Title: The Social determinants of mental health disorders among women with infertility: a
systematic review
Version: 0 Date: 03 Oct 2023
Reviewer's report:
This is a systematic review on 32 articles summarising the research literature on social
determinants of mental health amongst women with infertility. The is a well written review.
However, I have some reservations which I have highlighted below.
Abstract – I think the abstract should be re-written. The introduction and discussion can be much
shorter and the result section needs to actually contain their main findings.
Introduction – Again some re-writing is probably warranted here. I would have liked the
introduction to be more focused and relevant on social determinants of mental health in female
infertility cases. I particularly would have liked to see an argument on why a literature synthesis
on social determinants is necessary and exciting.
The first two paragraphs (lines 83-97) could be simply summarised in a line or two or ignored
and line 104  needs to be changed from ‘hasn’t’ to ‘has not’
Method – The reporting of the method is clear and well-structured. However, I have some
reservations regarding methodology.
First, I think the argument for time selection of 2010 onwards is not convincing -  at least
for me. WHO report on health system financing in 2010 (highlighting the need to remove
barriers to healthcare) does not really have any methodological impact on observational studies
investigating social determinants of mental health amongst female infertility – particularly as
the authors are not exclusively focusing on women undergoing health treatment for infertility.
Also, the search was last updated June 2022 and it is already outdated by 1 year. The authors
need to consider updating the search.
Second, the authors have only included English language studies and need to justify the
exclusion of non-English studies, even if that is reporting lack of funding for translation. This is
important because majority of studies included in the review were from Non-Western countries
[Asia (n=21, 63.6%) and Africa (n=8, 24.2%)] – so presumably there would be many studies
excluded from these countries which have not been published in English. The methodological
limitation of only including English language studies needs to be acknowledged in more detail
in the discussion.
Finally, as the authors have used standardised measurements for mental health outcomes, I was
surprised the authors did not attempt a meta-analysis with some of the data (although some odds
ratio were presented in results). Could the authors explain why meta-analysis was not considered
because they had some quantitative data extracted. I think this would have made a more novel
contribution.
Results – The authors have combined all the sub-groups together (primary and secondary
infertility and those in treatment and those not in treatment). Could the authors justify the
decision not to separate the findings depending on population? Were the findings between
the groups similar? Certain social determinants under investigation (etc wealth/education) also
determine whether women can afford fertility treatment or not (therefore determine group
classification). Personally I think these are very distinct groups and I would have liked to see
the findings separated for them.
Further, numerical data is reported throughout the results section and I felt a meta-analysis would
have worked very well in this sys review.
Overall, the results do not summarise findings which are novel or unexpected.  I think the
decision not to separate sub-groups  and lack of meta-analysis might explain some of this.
Discussion – The discussion is generally fine. But as the authors did not separate different
infertile populations in results and/or did not report a meta-analysis, I think this has led to a
discussion of findings which are very expected. I think the authors needed to acknowledge their
study weaknesses in more detail (for example, lack of inclusion of non-English papers).