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Depression and Infertility: Treatment Considerations

By Alice D. Domar, PhD
Published in Resolve for the journey and beyond, Spring 2014

Symptoms of depression are incredibly common during infertility. Being sad when you cannot easily conceive is of course an incredibly natural reaction. Procreation is the strongest instinct in the animal kingdom; the desire to want a baby is the most natural thing in the world. My patients usually tell the same story: they gleefully do away with the birth control, happily try for a few months, and then usually get somewhat worried. As time goes by the worry turns to genuine concern and when they finally see a doctor, anxiety and sadness might have already set in. By the time they see an infertility specialist, they have experienced the roller coaster of emotions every month, feel that absolutely everyone in their life is pregnant or has a new baby, and if one more person tells them to “just relax”, they may be in danger of losing it totally.

It does not help that men and women tend to react to infertility differently. In addition, it can have a big impact on your sex life, it can negatively impact your relationships with friends and family, your finances, and even your religious/spiritual beliefs. Thus it is no surprise that almost half of infertility patients report high levels of depression/anxiety prior even to their first doctor’s visit.

If you are experiencing tearfulness, not looking forward to things as much as you used to, have issues with sleeping and/or eating, are not enjoying activities like you did in the past, and are feeling irritable, it is possible that you are depressed. But you have to remember that feeling depressed as you are going through infertility is completely normal. How can you not feel sad when you want a baby more than anything in the world, everyone you know seem to conceive effortlessly, but no matter what you do or how hard you try, it isn’t happening for you?

Treating symptoms of depression is necessary for a variety of reasons:

  • It is unpleasant to feel sad.
  • Women who are depressed are more likely to drop out of treatment, thus limiting their chances of conceiving.
  • Women who are depressed may have lower chances of conceiving, even with IVF.

Medical Considerations

The most common treatment for depression in the US is antidepressant medication, usually with a class of medications called SSRIs. However, in a recent literature review I wrote, along with two infertility doctors and a high risk obstetrician*, we came to the conclusion that SSRIs may well not be the best first choice line of treatment for the following reasons:

  • There is little research on the impact of antidepressant medication on fertility. There have been only a couple of studies, but both showed that women who were taking antidepressant medication had poorer outcomes from IVF than did women who were not taking antidepressant medication.
  • Taking antidepressant medication during pregnancy is associated with a number of risks, including higher rates of miscarriage and preterm birth.
  • Babies who were exposed to antidepressant medication during pregnancy were more likely to experience complications as newborns, including a 30% risk of newborn behavioral syndrome.
  • Children who were exposed to antidepressant medication during pregnancy had some developmental delays (i.e. walking about a month later than babies who were not exposed) and there appears to be an increased risk of autism.

We concluded that women who are trying to conceive who have symptoms of depression and are contemplating taking antidepressant medication should speak to their doctor about trying other non-pharmacological approaches first. We also recommended that women who are trying to conceive and are already taking antidepressant medication should speak to a psychiatrist or other mental health professional about the pros and cons of remaining on their medication, versus tapering off their medication after they have successfully learned other strategies to treat their depressive symptoms.

Cognitive-Behavioral Therapy

Most of the research on non-medication treatments for depression has been on psychotherapy, specifically cognitive-behavioral therapy (CBT), which is a short-term form of therapy in which the patient learns to recognize and challenge automatic and distorted thought patterns (“I will never have a baby,” “the infertility is all my fault”). The goal is to move towards self talk such as “I am doing everything I can to get pregnant,” and “I didn’t do anything to cause my infertility.”

The research shows that CBT is equivalent to, or in some cases better than, antidepressant medication. In one randomized controlled study with infertile depressed women, 79% of those who received CBT reported significant decreases in depressive symptoms, compared to 50% in the antidepressant medication group and 10% of the controls. Other research on CBT delivered in a mind/body group format showed that depression scores returned to normal by the end of the 10 week program and pregnancy rates were significantly higher in the mind/body group patients when compared to the control group.

The research on exercise shows decreases in depressive symptoms in the general population, but there has not been research with infertile patients yet. Acupuncture research is preliminary but does show promise in the treatment of depression in the infertile population. Yoga, relaxation training, and certain supplements show promise, but there is no definitive research yet.

The vital issue here is that if you are experiencing symptoms of depression, or have in the past but they are well controlled on medication, you need to sit down with a mental health professional and carefully review the pros and cons of antidepressant medication versus the non-medication route. If you are experiencing mild or moderate symptoms, either individual CBT or a mind/body group program may effectively, safely, and quickly treat your symptoms. If your depressive symptoms fall into the severe category, you might want to consider taking a break from trying to conceive, going on medication, mastering the CBT strategies while stabilized on medication, and then tapering off the medication and using the CBT methods as you start to try to conceive again.

If you have concerns about your mood, ask your infertility doctor to refer you to a local counselor who specializes in infertility counseling, ideally one who knows CBT. She/he can assess the severity of your symptoms and make recommendations based on how you are feeling, the availability of individual and/or group CBT, and your interest in incorporating the new skills into your life.

Be aware that infertility is a temporary crisis. You will not feel this way for the rest of your life. As the researcher Judith Daniluk discovered when she interviewed women decades after experiencing infertility, some of whom had conceived, some adopted, and some never had children, their level of happiness and life satisfaction were not influenced by the outcome of their infertility. But it is crucial now to find out if you are indeed depressed and if so, to choose a treatment modality which will maximize the chance that you will quickly conceive a healthy baby.

Alice D. Domar, Ph.D is the executive director of the Domar Center for Mind/Body Health at Boston IVF, and an associate clinical professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. She is the founder of the Mind/Body Program for Infertility, the author of six books, including “Conquering Infertility”, and the chief scientific officer for TriaDea Integrative Healthcare. Dr. Domar serves on the Board of Directors of RESOLVE: The National Infertility Association.

*Domar, A, Moragianni V, Ryley D, Urato A. The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, January, 2013.