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Complementary and Alternative Medicine Series

Infertility and the Mind/Body Connection

Alice D. Domar, PhD

The relationship between stress and infertility has been recognized since biblical times.1 Nonetheless, most infertility patients today are told that their stress level has nothing to do with their ability to conceive. However, recent research indicates that distress may indeed influence the outcome of infertility treatment, and that psychological interventions are associated with increased pregnancy rates.

PSYCHOLOGICAL IMPACT

Women who experience infertility report increased levels of distress, as this condition has an impact on virtually every aspect of their lives—ie, partner relationships, sex life, employment, relationships with fertile family members and friends, financial stability (most insurance policies do not cover treatment), and even religious beliefs. In addition, many infertile women are blamed by others for their condition.

Previous research on the psychological impact of infertility routinely utilized self-reporting, which tended to underestimate the true level of distress. The Àgold standard” in psychological evaluation is a structured personal interview with a trained mental health professional. In a study of 112 infertile women who were interviewed by a psychiatrist prior to treatment, 40.2% met criteria for a psychiatric disorder.2 The most common diagnosis was an anxiety disorder (23.2%), followed by major depressive disorder (17%); this compares with an average prevalence of 3%. The level of distress in infertility patients tends to increase as treatment intensifies,3 so it is possible that the 40% noted in this study would be even higher in a population of patients undergoing in vitro fertilization (IVF).

Because IVF is the most invasive and intensive form of infertility treatment, patient distress is common. In fact, most IVF patients report that treatment is more of a psychological than a physical stressor.4 Many IVF patients report depressive symptoms prior to initiation, which likely reflects the impact of prior unsuccessful forms of treatment. Demyttenaere et al5 reported that 54% of patients reported mild depressive symptoms prior to IVF, and 19% had moderate to severe levels. Almost 50% of IVF patients reported that infertility was the most upsetting experience of their lives.6

Most IVF patients report symptoms of depression, anxiety, anger, and isolation after unsuccessful treatment, and many of these feelings persist over time. In a retrospective study of 86 couples who did not conceive with IVF,7 66% of women and 40% of men reported symptoms of depression, and 33% of respondents noted depressive symptoms 18 months later.

While it is not surprising that infertility patients experience psychological symptoms after unsuccessful treatment, it is troubling that the majority of patients also report such symptoms prior to treatment. If psychological distress can interfere with the success of treatment and most patients are affected, then the impact of distress can not be overestimated.

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DISTRESS AND OUTCOME

Of the 21 studies on stress and IVF identified in the literature, 15 support the theory that distress adversely affects pregnancy rates, two found a trend, three found no relationship between distress and pregnancy, and one study did not supply data to support any conclusion. The studies that found a statistically significant relationship between distress and IVF outcome are summarized in Table 1,5,8-21 and those that noted no significant relationship are listed in Table 2.22-27

Table not available online

TABLE 1. Studies Indicating a Positive Relationship Between Distress and IVF Outcome IVF = In vitro fertilization.

Table not available online

TABLE 2. Studies Indicating No Relationship Between Distress and IVF Outcome IVF = In vitro fertilization; hCG = human chorionic gonadotropins.

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DROPOUT RATES

Because infertility patients are highly motivated, factors affecting the voluntary dropout rate (other than cost) have been underexplored until recently. It is widely presumed that patients discontinue therapy either because the physician instructs them to do so, or because they have exhausted their funds. However, active censoring by the physician or medical team is rare. A study in the Netherlands, where assisted reproduction cycles are covered by insurance, showed a cumulative dropout rate after three cycles of 62%, with only 14% due to active censoring.29

Research also suggests that cost is not the determinant for many IVF patients. In a study of 974 Swedish couples, 65% did not complete the three covered IVF cycles due to the psychological burden of therapy.30 Australian couples who were offered up to six cycles free of charge started a mean number of 3.1 cycles, regardless of whether a livebirth was achieved.31 The most common reasons for terminating treatment were emotional (66%).

A retrospective study analyzed data on 2,130 German patients who were covered by insurance for four cycles.32 The dropout rate for nonpregnant patients was 40% after the first cycle and 62% after the fourth cycle, and was attributed to increasing stress and frustration. This study included an analysis of the cumulative pregnancy rates for patients who did not discontinue treatment. The patients underwent a mean of only 1.92 IVF cycles, even though the mean number of cycles to conception was 2.12, and 49% underwent only one cycle. The real cumulative pregnancy rate was 31.4% after four cycles. However, it was estimated that if all nonpregnant patients had returned for only one more cycle, the cumulative pregnancy rate would have increased to 41%—translating to an ongoing pregnancy rate of 53%, increasing to 60% after six cycles.32

In a study of 211 couples who had insurance coverage for IVF but discontinued for reasons other than active censoring, the most commonly cited factor was psychological burden, followed by the perception of poor prognosis.33 Patients who discontinued treatment were as satisfied with therapy as those who continued. This is consistent with prior research showing that IVF poses more of a psychological than physical burden.4

A patient¡s psychological state prior to treatment may predict dropout behavior. In a prospective study, Smeenk et al34 gave new patients a battery of psychological questionnaires prior to starting treatment. All patients had insurance coverage for three IVF cycles. Pretreatment levels of depression were highly predictive of patient dropout behavior after only one cycle.

Thus, the majority of insurance-covered patients voluntarily terminate treatment prior to completing the allotted cycles. Not only are anxious and depressed patients more likely to discontinue treatment after only one cycle, but patients who prematurely terminate treatment cite psychological burden as the primary reason. Prematurely discontinuing treatment severely limits a couple¡s chance of conception. While the potential impact of psychological intervention on treatment termination decisions is unknown, it is plausible to assume that patients who receive support services should have lower discontinuation rates.

Perhaps it is time to consider psychologically screening all prospective infertility patients. If a patient is found to be psychologically healthy, she could undergo therapy knowing that her psychological state should have little or no impact on the outcome. However, a patient who is determined to be highly distressed could be counseled that receiving support services is likely to facilitate treatment, and may increase the chance of pregnancy and decrease the risk of premature termination. Current psychological interventions for infertility patients include psychotherapy, support groups, and mind/body approaches. Although there are few studies, a mind/body approach appears to hold promise.

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MIND/BODY INTERVENTIONS

Since 1987, mind/body infertility programs have been established throughout the United States and abroad.35,36 They generally include training in relaxation, stress management, and coping skills, plus group support. Programs range from five to 10 sessions, and most include the male partners. Sessions are led by mental health professionals, nurses, or both. Participants report significant decreases in all assessed psychological and physical symptoms, including depression, anxiety, hostility, fatigue, headaches, insomnia, and abdominal pain.35 Approximately 45% of patients conceive within 6 months of program completion.

A randomized, controlled, prospective study of infertile women assessed both symptom improvement and pregnancy rates.37,38 Participants were randomized into a 10-session mind/body group, a 10-session support group, or a routine care control group. There were significant differences in birth rates—55% in the mind/body group, 54% in the support group, and 20% in the control group. There were also significant differences in psychological status, with the mind/body patients reporting improvement, the support group reporting no change, and the control subjects reporting an increase in psychological symptoms.

The mechanism whereby such interventions increase pregnancy rates is unknown. However, in a randomized, prospective study that assessed natural killer cell activity in a group of 74 infertile women, 50% were randomized to a five-session mind/body group and 50% served as routine care controls.39 Psychological distress and natural killer cell activity decreased significantly in the intervention group, while the control group had no change. In addition, 38% of the intervention subjects conceived during the 1-year follow-up compared with only 13.5% of the controls (P < .03).

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CONCLUSION

Infertile women report elevated levels of distress, which may in turn contribute to their infertility. Highly distressed patients have lower pregnancy rates, and are more likely to terminate treatment. Preliminary research indicates that psychological interventions can decrease emotional symptoms and increase pregnancy rates. Specifically, mind/body approaches show the greatest promise in symptom improvement, and also appear to promote pregnancy. Because mind/body programs are easy to administer and utilize a group format, they are highly cost-effective as well.

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Alice D. Domar, PhD, is director, Mind/Body Center for Women¡s Health at Boston IVF, and assistant professor, Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Mass.

References

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