Despite the richness of the English language, we wrestle to express the connection between the mind and the body in non-dichotomous terms. Our metaphors, however, have no such problems. We speak of heartache, of someone getting under our skin, or of being a pain in the neck. Sometimes the metaphors are connected to quite similar manifestations in our bodies. Most of us are readily aware that stress negatively affects our physical health, and joy and laughter relieve pain and make us feel better, or even our infertility.
Growing research reveals the physiology underlying these connections. In this article, I will review the mechanisms by which stress may impair fertility as well as the studies that reveal how relaxation may make it easier to conceive. I will also describe practices that tone your autonomic nervous system, reduce your stress, and enhance your well-being.
The Physiology of Stress
The body uses hormones to signal when it is overly stressed. While many are aware that the brain signals the adrenals to produce cortisol during times of stress, fewer know that the hypothalamus and pituitary glands also signal the ovaries and testes.
Under normal—i.e., non-stressful—circumstances, signaling begins when the hypothalamus secretes gonadotropin-releasing hormones (GnRH). In turn, GnRH instructs the pituitary glands to produce luteinizing and follicle-stimulating hormones (LH and FSH) which then signal the ovaries and the testes to produce hormones. In women, FSH stimulates the growth of follicular cells and the production of estrogen. Luteinizing hormone controls the maturation of the egg as well as ovulation and the development of the corpus luteum, which produces progesterone. The whole dynamic system reverses when the brain recognizes that no more estrogen and progesterone are needed. This bidirectional feedback loop is classical for endocrine systems.
Stress turns out to have both a direct and an indirect effect on the brain, as well as on the sexual organs of men and women. Stress acts directly on the hypothalamus by suppressing GnRH, which reduces the secretion of LH and FSH, the hormones that signal the ovaries. In men, stress can have a negative effect on the testes, reducing testosterone production and the creation of sperm.
When we are stressed, the hypothalamus also signals our adrenal glands to produce glucocorticosteroids. Women have glucocorticoid receptors throughout their bodies, including on their follicles, corpus luteum, and ovaries. These receptors allow the stress hormones to signal the ovaries that the timing is not right for reproduction. Glucocorticosteroids also directly signal the hypothalamus to produce less GnRH.
From the perspective of evolutionary biology, this interdependence makes perfect sense: when a woman is under great stress, it signals the body that this is a time to focus on survival rather than reproduction.
But therein lies the problem: many of us live chronically stressed lives. We are constantly activating our sympathetic nervous system, which is responsible for the fight-or-flight reaction. We need to activate the quieting side, our parasympathetic nervous system. We can learn to do so: with regular practice our bodies can rapidly go to a place of deep relaxation. If you have trained your body in relaxation, the well-established pathway in your brain greatly improves its ability to calm itself in times of stress.
There are many mind-body methods to choose from. The key involves finding one that resonates for you, one you will do with regularity, turning it into a practice. Type-A personalities often have a terrible time sitting still, and therefore struggle with meditation or breath counting. More active forms of relaxation—such as yoga, t’ai chi, or progressive muscle relaxation—often work better. Other people are attracted to interactive guided imagery, mindfulness-based stress reduction, or breathing practices.
Breath work is what I recommend most often to my patients. Our breath is free, is always with us, and we can learn techniques quickly and do them anywhere with no special equipment. One meditative breathing practice that I teach women struggling with infertility comes from the Vietnamese Buddhist teacher, Thich Nhat Hanh:
Sit quietly and begin to notice your breathing. Then recite quietly in your head in sync with your inhalation and exhalation: “Breathing in, I notice my body. Breathing out, I smile at my body.”
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Thich Nhat Hanh asks that we smile at ourselves the way a mother smiles to her newborn baby. Clearly most of us do not view our bodies this way. Instead we worry about a bit of extra weight here or a wrinkle there.
I often recommend multiple-session mind-body groups to couples struggling with infertility. These skill-building classes have been studied and found to be more effective than counseling or education classes. Typically participants are taught a wide range of strategies including yoga, imagery, breath work, mindfulness, journaling, body scanning, and cognitive restructuring. This smorgasbord allows people to experiment with multiple techniques with the goal of finding one or more that truly resonate.
Can Stress Reduction Relieve Infertility?
While stress may be implicated in causing infertility initially, there’s also a snowball effect when having difficulty with conception or being labeled infertile raises stress levels even further. Infertility is so stressful it has been shown to be on par with an HIV or cancer diagnosis.
One survey looked at 121 couples dealing with infertility. Nineteen percent of the women experienced moderate depression; 13 percent had severe depression; and 26 percent were at high risk for sexual dysfunction. Many studies, but not all, suggest that depressive symptoms may reduce the success rate of fertility treatment. But does stress reduction relieve infertility? Some data suggest that it can.
In 2000 Alice Domar, PhD, published a study about 184 infertile women who went through her mind-body skills-building course. Most had been trying to conceive for one to two years, and all were under the care of reproductive endocrinologists. Dr. Domar wanted to see if she could help them cope with their sky-high stress levels. What she found was that learning to cope with stress increased the women’s pregnancy rates.
Reduce Stress to Manage Infertility
Following up on Dr. Domar’s pioneering work, other researchers have continued to explore whether stress reduction makes it easier to become pregnant. A 2011 meta-analysis combining the results of these studies of psychological interventions found that they were more effective than educational programs. The most effective type of mind-body program taught participants new skills.
Mind-body support groups were also found to work better than individual therapy. This may be due to the peer support in a condition often experienced as extremely isolating. A second meta-analysis showed that a minimum of six sessions of cognitive behavioral therapy, relaxation training, negative health behavior modification, and social support was more effective than fewer session groups.
Mind-body studies have researched a variety of practices that can help restore normal physiology. Sarah Berga, MD, is a professor of reproductive endocrinology and infertility at Emory University. She studied stress-induced anovulation (menstrual cycles in which stress interferes with the release of an egg from the ovary) and documented that women with this condition lack the normal rise in basal body temperature and changes in cervical mucus that signal ovulation. She also studied a subtler pattern called functional hypothalamic amenorrhea (lack of menstrual cycle in women of childbearing age), in which women have a blunted hormonal response to FSH or GnRH.
Dr. Berga is concerned that when reproductive endocrinologists use gonadotropins to stimulate the ovaries, they are not addressing the effect of stress on cortisol levels and thyroid function. This, Dr. Berga believes, may be risky for a woman’s overall health and the health of her unborn child. She strongly recommends that the stress be addressed, thus reversing the hormonal abnormalities, rather than just stimulating the ovaries to produce eggs.
In pilot studies Dr. Berga has found that cognitive behavioral therapy not only leads to ovarian function recovery, it also improves the adrenal and thyroid functions. In 2003, she enrolled 15 women with functional hypothalamic amenorrhea in a 20-week study. Berga measured estrogen and progesterone levels as well as vaginal bleeding and found that, of the eight women randomly assigned to cognitive behavioral therapy, six resumed ovulating. The other two women had partial recovery of ovarian function. Of the six women who did not receive therapy, only two experienced renewed ovarian activity. This small study suggests that cognitive behavioral therapy might be effective in restoring normal ovulation.
Hypnosis has also been shown to relieve stress-induced infertility. Dr. Berga provided one session of hypnotherapy to 12 women who suffered from functional hypothalamic amenorrhea. She then followed them for 12 weeks to determine whether menstruation resumed and queried them about their overall wellbeing and self-confidence. Nine out of 12 participants got their periods, and all 12 described broad improvement in well-being and self-confidence. While a small study, it is remarkable that one hypnotherapy session led to resumed menstruation in 75 percent of the women, and in a broad positive effect in all.
Women’s bodies respond to stressors with physiological changes that interfere with conception; preliminary evidence supports that mind-body practices can help restore fertility. In addition, these practices help us feel centered and enhance our well-being, all of which make for a healthier and happier pregnancy.
While telling anyone to “just relax” is never appropriate, encouraging someone to begin a regular practice of yoga, t’ai chi, meditation, guided imagery, or breathing exercises may help normalize the hormonal cascade, and improve her health as well as the health of her children.
By Victoria Maizes, MD