Behavioural Therapy Can Restore Ovulation In
Infertile Women
June 21, 2006
Fertility can be restored in some women by the use of behavioural therapy, thus
avoiding recourse to expensive medicines and complex procedures, a scientist
told the 22nd annual conference of the European Society of Human Reproduction
and Embryology in Prague, Czech Republic on Tuesday 20 June 2006. Professor
Sarah L. Berga, from the Department of Gynecology and Obstetrics, Emory
University, Atlanta, Georgia, USA, said that her work was the first to show that
reducing stress through psychological intervention could restore ovulation in
women whose ovarian function had previously been impaired.
"Contrary to what had previously been believed", she said, "we
found that multiple small stressors that seemingly would have minimal impact on
reproductive competence can play a major role in causing anovulation. Up till
now it was thought that failure to ovulate was usually caused by the energy
deficits induced by excessive exercise and/or undernutrition, but we asked why
women undertake such behaviours. Often dieting and exercise are a way of coping
with psychosocial stress, and our previous work had shown that such stress is
often increased in women who do not ovulate."
Professor Berga and her team set out to study the causes of functional
hypothalamic amenorrhea (FHA) in women of normal weight who had not had a
menstrual period for more than six months. FHA is caused by a prolonged
reduction in gonadotropin-releasing hormone (GnRH), which signals the release
into the bloodstream of hormones that simulate ovulation.
Analysis of the cerebrospinal fluid in women with FHA, as opposed to women who
were ovulating normally, showed increased levels of cortisol, a hormone related
to stress. Chronic elevation of cortisol levels heightens the risk for other
health burdens, such as depression or osteoporosis, but chronic cortisol
increases can often be reversed with behavioural therapy
In a pilot study, Professor Berga's team randomised 16 women with FHA into two
groups. One group received cognitive behaviour therapy (CBT) for 20 weeks;
members of the other group were observed. "A staggering 80% of the women
who received CBT started to ovulate again, as opposed to only 25% of those
randomised to observation", said Professor Berga. "Neither group
gained weight nor showed significant changes in their levels of leptin, a
hormone involved in regulating body weight and metabolism. This study underlines
the important contribution that lifestyle factors play in determining overall
health and reproductive health in particular. To reverse stress-induced
ovulation, it is not enough simply to address metabolic sources of stress."
Professor Berga told the conference that the recovery of the stress and ovarian
axes appears to occur independently of major metabolic changes such as an
increase in leptin or thyroxine (a hormone that affects how cells use energetic
compounds). Since CBT caused a drop in cortisol and a rise in TSH, it may be
that the hypothalamic-pituitary-thyroid axis, involved in the regulation of
metabolism, recovers, but only later.
The current practice in the treatment of anovulatory women is to offer hormonal
treatments such as oral contraceptives, if immediate fertility is not desired,
or ovulation induction if it is. "Aside from cost, these approaches mask
ongoing endocrine disturbance", said Professor Berga. "Since these
disturbances pose a risk to overall health, it is important to use a therapy
that restores the endocrine system, including the reproductive system. Cognitive
behaviour therapy offers a holistic treatment that is safe, cost effective, and
easy to implement."
The team now intends to analyse further data from the pilot and to follow with a
multi-centre trial involving a large number of women. "If the larger scale
study confirms our earlier results," said Professor Berga, "we will
have very strong evidence for offering stress reduction as an effective therapy
for a significant group of infertile women."
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European Society for Human
Reproduction and Embryology
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