Stress is defined as “a state of mental and emotional tension resulting from adverse circumstances.” The desire to be a parent is a primordial urge. Many individuals are unable to attain this goal and suffer from guilt, helplessness, and depression. There is growing evidence that infertility can affect the overall quality of life of people. Psychological support and counseling are known to decrease the impact of these negative feelings. This review, as illustrated in the clinical case presentations, highlights the stress associated with this challenge. In each presentation, recommendations are made for assessing and dealing with the ongoing burden of stress.
Key points
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Identifying stressors in different patient populations.
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Educating patients to deal with their infertility journey.
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Counseling and support services for infertility patients.
Introduction
Infertility remains a global public health problem. About 186 million people worldwide and about 1 in 8 US couples are infertile. From 2006 to 2010, 6.9 million women (17%) between the ages of 25 and 44 years used infertility services in the interval from 2006 to 2010.
Significant advances occurred in infertility treatment since the birth of the first in vitro fertilization (IVF) baby, Louise Brown, in 1978. Increased utilization of these services resulted in approximately 2.3% of births in the United States every year. In 2021, the Centers for Disease Control and Prevention (CDC) Fertility Clinics Success Rates Report stated that 413,776 assisted reproductive technology (ART) cycles were performed in the United States. Of these, 167,689 were egg or embryo banking cycles. There were 91,906 live births and 97,128 live-born infants (CDC 2021 ART Fertility Clinic and National Summary report).
It is important to recognize that the treatment of infertility is a lengthy process and is accompanied by many challenges and failures. Combined with the biologic clock is society’s pressure to assume the role of parenthood.
Societal pressures lead to a stigma associated with the failure to reproduce. It is well-documented that infertility patients suffer from anxiety and depression as much as patients with cancer. Women who have experienced recurrent miscarriages and pregnancy losses meet the criteria for post-traumatic stress disorder.
Low self-esteem, guilt, anger, and frustration lead to feelings of shame, depression, anxiety, and a poor quality of life.
This review emphasizes the connection between stress and infertility. The article also discusses the diversity of professionals required to work together, incorporating holistic and medical options.
Discussion
Stress is ubiquitous and often connoted as “bad,” yet stress holds an essential purpose as it assists humans in reaching their performance potential (whether it is cognitive or physical).
Much has been written about the differences among eustress, distress, and a newer concept in stress called weathering. However, less research has looked at each of these categories of stress as it relates to infertility. Particularly when it comes to engaging with ART, this process is inherently considered stressful.
One place where stress is overstated is in its relationship with infertility, particularly as a cause agent of the disorder, which leads to a devastating cascade of negative emotions and an impact on a person’s sense of self. This article explores the interactions between stress and fertility treatments how patients might experience the two and the potential for negative consequences when they are ignored.
Decades-old research shows that an infertility diagnosis is equivalent in its emotional distress to a diagnosis of heart disease, cancer, or human immunodeficiency virus. Additionally, there is no argument that infertility treatment, with its rigorous schedules, the importance of medication being timed appropriately, frequent invasive examinations, seemingly endless waiting for the next steps, and the potential for negative outcomes, is stressful. This is often a reason that patients discontinue treatment, even if there is not a component of financial burden.
In infertility literature, 2 types of stressors are researched: the impact of stress on infertility outcomes (which typically looks at cortisol levels) and the impact of psychogenic stress, also known as the emotional burden of treatment. Separating these two concepts is important, as they speak to different challenges and perceptions that patients might experience.
Additionally, one looks at a potential biologic reason to explain (and thus cure) infertility; the other is a reaction to treatment within a system and its protocols. Research seems to suggest that while persistence seems to be the antidote to bringing home a baby, the stress (emotional, financial, and resources such as embryos) inhibits couples from continuing to try.
A conundrum that patients often encounter (by well-meaning loved ones) is the pervasive myth that stress causes infertility. So, patients are inundated with the advice of “just relax” or “go on vacation” as “cures” for infertility. Such interventions only have anecdotal evidence to support them, and yet continue to be pervasive, that even physicians believe that stress causes infertility, and counsel patients within that framework.
Complicating this, the stress-causing fertility myth is so rooted in the public’s view that the majority of fertility patients believe that stress causes infertility. What might be more beneficial to consider is the impact of fertility treatment on a person’s physical health, rather than the stress-causing infertility.
Infertility treatment varies based on the diagnosis and past treatment. Infertility also presents as both a “chronic stressor resulting from the threat of loss of plans to have children and an acute stressor resulting from the infertility treatment itself.”
Many studies look at stress as a justification to suggest psychological intervention. Whereas therapy or counseling can help in managing the many feelings that arise with both a diagnosis of infertility and the treatment itself, this is a normal reaction rather than the presence of a mental health disorder.
It is not a universal recommendation that every infertility patient needs counseling during treatment, as a majority of people adjust to their infertility treatment and return to their baseline pretreatment. Although certain conditions correlate positively to mental health challenges, such as polycystic ovarian syndrome (PCOS), fibroids, and endometriosis, where a more universal recommendation to seek mental health treatment is warranted. That being said, counseling during infertility does prevent the interpersonal and marital problems that can arise during treatment.
In discussing all aspects of the origins of stress, it is also important to mention the stress at the clinic itself, which the patient either interacts with or subtly feels.
In the last decade, there has been a major shift in the organization of private fertility clinics as venture capital and private equity buy clinics and consolidate. While the stated goal of this venture is to improve efficiencies and reduce redundancies in the clinic operations, these firms are notorious for expecting a return on investment within 3 to 7 years, which brings concerns about patient care.
Physicians and staff are given goals to reach to increase cycles performed and money earned, which often equals procedural or testing add-ons that are not seen as a standard of care, which are offered as ways of (hopefully) garnering success. This creates a layer of stress within the team regarding a clinic’s earning performance, which is not considered a medical indicator of care but is driven by the pressure of a quick turnaround for profit.
This might translate to overworked front office staff, nurses having caseloads that might be too heavy to manage, physicians performing procedure after procedure, or feeling the pressure to “sell” IVF versus less invasive (and expensive) treatment modalities.
Such stress, though unspoken, is often felt by patients who might doubt their ability to be successful in achieving pregnancy or who might feel minimized and unseen ( Fig. 1 ).
Perhaps a more helpful framework in which to think about the emotional “asks” of patients during infertility treatment is their quality of life. While the impact on a person’s quality of life can be the emergence (or reemergence) of a mental health condition (such as depression or anxiety) as well as the emergence of sexual dysfunction, it can also have an impact on a person’s (particularly the male partner’s) self-esteem.
These findings span across cultures and are replicated worldwide. Several validated measures to assess the impact of infertility on a person’s quality of life are easy to administer and might assist physicians in making suggestions as to mental health care during fertility treatment. Examples include the fertility quality of life, which has been used for over a decade and is the tool most used in research about these 2 intersections. Other instruments include the fertility problem inventory, fertility problem stress, and the infertility questionnaire. All the instruments taken together can give a robust snapshot of a patient’s emotional response to treatment.
Another aspect to consider is how infertility impacts a person’s identity. Parenthood status is often correlated with the perceived achievement of one’s gender identity status within society, and this identity-seeking is typically more critical to cisgender female patients than male. This is another consideration when treatment is not proceeding as imagined, as the internalized stressor of failing to become a parent.
The earlier frameworks are valuable ways of looking at the acute stress that infertility can bring to a person or a couple. The data are far from conclusive about acute stress contributing to infertility.
There are outcome differences in race that cannot be accounted for based on past theories of obesity and access to care.
Minoritized individuals due to race, ethnicity, religion, sexual orientation, or gender identity are more likely to internally carry stress as they interact with the world. The minority stress model (MSM) lays out the complexity of having a minority status in the world and how it stigmatizes and is prejudiced against these identities. Meyer’s initial model did not account for the intersectionality of identities, or the variety of gender identities people connect to.
A newer model expands on the MSM and describes how minority stress can be additive based on intersecting identities. It also accounts for the fact that various identities do not exist separately but interact and intersect within a person.
The temporal intersectional minority stress (TIMS) model updates Meyer’s critical work and incorporates the idea of multiple layers of identity in how a person experiences stress as they work within systems that were not constructed with these identities in mind. TIMS includes the additional factors of historic time, ontological time, generational time, and social hegemonies to the existing MSM factors of intersectional identities (historically, this was LGB), general stressors, proximal and distal minority stress processes, perception of identities, coping and social support (both on an individual and community level), and health and well-being. This model enables health care providers to consider all aspects of stress that a patient might walk into the consulting room with.
While there has yet to be a study to document the patient’s experience, it is often recounted in therapy rooms. There are a multitude of stressors, external, internal, environmental, and situational that can impact a person’s experience while undergoing fertility treatment. These stressors are important to acknowledge and account for, though correcting them is impossible.
Clinical care presentations
The following case examples demonstrate how the intersection of stressors might manifest. Suggestions and recommendations are provided. These are not the only ways to manage these clinical situations, but the authors have found they are most often successful within our practice experiences.
Advanced Maternal Age
History
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A 42 year old African American single woman.
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Started exploring fertility options at the age of 40 years. She underwent a myomectomy.
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Followed by another hysteroscopic surgery to remove additional fibroids 6 months later. This was followed by another laparotomy 1 year later. Several fibroids were removed, and endometriosis was diagnosed and treated.
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At the age of 42 years, she was interested in finding out her reproductive options.
Assessment
This case illustrates many factors that may either cause or exacerbate existing stressors, and it is crucial for the health care provider to take these into account.
Many women feel a sense of urgency as their reproductive window narrows. This urgency can impact many life decisions, ranging from relationships to career choices. The recent availability of egg cryopreservation has helped to lessen this burden. Still, egg cryopreservation procedures are expensive (and often not covered by insurance), and the frozen eggs are not guaranteed to lead to a successful pregnancy. Recent studies suggest that only about 12% of women who freeze their eggs return to using them.
The decision to pursue parenthood is often a joint decision, but in a case such as this, the decision to pursue parenting as a single woman can add additional stress. There can be issues of isolation and shame. Fortunately, community resources such as Single Mothers by Choice can help support a woman during the decision-making process and act as a support network after the baby is born. Having a robust family and friends’ network also helps to alleviate the burdens of single parenthood, and it is a worthwhile suggestion for the patient to begin to lean on and cultivate these supports early in treatment.
A delay in the treatment process is frustrating and stressful. In this case, 3 surgeries delayed pursuing fertility treatment for 2 years. Every surgery was most likely accompanied by the emotional toll of the sense of wasting valuable time along with a sense of betrayal of one’s own body. These issues can affect the healing process and should be considered during her postoperative care.
Recent studies on the cultural issues surrounding infertility treatment suggest that black women are more likely to experience fertility issues when compared to their white counterparts. Still, they are far less likely to seek treatment because of cultural or religious barriers. In the last 10 years, community organizations such as Fertility for Colored Girls, founded by the Reverend Stacey Edwards-Dunn, and The Broken Brown Egg, founded by Regina Townsend, have stepped in to address this inequity.
Given her age, the reality of her being a genetic parent to a child is dwindling. Moving to the potential next step of using a donor egg or embryo creates another aspect that patients can find overwhelming, particularly when they did not expect surgical delays in their family-building journey. This can be an added area of difficulty to accept depending on the patient’s religious and cultural affiliations, as many groups place a high value on kinship relationships in terms of belonging to the community and inheritance.
Treatment recommendations
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Develop a support plan with the patient regarding places and people that she can turn to for emotional support (this will also be useful during pregnancy and parenting.).
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Review recent blood work results to explore her options of being a genetic parent.
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Discuss recommendations about using donor gametes or embryos for future-assisted reproduction.
Recurrent Pregnancy Loss
History
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A 35 year old Caucasian woman married to a 31 year old man who has children from a prior relationship.
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History of recurrent pregnancy loss: Gravida 7, para 0, Elective termination 1, ectopic pregnancy 1, miscarriages 5 (including 4 preimplantation genetic tested euploid embryos (PGT-A).
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Spontaneous conceptions 2.
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Intrauterine inseminations 1.
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In vitro fertilization cycles 4.
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Extensive evaluation into causes of repeat pregnancy loss is unremarkable.
Assessment
Pregnancy loss is often associated with a sense of grief, frustration, and self-blame. Studies have shown that bereavement experienced by patients is like the death of a loved one, but pregnancy loss is often considered to be a disenfranchised type of grief, as it tends to be invisible to all, but those directly experiencing it. In addition to a thorough clinical evaluation, it is imperative these patients get emotional and psychosocial support, which can come in the form of online groups, in-person groups, social media groups, individual therapy, or couples therapy.
The sense of failure experienced by these patients is compounded by the pressures in the couple’s relationship. Since the partner has biologic children already, the patient feels further loss. It is imperative to consider the dynamics of the couple’s relationship when treating these patients. Emotional and financial pressures can damage relationships and result in marital separation.
Counseling and reassurance are essential. Although a cause for miscarriages can be found in about 60% of cases, there is a minority of patients who have unexplained pregnancy losses. These women should be reassured that instead of losing hope, they have a 40% to 50% chance of having a successful conception. These patients are fragile and need exceptional understanding. Support groups for these patients are important and are available through organizations like the RESOLVE, the Return to Zero Hope, and the Recurrent Pregnancy Loss Association.
Individual and group counseling have shown that treatment outcomes have improved after stress reduction. Shown to decrease the sense of self-isolation, groups can also bring out other loss experiences that occur later in pregnancy, which can be frightening.
Treatment recommendations
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A thorough and detailed evaluation of causes of recurrent pregnancy loss.
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Reassurance that 40% of cases have unexplained pregnancy loss and the success rate is as high as 50% to 60% in these couples of achieving their goal of a family.
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Referral to a mental health professional for grief counseling and relationship and couples counseling.
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Sharing of online resources that might be more peer support based.
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Support from friends and family.
Transgender Fertility Care
History
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A 32 year old African American trans-male married to a 28 year old biracial cis-female. They want to have a family using the eggs from the trans-male, fertilized with donor sperm, to be carried by the cis-female partner.
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The trans-male patient has been on testosterone therapy for 6 years until 2 months before the visit to the clinic.
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He had undergone top surgery before the marriage. Since the marriage, he has undergone bottom surgery and phalloplasty.
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In vitro fertilization was used to create embryos that resulted in pregnancy.
Assessment
Historically, family building has been considered a heteronormative, cis-normative endeavor. Only a small percentage of patients receive counseling for fertility preservation before embarking on gender-affirming protocols, or surgery.
Although society has started accepting more gender-affirming family-building options, the path to parenthood for lesbian, gay, bi-sexual, transgender, queer (LGBTQ) individuals is complex and uncertain. Inequitable access to reproductive care results from lack of access, lack of financial resources, and the lack of providers that have the knowledge and the training to help this marginalized population. The potential of hormonal interventions is often misunderstood by untrained providers.
Transgender individuals may also be concerned about the interference with their transition journey. Cessation of hormonal therapy may generate gender dysphoria in these individuals. The patients’ own experiences have been noted to be more acceptable if the clinic and the provider were knowledgeable and used gender neutral terminology.
Being a double minority means that the stress experienced by this individual is likely to be heightened in the fertility clinic. Clinics should take great care to be both trauma-informed and LGBTQ+ affirming to minimize this minority stress while undergoing treatment.
The recognition that transgender parenting is a complex and challenging process for the family (including any children and a cis gender partner) is important. Children born into a family with a transgender parent do not experience a sense of loss and are more likely to accept the status, as opposed to older children where one parent is transitioning later in life.
Treatment recommendations
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Referral to resources (health care providers, therapists, institutions) that are LGBTQ friendly and knowledgeable.
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Discussing communication regarding their family identity with their children and nonfamily members.
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Recognizing the lack of insurance coverage of fertility treatments, federal regulations for sperm and egg donation, and legal definitions of parenthood.
Fertility Preservation for Oncology Patients
History
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A 36 year old African American woman was referred by her hematologist-oncologist for fertility preservation.
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She had been previously diagnosed with idiopathic thrombocytopenic purpura and sickle cell trait.
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She had genetic carrier screening last year and was found to be a carrier of the breast cancer 1 gene mutation (BRCA 1 mutation).
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She had been advised to undergo a bilateral mastectomy and a bilateral salpingectomy.
Assessment
About 3% of breast cancers (about 7500 women per year) and 10% of ovarian cancers (about 2000 women per year) result from inherited mutations in the BRCA1 and BRCA2 genes.
In this case, preserving future fertility is complicated by an underlying medical disorder and a gene mutation that will place her at an increased risk for cancer. Although the recommended surgery will not remove her ovaries, the removal of her fallopian tubes will make in vitro fertilization necessary for conception. In addition, half of her eggs will carry the gene mutation so she should adjust her goal of how many eggs to freeze accordingly.
At a young age, she must prepare for future family building plans, in addition to dealing with her genetic predisposition to breast and ovarian cancer. Fortunately, with the advances in preimplantation genetics, the BRCA gene can be detected in the embryo.
A multidisciplinary approach including oncologists, geneticists, reproductive endocrinologists, nursing, and mental health professionals is necessary, to work as a team to guide her journey. It is daunting for a patient, to coordinate this care. But thinking of their future family needs and fertility preservation is an essential part of reducing the significant distress experienced by them.
Oncofertility benefits from a patient navigator, to decrease the stress and distress experienced by these patients.
Treatment recommendations
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Providing a clear set of treatment options including fertility preservation.
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Sharing resources for groups or mental health professionals to assist with complex treatment decisions.
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Access to a patient navigator can help guide her through the different providers.
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Ensuring psychosocial support for her and her family.
Summary
The case examples highlight how different factors can impact an already stressful process.
Most importantly, acute stress (the most common stress experienced) does not cause infertility; however, the infertility process does cause additional stress. From ceding control of one’s personal schedule, complying with an injection regimen, and having professionals examining one’s body, the actual procedure of fertility treatment is stressful.
The pregnancy rate in women using ART varies depending on the female’s age. However, the dropout rate from treatments has been reported to range from 20% to 60%. Several factors are responsible for this, including the financial burden associated with treatments.
Excluding financial factors, psychological stress (26%), and poor prognosis (25%) were the main reasons why patients stopped treatment.
Poor communication, difficulty in accessing the clinic, and lack of information from the medical staff were some of the main reasons verbalized by patients as contributing to the stress of their journey.
Staff training and organization are necessary to mitigate some of the psychological stress experienced by the patients.
In this article, the authors have highlighted areas of stress that may be present in people diagnosed with and being treated for infertility. The authors also outline potential tools to assist the clinician in identifying and treating these people ( Fig. 2 ).
