Fertility

Caveat on this rating: Dated: the search closed 31 December 2011 and the review has not been updated, so it predates the trauma-focused work of the last decade. Its conclusion applies to brief generic counselling as trialled up to 2011 and should not be read as evidence against structured psychological treatment for post-loss PTSD, depression, or complicated grief.

Caveat on this rating: These are screening-instrument prevalences drawn largely from cross-sectional studies with substantial heterogeneity, so they measure symptom burden rather than diagnosed disorder, and the pooled percentages are sensitive to which scales and cut-offs the contributing studies used.

Caveat on this rating: The control groups were not uniform — they mixed live births, difficult live births, and non-pregnant community samples — and "perinatal loss" spans early miscarriage through stillbirth, so the pooled risk ratios blur real differences between very different experiences.

Caveat on this rating: Only psychiatric conditions severe enough to require hospitalisation were captured, so ordinary depression and anxiety treated in primary care are invisible here — the absolute risks are small and the affective-disorder result should not be read as evidence that unsuccessful treatment protects against depression.

Caveat on this rating: The pregnancy-rate result is the weak half of this paper: the pooled studies were heterogeneous, not all randomised, and the finding directly contradicts the larger and better-controlled Boivin 2011 BMJ meta-analysis showing distress does not affect cycle outcome. Read this study as evidence that psychological support reduces distress, not as evidence that it makes you pregnant.

Caveat on this rating: Attrition was substantial and grew over follow-up: 67% of the loss cohort completed the one-month questionnaire, 58% at three months, and 46% at nine months, so the later percentages rest on a shrinking and possibly non-representative subgroup. These are validated screening thresholds, not clinical diagnoses.

Caveat on this rating: Partner response rates were low and fell over time (60%, 48%, and 39% at 1, 3, and 9 months), and all partners in the study were male, so nothing here speaks to same-sex-partner or non-birthing-mother grief. Men may also under-report distress on these instruments, which would bias the gap wider than it truly is.

Caveat on this rating: The authors themselves report evidence of moderate publication bias (contour-enhanced funnel plot, significant Egger's test, and a significant subgroup analysis on timing of the pregnancy test). Separately, the first author disclosed speaker fees from EMD Serono and Merck and a research grant from Merck Serono in the three years before publication, though the paper itself received no organisational support.

Caveat on this rating: These are screening-questionnaire symptom rates, not diagnosed major depressive disorder, and heterogeneity between the pooled studies was high. The published confidence interval for the HADS estimate (21.01%, 95% CI 15.61-34.42) is asymmetric around the point estimate as printed in the paper.