Table 3.

Characteristics of the included studies: Female.

References	Title	Study Design	Sample size & Age	Duration of infertility	Inclusion criteria	Cause(s) of infertility	Methods of cortisol measurement	Day, time and types of biological sample collected	Findings	Conclusion/comments
(22)	Endocrine Markers of Fertility Potential in Reproductive Age Women with Idiopathic Hyperprolactinemia (HP)	Cross sectional study	82: 27 healthy women 23.6 ± 0.3 years old, 33 patients with endocrine sub fertility with idiopathic HP (24.4 ± 0.3 years old), and 22 fertile women with idiopathic HP with mean age of 23.5 ± 0.4 years old.	Not stated	Group 0: healthy women who had pregnancy in 2 years back without any gynaecological pathology, without any lactation history Group 1: Infertility for at least two years of unprotected, timed intercourse, and a stable increase of serum prolactin level. Group 2: women with pregnancy 2 years back year but serum prolactin level was increased. The diagnosis of HP occurred before pregnancy and a year after child-birth.	IdiopathicHyperprolactinemia	Serum cortisol was assessed using (“Elisas”) immunoassay analyzer “Ultra Microplate Reader - Elx808”(USA).	Serum; from 8 to 9 am, within the early follicular phase (5-7 days of the menstrual cycle).	Group 0: 475,27 ± 140,59 Group 1 503,84 ± 238,21and Group 2 700,18 ± 352,59nm/l. The cortisol level was higher in the subfertile patients in relation to fertile women in condition of hyperprolactinemia by 37%.	Infertility due to idiopathic hyperprolactinemia elevates serum cortisol level. However, we need to take into account the altered prolactin level in this case, which may disrupt the function of HPA axis, hence the level of cortisol. This may not be the case for the other types of infertility.
(27)	Intensive hormone monitoring in women with unexplained infertility: evidence for subtle abnormalities suggestive of diminished ovarian reserve	Case-control prospective study	24 (12 infertile and 12 healthy control) average age of infertile women 33.2 ± 1.3 years; healthy: 32.8 ± 1.2	4.4 ± 0.8 years	25-40 years old; normal tubal and peritoneal anatomy; 121 ovulatory menstrual cycles from 26 to 32 days; BMI between 18 and 28 (kg/m2>. The male partner had no evidence of male factor infertility.	Unexplained infertility	Serum cortisol level was measured with ELISA using streptavidin technology as the detection system.	blood was taken every other day until the onset of menstruation.	No significant differences in the cortisol level between the groups (P = 0.141), nor was the interaction between group and phase (P = 0.72).	Unexplained infertility had no significant effect on serum cortisol level.
(10)	Interactions of Cortisol and Prolactin with Other Selected Menstrual Cycle Hormones Affecting the Chances of Conception in Infertile Women	prospective cohort study.	305 (205 infertile [26.7 ± 1.9 years] and 100 fertile women [26.8 ± 1.8 years]	Not stated	primary infertility; first entered for infertility therapy, no prior hormone treatment, patent fallopian tubes; no male factors.	Nothing specified	On the third day of the cycle cortisol level was assessed using electrochemiluminescence method using the Cobas c6000 analyzer.	Serum; obtained in the morning (3rd day of the cycle and 7 days after ovulation)	Infertile women recorded higher cortisol compared to the control during each phase of the menstrual cycle (p < 0.001) 3rd day, control: 138.54, infertile: 157.50 ug/dL 7th day after ovulation, control: 143.91, infertile: 216.51 ug/dL. Cortisol level after ovulation in infertile group was negatively correlated with LH during ovulation, progesterone after ovulation, estradiol during and post-ovulation, follicle size, and endometrial thickness during and post-ovulation (r<0, p<0.05). 17 out of 205 infertile women achieved pregnancy (8.3%). Women with + HCG test had significantly lower level of cortisol compared to those with -HCG test result (p < 0.001; 3rd day of the cycle 113.12 versus 161.62 µg/dL; during ovulation 162.24 versus 216.95 µg/dL; after ovulation 163.18 versus 221.46 µg/dL, respectively).	Increased cortisol in infertile women decreased the pre-ovulatory LH peak and estradiol, postovulatory estradiol, affecting the endometrial growth, and conception chances.
(25)	Low 11-deoxycortisol to cortisol conversion reflects extra-adrenal factors in the majority of women with normo-gonadotrophic normo-estrogenic infertility	Case-control study	49 (clomiphene citrate-resistant infertile=26, obese ovulatory control=11, lean ovulatory control=12). Mean age of infertile subjects 33 ± 5 (25 ± 44) obese (34 ± 5), lean 33 ± 4	Not stated	normoestrogenic, normo-gonadotroph, oligomenorrhoeic, witha history of oligomenorrhoea, otherwise healthy and had no endocrine disorders	oligomenhorrea	Cortisol level was assessed using solid-phase 3H radioimmunoassay	Serum; Collected between 0800 and 0900, after 12 h of fasting. Blood collected more than 3 months prior to inclusion in the study.	Comparisons of morning cortisol levels indicated similar morning cortisol concentrations (0.47 ± 0.15, 0.45 ± 0.16 and 0.47 ± 0.18 nmol/l) between 3 groups.	The authors concluded that extra adrenal factors were involved in infertility syndromes studied.
(23)	SIRTI and cortisol in unexplained infertile females; a cross sectional study, in Karachi Pakistan	cross sectional study	135 infertile cases (31.13 ± 5.7) and 207 fertile control (31.22 ± 6.02)	Duration of marriage, 8.03 ± 4.68 for fertile, and 8.47 ± 5.83 years for infertile groups	Infertile: duration of infertility more than two years, subjects aged between 16 and 45 years, from all ethnic backgrounds. Control: healthy females, aged between 16 and 50 years, with a child less than 5 years of age, from all ethnic groups.	Unexplained infertility	Serum cortisol was assessed using enzyme linked immunosorbent assay (ELISA) kits.	Venous blood; collected from 8 till 9 am	The cortisol level in fertile females was 9.98 ± 1.88 (ug/ml), and infertile group was 15.66 ± 7.73(ug/ml), which is significantly higher in the infertile group (<0.01).	In unexplained infertility cortisol level is significantly elevated.
(24)	Hair Cortisol Concentrations as a Biomarker to Predict a Clinical Pregnancy Outcome after an IVF Cycle: A Pilot Feasibility Study	Case-control study	43 subjects with a mean age of 36.3 ± 4.36 years [pregnant: 36.3 ± 4.76, non pregnant: 36.35 ± 3.97]	18.37 ( ± 8.68) in months	BMI of 19–30 kg/m2, no prior fertility treatments, undergoing in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) or in vitro fertilization with preimplantation genetic diagnosis (IVF/PGD), with delayed embryo transfer under the (GnRH) antagonist protocol	Female factor (46.5%), male factor (37.2%), mixed factor (16.2%)	Hair cortisol concentration was measured with a salivary ELISA cortisol kit and expressed in pg/mg	Hair sample was collected on T1: 2nd consultation with reproductive endocrinologist prior to first IVF cycle; T2: 12 weeks following post-transfer visit with the study coordinators (T2), days before human chorionic gonadotropin pregnancy test.	For pregnant women HCC at T1 was 364.63 (571.44) [mean (SD)] and non-pregnant women was 181.06 (169.74) Women with a negative pregnancy test had higher HCC at T2 (181.06 pg/mg vs. 741.06 pg/mg, p < 0.001) but HCC at T2 was not statistically different between pregnant women when compared to non-pregnant women. There were no statistical differences between HCC at T1 and HCC at T2. When BMI, time of infertility, number of follicles and age were included in model as covariates, an interaction effect was noticed between HCC at T1 and T2 F (1, 31) = 0.71, p = 0.01, and η2 = 0.16	HCC might be a promising biomarker to calculate the probability of pregnancy in women using assisted reproductive technologies.
(28)	Pituitary-adrenal and sympathetic nervous system responses to psychiatric disorders in women undergoing in vitro fertilization treatment	Prospective study.	264 (The infertile patient that remained non-pregnant, mean age was 33.4 (3.9). vs Infertile that conceived 33.1 (4.1)	7.0 (3.5) years.	Women that came for their first cycle of IVF or ICSI treatment, regular menstrual cycles and no hormonal contraceptive use.	Male factor, female factors, and explained	Cortisol level was measured by radioimmunoassay	Blood samples were taken in the luteal phase before treatment (T1) and on the day of oocyte retrieval (T2) between 8:00 and 9:00 AM.	There is no significant difference in cortisol levels at T1 between the pregnant and nonpregnant women, but at T2, serum cortisol was lower in the conception cycles (P<.001). Serum cortisol in nonpregnant women on T1 was 238.7 (78.2) (nmol/L). Follicular cortisol in the nonpregnant group was significantly higher than the pregnant group (P<.001). Serum cortisol on T2 was significantly correlated with the respective follicular values in all patients (P<.001).	Cortisol concentration imposes negative influence on pregnancy outcome in infertility treatment.
(29)	Prospective study of pregnancy outcome between perceived stress and stress-related hormones	Prospective study	128 (pregnant vs non-pregnant: Mean age ranging from pregnant: 32.75 ± 5.28, non-pregnant: 32.94 ± 4.04)	Not stated	Women aged 40 and below, undergoing the first IVF cycle, capable of completing anxiety and stress test	Primary and secondary	Serum cortisol level was measured through enzyme-linked immunosorbent assay.	Blood samples were collected at 8:00–8:30 on the morning of menstrual cycle day 3	No significant difference was found in cortisol, between the pregnant (18.4 ug/L) and nonpregnant (21.4 ug/L) groups. The cortisol level was significantly related to SDS score.	The authors found significantly higher level of salivary amylase and angiotensin II compared to cortisol in non- pregnant infertile women than the pregnant ones.
(7)	The influence of stress and state anxiety on the outcome of IVF-treatment: Psychological and endocrinological assessment of Swedish women entering IVF-treatment	Case-control prospective study	44 (22 infertile vs 22 fertile controls) infertile (33.4 ± 2.3 years) and fertile (33.1 ± 2.5 years old)	infertility treatment for 3.1 ± 1.6 years and waiting list before treatment was 4.3 ± 1.5 years	Infertile: Primary/secondary infertility, regular menstruation, male partners with normal spermiogram on at least 2 occasions; control: fertile, regular menstruation	Tubal infertility	Serum cortisol level was assessed using DELFIA fluoroimmunoassay kits	Blood samples; collected during a normal natural cycle in the morning between 07.30 h and 08.30 h, on days 3, 10–15 and 19–26.	There was a significant difference in the serum cortisol (p>0.01) during the entire menstrual cycle. There was no significant difference in the plasma cortisol measured between 8–12 o’clock on cycle day 3 between the pregnant and non-pregnant infertile women, and between fertile and infertile women. No significant correlation was reported between the hormonal measure and Karolinska Scales of Personality variables and total STAI scores.	On day 3 of the cycle no significant difference was seen in the cortisol level between the study groups.
(26)	Reproductive problems and intensity of anxiety and depression in women treated for infertility	Case-control study	200 (fertile control 100 and infertile 100) Mean age: infertile: 26.7 ± 1.9 Years, fertile: 26.8 ± 1.8	Not stated	Infertile: Women aged 23−30 with infertility Control: Fertile women with at least two children, and used the mechanical means of contraception during the study.	None specified	Cortisol level was assessed at Diagnostyka Group authorized laboratory	Blood was collected on day of ovulation (without hormonal stimulation)	The serum cortisol concentration was higher in infertile women (212 μg/dl and 217 μg/dl on average) than fertile women (141 μg/dl and 144 μg/dl on average). Cortisol also was higher in non-pregnant women (217 μg/dl and 221 μg/dl on average) than pregnant women (162 μg/dl and 163 μg/dl on average). In infertile women, the cortisol level during and post-ovulation is positively correlated with the severity of trait and state anxiety, symptoms of anxiety and depression.	Emotional state of women undergoing IVF treatment is worse than fertile women.
(30)	Psychological and Hormonal Changes in the Course of in Vitro Fertilization	Prospective study	113	Not stated	Women (age 23-47), completed elementary education, had been previously treated for infertility for at least 2 years, no history of psychological or psychiatric disorders.	Not stated	Cortisol concentration was assessed using the Coat-A-Count and the Double Antibody kits	Baseline measures were taken during early follicular phase (days 3-5 of the cycle), in the morning	The conceived and non-conceived groups recorded normal range of cortisol level at about 15-17 ~µg/dl and remained in this range until the ovum pickup day. On embryo transfer day, a decline in cortisol level was seen in both groups. In luteal phase on expectation of pregnancy results, the cortisol level was increased to 21-22 µg/dl in both groups. Significance correlation was found between cortisol and prolactin level in phase I, III, and IV of IVF treatment in non-conceiving group.	Hormonal and endorphin mediation may play an important role in successful IVF outcome.