Abstract
Purpose
This study aims to summarize and analyze the existing research on anxiety and depression within the field of assisted reproduction technology, exploring current hotspots, emerging frontiers, and trends, while offering insights for future research directions.
Methods
Relevant literature on anxiety and depression among assisted reproduction patients was retrieved from the Web of Science Core Collection up to December 31, 2023. The analysis, encompassing studies, countries, authors, institutions, keywords, and co-citation networks, was visualized using VOSviewer version 1.6.19 and the “bibliometrix” R package version 4.3.1.
Results
A total of 1458 studies were included in the analysis. The literature on anxiety and depression in assisted reproduction patients has shown a fluctuating upward trend. Human Reproduction was identified as the leading journal, with the highest citations across multiple journals. Boivin J emerged as the most prolific author, with Cardiff University contributing the most publications. The USA and China led in terms of both publications and citations. Highly cited studies were predominantly published between 1995 and 2007, with half of the included studies published before 2000. Key research hotspots included evidence synthesis, acupuncture treatment for infertility, and the mental health of patients undergoing assisted reproductive technology, particularly focusing on anxiety and depression.
Conclusion
As awareness of psychological health in assisted reproductive technology continues to grow, future research should focus on mitigating anxiety and depression to enhance patient outcomes and patient quality of life. Integrating psychological support and monitoring long-term psychological outcomes are crucial for optimizing assisted reproductive technology success and fostering holistic, patient-centered care.
Supplementary information
The online version contains supplementary material available at 10.1007/s10815-025-03422-8.
Keywords: Anxiety, Depression, Assisted reproductive technology, Bibliometric analysis
Introduction
According to the latest report from the World Health Organization (WHO), the global prevalence of infertility is 17.5% [1], and this rate continues to rise. Between 1990 and 2017, infertility increased annually by 0.37% in women and 0.29% in men [2]. Infertility is now recognized as the third most significant threat to human health, following tumors and cardiovascular diseases [3]. The development of assisted reproductive technology (ART) has provided hope for individuals facing infertility.
ART is a medical technique that employs methods involving eggs, sperm, fertilized eggs, and embryos to achieve fertilization. It encompasses techniques such as artificial insemination (AI), in vitro fertilization-embryo transfer (IVF-ET), and its derivatives [4]. Since the first successful IVF pregnancy in 1978, ART has been regarded as one of the most effective treatments for infertility [5].
Despite advancements that have improved clinical pregnancy rates, ART poses significant challenges for patients, including high costs, repeated invasive procedures, lengthy treatment cycles, and uncertainty about treatment success [6]. As a result, individuals undergoing ART often experience heightened psychological distress, particularly anxiety and depression [7, 8]. A meta-analysis of 53,300 infertility patients across 44 studies found that the prevalence of major depressive disorder, generalized anxiety, stress, and depression were 22.9%, 13.3%, 78.8%, and 31.6%, respectively [9]. Additionally, Gozuyesil et al. [10] found that 15% of women undergoing IVF-ET for the first time experience anxiety, while 18% experience depression.
These negative emotions not only reduce treatment adherence and cooperation but also trigger adverse physiological responses, such as elevated heart rate and blood pressure, which can negatively affect treatment outcomes and increase the risk of postoperative complications [11, 12]. Moreover, psychological distress can impact superovulation outcomes and egg quality during treatment [13, 14]. Intense emotional fluctuations may stimulate sympathetic nerve excitation, leading to the release of catecholamines, which cause uterine smooth muscle contractions and may impair embryo implantation, ultimately reducing pregnancy rate [15, 16]. Hence, it is crucial to pay attention to the psychological well-being of ART patients, provide effective psychological interventions to alleviate stress and negative emotions, and encourage positive coping mechanisms to enhance treatment efficacy.
With the continuous advancements in ART and the increasing demand for fertility treatments, research in this field has expanded significantly. However, the trends and thematic focus of research on ART-related anxiety and depression remain unclear. Therefore, a comprehensive bibliometric analysis is necessary to assess the current research landscape, emerging hotspots, and future directions in this field, providing valuable insights for clinical practice and future research development.
Methods
Search strategy
The Web of Science Core Collection (WoSCC, Clarivate Analytics) was selected as the most appropriate database for conducting a global-level bibliometric analysis [17, 18]. This study systematically retrieved bibliometric data on anxiety and depression in ART-related research. To ensure comprehensive coverage, we identified synonyms for “anxiety,” “depression,” and “assisted reproductive technology” using the MeSH database in PubMed. This research conducted a search for studies using subject-related search in the “title, abstract, and keywords” on the WoSCC. The search period encompassed the inception of the database up to December 31, 2023. There were no restrictions in terms of data category and document year. The detailed search strategy is provided in Supplementary Table 1.
Study selection
The retrieved literature was screened online according to the inclusion and exclusion criteria to obtain the final results.
Inclusion criteria: (1) Studies involving patients undergoing ART; (2) studies assessing anxiety, depression, or other negative psychological outcomes; (3) animal experiments that aim to explore mechanisms or psychological impacts relevant to human ART; (4) publications in the form of articles, reviews, or meeting abstracts; (5) no restrictions on language.
Exclusion criteria: (1) Studies unrelated to human-assisted reproduction, such as botanical research solely focusing on plant-based infertility treatments; (2) publication of research such as corrections, notes, and retracted articles; (3) duplicate publications.
Data analysis
Data visualization and bibliometric analysis were performed using VOSviewer (version 1.6.19) and the R package “bibliometrix” (version 4.3.1) to analyze the countries, institutions, authors, and keywords included in the literature. For results that could not be visualized using these tools, Microsoft Excel 2021 was used for data analysis, and the results were then supplemented in the form of charts or tables.
VOSviewer, developed by van Eck and Waltman, is a widely used tool for constructing and visualizing bibliometric networks, including their structure, evolution, and collaboration. In this research, VOSviewer was employed to visualize the collaborative relationships among authors and institutions, as well as the clustering of keywords. The size of each node represents the frequency of occurrence, the thickness of the lines indicates the strength of the connections, and the colors of the nodes signify different clustering relationships [19, 20]. For a comprehensive explanation, please refer to the analysis of the results.
Bibliometrix, a widely recognized R-based bibliometric software, is extensively used in data analysis and visualization in contemporary research [21]. It integrates data statistics and data visualization, enabling comprehensive analysis of co-citation, coupling, and co-word relationships [22]. In this study, the acquired data was imported into the Bibliometrix for an analysis of annual trends and research fields.
Results
Publication output and temporal trends
A total of 1458 relevant publications were identified based on the retrieval strategy (Supplementary Fig. 1), which were published from 1991 to 2023, averaging 66 publications per year. The annual publication trend demonstrated a generally fluctuating upward trajectory (Fig. 1). Before 2003, the annual number of research studies on anxiety and depression in ART patients was less than 20 publications. But since 2020, the number of annual publications has exceeded 100, with 2023 (133 studies, 9.12%) being the most prolific year. To assess research productivity, Price’s Law, a widely applied model for evaluating scientific output, was employed [23]. Data were exponentially adjusted and linearly fitted; we obtained the equation y = 3.5755e0.1177x (R2 = 0.9221), with the result of good fitting. This continuous increase in publications over time suggests that the issue of anxiety and depression in ART is gaining increasing attention, which can inform future research directions.
Fig. 1.
Global trend of annual publications
Prolific journals and cited journals
A total of 607 academic journals have published studies on anxiety and depression in ART. Table 1 lists the journals with more than ten publications. Human Reproduction (UK) had the largest number of studies (131), followed by Fertility and Sterility (71, USA), Journal of Assisted Reproduction and Genetics (26, USA), Journal of Psychosomatic Obstetrics and Gynecology (25, Netherlands), Reproductive Biomedicine Online (25, UK), Plos One (20, USA), Acta Obstetricia ET Gynecologica Scandinavica (19, Denmark), Human Fertility (18, UK), Journal of Reproductive and Infant Psychology (17, UK), Theriogenology (17, USA), European Journal of Obstetrics and Gynecology and Reproductive Biology (15, Netherlands), Frontiers in Psychology (13, Switzerland), International Journal of Environmental Research and Public Health (13, Switzerland), Journal of Dairy Science (12, USA), Journal of Psychosomatic Obstetrics and Gynecology (12, Netherlands), and Archives of Women’s Mental Health (11, Austria).
Table 1.
The journals with more than 10 publications ranked by publication number
| Rank | Journal title | n | IF*(2022) | TC | Region | H-index |
|---|---|---|---|---|---|---|
| 1 | Human Reproduction | 131 | 6.1 | 2079 | UK | 226 |
| 2 | Fertility and Sterility | 71 | 6.7 | 1188 | USA | 208 |
| 3 | Journal of Assisted Reproduction and Genetics | 26 | 3.1 | 273 | USA | 75 |
| 4 | Journal of Psychosomatic Obstetrics and Gynecology | 25 | 3.1 | 108 | Netherlands | 65 |
| 5 | Reproductive Biomedicine Online | 25 | 4 | 64 | UK | 111 |
| 6 | Plos One | 20 | 3.7 | 88 | USA | 332 |
| 7 | Acta Obstetricia ET Gynecologica Scandinavica | 19 | 4.3 | 197 | Denmark | 102 |
| 8 | Human Fertility | 18 | 1.9 | 50 | UK | 39 |
| 9 | Journal of Reproductive and Infant Psychology | 17 | 2.5 | 65 | UK | 47 |
| 10 | Theriogenology | 17 | 2.8 | 4 | USA | 133 |
| 11 | European Journal of Obstetrics and Gynecology and Reproductive Biology | 15 | 2.6 | 170 | Netherlands | 90 |
| 12 | Frontiers in Psychology | 13 | 3.8 | 8 | Switzerland | 110 |
| 13 | International Journal of Environmental Research and Public Health | 13 | 4.614** | 25 | Switzerland | 113 |
| 14 | Journal of Dairy Science | 12 | 3.5 | 11 | USA | 191 |
| 15 | Journal of Psychosomatic Obstetrics and Gynecology | 12 | 3.1 | 190 | Netherlands | 65 |
| 16 | Archives of Women’s Mental Health | 11 | 4.5 | 45 | Austria | 76 |
TC total citations
*Impact factor
**2021 impact factor
Geographically, most journals with more than ten publications were from the USA (5) and the UK (4), with the remaining journals coming from Netherlands (3), Switzerland (2), Denmark (1), and Austria (1). More than half of these journals belong to Reproductive Biology, Obstetrics, and Gynecology, with only two journals having an impact factor (IF) of more than 6. The IF of Human Reproduction (the most published journal) was 6.1 (2022), and the H-index was 226. Among the journals, the journal with the highest IF was 6.7 (2022), the Fertility and Sterility from the USA. It indicates that the studies published in this journal are influential in the field of anxiety and depression in ART patients. Although Plos One with the highest H-index was 332, may belong to multidisciplinary sciences. Archives of Women’s Mental Health had a small number of studies, with 11 studies.
In terms of citation impact, Human Reproduction was cited in the most journals (2079 times), followed by Fertility and Sterility (1188 times). The highest citation times of this journal may be due to it being the journal with the highest IF and the highest H-index in the field of anxiety and depression in ART patients. This also provides a direction for us to find relevant studies in the future. Journal of Assisted Reproduction and Genetics ranked third, with 273 times. The fifth and sixth, with more than 150 citations, were Journal of Psychosomatic Obstetrics and Gynecology (190 times) and European Journal of Obstetrics and Gynecology and Reproductive Biology (170 times), respectively. Figure 2 displays a dual-map overlay of journals from the included literature. The left side of the image represents the citing journals, which reflect the cutting-edge knowledge, while the right side shows the cited journals, indicative of the foundational knowledge. The lines connecting these two sections illustrate the citation relationships between the journals and their co-cited counterparts. In our study, the citing journals predominantly originated from interdisciplinary fields such as molecular biology, medicine, immunology, psychology, education, and public health. In contrast, the cited journals covered areas including molecular biology, genetics, medicine, nursing, health sciences, psychology, education, sociology, and related disciplines.
Fig. 2.
Relationships between journals and co-cited journals. The left section shows the citing journals (knowledge frontiers), while the right section represents the cited journals (foundational knowledge). The curved lines depict citation relationships, reflecting knowledge flow and interdisciplinary connections
Prolific authors
A total of 6125 authors contributed to the 1458 studies included in this analysis. In terms of the number of published studies, Boivin J (Cardiff University) leads the field of anxiety and depression in ART, with 30 studies (2.06%), followed by Schmidt L (21, 1.44%), Verhaak CM (17, 1.17%), Hammarberg K (14, 0.96%), and Domar AD (12, 0.82%). There were five authors who published 11 studies (0.75%), including Fisher JRW, Ng EHY, Svanberg AS, Tiitinen A, and Tulppala M (Table 3). In terms of citation frequency, Verhaak CM has been cited the most, up to 673 times. Boivin J, who published the most studies (30), is the second most frequently cited author after Verhaak CM, with 447 citations. Schmidt L was followed by Boivin J (cited 265 times), Hammarberg K (cited 226 times), Domar AD (cited 205 times), Fisher JRW (cited 188 times), Svanberg AS (cited 132 times), Tiitinen A (cited 124 times), Tulppala M (cited 124 times), and Ng EHY (cited 91 times). H-index was used to evaluate the influence of authors. The most influential author, Boivin J, had an H-index of 51, followed by Fisher JRW, with an H-index of 46. All of the top ten authors had an H-index greater than 20 (Table 2).
Table 3.
Top 10 institutions for anxiety and depression in assisted reproduction patients
| Rank | Institution | Region | n (%) | TC | Link strength |
|---|---|---|---|---|---|
| 1 | Cardiff University | UK | 40 (2.74) | 443 | 49 |
| 2 | Karolinska Institute | Sweden | 34 (2.33) | 393 | 26 |
| 3 | University of Copenhagen | Denmark | 34 (2.33) | 303 | 31 |
| 4 | University of Melbourne | Australia | 33 (2.26) | 251 | 20 |
| 5 | Tel Aviv University | Israel | 30 (2.06) | 144 | 8 |
| 6 | University of Helsinki | Finland | 29 (1.99) | 279 | 10 |
| 7 | Radboud University Nijmegen | Netherlands | 28 (1.92) | 894 | 8 |
| 8 | Shandong University | China | 28 (1.92) | 67 | 9 |
| 9 | University of Hong Kong | China | 27 (1.85) | 215 | 7 |
| 10 | University of Florida | USA | 26 (1.78) | 11 | 3 |
TC total citations
Table 2.
Top 10 authors of studies on anxiety and depression in assisted reproduction patients
| Rank | Author | Institution | n (%) | TC | H-index |
|---|---|---|---|---|---|
| 1 | Boivin J | Cardiff University | 30 (2.06) | 447 | 51 |
| 2 | Schmidt L | University of Copenhagen | 21 (1.44) | 265 | 42 |
| 3 | Verhaak CM | Radboud University Nijmegen | 17 (1.17) | 673 | 34 |
| 4 | Hammarberg K | Monash University | 14 (0.96) | 226 | 32 |
| 5 | Domar AD | Inception Fertility | 12 (0.82) | 205 | 29 |
| 6 | Fisher JRW | Monash University | 11 (0.75) | 188 | 46 |
| 7 | Ng EHY | University of Hong Kong | 11 (0.75) | 91 | 45 |
| 8 | Svanberg AS | Uppsala University | 11 (0.75) | 132 | 22 |
| 9 | Tiitinen A | University of Helsinki | 11 (0.75) | 124 | 36 |
| 10 | Tulppala M | University of Helsinki | 11 (0.75) | 124 | 24 |
TC total citations
Half of the top ten author institutions were in European; others were from Australia, the USA, and China. From the visualization map, it is evident the authors with more publications and higher central position tend to cooperate closely with other authors. It can be seen from Supplementary Fig. 2 that there were mainly four research teams in author cooperation, of which author Boivin J was the leader, with the highest frequency and the closest cooperation with other authors among the research teams. In the field of anxiety and depression in ART patients, most authors conducted research independently, and there was a lack of communication and cooperation between authors. However, highly published scholars, such as Boivin J, Schmidt L, and Verhaak CM, acted as core members, bridging the entire author collaborative network.
Distribution of institutions
A total of 53 institutions with more than eight publications were involved in this field (Supplementary Fig. 3). The ten institutions with the highest number of publications are listed in Table 3. Cardiff University (40 records, 2.74% of all studies) contributed the most publications, followed by the Karolinska Institute and University of Copenhagen, each with 34 records (2.33%), University of Melbourne (33, 2.26%), Tel Aviv University (30, 2.06%), University of Helsinki (29, 1.99%), Radboud University Nijmegen (28, 1.92%), Shandong University (28, 1.92%), University of Hong Kong (27, 1.85%), and University of Florida (26, 1.78%). To explore potential collaborations among institutions, we conducted a co-authorship analysis using VOSviewer. Among co-authored institutions publishing more than eight studies (Supplementary Fig. 3), the five institutions with the highest total link strength were Cardiff University (total link strength 49), University of Copenhagen (31), Karolinska Institute (26), Macquarie University (25), and Uppsala University (22). Among these institutions, universities were the main contributors, followed by hospitals. From the network, indicating that Cardiff University and the University of Copenhagen played a pivotal role in the cooperative relationships among institutions.
Prolific countries
The authors contributed were from 82 countries. The USA and China were the leading countries in terms of both publications and citations. The USA (264, 18.11%) published the most studies, followed by China (186, 12.76%), the UK (126, 8.64%), and Italy (101, 6.93%). Countries with fewer than 100 studies were Australia (86, 5.90%), Netherlands (68, 4.66%), Iran (60, 4.12%), Japan (59, 4.05%), France (58, 3.98%), and Turkey (56, 3.84%) (Table 4). The annual number of studies published by these countries shows a fluctuating trend. The number of published studies in the USA has decreased slightly in recent years, while the number of published studies in China has risen rapidly (Fig. 3A).
Table 4.
The top 10 productive countries
| Rank | Country | n (%) | TC | Link strength |
|---|---|---|---|---|
| 1 | USA | 264 (18.11) | 9070 | 124 |
| 2 | China | 186 (12.76) | 2599 | 32 |
| 3 | UK | 126 (8.64) | 3964 | 104 |
| 4 | Italy | 101 (6.93) | 1816 | 51 |
| 5 | Australia | 86 (5.90) | 2275 | 47 |
| 6 | Netherlands | 68 (4.66) | 3820 | 46 |
| 7 | Iran | 60 (4.12) | 800 | 10 |
| 8 | Japan | 59 (4.05) | 639 | 5 |
| 9 | France | 58 (3.98) | 889 | 29 |
| 10 | Turkey | 56 (3.84) | 696 | 4 |
TC total citations
Fig. 3.
A The annual publication number and trend of the 10 most productive countries. Different colors represent different countries, and the area of the bars indicates the volume of publications. The length of the bars represents the total annual publication volume of the top ten countries. B Distribution and international cooperation of countries that are involved in anxiety and depression in assisted reproduction patients. In the co-authorship network diagram of countries, the scientific connections between different countries are arranged radially to form a circle. A line connecting two points indicates a co-authorship relationship between them. The thicker the line, the stronger the co-authorship connection between the countries
Among the top ten productive countries, the highest citation was the USA (9070 citations), followed by those from the UK (396,427 citations), Netherlands (3820 citations), China (2599 citations), Australia (2275 citations), Italy (1816 citations), France (889 citations), Iran (800 citations), Turkey (696 citations), and Japan (639 citations). The network diagram in Fig. 3B clearly shows the collaboration patterns between nations. Notably, the USA, the UK, and China stand out as the countries with the highest publication output and the most significant involvement in international cooperation.
Articles analysis
Table 5 presents the top ten most frequently cited references related to studies on anxiety and depression in ART patients. These highly cited studies were published between 1995 and 2007, with half of them appearing before 2000. The top four studies have citation frequencies exceeding 100, with values of 151, 112, 108, and 101, respectively. “Women’s emotional adjustment to IVF: a systematic review of 25 years of research,” published by Verhaak CM et al. in Human Reproduction Update in 2007, received the most frequent citation. This study explored how women emotionally adjust to the various stages of IVF treatment, including anxiety, depression, or general distress. Eugster A’s 1999 study, titled “Psychological aspects of in vitro fertilization: a review” published in the journal Social Science and Medicine, has garnered the second highest number of citations. This study has been cited a total of 112 times, emphasizing psychological reactions before entering an IVF procedure, during an IVF treatment, and after both unsuccessful and successful IVF. Among the top ten most frequently cited studies, eight focused on the negative emotions experienced by ART patients and their coping strategies. This observation suggests that people have long been concerned about the adverse emotions of patients receiving ART treatment and how to deal with them. With the continuous development of ART, people are paying more attention to the impact of patients’ emotions on treatment outcomes. The dissemination of these research findings has played an important role in facilitating how to respond to ART treatment-related psychological problems.
Table 5.
Top 10 most frequently cited references related to studies on anxiety and depression in assisted reproduction patients
| Rank | Title | First author | Year | DOI | TC |
|---|---|---|---|---|---|
| 1 | Women’s emotional adjustment to IVF: a systematic review of 25 years of research | Verhaak CM | 2007 | 10.1093/humupd/dml040 | 151 |
| 2 | Psychological aspects of in vitro fertilization: a review | Eugster A | 1999 | 10.1016/s0277-9536(98)00386–4 | 112 |
| 3 | Infertility and psychological distress: a critical review of the literature | Greil AL | 1997 | 10.1016/s0277-9536(97)00102–0 | 108 |
| 4 | Psychological impact of infertility | Cousineau TM | 2007 | 10.1016/j.bpobgyn.2006.12.003 | 101 |
| 5 | A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer | Klonoff-Cohen H | 2001 | 10.1016/s0015-0282(01)02008–8 | 97 |
| 6 | The fertility problem inventory: measuring perceived infertility-related stress | Newton CR | 1999 | 10.1016/s0015-0282(99)00164–8 | 96 |
| 7 | Prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic | Chen TH | 2004 | 10.1093/humrep/deh414 | 89 |
| 8 | Coping style and depression level influence outcome in in vitro fertilization | Demyttenaere K | 1998 | 10.1016/s0015-0282(98)00089–2 | 88 |
| 9 | The effect of anxiety and depression on the outcome of in-vitro fertilization | Smeenk JMJ | 2001 | 10.1093/humrep/16.7.1420 | 86 |
| 10 | Stress level across stages of in-vitro fertilization in subsequently pregnant and nonpregnant women | Boivin J | 1995 | 10.1016/s0015-0282(16)57,858–3 | 84 |
TC total citations
Research hotspot and co-occurrence keyword clustering network analysis
Co-occurrence analysis of keywords can reflect research hotspots and trends. We analyzed a total of 91 keywords from 3040 keywords related to anxiety and depression in ART, each with a frequency of six or higher (Supplementary Fig. 4, Fig. 4). High-frequency keywords included infertility (376 times), in vitro fertilization (281 times), assisted reproductive technology (239 times), anxiety (216 times), and depression (216 times), and the frequency of other keywords were less than 100 times. Following this analysis, 91 keywords were categorized into six clusters, representing six main research directions. Cluster 1 focused on the psychological strain caused by infertility, particularly its impact on women and marital dynamics. It encompassed coping mechanisms, fertility treatments, and gender-specific mental health nuances. Essentially, this cluster encapsulated infertility’s psychological and social ramifications, alongside individuals’ resilience-seeking endeavors. Cluster 2 explored the psychological and social dimensions of ART within familial contexts. It addressed distress during fertilization, the unique pressures associated with multiple births, and postpartum support. It also contemplated male infertility’s psychological impacts, gender roles, and the ramifications of reproductive donation on individuals’ well-being. Cluster 2 highlighted the psychological effects of ART at both the individual and familial levels, as well as its enduring influence on parent–child relationships and personal welfare. Cluster 3 concentrated on the psychosocial effects of fertility treatment postpartum, such as postpartum depression, and the challenges faced during treatment, including oocyte retrieval, pain, ovarian stimulation, and endometriosis. This cluster emphasized the dual physical and psychological challenges women experience during fertility treatment and postpartum and how these challenges impact mental health. Cluster 4 delved into the psychological toll of depression and stress on infertile couples, notably amidst the COVID-19 crisis. It explored interventions like acupuncture and the efficacy of IVF-ET, along with their implications for reproductive outcomes and women’s well-being. This cluster unveiled infertility’s psychological facets amid epidemiological challenges and clinical practices. Cluster 5 focused on in vitro fertilization technology and related reproductive processes, exploring biological aspects such as hormone levels, behavioral responses, and emotional well-being, as well as the application of antidepressant medications. This cluster also included animal reproduction, particularly artificial insemination in dairy cows and embryo cryopreservation techniques. It highlighted the integration of ART, biomedical research, and studies on its emotional effects, emphasizing the diversity and complexity of both human and animal reproductive behavior. Cluster 6 concentrated on the ethical considerations of ART, such as reproductive counseling services, and the emotional connections within couples and during the reproductive process. It examined the impact of reproductive technology on quality of life and addressed ethical concerns. This cluster underscored the importance of ethical, psychological, and interpersonal dimensions in ART and its potential impact on quality of life and interpersonal relationships.
Fig. 4.
Co-occurrence analysis of keywords of research on anxiety and depression in assisted reproduction patients. Each node represents a keyword, and the lines connecting the nodes indicate the co-occurrence of these keywords in the literature. The thickness of the line corresponds to the frequency of co-occurrence, with thicker lines indicating a higher frequency of simultaneous appearance and a stronger relationship between the keywords. Different colors are used to distinguish between clusters based on the strength of the associations between keywords
Trends in anxiety and depression in assisted reproductive populations research and themes distribution
The dynamic overview of the research trends in ART from 1991 to 2023 is illustrated in Fig. 5A. The line lengths represent the duration of each research trend, and the blue circles represent the frequency of keyword bursts, offering a visual depiction of how interests in the field have evolved. Notably, mental health concerns associated with infertility and ART, particularly anxiety and depression, have consistently emerged as significant areas of study throughout this period. The accumulation of original research and the progression of evidence-based medicine have led to a noticeable increase in systematic reviews and meta-analyses. This trend reflects a growing commitment to evidence-based practices, aiming to enhance rational pharmacological use and support scientifically grounded decision-making and health management in infertility treatments.
Fig. 5.
A Annual hotspot outbreak trajectory trend. The blue circles represent the frequency of keyword occurrences, while the length of the lines indicates the duration of the keyword’s presence over time. B Strategic distribution of anxiety and depression in assisted reproduction patients. The four quadrants are defined based on the centrality and density of the themes. A position further to the right on the horizontal axis indicates a more central topic, while a position higher on the vertical axis reflects a deeper, more developed theme
The focus on reproductive health has broadened substantially in recent years, surpassing the mere absence of disease in the reproductive process to encompass a holistic view of well-being, which includes physical, psychological, and social aspects. This expanded perspective extends the discourse on reproductive health beyond the confines of mental health, integrating it into a wider socio-economic, sociological, and interdisciplinary context.
The thematic map in Fig. 5B categorizes research topics into four quadrants, each illustrating distinct characteristics. The first quadrant depicts motor themes, signifying high-maturity core topics. The second quadrant features highly developed and isolated themes, representing mature yet isolated topics. The third quadrant showcases emerging or disappearing themes, indicating topics that recently emerged or may soon decline. Lastly, the fourth quadrant encompasses basic and transversal themes, indicating low-maturity topics that may evolve into future hotspots or trends. The size of the bubbles on the map correlates with the frequency of keywords, while their positioning reflects the degree of development and thematic relevance. Our analysis identifies current research frontiers, such as mental health, acupuncture, pregnancy rates, and multiple pregnancies. Additionally, areas like pain management, embryo preservation, and ovarian stimulation, despite being well-developed, may not currently be prioritized in research agendas. Interest in animal inbreeding research has decreased over time. Infertility and its treatments, alongside IVF and meta-analysis, are categorized as basic and transversal themes, indicating foundational areas of research with broad applicability across different fields.
Discussion
Current research landscape
In recent years, the rising prevalence of infertility has significantly increased the demand for ART. While ART offers hope to infertile patients, it also imposes substantial psychological burdens, which may directly or indirectly affect treatment outcomes. Consequently, there has been growing interest in the relationship between negative emotions and ART, particularly research on anxiety and depression, which has seen a notable increase. From 2013 to 2023, publications on this topic have more than doubled.
Among the 1458 studies published in 607 academic journals, “Human Reproduction” in the UK and “Fertility and Sterility” in the USA stand out for their prolific output, supported by their impressive IF and H-indices. Boivin J from Cardiff University is the most prolific author in this field, highlighting the institution’s strong research capabilities, especially in biomedical, biological sciences, and psychology. Similarly, Verhaak CM’s 2007 update on “Women’s emotional adjustment to IVF: a systematic review of 25 years of research” has become the most cited document in the field. Monash University holds a significant position in the ART research due to its historic achievement of producing the world’s first IVF baby. In general, institutions with a substantial number of publications serve as key nodes within the collaboration network, fostering cooperation with other entities.
Geographically, half of the top ten authors come from European countries, including the UK, Denmark, and Finland. Meanwhile, the USA and China lead in publication volume, driven by advanced medical infrastructure, strong economic power, and increasing demand for ART. Notably, in China, the relaxation of family planning policies (such as the two-child and three-child policies) and the acceleration of population aging have significantly increased the demand for ART treatments. These demographic and policy shifts have directly and indirectly fueled the need for ART treatments.
Research hotspots and gaps
Keyword clustering analysis reveals that anxiety and depression have received considerable attention in ART research, particularly with the adoption of the bio-psycho-social medical model and ongoing advancements in ART research. Although organic diseases or functional abnormalities are major causes of infertility, a significant number of patients are diagnosed with unexplained infertility. This diagnostic gap has shifted focus toward the psychosocial dimensions of infertility, giving rise to the concept of “psychological infertility” [24]. Clinical studies have confirmed that negative emotional states, such as perceived stress, anxiety, and depression, are significantly associated with adverse pregnancy outcomes in ART patients [25, 26]. For example, patients with chronic anxiety and depression often exhibit elevated levels of catecholamines and cortisol, hormones that negatively affect pregnancy outcomes [27, 28]. Turner et al. [29] further demonstrated that higher levels of negative emotions correlate with fewer follicles and lower chances of pregnancy.
At the same time, advancements in evidence-based medicine have accelerated the development of systematic reviews and meta-analysis on anxiety and depression in ART. The emphasis on evidence synthesis has become more increasingly apparent. In addition to traditional psychotherapy, acupuncture has gained widespread acceptance as an alternative and complementary therapy in clinical practice. A significant body of research attests to its effectiveness in addressing female infertility [30] and suggests that it may also improve sperm quality in males [31]. A systematic review and meta-analysis, which included data from 27 randomized controlled trials, indicated that acupuncture not only improves pregnancy rates but also plays a significant role in alleviating stress, anxiety, and depression [32].
Future research directions
Despite the significant progress made, several key gaps in the field still require further exploration. While infertility does not directly threaten life, its presence and treatment processes profoundly affect patients’ marital and sexual relationships, psychological well-being, and social interactions [33, 34]. ART treatments are accompanied by complex emotional challenges, with negative emotions potentially persisting even after treatment. Yoshimasu et al. [35] indicated that, although ART generally shows a weak association to mother-infant emotional bonding, it may increase the risk of negative maternal emotions, such as emotional detachment or anger/rejection, especially in multiparous women. Therefore, there is a pressing need for more longitudinal studies to evaluate the long-term psychological outcomes of ART patients, particularly regarding parent–child relationships, postpartum mental health, and the broader impact on family dynamics.
Further research by La Rosa et al. [36] found that ART mothers experience higher stress levels compared to the general population, but psychological support interventions may improve both mental well-being and parent–child relationships. Long-term psychological assessments can help refine strategies or enhance psychological support, thereby improving overall treatment effectiveness and patient satisfaction. Additionally, further exploration of the interaction between psychological factors and ART outcomes can reveal how long-standing emotional issues affect physiological processes, such as hormone regulation and implantation success [25–27]. Thus, studying the long-term psychological impact on ART patients is crucial for enhancing their overall quality of life, fostering healthy parent–child relationships, and optimizing treatment interventions.
Finally, integrating psychological support into standard ART treatment protocols remains a critical direction for future research. Currently, studies on psychological interventions are often conducted independently of ART treatments, limiting their practical applicability. Future research should explore how to seamlessly incorporate psychological support into ART care pathways, ensuring that patients receive holistic, patient-centered care. By addressing these research gaps, future studies can contribute to optimizing ART outcomes and improving overall quality of life for patients.
Conclusion
This bibliometric analysis examines research on anxiety and depression in ART patients, highlighting its growing significance. While ART offers hope, emotional distress during and after treatment can negatively impact pregnancy outcomes and overall well-being. Despite advances in evidence-based medicine and alternative therapies like acupuncture, psychological interventions remain largely separate from ART care. Addressing these gaps through longitudinal studies, interdisciplinary collaboration, and the integration of mental health support into ART protocols is essential. Future research should focus on holistic, patient-centered approaches to enhance psychological well-being, optimize ART outcomes, and improve overall quality of life.
Supplementary information
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Supplementary file5 (DOCX 3.50 MB)
Acknowledgements
Helpful comments by anonymous reviewers are acknowledged with thanks.
Author contribution
Yongjia Zhou: conceptualization, methodology, investigation, data curation, software, formal analysis, visualization, project administration, writing—original draft, writing—review and editing. Qingyong Zheng: conceptualization, methodology, investigation, data curation, software, formal analysis, visualization, project administration, writing—original draft, writing—review and editing. Caihua Xu: data curation, software, validation, writing—review and editing. Yiyi Li: data curation, software, validation, writing—review and editing. Tengfei Li: data curation, software, validation, writing—review and editing. Lin Li: formal analysis, visualization, writing—review and editing. Li Wang: visualization, writing—review and editing. Jinhui Tian: conceptualization, methodology, validation, writing—original draft, writing—review and editing, supervision. Guangmei Xie: conceptualization, methodology, validation, writing—original draft, writing—review and editing, supervision.
Data availability
Data are available in a public, open-access repository. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval
The data sources for this study were taken from publicly available databases. Ethical approval was not required to be obtained for this study.
Consent for publication
Not applicable.
Conflict of interest
The authors declare no competing interests.
Provenance and peer review
Not commissioned; externally peer-reviewed.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yongjia Zhou and Qingyong Zheng contributed equally to this work.
Contributor Information
Jinhui Tian, Email: tjh996@163.com.
Guangmei Xie, Email: xgm721201@163.com.
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Associated Data
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Supplementary Materials
(PNG 144 KB)
(PNG 238 KB)
(PNG 305 KB)
(PNG 151 KB)
Supplementary file5 (DOCX 3.50 MB)
Data Availability Statement
Data are available in a public, open-access repository. The data that support the findings of this study are available from the corresponding author upon reasonable request.