Introduction

Ovarian hyperstimulation syndrome (OHSS) is a serious iatrogenic complication of controlled ovarian stimulation during in vitro fertilization (IVF) procedures. It results from an exaggerated ovarian response to gonadotropin stimulation. It is characterized by ovarian enlargement, fluid accumulation, hemoconcentration, and, in severe cases, thromboembolism, renal dysfunction, and respiratory compromise1. The incidence of severe OHSS remains a critical concern in reproductive medicine, and the reported rates range from 1 to 5% of IVF cycles, especially following embryo transfer (ET) in high-responder patients2.

Infertility is a medical condition that can drastically impact patients’ and couples’ emotional and mental well-being. Past literature has extensively explored the pathophysiological aspects and risk management of OHSS. However, its psychological impact, particularly in the post-ET phase, has received comparatively less attention3. Women experiencing severe OHSS frequently report elevated levels of anxiety, helplessness, and uncertainty related to treatment outcomes. All these factors contribute to heightened fertility-related stress and negatively impact treatment outcomes4. Fertility-related stress is a multidimensional construct that encompasses emotional distress, relationship strain, social stigma, and concerns about reproductive potential. This stress may compromise treatment adherence, psychological well-being, and pregnancy outcomes, highlighting the need for holistic and supportive care in this population34.

Recent evidence suggests that psychological capital is a positive psychological state comprising self-efficacy, optimism, resilience, and hope which may serve as a protective factor in stressful reproductive experiences5. Higher psychological capital has been linked to improved coping, better quality of life, and reduced emotional distress in women undergoing assisted reproductive technologies (ART)6. However, individual psychological resources are not the sole determinants of stress outcomes as interpersonal dynamics. Communication between partners is also considered to play an important role5,6,7.

Couple communication patterns have emerged as critical mediators of emotional adaptation in infertility. These patterns are generally classified as constructive communication (characterized by empathy, mutual support, and collaborative problem-solving), requested avoidance (involving complaints or withdrawal initiated by one partner), and complete avoidance (mutual disengagement or emotional detachment)7. Ineffective communication may exacerbate negative emotional responses, reduce mutual understanding, and increase psychological strain during IVF-related complications such as OHSS6,7.

Previous studies have independently associated communication quality and psychological capital with fertility-related stress6,7,8. However, there is limited research exploring the interactive or mediating effects of these variables among women with severe OHSS after ET. The post-ET period is a psychologically vulnerable phase, marked by physical discomfort, hormonal fluctuations, and fear of treatment failure9. Therefore, maladaptive communication may exacerbate emotional distress, potentially impairing recovery and reducing the likelihood of a successful pregnancy in women experiencing infertility-related stress8,9,10.

Psychological capital has emerged as a crucial protective factor in alleviating fertility-related stress among women undergoing infertility treatment10,11. Increased levels of hope, self-efficacy, resilience, and optimism characterize enhanced psychological capital. It has been associated with improved emotional well-being. In addition, spouse-focused psychological interventions, including structured psychological support and compassionate partner-based strategies, have shown promise in improving adaptation among women experiencing infertility-related stress12.

Despite increasing recognition of the psychosocial burden associated with OHSS, current clinical care protocols often overlook the relational and emotional dimensions of this condition. Most available interventions target physiological symptoms or provide general counseling support. Previous research has placed limited emphasis on how individual psychological resources and partner dynamics jointly influence treatment-related stress in infertility11,12,13,14. Moreover, infertility treatments have become increasingly common and are often accompanied by significant emotional burdens. There is a critical need to identify modifiable psychological and relational factors that could inform comprehensive, patient-centered care models15.

Investigating the interrelationships among psychological capital, couple communication styles, and fertility-related stress in women affected by severe OHSS post-ET can result in valuable insights into the psychosocial mechanisms underlying patient distress and recovery16,17. Therefore, this study aimed to examine the associations between couple communication patterns, psychological capital, and fertility-related stress in women diagnosed with severe OHSS post-ET in China. This study also explores whether couple communication patterns mediate the relationship between psychological capital and fertility-related stress.

Method

Study design

This study employed a cross-sectional design to examine the impact of couple communication patterns on fertility-related stress. Participants were recruited using a convenience sampling method from the reproductive ward of a tertiary hospital in China between June 2022 and December 2023. The target population consisted of women diagnosed with OHSS following ET during IVF treatment.

Inclusion and exclusion criteria

Women were chosen as the focus of this study because OHSS is a medical condition unique to females undergoing controlled ovarian stimulation during ART. Therefore, only women receiving IVF-ET who developed severe OHSS were eligible, ensuring clinical homogeneity and relevance to the study objectives. Previous studies have demonstrated that the psychological and physiological impact of OHSS primarily affects women, warranting gender-specific investigation12,13,14,15,16,17,18,19,20.

The inclusion criteria were as follows: (1) women aged 20–49 years undergoing IVF-ET and clinically diagnosed with severe OHSS; (2) legally married; (3) able to read, understand, and communicate without assistance; and (4) provided verbal and written informed consent to participate. Exclusion criteria included: (1) OHSS cases not linked to fertility treatment; (2) pre-existing psychiatric or cognitive disorders; (3) concurrent participation in other clinical studies; (4) serious systemic illnesses such as advanced hepatic, renal, cardiovascular, or cerebrovascular disease; and (5) any condition impairing the ability to complete the survey independently.

Sample size and sampling

The required sample size for this cross-sectional study was estimated using a standard formula widely used in prevalence research to ensure statistical accuracy:

$$n=\frac{{{Z^2} \cdot P \cdot (1 - p)}}{{{d^2}}}$$

Where:

n is the sample size.

Z is the Z-statistic corresponding to the desired confidence level. The value of Z is 1.96 For a 95% confidence interval.

P is the estimated prevalence of the condition in the population, which is 5%1 (0.05) in this case.

d is the desired margin of error, typically set at 5% (0.05) for a reasonable precision.

The calculated minimum sample size was 73 participants. However, we enrolled 175 participants, significantly exceeding this estimate to account for an anticipated 10–20% dropout rate (common in similar studies) and to improve statistical precision. The aim was to strengthen the reliability and validity of our findings.

Instruments

General information survey

This questionnaire was self-designed and developed from the studied literature. There were two main categories: (1) demographic data, such as age and place of residence, and (2) disease-related information, such as a history of infertility, the number of abortions, and types of assisted reproductive technology.

Fertility problem inventory (FPI)

Zurlo et al. (2017) studied the FPI to assess fertility-related stress among infertile women20. The scale has excellent reliability and validity and is widely used by researchers to study infertility-related stress. The FPI scale is composed of 46 items focused on measuring five dimensions of infertility problems: social stress (ten items), sexual stress (eight items), couple relationships (ten items), parental role demands (ten items), and rejection of a child-free lifestyle (eight items). The Cronbach’s α coefficients of the total scale and subscales ranged from 0.77 to 0.93. In 2011, Peng et al. (2011) translated and devised the Chinese version of this scale21. The Cronbach’s α coefficient of this total Chinese scale was 0.91, and subscales ranged from 0.74 to 0.85. A six-point Likert-type scoring method was applied (1–6 points) to calculate the total score, ranging from 1 “completely disagree” to 6 “completely agree.” The total score ranges from 46 to 276; higher scores indicate higher levels of fertility-related stress.

Psychological capital questionnaire

A 26-item questionnaire comprising four dimensions: self-efficacy, hope, optimism, and resilience was used to assess the psychological capital developed22. A 7-point Likert-type scoring method was used to analyze the psychological capital. Among those 26 items, 8, 10, 12, 14, and 25 were reverse questions. The higher total scores of items in each dimension indicate the higher individual’s psychological capital level. The Cronbach α coefficient of the questionnaire was 0.90.

Couple communication pattern questionnaire

The questionnaire for the present study was the Chinese version derived from the Christensen Marital Communication Model Questionnaire (1996 version)23. The Likert scale comprises 16 items scored from 1 “least likely” to 9 “most likely,” where participants are asked to choose the degree of conformity that best reflects the actual communication pattern between them and their spouses. The scale contains three subscales measuring three communication patterns: constructive communication, requested avoidance of communication, and complete avoidance of communication. The Cronbach’s α values of the three subscales were 0.512, 0.826, and 0.739, respectively.

Data collection

Data were collected via a single-center survey administered electronically through the WeChat platform. The principal investigator selected three trained surveyors (registered nurses from the reproductive unit with ≥ 2 years of clinical experience) based on their familiarity with OHSS patient care and adherence to research protocols. The surveyors completed two 4-hour training sessions that covered standardized questionnaire administration, ethical considerations (including confidentiality and informed consent procedures), and technical use of the WeChat survey interface. All surveyors were required to pass a written assessment with a minimum score of 80% to ensure competency. Additionally, supervisors implemented quality control measures through weekly random audits of 20% of submitted questionnaires to verify data accuracy and maintain consistency in data collection procedures.

Participants independently completed the electronic questionnaires by scanning a QR code distributed during morning nursing rounds. While surveyors were available on-site to address any participant questions or clarify items, they did not assist in answering or inputting responses. The average completion time for the questionnaires was approximately 20 min, with all responses being submitted immediately upon finishing. A written informed consent was obtained from every participant to ensure ethical compliance before beginning the survey.

Ethical considerations

This study was conducted in accordance with the ethical standards of the institutional and national research committees and adhered to the principles outlined in the Declaration of Helsinki (2013). Ethical approval was obtained from the Ethics Committee of Sir Run Run Shaw Hospital (Approval No. 20210729-127). Before participation, all individuals received comprehensive information regarding the study’s objectives, procedures, potential risks, and benefits. Informed consent was obtained from all participants in both verbal and written form. Participant confidentiality was strictly maintained by anonymizing all collected data and storing it securely. No personally identifiable information was disclosed at any stage of the research process.

Data analysis

Data were analyzed using SPSS, version 26.0, and AOMS version 24.0 (Statistical Package for Social Sciences, Inc., Chicago, IL, USA). First, descriptive statistics were employed to describe the social-demographic and clinical features of the sample and reported as absolute values and percentages. Univariate factor analysis assessed the mean differences in categorical variables such as age and education. Then, a bivariate Pearson’s correlation was conducted by calculating correlation coefficients to examine the relationships between psychological capital and -related stress. Additionally, hierarchical regression was conducted to examine the association between psychological capital and couple communication patterns on fertility stress. Finally, AMOS was applied to develop a structural equation model to test the mediating role of couple communication patterns. The evaluation criteria for model fit were 2/df < 3, GFI, TLI, and CFI > 0.8 RMSEA < 0.1.

Results

Demographic data and information on disease characteristics of the participants

A total of 200 questionnaires were distributed, and 183 were retrieved, with a recovery rate of 91.5%. After the survey, 175 questionnaires were selected as valid, producing a reasonable recovery rate of 87.5%. The women undergoing treatment ranged from 23 to 42 years, with an average age of 33.56 ± 3.24 years. Table 1 displays the demographic data and medical history information of the participants.

Table 1 General and disease-related characteristics of patients diagnosed with severe ovarian hyperstimulation syndrome (OHSS).
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Correlation analysis

The results of the Pearson correlation coefficient analysis revealed a significant positive correlation between psychological capital and constructive communication (P < 0.01); fertility-related stress and requested avoidance of communication (P < 0.01); and fertility-related stress and complete avoidance of communication (P < 0.01). A significant negative correlation was observed between psychological capital and requested avoidance of communication (P < 0.01); and fertility-related stress and psychological capital (P < 0.05). There was no correlation between fertility-related stress and constructive communication (P > 0.05). Refer to Table 2.

Table 2 Correlation between communication patterns, infertility-related stress, and psychological capital in patients with severe ovarian hyperstimulation syndrome (OHSS).
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Univariate and hierarchical regression analysis

Univariate analysis results presented in Table 3 revealed that literacy, place of residence, monthly household income, marital status, generation of embryo transfer treatment, currently preparing for a first or second child, psychological capital, and requested/completed avoidance communication patterns all had a significant effect on fertility-relates stress (P < 0.05). A multifactorial analysis was also conducted using the hierarchical regression technique. The significant univariate variables were taken as independent variables and fertility-related stress was the dependent variable in this analysis.

Table 3 Regression analysis of communication patterns and psychological capital on infertility-related stress in severe OHSS patients.
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The F-test of Models I and II indicated (P < 0.01) that the models were statistically significant. In the Hierarchical Regression, Model I presented an R2 value of 0.189. The R2 of Model II was 0.2836 with a variance of 0.094, suggesting that the addition of variables including psychological capital, requested avoidance of communication, and complete avoidance of communication, accounted for 9.4% of the variance of fertility-related stress.

The t-test significance of the regression coefficient corresponding to complete avoidance of communication was less than 0.05, indicating that complete avoidance of communication had a significant positive effect on fertility-related stress (b = 0.277, P < 0.05) and psychological capital. In contrast, requested avoidance of communication was found to have no significant effect on fertility-related stress (P > 0.05). Among the control variables, monthly household income had a significant adverse effect on fertility-related stress, higher in women preparing for a second child than those preparing for a first child, refer to Table 3.

Analysis of the mediating role of couple communication patterns

Bootstrap sampling (N = 2000) with Analysis of AMOS version 24.0 was applied to explore the significance of the mediating effect of couple communication patterns along three dimensions concerning psychological capital and fertility-related stress. The dependent variable was fertility-related stress, and the independent and mediating variables included psychological capital and couple communication patterns. The mediating effect was significant if the 95% confidence interval (CI) for the indirect effect did not include zero. The test results revealed that the 95% CI (− 0.207, − 0.005) for requested avoidance of communication did not include zero, and the 95% CI for constructive communication and complete avoidance of communication included zero. Thus, it inferred that the mediating effect of avoidance of communication was significant. Refer to Table 4; Fig. 1.

Table 4 Mediating effects of couples’ communication patterns on the relationship between psychological capital and infertility-related stress (N = 175).
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Fig. 1
figure 1

Mediation model of couple communication patterns between psychological capital and infertility-related stress in patients with severe OHSS. The model illustrates the mediating role of three types of couple communication patterns, constructive communication, requested avoidance, and complete avoidance in the relationship between psychological capital and infertility-related stress. Arrows indicate hypothesized pathways.

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Discussion

This cross-sectional study aimed to explore the mediating role of couple communication patterns in the relationship between psychological capital and fertility-related stress among women diagnosed with severe OHSS following ET. Although only women were enrolled, the analysis of couple communication patterns captured their perceptions of relational dynamics during fertility treatment, a widely accepted approach in psychosocial and reproductive health research. Women’s perspectives are especially pertinent in the context of OHSS, as they bear the physiological burden of the condition and are central to the emotional experience of the fertility journey. These findings contribute to a deeper understanding of how psychological and interpersonal factors intersect to influence distress in women undergoing complex reproductive interventions.

The correlation analysis indicated no statistically significant relationship between constructive communication and fertility-related stress. A potential explanation lies in the timing of our study. Our participants were in the post-ET phase, often marked by heightened physical discomfort and uncertainty. During this advanced stage of treatment, constructive communication alone may not be sufficient to buffer stress without additional emotional or medical support. This finding suggests that communication interventions may need to be tailored to the specific phase of infertility treatment and that more research is required to clarify the role of positive communication post-ET. These findings align with previous studies that emphasize the dynamic nature of partner communication, indicating that its effectiveness may vary depending on the emotional and physiological stressors present during different stages of assisted reproductive treatment21,22,23,24,25,26,27,28,29,30.

In our sample, negative communication behaviors such as avoidance and withdrawal were linked to higher stress levels. This finding is consistent with a previous study that shows that poor communication within couples diminishes relationship quality and exacerbates emotional distress30. These results highlight the need for targeted interventions that address intrapersonal coping mechanisms and interpersonal communication strategies during IVF-related complications. This finding contrasts with earlier studies, which demonstrated that supportive communication effectively reduced stress among couples during the early stages of infertility assessment30,31,32.

The univariate analysis in this study revealed that several demographic and treatment-related variables influenced fertility-related stress. These variables include literacy level, residence place, monthly household income, and whether the participant was preparing for a first or second child. These findings are consistent with previous research indicating that lower socioeconomic status, limited education, and rural residence are associated with heightened emotional distress during fertility treatment29,30,31,32. Women preparing for a second child reported higher stress levels, possibly due to increased familial and societal expectations. These results underscore the importance of delivering personalized psychosocial support with targeted interventions for vulnerable subgroups such as low-income patients or those undergoing secondary infertility treatment.

The hierarchical regression analysis highlighted that psychological capital and couple communication patterns contributed to the prediction of fertility-related stress. Specifically requested and complete avoidance significantly can play an important role. These psychosocial factors accounted for an additional 9.4% of the variance beyond the effects of demographic and clinical variables. This finding reinforces earlier research29 suggesting that both individual psychological strengths and relational dynamics significantly shape women’s stress responses during infertility treatment.

Our results showed that the average level of fertility-related stress in women with severe OHSS was lower than that reported in previous studies on infertility populations undergoing assisted reproductive treatments13,24,25. One possible explanation is that participants in this study had already completed the embryo transfer process and received comprehensive inpatient care, including close monitoring, psychological support, and health education from multidisciplinary professionals26. This structured care environment may have contributed to a reduction in uncertainty and emotional distress, consistent with prior findings that suggest medical and psychological guidance during IVF can buffer emotional burdens27,28. The proactive provision of coping strategies by hospital staff may also have strengthened participants’ emotional resilience, which aligns with studies demonstrating that psychoeducational interventions reduce stress and improve IVF outcomes25,26,27,28.

Our finding suggests that the higher levels of psychological capital exert a protective effect on infertility-related stress, consistent with previous studies32,33,34,35,36. Ni et al. (2021) also reported that higher psychological capital helps protect against infertility-related stress and broader emotional and behavioral challenges during fertility treatment. In our study, women with severe OHSS reported a mean psychological capital score of 4.65 ± 0.727. This variable was significantly negatively correlated with fertility-related stress. This result suggests that women with stronger psychological resources, including greater resilience, optimism, and self-efficacy, were better equipped to manage the psychological burden of severe OHSS after ET.

Women with severe OHSS are often burdened by family- and society-related stressors, including the high cost of IVF, disruption in family dynamics, lack of emotional support from partners, and prevailing societal stigma related to infertility. These additional pressures may erode psychological capital over time and exacerbate stress. Therefore, psychological interventions tailored to improve psychological capital are needed. Structured programs in positive thinking, cognitive behavioral therapy, emotional resilience training, and biofeedback may serve as valuable adjuncts to medical management36,37. Although these approaches have shown promise in broader infertility populations, their specific efficacy in women experiencing severe OHSS remains under-investigated and warrants further clinical exploration. Developing such tailored interventions for this high-risk group could offer significant improvements in mental health outcomes and treatment satisfaction.

Our findings further supported the relationship between psychological capital and fertility-related stress. A significant negative correlation was found between the two variables. These findings align with research identifying psychological capital as a protective factor in emotionally challenging medical contexts29,35. Women in our study reported moderate-to-high levels of psychological capital (mean score 4.65 ± 0.727), which may have mitigated the emotional burden of severe OHSS. Earlier studies showed that psychological capital promotes adaptive thinking, optimism, and emotional regulation33,34. All these factors enable women to manage uncertainty and physical distress more effectively.

Our mediation analysis revealed that requested avoidance of communication significantly mediated the relationship between psychological capital and fertility-related stress. Meanwhile, constructive and complete avoidance did not demonstrate significant mediating effects. This finding suggests that indirect stress regulation occurs through specific patterns of partner interaction. Particularly those involving one-sided emotional withdrawal, criticism, or avoidance. These findings are consistent with prior studies indicating that such patterns heighten relational strain and exacerbate emotional distress in infertile couples31,32. Lam et al. (2021) reported similar results, showing that avoidance-based communication amplifies the negative impact of low psychological capital. It leads to higher emotional strain38. Furthermore, the “silent treatment,” often used in avoidance patterns, has been shown to undermine intimacy, increase perceived rejection, and intensify internalized infertility stigma32.

Although this study included only women with severe OHSS, the analysis of couple communication patterns remains valid and clinically meaningful. OHSS is a medical complication that exclusively affects women undergoing controlled ovarian stimulation as part of ART32,33,34,35,36, which justifies a gender-specific sample. Moreover, assessing a couple’s communication from the woman’s perspective is methodologically and ethically appropriate, especially in reproductive health research, where the physical and emotional burden is unequally distributed. Women undergoing IVF often serve as the emotional focal point of the treatment process and are uniquely positioned to evaluate relational dynamics during times of heightened stress37,38.

Research in dyadic coping has shown that perceived partner communication is a reliable predictor of psychological outcomes, even when reported by a single partner32. Therefore, the insights gathered from women’s subjective experiences of couple communication provide critical information about how relational behaviors influence fertility-related stress during high-risk IVF treatment. This perspective is particularly relevant in clinical settings where the joint involvement of both partners is impractical, yet the patient’s psychological adjustment remains critical to achieving optimal care outcomes.

Our findings also revealed that the heightened mental stress extends beyond psychological well-being. Elevated stress levels have been linked to reduced IVF success rates, impaired hormonal balance, and poorer adherence to treatment protocols39. Overall, these findings indicate that improving couple communication, particularly by lowering avoidance-based patterns, could significantly enhance the effectiveness of psychological capital in managing fertility-related stress. Addressing both intrapersonal (psychological) and interpersonal (relational) dimensions is essential in delivering comprehensive, patient-centered care for women with severe OHSS after ET.

Study limitations and future directions

This study has two limitations: (1) the study employed a cross-sectional survey of infertile women in a post-ET period to examine the dynamic relationship between infertility-related stress, psychological capital, and couple communication patterns. Since the duration of severe OHSS can be 10- to 40 days, the stress varies with the severity of the disease symptoms. At the same time, a simple cross-sectional study can only reflect the stress at a particular time point or period but fails to reflect dynamics in the infertility-related stress of women at different periods during treatment. Thus, a longitudinal survey is needed in the future, mainly focusing on the relationship between couple communication patterns, psychological capital, and dynamic changes in infertility-related stress and stress prediction in women with severe OHSS after ET; (2) All the participants surveyed attended the reproductive ward of a tertiary care hospital in China. A convenience sampling method was adopted, and all participants were recruited from the same center, which may lead to sampling bias and limit the generalizability of results. A multi-center study is suggested to improve the generalizability and diversity of results.

Clinical implications

The findings of this study offer valuable considerations for clinical practice. Considering that fertility-related stress can adversely impact IVF outcomes, the development of stress reduction interventions should target both internal (psychological capital) and external (couple dynamics) factors. Communication-focused therapy, couple counseling, and educational interventions could be integrated into reproductive care to enhance emotional resilience and reduce negative communication tendencies. This study provides insight into how interpersonal dynamics may influence psychological adaptation in women experiencing severe OHSS. Targeted couple-based interventions such as communication skills training, marital counseling, or integrated psychoeducation may help transform harmful interaction styles into more supportive exchanges. These interventions can help protect or enhance psychological capital and reduce stress. This study contributes to the literature by providing novel evidence on the mediating role of couple communication in the link between psychological capital and fertility-related stress in women experiencing a high-risk IVF complication.

Conclusion

The results showed that couple communication patterns and the levels of psychological capital of women with severe OHSS could partly explain infertility-related stress. The negative communication styles, especially requested avoidance communication patterns in couple relationships, and low psychological capital levels can exacerbate women’s infertility-related stress. Furthermore, requested avoidance communication mediates psychological capital and infertility-related stress in the couple’s relationship. Therefore, nurses need to provide clinical care to women and assess women’s psychological capital level and the couple’s communication patterns. Finally, individualized interventions based on the assessment results are needed to reduce infertility-related stress, stabilize the patient’s emotional state during treatment, and increase the pregnancy rate.