Association between quality of life and resilience in infertile patients: a systematic review

This systematic review was carried out to describe QoL and resilience in infertile patients, as well as the relationship between them, and to give a theoretical foundation for clinical practice. The databases of CNKI, Wanfang data, VIP database, PubMed, Web of Science, and Embase were searched without a time limit. A narrative synthesis of relevant articles was undertaken. This systematic review was registered on PROSPERO in advance. Of 21 studies eligible for inclusion in this review, 13 focused on the relationship between QoL and resilience, 5 on QoL influencing factors (resilience included), and 3 on mediation effect analysis on mental health (resilience as a mediator). Resilience can significantly predict the QoL of infertile patients. It seems plausible that more resilient couples will be less vulnerable to the stress of infertility. A global consortium of infertile population research could make cross-cultural comparisons of QoL and resilience possible. Future research should focus on resilience therapies. Systematic review registration This systematic review was registered on PROSPERO in advance (CRD42023414706).

more mentally tolerant of excessive stress (10).We can hypothesize that resilience acts as a protective factor in increasing QoL.Previous research has focused on the relationship between QoL and resilience.However, the findings are inconclusive, and there are disparities in how much emphasis the studies place on men and women.Several studies have reported that levels of QoL are higher in more resilient populations (6,11), while others have found no significant correlation between QoL and resilience (12).This contradiction in the available literature may be attributable, at least in part, to variations in the scales and subjects utilized in these studies.Consequently, it is imperative to conduct a comprehensive review of the existing literature on QoL and resilience in infertile patients.This systematic review was carried out to describe QoL and resilience in infertile patients, as well as the relationship between them, and to give a theoretical foundation for clinical practice.The literature incorporated in this article encompasses diverse research designs and data analytical techniques, which are advantageous in elucidating the intricate interplay among biological, cognitive, and social determinants.This understanding could potentially facilitate the development of interventions aimed at assisting infertile patients in leading well-being lives.

Objective
This retrospective article attempts to provide supporting evidence by summarizing the relationship between quality of life and resilience in infertile patients.Potential countermeasures were investigated in order to design relevant future interventions for patients.

Design
This systematic review was registered on PROSPERO in advance.The System Review and Meta-Analysis Preferred Reporting Project (PRISMA) guidelines were used to select publications for inclusion (13).To assess the quality of the papers, the Agency for Healthcare Research and Quality (AHRQ) checklist (14) was employed.

Search strategy
We did a thorough literature search using the CNKI, Wanfang data, VIP database, PubMed, Web of Science, and Embase databases from their inception through April 2023.Using free words and a mix of logical operators, synonyms of the search phrases were obtained after multiple attempts and changes.Supplementary Table S1 displays the specific search formulas for each database.In addition, we analyzed the references of the included studies and manually obtained them as needed to locate other potential studies that satisfied the inclusion criteria.

Inclusion criteria
Our systematic review included research that met the following criteria: (1) observational studies, (2) patients with infertility included, (3) the link between quality of life and resilience documented, and (4) papers published in Chinese or English.Retrieved dissertations that met the inclusion criteria were also considered.Interventional studies, reviews, qualitative research, case reports and letters to the editor, preprint studies, and lack of access to the full text of articles were all excluded.Studies targeted at patients with known mental disorders were excluded.

Study selection
NoteExpress was used to remove duplicate entries from the database search.The first author conducted the searches and completed the initial screening from the titles and abstracts.The full texts of all potential titles were independently reviewed by 2 authors, and an article selection decision was made based on the inclusion criteria.The reasons for the article's exclusion were documented.A third reviewer resolved any disagreements between the two reviewers about the inclusion of an article.The PRISMA flow diagram of our study selection procedure is shown in Figure 1 (13).

Data extraction
Two reviewers worked independently to retrieve data.Disagreements were settled by enlisting the help of a third author to review the data.All of the included studies were cross-sectional.The data extraction form included the following items: (1) the first author, (2) the year of publication, (3) the study location, (4) the study period, (5) the settings, (6) the study populations, (7) the sampling strategies, (8) the sample sizes, (9) patient demographics (mean/median age), (10) screening instruments and scores, (11) data analysis, and ( 12) the research findings.

Quality assessment
Two reviewers independently assessed the quality of the papers using the AHRQ guideline (14).The AHRQ checklist provides a framework for evaluating reporting quality and bias risk in 5 domains: selection, implementation, measurement, reporting, and follow-up.This guide contains 11 items totaling 11 points.If an item satisfied the criteria, it received 1 point.If the description was negative or ambiguous, it received a score of zero.A score of ≥8 indicates that the article is of good quality.A medium-quality article has a score between 4 and 7. A score of ≤3 indicates a low-quality article.

Characteristics of the included literature
There were 21 cross-sectional studies included in this study (Figure 1).All of them were published in peer-reviewed publications.
In terms of resilience domains, 2 studies reported higher scores in self-improvement and lower scores in optimistic (25,26).

Association between QoL and resilience
Through correlation analysis and multiple linear regression, 20 studies discovered a favorable relationship between QoL and resilience (4,6,(10)(11)(12)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33).One study employed latent class analysis to identify potential resilience categories in infertile women and to examine differences in QoL across subgroups (24).There were 3 potential subgroups in this study: "low resilience group (C1)," "high resilience group (C2)," and "general resilience-low strength group (C3)." In the total score of QoL for each dimension, C2 scored the highest and C1 scored the lowest.Three studies used the mediation model and discovered that resilience mediated psychological stress (12), fertility-related stress (22), post-traumatic growth (25) and QoL, in that order.These studies have indicated that resilience may not directly influence QoL, but it does exert an indirect impact through the medium of social support.The actorpartner interdependence paradigm was the topic of 2 studies.One of them found that an infertile actor's resilience affects both his/her own and his/her partner's QoL (8).Another study, however, found that only the resilience of wives can predict the QoL of both couples (30).

Discussion
Infertility has evolved into a public health issue that requires immediate action.It is inextricably linked to the mental health and quality of life of patients.Previous findings are inconclusive, which may be attributable, at least in part, to variations in the scales and subjects utilized in these studies.Consequently, it is imperative to conduct a comprehensive review of the existing literature on QoL and resilience in infertile patients.This review summarized 21 studies including 7,892 patients, with 2,678 males and 5,214 females.Infertile women always receive more attention than infertile men.Our findings revealed that resilience is not only connected to QoL but also has a significant mediating effect on the association between various psychological markers (such as post-traumatic growth, psychological stress, and so on) and QoL.
The outcomes of this review on levels of QoL and resilience in infertile patients were varied (see Tables 1, 2).QoL was measured using three different tools: FertiQoL, WHOQOL-BREF, and QoLICQ (1998), (7,16).To test resilience, four different assessment instruments were used: CD-RISC, CD-RISC-10, RS-14, and RS (9,11,17,18).Only 3 studies reported better QoL using the FertiQoL (22,25,26), and one study reported better resilience using RS (29).Based on the similarities and differences in domains of each scale, we hypothesize that differences in measurement tools between studies aren't related to the heterogeneity of findings.
Considerable differences in population among studies may explain the heterogeneity of findings.This finding can be explained by the fact that highly educated patients and patients who live in cities are less likely to be influenced by traditional beliefs due to greater social resources (26).This could also be related to the fact that patients who are further along in the treatment cycle have less doubt and more hope than those who are still in the early stages (22,25).Cross-cultural differences could potentially explain contradictory conclusions.Asiatic infertile patients showed lower levels of resilience whereas European patients in Germany demonstrated higher levels of resilience (29).These contradictory findings may be explained by the traditional concept of carrying on the family line in Asian.However, the effects of these elements necessitate additional investigation and evidence summarization.
In comparison to infertile women, men have greater QoL and resilience scores (6,8,10,11,20,28,30,31).This is related to female patients' higher social and treatment pressures, implying that we should pay more attention to their mental health.Previous research has suggested a correlation between elevated externally oriented thinking in males relative to their partners and their QoL levels.Furthermore, the QoL of both partners appears to be intricately interconnected (35).This finding underscores the significance of implementing interventions aimed at couples as a collective unit.Our review discovered that patients' treatment tolerability domain and optimistic domain scored low (6,(24)(25)(26), indicating that infertilityrelated treatment has a more profound impact on patients' lives, and patients' attitude toward disease treatment is also more pessimistic.As a result, it is critical to pay attention to patients' psychological status throughout infertility treatment and aim to improve the quality of services provided during treatment, such as the provision of readily available health education, particularly for women.This review included papers that used correlation analysis, multiple linear regression analysis, and latent class analysis to investigate the relationship between QoL and resilience in infertile couples (4,6,(10)(11)(12)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33).This suggests that we should tailor intervention strategies to individual differences in mental resilience in order to improve patients' quality of life.In two research, the actorpartner interdependence model was applied.One of them discovered that the resilience of an infertile actor affects both his/her own and his/ her partner's QoL (8).However, another study discovered that only the resilience of wives can predict the QoL of both couples (30).Although the results differ, they do present us with a unique perspective on QoL therapies, namely interventions for spouses/ interventions for both couples.
Several studies, in contrast to the typical correlation analysis, use the mediation model, which revealed that resilience partially mediated psychological stress (12), fertility-related stress (22), post-traumatic growth (22), and QoL, in that order.One of the studies found that while resilience does not directly affect QoL in patients with polycystic ovary syndrome (PCOS), it does affect QoL indirectly through social support (12).This demonstrates that resilience can mitigate the detrimental impact of stress on QoL while enhancing the good impact of positive stress cognition on QoL.This partially explains the internal mechanism of the positive connection between resilience and QoL and stresses the importance of resilience intervention.
A strength of this review is the adherence to a strict systematic review process and well specified inclusion and exclusion criteria.To find all relevant publications, a comprehensive search approach was used.Another point in favor is the strong inter-rater reliability among reviewers during the screening phase, which reflects transparent selection approach.The current review additionally considered a variety of study approaches and thoroughly synthesizes the literature on QoL and resilience.Finally, this review examined both male and female infertility patients and analyzed the differences between the two, providing future clinical practice with a unique viewpoint to improve the physical and mental health of infertile patients.While this review explored QoL and resilience, it did not look at contributing factors that may have an impact on the balance of outcomes.
This review identified many inherent limitations of related literature.Firstly, the main sampling approach utilized in the included literature is convenience sampling, and there is no guarantee that these patients are a representative sample of all infertile population.Secondly, QoL and resilience were assessed using self-report.As with all self-reports, common methodological variance, social desirability biases, and response distortion due to ego-related defensive tendencies cannot be ignored (36).Not all studies explained any patient exclusions from analysis, and confounding factors were not taken into account.Furthermore, the handling of missing data is ambiguous, and the AHRQ quality assessment revealed poorly reported response rates.Relevant studies are cross-sectional, and the absence of follow-up made investigating cohort effects unfeasible.Finally, this review included only published studies, which will result in an inflated impression of the literature because published studies have more positive results.

Conclusion
Resilience can significantly predict the QoL of infertile patients.It seems plausible that more resilient couples will be less vulnerable to the stress of infertility.Methodological and population differences across studies may explain the variation in literature results.Future research could focus on broader concepts that include not only mental health but also physical and social well-being.Longitudinal analyses may also be utilised to infer causal relationships between the correlates of mental health, and to explore the changes in the psychological perspective of individuals during the reproductive process.A country's cultural environment may influence QoL and resilience in infertility.A global consortium of infertile population research could make cross-cultural comparisons of QoL and resilience possible.Future research should concentrate on resilience therapies that improve QoL and alleviate psychological burdens in infertile women.

TABLE 1
Characteristics of included studies.
M, male; F, female; QoL, quality of life; Dec., December; CS, cross-sectional; RIF, repeated implantation failure; FertiQoL, fertility quality of life; CD-RISC, Connor-Davidson resilience scale; MLR, multiple linear regression; CA, correlation analysis; CD-RISC-10, 10-item Connor-Davidson resilience scale; LCA, latent class analysis; PCOS, polycystic ovary syndrome; WHOQOL-BREF, The World Health Organization Quality of Life-BREF; MM, mediation model; APIM, actor-partner interdependence model; RS-14, The 14item Resilience Scale; RS, the resilience scale; QoLICQ, quality of life questionnaire for infertile couples.a FertiQoL and resilience of wives.b FertiQoL and resilience of husbands.c FertiQoL of husbands and resilience of wives.d FertiQoL of wives and resilience of husbands.

TABLE 2
Important findings and quality of included studies.Patients with RIF in ART have low psychological resilience and poor QoL.The family income, the number of hospitals visited, and resilience were independent risk factors of QoL in patients with RIF The levels of resilience and QoL of female patients with RIF are lower than those of general infertility.There is a positive correlation between resilience and FertiQoL, and resilience is an influencing factor of FertiQoL