Mind-Body Medicine as Treatment for Female Infertility
Mind-Body Medicine as Treatment for Female Infertility
July 2000; Volume 3; 79-82
A baby is an inestimable blessing and a bother.
Mark Twain,
letter to Annie Webster,
September 1, 1876
By V. Jane Kattapong, MD, MPH
Conceiving a baby can be a trial and a tribulation. In more than one quarter of infertile couples, no somatic cause can be determined.1 It is not surprising then that when women find that they are unable to conceive, they feel stressed. Reproduction, after all, is a basic species-survival instinct.
Both global and relationship stress may result from infertility.2 Women experiencing problems with fertility have a higher prevalence of negative feelings than women without fertility problems.3 Social, sexual, and relationship themes are among the stressors typically perceived by women undergoing infertility treatments.2 Since these stressors appear to weigh more heavily on women than men,2 stress reduction techniques designed for women being treated for infertility can provide a great service to these women.
Mechanism of Action
Does stress cause infertility, or does infertility cause stress? Although a relationship between the two has long been suspected, the causal role of one vis-à-vis the other remains unclear. In one case-control study of 22 infertile vs. 10 fertile couples, infertile couples were found to have higher mean anxiety scores based on the State Trait Anxiety Inventory, the Manifest Anxiety Scale, the Sixteen Personality Factor Test, and the Personality Questionnaire.4 Limited work has suggested that being free from anxiety may be associated with conception, and that high levels of anxiety are associated with the absence of conception.5
Stress and infertility do appear to be associated, and each may fuel the other. In addition, ovulatory prolactin elevation may be a marker for stress. Prolactin "spikes" are thought to be associated with excessive emotional response. Elevated prolactin levels occurring intermittently mid-cycle may be associated with low secretory-phase progesterone concentrations and early luteal regression.6 Prolactin levels, in some patients, may be a marker for stress-associated infertility.7
Finally, the physiologic effects of meditation have been studied since the 1970s by Harvard cardiologist Herbert Benson.8 Benson has described the phenomenon that occurs after 20 minutes of relaxation: physiologic changes including decreases in oxygen consumption, carbon dioxide elimination, heart rate, respiratory rate, blood pressure, muscle tone, and arterial blood lactate.8 Benson called this phenomenon "the relaxation response." Similar physiological responses have been described following hypnosis, progressive muscular relaxation, autogenic training, and meditation, and it is likely that these techniques are all methods for achieving the same relaxed state.9 Whether the relaxation response constitutes a mechanism of action, or simply a means to an end, deserves further exploration.
Animal Studies of Stress and Infertility
Although relatively little is known about the relationship between stress and infertility in humans, the effects of stress on infertility in animals have been studied in the veterinary and zoological literature. In pigs, a variety of factors related to infertility, including social, environmental, and management influences, have been described.10 Social factors such as crowding, repeated handling, and moving were thought to influence stress-related infertility in pigs. In ewes, transport occurring while the ewes were in the follicular phase of their menstrual cycle disrupted gonadotropin secretion, and was believed to have a negative impact on fertility.11 Thus, in the animal literature, stress seems to be fairly well accepted as a cause of infertility.
Mind-Body Medical Techniques
Hypnosis. In a literature review and case series study,12 14 of 15 patients who participated in a hypnosis treatment program were able to conceive successfully. The case study, involving two cases, utilized hypnotic techniques including induction, information provision, and positive suggestion. The induction consisted of optical fixation, progressive relaxation, and numerical countdown to achieve the state of hypnosis. During the hypnotic state, guided imagery was provided to enable visualization of fallopian tube musculature relaxation. Post-hypnotic instruction was given to enable self-hypnosis at home. Gravitz’s study was uncontrolled. (For more information on hypnosis and guided imagery, see Alternative Medicine Alert, March 2000, pp. 30-34, and June 1999, pp. 61-64.)
Autogenic therapy. Autogenic therapy consists of gentle exercises in body awareness and physical relaxation, progressively involving the limbs and viscera. The goal of autogenic training is to decrease stress responses and increase relaxation.7 Autogenic training has been described as a technique that may lower psychological stress in women with unexplained fertility. It may also lower the biochemical stress marker, prolactin.4
Relaxation response. The relaxation response is reasonably conceptualized as the opposite of the fight-or-flight response, and has been adapted as a treatment modality for many somatic disorders that may have a psychosomatic component.9 (For more information on the relaxation response, see Alternative Medicine Alert, February 1998, pp. 13-16.)
In one convenience study, 54 consecutively enrolled participants completed a behavioral treatment program.5 All participants had an established diagnosis of infertility and had completed their infertility work-up. Most participants had a diagnosis of unexplained infertility; the mean duration of infertility was 3.3 years. Using a pre-test/post-test design, significant (P < 0.05) decreases were found in participants’ scores on measures of depression, anxiety, and fatigue, as well as significant increases in vigor/activity. In addition, 18 (34%) of the participants became pregnant within six months of completing the program.
Though this study too was uncontrolled and limited in enrollment, a relatively high rate of pregnancy occurred as a "side benefit" of the program’s stated stress-reduction goals. Many participants reported dramatic improvements in feelings of self-esteem and self-empowerment.
Safety
No adverse effects of mind-body medicine, stress reduction, or autogenic training have been reported. Adverse effects for hypnosis have been reported, especially with individuals who have psychotic conditions as well as personality disorders.14 We have previously recommended that these persons be treated only under the supervision of an experienced, licensed health care provider with expertise in the use and limitations of hypnosis in the setting of psychiatric disorders.15
Training for Clinicians
Several prominent centers offer training for clinicians. The Washington D.C.-based Center for Mind-Body Medicine, among others, offers a week-long course to help clinicians integrate mind-body-spirit medicine into practice. In addition the British Association for Autogenic Training and Therapy (BAATT), formed in 1984 to train therapists and maintain standards, offers a three-year professional training course.
In September 1987, the Mind/Body Program for Infertility was established at Beth Israel Deaconess Medical Center in Boston. This 10-week program for individuals with stress associated with any medical condition focuses on teaching these individuals to elicit the relaxation response.13 (See Table 1 for physiological correlates of elicitation of the relaxation response.) Each session begins and ends with a group relaxation-response exercise that participants are expected to practice daily at home. Additional training is offered in stress management, physical exercise, nutrition, and group support.
| Table 1-Physiological correlates of elicitation of the relaxation response | ||
| • Decreased oxygen consumption | ||
| • Decreased carbon dioxide elimination | ||
| • Decreased heart rate | ||
| • Decreased respiratory rate | ||
| • Decreased blood pressure | ||
| • Decreased muscle tonus | ||
| • Decreased arterial blood lactate | ||
| Adapted from: Benson H. The Relaxation Response. New York: William Morrow; 1975. | ||
A focus on infertility required modification of Benson’s basic work. The infertility program limited the group size to 15, added a 30-minute sharing/support segment to the beginning of each of 10 sessions, invited husbands to attend two of the 10 sessions, had one of the sessions occupy an entire Sunday of yoga, exercise, and couples’ cognitive-behavioral exercises, and devoted one additional session to developing self-empathy and compassion. Other session topics included:5
• Introduction to the physiology of stress, the relaxation response, and the relationship between stress and the reproductive system
• Diaphragmatic breathing and mini-relaxation response exercises
• Cognitive restructuring and affirmations (the confrontation and subsequent rethinking of recurrent negative thought patterns)
• Developing self-empathy and compassion
• Mindfulness (increased awareness of sensations and perceptions)
Training for Patients
According to BAATT, typical autogenic training involves 8-10 weekly group sessions lasting approximately 90 minutes each. Patients learn a series of exercises to help them enter deep states of relaxation and experience relief from negative stress.
Conclusion
The relaxation response advocated by proponents of mind-body medicine may go by many different names: meditation, autogenic training, hypnosis, and more. Limited, mostly uncontrolled studies have suggested that regular elicitation of the relaxation response relieves stress associated with infertility and, in addition, improves pregnancy rates. Further well-designed, controlled studies will be necessary to establish the role of relaxation therapy modalities more conclusively. However, the utilization of mind-body medicine techniques to elicit the relaxation response appears to be a useful adjunct to more traditional forms of infertility treatment.
Recommendation
Regularly practicing to achieve the relaxation response may decrease anxiety and feelings of stress. It appears possible that a side-benefit of regularly eliciting the relaxation response is enhanced pregnancy rates in women treated for infertility. No adverse effects of the relaxation response have been reported. Despite limited evidence, elicitation of the relaxation response can be recommended for women with infertility since it may provide benefit and does not appear to be harmful.
Dr. Kattapong is a board-certified neurologist and principal in Medicat Consulting, a health services consulting firm in Tucson, AZ.
References
1. Speroff L, et al. Clinical Gynecologic Endocrinology and Infertility. 4th ed. Baltimore, MD: Williams and Wilkins; 1988.
2. Newton CR, et al. The Fertility Problem Inventory: Measuring perceived infertility-related stress. Fertil Steril 1999;72:54-62.
3. Oddens BJ, et al. Psychosocial experiences in women facing fertility problems—a comparative survey. Hum Reprod 1999;14:255-261.
4. Harrison RF, et al. Stress and fertility: Some modalities of investigation and treatment in couples with unexplained infertility in Dublin. Int J Fertil 1986;31:153-159.
5. Domar AD, et al. The mind/body program for infertility: A new behavioral treatment approach for women with infertility. Fertil Steril 1990;53:246-249.
6. Coutts JR, ed. Functional Morphology of the Human Ovary. Lancaster: MTP Press; 1981:205-220.
7. O’Moore AM, et al. Psychosomatic aspects in idiopathic infertility: Effects of treatment with autogenic training. J Psychosom Res 1983;27:145-151.
8. Benson H. The Relaxation Response. New York: William Morrow; 1975.
9. Bilkis MR, Mark KA. Mind-body medicine: Practical applications in dermatology. Arch Dermatol 1998;134:1437-1441.
10. Hennessy DP, Williamson PE. Stress and summer infertility in pigs. Aust Vet J 1984;61:212-215.
11. Dobson H, et al. Effect of transport on pulsatile and surge secretion of LH in ewes in the breeding season. J Reprod Fertil 1999;116:1-8.
12. Gravitz MA. Hypnosis in the treatment of functional infertility. Am J Clin Hypn 1995;38:22-26.
13. Borysenko J. Minding the Body, Mending the Mind. Reading, MA: Addison-Wesley Publishing Company, Inc.; 1987.
14. Vickers A, Zollman C. ABC of complementary medicine. Hypnosis and relaxation therapies. BMJ 1999;319:1346-1349.
15. Executive Committee of the American Psychological Association, Division of Psychological Hypnosis. Psychological Hypnosis: A Bulletin of Division 30. Washington, DC. 1993;2:7.
July 2000; Volume 3; 79-82
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