This study collects bibliometric data on infertility and psychology research for its review. In order to explore the influence of psychology on infertility, we selected “infertility” and “psychology” as the search terms based on previous literature retrieval methods. This study conducted a search for articles using the aforementioned search string in the”article title, abstract, and keywords” on the Web of science core collection (WoSCC). The WoSCC covers a considerable amount of high-quality scientific literature in the biomedical, natural, and social sciences, and it was used as the main data source. It is regarded as one of the most widely accepted and suitable databases for the bibliometric analysis of scientific publications (7). At the same time, it also contains the cited references in each publication, prepares the indexes according to the cited author, source and year of publication, and establishes the world’s most influential and authoritative citation index database. Through a unique citation index, the evolution of research content and research direction can be understood without being limited by keyword changes.

We expanded research literature retrieval, analysis, retrieval rules, and measurement methods through the WoSCC ( Figure 1 ). Then, 151 kinds of literature with the subject words “infertility” and “psychology” in the English language were selected from the Science Citation Index (SCI-Expanded) and the Social Sciences Citation Index from January 2001 to November 2021. All the documents published in the journal until 16 November 2021 were adopted. There were 151 documents in total, including articles, editorial materials, letters, meeting abstracts, and reviews. All the retrieved papers from the WoSCC, including the titles, keywords, author information, abstracts, and references, were downloaded and saved in the Bibtex file format.

To assess the final corpus of 151 articles on infertility and psychology, this study adopts a bibliometric analysis approach for its review. We imported all the Bibtex files obtained above into the Biblioshiny application by using R software (version 4.0.2), Rstudio software (version 1.3.959), and the bibliometrix R package (https://www.bibliometrix.org). We completed the conversion of the original data to the data frameset. These files were imported into Microsoft Excel 2019 for further data processing. Two researchers independently performed the literature selection, data extraction, and analysis to ensure the reliability of the results. Data extracted from the selected articles include the general information about the annual number of publications, citation frequency, original countries, authors, journals, and institutions. The author’s publication-quality was assessed based upon metrics that included the number of publications, citations in the research area, and publication h-index value. The above kinds of literature underwent data analysis and visualization using VOSviewer (Version 1.6.16, Leiden University, the Netherlands).VOSviewer was used to create network visualization maps to analyze the collaborative relationships between countries/regions, institutions, and authors of highly cited references. In addition, VOSviewer can classify keywords with high co-occurrence frequencies into several clusters and simultaneously color them by time course. Co-occurrence analysis identifies research hotspots and trends.

According to the above retrieval methods and data processing, a total of 151 publications were obtained from the WoSCC, which were published from 2001 to 2021. Broadly speaking, the number of publications was not large, which indicates that there is still a lack of research attention to infertility and psychology. Among them, there were 122 papers (80.79%), 18 reviews (11.92%), five editorial materials (3.31%), five meeting abstracts (3.31%), and one letter (0.66%). The literature category distribution can be found in Figure 2A . Since 2001, the publications of related literature on “infertility” and “psychology” showed a fluctuating upward trend, reaching two peaks in 2008 and 2012, and 2012 (12 publications, 7.95%) was the most prolific year for publications. The annual publication output was stable, at 8 in the next eight years ( Figure 2B ).

In total, 75 academic journals published papers about infertility and psychology. Table 1 and Figure 3B present the top 15 most popular journals contributing to articles on infertility and psychological topics, and it also shows the countries of origin and impact factor of the top 15 journals. Human Reproduction (England) was the leading journal, publishing the most papers (29 articles), followed by Fertility and Sterility (10 articles, United States), Journal of Psychosomatic Obstetrics and Gynecology (nine articles, Netherlands), Journal of Health Psychology (five articles, England), Acta obstetricia et Gynecologica Scandinavica (four articles, Denmark), Gynecologie Obstetrique and Fertilite (four articles, France), Human Fertility (four articles, England), Journal of Obstetrics and Gynaecology (three articles, England), Reproductive Biomedicine Online (three articles, England), American Journal of Men’s Health (two articles, United States), Cochrane database of systematic reviews (two articles, England), European Journal of Obstetrics and Gynecology and Reproductive Biology (two articles, Netherlands), Frontiers in Psychology (two articles, Switzerland), Ginekologia Polska (two articles, Poland), and Health and Quality of Life Outcomes (two articles, England). The impact factor (IF) of Human Reproduction (the most published journal) was 6.918 (2020), and the H-index was 19, putting it in the first place ( Figure 3D ). Among the top 15 journals, the highest IF was 9.289 (2020), the Cochrane database of systematic reviews from England. This journal had a small number of articles, with only two articles. The volume of literature in these journals has been increasing year by year. Human Reproduction had the largest increase among these journals ( Figure 3A ). As a result, the psychological aspect of infertility is attracting increasing attention, which can provide suggestions for future research. The presented data are consistent with the current model of bio-psycho-social medicine.

Figures 3C, E present the top 15 cited journals on infertility and psychology research. Human Reproduction was cited in the most journals (1208 times), followed by Fertility and Sterility (341 times). The highest citation frequency of this journal may be due to it being the journal with the highest H-index and the highest number of articles. This also provides a direction for us to find relevant articles in the future. Social Science and Medicine ranked third, with 232 citations. The fourth and fifth, with more than 150 citations, were Acta Obstetricia et Gynecologica Scandinavica (194 times) and Journal of Psychosomatic Obstetrics And Gynecology (187 times), respectively.

In terms of the number of published papers, Boivin J was the most prolific author, with 16 articles (10.60%), followed by Eiser C, Gameiro S, Schmidt L, and Thorn P, each with five articles (3.31%). There were five authors who published four articles, including Arden-close E, Merrick H, Pacey AA, Verhaak CM, and Wischmann T ( Figure 4A ). In terms of citation frequency, Boivin J published the most articles and was cited the most, up to 890 times. His articles were also cited mostly in local citations (cited 35 times, Figure 4C ). Schmidt L was the second most frequently cited author after Boivin J, with 390 citations. Schmidt l was followed by Kitzinger C (cited 215 times), Willmott J (cited 215 times), Braverman A (cited 205 times), Takefman J (cited 205 times), Hjelmstedt A (cited 196 times), Widstrom AM (cited 196 times), Wramsby H (cited 196 times), and Thorn P (cited 180 times) ( Figure 4B ).

H-index was used to evaluate the influence of authors. The most influential author, Boivin J, had an h-index of 14, followed by Schmidt L, with an h-index of 5. Moreover, authors with an h-index of 4 included Thorn P, Wischmann T, and Gameiro S ( Figure 4D ). We analyzed a total of 487 authors who had co-authored in more than one publication. It can be seen from Figure 4E that there were mainly three 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 ( Figure 4E ).

According to the statistics, a total of 251 institutions were involved in this field. The 20 institutions with the highest number of articles were obtained ( Figure 5A ). Cardiff University (25 records, 4.67% of all articles) contributed the most publications, followed by the University of Sheffield (15,2.80%), Radboud University Nijmegen (13, 2.43%), the University of Copenhagen (12, 2.24%), Oxford University (12, 2.24%) Gothenburg (11, 2.06%), and Karolinska Institute (10, 1.87%). Institutions that published more than four articles and fewer than ten articles were the University of Adelaide (9, 1.68%) and the University of Melbourne (7, 1.31%). University Catania, University of Edinburgh, and University Ferrara published six articles (1.12%). University Hospital Gasthuisberg and University of Rochester published five articles (0.93%). McGill University, Careggi University Hospital Trust Florence AOUC, Emory University, Inonu University, Institute Curie, and Institute Psychology published four articles (0.75%).

To reveal potential collaborations among institutions, we used the VOS viewer to conduct a co-authorship analysis in terms of institutions. Among 251 co-authored institutions publishing more than one article ( Figure 5B ), the five institutions with the highest total link strength were Cardiff University (total link strength 26), Heidelberg University Hospital (20), University Wales College Cardiff (19), University of Bristol (15), and Centre Hospitalier Universitaire Vaudois (14). Among these institutions, universities were the main contributors, followed by hospitals. Thus, the focus of infertility and psychology research has gradually transferred from the clinical area to the teaching area and become gradually known to the public.

The distribution of published articles is shown on a world map by R ( Table 2 ; Figure 6A ). Colors on the map represent different density values. A total of 20 countries contributed to publications in this field. The countries with the most publications were mainly European and the United States. The United Kingdom contributed the highest number of articles (34, 23.94% of all articles), followed by the United States (22, 15.49%), Sweden (11, 7.75%), and Italy (10, 7.04%). Countries with fewer than ten articles were the Netherlands (9, 6.34%); Australia and France (8, 5.63%); Poland (6, 4.23%); Belgium and Iran (5, 3.52%); Denmark, Germany, and Israel (4, 2.82%); and Brazil, Canada, China, Portugal, Turkey, Finland, and Greece publishing the fewest, with only one or two articles ( Table 2 ). The United Kingdom had the largest number of articles published by a single country (23 articles), followed by the United States (19 articles), and all other countries had fewer than ten articles.

Studies from the United Kingdom had the highest number of citations (1,218 citations), followed by those from the United States (545 citations), Sweden (484 citations), Australia (282 citations), Denmark (254 citations), Netherlands (225 citations), Belgium (143 citations), Italy (127 citations), Canada (83 citations), Israel (56 citations), Poland (55 citations), Iran (32 citations), Finland (27 citations), Brazil (22 citations), Germany (18 citations), Portugal (16 citations), France (15 citations), and Turkey (five citations) ( Figure 6B ). China and Hungary had the lowest number of citations, with four citations. According to the analysis of the countries with the highest annual citation frequency ( Figure 6C ), although the articles of British scholars were the most frequently cited in total, they ranked fourth in the annual citation frequency (35.82), and Denmark ranked first in the annual citation frequency (63.50), followed by Sweden (44) and Canada (41.50).

In terms of international cooperation, through the analysis of the countries of origin of the corresponding authors of the articles, the United Kingdom had the most precise cooperation with various countries ( Figure 6D ), with a total of 40 cooperation articles, including five cooperation articles with the United States; four cooperation articles with Denmark and Netherlands; three cooperation articles with Belgium, Canada, Germany, Italy, and Sweden; and two cooperation articles with Australia, New Zealand, and Portugal. The United Kingdom cooperated with China, Egypt, Singapore, South Africa, Spain, and Switzerland, the number of articles was one. A total of 36 countries with more than one publication in the field were analyzed in the co-authorship analysis ( Figure 6E ). The five countries with the highest total link strength were Wales (total link strength 29 times), England (23), Belgium (15), the United States (14), and Germany (13). Furthermore, Wales cooperated most closely with Denmark and Netherlands. These countries published more articles.

We conducted a statistical analysis of 151 articles and found that the citation analysis showed that seven documents had more than five citations ( Table 3 ), “Who Is at Risk of Emotional Problems and How Do You Know? Screening of Women Going for IVF Treatment” was cited ten times in local citations ( Figure 7A ). In addition, that article was not the most frequently cited article in global citations ( Figure 7B ). Kitzinger C’s article, “The Thief of Womanhood: Women’s Experience of Polycystic Ovarian Syndrome,” published in SOC SCI MED in 2002, was cited up to 215 times, and the current number of local citations was 1, ranking 20th.

Table 4 enumerates the basic information for the papers among the top 20 most cited. These highly cited studies were published between 1991 and 2012, and 11 studies were published before 2000. The most cited reference was GREIL AL’s book, Infertility and Psychological Distress: A Critical Review of the Literature, which was a literature review of the psychosocial effects of infertility, published in SOC SCI MED in 1997. It was cited 24 times. Verhaak CM (2005) wrote the second most highly cited paper, with 17 citations. The two papers written by Gameiro S (2012) and Verhaak CM (2007) ranked third, with 14 citations. The fourth position was occupied by Boivin J (2007), with 13 citations, followed by Slade P (1997) (13 citations), Eugster A (1999) (11 citations), and Newton CR (1999) (11 citations). The references written by Boivin J (2011), Cousineau TM (2007), Greil AL (2010), Jordan C (1999), and Verhaak CM (2010) were cited ten times. As shown in Figure 7C , the co-citation network consisted of 5000 cited references and could be shown as 78 cited references, which had more than five citations of a cited reference.

We analyzed a total of 38 keywords among 452 keywords related to infertility and applied research on psychological topics that were identified as having occurred more than five times ( Figure 8A ). The colors in the overlay visualization shown in Figure 8B indicate the average publication year of the identified keywords. Most of the keywords were published after 2014, with greener or yellower colors. The density visualization showed the same identified keywords mapped by frequency of appearance ( Figure 8C ). The top 10 keywords were: women (39 times), in-vitro salt (31 times), infertility (30 times), couples (25 times), impact (24 times), stress (22 times), attitudes (20 times), distress (16 times), IVF (16 times), and anxiety (1). Through the co-occurrence analysis of 452 keywords, the development trend and strategic coordinate map ( Figure 9 ) were drawn. It can be seen that the covered groups with psychological problems of infertility mainly existed in women and in both husbands and wives, and their negative emotions were mainly stress, distress, anxiety, and depression. IVF was most likely to cause these negative emotions during treatment, and finding a solution often depended on the patient’s attitude, which would also have an impact on the outcome of subsequent treatment ( Figures 9A, B ). The frequency of the above top 10 keywords increased with time ( Figure 9C ). The keyword “women” grew the fastest, followed by “in-vitro fertilization.” Through the strategic coordinate chart of keywords ( Figure 9D ), quality of life, psychological status, fertility, attitude, experience, and IVF couples were major themes; illness, responses, and management were highly developed and isolated themes; multifetal reduction, triplets, twins, female, and seeking behavior were emerging or declining themes; and women, in-vitro fertilization, and couples were basic and transversal themes.

Since the field emerged in 2001, its annual publication output has increased in a volatile fashion. The publication output in 2012 was the highest, accounting for 8.11% of all the included studies. It can be seen that psychology has attracted more and more attention in infertility, and various countries have begun to analyze the psychology of patients with infertility. The reason why psychology attracts more and more attention to infertility is that, on the one hand, the development of assisted reproductive technology is more and more mature and the patients’ psychology is concerned. For example, there are several articles published in 2012 related to in vitro fertilization, including Feasibility of Screening Patients for Emotional Risk Factors before In Vitro Fertilization in Daily Clinical Practice: A Process Evaluation and Perspectives on Access to In Vitro Fertilization in Portugal. On the other hand, the reason may be a change in the model of modern medicine. Psychogenic diseases caused by various psychological and social causes have occurred widely. The modern medical model has been transformed into the “Bio-Psycho-Social Medical Model”, and psychological factors have been paid more and more attention.

With the largest number of publications and citations and the top rank for co-authorship analysis by country, the United Kingdom is currently the world leader in the research of infertility and psychology. According to the analysis of publishing institutions, the first and second universities in publishing volume were from the United Kingdom, namely Cardiff University and the University of Sheffield. These two universities have very strong comprehensive strengths. Cardiff University was the most productive and was ranked first in co-authorship analyses conducted by the institution, suggesting its close cooperation with other institutions. The Faculty of Biomedical and Life Sciences is Cardiff University’s largest faculty, and the Department of Psychology is ranked 2nd in the UK university Research Strength Rankings (REF). As one of the red brick universities, six Nobel Prize winners have graduated from the University of Sheffield or have long worked for the university’s researchers. These results suggest that the United Kingdom, especially the two universities mentioned above, may significantly impact the direction of research in this field and participate in the strongest collaborations worldwide. In the follow-up research, we can strengthen the cooperation with the UK and other countries, which can further explore the role of psychology in infertility.

Boivin J, a doctor of psychology from Cardiff University, is a pioneer in the field of infertility and psychology. As a member of Cardiff Fertility Studies Research Group, he has studied the psychological aspects of infertility and had the largest number of publications (16, 10.60%) and citations (cited 890 times), and was the top rank for h-index and co-authorship analysis conducted. In a large Internet survey of 426 women from different countries about infertility counseling, he found that 56% had not consulted a doctor. Seeking medical advice for fertility problems is mainly associated with what women know or want to know about their fertility and their emotional health reactions to that knowledge. Negative reactions can substantially delay seeking help in 20% of women (17). He provided the guidelines for counseling in infertility about the purpose, objective, and typical issues and communication skills involved in psychosocial care to individuals using fertility services (15), and gave specific recommendations for infertility counselors in mental health and medical settings (44). He also proposed the idea that FertiQol is a reliable and sensitive measurement tool for quality of life in individuals with fertility problems, which provides an evaluation tool for future research on the psychological problems of infertile patients (10). He worked most closely with Schmidt L and Gameiro S, who are from the Institute of Public Health and have focused on the problems of both medical- and patient-centered (psychosocial) services (20, 25, 45). They have also suggested that men suffer from depression and stress during infertility (9, 11).

Keywords are the core of literature. They present the content of the whole article to the readers in the clearest way. By analyzing the composition, distribution, and clustering of keywords, the hot spot distribution in this field can be more quickly and effectively understood. The words “women,” “in-vitro fertilization,” “infertility,” and “couples” were the most frequently used keywords. This suggests that such psychological problems are widespread in women and more likely to occur during IVF treatment. Whether physical (e.g., failed treatment cycles, miscarriage, or fetal death) or emotional (e.g., loss of identity as a parent by never becoming pregnant), infertility diagnosis and the assisted human reproductive treatment process can have an impact on the emotional and mental health of couples. Through the strategic coordinate chart of keywords, we can see that the focus on infertility and psychology changed, for example, the quality of life, psychological status, fertility, attitude, experience, and the use of the keyword “IVF couples.” These words will be hot topics of psychological research on infertile patients in the future.

Causes and objects of negative infertility psychology: In terms of references cited, most of the top 20 references were reviews on the psychological aspects of infertility (27, 30, 46, 47), causes of negative psychology (48), and methods of emotional regulation (28, 31). Kitzinger C et al., who ranked first in global citations, clarified the causes of infertile patients’ negative psychology and psychological intervention from the perspective of PCOS (26). From PCOS and IVF, with the progress of medical technology and the development of new technologies, more factors affect infertile patients’ psychology. Greil AL from 1997 and SOC SCI MED, the most widely referenced source, focused specifically on the relationship between gender and infertility experience early on, noting that men also suffer from negative emotions (such as depression and anxiety) during infertility treatment. The research range of psychological factors of infertility has changed from female to male and female. Stress factors are the primary cause of negative psychology in infertile patients (27).

Treatment to improve the negative psychology of infertility patients: Researchers have found that improving the quality of life and fertility preservation is of utmost importance to ameliorate negative psychology in infertile patients (49). The patient’s attitude and experience play a crucial role in infertility psychological diagnosis and treatment, and positive psychotherapy is innovative for treating psychological disorders and enhancing positive emotions (50). When comparing the psychosocial characteristics of IVF-ET couples and couples without infertility, some scholars found that regardless of gender, the former had a significantly higher risk of anxiety and depression than the latter (51). Research has shown that 23% of patients end treatment prematurely because of perceived treatment burden (43). One-third of patients end treatment before pregnancy has been achieved (52). Anxiety about the viability and health of the fetus increased even after a successful pregnancy (21). Their anxiety and depression also increased with the embryo transfer (FET) process (53), which is in line with the ESHRE guidelines (54), stating that patient emotional stress peaks during the waiting period before FET and pregnancy testing. SCREENIVF can be used as a screening tool to identify women with a risk profile for emotional problems and is most effectively used in fertility clinics at the start of treatment in clinical practice (8, 55). In the psychological intervention of infertile patients with negative psychology, it is necessary to pay more attention to the psychological problem, put the patient at the center of nursing care, and view patients, the industry, and fertility clinics as all involved in delivering psychosocial care before, during, and after treatment (56).

It can be seen from the keyword analysis chart that the focus of attention has gradually shifted from the audience to the treatment methods and care (57–59). Currently, there is a lack of psychological coping plans and guidelines for infertility. Most of the literature is related to the treatment and care of infertility. Psychological support before, during, and after infertility treatment is critical for managing the psychosocial aspects of infertile couples’ grief responses. From a psychological perspective, grief in infertile women experiencing infertility treatment, whether it is caused by several physical examinations or pregnancy failure, will make it difficult to adhere to subsequent infertility treatment. Psychological interventions can be defined as a set of abilities that enable individuals to better adapt to challenging situations psychologically (60, 61). There are two main types of treatment: one based on mind-body intervention or relaxation therapy, and the other based on cognitive behavioral therapy, including understanding the cognitive situation, cognitive remodeling, and relaxation training. At the same time, various scales can be used to evaluate the patient’s psychological state, and psychological counseling or relaxation treatment can be carried out based on the cause.

Studies on the role of psychological factors in the etiology of infertility have not yet provided unique data and require further investigation (80). From the perspective of psychological stress theory, external factors include events such as self-anxiety, parental pressure, and complaints, which lead to long-term negative emotions, such as anxiety, depression, and low self-esteem in patients, which constitute psychological stress for patients, and have deleterious effects on the reproductive system, causing subsequent pregnancy failure (81–83). The source of stress can cause the patient to produce a stress response, thereby generating neurotransmitters (such as catecholamines, including dopamine and norepinephrine) that affect the hypothalamic-pituitary axis (84, 85). They can affect the secretion of LH by affecting the release of gonadotropin-releasing hormone (GnRH), resulting in an imbalance of reproductive endocrine secretions, which in turn affects fertility. Studies have shown that chronic psychological stress can lead to endocrine diseases such as PCOS, premature ovarian failure, and infertility in women; it can also directly change the frequency pattern of the GnRH release in the hypothalamus resulting in relative infertility (86, 87). A specification published by the American Society for Reproductive Medicine and the American Society for Reproductive Endocrinology in 2017 states that psychological stress is a major obstacle to sexual function and fertility (88).

In addition, under psychological stress, the activated hypothalamic-pituitary axis will also promote the secretion of the corticotropin-releasing hormone (CRH), thereby increasing the release of the adrenocortical hormone (ACTH) and inducing the increase of glucocorticoids (such as cortisol) (76, 89), possibly directly and indirectly leading to a reduction of GnRH levels and the secretion of downstream hormones such as FSH and LH, which in turn affect ovarian function. In particular, the enhanced secretion of cortisol is a key factor in the stress response and one of the mediators of stress-induced inhibition of the reproductive system. Glucocorticoids have effects on the ovary, uterus, and testes. They directly affect granulosa cells and oocytes, and the mechanism may be that corticosterone causes concentration-dependent activation of oocyte extracellular signal-regulated kinase 1/2 and prevents blastocyst development (90). Furthermore, glucocorticoids (such as cortisol) stimulate mitochondria and then affect oocyte development or cause granulosa cell death, resulting in decreased reproductive function (87, 91–93). Changes in glucocorticoids under psychological stress in the uterus may affect fertility through gene expression changes, endometrial growth inhibition, or estrogen antagonism. For male reproductive function, psychological stress such as anxiety, depression, and negativity, including psychological stress during sperm retrieval, can produce high levels of glucocorticoids, directly inhibit the function of the testes, and inhibit the production and maturation of sperm (57, 94).

There are many reasons leading to infertility. Different psychological problems are easy to occur in each stage. Based on the current research status, we still need to further discuss the following contents in future studies.

(1)Identify psychological problems at each stage of infertility treatment: There are many negative psychosocial manifestations, including depression, despair or loss of hope, guilt, anger, anxiety, depression, pain, shock, and even suicidal thoughts and feelings of isolation. However, there was a slight difference in the negative psychological performance at different stages of infertility treatment. Follow-up studies need to be summarized in order to facilitate follow-up targeted treatment.

(2)Pay attention to the couple’s psychology and joint treatment: Both men and women can have psychological problems due to infertility. Previous studies were mostly based on the perspective of women. In the follow-up studies, we need more scholars to sum up, and think deeply about male psychology. Joint therapy can better relieve psychological anxiety. If necessary, pressure from friends and family on both sides should also be paid attention to.

(3)Conduct a multidisciplinary study on the factors affecting the psychological state of infertility: From the current research, most of the factors affecting the psychological state of infertility patients are discussed from the perspective of physiology and pathology. We can be further explored in combination with multiple disciplines so as to carry out follow-up targeted diagnosis and treatment.

(4)Develop a consensus on psychological assessment methods and treatment: Considering that there are many psychological assessment scales at present, a unified evaluation standard is needed to evaluate the psychological status of infertility patients in future studies, which is also one aspect that we need to think about and summarize. It also has guiding significance for subsequent diagnosis and treatment. More importantly, we need a unified consensus on the treatment of infertility patients’ psychological problems. In future studies, we need more clinical medical staff to participate in the evaluation, selection and innovation of current treatment methods so as to form a systematic diagnosis and treatment theory.