Effective Mind-Body Strategies to Reduce the Stress of Infertility and Improve Mental Health

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Effective Mind-Body Strategies to Reduce the Stress of Infertility and Improve Mental Health

Research has shown that our mental state affects the outcomes of treatment in all disease conditions, including infertility, where it may decrease the chances of conception. Couples dealing with infertility go through immense stress, often times severe depression, as the follow up and treatment of infertility itself may cause anxiety and depression.

May is Mental Health Awareness Month and we are talking to practising psychologist Dr. Alice Domar, a pioneer in the field of mind/body medicine, director of integrative care at Boston IVF and associate professor of reproductive biology at Harvard Medical School. She conducts ongoing ground-breaking research which focuses on the relationship between stress and various medical conditions, the impact of cognitive behavioral interventions, as well as the impact of lifestyle habits on mental and physical health. She has been a keynote speaker and workshop leader at conferences worldwide.

In this talk, Dr. Domar will highlight effective mind-body strategies to reduce stress, decrease physical/psychological symptoms of infertility in men and women, and develop a positive mental state which may increase the chances of conception. You can follow Dr. Domar's slides HERE

Panelists

Talk Recorded on May 7, 2018, 6 p.m. EST </> Embed

Priya Menon Priya Menon

Shweta Mishra: Good evening and welcome to Cure Talks. I’m Shweta Mishra, your host joining you from India and today on this episode of Cure Talks you are going to learn about effective mind/body strategies to reduce the stress of infertility and improve mental health. Research has shown that our mental state affects the outcome of treatment in all disease conditions including infertility where it may decrease the chances of conception. Couples dealing with infertility go through immense stress oftentimes severe depression because the follow up and treatment of infertility itself  may cause anxiety and depression. May is Mental Health Awareness Month and we are talking to practicing psychologist Dr. Alice Domar, a pioneer in the field of mind/body medicine Director of Integrative Care at Boston IVF, Associate professor of reproductive biology at Harvard Medical COO and Executive Director of The Domar Center for Mind/Body Health.

Dr. Domar conducts ongoing groundbreaking research which focuses on relationship between stress and fertility, the impact of cognitive behavioral interventions as well as the impact of lifestyle habits on mental and physical health. She’s been a keynote speaker and workshop leader at conferences worldwide. Past chair of Mental Health Professional group of American Society of Reproductive Medicine, Dr Domar is on the board of Parents Magazine and served 10 years on the board of Resolve, The National Infertility Association. She is also the author of several books and co-creator of apps Ferticalm and Fertistrong. In this talk of Dr Domar will highlight effective mind/body strategies to reduce stress, decrease physical psychological symptoms of infertility in men and women and develop a positive mental state that may help increase the chances of conception.

I welcome you to Cure Talks Dr Domar. I extend a warm welcome to all our listeners and our listeners can follow Dr Domar’s presentation slide on the link that has been provided on curetalks.com. And I would like to remind our listeners that we will be discussing questions sent in via e-mail at the end of the show so you can email your questions to shweta@trialx.com. And if you want to ask a question please press 1 on your keypad and we will bring you on air to ask them or you can also post your questions directly on CureTalks website as you listen to the talk. So Dr Domar let’s begin.

So there’s some or the other kind of stress all around us, at almost all times in our lives Dr. Domar and everyone has to deal with it. But based on research what we also know is that our bodies have inbuilt mechanisms to deal with this stress and it’s just that most of us are not aware of how to kind of switch these mechanisms or  processes on in our bodies when needed. And personally I am a very firm believer of the thought that being in the positive frame of mind works wonders on human body and I’ve experienced this firsthand in my infertility journey. So it would be great Dr. Domar if you could begin by explaining how stress impacts fertility and how psychological interventions like your mind/body program can help people achieve success in their family building goals and our listeners can follow the slides on our website curetalks.com. And I’m sure they’re all eager to learn about some effective technique to reduce stress.

Dr Alice Domar: That sounds great. Thanks for that I really appreciate it. So if those of you who can see the slides, I would just go to the 4th slide in the deck and I’ll start from  there. It’s entitled “The stress of infertility”. And I think this may come as a huge shock to people but we published a paper about 20 years ago showing that women with infertility reported the same level of distress as did women with metastatic cancer heart disease or HIV positive status. And when we published that paper, it wasn’t a surprise to me because I was seeing patients with all different kinds of disease states. And I had already observed that infertility patients report a lot of distress. But many women go into infertility report it is the most difficult time of their lives and a groundbreaking study came out I think in 2004, until 2004 most researchers including me had assessed measured distress by basically handing women a questionnaire that say how distressed are you. And that drastically underreported how much stress women were under because a lot of women didn’t want to actually admit to how distressed they were because they were afraid that their doctor would refuse to let them to have treatment because they thought they wouldn’t be able to handle it. And this particular study used psychiatric interview and so they looked at women who are coming in for their very first clinic visits, seeing a fertility doctor and almost half of the women I think was 40 something percent reported psychiatric levels of anxiety depression or both. And this was not that women are crazy. Most of these women had no mental health history before infertility. They are simply normal healthy women of reproductive age who have been trying to get pregnant for a year or two or more. And by the time they saw an fertility specialist they were feeling very defeated and very anxious and very lonely. And a study came out about two years ago out of University of California San Francisco by a psychologist named Lauri Pasch and she surveyed several hundred women and men who were coming in for infertility treatment and they found that the majority of women were anxious, depressed or both, it’s just very very hard to go through infertility.

Slide 5: So you know a lay person might say that I do see mothers in law and I see partners and I see family members because I very much understand why my patients are feeling that this is so hard for them because infertility really does impact every aspect of a woman’s life, of an individual’s life and I’m really talking about women because I tend to see mostly female patients and it affects her relationship with her partner because in a heterosexual relationship I can tell you this. Men and women do not respond to infertility in the same way at the same time. In general in my opinion would tend to sort of be a year tend to be ahead of their partner in that you know they fall in love sooner and they want to get married sooner and they want to start trying sooner. And they think there’s a problem sooner and they want to see a doctor sooner. And they want to see a specialist sooner. They want to move on to high tech treatment sooner. And so when you sit down with the couple the wife will usually say he’s holding me back and the husband will usually say she’s pushing me to make decisions I don’t feel ready to make. And so that causes some friction because for a lot of people infertility is the first crisis of their relationship and it can be hard to be in a crisis with someone you love who’s not responding in the same way or at the same time. And on top of that women with infertility often feel almost phobic about being around pregnant women or they live in fear of pregnancy announcements and so they are afraid to go to social functions if they suspect they’ll be a pregnancy announcement or they don’t want to go home for a holiday if their sister is pregnant. And men don’t tend to feel the same way; men seem to feel pretty immune to pregnancy announcement so the pregnancy and so that can cause friction between the couple because she may want to avoid events where they might be a pregnant woman and he may not want to avoid those events. So it affects their relationship it also affects their sex life because they’re often told when they should and should not be making love. People start to associate sex with failure and a lot of people once they move on to more high tech treatment say well why should we bother having sex because it doesn’t work anyway. It impacts their relationship with their family in all likelihood their siblings are getting pregnant and so their parents are probably talking a lot about their grandchildren.

And so a lot of my patients don’t want to go home for family functions because they don’t want to see their siblings with their children, they don’t want to see their parents being happy grandparents and so they start to isolate themselves. And the same thing with their friends you know all their friends are getting pregnant and when people get pregnant and have babies that’s all they talk about. And so often you’ll see this couple in crisis who start to pull away from family and friends. And so they don’t have social support. It could impact their job or career because many jobs these days involve travel and you can’t travel when you’re undergoing treatment. A lot of which actually are a lot of women are in jobs that involve children they might have chosen to become a teacher or a nanny or a pediatrician thinking that would be flexible with their own children. I’ve had patients who were obstetricians and nurse midwives and labor and delivery room nurses and so all they do all day is hear pregnant women complain and they can’t get away from it. Infertility can also affect an individual or couple’s financial stability. Because in the United States I think there are only seven states that include IVF coverage. And so there often are there’s friction between the couple about what should they pay for and not pay for. So it can affect their financial stability. And finally it can affect their relationship with God. We’ve done research on this and for a lot of people they feel like this is the first time God has an answer to their prayers and they feel like they’re good people they would be amazing parents and they see so many children out there in the world who are not appreciated by their parents and they can’t understand why God won’t give them a baby.

So if you look at it infertility impacts every aspect of their life. And on top of it the average person going through infertility hears from everyone, just relax you will get pregnant or you’re working too hard or go on vacation or just adopt. And the essential theme behind all of that is it’s your fault. You’re too thin to get pregnant you’re too stressed out to get pregnant which means they’re blaming the victim. And you would never say to a cancer patient just relax and your cancer will go away. No one would ever do that. So it adds to the the burden.

Slide 6: So I think it’s pretty clear that infertility causes very high levels of stress in most people but the question then comes in does stress caused infertility. It’s controversial. It’s hard to assess it’s hard to do really good research. We know that women who have a history of depression are more likely to have infertility. There is a Director of Reproductive Epidemiology Ohio State who has shown that the more stressed a woman is the longer it takes her to get pregnant and the more likely she will experience infertility. What we don’t really know whether or not stress during treatment impacts treatment outcome. It is very hard to assess that because people tend to get optimistic before they start a treatment cycle and or women know their prognosis. And so a 44 year old with the higher FSH level is probably going to be more anxious before a cycle than a 25 year old who’s at this stage too. And so very hard to tease out those two things; do I personally believe that yes stress impacts treatment outcome. Yes I do believe that and that’s mostly because if you look at the Intervention Research it looks pretty clear.

Slide 7: Before we even look at the impact of stress on treatment outcome nobody likes feeling stressed, it’s unpleasant to be depressed, it’s really unpleasant to be anxious. So it’s just not good to feel stressed. We also know that people who are stressed are much more likely to drop out of treatment, even people with insurance. And people who drop out of treatment because of their distress level are often faced with regret later in life. And so I don’t want to ever see somebody drop out of treatment because they’re too stressed to continue if we know that there are ways that we can pretty easily decrease their stress level.

So let’s look at Slide 8. So what can you do, what can you do to decrease your stress. And I have to say I think there probably been 35 or 40 randomized controlled studies looking at different psychological interventions and there’s a thing called a meta analysis where they sort of pool all the studies and the most recent one showed that women who are going through infertility, who do some kind of psychological intervention are far more likely to get pregnant and they experience much lower levels of distress. And that was a very good study it was out of Scandinavia, I can’t remember the country, it was in Scandinavia. They had very solid results and the intervention form that they thought was the most effective is called cognitive behaviour therapy. Cognitive therapy involves teaching people how to challenge automatic negative thought patterns, it’s a very proactive kind of therapy and the analyses before that have shown that interventions that are at least six sessions are more effective than shorter ones and they’ve also shown that interventions that provide skills so not just sitting around talking about how hard infertility is but teaching women skills which they can use to help themselves feel better or more effective.

Slide 9: I started the program in 1987 called the mind/body Program for Infertility. It’s a 10 session group treatment program for women at any stage of treatment and includes cognitive behavioral therapy, it includes relaxation training. We talk about lifestyle habits. We talk about the safety and efficacy of alternative approaches like acupuncture and there’s a lot of group support like women can walk into this group and say my younger sister is pregnant for the third time and everyone in the group would go oh my god we’re so sorry. That is exactly where she needed to hear. And we also have peer counselors who are graduates of the program who are really there as role models and we have a buddy system so everybody gets a buddy in the group.

Slide 10: Every session has like an optional first half hour is like a mini support group where people get a chance to tell their stories. We do a different relaxation exercise each week and there’s like a topic each week that could be self nurturance, it could be countering automatic negative thought patterns like I’ll never have a baby and we talk about how to cope with anger, shame and isolation.

Slide 11: So we’ve done two large randomised controlled studies looking at the impact of the mind/body Program and the first one we looked at the take home baby rate and we found that women who did the mind/body program had a 55 % take home baby rate compared to 20 % under control and the controls are women who didn’t do any group, and mind/body patients also had significant decreases in anxiety and depression and then we followed up a few years ago with a study just on IVF patients and we found that when women did a mind/body program they had a 52 percent pregnancy rate compared again to a 20 percent pregnancy rate in the control group. So that’s pretty solid evidence that doing a mind/body form of intervention does seem to increase pregnancy rates and decreases distress.

Shweta: That is solid evidence 55% versus 20% that you just mentioned that’s actually great evidence. Right?

Dr Domar: Well I was pretty happy when we did the data analysis I’ve sort of this has been my whole career. So I was pretty happy when we looked at the data of women who aren’t doing research with us but are just patients in our mind/body program, we have found that about a little over half get pregnant within six months. We’ve also shown that most of the women who come into the program have some kind of physical symptoms like insomnia or headaches or back pain or shortness of breath. And we found that they have about a 67 % reduction in those symptoms. And we’ve also a while ago followed women for two years and found that 95 % within two years became moms in one way or another. So they is some long term happiness there. And then we recently did had one graduate student whose dissertation was converting the in-person mind/body program into an online program and her preliminary results which she presented last year at the American Society of Reproductive Medicine showed that the women who are who did the online program again had significantly higher pregnancy rates and really nice decreases in negative psychological symptoms in the control group. So you know that’s an innovative way of doing it online.

So moving on to slide 14. We also did another randomised controlled study a couple of years ago that we published about two or three years ago where we actually just mailed women a packet of information on how to do some cognitive therapy and we included some relaxation exercises and that’s something where we did not see a difference in pregnancy rate but we did see the really lovely decreases in distress and the women who got the Stress Management packet were 67 % less likely to drop out of treatment and the goal of that study had actually been to look at the impact on treatment terminations.

So moving on I might be old but I have to sort of keep up with technology and about a year ago my colleague Dr Elizabeth Grill who’s a psychologist who’s the chief psychologist at Cornell Medical Center in New York, she and I wrote and created a new app called Ferticalm and the idea of Ferticalm is she and I, I think between the two of us, I think we’ve been seeing patients through over 40-45 years. And so we know what’s hard for our patients and so we came up with the 50 situations which are the most likely to cause distress like the little sister announcing she’s pregnant at a family function or being at work and getting your period or sitting in the clinic waiting to be called in. And we came up with cognitive behavioral and relaxation strategies for each of those situations. So the way the app works is

I think on the next slide it sort of shows it. So let’s say you’re at work and you get your period you go in the bathroom you open the app and you can actually find that exact scenario and you push that pedal at the flower. And there are cognitive solutions, there are behavioral solutions. I think my favorite is called social solutions and it’s comeback lines for people who say stupid things. So basically gives you scripts on what to say. And the app has been licensed by Ferring Pharmaceuticals. So it’s actually free to download. I do not get paid per download so I feel very comfortable talking about the app. If anybody in the U.S. or Canada wants to download the app they just can go into their Apple or Android store, in the U.S. it’s also available in Spanish and in Canada, it’s available in French Canadian and they could use the app as they see fit. We don’t collect personal data everything is anonymous I promise you and it’s really nice for me because on weekends and evenings when my patients are in crisis they say that having the app makes them feel like I’m sitting in their phone. And so no matter what situation they’re in, they can find something on the phone. It also includes 10 relaxing guided relaxation in my voice. So I had a patient the other day who’s flying and she got really anxious and she listened to the relaxation, she felt better.

And we just two weeks ago moving on to Slide 17, released a new app because I think the only criticism we got for Ferticalm was that it was made for women, it is very clearly with pretty pastels, the flower and it’s very much directed for women and two weeks ago, we released a new app called Fertistrong and it’s basically the male equivalent. And so again you know Ferring licensed and so it’s free to download anywhere in the U.S.. Right now it’s only available in English but we’re working on that. And the idea is that these are men either for men with infertility or men whose partner has infertility. And it was written by two psychologists who have an expertise in men going through infertility and I’d say half of it is mind/body and relaxation skills for the guys. And half of it is what they can do when their wife is upset. So it is both. And we as I said we just launched.

So I’m back on slide 18,  wrapping up so just to conclude we know that women with infertility experience know really significant levels of distress. We know that distress is really unpleasant and may or may not impact pregnancy rates. But we do know that psychological interventions are associated with lower levels of  distress and higher pregnancy rates. And we are working to create new and innovative ways to address these issues through cognitive behaviour therapy and relaxation strategies that can be available on your phone. So that is my slide deck.

Shweta:  All right. Thank you so much. Thank you so much Dr. Domar for your very comprehensive presentation and thank you for sharing some great optimistic results from research studies which support the behavioral and cognitive behavioral therapy and the psychological intervention. I’m just wondering Dr Domar, the mind/body program on which the Ferticalm and Fertistrong apps are based is ongoing from 1987, like your slide shows.

Dr Domar: I was 3 when I started it, I am joking. I was not that…

Shweta: Oh … Of course. Yeah I was just wondering the efficacy of this program has already been proven by the randomized controlled studies. So I’m just curious are the doctors writing things like practice meditation or yoga or any other mind/body techniques for 15 minutes daily, on their prescription for patients? Are these apps prescribed to patients or if not then how how far are we in the position that they’ll be prescribing these apps to the patients?

Dr Domar:  Well it would be my dream for physicians to prescribe medication or a mind/body group or an app to a patient. I think there are some physicians who were very in tune with their patients’ emotional health and in fact I was giving a talk at the American Society of Reproductive Medicine meeting and I was talking about psychological interventions and I don’t really feel all that comfortable talking about the apps because they’re mine and I don’t want to self promote. And so I wasn’t talking about the apps and in the middle of my talk, this physician stood up which is just not done at these meetings and she said I have to stop you. She says I think you’re being irresponsible not to mention Ferticalm and I was like wow, and she said have you heard of it, I said I co-wrote it and then she tells the audience that she’s a physician she’s an RE, a reproductive endocrinologist and she said that she has this new routine that whenever she has to do a procedure on a patient that might be painful or unpleasant she walks into the exam room she greets the patient she tells the patient to download the app and asks them to do one of the relaxations on the app. And then she says I’ll be back in 15 minutes. And she said it’s really changed how she delivers care. So I thought that was an amazing story. I don’t know how many physicians in the country are recommending the app to their patients. I obviously wish more would, because the feedback we have gotten from patients has been really nice. As I said they really feel like there’s a psychologist in their pocket and no matter what’s going on in their lives there is some proactive solution in the app that they don’t feel alone.

Shweta: Yeah absolutely. So in one of your interviews I heard that you said that it’s mind/body techniques were a pill, every patient would take it and I believe that is so true. So can you shed some light on why is it so hard for people to get into the habit of inculcating these stress dissolving techniques into everyday life?

Dr Domar: Well I think there are a number of barriers. I mean yeah if there had been medication that led to the increases in pregnancy rates and the decreases in distress, if someone came up with a pill or even injection that created those positive changes, every infertility patient in the world would be taking that pill and especially if it was relatively cheap it had no side effects. And so it’s frustrating for me that I’ve spent 31 years of my career trying to convince people especially women and now physicians, that women need to be proactive, they’re things that they can do to help themselves feel better. They just you know need to take it. They need to take the time and again people, if there was a pill they’d be doing it. This is doing mind/body strategies takes time I mean doing the mind/body group takes a time commitment. It’s so interesting to me when I read the evaluations after women finished the program and almost everybody says you know this is the best thing I’ve ever done. I finally feel the way I did before infertility myself again. And I do tell people that for me the goal of the mind/body program is not pregnancy but the goal is to get their lives back, to be the person they were before infertility.

Shweta: Absolutely I totally agree with you. Believe me I’ve been there and done that, so totally believe that. So I have a question on the denial issue. People often discount the fact that mental health actually directly affects physical health and mental issues like depression anxiety and bipolar disorder, people mostly think of it as nature or anybody else’s nature and hence the denial problem. So how do you help such people in denial, when they might not be in a mood to go to a counselor at all?

Dr Domar: Well it’s almost like a catch 22 because when someone is feeling depressed they feel hopeless. And so when you’re feeling hopeless it’s very hard to be proactive. And in fact the vast majority of people around the world who are depressed, anxious, bipolar and never see a mental health professional. There is a sense of shame, there is a sense of embarrassment, there’s a sense of hopelessness as anyone can ever help you. And yet if you look at the research on the efficacy of all kinds of different interventions for infertility patients and others there are lots of things that are highly effective. I mean if you look at the data I am not a big believer in taking medication for depression when someone’s trying to get pregnant unless somebody has a really significant history. But if you look at the data on the efficacy for just depression of cognitive behavioral therapy or exercise or acupuncture these have efficacy rates of well over 50 % about the same as the efficacy of medication. And so I don’t think people should feel hopeless or helpless. I mean I have seen people who were just unbelievably depressed come either see me individually or more likely do the mind/body Program and within a month their depression really significantly left.

Shweta: So I would like to know and I’m sure the listeners would like to know too that what is one thing or an advice that you tell your patients with infertility related depression and anxiety that you have seen work in changing their frame of mind?

Dr Domar: Yeah everyone always asks me what the active ingredient is of the mind/body program because it’s cognitive behavior therapy and it’s relaxation strategies and it’s learning to express your emotions and adopting healthier lifestyle behaviors and it’s pursuing good alternative strategies and not pursuing bad ones. And this group support that’s really powerful and so people say well you know what’s the active ingredient and I like I don’t care, if it works why mess with it. And I think probably the answer is, different things work for different people. And I have had some people go wow that group support that’s exactly what I needed. I’ve had other people say oh it was the relaxation techniques like those are so valuable that other people say it was the cognitive strategies when they learn to think in a far less negative way. Some people say we have the partners come to three of the 10 sessions and some people say it was just my partner really learning about what I was going through. And now he really supports and respects me. I don’t think we can say what works. I mean the fact that the online program looks like it’s pretty darn effective, would actually suggest that the active ingredient is probably not social support. So there’s probably something to the cognitive strategies or lifestyle changes and the relaxation practice.

Shweta: Alright. Thank you. Thank you so much for your answer Dr Domar. And one last question from my end and then we’ll move on to the audience questions. Could you please talk a bit about latest research going on in the field of mind/body techniques?

Dr Domar: It’s a source of endless frustration for me that there aren’t more people certainly in the U.S. Europe tends to be ahead of us in terms of psychosocial research and infertility. And the European group is called Ashray and they tend to have much better research publications than we do in the U.S. Although I think for both organizations I can tell you that doing randomized controlled research trials is really tough. I mean in my 30 years of practice I’ve done three, I’m doing another small one now. It takes an enormous amount of money. It takes a huge amount of time and it’s really hard to recruit women with infertility to be in a randomized controlled trial because by definition it pretty much means half of them will get the intervention and the other half won’t. And it’s very hard to take people who are really distressed and say Hey thanks for volunteering you know we’ll see you in three months. That just doesn’t seem really good. So I think we probably need to do a little bit more research but when that meta analysis that came out a year or two ago which summarized 35 studies. I’m not sure how much more research we need to do that documents that women with infertility benefit enormously from psychological interventions. I think that’s sort of like a given now, like doing some kind of psychological or intervention is going to help you. It’s going to help you feel better psychologically and it’s likely to increase your chances of getting pregnant. I think what we probably need to focus on now is what’s the most effective mode of delivery. Like if somebody who lives far away from a mind/body group it’s not practical for her to do a mind/body group and we get that. So I think right now my body program looks like it’s showing some of the best results but it’s not practical for some people. We don’t have data on the apps and we’re not going to ever get data properly on Ferticalm because it’s out already. So unfortunately you know if we launched it before we had the time or the money to do a study on it we based it on previous research that had shown a huge impact.

Shweta: Absolutely. OK. Thank you for answering all my questions Dr Domar I’m just now moving on to submitted questions that have been put on our website. We have a question from Claire and she says many aches and pains that are rooted in brain processes that can be affected by your mental attitude and emotions. What do you think is the best way to tackle this?

Dr Domar: Well Claire is entirely right. I mean there is no barrier between the mind and the body. And as I mentioned earlier when we look at our mind/body patients – infertility mind/body patients almost all of them come in with headaches, neck pain, back pain, insomnia, abdominal pain, fatigue. Most of them don’t feel great and that’s most likely a manifestation of the stress that they’re experiencing. And so when we’re really stressed out, our body tells us it tells us by not allowing us to sleep well or by giving us headaches or shortness of breath or palpitations and so what I tell my patients is when you have these symptoms the current normal behavior is to take medication to treat symptoms. So if you have a headache you take ibuprofen or if you have a stomach ache you take something, if you have we tend to medicate our symptoms and when we really need to do is to stop and say ha I think my mind is trying to tell me something like If I’m not being well I can either pop a cup of Benadryl or I can stop and think ha why am I not sleeping well, what’s going on in my life. What do I need to do to be healthier.

Shweta: Right. Sure. Alright. So the next question is from Grayhaired mom and it’s a pretty long question. She says work-related stress during pregnancy was my biggest challenge, something that you talked about – travel during treatment Dr Domar, so much so that I sought professional help from a psychologist for the first time in my life to help deal with it. My OB/GYN told me that stress during pregnancy was not recognized as a legitimate reason to request medical leave from work. She said, “Women give birth to healthy babies in war zones. Stress isn’t a threat to your baby’s health.” I’ve read recently, though, that research is pointing to significant developmental problems in children when mothers are exposed to or experience stress during pregnancy. How worried/watchful should I be? Her son is 7 and seems completely unaffected in any negative way so far.

Dr Domar: Well her son seems great and I would be happy as a clam if I were her. The fact is it’s controversial about whether or not you know stress during pregnancy can lead to issues in the baby or children afterwards. As I said earlier feeling stressed is really unpleasant. So even if a study came out in five years showing that stress doesn’t have an impact on kids, I doubt that would happen but if it did it’s still unpleasant to feel stressed and pregnancy in and of itself is stressful. It requires enormous adaptations, physically, psychologically, financially, relationship wise and it’s a very very good time to learn mind/body strategies. We actually actually published a book a year and a half ago on mind/body strategies during pregnancy because I have some patients who are pregnant and who are really stressed out.

Shweta: Alright. Thanks for that Dr Domar. The next question comes from Emily and she has a couple of questions. Firstly, Can you talk about how infertility can impact the women’s partner/husband? What can a couple do together to reduce their stress from their infertility? How can a couple stay connected and not divided while struggling with infertility?

Dr Domar: It’s a great question and I think that’s probably why we did the app for men because infertility as I said at the beginning can have a huge impact on the couple. And I do a lot of couples counseling and what you hear from them over and over again is I’m reacting this way and my partners react to you in a different way. He or she is wrong. And I think with infertility women tend to express a lot more distress than men do and they thus make the assumption that their male partner is not distressed. And I don’t think that’s a fair assumption. I think that men by definition don’t tend to express to stress the same way women do. There’s a lot of social pressure that men shouldn’t get depressed. And when I talk to men without their wives around they’ll say I’m just as upset she is. But one of things us needs to keep it together, if I react like she does, we’re going to fall apart. So they feel like they have to be the rock, like they have to be the solid person and they suffer they suffer in private. So on one of the later sessions of the mind/body Program we have the men come and they go to a separate place with a therapist who asks the men how they’re doing and pour out their heart and soul because no one ever asked them. And Resolve which is a national infertility organization in the U.S. did a survey of men of partners, men experiencing infertility either themselves or in the partnership and basically ask them how distressed are you. And it was like unbelievable how distressed these men were. It’s really hard for them. They want a child and they’re seeing their wives be extremely upset and that’s a real problem for them and so I think that it’s amazing, it’s whatever she’s doing she’s thinking about her partner. She’s thinking about his feelings which is very sad. I think the first thing I tell couples is the way you’re reacting is the right way for you and the way your partner is reacting is the right way for him or her. Don’t try to change the way they’re coping. It’s the right way for him or her. It does not mean you’re right they’re wrong, just leave them be. Just respect the way they’re handling this right.

Shweta: Right. Absolutely. OK. The next question from Emily is that she explains, My work didn’t know that I was going through infertility treatments. It was so hard on me to have to juggle being at the doctor 3 days a week, having to do suppositories while at the office and having to wear loose clothes cause the bruising on my stomach from the injections hurt so much all, while having to still do an awesome job at my work. So many of us don’t want to tell our bosses what we are going through, and should not have to, yet the hormones and stress deeply impacts us in all aspects of our life, especially work. What can others do?

Dr Domar: It’s a really good question I think I get asked this about once a week and how do I handle work. Because the fact is if you have a presentation tomorrow at 2:00 o’clock the clinic calls you guys at 1:30, it can cause a conflict. I can very much understand why people don’t want to share this with their boss or supervisor, it’s private. They don’t want to be discriminated against whose business is. On the other hand you also don’t want your boss to think you are goofing off or taking advantage or whatever. So I think you have to sort of assess your position within your job and also think about your boss, if your boss is a 41 year old woman with triplets, my guess is she might understand what you’re going through. If your boss is 95 year old man with 18 grandchildren, not so much. So I think you need to survey your work situation and be self-protective. I mean this infertility doesn’t last forever, it’s a temporary crisis and you need to figure out how can you be most self protective.

Shweta: Correct. Correct. All right. One last question, Sally says I saw “unsuccessful cycle program” on your website. I went through several failed IVF’s and embryo transfers and I am financially and more so emotionally drained. I am terrified to go for another one. I don’t want to stop trying, but I am terrified. How can this program help?

Dr Domar: The Unsuccessful Cycle Program is not a programme it’s a free half hour with a psychologist. And basically what we do is we talk about what your experience has been, how you coped with your previous cycles, what worked for you and what didn’t work for you. And then we will provide you with some coping skills acquisition to use if you decide to do another treatment cycle.

Shweta: Ok, alright. Thank you so much for your answers Dr Domar and thank you so much for taking out time from your busy schedule. I guess we are at the end of the the scheduled time we had for this talk. Thank you for sharing some great advice on how people can deal with the much inevitable stress that comes with infertility and its treatment. I am sure this talk would be helpful to many people who are on their journey to parenthood and also help them deal with various other kinds of stress in their lives. People who want to learn more about the apps that Dr Domar mentioned, can go on ferticalm.com and fertistrong.com websites to know more.

Claire, Grayhairedmom, Emily and Sally, thank you for your great questions and audience I thank you for your support and I look forward to having you join us for our next Cure Talk on Multiple Myeloma on 10th May at 6pm Eastern and for more information on this show and other upcoming shows visit www.curetalks.com and I would love to hear your feedback about this curetalk on fertility issues and I would welcome your suggestions on topics that you feel should be covered on Cure Talks. Please email me on shweta@trialx.com and the link for today’s show will be sent via email to all the participants. Until next time, thank you everyone and goodbye.

 

Priya Menon Priya Menon

Interesting takeaways from the talk with Dr Alice Domar:

  • May is Mental Health Awareness Month. Studies show that women with infertility show equivalent levels of distress to women with metastatic cancer, heart disease, or HIV+ status.
  • Infertility impacts every aspect of an individual’s life – be it their relationship with their partner, their sex life, their relationship with their family, their relationship with their friends, their job/career, their financial stability as well as their relationship with God.
  • Women with a history of depression are more likely to experience infertility. Research indicates that the more stressed the women, the longer it takes her to conceive, and the more likely she will experience infertility.
  • Whether or not stress impacts treatment outcome is controversial. Some research shows that stress is in fact associated with lower pregnancy rates from IVF, but other studies have not shown a significant relationship.
  • Impact of psychological interventions – The most recent meta-analysis (a statistical pooling of data from many studies) showed that women who participated in a psychological intervention experienced significantly decreased emotional symptoms such as anxiety and depression as well as significantly increased pregnancy rates. The form of intervention which was recommended was cognitive behavior therapy (CBT). Previous meta-analyses have indicated that skills acquisition programs that are six sessions or more have the best results.
  • Mind/Body Program for Infertility: The Mind/Body Program for Infertility was founded in 1987. It is a ten session group treatment program for women at any stage of treatment. The program includes Cognitive Behaviour Therapy, relaxation training, information on the impact of lifestyle habits on fertility, information on the safety and efficacy of alternative approaches, and group support. Each group has two peer counsellors as well as a buddy system.
  • Two randomized controlled studies have supported the efficacy of the Mind/Body Program. In the first study, participants in the mind/body group had a “take home baby” rate of 55%, compared to 20% in the control (no treatment) group as well as significant improvements in depression and anxiety. In the second study, on IVF patients, the mind/body patients had a 52% pregnancy rate compared to a 20% rate in the control group. The mind/body program was recently converted into an online program. Preliminary results from this indicate that women who were randomized into the mind/body online program had significantly higher pregnancy rates and greater decreases in negative psychological symptoms than the control group.
  • Residents of US and Canada can try the Ferticalm (for women) and Fertistrong (for men) apps to help them deal with infertility. The apps are designed to apply CBT and relaxation strategies to the 50 most distressing situations for women experiencing infertility, such as a family member announcing their pregnancy, or receiving negative pregnancy test results while at work. People who want to learn more about the apps can visit ferticalm.com and fertistrong.com websites.
Priya Menon Priya Menon

Q: There’s some or the other kind of stress all around us Dr. Domar, and everyone has to deal with it. But based on research what we also know is that our bodies have inbuilt mechanisms to deal with this stress and it’s just that most of us are not aware of how to kind of switch these mechanisms or processes on in our bodies when needed. And personally I am a very firm believer of the thought that being in the positive frame of mind works wonders on human body as I’ve experienced this firsthand in my infertility journey. Could you explain how stress impacts fertility and how psychological interventions like your mind/body program can help people achieve success in their family building goals.

A: Dr Alice Domar: So if those of you who can see the slides, I would just go to the fourth slide in the deck and I’ll start from there. It’s entitled “The stress of infertility”. And I think this may come as a huge shock to people but we published a paper about 20 years ago showing that women with infertility reported the same level of distress as did women with metastatic cancer heart disease or HIV positive status. And when we published that paper, it wasn’t a surprise to me because I was seeing patients with all different kinds of disease states. And I had already observed that infertility patients report a lot of distress. But many women go into infertility report it is the most difficult time of their lives and a groundbreaking study came out I think in 2004, until 2004 most researchers including me had assessed measured distress by basically handing women a questionnaire that say how distressed are you. And that drastically underreported how much stress women were under because a lot of women didn’t want to actually admit to how distressed they were because they were afraid that their doctor would refuse to let them to have treatment because they thought they wouldn’t be able to handle it. And this particular study used psychiatric interview and so they looked at women who are coming in for their very first clinic visits, seeing a fertility doctor and almost half of the women I think was 40 something percent reported psychiatric levels of anxiety depression or both. And this was not that women are crazy. Most of these women had no mental health history before infertility. They are simply normal healthy women of reproductive age who have been trying to get pregnant for a year or two or more. And by the time they saw an fertility specialist they were feeling very defeated and very anxious and very lonely. And a study came out about two years ago out of University of California San Francisco by a psychologist named Lauri Pasch and she surveyed several hundred women and men who were coming in for infertility treatment and they found that the majority of women were anxious, depressed or both, it’s just very very hard to go through infertility.

(Next slide). So you know a lay person might say that I do see mothers in law and I see partners and I see family members because I very much understand why my patients are feeling that this is so hard for them because infertility really does impact every aspect of a woman’s life, of an individual’s life and I’m really talking about women because I tend to see mostly female patients and it affects her relationship with her partner because in a heterosexual relationship I can tell you this. Men and women do not respond to infertility in the same way at the same time. In general in my opinion would tend to sort of be a year tend to be ahead of their partner in that you know they fall in love sooner and they want to get married sooner and they want to start trying sooner. And they think there’s a problem sooner and they want to see a doctor sooner. And they want to see a specialist sooner. They want to move on to high tech treatment sooner. And so when you sit down with the couple the wife will usually say he’s holding me back and the husband will usually say she’s pushing me to make decisions I don’t feel ready to make. And so that causes some friction because for a lot of people infertility is the first crisis of their relationship and it can be hard to be in a crisis with someone you love who’s not responding in the same way or at the same time. And on top of that women with infertility often feel almost phobic about being around pregnant women or they live in fear of pregnancy announcements and so they are afraid to go to social functions if they suspect they’ll be a pregnancy announcement or they don’t want to go home for a holiday if their sister is pregnant. And men don’t tend to feel the same way; men seem to feel pretty immune to pregnancy announcement so the pregnancy and so that can cause friction between the couple because she may want to avoid events where they might be a pregnant woman and he may not want to avoid those events. So it affects their relationship it also affects their sex life because they’re often told when they should and should not be making love. People start to associate sex with failure and a lot of people once they move on to more high tech treatment say well why should we bother having sex because it doesn’t work anyway. It impacts their relationship with their family in all likelihood their siblings are getting pregnant and so their parents are probably talking a lot about their grandchildren.

And so a lot of my patients don’t want to go home for family functions because they don’t want to see their siblings with their children, they don’t want to see their parents being happy grandparents and so they start to isolate themselves. And the same thing with their friends you know all their friends are getting pregnant and when people get pregnant and have babies that’s all they talk about. And so often you’ll see this couple in crisis who start to pull away from family and friends. And so they don’t have social support. It could impact their job or career because many jobs these days involve travel and you can’t travel when you’re undergoing treatment. A lot of which actually are a lot of women are in jobs that involve children they might have chosen to become a teacher or a nanny or a pediatrician thinking that would be flexible with their own children. I’ve had patients who were obstetricians and nurse midwives and labor and delivery room nurses and so all they do all day is hear pregnant women complain and they can’t get away from it. Infertility can also affect an individual or couple’s financial stability. Because in the United States I think there are only seven states that include IVF coverage. And so there often are there’s friction between the couple about what should they pay for and not pay for. So it can affect their financial stability. And finally it can affect their relationship with God. We’ve done research on this and for a lot of people they feel like this is the first time God has an answer to their prayers and they feel like they’re good people they would be amazing parents and they see so many children out there in the world who are not appreciated by their parents and they can’t understand why God won’t give them a baby.

So if you look at it infertility impacts every aspect of their life. And on top of it the average person going through infertility hears from everyone, just relax you will get pregnant or you’re working too hard or go on vacation or just adopt. And the essential theme behind all of that is it’s your fault. You’re too thin to get pregnant you’re too stressed out to get pregnant which means they’re blaming the victim. And you would never say to a cancer patient just relax and your cancer will go away. No one would ever do that. So it adds to the the burden.

So let’s move on to Slide 6. So I think it’s pretty clear that infertility causes very high levels of stress in most people but the question then comes in does stress caused infertility. It’s controversial. It’s hard to assess it’s hard to do really good research. We know that women who have a history of depression are more likely to have infertility. There is a Director of Reproductive Epidemiology Ohio State who has shown that the more stressed a woman is the longer it takes her to get pregnant and the more likely she will experience infertility. What we don’t really know whether or not stress during treatment impacts treatment outcome. It is very hard to assess that because people tend to get optimistic before they start a treatment cycle and or women know their prognosis. And so a 44 year old with the higher FSH level is probably going to be more anxious before a cycle than a 25 year old who’s at this stage too. And so very hard to tease out those two things; do I personally believe that yes stress impacts treatment outcome. Yes I do believe that and that’s mostly because if you look at the Intervention Research it looks pretty clear.

So moving on to Slide 7. Before we even look at the impact of stress on treatment outcome nobody likes feeling stressed, it’s unpleasant to be depressed, it’s really unpleasant to be anxious. So it’s just not good to feel stressed. We also know that people who are stressed are much more likely to drop out of treatment, even people with insurance. And people who drop out of treatment because of their distress level are often faced with regret later in life. And so I don’t want to ever see somebody drop out of treatment because they’re too stressed to continue if we know that there are ways that we can pretty easily decrease their stress level.

So let’s look at Slide 8. So what can you do, what can you do to decrease your stress. And I have to say I think there probably been 35 or 40 randomized controlled studies looking at different psychological interventions and there’s a thing called a meta analysis where they sort of pool all the studies and the most recent one showed that women who are going through infertility, who do some kind of psychological intervention are far more likely to get pregnant and they experience much lower levels of distress. And that was a very good study it was out of Scandinavia, I can’t remember the country, it was in Scandinavia. They had very solid results and the intervention form that they thought was the most effective is called cognitive behaviour therapy. Cognitive therapy involves teaching people how to challenge automatic negative thought patterns, it’s a very proactive kind of therapy and the analyses before that have shown that interventions that are at least six sessions are more effective than shorter ones and they’ve also shown that interventions that provide skills so not just sitting around talking about how hard infertility is but teaching women skills which they can use to help themselves feel better or more effective.

( slide 9) I started the program in 1987 called the mind/body Program for Infertility. It’s a 10 session group treatment program for women at any stage of treatment and includes cognitive behavioral therapy, it includes relaxation training. We talk about lifestyle habits. We talk about the safety and efficacy of alternative approaches like acupuncture and there’s a lot of group support like women can walk into this group and say my younger sister is pregnant for the third time and everyone in the group would go oh my god we’re so sorry. That is exactly where she needed to hear. And we also have peer counselors who are graduates of the program who are really there as role models and we have a buddy system so everybody gets a buddy in the group.

Slide 10. Every session has like an optional first half hour is like a mini support group where people get a chance to tell their stories. We do a different relaxation exercise each week and there’s like a topic each week that could be self nurturance, it could be countering automatic negative thought patterns like I’ll never have a baby and we talk about how to cope with anger, shame and isolation.

Next slide 11. So we’ve done two large randomised controlled studies looking at the impact of the mind/body Program and the first one we looked at the take home baby rate and we found that women who did the mind/body program had a 55 % take home baby rate compared to 20 % under control and the controls are women who didn’t do any group, and mind/body patients also had significant decreases in anxiety and depression and then we followed up a few years ago with a study just on IVF patients and we found that when women did a mind/body program they had a 52 percent pregnancy rate compared again to a 20 percent pregnancy rate in the control group. So that’s pretty solid evidence that doing a mind/body form of intervention does seem to increase pregnancy rates and decreases distress.

 

Q: That is solid evidence 55% versus 20% that you just mentioned, that’s actually great evidence. Right?

A: Dr Domar: Well I was pretty happy when we did the data analysis I’ve sort of this has been my whole career. So I was pretty happy when we looked at the data of women who aren’t doing research with us but are just patients in our mind/body program, we have found that about a little over half get pregnant within six months. We’ve also shown that most of the women who come into the program have some kind of physical symptoms like insomnia or headaches or back pain or shortness of breath. And we found that they have about a 67 % reduction in those symptoms. And we’ve also a while ago followed women for two years and found that 95 % within two years became moms in one way or another. So there is some long term happiness there. And then we recently did had one graduate student whose dissertation was converting the in-person mind/body program into an online program and her preliminary results which she presented last year at the American Society of Reproductive Medicine showed that the women who are who did the online program again had significantly higher pregnancy rates and really nice decreases in negative psychological symptoms in the control group. So you know that’s an innovative way of doing it online.

So moving on to slide 14. We also did another randomised controlled study a couple of years ago that we published about two or three years ago where we actually just mailed women a packet of information on how to do some cognitive therapy and we included some relaxation exercises and that’s something where we did not see a difference in pregnancy rate but we did see the really lovely decreases in distress and the women who got the Stress Management packet were 67 % less likely to drop out of treatment and the goal of that study had actually been to look at the impact on treatment terminations.

So moving on I might be old but I have to sort of keep up with technology and about a year ago my colleague Dr Elizabeth Grill who’s a psychologist who’s the chief psychologist at Cornell Medical Center in New York, she and I wrote and created a new app called Ferticalm and the idea of Ferticalm is she and I, I think between the two of us, I think we’ve been seeing patients through over 40-45 years. And so we know what’s hard for our patients and so we came up with the 50 situations which are the most likely to cause distress like the little sister announcing she’s pregnant at a family function or being at work and getting your period or sitting in the clinic waiting to be called in. And we came up with cognitive behavioral and relaxation strategies for each of those situations. So the way the app works is I think on the next slide it sort of shows it. So let’s say you’re at work and you get your period you go in the bathroom you open the app and you can actually find that exact scenario and you push that pedal at the flower. And there are cognitive solutions, there are behavioral solutions. I think my favorite is called social solutions and it’s comeback lines for people who say stupid things. So basically gives you scripts on what to say. And the app has been licensed by Ferring Pharmaceuticals. So it’s actually free to download. I do not get paid per download so I feel very comfortable talking about the app. If anybody in the U.S. or Canada wants to download the app they just can go into their Apple or Android store, in the U.S. it’s also available in Spanish and in Canada, it’s available in French Canadian and they could use the app as they see fit. We don’t collect personal data everything is anonymous I promise you and it’s really nice for me because on weekends and evenings when my patients are in crisis they say that having the app makes them feel like I’m sitting in their phone. And so no matter what situation they’re in, they can find something on the phone. It also includes 10 relaxing guided relaxation in my voice.

So I had a patient the other day who’s flying and she got really anxious and she listened to the relaxation, she felt better. And we just two weeks ago moving on to Slide 17, released a new app because I think the only criticism we got for Ferticalm was that it was made for women, it is very clearly with pretty pastels, the flower and it’s very much directed for women and two weeks ago, we released a new app called Fertistrong and it’s basically the male equivalent. And so again you know Ferring licensed and so it’s free to download anywhere in the U.S.. Right now it’s only available in English but we’re working on that. And the idea is that these are men either for men with infertility or men whose partner has infertility. And it was written by two psychologists who have an expertise in men going through infertility and I’d say half of it is mind/body and relaxation skills for the guys. And half of it is what they can do when their wife is upset. So it is both. And we as I said we just launched. So I’m back on slide 18,  wrapping up so just to conclude we know that women with infertility experience know really significant levels of distress. We know that distress is really unpleasant and may or may not impact pregnancy rates. But we do know that psychological interventions are associated with lower levels of distress and higher pregnancy rates. And we are working to create new and innovative ways to address these issues through cognitive behaviour therapy and relaxation strategies that can be available on your phone. So that is my slide deck.

 

Q: The mind/body program on which the Ferticalm and Fertistrong apps are based is ongoing from 1987, like your slide shows, the efficacy of this program has already been proven by the randomized controlled studies. So are the doctors writing things like practice meditation or yoga or any other mind/body techniques for 15 minutes daily, on their prescription for patients? Are these apps prescribed to patients or if not then, how far are we in the position that they’ll be prescribing these apps to the patients?

A: Dr Domar: Well it would be my dream for physicians to prescribe medication or a mind/body group or an app to a patient. I think there are some physicians who were very in tune with their patients’ emotional health and in fact I was giving a talk at the American Society of Reproductive Medicine meeting and I was talking about psychological interventions and I don’t really feel all that comfortable talking about the apps because they’re mine and I don’t want to self promote. And so I wasn’t talking about the apps and in the middle of my talk, this physician stood up which is just not done at these meetings and she said I have to stop you. She says I think you’re being irresponsible not to mention Ferticalm and I was like wow, and she said have you heard of it, I said I co-wrote it and then she tells the audience that she’s a physician she’s an RE, a reproductive endocrinologist and she said that she has this new routine that whenever she has to do a procedure on a patient that might be painful or unpleasant she walks into the exam room she greets the patient she tells the patient to download the app and asks them to do one of the relaxations on the app. And then she says I’ll be back in 15 minutes. And she said it’s really changed how she delivers care. So I thought that was an amazing story. I don’t know how many physicians in the country are recommending the app to their patients. I obviously wish more would, because the feedback we have gotten from patients has been really nice. As I said they really feel like there’s a psychologist in their pocket and no matter what’s going on in their lives there is some proactive solution in the app that they don’t feel alone.

 

Q: So in one of your interviews I heard that you said that it’s mind/body techniques were a pill, every patient would take it and I believe that is so true. So can you shed some light on why is it so hard for people to get into the habit of inculcating these stress dissolving techniques into everyday life?

A: Dr Domar: Well I think there are a number of barriers. I mean, if there had been medication that led to the increases in pregnancy rates and the decreases in distress, if someone came up with a pill or even injection that created those positive changes, every infertility patient in the world would be taking that pill and especially if it was relatively cheap it had no side effects. And so it’s frustrating for me that I’ve spent 31 years of my career trying to convince people especially women and now physicians, that women need to be proactive, they’re things that they can do to help themselves feel better. They just you know need to take it. They need to take the time and again people, if there was a pill they’d be doing it. This is doing mind/body strategies takes time I mean doing the mind/body group takes a time commitment. It’s so interesting to me when I read the evaluations after women finished the program and almost everybody says you know this is the best thing I’ve ever done. I finally feel the way I did before infertility myself again. And I do tell people that for me the goal of the mind/body program is not pregnancy but the goal is to get their lives back, to be the person they were before infertility.

 

Q: The next question is on the denial issue. People often discount the fact that mental health actually directly affects physical health and mental issues like depression anxiety and bipolar disorder, people mostly think of it as their nature or anybody else’s nature and hence the denial problem. So how do you help such people in denial, when they might not be in a mood to go to a counselor at all?

A: Dr Domar: Well it’s almost like a catch 22 because when someone is feeling depressed they feel hopeless. And so when you’re feeling hopeless it’s very hard to be proactive. And in fact the vast majority of people around the world who are depressed, anxious, bipolar and never see a mental health professional. There is a sense of shame, there is a sense of embarrassment, there’s a sense of hopelessness as anyone can ever help you. And yet if you look at the research on the efficacy of all kinds of different interventions for infertility patients and others there are lots of things that are highly effective. I mean if you look at the data I am not a big believer in taking medication for depression when someone’s trying to get pregnant unless somebody has a really significant history. But if you look at the data on the efficacy for just depression of cognitive behavioral therapy or exercise or acupuncture these have efficacy rates of well over 50 % about the same as the efficacy of medication. And so I don’t think people should feel hopeless or helpless. I mean I have seen people who were just unbelievably depressed come either see me individually or more likely do the mind/body Program and within a month their depression really significantly left.

 

Q: What is one thing or an advice that you tell your patients with infertility related depression and anxiety that you have seen work in changing their frame of mind?

A: Dr Domar: Yeah everyone always asks me what the active ingredient is of the mind/body program because it’s cognitive behavior therapy and it’s relaxation strategies and it’s learning to express your emotions and adopting healthier lifestyle behaviors and it’s pursuing good alternative strategies and not pursuing bad ones. And this group support that’s really powerful and so people say well you know what’s the active ingredient and I like I don’t care, if it works why mess with it. And I think probably the answer is, different things work for different people. And I have had some people go wow that group support that’s exactly what I needed. I’ve had other people say oh it was the relaxation techniques like those are so valuable that other people say it was the cognitive strategies when they learn to think in a far less negative way. Some people say we have the partners come to three of the 10 sessions and some people say it was just my partner really learning about what I was going through. And now he really supports and respects me. I don’t think we can say what works. I mean the fact that the online program looks like it’s pretty darn effective, would actually suggest that the active ingredient is probably not social support. So there’s probably something to the cognitive strategies or lifestyle changes and the relaxation practice.

 

Q: Could you please talk a bit about latest research going on in the field of mind/body techniques?

A: Dr Domar: It’s a source of endless frustration for me that there aren’t more people certainly in the U.S. Europe tends to be ahead of us in terms of psychosocial research and infertility. And the European group is called Ashray and they tend to have much better research publications than we do in the U.S. Although I think for both organizations I can tell you that doing randomized controlled research trials is really tough. I mean in my 30 years of practice I’ve done three, I’m doing another small one now. It takes an enormous amount of money. It takes a huge amount of time and it’s really hard to recruit women with infertility to be in a randomized controlled trial because by definition it pretty much means half of them will get the intervention and the other half won’t. And it’s very hard to take people who are really distressed and say Hey thanks for volunteering you know we’ll see you in three months. That just doesn’t seem really good. So I think we probably need to do a little bit more research but when that meta analysis that came out a year or two ago which summarized 35 studies. I’m not sure how much more research we need to do that documents that women with infertility benefit enormously from psychological interventions. I think that’s sort of like a given now, like doing some kind of psychological or intervention is going to help you. It’s going to help you feel better psychologically and it’s likely to increase your chances of getting pregnant. I think what we probably need to focus on now is what’s the most effective mode of delivery. Like if somebody who lives far away from a mind/body group it’s not practical for her to do a mind/body group and we get that. So I think right now my body program looks like it’s showing some of the best results but it’s not practical for some people. We don’t have data on the apps and we’re not going to ever get data properly on Ferticalm because it’s out already. So unfortunately you know if we launched it before we had the time or the money to do a study on it we based it on previous research that had shown a huge impact.

 

Q: Many aches and pains that are rooted in brain processes that can be affected by your mental attitude and emotions. What do you think is the best way to tackle this?

A: Dr Domar: Well that is entirely right. I mean there is no barrier between the mind and the body. And as I mentioned earlier when we look at our mind/body patients – infertility mind/body patients almost all of them come in with headaches, neck pain, back pain, insomnia, abdominal pain, fatigue. Most of them don’t feel great and that’s most likely a manifestation of the stress that they’re experiencing. And so when we’re really stressed out, our body tells us it tells us by not allowing us to sleep well or by giving us headaches or shortness of breath or palpitations and so what I tell my patients is when you have these symptoms the current normal behavior is to take medication to treat symptoms. So if you have a headache you take ibuprofen or if you have a stomach ache you take something, if you have we tend to medicate our symptoms and when we really need to do is to stop and say ha I think my mind is trying to tell me something like If I’m not being well I can either pop a cup of Benadryl or I can stop and think ha why am I not sleeping well, what’s going on in my life. What do I need to do to be healthier.

 

Q: Work-related stress during pregnancy was my biggest challenge, so much so that I sought professional help from a psychologist for the first time in my life to help deal with it. My OB/GYN told me that stress during pregnancy was not recognized as a legitimate reason to request a medical leave from work. She said, “Women give birth to healthy babies in war zones. Stress isn’t a threat to your baby’s health.” I’ve read recently, though, that research is pointing to significant developmental problems in children when mothers are exposed to or experience stress during pregnancy. How worried/watchful should I be? My son is 7 and seems completely unaffected in any negative way so far.

A: Dr Domar: Well her son seems great and  I would be happy as a clam if I were her. The fact is it’s controversial about whether or not you know stress during pregnancy can lead to issues in the baby or children afterwards. As I said earlier feeling stressed is really unpleasant. So even if a study came out in five years showing that stress doesn’t have an impact on kids, I doubt that would happen but if it did it’s still unpleasant to feel stressed and pregnancy in and of itself is stressful. It requires enormous adaptations, physically, psychologically, financially, relationship wise and it’s a very very good time to learn mind/body strategies. We actually actually published a book a year and a half ago on mind/body strategies during pregnancy because I have some patients who are pregnant and who are really stressed out.

 

Q: Can you talk about how infertility can impact the women’s partner/husband? What can a couple do together to reduce their stress from their infertility? How can a couple stay connected and not divided while struggling with infertility?

A: Dr Domar: It’s a great question and I think that’s probably why we did the app for men because infertility as I said at the beginning can have a huge impact on the couple. And I do a lot of couples counseling and what you hear from them over and over again is I’m reacting this way and my partners react to you in a different way. He or she is wrong. And I think with infertility women tend to express a lot more distress than men do and they thus make the assumption that their male partner is not distressed. And I don’t think that’s a fair assumption. I think that men by definition don’t tend to express to stress the same way women do. There’s a lot of social pressure that men shouldn’t get depressed. And when I talk to men without their wives around they’ll say I’m just as upset she is. But one of things us needs to keep it together, if I react like she does, we’re going to fall apart. So they feel like they have to be the rock, like they have to be the solid person and they suffer they suffer in private. So on one of the later sessions of the mind/body program we have the men come and they go to a separate place with a therapist who asks the men how they’re doing and pour out their heart and soul because no one ever asked them. And Resolve which is a national infertility organization in the U.S. did a survey of men of partners, men experiencing infertility either themselves or in the partnership and basically ask them how distressed are you. And it was like unbelievable how distressed these men were. It’s really hard for them. They want a child and they’re seeing their wives be extremely upset and that’s a real problem for them and so I think that it’s amazing, it’s whatever she’s doing she’s thinking about her partner. She’s thinking about his feelings which is very sad. I think the first thing I tell couples is the way you’re reacting is the right way for you and the way your partner is reacting is the right way for him or her. Don’t try to change the way they’re coping. It’s the right way for him or her. It does not mean you’re right they’re wrong, just leave them be. Just respect the way they’re handling this right.

 

Q: My work didn’t know that I was going through infertility treatments. It was so hard on me to have to juggle being at the doctor 3 days a week, having to do suppositories while at the office and having to wear loose clothes cause the bruising on my stomach from the injections hurt so much all, while having to still do an awesome job at my work. So many of us don’t want to tell our bosses what we are going through, and should not have to, yet the hormones and stress deeply impacts us in all aspects of our life, especially work. What can others do?

A: Dr Domar: It’s a really good question I think I get asked this about once a week and how do I handle work. Because the fact is if you have a presentation tomorrow at 2:00 o’clock the clinic calls you guys at 1:30, it can cause a conflict. I can very much understand why people don’t want to share this with their boss or supervisor, it’s private. They don’t want to be discriminated against whose business is. On the other hand you also don’t want your boss to think you are goofing off or taking advantage or whatever. So I think you have to sort of assess your position within your job and also think about your boss, if your boss is a 41 year old woman with triplets, my guess is she might understand what you’re going through. If your boss is 95 year old man with 18 grandchildren, not so much. So I think you need to survey your work situation and be self-protective. I mean this infertility doesn’t last forever, it’s a temporary crisis and you need to figure out how can you be most self protective.

 

Q: I saw “unsuccessful cycle program” on your website. I went through several failed IVF’s and embryo transfers and I am financially and more so emotionally drained. I am terrified to go for another one. I don’t want to stop trying, but I am terrified. How can this program help?

A: Dr Domar: The Unsuccessful Cycle Program is not a programme it’s a free half hour with a psychologist. And basically what we do is we talk about what your experience has been, how you coped with your previous cycles, what worked for you and what didn’t work for you. And then we will provide you with some coping skills acquisition to use if you decide to do another treatment cycle.

 




  • T May 6, 2018, 2:40 p.m.  US/Eastern

    I saw “unsuccessful cycle program” on your website. I went through several failed IVF’s and embryo transfers and I am financially and more so emotionally drained. I am terrified to go for another one? I don’t want to stop trying, but I am terrified. How can this program help?

  • N/A May 4, 2018, 1:14 p.m.  US/Eastern

    Hi Shweta! Thanks for all of the awesome Infertility CureTalk Topics you do. Some questions: - Can you talk about how infertility can impact the women's partner/husband? What can a couple do together to reduce their stress from their infertility? How can a couple stay connected and not divided while struggling with infertility? - My work didn't know that I was going through infertility treatments. It was so hard on me to have to juggle being at the doctor 3 days a week, having to do suppositories while at the office and having to wear loose clothes cause the bruising on my stomach from the injections hurt so much all while having to still do an awesome job at my work. So many of us don't want to tell our bosses what we are going through, and should not have to, yet the hormones and stress deeply impacts us in all aspects of our life, especially work. What can others do? Thanks! Emily

  • N/A April 30, 2018, noon  US/Eastern

    Work-related stress during pregnancy was my biggest challenge, so much so that I sought professional help from a psychologist for the first time in my life to help deal with it. My OB/GYN told me that stress during pregnancy was not recognized as a legitimate reason to request a medical leave from work. She said, "Women give birth to healthy babies in war zones. Stress isn't a threat to your baby's health." I've read recently, though, that research is pointing to significant developmental problems in children when mothers are exposed to or experience stress during pregnancy. How worried/watchful should I be? My son is 7 and seems completely unaffected in any negative way so far.

  • F April 30, 2018, 5:22 a.m.  US/Eastern

    Many aches and pains are rooted in brain processes that can be affected by your mental attitude and emotions. What do you think is the best way to tackle this?