Artificial insemination with the husband’s sperm (AIH) is a fundamental assisted reproductive technology (ART) involving transuterine deposition of processed spermatozoa during the ovulatory window [1, 2]. This technique preserves genetic parenthood, distinguishing it from donor insemination, and circumvents cervical factors to achieve clinical pregnancy rates (CPR) of 8%–15% per cycle in unexplained infertility [1]. Population-specific data from China demonstrate an overall CPR of 13.0% across 3015 AIH cycles [3], consistent with global estimates. Published evidence has established that ovarian stimulation combined with intrauterine insemination (IUI-OS) significantly increases live birth rates (LBR) and CPR up to 3-fold compared to expectant management, thus supporting its role as a first-line therapeutic strategy for unexplained infertility [4]. Current evidence-based guidelines recommend age-stratified treatment algorithms, with IUI-OS being indicated for women aged 38 years with favorable prognoses, and in vitro fertilization (IVF) for patients aged $\ge$38 years [2]. This stratification framework may influence patient expectations and treatment-related anxiety. Notwithstanding the clinical benefits of AIH, the psychosocial implications remain a critically underexplored area of care delivery.

Accumulating evidence confirms that psychological stress adversely impacts AIH outcomes [5]. Elevated depressive symptoms (center for epidemiological studies depression scale (CES-D) $\ge$16) affect 59.1% of women [6], while the prevalence of anxiety can reach up to 75.9% in infertile females [7]. Pathophysiological mechanisms involve activation of the hypothalamic-pituitary-adrenal (HPA) axis, thereby increasing cortisol levels and inducing reproductive dysfunction [8]. Clinically, pretreatment anxiety has been associated with a 29% reduction in ovarian response and a 31% suppression of luteinizing hormone (LH) pulsatility, thereby impairing folliculogenesis. Stress-mediated increases in $\beta$-endorphin have been associated with a 42% decrease in tubal motility, while dysregulation of ghrelin doubles endometrial natural killer (NK) cell activity [8], compromising implantation. Multimodal interventions aimed at improving adverse psychological stress have demonstrated clinically significant efficacy. For instance, mindfulness-based therapies can increase cumulative pregnancy rates, while cognitive behavioral therapy (CBT) has been reported to reduce the rate of treatment discontinuation by 37% and improve patient-clinician communication dynamics [9]. Concurrently, structured stress management protocols combined with Mediterranean dietary interventions were shown to attenuate oxidative stress biomarkers, leading to increased CPR in ART populations [7]. Collectively, these findings indicate that infertility is a chronic stressor [10], necessitating the integration of biopsychosocial frameworks within AIH care paradigms.

The psychosocial burden associated with AIH stems from multifactorial stressors encompassing socioeconomic constraints, interpersonal discord, and cultural expectations. A cross-sectional analysis of 175 AIH patients revealed an inverse correlation between the severity of anxiety and the magnitude of perceived social support ($\beta$ = –0.41, p 0.01) [11]. Furthermore, a household income $\le$200% of the federal poverty level (FPL) was found to be an independent predictor of worse anxiety symptomatology (odds ratio (OR) = 2.3, 95% confidence interval (CI): 1.1–4.8). These findings establish socioeconomic status as a significant effect modifier of psychological distress, with robust social support networks conferring protective benefits. Transcultural psychiatric epidemiology studies have reported a high prevalence of affective disorders among infertility cohorts, including major depressive disorder (23.7%), illness anxiety (18.2%), and persecutory ideation (14.9%), with comorbid adoption of nutritionally suboptimal dietary patterns [7]. However, a prospective cohort study of 102 couples undergoing IVF found no statistically significant association between women’s anxiety/depression levels and oocyte count [12].

A prospective study combined psychological stress assessments with the analysis of salivary biomarkers ($\alpha$-amylase and cortisol) in 114 women aged $\le$42 years who underwent ART [10]. No significant differences in stress scores (general health questionnaire-28 item: 5.0 $\pm$ 3.7 vs. 5.1 $\pm$ 4.9; Self-Rating Depression Scale: 37.2 $\pm$ 6.3 vs. 36.7 $\pm$ 6.8) or biomarker levels ($\alpha$-amylase: 196.0 $\pm$ 144.6 vs. 202.0 $\pm$ 133.2 µg/dL; cortisol: 0.16 $\pm$ 0.10 vs. 0.15 $\pm$ 0.02 IU/mL) were observed between pregnant and non-pregnant groups, suggesting that combined psychological stress measures lack predictive utility for ART outcomes. Despite these insights, critical research gaps persist. To isolate psychological impacts, earlier studies included only couples with unexplained infertility, while systematically excluding confounding factors that could affect pregnancy outcomes [12]. Moreover, previous studies have often overlooked confounding biological variables, relied on static psychological assessment, ignored periodic stress fluctuations, and failed to adequately address the impact of male factors on the psychological burden of infertile women.

The present study aimed to address these gaps by evaluating the prevalence and severity of psychological stress in AIH patients, identifying modifiable psychosocial and biological predictors of stress, and measuring how stress affects pregnancy outcomes.

This study provides insights into the psychological stress experienced by women undergoing AIH, as well as the impact of this stress on the rate of pregnancy success. The findings highlight the significant role of demographic factors such as age, occupational status, and duration of infertility in predicting psychological issues like anxiety, somatic symptoms, and sleep disorders. These factors can influence the overall wellbeing of patients, and hence may indirectly affect the success of fertility treatments.

The prevalence of mental health disorders, including anxiety, depression, somatic symptoms and sleep disorder, was found to be high among women undergoing AIH. This finding concurs with the results of a systematic review of 32 studies conducted by Bagade and coworkers [21]. These authors found the prevalence of mental health disorders, including anxiety, depression, psychological distress, and stress, was higher among women with infertility compared to fertile women. Furthermore, we found that social determinants influenced the severity of anxiety, depression, somatic symptoms and sleep disorder. Women undergoing AIH experienced worse mental health and sleep quality if they were young (30 years), had a low education level, were unemployed, and had a long duration of infertility.

Age is a critical factor in the success of ART, including AIH. Age-specific disparities are quite pronounced, with women aged 30 years and 30–39 years exhibiting 3-fold higher pregnancy rates than those aged $\ge$40 years (13.7% and 13.0% vs. 4.8%, p 0.05), thus reinforcing age as a critical prognostic factor [3]. Age-specific outcomes have shown that women aged $\ge$38 years achieve significantly higher live birth rates with IVF than IUI-OS (risk ratio (RR) = 2.15, 95% CI: 1.16–4.00), a disparity that may amplify stress in older patients navigating prolonged IUI cycles before transitioning to IVF [4]. However, we found that younger women (30 years) were more prone to anxiety. This result is inconsistent with the findings of several other studies. Teklemicheal et al. [22] found that older women (35 years and older) had more infertility-related stress, while Ogawa et al. [23] and Alhassan et al. [24] both reported that increasing age was correlated with higher depression scores. A possible reason for the discordant results may stem from variations in the study populations. Our study only included patients who underwent AIH for the first time. Younger infertile women face greater social pressures and uncertainties in career development, suggesting they may require additional psychological support during fertility treatment. Unemployment was significantly associated with somatic symptoms and sleep disorders in the present study. This result aligns with previous studies by Alhassan et al. [24] and Honarvar and Taghavi [25], who found that employed women had lower anxiety, depression and stress levels. However, Ikemoto et al. [26] found that perceived difficulties to continue working during fertility treatment, and infertility-related harassment in the workplace, were associated with higher rates of psychological distress. The duration of infertility was also positively associated with somatic symptoms and sleep disorders in the current study. This concurs with the finding by Teklemicheal et al. [22] that women with 4–6 years of infertility experienced more severe infertility-related stress. Because such high-risk groups are prone to psychological stress, methods such as cognitive behavioral therapy (CBT) [27], stress-management [28], acupuncture [29], mindfulness-based group counselling, and expressive writing intervention [30] are recommended before entering the treatment cycle. Moreover, it is crucial that both the husband and wife receive psychological intervention. A study of 83 AIH patients demonstrated that psychological interventions centered around the couples, significantly enhanced emotional regulation, adaptive coping strategies, and marital quality compared to standard care, with improved treatment literacy in both the patients and their spouses [31].

Our study found no significant associations between psychological factors (anxiety, depression, somatic symptoms, sleep disorders) and conception success, even after adjustment for covariates such as age, occupational status, and sex hormones. However, some studies have demonstrated an association between psychological stress and pregnancy rate. A systematic review conducted by Matthiesen et al. [32] found that stress, trait anxiety, and state anxiety were negatively associated with clinical pregnancy rates. This inconsistency may be due to dynamic changes in the psychological stress of infertile women across treatment cycles, as well as differences between study populations (AIH vs. in vitro fertilization-embryo transfer). Psychological stress can impact reproductive outcomes through various mechanisms, including neuroendocrine changes and immune system dysfunction. For example, chronic stress can suppress LH pulsatility and reduce tubal motility, both of which can hinder the reproductive process. While cumulative clinical pregnancy rates reach 37.4% over three IUI-OS cycles, the live birth success rate declines by 25% per additional cycle (OR _adjusted = 0.75, 95% CI: 0.62–0.93), potentially exacerbating the psychological distress of couples as they undergo repeated unsuccessful attempts. Symptom Checklist-90 assessments revealed that recurrent AIH failures exhibited higher anxiety, hostility, phobic anxiety, and total scores compared to first-time patients (p 0.05), with the psychological distress increasing with each treatment cycle (p 0.05) [33]. Randomized trials have shown that preoperative psychological interventions can improve psychological wellbeing and pregnancy rates [34]. However, adjunctive psychological care has non-significant impacts on clinical conception rates, despite enhancing patient adherence and satisfaction [35]. Conversely, cumulative stressors and maladaptive traits predict conception failure [36], suggesting that psychological factors may operate indirectly through pathways such as treatment persistence or neuroendocrine modulation. Collectively, these studies highlight that psychological variables are likely to influence AIH outcomes via intermediary mechanisms rather than direct biological causality, reinforcing the need for holistic care models to address both mental health and reproductive goals.

This study examined associations between demographic characteristics and mental health disorders. Notwithstanding the methodological limitations, the findings of our study underscore the need for targeted psychological interventions among specific populations, including younger individuals, unemployed persons, and patients experiencing prolonged infertility. Although no statistically significant direct relationship was observed between mental health disorders and conception success, the amelioration of psychological wellbeing may enhance quality of life and overall health outcomes. Future research should further deconstruct the complex interplay between mental health and reproductive health to develop evidence-based interventions for vulnerable groups.

Our results support integration of the biopsychosocial model into treatment protocols for AIH, wherein psychological wellbeing constitutes an essential component of holistic patient care. By addressing psychological comorbidities—particularly anxiety, somatic symptom disorders, and sleep disturbances—this could not only optimize patient quality of life, but potentially improve the success rates of ART. Evidence-based multidisciplinary frameworks should engage both partners throughout therapeutic consultations and procedures, thereby enhancing coping mechanisms and treatment adherence while mitigating perceptions of isolation or unilateral responsibility [38]. Future investigations should aim to further delineate psycho-reproductive interactions, thereby developing more effective interventions to support dyadic wellbeing during fertility treatment.

The datasets used and analyzed during the current study available from the corresponding author on reasonable request.

MJR: design of the work, write the main manuscript; YYW: acquisition, analysis of data for the work, write the main manuscript; YP: study conception, design, data analysis. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study was approved by Ethics Committee of West China Second University Hospital, Sichuan University (No.2024248). We abided research process by the ethical principle of informed consent, voluntary, harmless. All study procedures were strictly followed the Declaration of Helsinki.

Not applicable.

This project was supported by Sichuan Nursing Association (H23008).

The authors declare no conflict of interest.