Recognizing the Psychological Toll of Infertility in Women
Recognizing the Psychological Toll of Infertility in Women
Infertility, clinically defined as the inability to conceive after at least one year of regular unprotected heterosexual intercourse (1), is common and associated with increased anxiety and depressive symptoms (2). Yet, the mental health needs of many people experiencing infertility remain unmet. Infertility and the psychological impacts of infertility affect both males and females, as well as people of all genders, albeit differently. While the impact on males and people of all genders is equally vital to understand and address, this blog will focus on the impact on cisgender women.
Infertility is common. Around 19% of married (heterosexual) nulliparous women aged 15 to 49 years old in the U.S. experience infertility (3). Like miscarriage, infertility is often not discussed within social circles, and women suffer in silence. They see pregnant women and women with newborns, but not the other women experiencing infertility with them. Women may not realize that others close to them are experiencing infertility simultaneously, and may feel shame attached to infertility. Infertility is estimated to be related to the female in a third of infertile heterosexual couples, related to the male in another third, and to combined factors in the remaining third (4). However, even when infertility is due to the male in a heterosexual couple, women undergo much of the medical fertility treatment, which is physically and emotionally taxing.
Many women struggling with infertility experience anxiety and depressive symptoms (2). As many as 21-52% of these women experience depression (5), suggesting an urgent need for access to mental health care for women experiencing infertility. Women with infertility who feel depressed are also less likely to undergo infertility treatment (6). In addition, distress experienced during infertility treatment may lead many couples to stop pursuing infertility treatment (4). Treatment of depression or distress may help people make an informed decision about whether to pursue infertility treatment. Depression and anxiety may also make it more difficult to conceive (7, 8). Providing support and psychological treatment to women experiencing infertility and distress may improve fertility outcomes.
Some women experiencing infertility decide to undergo assisted reproductive technology (ART). The ART process itself may be stressful and may place vulnerable women at risk for depression (9). The frequent and timed appointments for ART can be stressful to balance with other responsibilities, and the procedures may feel physically invasive for a woman. Waiting to find out whether a cycle is successful can feel painful, as can the news that it failed. In fact, many people cite distress as the reason for discontinuing ART (4). When women who experienced infertility become pregnant after ART, their rates of anxiety and depressive symptoms are once again similar to the rates for naturally pregnant women (2). While the process of ART can place certain women at risk of depression, unsuccessful ART and remaining childless with a continued wish for pregnancy after pursuing ART are also associated with depression and anxiety when compared to women who found other meaningful life goals (10). For others, financial cost may prohibit ART even if it is desired. This highlights the importance of screening and providing access to psychosocial support, psychotherapy, and, when indicated, pharmacological treatment to women struggling with infertility, including women undergoing ART or those with unsuccessful ART.
The psychological toll of infertility is evident in the literature and in clinical practice. However, there are evidence-based treatments such as cognitive behavioral therapy that can improve depression and anxiety in women struggling with infertility who are not undergoing fertility treatment as well as in those undergoing ART (11, 12).
The high prevalence of anxiety and depression in women experiencing infertility underscores the importance of collaboration between infertility clinics and specialized mental health providers. However, many women seeking infertility treatment who are experiencing depression or anxiety continue to lack access to mental health services (10, 13). In primary care, embedding mental health care has increased access to and utilization of mental health care and improved mental health outcomes (14). While the literature suggests an increasing role of embedding mental health care in fertility clinics (10, 14, 15), this remains less studied.
There is currently an unmet mental health need for women experiencing infertility. Embedded mental health care could help bridge this gap by providing access to care in the fertility clinic, a setting that may be more convenient and comfortable for women. Currently, the American Society for Reproductive Medicine recommends that all practices offering ART have access to a mental health professional who specializes in fertility counseling (16). It is important to identify women struggling with infertility and depressive or anxious symptoms in order to provide appropriate support and evidence-based mental health treatment. Finally, the majority of the literature focuses on the psychological effect of infertility on cisgender heterosexual women. It is imperative to study the psychological effects of infertility on a diversity of genders and people attempting to conceive.
- Carson SA, Kallen AN. Diagnosis and Management of Infertility: A Review. JAMA 2021;326:65-76.
- Salih Joelsson L, Tydén T, Wanggren K, Georgakis MK, Stern J, Berglund A et al. Anxiety and depression symptoms among sub-fertile women, women pregnant after infertility treatment, and naturally pregnant women. Eur Psychiatry 2017;45:212-9.
- Infertility. Key Statistics. In. Vol. 2022. National Survey of Family Growth. Center for Disease Control: National Center for Health Statistics, 2021.
- Cousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynaecol 2007;21:293-308.
- Kiani Z, Simbar M, Hajian S, Zayeri F. The prevalence of depression symptoms among infertile women: a systematic review and meta-analysis. Fertil Res Pract 2021;7:6.
- Crawford NM, Hoff HS, Mersereau JE. Infertile women who screen positive for depression are less likely to initiate fertility treatments. Hum Reprod 2017;32:582-7.
- Cesta CE, Viktorin A, Olsson H, Johansson V, Sjölander A, Bergh C et al. Depression, anxiety, and antidepressant treatment in women: association with in vitro fertilization outcome. Fertil Steril 2016;105:1594-602.e3.
- Nillni YI, Wesselink AK, Gradus JL, Hatch EE, Rothman KJ, Mikkelsen EM et al. Depression, anxiety, and psychotropic medication use and fecundability. Am J Obstet Gynecol 2016;215:453.e1-8.
- Freeman MP, Lee H, Savella GM, Sosinsky AZ, Marfurt SP, Murphy SK et al. Predictors of Depressive Relapse in Women Undergoing Infertility Treatment. J Womens Health (Larchmt) 2018;27:1408-14.
- Patel A, Sharma PSVN, Kumar P. Role of Mental Health Practitioner in Infertility Clinics: A Review on Past, Present and Future Directions. J Hum Reprod Sci 2018;11:219-28.
- Faramarzi M, Alipor A, Esmaelzadeh S, Kheirkhah F, Poladi K, Pash H. Treatment of depression and anxiety in infertile women: cognitive behavioral therapy versus fluoxetine. J Affect Disord 2008;108:159-64.
- Abdolahi HM, Ghojazadeh M, Abdi S, Farhangi MA, Nikniaz Z, Nikniaz L. Effect of cognitive behavioral therapy on anxiety and depression of infertile women: A meta–analysis. Asian Pacific Journal of Reproduction 2019:2(1):68-75.
- Pasch LA, Holley SR, Bleil ME, Shehab D, Katz PP, Adler NE. Addressing the needs of fertility treatment patients and their partners: are they informed of and do they receive mental health services? Fertil Steril 2016;106:209-15.e2.
- Sax MR, Lawson AK. Emotional Support for Infertility Patients: Integrating Mental Health Professionals in the Fertility Care Team. Women 2022;2:68-75.
- Schlaff WD, Braverman AM. Introduction: Role of mental health professionals in the care of infertile patients. Fertil Steril 2015;104:249-50.
- Practice Committee of the American Society for Reproductive Medicine PaCotSfART, and Practice Committee of the Society of Reproductive Biologists and Technologists. Electronic address: [email protected] Minimum standards for practices offering assisted reproductive technologies: a committee opinion. Fertil Steril 2021;115:578-82.
This blog post is sponsored by the the ADAA Women’s Mental Health Special Interest Group.