Sorting Out the Complicated Relationship Between Infertility and Depression

Medical Care
Young husband consoling wife - infertility-depression
Dealing with infertility and depression at the same time can seem overwhelming. But there is help available to help you build your family and cope with mental health challenges.(Photo source: iStock),

Anyone who follows the news has noticed what seems to be an epidemic of depression. [1] While rates may be on the rise, there is also a new willingness to discuss the issue more openly. In this way and others, depression and infertility have three things in common:

      • both are medical conditions
      • deserve to have treatment covered
      • more work remains to reduce the stigma of the condition

For some, a diagnosis of infertility and the ensuing treatment brings a chronic state of stress. This can lead to depression or make existing depression or anxiety worse.

Research suggests that the psychological symptoms of women facing infertility is similar to those facing other serious medical conditions, such as cancer.[2] Depression is more likely among those facing infertility if any of the following situations apply: 

      • They experienced depression before receiving their infertility diagnosis.
      • There is a family history of depression.
      • They lack a support network resulting in feelings of isolation.

Furthermore, the medications used to treat infertility and infertility treatment itself can be associated with emotional changes, including depression.

How can you tell the difference between sadness and depression in infertility patients?

How can you tell if what you are feeling – emotionally and physically – is explained by the situational stress of dealing with infertility? Or whether it is time to seek help for depression? It may not be so easy to decide.

According to the Harvard Mental Health Letter from Harvard Medical School [3]:

“Patients and clinicians may find it hard to figure out which reactions are psychological and which are caused by medications — yet identifying causes is essential for determining next steps.”

–Sadness

Stress and sadness are often part of coping with infertility because:

      • dreams of a family are altered
      • the relationship with your partner may be tested
      • the medications required during treatment can play havoc with mood

One question to ask is whether feelings of being sad and tearful are episodic and tied to specific events such as hormone treatment, a test result, or a friend’s pregnancy announcement. These feelings are important to acknowledge and should be addressed through counseling, a support group, and/or self-care.

–Depression

Depression is different. It ranges from mild to major and may be recurrent. Mild depression symptoms includes feeling tired and sad.

Common signs of moderate to major depression include some or all of the following [4]:

      • Sadness that persists, lasting for weeks or months
      • Feelings of hopelessness and helplessness
      • Frequent crying
      • Often feeling irritated or intolerant of others, especially people who you used to enjoy being around
      • Lack of motivation, struggling to get things done at work and/or home
      • Difficulty sleeping, either sleeping too much or insomnia
      • Problems with eating, overeating or low appetite
      • Struggling with experiencing pleasure in life, including a lack of interest in sex
      • Frequent feelings of anxiety or worry
      • Thoughts of dying, self-harm, or suicide – seek help immediately!

Does depression cause infertility?

A significant percentage of women of child-bearing age believe that there is an association between mental health and increased rates of infertility. In fact, in 2017 a women’s health company surveyed over 1000 women aged 25-33 who had a college education or advanced degree and earned over $50,000 per year. They found that over 70% of them believe that mental health problems (such as stress and anxiety) can have a negative impact on fertility even though it has not been proven.[5]

–Formal studies have yielded mixed results

More formal studies of the relationship between infertility and mental health, on the other hand, have yielded mixed results. For example, one large multi-center study evaluating the effects of depression and antidepressant use on non-IVF treatment outcomes found different results for men and women [6]:

  • Women with currently active major depression (MD) did not have lower pregnancy or live birth rates compared with women without MD
  • Male partners with current active major depression were less likely to achieve conception
  • The use of antidepressants by the mother was associated with an increased risk of miscarriage in the first trimester, particularly when the antidepressant was NOT an SSRI.

Lifestyle changes related to depression may impact fertility

Depression may lead to lifestyle changes that can negatively affect the chances of becoming pregnant. The following have been found to have an impact on fertility:

  • Appetite changes that lead to being over- or underweight 
  • Excessive alcohol consumption and/or smoking may start or increase with depression and anxiety. 
  • Depression-associated sleep disorders
  • Sleep disorders related to some infertility medications 

Does infertility increase the risk of depression?

Multiple studies have found that infertility in both women and men can increase stress, depression, and anxiety.[7] Further, early pregnancy loss can lead to post-traumatic stress disorder (PTSD).[8] 

In addition, hormonal imbalances that cause infertility may also contribute to mood disorders including depression. Hormone therapy to treat infertility, treatment failure and the isolation associated with infertility can also lead to depression.

Lifestyle changes that make a difference

With depression, it might be tempting to self-medicate with junk food or alcohol or to counter poor sleep with more coffee. However, each of these responses makes the situation worse in terms of both fertility and depression. The good news, though, is that certain lifestyle changes can positively impact both fertility and depression.

–A healthy diet is important

Various studies show that a poor diet – including fast food or food high in sugar [9] – increases the risk of infertility in women, negatively impacts sperm counts [10], and is associated with higher rates of depression and anxiety [11]. 

At the same time, a healthy diet has been shown to have a positive effect: one study showed that women undergoing IVF have better pregnancy outcomes from eating a Mediterranean diet.[12] Another suggested that men who eat healthily have better semen quality.[13] Further, the relatively new field of nutritional psychiatry is finding positive results of a healthy diet on depression and anxiety

Further, there is evidence consuming excessive caffeine (the equivalent of more than five cups of coffee per day) can hamper your ability to get pregnant [14].

Alcohol use is counterproductive

Excessive use of alcohol makes depressive symptoms worse [15]. The literature on alcohol consumption is mixed. There is no question that excessive alcohol use during pregnancy is associated with an increased risk of adverse pregnancy outsomes, including fetal alcohol syndrome.

However, the literature examining whether alcohol use impacts female fertility is difficult to interpret because there has been little to no standardization of the amount of alcohol consumed [16]. Some studies reporting no impact on fertility looked at consumption levels that many would consider modest (0-7 drinks per week). Daily drinking and binge drinking were not specifically called out.

Regardless of the impact on fertilitiy, most experts recommend that women planning on getting pregnant should avoid the use of alcohol because of its adverse impacts on pregnancy outcomes.

–Mind-body practices are beneficial

In my practice, we recommend certain mind-body practices to help improve your chances of becoming pregnant and feeling less depressed. These include 

  • yoga
  • meditation 
  • guided imagery 
  • mindfulness exercise 
  • being in nature.

Creative expression including expressive writing or journaling and art therapy may also help. While the effectiveness of each of these is supported by research, finding what works for you and what you’ll stick with is key.

How to treat depression during infertility treatment

If you’re experiencing any symptoms of a low mood or depression, talk to your infertility doctor. It may help your doctor diagnose your infertility and better manage your treatment and overall care.

You may have a hormonal imbalance that helps explain your infertility and depression. Or, if you’re taking fertility drugs – like synthetic estrogen – it may explain mood swings, anxiety and aggravate depression. Your specialist may be able to make changes in your medication to help, refer you to the appropriate fertility counselor or mental health professional. Or even suggest taking a short break from treatment.

–Mental health support options

There are multiple factors to consider in deciding treatment including the use of antidepressants:

  • history of depression;
  • whether it is recurrent and/or active;
  • severity (mild, moderate or severe)
  • what other types of support have worked or failed
  • the risks of untreated psychiatric illness 
  • fetal exposure to psychiatric medication

Counseling, support groups, self-help resources, telephone-coaching groups, and family and friends may work for many. Others may benefit from an ongoing one-on-one therapeutic relationship with a licensed mental health provider.

Individuals that require prescription psychiatric medications will need to see a licensed physician. They shoukd preferably be under the care of a psychiatrist with experience working with women who are undergoing fertility treatments as well as women who require psychiatric medications during pregnancy.

In general, the combination of medication and talk therapy (such as cognitive behavior therapy) is most effective for treating clinical depression and this combination may also enhance the chances of becoming pregnant.

Your infertility clinic may have mental health professionals on staff that can provide individual or group counseling. If not, your physician or clinic can likely provide a referral to mental health professionals that specialize in treating people facing infertility.

The Mental Health ProfessionalGroup of ASRM believes that mental health professionals with experience in infertility treatment can help a great deal on a range of issues including how to control stress, depression, and anxiety. [17[ Together, your fertility doctor and mental health professional can help determine which treatment(s) – especially if medication is indicated – are most effective and safe for your specific situation.

The bottom line

There’s no doubt that dealing with infertility or depression is a major challenge. Trying to cope with both – at once – can be overwhelming. Please remember that both are medical conditions that are not your fault and that treatment is available to help you build your family while addressing your depression.

References:

  1. Fact Sheets. Depression, World Health Organization (WHO), 2020 Jan. 30, https://www.who.int/news-room/fact-sheets/detail/depression. (Accessed 2/16/21)
  2. Domar A, Zuttermeister P, Freidman R. The psychological impact of infertility: a comparison with patients with other medical conditions, 1992, J Psychosom Obstet Gynecol, 14, suppl 45-52. https://pubmed.ncbi.nlm.nih.gov/8142988/
  3. Harvard Medical Letter. The psychological impact of infertility and its treatment, Harvard Mental Health Letter, Harvard Medical Publishing, Harvard Medical School, 2009 May. https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment
  4. Gurevich R. Depression-related Infertility Causes and Treatment, VeryWellFamily 2020 Aug 3. https://www.verywellfamily.com/infertility-and-depression-101-1959977  (Accessed 2/16/21)
  5. Gresge G. This Is the Biggest Misconception that Millennial Women Believe about Infertility. 2017, Dec. 24, Brit+Co. https://www.brit.co/millennial-women-attitudes-toward-fertility-celmatix-survey/
  6. Evans-Hoeker E, Eisenberg E, Diamond M, et al. Major depression, antidepressant use, and male and female infertility, Fertility and Sterility, 2018 May. https://www.fertstert.org/action/showPdf?pii=S0015-0282%2818%2930029-3
  7. Harvard Health Publishing. The psychological impact of infertility and its treatment, Harvard Mental Health Letter, 2009 May. https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment (Accessed 2/16/21)
  8. Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. Am J Obstet Gynecol, 2020 Apr. https://pubmed.ncbi.nlm.nih.gov/31953115/
  9. Boston University School of Medicine. One or more soda a day could decrease chances of getting pregnant.” ScienceDaily, 13 February 2018. https://www.sciencedaily.com/releases/2018/02/180213120426.htm
  10. BBC. Diets Linked to Low Sprem Counts, BBC News, March 12, 2012. https://www.bbc.com/news/health-17353804. Accessed 2/16/21
  11. Jacka F, Pasco J, Mykietun A, et as. Association of Western and Traditional Diets on Anxiety and Depression in Women, Am J Psychiatry Online, 2010 Mar. 1. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2009.09060881
  12. European Society of Human Reproduction and Embryology. Mediterranean diet may help women receiving IVF achieve successful pregnancies. Science Daily, 2018 January 26 htpps://www.sciencedaily.com/releases/2018/01/180129223846.htm
  13. Efrat M, Stein A, Pinkas H, et al. Dietary patterns are positively associated with semen quality. Fertil. Steril., 2018 May. https://www.fertstert.org/action/showPdf?pii=S0015-0282%2818%2930010-4
  14. European Society of Human Reproduction and Embryology. Five or more cups of coffee a day reduce the chance of IVF success by around 50 percent. Science Daily, 2012 July3. https://www.sciencedaily.com/releases/2012/07/120703120659.htm
  15. Godman H, Levine D. Is Alcohol a Depressant? US News and World Report, 2019 June 7. https://health.usnews.com/conditions/mental-health/depression/articles/is-alcohol-a-depressant
  16. deAngelis C, Nardone A., Garifalos F, et al. Smoking, Alcohol and Drug Addiction and Female Fertility. Repro Biol Endocrinol. 2020 March 12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069005/

Published Aug. 19, 2018. Updated by the author for republication on  Feb. 17, 2021