Infertility is the inability to achieve a viable pregnancy after 12 months of regular, unprotected sex or as a result of the impaired reproductive capacity of the individual or partner (American Society for Reproductive Medicine, 2020). Worldwide, about 15% of couples of childbearing age have infertility problems (Sun et al., 2019). In China, the proportion has reached as high as 25% and is rising (Zhou et al., 2018). With the advent of human-assisted reproductive technology (ART), a growing number of infertile couples are opting for in vitro fertilization and embryo transfer (IVF-ET) to fulfill their fertility wishes (Chen and Heilbronn, 2017). However, high costs, extensive testing and continual monitoring, uncontrollable outcomes, and alternating feelings of hope and disappointment throughout IVF-ET are everyday stressors for both the wife and the husband (Koert and Daniluk, 2017; Casu et al., 2018). These stresses lead to repeated feelings of tension, anxiety, and depression in infertile couples, which seriously affect their quality of life (Fallahzadeh et al., 2019; Dadhwal et al., 2022). Furthermore, chronic stress and adverse mood swings may reduce the chances of a successful outcome through psychobiological mechanisms (Ebbesen et al., 2009; Purewal et al., 2018). Hence, the couple must learn to cope with the range of psychological and physical distress accompanying this transition.

According to Lazarus and Folkman’s (1984) transactional model of stress and coping, coping is a self-regulatory process used to alleviate stress. It consists of intentional cognitive and physical efforts to manage internal or external demands that have been appraised as straining a person’s resources. Studies have shown that women were more likely to adopt emotion-focused strategies than men when coping with the stress of infertility. They reported greater use of self-blame and avoidance, which were associated with higher levels of depression, anxiety, and stress. They also made more effort to seek information and emotional support (Bayley et al., 2009). Partner communication difficulties and active-avoidance coping were predictors of high fertility stress. Men who reported frequently use of active-confronting coping and women who reported moderately or frequently use of meaning-based coping were significantly associated with low fertility stress (Schmidt et al., 2005). Moreover, the coping styles adopted by the partner were related to the personal, marital, and social distress of both men and women (Peterson et al., 2008). In intimate relationships, coping with stress includes individual efforts and mutual cooperation between the two partners.

Bodenmann (1995) further argued that the stress-coping model should not be viewed as an interaction based solely on the individual, but that both partners should perceive stress, evaluate stress, communicate stress, and manage stress together, and therefore proposed the systematic-transaction model (STM). The STM demonstrated that when a couple faces stress from both or one of them, the stress may be transformed into dyadic stress, which then activates dyadic coping due to the interdependence of the two sides. Dyadic coping is a couple’s response and strategy when dealing with dyadic stress. Dyadic coping can be either positive or negative, including stress communication, supportive, delegated, negative, and common dyadic coping (Bodenmann, 1995). Dyadic coping was initially used to highlight the influence of daily stressors on couples and then gradually has been used for cancer patients, chronic disease patients, infertile patients, and their spouses (Vaske et al., 2015; An et al., 2019; Bodenmann et al., 2019; Tang et al., 2022). In the infertile population, infertility and IVF-ET treatment affect both husband and wife as dyadic stressors. Therefore, dyadic coping plays an essential role in determining the outcomes of infertile couples (Casu et al., 2019). Positive dyadic coping strategies can release psychological distress (Patel et al., 2018) and contribute to better marital adaptation and greater relationship satisfaction (Facchin et al., 2021). While there are many benefits to positive dyadic coping, it is important to understand it in infertile people undergoing IVF-ET and find effective ways to improve it. Studies have also found that several factors, including religion, number of miscarriages, family relationships, family intimacy, and adaptability, may influence dyadic coping (Tang et al., 2022).

Self-esteem is the core of self-evaluation, an individual’s positive or negative attitude towards themselves based on self-cognition (Rosenberg, 1965). Self-esteem is an expression of intrinsic value, but it can be influenced by external factors, including physical and psychological conditions (Ucar et al., 2021; Cui C. et al., 2021). Family relationships, psychosocial stress, and physical pain caused by their infertility and treatment are the risk factors that affect the self-esteem of couples undergoing IVF-ET (Zurlo et al., 2020; Jing et al., 2021; Liu et al., 2021; Zhang et al., 2022). Many studies in the past have shown that one of the most prominent problems in the infertile population is stigma, which leads to varying degrees of reduced self-esteem (Cizmeli et al., 2013; Çavdar and Coşkun, 2018; Ruth and Akintayo, 2021; Cui C. et al., 2021). The level of self-esteem has an impact on coping strategies. A high level of self-esteem promotes positive coping behavior. People tend to use problem-focused strategies when they have a higher level of self-esteem. In comparison, they are more likely to use emotional-focused strategies when they have a lower level of self-esteem (Cui S. et al., 2021; Skwirczyńska et al., 2022). That self-esteem, as an expression of an overall sense of self-worth, is related to stress and coping styles (Bodenmann, 1995). Most existing studies have used self-esteem as a mediating variable to explore its protective effect on health outcomes in the context of various stressors from infertility (Kissi et al., 2013; Cui C. et al., 2021). However, little is known about the association between self-esteem and coping strategies among the infertile population undergoing IVF-ET, especially in intimate dyadic relationships. Therefore, we planned to explore the relationship between self-esteem and dyadic coping by providing theoretical evidence for future interventions aimed at improving dyadic coping.

In the dyadic relationship, many variables of the two individuals are interdependent and interact. Actor-partner interdependent model (APIM) is a method to analyze pairwise data (Olsen and Kenny, 2006). The APIM points out that individual dependent variables are affected not only by individual independent variables, that is, actor effects, but also by specific partners’ variables within a certain range, namely partner effects (Kenny et al., 2006; Kenny, 2011). The aim of this study was to investigate the relationship between self-esteem and coping in the dyadic interaction of infertile couples undergoing IVF-ET. Self-esteem was the independent variable and dyadic coping was the dependent variable. We hypothesized that the wife’s and the husband’s self-esteem would predict their own dyadic coping styles and, to some extent, those of their partner’s.

This study examined the association between self-esteem and dyadic coping among infertile couples undergoing IVF-ET. We adopted the APIM to explore the interdependence of the couples’ self-esteem and their dyadic coping. Overall, our findings supported our hypothesis that the couples’ self-esteem could significantly predict to their own and their partners’ dyadic coping.

Similar to previous surveys in Northeast and Southeast China, we found that the self-esteem of infertile couples undergoing IVF-ET is at the middle level (Cui C. et al., 2021; Wang et al., 2022). In contrast, infertile couples in Turkey (Çavdar and Coşkun, 2018), Athens (Ruth and Akintayo, 2021), and Egypt (Zayed and El-Hadidy, 2020) had low self-esteem and those in western countries such as American, had a higher self-esteem than the general population (Cizmeli et al., 2013). These differences could be the result of socioeconomic and cultural heterogeneity. In general, people of childbearing age in China are more open and receptive to infertility and ART treatment as education, social, economic, and cultural development have improved and knowledge has become more readily available in recent decades. However, there was still a difference in self-esteem between husbands and wives. Previous studies reported that self-esteem is tied to the stress and psychological distress of infertility, and women, as the main body of fertility, face greater reproductive pressure and psychological distress than their husbands, and therefore their self-esteem is more likely to be affected (Cui C. et al., 2021).

The analysis of dyadic coping in our study indicated that wives engaged in more stressful communication than their husbands. Such finding is consistent with earlier studies (Staff et al., 2017; Molgora et al., 2019). As a normal emotional expression, women are more prone to vent their stress to their spouse through words and behaviors in order to receive care and assistance. Conversely, men play a strong and rational role and are typically more emotionally restrained (Bodenmann et al., 2015; Fang et al., 2021). In the current study, husbands reported a better delegated dyadic coping than their wives. The result suggested that although husbands make an effort to assist wives in sharing household duties and to reduce their stress, their efforts may go unrecognized because of the difference between how support is perceived by recipients and how it is perceived by providers (Tang et al., 2022). The better individual dyadic coping in husbands may also reflect men’s socially expected roles as protectors and supporters of their families (Chaves et al., 2021).

The study also found a significant correlation between husbands and wives in self-esteem and dyadic coping, suggesting that individuals’ emotions and behaviors were affected by their partners in the intimate relationship, which supports the findings of Wang et al. (2022). There is a positive predictive effect between self-esteem and dyadic coping, higher self-esteem is associated with more positive dyadic coping of the couple. People with higher self-esteem tend to have better social acceptance, interpersonal relationships and even social resources, so they are more likely to deal with stress positively and provide support to their partner (Alirezaei et al., 2018). On the other hand, research also showed that providing support to the partner could enhance an individual’s sense of self-esteem and well-being, it is one of the effective ways to realize self-worth (Poulin et al., 2010). Getting support is beneficial to enhance self-worth and happiness, as well as adapt to different stressors (Ying et al., 2015). These findings suggested that while self-esteem is associated with a more positive dyadic coping, dyadic coping may also reinforce a person’s self-esteem.

Besides, we found that husband’s self-esteem had a more extensive influence on wife’s dyadic coping. Women are relatively more sensitive and perceptual, which makes their dyadic coping behavior easier to be affected by their husband’s self-esteem (Wang et al., 2022). As the main undertaker of treatment, women bear more psychological pressure and physical pain, and they are eager to get the support and care of their husbands, so they may pay more attention to their husbands’ reactions (Kim et al., 2020). Influenced by Chinese traditional wisdom, women in infertile couples tend to experience more psychological pressure from family and society than men, and are more likely to experience stigma, which persists during fertility treatment (Kong et al., 2019; Zhang et al., 2021). Studies have shown that men are more likely than women to accept childlessness, and the role of motherhood is very important for women, who have a greater sense of responsibility for childbearing (Nagorska et al., 2019). Especially in this study, female factors accounted for a large proportion of infertility, and about 30% of women were unemployed, and the uncertainty of treatment outcomes and financial burden maybe made them feel deeper guilt and sensitivity, and therefore care more about their husbands’ attitudes.

In summary, this study contributes to the understanding of the relationship of self-esteem and dyadic coping of infertile couples undergoing IVF-ET. Individual’s self-esteem is positively associated with their own dyadic coping and have an impact on their partners’ dyadic coping. Future psychological interventions should focus on enhancing self-esteem to assist infertile couples in positively coping dyadic stress.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Review Committee of the Reproductive Medicine Center of Northwest Women and Children’s Hospital (2022007). The patients/participants provided their written informed consent to participate in this study.

LiZ contributed to developing the study design, analyzing data and writing the entire manuscript. WG contributed to developing the study design, reviewing and revising the manuscript. XJ, SZ, NZ, and LuZ contributed to data collection. WW and YJ contributed to revising the manuscript. All authors contributed to the article and approved the submitted version.

This study received funding from Shaanxi Provincial Department of Science and Technology (2022SF-438), Teaching Reform Project of Postgraduate Innovation and Entrepreneurship Course of Xi’an Jiaotong University, and Shaanxi Maitian IoT Information Technology Co., Ltd. (SKH2022215). The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.