monthly tiips

Almost any scientific innovation is doomed to have unintended consequences.  Medicine is no exception.  As soon as a new breakthrough gets mainstreamed, the threshold for using it gets exponentially lower: recent publicity about gross overuse of stimulants, unnecessary back surgeries and coronary bypass, to name but a few, illustrates an important principle: the mere existence of a new treatment is not a license to use it indiscriminately.

I think such a trend is at play in the area of fertility treatment, especially that of IVF  (in vitro fertilization).

I have deep respect for IVF and its practitioners.  I had just graduated medical school in 1978 when Louise Brown, the first "test tube baby" was born. I remember the pride I felt in being part of a professional community that makes such wonders come true.  IVF offered a way for infertile women to become mothers - something most of us feel entitled to by nature, literally.

IVF was originally developed for women who had some mechanical obstacle to becoming pregnant. In most cases it was some form of obstruction in the Fallopian tubes - the organs that transfer the egg from the ovaries to the uterus- and where the first few days of gestation take place.  The obstruction made it impossible for the sperm and egg to meet and so IVF was a clever way to circumvent the obstacle.

Sooner or later women who had perfectly open tubes but experienced other difficulties in getting pregnant, joined the group of IVF beneficiaries. 

Predictably, as the technique got increasingly popular and transformed from a medical miracle into a routine, it became so widely available, that nowadays it is offered to almost anyone who can afford it. 

Consequently, IVF is now routinely considered even for women who may not need it to conceive and whom I call the "the worried thirty something".

Why is it a problem?
In principle, I believe that any treatment modality should be evaluated by its ease of administration, the availability of other, less risky methods, and the financial burden it places on the individual and/or society at large. 

IVF is not an easy way to conceive: it is very expensive, success is not assured and often times one needs multiple cycles until a pregnancy "holds".  Also the process itself entails daily injections of hormones, painful procedures and a great expenditure in time and emotional energy. 

Clearly those who can become pregnant only through IVF should definitely try it.  However, for those who do not really need it, it should be only a last resort rather than a first impulse.

What is preventing many women who have no obvious mechanical obstacle, who ovulate regularly and have a benign obstetric history from becoming pregnant?  I believe that the main contributing factor is stress.  It is well established that stress can actually become a major cause of infertility, since it interferes with the hormonal balance essential for conception and maintenance of pregnancy. 

Is getting pregnant these days more stressful than it used to be?

In my experience the higher the age of first pregnancy the larger the role that stress plays in infertility. According to the Centers for Disease Control (CDC) first births among women ages 30 to 39 have doubled in the past 15 years, and those for women 40 and older have increased 50 percent. This is another example   the way social trends affect everyday biology and psychology.    As more women become pregnant for the first time much later in life than it used to be, stress becomes a major factor for their infertility.  

Why is getting pregnant for the first time at a later age so stressful?
 Women over 30 who try to become pregnant for the first time often carry a complex emotional burden.  Their gynecological history may include bouts of STD, abortions, and prolonged contraceptive use.  They are more exposed to "horror stories" from their peers who find it hard to conceive, and the inevitable biological clock is running out of time.  A woman in her mid to late 30's is under pressure, that she has less fertility time, more possibilities for complications, and higher rates of miscarriage: all those factors make the woman feel rushed into pregnancy if she wants to have children before the window of opportunity closes. 

Not surprisingly these women approach their potential pregnancy with trepidation and worry. Every month that passes by without conception, increases their anxiety about their prospects of becoming pregnant.  Sooner than later, the notion of infertility treatment becomes a reality.   And it is easier than ever to become a candidate: advances in the field of In Vitro Fertilization (IVF) and Embryo Transfer (ET), have lowered the threshold for the procedure.  But even when IVF is administered, stress remains an important factor in the success of the treatment. 

Since stress interferes with hormonal balance and adds to difficulties in getting pregnant, (and maintaining a healthy pregnancy) it makes sense to address it before a woman embarks on the exhausting journey of infertility treatments.  The reality is that many obstetricians often lend only a cursory acknowledgment to this issue.  The way healthcare is delivered nowadays is by busy specialists who have little time to address emotional difficulties.  It is much easier to send a woman to fertility treatment than to spend the time discussing with her the fears she has about her ability to become pregnant. Even younger women in their early 30's who have plenty of time to get pregnant naturally, are rushed through the "time is running out" path where IVF appears to be a compelling option.  Whether stress is a cause for infertility, a contributing factor or "merely" an added difficulty, it should be addressed before costly and painful treatment would become a path of no return. 

Saying to the concerned person "just relax and don't worry" is an exercise in futility.  Worse, many doctors and close friends and family often say to her " you got to stop worrying about it as it compromises your chances of actually getting pregnant".  This is obviously the worst tact as no one can relax on command and the suggestion that the stress is contributing to the problem only causes further stress. It also fosters a sense of guilt in the person, thinking that her anxiety is undermining her chances to become pregnant.  

In founding the Institute for Integrative Psychiatry our goal was to call attention to exactly such issues.  Our biology and psychology are so completely intertwined that relating to one aspect while ignoring the other is simply mistaken. In many conditions the mutual impact of psychology and physiology is crucial for recovery and health.  I believe that we need to address the impact of stress in every woman who presents for infertility evaluation.  Our goal is to educate the public as well as clinicians dealing with infertility about ways to identify and treat stress as a part of infertility work -up.