Stress has been said to impact fertility. If you\u2019re trying to get tips on getting pregnant, simply Google and you\u2019ll find lots of advice on managing stress such as practicing relaxation techniques, ensuring adequate rest, taking up yoga or even referring to \u00a0self help books in the bid to conceive. But is stress really the cause of infertility? Many women have been able to conceive under highly stressful situations and yet there are those who struggle with infertility, even when they are of the right age and have no medical issues. How is this so? Not all stress causes infertility says Dr Tan Ee Ping\u2500Consultant Gynaecologist with special interest in fertility, endometriosis, laparoscopic and hysteroscopic surgery at CT Woman And Child Specialist Clinic, Seri Kembangan. She talks about this curious state of mind called \u2018Fertility Stress\u2019 and discusses with Motherhood Story how this can cause infertility. Defining Fertility Stress Q1: Can psychological and emotional factors cause 'infertility'? If so, what are these psychological factors? Apart from speaking about \u2018Fertility Stress\u2019 in this article, Dr Tan Ee Ping also has some very interesting advice pertaining to COVID-19 vaccinations and women in the videos below. Dr. Tan Ee Ping: I always describe stress or psychological or emotional factors in two categories. In the past, all doctors are aware that stress causes infertility, but until I went for the certification to be a fertility therapist, I realised that it is not as simple as what we used to think. When people talk about stress, generally, they are talking about work stress or daily stress but these are not Fertility Stress. Fertility Stress is very specific. It is categorised into two categories. Number 1 or the first group of stress is trying to get pregnant. Typically, this group has been trying to get pregnant for 10 years, or 15 years, or even 20 years. One day they just gave up and when they gave up, that is when they conceive. There are many, many cases out there like that. All they needed to do was to give up. And once they gave up, they conceived. In fact, I have about a handful of cases where after they gave up, they not only conceived but they conceived every year subsequently. And they may be in their 40s already and you may wonder what happened when they were in their 20s and 30s. They were not getting pregnant and now that they are in their 40s, they conceive so easily. This is the first factor\u2014they were so stressed trying to conceive. There can be many reasons. When we do fertility counselling for this group, we basically explore whether they belong to this group and we try to find out what made them so stressed. There are many possible reasons. Some women, who are of a certain age group, are very stressed because they think they are already so old and they don\u2019t have much time left. Some women have plans. Like, this year they\u2019ll get pregnant, next year they\u2019ll get a promotion, the following year, they\u2019ll open their business. They have these plans all laid out and when they can\u2019t conceive according to their timetable, they get very stressed. Another reason why some women are so stressed is because people keep asking them why they are not pregnant yet. There are people who are pressuring them\u2014their parents, their in-laws and this is a reason for their stress. For some of them, it\u2019s not the parents or in-laws, but their spouses. One person may be more anxious than the other and as a result, it gives pressure to the other person. I have seen couples where the wife will keep pressuring and blaming the husband for everything even though there is nothing wrong with the husband. Because of this kind of pressure, it is very hard to conceive. This is the first part. The second part of fertility stress is this group that is not stressed to get pregnant. They are chill and fine about it. But they have a 'but' as in, \u201cI want to get pregnant but\u2026\u201d So, this is another thing we commonly see. There can be many reasons: \u201cI want to get pregnant but I fear birth.\u201d \u201cI want to get pregnant but I am worried about becoming a mother.\u201d \u201cI want to get pregnant but I am scared I may end up with a miscarriage.\u201d \u201cI want to be a father but I am worried I may not be ready to be a father.\u201d We have seen cases where they have been pregnant once or twice and they got pregnant very easily. Then for years and years after, they don\u2019t conceive. If you explore into these cases, you\u2019ll find that actually something happened during the last pregnancy. One very good example is birth trauma. Women who have had a traumatic birth experience. After that, they cannot get pregnant anymore. And if you go through all their fertility tests, you will realise they have no problems at all. All they had was a psychological barrier and not a physical problem. Another good example is people with miscarriages, ectopic pregnancies, or molar pregnancies where they went through some pregnancy loss. Subsequently, they cannot conceive. I have cases where they have given birth and the baby almost died or something really bad happened to the child and then they cannot conceive again because this group of parents think \u201cI want to be a parent but I also don\u2019t think I deserve to be one.\u201d So when you have a 'but', that is another reason why they don\u2019t conceive. So Fertility Stress is not just about normal day to day stress. It has nothing to do with day to day stress in most cases. But sometimes it can be linked. Like, \u201cI am very stressed up at work but I need to stay stuck in this stressful job in order to earn enough money to support a family.\u201d So, there is a 'but'. Q2: There is a belief, and in many instances, it has proven true such as among my own aunties in the older generation, that if a woman cannot conceive, all she has to do is to adopt a child, and then her own babies will come. Why does this happen? What are the mental blocks that have been dropped to have suddenly \u201copened\u201d the door? Dr. Tan Ee Ping: This is an old belief you will see in many cultures. My parents and grandparents believe that as well. That\u2019s why my aunt was asked to adopt when she had difficulty conceiving. And I heard this practice among the other local cultures here as well. What I can postulate is \u2013 because couples in the past married young, many worried they wouldn't be able to cope being a parent.\u00a0 So when you give them an adopted child, it boosts their confidence in becoming a parent. That could be one of the reasons. Or the other could be that it was a way to distract them from trying to conceive. Give them a child to remove the stress of wanting a baby and the baby will come. Q3: In your experience, can you tell us some anecdotes or examples of Fertility Stress? If you have been trying very hard to get pregnant but are still not successful, it may be because you have some form of Fertility Stress. (Image credit: Freepik) Dr. Tan Ee Ping: I have seen many cases, some of which I mentioned earlier. There is this couple I still remember. They tried to conceive for two years and when they did all the tests, all their results came back normal. But when the couple went for fertility counselling, it was found that ever since they married, the wife realised that the husband became a very different man. Before they married, the husband was a very nice man but after they married the husband was always scolding the wife. She couldn\u2019t understand why she was always being scolded. When we explored in-depth, we discovered one incident that happened one month before their marriage. One month before they married, the husband\u2019s father passed away. In spite of the mourning period, they decided to get married as planned.\u00a0 Somehow, the husband had a lot of guilt in him. His father passed away from a car accident. When the husband was coming back from work, he actually saw the accident but didn\u2019t stop to see who was in the accident. Only when he arrived home did he realise that the accident involved his father. He was so angry with himself for not stopping to see whether he could have offered help and he blamed himself. Then there was this whole wedding thing that he felt he shouldn\u2019t have gone ahead with but his mother insisted on not changing the plans. As a result, he had this anger in him which he took out on his wife. He became very bad tempered. In what way would I consider this a fertility block? Because this wife, in trying to get pregnant, has a big BUT. \u201cWhat happened to my husband?\u201d \u00a0\u201cWhy after marriage am I getting scolded all the time?\u201d When she went for therapy, the therapist realised what the husband\u2019s issues were so we did therapy for the husband to help him accept the matters of the past and to stop being angry with himself. He reverted back to his old self and became a very nice man. And within a couple of months, the wife conceived. Another incident I can think of is of a childless couple. This couple was married for seven years. Although they did everything and their results were normal, they couldn\u2019t get pregnant. I told them everything is normal we cannot find a reason why you can\u2019t get pregnant. I recommended them to see the fertility therapists. This case was one of my early ones so I can remember it because it made a big impression on me. Then we discovered that this couple had many relationship problems between the wife and the in-laws. They had a big fight and as a result, the wife left the in-law\u2019s house and went back to her own parents house and she never stepped back into her in-laws house ever since then. So we did therapy and was able to settle the issue between the in-laws and the wife. Subsequently, she went back to her in-law\u2019s home for the weekends and she conceived. Just like that! This obviously means the But was the relationship problem. The husband was not happy with the wife having problems with the in-laws, and the wife too was not happy that the husband was not on her side. You see, many people have in-law problems but to have an in-law problem to the extent you never set foot into your in-laws house goes to show that the problem was quite big. I also have a case of physical abuse by the husband. He hit the wife every now and then. They had been married for four to five years and they could never conceive. They came for therapy and when we explored all their issues, we discovered that both husband and wife felt they should divorce because both partners felt they were causing each other a lot of stress. That is why he was losing his temper most of the time. The moment they made the decision to divorce, they actually conceived after the therapy. These cases are the extreme ones but if you want to look at the Buts, it could be endless. Some of these could be due to work stress causing financial problems. Then there are those couples who come from divorced homes. They always have this But. Quite a number of infertility couples who come from broken homes are quite common. Their But is, \u201cI want to get pregnant BUT what if my marriage doesn\u2019t last?\u201d \u201cWhat is going to happen to my child? \u201cWill my child be like me?\u201d Q4: The article \u201cInfertility is Not in Your Head\u201d argues that stress does not cause infertility because couples in high-stress situations such as those in war torn zones or who are prisoners of war, can and do get pregnant. Rape and assault victims also do get pregnant. There\u2019s also this study that says depression affects fertility. What is your take on all this? Does stress cause infertility? It depends on what type of stress it is, says Dr Tan Ee Ping (Image credit: Freepik) Dr. Tan Ee Ping: Can rape victims get pregnant? Definitely. Because you realise this is stress that is not related to fertility. Those who get raped or assaulted will be more worried over the emotional trauma or incident that they went through. They are not stressing about trying to get pregnant and they are not stressing about \u201cI want to be pregnant BUT.\u201d You see, that\u2019s why I say not all stress cause fertility problems. There are very specific emotions that cause fertility problems. That is why in our centre when we do fertility stress tests, we have a questionnaire that will have all the common questions. On depression, anxiety and even smoking, many of those who are depressed, who have anxiety and who smoke get pregnant but some don\u2019t although we try to link it.\u00a0 Like, say, if you have depression, yes it may affect fertility, anxiety may affect fertility, and smoking may affect fertility. Yet, there are tons of people out there who have depression, anxiety and who smoke who still conceive. It is not directly linked but you have to ask, what is the stressor? So of course, if you have depression, anxiety, trauma, and other psychological problems, there will be a higher chance that you will have a fertility block. Many people with depression, anxiety and trauma will have a lot of childhood trauma and these childhood trauma may be linked to a fertility BUT. Like, \u201cWhat if I become what my parent was and become abusive to my children?\u201d In fact, I have a case of a couple that was married for a long time but had no children. It took a long time before the wife conceived. And after she gave birth, she refused to touch her child and went into postnatal depression. Because she just refused to touch her child, her family members brought her to see me as it is not normal. We sent her to see our therapist and found out that when she was young, her mother was physically abusive to her. All the things that happened to her as a child was so horrendous she did not dare to hold her child because she was so scared that she too will hurt her child.\u00a0 She was afraid she would repeat the actions of her mother. So that\u2019s why it took her such a long time before she could conceive. And that was her fertility block. We knew all this after her pregnancy but when we found out, it all made sense why it was so difficult for her to get pregnant. I still remember, she was very young at the time, only in her 20s so it didn\u2019t make sense why she couldn\u2019t conceive. Q5: Can you give some advice on how to cope with the stress of Infertility? Dr. Tan Ee Ping: Coping with Fertility stress will depend on what you are referring to. If you are talking about BUT, I don\u2019t think this group of people have any stress at all. The typical couple will say that they are not stressed at all trying to get pregnant. So honestly, the way to go about it is to look for a fertility therapist. A fertility therapist will explore all these things. They understand the things that can block the person from getting pregnant. But of course, if you belong to the first category where you yourself know that you are very stressed, sometimes it is easy to say\u2014don\u2019t be stressed, just let go, just chill. A lot of spouses will tell me that \u201cI have told him or her to chill but she just can\u2019t chill.\u201d Like I had one case recently where the wife came for all her fertility tests. Every time she comes to my clinic, her heart rate would be 120. I was like, why are you so scared? She is so scared that I will find out something that will indicate that she cannot conceive. Her stress level is so high it can cause her to have a heart rate of 120. In this instance, I don\u2019t think she can just tell herself to stay calm, I\u2019m OK, I can chill\u2014it won\u2019t work. This group of people definitely need help from a therapist. Fertility counselling is the only way to go for couples who feel they are very stressed or they just cannot find the reason why they cannot get pregnant. More on Pregnancy and Fertility in Relation to Covid 19 Vaccinations \tCovid 19 Vaccine and Fertility https:\/\/www.youtube.com\/watch?vOGvRLiAMOAo \tCovid19. Important Tips during MCO 3.0 https:\/\/www.youtube.com\/watch?v0oJ4GzsiHt0 For more updates on pregnancy, fertility and conception, stay tuned to Motherhood Story.