Infertility and its impact on psychological well-being

Infertility is perceived as a problem of immense significance among millions of couples worldwide. Awareness around this issue is crucial for couples facing challenges in conceiving, as many continue to suffer in silence due to misconceptions, stigma, taboos and lack of scientific knowledge of its nature and effects. Raising awareness about infertility is the first step towards managing its impact on the mental and psychosocial well-being of an individual. 

What is infertility?

Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse. Both males and females can experience infertility issues and according to the World Health Organisation, roughly one in six globally experiences infertility, showcasing the urgent requirement for the treatment of those in need. Diagnosing this condition involves various infertility tests and evaluations. 

For women, ovulation tests, hormone level assessments and imaging tests like pelvic ultrasounds are generally used. As for men, semen analysis, hormone tests and radiological imaging (to check for blockages and structural issues) are common diagnostic procedures.

Infertility is broadly classified into three types

Primary infertility: It is when a couple has never been able to achieve a pregnancy.

Secondary infertility: This occurs when a couple has achieved at least one pregnancy and/or has successfully delivered in the past, but is facing difficulty in conceiving again.

Unexplained infertility: This diagnosis is given when all fertility tests of both partners yield normal results, yet pregnancy is still not achieved. Subtle, undetectable factors or a combination of multiple minor issues may be the reason behind this condition.

What are the common causes of infertility?

Early diagnosis leads to better recovery outcomes. To begin with, let us identify some of the causes of infertility among women

1. Ovulation problems: In women, conditions like thyroid dysfunction (hypothyroidism and hyperthyroidism) and polyendocrine metabolic ovarian syndrome PMOS (formerly PCOS) can disrupt regular ovulation. These disorders create an imbalance in hormone production, thereby leading to irregular or absent menstrual cycles and, eventually, infertility.
2. Anatomical problems: The most common problem is blocked fallopian tubes, which prevent the sperm from accessing the egg or the fertilised egg from travelling to the uterus for implantation. This could be due to pelvic inflammatory disease (PID), tuberculosis, endometriosis or surgeries.  Furthermore, issues within the uterus, such as fibroids and polyps, can interfere with embryo implantation and growth.
3. Autoimmune disorders: Autoimmune diseases occur when the immune system erroneously attacks healthy body tissues. Problems in the immune system may lead to an abnormal immune response to a pregnancy and antibodies produced in a woman’s system can fail to recognise a pregnancy and/or attack and kill the sperm before fertilisation. 
4. Age-related factors: Fertility in women naturally declines after the age of 35. This is due to a decline in both quantity and quality of eggs. 

Causes for male infertility:

1. Insufficient sperm count: Lack of a sufficient amount of sperm or absence of it decreases the chance of fertilisation. Hormonal imbalances, genetic factors, chronic stress and smoking are considered major contributing factors.
2. Poor sperm motility: The ability of the sperm to swim efficiently in order to fertilise the egg is crucial. This can severely hinder natural conception or IUI (intrauterine insemination). This could be due to genetic factors, structural abnormalities, chronic stress, depression and anxiety.
3. Abnormal sperm morphology: Structurally abnormal sperms rarely carry the genetic material and capability required to fertilise an egg, thereby making natural conception a challenge. Structural abnormalities can be caused by poor lifestyle habits such as smoking, alcohol consumption, poor diet, exposure to environmental toxins and chronic stress.
4. Hormonal imbalances: Abnormal amounts of male hormone (testosterone) or endocrine function can affect sperm production. Moreover, prolonged stress can activate hypothalamic-pituitary-adrenal axis (HPA axis), which floods the system with cortisol and other stress-related hormones, which further leads to a decrease in testosterone, which plays a key role in sperm production.
5. Smoking, illicit drug use, heavy alcohol consumption and obesity: Poor lifestyle habits in men and women dysregulate reproductive hormone production and damage sperm’s DNA and egg quality, thereby reducing the viability and function of reproductive cells. Furthermore, certain medications, such as chemotherapy drugs are known to decrease fertility in both genders.
6. Type 1 diabetes: In men, fluctuating insulin levels and high blood sugar levels may decrease testosterone levels, which hampers sperm production and quality and increases oxidative stress. 

In women, it may disrupt menstrual cycles and ovulation and/or affect the quality of eggs, making it more challenging to conceive. Moreover, fluctuating blood glucose levels can make a person feel physically and emotionally low.

Recognising the causal factors at an early stage can lead to an effective diagnosis and tailored treatment.

Psychological and emotional health impact of infertility

Parenthood is one of the most significant transitions in the life of both men and women. In our society, childbirth is considered a major prerequisite to a fulfilling life. Thus, couples who cannot achieve this feel sad, anxious and incomplete. 

Infertility is more than just a medical issue. It significantly hurts all aspects of life, especially mental health. A person goes through a myriad of psychosocial and emotional problems while navigating this difficult phase.

Psychological distress and infertility

Stress, depression, anxiety and grief are described as common consequences of infertility. 

The stress and disappointment associated with the non-fulfilment of a wish for a child can trigger a cascade of emotional and psychological reactions such as guilt, shame, anger, helplessness, depression, anxiety and sexual dysfunction. 

Infertility is a complex and traumatic stressor that triggers the body’s fight or flight system, leading to the release of primary stress hormones called cortisol and adrenaline. Stress hormones wreak havoc on the body’s ability to function optimally. These hormones are also known to disrupt various systems, including immune function, ovulatory frequency and patterns, sperm production and quality, thereby creating a barrier to conception.

Trying to get pregnant and depression: The cycle of helplessness and hopelessness

A couple go through a variety of stressors that affect their mental and emotional well-being while trying to get pregnant. 

Some of the factors that can be linked are as follows:

1. Personal and societal pressures: Persistent societal expectations and social pressures around ideal pregnancy (including a time frame within which women are expected to achieve pregnancy) are a significant predictor of depression. 
2. Individual expectations and self-imposed stress: Unrealistic expectations and beliefs that conception should happen effortlessly and immediately can add unnecessary emotional burden on an individual (male or female).
3. The pressure of tracking cycles, hospital visits: Keeping up with the requirements of medical interventions is often stressful and inconvenient. A research study found that women were more depressed and had lower self-esteem after a failed IVF treatment than they did before the treatment cycle. Hence, it is crucial to understand the signs/symptoms of depression in order to get an early intervention.
4. Uncertainty about the treatment outcomes, isolation, helplessness and feelings of inadequacy: Couples feel unsure and face fear of failure due to unfamiliarity with these procedures, making stress relief extremely challenging.

Infertility linked to severe anxiety and insomnia: Panic attacks and poor sleep

Anxiety can be experienced during certain traumatic or threatening life situations. People with infertility are at a higher risk of developing anxiety disorders. Anxiety disorders are more than temporary fears or worries. For a person with an anxiety disorder, the worry doesn’t fade away, but rather gets worse over a period of time and the symptoms can interfere with daily activities such as job performance, overall health, and relationships. 

Unchecked chronic anxiety among infertile patients can act as a catalyst for frequent panic attacks. 

Panic attacks are overpowering and debilitating, flooding the body with stress hormones that cause intense physical symptoms such as rapid heartbeat, dizziness, hot flashes, cold chills and shortness of breath.

Factors such as financial costs and timeline of treatments, social comparisons, discrimination, prejudice, stigma and side effects of fertility medicines add to the anxiety of fertility struggles.

Furthermore, anxiety is the most common feeling experienced by those who undergo In Vitro Fertilization (IVF). Research has indicated that men and women report elevated levels of anxiety, especially during the embryo implantation stage and while waiting for the outcome of the treatment.

Additionally, people experiencing high levels of anxiety usually report poor quality sleep. Studies have shown that chronic sleep impairment can disrupt the production of reproductive hormones, contribute to menstrual irregularities, increased miscarriages, and sperm production and sperm motility. Sleep problems can impair chances of successful conception and exacerbate symptoms of anxiety and stress that can eventually impact the effectiveness of treatments and overall health. 

Therefore, recognising the symptoms of anxiety can help couples prevent the compounding effects by seeking quick support.

Eating disorders and fertility: Does an eating disorder affect fertility?

Medical and psychological complications of eating disorders affect every organ system in the body. The relationship between eating disorders and pregnancy is complicated; understanding the relationship requires a collaborative effort from the psychiatric, nutrition and medical fields.

Women experiencing eating disorders are more likely to struggle with natural conception and are more susceptible to an increased chance of pregnancy complications, like preterm birth, low birth weight, miscarriages and birth defects. Some of the main reasons are malnutrition, weight suppression and hormonal disruptions in a woman.

For some women, pregnancy can be triggering due to the fear of gaining excessive weight or body perception issues/ poor body image. 

It is also very important for women already diagnosed with eating disorders to be extra vigilant while pregnant. They will need support around nutrition management and postnatal mental health care.

Impact of infertility on relationships and social functioning

Infertility is a complex situation with far-fetched psycho-social consequences. Unfortunately, the family and society act as the main source of stressors in the lives of infertile couples, due to the high social value attached to childbearing. 

Both men and women are stigmatised or ostracised. Women in particular face immense pressures, taunts, domestic violence, emotional stress, unrealistic expectations, discrimination, low self-esteem and divorce. Misunderstandings and conflicts surround people almost on a daily basis. 

In some instances, couples might feel insecure or fearful to use contraception if they feel they are socially obligated to prove their fertility, which can lead to unwanted pregnancies, with both couples being emotionally and psychologically unprepared to bring a child into the world. These situations can cause additional burden and lay the groundwork for depression, anxiety and marital instability.

Measures to manage mental health and ways to build overall quality of life while facing infertility

• Education and awareness: Increase your understanding of the reproductive system, hormones, common causes of infertility, along with comprehensive fertility treatments ranging from medications to surgery to assisted reproductive technologies like In Vitro Fertilisation (IVF). It is important for couples to know their options and subsequent timelines to achieving results in order to enhance clarity and hope and prevent/reduce psychological uncertainty.
• Effective communication: Infertility is a challenge which comes with a myriad of emotions. It is normal to feel all the emotions you are experiencing. It is important to have an unbiased discussion with your partner, doctor, trusted family members and friends. Do not let anything hold you back from a genuine discussion with the ones who really care. This will enhance your confidence and motivation, thereby alleviating a sense of isolation and loneliness. 
• You are not alone – seek professional support and counselling: If you feel your mental health is interfering with your daily functioning, then talk to a mental health specialist or GP.
• Psychological interventions: God has created a cure for every illness; mental health interventions are one among the cures. Take advantage of the psychological treatments and support that is available. 

Studies have shown that group cognitive behavioural therapy and group counselling for couples undergoing assisted reproduction showed reduced anxiety, depression, stress and anger scores, in addition to a higher successful conception rate.

• Avoid social isolation: Community/support groups give you an opportunity to meet potential friends. Sharing your experiences with people who are going through similar problems can help you navigate the confusion, loneliness and sadness surrounding infertility. 
• Find a purpose beyond pregnancy: You are not defined by the ability to give birth. Procreation is a beautiful thing, but it is not the only thing that has the ability to make you and your partner happy and satisfied. God has filled this world with many other opportunities, waiting to be seized. 

People who find higher purpose, meaning and direction beyond the scope of child-bearing are better able to accept, manage and cope with the uncertainty and emotional pressure around infertility and grief. Always remember – infertility may be an interruption, but it is definitely not the end of the journey.

• Lifestyle management: Regular exercise (next time take stairs instead of an elevator), engaging in hobbies, abstaining from smoking and excessive use of screens, optimising nutrition and sleep can improve overall health within a few months if not weeks. Moreover, early management of lifestyle issues can also prevent various lifestyle disorders such as diabetes, hypertension, obesity, depression and cancer.
• Mindfulness-based stress reduction: Mindful stretching, focused breathing, body scan meditation, progressive muscle relaxation, and mindful habits that include everyday tasks such as walking, eating, cooking and talking, can help you detach from mental hurriedness and enjoy the present moment.
• Try yoga: Yoga supports fertility by balancing hormones and increasing blood supply to the reproductive organs. It helps reduce stress and reinforce the success of treatments, thereby facilitating natural conception.
• Prayer and spirituality during difficult phases: Research suggests the benefits of having a spiritual anchor through the toughest phases of life. Spiritual intelligence is directly correlated to enhanced resilience in acceptance and adaptation to uncertainties.  

Integrating prayers, spiritual meditations that include duas [supplications] for patience and frequent letters to Huzoor (aa)^, along with your treatments (medical and psychological), will contribute to greater hope, emotional resilience and better treatment outcomes. God willing!

Finally, a note to the family members

Mental health and fertility are closely intertwined; family and loved ones play a significantly important role in helping the couple facing this issue.

In our societies, having a child is seen as a life that is fulfilled; couples who cannot achieve this goal often feel incomplete and undervalued. Inability to have a child is seen as a pitiable state.

Every person has a right to attain the highest standard of physical and mental health. Individuals and couples have the right to decide the number, timing and spacing of their children. Forcing anyone into this situation is only going to create and maintain difficulties in their lives.

Family’s support, trust and encouragement help alleviate mental health struggles of the couple and aid in strengthening unity, mutual bond and togetherness between the couple. Your support boosts morale and instils a sense of hope in them (and in YOU).

Let us break the cycle of abuse, discrimination and trauma within our homes. Let us be understanding and compassionate towards those who are facing this alone. And maybe this act would bring us one step closer to achieving nearness to Allah the Almighty!