Association of daily perceived stress with fertility outcomes in natural and controlled ovarian stimulation cycles: a feasibility study

PURPOSE: Females with infertility perceive stress, but most studies rely on single assessments. We examined the feasibility of repeated ecological momentary assessment (EMA) during IVF and whether stress trajectories across two cycles were associated with reproductive and IVF outcomes. METHODS: In a prospective cohort at a single academic center, 26 females (18-42 years) undergoing IVF with luteal estradiol priming were recruited; 25 completed follow-up. Perceived stress was assessed via text-message EMA three times daily during a priming month and the subsequent controlled ovarian stimulation (COS) cycle. Primary outcomes were ovulation in the priming cycle and a composite poor COS outcome (cycle cancellation, < 4 oocytes retrieved, no blastocyst, or no euploid blastocyst). Functional principal components analysis characterized stress trajectories, and regression models tested associations with outcomes. RESULTS: Mean age was 36 (SD 3.6); 64% were White and 24% Hispanic. All participants ovulated during priming. Two stress patterns explained 96% of follicular-phase variability. The dominant pattern (early decline then plateau) was not associated with outcomes. A second pattern (peak around cycle day 6 with subsequent rise) was associated with lower peak LH (b - 2.85, 95% CI - 4.60 to - 1.06; adjusted p = 0.004). Ten participants (40%) met the composite poor COS outcome, which was not associated with either stress pattern. Stress levels were similar between priming and COS. CONCLUSION: EMA is feasible during IVF. In patients reporting mild-to-moderate stress, perceived stress was stable and not associated with key IVF outcomes, though specific trajectories may modestly relate to hypothalamic-pituitary-ovarian-axis function.