In this session, Andreia Trigo, multi-awarded nurse consultant, author, and TEDx speaker and founder of Enhanced Fertility Programme has been talking about stress – how to manage it and how it can influence your fertility.
Based on the webinar, unfortunately, it is common that anyone who is struggling to get pregnant will feel distressed and anxious at a certain time in the journey as there is a significant amount of emotional stress as a consequence of the diagnosis of infertility that can affect the quality of life due to depression and feelings of low self-esteem. According to a study, 90% of people suffer from depression when undergoing treatment, while another alarming 42% of patients feel suicidal. Therefore, it is a clear fact that infertility does cause stress.
Additionally, based on a literature review, it was stated that 25% to 60% of people facing infertility had anxiety and depression in comparison to people who never experienced it. What is more, it was also stated that the medication provided for the treatment of infertility is also associated with psychological symptoms, as well as irritability and major depression.
Firstly, a distinction of different types of stress is explained. In most people, it is expected to feel anxious about routine events, yet chronic stress encompasses several factors of life that ultimately lead to constant stressful feelings that can extend for years.
During times of stress:
The hypothalamus signals the pituitary gland to produce a hormone, which in turn signals the adrenal glands to increase the production of cortisol.
Cortisol is a glucocorticoid, which is important not only for responding to stress but also for proper regulation of the immune system to reduce inflammation.
All in all, cortisol is known to be an active player in terms of increasing the level of energy to cope with a stressful situation. However, an impaired communication between the immune system and the system that regulates stress can develop because of chronic stress. This impaired communication has been connected to the future development of mental and physical problems such as chronic fatigue and diabetes.
Traditionally, it is known that this axis is also responsible for the stress response. It is described to be similar to the axis formerly stated above, as the hypothalamus and pituitary gland are equally involved in a relationship with the thyroid, which is responsible for the stress response. On top of that, the hypothalamus produces TSH hormones, causing stimulation of the pituitary glands and thus stimulating the production of thyroid-stimulating hormone (TSH). In this way, levels in the blood return to normal after the production of hormones T3 and T4.
It is commonly known that the regulation of fertility hormones is involved with this axis. Again, the hypothalamus and the pituitary gland are similarly involved with the gonads, known as the ovaries and testicles respectively.
Consequently, the production of GnRH (Gonadotropin-releasing hormone) by the hypothalamus induces the synthesis and release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland, triggering the release of testosterone and progesterone. It is said that without these hormones, the correct functioning of the reproductive system will not be effective.
As previously stated, even though there is a relationship among these axes because of organ-related factors, it is also known that this relationship is more complex. In this way, the production of glucocorticoids is known to affect the gonadal function at multiple levels in the HPG axis.
What is the relationship between HPT and HPG? It is known that increased levels of GnLH (Gonadotropin-inhibitory reduce circulating levels of gonadotropins in (LH and FSH) and gonadal hormones.
As regards psychological interventions for infertile individuals, cognitive behavioural therapy and educational interventions are the most frequently used. Moreover, self-administered cognitive coping mindset exercises such as meditation and yoga can be helpful. Most importantly, professional guidance in a cognitive behavioural group approach is said to be the most efficient approach.
- Questions and Answers
I think that’s a very interesting question, and it might be that we’re just so used to getting on with our day that we don’t realize our body’s response to stressful situations. Things that we probably wouldn’t notice but could tell us that we are feeling stressed is our muscles being tense. That would be a common symptom, or if we have very shallow breathing, that could also be another symptom. I’m not sure exactly what your reflexologist noticed, but there are certain signs that maybe we don’t notice because we’re focusing on other things, and we’re just getting on with life, but then we’re feeling stressed.
It’s interesting to see how does the reflexologist comment relate to how you were feeling. Were you feeling okay? Were you feeling happy, relaxed? You’re saying you were very calm during the appointment, and how about the outside appointment? How is your day-to-day life? Do you have a very stressful job, or do you have other stressful factors in your life? Sometimes, it’s family stuff. I know several patients who’ve been through several years of being in a stressful situation, or their family members were unwell, or they have a very demanding job, and we get used to all of those things. We just do what needs to be done without realizing that it’s causing a long-term effect on our bodies.
That’s so odd, so I don’t know why the acupuncturist would say that because it’s not my speciality at all, acupuncture or reflexology. So I don’t know what they base their assessment on, but again I don’t know if he was feeling something in your body that was more chronic or more long-term. I don’t know how the acupuncturist would assess to say that, but I think it can be possible for us to have chronic stress over several years without even noticing it, and then we just get used to it.
That is such a challenging situation to find yourself in because it’s really hard for us to control what other people do. We can only control what we do, but ultimately she’s carrying your baby, so I don’t know if you can have a conversation with her and try and find out what she feels she can do, what can she commit to that will help her feel more relaxed and try and protect the pregnancy. It might be that if you give them several strategies or if you give her ideas, she can maybe choose one or two and give them a try. It may be the one-to-one support with a counsellor or a psychologist or a coach, or it might be trying a gratitude diary every day saying two or three things that they are grateful for. Perhaps, just trying to introduce meditation into her day-to-day life. That this is a tricky one because we can only control what we do, maybe give her some strategies and see if she can engage with any of those strategies.
These two are connected because we need a healthy egg and sperm to have a successful pregnancy, so they are connected. I would say that stress can impact several aspects, not only biological and physical but also behavioural. What we are doing in response to the stress that may affect the egg and sperm health. When we are stressed, we’re more likely to eat unhealthy, for example, we are more likely to eat foods that have a high intake of sugar or a high intake of fat, and that is related to again sperm health. If we have other behaviours that can have an impact on the health of our eggs and sperm, then that will ultimately affect our chances of a successful pregnancy.
I would say that it’s important to see whether the stress factors can be addressed or not. If we have, for example, an unwell family member, and we’re caring for them, it might be hard, and there’s nothing we can do about it, and what we can do in that instance is trying and learn some strategies to cope with the stressful situation itself. Addressing the stressful factor or changing the way we respond to the stressful factor would be the way to go ahead in this situation.
It’s never that linear but let’s say you are making a complete lifestyle change. You are changing your nutrition, your physical activity, you’re taking your supplements, you’re doing all those things that maybe you weren’t doing before. When we’re talking about men, it takes 74 days for new sperm to be formed, and in women, it also takes around three months, so we usually say it takes 12 months to have to create a baby, three months of making these changes until we have healthier eggs, sperm and then nine months of pregnancy.
I think day-to-day stress won’t affect it, but if we have chronic stress, it can affect it. We’ve seen at the beginning of the presentation, there is a relationship between the cortisol levels that reduce the amount of LH, FSH and estrogen and progesterone. When our hormones are off-balance, our menstrual cycle might be irregular, so that there may be a connection there.
It’s important to know that implantation failure can happen for several reasons. So if you had a failed implantation, we need to check if you’ve had all the tests you need to do to guarantee whether there was a problem with the eggs or sperm or the embryo, that is the most common reason for failed implantation, genetic changes. When you say there was a good quality embryo – was it a good quality embryo after having a biopsy? A PGT-A test or was it a good quality embryo just by looking under the microscope and noticing that it looked good? Sometimes embryos look good, but when they are genetically tested, they are aneuploid. If the embryo was good (euploid, genetically tested), I think we need to look at the uterus itself, whether you’ve had changes in the uterus. If you’ve had a test where they look at the presence of any polyps or fibroids that could be affecting implantation, or it could be if the uterus lining wasn’t thick enough or if your progesterone levels didn’t last for the whole duration of the implantation period.
There’s also the possibility that doctors transferred the embryo outside your implantation window. In some women, it’s a couple of days before or after, so there’s a very interesting test ERA test that can tell you when your implantation window. Your progesterone level was 3 at transfers, so very low – maybe the doctor prescribed progesterone or anything help with implantation, if not, that might be the way to do it. We don’t know if your hormone levels, the progesterone was low as a consequence of your thyroid, but maybe it’s important to test your thyroid hormones to see if everything is okay because if it’s not, it’s possible to take medicine to adjust it as well. I think it’s important to look at all the possible things that could have been a cause for failed implantation, so if the embryo was normal, we’d need to look at the uterus, and if the uterus was okay, then we need to look at the hormone levels, and here we look at the reproductive hormones, and we look at the thyroid hormones as well. I think you should test your thyroid, it’s very common for people to have abnormal thyroid tests, so I think it’s an important thing to test because if it’s not normal, then you can speak with your doctor and see if you can take medication before the next transfer.
If you’re already being medicated, it’s because the doctors are already aware of your thyroid changes. It’s good that they are measuring them and making sure that you have the right levels ahead of transfer. The doctor who prescribed the thyroid medication must be speaking, or at least you can take that data to your fertility doctor, so they can see the data, and they can speak with each other and agree before your treatment starts. I think if you have changes in your thyroid, it could be stress, but it could be also lots of things, so you need to have an exam on your thyroid to see why is it not working properly. It’s usually a scan, some doctors might request if they notice any nodules, they might request a biopsy, but the endocrinologist needs to look at the reason why the thyroid is not working properly. Without doing those tests, it’s impossible to say for certain the cause of the thyroid changes. If it’s stress or if it’s something else.
Not really, so I think a couple of weeks, that’s fine. I usually believe that we don’t need to be perfect with our nutrition or stress or lifestyle because life is unpredictable sometimes, so it doesn’t need to be perfect, we’re not robots. We just need to do it in a good way most of the time, that’s fine. Eggs grow in every cycle, every month, you have a whole batch of hundreds of eggs that are growing and maturing. You have always new opportunities to grow and mature, good eggs, don’t beat your self up because that will just make you even more stressed. It’s hard as it is. If it feels like having a few bad weeks, just have two bad weeks, that’s fine.
The most important thing when it comes to egg quality is your age, so if you have frozen your eggs when you were under 35 years old, they will likely be of better quality. I think you will not find that to be a problem, and you say if you are in a much better place stress-wise when it comes to using the eggs you were trying, that’s brilliant, it might be that your eggs are really good. I think one thing that sometimes people don’t notice is that when we do egg freezing, it’s not always a guarantee of pregnancy, so we need a lot of eggs to achieve even 80% pregnancy rate of having one of them leading to a baby, so it’s important to have several eggs frozen. I don’t have the numbers here with me, but you need several because not all of those eggs will survive the defrosting, not all of those eggs will be fertilized, not all of those that fertilized will survive to day-3, not all of them will survive to day-5, not all of them will survive implantation, it’s like a funnel. You have lots, and it’s normal to have a very small amount of eggs at the end of the journey. For you to have a baby, you have to have a lot of eggs frozen.
Yes, I think it can because of the thyroid, so the HPT axis, as we’ve seen is connected with the HPG axis. Thyroid problems can affect the ability of the pituitary gland to stimulate the testicles and to produce testosterone. Testosterone is really important for male reproduction. I think it’s important for men to test their thyroid levels as well.
I’ve heard that there are some tests in the market that test cortisol levels. I think if we want to know and make sure what our levels are, it would be good to test it. It’s also good to have an idea of whether we are feeling stressed as well and to trust our bodies, but there are definitely ways of testing it. I don’t know what a healthy level is, but I can come back to you on that.