Abstract
BACKGROUND: Despite advances in the use of in vitro fertilization-embryo transfer (ET) in couples with infertility, recurrent implantation failure (RIF) after ET is still a major problem affecting women, with great psychological and economic burdens for the patient and his/her family. AIM: To investigate the psychological burden (anxiety and depression) and evaluate the clinical benefits of endometrial receptivity testing (ERT) in patients experiencing RIF following frozen-thawed ET. METHODS: A retrospective cohort study analyzed 371 patients experiencing RIF after assisted reproductive treatment at the First People's Hospital of Changde City between January 2021 and June 2024. Demographic and clinical data were systematically collected through standardized questionnaires. Psychological assessment utilized validated instruments: The Self-Rating Depression Scale for depression evaluation and the Self-Rating Anxiety Scale for anxiety assessment. Participants were stratified by psychological status (anxiety/non-anxiety and depression/non-depression) to analyze influencing factors for anxiety and depression. The cohort was further categorized into the ERT and non-ERT groups based on ERT implementation to comparatively analyze their clinical outcomes. Additionally, they were divided into clinical and nonclinical pregnancy groups to identify factors affecting clinical pregnancy using univariate and multivariate logistic regression models. Compared with the non-ERT group, the 226 patients who underwent ERT-guided ET achieved a higher clinical pregnancy rate, thicker endometrium on transfer day, fewer embryos transferred, and a lower miscarriage rate. RESULTS: The study identified a substantial psychological burden, with anxiety prevalence at 55.0% (mean Self-Rating Anxiety Scale score, 50.89 ± 9.34) and depression at 61.2% (mean Self-Rating Depression Scale score, 55.55 ± 9.48). Multivariate analysis identified annual household income > 100000 yuan as protective factors against both anxiety and depression, whereas advanced maternal age (> 35 years) and multiple implantation failures (≥ 3) served as risk factors. Additionally, anxiety-specific risk factors included prolonged infertility treatment (> 5 years) and the spouse's status as an only child. As to depression-specific risks, chronic infertility (> 3 years) and higher educational attainment (college/bachelor's degree or higher) were key determinants, whereas urban residence was a protective factor. Age > 35 years was a risk factor for clinical pregnancy in patients experiencing RIF, whereas blastocyst-stage ET, a higher number of embryos transferred, and thicker endometrium were protective factors. CONCLUSION: Patients experiencing RIF are particularly susceptible to anxiety and depression, and advanced maternal age and multiple implantation failures represent salient risk factors. Clinicians should implement proactive and evidence-based interventions to mitigate these psychological burdens. For patients experiencing RIF, ERT-guided ET demonstrates significant potential to improve assisted reproductive outcomes.