Monday, 15 July 2013

It was just her time...

Every infertile woman has been exposed to a plethora of stories of how there is some woman out there who tried to get pregnant for years and the moment she gave up, she finally conceived her rainbow baby. If it's not irritating enough to hear these tales, it's more frustrating to acknowledge that your friend thinks this strategy could be the answer for you. From her perspective, as it worked for someone else; it's a valid treatment method. (Brilliant observation from Annie at Sweetest in the Gale
"Although people mean well and are only trying to help, it's like someone who won the lottery handing out financial advice") When my lead physician  shared her story of conceiving spontaneously just before her RE consultation, she commented that she definitely thought that stress played a role. "Isn't that anecdotal?" I countered "we only know about the cases where couples 'stop trying' because they do conceive. There are probably many more uncounted cases of couples who stop actively pursuing conception, but don't use birth control and don't conceive..."

Even before I experienced infertility, I struggled to accept that an infertile couple suddenly became more fertile if they were 'un-intending to conceive' at the time of coitus. Maybe it's my years of focusing on contraceptive services, where we teach that if you aren't preventing a pregnancy then you're pursuing one. Even if couples are not cycle tracking or continuing infertility treatments, if they're not contracepting, they are technically still trying for a pregnancy. In particular, hoping to be one of those stories; 'it happened when we weren't thinking about it!' At the basic biological levels, the endometrium, ovaries and sperm do not have any independent cognitive processes. It's not as if they can network together to plot, "Hey! They're not paying attention, let's make it happen and surprise them!" Finally, it's important to remember that correlation does not imply causation. Just because an event happens under a particular set of circumstances does not mean it was influenced by said circumstances.  

I decided that I needed to examine the evidence. First, I referenced Clinical Gynecologic Endocrinology and Infertility. Although this edition was published in 1994, and the chapter on infertility evaluation was written before IVF was mainstream, the lead editor Leon Speroff is still considered to be the ultimate authority on gynecologic endocrinology. The following text is from a paragraph marked Myths and Appropriate Goals:

      It is important for physicians and other health care professionals to dispel the myths that are associated with infertility. Women should not be told that they are infertile because they are too nervous. Unless anxiety interferes with ovulation or coital frequency, there is no present evidence that infertility is caused by the usual anxieties besetting a couple trying to conceive. Despite many anecdotes to the contrary, adoption does not increase a couple's fertility...              

Turning to a source that is more Up To Date, I searched a database with that web domain (it's similar to PubMed, except others have already summarised the most current articles for you; yes, it's akin to using Cliff Notes) and found one article on Psychological Stress and Infertility. Here is her first paragraph:

     As health care professionals developed the ability to diagnose and treat most cases of infertility, they began to view it as an organic condition. Some infertility patients were told that their stress level had nothing to do with their ability to become pregnant. hmm, I'm starting to sense some bias However, there is evidence that stress levels influence the outcome of fertility treatment, as well as contribute to patients' decision to continue treatment. Stress also affects patients' reactions to pregnancy loss during infertility treatment and pregnancy complications Ya, think? Moreover, physiological distress is associated with treatment failure and interventions to relieve stress are associated with increased pregnancy rates.

The article then defines stress and discusses how it is difficult to measure or assess baseline stress levels, but notes such a task is best handled by a trained mental health professional (psychiatrist or psychologist). She notes that stress tends to be higher in the partner "with the fertility problem" and references a study of 112 infertile women who were evaluated by a psychiatrist. 23% were diagnosed with an anxiety disorder and 17% with major depressive disorder -a rate considered to be 10-12% higher than the general population.

The author then discusses the impact of stress on 'drop out'. She notes that specialists presume patients stop treatment for one of two reasons -recommendation to discontinue due to a poor prognosis, or lack of finances. She then introduces a challenge to these notions and suggests that the psychological burden of the procedures appear to be the major reasons for dropout. To support her argument she reviews a few studies that examined women who had IVF funded by insurance programs. A researcher of one study concluded that attrition was due to emotional burdens, but did not ask the couples themselves and another large study of 2130 patients noted an observation of "enormous stress and frustration" but the participants were not surveyed. So why are these studies being referenced?

So far, if I'm following her argument correctly, she's advocating that stress contributes to fewer pregnancy rates as it is the main reason why patients stop fertility treatments. That's not the same things as stress being the cause of infertility... She presented one study that had some conflicting results. 148 women were followed through 2 IVF cycles. They completed a baseline psychological survey and patients with higher distress levels had higher pregnancy rates than those who were rated with low stress levels. However patients who were at moderate distress levels and went through mind/body interventions were more likely to conceive than their moderately distress counterparts in the control group. She references a comprehensive mind/body infertility program, which I think is her own clinic.

Finally she concludes with a review of 25 independent evaluation studies and summaries that psychosocial interventions could reduce negative affect and could produce positive changes. Yet none of these reviews found that psychological interventions impacted pregnancy rates.  "It is unclear why psychological intervention might have a positive impact on pregnancy rates." Her final comments note that psychological stress of infertility patients should be assessed prior to treatment, and patients who exhibit signs of anxiety or depression should be treated. She offers relaxation techniques, stress-management, coping skills and group support as initial therapy, pharmacotherapy when indicated. Does blogging count?

Last summer after Todd Akin uttered the reprehensible words, "if it's a legitimate rape, the female body has ways to shut that whole thing down" the American College of Obstetrics and Gynecology (ACOG) issued a statement; "a woman who has been raped has no control over her ovulation, fertilisation, or implantation of a fertilised egg. To suggest otherwise contradicts basic biological truths." I thought his use of the word legitimate was worse than his lack of knowledge, as it demeans all women by perpetuating the notion that women lie about being raped. I cannot imagine how heinous that comment was to any woman who has been assaulted, let alone to the 32,000+ who experience a legitimate pregnancy as a result each year. I was pleased to see that ACOG took a position to correct the inaccuracy, and selfishly I thought it touched on the situation of infertility. We also don't have any control over our reproductive organs.

Also anecdotal, over the years I've seen many women become pregnant during very stressful times; financial hardships, academic pressures, troubled relationships, long working hours, drug and alcohol abuse and chronic health problems. Of course, these women are fertile and play by a different set of rules than the rest of us, but I feel it does refute some of the arguments that stress decreases fertility potential.

Last year when I attended the Infertility conference, I overheard two REs discussing the role of treating mild endometriosis. One commented, "I'll do a laparoscopy and note a few implants that I doubt are contributing to her failed cycles, but I'll go ahead and cauterise them and she'll get pregnant on her next transfer. Was it due to the surgical intervention, or maybe was it just her time?"

It was just her time. Such a brilliant and yet succinct explanation. One that is both comforting and yet scientific. For whatever reason and for every reason, at that moment, conditions were perfect and it was her time.

Last week our LVN presented a patient who was experiencing infertility due to male factor issues. They failed three IUIs and while deciding what to do next, they attended a destination wedding and conceived spontaneously. They didn't even consider the possibility that a pregnancy could occur and engaged in adventure sports and lots of alcohol. "It makes sense," she speculated "you let your guard down..." "Nope." I interjected and shook my head. "It was just their time."


  1. Aw, I feel so honored that you quoted me :) I love how you methodically challenged this myth with evidence to substantiate your claims--it's the scientist in you! And I think it's awesome how you pointed out all the statistical flaws and logical gaps in the article that suggested stress does contribute to infertility.

    I think people suggest we should "stop trying" or the all-time favorite, "just relax" (cue collective infertile groan) because it's the easy thing to say. Also, humans have a tendency to repeat anecdotal advice just like we have a tendency to use cliches and follow trends. We're impulsive creatures of habit, and unfortunately that leads to most people not thinking critically.

    Infertility makes fertiles, and even former infertiles who have successfully given birth, very uncomfortable. "Stress" becomes an easy, catch-all scapegoat in awkward situations. They don't want to say they lucked out biologically while we got the shitty end of the stick--we're just stressed! Yeah, we're stressed all right. But it's infertility that's causing our stress, not the other way around.

  2. GAHHH the old "stress is causing your infertility" drama. I've stopped arguing with people who say that to me now. It seems like everyone I know believes this myth to some extent and I was spending far too much energy trying to dispel it.

    I told my Mom "if stress is my problem, then why do women get pregnant during times of war or as a result of rape?!"
    and she said something along the lines of "I don't have all the answers, but a girl from work adopted and the next thing you know she was pregnant!" In the end, anecdotal evidence is far more compelling than scientific evidence. Now I just pretend that I agree with their line of reasoning because it's easier.

  3. Are you familiar with Alice Domar's work? (

    Here are a couple of articles that are worth looking at too.

    Though I completely agree with you about the "just relax" argument for resolving infertility, one of the things that is being looked into more and more is the impacts of anxiety/depression on treatment outcome. The more I read, the more I get the sense that the mind/body connection is just one aspect of the puzzle. Still, I don't think discounting the importance of seeking help while living with infertility/loss should be practiced as any life trauma usually requires intervention.

    I think ultimately all of this comes down to people trying to give simple explanations for a complex problem. Similar to linking brain cancer to cell phone use. The reality is that there's usually a number of factors to consider along the way (environment, genetic predisposition, physiological, etc), but as humans we are drawn towards simplicity.

  4. Or, data is not the plural of anecdote.

  5. Hmm. I just wrote a novel of a comment...and then realized that maybe I should write a post about this on my own blog, instead of getting on my soapbox in your turf! Thanks for your post, and for lighting a fire. ;)

  6. Thanks so much for posting this with references (I can't imagine the world of medicine without up-to-date)!

  7. I like your point about not hearing anecdotes about the couples who give up trying to conceive and go on to...not conceive. You never hear about them. I'm sure they're out there. They've gone on to live fulfilling child-free lives. Let's hear about that for a change.

  8. I have heard so many of those anecdotal stories over the last couple years. I know people are just trying to help, but it never made me feel any better.
    I also feel like my success was just "my time". So many things were similar to my failed cycles. Why did this one finally work? I did everything I could to help this cycle work, but in the end I think I just got lucky and the stars aligned and it worked.

  9. I really hope that stress doesn't affect one's ability to conceive. I am trying so hard to avoid stress, but with my personality, it's not easy.

    BTW, I was thinking about you earlier tonight. We're going on vacation in a week and one of the activities we had the option to sign up for was tennis aerobics!!!

  10. I really appreciate your balanced and thoughtful post with both medical information and your personal perspective. This reflection was helpful. Even the docs don't have the answers. All any of us can do is try.

  11. By the way, I also love "rainbow baby." Love.

  12. I once read a scientific article that after extensive research concluced that stress does not cause infertility, however going through infertility is a huge cause of stress.

    It irritates me so much when someone says something on the lines of : "it's all on your mind" or "go on a holiday"...

    These are biological / physiological problems we are dealing with, regardless of the fact that science does not know everything at this point, that so much remains mysterious and miraulous.

    I do believe that having a positive attitude helps, if anything, to preserve our sanity and to keep us going through this. Sometimes we have to laugh about it. Sometimes it'll be morbid humour. And sometimes it's just making the choice everyday of continuing to walk and hope. (Or to decide you had enough, also valid). But no one should judge or tell or imply that this is somehow the couple's fault, or karma...

  13. Well, we stopped using birth control about 14 years ago. We spent 3 years really actively ttc, with charting/temping and everything. Then we just let it go and left it up to chance. If it was a matter of "just relaxing" you'd think in all those years, which included several vacations, that our time would have come. Nope. It took some extra help from an RE and a few eggs donated from my sister for it to happen.