Here's how stress can impact your fertility
Reviewed by Eva Marie Luo, MD, MBA, FACOG,
Written by Rachel Sanoff
last updated: May 27, 2021
9 min read
Here's what we'll cover
Here's what we'll cover
Anxiety, stress, depression, and other mental health issues are tough to manage whenever they happen — and it's not uncommon for some of those same issues to come up when you're navigating fertility. But because stress and fertility are complex subjects to research on their own, understanding exactly how they work together is even more complicated.
Still, studies show that stress and anxiety may impact fertility, which can amplify the difficulties you're already experiencing while trying to conceive. The reverse is also true: Dealing with fertility issues can affect your mental health.
We'll cover what the research says below, but here's a heads-up on what you'll learn:
Whatever the reason for your anxiety is, the release of stress hormones (like cortisol) can lead to physiological changes that impact your reproductive health — and the symptoms of stress can be similar whether you're feeling it because of fertility issues, life challenges, or even serious illness.
Research shows that stress levels increase the longer you have difficulty getting pregnant.
Studies around stress and fertility are complex, but there's evidence that stress can impact your hormone levels and menstrual cycles.
As to whether or not stress ultimately impacts time to pregnancy, pregnancy rates, or in vitro fertilization (IVF) outcomes, the findings are mixed — some studies show adverse effects, while others don't.
We don't fully know how effective mental health interventions may be in increasing conception rates when stress levels are high, but there's value in improving your mental health whether or not it directly affects your fertility.
Throughout this article, we'll piece together what we know so far so you have up-to-date information as you potentially manage your own stress while trying to conceive.
First: A primer on stress and its physiological effects
When you're feeling psychological distress, your body triggers its fight or flight response by activating the hypothalamic-pituitary-adrenal axis and releasing stress hormones like cortisol and corticotropin-releasing hormone (CRH). This hormone production leads to physiological changes like increased heart rate, shallow breathing, high blood pressure, and headaches. (These physiological changes are some of the biomarkers used to assess stress in research, along with the presence of the alpha-amylase enzyme in saliva.)
During extremely stressful situations, any system that isn't necessary for survival shuts down. Stress can even shut down activity of the hypothalamic–pituitary–gonadal axis, which controls the reproductive system. This can disrupt the connection between your brain and your ovaries and cause delayed or absent ovulation and irregular or missed periods. (This is why your period can be late or stop completely when you're stressed out for an extended period of time.)
"Your body prioritizes the functions to help you get through this period. Back in the caveman days, this was increasing our ability to feed ourselves and outrun predators," explains Dr. Eva Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center, Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center, and Modern Fertility medical advisor. "Your body knows procreating while being hunted is a terrible idea, hence the reproductive system is impacted."
Fertility stress is no different
Symptoms of infertility-related stress can overlap with the kinds of symptoms we typically associate with chronic or long-term stress for other reasons. They can even be similar to the distress people experience when they have serious illnesses like cancer or HIV.
Not only are there physiological similarities between fertility stress and other kinds of chronic stress, but stress is especially common among people who are having trouble getting pregnant:
One study that followed 352 women seeking treatment for infertility found that more than half of them showed signs of depression and about 3 in 4 showed signs of anxiety.
Another study of 112 women seeking treatment found that 40% of participants had a diagnosable mental health issue throughout treatment, such as generalized anxiety or major depression.
Stress levels can increase as more time without successfully conceiving passes by.
We know that stress affects the body and that navigating fertility can be especially stressful, so what does that mean for fertility and pregnancy outcomes? We're still finding that out, but as we'll get into in the next section, it’s looking more and more likely that stress and fertility are linked — specifically that stress might increase the risk of having difficulty conceiving. And the degree of stress (low, moderate, high), whether the stress is chronic or acute, and when the stress occurs in relation to the menstrual cycle appear to all influence how stress impacts fertility.
How can stress impact your fertility?
Before we break down the data, it's important to understand how we even examine the effects of physiological stress — and the ways in which our current research methods influence the conclusions we're able to draw.
Studies like the ones we're referencing in this section measure stress experiences through self-reported questionnaires, professional psych assessments, stress scales (like the Perceived Stress Scale and the COMPI Fertility Problems Stress Scale), and biomarkers (like cortisol, CRH, and the alpha-amylase enzyme). But our current methods of stress research pose a few limitations:
Research into stress and fertility is ongoing and recent, so we have to base a lot of our knowledge on smaller studies that aren’t always of the highest quality — and small sample sizes don't put us in a position to make broad claims about anything.
Smaller studies also make it harder for us to eliminate the possibility of other factors impacting fertility, like age or the health of reproductive organs.
Stress and fertility research does not currently study a diverse group of people, and results mostly come from white women.
Similarly, much of what we know comes from IVF studies involving patients with known fertility issues, which means we know less about how implantation is impacted by stress in people with presumed fertility.
Different methods of measurements, both in terms of stress and reproductive health, can complicate findings.
We need a lot more research before we can make any kind of conclusive statement about stress and fertility — and we need to understand exactly what levels of stress can increase adverse outcomes and why. Now, onto the data.
Stress and the menstrual cycle
Like we mentioned earlier, the physiological effects of stress can have an impact on the function of our reproductive system and disrupt ovulation:
A 2015 study of 259 women who took perceived stress assessments found that the high-stress group had lower levels of estrogen, luteinizing hormone, and progesterone and higher levels of follicle-stimulating hormone during the luteal phase of their cycles, which meant a higher likelihood of anovulation.
Increased levels of cortisol brought about by stress can possibly interfere with follicular development and the inflammatory processes that are required for us to ovulate, but we need better research that separates confounding factors to know exactly how this connection works and if it's a direct one. (A 2016 study of mice did find a similar connection between stress-induced cortisol increases and interrupted inflammatory processes, affecting the mice’s cycles.)
It's important to note here that delayed ovulation or anovulation isn't the same as chronic infertility. Still, when your cycles are irregular, one of the biggest obstacles is not knowing when to time intercourse or insemination to increase your chances of getting pregnant — and if your period stops completely, then you can’t conceive at all. Your healthcare provider can help you look into potential causes of any irregularity and determine how to make timing intercourse or insemination easier.
Stress may also affect implantation. Abnormal levels of CRH, a stress hormone that also happens to be produced in reproductive tissues, can impact the uterine lining and placenta. (Additionally, increased CRH levels may be associated with preterm birth, but more research is needed.)
Stress, conception rates, and time to pregnancy
Some researchers found a relationship, while others didn't:
A 2010 study conducted by Oxford University and the National Institutes of Health found that the 25% of women with the highest levels of alpha-amylase, a substance that's secreted into the saliva and has been linked to stress response, had more trouble conceiving than women with lower alpha-amylase.
In October 2018, a study from Boston University's School of Public Health found that women who experienced higher levels of stress had lower rates of conception. However, the study also found that couples were less likely to conceive when the woman reported experiencing a high level of stress — if only the man reported experiencing a high level of stress, conception wasn’t affected.
But not every study points to a sturdy link between stress and fertility challenges: A December 2019 study of 111 women who kept journals reporting their stress levels found no difference in conception rates. Ultimately, this new study suggests that moderate levels of stress in relatively healthy women doesn't adversely impact getting pregnant.
In yet another 2019 study of 140 women trying to conceive, researchers found that daily perceived stress didn't negatively impact time to pregnancy if the woman already had proven fertility.
Stress and IVF outcomes
Researchers have found some inconclusive info about stress and in vitro fertilization (IVF) outcomes. Some studies show a link to adverse outcomes, while others don’t:
In a 2018 study of 45 couples doing IVF treatments, higher levels of stress-related cytokines (proteins) in the patient’s blood were related to a lower likelihood of pregnancy after one IVF cycle.
A large 2014 study of roughly 400 women undergoing IVF treatments found that women in the highest stress group (determined by the measurement of a stress biomarker in their saliva) had a 29% lower conception rate after one year, compared with women in the lowest stress group. Yet the study found no association between cortisol levels and pregnancy delay — and the same researchers’ 2010 study out of the UK found no association between self-reported stress and pregnancy outcomes.
An observational study conducted out of China in 2019 had similar results involving patients with that saliva biomarker, and also found that the group of participants with higher stress levels had lower endometrial thickness, potentially affecting implantation.
A 2009 study indicated that women with high amounts of stressful life events that negatively impact her quality of life may have less favorable IVF outcomes.
Contradicting that 2009 study, a 2017 study followed 485 women undergoing IVF treatments and concluded that perceived stress, infertility-related stress, and high cortisol levels “were not associated with IVF cycle outcomes.”
In a 2019 study of 1,214 women undergoing IVF treatments who had previously experienced 1-2 pregnancy losses, participants shared their stress levels through self-reported retrospective assessments in addition to their hormone data. In the high-stress group, researchers noticed that participants had lower estrogen levels, higher risks of anovulation, and lower chances of pregnancy.
Other ways stress may impact your fertility
Stress can decrease your libido, resulting in you and your partner having less frequent intercourse and fewer opportunities for the sperm and egg to meet.
A 2002 randomized controlled trial (RCT) looked at how immune system changes affect pregnancy and found that natural killer-cell (NK) activity increased with psychological stress, which is associated with infertility.
When you're stressed, the nervous system produces compounds called catecholamines (like dopamine, epinephrine, and norepinephrine). These compounds may affect blood flow to important reproductive organs. (The catecholamines are also what trigger the secretion of the alpha-amylase enzyme, one of the biomarkers of stress.)
Can managing stress levels while trying to conceive improve your chances?
We don't know yet if psychological interventions and mindfulness practices actually improve your chances of conception. Here’s what we do know, based on research looking into people dealing with infertility-related stress:
In the same 2002 RCT we cited above, conception outcomes improved when a mindfulness intervention was implemented to help manage stress.
One meta-analysis from 2015 followed couples experiencing infertility, and found that those who engaged in “psychological interventions such as cognitive-behavioral therapy or mindfulness” had higher rates of pregnancy than those who stuck to usual care.
Meanwhile, another meta-analysis from 2017 that followed couples experiencing infertility “compared psychological interventions such as mindfulness with control conditions, and found that pregnancy rates were comparable in the two groups.”
Still, improved mental health is always a victory — even if studies haven't demonstrated a direct link between stress interventions and odds of getting pregnant. So, how can you take control of a pretty uncontrollable situation to reduce the potential impact of stress on your fertility?
Manage the symptoms: Exercise, yoga, meditation, cognitive behavioral therapy, individual and group therapy, and mindfulness approaches can help you take control of your stress levels. Since infertility is such a common cause of depression and anxiety, it’s especially important to prioritize mental healthcare as those services are often not provided during fertility treatments.
Address potential causes: Take time to improve external factors that may be stressing you out. Aim for improved work-life balance, carve out more time for friendships, and work on strengthening your relationship if you have a partner.
Seek support with your partner: A 2018 study suggested that couples who are both emotionally affected by infertility should both be open to psychological interventions. Another 2017 study says that psychosocial care for couples undergoing fertility treatments can reduce cortisol levels and emotional distress, all of which can improve pregnancy outcomes.
You can also always reach out to your healthcare provider to talk about any stress you're experiencing while trying to get pregnant. Your healthcare provider can provide resources for support, like therapists and psychiatrists, help you feel more in control of the process, and work with you to make things as anxiety-free as possible.
"For example, having intercourse every day can be stressful. [We can] map out the fertility window and try sex every other day instead," explains Dr. Luo. Sometimes she'll see her patients more often for mental health check-ins or recommend taking a breather between cycles to reduce stress. "I try to reassure patients that it's my job as an OB-GYN to quarterback the medicine and science of fertility — and hopefully that takes some of the burden off."
The biggest takeaway? We don’t fully understand how stress impacts fertility
Study limitations and mixed findings mean we don't have a complete grasp on the effects of stress on fertility and conception rates. Even if stress does impact fertility, it's important to remember that stress is totally normal — especially if you're having trouble getting pregnant. Any physiological changes that may happen as a result are your body's natural response to protect you.
No matter what, checking in with stress levels is always a good idea. If your stress levels are fairly moderate and exploring mental health interventions like therapy or mindfulness techniques don't stress you out further, go for it! But if those activities make you feel more stressed, don’t pressure yourself. That said, if your cycle is often irregular and you experience high levels of stress, talk to your healthcare provider. (Since stress is difficult to reliably assess through biomarkers, your healthcare provider may first rule out other clinical causes of irregular cycles while also working with you to reduce stress.)
Anxiety can be frustrating and uncomfortable as you try to build the family you want, but you're definitely not alone.
This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.
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