Assessment of anxiety, depression, and sexual dysfunction in women undergoing fertility treatment

Article information

Clin Exp Reprod Med. 2025;52(1):38-43

Publication date (electronic) : 2025 February 28

doi : https://doi.org/10.5653/cerm.2024.07465

Joon Cheol Park

Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea

Corresponding author: Joon Cheol Park Department of Obstetrics and Gynecology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea Tel: +82-53-200-5722 Fax: +82-53-423-7905 E-mail: jcpark70@knu.ac.kr

Received 2024 August 24; Revised 2025 November 29; Accepted 2025 January 23.

Abstract

Introduction

Infertility is a condition that causes not only physical and emotional stress but also psychological distress among couples. Women facing infertility may experience higher rates of depression, anxiety, and stress compared to the general population [1,2]. Emotional symptoms in women are also associated with infertility, likely due to the impact of psychological difficulties on the secretion of female sex hormones and endometrial growth [3]. Additionally, couples undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) may experience depression and anxiety due to uncertainty and potential poor outcomes [1,4]. These conditions can be influenced by a variety of factors, including personality, stress coping strategies, family relationships, and support systems within the sociocultural context. Furthermore, women with infertility may experience sexual dysfunction more frequently than the general female population [5,6]. Challenges such as the adverse effects of fertility treatments and familial pressure can cause considerable stress, psychological distress, and physical pain among those seeking fertility assistance [7]. However, no consensus has yet formed regarding the risk factors for psychological and sexual difficulties, particularly in northeastern Asia. Therefore, this study aimed to evaluate anxiety, depression, and sexual dysfunction in Korean women with infertility and to investigate the risk factors associated with psychological distress in this context.

Methods

This cross-sectional study was conducted among women who visited fertility clinics due to an inability to conceive without contraception for at least 1 year. After the causes of infertility were evaluated, only individuals scheduled for IVF/ICSI treatment were enrolled. Women with a prior diagnosis of a psychological disorder and those on psychiatric medications were excluded. Prior to administering the questionnaire, the interviewer asked whether the participant had recently experienced any stressful life events other than infertility. Those reporting such events were not included in the study. Additionally, women diagnosed with uterine fibroids/adenomyosis or endometriosis via ultrasound, or who had a history of surgical or medical treatments for these conditions, were excluded.

Before the initiation of controlled ovarian hyperstimulation, women experiencing infertility were asked to complete standardized, validated questionnaires to assess anxiety, depression, and sexual function. Specifically, the Hospital Anxiety and Depression Scale (HADS), Depression Anxiety and Stress Scale (DASS), and Female Sexual Function Index (FSFI) were used. Data on age, duration of marriage, duration of infertility, cause of infertility, number of previous IVF cycles, number of miscarriages, and parity were collected for risk factor analysis. Of the 40 women with infertility who were asked to fill out the questionnaires, 31 completed them and were thus recruited for the study. For the control group, 40 healthy women seeking general health screening were given the questionnaires; 32 women who completed them were included in the control group. The dropout rate was 21.3%, with most exclusions occurring because participants did not complete the FSFI questionnaire.

The DASS is a self-report instrument commonly used in Korea to screen for depression and has demonstrated high reliability and validity. Previous research has reported reliability coefficients including Cronbach alpha values of 0.84 for depression, 0.94 for anxiety, and 0.89 for stress [8]. The Korean version of the FSFI-6 (FSFI-6K) has also shown high consistency and reliability, as demonstrated by a Cronbach alpha of 0.89 [9]. Scores on the self-reported questionnaires were analyzed using SPSS ver. 20.0 (IBM Corp.). This study received approval from the Institutional Review Board of Kyungpook National University Hospital (2022-03-013) was conducted in accordance with the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all patients.

Results

Among women with infertility, the mean age was 33.80±3.71 years, which was comparable to that of the control group. Women in the infertility group had been married for an average of 3.08±2.29 years, a longer duration compared to the control participants. The number of miscarriages reported by each group was similar; however, parity was significantly lower in the women with infertility. The mean height, weight, and body mass index of the women were similar between the groups. The mean duration of infertility was 2.89±2.29 years (Table 1).

Table 1.

Demographic data of each group

The mean HADS scores among women with infertility were 6.35±3.48 (range, 0 to 13) for anxiety and 8.32±3.78 (range, 2 to 15) for depression. Notably, 12.9% of the infertility group reported clinically significant anxiety, with HADS-Anxiety scores exceeding 11, while 32.3% of the women had depression, as indicated by HADS-Depression scores above 11. These percentages were significantly higher than those in the control group. Regarding DASS scores, the mean values were 8.29±8.84 (range, 0 to 37) for anxiety, 6.48±8.16 (range, 0 to 40) for depression, and 10.19±8.83 (range, 0 to 35) for stress. Furthermore, the prevalence rates of anxiety (25.8%), depression (29.0%), and stress (19.4%) were higher in women experiencing infertility than in control participants (Table 2). However, no significant correlations were found between psychological difficulties in women with infertility and age, duration of marriage, duration of infertility, or parity.

Table 2.

Psychological difficulties, including anxiety, depression, and stress, in women experiencing infertility and undergoing in vitro fertilization cycles compared with control women, assessed using the HADS, DASS, and FSFI

The total FSFI score for women experiencing infertility was 22.33, which was comparable to that of the control group. The mean scores for desire (3.09), arousal (3.48), lubrication (4.39), satisfaction (3.94), and pain (3.96) displayed no statistical differences between groups. However, the mean score for orgasm in women experiencing infertility was 3.16, significantly lower than that of the control group (Figure 1). FSFI score was not meaningfully influenced by age, duration of marriage, duration of infertility, or parity.

Figure 1.

Sexual function and sexual satisfaction in women experiencing infertility and undergoing in vitro fertilization cycles, compared with control women, assessed using the Female Sexual Function Index (FSFI). ^a)Significant difference.

Discussion

Infertility, often a highly distressing condition, is medically characterized by the inability to conceive after 1 year of regular, unprotected sexual intercourse. Women with infertility may experience psychological symptoms, such as depression and anxiety, at a higher rate than women without the condition [2]. For some women undergoing fertility treatment, infertility is the most stressful ordeal of their lives. A recent review indicated that between 25% and 60% of individuals dealing with infertility reported psychiatric symptoms, with levels of anxiety and depression significantly higher than those of controls [10]. In other research, women facing infertility did not report anxiety and depression symptoms that differed significantly from those of individuals without infertility. However, some women may ‘fake good,’ presenting themselves as mentally healthier than they are [2]. Despite its prevalence in modern society, infertility often leads to diminished self-esteem, as well as feelings of shame and guilt, in women who struggle to conceive naturally. These negative emotions can trigger depression, anxiety, and distress, further diminishing quality of life. Moreover, affected women may choose not to share their experiences with family or friends, which can exacerbate their psychological vulnerability [2].

Various factors, including age, duration of marriage, pregnancy and childbirth history, duration of infertility, cause of infertility, history of infertility treatment, education level, employment status, financial stress, and pressure from acquaintances, may contribute to mental stress in women experiencing infertility [11]. The risk factors for psychological symptoms in couples with infertility may vary by ethnicity due to socioemotional differences in the experience of this condition. Individuals’ perceptions of infertility are influenced by their personality structure, coping mechanisms, pre-existing psychopathology, environmental support, cultural context, and gender [12]. Depression scores tend to rise with patient age and the number of infertility treatments undergone. In one study, anxiety levels peaked in the second and third years of infertility, then declined, with a significant difference between 2–3 and >6 years [13]. However, Ogawa et al. [11] found that the duration of infertility did not significantly impact depression or anxiety levels.

Research has generally indicated that depression and perceived helplessness are more prevalent in women seeking treatment for their partner’s male infertility than for female infertility, as they are more likely to shoulder the burden of assisted reproductive technology (ART) procedures [14]. However, in Japan, women with infertile male partners reported lower psychological stress levels, possibly due to societal beliefs that women are primarily responsible for infertility. Additionally, unemployed women were more likely to experience depression than their employed counterparts, with particular strain due to inquiries from family and acquaintances about their childlessness [11]. These risk factors highlight potential ethnic differences shaped by social and cultural attitudes toward infertility.

Moreover, undergoing ART treatment can itself be a trigger for mental illness in couples with infertility. In a large Danish study of women who underwent ART, 35% tested positive for depression before the procedure [15]. Another study found that 39% of women undergoing fertility treatment had major depressive disorder [16]. In the present preliminary research, which was performed prior to ART cycles, HADS and DASS scores revealed that Korean women experiencing infertility also exhibited anxiety (12.9%–25.8%), depression (29.0%–32.3%), and stress (19.4%). These rates exceeded those in the control group, aligning with previous research. However, the HADS and DASS scores were not significantly influenced by age, duration of marriage, duration of infertility, or parity. Given the limited number of participants in this pilot study, further prospective studies with larger sample sizes are needed to elucidate the risk factors.

Some research has suggested that women with infertility who also experience severe psychological distress, such as anxiety or depression, have lower pregnancy rates even when undergoing IVF/ICSI fertility treatments [17]. Conversely, other studies have indicated that psychological distress does not impact the outcomes of IVF/ICSI [1,18]. Chronic stress may sensitize the hypothalamic-pituitary-adrenocortical axis, which in turn could negatively affect fertility. This may lead to a vicious cycle of more stress, anxiety, and depression [19]. Massey et al. [20] found that hair cortisol concentrations prior to ART were significant predictors of clinical pregnancy. Higher stress levels, as measured by salivary alpha-amylase, were linked to longer time to pregnancy and increased infertility risk [21]. However, salivary cortisol levels did not predict clinical pregnancy [20,21]. Although the association of anxiety and depression with IVF outcomes remains a matter of debate, high rates of anxiety and depression have been observed in women experiencing infertility. As such, appropriate evaluation and psychosocial intervention are essential to support the mental well-being and quality of life of couples facing infertility.

Female sexual dysfunction is defined as a sexual problem that causes personal distress, including disorders related to sexual desire, arousal, lubrication, orgasm, and pain [22]. Depression is associated with reduced sexual satisfaction, arousal difficulties, anorgasmia, and coital pain [23]. Couples diagnosed with infertility, undergoing infertility treatments, or facing unsuccessful outcomes may also experience sexual dysfunction [24]. A systematic review on female and male sexual dysfunction concluded that infertility adversely impacts the sexuality of couples, affecting 43%–90% of women and 48%–58% of men [25]. Another meta-analysis found that the prevalence of sexual dysfunction in women dealing with infertility ranged from 35.6% to 87.1% [26]. Furthermore, infertility was linked to decreased lubrication, orgasm, and satisfaction, but not to a reduction in sexual desire [26]. Dong et al. [22] reported that an infertility duration of over 8 years was a risk factor for diminished arousal, pain, and lubrication disorder, but not for desire and orgasmic dysfunction. However, another study did not find a significant association between the duration of infertility and sexual dysfunction [27]. Women with secondary infertility appear to exhibit lower levels of sexual desire, orgasm, and satisfaction than those with primary infertility [28]. When comparing groups with and without infertility, Gabr et al. [6] observed significant differences in satisfaction, pain, and orgasm, but not in desire, arousal, or lubrication.

The impact of infertility on the sexual function of couples is variable, with studies exploring diverse populations with varying sociocultural backgrounds using different assessment tools. Discussing sexual dysfunction can be embarrassing, and individuals from conservative communities may be uncomfortable completing related questionnaires. Additionally, other confounding factors, such as psychosocial distress, substance abuse, gynecological disorders, hormonal disruptions, and smoking, can contribute to sexual disorders. In the present study, the mean scores for desire (3.09), arousal (3.48), lubrication (4.39), satisfaction (3.94), and pain (3.96) did not significantly differ between women with infertility and control participants. However, the mean score for orgasm in women with infertility was 3.16, significantly lower than that of the control group. This difference is likely because for many women with infertility, the primary goal of sexual intercourse is conception rather than pleasure.

Reproductive health specialists must pay close attention to their patients’ sexual and mental well-being to more effectively identify issues and achieve favorable outcomes. In women facing infertility, greater severity of depression is associated with a lower likelihood of beginning infertility treatments and a higher tendency to discontinue ART [29]. Furthermore, 9.4% of women with infertility have reported suicidal ideation or attempts [30]. Within couples experiencing infertility, women are especially predisposed to low self-esteem, depression, anxiety, and reduced sexual and orgasmic function. Patients undergoing ART cycles face a considerable risk of developing psychiatric disorders; thus, reproductive physicians should acknowledge these risks and provide support throughout the diagnosis and treatment of infertility.

This preliminary study suggests that anxiety and depression are comparatively prevalent among women seeking treatment for infertility, and these women may experience fewer or diminished orgasms compared to their fertile counterparts. Routine screening with standardized questionnaires should be conducted to identify vulnerable women and to provide proper counseling before initiating infertility treatment. The study further elucidates the link between psychological difficulties and the distress associated with infertility, highlighting potential differences in risk factors across ethnic groups. As this research included a limited number of patients, future prospective studies with larger sample sizes should be undertaken to clarify the prevalence of and risk factors for anxiety, depression, and sexual dysfunction in women undergoing fertility treatment.

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