Blog banner research
April 25, 2022


FACTS Infertility Awareness Series

Addressing Emotional Barriers to Reproductive Care: A Review

By Ariya Mobaraki


Editor’s Note: As we conclude our month-long infertility series, this research overview highlights the psychological impact of infertility and the potential long-term effects on mental health. As a participant of the FACTS elective, Ariya Mobaraki, reviewed the article, Addressing the Emotional Barriers to Access to Reproductive Care, discussing how the emotional experience of infertility can create barriers to care.

Our upcoming conference, For the Future of Women’s Health will feature a number of different presentations about the latest research in treating infertility with restorative reproductive medicine. Register today to learn more!



Picture this: you are a young, healthy person married for two years. You and your spouse have been trying daily to have children for a year and a half with no success. Now imagine your parents are pressuring you for grandchildren, and your family keeps asking when the little ones will be coming during holiday dinners. Imagine your friends and co-workers conceiving with seemingly little effort over the course of a month. Imagine the baby pictures that populate your social media while you and your partner are burdened with the internal struggle of infertility.

Modern sexual education tends to overlook the topic of infertility and how impactful it can be on women and men’s physical and emotional health. In women aged 15 to 49 years with no prior births, almost 20% are not able to get pregnant after trying for one year; whereas, 6% of women who have had at least one prior birth still experience infertility and another 14% have difficulty getting or staying pregnant [1] . As we learned in the FACTS elective, many of these women face daily psychological stressors that can lead to long-term negative effects on their mental health. Within three months of trying and not being able to conceive, the disappointment of not getting pregnant can morph into anxiety and worry. By six months, 70% of women report great concern and an internalized fear that something was wrong with them personally [2] .

The psychological aspects of infertility can significantly impact a patient’s motivation to seek treatment or to even remain in the treatment process. In one study, 50% of women described infertility as one of the most upsetting experiences in their lives [3]. In a European survey of 445 women, about a third of whom were currently receiving treatment, researchers found that 74% of women experienced resentment when others easily conceived and 67% were tired of receiving suggestions. Of those women, 64% felt uncomfortable around pregnant women or babies, and some couples even chose to withdraw from family and friends due to societal pressure [4].

In addition to resentment and frustration, infertility patients will frequently report symptoms such as anxiety, depression, or isolation. In a study of 122 women visiting a fertility center for the first time, 40% were diagnosed with a psychiatric disorder after meeting with a psychiatrist. 23.2% were diagnosed with anxiety, while 17% were given a diagnosis of depression [2]. Among these women, there was a significant difference in age, education, income, or years of infertility. Thus, the psychological experience of infertility may generate emotional barriers to care in three key ways [2]:

  • Delay or failure to seek and receive care after failing to conceive
  • Failure to return for follow-up after the initial visits to establish care
  • Giving up on the treatment plan despite optimistic outcomes

Although a myriad of reproductive care services exists for these women to pursue, it is critical to first consider the emotional barriers that prevent the majority from even stepping in the door. About 50% of infertile couples never seek out fertility care and, of those who do, 20% wait for more than 2 years before seeing a specialist [2]. Studies have shown there is a combined lack of awareness, denial, and fear that contribute to this trend. In particular, fear of failure is one of the largest emotional barriers to care. In a survey of 585 couples trying to conceive within the past 2 years, 42% of those who had received treatment waited 6-12 months after their physician recommended treatment. Another 11% waited 18-24 months, and 14% waited over 24 months to begin treatment [2].

Many people assume the psychological burden of being unable to conceive is what leads to psychiatric disorders, but this is not always the case. Many forms of infertility treatments are also associated with depressive symptoms [2]. Furthermore, only 10% of women are satisfied with the quality of emotional services during fertility treatment. A study of more than 42,000 women who underwent IVF done in Denmark revealed that 34.7% had depression prior to undergoing Assisted Reproductive Techniques (ART), 4.7% were diagnosed during ART, and 60.7% were diagnosed after ART had been completed. In addition to this, we must also consider other issues surrounding treatment such as side effects, costs, time commitments, or injection concerns [5].

“Only 10% of women are satisfied with the quality of emotional services during fertility treatment.”

Another common assumption is that patients who drop out of treatment do so due to cost or physician recommendation. Although cost is the number one reason for the drop-out of uninsured patients, recent studies have shown that even for insured patients in both the U.S. and other countries, dropout rates tend to be as high at about 46-58%. Many cite the psychological burden throughout the IVF process as the primary reason for dropping out [2]. The strain of ART can also be harmful to the relationship of the couple, due to an imbalance in treatment between partners. Also, the presence of depressive symptoms before the first cycle of treatment can limit the willingness of a patient to undergo multiple treatment cycles. This creates a vicious cycle; depressive symptoms may worsen with each attempt, often causing patients to drop out even if the prognosis is looking good.


Where to Go from Here

You may now be wondering: what can we do with this information, and how can we help women and men overcome these barriers to reproductive care? The truth lies in the information – the more we know about the causes, the more we can help address the problems. First, it is well known that many women and men struggle silently, so it is important to provide emotional support and empower them with information about their fertility.  Learning to chart the female cycle with a fertility awareness-based method may be the first step in helping couples to identify their potential window of fertility. The cycle chart can also reveal cycle abnormalities that may suggest certain underlying causes of infertility.  When women learn to identify these issues early on, they may be able to receive treatment even sooner. Infertility treatment can be overwhelming and intimidating for patients, so easing women and couples into the process with individualized materials such as checklists, treatment surveys, DVDs, or pamphlets can be very beneficial in quelling anxieties about treatment.

Next, once patients are educated and informed, it is crucial to address their psychological and emotional needs. The recommendations for this include [2].

  • Screening for psychological issues in high-risk patients
  • Referring these patients to counseling
  • Providing them with coping mechanisms to guide them through the process

Many tools exist for clinicians to screen and identify at-risk patients, which can also serve to improve patient satisfaction and treatment outcomes. Evidence-based questionnaires such as Fertility Quality of Life and SCREENIVF are useful in individualizing the process for each patient and addressing specific needs. Incorporating anxiety and depression scales will also help identify psychological and emotional distress that may be co-occurring.

Partner support is another important factor to consider during infertility care, as communication and stress management are crucial amongst couples struggling to conceive. For example, couples may utilize Stress Management and Resilience Training (SMART), a cognitive-behavioral intervention that has been proven to improve generalized and fertility-related stress, anxiety, and happiness. Other interventions include the Mind/Body Program for Infertility and the Organic Conceptions Program, which focus on improving quality of life and decreasing psychologic distress. Research conducted by Organic Conceptions identified a common set of predictable stages that couples experience on their journey to parenthood and developed the first cognitive-based online program for both women and couples to confront fear through validation and remind women they are people, not parts. Studies have shown that psychological interventions, particularly cognitive behavioral therapy, have actually been shown to double pregnancy rates in infertile women as well.

In sum, infertility and its treatment process is a physically and mentally challenging process for a significant number of couples across the world. In a society that has imposed the false view that fertility should come naturally and easily, many women struggling with infertility are left feeling insecure, anxious, depressed, angry, and even “inadequate as a woman.” [2] As research has shown, these negative emotions  can further inhibit their ability to conceive and may disrupt the treatment progress. As healthcare workers, we must recognize this psychological burden and strive to address these issues early on to maximize our patients’ quality of life and satisfaction with treatment.


[1] Infertility. (2019, January 16). Retrieved April 24, 2022, from

[2] Rich, C. W., & Domar, A. D. (2016). Addressing the emotional barriers to access to reproductive care. Fertility and Sterility, 105(5), 1124-1127. doi:10.1016/j.fertnstert.2016.02.017.

[3] Ramezanzadeh, F., Aghssa, M.M., Abedinia, N. et al. (2004). A survey of relationship between anxiety, depression and duration of infertility. BMC Women’s Health, 4(9).

[4] A.D. Domar, K. Gordan, J. Garcia-Velasco, A. La Marca, P. Barriere, F. Beligotti. (2012). Understanding the perceptions of emotional barriers to infertility treatment: a survey in four European countries. Hum Reprod, 27, 1073-1079

[5] C.S. Sejbaek, I. Hageman, A. Pinborg, C.O. Hougaard, L. (2013). Schmidt Incidence of depression and influence of depression on the number of treatment cycles and births in a national cohort of 42 880 women treated with ART. Hum Reprod, 28, 1100-1109

About the Author

Ariya Mobaraki

Dr. Mobaraki is an OB/GYN resident at Penn State Milton S. Hershey Medical Center and a graduate of Drexel University College of Medicine with an interest in infertility.  Since early childhood, he has always relied on thinking outside of the box with the goal of making others smile. He inherited this trait from his mother, a survivor of breast cancer who has lived with epilepsy for a majority of her life. His time spent caring for her has given Ariya the motivation to pursue meaningful connections with others and to help them through difficult times.

General Promo post banner 12

Pin It on Pinterest