ma-
jor depressive disorder and anxiety have ranged
from 11% to 39% and 15% to 23%, respec-
tively, among infertile women, and 5% to 15%
and 5%, respectively, among men (Volgsten,
Svanberg, Ekselius, Lundkvist, & Sunderstrom
Poromaa, 2008), surpassing the prevalence rates
of the general population and supporting the
interconnection between infertility and stress.
In a U.S. probability-based sample of fertile
and infertile women, King (2003) found that
infertile women as a group, both treatment seek-
ers and nontreatment seekers, had higher anxi-
ety symptoms than fertile women. Infertile
women with self-reported depression were less
likely to seek medical advice, as well, although
this differences was not found for anxiety dis-
orders. Therefore, depression may be a barrier
to seeking treatment for infertility. It is impor-
tant to note that because only approximately
half of those experiencing infertility seek infer-
tility treatment (Boivin, Bunting, Collins, &
Nygren, 2007), approximately half of the infer-
tile population is omitted when a clinical sample
is used in a research paradigm.
Although Gameiro et al. (2016) in a Dutch
study found that 63% of women adjusted well to
their infertility treatment experience from pre-
treatment to 2.5 years posttreatment, 37%
showed transient or chronic maladjustment
(anxious or depressive) trajectories. Unsuccess-
ful in vitro fertilization (IVF) has been found to
be a risk factor for developing depressive symp-
toms (Verhaak et al., 2005), and can last up to
20 years (Wirtberg, Moller, Hogstrom, Tron-
stad, & Lalos, 2007). Because women at risk of
a maladaptive trajectory can be identified at the
start of treatment, that is, reporting marital dis-
satisfaction, lack of social support, and feelings
of helplessness (Gameiro et al., 2016), these
psychosocial factors are more amenable to
change than demographic or diagnostic vari-
ables. As there appears to be an interconnection
between infertility and stress, it seems reason-
able to provide psychosocial support, both dur-
ing and after treatment as a preventive approach
to infertility care.
Whereas most empirical studies have found
that infertile couples report normal levels of
marital adjustment relative to presumed fertile
couples (Greil, 1997), albeit with some sexual
dissatisfaction (Andrews, Abbey, & Halman,
1992), gender differences in response to infer-
tility exist. Women demonstrate stronger emo-
tional reactions earlier in treatment, regardless
of whether the infertility is due to female or
male factor (Verhaak et al., 2005). Men, how-
ever, more generally report more negative emo-
tional responses if the infertility is due to a male
factor (Nachtigall, Becker, & Wozny, 1992).
Men and women also cope differently. For
women, infertility stress often leads to general
distress, whereas men’s fertility stress remains
more contained (Andrews et al., 1992). A man’s
use of active avoidance coping can increase his
female partner’s distress, while a woman’s use
of confronting coping can increase her male
partner’s distress (Peterson, Pirritano, Chris-
tensen, & Schmidt, 2009). Women find relief in
processing their thoughts and feelings regarding
infertility with others, whereas men find these
discussions stressful (Conrad, Schilling, Lagen-
buch, Haidi, & Liedtke, 2001). When both
members of a couple blame themselves for their
infertility, both may experience increases in de-
pression and infertility stress, likely because
neither is available to console the other (Peter-
son, Newton, Rosen, & Skaggs, 2006).
Pasch, Dunkel Schetter, and Christensen
(2002) found that if both partners were equally
committed to conceiving, and if the man was
willing to talk to his female partner about this
shared experience, the quality of their commu-
nication when discussing infertility was less
negative, and women perceived infertility to
have a more positive effect on their relationship.
Conversely, lack of congruence between dyad
2 GALST
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members can add to women’s depression and
stress.
Does Stress Impact Fertility?
Selye (1950) first suggested an association
between stress and infertility, noting ovarian
atrophy in rats exposed to stressful stimuli. If
stress reduces short-term fertility, it may serve
an evolutionary advantage, preventing preg-
nancy during times when resources are sparse.
Chronic stress, however, can result in persistent
sexual dysfunction and suppressed fertility.
Research has attempted to delineate the
mechanisms contributing to the impact of stress
on fertility. Although difficult to isolate single
causal links between stress and infertility, asso-
ciations between stress and the hypothalamic-
pituitary-adrenal (HPA) and ovarian axes
(HPO) have been found to exist. For example,
in response to stress, a cascade of events occur
that involve cortisol and epinephrine, resulting
in a ‘fight-or-flight’ response to deal with a
threat (Dickerson & Kemeny, 2004). A sus-
tained level of cortisol interferes with the hypo-
thalamus, the region of the brain that produces
sex hormones and gonadotropin-releasing hor-
mone (GnRH). It can result in low levels of
GnRH, disrupting a woman’s ovulatory cycle.
Hypothalamic secretion of GnRH stimulates
production of luteinizing hormone (LH), caus-
ing a follicle to begin to mature and activating
the ovary to secrete estradiol and progesterone
preparing the lining of the uterus for implanta-
tion. Cortisol also increases gonadotropin-
inhibiting hormone (GnIH), which inhibits the
release of the fertility-enhancing gonadotropins
(Chrousos, Torpy, & Gold, 1998). A woman’s
reproductive system can be completely shut
down by functional hypothalamic amenorrhea,
and this state increases markedly in proportion
to chronic stress (Berga, Daniels, & Giles,
1997).
Lynch, Sundaram, Maisog, Sweeney, and
Buck Louis (2014) measured two stress bio-
markers during women’s attempt to conceive,
finding that higher levels of salivary alpha-
amylase, but not cortisol, were associated with a
longer time to pregnancy and an increased risk
of infertility. A recent study measured daily
self-reported distress and its relation to the
probability of conceiving naturally for up to 20
menstrual cycles among 400 women (Akhter,
Marcus, Kerber, Kong, & Taylor, 2016).
Whereas lower pregnancy rates were found with
increased self-reported stress during the follic-
ular phase of the menstrual cycle, higher stress
during the luteal phase was associated with an
increased probability of conception, possibly
due to changes in the hormone milieu and/or
knowledge of pregnancy.
Stress can affect sperm counts too, as high
stress levels have been associated with sup-
pressed libido and significantly lower semen
volume and sperm concentration, particularly in
chronically stressed men (Tilbrook, Turner, &
Clarke, 2000). In severe cases, erectile dysfunc-
tion can result in lower frequencies of inter-
course and subsequent infertility. Although the
role that stress plays in reproductive function
has been demonstrated both in animals and hu-
mans, whether the degree of stress typically
experienced in daily life is significant enough to
thwart the reproductive process, naturally or
through assisted reproductive technologies, re-
mains equivocal.
Does Infertility Treatment Cause Stress?
Women have reported variability in emo-
tional distress when undergoing infertility treat-
ment (Benyamini, Gozlan, & Kokia, 2005).
Even the medications used to stimulate ovarian
production and prepare the uterus for implanta-
tion can affect mood and contribute to distress
(Choi et al., 2005). Mild in vitro fertilization
(IVF) treatment (using GnRH antagonist and
single embryo transfer) was associated with
fewer symptoms of depression one week after
treatment failure than standard IVF (GnRH ag-
onist, long-protocol ovarian stimulation, and
double embryo transfer; de Klerk et al., 2007).
Boivin, Takefman, Tulandi, and Brender (1995)
found an inverted U reaction with women who
experienced a moderate amount of infertility
treatment failure (i.e., intrauterine insemination
with an average of 2.17 failed treatment cycles),
reporting more personal and couple distress
than women who had no prior treatment failure
or those with the most treatment failure (i.e.,
superovulation and IVF with an average of 6.6
failed treatment cycles). The times preceding
oocyte retrieval, before and after embryo trans-
fer and while waiting for a pregnancy test, have
been found to be particularly stressful (Boivin
& Takefman, 1995; Mahajan et al., 2010). The
3STRESS AND INFERTILITY
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most consistent finding has been an increase in
depression after one or more unsuccessful treat-
ment cycles. Consistent with the gender differ-
ences noted earlier, male partners showed no
change in anxiety or depression after either suc-
cessful or unsuccessful fertility treatments (Ver-
haak et al., 2007).
Women who did not become pregnant with
IVF reported higher stress levels during treat-
ment than those who became pregnant (Boivin
& Takefman, 1995). However, these women
also had a poorer biological response to IVF
(e.g., estradiol levels, oocytes retrieved). Thus,
the direction of causality could not be deter-
mined, as negative feedback during the cycle
could have contributed to increased stress. In-
terestingly, the recall of stress was higher than
the women’s daily reports of stress during treat-
ment.
The stress of infertility can be further im-
pacted by the coping skills the individual uses.
In women undergoing intrauterine insemina-
tion, Berghuis and Stanton (2002) similarly
found a significant increase in depressive symp-
toms after receiving negative pregnancy results.
Avoidant coping strategies (e.g., avoiding preg-
nant women) were associated with more distress
in response to negative results, whereas active
approach-oriented strategies (e.g., problem-
focused, positive reinterpretation, support seek-
ing) were associated with better adjustment to
negative results.
A cross-sectional study of women attending a
fertility clinic in Greece (Gourounti et al., 2012)
found avoidant coping was associated with in-
creased stress and state anxiety and a lower
perception of personal and treatment controlla-
bility. Problem-focused coping was associated
with reduced fertility-related stress and depres-
sive symptomatology and a higher perception of
treatment controllability. However, women who
frequently used emotionally focused coping had
higher levels of fertility-related stress. Abbey,
Halman, and Andrews (1992) also found that
perceived control was associated with reduced
stress for both women and men. Verhaak et al.
(2005), however, did not find that coping strat-
egies determined adjustment to unsuccessful
treatment. As infertility is an uncontrollable
stressor, they suggested that active problem-
focused coping would be ineffective in reducing
stress. Also, they did not find the expected pos-
itive relation between avoidant coping and anx-
iety or depression, and hypothesized that avoid-
ance coping may, in fact, be effective when
confronting uncontrollable and uncertain stress-
ful situations.
A longitudinal population-based sample of
U.S. women compared groups who had or had
not received treatment for infertility (Greil, Mc-
Quillan, Lowry, & Shreffler, 2011). They found
that women having no treatment and no live
births reported significantly lower levels of fer-
tility-specific distress than those who received
treatment, regardless of whether there was a live
birth. Whereas the highest levels of distress
were found in women unsuccessful after treat-
ment, distress was reported even among treated
women who had a live birth. The researchers
concluded that infertility treatment was associ-
ated with levels of distress that were higher than
those associated with the experience of infertil-
ity itself.
Research across a variety of countries has
also consistently found that stress affected IVF
treatment dropout (Domar, Smith, Conboy,
Inannone, & Alper, 2010; Gameiro, Boivin,
Peronace, & Verhaak, 2012). Thus, it appears
important to identify those patients who are
particularly stressed by treatment and provide
support to minimize nonmedically advised
dropout and the negative consequences of treat-
ment.
Does Stress Impact Treatment Outcomes?
An infertility diagnosis sets in motion an
emotional reaction that, if not addressed and
treated, may interfere with receiving appropri-
ate medical care and resolution. But does stress
impact the result of that treatment? Research
findings have been equivocal.
Nationwide European registry-based studies
have found that those with a pretreatment diag-
nosis of depression or anxiety are less likely to
undergo IVF and for those who did pursue IVF,
it reduced odds of a pregnancy and live birth
(Cesta et al., 2016; Sejbaek, Hageman, Pinborg,
Hougaard, & Schmidt, 2013). A meta-analysis
reported that anxiety, but not depression, was
associated with lower clinical pregnancy rates
(Matthiesen, Frederiksen, Ingerslev, & Zacha-
riae, 2011). Because depression has been re-
ported to be an obstacle to seeking care for
infertility, the rates of depression and anxiety in
4 GALST
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cohorts of women undergoing ART may be
underestimates.
Facchinetti, Volpe, Matteo, Genazzani, &
Artini (1997) found that a greater rise in dia-
stolic blood pressure in response to stressful
stimuli predicted a lower likelihood of preg-
nancy in women about to undergo IVF. More
recent studies have begun to assess both self-
reported stress and physiological markers of
stress during infertility treatment. An, Sun, Li,
Zhang, and Ji (2013), in a prospective study of
women in China, found that those who became
pregnant through IVF had lower levels of cor-
tisol both on the day of oocyte retrieval and the
pregnancy test, and lower state anxiety than
women who did not experience successful treat-
ment. Women in the Netherlands collected noc-
turnal urine samples to measure the hormonal
concentrations of adrenaline and cortisol at
three times (pretreatment, day of oocyte re-
trieval, day of embryo transfer) during their first
IVF/ICSI cycle (Smeenk et al., 2005). These
researchers found no significant differences in
hormone levels at pretreatment, but women who
were successful in achieving pregnancy had
lower concentrations of adrenaline at oocyte
retrieval and at the time of embryo transfer, and
lower self-reported anxiety and depression than
unsuccessful women.
Turner et al. (2013) reported that anxiety and
perceived stress were significantly higher, and
self-efficacy lower, on the day prior to oocyte
retrieval and while awaiting a pregnancy test in
women failing to conceive with IVF whether
first timers or repeat patients. A study control-
ling for covariates known to be linked to IVF
success (e.g., age, BMI, smoking, number of
oocytes retrieved and fertilized) assessed both
salivary cortisol levels, which measure acute
stress, and hair follicle cortisol, which measures
cumulative levels of the hormone, over three to
six months. They found that whereas there was
no relation between acute salivary cortisol and
IVF outcomes, higher levels of chronic cortisol
as measured in hair was associated with a sig-
nificantly (27%) lower probability of IVF preg-
nancy (Massey et al., 2016). However, causal
relations cannot be determined by these studies,
nor can the results be generalized to untreated
populations.
Many studies have also shown the opposite
results. Although 46% of their sample was
found to be stressed, Nouri et al. (2011) found
no relation between salivary cortisol, subjective
stress, or number of oocytes retrieved. Simi-
larly, Butts et al. (2014) found no association
between urinary cortisol on the day of oocyte
retrieval and IVF outcomes. A large multicenter
study in the Netherlands found no effect of
anxiety or depression on either cycle cancella-
tion or pregnancy rates for women undergoing
their first IVF/ICSI (Lintsen, Verhaak, Eijke-
mans, Smeenk, & Braat, 2009). A meta-analysis
of 14 studies also found no association between
pretreatment anxiety or depression in women
and pregnancy after an ART cycle (Boivin,
Griffiths, & Venetis, 2011). Similarly, a pro-
spective controlled study compared first-timers
and those with prior IVF failure (Costantini-
Ferrando Joseph-Sohan, Grill, Rauch, & Span-
dorfer, 2016). They found that neither self-
reported measures nor biological markers of
stress had any association to IVF outcome. In-
terestingly, cortisol levels dropped significantly
at the time of oocyte retrieval and embryo trans-
fer despite a rise in reported stress, but these
hormone levels rose again at the time of preg-
nancy testing. Those with repeated IVF failures
reported the greatest degree of psychological
distress, suggesting they may benefit from ad-
ditional psychological support during and after
treatment cycles.
There are many potential reasons for these
contradictory research findings, for example,
heterogeneity in study designs and whether pa-
tients were experiencing a first failure or mul-
tiple failure. In most studies, the etiology of the
infertility was not specified. If a woman has
implicit knowledge of a poor chance of treat-
ment success (e.g., from medical feedback dur-
ing treatment or her particular profile), she may
report more stress at the start of treatment cre-
ating a spurious relationship between stress and
treatment failure. In addition, infertility patients
may respond in socially desirable ways regard-
ing stress, to ensure acceptance for treatment.
Ultimately, the relation between distress and
IVF outcomes is likely highly complex and
results may well depend on when distress is
assessed. Although it is assumed that IVF treat-
ment can bypass the negative biological effect
of stress, depression, or anxiety on ovulation
with ovarian stimulation procedures, convinc-
ing evidence to support this is currently lacking.
If participants are responding less well during a
cycle, awareness of this poorer prognosis is
5STRESS AND INFERTILITY
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likely to affect their emotional state. For a true
test of the influence of stress on treatment out-
come, patients would need to be blinded to their
progress during the cycle. This, however, would
create potential ethical issues related to auton-
omy and informed consent for decisions to con-
tinue, cancel, or convert a cycle to an intrauter-
ine insemination.
Does Stress Reduction Impact Treatment
Distress and Outcome?
Contemporary high-technological medical
care, available to infertile patients over close to
four decades, is unmatched by psychological
services offered and utilized by this population
(Pasch et al., 2016). Indicators of high stress for
individuals undergoing infertility treatment sug-
gest the importance of investigating stress re-
duction modalities throughout treatment cycles
to support patients. This is particularly impor-
tant, as these psychological variables, unlike
age and other immutable variables, may be sen-
sitive to interventions that may increase the
chance of reduced distress and improved treat-
ment experiences.
Domar and her colleagues conducted some of
the earliest stress-targeted psychosocial group
intervention studies for infertile women. A ran-
domized controlled prospective study of 184
women starting an IVF cycle after trying to
conceive between one and two years, assigned
women to either a 10-session Mind-Body group
(including relaxation training, cognitive restruc-
turing, exercise and nutrition), a standard sup-
port group, or routine care. Pregnancy rates for
the three groups were 55%, 54%, and 20%,
respectively (Domar et al., 2000). No significant
difference was found between the two interven-
tion groups. High dropout rates [60%] in the
routine care control group negated unbiased
comparisons with this group, although the low
pregnancy rate does suggest its ineffectiveness.
In another study, Domar et al. (2011) found
participation in the Mind-Body group was as-
sociated with a 52% pregnancy rate versus 20%
in a no-treatment control. However, only 76%
had completed at least half of the sessions be-
fore beginning their second IVF cycle, demon-
strating the difficulty in having patients post-
pone treatment even when attempting to
increase their chance of success.
Four meta-analyses have assessed the effects
of psychosocial interventions on both psycho-
logical distress and clinical pregnancy rates. In
the earliest, Boivin (2003) found that psycho-
therapeutic interventions were associated with a
reduction in negative affect in women and cou-
ples undergoing infertility treatment. Group in-
terventions emphasizing psychoeducation and
skills training (e.g., relaxation training) were
significantly more effective in reducing depres-
sion, anxiety, and fertility-specific stress than
interventions emphasizing emotional expres-
sion and/or support, but had little influence on
pregnancy rates. Boivin concluded that the dis-
tress reduction did not have a sufficiently large
impact to overcome biological mechanisms in-
terfering with pregnancy. A subsequent meta-
analysis of 22 studies (de Liz & Strauss, 2005)
concluded that both group and individual/
couples psychotherapy resulted in decreases in
anxiety for patients undergoing fertility treat-
ment. Reductions in depression were greater six
months after treatment, but pregnancy rates
were not definitively enhanced.
In contrast, Hammerli, Knoj, and Barth
(2009) evaluated 21 exclusively controlled
studies, both randomized and nonrandomized,
and found a positive impact of psychosocial
interventions on pregnancy rates, albeit only for
couples not receiving IVF, but no significant
effect on mental health. A potential publication
bias was noted, however, as smaller studies that
did not demonstrate efficacy may not have been
published. Also, a trend toward higher effects
on pregnancy rates was found in nonrandom-
ized versus randomized studies, with no clear
explanation provided.
In the most recent meta-analysis including 39
studies, a significant effect of psychosocial in-
terventions on both psychological distress and
clinical pregnancy rates among couples under-
going infertility treatment was found, although
no statistically significant effects of the inter-
ventions were found on infertility stress, marital
functioning, or depressive symptoms (Frederik-
sen, Farver-Vestergaard, Skovgard, Ingerslev,
& Zacharie, 2015). No differences emerged be-
tween CBT or mind-body interventions (MBI),
but group interventions demonstrated better re-
sults than online, individual, or couple interven-
tions. Conversely, a systematic review of 20
randomized controlled psychosocial interven-
tion studies found none were effective in reduc-
6 GALST
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ing depression or stress for either individuals or
couples undergoing IVF treatment, although
none measured stress levels during the high
stress 2-week wait for pregnancy results, and
80% found no impact on pregnancy rates (Ying,
Wu, & Loke, 2016).
Briefer psychosocial interventions have been
developed in an attempt to make them more
attractive to patients. Domar, Gross, Rooney,
and Boivin (2015) mailed stress management
packets to participants’ homes and found lower
rates of psychological stress and reduced treat-
ment termination for women undergoing IVF.
Lancastle and Boivin (2008), targeting the
2-week waiting period between embryo transfer
and pregnancy results, randomized women to
either recommended twice-daily reading of 10
statements of a Positive Reappraisal Coping
Intervention (PRCI; e.g., During this experience
I will try to do something that made me feel
positive) or 10 statements of positive self-
affirmations (e.g., During this experience I feel
that I am a great person). Women reported that
the PRCI was more helpful in increasing posi-
tive feelings, minimizing the strain of waiting,
and allowing them to better sustain coping ef-
forts.
Online psychosocial support has also been
investigated. In one study (Cousineau et al.,
2008), women seeking medical treatment were
randomly assigned to online support or no on-
line support. Online support consisted of a MBI/
CBT program adapted from the Domar et al.
(2000) protocol. Women undergoing online
support reported less infertility distress and felt
more informed regarding medical decisions.
Those spending more than 60 min online with
the program demonstrated greater reductions in
global stress and increased self-efficacy. The
program appeared more beneficial for those
women using escape-avoidance coping, but re-
sulted in higher infertility distress in women
using distancing to cope, possibly because it
forced them to face issues they had been avoid-
ing. A pilot RCT comparing the 10-session
Mind/Body Program in an online format to a
wait list control found that the intervention
group demonstrated significantly lower depres-
sion, lower anxiety for those with elevated anx-
iety at baseline, and a 42% self-reported preg-
nancy rate compared to 17% for the control
group (Clifton et al., 2016).
In conclusion, the impact of psychosocial in-
terventions on anxiety, depression, fertility-
related stress, and pregnancy rates during infer-
tility treatment appears to be inconsistent. The
effects of psychosocial interventions may be
difficult to prove for a variety of reasons: vari-
ability in methodological rigor; difficulty find-
ing appropriate control groups; high drop-out
rates; prior patient awareness of their prognosis;
medications being used overriding any impact
of stress; possible subject selection and recall
bias; and potential social desirability response
bias. Assuming that there exists a negative im-
pact of stress on reproductive outcome, but
without clear evidence, has the potential to
blame the victim and add additional guilt and
frustration to an already burdened population.
Determining who may benefit from psychoso-
cial intervention to reduce treatment distress
may be of value. Clinical judgment of individ-
uals/couples in need of psychological interven-
tion in coping with infertility treatment can be
applied, but should not insinuate that stress is
causing the infertility or will reduce chances of
pregnancy. This is clearly an issue in need of
further research.
Is There Residual Stress After Treatment?
Does infertility-related stress continue to im-
pact women and their spouses after treatment
conclusion? Not surprisingly, infertile women
who became parents experience greater global
well-being than infertile women who did not
conceive. Those remaining childfree when eval-
uated up to 3 years posttreatment still experi-
enced depression, distress, and grief (McQuil-
lan, Greil, White, & Jacob, 2000). Both
personal and couple distress decreased for
women and men 5 years following unsuccessful
IVF (Peterson et al., 2009). Sydsjö, Skoog-
Svanberg, Lampic, and Jablonske (2011) found
positive relationships among couples 20 years
post unsucccessful treatment, although most
had added a child to their family. For those who
never added a child, women report increased
distress when their peers become grandparents
(Wirtberg et al., 2007).
During pregnancy, women and men con-
ceiving through IVF exhibit less ambivalence
about parenthood and greater anxiety regard-
ing losing the pregnancy than couples con-
ceiving spontaneously (Hjelmstedt, Wid-
7STRESS AND INFERTILITY
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ström, Wramsby, & Collins, 2004). In a
review, Monti et al. (2015) found no increase
in postpartum depression risk among women
using ART to conceive. The number of pre-
vious ART cycles was predictive of postpar-
tum blues, however, and mothers of multiples
were at an elevated risk.
The transition to parenthood is stressful for
most new parents. Infertile couples becoming
parents reported diminished couple well-being,
including a lower intimacy quality of life (QOL)
and less frequent sexual intercourse than infer-
tile childfree couples, as did presumed fertile
parents (Abbey et al., 1992). A review of 28
studies found consistent evidence that couple
satisfaction, emotional well-being, attachment
to the fetus, general anxiety, and the eventual
parent-child relationship was similar between
ART-conceiving and naturally conceiving par-
ents. However, pregnancy-specific anxiety re-
garding fetal health and survival was elevated in
ART women, especially among those who had
prolonged treatment failure and higher infertil-
ity-related stress. Mothers of multiples consis-
tently had higher rates of anxiety and depression
during pregnancy and higher levels of adjust-
ment difficulties after the pregnancy than sin-
gleton ART and spontaneously conceiving
mothers (Hammarberg, Fisher, & Wynter,
2008).
A series of studies compared parents through
IVF and donor insemination to those naturally
conceiving or adopting children. They found the
quality of parenting, the children’s relationship
with their parents, and the offsprings’ emotional
and behavioral adjustment from ages four to
adolescence in ART families were all similar or
superior to those of families with a spontane-
ously conceived or adopted child. A small per-
centage of ART mothers and fathers, however,
were found to be overly involved with their
children (Golombok, Cook, Bish, & Murray,
1995; Golombok et al., 2002).
In summary, whereas the body of evidence
on the issue of residual stress after infertility
treatment is still emergent, no major detrimental
impact on pregnancy nor parenting has been
found. Those who reported higher levels of in-
fertility distress were more anxious about losing
the pregnancy, however, than those with less
reported infertility-related distress, suggesting a
potential benefit to them of support during preg-
nancy.
Implications for Research
The causal impact of psychosocial interven-
tions may be difficult to prove for many rea-
sons. Most patients do not avail themselves of
in-person psychosocial support, either not per-
ceiving themselves in need or rejecting it for
practical reasons. This suggests that new and
alternative methods of psychological support
may need to be developed that prove effective,
feasible, and accessible (Boivin, Scanlan, &
Walker, 1999).
Future research on the interface of stress and
infertility should include use of rigorous re-
search designs (e.g., RCTs), that can allow one
to attribute change to the psychosocial treat-
ment itself and ensure reproducibility; deter-
mine appropriate control groups and reduce
dropout rates, especially in control groups; re-
cruit understudied portions of the infertile pop-
ulation (e.g., men, people of color); utilize mul-
ticenter studies to enhance generalizability;
create interventions in which patients are inter-
ested in availing themselves; and determine
what IVF programs can do to effectively lower
the stress of infertility treatment itself.
Conclusions and Clinical Guidelines
Despite years of research, the relation be-
tween stress and infertility remains elusive. Al-
though stress has been shown in basic animal
and human research to impact the reproductive
system, stress and fertility do not fall into a
simple causal association, and the exact mech-
anisms by which stress interferes with the hy-
pothalamic-pituitary-gonadal axis is still not
clearly understood. The most prudent conclu-
sion would seem to be that stress can disrupt
fertility, and although it can cause animals to
shut down reproductive function in times under
stress, it would seem rarely to permanently ob-
viate conception in humans. Indeed, women
have conceived during wars and famine. Nev-
ertheless, distress appears to be a primary rea-
son for patients abandoning fertility treatment
prematurely (Domar et al., 2010) and can also
cause individuals to indulge in other fertility
harming habits (e.g., smoking) or avoid sex
with their partner.
Evidence that psychological stress during
treatment is associated with negative IVF out-
comes is suggestive, but has insufficient causal
8 GALST
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
proof. A patient’s advance awareness of her
age-related prognosis make it difficult to prove
that psychotherapy alone impacts her treatment
trajectory. The medications used in IVF also
appear powerful enough to override the effect of
stress on the body. Due to the level of distress
patients express, however, offering support may
be beneficial during this difficult life experi-
ence. Longstanding concern that stressors dur-
ing pregnancy adversely affect fetal and infant
well-being also reinforce this recommendation
(Dunkel Schetter & Tanner, 2012). Because
most infertility patients and their partners are
not referred to mental health professionals
(Pasch et al., 2016), psychosocial services may
need to be more synergistically integrated into
infertility care, with periodic screening of the
psychological distress that patients are experi-
encing. At the same time, they need to be en-
sured that this will not result in treatment re-
fusal, only treatment support. A normalizing
and accepting attitude on the part of the medical
treatment team, with suggestions of the poten-
tial usefulness of psychological support while
patients traverse their family building journey,
may be more conducive to patients acknowl-
edging their level of stress.
Providing the space for patients to express
their feelings about their infertility is essential.
The medical goal of overcoming infertility and
the psychological goal of supporting one’s par-
ticipation in life even while coping with infer-
tility can complement each other, as patients
find themselves caught in a maelstrom of dis-
tress during treatment that can feel overwhelm-
ing. Working psychotherapeutically with pa-
tients experiencing infertility requires
sensitivity and attunement to the individual’s
and couple’s emotions and coping skills, as well
as medical knowledge. Offering such interven-
tions reflects understanding the complexity of
the infertility patient, a desire to help patients
reduce their distress and improve their quality
of life, and communicates the idea that infertil-
ity can set one on a journey, although stressful,
that has the power to be transforming. With a
strengthened sense of self, infertility can lose its
dominance over the patient’s life and allow for
life to be fully appreciated once more.
As mental health professionals, we are likely
to find people struggling with infertility in our
practices. Suggestions to help include:
• Manage expectations. Normalize stress and
loss of sexual spontaneity as an expected
outcome of infertility. Help patients regain
a sense of control, feeling prepared for both
the medical and emotional process they
will face, including preparation for emo-
tional reactions to unsuccessful treatment.
• View infertility as a shared problem. En-
courage open communication between
members of the couple, as well as time-out
from discussing infertility to allow for res-
toration and resilience-building. Help cli-
ents seek outside support to avoid overtax-
ing the primary relationship.
• Identify women and men who are likely to
experience emotional difficulties while ex-
periencing infertility (e.g., lack of couple or
social support; prior IVF failure) and offer
effective psychosocial interventions.
• Help support patients in their attempts to
accept treatment failure, make decisions re-
garding continuing or terminating treat-
ment, explore alternative means of family
building, or adjust to a childfree life. Help
expand patients’ identities beyond fertility.
Help them find ways to receive support and
provide for their self-care.
• Give concrete suggestions for handling the
stresses prior to, during, and after treat-
ment. Offer information about community
resources for emotional support to help re-
duce isolation.
• Encourage medical programs to decrease
patient stress by offering information about
the medical, emotional, and financial as-
pects of treatment; include both members
of a couple in treatment; encourage open
communication with staff; support single
embryo transfer; and provide general psy-
chosocial sensitivity in daily patient care,
as well as follow-up care after unsuccessful
treatment cycles.
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Received February 18, 2017
Accepted February 22, 2017 䡲
13STRESS AND INFERTILITY
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