Sleep is a vital physiological process essential for maintaining both physical and mental health, with individuals spending approximately one-third of their lifespan asleep. During pregnancy, ensuring adequate and restorative sleep is crucial not only for the mother’s well-being but also for the optimal development of the fetus. The National Sleep Foundation recommends that adults should aim for a sleep duration of seven to nine hours per night (1). A comprehensive review by Maniaci et al. highlights that conditions, like obstructive sleep apnea during pregnancy can affect maternal and fetal health, emphasizing the broader implications of sleep disturbances for pregnant women (2). These issues could negatively impact both maternal and fetal outcomes, potentially leading to complications such as preeclampsia, hypertension, gestational diabetes, cesarean deliveries, and excessive weight gain during pregnancy. However, specific guidelines for sleep duration, quality, and insomnia during pregnancy remained insufficient. Furthermore, sleep quality and disturbances are often linked to significant determinants of women’s health, particularly during critical life stages such as menstruation, pregnancy, and menopause. For instance, sleep disturbances are often associated with higher levels of depression and stress, as well as an increased risk of cardiovascular disease, hypertension, and diabetes (3). Furthermore, poor sleep quality and the prevalence of depression tend to be escalated throughout pregnancy (4). These issues could adversely affect both maternal and fetal outcomes, potentially leading to complications, including preeclampsia, hypertension, gestational diabetes, cesarean deliveries, and excessive weight gain during pregnancy (3, 5–7).

Animal studies have demonstrated that persistently disrupted light/dark cycles could significantly impair the preovulatory LH surge, leading to reduced fertility. In contrast, the reproductive effects of a single-phase shift on female mice could be minimized (8). Furthermore, sleep deprivation had been shown to diminish oocyte output, as transient activation of wake-promoting dopaminergic neurons negatively impacts reproductive performance (9). Sleep disorders were notably prevalent undergoing assisted reproductive technology (ART) treatments, and affected 57% of women undergoing in vitro fertilization/intra-cytoplasmic sperm injection(IVF/ICSI) before treatment, 43% during the stimulation phase, and 29% following embryo transfer (10). Philipsen et al. found that mean PSQI global scores before treatment were 8.1, with 91% of participants having PSQI scores > 5, indicating poor sleep quality (11). Research indicated that insufficient nocturnal sleep—specifically, less than seven hours per night with disrupted sleep patterns, is associated with reduced oocyte and embryo production. Conversely, excessively prolonged nocturnal sleep might decrease the likelihood of achieving a successful pregnancy. Additionally, the relationship between nocturnal sleep duration and ART outcomes is influenced by factors such as subjective sleep quality and maternal age (12).

Strong correlations have been established between sleep quality and both physical and mental well-being (13). The interplay between negative emotions and sleep difficulties can create a harmful cycle. Given that the high prevalence of sleep disorders among expectant mothers and their significant association with psychological symptoms, it is crucial to prioritize screening and counseling for psychological disorders in pregnant women to enhance sleep quality (4). Previous research also indicated that there are small but significant associations between stress and distress, which can further diminish the likelihood of successful pregnancies through ART (14). Moreover, the rates of anxiety and depression fluctuate depending on the stage of IVF/ICSI treatment. While many studies had examined women’s psychological health before and after IVF (15–17), few had focused on sleep quality and the psychological factors influencing sleep among IVF/ICSI patients during pregnancy. As a result, the relationship between sleep during pregnancy and positive psychological aspects remained poorly understood.

The existing body of research has largely focused on assessing sleep quality in individuals undergoing ART treatments. However, there is a notable gap in studies that investigate the impact of sleep quality among IVF/ICSI patients during pregnancy, particularly in comparison to women, who conceive naturally. In this study, we aim to gather data on sleep characteristics among women undergoing IVF/ICSI and those achieving natural conception. We hypothesize that both negative and positive psychological factors play a significant role in influencing sleep quality.

In this prospective cohort study, our findings reveal that women in the IVF/ICSI group consistently report significantly poorer sleep quality throughout all three trimesters compared to naturally conceiving women. To our knowledge, this study is the first to provide a comprehensive assessment of sleep quality, anxiety, depression, and perceived stress across different stages of pregnancy in both IVF/ICSI and naturally conceiving individuals. In the stratified analysis, we discovered that the association of sleep quality during the gestation during gestation was specifically influenced by maternal age, conception methods, anxiety status, depressive symptoms, and perceived stress. To the best of our knowledge, this is the first prospective study to evaluate sleep quality differences between the IVF/ICSI and NC groups during pregnancy.

The study revealed that a troubling trend in sleep quality among women undergoing IVF/ICSI during pregnancy. Only 38.93% reported good sleep quality in T1, decreasing to 33.51% in T3, though there was a slight improvement to 44.5% in T2. These findings are significant, as they aligned with previous research showing that pregnancy often leads to sleep disturbances, especially for those with infertility histories. Multivariate logistic regression analysis showed that age, conception methods, depression, anxiety, and perceived stress significantly impacted sleep quality. Although age was found to be significantly associated with reduced sleep quality, the group of women receiving IVF/ICSI treatment is significantly older than the natural conception group, which obviously impacts the finding of the difference between the two groups. Previous studies also have shown that sleep quality in pregnant women declines with increasing age (24). Furthermore, a meta-analysis of quantitative sleep parameters has demonstrated that sleep quality naturally diminishes as individuals age (25). Pregnant women aged 30 and older are more likely to experience stress and depressive symptoms during pregnancy, which may also elevate the risk of postpartum depression in this age group (26).

Sleep disorders are prevalent during pregnancy. Previous studies demonstrated that pregnant women experience variable levels of sleep quality deficits across all trimesters (24). PSQI scores exhibited an upward trend as pregnancy progressed, with the sleep quality of pregnant women being particularly susceptible to disruptions in the late stages of pregnancy (4). Contributing factors include emotional stress from the IVF process, physical discomfort as pregnancy progresses, and hormonal changes affecting sleep (27). Notably, the observed sleep decline in the NC group suggests that sleep issues during pregnancy are influenced by physiological and psychological demands rather than just conception methods. This study is consistent with previous findings, which suggest that around 46% of pregnant people experience sleep difficulties, with a notable drop in sleep quality occurring during the third trimester (28). This highlights the need for further investigation into sleep patterns among pregnant women, taking into account their medical histories and current health. During pregnancy, the significance of sleep for maintaining physical health was highlighted linking compromised sleep quality to negative pregnancy outcomes. The decline in sleep quality may impact maternal and fetal health, increasing risks of gestational complications, postpartum depression, and impaired maternal-fetal attachment. Studies have identified associations between sleep-disordered breathing and conditions such as gestational diabetes and hypertension (3, 29, 30). Additionally, insomnia and obstructive sleep apnea have been correlated with the increased risk of preterm birth (29).

Anxiety, depression, and stress associated with infertility treatment are essential issues. Our results reveal that while both groups exhibited similar median anxiety scores as measured by the SAS, pregnant women in the IVF/ICSI group reported significantly lower median scores on both the CES-D and PSS during T1 and T2. The retained comparability of anxiety scores across both groups throughout the pregnancy, with no statistically significant differences, suggested that the process of conception-whether through IVF/ICSI or natural means- does not lead to significant differing levels of anxiety in pregnant women. This could imply that the act of pregnancy itself, along with the accompanying physiological and emotional changes, may predispose all pregnant individuals to experience a standard level of anxiety regardless of their conception method. Significant differences in CES-D and PSS scores during the first two trimesters indicate that the IVF/ICSI group experiences lower depressive symptoms and perceived stress early in pregnancy. This may stem from a sense of accomplishment and relief from overcoming infertility. However, in the third trimester, CES-D and PSS scores equalize between groups, likely due to increased discomfortness and anxiety about childbirth affecting all pregnant women. This aligned with literature indicating that the third trimester often brings heightened physical discomfort and concerns about maternal health, impacting mental health. These findings underscored the need for individualized care approaches, suggesting that early emotional support and psychological interventions for the IVF/ICSI group could enhance their positive mental state. A study involving 842 patients undergoing IVF treatment showed that 39.4% of patients felt anxious, and 28.5% had depressive symptoms (31). Even though it is not entirely clear to what extent mental disorders affect fertility and to what extent infertility affects mental health (32), targeted interventions addressing psychological factors are crucial as pregnancies progress and challenges intensify.

The analysis of partners of pregnant women in the IVF/ICSI and NC groups revealed important insights into the emotional landscape surrounding ART and natural conception. With 498 partners from the IVF/ICSI group and 621 from the NC group, the study robustly compared mental health indicators, particularly anxiety levels measured by SAS scores. Partners in the IVF/ICSI group showed slightly higher anxiety scores, suggesting that the stress of infertility treatments affects their mental well-being. The emotional toll of IVF/ICSI, marked by uncertainty and financial strain, likely contributed to this heightened anxiety, aligning with literature on the psychological burden faced by couples undergoing fertility treatments. Interestingly, despite the increased anxiety, no significant differences in sleep quality, depression, or perceived stress were found between the two groups. This might suggest that while anxiety is a concern for IVF/ICSI partners, it does not lead to poorer sleep or higher depression levels compared to NC partners. The lack of sleep quality differences may reflect a broader trend where partners face similar sleep challenges during pregnancy, regardless of the conception method. These findings highlighted the need to consider partners’ mental health, especially for those undergoing IVF/ICSI. Future research should explore factors contributing to partner anxiety and potential interventions.

One limitation of this study is the absence of data on participants’ prior history of sleep, depression, and anxiety. This information could have provided a more comprehensive understanding of the psychological factors influencing sleep quality during pregnancy, particularly in women undergoing IVF/ICSI treatment. The lack of this data may limit our ability to fully assess the impact of pre-existing mental health conditions on the observed outcomes. Another notable limitation of this study is the reliance on self-reported questionnaires to assess sleep quality among participants. While these instruments provide valuable insights, they are subjective and may be influenced by various biases, including recall bias and social desirability bias. Previous research mainly focused on specific aspects of psychological distress without considering the interplay of multiple influencing factors. A more reliable insights into this association was highlighted. For sleep issues during pregnancy, there are pharmacological options, but there’s a lack of human data on their safety during pregnancy and lactation, raising concerns about potential birth defects and neonatal withdrawal (33). Future studies should utilize longitudinal designs to track mental health changes throughout pregnancy and identify key factors. This knowledge is vital for healthcare providers to establish support systems that help pregnant women maintain their psychological well-being during this critical period.

Achieving a pregnancy and establishing a family life holds significant value for individuals undergoing IVF/ICSI as it greatly influences their overall life happiness. Consequently, even slight increases in the likelihood of achieving a pregnancy may warrant the implementation of various measures aimed at achieving success. Our study indicates that a notable concern regarding sleep quality during pregnancy among women in both IVF/ICSI and NC groups, calling for immediate attention from health professionals to address this crucial aspect of maternal health. Moreover, our current understanding of the potential impact of sleep, perceived stress, and distress on the progression from early pregnancy stage to live births remains incomplete. While IVF/ICSI partners exhibit higher anxiety, the absence of significant differences in other mental health aspects underscores the importance of understanding psychological dynamics and addressing the mental health needs of both partners to foster a supportive pregnancy environment.