Anyone who follows the news has noticed what seems to be an epidemic of depression.  While rates may be on the rise, there is also a new willingness to discuss the issue more openly. In this way and others, depression and infertility have three things in common:
- both are medical conditions
- deserve to have treatment covered
- more work remains to reduce the stigma of the condition
For some, a diagnosis of infertility and the ensuing treatment bring a chronic state of stress. This can lead to depression or make existing depression or anxiety worse.
Research suggests that the emotional experience of women facing infertility is comparable to the emotional pain felt by women facing cancer, chronic rehabilitation, and hypertension.
Depression is more likely among those facing infertility if any of the following situations apply:
- They experienced depression before receiving their infertility diagnosis.
- There is a family history of depression.
- They lack a support network resulting in feelings of isolation.
Furthermore, the medications used to treat infertility and infertility treatment itself can be associated with emotional changes, including depression.
How can you tell the difference between sadness and depression in infertility patients?
How can you tell if what you are feeling – emotionally and physically – is explained by the situational stress of dealing with infertility? Or whether it is time to seek help for depression? It may not be so easy to decide.
According to the Harvard Mental Health Letter from Harvard Medical School :
“Patients and clinicians may find it hard to figure out which reactions are psychological and which are caused by medications — yet identifying causes is essential for determining next steps.”
Stress and sadness are often part of coping with infertility because:
- dreams of a family are altered
- the relationship with your partner may be tested
- the medications required during treatment can play havoc with mood
One question to ask is whether feelings of being sad and tearful are episodic and tied to specific events such as hormone treatment, a test result, or a friend’s pregnancy announcement. These feelings are important to acknowledge and should be addressed through counseling, a support group, and/or self-care.
Depression is different. It ranges from mild to major and may be recurrent. Mild depression includes feeling tired and sad.
Common signs of moderate to major depression include some or all of the following :
- Sadness that persists, lasting for weeks or months
- Feelings of hopelessness and helplessness
- Frequent crying
- Often feeling irritated or intolerant of others, especially people who you used to enjoy being around
- Lack of motivation, struggling to get things done at work and/or home
- Difficulty sleeping, either sleeping too much or insomnia
- Problems with eating, overeating or low appetite
- Struggling with experiencing pleasure in life, including a lack of interest in sex
- Frequent feelings of anxiety or worry
- Thoughts of dying, self-harm, or suicide – seek help immediately!
Can depression cause infertility? Or can infertility lead to depression?
A significant percentage of women of child-bearing age believe that there is an association between mental health and increased rates of infertility. In fact, oneFor example, in 2017, a women’s health company surveyed over 1000 women aged 25-33 who had a college education or advanced degree and earned over $50,000 per year. They found that over 70% of them believe that mental health problems (such as stress and anxiety) can have a negative impact on fertility even though it has not been proven.
More formal stories of the relationship between infertility and mental health have yielded a variety of findings. For example, one large multi-center study evaluating the effects of depression and antidepressant use on non-IVF treatment outcomes found different results for men and women. Male partners with current active major depression were less likely to achieve conception; women with active major depression not using an antidepressant had a different outcome – there was a slightly increased likelihood of pregnancy. Also, the use of antidepressants by the mother was associated with an increased risk of miscarriage in the first trimester, particularly when the antidepressant was NOT an SSRI. The researchers noted that further studies are needed to confirm this finding.
There may be links between depression and infertility due to hormonal issues that affect both conditions, negative lifestyle habits, and taking certain medications.
Peter Schlegel, MD, Past President of the American Society for Reproductive Medicine (ASRM), notes that although it was not directly evaluated here,
“male use of SSRI antidepressants has been previously linked to impaired sperm quality, without necessarily affecting standard semen parameters.”
He suggests that medication assessment of the male partner be part of any infertility evaluation.
Depression may also lead to lifestyle habits that can negatively affect your chances of becoming pregnant. Appetite is often affected and being overweight or underweight can cause infertility. Drinking or smoking which may start or increase with depression and anxiety can also create problems. Sleep disorders are also associated with depression (and some infertility medications) and can have a negative effect on fertility. There are changes you can make that both improve your depressive symptoms and your chances of getting pregnant.
What role does infertility have in depression? Multiple studies have found that infertility in both women and men often increases stress, depression, and anxiety; additionally, early or multiple miscarriages can lead to post-traumatic stress disorder (PTSD). Besides the effect of major chronic stress, hormonal imbalances that cause infertility may also contribute to mood disorders including depression. Hormone therapy to treat infertility, treatment failure and the isolation associated with infertility can also lead to depression.
Lifestyle Changes that Make a Difference
With depression, it might be tempting to self-medicate with junk food or alcohol or to counter poor sleep with more coffee but each of these makes the situation worse – for fertility and depression. The good news is that certain lifestyle changes can positively impact both fertility and depression.
Diet is important: various studies show that a poor diet including fast food or food high in sugar increase the risk of infertility in women, negatively impact sperm counts and are associated with higher rates of depression and anxiety. Alcohol makes depressive symptoms worse and excessive alcohol and drug use by both women and men can have a negative impact on fertility and treatment outcomes. Even consuming excessive caffeine (the equivalent of more than five cups of coffee per day) can hamper your ability to get pregnant. At the same time, a healthy diet has been shown to have a positive effect: a new study shows women undergoing IVF have better pregnancy outcomes from eating a Mediterranean diet and men who eat healthy have better semen quality. The relatively new field of nutritional psychiatry is finding positive results of a healthy diet on depression and anxiety.
There are also mind-body practices experts recommend that can help improve your chances of becoming pregnant and feeling less depressed. These include yoga; meditation or guided imagery; mindfulness; exercise and being in nature. Creative expression including expressive writing or journaling and art therapy may also help. While the effectiveness of each of these is supported by research, finding what works for you and what you’ll stick with is key.
How to Treat Depression During Infertility Treatment
If you’re experiencing any symptoms of a low mood or depression, talk to your infertility doctor. It may help your doctor diagnose your infertility and better manage your treatment and overall care. You may have a hormonal imbalance that helps explain your infertility and depression. Or, if you’re taking fertility drugs – like synthetic estrogen – it may explain mood swings, anxiety and aggravate depression. Your specialist may be able to make changes in your medication to help, refer you to the appropriate fertility counselor or mental health professional, or suggest taking a short break from treatment.
“The goal of mental health support is to help you maintain optimal functioning during a very difficult time,” explains Piave Pitisci Lake, MD, who serves on the Path2Parenthood Mental Health Advisory Board. Counseling, support groups, self-help resources, telephone-coaching groups, and family and friends may work for many. For a smaller group, there are multiple factors to consider in deciding treatment including the use of antidepressants: history of depression; whether it is recurrent and/or active; mild, moderate or severe; what other types of support have worked or failed; along with the risks of untreated psychiatric illness and fetal exposure to psychiatric medication.
While some antidepressants may affect fertility, not all do. In addition, Dr. Lake states “Much of the literature about antidepressants suggests that they are safe to use during pregnancy. The problems that have been attributed to psychiatric medications have “occurred in low numbers or are managed with medical support.” Another consideration: some infertility medications can interact with psychiatric drugs.
In general, the combination of medication and talk therapy (such as cognitive behavior therapy) is most effective for treating clinical depression and this combination may also enhance the chances of becoming pregnant. Your infertility clinic may have mental health professionals on staff that can provide individual or group counseling. If not, your physician or clinic can likely provide a referral to mental health professionals that specialize in treating people facing infertility.
The Mental Health Group of ASRM believes that mental health professionals with experience in infertility treatment can help a great deal on a range of issues including how to control stress, depression, and anxiety. Together, your fertility doctor and mental health professional can help determine which treatment(s) – especially if medication is indicated – are most effective and safe for your specific situation.
There’s no doubt that dealing with infertility or depression is a major challenge. Trying to cope with both – at once – can be overwhelming. Please remember that both are medical conditions that are not your fault and that treatment is available to help you build your family while addressing your depression.
- Fact Sheets. Depression, World Health Organization (WHO), 2020 Jan. 30, https://www.who.int/news-room/fact-sheets/detail/depression
- Domar A, Zuttermeister P, Freidman R. The psychological impact of infertility: a comparison with patients with other medical conditions, 1992, J Psychosom Obstet Gynecol, 14, suppl 45-52. https://pubmed.ncbi.nlm.nih.gov/8142988/
- Harvard Medical Letter. The psychological impact of infertility and its treatment, Harvard Mental Health Letter, Harvard Medical Publishing, Harvard Medical School, 2009 May. https://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment
- Gurevich R. Depression-related Infertility Causes and Treatment, VeryWellFamily 2020 Aug 3. https://www.verywellfamily.com/infertility-and-depression-101-1959977
- Gresge G. This Is the Biggest Misconception that Millennial Women Believe about Infertility. 2017, Dec. 24, Brit+Co. https://www.brit.co/millennial-women-attitudes-toward-fertility-celmatix-survey/
Published Aug. 19, 2018. Updated by the author for republication on Jan. 18, 2021