Stress and Reproductive Health

Reproductive health refers to the complete wellness of the reproductive processes and functions in a woman. Recent years have seen a steady increase in the number of women seeking medical help from issues ranging from irregularity and abnormality of menses to unsatisfactory sex life to infertility. The staggering rise in the prevalence of infertility in the population has been one of the major challenges staring at the face of modern medicine.

A year of not conceiving despite regular unprotected intercourse is the clinical definition of infertility. The considerable rise in infertility has led to speculations over the role of changing lifestyle and environmental factors in contributing to the same. Factors like increasing obesity, environmental pollutants, cigarette smoking and consumption of alcohol are believed to be the main culprits, however, late marriages and intentional delaying of pregnancy may also play an important role.

Whenever “modern lifestyle” is mentioned, the mention of the stress accompanying it becomes almost inevitable. Up to 30-40% cases of infertility remain unexplained, and though a part of this is suspected to be attributable to stress, the role of stress in infertility has not very well been established. This is essential because it is difficult to measure stress quantitatively. The cause of infertility has become less relevant in recent times owing to the emergence of increasingly better assisted reproduction technology (ART) techniques. However, optimizing natural fertility is nevertheless important. Such knowledge could potentially lead to relatively easier and cheaper lifestyle modulations prior to referring couples for ART interventions, as the use of ART too, is not without risk to the women.

The close link between the hypothalamic-pituitary axis (HPA) and hypothalamic–pituitary gonadal axis (HPG) is well known (i.e the link between the brain and the reproductive system) and physical and mental stress has consistently been shown to cause dysregulation of the women’s menstrual cycles. When a condition is perceived stressful by the body, the brain sends signals to the sympathetic system (the nervous system dealing with stress). The body is thereby “directed” to abandon any plans of conception in view of less than ideal conditions. Transient stressful stimuli are relatively benign but if the stress becomes chronic, the HPA becomes activated as well and may lead to the suppression of the normal menstrual cycle (hypothalamic amenorrhea). Cessation of menses at the time of competitive exams or following a relationship break down are frequently observed. This may culminate in infertility in severe, long-standing and established cases. 

Every menstrual cycle starts with the production of an egg in the ovary in anticipation of a pregnancy. For adequate folliculogenesis (formation of eggs in the ovary), a proper synchronization of the reproductive hormones is essential. The delicate balance (loss of GnRH pulsatility) between various female reproductive hormones is lost in presence of chronic stress. This leads to not only abnormal ovulatory patterns but also to diminished progesterone secretion during the luteal phase of the cycle. This progesterone is a hormone which is very essential for the establishment of pregnancy. Thus, irregular bleeding patterns, long irregular cycles, and abnormal luteal phases are typical of this syndrome (functional chronic anovulation syndrome). However, there is a relation between the severity of the stress and the proportion of women who develop reproductive issues, though it is nearly impossible to determine the threshold at which stress would affect fertility. 

Up to  30% decrease in fecundity (pregnancy potential) and up to 2 fold increased risk of infertility has been found among women with the highest stress levels in clinical studies. Highly stressed-out couples may have reduced frequency apart from more “mechanical” sexual intercourse further adding to the problem. Erectile dysfunction of males is also strongly related to stress, leading to marital disharmony. This results in a cruel and vicious cycle. The response of infertile patients in dealing with the lack of success may range from aggressively pursuing even the most ridiculous of treatment and procedures to completely withdrawing and giving up on all treatment attempts. Deferring treatment due to depression and stress is probably the worst scenario as age remains the most important and unrelenting determinant of a woman’s fertility. The psychological effects of infertility may range from a feeling of role failure, diminished self-esteem, guilt, loss of self-confidence to a feeling of incompetence, loneliness, fear, anger, shame or frustration. Depression and lack of sexual desire are almost always present.

• Depression & Infertility - Symbiotic Sisters Obstructing Pregnancy

Fertility treatment is frustrating for both the clinician as well as the patient, and some stress is inevitable. The mental anguish that arises from infertility is said to be nearly as incapacitating as the pain of other diseases. However, finding ways to minimize stress while pursuing treatment helps. Some of the popular methods for infertility patients are:

• Acupuncture 
• Aerobic exercise
• Listening to music
• Massage therapy
• Meditation
• Psychotherapy and cognitive behavioral therapy
• Self-help books
• Sex with no fertility agenda
• Support  groups
• Trekking
• Yoga

Reduced stress is good for health in general. Eliminating stress before trying to become pregnant might shorten the time couples need to become pregnant in comparison to ignoring stress. There are reports in the literature of unassisted conception following adoption in women labeled ‘infertile”, as are reports of increased pregnancy rates among women treated with psychotherapy compared with untreated women. However, stress is one of the many factors involved in infertility. Stress management would not lead to pregnancy per se in most cases, but coping strategies would make one feel more in control, reduce the pre-occupation with infertility, feel empowered and allow to explore and consider all the options available with a clearer mindset. By reducing stress, the merits and demerits of a particular treatment approach course over another can be more effectively weighed.

Thus the practical consideration following this discussion would possibly to closely look at one’s lifestyle following 6-8 months of unsuccessful attempts of pregnancy before seeking advanced medical help.