Abstract
Purpose
To better understand the beliefs about a causal role of emotional stress maintained by women seeking fertility care.
Methods
A cross-sectional, self-administered survey was distributed to fertility care patients at an academic fertility center in Illinois. Of 5000 consecutive patients, 1460 completed the survey and were included in the study sample.
Results
Members of our sample (N = 1460) were between 20 and 58 years (mean = 36.2, SD = 4.4). Most respondents were White (72.2%), were in a heterosexual relationship (86.8%), and felt that their physician understood their cultural background (79.4%). Of the sample, 28.9% believed emotional stress could cause infertility, 69.0% believed emotional stress could reduce success with fertility treatment, and 31.3% believed that emotional stress could cause a miscarriage, with evidence of significant racial differences. Less than a quarter (23.8%) of the sample believed emotional stress had no impact on fertility. Lower household income and educational attainment were associated with a greater belief in emotional stress as a causative factor in reproduction with regard to infertility, fertility treatment, and miscarriage.
Conclusion
The majority of women seeking fertility care believe emotional stress could reduce the success of fertility treatment. Furthermore, beliefs about emotional stress and reproduction significantly differ based on race/ethnicity, income, and education. Particular attention should be paid to specific groups of women who may more likely not be aware of the lack of a proven biological relationship between emotional stress and reproduction.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10815-021-02079-3.
Keywords: Stress, Fertility, Racial disparities, Internet resources, Medically assisted reproduction, MAR
Introduction
An estimated one in eight (6.7 million) women in the USA has trouble getting pregnant or sustaining a pregnancy each year [1]. Although not all women desire to be mothers, achieving motherhood allows many women to actualize a desired social and gender-identity role [2–4]. For those women who desire to bear children, the inability to reproduce naturally often results in feelings of shame, guilt, and a lowered self-esteem [5]. The emotional stress caused by infertility may also lead to depression, anxiety, decreased quality of life, and potentially the feeling that they are “flawed as women” [2, 6, 7]. When unable to conceive, women are increasingly turning to medically assisted reproduction (MAR) which can be physically demanding, emotionally taxing, and expensive, and often involve difficult decision-making [8]. Research has shown that even with a good prognosis and the financial resources to pay for MAR, discontinuation of treatment frequently results from psychological stress [9–11].
Mental health conditions, including anxiety and depression, have been estimated to affect 30 to 80% of infertile couples. Overall, previously published research clearly shows emotional stress to be a consequence of infertility but no rigorous research to date has shown a causal and biological role of stress in infertility. Multiple survey studies and meta-analyses have attempted to assess a causal role between stress and infertility, but due to ethical concerns, randomized controlled trials (RCTs) about stress as a cause of infertility are not possible [12–14]. Existing survey studies of stress and infertility include design flaws such as incomplete assessment of confounding variables (e.g., known medical causes of infertility and emotional stress such as PCOS and endometriosis and the confounded relationship between stress caused by patient knowledge of a poor prognosis and the expected poor treatment outcomes) and therefore are not rigorous enough to answer the question as to whether there is a biological role of emotional stress in infertility.
Furthermore, research on stress hormones have either shown no association with pregnancy chances, or are also marred by design flaws such as solitary assessment of the stress hormone despite a large study time period, failure to assess for infertility, or populations with exposure to other factors shown to be associated with infertility [6]. Finally, Cochrane analyses conducted on studies which examined the role of lowering stress either via psychotherapy or acupuncture on pregnancy chances did not find a positive relationship [15, 16]. Thus, although it has been well-established that infertility and the pursuit of fertility treatment are stressors which can result in psychological distress, the question remains: does emotional stress biologically cause or contribute to infertility?
Despite the lack of rigorous research demonstrating a biological cause of infertility, women who struggle to conceive often experience significant self-blame from feeling their infertility is caused by their own emotional stress [17, 18]. Although previous studies have examined patient beliefs regarding stress as a cause of miscarriage, limited research has examined the role of demographic and other factors (e.g., infertility diagnosis, psychiatric history, use of internet-based resources for medical information, and perception that their physician understands their cultural background) affecting patient perceptions of emotional stress as a cause of infertility or as something which could negatively affect fertility treatments. To better understand the beliefs about a causal role of emotional stress maintained by patients seeking fertility care, we surveyed women presenting to a large Midwestern fertility center. We hypothesized that many women believe (1) stress does have some bearing on their fertility status and (2) stress interferes with the success of their fertility treatment. We also hypothesized that these beliefs will differ based on demographic and other factors.
Material and methods
Data collection
Institutional Review Board approval was obtained from Northwestern University Feinberg School of Medicine prior to conducting the study. A 32-question survey was adapted from previous work of one of the study authors, and programmed into REDCap, a secure, HIPAA-compliant, data collection platform [19]. Modifications were made to improve understanding of patient experiences with infertility and to account for recent technological advancements in fertility care. The questionnaire was piloted and reviewed by a fertility physician, a non-fertility physician, a clinical psychologist, and five research study staff. The survey instrument collected information regarding demographics, infertility history, and beliefs about stress and reproduction. Additionally, the survey examined the use of specific internet resources to get information on infertility and patient self-reported history of other conditions (i.e., anxiety, depression, hypertension) related to stress.
The survey was emailed to 5000 unique patients who presented to the Northwestern Center for Fertility and Reproductive Medicine (FRM) for at least one visit between June 2018 and September 2019. The patient emails were obtained by the Northwestern Enterprise Data Warehouse (NEDW). In September 2019, the electronic consent form and survey were emailed using REDCap, and responses were obtained for the next month. To encourage survey completion, reminder emails were sent to non-respondents.
There were 377 undeliverable emails due to incorrect addresses. From the remaining 4623 valid email addresses, 1460 survey responses were obtained (32.0% response rate). Baseline demographic data were obtained from the 4623 invited individuals via the NEDW to compare the demographics between survey responders and non-responders and evaluate potential non-response bias.
Statistical analysis
Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics among survey respondents (N = 1460). A series of multiple logistic regression models were fit to examine factors associated with patient-report of believing that “stress can cause infertility,” “stress can reduce success with fertility treatment,” “stress can cause a miscarriage,” and “stress has no impact on fertility.” Each regression model included adjustment for a large set of covariates, detailed in Supplemental Figure 1.
Additional chi-square analyses examined whether the proportion of women endorsing the aforementioned statements varied significantly depending on whether patients sought information via specific internet-based resources, physician-diagnosed infertility cause, and clinical history. Adjusted predicted probabilities were calculated and visualized via the margins and marginsplot commands in Stata 15 (StataCorp LLC, College Station, TX). The coefplot command was used to visualize adjusted multiple regression coefficients. All reported p values are two-sided.
Results
Demographics
Members of our sample (N = 1460) were 20–58 years (mean = 36.2, SD = 4.4). Most women in our sample were White (72.2%) and in a heterosexual relationship (86.8%) (Table 1). The age distribution of our analytic sample (M = 36.0 (SD = 4.5)) was similar to that of the entire invited sample (M = 36.7 (SD = 7)). Analysis of the available race/ethnicity information from non-responders indicates that representation of racial/ethnic minority patients within the analytic sample was comparable to that of the invited sample (7.0% Black vs. 8.2% Black; 5.4% Hispanic vs. 4.5% Hispanic; 10% Asian vs. 9.7% Asian). Most women reported a bachelor’s (35.1%) or master’s (40.5%) degree and annual household income >$100,000 (81.2%). The most prevalent religious affiliations were Catholicism (37.5%), followed by non-religious (25.4%) and Protestant (15.0%) (Table 1).
Table 1.
Sample characteristics and stress- and infertility-related beliefs across demographic groups
| Sample characteristics N (%) |
“Do you believe that emotional stress…” | ||||
|---|---|---|---|---|---|
| Can cause infertility N (%) |
Can reduce success with fertility treatment N (%) |
Can cause a miscarriage N (%) |
Has no impact on fertility N (%) |
||
| Entire sample | 422 (28.9%) | 1008 (69.0%) | 457 (31.3%) | 347 (23.8%) | |
| Race or ethnicity (N = 1460) | |||||
| White | 1054 (72.2%) | 276 (26.2%) | 703 (66.7%) | 282 (26.8%) | 288 (27.3%) |
| Black or AA | 102 (7.0%) | 53 (52.0%) | 81 (79.4%) | 66 (64.7%) | 9 (8.8%) |
| Hispanic/Latinx | 79 (5.4%) | 27 (34.2%) | 64 (81.0%) | 37 (46.8%) | 9 (11.4%) |
| Asian | 146 (10.0%) | 47 (32.2%) | 99 (67.8%) | 40 (27.4%) | 28 (19.2%) |
| Multiple/other | 79 (5.4%) | 19 (24.1%) | 61 (77.2%) | 32 (40.5%) | 13 (16.5%) |
| p < 0.001 | p = 0.003 | p < 0.001 | p < 0.001 | ||
| Relationship status (N = 1457) | |||||
| Single | 99 (6.8%) | 38 (39.4%) | 77 (77.8%) | 49 (49.5%) | 12 (12.1%) |
| Heterosexual relationship | 1264 (86.8%) | 358 (28.3%) | 865 (68.4%) | 378 (29.9%) | 311 (24.6%) |
| Divorced or separated | 16 (1.1%) | 6 (37.5%) | 10 (62.5%) | 9 (56.3%) | 5 (31.3%) |
| Same sex relationship | 74 (5.1%) | 17 (23.0%) | 50 (67.6%) | 19 (25.7%) | 19 (25.7%) |
| Other | 4 (.3%) | 1 (25.0%) | 4 (100%) | 1 (25.0%) | 0 (0%) |
| p = 0.17 | p = 0.20 | p < 0.001 | p = 0.04 | ||
| Religion (N = 1418) | |||||
| Catholic | 531 (37.5%) | 165 (31.1%) | 373 (70.2%) | 177 (33.3%) | 124 (23.4%) |
| Other Christian | 102 (7.2%) | 36 (35.3%) | 73 (71.6%) | 44 (43.1%) | 18 (17.7%) |
| Protestant | 212 (15.0%) | 64 (30.2%) | 150 (70.8%) | 64 (30.2%) | 48 (22.6%) |
| Judaism | 122 (8.6%) | 30 (24.6%) | 78 (63.9%) | 30 (24.6%) | 36 (29.5%) |
| Hinduism | 48 (3.4%) | 18 (37.5%) | 31 (64.6%) | 13 (27.1%) | 10 (20.8%) |
| Non-religious | 360 (25.4%) | 85 (23.6%) | 247 (68.6%) | 98 (27.2%) | 94 (26.1%) |
| Other | 43 (3.0%) | 12 (27.9%) | 28 (65.1%) | 19 (44.2%) | 9 (20.9%) |
| p = 0.08 | p = 0.78 | p = 0.10 | p = 0.42 | ||
| Age (N = 1441) | |||||
| <35 years | 514 (35.7%) | 161 (31.3%) | 351 (68.2%) | 161 (31.3%) | 118 (22.9%) |
| 35–37 years | 402 (27.9%) | 109 (27.1%) | 272 (67.4%) | 115 (28.6%) | 111 (27.6%) |
| 38–40 years | 286 (19.9%) | 77 (26.9%) | 197 (68.9%) | 83 (29.0%) | 65 (22.7%) |
| 41–42 years | 132 (9.2%) | 36 (27.3%) | 98 (74.2%) | 47 (35.6%) | 28 (21.2%) |
| >42 years | 107 (7.4%) | 35 (32.7%) | 76 (71.0%) | 45 (42.1%) | 21 (19.6%) |
| p = 0.48 | p = 0.64 | p = 0.06 | p = 0.27 | ||
| Education (N = 1458) | |||||
| Less than a bachelor’s degree | 76 (5.2%) | 36 (47.4%) | 57 (75.0%) | 45 (59.2%) | 10 (13.2%) |
| 4-year college (bachelor’s) | 512 (35.1%) | 158 (30.9%) | 361 (70.5%) | 174 (34.0%) | 113 (22.1%) |
| Master’s degree | 591 (40.5%) | 159 (26.9%) | 412 (69.7%) | 164 (27.8%) | 135 (22.8%) |
| Professional degree | 279 (19.1%) | 69 (24.7%) | 177 (63.4%) | 74 (26.5%) | 88 (31.5%) |
| p = 0.001 | p = 0.11 | p < 0.001 | p = 0.002 | ||
| Annual household income (N = 1440) | |||||
| < $50,000 | 41 (2.9%) | 19 (46.3%) | 30 (73.2%) | 25 (61.0%) | 6 (14.6%) |
| $50,001–$100,000 | 230 (16.0%) | 77 (33.5%) | 168 (73.0%) | 100 (43.5%) | 44 (19.1%) |
| $100,001–$200,000 | 589 (40.9%) | 168 (28.5%) | 412 (70.0%) | 187 (31.8%) | 135 (22.9%) |
| $200,001–$400,000 | 425 (29.5%) | 113 (26.6%) | 285 (67.1%) | 108 (25.4%) | 119 (28.0%) |
| > $400,000 | 155 (10.8%) | 40 (25.8%) | 100 (64.5%) | 32 (20.7%) | 41 (26.5%) |
| p = 0.04 | p = 0.34 | p < 0.001 | p = 0.048 | ||
Participant beliefs regarding stress and infertility
Of the sample, 28.9% indicated they believed that emotional stress could cause infertility (Table 1). Over two-thirds of the sample (69.0%) believed emotional stress could reduce success with fertility treatment and 31.3% indicated they believed that emotional stress could cause a miscarriage. As seen in Supplemental Figure 1, most (79.4%) women in our sample felt that their physician understands their cultural background. However, those who felt their fertility physician did not understand their cultural background were also significantly more likely to indicate they believed stress could cause a miscarriage as compared to respondents who reported that their fertility physician understood their cultural background (no: 39.1%, yes: 29.2%, p < 0.05) (Table 2).
Table 2.
Stress-related beliefs
| “Do you believe that emotional stress” N = 1460 |
Can cause infertility | Can reduce success with fertility treatment | Can cause a miscarriage | Has no impact on fertility |
|---|---|---|---|---|
| Fertility physician understands cultural background | ||||
| Yes | 319 (28.2%) | 774 (68.3%) | 331 (29.2%)* | 284 (25.1%)* |
| No | 94 (32.0%) | 212 (72.1%) | 115 (39.1%)* | 56 (19.1%)* |
| Internet-based resources accessed | ||||
| Blogs | 169 (27.3%) | 432 (69.8%) | 193 (31.2%) | 145 (23.4%) |
| No blogs | 253 (30.1%) | 576 (68.5%) | 264 (31.4%) | 202 (24.0%) |
| Discussion groups | 144 (27.8%) | 353 (68.2%) | 151 (29.2%) | 129 (24.9%) |
| No discussion groups | 278 (29.5%) | 655 (69.5%) | 306 (32.5%) | 218 (23.1%) |
| YouTube | 84 (36.7%)* | 158 (69.0%) | 96 (41.9%)** | 51 (22.3%) |
| No YouTube | 338 (28.5%)* | 850 (69.1%) | 361 (29.3%)** | 296 (24.1%) |
| Search engines (Google, Yahoo, Bing) | 243 (30.2%) | 577 (71.6%)* | 269 (33.4%) | 177 (22.0%) |
| No search engines (Google, Yahoo, Bing) | 179 (27.4%) | 431 (65.9%)* | 188 (28.8%) | 170 (26.0%) |
| 97 (29.2%) | 223 (67.2%) | 106 (31.9%) | 85 (25.6%) | |
| No Facebook | 325 (28.8%) | 785 (69.6%) | 351 (31.1%) | 262 (23.2%) |
| 9 (36.0%) | 18 (72.0%) | 8 (32.0%) | 4 (16.0%) | |
| No Twitter | 413 (28.8%) | 990 (69.0%) | 449 (31.3%) | 343 (23.9%) |
| 82 (31.8%) | 180 (69.8%) | 81 (31.4%) | 61 (23.6%) | |
| No Instagram | 340 (28.3%) | 828 (68.9%) | 376 (31.3%) | 386 (23.8%) |
| Podcasts | 2 (11.8%) | 13 (76.5%) | 1 (5.9%)* | 4 (23.5%) |
| No podcasts | 420 (29.1%) | 995 (69.0%) | 456 (31.6%)* | 343 (23.8%) |
| Fertility apps | 4 (33.3%) | 9 (75.0%) | 4 (33.3%) | 2 (16.7%) |
| No fertility apps | 418 (28.9%) | 999 (69.0%) | 453 (31.3%) | 345 (23.8%) |
| Medical sites/journals | 3 (15.8%) | 12 (63.2%) | 5 (26.3%) | 7 (36.8%) |
| No medical sites/journals | 419 (29.1%) | 996 (69.1%) | 452 (31.4%) | 340 (23.6%) |
| None of the above | 104 (28.6%) | 241 (66.2%) | 112 (30.8%) | 97 (26.7%) |
| Any of the above | 318 (29.0%) | 767 (70.0%) | 345 (31.5%) | 250 (22.8%) |
| Physician-diagnosed cause of infertility | ||||
| Ovulation problem | 96 (31.3%) | 219 (71.3%) | 104 (33.9%) | 63 (20.5%) |
| No ovulation problem | 326 (28.3%) | 789 (68.4%) | 353 (30.6%) | 284 (24.6%) |
| Blocked fallopian tubes | 34 (37.8%) | 67 (74.4%) | 36 (40.0%) | 17 (18.9%) |
| No blocked fallopian tubes | 388 (28.3%) | 941 (68.7%) | 421 (30.7%) | 330 (24.1%) |
| Advanced age/decreased ovarian reserve | 105 (27.5%) | 267 (69.9%) | 119 (31.2%) | 92 (24.1%) |
| No advanced age/decreased ovarian reserve | 317 (29.4%) | 741 (68.7%) | 338 (31.4%) | 255 (23.7%) |
| Uterine factor | 35 (35.0%) | 78 (78%)* | 33 (33.0%) | 17 (17.0%) |
| No uterine factor | 387 (28.5%) | 930 (68.4%)* | 424 (31.2%) | 330 (24.3%) |
| Endometriosis | 29 (32.6%) | 63 (70.8%) | 33 (37.1%) | 23 (25.8%) |
| No endometriosis | 393 (28.7%) | 945 (68.9%) | 424 (30.9%) | 324 (23.6%) |
| Male factor | 63 (26.0%) | 149 (64.0%) | 65 (27.9%) | 61 (26.2%) |
| No male factor | 359 (29.3%) | 859 (70.0%) | 392 (32.0%) | 286 (23.3%) |
| Unexplained | 161 (29.3%) | 368 (66.9%) | 160 (29.1%) | 149 (27.1%)* |
| No unexplained | 261 (28.7%) | 640 (70.3%) | 297 (32.6%) | 198 (21.8%)* |
| Fertility preservation (cancer) | 13 (38.2%) | 25 (73.5%) | 15 (44.1%) | 4 (11.8%) |
| No fertility preservation (cancer) | 409 (28.7%) | 983 (68.9%) | 442 (31.0%) | 343 (24.1%) |
| Fertility preservation (elective) | 8 (44.4%) | 16 (88.9%) | 9 (50.0%) | 0 (0%)* |
| No fertility preservation (elective) | 414 (28.7%) | 992 (68.8%) | 448 (31.1%) | 347 (24.1%)* |
| Genetic factor | 9 (25.0%) | 22 (61.1%) | 11 (30.6%) | 11 (30.6%) |
| No genetic factor | 413 (29.0%) | 986 (69.2%) | 446 (31.3%) | 336 (23.6%) |
| Same sex | 4 (12.5%)* | 25 (78.1%) | 8 (25.0%) | 6 (18.8%) |
| No same sex | 418 (29.3%)* | 983 (68.8%) | 449 (31.4%) | 341 (23.9%) |
| History of | ||||
| Miscarriage | 157 (26.6%) | 385 (65.3%)* | 181 (30.7%) | 165 (28.0%)* |
| No miscarriage | 261 (30.6%) | 612 (71.8%)* | 271 (31.8%) | 177 (20.8%)* |
| High blood pressure (hypertension) | 24 (36.4%) | 48 (72.7%) | 29 (43.9%)* | 12 (18.2%) |
| No high blood pressure | 398 (28.6%) | 960 (68.9%) | 428 (30.7%)* | 335 (24.0%) |
| Anxiety | 105 (33.6%)* | 240 (76.7%)* | 109 (34.8%) | 60 (19.2%)* |
| No anxiety | 317 (27.6%)* | 768 (67.0%)* | 348 (30.3%) | 287 (25.0%)* |
| Depression | 63 (33.5%) | 143 (76.1%)* | 65 (34.6%) | 39 (20.7%) |
| No depression | 359 (28.2%) | 865 (68.0%)* | 392 (30.8%) | 308 (24.2%) |
| Alternative medicine | ||||
| Checked use of any alternative medicine overall | 351 (29.9%) | 818 (69.7%) | 361 (30.8%) | 270 (23.0%) |
| Unchecked use of any alternative medicine overall | 71 (24.8%) | 190 (66.4%) | 96 (33.6%) | 77 (26.9%) |
| Checked use of any traditional alternative medicine | 173 (29.0%) | 428 (71.7%) | 163 (27.3%)* | 135 (22.6%) |
| Unchecked use of any traditional alternative medicine | 249 (28.9%) | 580 (67.2%) | 294 (34.1%)* | 212 (24.6%) |
| Checked use of any body therapy | 197 (32.9%)* | 441 (73.6%)* | 195 (32.6%) | 116 (19.4%)* |
| Unchecked use of any body therapy | 225 (26.1%)* | 567 (65.9%)* | 262 (30.4%) | 231 (26.8%)* |
| Checked use of any diet therapy | 319 (29.9%) | 741 (69.4%) | 337 (31.6%) | 250 (23.5%) |
| Unchecked use of any diet therapy | 103 (26.3%) | 267 (68.1%) | 120 (30.6%) | 97 (24.7%) |
| Checked use of any mind therapy | 115 (31.1%) | 286 (77.3%)** | 120 (32.4%) | 68 (18.4%)* |
| Unchecked use of any mind therapy | 307 (28.2%) | 722 (66.2%)** | 337 (30.9%) | 279 (25.6%)* |
| Checked use of any senses therapy | 76 (40.4%)** | 144 (76.6%) | 83 (44.2%)** | 32 (17.0%)* |
| Unchecked use of any senses therapy | 346 (27.2%)** | 864 (67.9%) | 374 (29.4%)** | 315 (24.8%)* |
*p < 0.05
**p < 0.001
Over half of Black respondents (52.0%) share the belief that emotional distress can cause infertility, compared to roughly one-third of respondents of all other racial groups (p < 0.05). Latinx and Black women were the most likely to report the belief that emotional distress can reduce success of fertility treatment (Latinx: 81.0%, Black: 79.4%; p < 0.05) and that emotional distress can cause a miscarriage (Latinx: 46.8%, Black 64.7% vs. <68% of White and Asian respondents; p < 0.05).
Lower household income and respondent educational attainment were associated with a greater belief in stress as a causative factor in reproduction with regard to infertility, fertility treatment, and miscarriage (Table 1). Moreover, we were unable to draw conclusions by marital status given the low frequency of divorced patients, nor by religious affiliations due to the lack of statistical significance.
Information sources
As seen in Supplemental Figure 1, over half (55.0%) of respondents reported regularly accessing search engines (e.g., Google, Yahoo, Bing) for fertility education or support, followed by 42.3% who accessed blogs, and 35.6% who accessed discussion groups. Only 25.4% of women reported that they were not regularly accessing any internet-based fertility resources. However, those who accessed search engines were significantly more likely than those who did not access search engines to believe emotional stress can reduce success of fertility treatment (p < 0.05) (Table 2).
Medical history
Overall, women were most likely to report the following physician-diagnosed causes of infertility: unexplained (37.7%), advanced maternal age/decreased ovarian reserve (26.2%), and ovulation problems (21.0%) (Supplemental Figure 1). Commonly reported comorbidities included miscarriage (40.9%), anxiety (21.4%), depression (12.9%), and high blood pressure (4.5%). Women with a history of anxiety were significantly more likely than women without anxiety to believe emotional stress causes infertility (p < 0.05) and that emotional stress can reduce success with fertility treatment (p < 0.05) (Table 2). Women with a history of either anxiety or a miscarriage were more likely to believe emotional stress can reduce success with fertility treatment (p < 0.05). Finally, those with history of high blood pressure were more likely than those without high blood pressure history to hold the belief that emotional stress can cause a miscarriage (p < 0.05).
Use of complementary and alternative medicine
As seen in Supplemental Figure 1, 80.4% of women reported the use of any complementary and alternative medicine (CAM), including diet therapy (i.e., vitamin D, CoQ10, DHEA, other vitamins, herbal supplements, weight loss regimens, specific fruits/vegetables) (73.2%), body therapy (i.e., chiropractic, massage, Tai Chi, yoga, energy field therapy) (41.0%), traditional integrative medicine (i.e., acupuncture, Ayurveda, homeopathy, Chinese medicine) (40.9%), mind therapy (i.e., meditations/hypnosis, psychotherapy, biofeedback) (25.3%), and senses therapy (i.e., dance, music, visualization, and guided imagery) (12.9%). Women who reported use of body therapy and senses therapy were significantly more likely to believe that emotional stress can cause infertility (Table 2). Additionally, those who did not report using any traditional alternative medicine were less likely than those who had to believe emotional stress can cause a miscarriage (p < 0.05).
Determinants of patient beliefs regarding relationships between stress and fertility
As shown in Table 3 and Supplemental Figure 1, Black women were significantly more likely to believe that emotional stress can cause infertility (OR: 4.06; CI: 2.39–6.91) and to believe that emotional stress can cause a miscarriage (OR: 3.81; CI: 2.23–6.52), relative to White women, even after adjustment for numerous covariates. Latinx women were more than twice as likely than White women to believe that emotional stress can reduce success with fertility treatment (OR: 2.80; CI: 1.34–5.86) (Fig. 1). Moreover, multi-racial women were significantly more likely than their White counterparts to believe that emotional stress can cause a miscarriage (OR: 1.9; CI: 1.11–3.25). Compared to women who have not attained a bachelor’s degree, those with a bachelor’s, master’s, or professional degree were significantly less likely to believe that emotional stress can cause infertility (OR ≤ 0.44; p < 0.05). Likewise, individuals with a bachelor’s, master’s, or professional degree were significantly less likely to believe that emotional stress can cause a miscarriage compared to participants that have not attained a bachelor’s degree (OR ≤ 0.47; p < 0.05). Women with at least 75% insurance coverage for fertility treatment were less likely to believe that emotional stress can cause infertility (OR: 0.60; CI: 0.43–0.83) and are more likely to believe that emotional stress has no effect on fertility (OR: 1.67; CI: 1.13–2.47) in comparison to women with no insurance coverage. Also, parous women were less likely to believe that emotional stress can cause a miscarriage than those who are nulliparous (OR: 0.63; CI: 0.48–0.84).
Table 3.
Associations of respondent characteristics and stress beliefs
| Odds ratio | 95% Conf. interval | ||
|---|---|---|---|
| Predictors of respondent beliefs that stress can cause infertility | |||
| Black (vs White) | 4.06 | 2.39 | 6.91 |
| Age > 42 (vs age < 35) | 0.92 | 0.55 | 1.56 |
| Non-religious (vs Catholic) | 0.62 | 0.44 | 0.87 |
| Professional degree (vs less than bachelor’s) | 0.34 | 0.18 | 0.65 |
| Income > $200K (vs income < $100K) | 1.21 | 0.82 | 1.78 |
| ≥75% insurance coverage (vs no coverage) | 0.60 | 0.43 | 0.83 |
| Doc understands cultural background (vs Doc does not understand cultural background) | 0.95 | 0.69 | 1.30 |
| Past treatment history (vs currently seeking treatment) | 0.77 | 0.59 | 1.01 |
| Parous (vs nulliparous) | 0.81 | 0.61 | 1.08 |
| History of miscarriage (vs no history of miscarriage) | 0.90 | 0.69 | 1.18 |
| History of anxiety (vs no history of anxiety) | 1.35 | 0.95 | 1.93 |
| History of depression (vs no history of depression) | 1.06 | 0.70 | 1.62 |
| History of HBP (vs no history of HBP) | 1.06 | 0.60 | 1.88 |
| Predictors of respondent beliefs that stress can decrease success of fertility treatment | |||
| Black (vs White) | 1.68 | 0.93 | 3.03 |
| Age > 42 (vs age < 35) | 0.95 | 0.57 | 1.60 |
| Non-religious (vs Catholic) | 0.74 | 0.54 | 1.02 |
| Professional degree (vs less than bachelor’s) | 0.59 | 0.28 | 1.22 |
| Income > $200K (vs income < $100K) | 0.99 | 0.68 | 1.45 |
| ≥75% insurance coverage (vs no coverage) | 0.82 | 0.59 | 1.16 |
| Doc understands cultural background (vs Doc does not understand cultural background) | 1.02 | 0.74 | 1.40 |
| Past treatment history (vs currently seeking treatment) | 0.98 | 0.74 | 1.28 |
| Parous (vs nulliparous) | 0.76 | 0.58 | 1.01 |
| History of miscarriage (vs no history of miscarriage) | 0.82 | 0.63 | 1.06 |
| History of anxiety (vs no history of anxiety) | 1.42 | 0.99 | 2.05 |
| History of depression (vs no history of depression) | 1.26 | 0.81 | 1.96 |
| History of HBP (vs no history of HBP) | 1.09 | 0.60 | 1.98 |
| Predictors of respondent beliefs that stress can cause miscarriage | |||
| Black (vs White) | 3.81 | 2.23 | 6.52 |
| Age > 42 (vs age < 35) | 1.32 | 0.79 | 2.21 |
| Non-religious (vs Catholic) | 0.66 | 0.47 | 0.92 |
| Professional degree (vs less than bachelor’s) | 0.35 | 0.18 | 0.68 |
| Income > $200K (vs income < $100K) | 0.68 | 0.47 | 0.99 |
| ≥75% insurance coverage (vs no coverage) | 0.78 | 0.56 | 1.08 |
| Doc understands cultural background (vs Doc does not understand cultural background) | 0.81 | 0.60 | 1.11 |
| Past treatment history (vs currently seeking treatment) | 0.78 | 0.59 | 1.02 |
| Parous (vs nulliparous) | 0.63 | 0.48 | 0.84 |
| History of miscarriage (vs no history of miscarriage) | 1.05 | 0.81 | 1.37 |
| History of anxiety (vs no history of anxiety) | 1.20 | 0.84 | 1.71 |
| History of depression (vs no history of depression) | 1.01 | 0.66 | 1.54 |
| History of HBP (vs no history of HBP) | 1.30 | 0.74 | 2.30 |
| Predictors of respondent beliefs that stress has no effect on fertility | |||
| Black (vs White) | 0.32 | 0.14 | 0.71 |
| Age > 42 (vs age < 35) | 0.99 | 0.55 | 1.79 |
| Non-religious (vs Catholic) | 1.37 | 0.97 | 1.93 |
| Professional degree (vs less than bachelor’s) | 2.08 | 0.88 | 4.92 |
| Income > $200K (vs income < $100K) | 1.04 | 0.68 | 1.58 |
| ≥75% insurance coverage (vs no coverage) | 1.67 | 1.13 | 2.47 |
| Doc understands cultural background (vs Doc does not understand cultural background) | 1.09 | 0.76 | 1.55 |
| Past treatment history (vs currently seeking treatment) | 1.07 | 0.79 | 1.44 |
| Parous (vs nulliparous) | 1.21 | 0.90 | 1.64 |
| History of miscarriage (vs no history of miscarriage) | 1.30 | 0.98 | 1.71 |
| History of anxiety (vs no history of anxiety) | 0.72 | 0.49 | 1.07 |
| History of depression (vs no history of depression) | 0.92 | 0.57 | 1.49 |
| History of HBP (vs no history of HBP) | 0.81 | 0.41 | 1.63 |
Fig. 1.
Covariate-adjusted predictors of stress- and fertility-related beliefs. Each logistic regression model included adjustment for respondent age (<35, 35–37, 38–40, 41–42, >42); parity (parous vs nulliparous); race/ethnicity (White, Black, Latinx, Asian, other); income (<$50K, $50–100K, $100–200K, $200–400K, >$400K); religion (Catholic, Protestant, Jewish, non-religious/agnostic, Muslim, Hindu, other); education (less than bachelor’s, bachelor’s, master’s, terminal professional degree); insurance coverage for fertility treatment (none, <50% coverage, 50–75% coverage; >75% coverage); a dichotomous indicator of whether the respondent is currently seeking /undergoing fertility treatment or if they have previously completed fertility treatment; a dichotomous indicator of whether the respondent reports that their “fertility physician understands [their] cultural background”; and indicators of physician-diagnosed anxiety, depression, and/or hypertension. a Predictors of endorsing belief that stress can cause infertility. b Predictors of endorsing belief that stress can reduce success with fertility treatment. c Predictors of endorsing belief that stress can cause miscarriage. d Predictors of endorsing belief that stress has no effect on fertility
Discussion
Our study found that the majority of women seeking fertility care believe emotional stress could reduce the success of fertility treatment. Furthermore, beliefs about emotional stress and reproduction significantly differed based on race/ethnicity, income, and education. Women who were not White and who identified as being from lower socioeconomic status groups were more likely to believe that emotional stress can adversely affect reproduction. Taken together, it appears that some groups of patients may not be receiving the same information/education as other patients about the lack of a rigorously identified relationship between stress and reproduction.
Information on racial differences in beliefs about emotional stress held by women with infertility has been limited until our current study. We found that Black women were about four times more likely to believe that emotional stress can cause infertility and that stress can cause miscarriage compared to White women. Additionally, Latinx women were over twice as likely to believe that emotional stress can reduce success with fertility treatment, and multi-racial women were almost twice as likely to believe that stress can cause miscarriage than Whites. Clear racial divides exist in beliefs about emotional stress and fertility that may be explained by differences in exposure to accurate education from medical professionals regarding the causes of infertility. Regardless of racial background or belief about stress, all women who feel infertility hinders them from achieving goals to which they are strongly committed will likely suffer from fertility-specific distress [20]. Reducing the economic burden associated with reproductive care, increased proactive provision of accurate information on research related to the causes of infertility, and ensuring culturally competent physicians and counselors in all medical clinics could lessen emotional distress and improve patient knowledge.
Our study highlights the importance of the source from which patients obtain educational information about emotional stress and reproduction. It is unsurprising that few women in our study accessed published academic studies, as access is often limited to paid subscribers. Additionally, the academic writing style may not be conducive for the general population. Consequently, publicly available online sources may be more accessible/comprehensible to patients. Indeed, approximately 70% of adults in North America reported that they use the internet to retrieve health information [21]. A previous study indicated that 76% of women undergoing fertility treatment explored their options online while only 37% actually spoke with other women who had received such treatments [7]. When trying to understand the reasoning of infertile couples for using the internet, one study found that the main reasons included seeking information (diagnosis information, treatment, therapy), self-help (knowledge, awareness, choosing a clinic), and emotional, social, and psychological support [22].
Outside of the peer-review process in academia, little control exists regarding the accuracy of information online. Thus, use of online educational sources may negatively affect patients’ knowledge of reproduction and health. Among our sample, over half of women reported that they accessed search engines to seek fertility education. However, those who accessed search engines were significantly more likely to believe emotional stress can reduce success of fertility treatment when compared to those who did not use search engines. In an aforementioned study, researchers found that over two-thirds of participants reported that their needs were met by internet resources [21]. While patients may perceive that their needs are met, it is important to consider the reliability of their sources. For example, in our study, less than 2% of respondents were regularly accessing sources that are likely providing more reliable information, such as medical journals and websites, podcasts, or fertility apps. It can be difficult for patients and healthcare professionals alike to evaluate the accuracy of statements found online regarding any relationship between stress and fertility. We therefore recommend that those who are using social media to gather information about stress and fertility limit their access to only those sites which cite published peer-reviewed research, and which describe the limits of the research being discussed. Patient education may be improved when healthcare professionals create and disseminate easy to read, accurate information regarding emotional stress and reproduction in online formats, including via social media.
Despite there being no rigorous study showing a biologic relationship between emotional stress and reproduction, attention to patients’ experiences of emotional stress is warranted. Reducing the emotional burden of infertility on women not only would reduce overall stress but also could aid in nonbiologic ways to improve pregnancy chances. For example, mood improvement can result in improved lifestyle habits, increased engagement in intercourse, and decreased premature fertility treatment termination—all of which may improve chances of conception. A fertility physician’s understanding of a patient’s racial and cultural context is also important for reducing emotional stress associated with seeking fertility care. If patients feel understood by their providers, they will likely engage in more meaningful conversations at visits, allowing the comfortability to ask meaningful questions and receive the specialist referrals necessary for more complete education. We found that women who felt their fertility physician does not understand their cultural background were over 2.5 times more likely to believe emotional stress could cause infertility versus those who feel their culture is understood by their physician.
In addition to fertility physicians increasing their cultural competency, patient use of CAM should be explored. For example, women in our study who reported use of body or senses therapies were more likely to believe that emotional stress can cause infertility and reduce success with fertility treatment. Participation in CAM may help women cope with their stress levels by gaining some degree of control over their body and fertility through changes in diet, exercise, stress exposure, etc. However, given the often-high costs associated with traditional fertility treatments, the additional costs of CAM may be burdensome. Further, it may be anxiety-producing for patients unable to afford CAM but who believe that CAM could improve reproductive outcomes. Patient understanding of the potential emotional benefits of CAM, but lack of an identified rigorous relationship between reproduction and CAM, may improve informed consent regarding participation in such treatment.
With improvements in the provision of accurate education regarding causes and consequences of infertility and reproductive loss, improvements in the emotional support of these patients are also warranted. Multiple medical societies recognize the importance of psychological counseling for patients seeking fertility care [23–25]. However, a recent study of five fertility clinics in the USA found that a minority of patients received mental health support and only a quarter were aware of the available mental health support [26]. Further, a study of Canadian fertility patients found that, despite the majority of patients (60%) wanting such information, 79.8% of respondents said that their healthcare professional had not given them information about how to access psychological resources [27]. Multiple studies confirm that although fertility patients desire mental health support, only few receive information regarding such services [28, 29]. Patient-centered reproductive medicine should include emotional support from mental health professionals (MHPs) with specialized training in reproductive concerns [30]. Although these MHPs need not be employed by a fertility clinic, research finds that patients are more likely to utilize such resources when MHPs are embedded in medical clinics [31]. The presence of embedded MHPs may also increase the likelihood that (1) all patients regardless of demographic characteristics receive referrals for emotional support and (2) mental health treatment may be covered. It is unclear why some fertility clinics do not have MHPs on staff or provide patients with referrals to qualified MHPs with training in reproductive medicine. It is however possible that issues related to clinic space could impede a clinic’s ability to have MHPs on staff or clinics may not know of any appropriately trained MHPs in their area. Online resources such as those through the Mental Health Professional Group of the American Society of Reproductive Medicine (https://www.reproductivefacts.org/resources/find-a-health-professional/) are available for clinics and patients who are unaware of how to identify appropriately trained MHPs.
Strengths of our study included a large, geographically heterogeneous sample from a multi-site Midwestern clinic and a good survey response rate (>30%), with similar demographics observed between survey completers and non-completers. A potential limitation is that our entire population had already accessed fertility care, and therefore, the perspectives of those patients who were unable or unwilling to seek treatment owing to numerous structural and/or patient-level barriers were under-represented. For example, it is possible that highly stressed patients with strong beliefs that emotional stress is a key determinant of fertility are particularly under-represented as they may focus on stress reduction rather than fertility treatment for conception. It is also likely that patients from lower socioeconomic status groups were under-represented as they could not afford fertility care or had other treatment-related concerns [32, 33]. Of course, respondents likely accessed multiple internet resources simultaneously which makes it difficult to confirm the true influence each individual resource has on respondent beliefs. However, the information we have gathered provides important insight as to how participants are taking fertility concerns into their own hands to conduct independent searches of online resources for support and information. Finally, it may be that patients who have not struggled to conceive, and thus would be unlikely to be sampled in our study, may be less likely to believe stress influences reproductive outcomes.
Coming to complete agreement on the answer to the question “Does emotional stress biologically cause or contribute to infertility?” seems unlikely. Despite the fact that no rigorous research to date has shown a causal and biological role of emotional stress in infertility, we clearly have seen that many women hold some form of this belief. Our work reveals the importance of source credibility when it comes to where patients seek educational information on stress and reproduction. Unfortunately, there exist racial, socioeconomic, and educational divides in the beliefs about emotional stress and fertility. This indicates that more can and should be done to provide publicly available reputable information to all patients. There are many time points at which such education could begin, and healthcare professionals should not wait for patients of reproductive age to ask about the causes of infertility or miscarriage. All healthcare professionals should be appropriately educated about the research on stress and reproduction and can proactively share this information with patients.
Supplementary information
(DOCX 187 kb).
Acknowledgments
The authors thank Jocelyn Dorney, and Deepthi Devireddy for their assistance with survey design.
Declarations
Not applicable
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher’s note
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