The effects of nursing interventions on anxiety and depression in infertile females undergoing assisted reproduction: a systematic review and meta-analysis.

The current study was carried out according to the PRISMA recommendations for systematic reviews and meta-analyses (Fig.  1 ). The protocol for this research was previously registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251085109. Fig. 1 PRISMA flowchart PRISMA flowchart The PICO model was used to clarify the research question, and studies that did not meet the criteria based on this model were excluded. The criteria employed in the current study are outlined as follows. In the current systematic review, we included infertile women undergoing ART. Infertility was defined as the failure to conceive after 12 months or more of regular, unprotected intercourse, or as an impaired ability to reproduce, either individually or with a partner [ 29 ]. Infertility was confirmed based on medical diagnoses reported in the included studies. Participants were enrolled during their first ART treatment cycle. Individuals with a history of psychiatric disorders were excluded from the included studies. We included studies that implemented interventions targeting in infertile women undergoing ART. The interventions specifically addressed the psychological aspects of the patients. Here, interventions were compared between the routine care group and the intervention group, or between the periods before and after the intervention. The study examined the effectiveness of interventions on anxiety and depression in infertile women undergoing ART. A comprehensive literature search was conducted during the last week of June 2025 using the databases Cochrane, Scopus, PubMed, Medline, Embase, and Web of Science. To ensure thorough coverage, two sets of keywords were employed, combined using the Boolean operator “AND.” The first set included: “IVF” OR intracytoplasmic* OR “in vitro fertil*” OR “ICSI” OR “assisted reproduct*” OR “reproductive medicine” OR “sperm inject*”. The second set comprised: “psychological stress*” OR “depressive disorder*” OR “adjustment disorder*” OR “psychological adaption” OR stress* OR anxiety* OR distress OR emotion* OR “psychosomatic medicine” OR “major life event*” OR depression OR “social psychology”. The references of the papers included in the current review, as well as those from other relevant systematic reviews, were examined to identify additional related studies. In the current review, a comprehensive evaluation of cross-sectional and case studies was done. No restrictions on time or location were applied during the search and only papers published in English were included. The inclusion criteria for this review were as follows: studies involving infertile females planning to undergo or currently undergoing ART, including in vitro fertilization (IVF), intrauterine insemination (IUI), and intracytoplasmic sperm injection (ICSI); studies that involved an intervention; studies reporting outcomes for at least one of the following measures: anxiety or depression; and studies published in peer-reviewed English-language journals. Exclusion criteria included inability to access the full text after contacting the authors, as well as exclusion of conference supplements or proceedings, letters to the editor, and review articles. Two investigators (ZW, ZX) independently screened the titles and abstracts of all articles to exclude those deemed irrelevant by both reviewers. Based on pre-specified eligibility criteria, full-text versions of potentially relevant papers were retrieved and evaluated for inclusion by the two investigators. The investigators reached full in agreement on all studies, so a third investigator (QH) was not required, as originally planned for cases of uncertainty or disagreement. The quality of the included papers was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Tools. The total number of positive responses to the criteria was calculated, and these scores were employed to stratify studies into three groups: low quality (Q1), moderate quality (Q2), and high quality (Q3) [ 30 ]. In the current review, two investigators (XZ, JZ) independently examined the quality of the papers following the appraisal checklist. All full-text papers were reviewed by two investigators (ZW, ZX), and data were extracted according to pre-established criteria. Relevant information was obtained from the included studies and organized by the same two reviewers, including: first author, year of publication, country, number of participants, age of subjects, type and cause of infertility, type and timing of treatment, intervention type, number of sessions, intervention duration, session duration, outcome measures, delivery personnel, and outcomes (including anxiety and depression scores). The coefficient of Cohen’s kappa was used to assess the agreement between investigators during the data extraction process [ 31 ]. The obtained kappa values ​​for the commencement and ensuing steps were 0.91 and 0.94, respectively, indicating strong agreement between the two investigators. This study employed both qualitative and quantitative designs. In the qualitative design, the features of the included studies—such as study population, countries, interventions, and quality—were presented. All measurement scales were included in the narrative section to encompass all studies investigating nursing interventions on anxiety and depression in infertile women undergoing ART. In the quantitative design, mean scores of depression and anxiety, along with the 95% confidence interval (CI) of the effect size, were provided. Studies reporting either depression or anxiety in case and control groups were included in the meta-analysis. Regarding assessment tools, only studies using the Beck depression inventory (BDI) for measuring depression and the state-trait anxiety inventory (STAI) for measuring anxiety were included in the meta-analysis. To account for between-study differences in the scales used to assess depression or anxiety, the standardized mean difference (SMD) between case and control groups was calculated for each study. The Cochrane Q test and I 2 were applied to investigate heterogeneity among the selected studies. A random-effects model was used because the P -value for heterogeneity was less than 0.1 [ 32 ]. The Q test and I 2 statistics were also employed to evaluate the reduction in heterogeneity within predefined subgroups (region, income level, and timing of intervention). Studies were stratified into four regions: Europe, East/Southeast Asia, the Middle East, and the Americas. Countries were stratified into low- and middle-income (LMIC) or high-income (HIC) according to World Bank stratification [ 33 ]. Timing of intervention was stratified into three groups: before ART, during ART, and after ART. Funnel plot was generated to examine publication bias; Egger’s and Begg’s tests were employed to evaluate asymmetry [ 34 ]. Data analysis was conducted using STATA version 14.2.

A total of 44 papers were included in the current review, selected from an initial search of 33,034 records. Sixty-one studies were assessed in full text. After completing the full-text review, 17 papers were excluded (Fig.  1 ). Study characteristics are presented in Table  1 . The studies were carried out in different cultural settings: 30 in Asia, including 14 in Iran, 6 in China, 4 in Turkey, 2 in South Korea, and 1 each in Taiwan, Hong Kong, Jordan, and Japan. Five studies were carried out in the Americas, 3 in Brazil, 1 in the USA, and 1 in Canada. Nine studies were conducted in Europe, including 2 in Italy, 2 in the Netherlands, and 1 each in Hungary, Portugal, Spain, Greece, and Denmark (Fig.  2 ). Additionally, the study designs varied: 38 were case-control studies, and 6 were cross-sectional studies. Outcome measures were heterogeneous: 10 studies assessed anxiety scores, 7 assessed depression scores, and 27 assessed both anxiety and depression scores. Table 1 The total information of the extracted articles Author (year) Country Study type Sample size Age Type of infertility The reason of infertility Type of treatment Timing Intervention type Number of sessions, intervention duration, session duration Outcome measures Delivery person Outcome (OR, anxiety score, depression score or etc.) Quality Celia H Y Chan (2006) [ 35 ] China Case-control 227 (Case = 69, control = 115) Case = 36.0, control = 35.0 Primary& secondary Tubal, male factor, endometriosis, unexplained, mixed IVF Before embryo transfer (ET) Eastern body-mind-spirit (EBMS) group intervention (based on holistic concept of health) 4 weeks, 2 h State-trait anxiety inventory (STAI) Therapist The intervention reduced the state anxiety score in the patients. (state anxiety score: case = 42.69, control = 43.70) Q1 Ana Galhardo (2013) [ 18 ] Portugal Case-control 92 (Case = 55, control = 37) Case = 34.8, control = 33.1 Primary Female factor, male factor, female and male factor Ovarian stimulation, IVF, ICSI - Mindfulness-based program for infertility (MBPI) (psychosocial program including distribution of manual and audio CD regarding mindfulness meditation, mindfulness practice, metaphors and experiential exercises, share of experiences) 10 weeks, 2 h Beck depression inventory (BDI), state-trait anxiety inventory-Y1 (STAI-Y1) Psychologist The intervention reduced anxiety and depression scores in the patients. (depression score: case = 6.18, control = 10.22; anxiety score: case = 43.02, control = 47.57) Q1 Vania Valoriani (2014) [ 36 ] Italy Case-control 120 (Case = 45, control = 75) Case = 36.8, control = 36.0 Primary& secondary Female factor, male factor, female and male factor, unexplained IVF Before IVF cycle Hatha-yoga (HY) practice (Asana positions, breathing, relaxing) 3 months, 1.5 h State-trait anxiety inventory-Y1 (STAI-Y1), Edinburgh depression scale (EDS) Teacher The intervention reduced anxiety and depression scores in the patients. (depression score: case = 6.60, control = 6.40; anxiety score: case = 37.67, control = 39.24) Q1 Pinar Gursoy Guven (2020) [ 37 ] Turkey Case-control 72 (Case = 36, control = 36) Case = 30.3, control = 31.5 - Unexplained IVF After embryo transfer (ET) Acupuncture 3 State-trait anxiety inventory (STAI-1) Practitioner The intervention reduced the anxiety score in the patients. (anxiety score: case = 28.8, control = 41.1) Q1 Miok Kim (2014) [ 38 ] South Korea Case-control 50 (Case = 26, control = 24) ≤ 35->36 - Unexplained IVF After embryo transfer (ET) Mind-body therapeutic program (abdominal breathing, sharing experiences, identifying cognitive errors and irrational beliefs, ring feelings, reinforcing positive messages) 5, 5 weeks, 2 h State-trait anxiety inventory (STAI), Visual analog scale-anxiety [VAS-A] Practitioner The intervention reduced the anxiety score in the patients. (anxiety score (STAI): case = 28.12, control = 44.17; anxiety score (VAS-A): case = 68.65, control = 75.00) Q1 Nermin Gurhan (2007) [ 39 ] Turkey Case-control 67 (Case = 37, control = 30) ≤ 29-≥40 - - IVF Before embryo transfer (ET) Nursing counseling program (education, interview, emotional support) - Beck depression inventory (BDI) Nurse It was not found statistically significant difference between the case and control groups for depression scores after intervention Q1 Ana Heredia (2020) [ 40 ] Spain Case-control 26 (Case = 11, control = 15) Case = 34.7, control = 33.8 - Female factor, male factor, female and male factor, unexplained IVF Before IVF cycle Psychological intervention program (psychoeducation, relaxation training and coping skills) 4 weeks, 1.5 h State-trait anxiety inventory (STAI), beck depression inventory (BDI) Nursing staff, anesthetist It was not found statistically significant difference between the case and control groups for depression scores after intervention Q1 Wen Lu (2023) [ 41 ] China Case-control 100 (Case = 50, control = 50) Case = 33.8, control = 33.1 Primary& secondary - Assisted reproductive technology (ART) in - Targeted nursing care program (cognitive intervention, subconscious therapy, affective support, behavioral therapy) - Self-rating symptom scale (SCL-91) Nursing staff The intervention reduced anxiety and depression scores in the patients. (depression score: case = 1.92, control = 2.47; anxiety score: case = 1.93, control = 2.70) Q3 Maria Koumparou (2021) [ 42 ] Greece Case-control 144 (Case = 74, control = 70) - - Fallopian tube factor, male factor, unexplained IVF Stress management program (distribution of informative leaflets, control of physical symptoms of stress using biofeedback techniques, home exercise including diaphragmatic respiration technique and progressive muscular relaxation, diet care, cognitive care,) 8, 8 weeks, 50 min Depression, anxiety, stress scale 21 (DASS-21 Researcher The intervention reduced anxiety and depression scores in the patients. (depression score: case = 1.76, control = 7.24; anxiety score: case = 1.7, control = 7.1) Q3 Ying Li (2025) [ 43 ] China Case-control 368 (Case = 126, control = 242) Case = 31.1, control = 30.8 - Female factor, male factor, female and male factor, unexplained IVF During the controlled ovarian hyperstimulation (COH) stage of IVF Auricular acupressure - Self-rating symptom scale (SCL-91) Nurse The intervention reduced anxiety and depression scores in the patients. (depression score: case = 1.31, control = 1.82; anxiety score: case = 1.34, control = 1.97 Q1 Yilda Arzu Aba (2017) [ 44 ] Turkey Case-control 186 (Case = 89, control = 97) 22–45 Primary Female factor, male factor, female and male factor, unexplained IVF After embryo transfer (ET) Music therapy program 28 min State-trait anxiety inventory (STAI) Musicologist The intervention reduced the anxiety score in the patients. (anxiety state score: case = 33.39, control = 34.57; anxiety trait score: case = 38.19, control = 40.19) Q1 Lan-Feng Xing (2018) [ 45 ] China Case-control 334 (Case: TEAS-2 Hz (1) = 84, TEAS-100 Hz (2) = 80, TEAS-2/100Hz (3) = 86; control = 84) Case: 1 = 30.8, 2 = 32.1, 3 = 31.9; control = 31.2 - Tubal blockage IVF Before trans-vaginal oocyte retrieval (TVOR), before embryo transfer (ET) Transcutaneous electrical acupoint stimulation (TEAS) 30 min State-trait anxiety inventory (STAI), Amsterdam preoperative anxiety and information scale (APAIS) Acupuncturist It was found that 2/100Hz TEAS treatment considerably lessened the levels of state anxiety and preoperative anxiety scores. (anxiety state score: case: 1 = 41.82, 2 = 38.14, 3 = 41.82, control = 39.27) Q1 Reina Taguchi (2019) [ 46 ] Japan Cross-sectional 51 (needle-acupuncture = 32, laser-acupuncture = 19) Needle-acupuncture = 39.1, laser-acupuncture = 39.6 - Male factor, ovarian dysfunction, tubal factor, endometriosis, unknown IVF-ET, ICSI During IVF-ET, ICSI Needle and laser acupuncture 24, 3 months, 10 min State-trait anxiety inventory (STAI), profile of mood states (POMS) Researcher Needle-acupuncture reduced the anxiety scores in the patients. (anxiety state score: needle-acupuncture: before = 43.1, after = 38.9- laser-acupuncture: before = 37.9, after = 36.4; anxiety trait score: needle-acupuncture: before = 43.0, after = 40.9- laser-acupuncture: before = 38.5, after = 39.2) Q3 Celia H Y Chan (2019) [ 47 ] Hong Kong Cross-sectional 207 (relaxation techniques (SR) = 74, spiritually reflective exercises only (S) = 66, knowledge on body-mind wellness (BM) = 67) SR = 35.6, S = 35.4, BM = 35.4 Primary& secondary Female factor, male factor, female and male factor, unexplained IVF Before embryo transfer (ET) Integrative Body-Mind-Spirit model (I-BMS) (distribution of self-help education booklet containing spiritually reflective exercise and relaxation, knowledge on body-mind wellness) 1, 3 h State-trait anxiety inventory (STAI) Medical social worker It was not found Statistically significant difference between anxiety and depression scores after intervention. Q2 Elnaz Mousavi (2019) [ 48 ] Iran Case-control 45 (Case: unified protocol transdiagnostic (UP) = 15, mindfulness-based stress reduction (MBSR) = 15, control = 15) 20–45 - - IVF - Unified protocol transdiagnostic and mindfulness-based stress reduction program 10, 3 months, 2 h Beck anxiety inventory, beck depression inventory Psychologist The intervention reduced the anxiety and depression scores in the patients. (anxiety score: UP = 19.80, MBSR = 24.47, control = 37.00; depression score: UP = 20.20, MBSR = 23.93, control = 31.80) Q3 Judit Szigeti F (2024) [ 49 ] Hungary Case-control 154 (Case = 80, control = 74) Case = 34.3, control = 36.8 Primary Female factor, male factor, female and male factor, unexplained IUI, IVF - Mind/body program for infertility (MBPI) program (cognitive behavioural therapy, stress management exercise, positive psychology) 10 weeks, 135 min Beck depression inventory (BDI), state-trait anxiety inventory (STAI) Psychologist The intervention reduced the anxiety and depression scores in the patients. (anxiety score: case = 48.83, control = 50.41; depression score: case = 13.51, control = 14.05) Q1 Angelique J C M van Dongen (2016) [ 50 ] Netherlands Case-control 120 (Case = 61, control = 59) Case = 32.0, control = 32.4 Primary& secondary Female factor, male factor, female and male factor, unexplained IVF After IVF cycle Personalized e-therapy program (digital psycho-education, cognitive behavioural therapy) - Screening on distress in fertility treatment (SCREENIVF) questionnaire, hospital anxiety and depression scale (HADS) E-therapist The intervention reduced the percentage women having clinically related symptoms of anxiety and/or depression (risk difference of 24% (95% CI: 2–46%) Q1 Yoon Frederiksen (2017) [ 51 ] Denmark Case-control 163 (Case = 83, control = 80) Case = 31.9, control = 32.9 - Female factor, male factor, female and male factor, unexplained IVF, ICSI - Expressive writing intervention (EWI) (home-based writing exercises concentrating on emotional disclosure regarding infertility treatment) 3, 3 months, 20 min Beck depression inventory (BDI), state-trait anxiety inventory (STAI) Researcher The intervention reduced the anxiety and depression scores in the patients (anxiety score: case = 40.3, control = 40.6; depression score: case = 11.6, control = 13.1) Q1 Cai Feng Bai (2019) [ 52 ] China Case-control 234 (brief mindfulness (BM) = 78, gratitude journal (GJ) = 78, control = 78) BM = 30.23, GJ = 30.27, control = 30.36 - Female factor, male factor, female and male factor, unexplained IVF, ICSI Before embryo transfer (ET) Two guided self-administered intervention (listening to audio comprising guided mindfulness breathing and body scan, writing gratitude journals) 4, 4 weeks, 20 min Generalized anxiety disorder-7 (GAD-7) scale, patient health questionnaire-9 (PHQ-9) scale Psychology counselor The BM group showed a considerable reduction in depression score. (anxiety score: BM = 5.57, GJ = 5.82, control = 6.00; depression score: BM = 6.55, GJ = 7.23, control = 7.64) Q1 Sedigheh Keshavarz (2020) [ 53 ] Iran Case-control 50 (Case = 27, control = 28) Case = 30.47, control = 30.43 - Female factor, male factor, Female and male factor, unexplained IVF Before embryo transfer (ET) Antidepressant treatment (administration of Fluoxetine) 2 months Beck depression inventory (BDI) Psychiatrist The intervention reduced the depression score in the patients (depression score: case = 18.52, control = 19.70) Q3 Daniela Isoyama (2012) [ 54 ] Brazil Case-control 43 (Case = 22, control = 21) Case = 34.1, control = 34.3 - - IVF After embryo transfer (ET) Acupuncture 4, 4 weeks, 25 min Hamilton anxiety rating scale (HAS) Acupuncturist The intervention reduced the anxiety score in the patients (anxiety score: case = 19.4, control = 24.4) Q1 Shu Hsin Lee (2003) [ 55 ] Taiwan Case-control 132 (Case = 64, control = 68) Case = 31.8, control = 32.3 - Female factor, male factor, Female and male factor, unexplained IVF-ET During embryo transfer (ET) Nursing crisis intervention program (watching a video describing therapeutic process, self-hypnosis and muscle relaxation training, provision of cognitive-behavioral counseling) - Self-administered depression scale (SDS), state-trait anxiety inventory (STAI) Counselor The intervention reduced the anxiety state score in the patients (anxiety state score: case = 47.7, control = 50.9; anxiety trait score: case = 47.0, control = 47.0; depression score: case = 55.2, control = 56.9) Q1 Suping Zhang (2017) [ 56 ] China Case-control 200 (Case = 100, control = 100) - - Tubal and pelvic factors, ovulation disorder, endometriosis, failure of intrauterine insemination IVF - Positive psychological intervention (group counselling containing self-understanding, describing ideal self, describing events and intimate with loved ones, helping others participating meaningful work, describing happy events and regaining confidence and hope) 8 weeks, 1 h Symptom checklist-90 (SCL-90) Researcher The intervention reduced the anxiety and depression scores in the patients (anxiety score: case = 1.39, control = 1.60; depression score: case = 1.49, control = 1.71) Q2 Habibeh SoltanzadehMezreji (2016) [ 57 ] Iran Case-control 40 (Case = 20, control = 20) - - - IUI Before IUI cycle Group reality therapy program (members’ familiarization regarding basic and effective needs in life, how to plan problem solving, commitment to execution of medical programs, denying excuses on the execution of selected programs) 10, 1.5 h State-trait anxiety inventory (STAI) Researcher The intervention reduced the anxiety score in the patients (anxiety state score: case = 37.35, control = 49.95; anxiety trait score:: case = 37.35, control = 52.35) Q3 Leili Mosalanejad (2012) [ 58 ] Iran Case-control 31 (Case = 15, control = 16) 20–35 - - Assisted reproductive therapy (ART) - Cognitive behavioral therapy (CBT) program (stress management, negative thought blocking, relaxation therapy, biofeedback, cognitive restructuring, positive thoughts or beliefs, communication, problem-solving) 15 weeks, 1.5 h Depression, anxiety and stress scale (DASS) Researcher It was not found statistically significant difference between anxiety and depression scores after intervention. Q3 Leili Mosalanejad (2012) [ 59 ] Iran Case-control 65 (Case = 33, control = 32) 20–40 Primary Female factor, male factor Assisted reproductive therapy (ART) - E-cognitive group therapy program (CBT) (teaching how to identify and challenge negative thoughts and irrational beliefs, cognitive reconstructing, negative thought blocking, spirituality, muscle relaxation, birth exercises, imagination, elf-disclosure, biofeedback) 12, 3 months, 2 h Depression, anxiety and stress scale (DASS) Researcher The intervention reduced the anxiety score in the patients (anxiety score: case = 8.06, control = 9.25) Q2 Marzieh Ghasemi Gojani (2018) [ 60 ] Iran Case-control 103 (PRCI = 35, PSS = 34, control = 34) 18–40 Primary Female factor, male factor, female and male factor, unexplained IUI Before IUI Positive reappraisal coping intervention (PRCI) and problem-solving skills (PSS) training (completing coping thoughts cards, filling out daily monitoring forms) 2 Beck depression inventory (BDI) Researcher The intervention reduced the depression score in the patients (depression score: PRCI = 13.14, PSS = 12.52, control = 21.7) Q2 Fatemeh Kalhori (2020) [ 61 ] Iran Case-control 90 (Case = 45, control = 45) Case=, control= - - IVF During IVF cycles Mindfulness-based group counseling program (counseling regarding auto-guidance, confrontation with obstacles, breathing with mindfulness, staying in the moment, the untruthfulness of thoughts, how to take optimal care of oneself, practicing conscious yoga exercises) 8, 6 weeks, 1.5 h Beck depression inventory (BDI) Researcher The intervention reduced the depression score in the patients (depression score: case = 10.82, control = 21.33) Q2 Mahtab Moti (2024) [ 62 ] Iran Case-control 64 (Case = 32, control = 32) Case = 30.4, control = 29.1 - - IVF Before egg transfer Thiamine supplementation 4 weeks General health questionnaire 28 (GHQ-28) - The intervention reduced the depression score in the patients (depression score: case = 10.96, control = 16.25) Q1 Miok Kim (2020) [ 63 ] South Korea Case-control 50 (Case = 26, control = 24) < 34- ≥ 35 - Female factor, male factor, female and male factor, unexplained IVF - Psychological intervention program (emotional sharing and consolation, physical relaxation through guided imagery and musical activities such as listening, singing, expressing) 6, 4 weeks, 4 h Center for epidemiologic studies depression scale (CES-D) - The intervention reduced the depression score in the patients (depression score: case = 1.72, control = 2.90) Q1 Sedigheh Keshavarz (2021) [ 64 ] Iran Case-control 74 (midwifery consultation = 26, fluoxetine = 24, control = 24) Midwifery consultation = 30.0, fluoxetine = 30.1, control = 32.2 - - IVF On the day of embryo transfer (ET) Midwifery consultation and fluoxetine administration program 6, 8 weeks, 30 min Beck depression inventory (BDI), state-trait anxiety inventory (STAI) Psychiatrist, midwife The midwifery consultation intervention reduced significantly depression and anxiety scores. (depression score: midwifery consultation= 15.75, fluoxetine = 19.5, control = 19.86; state anxiety score: midwifery consultation = 42.10, fluoxetine = 44.69, control = 49.75; trait anxiety score: midwifery consultation = 39.20, fluoxetine = 45.73, control = 47.35) Q3 Mary Ellen McNaughton-Cassill (2002) [ 65 ] USA Case-control 45 (Case = 26, control = 19) Case = 33.5, control = 34.7 - - IVF Before IVF cycle Brief couples support groups program 1.5 h Beck depression inventory, beck anxiety inventory Psychiatrist, clinical psychologist The intervention reduced the anxiety score in the patients (anxiety score: case = 3.89, control = 5.70) Q1 Simone F Nery (2019) [ 66 ] Brazil Case-control 99 (Case = 62, control = 37) Case = 37.4, control = 37.0 Primary& secondary Male factor, anovulation, tubal obstruction, endometriosis, unexplained IVF - Mindfulness-based program (MBP) (meditation, relaxation, autogenic training, guided imagery, biofeedback) 10 weeks, 2 h Beck depression inventory (BDI) - The intervention reduced the depression score in the patients (depression score: case = 7.36, control = 9.15) Q1 Ahmad A Noorbala (2008) [ 67 ] Iran Cross-sectional 319 26.3 - Female factor, male factor, female and male factor, unexplained - before treatment, during treatment Psychological intervention program (cognitive-behavioral therapy (CBT), supportive psychotherapy, administration of fluoxetine) 6 months Beck depression inventory (BDI) Clinical psychologist The intervention reduced the depression score significantly before treatment in the patients (depression score: before treatment = 23.3, during treatment = 24.7) Q1 Henrietta Ockhuijsen (2014) [ 68 ] Netherlands Case-control 377 (PRCI- monitoring = 127, monitoring-control = 126, control = 124) PRCI- monitoring = 34.9, monitoring-control = 34.6, control = 34.8 Primary& secondary Female factor, male factor, female and male factor, unexplained IVF/ICSI Before IVF/ICSI cycle Positive reappraisal coping intervention (PRCI) program (distribution of a small card containing positive reappraisal statements, distribution of a leaflet containing a detailed explanation regarding the coping approach) 6 weeks Hospital anxiety and depression scale (HADS) - The intervention reduced the depression and anxiety scores in the patients (depression score: PRCI- monitoring = 3.67, monitoring-control = 3.70, control = 4.22; anxiety score: PRCI- monitoring = 7.30, monitoring-control = 7.52, control = 8.17) Q1 Sara P C Paiva (2015) [ 69 ] Brazil Cross-sectional 25 18–40 - - IVF - Mindfulness-based stress reduction (MBSR) program (mindfulness meditation, relaxation, autogenic training, biofeedback, guided imagery) 12 weeks, 2 h Psychological general well-being index (PGWBI) tool - The intervention improved the depression and anxiety status in the patients (depression score: before = 13.0, after = 14.2; anxiety score: before = 18.0, after = 22.9) Q3 Galia Oron (2015) [ 70 ] Canada Cross-sectional 49 35.7 Primary& secondary - IVF - Hatha yoga 6 weeks, 2 h State-trait anxiety inventory (STAI), beck depression inventory (BDI) - The intervention reduced the depression and anxiety scores in the patients (depression score: before = 7.77, after = 5.26; anxiety score: before = 46.7, after= 42.8) Q1 M Tarabusi (2004) [ 71 ] Italy Case-control 98 (Case = 50, control = 48) Case = 33.6, control = 34.4 - - IVF-ET, ICSI - Cognitive-behavioral treatment (CBT) program 12, 4 months Symptom rating test (SRT) Psychologist The intervention reduced the depression and anxiety scores in the patients (depression score: case = 3.90, control = 4.0; anxiety score: case = 4.81, control= 4.92) Q1 Roya Rahimi (2021) [ 72 ] Iran Case-control 52 (Case = 26, control = 26) Case = 34.4, control = 32.9 Primary& secondary Female factor, male factor IVF After IVF cycle Hope oriented group counseling program 6, 45–60 min Depression anxiety stress scale-21 (DASS-21) Researcher The intervention reduced the depression and anxiety scores in the patients (depression score: case = 13.3, control = 15.5; anxiety score: case = 12.2, control = 15.9) Q1 Kimia Sahraian (2024) [ 73 ] Iran Case-control 57 (Case = 29, control = 28) Case = 33.3, control = 34.7 - - IVF - Mindful self‑compassion (MSC) program (debut, overview,, discussion on self-compassion, fundamentals of mindfulness, developing a compassionate inner voice, discussion on techniques for coping with challenging emotions, discussion on coping with complicated experiences of interpersonal interactions) 8 weeks, 2 h 90-symptom checklist (SCL-90-R) Trainer The intervention reduced the depression and anxiety scores in the patients (depression score: case = 1.97, control = 3.06; anxiety score: case = 0.53, control = 1.34) Q1 Özen İnam (2025) [ 74 ] Turkey Case-control 34 (Case = 17, control = 17) ≤ 30-≥36 - - IVF Before IVF cycle Mindfulness-based nursing support program (mindfulness meditation training containing breath awareness, body & uterus awareness, injection therapy and ovary awareness, pre-Oosyte retrieval (OPU) diaphragmatic breathing, pre-embryo transfer uterus awareness, embryo and uterine awareness post-transfer via a mobile application) 8 weeks, 20 min Depression anxiety stress scale (DASS 21) - The intervention reduced the depression and anxiety scores in the patients (depression score: case = 4.35, control = 7.82; anxiety score: case = 4.88, control = 9.00) Q1 Cari Jo Clark (2024) [ 75 ] Jordan Cross-sectional 16 23–53 Primary& secondary Female factor, male factor IVF, ovulation induction, IUI - Cognitive behavioral therapy (CBT) program (group norms and goal-setting, comprehending psychosocial stress, recognition of stressors and effects on routine life, the effect of self-perception of routine life, expression and safe management of feelings, overcoming obstacles to communication, effective communication strategies, questioning assumptions and self-perceptions regarding problems, problem-solving and strategies for restructuring relationships, development of new approaches to life by removing unfounded anxieties) 11, 3 months, 1.5–2 h Hopkins symptoms checklist-25 Psychologist The intervention reduced the depression and anxiety scores in the patients (depression score: before = 2.5, after = 1.5; anxiety score: before = 2.4, after= 1.6) Q1 Fatemeh Kalhori (2019) [ 76 ] Iran Case-control 90 (Case = 45, control = 45) Case = 30.2, control = 29.6 Primary - IVF Before embryo transfer (ET) Mindfulness-based group counseling program (auto-guidance, barriers, breathing with mindfulness, staying in the moment, accepting and permission to attend, non-truthful thoughts, how to do self-care) 8, 1.5 h Spielberger anxiety scale questionnaire - The intervention reduced the anxiety score in the patients (apparent anxiety score: case = 37.86, control = 55.55; hidden anxiety score: case = 38.40, control= 54.64) Q3 Azadeh Bahrami Kerchi (2021) [ 77 ] Iran Case-control 45 (psychological empowerment (PE) = 15, dialectical behavior therapy (DBT) = 15, control = 15) PE = 39.6, DBT = 39.8, control = 40.0 Secondary - IVF During IVF cycle Psychological empowerment and dialectical behavior therapy program (group acquaintance, treatment of infertility-related depression problems, encouraging the subjects to challenge issues while reinforcing meaning and happiness, treatment of infertility-related cognitive problems, treatment of obsessive-compulsive disorder related to infertility, performing the diaphragmatic breathing technique and relaxation, familiarity with effective coping skills, technique, evaluation and anger exercise, expression training techniques, treatment of infertility-related social problems, treatment of infertility-related physical problems, introducing mind levels, practicing self-awareness and abdominal breathing, practice to strength tolerance, practice relaxation and oral presentation) 19, 1.5 h Depression, anxiety, and stress scale-21 (DASS-21) Psychologist, therapist The intervention reduced the anxiety score in the patients (anxiety score: PE = 23.00, DBT = 26.93, control = 29.86) Q3 The total information of the extracted articles Before embryo transfer (ET) Mind-body therapeutic program (abdominal breathing, sharing experiences, identifying cognitive errors and irrational beliefs, ring feelings, reinforcing positive messages) It was not found statistically significant difference between the case and control groups for depression scores after intervention It was not found statistically significant difference between the case and control groups for depression scores after intervention Depression, anxiety, stress scale 21 (DASS-21 Male factor, ovarian dysfunction, tubal factor, endometriosis, unknown It was not found Statistically significant difference between anxiety and depression scores after intervention. Unified protocol transdiagnostic and mindfulness-based stress reduction program Screening on distress in fertility treatment (SCREENIVF) questionnaire, hospital anxiety and depression scale (HADS) Two guided self-administered intervention (listening to audio comprising guided mindfulness breathing and body scan, writing gratitude journals) Generalized anxiety disorder-7 (GAD-7) scale, patient health questionnaire-9 (PHQ-9) scale Self-administered depression scale (SDS), state-trait anxiety inventory (STAI) Tubal and pelvic factors, ovulation disorder, endometriosis, failure of intrauterine insemination E-cognitive group therapy program (CBT) (teaching how to identify and challenge negative thoughts and irrational beliefs, cognitive reconstructing, negative thought blocking, spirituality, muscle relaxation, birth exercises, imagination, elf-disclosure, biofeedback) Psychological intervention program (emotional sharing and consolation, physical relaxation through guided imagery and musical activities such as listening, singing, expressing) Beck depression inventory, beck anxiety inventory Mindfulness-based program (MBP) (meditation, relaxation, autogenic training, guided imagery, biofeedback) Psychological intervention program (cognitive-behavioral therapy (CBT), supportive psychotherapy, administration of fluoxetine) Positive reappraisal coping intervention (PRCI) program (distribution of a small card containing positive reappraisal statements, distribution of a leaflet containing a detailed explanation regarding the coping approach) Cognitive-behavioral treatment (CBT) program Hope oriented group counseling program Mindful self‑compassion (MSC) program (debut, overview,, discussion on self-compassion, fundamentals of mindfulness, developing a compassionate inner voice, discussion on techniques for coping with challenging emotions, discussion on coping with complicated experiences of interpersonal interactions) Mindfulness-based nursing support program (mindfulness meditation training containing breath awareness, body & uterus awareness, injection therapy and ovary awareness, pre-Oosyte retrieval (OPU) diaphragmatic breathing, pre-embryo transfer uterus awareness, embryo and uterine awareness post-transfer via a mobile application) Cognitive behavioral therapy (CBT) program (group norms and goal-setting, comprehending psychosocial stress, recognition of stressors and effects on routine life, the effect of self-perception of routine life, expression and safe management of feelings, overcoming obstacles to communication, effective communication strategies, questioning assumptions and self-perceptions regarding problems, problem-solving and strategies for restructuring relationships, development of new approaches to life by removing unfounded anxieties) Hopkins symptoms checklist-25 Mindfulness-based group counseling program (auto-guidance, barriers, breathing with mindfulness, staying in the moment, accepting and permission to attend, non-truthful thoughts, how to do self-care) Spielberger anxiety scale questionnaire 45 (psychological empowerment (PE) = 15, dialectical behavior therapy (DBT) = 15, control = 15) Psychological empowerment and dialectical behavior therapy program (group acquaintance, treatment of infertility-related depression problems, encouraging the subjects to challenge issues while reinforcing meaning and happiness, treatment of infertility-related cognitive problems, treatment of obsessive-compulsive disorder related to infertility, performing the diaphragmatic breathing technique and relaxation, familiarity with effective coping skills, technique, evaluation and anger exercise, expression training techniques, treatment of infertility-related social problems, treatment of infertility-related physical problems, introducing mind levels, practicing self-awareness and abdominal breathing, practice to strength tolerance, practice relaxation and oral presentation) Fig. 2 The distribution of the included studies across various countries The distribution of the included studies across various countries Sixteen studies investigated the effect of interventions on anxiety levels using the State-Trait Anxiety Inventory (STAI). Four studies employed the Self-Rating Symptom Scale (SCL-91), two used the Beck Anxiety Inventory, and six utilized the Depression, Anxiety, and Stress Scale (DASS). Additionally, one study applied the Generalized Anxiety Disorder-7 (GAD-7) scale, one used the Hamilton Anxiety rating Scale (HAS), one employed the Hospital Anxiety and Depression Scale (HADS), one used the Psychological General Well-Being Index (PGWBI), one applied the Symptom Rating Test (SRT), one used the Spielberger anxiety scale questionnaire, and one employed the Hopkins symptom checklist. Twelve studies investigated the effects of interventions on depression levels using the Beck depression inventory (BDI) scale; four studies used the Self-Rating Symptom Scale (SCL-91); six studies employed the Depression, Anxiety, Stress Scale (DASS); one study utilized the Hospital Anxiety and Depression Scale (HADS); one study applied the Psychological General Well-Being Index (PGWBI); one study used the Symptom Rating Test (SRT); one study used the Edinburgh Depression Scale (EDS); and one study used the Hopkins symptom checklist. After a qualitative assessment of the included papers, 28 were rated as high quality (Q1), 5 as moderate quality (Q2), and 11 as low quality (Q3). The ages of infertile females ranged from 18 to 45 years. The types of infertility included primary, secondary, or both. The causes of infertility were female factors, male factors, mixed factors, ovarian dysfunction, endometriosis, tubal and pelvic factors, failure of intrauterine insemination, anovulation, and unexplained causes. Treatment options included intrauterine insemination (IUI), in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and ovarian stimulation. The timing of interventions varied, occurring both before and after ART. The number of sessions ranged from 1 to 19, with each session lasting between 10 and 180 min on average. The overall duration of the interventions spanned from 4 weeks to 6 months. Forty studies reported favorable outcomes regarding depression and anxiety levels in infertile women following various intervention programs. These included mind-body interventions (such as Eastern body-mind-spirit, mindfulness-based program for infertility [MBPI], integrative body-mind-spirit, and mind-body therapeutic programs), cognitive behavioral therapy (CBT), targeted nursing care programs, group psychotherapy, Hatha yoga (HY) practice, acupuncture, stress management programs, music therapy, nursing crisis intervention programs, positive psychological interventions, drug and supplementation therapies, and positive reappraisal coping intervention (PRCI) programs. Detailed descriptions of the interventions are provided in Table  1 . A total of 17 studies were included in the meta-analysis, reporting either depression or anxiety in case and control groups. Only studies that used the Beck Depression Inventory (BDI) to measure depression and the State-Trait Anxiety Inventory (STAI) to measure anxiety were included in the meta-analysis. Both depression and anxiety decreased after the intervention, with an overall pooled standardized mean difference (SMD) of −3.16 (95% CI: −4.38, −1.94) for depression and SMD of −1.23 (95% CI: −1.70, −0.76) for anxiety. Figures  3 and 4 present the meta-analysis findings for the overall pooled SMD for anxiety and depression, respectively. Subgroup analysis indicated that interventions implemented before ART were more effectual than those applied during or after ART. Tables  2 and 3 summarize the subgroup analysis findings for the overall pooled SMD for anxiety and depression, respectively. Fig. 3 Pooled SMD for anxiety Fig. 4 Pooled SMD for depression Pooled SMD for anxiety Pooled SMD for depression Table 2 Findings of subgroup analysis for the anxiety score Subgroup analysis Subgroup Category (number of studies) Pooled scores (mean) [95% CI] I 2 (%) Q statistic ( df ) p of heterogeneity Income level High income (6) LMICs (6) −0.98 [−1.61, −0.36] −1.50 [−2.28, −0.72] 93.3 95.7 5 5 < 0.001 < 0.001 Region Europe (4) East/southeast Asia/Oceania (4) Middle East (4) Americas (-) −0.47 [−0.86, −0.08] −1.16 [−1.99, −0.33] −2.24 [−3.78, −0.70] - 79.1 95.2 96.5 - 3 3 3 - 0.002 < 0.001 < 0.001 - Timing Before ART (4) During ART (2) After ART (3) −3.03 [−5.96, −0.09] −0.88 [−1.54, −0.23] −0.86 [−1.86, 0.14] 91.9 89.9 98.1 3 1 2 < 0.001 0.002 < 0.001 Findings of subgroup analysis for the anxiety score Pooled scores (mean) [95% CI] Q statistic ( df ) High income (6) LMICs (6) −0.98 [−1.61, −0.36] −1.50 [−2.28, −0.72] 93.3 95.7 5 5 < 0.001 < 0.001 Europe (4) East/southeast Asia/Oceania (4) Middle East (4) Americas (-) −0.47 [−0.86, −0.08] −1.16 [−1.99, −0.33] −2.24 [−3.78, −0.70] - 79.1 95.2 96.5 - 3 3 3 - 0.002 < 0.001 < 0.001 - Before ART (4) During ART (2) After ART (3) −3.03 [−5.96, −0.09] −0.88 [−1.54, −0.23] −0.86 [−1.86, 0.14] 91.9 89.9 98.1 3 1 2 < 0.001 0.002 < 0.001 Table 3 Findings of subgroup analysis for the depression score Subgroup analysis Subgroup Category (number of studies) Pooled scores (mean) [95% CI] I 2 (%) Q statistic ( df ) p of heterogeneity Income level High income (3) LMICs (6) −2.38 [−4.24, −0.52] −3.57 [−5.32, −1.81] 98.2 97.3 2 5 < 0.001 < 0.001 Region Europe (3) East/southeast Asia/Oceania (-) Middle East (5) Americas (1) −2.38 [−4.24, −0.52] - −3.81 [−6.13, −1.48] −2.46 [−2.99, −1.92] 98.2 - 97.9 - 2 - 4 0 < 0.001 - < 0.001 - Timing Before ART (2) During ART (2) After ART (-) −4.10 [−9.54, 1.33] −3.35 [−8.62, 1.90] - 99.0 98.7 - 1 1 - < 0.001 < 0.001 - Findings of subgroup analysis for the depression score Pooled scores (mean) [95% CI] Q statistic ( df ) High income (3) LMICs (6) −2.38 [−4.24, −0.52] −3.57 [−5.32, −1.81] 98.2 97.3 2 5 < 0.001 < 0.001 Europe (3) East/southeast Asia/Oceania (-) Middle East (5) Americas (1) −2.38 [−4.24, −0.52] - −3.81 [−6.13, −1.48] −2.46 [−2.99, −1.92] 98.2 - 97.9 - 2 - 4 0 < 0.001 - < 0.001 - Before ART (2) During ART (2) After ART (-) −4.10 [−9.54, 1.33] −3.35 [−8.62, 1.90] - 99.0 98.7 - 1 1 - < 0.001 < 0.001 - When we excluded studies with a high risk of bias, there was no difference in the overall effect estimates. However, publication bias was detected among the included studies (Egger’s and Begg’s tests, P  < 0.05) (Fig.  5 ). Fig. 5 Funnel plot to examine possibility of publication bias Funnel plot to examine possibility of publication bias

In the current review, various interventional approaches were adopted, including mind-body interventions, cognitive behavioral therapy (CBT), and acupuncture. Among these, CBT and BMS demonstrated the strongest evidence of effectiveness. Most interventions require significant financial resources and time commitment for regular individual practice, and they are often inaccessible to many infertile women. Nevertheless, acupuncture and music therapy, despite their low cost, can positively impact the mental health of infertile women undergoing ART. Therefore, these care interventions can be applied based on the desired level of effectiveness. Consequently, a new, evidence-based, multifaceted intervention should be developed specifically for infertile women undergoing ART treatment, particularly prior to ART procedures. Successful integration of high-impact nursing interventions necessitates close collaboration among healthcare providers, leaders, and policymakers. Policymakers and healthcare professionals must carefully consider healthcare priorities, as well as the effectiveness, benefits, and potential risks of interventions. Team members alone cannot successfully develop or implement a comprehensive system of high-impact nursing interventions; a collaborative approach is essential. It is important that management, together with healthcare staff, clearly define their roles and responsibilities in developing this comprehensive system and foster a culture that supports this framework.

The current review aimed to investigate the evidence regarding the efficacy of various interventions on anxiety and depression in infertile women undergoing ART. Nearly all 44 studies included in the current review reported favorable outcomes for anxiety and depression after implementing various types of interventions in this population. The pooled analysis of seventeen studies demonstrated significantly lower depression and anxiety scores in infertile women following these interventions. Despite subgroup analyses conducted to evaluate the effectiveness of nursing interventions on anxiety and depression in infertile women undergoing ART, the studies remain heterogeneous. This heterogeneity is primarily due to the use of various questionnaires across different studies and the small sample sizes involved. In general, female infertility and failure in infertility treatments are likely to have a negative impact on quality of life. The World Health Organization (WHO) defines quality of life as “a person’s perception of their position in life within the context of the culture and value systems in which they live, and in relation to their aims, expectations, criteria and concerns” [ 78 ]. A cross-sectional study investigated the quality of life in infertile Chinese women by examining various health and quality of life aspects and comparing them with those of fertile women. The results revealed that infertile women reported lower quality of life scores in areas such as spirituality/religion/personal beliefs, self-esteem, financial resources, and access to and quality of health and social care. They also experienced more pain and discomfort. However, infertile women showed positive adaptations mobility, activities of daily living, working capacity, sexual activity, freedom, physical safety, security, and transportation. The specific scores were as follows: physical health (infertile = 62.81, fertile = 65.68), pain and discomfort (infertile = 41.28, fertile = 34.61), energy and fatigue (infertile = 60.34, fertile = 62.73), sleep and rest (infertile = 69.37, fertile = 68.91), psychological well-being (infertile = 61.11, fertile = 63.13), positive feelings (infertile = 54.86, fertile = 56.09), self-esteem (infertile = 59.10, fertile = 63.83), negative feelings (infertile = 36.11, fertile = 32.73), financial resources (infertile = 58.18, fertile = 65.08), spirituality/religion/personal beliefs (infertile = 47.92, fertile = 56.56), and anxiety score (infertile = 38.57, fertile = 31.96) [ 79 ]. In the current review, various interventional approaches were adopted, including mind-body interventions such as Eastern body-mind-spirit therapy, mindfulness-based program for infertility (MBPI), integrative body-mind-spirit therapy, Hatha yoga (HY) practice, and mind-body therapeutic programs. Other approaches included cognitive behavioral therapy (CBT), targeted nursing care programs, group psychotherapy, acupuncture, stress management programs, music therapy programs, nursing crisis intervention programs, positive psychological interventions, drug and supplementation therapies, and positive reappraisal coping intervention (PRCI) programs. Mind-body interventions are methods that leverage the connection between mental and physical states to enhance health and well-being. These interventions utilize cognitive processes to influence bodily functions and symptoms. They often incorporate psychological, emotional, cognitive, and social dimensions to promote physical functioning. Key characteristics of mind-body interventions include the following: they emphasize the mind-body connection by recognizing the dynamic interaction between thoughts, feelings, and physical sensations; they adopt a holistic approach, considering the person’s overall well-being, including physical, psychological, and social aspects; they encompass a variety of techniques, such as relaxation, yoga, biofeedback, and meditation; and they offer potential benefits, including the reduction of stress, anxiety, and depression [ 80 , 81 ]. Chan et al. conducted a study to examine the impact of an Eastern Body-Mind-Spirit (EBMS) group intervention on the anxiety levels of infertile women undergoing IVF-ET. Anxiety was measured using the State-Trait Anxiety Inventory (STAI). The intervention was based on a holistic health concept, with each group session lasting two hours over four weeks. The intervention was administered prior to embryo transfer (ET). The results demonstrated that the intervention reduced state anxiety scores in the patients (state anxiety score: intervention group = 42.69, control group = 43.70) [ 35 ]. A study involving patients with breast cancer employed a case-control design to evaluate the effects of body-mind-spirit (BMS) group intervention. The experimental group participated in ten weekly sessions, each lasting 180 min, of BMS group therapy. This therapeutic approach integrates concepts and practices from both traditional Chinese medicine and Western medicine, including positive psychology and forgiveness therapy. Participants in the intervention group were invited to join a focus group interview to discuss their perceptions of the mechanisms of change experienced during treatment. The results indicated that culturally sensitive BMS group therapy lessened anxiety in breast cancer patients [ 82 ]. More broadly, the effectiveness of BMS in enhancing the mental health of infertile women can be attributed to increased awareness, attention to bodily sensations and movements, and stretching aimed at achieving peace and balance between mind and body. Because BMS addresses both mental and physical aspects, it benefits not only patients with mental disorders but also enhances well-being in healthy individuals [ 83 ]. Because individual well-being arises from the balance and harmony of the inner dimensions of mind, body, and spirit, BMS, as a holistic framework, helps infertile women reinterpret unpleasant experiences, thereby reducing psychological distress and improving mental health [ 35 ]. Galhardo et al. investigated the impact of a mindfulness-based program for infertility (MBPI) on anxiety and depression in infertile women undergoing ART. They utilized the State-Trait Anxiety Inventory-Y1 (STAI-Y1) and the Beck Depression Inventory (BDI) to assess anxiety and depression. The psychosocial program included the distribution of a manual and an audio CD covering mindfulness meditation, mindfulness practice, metaphors, experiential exercises, and sharing of experiences. Each session lasted two hours and was conducted over 10 weeks. The findings showed that the intervention lessened anxiety and depression scores in the patients (depression score: case = 6.18, control = 10.22; anxiety score: case = 43.02, control = 47.57) [ 18 ]. Valoriani et al. carried out a study to examine the effect of Hatha yoga (HY) practice on anxiety and depression in infertile women undergoing IVF. They used the State-Trait Anxiety Inventory-Y1 (STAI-Y1) and the Edinburgh Depression Scale (EDS) to measure anxiety and depression, respectively. The intervention included Asana postures, breathing exercises, and relaxation techniques. Each session lasted 1.5 h and was held over three months, with the intervention occurring before the IVF cycle. The intervention decreased anxiety and depression scores in the patients (depression score: case = 6.60, control = 6.40; anxiety score: case = 37.67, control = 39.24) [ 36 ]. Furthermore, Kim et al. conducted a study to evaluate the influence of a mind-body therapeutic program on anxiety in infertile women undergoing IVF-ET. They used the State-Trait Anxiety Inventory (STAI) and the Visual Analog Scale for Anxiety (VAS-A) to measure anxiety. The intervention included abdominal breathing, recounting experiences, recognizing cognitive errors and illogical thoughts, identifying feelings, and reinforcing positive messages. The program consisted of five sessions, each lasting two hours over five weeks. The intervention was administered after embryo transfer (ET). The findings revealed that the intervention reduced anxiety scores in the patients (anxiety score [STAI]: case = 28.12, control = 44.17; anxiety score [VAS-A]: case = 68.65, control = 75.00) [ 38 ]. Cognitive Behavioral Therapy (CBT) is a form of psychotherapy that emphasizes the connection between your thoughts, emotions, and behaviors. The goal of this approach is to help individuals recognize and modify negative or unhelpful thought patterns and behaviors that contribute to distress or psychiatric conditions. Key dimensions of CBT include: a focus on the present—CBT primarily addresses current issues and symptoms rather than past experiences; a collaborative approach—CBT involves a partnership between the therapist and the individual, working together to recognize and address specific challenges; a practical and goal-oriented method—CBT is a structured, time-limited treatment that emphasizes developing practical skills and strategies for managing thoughts, emotions, and behaviors; an emphasis on thoughts, emotions, and behaviors—CBT recognizes the interconnectedness of these elements and aims to change negative or maladaptive patterns in each; and an evidence-based approach—CBT is a well-researched and effective therapy for a variety of psychiatric conditions [ 84 , 85 ]. Mosalanejad et al. conducted a study to assess the impact of cognitive behavioral therapy (CBT) program on anxiety and depression in infertile women undergoing ART. They used the Depression, Anxiety, and Stress Scale (DASS) to measure anxiety and depression. The intervention included teaching participants how to identify and challenge negative thoughts and irrational beliefs, cognitive restructuring, negative thought blocking, spirituality, muscle relaxation, breathing exercises, imagination, self-disclosure, and biofeedback. The program consisted of 12 sessions, each lasting 2 h, over a period of 3 months. The findings showed that the intervention significantly reduced only the anxiety scores in the patients (anxiety score: case = 8.06, control = 9.25) [ 59 ]. In another study involving depressed subjects with Parkinson’s disease, CBT was administered in a randomized controlled trial. The primary outcome was measured using the Hamilton Depression Rating Scale (HAM-D). Secondary outcomes included the Beck Depression Inventory (BDI), anxiety, quality of life, coping, and Parkinson’s disease symptoms. The intervention lasted 10 weeks. The experimental group showed greater reductions in depression compared to the control group (HAM-D score: case = 14.52, control = 19.31). CBT also outperformed the control group on several secondary outcomes (BDI score: case = 11.18, control = 16.20; Hamilton anxiety score: case = 15.36, control = 18.30; unified Parkinson’s Disease Rating Scale score: case = 40.11, control = 49.59; brief COPE score: case = 5.16, control = 4.33) [ 86 ]. It can be stated that events and incidents do not upset people directly; rather, it is their way of thinking—shaped by their attitudes and beliefs—that influences how they process information and generate emotional reactions. Accordingly, a person’s thoughts and beliefs regarding infertility affect the type and intensity of their emotional response. Therefore, because CBT is a short-term psychological framework focused on skill development and aims to change maladaptive emotional responses by modifying patients’ thoughts and behaviors, it helps patients identify negative attitudes and acquire new skills for behavior change, communication, problem-solving, correcting erroneous beliefs and attitudes, and cognitive restructuring [ 87 ]. On the other hand, CBT tends to yield more favorable outcomes due to the application of techniques as problem-solving and muscle relaxation. These methods enhance self-awareness and facilitate recognition of the psychological aspects of anxiety and depression, leading to a reduction in symptoms. An individual’s understanding of the impact of negative emotions on mental health and the benefits of a positive lifestyle increases adherence to therapeutic tasks, resulting in decreased depression [ 87 ]. Generally, the efficacy of CBT in enhancing the mental health of infertile women can be attributed to the correction of faulty thinking patterns and beliefs, stress reduction, and the emotional support provided by group therapy. Stress reduction occurs through the modification of incompatible beliefs, cognitive errors, and maladaptive schemas related to infertility. Since many infertile patients feel isolated, perceive their problems as unique, and are reluctant to discuss them, CBT group sessions offer a safe environment for emotional release and overcoming loneliness [ 88 ]. Mosalanejad et al. investigated the effects of a CBT program on anxiety and depression in infertile women undergoing ART. They used the Symptom Rating Test (SRT) to assess anxiety and depression. The intervention consisted of 12 sessions over four months. The results demonstrated that the intervention significantly improved depression and anxiety scores compared to baseline (depression score: case = 3.90, control = 4.0; anxiety score: case = 4.81, control = 4.92) [ 71 ]. Most of the interventions presented in our review require significant funding and time commitment for routine individual practice and are also inaccessible to most infertile women. Despite being low-cost, acupuncture and music therapy have demonstrated acceptable effectiveness in the studies included in this review. Isoyama et al. examined the impact of acupuncture on the anxiety levels of infertile women undergoing IVF-ET. They used the Hamilton Anxiety Rating Scale (HAS) to measure anxiety. The intervention consisted of four sessions, each lasting 25 min, over four weeks. The timing of the intervention was after embryo transfer (ET). The findings showed that the intervention significantly reduced anxiety in the treatment group compared to the control group (anxiety score: case = 19.4, control = 24.4) [ 54 ]. Taguchi et al. also investigated the effects of needle and laser acupuncture on the anxiety levels of infertile women undergoing IVF-ET and ICSI. They used the State-Trait Anxiety Inventory (STAI) to assess anxiety. The intervention included 24 sessions, each lasting 10 min, over three months. The timing of the intervention was during ART. The results indicated that needle acupuncture was more effective than laser acupuncture (anxiety state scores: needle acupuncture before = 43.1, after = 38.9; laser acupuncture before = 37.9, after = 36.4; anxiety trait scores: needle acupuncture: before = 43.0, after = 40.9- laser acupuncture: before = 38.5, after = 39.2) [ 46 ]. Acupuncture has also been studied in other populations. In one study, acupuncture treatment for chronic insomnia was evaluated. The intervention was administered three times a week for four weeks, with a three-month follow-up. Outcomes measured included the Pittsburgh Sleep Quality Index (PQSI), Hamilton Anxiety Rating Scale (HAMA), and Hamilton Depression Rating Scale (HAMD). All outcomes were considerably lower in the experimental group compared to the control group (PSQI: case = 7.93, control = 12.48; HAMA: case = 7.17, control = 10.48; HAMD: case = 7.83, control = 11.48) [ 89 ]. Arzu Aba et al. conducted a study to investigate the influence of a music therapy program on the anxiety levels of infertile women undergoing IVF-ET. They used the State-Trait Anxiety Inventory (STAI) to measure anxiety. Each session lasted 28 min, and the intervention was administered by a musicologist after embryo transfer (ET). The findings showed that the intervention reduced anxiety scores in the patients following the intervention (anxiety state score: case = 33.39, control = 34.57; anxiety trait score: case = 38.19, control = 40.19) [ 44 ]. Music therapy has also been examined in other populations. Its effectiveness was studied in subjects with traumatic brain injury. Music therapy sessions lasted one hour and were conducted over 20 weeks. Each session was divided into two 30-minute segments: one dedicated to listening to music (acceptable music therapy) and the other to playing a musical instrument (active music therapy). The Hospital Anxiety and Depression Scale (HAD) and a face scale for measuring mood were used as outcome measures. Music therapy produced significant enhancements in mood from the beginning of the sessions. This short-term effect was confirmed by rapid changes in scores after music therapy sessions (from 4.6 to 2.6). Furthermore, music therapy resulted in considerable reductions in anxiety and depression from week 10 onwards [ 90 ]. Overall, based on the findings of the current review, several care interventions can effectively improve the psychological well-being of infertile women undergoing ART. Even so, the effectiveness of these interventions varies. Mind body interventions, cognitive behavioral therapy (CBT), targeted nursing care programs, and group psychotherapy have a considerable impact on enhancing patients’ psychological conditions. Nevertheless, these interventions require substantial financial resources and time commitment for routine individual practice and are often inaccessible to most infertile women. Therefore, it is recommended that service providers select and implement these interventions based on the severity of the patients’ conditions, incorporating a cost-benefit analysis. Importantly, various factors—including cost, duration, and convenience—should be considered alongside efficacy when choosing care interventions. Conversely, less expensive options such as acupuncture and music therapy may also offer beneficial effects. Future research should focus on the development and evaluation of these care interventions. Mental health conditions such as anxiety and depression are more common in infertile women undergoing ART. Nursing care interventions can advance the patients’ outcomes. The success of these care interventions can vary. Identifying the interventions with the greatest impact can be valuable in advancing the psychological well-being of infertile women undergoing ART. Based on this, the present systematic review and meta-analysis aimed to evaluate the efficacy of various interventions in enhancing the psychological health of infertile women undergoing ART. Most research suffers from inadequate methodology and poor reporting. The most common weaknesses include the lack of a clear case description, insufficient sampling methodology, failure to consider confounding variables, lack of description of assessment procedures, and incomplete reporting of sample details. Another limitation is the heterogeneity of studies concerning the type and timing of interventions related to infertility treatments. Some studies included in the current review exhibited a high risk of bias due to selective and incomplete reporting, which occurs when certain measured or analyzed results are omitted or only partially reported based on the nature of the findings (e.g., statistical significance or effect size). Most studies have not accounted for confounding factors, which is a significant oversight. It is crucial to eliminate the influence of these factors in future research. Additionally, it is suggested that study items be clearly defined, assessment protocols specified, and sample details thoroughly reported. Furthermore, studies conducted on infertile couples that did not report depression and anxiety outcomes separately were excluded from the current review. The current review provides several implications for healthcare providers working with infertile women undergoing ART. Studies have demonstrated that nursing interventions, such as cognitive behavioral therapy (CBT) and body-mind-spirit (BMS) group interventions, can help reduce anxiety and depression, particularly prior to ART. Due to the two-week waiting period for pregnancy test results, the effectiveness of these interventions on anxiety and depression during this time remains unproven. However, positive self-appraisal coping interventions may effectively enhance positive affect and dispositional optimism, potentially making the waiting period more manageable for infertile women undergoing ART. Considering that in some countries, such as Iran, couples are not routinely screened for depression and anxiety, it is suggested that all infertility clinics implement psychological screening for these conditions. For patients experiencing high levels of depression and anxiety, CBT and BMS interventions are advised. It is recommended that future studies investigate differences in the number of sessions, session duration, gender differences, and the duration of infertility. Women and men should be analyzed separately, as there are significant differences in how they process fertility issues. Additionally, further research should be conducted to examine the effects of nursing interventions on stress reduction.

Infertility is defined as the incapacity to conceive after one year of regular, unprotected sexual intercourse. According to the World Health Organization (WHO), 8 to 10% of people experience difficulty conceiving. Infertility is a significant reproductive health issue, and its prevalence is increasing worldwide. Individuals facing infertility often endure repeated and prolonged treatment cycles, which can be a continuous source of distress [ 1 – 3 ]. Several factors contribute to its occurrence [ 4 – 7 ]. It is widely recognized that infertility impacts women physically, emotionally, and socially. When women begin seeking infertility treatments, they often experience additional distress due to intrusive medical questions and procedures [ 8 – 10 ]. Roughly 3% of these women will be recommended assisted reproductive technologies (ART), and with 99% of these recommendations being for in vitro fertilization (IVF). Infertile women typically turn to ART only after exhausting other treatment options. Although ART offers new hope, it also imposes a significant burden due to its relatively low success rates, which range from 18.4% to 20.3% for frozen embryo transfer (FET) and fresh aspiration, respectively [ 11 ]. Concerning the impacts of infertility at the individual level, women undergoing ART treatment have been reported to experience significant levels of anxiety and depression before treatment, on the day of egg retrieval, during ETs, and throughout the two-week waiting period for treatment results [ 12 , 13 ]. Among ART procedures, IVF and ovarian stimulation are particularly anxiety-provoking for patients [ 14 – 18 ]. Investigations have also examined the impact of the psychological state of infertile couples on the outcomes of their ART treatments. Two systematic reviews and meta-analyses assessing the anticipated effects of psychological stress on IVF treatment outcomes yielded inconclusive results. The first review included 31 studies with a total of 4,902 participants and found a small but noticeable correlation between pretreatment stress and anxiety and decreased pregnancy rates. In contrast, another review of 14 studies involving 3,583 infertile women found no correlation between pretreatment anxiety and depression and IVF pregnancy outcomes. Nevertheless, the association between anxiety or depression and IVF treatment outcomes requires further investigation [ 19 , 20 ]. Several psychological interventions have been implemented for infertile women and couples undergoing IVF treatment to promote their mental health and improve pregnancy rates. Four systematic reviews have investigated the impacts of different psychosocial interventions on infertile individuals receiving fertility treatments. These reviews encompassed studies involving patients at various stages of infertility treatment, ranging from first-line therapies to assisted reproductive technologies (ART). Additionally, the reviews included non-randomized studies (NRs), and three of them incorporated investigations without comparison groups [ 21 – 24 ]. The findings from these reviews were inconsistent. Two reviews reported conflicting outcomes regarding the impact of interventions on emotional distress, although both identified some, albeit non-significant, effects on interpersonal outcomes. Moreover, these reviews primarily focused on the effects of psychological interventions on the mental health of infertile patients [ 10 , 21 – 25 ]. Several systematic reviews have been conducted [ 26 – 28 ]; however, to date, no comprehensive review has examined the efficacy of all types of interventions across all study designs on anxiety and depression in infertile women undergoing ART. The aim of the current systematic review and meta-analysis is to explore the effects of nursing interventions on anxiety and depression in infertile females undergoing ART. The findings of this study will provide valuable information regarding the efficacy and effect size of these nursing interventions, as well as their implications for medical practice and future research for healthcare providers and scholars. Furthermore, the findings will inform the development of nursing interventions designed to improve the experiences of infertile females undergoing ART.