Keeping intimacy alive

July 27th, 2020


As a couples counsellor specializing in premarital counselling, I love talking about relationship resources and tools.  

Couple in Bed

In previous weeks in this relationship series of videos, I spoke about communication and about conflict resolution.  Please feel free to check those videos out if you haven’t already.  Today I will be talking how to keep the flame alive in your long-term relationship, especially once little ones arrive on the scene.  

In the coming weeks, I will also be doing videos on other key topics in relationships, including:

4/ Boundaries (Cloud and Townsend)

5/ Adult Attachment (Susan Johnson)

6/ Love Languages (Gary Chapman)

7/ How to manage the inevitable struggles in a relationship (John Gottman)

8/ Personality Differences (MBTI)


So, let’s talk about sex.  At first in a relationship, it can be sizzling.  And then maybe you find that it just simmers down and possibly then down to nothing.  Why is that?  

Please click on this link to see my vlog on keeping intimacy alive:

It could be because you both get so caught up in the day to day demands of life that time just gets away from you.  It could be that it has started to get monotonous and routine and so you’ve lost interest.  It could be that once you had kids, all the focus was on them and you never quite went back to the sex life you once had.

In Esther Perel’s book, “Mating in Captivity,” she explains that “Family life flourishes in an atmosphere of comfort and consistency.  Yet eroticism resides in unpredictability, spontaneity, and risk” (p.128).  So it’s not surprising then, that when you are providing a stable home environment for your children, the spontaneity that sex thrives on is zapped out of the picture.  But it doesn’t have to be that way.  Believe it or not, children not only thrive in an atmosphere of consistency, but they also thrive in an atmosphere where their parents are emotionally and physically connected.  

It is normal for initial passion to give way to a deeper, more meaningful love.  It is possible to have both a deeper respectful love AND keep the sizzle. 

Whatever the reasons are that the love life has dwindled, it doesn’t have to stay that way.  If you are intentional about keeping the love and affection alive in your relationship, you can do it!  

Whether or not you have children, it is so important to create space and room in your schedules to focus in on each other.  It doesn’t necessarily mean sex right away.  It can mean spending a date night once a week where you can just reconnect and talk – but be sure to talk about anything other than kids!  I have met so many couples who don’t even know what to talk about anymore if they can’t talk about kids.  For those couples, I love to recommend Gary Chapman’s book, “101 Conversation Starters for Couples.”

And guess what happens when you reconnect emotionally?  You also reconnect physically!  The two go hand in hand.  It is not uncommon for men to need the physical first in order to feel emotionally connected, and women to need the emotional first in order to feel ready physically.  Both sides need that nurturance. 

So, to summarize, schedule in and protect that couple time on a regular basis, and be sure to nurture both the emotional and the physical connection.     

Hope this was helpful.  Let me know if there are any other relationship videos that might be useful to you.

Be Well,


No Comments »

Conflict Resolution Strategies

July 20th, 2020

Hi there!

As a couples counsellor specializing in premarital counselling, I love talking about relationship resources and tools.  

Last week I spoke about communication, specifically active listening.  Be sure to check out that vlog.  In this vlog, I will share some conflict resolution strategies, including taking a time-out, apologizing, and my favourite conflict resolution exercise that I use with my couples – The 10 Steps to Conflict Resolution.  It is part of the Prep-Enrich program that I use with my premarital couples.  

Couple Boxing Gloves

In the coming weeks, I will also be doing videos on other key topics in relationships, including:

3/ Intimacy and keeping the love alive (Esther Perel)

4/ Boundaries (Cloud and Townsend)

5/ Adult Attachment (Susan Johnson)

6/ Love Languages (Gary Chapman)

7/ How to manage the inevitable struggles in a relationship (John Gottman)

8/ Personality Differences (MBTI)


When I first decided to open my private practice, Prep-Enrich was the first training I did.  My husband and I were actually on vacation in Florida in September 2011 and he graciously agreed for me to take a day from our vacation to take this training.  I had written a few papers on premarital counselling prior to that, and really loved how useful and effective it is for couples. 

I love the idea that an ounce of prevention is worth a pound of cure.  We do not tend to learn these relationship strategies in school or even at home, so I feel it is invaluable for any couples to really take the time to invest in their relationship in this way.  There are tools that couples can learn at any point in their relationship that can bring them closer, enrich their bond, and help them navigate the inevitable challenges that they will face.    

Click here to see my vlog on conflict resolution:

If you ever want to get into a conflict with a loved one, just try hanging wallpaper together or do some kind of home renovation!

Last week, my dad came over to help me put wallpaper up in my dining room. We were arguing about how to hang that first crucial strip of wallpaper, and in the middle of that, I then had to go into an appointment.  It was actually my own therapy session that I had booked weeks ahead.  As much as it was an interruption to our wallpaper project, the timing ended up being a blessing in disguise, because it gave me a necessary emotional break.  

That time-out was an opportunity to process what was happening and reflect.  I returned much more calm and realized I was not exercising two important fruits of the spirit – patience and kindness.  So, I went back to my dad and apologized, and we finished the project in a much better emotional space.  By the end we got into a really good rhythm, and we felt so pleased with the new beautiful wall design.

So, if you ever feel that you get heated with a loved one try: 1/ taking a breath, 2/ taking a few moments away as a time-out to gain perspective and clarity, 3/ apologize if needed, 4/ forgive each other and 5/ move forward.  

If it is a larger issue or point of disagreement, try the 10 Steps to Conflict Resolution.  This is how I use it:  

1/ Decide on a good time and place to have a discussion about what you might have a difference of opinion on.  This is crucial so that you do not try to have an important conversation when one of you is in a rush, tired, hangry or distracted, etc.

2/ Figure out what the actual problem is and describe it in detail in one sentence.  Sometimes couples are fighting out two different things, so really take the time to define what the actual issue is.

3/ Describe how each of you contribute to the problem.  That’s right, it takes two to tango!

4/ List some ways that you both tried to resolve the issue in the past that did not work out well.  This helps to avoid repeating past mistakes.

5/ Step 5 is the crux of the exercise – brainstorming potential solutions to the problem.  No idea is outlandish, everything is on the table.  Just write them all down without thinking too much about it.

6/ Look at each of your brainstormed items and discuss the pros and cons of each.

7/ Decide on one (or two) best solution(s) to try.  I say it could be two, as sometimes one solution involves a second one.

8/ Figure out what each of you will do to work towards that solution.  Remember that whole it takes two thing?

9/ Arrange a follow-up meeting to discuss how the solution went.  Schedule in the date, time and location of the follow-up meeting during your initial brainstorming session.

10/ During your follow-up meeting, review your progress.  Congratulate each other on a job well done if you feel it went well.  If it did not go so well, then go back to the drawing board of the brainstormed items and decide on another plan of attack to the solution.  Work as  team to continue this process until you feel that a solution has been made.

Hope this was helpful.  Let me know if there are any other relationship videos that might be useful to you.

Be Well,


No Comments »

Communication Exercise – Vlog Series on Relationships

July 13th, 2020

As a couples counsellor specializing in premarital counselling, I love talking about relationship resources and tools. 


I was recently a guest on Dr. Talia’s podcast, called The Good Mood Podcast.  We spoke about various topics on relationships, and that inspired this relationship series vlog.  So in the coming weeks, I will be doing videos on key topics in relationships, including:

1/ Communication (Prep-Enrich)

2/ Conflict Resolution (Prep-Enrich)

3/ Intimacy and keeping the love alive (Esther Perel)

4/ Boundaries (Cloud and Townsend)

5/ Adult Attachment (Susan Johnson)

6/ Love Languages (Gary Chapman)

7/ How to manage the inevitable struggles in a relationship (John Gottman)

In this vlog, I will share my favourite communication exercise that I do with my couples – Active Listening.  It is part of the Prep-Enrich program that I use with my premarital couples.  

To see my vlog, click here:

This is how I use this exercise with my couples:

1/ make sure each of you have a piece of paper and pen

2/ write down three things that you want more of or less of in your relationship

3/ take turns sharing each of your three items

4/ when sharing, make sure that you have a quiet space free of distractions.  Tv is off, phones on silent.  

5/ share without interruption

6/ the speaker talks as long as they need to in order to share their point

7/ be tuned into what the speaker is saying, be respectful, be engaged

8/ the speaker can use “I statements”, such as “I would feel loved and nurtured if we had more quality time together”

9/ when the speaker has finished sharing their point, the listener feeds back what they heard the person say.  For example, “So what I heard you saying was that you would appreciate more time together.  If we did that, you would feel good, more loved and nurtured.”

10/ check in with the speaker – “did I hear that right?”.  The speaker can then say that yes they were accurate in their summary, or no they missed one part, or no they misunderstood and so then to explain the point again

Hope this was helpful.  Let me know if there are any other relationship videos that might be useful to you.

Be Well,


No Comments »

Summary of Self-Care Ideas

July 6th, 2020


This is the last of my self-care video series, that was inspired by all of the things going on in the world today. With all the stress and uncertainty in our society, we could all use a little more self-care these days.


Please feel free to check out my previous videos on self-care. Self-care series: 1/ box breathing 2/ progressive muscle relaxation 3/ grounding 4/ visualization 5/ Interview with Naturopathic Doctor, Dr. Talia, on why self-care is important, self-care ideas, and the chemistry behind self-care.

This video summarizes some of my favourite self-care strategies

In this video, I talk about yoga, colouring, mindful walking, mindful eating, photography, prayer/meditation, art, drawing, vision boards, walking barefoot in the sand (grounding), forest bathing/ hike in woods, mani/pedi/facial (spa time), massage, chiro, playing with my son, time with friends, baking, trying new vegan/plant-based/whole foods recipies, good healthy food, comfort foods, biking, the beach, being in nature, reading, regular consistent sleep, day trips, positive affirmations, limiting news, exercise including a punching bag, journalling, gratitude log, retreat, movies, appreciate beauty/art, relationship with God, listening to podcasts, watching Netflix (Netflix Party w friends), time with my dog, deep breathing, bubble baths, and utilizing support network.

Please feel free to let me know what some of your personal favourite self-care strategies are.

Be Well,





No Comments »

Self-care ideas, why it’s important and the chemistry behind it – interview with Dr. Talia

June 29th, 2020

Hi there!

Dr Talia Self-Care Workbook

This is part of a video series on self-care.  Please check out my other videos on box breathing, progressive muscle relaxation, grounding and visualization that are part of this series.  I had the pleasure to hold an interview with Dr. Talia Marcheggiani, a Naturopathic Doctor based in Toronto, who specializes in mental health.  She wrote a workbook on self-care, and you can find the link for that below   

Click here to see the interview:

Here are some of the take-aways from our interview:

1/ Self-care ideas – being outside in nature, good healthy eating, having a dog/time with animals, sleep, surfing, yoga, meditation, appreciate beauty, enjoy a sense of awe and reverence, listening to podcasts, deep breathing, bubble baths, mani/pedi, coffee dates with friends

Depleting/Nourishing Inventory – CBT/Mindfulness technique that involves taking an inventory of all your tasks of the day and labelling them as depleting, nourishing, both or neither.  For the nourishing activates, divide them into “mastery” or “pleasure”.  For example, mastery may be taking university classes.  For the depleting activities, see if you can bring any nourishment to them or get rid of any depleting tasks.  For example, if commuting is depleting but listening to a podcast/ audio book is nourishing, bringing the activity of podcast or audio book into the commute.   

How can you take care of yourself daily, weekly, monthly or yearly?

2/ Why is self-care important? It is important to prevent burn-out, prevent running out of gas and getting stranded on the high-way!  Important to take the time to fill your cup!  Continue to take care of yourself so that you can be your best self and take care of others.

3/ Chemistry of self-care:

The fight/ flight/ freeze system triggered when under immediate stress and under real or perceived stress.  When feel safe, these neurotransmitters leave system and are calm again.  However, if prolonged, body taps into cortisol system.  This leads to adrenal fatigue where the system is depleted, and we experience exhaustion, inflammation, hair loss, skin issues, sleep issues, low libido, and/ or digestive issues.  Decision-fatigue/ ego-depletion/ pre-frontal cortex fatigue/ will-power fatigue then kicks in, where we have exhausted our resources for the day for making decisions by the afternoon.  

Dopamine and serotonin are the neurotransmitters activated when we take care of ourselves. Dopamine activates pre-frontal cortex and gets us excited and motivated to do things, makes us feel good.  Dopamine is often drained by the end of the day, so to get yourself to that yoga class, for example, it helps to have a friend to go with so you get there.  Once you’re at the yoga class, serotonin is released which is the pleasure hormone, it makes you feel happy and content. 

4/ BACE  (by SCaR Foundation):

B for Body (sleep, healthy eating, hygiene, exercise, yoga) – exercise stimulates endorphins, which reduces pain and increases good feelings

A for Achievement (work, cooking, reading, chores, studying) – stimulates dopamine, gives sense of meaning.  Acetylcholine also helps with concentration and getting into a flow state.  

C for Connection (family, friends, pets, neighbours, community) – stimulates oxytocin, love/cuddle hormone

E for Enjoyment (hobbies, music, dancing, movies, playing) – enjoyable activities stimulate serotonin, makes us feel happy and content.

Hope you enjoyed the video interview and the information shared!

Be Well,



Dr. Talia’s website:

Dr. Talia’s Self-Care Workbook:

This cite refers to BACE and also connects the chemistry to these:

No Comments »

Progressive Muscle Relaxation

June 8th, 2020

Hi there!

With everything going on in the world, let’s take a moment for self-care.  You can use this progressive muscle relaxation on it’s own to relax your body and mind, or together with self-directed meditation.

Hope it’s helpful.  Let me know of any other videos that might be helpful for you to manage your mental/emotional well-being.

Be Well,


No Comments »

Box Breathing during these stressful COVID times

June 3rd, 2020

Hi everyone,

Feeling the general state of sadness and anxiety during this time in society.  Between COVID, and the massacre in New Brunswick, and the killing of George Floyd, it’s been a lot of stress on us as a whole.

Please remember to breathe!  Deep breathing has these benefits:

-reduces stress hormone, cortisol

-reduces anxiety, depression, stress

-cues the parasympathetic nervous system to go into rest and digest mode

-increases energy and clarity

In this video, I talk about box breathing.  Please give it a try.

Let me know if I can be of any other help to you,

Be Well,


No Comments »


May 8th, 2020

Hello there!

I do hope that you are doing alright during these COVID times.  My how the world has changed.  In this post, I share some updates, introduce my new Executive Assistant, and share some ways of how to cope with this pandemic.

It has been some time since my last blog post, sincere apologies for that.  Things have been rather busy between caring for a busy toddler and school and seeing clients.  I am still at Tyndale University part time, but now in the Master of Theology program, which is similar to the Master of Divinity, but more of a Biblical focus.  In the future, I am interested in doing a Doctorate in Ministry, but we’ll see, one step at a time!   

I am so pleased and grateful to have an Executive Assistant on board since January 2020.  Her name is Lena Chhouk.  She has a Bachelor of Applied Science in Psychology with an Honours Distinction, and has applied to do a Masters for September 2020.  You may have seen her before our office closed down for COVID, happily scanning resources at the front desk.  She has generously given her time to compose this blog on the Coronavirus, I hope it is helpful to you.  Please let me know if there is any way we can be of assistance to you during this trying time.  I am grateful I have had video sessions set up long before this virus came along, so if you need any on-line services, please do not hesitate to reach out.

All the very best to you and your family,



5 Ways to Cope with the Coronavirus

Composed by Lena Chhouk

Edited by Melissa Johari

The Coronavirus is a topic that is hard to avoid especially since it has negatively impacted the lives of so many people. Not only is this novel virus fear-inducing because it is invisible and the future is unpredictable at this time, but it is also amplified by seeing others resort to “panic buying.”  Some are stocking up on supplies for fear that essential stores will close or governments will implement more strict measures.

Whether it is through easy access to updates from local news stations or even more easy access to misinformation spread throughout social media, there is no doubt that this virus has had a large impact on the mental health of many people. With that being said, it is important to check in frequently with yourself because anxiety and stress due to the severity of the virus is normal.

Here are 5 ways you can cope with COVID:

1/ The Mental Health Commission of Canada recommends creating your own self-care plan because self-care looks different for everyone. Whether it is through activities such as journaling, detoxing from electronic devices or connecting with friends through a virtual game night, the possibilities are endless.

2/ Connecting with others in a time of need such as this pandemic has never been easier. Finding calm through talking with loved ones over Zoom or FaceTime can be helpful.  Checking in with elderly neighbours, of course from a safe physical distance!  Be neighbourly and get involved, maybe consider offering to pick up some groceries next time you go to the supermarket.  And if needed, there are resources available for crisis situations. Resources such as Crisis Text Line powered by Kids Help Phone can be used by texting “CONNECT” to 686868 or texting into the Ontario Online and Text Crisis Services at 258258 or calling the Ontario Mental Health Helpline at 1-866-531-2600.

3/ Staying informed from reputable sources and trusted agencies can help reduce anxiety. The Canadian Mental Health Association recommends getting credible information from sources such as the Government of Canada and the World Health Organization. It is important to remain self-aware of the amount of information you are exposing yourself to and take breaks whenever they are needed.

4/ Start thinking about what you can control during this uncertain time. Whether it is making arrangements for grocery deliveries, simply washing your hands, or helping out those in need, it is important to think about how you have had to adjust your lifestyle because of the virus. Additionally, the Anxiety Canada website has a course that kids and adults can enrol in to help cope with anxiety.  Given the unknown future, this is helpful as we are all struggling with a sense of anxiety these days.

5/ Lastly, be kind to yourself and do your part! By practising good hygiene, physical distancing and staying home, you are doing your part to flatten the curve. In a time of uncertainty, at least some things are under our control. By practicing gratitude and taking things day by day, it can get easier to cope with this pandemic.

While anxiety and stress may be a normal reaction for what is going on in the world right now, it is important to take some time to think of how you can mitigate these reactions for the sake of your health and those around you. Take what is helpful, leave what isn’t and know that we are all in this together.



Some other helpful resources to cope with COVID:

-Right Now Media – Jonathan Pokluda – COVID

-Right Now Media – Jenny Allen – Get Out of Your Head 

-MindShift App (resourceful CBT phone app) for book explaining COVID to kids – Tolerance for Uncertainty COVID Workbook – Coronavirus Anxiety Workbook

-Today’s Parent

No Comments »

Back to School

September 6th, 2018

Well, it has been some time since my last blog post! Wow! My humblest of apologies for not being more on top of this. I am hoping to be more diligent moving forward! I may even venture into vlogging – doing video blogs at some point soon.

Much has happened since my last blog entry. I did get into Adler School of Psychology, but had to turn it down as the timing was off. Why was the timing off?- well, I was finally pregnant!!! After years (and years) of trying and expensive interventions, we were finally blessed with a gorgeous healthy smart little baby boy!! We are so grateful that God has granted us this precious gift. He has been a joy to nurture, and I enjoyed having a year off to spend with him.

During my maternity leave, I also took a Fundamentals of Supervision course. This 30-hour course is required by AAMFT (American Association for Marriage and Family Therapy) and CRPO (College of Registered Psychotherapists of Ontario) in order to provide qualified supervision hours to other practitioners. Even though I have already been providing supervision services for years, I am grateful for the opportunity to take this course as the hours would now count towards being an Approved Supervisor with AAMFT.

Not only am I returning back to my private practice now that my maternity leave is over, but I am also going back to school. What am I taking? Surprisingly not psychology (although that may still happen at some point in the future). I will actually be going to Tyndale for my Master of Divinity (MDiv). What is that?? Well, it’s a combination of studies in Theology and in Counselling. So, I will be able to help clients not only from a secular perspective but also from a biblical perspective. It doesn’t necessarily mean that I would only be offering exclusively Christian Counselling- it just means that in addition to secular/ regular/ traditional counselling, I would be able to help from whatever spiritual faith my clients align with, on a deeper level.


Spirituality was always included as one of the wellness areas in my Relational Wellness Wheel (see home page), as that is part of the bigger picture of general wellness. Whether Muslim, Catholic, Jewish, Christian, Sikh, or even Atheist, that forms your values and belief system, which then impact upon your thoughts and behaviours. I believe it is important to work with clients on whatever level they are at spiritually, as that facilitates change and well-being, and helps them to achieve their personal goals.

So, we are now in September! School is back in for the little ones and for me too!!

Here are some tips for parents to manage the big return to school for your kids!

1/ Have a positive attitude! If you’re nervous, the kids would be nervous. If you’re excited, the kids would be excited. And it’s normal to have a bit of both! Nervous for a new teacher, maybe a new school, new challenges in school work, making new friends. Anything new is naturally nerve-wracking. But if you have an attitude of genuine excitement for the new challenge and new adventure, then this will be contagious. Or it would at least help to ameliorate some of the anxieties. Often times kids are nervous for the academic stuff but excited to see their friends again. If it is a new school, they are often more nervous about making new friends than the academic piece. This is all normal, and good to just talk about to help ease any anxieties. Offer some much needed assurances and help them get settled along the way.

2/ Be prepared – practically, organizationally and academically. Yes, that means all the practical “stuff” that the Staples ads say you need. Writing paper, printer ink, calculators, protractors, pencils, erasers, fun highlighters, running shoes, white socks, etc (etc, etc!). It’s nice to get them involved in choosing new items, as it helps get them excited for the new school year too. Also if they are new to riding the school bus, maybe practice riding a city bus together first so that they get an idea of what to expect.

Being prepared also means being ready organizationally. Have things in place so that you’re not scrambling during the school year. Before and after school care back up plans, or plans for who would pick the child(ren) up from school if they are sick, for example. And back-ups for the back-ups. Also consider having a family calendar on the fridge so everyone can see what is happening when. For older kids, this could be a shared google calendar. Also have some kind of system in place for tracking homework and assignments is helpful.

Being prepared academically is also amazing. This means getting back into school mode by reading a book to prepare for one of their more challenging classes or learning something new before school starts. This gets their brains back into the game of learning mode. We are not in fun play summer mode anymore! (boo!) Better still is to never stop learning- through the summer it’s great to balance having fun with also having some learning time too.

3/ Get involved. See the school, visit the classroom, meet the teacher, attend parent-teacher interviews, meet the new friends, arrange play dates. Get involved in school trips, parent associations, volunteer in the classroom, or fundraising if you are able to. Make sure there is open, clear and regular contact/ communication with the teacher(s), whether it be through a communication book, email, phone or in person. Also get the children involved- get them excited for joining different recreational/ extracurricular activities or clubs in/out of school. Just remember not to over-schedule things, as they still need time for school work and down-time and just time with friends and family.

4/ Have set and clear routines. Kids thrive on structure and regular routines. It gives them a sense of security and predictability. Morning routine, after school routine and chore charts are helpful. that way expectations are clear for everyone.

To make the morning routine of getting ready more enjoyable and hassle-free, you can have tools such as a checklist in the bathroom or bedroom of what needs to be done (brush teeth, wash face, get dressed, eat healthy breakfast, pick up backpack and lunch bag, etc). You can also make it fun by playing some sing-along high energy music to get everyone motivated.
For after school, have a set routine in place – for example, put shoes/coat away, unpack backpack/ lunch bag, snack, do homework at kitchen island while you cook dinner, review homework with you, eat dinner together, clear dishes/ load dishwasher, have one hour of screen time/ free time, pack lunch for next day and put out next day’s clothes, have school bag ready to go for next day with anything signed that needs signing, get ready for bed, in bed by 8:30pm, etc.
Get the routines in place at least a few days before school actually starts, so that they know what to expect and they can get into the rhythm of it.

5/ Be mindful. Schedule in breaks to refresh and have self-care. Stephen Covey calls this “sharpening the saw”. In order to work hard and be effective, you need to take a break to sharpen your saw. Otherwise you and the kids will just be sawing away with a dull blade and not seeing any productive outcomes. Their brains need rest to be sharp and be at their top performance. You need a break too. Spend time together as a family, and have some time to yourself too. Quality time together is important for optimal relational functioning. Have fun together and enjoy time alone too. Keeping that fine balance between we and me is critical. Sometimes if you have to choose between dusting and going to the park together – choose the park!!

I hope you found these helpful, please let me know if you have any other tips that you find useful.

Best of luck with the new school year!!!


No Comments »

Stress and Fertility – What’s the real scoop?!

July 20th, 2016

Sooooo…. I have applied to Adler School of Psychology to do my MPsy.  I have my interview coming up and am hoping to get in! As the first order of business, applicants took a “Thrive and Survive in Graduate School” course which entailed writing an essay.

I chose to write about stress and fertility, as it is very relevant in my life right now.  I have attached it here for your reading pleasure!  Sorry it’s lengthly, but I believe it’s well worth the read.  In the interest of space, I am not including the list of references here, but if you would like to see it, just shoot me an email.

Be Well,
Melissa  :)




Exploring the Relationship between Stress and Fertility in Women: Implications for Clinical Intervention
“Just relax, and it will happen!” Well meaning friends and family, as well as various health and helping professionals have said this to me over the past six years that my husband and I have been trying to have a baby. However, is this an old wives’ tale or is there actual empirical evidence in support of this? If a woman has various stressors in her life, such as a highly demanding job or a sudden move or a sick parent or a death in the family or looking at advancements in her career, could this impede upon her ability to get pregnant? The purpose of this paper is to explore the complex relationship between stress and fertility in women.
Impact of stress on fertility
From a biological and chemical and perspective, it does seem feasible that stress hormones could interfere with reproductive hormones. Several researchers have noted the role of the stress hormone system called the hypothalamic-pituitary-adrenal (HPA) axis (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993; Sanders and Bruce, 1997). When stressed, the hypothalamus releases corticotropin-releasing factor (CRF), which then stimulates the pituitary gland to release adrenocorticotropin hormone (ACTH), which in turn stimulates the adrenal glands to secrete stress hormones including: cortisol, adrenaline and noradrenaline (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993).
When the adrenal gland releases adrenaline and noradrenaline, part of the flight or flight response is activated and this may interfere with transporting gametes through the fallopian tubes or by altering uterine blood flow (Sanders and Bruce, 1997). Increased CRF and cortisol may also lead to suppression of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are the hormones responsible for ovulation (Coubrough, 1985; Harrison et al., 2005; Negro-Villar, 1993). Without ovulation, there is no egg for the sperm to fertilize. Disruption of ovulation also affects progesterone and estrogen levels, which are partially responsible for the regulation of fallopian tube motility (Harrison et al. 2005). When a stressor takes place, it immediately activates changes in these various hormones, and the body may adapt and distribute metabolic activity away from digestion and reproduction, in order to maintain other vital functions (Harrison et al., 2005; Negro-Villar, 1993).
In animal research, stress can be brought on in various ways, including environmental temperature, light, prolonged noise, isolation, confined spaces and moving locations (Coubrough, 1985). For example, with moving comes the stress of transport and the strangeness of the new environment which alters adrenal function, and was found to ultimately reduce fertility in cattle for up to two months (Coubrough 1985). Coubrough (1985) indicated that “Because of the clear influence of stressors on signal hormones of reproduction, some effect of stress on fertility is inescapable” (p. 155). The degree of the effect of stress would be determined by the intensity and duration of the stress (Coubrough, 1985) as well as the individual’s tolerance of stress (Bethea et al., 2005). Bethea et al. (2005) found in a study of 13 female cynomolgus monkeys that the combination of mild psychosocial stress (moving to unfamiliar surroundings), decreased food and increased activity level lead to a significantly greater release of cortisol, thus decreasing fertility, for stress-sensitive animals compared to high stress-resilient animals.
Cortisol can also impact upon fertility through suppressing the immune system (Sanders and Bruce, 1997), which then causes inflammation in the reproductive organs (Harrison et al., 2005). Immunological changes can impact on the ability of the body to accept foreign substances, such as an embryo (Gallinelli et al., 2001). For example, in a study with 40 women undergoing In Vitro Fertilization (IVF) fertility treatment, Gallinelli et al. (2001) found that prolonged stress was associated with high amounts of activated T cells in peripheral blood (T cells are a lymphocyte that is a subtype of white blood cells that attack infected cells) and a lower implantation rate of the embryo. It could be that the T cells mistakenly saw the embryo as an intruder. Thus, the chain reaction from the stressful event through to the various hormonal and immune system reactions can interfere with fertility.
Excessive stress may cause various reproductive issues in women, namely psychologic amenorrhea (no menses when stressed), pseudocyesis (phantom pregnancy), menstrual dysfunction, early pregnancy failure, (Negro-Villar, 1993), chronic anovulation (ovary not releasing egg) (Coubrough, 1985; Negro-Villar, 1993), delayed ovulation, cystic ovarian degeneration, (Coubrough, 1985), reduced fertilization/ conception rates, spontaneous abortions, (Coubrough, 1985 and Klonoff-Cohen, 2009), no live birth deliveries, low birth infants, multiple gestations, (Klonoff-Cohen, 2009), endometriosis (Harrison et al., 2005), longer natural cycles and poorer response to fertility treatment (Boivin and Schmidt, 2005). For example, Negro-Villar (1993) noted that changes in cortisol levels were found in women who had psychologic amenorrhea, which was more common for women who had stressful lives and occupations, were underweight, single and had a history of drug use.
From a behavioural perspective, stress can influence lifestyle habits and unhealthy coping strategies which can also have an impact on infertility. For example, eating disorders (under-eating or over-eating), overly intense exercise, (Negro-Vilar, 1993), caffeine intake, alcohol consumption (Klonoff-Cohen, 2009; Louis et al., 2011) and cigarette smoking (Louis et al., 2011). Louis et al. (2011) found that the highest mean caffeine (coffee, tea, pop, chocolate) consumption was in women who experienced pregnancy losses and Klonoff-Cohen (2009) found that caffeine had an impact on miscarriages, not achieving pregnancy and infant gestational age. It appears important, then, to use effective healthy coping strategies to manage stress and achieve well-being, to improve the chances of having full term healthy baby.
From a psychological perspective, stress can affect general mood which can in turn impact upon infertility. Psychologic distress has generally been recognized as a contributing factor to infertility (Negro-Vilar, 1993). For example, Barry et al. (2011) found that women with polycystic ovarian syndrome (PCOS) had significantly more difficulty coping with stress, were more neurotic, had more anger symptoms, withheld feelings of anger, and experienced more anxiety and depression than a control group of women with infertility problems that were not related to PCOS. Even when controlling for symptoms of PCOS with matched group comparisons, neuroticism and anger still remained higher in the PCOS group.
There was also a prospective study done by Sanders and Bruce (1997) that examined stress level and mood over several months for 13 women in the general community who were trying to conceive. The researchers collected samples to measure hormone levels (noradrenaline, adrenaline, and cortisol) and administered various questionnaires to assess psychosocial stress (State-Trait Anxiety Inventory and Bi-polar Profile of Mood States [POMS]) and lifestyle (sleep, work satisfaction, tiredness with work, time pressure, leisure time, and feelings of being hassled). Hassles were defined as irritants from minor annoyances to fairly major problems, pressures or difficulties.



The women reported significantly better mood states (more composed, agreeable, elated, confident, energetic, clear-headed), less anxiety and felt significantly less hassled during the month of conception compared to their previous non-conception (infertile) cycles. However, there was no significant difference in hormone secretions between the conception and non-conception cycles. There was also little relationship found between psychological mood and hormones during infertile cycles, aside from a negative association between noradrenaline and composed-anxious and clear-headed- confused scales of the POMS. In other words, during the infertile months, the higher the noradrenaline level, the less composed and clear-headed they were. During the conception cycle, there was a significant negative association between noradrenaline and the composed-anxious, agreeable-hostile and energetic-tired POMS scales. In other words, the month that women were successful in conceiving a baby, the higher the noradrenaline level, the less composed, agreeable and energetic they were.
There was also a trend for the women to find their work less mentally tiring and to get more adequate sleep during the conception cycle, although this relationship was not significant. Stress does appear to influence fertility in women, and the mechanism by which this occurs could be due to biological effects of stress on the quality or production of gametes, or on the subsequent fertilization, implantation or maintenance the pregnancy (Sanders and Bruce, 1997). It is important to capture data on not only hormones or the immune system, but also on psychological levels of distress.
There is inconsistent evidence in the literature of the impact of distress on fertility. Boivin et al. (2011) found that women’s emotional distress did not impact upon fertility. They performed a meta-analysis which included 14 studies of women who had undergone one cycle of a fertility treatment. Those 14 studies sampled a total of 3583 women in 10 different countries. The pretreatment emotional distress level, including depression and anxiety, before fertility treatment was not found to have an impact on achieving pregnancy. They only included studies that tested for anxiety and depression as a measure of emotional distress because they were reliably related to stress induced activation of the HPA axis. Boivin et al. (2011) pointed out that fertility rates are often highest in countries with harsh conditions such as war, famine and poverty, and so the hypothalamic-pituitary-gonadotrophin axis has likely evolved to guard against activation of the stress response in the HPA axis. They concluded that women and doctors should be reassured that emotional distress, whether caused by fertility issues or whether caused by other life events, would not compromise the chance of achieving pregnancy.
Impact of infertility on stress
It appears that stress could potentially have an impact on infertility through chemistry, biology, behaviour and/or psychology/mood, although the results are inconsistent. Alternatively, could infertility itself actually cause the stress? For women who experience more social pressure for motherhood, they viewed an infertility diagnosis as more stressful (Miles et al., 2009). In their study examining predictors of distress in infertile women, Miles et al. (2009) received personal statements from 56 participants, where they wrote about their experiences with infertility. They found that 55% of those women reported stress, anxiety and depression, and 27% wrote that infertility was “the most painful experience in their life” (p. 249). In addition, 12% expressed frustration with the lack of appropriate counselling services for those experiencing infertility treatment.
Not only is the diagnosis of infertility in and of itself stressful, but so are invasive infertility procedures such as IVF (Klonoff-Cohen, 2009). Greil et al. (2011) conducted a two wave national study comparing 266 infertile women who did and did not receive fertility treatments, in an effort to disentangle the effects of infertility treatment versus experiencing infertility on fertility-specific distress. The group with the highest increase in fertility-specific distress was the group that had fertility treatment at both waves and still did not have a child. The researchers found that infertility treatment itself is associated with levels of distress that are over and above those associated with the state of being infertile (Greil et al., 2011).
Eugster and Vingerhoets (1999) conducted a review of IVF research in the context of psychological state. They found that couples who entered into IVF treatment were generally well adjusted. The experience of waiting for the outcome of the treatment and the news of an unsuccessful IVF treatment were the most stressful for both men and women. During the IVF treatment, patients were commonly anxious and depressed, and after an unsuccessful IVF treatment, they were often sad, depressed and angry. Psychosocial factors, such as ineffective coping strategies, depression and/ or anxiety were associated with lower pregnancy rates with IVF treatment (Eugster and Vingerhoets, 1999).
Personally, I know first hand that the IVF treatment experience is stressful. It involves daily hormone injections of potent fertility drugs to stimulate the production of eggs making my ovaries feel like two uncomfortable tennis balls in your abdomen, painful progesterone oil needles administered into muscle, frequent visits to the infertility clinic for blood work and external and invasive internal ultrasounds, surgical transvaginal ultrasonography procedure (Boivin et al., 2011) to extract the eggs, fertilization of the eggs in the laboratory with the sperm, waiting impatiently for the embryos to develop, seeing embryos dying every day and hoping that the rest survive to the blastocyst stage (day 5 of development), another procedure to transfer the embryo(s) into the uterus, and finally the dreaded waiting for two to three weeks to find out whether our prayers have been answered. This is a stressful series of events which would all be absolutely worth it if the result is in our favour, but is devastating when it is not. Indeed, Boivin et al. (2011) found in a meta-analysis that there was significantly more distress in women who found out that they did not get pregnant compared to women who did get pregnant.
Klonoff-Cohen (2009) found that women who were concerned about the medical aspects of the IVF procedure by itself, such as side effects, surgery, anesthesia or pain, had 20% fewer oocytes (eggs) retrieved and 19% fewer oocytes fertilized. Further, women who were very concerned about missing work for the procedure had 30% fewer oocytes fertilized and those even moderately concerned about missing work had 2.83 times the risk of not achieving a pregnancy at all.


Another very recent study by Gana and Jakubowski (2016) found that infertility-related stress significantly predicted both emotional distress and, interestingly, marital distress. The effect was stronger for emotional distress, particularly life domains which included social, marital and sexual areas of the person’s life that are affected by infertility (Gana and Jakubowski, 2016).  It is plausible, therefore, that the diagnosis and subsequent treatment can itself contribute to the stress endured during the fertility journey.
Interaction of stress and fertility
Another alternative is that perhaps there is a reciprocal causation/ reciprocal determinism (Bandura, 1978) interaction, where daily chronic stress impacts upon infertility but also infertility increases daily chronic stress. According to Bandura’s (1978) model of reciprocal determinism, behaviour, cognitions and the external environment all interact with each other in such a way that each of these components interact with each other and influence each other. In applying this model, stress does not independently cause infertility and infertility does not independently cause stress. Rather, Bandura (1978) argues that personal and environmental factors do not function independently, but indeed determine each other. It is through actions that people produce environmental conditions that affect their behaviour in a reciprocal way. The experiences generated by behaviour also in part determine what people think, expect and do, which then affect their subsequent behaviour (Bandura 1978).
In application to fertility, the actions or behaviours can be over-working or under-eating or moving locations or drinking coffee that affects stress levels in a reciprocal fashion. The experience of infertility generated by the behaviour then determine self-perceptions, such as ruminating over the personal failure of being infertile (Gana and Jakubowski, 2016), and affect subsequent behaviour, which could look like seeking out fertility treatment. The experience of seeking out fertility treatment then has an interactive relationship that makes the person more stressed, which further impacts upon the infertility issues.
Wright et al. (1989) conducted a review of the research on psychosocial distress and infertility. In the 30 publications that they examined, they found that overall, patients diagnosed and treated in infertility clinics showed significantly higher psychosocial distress compared to control groups. However, it was difficult for them to conclude the exact nature of the relationship, namely whether psychosocial issues trigger infertility or infertility triggers psychosocial distress or whether there was an interactive causal relationship between infertility and psychosocial distress. More longitudinal research is required in order to make definitive conclusions (Wright et al., 1989).
The interactive causal relation can also include the couples’ marital relationship in the fertility process, as an external factor. Gana and Jakubowska (2016) found that there was an interaction between emotional distress and marital dissatisfaction in fertility. The more emotional distress people experience, the more dissatisfied in their marriage they were, and the more marital dissatisfaction they experience, the more emotionally distressed they were. This is in line with Bandura’s (1978) model of reciprocal determinism.
Further research is required in order to fully understand the exact relationship between stress and fertility. It is difficult to draw definitive conclusions due to the wide variation in study methods and measures of outcome, for example, in measures of emotional distress. The Spielberger State-Trait Anxiety Inventory has been the most commonly used tool (Boivin et al., 2011), but perhaps that is not specific enough to assess problems of infertility (Greil et al., 2011). In fact, there have been tools designed to measure infertility distress, such as the Fertility Problem Inventory (Newton et al., 1999). The Fertility Problem Inventory encompasses five dimensions: social concern, sexual concern, relationship concern, rejection of a childfree lifestyle, and need for parenthood.
It would also be helpful for future studies to include more data on men (Boivin and Schmidt, 2005; Negro-Vilar, 1993) and couples (Gana and Jakubowska, 2016). Limited research on men shows that stress for men is also related to infertility issues, namely poor semen quality (count, motility, morphology) (Boivin and Schmidt, 2005; Negro-Vilar, 1993), impotence, ejaculatory disorders and decreased serum lutinizing hormone and testosterone (Negro-Vilar, 1993). Men’s lifestyle habits can also have an impact on fertility. For instance, Klonoff-Cohen (2009) found that men’s alcohol use was associated with spontaneous miscarriages and not achieving a live birth.
Clinical Interventions
Although there is no conclusive empirical evidence as yet to demonstrate that reducing stress leads to higher take home baby rates (Boivin, 2003), there is mounting evidence to show that less stress is conducive to better fertility (Campagne, 2006). Given this information, it may be worth it to make attempts to reduce stress or learn to cope better with stress before even starting fertility treatments (Campagne, 2006). Doing so may make the fertility treatment no longer necessary or reduce the number of treatment cycles required before pregnancy is achieved, or it may prepare the couple for an initial failure of treatment if it comes to that (Campagne, 2006).


There are numerous infertility interventions available which have shown very positive results in lowering stress, such as acupuncture (Balk et al., 2010), Integrative Body-Mind-Spirit (I-BMS) therapy (Chan et al., 2012), art therapy (Hughes, 2010), expressive writing (Matthiesen et al., 2012), group therapy (Domar et al., 2000), hypnosis (Levitas et al., 2006) and even clown therapy (medical clown visits after an embryo transfer) (Friedler et al., 2011). Some of these have demonstrated success in improving pregnancy rates. For example, acupuncture for 57 women undergoing IVF treatment resulted in a 64.7% pregnancy rate compared to 42.5% who achieved pregnancy without acupuncture (Balk et al., 2010).


Chan et al. (2012) outlines a full I-BMS program for women in their first IVF treatment. They have four group sessions for I-BMS that involve education on the interconnectedness of body, mind and spirit, along with acceptance, forgiveness, self-love, letting go of high IVF expectations and growing through pain and personal transformation. Using a randomized controlled study of 339 women, they taught treatment participants mindfulness (living in the moment) and relaxation skills such as guided imagery and meditation. Although there was no significant difference found in biological outcomes (pregnancy) between the intervention group and control group, they did find that compared to baseline for the treatment group, they had significant decreases in trait anxiety, lower levels of physical distress, and disorientation. They reported being more tranquil and had significant increases in marital satisfaction. They also saw childbearing as less important compared to the control group. In other words, they were more accepting of the outcome in the event that no pregnancy was achieved. Disorientation (lack of vitality and loss of direction) could occur in women who see having a child as their next life goal and may feel blocked and incapable of moving forward if they are not able to conceive (Chan et al., 2012). To address this, the intervention group was encouraged to re-evaluate their life goals, focusing on personal fulfillment and broadening their perspectives, regardless of whether or not they become pregnant.  These types of programs would be helpful for women and couples going through fertility treatment, even if the result is better overall well-being and not achieving pregnancy.


Boivin (2003) compared psychosocial interventions in infertility, and found that when compared to counselling interventions, educational interventions resulted in twice as many positive changes across various measures including negative affect, interpersonal functioning and pregnancy. The most successful interventions lasted for six to 12 weeks, had a follow-up period of at least six months, and had strong educational and skills training and/or group format that emphasized medical knowledge and learning stress management and coping techniques (Boivin, 2003). Infertility education may increase understanding of the implications of infertility for the couples’ psychological health and help to eliminate the social stigma attached to childless families (Ridenour et al., 2009).
It would be helpful for clinical interventions to include the couple. Boivin and Schmidt (2005) found that higher marital stress, higher personal stress, older age and more years struggling with infertility were each associated with poorer fertility treatment outcome. Thus, strains on the marital relationship that are caused by fertility issues, could interfere with the success of the fertility treatment, and could actually make couples discontinue with treatment (Boivin and Schmidt, 2005). Boivin and Schmidt (2005) found that women who had more marital distress required more treatment cycles to conceive a child than women who had less marital distress.
Women require a supportive marital relationship to help them adjust to infertility diagnosis and to infertility treatment, especially if the treatment fails (Boivin and Schmidt, 2005). Experiencing the infertility journey together can either strengthen the couple or create a strain in the relationship. Peterson et al. (2003) found that couples who perceived an equal level of social infertility stress reported greater marital adjustment in comparison to couples who perceived the stress differently. High congruence, or agreement, between partners in relation to the stresses that they experience help them to successfully manage the impact of those stressful life events (Peterson et al., 2003). Thus, if couples view the infertility journey in the same way, then they are more likely to be stronger as a couple as a result.
Ridenour et al. (2009) developed an Infertility Resilience Model (IRM) that encompasses the individual, the couple, and external factors that influence resilience to infertility-related stress. The model provides research-based guidelines for assessing a couples’ level of resilience in relation to infertility. In the IRM, external or environmental influences (such as duration of infertility, culture, social support, etc.) affect each person, which forms the individual perception, and the collective perception or the congruence within the couple creates the couples’ resiliency. Protective factors for the couple could include the quality of the relationship that the couple had before infertility, communication skills, access to information and access to infertility treatments. Individual protective factors could include mental health and religion or spirituality. Ultimately resilience results in acceptance of infertility regardless of infertility treatment outcomes or external influences (Ridenour et al., 2009).
Ridenour et al. (2009) created a sample assessment questionnaire based on the IRM, that would be helpful for clinicians in working with couples. Sample items from this questionnaire include: “Do you feel pressure when friends and acquaintances become pregnant?”, “Is it wise to make a decision if your partner still has reservations?” and “How do you see your relationship if you were unable to have children?” (Appendix A, p. 47-48). A thorough assessment would allow the therapist to understand the individual circumstances and how these may affect couple interactions.
In closing, I feel blessed to have what I call “My Preconception Dream Team”, working with us to help us to achieve our goal of parenthood. We have a nutritionist, bio-energetic practitioner, naturopathic doctor who uses acupuncture, a massage therapist who is also a doula, a psychologist who is familiar with fertility issues and of course our fertility doctor. They do mainly work with me, but they have helped my husband as well. They help to make sure that my hormone levels are in their proper balance, we are taking the appropriate vitamins and supplements, we’re taking time to de-stress, we’re eating healthy foods that help with fertility, we have an open space to talk about our fertility journey and we are taking the appropriate medical measures. Reflecting upon all of the above research, I feel very lucky to have a husband who I feel congruent with as we continue to proceed along this fertility journey. I feel ever hopeful, that despite my highly demanding job, pending move, sick parent, recent death in the family and applying to an incredible graduate school, that we are resilient, and our dreams of being parents will come true. Together, we continue to remain hopeful, and whatever the outcome, we will accept it and embrace it.


No Comments »