What Is Stress?

Stress can have an impact on a person’s cognitive process, emotions, physiology, and behaviors.ⁱⁱ But what is stress? And does stress affect fertility?  Stress is a natural response to challenges to a person’s physical or mental stateⁱⁱⁱ that can cause changes to a person’s endocrine (hormonal) system,^iv immune system,^v and mental health,^vi among other body systems.^vii,viii,ix  

There are a range of types of stress (Table I). It is important to define and understand many of the key terms relevant to the topic of stress (Table I); however, this article focuses on emotional stress, and whether it can affect one's fertility and/or fertility treatments. It is also important for women to know what tools are available to them in coping with stress when experiencing fertility challenges.

Table I. Some key terms related to stress

Stress

The normal, physiological response to a challenge to homeostasis (how the body regulates its internal environment).^x Not all stress is bad; for example, performing weight-bearing exercise causes stress to the muscles but is beneficial in moderation for overall health.

Anxiety

The DSM-5-TR defines anxiety as anticipation of a future threat, and may include cognitive, affective, behavioral, and physiological components.^xi This may include intense, excessive, and/ or persistent worries that can interfere with daily life.

Acute Stress

Stress caused by a challenging event or incident, such as an impending deadline or being stuck in a traffic jam on the way to an important meeting. The body and mind are typically able to recover from acute stress once the stressor is removed.^xii,xiii

Chronic Stress

Stress sustained over a prolonged period, such as that experienced by people living with chronic health issues or financial instability. This type of stress can be further divided into chronic predictable stressors and chronic unpredictable stressors.^xiv,xv

Physical Stress

The physical effects of stress on a person’s body systems, including increased heart rate and breathing rate, aches and pains in the body, and gastrointestinal (digestive) problems.^xvi

Mental/Emotional Stress:

The mental/emotional effects of either acute or chronic stress on a person, such as mood changes and feeling overwhelmed.^xvii

Fertility and Stress

It is estimated that up to 1 in 6 people will experience fertility challenges in their lifetime.^xviii Every stage of the journey to parenthood can potentially cause stress - from seeking out and waiting for a diagnosis, to undergoing the fertility treatments themselves. It can feel like a chicken and egg situation to try to discern what comes first: does stress cause infertility, or does infertility cause stress?  

A quick Google search may add to feelings of stress and guilt, as there are some studies suggesting that elevated stress hormones prior to trying to conceive are associated with poorer outcomes. Similarly, some studies have been published showing that reducing anxiety levels through psychological interventions may increase pregnancy rates, but it is important to look under the surface of these claims. When researchers conducted analyses of these studies, they found that all of them have significant methodological concerns, such as high dropout rates, small sample sizes, no controls of important variables, and an elevated risk of bias.^xix,xx,xxi

While there is a lack of solid evidence showing the impact of stress on infertility, this does not minimize the very real effects that stress can have on a person’s mental, emotional, and physical well-being, nor should it be used to suggest that there is no benefit to seeking support for one’s mental health during fertility treatment; in fact, there are many studies that show a positive effect on mood as a result of mental health treatments, especially when targeted for fertility related-stress.^xxii

When taken together, the research suggests that stress does not directly cause infertility, but infertility can cause stress,^xxiii and there are benefits to supporting a person’s mental and emotional health during what can be a very difficult time in someone’s life.  

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Fertility Treatments and Stress

Overall, the evidence base does not support a link that fertility medication and/or fertility treatments (such as IVF) directly cause anxiety and/or depression. Although fertility medications have generally not been found to be harmful, it is understandable that the disruption of one’s life, repeated injections, expenses, and other factors associated with IVF can affect a person’s mood. In addition, some research shows that fertility medications can cause emotional and physical side effects similar to PMS (Premenstrual Syndrome).^xxiv,xxv While there are some online sources that report stress hormone elevation can impact fertility outcomes, this research has too many limitations to draw such conclusions.

Anti-depressants/ anti-anxiety medications and fertility

Depression and/or anxiety can result from acute and/or chronic stress,^xxvi and a person may be prescribed anti-depressants or anti-anxiety medications to manage the symptoms of these mood disorders. Research has conflicting results regarding whether the use of these medications may have a negative effect on male or female fertility and fertility treatment outcomes.  

It is worth noting that all the research studies examining psychotropic medication and fertility are correlational, meaning that they show an association as opposed to a “cause-and-effect” relationship. This means they cannot directly connect to the role such medications have on infertility.

A 2021 literature review noted that the use of selective serotonin reuptake inhibitors (SSRIs, a family of commonly prescribed antidepressant and anti-anxiety medication) has either no significant effect or a very small effect on female fertility.^xxvii In males, several small studies have shown a possible connection, but this has not been confirmed in larger studies.^xxviii Associated studies have shown that SSRI exposure does not impair semen analysis parameters (i.e. concentration, motility, morphology).^xxix In contrast, SSRIs may potentially have an impact on erectile dysfunction and/or reduced libido, which could potentially impact fertility.^xxx In summary, there is a need for further research in this area.

It is well known that untreated anxiety and/or depression can have a significant emotional and physical toll on those who experience these conditions. Further, untreated depression and anxiety in pregnancy may be associated with risks to a pregnant woman and her fetus due to poor health behaviors (e.g., decreased appetite, substance use) often seen in depressed people.^xxxi Thus, even if psychotropic medication had a small impact on fertility, the use of psychotropic medications may still be important to consider for those struggling with depression and/or anxiety. As with any medication, patients should discuss the possible risks and benefits with their health care provider.  

Social markers of stress

When determining whether stress can cause infertility in men and women, it is important to remember that most people begin family building from a place of hope and excitement. Stress does not begin to build for these individuals until after they are already having trouble conceiving.^xxxii First there is the emotional stress a diagnosis of infertility may cause, followed by possible physical stress on the body from fertility treatments. For many individuals the financial burden of treatment adds stress as well.^xxxiii,xxxiv The effects of social markers of stress can be challenging to study and draw conclusions from, in part because there are various socioeconomic factors that influence fertility care and outcomes.^xxxv,xxxvi

It is also known that in some cases, these stressors may cause tension or strain between partners and within families,^{xxxvii,xxxviii} and can sometimes pose marital challenges.^xxxix  Despite these challenges, research shows that fertility treatment does not increase the risk of partners splitting up.^xl,xli Like strain in interpersonal relationships, social markers of stress will affect different people differently; for example, the financial strain an individual or couple experiences from seeking fertility care will be different for households in higher versus lower income brackets.  

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Coping With Stress 

It is understandable that someone undergoing fertility struggles and/or fertility treatment may be experiencing stress. There are things a person can do to help cope with stress due to infertility or fertility treatments that are safe and effective and may help reduce the effects of stress on one’s mind and body.

Mindfulness and meditation

There is a growing body of research on the benefits of Mindfulness-Based Interventions (MBI) on a range of body systems. While clinical studies are often made up of small sample sizes, research on MBI has shown it to be effective in improving mood, memory, attention, and stress reduction.^{xlii,xliii,xliv}  

Counseling

Cognitive Behavioral Therapy (CBT) has been shown to alleviate symptoms of depression and anxiety,^xlv and a recent large-scale systematic review of the available literature showed that “T effectively alleviates depression, anxiety, psychological distress, and infertility-specific stress levels and improves the quality of life among women with infertility, with few risks or negative side effects.^xlvi CBT undertaken during fertility treatment can also improve stress levels throughout pregnancy.^xlvii

If one chooses to seek counselling services, it is possible to search for a counselor or therapist who is fertility-aware; speak with an REI (Reproductive Endocrinology and Infertility) team for recommendations, or consult the ASRM (American Society of Reproductive Medicine)^xlviii (note- these are mostly based in the United States but there are some listed in other countries). One can also look for therapists or counselors in the area and enquire if they have any expertise in fertility, and/or if they have completed any specific training to support patients with fertility challenges.  

Support groups

Sharing one’s experience with others who are on the same journey can help a person feel less isolated and provides a convenient and safe space to discuss one's feelings.^xlix Seek out a group from a well-established organization, such as Fertility Matters in Canada^l or Resolve in the United States.^li Online support groups can contain misinformation, so ensuring that any group joined is reputable and managed or monitored by professionals is important.^lii

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Alternative therapies

Many individuals may choose to seek alternative therapies when experiencing fertility struggles. For instance, a 2011 review estimated that over 30 percent of women experiencing fertility challenges will seek out alternative medicine practitioners either to treat their fertility issues, or alongside conventional ART.^liii There are many kinds of complementary and alternative therapies, but acupuncture appears to be relatively frequently used by fertility patients.^liv

Acupuncture

Acupuncture may have a beneficial effect on mood; however, research is limited and shows no beneficial effect on male or female fertility.^lv,lvi People thinking about utilizing acupuncture treatments should consult with their healthcare provider to see if this treatment is appropriate.

Things to avoid

Cannabis

While many people use cannabis products to relax or help with sleep disturbances, cannabis use at certain quantities may have negative effects on sperm motility and morphology,^lvii,lviii  and may also contribute to erectile dysfunction.^lix  

Alcohol

Many people are moderate consumers of alcohol and may use alcohol to relax and unwind. However, excessive or heavy use of alcohol (more than one alcoholic drink per day for most women and two alcoholic drinks per day for most men) may be associated with an increased risk of infertility in both men and women but the research is inconsistent.^lx  

It is important to seek advice from a health care provider for questions regarding the safety of substances or medications during fertility treatment and pregnancy.

Conclusion

The stress of infertility can cause a great deal of strain on a person’s mental and physical health and wellbeing. Stress is not the cause of infertility, but the toll of the stress on a person undergoing fertility treatment may contribute to difficulty coping with infertility and infertility treatment.  Speaking to a health care provider about how one is feeling may help determine if a person might benefit from additional support for their emotional and mental health. MBI and CBT are low-risk interventions that can improve wellbeing and reduce the symptoms of stress, and other treatment like anti-depressant and/or anti-anxiety medications may be beneficial as well.  

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