Mapping the symptom network of anxiety, depression, somatic symptoms and sleep disturbances in 15,642 infertile women: a retrospective cohort study identifying targets for fertility care.

BACKGROUND: The interrelationships among common psychological distress symptoms, as well as their associations with in vitro fertilization-embryo transfer (IVF-ET) outcomes, have not been fully characterized. This study aimed to identify the central and bridge symptoms of the psychological distress network in infertile women, and to investigate the associations between psychological distress and IVF-ET outcomes. METHODS: This retrospective cohort study included 15,642 infertile women treated between June 2020 and January 2024. Anxiety, depression, somatic symptoms, and sleep quality were assessed using validated standardized scales. A Gaussian graphical model with graphical lasso regularization was constructed to estimate the symptom network. Node centrality (expected influence, EI) and bridge centrality (bridge expected influence, BEI) were calculated, and network stability was assessed using bootstrapping. Multivariable modified Poisson regression was used to examine associations between psychological distress and IVF-ET outcomes. RESULTS: The prevalence rates of anxiety, depression, somatic symptoms, and sleep problems were 30.1%, 34.8%, 45.1%, and 13.3%, respectively. Network analysis identified trouble relaxing (A4, EI = 1.313) and uncontrollable worry (A2, EI = 1.240) as the most highly connected central symptoms, while daytime dysfunction (SQ7, BEI = 0.887) and fatigue (D3, BEI = 0.657) emerged as the top bridge symptom. Multivariable modified Poisson regression analysis showed that better subjective sleep quality was associated with a higher likelihood of clinical pregnancy (aRR = 1.026, 95% CI 1.008-1.044), and sleep medication use was associated with the risk of late miscarriage (aRR = 0.211, 95% CI 0.052-0.861). CONCLUSION: Anxious cognitive and mind-body symptoms represent the most highly connected structural features of the psychological distress network in this cohort. Sleep-related problems were associated with IVF-ET outcomes, providing hypothesis-generating evidence for the potential clinical relevance of sleep assessment in infertility care.