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Journal of Obstetrics and Gynaecology
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The efficacy of cognitive behavioural therapy on
stress, anxiety and depression of infertile couples:
a systematic review and meta-analysis
Sedigheh Abdollahpour, Ali Taghipour, Seyedeh Houra Mousavi Vahed &
Robab Latifnejad Roudsari
To cite this article: Sedigheh Abdollahpour, Ali Taghipour, Seyedeh Houra Mousavi Vahed &
Robab Latifnejad Roudsari (2021): The efficacy of cognitive behavioural therapy on stress, anxiety
and depression of infertile couples: a systematic review and meta-analysis, Journal of Obstetrics
and Gynaecology, DOI: 10.1080/01443615.2021.1904217
To link to this article: https://doi.org/10.1080/01443615.2021.1904217
Published online: 10 Jun 2021.
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REVIEW ARTICLE
The efficacy of cognitive behavioural therapy on stress, anxiety and depression
of infertile couples: a systematic review and meta-analysis
Sedigheh Abdollahpour
a
, Ali Taghipour
b
, Seyedeh Houra Mousavi Vahed
c
and Robab Latifnejad Roudsari
d,e
a
Department of Midwifery, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran;
b
Social
Determinants of Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran;
c
Department of Obstetrics and Gynecology,
Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran;
d
Nursing and Midwifery Care Research Center, Mashhad
University of Medical Sciences, Mashhad, Iran;
e
Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical
Sciences, Mashhad, Iran
ABSTRACT
Infertility is considered globally to be a stressful and hard experience that affects the couples psycho-
logically, socially and individually. The aim of this study was to systematically review the effectiveness
of cognitive behavioural therapy (CBT) on depression, stress and anxiety in infertile couples. In this sys-
tematic review and meta-analysis, databases were searched up to August 2019. Twelve articles were
included in the meta-analysis and analysed with Comprehensive Meta-Analysis (CMA) v2. The results of
pooled studies showed that the mean scores for depression and anxiety decreased in patients receiv-
ing CBT as compared to the control group. The results of three pooled studies showed no significant
difference on stress in patients receiving CBT as compared to the control group. The findings of this
study provides valuable suggestions for improving mental health status through applying CBT to
manage anxiety and depression in infertile couples.
KEYWORDS
Cognitive behavioural
therapy; stress; anxiety;
depression; infertility
Introduction
A couple are considered infertile if their unprotected sexual
intercourse after a full year does not lead to pregnancy (with-
out using contraception methods) (Berek 2007). All over the
world, infertility is considered as a stressful and hard experi-
ence that affects the couple psychologically, socially, indi-
vidually and culturally (Latifnejad Roudsari et al. 2011), and
therefore requires special reproductive and sexual health
attention (Ndegwa 2016; Gerrits et al. 2017).
Approximately, 80 million people are identified as infertile
couples in the world, with an outbreak ranging from 5 to
30% in different countries (Vayena et al. 2009). The preva-
lence of infertility in Iran is about 13.2%, of which 2.5% is
due to primary causes of infertility and 2–3% is due to sec-
ondary causes (Direkvand Moghadam et al. 2013).
Consequences and problems associated with infertility are
reported in 95.2% of men and 35% of women (Kamali et al.
2007; Sepidarkish et al. 2016).
Different dimensions of infertility at the individual and
social levels lead to psychological problems, lower self-
esteem, frustration, social isolation and even divorce (Anokye
et al. 2017). For example, the rate of depression in this cou-
ple is 79%, the rate of anxiety is 41% and the rate of stress is
69% (Yusuf 2016). Such couples are often subjected to con-
tempt, insults and scandals and are under pressure in the
cultural context, and are often encouraged to divorce and
remarriage by others (Dyer 2007; Amiri et al. 2015). Infertile
men are often involved in antisocial behaviours such as
smoking, alcohol abuse and prostitution (Berg and Wilson
1991). Infertility not only causes emotional problems at the
individual level (grief and depression), even leads to family-
level behaviours such as domestic violence, polygamy (Dyer
2007; Anokye et al. 2017) and poor quality of life for couples
(Martins et al. 2016). At the social level, infertility exposes the
couples to sexually transmitted diseases and AIDS (Dhont
et al. 2010), and at the economic level, the couples have to
carry the cost of health and traditional and biomedical
expenses. These couples are psychologically exposed to
depression and anxiety, lower self-esteem and dissatisfaction
(Nachtigall 2006), and exhibit behaviours such as anger, des-
pair and worthlessness, concern about sexual attractiveness,
isolation, physical complaints and sexual dissatisfaction, and
usually they need counselling and psychological treatment
(Slade et al. 2007).
So far, various psychotherapy methods have been con-
ducted with the aim of reducing the psychological harm of
infertile couples (Boivin 2003; Maleki-Saghooni et al. 2017).
Cognitive behavioural therapy (CBT) is one of the strongest
types of psychological method that focuses on rooting out
individual problems (Cuijpers et al. 2013). By examining indi-
vidual’s behaviours and personality, CBT identifies
CONTACT Robab Latifnejad Roudsari latifnejadr@mums.ac.ir Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences,
Mashhad, Iran
ß2021 Informa UK Limited, trading as Taylor & Francis Group
JOURNAL OF OBSTETRICS AND GYNAECOLOGY
https://doi.org/10.1080/01443615.2021.1904217
maladaptive behaviours and negative thoughts then, by
changing ineffective beliefs and introducing a new behaviour
it increases the individual’s power of adaptation and com-
patibility with problems (Beck 2011). Cognitive behavioural
therapy challenges people through techniques such as posi-
tive programming, relaxation and meditation, respiratory
techniques, physical activity, effective communication and
self-expression, problem-solving skills, negative opinion con-
trol and anger management (Lapp et al. 2010; Beck 2011)to
reduce the symptoms of diseases such as stress, depression,
anxiety, post-traumatic stress, chronic pain, panic disorder,
social phobia and marital conflicts (Butler et al. 2006). Since
stress, anxiety and depression of infertile couples could dem-
onstrate their psychological status, and the impact of cogni-
tive behavioural therapy on these attributes of infertile
couples has not been studied yet through a systematic
review and no reliable evidence exists on this topic, this
study aimed to investigate the effect of CBT on depression,
stress and anxiety in infertile couples.
Methods
This study is a systematic review that was registered at
Mashhad University of Medical Sciences, Mashhad, Iran in
February 2018. This systematic review was conducted accord-
ing to guidelines from the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement
(Moher et al. 2009). On the basis of the PICO (patient, prob-
lem or population; intervention; comparison, control or com-
parator; outcome) approach and the review by Kaltenthaler
et al. (2008), the criteria for inclusion were identified.
The main steps for writing this systematic review study
consisted of explaining the research question, extraction of
key words, searching in available data bases, extraction of
articles according to the selection criteria, checking the qual-
ity of articles according to the checklist, and assessment of
risk of bias. The research question was as follows: Do CBT
improve mental health (anxiety, depression, stress) in patients
with infertility?
For extraction of MeSH terms, key words considering both
British and American spellings were considered. A search
strategy combining the following search terms was used to
ensure complete coverage of studies: (‘infertility’OR ‘infertile
women’OR ‘infertile men’OR ‘infertile couple’) AND
(‘cognitive behavioral’OR ‘cognitive behavioral therapy’
OR ‘CBT’).
The search for relevant literature was conducted in 10 bib-
liographic databases, which are as follows: Web of
Science ¼3, PubMed ¼5, Embase ¼2095, Magiran ¼1,
Seciencedirect ¼1, Clinikalkey ¼23, SID ¼2, Scopus ¼806,
Google Scholar ¼12300, PsycINFO ¼1.
After removing duplicates identified in databases and ref-
erence lists, titles and abstracts of the texts were scanned to
examine indications for meeting the inclusion criteria. For all
remaining articles that deemed relevant, the full text was
reviewed. All information from the included studies was
collected by one reviewer and checked by the second,
independently.
The criteria for entering the study included experimental
or quasi-experimental studies with control groups which
focused on all infertile couples or individuals (men and
women) who were at each stage of the diagnosis or treat-
ment of various stages of infertility. The control group did
not receive any psychological intervention. They were either
on waiting lists or received routine care. The language of
studies was in Persian and English. The cognitive behavioural
interventions were provided in a variety of settings (i.e. indi-
vidual, couple or group; inpatient or outpatient) and the out-
come of studies included depression, stress and anxiety was
measured by a standard questionnaire.
Exclusion criteria included: non-interventional studies,
review articles, studies that have examined other variables as
the outcome.
The following key components of the included studies
were extracted and tabulated by two reviewers: general infor-
mation including first author, country of origin, number of
couples, sex of the patients, study design; characteristics of
the intervention:, numbers and duration of sessions, duration
and format of intervention; the efficacy of the interventions
based on the outcome measures including anxiety, depres-
sion, stress, the scale used for their measurement and quality
score (Table 1).
Study quality was assessed using the Jadad score (Moher
et al. 1995). Taking into account the difficulties in blinding,
we used a modified scale (Jadad et al. 1996). This scale
included three items: (1) Was the study designed as rando-
mised? (2) Was the study designed as double blind? (3) Was
there a description of withdrawals and drop outs? (for a total
of five points). In modified Jadad scale includes eight items:
(4) Were the objects of the study defined? (5) Were the out-
come measures defined clearly? (6) Was there a clear descrip-
tion of the inclusion and exclusion criteria? (7) Was the
sample size justified? (8) Was there a clear description of the
interventions? (9) Was there at least one control group? (10)
Was the method used to assess adverse effects described?
(11) Were the methods of statistical analysis described? These
eight items were answered ‘Yes’or ‘No’, which had a total of
eight points. The maximum possible score was 13, and more
than nine points was identified as good. Any disagreements
in the quality assessment between two reviewers were
resolved by discussion. The data from the evaluation of the
articles were recorded by Jadad scale in SPSS software (SPSS
Inc., Chicago, IL) and descriptive statistics. The quality ratings
for each criterion in each study and the total scores are
shown in Table 2.
Checking the risk of bias was done based on Cochrane
risk of bias tool (Higgins et al. 2008).
Results
Study selection
In the first screening, duplicates were identified, and titles
and abstracts were reviewed. A total of 44 studies were
found potentially relevant and reviewed independently by
two reviewers. The number of articles excluded was due to
the fact that in two articles cognitive-behavioural counselling
2 S. ABDOLLAHPOUR ET AL.
Table 1. Characteristics of included studies.
Author Country
Participant
I: intervention
C: control
(final analysis) Study design Intervention format
Number of
session
Intervention
duration (weeks)
Outcome:
A: anxiety
D: depression
S: stress
Quality score
J: jaded 0–5
MJ: modified Jadad 0–13
J (MJ)
McNaughton (McNaughton-Cassill
et al. 2002)
USA I: 43 (43)
C: 37 (37)
NRCT Couple 8 3 D: BDI
A: BAI
1 (9)
Nilforooshan (Nilforooshan et al. 2006) Iran I: 30 (30)
C: 30 (30)
RCT Group 6 6 D: BDI 1 (9)
1-Faramarzi (Faramarzi et al. 2008) Iran I: 42 (29)
C: 40 (30)
RCT Group 10 10 D: BDI
A: Cattell
3 (11)
Noorbala (Noorbala et al. 2008) Iran I: 288 (288) UCT Couple –24 D: BDI 0 (7)
1-Mosalanejad (Mosalanejad et al. 2012b) Iran I: 32 (32)
C: 33 (33)
RCT Group 12 12 D: DASS
A: DASS
S: DASS
2 (10)
2-Mosalanejad (Mosalanejad et al. 2012a) Iran I: 16 (16)
C: 15 (15)
RCT Group 15 16 D: DASS
A: DASS
S: DASS
2 (10)
Heidari (Heidari et al. 2002) Iran I: 55 (55)
C: 55 (55)
RCT individual 3 2 A: Speil Berger 2 (10)
Khalatbari (Khalatbari et al. 2011) Iran I: 15 (15)
C: 15 (15)
RCT Group 8 12 D: BDI
A: Cattell
1 (8)
2-Faramarzi (Faramarzi et al. 2013) Iran I: 42 (29)
C: 40 (30)
RCT Group 10 10 S: FPI 2 (10)
Talaei (Talaei et al. 2014) Iran I: 15 (10)
C: 15 (15)
RCT Group 10 10 D: BDI
D: HAM_D
2 (10)
Hamzehpour (Hamzehpour Tahereh and
Taher 2009)
Iran I: 15 (15)
C: 15 (15)
RCT Group 8 16 A: Cattell 1 (9)
Domar (Domar et al. 2000) USA I: 56 (20)
C: 63 (14)
RCT Group 10 24–48 A: STAI
D: BDI
2 (10)
Gharaie (Gharaie et al. 2004) Iran I: 30 (30)
C: 30 (30)
NRCT Group 10–15 3 A: Speil Berger 0 (8)
Ramezanzadeh (Ramezanzadeh et al. 2011) Iran I: 70 (70)
C: 70 (70)
RCT Couple 6–8 24 D: BDI 1 (9)
DASS21: Depression Anxiety Stress Scales; BDI: Beck Depression Inventory; FPI: completed fertility problem inventory; NRCT: non-randomised controlled trial; RCT: randomised controlled trial; UCT: uncontrolled trial (pre–-
post); HAM_D: Hamilton Rating Scale for Depression; STAI: State Trait Anxiety Inventory; BAI: the Beck Anxiety Inventory.
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3
was provided through the Internet, 26 did not study the
effect of the outcome, or did not meet the criteria for inclu-
sion, two articles were old and the remained article were not
available. Finally, 14 articles were included in the study.
Figure 1 shows a flowchart of the study selection process.
The study characteristics are summarised in Table 1. Based
on the outcome, 14 studies were aimed at reducing stress,
depression and anxiety. In these studies, stress, anxiety and
depression were studied either single or in combination. In
terms of design, there were 10 RCT studies, three NRCT stud-
ies and one UCT study. In these studies, three cases of couple
counselling, one individual counselling and 10 group coun-
selling were selected as the type of intervention design. Data
were extracted and analysed by Comprehensive Meta-
Analysis software, Version 2 (CMA.V2) and random
effects model.
Methodological quality and risk of bias of the
included studies
All included studies were methodologically assessed with the
original Jadad scale and the modified additional methodo-
logical criteria. The original Jadad scores ranged from 0 to 5
with a mean of 1.42, and the modified total quality scores
ranged from 1 to 13 with a mean of 9.2. In this study, the
score of 8 and above 8 was considered as quality studies, all
articles being included in this criterion. The methodological
quality of these studies was reasonably good.
In assessing the risk of bias, we used Cochrane Risk of
Bias tool for interventional studies. The results indicated that
the random sequence generation criterion was: (low risk of
bias ¼71.4%, high risk of bias ¼21.4%, unclear risk of bias
¼7.1%). The allocation concealment criterion was as (low
risk of bias ¼7.1%, high risk of bias ¼21.4%, unclear risk of
bias ¼71.4%). The blinding of participants and personnel
was: (low risk of bias ¼0%, high risk bias ¼14.3%, unclear
risk of bias ¼85.7%). The blinding of outcome assessment
was: (low risk of bias ¼0%, high risk bias ¼14.3%, unclear
risk of bias ¼85.7%). The incomplete outcome data criterion
was (low risk of bias ¼57.1%, high risk bias ¼14.3%, unclear
risk of bias ¼28.6%). The selective reporting criterion was:
(low risk of bias ¼85.7%, high risk bias ¼0%, unclear risk of
bias ¼14.3%). The intention to treat criterion was: (low risk
of bias ¼78.6%, high risk bias ¼7.1%, unclear risk of bias ¼
14.3%). Author’s judgments of risk of bias presented as per-
centages for each included study and across all included
studies are shown in Figures 2 and 3.
Depression
Depression was measured using Beck’s Depression Inventory
(BDI) (Domar et al. 2000; McNaughton-Cassill et al. 2002;
Nilforooshan et al. 2006; Faramarzi et al. 2008; Noorbala et al.
2008; Hamzehpour Tahereh and Taher 2009; Ramezanzadeh
et al. 2011; Talaei et al. 2014) and Depression Anxiety Stress
Scales (DASS21) (Mosalanejad et al. 2012a,2012b). A total of
10 articles reported qualitative synthesis of the effect of CBT
on depression, which was published in McNaughton’s article.
Also, in the Noorbala and Khalatbari’s paper, although the
Table 2. Modified Jadad scores (original Jadad criteria þ8 additional criteria).
Study
First part of Jadad Additional criteria
12 3 45 6 7 8 91011
Randomised
Double
blind
Withdrawals and
dropouts
Defined
object
Outcome
measures
Inclusion and
exclusion criteria
Sample
size justified
Description of the
interventions
Control
group
Effects
described
Statistical
analysis Jadad
Total
scores
McNaughton 0 0 1 1 1 1 1 1 1 1 1 1 9
Nilforooshan 1 0 0 1 1 1 1 1 1 1 1 1 9
1-Faramarzi 2 0 1 1 1 1 1 1 1 1 1 3 11
Noorbala 0 0 0 1 1 1 1 1 1 1 0 0 7
1-Mosalanejad 1 0 1 1 1 1 1 1 1 1 1 2 10
2-Mosalanejad 1 0 1 1 1 1 1 1 1 1 1 2 10
Heidari 1 0 1 1 1 1 1 1 1 1 1 2 10
Khalatbari 1 0 0 1 1 1 1 1 1 1 0 1 8
2-Faramarzi 1 0 1 1 1 1 1 1 1 1 1 2 10
Talaei 1 0 1 1 1 1 1 1 1 1 1 2 10
Hamzehpour 1 0 0 1 1 1 1 1 1 1 1 1 9
Domar 1 0 1 1 1 1 1 1 1 1 1 2 10
Gharaie 0 0 0 1 1 1 1 1 1 1 1 0 8
Ramezanzadeh 1 0 0 1 1 1 1 1 1 1 1 1 9
4 S. ABDOLLAHPOUR ET AL.
level of depression was examined, but it could not be homo-
genized with other reported values and so was excluded
from the meta-analysis. Finally, nine items of depression
scores were analyzed by mean difference and standard devi-
ation and the number of sample size of the intervention and
control groups. Of these, seven articles evaluated the depres-
sion score using standard Beck inventory, in which meta-anal-
yses were done to increase the homogeneity of the
instruments, separately. The result of nine pooled studies
showed that mean of depression decreased in patients
receiving counselling as compared to the control group
(difference between mean total depression score ¼0.531,
standard error ¼0.190, variance ¼0.036, lower and upper
limit ¼(0.158–0.904) and pvalue ¼.005) that indicating a
statistically significant effect for counselling with respect to
depression score. The results of the study on the effect of
CBT on depression based on Beck’s inventory are as follows:
difference between mean score ¼0.663, standard error ¼
0.213, variance ¼0.045, lower and upper limit ¼
(0.245–1.081) and pvalue ¼.002. A forest plot of the effects
of CBT on depression is shown in Figures 4 and 5.
Anxiety
Anxiety was measured using the State Trait Anxiety Inventory
(STAI) (Domar et al. 2000), the Beck Anxiety Inventory (BAI)
(McNaughton-Cassill et al. 2002), DASS21 (Mosalanejad et al.
2012a,2012b) and Speil Berger, Cattell (Heidari et al. 2002;
Gharaie et al. 2004). Due to the variety of instruments, the
study included heterogeneous tools; however, all of them
were standard questionnaires. A total of nine articles
reviewed the effect of CBT on anxiety, which was published
in McNaughton’s article and the separate results reported for
men and women. Also, in Khalatbari’s paper, although the
level of anxiety was examined, but it could not be homogen-
ized with other reported values and so was excluded from
the meta-analysis. Finally, nine items of anxiety scores were
analysed by mean difference and standard deviation and the
number of sample size of the intervention and control
groups. The result of nine pooled studies showed that mean
of anxiety has an decrease in patients receiving counselling
as compared to the control groups (difference between
mean anxiety score ¼0.794, standard error ¼0.268, variance
¼0.072, lower and upper limit ¼(0.268–1.319) and pvalue
Figure 1. PRISMA diagram for the selection process of the articles.
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 5
¼.003). A forest plot of the effects of CBT on the anxiety is
shown in Figure 6.
Stress
Stress was measured using the completed fertility problem
inventory (FPI) (Faramarzi et al. 2013); which measures the
level of stress and DASS21 (Mosalanejad et al. 2012a,2012b).
The number of articles that have examined the effect of
CBT on stress is small. Hence, in this study, three articles
were reviewed for qualitative synthesis and then meta-ana-
lysed (quantitative synthesis). The result of three pooled
studies showed that mean of stress has no significant effect
in patients receiving counselling as compared to the control
group (the difference between mean stress score ¼0.050,
standard error ¼0.661, variance ¼0.436, lower and upper
limit ¼(1.244–1.354) and pvalue ¼.939). A forest plot of
the effects of CBT on stress is shown in Figure 7.
Discussion
The purpose of this systematic review and meta-analysis
was to investigate the effect of CBT on stress, anxiety
and depression of infertile men and women who
referred to infertility clinics for any reason.
In this study, one article was focused on individual CBT
and 10 articles on group CBT which is in line with
Higgins’s study. Also in this study, three articles of CBT
were done for couples, which is in line with Higgins’s
study. In couple counselling, the goal is to modify the rela-
tionship between the couple to deal with the problems
Figure 2. Risk of bias summary: systematic review. Author’s judgements of risk of bias item for each included study.
Figure 3. Risk of bias graph: systematic review. Author’s judgements of risk of bias presented as percentages across all included studies.
6 S. ABDOLLAHPOUR ET AL.
that result from infertility and help couples to manage the
existing conflicts (Higgins et al. 2008;VandenBroeck
et al. 2010).
One of the results of this study was that CBT can have a
significant effect on depression score reduction (p
value <.005). In a study that assessed depression score with
Figure 5. Effects of cognitive behavioural therapy on depression.
Figure 6. Effects of cognitive behavioural therapy on anxiety.
Figure 4. Effects of cognitive behavioural therapy on depression with the Beck scale.
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 7
Beck’s depression inventory, the mean depression score
decreased significantly (pvalue <.002). In this systematic
review, all articles that used CBT to reduce depression in
infertile women and men led to a significant reduction in
depression score except two cases (Domar et al. 2000;
Mosalanejad et al. 2012b). Although in the study of
Frederiksen et al. (2015), the intervention was considered as
infertility counselling, it did not specifically address cognitive
behavioural counselling but in the Ying study none of these
interventions were found to be efficacious in relieving the
depression or stress of individuals or couples undergoing IVF
treatment (Ying et al. 2016). Also, the results of one system-
atic review and meta-analysis by H€
ammerli et al., indicated a
non-significant effect for psychological interventions with
respect to depressive symptoms (H€
ammerli et al. 2009). The
differences in results concerning mental health may be attrib-
uted to the strict criteria of the meta-analysis present for
inclusion versus those of other reviews, which encompassed
mixed counselling.
Another result of this study, showed that cognitive-behav-
ioural counselling can have a significant effect on anxiety
score reduction (pvalue <.003). The results of this study are
consistent with the Ying (Ying et al. 2016) and Frederiksen
study (Frederiksen et al. 2015) but in H€
ammerli study
(H€
ammerli et al. 2009) anxiety was assessed in 12 studies,
which pooled together produced an overall non-significant
result. The difference in results is likely to be due to the type
of intervention being sought. Also, in the present study,
there was a great deal of variation among tools that meas-
ure anxiety.
Contrary to the two results mentioned above, CBT could
not have a significant effect on depression score reduction (p
value <.939). Usually few studies have investigated the
effect of psychological discussion on the stress of infertile
couples. The Ying study explored the effect of interventions
on the stress levels of patients undergoing IVF treatment, so
no study reported a significant difference in stress level dem-
onstrated among infertile patients in the intervention and
control groups (Ying et al. 2016). The meta-analysis was per-
formed on only three studies with different tools that do not
have a strong citation, and it is recommended that future
reviews be done with more articles.
One of the strengths of this study was that three common
psychological complications in infertile couples have been
studied simultaneously, which provides a comprehensive
view for the reader. There are a few limitations suggested for
the present study results. One limitation of this study is the
small number of articles but these studies were found
through searching several relevant databases but studies that
specifically address cognitive behavioural counselling on
stress, anxiety and depression are few.
Recommendations for future research
We found evidence for improvement in general psychological
symptoms such as anxiety and depression, but not for stress.
A possible explanation for the latter could be the lack of sen-
sitivity of the stress measures used. It is recommended that
future studies examine the difference between the number
of sessions, the duration, the difference in sex, the duration
of the infertility and the type of counselling. Women and
men ought to be analysed separately as there are important
differences in their processing of fertility-related issues. Also
further studies should be conducted to determine the effect
of CBT on stress reduction.
Clinical implications
Given that in some countries, including Iran, couples are not
psychologically screened for stress, anxiety and depression, it
is recommended that in all infertility clinics, patients can be
screened for depression and anxiety. It is recommended to
provide CBT if they experience high levels of depression
and anxiety.
Conclusions
On the basis of the results, CBT is beneficial for infertile
patients, although more experimental studies are needed.
Despite the robust overall effect found, the considerable het-
erogeneity of the available studies with respect to methodo-
logical quality, intervention type and format still warrants
caution as to the conclusions which can be drawn. It is rec-
ommended that long-term follow-up of couples to receive
more psychological interventions be done according to the
stage of treatment.
Ethical statement
Research ethics confirmation (ethics code:
IR.MUMS.NURSE.REC.1397.029) for this study was received
Figure 7. Effects of cognitive behavioural therapy on stress.
8 S. ABDOLLAHPOUR ET AL.
from the Local Research Ethics Committee of Mashhad
University of Medical Sciences, Mashhad, Iran.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This study was funded by Mashhad University of Medical Sciences [Grant
Number 961503].
ORCID
Sedigheh Abdollahpour http://orcid.org/0000-0002-6112-0052
Robab Latifnejad Roudsari http://orcid.org/0000-0002-1438-8822
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