By Dara Roth Edney MSW, RSW, Reproductive Counsellor
Virtually everyone going through infertility or experiencing reproductive loss has heard this refrain from friends and family, as well as possibly even from your own, critical, internal voice, “you just have to relax!” Or this common suggestion, “It’s never going to work if you are so negative!” We live in a culture that tells people, especially women, to “relax” and to “stay positive” as though these things are easily done when experiencing something so difficult, and as though a positive mindset can change medical outcomes. We are also presented with the challenge of relaxing as though it is a state that if we try hard enough to achieve, we should be able to maintain.
The truth is that infertility and perinatal loss are devastating experiences that typically impact every aspect of a person’s life—from their intimate relationship to friendships and family connections, their work and their sense of their own bodies. A publication out of Harvard Medical School reported that levels of depression and anxiety in patients experiencing infertility are similar to those diagnosed with cancer, hypertension or heart disease. This experience feels so hard because it is so hard.
It is, therefore, unrealistic to expect yourself to reach and maintain a state of harmony and ease when month after month as an infertility patient, you measure your days in 2 weeks waits, cycling through feelings of excitement and hope, ambivalence and anxiety, despair and hopelessness, courage, and fear. And in fact, often the pressure to “relax” results in the exact opposite, in an increase in anxiety and self-blame.
I would like to present a new way to think about stress, emphasizing the process of reducing stress as an end goal itself, as opposed to the goal of eliminating stress in order to achieve or maintain a pregnancy.
Stress and Fertility
To begin, I’d like to note some reminders that challenge beliefs people may hold about stress and fertility:
• Most heterosexual couples start trying to conceive with joy and excitement, with little to no stress about the process at all, yet 1 in 6 Canadians end up with a diagnosis of infertility—their stress came after and as a result of their diagnosis, not before!
• Most 2SLGBTQ+ couples and single people come to the clinic with the assumption that once they access the donor or surrogate they need, they will have success, yet these patients can also experience unsuccessful treatment cycles and/or losses—their stress came after and as a result of their diagnosis, not before!
• Most people who have experienced recurrent losses were not inordinately anxious or worried before they had their 1st loss, yet that loss occurred—their stress came after and as a result of their miscarriage, not before!
• There are identifiable medical conditions that cause infertility—situations wherein a person had no reason to be under stress about their fertility until after they were told there was a concern about their reproductive system!
• There are a number of reproductive diseases that actually cause anxiety and depression (PCOS, endometriosis, low testosterone), so we know the mood disorders are a result of the disease, not the other way around!
• Many, many people all around the world are living in highly stressful, sometimes even dangerous situations, and yet, millions and millions of people worldwide get and stay pregnant—all while experiencing these stressors!
• IUI and IVF statistics illustrate the ways in which assisted human reproductive technologies can work—and yet every person you see in your doctor’s waiting room is living with the distress of their diagnosis, and with many with other significant life stresses as well. Yet we know that many will have successful cycles, despite the stress we know they are experiencing!
All this is to say that while there is overwhelming evidence that infertility and miscarriage cause stress, distress and trauma, there is no clear evidence that stress causes infertility and loss.
Stress and the Body
Here is what we do know about stress:
• When we are under significant stress, we do not sleep as well and are more likely to make poor choices in regard to nutrition, exercise and substance use
• When our bodies are sleep deprived, not properly hydrated and tense, bloodwork, transvaginal ultrasounds and procedures are more painful
• High degrees of distress can result in increased conflict between partners and distancing from support networks
• High levels of stress can impact attention span and memory, making it more difficult to focus on what our medical specialists are telling us, thereby impacting decision-making
• Research tells us that one of the significant reasons IVF is not successful is that people stop treatment before they might be successful—and the top reason for treatment discontinuation is psychological distress.
All these factors are good arguments for managing stress—not because reducing stress will directly lead to a pregnancy or prevent miscarriage, but because reducing stress will help make an objectively difficult process more tolerable and manageable.
This brings me to the final point in my post today—when you are experiencing something as life-impacting as infertility or recurrent loss, you have a right to have an emotional response. When you are going through what for many people is the hardest and most painful time in their lives, you have a right to feel distressed about your situation. The goal of stress management (or as I think of it, distress management), is not to eliminate all traces of anxiety, worry, fear or even “negative thinking.” The goal is to increase opportunities to feel other emotions so that by the end of a day or a week, it does not feel like every day, all day was filled with sadness and grief.
For example, imagine a Saturday that includes a 1-hour walk in the fresh air wherein you notice how calming your breath feels in your body and how energizing the wind feels on your face. Then what if you have a 30-minute chat with a loved one and leave that conversation feeling supported and loved? Maybe you then take a 1.5-hour nap and wake up feeling refreshed, engage in an activity that you enjoy for another hour or so, and then eat a delicious meal and watch a 2-hour funny movie.
None of these activities will “make you happy” as a permanent state that eliminates your sadness or worry about an ongoing source of sadness and worry. But, if you are able to focus on these things as they are happening and recall them later that day or the next and continue doing this as a practice as much as you can, you may start to notice a perspective shift—that the entirety of all your days do not feel burdened by sadness and grief, but layered in with other feelings as well. You may not “be happy” as an overall state of being, but maybe you begin to notice that you are not always feeling the same degree of sadness. Maybe, in with the sadness is a culmination of a few hours a day, when you feel supported, comforted, strong in your body, rested, distracted, or calm. Think of these times as opportunities to recharge your internal “resilience” battery, so you are fully charged when your distress is high.
The goal of reducing distress, therefore, is not so you can “be positive” or “relaxed” in order to achieve a successful pregnancy since your distress is not preventing this in the first place. The goal of reducing distress is so you can give yourself the gift of feeling better instead of worse some moments of some days, so you can gather the strength you need to better tolerate the hard things you are doing. And in this way, be able to do the hard things that give you the best chance of having the family you are already doing everything you can do, to have.
(1) Cumulative IVF pregnancy rates are compromised by the large number of couples who drop-out of treatment before achieving pregnancy. (Verberg MF, Eijkemans MJ, Heijnen EM, Broekmans FJ, de Klerk C, Fauser BC, Macklon NS. Why do couples drop-out from IVF treatment? A prospective cohort study. Hum Reprod. 2008 Sep;23(9):2050-5. doi: 10.1093/humrep/den219. Epub 2008 Jun 10. PMID: 18544578.)
(2) A prospective investigation into the reasons why insured United States patients drop out of in vitro fertilization treatment. Alice D. Domar, Ph.D., Kristin Smith, Lisa Conboy, Sc.D., Marie Iannone, M.S., and Michael Alper, M.D. Boston IVF, Beth Israel Deaconess Medical Center, Harvard Medical School, Waltham, Massachusetts