Infertility and anxiety: a cycle that feeds itself

Day nine. A faint twinge low in the belly. Is it a good sign or a bad one? The phone is already in hand, the search engine already open. The first result says it may be an early sign of pregnancy. The second, that it is a normal sign your period is on its way. The third is a forum where two hundred women describe two hundred different twinges. It is eleven at night. At two in the morning, the phone is still in hand.

If you have ever waited for the result of a treatment cycle or for the end of yet another month, you probably know this scene. Perhaps you know it from the other side too — as the partner lying next to her, not knowing whether to ask what’s wrong or to stay quiet.

Infertility and anxiety go hand in hand so often that people rarely separate them. But it is worth looking at them separately, because anxiety around infertility has a characteristic shape: a cycle that feeds itself. Uncertainty breeds worry, worry breeds checking, checking brings brief relief and then even more uncertainty. And on top of that, another thought often gets caught up in the cycle and spins it faster: “If I’m this anxious, I’ll never get pregnant.”

In this post I will explain how the cycle closes, what we actually know about the link between stress and infertility, and what you can do to loosen the cycle at least a little.

Anxiety with good reason

First, something important to say at the outset: anxiety around infertility is not an overreaction. In 2023 the World Health Organization estimated that roughly one in six adults experiences infertility at some point in their life. That is common. But being common doesn’t make it easier — every couple lives through it as if they were the only ones.

As far back as 1993, Alice Domar and colleagues compared the psychological distress of women with infertility with that of women with serious chronic illnesses, including cancer and heart disease. They found that levels of anxiety and depression in women with infertility were comparable. This doesn’t mean infertility is “the same” as cancer. It does mean that the distress it brings is serious, and not a matter of weakness or oversensitivity.

Infertility brings together almost everything that feeds anxiety: uncertainty with no end date, the sense that the outcome is out of your control, repeated waiting for an answer, and very high stakes. You can also find a short explanation of how infertility shows up as distress in the knowledge base under infertility and distress. I have described how assisted reproduction affects emotions more generally in Assisted reproduction and its emotional cost. Here I am staying with anxiety and its cycle.

How the cycle closes

Anxiety rarely stops at a single thought. It runs in a cycle with several stations:

1. Uncertainty. “Will it work?” There is no answer to that question until the test — and even the test is often just the start of a new wait.
2. Worry. The mind tries to resolve uncertainty by playing through every possibility in advance, especially the worst ones. We call this catastrophising; there is more in the knowledge base under catastrophising.
3. Checking and control. Watching the body, looking for signs, reading forums, testing too early, strict rules about food, exercise and sleep.
4. Brief relief. For a few minutes it feels as though you are doing something, as though you have things in hand.
5. More uncertainty. Checking doesn’t bring an answer. It brings new questions, new symptoms, other people’s stories. The cycle starts again, a little faster.

That is how the cycle feeds itself: every attempt to calm the anxiety also gives it something new to feed on. This isn’t a flaw of character. It is the mind’s understandable attempt to find at least a scrap of control in a situation that offers none.

The cruellest part of the cycle: “you just need to relax”

Almost everyone who has faced infertility has at some point heard a version of: “Stop thinking about it and it’ll happen.” Or: “Go on holiday, relax.” It is meant kindly. But it works like pouring oil on a fire. It adds another layer to the anxiety — fear of your own anxiety. You no longer worry only about whether a pregnancy will come, but also that your worry might be preventing it.

What does the research say? In 2011, Jacky Boivin, Elin Griffiths and Christos Venetis published a meta-analysis in the BMJ of prospective studies that measured women’s emotional distress before treatment and then followed whether they became pregnant. They found no association between distress before treatment and whether treatment succeeded. The authors wrote that this finding could reassure women who worry that their emotions might affect the outcome.

This doesn’t mean stress has no effect on the body at all — in a 2018 review, Kristin Rooney and Alice Domar describe the relationship between stress and infertility as complex, with research that isn’t consistent. But it does mean that the simple story “you don’t get pregnant because you worry” is too strong, and shouldn’t weigh on you further. Questions about what matters for your body and your treatment belong with your gynaecologist or the clinic where you are being treated — not on a forum at two in the morning.

So anxiety is a response to infertility, not a cause anyone should be blamed for. When you truly hear that, the cycle often slows a little already.

The two-week wait

The hardest part of the cycle is often the time between treatment and the test — or between ovulation and the expected period. People who have been through it often just call it “the two weeks”. It is a time when there is nothing you can do, yet the result is already written somewhere. For anxiety it is the ideal situation: lots of uncertainty, no influence.

Diana Lancastle and Jacky Boivin tested a simple intervention for this period: a card with short statements that help women positively reappraise the situation and find at least a scrap of meaning in a hard time. Women used it during the wait. The study was a feasibility study — it showed that such a simple tool is workable and that women accept it well. It isn’t a miracle cure, but it is evidence that even when you can do nothing about the outcome, you can do something for yourself.

Waiting has another trap: rumination — turning the same thoughts over without moving forward. Rumination feels like thinking, but it leads nowhere; I have described the difference between the two in Thinking isn’t solving. You can also find a short explanation in the knowledge base under rumination.

How the cycle shows up in everyday life

Anxiety around infertility rarely looks like a panic attack. More often it weaves itself into small everyday habits that each seem sensible on their own:

• watching every bodily sensation and looking for “signs”,
• reading forums and comparing your story with other people’s,
• testing too early and too often,
• ever stricter rules about food, coffee, exercise and sleep — not because a doctor recommended them, but because rules give a sense of control,
• avoiding people, events and conversations that might be reminders of pregnancy or children,
• poor sleep, because thoughts are loudest at night.

If you recognise yourself in any of these, it doesn’t mean you are “doing it wrong”. It means your mind is doing exactly what any mind does under prolonged uncertainty. I have described a similar pattern in Perfectionism and overthinking: two sides of the same fear — when we can’t control the outcome, we try to control everything else.

The conversation below is a composite (not a real person), but one I could hear in many a therapy room:

“I know it’s silly. But if I don’t check, I feel I’ve missed something.”
“And when you do check?”
“For five minutes it’s better. Then I find something new to worry about.”
“What do you think would happen if you didn’t check for one evening?”
“I don’t know. Maybe nothing. That’s the scariest part — that there’s nothing I can do.”

The last sentence holds the core. Checking isn’t so much a search for an answer as an escape from the feeling of helplessness. And helplessness is a feeling that has to be borne somewhere, not removed by more searching.

The cycle in a couple

Anxiety rarely stays with one person. In a couple, roles often split: one worries, the other reassures. “It’ll be fine.” “Don’t think about it.” Reassurance works for a few minutes, then the worry returns — and with each reassurance the cycle grows stronger, because the anxious partner learns that relief comes from outside. The reassuring partner slowly wears out and withdraws. And then the one who worries feels even more alone.

I have written about what a partner standing beside someone with anxiety can do in How to help someone you love with anxiety — without burning out. With infertility one thing applies in particular: comfort through promises (“it’s bound to work”) often does more harm than good. It helps more if your partner stays with you in the uncertainty rather than trying to remove it: “I don’t know if it will work. But I know I’m here.”

When anxiety builds up for a long time, it can also lead to one partner saying one day that they can’t go on. I have written about that in When your partner doesn’t want to continue treatment: what lies behind “I can’t do this any more”.

Exercise: a worry window

This exercise comes from cognitive behavioural approaches to anxiety. It is simple, but it takes some persistence. It doesn’t get rid of worry. It gives worry a place and a time, so it doesn’t take up the whole day. There is more on the technique in the knowledge base under worry postponement.

1. Set a window. Choose fifteen minutes a day, always at the same time and not just before bed — for example at six in the evening.
2. Write it down and set it aside. When a worry or an urge to check something comes up during the day, write it in one sentence on a note or in your phone and tell yourself: “I’ll come back to this at six.”
3. Return to what you were doing. Bring your attention back to whatever you were busy with. A few slow out-breaths can help, for example breathing with a longer out-breath.
4. Open the window. At the agreed time, read the worries you wrote down. For each one, ask: can I do anything about this now? If you can — for example, write down a question for the doctor — do it. If not, cross it out.
5. Close the window. When the fifteen minutes are up, stop, even if not every worry has been dealt with. Whatever is left can wait until the next day.

For the first few days it will seem not to work. The worries will push their way back. That is to be expected. The effect usually shows only after a few weeks, once the mind discovers that a worry won’t be lost if it waits.

Where this view falls short

This whole post is about how to loosen the anxiety cycle. But it matters to say what this approach can’t do, and where it would even be wrong.

Anxiety isn’t the enemy. Fear around infertility is a reasonable response to real uncertainty and real loss. The aim isn’t to feel nothing, but to keep anxiety from taking over your whole life. If anyone promised you that you would go through treatment calmly and without fear, they wouldn’t be telling you the truth.

Some worries are legitimate questions. Not every worry is catastrophising. If you are worried about pain, bleeding, side effects of medication or anything else to do with your body, that isn’t something to set aside for the worry window, but a question for your doctor. The worry window is for thoughts that go round in circles, not for symptoms that need checking.

When anxiety grows into something more. If you are having panic attacks, if you are barely sleeping, if you have lost interest in everything that used to bring you joy, or if checking takes up hours a day, it makes sense to see your GP or a psychiatrist. Sometimes medication helps alongside psychotherapy; I have summarised what the research says in Therapy or medication for anxiety. Any medication during fertility treatment must be discussed with the doctor treating you. If you are having suicidal thoughts, the Mental Distress Line is available on 01 520 99 00 in Slovenia (7 pm to 7 am), the Samaritan helpline on 116 123 in Slovenia (24 hours a day), and in an emergency call 112 in Slovenia.

When the answer lies in changing course. Sometimes anxiety isn’t telling you that you need to get better at waiting, but that the current pace is too much. A break between treatment cycles, a different agreement with your partner or a decision about how to go on may make more sense than yet another technique for managing worry.

What therapy can offer

In therapy we won’t remove uncertainty — nobody can. But together we can look at how your cycle turns: where it starts, what you feed it with, and what happens when you try to stop it. It often turns out that anxiety around infertility didn’t come out of nowhere. Sometimes it leans on older experiences — the sense that you must keep everything under control or it will fall apart, or that you have to be “good” in order to receive something.

In relational family therapy, the approach I am training in, we look closely at exactly these links between present distress and the patterns we carry from our families. Once you recognise them, the anxiety doesn’t disappear, but it becomes more understandable — and less something to blame yourself for. You can come to sessions on your own or as a couple; they take place in person in Ljubljana, and I also work with English-speaking clients.

If you recognise that nobody notices your anxiety from the outside because everything still works, you may also relate to High-functioning anxiety.

What to remember

• Anxiety around infertility is a reasonable response to prolonged uncertainty, not a sign of weakness.
• The cycle feeds itself: uncertainty, worry, checking, brief relief — and then even more uncertainty.
• A meta-analysis of prospective studies found no link between distress before treatment and its outcome. Your worry isn’t to blame for the outcome.
• A worry window, written questions for the doctor and presence instead of promises loosen the cycle without denying the fear.
• Panic attacks, insomnia or loss of interest are reasons to see a doctor; worries about your body belong with your gynaecologist, not on a forum.