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

BMJ 2011; 342 doi: (Published 23 February 2011) Cite this as: BMJ 2011;342:d223
  1. J Boivin, professor and health psychologist1,
  2. E Griffiths, assistant clinical psychologist2,
  3. C A Venetis, research fellow3
  1. 1Cardiff Fertility Studies Research Group, School of Psychology, Cardiff University, Cardiff, UK
  2. 2The Lawns Resource Centre, The Baulk, Biggleswade, UK
  3. 3Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
  1. Correspondence to: J Boivin, Cardiff Fertility Studies Research Group, School of Psychology, Cardiff University, Tower Building, Park Place, Cardiff, UK boivin{at}
  • Accepted 2 November 2010


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.


  • We thank Todd Bailey of Cardiff University for help with the meta-analysis tools used in earlier drafts of this manuscript, and Andrew Kolarik and Stamatis Papaharitou for their help with translation. We thank the authors of the source studies for providing additional information (where relevant). We also thank Christianne Verhaak of Radboud University Nijmegen Medical Centre (Medical Psychology) and Glyn Elwyn from Cardiff University for providing feedback on a first draft of this manuscript.

  • Funding: None.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work for all three authors; EG and CAV declare no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; JB received speaker fees from EMD Serono Inc. and Merck & Co. (then Schering Plough), and a research grant from Merck Serono S.A. in the previous three years; no other relationships or activities that could appear to have influenced the submitted work for the three authors.

  • Ethical approval: Not required.

  • Contributors: JB, EG, and CAV contributed to the conception and design of the study. EG and JB discussed search terms and EG executed the search with search experts from Cardiff University. JB and EG both determined eligibility and inclusion of studies and extracted data from the studies, and JB and CAV assessed study quality. EG entered and organised the data, and JB and CAV conducted the analyses and contributed to the interpretation of the data. JB drafted the manuscript, CAV reviewed it for conceptual and analytic integrity, and EG reviewed for accuracy and consistency. JB is the guarantor.

  • Data sharing: An Excel file of the excluded studies and reasons for exclusion are available from the corresponding author at boivin{at}

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