Obesity, Trauma & Infertility​

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• Because the brain and body are directly affected by stress and trauma, some physical health issues may appear in patients with PTSD. Two physical changes to the body that may be the result of  abuse are obesity and sexually transmitted disease which are both reported at higher rates in women with PTSD. (11)

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• Obesity falls in both physical and behavioral health categories of PTSD related issues. Physically, obesity may be the body’s reaction to stress. Physiologically, stress induces elevations in glucocorticoids (cortisol) which may promote food intake and obesity as well as hormone imbalance caused by elevated corticotropin-releasing hormone consistent with increased activity of the HPA axis in traumatized individuals. (3).

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• Obesity may affect infertility and reproduction in women by affecting ovulation and interfering with outcomes of A.R.T. Longer periods of ovarian stimulation and higher cancellation rates of follicular asynchrony have been found in obese patients undergoing IVF (14). Research into obesity and infertility reported menstrual disturbances were four times more common in obese women and it appears that even high normal to slightly overweight BMI levels have an effect on fertility (13).

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Inflammation, Sexual Trauma & Infertility

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• Another common cause of infertility in women, tubal factor infertility (TFI) is due to an inflammation of the epithelial surfaces in the fallopian tubes and subsequent pelvic-perionatal adhesions. Several sexually transmitted diseases including Chlamydia Trachomatis and Neisseria Gonorrhea have been linked to this type of inflammation, both of which are most commonly caused by previous or persistent infections (18). Trichomoniasis, BV, Gonorrhea, and Chlamydia infection are the most frequently diagnosed infections among women who have been sexually assaulted (16).

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• While thorough screening for STD’s is conducted as part of A.R.T. practice, it is worth noting that the cause of the infection in some cases may suggest undisclosed past trauma. Reproductive endocrinologists and medical staff should be aware that more patients than they think may have a significant trauma history.   

• Exposure to childhood stressors is associated with diminished ovarian reserve and function as well as reported infertility and reduced probability of achieving pregnancy in one menstrual cycle (6).

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• Because PTSD has been linked to neuroendocrine alterations (dysregulation of cortisol, altered functioning of the HPA axis, vasopressin, oxytocin, etc.) (11) PTSD is likely to affect ovarian function and menstruation (1).

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• Menstrual cycle is regulated by the hypothalamic gonadotropin-releasing hormone which may be inhibited by hormones released by the hypothalamic-pituitary-adrenal (HPA) axis in response to stress (6). 

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• Activation of the HPA axis during times of stress and/or fear increases survival processes (blood pressure, flow of blood to muscles, circulating levels of glucose) while decreasing processes related to nonessential functions to conserve energy (1) effecting reproduction via decreased ovarian function, and menstrual cycle irregularities.

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• One study (6) illustrated that as the number of adverse childhood experiences increased, the risk of fertility difficulties also increased.

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• Overall, the risk of fertility difficulties increased by 6% for each additional ACE experienced but specifically, sexual and physical abuse showed the strongest associations with fertility difficulties (6). 

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• Because abnormalities in menstrual cycle have been associated with various types of infertility, the connection between menstrual function and PTSD may be an important factor to assess for in reproductive endocrinology practice.

PTSD has been linked with a variety of behavioral health risk factors.

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• Approximately one fifth of individuals with PTSD will use alcohol, drugs or both to reduce their symptoms (9).

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• People with PTSD are more likely to use substances in response to negative emotions and triggers. 

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• Some mental/behavioral health co-morbidity factors include smoking, alcohol consumption, drug use, and eating disorders) all of which can affect fertility in women.

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• Tobacco use, alcohol misuse, marijuana use, and opioid use and misuse can all affect the female reproductive system so while women with PTSD are more likely to use substances as a way of self-medicating or coping with stress and trauma, these same women are also more often seen by reproductive endocrinologists and may be more likely to have worse outcomes from fertility treatments than women without Substance Use Disorders (SUDs) (20).

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Smoking has been found to significantly impact fertility (8)

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• Menopause occurs one to four years earlier in smoking women than in non-smokers.

• Chemicals in cigarette smoke appear to accelerate follicular depletion and the loss of reproductive function. Mean gonadotropin dose requirements for smokers receiving stimulation for in-vitro fertilization (IVF) are higher when compared to those of non-smoking women

• and overall the percentage of women who experience conception delay for over 12 months was found to be 54% higher for smokers than nonsmokers. (17).

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Alcohol use even in moderation can effect fertility

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• Alcohol use disorders are associated with amenorrhea, anovulation, luteal phase disruption, hyperlactatemia, and increased risk of spontaneous miscarriage (20).

• Alcohol disrupts normal menstrual cycling. Alcoholic women are known to have a variety of menstrual and reproductive disorders, from irregular menstrual cycles to complete cessation of menses, absence of ovulation and infertility (4).

• Alcohol ingestion, even in small amounts can disrupt the delicate balance critical to maintaining human female reproductive hormonal cycles and result in infertility, anovulation which was associated with a reduced or absent pituitary LH secretion.

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Marijuana use and fertility

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• Marijuana use has been shown to increase menstrual irregularity as well as decrease oocyte (egg) retrieval and opioids have a direct effect on the hypothalamic pituitary axis thus increasing the incidence of oligomenorrhea (frequent menstrual periods) and irregular menses.

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Opiate use and fertility

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• Opioids have a direct effect on the hypothalamic-pituitary axis thus increasing the incidence of oligomenorrhea and irregular menses (20). 

• Some forms of childhood trauma are significant predictors of eating psychopathology, specifically emotional abuse (7).

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• Sexual and emotional abuse may be a predictor for perfectionism, problems with impulse control and emotion dysregulation which may contribute to disordered eating.

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Being underweight or overweight may affect fertility.

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• Eating Disorders typically affect women at peak age of reproductive functioning. Patients frequently present by means of physical sequalae, rather than the disorder itself. One study found 16% of patients in an infertility clinic had a primary, hidden eating disorder (10).

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Menstrual cycle

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• Primary or secondary amenorrhea results from hypogonadotropic hypogonadism in anorexia.

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• Anorexic patients present with a reduced response to LHRH, and clomiphene and menstrual abnormalities in anorexia reflect loss of body fat below the necessary threshold for fertility due to caloric restriction, excessive exercise or stress (10). 

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Ovarian Function

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• Ovarian function is also down regulated in anorexic patients as there is a correlation between BMI and ovarian dysfunction high and low. Infertility may be the body’s response to weight gain or weight loss due to an eating disorder secondary to the patient’s experience of trauma (10). 

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• It is hypothesized that due to stress related hypothalamic–pituitary–adrenal (HPA) axis dysfunction, earlier victimization experiences recalibrate stress response systems and may contribute to sensation seeking and self-destructive behaviors explaining some of the behavioral changes in victims of abuse that increase the risk of substance use/abuse and the perpetuation of anorexia nervosa and binge-type behaviors (Bulimia Nervosa and Binge Eating Disorder) (2, 10, 7).