Infertility is a common, life-altering condition that affects about one in six people globally at some point in their lives, underscoring the need to understand its psychological sequelae alongside biomedical care [1]. Growing evidence suggests the absolute number of people living with infertility has risen over recent decades, driven in part by population growth and changing demographics, with important implications for health systems in low- and middle-income countries [2]. Beyond impaired fecundity, infertility is consistently associated with elevated risks of depression and anxiety, diminished quality of life, and relationship strain, making mental-health screening and support essential components of comprehensive infertility care [3].

Women often carry a disproportionate emotional burden in the infertility journey. Comparative studies in the region indicate that depression, anxiety, and stress are more prevalent in infertile women than in infertile men, highlighting gendered vulnerabilities and the need for targeted psychosocial support [4]. Systematic reviews from diverse settings similarly report high pooled prevalences of depressive symptoms among women with infertility, reinforcing that the mental-health impact is both substantial and widespread [5].

Polycystic ovary syndrome (PCOS)—a prevalent endocrine and metabolic disorder across reproductive ages—adds another layer of complexity. Contemporary meta-analyses show that women with PCOS have higher odds of both depression and anxiety compared with women without PCOS, independent of weight in many analyses, suggesting intrinsic biological and psychosocial drivers [6]. Large observational cohorts and reviews further document elevated prevalences of these conditions in PCOS and advocate for routine mental-health screening [7]. Mechanistically, emerging syntheses implicate hypothalamic-pituitary-adrenal axis dysregulation, insulin resistance, hyperandrogenism, and low-grade inflammation—pathways that may converge to increase vulnerability to mood and anxiety disorders in PCOS [8].

International guidance has recently been updated to standardize PCOS diagnosis and management, with explicit emphasis on patient-centred, multidisciplinary care that includes mental-health assessment and support [9]. Within infertility services, integrating routine psychosocial assessment aligns with these recommendations and with broader calls to embed mental-health care into reproductive medicine [3].

In India, infertility is often compounded by strong sociocultural expectations surrounding childbearing, where women frequently face societal stigma, familial pressure, and personal distress if unable to conceive [10]. In such contexts, understanding the mental-health implications of infertility, particularly in the presence of PCOS, is vital for shaping holistic patient care. This study therefore seeks to determine whether infertile women with PCOS experience a different burden of depression and anxiety compared to infertile women without PCOS, within the setting of a tertiary care center in India, with the aim of informing targeted screening and intervention strategies [2,9].

This cross-sectional observational study was conducted in the Department of Obstetrics and Gynecology at a tertiary care center in India over a period of twelve months. The study included a total of 120 infertile women, aged between 20 and 40 years, who attended the infertility clinic during the study period. Infertility was defined according to the World Health Organization criteria as the inability to conceive after twelve months of regular unprotected sexual intercourse. Participants were further categorized into two groups: infertile women diagnosed with polycystic ovary syndrome (PCOS group) and infertile women without PCOS (non-PCOS group), based on the revised Rotterdam criteria, which require the presence of at least two of the following features: oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasonography.

Eligible participants were selected consecutively after obtaining written informed consent. Women with a history of psychiatric illness prior to infertility diagnosis, those on psychotropic medication, and those with chronic systemic diseases such as hypothyroidism, diabetes mellitus, or cardiovascular disease were excluded to avoid confounding factors. Detailed demographic, clinical, and reproductive histories were obtained through structured interviews.

The assessment of depression and anxiety was carried out using the Hospital Anxiety and Depression Scale (HADS), a validated screening tool consisting of 14 items, with seven items each for anxiety and depression subscales. Each item was scored on a scale of 0 to 3, with higher scores indicating greater symptom severity. A subscale score of 8 or above was considered indicative of clinically significant anxiety or depression. The HADS questionnaire was administered in the participant’s preferred language, and trained investigators ensured that all questions were clearly understood before responses were recorded.

All participants underwent standard infertility work-up including hormonal profile, pelvic ultrasound, and relevant laboratory investigations to confirm the presence or absence of PCOS. Data were compiled and entered into a secure database. Statistical analysis was performed using SPSS software version 25.0. Continuous variables were expressed as mean ± standard deviation and compared between groups using the independent t-test. Categorical variables, including the presence of depression and anxiety, were presented as frequencies and percentages and analyzed using the chi-square test. A p-value of less than 0.05 was considered statistically significant.

Table 1 presents the demographic characteristics of the studied sample of 120 infertile women. The majority of participants, 83.3%, had an education level up to sub-diploma or diploma, while 14.2% held a bachelor’s degree and only 2.5% had completed a master’s degree. Regarding occupational status, a significant proportion were housewives (93.3%), with only 6.7% engaged in formal employment. In terms of economic situation, 41.7% of participants reported being in the weak category, followed by 34.2% in the medium range, 20.8% in the very weak category, and 3.3% in the top category. This distribution highlights the predominance of lower educational attainment, limited formal employment, and modest economic status in the study population.

Table 2 illustrates the frequency distribution of depression and anxiety levels among the studied samples. Clinically significant depression was present in 27.5% of participants, while the remaining 72.5% did not meet the threshold for depression. Anxiety levels were predominantly very low, with 95% of women scoring in the very little category, 4.2% in the low category, and only 0.8% in the medium category. None of the participants had intense anxiety. These findings indicate that while depression affected over a quarter of the sample, anxiety levels were generally minimal.

Table 3 compares depression and anxiety frequencies between infertile women with PCOS and those without PCOS. Depression was significantly more common among women with PCOS (31.7%) compared to those without PCOS (13.3%), with a p-value of 0.003 indicating statistical significance. In contrast, anxiety levels did not differ significantly between the two groups (p=0.35). Most women in both groups reported very little anxiety, with 95% in the PCOS group and 93.3% in the non-PCOS group, and small proportions reporting low or medium anxiety. These results demonstrate a notable association between PCOS and depression but not with anxiety severity.

Table 4 examines the relationship between the duration of PCOS and the presence of depression and anxiety among women with PCOS. The mean duration of PCOS in women with depression was 4.9 ± 3.4 years, compared to 5.7 ± 2.5 years in those without depression, and this difference was statistically significant (p=0.02). For anxiety, the mean duration of PCOS was 5.3 ± 3.1 years in those with very little anxiety, 1.7 ± 1.1 years in those with low anxiety, and 4.0 ± 1.0 years in those with medium anxiety, though these differences were not statistically significant (p=0.15). These findings suggest that a shorter duration of PCOS may be associated with a higher prevalence of depression, while no clear relationship was observed between PCOS duration and anxiety severity.

Table 1: Demographic characteristics of the studied samples

Table 2: Frequency distribution of depression and anxiety level in the studied samples

Table 3: Frequency distribution of depression and anxiety level in women with PCOS and without PCOS

Table 4: The relationship between the presence of depression and anxiety with the duration of PCOS in women with PCOS

The present study identified a significantly higher prevalence of depression among infertile women with PCOS compared to those without PCOS, while anxiety levels were generally low and showed no statistically significant difference between the groups. These findings are consistent with recent literature suggesting that PCOS is associated with a heightened risk of depressive symptoms, independent of body mass index and other metabolic parameters [11]. The pathophysiology underlying this association is multifactorial, with hyperandrogenism, chronic inflammation, and insulin resistance contributing to neurochemical imbalances that predispose to mood disorders [12]. Additionally, visible manifestations of PCOS such as hirsutism, acne, and obesity may contribute to negative body image and reduced self-esteem, further aggravating psychological distress [13].

The lower levels of anxiety observed in both groups in our study contrast with some previous reports that have identified high anxiety prevalence in infertile women [14]. One possible explanation may lie in sociocultural differences, as participants in the current study were recruited from a tertiary care center in India, where extended family support systems and religious coping strategies may buffer anxiety in the context of infertility. Furthermore, the study setting involved women actively seeking infertility treatment, which may provide a sense of agency and hope, thus mitigating anxiety levels [15].

The relationship between PCOS duration and depression in our study is noteworthy, with a shorter duration of the disorder associated with higher rates of depression. This contrasts with the expectation that chronicity would worsen psychological morbidity. It is plausible that the early years following diagnosis are characterized by greater emotional distress due to the abrupt confrontation with symptoms, altered fertility expectations, and the initiation of often complex treatment regimens [11]. Over time, women may develop coping strategies, adjust expectations, or benefit from treatment-related symptom control, leading to a relative reduction in depressive symptoms [13].

The lack of a significant relationship between PCOS duration and anxiety may suggest that anxiety in this population is influenced more by situational stressors, personality traits, and immediate treatment-related uncertainties than by the chronic course of the syndrome [14]. These observations highlight the need for mental-health screening early in the diagnostic and treatment journey of women with PCOS and infertility, with particular attention to depression risk during the initial phase post-diagnosis [12,15].

This study demonstrates that infertile women with PCOS have a significantly higher prevalence of depression compared to their non-PCOS counterparts, while anxiety levels remain low and comparable between the groups. A shorter duration of PCOS was associated with increased depression risk, underscoring the importance of early psychosocial support. Integrating routine mental-health assessment into infertility care, particularly during the initial years following PCOS diagnosis, may improve overall well-being and treatment outcomes.

1. World Health Organization. 1 in 6 people globally affected by infertility: WHO. 2023.
2. Feng J, Zhao Y, Li H, et al. Epidemiological characteristics of infertility, 1990–2021, and global trends. Reprod Health. 2025.
3. Braverman AM, Leach B, McCoyd J, et al. Depression, anxiety, quality of life, and infertility: a global perspective. Fertil Steril. 2024.
4. Khalesi ZB, Yazdanpanah D, et al. Anxiety, depression, and stress in infertile couples: a comparative study. BMC Womens Health. 2024.
5. Tadesse S, et al. Prevalence and contributing factors of depression among women with infertility in low-resource settings: systematic review and meta-analysis. 2025.
6. Infante-Cano M, et al. The prevalence and risk of anxiety and depression in women with PCOS: meta-analysis. 2024.
7. BMC Psychiatry Editorial Group. Prevalence of depression and anxiety in women with PCOS: multicentre study. BMC Psychiatry. 2024.
8. Dubé-Zinatelli E, et al. The overlooked mental-health burden of polycystic ovary syndrome: mechanisms and care gaps. Curr Probl Pediatr Adolesc Health Care. 2025.
9. Teede HJ, Peña AS, et al. Recommendations from the 2023 International Evidence-Based Guideline for the assessment and management of PCOS. J Clin Endocrinol Metab. 2023.
10. Moutzouri M, et al. Assessment of construct validity and reliability of the Hospital Anxiety and Depression Scale in couples with infertility. BMC Psychol. 2024.
11. Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2025.
12. Palomba S, Santagni S, Falbo A, La Sala GB. Complications and challenges associated with polycystic ovary syndrome: current perspectives. Int J Womens Health. 2024.
13. Blay SL, Aguiar JV, Passos IC. Psychological sequelae of polycystic ovary syndrome: body image and quality of life. J Psychosom Obstet Gynaecol. 2024.
14. Iftikhar PM, Abaid S, Iftikhar A, et al. Anxiety in women with infertility: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2023.
15. Kaur R, Sharma A, Aggarwal A. Coping mechanisms and psychosocial adaptation in women with infertility in Indian cultural context. Indian J Psychiatry. 2024.