JBRA Assisted Reproduction 2025;29(Suppl.2 SBRA 2025):198
Poster Presentation
29^th Annual Congress of the SBRA. São Paulo/SP - Brazil, 2025
doi: 10.5935/1518-0557.20263887

P-186. Psychological Stress and Pregnancy Outcomes in Assisted Reproduction: An Integrative Review

Drielly dos Reis Franzoi¹, Raissa de Jesus Faria¹, Jullia Almeida Menezes¹, Gabriela de Souza Silva¹, Ana Luisa Garcia Longo¹, Amanda Inocêncio Sarkis¹, Maria Monica Pereira¹

¹ Centro Universitário São Camilo - São Paulo - SP - Brasil

Objective: To evaluate the association between levels of psychological stress and/or anxiety and reproductive outcomes, such as clinical pregnancy and embryo implantation rate, in women undergoing assisted reproduction treatments.
Methods: An integrative review was conducted to address the question: "In women undergoing assisted reproduction, is exposure to high levels of psychological stress associated with poorer reproductive outcomes compared to patients with low stress levels?" In July 2025, searches were performed in MEDLINE via the Virtual Health Library (VHL) and PubMed, LILACS via VHL, and Scopus via Elsevier. The main descriptors (DeCS/MeSH) included "in vitro fertilization," "psychological stress," "anxiety," "pregnancy outcomes," and "implantation rate," combined using Boolean operators AND, OR, and NOT, and adapted to each database. Filters applied included date limits (last 10 years), study types (observational studies, randomized clinical trials, reviews, and systematic reviews), and full-text availability. The PECO acronym guided inclusion criteria (P: women undergoing IVF/ICSI; E: high levels of stress/anxiety; C: absence or lower levels of stress/anxiety; O: reproductive outcomes). Studies unrelated to the topic or without free full-text access were excluded.
Results: The search yielded 85 articles, of which 13 were included in the final review. Among the ten studies directly investigating the association between stress/anxiety and reproductive outcomes, five reported a negative impact on assisted reproduction success. Only one study reported implantation rates: 21.56% in the low anxiety group, 18.91% in the moderate anxiety group, and 7.14% in the high anxiety group. Other studies observed lower clinical pregnancy and live birth rates in women with high anxiety levels. Anxiety levels were consistently higher in patients undergoing assisted reproduction, especially during critical treatment periods. Divergences exist regarding the most stressful phase of treatment. While two studies identified embryo retrieval day as the most critical, based on the State-Trait Anxiety Inventory (STAI) and Beck Anxiety Inventory (BAI), another, assessing cortisol levels alongside STAI, indicated that peak stress occurs on oocyte retrieval day, with lower levels during embryo transfer. Interventions such as acupuncture and psychological support demonstrated reductions in anxiety and increased clinical pregnancy rates. Psychological counseling, particularly on embryo transfer day, was highlighted for its potential positive effect on implantation rates. Recent findings indicate fertility-related stress, measured by the Fertility Problem Inventory, correlates with Doppler parameter changes suggestive of decreased endometrial receptivity, suggesting a physiological pathway influencing outcomes. Conversely, five studies found no significant association between anxiety levels (STAI) on retrieval and transfer days and IVF/ICSI success; one study reported elevated noradrenaline levels (p=0.015) in women without clinical pregnancy. Regarding biomarkers, one study showed elevated cortisol levels in follicular fluid associated with higher fertilization rates (p=0.004), suggesting that stress did not negatively impact outcomes. Additionally, two studies indicated that psychological factors and related interventions did not directly influence treatment success rates but improved patients' emotional well-being.
Conclusion: The available evidence is heterogeneous and inconclusive, with limited support for an association between anxiety and reproductive outcomes. These findings underscore the importance of psychological follow-up as an integral part of care in assisted reproduction and highlight the need for prospective controlled studies systematically evaluating the influence of emotional factors on pregnancy outcomes.