Background
As per the World Health Organization (WHO), infertility has been associated with a possible contribution to disability through functional limitations, which can impact a person's overall well-being [
1,
2]. As a serious life challenge, infertility can incur a disproportionate emotional burden similar to a traumatic experience and can be incredibly distressing for women [
3]. Infertile patients receiving In Vitro fertilization (IVF) therapy face significant psychological distress due to their infertility, demanding medical interventions, expensive expenditures, and unexpected results [
4]. Infertility among women of reproductive age is expected to afflict one in seven couples in Western nations and one in four couples in underdeveloped countries [
5]. According to the WHO's recent report, 48 million couples and 186 million people globally struggle with infertility [
6], with a prevalence rate of 5.0% and 2.0% for primary and secondary infertility among the Iranian population, respectively [
7].
Infertility places significant emotional and social pressures on couples as well as on their social interactions. This mental distress may be exacerbated by the IVF process. As a result, the emotional state of infertile patients throughout the IVF cycle has been labeled an "emotional rollercoaster" [
8], resonating with its volatility, instability, and susceptibility. On par with these adverse effects, it is found that psychological distress among these patients is significantly associated with marital instability [
9]. Although infertility is not a substantial psychological disorder, it can nevertheless cause serious problems with well-being and mental health, such as depression, emotional distress, and financial challenges [
10,
11]. Also, adverse emotions comprising anger, guilt, anxiety, sadness, and depression may arise among infertile couples, as well as feelings of hopelessness along with poor self-esteem and self-confidence [
12‐
14]. According to the study by Aanchal and Deepti [
15], isolation and reduced quality of life are other possible negative consequences that are frequently experienced by infertile women, in addition to anger and interpersonal antagonism [
15]. Hajizade-Valokolaee et al. [
16] found that there is heightened domestic violence against women undergoing IVF and higher divorce rates, which impacts treatment success rates and other indicators of well-being [
16]. Several studies have found that the infertile population has a greater incidence of mental problems, such as increased depressive and anxious symptoms [
17‐
19], higher levels of hopelessness [
20‐
22], alexithymia [
23‐
25], interpersonal problems [
26,
27], and lower levels of quality of life [
28‐
30]. Unfortunately, few established therapies are available for women facing infertility-related distress [
31].
Infertility facilities should deliver psychosocial and emotional support to patients according to the European Society of Human Reproduction and Embryology (ESHRE) Guidelines [
32] and Guidelines for Counseling in Infertility [
33]. There has been a recent surge in research on psychological interventions for IVF patients. In a systematic review, Chu et al. (2017) found that nonpharmacological interventions significantly reduced negative emotions and anxiety among IVF patients [
34]. Consistently, Ying et al. [
35] concluded that there is utility in implementing psychosocial treatments among women and men undergoing IVF, leading to better marital function [
35]. These interventions are likely to be essential, especially during the mentally taxing period of waiting for the pregnancy test results and after failed cycles [
11]. Of particular import, in their assessment of psychotherapies for IVF patients, De Liz and Strauss [
36] reported that group and individual/couple psychotherapy reduced anxiety and depression symptoms which were preserved in six months of follow-up [
36]. The findings indicate the favorable effects of psychotherapy for infertile individuals. However, others indicate little benefit for psychosocial interventions [
37]. As a result, more study into the effectiveness of psychological treatments and their incorporation into the treatment protocol for infertility conditions is necessary [
38]. The present study focused on one particularly understudied question: Can an intervention that promotes self-compassion and mindfulness improve the well-being of women undergoing IVF?
Self-compassion and the mindful self-compassion program
Kabat-Zinn defined mindfulness as “ the awareness that arises from paying attention, on purpose, in the present moment and non-judgmentally (p. 24)” [
39]. And it is increasingly being employed and has been shown to be effective in a variety of health sectors [
40‐
44]. In recent years, mindfulness research has gained attraction in Iran [
45], and specific attention has been concentrated on intervention studies for individuals suffering from related conditions (e.g., infertility, menopausal difficulties, etc.), with encouraging results [
46‐
48]. Some promising research suggests that mindfulness therapies might lessen depression and anxiety symptoms (For a review, see [
49,
50]) and also other forms of psychopathology [
51]. Nevertheless, few studies have delved into mindfulness-based programs (MBPs) to help infertile patients with negative emotions. A seminal clinical trial involving eight cases and no control subjects found that eight weeks of mindfulness-based cognitive therapy (MBCT) enhanced the well-being and psychological distress of infertile women (IW) [
52]. Galhardo et al. [
53] allocated IW to the MBP in a controlled clinical study. Program participants reported a significant decrease in depressed mood, inner and outward shame, feelings of entrapment, and failure [
53]. Also, improvements in mindfulness and self-efficacy in dealing with infertility were shown to be statistically significant. Another non-randomized controlled study found that IW who participated in the intervention (i.e., mindfulness-based intervention) improved significantly in self-compassion, coping strategies based on meaning-making, mindfulness, and all fertility quality of life categories. They, moreover, revealed a considerable amelioration in emotional dysregulation strategies and active/passive avoidance coping behaviors [
54].
In the context of coping with infertility and its repercussions, self-compassion as an emotion regulation strategy has been demonstrated to be highly relevant, and new research indicates that this strategy may be a milestone for future research and intervention. Cunha et al. [
55] demonstrated that infertile couples, and notably women, utilize fewer emotional coping skills like self-compassion and implement more experiential avoidance and self-critical strategies [
55]. In another study, Raque-Bogdan & Hoffman [
56] identified that among women with primary or secondary infertility, self-compassion mediated both the relationship between the need for parenthood and subjective well-being as well as the relation between social concern and subjective well-being [
56]. This finding may be especially significant given the social marginalization and stigmatized social identity of childlessness of those who are dealing with infertility in whom self-compassion can be utilized as a strategy of emotional regulation and resilience when facing self- or other-imposed blame for infertility. Also, a related study revealed that self-compassion plays a unique function in the interaction between shame and stress imposed on by infertility in both men and women [
53].
The Mindful Self-Compassion Program (MSC; [
57]) is a program that combines mindfulness and self-compassion and can be employed by the general public as well as clinical patients. The term "mindful" is included in the MSC program's name since it promotes principal mindfulness capabilities, which, as previously indicated, are vital to qualify for self-compassion. Participants in MSC meet once a week for two hour for eight weeks, as well as attend a half-day meditation retreat, as per the Mindfulness-Based Stress Reduction (MBSR) intervention. It should be considered that the MSC program puts emphasis on assisting participants in developing self-compassion, with mindfulness as an ancillary focus (The eight-week program devotes just one session to the cultivation of mindfulness techniques). This shows that the MSC program is a good complement to MBSR or MBCT, which have more time to spend establishing a thorough grasp of mindfulness. MSC teaches self-compassion in both formal (meditation) and casual (everyday living) settings. Each MSC session includes experiential exercises, group discussions, and homework assignments to help individuals learn how to be compassionate to themselves. The objective is to equip participants with a range of methods to help them enhance self-compassion, which they may incorporate into their daily lives as they see fit. The program also promotes broad loving-kindness skills, which are acts of friendly benevolence performed on oneself in ordinary settings [
57].
Considering the emerging and promising results but a dearth of MBPs in the mental well-being of IW undergoing IVF, this study tries to underlie the knowledge scarcity by assessing the effectiveness of MCS therapy on psychopathology symptoms, psychological distress, and life expectancy among this group. The concentration on self-compassion in the setting of infertility distinguishes it from conventional mindfulness therapies that improve self-awareness and acceptance. MSC becomes especially important in the context of infertility, as people are dealing with significant feelings of shame, guilt, and suffering. MSC is a specialized approach that addresses these emotional difficulties directly. Self-compassion, in addition to being a result of mindfulness, works as an effective mediator for a variety of psychological factors. Through self-compassion, one may cultivate a compassionate and understanding connection with oneself, which aids in reducing the negative impact of fertility-related despair. This program tries to deftly inculcate self-compassion which can function as a mediator, giving participants a comprehensive grasp of its therapeutic function when navigating the complications of infertility. It is hypothesized that the intervention would significantly improve baseline condition and that the effect would endure after treatment (i.e., at the post-treatment and follow-up), and that the intervention group would also benefit psychologically (i.e., reduction of psychological disorder and psychopathological symptoms) more than the group receiving treatment-as-usual (TAU) protocol, resulting in a progressive, significant decrease in psychopathology symptoms and psychological distress levels.
Discussion
The effects of infertility are overarching and may entail negative social effects in addition to individual anguish. Despite obstacles related to medical coverage and expense, advances in assisted reproductive technologies, such as IVF, can bring relief to plenty of couples when treatment is available and viable. Inadvertently, the medical model of infertility has resulted in disdaining from the couples' adverse feelings and emotions, which entails psychological distress, a diminished sense of control, social stigma, and a deviation from the normal course of adulthood growth [
12]. Furthermore, self-compassion is a powerful emotion-regulation skill [
72]. This points to the necessity for further hands-on research and intervention trials with infertile individuals. According to research, self-compassion can serve as a psychological mechanism that reduces the influence of negative feelings like shame and self-blame on the emotional burden of infertility [
53]. We may be able to improve their psychological well-being and potentially even impede the development of mental health difficulties as a result of their infertility experiences if we promote self-compassion in this vulnerable population. Thus, the present study aimed to explore whether MSC therapy might have the potential to reduce psychological distress and symptoms related to mental health in individuals undergoing IVF treatment. We also aimed to understand if it could have a positive influence on life expectancy in this group. Our data showed that women receiving MSC therapy experienced a significant decline in hopelessness. On par with this finding, a large body of research indicates that mindfulness and self-compassion have negative associations with hopelessness in a variety of health (i.e., physical or psychological) conditions, [
73‐
75].
Our findings revealed a significant drop in the anger-hostility index among IVF participants of the MSC program. In accordance with this finding, Morley et al. (2016) have reported that self-compassion plays a buffering role against hostility when individuals are facing adverse life events [
76]. One plausible rationale is that self-compassion could potentially discourage individuals from engaging in self-criticism, blame, or censure toward themselves and others when goals remain unmet (for example, the inability to get pregnant) [
77]. This can potentially diminish the experience and manifestation of hostile behavior and anger. Consistent with this view, research suggests that self-compassion helps people eschew being judgmental of others and controlling their own and others' emotions, accept their own and others' flaws, and encourage reconciliation in themselves and others [
78,
79]. These important qualities of self-compassion may operate as a buffer against the negative demands of the exacting circumstances of the inability to reproduce and also undergo IVF, as well as their consequent feelings of hostility and anger.
The findings regarding anxiety and the MSC program yielded promising results. We observed a significant drop in the anxiety level of patients, which is substantiated by the evidence thus far. A large body of data supports the substantial effect of self-compassion in anxiety spectrum disorders [
80‐
83]. In a relative vein, Makadi and Koszycki (2020) examined the association of mindfulness and self-compassion with social anxiety disorder and other mental health indicators (e.g., depression, life satisfaction, etc.) and noted that individuals with higher levels of mindfulness and self-compassion reported less severe symptoms [
84]. They also demonstrated that self-compassion plays a more pivotal role in clinical variables in this context, and the link between self-compassion and social anxiety was mediated by different aspects of mindfulness. According to Gilbert and Miles (2000), self-criticism causes anxiety reactions and might result in blaming if the person feels their critical thoughts are legitimate. Self-compassion is a healthy choice instead of self-defeating behaviors (i.e., self-judgment), and adopting a compassionate and caring attitude toward oneself, particularly when confronted with a social blunder or self-blame, might diminish anxiety and avoidant behavior through its influence on self-criticism and other analogous processes [
85].
We found a significant decrease in interpersonal sensitivity among patients in the MSC group. While experiencing social support is a well-established indicator of life quality and mental health, interpersonal sensitivity symptoms may erode this association [
86]. Research has found that self-compassion is positively linked with a wide range of advantages in interpersonal relationships (e.g., flexible interpersonal and conjugal functioning, as well as adaptable parenting behaviors, etc.). Accordingly, promoting self-compassion among patients receiving IVF would possibly improve their interpersonal relations (which might be a significant cause of stress and emotional distress due to infertility issues; see [
87‐
89], and in return, it would enhance their interpersonal relationships, which provides a resourceful cycle of positive feedbacks between individual and their social/emotional milieu [
90].
Finally, we found that depressive mood and symptomology declined significantly among patients in the MSC program group. The effectiveness of self-compassion-oriented treatment for depression has received a great deal of attention [
91], and the findings have been encouraging so far [
92]. It has been proposed that self-compassion serves as a repertoire of adaptive emotion-regulation strategies [
93] in depressed individuals and is more efficient in regulating emotions at higher depressive states than other strategies, such as reappraisal and acceptance [
92,
94,
95]. Adaptive/maladaptive emotion regulation strategies have been found to be critical in depression and other adverse affective states [
96‐
102], and self-compassion as a positive emotion regulation strategy may buffer against other maladaptive emotion regulation strategies such as self-blame or other blame [
103], which are highly prevalent among IW undergoing IVF. These findings suggest that MSC therapy reduces psychopathology symptoms and psychological distress and enhances life expectancy in IW undergoing IVF treatment. In the Iranian cultural context, women grappling with infertility often contend with pervasive infertiulity stigma [
104], which usualy contributes to feelings of shame and guilt [
105]. The MSC program, designed to cultivate compassionate self-behavior, acknowledge shared human experiences, and enhance mindfulness [
57], emerges as a potential intervention to alleviate the negative psychological impact of these emotions. MSC has the transformative capacity to reduce self-criticism by providing a perspective that acknowledges the commonality of infertility challenges among many others. It communicates that grappling with profound feelings and emotions is an inherent and shared aspect of the human experience, offering solace to those undergoing such difficulties. This integration may be helpful for women going through IVF since self-compassion can help reduce the feelings of guilt, shame, and distress that are frequently associated with reproductive procedures. The participants' qualitative input revealed enhanced emotional resilience, less self-criticism, and a better capacity to manage the emotional intricacies of in vitro fertilization. In a related RCT, Li et al. (2016) explored the impact of mindfulness-based interventions on quality of life and pregnancy rates in women undergoing IVF for the first time and concluded that awareness of the present moment without judgment aided in better therapeutic interactions, as well as self-compassion and emotion regulation, all of which contributed to higher pregnancy rates and quality of life improvements [
106]. The non-pharmacological, short-term (i.e., eight-week) duration of this intervention makes it a safe, viable treatment for IVF recipients. McDowell et al. (2016) conducted a longitudinal research in which 305 IVF women participated in a one-year follow-up survey [
107]. They found that several psychological factors, such as secure attachment, social support, mindfulness, and self-compassion, may positively influence the success of IVF treatment.
In terms of participant and therapist compliance, we continually monitored and assessed their engagement throughout the study. Participants in the both therapy group demonstrated impressive compliance, with a high attendance rate at planned treatment sessions and continuous involvement in mindfulness activities between sessions. This level of commitment was notably encouraging, given the mental and physical strains of IVF infertility treatment. In addition, therapists who delivered the intervention adhered strictly to the stated procedure, guaranteeing uniform and standardized administration of mindfulness self-compassion therapy. This dedication was maintained by regular monitoring and fidelity checks, which contributed to the internal validity and reliability of the study. The commitment and cooperation of both participants and therapists were critical to the study's success and the valuable insights gained from our examination.
Limitations and future research
Despite its positive outcomes, the current study featured a number of limitations. We could only employ a modest sample size and compare the experimental intervention to a static TAU group, potentially limiting the generalizability of the results in comparison to other demographics and other psychological treatments. We were guided by the evidence-based MSC guidelines in clinical settings. However, further study on the MSC protocol in medical contexts is required. Themes of research might include analyzing and adjusting for the possible impacts of different diagnoses or treatment procedures, investigating how these factors impact participants' therapeutic compliance or engagement, and finding ideal ways/populations to deliver MSC. Also, we controlled for age and educational level, recognizing their potential impact on psychological outcomes. Furthermore, to ensure a comprehensive analysis, we suggest for future direction to to encompass various covariates, such as individual differences, contextual variables, and therapeutic elements. By incorporating a range of covariates, we could enhance the robustness of our analysis and facilitate a nuanced interpretation of the observed changes in psychological outcomes—from pre to post-intervention and follow-up.
In this study, we have tried to explore the most accentuated problematic emotions and conditions in IVF literature. Nonetheless, clinging to the literature and extant studies has unintentionally hindered us from having the prerequisites (i.e., all the SCL-90 subscales) to assess the Global Severity Index (GSI) and Positive Symptom Distress Index (PSDI). Future studies can depict a more comprehensive delineation of psychological distress and severity among IVF patients by implementing all the subscales of SCL-90. During our trial, we met some real-world obstacles that highlighted the practical limits of these methods. The significant time commitment necessary for participants to continue a regular mindfulness practice within the framework of self-compassion was one notable barrier. Our experiment showed that, while everyday practice is optimal for the greatest benefits, it proved difficult for many of our paricipants owing to the demands of their daily lives. Mindfulness practices urge individuals to pay attention to their thoughts and emotions (apecifically adverse ones), which might elicit unpleasant or upsetting emotions. The results showed that some participants experienced discomfort when they began initial sessions, with a heightened awareness of uncomfortable thoughts and feelings. This initial uneasiness, if not handled properly, may impede their continuing participation in the therapy. Finally, our outcomes were focused on self-report. Feedback from clinicians who are not informed of the treatment condition may be a more robust indication of improvement than patient reports. Future research may benefit from integrating behavioral, psychophysiological, and neurological examinations [
108]. In conclusion, the MSC program's implementation on IW undergoing IVF and its encouraging results demonstrated that it can be a flexible tool in medical settings when medical conditions are accompanied by exacerbating psychological difficulties.
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