Effectiveness of Gestalt therapy on depression, psychological capital, and gratitude among infertile men

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The present study investigated the efficacy of Gestalt group therapy in mitigating these challenges. Methods This single-center, parallel-group randomized controlled trial was conducted in Mashhad, Iran, in 2024. Sixty infertile men were recruited and randomly allocated (1:1) to either Gestalt group therapy (10 weekly sessions of 2 hours each) or a wait-list control group receiving treatment as usual. Outcomes were assessed at baseline and immediately post-intervention using validated Persian versions of the Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), Gratitude Questionnaire-6 (GQ-6), and Compound Psychological Capital Scale-12 (CPC-12). Between-group differences were examined using Welch's t-tests. Results Groups were well-balanced at baseline (all p > 0.05). Following the intervention, participants in the Gestalt group demonstrated significantly greater reductions in depression ( p < 0.001, Cohen's d = -0.99), state anxiety ( p < 0.001, d = -1.41), and trait anxiety ( p < 0.001, d = -1.65), as well as larger increases in gratitude ( p < 0.001, d = 1.01) and psychological capital ( p < 0.001, d = 1.90). Conclusions Gestalt group therapy appears to be an effective and practical intervention for alleviating psychological distress and strengthening positive resources among infertile men. Future studies should include longer-term follow-up and active comparison conditions. Trial registration : This trial was registered at the Iranian Registry of Clinical Trials (IRCT20251026067770N4) on December 20, 2025. The trial is available at: Available at: https://irct.behdasht.gov.ir/trial/88123 ; https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20251026067770N4 Infertility Gestalt therapy Depression State anxiety Trait anxiety Gratitude Psychological capital Randomized controlled trial Figures Figure 1 Introduction Infertility affects approximately 15% of couples worldwide, with male factors contributing to about 50% of cases [ 35 ]. Beyond its medical implications, infertility imposes a substantial psychological burden on men, including elevated depressive symptoms, anxiety, reduced self-efficacy, and eroded positive psychological resources [ 8 , 10 , 25 , 26 , 27 , 43 , 48 , 49 ]. In sociocultural contexts where masculinity is tied to fertility, men may experience intensified shame, social withdrawal, and barriers to seeking help [ 14 , 21 ]. These challenges underscore the need for interventions that not only alleviate symptoms but also bolster adaptive resources like gratitude and psychological capital [ 24 , 28 , 30 , 46 ]. In Iran, where cultural stigma around male infertility can amplify these effects, studies have documented higher prevalence of depression (pooled 27.6%) and anxiety among infertile men compared to fertile counterparts, often linked to diminished quality of life and relational strain [ 26 , 27 , 25 ]. For instance, recent research highlights severe depression, anxiety, and stress in up to 65% of infertile Iranian men, emphasizing the urgency for targeted psychological support [ 25 , 27 ]. Despite growing recognition of the psychological impact of infertility on men, the majority of intervention studies have primarily focused on women or couples, with relatively few trials exclusively targeting male-factor infertility [ 8 , 10 , 25 , 26 , 27 ]. Moreover, existing psychological interventions for infertility-related distress often emphasize cognitive-behavioral approaches, which have shown efficacy in reducing anxiety and depression [ 5 , 10 , 11 , 15 , 36 ]. However, humanistic and experiential therapies remain underexplored in this population. Gestalt therapy, an experiential approach rooted in humanistic psychology, emphasizes present-moment awareness, emotional processing, and integration of disowned experiences through techniques such as role-play, empty-chair dialogue, and awareness experiments [ 40 , 44 , 45 ]. It promotes agency, authentic contact, and personal responsibility, making it potentially suitable for addressing infertility-related distress, including grief, shame, and identity threats [ 2 , 16 , 18 , 29 , 32 , 34 , 38 , 41 ]. Compared to cognitive-behavioral therapy (CBT), which excels in restructuring maladaptive thoughts [ 5 , 10 , 11 , 15 , 36 ], Gestalt offers distinct advantages in fostering holistic emotional integration and experiential exploration of suppressed feelings—elements that may be particularly relevant for chronic stressors like infertility, where evidence for its application remains limited [ 5 , 9 , 12 , 15 , 36 , 42 ]. Preliminary evidence from smaller studies and related contexts suggests that Gestalt therapy can effectively reduce depression and anxiety while enhancing self-awareness and emotional regulation [ 2 , 16 , 18 , 29 , 32 , 34 , 38 , 41 ]. Its group format may further provide peer validation and reduce isolation, which are common in male infertility experiences [ 9 , 18 ]. However, no randomized controlled trials have yet evaluated Gestalt group therapy specifically in infertile men. The current randomized controlled trial sought to evaluate the effectiveness of a structured Gestalt group therapy program compared to a wait-list control in men with long-term male-factor infertility and moderate depressive symptoms. We hypothesized that participants receiving the intervention would show greater post-treatment improvements: (1) reduced depression; (2) reduced state and trait anxiety; (3) increased gratitude; and (4) increased psychological capital. Methods Design and Registration This was a parallel group randomized controlled trial with assessments conducted at baseline and immediately after the intervention. The study followed CONSORT reporting guidelines and received approval from the Research Ethics Committee of the Faculty of Medicine, Islamic Azad University, North Tehran Branch (IR.IAU.TNB.REC.1403.248). The trial was retrospectively registered at the Iranian Registry of Clinical Trials (IRCT; registration number: IRCT20251026067770N4; registration date: December 20, 2025; URL: https://irct.behdasht.gov.ir/trial/88123 ) following completion of data collection due to an administrative oversight. The study protocol remained unchanged from the original ethics-approved design, and all procedures adhered to ICMJE guidelines for trial conduct and reporting. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki. Participants and Recruitment Men with diagnosed male-factor infertility were recruited through convenience sampling at a urology clinic in Mashhad, Iran, from January to June 2024. Eligible participants met the following criteria: documented infertility duration of at least 5 years; age between 25 and 70 years; moderate depressive symptoms (BDI-II score ≥ 14), confirmed by psychiatric screening to indicate clinically significant but not severe depression (excluding major depressive disorder requiring immediate intervention); no psychotherapy in the preceding 6 months; and stable psychotropic medication status. Individuals with severe depression or acute suicidality were excluded and referred for immediate care, as were those with psychosis, bipolar disorder, or spouse pregnancy during the study period. Consent withdrawal or attendance at fewer than seven sessions also led to exclusion. There was no patient or public involvement in the design, conduct, or reporting of this trial. Sample size was determined a priori using G*Power software [ 22 ], assuming a medium-to-large effect size (Cohen's d = 0.8), 80% power, and α = 0.05, resulting in 30 participants per arm after allowing for potential attrition Randomization and Blinding Random allocation (1:1) was performed using a computer-generated sequence via Randomization.com, managed by an independent researcher. Allocation concealment was achieved with sealed opaque envelopes. Outcome assessors were blinded to group assignment, whereas participants and the therapist were necessarily unblinded due to the nature of the intervention. Intervention The Gestalt group therapy program consisted of 10 weekly 2-hour sessions delivered in small groups (6–8 participants) by a certified Gestalt therapist with over 10 years of clinical experience. Sessions emphasized present-centered awareness, emotional exploration, personal responsibility, and infertility-related themes such as grief, shame, and identity shifts. A structured treatment manual guided delivery, incorporating core Gestalt techniques including role-play, empty-chair work, two-chair dialogue, exaggeration exercises, and body awareness practices. A detailed session-by-session description, including content and homework assignments, is provided in Table 1 . Treatment fidelity was monitored through audio recordings, with 20% of sessions independently reviewed for adherence. Table 1 Detailed Description of Gestalt Group Therapy Sessions, Including Content and Homework Assignments Session Descriptions Assignment and Outcome 1 Accepting responsibility for one’s choices : The therapist asks participants to repeatedly say, “I accept responsibility for my actions.” The goal of this exercise is to help participants recognize that they alone are responsible for their feelings, behaviors, and thoughts. For instance, a participant may say, “I am anxious, and I accept responsibility for this anxiety.” Start the day with a positive mindset : Participants are encouraged to begin each day with a positive attitude and to list their positive mindsets. 2 Thoughts and feelings : Participants are guided to pay attention to all ongoing internal experiences, including thoughts, feelings, behaviors, and memories. These experiences are considered behavioral outputs so that both therapist and participant can translate experiential events into actionable words and develop strategies for change. Focus-on-feelings exercises : Participants practice exercises aimed at enhancing awareness of their emotions and report on their experiences in the following session. 3 Focus : Participants are guided to attend to anxiety-inducing physical sensations such as palpitations, sweating, and worry. The goal of this exercise is to help participants observe themselves through these signals and discern the message each symptom is conveying. Participants were instructed to practice body-focused attention exercises in their daily lives and to present a report on their experiences in the following session. 4 Staying in the Present : This exercise helps participants bring avoidant behaviors into conscious awareness, thereby fostering balance. When individuals become aware of unwanted impulses, arousal, and emotions, they can interact with their environment more safely and adaptively. Participants are instructed to practice the “I see, I feel, I think” exercise until the next session. 5 Imaginary Journeys : Participants are invited to experiment with experiences they would normally avoid, with the understanding that they can stop at any time. The aim is to identify which aspects of the experience are congruent or incongruent with the participant’s awareness. Participants are encouraged to explore one or more imagined experiences they typically lack the courage to attempt in daily life and reflect on them before the next session. 6 and 7 Exaggeration : In this technique, participants are asked to repeat anxiety-provoking behaviors or feelings multiple times. For example, a participant may state, “My heart is racing,” or “I feel worried,” or “My hands are trembling.” The therapist then instructs the participant to exaggerate these sensations verbally. The goal is to enhance self-awareness and saturate the need for avoidance. Participants are encouraged to compile a list of anxiety-provoking behaviors encountered in daily life and bring it to the next session. 8 Dream Work : Different elements of dreams reflect various aspects of the participant’s personality. Participants are asked to recount their dreams in the present tense, as if they are happening now. The goal is to identify and explore the participant’s “lost” or unrecognized self-aspects. Participants are encouraged to examine both completed and unfinished dreams outside of sessions and compare them to their core beliefs. 9 Symbolic Play : Participants are invited to enact parts of their dreams and facilitate dialogue between these elements. This process helps clarify and make sense of internal conflicts. This exercise is similar to that of session eight. 10 Listening to Metaphors : Therapists listen carefully to the metaphors that participants use, which provide important clues to inner conflicts. Suppressed internal dialogues are often embedded within these metaphors. Examples include statements such as “I feel my soul is shattered” or “Sometimes I feel like a broken glass.” Participants are encouraged to note recurring metaphors in daily life and compare them with past experiences. The control group continued with routine urological care and was offered the intervention after study completion. The use of a wait-list control was ethically justified given that participants had ongoing access to standard medical care, were screened to exclude severe cases (with referrals as needed), and experienced only a brief delay in receiving the intervention, which posed minimal risk for this population with moderate symptoms. This design aligns with common practices in exploratory psychotherapy trials for non-severe distress. Harms Potential harms, such as temporary emotional distress from discussing infertility-related topics, were monitored non-systematically through therapist observation and participant self-report during sessions. Participants were informed that they could withdraw at any time, and referrals to additional care were available if needed. No interim analyses or stopping guidelines were implemented due to the short duration and low-risk nature of the trial. Measures All instruments were Persian-validated versions with established psychometric properties in Iranian populations. Internal consistency in the current sample was strong (Cronbach's α > 0.80 for all scales). Depression: Beck Depression Inventory-II (BDI-II; scores 0–63, higher indicating greater depression). The Persian version has demonstrated good reliability and validity in Iranian samples [Ghassemzadeh et al., 2005; 3,19]. Anxiety: State-Trait Anxiety Inventory (STAI; state and trait subscales, 20–80 each, higher indicating greater anxiety). The Persian version, normalized by Mahram (1993), has shown acceptable psychometric properties [ 11 ]. Gratitude: Gratitude Questionnaire-6 (GQ-6; scores 6–42, higher indicating greater gratitude). The Persian translation has been used in Iranian research with evidence of convergent validity and reliability [ 1 , 6 , 31 ]. Psychological Capital: Compound Psychological Capital Scale-12 (CPC-12; scores 12–60, higher indicating greater psychological capital, encompassing hope, efficacy, resilience, and optimism) [ 13 , 17 , 46 ]. Statistical Analysis Analyses were conducted in SPSS version 26 using an intention-to-treat approach, with last observation carried forward for any missing data (minimal in this study). Baseline differences were tested with Welch's t-tests for continuous variables and chi-square tests for categorical variables. Post-intervention between-group effects were evaluated using Welch's t-tests, accompanied by Cohen's d effect sizes. Statistical significance was set at two-tailed p < 0.05; no adjustments for multiple comparisons were applied given the focused hypotheses. Results Participant flow through the study is illustrated in the CONSORT flow diagram (Fig. 1 ). All 60 randomized participants completed the trial with no dropouts. No harms or unintended adverse events were reported in either group. Demographic characteristics and baseline outcome scores were comparable across groups (Tables 2 and 4 ). At post-intervention (Table 3 ), the Gestalt group showed clinically meaningful within-group improvements: depression decreased from 27.23 ± 6.53 to 21.63 ± 5.59, state anxiety from 44.10 ± 5.67 to 35.17 ± 7.77, trait anxiety from 44.03 ± 6.34 to 32.67 ± 8.94, gratitude increased from 17.23 ± 5.66 to 22.40 ± 3.46, and psychological capital from 31.53 ± 6.05 to 41.63 ± 5.40 (all p 0.05). Between-group comparisons revealed large effect sizes favoring the Gestalt group on all outcomes (Table 5 ; depression d = − 0.99, state anxiety d = − 1.41, trait anxiety d = − 1.65, gratitude d = 1.01, psychological capital d = 1.90; all p < 0.001). Table 2 Baseline Participant Characteristics Variable Gestalt (n = 30) Control (n = 30) Test Statistic p -value Age (years) 48.17 ± 12.31 52.03 ± 10.92 Welch t (57.85) = -1.28 0.204 Infertility duration (years) 8.40 ± 4.50 7.50 ± 3.20 Welch t (56.59) = 0.89 0.376 Education (n) χ² (5) = 0.86 0.973 Elementary school 3 4 High school 3 4 Associate degree 2 2 Bachelor degree 13 12 Master degree 7 5 Doctorate 2 3 Note : Continuous variables: mean ± SD, compared using Welch's t-test due to potential unequal variances. Categorical: chi-square test. Table 3 Psychological Outcomes at Baseline and Post-Intervention (Mean ± SD) Outcome Time Gestalt (n = 30) Control (n = 30) Depression (BDI-II; 0–63) Baseline 27.23 ± 6.53 27.23 ± 6.21 Post 21.63 ± 5.59 27.50 ± 6.20 State Anxiety (STAI; 20–80) Baseline 44.10 ± 5.67 45.40 ± 7.17 Post 35.17 ± 7.77 48.80 ± 11.28 Trait Anxiety (STAI; 20–80) Baseline 44.03 ± 6.34 46.07 ± 7.05 Post 32.67 ± 8.94 46.00 ± 7.09 Gratitude (GQ-6; 6–42) Baseline 17.23 ± 5.66 17.27 ± 7.05 Post 22.40 ± 3.46 16.93 ± 6.85 Psychological Capital (CPC-12; 12–60) Baseline 31.53 ± 6.05 31.93 ± 4.90 Post 41.63 ± 5.40 32.17 ± 4.51 Note : Higher scores indicate greater levels of the construct. Values are unadjusted descriptive statistics. Table 4 Baseline Comparability for Psychological Outcomes (Welch's t-test) Outcome Test Statistic p -value Cohen's d Depression Welch t (57.85) = 0.00 1.000 0.00 State Anxiety Welch t (55.07) = -0.78 0.439 -0.20 Trait Anxiety Welch t (57.36) = -1.18 0.243 -0.30 Gratitude Welch t (55.41) = -0.02 0.981 -0.01 Psychological Capital Welch t (55.60) = -0.28 0.779 -0.07 Note : Welch's t-test used due to potential unequal variances; Cohen's d for descriptive purposes. Table 5 Post-Intervention Between-Group Comparisons (Welch's t-test) Outcome Test Statistic p -value Cohen's d Depression Welch t (57.39) = -3.85 < 0.001 -0.99 State Anxiety Welch t (51.46) = -5.45 < 0.001 -1.41 Trait Anxiety Welch t (55.14) = -6.40 < 0.001 -1.65 Gratitude Welch t (42.89) = 3.90 < 0.001 1.01 Psychological Capital Welch t (56.22) = 7.36 < 0.001 1.90 Note : Welch's t-test used due to potential unequal variances. Negative d for lower scores in Gestalt group (depression/anxiety); positive for higher (gratitude/psychological capital). Discussion Principal Findings The results of this trial provide clear evidence that a 10-session Gestalt group therapy program led to substantial reductions in depression and both state and trait anxiety, while simultaneously producing robust increases in gratitude and psychological capital among men experiencing long-term infertility. These findings align with prior evidence on Gestalt therapy's efficacy in distress reduction [ 2 , 16 , 18 , 29 , 32 , 34 , 38 , 41 ] and extend it to infertility contexts [ 5 , 9 , 12 , 15 , 36 , 42 ]. Interpretation These benefits likely arise from core Gestalt principles and techniques, which facilitate experiential processing of suppressed emotions (such as grief and shame), expansion of awareness to encompass present positives (fostering gratitude), and emphasis on personal agency and small actionable steps (enhancing psychological capital). The group modality itself may have contributed by offering validation, reducing isolation, and providing a safe space to practice new interpersonal patterns [ 9 , 18 ]. Specifically, reductions in depression and anxiety may stem from techniques like the empty-chair dialogue and two-chair work, which encourage direct confrontation and integration of disowned emotions—common in infertility-related grief, shame, and rumination [ 37 , 43 , 49 ]. By externalizing internal conflicts (e.g., self-blame or societal pressures on masculinity), these methods interrupt avoidance cycles, potentially lowering state anxiety through immediate arousal regulation and trait anxiety via sustained emotional tolerance [ 40 , 44 ]. Here-and-now awareness exercises further ground participants in the present, mitigating catastrophic thinking about future infertility outcomes and aligning with observed decreases in both anxiety subscales. Enhancements in gratitude may reflect the role of exaggeration exercises and role-playing, which broaden perceptual fields from deficit-focused narratives (e.g., loss of fertility) to recognizing overlooked positives, such as supportive relationships or personal strengths [ 4 , 7 , 24 , 28 , 30 ]. In group settings, witnessing peers' stories via these techniques fosters empathy and collective appreciation, shifting attention from chronic inadequacy to moments of meaning, consistent with gratitude's mediating role in stress and well-being [ 3 ]. Similarly, improvements in psychological capital—encompassing hope, efficacy, resilience, and optimism—could derive from responsibility-taking practices and reversal techniques, where participants experiment with empowered behaviors (e.g., asserting agency despite uncontrollable infertility factors) [ 13 , 17 , 46 ]. These methods restore mastery through small, achievable actions, buffering setbacks and reframing infertility as part of a broader life context, thereby enhancing resilience and optimistic outlooks [ 3 , 8 ]. Overall, Gestalt's dual focus on symptom alleviation and resource building underscores its holistic impact on these variables. Strengths and Limitations Notable strengths include successful randomization, blinded outcome assessment, a manualized and fidelity-checked intervention, zero attrition, and consistent effects across a range of distress and resource outcomes. Limitations include recruitment from a single clinic via convenience sampling, which restricts generalizability; absence of follow-up assessments to evaluate maintenance of gains; reliance on self-report measures; use of a wait-list rather than active control; a sample size that, while adequate for primary hypotheses, precludes more sophisticated modeling approaches (e.g., ANCOVA or mixed-effects models) recommended for larger confirmatory studies; and the retrospective registration of the trial, while compliant with registry policies and transparently reported, may be viewed as a limitation. Clinical Implications Given that psychological support for men in infertility care is often underdeveloped [ 8 , 10 , 14 , 21 , 25 , 26 , 27 , 33 , 47 ], this brief, group-based Gestalt program offers a feasible adjunct that could be integrated into routine clinical pathways. It addresses both symptom relief and resource building while capitalizing on the efficiency and peer support inherent in group delivery. Implementation would require appropriate screening and clear referral pathways for severe cases. Future Research Replication in multi-site trials incorporating active comparators (e.g., cognitive-behavioral therapy), extended follow-up periods, mediation analyses of putative mechanisms (e.g., changes in emotional awareness or shame), and more diverse participant samples would substantially strengthen the evidence base. Conclusion Gestalt group therapy emerges as a promising, resource-oriented intervention capable of meaningfully reducing psychological distress and bolstering adaptive strengths in men facing infertility. Further high-quality research is encouraged to consolidate and extend these initial findings. Declarations Declarations Ethics Approval and Consent to Participate: Approved by the Research Ethics Committee of the Faculty of Medicine, Islamic Azad University, North Tehran Branch (IR.IAU.TNB.REC.1403.248). Written informed consent obtained from all participants. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki. Trial Protocol : The full trial protocol is provided as a supplementary document submitted for peer review and can be accessed upon request from the corresponding author. Consent for Publication: Not applicable. Availability of Data and Materials: Available from the corresponding author upon reasonable request. Competing Interests: None declared. Funding: None. Authors’ Contributions: Study conception and design: KB, NA, MT; Data collection: KB; Data analysis and interpretation: KB, NA, MT; Drafting of manuscript: KB, NA, MT; Critical revision of manuscript: KB, NA, MT. Acknowledgements: We thank participants for their contributions. References Aghababaei N, Akbarilakeh M, Ahmady S, Arbabisarjou A, Ghaempanah Z. Translation and validation of Iranian version of the Gratitude at Work Scale (GAWS). J Relig Health. 2024;63(5):3778–92. Ali N, Cerkez Y. The effects of group counseling with Gestalt therapy in reducing depression, anxiety and stress among traumatized people. Revista de Cercetare si Interventie Sociala. 2020;71:1–15. Almeida S, Camacho M, Barahona-Corrêa JB, Oliveira J, Lemos R, da Silva DR, Oliveira-Maia AJ. 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WHO fact sheet on infertility gives hope to millions of infertile couples worldwide. Facts Views Vis ObGyn. 2020;12(4):249–51. Patel A, Sharma PSVN, Kumar P. Application of mindfulness-based psychological interventions in infertility. J Hum Reproductive Sci. 2020;13(1):3–21. Pozza A, Dèttore D, Coccia ME. Depression and anxiety in pathways of medically assisted reproduction: The role of infertility stress dimensions. Clin Pract Epidemiol Mental Health. 2019;15:101–9. https://doi.org/10.2174/1745017901915010101 . Raffagnino R. Gestalt therapy effectiveness: A systematic review of empirical evidence. Open J Social Sci. 2019;7(6):66–83. Ratnasari R. (2023). Perencanaan konseling pastoral dengan pendekatan Gestalt terhadap wanita yang mengalami gangguan infertilitas di Gereja Kibaid Jemaat Kulaya (Doctoral dissertation, Institut Agama Kristen Negeri Toraja). Roubal J, Francesetti G. Field theory in contemporary Gestalt therapy part two: Paradoxical theory of change reconsidered. Gestalt Rev. 2022;26(1):1–33. Saadati H, Lashani L. Effectiveness of Gestalt therapy on self-efficacy of divorced women. Procedia – Social Behav Sci. 2013;84:1171–4. Shahrahmani N, Mollazadeh S, Taghipour A, Mahmoudinia M, Roudsari RL. (2023). The impact of emotion-focused counseling on marital issues of infertile couples: A systematic review. J Midwifery Reproductive Health, 11(4). Simionescu G, Doroftei B, Maftei R, Obreja BE, Anton E, Grab D, Ilea C, Anton C. The complex relationship between infertility and psychological distress (Review). Experimental Therapeutic Med. 2021;21:306. https://doi.org/10.3892/etm.2021.9737 . Skottun G, Krüger Å. Gestalt therapy practice: Theory and experiential learning. Routledge; 2021. Turemuratova A, Amonov U, Õrozboyev A. General information about Gestalt therapy and its basic principles. Mod Sci Res. 2025;4(4):297–302. Wang J, Bu L, Li Y, Song J, Li N. The mediating effect of academic engagement between psychological capital and academic burnout among nursing students during the COVID-19 pandemic: A cross-sectional study. Nurse Educ Today. 2021;102:104938. Wang Y, Fu Y, Ghazi P, Gao Q, Tian T, Kong F, Zhan S, Liu C, Bloom DE, Qiao J. Prevalence of intimate partner violence against infertile women in low-income and middle-income countries: A systematic review and meta-analysis. Lancet Global Health. 2022;10(6):e820–30. https://doi.org/10.1016/S2214-109X(22)00098-5 . Wdowiak A, Bień A, Iwanowicz-Palus G, Makara-Studzińska M, Bojar I. Impact of emotional disorders on semen quality in men treated for infertility. Neuroendocrinol Lett. 2017;38(1):50–8. Zurlo MC, Della Volta C, M. F., Vallone F. Infertility-related stress and psychological health outcomes in infertile couples undergoing medical treatments: Testing a multi-dimensional model. J Clin Psychol Med Settings. 2020;27(4):662–76. https://doi.org/10.1007/s10880-019-09653-z . Ghassemzadeh H, Mojtabai R, Karamghadiri N, Ebrahimkhani N. Psychometric properties of a Persian-language version of the Beck Depression Inventory–Second edition: BDI-II-PERSIAN. Depress Anxiety. 2005;21(4):185–92. https://doi.org/10.1002/da.20070 . Mahram B. (1993). Standardization of Spielberger State-Trait Anxiety Inventory in Mashhad, Iran [Master's thesis]. Allameh Tabataba'i University. McCullough ME, Emmons RA, Tsang JA. The grateful disposition: A conceptual and empirical topography. J Personal Soc Psychol. 2002;82(1):112–27. https://doi.org/10.1037/0022-3514.82.1.112 . Additional Declarations No competing interests reported. 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Beyond its medical implications, infertility imposes a substantial psychological burden on men, including elevated depressive symptoms, anxiety, reduced self-efficacy, and eroded positive psychological resources [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In sociocultural contexts where masculinity is tied to fertility, men may experience intensified shame, social withdrawal, and barriers to seeking help [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These challenges underscore the need for interventions that not only alleviate symptoms but also bolster adaptive resources like gratitude and psychological capital [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Iran, where cultural stigma around male infertility can amplify these effects, studies have documented higher prevalence of depression (pooled 27.6%) and anxiety among infertile men compared to fertile counterparts, often linked to diminished quality of life and relational strain [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. For instance, recent research highlights severe depression, anxiety, and stress in up to 65% of infertile Iranian men, emphasizing the urgency for targeted psychological support [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Despite growing recognition of the psychological impact of infertility on men, the majority of intervention studies have primarily focused on women or couples, with relatively few trials exclusively targeting male-factor infertility [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Moreover, existing psychological interventions for infertility-related distress often emphasize cognitive-behavioral approaches, which have shown efficacy in reducing anxiety and depression [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, humanistic and experiential therapies remain underexplored in this population.\u003c/p\u003e \u003cp\u003eGestalt therapy, an experiential approach rooted in humanistic psychology, emphasizes present-moment awareness, emotional processing, and integration of disowned experiences through techniques such as role-play, empty-chair dialogue, and awareness experiments [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. It promotes agency, authentic contact, and personal responsibility, making it potentially suitable for addressing infertility-related distress, including grief, shame, and identity threats [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Compared to cognitive-behavioral therapy (CBT), which excels in restructuring maladaptive thoughts [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], Gestalt offers distinct advantages in fostering holistic emotional integration and experiential exploration of suppressed feelings\u0026mdash;elements that may be particularly relevant for chronic stressors like infertility, where evidence for its application remains limited [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Preliminary evidence from smaller studies and related contexts suggests that Gestalt therapy can effectively reduce depression and anxiety while enhancing self-awareness and emotional regulation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Its group format may further provide peer validation and reduce isolation, which are common in male infertility experiences [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, no randomized controlled trials have yet evaluated Gestalt group therapy specifically in infertile men.\u003c/p\u003e \u003cp\u003eThe current randomized controlled trial sought to evaluate the effectiveness of a structured Gestalt group therapy program compared to a wait-list control in men with long-term male-factor infertility and moderate depressive symptoms. We hypothesized that participants receiving the intervention would show greater post-treatment improvements: (1) reduced depression; (2) reduced state and trait anxiety; (3) increased gratitude; and (4) increased psychological capital.\u003c/p\u003e"},{"header":"Methods Design and Registration","content":"\u003cp\u003eThis was a parallel group randomized controlled trial with assessments conducted at baseline and immediately after the intervention. The study followed CONSORT reporting guidelines and received approval from the Research Ethics Committee of the Faculty of Medicine, Islamic Azad University, North Tehran Branch (IR.IAU.TNB.REC.1403.248).\u003c/p\u003e \u003cp\u003eThe trial was retrospectively registered at the Iranian Registry of Clinical Trials (IRCT; registration number: IRCT20251026067770N4; registration date: December 20, 2025; URL: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://irct.behdasht.gov.ir/trial/88123\u003c/span\u003e\u003cspan address=\"https://irct.behdasht.gov.ir/trial/88123\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) following completion of data collection due to an administrative oversight. The study protocol remained unchanged from the original ethics-approved design, and all procedures adhered to ICMJE guidelines for trial conduct and reporting. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003e \u003cb\u003eParticipants and Recruitment\u003c/b\u003e Men with diagnosed male-factor infertility were recruited through convenience sampling at a urology clinic in Mashhad, Iran, from January to June 2024. Eligible participants met the following criteria: documented infertility duration of at least 5 years; age between 25 and 70 years; moderate depressive symptoms (BDI-II score\u0026thinsp;\u0026ge;\u0026thinsp;14), confirmed by psychiatric screening to indicate clinically significant but not severe depression (excluding major depressive disorder requiring immediate intervention); no psychotherapy in the preceding 6 months; and stable psychotropic medication status. Individuals with severe depression or acute suicidality were excluded and referred for immediate care, as were those with psychosis, bipolar disorder, or spouse pregnancy during the study period. Consent withdrawal or attendance at fewer than seven sessions also led to exclusion.\u003c/p\u003e \u003cp\u003eThere was no patient or public involvement in the design, conduct, or reporting of this trial.\u003c/p\u003e \u003cp\u003eSample size was determined a priori using G*Power software [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], assuming a medium-to-large effect size (Cohen's d\u0026thinsp;=\u0026thinsp;0.8), 80% power, and α\u0026thinsp;=\u0026thinsp;0.05, resulting in 30 participants per arm after allowing for potential attrition\u003c/p\u003e \u003cp\u003e \u003cb\u003eRandomization and Blinding\u003c/b\u003e Random allocation (1:1) was performed using a computer-generated sequence via Randomization.com, managed by an independent researcher. Allocation concealment was achieved with sealed opaque envelopes. Outcome assessors were blinded to group assignment, whereas participants and the therapist were necessarily unblinded due to the nature of the intervention.\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e The Gestalt group therapy program consisted of 10 weekly 2-hour sessions delivered in small groups (6\u0026ndash;8 participants) by a certified Gestalt therapist with over 10 years of clinical experience. Sessions emphasized present-centered awareness, emotional exploration, personal responsibility, and infertility-related themes such as grief, shame, and identity shifts. A structured treatment manual guided delivery, incorporating core Gestalt techniques including role-play, empty-chair work, two-chair dialogue, exaggeration exercises, and body awareness practices. A detailed session-by-session description, including content and homework assignments, is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Treatment fidelity was monitored through audio recordings, with 20% of sessions independently reviewed for adherence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetailed Description of Gestalt Group Therapy Sessions, Including Content and Homework Assignments\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssignment and Outcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAccepting responsibility for one\u0026rsquo;s choices\u003c/b\u003e: The therapist asks participants to repeatedly say, \u003cem\u003e\u0026ldquo;I accept responsibility for my actions.\u0026rdquo;\u003c/em\u003e The goal of this exercise is to help participants recognize that they alone are responsible for their feelings, behaviors, and thoughts. For instance, a participant may say, \u003cem\u003e\u0026ldquo;I am anxious, and I accept responsibility for this anxiety.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStart the day with a positive mindset\u003c/b\u003e: Participants are encouraged to begin each day with a positive attitude and to list their positive mindsets.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eThoughts and feelings\u003c/b\u003e: Participants are guided to pay attention to all ongoing internal experiences, including thoughts, feelings, behaviors, and memories. These experiences are considered behavioral outputs so that both therapist and participant can translate experiential events into actionable words and develop strategies for change.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFocus-on-feelings exercises\u003c/b\u003e: Participants practice exercises aimed at enhancing awareness of their emotions and report on their experiences in the following session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFocus\u003c/b\u003e: Participants are guided to attend to anxiety-inducing physical sensations such as palpitations, sweating, and worry. The goal of this exercise is to help participants observe themselves through these signals and discern the message each symptom is conveying.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants were instructed to practice body-focused attention exercises in their daily lives and to present a report on their experiences in the following session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStaying in the Present\u003c/b\u003e: This exercise helps participants bring avoidant behaviors into conscious awareness, thereby fostering balance. When individuals become aware of unwanted impulses, arousal, and emotions, they can interact with their environment more safely and adaptively.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants are instructed to practice the \u003cem\u003e\u0026ldquo;I see, I feel, I think\u0026rdquo;\u003c/em\u003e exercise until the next session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eImaginary Journeys\u003c/b\u003e: Participants are invited to experiment with experiences they would normally avoid, with the understanding that they can stop at any time. The aim is to identify which aspects of the experience are congruent or incongruent with the participant\u0026rsquo;s awareness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants are encouraged to explore one or more imagined experiences they typically lack the courage to attempt in daily life and reflect on them before the next session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 and 7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eExaggeration\u003c/b\u003e: In this technique, participants are asked to repeat anxiety-provoking behaviors or feelings multiple times. For example, a participant may state, \u003cem\u003e\u0026ldquo;My heart is racing,\u0026rdquo;\u003c/em\u003e or \u003cem\u003e\u0026ldquo;I feel worried,\u0026rdquo;\u003c/em\u003e or \u003cem\u003e\u0026ldquo;My hands are trembling.\u0026rdquo;\u003c/em\u003e The therapist then instructs the participant to exaggerate these sensations verbally. The goal is to enhance self-awareness and saturate the need for avoidance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants are encouraged to compile a list of anxiety-provoking behaviors encountered in daily life and bring it to the next session.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDream Work\u003c/b\u003e: Different elements of dreams reflect various aspects of the participant\u0026rsquo;s personality. Participants are asked to recount their dreams in the present tense, as if they are happening now. The goal is to identify and explore the participant\u0026rsquo;s \u0026ldquo;lost\u0026rdquo; or unrecognized self-aspects.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants are encouraged to examine both completed and unfinished dreams outside of sessions and compare them to their core beliefs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSymbolic Play\u003c/b\u003e: Participants are invited to enact parts of their dreams and facilitate dialogue between these elements. This process helps clarify and make sense of internal conflicts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThis exercise is similar to that of session eight.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eListening to Metaphors\u003c/b\u003e: Therapists listen carefully to the metaphors that participants use, which provide important clues to inner conflicts. Suppressed internal dialogues are often embedded within these metaphors. Examples include statements such as \u003cem\u003e\u0026ldquo;I feel my soul is shattered\u0026rdquo;\u003c/em\u003e or \u003cem\u003e\u0026ldquo;Sometimes I feel like a broken glass.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants are encouraged to note recurring metaphors in daily life and compare them with past experiences.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe control group continued with routine urological care and was offered the intervention after study completion.\u003c/p\u003e \u003cp\u003eThe use of a wait-list control was ethically justified given that participants had ongoing access to standard medical care, were screened to exclude severe cases (with referrals as needed), and experienced only a brief delay in receiving the intervention, which posed minimal risk for this population with moderate symptoms. This design aligns with common practices in exploratory psychotherapy trials for non-severe distress.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHarms\u003c/h2\u003e \u003cp\u003e Potential harms, such as temporary emotional distress from discussing infertility-related topics, were monitored non-systematically through therapist observation and participant self-report during sessions. Participants were informed that they could withdraw at any time, and referrals to additional care were available if needed. No interim analyses or stopping guidelines were implemented due to the short duration and low-risk nature of the trial.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eAll instruments were Persian-validated versions with established psychometric properties in Iranian populations. Internal consistency in the current sample was strong (Cronbach's α\u0026thinsp;\u0026gt;\u0026thinsp;0.80 for all scales).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDepression: Beck Depression Inventory-II (BDI-II; scores 0\u0026ndash;63, higher indicating greater depression). The Persian version has demonstrated good reliability and validity in Iranian samples [Ghassemzadeh et al., 2005; 3,19].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAnxiety: State-Trait Anxiety Inventory (STAI; state and trait subscales, 20\u0026ndash;80 each, higher indicating greater anxiety). The Persian version, normalized by Mahram (1993), has shown acceptable psychometric properties [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGratitude: Gratitude Questionnaire-6 (GQ-6; scores 6\u0026ndash;42, higher indicating greater gratitude). The Persian translation has been used in Iranian research with evidence of convergent validity and reliability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePsychological Capital: Compound Psychological Capital Scale-12 (CPC-12; scores 12\u0026ndash;60, higher indicating greater psychological capital, encompassing hope, efficacy, resilience, and optimism) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAnalyses were conducted in SPSS version 26 using an intention-to-treat approach, with last observation carried forward for any missing data (minimal in this study). Baseline differences were tested with Welch's t-tests for continuous variables and chi-square tests for categorical variables. Post-intervention between-group effects were evaluated using Welch's t-tests, accompanied by Cohen's \u003cem\u003ed\u003c/em\u003e effect sizes. Statistical significance was set at two-tailed \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; no adjustments for multiple comparisons were applied given the focused hypotheses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant flow through the study is illustrated in the CONSORT flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All 60 randomized participants completed the trial with no dropouts. No harms or unintended adverse events were reported in either group. Demographic characteristics and baseline outcome scores were comparable across groups (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt post-intervention (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), the Gestalt group showed clinically meaningful within-group improvements: depression decreased from 27.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.53 to 21.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.59, state anxiety from 44.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67 to 35.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.77, trait anxiety from 44.03\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34 to 32.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.94, gratitude increased from 17.23\u0026thinsp;\u0026plusmn;\u0026thinsp;5.66 to 22.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46, and psychological capital from 31.53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.05 to 41.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40 (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The control group showed no significant changes (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eBetween-group comparisons revealed large effect sizes favoring the Gestalt group on all outcomes (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e; depression d = \u0026minus;\u0026thinsp;0.99, state anxiety d = \u0026minus;\u0026thinsp;1.41, trait anxiety d = \u0026minus;\u0026thinsp;1.65, gratitude d\u0026thinsp;=\u0026thinsp;1.01, psychological capital d\u0026thinsp;=\u0026thinsp;1.90; all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Participant Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGestalt (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.17\u0026thinsp;\u0026plusmn;\u0026thinsp;12.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (57.85) = -1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfertility duration (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (56.59)\u0026thinsp;=\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; (5)\u0026thinsp;=\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote\u003c/em\u003e: Continuous variables: mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, compared using Welch's t-test due to potential unequal variances. Categorical: chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePsychological Outcomes at Baseline and Post-Intervention (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGestalt (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression (BDI-II; 0\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27.23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState Anxiety (STAI; 20\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e45.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e35.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e48.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrait Anxiety (STAI; 20\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.03\u0026thinsp;\u0026plusmn;\u0026thinsp;6.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e46.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e46.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGratitude (GQ-6; 6\u0026ndash;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.23\u0026thinsp;\u0026plusmn;\u0026thinsp;5.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17.27\u0026thinsp;\u0026plusmn;\u0026thinsp;7.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e16.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological Capital (CPC-12; 12\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e31.93\u0026thinsp;\u0026plusmn;\u0026thinsp;4.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e41.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e32.17\u0026thinsp;\u0026plusmn;\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: Higher scores indicate greater levels of the construct. Values are unadjusted descriptive statistics.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Comparability for Psychological Outcomes (Welch's t-test)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCohen's \u003cem\u003ed\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (57.85)\u0026thinsp;=\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (55.07) = -0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.439\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrait Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (57.36) = -1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGratitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (55.41) = -0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.981\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological Capital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (55.60) = -0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: Welch's t-test used due to potential unequal variances; Cohen's \u003cem\u003ed\u003c/em\u003e for descriptive purposes.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-Intervention Between-Group Comparisons (Welch's t-test)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCohen's \u003cem\u003ed\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (57.39) = -3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eState Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (51.46) = -5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrait Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (55.14) = -6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGratitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (42.89)\u0026thinsp;=\u0026thinsp;3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological Capital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWelch \u003cem\u003et\u003c/em\u003e (56.22)\u0026thinsp;=\u0026thinsp;7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: Welch's t-test used due to potential unequal variances. Negative \u003cem\u003ed\u003c/em\u003e for lower scores in Gestalt group (depression/anxiety); positive for higher (gratitude/psychological capital).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cb\u003ePrincipal Findings\u003c/b\u003e The results of this trial provide clear evidence that a 10-session Gestalt group therapy program led to substantial reductions in depression and both state and trait anxiety, while simultaneously producing robust increases in gratitude and psychological capital among men experiencing long-term infertility. These findings align with prior evidence on Gestalt therapy's efficacy in distress reduction [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] and extend it to infertility contexts [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eInterpretation\u003c/b\u003e These benefits likely arise from core Gestalt principles and techniques, which facilitate experiential processing of suppressed emotions (such as grief and shame), expansion of awareness to encompass present positives (fostering gratitude), and emphasis on personal agency and small actionable steps (enhancing psychological capital). The group modality itself may have contributed by offering validation, reducing isolation, and providing a safe space to practice new interpersonal patterns [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSpecifically, reductions in depression and anxiety may stem from techniques like the empty-chair dialogue and two-chair work, which encourage direct confrontation and integration of disowned emotions\u0026mdash;common in infertility-related grief, shame, and rumination [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. By externalizing internal conflicts (e.g., self-blame or societal pressures on masculinity), these methods interrupt avoidance cycles, potentially lowering state anxiety through immediate arousal regulation and trait anxiety via sustained emotional tolerance [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Here-and-now awareness exercises further ground participants in the present, mitigating catastrophic thinking about future infertility outcomes and aligning with observed decreases in both anxiety subscales.\u003c/p\u003e \u003cp\u003eEnhancements in gratitude may reflect the role of exaggeration exercises and role-playing, which broaden perceptual fields from deficit-focused narratives (e.g., loss of fertility) to recognizing overlooked positives, such as supportive relationships or personal strengths [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In group settings, witnessing peers' stories via these techniques fosters empathy and collective appreciation, shifting attention from chronic inadequacy to moments of meaning, consistent with gratitude's mediating role in stress and well-being [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, improvements in psychological capital\u0026mdash;encompassing hope, efficacy, resilience, and optimism\u0026mdash;could derive from responsibility-taking practices and reversal techniques, where participants experiment with empowered behaviors (e.g., asserting agency despite uncontrollable infertility factors) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. These methods restore mastery through small, achievable actions, buffering setbacks and reframing infertility as part of a broader life context, thereby enhancing resilience and optimistic outlooks [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Overall, Gestalt's dual focus on symptom alleviation and resource building underscores its holistic impact on these variables.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and Limitations\u003c/b\u003e Notable strengths include successful randomization, blinded outcome assessment, a manualized and fidelity-checked intervention, zero attrition, and consistent effects across a range of distress and resource outcomes. Limitations include recruitment from a single clinic via convenience sampling, which restricts generalizability; absence of follow-up assessments to evaluate maintenance of gains; reliance on self-report measures; use of a wait-list rather than active control; a sample size that, while adequate for primary hypotheses, precludes more sophisticated modeling approaches (e.g., ANCOVA or mixed-effects models) recommended for larger confirmatory studies; and the retrospective registration of the trial, while compliant with registry policies and transparently reported, may be viewed as a limitation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClinical Implications\u003c/b\u003e Given that psychological support for men in infertility care is often underdeveloped [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], this brief, group-based Gestalt program offers a feasible adjunct that could be integrated into routine clinical pathways. It addresses both symptom relief and resource building while capitalizing on the efficiency and peer support inherent in group delivery. Implementation would require appropriate screening and clear referral pathways for severe cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFuture Research\u003c/b\u003e Replication in multi-site trials incorporating active comparators (e.g., cognitive-behavioral therapy), extended follow-up periods, mediation analyses of putative mechanisms (e.g., changes in emotional awareness or shame), and more diverse participant samples would substantially strengthen the evidence base.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003e Gestalt group therapy emerges as a promising, resource-oriented intervention capable of meaningfully reducing psychological distress and bolstering adaptive strengths in men facing infertility. Further high-quality research is encouraged to consolidate and extend these initial findings.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e \u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e Approved by the Research Ethics Committee of the Faculty of Medicine, Islamic Azad University, North Tehran Branch (IR.IAU.TNB.REC.1403.248). Written informed consent obtained from all participants. All methods were performed in accordance with the relevant guidelines and regulations, including the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Protocol\u003c/strong\u003e: The full trial protocol is provided as a supplementary document submitted for peer review and can be accessed upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e Available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e None declared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions:\u003c/strong\u003e Study conception and design: KB, NA, MT; Data collection: KB; Data analysis and interpretation: KB, NA, MT; Drafting of manuscript: KB, NA, MT; Critical revision of manuscript: KB, NA, MT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We thank participants for their contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAghababaei N, Akbarilakeh M, Ahmady S, Arbabisarjou A, Ghaempanah Z. 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Standardization of Spielberger State-Trait Anxiety Inventory in Mashhad, Iran [Master's thesis]. Allameh Tabataba'i University.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCullough ME, Emmons RA, Tsang JA. The grateful disposition: A conceptual and empirical topography. J Personal Soc Psychol. 2002;82(1):112\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0022-3514.82.1.112\u003c/span\u003e\u003cspan address=\"10.1037/0022-3514.82.1.112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infertility, Gestalt therapy, Depression, State anxiety, Trait anxiety, Gratitude, Psychological capital, Randomized controlled trial","lastPublishedDoi":"10.21203/rs.3.rs-9347062/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9347062/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMale infertility is frequently accompanied by considerable psychological distress, manifesting as elevated depression and anxiety, alongside a decline in positive psychological resources such as gratitude and psychological capital. The present study investigated the efficacy of Gestalt group therapy in mitigating these challenges.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-center, parallel-group randomized controlled trial was conducted in Mashhad, Iran, in 2024. Sixty infertile men were recruited and randomly allocated (1:1) to either Gestalt group therapy (10 weekly sessions of 2 hours each) or a wait-list control group receiving treatment as usual. Outcomes were assessed at baseline and immediately post-intervention using validated Persian versions of the Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory (STAI), Gratitude Questionnaire-6 (GQ-6), and Compound Psychological Capital Scale-12 (CPC-12). Between-group differences were examined using Welch's t-tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGroups were well-balanced at baseline (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Following the intervention, participants in the Gestalt group demonstrated significantly greater reductions in depression (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cohen's \u003cem\u003ed\u003c/em\u003e = -0.99), state anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e = -1.41), and trait anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e = -1.65), as well as larger increases in gratitude (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.01) and psychological capital (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.90).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eGestalt group therapy appears to be an effective and practical intervention for alleviating psychological distress and strengthening positive resources among infertile men. Future studies should include longer-term follow-up and active comparison conditions.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003e: This trial was registered at the Iranian Registry of Clinical Trials (IRCT20251026067770N4) on December 20, 2025. The trial is available at: Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://irct.behdasht.gov.ir/trial/88123\u003c/span\u003e\u003cspan address=\"https://irct.behdasht.gov.ir/trial/88123\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20251026067770N4\u003c/span\u003e\u003cspan address=\"https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20251026067770N4\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e","manuscriptTitle":"Effectiveness of Gestalt therapy on depression, psychological capital, and gratitude among infertile men","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:18:25","doi":"10.21203/rs.3.rs-9347062/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"243026095307710363631201392980026857622","date":"2026-05-11T04:51:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T19:19:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T22:34:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53953956017662326351839897603945184319","date":"2026-04-24T20:40:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T20:51:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260583177465410335343749421594688581370","date":"2026-04-23T20:48:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85024088960583509635917643203077302984","date":"2026-04-23T20:17:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-23T18:01:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-21T15:06:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-17T08:04:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-14T09:21:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Mental Health","date":"2026-04-14T08:50:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d75c1669-53f4-4b18-8cf3-9f71b7d9a9e9","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"243026095307710363631201392980026857622","date":"2026-05-11T04:51:06+00:00","index":54,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T16:18:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:18:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9347062","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9347062","identity":"rs-9347062","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}