Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies

Boivin J et al, BMJ 2011;342:d223

British Medical Journal

A large meta-analysis of 14 prospective studies between 1985 and 2009, found no relationship between pre IVF emotional distress and IVF outcomes.  The authors state that their meta-analysis is probably not the final word on
emotional distress and ART and since the publication of this meta-analysis there have been 6 more studies published that might add further consideration to the conclusion.


Objective To examine whether pretreatment emotional distress in women is associated with achievement of pregnancy after a cycle of assisted reproductive technology.

Design Meta-analysis of prospective psychosocial studies.

Data sources PubMed, Medline, Embase, PsycINFO, PsychNET, ISI Web of Knowledge, and ISI Web of Science were searched for articles published from 1985 to March 2010 (inclusive). We also undertook a hand search of reference lists and contacted 29 authors. Eligible studies were prospective studies reporting a test of the association between pretreatment emotional distress (anxiety or depression) and pregnancy in women undergoing a single cycle of assisted reproductive technology.

Review methods Two authors independently assessed the studies for eligibility and quality (using criteria adapted from the Newcastle-Ottawa quality scale) and extracted data. Authors contributed additional data not included in original publication.

Results Fourteen studies with 3583 infertile women undergoing a cycle of fertility treatment were included in the meta-analysis. The effect size used was the standardised mean difference (adjusted for small sample size) in pretreatment anxiety or depression (priority on anxiety where both measured) between women who achieved a pregnancy (defined as a positive pregnancy test, positive fetal heart scan, or live birth) and those who did not. Pretreatment emotional distress was not associated with treatment outcome after a cycle of assisted reproductive technology (standardised mean difference −0.04, 95% confidence interval −0.11 to 0.03 (fixed effects model); heterogeneity I²=14%, P=0.30). Subgroup analyses according to previous experience of assisted reproductive technology, composition of the not pregnant group, and timing of the emotional assessment were not significant. The effect size did not vary according to study quality, but a significant subgroup analysis on timing of the pregnancy test, a contour enhanced funnel plot, and Egger’s test indicated the presence of moderate publication bias.

Conclusions The findings of this meta-analysis should reassure women and doctors that emotional distress caused by fertility problems or other life events co-occurring with treatment will not compromise the chance of becoming pregnant.

In 6 more recent publications the authors claim that stress detrimentally affected IVF outcomes or parameters related to outcome.

Kleanthi Gourounti et al, 2011 Women & Health 51, 321-339

Xiao Hong Li et al 2011, Gynecological Endocrinology 27,139-143

Hongmei Xu et al, 2017 Psychology, Health & Medicine , 22, 37-43

Yuan An et al, 2013 J Assist Reprod Genet. 30(1): 35–41

Quant H et al, 2013, Jnl Assisted Reprod Genet 30, 1451- 58

Turner K et al, 2013 PLoS One. 8(5):e63743

On the other hand this study may support the finding of the meta-analysis

Donarelli Z et al, Reprod Biomed Soc Online. 2016 Dec; 3: 16–23. – measured ovarian response to stimulation and  and found no effect on this of stress.