A Mother's Love- Infertility and Pregnancy Loss

(photo: Sher Institutes)

One could argue that there's nothing more intense than a mother's love, long before her child is even born.

This week we celebrate the National Infertility Awareness Week, a movement that started in 1989.  My interest in Women’s Mental Health and Reproductive Psychiatry began a little less than two decades later, when my husband and I were diagnosed with infertility. Suddenly, this two-physician couple assumed the patient role, with all its emotional and physical pains, challenges and distress. Denial, anger, shock, grief and disbelief, depression and anxiety all followed. A terrifying sense of loss of control marked that turbulent, draining road.

Relationships suffer- marital discord arises, friendships get affected, one’s social life may vanish. Diminished quality of life, complicated grief, major depressive disorder, anxiety disorders, and post-traumatic stress disorder may develop.

Infertility is the inability to achieve pregnancy for one year (or six months if over 35) or being unable to carry a pregnancy to live birth. It is quite common, affecting approximately 1 in 8 couples. One third of infertility is attributed to the female partner, 1/3 attributed to the male partner and 1/3 is unexplained or results from a combination of problems in both partners 

According to Dr. John Rapisarda, Reproductive Endocrinologist and Vice President of Fertility Centers of Illinois, “The most common causes of infertility in women are Polycystic Ovarian Syndrome (PCOS) and other ovulation disorders, blockage of the Fallopian tubes and diminished ovarian reserve while the most common causes of infertility in men are hormonal imbalances, low sperm count, abnormal sperm shape, and poor sperm movement (motility)”.

The frustration, pressure and uncertainty that surround infertility have been shown to cause significant mental stress, particularly anxiety and depression. In addition to that, fertility treatment often involves invasive, time-consuming tests and procedures, and complicated medication schedules that further add to the stress of the diagnosis. That is commonly accompanied by feelings of grief, failure, and guilt. 

The prevalence of depressive symptoms among infertile women has been reported as being twiceas high as that of fertile women. Further, levels of distress and anxiety in infertile women persist over extended periods of time, tending to increase as treatment intensifies and the duration of treatment lengthens. Several factors are involved: 

·         The drugs and hormones that are commonly used to treat infertility often cause a myriad of psychological side effects. Clomiphene citrate (Clomid, Serophene), frequently prescribed because it improves ovulation and increases sperm production, may cause anxiety, sleep interruptions, mood swings, and irritability; Oral contraceptives, often part of the treatment protocols, have higher doses of progesterone, which has been associated with increased depression. GnRH Agonists (Leuprolide/Lupron) are associated with depression, emotional lability, and changes in libido; Steroids and immunosuppresants may also cause depression, mania, anxiety and psychosis. 

·         Financial Difficulties: insurance coverage varies widely, and infertility treatments can be financially draining while still offering disappointing success rates in a lot of cases;

·         Religious ambivalence: fertility treatment goes against several religious doctrines, further adding to feelings of guilt and anxiety or social criticism.

·         Social aspects: patients may find it very distressing to socialize with their friends who are pregnant or have children. They may feel guilty for not being able to fully rejoice with them and end up opting to exclude them from their lives, becoming increasingly withdrawn and seclusive, with fewer support systems at a time when social support could be so helpful.

   

 While it is clear that infertility can affect mental health, researchers are not sure if mental health can affect fertility. Some studies have proposed that high levels of depression, anxiety, and stress can affect some of the hormones that regulate ovulation. The hormonal impact on mood and its correlation with pre-menstrual syndrome, pre-menstrual dysphoric disorder, pregnancy and postpartum depression, and menopause are well-established. The psychological impact of the hormones used in fertility treatments, however, hasn’t been as widely studied.

A Japanese study with 83 women undergoing fertility treatment showed that the rates of anxiety and depression were higher as the age increased. They also found that patients who underwent infertility treatment were more likely to have higher depression scores compared to patients who had not undergone treatment. Additionally, patients whose husbands were infertile had significantly lower total mood and anxiety scores than those whose husbands were not infertile.

“Eliminating psychological stress may be necessary for successful infertility treatment.

Women appear to have a higher rate of infertility-related stress than men. Studies have also found that greater than half of the women receiving infertility treatment feel that infertility is the most stressful experience of their lives", they conclude.

One study of 200 couples seen at a fertility clinic, for example, found that half of the women and 15% of the men said that infertility was "the most upsetting experience" of their lives. Another study of 488 American women who filled out a standard psychological questionnaire before undergoing a stress reduction program concluded that women with infertility felt as anxious or depressed as those diagnosed with cancer, hypertension, or recovering from a heart attack.

Despite the evidence that infertility has a profound impact on mood and anxiety, mental health care during this treatment is often neglected. A couple dealing with infertility may benefit from several treatment approaches observing the biopsychosocial model. Those include counseling and psychotherapy, relaxation techniques, yoga, meditation and exercises (see our post about that here) and psychiatric medications that may alleviate mood and anxiety symptoms. The prevalence of antidepressant use has been reported to comprise as much as 4 and 11% of women undergoing infertility treatment according to some studies.

But is there any evidence that antidepressants increase the fertility rates? 

A study published this year on the Journal of Psychosomatics Research by a Canadian group did a systematic review of databases from January 1950 to November 2015 and did not find that antidepressant use by women receiving fertility therapy impacted gamete quality or pregnancy success. “Collectively, the findings of the four studies meeting inclusion criteria reflect no differences between antidepressant users and comparators in assisted reproductive outcomes (i.e., peak serum FSH or estradiol levels, oocyte retrieval, or embryo maturation, transfer and implantation rates). This is consistent with Worly and Gur's findings that clinical studies have yet to demonstrate a deleterious effect of psychotropic medications on oocyte quality or reproductive success”.

A Swedish nation-wide study including 23,557 nulliparous women undergoing their first IVF cycle between January 1, 2007 and December 31, 2012 found no statistically significant associations between SSRI treatment and IVF outcomes. Conversely, women treated with non-SSRI antidepressants had reduced odds of pregnancy (Adjusted Odds Ratio (AOR): 0.41; 95% CI: 0.21, 0.80) and live birth (AOR: 0.27; 95% CI: 0.11, 0.68) and an increased likelihood of miscarriage (AOR: 3.56; 95% CI: 1.06, 11.9). These risks were also significant for untreated individuals in pregnancy (AOR: 0.58; 95% CI: 0.41, 0.82) and live birth (AOR: 0.60; 95% CI: 0.41, 0.89) but not miscarriage (AOR = 1.28; 95% CI: 0.49, 3.39).

It is crucial to note, however, that each patient should be treated according to the severity of her symptoms and medications are often required to ensure safety and well-being. In fact, a recent study on suicidal risk among infertile women undergoing in-vitro fertilization found that being "childless, depressive and non-positive reappraisal predict suicide risk" and stressed that suicidal risk is recommended for women in the course of IVF.

“The incidence of suicide risk was 9.4%. Suicidal women were more likely to be childless or had fewer children and experienced higher levels of depressive symptoms. In addition, they reported more frequently on denial, social withdrawal and self-blame coping strategies compared to participants without suicidal risk”. 

Perinatal loss (miscarriage, stillbirth) is another major risk factor for depression and other psychiatric issues. A recently-published study entitled “Infertility and Perinatal Loss: When the Bough Breaks” does a comprehensive review on the correlation between pregnancy loss, depression, suicidality and trauma:

"Young women, who lack social supports, have experienced recurrent pregnancy loss or a history of trauma and / or preexisting psychiatric illness are at a higher risk of experiencing psychiatric illnesses or symptoms after a perinatal loss or during infertility.

Perinatal loss is the non-voluntary end of pregnancy or death of the baby from conception until 28 days into a newborns life. The term perinatal loss includes miscarriage, stillbirth, and neonatal death.

Psychological Aspects of Perinatal Loss Understanding and addressing psychological aspects of perinatal loss is critical because of the psychological reactions of women (grief, depression, anxiety, PTSD, suicide) and the impact on subsequent pregnancies and relationships with partners and surviving siblings. The grief that follows miscarriage often declines significantly by 6 months for both men and women, yet sometimes persists for up to 2 years. Perinatal loss leads to complicated grief more frequently than other losses. Several factors may contribute to this. Pregnancy loss is often sudden and unexpected. The grief that parents experience after early pregnancy loss is often not openly acknowledged or socially supported. Perinatal loss is associated with guilt or self-blame, and women may feel that their bodies have failed. Predictors of complicated grief following perinatal loss include lack of social support, previous loss, major depression, ambivalence about pregnancy, and termination of pregnancy for fetal anomaly. Termination of pregnancy for fetal anomaly is associated with higher levels of self-blame, guilt, and social isolation. Other factors that have been reported as predictive in some, but not all studies include older maternal age, having viewed an ultrasound, having experienced quickening (fetal movement), having named the baby or bought things for the baby, and length of gestation.  Whether miscarriage is managed medically or surgically does not have a bearing on the intensity or duration of grief. The presence of living children is protective against grief after perinatal loss. The perinatal loss of a co-twin or a higher order pregnancy is associated with unique challenges such as enduring the trauma of prolonged hospitalization for the surviving twin. Grief following perinatal loss is a normal phenomenon. Nonetheless, women, especially those with risk factors, should be monitored for prolonged or complicated grief and persistence of depression, anxiety, or posttraumatic symptoms. Women who experience a perinatal loss have fourfold higher odds than women with a live birth of screening positive for depression. Risk factors for persisting depression/ psychological distress after miscarriage are infertility treatment, recurrent pregnancy loss, prior history of depression, prior PTSD, intimate partner violence (IPV), and high levels of distress immediately after miscarriage. There is also a higher risk of inpatient or outpatient psychiatric treatment 12 months after fetal death. The highest risk is for women with a loss occurring after 20 weeks of gestation, and the most commonly reported psychiatric disorder is adjustment disorder. However, 5 to 18 years after intrauterine fetal death (IUFD), there are no significant increases in depression scores. Thus, while women with recurrent miscarriages and a past history of depression and fetal death after 20 weeks of gestation are at a high risk of depression/ adjustment disorder in the year following perinatal loss, this risk declines subsequently.

Post-Traumatic Stress Disorder (PTSD) rates are increased after all types of perinatal loss—miscarriage, termination of pregnancy, stillbirth, and neonatal death. Risk factors for PTSD include younger age, lower education, previous trauma, and mental health problems. Longer gestational ages are associated with greater severity of PTSD. Even 9 months after a stillbirth or neonatal death, women have a sevenfold higher rate for screen positive PTSD when compared with women with live births. It is important to encourage the use of available social support because having a support network is associated with less depression and PTSD. The mean annual suicide rate is higher (18.1 per 100,000) in the first year after miscarriage than after live birth (5.9) or in the general population (11.3)”.

They proceed to commenting on the guidelines for the management of psychological responses after stillbirth, which remain controversial, “especially surrounding the parent’s decision to hold the baby. Although there is a dearth of randomized controlled trials of bereavement counseling or specialized psychotherapy for mothers, fathers, and families after perinatal death, there is evidence from studies using other study designs. Some studies have found that holding the baby may increase the risk of depression, anxiety, and PTSD in the mother, sometimes up to 7 years after stillbirth. However, other studies have found that parents appreciate time and contact with their deceased infant, and that parents who see and hold their baby report fewer poor mental health outcomes. Encouragement of parents to see and hold their deceased baby may be best done under guidance from experienced staff , always emphasizing the importance of respecting culturally diverse approaches to neonatal death. In the case of termination of pregnancy for fetal anomaly, observing a deformed baby can be traumatic, but it may also help to reduce guilt if observing the baby convinces the mother that she made the right decision. Other approaches to supporting parents grieving after a stillbirth have included supportive DVDs, internet-based cognitive behavior therapy and mindfulness-based therapy. Physical activity may help as shown in a recent study, which found that in women within a year of stillbirth, those who reported higher levels of physical activity reported lower levels of depressive symptoms. There is a dearth of studies or reviews specifically examining the use of SSRIs or other psychotropics in the aftermath of perinatal loss. However, it is worth noting that the association between SSRI use and miscarriage is controversial, and there is no association between SSRI use and stillbirth. Although all women may not need preventive psychosocial interventions after miscarriage, stillbirth, or neonatal death, it is important that they be monitored, especially if they have established risk factors. Given the lack of evidence for any specific approach, we recommend a customized treatment plan based on the individual’s preferences.

Couples dealing with infertility and pregnancy loss eventually come to some form of resolution achieved through biological children, adopted children, surrogacy, embryo/egg/sperm donation, or a decision to have a life without children. Whatever the outcome is, the experience will change some of the most important aspects of who you are- you may reframe your self-identity and self-perception, strengths and weaknesses, relationships, and even your global view of existence.