We used three markers to assess mental health risks: recent levels of psychological distress, chronic pain as a somatic symptom, and death fantasies. The results of this study suggest that mental health risks associated with unintended natural pregnancies or fertility treatments may vary depending on the time before and after childbirth, as well as the parent’s gender. These findings are consistent with previous meta-analyses showing an increased risk of depression and stress, although variations were observed according to gender and conception method [45, 46]. Notably, women with naturally conceived unintended pregnancies showed a higher tendency for psychological distress during pregnancy, but this distress tended to decrease after childbirth. Moreover, several covariates, such as history of depression, fetal/infant/child health problems, and socioeconomic status, showed stronger associations with mental health outcomes than the conception method variable itself. However, caution is needed in interpreting these results, considering the study’s limitations. These findings highlight the need for flexible and comprehensive mental health support for parents who experience unintended pregnancies or undergo fertility treatments, both during pregnancy and after childbirth. The limitations of this study, including those discussed below, must be taken into account when interpreting these results.
Naturally conceived unintended pregnancy significantly was associated with the risk of recent psychological distress, chronic pain, and death fantasies in women. Notably, recent psychological distress within the past 30 days was higher during pregnancy for women with naturally conceived unintended pregnancies, but lower after delivery, suggesting that the distress may be related to the pregnancy period rather than being prolonged. In men, non-significant trends toward increased risks were observed, but these did not reach statistical significance. Given the confidence intervals, these trends may be clinically important. This finding is consistent with previous studies showing that unintended pregnancy increases the risk of maternal depression and stress, although these risks may diminish as parents adjust after childbirth [47]. These findings support meta-analyses showing an association between naturally conceived unintended pregnancy and increased risk of depression, although this risk may decrease over time [48]. Although this study did not examine whether or not the women were planning to have an abortion during their pregnancy, it is possible that the strong psychological stress of considering whether or not to have an abortion or of having an abortion planned for the near future may have affected the women with naturally conceived unintended pregnancies. They may be associated with feelings of pressure from the male partner, family, or others to have an abortion that is contrary to the woman’s own values and preferences. The mental health risks related to pregnancy loss including abortion on mental health are well known [35,36,37, 39, 49]. Therefore, it is important to consider the negative impact that unintended pregnancies can have on mental health, especially during pregnancy.
Our findings from this study support recent critiques of the unintended pregnancy framework, as highlighted by Auerbach et al. (2023) [50], suggesting that underlying factors may play a greater role in mental health outcomes than pregnancy intention itself. The strong association between mental health risks during pregnancy and postpartum supports the argument that pre-existing mental health conditions are more predictive of postpartum mental health than pregnancy intention [50]. In addition, our findings add to the evidence that the relationship between unintended pregnancy and mental health is complex and multifaceted [50]. Pre-existing mental health problems may influence both the perception of a pregnancy as unintended and the subsequent postpartum challenges [51]. This perspective shifts the focus from the unintended pregnancy itself to the broader context of pre-pregnancy mental health conditions. This interpretation is consistent with the findings of comprehensive reviews, as highlighted in a previous report, which concluded that abortion is not a direct cause of mental health problems [49]. Instead, associations often reflect pre-existing or concurrent mental health conditions associated with unintended pregnancy or abortion. These findings underscore the importance of addressing the broader psychosocial factors that shape both pregnancy intentions and mental health outcomes. In light of these findings, future research should take a more nuanced approach that includes the broader social and structural context, including pre-existing mental health conditions, socioeconomic factors, and other potential confounders. This comprehensive approach will better capture the interplay between pregnancy intentions and mental health outcomes.
We found that during pregnancy, SI/OI use was generally associated with higher mental health risks for both men and women, compared with individuals who had children through naturally conceived intended pregnancies. Notably, men who used SI/OI during early parenthood also demonstrated a significantly higher risk of chronic pain and death fantasies than men who experienced a naturally conceived intended pregnancy. Conversely, women who used SI/OI during early parenthood did not show an increased mental health risk. The reasons for the observed differences in mental health risks, with men showing an increased risk of chronic pain and death fantasies while women did not, are unclear, but the stress associated with timed intercourse may place additional strain on relationships. Women may be less affected during early parenthood, when the pressure to time intercourse has subsided.
This study is the first to categorize assisted reproductive technology (ART) into IUI and IVF/ICSI to examine their differential effects on mental health risks in male and female parents in early parenthood. During pregnancy, participants who had children using ART demonstrated lower or the same mental health risks as those who had children through naturally conceived intended pregnancy. It is reasonable to assume that individuals who have had a child after enduring the difficulties of infertility and the physical and financial burdens of ART have lower mental health risk than those who conceived easily without such challenges. Men who used IUI during early parenthood showed an unexpected increase in risk of death fantasies, whereas IVF had no effect on mental health outcomes at any stage. For women, ART did not generally increase mental health risks, with the exception of postpartum death fantasies among IVF/ICSI users. The reasons why IUI had a greater effect on men during early parenthood remain unclear.
Differences in stress experienced by men undergoing IUI and IVF/ICSI may reflect factors such as the timing of semen sample collection, which member of the couple is infertile, and differences in men’s perception of their role in fertility treatment. IUI semen sample collection is typically timed to coincide with ovulation, which is predicted by monitoring ovarian follicle growth. In contrast, IVF tends to be more predictable, with semen collection typically timed to a controlled cycle. Additionally, when IUI is used, there is often no cause of female infertility (e.g., tubal occlusion), which may increase pressure on the male partner. Furthermore, in Japan, fertility treatments typically progress from SI/OI to IUI (up to six attempts) and finally to IVF [52], which may increase psychological relief for men after successful IVF attempts. A previous study also showed that women who used IVF or ICSI experienced less recent psychological distress than those who used OI or male artificial insemination [53], which is consistent with our findings.
This study’s approach of investigating both naturally conceived unintended pregnancies and those resulting from fertility treatments offers a more comprehensive understanding of how pregnancy intention affects mental health. While these scenarios represent opposite ends of the pregnancy intentionality spectrum, they share certain mental health impacts. Women with unintended pregnancies experienced higher risks of psychological distress, chronic pain, and death fantasies during pregnancy, likely due to unexpected stressors and lack of preparation associated with unplanned pregnancies. In contrast, women who underwent IVF/ICSI showed a significantly lower risk of chronic pain during pregnancy, possibly reflecting the extensive medical support and psychological preparation involved in fertility treatments.
However, despite these differences, both groups also share some common mental health challenges. For example, while the IVF/ICSI group exhibited a lower risk of chronic pain during pregnancy, they showed a higher risk of suicidal ideation and death fantasies during early parenthood. This might reflect a mismatch between the expectations formed during long-term fertility treatment and the realities of parenting, or a lack of post-treatment support. Similarly, unintended pregnancies, while associated with heightened stress during pregnancy, may lead to ongoing relationship tensions and adjustment difficulties in the postpartum period.
Both unintended pregnancy and fertility treatment can contribute to mental health risks through direct stressors, such as the emotional and financial burdens of treatment or the strain of an unplanned pregnancy. Relationship deterioration of fertility treatment is a common reason for discontinuation [6]. These stressors may also lead to indirect impacts, such as relationship strain and disruptions to work or social life. While the immediate stress from fertility treatments after childbirth, relationship tensions and difficulties in accepting an unintended pregnancy could persist, potentially contributing to mental health risks in the postpartum period. Further research is needed to explore these shared and distinct pathways.
This is the first study to indicate that men who use IVF are not associated with increased psychological risk during pregnancy and early parenthood. These findings provide psychological reassurance to both individuals and health care providers. However, men undergoing SI/OI and IUI may face increased mental health risks during early parenthood. Targeted mental health support is critical for male parents using these treatments, as well as for female parents coping with unintended pregnancy.
There are several limitations that should be considered when interpreting these findings. First, the data do not necessarily represent all residents in Japan, and respondents to web-based surveys may differ in important ways from the general population. However, the data were obtained by sending random invitations to many registrants across Japan, and therefore have some validity regarding representation. Second, this was a cross-sectional study, so temporal causality cannot be assumed. For instance, individuals at psychological risk may be more likely to experience infertility and to use ART [54]. However, this seems unlikely because mental health risk among participants who used IVF did not increase during pregnancy and early parenthood. Moreover, the results remained unchanged after the model was adjusted for depression history. Third, this study was conducted during the COVID-19 pandemic in 2021. The pandemic may have exacerbated negative emotions and thus increased the risk of mental health problems. Fourth, we did not consider the duration of fertility treatment. Generally, even with the same conception method, patient burden increases with longer duration, so length of treatment may have affected the findings. Fifth, while we accounted for pregnancy loss by calculating the difference between the number of pregnancies and live births, this approach does not allow us to distinguish between induced abortions, miscarriages, and stillbirths. In addition, our definition of recurrent pregnancy loss does not take into account whether losses were consecutive, which is the standard criterion. This limitation may affect the precision of our findings regarding the impact of pregnancy loss on psychological outcomes. Sixth, the potential overlap of two different time periods—during pregnancy and postpartum—for women who gave birth or had an abortion in 2021, which may affect the interpretation of the results. Additionally, we did not collect data on whether pregnant women were considering abortion, planning to abort, or facing pressure to abort from others, which may have contributed to psychological distress across all three outcome measures. Furthermore, the measure used to assess death fantasies was not a validated scale for suicidal risk, which may limit the interpretation of the results in this area. Seventh, the study used a binary measure of pregnancy intention rather than a specific scale, which may have missed the more nuanced aspects of participants’ attitudes. Respondents were asked directly whether the pregnancy was considered “intended” or “unintended.” This binary approach may not fully capture the complexity of pregnancy intentions. As Santelli et al. (2009) suggest [55], pregnancy intentions are multidimensional and include aspects such as the timing of pregnancy, emotional reactions, and partner-specific factors. The lack of a more detailed measure in our study limits the depth of insight into participants’ pregnancy intentions and may obscure important variations that could affect the observed outcomes.
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