by Daniel Shapiro, M.D.
Infertility patients know this better than anyone- emotions go haywire during a fertility treatment odyssey. Pregnancy and the post-partum period can be just as bad, with extreme cases of post-partum psychosis making it into the news ever year with horrific stories of infanticide, suicide or homicide.
Little is understood as to why post-partum patients experience depression and related disorders, but the treatment paradigms are fairly well established. The overwhelming majority of patients with post-partum depression are treated successfully with selective serotonin re-uptake inhibitors (SSRIs) like Prozac or Zoloft. Mercifully, full blown psychosis is very rare so the need for more intensive medication is uncommon.
When identified quickly, post-partum depression can be treated efficiently and fully, with maximal benefit to the new mom, her partner and newborn.
Depression during pregnancy gets less attention than depression after pregnancy and depression while infertile gets less than both. For obvious reasons, many doctors are reluctant to prescribe anti-depressants during pregnancy and there is plenty of evidence that doctors are equally or even more reluctant to prescribe when a patient is in the midst of fertility treatment. My best guess is that we just don’t think about taking care of what’s going above the waist in a lot of these patients, and frankly, patients rarely ask. We in the REI community often find out a patient is ‘suffering the miz’ when she announces (usually suddenly) that she can’t take the stress anymore and quits or she drops out of sight with no explanation. Sometimes we learn about how bad the first go ‘round was because she shows up with a new husband.
There is data on anti-depressant use in pregnancy and the SSRIs are generally thought to be safe enough. Paxil is the exception to this as there does appear to be an increased risk of certain malformations in newborns when mom was on this drug. For Zoloft and Prozac however the effects on the newborn, if any, appear to be brief and behavioral, making these 2 drugs the preferred choices when the mother is clearly depressed. FOR ALL drugs in pregnancy, the benefit of being on the drug must clearly outweigh any known risks to a fetus and in all cases, the drug within a class with the least noxious risks to a baby should be chosen. This requires that the prescribing MD be well versed in the use of anti-depressants in pregnancy AND that a trained mental health specialist be the one to determine the severity of a patient’s psychological or psychiatric symptoms while pregnant.
Once a decision to start medication in pregnancy has been made, the patient should be carefully followed by the same care team that initiated therapy. A decision to stop anti-depressants in pregnancy should be considered just as carefully as a decision to start. Since patients with depression during pregnancy have at least a 25% chance of a post-partum depression, the care team needs to monitor medication after delivery and in some cases, increase the dose of medication or change the regimen.
As for the patient trying to conceive, the principles of treatment for pregnant patients usually apply. There are no known serious risks to treatment for depression on eggs or sperm, and frankly depressed people probably don’t have as much opportunity to get pregnant on their own as others. Who wants to have sex when they feel rotten?
As for patients who know they need an assisted reproductive technology, the anti-depressant drugs we commonly use don’t interfere with ovarian response, fertilization, implantation or embryo development. Makes sense that if psychological symptoms are interfering with a couple’s ability to achieve pregnancy that treatment for the symptoms will help. Anecdotally, I freely offer Prozac or Zoloft so long as the patient has a counselor who sees her regularly and agrees with the treatment plan. Another benefit to these 2 drugs in particular is that they have an anti-anxiety effect too, which could help an awful lot of patients going through fertility treatment. Though again there are certain minor risks to these two drugs in pregnancy, both can be continued after ART is successful.
Our task in the REI community is to ask about psychological symptoms as part of our regular evaluation. Though estimates vary, my best guess is that about 40% of our patients suffer needlessly during fertility evaluation and treatment and that depressive disease may account for a large and unappreciated part of our ‘failure to complete treatment’ rate.