How to treat depression, stress associated with infertility treatment

In one prospective, controlled, single-blind study, 184 women who had been trying to conceive for 1 to 2 years were randomly assigned to 10 sessions of group cognitive-behavioral therapy (CBT), a standard support group, or usual care. Sixty-four women withdrew before the study ended. After 1 year, women who received psychological interventions—47 in the CBT group and 48 in the standard support group—had statistically significant higher pregnancy rates, compared with 25 women who received usual care.¹⁶ Conversely, a literature review and evaluation of 25 studies found psychosocial interventions unlikely to improve pregnancy rates in infertile women.¹⁷

Methodologic problems. Most studies of stress’ influence on fertility are small, and many have methodologic problems.⁴ In some, researchers lumped together women whose infertility was caused by disparate diagnoses such as male-factor infertility, blocked fallopian tubes, and advanced age. Retrospective studies also must be interpreted with caution because:

• patients who did not become pregnant may have exaggerated the degree of their depression and its effects
  
• those with pre-existing medical problems would know they were unlikely to conceive and might have been more depressed before and during infertility treatments.¹⁸
  

The literature on infertility and stress is dominated by correlational studies. Because of insufficient controlled data, it is unclear whether stress affects the reproductive system.⁴

Recommendation. When counseling patients about the role of stress in infertility and its treatment, we recommend emphasizing that:

• infertility can cause stress in many areas of life
  
• the effect of stress on fertility, if any, is likely to be minimal for most women.
  

An infertile woman might respond to psychological counseling or psychotherapy even when a pregnancy is not achieved.^4,17,19

Case continued: Strain and anger

You begin to see Mrs. S weekly for supportive therapy, using cognitive restructuring and relaxation techniques to alleviate her anxiety and depression. She decides not to start an antidepressant because she does not want to be on medication if she becomes pregnant.

During the next 2 months she finishes an unsuccessful IUI cycle and reports that her relationship with her husband has become strained. She avoids friends who have children and feels angry when she sees a pregnant woman. She dislikes going to family events because relatives sometimes ask, “When are you going to get pregnant?”

Her work as a manager is suffering because of her many visits to fertility specialists. Her Beck Depression Inventory score has increased to 33, indicating worsening depression.

Infertility’s psychological toll

Patients rarely accept infertility with equanimity, and their responses include shock, denial, anger, isolation, guilt, and grief.⁶ Some women say the experience of being infertile feels comparable to having cancer.²⁰

The incidence of clinical major depression, poor self-esteem, and sexual dysfunction in women who undergo infertility evaluation does not differ significantly from that of their fertile peers.⁹ Even so, infertile women report a roller-coaster ride of emotions: hope as treatments are tried, despair when treatments fail.

Health care providers can add to the angst by telling women they have an “incompetent” cervix, “poor-quality” or “old” eggs, or “inadequate” mucus; these insensitive descriptions can lead women to blame themselves and feel ashamed, guilty, and depressed.^4,5,18

Psychotherapy. Providing education and teaching skills such as relaxation training has been shown to reduce depressive symptoms more effectively than having patients discuss their thoughts and feelings about infertility.¹⁷ Helpful psychotherapies emphasize CBT and improved coping skills.

Negative coping strategies include escape/avoidance conduct or self-blame (such as, “I’m not getting pregnant because I work too hard”). Encourage patients to replace these with protective coping strategies, such as seeking social support and engaging in active problem-solving (“I reach out to friends who help comfort me, and I set limits with friends who make me feel bad about myself ”).^21-23

Medication. Even though sadness and anxiety are normal responses to infertility, psychotropic medications might be appropriate after a thorough evaluation. Keep in mind, however, that selective serotonin reuptake inhibitors (SSRIs) can cause prolactinemia, which could interfere with ovulation.⁹ Miscarriage and stillbirth rates among women taking SSRIs are similar to those of the general population.²⁴

Case continued: It takes two

Despite three IUI cycles over 12 months Mrs. S has not become pregnant. She considers IVF but is concerned about the cost and the less than 50% chance of success.

You encourage her to continue individual supportive and cognitive therapy and to consider couple’s therapy. She and her husband decide to attend a group for couples with infertility. She accepts your referral to RESOLVE, a national support program for infertile patients (see Related resources).