A Low-Tech Approach to Fertility: Just Relax

Dr. Sarah L. Berga has devoted her career to one of the most hotly debated subjects in the fertility business: getting pregnant without costly drugs. She is one of a handful of physician-scientist s exploring how chronic stress may keep some women from ovulating and how relaxation techniques may help. More precisely, these researchers are examining how chronic stress alters brain signals to the hypothalamus, the walnut-size organ that serves as the
master of ceremonies overseeing the delicately timed hormonal dance. Or as Dr. Berga puts it, she explores "how the hypothalamus talks to the pituitary that in turns talks to the ovary."
Her research suggests that a cascade of events, beginning with stress, leads to reduced levels of two hormones crucial for ovulation. And her published studies, small but scrupulous, are starting to convince her critics. In a study of 16 women reported in 2003 in the journal Fertility and Sterility, Dr. Berga showed that ovulation was restored in 7 of 8 women who underwent cognitive behavioral therapy, compared with 2 of 8 who did not get therapy. In 2006, in The Journal of Clinical Endocrinology & Metabolism, she reported that women who did not ovulate had excessive levels of cortisol, a stress hormone, in the brain fluid. Dr. Berga spoke recently about her research from her office at Emory University.

Q. You've studied not only people but also animals. What did those studies tell you about stress?
A. Before we did the 16-woman study, we studied monkeys. We found that when we stressed monkeys alone, 10 percent stopped menstruating temporarily. When we added exercise and limited their food intake, again about 10 percent stopped menstruating temporarily. But when we combined stress, exercise, and cut down on food, 75 percent became amenorrheic.

Q. Then you did a similar study in which two groups of women - one group with normal ovulation, the other group with stress-related amenorrhea - exercised almost to their full potential. What did you find?
A. We saw that if you are stressed when you start exercise, your body reacts differently than if you are not chronically stressed and exercise. Not only does it appear that exercise was more stressful for already stressed women, but certainly exercise did not help them lower their stress hormones, which is of course one reason people take up exercising.

Q. Today, you head a department at a prestigious university, which must help you promote your message. How was your research received initially?
A. With great skepticism. There are definitely more people now who endorse our work but there is certainly a group that doesn't want to believe it. Chronic stress, whether emotional or physical, taxes the body. We can accept that stress is linked to heart disease, but not to fertility.

Q. Are you saying that a woman who may have had a stressful month at work is hurting her fertility? Isn't life without stress impossible?
A. We are talking about chronic stress related to behavior or personality. People are designed to endure acute stress. That is a part of life. I am telling women, and men, that it is important to find a balance and learn to cope with their stress.

Q. Some of your work focuses on undereaters and overexercisers. Isn't it the nutritional state that is hurting the women, not their mental state?
A. Anorexia or excessive exercise can certainly make women stop menstruating. But I believe that many of these women undertake exercise or limit food intake to deal with stress. I believe that treating the underlying stress is more likely to encourage women to relax, eat healthier and exercise healthier rather than just telling women to change their diet and exercise regime.

Q. Do you hope that your research will change the way fertility treatment is administered? How would you want to see it change?
A. Ideally, it would be good for doctors and patients to understand the link between stress and fertility so that they would know when to offer some sort of intervention. For instance, cognitive behavioral therapy is a relatively simple and inexpensive 16-week program that sometimes removes the need for expensive and risky infertility drugs and procedures.

Q. It sounds as if you're against fertility drugs, which are a necessary component of in vitro fertilization.
A. We do I.V.F. in this department. I like to think we offer the least technology necessary to get the job done. I do think that with a certain population of women - women who may be infertile due to stress - benefit the least from I.V.F. Others absolutely need these drugs and procedures. I also believe that it is imperative that doctors communicate the risks of the drugs and help patients understand when they are and are not necessary.

Q. You have not studied the fetus as much as female hormones, but do you believe that stress hurts the fetus?
A. I do believe stress on the mother may imprint the fetal genome forever. There is some pretty solid animal research, done by other researchers, and some highly suggestive human studies. Other researchers have shown that stress decreases thyroxine levels, which controls energy availability. The mother is the sole source of thyroxine for the fetus during the first trimester of pregnancy and the major source of thyroxine for the second two trimesters. And thyroxine is absolutely vital for appropriate fetal brain development. I think doctors should tell women that if the maternal component is stressed, the fetal component will also be exposed to maternal stress hormones.

Q. In the 1940s, Freudian analysts told infertile women that lurking antimaternal thoughts made them sterile. Feminists later attacked this theory. Do you think of yourself as a continuum of this practice, or do you feel your ideas are completely different?
A. Back then they did not know the mechanisms and they intuited relationships, but they were not all wrong. They were closer to the truth than we'd like to believe. The truth is that if you are not in harmony with yourself and your culture, you are stressed. That is not totally different from Freud.

Q. Do you insist all of your patients have cognitive behavioral therapy before drug therapy?
A. I try to come at it from the perspective of suggestion. I went into women 's health to protect women's autonomy, so the last thing I would want to do is to make a decision for my patients without their input. At the end of the day, it's the couple who is trying to get pregnant who bears the most immediate consequences.

[NYT]