Everyone experiencing infertility and ART has heightened needs for psychological support, but few will require specialist assistance to meet these needs. Symptoms of anxiety and depression are often elevated in people experiencing infertility, but rates of psychopathology are similar to the general population. Some people may experience despair and the loss of existential meaning at the prospect of a future without biological progeny. Unlike other adverse life events, infertility is regarded as uniquely distressing because it can last for many years, there is uncertainty about whether it will be resolved, and, for many, it will not be concluded by the birth of a baby. An “infertility strain profile” is characterized by increased anxiety, irritability, profound sadness, self-blame, lowered energy levels, social isolation, and heightened interpersonal sensitivity [3]. Almost all people presenting for treatment are having some of these experiences that might best be conceptualized as a normal emotional response to a painful predicament.

Guilt is especially prominent among women, linked in particular to fears that earlier sexual experiences, sexually transmitted infections, abortion, the use of contraceptives, or delaying conception while pursuing other goals has compromised fertility. The lack of agency and frustration associated with being unable to control conception and physiological functioning can lead to anger, which may be directed toward the infertile partner, friends and associates who have been able to conceive easily, and people who offer unsolicited advice. Reaction to infertility is also conceptualized as “disenfranchised grief.” The many intangible potential losses include sexual spontaneity; the experiences of pregnancy, childbirth, and breastfeeding; the children and grandchildren who will not exist; genetic continuity; parenthood and the activities and relationships it entails; and an element of adult and gender identity that will never be realized and can be substituted with an infertile identity.

Infertility, particularly of unknown etiology, and among women, was once widely attributed to personality characteristics or psychiatric conditions, so-called “psychogenic infertility.” This led to misattribution of the cause of infertility and blaming of victims. A systematic review found no significant differences in rates of psychiatric illness, other psychopathology or personality factors between presumed fertile groups and those seeking infertility treatment, or between infertile groups and population norms, or between groups with infertility of different etiology and duration [4].

Infertility and its treatment are often socially isolating experiences. Spontaneous disclosure of emotional needs and explicit support-seeking are uncommon, particularly among men affected by infertility. They are more likely to confide in and desire information and emotional support from infertility clinicians rather than from friends or mental health professionals.

Women experience more emotional distress associated with infertility than men, except in cases of male factor infertility where the degree of distress is similar. Even when male factors are implicated, women experience more guilt and self-blame than their male partners, which may be because most of the investigations and treatments focus on the female partner.

Most men aspire to parenthood and can experience chronic grief if this goal is not realized. Infertility-specific anxiety is elevated in men at the initiation of diagnostic investigations, confirmation of diagnosis, and during treatment, but the overall prevalence of clinically significant symptoms of depression and anxiety is no higher than in the general population [5]. Some men appear able to compartmentalize their emotions and to continue to participate in their lives without being preoccupied or disabled by anxiety or to suspend their emotional needs in service of their partner’s increased need for support. Both women and men can fear losing significant relationships, in particular with the partner, and some may offer to allow their spouse to partner with someone else in order to have a child.

People respond to disturbing life events in individual ways. Studies of women show that those who participate actively in seeking information and making treatment decisions have lower levels of depression and attract more social support than those who submit passively to medical recommendations. Individuals with high self-esteem and dispositional optimism are protected against severe depression. The reciprocal is also true: better mood is associated with solution-focused problem-solving and increased emotional support [6].

People who use avoidant coping and deny the emotional impact of infertility may seek multiple medical opinions in order to find an optimistic assessment. They are at higher risk of becoming more severely depressed or anxious and may also be vulnerable to exploitation by extravagant claims for treatments, including for complementary therapies for which there is scant scientific evidence. Fertility difficulties challenge personal identity and disrupt an individual’s achievement of their planned life goals. It can exert a pervasive negative effect on quality of life, compromising planning and commitment to other life activities.

Comprehensive psychosocially informed care in couples seeking ART involves: