Reassessing psychosocial care in infertility: a systematic review and meta-analysis of bias-adjusted psychological and reproductive outcomes

Infertility is associated with substantial psychological distress. Although psychosocial interventions are increasingly incorporated into fertility care, previous reviews have reported inconsistent findings, particularly regarding clinical pregnancy outcomes, and have variably addressed publication bias and evidence certainty. This systematic review and meta-analysis followed PRISMA 2020 guidelines and was registered in PROSPERO (CRD420251033421). MEDLINE, Embase, Cochrane CENTRAL, PsycINFO, and CINAHL were searched to April 23, 2025. Randomised controlled trials evaluating theory-based psychosocial interventions among individuals or couples undergoing infertility treatment were included. Risk of bias was independently assessed by two reviewers using the Cochrane Risk of Bias 2 tool. Random-effects meta-analyses were conducted for depression, anxiety, infertility-related stress, quality of life, and pregnancy outcomes. Publication bias was assessed using funnel plots and Egger’s and Begg’s tests, with trim-and-fill analyses where indicated. Prespecified subgroup analyses compared individual- and couple-based interventions. Evidence certainty was assessed using GRADE. Forty-four trials involving 7,373 participants met the inclusion criteria, and 37 contributed to meta-analysis. Unadjusted analyses showed reductions in depression (SMD = −0.68), anxiety (SMD = −0.61), and infertility-related stress (SMD = −0.55), and higher odds of pregnancy (OR = 1.40, 95% CI 1.06 to 1.85). No significant effect was observed for quality of life. After trim-and-fill adjustment, the effect on depression was attenuated (SMD = −0.37, P = .060), anxiety and infertility-related stress were no longer statistically significant, and the pregnancy benefit was no longer evident (OR = 1.05, 95% CI 0.77 to 1.43). Excluding high-risk studies similarly attenuated the pregnancy effect (OR = 1.19, 95% CI 0.91 to 1.58). No significant subgroup differences were observed. Evidence certainty ranged from low to very low. Primary analyses suggested an association with reduced depressive symptoms; however, this association was substantially attenuated after adjustment for potential publication bias, limiting confidence in the observed effect. Evidence regarding anxiety, infertility-related stress, quality of life, and pregnancy outcomes remains uncertain. Psychosocial interventions may nevertheless have a supportive role in addressing psychological needs during infertility care. Further adequately powered, registered randomised controlled trials with standardised outcome assessment are needed.