Andreia Trigo, Founder of Enhanced Fertility Programme, is talking about how to manage stress, anxiety fear and anger connected with infertility.
Many of us are navigating the fear, the uncertainty, and the change. We are being asked to change and adapt very quickly to circumstances, maybe circumstances around jobs and the uncertainty of our income strings, maybe about being home all the time, or maybe even about working remotely or having our treatment stopped.
It’s not really unsurprising that people are feeling a bit more stressed, anxious, angry, or fearful. Today this is a very important topic, and we’re going to discuss some of the strategies that you can use to manage these fabulous four emotions.
Andreia was diagnosed with infertility at the very young age of 17, and at that stage, she certainly felt all of those emotions and many more, usually what we call the rollercoaster of emotions, but throughout her career, she has become a nurse and made the decision to dedicate herself to people who are struggling with infertility because she managed to cope with her emotions rather well, and she wanted to give back to people who are in this journey so that they can manage their emotions as well and maybe reach the train they have on building their families.
The first thing I’d like to tell you is that if you have felt any of these emotions recently or if you’re even if you are feeling it right now, I want you to know that your response is 100% normal. You are living in unprecedented circumstances, which means that your treatment or whatever plan you had for your journey is not being able to go ahead. You have so many aspects that are uncertain in your life right now, so it’s normal to be fearful, is normal to be angry, anxious, or stressed. Don’t beat yourself up if you’re feeling any of these emotions.
The second thing Andreia shared is that because you’ve been on this journey of trying to conceive, and you have faced some challenges that most people don’t have to face in their lives, you already have some coping mechanisms inside you and those coping mechanisms have given you some strengths. Strengths from overcoming the things that once you thought you couldn’t, so these things that you are facing at the moment, all the uncertainty, and the need to adapt quickly to change is something that you can do.
We’ve all felt stressed at some point, but I think it can be quite difficult for people to define exactly what is stress. Stress is your body’s response to any change that requires you to adjust to your environment, and your body reacts with changes that are physical, mental, and emotional responses.
Stress is a normal part of life, and you can experience stress from your environment, from your body, but sometimes you can even experience stress from your thoughts, the things that go through your head, things that are real, and things that haven’t happened yet, things that you might be worried about in the future.
Stress can be defined as:
The degree to which you feel a bit overwhelmed or maybe even unable to cope with the pressures that you have around you or within you.
If we look now at anxiety, we know that stress and anxiety are usually linked together.
Anxiety is usually defined as:
a feeling of unease, and it’s your body’s natural response to feeling stress.
You usually feel the fear or the apprehension about what is about to happen or what might happen in the future. You might be worried or nervous, and you might have some feelings of tension or worried thoughts. Furthermore, you may be worried about something that is happening now, or you might even worry about the future, things that haven’t happened yet.
When it comes to anger, it’s a bit different. It has a bit more energy compared to the anxiety.
Anger is an emotion that you feel towards something or someone that you feel has deliberately done wrong. It’s absolutely normal, it’s a natural response and, sometimes, it can come without expecting, sometimes we may even feel it’s a bit irrational, but most of us, all of us, will feel angry at some point in time, and it’s a natural way for our bodies to survive and protect ourselves from anything that we consider in our beliefs to be wrongdoing towards ourselves.
The fourth emotion is fear. Fear is what we feel when there is a perceived danger or perceived threat towards ourselves. It causes physiological changes and ultimately behavioural changes because when we are afraid we behave differently.
Fear is usually a response to something that is happening in the present, but just like those other emotions, it can also happen in anticipation of something that might be happening in the future that may or may not happen, but we might still be afraid.
The reason I decided to talk about these four emotions is because there is something that I usually call ‘crazy eight’. What happens is that usually you might be stressed or fearful about your circumstances and that’s when you decide,
I’ve had enough, I’m not going to take action. I just need to move on and move forward.
Then, there’s a time when you might feel a bit angry, and you say, ‘No, I need to do something about it,’ and then you try to do something about it and then that cycle doesn’t work. Some people continue in this crazy eight of feeling stressed, angry, afraid, anxious, all the time, one after the other and not really being able to break the cycle of the crazy eight.
I want to tell you today that it is possible to break the cycle and with some of the strategies that we’ll talk about today, you can break this cycle and you will be able to go through the normal circumstances that you are going through in a way that your emotions are not as intense and you are a bit more in control of how you are feeling. You can make decisions that are not so based on the intense emotion that makes you act differently because of fear, because of stress, or because of angry. You want decisions that are based on a more balanced response, that is not just based on strong emotions.
You are not your emotions.
Usually, we say ‘I am angry’, ‘I am stressed’, ‘I am anxious’, and what I would like to invite you to do instead of saying ‘I am…’, is to say, ‘I feel’. Instead of saying ‘I am angry’, I say ‘I feel angry’, and the moment we change from ‘I am’ to ‘I feel’, we detach our emotions from ourselves, from our identity, and that’s the first step to being able to manage something. It’s easier to manage something that is not us, that is not our identity.
So, detaching and saying ‘I feel’ instead of ‘I am’.
All our feelings that we have, either fear, anger, anxiety, stress, or even good feelings like happiness, hope, all of those feelings are triggered by certain thoughts that we have in our head.
Whatever we think about the circumstances that are happening around us that leads to the feelings and emotions that we have, and because I feel a certain way, I will take a certain action and the actions I take will give me the result I have in life.
If I have a certain thought about, for example, the coronavirus or my fertility and I have a feeling of being fearful, and afraid, I might not be willing to take certain actions. I might, for example, be less likely to take risks and that means that I will get results that are a result of that action; however, if I’m angry, for example, I will take very different actions. The actions I take if I’m afraid, the actions I take if I am happy, or if I’m hopeful; so, it’s really important that when we understand there is a link between our thoughts or feelings, our actions and our results.
The second thing I would like to invite you to do today is to analyse and look at the thoughts that you’re having whenever you have these emotions; if you are feeling anxious, what is the thought that is triggering that anxiety? If you’re feeling angry, what is the thought that is triggering that feeling of being angry? Or being fearful or being stressed.
Looking at the thoughts is a great way of addressing that feeling, and you might notice that, even though you are analysing the thought, sometimes you just can’t prevent that feeling from coming, it’s almost like you can’t prevent it; however, it’s significant that we catch those emotions as soon as they come. The sooner we get them, the easier it will be to manage them.
I would like you to think about, for example, being in pain. If you are in pain on a scale of 0 to 10, let’s say you are a 3 or 4 in pain, you can take paracetamol or ibuprofen and that may take your pain away; however, if you don’t take any painkillers, and you let your pain develop to a level 8, 9 out of 10, that’s a very severe pain. If you take paracetamol or ibuprofen at that point, your pain is not as easy to manage, so it’s not likely that you’ll be able to bring it down.
My idea is that we need to catch our emotions when they are just coming to us, so when they are at that lowest level, they’re not still set in our brains because the longest we leave our emotions here or here, the more difficult we will have to manage them.
I would like to invite you to think about common triggers that usually we know can trigger fear, anger, anxiety, or distress.
One of the most common triggers we have is:
How many of you have felt angry when you haven’t eaten for a while? My husband will tell me that that is correct because I get angry when I haven’t eaten for a while. So, when you don’t have your basic human needs met, you are more likely to be angry, stressed, or anxious.
When you have situations that are uncertain, new, or unpredictable, you will also feel stressed, anxious, and fearful. That might be, for example, for those of you who have infertility and who are trying to conceive using medical approaches, you know that IVF is uncertain, you know that it’s something new to you, that you haven’t had previous experience with it, and you know it’s a bit unpredictable. You don’t know what’s going to come out of it, if you will have the baby or not, so the whole situation that you’re facing in terms of fertility is uncertain and unpredictable. It’s a perfect source to cause all of these emotions that we’re talking about today.
If we think about the pandemic that all of us are going through, it’s also uncertain, new, and, unpredictable. It’s, again, just to top up all the emotions that you already have, for our normal circumstances, it just enhances it a bit further.
We know that loss and grief are also common triggers for all of these emotions and when we go through infertility, we are constantly having this feeling of loss. We have a loss for not having children the normal and natural way that we thought we would, and so many times we have loss after loss when you go through a cycle that doesn’t work and then you try again and then there’s another loss.
When you experience miscarriages or even when you have to try, for example, egg donation or adoption, every time you need to change your plan and adjust your plan you need to grieve the loss of something that didn’t happen the way you thought it would happen, and we know that this is a common trigger for all of these emotions.
We know that situations that cause injustice, criticism, or threat are also triggers for these emotions, and so many times have we not felt injustice because of the fertility problems that we have because of not being understood by other people who are not going through it or even the way fertility treatments in different countries is distributed and so many people don’t have access to it, so it can be very unjust.
We know that when we have our values and beliefs challenged when we don’t see eye to eye with other people, then we’re also more likely to feel anxious, angry, fearful, or stressed. If you know that these are triggers and you know that you might be feeling these emotions, you are more likely to be able to catch these emotions if you know that you are facing these situations.
Let’s say you are starting to feel a bit anxious or fearful and you have this image of the four photos of me that I took with all these emotions, and I’d like to talk to you about the four molders of these emotions. Molders are things that allow us to adjust the intensity of the emotion and all the emotions have three molders which are the focus of the language and the posture.
If you think about a time when you were afraid or when you were anxious or angry or stressed, I want you to think about the posture of your body, how did your body look like? You might remember that in the picture where I was afraid, I had this body posture, or stressed I was grabbing my head. So, all of these body postures are universal and everyone here or in different countries, in different cultures, will show similar postures to each of these emotions.
It might be that even if someone is a couple of meters away from you and you see them with a certain posture, you can easily say if they are sad, happy, fearful, or angry, even without talking to them. Posture is a big molder and gives meaning to each emotion that we are feeling.
The second one that I would like to talk about is the language that we use towards ourselves when we are feeling these emotions. If you are fearful or anxious, you might be using certain language that is not very friendly towards yourself you might say, for example, ’ You are not good enough’ or ‘There’s no point even trying’ or ‘Why does this all always happens to you’ or ‘you’ll never be able to do anything else.’ How many of you have had that sort of language towards yourself? We’ve all been there.
When you are feeling fearful, you have a certain language that you use in your head. When you’re feeling angry, you have a certain language. When you’re feeling anxious or stressed, you are using a certain language towards yourself.
The third molder means, that two emotions are focused. If you are angry, there is something that you are focusing on. If you are stressed, there is a particular circumstance or person, something that happened, that you are focusing on. If you are afraid, you are not focusing on something.
I tell you this because just like we have these three molders of meaning to these emotions that were talked about today, if you think about a situation when you were happy you will very easily see that you can also have a specific posture, language, and focus for that time when you were happy. So, one of the things that you can use to speak, to grasp these emotions as soon as they start is by noticing where your focus, your language, and your posture look like. I might not even notice that I’m stressed, but I might notice that my muscles are tensed, I have aches and pains in my body, my focus is on something, I’m using certain language towards myself, or that I’m a bit restless so I’m unable to relax. Those are certain things that might help me identify these emotions very quickly and be able to grasp them and grab them so I can take hold of them instead of letting them take hold of me.
Some of the things that you might be feeling are:
If you’re noticing any of these physical or mental psychological signs, then it’s likely that you are feeling one of these emotions. What you can do next is try to identify what emotion you’re feeling.
The next step is just to say, ‘Okay, it’s okay to feel the way I feel. I know I’m not feeling okay, but it’s okay.’ So, you were being a bit compassionate towards yourself, you’re acknowledging that you are human, and this emotion that you are feeling right now is just one of many emotions that you, as a human being, are able to experience.
We have here this wheel called the wheel of emotions, and it was created by Robert Plutchik. It helps us identify the emotions that we are feeling. If you’re feeling all these things in your body, one of the things that you can do is grab this wheel of emotions.
We know that as human beings, do you know how many emotions we can feel? It’s over 34,000 emotions, so that is a lot, but Robert said that there are about eight basic emotions, and they are here in this wheel. You have eight basic emotions:
You have these emotions here and you will notice that they have different colours. Let’s look at the colour closer to the centre, the colour is a bit brighter and towards the outside of the wheel, it’s not as bright. That has to do with the intensity of the emotion. If we look at your joy, for example, if you feel joy at a very high level, very intense level, you can call it ecstasy, but if you feel it at a lower level you can define it as serenity. For example, you have anger, which we’re talking about today, at the lowest level is just a bit of an annoyance that you have, but if it’s a bit more intense you call it rage.
There is an intensity that you can see in each emotion. You can identify your emotion and you can identify how intense that emotion is. Another interesting thing about this wheel is that we have opposites. For example, joy is the opposite of sadness, and they are immediately positioned in front of each other, so joy is the opposite of sadness.
Disgust is the opposite of trust.
Anger is the opposite of fear.
It’s quite useful to understand what you are feeling. Some so many people have difficulty in labelling what they are feeling, so when you look at this wheel, it makes it a bit easier. The last thing I’d like to do about this wheel is that there are some emotions that are here in white, in between the petals, they are the combination of the emotions on each side. For example, love is the combination of joy and trust. Optimism is the combination of joy and anticipation.
This wheel is about trying to pinpoint what is happening in the medium, so let’s say you are noticing that thought or trigger or maybe you are at the stage where you’re not seeing something in your system, in your body, that isn’t right, you grab the wheel and you try to identify it; what emotion, what feeling it is.
The next thing you’re going to do is you’re going to ask yourself, ‘Is this emotion healthy or unhealthy? Is this emotion the way I want to respond to my circumstances? Can I respond differently? Is there any other way that I can choose to respond to the circumstance that is a bit more useful to me?’
If what is happening around me is making me feel fearful or angry, ‘is this the way that I want to respond? Am I going to get what I want by being angry? Am I getting what I want by being fearful or by being anxious? These are really useful questions to ask yourself.
Once you try and answer these questions yourself, write down your thoughts because all these exercises are a bit challenging. We don’t do it naturally, but it’s something that you can try doing at home.
Writing it down is a way of taking these emotions again away from our identity onto paper and once they are on paper they are easier to manage. Once they are on paper, you can also try and respond towards yourself and your circumstances with a bit more compassion.
For example, going to the supermarket. This is a situation that made me feel a bit stressed and anxious, fearful that I’m going to get the virus, or angry that other people are not following the restrictions and they’re not staying two meters away from me. So, the situation was going to the supermarket, that is the trigger for me. I felt stressed anxious, angry, and fearful, and the automatic thought that pops in my head is that I’m going to get infected with the virus, and then I’m going to get everyone in my household infected and we’re all going to die. That is my thought and once I write it on paper, what I can do, is write a compassionate response to what I’m going through.
What I’ve written here is, ‘It’s normal to be worried about getting any infection, it’s okay to be concerned about my well-being, but I’m taking all the steps I can to minimize the risk, so I’m washing hands, I am wearing a mask, I’m keeping the social distance, and I’m disinfecting all my purchases. I’m allowing myself to feel the way I feel and I’m reassuring myself that I’m doing everything that I can do so that I can lower the intensity of these emotions.
We can think about another example. Let’s say you are feeling stressed or fearful for your fertility journey because you haven’t been able to go ahead with treatment yet, so the situation is you’re not able to go ahead with your embryo transfer or with your simulated cycle, for example, and you’re feeling stress, fearful, and you’re angry at all of this. Your automatic thought is, ‘I’m never going to get pregnant,’ and your compassionate response might be, ‘It’s normal to be worried, concerned about not being able to get pregnant straight away. It’s okay to feel the way you feel; however, you’re taking all the steps you can during this lockdown period to look after your fertility. For example, you’re eating healthier, you’re exercising, and you’re here listening to these podcasts regularly to keep updated, so it’s all about inviting a compassionate response towards yourself instead of just being so harsh about yourself and this will allow you to reduce the intensity of stress, anxiety, anger, and fear.
I want to say that even if you do all of these things, sometimes you might still need help managing these emotions and it’s completely understandable. There are lots of people who do need help; so, when should you ask for help?
You should ask for help if:
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Understandably, you feel frustrated at this time. Usually, when we are facing a crisis what we expect from the clinics and the governments is to over-communicate. That’s what I have been telling all the clinics, you need to over-communicate social media, you need to call patients, email patients because that’s what people expect when it’s a crisis, people expect you to show them that you have a plan and that everything is under control and that you’re giving them hope that they can go ahead, but unfortunately, I know that a lot of clinics are still not doing that, so the best thing that I could say is to continue chasing them and calling them because if they are not calling you, that’s the only way of you getting an answer is by getting in touch with them. In terms of managing your emotions I think you can also f. e. try and keep track of the changes that are happening around Spain and around the UK, what travel restrictions are in place and when clinics might be open, so there might be ways of being aware of that through the news or through social media or by being in touch with other patients that are in that clinic or maybe even following the clinics on social media, some of them are sharing some of the news about being closed or open or running other webinars like this one. It might be a way of getting in touch with them. I would say that to manage your frustration, the best thing would be to try and keep busy and try and schedule a time to look into these topics because otherwise, it can consume all your time and all your worry if you are so focused on this topic. So, if you allow yourself f. e. half an hour a day, at the end of the day to look into it and go on social media to check the clinic, email the clinic or try and call them, just do everything you need to do in half an hour. Then allow yourself for the rest of the time to engage in other activities and other things that do allow, to continue having a life outside of these restrictions.
Unfortunately, these drugs do you affect fertility, it’s well known, but I mean if you have been taking them for a long time and if you talk to your general practitioner or if you have a fertility doctor does tell them that you are taking these drugs, but these do tend to affect fertility, they usually affect libido, and some anti-psychiatric drugs, like SSRIs, can also affect the quality of sperm, so I would definitely say to speak with your general practitioner or a fertility doctor if you are taking those medications to see if it’s a possible reason why you haven’t gotten pregnant yet.
I don’t think you need it. When we look at the evidence behind supplements, there is a very little effect on supplements apart from folic acid, and there’s mixed research on vitamin D. The most important thing for you is to have a good sleep and make sure that you’re allowing yourself a calming period before that. If you have dinner you need at least 2 or 3 hours between dinner and going to bed and before going to bed that last hour you have a cooling down period, so you can maybe do a bit of relaxing yoga, or you can do a bit of reading, but you should start toning down the lights, no artificial lights, your phone shouldn’t be near your bed, you can do a little bit of mindfulness and meditation, that will allow you to have a good sleep. Sleep is actually important for fertility, but you can achieve good melatonin levels by making this lifestyle and environment changes instead of just taking more supplements.
It’s the same situation with supplements, there isn’t any strong evidence saying that supplementing your diet with magnesium is needed or has any effect. I think the most important thing to manage stress would be trying to manage the thought. Remember, we said that the thought leads to the feeling and the feeling leads to the action. Try to identify the thoughts, manage the environment around you, reduce the stressful triggers around you, do a bit of mindfulness or meditation, try not to have a list of to-do things that is too big. I’ve done that myself over the years, I was just adding 5,6,7 things to do during my day, and it was impossible to do them, so plan the things that you’re giving yourself to do realistically and you’re able to do everything that you want to do. There are also other situations where you’re facing stress that you cannot really relieve the trigger, so I’m not quite sure what your circumstances are in particular, but and there are people who are suffering from chronic stress f. e. related to family situations, having to take care of family members who are not well, or being in job positions where it’s very stressful, very demanding, so it depends on if it’s the stress that you’re feeling in one moment or it is a stress that has been continuing for a long time, but the best way to manage stress is to remove the trigger, not take supplements to be able to cope with it. If you’re feeling stressed, your body is telling you that something isn’t quite right, so it’s all about listening to your body and adjusting what isn’t right instead of just taking something to try and hide it or manage it somehow.
There’s a lot of studies around fertility and stress and what we tend to believe at the moment is that stress does not cause infertility, but infertility does cause stress. So if you have been trying for a long time, I’m not surprised that you’re feeling anxious or stressed a lot of the time. We know that if you’re feeling stressed, you are less likely to have intercourse f. e., so you’re less likely to get pregnant, that’s what research has shown us. In terms of the two-week-wait if you’re feeling stressed we need to think about if I’m feeling stressed what actions am I taking because that will give you the results that you’re getting. So if you’re feeling stressed, but you’re finding a way of still coping with your day-to-day, and you’re doing the things you want to do, then it won’t affect your results, but if you’re feeling stressed and it is in your taking actions that might somehow affect the treatment, that you’ve just had, it can affect it. In terms of research, what we know is that the level of stress does not affect the fertility outcome, but the outcome, can cause stress. I would say that if you want we can schedule a free consultation and we can talk about some of the strategies around anxiety and stress, and we can do a small assessment to see if that’s something that you can implement in your day-to-day life or if you do need some medication because some people will eventually need medication. I would say you need an assessment initially, and then we can talk about virtually needing medication or being able to manage it with some behavioural strategies.
The research doesn’t show that stress affects egg quality and follicle count. What we know is that if you are being followed in the fertility clinic and you are aware that your egg count is low or that your egg quality is low, then you might feel stressed about it, but stress does not make you infertile. We know that if you’re stressed you are less likely to have sex, so let’s say you go to the doctor, and you know that you have poor egg quality or fewer eggs and that makes you feel stressed, and then you’re less likely to have sex, so you’re like in a vicious circle. Stress does not cause infertility, but infertility may make you stressed. The biggest factors on egg quality and egg count are age, so woman’s fertility starts worsening from the age of 35, so we know that our egg quality and the number of our eggs starts reducing from that age, and after the age 40, it becomes very low, the chances of fertility treatment working over 40 are very, very low and there’s a point when you might need to consider egg donation. Apart from that, stress or any other mental health problems do not affect the quality or the number of your eggs.
