The efficacy of psychological interventions for infertile women: a systematic review and meta-analysis.

The study protocol for this systematic review and meta-analysis was registered with PROSPERO (CRD42024564099). The review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 27 ]. The PICO model was used to guide the study selection process. The inclusion and exclusion criteria are presented in Table  1 . Table 1 Inclusion and exclusion criteria used when selecting articles in the systematic review. Inclusion Criteria Exclusion Criteria Population Women aged 18 years and older diagnosed with infertility, defined as “a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner” [ 3 ]. Men; people under 18 years of age; individuals without a diagnosis of infertility. Intervention/Exposure Psychological interventions delivered in any format (individual, couple, group, online/self-administered). Interventions aimed at improving psychological well-being, delivered by a mental health professional or trained facilitator. Interventions involving psychotropic medication or alternative therapies (yoga, massage) as the primary intervention or delivered in conjunction with a psychological intervention, compound interventions without a standalone psychological component. Comparison Randomised or non-randomised controlled trials with an inactive (waitlist, treatment as usual) control group. Studies with multiple groups compared separately. No control group; comparison group receiving compound or non-psychological interventions; studies comparing two psychological interventions without a clear control group. Outcome Assessment of psychological outcomes including depression, anxiety, stress, general distress, infertility-related distress, and well-being. Outcomes measured using validated self-report or clinician-rated scales at baseline and post-intervention. Studies only reporting biological outcomes (pregnancy rates, hormone levels), marital satisfaction, body image, or single timepoint measurements of psychological outcomes. Study Design Quantitative studies including randomised controlled trials, randomised wait-list crossover trials, and quasi-experimental designs. Qualitative studies; systematic reviews, meta-analyses, feasibility or prospective studies; single case reports; non-peer-reviewed grey literature. Language English Non-English Other Published in a peer-reviewed journal. Studies were excluded if they presented methodological concerns, such as inappropriate or unclear statistical analyses (failure to control for baseline differences, invalid test use), or lack of clarity in intervention or study design. Inclusion and exclusion criteria used when selecting articles in the systematic review. This review considered studies evaluating the efficacy of psychological interventions for women experiencing infertility. Eligible designs included randomised controlled trials (RCTs), waitlist crossover trials, and quasi-experimental studies with appropriate comparison groups. If multiple publications were drawn from the same trial, the most comprehensive report was included. Study quality was assessed through visual inspection and author consensus, with reference to PICO criteria. To be eligible for the review, studies were to be conducted on adult women (18 years and older) who met the definition of infertility: “a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner” [ 3 ]. While characteristics of the study population (history of failed treatment, pregnancy loss, or infertility cause) are likely to influence the effectiveness of psychological interventions, a moderation analysis was not feasible in the current review due to substantial missing or inconsistently reported data across studies. The absence of detailed reporting on these variables limited our ability to conduct a reliable quantitative examination. This remains an important direction for future research, and we recommend that future trials provide more systematic reporting of treatment history, infertility cause, and loss experiences to enable meaningful subgroup analyses. Psychological interventions were defined as mental health treatments grounded in psychological theories or techniques, aiming to improve emotional, cognitive, or social functioning [ 28 ]. These could be delivered individually, in groups or couples, either face-to-face or via self-guided formats (web-based modules, phone applications). This review specifically focused on the effect of psychological interventions on infertility-related distress. Interventions involving pharmacological or psychotropic medications (antidepressants, anxiolytics) or complementary and alternative therapies (yoga, relaxation massage) were excluded when these represented the primary intervention or were delivered in conjunction with a psychological intervention in a way that confounded attribution of effects. However, such interventions were not excluded when used as active controls, as the comparator groups were analysed separately from the psychological intervention arms. To be eligible, studies had to evaluate a psychological intervention compared to an inactive control group. Inclusion in the meta-analysis required the study to report sufficient data to calculate an effect size for the treatment. Treatment comparisons were classified into one of three categories: treatment as usual (TAU), waitlist, or active control. TAU was defined as participants receiving their standard care, with the only difference being their completion of outcome measures [ 29 ]. Waitlist controls consisted of participants who did not receive any intervention during the measurement period but were offered the intervention afterward. Active controls included non-psychological interventions such as pharmacotherapy. Importantly, pharmacotherapy arms were only retained in the systematic review and when used as comparator conditions and were not pooled with psychological interventions. This approach allowed us to assess the relative effectiveness of psychological interventions against established standards of care, while maintaining a clear focus on psychological interventions as the intervention of interest. When studies had both an active control and either a waitlist or TAU control, data from the inactive control group were selected as the control group of interest. In studies where two psychological interventions were compared, each intervention was analysed separately. For inclusion in this review, the outcomes of the trials had to assess psychological distress or well-being using validated self-report or clinician-rated instruments, assessed at both baseline and post-intervention. Primary outcomes included depression, anxiety, stress, general distress, infertility-specific distress, and overall well-being. In addition to primary outcomes, the following variables were extracted and analysed as potential moderators of intervention effectiveness: therapeutic approach, intervention duration, frequency and length of sessions, delivery format, and study quality rating. Although well-being is conceptually distinct from distress-related outcomes, it was included in a combined analysis to explore the overall impact of psychological interventions on psychological functioning. However, due to its distinct conceptual underpinnings, a separate analysis was conducted without well-being as a domain. Psychological distress measures assess negative psychological states whereas well-being captures positive psychological states. Studies assessing each domain employed different measurement tools and conceptual frameworks, contributing to heterogeneity. The distinct nature of these outcomes justified analysing well-being separately to provide a clearer understanding of how psychological interventions influence positive mental health aspects independently of distress reduction. A comprehensive search of the following databases from inception until March 2024 was conducted: Scopus , PubMed , Web of Science , Google Scholar . The search strategy combined terms related to infertility (infertility, infertile, infertility treatment, infertile women, fertility, fertile) and psychological interventions (cognitive behavioural therapy, CBT, ACT, psychological intervention, EMDR, Schema, ITP, DBT, mindfulness, therapy, depression, anxiety, well-being). No date or language limits were applied to the initial search. In addition to database searches, reference lists of included studies and relevant systematic reviews were manually searched to identify additional eligible studies. The full search strategies for each database, including search terms and filters are provided in Supplementary Material A. An updated search was conducted in August 2025 to ensure currency of the review. The initial database search yielded 8,068 results, which were screened at the title and abstract level for eligibility using Covidence [ 30 ], after duplicates were removed. The title/abstract screening was conducted by the primary author, while the full text screening was completed by all four authors, with each study screened by two reviewers. Inter-rater reliability was calculated using Cohen’s kappa for three reviewer pairs. The resulting kappa values ranged from 0.00 to 0.45, indicating variable agreement across pairs. Moderate agreement was observed in two of the three pairs (κ = 0.44–0.45). A subsequent update search was conducted to ensure the review was current with recently published studies. Data on participants, methods, interventions, and outcome measures were extracted and managed in Covidence, and was completed by all four authors. Disagreements during both the full-text screening and data extraction phases were resolved through group discussions with all four authors. Participant characteristics extracted included sample size, age, duration of infertility, cause of infertility, and ART status. Study characteristics were also extracted, including the country of origin, intervention name, type, delivery format, duration, session frequency, and control condition. Additionally, continuous outcome data were recorded, including means and standard deviations at baseline and post-intervention for the psychological outcomes of interest. When relevant outcome data were missing, study authors were contacted. Study quality and risk of bias were assessed using the Risk of Bias 2 (RoB2) criteria [ 31 ]. The RoB2 tool was used to assess sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective outcome reporting and any other source of bias. For each study, each domain on the quality assessment template was rated with a risk of bias as either ‘High’, ‘Low’, or ‘Unclear’. A three-level random-effects model was applied to account for the assumption that the included primary studies represent a random sample from a larger population of potential studies [ 32 ]. Given that many studies reported multiple outcomes, such as anxiety, depression, stress, generalized distress, infertility-related distress, and well-being, multiple effect sizes were extracted from single primary studies. This approach was necessary to capture the range of psychological outcomes associated with infertility-related distress. Consistent with standard meta-analytic practice, it is assumed that effect sizes drawn from the same primary study are more homogenous than those drawn from different studies, as they share common participants, instruments, and intervention conditions [ 33 ]. To account for this non-independence of effect sizes, three-level meta-analytic models were employed to appropriately model effect size dependency [ 34 ]. This was conducted in R (version 4.4.3) [ 35 ] using the rma.mv function from the metafor package [ 36 ] with restricted maximum likelihood (REML) estimation and Knapp–Hartung adjustments applied to improve the accuracy of standard errors and confidence intervals. For each pooled model, 95% prediction intervals (PIs) were calculated to indicate the range of true effects expected in a new, similar study [ 37 ]. Within-study correlations between outcomes were not assumed a priori; instead, dependency among outcomes from the same study was modelled through estimation of the level-2 variance component (σ²₂) [ 38 , 39 ]. This model estimates three distinct sources of variance: variance between studies (level 3), variance between effect sizes within the same study (level 2), and sampling variance of the effect sizes (level 1) [ 38 – 40 ]. Level-1 variance was treated as known and calculated using reported standard errors from each study, transformed into variances as per Cheung’s methodology (2014) [ 38 ]. Within-study correlations between outcomes were not assumed a priori, dependency among outcomes reported within the same study was modelled through the estimation of the level-2 variance component. An initial three-level meta-analysis was conducted to evaluate the overall effect of psychological interventions across all outcomes. To account for potential differences in intervention effectiveness across psychological constructs, additional domain-specific models were then estimated: anxiety, depression, stress, general psychological distress, infertility-related distress, and well-being. Studies that reported both distress and well-being outcomes contributed effect sizes to each relevant model. These constructs were analysed separately due to their conceptual and measurement distinctions, with dependency appropriately modelled through the three-level structure. Distress outcomes reflect negative psychological states, while well-being reflects positive psychological functioning. This allowed for a more precise evaluation of how interventions affected distinct aspects of mental health. For all models, variance components at each level were examined to determine the distribution of variance. The full model combining all outcomes showed significant within-study variance (level 2), indicating heterogeneity in effect sizes reported within studies. This confirmed the appropriateness of the three-level structure and the need for moderator analysis to explain between- and within-study variability [ 38 , 41 ]. Sensitivity analyses were conducted excluding infertility-specific distress outcomes and psychoeducation interventions, which had been identified as unstable and extreme in preliminary models, to examine the robustness of results. To explore potential sources of heterogeneity in intervention effects, three-level meta-regression models were conducted using the following outcome groupings: (i) all psychological outcomes, (ii) distress (comprising anxiety, depression, stress, general psychological distress, with infertility-related distress analysed separately due to instability), and [ 3 ] well-being (life satisfaction, self-efficacy, and quality of life). This grouping approach was implemented due to the conceptual overlap between anxiety, depression, stress, and general distress, which frequently co-occur in response to infertility and share common psychological mechanisms such as loss of control and identity disruption [ 42 , 43 ]. These constructs are often subsumed under the broader domain of psychological distress in dimensional models of psychopathology [ 44 ]. Integrating these constructs enhance statistical power and allowed for more stable estimation of moderator effects, consistent with established meta-analytic practices [ 45 , 46 ]. While domain-specific analyses were used to examine outcome-level effects, the broader distress grouping provided a theoretically coherent and methodologically robust framework for moderator exploration. Both study-level and intervention-level moderators were included, such as intervention type, dosage characteristics (number of sessions, session duration, and overall intervention length), intervention format (individual, group, or couples-based), delivery mode (in-person, online, self-guided, or blended), and study region (Western countries, East Asia, or the Middle East). In addition, ART status was examined as a study-level moderator, coded into four categories to reflect whether participants were engaged in an active ART cycle, were pre-ART candidates, had experienced failed ART cycles (post-ART), or were recruited from infertility clinics without ART information. This allowed us to explore whether intervention effects differed depending on proximity to fertility treatment. In line with the analytic plan, psychological outcomes were categorised into two broad domains: distress (comprising anxiety, depression, stress, and general psychological distress) and well-being (life satisfaction, self-efficacy, and quality of life). These outcome domains were used to guide separate meta-analytic models in order to evaluate intervention effects on negative and positive indicators of psychological functioning. Moderator variables were incorporated into separate models. Outcome domain was included in a model testing differences in pooled effects across distress and well-being, while dosage and delivery characteristics were analysed in distinct models to isolate their contributions and avoid overfitting. In total, six moderator models were estimated: [ 1 ] a dosage-only model [ 2 ], a domain-only model (distress vs. well-being) [ 3 ], a dosage x domain interaction model [ 4 ], an intervention format and delivery mode model [ 5 ], a region model and [ 6 ] an intervention type model and [ 7 ] an ART status model. ART status was examined as a categorical moderator with four levels (active ART, pre-ART, past-ART, and not specified), and was also explored separately within distress and well-being outcome domains to assess whether proximity to fertility treatment influenced intervention effects. All moderator analyses used restricted maximum likelihood estimation with the Knapp-Hartung correction to improve accuracy of confidence intervals [ 47 ]. Categorical moderators were dummy coded, and continuous variables were mean-centred to reduce multicollinearity. Psychoeducation was excluded from moderator models due to its outlier effect and limited representation, which substantially inflated heterogeneity and skewed parameter estimates. Sensitivity analyses confirmed that exclusion of both infertility distress and psychoeducation produced more stable estimates with markedly reduced heterogeneity.

Of the 8,068 studies initially identified, 57 met the eligibility criteria. An updated search was subsequently conducted to ensure currency of the review, which identified an additional 12 eligible studies. In total, 69 studies were included in the systematic review. Figure  1 presents the PRISMA flow diagram outlining the number of studies excluded at each stage of the selection process and the reasons for exclusion. Collectively, these studies examined the effect of psychological interventions on infertility distress in 5935 infertile women. Participants characteristics are detailed in Table  2 , while intervention characteristics are shown in Table  3 . After removing duplicates and screening titles/abstracts based on the inclusion criteria, 81 full-text studies were assessed for eligibility. After screening 81 full-text reports for eligibility, 57 intervention studies from the original search met inclusion criteria and were included in the qualitative synthesis. Of these, 50 provided sufficient data and were included in the meta-analysis. An updated search was then conducted to ensure currency of the review, which identified a further 12 eligible studies. This brought the total to 69 intervention studies included in the qualitative synthesis, of which 60 provided sufficient quantitative data for inclusion in the meta-analysis. Fig. 1 Flow diagram of study selection process Flow diagram of study selection process The total number of participants for all the included studies was 5935 women. The number of participants in each study ranged from 22 to 251. The age of the participants ranged from 20 to 45 years. Of the 69 studies included, the majority originated from Iran (k = 42), followed by Turkey (k = 7) China (k = 6), United States (k = 5), Portugal (k = 2), South Korea (k = 2), United Kingdom (k = 1), Spain (k = 1), Taiwan (k = 1), Japan (k = 1) and Brazil (k = 1). Of the 51 studies reporting duration of infertility, the mean duration of infertility was approximately 4.95 years. Of the 29 studies reporting the causes of infertility in their participant sample, an average of 33.9% of cases were deemed to be female factor infertility, 37.7% male factor, 16.2% combined and 19.8% unexplained. Fertility treatment status was reported in the majority of the studies (k = 55). Of these, participants were undergoing active ART cycles (k = 20), had experienced one or more failed ART attempts (k = 5), were pre-ART candidates preparing for treatment (k = 5), or were drawn from mixed ART populations including IVF, ICSI, IUI, or medical treatment (k = 7). A further 16 studies recruited infertility clinic patients where ART status was not specified, and two studies recruited community-based infertility samples without ART specification. Participant characteristics are presented in Table  2 . Table 2 Participant characteristics Study Participants allocated ( n ) i: intervention c: control Age Intervention (Range, n , %) OR (Mean, SD) Age Control Cause of Infertility Intervention Cause of Infertility Control Duration of Infertility Intervention Duration of Infertility Control ART Treatment Specified Type of ART Aba et al., 2017[ 48 ] I: 100 C: 100 22–35: (60.7%) 36–45: (39.3%) 22–35: (52.6%) 36–45: (47.4%) Female (43.8%) Male (12.4%) Both (10.1%) Unknown (33.7%) Female (29.9%) Male (24.7%) Both (13.4%) Unknown (32.0%) 1–5 years: (84.3%) 6–10 years: (10.1%) > 11 years: (5.6%) 1-5years: (79.4%) 6-10years: (16.5%) > 11 years (4.1%) Yes IVF ET Ahmadi et al., 2019[ 49 ] I: 12 C: 12 N.R. N.R. N.R. N.R. N.R. N.R. No N.R. Bahremand et al., 2025[ 50 ] I: 20 C:20 36.69 (6.74) 38.12 (7.30) N.R. N.R. 6.85 (2.19) 8.25 (3.60) No N.R. Bai et al., 2019 [ 1 ] [ 51 ] I: 78 2I: 78 C: 78 30.23 (4.14) 30.36 (4.82) Female ( n  = 30) Male ( n  = 15) Both ( n  = 19) Unknown ( n  = 14) Female ( n  = 32) Male ( n  = 18) Both ( n  = 13) Unknown ( n  = 15) 3.96 (2.77) 3.66 (3.08) Yes IVF ICSI (first cycle only) Bai et al., 2019 [ 2 ] [ 51 ] I: 78 2I: 78 C: 78 30.27 (4.14) 30.36 (4.82) Female ( n  = 32) Male ( n  = 11) Both ( n  = 14) Unknown ( n  = 21) Female ( n  = 32) Male ( n  = 18) Both ( n  = 13) Unknown ( n  = 15) 4.29 (3.05) 3.66 (3.08) Yes IVF ICSI (first cycle only) Bal & Uçar, 2024 [ 1 ] [ 52 ] I: 35 2I: 35 C: 34 30.70 (4.83) 32.50(5.58) N.R. N.R. 5: (50%) Years  5: (40%) Years Yes IVF unit (IVF and insemination referenced, not participant-specific) Bal & Uçar, 2024 [ 2 ][ 52 ] I: 35 2I: 35 C: 34 30.86 (5.09) 32.50 (5.58) N.R. N.R. 5: (43.3%) Years  5: (40%) Years Yes IVF unit (IVF and insemination referenced, not participant-specific) Basirat et al., 2022[ 53 ] I: 20 2I: 20 C: 20 32.7 (6.8) 32.2(5.8) N.R. N.R. Month 69.6 (54.3) Month 60.6 (56.1) No N.R Bidgoli & Latifnejad, 2018[ 54 ] I: 40 C: 40 20–24: (10.3%) 25–29: (37.9%) 30–34: (24.1%) 35–40: (27.6%) 20–24: (12.9%) 25–29: (54.8%) 30–34: (25.8%) 35–40: (6.5%). Female (31%) Male (34.5%) Both (13.8%) Unknown (20.7%) Female (25.8%) Male (51.6%) Both (9.7%) Unknown (12.9%) 5.62 (4.26) 6.08 (4.31) Yes IVF Chan et al., 2006[ 55 ] I:69 C: 115 36.0 3.28 35.0 3.49 N.R. N.R. 5.0 (2.0–11.0) 5.0 (1.0–15.0) Yes IVF-ET; IVF or ICSI (first cycle only) Chan et al., 2012[ 56 ] I: 141 C: 110 34.51 (3.42) 34.32 (3.09) Tubal (29.7%) Endometriosis (9.4%) Male (42%) Both (8.6%) Unknown (8%) Tubal (30.6%) Endometriosis (16.7%) Male (40.7%) Both (6.5%) Unknown (5.6%) 5 year mean (2–15 range) 5 year mean (1–16 years range) Yes IVF (first cycle only) Chehreh et al., 2025[ 57 ] I: 10 C: 10 31.92 [ 6 ] 32.38 [ 6 ] N.R N.R. 4.31 (2) 4.45 (2) No Not Specified Connolly et al., 1993[ 58 ] I: 37 C: 45 Overall Females 32 (4.1) Overall Female (37.5%) Male (16.9%) Both (11.8%) Overall 5.4 (3.1) years Yes IVF (first cycle only) Cousineau et al., 2008[ 59 ] I1: 49 I2: 47 C1: 49 C2: 43 I1: 34.53 (4.35) I2: 34.26 (4.58) C1: 34.14 (4.29) C2: 33.93 (4.30) I1: Female (38.8%) Male (10.2%) Both (18.4%) Unknown (32.7%) I2: Female (42.6%) Male (14.9%) Both (10.6%) Unknown (31.9%) C1: Female (42.9%) Male (12.2%) Both (18.4%) Unknown (26.5%) C2: Female (32.6%) Male (16.3%) Both (18.6%) Unknown (32.6%) N.R. N.R. No Not Specified Damghanian et al., 2025[ 60 ] I: 30 C: 30 35.21 (4.39) 34.93 (5.46) 4.93 (3.68) 4.43 (3.84) Yes IVF Daneshfar et al., 2024[ 61 ] I:43 C:43 32.31 (6.30) 32.10 (6.30) 4 (1) 3 (2) No Not Specified (HSG diagnostic) Dastjerdi et al., 2021[ 62 ] I: 25 C: 25 28.01 (4.1) 28.04(3.64) N.R. N.R. N.R. N.R. No Not Specified Domar et al., 2000 [ 1 ][ 63 ] I: 56 2I: 65 C: 63 33.96 (4.32) 35.19 (4.84) N.R. N.R. Months 18.68 (3.66) Months 17.44 (3.36) No Not Specified Domar et al., 2000 [ 2 ][ 63 ] I: 56 2I: 65 C: 63 33.71 (4.65) 35.19 (4.84) N.R. N.R. Months 17.99 (4.11) Months 17.44 (3.36) No Not Specified Domar et al., 2015[ 64 ] I: 89 C: 77 34.67 (4.26) 35.03 (4.18) N.R. N.R. 35.03 (4.18) 35.03 (4.18) Yes IVF (first stimulated ART cycle) Ehsan et al., 2019[ 65 ] I:45 C:45 30.83 (6.6) 30.80 (5.8) N.R. N.R. 5.91 (4.1) 6.38 (4.3) No Not Specified Elahe et al., 2018[ 66 ] I: 20 C: 20 32.7 (5.1) 29.5 (5.8) N.R. N.R. N.R. N.R. No Not Specified Erdemoğlu & Derya, 2024[ 67 ] I: 51 C: 56 34.13 (6.1) 32.08 (6.48) N.R. N.R. N.R. N.R. Yes IVF First cycle ( n  = 34), second cycle ( n  = 9), third + cycle ( n  = 8) Faramarzi et al., 2008[ 68 ] I: 42 2I:42 C:40 I: 28.3 (3.8) 2I: 29.8 (5.3) 28.4 (5.3) Female (38%) Male (26%) Both (24%) Unknown (12%) Female (34%) Male (24%) Both (26%) Unknown (16%) I: 5.4 (3.9) 2I: 6.3 (3.4) 5.7 (4.4) Yes IVF/ICSI 75%: ≥2 cycles IUI (13%) Faramarzi et al., 2013[ 69 ] I: 42 2I:42 C:40 I: 28.3 (3.8) 2I: 29.8 (5.3) 28.4 (5.3) N.R. N.R. I: 5.4 (3.9) 2I: 6.3 (3.4) 5.7 (4.4) Yes IVF Fard et al., 2018[ 70 ] 1I: 15 2I: 15 C1: 15 C2: 15 1I:  30 (20%) 2I:  30 (20%) 1 C:  30 (73%) 2 C: 30 (47%) N.R. N.R. N.R. N.R. Yes ART Care Galhardo et al., 2013[ 71 ] I: 61 C: 41 38.47 (4.20) 33.14 (3.94) Female (34.50%) Male (21.80%) Both (25.50%) Unknown (18.20%) Female (40.50%) Male (37.80%) Both (18.90%) Unknown (2.70%) 3.35 (2.53) years 3.05 (2.44) years Yes Mixed ART: IVF (21.8%), ICSI (21.8%), ovarian stimulation (3.6%), assessment/waiting (52.7%), donor gametes (3.6–13.5%) Galhardo et al., 2018[ 72 ] I:55 C:37 34.87 (4.20) 33.14 (3.94) Female (34.50%) Male (21.80%) Both (25.50%) Unknown (18.20%) Female (40.50%) Male (37.80%) Both (18.90%) Unknown (2.70%) 3.35 (2.53) years 3.05 (2.44) years Yes Infertility medical treatment (type not specified) Gity et al., 2025[ 73 ] I: 15 I2: 15 C: 15 Age Range 20–45 Age Range 20–45 > 1 year > 1 year No Not Specified Gojani et al., 2017[ 74 ] I: 34 C:36 25.28 (4.20) 25.85 (3.39) Female ( n  = 4) Male ( n  = 14) Both ( n  = 8) Unknown ( n  = 10) Female ( n  = 4) Male ( n  = 10) Both ( n  = 8) Unknown ( n  = 13) N.R. N.R. Yes IUI (current treatment) Prior ART history: No ART 53.5%, IUI 32.4%, Other 14.1% Haji-Adineh et al., 2019[ 75 ] I: 15 C: 15 34.23 (6.22) 35.32 (7.14) N.R. N.R. N.R. N.R. No Not Specified Hamzehgardeshi et al., 2019[ 76 ] I: 25 C:25 20–29 (37.5%) 30–39 (58.3%) 40–45 (4.2%). 20–29 (44%) 30–39 (52%) 40–45 (4%). Female (20.8%) Male (41.7%) Both (25%) Unknown (12.5%) Female (8%) Male (44%) Both (16%) Unknown (32%). 3.52 (1.85) 4.04 (1.64) Yes IVF/ICSI (first cycle) Heredia et al., 2020[ 77 ] I: 23 C: 23 34.7 33.8 Female (9%) Male (27%) Both (18%) Unknown (45%) Female (40%) Male (20%) Both (27%) Unknown (13%) 4.3 4.4 Yes IVF Hosseinpanahi et al., 2020[ 78 ] I: 27 C: 27 31.5 (5.3) (Females) 30.3 (4.6) (Females) Female (50%) Male (24%) Both (18.5%) Unknown (7.4%) Female (44.4%) Male (18.5%) Both (29.6%) Unknown (7.4%) 3.0 (2.1) 2.4 (1.2) No Not Specified (mentioned all participants had at least one treatment failure) İnam & Satılmış, 2025[ 79 ] I: 17 C: 17  36: 7  36: 9 N.R. N.R. N.R. N.R. Yes IVF (beginning treatment, ≤ 3 prior IVF attempts) Kalhori et al., 2020[ 80 ] I: 45 C: 45 30.28 (4.41) 29.64 (4.71) N.R. N.R. 5.26 (3.20) 4.93 (3.38) Yes IVF Karaca et al., 2019[ 81 ] I: 55 C: 52 31.44 (6.04) 29.48 (5.26) Female (30.8%) Male (11.5%) Both (9.6%) Unknown (48.1%) Female (25%) Male (23.1%) Both (19.2%) Unknown (32.7%) 4.5 Median (1–20 Range) 4.00 Median (1–20 Range) Yes ART unit patients Kerchi et al., 2021 [ 1 ][ 82 ] I: 15 2I: 15 C:15 39.66 (3.26) 40 (1.90) N.R. N.R. 5.52 (1.86) 5.68 (1.91) Yes IVF (pretreatment phase) Kerchi et al., 2021 [ 2 ][ 82 ] I: 15 2I: 15 C:15 39.81 (2.77) 40 (1.90) N.R. N.R. 5.15 (1.72) 5.68 (1.91) Yes IVF (pretreatment phase) Kim et al., 2014[ 83 ] I: 26 C: 24 33.85 (3.17) 34.67 (2.73) N.R. N.R. 25.35 (11.84) months 26.25 (10.94) months Yes IVF (second cycle, long protocol, after failed first IVF; own oocytes only) Kim et al., 2020[ 84 ] I: 26 C: 24  35 (80.8%)  35 (79.2%) Female (53.8%) Male (11.5%) Both (7.7%) Unknown (26.9%) Female (37.5%) Male (20.8%) Both (0%) Unknown (41.7%).  5 (61.5%)  5 (54.2%) Yes IVF (rest stage after ≥ 1 failed cycle, before next attempt) Kiyak & Kocoglu-Tanyer, 2021[ 85 ] I: 74 C: 72 30.7 (6.44) 30.7 (6.37) N.R. N.R. 50.75 (57.91) months 50.66 (60.42) months? Yes IVF Lee, 2003[ 86 ] I: 64 C: 68 31.8 (4.2) 32.3 (4.1) Female (53.1%) Male (26.6%) Both (12.5%) Unknown (7.8%) Female (42.6%) Male (36.8%) Both (10.3%) Unknown (10.3%) 4.3 (2.5) years 4.4 (3.6) years Yes IVF-ET Li et al., 2016[ 87 ] I: 58 C:50 30.66 (4.29) 30.70 (4.77) Female ( n  = 32) Male ( n  = 11) Both ( n  = 14) Unknown ( n  = 1) Female ( n  = 31) Male ( n  = 4) Both ( n  = 14) Unknown ( n  = 1) 4.66 (3.06) 5.20 (3.03) Yes IVF (first cycle only) Ma et al., 2018[ 88 ] I: 87 C: 98  30 (52.5%) 30 (50%) Female (55%) Male (45%) Female (42.5%) Male (58.8%) 4 years (51.2%) 4years (60%) No Not Specified Marashi et al., 2021[ 89 ] I: 34 C: 34 31 (4.7) 31 (4.7) Overall Female ( n  = 6) Male ( n  = 18) Both ( n  = 7) Unknown ( n  = 3) 5.1 (2.8) 4.2 (2.9) No Not Specified Masoumi et al., 2025[ 90 ] I: 28 C:29 37.29 (2.47) 36.14 (3.50) Female (35.7%) Male (32.1%) Both (32.1%) Female (41.4%) Male (17.2%) Both (41.4%) 10.21 (3.65) 9.48 (4.37) Yes IVF (≥ 2 prior failed cycles; 53.6% ≥4 failures, 35.7% 3 failures, 10.7% 2 failures) McQueeny et al., 1997[ 91 ] 1I: 10 2I: 10 C: 9 Overall 31.48 (3.53) years Overall Female (59%) Male (7%) Both (17%) Unknown (17%) Overall 45.79 (15.37) Months No Not Specified Moeenizadeh & Zarif, 2017[ 92 ] I: 11 C: 11 27.45 (3.62) 28.18 (4.29) N.R. N.R. 4.18 (1.27) years 3.73 (1.17) years No Not Specified Moein et al., 2018[ 93 ] I: 15 C: 15 21–35 21–35 N.R. N.R. 1–4 years 1–4 years No Not Specified Mori et al., 2009[ 94 ] I: 99 C: 46 30.4 (2.87) 31.3 (2.49) Female (42.4%) Male (2.4%) Both (9.4%) Unknown (54.9%) Female (62.5%) Male (5%) Both (7.5%) Unknown (25%) 2.3 (1.43) 2.2 (1.5) Yes General fertility treatment only (excluded IVF/ICSI; some ovulation-enhancing agents used) Mosalanejad et al., 2012[ 95 ] I: 32 C: 33 20–30 ( n  = 18) 31–40 ( n  = 19) Female n  = 18 Male n  = 3 Female n  = 16 Male n  = 7 12 16 Yes Hormonal therapy or ART (not specified) Mosalanejad et al., 2012 (overall)[ 96 ] I: 16 C: 15 20–25 (9.67%) 26–31 (77.42%) 31–35 (12.95%) N.R. N.R. N.R. N.R. Yes ART (type not specified) Mousavi et al., 2020[ 97 ] I: 15 C: 15 34.27 (4.75) 36.20 (5.11) N.R. N.R. N.R. N.R. Yes IVF (no prior ART history) Nery et al., 2019[ 98 ] I: 97 C: 81 37.4 (5.3) 37.0 (6.5) N.R. N.R. 7.5 (3.8) 9.1 (5.2) Yes IVF Nezhad et al., 2020[ 99 ] I: 25 C: 25 28.52 (5.76) 31.32 (5.98) Female (34%) Both (20%) Unknown (36%) Female (52%) Both (32%) Unknown (16%) Months 42.36 (40.18) Months 55.4 (44.39) Yes Infertility treatment (fertility drugs/ART, type not specified) Nilforooshan et al., 2006[ 100 ] I: 15 C: 15 28.6 (5.16) 25.5 (4.08) N.R. N.R. N.R. N.R. No Not Specified Pasha et al., 2013[ 101 ] I: 42 2I: 40 C: 42 I: 28.3 (3.8) 2I: 29.8 (5.3) 28.4 (5.3) N.R. N.R. I: 5.4 (3.9) years 2I: 6.3 (3.4) years 5.7 (4.5) years Yes IVF (≥ 1 prior cycle; not undergoing ART during intervention) Pasha et al., 2018[ 102 ] I: 31 2I: 31 C: 31 Overall Age 29 (5.44) I: Female (6.5%) Male (35.5%) Both (29%) Unknown (29%) 2I: Female (6.5%) Male (35.5%) Both (32.3%) Unknown (25.8%) Female (16.1%) Male (29%) Both (22.6%) Unknown (32.3%) N.R. N.R. No Not Specified Rahimi et al., 2021[ 103 ] I: 30 C: 30 34.4 (6.0) 32.9 (7.4) N.R. N.R. 6.8 (3.1) 6.8 (3.0) Yes IVF Rahimi & Bazazian, 2023[ 104 ] I: 15 C:15 N.R. N.R. N.R. N.R. N.R. N.R. Yes IVF (previous failed cycles) Rahmani et al., 2018[ 105 ] I: 12 C: 12 32.33 (2.77) 32.25 (3.07) N.R. N.R. N.R. N.R. No Not Specified Sahraian et al., 2024[ 106 ] I: 29 C:57 33.36 (6.30) 34.72 (6.84) N.R. N.R. N.R. N.R. Yes IVF Sexton et al., 2010[ 107 ] I: 21 C: 22 Overall 32.6 (4.8) Overall Female (42%) Male factor (22.5%) Both (22.5%) Unknown (13%) Overall 2.5 (2.1) years Yes Mixed: 58% ART (IVF/ICSI), 6.5% IUI, 16% injections, 10% oral ovulation induction, 6.5% undecided, 3% other (surgery/acupuncture) Seyedi Asl et al., 2016[ 108 ] I: 18 C:18 32.33 (4.82) 29.25 (5.65) N.R. N.R. 5.27 (5.37) 3.93 (3.13) No Not Specified Shafaghi et al., 2024[ 109 ] I: 32 C: 31 31.97 (6.167) 33.55 (5.163) Male: 15 Female: 7 Both: 7 Unknown: 3 Male: 11 Female: 8 Both: 9 Unknown: 6 50.32 (68.49) 77.80 (31.14) Yes IVF (failed cycle, post-treatment counseling) Shargh et al., 2016[ 110 ] I: 30 C: 30 Overall 20–28 ( n  = 15) 29–37 ( n  = 38) 38–45 ( n  = 7) N.R. N.R. Overall 1–3 ( n  = 12) 4–7 ( n  = 42) 8–10 ( n  = 6) No Not Specified Soleimani et al., 2023[ 111 ] I: 30 C: 30 N.R. N.R. Female (41.7%) Male (20.8%) Both (25%) Unknown (12.5%) Female (44%) Male (8%) Both (16%) Unknown (32%) N.R. N.R. Yes IVF (throughout the cycle) Taheri et al., 2025[ 112 ] I: 33 C:30 30.1 (4.5) 30.1 (5.4) 63.8 (37.6) 68 (40.2) Yes IVF (first cycle) Yahyavi Koochaksaraei et al., 2024[ 113 ] I:45 C: 45 33.51 (7.03) 35.16 (6.33) Male: 9 Female: 7 Unknown: 13 Both: 16 Male: 12 Female: 12 Unknown: 10 Both: 11 7.16 (4.65) 6.58 (5.14) Yes Mixed ART: IVF 40%, IUI 26.3%, Medical 15.6%, Other 17.8% Yanık & Budak, 2023[ 114 ] I: 62 C: 62 30.71 (6.60) 28.69 (5.56) N.R. N.R. Less than 1 year: (40.5%) 1–4 Years: (31%) 5–9 Years: (19%) 10 years +: (9.5%) Less than 1 year: (48.4%) 1–4 Years: (41.9%) 5–9 Years: (8.1%) 10 years +: (1.6%) Yes Mixed ART: IVF + IUI/vaccination (infertility treatment) Zahra et al., 2019[ 115 ] I: 25 C: 25 N.R. N.R. N.R. N.R. N.R. N.R. Yes IVF/IUI (mixed) Zhang et al., 2017[ 116 ] I: 100 C:100 N.R. N.R. N.R. N.R. N.R. N.R. Yes IVF I  Intervention, C  Control, SD  Standard Deviation, ART  Assisted Reproductive Technology. IVF  In Vitro Fertilization, ICSI  Intracytoplasmic Sperm Injection, IUI  Intrauterine Insemination, ET  Embryo Transfer, N.R  Not Reported Participant characteristics 22–35: (60.7%) 36–45: (39.3%) 1–5 years: (84.3%) 6–10 years: (10.1%) > 11 years: (5.6%) 1-5years: (79.4%) 6-10years: (16.5%) > 11 years (4.1%) IVF ET Female ( n  = 30) Male ( n  = 15) Both ( n  = 19) Unknown ( n  = 14) Female ( n  = 32) Male ( n  = 18) Both ( n  = 13) Unknown ( n  = 15) IVF ICSI (first cycle only) Female ( n  = 32) Male ( n  = 11) Both ( n  = 14) Unknown ( n  = 21) Female ( n  = 32) Male ( n  = 18) Both ( n  = 13) Unknown ( n  = 15) IVF ICSI (first cycle only) 5: (50%) Years  5: (40%) Years 32.50 (5.58) 5: (43.3%) Years  5: (40%) Years 20–24: (10.3%) 25–29: (37.9%) 30–34: (24.1%) 35–40: (27.6%) 20–24: (12.9%) 25–29: (54.8%) 30–34: (25.8%) 35–40: (6.5%). Female (31%) Male (34.5%) Both (13.8%) Unknown (20.7%) Female (25.8%) Male (51.6%) Both (9.7%) Unknown (12.9%) IVF-ET; IVF or ICSI (first cycle only) Tubal (29.7%) Endometriosis (9.4%) Male (42%) Both (8.6%) Unknown (8%) Tubal (30.6%) Endometriosis (16.7%) Male (40.7%) Both (6.5%) Unknown (5.6%) IVF (first cycle only) I: 10 C: 10 Overall Females 32 (4.1) Overall Female (37.5%) Male (16.9%) Both (11.8%) Overall 5.4 (3.1) years IVF (first cycle only) I1: 34.53 (4.35) I2: 34.26 (4.58) C1: 34.14 (4.29) C2: 33.93 (4.30) I1: Female (38.8%) Male (10.2%) Both (18.4%) Unknown (32.7%) I2: Female (42.6%) Male (14.9%) Both (10.6%) Unknown (31.9%) C1: Female (42.9%) Male (12.2%) Both (18.4%) Unknown (26.5%) C2: Female (32.6%) Male (16.3%) Both (18.6%) Unknown (32.6%) IVF (first stimulated ART cycle) I: 51 C: 56 IVF First cycle ( n  = 34), second cycle ( n  = 9), third + cycle ( n  = 8) I: 28.3 (3.8) 2I: 29.8 (5.3) Female (38%) Male (26%) Both (24%) Unknown (12%) Female (34%) Male (24%) Both (26%) Unknown (16%) I: 5.4 (3.9) 2I: 6.3 (3.4) IVF/ICSI 75%: ≥2 cycles IUI (13%) I: 28.3 (3.8) 2I: 29.8 (5.3) I: 5.4 (3.9) 2I: 6.3 (3.4) 1I: 15 2I: 15 C1: 15 C2: 15 1I:  30 (20%) 2I:  30 (20%) 1 C:  30 (73%) 2 C: 30 (47%) Age Range 20–45 Age Range 20–45 Female ( n  = 4) Male ( n  = 14) Both ( n  = 8) Unknown ( n  = 10) Female ( n  = 4) Male ( n  = 10) Both ( n  = 8) Unknown ( n  = 13) IUI (current treatment) Prior ART history: No ART 53.5%, IUI 32.4%, Other 14.1% 20–29 (44%) 30–39 (52%) 40–45 (4%). Female (20.8%) Male (41.7%) Both (25%) Unknown (12.5%) Female (8%) Male (44%) Both (16%) Unknown (32%). Female (9%) Male (27%) Both (18%) Unknown (45%) Female (40%) Male (20%) Both (27%) Unknown (13%) Female (50%) Male (24%) Both (18.5%) Unknown (7.4%) Not Specified (mentioned all participants had at least one treatment failure)  36: 7  36: 9 Female (25%) Male (23.1%) Both (19.2%) Unknown (32.7%) I: 15 2I: 15 C:15 IVF (pretreatment phase) I: 15 2I: 15 C:15 IVF (pretreatment phase) 26.25 (10.94) months  35 (79.2%)  5 (61.5%)  5 (54.2%) Female (53.1%) Male (26.6%) Both (12.5%) Unknown (7.8%) Female (42.6%) Male (36.8%) Both (10.3%) Unknown (10.3%) Female ( n  = 32) Male ( n  = 11) Both ( n  = 14) Unknown ( n  = 1) Female ( n  = 31) Male ( n  = 4) Both ( n  = 14) Unknown ( n  = 1) IVF (first cycle only)  30 (52.5%) 30 (50%) Female (55%) Male (45%) Female (42.5%) Male (58.8%) 4 years (51.2%) 4years (60%) Overall Female ( n  = 6) Male ( n  = 18) Both ( n  = 7) Unknown ( n  = 3) Female (35.7%) Male (32.1%) Both (32.1%) Female (41.4%) Male (17.2%) Both (41.4%) Overall 31.48 (3.53) years Overall Female (59%) Male (7%) Both (17%) Unknown (17%) Overall 45.79 (15.37) Months Female (42.4%) Male (2.4%) Both (9.4%) Unknown (54.9%) Female (62.5%) Male (5%) Both (7.5%) Unknown (25%) Female n  = 18 Male n  = 3 Female n  = 16 Male n  = 7 ART (type not specified) IVF (no prior ART history) Female (34%) Both (20%) Unknown (36%) Female (52%) Both (32%) Unknown (16%) I: 28.3 (3.8) 2I: 29.8 (5.3) I: 5.4 (3.9) years 2I: 6.3 (3.4) years Overall Age 29 (5.44) I: Female (6.5%) Male (35.5%) Both (29%) Unknown (29%) 2I: Female (6.5%) Male (35.5%) Both (32.3%) Unknown (25.8%) Female (16.1%) Male (29%) Both (22.6%) Unknown (32.3%) IVF (previous failed cycles) Overall 32.6 (4.8) Overall Female (42%) Male factor (22.5%) Both (22.5%) Unknown (13%) Overall 2.5 (2.1) years Male: 15 Female: 7 Both: 7 Unknown: 3 Male: 11 Female: 8 Both: 9 Unknown: 6 Overall 20–28 ( n  = 15) 29–37 ( n  = 38) 38–45 ( n  = 7) Overall 1–3 ( n  = 12) 4–7 ( n  = 42) 8–10 ( n  = 6) Female (41.7%) Male (20.8%) Both (25%) Unknown (12.5%) Female (44%) Male (8%) Both (16%) Unknown (32%) IVF (throughout the cycle) IVF (first cycle) Male: 9 Female: 7 Unknown: 13 Both: 16 Male: 12 Female: 12 Unknown: 10 Both: 11 Less than 1 year: (40.5%) 1–4 Years: (31%) 5–9 Years: (19%) 10 years +: (9.5%) Less than 1 year: (48.4%) 1–4 Years: (41.9%) 5–9 Years: (8.1%) 10 years +: (1.6%) IVF/IUI (mixed) I: 100 C:100 I  Intervention, C  Control, SD  Standard Deviation, ART  Assisted Reproductive Technology. IVF  In Vitro Fertilization, ICSI  Intracytoplasmic Sperm Injection, IUI  Intrauterine Insemination, ET  Embryo Transfer, N.R  Not Reported Intervention characteristics are presented in Table 3 . Various types of psychological interventions were implemented that varied in length (from one day to four years). Psychological interventions were categorized as Acceptance and Commitment Therapy (ACT) (k = 4), Cognitive Behaviour Therapy (CBT) (k = 19), Counselling (k = 15), Dialectical Behaviour Therapy (DBT) (k = 1), Eye Movement Desensitization and Reprocessing Therapy (EMDR) (k = 1), Intensive Short-term Dynamic Psychotherapy (ISTDP) (k = 1) Mindfulness (k = 19), Psychoeducation (k = 4), Schema Therapy (k = 1), and Other (k = 10). Five studies included two psychological interventions each. Interventions included in the “Other” category were Music Therapy [ 48 ], Hypnofertility [ 67 ], Journalling [ 51 , 73 , 94 ], Support Group [ 63 ], Laughter Therapy [ 85 ], Well-being Therapy [ 92 ], Positive Psychotherapy Training [ 114 ], Guided Imagery [ 60 ]. Psychological interventions were conducted in group (k = 41), individual (k = 26), and couples (k = 3) settings. These interventions were delivered in person (k = 57), online (k = 6), self-administered (k = 4), or through a mixed format (k = 5). Session durations ranged from 28 to 180 min, with the number of sessions varying between 2 and 832. The overall intervention duration spanned from a single day to four years. Among the 69 studies, the majority (k = 65) used treatment as usual (TAU) as the control condition, while four studies employed a waitlist control. Although some studies implemented an active control condition, the present meta-analysis only compared data from groups that did not receive any intervention. Specifically, three studies utilized an active psychological intervention as the control, and five studies implemented pharmacotherapy as an active control. These active control groups were excluded from the pooled meta-analytic comparisons to ensure consistency in evaluating the effect of psychological interventions against no-treatment controls. The effect of psychological interventions on infertility distress was measured through outcomes including anxiety, depression, generalised distress, infertility related distress and well-being. These domains were assessed using various validated psychological measurement tools. Anxiety was measured in 23 studies with the State-Trait Anxiety Inventory [ 117 ] (STAI, k = 14), Depression Anxiety and Stress Scale [ 118 ] (DASS-21, k = 5), Beck Anxiety Inventory [ 119 ] (BAI, k = 1), Symptom Checklist [ 120 ] (SCL-90, k = 1), General Health Questionnaire [ 121 ] (GHQ-28, k = 1) and the Generalized Anxiety Disorder Scale [ 122 ] (GAD-7, k = 1). Depression was measured in 25 studies with the Beck Depression Inventory [ 123 ] (BDI, k = 14), Depression Anxiety and Stress Scale [ 118 ] (DASS-21, k = 5), Zung Self-Rating Depression Scale [ 124 ] (SDS, k = 2), Center for Epidemologic Studies of Depression Scale [ 125 ] (CES-D, k = 1), Symptom Checklist [ 120 ] (SCL-90, k = 1), General Health Questionnaire [ 121 ] (GHQ-28, k = 1) and the Patient Health Questionnaire [ 126 ] (PHQ-9, k = 1). Stress was measured in seven studies with the Depression Anxiety and Stress Scale [ 118 ] (Dass-21, k = 3), Perceived Stress Scale [ 127 ] (PSS, k = 3), and Lipps’ Stress Symptom Inventory [ 128 ] (k = 1), General psychological distress was measured in 14 studies with the General Health Questionnaire [ 121 ] (GHQ-28, k = 6), Depression Anxiety and Stress Scale [ 118 ] (DASS-21, k = 4), Symptom Checklist [ 120 ] (SCL-90, k = 2), Distress Tolerance Scale [ 129 ] (DTS, k = 1) and the Hospital Anxiety and Depression Scale [ 130 ] (HADS, k = 1). Infertility related distress was measured in 19 studies with the Fertility Problem Inventory [ 131 ] (FPI, k = 14), Infertility Distress Scale [ 132 ] (IDS, k = 1), Stanton’s Infertility Specific Distress Scale [ 133 ] (k = 1), The Questionnaire on Reproductive Problems (k = 1), COMPI Fertility Problems Scale [ 134 ] (k = 1), Irrational Parenthood Cognition Scale [ 135 ] (IPC, k = 1). Well-being was measured in 25 studies with Fertility Quality of Life Scale [ 136 ] (FertiQol, k = 5), Infertility Self-Efficacy Scale [ 137 ] (ISE, k = 4), Ryff’s Psychological Well-Being Scale [ 138 ] (PWBS, k = 7), Rosenberg Self-Esteem Scale [ 139 ] (RSES, k = 2), Eyesneck’s Self Esteem Questionnaire [ 140 ] (k = 1), COMPI Coping Strategy Scale [ 141 ] (k = 1), Ways of Coping-Revised [ 142 ] (WOC-R, k = 1), World Health Organization Quality of Life – Brief [ 143 ] (WHOQOL-BREF, k = 1), Psychological General Well-Being Index [ 144 ] (PGWBI, k = 1), Satisfaction With Life Scale [ 145 ] (SWS, k = 1), Memorial University of Newfoundland Scale of Happiness [ 146 ] (MUNSH, k = 1). Table 3 Intervention characteristics Study Country of Assessment Participants ( n ) i: intervention c: control (final analysis) Intervention (Category) Comparison Format Delivery Mode Number of Sessions Duration of Intervention Session Duration Outcome of Interest Measurement of Assessing Distress Outcome Aba et al., 2017[ 48 ] Turkey I: 89 C: 97 Music Therapy (Other) TAU Individual In person Two One Day 28 min Anxiety STAI[ 117 ] NS Ahmadi et al., 2019[ 49 ] Iran I: 12 C: 12 Couples Behavioural Treatment (CBT) TAU Couples In person Ten Ten Weeks 90 min General Health GHQ-28[ 121 ] S Bahremand et al., 2025[ 50 ] Iran I: 20 C: 20 Intensive Short-Term Dynamic Psychotherapy (ISTDP) TAU Individual In person Eight Eight Weeks 90 min Distress Tolerance DTS[ 129 ] S Bai et al., 2019 (1)[ 51 ] China I: 78 2I: 78 C: 78 Brief Mindfulness Intervention (Mindfulness) TAU Individual Self-administerd Twenty Eight Four Weeks 60 min per week 20 min daily Depression Anxiety Infertility Stress PHQ-9[ 126 ] GAD-7[ 122 ] FPI[ 131 ] S NS NS Bai et al., 2019 (2)[ 51 ] China I: 78 2I: 78 C: 78 Gratitude Journal (Other) TAU Individual Self-administered Twenty Eight Four Weeks 60 min per week Three things daily Depression Anxiety Infertility Stress PHQ-9[ 126 ] GAD-7[ 122 ] FPI[ 131 ] NS NS NS Bal & Uçar, 2024 (1)[ 52 ] Turkey I: 30 2I: 30 C: 30 Cognitive Behaviour Therapy (CBT) TAU Individual In person Six Three Weeks 40–45 min Infertility Distress Infertility Distress Scale[ 132 ] S Bal & Uçar, 2024 (2)[ 52 ] Turkey I: 30 2I: 30 C: 30 EMDR (EMDR) TAU Individual In person Six Three Weeks Flexible Infertility Distress Infertility Distress Scale[ 132 ] S Basirat et al., 2022[ 53 ] Iran I: 19 2I: 13 C: 18 Group Cognitive Behavioural Therapy (CBT) TAU + Pharmacotherapy Group In person Ten Ten Weeks 90 min Depression Infertility Stress Anxiety BDI[ 123 ] FPI[ 131 ] STAI[ 117 ] S S NS Bidgoli & Latifnejad, 2018[ 54 ] Iran I: 29 C: 31 Collaborative Counselling (Counselling) TAU Individual In person Five Eight to Nine Weeks 45–60 min Coping WOC-R[ 142 ] S Chan et al., 2006[ 55 ] China I:69 C: 115 Eastern Body-Mind-Spirit Intervention (EBMS) (Mindfulness) TAU Group In person Four Four Weeks 3 h Anxiety STAI[ 117 ] S Chan et al., 2012[ 56 ] China I: 141 C: 110 Integrative Body Mind Spirit (Mindfulness) TAU Group In person 832 Four Years 3 h Anxiety STAI[ 117 ] S Chereh et al., 2025[ 57 ] Iran I: 10 C: 10 Cognitive Behavioural Stress Management Training (CBT) TAU Group In person Eight Four Weeks 180 min Infertility Distress The Questionnaire on Reproductive Problems S Connolly et al., 1993[ 58 ] United Kingdom I: 37 C: 45 Couples Counselling (Counselling) TAU Couples In person Three Approx. Ten Weeks 60 min Psychological Distress State Anxiety Self-Esteem GHQ[ 121 ] STAI[ 117 ] RSES[ 139 ] NS S NS Cousineau et al., 2008[ 59 ] United States I1: 49 I2: 47 C1:49 C2:43 Online Psychoeducational Support (Psychoeducation) TAU Individual Online Eight Four Weeks 45 min Infertility Stress Infertility Self-Efficacy FPI[ 131 ] ISE[ 137 ] S S Damghanian et al., 2025[ 60 ] Iran I:28 C: 28 Guided Imagery (Other) TAU Individual Online Six Three Weeks 45 min Infertility Stress FPI[ 131 ] NS Daneshfar et al., 2024[ 61 ] Iran I: 43 C:43 Education Program (Psychoeducation) TAU Group In person Two One Week 30 min Anxiety STAI[ 117 ] S Dastjerdi et al., 2021[ 62 ] Iran I: 25 C: 25 Cognitive Behavioural Therapy (CBT) TAU Group In person Ten Ten Weeks 90 min Depression BDI[ 123 ] S Domar et al., 2015[ 64 ] United States I: 89 C: 77 Cognitive Coping and Relaxing Intervention (Mindfulness) TAU Individual Self-administered One Year Twice Per Day Fertility Quality of Life Anxiety FertiQol[ 136 ] STAI[ 117 ] S S Domar et al., 2000 (1)[ 63 ] United States I: 56 2I: 65 C: 63 Group CBT (CBT) TAU Group In person Ten Ten Weeks 2 h Depression Self-Esteem BDI[ 123 ] RSES[ 139 ] S S S Domar et al., 2000 (2)[ 63 ] United States I: 56 2I: 65 C: 63 Support Group (Other) TAU Group In person Ten Ten Weeks 2 h Depression Self-Esteem BDI[ 123 ] RSES[ 139 ] S S S Ehsan et al., 2019[ 65 ] Iran I: 40 C: 40 Group Counselling (Counselling) TAU Group In person Five Three Weeks 90 min Infertility Stress FPI[ 131 ] S Elahe et al., 2018[ 66 ] Iran I: 18 C: 17 Acceptance and Commitment Therapy (ACT) TAU Group In person Sixteen Eight Weeks 90 min Anxiety BAI[ 119 ] S Erdemoğlu & Derya, 2024[ 67 ] Turkey I: 51 C:56 Hypnofertlity (Other) TAU Individual Mixed One structured then at home practice daily Two – Three Weeks 30–40 min Infertility Distress Coping COMPI Fertility Problem Stress Scales[ 134 ] COMPI Coping Strategy Scale[ 141 ] S S Faramarzi et al., 2008[ 68 ] Iran I: 29 2I: 30 C:30 CBT Group (CBT) TAU + Pharmacotherapy Group In person Ten Ten Weeks 120 min General Health Depression GHQ[ 121 ] BDI[ 123 ] S S Faramarzi et al., 2013[ 69 ] Iran I: 29 2I: 30 C:30 CBT Group (CBT) TAU + Pharmacotherapy Group In person Ten Ten Weeks 120 min Infertility Stress FPI[ 131 ] S Fard et al., 2018[ 70 ] Iran 1I: 15 2I: 15 C1:15 C2:15 Mindfulness Based Cognitive Therapy (MBCT) TAU Group In person Eight Eight Weeks 120 min Well-being Ryff’s PWB (Persian)[ 138 ] S Galhardo et al., 2013[ 71 ] Portugal I: 55 C:37 Mindfulness-Based Program (Mindfulness) TAU Group In person Ten Ten Weeks 120 min Depression Anxiety BDI[ 123 ] STAI[ 117 ] S S Galhardo et al., 2018[ 72 ] Portugal I: 55 C: 37 Mindfulness Based Program for Infertility (Mindfulness) TAU Group In person Ten Ten Weeks 120 min Depression Infertility Self-Efficacy BDI[ 123 ] ISE[ 137 ] S N/A Gity et al., 2025 (1)[ 73 ] Iran I: 15 C: 15 Written Emotional Expression (Other) Waitlist Control Individual Self-administered Eight Four Weeks 15–30 min Anxiety Depression GHQ-28[ 121 ] GHQ-28[ 121 ] S S Gity et al., 2025[ 73 ] (2) Iran I: 15 C: 15 Rational Emotive Behaviour Therapy (CBT) Waitlist Control Group In person Twelve Six Weeks 60 min Anxiety Depression GHQ-28[ 121 ] GHQ-28[ 121 ] S S Gojani et al., 2017[ 74 ] Iran I: 34 C: 34 Problem Solving Skills (Psychoeducation) TAU Individual In person Three Four Weeks 45 min Anxiety Depression STAI[ 117 ] BDI[ 123 ] S S Hamzehgardeshi et al., 2019[ 76 ] Iran I: 24 C:25 Group Counselling (Counselling) TAU Group In person Six Six Weeks 120 min Infertility Stress FPI[ 131 ] S Haji-Adineh et al., 2019[ 75 ] Iran I: 15 C: 15 Acceptance and Commitment Therapy (ACT) TAU Group In person Eight Eight Weeks 120 min Well-being Ryff’s PWB[ 138 ] S Heredia et al., 2020[ 77 ] Spain I: 11 C: 15 Psychological Intervention (Counselling) TAU Individual In person Four Four Weeks 90 min Anxiety Fertility Quality of Life STAI[ 117 ] FertiQol[ 136 ] S S Hosseinpanahi et al., 2020[ 78 ] Iran I: 27 C: 27 Acceptance and Commitment Therapy (ACT) TAU Group In person Eight Eight Weeks 90 min Psychological Distress Fertility Quality of Life GHQ-28[ 121 ] FertiQol[ 136 ] S S İnam & Satılmış, 2025[ 79 ] Turkey I: 17 C: 17 Mindfulness Meditation (Mindfulness) TAU Individual Online 56 Eight Weeks 20 min Anxiety Depression Stress Infertility Self-Efficacy DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] ISES[ 137 ] S S S S Kalhori et al., 2020[ 80 ] Iran I: 45 C: 45 Mindfulness Based Counselling (Mindfulness) TAU Group In person Eight Four Weeks 90 min Depression BDI[ 123 ] S Karaca et al., 2019[ 81 ] Turkey I: 46 C: 48 Cognitive Behavioural Group Therapy (CBT) Waitlist Group In person Eleven Eleven Weeks 120 min Infertility Stress Psychological Distress FPI[ 131 ] GHQ-28[ 121 ] S S Kerchi et al., 2020 (1)[ 82 ] Iran I: 15 2I: 15 C:15 Psychological Empowerment (Counselling) TAU Group In person Eleven Six Weeks 90 min Anxiety DASS-21[ 118 ] S Kerchi et al., 2020 (2)[ 82 ] Iran I: 15 2I: 15 C:15 Dialectical Behaviour Therapy (DBT) TAU Group In person Eight Eight Weeks 90 min Anxiety DASS-21[ 118 ] S Kim et al., 2014[ 83 ] South Korea I: 26 C: 24 Mind-Body Therapeutic Program (Mindfulness) TAU Individual In person Five Five Weeks 120 min Anxiety STAI[ 117 ] S Kim et al., 2020[ 84 ] South Korea I: 26 C: 24 Psychological Intervention (Mind-Body) (Mindfulness) TAU Group In person Six Six Weeks 240 min Infertility Stress Depression FPI[ 131 ] CES-D [ 20 ][ 125 ] S S Kiyak & Kocoglu-Tanyer, 2021[ 85 ] Turkey I: 74 C: 70 Laughter Therapy and PMR (Other) TAU Group In person Three/Four 15 Days 40 min Depression Anxiety BDI[ 123 ] STAI[ 117 ] S S Lee, 2003[ 86 ] Taiwan I: 64 C: 68 Nursing Crisis Intervention (Counselling + CBT) TAU Individual Mixed One to two per week Til embryo transfer 30 min and 40 min videos Depression Anxiety Zung SDS[ 124 ] STAI[ 117 ] NS NS Li et al., 2016[ 87 ] China I: 58 C:50 Mindfulness Based Intervention for Infertility (MBII) (Mindfulness + ACT) TAU Group In person Six Six Weeks 120–150 Mintes Fertility Quality of Life FertiQol[ 136 ] S Ma et al., 2018[ 88 ] China I: 80 C: 80 Psychological Nursing Intervention (CBT) TAU Individual In person Depression Zung SDS[ 124 ] S Masoumi et al., 2025[ 90 ] Iran I: 28 C: 29 Positive Counselling and Cognitive Restructuring (CBT) TAU Individual In person Eight Four Weeks 45–60 min Perceived Stress PSS[ 127 ] S Marashi et al., 2021[ 89 ] Iran I: 32 C: 31 CBT Group Counselling (CBT) TAU Group In person Eight Eight Weeks 90 min Well-being Ryff’s PWB[ 138 ] S McQueeny et al., 1997 (1)[ 91 ] United States 1I: 10 2I: 10 C: 9 Emotion-focused group therapy (Counselling) TAU Group In person Six Six Weeks 90 min Depression Infertility Specific Distress BDI[ 123 ] Stanton (1991) Infertility Specific Distress[ 133 ] S S McQueeny et al., 1997 (2)[ 91 ] United States 1I: 10 2I: 10 C: 9 Problem-focused group therapy (Counselling) TAU Group In person Six Six Weeks 90 min Depression Infertility Specific Distress BDI[ 123 ] Stanton (1991) Infertility Specific Distress[ 133 ] S S Moeenizadeh & Zarif, 2017[ 92 ] Iran I:11 C: 11 Well-being therapy (Other) TAU Group In person Eight Eight Weeks 45–60 min Well-being Depression Ryff’s PWB[ 138 ] DASS-21[ 118 ] S S Moein et al., 2018[ 93 ] Iran I: 15 C: 15 Mindfulness Based CBT (MBCT) TAU Group In person Eight Eight Weeks 90 min Quality of Life WHOQOL-BREF[ 143 ] S Mori et al., 2009[ 94 ] Japan I: 65 C: 38 Stress Management Journal (Other) TAU Individual Self-administered Three submissions Three Months Psychological Distress HADS[ 130 ](Japanese Version) NS Mosalanejad et al., 2012[ 95 ] Iran I: 32 C: 33 E-CBT (CBT) TAU Group Online Twelve Twelve Weeks 120 min Psychological Distress DASS-21[ 118 ] S Mosalanejad et al., 2012 (overall)[ 96 ] Iran I: 16 C: 15 CBT Group (CBT) TAU Group In person Fifteen Fifteen Weeks 90 min Depression Anxiety Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Mousavi et al., 2020[ 97 ] Iran I: 15 C: 15 Mindfulness Based Stress Reduction (Mindfulness) TAU Group In person Eight Eight Weeks 120 min Anxiety Depression Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Nery et al., 2019[ 98 ] Brazil I: 62 C: 37 Mindfulness-Based Program (Mindfulness) TAU Group In person Ten Ten Weeks 120 min Stress Depression Well-Being Lipp’s Stress Symptom Inventory[ 128 ] BDI[ 123 ] PGWBI[ 144 ] S S S Nezhad et al., 2020[ 99 ] Iran I: 20 C:20 Counselling (Counselling) TAU Group In person Nine Nine Weeks 90 min Irrational Parenthood Cognition IPC[ 135 ] S Nilforooshan et al., 2006[ 100 ] Iran I: 15 C: 15 Interacting Cognitive Systems (CBT + Counselling) TAU Couples In person Six Six Weeks Depression BDI[ 123 ] S Pasha et al., 2013[ 101 ] Iran I: 29 2I: 30 C: 30 CBT (CBT) TAU + 2nd Intervention (Fluoxetine) Group In person Ten Ten Weeks 120 min Infertility Self-Efficacy ISE[ 137 ] S Pasha et al., 2018[ 102 ] Iran I: 31 2I: 31 C: 31 Psychosexual Therapy (Including MBCT) (MBCT) TAU + 2nd Intervention (Bupropion ER) Group In person Eight Eight Weeks 120 min Depression BDI[ 123 ] S Rahimi et al., 2021[ 103 ] Iran I: 26 C: 26 Hope-oriented group counselling (Counselling) TAU Group In person Six Six Weeks 45–60 min Depression Anxiety Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Rahimi & Bazazian, 2023[ 104 ] Iran I: 15 C: 15 Schema Therapy (Schema Therapy) TAU Individual In person Ten 60 min Emotion Regulation Perceived Stress S S Rahmani et al., 2018[ 105 ] Iran I: 12 C: 12 Mindfulness Based Cognitive Therapy (MBCT) TAU Group In person Eight Eight Weeks 120 min Quality of Life Infertile Couple’s QoL Questionnaire S Sahraian et al., 2024[ 106 ] Iran I: 25 C:25 Mindful Self-Compassion Program (Mindfulness) TAU Group In person Eight Eight Weeks 120 min Anxiety Depression SCL-R[ 120 ] SCL-R[ 120 ] S S Sexton et al., 2010[ 107 ] United States I: 15 C: 16 Web based CBT (CBT) Waitlist Individual Online Two Weeks General Stress Infertility Stress SCL-90[ 120 ] FPI[ 131 ] S NS Seyedi Asl et al., 2016[ 108 ] Iran I: 15 C: 16 Positive Psychotherapy (Counselling) Waitlist Group In person Six Six Weeks 90 min Satisfaction with Life SWS[ 145 ] S Shafaghi et al., 2024[ 109 ] Iran I: 32 C: 31 Supportive Counselling (Counselling) TAU Individual Mixed Four Four Weeks 60 min Self-Esteem Eysenck Self Esteem Questionnaire[ 140 ] S Shargh et al., 2016[ 110 ] Iran I: 30 C: 30 Mindfulness Based Cognitive Therapy (MBCT) TAU Group In person Eight Eight Weeks Psychological Distress GHQ-28[ 121 ] S Soleimani et al., 2023[ 111 ] Iran I: 28 C: 28 Infertility Coaching Program (Counselling) TAU Individual In person Six 45 min Infertility Stress FPI[ 131 ] S Taheri et al., 2025[ 112 ] Iran I: 33 C:30 Acceptance and Commitment Therapy (ACT) TAU Individual In person Six 30 Days 45–60 min Infertility Stress FPI[ 131 ] S Yahyavi Koochaksaraei et al., 2024[ 113 ] Iran I: 41 C: 44 Digital Self-Care (Psychoeducation) TAU Individual Online Six Six Weeks 25–35 min Well-Being Depression Anxiety Infertility Distress Perceived Stress Ryff’s PWB[ 138 ] BDI[ 123 ] STAI[ 117 ] FPI[ 131 ] PSS[ 127 ] S S S S S Yanık & Budak, 2023[ 114 ] Turkey I: 42 C: 62 Positive Psychotherapy Training (Other) TAU Individual In person Eight Four Weeks 40 min Well-being Ryff’s PWB[ 138 ] S S Zahra et al., 2019[ 115 ] Iran I: 25 C: 25 Group Counselling (CBT) TAU Group In person Ten Ten Weeks 90 min Infertility Stress FPI[ 131 ] S Zhang et al., 2017[ 116 ] China I: 100 C:100 Group Counselling (Counselling) TAU Individual In person Eight Eight Weeks 60 min General Stress Happiness Scale SCL-90[ 120 ] MUNSH[ 146 ] S S Studies marked with (1) and (2) indicate that the same study included multiple psychological intervention arms. Overall refers to studies that did not report disaggregated data by group or timepoint. TAU = treatment as usual, defined as standard medical or fertility care provided without an additional psychological intervention S  statistically significant effect ( p  <.05), NS  not statistically significant ( p  ≥.05), CBT  cognitive behaviour therapy, EMDR  eye movement desensitization and reprocessing, ACT  acceptance and commitment therapy, DBT  dialectical behaviour therapy, MBCT  mindfulness-based cognitive therapy, ISTDP  Intensive Short-Term Dynamic Psychotherapy, STAI  State-Trait Anxiety Inventory, DASS-21  Depression Anxiety and Stress Scale, BAI  Beck Anxiety Inventory, GAD-7  Generalized Anxiety Disorder Scale, BDI  Beck Depression Inventory, SDS  Zung Self-Rating Depression Scale, CES-D  Center for Epidemiologic Studies Depression Scale, PHQ-9  Patient Health Questionnaire–9, GHQ-28  General Health Questionnaire, SCL-90  Symptom Checklist–90, HADS  Hospital Anxiety and Depression Scale, FPI  Fertility Problem Inventory, IDS  Infertility Distress Scale, IPC  Irrational Parenthood Cognition Scale, ISE  Infertility Self-Efficacy Scale, PWBS  Ryff’s Psychological Well-Being Scale, RSES  Rosenberg Self-Esteem Scale, WOC-R  Ways of Coping–Revised, WHOQOL-BREF  World Health Organization Quality of Life–Brief, PGWBI  Psychological General Well-Being Index, SWS  Satisfaction With Life Scale, MUNSH  Memorial University of Newfoundland Scale of Happiness, NR/N.R. Not Reported, Other  category including Music Therapy, Hypnofertility, Journaling, Support Groups, Laughter Therapy, Guided Imagery Intervention characteristics Music Therapy (Other) Intensive Short-Term Dynamic Psychotherapy (ISTDP) 60 min per week 20 min daily Depression Anxiety Infertility Stress PHQ-9[ 126 ] GAD-7[ 122 ] FPI[ 131 ] S NS NS 60 min per week Three things daily Depression Anxiety Infertility Stress PHQ-9[ 126 ] GAD-7[ 122 ] FPI[ 131 ] NS NS NS Cognitive Behaviour Therapy (CBT) EMDR (EMDR) Depression Infertility Stress Anxiety BDI[ 123 ] FPI[ 131 ] STAI[ 117 ] S S NS Collaborative Counselling (Counselling) Eastern Body-Mind-Spirit Intervention (EBMS) (Mindfulness) Integrative Body Mind Spirit (Mindfulness) Cognitive Behavioural Stress Management Training (CBT) Couples Counselling (Counselling) Psychological Distress State Anxiety Self-Esteem GHQ[ 121 ] STAI[ 117 ] RSES[ 139 ] NS S NS Online Psychoeducational Support (Psychoeducation) Infertility Stress Infertility Self-Efficacy FPI[ 131 ] ISE[ 137 ] S S Guided Imagery (Other) Education Program (Psychoeducation) Cognitive Behavioural Therapy (CBT) Cognitive Coping and Relaxing Intervention (Mindfulness) Fertility Quality of Life Anxiety FertiQol[ 136 ] STAI[ 117 ] S S Group CBT (CBT) Depression Self-Esteem BDI[ 123 ] RSES[ 139 ] S S S Support Group (Other) Depression Self-Esteem BDI[ 123 ] RSES[ 139 ] S S S I: 51 C:56 Hypnofertlity (Other) Infertility Distress Coping COMPI Fertility Problem Stress Scales[ 134 ] COMPI Coping Strategy Scale[ 141 ] S S General Health Depression GHQ[ 121 ] BDI[ 123 ] S S I: 55 C:37 Mindfulness-Based Program (Mindfulness) Depression Anxiety BDI[ 123 ] STAI[ 117 ] S S I: 55 C: 37 Depression Infertility Self-Efficacy BDI[ 123 ] ISE[ 137 ] S N/A Gity et al., 2025 (1)[ 73 ] Written Emotional Expression (Other) Anxiety Depression GHQ-28[ 121 ] GHQ-28[ 121 ] S S Gity et al., 2025[ 73 ] (2) Rational Emotive Behaviour Therapy (CBT) Anxiety Depression GHQ-28[ 121 ] GHQ-28[ 121 ] S S Anxiety Depression STAI[ 117 ] BDI[ 123 ] S S Group Counselling (Counselling) Acceptance and Commitment Therapy (ACT) Anxiety Fertility Quality of Life STAI[ 117 ] FertiQol[ 136 ] S S Acceptance and Commitment Therapy (ACT) Psychological Distress Fertility Quality of Life GHQ-28[ 121 ] FertiQol[ 136 ] S S Mindfulness Meditation (Mindfulness) Anxiety Depression Stress Infertility Self-Efficacy DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] ISES[ 137 ] S S S S Mindfulness Based Counselling (Mindfulness) Cognitive Behavioural Group Therapy (CBT) Infertility Stress Psychological Distress FPI[ 131 ] GHQ-28[ 121 ] S S I: 15 2I: 15 C:15 Psychological Empowerment (Counselling) I: 15 2I: 15 C:15 Dialectical Behaviour Therapy (DBT) Mind-Body Therapeutic Program (Mindfulness) Psychological Intervention (Mind-Body) (Mindfulness) Infertility Stress Depression FPI[ 131 ] CES-D [ 20 ][ 125 ] S S Laughter Therapy and PMR (Other) Depression Anxiety BDI[ 123 ] STAI[ 117 ] S S I: 64 C: 68 Nursing Crisis Intervention (Counselling + CBT) Depression Anxiety Zung SDS[ 124 ] STAI[ 117 ] NS NS Mindfulness Based Intervention for Infertility (MBII) (Mindfulness + ACT) Psychological Nursing Intervention (CBT) Positive Counselling and Cognitive Restructuring (CBT) CBT Group Counselling (CBT) Emotion-focused group therapy (Counselling) Depression Infertility Specific Distress BDI[ 123 ] Stanton (1991) Infertility Specific Distress[ 133 ] S S Problem-focused group therapy (Counselling) Depression Infertility Specific Distress BDI[ 123 ] Stanton (1991) Infertility Specific Distress[ 133 ] S S Well-being therapy (Other) Well-being Depression Ryff’s PWB[ 138 ] DASS-21[ 118 ] S S Mindfulness Based CBT (MBCT) Stress Management Journal (Other) E-CBT (CBT) CBT Group (CBT) Depression Anxiety Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Mindfulness Based Stress Reduction (Mindfulness) Anxiety Depression Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Mindfulness-Based Program (Mindfulness) Stress Depression Well-Being Lipp’s Stress Symptom Inventory[ 128 ] BDI[ 123 ] PGWBI[ 144 ] S S S Counselling (Counselling) Interacting Cognitive Systems (CBT + Counselling) CBT (CBT) Psychosexual Therapy (Including MBCT) (MBCT) TAU + 2nd Intervention (Bupropion ER) Hope-oriented group counselling (Counselling) Depression Anxiety Stress DASS-21[ 118 ] DASS-21[ 118 ] DASS-21[ 118 ] S S S Schema Therapy (Schema Therapy) Emotion Regulation Perceived Stress S S Mindfulness Based Cognitive Therapy (MBCT) Mindful Self-Compassion Program (Mindfulness) Anxiety Depression SCL-R[ 120 ] SCL-R[ 120 ] S S Web based CBT (CBT) General Stress Infertility Stress SCL-90[ 120 ] FPI[ 131 ] S NS Positive Psychotherapy (Counselling) Supportive Counselling (Counselling) Mindfulness Based Cognitive Therapy (MBCT) Infertility Coaching Program (Counselling) Acceptance and Commitment Therapy (ACT) Digital Self-Care (Psychoeducation) Well-Being Depression Anxiety Infertility Distress Perceived Stress Ryff’s PWB[ 138 ] BDI[ 123 ] STAI[ 117 ] FPI[ 131 ] PSS[ 127 ] S S S S S Positive Psychotherapy Training (Other) S S Group Counselling (CBT) I: 100 C:100 Group Counselling (Counselling) General Stress Happiness Scale SCL-90[ 120 ] MUNSH[ 146 ] S S Studies marked with (1) and (2) indicate that the same study included multiple psychological intervention arms. Overall refers to studies that did not report disaggregated data by group or timepoint. TAU = treatment as usual, defined as standard medical or fertility care provided without an additional psychological intervention S  statistically significant effect ( p  <.05), NS  not statistically significant ( p  ≥.05), CBT  cognitive behaviour therapy, EMDR  eye movement desensitization and reprocessing, ACT  acceptance and commitment therapy, DBT  dialectical behaviour therapy, MBCT  mindfulness-based cognitive therapy, ISTDP  Intensive Short-Term Dynamic Psychotherapy, STAI  State-Trait Anxiety Inventory, DASS-21  Depression Anxiety and Stress Scale, BAI  Beck Anxiety Inventory, GAD-7  Generalized Anxiety Disorder Scale, BDI  Beck Depression Inventory, SDS  Zung Self-Rating Depression Scale, CES-D  Center for Epidemiologic Studies Depression Scale, PHQ-9  Patient Health Questionnaire–9, GHQ-28  General Health Questionnaire, SCL-90  Symptom Checklist–90, HADS  Hospital Anxiety and Depression Scale, FPI  Fertility Problem Inventory, IDS  Infertility Distress Scale, IPC  Irrational Parenthood Cognition Scale, ISE  Infertility Self-Efficacy Scale, PWBS  Ryff’s Psychological Well-Being Scale, RSES  Rosenberg Self-Esteem Scale, WOC-R  Ways of Coping–Revised, WHOQOL-BREF  World Health Organization Quality of Life–Brief, PGWBI  Psychological General Well-Being Index, SWS  Satisfaction With Life Scale, MUNSH  Memorial University of Newfoundland Scale of Happiness, NR/N.R. Not Reported, Other  category including Music Therapy, Hypnofertility, Journaling, Support Groups, Laughter Therapy, Guided Imagery Table  4 presents the results of the risk of bias assessment, highlighting concerns across all evaluated domains. Most studies had a high risk of bias concerning allocation concealment and the blinding of participants and personnel. However, blinding in behavioural trials is often impractical or even impossible. In contrast, the blinding of outcome assessors is generally feasible and advisable but was not reported in many studies, leading to a high risk of bias in this area. Additionally, many studies did not specify how the randomization sequence was generated and did not report on outcome assessor blinding. Most studies did not provide details on how they handled missing data. The Covidence software of risk of bias examined all the included studies from seven domains and the results are shown in Fig.  2 . Table 4 Risk of bias assessment Study Allocation Concealment Blinding of Outcome Assessors Blinding of Participants and Personnel Incomplete Outcome Data Other Sources of Bias Selective Outcome Reporting Sequence Generation Aba et al., 2017[ 48 ] Low High High Low Unclear High Low Ahmadi et al., 2019[ 49 ] High High High High Low Low Low Bahremand et al., 2024[ 50 ] Unclear Unclear High Low Unclear Low Low Bai et al., 2019[ 51 ] Low Low High Low Low Low Low Bal & Uçar, 2024[ 52 ] High Low High Low High Low Low Basirat et al., 2022[ 53 ] High High High Low Low Low Low Bidgoli & Latifnejad, 2018[ 54 ] Unclear High High Low Low Low Low Chan et al., 2006[ 55 ] High High High Low High High Low Chan et al., 2012[ 56 ] High High High Low Unclear High Low Chehreh et al., 2025[ 57 ] Low Unclear High Low Unclear Low Low Connolly et al., 1993[ 58 ] High High High High High Low Low Cousineau et al., 2008[ 59 ] Low Unclear High Low Low High Low Damghanian et al., 2025[ 60 ] Unclear Unclear High Low Unclear Low Low Daneshfar et al., 2024[ 61 ] Unclear Unclear Low Low Unclear Low Low Dastjerdi et al., 2021[ 62 ] High Unclear High Low High Low High Domar et al., 2015[ 64 ] Low Low High Low High Low Low Domar et al., 2000[ 63 ] High Low High High Low Low Low Ehsan et al., 2019[ 65 ] Unclear Unclear High Low High High Low Elahe et al., 2018[ 66 ] High High High Low Unclear High Low Erdemoğlu & Derya, 2024[ 67 ] Unclear Unclear High Low Unclear Low Low Faramarzi et al., 2008[ 68 ] High Unclear High High Low High Low Faramarzi et al., 2013[ 69 ] High Unclear High Low Low High Low Fard et al., 2018[ 70 ] Low Low High High High Low Low Galhardo et al., 2013[ 71 ] High Unclear High Low High Low High Galhardo et al., 2018[ 72 ] High Unclear High High Low High Unclear Gity et al., 2025[ 73 ] Unclear Unclear High Low Unclear Unclear Unclear Gojani et al., 2017[ 74 ] Unclear Unclear High Low Low Low Low Haji-Adineh et al., 2019[ 75 ] High Unclear High Low Low Low Low Hamzehgardeshi et al., 2019[ 76 ] Low Low High Unclear Low Low Low Heredia et al., 2020[ 77 ] Unclear High High High Low High Low Hosseinpanahi et al., 2020 High High High Low Low Low Low İnam & Satılmış, 2025[ 79 ] Unclear Unclear High Low Unclear Low Low Kalhori et al., 2020[ 80 ] High Unclear High Low Low Low Unclear Karaca et al., 2019[ 81 ] High Unclear High Low Low Low Low Kerchi et al., 2020[ 82 ] High High High Unclear Unclear High Unclear Kim et al., 2014[ 83 ] Low High High Unclear Low Unclear Low Kim et al., 2020[ 84 ] High Low High Low Unclear Unclear Low Kiyak & Kocoglu-Tanyer, 2021[ 85 ] High Low High Low Low Low Low Lee, 2003[ 86 ] High Unclear High Low High Low Low Li et al., 2016[ 87 ] Unclear Unclear Unclear Unclear Unclear Unclear Unclear Ma et al., 2018[ 88 ] High Unclear High High High Low Unclear Marashi et al., 2021[ 89 ] Low Unclear High Unclear Low Low Low Masoumi et al., 2025[ 90 ] Low Unclear High Low Unclear Low Low McQueeny et al., 1997[ 91 ] High Low High High High Low Unclear Moeenizadeh & Zarif, 2017[ 92 ] High Unclear High Low High Unclear Low Moein et al., 2018[ 93 ] High High High High Low Unclear Low Mori et al., 2009[ 94 ] High High High Low Low Unclear Low Mosalanejad et al., 2012 a[ 95 ] High High High High High Unclear High Mosalanejad er al., 2012[ 96 ] High High High Low High Unclear Low Mousavi et al., 2020[ 97 ] High Low High Low Low Unclear Low Nery et al., 2019[ 98 ] Unclear Unclear Unclear Unclear Unclear Unclear Unclear Nezhad et al., 2020[ 99 ] High High High Low Low Low Low Nilforooshan et al., 2006[ 100 ] High Unclear High Low Low Unclear Low Pasha et al., 2013[ 101 ] High High High High High Unclear High Pasha et al., 2018[ 102 ] High High High High Unclear Unclear Low Rahimi et al., 2021[ 103 ] Low Low High Low Low Unclear Low Rahimi & Bazazian, 2023[ 104 ] High High High Low High Low High Rahmani et al., 2018[ 105 ] High High High Low High Unclear High Sahraian et al., 2024[ 106 ] Low Low High Low Unclear Low Low Sexton et al., 2010[ 107 ] Low High High Low Low Unclear Low Seyedi Asl et al., 2016[ 108 ] High High High High Low Unclear High Shafaghi et al., 2024[ 109 ] Low Unclear High Low Unclear Low Low Shargh et al., 2016[ 110 ] High High High High High Unclear Low Soleimani et al., 2023[ 111 ] Low High High Low Low Unclear Low Taheri et al., 2025[ 112 ] Unclear Unclear High Low Unclear Low Low Yahyavi Koochaksaraei et al., 2024[ 113 ] Unclear Unclear High Low Unclear Low Low Yanık & Budak, 2023[ 114 ] High High High Low Low Low Low Zahra et al., 2019[ 115 ] Low High High High High Unclear Low Zhang et al., 2017[ 116 ] High High High Low High Unclear Unclear Risk of bias assessment Fig. 2 Risk of bias summary Risk of bias summary A three-level meta-analysis was conducted to evaluate the overall effect of psychological interventions on infertility-related psychological outcomes, accounting for dependent effect sizes nested within studies. The analysis included 107 effect sizes from 60 independent studies. The overall pooled effect size was not statistically significant g = −0.21 (95% CI −0.85, 0.4452, p =.53, 95% PI −5.49, 5.08), with substantial heterogeneity observed across effect sizes ( Q [ 106 ] = 1349.70, p <.001). Variance was present at both the study and within-study levels (σ²₂ = 4.46; σ²₃ = 2.54), indicating considerable between- and within-study variability. To explore variation across outcome domains, separate three-level models were conducted for each psychological domain. A large, significant effect was found for anxiety g = −0.83 (95% CI −1.22, −0.44], p  =.001), and a large, significant effect was observed for depression g = −0.88 (95% CI −1.22, −0.55, p  <.001). Stress outcomes showed a large but non-significant effect g = −1.25 (95% CI −2.48 to −0.02, p  =.048). Effects for general psychological distress g = −0.75 ( p  =.24) and infertility-related distress g  = 0.61 ( p  =.71) were not statistically significant. In contrast, psychological interventions produced a large and statistically significant effect on well-being outcomes g  = 1.39 (95% CI 0.53, 2.25, p  =.004, 95% PI − 2.17, 4.94), based on 17 effect sizes. These findings are summarized in Table  5 . These findings suggest that psychological interventions may be more effective at improving well-being than reducing distress in this population. Sensitivity analyses excluding infertility-specific distress and psychoeducation revealed a significant overall effect g = −0.48 (95% CI −0.87 to −0.09, p  =.017), with both distress ( g = −0.93, p  <.001) and well-being ( g  = 1.42, p  <.001) showing robust improvements. Heterogeneity was markedly reduced, indicating that instability in infertility-specific distress and psychoeducation outcomes accounted for much of the variability in the full models. Table 5 Main effect of psychological interventions on outcomes Outcome k (effects) k (studies) Hedge’s g (95% CI) p 95% PI Variance (σ²₂/σ²₃) Anxiety 26 23 −0.83 (−1.22, −0.44) 0.00 (−2.64, 0.98) 0.74/0.00 Depression 24 22 −0.88 (−1.22, −0.55) 0.00 (−2.37, 0.61) 0.29/0.20 Stress 7 7 −1.25 (−2.48, −0.02) 0.05 (−4.62, 2.12) 0.82/0.82 Infertility-Related Distress 18 16 0.61 (−2.80, 4.02) 0.71 (−13.40, 14.60) 41.54/0.00 Generalized Distress 15 15 −0.75 (−2.05, 0.56) 0.24 (−5.91, 4.42) 2.71/2.71 Well-being 17 17 1.39 (0.53, 2.25) 0.00 (−2.17, 4.94) 1.33/1.33 k (effects) represents the number of effect sizes and k (studies) is the number of studies included for each outcome. Hedges’ g was computed using a three-level random-effects model using REML. Knapp-Hartung confidence intervals and p values are reported. The 95% prediction interval (PI) indicates the range in which the true effect of a similar new study is expected to fall. Variance components (σ²₂/σ²₃) show the distribution of heterogeneity across levels: σ²₂ = variance between effect sizes within studies; σ²₃ = variance between studies; level-1 sampling variances were treated as known from study SEs CI  Confidence Interval, SE  Standard Error, Q  Cochran’s Q (test of heterogeneity). Effect sizes were oriented so that reductions in distress outcomes are negative and improvements in well-being are positive (scales were harmonized as needed). Analyses were conducted in R (v4.4.3) with the metafor package ( rma.mv ) Main effect of psychological interventions on outcomes k (effects) represents the number of effect sizes and k (studies) is the number of studies included for each outcome. Hedges’ g was computed using a three-level random-effects model using REML. Knapp-Hartung confidence intervals and p values are reported. The 95% prediction interval (PI) indicates the range in which the true effect of a similar new study is expected to fall. Variance components (σ²₂/σ²₃) show the distribution of heterogeneity across levels: σ²₂ = variance between effect sizes within studies; σ²₃ = variance between studies; level-1 sampling variances were treated as known from study SEs CI  Confidence Interval, SE  Standard Error, Q  Cochran’s Q (test of heterogeneity). Effect sizes were oriented so that reductions in distress outcomes are negative and improvements in well-being are positive (scales were harmonized as needed). Analyses were conducted in R (v4.4.3) with the metafor package ( rma.mv ) To evaluate the differential impact of psychological interventions, moderator analyses were conducted by intervention type across both combined distress outcomes and well-being domains. A three-level meta-regression including all 107 effect sizes extracted from 60 independent studies was conducted to evaluate differences in effectiveness between intervention types. These 107 effect sizes reflect multiple psychological outcomes (anxiety, depression, stress, well-being, infertility distress, general distress) reported within the same study. The three-level meta-regression revealed significant variation between intervention types ( QM [ 7 ] = 23.54, p =.003). Psychoeducation emerged as an outlier with an effect size of g = 5.43.16 (95% CI 0.97, 9.89, p =.018). A separate pooled model of psychoeducation outcomes (k = 9) estimated g = 6.00 (95% CI − 9.51, 21.52), with extremely high within-study heterogeneity (σ² = 180.13). In addition, infertility-specific distress outcomes demonstrated unstable estimates with very high variance and were non-significant in domain-level analyses. As both categories substantially inflated heterogeneity and distorted pooled estimate, infertility-specific distress and psychoeducation were excluded from subsequent moderator models. EMDR, which only contributed infertility-specific distress outcomes, was not included in moderator models. This decision aligns with best-practice recommendations in meta-analysis and was supported by sensitivity analyses demonstrating exclusion of these outcomes produced more stable and interpretable models [ 47 ]. When effect sizes were restricted to combined distress outcomes and well-being, the model remained significant and yielded more consistent estimates. Intervention type was analysed separately for distress and well-being outcomes These results are presented in Table 6 . This precluded the use of a distress x intervention type interaction model, which would have resulted in unstable estimates or convergence issues. For combined distress outcomes, the largest and most consistent effects were observed for Cognitive Behavioural Therapy (CBT) g = −0.79 (95% CI −1.55, −0.04], p  =.04) and Counselling g = −0.71 (95% CI −1.42, 0.00], p  =.05). Acceptance and Commitment Therapy (ACT) showed a small, non-significant effect g = −0.28 ( p  =.74). Other approaches including Mindfulness (g = −0.44, p  =.23), DBT and ISTDP (each k = 1, wide confidence intervals, not significant), and those grouped under “Other” (g = −0.17, p  =.72) did not yield statistically significant effects on distress reduction. At the domain level, psychological interventions produced a large and statistically significant improvement in well-being ( g  = 1.39, p  =.002). However, when disaggregated by intervention type, none of the individual categories reached statistical significance due to wide confidence intervals and limited representation. CBT ( g  = 3.37, 95% CI – 26.0 to 32.7, p  =.38) and Mindfulness ( g  = 1.41, 95%CI − 1.07 to 3.90, p  =.19) showed large positive estimates, but these effects were imprecise. Counselling ( g  = 0.61, p  =.33) and “Other” ( g  = 2.10, p  =.19) interventions also showed non-significant effects. These findings suggest that the overall improvement in well-being is consistent across psychological interventions, but the evidence base is currently too sparse to reliably detect differences between modalities. Table 6 Main effect of psychological interventions Distress Well-being Psychological Intervention k Hedge’s g (95% CI) p Psychological Intervention k Hedge’s g (95% CI) p ACT 5 −0.28 (−1.90, 1.35) 0.74 ACT 2 1.01 (−8.14, 10.20) 0.40 CBT 29 −0.79 (−1.55, −0.04) 0.04 CBT 2 3.37 (−26.0, 32.70) 0.38 Counselling 20 −0.71 (−1.42, 0.00) 0.05 Counselling 5 0.61 (−0.92, 2.14) 0.33 DBT 1 0.19 (−5.34, 5.73) 0.94 DBT NA NA NA ISTDP 1 3.22 (−3.69, 10.13) 0.36 ISTDP NA NA NA Mindfulness 28 −0.44 (−1.16, 0.27) 0.23 Mindfulness 5 1.41 (−1.07, 3.90] 0.19 Other 13 −0.17 (−1.09, 0.75) 0.72 Other 2 2.14 (−6.16, 10.40) 0.19 Effect sizes (Hedges’ g) were computed using three-level random-effects models with Knapp–Hartung correction. k represents the number of independent effect sizes) included for each intervention-outcome combination. Confidence intervals (95% CI) indicate the precision of the effect size estimates. p-values reflect the statistical significance of the intervention’s impact. Interventions without available estimates for well-being are indicated as NA PI  Prediction Interval (95% PI shows the range in which the effect of a new study is expected to fall), QM  omnibus test of moderators, σ²₂ = variance between effect sizes within studies; σ²₃ = variance between studies. CBT  Cognitive Behaviour Therapy, ACT  Acceptance and Commitment Therapy, DBT  Dialectical Behaviour Therapy, ISTDP  Intensive Short-Term Dynamic Psychotherapy, MBCT  Mindfulness-Based Cognitive Therapy Main effect of psychological interventions −0.28 (−1.90, 1.35) 1.01 (−8.14, 10.20) −0.79 (−1.55, −0.04) 3.37 (−26.0, 32.70) −0.71 (−1.42, 0.00) 0.61 (−0.92, 2.14) 0.19 (−5.34, 5.73) 3.22 (−3.69, 10.13) −0.44 (−1.16, 0.27) 1.41 (−1.07, 3.90] −0.17 (−1.09, 0.75) 2.14 (−6.16, 10.40) Effect sizes (Hedges’ g) were computed using three-level random-effects models with Knapp–Hartung correction. k represents the number of independent effect sizes) included for each intervention-outcome combination. Confidence intervals (95% CI) indicate the precision of the effect size estimates. p-values reflect the statistical significance of the intervention’s impact. Interventions without available estimates for well-being are indicated as NA PI  Prediction Interval (95% PI shows the range in which the effect of a new study is expected to fall), QM  omnibus test of moderators, σ²₂ = variance between effect sizes within studies; σ²₃ = variance between studies. CBT  Cognitive Behaviour Therapy, ACT  Acceptance and Commitment Therapy, DBT  Dialectical Behaviour Therapy, ISTDP  Intensive Short-Term Dynamic Psychotherapy, MBCT  Mindfulness-Based Cognitive Therapy Dosage-related variables (number of sessions, session duration, and total intervention length) were first entered into a model. The overall test of moderators was not significant ( QM [ 3 ] = 0.40, p =.75), and no individual predictor reached significance ( ps > 0.32), though session duration showed a non-significant trend toward a negative association with effect size ( b = − 0.01, p =.32). This suggests that dosage characteristics alone did not meaningfully predict treatment effectiveness. A follow-up interaction model tested whether the influence of dosage variables differed by outcome domain (distress vs. well-being). This model was statistically significant ( QM [ 7 ] = 119.01, p <.001). Notably, for well-being outcomes, a greater number of sessions predicted enhanced effect sizes ( b = 0.12, p =.001), whereas longer interventions ( b = − 0.66, p =.031) and longer session durations ( b = − 0.04, p =.059) were associated with diminished effects. No such effects were observed for distress outcomes. These findings suggest that brief, structured interventions delivered over multiple sessions may be optimal for improving well-being. Intervention format and delivery mode were examined in a separate three-level meta-regression model to explore whether the structure or delivery of treatment influenced its effectiveness. The overall moderator test was not significant ( QM [ 4 ] = 1.18, p =.32), indicating limited evidence that these features influenced overall effect size. However, online delivery was associated with significantly greater effects compared to in-person delivery b = 2.82 (95% CI −0.11, 5.75, p =.060), however, this did not reach significance. Other delivery formats (self-administered or mixed) and intervention settings (individual, group, or couple-based) did not significantly moderate outcomes. Region was also examined as a moderator. The overall test was not significant (QM [ 3 ] = 2.40, p =.073), but pairwise contrasts revealed that interventions conducted in Western countries produced significantly larger effects compared to those in East Asia (b = −3.42, 95% CI −6.58 to −0.26, p =.034) and the Middle East (b = −3.59, 95% CI −6.25 to −0.92, p =.009). No significant differences were observed between East Asia and the Middle East. These findings may reflect differences in cultural acceptability, clinical delivery standards, or population-level expression of distress across regions.

Assisted Reproductive Technology (ART) status was examined as a categorical moderator with four levels (active ART, pre-first cycle ART, post failed ART, and not specified). For distress outcomes, the overall moderator test was not significant ( QM [ 4 ] = 1.32, p =.27) and no significant effect was observed across the ART categories. For well-being outcomes, the moderator test approached significance ( QM [ 4 ] = 2.96, p =.07). A large significant positive effect was observed among women with post ART failures g = 2.11 (95% CI 0.14, 4.08, p =.04), while effects for women in active ART cycles, pre-ART cycles and studies without specified ART status were positive but non-significant.

This systematic review with meta-analysis offers compelling evidence that psychological interventions are effective in reducing psychological distress and improving well-being among women experiencing infertility distress. These findings highlight the need for continued integration of psychological interventions into infertility treatment protocols and highlight the importance of focusing on both distress reduction and well-being enhancement. Further research is needed to refine treatment approaches and explore long-term outcomes to support women navigating the psychological challenges of infertility.

This meta-analysis aimed to evaluate the effectiveness of psychological interventions for women experiencing infertility-related distress, and to examine which factors moderated their effectiveness. A three-level meta-analysis of 60 studies and 107 effect sizes found no statistically significant overall effect across all psychological outcomes ( g = −0.21, 95% CI [−0.85, 0.44], p =.53), though substantial heterogeneity was observed. Domain-specific analyses revealed large significant effects for anxiety ( g = −0.83), depression ( g = −0.88), and well-being ( g = 1.39), supporting the value of psychological treatments in this population. These findings suggest that while effects may not be uniform across domains, psychological treatments can meaningfully reduce specific symptoms such as anxiety and depression and enhance well-being for women undergoing infertility. They also underscore the importance of outcome measure selection and treatment matching in both clinical practice and research. Given the considerable psychological burden of infertility [ 4 ], integrating evidence-based psychological interventions into fertility care remains a necessity. Psychological interventions were effective in reducing anxiety and depression but did not significantly reduce infertility-related or general psychological distress, even though the observed effect sizes were moderate-to-large. This pattern may reflect limitations in measurement sensitivity and statistical power, rather than a true absence of therapeutic benefit. Infertility-specific distress outcomes were removed from the final moderator models due to instability and high heterogeneity, suggesting that current evidence in this domain is inconclusive rather than indicative of ineffectiveness. While general and infertility-specific distress measures aim to capture broader emotional impacts, their non-significant effects in this review suggest that current interventions may not be adequately targeting the deeper psychological themes most relevant to infertility (such as identity disruption, uncertainty, and grief) [ 147 ]. From a theoretical standpoint, infertility-related distress reflects broader disruptions to life narrative, self-concept, and social belonging, rather than discrete psychiatric symptoms [ 42 ]. Treatments like CBT may be effective for reducing symptoms of anxiety and depression, but tailored approaches that explicitly address these existential and relational dimensions may be needed to more fully alleviate distress in this population. In addition, measurement and cultural considerations may contribute to these patterns. It is unclear if the existing distress scales can capture the infertility-specific themes experienced in these samples. Cross-cultural equivalence is also uncertain as several instruments were developed and validated primarily in Western samples. Moreover, cultural norms regarding disclosure and stigma could further dampen self-reported distress. Domain-specific analyses also showed that psychological interventions significantly improved well-being ( Hedges’ g = 1.39), consistent with previous research highlighting the broader impact of infertility on women’s emotional health and life satisfaction (Graham et al., 2011; Holton et al., 2010). However, the high heterogeneity observed in these outcomes (I² = 95%) suggests that improvements in well-being were less consistent across studies than reductions in distress. One likely explanation lies in the diverse ways well-being is conceptualised and measured. Some studies used general psychological well-being scales (Ryff’s PWB), others used infertility-specific measures (FertiQol), and some employed general health-related instruments (WHOQOL-BREF). These tools capture different dimensions of well-being (such as, self-acceptance, relationship satisfaction, and life purpose) making it difficult to draw unified conclusions [ 136 , 138 , 143 ]. Sensitivity analyses indicated that well-being improvements remained robust when unstable categories were excluded, underscoring the potential value of psychological interventions for enhancing positive adjustment in women experiencing infertility. Future research would benefit from greater standardisation in well-being measurement to improve comparability across studies and clarify the specific pathways through which psychological interventions enhance well-being. Additionally, the psychological mechanisms that drive improvements in well-being may differ from those that reduce distress. While reductions in anxiety and depression may result from emotional regulation or symptom relief, improvements in well-being often require deeper shifts in identity, meaning making, and acceptance of infertility [ 148 ]. Interventions that include values clarification (ACT) or foster self-compassion (mindfulness-based approaches) may be better positioned to improve well-being than strictly symptom-focused therapies. This distinction underscores the importance of selecting outcome measures that align with the intervention’s theoretical mechanisms. Studies may report weak or inconsistent effects on well-being not because the intervention was ineffective, but because the measure used did not reflect the type of psychological change being targeted. Moderator analyses indicated that intervention type significantly influenced treatment outcomes. For distress, the strongest effects were observed for CBT and Counselling. CBT demonstrated the most effective intervention for reducing distress, producing the largest and most consistent effect across studies. This aligns with its well-established efficacy in treating depression and anxiety in broader clinical populations underscoring its value for women facing infertility [ 46 , 149 ]. CBT’s structured approach to identifying and modifying maladaptive cognitions is particularly relevant for infertility, where self-blame, hopelessness, and catastrophic thinking are common. By challenging these patterns and promoting more adaptive appraisals, CBT may directly reduce the psychological burden of infertility [ 150 ]. Counselling also showed a strong effect for distress, despite its less defined theoretical orientation. In many studies, counselling involved supportive, non-directive approaches that may foster emotional expression, normalisation, and therapeutic alliance all of which are likely important when working with individuals navigating the ambiguity, shame, and isolation associated with infertility [ 151 , 152 ]. These relational and empathic processes may be particularly helpful for distress domains that are not strictly symptom-based, such as infertility-related grief or identity disruption. In contrast to distress outcomes, improvements in well-being were more consistent at the overall domain level than at the intervention-specific level. The pooled effect was large and statistically significant ( g  = 1.39, p  =.00), yet none of the individual intervention categories reached statistical significance due to wide confidence intervals and limited representation. CBT and interventions grouped as “Other” yielded the largest positive estimates, but these effects were imprecise. Similarly, ACT, Mindfulness, and Counselling produced positive but non-significant effects in the well-being domain. These findings suggest that while psychological interventions can meaningfully enhance well-being overall, current evidence does not allow firm conclusions about the superiority of any one modality. Greater standardisation of well-being measures and larger, well-powered trials are needed to clarify which approaches are most effective for improving well-being in women experiencing infertility. Moderator analyses indicated that session duration, number of sessions, and overall intervention length did not predict effect sizes when analysed as main effects, suggesting that logistical features alone may not determine intervention efficacy. However, a significant interaction was found between outcome domain and dosage variables: for well-being outcomes, a higher number of sessions predicted greater effect sizes, while longer sessions and extended intervention length were associated with reduced effects. This pattern suggests that brief, structured interventions delivered over multiple sessions may be optimal for enhancing well-being. One possible explanation for these patterns is the quality and specificity of the intervention, such as targeting infertility-related cognitions and enhancing emotional regulation may play a more critical role in driving psychological change than simply increasing time or frequency. Focused and theoretically grounded sessions may yield meaningful outcomes, especially when they provide clients with practical tools they can continue using independently (mindfulness, cognitive restructuring, grief processing and meaning making). This aligns with findings from psychotherapy research suggesting that therapeutic alliance and intervention focus often outweigh dosage or duration in predicting outcomes [ 153 , 154 ]. For women experiencing infertility distress, interventions that resonate with lived experiences such as grief, shame, identity loss, or uncertainty may be more impactful than interventions that are longer but less targeted. These findings underscore the importance of designing tailored, mechanism-informed interventions, rather than assuming that more treatment automatically yields better results. Delivery format also emerged as a significant moderator, with online interventions associated with greater effect sizes compared to in-person delivery. This may reflect the unique advantages of digital interventions, including enhanced accessibility, reduced stigma, and increased autonomy, which may be particularly valuable for women navigating infertility-related distress [ 155 ]. Digital delivery may also improve engagement by allowing participants to engage with content flexibly and privately, potentially fostering greater uptake and adherence. Exploratory contrasts suggested larger effects in Western samples. This pattern should be interpreted with caution, as this likely bundles multiple study-level differences (intervention mix, delivery context, and outcome measurements). The regional contrasts are best viewed as hypothesis-generating rather than causal. Cross-cultural trials of the same intervention with harmonised protocols (or individual participant data meta-analysis) and outcomes are needed to determine whether true context effects exist. Assisted Reproductive Technology (ART) status did not significantly moderate distress outcomes; however, analyses indicated a stronger effect for well-being. Women who had experienced failed ART cycles showed a large and statistically significant improvement in well-being following psychological intervention, whereas effects for women undergoing active treatment, preparing for ART, or with unspecified treatment status were positive but non-significant. This finding suggests that the psychological benefits of intervention may be particularly salient in the aftermath of treatment failure, when distress and identity disruption are often most pronounced [ 156 ]. In these contexts, interventions may help women re-establish meaning, strengthen coping resources, and buffer against hopelessness. However, these results should be interpreted cautiously given the small number of studies in each subgroup and wide confidence intervals. The high heterogeneity observed across studies suggests that further investigation is needed to better understand the factors contributing to variability in treatment outcomes. Future research should focus on examining moderators such as demographic variables and infertility characteristics (duration and cause) to identify if these contribute to the effectiveness of psychological interventions for infertility distress. There is also a need for greater consistency in outcome measurement, future research would benefit from the use of a standardized, psychometrically robust instrument tailored to infertility-related distress. A stronger focus on manualised, theoretically grounded interventions would improve both the replicability and quality of future trials. In addition, several methodological limitations across the included studies should be acknowledged. Risk of bias was common, particularly in relation to randomisation, allocation concealment, blinding of outcome assessors, and handling of missing data, which reduces confidence in the robustness of effect estimates. The possibility of publication bias and small-study effects also cannot be ruled out, given the predominance of small, single-site trials. Furthermore, the grouping of diverse approaches into broad categories such as “Other” may have obscured meaningful differences between interventions, limiting interpretability. Finally, the reliance on short-term outcomes without extended follow-up leaves the sustainability of intervention effects uncertain. The field of psychological interventions for infertility distress remains at an early stage of development, with studies differing widely in design, delivery format, and methodological rigour. These limitations inevitably contribute to both risk of bias and heterogeneity. At the same time, such variability reflects the formative nature of the science and the ongoing evolution of intervention models in this area. In this context, the role of a meta-analysis is not only to estimate pooled effects, but also to map the emerging evidence base, highlighting both signals of promise and areas requiring methodological strengthening. While the findings must therefore be interpreted cautiously, synthesising the literature at this stage is critical to advance the field. Quantitative synthesis allows for the systematic identification of where inconsistencies arise, brings transparency to the degree of uncertainty, and provides direction for future research priorities. In this way, the current analysis should be viewed less as a definitive statement of efficacy and more as a scaffold for the next generation of trials. Additionally, while this analysis provides evidence for the efficacy of psychological interventions, it is important to consider the long-term effects of these interventions. This meta-analysis focused on short-term outcomes, and further research is needed to assess the sustainability of treatment benefits over time. It is important to note, the geographic concentration of studies raises concerns about the generalizability of the findings to other regions, as cultural, social, and healthcare system factors may influence both the experience of infertility and the effectiveness of psychological interventions. Future research should aim to include more diverse populations to better understand how these interventions work across different cultural and geographic contexts. These steps will enhance clinical applicability of psychological interventions for infertility distress.

Infertility affects millions of people worldwide. Around 17.5% - approximately 1 in 6 adults, experience infertility and it is the fifth leading cause of disability globally [ 1 , 2 ]. Infertility was defined in accordance with the International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization as “a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner” [ 3 ]. Over the past two decades, the psychological repercussions of infertility have become increasingly investigated [ 4 , 5 ]. Studies have demonstrated a link between infertility and adverse mental health outcomes [ 6 , 7 ]. These findings are consistent with the growing recognition within the healthcare system that infertility impacts both psychological distress and impairs overall well-being [ 8 , 9 ]. Psychological symptoms of infertility can be understood across emotional, cognitive, and somatic domains. Emotionally, individuals often report feelings of sadness, grief, anger, shame and loneliness, reflecting the profound sense of loss and disrupted life expectations associated with infertility [ 10 ]. Cognitively, self-blame and failure are common, with evidence suggesting these are a result of internalised societal or personal expectations about fertility [ 11 , 12 ]. Affective symptoms such as anxiety and depression, which often manifest with somatic features like fatigue, tension and disrupted sleep, signal the broader physiological toll of chronic psychological stress [ 13 , 14 ]. To determine gender distribution and infertility aetiologies, the WHO performed a large multinational study. The findings indicated that in 37% of infertile couples, female infertility was the primary cause [ 15 ]. Male infertility was found to be the sole cause in around 20–30% of cases, however, men are estimated to contribute about 50% of all infertility cases overall, either as the sole factor or, in combination with female-related factors [ 16 ]. In approximately one-third of cases, infertility is due to combined male and female factors or remains unexplained [ 17 ]. Despite women and men being equally likely to struggle with infertility, women struggling with infertility are more likely to experience psychological distress (such as anxiety, depression, and low quality of life) when compared with men [ 4 , 18 – 20 ]. A recent meta-analysis identified a 60% increased risk of psychological distress among women with infertility versus the general population. More specifically, the risks of anxiety and depression in infertile women are 60% and 40% higher than other women [ 4 ]. This heightened vulnerability is underscored by a number of biopsychosocial factors. In social contexts, fertility remains closely linked to female identity and social value, potentially exacerbating feelings of shame, failure, and isolation when infertility occurs [ 12 ]. Psychologically, infertility can disrupt a woman’s core sense of self, leading to identity confusion, chronic stress, and maladaptive coping responses [ 21 ]. Neurobiologically, the prolonged experience of uncertainty, loss, and perceived lack of control may activate stress-related pathways, contributing to heightened symptoms of anxiety and depression [ 22 ]. Women undergoing assisted reproductive technologies may also have multiple hormonal, drug and surgical treatments that further worsen the physical toll of infertility [ 23 ]. Overall, women who are childless due to infertility reported reduced emotional health and lower social wellbeing than the overall female population of Australia [ 8 , 9 , 24 ]. In light of the mental health impacts of infertility, psychological interventions are now considered an important part of interprofessional treatment [ 10 , 18 ]. This recognition highlights the importance of identifying the most effective psychological interventions to improve mental health in women experiencing infertility related distress [ 18 ]. Chow et al. (2016) [ 25 ] conducted a critical review of 12 studies evaluating psychosocial interventions for infertile couples and concluded that such interventions generally improve psychological wellbeing, marital relationships, and pregnancy rates. However, the review noted significant variability in intervention design and called for more rigorous research to establish which components are most effective. Katyal and colleagues (2021) [ 26 ] systematic review and meta-analysis of 15 RCTs demonstrated psychosocial interventions improved pregnancy rate outcomes in couples undergoing Assisted Reproductive Technologies (ART) but did not address the potential psychological impacts directly These outcomes, alongside the emergence of newer interventions such as Eye Movement Desensitization and Reprocessing (EMDR) Therapy and Acceptance and Commitment therapy (ACT), highlight the need for a more targeted synthesis focused on distress and psychological wellbeing. A recent systematic review and meta-analysis by Dube et al. (2023) [ 10 ]provides current insights into the efficacy of psychological interventions for improving mental health and pregnancy outcomes among individuals and couples with infertility. The findings indicated that psychological interventions were generally effective in reducing distress and improving pregnancy rates overall independent of therapeutic approach, format, or duration. Notably, this study was not focused on women. Further research is needed to explore which elements of the psychological and methodological moderators are influencing intervention outcomes. Another 2023 systematic review of 60 studies by Koochaksaraei and colleagues [ 18 ] highlighted range of interventions focusing on women’s mental health during infertility did not provide statistical estimates of effectiveness leading to a notable gap in our understanding of the impacts of these interventions on women’s mental health during infertility. This evidence gap limits the development of clear, evidence-based psychological treatment guidelines focused on women. The aim of this systematic review and meta-analysis is to address these limitations by applying a three-level meta-analytic approach that provides a comprehensive evaluation of psychological interventions for women experiencing infertility-related distress. This review evaluates the effectiveness of interventions across key mental health outcomes, including anxiety, depression, stress, general psychological distress, infertility-specific distress, and well-being. In addition, it examines potential treatment moderators such as therapeutic approach, intervention format, dosage characteristics, and fertility treatment status to identify psychological and methodological factors that may influence efficacy. Finally, the review highlights gaps and opportunities in the existing literature to inform the design of future research and clinical practice.

Supplementary Material 1. Supplementary Material 1. Supplementary Material 2. Supplementary Material 2.