Psychiatric Aspects of Infertility
“The findings, opinions, and conclusions of this report do not necessarily represent the views of the officers, trustees, or all members of the American Psychiatric Association. Views expressed are those of the authors.” – APA Operations Manual.
At its February 2019 meeting, the APA Joint Reference Committee voted to approve a Resource Document developed by the Council on Consultation-Liaison Psychiatry workgroup on Psychiatric Aspects of Infertility. The workgroup had been charged with reviewing and summarizing the literature on the psychiatric impact of infertility to help educate about its impact in order to improve care. The following summarizes the workgroup report.
In the United States, the estimated prevalence of infertility is between 6% and 18% with increasing incidence with advancing age (1, 2). Infertility poses a significant psychological burden, and patients receiving assisted reproductive therapies are at risk for psychiatric comorbidity (3). There are multiple triggers for the development of depression and anxiety during infertility treatment, including wanting to conform to social expectations by becoming a parent, loss of sexual self-esteem and enjoyment, scheduling sexual activity, fear of advancing age, financial concerns due to expense of treatments, and impairment in quality of life (4, 5).
Depressive and anxiety disorders commonly affect women who are trying to conceive, although there are conflicting results regarding their effects on ability to conceive. Stress, anxiety, and depression may have both direct and indirect effects on fertility. It is unclear whether premorbid diagnoses of anxiety or depression contribute to infertility or whether they result from the psychological distress of infertility and its treatments. There is a high prevalence of these disorders among infertile women, with up to 40% meeting criteria for a psychiatric diagnosis with generalized anxiety disorders most prevalent, followed by major depressive disorder and dysthymia (3). An increased risk of suicidal ideation has been reported in women who suffer from infertility (e.g., a 9.4% incidence) (6) with even higher risks for women who were not able to successfully have a child after assisted reproductive treatments (7). Despite these high rates of psychiatric comorbidity, very few patients seek psychiatric care (with one study noting only 6.7% of patients sought care [3]).
Fertility medications can also impact mood. Many women experience mood fluctuations related to normal hormonal changes during their natural reproductive cycles (8). Fertility medications target these same hormones affecting the hypothalamic pituitary ovarian axis and thus can have similar effects on mood (9, 10). These symptoms are often more clinically impairing in women with a history of depressive disorders and increase their risk for recurrent episodes of psychiatric illness (11–15).
Some psychotropic medications may confer risk when used during the time when trying to conceive; this varies according to the class and type of medication. Most studies looking at the exposure to SSRIs during IVF show no difference in pregnancy outcomes when compared with control groups (16–18). However, SSRIs and other antidepressants can indirectly reduce fertility by causing sexual dysfunction (19, 20). Antipsychotics and some mood stabilizers can also impair fertility, either directly through hormonal changes, or indirectly through weight gain, which increases the risk of polycystic ovarian syndrome (21–27). Long-term benzodiazepine use has been associated with decreased fertility (28), and medicinal cannabis can cause menstrual and ovulation changes, as well as decrease oocyte retrieval rate during in vitro fertilization (29). There is minimal data on the reproductive function effects of other psychotropics. Any risk must be considered in the context of indication for the patient and weighed against the impact of an untreated psychiatric illness. Psychotherapy can also play a role in the treatment of mood disorders. In some cases, alternative treatments can also help with managing mood symptoms both during and after infertility treatments. More studies are needed to better understand the impact of alternative and complementary medicine for the treatment of mood symptoms during infertility.
The relationship between psychiatric illness and infertility is complex. Awareness of the potential psychological effects of infertility treatments is important, as many women are reluctant to discuss their distress and very few seek help. Deciphering grief reactions, bereavement, eating disorders, depressive or anxiety disorders, and medication side effects is important in determining optimal treatment for patients. Understanding the impact of psychiatric treatment on fertility is essential for clinicians treating women when they are trying to conceive.
1 : Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. Natl Health Stat Rep 2013; 67:1–18, 1, 19Google Scholar
2 : Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertil Steril 2013; 99:1324–1331.e1Crossref, Medline, Google Scholar
3 : Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. Hum Reprod 2004; 19:2313–2318Crossref, Medline, Google Scholar
4 : Anxiety and depression among infertile women: a cross-sectional survey from Hungary. BMC Womens Health 2017; 17:48Crossref, Medline, Google Scholar
5 : Anxiety and depression in women undergoing infertility treatment. Ginekol Pol 2017; 88:109–112Crossref, Medline, Google Scholar
6 : Suicidal risk among infertile women undergoing in-vitro fertilization: Incidence and risk factors. Psychiatry Res 2016; 240:53–59Crossref, Medline, Google Scholar
7 : Suicide in Danish women evaluated for fertility problems. Hum Reprod 2011; 26:2401–2407Crossref, Medline, Google Scholar
8 : The social epidemiology of coping with infertility. Hum Reprod 2005; 20:1044–1052Crossref, Medline, Google Scholar
9 : To pill or not to pill in GnRH antagonist cycles: that is the question! Reprod Biomed Online 2015; 30:39–42Crossref, Medline, Google Scholar
10 : Psychological and hormonal changes in the course of in vitro fertilization. J Assist Reprod Genet 1992; 9:161–169Crossref, Medline, Google Scholar
11 : Psychosomatic medicine. Side effects of oral contraceptive medication: a psychosomatic problem. Can Psychiatr Assoc J 1972; 17:3–10Crossref, Medline, Google Scholar
12 : Depression and its influence on reproductive endocrine and menstrual cycle markers associated with perimenopause: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 2003; 60:29–36Crossref, Medline, Google Scholar
13 : Prevalence and predictors of depressive symptoms in older premenopausal women: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 1999; 56:418–424Crossref, Medline, Google Scholar
14 : Interface of Women’s Mental and Reproductive Health. Curr Psychiatry Rep 2005; 7:220–227Crossref, Medline, Google Scholar
15 : The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial. J Fam Plann Reprod Health Care 2016; 42:171–176Google Scholar
16 : Embryo aneuploidy is not impacted by selective serotonin reuptake inhibitor exposure. Fertil Steril 2017; 108:973–979Crossref, Medline, Google Scholar
17 : Fluoxetine treatment for anxiety in women undergoing in vitro fertilization. Int J Gynaecol Obstet 2009; 105:136–139Crossref, Medline, Google Scholar
18 : Effect of selective serotonin reuptake inhibitors on in vitro fertilization outcome. Fertil Steril 2009; 92:1312–1314Crossref, Medline, Google Scholar
19 : Sexual dysfunction, depression and antidepressants: a translational approach, in Sexual Dysfunction. Edited by Olivier B. London, InTechOpen, 2017Google Scholar
20 : Female Sexual Dysfunction. Psychiatr Clin North Am 2017; 40:267–284Crossref, Medline, Google Scholar
21 : Contraception for women with epilepsy: counseling, choices, and concerns. Open Access J Contracept 2016; 7:69–76Crossref, Medline, Google Scholar
22 : Valproate, bipolar disorder and polycystic ovarian syndrome. Med Pregl 2016; 69:121–126Crossref, Medline, Google Scholar
23 : Valproic acid in women and girls of childbearing age. Curr Psychiatry Rep 2017; 19:58Crossref, Medline, Google Scholar
24 : Hyperprolactinaemia: psychological aspects and menstrual attitudes of women with schizophrenia. Psychiatry Res 2015; 226:525Crossref, Medline, Google Scholar
25 : Disorders of reproduction in patients with epilepsy: antiepileptic drug related mechanisms. Seizure 2008; 17:111–119Crossref, Medline, Google Scholar
26 : Effects of antipsychotics on sexual and endocrine function in women: implications for clinical practice. J Clin Psychopharmacol 2003; 23(Suppl 1):S27–S32Crossref, Medline, Google Scholar
27 : Higher androgens and weight gain with valproate compared with lamotrigine for epilepsy. Epilepsy Res 2003; 54:189–199Crossref, Medline, Google Scholar
28 : Depression, anxiety, and psychotropic medication use and fecundability. Am J Obstet Gynecol 2016; 215:453.e1–453.e8Crossref, Google Scholar
29 : Jekyll and Hyde: two faces of cannabinoid signaling in male and female fertility. Endocr Rev 2006; 27:427–448Crossref, Medline, Google Scholar
