The Role of Mental Health in Infertility

How much do Psychological Interventions Contribute to Reproductive Health

Literature Review, 2021

45 Pages, Grade: A2

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Table of Content



Problem statement

Aim of study

Research Questions (RQ)

Research Design

Literature review

Overview of Infertility

Etiology/Contributory factors of Infertility
Male and Female Infertility
Male-Factor Infertility
Female-factor Infertility
Idiopathic Factor:
Diagnosis of Infertility
Medical Interventions (Assisted Reproduction Technologies)

Mental Health and Psychological Trends of Infertility
Stress, Distress, and Infertility
Coping Strategies with Infertility: Women
Coping Strategies with Infertility: Men
The Impact of Infertility on the Couple
Overview of Psychological Interventions
Psychotherapy and Infertility treatment: Evidence-Based Review
Cognitive and Behavioral Therapies (CBT)
Acceptance and Commitment Therapy
Psychoeducational Interventions
Online Interventions
Empirical Studies Relating to Mental and Reproductive Health

Conclusion/Future Directions




Background: The subject of reproduction has, since recent history been gaining a lot of attention as there has been reports of decline in successful pregnancy rate by the World Health Organisation and other global health organisations. Healthcare professionals and researchers have attributed the root causes of the declining reproduction success to a myriad of factors including untreated mental health challenges. Globally, there has been anecdotal and empirical evidences that individuals diagnosed as infertile may also be faced by co-morbidity of mental health disorders. This arguably has been the basis of a hypothesis on a ‘dyadic’ nature of mental health and reproductive health.

Rationale/Objectives: The theory of untreated psychological stress leading to obstetric complications and treatment failure is quite alarming. It is therefore imperative to investigate the extent to which patients exposed to mental health ailments (or psychological disturbances) are threatened by obstetric complications and reduced chances of pregnancy – a subject which is yet to be well-explored. Hence, the present study. Alternatively, the present review seeks to evaluate the evidences on a possible association between mental health and reproduction success. Reproduction success in the context of this review, is defined by improvement in fertility treatment outcomes including pregnancy.

Outcomes: The review employed the use of psychological and medical research databases such as Google Scholar, PsycINFO, PubMed, Human Reproduction Update, Web of Science, EBSCO and the Cochrane Library. The systematic search considered open-access published papers (in English language) based on keywords such as infertility, mental health and reproductive health, infertility treatment, reproduction success rate, assisted reproduction technologies, psychological traits, psychological intervention, coping strategies among others.

The study found evidences of possible association between variables of mental health (or psychotherapy) and infertility treatment outcomes including significant increases in pregnancy rate, reduction in obstetric complications among others. The researchers concluded on the need for psychotherapy as complementary or support care in infertility treatment. In spite of this, there were also evidences of no or little effect following psychological intervention and coping strategies.

Wider implications: The present review also found certain limitations owing to the high level of non-homogeneity and variability across the study designs of many studies. This inevitably therefore served as a barrier to ascertaining the significant role of mental health in achieving the goals of infertility treatment programs, one of which include increasing the chances of conception while catering for the psychological burden of infertility. It is important that subsequent research incorporate the research capacities of various healthcare professionals and researchers in order to improve the quality of research on this subject.

Keywords: infertility, mental health and reproductive health, infertility treatment, reproduction success rate, assisted reproduction technologies, psychological traits, psychological intervention, coping strategies.


Infertility (or subfertility as designated in various literature [Verkuijlen et al., 2016]) is a global phenomenon. It has been described as a medical condition of the reproductive system characterized by the inability to achieve pregnancy when couples have regular ‘unprotected’ intercourse (World Health Organization (WHO), 2016).

In a bid to evaluate infertility, various scholarly works have further categorized the ability to achieve pregnancy in terms of whether (i) the couple is attempting to achieve pregnancy for the first time (primary infertility) (ii) the couple is unable achieve pregnancy despite previous success or is unable to carry a pregnancy to a ‘live birth’ despite previous success (secondary infertility) (RESOLVE, 2012; Mansour, 2014; Musa, 2014). Esselstrom (2014) replaced secondary infertility with the term ‘Impaired fecundity.’

It is important to critically consider also how scholars and healthcare professionals perceived infertility by various criteria. For instance, some healthcare professionals may diagnose infertility in women over 35 years of age after six months of unsuccessful attempts to achieve pregnancy. Such diagnosis may be partly aimed to encourage early commencement of fertility treatment (CDC, 2012). Bell (2013) however among those researchers that argue against such under-1-year diagnosis in favor of allowing couples longer period to achieve conception.

Researches have highlighted that the reproduction health deficiency in fact affects millions of couples across the world regardless of their demography. In one study, variables such as age was implicated as predisposing couples to infertility (and/or infertility treatment outcomes). Couples attempting to achieve pregnancy for the first time had been investigated where it was found that infertility was ‘[…] higher among women aged 20 to 24 years in comparison with women aged 25 to 29 years’ (Mascarenhas, 2012). The study further concluded that a degree of secondary infertility amongst aged 40 to 44 years compared to women aged between 20 and 24 years.

Problem statement

Across the world, there has been anecdotal and empirical evidence that many couples that are diagnosed as infertile were subject to immense psychology stress and distress. This has also led researchers to a hypothesis on a ‘dyadic’ nature of mental health and reproductive health. In other words, certain scholars believe that there might be a possible link between the psychological state of infertility patients and their ability to achieve pregnancy.

In a review by Thornton et al. (2010); it was highlighted that there were increasing reports that pregnant women were experiencing increasing rate of serious obstetric complications during labor and delivery ‘many of which are preventable through optimal obstetric care’ (Danel et al., 2003; Guendelman et al., 2006; Remy et al., 2008). This is also consistent with a few previous research works that have attempted to investigate the subject of supportive care (via psychotherapy) during the period of infertility or infertility treatment (Van den Broeck et al., 2009; Turner et al., 2013). The consequences of untreated psychological stress leading to obstetric complications and treatment failure is quite alarming. It is therefore imperative to investigate the extent to which women exposed to mental health ailments (or psychological disturbances) are threatened by obstetric complications and reduced chances of pregnancy – a subject which is yet to be well-explored. Hence, the present study.

Aim of study

To investigate the effectiveness of psychological interventions on fertility treatment outcomes.

The subject of the review will contribute knowledge on the psychological needs of individuals and couples seeking fertility services for various healthcare professionals.

Research Questions (RQ)

This narrative review seeks to explore the extant literature that addresses the following questions:

RQ1: Do psychological interventions affect infertility treatment?

RQ2: Do psychological traits, coping strategies and psychological interventions affect infertility treatment outcomes?

Research Design

The present review adopted the modified methods of Boivin (2003), Hammerli et al. (2009) and Verkuijlen et al. (2016) in a systematic search that identified all open-access published papers written only in English language. Such search was based on literature that included words, phrases and sentences on the topic of ‘(a) psychosocial interventions (b) psychological traits and coping strategies in infertility (c) assisted reproduction technologies and other infertility treatments (d) the effect of any of the treatment outcomes in infertility programs.’

Additionally, the review employed the use of psychological and medical research databases such as Google Scholar, PsycINFO, PubMed, Human Reproduction Update, Web of Science, EBSCO and the Cochrane Library.

Literature review

Overview of Infertility

According to the 2010 World Health Organization’s (WHO) report, it was estimated that approximately 45 million couples across the world were affected by fertility-related problems (Mascarenhas et al., 2012). Interestingly, there has also been an increase in scientific innovations in the field of reproduction medicine that has seen the introduction of assisted reproductive technologies. Accordingly, a number of these reproductive technological innovations have been applied in the management of infertility including (but not limited to): ‘in-vitro fertilization’ (IVF), ‘intracytoplasmatic sperm injection’ (ICSI) or ‘intrauterine insemination’ (IUI) (Dunn et al., 2014).

Etiology/Contributory factors of Infertility

Several biological, psychological and environmental variables have been implicated for their role in infertility. According to a Center for Disease Control and Prevention (CDC) report, age has been found to be one of the strongest predictors in the ability to achieve pregnancy (and/or fertility treatment outcomes) (CDC, 2005).

The National Fertility Association, RESOLVE in their 2012 report estimated that female fertility has reduced from 90% to 15% by age 50. Their research suggested that this may be as a result of the combinations of age-related health complications and potential chromosomal aberrations in the female sex cell as they age. Hence, the increased cases of miscarriage in older woman (RESOLVE, 2012).

Male and female fertility have also been reported to be adversely affected by certain personal, social and environmental factors such as ‘[…] smoking, excessive alcohol use, poor diet, engaging in unprotected sexual intercourse, athletic training, obesity or anorexia, and environmental exposure (CDC, 2012; 2013; Lynch et al., 2014).’ This is in addition to research papers on environmental changes such as exposure to toxic chemical, radiation, and high temperatures which has been associated with reduced fertility in men and women (RESOLVE, 2012).

Interestingly, other studies have reported a link between the body mass index (BMI) and the likelihood of pregnancy in relation to hormone regulation in the female reproductive system (Khaskheli et al., 2013; Kort et al., 2014).

Male and Female Infertility

As highlighted in Esselstrom (2014), the causes of infertility are multiparous. However, in this section; infertility was discussed with respect to biological factors.

Male-Factor Infertility

Unlike the female reproductive system; male infertility has been linked to disturbances in the hypothalamic-pituitary-testicular axis (CDC, 2011). The hypothalamic-pituitary-testicular system controls the processes of steroidogenesis and spermatogenesis. Steroidogenesis is concerned with male hormonal imbalances while spermatogenesis deals with the production of morphologically and functionally-normal sperm cells (Choy and Ellsworth, 2012).

Female-factor Infertility

Based on the suggestions from various research findings, biological factors that have been studied to be the sources of female infertility include age; endometriosis ; tubal disturbance which is a blockage or damage in fallopian tube leading to difficulty in fertilization and travel of an embryo to the uterus; ovulatory disorders ‘any condition that impacts ovulation’ and uterine disorders, which could ‘[…] impact a woman’s ability to conceive and carry a pregnancy to term’ (CDC, 2011; RESOLVE, 2012)

With women undergoing assisted reproduction; fertility treatment can be impaired as a result of insufficient eggs in spite of large doses of ovulation stimulating medications. Such condition for instance may also be due to premature ovarian failure (RESOLVE, 2012).

It is also important to consider the presence of other biological/medical variables such as presence of chromosomal aberrations, cancer chemotherapy, immune system, and other serious medical conditions (CDC, 2011; RESOLVE, 2012).

Idiopathic Factor:

In the absence of the male- and female-factor source of infertility as mentioned such as ‘[…] ovulatory function, sufficient ovarian reserve, a normal uterine cavity, unobstructed fallopian tubes, and normal semen quality’, a diagnosis of idiopathic infertility may be provided (Fritz, 2012). To this end, other possible sources of infertility have been hypothesized including the presence of psychogenic elements (Lykeridou et al., 2009; Romano et al., 2012).

There is a myriad of scholarly works whose findings suggests an interaction between psychogenic factors (such as psychotropic drugs, mental ailments) and infertility among couples (Ramezanzadeh et al., 2004; Chiaffarino et al., 2011).

Hajela et al. (2016) for instance; reported that psychological stress induced by inability to achieve pregnancy; coupled with the exposure to psychological traits (such as anorexia and depressive disorders) may significantly alter the hypothalamic-pituitary-ovarian (HPO) axis of the woman. Consequently, such imbalances within the HPO axis could negatively impact a woman’s reproductive health function. Hence, the cause of infertility.

Hajela et al. (2016) also reported the link between psychological stress in men and coital dysfunction, which has been implicated in male infertility.

Diagnosis of Infertility

The root cause of infertility amongst couples could said to be definitive or non-specific as highlighted above. For the specific or definitive root causes, investigations of a normal functioning male and female reproductive system are typically carried out.

Esselstrom (2014) stressed that couples who resolve to talk to a professional at a fertility clinic have to pass through different stages before treatment is administered – beginning with a diagnostic interview.

The aim of the diagnostic interview is to collect relevant information on the patient (s) including ‘[…] data on drug use, marital status, stability of relationship with spouse or partner, mental and physical health of existing children, sexual orientation, reasons for wanting a child, and financial stability, HIV status, race, mental health, data on previous pregnancies and associated complications, sexual history, duration of infertility, and assessment of physical symptoms’ (Gurmankin et al., 2003; Fritz, 2012).

Esselstrom noted that sequel to the data collection phase, couples commence the process of diagnostic testing, which may be followed sessions to discuss results and more testing until a final diagnosis is attained (Fritz, 2012). Accordingly, to assess male fertility, the males are required to provide a semen sample which will be used to assess certain sperm parameters such as sperm motility and morphology. A urologic and endocrinology screening is also done. Women on the other hand, are subjected a battery of test to assess their potential for fecundity. A few of them include ‘[…] basal body temperature, a transvaginal ultrasound, serum hormonal levels such as progesterone, antimullerian hormone’ (Esselstrom, 2014).

Quite visibly, the infertility treatment journey requires several tasks in a bid to assess the primary and secondary causes of infertility such as the physiological state of the couple in addition to other data as required in the diagnostic procedures. Therefore, one might understand why the success or failure of the treatment has in recent times been discussed in relation to mental health.

Medical Interventions (Assisted Reproduction Technologies)

The recent advancements of reproductive medicine may be translated to the availability of multiple treatment options for couples seeking infertility treatment.

The Assisted Reproduction Technologies (ART) as defined by the “1992 Fertility Clinic Success Rate and Certification Act’ comprise includes all fertility treatments where both eggs and sperm are handled” (CDC, 2011).

Summarily, some of the common ART approaches to treating infertility include in-vitro fertilization (IVF); intracytoplasmic sperm injection (ICSI); gamete intrafallopian transfer (GIFT); zygote intrafallopian transfer (ZIFT) amongst others – with varying success rates (CDC, 2011; RESOLVE, 2012).

Other non-ART approaches have also been highlighted including intrauterine insemination and procedures that involve medication use to stimulate egg production without intended retrieval of the eggs (CDC, 2011).

Mental Health and Psychological Trends of Infertility

The psychological intervention approach to infertility treatment arguably stem from advocacy work of Barbara Eck Menning in 1980 and has since been supported by various organisations (such as RESOLVE) and healthcare professionals in reproductive medicine (Boivin and Kentenich, 2002).

As mentioned earlier on the origin of infertility, Verkuijlen et al., (2016) in their report mentioned that 20% of all unfertile couples seeking fertility treatment show clinically relevant levels of anxiety, depression, or distress. For this reason, there has been strong recommendations on the need for psychotherapeutic measures amongst other medical care. Its effectiveness however has been subjected a lot of debates on how psychological intervention actually do have impact infertility treatments whether primary or secondary.

Studies have suggested that fertility treatment may result in tremendous psychological burden, particularly in the event of failure to achieve in a clinical pregnancy or a live birth (Gameiro, 2012). This was revealed in the research works such as Verhaak (2005) , Chiaffarino (2011) where the incidence of depressive or anxious symptoms, measured between the first visit to a fertility clinic and the start of treatment, were reported to higher in both women and men seeking fertility treatment following the commencement of the treatment cycle.

Various literature also estimated that in many cases during the fertility treatment cycle, one-fifth of all infertile couples receiving reproductive medical care would need some form of psychotherapy (Verhaak, 2007; Gameiro, 2015), and, according to Gameiro (2015), may even cease fertility treatment due to ‘psychological burden or relational and personal problems across any stage of fertility treatment.’

To this end, some scholars have opined on the need to provide supportive care for families diagnosed to be under psychological stress owing to the fertility treatment. This has been agreed to lead to ‘[…] better functioning in daily life and reduce discontinuation of fertility treatment (De Liz 2005; Gameiro 2012).’ This is consistent with the position of some scholars that believe that psychological interventions increase the chances of pregnancy following treatment programs (De Liz, 2005; Hämmerli, 2009).

The proceeding sections are included to highlight important aspects of psychotherapy on assisted reproduction.

Stress, Distress, and Infertility

Podolska and Bidzan (2011) (cited in Gdańska et al., 2017) mentioned that often times, infertility treatment was often a long term process which has been found to elicit psychological stress within affected individuals. Anxiety and depression are a few commonly reported examples of mental health disturbance. This was reiterated in a review by Hajela et al. (2016) on the relationship between stress and infertility which favored the argument that imbalances in mental health could interfere fertility and success in infertility treatment procedure.

The role of the mental health as an integral component of total well-being is increasing receiving attention in recent times. In the case of fertility, the role of mental health in relation to the likelihood of achieving pregnancy is currently being considered among researchers (Holka-Pokorska et al., 2015) in spite of mixed findings on the psychogenic roots of male and female infertility (Pook et al., 2004; Lynch et al., 2014).

As mentioned earlier, the long-term psychological burden of infertility treatment has been linked to the risk of anxiety and depression which in turn complicates the goal of achieving pregnancy.

According to Oxford Handbook of Psychiatry (2013); anxiety is a normal ‘adaptive response’ to an exposure to stressful events. However, this could become pathological if not controlled. Depression on the other hand; marked by ‘[…] lowered mood, lowered activity, loss of interest and an inability to experience pleasure from joyful activities’ is another subject gaining significant public health concern. It is important to note here that, both anxiety and depression are broad terms that defined a myriad of psychological disorders according to the Diagnostic and Statistical Manual of mental Disoders (DSM).

In the context of fertility, anxiety and depressive disorders and other psychogenic ailments have been suggested from various works to affect outcomes of infertility treatment (Chiaffarino et al., 2011; Baghianimoghadam et al., 2013; Reis et al., 2013; Schaller et al., 2016). However, as discussed below, this argument has generated conflicting findings (Gdańska et al., 2017).

This was also the concern of Esselstrom (2014) in a doctoral research that was based on the fact that: ‘(i) stress decrease fertility in men and women, and may also impact fertility treatment outcomes. (ii) psychological burden was linked to treatment discontinuation, due to the physical and emotional stress associated with the personal, social, and medical aspects of infertility.’

Various works have documented the psychological experience of couples affected by infertility medical care; to which Esselstrom stressed that the theory of such experience should also be extended to couples desiring pregnancy via natural means (Esselstrom, 2014).

Coping Strategies with Infertility: Women

It is not uncommon that most literature search often lead to results on the impact of infertility on mental health. However, the focus of this review is on the effect of psychological intervention and / or psychological coping strategies on chances of achieving pregnancy.

Scholars have ranked infertility as the ‘fourth most distressing experience’ in a woman’s life (Lykeridou et al., 2009). Accompanied by elevated stress levels, infertility was found to be associated with feelings of grief, depression, guilt, and anxiety. This is consistent with the work of McQuillan et al. (2003). More so, there are studies that reveal that when matched to women who can achieve pregnancy via natural means, ‘distress in infertile women was reported to be significantly higher (Lewis et al., 2013).

Interestingly, Johnson and Fledderjohann (2012) work on women in the United States aimed at determining ‘[…] the relationship between infertility diagnosis, treatment type, distress levels, and self-identification as infertile.’ Found that women who were medically diagnosed as infertile were more likely to self-identify as infertile. Women seeking treatment for male factor infertility were less likely to identify as infertile. Women who identified as infertile endorsed higher levels of distress.

The researchers concluded that ‘self-identification-as-infertile, as opposed to type of infertility diagnosis was directly related to distress levels.’ (Johnson and Fledderjohann, 2012).

In the context of the present study, asides highlighting the tremendous psychological burden experienced by women desiring pregnancy; it is also important to highlight how affected individuals are able to cope with the burden of infertility during treatment courses.

Several researchers in a study developed a “[…] fifty-one-item measure, ‘Coping with Infertility Questionnaire’ to assess styles of coping related to the infertility experience (Benyamini et al. 2008).” Three main coping areas were revealed from their study and each is composed of more specific coping styles as mentioned in Esselstrom (2014): The approach-avoidance coping strategy which includes aspects of social withdrawal, denial, self-blame, self-neglect, disclosure, acceptance, and positive re-interpretation. Relationship coping strategy which includes seeking spousal support. Practical management coping strategy which includes self-nurturing, seeking social support, planning and information-seeking, and faith.

Benyamini and colleagues also compared ‘[…] coping with psychological adjustment, which was assessed through measures of well-being, distress, life satisfaction, and somatic symptoms. They found that emotional approach coping such as self-nurturing, and problem appraisal strategies such as positive reinterpretation were associated with better psychological adjustment. On the other hand, emotional avoidance, and problem-management strategies such as seeking social support and information-seeking were associated with worse adjustment.’ This however conflicted with the work of La Joie (2003) that suggested that ‘[…] strong social support, including marital support, was associated with lower distress levels.’

The study by Benyamini and colleagues was further corroborated by Adams (2002) (cited in Esselstrom, 2014) that found that women experiencing primary or secondary infertility typically used social support, problem solving, and positive reappraisal in coping with distress. They were less likely to use avoidance, self-controlling, distancing, accepting responsibility, and confrontational coping to resolve the situation. For those experiencing primary infertility, accepting responsibility and avoidance were associated with increased levels of distress.

Another interesting investigation has been on the interaction of various coping strategies across various phases of the infertility treatment. In one study by Gerrity, as noted in Esselstrom (2014): ‘[…] the affected women were most likely to use seeking social support and escape avoidance across all treatment stages (Gerrity, 2001). Self-control was also commonly used, though women no longer undergoing treatment were less likely to use this coping technique. More so, those with five or more years of unsuccessful medical interventions) were more likely to use accepting responsibility than those who had concluded infertility treatment.’

A study by Sexton and colleagues revealed that women experiencing infertility demonstrated lower resilience than normal populations and that lower resilience was associated with higher levels of infertility-related and general distress (Sexton et al., 2009).

Lastly, as indicated in the aforementioned scholarly works, there is a need to investigate the psychological dimensions to female infertility. This is also based on the position by some scholars that claim ‘women experience peak prevalence of psychiatric disorders occurs during the childbearing years’ (Burke et al., 1991).

Coping Strategies with Infertility: Men

Similar to women, there exists scholarly works that reveal that male fertility could be impacted by psychogenic stress (Pook et al., 2004: Culley et al., 2013). Although as Esselstrom (2014) aptly observed there exists a disproportionately low body of work on the male experience during infertility treatment including their support needs, or their decisions to end treatment. Bell (2013) and Herrera (2013) argued that the paucity of research may be due to the fact that infertility treatments may mainly and unconsciously target the female partner in the relationship.

Meanwhile, considering the psychological coping strategies favored by men undergoing fertility treatment; a study by Schmidt and other researchers carried out in the Netherland found that men of higher social class, as determined by ‘education, vocational training, and occupation, were more likely to use active-avoidance coping than men of middle or lower social class (Schmidt et al., 2005).’ The use of ‘avoidance coping and self-blame’ techniques have been linked to increased psychological stress levels (Esselstrom, 2014).

Furthermore, Stanton and colleagues (1992) studied the differences in coping with infertility between men and women. Their findings pointed to the fact that the male partner was more likely to employ “[…] distancing, more organised problem-solving, and self-control strategies to cope with infertility compared to their female partners.’ They added that the male partners were more like to adopt social support in response to the psychological stress that comes with infertility and infertility treatment compared to the women (Stanton et al., 1992).

Interestingly, the likelihood for affected individuals to adopt ‘social support, distancing and organised problem solving approach has been reported to correlate with lower infertility-related distress. On the other hand, adopting self-control has associated with increased infertility-related distress (Esselstrom, 2014).

From other researchers; it was concluded that the (i) male partners diagnosed to be infertile used fewer coping strategies unlike their female partners (Stanton et al., 1992; Esselstrom, 2014). Although when compared with fertile men; ‘greater utilization of coping strategies’ among sub-fertile males (Hurst et al., 1999). (ii) men were more likely to adopt coping a strategy of withholding information on their psychological stress, which has further been correlated with higher fertility and general distress levels (Dooley et al., 2011). (iii) self-control, relaxation, search for self-affirmation, intrusive thoughts, disparagement, avoidance, and escape are among several commonly employed coping mechanisms for managing male infertility psychological stress as reported in a doctoral research by Esselstrom (2014).

The Impact of Infertility on the Couple

Fundamentally, as observed in various literature; the level of stress induced by infertility in the lives of couples can quite overwhelming. Therefore, the role played by the partners towards themselves cannot be downplayed. Hammarberg et al. (2010) in their report noted that couple undergoing infertility treatment programs typically serve as ‘primary source of support’ for each other.

Regardless of the source of the infertility, research has shown that the success or failure of achieving pregnancy following the diagnosis of infertility may depend on the effectiveness of the coping strategies adopted by the couple.

Various studies in varying degrees have been able to link more ‘negative affect’ or the inability to control psychological distress (resulting in psychological traits such as anxiety disorders, depression) during the ‘infertility journey’ to the potential for success in achieving pregnancy and ‘marital satisfaction’ (Pasch et al., 2002; Peterson et al., 2006; Benyamini et al., 2009; Martins et al., 2014).

In similar manner, other studies have investigated the beneficial effect of infertility including sexual performance and other marital advantages (Pasch et al., 2002; Schmidt et al., 2005; Smith et al., 2009; Hammarberg et al., 2010; Wischmann, 2010; Ferraresi et al., 2013). This was underscored in a study where negative psychological traits and coping strategies was associated with lower sexual performance (Nelson et al., 2008). Similarly, there are reports that suggest the positive outcomes in the marital lives of couples undergoing assisted reproduction technologies (Onat and Beji, 2012).

On the other hand, other researchers have held opposing views in support of the negative consequences of infertility over long period and failure of infertility treatment with reduced marital benefits (Peronance et al., 2007; Drosdzol and Shrzypulec, 2009; Sina et al., 2010).

Considering these studies, it is important to note how they highlight the ‘dyadic potential of the infertility experience how ‘understanding the potential benefits of infertility may assist couples to adopting more effective stress-coping mechanisms (Sina et al., 2010; Esselstrom, 2014).

Overview of Psychological Interventions

Various literature on mental health have continued to advocate on standard routines for stress management such as psychological interventions (Hajela et al. (2016). In the context of reproductive medicine and infertility, psychological interventions are specific therapies designed to assist couples affected by infertility, in meeting their psychological needs in the period of infertility and infertility treatment.

Since recent history, researchers and healthcare professionals have gained new perspectives on the role of psychotherapy in relation to achieving pregnancy. Verkuijlen and other researchers highlighted common interventions employed in the course of the infertility treatments including psychological and educational interventions (van Peperstraten, 2010; Verkuijlen et al., 2016). Fundamentally, psychological treatment is targeted towards behavioral changes while educational interventions is aimed at providing vital medical or procedural information on infertility including “[…] its causes, treatment, and techniques on ‘self-management and self-efficacy’ such as skills training, psycho-education.” (Verkuijlen et al., 2016).

In the context of this review; the goals of psychological interventions in providing support for individuals affected by infertility and its treatment has been categorized in the following dimensions designated as cognitive, behavioural, and psychodynamic therapies (Verkuijlen et al., 2016). In another way, the aim of the interventions for infertility patients is ‘[…] to improve their mental health and increase their pregnancy rate.’

Briefly, cognitive therapeutic interventions encompass ‘[…] changing dysfunctional cognitions and beliefs about infertility and its consequences.’ Studies have shown that holding certain negative beliefs about stressful situations often pre-dispose individuals to psychological stress and distress. Therefore, an effective approach at managing detect such dysfunctional beliefs have been theorized to alleviating psychological stress (Cuijpers, 2013).

The cognitive therapeutic interventions are often joined with behavioural interventions (Verkuijlen et al., 2016). The behavioural interventions are designed toward a shift in negative behavior associated with infertility.

Lastly, psychodynamic interventions are developed in a bid to ‘[…] alleviating internal conflicts that are believed to involve strong negative emotion about pregnancy for instance’ (Verkuijlen et al., 2016). Such emotions often originate from childhood experiences in women (Boivin, 2003).

Psychotherapy and Infertility treatment: Evidence-Based Review

There appears to be an ongoing debate on exploring the possible psychogenic source of infertility in a quest to providing effective and optimum healthcare service delivery for infertility patients. The subject of efficacy of psychological interventions are being addressed by various researchers.

As highlighted earlier, psychotherapy in infertility treatment comprise of several dimensions, some of which include (but not limited to): ‘[…] psycho-analysis, psychodynamic, cognitive-behavioral therapy, psycho-education therapies amongst others.’ (Boivin, 2003).

The purpose of this section is to present some of the scholarly works that have investigated the role of psychotherapy in infertility.

Cognitive and Behavioral Therapies (CBT)

Findings from various studies revealed that the coping strategies ‘(such as self-blame, rumination, and catastrophizing’ that people use in managing infertility-related distress may be a predictor of a tendency towards depressive symptoms (Kraaij et al., 2008; Kraaij et al., 2010). Hence, the goal of the healthcare professional should be focused on fostering positive coping strategies in management of infertility-related distress (Esselstrom, 2014).

Accordingly, one study by Domar et al. (2000) found that the recruitment of CBT in a 10-session group therapy program facilitated significant improvement in psychological outcomes in the support group compared to the control group. Significant improvements were also seen in the support group.

Faramarzi and colleagues studied the benefits of psychotropic substances (such as antidepressant) compared to CBT in women experiencing infertility and depression. The study found significant improvement in depressive symptoms in 79.3% of CBT group participants compared to 50% in patients administered the psychotropic drug, and 10% of controls.’ (Faramarzi et al., 2008). Furthermore, the study also showed similar pattern with infertile patients diagnosed with anxiety disorder: the CBT group showed a significant reduction in anxiety following treatment which was better than groups for the psychotropic drugs and control group. This was consistent in the study by Faramarzi et al. (2013).

Furthermore, based on available literature, Cognitive behavioral therapy was associated with several benefits in infertility treatment including ‘[…] optimizing likelihood of pregnancy, improved sexual performance, better couple relationship, reduction in depressive symptoms’ (Tuschen-Caffier et al., 1999).

Acceptance and Commitment Therapy

This intervention is designed to reinforce ‘[…] non-judgmental self-awareness, acceptance, and living out one’s values’ in place of avoidance as a coping strategies to dealing with psychological stress (Peterson and Eifert, 2011; Esselstrom, 2014). Esselstrom (2014) reported that this therapy was associated with lowered psychological distress in women and reduced sexual infertility-related stress in men over a period of one year, amongst other benefits (Van Rooij et al., 2007; Lykeridou et al., 2009).

Another instance where the acceptance and commitment therapy can be used is the subject of body mass index (BMI). As earlier explained, excessive weight gain or loss could interfere with the female reproductive system (RESOLVE, 2012). Esselstrom (2014) highlighted the result of a 24-week group treatment program for obese, infertile women. It is found that sequel to the intervention program, the women achieved lower weight and improvements in self-esteem, anxiety, depression, and general health (Galletly et al., 1996). It was also reported that at ‘follow-up, the majority of participants achieved pregnancy.’ (Galletly et al., 1996).

Psychoeducational Interventions

Educational interventions are designed to provide vital medical or procedural information on infertility. It addresses the subject of effective communication which as Schmidt et al. mentioned leads to an increased adoption of social support as a coping strategies for stress management (Schmidt et al., 2005).

Schimdt and other researchers (cited in Esselstrom, 2014) reported that ‘[…] couples who underwent a stress management and communication skills building program spoke more often with each other and others regarding their infertility, and were more likely to contact support groups or other psychological services.’ (Schmidt et al., 2005).

There are also reports of benefits in terms of improved spousal relationship and well-being which was evident following a study designed to assess the impact of ‘a problem-focused versus emotion-focused coping skills treatment program for 6 weeks’ (McQueeney et al., 1997). Esselstrom further noted that both problem-solving and emotion-focus coping skills are integral components of the program. ‘[…] Emotion-focused treatment was developed to assist in regulating mood-related disorders whereas the problem-solving skills was focused on increased perceived control over the infertility which is reinforced by building assertive communication skills […].’ (Esselstrom, 2014)

Online Interventions

The world wide web has in many aspects of life revolutionalised the way healthcare services are being delivered. It has also been able to create greater opportunities to the ease of accessibility particularly in providing psychological support for (Esselstrom, 2014). Couples undergoing infertility programs (in online support group) reported several benefits due to online intervention, such as ‘[…] improved relationship with their partner, reduced sense of isolation, and gaining information and empowerment (Malik and Coulson, 2008). There are research works that highlighted the demographic pattern of internet use. For instance; Haagen and colleagues study highlighted the fact that more than 50% of couples with fertility-related problems accessed the internet for consultative services including providing psychological support for infertility treatment (Haagen et al., al., 2003; Slauson-Blevins et al., 2013).

Due to its ability to provide anonymity, internet-based forums may provide a platform for couple to express the mental and psychological burden associated with infertility more openly (Malik and Coulson, 2008).

On the other hand, some researchers have also highlighted the drawbacks of online intervention including the risk of ‘[…] misunderstandings between members of the support group, feeling overwhelmed by the stories of others, and ineffectively managing involvement with the online group.’ (Malik and Coulson, 2010). This may also be consistent with studies such as one conducted by Sexton et al. (2010) that concluded that ‘[…] psychological distress among infertile couples was not significantly reduced through this intervention.

Consequently, the efficacy of these interventions have been questioned among scholars. For instance; in a review conducted by Boivin (2003) to provide evidence on whether the interventions provided better treatment outcomes than usual care; the paper reported mixed results. Boivin reported that the psychological interventions did indeed provide better results particularly among infertile patients diagnosed with anxiety disorder (8 of 13 analyses, 61.5%) compared to infertile patients suffering from depressive disorders (5 of 13 analyses, 38.4%). There was also reduction in infertility-specific stress following the psychological interventions (6 of 6 analyses, 100%) and changes in sexual behaviour in 10 of 10 analyses (100%). As noted by the researcher (Boivin, 2003); there was however, no clear indications on the efficacy for interventions on pregnancy rates after completion of infertility treatment. Of the 8 analyses conducted, only three (3) recorded increase in pregnancy rate with 18 months following psychological intervention.

In similar manner, a meta-analysis by de Liz and Strauss (2005) was conducted to investigate how efficacious the psychological interventions were across several studies (anxiety, N = 10), depressive symptoms, N = 10 and pregnancy rate, N = 16). Their effect size (pre and post) was assessed via psychometric scales for anxiety and depressive disorders while pregnancy was compared by successful pregnancy rate. The results showed similar pattern with Boivin’s (2003) for the effect of the psychological interventions on anxiety and depression. For instance; the effect sizes for pre-post analyses for anxiety disorders following the interventions were higher than those for the depressive disorders. However, the study indicated an increased successful pregnancy rate among the patients sequel to the psychological interventions.

As in both review, researchers undertaking quantitative and qualitative systematic reviews have highlighted that regardless of the findings of treatment outcomes following various psychological interventions; these analyses were often replete with varying levels of heterogeneity in the study design and methodologies (Chan et al., 2006; Domar et al., 2011; Koszycki et al., 2012; Matthiesen et al., 2012). This has been highlighted as a barrier to relying on evidence on whether psychological interventions do indeed have a significant effect on treatment outcomes.

Empirical Studies Relating to Mental and Reproductive Health

As mentioned earlier, the root causes of fertility disorders are quite multifactorial. However, in the context of the present review, more evidence on the phenomenon of “psychogenic infertility” is presented.

Available literature has for instance; highlighted the interaction between anomalies of mental health and infertility. For instance; Gdańska et al. (2017) reviewed the dyadic relationships between anxiety and depression; and how they may interfere with the success of infertility treatment.

A popular hypothesis on the root causes of infertility has been on the psychogenic model which postulates that the chances of fertility is reduced in the presence of psychogenic factors such as ‘personality traces, family relations, sexual disorders, feeling of guilt, an urge need to possess a baby or even the fear of parturition […]’ (Podolska and Bidzan, 2011).

This model arguably further produced another model that was based on a possible complex interaction between psychological and social factors and the success of achieving pregnancy (Holka-Pokorska et al., 2015). The models as Gdańska et al. (2017) noted puts into consideration the modulation of the reproductive system by the action of the hypothalamus-pituitary-adrenal (HPA) axis which is believe to juxtapose the mechanism of stress and physiological functions of reproductive system.

Interestingly, there are several studies that supports this argument. An et al. (2011) for example; worked on evaluating the relationship between HPA axis, the level of anxiety and the efficacy of IVF treatment. The sample size of the study comprised of 264 women undergoing IVF treatment. Findings from the study revealed a significant elevation in the level of norepinephrine and cortisol on the oocyte-retrieval day’ compared to the levels prior to the ART procedure. The researchers also found a relationship between the ‘concentration of serum cortisol and the intensity of state anxiety in the psychometric questionnaires.’ as reported in Gdańska et al. (2017). Additionally, it was also reported women who became pregnant recorded reduced levels of norepinephrine and cortisol in the serum and intracellular fluid.

Meanwhile, another study conducted by Turner et al. (2013) using a lower sample size (n = 44) documented an increase in anxiety levels throughout the infertility treatment course (measured by psychometric scales) in women undergoing IVF treatment. Furthermore, the study noted that women who had a lower level of anxiety before the oocyte retrieval procedure, recorded a greater success rate of pregnancy.

On the other hand, several other scholarly works did not find a relationship between anxiety and the likely of success during the infertility treatment (Hashemi et al., 2012; Pasch et al., 2016). This was also reflected in a quantitative systematic review of 31 prospective studies in Denmark where the researchers could not find anxiety disorders to be a predictor of the success of infertility treatment (Matthiesen et al., 2011).

Alternatively, depressive disorders have also been assessed as a predictor of infertility or success of the ART treatments (Gdańska et al., 2017). Some studies agree that depressive disorders actually do lead to infertility treatment failures. One of these studies – cohort study revealed that women diagnosed with depressive disorders and receiving ART treatment recorded a ‘[…] lower rate of commenced ART cycles compared to women without diagnosed depression. women with a prior diagnosis of depression had a lower mean number of live births after ART procedures compared to women without depression (Sejbaek et al., 2013).’

As Gdańska and colleagues noted several other researchers had opposing views to the fact that depression actually reduces chances of a successful infertility treatment (Pasch et al., 2002). This was consistent with the study conducted by Mathiessen et al. (2011).

Hajela et al. (2016) mentioned the negative consequences of anxiety. This was addressed in a study done in Europe (Bergner et al., 2008) that found that women diagnosed with anxiety disorders ‘[…] took longer to conceive and were more likely to miscarry, compared to women who have lower levels of anxiety. This was similar to another study that associated an history of depression to infertility. This was in fact related to ‘elevated level of luteinizing hormone in depressed woman.’

As Hammerli and other researchers stressed, there exist several evidence-based scholarly works that suggest that high levels of depressive symptoms, anxiety and psychological distress negatively impacted the success rate of achieving pregnancy during infertility program such as ART (Klonoff-Cohen et al., 2001; Smeenk et al., 2001; Hammerli et al., 2009).

It is also important to highlight the similarity of this claim with the results of various systematic reviews that eventually concluded that ‘[…] psychosocial variables such as psychosocial distress, ineffective coping strategies, anxiety and depression may possibly increase likelihood of the failure of infertility treatment.’ (Klonoff-Cohen, 2005; Homan et al., 2007; Hammerli et al., 2009).

Based on various reviews; in addition to the effect of psychotherapy on the mental well-being of patients; table 1 (in appendix section) below purposively categorised several research works that indicate an association between psychological variables and various treatment outcomes of infertility treatment programs.

Conclusion/Future Directions

The present review has addressed the fact that infertility undeniably impacts huge psychological burden to individuals and couples desiring to achieve pregnancy (Bell, 2013). More so, it addressed the subject of the root causes of infertility which have been traced to the combined effect of physiological and psychosocial factors (Peronace et al., 2007; Ferland & Caron, 2013). Lastly, the question on whether psychological traits, coping strategies and psychological interventions do in fact affect infertility treatment outcomes?

Meanwhile, stress particularly psychological stress has been implicated in the etiology of infertility and has been associated with the success rates of pregnancy following treatments (Read et al., 2013; Turner et al., 2013; Lynch et al., 2014). Hence, the importance of the review.

To this end, it is important to highlight the fact that several scholars are actually in favor of the use of psychological intervention as complementary, adjunct or supportive care (Emery et al., 2003; Wischmann et al., 2009; Funderburk et al., 2012; Vickers et al., 2013).

As observed in the current review; based on the several stand-alone studies and systemic reviews, there are findings that indicate that addressing the psychological needs of infertility patients was integral to the success rate of infertility programs. On the other hand, there are still a myriad of studies that had opposing views.

Lastly, as advanced in similar researches to investigate possible linkages, there is need for more homogeneity (a hallmark of systemic reviews) across the currently available studies. Specifically, there were a lot of concerns on the reliability and validity of these studies (in the reviews of Boivin, 2003; Thornton et al., 2010; Matthiesen et al., 2011; Esselstrom, 2014; Gdańska et al., 2017). This inevitably therefore served as a barrier to ascertaining the significant role of mental health in achieving the goals of infertility treatment programs, one of which include increasing the chances of conception while catering for the psychological burden of infertility.

It is thus important, that subsequent research effort incorporate the research capacities of various healthcare professionals and researchers in order to improve the quality of research on this subject.


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Table 1: Impact of psychological variables and Treatment Outcomes (adopted from Boivin (2003) and Thornton et al., 2010)

Abbildung in dieser Leseprobe nicht enthalten

Note: The study designs comprised of longitudinal and cross-sectional studies (randomized and non-randomized) with varying sample sizes and treatment outcomes (pregnancy, disorders of male and female reproductive system; obstetrics complications).


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The Role of Mental Health in Infertility
How much do Psychological Interventions Contribute to Reproductive Health
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infertility, mental health and reproductive health, infertility treatment, reproduction success rate, assisted reproduction technologies, psychological traits, psychological intervention, coping strategies
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