Review: Infertility Associated With Depression, Anxiety, and Emotional Distress

Infertility and mental health have a complex relationship, with the impact of mental distress in evaluating for infertility and fertility treatments being quite significant.

Many pharmacologic treatments in assisted reproduction technology (ART) can affect mental health. Similarly, depression, anxiety, and emotional distress may affect the outcomes of (ART) and other infertility treatments, although this is controversial.

According to a review by authors from the University of South Carolina, School of Medicine, Greenville/Prisma Health, prior infertility and mental health studies suggest individuals and couples who are struggling with infertility should be evaluated for mental health and emotional distress as early as possible, to provide appropriate support and intervention that can ensure the best outcomes.

“Irrespective of the aforementioned facts, depression, anxiety, and emotional distress are common in the infertility population, and evidence-based treatment options should be offered,” noted the authors of this review.

Infertility affects around 15% of reproductive-aged couples in the United States. Approximately 37% of infertility cases are attributed to female factors, 8% to male factors, 35% to combined factors, and 20% are unknown. Additionally, ART interventions have increased each year, with 42% to 76% of women seeking infertility treatment, worldwide.

Many causes of infertility have been linked to psychiatric illnesses or symptoms, including polycystic ovarian syndrome (PCOS), endometriosis, and autoimmune thyroid disorders.

PCOS is associated with higher rates of anxiety, depression, and eating disorders. One study reported the prevalence of infertility in women with PCOS was as high as 73%, compared to those without PCOS.

Another prospective cohort study in 2021 found higher incidences of anxiety, depression, and self-directed violence in women with endometriosis and back pain associated with endometriosis than those without.

Thyroid disorders are also known to affect mood, energy levels, anxiety, and depression.

Common screening tools—including the Patient Health Questionnaire (PHQ)–9 and PHQ-2, as well as PHQ-4, a tool composed of both the PHQ-2 and Generalized Anxiety Disorder-2—allow for quick evaluation and assessment of new and existing and mental health conditions that may be exacerbated by infertility.

“Because infertility is considered a chronic stressor and ART involves treatments with potential neuropsychiatric effects, thorough psychiatric screening is important for all individuals with infertility, with a particular focus on the presence of symptoms at times of hormone fluctuation, including the premenstrual and peripartum periods, and with exogenous hormone use,” wrote the reviewers.

Additionally, the outcomes of ART and fertility treatments have also been found to affect an individual’s emotional distress and quality of life.

Treatment failure, the unfulfilled desire to bear children, and poor coping mechanisms can be linked to emotional distress and poor quality of life for both men and women, particularly guilt, anger, and a sense of isolation in women.

In one study, women associated feelings of emotional distress with childlessness and depression, whereas their partner associated feelings of emotional distress to dissatisfaction in their relationship and sexuality.

A 2019 study identified an association between high levels of physical, personal, and marital stress in women undergoing ART and antidepressant prescription to be strongest in those who did not deliver a child.

Women also frequently discontinue psychiatric medication with ART, leading to higher relapse rates of depression, attributed to chronic stress of treatment and occurs despite psychopharmacologic intervention.

“There is concern that psychotropic medication may increase the risk of infertility through downstream effects on prolactin levels, weight gain, insulin resistance, and thyroid function,” wrote the reviewers.

However, studies evaluating the use of psychotropic medication and associations with ART have shown inadequate evidence of negative impacts concerning ART outcomes.

“Psychotherapy is the first-line treatment of depression and anxiety in infertility, with multiple effective modalities including [cognitive behavioral therapy], [mind/body interventions], mindfulness, and others,” wrote the reviewers.


Hudepohl NS, Smith K. Infertility and its association with depression, anxiety, and emotional distress: A current review. Advances in Psychiatry and Behavioral Health. 2022;2(1):119-132. doi:10.1016/j.ypsc.2022.05.005

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