Predicting Psychological Distress Based on Psychological Flexibility, Attachment Needs, and Alexithymia in Infertile Women Following Unsuccessful IVF

Somayeh Esmaili; Azarmidokht Rezaei; Maryam Zarnaghash; Forouzan Esmaielzadeh

Authors

Somayeh Esmaili Department of Psychology, Marv.C., Islamic Azad University, Marvdasht, Iran. Author https://orcid.org/0009-0007-6717-2500
Azarmidokht Rezaei Department of Psychology, Marv.C., Islamic Azad University, Marvdasht, Iran. Corresponding Author https://orcid.org/0000-0002-2680-7414
Maryam Zarnaghash Department of Psychology, Marv.C., Islamic Azad University, Marvdasht, Iran. Author https://orcid.org/0000-0002-2500-2673
Forouzan Esmaielzadeh Department of Biology, Marv.C., Islamic Azad University, Marvdasht, Iran. Author https://orcid.org/0000-0001-7566-4256

Keywords:

Psychological Distress, Psychological Flexibility, Attachment Needs, Alexithymia, Infertility, Unsuccessful IVF

Abstract

Objective: The present study aimed to predict psychological distress based on psychological flexibility, attachment needs, and alexithymia among infertile women who had experienced unsuccessful in vitro fertilization (IVF).

Methods and Materials: This quantitative, cross-sectional, descriptive-correlational study was conducted using structural equation modeling. The statistical population comprised infertile women receiving treatment in infertility centers in Shiraz, Iran, during 2025–2026 who had experienced at least one unsuccessful IVF cycle. A total of 280 eligible women were selected through purposive non-probability sampling. Data were collected using the Depression Anxiety Stress Scales-21 (Lovibond & Lovibond, 1995), Cognitive Flexibility Inventory (Dennis & Vander Wal, 2010), Marital Attachment Needs Scale (Samani et al., 2023), and Toronto Alexithymia Scale-20. Data were analyzed using Pearson correlations and structural equation modeling with SPSS 26 and AMOS 24.

Findings: Structural analyses showed that psychological flexibility significantly predicted psychological distress (β = .58, p < .001). Attachment needs were also a significant predictor of psychological distress (β = .48, p < .001). In addition, alexithymia significantly predicted psychological distress (β = .43, p < .001). Correlation analysis further showed significant associations between psychological distress and psychological flexibility (r = −.17, p < .01), attachment needs (r = −.47, p < .05), and alexithymia (r = .65, p < .01).

Conclusion: Psychological flexibility, attachment needs, and alexithymia are important psychological factors associated with distress following unsuccessful IVF. Assessment of these variables may help identify women at greater psychological risk and support the development of targeted psychological interventions alongside infertility treatment.

Downloads

Download data is not yet available.

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. N. (2015). Patterns of Attachment: A Psychological Study of the Strange Situation. Psychology Press. https://doi.org/10.4324/9780203758045

Asghari, A., & Nicholas, M. K. (2001). Pain Self-Efficacy Beliefs and Pain Behaviour: A Prospective Study. Pain, 94(1), 85-100. https://doi.org/10.1016/S0304-3959(01)00344-X

Balsom, A. A., Klest, B., Sander, B., & Gordon, J. L. (2024). Acceptance and Commitment Therapy Adapted for Women with Infertility: A Pilot Study of the Infertility ACTion Program. Reproductive Health, 21(1), 43. https://doi.org/10.1186/s12978-024-01766-5

Calvo, V., Fusco, C., Pellicelli, C., & Masaro, C. (2023). Romantic Attachment, Infertility-Related Stress, and Positive Body Image of Women Dealing with Infertility. Frontiers in psychology, 13, 1067970. https://doi.org/10.3389/fpsyg.2022.1067970

Campos, A. D., Huelva, P. A., Astorga, A. A., Corgo, S. R., Vicente, E. P., Pey, M. A., & Martín, A. M. (2023). Female Infertility, Alexithymia and Stress. European Psychiatry, 66(S1), S648-S648. https://doi.org/10.1192/j.eurpsy.2023.1348

Carlson, L. E., Tamagawa, R., Stephen, J., Drysdale, E., Zhong, L., & Speca, M. (2016). Randomized-Controlled Trial of Mindfulness-Based Cancer Recovery versus Supportive Expressive Group Therapy among Distressed Breast Cancer Survivors (MINDSET): Long-Term Follow-Up Results. Psycho-Oncology, 25, 750-759. https://doi.org/10.1002/pon.4150

Cyniak-Cieciura, M. (2021). Psychological Flexibility, Temperament, and Perceived Stress. Current Issues in Personality Psychology, 9(4), 306-315. https://doi.org/10.5114/cipp.2021.108685

Dadhwal, V., Choudhary, V., Perumal, V., & Bhattacharya, D. (2022). Depression, Anxiety, Quality of Life and Coping in Women with Infertility: A Cross-Sectional Study from India. International Journal of Gynaecology and Obstetrics, 158(3), 671-678. https://doi.org/10.1002/ijgo.14084

Dong, X., Liu, Y., Fang, K., Xue, Z., Hao, X., & Wang, Z. (2024). Effects of Mindfulness-Based Therapy for Cancer Patients: A Systematic Review and Meta-Analysis. BMC psychology, 12(1), 619. https://doi.org/10.1186/s40359-024-02092-y

Fallah, B., Fathi, F., Fallah, F., Nasiriani, A. R., Mehrab, K., & Beik, A. (2023). Psychological Adjustment to Cancer and Its Effect on Quality of Life among Women with Breast Cancer. Journal Of Shahid Sadoughi University Of Medical Sciences, 31(12), 7351-7362.

Gillath, O., Karantzas, G. C., & Fraley, R. C. (2016). Adult Attachment: A Concise Introduction to Theory and Research. Academic Press.

Gorday, J. Y., Bardeen, J. R., Rogers, T. A., & Benfer, N. (2023). A Prospective Examination of the Role of Psychological (In)Flexibility in Posttraumatic Stress: A Cross-Lagged Panel Design. Journal of anxiety disorders, 97, 102725. https://doi.org/10.1016/j.janxdis.2023.102725

Gourounti, K., & Giannikaki, M. (2021). Alexithymia, Stress and Depression in Infertile Women: A Case Control Study. Materia socio-medica, 33(1), 70-74. https://doi.org/10.5455/msm.2021.33.70-74

Greil, A. L., Slauson-Blevins, K. S., Lowry, M. H., & McQuillan, J. (2020). Concerns about Treatment for Infertility in a Probability-Based Sample of US Women. Journal of Reproductive and Infant Psychology, 38(1), 16-24. https://doi.org/10.1080/02646838.2019.1587395

Jackson, P. L., Saunders, P., Mizzi, S., & Hallam, K. T. (2025). The Efficacy of Psychological Interventions for Infertile Women: A Systematic Review and Meta-Analysis. BMC Women's Health, 25(1), 506. https://doi.org/10.1186/s12905-025-04054-x

Jiang, L., Zeng, T., Wu, M., Yang, L., Zhao, M., Yuan, M., & Lang, X. (2024). Infertility Psychological Distress in Women Undergoing Assisted Reproductive Treatment: A Grounded Theory Study. Journal of clinical nursing, 33(9), 3642-3658. https://doi.org/10.1111/jocn.17195

Kafiabadi, S., Asayesh, M., Naghsh, Z., & Bahonar, F. (2024). Attachment Styles and Positive Feelings in Infertile Couples: The Mediating Role of Emotional Information Processing. Iranian Journal of Health Psychology, 7(3), 9-20.

Kamboj, N., Saraswathy, K. N., Prasad, S., Babu, N., Puri, M., Sharma, A., & Mahajan, C. (2023). Women Infertility and Common Mental Disorders: A Cross-Sectional Study from North India. PLoS One, 18(1), e0280054. https://doi.org/10.1371/journal.pone.0280054

Kargar, S. T., Vakili, F., Peivandi, S., Jahanfar, S., Elyasi, F., & Hamzehgardeshi, Z. (2024). Emotional Risk Factors before In Vitro Fertilization among Infertile Couples in Daily Clinical Practice in Sari in 2020-2022. BMC psychology, 12(1), 309. https://doi.org/10.1186/s40359-024-01796-5

Koochaksaraei, F. Y., Simbar, M., Khoshnoodifar, M., Faramarzi, M., & Nasiri, M. (2023). Interventions Promoting Mental Health Dimensions in Infertile Women: A Systematic Review. BMC psychology, 11, 254. https://doi.org/10.1186/s40359-023-01285-1

Li, G., Jiang, Z., Kang, X., Ma, L., Han, X., & Fang, M. (2021). Trajectories and Predictors of Anxiety and Depression amongst Infertile Women during Their First IVF/ICSI Treatment Cycle. Journal of psychosomatic research, 142, 110357. https://doi.org/10.1016/j.jpsychores.2021.110357

Martinez-Calderon, J. (2018). The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: A Systematic Review. The Journal of Pain, 19(1), 10-34. https://doi.org/10.1016/j.jpain.2017.08.008

Nik Hazlina, N. H., Norhayati, M. N., Shaiful Bahari, I., & Nik Muhammad Arif, N. A. (2022). Worldwide Prevalence, Risk Factors and Psychological Impact of Infertility among Women: A Systematic Review and Meta-Analysis. BMJ open, 12(3), e057132. https://doi.org/10.1136/bmjopen-2021-057132

Renzi, A., Di Trani, M., Solano, L., Minutolo, E., & Tambelli, R. (2020). Alexithymia, Infertility-Related Stress and Quality of Life in Women Undergoing an Assisted Reproductive Treatment. Stress and Health, 36(5), 654-662. https://doi.org/10.1002/smi.2967

Samani, S., Sohrabi Shekefti, N., Moslehi, M., & Vesal Shirazi, M. (2023). Developing a Marital Attachment Needs Scale. Iranian Evolutionary Educational Psychology Journal, 5(4), 241-252.

Tacchino, C., Castellano, R., Rogier, G., Cocchiaro, T., Lago, A. D., Rago, R., & Velotti, P. (2025). Attachment Dimensions and Infertility: Exploring Psychological Outcomes through Systematic Review and Meta-Analysis. Journal of marital and family therapy, 51(4), e70073. https://doi.org/10.1111/jmft.70073

Wang, L., Tang, Y., & Wang, Y. (2023). Predictors and Incidence of Depression and Anxiety in Women Undergoing Infertility Treatment: A Cross-Sectional Study. PLoS One, 18, e0284414. https://doi.org/10.1371/journal.pone.0284414

Yildiz, M., & Eldeleklioglu, J. (2021). The Relationship between Decision-Making and Intolerance to Uncertainty, Cognitive Flexibility and Happiness. Eurasian Journal of Educational Research, 91, 39-60. https://doi.org/10.14689/ejer.2021.91.3

Zhang, J., Chan, D. N. S., Liu, X., Cai, Y., Chen, J., & Xie, M. (2023). Effects of Self-Management Interventions for Cancer Patients with Pain: A Systematic Review of Randomised Controlled Trials. Journal of clinical nursing, 32, 5652-5667. https://doi.org/10.1111/jocn.16669