I have been researching the stress/infertility relationship for more than 30 years, and in fact, have devoted much of my career to it. I am an associate professor of obstetrics, gynecology, and reproductive biology, part-time, at Harvard Medical School, and the chief psychologist for Boston IVF, one of the largest infertility centers in the US. I have personally conducted four large randomized controlled trials on the topic and written several books, including a recent textbook published by Cambridge University Press.
My parents' experience likely influenced me; I grew up hearing the story of my mom’s miserable experience with infertility, which was miraculously solved by the conception of my older sister after a month or two of antianxiety medication. Hence, in our family, it was accepted that infertility causes stress and stress causes infertility.
But am I suggesting that if an individual or couple can’t get pregnant easily, it is their fault because it means that they are too stressed? Definitely not.
I want to make the case that the conversation should focus on how profoundly infertility can impact the lives of individuals and couples and what can be done to help.
The conversation should focus on how profoundly infertility can impact the lives of individuals and couples and what can be done to help.
We Know Infertility Causes Stress
There is no doubt that infertility causes stress. One of my earlier publications showed that the anxiety and depression level of women with infertility was equivalent to that of women with cancer, HIV+, or heart disease.
More recently, in a study of several thousand women undergoing infertility treatment during the first Covid19 surge, we found that infertility was a more frequently cited stressor than the pandemic.
That may be surprising to some but not to those of us who work with infertility patients daily.
Infertility can have a negative impact on virtually every aspect of an individual’s or couples’ life; their relationship, their sex life, their relationship with family and friends, their job/career, their financial security, and their religious faith.
Research out of UCSF showed that women and men undergoing infertility treatment report far higher levels of depression and anxiety than community norms.
It is an accepted fact that infertility does indeed cause enormous stress.
The urge to procreate is one of the strongest urges in the animal kingdom. So at this point, it is an accepted fact that infertility does indeed cause enormous stress. It is also accepted that the stress of infertility can impact behaviors that can influence fertility, such as decreased libido, smoking, drinking alcohol, eating too much or too little, etc.
Infertility is a Disease; Stress Doesn't Change That
But is it true that if you “just relax,” you will get pregnant? No. The World Health Organization (WHO) has classified infertility as a disease. Most individuals with infertility need medical and/or surgical treatment to conceive. However, the fact that most people with infertility need treatment to conceive does not mean that stress has no impact on fertility.
Is it possible that stress can make it harder to conceive, even with high-tech treatment?
Self-Reported Research on Stress & Infertility
There have been dozens of studies that have examined the self-reported stress levels of infertility patients and looked to see if they are connected to subsequent pregnancy rates (e.g., Eisenberg et al., 2010, Gameiro et al., 2009; Verhaak et al., 2005 Cousineau & Domar, 2007; Zimmerman & Coryell, 1994).
Some of the studies have shown that yes, the more anxious or depressed the woman, the less likely she is to conceive. And some of the studies have not shown a connection.
Although it doesn’t seem to make sense, there are a variety of possible explanations: women knowing their prognosis, which can impact their mood at cycle start, individuals “faking good” on self-report questionnaires since they may not want their physician to know how distressed they are, and the fact that many women feel more optimistic when they start a cycle so their stress level then may not be reflective of their overall stress level.
Thus, asking patients to self-report how they feel at the start of a cycle may not be an accurate way to assess stress. What would be?
IVF, Stress & Cortisol Levels
A group in Europe is doing unique research on measuring stress by looking at cortisol levels in hair. That way, one doesn’t have to depend on a patient’s perception of stress since cortisol is a physiological measure of stress.
And since hair grows slowly, one can assess stress over a period of months, not days or weeks. This group has performed several research projects on women undergoing IVF, and all of their research has determined the same thing; the higher the hair cortisol level, the lower the subsequent pregnancy rates from IVF treatment.
Other research has also strongly indicated the role that stress can play. In a study, doctors from Boston IVF contacted women who had received treatment for infertility 2001-2006. They discovered that an astonishing 64% of these women achieved a spontaneous conception after treatment.
Wouldn’t this suggest that stress can play a role?
Psychological Intervention & Pregnancy Rates
More evidence for the stress/infertility connection lies in the research on the pregnancy rates in women who receive a psychological intervention, such as cognitive behavior therapy either individually or as part of a group.
Although it is challenging to conduct such research, the most recent meta-analyses indicate that psychological interventions are correlated to significantly higher pregnancy rates.
If a woman who attends some psychological intervention is significantly more likely to get pregnant than a woman who was assigned to a routine care control group, doesn’t that indicate that stress plays a significant role?
Physiological Evidence of Stress
A groundbreaking study published in the Journal of Neuroscience has finally provided physiological evidence that suggests stress and fertility are linked. Senior author Greg Anderson, at the University of Otago School of Biomedical Sciences in New Zealand, reports that after ten years of research, they have discovered a part of the brain that links the stress response and reproduction.
When activated by stress, the group of neurons, called RFRP neurons, decreases fertility by suppressing ovulation and other aspects of fertility. When the researchers destroyed that area of the brain, stressing the mice did not decrease fertility. This suggests that stress and fertility are indeed related.
Dr. Anderson points out that this has only been determined in animal studies, but they are hoping in the next 5-10 years, they will be able to block that connection with medication. Anyone experiencing infertility could take that medication, and it would block any harmful impact of stress on their ability to conceive.
Learning to Manage Stress is Important
So what should the takeaway message be? If an individual or couple are stressed and cannot get pregnant easily, is it their fault? Again, definitely not. The vast majority of people who experience infertility and have a thorough workup receive a definitive diagnosis. And most of them will conceive with appropriate treatment.
But that journey brings many ups and downs, which I consider a true roller coaster ride. So people get stressed, and at that point, their stress level may contribute to the problem. Plus, being stressed is unpleasant. It can lead to physical symptoms such as insomnia, headaches, neck and back pain, gastrointestinal symptoms, etc. When one is stressed, it can lead to irritability, food cravings, fatigue, and loneliness.
As a psychologist, I would far rather see people learn how to decrease their stress levels via counseling, meditation, exercise, acupuncture, joining a group to learn mind/body skills, or a host of other ways to decrease stress. Still, there is some comfort to know that if none of those methods are effective, there may be a pharmaceutical backup available in the future.
Learning ways to decrease stress can only be a good thing. Even if you don’t believe that stress and infertility are linked, what is the downside of sleeping better, feeling healthier, having less pain, and being more pleasant to be around?
Even if you don’t believe that stress and infertility are linked, what is the downside of sleeping better, feeling healthier, having less pain, and being more pleasant to be around?
I founded the Mind/Body Program for Infertility in 1987, and we have been collecting data on participants since then. In our research on the mind/body program, pregnancy rates have averaged more than 50% (see studies below), within six months of completing the program. Physical and psychological symptoms decrease; insomnia disappears, headaches are far less frequent, depressive symptoms fall, and most women report rediscovering “their old self.”
We have conducted two randomized controlled trials (2000, 2011), both of which showed significantly higher pregnancy rates in the women who participated in the mind/body program. Participants also reported less anxiety, depression, and irritability. And a recent study on a new online version of the program showed the same results.
The Real Focus: Quality of Life
What we need to attend to is how profoundly infertility can impact the lives of individuals and couples struggling with infertility.
I have stopped researching the stress/fertility connection since I don’t think arguing about the direction of the relationship helps anyone. Instead, my research focuses on improving our patients' quality of life; I have been training physicians, nurses, and support staff on how to communicate more empathetically.
For the past five years, I have been trying to determine how best to care for patients during treatment to not drop out due to stress, which is the leading cause of treatment termination for insured patients. I am about to start a study to investigate better ways to break the bad news to our patients. We all need to practice patient-centered care.
Let's stop arguing about whether or not stress contributes to infertility. We know that infertility causes stress but does it really matter if stress does or does not cause infertility? I believe that the research does show a connection, but the last thing I would ever want is for an individual or couple to feel guilty about their stress level.
What we need to attend to is how profoundly infertility can impact the lives of individuals and couples struggling with infertility, and how to apply what we know to teach them how to get their lives back, how to feel physically and psychologically healthy, and how to steer them in the direction of conceiving a healthy baby.
Editor's Note: The American Society for Reproductive Medicine (ASRM) position is that "it is not clear how exactly stress impacts fertility." For an alternative expert opinion, see What Research Says About Stress as a Cause of Infertility
- Infertility remains a top stressor despite the COVID-19 pandemic. (2020).
- Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services?. (2016).
- Infertility is a global public health issue. (n.d.).
- Are increased levels of self-reported psychosocial stress, anxiety, and depression associated with fecundity?. (2012).
- Relationship between hair and salivary cortisol and pregnancy in women undergoing IVF. (2016).
- LONG TERM FOLLOW UP OF REPRODUCTIVE OUTCOMES IN FASTT PARTICIPANTS. (2020).
- Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis. (2014).
- Impact of group psychological interventions on pregnancy rates in infertile women. (2000).
- RFamide-Related Peptide Neurons Modulate Reproductive Function and Stress Responses. (2020).
- Recognizing and easing the physical symptoms of anxiety. (2020).
- Impact of group psychological interventions on pregnancy rates in infertile women. (2000).
- Impact of a group mind/body intervention on pregnancy rates in IVF patients. (2011).