by Andrea Mechanick Braverman, PhD
"Just relax and you'll get pregnant.."
"Take a vacation.."
"Don't think about it too much.."
"You're trying too hard.."
"Just adopt and you'll get pregnant.."
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 will share with me that they do not feel like "real women" and are not members of the club who have experienced pregnancy and childbirth. These women will tell me 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.
The Relationship Between Stress and Infertility
Which is Cause and Which is Effect?
The relationship between stress and infertility can be seen as either causative (where stress causes infertility) or reactive (where infertility causes stress). Researchers have studied the possibility that stress causes infertility. Unfortunately, these studies have contradicted each other. Some studies show a relationship and others do not. In my opinion, the best designed studies have not shown a strong relationship between stress and the ability to become pregnant.
This relationship is very hard to study. 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.
When working with individuals going through infertility treatment, I often hear them wish they had more control over the events in their lives, particularly their fertility. 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.
The Impact of Infertility on Self-Esteem
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" reflects 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.
I believe that infertility causes our self-esteem to take a hard knock because there is nothing in life to prepare us for its emotional blow. We grow up assuming we are fertile; most couples with whom I work have been actively using contraception to prevent pregnancy. 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. It is not uncommon to hear an infertile partner offer (only half-jokingly) to divorce their partner so that they can have a child with someone else.
Living in Limbo
Stress may also arise from uncertainty in the future. Many times patients share with me "I could do this for years if they would just tell me that in the end I will get pregnant". Barbara Eck Menning, the founder of Resolve, a non-profit group dedicated to the support, education and advocacy of people with infertility, described infertility like being in "limbo." Couples postpone vacations "in case" they are pregnant. Women will put off buying clothes with the hope that they will be pregnant and not need them. 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. I frequently hear men joke that they feel like a "sperm donor" during sex. "My wife wanted my sperm and not me last night," one man quipped.
Couples may also feel that sex and pregnancy are no longer related. This may be the case if the couple is going through insemination or through assisted reproductive technologies. To this couple, sex may represent something that has failed them. "It seems pointless and indulgent" is a phrase I hear from couples who feel like their sex lives have changed. 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.
A Stressful Schedule
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 stresses that infertility treatment can put on one's schedule is well-illustrated in the example below:
Ms. M had a demanding job which usually required her being in the office by around 8:00 a.m. Normally, she arose around 6:00 a.m. During treatment cycles, Ms. M would arise at 5:00 a.m. in order to reach the doctor's office by 7:00 a.m. (and hopefully be the first person in line for bloodwork).
Her workday extended later than usual because she often arrived at the office around 8:30 a.m. and her day was interrupted to take phone calls from the doctor's office. Instead of getting home around 7 p.m., Ms. M was getting home around 8 p.m. After dinner and clean up, Ms. M would start her work around the house; she found she was getting to bed later and later. Exhaustion, both physical and emotional, began to set in.
Ms. M found that she was putting in more hours everywhere, but was getting less done. She was in a vicious cycle of fatigue and inefficiency, but Ms. M saw it as her own failing at everything in life.
After examining the sequence of events in her life, Ms. M began to see that she had a lot of negative feelings about herself and was subsequently not looking after her own physical and mental well being. Ms. M began ease up on her work schedule during treatment cycles to better accommodate both her job and clinic appointments. Mr. and Ms. M also looked to their evenings and weekends to try to lighten their responsibilities and have more free time.
The Impact of Medication
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, 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.
Coping with Infertility
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.
Do consider your schedule at home and work (if applicable) and how to accommodate it to your treatment schedule. Look at the costs and benefits with sharing the fact of your infertility with others. Remember, no one is going to react and respond well all of the time.
If you do decide to share your infertility with others, let them know what is helpful to you. People want to help and they are usually eager to know what to do. Some people find structured approaches helpful. There are groups on coping with infertility run by Alice Domar, Ph.D. at the Mind Body Program and at Harvard. Resolve, the non-profit group, often has support groups at a local level. Most of all, it is important to find the best way to take care of yourself.
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.
Dr. Andrea Mechanick Braverman is the Director of Psychological Services for Pennsylvania Reproductive Associates (PRA) and the Women's Institute for Fertility, Endocrinology and Menopause in Philadelphia, and is Associate Professor in Obstetrics and Gynecology for Thomas Jefferson University Hospital. Dr. Braverman received her undergraduate degree from the University of Pennsylvania and went on to complete two master's degrees in literature and in psychology and completed her Ph.D. at the University of Pennsylvania. Dr. Braverman trained in women's health and infertility and began as Director of Psychological Services at PRA in 1989.
Dr. Braverman is the past chair of the Mental Health Professional Group of the American Society for Reproductive Medicine and has served on many committees for the ASRM. She has been an active researcher and has published on many aspects of the field of infertility; Dr. Braverman has taught nationally and internationally. She continues to be active in Resolve, a non-profit group dedicated to the education, advocacy and support for infertility for infertility individuals.
Copyrighted © Andrea Braverman. Permission to republish granted to Pregnancy.org, LLC.