Infertility is accompanied by many forms of physical difficulties as well as psychological distress, ranging from the difficulty in conceiving to giving birth. The prevalence of depressed mood in women undergoing infertility has been reported to be similar to that in patients with heart disease [10]. Recent studies have demonstrated that the prevalence of depression in women with infertility is increasing and can be as high as 40% in contrast to the general population [12]. In reality, being infertile leads to a deep sense of loss, low self-esteem, and loss of identity, and these feelings can cause depression. Simionescu et al. [14] discovered that infertility can lead to social isolation and psychological distress, leading to reduced interaction with family and friends, which can intensify feelings of loneliness and depression. As infertility persists, a woman may experience loss of interest, gradually withdrawing from socializing, and experience difficulty with daily activities, consequently losing social adaptability [15]. The resulting ongoing distress can bring about a vicious cycle of infertility, especially a chronic stage.

The infertility treatment process itself also triggers significant emotional stress. The invasive nature of infertility treatments and uncertainty about treatment outcomes can cause considerable psychological distress. This process requires women to not only endure physical but also emotional strain, which tends to increase distress. This has a negative impact on the mental health and overall quality of life of infertile women. Massarotti et al. [16] reported that high levels of anxiety and depression among women undergoing infertility treatment act as a psychological burden during the infertility treatment process, directly contributing to negative treatment outcomes. Conversely, unsuccessful infertility treatments can also have a negative impact on the overall quality of life and self-esteem of infertile women. These failures can cause tension in the interpersonal relationships of women and, in some cases, increase their social isolation [17]. If the emotional stress of the infertility treatment process is prolonged, it can lead to prolonged depression. Joseph and Whirledge [18] emphasized the importance of long-term mental health support as women may experience persistent mental health issues even after completion of infertility treatment. Thus, it is important to assess and manage emotional distress in infertile women in the long term as well as the short term.

Psychological stress can disrupt female sex hormonal balance by promoting the release of stress hormones such as cortisol, which may affect the signaling pathways that regulate reproductive function [19]. These conditions can hamper the functioning of the immune system, which can trigger an inflammatory response, negatively impacting the reproductive health [20]. Elevated cortisol levels, commonly a result of both acute and chronic stress, can impair these signaling pathways further, disrupting functions including ovulation, fertilization, and embryo implantation. This primarily affects the hypothalamic-pituitary-gonadal axis, leading to decreased production of gonadotropins and subsequently reduced fertility potential [21].

Psychosocial stress can affect the production of progesterone and estrogen, the main hormones related to the process of pregnancy [19]. These hormones play an essential role in preparing for and maintaining pregnancy, and stress-induced hormonal imbalances can contribute to infertility. Previous studies have shown that women who experience high levels of stress are at increased risk for ovulation issues and infertility [22]. Depression as a comorbidity is also strongly associated with infertility. Individuals with depression experience social isolation, difficulties in sleep, and eating problems, all of which can affect reproductive health. Specifically, depression can disrupt biological rhythms, which can disturb hormonal secretion and increase the risk of infertility [20]. Thus, psychological stress affects infertility through various pathways, manifesting as a disruption of the body’s hormonal balance and physiological processes. Therefore, emotional management is critical during a woman’s pregnancy plan.

Psychosocial stress not only affects the possibility of pregnancy but also has a significant impact on the overall process and outcome of infertility treatment. Women with high levels of psychological stress are less likely to follow prescribed infertility treatment protocols and are more likely to maintain unhealthy lifestyle habits. This can reduce the effectiveness of the treatment, consequently reducing the treatment success rate [23]. Kim et al. [24] examined factors affecting intention to continue infertility treatment among women undergoing assisted reproductive techniques and reported that patients with higher levels of emotional distress were significantly less likely to continue treatment. Thus, psychological stress can have a massive impact on women undergoing infertility treatment, causing them to discontinue treatment prematurely [25]. Assessing and managing the effect of psychosocial stress on infertility treatment is critical during the course of infertility treatment, and managing a patient’s mental health is vital to increasing the success rate of treatment. This can help patients better understand the treatment process and ensure they get the care they need (Figure 1).

Although infertility is considered primarily a women’s issue, it has a considerable impact on men as well. Social pressure to conceive can create feelings of inadequacy and failure in infertile men, which can be a powerful trigger for depression and anxiety. The prevalence of mental health issues among infertile men is known to be significant, but the problem is not easily recognized and is less likely to lead to treatment [26]. Men diagnosed with infertility often perceive their infertility status as a failure in their lives, which can lead them to experience mental health issues such as depressive disorders and anxiety disorders [26,27]. The stress from infertility makes it difficult for men to express their feelings and ask for emotional support, which creates a vicious cycle aggravating social isolation and undermining psychological stability [28]. Prolonged depression can have a serious impact on a man’s daily life, interpersonal relationships, and social functions.

Research by Wischmann and Thorn [29] highlights the psychosocial challenges faced by men dealing with infertility, emphasizing the benefits of targeted psychological interventions like cognitive behavioral therapy and support groups. These interventions are crucial as they address the unique needs of infertile men, helping to reduce feelings of isolation and improve coping strategies.

Moreover, a qualitative study by Hanna and Gough [30] delves into men’s experiences with infertility, illustrating how personalized counseling helps in navigating the complex emotions and societal pressures associated with infertility diagnoses.

In a society, men are held responsible for carrying on the family line and having children. When infertility issues prevent them from fulfilling these roles, men experience deep doubts about their “masculinity” and low self-esteem. In a social environment that is reluctant to acknowledge infertility as a men issue, it is taboo to discuss these issues openly, which can lead men to internalize their identity issues, and this can lead to serious emotional distress [31]. This internalized stress can make it more challenging for men to admit to themselves that they have infertility issues [32]. The effect of infertility on men’s psychology and emotions is complex, and understanding and coping with these issues is an important challenge for men with infertility.

Men with infertility problems often do not get the social support they need, which is a major factor that contributes to their emotional distress [33]. There is a need for tailored support programs and open dialogue for men with infertility, which can play a huge role in helping men deal with emotional issues related to infertility in a healthy manner (Figure 1).

Psychotherapy is an important treatment option to alleviate the emotional stress experienced by infertile patients. Infertility causes severe stress in a patient’s life, which can often lead to depressive disorders or anxiety disorders. Psychotherapy helps to reduce this emotional burden and to improve the individual’s psychosocial functions. Individuals experiencing infertility often struggle to come to accept their difficulties, and these feelings can lead to chronic stress. Psychotherapy can help process these negative feelings and promote healthy emotional responses [34].

The main psychotherapeutic methods include cognitive behavioral therapy, behavioral activation therapy, group psychotherapy, and psychoanalysis. First, cognitive behavioral therapy teaches infertile patients how to identify and manage negative thoughts and emotions. This therapy helps patients develop healthier thought patterns during stressful situations and teaches them how to cope more effectively with stressful situations [35,36]. Behavioral activation therapy is especially useful for infertile patients with depressive symptoms and encourages patients to engage in positive activities, which can help them break negative emotional patterns and experience improvement of depressed mood [37]. As the personal activity increases, the patient’s self-esteem and confidence improves, which contributes to better overall functioning of the patient. Group psychotherapy provides an opportunity for people experiencing infertility to share their experiences and receive empathy and support. This provides participants with a sense of belonging and helps reduce isolation. Sharing experiences within a group can help patients better understand and accept their feelings [38]. Finally, psychoanalysis focuses on exploring the unconscious and early experiences of the infertile patient to understand and address the impact of infertility on the patient’s emotional state [39]. It helps patients gain a deeper understanding of their feelings and attitudes, identify connections between past experiences and current feelings, and learn how to manage the psychological stress that results from them [40].

In a study comparing cognitive behavioral therapy and pharmacotherapy in women with infertility, both cognitive behavioral therapy group and pharmacotherapy group with fluoxetine reported significant improvements in depressive symptoms compared to the control group, and the cognitive behavioral therapy group exhibited more significant improvements in distress from infertility compared to the pharmacotherapy group [35].

Therefore, psychotherapy is as effective as pharmacotherapy in improving emotional functioning and reducing psychological stress, such as depression and anxiety, in infertile patients. Specifically, cognitive behavioral therapy and behavioral activation are extremely useful in reducing depression and anxiety experienced during infertility treatment, which can have a positive impact on fertility rates [41].

Finally, it is imperative to consider the individual needs and circumstances of the patient when conducting psychotherapy. Therapists need to understand the patient’s cultural and personal background and tailor their approach accordingly. Moreover, they should also periodically evaluate the effectiveness of the treatment and adjust the treatment plan as needed. Active participation from the patient and a trusting relationship with the therapist are paramount for effective psychotherapy [42].

When a woman is diagnosed with a psychiatric condition such as depressive disorders or anxiety disorders, various forms of psychotropic medication may be prescribed. Antidepressants are the most commonly used psychopharmacological drugs, effectively improving mood, reducing anxiety, and promoting emotional stability [43]. Psychopharmacotherapies include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, and mood stabilizers, and, if necessary, anxiolytic medications such as benzodiazepines may also be used temporarily [44,45].

SSRIs, which are most commonly used to treat depressive disorders or anxiety disorders in infertile women, work by regulating serotonin levels in the brain to reduce depressive or anxious symptoms, ameliorating emotional difficulties and reducing psychological stress in their daily lives. However, each person’s response to the drug often varies, so consistent monitoring and tailored prescription is necessary [46].

Although SSRIs have various side effects, they are often temporary. However, side effects such as sexual dysfunction can cause a variety of challenges for women and men with infertility. Since sexual dysfunction is likely to be associated with failure of infertility treatment, which can lead to poor adherence to depression treatment in infertile patients, specialists should determine the choice of medication and dosage very carefully, and should regularly check the patient’s condition to establish an optimal treatment plan [47].

Integrative treatment combines the benefits of psychopharmacologic agents with the supportive interactions provided by psychotherapies to improve patients’ overall treatment satisfaction and outcomes. This approach can play a vital role in maximizing treatment effectiveness and preventing relapse [48].

Infertile patients may be reluctant to engage in pharmacotherapies to help them achieve a successful pregnancy, even if they have comorbid depressive disorders or anxiety disorders. Electroconvulsive therapy and transcranial magnetic stimulation, as biological treatments, improve emotional health by regulating neurophysiological processes without the use of medication.

First, electroconvulsive therapy uses electric stimulation of the brain to rebalance neurotransmitters to relieve symptoms [49]. Recent studies such as “Predictors of Electroconvulsive Therapy Outcome in Major Depressive Disorder” (Su et al. [50]) highlight the effectiveness of electroconvulsive therapy, especially in treatment-resistant depression, with modern techniques reducing cognitive side effects. This could offer therapeutic benefits to patients experiencing severe psychological stress due to infertility. Electroconvulsive therapy can induce a rapid depressive symptomatic response, and therefore, can be applied to infertile patients with severe depression. Transcranial magnetic stimulation is a noninvasive method that uses magnetic fields to target specific areas of the brain and can treat depressive disorders and anxiety disorders in infertile women who are reluctant to take antidepressants [51]. “Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression” (Cole et al. [52]) presents rapid remission results in severe depression, suggesting that transcranial magnetic stimulation can be a non-invasive alternative for managing infertility-related depression. Although light therapy has been used primarily to treat seasonal affective disorder, it can also promote emotional stability by resetting the biological clock and improving hormonal balance in infertile patients who experience depressive symptoms associated with lack of sunlight. Light therapy is also well known its affordability while high reliable [53,54]. Patients’ overall health and psychological state should be thoroughly evaluated before applying these biological treatments. This helps determine the suitability of the treatment and minimize side effects. Specifically, severity of depression, previous treatment response, and patient preferences must be considered. Finally, the side effects and safety of each treatment method should be explained. Common side effects include transient amnesia with electroconvulsive therapy, headaches or scalp pain with transcranial magnetic stimulation, and eye strain or headaches with light therapy; thus, it is important to take this into consideration and plan the treatment according to the patient’s condition [49-54].

Digital therapy has gained traction as a way to manage and treat emotional stress in patients by using modern, advanced digital technologies. These therapies are conducted through a variety of digital platforms and tools, especially virtual reality (VR), mobile apps, and web-based psychotherapy programs are used. Digital therapies, including VR, mobile apps, and web platforms, support stress management anytime, anywhere. These technologies offer flexibility, tailoring treatment to individual needs [55,56].

Benefits of digital therapy include greater accessibility. They can provide specialized treatment services across time and space to anyone with internet access [57]. They are also more cost effective than traditional face-to-face therapy [55,58]. However, digital therapies may be limited in capturing emotional connection or nonverbal cues due to the lack of direct face-to-face interaction between patient and therapist, and [59] not all users are skilled in using digital technology. Therefore, for older users or those who are less technologically adept, these technological barriers may limit access to treatment. Additionally, technical errors or system failures may also interfere with the treatment process [60].

Notably, digital therapeutics for psychological stress management in infertility is just beginning and are still limited in application, but literature suggests that they are amply competitive. In a preliminary study of an internet-based psychological/physical intervention for infertile women, Clifton et al. [61] demonstrated significant reductions in depression, anxiety, and infertility stress in the intervention group compared to the control group; Bjornsdottir et al. [56] reported significant reductions in depressive symptoms and general stress as well as infertility stress after an internet-based cognitive behavioral therapy program, ”Overcome Fertility Stress,” was administered to women experiencing infertility stress. Digital therapies have great potential to improve physical and mental health by effectively managing the psychological stress from the infertility treatment process as well as relevant mental illnesses, such as depression or anxiety disorders, which could have a positive impact on increasing pregnancy success rates.

Digital therapies will be able to attain a competitive edge over traditional psychological intervention in the future if technological advances, including the elemental incorporation of artificial intelligence, and more sophisticated personalized approaches are applied.