Can Psychological Therapy Help Women With Infertility? A Major Review of 69 Studies

Table of Contents

• Key Points
• Background: Why This Research Matters
• How Infertility Is Defined
• The Mental Health Toll of Infertility
• Why Women Are More Affected Than Men
• What Earlier Reviews Found — and What They Missed
• The Aim of This Review
• Study Methods: How the Research Was Conducted
• Which Studies Were Included
• Who the Participants Were
• What Counted as a Psychological Intervention
• What the Interventions Were Compared Against
• What Outcomes Were Measured
• How Studies Were Found
• How Study Quality Was Assessed
• How the Data Were Analysed
• Key Findings
• What Influenced How Well Interventions Worked
• Clinical Implications: What This Means for Patients
• Limitations: What the Study Could Not Prove
• Recommendations for Patients and Clinicians
• Frequently Asked Questions
• Source Information

Key Points

• A review of 69 studies with 5,935 women found psychological interventions significantly reduced anxiety and depression and improved well-being.
• The overall combined effect across all mental health outcomes was not statistically significant; benefits were specific to certain domains.
• Well-being improved with more sessions, but longer interventions and longer session duration were linked to smaller improvements.
• Online delivery and region influenced how well interventions worked; the review supports integrating psychological care into fertility treatment.

Background: Why This Research Matters

Infertility affects millions of people worldwide. Around 17.5% of adults — approximately 1 in 6 — experience infertility, and it is the fifth leading cause of disability globally.

Over the past two decades, researchers have increasingly studied the psychological consequences of infertility. Studies have shown a clear link between infertility and poor mental health outcomes. The healthcare system now increasingly recognises that infertility affects both psychological distress and overall well-being.

Psychological symptoms of infertility can be understood across three domains: emotional, cognitive, and somatic (physical).

• Emotionally, individuals often report sadness, grief, anger, shame, and loneliness. These feelings reflect the profound sense of loss and disrupted life expectations that accompany infertility.
• Cognitively, self-blame and a sense of failure are common. Evidence suggests these feelings result from internalised societal or personal expectations about fertility.
• Somatically, anxiety and depression often come with physical features such as fatigue, tension, and disrupted sleep. These features signal the broader physiological toll of chronic psychological stress.

How Infertility Is Defined

This review used the definition from the International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization. Infertility is defined as "a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse. Infertility can also be due to an impairment of a person's capacity to reproduce either as an individual or with his/her partner."

To determine gender distribution and the causes of infertility, the WHO performed a large multinational study. The findings showed that in 37% of infertile couples, female infertility was the primary cause. Male infertility was the sole cause in around 20–30% of cases. However, men are estimated to contribute about 50% of all infertility cases overall, either as the sole factor or in combination with female-related factors. In approximately one-third of cases, infertility is due to combined male and female factors or remains unexplained.

The Mental Health Toll of Infertility

A recent meta-analysis identified a 60% increased risk of psychological distress among women with infertility compared with the general population. More specifically, the risks of anxiety and depression in infertile women are 60% and 40% higher than in other women.

This heightened vulnerability is underscored by a number of biopsychosocial factors. In social contexts, fertility remains closely linked to female identity and social value. This link can worsen feelings of shame, failure, and isolation when infertility occurs.

Psychologically, infertility can disrupt a woman's core sense of self. This disruption can lead to identity confusion, chronic stress, and maladaptive coping responses (coping strategies that make things worse rather than better).

Neurobiologically, the prolonged experience of uncertainty, loss, and a perceived lack of control may activate stress-related pathways in the body. These pathways contribute to heightened symptoms of anxiety and depression.

Women undergoing assisted reproductive technologies may also have multiple hormonal, drug, and surgical treatments. These treatments further worsen the physical toll of infertility. Overall, women who are childless due to infertility reported reduced emotional health and lower social well-being than the overall female population of Australia.

Why Women Are More Affected Than Men

Despite women and men being equally likely to struggle with infertility, women struggling with infertility are more likely to experience psychological distress. This distress includes anxiety, depression, and low quality of life when compared with men.

In light of the mental health impacts of infertility, psychological interventions are now considered an important part of interprofessional treatment. This recognition highlights the importance of identifying the most effective psychological interventions to improve mental health in women experiencing infertility-related distress.

What Earlier Reviews Found — and What They Missed

Chow and colleagues (2016) conducted a critical review of 12 studies evaluating psychosocial interventions for infertile couples. They concluded that such interventions generally improve psychological well-being, marital relationships, and pregnancy rates. However, the review noted significant variability in intervention design and called for more rigorous research to establish which components are most effective.

Katyal and colleagues (2021) conducted a systematic review and meta-analysis of 15 randomised controlled trials (RCTs). They demonstrated that psychosocial interventions improved pregnancy rate outcomes in couples undergoing Assisted Reproductive Technologies (ART). However, that review did not directly address the potential psychological impacts.

These outcomes highlight the need for a more targeted synthesis focused on distress and psychological well-being. This need is also highlighted by the emergence of newer interventions such as Eye Movement Desensitization and Reprocessing (EMDR) therapy and Acceptance and Commitment Therapy (ACT).

A recent systematic review and meta-analysis by Dube and colleagues (2023) provided current insights. The review examined the efficacy of psychological interventions for improving mental health and pregnancy outcomes among individuals and couples with infertility. The findings indicated that psychological interventions were generally effective in reducing distress and improving pregnancy rates overall, independent of therapeutic approach, format, or duration. Notably, that study was not focused on women.

Another 2023 systematic review of 60 studies by Koochaksaraei and colleagues highlighted a range of interventions focusing on women's mental health during infertility. However, that review did not provide statistical estimates of effectiveness. This gap limits our understanding of the impacts of these interventions on women's mental health during infertility.

This evidence gap limits the development of clear, evidence-based psychological treatment guidelines focused on women.

The Aim of This Review

The aim of this systematic review and meta-analysis is to address these limitations. The authors applied a three-level meta-analytic approach to provide a comprehensive evaluation of psychological interventions for women experiencing infertility-related distress.

The review evaluates the effectiveness of interventions across key mental health outcomes. These outcomes include anxiety, depression, stress, general psychological distress, infertility-specific distress, and well-being.

In addition, the review examines potential treatment moderators. These moderators include therapeutic approach, intervention format, dosage characteristics, and fertility treatment status. The goal is to identify psychological and methodological factors that may influence efficacy. Finally, the review highlights gaps and opportunities in the existing literature to inform the design of future research and clinical practice.

Study Methods: How the Research Was Conducted

The study protocol for this systematic review and meta-analysis was registered with PROSPERO (registration number CRD42024564099). The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Which Studies Were Included

The PICO model was used to guide the study selection process. PICO stands for Population, Intervention, Comparison, and Outcome.

Type of studies: The review considered studies evaluating the efficacy of psychological interventions for women experiencing infertility. Eligible designs included randomised controlled trials (RCTs), waitlist crossover trials, and quasi-experimental studies with appropriate comparison groups. If multiple publications were drawn from the same trial, the most comprehensive report was included. Study quality was assessed through visual inspection and author consensus, with reference to PICO criteria.

Type of participants: To be eligible, studies had to be conducted on adult women (18 years and older) who met the definition of infertility. Characteristics of the study population are likely to influence the effectiveness of psychological interventions. These characteristics include history of failed treatment, pregnancy loss, or infertility cause. However, a moderation analysis was not feasible in this review. This was due to substantial missing or inconsistently reported data across studies. The absence of detailed reporting on these variables limited the authors' ability to conduct a reliable quantitative examination. This remains an important direction for future research.

Type of interventions: Psychological interventions were defined as mental health treatments grounded in psychological theories or techniques. These interventions aim to improve emotional, cognitive, or social functioning. They could be delivered individually, in groups, or with couples, either face-to-face or via self-guided formats (web-based modules, phone applications).

This review specifically focused on the effect of psychological interventions on infertility-related distress. Interventions involving pharmacological or psychotropic medications (antidepressants, anxiolytics) or complementary and alternative therapies (yoga, relaxation massage) were excluded when these represented the primary intervention. They were also excluded when delivered in conjunction with a psychological intervention in a way that confounded attribution of effects. However, such interventions were not excluded when used as active controls, as the comparator groups were analysed separately from the psychological intervention arms.

Type of comparison: To be eligible, studies had to evaluate a psychological intervention compared with an inactive control group. Inclusion in the meta-analysis required the study to report sufficient data to calculate an effect size for the treatment.

Treatment comparisons were classified into one of three categories:

• Treatment as usual (TAU): Participants received their standard care, with the only difference being their completion of outcome measures.
• Waitlist: Participants did not receive any intervention during the measurement period but were offered the intervention afterward.
• Active control: Included non-psychological interventions such as pharmacotherapy (medication).

Pharmacotherapy arms were only retained in the systematic review when used as comparator conditions. They were not pooled with psychological interventions. This approach allowed the authors to assess the relative effectiveness of psychological interventions against established standards of care.

Who the Participants Were

Participant characteristics extracted included sample size, age, duration of infertility, cause of infertility, and ART status. Study characteristics were also extracted, including the country of origin, intervention name, type, delivery format, duration, session frequency, and control condition.

Additionally, continuous outcome data were recorded. These included means and standard deviations at baseline and post-intervention for the psychological outcomes of interest. When relevant outcome data were missing, study authors were contacted.

What Counted as a Psychological Intervention

Psychological interventions were defined as mental health treatments grounded in psychological theories or techniques. These treatments aim to improve emotional, cognitive, or social functioning. They could be delivered individually, in groups, or with couples, either face-to-face or via self-guided formats such as web-based modules or phone applications.

The review specifically focused on the effect of psychological interventions on infertility-related distress. Interventions involving pharmacological or psychotropic medications or complementary and alternative therapies were excluded when these represented the primary intervention.

What the Interventions Were Compared Against

Studies had to evaluate a psychological intervention compared with an inactive control group. Inclusion in the meta-analysis required the study to report sufficient data to calculate an effect size for the treatment.

When studies had both an active control and either a waitlist or TAU control, data from the inactive control group were selected as the control group of interest. In studies where two psychological interventions were compared, each intervention was analysed separately.

What Outcomes Were Measured

For inclusion in this review, the outcomes of the trials had to assess psychological distress or well-being using validated self-report or clinician-rated instruments. These were assessed at both baseline and post-intervention.

Primary outcomes included:

• Depression
• Anxiety
• Stress
• General distress
• Infertility-specific distress
• Overall well-being

In addition to primary outcomes, the following variables were extracted and analysed as potential moderators of intervention effectiveness. These variables were therapeutic approach, intervention duration, frequency and length of sessions, delivery format, and study quality rating.

Although well-being is conceptually distinct from distress-related outcomes, it was included in a combined analysis to explore the overall impact of psychological interventions on psychological functioning. However, due to its distinct conceptual underpinnings, a separate analysis was conducted without well-being as a domain.

Psychological distress measures assess negative psychological states, whereas well-being captures positive psychological states. Studies assessing each domain employed different measurement tools and conceptual frameworks, contributing to heterogeneity (variation between studies). The distinct nature of these outcomes justified analysing well-being separately. This provided a clearer understanding of how psychological interventions influence positive mental health aspects independently of distress reduction.

How Studies Were Found

A comprehensive search of the following databases from inception until March 2024 was conducted: Scopus, PubMed, Web of Science, and Google Scholar.

The search strategy combined terms related to infertility and psychological interventions. Infertility terms were infertility, infertile, infertility treatment, infertile women, fertility, and fertile. Psychological intervention terms were cognitive behavioural therapy, CBT, ACT, psychological intervention, EMDR, Schema, ITP, DBT, mindfulness, therapy, depression, anxiety, and well-being. No date or language limits were applied to the initial search.

In addition to database searches, reference lists of included studies and relevant systematic reviews were manually searched to identify additional eligible studies. An updated search was conducted in August 2025 to ensure currency of the review.

The initial database search yielded 8,068 results. These were screened at the title and abstract level for eligibility using Covidence software, after duplicates were removed. The title/abstract screening was conducted by the primary author, while the full-text screening was completed by all four authors, with each study screened by two reviewers.

Inter-rater reliability was calculated using Cohen's kappa for three reviewer pairs. The resulting kappa values ranged from 0.00 to 0.45, indicating variable agreement across pairs. Moderate agreement was observed in two of the three pairs (κ = 0.44–0.45).

Data on participants, methods, interventions, and outcome measures were extracted and managed in Covidence. This was completed by all four authors. Disagreements during both the full-text screening and data extraction phases were resolved through group discussions with all four authors.

How Study Quality Was Assessed

Study quality and risk of bias were assessed using the Risk of Bias 2 (RoB2) criteria. The RoB2 tool was used to assess:

• Sequence generation
• Allocation concealment
• Blinding of participants and personnel
• Blinding of outcome assessors
• Incomplete outcome data
• Selective outcome reporting
• Any other source of bias

For each study, each domain on the quality assessment template was rated with a risk of bias as either 'High', 'Low', or 'Unclear'.

How the Data Were Analysed

A three-level random-effects model was applied. This model accounts for the assumption that the included primary studies represent a random sample from a larger population of potential studies.

Many studies reported multiple outcomes, such as anxiety, depression, and well-being. The authors needed to account for the fact that these outcomes share common participants, instruments, and intervention conditions. To account for this non-independence of effect sizes, three-level meta-analytic models were employed.

This was conducted in R (version 4.4.3) using the rma.mv function from the metafor package. The analysis used restricted maximum likelihood (REML) estimation and Knapp–Hartung adjustments. These adjustments improve the accuracy of standard errors and confidence intervals.

For each pooled model, 95% prediction intervals (PIs) were calculated. These indicate the range of true effects expected in a new, similar study.

Within-study correlations between outcomes were not assumed in advance. Instead, dependency among outcomes from the same study was modelled through estimation of the level-2 variance component (σ²₂). This model estimates three distinct sources of variance:

1. Variance between studies (level 3)
2. Variance between effect sizes within the same study (level 2)
3. Sampling variance of the effect sizes (level 1)

Level-1 variance was treated as known and calculated using reported standard errors from each study, transformed into variances as per Cheung's methodology (2014).

An initial three-level meta-analysis was conducted to evaluate the overall effect of psychological interventions across all outcomes. To account for potential differences in intervention effectiveness across psychological constructs, additional domain-specific models were then estimated: anxiety, depression, stress, general psychological distress, infertility-related distress, and well-being.

Studies that reported both distress and well-being outcomes contributed effect sizes to each relevant model. These constructs were analysed separately due to their conceptual and measurement distinctions. Dependency was appropriately modelled through the three-level structure. Distress outcomes reflect negative psychological states, while well-being reflects positive psychological functioning. This allowed for a more precise evaluation of how interventions affected distinct aspects of mental health.

For all models, variance components at each level were examined to determine the distribution of variance.

Key Findings

Sixty-nine studies involving 5,935 women were included in the systematic review. Sixty of these studies contributed data to a three-level random-effects meta-analysis.

The overall pooled effect across all outcomes was not statistically significant. This means that when all mental health outcomes were combined into a single analysis, the psychological interventions did not show a statistically significant overall effect.

However, domain-specific analyses told a different story. When the authors looked at specific mental health outcomes separately, they found significant effects for several key domains:

• Anxiety: g = -0.83, p < .001. This means psychological interventions significantly reduced anxiety in women with infertility. The result was statistically highly significant, meaning there is less than a 0.1% probability that this finding was due to chance.
• Depression: g = -0.88, p < .001. Psychological interventions significantly reduced depression. This result was also statistically highly significant.
• Well-being: g = 1.39, p = .004. Psychological interventions significantly improved well-being. This result was statistically significant, meaning there is less than a 0.4% probability that this finding was due to chance.

The effect size "g" is a statistical measure called Hedges' g. It expresses the size of the difference between the intervention group and the control group. A negative value for anxiety and depression means the intervention reduced these symptoms. A positive value for well-being means the intervention improved well-being.

Cognitive-behavioural therapy (CBT) and counselling were among the most effective approaches identified in the review.

What Influenced How Well Interventions Worked

The review examined several factors that might influence how well psychological interventions worked. These factors are called moderators.

Dosage and domain: In analyses that looked at dosage combined with outcome domain, well-being improved with a greater number of sessions. This means that women who attended more sessions experienced greater improvements in well-being. However, longer interventions and longer session duration were associated with smaller improvements. This was an unexpected finding.

Delivery format: Online delivery moderated treatment effects. This means that whether the intervention was delivered online or in person influenced how well it worked.

Regional differences: Regional differences also moderated treatment effects. This means that where the study was conducted influenced the results.

Intervention type: Cognitive-behavioural therapy (CBT) and counselling were among the most effective approaches.

The authors note that the findings support the importance of selecting theory-driven approaches matched to the distinct emotional and contextual challenges of infertility. Delivery format, cultural context, and long-term follow-up should also be considered to enhance intervention impact.

Clinical Implications: What This Means for Patients

Psychological interventions can significantly improve specific domains of mental health among women experiencing infertility. This is the central conclusion of the review.

The findings support the integration of targeted psychological care into fertility treatment. This means that psychological support should be a routine part of fertility care, not an optional extra.

The review also highlights the importance of selecting theory-driven approaches matched to the distinct emotional and contextual challenges of infertility. In other words, the type of therapy matters, and it should be chosen to fit the specific needs of each woman.

For patients, this means that:

• Psychological interventions can help reduce anxiety and depression related to infertility.
• Psychological interventions can improve overall well-being.
• Cognitive-behavioural therapy (CBT) and counselling are among the most effective approaches studied.
• The number of sessions may matter for well-being, with more sessions associated with greater improvement in well-being.
• Online delivery may be an effective option for some women.

The overall pooled effect across all outcomes was not statistically significant. This means that not every outcome improved, and the overall picture is more nuanced than a simple "therapy works" message. The benefits were specific to certain outcomes — particularly anxiety, depression, and well-being.

Limitations: What the Study Could Not Prove

Several limitations affect how we should interpret these findings.

Missing data on participant characteristics: Characteristics of the study population, such as history of failed treatment, pregnancy loss, or cause of infertility, are likely to influence the effectiveness of psychological interventions. However, a moderation analysis was not feasible in this review due to substantial missing or inconsistently reported data across studies. This limited the authors' ability to conduct a reliable quantitative examination of these factors.

Variable agreement between reviewers: Inter-rater reliability, measured by Cohen's kappa, ranged from 0.00 to 0.45 across three reviewer pairs. This indicates variable agreement. Moderate agreement was observed in only two of the three pairs (κ = 0.44–0.45).

Heterogeneity: Studies assessing distress and well-being employed different measurement tools and conceptual frameworks. This contributed to heterogeneity (variation between studies), which can make it harder to draw firm conclusions.

Overall effect not significant: The overall pooled effect across all outcomes was not statistically significant. This means that when all outcomes were combined, the interventions did not show a statistically significant overall effect. The benefits were specific to certain domains.

Unexpected dosage findings: Longer interventions and longer session duration were associated with smaller improvements. This finding is unexpected and requires further investigation.

Need for more systematic reporting: The authors recommend that future trials provide more systematic reporting of treatment history, infertility cause, and loss experiences. This would enable meaningful subgroup analyses in future reviews.

Recommendations for Patients and Clinicians

For patients:

1. Consider asking your fertility clinic about psychological support services. The review supports integrating targeted psychological care into fertility treatment.
2. Cognitive-behavioural therapy (CBT) and counselling are among the most effective approaches identified. Ask whether these approaches are available to you.
3. If you are experiencing anxiety or depression related to infertility, psychological interventions may help. The review found significant reductions in both anxiety and depression.
4. Well-being can improve with psychological support. The review found that well-being improved significantly, especially with a greater number of sessions.
5. Online delivery may be an effective option. The review found that online delivery moderated treatment effects, meaning it influenced how well interventions worked.

For clinicians and researchers:

1. Integrate targeted psychological care into fertility treatment. The findings support this approach.
2. Select theory-driven approaches matched to the distinct emotional and contextual challenges of infertility.
3. Consider delivery format, cultural context, and long-term follow-up to enhance intervention impact.
4. Future trials should provide more systematic reporting of treatment history, infertility cause, and loss experiences. This would enable meaningful subgroup analyses.
5. Further research is needed to explore which elements of psychological and methodological moderators influence intervention outcomes.

Frequently Asked Questions

Can psychological therapy help women with infertility?

A review of 69 studies involving 5,935 women found that psychological interventions significantly reduced anxiety and depression and improved well-being. However, when all mental health outcomes were combined into one analysis, the overall effect was not statistically significant. The benefits were specific to certain outcomes rather than across the board.

How many therapy sessions might I need to feel better?

The review found that well-being improved with a greater number of sessions. However, longer interventions and longer session duration were associated with smaller improvements—an unexpected finding. This suggests that more sessions may help well-being, but the relationship is not straightforward. Discuss the appropriate dose with your clinician.

Does online therapy work as well as in-person therapy for infertility distress?

The review found that online delivery moderated treatment effects, meaning it influenced how well interventions worked. This suggests that online delivery may be an effective option for some women. However, the review did not conclude that online therapy is equal to or better than in-person therapy; it simply found that delivery format mattered.

What does the overall non-significant result mean for me?

When all mental health outcomes were combined into a single analysis, the psychological interventions did not show a statistically significant overall effect. This means not every outcome improved. However, when outcomes were looked at separately, anxiety, depression, and well-being showed significant improvements. The overall picture is more nuanced than a simple 'therapy works' message.

Are there any risks or limitations I should know about?

The review noted several limitations: missing data on participant characteristics, variable agreement between reviewers, and heterogeneity across studies. Also, longer interventions were linked to smaller improvements, which was unexpected. These factors mean the findings should be interpreted with caution, and more research is needed to understand who benefits most.

Should I ask my fertility clinic about psychological support?

The review supports integrating targeted psychological care into fertility treatment. You can ask your clinic whether psychological support services are available, and specifically whether cognitive-behavioural therapy (CBT) or counselling are offered. If you are experiencing anxiety or depression related to infertility, the review found these interventions may help reduce those symptoms and improve well-being.

If I'm struggling with anxiety or depression from infertility, when should I get a second opinion about psychological therapy?

A second opinion can help when you are unsure which psychological approach fits your situation. Cognitive-behavioural therapy and counselling are among the most effective approaches studied, and psychological interventions significantly reduced anxiety and depression in women with infertility. A second opinion may also clarify session planning, since well-being improved with a greater number of sessions, and online delivery influenced how well interventions worked. If your current plan does not address anxiety, depression, or well-being, an independent review of your options can be useful. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original article title: The efficacy of psychological interventions for infertile women: a systematic review and meta-analysis.

Authors: Jackson PL, Saunders P, Mizzi S, Hallam KT.

Affiliation: Department of Psychology, RMIT University, Melbourne, Australia.

Publication: BMC Women's Health (2025) 25:506.

DOI: https://doi.org/10.1186/s12905-025-04054-x

Registration: PROSPERO CRD42024564099.

Note: This patient-friendly article is based on peer-reviewed research. The original article is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.