Psychogenic infertility is the absence of pregnancy for 12 months of regular sexual life without protection, due to psychological reasons. It is manifested by the impossibility of conception against the background of somatic well—being, constant control of ovulation, sexual activity and the success of fertilization, hysteria during menstruation, less often – oligomenorrhea, opsomenorrhea, amenorrhea. It is diagnosed by excluding other forms of infertility with subsequent psychological counseling. Psychotherapeutic techniques, sedatives, antidepressants, tranquilizers, physiotherapy, ART are used for treatment.
N97.8 Other forms of female infertility
Psychogenic (psychological, idiopathic, functional) infertility is diagnosed in 5-10% of women who cannot get pregnant. Its key feature is the absence of obvious reasons preventing conception. The risk group consists of wealthy 30-35-year-old women with pronounced masculine qualities, focused on professional growth and career building, as well as emotionally immature patients who depend on their environment. A serious problem is the combination of psychogenic infertility with other forms of infertility: according to the results of observations, 35-40% of infertile women, in addition to organic pathology, reveal psychological factors that reduce the effectiveness of therapy.
Functionally conditioned inability to get pregnant is associated with the action of factors affecting the central links of neurohumoral regulation of menstrual and reproductive functions. According to the observations of specialists in the field of obstetrics and gynecology, the main prerequisites for the occurrence of idiopathic infertility are usually:
- Physical and psycho-emotional stress. As a result of prolonged fatigue, nervous conditions at home and at work, social insecurity, a woman is in a state of chronic stress. Hormonal changes characteristic of stressful situations have a retarding effect on the release of gonadotropins, change the activity of the parasympathetic and sympathetic parts of the autonomic nervous system. The extreme degree of neurohumoral imbalance is stress inhibition of ovulation and the development of psychogenic amenorrhea.
- Obsessive desire to get pregnant. The inability to conceive and give birth to a child is one of the most severe traumatic situations for a woman. Constant monitoring of physiological processes with constant negative pregnancy tests provokes the occurrence of chronic stress that disrupts the neuroendocrine regulation of reproductive function. At the same time, the attitude to intimate relationships as a “medical procedure” worsens the quality of the patient’s sexual life and provokes the development of stagnant phenomena in the pelvic organs.
- Fears related to pregnancy and motherhood. Fear of gestational complications, pain in childbirth, responsibility, concerns about changes in figure and weight, doubts about the ability to become a good mother, to provide the child with everything necessary can form a dominant focus in the cerebral cortex that prevents conception. A similar effect is possible with experiences associated with the violation of important career, household, personal plans, or subconscious resistance to the pressure of relatives insisting on the need for pregnancy.
Research in the field of reproductology has revealed a number of personality-psychological and interpersonal-family characteristics that increase the risk of psychogenic infertility. Such women are significantly more likely to assess their own and their parents’ marriage as failed, differ in emotional restraint and practicality. They are prone to dominance, isolation, rivalry, suspicion, anxiety, tension, depression, conservatism and rigidity of judgments. In sexual relations with a spouse, the leading ones are jealousy, greed, scrupulousness, selectivity, which worsen with age. Compared with women suffering from other forms of infertility, patients with psychological infertility have a less pronounced need to feel loved, they consider themselves less expressive, gentle, sexual.
The mechanism of development of psychogenic infertility is common, regardless of the reasons that caused it: neurochemical changes at the level of the central nervous system have a systemic regulatory effect on the entire body, including the reproductive organs. Neuro-humoral disorders in women with idiopathic infertility are similar to the processes occurring during a stress reaction. In fact, such patients experience maladaptive somatization of stress. The situation is aggravated and supported by the formation of a reproductive hyperdominant — a cortical dominant focus of tension that maintains an imbalance in the work of subcortical structures.
In response to stress, as a result of activation of the hypothalamic-pituitary-adrenal mechanism, the level of cortisol and ACTH increases and at the same time the secretion of gonadotropic releasing factors is inhibited. A decrease in the secretion of follicle-stimulating and luteinizing hormones disrupts the secretion of estrogen, ovulation and progesterone production. Prolactin also has an anovulatory effect, the synthesis of which increases under stress. In the most severe cases, the failure of neurohumoral regulation leads to the occurrence of dysfunctional uterine bleeding and psychogenic amenorrhea.
Against the background of hypoestrogenism, the cervical mucus becomes thicker and more viscous, its acidity increases, which prevents the penetration of spermatozoa into the uterus. Compaction of the protein membrane of the follicle disrupts the ovulation process, and a change in the characteristics of the egg membrane reduces the likelihood of fertilization. Insufficient progesterone levels in combination with a stressful increase in adrenaline levels provoke a violation of the functional activity of the atrial epithelium and peristalsis of the fallopian tubes, spasms of smooth muscle fibers, increased uterine tone, which prevents the normal passage of the egg and its implantation after fertilization. In some patients, pathophysiological processes are transient, which complicates their detection by laboratory and instrumental methods.
Symptoms of psychogenic infertility
With psychological infertility, women complain about the inability to get pregnant during a year of regular sexual activity without contraception in the absence of any somatic complaints. A characteristic feature of the disorder is the “pregnancy waiting symptom”: constant monitoring of the timing of ovulation, increased sexual activity in the middle of the menstrual cycle, daily conception tests before the expected menstruation, hysterical excitement at the beginning of the next menstruation. Patients with psychogenic infertility often have low self-esteem, are prone to anxiety-depressive reactions. Some women have opsomenorrhea, oligomenorrhea. In 5% of cases, psychogenic amenorrhea is observed.
Prolonged inability to get pregnant in the absence of organic pathology is a prerequisite for the development of neuroses, psychogenic depressions, obsessive states. Functional neurohumoral disorders can reduce the effectiveness of assisted reproductive technologies (ART) used to overcome the problem of infertility. In some patients, a false pregnancy may occur. The attitude to sex as part of treatment worsens the quality of intimate life: a woman with psychogenic infertility has a decreased libido, anorgasmia is more often observed. Maintaining a negative emotional state during pregnancy increases the likelihood of its termination by spontaneous miscarriage or premature birth due to increased uterine tone.
The diagnosis of psychogenic infertility is justified only if other types of infertility are excluded — tubal-peritoneal, uterine, cervical, endocrine, immunological, male. The patient is shown a comprehensive examination that allows an objective assessment of the state of the internal genitals, hormonal background, psychological state. Recommended research methods for suspected psychogenic infertility are:
- Gynecological examination. During the examination on the chair, any pathological symptoms are not determined. The uterus and appendages are painless, have the usual size, consistency, surface. There are no visible signs of inflammation of the mucous membrane of the vagina and cervix.
- Gynecological ultrasound. The study makes it possible to exclude congenital and acquired pathology of the genitals. Ultrasound of the pelvic organs is supplemented with color Doppler mapping to assess the characteristics of the organ blood supply, folliculometry to control ovulation. In difficult cases, CT and MRI are prescribed.
- Hormonal studies. In the psychogenic variant of infertility, the levels of cortisol, ACTH, prolactin may be increased, the concentrations of estradiol, progesterone, FSH, LH may be reduced. After the onset of menstruation, due to another unsuccessful attempt at conception, an increase in the content of catecholamines is possible.
To exclude organic pathology, ultrasound hysterosalpingoscopy, assessment of the follicular reserve of the ovaries, examination of the patency of the fallopian tubes (echohydrotubation), hysteroscopy, diagnostic laparoscopy, postcoital test of cervical mucus, smear on flora, instrumental studies of the skull and brain can be used as additional methods. An important role in the diagnosis of psychogenic infertility is played by the consultation of a psychologist who identifies the fears and hidden motives of the patient, assesses the level of her emotional response. If necessary, in addition to the obstetrician-gynecologist and reproductologist, the woman is examined by an endocrinologist, neurologist, infectious disease specialist, phthisiologist, oncologist. The patient’s husband is undergoing laboratory and instrumental examination by an andrologist.
Treatment of psychogenic infertility
Medical tactics are aimed at reducing the level of stress response, restoring a normal emotional background, correcting psychological problems. Often, functional forms of infertility are characterized by high therapeutic resistance and require long-term complex treatment. A woman with signs of psychogenic infertility is recommended:
- Destruction of the reproductive hyperdominant. Conception often occurs after the infertile patient ceases to concentrate on the impossibility of getting pregnant. In some cases, switching to new tasks — IVF, adoption, the use of surrogate mother services — contributes to the restructuring of neurohumoral regulation and the onset of pregnancy. Distraction to bright positive emotions (travel, family vacation in an unusual place, etc.) can be effective.
- Reducing stress levels. In case of idiopathic infertility that has arisen against the background of constant overloads, it is recommended to reduce the volume of work and household duties, adjust the work and rest regime, normalize night sleep. The rejection of ovulation control is often positive. Sedatives, tranquilizers, antidepressants, physiotherapy (magnesium electrophoresis, electroson, hot tubs, etc.) can help women with severe emotional disorders.
- Psychotherapeutic effects. Working with a clinical psychologist or psychotherapist allows you to accurately identify and then eliminate psychological blocks (fears, secondary benefits from infertility, interpersonal conflicts, etc.) that prevent conception. Depending on the personal and characterological characteristics of the patient, different methods are used: cognitive behavioral therapy, psychoanalytic sessions, body-oriented effects, gestalt therapy, art therapy.
Drug stimulation of ovulation in psychological infertility may be ineffective due to hormonal imbalance and concomitant functional disorders in the reproductive organs. In persistent forms of psychogenic infertility after correction of psychoemotional disorders, assisted reproductive technologies (stimulation of superovulation, artificial insemination, IVF, participation in the surrogacy program) are shown.
Prognosis and prevention
Despite the functional nature of the disorder, the restoration of fertility in the psychological form of infertility is considered one of the most difficult therapeutic tasks in reproduction. Achieving positive results is possible only with an integrated approach combining properly selected medical and psychological effects with lifestyle changes. Primary prevention of psychogenic infertility has not been developed in detail. A balanced work schedule, sufficient rest, a positive worldview, and the maintenance of friendly family relationships are considered useful for maintaining fertility.