Interventions promoting mental health dimensions in infertile women: a systematic review

Background Scientific developments have brought hope to infertile couples; however, the results are not always favorable. This makes women suffer psychological pressure. Therefore, previous studies have investigated the effectiveness of many psychological interventions but no research identified the most common psychological interventions. In this regard, the present review aimed to investigate different psychological interventions that promote mental health in infertile to identify the most frequent (common) ones. Methods In the present study, the search was carried out using appropriate keywords Infertility, psychological interventions, mental health, stress, anxiety, depression and women in the Google Scholar، Magiran، SID، Pubmed، Scopus، Science Direct، ProQuest، Web of Science databases and One of the leading websites in health- WHO with Persian and English languages and two operators of “AND” and “OR” between 2000 and 2021. Results First, 7319 articles were searched, 6948 articles of which were removed due to irrelevant subjects, and 31 articles were removed due to duplication. 340 abstracts were examined and the results of 60 articles were extracted. Two approaches (examining the type and content of intervention) were used to extract findings. The first approach indicated high diversity in psychological interventions, leading to the categorization of the interventions into 4 categories of cognitive behavioral therapy (CBT), mind-body interventions (MBI), stress management skills, and others. CBT and MBI and stress management skills were found as the most frequent promoting interventions for mental health in infertile women. The second approach indicated the differences in protocols (number of sessions and time of interventions). Conclusion Despite differences in protocol of interventions under study, the results of all articles revealed the effectiveness of interventions in improving infertile women’s mental health; therefore, it is suggested to apply the most common psychological interventions based on scientific evidence (CBT, MBI, and stress management skills) along with infertility treatment methods. The results will help the specialists, policy-makers, and planners to select and implement the most appropriate psychological interventions for infertile women. Supplementary Information The online version contains supplementary material available at 10.1186/s40359-023-01285-1.


Introduction
According to the World Health Organization (WHO), infertility as one of the world's health problems has affected millions of people in their reproductive age.About 48 million couples and 186 million individuals suffer from infertility around the world, and infertilitycaused disability is the fifth disability in the world [1].The prevalence of infertility is 15% in the world [1,2] and it has been reported between 5 and 22% (on average 9.10%) in Iran [3].In recent years, the prevalence of infertility has been on the rise due to sexually transmitted diseases and environmental pollution [2].Pregnancy is one of the important goals of developing countries, and infertility is considered a harmful factor for reproductive health, which is associated with many physical and psychological problems [4,5].Infertility and treatment for it is a source of mental suffering for infertile women, with direct effects on different dimensions of their mental health (stress, anxiety, and depression) [6,7].The results of studies have revealed the reduction of mental health indicators in infertile women so that 44% of infertile women suffer from mental problems and are twice higher at risk of suffering from mental disorders than infertile men [8,9] and are emotionally more anxious, distressed, and depressed than their husbands [10].Therefore, it is necessary to identify and use the most common psychological interventions that promote mental health in women with infertility to deal with the psychological consequences of infertility.
The fact that the mental disorders caused by infertility can be prevented and, like other diseases, their implications and chronicity can be mitigated if diagnosed and treated timely can explain the importance of the research [11].Also, recently, mental health professionals have concluded that psychological interventions are as necessary as medical treatments for infertility.Therefore, it is a need to identify the most common scientific evidencebased psychological interventions to improve mental health and use them along with medical treatments for infertility.In this regard, with the rapid development of assisted reproductive technology (ART), many infertility centers were set up around the world to provide counseling, treatment, and attention to the concerns and emotional needs of infertile patients [12], and many interventional studies have designed and implemented to improve and promote mental health in these patients.However, it should be noted that most interventional studies and even systematic and review studies have only focused on the effects of a single treatment approach (cognitive behavioral, mind-body interventions, educational programs, psychotherapist programs, and counseling) [13][14][15][16][17][18][19], and no review or systematic study has investigated a large range of psychological interventions that promote mental health in women with infertility.
Considering the above-mentioned issues, there are various and complex psychological interventions on the issue of infertility; however, no research identified the most common (frequent) psychological interventions in this regard.The present study is an attempt to address this gap for the first time.Regarding the results of previous studies that indicated the importance of performing appropriate psychological interventions along with supporting patients with infertility [20], the present study aimed to systematically review different types of psychological interventions that promote mental health in infertile women to determine the most common psychological interventions used for women with infertility.

Materials and methods
This study was carried out based on the PRISMA (Preferred reporting items for systematic reviews and metaanalyses) systematic review and meta-analysis checklist (Fig. 1).A comprehensive and systematic search was carried out on articles published between 2000 and 2021.The keywords taken from MeSH included infertility, psychological interventions, mental health, stress, anxiety, depression, and women.The databases included Google Scholar, Magira, SID, Pubmed, Scopus, Science Direct, ProQuest, Web of Science, and One of the leading websites in health-WHO.The search was carried out in Persian and English using two operators "AND" and "OR"; for the keywords of the same category, the operator "OR" was used, and "AND" was used to combine the words.Then, considering the following 4 criteria, the articles were selected and the present systematic review was compiled.The criteria included (1) determining the research questions, (2) searching the databases to select articles, (3) selecting articles, and (4) drawing diagrams and Table [21].
To determine the research question, the PICO format was first determined.Then, the research question, i.e. (what are the most frequent (common) psychological interventions to improve mental health in women with infertility?) was typed to be searched.P (Patient): Infertile women.I (Intervention): Interventions that promote different dimensions of mental health (stress, anxiety, and depression).
To search the databases, the researchers used the keywords taken from MeSH, including infertility, psychological interventions, mental health, stress, anxiety, depression, and women to retrieve the related articles for 4 weeks from 30 April to 31 March 2022.Using a manual search, the researchers reviewed the reference list of the retrieved articles to find more articles.
To select the articles, two authors independently evaluated the articles based on the inclusion and exclusion criteria.The inclusion criteria included infertile women, Persian or English articles, articles published in domestic or international journals, articles that examined the effectiveness of psychological interventions on the mental health, anxiety, stress, and depression of infertile women and experimental and quasi-experimental studies.The exclusion criteria were lack of access to the full text of articles, articles that examined other factors such as self-efficacy, psychological well-being, etc. in infertile women, articles with a male target group, review and observational articles, and protocols.Any disagreement in selecting articles was solved by negotiation and the help of a third person in the next step.
The Effective Public Health Practice Project (EPHPP) tool was used to assess the quality of the articles.It is a general instrument to assess different types of interventional studies in six categories: selection bias, study design, confounders, blinding, data collection practices, withdrawals, and dropouts.Once the assessment was fulfilled, each examined practice received a mark ranging between "weak" (1) "moderate" (2), and "strong" (3).The total score was obtained by calculating the average score of each study.The maximum average total score in each study was 3.00.According to the average total score, the quality of the articles was categorized as weak (1.00-1.50),medium (1.51-2.50),or strong (2.51-3.00)[22].To prevent bias, searching the articles and assessing their quality was performed by two researchers.To select the articles, two authors independently evaluated the titles, abstracts, and full texts of the articles were first examined.Then, the articles were checked concerning the inclusion and exclusion criteria.The full texts of articles were read and the information (authors' names, publication year, type of intervention, the content of the intervention, number of sessions, results, main findings, and conclusion) were extracted.Then, the findings were organized into different categories to conduct a review study and answer the research question.The information was shown in 4 tables (interventions related to cognitivebehavioral treatment (Table 1), interventions related to mind-body interventions (Table 2), interventions related to stress management skills (Table 3), and other interventions (Table 4), and the PRISMA flowchart (Fig. 1).The protocol of study was not prepared and the review was not registered.

Ethical considerations
Ethics approval is not required as the systematic review does not involve the participation of human subjects; rather it involves reviewing and collecting data from publicly available sources.However, the present research was extracted from the doctoral dissertation on reproductive health with code of ethics (IR.SBMU.PHARMACY.REC.1400.011)from Shahid Beheshti University of Medical Sciences.

Results
First, according to the research question, 7319 articles were found.Then, 6979 articles were removed (6948 articles due to irrelevant titles and 31 articles due to duplicate data).The abstracts of the remaining 340 articles were examined.After reviewing the abstracts, 275 articles were removed and 65 articles remained.Then, the full texts of 65 articles were examined and 5 other articles were removed, and finally, the results of the remaining 60 articles published between 2002 and 2021 were used to write the present review (Fig. 1).To extract the findings from 60 articles, the researchers used two approaches (investigating types and contents of interventions).The results of the first approach indicated high diversity of psychological interventions on women with infertility so that among the articles under study, 19 studies investigated cognitive-behavioral treatment (CBT), 6 articles investigated mind-body interventions (MBI), 5 articles focused on stress management skills (SMS), 3 articles studied collaborative counseling, 3 articles investigated positive psychology (PP), 2 articles examined problemsolving skills, 2 articles investigated music therapy, 2 articles studied holistic psychological interventions (HPI), and 18 articles focused on other interventions (like yoga, acupuncture, relaxation, etc.).On the other hand, this approach led to the organization of psychological interventions into 4 categories of cognitive behavioral therapy, mind-body interventions, stress management skills, and other interventions.Thus, three more common interventions that promote mental health in women with infertility (anxiety, stress, and depression), i.e., cognitive behavioral therapy, mind-body interventions, and stress management skills, were identified.The results of the second approach (investigating the contents of the intervention) indicated the differences in implementation protocols (number of sessions and time), which are discussed in the following.

Cognitive behavioral therapy (CBT)
19 articles used in this study focused on this technique.The interventions were often in the form of individual or group training sessions; however, they varied in terms of the number of sessions and duration of intervention; 3 studies conducted cognitive behavioral interventions in ten 90-minute sessions, 1 study in 8 sessions, 1 study in 6-8 sessions, 1 study in fifteen 90-minute sessions (15 weeks), 1 study in 12 h per week for 3 months, 1 study in 15-20 days, 1 study in 12-13 days, 1 study conducted the internet-based cognitive behavioral therapy for 8 weeks (13 sessions), 1 study conducted 1-hour sessions 4 days a week for 4 weeks, 1 study conducted ten 120-minute sessions for 2/5 months ,2 study conducted psychotherapy with CBT along with supportive psychotherapy and medication therapy for 6 months, 2 studies conducted an electronic and web-based intervention during the ART cycle and the waiting period after embryo transfer and 3 studies conducted CBT and Pharmacotherapy (20 mg fluoxetine daily for 90 days).The results of all studies indicated that CBT is an effective intervention in changing attitudes and beliefs and can help improve mental health and prevent and reduce anxiety, stress, and depression in women with infertility (Table 1).
The results of studies by Oraki et al. [24], Faramarzi et al. [29], and Manochehri et al. [27] indicated the effectiveness of CBT in improving mental health in infertile women [24,27,29].Starabadi et al. [35], Afshariyan et al. [25], Faramarzi et al. [28], and Minden et al. [38] revealed the effectiveness of CBT in reducing stress caused by infertility.Starabadi et al. found that cognitive-behavioral techniques caused adaptive thoughts in individuals, and training in behavioral methods was an effective treatment to reduce stress and depression caused by infertility [35].Afshariyan et al. showed that the integrated approach of positive cognitive behavioral therapy was effective in reducing stress caused by infertility and increasing hope, and suggested its application [25].Faramarzi et al. also confirmed the effectiveness of CBT in reducing infertility compared to fluoxetine [28].

Mind body intervention (MBI)
In the present study, 6 articles used this technique.In all of these articles, the interventions were in the form of training sessions; however, there were differences in the number of sessions and duration of interventions; 2 studies investigated mind-body intervention in ten 120-minute sessions, 1 study investigated internet-based intervention in ten 60-minute sessions, 1 study in eight 90-minute sessions, 1 study in four 60-minute sessions along with 20 min of daily practices at home, and 1 study conducted the intervention in four 3-hour sessions.Also, the results indicated the positive effect of MBI in improving mental health and mitigating the symptoms of anxiety, stress, and depression in women with infertility (Table 2).In the study of Clifton et al. [16], the internet-based mind-body intervention reduced distress (anxiety, depression, stress) in women with infertility, and the chance of fertility in the intervention group was 4.47 times more than that in the control group [16].The results of studies by Kalhori et al. [17], Bai et al. [40], Psaros et al. [43], and Galhardo et al. [41] showed the effectiveness of MBI in reducing infertility-caused depression.
In the study of Kalhori et al. group counseling based on mindfulness was effective in reducing depression symptoms in women undergoing IVF [17].Bai et al. showed that mindfulness not only reduced depression but also improved sleep quality [40].The results of a study by Psaros et al. indicated the effect of MBI on reducing perceived depression and stress and increasing perceived social support [43].Galhardo et al. found a significant difference in the score of depression between the intervention and control groups after the intervention so that an increase in mindfulness skills, acceptance, and decentralization led to reduced mental distress in women with infertility [41].The study by Chan et al. also indicated the effectiveness of the mind-body-spirit intervention in reducing anxiety in women undergoing IVF (In vitro fertilization) compared to women in the control group, and the fertility rate was higher in the intervention group than in the control group [42].

Stress management skill (SMS)
In the present study, 5 articles investigated the use of this technique in the form of training sessions.However, they varied in terms of the number and duration of the sessions; 1 study investigated the stress management intervention in twelve 120-minute sessions, 1 study in ten 120-minute sessions, 1 study in 8 sessions of a maximum of 60 min, 1 study in one 90-minute session, and 1 study sent the interventions monthly to email addresses of women with infertility for 3 months.The results of the studies indicated the effectiveness of SMS in improving mental health and reducing the symptoms of anxiety, stress, and depression in women with infertility (Table 3).
In the study of Hashemi et al. [44], training stress management skills were found to be effective in increasing mental health in women with infertility [44].The findings of a study by Koumparou et al. [45] indicated the effectiveness of stress management sessions in reducing the stress of all women undergoing IVF [45].Akiko et al. [48], Hamid [46].and Heredia et al. [47] revealed the effectiveness of stress management skills in reducing anxiety and depression.Akiko et al. performed a supportive stress management program on women undergoing infertility treatment and succeeded to reduce anxiety and depression in patients [48].Hamid found significant differences in the scores of depression and anxiety between the intervention and control groups after the intervention and during a 12-month follow-up process [46].Heredia et al. found that short-term interventions focusing on stress management can contribute to psychological adjustment in women undergoing IVF, reduce their anxiety levels and improve their quality of life [47].

Other interventions
In the 4th category, other psychological interventions that promote mental health in women with infertility were examined.The number of retrieved articles related to other interventions was less than that of CBT, MBI, and SMS. 3 articles studied collaborative counseling, 3 articles investigated positive psychology (PP), 2 articles examined problem-solving skills, 2 articles investigated music therapy, 2 articles studied holistic psychological interventions (HPI), and other interventions (yoga, acupuncture, relaxation, etc.) were examined each in one separate study.

Discussion
The results of this systematic review study indicated a high diversity in the types and protocols of psychological interventions in infertile women.Moreover, the examinations not only led to the categorization of In explaining the findings, it can be said that the events and accidents do not upset individuals but their thinking way that is the result of their attitudes and beliefs and influences the information process and causes emotional reactions in individuals; therefore, one's thoughts and beliefs about infertility affect the person's type and level of reaction.Thus, since CBT is a short-term skill-focused psychological approach and aims at changing maladaptive emotional responses through changing thoughts and behaviors in patients, it helps patients to identify their negative attitudes and obtain new skills to change behaviors, communicate with others, solve problems, change wrong beliefs and attitudes, and reconstruct cognitions [35,76].
On the other hand, in cognitive behavioral therapy, more desired results are achieved due to the use of such techniques so that the problem-solving technique and muscle relaxation cause self-awareness, and recognition of the psychological aspects of anxiety and stress, leading to reduced symptoms (anxiety and stress).The person's awareness and knowledge about the effect of negative emotions on mental health, and the advantages of a happy life will cause an increase in performing the tasks learned in therapy sessions, and as a result, depression will be reduced [35].In general, the effectiveness of CBT in improving the mental health of infertile women can be attributed to the correct thinking way and wrong beliefs, reduced tension, and psychological support of the group.Reduced tension is the result of correcting and adjusting incompatible beliefs and values, cognitive errors, and defective schemas about infertility, and since most infertile patients feel lonely and consider their problems as unique and they cannot talk about their problems, so CBT group sessions are the safest place for emotional discharge and overcoming the feeling of loneliness [77].Therefore, it is suggested to use CBT preferably in a group as a supplement to infertility medical treatment.According to findings, after CBT, mind-body interventions (with 6 related articles) were used to improve mental health in women with infertility and showed great effects in improving mental health, stress, depression, and anxiety.In explaining the result, it can be said that the interventions based on mindfulness belong to thirdgeneration cognitive behavioral therapies with roots in Eastern religious traditions, especially Buddhism [78].This style promotes psychological improvement through  compromise and flexibility methods and includes interventions that focus on the relationship between the brain, mind, body, behavior, and their effects on health and diseases, and helps the person to be aware of thoughts, feelings, and physical states from moment to moment [79].
Conscious living helps the person to gain a deeper understanding of the realities of life and perceive things "as they are" without attributing expectations, judgments, pessimism, or apprehensions to them, and to see the sufferings, desires, dependence, and instabilities of life [80].
Another prominent feature of this skill is that the person is trained in loving kindness, and the person repeats it during breathing, so it helps to understand experiences in a compassionate and open-minded way [80].In general, the effectiveness of MBI in improving the mental health of infertile women can be considered to be the result of increasing awareness, paying attention to the body and its movements, and stretching the body to achieve relaxation and mind-body balance; therefore, since it focuses on both mental and physical dimensions, not only it is beneficial for patients with psychological disorders but also to improve wellbeing in normal people [81].Since personal well-being is the result of balance and harmony of the inner aspects of mind-body-spirit and MBI is a holistic approach, it helps women with infertility experience negative states in new ways and reduces mental distress, and improves mental health [42].In this regard, it is suggested to use MBI along with infertility medical treatment.According to findings, after CBT and MBI, stress management skills (with 5 related articles) were among the interventions used to promote mental health in women with infertility, and the results indicated the effectiveness of this intervention in improving dimensions of mental health.It can be explained that stress is the body's uncertain response to any demand and is one of the psychological factors of infertility [6,7,82].Stress management is an individual's ability to reduce stress and adjust to stressful situations [83].Stress management interventions contain several interventions including knowledge about stress, identifying inefficient thoughts, self-expression skills, anger, and time management.The purpose of the intervention is to create and develop a set of skills to reduce stress and better deal with the needs and challenges of life [45].
The most important feature of stress management skills (SMS) is helping people to identify the source of stress, precisely evaluate the situations, feelings, and thoughts, and use efficient and problem-solving-based coping styles; as a result, it leads to finding the best solution and provides psychological satisfaction [44].Since infertile women use emotion-focused coping more to deal with the mental pressure of infertility and have less general health, focusing on stress management skills to make more use of efficient and problem-solving-based coping styles can be effective in improving their mental health [47].Given that individuals who receive stress management skills can overcome distressing thoughts and experience lower levels of stress, anxiety, and depression, stress management skills (SMS) can be an effective intervention, and it is suggested to use it along with infertility treatment methods.
The search and examination of a variety of psychological interventions in infertility was one of the strengths of the present study.In addition, the research team used two approaches to precisely examine articles in terms of types and contents of interventions, and could identify the most frequent psychological interventions in infertility; however, since it was not possible to access all international databases, a limited number of articles may not have been retrieved, which can be considered as a limitation of this study.Another limitation is that to find relevant articles, articles with an infertile male target group were excluded and only the most common psychological interventions were identified in infertile women, so it is suggested to identify common psychological interventions that promote mental health in infertile men.
Since infertile women face different mental-social challenges and a lack of appropriate interventions and support during treatment influence all aspects of their lives [84], the findings of this research will help specialists and policy-makers in this field to include scientific evidencebased psychological intervention in the care program of infertile women.These can also be used as the foundation for designing training, treatment, counseling, and support programs to reduce psychological disorders and increase adjustment in women with psychological problems caused by infertility.
Given that in most studies, the effectiveness of interventions was evaluated immediately or shortly (1 to 3 months) after finishing the intervention, it is suggested to conduct studies to evaluate the long-term effectiveness of these methods (CBT, MBI, and stress management skills) in infertile women's psychological empowerment.

Conclusion
The review of findings of 60 articles not only indicated high diversity of psychological interventions in women with infertility in terms of types and contents of interventions, but also helped to categorize the interventions into 4 categories of CBT, MBI, SMS, and other interventions.According to findings, cognitive behavioral therapy (CBT), mind-body interventions (MBI) and stress management skills (SMS) have been the most frequent and common psychological interventions in infertile women.The application of the most common scientific evidencebased psychological interventions is of great importance to psychologically empower infertile women, especially in societies where women are blamed for infertility, and this causes them suffer psychological pressure.Due to the importance of having children in line with the population policies of the country and the increasing prevalence of infertility in some societies, including Iran, the use of scientific evidence-based intervention in infertility treatment centers by a team skilled in the field of psychological infertility problems, including reproductive health specialists, psychologists, and midwives is necessary to reduce mental disorders, increase adjustment, and improve the results of infertility treatment.Also, a metaanalysis study on different types of psychological interventions in different aspects of mental health in infertile women is suggested.

Fig. 1
Fig. 1 PRISMA flowchart of study entry and exit process

Table 1 (
continued) EPHPPa: Effective Public Health Practice Project, d = Cohen's d effect size, D: Difference between the Pre-and Post-measures, MD: mean difference, CES-D center for epidemiologic studies depression scale, IDS infertility distress scale

Table 2
General characteristics of studies that were performed by MBI (N = 6) Table 4 presents the following a : Effective Public Health Practice Project, BDI = Beck's Depression Inventory-II; BAI = Beck's Anxiety Inventory; PSS = Perceived Stress Scale; FPI = Fertility Problem Inventory; d = Cohen's d effect size, D: Difference between the Pre-and Post-measures, MD: mean difference, MOS Social Support Survey (emotional information support subscale), Life Orientation Test-Revised (LOT-R), Perceived Stress Scale (PSS-4), brief mindfulness group (BMG), gratitude journal group (GJG), control group (CG).

Table 3
General characteristics of studies that were performed by SMS (N = 5) a : Effective Public Health Practice Project, d = Cohen's d effect size, D: Difference between the Pre-and Post-measures, MD: mean difference, quality of life (QoL).

Table 4
General characteristics of studies that were performed by other interventions(N = 30)