Network structure of depression and anxiety symptoms with psychosocial factors among Chinese women with primary infertility: a multi-center cross-sectional study

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BACKGROUND: Women with primary infertility experience elevated psychological distress, yet the interplay between individual symptoms and psychosocial factors remains unclear. This study aimed to identify central and bridge symptoms within a network of depression, anxiety, and psychosocial factors in Chinese women with primary infertility. METHODS: A total of 1,062 women with primary infertility were recruited from four reproductive medicine centers in China between February and December 2025. Depression (PHQ-9), anxiety (GAD-7), perceived stress (PSS-10), fertility-specific stress (COMPI-FPSS-SF), infertility stigma (ISS), social support (MSPSS), and resilience (CD-RISC-10) were assessed. Network analysis using regularized partial correlation networks was conducted to estimate network structure, centrality, bridge centrality, and predictability. RESULTS: Of the participants, 9.6% met clinical thresholds for depression and 5.3% for anxiety. Difficulty relaxing exhibited the highest centrality among symptoms. Public stigma showed the strongest centrality among psychosocial factors, with a robust connection to family stigma (edge weight = 0.538). Perceived stress emerged as the primary bridge linking psychosocial factors to symptoms (bridge expected influence = 0.297), followed by fertility-specific stress (bridge expected influence = 0.143). Guilt was the key bridge symptom (bridge expected influence = 0.086). Resilience showed the strongest negative association with perceived stress (edge weight = - 0.275). Network stability was excellent (CS-coefficient = 0.75). CONCLUSIONS: Difficulty relaxing, perceived stress, and guilt emerged as potentially important nodes that warrant further investigation as candidate intervention targets for psychological distress in women with primary infertility. Interventions targeting relaxation training, stress appraisal, and self-compassion, alongside resilience enhancement, warrant further investigation. CLINICAL TRIAL NUMBER: Not applicable.

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