Research on Depression and Anxiety and Mind Body Interventions on Fertility and Pregnancy Outcomes

C Shani et all (2016) Suicidal risk among infertile women undergoing in-vitro fertilization: Incidence and risk factors, Psychiatry Research

Despite the fact that depression and other emotional distress are well documented in infertile women, little is known about the relationship between infertility and suicidal risk. The aim of this cross sectional study was to examine the rate of suicide risk (suicidal ideation/suicidal attempts) among 106 infertile women visiting Infertility and In-Vitro Fertilization (IVF) Hospital Unit, and to identify the demographic, medical and clinical correlates to suicidal risk. The incidence of suicide risk was 9.4%. Suicidal women were more likely to be childless or had fewer children and experienced higher levels of depressive symptoms. In addition, they reported more frequently on denial, social withdrawal and self-blame coping strategies compared to participants without suicidal risk. A multiple logistic regression model revealed that being childless, using non-positive reappraisal and exhibiting depressive symptoms were significant predictors of suicide risk in the future. These results suggest that routine assessment of suicidal risk and depression should be provided for infertile women in the course of IVF. Furthermore, future interventions should focus on helping them acquire different emotions regulation strategies and provide alternative skills for positive coping.


A D Domar, P C Zuttermeister, R Friedman (1993) The psychological impact of infertility: a comparison with patients with other medical conditions, Journal of Psychosomatic Obstetrics and Gynaecology

The infertile women had global symptom scores equivalent to the cancer, cardiac rehabilitation and hypertension patients, but lower scores than the chronic pain and HIV-positive patients (p < 0.0001 and p < 0.02 respectively). The anxiety and depression scores of the infertile women were significantly lower than chronic pain patients but not statistically different from the other groups. The results suggest that the psychological symptoms associated with infertility are similar to those associated with other serious medical conditions. Therefore, standard psychosocial interventions for serious medical illness should also be applied in infertility treatment.


M Faramarzi et al (2007) Treatment of depression and anxiety in infertile women: cognitive behavioral therapy versus fluoxetine, Journal of Affective Disorders

In a randomized controlled clinical trial, 89 mild to moderate depressed infertile women (Beck scores 10-47) were recruited into three groups; cognitive behavior therapy (CBT), antidepressant therapy, and a control group. Twenty-nine participants in the CBT method received relaxation training, restructuring, and eliminating of negative automatic thoughts and dysfunctional attitudes to depression for 10 sessions. Thirty participants in the pharmacotherapy group took 20 mg fluoxetine daily for 90 days. Thirty control subjects did not receive any intervention. All participants completed the Beck Depression Inventory and Cattell Anxiety Inventory at the beginning and end of the study. Chi2 test, paired t-test, and ANOVA were used to analyze the data. CBT was not only a reliable alternative to pharmacotherapy but also was superior to fluoxetine in the resolution or reducing of depression and anxiety of infertile women. Fluoxetine was superior to no therapy in the treatment of depression but not anxiety.


K Rooney and A Domar (2018), The relationship between stress and infertility, The relationship between stress and infertility

The relationship between stress and infertility has been debated for years. Women with infertility report elevated levels of anxiety and depression, so it is clear that infertility causes stress. What is less clear, however, is whether or not stress causes infertility. The impact of distress on treatment outcome is difficult to investigate for a number of factors, including inaccurate self-report measures and feelings of increased optimism at treatment onset. However, the most recent research has documented the efficacy of psychological interventions in lowering psychological distress as well as being associated with significant increases in pregnancy rates. A cognitive-behavioral group approach may be the most efficient way to achieve both goals. Given the distress levels reported by many infertile women, it is vital to expand the availability of these programs.

One of the main challenges in assessing the distress levels in women with infertility is the accuracy of self-report measures. It is possible that women “fake good” in order to appear mentally healthier than they are. It is also possible that women feel a sense of hopefulness/increased optimism prior to initiating infertility treatment, which is when most assessments of distress are collected. Some early studies concluded that infertile women did not report any significant differences in symptoms of anxiety and depression than fertile women. However, a 2004 study  utilized a structured psychiatric interview. A total of 122 women were interviewed prior to their first infertility clinic visit and the results were striking; 40% of women were diagnosed as having anxiety, depression, or both. Subsequent research has supported these findings. Volgsten and colleagues reported a 31% prevalence of psychiatric symptoms, the most common of which was major depression. In a large Danish study of 42 000 women who underwent ART treatment and were screened for depression prior to treatment, 35% screened positive. In another recent study of 174 women undergoing infertility treatment, 39% met the criteria for major depressive disorder. In one of the largest studies to date, 352 women and 274 men were assessed in infertility clinics in northern California. It was determined that 56% of the women and 32% of the men reported significant symptoms of depression and 76% of the women and 61% of the men scored reported significant symptoms of anxiety. Not surprisingly, recent research documents that infertility patients consistently report significantly more symptoms of anxiety and depression than fertile individuals. Finally, in a recent concerning study on suicidality in 106 women with infertility, 9.4% of the women reported having suicidal thoughts or attempts.

A recent literature review on the prevalence of psychological symptoms in infertility concluded that 25% to 60% of infertile individuals report psychiatric symptoms and that their levels of anxiety and depression are significantly higher than in fertile controls.

The medications used to treat infertility, including clomiphene, leuprolide, and gonadotropins, are associated with psychological symptoms such as anxiety, depression, and irritability. Thus, when assessing symptoms of women mid-treatment, it is difficult to differentiate between the psychological impact of infertility versus the side effects of the medication. Thus, studies which included measures of these symptoms prior to beginning medication, or after going off it, may be more accurate than those done only on women as they cycle.

The further into treatment a patient goes, the more often they display symptoms of depression and anxiety. Patients with one treatment failure had significantly higher levels of anxiety, and patients with two failures experienced more depression when compared with those without a history of treatment. However, it has also been shown that the more depressed the infertile woman, the less likely she is to start infertility treatment and the more likely she is to drop out after only one cycle. Researchers have also shown that despite a good prognosis and having the finances available to pay for treatment, discontinuation is most often due to psychological reasons.

A diagnosis of infertility can be a tremendous burden for patients. The pain and suffering of infertility patients is a major problem. Patients must be counseled and supported as they go through treatment. Although neither the American Society for Reproductive Medicine nor the European Society for Human Reproduction and Embryology have formal requirements for psychological counseling for infertility patients, there is acknowledgement that incorporating psychological interventions into routine practice at ART clinics is beneficial. It has been well documented that infertility causes stress. The impact of stress on ART outcome is still somewhat controversial. However, it is clear that psychological interventions for women with infertility have the potential to decrease anxiety and depression and may well lead to significantly higher pregnancy rates.

Further reading:

M Faramarzi et al (2008), Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women? A randomized clinical trial, European Journal of Obstetrics, Gynaecological and Reproduction Biology

n a randomized controlled clinical trial, 89 depressed infertile women that they were recruited and divided into three groups in three groups: cognitive behavior therapy (CBT), antidepressant therapy, and a control group. Twenty-nine participants in the CBT method received 10 sessions on relaxation training, restructuring, and eliminating negative automatic thoughts and dysfunctional attitudes to infertility. Thirty participants in the pharmacotherapic group took 20mg fluoxetine daily for 90 days. Thirty control subjects did not receive any intervention. All participants completed the Beck Depression Inventory (BDI) and the General Health Questionnaire (GHQ) at the beginning and end of the study. Paired t-test, ANOVA, chi(2), and McNemar tests were used to analyze the data.

Psychotherapy, such as group CBT, was superior to or at least as effective as pharmacotherapy to promote the well being of depressed infertile women.


M Taebi, M Simbar and S Abdolahian (2018), Psychological empowerment strategies in infertile women: A systematic review, Journal of Education and Health Promotion

Infertility requires long-term care and treatments which would influence different aspects of health including the mental health of infertile women. The present study was conducted to determine strategies for psychological empowerment of infertile women. This systematic review was performed on previously conducted clinical trials. To achieve the intended studies, databases of Magiran, Scientific Information Database, Google Scholar, Scopus, PubMed, ProQuest, ScienceDirect, and Web of Science and also Iranian Registry of Clinical Trials website were searched using “infertility and infertile women” as the keywords. The inclusion criteria were being an interventional study and assessing the psychological status of infertile women. Performed studies in Iran with no time limitations were evaluated. Based on the Jadad criteria, studies with a score of 3 or more were enrolled in the systematic review. After assessing the quality of the studies, 21 studies were enrolled in the review for final evaluation. Reviewing the conducted studies showed that educational and counseling interventions could be effective in improving the aspects of psychological well-being of infertile women. Existing evidence revealed that applying coping strategies is effective in improving the quality of life in infertile women, which consequently lead to the improvement of psychological empowerment of infertile women.


K Turner et al (2013) Stress and Anxiety Scores in First and Repeat IVF Cycles: A Pilot Study, PLOS ONE

Stress and anxiety levels remained elevated across all cycles. Women with lower stress and anxiety levels on the day prior to oocyte retrieval had a higher pregnancy rate. These results emphasize the need to investigate stress reduction modalities throughout the IVF cycle.


S McLeod (2017) Type A Personality. Simply Psychology.

The researchers found that more than twice as many Type A people as Type B people developed coronary heart disease. When the figures were adjusted for smoking, lifestyle, etc. it still emerged that Type A people were nearly twice as likely to develop heart disease as Type B people.

For example, eight years later 257 of the participants had developed coronary heart disease. By the end of the study, 70% of the men who had developed coronary heart disease (CHD) were Type A personalities. The Type A personality types behavior makes them more prone to stress-related illnesses such as CHD, raised blood pressure, etc. Such people are more likely to have their ”flight or fight” response set off by things in their environment. As a result, they are more likely to have the stress hormones present, which over a long period of time leads to a range of stress-related illnesses.


H Klonoff-Cohen and L Natarajan (2004) The concerns during assisted reproductive technologies (CART) scale and pregnancy outcomes, Fertility and Sterility

At baseline, women who were concerned about the medical aspects (i.e., side effects, surgery, anesthesia, not enough information, pain, and recovery) of the procedure had 20% fewer oocytes retrieved and 19% fewer oocytes fertilized, while simultaneously adjusting for female age, race, education, smoking status, parity, type of assisted reproductive technologies (ART) procedure (IVF or GIFT), type of infertility, and number of previous attempts. Women who were very concerned about missing work had 30% fewer ooyctes fertilized. For women who were moderately concerned about missing work, the odds ratio was 2.83 for not achieving a pregnancy. Women who were extremely concerned about the finances associated with the procedure had a very high risk (odds ratio [OR] = 11.62) of not achieving a successful live birth delivery.

G Csemiczky 1, B M Landgren, A Collins (2000) The influence of stress and state anxiety on the outcome of IVF-treatment: psychological and endocrinological assessment of Swedish women entering IVF-treatment, Acta Obstetricia et Gynecologia Scandanavia

Comparison of the personality profiles of the two groups, showed that infertile women had significantly higher scores of suspicion (p>0.05), guilt (p>0.05), and hostility (p>0.01), but lower somatic anxiety (0.05) and indirect aggression (0.05) than fertile controls. The infertile women also had significantly higher levels of prolactin and cortisol throughout the menstrual cycle. Serum cortisol, prolactin and FSH levels on cycle day 3 did not differ between the women who conceived after IVF treatment and those who did not conceive. However, significant differences were found in E2 and P4 AUC (p>0.01) in the luteal phase between those women who became pregnant and those who failed. There was a trend (p<0.06) toward higher state anxiety levels among the women who did not succeed in becoming pregnant after IVF treatment.

K Demyttenaere et al (1992) Coping and the ineffectiveness of coping influence the outcome of in vivro fertilization through stress responses, Psychoneuroendocrinology

The effect of a coping-ineffectiveness of coping construct and of psychoendocrine stress responses upon the outcome of in vitro fertilization treatment was investigated in 40 women. Women with a high Zung depression score, high active coping, high avoidance, and a high expression of emotion have lower pregnancy rates. The mechanisms for this personality effect are not clear, although the desensitization-stimulation process (FSH, E2 concentrations) seems to be involved. The psychoendocrinological responses to the stress of oocyte retrieval and embryo transfer are important: Women with high anticipatory state anxiety levels and high anticipatory cortisol concentrations have lower pregnancy rates. The influence of prolactin stress concentrations is unclear: Women with high prolactin concentrations seem to have more oocytes but lower fertilization rates.


Demyttenaere, K., Nijs, P., Steeno, O., Koninckx, P., & Evers-Kiebooms, G. (1988). Anxiety and conception rates in donor insemination. Journal of Psychosomatic Obstetrics & Gynecology, 8(3), 175–181

Examined whether there is a relationship between anxiety levels and conception rates by administering the State-Trait Anxiety Inventory to 116 married women entering an artificial donor insemination treatment. 60 Ss became pregnant after 1–7 cycles, and all pregnancy groups were comparable in duration of infertility, age of the S, female fertility status, and the husband’s infertile status. A significant relation was found between initial trait anxiety level and the number of treatment cycles necessary for conception. Ss having early spontaneous abortions were initially more stressed than the other pregnant


Domar et al (2000) Impact of group psychological interventions on pregnancy rates in infertile women, Fertility and Sterility

Depression is associated with abnormal regulation of luteinizing hormone (17). Activation of the hypothalamic-pituitary-adrenal axis can profoundly inhibit reproductive function. This inhibition of reproductive function can be at many levels, ranging from inhibition of hypothalamic GnRH to possible direct actions on the ovary and endometrium in a manner that could prevent pregnancy. Furthermore, stress and depression alters immune function and specific cytokines (18), which in turn could adversely affect reproductive function.

Because mind/body programs are effective in reducing negative emotions that may impair IVF success, patients should be offered such a program in conjunction with IVF (7). The results of this study suggest that psychological interventions may affect pregnancy rates at an earlier point and should perhaps be implemented in conjunction with initial medical treatment.

Women who participated in a group psychological intervention had significantly increased viable pregnancy rates compared to women who did not participate in any psychological intervention. This difference was not due to any group demographic differences, including age and duration of infertility, nor was it because of group differences in medical interventions.


Domar et al (2011) Impact of a group mind/body intervention on pregnancy rates in IVF patients, Fertility and Sterility

The negative effect of stress in reproductive health is generally accepted as occurring through increased hypothalamic-pituitary-adrenal axis activity . The distress-conception relationship is complicated. Numerous studies have shown that distress is associated with lower IVF success rates.

In this study, women who were about to begin their first IVF cycle underwent a 10 week mind body program or a control group and were monitored over two IVF cycles. Pregnancy rates for cycle two were 52% for the mind body group and only 20% for the control group.

This study also recommended that the most effective psychologic intervention would be skills-based of six or more sessions.


J Kiecolt-Glaser, H Derry and C Fagundes (2015) Inflammation: depression fans the flames and feasts on the heat, The American Journal of Psychiatry

Ohio and Rice Universities analysed 200 previous pieces of research in 2015 that found that chronic inflammation (i.e. the same inflammation present in conditions such as PCOS, Endometriosis, Auto-Immune Conditions and more) exacerbated depression greatly and also then contributed to more inflammation.

This study also found that the depression and inflammation was resistant to traditional forms of treatment (such as traditional anti-depressants and therapy) but that mind-body programs such as yoga and meditation DID reduce both cortisol levels and inflammation.


S Berga, Cognitive Behavioural Therapy can restore ovulation in infertile women, Emory University, European Society of Human Reproduction and Embryology (22nd annual conference)

A study by researchers from Emory University in Atlanta, Georgia, found that cognitive behavioural therapy can aid fertility by reducing anxiety, which often inhibits ovulation. A study by Emory University in Atlanta, Georgia took several women who had not had a period in six months. Half were introduced to cognitive behavioural therapy for 20 weeks and half were merely observed.

At the end of this, 80% who were given CBT regained full fertility and 25% of them became pregnant within two months. In the women who didn’t, only 12.5% recovered fertility.


Edelmann RJ (1990) Emotional aspects of in vitro fertilization procedures: review. J Reprod Infertil Psychol 8:161–73
A 1990 study compared 63 women about to undergo an IVF cycle. Those who attended a 2 week relaxation course, showed significantly improved success rates on their first cycle.



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