Psychological Distress and Quality of Life Among Women Experiencing Infertility: A Systematic Review and Meta-analysis

1. Introduction

Infertility is a global reproductive health concern that affects millions of women and couples worldwide. Standardized terminology defines infertility on the basis of failure to achieve a clinical pregnancy after a period of regular unprotected intercourse, yet the lived consequences extend far beyond reproduction to include distress, stigma, social pressure, marital strain, and reduced quality of life.^1,2

Women experiencing infertility commonly report depression, anxiety, stress, sleep disturbances, low self-esteem, and deterioration in fertility-related quality of life. Earlier validation work on the FertiQoL instrument and related psychosocial studies established that emotional distress and impaired quality of life are closely intertwined in infertility care.^3–5

Recent evidence from Asia, the Middle East, Europe, Latin America, and Africa has reinforced that infertility is not only a gynecologic or endocrine problem but also a substantial psychosocial challenge.^6-10 Cross-sectional, case-control, and comparative studies have consistently documented elevated depression and anxiety among women undergoing infertility evaluation or treatment.^11–15

Contemporary syntheses have reached similar conclusions, indicating that infertility is associated with higher psychological morbidity and lower quality of life, especially in women. At the same time, heterogeneity remains considerable because studies differ in clinical setting, infertility diagnosis, treatment stage, and psychological instruments such as the DASS, HADS, PHQ, Beck Depression Inventory, WHOQOL-BREF, and FertiQoL.^16–20

From a women’s health nursing perspective, this topic is especially important because nurses often provide the most continuous point of contact throughout infertility care pathways. A clear synthesis of the evidence can support better screening, referral, counseling reinforcement, and psychosocial support. Therefore, this review aimed to synthesize recent evidence on psychological distress and quality of life among women experiencing infertility and to estimate pooled depression prevalence using studies with extractable event data.^21–23

2. Methods

The study selection process was performed according to the PRISMA 2020 reporting guideline. The PRISMA 2020 flow diagram detailing identification, screening, eligibility assessment, exclusions, and study inclusion is presented in Figure 1. The review protocol registration details were verified during revision and are reported as issued in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420261334124).

Fig. 1. PRISMA 2020 flow diagram illustrating the study selection process for systematic review and meta-analysis.

A topic-focused search framework was developed for women experiencing infertility, infertility treatment, infertility-related stigma, psychological distress, anxiety, depression, stress, and fertility-related quality of life. The PubMed and Scopus databases were searched for recent studies published between January 2020 and March 2025. The main PubMed strategy was (("infertility" OR "female infertility" OR "assisted reproductive technology" OR IVF OR ICSI) AND (women OR female) AND ("psychological distress" OR depression OR anxiety OR stress OR "quality of life" OR FertiQoL)).

Studies were eligible if they included women experiencing infertility or infertility-related conditions, reported psychological or quality-of-life outcomes, and were published in English between 2020 and 2025. Observational studies, intervention studies, and recent systematic reviews were retained for the narrative synthesis. For the quantitative synthesis, studies were included only if they reported women-specific sample size and depression event data, or clearly derivable prevalence, in the abstract or full text.

Titles and abstracts were screened for relevance, and potentially eligible reports were assessed in full text. The study selection process followed the PRISMA 2020 reporting guideline. The final PRISMA counts were as follows: records identified through database searching (n = 1,246), duplicate records removed (n = 261), records screened (n = 985), records excluded after title and abstract screening (n = 911), full-text articles assessed for eligibility (n = 74), reports excluded with reasons (n = 44), studies included in the qualitative synthesis (n = 30), and studies included in the quantitative synthesis/meta-analysis (n = 8).

Data extraction covered country, study design, sample size, participant profile, psychological instruments, quality-of-life tools, and key findings related to depression, anxiety, stress, stigma, and fertility-related quality of life. The methodological quality of the observational studies was appraised using the Newcastle-Ottawa Scale framework. The pooled outcome selected for the meta-analysis was the prevalence of depression among women experiencing infertility. A random-effects model was chosen due to anticipated clinical and methodological differences between studies. Event proportions were transformed on the logit scale, pooled using inverse-variance weighting with the Der Simonian–Laird estimation of between-study variance, and back-transformed to the proportion scale for reporting. Publication bias was explored visually using a funnel plot and analytically with Egger’s regression test. The study selection process followed the PRISMA 2020 reporting guideline.

3. Results

The included evidence consistently showed that women experiencing infertility carry a substantial mental health burden. Clinic-based studies from India, Bangladesh, China, Saudi Arabia, Ethiopia, Brazil, Turkey, Greece, Spain, and the Netherlands have repeatedly reported higher symptom scores or a higher prevalence of depression and anxiety, often alongside poorer fertility-related quality of life. Distress also varied across treatment stage, service disruption, stigma, resilience, social support, and clinical context.^{1-10,13-16,20-30}

Thirty recent studies were included to anchor the review narrative. These studies spanned observational clinic cohorts, case-control comparisons, women-only cross-sectional surveys, psychosocial intervention studies, randomized trials, and recent systematic reviews. The characteristics of the included studies are summarized in Table 1.1-30

Table 1. Characteristics of included studies examining psychological distress and quality of life among women experiencing infertility (2020-2025).1-30
Study	Year	Country	Design	Sample	Key instruments	Key finding	DOI
Bhamani et al.	2020	Pakistan	Cross-sectional	668 infertile adults (334 women)	FertiQoL, BDI-II, RS-14	Female participants had a higher depression burden and lower fertility-related QoL than male participants.	10.1186/s12889-020-09706-1
Ulusoy and Colak	2020	Turkey	Case-control	44 infertile women, 30 controls	BDI, BAI, SF-36	Hyperthymic temperament appeared protective, and depression and anxiety were linked to lower QoL.	10.5222/MMJ.2020.96646
Bose et al.	2021	India	Cross-sectional	100 primary infertile couples	FertiQoL, COMPI-FPSS	Stress and marital duration were associated with poorer QoL and a worse burden in women.	10.4103/jhrs.jhrs_233_20
Bivia-Roig et al.	2021	Spain	Cross-sectional	85 women	HADS, FertiQoL	COVID-19 era service disruptions increased anxiety, depression, and reduced fertility-related QoL.	10.3389/fpubh.2021.686115
Cui et al.	2021	China	Cross-sectional	536 women	HADS, FPI, RSES	The prevalence of depression was 27.9%, that of anxiety was 42.2%, and self-Esteem buffered infertility stress.	10.2147/PRBM.S326994
Dadhwal et al.	2022	India	Cross-sectional	150 women	HDRS, HAM-A, WHOQOL-BREF, Brief-COPE	Depression affected 58% and anxiety 24%; poor QoL was clustered with maladaptive coping and discrimination.	10.1002/ijgo.14084
Zhang et al.	2022	China	Cross-sectional	1247 infertile couples	SAS, SDS	Women were more vulnerable to anxiety than men, and anxiety and depression interacted within couples.	10.1186/s12888-022-04256-9
Kulaksiz et al.	2022	Turkey	Prospective cross-sectional	Women with male-factor vs female-factor infertility	BDI, BAI, QoL and sexual function scales	Psychological burden and QoL impairment were present regardless of the infertility factor.	10.1007/s00404-022-06713-y
Bueno-Sanchez et al.	2022	Spain	Cross-sectional	438 women	FertiQoL, CFNI-23	Women in the treatment group showed vulnerable mental health profiles and lower fertility-related QoL.	10.3390/ijerph191610031
Ceran et al.	2022	Turkey	Prospective case-control	93 women	WHOQOL-BREF, BDI, BAI	Endometriosis in infertility care was associated with higher depression and lower psychological quality of life.	10.1080/0167482X.2020.1787978
Shafierizi et al.	2022	Iran	Cross-sectional	162 infertile individuals (122 women)	STAI, BDI-II, resilience and social support scales	Depressive symptoms affected 40.7% and anxiety symptoms 45.7%, while resilience predicted better adjustment.	10.1111/ppc.13023
Hazlina et al.	2022	Global	Systematic review and meta-analysis	32 studies, 124,556 women	Meta-analysis	Infertility was associated with higher psychological distress and depression than fertility.	10.1136/bmjopen-2021-057132
Hasan et al.	2023	Bangladesh	Cross-sectional	375 women	DASS-21, SF-12	The prevalences of depression, anxiety, and stress were 59.7%, 55.0%, and 48.7%, respectively.	10.1371/journal.pgph.0002680
Wang et al.	2023	China	Cross-sectional	1712 women	PHQ-9, GAD-7	Depression affected 31.3% and anxiety 25.2%, and somatic symptoms and poor sleep quality were strong predictors.	10.1371/journal.pone.0284414
Kamboj et al.	2023	India	Cross-sectional case-control	250 infertile women and 250 fertile controls	PSS, GAD-7, PHQ-9	Stress, anxiety, and depression were more prevalent in infertile women than in fertile controls.	10.1371/journal.pone.0280054
Dourou et al.	2023	Greece	Cross-sectional	101 couples	FertiQoL	Higher anxiety and depression levels were significantly associated with worse fertility-related QoL.	10.3390/clinpract13010023
Asazawa et al.	2023	Japan	Quasi-experimental	Men undergoing infertility treatment	Distress and QoL scales	Psychosocial support interventions can help preserve quality of life during infertility treatment.	10.1111/jjns.12536
Xie et al.	2023	China/Global	Systematic review	16 studies	Systematic review	Stigma worsened mental health and quality of life and was a key target for nursing intervention.	10.3389/fpsyg.2022.1093459
Almutawa et al.	2023	Global	Systematic review and meta-analysis	35 studies	Meta-analysis	Women in infertile couples had higher stress, anxiety, and depression, and lower quality of life than men.	10.7759/cureus.37327
Bahadur et al.	2024	India	Case-control	Infertile and fertile women	DASS-21, WHOQOL-BREF	Women with infertility had worse QoL and higher depression/anxiety than their fertile counterparts.	10.7759/cureus.55837
Alsahel et al.	2024	Saudi Arabia	Cross-sectional case-control	Infertile and fertile women	DASS-21	Depression, anxiety, and stress scores were significantly higher in infertile women than in fertile women.	10.7759/cureus.63823
Mori et al.	2024	Brazil	Cross-sectional comparative	201 infertile women	Hamilton Anxiety, BDI, FertiQoL	Infertility with endometriosis is associated with lower QoL and more depressive symptoms.	10.1186/s12905-024-03080-5
Silva et al.	2024	Brazil	Cross-sectional	229 women with endometriosis	EHP, FSFI, BDI, BAI	Pain plus infertility markedly worsened anxiety, depression, and quality of life.	10.1007/s00404-024-07464-8
Jannink et al.	2024	Netherlands	Cross-sectional	1025 women in infertility treatment	Validated anxiety/depression scales	Similar levels of clinically relevant anxiety/depression in women with and without PCOS.	10.1093/humrep/deae016
Clark et al.	2024	Jordan	Pre/post pilot	IVF clinic clients	Depression, anxiety, PTSD, social support, FertiQoL	In this pilot study, CBT-informed care reduced depression and anxiety, and improved FertiQoL.	10.1186/s12978-024-01860-8
Szigeti et al.	2024	Hungary	Randomized controlled trial	Women with elevated distress in fertility care	Wellbeing, distress and treatment outcomes	MBIs improved well-being and treatment-related outcomes compared to controls.	10.1093/humrep/deae119
Priya et al.	2025	India	Cross-sectional	Infertile couples	HADS, FertiQoL	Higher anxiety and depression levels were negatively associated with fertility-related QoL.	10.1007/s10815-025-03674-4
Celda-Belinchon et al.	2025	Spain	Cross-sectional	Women and men with infertility	Psychological screening tool, fertility-specific QoL questionnaire	Women reported significantly lower emotional, physical, and social QoL than men.	10.1016/j.ejogrb.2025.114649
Peterson et al.	2025	Multinational	Cross-sectional	458 women and 89 men	Stigma, openness, depressive symptoms scales	Higher infertility stigma was associated with more depressive symptoms, and openness was protective.	10.1186/s12978-025-01983-6
Esubalew et al.	2025	Ethiopia	Cross-sectional	375 women	Structured questionnaire, DASS-like assessment	The prevalences of depression, anxiety, and stress were 62.93%, 58.13%, and 52.00%, respectively.	10.1007/s44192-025-00302-6

Eight studies provided women-specific depression prevalence data suitable for pooled analysis; the dataset used for the pooled estimate is shown in Table 2. The combined sample comprised 4,859 women. As shown in Figure 2, the random-effects pooled prevalence of depression was 37.6% (95% confidence interval, 25.3%–51.7%), with very high between-study heterogeneity (I² = 98.6%). Publication bias was explored using the funnel plot shown in Figure 3. Substantial heterogeneity likely reflects differences in country, healthcare setting, infertility stage, treatment exposure, assessment scale, threshold definition, and the inclusion of cohorts with endometriosis or polycystic ovary syndrome.^{1,5,6,13,14,24,30,46}

Fig. 2. Forest plot of depression prevalence among women experiencing infertility. Random-effects pooled prevalence = 37.6% (95% confidence interval 25.3%–51.7%); I² = 98.6%.

Table 2. Meta-analysis dataset used for the pooled estimation of depression prevalence.

Study	Year	Country	Depression cases	Total women	DOI / source
Bhamani et al.	2020	Pakistan	46	334	10.1186/s12889-020-09706-1
Cui et al.	2021	China	150	536	10.2147/PRBM.S326994
Dadhwal et al.	2022	India	87	150	10.1002/ijgo.14084
Hasan et al.	2023	Bangladesh	224	375	10.1371/journal.pgph.0002680
Wang et al.	2023	China	536	1712	10.1371/journal.pone.0284414
Monika et al.	2023	Bangladesh	175	352	PMID 37777908
Jannink et al.	2024	Netherlands	154	1025	10.1093/humrep/deae016
Esubalew et al.	2025	Ethiopia	236	375	10.1007/s44192-025-00302-6

Fig. 3. Funnel plot for the meta-analysis of depression prevalence. Egger regression intercept p = 0.545; interpretation should remain cautious because only eight highly heterogeneous studies were available.

4. Discussion

This review confirmed that infertility is associated with a clinically meaningful psychological burden in women. Across diverse settings, women have reported experiencing overlapping depression, anxiety, stress, hopelessness, stigma, low self-esteem, relationship strain, and reduced fertility-related quality of life. The pooled prevalence of depression in the present meta-analysis demonstrated that depressive burden was common enough to justify routine psychosocial screening in infertility care.^{1-6,13-16,20-30,31-35}

The second important finding is contextual amplification. Distress tended to worsen when infertility intersected with service uncertainty, socioeconomic strain, treatment failure, poor social support, violence exposure, stigmatizing norms, and coexisting gynecologic disease such as endometriosis.^36-40 Comparative studies from Brazil and Turkey, along with recent work from Saudi Arabia, Bangladesh, India, Ethiopia, and the Netherlands, showed that the psychosocial burden is not uniform and that vulnerable subgroups may carry a disproportionate burden.^{10,13,20-25,30-36,45}

The pooled estimates should nevertheless be interpreted cautiously. The very high heterogeneity indicates that region, assessment tool, treatment stage, infertility diagnosis, and comparator type should be explored explicitly in future updates of this review. Similar concerns have been raised in previous systematic reviews and global commentaries, which noted that prevalence estimates vary considerably according to instrument thresholds and clinical context.^16–20

The implications for nursing and reproductive health practices are substantial. Fertility nurses are uniquely positioned to normalize emotional reactions without trivializing them, distinguish expected situational distress from clinically significant symptoms, identify risk markers such as recurrent loss, prolonged infertility, poor partner support, or social isolation, and reinforce coping strategies during treatment transitions. Recent intervention studies and meta-analytic evidence also suggest that psychosocial and mind-body interventions may improve wellbeing and fertility-related quality of life in selected groups.^17,25,26,38

This review also supports women-centered reporting. Sex-specific data should be preserved rather than collapsed into couple-level estimates whenever they are available, because the psychosocial burden often differs between women and men. The relationship between distress and quality of life is likely bidirectional, and resilience and openness may moderate this relationship in important ways.^{19,28,29,43,45}

5. Strengths and limitations

The strengths of this review include prioritization of recent evidence, inclusion of women-centered studies from multiple regions, integration of qualitative synthesis with pooled quantitative estimates, and use of real extractable event data for the meta-analysis. Limitations should also be acknowledged. The meta-analysis was restricted to eight studies with women-specific prevalence data, heterogeneity was very high, and not all 30 studies contributed comparable numerical data. Some reference records remained early online publications with limited bibliographic detail; however, DOI identifiers were retained for transparency and traceability.

6. Conclusion

Recent literature leaves little doubt that infertility can substantially worsen women’s psychological well-being and quality of life. Depression, anxiety, stress, stigma, and reduced fertility-related quality of life have been observed across countries and treatment settings, although prevalence varies widely by context and measurement strategy. Overall, the available evidence supports integrating routine psychosocial screening, counseling, and nursing support into infertility care.^{12,19,37,41,42}

Ethical approval

This systematic review and meta-analysis of previously published studies did not require ethical approval or informed consent.

Funding

This research did not receive any external funding.

Conflict of interest

The authors declare no conflicts of interest.

Author contributions

Amani Abdelgader conceived the review, supervised manuscript preparation, and approved the final version. Hawa Hamid contributed to data organization, evidence synthesis, and drafting of the manuscript. Nagat Yasin contributed to study interpretation, critical revision, and final approval of the submitted version.

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